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.