A new indocyanine green fluorescence lymphography protocol for identification of the lymphatic drainage pathway for patients with breast cancer-related lymphoedema

Abstract

BackgroundBreast cancer related lymphoedema (BCRL) is a common side effect of cancer treatment. Recently indocyanine green (ICG) fluorescent lymphography has become a popular method for imaging the lymphatics, however there are no standard protocols nor imaging criteria. We have developed a prospective protocol to aid in the diagnosis and therapeutic management of BCRL.MethodsLymphatic imaging procedures were conducted in three phases. Following initial observation of spontaneous movement of ICG in phase one, manual lymphatic drainage (MLD) massage was applied to facilitate ICG transit via the lymphatics in phase two. All imaging data was collected in phase three. Continuous lymphatic imaging of the upper limb was conducted for approximately an hour and lymphatic drainage pathways were determined. Correlations between the drainage pathway and MD Anderson Cancer Centre (MDACC) ICG lymphoedema stage were investigated.ResultsOne hundred and three upper limbs with BCRL were assessed with this new protocol. Despite most of the patients having undergone axillary node dissection, the ipsilateral axilla drainage pathway was the most common (67% of upper limbs). We found drainage to the ipsilateral axilla decreased as MDACC stage increased. Our results suggest that the axillary pathway remained patent for over two-thirds of patients, rather than completely obstructed as conventionally thought to be the case for BCRL.ConclusionsWe developed a new ICG lymphography protocol for diagnosing BCRL focusing on identification of an individual patient’s lymphatic drainage pathway after lymph node surgery. The new ICG lymphography protocol will allow a personalised approach to manual lymphatic drainage massage and potentially surgery.

Prospective Validation of Indocyanine Green Lymphangiography Staging of Breast Cancer-Related Lymphedema

“…Stages 1–5 depict abnormal lymphatic patterns with various degrees of dermal backflow. Both the MDA and ADB staging systems are widely used for BCRL staging and evaluation of surgical outcomes [ 1 , 2 , 3 , 5 , 6 , 8 , 9 , 10 , 11 , 12 ]; however, neither classifications have undergone validation.…”

Maltohexaose-indocyanine green (MH-ICG) for near infrared imaging of endocarditis

“…Similar to ICG, the penetration of excitation and emission wavelength of MH-ICG is limited to a few centimeters of tissue, and endocarditis lesions could not be imaged through the chest wall with MH-ICG. However, visualization of the extent of bacterial infiltration could be assessed during valve replacement and other surgeries for infectious lesions such as orthopedic device infection; similar fluorescence imaging is done in certain settings [ 15 , 28 – 31 ]. Moreover, MH-ICG might be useful for bedside diagnosis of device infections near the skin such as pacemakers and left ventricular assist devices (LVADs) infections.…”

A Novel Way of Standardization of ICG Lymphangiography Reporting

“…For upper limb, first and fourth web space, radial and ulnar aspect of the volar wrist were chosen as injection sites, whereas for lower limb, first web space and lateral to tendoachilles were injected based on cadaveric lymphatic studies. 1 2 Additional injections near the elbow or knee can be given to hasten the proximal dye uptake, and in severe lymphedema, with diffuse dermal backflow distally. An amount of 0.5 mL of 2% lignocaine was injected, followed by 0.5 mL of Aurogreen dye (Aurolab, India) (ICG–25 mg vial diluted with 10 mL distilled water) injected intradermally into each site, using a 1 mL syringe with 31G needle.…”