Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema

Abstract

Background: Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA.

Methods: A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA.

Results: Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes.

Conclusion: The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.

Fig 1. A flow chart depicting the criteria for included patients.

LVA: Lymphaticovenous anastomosis, UEL: Upper extremity lymphedema, LEL: Lower extremity lymphedema.

Fig 2. Treatment outcomes according to clinical findings.

Box and whisker plots comparing LC rate (%) after LVA based on (A) primary malignancy, (B) ISL stage, and (C) history of radiation therapy. The boxes represent the interquartile distribution. Results showed significant differences in primary malignancy between ovarian cancer and other malignancy. While superior outcomes were observed with increasing ISL stage, statistical significance was not achieved. Radiation therapy did not yield significant differences in LC rate after LVA.

Fig 3. Treatment outcomes according to lymphoscintigraphy findings.

Box and whisker plots comparing LC rate (%) after LVA based on (A) extent of dermal backflow (DBF), (B) patterns of main lymphatics, and (C) visualization of regional lymph nodes (LNs). The boxes represent the interquartile distribution. Significant differences were observed based on the extent of DBF, while no significant differences were found for the patterns of main lymphatics and visualization of regional lymph nodes.

Fig 4. Representative case of LEL patients who underwent LVA based on lymphoscintigraphic findings.

A 54-year-old woman with a history of endometrial cancer underwent radical abdominal hysterectomy (RAH) and bilateral pelvic lymph node dissection (BPLND) She had lymphedema in her left leg for the 9 months and had no history of cellulitis (A-C). (A) Lymphoscintigraphy revealed large extent of dermal backflow (DBF) on her left leg without visualization of regional lymph nodes. The main lymphatic vessels exhibited a lower-leg restricted pattern. (B) Preoperative photograph of lower extremities. The left leg presented with Stage II lymphedema with redness and pitting edema. The preoperative LELi was 446.8. (C) Postoperative photograph at 6 months. Following LVA on the left leg with three anastomoses at the saphenous, medial calf, and lateral calf, improvement in LELi was observed with enhanced redness and reduced pitting edema. After LVA, she had significant changes in LELi, with a LC rate of -13.48%. A 54-year-old woman with a history of endometrial cancer also underwent RAH and BPLND. She had lymphedema in her right leg for the 3 months and had no history of cellulitis (D-F). (D) Lymphoscintigraphy revealed no DBF with a trunk pattern of lymphatic vessels and visualized regional lymph nodes in her right leg. (E) Preoperative photograph of lower extremities. The right leg exhibited Stage II lymphedema with mild redness and pitting edema. The preoperative LELi was 440.5. (F) Postoperative photograph at 5.5 months. Four LVA anastomoses were performed at the mid lower leg, proximal lower leg, and mid-thigh. While the redness improved, pitting edema persisted. The LELi did not show improvement, with a total LC rate of 7.11%.