GOG 244 - The Lymphedema and Gynecologic cancer (LeG) study: The impact of lower-extremity lymphedema on quality of life, psychological adjustment, physical disability, and function

Lower extremity lymphedema in patients with gynecologic cancer: Validation of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ) in German language and investigation of lymphedema real-world treatment

PURPOSE

The Gynecologic Cancer Lymphedema Questionnaire (GCLQ) is an established patient-reported outcome measure for lower extremity lymphedema (LEL) in gynecologic oncology. We aimed to validate the GCLQ in German language (GCLQ-GER) for lymphedema detection in German-speaking patients and also investigated real-world patterns of lymphedema treatment.

METHODS

The GCLQ was translated from English into German in accordance with the standards of a professional translation process. Subsequently, the questionnaire was administered in a prospective observational study including 102 patients who had undergone lymph node dissection (LND) within gynecologic cancer surgery. Various test quality criteria were calculated for the GCLQ-GER. As gold standard of testing methods, patients were clinically evaluated for LEL, and limb volume measurements were taken. Further data for lymphedema treatment were collected in patients with lymphedema diagnosis.

RESULTS

Patients with LEL had increased GCLQ-GER total scores (mean 7.27) compared to patients without LEL (mean 1.81), p < 0.001. High diagnostic accuracy was indicated by the large area under the receiver operating characteristics curve (AUC) of 0.874 (95% CI 0.802-0.946). Based on sensitivity and specificity values ≥ 79.0%, the GCLQ total score ≥ 4 was determined as the optimal cut-off value to identify LEL. Excellent internal consistency was demonstrated by Cronbach's alpha of 0.876. The clinical examination revealed a LEL prevalence of 48.0% (n = 49), and 85.7% (n = 42) of these patients received treatment.

CONCLUSION

The GCLQ-GER is a valid and feasible patient-reported outcome measure for lymphedema detection in German-speaking gynecologic cancer survivors. Its clinical introduction could improve secondary prevention of lymphedema and real-world treatment.

Clinical impact of surgical energy device (Caiman®) IN elderly patients with Endometrial Cancer (protocol ID: Cineca)

STUDY OBJECTIVE

To investigate the clinical performance of the Caiman® energy device in class A radical laparoscopic hysterectomy (RLH) according to Querleu-Morrow classification, combined with bilateral salpingo-oophorectomy (BSO) and pelvic lymph node assessment in elderly patients with early-stage endometrial cancer (EC), specifically focusing on hemostatic effectiveness and safety.

DESIGN

Single-institution, prospective observational study.

SETTING

Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

PATIENTS

Forty-three women over 65 years with FIGO stage IA or IB endometrioid EC were enrolled from September 2021 to August 2023.

INTERVENTIONS

Use of Caiman® energy device in RLH combined with BSO and pelvic lymph node assessment in elderly patients.

MEASUREMENTS

The primary endpoint was operative time, with secondary endpoints including perioperative outcomes and postoperative complications.

MAIN RESULTS

Results demonstrated a median surgical time of 135 min, with no significant intraoperative complications attributed to the Caiman® device. Postoperative complications were minimal, with no severe complications (Grade 4 or 5) and a median hospital stay of two days.

CONCLUSION

The study highlights the advantages of the Caiman® in enhancing surgical efficiency while minimizing risks for elderly patients, suggesting its potential for improving resource allocation and patient outcomes in oncologic surgery. The findings of this study suggest the feasibility of using the Caiman® device for surgical procedures in elderly patients with early-stage endometrial cancer. Future prospective randomized trials are needed to establish its efficacy compared to traditional surgical methods.

Effects of aerobic cycling training in patients with gynaecologic cancer-related lower extremity lymphedema: A randomised comparative study

PURPOSE

Lower extremity lymphedema (LEL) after gynaecological cancer is a chronic disease that affects quality of life and functionality negatively. Exercise therapies help to volume reduction and improved lower extremity functionality and quality of life in patients with lymphedema. However, studies on this subject were mostly focused on upper extremity lymphedema. In this study, we aimed to compare complete decongestive therapy (CDT) and CDT + cycle ergometry in terms of quality of life, lower extremity functionality and volume measurement in patients with gynaecological cancer-related lower extremity lymphedema.

METHODS

This study included 63 patients who gave written and verbal informed consent. The participants were randomly divided into two groups as cycling (32 patients) and non-cycling group (31 patients). Demographic and clinical data of patients were recorded. While patients in non-cycling group were treated with only CDT for 3 weeks, patients in cycling group were treated with CDT + cycle ergometry for 3 weeks. Cycle ergometry treatment was performed with Voit AT-200 Black Collection horizontal bike for 20 min. Exercise intensity was adjusted to 40-59% of heart rate reserve (HRR). Volume measurement was evaluated by circumference measurement method, quality of life was evaluated by Lymphedema Quality of Life Questionnaire (LYMQOL) and lower extremity functionality was evaluated by Lower Extremity Functional Scale (LEFS) in all participants.

RESULT

Both cycling group and non-cycling group benefited from treatments in terms of volume reduction, LEFS and LYMQOL (function, appearance, symptom, mood and overall quality of life) values (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively). In comparison of cycling and non-cycling groups, significant differences were found in favor of cycling group in terms of delta (Δ) extremity volume values (ml), Δ LEFS, Δ LYMQOL (function, appearance, symptom, mood and overall quality of life) (p = 0.04, p = 0.03, p < 0.001, p = 0.04, p = 0.002, p = 0.002, p < 0.001, p < 0.001 and p = 0.003, respectively). In other words; both groups benefited from treatments in terms of volume reduction, functionality and quality of life. However, benefit of cycling group is greater than benefit of non-cycling group.

CONCLUSION

Aerobic exercise added to CDT in gynaecological cancer-related lower extremity lymphedema is effective in terms of volume reduction, improved lower extremity functionality and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06200948 .

Prevalence of lower extremity edema following inguinal lymphadenectomy: A systematic review and meta-analysis

Background

Lower extremity lymphedema (LEL) can develop because of inguinal lymph node dissection in the treatment of gynecologic, genitourinary, and dermatological malignancies. To optimize patient counseling and patient selection for microsurgical interventions aimed at preventing or treating LEL, its prevalence and associated patient characteristics must be accurately documented. This systematic review and meta-analysis provides a comprehensive overview of literature on the reported prevalence of LEL in patients undergoing inguinal lymphadenectomy.

Methods

From Embase, PubMed, and Web of Science databases, 23 studies were identified that met the inclusion criteria. This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies-of Exposure tool.

Results

Random-effects meta-analyses of proportions estimated a 24% (95% confidence interval [CI]: 17-31) pooled prevalence of LEL with a high degree of heterogeneity between the studies (I2 =96%, p < 0.01). Subgroup analysis revealed significant differences in LEL prevalence based on the indications for inguinal lymphadenectomy. The pooled LEL prevalence was 25.75% (95% CI: 0.00-96.16) for patients who underwent lymphadenectomy for melanoma, 12.22% (95% CI: 1.03-23.40) for penile cancer, 30.96% (95% CI: 21.08-40.84) for vulvar cancer, and 13.62% (95% CI: 0.00-51.02) for miscellaneous indications.

Conclusion

The findings from this study emphasize the importance of considering malignancy etiology when assessing the risk of LEL following inguinal lymphadenectomy. This knowledge could aid physicians in informing patients about the risk of LEL, while also facilitating proper patient selection for microsurgical interventions.

Evaluation of Respiratory Function, Respiratory Muscle Strength, Physical Activity, and Functionality in Patients with Lower Extremity Lymphedema

Background: Lymphedema is a chronic, progressive condition that has major physical and psychological consequences. It was aimed to examine the respiratory functions, respiratory muscle strength, physical activity level, and functionality of patients with lower extremity lymphedema and to compare them with healthy controls. Methods and Results: A total of 82 individuals (29.3% male, 70.7% female, with a mean age of 49.89 ± 15.07 years) with lower extremity lymphedema (Group 1) and healthy individuals (Group 2) were included. Respiratory functions of the participants were evaluated by spirometry, respiratory muscle strength by maximum oral pressure measurements, physical activity levels using the International Physical Activity Questionnaire-Short Form (IPAQ-SF), functionality by Lower Extremity Functional Scale (LEFS) and Timed Up and Go test (TUG test). All respiratory function test measurements were lower in mean Group 1 than in Group 2 (p < 0.05). While inspiratory muscle strength did not differ between the groups (p > 0.05), expiratory muscle strength was lower in Group 1 than Group 2 (p < 0.05). Although spent time and energy for sitting were higher in Group 1 (p < 0.05), IPAQ vigorous-, moderate-, and light-intensity physical activity (MET-min/week) and IPAQ-total score did not differ between groups (p > 0.05). In Group 1, mean of LEFS score was lower and TUG test (seconds) in Group 1 was longer compared to Group 2 (p < 0.05). Conclusions: Respiratory functions, expiratory muscle strength, and functionality in patients with lower extremity lymphedema were adversely affected; however, inspiratory muscle strength and physical activity levels were similar to those of healthy controls.

Prevalence of lymphedema symptoms across cancer diagnoses and association with depression, pain interference and health-related quality of life

BACKGROUND AND PURPOSE

Lymphedema is a debilitating late effect of cancer treatments, yet its prevalence beyond breast cancer remains understudied. This study examined the prevalence of lymphedema symptoms across cancer diagnoses and their association with depression, pain interference, and health-related quality of life (HRQoL).

PATIENTS/MATERIAL AND METHODS

This cross-sectional study was conducted at the Department of Oncology, Copenhagen University Hospital, from February to April 2021, as part of a broader investigation into cancer-related late effects. Here, we present data from patients in follow-up who received online lymphedema symptom assesments (swelling, heaviness, or tightness). Utilized questionnaires were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the Major Depression Inventory, and the Brief Pain Inventory. Associations between lymphedema symptoms and depression, pain interference, and HRQoL were examined via multiple linear regression.

RESULTS

Of 1,901 patients in follow-up who received the lymphedema symptom items, 1,296 responded. Most participants had breast cancer (48%), followed by testicular (17%), gynecological (16%), and head/neck cancer (11%). One-third (n = 397) reported lymphedema symptoms, with 38% (n = 152) reporting moderate/severe symptoms. The highest symptom prevalence was seen in gynecological cancer (59%), followed by head/neck (41%), breast (21%), and testicular cancer (19%). Participants with moderate/severe lymphedema symptoms were significantly more likely to report higher depression and pain interference scores and lower HRQoL scores compared to those with no/mild symptoms.

INTERPRETATION

Lymphedema symptoms are highly prevalent among patients who have completed treatment for diverse cancers and associated with higher scores for depression and pain interference, and lower HRQoL.

Preserving circumflex iliac lymph nodes to reduce the incidence of lower limb lymphedema following lymphadenectomy in cervical and endometrial cancers: A prospective randomized controlled trial

Lower limb lymphedema (LLL) is a common postoperative complication following lymphadenectomy in cervical and endometrial cancers. Removal of the circumflex iliac nodes distal to the external iliac node (CINDEIN) is associated with LLL. Here, we sought to evaluate whether preserving the CINDEIN is helpful in reducing the incidence of LLL in women with cervical and endometrial cancers and to evaluate the safety of preserving CINDEIN. In this prospective randomized controlled trial, patients with clinical stage I A2 to II A cervical cancer and stage I to III endometrial carcinoma undergoing surgery were randomly assigned (1:1) to undergo pelvic lymphadenectomy with CINDEIN removal or preservation. The primary endpoint was the incidence of LLL at 24 months post-surgery. Eligible patients underwent sentinel lymph node (SLN) mapping with carbon nanoparticles (CNP). The study was registered with ClinicalTrials.gov, number ChiCTR2300071911. Between Jun 1, 2017, and Dec 31, 2018, 328 participants were randomly assigned to the two groups. Thirteen patients were excluded from the lymphedema analysis. A total of 158 patients in the CINDEIN preservation group and 157 in the CINDEIN removal group completed the follow-up examination. At baseline, no significant differences were observed between the two groups. The 3-year overall survival rate was 96.9% in the preservation group and 95.7% in the resection group. For cervical cancer and endometrial carcinoma, the incidence of LLL were significantly lower in the preservation group than in the removal group both at 24 months. No differences in the occurrence time of LLL were observed between the two groups. The LLL stages also showed no significant difference between the two groups. In the removal group, no CINDEIN metastases were identified in any patient. A total of 125 evaluable patients received the injection of CNP. None of the patients had CINDEIN detected as SLNs. CINDEIN removal is an important risk factor for LLL following lymphadenectomy in cervical and endometrial cancers. The metastasis rate of CINDEIN in cervical cancer and early endometrial cancer is relatively low, and preserving CINDEIN might be safe and helpful in reducing the occurrence of LLL.

Patterns of patient-reported outcomes (PROs) in a diverse group of gynecologic cancer survivors

OBJECTIVES

Racial and ethnic disparities in patient-reported outcomes (PROs) among gynecologic cancer survivors are not well studied. We evaluated whether individual-level characteristics were associated with PROs in diverse gynecologic cancer survivors.

METHODS

Gynecologic cancer patients in an ambulatory oncology clinic completed a psychosocial and practical needs assessment before their appointments through the electronic medical record (EMR) patient portal. Assessments were available in English and Spanish. Fatigue, pain, physical function, depression, and anxiety were assessed with Patient-Reported Outcomes Measurement Information System (PROMIS®) computer adaptive tests, and health-related quality of life was assessed by FACT-G7. PROs were dichotomized based on severity (normal/mild vs moderate/severe). Demographic and clinical information was collected. Analyses were performed using Chi-square, t-tests, and Kruskal-Wallis tests.

RESULTS

A total of 582 women completed the assessment; 20% (n = 116) were racial minorities, and 54.5% (n = 310) were Hispanic. A total of 192 (32.8%) completed the assessments in Spanish. Hispanic patients had lower mean fatigue scores (49.31 vs 51.74, p = 0.01), and patients whose preferred language was Spanish had lower mean depression (47.63 vs 48.97, p = 0.05) and fatigue scores (48.27 vs 51.27, p < 0.01). There were no significant differences in the severity of PROs by race, ethnicity, or preferred language. QOL scores were worse in patients with high symptom severity for anxiety (p = 0.04) and physical functioning (p < 0.01). Current smokers had worse physical functioning (13.4% vs 6.5%, p = 0.03).

CONCLUSIONS

We found no significant differences in severity of PROs by race, ethnicity, or preferred language. Quality of life scores were worse for patients with high symptom severity for physical functioning and anxiety.

Lymphovenous anastomosis and complex decongestive therapy for severe deformed lymphedema with recurrent infection: A case report

BACKGROUND

Lower extremity lymphedema is a common complication following treatment for gynecological malignancies. Its incidence rate can reach up to 70%, affecting ~20 million people worldwide. However, specialized treatment centers are scarce, and there is a lack of consensus on treatment approaches. Furthermore, there are even fewer reports on the systematic and effective treatment of severe lymphedema with malformations. Effective management of this condition remains a significant challenge for clinicians.

CASE SUMMARY

A 40-year-old woman developed bilateral leg swelling 6 years after receiving treatment for endometrial cancer. Since August 2018, she experienced > 30 episodes of lymphangitis. Upon presentation, she exhibited bilateral leg swelling and deformation, with four large swellings in the posterior thigh that impeded movement, and pain in the limbs. Skin manifestations included lichenoid lesions and features of deep sclerosis. Radionuclide lymphoscintigraphy confirmed the diagnosis of lower limb lymphedema. After 6 mo of complex decongestive therapy (CDT) and three lymphaticovenous anastomosis (LVA) treatments, the patient lost 49 kg in weight. She also experienced a maximum circumference reduction of 35.2 cm in the left lower limb and 37.5 cm in the right lower limb. The leg pain disappeared, her swelling significantly decreased, and she regained the ability to walk, cycle, and run normally.

CONCLUSION

The combined application of CDT and LVA therapy demonstrates significant positive effects in the treatment of severe, deformed stage III lymphedema.

Risks and benefits of sentinel lymph node evaluation in the management of endometrial intraepithelial neoplasia

INTRODUCTION

Endometroid intraepithelial neoplasia (EIN) is a premalignant lesion to endometrial cancer. Increasing number of gynecologic oncologists are performing sentinel lymph node (SLN) evaluation during hysterectomy for EIN to ensure complete staging if there is cancer on the final specimen. However, there are no clear guidelines and the benefits and risks to performing SLN evaluation for EIN patients are unclear.

AREAS COVERED

This narrative review examines the advantages and disadvantages of SLN evaluation for EIN patients and provides an algorithm to assist clinicians in selectively applying the procedure for maximal patient benefit. Relevant articles up to March 2024 were obtained from a PubMed search on SLN use with endometrial pathology.

EXPERT OPINION

Sentinel lymph node evaluation for patients with EIN is safe, feasible, and particularly important for the approximately 10% of patients with high-risk endometrial carcinoma on final pathology. However, as most diagnosed carcinomas are low-risk, SLN evaluation would have limited oncologic benefit. While SLN assessment may overtreat most patients with EIN, a significant minority of patients will be improperly staged. We propose an algorithm highlighting the importance of maximal preoperative endometrial sampling and stratifying patients via risk factors to selectively identify those who would benefit most from SLN evaluation.

The Experience of Cervical Cancer Patients Undergoing Hysterectomy: A Qualitative Study

INTRODUCTION

Due to different social and cultural backgrounds, cervical cancer patients' experience of the treatment process and quality of life after treatment will be different. This study sought to gain in-depth understanding of the experiences of Chinese cervical cancer patients as regards their quality of life and physical symptoms.

METHODOLOGY

Semi-structured interviews were used to collect data. We recruited 15 women with cervical cancer in eastern China for in-depth interviews. All data were entered into the NVivo 12 software program for analysis.

RESULTS

Four themes emerged from the data: (a) uncertainty; (b) physical suffering; (c) psychological pressure; and (d) challenges of marriage and family.

DISCUSSION

Cervical cancer patients showed concerns about the disease itself and the physical discomfort it causes, as well as changes in social relations. Health professionals need to talk about these issues and develop strategies to address them accordingly.

Lower limb lymphedema after surgical staging for endometrial cancer: Current insights and future directions

Lower extremity lymphedema (LEL) is a common complication following surgical staging of endometrial cancer. LEL is a chronic condition associated with significant impact on patient morbidity and quality of life (QoL). This review aimed to report the current evidence in the literature on secondary LEL after surgical staging for endometrial cancer, focusing on the incidence based on different approaches to lymph node staging, diagnosis, risk factors, and the impact on QoL. Due to the absence of a standardized agreement regarding the methodology for evaluating LEL, the documented frequency of occurrence fluctuates across different studies, ranging from 0% to 50%. Systematic pelvic lymphadenectomy appears to be the primary determinant associated with the emergence of LEL, whereas the implementation of sentinel lymph node biopsy has notably diminished the occurrence of this lymphatic complication after endometrial cancer staging. LEL is strongly associated with decreased QoL, lower limb function, and negative body image, and has a detrimental impact on cancer-related distress reported by survivors. Standardization of lymphedema assessment is needed, along with cross-cultural adaptation of subjective outcome measures for self-reported LEL. The advent of sentinel lymph node mapping represents the ideal approach for accurate nodal assessment with less short- and long-term morbidity. Further research is needed to definitively assess the prevalence and risk factors of LEL and to identify strategies to improve limb function and QoL in cancer survivors with this chronic condition.

Adjuvant Radiotherapy for Groin Node Metastases Following Surgery for Vulvar Cancer: A Systematic Review

Background: Lymph node metastasis in vulvar cancer is a critical prognostic factor associated with higher recurrence and decreased survival. A survival benefit is reported with adjuvant radiotherapy but with potential significant morbidity. We aim to clarify whether there is high-quality evidence to support the use of adjuvant radiotherapy in this setting. Objectives: The aim of the study was to assess the effectiveness and safety of adjuvant radiotherapy to locoregional metastatic nodal areas. Search Methods: We conducted a comprehensive and systematic literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the National Cancer Institute. We considered only randomized controlled trials (RCTs). Main Results: We identified 1,760 records and finally retrieved only one eligible RCT (114 participants with positive inguinofemoral lymph nodes). All women had undergone radical vulvectomy and bilateral inguinal lymphadenectomy and had been randomized to adjuvant radiotherapy or to intraoperative ipsilateral pelvic lymphadenectomy without adjuvant radiotherapy. At 6 years, the overall survival (OS) was 51% versus 41% in favor of radiotherapy (HR 0.61; 95% CI 0.30-1.3) without significance and with very low certainty of evidence. At 6 year, the cumulative incidence of cancer-related deaths was 29% versus 51% in favor of adjuvant radiotherapy (HR 0.49; 95% CI 0.28-0.87). Recurrence-free survival at 6 years was 59% after adjuvant radiotherapy versus 48% after pelvic lymphadenectomy (HR 0.39; 95% CI 0.17-0.88). Three (5.3%) versus 13 (24.1%) groin recurrences were noted, respectively, in the adjuvant radiotherapy and pelvic lymphadenectomy groups. There was no significant difference in acute toxicities for pelvic lymphadenectomy compared to radiotherapy. In women with positive pelvic lymph nodes (20%), the OS at 6 year was 36% compared with 13% in favor of adjuvant radiotherapy. Late cutaneous toxicity rate appeared to be greater after radiotherapy (19% vs. 15%) but with less chronic lymphedema (16% vs. 22%). Conclusion: There is only very low-quality evidence on administering adjuvant radiotherapy for inguinal lymph node metastases. Although the identified study was a multicenter RCT, there was a reasonable imprecision and inconsistency because of small study numbers, wide confidence intervals in the data, and early trial closure, resulting in downgrading of the evidence.

Detection of metastatic lymph node and sentinel lymph node mapping ​using mannose receptor targeting in in vivo mouse footpad tumor models and rabbit uterine cancer models

BACKGROUND

This study aimed to evaluate the effectiveness of neo-mannosyl human serum albumin-indocyanine green (MSA-ICG) for detecting metastatic lymph node (LN) and mapping sentinel lymph node (SLN) using mouse footpad uterine tumor models. Additionally, the authors assessed the feasibility of MSA-ICG in SLN mapping in rabbit uterine cancer models.

MATERIALS AND METHODS

The authors compared the LN targeting ability of MSA-ICG with ICG. Six mouse footpad tumor models and two normal mice were each assigned to MSA-ICG and ICG, respectively. After the assigned tracers were injected, fluorescence images were taken, and the authors compared the signal-to-background ratio (SBR) of the tracers. A SLN biopsy was performed to confirm LN metastasis status and CD206 expression level. Finally, an intraoperative SLN biopsy was performed in rabbit uterine cancer models using MSA-ICG.

RESULTS

The authors detected 14 groin LNs out of 16 in the MSA-ICG and ICG groups. The SBR of the MSA-ICG group was significantly higher than that of the ICG group. The metastatic LN subgroup of MSA-ICG showed a significantly higher SBR than that of ICG. CD206 was expressed at a high level in metastatic LN, and the signal intensity difference increased as the CD206 expression level increased. SLN mapping was successfully performed in two of the three rabbit uterine cancer models.

CONCLUSIONS

MSA-ICG was able to distinguish metastatic LN for an extended period due to its specific tumor-associated macrophage-targeting property. Therefore, it may be a more distinguishable tracer for identifying metastatic LNs and SLNs during uterine cancer surgery. Further research is needed to confirm these results.

Lymphedema self-assessment among endometrial cancer survivors

PURPOSE

Lower extremity lymphedema (LEL), which causes ankle, leg, and feet swelling, poses a significant challenge for endometrial cancer survivors, impacting physical functioning and psychological well-being. Inconsistent LEL diagnostic methods result in wide-ranging LEL incidence estimates.

METHODS

We calculated the cumulative incidence of LEL based on survivor-reported Gynecologic Cancer Lymphedema Questionnaire (GCLQ) responses in addition to survivor- and nurse-reported leg circumference measurements among a pilot sample of 50 endometrial cancer survivors (27 White, 23 Black) enrolled in the ongoing population-based Carolina Endometrial Cancer Study.

RESULTS

Self-leg circumference measurements were perceived to be difficult and were completed by only 17 survivors. Diagnostic accuracy testing measures (sensitivity, specificity, positive and negative predictive value) compared the standard nurse-measured ≥ 10% difference in leg circumference measurements to GCLQ responses. At a mean of ~11 months post-diagnosis, 54% of survivors met established criteria for LEL based on ≥ 4 GCLQ cutpoint while 24% had LEL based on nurse-measurement. Percent agreement, sensitivity, and specificity approximated 60% at a threshold of ≥ 5 GCLQ symptoms. However, Cohen's kappa, a measure of reliability that corrects for agreement by chance, was highest at ≥ 4 GCLQ symptoms (κ = 0.27).

CONCLUSION

Our findings emphasize the need for high quality measurements of LEL that are feasible for epidemiologic study designs among endometrial cancer survivors. Future studies should use patient-reported survey measures to assess lymphedema burden and quality of life outcomes among endometrial cancer survivors.

Lower Limb Lymphedema Awareness among Gynecological Cancer Patients: An International Survey Supported by the European Network of Gynecological Cancer Advocacy Groups (ENGAGe) Group

INTRODUCTION

Patient awareness of postoperative lymphedema in the field of gynecologic oncology has been poorly documented in the international literature. We wished to capture and document the awareness among gynecological cancer survivors about postoperative lymphedema, including aspects such as the adequacy of perioperative counseling, management, and quality of life.

METHODS

A web-based survey comprising 25 multiple-choice questions was distributed to gynecological cancer advocacy groups within the European Network of Gynecological Cancer Advocacy Groups (ENGAGe) group. The survey was validated in a pilot group of gynecological patients prior to distribution.

RESULTS

Overall, 386 women from 20 countries completed the questionnaire. Only half of the patients (n = 211) knew what lymphedema is, whereas 52% of the respondents stated that they were never informed at their pre-operative assessment about the potential risk of developing lymphedema. Fifty-three percent of those women who were informed about the risk and management of lymphedema received information through self-initiative, connecting mainly with patient groups or online. Approximately 84% of patients with lymphedema reported that they informed their doctor about their symptoms. Ninety-four patients (55.3%, which is not 55% of the 386) were treated for lymphedema. Forty-five women out of 136 reported that lymphedema significantly affected their everyday lives.

DISCUSSION

We report a large lack of awareness and a significant gap of knowledge about the risks and treatment options related to postoperative lymphedema among gynecological cancer survivors. Institutional practice routines and awareness among professionals need to be urgently recalled and adapted to adequately inform and support gynecological cancer patients.

Preoperative evaluation and a nomogram prediction model for pelvic lymph node metastasis in endometrial cancer

OBJECTIVE

The primary objective of this study is to explore the preoperative risk factors of pelvic lymph node metastasis (PLNM) in endometrial cancer patients, and construct a nomogram prediction model.

MATERIALS AND METHODS

We retrospectively collected various preoperative clinical characteristics of patients and analyzed their relationship with PLNM. Logistic regression analysis was used to screen for independent risk factors for PLNM of endometrial cancer. A nomogram prediction model was constructed, the receiver operating characteristic (ROC), calibration curve and decision curve analysis (DCA) were constructed and used to assess discrimination, calibration, and net benefit.

RESULTS

Out of the 276 patients, 74 (26.81%) with postoperative pathological confirmation of PLNM. Multivariate logistic regressive analysis demonstrated that preoperative depth of myometrial invasion (DIM) ≥50% determined by Magnetic Resonance Imaging (MRI) (p = 0.003), carbohydrate antigen 125 (CA125) (p = 0.030), carbohydrate antigen 19-9 (CA 19-9) (p = 0.044), and platelet/lymphocyte ratio (PLR) (p = 0.025) could serve as independent risk factors for PLNM. A risk factors-based nomogram prediction model was constructed, which showed good discrimination (AUC = 0.841, p < 0.001) and good efficacy (C-index = 0.842) and good calibration (mean absolute error = 0.046). DCA showed that the model can provide clinical benefits.

CONCLUSIONS

Preoperative DIM ≥50% determined by MRI, serum CA 19-9, CA125 and PLR could be utilized to predict PLNM in endometrial cancer patients. This nomogram prediction model can provide preoperative help for evaluation and identification of patients with endometrial cancer, and provide a theoretical basis for clinical intervention.

Positive Impact of a New Compressive Garment in Patients with Genital Lymphedema: OLYMPY Study

Purpose: Genital lymphedema is a chronic debilitating condition associated with highly impaired health-related quality of life (QoL). This prospective multicenter study evaluated the use of a new compressive garment in patients with secondary and primary genital lymphedema. Methods: Thirty-two patients prospectively enrolled were advised to wear the compressive garment for 12 weeks (day and night). The primary endpoint was change in patient-reported QoL at 12 weeks via the patient global impression of change (PGI-C) instrument. Secondary outcomes included change in other QoL measures at 12 weeks (visual analog scale, Lymphedema Quality of Life Inventory [LyQLI], and EQ-5D questionnaires), lymphedema severity (genital lymphedema score [GLS]), and physician assessment (Clinical Global Impression-Improvement [CGI-I]). Safety and tolerability were also assessed. Results: After 12 weeks, improvement was reported in 78.6% of patients (PGI-C). Physician assessment (CGI-I) indicated clinical improvement in 82.8% of patients. Patient assessment of lymphedema symptoms showed a significant decrease in discomfort (p = 0.02) and swelling (p = 0.01). Significant declines in the mean global GLS (p < 0.0001), and in the proportion of patients reporting heaviness, tightness, swelling, or urinary dysfunction (p < 0.05 for all), were also observed. LyQLI scores decreased (indicating improved QoL) in each of the physical, psychosocial (p = 0.05), and practical domains. The compressive garment was well tolerated with high compliance, and adverse events (due to swelling or discomfort) led to permanent discontinuation in only three patients. Conclusion: The use of a new genital compression garment over 12 weeks improves the QoL and clinical measures in patients with genital lymphedema (ClinicalTrials.gov ID: NCT04602559; Registration: October 20, 2020).

Side effects screening and early intervention to impact in quality of life of patients with gynecological cancers (HALIS study)

BACKGROUND

Advances in the treatment of gynecological cancers have led to increased survival in patients with gynecological cancers. Nevertheless, patients may still experience prevalent long term consequences, including lower limb lymphedema, depression, anxiety, sexual dysfunction, malnutrition, and sarcopenia, that negatively impact their quality of life.

PRIMARY OBJECTIVE

To assess the impact on self-perceived quality of life of systematic screening and early treatment of lower limb lymphedema, anxiety and depression, sexual dysfunction, and sarcopenia and malnutrition compared with standard practice.

STUDY HYPOTHESIS

Systematic screening with validated questionnaires leading to early diagnosis and treatment of side effects will have a positive impact on quality of life.

TRIAL DESIGN

This prospective clinical trial will randomize candidates for surgery to either standard of care or systematic screening every 2 months for 2 years. Quality of life data will be collected every 4 months. After randomization, patients in the control group will follow standard usual care. Their screening scales will not be considered. In the experimental group, positive screenings will generate an alert to the physician, and patients will be referred to the corresponding specific area (rehabilitation unit, psycho-oncology unit, sexual health unit, or nutrition unit).

MAJOR INCLUSION AND XCLUSION CRITERIA

Patients aged ≥18 years with ovarian, cervical, or endometrial cancer who are candidates for surgery will be included.

PRIMARY ENDPOINT

Self-reported quality of life questionnaire score.

SAMPLE SIZE

168 patients will be randomized to detect a difference of 6 points in the questionnaires.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

Study completion is estimated for January 2026 and the results will be presented in May 2026.

TRIAL REGISTRATION NUMBER

NCT05918770.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients

Background  This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods  The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results  The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p  < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p  < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p  = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p  = 0.659, r  = - 0.041), and amount of limb volume reduction ( p  = 0.454, r  = - 0.070) showed no statistical significance. Conclusion  The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Impaired sexual health among women treated for vulvar cancer: An integrated review

BACKGROUND

Although gynaecological cancer's negative effects on sexual function are well known, most studies on the subject have not included vulvar cancer patients or a multidimensional perspective on sexual health. Therefore, this review aimed to address this research gap and explored the impact of vulvar cancer on women's sexual health from a multidimensional perspective.

METHODOLOGY

An integrated review was conducted, as described by Whittemore and Knafl. The PubMed, CINAHL, PsycINFO and Embase databases were searched in March 2021 and updated in August 2022 and March 2023. The data were thematically analysed using NVivo, and the PRISMA-ScR and ENTREQ guidelines were followed.

FINDINGS

The following themes were identified in the 28 reviewed articles: impact of a changed female body, impact on women's sexual identity, consequences for women's sexual relationships and unmet needs and loneliness caused by taboos about sexual health.

DISCUSSION

Women's impaired sexual health after vulvar cancer points to a great need to understand and holistically investigate sexual health. In addition, healthcare professionals have an obligation to care for the sexual health issues of patients with vulvar cancer. However, most questionnaires used in the selected studies revealed a narrow understanding of sexual health and focused on sexuality as a genital activity.

CONCLUSION

The sexual health of women with vulvar cancer was tabooed and stigmatised for patients and healthcare professionals. Consequently, women received sparse sexual guidance, felt isolated and had unmet needs.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need knowledge and training on how to break taboos and address the sexual needs of vulvar cancer patients. Systematic screenings for sexual health needs should be conducted using a multidimensional perspective.

TRIAL AND PROTOCOL REGISTRATION

The protocol was preregistered at the Open Science Framework (www.osf.io), registration DOI: https://doi.org/10.17605/OSF.IO/YDA2Q PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Impact of comorbidities and extent of lymphadenectomy on quality of life in endometrial cancer patients treated with minimally invasive surgery in the era of sentinel lymph nodes

OBJECTIVE

To identify predictors of quality of life (QoL) among patients who undergo surgical staging with sentinel lymph node (SLN) biopsy or lymphadenectomy for endometrial cancer.

METHODS

Patients who underwent minimally invasive surgery for primary endometrial cancer at the Mayo Clinic from October 2013 to June 2016 were mailed a 30-item QoL in Cancer survey (QLQ-C30) and a validated 13-item lower extremity lymphedema screening questionnaire. Patients who answered <50% of the items or had a pre-operative history of lymphedema were excluded. Multivariable linear regression models were fit to evaluate predictors of QoL using inverse-probability of treatment weighting to adjust for differences at the time of the surgery between the lymphadenectomy and SLN groups.

RESULTS

The 221 patients included in the analysis were stratified into two groups: patients who underwent (1) bilateral lymphadenectomy as 'backup' after SLN mapping (lymphadenectomy group; n=101) or (2) SLN removal with or without side-specific lymphadenectomy (SLN group; n=120). On multivariable analysis, obesity, lower extremity lymphedema, and kidney disease had significant (p<0.05) and clinically meaningful negative impacts on global QoL. Declines in average adjusted global QoL scores were marked (19.7 points lower) in patients with BMI ≥40 kg/m2 and lower extremity lymphedema compared with non-obese patients without lower extremity lymphedema. In contrast, there was only a 2.9 point difference in the adjusted average global QoL score between the SLN and lymphadenectomy groups.

CONCLUSIONS

Lower extremity lymphedema coupled with obesity predicts poorer QoL in patients who undergo surgical staging for endometrial cancer. In this population, reduction of lower extremity lymphedema by performing SLN instead of lymphadenectomy and earlier targeted interventions may improve patients' QoL. Future research focusing on targeted interventions is needed.

Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer

Sentinel node biopsy (SNB) is performed worldwide in patients with endometrial cancer (EC). The aim of this study was to evaluate and compare the occurrence rate of lymphatic complications between SNB and pelvic lymphadenectomy (LND) for EC. The medical records of women who underwent SNB or pelvic LND for EC between September 2012 and April 2022 were assessed. A total of 388 patients were enrolled in the current study. Among them, 201 patients underwent SNB and 187 patients underwent pelvic LND. The occurrence rates of lower-extremity lymphedema (LEL) and pelvic lymphocele (PL) were compared between the patients who underwent SNB and those who underwent pelvic LND. The SNB group had a significantly lower occurrence rate of lower-extremity LEL than the pelvic LND group (2.0% vs. 21.3%, p < 0.01). There were no patients who had PL in the SNB group; however, 4 (2.1%) patients in the pelvic LND group had PL. The occurrence rates of lower-extremity LEL and PL were significantly lower in patients who underwent SNB than those who underwent pelvic LND. SNB for EC has a lower risk of lymphatic complications compared to systemic LND.

European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

BACKGROUND

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer.

OBJECTIVE

To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer.

METHODS

The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives.

RESULTS

The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Analysis of load status and management strategies of main caregivers of patients with malignant tumors of digestive tract

Caregiver load refers to the subjective and objective negative impact of caregivers in the care of patients, and excessive load will have a serious impact on patients and caregivers themselves and can reduce their quality of life. For the main caregivers, it not only needs to care for the patients in life and daily life, but also needs to pay the cost of treatment for the patients, coupled with the need to carry out their own original work, life, etc. excessive life pressure, economic pressure, work pressure, emotional pressure, etc. lead to heavy load of the main caregivers, which can easily cause caregivers to have different degrees of psychological problems, which will cause serious adverse effects on the caregivers themselves and cancer patients, not conducive to the construction of a harmonious family and society. This article analyzes the current situation of primary caregiver burden in patients with gastrointestinal malignant tumors, analyzes its influencing factors, and specifies specific treatment strategies. It is hoped to provide scientific guidance for later related research and application.

Sentinel Lymph Node Impact on the Quality of Life of Patients with Endometrial Cancer

OBJECTIVE

Given the improvement in the surgical treatment of endometrial cancer with the inclusion of sentinel lymph node biopsy (SLNB), our aim was to evaluate the impact of this minimally invasive and tailored nodal assessment on patients' quality of life (QoL).

METHODS

This was a cross-sectional study conducted in a single-centre, tertiary-level hospital. Patients diagnosed with preoperative early-stage endometrial cancer, who underwent primary surgical treatment between August 2015 and November 2021, were included. The enrolled patients were divided into two cohorts according to the nodal staging performed: the first group underwent only SLNB (SLNB group); the second group underwent pelvic and/or para-aortic lymphadenectomy (LND group). We evaluated the overall QoL using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life core 30-item questionnaire (EORTC QLQ-C30) and a sexual health questionnaire (EORTC SHQ-C20). The scores were compared between the groups.

RESULTS

Ninety patients were enrolled in the study: 61 (67.8%) in the SLNB group and 29 (32.2%) in the LND group. In the LND group, 24 (82.7%) patients underwent pelvic and para-aortic LND, while 5 (17.3%) patients underwent pelvic LND. The assessment of the functional scales showed better results for the SLNB group than for the LND group, with a significantly lower impact on physical status (8.2% vs. 25%, respectively; p = 0.031). In terms of the symptom scales, the SLNB group reported a significantly lower negative impact on sleep quality (4.9% vs. 27.6%, respectively; p < 0.01), pain (1.6% vs. 13.8%, respectively; p = 0.019), and dyspnoea (0% vs. 10.3%, respectively; p = 0.011) than the LND group. The SLNB group had better results for all analysed items regarding sexual QoL.

CONCLUSIONS

The implementation of a surgical technique with SLNB improved patients' overall QoL by increasing their well-being in the functional and symptom spheres.

Factors associated with health-related quality of life in gynaecologic cancer survivors with lower limb lymphedema: a cross-sectional study in Taiwan

BACKGROUNDS

Gynaecological cancer survivors may develop lower limb lymphoedema after surgery, which negatively impacts quality of life. The purposes of this study were (1) to assess the levels of symptom distress, depression, body image, and health-related quality of life (HRQoL); (2) to recognize factors associated with HRQoL related in gynaecologic cancer survivors with lower limb lymphoedema.

METHODS

A cross-sectional study was conducted with convenience sampling of gynaecologic cancer survivors with lower limb lymphoedema. Gynaecologic cancer survivors were assessed for symptom distress, depression, body image, and HRQoL. Multiple regression analysis was conducted to recognize the factors associated with HRQoL. Independent-samples t-test was used to compare symptom distress, depression, body image, and HRQoL by grade of lymphoedema.

RESULTS

The most common distressing symptoms of lower limb lymphoedema were lower extremity oedema, lower extremity tightness, and lower extremity stiffness. Worse HRQoL was associated with more symptom distress, less satisfaction with body image, a high grade of lymphoedema, and a longer duration of lower limb lymphoedema. These factors explained 76.5% of the variance in HRQoL. Gynaecologic cancer survivors with late grade lymphoedema experienced lower HRQoL and higher levels of symptom distress, depression, and greater dissatisfaction with body image than those who had early grade lymphoedema.

CONCLUSIONS

Symptom distress had the strongest association with overall HRQoL and with all individual domains of HRQoL, except mental function. These results suggest that educating gynaecologic cancer survivors to assess lower limb lymphoedema-related problems, providing symptom management, and guiding survivors in physical activity to relieve lower extremity discomfort can improve HRQoL.

Impact of lymphadenectomy in patients with locally recurrent or persistent cervical cancer treated with salvage hysterectomy

AIM

To investigate the role of lymphadenectomy (LND) in locally recurrent or persistent cervical cancer patients treated with salvage hysterectomy.

METHODS

Locally recurrent or persistent cervical cancer patients treated with salvage hysterectomy, with or without LND, were identified. Patients were divided into two groups according to the status of radiologic evidence of lymph node metastasis, and the impact of LND was investigated by evaluating postoperative survival.

RESULTS

This study included 72 patients; 48 did not show radiological evidence of lymph node metastasis (Group 1) while 24 did (Group 2). Overall, the addition of LND to salvage hysterectomy resulted in increased postoperative complications. In Group 1, salvage hysterectomy plus LND resulted in the identification of five cases with false-negative lymph nodes (19.2%), but showed no advantage over salvage hysterectomy alone in terms of postoperative survival. In Group 2, all patients underwent LND, which resulted in the identification of eight cases with false-positive nodes (33.3%), and reasonably long postoperative survival. The estimated 3-year postoperative survival rate in this group was 39.7%.

CONCLUSION

Including LND in salvage hysterectomy allows for precise lymph node staging but increases risk of postoperative complications. However, considering the inability to improve survival, LND should not be performed during salvage hysterectomy in patients without radiological evidence of lymph node metastasis. In patients with radiological evidence of lymph node metastasis, salvage hysterectomy plus LND can only be performed in those who understand the risk of postoperative complications and the limited evidence supporting its survival advantage.

Water-based exercise for upper and lower limb lymphedema treatment

BACKGROUND

Lymphedema is a debilitating illness caused by insufficient lymph drainage, which can have serious physical and psychological consequences. Although water-based exercise can be useful, at present, little evidence is available regarding the outcomes of aquatic treatment for patients with lymphedema. Therefore, the aim of the present scoping review was to evaluate, from reported studies, the effects of water-based exercise on pain, limb motor function, quality of life (QoL), and limb volume among patients affected by primary and secondary upper and lower limb lymphedema.

METHODS

We performed a scoping review to examine clinical studies and randomized controlled trials reported in English from 2000 to 2021 by screening the MEDLINE (PubMed) and PEDro databases.

RESULTS

The search produced a total of 88 studies. Eight randomized controlled trials and one clinical study of patients with primary or secondary lymphedema of upper or lower limbs who had undergone water-based treatment were included in the present study. Most trials had focused on breast cancer-related lymphedema. The shoulder range of flexion, external rotation, and abduction have been shown to improve after performing a water-based exercise protocol. Some evidence has also demonstrated that the lymphedematous limb strength can improve. Moreover, water-based exercise seemed to improve pain perception and QoL for patients with upper or lower limb lymphedema. In contrast, in the control groups, the QoL showed a tendency to worsen over time. Although some studies had not reported beneficial effects on the lymphedematous limb volume, most of the studies examined had reported a reduction in volume, especially in the short term. No adverse events were reported in the included studies.

CONCLUSIONS

The findings from the present review have shown the potential for aquatic exercise in lymphedema management. However, at the same time, the findings underline the multiple limitations resulting from the heterogeneity in the study populations and related physical activity protocols. The role of aquatic exercise in the conservative treatment of lymphedema requires further investigation in the future to define specific protocols of application.

AB, McCook-Veal AA, Switchenko JM, Cole TE, Khanna N, Han CH, Gordon AN, Starbuck KD, Remick JS. Incidence and predictors of toxicity in the management of vulvar squamous cell carcinoma treated with radiation therapy

Purpose/Objective

Given the rarity of vulvar cancer, data on the incidence of acute and late severe toxicity and patients' symptom burden from radiotherapy (RT) are lacking.

Materials/Methods

This multi-center, single-institution study included patients with vulvar squamous cell carcinoma treated with curative intent RT between 2009 and 2020. Treatment-related acute and late grade ≥ 3 toxicities and late patient subjective symptoms (PSS) were recorded.

Results

Forty-two patients with predominantly stage III/IV disease (n = 25, 59.5 %) were treated with either definitive (n = 25, 59.5 %) or adjuvant (n = 17, 40.5 %) external beam RT to a median dose of 64 Gy and 59.4 Gy, respectively. Five patients received a brachytherapy boost with a median total dose of 84.3 Gy in 2 Gy-equivalent dose (EQD2). Intensity-modulated RT was used in 37 (88.1 %) of patients, and 25 patients (59.5 %) received concurrent chemotherapy. Median follow-up was 27 months. Acute grade ≥ 3 toxicity occurred in 17 patients (40.5 %), including 13 (31.0 %) acute grade 3 skin events. No factors, including total RT dose (p = 0.951), were associated with acute skin toxicity. Eleven (27.5 %) patients developed late grade ≥ 3 toxicity events, including 10 (23.8 %) late grade ≥ 3 skin toxicity events. Patients with late grade ≥ 3 skin toxicity had a higher mean body-mass index (33.0 vs 28.2 kg/m²; p = 0.009). Common late PSS included vaginal pain (n = 15, 35.7 %), skin fibrosis (n = 10, 23.8 %), and requirement of long-term opiates (n = 12, 28.6 %).

Conclusion

RT for vulvar cancer is associated with considerable rates of severe acute and late toxicity and PSS burden. Larger studies are needed to identify risk factors, explore toxicity mitigation strategies, and assess patient-reported outcomes.

Community-based outpatient cancer rehabilitation services for women with gynecologic cancer: acceptability and impact on patient-reported outcomes

OBJECTIVE

Women with gynecologic cancers often experience functional impairments impacting quality of life. Physical and occupational therapy (PT/OT) treat functional impairment; however, the acceptability and impact of these services for women with gynecologic cancer are unknown.

METHODS

We reviewed rehabilitation charts of women with gynecologic cancer who received PT/OT (i.e., patients) in 2019 and completed patient-reported outcome measures (PROMs) selected by their therapist at intake (pre) and discharge (post). We calculated descriptive statistics for patient, rehabilitation, and acceptability (0-10) data. For PROM data, we used paired samples t-tests to evaluate pre-post change, and then calculated effect size (Hedge's g) and the proportion who achieved a minimal detectable change (MDC).

RESULTS

PT/OT patients (N = 84) were 64.63 ± 11.04 years old with predominant diagnoses of ovarian (41.7%) or endometrial (32.1%) cancer. They attended a median of 13 sessions (IQR = 8.0-19.0). Sessions were predominantly PT (86%) vs. OT (14%). Median acceptability was 10 (IQR = 9.8-10.0). Pre-post improvement was observed for each of the 17 PROMs used by therapists. Significant improvement (p < .05) was observed for four PROMs: the Patient-Specific Functional Scale (M∆ = 2.93 ± 2.31, g = 1.47, 71% achieved MDC), the Lower Extremity Functional Scale (M∆ = 12.88 ± 12.31, g = 0.61, 60% achieved MDC), the Lymphedema Life Impact Scale (M∆ = 20.50 ± 20.61, g = 1.18, 58% achieved MDC), and the Modified Fatigue Impact Scale (M∆ = 6.55 ± 9.69, g = 0.33, 7% achieved MDC).

CONCLUSION

PT/OT was acceptable and improved patient-reported outcomes for women with gynecologic cancers. Future research is needed to establish gynecologic-specific guidelines for referral and PT/OT practice.

GCIG-Consensus guideline for Long-term survivorship in gynecologic Cancer: A position paper from the gynecologic cancer Intergroup (GCIG) symptom benefit committee

INTRODUCTION

Long-term survivors of gynecological cancers may be cured but still have ongoing health concerns and long-term side effects following cancer treatment. The aim of this brainstorming meeting was to develop recommendations for long-term follow-up for survivors from gynecologic cancer.

METHODS

International experts, representing each member group within the Gynecologic Cancer InterGroup (GCIG), met to define long-term survival, propose guidelines for long term follow-up and propose ways to implement long term survivorship follow-up in clinical trials involving gynecological cancers.

RESULTS

Long-term survival with/from gynecological cancers was defined as survival of at least five years from diagnosis, irrespective of disease recurrences. Review of the literature showed that more than 50% of cancer survivors with gynecological cancer still experienced health concerns/long-term side effects. Main side effects included neurologic symptoms, sleep disturbance, fatigue, sexual dysfunction, bowel and urinary problems and lymphedema. In this article, long-term side effects are discussed in detail and treatment options are proposed. Screening for second primary cancers and lifestyle counselling (nutrition, physical activity, mental health) may improve quality of life and overall health status, as well as prevent cardiovascular events. Clinical trials should address cancer survivorship and report patient reported outcome measures (PROMs) for cancer survivors.

CONCLUSION

Long-term survivors after gynecological cancer have unique longer term challenges that need to be addressed systematically by care givers. Follow-up after completing treatment for primary gynecological cancer should be offered lifelong. Survivorship care plans may help to summarize cancer history, long-term side effects and to give information on health promotion and prevention.

The frequency and persistence of lymphedema diagnosis and self-reported symptoms over 5 years in patients with endometrial carcinoma

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Numbness, aching, and poor physical function were commonly reported symptoms in endometrial cancer patients.

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Lymphedema symptoms that develop soon after diagnosis of endometrial cancer can persist for at least 5 years.

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Lymphedema symptoms could develop up to 7 years after initial diagnosis or treatment for endometrial cancer.

A potentially debilitating sequela of diagnosis or treatment for endometrial cancer islower limb lymphedema (LLL), which can have significant impacts on quality of life. Theobjective of this study was to determine the frequency of LLL symptoms in uterinecancer survivors over a 5-year study period. An IRB-approved prospective study of quality of life of endometrial cancer patients whounderwent surgical intervention was undertaken. The Gynecologic CancerLymphedema Questionnaire (GCLQ) was used to survey patients in 2011 and again in2016 to evaluate for symptoms of LLL.205 patients initially answered the survey, and 75 patients completed the follow upsurvey as well, with no differences in demographics between the cohorts. 90.7% ofpatients underwent lymph node dissection. Patients commonly reported symptoms ofnumbness (66.83%), aching (54.2%), and poor physical function (47.8%). On initialsurvey, 14.7% (n = 11) of patients met criteria for LLL by GCLQ criteria, with 8 patientsreporting improvement in symptoms and 3 reporting persistent diagnosis at follow up. At follow up survey, 12.0% (n = 9) patients meeting criteria five years later, with 6patients newly meeting criteria. The most persistent symptoms were poor physicalfunction (70.6%), numbness (72.5%), general swelling (55.6%), aching (64.1%), andlimb-related swelling (60%).While the rate of LLL was similar to previous reports, there were a number of newdiagnoses of LLL at interval follow up distant from surgery, up to 7 years later.Symptoms of LLL also persisted for many years after diagnosis.

Utilization and Outcomes of Sentinel Lymph Node Biopsy for Early Endometrial Cancer

OBJECTIVE

To examine trends, characteristics, and oncologic outcomes of sentinel lymph node biopsy for early endometrial cancer.

METHODS

This observational study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program by examining 83,139 women with endometrial cancer who underwent primary hysterectomy with nodal evaluation for T1 disease from 2003 to 2018. Primary outcome measures were the temporal trends in utilization of sentinel lymph node biopsy and patient characteristics associated with sentinel lymph node biopsy use, assessed by multivariable binary logistic regression models. Secondary outcome measure was endometrial cancer-specific mortality associated with sentinel lymph node biopsy, assessed by propensity score inverse probability of treatment weighting.

RESULTS

The utilization of sentinel lymph node biopsy increased from 0.2 to 29.7% from 2005 to 2018 (P<.001). The uptake was higher for women with endometrioid (0.3-31.6% between 2005 and 2018) compared with nonendometrioid (0.6-21.0% between 2006 and 2018) histologic subtypes (both P<.001). In a multivariable analysis, more recent year surgery, endometrioid histology, well-differentiated tumors, T1a disease, and smaller tumor size were independently associated with sentinel lymph node biopsy use (P<.05). Performance of sentinel lymph node biopsy was not associated with increased endometrial cancer-specific mortality compared with lymphadenectomy for endometrioid tumors (subdistribution hazard ratio [HR] 0.96, 95% CI 0.82-1.13) or nonendometrioid tumors (subdistribution HR 0.85, 95% CI 0.69-1.04). For low-risk endometrial cancer, the increase in sentinel lymph node biopsy resulted in a 15.3 percentage-point (1.4-fold) increase in surgical nodal evaluation by 2018 (expected vs observed rates, 37.8 vs 53.1%).

CONCLUSION

The landscape of surgical nodal evaluation is shifting from lymphadenectomy to sentinel lymph node biopsy for early endometrial cancer in the United States, with no indication of a negative effect on cancer-specific survival.

SENTIREC - The sentinel node mapping in women with cervical cancer study - Patient-reported early lymphedema and its impact on quality of life

OBJECTIVE

To evaluate patient-reported incidence and severity of early lymphedema and its impact on quality of life (QoL) after sentinel lymph node (SLN) mapping only and after SLN and pelvic lymphadenectomy (PL) in women undergoing surgery for early-stage cervical cancer.

METHODS

In a national prospective multicenter study, we included women with early-stage cervical cancer from March 2017-January 2021 to undergo radical surgery including SLN mapping. Women with tumors >20 mm underwent completion PL. The incidence and severity of early lymphedema and its influence on QoL were evaluated using validated patient-reported outcome measures before surgery and three months postoperative. We investigated changes over time using linear regression.

RESULTS

Two hundred of 245 (81.6%) included women completed questionnaires at baseline and three months postoperatively. The incidence of early lymphedema was 5.6% (95% CI 2.1-11.8%) and 32.3% (95% CI 22.9-42.7%) in women who underwent SLN mapping only and SLN + PL, respectively. Lymphedema symptoms in the legs, genitals, and groins increased in both groups postoperatively but three times more in women who underwent PL. Lymphedema symptoms after SLN + PL significantly impaired physical performance (p = 0.001) and appearance (p = 0.007). Reporting lymphedema was significantly associated with impaired body image, physical-, role-, and social functioning, and a high level of fatigue.

CONCLUSIONS

SLN mapping alone carries a low risk of lymphedema in women undergoing surgery for early-stage cervical cancer. In contrast, completion PL is associated with a high incidence of early lymphedema. Reporting lymphedema is associated with significant impairment of several physical, psychological, and social aspects of QoL.

Impact of lymphadenectomy on short- and long-term complications in patients with endometrial cancer

Introduction

Early endometrial cancer is primarily treated surgically via hysterectomy, adenectomy and, depending on tumor stage and subtype, lymphadenectomy. Systematic lymph node dissection is known to cause surgical complications. The aim of the present study was to investigate morbidity and mortality rates associated with lymphadenectomy in patients with endometrial cancer who underwent surgery in a routine clinical setting.

Methods

We collected data from 232 patients who were operated for endometrial carcinoma between 2006 and 2018 at the University of Lubeck, Germany. Surgical complications were viewed in relation to surgical risk factors. Additionally, a questionnaire concerning long-term lymphatic complications and survival was completed. Survival was compared between patients who underwent lymphadenectomy (group I) and those who did not (group II).

Results

Patients in group I needed revision surgery significantly more often due to postoperative complications (such as lymphoceles) compared to those in group II (p = 0.01). The results indicate more serious complications in patients who underwent a systematic lymphadenectomy and in those with lymph node metastases. 15% of patients who underwent a systematic lymphadenectomy had lymph node metastases. Recurrences occurred in 12.5% of cases and were significantly more frequent in patients who had undergone a lymphadenectomy, even if the lymph nodes were negative (p = 0.02). A comparison of survival data during the follow-up period revealed no significant difference. The study highlighted the need for a better preoperative risk stratification and the avoidance of lymphadenectomy for surgical staging alone.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-022-06396-5.

The Impact of COVID-19 Lockdown on Patients with Lymphedema

Background: The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to management of lymphedema. The aim of this study was to assess general health conditions and evaluate the problems and concerns of lymphedema patients with regard to access to care and provision of management and control follow-ups during the lockdown period between March and June 2020. Methods: A web-based online survey, which included questions about demographic and clinical properties, compliance with restrictions and self-management, complications, needs, and difficulties in accessing health care, as well as the presence of psychological symptoms, was applied. Results: Two hundred three patients (190 female and 13 male) replied. Majority of them (73.4%) were between 30 and 60 years old and had high school/university education (67%). The duration of lymphedema was more than 3 years and sites were commonly extremities with mild to moderate intensity in 70.5% patients. Majority of them adhered to stay home warnings (88.7%). Weight gain was a common problem and self-care methods were generally skipped (81.8%). Seventeen percent of them had wounds and/or cellulitis. Forty percent of patients needed to apply to health centers to renew the pressure garment, but could not reach it. More than 70% of patients had sleep disorders and anxiety/stress. Majority of patients used television and social media to get information related to COVID-19 and the exposure time was commonly 2 to 6 hours. Conclusions: The COVID-19 lockdown had a great impact on lymphedema patients' health care not only from medical but also from psychosocial aspects. All these implications have to be identified and dealt with properly to avoid concerns and consequences of future pandemic lockdowns. Lymphedema services should be well prepared to be delivered virtually, enable effective care, and share knowledge to meet the needs of patients suffering from lymphedema.

Volumetric Modulated Arc Therapy Capabilities for Treating Lower-Extremity Skin Affected by Several Merkel Cell Carcinoma Nodules: When Technological Advances Effectively Achieve the Palliative Therapeutic Goal while Minimising the Risk of Potential Toxicities

The peculiar and rare clinical condition below clearly requires a customized care approach in the context of personalized medicine. An 80-year-old female patient who was subjected in 2018 to surgical removal of a cutaneous Merkel cell carcinoma (MCC) nodule located on the posterior surface of the left thigh and to three subsequent palliative radiotherapy treatments developed a fourth relapse in October 2020, with fifteen nodular metastases located in the left thigh and leg. Since the overall macroscopic disease was still exclusively regionally located and microscopic spread was likely extended also to clinically negative skin of the thigh and leg, we performed an irradiation of the whole left lower extremity. For this purpose the total target (65.5 cm) was divided into three sub-volumes. Dose prescription was 30 Gy in 15 daily fractions. A sequential boost of 10 Gy in 5 daily fractions was planned for macroscopic nodules. Plans were calculated by means of volumetric modulated arc therapy (VMAT) with the field overlap technique. Thanks to this, we obtained a homogeneous dose distribution in the field junction region; avoidance structures were delineated in the central part of the thigh and leg with the aim of achieving an optimal superficial dose painting and to reduce bone exposure to radiation. This case study demonstrates that VMAT allows for a good dose coverage for circumferential cutaneous targets while sparing deeper organs at risk. A reproducible image-guided set-up is fundamental for an accurate and safe dose delivery. However, local treatments such as radiotherapy for very advanced MCC of the lower extremities might have limited impact due to the high probability of systemic progression, as illustrated in this case. Radiation is confirmed as being effective in preventing MCC nodule progression toward skin wounding.

Cervical re-injection of indocyanine green to improve sentinel lymph node detection in endometrial cancer

OBJECTIVES

To evaluate the role of cervical re-injection of indocyanine green (ICG) to increase the detection rate of sentinel lymph node (SLN) in patients with endometrial cancer (EC) who underwent robotic-assisted surgical staging.

METHODS

We retrospectively identified consecutive EC patients undergoing robotic-assisted staging with SLN biopsy at our Institution between June 2016 and April 2020. Patients were excluded if they had open abdominal surgical approach, neoadjuvant chemotherapy, and advanced stage [International Federation of Gynecology and Obstetrics (FIGO) stage III-IV] at diagnosis. According to our SLN protocol, in case of either unilateral or no SLN detection, we performed an ipsilateral or bilateral cervical re-injection of ICG.

RESULTS

In total, 251 patients meeting inclusion criteria were included in the analysis. At first injection, bilateral detection was achieved in 184 (73.3%), unilateral detection in 57 (22.7%), and no detection in 10 (4.0%) patients. Cervical re-injection was performed in 51 of 67 patients with failed bilateral mapping. After cervical re-injection, bilateral detection rate increased to 94.5% (222/235), while unilateral and no detection were 5.1% (12/235) and 0.4% (1/235), respectively.

CONCLUSIONS

Our results suggest that cervical re-injection of ICG, in case of failed bilateral mapping of SLN, brings about a significant improvement in SLN detection rates, therefore reducing the number of side-specific required lymphadenectomies.