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MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures.

Methods

Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0–3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen’s kappa was calculated to compare MRI staging by two readers.

Results

STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs = 0.63, p < 0.0001), larger % difference in limb volume (rs = 0.68, p < 0.0001), and higher L-Dex® ratio (rs = 0.84, p < 0.0001). Cohen’s kappa was 0.92 (95% CI, 0.85–1.00).

Conclusion

An MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning.

Key Points

• Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists.

• MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients.

• In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.

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Abbreviations

ANOVA:

Analysis of variance

BMI:

Body mass index

DB:

Dermal backflow

ICG:

Indocyanine green

ISL:

International Society of Lymphology

LYMQOL:

Lymphedema Quality of Life

MRI:

Magnetic resonance imaging

QoL:

Quality of life

STIR:

Short-tau inversion recovery

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Funding

This study has received funding by the RSNA R&E Resident Research Grant RR1820.

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Authors and Affiliations

  1. Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA

    Geunwon Kim, Martin P. Smith, Kevin J. Donohoe & Leo L. Tsai

  2. Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA

    Anna Rose Johnson & Dhruv Singhal

Authors
  1. Geunwon Kim
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  2. Martin P. Smith
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  3. Kevin J. Donohoe
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  4. Anna Rose Johnson
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Corresponding author

Correspondence to Geunwon Kim.

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The scientific guarantor of this publication is Geunwon Kim.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

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Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board approval was obtained.

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• Retrospective

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Kim, G., Smith, M.P., Donohoe, K.J. et al. MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements. Eur Radiol 30, 4686–4694 (2020). https://doi.org/10.1007/s00330-020-06790-0

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  • DOI: https://doi.org/10.1007/s00330-020-06790-0

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