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23 Quality ofLife inLower Limb Lymphoedema Patients
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debulking of lymphoedematous skin and subcutaneous tissue. This combined
approach also improved both the LYMQoL overall score and individual domain
scores [42].
23.5.5 Lymphovenous Anastomosis
LVA involves the joining of a lymphatic channel to a subdermal venule, creating a
new channel through which lymphatic uid can return to the venous circulation. As
mentioned previously, this technique was not found to result in signicant improvements on LYMQoL overall and individual domain scores in a cohort study from
Taiwan [38]. However, two other cohort studies found a positive HRQoL impact in
patients undergoing LVA.
In a study from Italy that observed 26 patients with lower limb lymphoedema
(together with 44 patients with upper limb lymphoedema), signicant improvement
in LYMQoL overall and individual domain scores were seen post-LVA. This
improvement was greater in patients with lower limb lymphoedema when compared
to those with upper limb lymphoedema [43]. A cohort study from the UK who
underwent LVA found that 24 out of 29 patients showed improved HRQoL postoperatively, with median LYMQoL overall score improving from 72 to 90 points.
Interestingly though, no association between limb volume reduction and HRQoL
improvements were seen [44].
23.6 Discussion
Lymphoedema is a debilitating chronic condition characterised by excessive accumulation of uid in the interstitium of soft tissues secondary to impaired lymphatic
drainage. While initially presenting with swelling, heaviness, and pain in the
affected limb(s), skin and subcutaneous changes soon follow if left untreated, leading to skin brosis and fat accumulation [45]. HRQoL is well documented to be
signicantly affected in patients living with chronic conditions [46–48], and lymphoedema is no different.
Clearly, the impact of lower limb lymphoedema on patients’ HRQoL can only be
a negative one. With lymphoedema eventually leading to extremity disability, recurrent skin infections, breakdown and ulceration, and even malignant transformation
(e.g., lymphangiosarcoma), the impact on physical health only compounds with
time. Quantiable decreases in HRQoL have been recorded in all the studies that
have been included in this literature review, with statistically signicant impacts
noted on both generic and disease-specic instruments. What is interesting to note
is that patients with primary lymphoedema appear to have physical HRQoL impairments that are less severe compared to those with secondary lymphoedema [15],
and physical HRQoL levels in this population is also comparable to population
norms [15, 16].
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M. K. H. Tan and A. H. Davies
Psychological and emotional HRQoL may, on the other hand, be related to how
well patients cope with the disease and the ability to which they are able to adjust to
the complications that arise from lymphoedema. The literature is less clear-cut with
regards to the impact of lymphoedema on these HRQoL domains—this may be
dependent on the specic patient population in question. It appears that primary
lymphoedema patients once again have an advantage over their secondary lymphoedema peers, with no signicant differences in psychological scores were seen from
population norms, while secondary lymphoedema patients exhibited worse scores.
It has been speculated that this could be due to primary lymphoedema patients having developed better coping strategies for their disease, having lived with the condition for longer than those with secondary lymphoedema. This level of resilience
may also differ from patient to patient, leading to a less direct correlation between
disease and the mental state of patients.
However, in lymphoedema research, dening the target population is further
complicated by two-tiered system, with a greater focus on secondary lymphoedema
related to cancer (specically breast cancer and thus upper limb lymphoedema) and
HRQoL studies and treatment provision are therefore often restricted to these
patients [49]. Patients suffering from lymphoedema of other causes are oft neglected
[50]. For example, a systematic review that considered treatment gaps in lymphoedema found that 94% of breast cancer-related lymphoedema patients received treatment for limb swelling, while only 82% of venous leg ulcer patients with
phlebolymphoedema were treated [50]. Interestingly, the current literature review
has highlighted a paucity of research into HRQoL for non-gynaecological cancerrelated lymphoedema (including melanomas, prostate, etc.), suggesting that the
greater focus in gynaecological cancers may be in part due to lower limb lymphoedema being a better recognised complication by both physicians and patients.
Furthermore, few studies also looked at primary lymphoedemas independently,
which particularly in HRQoL research may be problematic due to the issues raised
in the previous paragraphs.
With regards to treatment for lower limb lymphoedema, CDP is currently considered the optimal treatment and is recommended as the rst line for the management of lymphoedema [1]. This is not surprising given the proven clinical
effectiveness of CDP, but this evidence is largely based on the reduction of limb
volume and oedema [51–53]. However, the evidence is less clear on the impact of
isolated on CDP on HRQoL improvements, with recent studies combining this therapy with longer term rehabilitation exercises with resulting improvements in
patients’ physical function. Clinical endpoints mean less to patients than to clinicians, and preserving physical function would likely be of greater importance to the
patient than limb volume measurements.
While surgical intervention appears to improve HRQoL in lower limb lymphoedema, where it ts into the picture is currently unclear. This may be in part be due
to the novelty of this approach, and as a result, while increasing in popularity, small
numbers of operations have been performed. Indeed, within this literature review,
the largest patient cohort of 107 lower limb lymphoedema patients undergoing
VLNT was only achieved after 24years of recruitment (1983 to 2007) [41], with
23 Quality ofLife inLower Limb Lymphoedema Patients
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other studies recruiting smaller cohorts of between 10 to 29 patients after 2 to
8years of recruitment. This leads to difculty when comparing surgical approaches
(for e.g., LVA versus VLNT) and conservative methods. Further trials are indeed
required to compare the impact of conservative, pharmacological, and surgical
interventions on lymphoedema patients’ both from a clinical effectiveness and
HRQoL point of view. These trials should also focus on if and how treatment outcomes relate to HRQoL changes—limb volume changes may not be sufcient as a
clinical endpoint in future studies. It would also be important to determine the right
treatments for the right populations; with HRQoL impacted differently between
primary and secondary lymphoedema patients, this may necessitate different treatment regimens for these disparate populations.
23.7 Conclusions
In the most recent 10years of literature, studies largely agree that lower limb lymphoedema is a chronic, debilitating condition that has a negative impact on patients’
HRQoL, with consequences on both physical and psychological HRQoL.The body
of evidence is not yet completely clear regarding the actual domains and degree of
impact, with differential impact stratied based on the primary and secondary
lymphoedema populations. Further trials are required to compare the impact of conservative and surgical interventions on patients’ HRQoL.Further work is required
to determine the target populations for specic interventions to maximise HRQoL
benets.
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