Lymphoedema Evidence Library › Topics › Diagnosis and measurement
Diagnosis and measurement
Diagnosis and measurement
66 sources
Evidence in one minute
- Diagnosis is clinical in most patients (history, pitting, Stemmer sign, skin changes, limb shape). In adult unilateral oedema exclude tumour obstruction; duplex to exclude DVT/venous disease. Executive Committee of the International Society of Lymphology 2023
- Lymphoscintigraphy is the core confirmatory test (not standardised); ICG lymphography stages superficial lymphatic function and plans LVA; MR lymphography in specialist centres; oil-contrast lymphography only for chylous reflux/thoracic duct. Avoid biopsy of enlarged nodes in long-standing lymphoedema. Historic SA contrast lymphangiography series: Abramowitz 1971 · Smith 1966.
- Always measure both limbs and report excess volume — ignoring the control limb overestimates treatment effect; 4 cm leg segments are not needed (8–12 cm agree). Moderate certainty (large retrospective data). Mayrovitz 2007
- Tissue dielectric constant (TDC) measures local skin-to-fat water (~2.5 mm): no dominance effect, site- and depth-specific normal values; one reading suffices; affected/contralateral forearm ratio in established BCRL ~1.6; proposed pre-clinical threshold ≥1.2 (2014) or 1.26 (2009) — derived from control variability, not validated prospectively. Low certainty for diagnostic use. Mayrovitz 2014 · Mayrovitz 2009 · Mayrovitz 2008 · Mayrovitz 2009
- TDC detects local change girth misses (one MLD session: TDC −9.8% vs girth −1.5%). Mayrovitz 2008
- Bioimpedance detects early extracellular fluid change (pilot after gynaecological node dissection). Takeuchi 2013
- Prospective surveillance: baseline bilateral measurement before cancer surgery, then ~3-monthly in year 1; subclinical threshold 3–5% volume change (ISL). The SA referral pathway proposes pre-treatment limb measurement for every newly diagnosed breast cancer. Marco 2014
- Lymphoedematous arms are not hypoxic on TcPO2 — a low reading suggests another cause. Mayrovitz 2005
- ABPI before leg compression — often unreliable in oedematous limbs (cuff size, clinical correlation); UK guidance allows ≤20 mmHg before ABPI if no red flags. Keast 2025 · Fletcher 2024
Overlap warning
Mayrovitz 2008 and Mayrovitz 2009 report the same 10 lymphoedema patients — count once.
Update 2026-10-08 — downloaded evidence
- TDC reference values now from 403 healthy women: inter-arm forearm ratio ≥1.20 abnormal (only 0.74% of healthy women exceed it), 1.15–1.20 borderline; independent of age and BMI. Compare ratios, not absolute values (probe, depth, sex and body fat change absolute TDC). Forearm and biceps usable, hand too variable (1.57); truncal thresholds 1.32 (thorax/thorax). After surgery, ratios track symptoms and nodes removed (proposed 1.30 forearm). Mayrovitz 2026 · Mayrovitz 2007 · Mayrovitz 2016 · Mayrovitz 2018 · Mayrovitz 2015 · Mayrovitz 2019 · Mayrovitz 2019 · Mayrovitz 2015
- Bioimpedance surveillance (PREVENT RCT, ImpediMed-sponsored): BIS-triggered compression led to less chronic BCRL than tape-triggered compression (all patients 5.6% v 9.4%; among those triggered 7.9% v 19.2%). Low certainty (revised 2026-10-08): outcome measured by unblinded tape, and tape-triggered patients started at 5–10% on that same tape; ImpediMed designed the trial. BIS triggers fewer sleeves (20% v 28%, moderate). "Guideline" (written largely by ImpediMed's CMO and advisers; AGREE II 2/7): baseline, then quarterly for 3 years, act at L-Dex change ≥6.5 — the schedule matches ISL 2023, which is the better source to cite (revised 2026-10-09). Ridner 2022 Ridner 2019 · Boyages 2023 · Shah 2023
- The 2009 LRB (30 per group) and 2014 Lymphology (80 per group) TDC threshold studies probably share participants — treat as one data set. Mayrovitz 2009
- Firmness (indentation) and water (TDC) are independent measures. Mayrovitz 2009
- Vascular imaging sequence: duplex first, lymphoscintigraphy to confirm, ICG where surgery is considered — expert opinion; duplex accuracy rests on small single-centre studies (revised 2026-10-09). O'Donnell 2017
Appraisal update 2026-10-09
- Bioimpedance pilot after gynaecological node dissection (Takeuchi 2013, n = 18, 7 days): Table 3 reports identical pre- and post-operative means with p = 0.005 — the claimed early E/T rise cannot be checked; very low certainty. Takeuchi 2013
Gaps
No prospective validation of the TDC threshold in this library; retrieve Mayrovitz 2015 (Ann Surg Oncol, pre/post-surgery) and the 2012 ISL proceedings.
Update 2026-10-09 — historic SA lymphangiography (Sabinet)
- Oil-contrast lymphangiography (Cape 1965, Rhodesia 1972, Durban 1975) often failed in lymphoedema and caused oil embolism (one death in 277); superseded by lymphoscintigraphy. Van Rensburg LCJ 1965 · Gordon 1972 · Grant 1975 · Field 1991
Update 2026-10-09 — open-access batch 4
- Pre-treatment baseline (Chen 2025, PREVENT): 71% of BIS triggers and 88% of tape triggers lay inside normal ranges at the time of detection, so they would be missed without a pre-surgery measurement — low; ImpediMed-linked authors. Chen 2025
- Who to survey (Boyages 2021, PREVENT): subclinical triggers rose from 20% without nodal radiotherapy to 43% with SCF plus axillary fields — low. The BIS-v-tape comparison uses unequal thresholds. Boyages 2021
Update 2026-10-09 — open-access batch 5
- Tablet 3D laser scanning correlated closely with tape and was quicker (Invernizzi 2020) — pilot only; correlation is not agreement. Invernizzi 2020
Update 2026-10-09 — open-access batch 8 (reviews)
- Breast lymphoedema: ultrasound dermal thickness is the only measure with sufficient reliability (Fearn 2023, COSMIN) — moderate. Fearn 2023
- BIS review (Forte 2021) overstates certainty. Forte 2021
Update 2026-10-09 — open-access batch 9 (reviews)
- Questionnaires: no lymphoedema PROM fully meets COSMIN standards (Beelen 2021); head and neck — Patterson scale and LIDS-H&N best (Arends 2023). MR lymphography maps vessels ≥0.5 mm (Miseré 2020). Beelen 2021 · Arends 2023 · Miseré 2020
Update 2026-10-09 — open-access batch 10 (reviews)
- Shah 2021 (ImpediMed-funded): claims BIS monitoring cuts chronic BCRL by 69–81% by comparing incidence across unrelated studies — very low; do not quote. Shah 2021
Update 2026-10-09 — open-access batch 11 (reviews)
- Arm QoL questionnaire: Lymph-ICF-UL has the best measurement properties (Meilani 2022). ICG lymphography in primary lymphoedema: unstandardised (Brezgyte 2025). Meilani 2022 · Brezgyte 2025
How the evidence points
| High | Mod. | Low | V. low | None | |
|---|---|---|---|---|---|
| Positive | 0 | 0 | 1 | 1 | 0 |
| Null or negative | 0 | 0 | 0 | 0 | 0 |
Sources on this page with a comparison, by the result of their primary outcome and the GRADE certainty of their main finding (Mod. = Moderate, V. low = Very low, None = not graded). Context sources are not counted. How direction is decided.
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