From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center.
Plast Reconstr Surg. 2023 Jun 1;151(6):1015e-1021e. doi: 10.1097/PRS.0000000000010118. Epub 2022 Dec 26.
Current predictive models of lymphedema risk cannot predict with 100% certainty which patients will go on to develop lymphedema and which will not. Patient-specific anatomic and physiologic differences may be the missing factor. The authors hypothesize that patients with accessory lymphatic pathways may have improved lymphatic drainage, resulting in smaller limb volumes.
The authors reviewed indocyanine green (ICG) lymphography images of all patients who presented to their institution for evaluation of breast cancer-related lymphedema. Patients with unilateral upper extremity lymphedema, a full set of bilateral limb measurements, and ICG images of both limbs were included. Other variables of interest included patient demographics and length of follow-up. Patients with accessory pathways were determined independently, and conflicts were resolved with discussion. Abnormal images were also evaluated for common drainage pathways.
Thirty patients were identified as having accessory lymphatic drainage pathways. These patients had significantly smaller limb volume differences [8.19% (SD, 11.22)] compared with patients who did not exhibit these pathways [20.74% (SD, 19.76); P < 0.001]. The most common pathway was absence or rerouting of the radial bundle to the ulnar or volar bundles ( n = 16).
The ability to create accessory lymphatic drainage pathways may be associated with improved lymphatic drainage, resulting in smaller limb volumes. Furthermore, certain drainage pathways appear to be more common than others. Description of these pathways should be considered for inclusion in ICG lymphography image grading criteria. Further study is needed to clarify the nature of these pathways and whether these pathways affect subjective symptoms and quality of life.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
目前的淋巴水肿风险预测模型不能 100% 确定哪些患者会发展为淋巴水肿，哪些不会。患者特有的解剖和生理差异可能是缺失的因素。作者假设，具有辅助淋巴途径的患者可能具有更好的淋巴引流，从而导致肢体体积更小。
作者回顾了所有因乳腺癌相关淋巴水肿就诊于他们机构的患者的吲哚菁绿（ICG）淋巴造影图像。纳入单侧上肢淋巴水肿、双侧肢体完整测量值和双侧 ICG 图像的患者。其他感兴趣的变量包括患者人口统计学特征和随访时间。独立确定具有辅助途径的患者，并通过讨论解决冲突。还评估了异常图像的常见引流途径。
确定 30 例患者存在辅助淋巴引流途径。这些患者的肢体体积差异明显较小[8.19%（SD，11.22）]，与未表现出这些途径的患者[20.74%（SD，19.76）；P < 0.001]相比。最常见的途径是桡束缺失或改道至尺侧或掌侧束（n = 16）。
创建辅助淋巴引流途径的能力可能与改善的淋巴引流有关，从而导致肢体体积更小。此外，某些引流途径似乎比其他途径更常见。应考虑将这些途径的描述纳入 ICG 淋巴造影图像分级标准中。需要进一步研究以阐明这些途径的性质，以及这些途径是否影响主观症状和生活质量。
临床问题/证据水平：风险，II。
