Risk evaluation in cutaneous melanoma patients undergoing lymph node dissection: impact of POSSUM

Abstract

INTRODUCTION When lymphatic metastasis occurs, surgery is the primary treatment modality in melanoma patients. Depending on the tumour stage, patients receive a completion lymph node dissection (CLND) when a positive sentinel node is detected. Patients with clinically evident disease of the regional lymph nodes are recommended to undergo a therapeutic lymph node dissection (TLND). The aim of this study was to assess the morbidity of CLND and TLND and to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) for preoperative risk adjustment of postoperative morbidity. METHODS The hospital files of 143 patients who underwent CLND and TLND for malignant melanoma were analysed. The POSSUM score was used to predict morbidity rates after surgery for the total patient group as well as separated for CLND and TLND patients. RESULTS The overall complication rate was 28.0% and the mortality rate was 0%. The morbidity rate predicted by POSSUM was 32.9%, the mortality 8.3%. Morbidity in patients undergoing CLND was significantly higher with regard to overall wound complications compared with patients with TLND. In these subgroups, POSSUM failed to predict the rates precisely. CONCLUSIONS The POSSUM score predicted the morbidity of the total patient group accurately but failed to predict the rates in the TLND and CLND subgroups. Patients receiving CLND showed the highest morbidity rates. Preoperative sentinel lymph node biopsy therefore has more influence on postoperative morbidity than the physiological parameters represented in the POSSUM physiological score.

Surgical outcomes in patients with cutaneous malignant melanoma in Europe – a systematic literature review

“…In addition, it has been considered questionable whether the prognosis of patients treated with CLND after positive SLNB is superior to that in patients treated with TLND after occurrence of clinical nodal disease . Evidence from seven studies in this review confirms that no clear advantage for CLND can be established, although there is some evidence in its favour: five studies reported numerically higher survival rates or survival time for patients who underwent CLND, and one study reported significantly higher DSS . Moreover, one study reported significantly better OS for CLND vs. TLND in patients with tumour thickness of 1–4 mm, suggesting that certain patient subpopulations are more likely to benefit from this surgical procedure.…”

“…Similarly, Egberts et al . reported longer OS for patients undergoing CLND vs. TLND (43 vs. 27 months) (Table a). The latter study also reported non‐significantly longer median progression‐free survival (PFS) for CLND vs. TLND.…”

“…Twenty‐three studies met all criteria and were included in the study. These evaluated 18 332 patients treated between 1979 and 2009, representing data from 11 European countries (Denmark, Estonia, Finland, France, Germany, Italy, Norway, Poland, Sweden, The Netherlands and the United Kingdom) (Table ). Of these studies, 21 were observational and two were RCTs (Table ).…”

“…42 CLND and therapeutic lymph node dissection (TLND) CLND refers to surgical removal of regional lymph nodes after positive SLNB, whereas TLND refers to surgical removal of regional lymph nodes after detection of cancerous lymph nodes during clinical examination. 42 Seven observational studies evaluated outcomes in patients undergoing CLND or TLND 22,27,33,34,[37][38][39] (Table 3a).…”

Dissections of regional lymph nodes for treatment of skin cancer: predicting annual caseloads that will optimise outcomes

“…1 The prevalence of complications and morbidity associated with dissection of RLNs can be high: 28-77%. [2][3][4][5][6][7][8] Groin dissections are typically associated with a higher prevalence of complications than axillary dissections. 2,[9][10][11][12] In 1992, Baas et al undertook a retrospective review of 151 consecutive groin dissections.…”