Risk factors for cellulitis in patients with secondary lower limb lymphedema associated with gynecological cancer treatment

Abstract

Introduction: Lower limb lymphedema (LLL) is one of the most disabling and debilitating complications of gynecological cancer treatment. The clinical presentations of LLL are usually chronic progressive and ultimately leads to reduced quality of life. Cellulitis is recognized as one of the most common comorbidities associated with LLL during the treatment period. The aim of this study was to examine risk factors of cellulitis in patients with LLL after gynecological cancer treatment. Materials and methods: We conducted a multicenter, retrospective study from 2002 to 2015, using the records of the seven medical institutions. Patients, who developed LLL after gynecological cancer treatment, were eligible. All the patients were received compression-based physical therapy. The risk factors for cellulitis and their predictive powers were quantified by odds ratios (ORs) with corresponding 95% confidence intervals (CI). Result: In total, 1034 patients visited to the seven institutions during the study period fulfilled the required criteria. The mean age of the patients was 58.0 (SD = 11.7) years, and the mean BMI was 22.7 (SD = 3.9) kg/m2. The prevalence of cervical cancer, endometrial cancer, and ovarian cancer were 414 (40.0%), 274 (26.5%), and 159 (15.4%), respectively; the rest of 187 (18.1%) patients were recorded as uterine cancer and the origin was uncertain. Pelvic lymphadenectomy was performed in 581 (56.2%) patients, where 264 (25.5%) of them underwent added paraaortic lymphadenectomy. Performance of lymphadenectomy or its site in the rest of 189 (18.3%) patients was unidentified. Chemotherapy was administered in 87 (8.4%) patients, while 268 (25.9%) patients received radiation therapy. All the patients received physical compression therapy and manual lymphatic drainage (MLD) was performed 881 (85.2%) patients. The results of univariate and multivariate analysis were shown in Table. A multivariate analysis identified following independent risk factors: age (OR = 1.019 [95%CI: 1.002–1.036]; P = 0.025), initial limb circumference (OR = 1.034 [95%CI: 1.021–1.046]; P < 0.001), and MLD (OR = 4.282 [95%CI: 2.117–8.420]; P < 0.001). Conclusion: Our study showed some independent risk factors of developing cellulitis during compression-based physical therapy for LLL, which may be considered to imply clinical alerts. In the patients with higher age and larger limb circumference were revealed to increase the risk of developing cellulitis. The result of the multivariate analysis also suggested MLD was the strongest contributor to developing cellulitis. This might be because MLD hematogenously or lymphogenously spread a latent skin infection and cause apparent cellulitis. However, it was uncertain when cellulitis occurred during the follow-up period or how the skin condition was before and after performance of MLD. Further studies should guarantee its efficacy and safety for treatment of LLL after gynecological cancer treatment.