Lymphedema after treatment for endometrial cancer A review of prevalence and risk factors

Emma Lindqvista, Madelene Wedinb, Mats Fredriksonc,d, Preben Kjølhedeb, European Journal of Obstetrics & Gynecology and Reproductive Biology 211 (2017) 112–121

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Lymphedema after treatment for endometrial cancer: A review of prevalence and risk factors

Emma Lindqvista, Madelene Wedinb, Mats Fredriksonc,d, Preben Kjølhedeb, European Journal of Obstetrics & Gynecology and Reproductive Biology 211 (2017) 112–121

Lymphedema is one of the least studied complications of cancer treatment and a chronic condition with a substantial impact on health-related quality of life (HQoL). Lymphedema of the legs (LLL) constitutes a common adverse side effect of lymphadenectomy LA in gynecologic cancer treatment. Primary treatment of endometrial cancer (EC) comprises hysterectomy and bilateral salpingo-oophorectomy. Pelvic and para-aortic lymphadenectomy is recommended in prognostic high risk groups of EC. This review summarizes the published literature concerning the prevalence of LLL after treatment for EC, methods used for measuring LLL, risk factors and HQoL impact. The main findings are that the reported prevalence of LLL varies significantly between 0% and 50%. This is due to a lack of a generally accepted standardization of terminology in assessment of lymphedema. The studies use different methods to assess and grade lymphedema and often the methodology used for determining LLL is poorly described and lacks baseline measurement. Lymphadenectomy, number of lymph nodes removed, and radiation therapy seems to increase the risk for LLL. All studies dealing with HQoL show that women with LLL have impaired HQoL. The level of evidence in the published studies is generally low. Consequently it is difficult to make clear-cut conclusions about the true prevalence or determination of risk factors. More prospective longitudinal or randomized trials with LLL as the primary outcome are necessary before conclusions can be drawn regarding prevalence of LLL and risk factor determination in EC. An internationally accepted standardization for terminology and methodology in lymphedema in research is needed.

Main findings

  • The true prevalence of lower limb lymphoedema (LLL) after treatment of endometrial cancer remains to be established. The great variance in the reported prevalence of LLL in the research reflects the lack of standardisation of terminology, ways of measuring LLL and the use of inadequate methodology.
  • The purpose of this study was to perform a systematic review with a meta-analysis of the studies included, but due to the large differences in methodology regarding measuring lymphoedema, and the lack of objective and uniform definition of the disease, the results of the studies are not, in most cases, comparable with each other.
  • The vast majority of the published studies lack baseline measuring of limbs or symptom scoring and are not designed to measure LLL as the primary outcome.
  • The ISL grading recommendation is rarely used in the published articles.
  • Due to the lack of reliable measuring there is a risk that mild and moderate oedemas may be overlooked and consequently the prevalence of LLL may be underestimated.
  • The risk factors to develop LLL after management of endometrial cancer are yet to be adequately determined due to the current poorly designed trials. That said lymphadenectomy, number of lymph nodes removed and radiation therapy appear to be the strongest causes of lymphoedema in this population.