Incidence and Severity of Lymphoedema following Limb Salvage of Extremity Soft Tissue Sarcoma

Abstract

Background and Purpose. Lymphoedema is a serious complication following limb salvage for extremity soft tissue sarcomas (STSs) for which little is known. We aimed to evaluate its incidence, its, severity and its associated risk factors. Material and Method. Patient and tumor characteristics, treatment modalities and complications and functional outcomes (MSTS 1987, TESS), and lymphoedema severity (Stern) were all collected from prospective databases. Charts were retrospectively abstracted for BMI and comorbidities. Results. There were 289 patients (158 males). Mean age was 53 (16–88). Followup ranged between 12 and 60 months with an average of 35 and a median of 36 months. Mean BMI was 27.4 (15.8–52.1). 72% had lower extremity tumors and 38% upper extremity. Mean tumor size was 8.1 cm (1.0–35.6 cm). 27% had no adjuvant radiation, 62% had 50 Gy, and 11% received 66 Gy. The incidence of lymphoedema was 28.8% (206 none, 58 mild, 22 moderate, 3 severe, and 0 very severe). Mean MSTS score was 32 (11–35) and TESS was 89.4 (32.4–100). Radiation dose was significantly correlated with tumor size > 5 cm (P = 0.0001) and TESS score (P = 0.001), but not MSTS score (P = 0.090). Only tumor size > 5 cm and depth were found to be independent predictors of significant lymphoedema. Conclusion. Nine percent of STS patients in our cohort developed significant (grade ≥ 2) lymphoedema. Tumor size > 5 cm and deep tumors were associated with an increased occurrence of lymphoedema but not radiation dosage.

The Effect of Smoking and Major Vein Resection on Post-therapy Lymphedema in Soft Tissue Sarcomas Treated With Neoadjuvant Radiation and Limb-salvage Surgery

“…4,8,15 Post-therapy lymphedema is a potential complication that occurs in approximately 20% to 30% of patients with STS; however the incidence, severity, and predictors for post-therapy lymphedema in patients with STS remain unclear. 4,8,10,11,15,16 In this study, 24% of patients had some degree of lymphedema, as defined on clinical exam as either mild or significant, with the majority of post-therapy lymphedema complications occurring in patients who had proximal lower extremity STS. Of the patients who developed post-therapy lymphedema, 31% were classified as moderate or severe lymphedema that impacted activities of daily living and may have required intervention.…”

“…In this series, 29% of patients developed lymphedema, as graded by the Stern's rating, and timing of radiation, tumor size >5 cm and depth of tumor were found to be predictors on UVAs. 16 Proposed mechanisms of lymphedema in the post-therapy setting are likely due to damage of the lymphatic drainage, either due to valvular or nodal abnormalities. However, other methods of lymphedema include alteration in protein concentration and vascular changes, such as angiogenesis and blood flow.…”

“…Risk factors identified in previous studies include, but are not limited to field size, >35 cm radiation portals, tumor size > 5 cm, and tumor depth. 11,15,16 The primary objective of this study was to determine the rate of lymphedema in patients with STS of the extremity and body wall treated with preoperative radiation with or without sequential chemotherapy followed by limb-sparing surgery. The second objective of the study was to identify prognostic indicators for post-therapy lymphedema.…”

Health‐related quality of life, psychosocial functioning, and unmet health needs in patients with sarcoma: A systematic review

“…However, treatment can cause significant side‐effects: patients receiving radiotherapy become susceptible to radiation fibrosis syndrome and osteoporosis, whilst limb‐sparing surgery can damage anatomical structures proximal to the tumour site and may be associated with an increased risk of muscle weakness, poor motor control, and ongoing pain . Up to 50% of survivors live with long‐term disability, and this can have negative effects on HRQoL.…”

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects

“…Historically, the best practice for management of limb sarcomas was amputation . Subsequently, limb salvage by means of wide resection (of at least 2 cm), radiotherapy and soft tissue reconstruction has not been found to increase rates of mortality or recurrence and this has become the new standard . The resulting soft tissue defect is often significant and requires soft tissue flap reconstruction in 10–20% of patients .…”