The impact on morbidity and length of stay of early versus delayed complete lymphadenectomy in melanoma: results of the Multicenter Selective Lymphadenectomy Trial (I)

Abstract

Background: Complete lymph node dissection, the current standard treatment for nodal metastasis in melanoma, carries the risk of significant morbidity. Clinically apparent nodal tumor is likely to impact both preoperative lymphatic function and extent of soft tissue dissection required to clear the basin. We hypothesized that early dissection would be associated with less morbidity than delayed dissection at the time of clinical recurrence.

Materials and methods: The Multicenter Selective Lymphadenectomy Trial I randomized patients to wide excision of a primary melanoma with or without sentinel lymph node biopsy. Immediate completion lymph node dissection (early CLND) was performed when indicated in the SLN arm, while therapeutic dissection (delayed CLND) was performed at the time of clinical recurrence in the wide excision-alone arm. Acute and chronic morbidities were prospectively monitored.

Results: Early CLND was performed in 225 patients, and in the wide excision-alone arm 132 have undergone delayed CLND. The 2 groups were similar for primary tumor features, body mass index, basin location, and demographics except age, which were higher for delayed CLND. The number of nodes evaluated and the number of positive nodes was greater for delayed CLND. There was no significant difference in acute morbidity, but lymphedema was significantly higher in the delayed CLND group (20.4% vs. 12.4%, P = .04). Length of inpatient hospitalization was also longer for delayed CLND.

Conclusion: Immediate nodal treatment provides critical prognostic information and a likely therapeutic effect for those patients with nodal involvement. These data show that early CLND is also less likely to result in lymphedema.

Figures

Figure 1

Percentage of acute toxicity in each group. There are no significant differences between early and delayed CLND. (Sample size: Early CLND n=225, Delayed CLND n=132)

Figure 2

Percentage of chronic toxicity. Only lymphedema showed a significant difference between early and delayed CLND. (Sample size: Early CLND n=225, Delayed CLND n=132)

Figure 3

Percentage of lymphedema by nodal basin site. There was no indication that the difference between early and delayed CLND was limited to axillary or inguinal sites. (Axilla: early CLND 9 of 125 (7.2%) delayed CLND 8 of 64 (12.5%). Inguinal: early CLND 17 of 75 (22.7%), delayed CLND 17 of 53 (32.1%)).

Figure 4

Percentage of lymphedema by extent of inguinal dissection. There was no significant difference with the addition of the deep nodal basin. (Immediate CLND: Superficial =9 of 42 [21.4%], with deep = 7 of 31 [22.6%], p=0.90. Delayed CLND: Superficial = 4 of 11 [36.4%], with deep = 13 of 38 [34.2%], p=0.89.)