The water displacement method is another way to evaluate arm edema. A volume difference of 200 mL or more between the affected and opposite arms is typically considered to be a cutoff point to define lymphedema.
One common method of lymphedema classification uses three stages based on severity. Stage I is spontaneously reversible and typically is marked by pitting edema, increase in upper-extremity girth, and heaviness. Stage II is characterized by a spongy consistency of the tissue without signs of pitting edema. Tissue fibrosis can then cause the limbs to harden and increase in size. Stage III, also called lymphostatic elephantiasis, is the most advanced stage, but is rarely seen following breast cancer treatment.
Another commonly used approach to classifying lymphedema is the Common Terminology Criteria for Adverse Events v3.0 (CTCAE), which were developed for grading adverse events in the context of clinical trials. A key advantage of the CTCAE approach is that it includes both objective measures (interlimb discrepancy) and subjective, clinical assessments in diagnosing lymphedema. This allows for the very real possibility that a patient could have clinically meaningful, treatable lymphedema isolated to a segment of his or her limb that would not meet objective interlimb discrepancy criteria, but which could still be graded according to severity by signs and symptoms, as follows:
- Grade 1: 5% to 10% interlimb discrepancy in volume or circumference at point of greatest visible difference; swelling or obscuration of anatomic architecture on close inspection; pitting edema.
- Grade 2: More than 10% to 30% interlimb discrepancy in volume or circumference at point of greatest visible difference; readily apparent obscuration of anatomic architecture; obliteration of skin folds; readily apparent deviation from normal anatomic contour.
- Grade 3: More than 30% interlimb discrepancy in volume; lymphorrhea; gross deviation from normal anatomic contour; interfering with activities of daily living.
- Grade 4: Progression to malignancy (e.g., lymphangiosarcoma); amputation indicated; disabling lymphedema.
- Meneses KD, McNees MP: Upper extremity lymphedema after treatment for breast cancer: a review of the literature. Ostomy Wound Manage 53 (5): 16-29, 2007.
- Hewitt M, Ganz PA, eds.: From Cancer Patient to Cancer Survivor - Lost in Transition: An American Society of Clinical Oncology and Institute of Medicine Symposium. Washington, DC: The National Academies Press, 2006.
- Petrek JA: Commentary: prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 17-9, 2004.
- Horsley JS, Styblo T: Lymphedema in the postmastectomy patient. In: Bland KI, Copeland EM, eds.: The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia, Pa: Saunders, 1991, pp 701-6.
- Bicego D, Brown K, Ruddick M, et al.: Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther 86 (10): 1398-405, 2006.
- Meek AG: Breast radiotherapy and lymphedema. Cancer 83 (12 Suppl American): 2788-97, 1998.
- Roberts CC, Levick JR, Stanton AW, et al.: Assessment of truncal edema following breast cancer treatment using modified Harpenden skinfold calipers. Lymphology 28 (2): 78-88, 1995.
- Pyszel A, Malyszczak K, Pyszel K, et al.: Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema. Lymphology 39 (4): 185-92, 2006.
- Ridner SH: Quality of life and a symptom cluster associated with breast cancer treatment-related lymphedema. Support Care Cancer 13 (11): 904-11, 2005.
- Paskett ED, Naughton MJ, McCoy TP, et al.: The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 16 (4): 775-82, 2007.
- Shaw C, Mortimer P, Judd PA: Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer 109 (10): 1949-56, 2007.
- Petrek JA, Senie RT, Peters M, et al.: Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 92 (6): 1368-77, 2001.
- Beesley V, Janda M, Eakin E, et al.: Lymphedema after gynecological cancer treatment : prevalence, correlates, and supportive care needs. Cancer 109 (12): 2607-14, 2007.
- Norman SA, Localio AR, Potashnik SL, et al.: Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 27 (3): 390-7, 2009.
- Purushotham AD, Bennett Britton TM, Klevesath MB, et al.: Lymph node status and breast cancer-related lymphedema. Ann Surg 246 (1): 42-5, 2007.
- Borup Christensen S, Lundgren E: Sequelae of axillary dissection vs. axillary sampling with or without irradiation for breast cancer. A randomized trial. Acta Chir Scand 155 (10): 515-9, 1989.
- Liljegren G, Holmberg L: Arm morbidity after sector resection and axillary dissection with or without postoperative radiotherapy in breast cancer stage I. Results from a randomised trial. Uppsala-Orebro Breast Cancer Study Group. Eur J Cancer 33 (2): 193-9, 1997.
- Lucci A, McCall LM, Beitsch PD, et al.: Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol 25 (24): 3657-63, 2007.
- Celebioglu F, Perbeck L, Frisell J, et al.: Lymph drainage studied by lymphoscintigraphy in the arms after sentinel node biopsy compared with axillary lymph node dissection following conservative breast cancer surgery. Acta Radiol 48 (5): 488-95, 2007.
- Wilke LG, McCall LM, Posther KE, et al.: Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 13 (4): 491-500, 2006.
- Francis WP, Abghari P, Du W, et al.: Improving surgical outcomes: standardizing the reporting of incidence and severity of acute lymphedema after sentinel lymph node biopsy and axillary lymph node dissection. Am J Surg 192 (5): 636-9, 2006.
- Jemal A, Siegel R, Ward E, et al.: Cancer statistics, 2009. CA Cancer J Clin 59 (4): 225-49, 2009 Jul-Aug.
- Sagen A, K�resen R, Risberg MA: Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up. Acta Oncol 48 (8): 1102-10, 2009.
- Ridner SH, Dietrich MS, Stewart BR, et al.: Body mass index and breast cancer treatment-related lymphedema. Support Care Cancer 19 (6): 853-7, 2011.
- Radak Z, Chung HY, Koltai E, et al.: Exercise, oxidative stress and hormesis. Ageing Res Rev 7 (1): 34-42, 2008.
- Schmitz KH: Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc Sport Sci Rev 38 (1): 17-24, 2010.
- Cheema B, Gaul CA, Lane K, et al.: Progressive resistance training in breast cancer: a systematic review of clinical trials. Breast Cancer Res Treat 109 (1): 9-26, 2008.
- McKenzie DC, Kalda AL: Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. J Clin Oncol 21 (3): 463-6, 2003.
- Ahmed RL, Thomas W, Yee D, et al.: Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol 24 (18): 2765-72, 2006.
- Courneya KS, Segal RJ, Mackey JR, et al.: Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 25 (28): 4396-404, 2007.
- Schmitz KH, Ahmed RL, Troxel AB, et al.: Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA 304 (24): 2699-705, 2010.
- Rockson SG: Lymphedema. Am J Med 110 (4): 288-95, 2001.
- Ridner SH, Montgomery LD, Hepworth JT, et al.: Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema. Lymphology 40 (1): 35-46, 2007.
- Mondry TE, Riffenburgh RH, Johnstone PA: Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 42-8; discussion 17-9, 2004 Jan-Feb.
- Cheville AL, McGarvey CL, Petrek JA, et al.: The grading of lymphedema in oncology clinical trials. Semin Radiat Oncol 13 (3): 214-25, 2003.