Fluorescence-guided thoracoscopic surgery for postoperative chylothorax: A technical note with video vignette.

TECHNIQUE: The surgical management for high-output postoperative chylothorax typically necessitates ligation of the thoracic duct (TD) above the leak site and/or sealing the leak with a clip. However, pinpointing these structures during subsequent surgeries can be challenging due to their variable course and the presence of traumatized tissues surrounding the leak area. In response to this, we have developed a novel, fluorescence-guided technique that significantly enhances intraoperative identification of the leak point and the TD. This method was applied in the case of a 52-year-old man suffering from refractory chylothorax following a previous lung cancer surgery. This study documents the surgical procedure and includes a video vignette for a comprehensive understanding. RESULTS: A bilateral inguinal lymph node injection of saline (10 mL), guided by ultrasound and containing 2.5 mg/mL indocyanine green (ICG), was administered 20 min prior to surgery. During thoracoscopic exploration, the leak point was precisely pinpointed in the right paratracheal area by transitioning from bright light to fluorescent mode. The TD was clearly identified, and upon ligation, there was no further leakage of fluorescent lymph, indicating a successful closure of the lymphatic structure. The surgery proceeded uneventfully, and the patient was able to resume oral intake on the third postoperative day. There was no evidence of recurring symptoms, leading to his discharge. CONCLUSION: The intralymphatic injection of ICG offers a rapid visualization of the TD's anatomy and can effectively pinpoint the leak point, even amidst traumatized tissues. Moreover, it provides prompt feedback on the efficacy of ligation.

Personalized neoantigen-based T cell therapy triggers cytotoxic lymphocytes expressing polyclonal TCR against metastatic ovarian cancer.

Neoantigen-reactive cytotoxic T lymphocytes play a vital role in precise cancer cell elimination. In this study, we demonstrate the effectiveness of personalized neoantigen-based T cell therapy in inducing tumor regression in two patients suffering from heavily-burdened metastatic ovarian cancer. Our approach involved the development of a robust pipeline for ex vivo expansion of neoantigen-reactive T lymphocytes. Neoantigen peptides were designed and synthesized based on the somatic mutations of the tumors and their predicted HLA binding affinities. These peptides were then presented to T lymphocytes through co-culture with neoantigen-loaded dendritic cells for ex vivo expansion. Subsequent to cell therapy, both patients exhibited significant reductions in tumor marker levels and experienced substantial tumor regression. One patient achieved repeated cancer regression through infusions of T cell products generated from newly identified neoantigens. Transcriptomic analyses revealed a remarkable increase in neoantigen-reactive cytotoxic lymphocytes in the peripheral blood of the patients following cell therapy. These cytotoxic T lymphocytes expressed polyclonal T cell receptors (TCR) against neoantigens, along with abundant cytotoxic proteins and pro-inflammatory cytokines. The efficacy of neoantigen targeting was significantly associated with the immunogenicity and TCR polyclonality. Notably, the neoantigen-specific TCR clonotypes persisted in the peripheral blood after cell therapy. Our findings indicate that personalized neoantigen-based T cell therapy triggers cytotoxic lymphocytes expressing polyclonal TCR against ovarian cancer, suggesting its promising potential in cancer immunotherapy.

Vascular responses of penetrating vessels during cortical spreading depolarization with ultrasound dynamic ultrafast Doppler imaging.

The dynamic vascular responses during cortical spreading depolarization (CSD) are causally related to pathophysiological consequences in numerous neurovascular conditions, including ischemia, traumatic brain injury, cerebral hemorrhage, and migraine. Monitoring of the hemodynamic responses of cerebral penetrating vessels during CSD is motivated to understand the mechanism of CSD and related neurological disorders. Six SD rats were used, and craniotomy surgery was performed before imaging. CSDs were induced by topical KCl application. Ultrasound dynamic ultrafast Doppler was used to access hemodynamic changes, including cerebral blood volume (CBV) and flow velocity during CSD, and further analyzed those in a single penetrating arteriole or venule. The CSD-induced hemodynamic changes with typical duration and propagation speed were detected by ultrafast Doppler in the cerebral cortex ipsilateral to the induction site. The hemodynamics typically showed triphasic changes, including initial hypoperfusion and prominent hyperperfusion peak, followed by a long-period depression in CBV. Moreover, different hemodynamics between individual penetrating arterioles and venules were proposed by quantification of CBV and flow velocity. The negative correlation between the basal CBV and CSD-induced change was also reported in penetrating vessels. These results indicate specific vascular dynamics of cerebral penetrating vessels and possibly different contributions of penetrating arterioles and venules to the CSD-related pathological vascular consequences. We proposed using ultrasound dynamic ultrafast Doppler imaging to investigate CSD-induced cerebral vascular responses. With this imaging platform, it has the potential to monitor the hemodynamics of cortical penetrating vessels during brain injuries to understand the mechanism of CSD in advance.

Outcomes of type Ia endoleaks after endovascular repair of the proximal aorta.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) can be complicated by a type Ia endoleak. However, its natural history remains unclear. This report describes the natural history and midterm outcome of conservatively treated type Ia endoleaks in the proximal aorta. METHODS: Between 2007 and 2015, 395 patients underwent TEVAR at our institution. Only TEVARs landing proximally at landing zones 0, 1, and 2 were included (221/395). Type Ia endoleak's flow was classified as "fast" or "slow" based on the time needed to visualize the aneurysmal sac during arteriogram. RESULTS: The median follow-up was 4.1 years. Aortic dissection, thoracic aortic aneurysm, and traumatic aortic injury were the most common indications for TEVAR; the incidence of type Ia endoleak was not statistically different. Forty-seven patients (21.3%) had a type Ia endoleak. TEVAR landing proximally at zone 1 increased the odds of developing a type Ia endoleak (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = .0072). The 30-day mortality and the overall survival was not influenced by the development of immediate-type Ia endoleak. In 34 (72.3%) patients, the endoleak resolved spontaneously. Ninety-four percent of these patients had a SlowE (n = 32/34). All of spontaneous resolutions occurred before the end of the first postoperative year. CONCLUSIONS: SlowE tends to resolve within 1 year after TEVAR. Initial conservative treatment seems to be a reasonable approach in patients with SlowE.

Enhanced Paclitaxel Efficacy to Suppress Triple-Negative Breast Cancer Progression Using Metronomic Chemotherapy with a Controlled Release System of Electrospun Poly-d-l-Lactide-Co-Glycolide (PLGA) Nanofibers.

Triple-negative breast cancer (TNBC) is highly aggressive and responds poorly to conventional chemotherapy. The challenge of TNBC therapy is to maximize the efficacies of conventional chemotherapeutic agents and reduce their toxicities. Metronomic chemotherapy using continuous low-dose chemotherapy has been proposed as a new treatment option, but this approach is limited by the selection of drugs. To improve antitumor therapeutic effects, we developed electrospun paclitaxel-loaded poly-d-l-lactide-co-glycolide (PLGA) nanofibers as a topical implantable delivery device for controlled drug release and site-specific treatment. The subcutaneously implanted paclitaxel-loaded nanofibrous membrane in mice was compatible with the concept of metronomic chemotherapy; it significantly enhanced antitumor activity, inhibited local tumor growth, constrained distant metastasis, and prolonged survival compared with intraperitoneal paclitaxel injection. Furthermore, under paclitaxel-loaded nanofiber treatment, systemic toxicity was low with a persistent increase in lean body weight in mice; in contrast, body weight decreased in other groups. The paclitaxel-loaded nanofibrous membranes provided sustained drug release and site-specific treatment by directly targeting and changing the tumor microenvironment, resulting in low systemic toxicity and a significant improvement in the therapeutic effect and safety compared with conventional chemotherapy. Thus, metronomic chemotherapy with paclitaxel-loaded nanofibrous membranes offers a promising strategy for the treatment of TNBC.

A preliminary study of hepatocellular carcinoma post proton beam therapy using MRI as an early prediction of treatment effectiveness.

PURPOSE: To demonstrate the feasibility of magnetic resonance imaging (MRI) for early prediction of proton beam therapy (PBT) effectiveness in hepatocellular carcinoma (HCC). METHODS: Clinical data of the HCC patients without regional lymph node involvement or distant metastasis who received PBT at this institution between 2014 and 2017 were reviewed. A total of 43 patients were included. Tumor regression pattern after PBT were examined on the basis of follow-up duration. The variables were compared between patients with and without early tumor regression (ETR). RESULTS: The median follow-up duration was 40 months (range, 9-62 months). The cumulative overall survival rate at 6 months, 1 years and 5 years was 100%, 88.4%, 63.4%, respectively. Child-Pugh class A, local tumor control (LTC), complete response (CR), and ETR were significantly associated with overall survival (p < 0.05 each). Of 43 patients, 25 patients (58.1%) reached CR in the PBT-irradiated region. Twelve patients (27.9%) had a partial response and 3 patients (7.0%) had a stationary disease. Three patients (7.0%) developed in-field progression. The LTC rate at 5 years was 93.0%. Of the 25 patients who achieved a CR in the PBT-irradiated region, the median time to CR was 5 months (range, 1-19 months). Twenty-two patients (51.2%) showed ETR of the HCC, while 21 patients (48.8%) showed non-ETR. A significant association was observed between ETR and CR of the HCC after PBT (p < 0.001). CONCLUSION: The post-PBT MRI follow-up at 3 months is helpful for monitoring therapeutic response. ETR of the HCC predicted a higher rate of CR and was associated with overall survival, which provides more accurate clinical management.

Comparison between Totally Percutaneous Approach and Femoral Artery Cut-Down in Endovascular Aortic Repair of Ruptured Abdominal Aortic Aneurysms in a Single Hospital.

PURPOSE: To evaluate the short-term outcome of totally percutaneous endovascular aortic repair (pEVAR) of ruptured abdominal aortic aneurysms (AAAs) compared with femoral cut-down endovascular aortic repair (cEVAR). MATERIALS AND METHODS: The medical records of patients with ruptured AAAs that underwent EVAR between March 2010 and April 2017 were retrospectively reviewed. Demographic information, preoperative vital signs, preoperative laboratory data, method of anesthesia, procedure duration, aneurysm morphology, brand of device used, length of hospital stay, access complications, and short-term outcomes were recorded. Univariate as well as multivariate logistic regression was used to identify predictors of 30-day mortality. RESULTS: Among 77 patients with ruptured AAAs, 17 (22.1%) received cEVAR and 60 (77.9%) received pEVAR. Significant differences in the procedure time (P = 0.004), method of anesthesia (P = 0.040), and 30-day mortality (P = 0.037) were detected between the cEVAR and pEVAR groups. Local anesthesia plus intravenous general anesthesia (odds ratio = 0.141, P = 0.018) was an independent factor associated with 30-day mortality and local anesthesia was better than general anesthesia for 24-hr mortality (P = 0.001) and 30-day mortality (P = 0.003). CONCLUSION: In patients with ruptured AAAs, pEVAR procedures took less time than cEVAR procedures, but the length of hospital stay did not differ significantly. The 30-day mortality rate was lower with pEVAR than with cEVAR. Local anesthesia may be the key factor in EVAR to improved technical and clinical success.

Outpatient Percutaneous Endovascular Abdominal Aortic Aneurysm Repair: A Single-Center Experience.

PURPOSE: To evaluate the safety of outpatient percutaneous endovascular abdominal aortic repair (PEVAR) versus inpatient PEVAR without or with adjunct procedures. MATERIALS AND METHODS: Between January 2012 and June 2019, a cohort of 359 patients comprising 168 (46.8%) outpatients and 191 (53.2%) inpatients who had undergone PEVAR were enrolled. All the patients were asymptomatic but had indications for endovascular aortic repair, ie, fit for intravenous anesthesia and anatomically feasible with standard devices. Patient sex, age, comorbidities, smoking status, type of anesthesia, adjunct procedures, type of graft device, operative times, mortality, complications, and readmissions were analyzed. RESULTS: Median follow-up period was 16.5 months (interquartile range, 9-31 months). Except for a higher percentage of tobacco use (42.6% vs 28.8%; P = .04), dyslipidemia (39.7% vs 19.2%; P < .01), and use of local anesthesia (99.4% vs 82.2%; P < .01) in the outpatients, there was no significant difference in the type of graft and adjunct procedures used. No outpatient mortality occurred. There was no difference in the number, severity, and onset of complications (all P > .05). Outpatient unexpected same-day admission, 30-day readmission, and emergency department visit rates were 4.8%, 2.4% (P = .13), and 10% (P < .01), respectively. Operative times for outpatient PEVAR without adjunct procedures were shorter (P < .01). CONCLUSIONS: Outpatient PEVAR can be performed with a safety profile similar to that of inpatient PEVAR. The unexpected same-day admission, 30-day readmission, and emergency department visit rates were low. The outpatient PEVARs without adjunct procedures took less time.

Volumetric Differences in the Suprafascial and Subfascial Compartments of Patients with Secondary Unilateral Lower Limb Lymphedema.

BACKGROUND: The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema. METHODS: Thirty-two female patients with unilateral lower extremity lymphedema were enrolled, with eight patients in each of Cheng lymphedema grades I to IV. The volumes of the suprafascial and subfascial compartments were calculated after manually drawing the region of interest on computed tomographic images. The volumetric differences and their ratios in the suprafascial and subfascial compartments between each patient's bilateral limbs were compared. RESULTS: The volume of the lymphedematous limbs (9647 ml) was significantly greater than the volume of unaffected limbs (6906 ml), with a median volumetric difference of 2097 ml (30.6 percent) (p < 0.01). The median suprafascial compartment volumetric difference was 1887 ml (56.6 percent) and the subfascial compartment volumetric difference was 208 ml (4.7 percent) (p < 0.01). The median volumetric difference ratio of the thigh and lower leg was 24.6 percent and 40.6 percent, respectively. The median volumetric differences in Cheng lymphedema grades I to IV were 1012, 1787, 2434, and 4107 ml, respectively, which were statistically significant among the four Cheng lymphedema grades using the Kruskal-Wallis test (p < 0.01). CONCLUSIONS: The volumetric differences in the lymphedematous limb were statistically significantly greater than in the unaffected limb, including both suprafascial and subfascial compartments. The volumetric differences are consistent with the Cheng lymphedema grading system as a reliable indicator of unilateral extremity lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Preparation and in vitro/in vivo evaluation of doxorubicin-loaded poly[lactic-co-glycol acid] microspheres using electrospray method for sustained drug delivery and potential intratumoral injection.

For cancer treatment, intratumoral drug injection has many limitations and not commonly adopted. The poly[lactic-co-glycolic acid] (PLGA) has emerged as a promising vehicle to enhance the in vitro/in vivo characteristic of various drugs. We prepared doxorubicin-PLGA microspheres (DOX-PLGA MSs) using the electrospray method. An in vitro elution method was employed to evaluate the release of DOX from the MSs. We performed an in vivo study on rats, in which we directly injected DOX-PLGA MSs into the liver. We measured liver and plasma DOX concentrations to assess local retention and systemic exposure. The mean diameter of the MSs was 6.74 ±â€¯1.01 µm. The in vitro DOX release from the MSs exhibited a 12.3 % burst release on day 1, and 85.8 % of the drug had been released after 30 days. The in vivo tests revealed a higher local drug concentration at the target lobe of the liver than at the adjacent median lobe. In the first week, the DOX concentration in the peripheral blood of the MS group was lower than that of the direct DOX injection group. Based on the measured intrahepatic concentration and plasma pharmacokinetic profiles, DOX-PLGA MSs could be suitable vectors of chemotoxic agents for intratumoral injection.

Characterization of limb lymphedema using the statistical analysis of ultrasound backscattering.

BACKGROUND: Lymphedema is a disease in which tissue swelling is caused by interstitial fluid retention in subcutaneous tissue. It is caused by a compromised lymphatic system. Lymphoscintigraphy is the current and primary modality used to assess lymphatic system dysfunction. Ultrasound elastography is a complementary tool used for evaluating the tissue stiffness of the lymphedematous limb. Tissue stiffness implies the existence of changes in tissue microstructures. However, ultrasound features related to tissue microstructures are neglected in clinical assessments of lymphedematous limbs. In this study, we aimed to evaluate the lymphedematous diagnostic values of ultrasound Nakagami and entropy imaging, which are, respectively, model- and nonmodel-based backscattered statistical analysis methods for scatterer characterization. METHODS: A total of 60 patients were recruited, and lymphoscintigraphy was used to score the patient's clinical severity of each of their limb lymphedema (0: normal; 1: partial lymphatic obstruction; and 2: total lymphatic obstruction). We performed ultrasound examinations to acquire ultrasound backscattered signals for B-mode, Nakagami, and entropy imaging. The envelope amplitude, Nakagami, and entropy values, as a function of the patients' lymphatic obstruction grades, were expressed in terms of their median and interquartile range (IQR). The values were then used in both an independent t test and a receiver operating characteristic (ROC) curve analysis. RESULTS: For each increase in a patient's score from 0 to 2, the envelope amplitude values were 405.44 (IQR: 238.72-488.17), 411.52 (IQR: 298.53-644.25), and 476.37 (IQR: 348.86-648.16), respectively. The Nakagami parameters were 0.16 (IQR: 0.14-0.22), 0.26 (IQR: 0.23-0.34), and 0.24 (IQR: 0.16-0.36), respectively, and the entropy values were 4.55 (IQR: 4.41-4.66), 4.86 (IQR: 4.78-4.99), and 4.87 (IQR: 4.81-4.97), respectively. The P values between the normal control and lymphedema groups obtained from B-mode and Nakagami analysis were larger than 0.05; whereas that of entropy imaging was smaller than 0.05. The areas under the ROC curve for B-mode, Nakagami, and entropy imaging were 0.64 (sensitivity: 70%; specificity: 47.5%), 0.75 (sensitivity: 70%; specificity: 75%), and 0.94 (sensitivity: 95%; specificity: 87.5%), respectively. CONCLUSIONS: The current findings demonstrated the diagnostic values of ultrasound Nakagami and entropy imaging techniques. In particular, the use of non-model-based entropy imaging enables for improved performance when characterizing limb lymphedema.

Intra-abdominal chylovenous bypass treats retroperitoneal lymphangiomatosis.

BACKGROUND: Retroperitoneal lymphangiomatosis (RL) is a rare form of primary lymphedema featuring aberrant retroperitoneal lymphatic proliferation. It causes recurrent cellulitis, repeated interventions, and poor life quality. This study aimed to investigate proper diagnositc criteria and surgical outcomes for RL with extremity lymphedema. METHODS: Between 2012 and 2018, 44 primary lower-extremity lymphedema cases received lymphoscintigraphy, magnetic resonance imaging, and single-photon electron computed tomography to detect RL. RL patients underwent vascularized lymph node transfers (VLNT) for extremity lymphedema and intra-abdominal side-to-end chylovenous bypasses (CVB) for chylous ascites. Complications, CVB patency, and quality of life were evaluated postoperatively. RESULTS: Six RL patients (mean age of 30.3 years) had chylous ascites with five had lower-extremity lymphedema. All CVBs remained patent, though one required re-anastomosis, giving a 100% patency rate. Four unilateral and one bilateral extremity lymphedema underwent six VLNTs with 100% flap survival. Patients reported improved quality of life (P = 0.023), decreased cellulitis incidence (P = 0.041), and improved mean lymphedema circumference (P = 0.043). All patients resumed a normal diet and activity. CONCLUSIONS: Evaluating primary lower-extremity lymphedema patients with MRI and SPECT could reveal a 13.6% prevalence of RL and guide treatment of refractory extremity lymphedema. Intra-abdominal CVB with VLNT effectively treated RL with chylous ascites and extremity lymphedema.

Comparisons of Manual Tape Measurement and Morphomics Measurement of Patients with Upper Extremity Lymphedema.

BACKGROUND: Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema. METHODS: Fifteen participants with diagnosed upper limb lymphedema were included between July 2013 and June 2017 at Chang Gung Memorial Hospital in Taipei, Taiwan. Affected and unaffected arm circumferences were measured using a flexible tape or morphomic measurement at 10 cm above and below the elbow. Computed tomography scans were standardized, processed, smoothed with a piecewise polynomial algorithm for Analytic Morphomics of arm circumference. Comparative plots, mean percent difference, and adjusted coefficient of determination (R 2) were utilized to compare the consistency of both measurement procedures. RESULTS: The tape measure and Analytic Morphomics demonstrated consistent measures of arm circumference. On the affected arm, the mean (95% CI) difference in arm circumference between methods was 1.60 cm (0.99-2.20) above, and 0.57 cm (0.23-0.91) below the elbow. Mean percent differences in circumference was 6.65% (SD 3.52%) above and 1.38% (SD 2.11%) below the elbow. The adjusted R 2 for both methods was 94% above and 96% below the elbow. CONCLUSIONS: Analytic Morphomics showed strong consistency with the manual tape measure of arm circumference measurement in those with upper extremity lymphedema. Analytic Morphomics present an opportunity for a precise, granular measurement of limb composition for assessment of disease state and patient planning.

Transarterial embolization of a large high-flow right renal arteriovenous fistula using stents and an across-stent wire-trapping technique.

Renal arteriovenous fistulas (AVFs) are rare vascular abnormalities. Their high-flow nature may result in increased cardiac output and lead to heart failure. Transcatheter endovascular management of renal AVFs with various embolization materials has been the treatment of choice in recent years. Embolization of large renal AVFs poses a risk of embolization through the AVF to the pulmonary circulation. Herein, we present the case of a patient whose large high-flow renal AVF was treated by a novel method involving the use of a bare stent and detachable metallic coils-called a wire-trapping technique-as well as compare this method with vascular plugs.

Effectiveness of Vascularized Lymph Node Transfer for Extremity Lymphedema Using Volumetric and Circumferential Differences.

BACKGROUND: Circumferential difference of lymphedematous limbs at designated anatomic distances has been the primary mode for measuring lymphedematous extremities. Computed tomography (CT) imaging produces accurate, consistent, hygienic volume measurements and a direct limb representation. This study compares these 2 main modalities and assesses their correlation. METHODS: CT and circumferential difference measurements, costs, and correlation of patient limbs that received vascularized lymph node transfer were compared. RESULTS: Mean circumferential difference by tape measurement pre- and postoperatively was 31.4% ± 19.1% and 17.4% ± 8.8% for upper limbs and 43.2% ± 16.1% and 22.4% ± 12% for the lower limbs, respectively. Mean CT volumetric difference pre- and postoperatively were 36.1 ± 4.1% and 27.2 ± 2.8% for the upper limb and 46.2 ± 3.2% and 33.2 ± 2.1% for the lower limbs, respectively. CT volume measurements significantly correlated with their respective circumferential difference with Pearson correlation coefficient of r = +0.7, which was statistically significant (P = 0.03), indicating a strong positive correlation between circumferential difference and actual limb volume changes as determined by CT imaging. Circumferential differences are more cost effective than CT volume assessments in the domains of measurement frequency (P = 0.03), fee (P < 0.01), time (P = 0.03), total cost per year (P < 0.01), and cost/minute (P = 0.03). CONCLUSIONS: Standardized circumferential differences that are currently used are comparable to unbiased CT volumetric measurements and can be used as a reliable, reproducible, minimally invasive, low cost, and accurate method of measuring the lymphedematous limbs.

Modified Candy-Plug Technique for Rescue Type B Aortic Dissection with False Lumen Rupture.

Despite recent advances in surgical techniques and endovascular devices, the management of ruptured type B aortic dissection remains challenging. Herein, we describe a patient with a history of chronic type B aortic dissection who presented to the emergency department with a massive left hemothorax and profound shock. Computed tomography demonstrated a thoracic dissecting aneurysm with false lumen rupture. He underwent emergent thoracic endovascular aortic repair and carotid-carotid crossover bypass in a hybrid operating room. Although the thoracic endovascular aortic repair resulted in suitable sealing over the primary entry tear, aortography revealed prominent retrograde flow through the distal re-entry tear into the false lumen. To depressurize the ruptured aortic segment fully, we implanted a modified candy-plug device in the false lumen and successfully occluded the retrograde flow. This case report illustrates the preliminary experience of using modified candy-plug device to rescue a critical patient with ruptured type B aortic dissection.

Lymphedema and concomitant venous comorbidity in the extremity: Comprehensive evaluation, management strategy, and outcomes.

BACKGROUD: The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions. METHODS: Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and concomitant vascular lesions treated with vascularized lymph node flaps were reviewed. The patients had vascular interventions discovered during workup for lymphedema surgery. Outcomes were assessed using circumferential difference (CD) and circumferential reduction rate (CRR) at 12-month and final follow-up visits. RESULTS: Vascular lesions (n = 15) included proximal arterial occlusion ( n = 1), vascular malformation ( n = 2), and proximal venous compression/stenosis ( n = 12). Concomitant vascular lesions had an incidence of 15.8% in patients that underwent vascularized lymph node transfers (VLNTs). We had 100% VLNT survival rate and average number of episodes of cellulitis after VLNTs decreased significantly ( p < 0.05). The CRR for the below knee/elbow measurement at 12-months follow-up was significantly higher for patients that underwent vascular intervention for venous lesions before VLNT instead of concurrently or after (23.7% vs 12.2%, P = 0.23). Final mean CRR was 23.7% and 12.2% respectively. CONCLUSION: Preoperative workup of concomitant vascular lesions is important for lymphedema management. We suggest appropriate vascular intervention should be done prior to VLNT to maximize the short-term and long-term outcomes.

Acoustic Radiation Force Impulse Elastography: Tissue Stiffness Measurement in Limb Lymphedema.

Purpose To evaluate the feasibility of cutaneous and subcutaneous limb tissue elasticity measurement in participants with limb lymphedema by using acoustic radiation force impulse (ARFI) elastography. Materials and Methods From July 2015 to June 2017, ARFI elastography was performed in 64 participants with lymphedema (seven men and 57 women; age range, 23-85 years) by using a US system. Tissue stiffness quantification with shear-wave velocity (SWV) was obtained in the cutaneous and subcutaneous limb tissues. Lymphoscintigraphy was the reference standard. Results SWV was significantly higher in limbs with lymphatic obstruction than in unaffected limbs (cutaneous tissue: 2.75 m/sec vs 1.74 m/sec, respectively; subcutaneous tissue: 1.90 m/sec vs 1.35 m/sec, respectively; P < .001). SWV was significantly different among limbs without lymphatic drainage obstruction, with partial obstruction, and with total obstruction (cutaneous tissue: 1.74 m/sec vs 2.75 m/sec vs 2.77 m/sec; subcutaneous tissue: 1.35 m/sec vs 1.90 m/sec vs 1.90 m/sec, respectively; P < .001). By using a cut-off value of 2.10 m/sec and 1.43 m/sec for cutaneous and subcutaneous tissue, respectively, sensitivity was 83.1% (59 of 71) and 80.3% (57 of 71), and specificity was 86.0% (49 of 57) and 70.2% (40 of 57) for manifestation of lymphatic obstruction. The corresponding areas under the receiver operating characteristic curve were 0.91 and 0.83, respectively. Conclusion Acoustic radiation force impulse elastography showed that cutaneous and subcutaneous tissues are stiffer in lymphedematous limbs than in unaffected limbs. Acoustic radiation force impulse elastography is a feasible imaging modality for noninvasive tissue stiffness quantification in limb lymphedema. © RSNA, 2018 Online supplemental material is available for this article.

Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema.

BACKGROUND: Vascularized lymph node transfer has shown promising results in the treatment of lower limb lymphedema, but little is known about the number of lymph nodes needed for the transfer to achieve optimal results. This study investigated the correlation between number of transferred lymph nodes in submental vascularized lymph node transfer and outcomes regarding limb circumference reduction and cellulitis incidence. METHODS: Thirty-five patients who had received vascularized submental lymph node transfer to an ankle for lower limb lymphedema following gynecologic cancer treatment were included in the study. Limb circumference was determined by means of tape measurement preoperatively and postoperatively and was used to calculate the circumferential difference. Ultrasonography was performed postoperatively to determine the number of lymph nodes within the transferred flap. Patients were divided into groups A through C depending on the number of transferred lymph nodes: 1 or 2 (n = 10), 3 or 4 (n = 14), and 5 to 8 (n = 11), respectively. RESULTS: The mean age of the patients was 60.0 ± 9.2 years. All flaps survived. The mean improvement of circumferential difference for the whole cohort was 19.8 ± 9.2 percent. Groups B and C both had significantly higher improvements in the circumferential difference than group A (p = 0.04 and p = 0.02, respectively), but when compared to each other, the difference was nonsignificant. All groups had significant reductions in the incidence of cellulitis postoperatively. CONCLUSIONS: Submental vascularized lymph node transfer for lower limb lymphedema reduced the incidence of cellulitis, regardless of the number of transferred lymph nodes. The transfer of three or more lymph nodes provided significantly better outcome regarding limb circumference reduction than the transfer of two or fewer lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Accurate Prediction of Submental Lymph Nodes Using Magnetic Resonance Imaging for Lymphedema Surgery.

BACKGROUND: Submental lymph node transfer has proved to be an effective approach for the treatment of lymphedema. This study was to investigate the anatomy and distribution of vascularized submental lymph node (VSLN) flap using magnetic resonance imaging (MRI) and their clinical outcome. METHODS: Fifteen patients who underwent 19 VSLN flap transfers for upper or lower limb lymphedema were retrospectively analyzed. The number of submental lymph nodes was compared among preoperative MRI, preoperative sonography, intraoperative finding, postoperative sonography, and postoperative computed tomography angiography. The outcome was compared between preoperatively and postoperatively. RESULTS: All 19 VSLN flaps survived. Two hundred fifteen lymph nodes were identified in 30 submandibular regions by MRI. The mean number of submental lymph nodes on preoperative MRI was 7.2 ± 2.4, on preoperative sonography was 3.2 ± 1.1, on intraoperative finding was 3.1 ± 0.6, postoperative sonography was 4.6 ± 1.8, and postoperative CTA was 5.2 ± 1.9. Sixty-one percent of the lymph nodes were located in the central two-quarters of the line drawn from the mental protuberance to the mandibular angle. The actual harvest rate of submental lymph nodes was 72.2%. At a 12-month follow-up, mean episodes of cellulitis were improved from 2.7 ± 0.6 to 0.8 ± 0.2 (P < 0.01); mean of circumferential difference was improved 3.2 ± 0.4 cm (P < 0.03). The overall lymphedema quality-of-life was improved 4.9 ± 0.3 (P < 0.04). CONCLUSIONS: The preoperative MRI is a useful tool for the detection of mean 7.2 submental lymph nodes. Mean 72.2% of submental lymph nodes can be successfully transferred for extremity lymphedema with optimal functional recovery.