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How can near-infrared ICG
fluorescence imaging optimize
compression therapy?
Sarah Thomis, MDCoordinator Lymphovenous Center,
Department of Vascular Surgery,
University Hospitals Leuven, Belgium
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IMAGING LYMPHOEDEMA
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Imaging lymphoedema
• US:
- Tickening of the skin = typical sign of
lymphoedema
- Duplex ultrasound can eliminate other
causes of swelling e.g. DVT
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Skin
Sub-
cutis
Muscle
Skin
Sub-
cutis
Muscle
LYMPHOEDEMA NORMAL
Infosessie lymfestelsel, lymfoedeem en preventie
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Imaging lymphoedema
• CT/MRI
(lymphangio)
- Visualisation of
enlarged lymph
nodes
- Visualisation of
lymphoedema/lymph
vessels, but no
information on
functionality
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Imaging lymphoedema
• Lymphoscintigraphy:
- Injection of an isotopicagent in the first/second webspace of the extremity
- Product is absorbed by thelymph vessels
- Different scan moments
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Imaging lymphoedema
• Lymphoscintigraphy:
- Idea of the lymph transport/amount of
lymph nodes
- Calculation of the extraction time
- Visualisation of dermal backflow
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LYMPHOFLUOROSCOPY
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ICG fluoroscopy
• Indocyanine Green (ICG) is used in
ophtalmological interventions, monitoring
liver function in ICU, sentinel lymph node
mapping
• Lymphofluoroscopy:
– Details of architecture of lymph vessels (max 2 cm
depth!)
– Different patterns
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Procedure
• Patient in sitting/ supine
position
• Injection of ICG/ aqua (1:1)
intradermally: 0,2 ml in 1st and
4th webspace
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Procedure
• Indocyanine green injected intradermally
dermal lymphatic capillaries
pre-collector and collector
• PDE camera to obtain
fluorescence images
• Two sessions (in rest –
after exercise)
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• tekening uit artikel
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With permission: JP Belgrado, Washington Sept 2014
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Classification images secundary LO
• Normal pattern: linear
• Abnormal pattern: dermal backflow (DB)
– Mild damage/ obstruction: splash DB pattern
– Severe damage: stardust DB pattern
– Destructed: diffuse DB pattern
(Yamamoto et al 2011)
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• Foto Belgrado
With permission: JP Belgrado, Washington Sept 2014
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Splash/ stardust
• Beelden declerck
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Moving liquid through interstitium/
network
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Advantages fluoroscopy
• No isotopic agents
• Lower cost
• Details of the superficial architecture
• Better visualisation of oedema of the
foot/hand
• Real-time imaging
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Pitfalls fluoroscopy
• No visualisation of deep lymph
vessels (only 2 cm deep)
• In lymphoedema patients no
quantification possible
• In Belgium: off label use
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Indication lymphofluroscopy
• Difficult to treat certain areas
• Deterioration of oedema
• Aid for surgical interventions
optimize compression devices and
manual lymph drainage
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Normal
Lymphatic
system
Not normal
Lymphatic
system
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Normal
lymphatic
system
Not normal
lymphatic
system
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Adjusting compression
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CASE REPORTS
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Patient 1: pubic/ genital oedema
• Age: 75 y
• Prostate cancer:
– 2011 prostatectomy and radiotherapy
– 8-2014 lymphadenectomy ilioinguinal
• 1m postop, pubic and left leg oedema
• DLT: great improvement leg oedema,
still inguinal and pubic/ scrotal oedema
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Adjustment compression: AG
compression stocking + bermuda short
with extra padding scrotal area
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Patient 2: arm oedema
• Female, Age: 54 y
• Mastectomy and ALND left
• Pitting oedema lower arm ++
(especially distal and ventral area)
• MLD and sleeve with glove without
fingers
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Adjustment: Long glove with fingers,
no arm sleeve
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Patient 3: leg oedema
• Female, Age: 46 y
• 2016: bilateral oedema lower legs, no
good result with lymph drainage
• 06-2016: lymphoscintigraphy: bilateral
disturbance lymphatic transport lower
legs, no majeur abnormalities
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Prescription of a compression
stocking AD flat knit and a toe kap left
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Patient 4: hand oedema
• Female, Age: 57 y
• 2015: breast cancer left: Breast sparing
surgery and ALND + radiotherapy +
chemotherapy
• oedema left hand ++ dorsal and ventral
side, lower arm
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Lymph pads ventral/dorsal hand
and lower arm under sleeve/glove
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Patient 5: oedema face
• Male, Age: 53 y
• 11-02-2014: diagnosis Morbihan Disease
• Lymphoscintigraphy:
1. Good lymph transport from the chin tosubmental area bilateral and visualisation of some submental and supraclavicular nodes
2. From the preauricular area no visualisation of a clear lymph vessel
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Adjusting lymph drainage and
prescribing an adjusted mask
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Patient 6: hand oedema
• Female, Age: 40 y
• 2003: breast cancer right: mastectomyand ALND + radiotherapy
• 2014: erysipelas
• Oedema hand since surgery, increaseoedema since erysipelas
• Nevertheless consequent compression, no decrease of oedema
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Patient 7: oedema arm
• Female, Age: 52 y
• 1996: Breast sparing surgery + ALND
right
• Chemotherapy and radiotherapy
• Persistent oedema dorsal lower arm
despite compression and MLD
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Conclusions
• ICG lymphofluoroscopy:
- New information
- To optimize treatment: compression
treatment and MLD
- Future: quantification of the function of
lymph transport
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• Thanks to JP Belgrado to introduce us
in the lymphofluoroscopy
• Thanks to our team!
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And thank you for your attention!!