This is an old revision of the document!
Last week one of the members of our online support group Advocates for Lymphedema asked if there were statistics for the incendence of secondary lymphedema, especially leg lymphedema in gynecologic cancers.
Sadly, not many studies have been done and the information is slim.
I did find some however, and thought it might be helpful to put them together and make them readily available along with some related abstracts. As updated information becomes available, we will update our page.
ARTICLES Cancer Nursing. 30(4):E11-E18, July/August 2007. Lockwood-Rayermann, Suzy PhD, RN
There is a paucity of research on the incidence and impact of lower body lymphedema in the gynecologic cancer population. The cornerstone of management for gynecologic cancer is cytoreductive surgery. Depending on the site of the cancer, surgery traditionally involves removal of the ovaries, fallopian tubes, uterus and cervix, accompanied with extensive node dissection throughout the pelvic cavity, and, in the case of ovarian cancer, removal of the omentum. Resection of pelvic lymph nodes and vessels, compounded by gravitational influences on lymphatic flow, can lead to lymphatic congestion that impairs mobility, raises intra-abdominal pressure, and increases abdominal and extremity girth. Lymphedema can be an indicator of recurrence and is frequently associated with toxicities such as skin breakdown, pain, neuropathy, and myopathy. Physical changes, role changes, and psychosocial issues are common symptoms reported by breast cancer survivors with lymphedema. Assessment and management strategies for upper extremity lymphedema following treatment of breast cancer cannot be directly transferred to lower extremity lymphedema affecting women with cancer of the ovary, cervix, uterus, and vulva because of limb size, volume, and location. Clinicians have anecdotally reported the presence of lower body lymphedema in many gynecologic cancer patients. Survivors have described tightness, swelling, and heaviness. Despite these clinical findings, no systematic study of lower body lymphedema in women with gynecologic cancer has been conducted. Whether lower body lymphedema is as debilitating and long-term as post-mastectomy lymphedema is not empirically known.
Kathleen Appollo, RN, BSN, OCN®
H.F. is a 56-year-old woman who presented to the gynecologic oncology department at a major comprehensive cancer center after an endometrial biopsy revealed an International Federation of Gynecology and Obstetrics grade III serous carcinoma of the endometrium. In addition to relevant endometrial cancer statistics, she received information about choices for treatment. The standard surgical treatment at the cancer center consists of a total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. The acute and chronic side effects of surgery were discussed, including development of lower-extremity lymphedema. H.F. was informed that the lymphedema could occur anytime after surgery and she would need to monitor for lymphedema development for the rest of her life.
After preoperative testing, H.F. had an uneventful surgical procedure and routine postoperative course. The final pathology showed high-grade stage IIIC papillary serous carcinoma deeply invading the endometrium, with spread to a left para-aortic lymph node. As a result, her oncologist recommended both radiation and chemotherapy.
H.F. completed all therapy and was scheduled to return every three months for evaluation. She was cautioned to maintain skin integrity by applying moisturizers and sunscreen as needed and to avoid sources of trauma, injury, infection, and constriction to the lower extremities. In addition, she was encouraged to maintain her weight with a healthy diet and nonstrenuous exercise. Because H.F. lived out of state, she was advised to ambulate and hydrate during air travel to the cancer center and consider the use of individually fitted compression stockings (see Figure 1).
H.F. knew that she had a serious cancer diagnosis, but after the treatment was completed, she expressed joy and hope for the future. She was determined to get back to her former lifestyle. She worked full-time as a high school music teacher, gave private piano lessons, and performed with a local theater group every month. H.F. was active in her church, playing the organ at Sunday services. In addition, she played the piano at a local nursing home each week. She said that she received so much more than she gave when she saw the positive effect that music had on others. H.F. maintained her weight with diet and by walking briskly with her dog and a group of dog owners. She now added the required three-month follow-up appointments to her busy schedule.
Approximately six months after completion of treatment, H.F. called the office to report that she had developed swelling in her left leg. She was not sure exactly when it had developed because the swelling decreased at night when she elevated her leg. Although the swelling returned during the day, she attributed it to “doing too much.” She stopped walking her dog with the group, thinking that it may have caused the swelling. In the previous few days, H.F. noticed that the swelling did not automatically resolve after a night of sleep.
H.F. was seen for an office visit. Examination of her left leg revealed that she had pitting edema of the left foot, ankle, and calf with shiny tight skin. The leg was not red or warm to touch, and no areas were open on the skin. Her toenails and the creases between her toes were intact. A Doppler ultrasound of the left lower extremity was negative for deep vein thrombosis. A computed tomography scan of the abdomen and pelvis revealed no evidence of recurrent cancer.
H.F. was referred to a lymphedema specialist for evaluation and complex decongestive therapy, a multimodality approach to lymphedema treatment consisting of manual lymphatic drainage, compression wrapping, exercises, and skin care recommendations. H.F. was taught various exercises and how to wrap the affected limb. She was fitted for a compression gradient stocking to wear when traveling by plane (see Figure 2).
A few months later, H.F. returned to the office for a routine follow-up examination and was not in her usual upbeat mood. She admitted to being lax about lymphedema home care, and now the swelling had returned. In addition, the swelling seemed more resistant to self-treatment and was affecting many areas of H.F.’s life. She noticed that when she sat at the piano for lessons or at the organ in church on Sundays, the swelling in her leg increased. H.F. now had to modify her clothing by wearing long skirts and dresses to cover her large, uneven leg. She began to take over-the-counter pain medication for the heavy, achy feeling in her leg. H.F. continued to teach because she needed a source of income, but she lost her desire to be in public. She stopped playing the organ in church and the piano for the seniors at the nursing home. She continued to walk her dog but noticed that her pace was slower.
H.F. was given a prescription for pain and sleep medication to use as needed. She was referred to a psychologist to evaluate any depression and bolster her coping mechanisms. She was encouraged to find a local support group through the American Cancer Society.
After a thorough medical examination determined that H.F. did not have recurrent disease, she was advised to return to the lymphedema specialist for lymphedema control.
She understands that she must be diligent in her care to maintain control. H.F. knows that she should be joyous that she is free from cancer but often wonders about the sacrifices that she has made in the quality of her personal life. She did not feel the need to seek professional psychiatric help but did join a support group. Although the members of the group all have cancer, none has lymphedema. Even so, H.F. has found that sharing difficulties with others has helped her to cope, and she feels good when she has helped another deal with a difficult issue. Although she has not returned to her former music activities, she has found that helping others in the support group has given her the same satisfaction that she felt when her music brought happiness to others.
Lymphatic System and Lymphedema
Lymph is extracellular fluid composed of water, fats, proteins, bacteria, and waste products. The lymphatic system is an interconnected network of organs, lymph vessels, and lymph nodes that transports lymph from body tissues to the bloodstream, helping to maintain body fluid balance. It also is a major component of the body’s immune system. The superficial lymphatic capillaries are made up of endothelial cells that overlap but do not form a continuous connection. Each cell is anchored to surrounding tissue by filaments that pull on the cells in response to changes in tissue pressure. As the cell is pulled by the filament, fluid drains into the vessel. Pressure changes occur during muscle contraction, respiration, and arterial pulsation and when the skin is stretched. Lymph flows into progressively larger deep vessels that have one-way valves to ensure that the fluid moves away from tissues in a slow, steady, low-pressure system. Afferent vessels carry lymph into lymph nodes, where the lymph is filtered of cellular waste products, pathogens, and cancer cells and where lymphocytes are added.
Efferent vessels carry lymph out of the lymph nodes to return to circulation. Lymph drains from the lower limbs into the lumbar lymphatic trunk, joining the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties lymph into the left subclavian vein (Casely-Smith & Casely-Smith, 1997; Mortimer, 1998).
Lymphedema occurs when lymph remains in the tissues because the lymphatic system is unable to transport interstitial filtrate (Foldi, 1998; International Society of Lymphology, 2003). Primary lymphedema is a result of an absence of or abnormalities in lymphatic tissue. Secondary lymphedema, which is the focus of this discussion, results when the flow of lymph is interrupted because of malignancies, surgery, infection, trauma, or postradiation fibrosis and the lymph remains in the tissue.
Incidence and Risk Factors
Although much has been written about upper-extremity lymphedema after breast surgery, information about lower-extremity lymphedema is lacking. The literature varies widely about the number of patients affected. In one study, the incidence of lymphedema in patients after a hysterectomy with lymph node removal was 20% (Ryan, Stainton, Slaytor, et al., 2003). Another study reported a 3.4% incidence rate in patients following endometrial staging surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection (Abu-Rustum et al., 2006). A retrospective series of staging surgery for endometrial cancer followed by radiation therapy reported an incidence of 4.6% (Nunns, Williamson, Swaney, & Davy, 2000).
H.F. was at risk to develop lymphedema after her surgery for endometrial cancer because of the disruption of lymphatics and lymph nodes during staging surgery. She was at additional risk because of the postoperative radiation. Other risk factors are believed to include injury, trauma, heat changes, infection to the extremity, and weight gain and decreased mobility (Brewer, Hahn, Rohrbach, Bell, & Baddour, 2000; Mortimer, 1998).
Although research is lacking to support many recommendations for the prevention of lymphedema (Ridner, 2002), education regarding measures that are believed to reduce risk include protecting the skin from trauma and infection. Those measures were discussed with H.F. postoperatively and at each office visit. The plan is based on the concept that any action or condition that predisposes a patient to or increases swelling may disrupt the fine balance of drainage after surgery (Mortimer, 1998). In addition, open skin may lead to infection, which can occur more easily in stagnant, protein-rich lymph fluid, a perfect medium for bacteria growth (Brewer et al., 2000). Because deep vein thrombosis and cancer recurrence can cause swelling, they were ruled out before H.F. was referred for complex decongestive therapy. Her treatment began with manual lymphatic drainage, a gentle massage that starts proximally to encourage the flow of lymph from the distal extremity. More lymph is encouraged to move into the normally functioning lymphatics (Cheville et al., 2003; Foldi, 1998; Lerner, 1998). Massage was followed by padding of the extremity and application of short stretch compression bandages with gradual pressure changes distally to proximally. That type of bandaging helps the flow of lymph to the nodal basins (Cheville et al.; International Society of Lymphology, 2003).
H.F. was taught the techniques so that she could continue maintenance therapy at home. She was encouraged to practice manual lymphatic drainage, use compression bandages at night, wear a fitted compression garment, follow meticulous skin care guidelines, protect the leg from trauma and injury, and perform muscle-building exercises. H.F. also was taught to wear the compression garment especially during air travel because changes in atmospheric pressure may increase the pressure balance in the leg (National Lymphedema Network, 2005).
Quality of Life
Lymphedema may have a profound effect on the lives of cancer survivors (Kwan et al., 2002; Ryan, Stainton, Jaconelli, et al., 2003). H.F. described a heavy, achy feeling in her leg, which has been reported in patients with breast cancer before swelling occurred (Armer, Radina, Porock, & Culbertson, 2003). Pain assessment is crucial in helping patients to cope. An over-the-counter medication may suffice, but some patients may need prescription-strength pain medication, making individual assessment critical.
H.F. stated that her pace was slower in her walks. In patients with breast cancer, fatigue often is a troublesome symptom affecting quality of life (Armer & Porock, 2002). Pacing activities or decreasing distances may help to maintain stamina. Pacing also may deter swelling that is associated with strenuous or long-distance exercise. The need for sleep medication should be evaluated because insomnia caused by leg discomfort or worry may contribute to fatigue.
Changes in wardrobe often are necessary when swelling occurs (Ryan, Stainton, Jaconelli, et al., 2003). Alteration in body image may result in changes to regular social activities and may lead to social isolation (Tobin, Lacey, Meyer, & Mortimer, 1993). Referrals to support groups or individual therapy sessions may be indicated depending on patient preference. H.F. found that she gained much by participating in a support group and thereby moved from one type of social interaction to another. Healthcare professionals must be sensitive to lifestyle changes as well as the financial burden that may result from a forced change in wardrobe.
With increased survival after cancer treatment, the long-term sequelae caused by cancer treatment should be recognized and treated. Patients must be informed about the potential lifelong side effects of treatment. Although H.F. was informed about the possibility of lymphedema development, many patients have reported that they were not informed about this life-alterating condition until they developed symptoms (Beesley, Janda, Eakin, Obermair, & Battistutta, 2007; Ryan, Stainton, Jaconelli, et al., 2003). Continued research is needed to determine the best interventions to decrease the side effects of treatment and maximize quality of life.
Cancer. 2007 Jun 15 eesley V, Janda M, Eakin E, Obermair A, Battistutta D. Queensland University of Technology, School of Public Health, Institute of Health and Biomedical Innovation, Brisbane, Australia. email@example.com
BACKGROUND: Few studies have evaluated lymphedema after gynecological cancer treatment. The aim of this research was to establish prevalence, correlates, and supportive care needs of gynecological cancer survivors who develop lymphedema.
METHODS: In 2004, a population-based cross-sectional mail survey (56% response rate) was completed by 802 gynecological cancer survivors. The questionnaire included demographic questions, a validated, generic supportive care needs measure, and a supplementary, newly developed, lymphedema needs module.
RESULTS: Ten percent (95% confidence interval [CI], 8%-12%) of participants reported being diagnosed with lymphedema, and a further 15% (95% CI, 13%-17%) reported undiagnosed “symptomatic” lower limb swelling. Diagnosed lymphedema was more prevalent (36%) amongst vulvar cancer survivors. For cervical cancer survivors, those who had radiotherapy or who had lymph nodes removed had higher odds of developing swelling. For uterine and ovarian cancer survivors, those who had lymph nodes removed or who were overweight or obese had higher odds of developing swelling. Gynecological cancer survivors with lymphedema had higher supportive care needs in the information and symptom management domains compared with those who had no swelling.
CONCLUSIONS: This population-based study provided evidence that lymphedema is a morbidity experienced by a significant proportion of gynecological cancer survivors and that there are considerable levels of associated unmet needs. Women at risk of lymphedema would benefit from instructions about early signs and symptoms and provision of referral information. Copyright 2007 American Cancer Society.
Gynecol Oncol. 2007 Feb Hodgkinson K, Butow P, Fuchs A, Hunt GE, Stenlake A, Hobbs KM, Brand A, Wain G. Department of Gynecologic Cancer, Westmead Hospital, Westmead, and Department of Psychological Medicine, University of Sydney, NSW 2006, Australia. firstname.lastname@example.org
Keywords: Gynecologic cancer survivors; Long term; Psychosocial outcomes; Supportive care needs; Positive outcomes
OBJECTIVES: To assess the long-term psychosocial outcomes and supportive care needs of gynecologic cancer survivors.
METHODS: Women who had received care in a tertiary-based gynecologic cancer center 1-8 years earlier and who were disease-free were invited to complete a mailed self-report questionnaire to assess psychosocial outcomes and supportive care needs.
RESULTS: In total, 199 survivors participated in the study. Survivors reported normal quality of life and relationship adjustment although functioning was at the lower end of the range; over two-thirds (68%) reported positive outcomes. However, nearly one-third (29%) reported clinical levels of anxiety and the most frequently endorsed need concerned fear of disease recurrence (24%). About one-fifth (19%) reported symptoms that indicated posttraumatic stress disorder (PTSD) and this rose to close to one-third (29%) for survivors of advanced stage disease. Nearly 90% of survivors reported supportive care needs and the diagnosis of anxiety or PTSD resulted in a four-fold increase in unmet needs. Needs most frequently concerned “existential survivorship” (e.g., spiritual beliefs, decision making, the meaning of life) and “comprehensive cancer care” (e.g., team care, communication, local health care services). Years since diagnosis was not related to distress or need levels.
CONCLUSIONS: All members of the care team need to be aware that significant psychosocial morbidity may occur many years after the successful treatment of a gynecologic malignancy and may be associated with elevated supportive care needs. Comprehensive and extended supportive care services are required to address anxiety and trauma responses and investigate strategies to meet ongoing needs in order to improve long-term psychosocial outcomes.
Oncol Nurs Forum. 2003 May Ryan M, Stainton MC, Jaconelli C, Watts S, MacKenzie P, Mansberg T. Gynaecological Cancer Centre of the Royal Hospital for Women, Randwick, New South Wales, Australia.email@example.com
PURPOSE/OBJECTIVES: To describe women's experiences with lower limb lymphedema to inform both preventive and management clinical practices.
DESIGN: A retrospective survey.
SETTING: The gynecology/oncology unit of a tertiary referral women's hospital in Australia. SAMPLE: 82 women who developed lower limb lymphedema after surgical and radiation treatment for gynecologic cancers.
METHODS: Structured interviews.
MAIN RESEARCH VARIABLES: Psychosocial and emotional impact, physical effects, knowledge, support, treatment modalities. FINDINGS: Women identified changes in appearance and sensation in the legs and the triggers that both preceded and exacerbated symptoms. Women described seeking help and receiving inappropriate advice with as many as three assessments prior to referral to lymphedema specialists. Many women implemented self-management strategies. Lower limb lymphedema had an impact on appearance, mobility, finances, and self-image.
CONCLUSIONS: Increasing longevity after gynecologic oncology treatment requires all practitioners to be aware of known or potential triggers of lower limb lymphedema and the appropriate referral and management strategies available. Women at risk need to know early signs and symptoms and where to seek early care.
IMPLICATIONS FOR NURSING: The role of nursing in acute and community care of women at risk for developing lower limb lymphedema includes (a) engaging women in protecting their legs from infection or trauma pre- and postoperatively, (b) providing nursing care and education during the pre- and postoperative phases, and © ensuring that women being discharged are aware of early signs and symptoms of lower limb lymphedema and how to access qualified, specialized therapists so that early and effective management can be initiated.
Aust N Z J Obstet Gynaecol. 2003 Apr Ryan M, Stainton MC, Slaytor EK, Jaconelli C, Watts S, Mackenzie P. Gynaecological Cancer Centre, Royal Hospital for Women, Randwick, New South Wales, Australia. firstname.lastname@example.org
OBJECTIVE: To determine the prevalence and incidence of lower limb lymphoedema (LLL) in a cohort of women who had treatment for gynaecological cancer between May 1995 and April 2000.
DESIGN: A retrospective survey.
SETTING: The study took place at an urban referral centre in an Australian tertiary referral women's hospital.
SAMPLE: The data collection was based on 66% of 743 women on the database of the Gynaecological Cancer Centre.
METHODS: Interviews and assessments were conducted to determine the status of lower limbs; medical records were reviewed for age, weight, site and type of cancer and treatment.
MAIN OUTCOME MEASURES: Leg swelling, diagnosed lower limb lymphoedema, no swelling of the legs and type of surgery were determined as the main outcome measures.
RESULTS AND CONCLUSIONS: The diagnosis of lower limb lymphoedema was made in 18% of the total sample: 53% of these were diagnosed within 3 months of treatment, a further 18% within 6 months, 13% within 12 months and the remaining 16% up to 5 years following treatment. Women most at risk for developing LLL were those who had treatment for vulvar cancer with removal of lymph nodes and follow up radiotherapy. For this subsample, the prevalence was 47%. The finding that LLL occurs within the first year is earlier than hitherto generally believed. It is therefore imperative for all health professionals to include care and assessment of the legs particularly during the immediate pre- and postoperative period.
Gynecol Oncol. 2006 Nov
Abu-Rustum NR, Alektiar K, Iasonos A, Lev G, Sonoda Y, Aghajanian C, Chi DS, Barakat RR. Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA. email@example.com
Keywords: Lymphedema; Lymphadenectomy; Lymph nodes; Endometrial cancer
OBJECTIVES: To describe the incidence of symptomatic postoperative lower-extremity lymphedema in women treated for uterine corpus cancer, and to evaluate its relationship to regional lymph node removal and postoperative therapy.
METHODS: A retrospective chart review of all patients with uterine corpus cancer managed over a 12-year period (1/93-12/04). All patients had a hysterectomy as part of their therapy. We identified patients with leg lymphedema - as described by the physician or reported by the patient - through medical records. We excluded cases of leg edema that developed secondary to medical conditions such as cardiovascular and renal disease, venous thrombosis, and end-stage recurrent malignancy. Lymphedema dermal changes and related fibrosis were graded using the common terminology criteria for adverse events.
RESULTS: In all, 1,289 patients with uterine corpus malignancy were evaluated. We excluded other chronic lower-extremity edema that was related to a variety of medical conditions in 74 patients (5.7%). With a median follow-up of 3 years (interquartile range, 1.1-5.4 years), new symptomatic post-treatment lower-extremity lymphedema was noted in 16 patients. Patients who had lymph nodes removed at initial surgery had a higher rate of developing lymphedema (16/670, 2.4%) than those who did not (0/619, 0%) (P = 0.0001). Furthermore, symptomatic lymphedema was limited to patients who had 10 or more regional lymph nodes removed 16/469 (3.4%). Lymphedema was noted at a median of 5.3 months after surgery (range, 1-32 months). Lymphedema was unilateral in 11 patients (69%) and bilateral in 5 (31%); moreover, it was considered grade 1 in 12 patients (75%) and grade 2 in 4 (25%). Age, weight, stage, type of hysterectomy, and type of postoperative adjuvant therapy were not associated with lymphedema.
CONCLUSIONS: To date, this is the largest series evaluating symptomatic lower-extremity lymphedema in women with uterine corpus cancer. Patients who had 10 or more regional lymph nodes removed at initial surgery appeared to be at higher risk for developing new symptomatic leg lymphedema. Patients undergoing surgery with lymphadenectomy for uterine corpus malignancy should be informed about the possibility of postoperative new symptomatic leg lymphedema. A prospective evaluation of leg lymphedema is needed to accurately determine the incidence, severity, and risk factors of this complication.
Oncol Nurs Forum. 2003 Mar-Apr
Ekwall E, Ternestedt BM, Sorbe B. Department of Gynecologic Oncology, Orebro Medical Center Hospital, Orebro, Sweden. firstname.lastname@example.org
PURPOSE/OBJECTIVES: To describe what women diagnosed with primary gynecologic cancer reported to be important during their interaction with the healthcare system.
SETTING: A specialized gynecologic cancer care unit in central Sweden.
SAMPLE: 14 women diagnosed with primary gynecologic cancer were recruited. The women had been referred to the specialized care unit for radiation or cytostatic therapy.
METHODS: Tape-recorded interviews were transcribed, coded, categorized, and analyzed.
MAIN RESEARCH VARIABLES: Primary diagnosed women with cancer and their experience with quality of care during diagnosis and treatment.
FINDINGS: Three partly overlapping categories (i.e., optimal care, good communication, and self-image and sexuality) were found to be of central importance in quality of health care. Participants stated that health care should be based on their own perceptions of the need for information and dialogue and how the disease and treatment would affect their health, self-image, and sexuality. Everyday conversations also were very important.
CONCLUSIONS: Central importance in health care for the women included both rational and human aspects. The primary need of participants was to achieve a rapid cure, which necessitated health care that was available, competent, and coordinated.
IMPLICATIONS FOR NURSING: Women with gynecologic cancer should be given individualized information and care to satisfy their individual needs and reinforce their self-image. Nurses have an important role in strengthening women's feelings of hope and supporting them in maintaining as positive a self-image as possible. Information and everyday conversation are of great significance. Sexuality should be an integral part of holistic care; to this end, inclusion of each woman's sexual partner may be helpful when discussions concerning sexuality occur.
Oncol Nurs Forum. 1997
Steginga SK, Dunn J. Patient and Community Services, Queensland Cancer Fund, Brisbane, Australia.
PURPOSE/OBJECTIVES: To describe women's experiences after treatment for gynecologic cancer in relation to psychosocial and physical difficulties and perceptions of the helpfulness of healthcare professionals. DESIGN: Descriptive, retrospective, mailed survey.
SETTING: Women previously treated for gynecologic cancer at a large urban hospital in Queensland, Australia.
SAMPLE: Eighty-two women of all ages completed the survey. Diagnoses included cervical (45%), uterine (30%), ovarian (20%), and vulvar (4%) cancer.
METHODS: A self-report questionnaire and elicited demographic/medical data and qualitative data about women's experiences. Researchers also explored subjects' perceptions of the helpfulness of nurses, doctors, and social workers.
MAIN RESEARCH VARIABLES: Psychosocial and physical difficulties; informational, emotional, and practical support; personal coping strategies.
FINDINGS: Women described a range of psychosocial difficulties including depression, anxiety, and fear of dying. Physical side effects included fatigue, pain, bladder dysfunction, and vaginal problems. Women most often described emotional support from family members as assisting them to cope with difficulties. The most commonly described personal coping strategy was the use of positive thinking. Descriptions of how healthcare professionals were helpful reflected their roles within the healthcare system.
CONCLUSIONS: Women's existing social supports may be most important in determining how they cope with gynecologic cancer. Patients may evaluate the assistance provided by healthcare professionals in relation to professional roles.
IMPLICATIONS FOR NURSING PRACTICE: Nurses are uniquely positioned to provide informational support to patients. However, patients' immediate difficulties and their perceptions of the nurse's role as helper may interfere with this process.
J Clin Oncol. 2008 Feb
Van der Zee AG, Oonk MH, De Hullu JA, Ansink AC, Vergote I, Verheijen RH, Maggioni A, Gaarenstroom KN, Baldwin PJ, Van Dorst EB, Van der Velden J, Hermans RH, van der Putten H, Drouin P, Schneider A, Sluiter WJ. Department of Obstetrics and Gynecology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands. email@example.com
PURPOSE: To investigate the safety and clinical utility of the sentinel node procedure in early-stage vulvar cancer patients.
PATIENTS AND METHODS: A multicenter observational study on sentinel node detection using radioactive tracer and blue dye was performed in patients with T1/2 (< 4 cm) squamous cell cancer of the vulva. When the sentinel node was found to be negative at pathologic ultrastaging, inguinofemoral lymphadenectomy was omitted, and the patient was observed with follow-up for 2 years at intervals of every 2 months. Stopping rules were defined for the occurrence of groin recurrences.
RESULTS: From March 2000 until June 2006, a sentinel node procedure was performed in 623 groins of 403 assessable patients. In 259 patients with unifocal vulvar disease and a negative sentinel node (median follow-up time, 35 months), six groin recurrences were diagnosed (2.3%; 95% CI, 0.6% to 5%), and 3-year survival rate was 97% (95% CI, 91% to 99%). Short-term morbidity was decreased in patients after sentinel node dissection only when compared with patients with a positive sentinel node who underwent inguinofemoral lymphadenectomy (wound breakdown in groin: 11.7% v 34.0%, respectively; P < .0001; and cellulitis: 4.5% v 21.3%, respectively; P < .0001). Long-term morbidity also was less frequently observed after removal of only the sentinel node compared with sentinel node removal and inguinofemoral lymphadenectomy (recurrent erysipelas: 0.4% v 16.2%, respectively; P < .0001; and lymphedema of the legs: 1.9% v 25.2%, respectively; P < .0001).
CONCLUSION: In early-stage vulvar cancer patients with a negative sentinel node, the groin recurrence rate is low, survival is excellent, and treatment-related morbidity is minimal. We suggest that sentinel node dissection, performed by a quality-controlled multidisciplinary team, should be part of the standard treatment in selected patients with early-stage vulvar cancer.
Int J Gynaecol Obstet. 2007 Oct
Loar PV 3rd, Reynolds RK. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109-0276, USA.
Keywords: Sentinel node, Gynecologic oncology, Vulvar carcinoma, Cervical carcinoma, Endometrial carcinoma
Lymph node status is the most important prognostic factor for women with vulvar, cervical and endometrial carcinoma and complete lymph node dissection has historically been an integral part of the surgical treatment of these diseases. Lymphadenectomy can be morbid for patients, who may experience wound breakdown, lymphocyst formation or chronic lymphedema, among other problems. Sentinel lymph node mapping is a newer technology that allows selective removal of the first node draining a tumor thereby allowing a potentially less aggressive procedure to be performed. Sentinel node mapping is well accepted for the management of breast carcinoma and cutaneous melanoma, and has resulted in reduced morbidity without adversely affecting survival. Sentinel node mapping is currently being investigated for treatment of gynecologic cancers. Recent studies show promise for incorporating the sentinel node mapping technique for treatment of several gynecologic malignancies.
Carter J, Raviv L, Appollo K, Baser RE, Iasonos A, Barakat RR.
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA. firstname.lastname@example.org
Keywords Gynecologic cancer; Lymphedema; Lower extremity; Assessment tool; Gynecologic Cancer Lymphedema Questionnaire
OBJECTIVE: This study aimed to determine the feasibility and efficacy of using the Gynecologic Cancer Lymphedema Questionnaire (GCLQ) as a symptom scale for lymphedema of the lower extremity (LLE).
METHODS: Twenty-eight gynecologic cancer survivors with documented LLE and 30 without a history or presence of lymphedema completed the GCLQ and provided feedback about their satisfaction with and feasibility of using the GCLQ at their oncology follow-ups. The study survey took approximately 5-10 min to complete, and it was easily understood by the majority of the sample.
RESULTS: Participants had a mean age of 59.6 years (range, 28-80 years). Twenty-eight women (48%) had LLE, and 30 (52%) had no history or presence of LLE (confirmed by limb volume [LV] measurements at assessment). Type of cancer history included endometrial, 38 (66%); cervical, 13 (22%); and vulvar, 7 (12%). GCLQ scores differed significantly by lymphedema diagnosis; LLE patients had higher scores (P<0.01). The large area under the curve (AUC) of 0.95 (95% CI: 0.90-1.000) suggests that the GCLQ can distinguish between patients with and without LLE. Although all 28 (100%) of the LLE patients were aware of their LLE diagnosis, only 23 (82%) underwent treatment. The GCLQ was easily understood by most (55/58, 95%), and overall, patients showed a high willingness (56/58, 96%) to complete the questionnaire at future appointments. Twenty-five (88%) of the LLE patients found the GCLQ to be helpful in identifying symptoms of lymphedema.
CONCLUSIONS: The GCLQ effectively distinguished between gynecologic cancer survivors with and those without LLE, with good sensitivity and specificity. The patients, particularly those with LLE, showed high confidence in the GCLQ's ability to detect LLE symptoms.