Changes in Indocyanine Green Lymphography Patterns after Physical Treatment in Secondary Upper Limb Lymphedema
María Elena Medina‐Rodríguez 1,2, María de‐la‐Casa‐Almeida 3,*, Jesús González Martín 4, María Hermida Anllo 5 and Esther M. Medrano‐Sánchez 6. J. Clin. Med. 2020, 9, 306
Abstract
Changes in Indocyanine Green Lymphography Patterns after Physical Treatment in Secondary Upper Limb Lymphedema
María Elena Medina‐Rodríguez 1,2, María de‐la‐Casa‐Almeida 3,*, Jesús González Martín 4, María Hermida Anllo 5 and Esther M. Medrano‐Sánchez 6. J. Clin. Med. 2020, 9, 306.
Indocyanine green (ICG) lymphography is used to evaluate the lymphatic function before and after pneumatic compression or post‐manual lymphatic drainage. The aim of this study was to ascertain the changes in the fluoroscopic pattern produced by the provision of complex physical therapy. This prospective analytic (pre test-post test) study was conducted in 19 patients with upper lymphedema secondary to breast cancer. Nine patients were excluded due to ICG found after 3 weeks. The ICG patterns were analyzed under basal conditions and after three weeks of treatment. After the treatment, 45% of the patients presented tracer remains in the affected limb, and this finding was significantly related to time of the lymphedema development. In one subject, the patterns remain unchanged or cannot be defined. Three of the ten patients observed present the worsening of at least 1 of the patterns and in the rest of the subjects, six cases, the improvement of the patterns is observed. In 60% of the cases, the most severe pattern reversed towards slight (splash) cases, and moderate cases reversed towards a slight case in 70% of cases. Therefore, after treatment with complex physical therapy, the pathological patterns observed in the pretest, which evolved positively, reverted their severity toward milder disease patterns or towards normality.
Main findings
- The study was structured in three phases: pre‐treatment evaluation, three‐week intensive physiotherapy treatment and post‐treatment evaluation.
- 11 reference points for measuring the perimeter of each limb. Each reference was identified on the anterior and posterior side of the extremity with white adhesive tape, opaque to infrared light.
- Each point was measured, three times and the average of the three measurements was
- After injection, patients were asked to remain motionless for five minutes and then performed isolated movements of flexion and extension of the fingers of the affected limb for another five minutes.
- At 90 min, post ICG injection, under basal conditions, a team formed by a vascular surgeon and a physiotherapist observed the presence of the ICG tracer through an infrared camera (Photodynamic Eye, Hamamatsu Photonics K.K., Hamamatsu, Japan). A third observer, a physiotherapist, verified the correct visualization and recording of the images obtained
- The team checked the type of fluoroscopic pattern present in the same areas that were selected for the perimeter measurement.
- Treatment included 15 sessions involving skin care, multlayer compression bandages, pressotherapy, MLD and exercises.
- To check the evolution of the ICG lymphography pattern after treatment, they analyzed the criterion change of the initial‐final pattern, after physical therapy treatment, and established 4 possible outcomes: improvement, worsening, no variation and no evaluation.
- The change of the initial ICG lymphography pattern after treatment, in all the body regions explored, was improvement in 26%, worsening in 7%, no variation in 32%, and in no evaluation in 35%. The most change was observed in the elbow region. The more distal regions, with respect to the elbow, evolved more favorably.
- The diffuse (severe) pattern evolved to a splash pattern (mild) in 60% of cases, and 36% evolved to a linear pattern. Only one case (4%) evolved to a moderate or stardust.
- In the lymphedemas of longer duration, more than one year, three weeks of intensive physical treatment were not sufficient to achieve the reabsorption of the ICG tracer.
- Intensive treatment through complex physical therapy achieves the positive evolution of stardust pattern toward splash in secondary lymphedema involving breast cancer.
- Visualization via ICG lymphography demonstrated the remains of tracer dye after three weeks of intensive treatment in 47.4% of the cases under study. We found that this result was associated with a single variable: lymphedema evolution time. Lymphedemas that were more than one year old were more likely (80%) to demonstrate ICG tracer remains despite three weeks of intensive treatment. After three weeks of intensive physiotherapy treatment, the patterns that improved did so as follows: the diffuse pattern (severe) evolved in 60% of cases (14 areas) to a splash pattern (mild) and, in 36% of cases (9 areas), to a linear pattern. The stardust pattern (moderate) evolved in 70% of cases (15 areas) toward a slight pattern or splashes and the rest (6 areas) toward a linear pattern. ICG patterns that were slight (splash) remained unchanged and stable in 43% of cases (12 areas) after intensive therapy.