2803 American Cancer Society Lymphedema Workshop Supplement to Cancer A Review of Measures of Lymphedema Lynn H. Gerber, M.D. Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland. BACKGROUND. Lymphedema usually is identified by patients, and rarely is it screened for routinely. Many assessments have been reported and have been used in evaluating a variety of treatments for lymphedema. METHODS. A review of the literature was undertaken. RESULTS. Five frequently used measures of lymphedema include circumferential measures of limbs at various points (usually at bony landmarks); volumetric measures using limb submersion in water; skin tonometry, in which soft tissue compression is quantified; imaging techniques to describe tissue characteristics as well as to quantify soft tissue swelling (magnetic resonance imaging and computerized tomography; and ultrasound with and without Doppler flow studies for volumetric measures. Circumferential measures with calculations designed to compute limb volumes and volumetric measures are used most frequently, but these have some difficulty with reliability. No significant effort has been made to develop a patient based questionnaire that describes the size as well as the impact of lymphedema on an individual’s functional level. CONCLUSIONS. Existing physical measures of lymphedema are available that are easy to use, inexpensive, have limited reliability, and do not address the issue of functional impact. Imaging techniques may provide valuable qualitative and quantitative information in selected populations. Cancer 1998;83:2803– 4. © 1998 American Cancer Society. KEYWORDS: lymphedema, assessment, circumferential measurements, volumetrics, tonometry, ultrasound. T Presented at the American Cancer Society Lymphedema Workshop, New York, New York, February 20 –22, 1998. Address for reprints: Lynn H. Gerber, M.D., Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892. Received July 2, 1998; accepted August 20, 1998. © 1998 American Cancer Society he woman who had undergone treatment for breast carcinoma is subject to adverse as well as curative effects of surgical, radiation, and chemo-/biologic therapeutics. Lymphedema of the chest wall of the breast for those who undergo breast sparing procedures and for each segment of the upper extremity (arm, forearm, and hand) has been reported.1 Knowledge about the incidence, severity, and rate at which it resolves when treated is lacking. This in part is because measurement techniques have not been applied widely. There is an as yet, unmet need for easy, low risk, cost effective, and accurate measures of lymphedema that can be used routinely at bedside and clinic. Developing good measures will help in determining the incidence of the problem, its response to treatments, and the impact of lymphedema on function.2 Typically, it is patients who observe a change in status. They note inability to wear rings, bracelets, and watches, or they have difficulty fitting into clothing. Commonly, they will observe a change in the appearance of their skin: It appears tight or shiny, has fewer folds, and feels stiff or taut. Occasionally, there is limited range of motion of elbow, wrist, or fingers. The health care provider often observes pitting with digital compression, loss of skin folds, or asymmetry of the extremities. 2804 CANCER Supplement December 15, 1998 / Volume 83 / Number 12 The use of circumferential measurements in quantifying lymphedema has been the most frequently used method.3–5 Techniques have included measuring the circumference of bony landmarks, (ulnar styloid, olecranon, metacarpal phalangeal joints) or measuring equilinear segments of the arm and computing volume, (i.e., 100 mm length, measuring the circumference at the proximal and distal border, and calculating the volume [volume ⫽ (circumference/2)2h]. Problems with measurements are many. Using bony landmarks defines segments that are not equidistant. Measuring the circumference of the hand is an inaccurate way of determining volume because of its highly irregular shape. Another method of measuring volume is by water displacement. The limb is submerged in a cylinder filled to a known level of water. The amount of water displaced by the submerged limbs is equivalent to its volume.6 The third frequently used method is that of a tissue tonometer.7 This measures the amount of pressure necessary to depress the skin a specified amount. This degree of compressibility has been correlated with circumference and, thus, with the amount of lymphedema.8 The reliability of these techniques has been tested and, to some extent, compared with one another.7 Nonetheless, circumferential measures have been the most frequently used technique, probably because of the ease with which they can be applied, the low cost, and the ability to generate quantitative data. Quantitative measures of soft tissue edema also can be assessed by using magnetic resonance imaging (MRI), computerized tomography (CT), and ultrasound. These measures have been used to describe the characteristics of tissue involvement as well.9 –11 Recently, reports have been published that describe the problem of lymph stasis in which an attempt to image flow through the lymphatic system has been made. Much of this work has been done in patients with filariasis or in those who are evaluated pre- and postlymphatic-venous-lymphatic anastomoses. Imaging techniques with isotopic scintigraphy and Doppler venous flow metrics have been combined to evaluate treatment.12 Many techniques are available for lymphedema assessment. What is needed is to encourage the use of measurements on a more routine base. This type of measurement should be easy to use, accessible, inexpensive, reliable, and quantifiable. For those studies in which outcome measures need to be highly sensitive, quantitative imaging techniques probably are more sensitive but also are less accessible and more expensive. A fruitful area for research and development is to devise a patient-administered questionnaire to assess the degree of swelling and its impact on function. It would not be difficult to ask patients to evaluate quantitatively the amount of skin change, pitting, increase in size, stiffness, and the impact these changes have on daily routines, work, and recreational activity. This would give use valuable incidence information as well as an understanding of the input lymphedema has on the daily activities and life of the breast carcinoma patient. REFERENCES 1. Kissin MW, Querci Della Rovere G, Easton D, et al. The risk of lymphedema following the treatment of breast cancer. Br J Surg 1986;73:580 – 4. 2. Sitzia J, Stanton AW, Badger C. A review of outcome indicators in the treatment of chronic limb edema. Clin Rehabil 1997;11:181–91. 3. Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg 1989;22:505–15. 4. Bunce IH, Mirolo BR, Hennessy JM, et al. Post mastectomy lymphoedema treatment and measurement. Med J Aust 1994;161:125– 8. 5. Mortimer PS. Investigation and management of lymphoedema. Vasc Med Rev 1990;1:1–20. 6. Kaulesar Sukal DMKS, den Hoed PT, Johannes EJ, et al. Direct and indirect methods for the quantification of leg volume: comparison between water displacement volumetry, the dish model method and the frustum sign model method, using the correlation coefficient and the limits of agreement. J Biomed Eng 1993;15:477– 80. 7. Clodius L, Deak L, Piller NB. A new instrument for the evaluation of tissue tonicity in lymphoedema. Lymphology 1976;9:1–5. 8. Piller NB, Clodius L. The use of a tissue tonometer as a diagnostic aid in extremity lymphoedema: a determination of its conservative treatment with benzo-pyrones. Lymphology 1976;9:127–32. 9. Duwell S, Hagspiel KD, Zuber J, et al. Swollen lower extremity: role of MR imaging. Radiology 1992;184:227–31. 10. Stewart G, Hurst PAG, Lea Thomas M, et al. CAT scanning in the management of the lymphoedematous limb. Immunol Haematol Res 1983;2:241–3. 11. Flippetti M, Santoro E, Graziano F, et al. Modern therapeutic approaches to post mastectomy brachial lymphedema. Microsurgery 1994;15:604 –10. 12. Campisi C, Boccardo F, Tacchella M. Reconstructive microsurgery of lymph vessels. Microsurgery 1995;16:161– 6.