Lower limb lymphedema disrupts both static and dynamic balance

BACKGROUND

The impact of lower-limb-lymphedema on quality of life of patients regarding balance is unclear due to the scarcity of literature. The aim of this study was to determine the static and dynamic balance of patients with lower-limb-lymphedema in comparison with healthy subjects.

METHODS

This case-control designed study included 30 lymphedema patients and 30 healthy individuals, of whom were 52 female and 8 male with a mean age of 50.63 ± 9.72 years. Static balance stability and anterior-posterior with lateral sway parameters on four conditions (eyes-opened-stable-ground, eyes-closed-stable-ground, eyes-opened-unstable-ground, eyes-closed-unstable-ground) and dynamic stability of all participants were evaluated.

FINDINGS

The demographic variables were similar between the groups. Majority of the patients had lymphedema due to cancer surgery with a stage of 2. Dynamic stability was significantly disrupted in lymphedema group in comparison with controls (P = 0.049). Static balance parameters were impaired on all conditions except the eyes opened-stable ground in lymphedema patients (P = 0.048,P = 0.043,P = 0.017). The dynamic with static balance and lateral sway parameters were correlated with the duration of lymphedema(P = 0.046,P = 0.002,P = 0.005). Anterior-posterior sway on eyes-closed-unstable-ground condition was correlated with functional status (P = 0.02). Static balance on eyes-opened-unstable-ground condition and anterior-posterior sway parameters were correlated with physical activity level (P = 0.015,P = 0.016,P < 0.05).

INTERPRETATION

Closing eyes and the deterioration of ground caused significant alteration of the static and dynamic balance both separately and together in patients with lower-limb-lymphedema compared to healthy subjects. Regarding the static and dynamic imbalance, we suggest the evaluation of balance and inclusion of balance exercises in routine lymphedema rehabilitation program, especially in the early period of disease.

Preventing lower limb lymphedema after pelvic lymphadenectomy with progressive resistance exercise training: A randomized controlled trial

Objective

This study aimed to assess the efficacy of a self-designed progressive resistance exercise training program for preventing the development of lower limb lymphedema.

Methods

An open-label randomized controlled trial was conducted in patients who underwent radical surgery for cervical cancer treatment in our department between October 7, 2019, and October 7, 2021. The participants were randomly assigned to one of three groups: progressive resistance exercise training, graduated compression stocking, and control group.

Results

A total of 267 patients were enrolled (89 in each group). The incidence of lower limb lymphedema was 9.0% (n = 8) in the progressive resistance exercise training group, 28.1% (n = 25) in the graduated compression stocking group, and 42.7% (n = 38) in the control group. Over the 2-year follow-up period, the risk of lower limb lymphedema was significantly lower in the progressive resistance exercise training group than in the control group, with a hazard ratio (HR) (95% confidence interval [CI]) of 0.156 (0.073-0.335). The study was underpowered to demonstrate a statistically significant reduction in risk in the graduated compression stocking group, with an HR (95% CI) of 0.624 (0.376-1.033).

Conclusions

Progressive resistance exercise training is an effective strategy for preventing lower limb lymphedema after pelvic lymphadenectomy for cervical cancer. It imposes no additional economic burden and can be performed conveniently without the need for dedicated exercise facilities. This makes it particularly accessible to patients in developing countries, allowing them to exercise at their convenience.

Trial registration

ChiCTR1800014905.

Challenges in lower limb lymphoedema assessment based on limb volume change: Lessons learnt from the SENTIX prospective multicentre study

BACKGROUND

Lower limb lymphoedema (LLL) is the most disabling adverse effect of surgical staging of pelvic lymph nodes. However, the lack of standardisation of volumetric LLL assessment hinders direct comparison between the studies and makes LLL reporting unreliable. The aim of our study is to report outcomes from a prospective trial that have implications for LLL assessment standardisation.

METHODS

In the prospective international multicentre trial SENTIX, a group of 150 patients with stage IA1-IB2 cervical cancer treated by uterine surgery with bilateral sentinel lymph node biopsy was prospectively evaluated by objective LLL assessment, based on limb volume change (LVC) using circumferrential limb measurements and subjective patient-reported swelling. The assessments were conducted in six-month periods over 24 months post-surgery.

RESULTS

Patient LVC substantially fluctuated in both positive and negative directions, which were comparable in frequency up to ±14% change. Thirty-eight patients experienced persistent LVC increase >10% classified as LLL, with nine months median time to onset. Some 34.2% of cases experienced onset later than one year after the surgery. Thirty-three patients (22%) experienced transient oedema characterised as LVC >10%, which resolved without intervention between two consequent follow-up visits. No significant correlation between LVC >10% and a patient-reported swelling was observed.

CONCLUSIONS

Given that we observed comparable fluctuations of the the lower-limb volumes after surgical treatment of cervical cancer in both positive and negative direction up to ±14%, the diagnostic threshold for LLL diagnosis based on LVC should be increased to >15% LVC. The distinction of transient oedema from persistent LLL requires repeated measurements. Also, as one-third of LLL cases are diagnosed >1-year post-surgery, a sufficient follow-up duration needs to be ensured. Patient-reported swelling correlated poorly with LVC and should only be used as an adjunct to objective LLL assessment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02494063.

Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema

The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.

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

Background

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

Methods

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

Results

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

Conclusion

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

Risk factors and a prediction model for lower limb lymphedema following lymphadenectomy in gynecologic cancer: a hospital-based retrospective cohort study

Background

Lower limb lymphedema (LLL) is a chronic and incapacitating condition afflicting patients who undergo lymphadenectomy for gynecologic cancer. This study aimed to identify risk factors for LLL and to develop a prediction model for its occurrence.

Methods

Pelvic lymphadenectomy (PLA) with or without para-aortic lymphadenectomy (PALA) was performed on 366 patients with gynecologic malignancies at Yaizu City Hospital between April 2002 and July 2014; we retrospectively analyzed 264 eligible patients. The intervals between surgery and diagnosis of LLL were calculated; the prevalence and risk factors were evaluated using the Kaplan-Meier and Cox proportional hazards methods. We developed a prediction model with which patients were scored and classified as low-risk or high-risk.

Results

The cumulative incidence of LLL was 23.1% at 1 year, 32.8% at 3 years, and 47.7% at 10 years post-surgery. LLL developed after a median 13.5 months. Using regression analysis, body mass index (BMI) ≥25 kg/m² (hazard ratio [HR], 1.616; 95% confidence interval [CI], 1.030–2.535), PLA + PALA (HR, 2.323; 95% CI, 1.126–4.794), postoperative radiation therapy (HR, 2.469; 95% CI, 1.148–5.310), and lymphocyst formation (HR, 1.718; 95% CI, 1.120–2.635) were found to be independently associated with LLL; age, type of cancer, number of lymph nodes, retroperitoneal suture, chemotherapy, lymph node metastasis, herbal medicine, self-management education, or infection were not associated with LLL. The predictive score was based on the 4 associated variables; patients were classified as high-risk (scores 3–6) and low-risk (scores 0–2). LLL incidence was significantly greater in the high-risk group than in the low-risk group (HR, 2.19; 95% CI, 1.440–3.324). The cumulative incidence at 5 years was 52.1% [95% CI, 42.9–62.1%] for the high-risk group and 28.9% [95% CI, 21.1–38.7%] for the low-risk group. The area under the receiver operator characteristics curve for the prediction model was 0.631 at 1 year, 0.632 at 3 years, 0.640 at 5 years, and 0.637 at 10 years.

Conclusion

BMI ≥25 kg/m², PLA + PALA, lymphocyst formation, and postoperative radiation therapy are significant predictive factors for LLL. Our prediction model may be useful for identifying patients at risk of LLL following lymphadenectomy. Providing an intensive therapeutic strategy for high-risk patients may help reduce the incidence of LLL and conserve the quality of life.