Subclinical Lymphedema

Sir: We read with great interest the February 2013 article entitled “Early Diagnosis and Risk Factors for Lymphedema following Lymph Node Dissection for Gynecologic Cancer,” by Akita et al. (Plast Reconstr Surg. 2013;131:283–290).1 Their work is revolutionary in that they elucidated dynamic lymph circulatory changes after lymph node dissection for gynecologic cancer using indocyanine green lymphography. As we have previously reported, the indocyanine green lymphography pattern changes from normal linear pattern to abnormal dermal backflow patterns in obstructive peripheral lymphedema; with progression of lymphedema, dermal backflow patterns change from the splash pattern to the stardust pattern, and finally to the diffuse pattern.2–4 In the prospective cohort study conducted by Akita et al., the splash pattern was observed in 31 patients; five (16 percent) improved to the linear pattern, 17 (55 percent) remained with the splash pattern, and nine (29 percent) worsened to the stardust pattern. On the other hand, none of 27 patients with the stardust pattern (0 percent) improved to the splash or linear pattern, even with conservative therapies, and 24 (93 percent) of the 27 patients with the stardust pattern developed symptomatic chronic lymphedema within the study period.1 The results support our “subclinical lymphedema” concept that patients with the splash pattern should be followed carefully to avoid overtreatment or delay of intervention (Table 1).2–4 Based on the results that most patients with the stardust pattern eventually suffered from progressive symptomatic lymphedema despite conservative therapies, surgical intervention, such as supermicrosurgical lymphaticovenular anastomosis, can be an optimal treatment for patients with the stardust pattern, regardless of subjective symptoms.2,3,5 However, surgery for patients with the splash pattern may be an overtreatment, because only 29 percent of patients with the splash pattern progressed to the stardust pattern in the prospective cohort study.Table 1: Dermal Backflow Stage Based on Indocyanine Green Lymphography Findings and Clinical Management of LymphedemaAlthough intervention in patients with the splash pattern has a risk of being overtreatment, early intervention can be a curative treatment for lymphedema; lymphedema cure (i.e., complete lymphedematous volume reduction with complete normalization of abnormal lymph circulation) can be achieved. As the splash pattern represents dilated lymphatic precollectors and capillaries making collateral lymphatic pathways, manual lymph drainage is considered an optimal therapeutic modality for patients with the splash pattern; manual lymph drainage aims to facilitate development of collateral lymphatic pathways.2–4 Although it is invasive, supermicrosurgical lymphaticovenular anastomosis can be a treatment option, as it is likely to be more effective at an earlier stage.5 Treatment of lymphedema is challenging, and no curative treatment protocol has been established. Based on the progressive nature of obstructive lymphedema, treatment should be commenced at an early stage regardless of symptoms, although overtreatment must be avoided. Indocyanine green lymphography, which is the most sensitive to visualize abnormal lymph flows, is the method of choice for routine follow-up after lymph node dissection. The concept of subclinical lymphedema can be a key concept to develop a protocol for lymphedema cure, and further studies aimed at lymphedema cure should be conducted on patients at a subclinical stage of lymphedema. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Takumi Yamamoto, M.D. Isao Koshima, M.D.