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Preoperative Assessment Of Upper Extremity Secondary Lymphedema
Itay Wiser, MD, PhD, Elizabeth Kenworthy, MD, Michelle Coriddi, MD, Babak Mehrara, MD, Joe Dayan, MD.
Memorial Sloan Kettering, New York, NY, USA.

Purpose: Advances in operative techniques have broadened the indications for lymphedema surgical treatment. Assessment of outcomes, however, has been hampered by a heterogeneity of methods used, resulting in duplication of efforts and costs. The purpose of this study was to systematically analyze secondary upper extremity lymphedema preoperative assessment tools. Methods: A prospective cohort study. Lymphedema evaluation included limb volume excess measurement using manual or perometer techniques, and limb single circumference measurement, bio-impedance measurement (L-Dex), indocyanine green (ICG) lymphography, lymphoscintigraphy, magnetic resonance angiography (MRA), lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires (PROMs). Results: One hundred and eighteen patients were evaluated. Limb volume measurements obtained manually or with the perometer highly correlated with each other and with single circumference measurements. L-Dex score highly correlated with Limb volume excess (r2=0.714, p<0.001), and had high sensitivity (91.2%) and positive predictive value (87.3%). ICG abnormalities were noted in all patients, including those without limb volume excess. Lymphoscintigraphy had low sensitivity (88%) and specificity (41.4%). MRA evidence of adipose hypertrophy had high sensitivity (96.2%). Evidence of axillary vein stenosis on MRA was noted in 12 patients (15.4%). High correlation was found between the different PROMs domains impairment scores. We found no significant correlations between ICG stage and PROMs. Conclusion: Preoperative assessment of lymphedema is complex and requires objective and subjective measures. Lymphedema multi-modal assessment is helpful to achieve a more precise degree of its severity. PROMs are critical since the degree of disability has a low correlation with arm volume excess.





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