Lymphedema after gynecological cancer treatment : prevalence, correlates, and supportive care needs

Quality of life in endometrial cancer survivors: single institution experience in Slovakia

BACKGROUND

To evaluate the association between body mass index (BMI) and quality of life among endometrial cancer survivors.

METHODS

Women diagnosed with endometrioid endometrial cancer at the Slovakian university hospital between January 2010 and December 2018 were identified. Three hundred ninety women diagnosed with endometrial cancer were invited to participate. Quality of life was measured using the EORTC (European Organisation for Reseach and Treatment of Cancer) quality of life questionnaires (QLQ-C30 and QLQ-EN24). Univariate and multiple regression analyses were used to determine associations between BMI and quality-of-life outcome variables. T-test was used to determine differences between groups.

RESULTS

337 (95.2%) women completed the questionnaire. 131 (38.8%) were pre-obese, 111 (32.9%) were class I and II obese and 29 (8.6%) were class III obese. Women with highher BMI experienced poorer physical, emotional and social functioning compared to normal weignt and pre-obese pacients (p <  0.05). Class I-III obese women had significantly more lymphoedema (59% v. 41%, p = 0.048) and dyspnea (73% v. 27%, p = 0.029), and experienced more fatigue (68% v, 32%, p = 0.036) and pain (65% v. 35%, p = 0.041).

CONCLUSIONS

Class I-III obesity was associated with poorer quality of life in endometrial cancer survivors. Increasing BMI was inversely associated with QoL. Pre-obese and obese patients should be informed about greater incidence of pain, fatigue and dyspnea. Lifestyle changes (e.g., dietary interventions, physical activity) might reduce obesity and improve quality of life among endometrial cancer survivors.

Lymphaticovenular anastomosis for recurrent cellulitis in a dementia patient with lymphedema

We describe a dementia patient with comorbid recurrent cellulitis and lymphedema in the left lower limb who was treated successfully for recurrent cellulitis by lymphaticovenular anastomosis (LVA). The patient, an 83-year-old woman, suffered from recurrent cellulitis three times a year on average for 15 years. Compression therapy was impossible because of dementia. After LVA, there has been no recurrence of cellulitis for 2 years.

It is difficult to administer decongestive lymphatic therapy in some patients, such as patients with dementia. LVA is a promising treatment for recurrent cellulitis in a dementia patient with lymphedema.

Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities

Background

Extremity lymphedema can occur bilaterally with different severities on each side. The aim of this study is to investigate the treatment outcomes of such patients with bilateral extremity lymphedema of different severities.

Patients and Methods

Between 2013 and 2017, patients with bilateral extremity lymphedema of different severities according to the Taiwan Lymphoscintigraphy Staging (TLS) system were retrospectively reviewed. Ipsilateral vascularized lymph node transplantation (VLNT) was indicated in TLS total obstruction and contralateral lymphovenous anastomosis (LVA) in TLS partial obstruction with patent lymphatic vessels on indocyanine green lymphography. Outcomes were assessed using circumference improvement, frequency of cellulitis, and lymphedema-specific quality of life (LYMQoL) questionnaires.

Results

A total of 10 patients with bilateral extremity lymphedema with median age of 63 (range 12–75) years were included. The median symptom duration of the lymphedematous limb was 60 (range 36–168) months and 12 (range 1–60) months in the VLNT and LVA group, respectively (p < 0.05). At average follow-up of 37.5 (range 14–58) months, the average limb circumference improvement was 2.4 (range − 3.3 to 7.8) cm in the VLNT group and 2.3 (range 0.3–7) cm in the LVA group (p = 1). The median episodes of cellulitis decreased significantly from 4 to 0.5 and 1 to 0 times/year in the VLNT and LVA group, respectively (p = 0.02, p = 0.06). The overall LYMQoL score improved from 4.5 preoperatively to 7.5 postoperatively (p < 0.01).

Conclusions

Limb-specific VLNT and LVA selected by TLS effectively treated bilateral extremity lymphedema with different severities.

Ultrasound Vibroelastography for Evaluation of Secondary Extremity Lymphedema: A Clinical Pilot Study

BACKGROUND

Lymphedema treatment is an ongoing challenge. It impacts quality of life due to pain, loss of range of motion of the extremity, and repeated episodes of cellulitis. Different modalities have been used to evaluate lymphedema; some are more error-prone and some are more invasive. However, these measurements are poorly standardized, and intrarater and interrater reliabilities are difficult to achieve. This pilot study aims to assess the feasibility of ultrasound vibroelastography for assessing patients with extremity lymphedema via measuring shear wave speeds of subcutaneous tissues.

METHODS

Patients with clinical and lymphoscintigraphic diagnosis of secondary lymphedema in the extremities without prior surgical treatment were included. A 0.1-s harmonic vibration was generated at three frequencies (100, 150, and 200 Hz) by the indenter of a handheld shaker on the skin. An ultrasound probe was used for noninvasively capturing of wave propagation in the subcutaneous tissue. Wave speeds were measured in the subcutaneous tissues of both the control and affected extremities.

RESULTS

A total of 11 female patients with secondary lymphedema in the extremities were enrolled in this study. The magnitudes of the wave speeds of the region of interest in the subcutaneous tissue at lymphedema sites in the upper extremity (3.9 ± 0.17 m/s, 5.96 ± 0.67 m/s, and 7.41 ± 1.09 m/s) were statistically higher than those of the control sites (2.1 ± 0.27 m/s, 2.93 ± 0.57 m/s, and 3.56 ± 0.76 m/s) at 100, 150, and 200 Hz (P < 0.05), and at 100 and 200 Hz (P < 0.05) between lymphedema (4.33 ± 0.35 m/s, 4.17 ± 1.00 m/s, and 4.56 ± 0.37 m/s) and controls sites (2.48 ± 0.43 m/s, 2.77 ± 0.55 m/s, and 3.06 ± 0.29 m/s) in the lower extremity.

CONCLUSIONS

These preliminary data suggest that ultrasound vibroelastography may be useful in the evaluation of secondary lymphedema and can be a valuable tool to noninvasively track treatment progress.

Potential role of transforming growth factor-beta 1/Smad signaling in secondary lymphedema after cancer surgery

Secondary lymphedema often develops after cancer surgery, and over 250 million patients suffer from this complication. A major symptom of secondary lymphedema is swelling with fibrosis, which lowers the patient's quality of life, even if cancer does not recur. Nonetheless, the pathophysiology of secondary lymphedema remains unclear, with therapeutic approaches limited to physical or surgical therapy. There is no effective pharmacological therapy for secondary lymphedema. Notably, the lack of animal models that accurately mimic human secondary lymphedema has hindered pathophysiological investigations of the disease. Here, we developed a novel rat hindlimb model of secondary lymphedema and showed that our rat model mimics human secondary lymphedema from early to late stages in terms of cell proliferation, lymphatic fluid accumulation, and skin fibrosis. Using our animal model, we investigated the disease progression and found that transforming growth factor‐beta 1 (TGFB1) was produced by macrophages in the acute phase and by fibroblasts in the chronic phase of the disease. TGFB1 promoted the transition of fibroblasts into myofibroblasts and accelerated collagen synthesis, resulting in fibrosis, which further indicates that myofibroblasts and TGFB1/Smad signaling play key roles in fibrotic diseases. Furthermore, the presence of myofibroblasts in skin samples from lymphedema patients after cancer surgery emphasizes the role of these cells in promoting fibrosis. Suppression of myofibroblast‐dependent TGFB1 production may therefore represent an effective pharmacological treatment for inhibiting skin fibrosis in human secondary lymphedema after cancer surgery.

Bowel dysfunction in survivors of gynaecologic malignancies

PURPOSE

To assess the prevalence of bowel dysfunctions after treatment for gynaecological cancer and the impact on the quality of life.

METHODS

We identified a cohort of 217 eligible women treated with radiotherapy (RT) with curative intention, alone or as combined treatment, for gynaecological malignancies at three institutions in Catalonia (Spain). Demographic, diagnosis and treatment modality were reviewed. Patients were sent validated questionnaires to assess bowel function and a set of questions asking on the changes after RT in bowel function, urinary function, sexuality, pain and lymphoedema.

RESULTS

Questionnaires were returned by 109 patients (50.2%) with a mean age of 65 ± 11 years. Of them, 71.8% had been treated for endometrial cancer and 28.2% for cervical cancer. Overall, 42.7% of patients reported bowel dysfunction, affecting their quality of life in 36% of cases. Symptoms were more frequent in patients who had undergone external beam RT compared to brachytherapy. The most common symptom was defecatory urgency which was reported by more than 40% of patients according to the St Mark's score, although it was less common in other questionnaires. Overall, faecal incontinence ranged between 10 and 15%, and usual loose stools and diarrhoea were reported by 13.5% and 5.1%, respectively.

CONCLUSION

Prevalence of bowel symptoms after treatment of gynaecological malignancies is high. A systematic evaluation using validated questionnaires should be performed in order to allow the decision-making process and also because there are a number of treatments available to improve the quality of life of cancer survivors.

Development of prediction models for lymph node metastasis in endometrioid endometrial carcinoma

BACKGROUND

In endometrioid endometrial cancer (EEC), current clinical algorithms do not accurately predict patients with lymph node metastasis (LNM), leading to both under- and over-treatment. We aimed to develop models that integrate protein data with clinical information to identify patients requiring more aggressive surgery, including lymphadenectomy.

METHODS

Protein expression profiles were generated for 399 patients using reverse-phase protein array. Three generalised linear models were built on proteins and clinical information (model 1), also with magnetic resonance imaging included (model 2), and on proteins only (model 3), using a training set, and tested in independent sets. Gene expression data from the tumours were used for confirmatory testing.

RESULTS

LNM was predicted with area under the curve 0.72-0.89 and cyclin D1; fibronectin and grade were identified as important markers. High levels of fibronectin and cyclin D1 were associated with poor survival (p = 0.018), and with markers of tumour aggressiveness. Upregulation of both FN1 and CCND1 messenger RNA was related to cancer invasion and mesenchymal phenotype.

CONCLUSIONS

We demonstrate that data-driven prediction models, adding protein markers to clinical information, have potential to significantly improve preoperative identification of patients with LNM in EEC.

Prognostic impact of pelvic and para-aortic lymphadenectomy on clinically-apparent stage I primary mucinous epithelial ovarian carcinoma: a multi-institutional study with propensity score-weighted analysis

BACKGROUND

The exact impact of full-staging lymphadenectomy on patients with primary mucinous epithelial ovarian carcinoma confined to the ovary is still unclear. In this study, we investigated the prognostic impact of lymphadenectomy covering both pelvic and para-aortic lymph nodes in patients with clinically-apparent stage I mucinous epithelial ovarian carcinoma, using data from multi-institutions under a central pathological review system and analyses with a propensity score-based method.

METHODS

We conducted a regional multi-institutional retrospective study between 1986 and 2017. Among 4730 patients with malignant ovarian tumors, a total of 186 women with mucinous epithelial ovarian carcinoma were eligible. We evaluated differences in survival outcomes between patients with both pelvic and para-aortic lymphadenectomy and those with only pelvic lymphadenectomy and/or clinical lymph node evaluation. To analyze the therapeutic effects, the baseline imbalance between patients with both pelvic and para-aortic lymphadenectomy and others was adjusted with an inverse probability of treatment weighting using propensity score involving independent clinical variables.

RESULTS

Fifty-five patients received both pelvic and para-aortic lymphadenectomy. With PS-based adjustment, both pelvic and para-aortic lymphadenectomy did not have additive effects regarding overall survival (P = 0.696) and recurrence-free survival (P = 0.978). Multivariate analysis similarly showed no significant impact of both pelvic and para-aortic lymphadenectomy on their prognosis.

CONCLUSIONS

The effect of pelvic and para-aortic lymphadenectomy is limited for clinically-apparent stage I primary mucinous epithelial ovarian carcinoma as long as full peritoneal and clinical lymph node evaluations are conducted. The results of this study should be used as the basis for additional studies, including prospective trials.

Lower extremity lymphedema in patients with gynecologic malignancies

Lower extremity lymphedema is a chronic, often irreversible condition that affects many patients treated for gynecologic malignancies, with published rates as high as 70% in select populations. It has consistently been shown to affect multiple quality of life metrics. This review focuses on the pathophysiology, incidence, trends, and risk factors associated with lower extremity lymphedema secondary to the treatment of cervical, endometrial, ovarian, and vulvar cancers in the era of sentinel lymph node mapping. We review traditional and contemporary approaches to diagnosis and staging, and discuss new technologies and imaging modalities. Finally, we review the data-based treatment of lower extremity lymphedema and discuss experimental treatments currently being developed. This review highlights the need for more prospective studies and objective metrics, so that we may better evaluate and serve these patients.

Risk factors for late-onset lower limb lymphedema after gynecological cancer treatment: A multi-institutional retrospective study

INTRODUCTION

Late-onset lower limb lymphedema (LLL) is a significant clinical challenge for physicians dealing with patients that undergo treatment involving the pelvic cavity. We aimed to clarify the prevalence of and risk factors for late-onset LLL after treatment for gynecological cancer.

METHODS

We conducted a multicenter retrospective study using records of cases in which LLL diagnosed by physical findings and measurement of limbs girths. Patients with LLL after treatment for uterine cervical, endometrial, and ovarian cancer were sequentially enrolled. We examined the timing of LLL onset and the associations between the time to onset and clinical characteristics, including age, type of cancer, lymphadenectomy sites, and performance of radiotherapy. We also investigated the risk factors for late-onset LLL and their effects on the cumulative incidence of late-onset LLL.

RESULTS

In total, 711 patients fulfilled the required criteria. Mean age of was 50.2 years old and median follow-up period was 5.05 years. More than half of them (50.5%) presented with LLL ≥5 years after undergoing treatment for gynecological cancer. A substantial number of patients (29.4%) developed LLL ≥10 years after undergoing treatment for gynecological cancer. Being aged <50 years [(odds ratio (OR): 1.919, P = 0.001), cervical cancer (OR: 1.912, P = 0.001), and radiotherapy (OR: 1.664, P = 0.017) were identified as significant risk factors for late-onset LLL in multivariate logistic regression analysis.

CONCLUSIONS

A substantial number of patients present with LLL ≥5 years after receiving treatment for gynecological malignancies. Clinicians are required to identify high-risk patients and inform them of the risk of late-onset LLL.

Is the risk of lymphedema life-long following treatment for gynecologic cancer?-A case report

Lymphedema is a common complication following oncologic surgeries and is classically described to occur months to a few years after these procedures. A 64 year-old woman with history of total abdominal hysterectomy and bilateral salpingo-oophorectomy developed right-sided lower extremity lymphedema 7 years after the surgeries. Lymphographic imaging performed approximately twenty years after the original surgeries revealed development of subclinical, asymptomatic lymphedema on the contralateral lower extremity. This delayed presentation of lymphedema after initial injury, is the first described case of subclinical lymphedema without detectable lymphatic injury, making it important to continuously monitor patients at risk for lymphedema long-term.

Risk factors for lower limb lymphedema in gynecologic cancer patients after initial treatment

Background

Most studies on lower limb lymphedema have been conducted in gynecologic cancer patients who underwent surgery for gynecologic malignancy. This study aimed to evaluate the risk factors for lower limb lymphedema development in gynecologic cancer patients who underwent initial treatment.

Methods

A retrospective cohort design was used to follow 903 gynecologic cancer patients who underwent treatment at Kurume University Hospital between January 1, 2013 and December 31, 2015. Data analyses were performed in 356 patients, and the patients were followed up until December 31, 2017. The model comprised two components to facilitate statistical model construction. Specifically, a discrete survival time model was constructed, and a complementary log–log link model was fitted to estimate the hazard ratio. Associations between risk factors were estimated using generalized structural models.

Results

The median follow-up period was 1083 (range 3–1819) days, and 54 patients (15.2%) developed lower limb lymphedema, with a median onset period of 240 (range 3–1415) days. Furthermore, 38.9% of these 54 patients developed lower limb lymphedema within 6 months and 85.2% within 2 years. International Federation of Gynecology and Obstetrics stage, radiotherapy, and number of lymph node dissections (≥ 28) were significant risk factors.

Conclusion

Simultaneous examination of the relationship between lower limb lymphedema and risk factors, and analysis among the risk factors using generalized structural models, enabled us to construct a clinical model of lower limb lymphedema for use in clinical settings to alleviate this condition and improve quality of life.

Vascularized lymph node transfer with submental free flap

Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis. Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required. In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients.

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects

BACKGROUND

Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity.

METHODS

A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant.

RESULTS

Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months.

CONCLUSION

Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.

GOG 244 - The LymphEdema and Gynecologic cancer (LEG) study: The association between the gynecologic cancer lymphedema questionnaire (GCLQ) and lymphedema of the lower extremity (LLE)

OBJECTIVE

To explore whether patient-reported lymphedema-related symptoms, as measured by the Gynecologic Cancer Lymphedema Questionnaire (GCLQ), are associated with a patient-reported diagnosis of lymphedema of the lower extremity (LLE) and limb volume change (LVC) in patients who have undergone radical surgery, including lymphadenectomy, for endometrial, cervical, or vulvar cancer on Gynecologic Oncology Group (GOG) study 244.

METHODS

Patients completed the baseline and at least one post-surgery GCLQ and LVC assessment. The 20-item GCLQ measures seven symptom clusters-aching, heaviness, infection-related, numbness, physical functioning, general swelling, and limb swelling. LLE was defined as a patient self-reported LLE diagnosis on the GCLQ. LVC was measured by volume calculations based on circumferential measurements. A linear mixed model was fitted for change in symptom cluster scores and GCLQ total score and adjusted for disease sites and assessment time.

RESULTS

Of 987 eligible patients, 894 were evaluable (endometrial, 719; cervical, 136; vulvar, 39). Of these, 14% reported an LLE diagnosis (endometrial, 11%; cervical, 18%; vulvar, 38%). Significantly more patients diagnosed versus not diagnosed with LLE reported ≥4-point increase from baseline on the GCLQ total score (p < 0.001). Changes from baseline were significantly larger on all GCLQ symptom cluster scores in patients with LLE compared to those without LLE. An LVC increment of >10% was significantly associated with reported general swelling (p < 0.001), heaviness (p = 0.005), infection-related symptoms (p = 0.002), and physical function (p = 0.006).

CONCLUSIONS

Patient-reported symptoms, as measured by the GCLQ, discerned those with and without a patient-reported LLE diagnosis and demonstrated predictive value. The GCLQ combined with LVC may enhance our ability to identify LLE.

"Pleurex Desalination" in Malignancy-related Ascites: A Novel Mechanism of Hyponatremia

OBJECTIVE

Pleurex catheters are a form of palliative therapy for patients, offering relief from symptomatic ascites while also affording greater independence and flexibility; however, aggressive drainage can lead to significant total body sodium losses. We describe the course of patients with "Pleurex desalination," an under-appreciated cause of hypovolemic hyponatremia, highlighting its unique pathophysiology and providing recommendations on how to manage these complex patients.

PATIENTS AND METHODS

We included representative patients with "Pleurex desalination" who were evaluated and treated by the renal consult service at Brigham and Women's between 2017 and 2019.

RESULTS

We identified 3 patients who were hospitalized with "Pleurex desalination" and had complete data on serum and urine studies, as well as treatment course. We demonstrate that patients with "Pleurex desalination" were removing up to 1 to 2 L of ascitic fluid a day and were admitted with signs and symptoms of profound hypovolemia and hyponatremia. Patients worsened with administration of diuretics and salt restriction and improved with aggressive fluid resuscitation in the form of hypertonic saline, normal saline, and/or intravenous albumin.

CONCLUSION

"Pleurex desalination" is an under-recognized cause of hyponatremia; at-risk patients require close observation and periodic resuscitation with intravenous, volume-expanding fluids.

The feasibility of implementing an exercise programme for deconditioned cancer survivors in a national cancer centre: FIXCAS Study

Introduction: As both the number of cancer survivors and the length of survival time are increasing, long-term health issues related to cancer and its treatment are becoming more prevalent. Research suggests that exercise can mitigate several negative health consequences in cancer survivors and improve physical function and quality of life. Multi-modal exercise interventions have been proposed as a cornerstone for survivorship care. However, studies evaluating exercise programmes within the Irish population are lacking. Purpose: To evaluate the introduction, implementation and acceptability of a multi-modal exercise rehabilitation programme for deconditioned cancer survivors in a real-world, standard practice setting. Methods and analysis: In this single-arm prospective feasibility study, cancer survivors (n=40) will undergo a 10-week multi-modal exercise programme. The study population will comprise of cancer survivors attending outpatient services in an Irish national cancer centre. Participants will be aged 18 or older and have completed treatment with curative intent. Feasibility will be evaluated in terms of recruitment, adherence and compliance to the programme. Secondary outcomes will examine physical function and quality of life measures. In addition, the acceptability of the programme will be assessed through patient feedback. Ethics and dissemination: Ethical approval through the St. James's Hospital and Tallaght University Hospital Research and Ethics Committee is currently pending. The study results will be used to optimise the intervention content and may serve as the foundation for a larger definitive trial. Results will be disseminated through peer-review journals, congresses and relevant clinical groups. Trial registration: ClinicalTrials.gov NCT04026659 (19/07/19).

Development of a Noninvasive Skin Evaluation Method for Lower Limb Lymphedema

Background: The skin's condition is altered in lymphedema patients, and evaluating this change is important. Some noninvasive methods for evaluating skin condition have been reported, especially in upper limb lymphedema. However, evaluating the skin in lower limb lymphedema remains challenging and is often limited to palpation. We aimed to develop a noninvasive skin evaluation method for lower limb lymphedema patients. Methods and Results: Twenty-five lower limb lymphedema patients were included. Skin induration and elasticity were measured using Indentometer^® IDM 400 and Cutometer^® MPA580. The relationship between the properties of skin from the healthy forearm and thigh, those of the affected thigh, and age was analyzed. Predicted skin induration age (IA) and elasticity age (EA) were calculated from the forearm, whereas actual values were calculated from the thigh, and the differences (ΔIA and ΔEA) were assessed. Patients were classified according to the International Society of Lymphology clinical staging system, and the differences in ΔIA and ΔEA were analyzed among the three groups (healthy, stage I/IIa, and stage IIb/III). Skin biopsy was performed in five unilateral lower limb lymphedema patients, and the dermal elastic fiber area was determined using microscopy with Elastica van Gieson staining. ΔEA significantly increased with disease progression, but ΔIA did not change significantly. Microscopy revealed elastic fiber filamentous changes, with decreased elastic fiber areas in lymphedema-affected skin. Conclusion: To our knowledge, this is the first report to evaluate lower limb skin elasticity in lymphedema quantitatively and noninvasively. ΔEA is useful for evaluating skin condition progression in lymphedema patients.

A GCIG international survey: clinical practice patterns of sentinel lymph node biopsies in cervical cancer

PURPOSE

To evaluate the practice patterns among centers and physicians worldwide regarding sentinel lymph node biopsies (SLNB) in cervical cancer (CC) patients.

METHOD

A validated 35-item questionnaire regarding SLNB in CC supported by the Gynecologic Cancer Intergroup (GCIG), and sponsored by the North-Eastern German Society of Gynaecologic-Oncology (NOGGO) was sent to all major gynecological cancer societies across the globe for further distribution from October 2015 and continued for a period of 7 months.

RESULTS

One hundred and sixty-one institutions from around the world participated. One hundred and six (66%) of the participants were from university centers and 111 (69%) were gynecologic oncologists. One hundred and fifty-two (97%) performed lymphadenectomy (LNE) and 147 (94%) did so systematically; 97 (60%) used SLNB, due to lower morbidity (73%), reliability (55%) and time-saving (27%). In cases of positive SLNB (pN+), 39% of respondents stopped the operation and sent the patient for chemoradiation (CRT), 45% completed pelvic and paraaortic LNE, whereas 26% went on to perform a radical hysterectomy (RH) and systematic pelvic and paraaortic LNE. In case of negative SLNB (pN0), 39% of institutions still performed a systematic pelvic and paraaortic LNE.

CONCLUSION

In this survey worldwide, SLNB adoption is an encouraging 60%, yet ample differences exist regarding strategy, and to a lower extent the techniques used. Lack of experience is the most common reason SLNB is not performed. Efforts to increase surgical education on SLNB technique and multicenter prospective trials providing evidence-based guidelines are warranted.

Supportive care needs and quality of life in patients with breast and gynecological cancer attending inpatient rehabilitation. A prospective study

BACKGROUND

Among patients with breast or gynecological cancer, supportive care needs are both highly prevalent and enduring. However, little is known about whether meeting patients' needs is accompanied by increased quality of life (QoL). We aimed to explore patients' supportive care needs reported at the beginning of inpatient rehabilitation and examined whether meeting these needs resulted in improved QoL.

MATERIAL AND METHODS

In a multicenter, prospective cohort study with 2 measurement occasions (beginning and end of inpatient rehabilitation), 292 patients with breast and gynecological cancer (mean age 55 years; 71% breast cancer) were enrolled. In 73%, time since diagnosis was longer than 6 months. We obtained self-reports of supportive care needs in 12 domains and measured QoL using the EORTC QLQ-C30 functioning subscales.

RESULTS

At the beginning of inpatient rehabilitation, top-ranking severe supportive care needs concerned coordination of care (48%), medical information (45%), alleviation of physical symptoms (42%) and support with improving health behaviors (36%). At the end of inpatient rehabilitation, all needs assessed declined significantly, although many patients still expressed strong needs in some domains. However, meeting patients' needs was accompanied by improvements in all functioning subscales.

CONCLUSIONS

This is the first study to show that meeting breast and gynecological cancer patients' supportive care needs during inpatient rehabilitation resulted in improved QoL. Given the considerable proportions of patients still reporting unmet needs at the end of their stay, stronger and continuing efforts seem warranted to meet these needs and thus further increase QoL.

A pilot study of lower extremity lymphedema, lower extremity function, and quality of life in women after minimally invasive endometrial cancer staging surgery

OBJECTIVE

The primary aim of this study was to pilot the use of an objective measurement technique to prospectively evaluate the incidence of lower extremity lymphedema (LEL) after minimally invasive staging surgery for endometrial cancer. Secondary objectives included observation of changes in lower extremity function and quality of life in this patient population.

METHODS

A prospective evaluation of LEL was performed in 97 women who underwent minimally invasive staging surgery for endometrial cancer using comparative circumferential volume measurements. Postoperative changes in lower extremity function and global quality of life were also assessed using patient-reported outcome measures.

RESULTS

Ninety-seven patients were included for lymphedema analysis. The rate of LEL was 25% at 4-6 weeks, 19% at 6-9 months, and 27% at 12-18 months postoperatively. The presence of LEL was associated with a significant worsening from baseline Lower Extremity Functional Scale (LEFS) scores at 4-6 weeks (-27.0% vs -3.7%, p = 0.02) and 6-9 months (-13.0% vs 0%, p = 0.01). LEL was not associated with a change in patient-reported global quality of life.

CONCLUSIONS

Up to one in four women experience lymphedema following surgical staging for endometrial cancer, and its presence is associated with diminished lower extremity function. Larger, prospective trials using the objective methodology piloted in this study should better clarify risk factors and long-term outcomes of this morbidity.

Therapeutic value of selective lymphadenectomy in interval debulking surgery for stage IIIc and IV epithelial ovarian cancer

OBJECTIVE

The role of selective lymphadenectomy at the time of interval debulking surgery in patients with advanced ovarian cancer remains a topic of debate. This study aimed to evaluate the value of selective lymphadenectomy during interval debulking surgery in patients with radiologic evidence of lymph node metastasis at initial diagnosis that ultimately become negative on imaging after neoadjuvant chemotherapy.

METHODS

A retrospective analysis including patients with stage IIIC-IV epithelial ovarian cancer and suspicious pelvic or para-aortic lymph node metastasis by imaging at diagnosis that resolved after neoadjuvant chemotherapy. The study was conducted from January 1996 to June 2016 with R0 interval debulking surgery. The patients with disease progression after neoadjuvant chemotherapy were excluded. Suspicious metastatic lymph nodes at initial diagnosis by computed tomography/magnetic resonance imaging were excised by selective lymphadenectomy. Survival curves were constructed by the Kaplan-Meier method, and a multivariate analysis was performed using Cox regression.

RESULTS

There were a total of 330 patients included in the analysis. Selective lymphadenectomy of suspicious nodes (Group 1) was performed in 145 patients. Systematic lymphadenectomy (Group 2) was performed in 118 patients. Sixty-seven patients did not undergo lymphadenectomy (Group 3). There were no significant differences in clinicopathologic features among the groups. Median progression-free survival was 28, 30.5, and 22 months in Groups 1, 2, and 3, respectively (log-rank, p=0.049). No-lymphadenectomy was an independent factor affecting progression-free survival (Cox analysis, HR=1.729, 95% CI 1.213 to 2.464, p=0.002), with no difference between Groups 1 and 2 (Cox analysis, HR=1.097, 95% CI 0.815 to 1.478, p=0.541). Median overall survival was 50, 59, and 57 months in Groups 1, 2, and 3, respectively (Cox analysis, p=0.566). Patients who underwent selective lymphadenectomy had lower 1-year frequencies of lower extremity lymphedema and lymphocysts than those with systematic lymphadenectomy (6.2% vs 33.1%, p<0.001, and 6.2 % vs 27.1%, p<0.001, respectively).

CONCLUSIONS

Extent of lymphadenectomy (systematic or selective) had no significant impact on progression-free survival or overall survival. In addition, the risks of lower extremity lymphedema and lymphocysts were lower in patients who underwent selective lymphadenectomy.

Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema

BACKGROUND

Vascularized lymph node transfer has shown promising results in the treatment of lower limb lymphedema, but little is known about the number of lymph nodes needed for the transfer to achieve optimal results. This study investigated the correlation between number of transferred lymph nodes in submental vascularized lymph node transfer and outcomes regarding limb circumference reduction and cellulitis incidence.

METHODS

Thirty-five patients who had received vascularized submental lymph node transfer to an ankle for lower limb lymphedema following gynecologic cancer treatment were included in the study. Limb circumference was determined by means of tape measurement preoperatively and postoperatively and was used to calculate the circumferential difference. Ultrasonography was performed postoperatively to determine the number of lymph nodes within the transferred flap. Patients were divided into groups A through C depending on the number of transferred lymph nodes: 1 or 2 (n = 10), 3 or 4 (n = 14), and 5 to 8 (n = 11), respectively.

RESULTS

The mean age of the patients was 60.0 ± 9.2 years. All flaps survived. The mean improvement of circumferential difference for the whole cohort was 19.8 ± 9.2 percent. Groups B and C both had significantly higher improvements in the circumferential difference than group A (p = 0.04 and p = 0.02, respectively), but when compared to each other, the difference was nonsignificant. All groups had significant reductions in the incidence of cellulitis postoperatively.

CONCLUSIONS

Submental vascularized lymph node transfer for lower limb lymphedema reduced the incidence of cellulitis, regardless of the number of transferred lymph nodes. The transfer of three or more lymph nodes provided significantly better outcome regarding limb circumference reduction than the transfer of two or fewer lymph nodes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Sentinel lymphatic mapping among women with early-stage cervical cancer: A systematic review

The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer.

Treatment of gynaecological cancer related lower limb lymphoedema with liposuction

OBJECTIVE

To evaluate outcomes in patients with gynaecological cancer related lymphoedema treated with liposuction.

METHODS

A prospective analysis of 21 patients who underwent liposuction followed by compression therapy for chronic unilateral lower limb lymphoedema with up to 8 years follow up was performed.

RESULTS

Duration of lymphoedema prior to liposuction ranged from 4 to 28 years (mean 15.2 years). The mean age at time of liposuction was 52 years (range 37-67). Estimated volume excess in the affected limb ranged from 1.6 to 12 l (mean 4.7 l). The mean percentage reduction was 92.6% at 6 months (range 59.4-159.9) and 88.9% (range 60.9-127.5) at 1 year. Longer term follow-up of 6 patients at 5 years post-liposuction revealed a mean percentage reduction of 113.6% (range 83.5-155.5).

CONCLUSION

Our experience of liposuction combined with compression garments has demonstrated significant and sustainable reduction in limb volume in patients with lower limb lymphoedema secondary to gynaecological malignancy.

The supportive care needs of women experiencing gynaecological cancer: a Western Australian cross-sectional study

Background

Women diagnosed with gynaecological cancer experience supportive care needs that require care provision to reduce the impact on their lives. International evidence suggests supportive care needs of women with gynaecological cancer are not being met and provision of holistic care is a priority area for action. Knowledge on gynaecological cancer supportive care needs is limited, specifically comparison of needs and cancer gynaecological subtype.

Our aim was to identify supportive care needs of Western Australian women experiencing gynaecological cancer, their satisfaction with help and explore associations between participant’s demographic characteristics and identified needs.

Methods

A cross-sectional design incorporating a modified version of the Supportive Care Needs Survey – short form (SCNS-SF34) assessed 37 supportive care needs under five domains in conjunction with demographic data. Three hundred and forty three women with gynaecological cancer attending a tertiary public referral hospital completed the survey over 12 months. Statistical analysis was performed using the R environment for statistical computing. A linear regression model was fitted with factor scores for each domain and demographic characteristics as explanatory variables.

Results

Three hundred and three women (83%) identified at least one moderate or high level supportive care need. The five highest ranked needs were, ‘being informed about your test results as soon as feasible’ (54.8%), ‘fears about cancer spreading’ (53.7%), ‘being treated like a person not just another case’ (51.9%), ‘being informed about cancer which is under control or diminishing (that is, remission)’ (50.7%), and ‘being adequately informed about the benefits and side-effects of treatments before you choose to have them’ (49.9%). Eight of the top ten needs were from the ‘health system and information’ domain. Associations between supportive care items and demographic variables revealed ‘cancer type’, and ‘time since completion of treatment’ had no impact on level of perceived need for any domain.

Conclusions

Western Australian women with gynaecological cancer identified a high level of supportive care needs. The implementation of a supportive care screening tool is recommended to ensure needs are identified and care is patient-centred. Early identification and management of needs may help to reduce the burden on health system resources for managing ongoing needs.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4812-9) contains supplementary material, which is available to authorized users.

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

Lymphedema occurs commonly in cancer survivors. It is crucial to properly assess cancer patients in order to distinguish lymphedema from general edema and to initiate evidence based treatment.

PURPOSE

To provide evidence based recommendations for screening, evaluating, and treating lymphedema and to establish the role of the nurse in the care of patients with lymphedema.

METHODOLOGY

Comprehensive overview with narrative literature review of evidence based lymphedema diagnosis and treatment.

FINDINGS

Cancer-related edema represents numerous complex conditions. A variety of interventions are needed to address prevention, early detection, patient education, and effective treatment.

CONCLUSION

Lymphedema treatment is complex and multimodal, and is provided by an interdisciplinary team of properly trained professionals. Nurses play a major role in evaluating, treating and educating patients on the signs and symptoms of cancer-related edema and patient self-management.

CLINICAL IMPLICATIONS

Evidence-based assessment and treatment should be initiated early to improve outcomes and quality of life in patients with cancer-related lymphedema.

Mesoappendix as potential donor site for vascularized lymph node transfer: anatomic study

BACKGROUND

The standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a "spare part," may be an ideal autologous lymph node transfer donor site.

METHODS

In this Institutional Review Board-approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length.

RESULTS

A single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively.

CONCLUSIONS

The mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.

Assessing Patient-reported Quality of Life Outcomes in Vulva Cancer Patients: A Systematic Literature Review

Objectives

Vulva cancer (VC) treatment carries a high risk of severe late effects that may have a negative impact on quality of life (QoL). Patient-reported outcome measures (PROMs) are increasingly used when evaluating disease- and treatment-specific effects. However, the adequacy of measures used to assess sequelae and QoL in VC remains unclear. The aims of the present study were to evaluate disease- and treatment-related effects as measured by PROMs in VC patients and to identify available VC-specific PROMs.

Methods/Materials

A systematic literature search from 1990 to 2016 was performed. The inclusion criterion was report of disease- and treatment-related effects in VC patients using PROMs in the assessment. Methodological and reporting quality was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review was performed as part of phase 1 of the development of a European Organisation for Research and Treatment of Cancer QoL questionnaire for VC patients.

Results

The search revealed 2299 relevant hits, with 11 articles extracted including a total of 535 women with VC; no randomized controlled trials were identified. The selected studies exhibited great heterogeneity in terms of PROMs use. Twenty-one different instruments assessed QoL. Most of the questionnaires were generic. Different issues (sexuality, lymphedema, body image, urinary and bowel function, vulva-specific symptoms) were reported as potentially important, but the results were not systematically collected. Only one VC-specific questionnaire was identified but did not allow for assessment and reporting on a scale level.

Conclusions

Vulva cancer treatment is associated with considerable morbidity deteriorating QoL. To date, there is no validated PROM available that provides adequate coverage of VC-related issues. The study confirms the need for a VC-specific QoL instrument with sensitive scales that allows for broad cross-cultural application for use in clinical trials.

Use of lymphoscintigraphy to differentiate primary versus secondary lower extremity lymphedema after surgical lymphadenectomy: a retrospective analysis

Background

When managing patients with cancer, lymphedema of the lower limbs (LLL) is commonly reported as secondary to the surgical excision and/or irradiation of lymph nodes (LNs). In the framework of lymphoscintigraphic imaging performed to evaluate secondary LLL, some lympho-nodal presentations have been observed that could not be explained by the applied treatments, suggesting that these LLL might be primary. Therefore, all our lymphoscintigraphic examinations that were performed in patients for LLL after surgery for gynecological or urological cancer were retrospectively analyzed in order to evaluate the frequency in which these LLL might not be secondary (either completely or partially) but primary in origin.

Methods

Lymphoscintigraphies performed in 33 patients who underwent LN dissection (limited to the intra-abdominal LN) with or without radiotherapy for histologically confirmed ovarian cancer (n = 6), uterine cancer (n = 14 with cervical cancer and n = 7 with endometrial cancer), or prostate cancer (n = 6) were compared to lymphoscintigraphies obtained in primary LLL.

Results

In 12 (33% of the) patients (3 men plus 9 women, 4 with cervical cancer and 5 with endometrial cancer), scintigraphy of the lower limbs revealed lympho-nodal presentation that did not match with the expected consequences of the surgical and/or radiological treatments and were either suggestive or typical of primary lymphedema.

Conclusions

This retrospective analysis of a limited but well-defined series of patients suggests that the appearance of LLL might not be related to cancer treatment(s) but that these LLL may represent the development of a primary lymphatic disease latent prior to the therapeutic interventions.

Individualized pelvic lymphadenectomy should follow neoadjuvant concurrent chemoradiotherapy for locally advanced cervical cancer

To study the outcomes following concurrent chemoradiotherapy (CCRT) and subsequent radical surgery for locally advanced cervical cancer (LACC), analyze the relationship between imaging-diagnosed and postoperative-diagnosed lymph node (LN) involvement, and identify patients who would benefit from individualized pelvic lymphadenectomy.We retrospectively reviewed records of 410 patients who underwent CCRT followed by radical surgery for International Federation of Gynecology and Obstetrics Stage Ib2-IIIb disease. Correlations of LN size on imaging before CCRT with pathological responses after CCRT, overall survival (OS), distant metastasis-free survival (DMFS), and complications were analyzed.During a median follow-up of 51.3 months, the respective 5-year OS and DMFS were 86.7% and 88.6%, respectively. Pathological primary tumor type, LN size on imaging before CCRT, and pathologic response after CCRT were independent prognostic factors for OS. Patients with a LN ≥0.8 cm had a significantly higher residual carcinoma rate versus those with LN <0.8 cm (33% vs 22.6%, P = .032). Postoperative pathological positive LN frequencies differed significantly by LN size on imaging (LN <0.8 cm vs LN ≥0.8 cm, 3% vs 19.3%, P < .0001). Grade 1-3 lower extremity edema occurred in 23.9% of cases; no grade 3-4 gastrointestinal and genitourinary toxicities were observed.CCRT followed by radical surgery for LACC yielded encouraging outcomes without unacceptable complications. Additionally, patients with a LN <0.8 cm on imaging before CCRT had a very low risk of postoperative pathological positive LN identification. Individualized pelvic lymphadenectomy (e.g., omitting or limiting the extent of LN dissection) might be an alternative option for some patients with a low risk of LN metastasis.

Distribution and Determinants of Unmet Need for Supportive Care Among Women with Breast Cancer in China

Background

The aim of this study was to determine the need for supportive care among women suffering from breast cancer in China and to identify its potential determinants to inform the development of effective and efficient healthcare services across different settings.

Material/Methods

In a tertiary-care hospital in Weifang, China, between July 2015 and January 2016, all women attending the Breast Cancer Clinic for regular physical examinations after treatment for breast cancer were consecutively recruited. The 34-item Supportive Care Needs Survey tool (Chinese version) (SCNS-SF34-C) was used to assess the unmet needs among participants.

Results

Among 264 recruited patients, based on at least single-item endorsement, 60.2% had moderate to high level of need for supportive care, while only 13.3% expressed no need. Lack of information regarding health systems was the most common domain with moderate to high unmet needs, more so among rural patients (8 vs. 5 out of 10). In each information-related domain, huge unmet need was observed among all patients irrespective of urban or rural residence. Both overall and individual information-related domain-specific unmet needs were significantly higher among rural patients as opposed to their urban counterparts. Multiple regression analyses revealed a significant rural-urban variation of unmet needs. Moreover, education and post-diagnosis time duration were negatively associated with unmet needs while stage of cancer was positively associated with these unmet needs.

Conclusions

There is a huge burden of unmet needs for information on the healthcare system among breast cancer survivors in China. Rural residence, less education, advanced stage of cancer, and shorter duration since diagnosis were the identified determinants requiring targeted intervention.

Lymphedema in ovarian cancer survivors: Assessing diagnostic methods and the effects of physical activity

BACKGROUND

Lymphedema is a poorly understood side effect of gynecologic cancer treatment. This study was designed to determine the prevalence of lower limb lymphedema (LLL) in a sample of ovarian cancer survivors via 3 different diagnostic methods and to assess the effect of a randomized exercise intervention.

METHODS

Physically inactive ovarian cancer survivors (n = 95) were enrolled in a 6-month randomized trial of exercise (primarily brisk walking) versus attention control. LLL was measured at baseline and 6-month visits via a self-report questionnaire, optoelectronic perometry, and an evaluation by a certified lymphedema specialist.

RESULTS

LLL prevalence ranged from 21% to 38% according to the diagnostic method, and there was substantial agreement between the self-report questionnaire and the lymphedema specialist evaluation (κ = 0.61). There was no agreement between the evaluation with optoelectronic perometry and the specialist evaluation. With LLL defined by any method, the baseline prevalence was 38% in both groups. At 6 months, both groups experienced a decreased LLL prevalence: 28% in the exercise group and 35% in the control group. There was no difference in the change in lymphedema prevalence between the 2 groups (P = .64). Body mass index was a significant predictor of LLL.

CONCLUSIONS

With a potential prevalence of LLL as high as 40%, further evaluation of diagnostic methods is required to better characterize this side effect of ovarian cancer treatment. No adverse effect of exercise on LLL was found. Further research is strongly needed to evaluate predictors of LLL and the effects of exercise on LLL in order to develop effective physical activity recommendations for women with ovarian cancer. Cancer 2018;124:1929-37. © 2018 American Cancer Society.

The Combination of Preoperative Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Sentinel Lymph Node Mapping in the Surgical Management of Endometrioid Endometrial Cancer

OBJECTIVE

The goal of this study was to evaluate the combination of sentinel lymph node (SLN) mapping and F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan in detection of lymph node involvement in patients with endometrioid endometrial cancer (EEC).

METHODS/MATERIALS

Ninety-five patients with EEC who had preoperative PET/CT imaging and underwent SLN mapping were retrospectively analyzed. Methylene blue dye was used and injected to the cervix at 3- and 9-o'clock positions (a total of 4 mL). Pelvic lymphadenectomy was performed on all of the patients after SLN mapping. If the SLN was negative in the initial hematoxylin and eosin staining, an ultrastaging study was performed for the SLNs.

RESULTS

Sentinel lymph nodes were detected in 77 (81.1%) of 95 patients, with a mean of 2.95 SLNs. There was only 1 case (1.4%) with a positive SLN in the intraoperative frozen section examination in those patients with negative PET/CT findings and in whom SLNs were detected (n = 70). Among the remaining 69 patients with negative preoperative PET/CT findings and negative frozen section results for the SLNs, there were 2 patients with SLN involvement in the final ultrastaging pathology. In the patient-based analyses, the sensitivity, specificity, and positive and negative predictive values of the PET/CT and SLN frozen section were 33%, 100%, 100%, and 97.1%, respectively.

CONCLUSIONS

As no metastases in the nonsentinel pelvic lymph nodes were found in patients with EEC who had both negative PET/CT findings and frozen section results of the SLNs in both hemipelvises, we suggest using both methods to reduce the incidence of unnecessary systematic lymphadenectomy.

Incidence and Risk Factors of Lower Extremity Lymphedema After Gynecologic Surgery in Ovarian Cancer

OBJECTIVE

There is no standard method to establish an early diagnosis of lower extremity lymphedema (LEL). Lower extremity lymphedema can be diagnosed by physical examination and laboratory tests when patients complain of typical clinical symptoms. The objective of this study was to investigate the incidence and risk factors of LEL in patients with ovarian cancer.

METHODS

The medical records were reviewed retrospectively in patients with ovarian cancer treated at Seoul St. Mary's Hospital from January 2000 to July 2014.

RESULTS

A total of 413 patients with epithelial ovarian cancer were analyzed. Forty-six patients (11.1%) developed LEL, and 67.4% of these patients had LEL within 1 year after surgery. The mean number of resected lymph nodes (LNs) was larger in patients with LEL (43.1 ± 16.7; range, 12-80) than in those without (32.3 ± 19.8; range, 0-99) (P < 0.0001). The number of resected LNs was significantly associated with the occurrence of LEL (odds ratio, 1.025; 95% confidence interval, 1.005-1.045; P < 0.05).

CONCLUSION

A significant proportion of patients with ovarian cancer could develop LEL after surgery. This study suggests that the occurrence of LEL is associated with the number of resected LNs.

Lymphedema: Pathophysiology and clinical manifestations

Lymphedema is a localized form of tissue swelling resulting from excessive retention of lymphatic fluid in the interstitial compartment and caused by impaired lymphatic drainage. Lymphedema is classified as primary or secondary. Primary lymphedema is caused by developmental lymphatic vascular anomalies. Secondary lymphedema is acquired and arises as a result of an underlying systemic disease, trauma, or surgery. We performed PubMed and Google Scholar searches of the English-language literature (1966-2017) using the terms lymphedema, cancer-related lymphedema, and lymphatic complications. Relevant publications were manually reviewed for additional resources. This progressive chronic disease has serious implications on patients' quality of life. It is often misdiagnosed because it mimics other conditions of extremity swelling. There is no definitive cure for lymphedema. However, with proper diagnosis and management, its progression and potential complications may be limited.

Mechanotransduction in Blood and Lymphatic Vascular Development and Disease

The blood and lymphatic vasculatures are hierarchical networks of vessels, which constantly transport fluids and, therefore, are exposed to a variety of mechanical forces. Considering the role of mechanotransduction is key for fully understanding how these vascular systems develop, function, and how vascular pathologies evolve. During embryonic development, for example, initiation of blood flow is essential for early vascular remodeling, and increased interstitial fluid pressure as well as initiation of lymph flow is needed for proper development and maturation of the lymphatic vasculature. In this review, we introduce specific mechanical forces that affect both the blood and lymphatic vasculatures, including longitudinal and circumferential stretch, as well as shear stress. In addition, we provide an overview of the role of mechanotransduction during atherosclerosis and secondary lymphedema, which both trigger tissue fibrosis.

The Influence of Adverse Effects on Quality of Life of Survivors of Gynecologic Cancer

Objective

The objective of this observational study was to investigate correlations between adverse effects (lower-extremity lymphedema [LEL], dysuria, and severe gastrointestinal symptoms) and quality of life (QOL) (physical well-being [PWB], social well-being, emotional well-being [EWB], and functional well-being) before treatment, at least 6 weeks after treatment (posttreatment1), and 3 or 6 months after treatment (posttreatment2) of patients with gynecologic cancer (GC).

Methods

From August 2012 to October 2016, questionnaire responses and clinical data of 75 patients with GC were collected and assessed by treatment received. The χ2 test was used to determine the significance of correlations.

Results

Participants with LEL had significantly poorer QOL than did those without it in the domains of PWB at posttreatment1 (P = 0.026) and EWB at posttreatment2 (P = 0.020). Moreover, patients with 2 adverse effects (LEL plus dysuria or severe gastrointestinal symptoms) had significantly poorer QOL than did those with no or single adverse effect in the domains of PWB at posttreatment1 and posttreatment2 (posttreatment1: P = 0.049, P = 0.001; posttreatment2: P = 0.002, P = 0.028) and poorer QOL compared with those with no adverse effect in the domain of EWB at posttreatment1 (P = 0.017).

Conclusions

Poorer QOL in emotional and physical domains is associated with adverse effects of treatment in patients with GC. It is important to consider the effects of radical therapy not only on survival but also on the QOL of survivors.

[Not Available]

Zusammenfassung. Das Lymphödem ist eine häufige, chronisch fortschreitende und potenziell invalidisierende Erkrankung. In den entwickelten Ländern ist das Extremitätenlymphödem am häufigsten iatrogen nach Krebstherapien erworben. Meist gehören die radikale Lymphadenektomie sowie die Radiotherapie als essenzielle Bestandteile zum Therapiekonzept bei Krebserkrankungen. Diese sind stark assoziiert mit dem Extremitätenlymphödem. Resezierende Verfahren sollten nur im Endstadium der Erkrankung evaluiert werden, wobei die Liposuktion als Ausnahme und weniger invasives resezierendes Verfahren zu einer effektiven Gewebereduktion führen kann. Lymphovenöse Anastomosen und der mikrovaskuläre Lymphknotentransfer haben das experimentelle Stadium verlassen und stellen für ein korrekt auserwähltes Patientenkollektiv echte therapeutische Optionen dar, um die Hautqualität zu verbessern und das Fortschreiten der Erkrankung aufzuhalten. Die Kosten dafür werden zurzeit nur teilweise auf Antrag von den Krankenkassen übernommen. Für Betroffene eröffnen sich mit den mikrochirurgischen Methoden neue Aussichten auf ein besseres Leben. Um das geeignete Patientenkollektiv noch genauer zu definieren und die guten Resultate zu bestätigen, sind prospektive Studien mit höheren Fallzahlen und Langzeitstudien notwendig.

Incidence of lower limb lymphedema after vulvar cancer: A systematic review and meta-analysis

BACKGROUND

Lower limb lymphedema (LLL) is an important concern for patients with vulvar cancer. Studies of the incidence of vulvar cancer-related lymphedema and its risk factors have substantially increased in the new millennium.

OBJECTIVES

This article is a meta-analysis that aimed to systematically evaluate the incidence of LLL and its risk factors related to vulvar cancer.

DATA SOURCES

Data were collected from eligible studies from PubMed, ScienceDirect, and Web of Science.

SYNTHESIS METHODS

Random effects models were used to calculate a pooled overall estimate of LLL incidence, and subgroup analyses were performed to assess the effects of different study designs, countries of study origin, diagnostic methods, and extent of lymph node surgery. Risk factors for lymphedema were also evaluated.

RESULTS

Twenty-seven studies met the inclusion criteria for the assessment of lymphedema incidence with a pooled estimate of 28.8% [95% confidence interval (CI) 22.1-35.5]. The estimate was 16.7% (95% CI 9.7-23.7) when data were restricted to prospective cohort studies (7 studies). The incidence of LLL was increased by approximately 5-fold in women who underwent inguinofemoral lymph node dissection compared to those who underwent sentinel lymph node biopsy. The reported risk factors included wound infection, inguinofemoral lymphadenectomy, older age, body mass index (BMI), and radiation therapy.

CONCLUSIONS

Approximately 3 in 10 women who survive vulvar cancer will develop lower limb lymphedema. More studies are needed to improve the understanding of its risk factors and to develop prevention and management strategies to alleviate this distressing disorder.