| 제목 |
ICG lymphography and lymphoscintigraphy stage showed strong correlation in lower limb lymphedema |
| 소속 |
Pusan National University School of medicine, Pusan National University Hospital, Department of Rehabilitation Medicine1, Busan Cancer Center, Pusan National University Hospital and Biomedical Research Institute, Pusan National University Hospital, Department of Plastic and Reconstructive Surgery2 |
| 저자 |
Sang Hun Han1*, Min Soo Choi1, Dong Min Kim1, Da Hwi Jung1, Ho Eun Park1, Jae Hyeok Chang1, Myung Jun Shin1, Joo Hyoung Kim2, Jin A Yoon1† |
Purpose: To examine the correlation between lymphedema severity on lymphoscintigraphy and indocyanine green (ICG) lymphography in patients with secondary lower extremity lymphedema.
Method: Lymphoscintigraphy and ICG lymphography images were classified into type I–V according to dermal backflow (DB) stage and MD Anderson Cancer Center (MDACC) stage based on lymphatic flow preservation and how DB was extended (Fig. 1, 2). Correlation between the scales was analyzed.
Result: Forty-four patients attended our hospital for evaluation of secondary lower extremity lymphedema. Correlation analysis showed that lymphoscintigraphy and ICG DB (anterior) stage (r = 0.92), lymphoscintigraphy and ICG DB (posterior) stage (r = 0.94), and lymphoscintigraphy and MDACC stage (r = 0.93) exhibited very strong positive correlations (Table 1). Intra-rater agreement between lymphoscintigraphy and ICG DB (posterior) stage was substantial (κ = 0.65), and moderate between lymphoscintigraphy and ICG DB (anterior) stage (κ = 0.59) and lymphoscintigraphy and MDACC stage (κ = 0.52). Lymphedema severity stages and maximal circumference differences exhibited moderate positive correlations (Table 2).
Discussion: In this study, although the degree of agreement was relatively low because the criteria for dividing the type by extension of DB were somewhat different between the two tests, the correlation between lymphoscintigraphy and ICG DB stages was high. DB flow is the phenomenon of lymph backflow from the collecting lymph duct to the dermis. Therefore, since DB is located in a shallow region, there is no significant difference in the confirmation of DB between ICG lymphography, which mainly detects superficial lymphatics, and lymphoscintigraphy, which mainly detects deep lymphatics. There may be limitations in both tests for discriminating the part of the lymphatic vessel that is partially preserved and covered under the DB. In terms of concordance, ICG DB stage showed a somewhat higher kappa value than ICG MDACC stage. This may be because the lymphoscintigraphy stage and the ICG DB stage coincide with the disease progression generally occurring in the proximal to distal direction in secondary lower extremity lymphedema and the grading in terms of resulting extension of the DB. However, in MDACC, types are divided according to preserved lymphatic vessels, which can be easier to use as a prognostic tool through lymphatic mapping during microsurgery. In the case of ADB stages III to V, which are divided based on stardust and diffuse DB patterns, it is easy to determine postoperative improvement. However, it is excluded from the criteria that determining possibility of lymphaticovenous anastomosis, because precise evaluation is easier with the MDACC stage.
Conclusion: Lymphoscintigraphy and ICG lymphography stage were strongly and positively correlated. These studies can work synergistically as complementary studies of lymphedema severity. |
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Figure 1. ICG lymphography images of cases of ICG DB stage and MDACC stage Type I to V, A: ICG DB type I, MDACC type I, B: ICG DB type II, MDACC type II, C: ICG DB type III, MDACC type III, D: ICG DB type IV, MDACC type IV, E: ICG DB type V, MDACC type IV, F: ICG DB type V, MDACC type V, * ICG, indocyanine green; DB, dermal back flow; MDACC, MD Anderson Cancer Center
Figure 2. Lymphoscintigraphy images of cases of Type I to V
Table 1. Correlation analysis between lymphedema severity stages, Table 2. Correlation analysis between lymphedema severity stages and circumferential measurements
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