Percutaneous fractionated radiotherapy of the groin to eliminate lymphatic fistulas after vascular surgery

Abstract

Background: Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3-0.5 to 1-12 Gy should be sufficient for the purpose. Currently, radiotherapy is a "can" recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas.

Patients and methods: As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed.

Results: Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications.

Conclusion: Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.

Keywords: Amputation; Benign disease; Radiation therapy; Side effects; Surgery; Wound healing.

Fig. 1

Patient with lymphatic fistula after vascular surgery. Panel A lymphatic fistula after 4 weeks of surgery, with more than 300 ml per day; Panel B wound at the beginning of radiotherapy; Panel C after 6 days of radiation therapy, the fistula is closed

Fig. 2

Therapeutic options for treating a lymphatic fistula. Our protocol is presented in the last row

Fig. 3

Possible complications of lymphatic fistulas

Fig. 4

Dose distribution of an intensity modulated arc therapy plan in a representative axial section. The clinical target volume is defined as the drainage channel with 2 cm anatomically adapted margin and the superficial and deep inguinal lymph nodes and vessels in the operating field

Fig. 5

Number of fractions for each patient until the fistula is closed