Prevention and risk factor assessment of secondary oncologic lymphedema

Introduction

Lymphedema(LE) is a chronic condition and is considered one of the main sequelae of Cancer Survivors. In Italy, the total number of living cancer patients with secondary LE (in the various clinical stages) is about 200,000;  oncological treatment for breast, skin (melanoma), gynecologic and urologic cancers[ 1 ]. In view of the developmental tendency of LE toward the development of irreversible organic damage, treatment should begin as early as possible, and prevention should guide the patient’s entire course of treatment beginning with the diagnosis of cancer to identify risk factors(RF) for the development of LE[ 2 ]. Our study aims to detect from the scientific literature what are the RF and clinical signs of subclinical LE so that the physiotherapist can contribute, within a multidisciplinary approach, to patient surveillance and implement all necessary actions to counteract the development of LE

Methods

A scoping review was performed to examine preventive and risk factors in the assessment of secondary oncologic lymphedema by screening MEDLINE (PubMed) and PEDro databases using the following keywords: prospective surveillance, risk factors, lymphedema. Inclusion criteria: clinical studies, randomized controlled trials, review and systematic review, articles written in English and published in the last 10 years.

Results

Forty-nine articles published since 2013 to date were selected, including 33 related to breast cancer, 9 gynecological cancer, 1 melanoma, and 6 was not relevant to the study objective or not in English language. In breast cancer related lymphedema (BCRL), the RF are: axillary lymph node dissection (ALND) (p < .001), taxane-based chemotherapy (p < .001), regional lymph node irradiation (RNI) (p ≤ .001), BMI >30 ( p = .002), rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not statistically associated with the risk of BCRL[ 3 ]. In gynecologic cancer a multivariate analysis confirmed that removal of circumflex iliac lymph nodes (hazard ratio [ HR ], 4.28; 95% confidence interval [ CI ], 2.09-8.77; P < 0.0001), cellulitis (HR, 3.48; 95% CI, 2.03-5.98; P < 0.0001), and number of removed lymph nodes (HR, 0.99; 95% CI, 0.98-0.99; P = 0.038) were independent RF for lower limb lymphedema (LLL)[ 4 ].

Discussion and Conclusion

Many risk factors are common to all oncologic procedures requiring lymph node dissection. The etiology of risk factors is multifactorial, and the association of multiple factors increases the likelihood of developing secondary LE. Stratification according to risk: High Risk – immediate treatment: patients undergoing ALND and regional lymph node irradiation (RLNR); Low Risk – developmental monitoring with clinical examination and measurements: patients undergoing Sentinel lymph node biopsy (SLNB). When patients report symptoms in the absence of RVC ≥ 10%, LE diagnosis should not be ruled out. These patients should be considered at high risk for BCRL development and therefore be followed vigilantly and longitudinally[ 5 ].The studies use different methods to assess and grade LE and often the methodology used for determining LLL is poorly described and lacks baseline measurement. [ 6 ]

REFERENCES

1- Linee di indirizzo sul LE ed altre patologie correlate al sistema linfatico, REP-Atti n. 159/CSR del 15 settembre 2016. 2- Damstra RJ, Halk AB. The Dutch LE guidelines based on the ICFunctioning, Disability, and Health and the chronic care model J of Vascular Surgery: Venous and Lympha Disorders Vol 5, Number 5: 576-765. 3-Koelmeyer LA, Gaitatzis K, Dietrich MS, Shah CS, Boyages J, McLaughlin SA, Taback B, Stolldorf DP, Elder E, Hughes TM, French JR, Ngui N, Hsu JM, Moore A, Ridner SH. Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention. Cancer. 2022 Sep 15;128(18):3408-3415.4- Hayes SC, Janda M, Ward LC, Reul-Hirche H, Steele ML, Carter J, Quinn M,Cornish B, Obermair A. Lymphedema following gynecological cancer: Results from a prospective, longitudinal cohort study on prevalence, incidence and risk factors. Gynecol Oncol. 2017 Sep;146(3):623-629.