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Kleeven A, Jonis YMJ, Tielemans H, van Kuijk S, Kimman M, van der Hulst R, Vasilic D, Hummelink S, Qiu SS. The N-LVA Study: effectiveness and cost-effectiveness of lymphaticovenous anastomosis (LVA) for patients with cancer who suffer from chronic peripheral lymphoedema - study protocol of a multicentre, randomised sham-controlled trial. BMJ Open 2024; 14:e086226. [PMID: 38626967 PMCID: PMC11029230 DOI: 10.1136/bmjopen-2024-086226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Cancer-related lymphoedema is one of the most debilitating side-effects of cancer treatment with an overall incidence of 15.5%. Patients may suffer from a variety of symptoms, possibly resulting in a diminished health-related quality of life (HRQoL). A microsurgical technique known as lymphaticovenous anastomosis (LVA) might be a promising treatment option. The objective of this study is to evaluate whether LVA is effective and cost-effective compared with sham surgery in improving the HRQoL. METHODS AND ANALYSIS A multicentre, double-blind, randomised sham-controlled trial conducted in three university hospitals in the Netherlands. The study population comprises 110 patients over the age of 18 years with unilateral, peripheral cancer-related lymphoedema, including 70 patients with upper limb lymphoedema and 40 patients with lower limb lymphoedema. A total of 55 patients will undergo the LVA operation, while the remaining 55 will undergo sham surgery. The follow-up will be at least 24 months. Patients are encouraged to complete the follow-up by explaining the importance of the study. Furthermore, patients may benefit from regular monitoring moments for their lymphoedema. The primary outcome is the HRQoL. The secondary outcomes are the limb circumference, excess limb volume, changes in conservative therapy, postoperative complications, patency of the LVA and incremental cost-effectiveness. ETHICS AND DISSEMINATION The study was approved by the Medical Ethical Committee of Maastricht University Medical Center on 20 September 2023 (NL84169.068.23). The results will be presented at scientific conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT06082349.
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Affiliation(s)
- Alieske Kleeven
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Yasmine M J Jonis
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hanneke Tielemans
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Merel Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - René van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefan Hummelink
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shan Shan Qiu
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Sung C, Wang J, Chang J, Wong AK. Review of treatment strategies after lymphadenectomy: from molecular therapeutics to immediate microsurgical lymphatic reconstruction. J Vasc Surg Venous Lymphat Disord 2024:101844. [PMID: 38316291 DOI: 10.1016/j.jvsv.2024.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Lymphedema is a common complication of cancer treatment, such as lymphadenectomy and radiation therapy. It is a debilitating condition with pathologic tissue changes that hinder effective curative treatment and jeopardize patients' quality of life. Various attempts to prevent the development of lymphedema have been made, with improvements in the incidence of the pathology. However, it is still prevalent among survivors of cancer. In this paper, we review both molecular therapeutics and immediate surgical lymphatic reconstruction as treatment strategies after lymphadenectomy. Specifically, we discuss pro-lymphangiogenic molecules that have proved efficient in animal models of lymphedema and clinical trials, and review currently available microsurgical techniques of immediate lymphatic reconstruction. METHODS A literature search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar through May 2022. Searches were done separately for molecular therapeutics and microsurgical techniques for immediate lymphatic reconstruction. Search terms used for (1) non-surgical methods include 'lymphangiogenesis,' 'lymphedema,' 'growth factor,' and 'gene therapy.' Search terms used for (2) surgical methods include 'lymphedema,' 'lymph node excision,' 'lymphatic vessels,' 'primary prevention,' and 'microsurgery.' RESULTS Various pro-lymphangiogenic factors with therapeutic potential include VEGF-C, VEGF-D, HGF, bFGF, PDGF, IGF, Retinoic acid, Ang-1, S1P, TLR4, and IL-8. Microsurgical lymphatic reconstruction for prevention of secondary lymphedema includes lymphovenous anastomosis, vascularized lymph node flap transfer, and lymph-interpositional flap transfer, with promising clinical outcomes. CONCLUSIONS With growing knowledge of the lymphangiogenic pathway and lymphedema pathology and advances in microsurgical techniques to restore lymphatic channels, molecular and surgical approaches may represent a promising method for primary prevention of lymphedema.
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Affiliation(s)
- Cynthia Sung
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA; Keck School of Medicine of USC, Los Angeles, CA
| | - Jin Wang
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Jeff Chang
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Alex K Wong
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA.
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Chae Woon P, Kim I, Kim JH, Hwang JH. Association of clinical manifestations of secondary lymphedema and lymph node dissection sites in the lower extremities of patients with melanoma. Acta Oncol 2023; 62:880-888. [PMID: 37656769 DOI: 10.1080/0284186x.2023.2238547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/29/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Lymphedema is a chronic, debilitating disease that often requires life-long management. Predicting clinical manifestations and prognosis is crucial in clinical practice because the treatment of lymphedema should be individualized for best clinical outcome. The aim of this study is to explore the location and severity of lymphedema secondary to inguinal and/or iliac lymph node dissection (LND) in patients with melanoma. METHODS Patients with melanoma who received LND at a single tertiary medical center between 1 January 2010 and 31 September 2022 were retrospectively reviewed. Patient who received inguinal LND only were designate as the inguinal group while those who received both ilioinguinal LND were included in the ilioinguinal group. Volumetric measurement was used to objectify the severity and location of lymphedema. Clinical data was acquired for 12-15 months of follow-up. RESULTS Among 81 patients, 43 (53%) had developed lymphedema in the lower extremities at an average of 33 days after the surgery. Initially, patients manifested with medial thigh lymphedema in the inguinal group while patients were presented with whole leg lymphedema in the ilioinguinal group. Lower leg volume of the ilioinguinal group was significantly higher than the inguinal group. After more than 12 months of lymphedema treatment, upper leg volume was higher in the ilioinguinal group than the inguinal group (12.7% vs 5.4%, p < 0.05). CONCLUSION Lymphedema developed in early post-op period. The ilioinguinal group presented with a larger volume of lymphedema in the distal area of the legs. Even after sufficient treatment, predominant lymphedema remained in the proximal leg for the ilioinguinal group. Patients with both inguinal and iliac LND were associated with more severe lymphedema. Based on the dissection sites, the clinical manifestations and prognosis of leg lymphedema can vary widely. Thus, clinicians should consider the dissection site when approaching melanoma patients with lymphedema.
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Affiliation(s)
- Paek Chae Woon
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Inah Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Division of Endocrine Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Leonard LD, Beaty L, Thomas M, Quinn C, Colborn KL, de Araujo TB, Torphy RJ, Assumpção LR, Olino K, Studts CR, Rodriguez Franco S, McCarter M, Stewart C, Gleisner AL. Unmeasured factors are associated with the use of completion lymph node dissection (CLND) in melanoma. J Surg Oncol 2023; 127:716-726. [PMID: 36453464 DOI: 10.1002/jso.27153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/28/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Completion lymph node dissection (CLND) was the standard treatment for patients with melanoma with positive sentinel lymph nodes (SLN) until 2017 when data from the DeCOG-SLT and MLST-2 randomized trials challenged the survival benefit of this procedure. We assessed the contribution of patient, tumor and facility factors on the use of CLND in patients with surgically resected Stage III melanoma. METHODS Using the National Cancer Database, patients who underwent surgical excision and were found to have a positive SLN from 2012 to 2017 were included. A multivariable mixed-effects logistic regression model with a random intercept for the facility was used to determine the effect of patient, tumor, and facility variables on the risk of CLND. Reference effect measures (REMs) were used to compare the contribution of contextual effects (unknown facility variables) versus measured variables on the variation in CLND use. RESULTS From 2012 to 2017, the overall use of CLND decreased from 59.9% to 26.5% (p < 0.0001). Overall, older patients and patients with government-based insurance were less likely to undergo CLND. Tumor factors associated with a decreased rate of CLND included primary tumor location on the lower limb, decreasing depth, and mitotic rate <1. However, the contribution of contextual effects to the variation in CLND use exceeded that of the measured facility, tumor, time, and patient variables. CONCLUSIONS There was a decrease in CLND use during the study period. However, there is still high variability in CLND use, mainly driven by unmeasured contextual effects.
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Affiliation(s)
- Laura D Leonard
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laurel Beaty
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Madeline Thomas
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher Quinn
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Thiago B de Araujo
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert J Torphy
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lia R Assumpção
- Department of Surgery, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Kelly Olino
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christina R Studts
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Salvador Rodriguez Franco
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,The Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Martin McCarter
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Camille Stewart
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ana L Gleisner
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Deban M, Vallance P, Jost E, McKinnon JG, Temple-Oberle C. Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction? Curr Oncol 2022; 29:5655-5663. [PMID: 36005184 PMCID: PMC9406378 DOI: 10.3390/curroncol29080446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR). Methods: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment. Results: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema. Conclusion: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.
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Affiliation(s)
- Melina Deban
- Surgical Oncology, Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
- Correspondence:
| | - Patrick Vallance
- Surgical Oncology, Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Evan Jost
- Surgical Oncology, Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | | | - Claire Temple-Oberle
- Plastic and Reconstructive Surgery, Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
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Pinto M, Marotta N, Caracò C, Simeone E, Ammendolia A, de Sire A. Quality of Life Predictors in Patients With Melanoma: A Machine Learning Approach. Front Oncol 2022; 12:843611. [PMID: 35402230 PMCID: PMC8990304 DOI: 10.3389/fonc.2022.843611] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/25/2022] [Indexed: 12/20/2022] Open
Abstract
Health related quality of life (HRQoL) is an important recognized health outcome for cancer treatments, but also disease course with slower recovery and increased morbidity. These issues are of implication in melanoma, which maintains a risk of disease progression for many years after diagnosis. This study aimed to explore and weigh factors in the perception of the quality of life and possible relationships with demographic–clinical characteristics in people with melanoma via a machine learning approach. In this observational study, patients with melanoma, without metastatic disease, were recruited from January 2020 to December 2021 with a follow-up of at least one year. Demographic variables and clinics were collected, and the 12-Item Short-Form Health Survey (SF-12) was adopted as the physical and mental aspects of the Health-Related Quality of Life (HRQoL) measure. All the variables were processed in a random forest model to weigh at each node of each tree of this machine learning regression model, their actual weight in SF-12 score. We included 203 melanoma patients, mean aged 59.25 ± 15.1 years: 56 (27%) affecting the upper limbs and 147 (73%) affecting the trunk. The model of 142 patients with no missing value, generating 92 trees (MSE = 0.45, R2 of 0.78), reported that the lesion site was the most influencing variable on HRQoL based on the decrease in Gini impurity in variable weighing at each node intersection in forest generation. In this scenario, we built two distinct models for lesion sites and demonstrated that the variable that most influenced the quality of life in upper limb melanoma was lymphedema, while BMI was in the trunk. Given these results, random forest regressions could play a crucial role in the clinical and rehabilitation approach. The machine-learning model for detecting the HRQoL predictor in melanoma patients indicates that the experienced lymphedema and BMI may influence the HRQoL perception. This study suggests that the prevention and treatment of lymphedema and bodyweight reduction might improve the quality of life in melanoma.
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Affiliation(s)
- Monica Pinto
- Rehabilitation Medicine Unit, Strategic Health Services Department, Istituto Nazionale Tumori-Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS)-Fondazione G. Pascale, Naples, Italy
| | - Nicola Marotta
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Corrado Caracò
- Melanoma and Skin Cancer Surgery Unit, Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS)-Fondazione G. Pascale, Naples, Italy
| | - Ester Simeone
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori-Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS)-Fondazione G. Pascale, Naples, Italy
| | - Antonio Ammendolia
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Alessandro de Sire
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
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