Midline oedema is defined as lymphoedema of the face, head and neck, breast, torso and genitalia which is a reported side-effect of pelvic lymph node dissection (PLND). This blogpost will further discuss the cause, prevalence and assessment of midline oedema in light of my doctorate project.
Genital lymphoedema can occur primary due to anatomic malformation or secondary when it is caused by treatment of genitourinary cancer. Other causes for the development of genital lymphoedema are Crohn’s disease or an idiopathic inflammatory disease1.
Due to PLND in the pelvis, lymphoedema of the genitals and adjacent regions (pubis, groin and inner thigh(s)) are the most obvious result.
There are different extends of PLND. According to Keegan et al (2011) the more extensive the dissection of the lymph nodes, the more the morbidity may increase2. A few years later, Fossati et al (2017) conducted a systematic review about the benefits and harms of different extents of LND. They concluded the same but they underline that the quality of the studies included was low3. They indicate to follow the EAU prostate cancer (PCa) guidelines, which states that extended PLND is recommended in high and intermediate-risk patients for staging if there is a 5% risk that the lymph nodes are positive. PLND should be avoided in low-risk patients4.
According to the systematic review and meta-analysis of Cormier et al (2010) incidences of lymphoedema related to genitourinary cancers are 21% for penile cancer, 16% for bladder cancer and 4% for prostate cancer5. Caution is needed when reading these incidences because they come from a small number of studies. And most of these studies used subjective assessment. Therefore, there is an overall need on more extensive literature on lymphoedema related to genitourinary cancer in men.
As I mentioned above, in men with lymphoedema and genital oedema after treatment for genitourinary cancer the incidence seems to be under reported and therefore under treated. This delayed management could be due to the patient itself as to the health professional6,7.
In the UK, a self-reporting questionnaire has been developed in order to detect symptoms of genital or lower limb oedema in men after treatment for genitourinary cancer. The questionnaire is called the Lymphoedema Genito-Urinary Cancer Questionnaire (LGUCQ)8. Although it seems a promising tool, further research in terms of sensitivity, specificity and broader generalizations is needed8,9.
Further, another gap in literature is that there is no standard protocol to evaluate genital lymphoedema. This makes it only harder to investigate the incidence.
Despite these gaps, what we do know is that (genital) lymphoedema has an important impact on the quality of life of the patient10,11. Not only physically, also psychologically or sexually12.
If a standard protocol to assess genital lymphoedema could be developed, investigation of incidence rates would be easier in my opinion. Therefore I hope that I can contribute to filling these gaps in literature.
Charlotte Van Calster
1. Mortimer P, Levine G. Let's Talk Lymphoedema: The Essential Guide to Everything You Need to Know: Elliott and Thompson Limited; 2017.
2. Keegan KA, Cookson MS. Complications of Pelvic Lymph Node Dissection for Prostate Cancer. Current Urology Reports. 2011;12(3):203-208.
3. Fossati N, Willemse PM, Van den Broeck T, et al. The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review. Eur Urol. Jul 2017;72(1):84-109.
4. Mottet N, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. Feb 2021;79(2):243-262.
5. Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. Nov 15 2010;116(22):5138-5149.
6. Noble-Jones R, Thomas MJ, Davies L, Morgan K. Are you handling genital oedema confidently? Br J Community Nurs. Oct 1 2019;24(Sup10):S19-s22.
7. Noble-Jones R, Thomas MJ, Gabe-Walters M. The education needs of health professionals conservatively managing genital oedema: UK survey findings. Br J Nurs. May 13 2021;30(9):S18-s26.
8. Noble-Jones R, Fitzpatrick B, Sneddon MC, Hendry DS, Leung HY. Development of the lymphoedema genito-urinary cancer questionnaire. Br J Nurs. Oct 9 2014;23 Suppl 18:S14-19.
9. Rhian Noble-Jones MJT, Pradeep Bose MBBS FRCSEd. The Lymphoedema Genitourinary Cancer Questionnaire in urology follow-up clinics. INt J Urol Nurs 2019;13(1):5-12.
10. Morgan PA, Franks PJ, Moffatt CJ. Health-related quality of life with lymphoedema: a review of the literature. Int Wound J. Mar 2005;2(1):47-62.
11. Ridner SH. Pretreatment lymphedema education and identified educational resources in breast cancer patients. Patient Educ Couns. Apr 2006;61(1):72-79.
12. Bowman C, Piedalue KA, Baydoun M, Carlson LE. The Quality of Life and Psychosocial Implications of Cancer-Related Lower-Extremity Lymphedema: A Systematic Review of the Literature. J Clin Med. Oct 2 2020;9(10).