Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 5 , Pages 803-809, May 2009

Validity for the Simplified Water Displacement Instrument to Measure Arm Lymphedema as a Result of Breast Cancer Surgery

  • Åse Sagen, PT, MS

      Affiliations

    • Department of Breast and Endocrine Surgery, Ullevaal University Hospital, Oslo, Norway
    • Corresponding Author InformationReprint requests to Åse Sagen, PT, MS, Cancer and Surgical Division, Ullevaal University Hospital, Kirkeveien 166, 0407 Oslo, Norway
    • ,
  • Rolf Kåresen, MD, PhD

      Affiliations

    • Department of Breast and Endocrine Surgery, Ullevaal University Hospital, Oslo, Norway
    • ,
  • Per Skaane, MD, PhD

      Affiliations

    • Department of Radiology, Ullevaal University Hospital, Oslo, Norway
    • ,
  • May Arna Risberg, PT, PhD

      Affiliations

    • Norwegian Research Center for Active Rehabilitation, Orthopedic Center, Ullevaal University Hospital, Oslo, Norway

Article Outline

Abstract 

Sagen Å, Kåresen R, Skaane P, Risberg MA. Validity for the Simplified Water Displacement Instrument to measure arm lymphedema as a result of breast cancer surgery.

Objectives

To evaluate concurrent and construct validity for the Simplified Water Displacement Instrument (SWDI), an instrument for measuring arm volumes and arm lymphedema as a result of breast cancer surgery.

Design

Validity design.

Setting

Hospital setting.

Participants

Women (N=23; mean age, 64±11y) were examined 6 years after breast cancer surgery with axillary node dissection.

Interventions

Not applicable.

Main Outcome Measures

The SWDI was included for measuring arm volumes to estimate arm lymphedema as a result of breast cancer surgery. A computed tomography (CT) scan was included to examine the cross-sectional areas (CSAs) in square millimeters for the subcutaneous tissue, for the muscle tissue, and for measuring tissue density in Hounsfield units. Magnetic resonance imaging (MRI) with T2-weighted sequences was included to show increased signal intensity in subcutaneous and muscle tissue areas.

Results

The affected arm volume measured by the SWDI was significantly correlated to the total CSA of the affected upper limb (R=.904) and also to the CSA of the subcutaneous tissue and muscles tissue (R=.867 and R=.725), respectively (P<.001). The CSA of the subcutaneous tissue for the upper limb was significantly larger compared with the control limb (11%). Tissue density measured in Hounsfield units did not correlate significantly with arm volume (P>.05). The affected arm volume was significantly larger (5%) than the control arm volume (P<.05). Five (22%) women had arm lymphedema defined as a 10% increase in the affected arm volume compared with the control arm volume, and an increased signal intensity was identified in all 5 women on MRI (T2-weighted, κ=.777, P<.001).

Conclusions

The SWDI showed high concurrent and construct validity as shown with significant correlations between the CSA (CT) of the subcutaneous and muscle areas of the affected limb and the affected arm volume (P>.001). There was a high agreement between those subjects who were diagnosed with arm lymphedema by using the SWDI and the increased signal intensity on MRI, with a kappa value of .777 (P<.001). High construct validity for the SWDI was confirmed for arm lymphedema as a volume increase, but it was not confirmed for lymphedema without an increase in arm volume (swelling). The SWDI is a simple and valid tool for estimating arm volume and arm lymphedema after breast cancer surgery.

Key Words: Breast neoplasms, Cancer, Rehabilitation

List of Abbreviations: ALE, arm lymphedema, BMI, body mass index, CSA, cross-sectional area, CT, computed tomography, HU, Hounsfield unit, mm2, square millimeter, MRI, magnetic resonance imaging, SI, signal intensity, SWDI, Simplified Water Displacement Instrument

 

ARM LYMPHEDEMA CAN BE defined as a chronic swelling of the limb predominantly caused by an impairment of lymph drainage,1 described as a secondary lymphedema,2 and is a well-known severe complication after breast cancer surgery with axillary node dissection.3 ALE can involve considerable pain and disability during activities of daily living.4, 5 Although the incidence of severe ALE has decreased because of less radical surgical methods,6 the incidence of mild edema appears to be increasing.7 The reported incidence of ALE after breast cancer surgery varies from 6%8 to 80%9 and can occur weeks or years after surgery.10 Variations in the reported incidence of ALE are partly caused by a lack of agreement on how to define ALE,11 the use of different measurement techniques, and differences in the reported follow-up time after breast cancer surgery.12, 13, 14, 15 Reliable and valid assessment tools for ALE are necessary for diagnosing, monitoring, and comparing treatment responses.16

Several measurement techniques have been used to evaluate ALE by measuring differences in the involved arm size compared with the uninvolved arm size after breast cancer surgery.13, 17, 18 The water displacement method has been recognized as the criterion standard for measuring the degree of swelling in arm lymphedema.16, 18, 19 However, the validity of the water displacement method needs to be examined because of the inability of the method to distinguish between changes in arm volume caused by changes in subcutaneous tissue or changes in muscle tissue. Lymphedema can also be confirmed through imaging modalities, including CT scans and MRI.20, 21 These methods can identify changes in subcutaneous tissue and muscle tissue. CT scans have been used for measuring the CSA in mm2 for muscle and subcutaneous tissues and for measuring tissue density (water content) by HUs.22 Furthermore, MRI has been reported to evaluate ALE20, 21, 23 by using increased SI on T2-weighted images. Increased water content in muscles and subcutaneous tissues is clearly shown on MRI by its brightness and thus shows edema.24, 25

A 10% increase in the affected arm volume compared with the control arm volume after breast cancer surgery has been reported to be the cutoff value for the diagnosis of ALE.1, 18 The 10% increase in arm volume as a result of breast cancer surgery is meant to reflect an increased water content24 in the subcutaneous tissue.20, 21, 23 However, changes in arm volume can also represent changes in muscle tissue.

A new water displacement technique, the SWDI, was developed by our group for examining arm volume and changes in arm volume after breast cancer surgery. The SWDI has been shown to be highly reliable,26 time sparing, and easy to handle and transport. Water displacement instruments have previously been evaluated for reliability and concurrent validity (circumferential measurements),16, 19, 26, 27 but to our knowledge the method has not been evaluated for its construct validity for ALE after breast cancer surgery.

Therefore, the objective of this study was to evaluate not only concurrent but also construct validity for the SWDI as a result of breast cancer surgery by using CT scans and MRI. We hypothesized that arm volume measured with the SWDI would correlate highly to the total CSA of the affected limb. Furthermore, we hypothesized that arm volume measured with the SWDI would correlate highly to the CSA of the subcutaneous tissue of the affected arm. Finally, we hypothesized that arm volume measured with the SWDI would be highly correlated to tissue density (HUs) by using CT scans and to SI by using MRI T2-weighted images.

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Methods 

Participants 

Twenty-three women aged 48 to 82 (mean, 64±11) years who all underwent axillary node dissection level I and II and mastectomy or breast-conserving surgery for early-stage breast cancer in 1999 were included 6 years after surgery. Fourteen women had gone through surgery on the dominant side and 9 women on the nondominant side. Twenty-two women were right-handed, and 1 woman was left-handed. The mean BMI (kg/m2) was 25±4.4 (minimum, 17; maximum, 36). The women were asked to enter the study after a consecutive sample from an ongoing randomized controlled trial for evaluating ALE after breast cancer surgery at Ullevaal University Hospital, Oslo, Norway.28 All the patients have been closely followed regarding the development of ALE since 1999, and 6 of the participants in this study have been previously treated for ALE. Informed consents were given before participating in the examinations. The regional committee for medical research ethics approved the study.

Measurements 

Arm volumes (mL) for affected and control limbs were measured by using the SWDI26 (fig 1A–C). The method is simplified compared with traditional water displacement methods by the use of a stop/reduction valve to level off the overflow of water as the limb immerges slowly into the fulfilled cylinder. When the limb is immerged (to the armpit) into the cylinder and it is completely filled (water level is equal to the top of the cylinder, which has a height of 735mm), the tap is closed (see fig 1A). The limb is then removed, and the difference in water level with and without the limb represents the arm volume (mL) (see fig 1B). The high reliability of the instrument was gained by 2 factors26: first, because of its simplicity; there is not a loss of water caused by spillage or to be weighed or measured outside the cylinder. Second, the water surface level on the limb at the fully filled cylinder was marked with a felt pen on the skin (see fig 1C). The measurement of the length of the limb between the lateral epicondyle and the water surface mark was recorded (see fig 1C). Thus, the exact length for the measurement of the limb was controlled for subsequent measurements and with comparison to the contralateral limb (see fig 1C). ALE was defined as a 10% increase in the affected limb compared with the control limb volumes ([affected – control/control] × 100).18

CT (Brilliance 64)a was used to calculate the CSA and tissue density for the forearm and upper arm for the affected and control limbs (fig 2A). A CT spiral scanner was used to achieve the exact CT scan level for the affected and control arm. The matching images, 1 pair from the middle (and thickest part) for the upper arm and 1 pair for the middle (and thickest part) of the forearm, were selected (see fig 2A). The women were precisely positioned to avoid discrepancy in positioning of the shoulder/elbow angle between the affected and the control side between CT scans and MRI and between the participants lying in a supine position with the arm as straight as possible along the side with the hand palms to the calf (see fig 2A). Discrepancies and problems with holding the elbow in full extension have small effects on the CSA calculations, 1% at 8°, 2% at 11.5°, and 3.5% at 15°. Both CSAs and CT density of the selected images were measured by using the CT computer. The circumference of the whole limb, the muscle area, and the bones were traced by using a digitizer pen linked to the CT computer to measure the subcutaneous area (S), the total area (T), and the muscle area (M) in mm2 (S = T – [M + bone]) (fig 2B). Subcutaneous tissue density, using mean HUs, was measured from 3 areas for the upper arm (area 1, 2, 3): 2 lateral (1 caudal and 1 cranial) and 1 medial (see fig 2B). The mean HUs for the forearm was measured from 2 lateral areas (1 caudal and 1 cranial) (see fig 2B). The attenuation value of water is 0 and the attenuation values of subcutanous tissue about –120, but the range is wide and standardized measurement values have been reported to be between –190 and –30, depending on the scanning device, body localization, and individual differences.29, 30

MRI (Intera Release 11, 1.5T)a was performed by T2-weighted images (T2 STIR: thickness of slices: 7mm, 10 slices, gap: 0.7mm, TR: shortest; 1570ms, TE: 70ms, Fov: 400, Rfov: 60, Matrise: 256/256, NSA: 5, TSE factor: 12, scan %: 80) to detect water content by increased SI. Based on the study protocol, the MRI images were taken in the area of the limb where it is most likely to detect ALE (the thickest parts) with 1 scan for the upper arm at armpit level and 1 scan for the middle forearm for the affected and control limbs (see fig 2A). An experienced radiologist (P.S.) who was masked to information regarding which side that was affected, BMI, and other patient characteristics evaluated the SI as increased or not (yes or no) in subcutaneous tissue and muscle tissue area of the MRI images.

Statistical Analysis 

Data were analyzed by using the software program SPSS 11.0b; t tests were used to detect significant differences between the affected and control limbs. Concurrent validity was evaluated by using Pearson correlation coefficients between arm volume in mL (SWDI) and CSA (CT) in mm2. Construct validity was evaluated by using Pearson correlation coefficients between arm volume in mL (SWDI) and CSA (CT) in mm2 for both subcutaneous tissue and muscle tissue. Furthermore, the Pearson correlation coefficient was used to evaluate the relationship between arm volume in mL (SWDI) and tissue density by HUs (CT density). Construct validity was also evaluated by using the kappa coefficient for evaluating the agreement between the subjects with ALE (10% increase in arm volume using the SWDI) and the subjects with increased SI (MRI).

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Results 

The correlation coefficient between arm volume (SWDI) and the total CSA for the upper arm was .904 (P<.001) (table 1, fig 3A). The correlation coefficients between arm volume and the CSA for the subcutaneous and muscle tissues for the upper arm were .867 and .725, respectively (P<.001) (see table 1, fig 3B). For the forearm, the correlation coefficients between arm volume, subcutaneous tissue area, and muscle tissue areas (CSA) were .501 (P<.002) and .182 (nonsignificant), respectively (see table 1). The CSA of the subcutaneous tissue of the affected upper arm was 4705±1619mm2 and significantly larger (11%) than the CSA of subcutaneous tissue in the control upper limb (4250±1284mm2, P<.001) (table 2). The CSA of the subcutaneous tissue for the affected forearm was 1772±631mm2 and significantly larger (11%) than the control forearm (1578±728mm2, P<.05) (see table 2). The CSA of the muscle tissue in the affected limb was 2537±455mm2 and showed a 1% larger affected upper-arm area compared with the control limb area (2521±558mm2) and a 2% larger affected forearm area (2444±289mm2) compared with the control limb area (2398±371mm2, nonsignificant) (see table 2).

Table 1. R and P Values for the Affected Limb Between Arm Volume (SWDI) and CT Measurements of CSA and HU
RP
Total CSA (CT).904.001⁎
CSA subcutaneous tissue (CT)
Upper arm.867.001⁎
Forearm.501.002⁎
CSA muscle tissue (CT)
Upper arm.725.001⁎
Forearm.182.406
HU (CT density)
Upper arm−.058.792
Forearm−.093.674

⁎P<.05.

  • View full-size image.
  • Fig 3. 

    SI in MRI T2-weighted images in the affected forearm (B) and the upper arm (C) with the corresponding control limbs (A and D). Upper images: increased SI in the (B) affected forearm in the subcutaneous tissue area visualizing a “honeycomb pattern.” (B) There is also skin edema. (A) The control limb. Lower images: increased SI in the (C) affected upper arm in the subcutaneous tissue area and (C) a considerable skin edema. (D) The control limb.

Table 2. Difference Between Affected and Control Limbs for Arm Volume (SWDI) and CT Measurements of CSAs and HU
Participants (N=23)AffectedControlDifference (%)P
SWDI volume (mL)2484±5682363±475121±270(5).030⁎
CSA subcutaneous tissue (mm2)
Upper arm4705±16194250±1284455±98(11).001⁎
Forearm1772±6311578±728194±90(11).044⁎
CSA muscle tissue (mm2)
Upper arm2537±4552521±55816±242(1).768
Forearm2444±2892398±37146±193(2).269
Density (HU)
Upper arm–117±7.1–116±5.9 .450
Forearm–129±10.4–129±9.7 .886

NOTE. Values are mean ± SDs unless otherwise indicated.

⁎t tests, P<.05.

The correlation coefficients between arm volume (SWDI) and tissue density measured by HUs were –.058 for the upper arm and –.093 for the forearm (see table 1). There was no significant difference in HUs between the affected limb and the control limb for the CSA of the subcutaneous tissue. The HU for the affected upper arm was –117±7, and, for the control upper arm, it was –116±6 (see table 2). The HU for the affected forearm was –129±10, and, for the control forearm, it was –129±10 (see table 2).

The MRI images showed an increased SI in the affected upper arm for 7 of the 23 women, but no increased SI was found in the control limbs. Five of these 7 women had ALE (κ=.777, P<.001) (table 3). All 7 women had increased SI in the subcutaneous tissue area and no increased SI in the muscle tissue area (see table 3). No women had ALE without increased SI. The 2 women with the strongest SI also had a marked skin edema (see fig 3B, 3C).

Table 3. Measure of Agreement, Kappa, Between Increased SI (MRI T2-Weighted) and Arm Lymphedema, ALE (SWDI)
ALETotal (N=23)
NoYes (%)
SI (MRI T2 weighted)
No16016
Yes257
Total (N=23)185 (22)23

NOTE. κ=.777 (P<.001).

There was a significant increased arm volume for the affected limb compared with the control limb, with a difference in volume of 121±270mL, indicating a 5% larger arm volume for the affected limb compared with the control limb (P<.05) (see table 2).

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Discussion 

Our first hypothesis was confirmed by the high correlation coefficient between the total CSA and the arm volume, indicating good concurrent validity (R=.904, P<.001) (see table 1, fig 4A). The second hypothesis was also confirmed by the fact that the CSA of subcutaneous tissue in the upper arm highly correlated with arm volume (R=.867, P<.001) and also that the CSA of the muscle tissue in the upper arm highly correlated with arm volume (R=.725, P<.001), indicating good construct validity (see table 1, fig 4B). Finally, good construct validity was also shown for the SWDI, showing high agreement, with a κ coefficient of .777 (P<.001), between those subjects with defined ALE and those subjects with increased SI on the MRI T2-weighted images (see table 3). However, the arm volume measurements taken by using the SWDI did not correlate with the tissue density (HUs) (see table 1).

  • View full-size image.
  • Fig 4. 

    (A) Correlation between arm volume (SWDI) on the affected side and total CSA of the affected upper arm. (B) Correlation between arm volume (SWDI) on the affected side and CSA of subcutaneous tissue of the affected upper arm.

The CT results for the total CSA, subcutaneous tissue, and muscle tissue of the limb correlated highly with the SWDI volume (see table 2, fig 4A, B). These results confirmed a good concurrent and construct validity. Similarly, circumferential measurements of the limbs taken by using tape measurements have previously shown good concurrent validity by high correlations between arm volume, when using the water displacement method, and arm circumferential measurements.16, 27, 31 The good construct validity results correspond with the findings of Collins et al21 who also found the greatest differences between the swollen limb and the control limb after breast cancer surgery in the subcutaneous tissue area. Furthermore, it has been shown that the aspirated edema from subcutaneous tissue in patients with ALE after breast cancer surgery contained 93% adipose tissue.23 The CSA of the subcutaneous tissue of the affected upper limb and forearm was significantly larger (11%) compared with the control limb (P<.05) (see table 2). The correlation between the affected arm volume and the CSA of the muscle tissue was lower than for the correlation between the arm volume and the CSA of the subcutaneous tissue (see table 1). Furthermore, there were no significant differences between the CSA of the muscle tissue of the affected limb compared with the control limb (1%–2%) (see table 2). Similar results for the CSA of the muscle tissue between the affected limb and the control limb have been shown previously both in patients with primary and secondary lymphedema of the upper limbs.21, 32 This indicates that the recorded increase in arm volume after breast cancer surgery reflects an increased area of the subcutaneous tissue and does not reflect changes in the muscle tissue. These results clearly showed that the SWDI is a valid measurement for examining increased arm volume as an increase primarily in the subcutaneous tissue after breast cancer surgery and not a false low arm volume masked by a decrease in muscle tissue because of muscle atrophy.

The CT-density data (HUs) did not correlate well with arm volume (SWDI) (P>.05) (see table 1). The results did not confirm our hypothesis that arm volume was highly correlated with tissue density measured by HUs. Subcutaneous tissue density in lymphedema limbs has been reported by Collins21 to decrease after treatment with bandaging from –70 to –120, similar results as for normal limbs. The results from Collins were based on women with untreated and severe ALE after breast cancer surgery of at least 20% difference between swollen and control limbs. Our subjects with ALE had been previously treated for ALE, and only 5 women in our study had ALE, which was defined as a 10% increase in arm volume between affected and control limbs (see table 3). Our results showed similar values for HUs in ALE patients as compared with normal limbs (see table 2) and similar data to the treated ALE patients in the study by Collins. The use of HUs (CT density) was obviously not an appropriate measurement for distinguishing ALE and previously ALE-treated limbs from control limbs. The small difference in HUs between the upper limb and forearm and the large SD, both in the affected limb and the control limb, might partly be caused by the artifacts from bones in the forearm30 (see table 2).

The MRI results showed that increased SI was only present in the affected limbs (see table 3, fig 3). Two of the women with the highest SI had the largest arm volume and the highest BMI and were the 2 patients with skin edema (see figs 3B, 3C). SI measured by using T2-weighted MRI has previously been reported for subcutaneous tissue in patients with lymphedema,24 but increased SI from MRI for the muscle tissue has also been described in patients with primary lymphedema in the leg.25 The increased SI that was observed in our 7 patients corresponded to the 5 women with ALE (10% increase in arm volume using the SWDI) and 2 more women who had been previously successfully treated for ALE (see table 3). There was a high agreement between those subjects who were diagnosed with ALE by using the SWDI and the increased SI on MRI, with a kappa value of .777. The kappa value is preferably used to describe the corrected proportional agreement and the best approach when only 2 categories are used and when the prevalence of the categories does not differ much, as in our results.33 The presence of increased SI without ALE could be caused by subclinical states of lymphatic impairment symptoms without swelling, as described in the literature about the complexity of defining lymphedema.2, 34

The affected arm volume (SWDI) was 5% larger than the control arm volume (P<.05) (see table 2). The right dominant limb has been reported to be 3.3% larger in a previous study with healthy individuals.26 Our study population had a similar incidence of ALE as in previous studies7, 35, 36 and should therefore be considered a representative sample for individuals having gone through breast cancer surgery including axillary node dissection, although the study sample is small.

This is the first study to report construct validity data for the water displacement method. Our study showed that both the CSA measured by CT and the SI measured by MRI identified differences in subcutaneous tissue between those with ALE and those without. Our results also indicated that MRI might have a potential for showing arm lymphedema in women with equivocal findings at SWDI. However, MRI has a tremendously higher cost.

In a previously published study by our group,26 we found the following reliability data: intratester variations over time of less than 3% and intertester variations of less than 2%.26 An increase in arm volumes of more than 3% between the affected and the control limbs can therefore be considered as real changes in arm volume. Furthermore, we have shown in a previously published randomized controlled trial28 with 3-month, 6-month, and 2-year follow-ups that the SWDI is sensitive to changes in arm volume over time. Thus, the SWDI has proved to be a simple, cost-effective, reliable, and valid instrument that can be used in rehabilitation to monitor changes in arm volume and the development of ALE after breast cancer surgery.

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Conclusions 

The SWDI showed good concurrent validity with a high correlation to the CSA (CT) of the affected limb (R=.904, P<.001). Good construct validity for the SWDI was also confirmed by the high correlation to the CSA (CT) for subcutaneous tissue and muscle tissue (R=.867 and R=.725, P<.001) and by the increased SI (T2-weighted MRI) in all subjects with ALE (defined as a 10% increase in affected arm volume in mL compared with control arm volume). There was a high agreement between those subjects who were diagnosed with ALE by using the SWDI and the increased SI on MRI, with a κ value of .777 (P<.001). The SWDI is a simple and valid tool for estimating arm volume and ALE after breast cancer surgery.

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Acknowledgements 

We thank Lena Korsmo and Nina Bhargava, Department of Radiology, Ullevaal University Hospital, Oslo, for their assistance with performing the CT and MRI examinations.

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  • a Philips Healthcare, PO Box 10,000, 5680 DA Best, The Netherlands.
  • b SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

 Supported by the Health and Rehabilitation, the Norwegian Cancer Society, and The Norwegian Women's Public Health Association.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

PII: S0003-9993(09)00134-8

doi:10.1016/j.apmr.2008.11.016

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 5 , Pages 803-809, May 2009

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