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Cucinella G, Di Donna MC, Casarin J, Schivardi G, Multinu F, Borsellino L, Buono N, Zaccaria G, Abbate A, Laganà AS, Chiantera V. Lower limb lymphedema after surgical staging for endometrial cancer: Current insights and future directions. Taiwan J Obstet Gynecol 2024; 63:500-505. [PMID: 39004476 DOI: 10.1016/j.tjog.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 07/16/2024] Open
Abstract
Lower extremity lymphedema (LEL) is a common complication following surgical staging of endometrial cancer. LEL is a chronic condition associated with significant impact on patient morbidity and quality of life (QoL). This review aimed to report the current evidence in the literature on secondary LEL after surgical staging for endometrial cancer, focusing on the incidence based on different approaches to lymph node staging, diagnosis, risk factors, and the impact on QoL. Due to the absence of a standardized agreement regarding the methodology for evaluating LEL, the documented frequency of occurrence fluctuates across different studies, ranging from 0% to 50%. Systematic pelvic lymphadenectomy appears to be the primary determinant associated with the emergence of LEL, whereas the implementation of sentinel lymph node biopsy has notably diminished the occurrence of this lymphatic complication after endometrial cancer staging. LEL is strongly associated with decreased QoL, lower limb function, and negative body image, and has a detrimental impact on cancer-related distress reported by survivors. Standardization of lymphedema assessment is needed, along with cross-cultural adaptation of subjective outcome measures for self-reported LEL. The advent of sentinel lymph node mapping represents the ideal approach for accurate nodal assessment with less short- and long-term morbidity. Further research is needed to definitively assess the prevalence and risk factors of LEL and to identify strategies to improve limb function and QoL in cancer survivors with this chronic condition.
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Affiliation(s)
- Giuseppe Cucinella
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133 Palermo, Italy; Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy.
| | - Mariano Catello Di Donna
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133 Palermo, Italy; Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Gabriella Schivardi
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Francesco Multinu
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Letizia Borsellino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Natalina Buono
- Ospedale San Leonardo, Castellammare di Stabia, ASL NA3 SUD, Naples, Italy
| | - Giulia Zaccaria
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Antonino Abbate
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", 90127 Palermo, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy; Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127 Palermo, Italy
| | - Vito Chiantera
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
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Bjørnholt SM, Mogensen O, Bouchelouche K, Sponholtz SE, Parner ET, Hildebrandt MG, Loft A, Neumann G, Bjørn SF, Dahl K, Markauskas A, Frøding LP, Jensen PT. Identifying safe diagnostic algorithms for sentinel lymph node mapping in high-risk endometrial cancer: The SENTIREC-endo study. Gynecol Oncol 2024; 182:179-187. [PMID: 38335900 DOI: 10.1016/j.ygyno.2024.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION It is unclear if sentinel node (SLN) mapping can replace pelvic- (PLD) and paraaortic lymphadenectomy (PALD) for high-risk endometrial cancer (EC). A diagnostically safe surgical algorithm, taking failed mapping cases into account, is not defined. We aimed to investigate the diagnostic accuracy of SLN mapping algorithms in women with exclusively high-risk EC. METHODS We undertook a prospective national diagnostic cohort study of SLN mapping in women with high-risk EC from March 2017 to January 2023. The power calculation was based on the negative predictive value (NPV). Women underwent SLN mapping, PLD and PALD besides removal of suspicious and any FDG/PET-positive lymph nodes. Accuracy analyses were performed for five algorithms. RESULTS 170/216 included women underwent SLN mapping, PLD and PALD and were included in accuracy analyses. 42/170 (24.7%) had nodal metastasis. The algorithm SLN and PLD in case of failed mapping, demonstrated a sensitivity of 86% (95% CI 74-100) and an NPV of 96% (95% CI 91-100). The sensitivity increased to 93% (95% CI 83-100) and the NPV to 98% (95% CI 94-100) if PLD was combined with removal of any PET-positive lymph nodes. Equivalent results were obtained if PLD and PALD were performed in non-mapping cases; sensitivity 93% (95% CI 83-100) and NPV 98% (95% CI 95-100). CONCLUSION SLN-mapping is a safe staging procedure in women with high-risk EC if strictly adhering to a surgical algorithm including removal of any PET-positive lymph nodes independent of location and PLD or PLD and PALD in case of failed mapping.
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Affiliation(s)
- Sarah Marie Bjørnholt
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark.
| | - Ole Mogensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Clinical Medicine - Nuclear Medicine and PET, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Sara Elizabeth Sponholtz
- Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
| | - Erik Thorlund Parner
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark
| | - Malene Grubbe Hildebrandt
- Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark; Department of Nuclear Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Annika Loft
- Department of Clinical Physiology & Nuclear Medicine, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Gudrun Neumann
- Department of Gynaecology and Obstetrics, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Signe Frahm Bjørn
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Katja Dahl
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Algirdas Markauskas
- Department of Gynaecology and Obstetrics, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ligita Paskeviciute Frøding
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Pernille Tine Jensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark; Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
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Koelmeyer LA, Gaitatzis K, Thompson B, Ward LC. Effects of Body Positioning When Assessing Lymphedema of the Lower Limb Using Bioimpedance Spectroscopy. Lymphat Res Biol 2024; 22:43-54. [PMID: 37851985 DOI: 10.1089/lrb.2022.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Background: Bioimpedance spectroscopy (BIS) measurements are conventionally performed in supine position with a lead device attached to gel-backed electrodes, and more recently, with a stand-on device that uses fixed stainless-steel electrodes under the hands and feet. The aim of this study was to assess and compare BIS measurements made in supine, sitting, and standing positions using lead and stand-on impedance devices in participants with and without unilateral leg lymphedema. Materials and Methods: Participants with self-ascribed unilateral leg lymphedema (n = 24) and healthy controls (n = 71) were recruited using a cross-sectional study design. Triplicate BIS measurements were taken for each device in each position. Results: Impedance measurements with either device were reliable with coefficient of variation of 0.6% or lower. The magnitude of mean differences in absolute impedance values between devices were between 1% and 6% dependent on condition. L-Dex scores between the two devices were highly correlated (r = 0.82) and ∼70% of participants in the lymphedema group were classified as having lymphedema using the recommended cut-off with either device. There was no significant interleg difference of controls using the lead device; however, small, but significant differences (p = 0.0001) were found when using the stand-on device. Conclusion: The findings demonstrate that reliable impedance measurements of the legs can be made with either device in lying, sitting, or standing positions. However, data between the devices were not directly interchangeable. Although the risk of misidentification was small, reference ranges appropriate to the device and measurement position should be used when converting data to L-Dex scores.
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Affiliation(s)
- Louise A Koelmeyer
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Katrina Gaitatzis
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Belinda Thompson
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Leigh C Ward
- Australian Lymphoedema Education, Research and Treatment Centre, Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, Brisbane, Australia
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Yoo MY, Woo KJ, Kang SY, Moon BS, Kim BS, Yoon HJ. Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema. PLoS One 2024; 19:e0296466. [PMID: 38165945 PMCID: PMC10760657 DOI: 10.1371/journal.pone.0296466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/13/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA. METHODS A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA. RESULTS Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes. CONCLUSION The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.
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Affiliation(s)
- Min Young Yoo
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
- Department of Nuclear Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Kyong-Je Woo
- Department of Plastic Surgery, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Seo Young Kang
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Byung Seok Moon
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Bom Sahn Kim
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hai-Jeon Yoon
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
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Bjerre Trent PK, Nordskar NJ, Wangen KR, Engeskaug MI, Opheim MLØ, Aune G, Staff AC, Thorsen L, Falk RS, Eriksson AGZ. Self-reported lower extremity lymphedema and quality of life after surgical staging of endometrial carcinoma: A population based cross-sectional study. Gynecol Oncol 2023; 175:72-80. [PMID: 37327542 DOI: 10.1016/j.ygyno.2023.05.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Sentinel lymph node biopsy (SLN) has replaced lymphadenectomy in staging of endometrial carcinoma. The aims of the study were to explore the prevalence of self-reported lymphedema (LEL), identify factors associated with LEL, compare quality of life (QoL) scores using thresholds of clinical importance, and assess correlation between different questionnaires. METHODS Women who underwent staging for endometrial carcinoma from 2006 to 2021 were invited to complete the Lower Extremity Lymphedema Screening Questionnaire (LELSQ), EORTC QLQ-C30, QLQ-EN24 and EQ-5D-5L. RESULTS Of 2156 invited survivors, 61% participated in the study, whereof 1127 were evaluable by LELSQ. The LEL prevalence was 51%, 36% and 40% after lymphadenectomy, SLN and hysterectomy, respectively (p < 0.001). Higher BMI, undergoing lymphadenectomy and receiving adjuvant chemotherapy were associated with LEL; odds ratios 1.07 (95% CI 1.05-1.09), 1.42 (95% CI 1.03-1.97) and 1.43 (95% CI 1.08-1.89) respectively. QoL was lower for women with LEL compared to those without. In women with musculoskeletal complaints the prevalence of LEL was 59%, 50% and 53% after lymphadenectomy, SLN and hysterectomy (p = 0.115), respectively, compared to 39%, 17% and 18% (p < 0.001) in women without musculoskeletal complaints. Spearman's correlation was moderate to strong between the questionnaires. CONCLUSION SLN implementation is not associated with increased LEL prevalence compared to hysterectomy alone, but is associated with a significantly lower prevalence compared to lymphadenectomy. LEL is associated with lower QoL. Our study demonstrates moderate to strong correlation between self-reported LEL and QoL scores. Available questionnaires may not distinguish between symptoms caused by LEL and musculoskeletal disease.
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Affiliation(s)
- Pernille K Bjerre Trent
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nina Jebens Nordskar
- Section of Gynecologic Oncology, Dept. of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Knut R Wangen
- Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ms Ida Engeskaug
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Ms Linn Ø Opheim
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Guro Aune
- Section of Gynecologic Oncology, Dept. of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Cathrine Staff
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Lene Thorsen
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway; Department of Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Ragnhild S Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Ane Gerda Z Eriksson
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway.
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Terada S, Tanaka T, Murakami H, Tsuchihashi H, Toji A, Daimon A, Miyamoto S, Nishie R, Ueda S, Hashida S, Morita N, Maruoka H, Konishi H, Kogata Y, Taniguchi K, Komura K, Ohmichi M. Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer. J Clin Med 2023; 12:4540. [PMID: 37445574 DOI: 10.3390/jcm12134540] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Sentinel node biopsy (SNB) is performed worldwide in patients with endometrial cancer (EC). The aim of this study was to evaluate and compare the occurrence rate of lymphatic complications between SNB and pelvic lymphadenectomy (LND) for EC. The medical records of women who underwent SNB or pelvic LND for EC between September 2012 and April 2022 were assessed. A total of 388 patients were enrolled in the current study. Among them, 201 patients underwent SNB and 187 patients underwent pelvic LND. The occurrence rates of lower-extremity lymphedema (LEL) and pelvic lymphocele (PL) were compared between the patients who underwent SNB and those who underwent pelvic LND. The SNB group had a significantly lower occurrence rate of lower-extremity LEL than the pelvic LND group (2.0% vs. 21.3%, p < 0.01). There were no patients who had PL in the SNB group; however, 4 (2.1%) patients in the pelvic LND group had PL. The occurrence rates of lower-extremity LEL and PL were significantly lower in patients who underwent SNB than those who underwent pelvic LND. SNB for EC has a lower risk of lymphatic complications compared to systemic LND.
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Affiliation(s)
- Shinichi Terada
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Tomohito Tanaka
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hikaru Murakami
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiromitsu Tsuchihashi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Akihiko Toji
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Atsushi Daimon
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Shunsuke Miyamoto
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Ruri Nishie
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Shoko Ueda
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Sousuke Hashida
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Natsuko Morita
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiroshi Maruoka
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiromi Konishi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Yuhei Kogata
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Kohei Taniguchi
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Kazumasa Komura
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
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Wu EB, Lin YH, Yang JCS, Lai CW, Chin JC, Wu SC. Density Spectral Array Enables Precise Sedation Control for Supermicrosurgical Lymphaticovenous Anastomosis: A Retrospective Observational Cohort Study. Bioengineering (Basel) 2023; 10:bioengineering10040494. [PMID: 37106682 PMCID: PMC10135781 DOI: 10.3390/bioengineering10040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
Supermicrosurgical lymphaticovenous anastomosis (LVA) is a minimally invasive surgical technique that creates bypasses between lymphatic vessels and veins, thereby improving lymphatic drainage and reducing lymphedema. This retrospective single-center study included 137 patients who underwent non-intubated LVA in southern Taiwan. A total of 119 patients were enrolled and assigned to two study groups: the geriatric (age ≥ 75 years, n = 23) and non-geriatric groups (age < 75 years, n = 96). The primary outcome was to investigate and compare the arousal and maintenance of the propofol effect-site concentration (Ce) using an electroencephalographic density spectral array (EEG DSA) in both groups. The results showed that the geriatric group required less propofol (4.05 [3.73-4.77] mg/kg/h vs. 5.01 [4.34-5.92] mg/kg/h, p = 0.001) and alfentanil (4.67 [2.53-5.82] μg/kg/h vs. 6.68 [3.85-8.77] μg/kg/h, p = 0.047). The median arousal Ce of propofol among the geriatric group (0.6 [0.5-0.7] μg/mL) was significantly lower than that in patients aged ≤ 54 years (1.3 [1.2-1.4] μg/mL, p < 0.001), 55-64 years (0.9 [0.8-1.0] μg/mL, p < 0.001), and <75 years (0.9 [0.8-1.2] μg/mL, p < 0.001). In summary, the combined use of EEG DSA provides the objective and depth of adequate sedation for extensive non-intubated anesthesia in late-elderly patients who undergo LVA without perioperative complications.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Yu-Hsuan Lin
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Chiung-Wen Lai
- Department of Anesthesiology Jen-Ai Hospital, Taichung 412, Taiwan
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung 813, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
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Bjørnholt SM, Sponholtz SE, Mogensen O, Bouchelouche K, Parner ET, Neumann G, Jochumsen KM, Hamid BH, Davidsen MB, Bjørn SF, Dahl K, Jensen PT. The SENTIREC-endo study - Risks and benefits of a national adoption of sentinel node mapping in low and intermediate risk endometrial cancer. Gynecol Oncol 2023; 171:121-128. [PMID: 36893488 DOI: 10.1016/j.ygyno.2023.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The SENTIREC-endo study aims to investigate risks and benefits of a national protocolled adoption of sentinel lymph node (SLN) mapping in women with early-stage low-grade endometrial cancer (EC) with low- (LR) and intermediate-risk (IR) of lymph node metastases. METHODS We performed a national multicenter prospective study of SLN-mapping in women with LR and IR EC from March 2017-February 2022. Postoperative complications were classified according to Clavien-Dindo. Lymphedema was assessed as a change score and as incidence of swelling and heaviness evaluated by validated patient-reported outcome measures at baseline and three months postoperatively. RESULTS 627 women were included in the analyses; 458 with LR- and 169 with IR EC. The SLN detection rate was 94.3% (591/627). The overall incidence of lymph node metastases was 9.3% (58/627); 4.4% (20/458) in the LR- and 22.5% (38/169) in the IR group. Ultrastaging identified 62% (36/58) of metastases. The incidence of postoperative complications was 8% (50/627) but only 0.3% (2/627) experienced an intraoperative complication associated with the SLN procedure. The lymphedema change score was below the threshold for clinical importance 4.5/100 CI: (2.9-6.0), and the incidence of swelling and heaviness was low; 5.2% and 5.8%, respectively. CONCLUSION SLN mapping in women with LR and IR EC carries a very low risk of early lymphedema and peri- and postoperative complications. The national change in clinical practice contributed to a more correct treatment allocation for both risk groups and thus supports further international implementation of the SLN technique in early stage, low grade EC.
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Affiliation(s)
- Sarah Marie Bjørnholt
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark.
| | | | - Ole Mogensen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Kirsten Bouchelouche
- Department of Clinical Medicine - Nuclear Medicine and PET, Aarhus University Hospital, Denmark
| | | | - Gudrun Neumann
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark
| | | | | | | | - Signe Frahm Bjørn
- Department of Gynecology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Katja Dahl
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark
| | - Pernille Tine Jensen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark; Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
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9
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Koehler L, Penz LE, John F, Stenzel A, Jewett P, Teoh D, Blaes A, Rivard C, Vogel R. Functional and psychosocial quality of life in gynecologic Cancer survivors with and without lymphedema symptoms. Gynecol Oncol 2023; 170:254-258. [PMID: 36738483 PMCID: PMC10023405 DOI: 10.1016/j.ygyno.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The goal of this study was to compare function, quality of life, body image and distress levels between gynecologic cancer survivors with and without lymphedema symptoms as well as to determine how many individuals received rehabilitation treatment following treatment for gynecological malignancy. METHODS This prospective longitudinal cohort study sought to examine long-term physical and psychosocial outcomes among gynecologic cancer survivors. RESULTS Participants in the symptomatic group reported lower quality of life, lower function scores, and greater cancer-related, with greater rates of clinically significant levels of distress. These results remained largely consistent in multivariable models. CONCLUSIONS We found lower extremity lymphedema to be associated with lower quality of life, lower limb function, greater distress, and negative body image.
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Affiliation(s)
- Linda Koehler
- University of Minnesota, Department of Rehabilitation Medicine, Medical School, Divisions of Physical Therapy & Rehabilitation Science, MMC 388; 420 Delaware St. SE, Minneapolis, MN 55455, United States of America; Masonic Cancer Center, University of Minnesota, 425 E River Pkwy, Minneapolis, MN 55455, United States of America.
| | - Lauren Elyse Penz
- University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455, United States of America.
| | - Florence John
- Masonic Cancer Center, University of Minnesota, 425 E River Pkwy, Minneapolis, MN 55455, United States of America; University of Minnesota, Department of Rehabilitation Medicine, Medical School, Division of Physical Medicine & Rehabilitation, 500 Boynton Health Service Bridge, 410 Church Street SE, Minneapolis, MN 554552, United States of America.
| | - Ashley Stenzel
- University of Minnesota Medical Center, Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, Moos Tower, 12(th) Floor, 515 Delaware St SE, Minneapolis, MN 55455, United States of America
| | - Patricia Jewett
- University of Minnesota Medical Center, Department of Medicine, Division of Hematology, Oncology and Transplantation, 420 Delaware Street SE MMC 395, Minneapolis, MN 55455, United States of America.
| | - Deanna Teoh
- University of Minnesota Medical Center, Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, Moos Tower, 12(th) Floor, 515 Delaware St SE, Minneapolis, MN 55455, United States of America.
| | - Anne Blaes
- University of Minnesota Medical Center, Department of Medicine, Division of Hematology, Oncology and Transplantation, 420 Delaware Street SE MMC 395, Minneapolis, MN 55455, United States of America.
| | - Colleen Rivard
- University of Minnesota Medical Center, Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, Moos Tower, 12(th) Floor, 515 Delaware St SE, Minneapolis, MN 55455, United States of America.
| | - Rachel Vogel
- University of Minnesota Medical Center, Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, Moos Tower, 12(th) Floor, 515 Delaware St SE, Minneapolis, MN 55455, United States of America.
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10
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Burton JS, Sletten AC, Marsh E, Wood MD, Sacks JM. Adipose Tissue in Lymphedema: A Central Feature of Pathology and Target for Pharmacologic Therapy. Lymphat Res Biol 2023; 21:2-7. [PMID: 35594294 DOI: 10.1089/lrb.2022.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Lymphedema is a chronic condition of impaired lymphatic flow that results in limb swelling and debilitation. The pathophysiology of lymphedema is characterized by lymphatic stasis that triggers inflammation, fibrosis, and adipose tissue deposition in the extremities. Most often, this condition occurs in cancer survivors in the years after treatment with combinations of surgery, radiation, or chemotherapy, with the major risk factor being lymph node dissection. Interestingly, obesity and body mass index are independent risk factors for development of lymphedema, suggesting interactions between adipose and lymphatic tissue biology. Currently, treatment of lymphedema involves palliative approaches, including compression garments and physical therapy, and surgical approaches, including liposuction, lymphovenous bypass, and vascularized lymph node transfer. Emerging lymphedema therapies that focus on weight loss or reducing inflammation have been tested in recent clinical trials, yielding mixed results with no effect on limb volumes or changes in bioimpedance measurements. These studies highlight the need for novel therapeutic strategies that target the driving forces of lymphedema. In this light, animal models of lymphedema demonstrate a role of adipose tissue in the progression of lymphedema and suggest these processes may be targeted in the treatment of lymphedema. Herein, we review both conventional and experimental therapies for lymphedema as well as the defining characteristics of its pathophysiology. We place emphasis on the aberrant fibroadipose tissue accumulation in lymphedema and propose a new approach to experimental treatment at the level of adipocyte metabolism.
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Affiliation(s)
- Jackson S Burton
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arthur C Sletten
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan Marsh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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11
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Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer. Gynecol Oncol Rep 2022; 44:101080. [PMID: 36249905 PMCID: PMC9554829 DOI: 10.1016/j.gore.2022.101080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
Objective Sentinel lymph node (SLN) mapping is a highly accurate surgical technique for detecting metastases in endometrial cancer. The objective of this study was to identify clinical factors associated with failed mapping. Methods All patients with endometrial cancer undergoing minimally-invasive staging and planned SLN biopsy from 1/1/2017 to 12/31/2020 at a single institution were identified retrospectively. Demographic, clinicopathologic and treatment data were obtained. Data were compared using descriptive statistics. Univariate and multivariable logistic regression were performed to identify predictors of failed mapping. Results 819 patients were identified with a mean age of 64.6 years (range 26-93) and mean BMI of 35.6 kg/m2 (range 18-68). Most (88.5 %, 725/819) had early-stage disease and endometrioid histology (82.3 %, 674/819). A majority (74.2 %, 608/819) had successful bilateral mapping, and 54 (6.6 %) had unsuccessful bilateral mapping. Increasing BMI was significantly associated with unsuccessful bilateral mapping: patients with BMI > 30 were more likely to have unsuccessful SLN mapping (p = 0.033). Among patients with known lymph node status (799/819), patients with macrometastases and micrometastases were more likely to have failed bilateral mapping compared to those with negative SLNs or isolated tumor cells (p = 0.013). On multivariable analysis, higher BMI and histology were associated with failed bilateral mapping (OR = 1.023, 95 % CI (1.005, 1.041) and OR = 1.678, 95 % CI (1.177, 2.394), respectively). Conclusion SLN mapping has a high success in patients undergoing minimally-invasive surgical staging for endometrial cancer. Increasing BMI, high risk histology, and lymph node metastases are risk factors for failed mapping.
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12
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Lymphaticovenous Anastomosis for Treating Secondary Lower Limb Lymphedema in Older Patients-A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11113089. [PMID: 35683479 PMCID: PMC9181524 DOI: 10.3390/jcm11113089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/19/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022] Open
Abstract
Despite an increased incidence of secondary lower limb lymphedema (LLL) and severity of comorbidities with age, the impact of age on the effectiveness of lymphaticovenous anastomosis (LVA) in the older patients remains unclear. Methods: This retrospective cohort study enrolled older patients (age > 65 years) with secondary unilateral LLL. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings including lymphatic vessel (LV) diameter, LV functionality (indocyanine green-enhanced and Flow positivity), and lymphosclerosis classification were recorded. Magnetic resonance volumetry was used for measuring preoperative and postoperative volume changes at 6 months and one year after LVA as primary and secondary endpoints. Results: Thirty-two patients (29 females/3 males) with a median age of 71.0 years [range, 68.0 to 76.3] were enrolled. The median duration of lymphedema was 6.4 [1.0 to 11.7] years. The median LV diameter was 0.7 [0.5 to 0.8] mm. The percentage of ICG-enhanced and Flow-positive LVs were 89.5% and 85.8%, respectively. The total percentage of suitable LVs (s0 and s1) for LVA based on lymphosclerosis classification was 75.9%. There were significant six-month and one-year post-LVA percentage volume reductions compared to pre-LVA volume (both p < 0.001). A significant reduction in cellulitis incidence was also noted after LVA (p < 0.001). No surgical or postoperative complications were found. Conclusion: Relief of secondary LLL was achievable through LVA in older patients who still possessed favorable LV characteristics, including larger LV diameters as well as a high proportion of functional LVs with a low grade of lymphosclerosis.
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13
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Morrison J, Balega J, Buckley L, Clamp A, Crosbie E, Drew Y, Durrant L, Forrest J, Fotopoulou C, Gajjar K, Ganesan R, Gupta J, Hughes J, Miles T, Moss E, Nanthakumar M, Newton C, Ryan N, Walther A, Taylor A. British Gynaecological Cancer Society (BGCS) uterine cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2022; 270:50-89. [DOI: 10.1016/j.ejogrb.2021.11.423] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/19/2021] [Indexed: 12/24/2022]
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14
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Obermair A, Nicklin J, Gebski V, Hayes SC, Graves N, Mileshkin L, Lin MY, Beale P, Baxter E, Robledo K, Salomon C, Hanna GB, Janda M. A phase III randomized clinical trial comparing sentinel node biopsy with no retroperitoneal node dissection in apparent early-stage endometrial cancer - ENDO-3: ANZGOG trial 1911/2020. Int J Gynecol Cancer 2021; 31:1595-1601. [PMID: 34728527 DOI: 10.1136/ijgc-2021-003029] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Sentinel node biopsy is a surgical technique to explore lymph nodes for surgical staging of endometrial cancer, which has replaced full retroperitoneal lymph node dissection. However, the effectiveness of sentinel node biopsy, its value to patients, and potential harms compared with no-node dissection have never been shown in a randomized trial. PRIMARY OBJECTIVES Stage 1 will test recovery from surgery. Stage 2 will compare disease-free survival at 4.5 years between patients randomized to sentinel node biopsy versus no retroperitoneal node dissection. STUDY HYPOTHESIS The primary hypothesis for stage 1 is that treatment with sentinel node biopsy will not cause detriment to patient outcomes (lymphedema, morbidity, loss of quality of life) and will not increase treatment-related morbidity or health services costs compared with patients treated without a retroperitoneal node dissection at 12 months after surgery. The primary hypothesis for stage 2 is that disease-free survival at 4.5 years after surgery in patients without retroperitoneal node dissection is not inferior to those receiving sentinel node biopsy. TRIAL DESIGN This phase III, open-label, two-arm, multistage, randomized non-inferiority trial (ENDO-3) will determine the value of sentinel node biopsy for surgical management of endometrial cancer. Patients with endometrial cancer are randomized to receive: (1) laparoscopic/robotic hysterectomy, bilateral salpingo-oophorectomy with sentinel node biopsy or (2) laparoscopic/robotic hysterectomy, bilateral salpingo-oophorectomy without retroperitoneal node dissection. In stage 1, 444 patients will be enrolled to demonstrate feasibility and quality of life. If this is demonstrated, we will enroll another 316 patients in stage 2. MAJOR INCLUSION AND EXCLUSION CRITERIA Inclusion criteria include women aged 18 years or older with histologically confirmed endometrial cancer; clinical stage 1, who meet the criteria for laparoscopic or robotic total hysterectomy and bilateral salpingo-oophorectomy. Patients with uterine mesenchymal tumors are excluded. PRIMARY ENDPOINTS The endpoint for stage 1 is surgical recovery, with the proportion of patients returning to usual daily activities at 3 months post-surgery as measured with the EQ-5D. Stage 2 is disease-free survival at 4.5 years. SAMPLE SIZE 760 participants (both stages). ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS Stage 1 commenced in January 2021 and is planned to be completed in December 2024 when 444 participants have completed 12 months' follow-up. Stage 2 will enroll a further 316 participants for a total of 760 patients. TRIAL REGISTRATION NCT04073706.
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Affiliation(s)
- Andreas Obermair
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, Brisbane, Queensland, Australia .,Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jim Nicklin
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Val Gebski
- Biostatistics and Research Methodology, University of Sydney NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia
| | - Sandra C Hayes
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Linda Mileshkin
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ming Yin Lin
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Phillip Beale
- Australia New Zealand Gynaecological Oncology Group (ANZGOG), Sydney, New South Wales, Australia
| | - Eva Baxter
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Kristy Robledo
- Biostatistics and Research Methodology, University of Sydney NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia
| | - Carlos Salomon
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - George B Hanna
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Monika Janda
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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15
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Wedin M, Stalberg K, Marcickiewicz J, Ahlner E, Ottander U, Åkesson Å, Lindahl G, Wodlin NB, Kjølhede P. Risk factors for lymphedema and method of assessment in endometrial cancer: a prospective longitudinal multicenter study. Int J Gynecol Cancer 2021; 31:1416-1427. [PMID: 34610970 DOI: 10.1136/ijgc-2021-002890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of the study was to determine risk factors for lymphedema of the lower limbs, assessed by four methods, 1 year after surgery for endometrial cancer. METHODS A prospective longitudinal multicenter study was conducted in 14 Swedish hospitals. 235 women with endometrial cancer were included; 116 underwent surgery including lymphadenectomy, and 119 had surgery without lymphadenectomy. Lymphedema was assessed preoperatively and 1 year postoperatively objectively by systematic circumferential measurements of the legs, enabling volume estimation addressed as (1) crude volume and (2) body mass index-standardized volume, or (3) clinical grading, and (4) subjectively by patient-reported perception of leg swelling. In volume estimation, lymphedema was defined as a volume increase ≥10%. Risk factors were analyzed using forward stepwise logistic regression models and presented as adjusted odds ratio (aOR) and 95% confidence interval (95% CI). RESULTS Risk factors varied substantially, depending on the method of determining lymphedema. Lymphadenectomy was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 14.42, 95% CI 3.49 to 59.62), clinical grading (aOR 2.11, 95% CI 1.04 to 4.29), and patient-perceived swelling (aOR 2.51, 95% CI 1.33 to 4.73), but not when evaluated by crude volume. Adjuvant radiotherapy was only a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 15.02, 95% CI 2.34 to 96.57). Aging was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 1.07, 95% CI 1.00 to 1.15) and patient-perceived swelling (aOR 1.06, 95% CI 1.02 to 1.10), but not when assessed by crude volume or clinical grading. Increase in body mass index was a risk factor for lymphedema when estimated by crude volume (aOR 1.92, 95% CI 1.36 to 2.71) and patient-perceived swelling (aOR 1.36, 95% CI 1.11 to 1.66), but not by body mass index-standardized volume or clinical grading. The extent of lymphadenectomy was strongly predictive for the development of lymphedema when assessed by body mass index-standardized volume and patient-perceived swelling, but not by crude volume or clinical grading. CONCLUSION Apparent risk factors for lymphedema differed considerably depending on the method used to determine lymphedema. This highlights the need for a 'gold standard' method when addressing lymphedema for determining risk factors.
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Affiliation(s)
- Madelene Wedin
- biomedical and clinical science, Linköping University, Linkoping, Sweden
| | - Karin Stalberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Eva Ahlner
- Department of Oncology, and Department of Biomedical and Clinical Science, Linköping University Hospital, Linkoping, Sweden
| | - Ulrika Ottander
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Åsa Åkesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Institute of clinical sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Gabriel Lindahl
- Department of Oncology, and Department of Biomedical and Clinical Scienses, Linköping University, Linköping, Sweden
| | - Ninnie Borendal Wodlin
- Department of Obstetrics and Gynecology in Linköping and Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - Preben Kjølhede
- Department of Obstetrics and Gynecology in Linköping and Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
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Eriksson AGZ, Davidson B, Bjerre Trent P, Eyjólfsdóttir B, Dahl GF, Wang Y, Staff AC. Update on Sentinel Lymph Node Biopsy in Surgical Staging of Endometrial Carcinoma. J Clin Med 2021; 10:jcm10143094. [PMID: 34300260 PMCID: PMC8306601 DOI: 10.3390/jcm10143094] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Sentinel lymph node (SLN) biopsy has emerged as an alternative staging approach in women with assumed early-stage endometrial carcinoma. Through image-guided surgery and pathologic ultrastaging, the SLN approach is introducing “precision medicine” to the surgical management of gynecologic cancers, providing a comprehensive evaluation of high-yield lymph nodes. This approach improves the surgeons’ ability to detect small-volume metastatic disease while reducing intraoperative and postoperative morbidity associated with lymphadenectomy. Although the majority of clinicians in Europe and the USA have recognized the value of SLN biopsy in endometrial carcinoma and introduced this as part of clinical practice, there is ongoing debate regarding its role in very low-risk patients as well as in patients at high risk of nodal metastasis. The significance of low-volume metastasis is not fully understood, and there is no consensus in regard to how the presence of isolated tumor cells should guide adjuvant therapy. Standardized protocols for histopathologic evaluation of SLNs are lacking. In this review article we aim to provide a framework for the introduction of SLN biopsy in endometrial cancer, give an updated overview of the existing literature, as well as discuss potential controversies and unanswered questions regarding this approach and future directions.
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Affiliation(s)
- Ane Gerda Z Eriksson
- Department of Gynecologic Oncology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway; (P.B.T.); (B.E.); (G.F.D.); (Y.W.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, N-0316 Oslo, Norway; (B.D.); (A.C.S.)
- Correspondence:
| | - Ben Davidson
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, N-0316 Oslo, Norway; (B.D.); (A.C.S.)
- Department of Pathology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway
| | - Pernille Bjerre Trent
- Department of Gynecologic Oncology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway; (P.B.T.); (B.E.); (G.F.D.); (Y.W.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, N-0316 Oslo, Norway; (B.D.); (A.C.S.)
| | - Brynhildur Eyjólfsdóttir
- Department of Gynecologic Oncology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway; (P.B.T.); (B.E.); (G.F.D.); (Y.W.)
| | - Gunn Fallås Dahl
- Department of Gynecologic Oncology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway; (P.B.T.); (B.E.); (G.F.D.); (Y.W.)
| | - Yun Wang
- Department of Gynecologic Oncology, Oslo University Hospital, Norwegian Radium Hospital, N-0310 Oslo, Norway; (P.B.T.); (B.E.); (G.F.D.); (Y.W.)
| | - Anne Cathrine Staff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, N-0316 Oslo, Norway; (B.D.); (A.C.S.)
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Ullevål, N-0424 Oslo, Norway
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