Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients

PURPOSE OF REVIEW

The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer.

RECENT FINDINGS

The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes.

SUMMARY

The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Evaluation of the Superficial Collecting Lymph Vessels' Vasa Vasorum in Lymphoedematous Limbs Using Video Capillaroscopy

OBJECTIVE

The pre-collecting and collecting lymph vessels have smooth muscle cells, and sufficient perfusion is vital to maintain their function. Although the vasa vasorum of the collecting lymph vessels (VVCL) have been histologically investigated, little is known about their physiology. This study aimed to investigate the relationship between morphology and blood flow of the VVCL in lymphoedematous limbs.

METHODS

Medical records of lower extremity lymphoedema patients who underwent video capillaroscopy observation during supermicrosurgical lymphaticovenous anastomosis (LVA) surgery were reviewed. The collecting lymph vessels, dissected for LVA, were examined under video capillaroscopy (GOKO Bscan-ZD, GOKO Imaging Devices Co., Japan) with a magnification of 175x and 620x. Blood flow velocity of the VVCL was calculated by measuring the red blood cell movement using software (GOKO-VIP ver. 1.0.0.4, GOKO Imaging Devices Co., Japan). Based on the video capillaroscopy findings, the VVCL were grouped according to their morphology; the VVCL morphology types and blood flow velocity were then compared according to the lymphosclerosis severity grade.

RESULTS

Sixty-seven lymph vessels in 20 lower extremity lymphoedema patients were evaluated, including s0 in 19 (28.4%), s1 in 34 (50.7%), s2 in 10 (14.9%), and s3 in four (6.0%) lymph vessels. The VVCLs were grouped into four types: type 1 (n = 4), type 2 (n = 37), type 3 (n = 19), and type 4 (n = 7). Blood flow velocity of the VVCL ranged 0 - 189.3 μm/sec (average 26.40 μm/sec). There were statistically significant differences in VVCL morphology (p < .001) and blood flow velocity (p < .001) according to lymphosclerotic severity.

CONCLUSION

Vasa vasorum of the collecting lymph vessels could be grouped into four types with different characteristics. Morphological and physiological changes of the VVCL were related to sclerotic changes of the collecting lymph vessels.

Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema

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.

Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer

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.

Multi-segment bioimpedance in the evaluation of treatment for secondary lower limb lymphedema: Gynecological cancer

<b>Aim</b>: The present aimed study was to report the mobilization of body fluids after five days of intensive treatment for secondary lower limb lymphedema.<br /> <b>Materials and methods</b>: A crossover clinical trial was conducted involving the analysis of changes in intracellular and extracellular fluids in all extremities and the trunk in women with lower limb lymphedema secondary to treatment for gynecological cancer. Evaluations were performed with multi-segment bio impedance analysis before and after intensive treatment using Godoy Method® eight hours per day for five days. Comparisons were made using Wilcoxon signed-ranks test.<br /> <b>Results</b>: Significant changes in intracellular and extracellular fluids were found in all extremities and the trunk (p&lt;0.0001 for all comparisons).<br /> <b>Conclusion</b>: Intensive Godoy Method® leads to important changes in the distribution of body fluids in the treatment of lower limb lymphedema following treatment for gynecological cancer, with a significant increase in fluids in the upper limbs and trunk as well as significant reductions in the lower limb and in intracellular and extracellular water.

Lymphocele following lymph node dissection in cervical and endometrial cancer: A systematic review and meta-analysis

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.

Clinical Impact of Severe Obesity in Patients with Lymphoedema

OBJECTIVE

With the rate of obesity increasing worldwide, patients with lymphoedema with and without a concomitant diagnosis of severe obesity (SO) were compared in regard to their baseline demographics, health related characteristics, treatment plans, and patient outcomes.

METHODS

This was a retrospective observational cohort study. The IBM MarketScan database was examined (2013 - 2019) for patients with a new diagnosis of lymphoedema. Of 60 284 patients with lymphoedema identified, 6 588 had SO defined by a body mass index > 40 kg/m2. The demographics and other characteristics of SO were compared with patients with lymphoedema without SO.

RESULTS

SO and lymphoedema diagnosis increased two fold from 2013 to 2019. The lymphoedema SO+ group was younger (57.8 vs. 60.8 years, p < .001) and with a higher proportion of men (37.7% vs. 24.9%, p < .001) than the lymphoedema SO- group. More comorbidities were observed in the lymphoedema SO+ group than the lymphoedema SO- group: diabetes 46.0% vs. 24.9 % (p < .001), heart failure 18.3% vs. 7.4% (p < .001), hypertension 75.0% vs. 47.6% (p < .001), and renal disease 24.8% vs. 11.9% (p < .001). Use of diuretics in the lymphoedema SO+ group was greater: 57.6% vs. 38.0% (p < .001). Patients with lymphoedema SO+ had higher risk of cellulitis: 34.5% vs. 13.5% (p < .001). Specific lymphoedema treatment was given more often to lymphoedema SO-: 66.3% vs. 64.3% (p = .003). This was significant for manual lymphatic drainage (46.6% vs. 40.0%; p < .001) and physical therapy (55.4% vs. 51.6%; p<.001), but not for compression garments (18.2% vs. 17.7%; p = .38). However, more patients with lymphoedema SO+ received pneumatic compression device treatment: 20.9% vs. 13.7% (p < .001).

CONCLUSION

There was an increase in SO associated lymphoedema. Patients with lymphoedema SO+ have over a two and half fold increase in cellulitis incidence, with a significant increase in medical resource use and cost. Despite this, patients with lymphoedema and SO receive less specific therapy such as compression, which has proven to reduce cellulitis incidence.

Calcium channel blocker and risk of postoperation lymphatic-related complications among gynecologic malignances

Purpose

This study was performed to assess the association of calcium channel blockers (CCB) and other potential factors with postoperative lymphatic-related morbidity in patients with cervical cancer and endometrial carcinoma.

Methods

Patients diagnosed with cervical cancer or endometrial carcinoma with pelvic lymphadenectomy between January 2017 and January 2022 were enrolled. Postoperative lymphatic-related morbidity was evaluated by calculating the lymph cyst occurrence within 3 months after surgery and the duration of pelvic drainage. Univariate analyses evaluating the risk factors for lymphatic-related morbidity were performed.

Results

Of a total of 251 patients, 52 patients were diagnosed with lymphatic cysts by B-ultrasound or computed tomography, and the duration of drainage from 110 patients exceeded the average number of days. Univariable analysis revealed that hypertension, CCB, and lymph node metastasis were independent predictors of postoperative complications.

Conclusions

This study demonstrated that CCB may be a factor associated with the incidence of postoperation lymph cysts, and CCB usage prolongs the duration of pelvic drainage.

Invisible cervical cancers on MRI: Can the type of histology (SCC versus non-SCC) influence surgical planning?

Background

Invisible cervical cancers on MRI can indicate less invasive surgery. Cervical cancers consist of squamous cell carcinoma (SCC) and non-SCC, each with different long-term outcomes. It is still unclear if surgical planning should be changed according to the histologic type of cervical cancer when it is not visible on MRI.

Purpose

The purpose of the study was to determine if surgical planning for cervical cancer that is not visible on MRI is influenced by the histologic type.

Materials and methods

Between January 2007 and December 2016, 155 women had Federation of Gynecology and Obstetrics (FIGO) stage 1B1 cervical cancer that was not visible on preoperative MRI. They underwent radical hysterectomies and pelvic lymph node dissections. Among them, 88 and 67 were histologically diagnosed with SCC and non-SCC, respectively. The size of the residual tumor, depth of stromal invasion, parametrial invasion, vaginal invasion, lymphovascular invasion, and lymph node metastasis were compared between these patients using the t-test, Mann-Whitney U test, Chi-squared test, or Fisher's exact test. The recurrence-free and overall 10-year survival rates were compared between the groups by Kaplan-Meier analysis.

Results

The mean sizes of residual tumors were 8.4 ± 10.4 mm in the SCC group and 12.5 ± 11.9 mm in the non-SCC group (p = 0.024). The mean depth of stromal invasion in the SCC group was 12.4 ± 21.2% (0%-100%), whereas that in the non-SCC group was 22.4 ± 24.4 (0%-93%) (p = 0.016). However, there was no difference in parametrial or vaginal invasion, lymphovascular invasion, or lymph node metastasis (p = 0.504-1.000). The recurrence-free and overall 10-year survival rates were 98.9% (87/88) and 95.5% (64/67) (p = 0.246), and 96.6% (85/88) and 95.5% (64/67) (p = 0.872), respectively.

Conclusions

The non-SCC group tends to have larger residual tumors and a greater depth of stromal invasion than the SCC group, even though neither is visible on MRI. Therefore, meticulous care is necessary for performing parametrectomy in patients with non-SCC cervical cancer.

Lymphaticovenous Anastomosis for Treating Secondary Lower Limb Lymphedema in Older Patients-A Retrospective Cohort Study

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.

Progressive resistance exercise training to prevent lower-limb lymphedema after cervical cancer surgery: A feasibility study

Objective

Radical hysterectomy with pelvic lymphadenectomy is the standard surgical treatment for early stage cervical cancer. One of the most common complications after this surgery is lower extremity lymphedema (LLL). Program of progressive resistance exercise training (PRET) is a possible way to prevent LLL for cervical cancer patients postoperatively. Before we start a randomized controlled trial to evaluate the preventive effect of PRET, we conducted this pilot study to assess the feasibility of PRET after cervical cancer surgery.

Methods

The primary purpose of the pilot study was the feasibility of PRET, as well as the satisfaction and adherence to the PRET assessed by a questionnaire. We conducted a single-arm prospective study involving cervical cancer patients who underwent radical hysterectomy with pelvic lymphadenectomy. Participants exercised twice a day for 24 weeks (two weeks of supervised in hospital and then 22 weeks of home-based training) after surgical treatment. All patients were followed up for 12 months. Information that included the limb volume, BMI, perceived difficulty level and adherence rate was collected.

Results

From February to April 2019, a total of 24 patients participated in the study. None of them dropped out. The adherence rate was more than 75% in majority of the patients, the perceived difficulty level of the PRET was high (for the first phase, the fourth phase and the fifth phase, more than half of the participants felt the intensity of the exercise appropriate), and no serious adverse events in the study were observed.

Conclusions

Exercise training was safe and feasible. The preliminary results offered us the possibility to further test the preventive effect of PRET in a full-scale randomized controlled trial.

Current Status and Progress in the Treatment of Lower Limb Lymphedema After Treatment of Gynecological Oncology

Purpose: To discuss the status and progress of treatment of lower limb lymphedema (LLL) after gynecological cancer treatment. Common gynecological malignancies include endometrial cancer, cervical cancer, ovarian cancer, and vulvar cancer. LLL is one of the common complications after gynecological cancer treatment. LLL is one of the common complications after gynecological cancer treatment, which seriously affects patients' quality of life. Methods: We searched the Medline database for literature on LLL after gynecological oncology treatment, reviewed the incidence and risk factors for LLL in different gynecological malignancies, and summarized advances in the prevention and treatment of LLL after gynecological malignancy treatment. Finally, we review data-based approaches for the treatment of LLL and discuss experimental therapies currently in development. Results: Treatment of LLL is usually combined, conservative, and surgical. Complete decongestive therapy is the gold standard for the treatment of LLL. Prevention and treatment of lymphedema of the lower extremities are important for patients with gynecological cancers. Conclusion: Clinicians should be aware of the prevention and treatment of LLL, with a precise diagnosis and effective intervention at an early stage to delay its progression and improve patients' quality of life.

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.

Useful MRI Findings for Minimally Invasive Surgery for Early Cervical Cancer

Simple Summary

Radical hysterectomy and lymph node dissection are extensive procedures with severe post-operative morbidities and should be avoided on patients with low risk of recurrence. Still, due to lack of good prognostic tools, radical surgery is performed on most patients with early stage cervical cancer, leading to overtreatment and unnecessary morbidities. The recent International Federation of Gynecology and Obstetrics (FIGO) staging system accepts the use of magnetic resonance imaging (MRI) in addition to physical examination. Currently, 3 Tesla (3T) MRI is available widely and, due to its high soft tissue contrast, can provide more useful information on precise estimation of tumor size and metastasis than can physical examination in patients with cervical cancer. Therefore, this imaging modality can help gynecologic oncologists to determine whether minimally invasive surgery is necessary and can be used for early detection of small recurrent cancers.

Abstract

According to the recent International Federation of Gynecology and Obstetrics (FIGO) staging system, Stage III cervical cancer indicates pelvic or paraaortic lymph node metastasis. Accordingly, the new FIGO stage accepts imaging modalities, such as MRI, as part of the FIGO 2018 updated staging. Magnetic resonance imaging (MRI) is the best imaging modality to estimate the size or volume of uterine cancer because of its excellent soft tissue contrast. As a result, MRI is being used increasingly to determine treatment options and follow-up for cervical cancer patients. Increasing availability of cancer screening and vaccination have improved early detection of cervical cancer. However, the incidence of early cervical cancers has increased compared to that of advanced cervical cancer. A few studies have investigated if MRI findings are useful in management of early cervical cancer. MRI can precisely predict tumor burden, allowing conization, trachelectomy, and simple hysterectomy to be considered as minimally invasive treatment options for early cervical cancer. This imaging modality also can be used to determine whether there is recurrent cancer following minimally invasive treatments. The purpose of this review is to highlight useful MRI features for managing women with early cervical cancer.