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Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs.

Mihara M, Hara H, Araki J, Kikuchi K, Narushima M, Yamamoto T, Iida T, Yoshimatsu H, Murai N, Mitsui K, Okitsu T, Koshima I - PLoS ONE (2012)

Bottom Line: In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography.These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema.ICG lymphography showed a dermal backflow pattern in these cases.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic Surgery and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan. mihara@keiseigeka.name

ABSTRACT

Background: Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography.

Patients and methods: Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis.

Results: The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases.

Conclusions: Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

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Related in: MedlinePlus

ICG lymphography findings in Case 3.Two linear patterns (LP) were noted in the wrist. A splash pattern (SP) was observed in the lateral forearm over the upper arm. Diffuse (DP) and splash patterns were mixed in some regions of the medial upper arm.
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pone-0038182-g002: ICG lymphography findings in Case 3.Two linear patterns (LP) were noted in the wrist. A splash pattern (SP) was observed in the lateral forearm over the upper arm. Diffuse (DP) and splash patterns were mixed in some regions of the medial upper arm.

Mentions: The patient in Case 3 was a 55-year-old woman who underwent mastectomy, axillary lymph node dissection, and chemotherapy and radiotherapy (45 Gy) for right breast cancer 12 years ago. Lymphedema had appeared in the right upper limb 2 years ago and slowly aggravated. Conservative treatment with lymph massage and elastic stockings was used from immediately after the appearance of lymphedema, but edema was not remitted. A physical examination revealed enlargement of the circumference of the right upper extremity by +1.5 cm at the upper arm, +1.0 cm at the elbow, +1.0 cm at the forearm, and +0.5 cm at the wrist, compared to the left upper extremity (Figure 1a,b). Pitting edema was noted in the forearm and medial upper arm. On preoperative lymphoscintigraphy, dermal backflow was noted in the right upper arm over the forearm, compared to normal lymph flow in the healthy left arm, showing mild lymphatic circulatory disorder (Figure 1c). In ICG lymphography (Figure 2, Video S1), several vivid dynamic images of a superficial lymphatic flow pattern in the wrist area were obtained within a few minutes after injection. A splash pattern indicating mild-damaged lymph flow was present in the right forearm and upper arm. A diffuse pattern indicating severely damaged lymph flow was present in the right medial upper arm. As a normal control, ICG lymphography image of contralateral side is shown in Video S2. On MRI, fluid retention was noted in the fat layer of the forearm and medial upper arm. On CT, partial mild fibrosis was apparent in the fat layer of the medial upper arm.


Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs.

Mihara M, Hara H, Araki J, Kikuchi K, Narushima M, Yamamoto T, Iida T, Yoshimatsu H, Murai N, Mitsui K, Okitsu T, Koshima I - PLoS ONE (2012)

ICG lymphography findings in Case 3.Two linear patterns (LP) were noted in the wrist. A splash pattern (SP) was observed in the lateral forearm over the upper arm. Diffuse (DP) and splash patterns were mixed in some regions of the medial upper arm.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3366958&req=5

pone-0038182-g002: ICG lymphography findings in Case 3.Two linear patterns (LP) were noted in the wrist. A splash pattern (SP) was observed in the lateral forearm over the upper arm. Diffuse (DP) and splash patterns were mixed in some regions of the medial upper arm.
Mentions: The patient in Case 3 was a 55-year-old woman who underwent mastectomy, axillary lymph node dissection, and chemotherapy and radiotherapy (45 Gy) for right breast cancer 12 years ago. Lymphedema had appeared in the right upper limb 2 years ago and slowly aggravated. Conservative treatment with lymph massage and elastic stockings was used from immediately after the appearance of lymphedema, but edema was not remitted. A physical examination revealed enlargement of the circumference of the right upper extremity by +1.5 cm at the upper arm, +1.0 cm at the elbow, +1.0 cm at the forearm, and +0.5 cm at the wrist, compared to the left upper extremity (Figure 1a,b). Pitting edema was noted in the forearm and medial upper arm. On preoperative lymphoscintigraphy, dermal backflow was noted in the right upper arm over the forearm, compared to normal lymph flow in the healthy left arm, showing mild lymphatic circulatory disorder (Figure 1c). In ICG lymphography (Figure 2, Video S1), several vivid dynamic images of a superficial lymphatic flow pattern in the wrist area were obtained within a few minutes after injection. A splash pattern indicating mild-damaged lymph flow was present in the right forearm and upper arm. A diffuse pattern indicating severely damaged lymph flow was present in the right medial upper arm. As a normal control, ICG lymphography image of contralateral side is shown in Video S2. On MRI, fluid retention was noted in the fat layer of the forearm and medial upper arm. On CT, partial mild fibrosis was apparent in the fat layer of the medial upper arm.

Bottom Line: In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography.These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema.ICG lymphography showed a dermal backflow pattern in these cases.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic Surgery and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan. mihara@keiseigeka.name

ABSTRACT

Background: Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography.

Patients and methods: Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis.

Results: The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases.

Conclusions: Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

Show MeSH
Related in: MedlinePlus