Elsevier

Gynecologic Oncology

Volume 119, Issue 1, October 2010, Pages 60-64
Gynecologic Oncology

Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy

https://doi.org/10.1016/j.ygyno.2010.06.018Get rights and content

Abstract

Objective

The aim of this study was to determine the incidence rate of lower-extremity lymphedema after systematic lymphadenectomy in patients with uterine corpus malignancies and to elucidate risk factors for this type of lymphedema.

Methods

A retrospective chart review was carried out for all patients with uterine corpus malignant tumor managed at Hokkaido Cancer Center between 1991 and 2007. Patients who did not undergo lymphadenectomy as a treatment or died of cancer/intercurrent disease were excluded from this study. All living patients included in this study had hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy and their medical records were reviewed. We identified patients with postoperative lower-extremity lymphedema (POLEL). Logistic regression analysis was used to select the risk factors for POLEL.

Results

Of 286 patients evaluated, 103 (37.8%) had POLEL. Multivariate analysis confirmed that adjuvant radiation therapy (OR = 5.2, 95% CI = 2.1–12.7), resection of more than 31 lymph nodes (OR = 2.6, 95% CI = 1.4–4.9), and removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) (OR = 6.1, 95% CI = 1.3–28.2) were independent risk factors for POLEL.

Conclusion

Adjuvant radiation therapy should be avoided in patients who undergo systematic lymphadenectomy if an alternative postoperative strategy is possible. Although reducing the number of resected lymph nodes is not appropriate from a therapeutical point of view, elimination of CINDEIN dissection may be helpful in reducing the incidence of POLEL. The clinical significance of CINDEIN dissection needs to be investigated by a randomized controlled trial.

Introduction

Lymphedema is a chronic disease that lasts a lifetime in most cases [1], [2], [3], and many patients face physical and psychological pain, as well as economic burdens, as a result of the disease. Sentinel lymph node navigation surgery is a promising treatment for lowering the frequency of postoperative leg edema in patients with cervical carcinoma of the uterus [4]. However, it is unknown at present whether sentinel lymph node navigation surgery can be applied in endometrial cancer [4]. It has been suggested that the total number of resected lymph nodes has relevance to the incidence of lower-extremity lymphedema [5], [6]. A wide range of incidences (1.2–27.3%) of postoperative lower-extremity lymphedema in patients with uterine corpus cancer has been reported [6], [7], the difference considered to be due to the difference in total number of resected lymph nodes. On the other hand, it has recently been reported that not selective but systematic lymphadenectomy including para-aortic lymphadenectomy has therapeutic significance for patients with intermediate-/high-risk endometrial cancer [8]. Several studies have also suggested that the total number of resected lymph nodes, especially removal of 11 or more nodes, has relevance to better survival in patients with endometrial cancer [9], [10]. Therefore, careful consideration should be given to reducing the number of resected lymph nodes. Gynecologic oncologists are facing a dilemma of whether to remove more regional lymph nodes for improving prognosis or to remove less of them for reducing the incidence of lower-extremity lymphedema. Although unsubstantiated by data, Abu-Rustum et al. [11] suggested that removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) is likely a factor contributing to the risk of postoperative lower-extremity lymphedema. The authors are, therefore, paying attention to these nodes to overcome this dilemma. The aim of this study was to determine the incidence rate of lower-extremity lymphedema after systematic lymphadenectomy in patients with endometrial cancer and to elucidate risk factors for this type of lymphedema.

Section snippets

Patients and clinicopathologic findings

A total of 530 patients with malignant tumor of the uterine corpus were treated in the National Hospital Organization, Hokkaido Cancer Center during the period from January 1986 to December 2007. Twenty patients did not undergo surgery and 130 patients underwent surgery without lymphadenectomy. Sixty-four patients died of cancer or intercurrent disease. Medical records concerning postoperative lower-extremity lymphedema in thirty patients were missing. Finally, 286 living patients who underwent

Results

With a median follow-up period of 71 months (interquartile range, 45-108 months), POLEL was noted in medical records of 108 patients (37.8%). Table 2 shows the occurrence of POLEL according to the range of number of resected lymph nodes. Regarding correlation of the number of resected lymph nodes and POLEL, a significant relationship was found between the cut-off number of 21 or 31 and POLEL (chi-square test; p = 0.0230 and p = 0.0055, respectively). On the other hand, no significant relationship was

Discussion

Lower-extremity lymphedema is a serious complication following lymphadenectomy and a chronic disease that lasts a lifetime in most cases [1], [2], [3]. The incidence rate of lower-extremity lymphedema that originates in lymphadenectomy has been reported to be 1.2–27.3% in patients with uterine corpus cancer [6], [7].

The overall rate of lymphedema of 37.8% in our study is higher than rates reported in the literature. This may be due to the number of lymph nodes dissected. It has been reported

Conflict of interest statement

There is no conflict of interest with others about the research content, conclusions, and significance of this study.

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