Classification of lymphoscintigraphy and relevance to surgical indication for lymphaticovenous anastomosis in upper limb lymphedema.

Upper limb lymphedema that develops after breast cancer surgery causes physical discomfort and psychological distress, and it can require both conservative and surgical treatment. Lymphaticovenous anastomosis has been reported to be an effective treatment; however the disease severity criteria that define indications for this treatment remain unclear. Here, we examined lymphoscintigraphic findings in 78 patients with secondary upper limb lymphedema and classified them into 5 major types (Type I-V) and 3 subtypes (Subtype E, L, and 0). Results revealed that this classification is related to the clinical stage scale of the International Society of Lymphology. Based on intraoperative examination findings in 20 of the 78 patients, lymphatic pressure is likely to be further elevated in Type II-V cases which are characterized by the presence of dermal back flow. Therefore, lymphaticovenous anastomosis should be considered as a treatment option for lymphedema in Type II-V cases. Furthermore, there are only limited lymph vessel sites usable for lymphaticovenous anastomosis in more severe lymphedema types [Types IV and Type V (which is characterized by dermal backflow only in the hand)]. The findings in Type IV-V cases suggest that therapeutic strategies for severe upper limb lymphedema need further consideration.