A Prospective Study in Detection of Lower-Limb Lymphedema and Evaluation of Quality of Life After Vulvar Cancer Surgery

Time to extend the indication for sentinel node biopsy in vulvar cancer? Results from a prospective nationwide Swedish study

OBJECTIVE

To assess detection rates and negative predictive values of sentinel node biopsy in vulvar squamous cell carcinoma with tumors ≥4 cm, multifocal tumors, and in locally recurrent disease.

METHODS

Between December 2019 and December 2022, patients with vulvar squamous cell carcinoma with tumors ≥4 cm (group 1), multifocal tumors (group 2), or a first local recurrence without or with previous groin treatment (groups 3 and 4, respectively) were included in a prospective, nationwide multicenter interventional pilot study. The participants underwent a sentinel node biopsy followed by inguinofemoral lymph node dissection. Detection rates, negative predictive values, the proportion of micrometastases, and isolated tumor cells were determined separately for each group.

RESULTS

In all, 64 women were included, 36 women in group 1 (56%), and 17 women in group 2 (27%). Due to the small number and heterogeneity of the 11 women in groups 3 and 4, they were excluded from further analyses. In groups 1 and 2, 25 women (47%) were diagnosed with node-positive disease, and in 16 women (64%) only in the sentinel nodes. The detection rates varied between 94.1-100% per patient and 84.1-85.3% per groin. No false-negative sentinel nodes were identified, giving a negative predictive value of 100% for group 1 (95% CI 91.2% to 100%) and for group 2 (95% CI 83.9% to 100%). Of the node-positive patients, 32% had micrometastasis or isolated tumor cells only. One third of the metastases were detected by ultrastaging. In 27% of the non-mapping groins, metastases were found in the lymphadenectomy specimen, and in 75% the metastases showed extranodal growth.

CONCLUSION

In this small cohort of patients, we provide further data that may widen the indication of the sentinel node technique to women with tumors ≥4 cm and multifocal tumors.

TRIAL REGISTRATION NUMBER

NCT04147780.

Etiology and treatment of cancer-related secondary lymphedema

Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.

The Effects of Methylene Blue and Carbon Nanoparticles on Transplanted Lymph Node Survival, Reconstructed Lymphatic Function, and Changes in Inflammatory and Fibrosis Factors

BACKGROUND AND OBJECTIVES

Methylene blue (MB) and carbon nanoparticles (CNs) can be used as a simple method for reverse lymphatic mapping. We investigated whether the two tracers had an impact on the survival of lymph nodes and the function of reconstructed lymph vessels after transplantation, as well as the changes in surrounding related factors.

METHODS

The stained lymph nodes were non-vascularized transplanted into the contralateral popliteal fossa in mice. After 4 weeks, the lymphatic recanalization was detected. The samples were harvested for pathological detection and PCR. In addition, the transport ability of the recanalized lymphatics to tumor cells was also explored.

RESULTS

Compared with the control group, there was no significant difference of the MB and CNs groups in the drainage function of recanalized lymphatic vessels, the survival of lymph nodes, or the transport capacity to tumor cells. TNF-α and IL-6 were significantly higher in the two tracer groups (**p < 0.01). Besides, the α-SMA was significantly increased in the CNs group (*p < 0.05).

CONCLUSIONS

Two tracers have no effect on the survival of transplanted lymph nodes, nor do they affect the drainage ability or tumor cell capture ability of the reconstructed lymphatics, despite improving TNF-α and IL-6 levels and the deposition of CNs.

Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema

PURPOSE

Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy.

METHODS

We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas.

RESULTS

Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P < 0.05).

CONCLUSIONS

Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone.

Impact of Vulvar Cancer Surgery on Quality of Sex Life: A Review of Literature

OBJECTIVES

Vulvar cancer is a gynecological cancer for which posttreatment morbidity must be known to propose the appropriate medical strategy. The objectives of this article were to review and to summarize the available studies evaluating the impact of vulvar surgery on the quality of sex life.

MATERIALS AND METHODS

We searched MEDLINE abstracts (source PubMed) and included all studies published between 1990 and 2020 that evaluated the impact of vulvar surgery on the patients' sex life. Articles were selected in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. We evaluated the quality of the studies using the "study quality assessment tools" established by the National Heart Lung and Blood Institute and the health-related quality-of-life score. Summary statistics were used to report the results of the studies selected.

RESULTS

A total of 41 articles were screened, and 15 studies were included in this review. Two questionnaires, that is, European Organization for Research and Treatment of Cancer QLC C30 and Female Sexual Function Index, were used in 60% of the studies. The quality of the studies was heterogeneous. None of them had a high level of evidence. Eleven of the 16 studies reported an impairment of quality of sex life, mainly related to the size of the initial lesion and the type of surgery performed. Preoperative sexual status, that is, active sex life, age, and morbidity seemed to be important factors.

CONCLUSIONS

None of the studies had a high level of evidence, and their methodological quality was heterogeneous. More powerful studies using validated questionnaires are necessary. Because this is essential surgery, patients should be informed that if it impacts their sexual life, management strategies will be part of their postoperative care.

The Impact of Vulvar Cancer on Psychosocial and Sexual Functioning: A Literature Review

Simple Summary

The diagnostic and therapeutic pathway of vulvar cancer impacts severely on the psychosocial and psychosexual equilibrium of women affected by it. The current literature shows the presence of depressive and anxious symptoms in association with physical, psychological and behavioural alterations in sexuality as well as deterioration of partner relationship. The aim of this article is to highlight the difficulties and challenges faced by women diagnosed and treated for vulvar cancer to provide early recognition and appropriate assistance. By implementing an integrated care model, it should be possible to detect unmet needs and improve the quality of life of these women.

Abstract

Women who are diagnosed and treated for vulvar cancer are at higher risk of psychological distress, sexual dysfunction and dissatisfaction with partner relationships. The aim of this article is to provide a review of the psychological, relational and sexual issues experienced by women with vulvar cancer in order to highlight the importance of this issue and improve the quality of care offered to these patients. A review of the literature was performed using PubMed, CINAHL, PsycINFO, and the Cochrane Library. The results are presented as a narrative synthesis and highlight the massive impact of vulvar cancer: depressive and anxiety symptoms were more frequent in these women, and vulvar cancer may have a negative effect on sexuality from a physical, psychological and behavioural point of view. Factors that may negatively affect these women’s lives are shame, insecurity or difficulties in self-care and daily activities. This review highlights the psychosocial and psychosexual issues faced by women diagnosed and treated for vulvar cancer, although more studies are needed to better investigate this field of interest and to identify strategies to relieve their psychological distress. Care providers should implement an integrated care model to help women with vulvar cancer recognise and address their unmet needs.

The Association Between the Number of Retrieved Pelvic Lymph Nodes and Ipsilateral Lower Limb Lymphedema in Patients With Gynecologic Cancer

PURPOSE

While the risk of lower limb lymphedema (LLE) after radical surgery for gynecologic malignancies is multifactorial, the limited assessment of lymph nodes (LNs), such as sentinel LN biopsy, has been incorporated into a standard procedure. We assessed the relationship between the number of LNs retrieved from the hemipelvis and the incidence of ipsilateral LLE (iLLE).

METHODS

This retrospective study included 103 women with gynecologic cancer who had LNs removed with minimally invasive surgery between January 2014 and December 2018. For early detection of LLE, the patients were followed up by a lymphedema specialist who complied with the International Society of Lymphedema criteria. Potential risk factors for LLE were collected, and the risk factors were further investigated according to the number of LNs removed in a side-specific manner.

RESULTS

LLE was diagnosed in 32 (31.1%) patients, and most of them were diagnosed with unilateral (n = 22) LLE rather than bilateral (n = 10). The number of pelvic LNs removed (p = 0.018), no lymphatic mapping (p = 0.034), and radiation (p = 0.020) were associated with the development of one or both LLEs. A side-specific analysis revealed that the incidence of iLLE increased significantly when four or more LNs were removed from the hemipelvis compared with three or fewer LNs (22.9% vs. 8.3%, p = 0.048).

CONCLUSIONS

The number of pelvic LNs retrieved was associated with the incidence of LLE in patients with early gynecologic cancer. We identified the cutoff number per hemipelvis through side-specific analysis that could minimize the risk of iLLE. Further studies are needed to validate our results.

Body Fluid Trend and Prevalence of Lymphedema After Gynecological Cancer Surgery

Background: This study aimed at understanding the trend in extracellular fluid (ECF) change and estimating the efficacy of the early complex decongestive therapy (CDT) program in terms of prevalence of lower limb lymphedema, as well as at identifying the quality of life (QoL) associated with response to CDT after gynecological cancer therapy. Methods and Results: Thirty-one patients undergoing gynecological cancer treatment were enrolled and randomly assigned to the CDT and control groups. In the CDT group, CDT was started within 2 weeks after surgery for 30 minutes a day, for 2 weeks (5 days per week). The patients' QoL was assessed through the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire; version 3. Inbody S10^® (Biospace, Seoul, South Korea) was used to calculate the ECF. The assessment was performed at pre- and post-surgery and at 3, 6, and 12 months after surgery. Statistically significant differences, in favor of the CDT group, were encountered at the 3-month follow-up visit, especially with respect to the QoL score. Regarding the prevalence of lymphedema, no significant difference was observed between groups. The mean value of the impedance ratio was low in the CDT group during the entire 12 month follow-up. Conclusions: The results of the present study show that early CDT had a positive effect on the prevalence of lymphedema and body composition. Long-term follow-up studies with a larger sample size are needed to warrant the time-group effect of early rehabilitation.

Psychometric Evaluation of a Brazilian Version of the Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema in Patients After Cancer Treatment

Background: The aim of this study was to evaluate psychometric properties of the Lymphedema Functioning, Disability and Health Questionnaire for lower limb lymphedema (Lymph-ICF-LL) in Brazilian patients with secondary lower limb lymphedema after cancer treatment. Methods and Results: A diagnostic test study was performed in 30 patients with lower limb lymphedema. To assess the reliability, the intraclass correlation coefficient (ICC) was analyzed through test-retest, Cronbach alpha coefficient, magnitude of intrasubject variability by standard error of measurement (SEM), and smallest real difference (SRD). To assess the face and content validity, a specific questionnaire was applied to assess the clarity of the scoring system and comprehensiveness of questions. To assess construct validity, correlations between the final Brazilian version of the Lymph ICF-LL and the quality of life questionnaire SF-36 (36-Item Short Form Health Survey Questionnaire) were analyzed. The ICCs and general internal consistency scores of Lymph-ICF-LL were high (ICCs >0.90 and the Cronbach alpha coefficient >0.90, respectively). Measurement variability between the tests was acceptable (SEM 5.9) with SRD of 16.4. Face and content validity were considered excellent by the patients as the scoring system was clear and questions were understandable for 97% and 90% of the patients, respectively. Construct validity was classified as good and all hypotheses for assessing convergent validity were accepted (medium to strong correlation, from -0.69 to -0.84). Conclusion: The Brazilian version of the Lymph-ICF-LL is a reliable and valuable instrument for assessing Brazilian patients with secondary lower limb lymphedema associated with cancer treatment.

Postoperative health-related quality of life of patients with gynecological malignancy: a meta-analysis

OBJECTIVE

We sought to describe the short-term (1, 3, 6, 12 months) QoL changes after surgery for patients with gynecological malignancies in a meta-analysis.

METHODS

We collected studies based on the PICOS (patients, intervention, comparison, outcome, and study design) framework (P: patients with gynecological malignancy; I: surgery; C: presurgery; O: QoL scores; S: randomized controlled trials, case-control studies, or cohort studies) in the Cochrane Library, MEDLINE, EMBASE, Web of Science, EBSCO, and China National Knowledge Infrastructure (CNKI) databases up to June 28, 2020. Then, two reviewers independently performed article screening, data extraction, and study quality evaluation. Stata 15.0 software was utilized for data analysis.

RESULTS

Nine studies with 1476 patients were ultimately included. QoL in global health status improved until 12 months after surgery with a maximum improvement (6.99 [0.31, 13.68], P = 0.04), and QoL in emotional functioning reduced significantly until 12 months after surgery with a maximum reduction (14.87 [10.29, 19.45], P < 0.00001). All of the symptom scales were reduced significantly until 12 months postoperation, indicating quality of life improvement. There was a clinical reduction in QoL but symptom experience (-3.31 [-5.51, -1.12], P=0.003) at six months after surgery compared with baseline (presurgery), with only sexual worry being statistically significant (4.61 [0.95, 8.27], P=0.01).

CONCLUSIONS

The recovery time varied among each dimension of the postoperative QoL of patients with gynecological malignancies; only a few functions and symptoms began to improve at 1 month postoperation and more at 12 months postoperation. Therefore, it is vitally important to develop extended care programs targeting the multidimensional aspects of QoL for patients with gynecological malignancies after surgery.

Quality of life and associated factors after surgical treatment of vulvar cancer by vulvar field resection (VFR)

Purpose

To investigate patient-reported quality of life (QoL) and associated factors in vulvar cancer patients treated surgically by vulvar field resection (VFR) without adjuvant radiation.

Methods

We retrospectively evaluated patient-reported QoL as part of the prospective monocentric VFR trial using the 30-item European Organization for Research and Treatment of Cancer quality-of-life questionnaire (EORTC QLQ-C30) supplemented by a question assessing sexual activity. All patients had been treated by VFR and no participant had received adjuvant radiotherapy. The gynecologic cancer lymphedema questionnaire (GCLQ) was used to determine the presence of lymphedema. Structured telephone interviews were conducted to assess postoperative sequelae and long-term complications.

Results

Forty-three VFR patients (median age 63 years) were available for QoL assessment. Thirty-eight (88%) had received inguinal lymph-node dissection in addition to VFR. Mean global QoL (global health status) rating among all patients was 66.1 (± 25.5) on a scale from 0 to 100 with higher scores indicating better QoL. Higher GCLQ scores were significantly associated with lower global QoL scores (Spearman's rank correlation ρ =− 0.7, p < 0.0001). The presence of preoperative co-morbidities and postoperative wound-healing complications were also linked to reduced QoL (p < 0.01 for both). In a multivariable regression model, there was a significant interaction between preoperative co-morbidities and wound-healing complications with regard to global QoL (p < 0.05).

Conclusion

Overall, VFR patients exhibit good quality of life postoperatively. The presence of lymphedema, wound-healing complications, and preoperative morbidities were associated with reduced QoL. Prospective longitudinal studies have to confirm our findings in the future.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05584-5) contains supplementary material, which is available to authorized users.

The Therapeutic Effects of Goreisan, a Traditional Japanese Herbal Medicine, on Lower-Limb Lymphedema after Lymphadenectomy in Gynecologic Malignancies: A Case Series Study

Background

Lower-limb lymphedema (LLL) is a chronic and progressive complication of gynecologic cancer treatment, including pelvic lymphadenectomy. This study aims to investigate the therapeutic effect of goreisan, a traditional Japanese medicine, which has been used for hydrostatic modulation on patients with LLL.

Methods

Patients diagnosed with LLL in our hospital in 2018 were included and principally treated with complex decongestive therapy (CDT), including elastic clothing and lymph drainage. The patients who received a combination therapy of CDT and goreisan (CDT-G group) were prescribed goreisan extract granules, with a dose of 7.5 g per os daily in three doses. Patients who were not prescribed goreisan received CDT alone (CDT group). The severity of lymphedema was evaluated by the estimated limb volume calculated by limb circumferences and the ratio of extracellular water (ECW) to total body water (TBW).

Results

Nineteen women with LLL after pelvic lymphadenectomy were included in the study. The number of patients in the CDT and CDT-G groups was 8 and 11, respectively. There were no statistically significant differences between the CDT and CDT-G groups in terms of patient characteristics and severity of LLL before treatment. Reduction in ECW/TBW in the CDT-G group (in the whole body and the affected lower limb) after the intervention was significantly more remarkable than that in the CDT group.

Conclusions

Goreisan-based Japanese herbal therapy may be effective in patients with LLL after retroperitoneal lymphadenectomy.

Feasibility of internal inguinoperitoneal drainage after inguinofemoral lymphadenectomy in vulvar cancer

PURPOSE

Despite the introduction of sentinel node biopsy in patients with vulvar cancer, still approximately 50% of all patients have to undergo an inguinofemoral lymphadenectomy. This is associated with a high incidence of postoperative complications, which may be influenced by inguinal drain management. The aim of this study was to investigate the feasibility of a new surgical technique regarding drain management with an inguinoperitoneal drainage.

METHODS

A retrospective analysis of 21 vulvar cancer patients with inguinofemoral lymphadenectomy was conducted. A silicone drain was circularly placed with the perforated end in the groin and the other end in the space of Douglas. The removal after 3 months was performed under local anesthesia. All patients were questioned during clinical follow-up regarding their personal experiences with the procedure, the occurrence of complications, and side effects using a clinical questionnaire.

RESULTS

In 100% of the patients, the procedure was feasible. Regarding the number of groin punctures due to lymphocyst formation, 15 (71.4%) patients did not need any intervention and 3 (14.3%) patients needed 1-3 punctures. The patient satisfaction with the internal drainage was ranked as good by 17 (81.0%) patients and as moderate by 1 (4.8%) patient. In 3 (14.3%) patients, information about the number of groin punctures and the patient satisfaction were missing.

CONCLUSION

Inguinoperitoneal drainage after inguinofemoral lymphadenectomy in vulvar cancer patients is feasible and safe and a patient satisfaction of 81% is promising. For definitive conclusions regarding the efficacy of this technique, further investigations and prospective multicenter trials are needed.

Effect of cryopreservation on lymph node fragment regeneration after autologous transplantation in the minipig model

Introduction

Lymphoedema is a worldwide pandemic causing swelling of tissues due to dysfunctional transport of lymph fluid. Present management concepts are based in conservative palliation of symptoms through manual lymphatic drainage, use of compression garments, manual lymph drainage, exercise, and skin care. Nevertheless, some curative options as autologous lymph node transplantation were shown to reduce lymphoedema in selected cases. Lately, some concern has arisen due to reports of donor site morbidity. A possible solution could be the development of artificial lymph node scaffolds as niches of lymphatic regeneration. Engineering these scaffolds has included cryopreservation of lymph node stroma. However, the effects of cryopreservation on the regeneration capacities of these organs were unknown.

Materials and methods

Here, we used the minipig animal model to assess lymphatic regeneration processes after cryopreservation of autologous lymph nodes. Superficial inguinal lymph nodes were excised and conserved at -80°C for 1 month. Thereafter, lymph node fragments were transplanted in the subcutaneous tissue.

Results

Regeneration of the lymph nodes was assessed five months after transplantation. We show that lymph node fragment regeneration takes place in spite of former cryopreservation. Transplanted fragments presented typical histological appearance. Their draining capacity was documented by macroscopic transport of Berlin Blue dye as well as through SPECT-CT hybrid imaging.

Discussion

In conclusion, our results suggest that processes of cryopreservation can be used in the creation of artificial lymph node scaffolds without major impairment of lymph node fragments regeneration.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

SYNTHESIS METHODS

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

RESULTS

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

CONCLUSIONS

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

A Comparison of the Quality of Life in Patients With Primary and Secondary Lower Limb Lymphedema: A Mixed-Methods Study

Patients with lower limb lymphedema experience symptoms that may differ in intensity and distress. This mixed-methods study compares symptom intensity and distress and the impact of lymphedema on patients' quality of life by primary and secondary (cancer and noncancer) lymphedema groups. Individuals completed an online questionnaire (i.e., demographic form, Lymphedema Symptom Intensity and Distress Survey-Leg, and an open-ended question). Analyses included descriptive and inferential statistics (quantitative data) and content analysis (qualitative data). Participants differed statistically significantly by gender, employment status, and lymphedema location. Groups differed significantly in lack of self-confidence, χ(2)(df = 2) = 9.19, p = .010. Cancer patients reported higher intensity and distress scores for some symptoms, but these differences were not statistically significant. Patients reported lacking psychosocial well-being and resources and experiencing physical and functional impairments and treatment and care challenges. Patients with lower limb lymphedema experience psychosocial impairments and problems with quality of and access to care.

Symptom Frequency, Intensity, and Distress in Patients with Lower Limb Lymphedema

BACKGROUND

Patients with lower limb lymphedema experience symptoms of pain, swelling, tightness, and heaviness in their legs. Less is known of the intensity and distress associated with these symptoms. This study sought to identify and compare the symptoms and the level of intensity and distress associated with symptoms by type of lymphatic disruption.

METHODS AND RESULTS

A cross-sectional design was used. Patients completed an online survey that included: a demographic form, the Lymphedema Symptom Intensity and Distress Survey-Leg, and an open-ended question. The most prevalent symptoms were swelling, concerns about looks, heaviness, tightness, fatigue, and reduced physical activity. Statistically significant differences were found among groups in coldness in legs (χ(2) (df=3) = 9.0, p = 0.03), lack of confidence in self (χ(2) (df=3) = 10.6, p = 0.014), and feeling less sexually attractive (χ(2) (df=6) = 12.6, p = 0.049). Group differences were also observed in the intensity of heaviness (χ(2) (df=3) = 9.11, p = 0.03), numbness, (χ(2) (df=3) = 10.66, p = 0.014), achiness (χ(2) (df=3) = 12.40, p = 0.006), skin flakiness (χ(2) (df=3) = 13.22, p = 0.004), and lack of interest in sex (χ(2) (df=3) = 8.95, p = 0.030). Statistically significant group differences were not found in distress related to symptoms.

CONCLUSIONS

Despite the number of symptoms reported by patients with lower-limb lymphedema, only a few statistically significant differences in symptoms and level of intensity were observed by type of lymphatic disruption. No statistically significant group differences were found in the distress level associated with any of the symptoms.

The impact of surgery for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of treatment: a longitudinal, mixed methods study

OBJECTIVE

To measure the long-term impact of surgical treatment for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of therapy.

METHODS

Prospective, longitudinal, mixed-methods study. Twenty-three women aged >18 years with a new diagnosis of vulval cancer were recruited. The EORTC QLQ C30, SF-36 and an electronic pelvic floor assessment questionnaire (ePAQ-PF) were administered at baseline (pre-treatment) and 3, 6, 9 and 12 months post-treatment. Mixed effects repeated measures models (all adjusted for age and BMI) were used to investigate changes over time and differences between cancer stage. Qualitative interviews were carried out with 11 of the women and analysed using a thematic approach.

RESULTS

Mean age was 59.9 years (SD = 15.3; range = 23.8-86.6 yrs). Mean BMI was 30.0 (SD = 4.5; range = 24.4-38.2). Sixteen women had early (Stage 1 to 2B), and seven women had advanced stage disease (Stage 3 to 4B). Questionnaire scores revealed that physical and social functioning, fatigue, pain and general sex life were significantly worse at 12 months than pre-treatment (p = < 0.05). Qualitative analysis revealed multiple treatment side effects which were perceived as severe and enduring. Women with advanced vulval cancer had significantly worse SF-36 mental health scores at 12 months compared to women with early stage disease (p = 0.037).

CONCLUSIONS

Surgery for vulval cancer has long-term implications which can be persistent 12 months post-treatment. High rates of morbidity relating to lymphoedema and sexual function re-enforce the need for specialist clinics to support women who suffer these complications. © 2015 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

The effect of groin treatment modality and sequence on clinically significant chronic lymphedema in patients with vulvar carcinoma

OBJECTIVE

Chronic lymphedema (CL) after inguinal lymph node dissection (ILND) or radiotherapy (RT) is a significant problem for vulvar cancer survivors. The treatment modality or combination of therapies that poses the greatest risk is not known. The objective of this study was to describe rates of clinically significant CL conferred by different groin treatment modalities.

METHODS

Medical records of vulvar cancer patients who had groin treatment with ILND, RT, or both were retrospectively reviewed. Each treated groin was considered individually, and divided into 4 treatment groups: ILND alone, ILND with adjuvant RT, neoadjuvant chemoradiation therapy (NCRT), or NCRT followed by ILND. Clinically significant CL was defined as that which required treatment and was recorded by laterality. Differences among groups were evaluated with χ(2) and Fisher exact test.

RESULTS

Between 2000 and 2010, 146 patients with vulvar cancer who underwent therapy to 1 or both groins were identified for a total of 266 treated groins. The rates of CL for single-modality treatment, ILND or NCRT, were 10.9% and 6.7%, respectively. Multimodal treatment resulted in higher rates of CL, 13.5% for ILND followed by RT and 17.2% for NCRT followed by ILND, although differences were not significant (P = 0.37).

CONCLUSIONS

Clinically significant CL was not different between treatment modalities in this study, but is underpowered. The results provide valuable information about treatment complications that will be useful for patient-centered counseling. Prospective evaluation of CL and its impact on quality of life is warranted.

A prospective study in the evaluation of quality of life after vulvar cancer surgery

OBJECTIVE

The aim of this study was to prospectively monitor the patients' quality of life (QoL) after vulvar cancer surgery.

DESIGN

The design was prospective clinical study.

SETTING

The study was set in the Department of Obstetrics and Gynecology, 2nd Medical Faculty of the Charles University and University Hospital Motol, Prague, Czech Republic.

METHODS

A group of 36 patients underwent vulvar cancer surgery: 24 patients were subject to inguinofemoral lymphadenectomy (RAD) and 12 to sentinel lymph node biopsy. To evaluate QoL, the European Organisation for Research and Treatment of Cancer, QoL questionnaires (QLQ-C30 and QLQ-CX24) were administered to patients before and 6 and 12 months after surgery.

RESULTS

In patients with vulvar cancer after inguinofemoral lymphadenectomy, increased fatigue and impaired lymphedema were observed. In the group of patients after sentinel lymph node biopsy, none of the QoL variables worsened postoperatively. Comparing both groups 12 months after surgery, the RAD group had significantly worse outcomes in body image and cognitive functioning than the sentinel lymph node biopsy group.Patients in the RAD group, who received adjuvant radiotherapy (n = 13), had worse QoL in symptom experience (P < 0.05) at 6 and 12 months after the surgery than patients without radiotherapy (n = 11).

CONCLUSIONS

Less radical surgery showed objectively better QoL results.

Recent progress in the treatment and prevention of cancer-related lymphedema

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

Quality of Life After Complete Lymphadenectomy for Vulvar Cancer: Do Women Prefer Sentinel Lymph Node Biopsy?

Objectives

Leg lymphoedema occurs in up to 60% of women after a complete inguinal-femoral lymphadenectomy for vulvar cancer. To avoid lymphoedema, sentinel lymph node biopsy has become the preferred method of staging. However, false-negative results may influence survival, making the sentinel node procedure unacceptable to many fully informed women. The aims of this study were to measure the quality of life (QoL) in women after a complete lymphadenectomy for vulvar cancer and to quantify the risk to survival these women would be prepared to take with sentinel node biopsy.

Materials and Methods

Sixty women who had a complete lymphadenectomy for early-stage vulvar cancer participated in structured interviews. The severity of lymphoedema symptoms was recorded. The QoL-adjusted survival was measured using the Utility-Based Questionnaire-Cancer, a cancer-specific validated QoL instrument. The women stated their preference for sentinel node biopsy or complete lymphadenectomy. A “standard-gamble” preference table was used to quantify the degree of risk to survival they would take to avoid lymphoedema.

Results

Seventy-three percent of women reported lymphoedema after complete lymphadenectomy. Women with lymphoedema or leg pain had significantly worse scores for QoL in terms of social activity as well as physical and sexual function. Overall, 80% of women would choose complete lymphadenectomy rather than sentinel node biopsy if the risk of missing a positive lymph node was higher than 1 in 100, but if the risk of missing a positive lymph node was lower than 1 in 100, almost one third of the women would prefer sentinel node biopsy.

Conclusions

Although women treated for early-stage vulvar cancer report reduced QoL after complete lymphadenectomy, most would choose complete lymphadenectomy over sentinel node biopsy. However, there is an individual level of risk that each woman can define with regard to her preference for the sentinel node procedure. Women with early-stage vulvar cancer should be offered an informed choice between complete lymphadenectomy or sentinel node biopsy.

Breast and gynecologic cancer-related extremity lymphedema: a review of diagnostic modalities and management options

Lymphedema remains a poorly understood entity that can occur after lymphadenectomy. Herein, we will review the pathogenesis of lymphedema, diagnostic modalities and the natural history of extremity involvement. We will review the incidence of upper extremity lymphedema in patients treated for breast malignancies and lower extremity lymphedema in those treated for gynecologic malignancy. Finally, we will review traditional treatment modalities for lymphedema, as well as introduce new surgical treatment modalities that are under active investigation.