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American Cancer Society Lymphedema Workshop
Supplement to Cancer
A Review of Measures of Lymphedema
Lynn H. Gerber,
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.
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.
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
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
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
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
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
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.
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