CPG Lymph Dx - SUQCRL

Question 1

International Society of Lymphology (ISL) Classification of Lymphedema Severity

Answer 1

• At Risk = insult to LS, wo/sx or signs of impaired lymphatic transport non-ISL
• Stage 0 = sub clinical state = impaired lymphatic transport, no peripheral swelling; Sx and subtle skin changes may be present
• Stage I = early Lymph = early onset visible swelling that subsides w/elevation; pitting may/may not be present
• Stage II = Moderate Lymph = pitting; consistent volume change; fibrosis may/may not be present [progressive fibrosis]
• Stage III = Late Lymph = nonpitting; skin changes; very fibrotic

Question 2

Clinical Examination and Patient-Reported Symptom Assessments:
Clinical Examination for All Patients at risk for SUQL

Answer 2

• Palpation: for fibrosis, pitting, and overall tissue quality - may be clinically helpful for staging; however, it has not been investigated for diagnostic purposes.
• H/N: HN-ELAF can be used w/CM for Dx purposes

Question 3

Clinical Examination and Patient-Reported Symptom Assessments:
Patient-Reported Sx Assessments for All Patients at risk for SUQL

Answer 3

• Self-reported symptoms: of swelling, heaviness, and numbness should be investigated for early diagnosis —> should signal clinician to use other SUQL Measures
• Questionnaires to Consider to Assist in Dx: the Norman Questionnaire; or the Morbidity Screening Tool

Question 4

Categories and subcategories for practice recommendations were written for the following:

Answer 4

-All patients at risk for SUQL
-Secondary upper-extremity lymphedema
—>At risk, early
—>Moderate/established
—>Late
-Lymphedema primarily in the hand
-Trunk/breast lymphedema
-Head and neck lymphedema

Question 5

Bioimpedance analysis should be used to detect _____________ and diagnose _____ and _______ _______ in patients at risk for ________

Answer 5

Bioimpedance analysis should be used to detect lymphatic transport impairments and diagnose subclinical and early-stage lymphedema in patients at risk for breast cancer–related lymphedema

Question 6

L-Dex Score: Dx Criterion if No Preop Baseline Available

Answer 6

L-Dex score of more than 7.1 should be used as a diagnostic criterion for breast cancer–related lymphedema when no preoperative assessment is available.

Question 7

L-Dex Score: Dx Criterion if Preop Baseline Available

Answer 7

score of more than 10 above preoperative baseline measures should be used as a diagnostic criterion.

Question 8

BIA in moderate- to late-stage breast cancer–related lymphedema ___ be used as a Dx tool, however, clinicians must be aware of the potential for ________ ECF even with ____ tissue volume.

Answer 8

In moderate- to late-stage breast cancer–related lymphedema, as fibrosis and tissue changes occur, BIA may be used as a diagnostic tool; however, clinicians must be aware of the potential for decreasing extracellular fluid even with increased tissue volume.

Question 9

BIA may not capture _______ _____ such as fibrosis or adipose infiltration that are seen in _____-______ lymphedema.

Answer 9

BIA may not capture tissue changes such as fibrosis or adipose infiltration that are seen in later-stage lymphedema.

Question 10

Volume assessment tools for clinicians

Answer 10

Perimeter; water displacement; CM; 3-D imaging; more?

Some have established diagnostic criterion

Question 11

Are clinical volume assessment tools interchangeable?

Answer 11

No.

They are not equivalent and thus not interchangeable.

Clinicians should use the same method for all assessments of an individual.

Question 12

Circumferential Measurements for UQSL

Answer 12

• UE - Dx tool
• Hand - assessment tool
• H/N - assessment tool

Question 13

CM should be used to Dx UE Lymphedema stage ___ or greater

Answer 13

CM should be used to Dx UE Lymphedema stage I or greater

—> with or without hand involvement!

Question 14

UE CM Volume Ratio indicative of Lymphedema

Answer 14

A volume ratio of 1.04 may be indicative of upper-extremity lymphedema

Question 15

UE CM Calculated volume differential between sides:

1) > or = ____ will help rule in lymphedema BUT
2) values < ____ cannot be used to rule out.

Answer 15

Calculated volume differential between sides (≥200 mL) will help rule in lymphedema, but values below 200 mL cannot be used to rule out.

Question 16

UE CM Calculated Volume: If preoperative measures are available, a ___% or greater volume change from baseline _____ and _____ the _____ is _______ of upper-extremity lymphedema.

Answer 16

If preoperative measures are available, a 5% or greater volume change from baseline above and below the elbow is diagnostic of upper-extremity lymphedema.

Question 17

UE CM: CM taken at any single site along the UE, and specifically a difference of 2 cm or more, should _____ be used as a _____ ______ for UE lymphedema due to ____ ____.

Answer 17

CM taken at any single site along the UE, and specifically a difference of 2 cm or more, should not be used as a diagnostic criterion for UE lymphedema due to poor accuracy.

Question 18

CM Volume Measurement - Hand Lymphedema:

“figure-of-eight” method of CM may be used as ________ tool for determining hand _____.

Answer 18

For hand lymphedema, “figure-of-eight” method of circumferential measurement may be used as an assessment tool for determining hand volume; however, this method has not been studied as a diagnostic test.

Excellent intratester reliability for hand swelling in BCRL

Question 19

CM Volume Measurement - head and neck lymphedema: circumferential measurement taken at a ___ ____ of the upper neck (under the jawline) may be useful for _____ but has not been studied as a _____ test.

Answer 19

For head and neck lymphedema, circumferential measurement taken at a single point of the upper neck (under the jawline) may be useful for assessment but has not been studied as a diagnostic test.

Question 20

-Reliability for limb volumes calculated from demonstrates _____ interrater and intrarater reliability for the arm ___ and ____ the hand measurements.

____ or ____ frustum cone for calculating arm volumes demonstrates _____ intrarater and interrater reliability

Answer 20

Reliability for limb volumes calculated from circumferential measurement demonstrates excellent interrater and intrarater reliability (ICC = 0.93-0.99) for the arm with and without the hand measurements.

Single or summed frustum cone for calculating arm volumes demonstrates excellent intrarater (ICC = 0.96-0.99) and interrater reliability

Question 21

Either method (cylindrical formula; single or summed truncated cone formula) for calculating arm volume can result in an ______ of the actual limb volume.

Answer 21

Either method can result in an overestimation of the actual limb volume.

The literature suggests:

• cylindrical formula may overestimate the limb volume up to 5%
• single or summed truncated cone formula by at least 100 mL.

Question 22

H/N CM: 3 points with excellent interrater reliability:

Answer 22

ear to ear (ICC = 0.94); upper neck (ICC = 0.97); and lower neck (ICC = 0.98).

Question 23

Calculated volume from CM is highly correlated with ____ ______ of the arm, suggesting calculate arm volume from CM is a _____ method of determining ______ ______.

Answer 23

Volumes calculated from circumferential measurement have been found to be highly correlated with water displacement of the arm (r = 0.93-0.98), suggesting validity for this method of determining limb volume

Question 24

CM at either __ specific points or every __ cm along the arm is highly correlated with _____ ______.

Answer 24

CM at either 4 specific points or every 10 cm along the arm is highly correlated with water displacement.

Use of 4 specific points, as is commonly used for garment measuring, may save the clinician time during the examination.

Question 25

CM taken by physical therapists are highly correlated with _____ measurements

Answer 25

CM taken by physical therapists are highly correlated with patient measurements

Question 26

CM SEM = ___%

CM SDC = ___%

1.04 volume ratio = ___% difference

Answer 26

CM SEM = 2.8%

CM SDC = 6.6%

1.04 volume ratio = 4% difference

Question 27

Diagnostic accuracy of 75 mL cutoff amount for calculated volume difference

Answer 27

using the 75-mL interlimb volume difference suggested good accuracy for detecting lymphedema (sensitivity = 0.67, specificity = 0.85); however, because this value is still below the SEM, use of this threshold may misdiagnose a number of individuals.

Question 28

***The debate over the most appropriate cut point for diagnosis continues. Currently, the best sensitivity and specificity, while being above the SEM, come from using either….. ____ OR ____

Answer 28

***Currently, the best sensitivity and specificity, while being above the SEM, come from using either….. the volume difference of 200 mL or more or the 1.04 ratio of affected:unaffected limb.

Question 29

Clinicians should understand that using a criterion of _____ may incorrectly classify milder cases of Lymphedema(eg, _____) as not having lymphedema.
Likewise, some of the criteria that are more sensitive (1.04 ratio; 5% volume increase), may still misclassify when used as a sole diagnostic criterion.

A __ ______ _____ may better detect lymphedema and is closer to the SDC of the measure, but it requires ________ ________

Answer 29

Clinicians should understand that using a criterion of > 200 mL may incorrectly classify milder cases of lymphedema (eg, 150-mL) as not having lymphedema.
Likewise, some of the criteria that are more sensitive (1.04 ratio; 5% volume increase), may still misclassify when used as a sole diagnostic criterion.

A 5% volume change in a limb may better detect lymphedema and is closer to the SDC of the measure, but it requires preoperative measurement for comparison purposes.

Question 30

Water displacement

Answer 30

• may be used to diagnose lymphedema with volumetry of more than 200 mL when compared with the contralateral arm and with volumes of more than 10% interlimb difference. -limited by clinical utility
• excellent reliability, validity
• considered the reference standard in much of the validity and diagnostic accuracy research
• little evidence on its diagnostic accuracy

Question 31

Perometry

Answer 31

• may be used for assessment of volume but not as a diagnostic tool for upper-extremity lymphedema
• limited in clinical utility.

A perometer is an optoelectrical imaging device for measuring indirect limb volume. The arm volume is then calculated, summing the volumes of elliptical segments every centimeter for 40 cm using computer software.

Question 32

Stout et al13 defined breast cancer–related lymphedema as an increase of more than __% limb volume as compared with a _______ volume measurement

Answer 32

Stout et al13 defined breast cancer–related lymphedema as an increase of more than 3% limb volume as compared with a preoperative volume measurement

Question 33

3-D camera imaging

Answer 33

Although 3-dimensional (3D) camera imaging may not be used as a diagnostic tool, it can be used to calculate volume measurements, as it has not been studied for diagnostic purposes

A new imaging technique, using 3D imaging cameras, calculates volume measurements using different methods (6 digital single-lens reflex cameras,81 positional laser and 3 cameras,91 and Microsoft Kinect infrared sensor) to develop a 3D model