Janice N. Cormier, MD, MPH
Department of Surgical Oncology
University of Texas M.D. Anderson Cancer Center
Houston, TX
jcormier@mdanderson.org

Latunya Davidson
Department of Surgical Oncology
University of Texas M.D. Anderson Cancer Center
Houston, TX

Wendy J. Evans
Sinclair School of Nursing and Ellis Fischel Cancer Center
University of Missouri-Columbia
Columbia, MO

Jane M. Armer
Sinclair School of Nursing and Ellis Fischel Cancer Center
University of Missouri-Columbia
Columbia, MO

Note. This article originally appeared in volume 17, Issue 1, 2005, of LymphLink. Reprinted with permission.

Melanoma is a growing public health problem with an estimated 132,000 cases diagnosed annually worldwide (World Health Organization, 2004). It is the sixth most common malignancy among Americans (American Cancer Society, 2004) and accounts for more than 79% of all skin cancer-related deaths (Geller & Annas, 2003; Trask et al., 2001). Fortunately, the majority of patients diagnosed with melanoma present with early-stage disease that is cured by surgical excision alone. For others, presenting with regional or distant metastatic disease, the prognosis is not as favorable. The most critical factors for determining the prognosis of patients with melanoma are primary tumor thickness and the status of regional lymph nodes. Both of these elements are incorporated into the American Joint Committee on Cancer staging system for melanoma (American Joint Committee on Cancer, 2002).

Surgical Treatment
The most important information for determining surgical treatment of melanoma is the thickness (Breslow thickness), which is measured in millimeters and is determined by pathologic examination of a biopsy of the primary tumor. Current surgical guidelines (National Comprehensive Cancer Network, 2004) include a wide local excision (WLE) of the primary tumor. Regional lymph nodes are the most common first site of melanoma metastases. Over the last decade, sentinel lymph node (SLN) biopsy has emerged as a reliable technique for identifying micrometastatic disease in clinically negative regional lymph node basins. SLN biopsy is a highly accurate, minimally invasive surgical procedure based on the theory that lymphatic metastases associated with melanoma follow an orderly progression through lymph channels from the primary tumor to a particular lymph node (designated the “sentinel” lymph node) before spreading into other regional (“nonsentinel”) lymph nodes (Reintgen et al., 1994).

Current guidelines outlined by the National Comprehensive Cancer Network for the treatment of patients with melanoma recommend SLN biopsy for all patients with primary melanomas greater than 1 mm thickness and subsets of patients with high-risk thin (< 1 mm) melanomas (Ak, Stokkel, Bergman, & Pauwels, 2000). In patients with an SLN that tests negative for presence of cancer, no further surgical therapy is recommended. In patients with metastases identified in the SLN, a complete lymph node dissection is performed. This combination of surgical treatments, a WLE of a primary tumor along with SLN biopsy and possible subsequent complete lymph node dissection, results in multiple sites of lymphatic disruption.

Unlike axillary (“armpit”) node dissection for patients with breast cancer, which includes dissection of level I and II lymph nodes, axillary node dissection for patients with melanoma of the upper extremity or trunk includes the routine dissection of level I, II, and III lymph nodes. Level III lymph nodes are the highest axillary nodes (apical). A standard lymph node dissection for patients with lower extremity or truncal melanomas draining to the inguinal region includes the removal of lymph nodes located in the inguinofemoral (groin) region. In addition, subsets of patients with melanoma with bulky nodal disease undergo an additional deep pelvic dissection.

The surgical treatment of melanoma results in varying degrees of lymphatic disruption resulting in a lifetime risk for developing lymphedema. It is postulated that lymphedema may occur more frequently in patients with melanoma because of: (1) multiple surgical sites (e.g., primary tumor excision on an extremity in conjunction with lymph node biopsy or dissection), (2) extent of nodal dissections, and (3) anatomic sites, particularly the lower extremity, which may be at increased risk due to physiologic reasons.

Review of the Literature
The data estimating the incidence of lymphedema in patients with melanoma are far from complete. We have systematically reviewed the literature and found a total of 25 studies performed between 1972 and 2004 pertaining to melanoma and lymphedema. Of these 25 studies, 12 (48%) were retrospective, 10 (40%) prospective, 2 (8%) clinical trials, and 1 (4%) a case series. As with the reported incidence of postsurgical lymphedema for patients with breast cancer (Passik & McDonald, 1998; Petrek & Heelan, 1998), the reported incidence of lymphedema in patients with melanoma varies widely, with reported rates ranging from 2% to 67%. The disparity likely relates to the heterogeneity of the reports, which will be discussed below.

Measurement Methods
Volume measurement using water displacement historically has been regarded as the most sensitive and accurate measure; however, clinicians rarely use this cumbersome approach (Petlund, 1991; Tierney, Aslam, Rennie, & Grace, 1996). Two of the 25 studies used water displacement alone (James, 1982) or in combination with circumference measurements (Baas et al., 1992). Circumference measurements were utilized in five of the studies (Holmes et al., 1977; Karakousis, Heiser, & Moore, 1983; Lawton, Rasque, & Ariyan, 2002; Papachristou & Fortner, 1977; Urist, Maddox, Kennedy, & Balch, 1983). The remaining 15 studies reported on lymphedema in patients with melanoma using clinical definitions with no objective measurement criteria.

Lymphedema Classification
In one study in which significant lymphedema was defined as greater than 1 inch difference (measured at the ankle or midcalf) between the affected and unaffected limb, lymphedema was reported in 80% of patients five years after surgery (Papachristou & Fortner, 1977). Two other studies reported rates of 21%–26% when 2–4 cm (Urist et al., 1983) or 3–4.5 cm (Karakousis et al., 1983) differences were used as criteria.

Surgical Procedures
In 235 patients who underwent SLN biopsy in the axillary or inguinofemoral region, only 5 patients (2%) were reported to have lymphedema on an average of six weeks after surgery (range of 2–10 weeks) (Wrone et al., 200). Three studies reported lymphedema in 20%–45% of patients undergoing inguinofemoral dissections, with no difference noted between superficial dissections alone or in combination with deep pelvic dissections (Baas et al., 1992; Karakousis & Driscoll, 1994; Stevens et al., 2000).

Postoperative wound complications often are associated with extensive nodal dissections, particularly in the inguinal region. Seven studies reported postoperative wound complications, including cellulitis in 6%–33% of patients (Baas et al., 1992; Ingvar, Erichsen, & Jonsson, 1984; Karakousis & Driscoll, 1994; Lawton et al., 2002; Serpell, Carne, & Bailey, 2003; Strobbe, Jonk, Hart, Nieweg, & Kroon, 1999; Urist et al., 1983).

Anatomic Variation—Upper Versus Lower Extremity
It is difficult to make direct comparisons of rates of lymphedema at various anatomic sites among studies given the heterogeneity of the reports. Of the studies that examined lymphedema associated with axillary versus inguinofemoral nodal dissections, similar trends were noted. The reported range of upper extremity lymphedema was 5%–8% (Shaw & Koea, 1992; Urist et al., 1983) compared to 14%–29% for lower extremity lymphedema (Lawton et al., 2002; Serpell et al., 2003). It appears from these reports that the incidence of lower extremity lymphedema may be twice as high as upper extremity lymphedema.

Time Horizon
It has been noted that breast cancer lymphedema studies with the shortest follow-up (12 months) report the lowest incidence (6%) (Petrek & Heelan, 1998), whereas studies with the longest follow-up have the highest incidence. Similar trends are noted in this review, with the lowest lymphedema rates (upper and lower extremity) noted in studies that examined patients six months postoperatively (Wrone et al., 2000), whereas the highest incidence (67%, lower extremity lymphedema) had the longest follow-up (20 years) (Papachristou & Fortner, 1977). High rates (44%) also were noted when lymphedema was defined as swelling lasting more than six months (Beitch & Balch, 1992).

Discussion
All people diagnosed with melanoma are at a lifetime risk of developing lymphedema because of the extensive lymphatic disruption associated with surgical treatment. Lymphedema and its sequelae are much-understudied morbidities associated with cancer treatment, particularly in patients with melanoma. In patients with breast cancer, lymphedema has been described as an overlooked, underdiagnosed, and undertreated condition, which, other than tumor recurrence, is the most feared effect of treatment (Disa & Petrek (2001)). The same likely can be said of melanoma and lymphedema.

Lymphedema is a significant problem. In addition to the symptoms and risks, the associated challenges also may lead to post-treatment psychosocial distress. Although researchers have documented the psychological sequelae of breast cancer treatment (Tobin, Lacey, Meyer, & Mortimer, 1993), we know little about such issues in patients with melanoma, especially those that may involve lymphedema of the lower extremity. A conclusion by Maunsell, Brisson, and Deschenes (1993) still stands: “The impact of lymphedema problems on patient quality of life has not been quantitatively assessed.” This research has been hampered by the traditional view that quality of life is less important than the eradication of cancer and detection of recurrence. Unfortunately, lack of attention to lymphedema by health professionals has not only meant that many people go undiagnosed and fail to receive basic preventive information (Maunsell et al.), but this lack of attention also has hindered the development of effective psychosocial and physiological therapeutic interventions.

Early detection and intervention hold the greatest promise of reducing this widespread condition (Petrek, Pressman, & Smith, 2000; Rockson, 1998). The range of findings in the literature reflects inconsistent criteria for defining lymphedema, small studies, retrospective analyses, and short follow-up. We must clearly identify epidemiological and clinical factors associated with risk and incidence to build a foundation for preventive interventions.

References

Ak, I., Stokkel, M.P., Bergman, W., & Pauwels, E.K. (2000). Cutaneous malignant melanoma: Clinical aspects, imaging modalities and treatment. European Journal of Nuclear Medicine, 27, 447–58.

American Cancer Society. (2004). Cancer facts and figures, 2004. Atlanta, GA: Author.

American Joint Committee on Cancer. (2002). Cancer staging handbook from the AJCC cancer staging manual. Heidelberg, NY: Springer.

Baas, P.C., Schraffordt Koops, H., Hoekstra, H.J., van Bruggen, J.J., van der Weele, L.T., & Oldhoff, J. (1992). Groin dissection in the treatment of lower-extremity melanoma. Short-term and long-term morbidity. Archives of Surgery, 127, 281–286.

Beitch, P., & Balch, C. (1992). Operative morbidity and risk factor assessment in melanoma patients undergoing inguinal lymph node dissection. American Journal of Surgery, 164, 462–466.

Disa, J., & Petrek, J. (2001). Rehabilitation after treatment for cancer of the breast. In V. Devita, S. Hellman, & S. Rosenberg (Eds.), Cancer: Principles and practice of oncology (pp. 1717–1725). Philadelphia: Lippincott Williams and Wilkins.

Geller, A.C., & Annas, G.D. (2003). Epidimiology of melanoma and nonmelanoma skin cancer. Seminars in Oncology Nursing, 19, 2–11.

Holmes, E.C., Moseley, H.S., Morton, D.L., Clark, W., Robinson D., & Urist, M.M. (1977). A rational approach to the surgical management of melanoma. Annals of Surgery, 186, 481–490.

Ingvar, C., Erichsen, C., & Jonsson, P.E.. (1984). Morbidity following prophylactic and therapeutic lymph node dissection for melanoma-A comparison. Tumori, 70, 529–533.

James, J.H. (1982). Lymphoedema following ilio-inguinal lymph node dissection. Scandinavian Journal of Plastic and Reconstructive Surgery, 16, 167–171.

Karakousis, C.P., & Driscoll, D.L. (1994). Groin dissection in malignant melanoma. British Journal of Surgery, 81, 1771–1774.

Karakousis, C.P., Heiser, M.A., & Moore, R.H. (1983). Lymphedema after groin dissection. American Journal of Surgery, 145, 205–208.

Lawton, G., Rasque, H., & Ariyan, S. (2002). Preservation of muscle fascia to decrease lymphedema after complete axillary and ilioinguinofemoral lymphadenectomy for melanoma. Journal of the American College of Surgeons, 195, 339–351.

Maunsell, E. Brisson, J., & Deschenes, L. (1993). Arm problems and psychological distress after surgery for breast cancer. Canadian Journal of Surgery, 36, 315–320.

National Comprehensive Cancer Network. (2004). Clinical practice guidelines in oncology. Retrieved from www.nccn.org.

Papachristou, D., & Fortner, J.G. (1977). Comparison of lymphedema following incontinuity and discontinuity groin dissection. Annals of Surgery, 185, 13–16.

Passik, S.D., & McDonald, M.V. (1998). Psychosocial aspects of upper extremity lymphedema in women treated for breast carcinoma. Cancer, 83(12, Suppl. American), 2817–2820.

Petlund, C.F. (1991). Volumetry of limbs. In W.I. Olszewski (Ed.), Lymph stasis: Pathophysiology, diagnosis and treatment (pp. 444–451). Boston: CRC Press.

Petrek, J.A., & Heelan, M.C. (1998). Incidence of breast carcinoma-related lymphedema. Cancer, 83(12, Suppl. American), 2776–2781.

Petrek, J.A., Pressman, P.I., & Smith, R.A. (2000). Lymphedema: Current issues in research and management. CA: A Cancer Journal for Clinicians, 50, 292–307.

Reintgen, D., Cruse, C.W., Wells, K., Berman, C., Fenske, N., Glass, F., et al. (1994). The orderly progression of melanoma nodal metastases. Annals of Surgery, 220, 759–767.

Rockson, S.G. (1998). Precipitating factors in lymphedema: Myths and realities. Cancer, 83(12, Suppl. American), 2814–2816.

Serpell, J.W., Carne, P.W., & Bailey, M. (2003). Radical lymph node dissection for melanoma. ANZ Journal of Surgery, 73, 294–299.

Shaw, J.H.F., & Koea, J. (1992). Morbidity of lymphadenectomy for melanoma. Surgical Oncology Clinics of North America, 1, 195–203.

Stevens, G., Thompson, J.F., Firth, I., O'Brien, C.J., McCarthy, W.H., & Quinn, M.J. (2000). Locally advanced melanoma: Results of postoperative hypofractionated radiation therapy. Cancer, 88, 88–94.

Strobbe, L.J., Jonk, A., Hart, A.A., Nieweg, O.E., & Kroon, B.B. (1999). Positive iliac and obturator nodes in melanoma: Survival and prognostic factors. Annals of Surgical Oncology, 6, 255–262.

Tierney, S., Aslam, M., Rennie, K., & Grace, P. (1996). Infrared optoelectronic volumetry, the ideal way to measure limb volume. European Journal of Vascular and Endovascular Surgery, 12, 412–417.

Tobin, M.B., Lacey, H.J., Meyer, L., & Mortimer, P.S. (1993). The psychological morbidity of breast cancer-related arm swelling. Psychological morbidity of lymphoedema. Cancer, 72, 3248–3252.

Trask, P.C., Paterson, A.G., Hayasaka, S., Dunn, R.L., Riba, M., & Johnson, T. (2001). Psychosocial characteristics of individuals with non-stage IV melanoma. Journal of Clinical Oncology, 19, 2844–2850.

Urist, M.M., Maddox, W.A., Kennedy, J.E., & Balch, C.M. (1983). Patient risk factors and surgical morbidity after regional lymphadenectomy in 204 melanoma patients. Cancer, 51, 2152–2156.

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Wrone, D.A., Tanabe, K.K., Cosimi, A.B., Gadd, M.A., Souba, W.W., & Sober, A.J. (2000). Lymphedema after sentinel lymph node biopsy for cutaneous melanoma: A report of 5 cases. Archives of Dermatology, 136, 511–514.

Nurse Uses Her Personal Battle With Lymphedema to Help Educate Patients

Editor’s Message
Spotlight on the “Voice of Patients With Lymphedema”

In the last newsletter, I named specific attendees at the 2004 National Lymphedema Network (NLN) conference who regularly contribute to the Lymphedema SIG Newsletter. But I failed to mention Saskia Thiadens, RN, conference director and founder of the NLN and the ONS Lymphedema Management SIG. I wondered, when this was brought to my attention, why this happened. I realize that Saskia is not just an attendee. Saskia is the NLN and the voice of patients with lymphedema. The Lymphedema Management SIG is in its 16th year. This is a summary of an interview I had with Saskia on February 25, 2005. Since 1987, in some form or another, Saskia has been working tirelessly for patient care for lymphedema. Her curriculum vitae is impressive; she was born in Holland, attended university in nursing and midwifery, and then came to the United States, where she started a career in nursing, mostly emergency room nursing. Although she arrived in New York, she moved to San Francisco, CA, in the early 1970s.

By 1982, Saskia owned and operated Aurora Manor, a recovery center for patients who had undergone cosmetic and reconstructive surgery. The first time she encountered lymphedema, the patient had a memorable case. It was a massive arm, and this triggered her initial interest in lymphedema. She immediately sensed that something was wrong that this arm could be so neglected. She spoke with a physician from the University of California, wanting to know whether this condition "had a name." She began treating such cases in any way she could. Although from Holland, she was not aware of the strides Europeans were making in this field. She just did what she could with bandaging, skin care, and, later, pumps. In early 1987, she closed the postoperative clinic and opened Aurora Medical Lymphedema Clinic. She still did not realize the enormity of the problem, but it fascinated her. She also created her nonprofit organization, the NLN, in 1988. Robert Lerner, MD, was one of her original collaborators; as a vascular physician, he was dealing with the same problems. In 1989, Saskia was in contact with Marlys Witte, MD, who told her about the International Society of Lymphology conference to be held in Tokyo, Japan. She went and was the first clinical nurse to participate. The others were researchers. They didn’t know what to do with her. But she accomplished the most important point, she met all of the lymphology leaders, all of whom would continue to be mentors and friends and supporters of her and her conferences in years to come.

The interesting thing about Saskia is that she always keeps the focus on patient care. One of her proudest accomplishments was at the 1993 International Society of Lymphology (ISL) conference in Washington, DC. Saskia said she would attend, but only if she could bring 40 patients. The researchers were not interested; after all, ISL is a medical professional conference, not a patient conference. They finally allowed her to come, and this was the start of the patient clinic, with Saskia as the moderator. The medical panel was made up of major researchers who solved very compelling lymphedema problems. Saskia brought only very complex cases. The evening was so successful that it was repeated the next evening. Since then, Saskia always has included patients at NLN conferences, and, to this day, even ISL has patient clinic events.

Saskia is by nature a problem solver. She knew that the problem with lymphedema was lack of awareness. So she single-handedly introduced people to lymphedema. She has published more than 25 times and has made more than 50 presentations. The NLN currently has more than 6,000 members, and its newsletter, LymphLink, is on volume 17. More than 200 treatment centers are listed. The NLN had its first conference in 1994 in San Francisco, and the 10th biennial conference was in Reno, NV, in 2004.

Early on, Saskia realized that oncology nurses need to be involved in lymphology, so she started presenting to ONS with questions such as, “What are you doing for lymphedema?” In 1993, ONS was starting focus groups for all aspects of cancer. Saskia was there to represent lymphedema. Eventually, the focus group progressed into a SIG, the Lymphedema Management SIG, because of Saskia’s persistence and hard work. She completes what she sets out to accomplish.

Asked what should be the present focus of the SIG, Saskia responded that the SIG should declare a position on lymphedema for ONS. In addition, ONS should offer preconference instructional sessions before each annual conference, she said. After educating patients, educating healthcare workers is the focus of the NLN. Saskia said that nurses play a pivotal role in patients with lymphedema; nurses should educate patients before and after surgery, educate patients about lymphedema do’s and don’ts, and assess patients for lymphedema by identifying signs and symptoms and referring.

Recently, Saskia experienced “being a patient.” She underwent gynecologic surgery followed by chemotherapy and radiation, completed in January 2005. After the initial shock, she just proceeded forward. She said she is “absolutely not afraid.” This is how she approaches all things. She describes herself as a caretaker. She is determined to find a solution; she “needs answers.” She makes a decision and resolutely takes action. She also describes herself as “a pusher of new things.” We are all better because of this determined character.

News From ONS

Why Should You Attend the ONS 30th Annual Congress?
Because it’s the one conference that will meet all of your professional learning needs. Held April 28–May 1 in Orlando, FL, this year’s event includes four days filled with sessions focusing on the issues affecting you and your patients in today’s cancer-care arena. Plus, special preconference programming, including the ONS Chemotherapy and Biotherapy Courses, the Radiation Therapy Course, and certification reviews, will enhance your Congress experience. For more information, visit www.ons.org/meetings/congress05/index.shtml.

2005 Oncology Nursing Day and Month Kits Are Here!
Begin preparing now for the 2005 Oncology Nursing Day and Month celebration starting Thursday, April 28, with the new nursing month kit from ONS. You can view the contents online or download the entire kit, including the new color poster. Go to www.ons.org/membership/nursemonth.shtml to get started!

Updated Radiation Manual Is Available
Supporting the ongoing efforts of radiation oncology nurses, this new, third edition provides you with expanded coverage on issues such as patient education, radiation protection, and more. Also included are new sections on evidence-based practice, new technology, clinical trials, and much more. Go to http://esource.ons.org/productdetails.aspx?sku=INPU0549 for more information and to order your copy.

Get the Latest in Priority Symptom Management (PRISM) Information
This new series of four Web casts offers timely research insights on topics key to your everyday practice. In addition, you can earn free continuing education credits when you attend each Web cast and complete and return your evaluation. Topics include sleep and fatigue in children and adolescents with cancer, computerized symptom and quality-of-life assessment, telephone support interventions, and hot flash physiology in breast cancer. Each Web cast is worth 1.2 contact hours. Visit http://onsopcontent.ons.org/education/webcasts/prism04/.

Coming Soon!
Providing an in-depth review of general and oncology nursing management principles, Nursing Management: Principles and Practice is designed to guide the practice and development of nurse managers involved with cancer care. An expert roster of contributors addresses topics such as leadership development, financial management, staff development and continuing competency, accreditation, and much more. Order your copy now and take advantage of a special new publication price. For details, visit http://esource.ons.org/ProductDetails.aspx?sku=INPU0553.

New Package Provides Discount on Standards of Practice
Save 20% when you order all four standards of oncology nursing from ONS: standards of oncology nursing practice, nursing education, oncology education, and the advanced practice nursing standards. Go to http://esource.ons.org/ProductDetails.aspx?sku=KTPU0007 for information on this valuable package deal.

Are You New to Oncology?
If so, enroll in the Cancer Basics online course series. This new, four-part, online series will provide you with a fundamental understanding of cancer care. If you are an experienced cancer professional, it will serve as a valuable review. For complete information or to register, visit http://onsopcontent.ons.org/education/distanceeducation/cancerbasics/index.shtml.

Check Out the Redesigned Evidence-Based Practice Resource Area
Use the Evidence-Based Practice Resource Area as your guide to identify, critically appraise, and use evidence to solve clinical problems. Be sure to check out the new format, which allows for much easier use and navigation. Visit http://onsopcontent.ons.org/toolkits/evidence/index.shtml.

Editor’s Choice
The Coping with Chemo Webisodes is a series of short, animated, Web-based movies that speak to teenagers in their own language about issues ranging from diagnosis to the side effects of chemotherapy and feeling out of place among peers. Visit www.slsb.org/chemo/.

Membership Information

Lymphedema Management SIG Officers

To view past newsletters, click here.

ONS Membership/Leadership Team Contact Information

Angie Stengel, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Administrative Assistant
cdemarco@ons.org
412-859-6230

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

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