Azusa Oshima

Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns.

Background: Indocyanine green lymphography has been a highly useful modality in the clinical examination and surgical management of patients with lymphedema. No formal classification system of indocyanine green imaging findings according to the severity of lymphedema exists, however. The purpose of this study was to describe, analyze, and classify characteristic indocyanine green lymphography findings to uniformly guide surgical management of lymphedema using this modality. Methods: Forty-five patients (78 limbs) with lower extremity lymphedema underwent indocyanine green lymphography. All lymphography images were recorded in photographs and videos. Images were reviewed and analyzed to classify characteristic findings according to clinical severity as determined by Campisi clinical lymphedema staging. Results: Lymphography findings were classifiable into two patterns. Mild cases of lymphedema were characterized by a linear lymphatic channel pattern (linear pattern). In more severe cases, lymphatic channels demonstrated retrograde lymphatic flow (dermal backflow pattern) and diminution or absence of linear channel patterning. Three dermal backflow patterns, splash, stardust, and diffuse, were identified and correlated with the progression of lymphedema severity. These findings supported the generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system. Conclusions: Indocyanine green lymphography is a safe, minimally invasive, and useful tool for the surgical evaluation of extremity lymphedema. Characteristic indocyanine green lymphography patterns are consistent and correlate with clinical severity. The dermal backflow staging system can facilitate patient stratification, discussion between referring parties, and surgical planning.

Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns.

Background: Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema. Methods: Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages. Results: The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p = 0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p = 0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y = 1.092x + 0.083 (R2 = 0.997; analysis of variance, p < 0.001). Conclusions: Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, V.

The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema.

Background: Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy. Methods: Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage. Results: Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n = 19) and limbs without them (n = 9): age, 51.4 ± 15.3 years versus 34.8 ± 12.7 years (p = 0.007); body weight, 75.1 ± 7.9 kg versus 50.1 ± 5.3 kg (p = 0.012); body mass index, 23.1 ± 4.2 versus 19.7 ± 1.8 (p = 0.005); leg dermal backflow stage of asymptomatic limb, 1.2 ± 0.4 versus 0.0 ± 0.0 (p < 0.001); and leg dermal backflow stage of symptomatic limb, 3.5 ± 0.6 versus 2.8 ± 0.8 (p = 0.033). Conclusions: The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, V.

Comparison of Donor Site Drainage Duration and Seroma Rate Between Latissimus Dorsi Musculocutaneous Flaps and Thoracodorsal Artery Perforator Flaps

Introduction Donor site seroma formation and prolonged drainage duration are common complications of using latissimus dorsi musculocutaneous (LDMC) flaps. The present retrospective study aimed to investigate the effect of types of back flap harvest on drainage duration and seroma formation rates. Methods Adult patients (n = 155) who underwent reconstruction with a latissimus dorsi flap from January 2010 to October 2015 were included in the study, of which 54 patients underwent breast reconstruction with a pedicled LDMC flap (LD breast group), 80 patients underwent an LDMC flap transfer for purposes other than breast reconstruction (LD nonbreast group), and 21 patients underwent soft tissue reconstruction with a thoracodorsal artery perforator (TAP) flap (TAP group). Flap size, drainage durations, and seroma formation rates at donor sites were compared among the 3 groups. Results Flap sizes significantly differed between the LD nonbreast group (median value, 185.5 cm2) and the other 2 groups (119 cm2 in the LD breast group. 127.5 cm2 in the TAP group), with no significant difference observed between the LD breast and TAP groups. The mean drainage duration was 11.6 days for the LD breast group. 9.82 days for the LD nonbreast group, and 4.81 days for the TAP group. Drainage durations significantly differed among the groups. Seroma formation rate of the LD breast group (42.6%) was significantly higher than those of the other groups. Conclusions The type of back flap harvest used significantly affected drainage duration and seroma formation rate in the present study. Lumbar fat extension with the use of a LDMC flap for breast reconstruction may lead to seroma formation. Thoracodorsal artery perforator flaps are associated with minimal risks of seroma formation and significantly shortened drainage duration compared with LDMC flaps.