-
-
-
-
-
Stages of Change With Lymphedema
-
-
-
-
-
-
-
-
-
STAGES OF
LYMPHEDEMA
Whether primary or
secondary, lymphedema develops in stages, from mild to severe. Methods of staging are numerous and
inconsistent. They range from three to
as many as eight stages.
The most common method
of staging was defined by the Fifth WHO Expert Committee on
Filariasis:
Stage 0
(latent):
·
The lymphatic vessels
have sustained some damage which is not yet apparent.
·
Transport capacity is
still sufficient for the amount of lymph being removed.
·
Lymphedema is not
present.
Stage 1 (spontaneously
reversible):
·
Tissue is still at the
"pitting" stage: when pressed by the fingertips, the affected area indents and
holds the indentation.
·
Usually upon waking in
the morning, the limb or affected area is normal or almost normal in
size.
Stage 2 (spontaneously
irreversible):
·
Tissue has a spongy
consistency and is "non-pitting”: when pressed by the fingertips, the tissue
bounces back without any indentation.
·
Fibrosis found in Stage
2 Lymphedema marks the beginning of the hardening of the limbs and increasing
size.
Stage 3 (lymphostatic
elephantiasis):
·
A swelling is irreversible
and usually the limb(s) or affected area is (are) very large.
·
Tissue is hard (fibrotic)
and unresponsive.
A new staging system has
been set forth by Lee, Morgan and Bergan and endorsed by the American Society of
Lymphology. This provides a clear
technique which can be employed by clinical and laboratory assessments to more
accurately diagnose and prescribe therapy for lymphedema. In this improved version, there are four
stages identified (I-IV). Physicians and
researchers can utilize additional laboratory assessments such as bioimpedance,
MRI, or CT to build on the findings of a clinical assessment (physical
evaluation). From this, results of
therapy can be accurately determined and reported in documentation as well as
research.
Risk is another
measurement altogether. Current research
using bioimpedance to measure risk of lymphedema is very
promising.
Grades
Lymphedema can also be
categorized by its severity (usually referenced to a healthy
extremity):
Grade 1 (mild
edema):
·
Lymphedema involves the
distal parts such as a forearm and hand or a lower leg and
foot.
·
The difference in
circumference is less than 4 centimeters, and other tissue changes are not yet
present.
Grade 2 (moderate
edema):
·
Lymphedema involves an
entire limb or corresponding quadrant of the trunk.
·
Difference in
circumference is more than 4, but less than 6 centimeters.
·
Tissue changes, such as
pitting, are apparent.
·
The patient may
experience erysipelas.
Grade 3a (severe
edema):
·
Lymphedema is present in
one limb and its associated trunk quadrant.
·
The difference in
circumference is greater than 6 centimeters.
·
Significant skin
alterations, such as cornification or keratosis, cysts and/or fistulae, are
present.
·
Additionally the patient
may experience repeated attacks of erysipelas.
Grade 3b (massive
edema):
·
The same symptoms as
Stage 3a except that two or more extremities are affected.
Grade 4 (gigantic
edema):
·
Also known as
elephantiasis.
·
In this stage of
lymphedema, the affected extremities are huge due to almost complete blockage of
the lymph channels.
·
Elephantiasis may also
affect the head and face.
Diagnosis, assessment
and monitoring
The diagnosis or early
detection of lymphedema is difficult. The first signs may be subjective observations
such as "my arm feels heavy" or "I have difficulty these days getting rings on
and off my fingers". These may be
symptomatic of early stage of lymphedema, where accumulation of lymph is mild
and not detectable by any difference in arm volume or
circumference.
As lymphedema develops
further, then definitive diagnosis is commonly based upon an objective
measurement of difference between the affected or at-risk limb to the opposite
unaffected limb (e.g. in volume or circumference).
Unfortunately, there is
no generally accepted world-wide criterion of difference definitively diagnostic
although a volume of difference of 200 ml between limbs or a 4 cm (at a single
measurement site or set intervals along the limb) is often used.
Recently, the technique
of bioimpedance measurement (a method that measures the amount of fluid in a
limb) has been shown to have greater sensitivity than these existing methods and
holds promise as a simple diagnostic and screening tool. Impedance analyzers specifically designed for
this purpose are now commercially available.
Similarly, assessment
and monitoring of lymphedema progression, or its response to treatment, is
usually based on the changes in volume, circumference, or impedance over
time.
Stage II - Pitting may
or may not occur as tissue fibrosis develops. Limb elevation alone rarely reduces tissue
swelling.
Stage III - A severe
increase in swelling may develop, along with skin changes, such as thickening of
the skin, fat deposits, and warty over-growths. This stage of lymphedema may also be called
lymphostatic elephantitis.