Changes in Indocyanine Green Lymphography Patterns after Physical Treatment in Secondary Upper Limb Lymphedema

Visualising lymphatic flow dynamics during complex physical therapy: A photoacoustic imaging study

Background

Complex physical therapy (CPT), which combines compression and exercise therapies, is the cornerstone of lymphedema treatment. However, assessing lymphatic flow in living humans is challenging owing to the small size and transparent nature of lymphatic vessels. Herein, we introduce a novel approach utilising photoacoustic imaging (PAI) to visualise lymphatic flow dynamics under CPT conditions. Compared with existing modalities, PAI offers superior details, enabling real-time evaluation of lymphatic vessels during compression and exercise. Real-time evaluation of lymphatic flow may enable advanced research on optimal perioperative compression therapy and exercise therapy.

Methods and Results

Herein, PAI was used to assess lymphatic flow in four healthy subjects. Detailed images of lymphatic and blood vessels were obtained using photoacoustic lymphangiography, which utilises indocyanine green as a light absorber. The participants underwent simulated compression using a transparent film dressing, with a pressure of approximately 20 mmHg. Exercise stress was applied to mimic CPT conditions. Compression facilitated the collapse of superficial veins while lymphatic vessels remained intact. Additionally, the lymphatic pumping frequency was the highest during combined compression and exercise, highlighting the synergistic effect of these therapies on lymphatic flow.

Conclusion

Our findings underscore the potential of PAI in elucidating the mechanisms underlying the efficacy of CPT. PAI may enable comprehensive assessments of vascular changes during CPT by allowing simultaneous delineation of veins and lymphatic vessels. While our study represents a significant step forward, its limitations, including small sample size and exercise regimen specificity, warrant further investigations.

Physiotherapy protocol to reduce the evolution time of axillary web syndrome in women post-breast cancer surgery: a randomized clinical trial

OBJECTIVE

To reduce the evolution time of axillary web syndrome in women who have undergone breast cancer surgery.

METHODS

A prospective, randomized, single-blind clinical trial was conducted on 46 post breast cancer surgery patients from October 2021 to September 2024, in a single university hospital with painful Axillary Web Syndrome (AWS) that restricts arm mobility. The treatment for the intervention group consisted of stretching combined with manual therapy and scar massage to release adhesion and lymphatic cord during 15 physiotherapy sessions of 30 min duration each. The main outcome measures were: healing time, pain, evaluated with Visual Analogue Scaler (VAS) and arm Range of Motion (ROM), evaluated with goniometry.

RESULTS

Significant differences were detected in pain and in ROM. The effect of the intervention varied over time with 95% confidence interval (risk alpha 0.05) and a statistical power of 90% (risk beta 0.1). Comparisons between Control and Intervention Groups showed significant statistical and clinical differences in favour of Intervention Group after 30, 60 and 90 days of intervention at follow-ups for all measured parameters. The proportion of healed patients was significantly higher in the intervention group from day 30 onwards (two-sample test for equality of proportions: p < 0.001), indicating a faster recovery in the intervention group.

CONCLUSION

The results suggested that stretching combined with scar massage and manipulative tissue release techniques lead to a faster recovery and reduce the evolution time of axillary web syndrome. The physiotherapy technique described in this article could be the technique of choice for this surgical sequela.

TRIAL REGISTRATION

ClinicalTrials.gov Registry (NCT05115799) on June 10th 2021 and the approval of the Andalucía Ethics Committee (PEIBA code 1909-N1-21, reg. number 171.21).

The Effectiveness of Fluoroscopy-Guided Manual Lymph Drainage as Part of Decongestive Lymphatic Therapy on the Superficial Lymphatic Architecture in Patients with Breast Cancer-Related Lymphoedema: A Randomised Controlled Trial

The objective of this trial was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD), as part of decongestive lymphatic therapy (DLT), on the superficial lymphatic architecture in patients with chronic mild to moderate breast cancer-related lymphoedema (BCRL). This trial was a multicentre, double-blind, randomised controlled trial involving 194 participants with BCRL. Participants were randomised into (1) DLT with fluoroscopy-guided MLD (intervention group), (2) DLT with traditional MLD (control group), or (3) DLT with placebo MLD (placebo group). Superficial lymphatic architecture was evaluated as a secondary outcome, visualised by ICG lymphofluoroscopy at the baseline (B0), post-intensive (P), and post-maintenance phases (P6). Variables were (1) number of efferent superficial lymphatic vessels leaving the dermal backflow region, (2) total dermal backflow score, and (3) number of superficial lymph nodes. The traditional MLD group showed a significant decrease in the number of efferent superficial lymphatic vessels at P (p = 0.026), and of the total dermal backflow score at P6 (p = 0.042). The fluoroscopy-guided MLD and placebo group showed significant decreases in the total dermal backflow score at P (p < 0.001 and p = 0.044, respectively) and at P6 (p < 0.001 and p = 0.007, respectively); the placebo MLD group showed a significant decrease in the total number of lymph nodes at P (p = 0.008). However, there were no significant between-group differences for the changes in these variables. In conclusion, based on lymphatic architecture outcomes, the added value of MLD, in addition to the other parts of DLT, could not be demonstrated in patients with chronic mild to moderate BCRL.

Value of one additional injection at the root of the limb in the lymphoscintigraphic evaluation and management of primary and secondary lower-limb lymphedemas

Introduction

The classical lymphoscintigraphic investigations of lower-limb lymphatic edema [LLLE] sometimes reveal either no or few lymph nodes [LNs] at the root of the limb[s] and/or in the abdomen. The aim of the present paper is to report the results of performing one additional injection at the root of the edematous limb[s] to force the visualization of the LNs and/or to demonstrate the collateral lymphatic pathways in such patients.

Methods and findings

We retrospectively reviewed our database and found 99 patients [44 primary LLLE with 47 limbs injected and 55 with LLLE secondary to treatments for cancer with 64 limbs injected] where such an additional injection had been performed.

In the 43 LLLE patients where no LNs were seen at the end of the classical exam [15 primary LLLE and 28 secondary LLLE], the extra injection showed lymphatic drainage toward LN[s] in all except 3 and when at least one LN was seen, the injection showed lymphatic drainage in every case toward the same ipsilateral [inguinal and/or iliac] LNs [as shown by the classical injection] and/or toward additional LNs.

In 40.7% of patients, we observed one or more additional lymphatic pathways: prepubic superficial lymphatic vessels [LV] crossing the midline anteriorly toward contralateral inguinal LNs in 21 [18.9%], “posterior” LV [toward contralateral inguinal LNs and/or ipsi- or contralateral lumbo-aortic and/or para-renal LNs] in 14 [12.6%], but deep LV toward the ipsilateral common iliac LNs passing between the gluteal muscles in 32 [28.8%].

Conclusion

Our work pinpoints one limitation of classical bipedal radionuclide lymphangiography. In patients with primary and secondary LLLE where inguinal and/or iliac LNs cannot be seen on bipedal radionuclide lymphangiography, this additional injection reveals the true lympho-nodal status and shows unexpected collateral lymphatic pathways in 40% of cases. Such information is of the utmost importance in LLLE management and its acquisition is consequently recommended in these patients.

Inflow Occlusion Combined With Bleomycin Sclerotherapy for Management of Macro/Mixed Cystic Lymphatic Malformation in Children

Background: The link between cystic lymphatic malformation (cLM) and normal lymphatic system has become the focus of research. This study aimed to assess the outcomes of indocyanine green (ICG) lymphography-guided inflow occlusion combined with bleomycin sclerotherapy for the management of macro or mixed cLM in children. Methods: Between June 2018 and October 2020, inflow occlusion combined with bleomycin sclerotherapy was performed in 81 cLM patients (age range from 6 months to 8 years). All cases were evaluated by the following parameters: cLM location, histological typing, number of afferent lymph vessels, dermal backflow, curative effects, treatment frequency, and postoperative complications. The duration of postoperative follow-up was from 10 to 16 months. Results: All cLM cases could be found with at least one lymphatic inflow. Excellent outcomes were observed in 68 cases (84.0%), 11 cases (13.6%) experienced good outcomes, and two (2.5%) cases had fair outcome. No case experienced repeated treatment for more than three times. Wound infection, fever, and scar hyperplasia were the independent adverse events, which were managed by symptomatic treatment. Conclusion: Inflow occlusion combined with bleomycin sclerotherapy renders a safe and efficient approach for the management of macro or mixed cLM.