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Min I, Lim SJ, Cheon GJ, Suh M, Seo KS. Pneumatic Compression-Assisted Lymphoscintigraphy for Quantitative Evaluation of Breast Cancer-Related Lymphedema. Clin Nucl Med 2023; Publish Ahead of Print:00003072-990000000-00595. [PMID: 37276486 DOI: 10.1097/rlu.0000000000004722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Acquired lymphedema of upper extremity is a chronic pathologic status that frequently occurs after breast cancer treatment. Reliable and quantitative evaluation of lymphedema is crucial for successful management of patients. Although lymphoscintigraphy is the primary investigation for the confirmation and evaluation of lymphedema, the specific protocol of stress intervention is not well established. This study aims to introduce intermittent pneumatic compression (IPC) as a part of stress lymphoscintigraphy and compare the effectiveness of conventional stress lymphoscintigraphy (CSL) and pneumatic compression-assisted lymphoscintigraphy (PCAL). METHODS Our study was designed as a retrospective analysis of 85 breast cancer patients with lymphedema who underwent lymphoscintigraphy utilizing either IPC device or conventional stress maneuver and received complex decongestive therapy. The flow extent of the lymphatic fluid (FE) was evaluated using a 0- to 4-point scale based on lymphoscintigraphic images. The visualization of lymph nodes was also assessed. The clinical outcomes were evaluated by changes in side-to-side circumferential and volume differences of upper extremities and compared between groups. RESULTS Of 85 patients, 47 underwent CSL, and 38 underwent PCAL. Participants with relatively preserved flow extent of the lymphatic fluid (FE 3) showed a significant difference in percentage reduction of volume (PRV) between CSL and PCAL groups (P = 0.036). In the other groups, CSL and PCAL demonstrated comparable differences in PRV without statistical significance. CONCLUSION Our study suggests that participants in the PCAL group with relatively preserved lymphatic flow extent (FE 3) had better PRV compared with those in the CSL group. The use of IPC devices in lymphoscintigraphy with the novel stress maneuver can help in the quantitative description of lymphedema status and the selection of an appropriate treatment method.
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Affiliation(s)
- Ingi Min
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
| | - Sung Joon Lim
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Minseok Suh
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwan Sik Seo
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
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Shen G, Kuang A. Lymphoscintigraphic Findings of Scrotal Lymphangioma. Clin Nucl Med 2022; 47:888-889. [PMID: 35383611 DOI: 10.1097/rlu.0000000000004209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
ABSTRACT As congenital lymphatic malformations, lymphangiomas commonly occur in the neck, tongue, and extremities, whereas scrotum is one of the least frequent sites. For this lymphatic flow disease, lymphoscintigraphy is regarded as a useful imaging method. Herein, in a child with scrotal cysts, scrotal region activity was detected in lymphoscintigraphy, consistent with likely lymphatic disorder. The postsurgical pathology confirmed the diagnosis of lymphangioma.
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Affiliation(s)
- Guohua Shen
- From the Department of Nuclear Medicine, Laboratory of Clinical Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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3
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Maita K, Garcia JP, Torres RA, Avila FR, Kaplan JL, Lu X, Manrique OJ, Ciudad P, Forte AJ. Imaging biomarkers for diagnosis and treatment response in patients with lymphedema. Biomark Med 2022; 16:303-316. [PMID: 35176878 DOI: 10.2217/bmm-2021-0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.
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Affiliation(s)
- Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Ricardo A Torres
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jamie L Kaplan
- Division of General Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Xiaona Lu
- Division of Plastic & Reconstructive Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Oscar J Manrique
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY, 14627, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive & Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
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Wong M, Eaton PK, Zanichelli C, Moore C, Hegarty C, MacDonald N. The prevalence of undiagnosed postoperative lower limb lymphedema among gynecological oncology patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 48:1167-1172. [PMID: 34980543 DOI: 10.1016/j.ejso.2021.12.464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 12/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Lower limb lymphedema (LLL) is a common postoperative complication among gynecological oncology patients following lymph node resection. In the absence of a screening strategy, LLL is frequently diagnosed only through patient's self-reported symptoms. This study investigated the prevalence of undiagnosed postoperative LLL among gynecological oncology patients and identified the associated risk factors. MATERIALS AND METHODS This was a cross-sectional postal questionnaire survey at a tertiary gynecological oncology center. Women with gynecological malignancies who underwent lymph node (inguinal/pelvic/para-aortic) resection between 2010 and 2017 were eligible. The Gynecological Cancer Lymphedema Questionnaire (GCLQ) was used and those with a score of ≥4 were referred to a lymphedema specialist for clinical confirmation. RESULTS Among 376 eligible women, postoperative LLL was already diagnosed in 45/376 (12%) women. In the remaining women, 117/331 (35.3%) completed the GCLQ, of which 67/117 (57.3%) scored ≥4. Fifty-five women (55/67, 82.1%) were assessed by a lymphedema specialist and eight cases of postoperative LLL were confirmed. In the 12/67 who declined a clinical assessment, they reported no evidence of LLL. The prevalence of undiagnosed postoperative LLL in our study was 8/117 (6.8%, 95% C.I. 2.3-11.4). On univariate analysis, older women were more likely to have undiagnosed postoperative LLL. CONCLUSIONS Undiagnosed postoperative LLL is not uncommon among gynecological oncology patients, especially in older patients. No vulvar cancer patient had undiagnosed LLL. Increased awareness and improved strategies for lymphedema screening are required after lymph node surgery in gynecological oncology.
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Affiliation(s)
- Michael Wong
- Department of Gynecological Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Patricia Kay Eaton
- Lymphedema Service, Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Carla Zanichelli
- Lymphedema Service, Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Christina Moore
- Lymphedema Service, Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Catherine Hegarty
- Lymphedema Service, Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Nicola MacDonald
- Department of Gynecological Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Liu Y, Tong G, Wen Z, Zhuang H. Hyperthyroidism Incidentally Noted on Lymphoscintigraphy. Clin Nucl Med 2021; 46:761-763. [PMID: 34028408 DOI: 10.1097/rlu.0000000000003688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 43-year-old woman with edema in both left upper limb and lower limb underwent lymphoscintigraphy to evaluate possible lymphedema. Two separate lymphoscintigraphies, one for the lower and the other for the upper limbs, were performed with interval of 3 days. Incidentally, an activity in the region of the thyroid glands was noted in the delayed images of both studies. Subsequently, Graves disease was diagnosed based on the patient's symptoms and the results of laboratory examinations.
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Affiliation(s)
- Yong Liu
- From the Departments of Ultrasonography
| | - Guansheng Tong
- Nuclear Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhe Wen
- Nuclear Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hongming Zhuang
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Kim HO, Woo KJ, Kim BS, Kang SY, Moon BS, Yoon HJ. Lymphoscintigraphic Findings as Indicators of Lymphaticovenous Anastomosis Outcome in Patients With Extremity Lymphedema: A Retrospective Cohort Study. Clin Nucl Med 2021; 46:549-555. [PMID: 33826571 DOI: 10.1097/rlu.0000000000003630] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE This study was performed to evaluate the usefulness of lymphoscintigraphy in predicting the surgical outcomes of lymphaticovenous anastomosis (LVA) in a patient with extremity lymphedema. PATIENTS AND METHODS We retrospectively evaluated 133 patients with extremity lymphedema who underwent lymphoscintigraphy followed by LVA surgery from February 2018 to March 2020. Lymphoscintigraphic findings were evaluated on the following parameters: the extent of dermal backflow (small/large), lymphatic flow patterns (trunk flow pattern/proximal-restricted pattern/distal-restricted pattern), visualization of lymph nodes, and collateral lymphatic vessels. The mean circumferential difference change before and after surgery, circumferential reduction (CR) rate (%), was used as the clinical outcome variables. RESULTS A decrease in circumference was observed in 93 (69.9%) of 133 patients after LVA. The extent of dermal backflow and lymphatic flow patterns was significantly correlated with improved clinical outcomes after LVA. The large extent of the dermal backflow group showed a more significant CR rate than the small extent (19.27% vs 1.24%, P = 0.005). The TP group showed the most significantly decreased CR rate to 21.46%, and the proximal-restricted pattern and distal-restricted pattern groups were -2.49% and -5.33%, respectively (P < 0.001). Multivariate analysis revealed that dermal backflow and lymphatic flow patterns were independent predictors of therapeutic outcome (P < 0.001). CONCLUSIONS Our study demonstrates that pretreatment lymphoscintigraphy may help predict the therapeutic effect of LVA in patients with extremity lymphedema. Furthermore, dermal backflow and lymphatic flow patterns are independent predictors of CR rate after LVA surgery for extremity lymphedema.
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Affiliation(s)
- Hye Ok Kim
- From the Departments of Nuclear Medicine
| | - Kyong-Je Woo
- Plastic Surgery, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Brahma B, Putri RI, Reuwpassa JO, Tuti Y, Alifian MF, Sofyan RF, Iskandar I, Yamamoto T. Lymphaticovenular Anastomosis in Breast Cancer Treatment-Related Lymphedema: A Short-Term Clinicopathological Analysis from Indonesia. J Reconstr Microsurg 2021; 37:643-654. [PMID: 33648010 DOI: 10.1055/s-0041-1723940] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients. METHODS This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones. RESULTS Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period. CONCLUSION LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.
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Affiliation(s)
- Bayu Brahma
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rizky Ifandriani Putri
- Department of Anatomical Pathology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Jauhari Oka Reuwpassa
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Yustia Tuti
- Department of Nuclear Medicine, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Muhammad Farid Alifian
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rian Fabian Sofyan
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Iskandar Iskandar
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Suami H, Heydon-White A, Mackie H, Czerniec S, Koelmeyer L, Boyages J. A new indocyanine green fluorescence lymphography protocol for identification of the lymphatic drainage pathway for patients with breast cancer-related lymphoedema. BMC Cancer 2019; 19:985. [PMID: 31640623 PMCID: PMC6806520 DOI: 10.1186/s12885-019-6192-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/23/2019] [Indexed: 11/22/2022] Open
Abstract
Background Breast 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. Methods Lymphatic 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. Results One 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. Conclusions We 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.
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Affiliation(s)
- Hiroo Suami
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia.
| | - Asha Heydon-White
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia.,Mt Wilga Private Hospital, Hornsby, NSW, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Louise Koelmeyer
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - John Boyages
- Australian Lymphoedema Education Research Treatment (ALERT) Program, Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Rd, Sydney, NSW, 2109, Australia
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Blei F. Update October 2019. Lymphat Res Biol 2019. [DOI: 10.1089/lrb.2019.29072.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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