6. How is lymphoedema diagnosed?
An accurate diagnosis is essential for appropriate therapy. This is determined from the clinical history and physical examination. Co-morbid and confounding conditions of morbid obesity, lipoedema, cardiac disease, renal disease, metabolic disorders, infection, and venous insufficiency will require thorough medical evaluation.
Lymphoedema usually has a gradual onset. However when lymphoedema has an acute onset appropriate tests to exclude, deep venous thrombosis (DVT), recurrence of cancer and infection may be necessary. Sometimes lymphoscintigraphy will be offered to confirm a clinical diagnosis of Primary Lymphoedema.
Whether primary or secondary, lymphoedema develops in stages, from mild to severe. Methods of staging are numerous and inconsistent. They ranged from three to as many as eight stages. In Australasia, the most commonly used stage scale is that adopted by The International Society of Lymphology (ISL) (3), which identifies the following stages:
Stage 0 A latent or subclinical state where swelling is not evident despite impaired lymph transport.
Stage I This represents early onset of the condition where there is an accumulation of tissue fluid with higher protein content, which subsides with limb elevation. The oedema may be pitting at this stage.
Stage II Limb elevation alone rarely reduces swelling and pitting is manifest. In later Stage II the limb may or may not pit as fat and fibrosis supervenes.
Stage III The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowth develop. Stage III encompasses lymphostatic elephantiasis. At this stage, the swelling is spontaneously irreversible and usually the limb(s) is very large.