Could Exercise Have a Role in Lymphedema Diagnosis and Tracking?
by Evelyn S. Qin, MD
Lymphedema occurs when there is damage or abnormal lymph vessels, preventing adequate lymphatic fluid drainage (1). It is a well-known and dreaded complication of cancer therapies such as lymph node dissections for breast or gynecological cancers (2,3). Lymphedema has traditionally been diagnosed based on clinically history and presentation. However, due to the profound disability and effect it has on quality of life, emphasis has been placed on early and accurate diagnosis.
There are several tools that have been used by healthcare providers to diagnose and track lymphedema. Indocyanine green (ICG) lymphography (figure 2) is an advanced imaging tool that is non-invasive, non-radioactive, and can visualize lymph flow in real time. It has been used increasingly by lymphedema specialists for lymphedema diagnosis, severity staging, treatment planning, and as well as intra-operative guidance, and post-operative management. ICG lymphography has a higher sensitivity and specificity than lymphoscintigraphy (4), the traditional gold standard for visualizing the lymphatic system. It requires an initial and delayed scan to fully visualize disease patterns. However, one of the largest frustrations with ICG scans is the long wait between initial and delayed scans and difficulty controlling for patient activity between scans. Current methods utilizes up to a 24-hours between immediate and delayed scanning (5, 6), and limits the amount of patients that can be imaged in a typical clinic day.
Exercise has been shown to increase lymphatic drainage (7, 8) and is beneficial in patients with lymphedema (9, 10). A recent pilot study at the University of Iowa Hospitals and Clinics was performed to determine if controlled exercise could increase the rate at which ICG dye to plateaus with the goal of developing a standardized ICG lymphography protocol to increase the efficiency and reliability of ICG lymphography in patients with lymphedema. Patients with lymphedema exercised on a recumbent cross trainer (figure 1) with ICG lymphography scans performed after 5 minutes of exercise for a total of twenty minutes. Results showed the ICG dye plateaued after three cycles of exercise (15 minutes of exercise in total) in all patients, and the dye receded after 4 hours. Patients stated they preferred the exercise protocol over the traditional immediate and delayed scans because it shortened their office visits significantly and was not too challenging to do.
We are excited by these preliminary findings as it shows that exercise can accelerate lymph flow. This means exercise allows for more efficient and accurate ICG lymphography studies. In addition, this brings up the exciting question on the ability of exercise to help increase lymph transit during rehabilitation therapies, and the possible positive long-term affects it may have on lymph flow in patients with lymphedema.
References:
1. Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008;59(2):324–31.
2. Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. 2010;116(22):5138–49.
3. Brayton KM, Hirsch AT, PJ OB, Cheville A, Karaca-Mandic P, Rockson SG. Lymphedema prevalence and treatment benefits in cancer: impact of a therapeutic intervention on health outcomes and costs. PLoS One. 2014;9(12):e114597.
4. Mihara M, Hara H, Araki J, Kikuchi K, Narushima M, Yamamoto T, et al. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PLoS One. 2012;7(6):e38182.
5. Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine Green Lymphography Findings in Primary Leg Lymphedema. Eur J Vasc Endovasc Surg. 2015;49(1):95–102.
6. Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine Green Lymphography Findings in Limb Lymphedema. J Reconstr Microsurg. 2016;32(1):72–9.
7. Desai P, Williams AG, Jr., Prajapati P, Downey HF. Lymph flow in instrumented dogs varies with exercise intensity. Lymphat Res Biol. 2010;8(3):143–8.
8. Downey HF, Durgam P, Williams AG, Jr., Rajmane A, King HH, Stoll ST. Lymph flow in the thoracic duct of conscious dogs during lymphatic pump treatment, exercise, and expansion of extracellular fluid volume. Lymphat Res Biol. 2008;6(1):3–13.
9. Singh B, Disipio T, Peake J, Hayes SC. Systematic Review and Meta-Analysis of the Effects of Exercise for Those With Cancer-Related Lymphedema. Arch Phys Med Rehabil. 2016;97(2):302–15 e13.
10. Morris C, Wonders KY. Concise review on the safety of exercise on symptoms of lymphedema. World J Clin Oncol. 2015;6(4):43–4.
Evelyn Qin is a PGY-2 in the Physical Medicine and Rehabilition residency at the University of Washington in Seattle. Follow her on Twitter @EvelynQinMD.
