RESEARCH

Arm Volumetry Versus Upper Extremity Lymphedema Index Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation Nana Yamamoto, MD, Takumi Yamamoto, MD, Nobuko Hayashi, MD, Akitatsu Hayashi, MD, Takuya Iida, MD, and Isao Koshima, MD Background: Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. Methods: Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees’ BMI was classified into 3 groups, namely, low BMI (BMI, G20 kg/m2), middle BMI (BMI, 20Y25 kg/m2), and high BMI (BMI, 925 kg/m2). Arm volume and UEL index were compared with corresponding BMI groups. Results: Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P G 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P 9 0.5]. Conclusions: Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry. Key Words: arm, lymphedema, breast, cancer, circumference, index, volume, upper, extremity (Ann Plast Surg 2016;76: 697Y699)

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pper extremity lymphedema (UEL) is a major health problem among breast cancer survivors.1 Due to progressive nature of the disease, prevention and early diagnosis and treatment are important for UEL management.2Y4 Arm volumetry, measurement of arm volume, is one of the most commonly used evaluations for UEL, and allows subjective and quantitative evaluation.5Y9 Volumetry, however, would be inappropriate for comparing different patients with different physiques, because body-type greatly affects arm volume. Body-type correction should be taken into consideration for UEL evaluation. Upper extremity lymphedema index was developed for lymphedematous volume evaluation of UEL patients.10 The UEL index is calculated using circumferences and body mass index (BMI) to be body-type corrected. Although UEL index was demonstrated to correlate with clinical severity of UEL, no study has been reported to Received February 12, 2014, and accepted for publication, after revision, April 9, 2014. From the Department of Plastic and Reconstructive Surgery, University of Tokyo, Bunkyo-ku, Tokyo, Japan. Conflicts of interest and sources of funding: This study was supported, in part, by Takeda Science Foundation (to T.Y.). Reprints: Takumi Yamamoto, MD, Department of Plastic and Reconstructive Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7606-0697 DOI: 10.1097/SAP.0000000000000259

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validate that UEL index allows better body-type corrected volume evaluation compared with arm volumetry. This study aimed to compare arm volumetry and UEL index regarding body-type correction in nonedematous arms.

METHODS Seventy arms of 35 female participants who had no history of arm edema, breast cancer, or axillary surgery were evaluated to compare arm volumetry and UEL index according to BMI. Participants’ age ranged from 34 to 80 years (average, 52.1 years), body height 149 to 167 cm (average, 159.0 cm), body weight 39 to 75 kg (average, 54.6 kg), and BMI 15 to 30 (average, 21.6). Participant’s arms were measured to obtain circumferences at the olecranon, 5 cm above and below the olecranon, the wrist, and the dorsum of the hand, and distances between adjacent circumference measurement levels. Arm volume was calculated using a summed truncated cone model; 4 truncated cones’ volumes were calculated from circumferences and heights, and were summed to approximate arm volume (Fig. 1). The UEL index was calculated using circumferences and BMI; a summation of squared circumferences was divided by BMI (Fig. 2). Examinees’ BMI was classified into 3 groups as follows: low BMI (BMI, G20), middle BMI (BMI, 20Y25), and high BMI (BMI, 925). Arm volume and UEL index were compared with corresponding BMI groups. Plus-minus value expressed mean (SD). Statistical analyses were done using analysis of variance. Statistical significance was defined as P G 0.05. This study was conducted in accordance with ethical guidelines for clinical research in the University of Tokyo Hospital, and all participants gave written consents to the study.

RESULTS Mean arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). Twelve participants (24 arms) were classified into lowBMI group, 18 participants (36 arms) into middle-BMI group, and 5 participants (10 arms) into high-BMI group. Mean arm volumes in low-BMI, middle-BMI, and high-BMI group were 945.2 (107.4), 1045.2 (87.5), and 1443.1 (244.4) mL, respectively (Fig. 3). There were statistically significant differences in arm volume between low-BMI and middle-BMI groups (P G 0.001), low-BMI and high-BMI groups (P G 0.001), and middle-BMI and high-BMI groups (P G 0.001). Mean UEL indices in low-BMI, middle-BMI, and high-BMI group were 97.2 (4.2), 96.6 (4.6), and 96.7 (9.9), respectively (Fig. 4). There was no statistically significant difference in UEL index between low-BMI and middle-BMI groups (P = 0.667), lowBMI and high-BMI groups (P = 0.765), or middle-BMI and highBMI groups (P = 0.998).

DISCUSSION Among various methods for evaluating extremity lymphedema, volume measurement is one of the most commonly used methods www.annalsplasticsurgery.com

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FIGURE 1. Calculation of arm volume using a summed truncated cone model. A summation of 4 truncated cones’ volumes approximates arm volume (mL). C1Y5 (cm) and h1Y4 (cm) denote circumferences and heights of each truncated cone, respectively. C1 denotes circumference at 5 cm above the olecranon, C2 circumference at the olecranon, C3 circumference at 5 cm below the olecranon, C4 circumference at the wrist, and C5 circumference at the dorsum of the hand.

because of its objectivity.5Y9 However, as demonstrated in this study, normal arm volume increases with increase of BMI. Therefore, comparison of arm volume between different cases with different physiques would be inappropriate; body-type corrected volume evaluation is required for this reason. The UEL index has been reported to be more useful for evaluation of clinical severity of UEL patients than circumference measurements, and for evaluation of therapeutic interventions to UEL patients.10Y13 However, no study has compared the UEL index with volumetry. This study revealed that UEL index in normal arm stayed constant regardless of BMI. Unlike arm volumetry, UEL index allows body-type corrected arm volume evaluation by being divided by BMI. Other body-type corrected volume evaluation methods can be used, such as arm volume divided by body surface area (BSA) and arm volume divided by BMI. Because lymphatic vessel is the third

FIGURE 2. Calculation of UEL index. The UEL index is calculated using circumferences (C1Y5, cm) and BMI. C1 denotes circumference at 5 cm above the olecranon, C2 circumference at the olecranon, C3 circumference at 5 cm below the olecranon, C4 circumference at the wrist, and C5 circumference at the dorsum of the hand. 698

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FIGURE 3. Arm volume and BMI. Mean arm volumes in low-BMI, middle-BMI, and high-BMI group were 945.2 (107.4), 1045.2 (87.5), and 1443.1 (244.4) mL, respectively. There were statistically significant differences in arm volume between low-BMI and middle-BMI groups (P G 0.001), low-BMI and high-BMI groups (P G 0.001), and middle-BMI and high-BMI groups (P G 0.001).

vessel next to artery and vein, lymphedema is considered a vascular disease.14 As widely used in the realm of cardiovascular medicine, body-type corrected index would be appropriate evaluation method for lymphedema; for example, cardiac index and glomerular filtration rate.15,16 Volume divided by BSA or by BMI seems more precise for body-type corrected volume evaluation, but calculation of volume and BSA is more complex and time-consuming than that of UEL index.6Y10,17 As this study revealed validity of UEL index for bodytype correction, UEL index would be more practical for routine evaluation of UEL patients.

FIGURE 4. UEL index and BMI. Mean UEL indices in low-BMI, middle-BMI, and high-BMI group were 97.2 (4.2), 96.6 (4.6), and 96.7 (9.9), respectively. There was no statistically significant difference in UEL index between low-BMI and middle-BMI groups (P = 0.667), low-BMI and high-BMI groups (P = 0.765), or middle-BMI and high-BMI groups (P = 0.998). * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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Volumetry vs UEL Index

Limitations of the present study are that the number of examinees was relatively small, that all participants were Japanese female adults, and that arm volume was not measured with more objective volumetry such as water displacement method but by approximation using a summed truncated cone model. Because this study included only Japanese female adults, it remains unclear whether UEL index allows body-type corrected arm volume evaluation for men, children, or other ethnic groups. Although arm volume was not measured using water displacement method in this study, approximation of arm volume using a summed truncated cone model has been reported to correlate well with more objective volumetry.6,8 Thus, arm volume, even if measured by more objective method, would also increase with increase of BMI. Although further studies are required to clarify usefulness of UEL index for men, children, or nonYJapanese ethnic groups, UEL index has a potential to allow better body-type corrected arm volume evaluation compared with arm volumetry.

4. Yamamoto T, Koshima I. Subclinical lymphedema: understanding is the clue to decision making. Plast Reconstr Surg. 2013;132:472eY473e.

CONCLUSIONS

10. Yamamoto T, Yamamoto N, Hara H, et al. Upper extremity lymphedema (UEL) index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg. 2013;70:47Y49.

In nonedematous arm, arm volume increases with increase of BMI, whereas UEL index stays constant regardless of BMI. The UEL index allows better body-type corrected arm volume evaluation compared with arm volumetry. ACKNOWLEDGMENTS The authors thank Rico, and all members of our department for their kind support to this study. REFERENCES 1. Petrek JA, Senie RT, Peters M, et al. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92:1368Y1377. 2. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green (ICG)Yenhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow (DB) patterns. Plast Reconstr Surg. 2011;128: 941Y947. 3. Yamamoto T, Narushima M, Yoshimatsu H, et al. Dynamic indocyanine green lymphography for breast cancer-related arm lymphedema. Ann Plast Surg. 2014; 73:706Y709.

* 2014 Wolters Kluwer Health, Inc. All rights reserved.

5. de Godoy JM, Godoy Mde F. Evaluation of a new approach to the treatment of lymphedema resulting from breast cancer therapy. Eur J Intern Med. 2013;24: 59Y62. 6. Karges JR, Mark BE, Stikeleather SJ, et al. Concurrent validity of upperextremity volume estimates: comparison of calculated volume derived from girth measurements and water displacement volume. Phys Ther. 2003;83: 134Y145. 7. Deltombe T, Jamart J, Recloux S, et al. Reliability and limits of agreement of circumferential, water displacement, and optoelectronic volumetry in the measurement of upper limb lymphedema. Lymphology. 2007;40:26Y34. 8. Gjorup C, Zerahn B, Hendel HW, et al. Assessment of volume measurement of breast cancer-related lymphedema by three methods: circumference measurement, water displacement, and dual energy X-ray absorptiometry. Lymphat Res Biol. 2010;8:111Y119. 9. Megens AM, Harris SR, Kim-Sing C, et al. Measurement of upper extremity volume in women after axillary dissection for breast cancer. Arch Phys Med Rehabil. 2001;82:1639Y1644.

11. Coriddi M, Khansa I, Sephens J, et al. Analysis of factors contributing severity of breast cancer-related lymphedema. Ann Plast Surg. 2015;74:22Y25. 12. Yamamoto T, Yamamoto N, Numahata T, et al. Navigation lymphatic supermicrosurgery for the treatment of cancer-related peripheral lymphedema. Vasc Endovasc Surg. 2014;48:139Y143. 13. Yamamoto T, Narushima M, Yoshimatsu H, et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014;72:67Y70. 14. Alitalo K. The lymphatic vasculature in disease. Nat Med. 2011;17: 1371Y1380. 15. Taylor HL, Tiede K. A comparison of the estimation of the basal cardiac output from a linear formula and the cardiac index. J Clin Invest. 1952;31:209Y216. 16. Peters AM, Howard B, Neilly MD, et al. The reliability of glomerular filtration rate measured from plasma clearance: a multi-centre study of 1878 healthy potential renal transplant donors. Eur J Nucl Med Mol Imaging. 2012;39: 715Y722. 17. Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be known. Nutrition. 1989;5:303Y311.

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Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation.

Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between dif...
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