Abstract

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

Teruyo Kunitake1,2  · Tatsuyuki Kakuma3 · Kimio Ushijima4. International Journal of Clinical Oncology. January 2020

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.

Main findings

• This study aimed to estimate the “survival curve” of LLL in gynecologic cancer patients after initial treatment using 5-year follow-up records, and to construct a clinical pathology model of LLL development based on structural equation modeling where risk factors associated with LLL incidence and clinically interpretable relationships between risk factors can be simultaneously examined.
• Data on 19 risk factors were obtained from hospital medical records; they were grouped into internal and external risk factors to facilitate the construction of statistical models.
• As a result, the number of LNs dissected (≥ 28) was a significant risk factor for LLL development regardless of site and extent of LN dissection. Nine out of 54 cases of LLL showed recurrence. However, the relationship between recurrence as a pelvic mass and occurrence of LLL could not be denied in only one case of recurrence.
• From the results of this study, regardless of the type of treatment, it is clear that LLL occurs in about 15% of patients within 2 years of initial treatment. Therefore, accurate information can be provided to patients.
• The incidence of LLL was high when there were 28 or more LN dissections.
• In this study, the risk factors directly affecting LLL development were FIGO progression stage (III–IV), number of LNs dissected (≥ 28), and radiotherapy (performed).