Stout Gergich, N.L., Pfalzer, L.A., McGarvey, C., Springer, B., Gerber, L.H., & Soballe, P. (2008). Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer, 112(12), 2809–2819.

Successful management of lymphedema relies on early diagnosis. The aim of this study was to demonstrate the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical lymphedema. Inconsistent measurements have prevented a surveillance model from becoming an accepted standard of care.

Limb volume measured prior to surgery and at three-month intervals after surgery. If an increase more than 3% in upper-limb volume developed compared with the preoerative volume, a diagnosis of lymphedema was made and a compression garment intervention was prescribed for four weeks. Upon reduction of lymphedema, compression was worn only for strenuous activity, with symptoms of heaviness, or with visible swelling. The compression garment was a lightweight Jobst^® (BSN medical) ready-made 20–30 mm/HG compression sleeve and gauntlet fitted by the physical therapist. Two patients required custom-fitted garments because of arm size. Garments were worn daily and no activity limitations were given. Patients were advised to follow up for repeated measure in one month. At follow-up, when limb volume decreased, as indicated by the measurements, women were advised to only wear compression for strenuous activity with symptoms of heaviness or with visible swelling. Women were reassessed at their next three-month interval surveillance visit for repeated measures, or sooner, if symptoms were exacerbated.

• The sample (N = 196) was comprised of women with newly diagnosed, unilateral, early-stage breast cancer (stage I–III) preoperatively.
• Patients were excluded from the study if they had a previous history of breast cancer, bilateral breast cancer, prior severe trauma, or surgery of the affected upper extremity.
• Patients were included in the study if they had a diagnosis of subclinical lymphedema.
• A volume increase of greater than or equal to 3% in the affected upper extremity was compared with patients' preoperative measurements and with consideration of the contralateral limb volume changes. This is set below the criteria currently outlined in the medical literature to facilitate early treatment of lymphedema before a clinically apparent onset.
• Exclusion from the compression sleeve intervention were swelling because of infection or blood clot (n = 5).

The study used a prospective trial design.

• Bilateral upper-extremity strength, range of motion, and volume were assessed at the preoperative visit and reassessed at 1, 3, 6, 9, 12, and 18 months postoperatively.
• Measurements for both upper extremities were taken in a standard position with the perometer.
• Lymphedema volume was calculated by suing 80% of the total limb length, which was measured from the styloid process of the ulna to the tip of the acromion for standardization.
• Body weight was recorded at each visit to control for weight change.

The time to onset of lymphedema averaged 6.9 months postoperatively. The mean affected limb volume increase was 83 ml at lymphedema onset (p = 0.005) compared with baseline. After the intervention, a statistically significant mean of 48 ml volume decrease was realized (p < 0.001). The mean duration of the intervention was 4.4 weeks. Volume reduction was maintained at an average follow-up of 4.8 months after the intervention. A short trial of compression garments effectively treated subclinical lymphedema. Detection and management of lymphedema at this early stage may prevent the condition from progressing to a chronic, disabling stage and may enable a more cost-effective, conservative intervention. The authors speak of a shift from current practice pattern in favor of a surveillance model. Throughout the surveillance trial, 43 women ages 34–82 years were diagnosed with subclinical lymphedema. An age-matched control group of women without lymphedema was selected from the trial for comparison.

• A perometer is a very costly machine that required training for patients to use, making it unlikely to be replicated.
• Not a randomized control trial.

The results of the study support the continued search for an easy measurement.