Keywords
quality of life - lymphedema - patient-reported outcome measures
Introduction
Lymphedema is a growing problem that may involve as much as 250 million patients worldwide
that deteriorates the patient's quality of life (QOL).[1] Although etiology may vary among regions, most secondary lymphedema in the developed
world is from cancer-related treatments. Lower limb lymphedema, in particular, often
occurs after gynecological or genitourinary malignancies with an increased risk for
patients undergoing pelvic dissections and radiation therapy.[2]
[3]
[4] The sense of heaviness, early tiredness, and other symptoms caused by swelling can
limit the patient's daily activities.[5] In advanced cases, the skin begins to change causing fibrosis, leathery texture,
elephantiasis (warty hyperkeratotic cobblestone appearance) which leads to the formation
of fissures and discharge. Cellulitis may occur requiring admission and antibiotics
use.[6] Mental health may be affected from dissatisfaction of appearance to reduced self-esteem.[7]
[8] Impaired sexual function from genital swelling or vaginal discharge may limit the
patient's sexual life as well.[9] Most of all, lymphedema serve as a constant reminder of the cancer causing constant
fear.[5]
[10] As mentioned, numerous studies have shown and continue to show that patients developing
lymphedema exhibit high levels of not only functional but psychological, social, and
sexual morbidity as well.
Therefore, in lymphedema patients, where cure is not possible, QOL measures are designed
to enable patients' perspectives on the impact of health and health care interventions
on their lives to be assessed and taken into account in clinical decision-making and
research.[11] Furthermore, the change in patients' perception after surgical intervention will
be an important factor to measure as most papers related to improvement focus on clinical
improvement rather than the QOL. The reality often shows the discrepancy between patient
satisfaction and improvement of symptoms such as reduction of limb circumference making
it difficult to rationalize surgery from the patient's perspective. Thus, using patient-reported
outcome measurement (PROM) studies to collect subjective information directly from
the patient regarding specific or general conditions and add to clinical and functional
outcomes and turn unmeasurable subjective qualities into quantitative measures will
allow us to understand the impact of surgery.[12]
[13] The use of PROM in breast surgery, Breast-Q, has provided important insights highlighted
by the literature concerning autologous reconstruction, implant type, fat grafting,
and patient education.[14]
[15] Thus, to further understand the impact of lymphedema surgery, it will be prudent
to have PROM studies.
Several PROMs have been developed for lymphedema patients, and among them, a Quality
of Life Measure for Limb Lymphedema (LYMQoL) developed by Keeley et al is one of the
widely used tool.[16] LYMQoL has the advantage of evaluating not only patient's overall satisfaction,
but also measures satisfaction by subcategory of function, appearance, symptom, and
mood. There have been few studies that have used LYMQoL and showed that surgical intervention
such as lymphaticovenous anastomosis (LVA) has the potential to improve patients'
QOL.[17]
[18]
[19] But the previous study have only a limited number of patients who participated in
the study and lacks focus on the lower extremity.[17]
[18]
[19] The small number of participants also makes it difficult to obtain meaningful subcategory
and subgroup analysis for further insight.[2] For example, will the response be different from patients who had long duration
of lymphedema versus shorter duration or patients who had better volume reduction
compared with the less?
The primary purpose of this study was to evaluate lower limb lymphedema patients'
QOL using the LYMQoL questionnaire who underwent LVA. Furthermore, the relationship
between patient's QOL survey outcome and lymphedema severity, duration, or amount
of volume reduction after surgery was evaluated to gain further insight. This is the
largest patient-enrolled study till date according to our knowledge.
Methods
This is a prospective study on patients who underwent LVA for secondary lymphedema
of the lower limb between January 2018 and October 2020. The study was approved by
the institutional review board of Asan Medical Center. Exclusion criteria were (1)
patients with combined liposuction or lymph node transfer, (2) follow-up of less than
1 year, (3) who submitted incomplete questionnaire, and (4) who refused to participate
the study.
The demographic data included age, sex, marital status, urban–rural status, body mass
index (BMI), comorbidity, etiology and extent of lymphedema, history of radiotherapy,
time from cancer-ablation surgery/trauma to LVA, duration of lymphedema, history of
cellulitis requiring admission, International Society of Lymphology (ISL) stage, and
follow-up period. The surgical data included the mean number of performed LVA for
the affected limb and the anastomosis method.
The Korean version of the LYMQoL lower leg tool was produced through a forward-backward
translation process as recommended.[20]
[21] Seven translators participated in the forward translation procedure, and two translators
participated in the backward translation procedure. The forward translation was performed
by Korean-native speakers fluent in English. Translation was performed independently,
and a consensus was reached. Backward translation was done by native English speakers
fluent in Korean. After a consensus was reached on the two backward-translated versions,
it was given to a Korean not working in the medical field to evaluate whether it contained
any parts that were difficult to understand. At the end of this study, there was news
that LYMQoL validation was being studied at another medical institution, and it was
agreed that there was no significant difference between the version ongoing validation
process and the version used in this paper.
The outcome measurement included LYMQoL leg scoring system tool surveyed at preoperative,
postoperative 1 month, 6 months, and 12 months. LYMQoL tool is comprised of 27 questions
for 4 domains (8 for function, 7 for appearance, 5 for symptom, 6 for mood domains,
and 1 for overall score).[16] Regarding the score of function, appearance, symptom, and mood, lower score reflected
better QOL. In contrast, the overall score on a scale of 10, higher score reflected
better QOL. The postoperative improvement in the score for each domain and overall
score were analyzed.
The volume of limb was calculated by using tape-measured circumference (5, 10, and
15 cm above and below the popliteal crease in standing position) applied to an equation
(volume = π × H × (R2 + r2 + Rr)/3 (π = constant, H = height, R = radius [base], r = radius [top]).[22]
[23] The ratio of the reduction volume compared with the preoperative volume at each
follow-up interval were calculated and used as an outcome parameter.
Correlation analysis was performed to see whether these three factors played a role
in the outcome of LYMQoL tool: based on ISL stages, disease duration, and amount of
volume reduction.
Lymphaticovenous Anastomosis Protocol
The main indication for LVA is patients where lymphedema is resistant to volume reduction
despite 2 months of intensive compressive therapy.[24] Regardless of the ISL stage, LVA was performed as a first-line surgical treatment
when possible.[4]
[22]
[24] To identify functioning lymphatics and sizable superficial vein, magnetic resonance
lymphangiography and high-frequency ultrasonography were used preoperatively. In addition,
indocyanine green (ICG) and 0.2 cc of 10% fluorescein sodium (Fluorescite, Alcon,
Fort worth, TX) dye were used intraoperatively for visualizing the functioning lymphatics.[25] The LVAs were performed on either side (lymphatic vessel)-to-end (vein) or end-to-end
with a 11–0 nylon sutures.[26] After anastomosis, patency was confirmed based on intraluminal color change of the
vein and confirmation from the flow of ICG.
Statistical Analysis
A paired t-test was used to analyze the volume difference (postoperative 1 month and 6 months),
while Wilcoxon test was used (postoperative 12 months) when there was a skewness at
normality test. To analyze the longitudinal data of LYMQoL, linear mixed effects modeling
(covariance pattern model) was performed. The pattern of covariance between repeated
observations was modeled using a covariance pattern model to account for the correlation
between the observations within the subject. A selection of covariance patterns was
made by the comparison between the models using likelihood ratio tests. For the correlation
analysis, Pearson correlation was used for disease duration and amount of volume reduction
variables and Spearman correlation was used for ISL stage variable. All statistical
analyses were performed using IBM SPSS version 21.0 (IBM Corp., Armonk, NY). p-Values < 0.05 were considered to indicate statistical significance.
Results
Total of 118 patients were enrolled in this study. The average age of the patients
was 54.4 ± 12.3 years, 92.4% were female, 80.5% were married, 83.9% lived in urban
area and the average BMI was 24.9 ± 3.9 kg/m2. Bilateral lymphedema patients were seen in 19.5%, median duration of lymphedema
was 48 months (IQR = 70 months), and 50% of patients had history of cellulitis requiring
hospitalization. The distribution of ISL stages were 4.2%, 38.1, 31.4, and 26.3%,
respectively, for stage I, II early, II late, and III. The number of LVA performed
per limb was 3.4 ± 1.3. The LVA methods were 28.4, 37.8, and 33.8%, respectively,
for end-to-end only, side (lymphatic vessel)-to-end (vein) only, and combined. The
patient demographics are shown in [Table 1].
Table 1
Patient demographics
|
Patient demographics (n = 118)
|
|
Age, years
|
54.4 ± 12.3
|
|
Male/Female, n (%)
|
9 (7.6)/109 (92.4)
|
|
Single/Married status, n (%)
|
23 (19.5)/95 (80.5)
|
|
Urban/Rural status, n (%)
|
99 (83.9)/19 (16.1)
|
|
BMI, kg/m2
|
24.9 ± 3.9
|
|
DM, n (%)
|
9 (7.6)
|
|
HTN, n (%)
|
26 (22.0)
|
|
Etiology, n (%)
|
|
Cervix cancer
|
67 (56.8)
|
|
Ovarian cancer
|
16 (13.6)
|
|
Endometrial cancer
|
12 (10.2)
|
|
Other malignancy
|
14 (11.9)
|
|
Trauma
|
9 (7.6)
|
|
Uni-/bilaterality, n (%)
|
95 (80.5)/23 (19.5)
|
|
Etiology to LVA, months
|
143 ± 108.4
|
|
LE disease duration, months
|
median: 48 (IQR: 70)
|
|
Radiotherapy, n (%)
|
41 (34.7)
|
|
Cellulitis
|
59 (50.0)
|
|
ISL stage, n (%)
|
|
I
|
5 (4.2)
|
|
II early
|
45 (38.1)
|
|
II late
|
37 (31.4)
|
|
III
|
31 (26.3)
|
|
Follow-up duration, months
|
27.3 ± 8.7
|
|
N of performed LVA
|
3.4 ± 1.3
|
|
LVA methods
|
|
End-to-end only
|
23 (19.5)
|
|
Side-to-end only
|
63 (53.4)
|
|
Combined
|
32 (27.1)
|
Abbreviations: BMI, body mass index; DM, diabetes mellitus; Etiology to LVA, time
period from cancer-ablation surgery or trauma to LVA; HTN, hypertension; ISL, International
Society of Lymphology; LE, lymphedema; LVA, lymphaticovenous anastomosis; N, number.
The ratio of volume reduced compared with the preoperative volume was 10.2 ± 6.4,
8.9 ± 7.4, and 9.8 ± 8.8%, respectively, at postoperative 1, 6, and 12 months (p < 0.001; [Fig. 1]). The median value of volume reduction was 8%.
Fig. 1 Ratio of volume reduction compared with the preoperative volume. There were 11.0 ± 6.6%,
10.4 ± 7.5%, and 11.7 ± 9.5% volume reduction, respectively, at postoperative 1 month,
6 months, and 12 months (p < 0.001).
The LYMQoL tool overall satisfaction score significantly increased at all intervals
measured 4.4 ± 0.2 at the preoperative survey reaching 6.5 ± 0.3 at postoperative
12 months (p < 0.001) showing improved overall satisfaction. There was a statistically significant
decrease in domain scores at LYMQoL questionnaire at 12 months; function score decreased
from 18.6 ± 0.5 to 15.4 ± 0.6 (p < 0.001), appearance score decreased from 17.8 ± 0.5 to 16.0 ± 0.6 (p = 0.015), symptom score decreased from 11.8 ± 0.3 to 8.9 ± 0.4 (p < 0.001), and mood score decreased from 14.5 ± 0.4 to 11.4 ± 0.5 (p < 0.001). These decreased scores represent an improvement of each category ([Table 2], [Fig. 2]). When evaluating each interval for function, symptom, and mood scores, they significantly
decreased at postoperative 1, 6, and 12 months, while the appearance score significantly
decreased only at postoperative 6 and 12 months.
Fig. 2 Lymphedema Quality of Life (LYMQoL) score after lymphaticovenous anastomosis (LVA).
There was statistically significant improvement at function, appearance, symptom,
and mood scores. Overall score was significantly increased from 4.3 ± 0.2 to 6.4 ± 0.3
at postoperative 12 months (p < 0.001).
Table 2
Progress pattern of Lymphedema Quality of Life (LYMQoL) score after lymphaticovenous
shunt
|
Preoperative
|
1 mo
|
6 mo
|
12 mo
|
p-Value(overall)
|
|
Function (range)(paired p-value)[a]
|
18.6 ± 0.5 (8–32)
|
16.4 ± 0.5 (8–32) (<0.0001)
|
15.7 ± 0.6 (8–29) (<0.0001)
|
15.4 ± 0.6 (8–32) (<0.0001)
|
<0.0001
|
|
Appearance(range)(paired p-value)[a]
|
17.8 ± 0.5 (7–28)
|
17.0 ± 0.5 (7–28) (0.0653)
|
16.0 ± 0.6 (7–27) (0.0005)
|
16.0 ± 0.6 (7–28) (0.0015)
|
0.0006
|
|
Symptoms(range)(paired p-value)[a]
|
11.8 ± 0.3 (5–20)
|
10.0 ± 0.3 (5–20) (<0.0001)
|
9.4 ± 0.3 (5–18) (<0.0001)
|
8.9 ± 0.4 (5–20) (<0.0001)
|
<0.0001
|
|
Mood(range)(paired p-value)[a]
|
14.5 ± 0.4 (6–24)
|
12.4 ± 0.4 (6–24) (<0.0001)
|
11.6 ± 0.4 (6–22) (<0.0001)
|
11.4 ± 0.5 (6–24) (<0.0001)
|
<0.0001
|
|
Overall(range)(paired p-value)[a]
|
4.4 ± 0.2 (0–9)
|
5.7 ± 0.2 (1–10) (<0.0001)
|
6.4 ± 0.2(1–10)(<0.0001)
|
6.5 ± 0.3 (1–10) (<0.0001)
|
<0.0001
|
a
p-Value of comparison between preoperative volume and postoperative volume.
The outcome of the correlation analysis between the improvement of overall score and
the ISL stage shows no statistical significance (p = 0.610, correlation coefficient(r) = -0.047) ([Fig. 3], [Table 3]; [Supplementary Table S1], available in the online version). In addition, there was no correlation between
the improvement of overall score and disease duration (p = 0.659, r = − 0.041) ([Fig. 4], [Table 3]). There was no correlation between the improvement of overall score and the amount
of limb volume reduction (p = 0.454, r = − 0.070; [Fig. 5] and [Table 3]).
Fig. 3 The relation between disease severity (international society of lymphology [ISL]
stage) and the improvement of overall score at postoperative 12 months. There was
no significant correlation between ISL stage and improvement of overall score (p-value = 0.610). In this graph, the number of the patients corresponding to each plot
is indicated in parentheses.
Fig. 4 The relation between disease duration and the improvement of overall score at postoperative
12 months. There was no significant correlation between disease duration and improvement
of overall score (p-value = 0.659).
Fig. 5 The relation between the amount of limb volume reduction and the improvement of overall
score at postoperative 12 months. There was no significant correlation between the
amount of limb volume reduction and improvement of overall score (p-value = 0.454).
Table 3
The outcome of correlation analysis between improvement of overall score at 12 months
and the international society of lymphology (ISL) stage, disease duration, the amount
of limb volume reduction
|
p-Value
|
Correlation coefficient
|
|
ISL stage
|
0.610
|
−0.047
|
|
Disease duration
|
0.659
|
−0.041
|
|
Amount of limb volume reduction
|
0.454
|
−0.070
|
Note: Spearman correlation analysis was performed for analyzing ISL stage variable
and Pearson correlation analysis was performed for analyzing disease duration and
amount of limb volume reduction variables.
Discussions
This is the first large study to evaluate QOL after LVA in patients with lower limb
lymphedema. Currently, there is no wide consensus on a universal PROM tool and various
ad hoc tools along with more validated tools have reported good outcomes for lymphedema.[7]
[27] However, even with using these, most of the reports focused on the upper limb lymphedema
and lacks studies focused on the lower extremity.[2]
[19]
[27] Thus, this PROM study was designed to include a large patient pool who underwent
LVA to evaluate the QOL and to further provide meaningful insight through correlation
analysis and subgroup analysis.
Including bilateral lymphedema was a potential issue to be included in the study.
However, the comparison between the unilateral group and the bilateral group was performed
prior to the study. Both statistical analysis and pattern analysis show no difference
between the unilateral group and the bilateral group. Therefore, both unilateral group
and bilateral group were included in this study ([Supplementary Table S2] and [Supplementary Fig. S1], available in the online version).
In this study, the overall satisfaction score from the LYMQoL leg scoring system significantly
improved after LVA (4.4 ± 0.2 at preoperative survey reaching 6.5 ± 0.3 at postoperative
12 months). The overall score increased as much as 2.1 ± 0.2 during 1 year, and it
was similar to the 2.6 value from the study by Salgarello et al conducted with 26
patients.[17] Thus, the patients who underwent LVA have a significant improvement in overall QOL
supporting this surgical approach. However, further evaluation showed a peculiar pattern
for patients with stage I lymphedema. The overall satisfaction score was aggravated
at postoperative 1 month despite the improvement of volume. In contrast, the overall
score of ISL stage IIa, IIb, and III patients continued to improve throughout the
different intervals ([Supplementary Fig. S2], available in the online version). Although the overall score for stage I patients
also improved after 6 months, it is noteworthy that the expectations of the patients
with milder lymphedema may be different from the more advanced stage patients.
When looking into the specific domains for LYMQoL, each domain showed improvement
over time but there was a difference in the time point for improvement. Significant
improvement in the function, symptom, and mood domains was noted early from postoperative
1 month. However, the appearance domain did not show significant improvement till
postoperative 6 months. Even though the most reduction occurred in the first month
(10.2 ± 6.4% volume reduction), the patient's perception of improvement may take much
longer. This may be because a high discrepancy between the expectations of the patient
and surgeon may exist. Even on the basic understanding of what constitutes QOL, doctor,
and patient perceptions may significantly diverge.[28] Therefore, based on these results, it will be necessary to explain in detail how
the recovery progresses including patient perception of appearance. If QOL issues
and the potentially divergent perspectives are not acknowledged and integrated into
the patient's assessment, it can result in a lack of understanding about the efficacy
of treatment or even lack of compliance.
In this study, three types of correlation analysis were performed according to the
disease severity, disease duration, and the amount of limb volume reduction after
LVA. There was no significant correlation between the improvement of overall LYMQoL
score and disease severity or duration. The authors recently have reported on how
to increase the success of LVA for advanced lymphedema patients by using enhanced
preoperative imaging resulting in significant volume reduction.[22]
[25] Thus, successful LVA can meaningfully help in improving QOL regardless of the stage
and duration of the disease. This similar finding was also reported in a systemic
review looking at QOL after lymphedema surgery for the lower limb.[2] Finally, when looking at the correlation based on the amount of limb volume reduction,
there was no significant correlation between the improvement of the overall score
and the amount of volume reduction. Although one can assume that satisfaction may
be closely related to the amount of improvement, there was no significant correlation
between improvement of limb volume after LVA and QOL in this study. This is a peculiar
finding after LVA. However, studies have shown conflicting reports in regard to the
correlation between QOL and volume reduction.[29]
[30]
[31]
[32] Further evaluation will be needed to ultimately determine how volume reduction will
play a role in improving the overall QOL. This study suggests that significant improvements
are made in the QOL of patients after LVA based on multiple factors not only limited
to but including the amount of lower limb volume reduction.
There are few limitations of this study. First, although this is the largest lower
extremity lymphedema LYMQoL series to date, it will be ideal to have more patients
enrolled to further evaluate and perform subgroup analysis. Second, the follow-up
period of this study was limited to 1 year. This is based on our experience and studies
that show most volume reduction occurs in the first few months. However, longer investigation
up to several years will bring better insight into how the patient perception changes
over long period of time. Third, there are too many variables that need to be taken
into account such as BMI, smoking, compliance, etiology, and others. It would be ideal
if these variables could be controlled but considering the diversity of clinical manifestation
of lymphedema patients and the difficulty of the PROM study, it is hard to control
these variables unless increasing the collected data by multiple folds. Even though
this is the largest study to date, the number of patients is still insufficient to
conduct a multivariated study. Therefore, a follow-up study based on more patients
is warranted. Nevertheless, the data and result at this stage still provide a meaningful
conclusion that may help the surgeons understand the patients' perspective.
The QOL of secondary lower limb lymphedema patients were significantly improved after
LVA regardless of the severity of disease, duration of disease, and amount of volume
reduction after LVA. Understanding the PROM will help the surgeons to manage and guide
the expectations of the patients.
