Refining Planning of Lymphedema Surgery of the Extremities Using MRI and CT Imaging Techniques

Key Points

Lymphedema (surgical) treatment is nowadays tailored to the patient’s needs and even more specifically to the local needs in one affected limb.
Lymphoscintigraphy and near-infrared fluoroscopy are baseline imaging techniques for lymphedema, but both have limitations, especially for surgical planning in more advanced cases.
Magnetic resonance (MR) lymphography permits us to have a full mapping of the lymphedematous limb as to the local needs, differentiating edema of the different layers, fatty deposition, or fibrotic changes.
The gadolinium-based contrast injection of MR lymphography gives us a mapping of the functional lymphatic channels and good differentiation with venous structures. The crossing points of functional lymphatics and veins of a similar caliber with exact coordinates are obtained and can be used for planning of lymphovenous anastomosis (LVA), minimizing the length of incisions and making LVA surgery faster and more predictable.
For the planning of vascularized groin lymph node flap, a computed tomography scanner can be used in order to map the groin (number and position of the lymph nodes and relationship to vascular structures).

Introduction

Lymphedema is caused by insufficient lymphatic drainage or blockage of the lymphatic system leading to an abnormal accumulation of a protein-rich interstitial fluid within the soft tissues. Primary lymphedema results from a structural defect of the lymphatic system (congenital or clinically seen later in life). However, most cases in developed countries are secondary lymphedema with an iatrogenic cause (cancer surgery, radiotherapy, surgical trauma, etc.). The diagnosis of lymphedema can be made by taking the patient’s history and performing a physical examination and may be confirmed by imaging studies. The most widely used studies are lymphoscintigraphy, magnetic resonance (MR) lymphangiography, and indocyanine green (ICG) lymphography. Nonsurgical treatment is still the core of lymphedema management. However, advances in microsurgical techniques have opened up surgical treatment options, which are now part of the international consensus for lymphedema treatment.

Imaging Techniques in Lymphedema

Several techniques are advocated in order to map the lymphatic anatomy of an affected limb, each with its advantages and disadvantages.

It is not in the scope of this chapter to go into the details of each technique, but we will give a general overview of the information that can be extracted from each imaging technique.

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