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

Makoto Mihara, Hisako Hara, Jun Araki, Kazuki Kikuchi, Mitsunaga Narushima, Takumi Yamamoto, Takuya Iida, Hidehiko Yoshimatsu, Noriyuki Murai, Kito Mitsui, Taro Okitsu, Isao Koshima, Makoto Mihara, Hisako Hara, Jun Araki, Kazuki Kikuchi, Mitsunaga Narushima, Takumi Yamamoto, Takuya Iida, Hidehiko Yoshimatsu, Noriyuki Murai, Kito Mitsui, Taro Okitsu, Isao Koshima

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.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Case 3.
Figure 1. Case 3.
(a, b) Edematous condition before LVA. Compared to the healthy side (left), the circumferences were increased by 1.5, 1.0, 1.0, and 0.5 cm for the upper arm, elbow, forearm, and wrist, respectively. (c) Findings from lymphoscintigraphy. Reflux in the skin (dermal backflow) was observed in the medial and lateral upper arm and lateral forearm in the right upper limb. A normal lymph vessel distribution was apparent in the left upper limb.
Figure 2. ICG lymphography findings in Case…
Figure 2. 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.
Figure 3. Case 3.
Figure 3. Case 3.
Collecting lymph vascular endothelial cells in (a) linear pattern (LP), (b) splash pattern (SP), and (c) diffuse pattern (DP) areas. Regions in which endothelial cells were detached are indicated with red arrows. (d) ‘Contractile’ smooth muscle cells in (d) LP, (e) SP, and (f) DP areas. The space between smooth muscle cells was widened due to overgrowth of collagen fibers.
Figure 4. Case 3
Figure 4. Case 3
. (a, b) Macroscopic and ICG lymphography findings in the dorsum of the hand over the forearm. (c) Magnified ICG lymphography findings in (c) splash pattern (SP) and (d) linear pattern (LP) areas. (e) Immunostaining of the skin in the SP area (LYVE-1). Overgrowth of subcutaneous capillary lymph vessels was apparent (red arrows). (f) Immunostaining of the skin in the LP area (LYVE-1). Skin capillary lymph vessels are diffusely present directly below the dermis (red arrows).
Figure 5. Case 17.
Figure 5. Case 17.
(a, b) Clinical presentations. The circumferences were increased by 0.5, 0.5, 1.0, and 0 cm in the upper arm, elbow, forearm, and wrist, respectively, compared to the healthy side (left). (c) Findings from lymphoscintigraphy. A normal lymph vessel distribution was found in both upper limbs.
Figure 6. ICG lymphography findings in Case…
Figure 6. ICG lymphography findings in Case 17.
A linear pattern (LP) was noted in the shoulder. A splash pattern (SP) was present in the lateral forearm over the upper arm, axilla, and precordia. In the medial upper arm, diffuse (DP) and splash patterns were mixed in some regions.

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Source: PubMed

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