The patient, C.W., is a 46-year-old white female who presented to her gynecologist complaining of an egg-shaped mass between her right hip bone and umbilicus, and irregular menstrual cycles. Physical examination confirmed a large palpable mass in her lower abdominal area. Past medical history was unremarkable. She was not taking any regular medications. She has been married for 17 years and has worked as a respiratory therapist for 16 years in a large pediatric hospital. She had been actively participating in a program of daily exercise at an area health club that included aerobics and weight training. She is a social drinker and denies any illicit drug use.

She was subsequently referred to a gynecologic oncologist who ordered an abdominal sonogram and computed tomography (CT) scan of the abdomen and pelvis to be completed prior to her appointment. Both exams confirmed a large mass on her right ovary. She was scheduled for and underwent a radical hysterectomy. Pathology specimens included the uterus, cervix, bilateral tubes and ovaries, and omentum. Additional specimens included 15 lymph nodes from the right/left common iliac artery, right/left periaortic area, and nodes from the rectal sigmoid and pelvic area. Final pathology revealed stage IIIC poorly differentiated adenocarcinoma of the ovary.

Treatment Summary

C.W. had an uneventful recovery period and was able to return to work 8 weeks after surgery. She was also able to resume her routine at her local health club with limited modification. C.W. began chemotherapy 10 days following surgery. She received cisplatin at 500 mg/m2 and paclitaxel at 270 mg/m2 every 3 weeks. During her fifth chemotherapy cycle, approximately 4 months postoperatively, she noticed that her left leg was somewhat larger and that the top of her left thigh was accumulating fluid. She reported this to her gynecologic oncologist at her next prechemotherapy appointment. He was initially unconcerned; however, he ordered a CT scan and sonogram of her left leg to rule out the presence of deep vein thrombosis. CT was unremarkable and the sonogram revealed no thrombus. C.W. continued to monitor her leg, even taking pictures to document changes. Six months postoperatively, she went in for her regular prechemotherapy lab work wearing a short skirt and sandals, aware that her leg was noticeably swollen. The oncology nurse recognized the lymphedema and had the gynecologic oncologist see C.W. while she was in the office that day.

Nursing Management

Lymphedema can occur months to years following surgery for gynecologic cancer with lymph node removal. The role of the nurse in management of lower limb lymphedema has not been explored. However, as in this case, it is frequently the nurse to whom the patient will first complain about leg swelling. The nurse must be the patient's advocate with the oncologist to ensure that timely and appropriate referrals are made. In this case, the patient was also totally unaware of the risk for lower limb lymphedema secondary to ovarian cancer treatment. Information about this risk should be included in patient teaching prior to any treatment or surgical intervention that involves removal of lymph nodes. Best practices for risk reduction of lower limb lymphedema following cancer treatment involving lymph node dissection and/or radiation should be included in patient education postoperatively.[1]

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