Lymph node dissections carry significant morbidity with high rates of both acute and chronic complications. These complications negatively impact on the overall function and quality of life of these patients and also pose a significant financial burden to the health system. Surgery, in itself, has been implicated as a potential promoting factor in the propagation of malignant lesions [14
] and may also suppress cell-mediated immunity [16
]. Taking this into account, both surgery and the complications of surgery can synergistically combine to facilitate the establishment of new metastases and the progression of preexisting micrometastases [17
]. For these reasons, we hypothesise that high complication rates following lymph node dissection might have an effect on metastases and could be used as a prognostic indicator for recurrence.
The anatomical location of the primary lesion has been reported as an independent predictor of a positive SLN and disease-free survival. However, this role is limited when compared to other well-established variables [10
]. Our results show an increased incidence of upper limb and truncal melanomas in male patients whereas females had an increased incidence of lower limb melanomas. With regards to Breslow thickness, it was observed that patients with upper limb melanomas had thinner tumours and a better overall survival. These findings are in accordance with previous reports [9
]. The anatomical distribution and its relation to gender could be explained by different sun exposure patterns between genders. In addition, upper limb lesions are more likely to be noticed at an earlier stage, and thus treatment can be initiated sooner. This could account for the preponderance of thinner lesions in the upper limbs.
A significant amount of heterogeneity was observed in our data among patients with nodal basin metastases. According to the MSLT, node-positive patients who underwent an immediate lymphadenectomy had a longer disease-free survival with a lower risk of recurrence [18
]. The long-term survival was also observed to be extended when a lymphadenectomy was performed for micrometastases compared to being performed in the setting of clinically detectable nodal disease [20
]. Unfortunately, we reported a high mortality rate in our patients with no clinically detected nodes who went on to have an immediate lymphadenectomy. This is most likely explained by the disease stage at presentation; 49% of our patients had a Breslow thickness of >3.5
mm, which is the upper limit in most trials as it has been associated with a poor outcome [3
]. Nonetheless, we included this category of patients in our study as it is a real-time reflection of our overall practice and to avoid any selection bias.
It has been reported that morbidity is higher in patients undergoing inguinal lymphadenectomy compared to those undergoing axillary or cervical lymph node dissection [21
]. However, in the literature, there is no difference in the complication rates between ALND and ILND [22
] which correlated with the findings in this study (39.7% in ILND versus 34.1% in ALND, P
The literature was reviewed with particular emphasis on differences between the dissection groups. In the ILND group there was no significant difference in early postoperative mortality. A trend for developing lymphedema was noted in the deep dissection group [23
]. Despite the higher rate of regional recurrence after superficial dissections compared to deep dissections no significant difference was seen in overall survival rates [24
]. The published rate of complications following groin dissection is quite variable. Using wound infection rates as an example, our 9.5% infection rate is midway in the published figures which range from 5 to15% [25
]. Similarly, our lymphedema rate of 22.2% is comparable to the published range of 21–40% [25
Variations in surgical technique of ALND have a minimal effect on the development of complications. For example, dissections either above or below the axillary vein do not increase the complication rate [27
] with an incidence of long term lymphedema between 1–12% [12
]. We report an incidence of 14.6% for both lymphedema and seroma formation in our study. It is worthwhile mentioning that due to the high incidence of seroma formation after axillary surgery, some authors consider it as a consequence of the surgery other than a direct complication [28
Our results did not show a statistical significant correlation between the development of postoperative complications and the risk of recurrence of melanoma. It is important to remember that this data applies to a cohort of patients with relatively very thick melanomas which inheritably carries a higher recurrence rate. However, it is not yet known if this data applies to patients with “thinner” melanomas.
In conclusion, the overall complication rate is comparable for both groin and axillary dissections. Male patients tend to have more complications after axillary clearance compared to females. In the ILND group, a Clark's level of 4 or more is a predictor for the development of complications. Finally this study shows that patients who developed complications had a higher incidence of melanoma recurrence; however, this did not reach significance and hence may not represent a true association.