Spillane Andrew J, Saw Robyn P M, Tucker Monica, Byth Karen, Thompson John F
Sydney Melanoma Unit at the Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia.
Ann Surg. 2008 Aug;248(2):286-93. doi: 10.1097/SLA.0b013e31817ed7c3.
This study aims to objectively define the criteria for assessing the presence of lymphedema and to report the prevalence of lymphedema after inguinal and ilio-inguinal (inguinal and pelvic) lymph node dissection for metastatic melanoma.
Lymphedema of the lower limb is a common problem after inguinal and ilio-inguinal dissection for melanoma. The problem is variably perceived by both patients and clinicians. Adding to the confusion is a lack of a clear definition or criteria that allow a diagnosis of lymphedema to be made using the various subjective and objective diagnostic techniques available.
Lymphedema was assessed in 66 patients who had undergone inguinal or ilio-inguinal dissection. Nine patients received postoperative radiotherapy. Assessment was performed by limb circumference measurements at standardized intervals, volume displacement measurements, and volumetric assessment calculated using an infrared optoelectronic perometer technique. Comparisons were made with the contralateral untreated limb. Patient assessment of the severity of lymphedema was compared with objective measures of volume discrepancy. Classification and regression tree analysis was used to determine a threshold fractional leg volume or circumference increase above which patients could self-detect volume changes that they reliably considered to indicate lymphedema.
Based on classification and regression tree analysis, both the whole limb perometer volume percentage change > or = 15% and the sum of circumferences (of 6 defined sites along the limb) percentage change > or = 7% performed well overall in predicting moderate or severe perceived swelling (defined as "lymphedema"). Both definitions predicted lymphedema in approximately the same fraction of patients with misclassification rates of 16% and 15%, sensitivity 56% and 50%, specificity 95% and 100%, respectively. Using > or = 15% of whole perometer volume percentage change, 12% of patients with inguinal dissection had lymphedema compared with 23% of patients with ilio-inguinal dissection. Combining both groups, 18% of patients had lymphedema, positive and negative predictive values 82% and 84%. Using the definition > or = 7% of the sum of circumferences percent change, 7% of patients with inguinal dissection had lymphedema compared with 19% of patients with ilio-inguinal dissection (overall 14% had lymphedema, positive and negative predictive values 100% and 82%, respectively). Of the variables assessed, only radiotherapy was significantly associated with predicted lymphedema (OR 12.6; 95% CI 1.7 to > 100; P = 0.001 using whole perometer change > or = 15%; and OR 13.0; 95%CI 1.4 to > 100; P = 0.021 using sum circumference change > or = 7%).
A whole limb perometer volume percentage change of > or = 15% and increase in the sum of circumferences of the defined points along the limb > or = 7% provide robust definitions of lower limb lymphedema.
本研究旨在客观地确定评估淋巴水肿存在的标准，并报告转移性黑色素瘤腹股沟和髂腹股沟（腹股沟和盆腔）淋巴结清扫术后淋巴水肿的患病率。
下肢淋巴水肿是黑色素瘤腹股沟和髂腹股沟清扫术后的常见问题。患者和临床医生对该问题的认知存在差异。由于缺乏清晰的定义或标准，使得在使用各种主观和客观诊断技术诊断淋巴水肿时产生混淆。
对66例行腹股沟或髂腹股沟清扫术的患者进行淋巴水肿评估。9例患者接受了术后放疗。通过在标准化间隔时间测量肢体周长、测量体积位移以及使用红外光电周长仪技术计算体积评估来进行评估。与对侧未治疗的肢体进行比较。将患者对淋巴水肿严重程度的评估与体积差异的客观测量结果进行比较。使用分类和回归树分析来确定腿部体积分数或周长增加的阈值，超过该阈值患者能够自我检测到他们可靠地认为表明淋巴水肿的体积变化。
基于分类和回归树分析，整个肢体周长仪体积百分比变化≥15%以及肢体上6个定义部位的周长总和百分比变化≥7%在预测中度或重度感知肿胀（定义为“淋巴水肿”）方面总体表现良好。这两种定义预测淋巴水肿的患者比例大致相同，错误分类率分别为16%和15%，敏感性分别为56%和50%，特异性分别为95%和100%。使用整个周长仪体积百分比变化≥15%，腹股沟清扫术患者中有12%发生淋巴水肿，而髂腹股沟清扫术患者中有23%发生淋巴水肿。合并两组，18%的患者发生淋巴水肿，阳性和阴性预测值分别为82%和84%。使用周长总和百分比变化≥7%的定义，腹股沟清扫术患者中有7%发生淋巴水肿，而髂腹股沟清扫术患者中有19%发生淋巴水肿（总体14%发生淋巴水肿，阳性和阴性预测值分别为100%和82%）。在所评估的变量中，只有放疗与预测的淋巴水肿显著相关（使用整个周长仪变化≥15%时，OR为12.6；95%CI为1.7至>100；P = 0.001；使用周长总和变化≥7%时，OR为13.0；95%CI为1.4至>100；P = 0.021）。
整个肢体周长仪体积百分比变化≥15%以及沿肢体定义点的周长总和增加≥7%为下肢淋巴水肿提供了可靠的定义。
