THE DIAGNOSIS AND TREATMENT OF PERIPHERAL LYMPHEDEMA: 2016 CONSENSUS DOCUMENT OF THE INTERNATIONAL SOCIETY OF LYMPHOLOGY

Abstract

This International Society of Lymphology
(ISL) Consensus Document is the latest
revision of the 1995 Document for the
evaluation and management of peripheral
lymphedema (1). It is based upon modifications:
[A] suggested and published following
the 1997 XVI International Congress of
Lymphology (ICL) in Madrid, Spain (2),
discussed at the 1999 XVII ICL in Chennai,
India (3), and considered/ confirmed at the
2000 (ISL) Executive Committee meeting in
Hinterzarten, Germany (4); [B] derived from
integration of discussions and written
comments obtained during and following the
2001 XVIII ICL in Genoa, Italy as modified
at the 2003 ISL Executive Committee meeting
in Cordoba, Argentina (5); [C] suggested
from comments, criticisms, and rebuttals as
published in the December 2004 issue of
Lymphology (6); [D] discussed in both the
2005 XX ICL in Salvador, Brazil and the
2007 XXI ICL in Shanghai, China and
modified at the 2008 Executive Committee
meeting in Naples, Italy (7,8);[E] modified
from discussions and written comments from
the 2009 XXII ICL in Sydney, Australia, the
2011 XXIII ICL in Malmö, Sweden, the 2012
Executive Committee Meetings (9),and [F]
from discussions at the 2013 XXIV ICL in
Rome, Italy, and the 2015 XXV ICL in San
Francisco, USA, as well as multiple written
comments and feedback from Executive
Committee and other ISL members during
the 2016 drafting.
The document attempts to amalgamate
the broad spectrum of protocols and practices
advocated worldwide for the diagnosis and
treatment of peripheral lymphedema into a
coordinated proclamation representing a
“Consensus” of the international community
based on various levels of evidence. The
document is not meant to override individual
clinical considerations for complex patients
nor to stifle progress. It is also not meant to
be a legal formulation from which variations
define medical malpractice. The Society
understands that in some clinics the method
of treatment derives from national standards
while in others access to medical equipment
and supplies is limited; therefore the suggested
treatments might be impractical. Adaptability
and inclusiveness does come at the price that
members can rightly be critical of what they
see as vagueness or imprecision in definitions,
qualifiers in the choice of words (e.g., the use
of “may... perhaps... unclear”, etc.) and
mentions (albeit without endorsement) of
treatment options supported by limited hard
data. Most members are frustrated by the
reality that NO treatment method has really
undergone a satisfactory meta-analysis
(let alone rigorous, randomized, stratified,
long-term, controlled study). With this understanding,
the absence of definitive answers
and optimally conducted clinical trials,
and with emerging technologies and new
approaches and discoveries on the horizon,
some degree of uncertainty, ambiguity, and
flexibility along with dissatisfaction with
current lymphedema evaluation and management
is appropriate and to be expected.
We continue to struggle to keep the document
concise while balancing the need for depth
and details. With these considerations in
mind, we believe that this 2016 version
presents a Consensus that embraces the entire
ISL membership, rises above national
standards, identifies and stimulates promising 

areas for future research, and represents the
best judgment of the ISL membership on how
to approach patients with peripheral lymphedema
in the light of currently available
evidence. Therefore, the document has been,
and should continue to be, challenged and
debated in the pages of Lymphology (e.g., as
Letters to the Editor) and ideally will remain a
continued focal point for robust discussion at
local, national and international conferences
in lymphology and related disciplines. We
further anticipate as experience evolves and
new ideas and technologies emerge that
this “living document” will undergo further
periodic revision and refinement as the
practice and conceptual foundations of
medicine and specifically lymphology change
and advance.