Ovarian Cancer and Lower Limb Lymphedema

July 1, 2007

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.

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]

Outcome

The patient was referred to a lymphedema treatment center for evaluation 7 months after her initial surgery for ovarian cancer. Leg measurements were taken for a full-length left leg compression stocking (Juzo). No additional intervention was ordered at that time. As a respiratory therapist, C.W. stands during most of her 12-hour work day; she found wearing the stocking comfortable and reported that it minimized swelling in her leg. One year after she completed chemotherapy, she experienced a recurrence of ovarian cancer that necessitated a new chemotherapy regimen.

Two years after her initial diagnosis, she underwent 20 sessions of abdominal radiation along the periaortic lymph nodes. Following radiation, swelling in her left leg increased and the impact on her level of activity intensified. Her gynecologic oncologist referred her back to the lymphedema treatment center. The lymphedema specialist recommended that the patient elevate her leg frequently, stop use of the rowing machine and decrease her running. The patient began using a compression stocking every day upon waking in addition to sleeping in a compression legging at night. She was also instructed in manual lymphatic drainage and bandaging.

C.W. reports that the stocking has been the most beneficial technique used in the management of her leg lymphedema. However, she remains unable to participate in the level of exercise that she desires, owing to increased swelling. Additionally, she has had to adjust her attire as a result of the leggings, particularly during the summer. Almost 7 years post diagnosis with ovarian cancer, her attitude about the leg lymphedema is unique. She wonders if the aggressive removal of lymph nodes during her original surgery that led to the lymphedema also increased her survival from a disease that routinely has a poor long-term survival rate. At this time she is not receiving any treatment and is able to work and remain active.

Discussion

Survival among patients with gynecologic cancer has steadily improved. Compared with 1950-1954 data, for example, survival rates have increased by 14%.[2] Improvements in survival, however, can come with long-term sequelae, including lymphedema, which has received minimal attention. The cornerstone of management for most gynecologic cancers is cytoreductive surgery, the goal being to remove as much visible tumor as possible. Depending on the cancer site within the reproductive tract, surgery traditionally involves removal of the ovaries, fallopian tubes, uterus, and cervix, with extensive node dissection throughout the pelvic cavity. In the case of ovarian cancer, the omentum is removed. Radiation and chemotherapy are commonly part of the treatment plan for women with gynecologic cancer.

Lymphedema development is a risk that gynecologic cancer survivors do not anticipate and often are not informed about. Limb swelling frequently is not managed aggressively, owing to an appropriate focus on management and treatment of the malignancy. Node sampling in the pelvis is considered necessary for adequate staging of gynecologic disease and confers a risk for lymphedema. Furthermore, recurrence and metastasis of gynecologic cancers increase the risk for lymphedema by further impairing lymph drainage. Patient education concerning the possibility of lymphedema should be included in pre- and postoperative planning.

Assessment and management strategies for upper-extremity lymphedema cannot be directly transferred to lower-extremity lymphedema. Lymphedema development following node dissection for breast cancer is different from lymphedema following node dissection in gynecologic cancer. Limb size, volume, and location create distinctive characteristics.[3]

Lymphedema, an acute or chronic swelling associated with disruption of the lymphatic system, is a perplexing and poorly understood clinical entity.[4,5] Cancer and its treatment can cause lymphedema at any time to upper and lower extremities.[6] It is well documented in the breast cancer literature that patients experience lymphedema secondary to surgical resection of lymph vessels and nodes, from radiation or from obstruction of the lymph system by metastatic cancer.[5] Lymphedema can be an indicator of recurrence and is associated with toxicities such as skin breakdown, pain, neuropathy, and myopathy.[7]

Accurate methods of measuring the lower body are needed, to establish lymphedema grade in pelvic regions.[8] Strategies are also needed for responding to a clinical presentation of discomfort and impaired mobility related to lower extremity lymphedema. The relationship of lymphedema and surgical technique, and degree and location for node dissection require further study. Do less radical surgeries, for example, result in fewer cases of lymphedema? There is evidence to suggest that this is the case in breast cancer, with sentinel node rather than axial node dissection appearing to reduce the risk of lymphedema,[9,10] without compromising local control.[11]

In a study by researchers from Memorial Sloan-Kettering Cancer Center evaluating symptomatic lowerextremity lymphedema in more than 1,200 women with cancer of the uterine corpus, 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,[12] and the investigators concluded that women undergoing surgery with lymphadenectomy for this malignancy should be informed about the risk of developing leg lymphedema postoperatively.

Clinicians and patients have anecdotally reported the presence of lower-body lymphedema in many gynecologic cancer patients. With increased survival rates, more patients are at risk for developing lymphedema. Further research is needed documenting the incidence of lymphedema and experience of patients with lower-extremity lymphedema. The Gynecologic Oncology Group (GOG) is considering an intervention protocol on lower-extremity lymphedema. Additionally, a questionnaire developed as part of a research study focused on collection of data from women with gynecologic cancer can be requested from the author. Long-term consequences for women undergoing major surgical debulking procedures along with multiple and aggressive courses of cytotoxic treatments must be better understood. To this end, the National Lymphedema Network is gathering detailed patient demographic, clinical, and treatment information through an online survey (www.lymphnet.org/questionnaire.htm), to facilitate patient education and development of new interventions to improve quality of life for patients with lymphedema.

References:

1. NLN. Lymphedema risk reduction practices, 2005. Available at www.lymphnet.org.

2. Gynecologic Cancer Foundation. 2005 State of the State of Gynecologic Cancers: Third Annual Report to the Women of America. Available at: http://www.sgo.org/policy/state_of_state_2005.pdf. Accessed 5/23/07.

3. Logan VB: Incidence and prevalence of lymphedema: A literature review. J Clin Nursing 4: 213-219, 1995.

4. Foldi E: The treatment of lymphedema. CANCER Supp 83: 2833-2934, 1998.

5. Petrek JA, Pressman PI, Smith RA: Lymphedema: Current issues in research and management. CA-A Cancer J Clin 50: 292-307, 2000.

6. Mortimer PS: The pathophysiology of lymphedema. CANCER Supp 83: 2798-2802, 1998.

7. Cohen SR, Payne DK, Tunkel RS. Lymphedema: Strategies for management. Cancer 92: 980-987, 2001.

8. Sander AP, Hajer NM, Hemenway K, et al. Upper extremity volume measurements in women with lymphedema: A comparison of measurements obtained via water displacement with geometrically determined volume. Physl Therapy 82:1201-1213, 2002.

9. Swenson KK, Nissen MJ, Ceronsky C, et al: Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer. Ann Surg Oncol 9(8):745-753, 2002.

10. Rietman JS, Geertzen JH, Hoekstra HJ, et al: Long term treatment related upper limb morbidity and quality of life after sentinel lymph node biopsy for stage I or II breast cancer. Eur J Surg Oncol 32(2):148-152, 2006.

11. Schulze T, Mucke J, Markwardt J, et al: Long-term morbidity of patients with early breast cancer after sentinel lymph node biopsy compared to axillary lymph node dissection. J Surg Oncol 93(2):109-119, 2006.

12. Abu-Rustum NR, Alektiar K, Iasonos A, et al: The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: A 12-year experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol 103(2):714-718, 2006.