Lymphedema (PDQ®): Supportive care - Health Professional Information [NCI] - Overview
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.
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