Visualization of Accessory Lymphatic Pathways, before and after Manual Drainage, in Secondary Upper Limb Lymphedema Using Indocyanine Green Lymphography.

María Elena Medina-Rodríguez,Esther M Medrano-Sánchez,María De-La-Casa-Almeida,Arminda Ojeda-Cárdenes,Efrén Martel-Almeida

doi:10.3390/jcm8111917

Abstract

Manual Lymphatic Drainage (MLD) appears to stimulate lymphatic contraction, aid in the development of secondary derivation pathways, and stimulate the appearance of collateral pathways that could function as the main drainage routes of the limb in case of lymphedema. Through stretching, call up maneuvers are used to stimulate lymphangion reflex contraction and, therefore, lymphatic function. The aim was to describe the presence of areas and pathways of collateral lymphatic drainage under basal conditions and to determine, using Indocyanine Green (ICG) lymphography, whether an increase in these pathways occurs after 30 min of manual lymphatic stimulation with only call up maneuvers according to the Leduc Method®®. In this prospective analytical study (pretest–posttest), the frequency of presentation of areas and collateral lymphatic pathways was analyzed in 19 patients with secondary lymphedema of the upper limb after breast cancer using an infrared camera. Analyses were completed at three time points: after ICG injection, at baseline (pretest), and after the application of MLD (post-test). The Leduc Method maneuvers were applied to the supraclavicular and axillary nodes, chest, back, Mascagni, and Caplan pathways. The areas visualized in the pretest continued to be visible in the posttest. Additional pathways and fluorescent areas were observed after the maneuvers. The McNemar test showed statistical significance (p = 0.008), the odds ratio was infinite, and the Cohen’s g value was equal to 0.5. Manual stimulation by call up maneuvers increased the observation frequency of areas and collateral lymphatic pathways. Therefore, ICG lymphography appears to be a useful tool for bringing out the routes of collateral bypass in secondary lymphoedema after cancer treatment.

Highlights

Manual Lymphatic Drainage (MLD) increases the contractile activity of the lymphangion by gently pulling on its wall, sending the edematous fluid through the lymphatic dividing lines from the edematous area to neighboring lymphosomes, through the interstitial tissues areas, where the edema can be reabsorbed by healthy lymphatics [1,2,3]
Our study aims to identify and describe the presence of collateral drainage areas and pathways, using Indocyanine Green (ICG) lymphography, in patients with secondary upper limb lymphedema after breast cancer treatment under baseline conditions and to determine whether an increase in the presence of collateral drainage areas and pathways is observed after MLD treatment using the call up maneuvers described by the Leduc®® method
Our results suggest that manual stimulation of the proximal regions and collateral pathways by means of call up maneuvers could facilitate the observation of these drainage routes and the mapping of the functional pathways of each patient, allowing the development of personalized treatment guidelines to the characteristics observed in all patients

Summary

Introduction

Manual Lymphatic Drainage (MLD) increases the contractile activity of the lymphangion by gently pulling on its wall, sending the edematous fluid through the lymphatic dividing lines from the edematous area to neighboring lymphosomes, through the interstitial tissues areas, where the edema can be reabsorbed by healthy lymphatics [1,2,3]. By injecting a dye dissolved in turpentine, he detected numerous replacement pathways, mostly located in the posterior region of the shoulder, capable of evacuating lymph from the upper extremity They stated that often, to allow the drainage replacement of the normal routes by collateral routes, it is necessary to facilitate the opening of these collaterals through increasing the hydrostatic pressure inside the lymphatic system by means of careful manipulations. Our study aims to identify and describe the presence of collateral drainage areas and pathways, using ICG lymphography, in patients with secondary upper limb lymphedema after breast cancer treatment under baseline conditions (pretest) and to determine whether an increase in the presence of collateral drainage areas and pathways is observed after MLD treatment using the call up maneuvers described by the Leduc®® method

Study Cohort

Intervention

Statistical Analysis

Findings

Conclusions