S. J. Diljak1, R. D. Kramer1, R. J. Strobel1, B. Sunkara1, D. J. Mercante1, J. S. Jehnsen1, J. F. Friedman1, A. Durham2, M. Cohen1 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Dermatology,Ann Arbor, MI, USA
Introduction: Secondary lymphedema (SLE) is a significant complication following lymphadenectomy in melanoma patients, with a reported incidence between 9-25% for axillary dissection (ALND) and as high as 24-44% for inguinal dissections (ILND). While radiation therapy and tumor burden are positive predictors for arm lymphedema in breast cancer, this has not been as well defined in the melanoma population using large cohorts. The purpose of this study is to identify unique post-operative and surgical risk factors for SLE in patients with regionally metastatic melanoma using the largest cohort to date compiled from a prospectively collected database of melanoma patients following an ALND or ILND.
Methods: From a prospectively collected, IRB-approved database we identified 688 melanoma patients receiving a complete lymphadenectomy (June 2005-June 2015) with 557 patients having either an ALND or ILND. Patients having iliac or bilateral dissections, or pre-op chemotherapy were excluded. Demographic, clinical, and post-op data were reviewed from the electronic medical record (EMR). SLE was defined as being mentioned in more than one post-operative note or a documented referral to the lymphedema clinic. Univariate statistical analysis and odds ratios (OR) with 95% confidence intervals (CI) were used to determine independent post-op and surgical predictors of SLE.
Results: Of the cohort of 557 melanoma patients, 119 (21.4%) developed SLE following lymph node dissection. The cohort was split between ALND (N=322 (57.8%); 10.9% with SLE) and ILND (N=235 (42.2%); 35.7% with SLE). On univariate logistic regression [Table], having an ILND (OR=4.58; CI: 2.95-7.11), post-operative adjuvant (OR=1.61 CI: 1.07-2.42) or radiation therapy (OR=1.81 CI: 1.02-3.22), and developing non-SLE complications (e.g. hematoma, infection, DVT) (OR=1.84 CI: 1.21-2.80), were each significantly associated with an increased risk of developing SLE. Non-SLE post-op complications increased the risk of SLE only in the first 2 months after surgery (OR=2.25 CI: 1.35-3.74). Use of an energy device during surgery, number of nodes removed, blood loss, and operative times were not significantly associated with risk of SLE. The average post-op time to develop SLE was 103 ± 126 days and follow-up was 1.9 ± 2.2 years.
Conclusion: This is the largest study to date evaluating surgical/post-op risk factors for SLE in melanoma patients after ALND or ILND. Post-operative factors significantly increasing the risk of SLE include adjuvant or radiation therapy, having an ILND, or non-SLE post-op complications. We believe that this work, combined with further evaluation of patient pre-op characteristics, will enhance informed clinical decision-making and risk assessment.
