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LYMPHOFLUOROSCOPY-GUIDED MANUAL LYMPHATIC DRAINAGE – A NEW EVIDENCE BASED APPROACH
BELGRADO J.-P . 1, V ANDERMEEREN L. 2, V ANKERCKHOVE S. 2, V ALSAMIS J.-B. 1, GIACALONE G. 3, SINÈGRE A. 1, MORAINE J.-J. 1
1 Université Libre de Bruxelles - Lymphology Research Unit, Bruxelles, Belgium 2 C.H.U. St-Pierre - Lymphology Clinic of Brussels, Belgium
3 University of Hasselt - Lymphatic Surgery, Hasselt, Belgium
Background: According to international guidelines, lymphedema must be treated by complete decongestive therapy (CDT), including Manual Lymphatic Drainage (MLD), Multicomponent Bandaging (MCB), sleeves and skin care. The application of this complete set of ingredients is consensually recognized by the “lymphologist” community to be efficient to reduce lymphedema. Meta-analysis on the efficiency of MLD conclude that the current evidence from RCTs does not support the use of MLD to prevent or reduce lymphedema.
Method of manual lymphatic drainage were historically conceptualized and based on indirect and multivariate data but not yet on easy visualization of the living human superficial lymph flow. It is currently possible thanks to near infrared fluoroscopy (NIRF).
In this study NIRF was used to evaluate lymph flow mean velocity in healthy subject in rest conditions, and applying an optimized MLD manoeuver developed under NIRF feedback.
Method: The protocol used for this exploratory study was approved by the Ethical Committee (OM_026 CE2013/96) and by the Federal Agency for Medicines and Health Products (EudraCT n° 2013-001360-36).
On the forearm of healthy volunteers we delimited a rectangular landmark with a fluorescent pen. After unilateral intradermal injection of 0,2mg ICG in the first interdigital space, videos of lymph flow were acquired during rest period as baseline, and during MLD manoeuvers. Video sequences were blindly analyzed using IC-CALC 2.0 software. At a known distance, two regions of interest (ROI’s) were delimited in which variation of fluorescence intensity was evaluated during lymph transfer. Time needed for a bolus of lymph to transfer between the two ROI’s allowed us to estimate mean lymph velocity.
Results: 14 healthy volunteers, mean age de 52 years ± 10 years, were consecutively recruited.
The mean lymph velocity in rest condition was evaluated at 0,0056 m/s ± 0,0018 m/s and reached 0,0243 m/s ± 0,0148 m/s during optimized MLD manoeuvres.
Fluoroscopy feedback allowed us to characterize optimal forces to be applied in order to improve manual lymph drainage efficacy. Two consecutive and repeated steps are needed:
“fill in” movement (4X) to transfer fluids from the interstitium to the lymphatic network, and
“flush” movement (2X) to propel lymph along the collectors. This is a component of the “fill and flush” method.
Conclusion: Lymphofluoroscopy seems to be an efficient and easy tool to study MLD technique on the superficial lymphatic network. The “fill and flush” method designed thanks to fluoroscopy feedback allowed transferring fluids from the interstitium to the lymphatic vessels and increasing fivefold lymph propagation into the collectors.
ACOUSTIC STRUCTURE QUANTIFICATION (ASQ): A NON-INVASIVE TOOL TO DETERMINATE LYMPHEDEMA TISSUE CHANGES?
TASSENOY A. 1, VANDERHASSELT T. 2, ADRIAENSSENS N. 1, LIEVENS P. 1
1 Department of Rehabilitation Research, Free University of Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium 2 Department of Radiology, UZBrussels, Brussels, Belgium
Background: The aim of this study was to determine the validity and reliability of the ASQ scoring method on an echographic image and to investigate whether ASQ values could be linked to different stages of lymphedema as observed by the patient’s own perception, the volume difference with the healthy arm and tissue changes observed on ultrasound images.
Methods and results: It is an observational survey with a cross-sectional design. 9 healthy subjects and 31 breast cancer patients, with different stages of lymph edema, were enrolled in the study. After completing a questionnaire concerning personal, demographic and medical data, arm volume of both arms were determined using an opto-electric perometer. Four ultrasound images were made on different standardized locations of both arms. The ASQ scoring method of raw ultrasound images showed a high inter- and intra- observer reliability, with intraclass correlation coefficients ranging from .894 to .995 in the patient group (from .883 to .998 in the control group). The correlation of the ASQ-scoring on raw data images with echogenicity analysis on standard ultrasound images delivered a Spearman’s r between rs= .785 and rs =.969. Based on observed tissue changes, ASQ could made the distinction between acute “fluid like” changes and chronic “fibrotic” tissue changes. Patients with a volume difference of >10%, had significant higher ASQ-values, than patients with less edema. No statistical difference in ASQ-value could be made based on patient’s own perception.
Conclusions: ASQ-scoring of ultrasound images of lymphedema can be a useful tool in staging lymphedema.
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THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXVI - Nr. 72 - 2015