Indocyanine Green Lymphography for Lymphedema Screening following Breast Cancer Treatment

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We read with great interest the article entitled “Early Detection of Lymphatic Disorder and Treatment for Lymphedema following Breast Cancer” by Akita et al. (Plast Reconstr Surg. 2016;138:192e–202e).1 Their work is of clinical significance in that they elucidated prognosis of breast cancer treatment–related arm lymphedema.
As in leg lymphedema secondary to pelvic cancer treatment, some secondary arm lymphedema patients showed abnormal findings on indocyanine green lymphography before symptom manifestation. The results indicated the importance of the subclinical lymphedema concept also in secondary arm lymphedema management; cancer survivors with abnormal indocyanine green lymphographic findings, usually with a splash pattern first and then with a stardust or diffuse pattern, should be carefully followed or treated prophylactically regardless of subjective symptoms (Table 1).2,3 Unlike secondary leg lymphedema, follow-up indocyanine green lymphography showed improvement of lymph circulation in some secondary arm lymphedema patients after conservative treatments.1,2 The results suggest that prophylactic surgical treatment for subclinical arm lymphedema would be overtreatment. To maximize the therapeutic efficacy of compression and to avoid unnecessary surgical treatment, indocyanine green lymphography screening is important for early diagnosis of subclinical arm lymphedema. There are several methods for lymph flow visualization, such as lymphoscintigraphy and magnetic resonance lymphography. However, indocyanine green lymphography allows the clearest lymph flow visualization without radiation exposure in real time, and can be repeated without adverse effects.4,5 Therefore, breast cancer survivors with a high risk of arm lymphedema development should undergo screening for secondary lymphedema using indocyanine green lymphography.
Although further studies are required to confirm the best way of screening and its cost-effectiveness, secondary lymphedema screening using indocyanine green lymphography is considered to be useful for early diagnosis of secondary lymphedema and prevention of symptomatic progressive lymphedema with conservative treatments to avoid lymphedema surgery.

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