Comparison of lymphoscintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema

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Summary

Background

Lymphoscintigraphy is the gold-standard examination for extremity lymphoedema. Indocyanine green lymphography may be useful for diagnosis as well. We compared the utility of these two examination methods for patients with suspected extremity lymphoedema and for those in whom surgical treatment of lymphoedema was under consideration.

Methods

A total of 169 extremities with lymphoedema secondary to lymph node dissection and 65 extremities with idiopathic oedema (suspected primary lymphoedema) were evaluated; the utility of indocyanine green lymphography for diagnosis was compared with lymphoscintigraphy. Regression analysis between lymphoscintigraphy type and indocyanine green lymphography stage was conducted in the secondary lymphoedema group.

Results

In secondary oedema, the sensitivity of indocyanine green lymphography, compared with lymphoscintigraphy, was 0.972, the specificity was 0.548 and the accuracy was 0.816. When patients with lymphoscintigraphy type I and indocyanine green lymphography stage I were regarded as negative, the sensitivity of the indocyanine green lymphography was 0.978, the specificity was 0.925 and the accuracy was 0.953. There was a significant positive correlation between the lymphoscintigraphy type and the indocyanine green lymphography stage. In idiopathic oedema, the sensitivity of indocyanine green lymphography was 0.974, the specificity was 0.778 and the accuracy was 0.892.

Conclusion

In secondary lymphoedema, earlier and less severe dysfunction could be detected by indocyanine green lymphography. Indocyanine green lymphography is recommended to determine patients' suitability for lymphaticovenular anastomosis, because the diagnostic ability of the test and its evaluation capability for disease severity is similar to lymphoscintigraphy but with less invasiveness and a lower cost. To detect primary lymphoedema, indocyanine green lymphography should be used first as a screening examination; when the results are positive, lymphoscintigraphy is useful to obtain further information.

Section snippets

Patients and methods

A retrospective study was conducted in 134 consecutive patients who underwent both lymphoscintigraphy and indocyanine green lymphography to investigate extremity oedema at Chiba University Hospital between August 2010 and March 2012. The study protocol was approved by the institutional review board and written informed consent was obtained from all subjects. In all patients, both extremities, whether involved or uninvolved, were injected and imaged simultaneously. Patients were divided into a

Results

The patient population comprised 115 females and 19 males. The average patient age was 58.5 years, ranging from 9 to 82 years. Unilateral oedema was present in 71 patients and 63 had bilateral oedema. Secondary oedema after lymph node dissection was present in 95 patients: these patients made up the secondary group. The other 39 patients had idiopathic extremity oedema, suspected of being primary lymphoedema after other causes were excluded: these patients made up the idiopathic group.

Of the 95

Discussion

In both the secondary group and the idiopathic study group, the sensitivity and NPV of indocyanine green lymphography were very high when their results were compared with those of the gold standard, lymphoscintigraphy. The specificity and the PPV, however, were not very high, as a number of limbs were positive by indocyanine green lymphography but negative by lymphoscintigraphy.

With respect to secondary lymphoedema, Mihara et al. reported that, because histological changes could already be

Conclusion

Indocyanine green lymphography is recommended to evaluate the suitability of patients with secondary lymphoedema for lymphaticovenular anastomosis. The diagnostic ability of the test and its capability to evaluate the severity of oedema are similar to lymphoscintigraphy while the invasiveness and examination costs are less.

To detect primary lymphoedema in patients with idiopathic extremity oedema, we recommend that indocyanine green lymphography be conducted first as a screening examination.

Ethical consent

This study was carried out in Chiba University Hospital (Chiba, Japan) with approval of the institutional review board and permission from the ethics committee. Written permission for publication of photographs was obtained from all patients before they were included in this study.

Conflict of interest/funding

None.

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