Publications

OBJECTIVE: To assess changes in noncontrast magnetic resonance imaging (MRI)-based biomarkers after upper extremity lymphedema surgery.

METHODS: We retrospectively identified secondary upper extremity lymphedema patients who underwent vascularized lymph node transplant (VLNT), debulking lipectomy, or VLNT with a prior debulking (performed separately). All patients with both preoperative and postoperative MRIs were compared. An MRI-based edema scoring system was used: 0 (no edema), 1 (<50% fluid from myofascial to dermis), and 2 (≥50% fluid from myofascial to dermis). Edema scores and subcutaneous thickness (ST) were obtained along four quadrants across the upper and lower third of the arm and forearm each-for a total of 16 anatomical locations-and compared before and after surgery. Net changes in edema scores and ST were then correlated with Lymphoedema Quality-of-Life Questionnaire scores, L-Dex (bioimpedance), and limb volume difference by perometry.

RESULTS: Patients who underwent lymphatic surgeries between January 2017 and December 2022 and successfully completed preoperative and postoperative MRI were included, resulting in a total of 33 unilateral secondary upper extremity lymphedema patients m(mean age, 63 ± 14 years; 32 female). The median postoperative follow-up times were 12.5 months (range, 6-19 months) for VLNT, 13.5 months (range, 12-40 months) for debulking, and 12.0 months (range, 12-24 months) for patients who underwent VLNT after debulking surgery. There was a decrease in mean ST in 15 of 16 anatomical segments of the upper extremity after debulking (P < .001), and the edema score increased in 7 of 16 segments (P ≤ .001-.020). Edema stage did not change in patients who underwent VLNT only or VLNT after debulking. ST decreased only along the radial forearm in patients who underwent VLNT after debulking despite an improvement in the Lymphoedema Quality-of-Life Questionnaire score in the former group. There was correlation between a decrease in ST with a decrease in volume within the debulking group (r = 0.79; P < .001). A decrease in ST also correlated with improved lymphedema quality of life questionnaires in the debulking group (r = 0.49; P = .04).

CONCLUSIONS: A decrease in ST was demonstrated in most anatomical segments after liposuction debulking, whereas edema stage was increased. Fewer changes were seen with VLNT, possibly a reflection of more gradual changes within this short follow-up period, with the radial forearm potentially revealing the earliest response.

BACKGROUND: Variations of hand and forearm lymphatic drainage to upper-arm lymphatic pathways may impact the route of melanoma metastasis. This study compared rates of lymphatic drainage to epitrochlear nodes between anatomic divisions of the hand and forearm to determine whether the anatomic distribution of hand and forearm melanomas affects the likelihood of drainage to epitrochlear lymph nodes.

METHODS: Using a single-institution lymphoscintigraphy database, we identified all patients with cutaneous melanoma on the hand and forearm. A body-map two-dimensional coordinate system was used to classify cutaneous melanoma sites between radial-ulnar and dorsal-volar divisions. Sentinel lymph nodes (SLNs) visualized on lymphoscintigraphy were recorded. Proportions of patients with epitrochlear SLNs were compared between anatomic divisions using χ2 analysis.

RESULTS: Of 3628 upper extremity cutaneous melanoma patients who underwent lymphatic mapping with lymphoscintigraphy, 1400 met inclusion criteria. Twenty-one percent of patients demonstrated epitrochlear SLNs. Epitrochlear SLNs were observed in 27% of dorsal forearm melanomas and 15% of volar forearm melanomas (p < 0.001). Epitrochlear SLNs were observed in 31% of ulnar forearm melanomas and 17% of radial forearm melanomas (p < 0.001).

CONCLUSIONS: Higher proportions of dorsal and ulnar forearm melanomas have epitrochlear SLNs. Metastasis to epitrochlear SLNs may be more likely from melanomas in these respective forearm regions.

BACKGROUND: Lymphatic drainage from the arm may be altered after axillary lymph node dissection (ALND). Understanding these alterations is important as they may change standard surgical and radiation treatment in recurrent breast cancer or upper extremity skin cancers, including melanoma.

METHODS: Utilizing a single-institution planar and single photon emission computed tomography/computed tomography lymphoscintigraphy database, we identified patients with a diagnosis of upper extremity cutaneous melanoma from 2008 to 2023 who previously underwent ALND for cancer treatment and did not develop upper extremity cancer-related lymphedema. ALND patients were matched to control patients presenting with cutaneous melanomas at the same anatomic sites. Sentinel lymph nodes (SLNs) were compared between both groups.

RESULTS: Of 3628 upper extremity melanoma cutaneous patients, 934 met inclusion criteria, including 22 ALND and 912 control patients. Level I axillary SLN drainage was observed in 98% of controls and 27% of ALND patients (p < 0.001). Level II axillary SLN drainage was observed in 3% of controls and 27% of ALND patients (p < 0.001). Level III axillary SLN drainage was observed in 1% of controls and 32% of ALND patients (p < 0.001). Epitrochlear SLN drainage was observed in 9% of controls and 32% of ALND patients, respectively (p < 0.046). Brachial SLN drainage was observed in 4% of controls and 23% of ALND patients (p < 0.001).

CONCLUSIONS: Distinct changes in functional lymphatic drainage were seen between the arms of patients who previously underwent ALND versus control patients. Levels II and III axillary, epitrochlear, and brachial nodes are possible sites of metastatic disease that should be considered in patients with a prior ALND.

OBJECTIVE: We evaluated whether superficial lymphatic anatomy and functional lymph node drainage are symmetric between the right and left upper extremities of healthy female volunteers, and if handedness is associated with symmetry of superficial lymphatic anatomy.

BACKGROUND: Symmetry of lymphatic anatomy has been assumed historically. This assumption of individual anatomic symmetry is being utilized clinically and in research without validation.

METHODS: 36 normal female volunteers underwent bilateral indocyanine green (ICG) lymphography and lymphoscintigraphy of the upper extremities. Eight collecting vessel pathways of each upper extremity were mapped on ICG lymphography. 13 lymph node groups were visualized on lymphoscintigraphy. Symmetry of lymphatic anatomy and functional drainage were established by comparing the right and left extremities of each participant. Hand dominance was assessed by hand grip strength on a hand dynamometer.

RESULTS: Among the 36 participants, 10 (28%) showed symmetry of all eight upper extremity lymphatic pathways with ICG. However, only 1 (3%) participant demonstrated complete symmetry amongst the 13 lymph node groups. Total symmetry of lymphatic channels was observed on ICG in seven (39%) participants with hand dominance and three (17%) participants without hand dominance (X2 = 2.215, P = 0.137).

CONCLUSION: Lymphatic anatomy and functional drainage of the upper extremities are not consistently symmetric. Functional nodal drainage as demonstrated by lymphoscintigraphy shows less symmetry than anatomic studies of lymphatic channels using ICG. Symmetric lymphatic anatomy does not appear to correlate with hand dominance. These findings challenge the prevailing assumption of left-right lymphatic symmetry.

Background: Secondary upper extremity lymphedema occurs after an insult such as surgery. One theory suggests underlying lymphatic dysfunction predisposing certain patients into developing secondary lymphedema. We aim to determine the rate of incidental edema in the contralateral upper extremity of patients with secondary unilateral lymphedema. Methods and Results: MRI of the upper extremities were obtained in patients with lymphedema who were referred by a lymphedema clinic from 2017 to 2019. Axial short-tau inversion recovery MR images of the symptomatic and contralateral arms were retrospectively reviewed and edema severity was graded. Interobserver agreement was calculated. Indocyanine green (ICG) lymphography was compared against MRI stage in symptomatic and contralateral. Age, symptom duration, body mass index (BMI), and history of chemotherapy were compared between patients with and without contralateral limb lymphedema. ICG severity was compared against MRI stage. Seventy-eight patients were analyzed. The MRI stages of symptomatic versus contralateral arms were 1.7 ± 1.1 versus 0.1 ± 0.4 (p < 0.00001). Interobserver agreement was 0.86 (0.79-0.94). Of the patients with MRI Stage 1 or above in the symptomatic arm (n = 64), 55 (82.1%) patients demonstrated no abnormality in the contralateral arm. Nine patients (14.1%) demonstrated asymptomatic edema (MRI Stage 1). The mean ICG lymphography stage of symptomatic versus contralateral arms was 1.83 ± 0.96 versus 0.04 ± 0.25 (p < 0.00001). There was no difference in the age, symptom duration, BMI, or history of chemotherapy between patients with or without edema in the contralateral arm. Conclusion: Asymptomatic contralateral edema was detected in 14.1% of patients with unilateral secondary upper extremity lymphedema using MRI modality.

Lymphedema is a devastating disease that has no cure. Management of lymphedema has evolved rapidly over the past two decades with the advent of surgeries that can ameliorate symptoms. MRI has played an increasingly important role in the diagnosis and evaluation of lymphedema, as it provides high spatial resolution of the distribution and severity of soft tissue edema, characterizes diseased lymphatic channels, and assesses secondary effects such as fat hypertrophy. Many different MR techniques have been developed for the evaluation of lymphedema, and the modality can be tailored to suit the needs of a lymphatic clinic. In this review article we provide an overview of lymphedema, current management options, and the current role of MRI in lymphedema diagnosis and management. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.

PURPOSE: The tricipital, or Caplan's, lymphatic pathway has been previously identified in cadavers and described as a potential compensatory pathway for lymphatic drainage of the upper extremity, as it may drain lymphatic fluid directly to the scapular lymph nodes, avoiding the axillary lymph node groups. The aim of this study was to map the anatomy of the tricipital pathway in vivo in patients without lymphatic disease.

METHODS: A retrospective review was performed to identify patients with unilateral breast cancer undergoing preoperative Indocyanine green (ICG) lymphography prior to axillary lymph node dissection from May 2021 through January 2022. Exclusion criteria were evidence or known history of upper extremity lymphedema or non-linear channels visualized on ICG. Demographic, oncologic, and ICG imaging data were extracted from a Lymphatic Surgery Database. The primary outcome of this study was the presence and absence of the tricipital pathway. The secondary outcome was major anatomical variations among those with a tricipital pathway.

RESULTS: Thirty patients underwent preoperative ICG lymphography in the study period. The tricipital pathway was visualized in the posterior upper arm in 90% of patients. In 63% of patients, the pathway had a functional connection to the forearm (long bundle variant) and in 27%, the pathway was isolated to the upper arm without a connection to the forearm (short bundle variant). In those with a long bundle, the contribution was predominantly from the posterior ulnar lymphosome. Anatomic destinations of the tricipital pathway included the deltotricipital groove and the medial upper arm channel, which drains to the axilla.

CONCLUSION: When present, the tricipital pathway coursed along the posterior upper arm with variability in its connections to the forearm distally, and the torso proximally. Long-term follow-up studies will help determine the significance of these anatomic variations in terms of individual risk of lymphedema after axillary nodal dissection.

Immediate lymphatic reconstruction (ILR) has become increasingly utilized for the prevention of breast cancer-related lymphedema (BCRL). A growing body of evidence has demonstrated the long-term efficacy of ILR in reducing the rate of BCRL. While certain risk factors for BCRL are well-recognized, such as axillary lymph node dissection, regional lymph node radiation, and elevated body mass index, other potential risk factors such as age and taxane-based chemotherapeutics remain under discussion. Our experience with ILR has highlighted an additional potential risk factor for BCRL. Lymphatic anatomy, specifically compensatory lymphatic channels that bypass the axilla, may play a largely underrecognized role in determining which patients will develop BCRL after ILR. Foundational anatomic knowledge has primarily been based on cadaveric studies that predate the twentieth century. Modern approaches to lymphatic anatomical mapping using indocyanine green lymphography have helped to elucidate baseline lymphatic anatomy and compensatory channels, and certain variations within these channels may act as anatomic risk factors. Therefore, the purpose of this review was to highlight ways in which variations in lymphatic anatomy can inform the application and improve the accessibility of this procedure. As ILR continues to advance and evolve, anatomical mapping of the lymphatic system is valuable to both the patient and lymphatic microsurgeon and is a critical area of future study.

Breast lymphedema is a type of breast cancer related lymphedema that leads to significant discomfort and negative impact on body image. Conservative therapy and lymphovenous bypass have been previously described as possible treatment methods for breast lymphedema, however, a unified approach to treatment is lacking. The current report describes a case of breast lymphedema successfully treated with vascularized lymph node transfer (VLNT) after failed attempt at management with conservative therapy. The patient is a 48-year-old female with right-sided breast cancer who underwent breast conservation therapy in 2015 and subsequently developed pain and swelling of the right breast. The diagnosis of breast lymphedema was supported by clinical evaluation as well as MRI, lymphoscintigraphy, and lymphography. In consultation with a breast surgeon, breast lymphedema was determined not to be an indication for mastectomy. The patient was offered and underwent an omental VLNT to the right breast. A 20 cm segment of omentum with associated gastroepiploic vessels and lymph nodes was harvested, transferred to the right axilla and gastroepiploic vessels were anastomosed to the recipient thoracodorsal vessels. The patient tolerated the procedure well and there were no complications. Additional donor sites were considered, such as the groin and submental regions, but an omental flap was favored in this case because of the lower risk of donor site lymphedema. In the years following, the patient reported significant improvement in symptoms as well as objective reduction of edema on MRI. We propose the consideration of VLNT for breast lymphedema refractory to other methods of management.