Imaging of the Lymphatic Vessels for Surgical Planning: A Systematic Review

Abstract

Background Secondary lymphedema is a common complication after surgical or radiotherapeutic cancer treatment. (Micro) surgical intervention such as lymphovenous bypass and vascularized lymph node transfer is a possible solution in patients who are refractory to conventional treatment. Adequate imaging is needed to identify functional lymphatic vessels and nearby veins for surgical planning. Methods A systematic literature search of the Embase, MEDLINE ALL via Ovid, Web of Science Core Collection and Cochrane CENTRAL Register of Trials databases was conducted in February 2022. Studies reporting on lymphatic vessel detection in healthy subjects or secondary lymphedema of the limbs or head and neck were analyzed. Results Overall, 129 lymphatic vessel imaging studies were included, and six imaging modalities were identified. The aim of the studies was diagnosis, severity staging, and/or surgical planning. Conclusion Due to its utility in surgical planning, near-infrared fluorescence lymphangiography (NIRF-L) has gained prominence in recent years relative to lymphoscintigraphy, the current gold standard for diagnosis and severity staging. Magnetic resonance lymphography (MRL) gives three-dimensional detailed information on the location of both lymphatic vessels and veins and the extent of fat hypertrophy; however, MRL is less practical for routine presurgical implementation due to its limited availability and high cost. High frequency ultrasound imaging can provide high resolution imaging of lymphatic vessels but is highly operator-dependent and accurate identification of lymphatic vessels is difficult. Finally, photoacoustic imaging (PAI) is a novel technique for visualization of functional lymphatic vessels and veins. More evidence is needed to evaluate the utility of PAI in surgical planning.

Static and dynamic analysis of in-vivo imaging for early-detection of lymphedema via near-infrared fluorescence indocyanine green lymphangiography

“…The disruption of the lymphatic flow increases the pressure in the collective lymph vessels which leads to lymph fluid leakage into the interstitial tissue through the endothelial-intercellular junction [ 39,40 ]. This is another cause of worsening lymphedema and is different from postsurgical lymphatic leakage It and can be identified through static analysis of NIRF-ICG lymphangiography images.…”

“…The evaluation of lymphatic function in this way after LN dissection or radiotherapy, both of which can damage the lymphatic system, may therefor predict the development of lymphedema. Second, because this dynamic analysis can be used to select lymphatic vessels with good function, the prognosis from functional surgery for the treatment of lymphedema such as LVA may be improved by using lymphatic vessels that remain well functioning [ 40 ]. If damaged lymphatic vessels are used for LVA, blood flow back into the lymphatic vessel may occur due to a lower pressure in these vessels and outflow obstruction [ 54 ].…”

“…This indicated a relatively mild level of severity only but they never returned to a linear form. 39,40 ]. This is another cause of worsening lymphedema and is different from postsurgical lymphatic leakage It and can be identified through static analysis of NIRF-ICG lymphangiography (which was not certified by peer review) is the author/funder.…”

Imaging peripheral lymphatic dysfunction in chronic conditions

“…Below we briefly review the use of these modalities for lymphatic imaging procedures before introducing point-of-care ICG lymphography/NIRF-LI. For more details on these conventional imaging modalities, readers are referred to recent comprehensive reviews ( Schwartz et al, 2020 ; Polomska and Proulx, 2021 ; van Heumen et al, 2023 ).…”

LED-based photoacoustic imaging for preoperative visualization of lymphatic vessels in patients with secondary limb lymphedema

“…On the other hand, magnetic resonance lymphography provides high-resolution images but is time consuming. Additional limitations of these techniques are high costs and lack of portability [10] . Near-infrared fluorescence lymphography (NIRF-L) has become popular and facilitates visualization of the lymphatic tracts and DBF in real-time using indocyanine green (ICG) contrast (see Fig.…”