title: Diagnosis of upper limb lymphedema: development of an evidence-based approach.
abstract: BACKGROUND
  The diagnosis of secondary upper limb lymphedema (LE) is complicated by the lack of an agreed-upon measurement tool and diagnostic threshold. The aim of this study was to determine which of the many commonly used and normatively determined clinical diagnostic thresholds has the best diagnostic accuracy of secondary upper limb LE, when compared to diagnosis by an appropriate reference standard, lymphoscintigraphy.
  
  
  METHODS
  The arms of women treated for breast cancer with and without a previous diagnosis of LE, as well as healthy controls, were assessed using lymphoscintigraphy, bioimpedance spectroscopy (BIS) and perometry. Dermal backflow score determined from lymphoscintigraphy imaging assessment (reference standard) was compared with diagnosis by both commonly used and normatively determined diagnostic thresholds for volume and circumference measurements as well as BIS.
  
  
  RESULTS
  For those with established dermal backflow, all commonly used and normatively determined diagnostic thresholds accurately identified presence of LE compared with lymphoscintigraphy diagnosis. In participants with mild to moderate changes in dermal backflow, only a normatively determined diagnostic threshold, set at two standard deviations above the norm, for arm circumference and full arm BIS were found to have both high sensitivity (81% and 76%, respectively) and specificity (96% and 93%, respectively). For this group, strong, and clinically useful, positive (23 and 10, respectively) and negative likelihood (0.2 and 0.3) ratios were found for both the circumference and bioimpedance diagnostic thresholds.
  
  
  CONCLUSIONS
  For the first time, evidence-based clinical diagnostic thresholds have been established for secondary LE. With mild LE, normatively determined circumference and BIS thresholds are superior to the commonly used thresholds.
authors.affiliation: a Faculty of Health Sciences , University of Sydney , Sydney , New South Wales , Australia.
authors.forename: E S
authors.initials: ES
authors.lastname: Dylke
authors.affiliation: b Nuclear Medicine Department , Royal North Shore Hospital , Sydney , New South Wales , Australia.
authors.forename: G P
authors.initials: GP
authors.lastname: Schembri
authors.affiliation: a Faculty of Health Sciences , University of Sydney , Sydney , New South Wales , Australia.
authors.forename: D L
authors.initials: DL
authors.lastname: Bailey
authors.affiliation: b Nuclear Medicine Department , Royal North Shore Hospital , Sydney , New South Wales , Australia.
authors.forename: E
authors.initials: E
authors.lastname: Bailey
authors.affiliation: c School of Chemistry and Molecular Biosciences, the University of Queensland , Brisbane , Queensland , Australia.
authors.forename: L C
authors.initials: LC
authors.lastname: Ward
authors.affiliation: a Faculty of Health Sciences , University of Sydney , Sydney , New South Wales , Australia.
authors.forename: K
authors.initials: K
authors.lastname: Refshauge
authors.affiliation: d Chris O'Brien Lifehouse , Camperdown , New South Wales , Australia.
authors.forename: J
authors.initials: J
authors.lastname: Beith
authors.affiliation: a Faculty of Health Sciences , University of Sydney , Sydney , New South Wales , Australia.
authors.forename: D
authors.initials: D
authors.lastname: Black
authors.affiliation: a Faculty of Health Sciences , University of Sydney , Sydney , New South Wales , Australia.
authors.forename: S L
authors.initials: SL
authors.lastname: Kilbreath
mesh_terms: D001943:Breast Neoplasms / Q000150:complications* / Q000628:therapy; D016022:Case-Control Studies; D003131:Combined Modality Therapy / Q000009:adverse effects*; D019317:Evidence-Based Medicine; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008209:Lymphedema / Q000175:diagnosis* / Q000209:etiology; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D034941:Upper Extremity / Q000473:pathology*