ICG Is a Tool for Very Early Detection of Lymph Stasis in Patients After Mastectomy

Introduction, Objectives, and/or Purpose: Objective. Breast cancer is the most common malignant tumor in women. Due to early diagnosis and effective treatment methods, the average survivor rate of women treated due to breast cancer is high.
The most common complication developed after breast cancer therapy is lymphedema of the upper limb, affecting 50-60% of patients. Surgical treatment, lymphadenectomy, and irradiation impaired lymphatic drainage in the affected arm. These cause abnormal accumulation of tissue fluid with all its constituents as protein, cytokines, growth factors, and bacteria, and fibrosis of subcutaneous tissue. Subsequently, limb size and weight increase, causing functional disability and reduced quality of life.
Early diagnosis of upper limb edema, even in the subclinical phase, and early therapy intervention should bring about a better outcome and prevent the development of lymphedema.
ICG lymphography is a minimally invasive investigation allowing evaluation of lymphatics architecture and function.
Aim. We aimed to evaluate the effectiveness of ICG lymphography in detecting early changes in lymph drainage in upper limb patients after breast cancer therapy.

Methods: Methods. Twenty patients after breast cancer therapy (surgery, lymphadenectomy, and irradiation) without visible upper limb edema appearing in our Out-Patients Clinic and reporting pain, heaviness, or stiffness in some parts of the arm were included. Limb circumference and skin water concentrations (LympScanner; Delfin Technologies Ltd.) were compared with a contralateral healthy arm. Then all patients underwent ICG lymphography. 0.4 ml 5% of ICG dye (Pulsion, Munich, Germany) was injected into the fingers of both hands. Observation and video recording (Photodynamic Eye; Hamamatsu Photonics) was done 3 minutes after injection, after 3 minutes of squeezing the rubber ball, and after 1 hour.

Results: Results. The changes in limb circumference between affected and healthy limbs were less than 2 cm (which is considered lymphedema) in all limb levels. The mean skin water concentration was higher in all limb levels in the affected than healthy limb, with the highest water accumulation in the hand and forearm (42% and 43% vs. 35% and 36%). It varies; in some patients, skin water concentration reached even 60% in the forearm.
In ICG lymphography, we observe abnormalities in lymph drainage in 98% of patients. There was: dilatation of lymphatic vessels in the hand and forearm, the confluent spread of dye, spotty foci in a different part of the forearm and arm, and dilated fogy images of lymphatics in the arm did not reach the axilla region. The area of images corresponds to the pain, heavy, and stiff.

Conclusion(s): Conclusions. The ICG lymphography can detect changes in lymph drainage and fluid accumulation in patients' upper limbs after breast cancer therapy, even in the subclinical phase. Early initiation of conservative or surgical (LVA) intervention can prevent the development of advanced lymphedema and its complications and improve breast cancer survivors' quality of life.