Correlation between Lymphatic Surgery Outcome and Lymphatic Image-Staging or Clinical Severity in Patients with Lymphedema

Abstract

Lymphoscintigraphy and indocyanine green (ICG) lymphography reveal the severity of extremity lymphedema. Lower extremity lymphedema (LEL) index and NECST classification are related to the clinical severity of lymphedema. We aimed to investigate the correlation between lymphatic surgery, lymphatic imaging, and clinical severity in patients with lymphedema. Thirty-five patients with lower-extremity lymphedema who underwent lymphatic venous anastomosis (LVA) were evaluated. Ten of the thirty-five patients underwent multi-surgery (additional vascularized lymphatic transfer and/or liposuction). We investigated the correlation between the LEL index, NECST classification, lymphoscintigraphy staging, ICG lymphography staging, and rate of improvement (RI: [preoperative LEL index − postoperative LEL index]/[preoperative LEL index] × 100). The LEL index in 35 patients after LVA and all procedures decreased significantly compared to that of preoperative (272.4 vs. 256.2 vs. 243.5, p < 0.05). RI after LVA and all procedures showed positive correlations with the preoperative LEL index; however, there was no correlation with any other lymphatic image or clinical severity. LVA can reduce lymphedema circumference at any stage. Additional surgery improved the circumference. Hence, LVA as the first line of treatment, and vascularized lymphatic transfer and liposuction as additional procedures, should be considered as the standard treatment for lymphedema.

Utilization of Noncontrast Magnetic Resonance Lymphangiography for Selection of Effective Surgical Method in Breast Cancer-Related Lymphedema

“…Cutting-edge imaging techniques, such as lymphoscintigraphy, indocyanine green (ICG) lymphography, high-frequency ultrasonography, and magnetic resonance (MR) lymphangiography, are now being implemented in the domain of lymphedema [ 15 , 18 , 25 , 26 , 27 ]. This has facilitated the more precise and sensitive identification of lymphatic vessels and collections of lymphatic fluid.…”

“…Nonetheless, some scholars have speculated that LVA may not be sufficient for treating chronic lymphedema patients, particularly those in the later stages of the International Society of Lymphology (ISL) lymphedema classification [ 26 , 27 , 28 , 29 , 30 ]. Past pathophysiological investigations have demonstrated that chronic inflammation and lymphatic fluid stagnation lead to the breakdown of the lymphatic vessels’ pumping function and programmed cell death in lymphatic endothelial cells [ 31 , 32 , 33 ].…”

Clinical application of magnetic resonance lymphangiography in the vascularized omental lymph nodes transfer with or without lymphaticovenous anastomosis for cancer-related lower extremity lymphedema

“…Based on the preoperative MRL and intra-operative ICG fluorescence result, we decided to perform LVA alone for the patients with healthy lymphatic vessels and nodes, for LVA should be regarded as the primary treatment for lymphedema, while vascularized lymph nodes transfer and liposuction may be considered as additional procedures, thus establishing this as the standard approach for lymphedema ( 12 ). However in our study, none of the enrolled patients had sufficient healthy lymphatic vessels, all of objects combined function impairment of inguinal lymph nodes ( 13 , 14 ).…”

Supermicrosurgical lymphovenous anastomosis

“…LVA is indicated in the lymphedema patient with stage 2 to 5. 51 Recently, Imai et al, 65 studied 35 patients with lower extremity lymphedema and found a strong correlation between lymphoscintigraphy and ICG-L, but there was no correlation with any other lymphatic image or clinical severity. MDA classification also has 0 to 5 stage to grade the degree of lymphedema severity.…”