title: Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns.
abstract: BACKGROUND
  Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema.
  
  
  METHODS
  Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages.
  
  
  RESULTS
  The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p=0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p=0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y=1.092x+0.083 (R=0.997; analysis of variance, p<0.001).
  
  
  CONCLUSIONS
  Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema.
  
  
  METHODS
  Diagnostic, V.
authors.affiliation: Tokyo, Japan From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo.
authors.forename: Takumi
authors.initials: T
authors.lastname: Yamamoto
authors.forename: Nana
authors.initials: N
authors.lastname: Yamamoto
authors.forename: Kentaro
authors.initials: K
authors.lastname: Doi
authors.forename: Azusa
authors.initials: A
authors.lastname: Oshima
authors.forename: Hidehiko
authors.initials: H
authors.lastname: Yoshimatsu
authors.forename: Takeshi
authors.initials: T
authors.lastname: Todokoro
authors.forename: Fusa
authors.initials: F
authors.lastname: Ogata
authors.forename: Makoto
authors.initials: M
authors.lastname: Mihara
authors.forename: Mitsunaga
authors.initials: M
authors.lastname: Narushima
authors.forename: Takuya
authors.initials: T
authors.lastname: Iida
authors.forename: Isao
authors.initials: I
authors.lastname: Koshima
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D004396:Coloring Agents; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D008209:Lymphedema / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D008220:Lymphography / Q000379:methods*; D008408:Mastectomy / Q000009:adverse effects* / Q000379:methods; D008875:Middle Aged; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000000981:diagnostic imaging; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D034941:Upper Extremity
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green