Lymphatic fistulae and/or lymphoceles in the groin following radical lymphadenectomy are frequent, and therapeutic options are needed to avoid severe restrictions for oncologic patients waiting for adjuvant medical therapies. This is the key message Florian Offensperger (General and Interventional Radiology, Stuttgart Clinics, Stuttgart, Germany) wants audience members to take home from the 2020 virtual Global Embolization and Cancer Symposium Technologies (GEST) meeting (4–6 September).
“It is important to say that there are treatment options,” he told attendees of the live event on Friday 4 September, “because we often have excellent patients who have been told that there is no other option but to wait.”
Stuttgart Clinics, where Offensperger works, is one of the largest surgical centres in Germany. Discussing postoperative lymphatic complications following radical inguinal lymphadenectomy in patients with malignant melanoma, Offensperger says: “Where wood is chopped, splinters must fall”. However, his talk offers hope for how best to deal with these splinters—a complication need not spell disaster for a patient.
The basic lymphatic intervention performed at the Stuttgart Clinics for patients with postoperative complications from radical inguinal lymphadenectomy is pedal Lipiodol lymphangiography combined with second-line interventions. “In our opinion,” Offensperger says, this is “the best treatment for these patients”.
He informs the GEST audience that the technical success rate of conventional lymphangiography is 75–100%, and the cure rate of postoperative lymphatic leakage for pedal conventional lymphangiography is 51–70% (time to cure, 2–29 days). “Conventional lymphangiography is safe, feasible, and effective in the management of postoperative lymphatic leakage,” he concludes, showing a pre-recorded video of the procedure to illustrate how it works to his listeners. “Personally, I really like this intervention, because it is a delicate task requiring many interventional techniques,” he shared.
In the present study, Offensperger and colleagues conducted a prospective analysis of their institutional digital databases for melanoma patients. They compared patients who had been treated with lymphatic angiography alone with those who had been treated with lymphatic angiography combined with sclerotherapy.
Between October 2014 and June 2019, 13 patients met the inclusion criteria: nine in the lymphatic angiography alone group, and four in the combined lymphatic angiography and sclerotherapy group. Mean patient age was 66.4 years (range: 46.8–83.4 years), and the interval between radical inguinal lymphadenectomy and lymphatic angiography was 17.8 days (range: seven to 34). The technical success rate for lymphatic angiography was 93%. The amount of Lipiodol used to perform the procedure was 15.4ml (range: six to 22ml), and in the combined group sclerotherapy was applied after an interval of 10 days (range: zero to 23). Sclerotherapy was performed either with 3–5ml ethanol, or with a glue/ Lipiodol 1:5 mixture (6–8ml) under fluoroscopy or computed tomography (CT) guidance.
The clinical success rate was higher in patients treated with lymphatic angiography and sclerotherapy, 100% compared with 78%. However, the interval between intervention and cure was slightly shorter in the cohort treated with lymphatic angiography alone: 23 days (range: four to seven) versus 29 days (range: 24–33). While there were no minor procedure-related complications in the group of patients treated with lymphatic angiography alone, there was one in the combined cohort (representing 25% of the patients treated in this arm of the study), a local infection cured by antibiotic treatment. There were no major procedure-related complications in the study.
These results led Offensperger to conclude that “Lymphatic angiography, with or without sclerotherapy, is an essential tool to cure therapy-refractory lymphatic fistulae after radical inguinal lymphadenectomy in patients with malignant melanoma.
“Lymphatic angiography in combination with sclerotherapy seems to result in higher clinical success rates,” he continued, “but also in higher complication rates when compared with lymphatic angiography alone.” However, he stressed that he wanted to leave GEST attendees with the understanding that lymphatic angiography in combination with sclerotherapy is a safe and effective option.