Integrating Bioimpedance Spectroscopy: Streamlining Early Lymphedema Detection

For oncology clinicians, lymphedema has long been a challenging, often irreversible complication that is frequently detected only after clinical symptoms manifest. At Virginia Commonwealth University (VCU) Massey Cancer Center, a new multidisciplinary approach is shifting the paradigm from symptom management to early detection and prevention through the integration of L-Dex bioimpedance spectroscopy. By measuring the resistance of electrical signals through body tissues to quantify extracellular fluid, bioimpedance spectroscopy allows providers to identify subclinical changes months or even years before they are visible to the naked eye.

In this interview with CancerNetwork®, Kandace P. McGuire, MD, professor of surgery and chief of breast surgery, and Paschalia Mountziaris, MD, PhD, assistant professor of surgery in the Division of Plastic and Reconstructive Surgery at VCU Massey Cancer Center, discuss the seamless integration of this technology into standard vitals workflows. They explore how longitudinal monitoring—from preoperative baselines to multi-year follow-ups—is facilitating earlier referrals to physical therapy and enabling advanced physiologic interventions like prophylactic lymphovenous bypass. From addressing the diagnostic hurdles in high-body mass index (BMI) populations to utilizing electronic medical records (EMR)-automated alerts for abnormal values, VCU Massey’s experts outline a roadmap for improving long-term survivorship outcomes through proactive lymphatic care.

CancerNetwork: Briefly, can you explain why lymphedema is detected late, and, traditionally, what it takes to manage its symptoms?

McGuire: If we want to break it down into the simplest terms, it is swelling of an extremity or swelling somewhere within the body, and that is due to lymphatic obstruction. Beyond the circulatory system, we have the lymphatic system that collects fluid from the extracellular fluid in the body and then dumps it into the vascular system. Normally, it works incredibly well. Some patients, whether it’s a primary lymphedema, meaning it happens just because, and it’s probably idiopathic, or it’s due to some form of an injury, whether it’s a lymph node dissection, radiation, anything along those lines, it obstructs the lymphatics, and wherever it obstructs those lymphatics, you are going to experience swelling within that limb. The reason it can be delayed is that it takes some time for those changes to occur. Especially when we are talking about lymphedema associated with breast cancer surgery, even something as small as a sentinel lymph node biopsy can cause some damage in that area, and then the additive effect of radiation can also cause some obstruction, and then over time, that minute amount of obstruction will cause symptoms. For some patients, that will happen sooner, but for many patients, it can happen months to years down the road.

What is bioimpedance spectroscopy? How does it detect lymphedema? Why is it beneficial, or a good addition to VCU Massey’s arsenal of tools?

McGuire: Bioimpedance spectroscopy is the use of a small electrical signal that measures “bioimpedance”. What that means is looking at the impedance of tissue to the transit of that electrical signal from one place to another. In the early years, it was done with old school EKG leads, where the impedance was measured between the leads. Now, with new technology, it’s similar to those body composition scales you see that people use, where you are putting your bare feet on one part of the unit, and your ungloved hands on one part of the unit, and then it’s measuring the transit of that signal from your hands to your feet, vice versa. The longer it takes the signal to get from one point to the other, the more fluid there is in the body, and the more likely it is that a patient’s going to experience lymphedema.

What clinical protocols have you/VCU Massey established to integrate this technology into the standard workflow? When do you record these measurements post-operatively?

McGuire: It’s a well-established workflow through multiple clinical trials, and any of the companies that create these bioimpedance machines will help you establish that. What we want to do is get a measurement pre-operatively, because everyone’s going to have a different baseline of natural bioimpedance within their body. When a patient first presents to our clinic, we are going to evaluate them, decide what surgery they are going to need, and if it’s lymphatic surgery as part of their treatment, or radiation to the lymphatic [system]. Then, before that treatment, they will get a baseline measurement. They are then measured postoperatively, and then every 3 months for the first 3 years, every 6 months for the next 2 years, and then yearly thereafter. That mimics the rapidity and the likelihood of developing lymphedema. It’s an easy process and can be done through a nursing visit. Despite the fact that it’s more frequent than those first 3 years, patients are not having a medical visit attached to that, and a copay attached to that; it’s just going to be that measurement.

Notably, the bioimpedance readings are taken alongside standard vitals. How has this streamlined approach impacted workflow/patient experience, and what training was required for the nurses or other multidisciplinary staff administering these tests?

McGuire: It’s integrated, thus far, seamlessly into our standard vitals measurement system. The surgeon or the treating physician will enter an order, and when our medical assistants are checking patients in, they will see that order is there. The scale and the blood pressure machine are sitting right there, and then they just have to step over one and hop on the bioimpedance machine to have that measurement done. It adds about 2 minutes to the check-in process. In terms of training, we did have some fairly extensive training for the medical assistants and the nurses who are going to be managing a lot of the day-to-day of this, and then the physicians, we had a very simple, sort of 30-minute webinar with some supporting documents that got them up and running. It’s been an easy process to implement.

Along the same lines, what was the experience integrating this technology into the workflow, logistically? What care providers does this impact most heavily?

McGuire: For us, in the short term, we are working out how this will be implemented. We may see a few more preoperative visits, because patients are going to be strong and desirous of getting the measurement done. It does require pre-authorization, so if that cannot be done that day, they may need to come back. What I see is that it’s simplifying the process of identifying lymphedema so that we do not have to wait for the patient to have symptoms, because at that point, it’s largely irreversible. It’s manageable at that point. It’s helping us identify things earlier and in a more streamlined and easier process, rather than doing measurements with a tape measure or sending somebody to physical therapy. It’s going to help us have that alarm button way faster and easier than we normally would, which is going to allow us to get them to occupational or physical therapy as soon as possible, and if they have persistent symptoms, then get them to our plastic surgeons to talk about lymphedema surgery.

Mountziaris: As one of the main providers here at VCU who does lymphedema surgery, including lymphedema surgery at the time of axillary lymphadenectomy, with the goal of preventing lymphedema from ever setting in, lymphedema can be subtle in its presentation. Having one more noninvasive method to quantify things and either provide reassurance to a patient that what is going on is not lymphedema, or to identify it and treat it, or just for me to get feedback on how we are doing in terms of the surgeries that I do, and helping to improve lymphedema. It’s just a valuable tool for us, the providers, for our continuous learning and improvement of the care that we provide, also for us to help advise the patients of their risks and what's going on.

Are there any subsets of patients who benefit more from this technology?

McGuire: I would suspect our patients who are still having axillary lymph node dissections are the patients who are at extraordinarily high risk for lymphedema. Axillary lymph node dissection has been associated with as much as a 35% to 40% risk of lymphedema. In some studies, when you partner that with radiation, it can go even higher. Now we do preventative, lymphovenous bypass to try to bring those numbers back down to hopefully, as close to single digits as possible, but our patient population will be targeting the most with this technology, because they are the ones who are most likely to benefit from it.

Mountziaris: It’s the patients with early-stage lymphedema where it’s more of a subtle difference if you were measuring the limb girth, not these patients with the [obvious lymphedema]. That’s where it’s valuable, because there are, in addition to the preventative things that we do at the time of axillary lymphadenectomy, additional adjuncts that we could add, so identifying and monitoring disease progression can help us to add those adjuncts in an earlier fashion.

For patients with higher BMI, it might be harder to detect lymphedema. Is there a way this technology might have an added benefit for this population?

McGuire: Not only do they have a higher risk of lymphedema at baseline, but it is more difficult to detect with things like measurements, because their limbs may be a bit larger at baseline, and in terms of symptoms, they are not going to visually notice a difference as easily as somebody who may have a slimmer arm at baseline. Not only because of their risk, but also with their difficulty in actually identifying early symptoms, that’s going to be a patient population that [we are] interested to study and see if they benefit.

Mountziaris: We are in the south, and we have a higher proportion of obese patients just due to the location of our practice. On the flip side of that, some lymphedema surgeons have BMI cut-offs that are fairly low, like they will cut off at a body mass index of 30 or 35, which would cut out a significant fraction of our patients. As long as it’s safe to do the surgery, there's no reason for us to cut them out. If we include them, like Dr McGuire was saying, we want to be able to have a more nuanced way to detect what’s going on with them, just due to the challenges of having an increased amount of subcutaneous fat that may be masking what’s going on.

What are the specific threshold triggers (e.g., L-Dex unit change) that prompt a referral to occupational or physical therapy vs continued observation?

McGuire: The way that the measurements are, it’s hard to say what the threshold is. It’s a difference of [approximately] .59 or something like that. It’s not like it’s a cm difference. It’s a very specific number, depending on which machine you are using. The good thing about it is that the way that we have designed it is that it will alert in our electronic medical record system as an abnormal value. We do not need to remember what that number is. Not only will the printout sheet tell you that it’s abnormal, but the EMR is going to tell you it’s abnormal and prompt you to do a referral.

How is the communication between the breast surgery oncology team, the plastic/reconstructive team, and the physical rehabilitation specialists, especially when a patient flags for fluid changes?

McGuire: A lot of this is going to be automated, but the fantastic thing about our program is how collaboratively we work. We work to try to get patients at extraordinarily high risk for lymphedema, a prophylactic lymphovenous bypass. That communication has a lot to do with how we work together preoperatively and managing patients, managing their risk, figuring out who needs to have operations sooner than others, and who can wait so that they can have a joint case. When we have somebody with an abnormal value, we let somebody know verbally and through writing, but also through that EMR safety net, where that alert will come up with an order set to consult, to physical therapy, and plastic surgery, if we think it's indicated. It’s a 2-pronged approach. I do not think they have had too many abnormal values. Thank goodness, thus far, so we have not [fully] tested the process, but I could definitely let Dr Mountziaris talk about how that would be received on their end.

Mountziaris: We have excellent communication in terms of referrals of patients, like Dr McGuire was saying. If we have patients who we think are high risk, we will oftentimes be involved from the get-go and in consideration of doing a prophylactic, immediate lymphovenous bypass to try and reduce the risk or even prevent the onset of lymphedema. There’s a lot of postoperative care that happens in those patients. We have got our lymphedema therapists on board. We have got Dr McGuire's team. We have got myself, and they’ll also be following up with their oncologist. From my point, what I have always been doing is seeing them, monitoring how they are doing in terms of any breast reconstruction that I may have done, but also how they are doing in terms of their lymphedema treatment and their lymphedema care. There are patients that I will see longitudinally and keep writing those prescriptions for them to keep going with therapy. The nice thing about it being programmed in our system is, [it showing] this is abnormal, which is what happens when there’s an abnormal blood pressure reading that one of our medical assistants can measure and then [report] to whoever the provider is seeing that patient that day. Even if it’s a patient who has stopped following up with me in plastic surgery, we can get them plugged back in, or if it happens to be the rare patient that has not seen me at all, we can get them in and talk about options, if the surgery side of lymphedema care is what is needed.

Are there any recent advances in lymphedema care you are awaiting or looking forward to?

McGuire: Making the bioimpedance spectroscopy more accessible. Right now, it’s something where a patient still needs to go to a physician’s office. With these new scales, we see people using them at home. Would it not be fabulous if this were something a patient could do by themselves at home? That would be the way to get most patients screened most efficiently and get them to the right people as soon as possible.

Mountziaris: The sort of physiologic surgeries that we offer for lymphedema are all still considered new. Even as recent as 10 years ago, when I was a resident, we were still relying heavily on things like liposuctioning of large limbs, the Charles procedure, which is a very morbid procedure where you basically take off all the skin and subcutaneous fat down to the person’s fascia, and then skin graft the skin to the fascia, which gives its own deformity and in its own set of difficulties to the patient. Now we have moved to lymphovenous bypass to try and even prevent lymphedema. [We have done a] free-tissue transfer that includes moving lymph nodes to the site where the lymph nodes were removed, or even, in some cases, right onto the extremity in the site where we think that the blockage is based on our mapping of the lymph node. These are all things that was in the past 5 to 6 years have gained frequency and traction but are still only offered at major cancer centers. We are privileged that Dr McGuire and I have a great team and that I have the equipment that we’re able to provide these things for our patients. From my standpoint, some of these patients appear, to me and by measurements and everything else, to have been cured of their lymphedema after these interventions. Getting an L-Dex score on them is just another way to demonstrate that we did bring them to stage 0 or no lymphedema.

Reference

VCU Massey now offers new technology for early detection of lymphedema. News release. December 8, 2025. Accessed December 23, 2025. https://tinyurl.com/2ktfzf5k