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Moon T, O'Donnell TF, Weycker D, Iafrati M. Lymphoscintigraphy is frequently recommended but seldom used in a "real world setting". J Vasc Surg Venous Lymphat Disord 2024; 12:101738. [PMID: 38103890 DOI: 10.1016/j.jvsv.2023.101738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Lymphedema (LED) lacks a standard, simple, guiding noninvasive diagnostic test, unlike the two other circulatory disorders-arterial or venous disease. Lymphoscintigraphy (LSG) has been recommended by several guidelines as the diagnostic test of choice for LED. Several recent expert panels, however, have suggested from anecdotal experience that LSG was used infrequently, and that the diagnosis of LED is usually based on clinical examination. METHODS To determine the use of LSG in a large real-world LED population, the International Business Machines MarketScan Research Database was examined from April 2012 to March 2020 for patients with a new diagnosis of LED (the index date). Use of LSG (LSG+) was ascertained during the period beginning 12 months prior to the initial coding of a LED diagnosis and ending 12 months after the index date based on the corresponding Current Procedural Terminology code; LSG use for sentinel node mapping at the time of oncologic surgery was excluded. Demographic profiles, comorbidities, and causes of LED among patients with and without evidence of LSG were characterized. RESULTS We identified 57,674 patients, aged ≥18 years, who had a new diagnosis of LED and health care coverage for ≥12 months before and after this index date. Only a small number (1429; 2.5%) of these patients underwent LSG during the study period. The LSG + cohort was younger (53.7 vs 60.7 years), had a higher proportion of women (91.3% vs 73.4%), but a lower percentage of diabetes (12.8% vs 27.5%), heart failure (2.2% vs 8.7%), hypertension (32.4% vs 51.0%), and obesity (15.1% vs 22.2%) compared with the LED population who did not undergo LSG (all P < .001). Most importantly, the use of LSG for diagnosis varied with the etiology of LED (LSG was most frequently utilized among patients with melanoma-LED (9.5%) and patients with breast cancer-LED (6.7%), in contrast to patients with advanced venous disease-related LED (1.1%; P < .05 for both comparisons). CONCLUSIONS Despite four guidelines recommending LSG, including the Guidelines of the American Venous Forum (Handbook of Venous and Lymphatic Disease-4th edition), which recommended LSG "for the initial evaluation of patients with LED" with a 1B recommendation, LSG plays a minor role in establishing the diagnosis of LED in the United States. This underlines the need for a better, simple diagnostic test for LED to complement clinical examination.
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Affiliation(s)
- Tina Moon
- Department of Surgery, Tufts Medical Center, Boston, MA
| | - Thomas F O'Donnell
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Mark Iafrati
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Drobot D, Zeltzer AA. Surgical treatment of breast cancer related lymphedema-the combined approach: a literature review. Gland Surg 2023; 12:1746-1759. [PMID: 38229846 PMCID: PMC10788573 DOI: 10.21037/gs-23-247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
Background and Objective Breast cancer therapy is a common cause of lymphedema, a chronic condition resulting from impaired fluid drainage through the lymphatic system. The accumulation of fluid in the affected limb leads to swelling, inflammation, and fibrosis, causing irreversible changes. While conservative therapy is the initial treatment for lymphedema, it may prove ineffective for advanced-stage cases that require surgical intervention. Physiological approaches such as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) aim to restore lymphatic circulation, while reductive approaches such as excision of excess tissue and liposuction (LS) aim to eliminate fibrofatty tissue. In advanced stages of breast cancer-related lymphedema, a treatment that incorporates both physiological and reductive methods is advantageous. The timing of these approaches varies, and recent simultaneous procedures have been introduced to address both aspects in one surgery. Additionally, lymphedema treatment can be combined with breast reconstruction. Current imaging techniques provide a better assessment of the lymphedematous limb, aiding in the tailoring of a personalized combined approach within a single surgery. This study aims to review the combined approach for breast cancer-related lymphedema treatment and propose a new therapeutic algorithm based on recent literature. The research aims to optimize the management of breast cancer-related lymphedema and improve patient outcomes. Methods PubMed/MEDLINE was used as the database to conduct a review of the currently available literature concerning combined surgical techniques for treating breast cancer related lymphedema (BCRL). Key Content and Findings In our review, we discuss imaging methods for assessing lymphatic system anatomy and function in surgical preparation and decision-making. Simultaneously, we examine a range of combined surgical techniques for treating BCRL, encompassing the combined physiologic approach, breast reconstruction with physiologic surgery, and the combination of reductive and physiologic procedures. Our emphasis remains on key parameters, including patient demographics, lymphedema staging, procedure types, follow-up duration, and objective limb measurements. Conclusions Surgical treatment of BCRL can include several surgical modalities that can be performed simultaneously. Current imaging techniques enable the tailoring of a personalized combined one-stage surgery for BCRL patients.
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Affiliation(s)
- Denis Drobot
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Assaf Aviram Zeltzer
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
- Bruce and Ruth Rappaport Faculty of Medicine, Technion, Israel
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Liu M, Zhang Y, Li X, Hao Q, Li B, Wang R. MRI-based volume measurement methods for staging primary lower extremity lymphedema: a single-center study of asymmetric volume difference-a diagnostic study. BMC Musculoskelet Disord 2023; 24:810. [PMID: 37828475 PMCID: PMC10568749 DOI: 10.1186/s12891-023-06912-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Lower extremity lymphedema (LEL) staging is mainly assessed by systems that solely depend on physical examinations and lack quantitative assessment based on modern imaging. OBJECTIVE To explore the value of MRI-based asymmetric volume measurements in the clinical staging of primary LEL. METHODS 92 patients with unilateral primary LEL underwent MRI examinations to determine the volume of the mid-calf (Vcl) calculated using the clinical dermatome method as well as the total volume (Vmri), musculoskeletal volume (VM), and subcutaneous volume (VS) volume of the middle calves. The difference between Vmri (DVmri) and VS (DVS) of the affected and unaffected calves was obtained and defined as the asymmetric volume difference. Meanwhile, the volume of the mid-calf (Vcl) and the difference in volume (DVcl) were calculated using the clinical circumferential method. The relationship between the asymmetric volume difference and clinical staging was then evaluated. Interobserver consistency was assessed through the intraclass correlation coefficient (ICC). Volume comparisons between the three groups were performed using the one-way analysis of variance (ANOVA) or the Kruskal-Wallis test. Spearman's correlation was used to assess volume and clinical stage correlation. The receiver operating characteristic (ROC) curve was used to evaluate the value of asymmetric volume difference for clinical staging. RESULTS The asymmetric volume difference was statistically significant in stage I compared to stages II and III (p < 0.05). The asymmetric volume difference (DVmri: r = 0.753; DVS: r = 0.759) correlated more with the clinical stage than the affected Vcl (r = 0.581), Vmri (r = 0.628), VS (r = 0.743), and DVcl (r = 0.718). The area under the ROC curve (AUC) for identifying the clinical stage by the asymmetric volume difference was greater than that for the affected Vcl, Vmri, VS, and DVcl, with DVS (AUC = 0.951) having the largest area under the curve to distinguish between stages I and II. CONCLUSION MRI-based asymmetric volume difference is an adjunctive measure for LEL clinical staging with good reproducibility. DVS could be the best indicator for differentiating between stages I and II of primary LEL.
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Affiliation(s)
- Mengke Liu
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Yan Zhang
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Xingpeng Li
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Qi Hao
- Department of Radiology, Affiliated the ninth Clinical Medical College, Peking University, Beijing, 100038, China
| | - Bin Li
- Department of MRI, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
| | - Rengui Wang
- Department of Radiology, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
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Liu M, Li B, Hao K, Zhang Y, Hao Q, Li X, Wang R. Quantitative evaluation of primary lower extremity lymphedema staging using MRI: a preliminary study. Quant Imaging Med Surg 2023; 13:4839-4851. [PMID: 37581039 PMCID: PMC10423363 DOI: 10.21037/qims-22-795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 05/11/2023] [Indexed: 08/16/2023]
Abstract
Background The staging of primary lower extremity lymphedema (LEL) is difficult yet vital in clinical work, and magnetic resonance imaging (MRI) can be used for quantitative assessment of primary LEL due to its high resolution for soft tissues. In this study, we evaluated the value of MRI-based soft tissue area measurements for staging primary LEL. Methods A total of 90 consecutive patients with clinically diagnosed primary lower limb lymphoedema from January 2017 to December 2019 in Beijing Shijitan Hospital were enrolled retrospectively. Short time inversion recovery (STIR) sequence was applied to measure the total, muscle, bone, and subcutaneous areas in the upper 1/3 level of the bilateral lower calf. The difference between the affected and unaffected calf regarding the subcutaneous area was obtained, and (subcutaneous area)/(bone area) and (subcutaneous area)/(muscle area) were calculated. According to the International Society of Lymphology (ISL) clinical staging standard established in 2020, all patients were divided into stages I, II, and III, accordingly. Statistical analysis was performed to determine the validity of MRI measurements in staging LEL. Results There were 33 patients classified as stage I clinically, 44 patients as stage II, and 13 patients as stage III. There were significant differences in total, subcutaneous, the difference in subcutaneous area of limbs, subcutaneous/bone (S/B), and subcutaneous/muscle (S/M) between stage I and II as well as between stage I and III (P<0.001), but not between stage II and III (P=0.706, 0.329, and 0.229, respectively). A positive correlation was detected between the clinical stage and difference in subcutaneous area of limbs (rho =0.752, P<0.001), S/B (rho =0.747, P<0.001), S/M (rho =0.709, P<0.001), and subcutaneous (rho =0.723, P<0.001). For staging primary LEL, receiver operating characteristic (ROC) curves indicated that the difference in subcutaneous area of limbs had the best discrimination ability among parameters [area under the ROC curve (AUC) =0.950; 95% confidence interval (CI): 0.875-0.987; sensitivity: 95.45%; specificity: 84.85%], followed by S/B (AUC =0.930; 95% CI: 0.848-0.975; sensitivity: 77.27%; specificity: 93.94%) and S/M (AUC =0.895; 95% CI: 0.804-0.953; sensitivity: 77.27%; specificity: 90.91%). The ROC curves indicated that subcutaneous area (AUC =0.927; 95% CI: 0.844-0.974; sensitivity: 84.09%, specificity: 90.91%) and total (AUC =0.852; 95% CI: 0.753-0.923; sensitivity: 70.45%; specificity: 90.91%) also had discrimination ability between stage I and II. Conclusions The measurement of the soft tissue area of the calf may be used as an auxiliary method for staging primary LEL. For patients with unilateral primary LEL, the difference in subcutaneous area of limbs could be a specific indicator to distinguish clinical stage I from II.
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Affiliation(s)
- Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bin Li
- Department of MRI, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qi Hao
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Schols RM, Dip F, Lo Menzo E, Haddock NT, Landin L, Lee BT, Malagón P, Masia J, Mathes DW, Nahabedian MY, Neligan PC, Newman MI, Phillips BT, Pons G, Pruimboom T, Qiu SS, Ritschl LM, Rozen WM, Saint-Cyr M, Song SY, van der Hulst RRWJ, Venturi ML, Wongkietkachorn A, Yamamoto T, White KP, Rosenthal RJ. Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery. Surgery 2022; 172:S46-S53. [PMID: 36427930 DOI: 10.1016/j.surg.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. METHODS A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. RESULTS Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. CONCLUSION ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.
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Affiliation(s)
- Rutger M Schols
- Maastricht University Medical Center, Masstricht, Netherlands
| | - Fernando Dip
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina.
| | | | | | - Luis Landin
- FIBHULP/IdiPaz, Hospital Universitario La Paz, Madrid. Spain
| | - Bernard T Lee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Paloma Malagón
- Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jaume Masia
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | | | | | - Gemma Pons
- Hospital de la Santa Creu, Barcelona, Spain
| | - Tim Pruimboom
- Maastricht University Medical Center, Masstricht, Netherlands
| | - Shan Shan Qiu
- Maastricht University Medical Center, Masstricht, Netherlands
| | - Lucas M Ritschl
- Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Warren M Rozen
- Monash University, Peninsula Campus, Frankston Victoria, Australia
| | | | - Seung Yong Song
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | - Mark L Venturi
- VCU School of Medicine INOVA, National Center for Plastic Surgery, Washington, DC
| | | | - Takumi Yamamoto
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Kevin P White
- ScienceRight Research Consulting Services, London, Ontario Canada
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6
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Dip F, Aleman J, DeBoer E, Boni L, Bouvet M, Buchs N, Carus T, Diana M, Elli EF, Hutteman M, Ishizawa T, Kokudo N, Lo Menzo E, Ludwig K, Phillips E, Regimbeau JM, Rodriguez-Zentner H, Roy MD, Schneider-Koriath S, Schols RM, Sherwinter D, Simpfendorfer C, Stassen L, Szomstein S, Vahrmeijer A, Verbeek FPR, Walsh M, White KP, Rosenthal RJ. Use of fluorescence imaging and indocyanine green during laparoscopic cholecystectomy: Results of an international Delphi survey. Surgery 2022; 172:S21-S28. [PMID: 36427926 DOI: 10.1016/j.surg.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Published empirical data have increasingly suggested that using near-infrared fluorescence cholangiography during laparoscopic cholecystectomy markedly increases biliary anatomy visualization. The technology is rapidly evolving, and different equipment and doses may be used. We aimed to identify areas of consensus and nonconsensus in the use of incisionless near-infrared fluorescent cholangiography during laparoscopic cholecystectomy. METHODS A 2-round Delphi survey was conducted among 28 international experts in minimally invasive surgery and near-infrared fluorescent cholangiography in 2020, during which respondents voted on 62 statements on patient preparation and contraindications (n = 12); on indocyanine green administration (n = 14); on potential advantages and uses of near-infrared fluorescent cholangiography (n = 18); comparing near-infrared fluorescent cholangiography with intraoperative x-ray cholangiography (n = 7); and on potential disadvantages of and required training for near-infrared fluorescent cholangiography (n = 11). RESULTS Expert consensus strongly supports near-infrared fluorescent cholangiography superiority over white light for the visualization of biliary structures and reduction of laparoscopic cholecystectomy risks. It also offers other advantages like enhancing anatomic visualization in obese patients and those with moderate to severe inflammation. Regarding indocyanine green administration, consensus was reached that dosing should be on a milligrams/kilogram basis, rather than as an absolute dose, and that doses >0.05 mg/kg are necessary. Although there is no consensus on the optimum preoperative timing of indocyanine green injections, the majority of participants consider it important to administer indocyanine green at least 45 minutes before the procedure to decrease the light intensity of the liver. CONCLUSION Near-infrared fluorescent cholangiography experts strongly agree on its effectiveness and safety during laparoscopic cholecystectomy and that it should be used routinely, but further research is necessary to establish optimum timing and doses for indocyanine green.
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Affiliation(s)
- Fernando Dip
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Julio Aleman
- Hospital Centro Médico, Laparoscopic surgery, Guatemala
| | - Esther DeBoer
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Luigi Boni
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, University of Milan, Milan, Italy
| | | | | | - Thomas Carus
- Niels-Stensen-Kliniken, Elisabeth-Hospital, Thuine, Germany
| | - Michele Diana
- Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | | | | | | | - Norihiro Kokudo
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Kaja Ludwig
- Klinikum Suedstadt Rostock, Rostock, Germany
| | | | - Jean Marc Regimbeau
- CHU Amiens-Picardie, Site Sud, Service de Chirurgie Digestive, Amiens, France
| | | | | | | | - Rutger M Schols
- Maastricht University Medical Center, Maastricht, Netherlands
| | | | | | - Laurent Stassen
- Maastricht University Medical Center, Maastricht, Netherlands
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7
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Use of fluorescence imaging during lymphatic surgery: A Delphi survey of experts worldwide. Surgery 2022; 172:S14-S20. [PMID: 36427924 DOI: 10.1016/j.surg.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fluorescence imaging with indocyanine green is increasingly used during lymphedema patient management. However, to date, no guidelines exist on when it should and should not be used or how it should be performed. Our objective was to have an international panel of experts identify areas of consensus and nonconsensus in current attitudes and practices in fluorescence imaging with indocyanine green use during lymphedema surgery patient management. METHODS A 2-round Delphi study was conducted involving 18 experts in the use of fluorescence imaging during lymphatic surgery, all asked to vote on 49 statements on patient preparation and contraindications (n = 7 statements), indocyanine green dosing and administration (n = 10), fluorescence imaging uses and potential advantages (n = 16), and potential disadvantages and training needs (n = 16). RESULTS Consensus ultimately was reached on 40/49 statements, including consistent consensus regarding the value of fluorescence imaging with indocyanine green in almost all facets of lymphedema patient management, including early detection, assessing disease extent, preoperative work-up, surgical planning, intraoperative guidance, monitoring short- and longer-term outcomes, quality control, and resident training. All experts felt it was very safe, while 94% felt it should be part of routine care and that indocyanine green was superior to colored dyes and ultrasound. Nonetheless, there also was consensus that limited high-quality evidence remains a barrier to its widespread use and that patients should still be provided with specific information and asked to sign specific consent for both fluorescence imaging and indocyanine green. CONCLUSION Fluorescence imaging with or without indocyanine green appears to have several roles in lymphedema prevention, diagnosis, assessment, and treatment.
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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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