Reply: Time to Reconsider a Gold Standard of Lymph Flow Imaging: Importance of Reliability to Detect Abnormal Lymphodynamics in Lymphedema Screening after Cancer Treatments

Rossi, Matteo M.D.; D’Arpa, Salvatore M.D., Ph.D.; Costa, Renato M.D.; Moschella, Francesco M.D.; Cordova, Adriana M.D.

Plastic & Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 1029e–1030e
doi: 10.1097/PRS.0000000000003205
Letters

Plastic and Reconstructive Surgery, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Palermo, Italy

Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium

Nuclear Medicine, Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy

Plastic and Reconstructive Surgery, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Palermo, Italy

Plastic and Reconstructive Surgery, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Palermo, Italy

Correspondence to Dr. Rossi, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy, matt.rossi17@virgilio.it

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Sir:

We appreciate the comments of Dr. Yamamoto et al. Dr. Yamamoto correctly emphasizes that, compared to lymphoscintigraphy, indocyanine green lymphography allows visualization of superficial lymph flow very clearly, without radiation exposure, and allows accurate early diagnosis of subclinical or clinical lymphedema. He also points out that there are other methods, such as magnetic resonance lymphography, computed tomographic lymphography, and ultrasonographic lymphography, that might be more useful for early diagnosis.1

We share his thoughts as partially pointed out in our article. However, the purpose of our study was not to investigate which is the best technique for diagnosing lymphedema, but rather to question the lymphoscintigraphic criteria still used to evaluate lymphatic alterations.

The limbs are currently considered symmetric from a lymphodynamic standpoint, and it is generally believed that, under normal conditions, the radiolabeled tracer appearance time in the axillary nodes should be less than 30 minutes. Such assumptions come mostly from articles that use the contralateral limb of lymphedema patients as a healthy control (and assuming often that the behavior of the upper and lower limbs is similar). Our study, performed on healthy volunteers and on melanoma patients before any lymphatic operation, demonstrates that up to 50 percent of cases show lymphoscintigraphic asymmetries, and the tracer appearance time is greater than 30 minutes in the majority of cases. Our findings suggest that the contralateral arm of a patient with lymphedema is not a reliable model with which to study the physiology of the lymphatic system and that a tracer appearance time greater than 30 minutes may not necessarily be abnormal.2 Even Dr. Yamamoto et al. investigated, through indocyanine green lymphography, the contralateral limbs in lymphedema patients.3,4

The contralateral limbs can have lymph flow alterations caused by a general compromise of the lymphatic system or also caused by a condition that was present before the onset of lymphedema. It is only by investigating patients in a preoperative phase and then following them that we can answer this question. In addition, we believe that diagnostic modalities such as indocyanine green lymphography could be used in the prevention of lymphedema rather than only in the early diagnosis, to allow early and selective surgical prophylactic strategies (e.g., lymphaticovenular anastomoses, lymph node transfer). However, any imaging technique used to detect predictive factors for development of lymphedema should provide a preoperative screening of the lymphatic system and not just a postoperative evaluation. It has been shown that lymphedema has a systemic and not just a local effect5; this means that the contralateral limb cannot be used as a control in a lymphedema patient. We still have a long way to go, and if we want to understand the lymphatic system, we should prospectively evaluate, with different imaging techniques, the lymphatic system over time in patients before and after surgery.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Matteo Rossi, M.D.

Plastic and Reconstructive Surgery

Department of Surgical, Oncological, and Oral Sciences

University of Palermo

Palermo, Italy

Salvatore D’Arpa, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery

Ghent University Hospital

Ghent, Belgium

Renato Costa, M.D.

Nuclear Medicine

Biomedical Department of Internal and Specialist Medicine

University of Palermo

Palermo, Italy

Francesco Moschella, M.D.

Plastic and Reconstructive Surgery

Department of Surgical, Oncological, and Oral Sciences

University of Palermo

Palermo, Italy

Adriana Cordova, M.D.

Plastic and Reconstructive Surgery

Department of Surgical, Oncological, and Oral Sciences

University of Palermo

Palermo, Italy

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REFERENCES

1. Yamamoto T, Yamamoto N, Ishiura RTime to reconsider a gold standard of lymph flow imaging: Importance of reliability to detect abnormal lymphodynamics in lymphedema screening after cancer treatments. Plast Reconstr Surg. 2016. doi: 10.1097/PRS.0000000000003204. [Epub ahead of print].
2. Rossi M, Grassi R, Costa R, et alEvaluation of the upper limb lymphatic system: A prospective lymphoscintigraphic study in melanoma patients and healthy controls. Plast Reconstr Surg. 2016;138:1321–1331.
3. Yamamoto T, Matsuda N, Doi K, et alThe earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128:314e–321e.
4. Yamamoto T, Narushima M, Yoshimatsu H, et alDynamic indocyanine green (ICG) lymphography for breast cancer-related arm lymphedema. Ann Plast Surg. 2014;73:706–709.
5. Mortimer PArm lymphoedema after breast cancer. Lancet Oncol. 2013;14:442–443.
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