Gynolymph-trial: Lower limb lymphedema after gynaeco-oncologic therapy: can we prevent irreversible lymphedema?

Improved knowledge on the diagnosis and treatment of cancer has resulted in an increased number of cancer survivors.  Consequently, more patients are confronted, often life-long, with the complications of their cancer treatment.  These chronic conditions impact daily functioning and quality of life (QoL), complicate the resumption of work and undermine psycho-social well-being.  One of the most frequent and disabling complications is lymphedema, a condition undermining QoL to an extent exceeding even a 10-year age increase(1).

The damage of lymphedema covers many aspects of daily life: it changes body image and complicates daily activities as basic as clothing(2), it increases patient-related health expenditures for treatment and for coping with the disease(3), reduces patient autonomy in daily functioning and can even cause sensory or motor dysfunctions(4).  So far, no definitive cure exists for lyphedema: patients are confined to life-long preventive measures, compression therapy and regular lymph drainage.  Surgical repair may be an option in selected cases, but evidence on surgical techniques is limited and their long-term effects are still unknown.  Moreover, even after successful repair, conservative treatment is still needed.

Most studies on lymphedema are limited to upper limb lymphedema (ULL), mainly after breast cancer treatment.  Only few publications focus on lower limb lyphedema (LLL), despite its detrimental impact on QoL (5-8).  This could be due to the difficulties to diagnose and treat LLL in comparison to ULLL: LLL often occures biltaterally or at the level of the groins or genital region, hence impeding diagnosis through comparison.  Perimetric measurement of large cone-like edematous legs is cumbersome.  Lymph drainage and application of compressive garments is more strenuous for legs than for arms, and the typical bilateral occurence and large voulmes of LLL inflate the cost of treatment garments.  The low appeal of gynae-oncologic cancer in contrast to breast cancer is just another hurdle to overcome for trial development and funding in this area.

As thus, little evidence exists on diagnostic techniques for detection of early LLL and on early intervention intended to avoid progression to a consolidated advanced stage LLL.  To obtain an answer to these questions, this observational cohort trial will follow women diagnosed with gynae-oncologic cancer from the start of their cancer treatment.  To evaluate the added value of lymphedema detection-questionnaires and of non-invasive diagnostic measurements, these will be compared to lymphoscintigraphy, wich is the gold standard for diagnosing lymphedema(9,10).  ICG-lymphography is a new technique to visualize on an anatomic level the subcutaneous lymphatic flow(11,12).  It's role in early mapping of lypmhatic insufficiency in the legs will be evaluated by comparing early patient-reported signalling of symptoms related to lymphedema to this exam and to lymphoscintigraphy.