Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients

Mads Gustaf Jørgensen, Navid Mohamadpour Toyserkani, Jørn Bo Thomsen, Jens Ahm Sørensen. Journal of Plastic, Reconstructive & Aesthetic Surgery, November 2017

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Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients

Mads Gustaf Jørgensen, Navid Mohamadpour Toyserkani, Jørn Bo Thomsen, Jens Ahm Sørensen. Journal of Plastic, Reconstructive & Aesthetic Surgery, November 2017

Summary Background and Objectives: Cancer-related lymphedema is a common complication following lymph node excision. Prevention of lymphedema is essential, as treatment options are limited. Known risk factors are firmly anchored to the cancer treatment itself; however potentially preventable factors such as seroma and surgical-site infection (SSI) have yet to be asserted.

Methods: All malignant melanoma patients treated with sentinel lymph node biopsy (SNB) and/or complete lymph node dissection (CLND) in the axilla or groin between January 2008 and December 2014 were retrospectively identified. Identified patients were followed until March 2017 for the incidence of lymphedema.

Results: We identified 70 cases of extremity lymphedema following 640 SNB/CLND. SSI was an independent risk factor for developing lymphedema (HR 8.46, 95%CI 4.37–16.36,p < 0.001), whilst seroma was an independent risk factor for developing SSI (OR 6.92, 95%CI 4.11–12.54, p < 0.001). In addition, the risk of lymphedema was significantly larger following inguinal incisions compared to axillary incisions (HR 2.49, 95%CI 1.36–4.55,p < 0.05). Conclusion: SSI was the greatest independent risk factor for developing lymphedema. Additionally, patients’ that developed postoperative seroma were at an increased risk of also developing SSI. Future studies should examine if lymphedema can be prevented, by reducing seroma and SSI.

Main findings

  • 560 patients, 640 SNB/Complete LND were registered. CLND was performed due to a positive SNB in 127 cases.
  • Seroma, surgical site infection (SSI) and lymphedema occurred more frequently following CLND when compared to SNB.
  • These postoperative complications also occurred more often after inguinal operations compared to axillary operation.
  • Of the 110 that had a SSI, 52 developed lymphoedema.
  • Of the 130 that had a seroma, 41 developed lymphoedema.
  • Of the 67 complete axillary dissections 11 developed lymphoedema compared with 80 complete inguinal dissection of which 39 developed lymphoedema.
  • Of the 295 axillary SNB 5 developed lymphoedema compared with 198 inguinal SNB 15 developed lymphoedema.
  • This study suggests that SSI may mediate lymphedema onset following SNB and CLND in the axilla and groin. They found seroma to be the most predominant postoperative complication, and linked to an increased risk of subsequent SSI.
  • Seroma indicated an increased risk of lymphedema, however as seroma were often followed by infection, a multivariate analysis of both variables lead to the effect being mediated through infection.
  • Obesity and increasing age has previously been associated with a risk of lymphedema, however in this study, these parameters were not found to be independent risk factors.
  • The increased risk of lymphedema for patients with SSI may be elucidated by the immunological response. The immunological host response, to a bacterial infection, is a sustained release of bradykinin, which impairs physiological lymphatic function. The net effect is then a sequestration of macromolecules and fluid, which further distorts the lymphatic system.
  • This is a retrospective study and in this study, lymphedema was defined as the need for lymphotherapeutic treatment, and the incidence was found to be in the high end spectrum of previous reporting.
  • Patients, at high risk of developing lymphedema, could benefit from a high-efficacy screening program implemented at follow-up consultations.
  • A reduction in the number of patients with postoperative seroma and SSI, may also lead to a reduction in the number of patients with lymphedema.