Videoscopic Versus Open Inguinal Lymphadenectomy for Cancer

Inguinal lymphadenectomy is the standard procedure used to treat patients with metastatic lymphadenopathy to the groin. For melanoma, the majority of these patients are diagnosed via sentinel lymph node biopsy, which identifies disease at a very early stage. In up to 80% of patients no additional disease is identified in the lymphadenectomy specimen1,2, which is performed at a separate setting from the initial biopsy, unlike in breast cancer. Unfortunately, due to the nature of the incision and the location, inguinal lymphadenectomy is associated with an extremely high incidence of postoperative wound complications. As many as 50% of patients will develop wound infections ranging from simple cellulitis to significant wound abscesses requiring a reopening of the incision and considerable wound care, sometimes necessitating rehospitalization.3 These data are associated with an open procedure, generally requiring a 10-15 cm incision. Recently, a videoscopic approach to this procedure has been described.4 It has been well-proven that a minimally invasive approach to cancer surgery does not have a negative impact on outcomes from cancer treatment.5 Emory has long been at the forefront of minimally invasive surgery and it is only appropriate that the investigators continue to lead the field. As one of the busiest melanoma centers in the country, the investigators have the opportunity to demonstrate the utility of this approach and continue to lead the field in both cancer therapy and minimally invasive surgery.

The trial will randomize patients to either videoscopic or open lymphadenectomy to determine if there is any difference in wound complication rate and as a secondary endpoint, time to recurrence. It is expected that there will be a substantial (approximately 25% incidence versus traditional 50% incidence or half of the number of wound complications) decrease in the incidence of wound complications after minimally invasive lymphadenectomy. This is expected predominantly for two reasons: 1. The wounds for this procedure are outside of the groin, in contrast being located on the thigh, a less difficult area for healing; and 2. The wounds are markedly shorter in length, making wound healing easier. The investigators would expect recurrence patterns to be identical in the two groups. The investigators have performed 20 procedures using the minimally invasive approach, and our experience to this point has demonstrated that the mean and median number of nodes harvested was 9 and 10.5 respectively. Median procedure duration has been 147 minutes and there have been 3 patients (15%) with complications (1 seroma, 2 with superficial cellulitis) but there have been no wound dehiscences or superficial breakdowns.

While the investigators do not have immediate access to the entire dataset of patients treated at Emory with the open approach, the investigators do have complete data on the 40 patients most recently treated (over the last 2 years). Of these 40 patients, 17 (43%) had complications other than lymphedema. Of these, 5 required hospitalization and two had complete wound dehiscences requiring management with a wound vacuum-assisted closure (VAC). This data is not complete, but reasonably reflects the Emory experience and allows us to conclude that our data is similar to that reported in the literature historically.

While many minimally invasive approaches to open procedures have been applied without randomized trials proving their efficacy (splenectomy, hepatectomy, pancreatectomy, partial gastrectomy, to name a few), the investigators believe it is prudent when adopting a new approach for a cancer operation to study it in a prospective fashion. This is the only trial of its kind and the investigators are one of only a few centers in the world that has the minimally invasive knowledge and expertise and the volume of urologic and melanoma patients to have the potential to perform such a trial. It is incumbent upon us to complete this study.

The goal of this study is to determine if a videoscopic approach to a standard procedure offers a better outcome for patients with respect to wound complications and to prove that there is no inferiority between the videoscopic approach and the traditional open approach from a cancer outcome standpoint, specifically time to recurrence and nodal yield.

Patients will be considered for this study if they are between age 18 and 80, have either metastatic melanoma or merkel cell carcinoma diagnosed by sentinel lymph node biopsy or have indications for inguinal lymphadenectomy for urological malignancy.

The study will be designed as a randomized, prospective trial, analyzing wound complications as the primary endpoint and recurrence-free survival as a secondary endpoint. Our sample size calculation (see section 8.0 below) indicate that a sample size of 73 patients in the study arm and 37 patients in the control arm will be sufficient to detect a moderate-to-strong effect with an 80% power and a 95% level of statistical significance.