Reconstruction following radical resection of recurrent metastatic axillary melanoma

BACKGROUND: Recurrent axillary metastasis following axillary lymphadenectomy for melanoma is associated with a poor prognosis. Radical resection of such axillary recurrences with concomitant reconstruction may not only yield significant palliation of symptoms but also improve disease-free survival. The purpose of this study was to evaluate the outcomes of this radical surgical approach and help determine the risks and benefits for this patient population. METHODS: A retrospective review of all patients who underwent axillary reexcision and reconstruction for metastatic melanoma between 1990 and 2000 was conducted at The University of Texas M. D. Anderson Cancer Center. Nine patients were identified who underwent flap reconstruction following radical excision of axillary recurrence after a previous lymphadenectomy. RESULTS: A total of 14 flaps were performed on the nine patients (five free flaps and nine pedicled muscle or myocutaneous flaps). Indications for surgery included pain, bleeding, and infection. Seven of the nine patients received perioperative radiation therapy. Palliation of symptoms was achieved in all patients. Free flap survival was 100 percent. Complications occurred in four of nine patients and included seroma, lymphedema, and wound dehiscence. Three patients had second local recurrences necessitating reresection and reconstruction; the mean time to rerecurrence was 6.7 months (range, 2 to 12 months). Four of nine patients were alive with no evidence of disease at the end of the follow-up period, with a mean disease-free interval of 41 months (range, 5 to 77 months). One patient was alive with distant metastasis, and four patients had died of distant metastases. The mean disease-free interval following original lymphedema for the nine patients was 11 months (range, 2 to 40 months). CONCLUSIONS: Aggressive resection of axillary recurrence following lymphadenectomy can palliate symptoms in select individuals and may result in long-term disease-free survival. Critical to this evolving surgical strategy is the use of vascularized soft tissue in the form of pedicled or free flaps to provide durable coverage of the resulting resection defect.