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Nonlinear ICG Lymphography Findings: An Indication For Lymphatic Surgery?
James E. Fanning, B.S., Rosie Friedman, MD, Angela Chen, B.S., Aaron Fleishman, MPH, Kathleen Shillue, DPT, Yuma Fuse, MD, Kevin Donohoe, MD, Dhruv Singhal, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
PURPOSE: Approximately two thirds of patients will not develop breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND). We recruited volunteer female breast cancer survivors at least 2 years after ALND without a history of BCRL for lymphedema surveillance measures and lymphatic imaging.
METHODS: Female breast cancer survivors treated with ALND without a BCRL diagnosis were recruited and treatment records were obtained. Volunteers underwent bilateral limb volume measurements by perometry and bilateral bioimpedance measures with L-dex to exclude BCRL. Lymphatic imaging in the affected arm was performed with ICG lymphography and SPECT/CT lymphoscintigraphy. Relative limb volume difference (%), affected arm L-dex score, nonlinear anatomy on ICG, and dermal backflow on lymphoscintigram were recorded.
RESULTS: Twenty consecutive volunteers completed the study. The median time from surgery was 11.2 years and a median of 13.5 axillary lymph nodes were removed. In the affected arm, the median relative limb volume difference was 2.2% and the median L-dex score was -0.4. Abnormal, nonlinear ICG signs in the affected arm were visualized in 70% of volunteers. Dermal backflow in the affected arm was visualized on SPECT/CT lymphoscintigraphy in zero volunteers.
CONCLUSION: We observed abnormal, nonlinear ICG signs in the absence of dermal backflow on SPECT/CT lymphoscintigraphy in 70% (14/20) of volunteers without BCRL at least 2 years after ALND. Nonlinear ICG signs may commonly develop after ALND without clinical detection. Nonlinear ICG signs in the absence of positive lymphedema surveillance measures or dermal backflow on SPECT/CT lymphoscintigraphy do not warrant surgical intervention.
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