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Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study
Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
Uppsala Univ, Sweden.
Varberg Hosp, Sweden.
Linköping University, Department of Biomedical and Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology.
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2020 (English)In: Gynecologic Oncology, ISSN 0090-8258, E-ISSN 1095-6859, Vol. 159, no 1, p. 201-208Article in journal (Refereed) Published
Abstract [en]

Objective. The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year. Methods. A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy ( -LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patients perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography. Results. After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -IA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 43% after one year. Conclusions. Although the incidence of ILL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a gold standard of measurement of LLL in clinical practice and research. (C) 2020 Elsevier Inc. All rights reserved.

Place, publisher, year, edition, pages
ACADEMIC PRESS INC ELSEVIER SCIENCE , 2020. Vol. 159, no 1, p. 201-208
Keywords [en]
Endometrial cancer; Incidence; Lower limb; Lymphedema; Methodology; Oncology
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-170978DOI: 10.1016/j.ygyno.2020.07.014ISI: 000576604900030PubMedID: 32763108OAI: oai:DiVA.org:liu-170978DiVA, id: diva2:1485138
Note

Funding Agencies|Swedish Cancer Society [Cancerfonden]Swedish Cancer Society [CAN2013/620]; Medical Research Council of Southeast Sweden [FORSS-308611, FORSS-391311, FORSS-662141, FORSS-858611]; Uppsala-Orebro Regional Research Council [LUL-349271]; Scientific Council of the Region Halland; County Council of Ostergotland; Linkoping University

Available from: 2020-11-01 Created: 2020-11-01 Last updated: 2021-11-01
In thesis
1. On lymphedema of the lower limbs after treatment of endometrial cancer: with emphasis on incidence, quality of life, risk factors, and health economy
Open this publication in new window or tab >>On lymphedema of the lower limbs after treatment of endometrial cancer: with emphasis on incidence, quality of life, risk factors, and health economy
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: The overall purpose of this study was to investigate the long-term consequences of primary surgical treatment of endometrial cancer with emphasis on lymphadenectomy, lymphedema development in the limbs, health-related quality of life, and health economy aspects. The primary objective was to assess the incidence of lymphedema both objectively and subjectively by using three different methods to determine lymphedema. Secondary objectives were to determine risk factors for lymphedema, and to analyze the impact of lymphadenectomy and lymphedema on health-related quality of life. Another secondary objective was to evaluate the hospital costs of lymphadenectomy and lymphedema one year after primary treatment of endometrial cancer.

Material and methods: The study was a prospective observational longitudinal multicenter study with 15 Swedish hospitals participating between June 2014 and January 2018. Two hundred sixty-two women with presumed early stage endometrial cancer were included; 235 women completed the study. Of these, 119 were classified as having high-risk endometrial cancer and underwent surgery including lymphadenectomy, and 116 were classified as having low-risk endometrial cancer where no lymphadenectomy was performed. The women were evaluated preoperatively according to the national guidelines for endometrial cancer. The women were all monitored on four occasions: preoperatively, then four to six weeks, six months, and one year postoperatively. On all occasions, lymphedema was evaluated by means of two objective methods: systematic circumferential measurements of the lower limbs, enabling estimation of the leg volume, and by clinical grading of lymphedema of the lower limbs, and subjectively by means of the patient-reported perception of leg swelling. Health-related quality of life was evaluated using three different quality of life questionnaires. Two were generic: the SF-36 and EQ-5D-3L, and one was lymphedema-specific: the LYMQOL. Intraabdominal lymphocysts were evaluated by transvaginal ultrasound. Cost analysis of hospital costs was performed in relation to lymphadenectomy and lymphedema development.

Results: The incidence of lymphedema varied between 9.5% and 29.6%, depending on the method of assessment of lymphedema. The highest incidence was found when using patient-reported swelling. The incidences of lymphedema were significantly higher in the lymphadenectomy group (14.9% - 38.1%) compared with the non-lymphadenectomy group (3.4% - 21.4%). The inter-rater agreement of lymphedema between the various methods of determining lymphedema was low. The incidence of lymphocysts was 4.3% and did not seem to pose a clinical problem. Lymphadenectomy per se did not seem to affect health-related quality of life negatively; however, lymphedema, independent of the method of assessing lymphedema, affected the lymphedema-specific quality of life significantly negatively, mainly in physical domains. Lymphadenectomy, age, and adjuvant radiation therapy were independent risk factors for lymphedema. Lymphadenectomy generated higher hospital costs, independent of the mode of surgery.

Conclusions: A significant number of women develop lymphedema after lymphadenectomy in the treatment of endometrial cancer. The incidences vary, depending on the method of determining lymphedema. This inconsistency is also reflected in risk factors for lymphedema. Lymphadenectomy, increasing age, and adjuvant radiation are factors to pay attention to when planning treatment of endometrial cancer, not least because lymphedema has a negative impact on health-related quality of life. Lymphadenectomy is a cost-driving procedure and its use should be carefully evaluated in relation to its potential benefits.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2021. p. 94
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1777
National Category
Obstetrics, Gynecology and Reproductive Medicine Cancer and Oncology
Identifiers
urn:nbn:se:liu:diva-180705 (URN)10.3384/diss.diva-180705 (DOI)9789179296636 (ISBN)
Public defence
2021-12-10, Belladonna, Building 511, Campus US, Linköping, 09:00 (Swedish)
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Note

Funding agencies: Cancerfonden, The Medical Research Council of Southeast Sweden, Uppsala-Örebro Regional Research Council, The Scientific Council of the Region Halland, The County Council of Östergötland, Lions forskningsfond mot folksjukdomar

Available from: 2021-11-01 Created: 2021-11-01 Last updated: 2021-11-10Bibliographically approved

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Wedin, MadeleneAhlner, EvaLindahl, GabrielKjölhede, Preben
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Division of Children's and Women's HealthFaculty of Medicine and Health SciencesDepartment of Gynaecology and Obstetrics in LinköpingDepartment of Biomedical and Clinical SciencesDepartment of OncologyDivision of Surgery, Orthopedics and Oncology
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