Investigations and diagnosis
The presence of lymphoedema is usually diagnosed on the findings of persistent pitting or non-pitting oedema in the extremity or body part where the lymphatic drainage from this region has been disturbed or excised. Other common causes of oedema should be excluded including deep venous thrombosis, infection (e.g. cellulitis), malignancy, and fluid retention associated with medications, cardiac or renal disorders.
Lymphoedema diagnosis should begin with an assessment of the patient including a patient history and a physical examination to ascertain severity and limb function.
Patient history should include the following:r
- age of onset
- areas of involvement
- patient reported subjective symptoms such as presence of heaviness, ache, pain, tightness or discomfort
- progression of symptoms (e.g, pain, swelling, tightness)
- past medical history (e,g infections, radiation therapy, chemotherapy regimens)
- surgical history – including lymph node dissection
- trauma to limb or body part
- cellulitis (including episode frequency and severity) and ulcers or skin breakdown
- travel history including past residence or prolonged travel to filariasis prone countries
- family history
- cardiac and renal disease history
- use of channel blocker medications.
- history of diuretic use (which is generally ineffective for lymphoedema treatment).
Physical exam of the affected limb or body part should include:r
- assessment of subcutaneous tissue for pitting/non-pitting oedema and tissue turgor
- presence and severity of swelling - use a tape measure to measure at regular intervals the circumference of the affected limb and compare this with the unaffected limb. Changes in circumference may be more difficult to detect in obese patients and in the upper extremity, they are subject to variation due to differences in muscle mass as a result of hand dominance and moving of fluid proximally or distally due to arm positioning and/or compression.r
- condition of skin including:
- dryness, flaking, leakage (lymphorrhoea), papilloma's, ulceration, cellulitis, fibrosis, and scar tissue.
- presence of Stemmer’s sign – thickened skin at the base of the second toe or middle finger, compared with the unaffected limb indicates persistent lymphoedema related fibrosis.
- weight and height (body mass index - BMI)
- cardiac and respiratory parameters
- joint mobility
- axillary cording - painful taut palpable line from the axilla down the arm representing a blocked and inflamed lymphatic vessel
- pattern of oedema – unilateral/bilateral.
Bioelectrical impedance analysis (BIA) may also be used to detect abnormal amounts of extracellular fluid.
Read more about grading of lymphoedema (including measuring guidelines and forms) on the Australasian Lymphology Association (ALA) Standards & Guidelines website.
The International Society of Lymphology staging criteriar
||A latent or subclinical state where swelling is not evident despite impaired lymph transport. It can be transient and may exist months or years before overt oedema occurs in later stages(I-III).
||This represents early onset of the condition where there is an accumulation of tissue fluid with higher protein content, which subsides with limb elevation. The oedema may be pitting at this stage. An increase in various types of proliferating/ regenerative cells may also be seen.
||Limb elevation alone rarely reduces swelling and pitting is manifest. In later Stage II the limb may or may not pit as subcutaneous fat and fibrosis appears.
||The tissue is hard (fibrotic), and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowth develop. Encompasses lymphostatic elephantiasis. At this stage, the swelling is spontaneously irreversible and usually the limb(s) is very large.
It should be noted that a limb may exhibit more than one stage at the same time.
Common Terminology Criteria for Adverse Events grading criteria
||Trace thickening or faint discoloration
||Marked discoloration; leathery skin texture; papillary formation; limiting instrumental activities of daily living (ADL)*
||Severe symptoms; limiting self care ADL**
*Instrumental ADL—the ability to prepare meals, shop for groceries or clothes, use the telephone, manage money, etc.
**Self care ADL—the ability to manage bathing, dressing, and undressing, feeding self, using the toilet, and taking medications, without being bedridden.
Common Terminology Criteria for Adverse Events (CTCAE) v5.0, 27 November, 2017