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PurposeThe purpose of the present study was to analyse the performance of non-contrast MR lymphography for the classification of primary lower limb lymphoedema in 121 consecutive patients with 187 primary lower limb lymphoedemas.Materials and methods121 consecutive patients with clinically diagnosed primary lower limb lymphoedema underwent non-contrast MR lymphography with a free-breathing 3D fast spin-echo sequence with a very long TR/TE (4000/884 ms). MR examinations were retrospectively reviewed for severity of lymphoedema (absent, mild, moderate, severe) and characteristics of inguinal lymph nodes and iliac and inguinal lymphatic trunks graded as aplasic (no lymph nodes or lymphatic trunks), hypoplasic (less lymph nodes or lymphatic trunks), normal and hyperplasic (more lymph nodes or more and/or dilated trunks).ResultsThere was an excellent correlation between clinical stage and severity of lymphoedema (Cramer’s V of 0,73 (p < 0.001)). Differentiation was feasible between inguinal lymphatic vessel aplasia (21%), hypoplasia (15%), normal pattern (53%) and hyperplasia (11%).Severe lymphoedema was observed in 46% of aplasic patterns and in 37% of hyperplasic patterns, but in only 15% of hypoplasic patterns and never observed in normal patterns (p < 0.001).ConclusionNon-contrast MR lymphography is able to classify primary lower limb lymphoedemas into hyperplasic, aplasic, hypoplasic and normal patterns.Key Points• Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas.• Lymphoedema can be classified in hyperplasic, aplasic, hypoplasic and normal patterns.• Non-contrast MR lymphography can optimize clinical management of primary lower limb lymphoedemas.

Background This prospective case series analyzed patients who underwent indocyanine green (ICG) fluorescent lymphography during open inguinal hernia repair. The aim of this study was to investigate the association between ICG leakage and postoperative hydroceles in patients who underwent inguinal hernia repair. Materials and Methods Data were analyzed from 40 patients who underwent primary open hernia repair between October 2020 and June 2021 (44 cases in total). Hydroceles were categorized into two types: symptomatic and “ultrasonic” (detected only by ultrasound imaging). Results In the univariate analysis, hernia type ( p  = 0.044) and ICG leakage ( p  = 0.007) were independent risk factors for postoperative ultrasonic hydroceles. Additionally, mesh type ( p  = 0.043) and ICG leakage ( p  = 0.025) were independent risk factors for postoperative symptomatic hydroceles. In the multivariate analysis, ICG leakage ( p  = 0.034) was an independent risk factor for postoperative ultrasonic hydroceles. Conclusions ICG leakage after inguinal hernia repair was independently associated with postoperative ultrasonic and symptomatic hydroceles. These findings suggest a relationship between lymphatic vessel injury and the incidence of postoperative hydroceles.

Background This study aims to investigate whether indocyanine green lymphography (ICGL) facilitates the effectiveness and accuracy of current management of lingual microcystic lymphatic malformation (mLM). Methods This retrospective included patients under 18 years old with mLM of the tongue staged I or IIA, who underwent ICGL-aided surgical resection and sclerotherapy (ICGL group) or only surgical resection and sclerotherapy (non-ICGL group) between January 2019 and June 2024. The peri- and postoperative parameters of safety and feasibility were compared between two groups. Results A total of 42 patients were included, 19 of whom received ICGL-guidance and the other 23 were in non-ICGL group. The comparison of baseline data between the two groups revealed no significant difference. Compared to the non-ICGL group, the ICGL group demonstrated superior efficacy ( P  = 0.017) and required fewer subsequent treatment sessions ( P  = 0.027), but had longer operative duration ( P  = 0.001). No significant differences were observed in terms of postoperative complications, length of hospital-stay, and follow-up period. Conclusions ICGL was associated with improved postoperative outcomes and less subsequent treatment. This technique may provide rational guidance with promising clinical prospects for management of mLM of the tongue. Trail registration This study was retrospectively registered on clinicaltrials.gov: NCT06755905, date of registration: January 20, 2025. What is known: Surgical resection and sclerotherapy is used for stage I or IIA microcystic lymphatic malformation of the tongue in children. What is new: Indocyanine green lymphography before surgical resection and sclerotherapy can increase efficacy and reduce subsequent treatment.

To evaluate the feasibility of laparoscopic fluorescence lymphography (LFL) using indocyanine green (ICG) via intradermal (ID) or intrapopliteal (IPP) administration in an ex vivo canine model. Six thawed adult male dog carcasses were placed in the Trendelenburg position after placing three surgical ports in triangulation. ICG (0.5 mg/ml; 0.05 mg/kg) was administered to five of the carcasses (one carcass was a pilot) via ID in the left torso and IPP (right position, by surgical access) to stain the lymphatic pathway and medial iliac lymph node (MILN). Fluorescence quality, staining time, structures stained, and lymph node histopathology were assessed. Thoracic duct staining was also evaluated. ID administration showed staining of parts of the lymphatic pathway of the iliosacral lymph center in all cases using a single dose of ICG, with left MILN visualization in four carcasses. IPP administration showed staining of the right MILN in all cases, using a single dose in four carcasses. ICG reached the thoracic duct in one case. The two administration routes showed similar results in terms of required ICG volume, staining time, and visualization quality, although IPP was more effective in staining the MILN. This study confirms the feasibility of staining the iliosacral lymph center (mainly the MILNs) by LFL in thawed dog carcasses via ID or IPP administration of ICG. However, the IPP route showed greater effectiveness in staining the MILN.

Fluorescent lymphography (FL) using indocyanine green (ICG) allows for the visualization of all draining lymph nodes (LNs), thereby increasing LN retrieval. However, no studies have assessed the efficacy of FL in high body mass index (BMI) gastric cancer patients, even as LN yield decreases with increasing BMI in gastrectomy. This study aimed to investigate the influence of FL on LN retrieval in high BMI gastric cancer patients. Gastric cancer patients who underwent laparoscopic or robotic gastrectomies from 2013 to 2021 were included. Patients were classified into two groups, with FL (FL group) or without FL (non-FL group). The effect of FL on LN retrieval was assessed by BMI. Inverse probability of treatment weighting (IPTW) was used to ensure comparability between groups. Retrieved LN number decreased as BMI increased regardless of FL application (P < 0.001). According to the IPTW analysis, the mean retrieved LN number was significantly higher in the FL group (48.4 ± 18.5) than in the non-FL group (39.8 ± 16.3, P < 0.001), irrespective of BMI. The FL group exhibited a significantly higher proportion of patients with 16 or more LNs (99.5%) than the non-FL group (98.1%, P < 0.001). The FL group also had a significantly higher proportion of patients with 30 or more LNs (86.6%) than the non-FL group (72.2%, P < 0.001). In both the normal and high-BMI patients, the FL group had a significantly larger percentage of patients with a higher nodal classification than the non-FL group. FL resulted in more LN retrieval, even in high BMI patients. FL ensures accurate staging by maintaining the appropriate retrieved LN number in high BMI gastric cancer patients.

BackgroundIn recent years, indocyanine green fluorescence lymphography has been introduced for lymphatic mapping in gastric cancer surgery. The aim of this study was to investigate the efficacy of ICGFL in lymph node dissection during minimally invasive surgery for gastric cancer.MethodsA systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed from the inception to January 2021 for all studies comparing ICGFL with non-ICGFL in GC patients undergoing minimal access gastrectomy. The primary outcome was the total number of harvested lymph nodes. The secondary endpoints were the number of metastatic LNs, operative time, estimated blood loss, and postoperative complications. The registration number of this protocol is PROSPERO CRD42020203443.ResultsA total of 13 studies including 1882 participants were included. In this meta-analysis, the use of ICGFL was associated with a higher number of harvested LNs (40.33 vs. 33.40; MD = 6.93; 95%CI: 4.28 to 9.58; P < 0.0001; I2 = 86%). No significant difference was found between the ICGFL and control groups in terms of metastatic LNs (2.63 vs. 2.42; MD = 0.21; 95%CI: −0.46 to 0.87; P = 0.54; I2 = 0%). In addition, the use of ICGFL could be safely performed without increasing the operative time (P = 0.49), estimated blood loss (P = 0.26) and postoperative complications (P = 0.54).ConclusionThe use of ICGFL may be a useful tool facilitating complete lymph node dissection during minimally invasive GC resection. However, more high-quality RCTs with large sample size are needed to validate this issue.

Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography. Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis. The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases. Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

Background Breast cancer related lymphoedema (BCRL) is a common side effect of cancer treatment. Recently indocyanine green (ICG) fluorescent lymphography has become a popular method for imaging the lymphatics, however there are no standard protocols nor imaging criteria. We have developed a prospective protocol to aid in the diagnosis and therapeutic management of BCRL. Methods Lymphatic imaging procedures were conducted in three phases. Following initial observation of spontaneous movement of ICG in phase one, manual lymphatic drainage (MLD) massage was applied to facilitate ICG transit via the lymphatics in phase two. All imaging data was collected in phase three. Continuous lymphatic imaging of the upper limb was conducted for approximately an hour and lymphatic drainage pathways were determined. Correlations between the drainage pathway and MD Anderson Cancer Centre (MDACC) ICG lymphoedema stage were investigated. Results One hundred and three upper limbs with BCRL were assessed with this new protocol. Despite most of the patients having undergone axillary node dissection, the ipsilateral axilla drainage pathway was the most common (67% of upper limbs). We found drainage to the ipsilateral axilla decreased as MDACC stage increased. Our results suggest that the axillary pathway remained patent for over two-thirds of patients, rather than completely obstructed as conventionally thought to be the case for BCRL. Conclusions We developed a new ICG lymphography protocol for diagnosing BCRL focusing on identification of an individual patient’s lymphatic drainage pathway after lymph node surgery. The new ICG lymphography protocol will allow a personalised approach to manual lymphatic drainage massage and potentially surgery.

To date, animal models for lymphographic studies mainly focused on dog, while lymphography is rarely reported in cats, and even less involving cutaneous lymphatic territories. This study aims to assess the feasibility of cutaneous lymphography using indocyanine green (ICG) fluorescence in cat cadavers and describe predictable lymphatic pathways from cutaneous regions of head and hind limb anatomical districts. Frozen or refrigerated cadavers of adult cats that died for causes unrelated to the study were included. Twenty cutaneous regions (6 from the head; 14 from the hind limb) were selected using easily assessable anatomical landmarks, and expected draining lymphocentrums were presumed based on canine studies since there is no similar information for cats. For each lymphography, a single selected cutaneous region per anatomical district was assessed. After intradermal ICG injections, lymphatic drainage was favored by massage and/or flexion-extension movements. For each lymphography, all expected and detected lymphocentrums were dissected, and lymph nodes extirpated. Variables regarding cadavers and lymphography characteristics were assessed. ICG-lymphography was repeated in 33 cadavers. Out of the 99 selected cutaneous regions available, 15 were excluded following inclusion criteria, therefore lymphographies were performed for a total of 84 selected cutaneous regions (26 from the head and 58 from the hind limbs). A success was recorded in 63/84 (75%) lymphographies, with a median migration time of 8 (1–30) minutes. The ICG drained to the expected lymphocentrum in 28/63 (44%) lymphographies, and to other ones in 35/84 (56%). ICG-lymphography is feasible in cat cadavers, regardless of technique or cadaver characteristics. The observed difference in lymphatic drainage (56% to unexpected lymphocentrums) highlights the importance of specifically mapping lymphatic territories in cats. ICG-lymphography demonstrated as an effective technique and could be used to improve knowledge of feline lymphatic physiology. Further studies may provide a more complete understanding of superficial lymphatic territories in cats.