Lymphoedema following sentinel node biopsy—a need for informed consent

312 SHO then this would perhaps leave them with less training time for more complex reconstructive procedures. The training of plastic surgical SHOs has changed significantly over the last decade as a result of a reduction in working hours and the introduction of shift work and the common practice for the plastic surgical SHO to cross-cover other specialties whilst on-call in order to comply with the new deal. In August 2004, the European Working Time Directive (EWTD) came into effect for junior doctors in training. This will further limit the number of hours that can be worked in a week. There will be a phased reduction of working hours to 58 h per week by August 2004, 56 h by August 2007 and 48 h by August 2009 (or 2012 if UK government applies for an an extension). Whilst we accept that this has been a small study we believe it provides a reasonable snapshot of the operative experience of plastic surgical SHOs pre- and post-new deal. It confirms what many trainers and trainees have suspected for some time in that there has been a reduction in training opportunities for plastic surgical SHOs. The Deanery has a responsibility to ensure that a plastic surgical SHO in a training post is adequately trained but the trainee must also take the initiative to maximise training opportunities. This may entail a more directed learning process similar to that of a Calman SpR where trainers can identify areas of weakness for the trainee to concentrate on. The trainee may need to utilise other sources for training such as training laboratories, internet based resources, telemedicine, attend more courses and conferences or come in off-duty to observe operative procedures. Observation is no substitute for hands on experience but evidence suggests that observing an action forms the basis for acquiring new motor skills.3 Surgical training has changed considerably over the last decade with the calman report, the new deal, the EWTD, the confidential enquiry into perioperative deaths (CEPOD) and will evolve further with the prospect of replacement of the SHO grade with a single foundation year as part of the modernising medical careers plan. It is important that the reduction in operative experience of the plastic surgical SHO or its equivalent grade in the future does not continue.

References 1. NHS Management Executive. Junior doctors—the new deal. London: Department of Health; 1991.

Short reports and correspondence 2. Hindmarsh A, Edwards JD, Huang JKC, Lewis MPN. Reduction in surgical SHO hours risks a reduction of operative experience. Ann R Coll Surg Engl 2003;85(Suppl):231–3. 3. Pakzad F, Hussain M. Monkey see, monkey do!. Ann R Coll Surg Engl 2005;87(Suppl):25–6.

Matthew Wong Sophie Jones Haroon Sheikh Nick James Department of Plastic Surgery, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire SG1 4AB, UK E-mail address: [email protected] q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.09.009

Lymphoedema following sentinel node biopsy—a need for informed consent Sentinel node biopsy for malignant melanoma was first described by Morton1 and subsequently numerous studies have demonstrated the usefulness of this procedure for assessing patients with clinically negative nodes.2,3 Sentinel node biopsy is generally perceived as a simple procedure with no significant morbidity and the consent forms used for sentinel node biopsy trials do not mention lymphoedema as a potential complication. We recently encountered two patients who developed significant lymphoedema following sentinel node biopsy for malignant melanoma. This case report is intended to increase the awareness about this problem and to underscore the need for informing patients about it during pre-operative counselling.

Case report Our unit has been performing sentinel node biopsies for melanomas since April 2002 and we have so far performed 43 procedures. There have been two patients with lymphoedema giving an incidence of 7%. The demographic and clinical profile of the patients and severity of the lymphoedema are summarised in Table 1.

Short reports and correspondence

313

Table 1 Age

Sex

Location and type of melanoma

Procedure

Sentinel node status

Location and severity of lymphoedema

59

F

Right leg, superficial spreading melanoma (1.1 mm thick)

Negative

Right lower limb, 7% increase in volume

64

F

Right leg, nodular melanoma (1.5 mm thick)

Excision and split skin graftingCsentinel node biopsy right groin Excision and split skin graftingCsentinel node biopsy right groin

Negative

Right lower limb, 6% increase in volume

Case 1 The first patient was a 59-year-old lady who underwent wide excision of a 1.1 mm malignant melanoma on her right leg and split skin grafting. A single lymph node from the right inguinal basin was removed using the standard sentinel node technique. The histopathology of the node showed no evidence of metastasis. During her post-operative review 3 months later she was noticed to have lymphoedema of right lower limb up to the level of mid-thigh. She was referred to the Occupational therapist and on assessment she was found to have 7% increase in volume of right leg. She was understandably upset and complained that the pre-operative information sheet did not mention this complication. Seven months later the lymphoedema has not subsided.

Case 2 The second patient was a 64-year-old lady who underwent wide excision of a 1.5 mm malignant melanoma from her right leg and reconstruction with a split skin graft. Simultaneously, a sentinel node biopsy of the right groin was performed and a single node was removed which on histopathological examination was negative for melanoma cells. During her review 3 weeks later a seroma was noticed and was aspirated. During the next review 3 months later the seroma was persistent and she was noticed to have lymphoedema of the entire right lower limb calculated to be an increase in 6% volume. It has now been 2 years since and her lymphoedema has remained unchanged.

Discussion With the advent of sentinel node biopsy the evaluation of nodal basin in patients with malignant melanoma has undergone significant changes. Sentinel node biopsies are now increasingly performed outside clinical trials. Compared with a

regional lymph node dissection, sentinel node biopsy is a smaller procedure. The reported complication rates in the literature for sentinel node biopsy vary from 4.6 to 33%4,5 as against the 25–61% complication rate for regional node dissection.6–8 However, it is important that patients are warned about the potential complications. Lymphoedema after sentinel node biopsy for malignant melanoma was first reported by Wrone et al.4 They noticed lymphoedema in five patients out of 253 amounting 1.7%. In a large series of 2120 patients Wrightson et al. reported an overall complication rate of 4.6% with a 0.7% incidence of lymphoedema following sentinel node biopsy. They also found that lymphoedema was more common after sentinel node biopsy of the groin as compared to axilla.9 In their series on 347 patients Topping et al. found that nine patients developed lymphoedema as a major complication. This amounted to 3% of the sentinel node negative patients.10 It is difficult to explain the mechanism of lymphoedema following sentinel node biopsy. The primary excision is unlikely to be the cause of lymphoedema in both our cases though one patient had a seroma, which could be contributory factor. There are not many studies in literature, which have prospectively analysed the complications following sentinel node biopsy, and it is likely that the true incidence of lymphoedema is not reported. It is, however, important to counsel patients about this risk amongst others while obtaining informed consent for the procedure. At present the patient information sheets for the clinical trials do not address this complication.

References 1. Morton DL, Wen DR, Wong JH, et al. Technical details of intra-operative lymphatic mapping for early stage melanoma. Arch Surg 1992;127:392–9. 2. Reintgen DS, Cox EB, McCarthy KM. Efficacy of elective lymph node dissection in patients with intermediate thickness primary melanoma. Ann Surg 1983;198:379–85.

314 3. Reintgen DS, Balch CM, Kirkwood J, Ross MI. Recent advances in the care of the patient with malignant melanoma. Ann Surg 1997;225:1–14. 4. Wrone DA, Tanabe KK, Cosimi AB, Gadd MA, Souba WW, Sober A. Lymphedema after sentinel lymph node biopsy for cutaneous melanoma: a report of 5 cases. Arch Dermatol 2000;136(4):511–4. 5. Hettiaratchy S, Kang N, O’Toole G, Allan R, Cook M, Powell B. Sentinel lymph node biopsy in malignant melanoma: a series of 100 consecutive patients. Br J Plast Surg 2000;53:559–62. 6. Bass PC, Schraffordt KH, Hockstra HJ, van Bruggen JJ, van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower extremity melanoma. Short term and long term morbidity. Arch Surg 1992;127:281–6. 7. Beitsch P, Balch C. Operative morbidity and risk factor assessment in melanoma patients undergoing inguinal lymph node dissection. Am J Surg 1992;164:462–5 8. Urist MM, Maddox WA, Kennedy JE, Balch CM. Patient risk factors and surgical morbidity after regional lymphadenectomy in 204 melanoma patients. Cancer 1983;51:2152–6. 9. Wrightson WR, Wong SL, Edwards MJ, et al. Complications associated with sentinel lymph node biopsy for melanoma. Ann Surg Oncol 2003;10(6):676–80.

Short reports and correspondence 10. Topping A, Dewar D, Rose V, Cavale N, Allen R, Cook M, et al. Five years of sentinel node biopsy for melanoma: the St George’s Melanoma Unit experience. Br J Plast Surg 2004; 57:97–104.

Rajive Jose John Holmes Stuart Nath Danish Imran Department of Plastic Surgery, Aberdeen Royal Infirmary, Aberdeen, UK E-mail address: [email protected] q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.09.002