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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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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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3
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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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Jansen A, de Jong A, Hoogendam JP, Baeten IGT, Jürgenliemk-Schulz IM, Zweemer RP, Gerestein CG. Lymphocele following lymph node dissection in cervical and endometrial cancer: A systematic review and meta-analysis. Gynecol Oncol 2023; 170:273-281. [PMID: 36738486 DOI: 10.1016/j.ygyno.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/31/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The purpose of this systematic review and meta-analysis was to evaluate the proportion and risk factors of lymphoceles and symptomatic lymphoceles after PLND in early-stage cervical and early-stage high or high-intermediate risk endometrial cancer. METHODS Studies reporting on the proportion of lymphocele after PLND were conducted in PubMed, Embase and Cochrane Library. Retrieved studies were screened on title/abstract and full text by two reviewers independently. Quality assessment was conducted using the Newcastle Ottowa Scale and the Cochrane risk-of-bias tool. Proportion of lymphocele and possible risk factors were pooled through random-effects meta-analyses. RESULTS From the 233 studies retrieved, 24 studies were included. The pooled proportion of lymphocele was 14% and of symptomatic lymphocele was 3%. Routinely performing diagnostics was associated with a significantly higher proportion of lymphocele compared to diagnostics performed on indication (21% versus 4%, p < 0.01). Laparotomic surgical approach led to a significantly higher proportion of lymphoceles than laparoscopic surgical approach (18% versus 7%, p = 0.05). The proportion of lymphocele was significantly higher when >15% of the study population underwent additional paraaortic lymph node dissection (PAOLND) opposed to <15% (15% versus 3%, p < 0.01). A mean number of lymph nodes dissected of <21 resulted in a significantly higher pooled proportion of lymphoceles opposed to when the mean number was 21 or higher (19% versus 5%, p = 0.02). Other risk factors analysed were BMI, lymph node metastasis, adjuvant radiotherapy and follow up. There was no sufficient data to detect significant risk factors for the development of symptomatic lymphoceles. CONCLUSION The pooled proportion of lymphocele was 14% of which symptomatic lymphoceles occurred in 3%. Significant risk factors for the total proportion of lymphoceles were laparotomic approach, decreased number of lymph nodes dissected and additional PAOLND.
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Affiliation(s)
- A Jansen
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A de Jong
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J P Hoogendam
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I G T Baeten
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - R P Zweemer
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - C G Gerestein
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Bjerre Trent P, Falk RS, Staff AC, Jorde D, Eriksson AG. Translation and cross-cultural adaptation of the Gynecologic Cancer Lymphedema Questionnaire and the Lower Extremity Lymphedema Screening Questionnaire. Int J Gynecol Cancer 2023; 33:231-235. [PMID: 36600491 PMCID: PMC9933152 DOI: 10.1136/ijgc-2022-003979] [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] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE There is a paucity of international data regarding self-reported lower extremity lymphedema and quality of life after surgery for gynecological cancer. Validated questionnaires are emerging, but translated versions are lacking. Cross-cultural adaptation is important to reduce the risk of introducing bias into a study. OBJECTIVE To translate and culturally adapt the Gynecologic Cancer Lymphedema Questionnaire and the Lower Extremity Lymphedema Screening Questionnaire for a Norwegian population. METHODS Permission to use the original English versions of the Gynecologic Cancer Lymphedema Questionnaire and the Lower Extremity Lymphedema Screening Questionnaire for translation was obtained. The questionnaires were translated using a procedure based on standard guidelines, including forward translation by native speakers of the target language, synthesis, back translation, and review. Seventeen patients from the Norwegian Radium Hospital gynecological cancer outpatient clinic, all expected to have stable disease, were invited for questionnaire test-retest by completing the same questionnaires twice at 3-4-week intervals. Internal consistency was assessed by calculating Cronbach's alpha. Test-retest reliability was assessed using an intra-class correlation coefficient. RESULTS Twelve patients completed the questionnaires twice. Cronbach's alpha was 0.75 for the Gynecologic Cancer Lymphedema Questionnaire and 0.89 for the Lower Extremity Lymphedema Screening Questionnaire. The intra-class correlation coefficient was 0.86 for the Gynecologic Cancer Lymphedema Questionnaire and 0.91 for the Lower Extremity Lymphedema Screening Questionnaire. CONCLUSIONS Translation and cross-cultural adaptation of these internationally validated patient-reported outcomes questionnaires for survivors of lower extremity lymphedema in gynecological cancer was feasible. The Norwegian translation of the Gynecologic Cancer Lymphedema Questionnaire and the Lower Extremity Lymphedema Screening Questionnaire showed acceptable internal consistency and the test-retest reliability was excellent.
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Affiliation(s)
- Pernille Bjerre Trent
- Department of Gynecological Oncology, Divison of Cancer Medicine, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ragnhild Sørum Falk
- Oslo Centre of Biostatistics and Epidemiology, Research Support Centre, Oslo University Hospital, Oslo, Norway
| | - Anne Cathrine Staff
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway,Division of Obstetrics and Gyneacology, Oslo University Hospital, Oslo, Norway
| | - Doris Jorde
- Faculty of Education, University of Oslo, Oslo, Norway
| | - Ane Gerda Eriksson
- Department of Gynecological Oncology, Divison of Cancer Medicine, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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Palmér M, Åkesson Å, Marcickiewicz J, Blank E, Hogström L, Torle M, Mateoiu C, Dahm-Kähler P, Leonhardt H. Accuracy of transvaginal ultrasound versus MRI in the PreOperative Diagnostics of low-grade Endometrial Cancer (PODEC) study: a prospective multicentre study. Clin Radiol 2023; 78:70-79. [PMID: 36270868 DOI: 10.1016/j.crad.2022.09.118] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 01/07/2023]
Abstract
AIM To investigate if the diagnostic accuracy of transvaginal ultrasound (TVUS) performed by gynaecologists is sufficient for preoperative assessment of low-grade endometrial cancer (EC) compared to magnetic resonance imaging (MRI). MATERIALS AND METHODS MRI and TVUS performed by gynaecologists were assessed at the participating centres. The MRI examinations were interpreted by two radiologists at the tertiary centre. Deep myometrial and cervical stroma invasion were visually assessed and compared to postoperative histopathology. RESULTS Two hundred and fifty-nine patients were included. There was a statistically significant difference in specificity assessing deep myometrial invasion between MRI and TVUS (MRI 0.88, TVUS 0.68). There was no difference in sensitivity (MRI 0.73, TVUS 0.68). When assessing cervical stroma infiltration, MRI had a higher specificity (MRI 0.96, TVUS 0.90), but there was no difference in sensitivity (MRI 0.41, TVUS 0.32). CONCLUSION MRI has higher specificity than TVUS performed by gynaecologists for assessing deep MI and CSI in low-grade EC, but similar sensitivities. The use of TVUS as a first-line test, rather than MRI, may be supported by this study in centres where access to MRI may be limited.
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Affiliation(s)
- M Palmér
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Å Åkesson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - J Marcickiewicz
- Department of Obstetrics and Gynaecology, Varberg Hospital, Varberg, Sweden
| | - E Blank
- Department of Obstetrics and Gynaecology, NU Hospital Group, Trollhättan, Sweden
| | - L Hogström
- Department of Obstetrics and Gynaecology, Skaraborg Hospital, Skövde, Sweden
| | - M Torle
- Department of Obstetrics and Gynaecology, Södra Älvsborg Hospital, Borås, Sweden
| | - C Mateoiu
- Department of Pathology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - P Dahm-Kähler
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - H Leonhardt
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden.
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Otsuka I. Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy. Cancers (Basel) 2022; 14:cancers14184516. [PMID: 36139675 PMCID: PMC9497184 DOI: 10.3390/cancers14184516] [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: 08/15/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. Abstract Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.
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Affiliation(s)
- Isao Otsuka
- Department of Obstetrics and Gynecology, Kameda Medical Center, Kamogawa 296-8602, Chiba, Japan
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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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Wedin M, Stålberg K, Marcickiewicz J, Ahlner E, Åkesson Å, Lindahl G, Wodlin NB, Kjølhede P. Impact of lymphadenectomy and lymphoedema on health-related quality of life 1 year after surgery for endometrial cancer. A prospective longitudinal multicentre study. BJOG 2021; 129:450-460. [PMID: 34437763 DOI: 10.1111/1471-0528.16870] [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] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the impact of lymphadenectomy and lymphoedema of the lower limbs (LLL) on health-related quality of life (HRQoL) 1 year after surgery for endometrial cancer (EC). DESIGN Prospective longitudinal cohort multicentre study. SETTING Departments of obstetrics and gynaecology at four university hospitals, six central hospitals and four county hospitals in Sweden. POPULATION Two-hundred-and-thirty-five women with early stage EC were included; 116 with high-risk EC underwent surgery including lymphadenectomy (+LA), and 119 with low-risk EC had surgery without lymphadenectomy (-LA). METHODS The generic SF-36 and EQ-5D-3L and the lymphoedema-specific LYMQOL questionnaire were used to assess HRQoL. LLL was assessed by systematic circumferential measurements of the legs enabling volume estimation, clinical evaluation and patient-reported perception of leg swelling. All assessments were carried out on four occasions; preoperatively, and 4-6 weeks, 6 months and 1 year postoperatively. MAIN OUTCOME MEASURE HRQoL scores. RESULTS No significant differences were seen in HRQoL between the +LA and -LA groups 1 year postoperatively. Irrespective of method of determining LLL, women with LLL were significantly more affected in the LYMQOL domains Function, Appearance/body image and Physical symptoms, but not in the domain Emotion/mood, than women without LLL. No such differences were seen in the generic HRQoL or in the LYMQOL global score between the groups with and without LLL. CONCLUSIONS Lymphadenectomy did not seem to affect generic HRQoL adversely. Irrespective of the method of measuring, LLL affected the lymphoedema-specific HRQoL negatively, mainly in physical domains, but had no impact on the generic HRQoL. TWEETABLE ABSTRACT Lymphoedema has impact on lymphoedema-specific, but not on generic, HRQoL, 1 year after surgery for EC.
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Affiliation(s)
- M Wedin
- Department of Obstetrics and Gynaecology in Linköping, Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - K Stålberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - J Marcickiewicz
- Department of Obstetrics and Gynaecology, Varberg Hospital, Varberg, Sweden
| | - E Ahlner
- Department of Oncology, Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - Å Åkesson
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - G Lindahl
- Department of Oncology, Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - N B Wodlin
- Department of Obstetrics and Gynaecology in Linköping, Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - P Kjølhede
- Department of Obstetrics and Gynaecology in Linköping, Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
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