How Lymphedema is Diagnosed

The Importance of Early Diagnosis and Treatment

Early diagnosis of lymphedema is important since treatment is most effective when it is started while the lymphedema is in the earliest stages.

Who Diagnoses Lymphedema?

The accurate diagnosis of lymphedema requires an evaluation by a physician or other healthcare provider. Often this individual is a primary care physician; however when necessary, when needed the patient may be referred to an  individual who is capable of performing specialized diagnositic testing.

There are exceptions:

• Lymphedema is not diagnosed by non-physician practitioners who use the title of “Certified Lymphologist.” This title describes alternative medicine treatment of the lymphatic system and these practitioners are not qualified to diagnose lymphedema or to refer patients for lymphedema treatment.
• When the condition is related to cancer treatment, the oncologist may make the diagnosis.
• For more complex cases, a consultation with a vascular surgeon may be recommended. The Society for Vascular Surgery website (www.vascularweb.org) includes a feature to aid in finding a member of their organization in your area.
• When lymphedema is present in conjunction with another disorder, such as a heart condition, it is essential that the more serious condition, in this case it would be the heart condition, be diagnosed and treated first.

How is Lymphedema Diagnosed

• There are several steps in an office visit for lymphedema. The first steps are information gathering.
• A family history is essential if primary lymphedema (PLE) is considered as a possibility. Since this is an inherited condition, it is important to discover if other family members, usually from an earlier generation, have or had, a history of a swollen feet, ankles, and legs due to an “unknown cause.” In the past, many of these cases were never accurately diagnosed or treated. For more details on the genetics of primary lymphedema see the article Genetics and Primary Lymphedema.
• The patient’s medical history in order to identify swelling of unknown causes. Patients who have been treated for cancer, injuries, or burns are at higher risk for secondary lymphedema (SLE). The risk of developing SLE is ongoing and the lymphedema symptoms may not develop until many years after.
• The physical examination is important very important because not all swelling is due to lymphedema! As an example, a woman who appears to be overweight from the hips down the legs to the ankles, may actually have lipedema. If these symptoms, plus swelling of the feet may be due to lipo-lymphedema.

Rule Outs 

Lymphedema is not the only condition that causes abnormal swelling of the tissues and it is important that the healthcare provider rule out these other conditions before reaching a diagnosis of lymphedema. A rule-out is the process of eliminating conditions that could possibly be causing the presenting symptoms.

• Sudden swelling could be a sign of a blood clot. This is a potentially serious condition that requires immediate medical attention.
• Slowly progressive swelling, particularly of the legs, can be due to other conditions such as lipedema or of a heart condition, that impair the circulation.
• Rapidly progressive and painful lymphedema-type swelling could be due to a fast-growing tumor that places pressure on lymph nodes and the nerves. This condition is known as malignant lymphedema; however it is the tumor, not the lymphedema, that is malignant.

Testing For Pitting Edema

Pitting edema is a diagnostic sign of Stage 1, Lymphedema. In this stage the tissues are swollen but are still soft.

Gentle pressure on swollen tissues. © Lymph Notes

Pitting edema of Stage 1 lymphedema. © Lymph Notes

This sign is determined by a very simple test. As shown at above at the left, a finger is very gently pressed against the swollen tissue. As shown at the right, if this leaves an indentation that soon fills in pitting edema is considered to be present.

Pitting edema is absent if the gentle pressure does not leave an indentation on the swollen area. This change in an area with a history of being swollen, is an indication that the lymphedema has progressed to stage 2 or stage 3 lymphedema.

• In stage 2, the tissues have become fibrotic (hardened) and are no longer soft. At this stage, treatment can usually improve the lymphedema
• In stage 3, the tissues are considerably hardened and treatment may be able to prevent the swelling from becoming worse; however, it cannot reverse the damage that has already occurred.

Testing for Stemmer Sign

Testing for Stemmer Sign.  © Lymph Notes.

Stemmer’s sign is a thickened fold of skin at the base of the second toe or second finger that can be gently pinched and lifted. (Also spelled Stemmer's sign.)

The presence of this sign is more commonly an early diagnostic indication of primary lymphedema; however, it also can develop later in secondary lymphedema.

• A positive test result is present when this skin cannot be lifted. This is considered to be an indication of the presence of lymphedema.
• The absence of Stemmer sign does not rule out the possibility of lymphedema. To test for Stemmer sign, the skin folds on the upper surface of the second toe or finger as shown here.

Additional Testing

• Measurements of the arm or leg has long been the standard way of detecting lymphedema. The most recent tests for this purpose include.
• Lymphoscintigraphy is an imaging method that is used to check the lymphatic system for disease. In this test, a radioactive substance that flows through the lymph ducts and can be taken up by lymph nodes is injected into the body. A scanner or probe is used to follow the movement of this substance on a computer screen. Lymphoscintigraphy is used to find the sentinel lymph node (the first node to receive lymph from a tumor). This node can be removed and checked to detect tumor cells. Lymphoscintigraphy is also used to diagnose certain diseases or conditions, such as lymphedema.

• Computed tomography (CT) uses x-radiation with computer assistance to produce multiple cross-sectional views of the body. In these images hard tissues are light, and soft tissues appear as shades of gray.
• Magnetic resonance imaging (MRI) uses a combination of radio waves and strong magnetic fields to produce images. Hard tissues are dark and soft tissues appear as shades of gray.
• Ultrasound techniques are used to deep body structures by recording echoes or pulses of sound waves that are above the range of human hearing.

Imp™ XCA (Courtesy of Impedimed)

Bioimpedance Spectroscopy (BIS) is a more recently developed method for measuring the water content of the body. BIS has been shown to provide reliable data to be used in the diagnosis of breat cancer-related lymphedema. The equipment required for this testing is small, portable, and the testing itself is not extremely time consuming. It is an excellent test for very early detection of lymphedema in situations such as after breast cancer treatment. For more details read the article Bioimpedance and Lymphedema.

References

[1] Position Statement of the National Lymphedema Network updated February 2011. http://lymphnet.org/

[2] The Society for Vascular Surgery website

[3] Tests that Examine the Lymphatic System Are Used to Diagnose Lymphedema. National Cancer Institute (NCI) Comprehensive Cancer Information Database. June 2009.

[4] Living Well with Lymphedema by A. Ehrlich, A. Vinjé-Harrewijn PT, CLT-LANA, and E. McMahon PhD. Lymph Notes 2005, pages 19-26 and 85-96.

[5] The Diagnosis and Treatment of Peripheral Lymphedema: Consensus Document of the International Society of Lymphology. Lymphology 36 (2003) 84-91.

[6] The Third Circulation: Radionuclide Lymphoscintigraphy in the Evaluation of Lymphedema by A Szuba et al. JNM, Volume 44, Number 1, January 2003.

© LymphNotes.com 2011. This information does not replace the advice of a qualified health care professional.

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Category: Are You at Risk for Lymphedema? Updated: 2011-09-27