Abstract

Sentinel lymph node identification by near infrared (NIR) fluorescence with indocyanine green (ICG) is recognized in the literature as a useful technique. NIR fluorescence technology could become key in the prevention and management of lymphedema after axillary dissection for breast cancer. Here, we conducted a systematic review focusing on ICG imaging to improve lymphedema prevention and treatment after axillary surgery.

A systematic literature review was performed using MEDLINE and Embase to identify articles focused on ICG imaging for breast-cancer-related lymphedema (BCRL). Qualitative analysis was performed to summarize the characteristics of reported ICG procedures. In situ tissue identification and functionality assessment based on fluorescence signal were evaluated. Clinical outcomes were appraised when reported.

Studies relating to axillary reverse mapping, lymphography and upper limb supermicrosurgery combined with ICG imaging were identified. We included a total of 33 relevant articles with a total of 2016 patients enrolled. ICG imaging for axillary reverse mapping was safe for all 951 included patients, with identification of arm nodes in 80%e88% of patients with axillary lymph nodes dissection. However, the papers discuss the oncologic safety of the approach and how – regardless of the contrast agent – concerns limit its adoption. ICG lymphography is openly supported in BCRL management, with 1065 patients undergoing this procedure in 26 articles. The technique is reported for lymphedema diagnosis, with high sensitivity and specificity, staging, intraoperative mapping and patency control in lymphaticovenular anastomosis. The substantial advantages/disadvantages of ICG imaging procedures are finally described.

Main findings

NIR fluorescence imaging is gaining interest in breast surgery, mainly for SLN identification but also for ARM node identification in axillary lymph node dissection and supermicrosurgery following BCRL. At present, it is not possible to conclude on its advantages over standard clinical techniques but the contribution of multidimensional real-time imaging that does not use a radiolabelled probe could undoubtedly provide new possibilities for BCRL prevention and management. Other non-invasive optical techniques to enable surgeons to accurately visualize the lymphatic system and flow (such as OCT, Doppler OCTand photoacoustic imaging) are also evolving rapidly, with intraoperative applications expected in the future.