Clinical Investigation
Factors Associated With External and Internal Lymphedema in Patients With Head-and-Neck Cancer

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Purpose

The purpose of this study was to examine factors associated with the presence of secondary external and internal lymphedema in patients with head-and-neck cancer (HNC).

Methods and Materials

The sample included 81 patients ≥3 months after HNC treatment. Physical and endoscopic examinations were conducted to determine if participants had external, internal, and/or combined head-and-neck lymphedema. Logistic regression analysis was used to examine the factors associated with the presence of lymphedema.

Results

The following factors were statistically significantly associated with presence of lymphedema: (1) location of tumor associated with presence of external (P=.009) and combined lymphedema (P=.032); (2) time since end of HNC treatment associated with presence of external (P=.004) and combined lymphedema (P=.005); (3) total dosage of radiation therapy (P=.010) and days of radiation (P=.017) associated with the presence of combined lymphedema; (4) radiation status of surgical bed was associated with the presence of internal lymphedema, including surgery with postoperative radiation (P=.030) and (salvage) surgery in the irradiated field (P=.008); and (5) number of treatment modalities associated with external (P=.002), internal (P=.039), and combined lymphedema (P=.004). No demographic, health behavior-related, or comorbidity factors were associated with the presence of lymphedema in the sample.

Conclusions

Select tumor and treatment parameters are associated with increased occurrence of lymphedema in patients with HNC. Larger and longitudinal studies are needed to identify adjusted effects and causative risk factors contributing to the development of lymphedema in patients with HNC.

Introduction

There are over one-half million head-and-neck cancer (HNC) survivors in the United States (1). Although aggressive use of multimodality therapy has contributed to improvement in overall survival rates, it has also left many patients with HNC at risk for experiencing secondary complications from their cancer and cancer treatment. Lymphedema is one of the under-reported but common side effects of HNC therapy 2, 3. Treatment for HNC may disrupt lymphatic structures and damage surrounding soft tissues, leading to increased accumulation of lymphatic fluid in interstitial spaces. The retention of lymphatic fluid activates inflammatory and immune responses and results in skin and subcutaneous soft tissue fibrosis and adipose deposition (4), which further impair lymphatic function.

Head-and-neck lymphedema may involve external structures (eg, soft tissue of the face and neck) (5), as well as internal anatomical sites (eg, mucous membranes and underlying soft tissues of the upper aerodigestive tract) (6). Thus, the potential clinical impact of head-and-neck lymphedema is profound. For instance, in patients with external lymphedema, swelling and fibrosis in the neck can cause decreased neck range of motion 2, 3; in patients with internal lymphedema, tissue swelling in the upper aerodigestive tract can affect articulation, cause airway obstruction, and result in swallowing difficulties 2, 3. Hence, it is particularly important to identify risk factors contributing to secondary lymphedema in patients with HNC in order to identify reversible or preventable causes. Currently, a limited number of studies are available in this area. The purpose of this study was to examine factors associated with external and internal lymphedema in patients with HNC.

Section snippets

Samples and setting

A cross-sectional, correlational design was used. A convenience sample of 103 participants was enrolled between December 2009 and May 2010 at a comprehensive cancer center. However, 81 participants (78.6%) underwent both physical and endoscopic examination, while the remaining 22 participants (21.4%) did not have an endoscopic examination available during the study data collection period. Half of those 22 participants (n=11) had no endoscopy appointments scheduled, while the other half (n=11)

Sample characteristics

Most participants were male (71.6%) and white (88.9%). Median age was 59.7 years. Sixty-eight percent of participants reported a smoking history, and 40.7% of participants reported drinking alcohol. The oropharynx was the most common (42.0%) primary tumor site. Advanced stage disease (III-IV) was present in 80.2% of all participants. The histological type of most participants’ tumors was SCC (95.1%). Most participants (87.6%) received at least 2 modalities of HNC treatment. The time since the

Discussion

This is the first study we are aware of that systematically examined associations between demographic characteristics, health-related behaviors, comorbidity status, tumor characteristics, and treatment parameters and the presence of lymphedema after HNC treatment. We focused on secondary lymphedema rather than acute edema; thus, we recruited patients with HNC who had completed their cancer treatment ≥3 months prior to study entry. Acute treatment-related swelling should have resolved prior to

Conclusions

Despite these limitations, the study findings can be used to inform patient care and future research. Healthcare professionals need to be aware that patients with HNC are at high risk of developing lymphedema following cancer treatment. Second, healthcare professionals need to conduct lymphedema assessment as a component of routine clinical examination, especially for individuals at high risk (eg, multimodality treatment involvement). Third, if internal or external lymphedema is identified,

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This project was supported by an Oncology Nursing Society Ann Olson Memorial Doctoral Scholarship, a Vanderbilt Dissertation Enhancement Award, and a Vanderbilt School of Nursing postdoctoral fellowship.

Conflict of interest: none.

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