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Background: The axillo-inguinal (or inguino-axillary) is a compensatory lymphatic drainage pathway regularly utilized by lymphedema therapists when applying manual lymphatic drainage (MLD) for upper and lower extremity lymphedema. However, there is limited evidence of the frequency of this pathway and the characteristics of patients with lymphedema in which this pathway is present. Indocyanine green (ICG) lymphography is an imaging technique that has the capability to identify lymphatic drainage pathways in lymphedema when combined with MLD. In this study, we used ICG lymphography in patients with upper and lower extremity lymphedema to investigate the presence of this pathway and its clinical characteristics. Methods and Results: A retrospective cohort audit of 563 patients with lymphedema (285 with upper extremity and 278 with lower extremity) who underwent ICG lymphography was conducted in combination with MLD. Compensatory lymphatic drainage was investigated. Patients demonstrating the axillo-inguinal pathway were identified, and their clinical characteristics were recorded. The axillo-inguinal pathway was not demonstrated in any patient with upper extremity and only five patients with lower extremity lymphedema. Of these five patients, all were female with a history of secondary cancer-related lymphedema following gynecological cancer. The majority (four) had bilateral lymphedema extending to the lower abdomen and presented with a greater severity of lymphedema. Conclusions: These findings suggest that the axillo-inguinal pathway is an infrequent compensatory drainage pathway in lower extremity lymphedema and rare in upper extremity lymphedema. Our findings have clinical implications for lymphedema management, in particular, the sequence in which MLD is applied.

Background: The Australian Lymphoedema Education, Research and Treatment Program (ALERT) at Macquarie University in Sydney, Australia is one of the flagship programs of Australia's first fully integrated academic health sciences centre, MQ Health. The aim of this study was to describe our findings of compensatory drainage demonstrated by indocyanine green (ICG) lymphography in cancer-related upper and lower limb lymphedema and how this may be translated into clinical practice. Methods and Results: Retrospective data from 339 patients aged between 18 and 90 years with secondary cancer-related unilateral or bilateral lymphedema of the upper or lower limb who underwent ICG lymphography assessment at the ALERT clinic between February 2017 and March 2020 were analyzed. In patients with upper limb lymphedema, the ipsilateral axilla was the most frequent drainage region (74.9%), followed by clavicular (41.8%) and parasternal (11.3%). For patients with mild upper limb lymphedema, 94.4% drained to the ipsilateral axilla. No patients drained to the ipsilateral inguinal region. For lower limb lymphedema, drainage to the ipsilateral inguinal was most common (52.3%), followed by contralateral inguinal (30.7%), popliteal (26.1%), and gluteal (21.6%) regions. Three main patterns of superficial lymphatic compensation were identified based on which anatomical structure carried lymph fluid. Manual lymphatic drainage (MLD) was used to facilitate movement of the dye. A light/effleurage technique was sufficient to move the dye through patent lymphatic vessels; a slow and firmer technique was required to move the dye through areas of bridging dermal backflow. Conclusion: The introduction of ICG lymphography to our program and its use in guiding personalized conservative management plans, including facilitative MLD techniques, has translated into clinical practice and changed research and educational priorities within the ALERT program.

Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal ( n  = 6) or supraclavicular fossa/neck ( n  = 4) regions and recipient sites were the axilla ( n  = 6) or elbow regions ( n  = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced ( n  = 4) or remained stable ( n  = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced ( n  = 3) or discontinued ( n  = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling ( n  = 3) and better response to conservative treatment ( n  = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.

Background: Lymphedema is an iatrogenic complication after breast cancer treatment in which lymph fluid in the affected limb progresses to fat deposition and fibrosis that are amenable to liposuction treatment. Magnetic resonance imaging (MRI) for lymphedema can differentiate fat tissue from fluid, but estimating relative volumes remains problematic., Methods and Results: Patients underwent routine bilateral arm MRI both before and after liposuction for advanced lymphedema. The threshold-based level set (TLS) segmentation method was applied to segment the geometric image data and to measure volumes of soft tissue (fat, muscle, and lymph fluid) and bone. Bioimpedance testing (L-Dex ® ) to detect extracellular fluid was also used. Volumes derived by using TLS or girth measurement were evaluated and showed consistent agreement, whereas L-Dex showed no significant reduction between pre- and postoperative measures. The percentage median volume difference between the affected and unaffected sides was 132.4% for girth measures compared with 137.2% for TLS (p = 0.175) preoperatively, and 99.8% and 98.5%, respectively (p = 0.600), postoperatively. MRI segmentation detected reductions in fat (median 52.6%, p = 0.0163) and lymph fluid (median 66%, p = 0.094), but the volumes of muscle and bone were relatively constant., Conclusions: MRI imaging with TLS technology may be a useful tool to quantitatively measure fat tissue and fluid for patients with advanced lymphedema and may assist in the selection of eligible liposuction candidates at initial assessment and follow-up of patients who proceed with surgery.

Recent advances in surgical management of lymphedema have provided options for patients who have failed conservative management with manual lymphatic massage and/or compression garments. The purpose of this review is to provide a historical background to the surgical treatment of lymphedema and how these options have evolved over time. In addition, we aim to delineate the various types of surgical approaches available, indications for surgery, and reported outcomes. Our goal is to increase awareness of these options and foster research to improve their outcomes.

Background: The degenerative process of lymph nodes is poorly documented., Methods: 161 lymph nodes of seven fresh and one embalmed human cadavers in the head and neck were studied. We used 6% hydrogen peroxide, lead oxide injectant, and radiographs to demonstrate lymphatic vessels, and found both solidified and transparent lymph nodes. They were removed, fixed in 10% formalin and sent for histopathology cross section., Results: Thirty-eight solidified and 123 transparent lymph nodes were found. A series of histopathological sections show the degenerative process is variable and continuous. Senile involution affects all elements of the lymph node including the cortex, the medulla, and the architecture., Conclusion: This study provides actual anatomical and histopathological images of lymph nodes in different degenerative stages in the head and neck region. It may help explain some clinical conditions in the elderly, especially their diminished immunological response to infection and cancer metastasis.