Lymphedema After Surgery for Endometrial Cancer

Abstract

Objective To estimate lower-extremity lymphedema prevalence in patients surgically treated for endometrial cancer, identify predictors of lymphedema, and evaluate the effects of lymphedema on quality of life. Methods One thousand forty-eight consecutive patients who were operated on between 1999 and 2008 at Mayo Clinic were mailed a survey, which included our validated 13-item lymphedema screening questionnaire and two validated quality-of-life measures. Logistic regression models were fit to identify factors associated with prevalent lymphedema; a multivariable model was obtained using stepwise and backward variable selection methods. The relationship between lymphedema and obesity with each quality-of-life score was evaluated in a separate multivariable linear model. Results There were 591 responders (56%) after exclusions. Our questionnaire revealed a previous self-reported lymphedema diagnosis in 103 (17%) patients and identified undiagnosed lymphedema in 175 (30%) (overall prevalence 47.0%; median 6.2 years follow-up). Lymphedema prevalence in patients treated with hysterectomy alone compared with lymphadenectomy was 36.1% and 52.3%, respectively (attributable risk, 23%). Lymphedema risk was not associated with the number of nodes removed or the extent of lymphadenectomy after adjusting for other factors. On multivariable analysis, higher BMI, congestive heart failure, performance of lymphadenectomy, and radiation therapy were associated with prevalent lymphedema. Multiple quality-of-life scores were worse in women with lymphedema. Conclusion The attributable risk of developing lower-extremity lymphedema was 23% for patients with endometrial cancer who underwent lymphadenectomy compared to hysterectomy alone, with an overall prevalence of 47%. Lymphedema was associated with reductions in multiple quality-of-life domains.

A prospective validation study of sentinel lymph node mapping for high-risk endometrial cancer

“…Despite these findings, many agree that the identification of metastatic disease in the lymph nodes is critical in the diagnosis and treatment of women with endometrial cancer and lymph node metastases are an important prognostic factor in overall survival (4) (5). The use of sentinel lymph node (SLN) mapping plus ultra-staging could potentially maximize the identification of positive nodes, while minimizing the known risks of lymphadenectomy including longer surgical times, intraoperative injury, blood loss, and lymph edema (6, 7). …”

Comparison of a sentinel lymph node and a selective lymphadenectomy algorithm in patients with endometrioid endometrial carcinoma and limited myometrial invasion

“…Comprehensive lymphadenectomy is associated with intraoperative complications, such as increased operating time, nerve and vessel injury, higher blood loss, and postoperative morbidity [8]. The rate of long-term lymphedema directly attributed to lymphadenectomy was recently reported to be 23% [9]. The morbidity associated with comprehensive lymphadenectomy is of particular concern in the low-risk population.…”

Does Obesity Affect Pathologic Agreement of Initial and Final Tumor Grade of Disease in Endometrial Cancer Patients?

“…Two randomized trials found no difference in overall survival or progression free survival in patients who underwent surgical staging in clinically early stage EMCA with or without lymphadenectomy supporting the potential limitation of staging as a part of initial surgical management (34-36). Pelvic and para-aortic lymph node dissections can also lead to significant morbidity including lower extremity lymphedema, lymphocele formation, neurovascular damage, and increased risk of thrombotic events (37-41). …”

“…Despite studies validating the low-risk of nodal metastases in early stage EMCA patients using these different triage techniques and considering the potential added morbidity following pelvic and para-aortic lymph node dissection, there is not complete consensus within the Gynecologic Oncology community as to the best way to identify patients who need operative lymph node evaluation (18-24, 37-41). …”