Lower extremity lymphedema in patients with gynecologic malignancies

Abstract

Lower extremity lymphedema is a chronic, often irreversible condition that affects many patients treated for gynecologic malignancies, with published rates as high as 70% in select populations. It has consistently been shown to affect multiple quality of life metrics. This review focuses on the pathophysiology, incidence, trends, and risk factors associated with lower extremity lymphedema secondary to the treatment of cervical, endometrial, ovarian, and vulvar cancers in the era of sentinel lymph node mapping. We review traditional and contemporary approaches to diagnosis and staging, and discuss new technologies and imaging modalities. Finally, we review the data-based treatment of lower extremity lymphedema and discuss experimental treatments currently being developed. This review highlights the need for more prospective studies and objective metrics, so that we may better evaluate and serve these patients.

Keywords: brachytherapy; cervical cancer; surgical oncology; uterine cancer; vulvar and vaginal cancer.

Figure 1.

Photographs of the ISL stages/grade of lymphedema. (A) Stage 1 mild lymphedema with <20% difference in limb size. (B) Stage 1 moderate lymphedema with a 20–40% difference in limb size. (C) Stage 2 moderate lymphedema with a 20–40% difference in limb size with associated fibrosis and irreversible edema. (D) Stage 3 severe lymphedema with >40% limb difference, and abnormal fat deposits. Adapted from Cheng MH, Chang DW, Patel KM (editors): Principles and Practice of Lymphedema Surgery. Elsevier Inc.; Oxford, UK. ISBN: 978-0-323-29897-1. July 2015.

Figure 2.

Summary algorithm for the treatment of lymphedema. All patients should be evaluated for risk of lymphedema prior to treatment for gynecologic malignancies and appropriate steps taken during treatment to reduce their risk, if possible. Patients should then be evaluated for lymphedema post-treatment. If clinically suspicious limb edema is present, other etiologies should be ruled out (Table 1), with the help of imaging or diagnostic modalities described in Table 3 as needed. Once lymphedema is diagnosed and appropriately staged, treatment is tailored to the patient stage, with more aggressive measures usually taken at higher stages. LEL, lower extremity lymphedema; MLD, manual leg decompression; LVA, lymphaticovenous anastomosis; LLB, lymphatic-lymphatic bypass; LVB, lymphaticovenous anastomosis; LN, lymph node; CTD, complete decongestive therapy.