Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

The many faces of intraperitoneal chemotherapy.

Cytoreductive surgery and intraperitoneal chemotherapy may offer chance for cure for patients with peritoneal metastasis. Many variations emerged, causing uncertainty when choosing the most suitable variant. By reviewing variability encountered in the management of peritoneal metastasis, we aim to raise awareness about this issue and hopefully initiate efforts to solve it. We review variance encountered in all aspects of this complex field of surgical oncology, indications, patient selection criteria, definition and extent of cytoreductive surgery and the numerous variables of intraperitoneal chemotherapy. Best benefit was achieved with pseudomyxoma peritonei, and to lesser extent in colorectal, ovarian and gastric cancer, but Indications keep expanding to include other tumors pathologies. Selection of patients depends on numerous prognostic indicators and criteria, according to tumor extent and pathology. The standard definition of cytoreductive surgery remains the same, but the boundaries of resection expand. Numerous chemotherapy regimens and administration methods are used, in search for best possible benefit. This variance must be reduced, to make the best use of, and further spread this treatment combination. Practical simple guidelines are needed for surgical oncologists willing to utilize this treatment for their patients, to be considered a true standard of care.

Challenging the Contraindications of Minimally Invasive Inguinal Lymph Node Dissection: Report of 2 Cases.

BACKGROUND: Endoscopic inguinal dissection is an emerging procedure utilizing minimally invasive technology to perform inguinal dissections aiming to avoid skin complications. Despite numerous reports there seems to be no consensus on inclusion and exclusion criteria, raising the question of when and when not to choose the minimally invasive technique. We compare the inclusion and exclusion criteria in published literature, and present our experience with 2 challenging cases; 1 with skin infiltration and the other with a previous lymphadenectomy scar. MATERIALS AND METHODS: We present 2 cases where this procedure was performed, despite limited nodal skin infiltration in the first case, and presence of a fresh scar of a previous biopsy and recent history of chemotherapy treatment in the second case. RESULTS: Despite skin infiltration by inguinal nodes, endoscopic inguinal dissection was performed and the attached skin was excised and delivered with the lymph nodes through the incision in the first case. Presence of a fresh scar and history of chemotherapy did not affect the outcomes in the second case, albeit fibrosis and adhesions. CONCLUSIONS: Skin infiltration, previous lymphadenectomy, and previous groin therapy might not represent absolute contraindications in selected cases and in the hands of experienced surgeons.

Minimally invasive inguinal lymph node dissection: initial experience and reproducibility in a limited resource setting-with technique video.

BACKGROUND: Conventional inguinal lymph node dissection comes with a high wound complication rate which increases hospital stay and may delay adjuvant treatment. Minimally invasive lymph node dissection (MILND) is a novel endoscopic technique which aims to minimize complications of lymphadenectomy. Herein we present our technique and experience with MILND to examine safety, feasibility and reproducibility in a setting of limited resources. METHODS: All patients undergoing MILND in the National Cancer Institute, Cairo were prospectively included following informed consent, IRB and ethical committee approval. Demographics, clinical, pathological data and postoperative complications according to Clavien-Dindo classification were recorded. Footage collected was used to create a step-by-step video demonstrating the technique. RESULTS: Twenty-seven procedures were included in the study. The most common indications were vulval cancer (44%) and skin melanoma (19%). There were 5 (18%) conversions to open procedure, all of them in the first 10 cases of the learning curve. The median (range) operative time was 120 (45-240) min and there was a trend towards shorter operative time after the first 5 cases. Wound dehiscence occurred in 4 cases (15%). Three of them (11%) required reoperation (grade III). Grade I/II complications in the form of seroma and wound infection occurred in 34%. The median (range) postoperative hospital stay was 2 (1-14). The median (range) number of retrieved lymph nodes was 12 (3-19). No grade III/IV lymphedema was recorded at 90 days after surgery. CONCLUSION: MILND is a safe, feasible technique associated with relatively low postoperative wound complications even when performed in a centre with relatively limited resources.