Figure 2.

Imaging guided surgery in a patient with stage I lymphedema. (A) ^99mTc-SC lymphoscintigraphy with anterior and posterior views showed dermal backflow from left calve to thigh and lymph node accumulation defect of the left side. The images were acquired at 6 h after tracer administration; (B) T₁-weighted MR lymphangiography using 3-dimensional gradient recalled echo (LAVA) (left) and fast spin echo (FSE) (middle) showed twisted, compensatory and discontinuous lymphatic channels of left medial calf (arrows). T₁-weighted with LAVA MIP reconstruction (right) showed multi-strip expansion and compensatory channels of left medial calf (arrows). (C–G) ⁶⁸Ga-NEB PET lymphangiography acquired at 60 min after tracer administration showed slight dermal backflow of the left lower-limb (C and G), lymph node accumulation defect at affected side (C) including left inguinal region (D), abnormal lymphatic channels at left lower medial calve (F) and potential anastomosis pathway inside of medial calf (E). (H) Intraoperative ICG fluorescence lymphangiography provides real-time delineation of subdermal lymphatics inside of medial calf. (I–K) Personalized surgical plan and lymphatic venous anastomosis (LVA) were performed with end-to-end lymphatic channel and suitable sized adjacent subcutaneous venule anastomosis. A length of dilated channel dissected was further confirmed as the lymphatic vessel (I) with pathological HE staining (K).