Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer
Publication Date: May 5, 2017
Last Updated: March 14, 2022
Practice Recommendations Based on Patient Presentation
All Patients At Risk for Secondary Upper Quadrant Lymphedema
Self-reported symptoms of swelling, heaviness, and numbness should be investigated for early diagnosis. (, B)
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Palpation for fibrosis, pitting, and overall tissue quality may be clinically helpful for staging; however, it has not been investigated for diagnostic purposes. (, D)
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If a questionnaire is used to assist with diagnosis, the Norman Questionnaire or Morbidity Screening Tool should be considered. (, B)
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At Risk/Early Upper Extremity Lymphedema (ILS Stage 0-I)
Bioimpedance Analysis:
Bioimpedance analysis (BIA) should be used to detect subclinical/early stage lymphedema. (, B)
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- Cutpoint of >7.1 L-Dex score should be used for diagnosis of breast cancer–related lymphedema when preoperative baseline measures are not available.
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- Cutpoint of >10 L-Dex score above preoperative baseline should be used for diagnosis of breast cancer–related lymphedema.
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- Preoperative assessment using BIA may enhance the ability to detect changes in tissue fluid earlier indicating lymphedema.
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Volume Measures:
Volume determined from circumferential measurements should be used to diagnose lymphedema. (, B)
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but may not capture subclinical and early-stage lymphatic transport impairment. (, D)
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- When using circumferential measurements, volume should be calculated.
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- Calculated volume differential between sides ≥200 ml, or a volume ratio of >1.04 (affected:unaffected), will help rule in lymphedema, but values <200 ml cannot be used to rule out.
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- Water displacement may be used in diagnosing lymphedema but is limited by clinical utility.
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- Volume can also be assessed by perometry, but diagnostic criteria need to be evaluated for this method.
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- Methods of volume measurement are not interchangeable; use the same method at each time point.
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Moderate or Established Upper Extremity Lymphedema (ILS Stage II)
Bioimpedance Analysis:
Bioimpedance analysis (BIA) is less useful in diagnosing lymphedema at this stage, and self-reported symptoms or volume measures should be used. (, B)
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Accuracy with BIA in diagnosing moderate to late stage lymphedema may decline due to tissue changes/fibrosis. (, )
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Volume Measures:
Volume measurements should be taken and used in the diagnosis of lymphedema. (, B)
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- When using circumferential measurements, volume should be calculated.
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- Calculated volume differential between sides of ≥200 ml, or a volume ratio of >1.04 (affected:unaffected), will help rule in lymphedema, but values <200 ml cannot be used to rule out.
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- Water displacement may be used in diagnosing lymphedema but is limited by clinical utility.
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- Volume can also be assessed by perometry but diagnostic criteria need to be evaluated for this method.
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- Methods of volume measurement are not interchangeable; use the same method each time point.
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Late Upper Extremity Lymphedema (ILS Stage III)
As tissue changes progress, excess fluid may decrease, but excess volume may remain because of fibrosis, increased fat deposition, and other skin changes. (, B)
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Volume Measures:
Volume measurements should be taken and used in the diagnosis of lymphedema. (, B)
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- When using circumferential measurements, volume should be calculated.
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- Calculated volume differential between sides of ≥200 ml, or a volume ratio of >1.04 (affected:unaffected), will help rule in lymphedema, but values <200 ml cannot be used to rule out.
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- Water displacement may be used in diagnosing lymphedema but has limited clinical utility.
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- Volume can also be assessed by perometry, but diagnostic criteria need to be evaluated for this method
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- Methods of volume measurement are not interchangeable; use the same method at each time point.
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Ultrasound:
- Ultrasound should be utilized to detect underlying tissue changes.
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Hand Lymphedema
Little research is available to guide diagnosis of hand lymphedema.
- Water displacement and figure of 8 method of circumferential measurement may be used for assessment but have not been studied as diagnostic tests.
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Trunk or Breast Lymphedema
Little research is available to guide diagnosis of truncal or breast lymphedema.
- Ultrasound has the potential to determine tissue changes consistent with different stages of lymphedema.
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- Tissue dielectric constant is an emerging diagnostic tool that may be useful in assisting with assessment of lymphedema.
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Head and Neck Lymphedema
Modified Head and Neck External Lymphedema and Fibrosis Assessment Criteria when combined with circumferential measurements may be useful for diagnostic purposes. (, D)
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Circumferential measurements at the upper neck point may be used in assessment. (, D)
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Tissue dielectric constant is an emerging diagnostic tool that may be useful in assessing lymphedema.
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Recommend a combined approach involving both the Modified Head and Neck External Lymphedema and Fibrosis Assessment and either circumferential measures or tissue dielectric constant.
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Recommendation Grading
Overview
Title
Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer
Authoring Organization
American Physical Therapy Association
Publication Month/Year
May 5, 2017
Last Updated Month/Year
August 3, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Home health, Operating and recovery room, Outpatient
Intended Users
Physical therapist, occupational therapist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management
Diseases/Conditions (MeSH)
D008206 - Lymphatic Diseases, D000072656 - Breast Cancer Lymphedema
Keywords
cancer, Lymphedema, cancer-related lymphedema
Source Citation
Kimberly Levenhagen, Claire Davies, Marisa Perdomo, Kathryn Ryans, Laura Gilchrist, Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association, Physical Therapy, Volume 97, Issue 7, July 2017, Pages 729 745, https://doi.org/10.1093/ptj/pzx050
Methodology
Number of Source Documents
116
Literature Search Start Date
January 1, 2000
Literature Search End Date
July 5, 2015