Lymphoedema following gynaecological cancer treatment

Lymphoedema is common after gynaecological cancers. Lymphoedema is the accumulation of excessive amounts of fluid resulting in swelling, most commonly in the arms or legs, but can also occur in other parts of the body. Lymphoedema after cancer treatment is called secondary lymphoedema. Symptoms include: the affected area feels heavy, tight and swollen, the skin feels hot, aching, pins and needles painful joints and reduced mobility. Previous studies varied widely in the estimated incidence (1.2% to >50%) of lymphoedema after gynaecological cancer.

At the European Gynaecological Oncology Congress in Vienna this month I presented data from the Lymphoedema Evaluation in Gynaecological cancer Study (LEGS) conducted at the Queensland Centre for Gynaecological Cancer. The goal of this study was to describe self-reported leg swelling and leg symptoms from before to up and until two years after gynaecological cancer surgery. We assessed the association of leg swelling with symptoms and the severity of those symptoms.

The LEGS study enrolled 408 women diagnosed with gynaecological cancers (235 uterine, 114 ovarian, 69 cervical, vulvar, or vaginal cancer; respectively). Women were eligible if they were 18 years and older, treated in one of six Queensland hospitals, and diagnosed between June 2008 to February 2011. Women in the study were followed from before cancer treatment to two years after surgery. At the end of the two year period we had data from 281 women available for analysis.

What were the results?

Most interestingly, up to 19% of patients reported leg swelling even before their cancer surgery.

The incidence of swelling after surgery was diverse; 38% of women continued to have no swelling over the next two years; 32% of women had low and decreasing swelling over the two year period;14% of women had low swelling before surgery whose swelling increased; and 15% of women who had high swelling before surgery had swelling that increased further.

What does this tell us? Swelling starts early for some women after surgery. For women with persistent or increased swelling this means they had higher risk of long-lasting symptoms, most prominently pain, numbness or weakness.

Currently we can’t predict who will develop lymphoedema after cancer treatment. We do know that patients who have many lymph nodes removed or who require radiation therapy will have a higher risk of lymphedema. Exercise can help reduce your risk but talk to your doctor first about when you can start to exercise after surgery and what type of exercises you can do.

Unfortunately, there is no cure for lymphoedema, but it can be managed to help reduce symptoms and swelling. A combination of skin care to prevent against infection and exercise and physical therapy can help to improve the symptoms of lymphoedema.

As a surgeon, the most important question is: How can we minimise the risk of adverse events from surgery? How can we minimise the risk of lymphoedema? We started using sentinel node biopsy to reduce the number of lymph nodes that I need to remove during surgery. The technique allows me to only pick 2 or 3 lymph nodes that are relevant and leave all other nodes intact and behind. I expect that this new technique will reduce leg swelling by at least 50% to 75%. Sentinel node biopsy is a critically important technique to prevent leg swelling.

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