Evolving treatment of locoregional metastatic melanoma

In melanoma patients, lymph node metastases are one of the most important predictors of survival. Lymph node dissection used to be standard treatment after a positive SLNB and still is standard surgical therapy in case of clinically palpable lymph nodes. Inguinal lymph node dissections(ILNDs) have a high rate of postoperative wound complications. Changes in the perioperative care around ILNDs in the UMCG have not led to a decrease in wound complications. Limiting the extent of the dissection in hope to decrease these complications, by determining pelvic nodal involvement prior to the dissection is not possible yet, as the available predictors are not accurate enough. At the UMCG a new surgical procedure (videoscopic inguinofemoral lymph node dissection) was introduced to limit the number of postoperative surgical complications. This might be a promising method to reduce wound complications after ILNDs, as it has a comparable complication rate and a good oncologic outcome.When lymph node metastases are deemed inoperable, patients used to be deemed palliative. And no operation was performed. Since the introduction of new systemic therapies, surgery can be preceded or followed by systemic therapy. This systemic treatment can be used to reduce tumor size, paving the way for a surgical resection. In patients with unfavorable tumor characteristics such as nodular ulcerated melanoma, adjuvant systemic therapy trials should be considered. Since the introduction of new systemic therapies, the surgical treatment of metastatic melanoma has changed and multidisciplinary approach is needed

Preoperative inhibition in patients with irresectable locally advanced stage III melanoma

Aim: Neoadjuvant treatment of locally advanced disease with BRAF inhibitors is expected to increase the likelihood of a R0 resection. We present six patients with stage III unresectable melanoma, neoadjuvantly treated with BRAF inhibitors. Methods: Patients with unresectable, BRAF-mutated, stage III melanoma, were treated with BRAF inhibitors between 2012 and 2015. Unresectability was determined based on clinical and/or radiological findings. At maximal response, resection was performed. The specimen was reviewed to determine the degree of response. Results: In five of six patients a radical resection was achieved. Postoperative complications were unremarkable. In five of six resected specimens, vital tumor tissue was found. Conclusion: Neoadjuvant BRAF inhibitor treatment of locally advanced melanoma is feasible and has the potential to facilitate an R0 resection

One-Year Morbidity Following Videoscopic Inguinal Lymphadenectomy for Stage III Melanoma

Simple Summary Inguinal lymphadenectomy (the removal of lymph nodes in the groin) is currently part of the treatment options for stage III melanoma patients. Surgery can be performed using one large inguinal incision (open approach) or a few smaller incisions (videoscopic approach). Previous research has already shown less severe complications and comparable oncologic outcomes after the videoscopic approach. Postoperative lymphedema following inguinal lymphadenectomy is a well-known problem which can potentially decrease quality of life. With the arrival of adjuvant systemic treatment options, less invalidating surgery is highly desirable. However, lymphedema and quality of life have only been investigated after the open approach. Therefore, we evaluated lymphedema and quality of life following videoscopic inguinal lymphadenectomy for stage III melanoma. The videoscopic inguinal lymphadenectomy is a feasible approach due to the comparable lymphedema incidence and normalization of quality of life during follow-up. Purpose: We aimed to elucidate morbidity following videoscopic inguinal lymphadenectomy for stage III melanoma. Methods: Melanoma patients who underwent a videoscopic inguinal lymphadenectomy between November 2015 and May 2019 were included. The measured outcomes were lymphedema and quality of life. Patients were reviewed one day prior to surgery and postoperatively every 3 months for one year. Results: A total number of 34 patients were included for participation; 19 (55.9%) patients underwent a concomitant iliac lymphadenectomy. Lymphedema incidence was 40% at 3 months and 50% at 12 months after surgery. Mean interlimb volume difference increased steadily from 1.8% at baseline to 6.9% at 12 months (p = 0.041). Median Lymph-ICF-LL total score increased from 0.0 at baseline to 12.0 at 3 months, and declined to 8.5 at 12 months (p = 0.007). Twelve months after surgery, Lymph-ICF-LL scores were higher for females (p = 0.021) and patients that received adjuvant radiotherapy (p = 0.013). The Median Distress Thermometer and EORTC QLQ-C30 summary score recovered to baseline at 12 months postoperatively (p = 0.747 and p = 0.203, respectively). Conclusions: The onset of lymphedema is rapid and continues to increase up to one year after videoscopic inguinal lymphadenectomy. Quality of life recovers to the baseline value

Morbidity After Inguinal Lymph Node Dissections:It Is Time for a Change

Inguinal lymph node dissection (ILND) for stage 3 melanoma is accompanied by high wound complication rates. During the past decades, several changes in perioperative care have been instituted to decrease the incidence of these complications. This study aimed to evaluate the effect of these different care protocols on wound complications after ILND. A retrospective analysis of prospectively collected data was performed with 240 patients who underwent an ILND in the University Medical Center Groningen between 1989 and 2014. Four groups with different treatment protocols were analyzed: A (>= 10 days of bed rest with a Bohler Braun splint), B (10 days of bed rest without a splint), C (5 days of bed rest), and D (1 day of bed rest). The effect of early mobilization, abolishment of the Bohler Braun splint and postural restrictions, and the introduction of prophylactic antibiotics were analyzed. One or more wound complications occurred in 51.2 % of the patients including wound infection (29.8 %), seroma (21.5 %), wound necrosis (13.6 %), and hematoma (5 %). In consecutive periods, respectively 44.4, 60.3, 44.9 and 55.2 % of the patients experienced wound complications. None of the instituted changes in protocols led to a decrease in wound complications. Changes in perioperative care protocols did not affect the rate of wound complications. Perhaps a change in the surgical procedure itself can lead to the necessary reduction of wound complications after ILND

Nodular Histologic Subtype and Ulceration are Tumor Factors Associated with High Risk of Recurrence in Sentinel Node-Negative Melanoma Patients

Since its introduction, the sentinel lymph node biopsy (SLNB) has become the standard staging procedure in clinical node-negative melanoma patients. A negative SLNB, however, does not guarantee a recurrence-free survival. Insight into metastatic patterns and risk factors for recurrence in SLNB negative melanoma patients can provide patient tailored guidelines. Data concerning melanoma patients who underwent SLNB between 1996 and 2015 in a single center were prospectively collected. Cox regression analyses were used to determine variables associated with overall recurrence and distant first site of recurrence in SLNB-negative patients. In 668 patients, SLNBs were performed between 1996 and 2015. Of these patients, 50.4 % were male and 49.6 % female with a median age of 55.2 (range 5.7-88.8) years. Median Breslow thickness was 2.2 (range 0.3-20) mm. The SLNB was positive in 27.8 % of patients. Recurrence rates were 53.2 % in SLNB-positive and 17.9 % in SLNB-negative patients (p <0.001). For SLNB-negative patients, the site of first recurrence was distant in 58.5 %. Melanoma located in the head and neck region (hazard ratio 4.88, p = 0.003) and increasing Breslow thickness (hazard ratio 1.15, p = 0.013) were predictive for distant first site of recurrence in SLNB-negative patients. SLNB-negative patients with a nodular melanoma and ulceration had a recurrence rate of 43.1 %; the site of recurrence was distant in 64 % of these patients. The recurrence rates of SLNB-negative nodular ulcerative melanoma patients approach those of SLNB-positive patients. Stringent follow-up is recommended in this subset of patients

Evaluation of the videoscopic inguinal lymphadenectomy in melanoma patients

Introduction: A completion or therapeutic inguinal lymph node dissection is a procedure accompanied with a high rate of postoperative complications. A novel, minimally invasive alternative has been developed; the videoscopic inguinal lymphadenectomy. The aim of this study is to present our first experience with the videoscopic inguinal lymphadenectomy among melanoma patients with inguinal metastases. Methods: Melanoma patients with a histologically confirmed inguinal metastases who underwent a videoscopic inguinal lymphadenectomy between November 2015 and January 2018 were included. Outcome measures were operation time, nodal yield, and postoperative complications. Furthermore, lymphedema measurements were performed both subjectively and objectively. Results: A total of 20 patients (3 males and 17 females) underwent a videoscopic inguinal lymphadenectomy. In 75% of patients the procedure was combined with an open iliac lymphadenectomy. Median operation time of the videoscopic procedure was 110 min (range, 79-165). There were no perioperative complications or conversions. In 12 patients (60%) there was >= 1 postoperative complication. The most frequent complications were seroma and wound infection. All complications were treated conservatively without the need for a surgical re-intervention. The median nodal yield of the videoscopic procedure was 9 (range, 1-19). Lymphedema was present in nine patients (45%) after three months of follow-up. Conclusion: Our initial results show that the videoscopic inguinal lymphadenectomy is an attractive alternative to the conventional open technique. The number of complications is comparable with the complication rate reported for the conventional open procedure, but they are less severe and there is no need for a surgical re-intervention. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved