Melanoma and lymphedema A clinical roundtable discussion

By Marize Ibrahim, Angela Yung, Marie-Eve Letellier and Anna Towers (in discussion with Anna Kennedy)

Pathways had the opportunity to host an online roundtable discussion with the team at McGill University Health Centre Lymphedema Program, regarding melanoma and lymphedema. Their clinical insights are captured in this article, along with the facts, statistics and references they kindly sourced and provided.

What is the prevalence of melanomarelated lymphedema in Canada?

Statistics are currently very difficult to find. The new international review being carried out later this year (see callout ) may shed some light. However, assuming the incidence of lymphedema after melanoma treatment is 20%, we will have 1800 new melanomarelated lymphedema cases per year in Canada. Assuming these persons, who tend to be younger, survive 25 years, the prevalence would be 45,000 persons in Canada living with lymphedema due to melanoma, or about 14% of all cancer-related lymphedema cases (using the 2018 estimate of total prevalence of 330,000 from The Canadian Lymphedema Framework).1 Most of these cases are undiagnosed and untreated. Canadian health care providers are more aware of breast cancerrelated lymphedema, and much less so of lymphedema related to other cancers.

A new review on the prevalence of lymphedema is being carried out this year in an international collaboration, spearheaded by the Lymphology Association of North America (LANA), in which the McGill group is participating. The results are scheduled to be published in early 2024 and are expected to shed some light on the prevalence of melanoma-related (among many other secondary cancerrelated) lymphedema in North America and abroad. Funding is being provided by the American Cancer Society.

Is there a difference between upper and lower extremity lymphedema incidence rates?

The development rate of lower extremity lymphedema in melanoma related lymphedema has a wide range.2

Lower extremity

7.6% to 35.1% after SLNB

48.8% to 82.5% after ILND

Upper extremity

4.4% to 14.6% after ALND

Marize Ibrahim PT, Angela Yung PT, Marie-Eve Letellier PhD and Anna Towers MD, work together in the McGill University Hospital Centre Lymphedema Program (Montreal, Quebec). All of them are recognized authors and presenters on lymphedema and regular contributors to Pathways magazine. They are involved in various research projects to develop novel treatment, assessment and imaging methods for lymphedema. In 2021, this group and their network were recognized as Canada’s first LE&RN Centre of Excellence—to date the only Centre to be so designated in Canada.

What are the risk factors?

Chronic lymphedema after axillary lymph node (LN) dissection is approximately 10%, whereas it can be up to 35% after inguinal LN dissection. The type of lymphadenectomy, whether sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND) or inguinal lymph node dissection (ILND) also impacts risk, with a greater risk associated with ILND than ALND and a greater risk for ALND than SLNB. Studies have also concluded that groin dissection, diabetes, high body mass index (BMI) and peripheral vascular disease increase the risk of lymphedema for melanoma patients.3

Why is there more lower limb lymphedema (LLL) after melanoma compared to pelvic cancers?

The rate of development in LLL is strikingly high (48.8%), compared to pelvic cancers, such as gynecological and prostrate cancer, because it involves the inguinal rather than the deep nodes.2 LLL following melanoma treatment has a different physiopathology from the LLL secondary to lymphadenectomy for pelvic cancer. American and European guidelines recommend pelvic lymphadenectomy and para-aortic lymphadenectomy in advanced gynecological and prostatic cancer.4 However, the difference is that these lymphadenectomies preserve the superficial limb lymph nodes, whereas they are removed during the ILND for melanoma. This is the cause of the higher rate of LLL in melanoma.

All institutions designated as a Center of Excellence have been evaluated by international leaders in an extensive review process. https://lymphaticnetwork.org/centers-of-excellence.

Does a melanoma lymphedema patient present later, rather than earlier, compared to the typical lympedema patient?

In general, lymphedema related to melanoma is underrecognized and so our concern is that they are not being diagnosed at all. The majority of melanoma sufferers are male (56% male vs. 44% female)5 who tend to be less concerned about body image issues and less likely to ask for help. Melanoma patients are also typically younger than other cancer patients.6 For many it’s a busy stage in their lives of juggling work and the demands of young families that make it difficult to find the time to come for assessment and treatment.

Lymphedema following melanoma treatment will usually start as mild painless swelling at first, as happens following breast cancer.

Why do you think these patients might not be referred appropriately and how might this be different than other secondary lymphedema patients? Because melanoma prevalence is not as high (7th most commonly diagnosed cancer in Canada) compared to breast cancer (1 in 8 women in Canada), lymphedema in these patients doesn’t get the same level of attention. Although there are prospective surveillance established programs for breast cancer, they have not yet been developed for many other types of cancer, including melanoma.

What can be done to increase awareness and knowledge among health care providers?

This article is a good first step, as is the new collaborative partnership between the Canadian Lymphedema Framework and Melanoma Network of Canada. We are doing well in the area of breast cancer, in that all major cancer centres across Canada, have at least one physiotherapist trained in lymphedema. Most are designated to work exclusively with breast cancer patients as these centres may not have the resources to expand beyond that. We are always competing with other priorities that these therapists might have. However, staffing with just one lymphedema-trained professional in a major cancer centre is not enough. You need more therapists to deal with all lymphedema patients. The problem is funding. As an example, to date, the McGill Lymphedema program at MUHC has had therapists for 15 years now and 90 percent of our funding has come from a breast cancer foundation. We are still charitably funded and not yet integrated into the health care system.

Is the treatment plan for melanomarelated lymphedema any different than for other types of lymphedema?

Following diagnosis, the treatment plan for this cohort of patients is similar to that of other lymphedema patients:

1—Decongestive therapy to reduce the swelling.

2—Compression therapy (bandaging and garments) to maintain the reduction in limb volume.

3—Exercise therapy and

4—Skin care.

These patients must be even more diligent in their skin care regime (like wearing higher SPF and covered clothing) because of the increased risk that sun exposure will further damage their skin.

How is compression more difficult to address in these patients?

Melanoma patients present uniquely in many ways. Depending on how much of the cancerous area required a wide local excision of the melanoma site, the circumference of the limb above or below the surgical site can be much less and may form an uneven limb shape. There could also be anatomical variations, including concave areas that can create a tourniquet, if not treated properly. Some patients may also have double limb lymphedema, where multiple melanoma locations were treated and/or skin grafts were taken from the contra-lateral limb. An experienced therapist requires creative solutions to ensure bandaging is done correctly, with swell spots and other customized tools so that a tourniquet is prevented and compression garments are fitted properly for the comfort of the patient. Unique compression challenges need to be addressed adequately, with the therapist being aware that in this population, many patients are still working and aesthetics may be more of a concern for them. Also, the patient population is younger compared to other cancers. It is one of the commonest cancers in young adults.

Why do these typically younger patients have more difficulty with adherence?

The challenge of working with younger patients is that their challenges are very different. This particular patient population ranges from young adults, who are busy with school and university, to young parents, who are at a stage in their lives when busy work schedules and looking after young children don’t allow much time for themselves. After their challenging diagnosis and cancer treatment is completed, they want to forget about their ordeal and are eager to get back to living a normal life. It is much more than just the compliance of donning a compression garment every day. Active participation in their care requires the time-consuming phase of getting monitored and assessed, numerous appointments for decongestive therapy, getting fitted for garments and learning how to actively participate in skin care and exercise. All of this seems too onerous for many of them.

A closing message for therapists

Unfortunately, most of the resources for publicly funded lymphedema treatment centres are supported by grant funding and donations related to breast cancer foundations.

If your physiotherapy facility (whether hospital-based or private clinic) doesn’t currently have an outreach program for melanoma patients, we encourage you to consider this and advocate for the resources. These patients need the same level of follow-up and prospective surveillance as patients suffering from other better-known cancers. Everyone that has melanoma in the lower limbs needs to be educated and followed up, as the risk they have in developing lymphedema is extremely high. Although therapists might be more familiar and comfortable treating breast cancer and gynecological related lymphedema, don’t be afraid to reach out to other populations, who also need your support. The treatment principles and pillars of care for melanoma related lymphedema are the same, except for some adaptations to maintain proper compression gradients. You also have a community of fellow lymphedema therapists to reach out to for support.

A closing message for patients

Prioritize your health and take the time to get assessed by a qualified lymphedema therapist. Take time early on after your melanoma treatment to get properly diagnosed and continue getting monitored for lymphedema, as you are at a lifetime risk. Early diagnosis always leads to better treatment outcomes. LP

Prioritize your health and take the time to get assessed by a qualified lymphedema therapist. Take time early on after your melanoma treatment to get properly diagnosed and continue getting monitored for lymphedema, as you are at a lifetime risk. Early diagnosis always leads to better treatment outcomes.

A full set of references can be found at https://www.canadalymph.ca/pathwaysreferences/

Lymphedema, or the presence of chronic edema due to decreased lymph transport, is one of the more significant complications that can occur after a lymph node dissection of the axillary or inguinofemoral lymph nodes. Typically, these lymph node dissection procedures are performed in the setting of nodepositive breast cancer and melanoma. Incidence n For axillary dissection in this setting, lymphedema rates of 6% to 15% have been reported n For inguinal dissection rates can be even higher at 29% to 41%

Risk factors for lymphedema

n Although risk factors for lymphedema in breast cancer patients having axillary dissections have been described in the literature, these risk factors in melanoma patients, especially in patients having inguinal dissections, have not been well studied.

n A large portion of melanoma ALNDs are in men.

n Lower limb lymphedema (LLL) is the one of the most frequent complications of both SLNB and inguinal lymph node dissection (ILND) in melanoma. Reported rates of LLL secondary to inguinal SLNB are from 7.6% to 35.1% and from 48.8% to 82.5% after n Upper limb lymphedema (ULL) rates after ALND for melanoma range from 4.4% to 14.6% in the reports and from 4.1% to 21.4% after ALND for breast cancer. These two rates are similar probably because the ALND is the same for both cancers. LP

ILND. These rates are higher than the LLL rates reported after surgical treatment of advanced pelvic cancers (studies report a range of 36.9% and 61%).