Sabel Michael S, Griffith Kent A, Arora Alisha, Shargorodsky Josef, Blazer Dan G, Rees Riley, Wong Sandra L, Cimmino Vincent M, Chang Alfred E
Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI,
Surgery. 2007 Jun;141(6):728-35. doi: 10.1016/j.surg.2006.12.018.
With the introduction of sentinel lymph node (SLN) biopsy for melanoma, inguinal lymph node dissections (ILND) are more commonly performed for microscopic disease than for clinically palpable disease. We sought to examine the effect this change has on the morbidity of the operation.
A retrospective review was performed of all patients who underwent an ILND for melanoma between October 1997 and April, 2006. Clinical and pathologic data were collected and correlated by multivariate analysis with the incidence of a major wound complication.
We identified 212 patients, 132 who underwent an ILND for a positive SLN and 80 for clinically palpable disease. Age, sex, and body mass index (BMI) were similar in both groups. Patients with clinically palpable disease had a significantly greater number of involved nodes (3.0 vs 1.96, P = .0013), more often had >or=4 involved nodes (29% vs 9%, P < .001), and a greater incidence of extranodal extension (47% vs 5%, P < .001). Of the 212 patients, 41 (19%) had a significant wound complication. This complication was significantly higher among patients with clinical disease compared to patients with a positive SLN (28% vs 14%, P = .02). Only BMI (odds ratio of 1.1) and the indication for the procedure (odds ratio of 2.2) were independent predictors of a major wound complication. Lymphedema occurred in 30% of the patients and was only significantly associated with clinical disease (41% vs 24%, P = .025). With a median follow-up of 2 years, regional recurrence was not significantly greater in patients with clinically palpable disease (13% vs 9%, P = not significant [ns]), although this result was possibly due to the significantly greater rate of distant recurrence (49% vs 18%, P < .001) and death (48% vs 21%) in these patients.
Patients undergoing an ILND for a positive SLN have a significantly lower risk of postoperative complication or lymphedema than do patients undergoing ILND for clinically palpable disease. There is a benefit in regard to the morbidity of treatment in surgically staging melanoma patients by SLN biopsy and preventing ILND for palpable disease.
随着前哨淋巴结（SLN）活检技术引入黑色素瘤治疗，腹股沟淋巴结清扫术（ILND）更多地用于处理显微镜下可见的疾病，而非临床上可触及的疾病。我们试图研究这一变化对手术 morbidity 的影响。
对1997年10月至2006年4月间所有接受ILND治疗黑色素瘤的患者进行回顾性研究。收集临床和病理数据，并通过多变量分析将其与严重伤口并发症的发生率相关联。
我们共纳入212例患者，其中132例因SLN阳性接受ILND，80例因临床上可触及的疾病接受ILND。两组患者的年龄、性别和体重指数（BMI）相似。临床上可触及疾病的患者受累淋巴结数量明显更多（3.0 对 1.96，P = 0.0013），≥4个淋巴结受累的情况更常见（29% 对 9%，P < 0.001），且结外扩展的发生率更高（47% 对 5%，P < 0.001）。在212例患者中，41例（19%）发生了严重的伤口并发症。与SLN阳性的患者相比，临床疾病患者的这一并发症发生率明显更高（28% 对 14%，P = 0.02）。只有BMI（优势比为1.1）和手术指征（优势比为2.2）是严重伤口并发症的独立预测因素。30%的患者发生了淋巴水肿，且仅与临床疾病显著相关（41% 对 24%，P = 0.025）。中位随访2年，临床上可触及疾病的患者区域复发率虽无显著升高（13% 对 9%，P = 无显著差异[ns]），但这一结果可能是由于这些患者远处复发率（49% 对 18%，P < 0.001）和死亡率（48% 对 21%）明显更高所致。
因SLN阳性接受ILND的患者术后并发症或淋巴水肿的风险明显低于因临床上可触及疾病接受ILND的患者。通过SLN活检对黑色素瘤患者进行手术分期并避免对可触及疾病进行ILND，在治疗 morbidity 方面具有益处。
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