Indocyanine Green Lymphography-Guided Personalized Conservative Management Recommendations in Breast Cancer-Related Upper Limb Lymphedema: A Retrospective Study
Restricted accessResearch articleFirst published online April, 2026
Indocyanine Green Lymphography-Guided Personalized Conservative Management Recommendations in Breast Cancer-Related Upper Limb Lymphedema: A Retrospective Study
Breast cancer-related upper limb lymphedema (BCRL), once established, requires lifelong self-management. Indocyanine green lymphography (ICGL) imaging is an approach used to visualize lymphatics to diagnose, stage, and guide lymphedema treatment. The impact of ICGL-based personalized conservative management on clinical outcomes (extracellular fluid measured by Lymphedema index [L-Dex] units) is unknown. This study aimed to explore the changes in strategies for BCRL management and clinical outcomes for 3 months following ICGL imaging.
Methods:
Data from 20 female adults with BCRL who underwent ICGL imaging at the Australian Lymphedema Education Research and Treatment Center clinic at Macquarie University were included in this study. Data related to the ICGL findings, personalized conservative recommendations, and objective outcome measures were extracted. Data were analyzed retrospectively.
Results:
Conservative recommendations post-ICGL were significantly different in the number of strategies from the pre-ICGL (median [IQR] = 6 [2] vs. 3 [6], p < 0.001). Likewise, the number of compression garments and types of fabric (flat knit) prescribed were significantly higher following ICGL, and these changes were largely maintained by participants at 3 months. There were positive influences of ICGL-guided conservative management changes on bioimpedance spectroscopy, indicating improvements in lymphedema severity.
Conclusion:
ICGL-guided personalized conservative recommendations often led to changes in participants’ management, resulting in positive clinical outcomes.
The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the international society of lymphology. Lymphology, 2020; 53(1):3–19.
2.
MoffattC, KeeleyV, QuereI. The concept of chronic Edema-A neglected public health issue and an international response: The LIMPRINT study. Lymphat Res Biol, 2019; 17(2):121–126.
3.
MoffattCJ, FranksPJ, DohertyDC, et al.Lymphoedema: An underestimated health problem. Qjm, 2003; 96(10):731–738.
4.
DonahuePMC, MacKenzieA, FilipovicA, et al.Advances in the prevention and treatment of breast cancer-related lymphedema. Breast Cancer Res Treat, 2023; 200(1):1–14.
5.
DylkeES, SchembriGP, BaileyDL, et al.Diagnosis of upper limb lymphedema: Development of an evidence-based approach. Acta Oncol, 2016; 55(12):1477–1483.
6.
DiSipioT, RyeS, NewmanB, et al.Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis. Lancet Oncol, 2013; 14(6):500–515.
7.
BoyagesJ, KalfaS, XuY, et al.Worse and worse off: The impact of lymphedema on work and career after breast cancer. Springerplus, 2016; 5:657.
8.
KoelmeyerLA, ThompsonBM, MackieH, et al.Personalizing conservative lymphedema management using indocyanine green-guided manual lymphatic drainage. Lymphat Res Biol, 2021; 19(1):56–65.
AkitaS, NakamuraR, YamamotoN, et al.Early detection of lymphatic disorder and treatment for lymphedema following breast cancer. Plast Reconstr Surg, 2016; 138(2):192e–202e.
11.
BadgerC, PrestonN, SeersK, et al.Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database Syst Rev, 2004(4):CD003141.
12.
BoyagesJ, KoelmeyerLA, SuamiH, et al.The ALERT model of care for the assessment and personalized management of patients with lymphoedema. Br J Surg, 2020; 107(3):238–247.
13.
International F. Best Practice for the Management of Lymphedema. International consensus. London: MEP Ltd; 2006.
14.
International Lymphedema Framework. Best Practice for the Management of Lymphedema. MEP Ltd: London; 2006.
15.
AdamsKE, RasmussenJC, DarneC, et al.Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema. Biomed Opt Express, 2010; 1(1):114–125.
16.
AldrichMB, GrossD, MorrowJR, et al.Effect of pneumatic compression therapy on lymph movement in lymphedema-affected extremities, as assessed by near-infrared flu-presence lymphatic imaging. J Innov Opt Health Sci, 2017; 10(2):1650049.
17.
GiacaloneG, BelgradoJP, BourgeoisP. A new dynamic imaging tool to study lymphedema and associated treatments. Eur J Lymphol Related Problems, 2011; 22(62):10–14.
18.
KitayamaS, MaegawaJ, MatsubaraS, et al.Real-time direct evidence of the superficial lymphatic drainage effect of intermittent pneumatic compression treatment for lower limb lymphedema. Lymphat Res Biol, 2017; 15(1):77–86.
19.
TrevethanM, BennettS, DoigE, et al.Navigating the application of new innovations: Establishing an indocyanine green lymphography clinic in Australia. Health Soc Care Community, 2022; 30(6):e5549–e5559. 2022, 30(6).
20.
ChangDW, SuamiH, SkorackiR. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg, 2013; 132(5):1305–1314.
21.
Heydon-WhiteA, SuamiH, BoyagesJ, et al.Assessing breast lymphoedema following breast cancer treatment using indocyanine green. Breast Cancer Res Treat, 2020; 181(3):635–644.
22.
OgataF, NarushimaM, MiharaM, et al.Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labelling in lym- phedema. Ann Plast Surg, 2007; 59(2):180–184.
23.
SuamiH, Heydon-WhiteA, MackieH, et al.A new indocyanine green fluorescence lymphography protocol for identification of the lymphatic drainage pathway for patients with breast cancer-related lymphoedema. BMC Cancer, 2019; 19(1):985.
24.
YamamotoT, MatsudaN, DoiK, et al.The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg, 2011; 128(4):314e–321e.
25.
JorgensenMG, ToyserkaniNM, HansenFCG, et al.Prospective validation of indocyanine green lymphangiography staging of breast cancer-related lymphedema. Cancers (Basel), 2021; 13(7):1540.
26.
CansızG, Arıkan DönmezA, KapucuS, et al.The effect of a self-management lymphedema education program on lymphedema, lymphedema-related symptoms, patient compliance, daily living activities and patient activation in patients with breast cancer-related lymphedema: A quasi-experimental study. Eur J Oncol Nurs, 2022; 56:102081.
27.
GradyPA, GoughLL. Self-management: A comprehensive approach to management of chronic conditions. Am J Public Health, 2014; 104(8):e25–e31.
28.
JohnstonePA, HawkinsK, HoodS. Role of patient adherence in maintenance of results after manipulative therapy for lymphedema. J Soc Integr Oncol, 2006; 4(3):125–129.
29.
PigottA, DoigE, McCannA, et al.It was just mind blowing to be honest: A qualitative phenomenological study exploring cancer survivor’s experiences of indocyanine green lymphography used to inform lymphedema therapy management. Support Care Cancer, 2021; 29(11):6389–6397.
30.
LorigKR, HolmanH. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med, 2003; 26(1):1–7.
31.
AbbaciM, ConversanoA, De LeeuwF, et al.Near-infrared fluores-cence imaging for the prevention and management of breast cancer-related lymphedema: A systematic review. Eur J Surg Oncol, 2019; 45(10):1778–1786.
32.
BeaneyT, ClarkeJ, WoodcockT, et al.Effect of timeframes to define long term conditions and sociodemographic factors on prevalence of multimorbidity using disease code frequency in primary care electronic health records: Retrospective study. BMJ Med, 2024; 3(1):e000474.
33.
KoelmeyerLA, WardLC, DeanC, et al.Body positional effects on bioimpedance spectroscopy measurements for lymphedema assessment of the arm. Lymphat Res Biol, 2020; 18(5):464–473.
34.
TrevethanM, DoigE, PattersonF, et al.Indocyanine green lymphography in conservative lymphedema management: An exploration of the impact on lymphedema therapy plans. Semin Oncol Nurs, 2025; 41(1):151792.
35.
RidnerSH, ShahC, BoyagesJ, et al.L-Dex, arm volume, and symptom trajectories 24 months after breast cancer surgery. Cancer Med, 2020; 9(14):5164–5173.
36.
LaidleyA, AnglinB. The impact of L-Dex(®) measurements in assessing breast cancer-related lymphedema as part of routine clinical practice. Front Oncol, 2016; 6:192.
37.
CiudadP, BustosSS, ForteAJ, et al.Manual lymphatic drainage guided by real-time indocyanine green lymphography in breast cancer-related lymphedema. Arch Plast Surg, 2021; 48(2):239–240.
38.
ThompsonB, GaitatzisK, JongeX, et al.Manual lymphatic drainage treatment for lymphedema: A sys- tematic review of the literature. J Cancer Surviv, 2021; 15(2):244–258.
39.
WiggJ, CooperG. How is lymphofluoroscopy mapping altering lymphoedema management? Br J Community Nurs, 2017; 22(Sup10):S16–S20.
40.
SoranA, SenolK, LupinacciK. Navigating lymphedema: The impact of indocyanine green lymphography on personalized therapy outcomes in breast cancer patients. Clin Breast Cancer, 2025; 25(1):19–26.
41.
FrameworkIL. Template for Practice: Compression hosiery in upper body lymphoedema. HealthComm UK Ltd: Aberdeen; 2009.
42.
HobdayA. Use of compression therapy in patients with lymphoedema. Nurs Stand, 2016; 30(27):50–58; quiz 60.
43.
ZaleskaM, OlszewskiWL, DurlikM. The effectiveness of intermittent pneumatic compression in long-term therapy of lymphedema of lower limbs. Lymphat Res Biol, 2014; 12(2):103–109.
44.
ShenA, WuP, QiangW, et al.Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study. J Clin Nurs, 2023; 32(19–20):7330–7345.
45.
VignesS, PorcherR, ArraultM, et al.Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy. Breast Cancer Res Treat, 2007; 101(3):285–290.
46.
HettrickH, EhmannS, McKeownB, et al.Selecting appropriate compression for lymphedema patients: American Vein and Lymphatic Society position statement. Phlebology, 2023; 38(2):115–118.
47.
DevoogdtN, ThomisS, GroefA, et al.The effectiveness of fluoroscopy-guided manual lymph drainage as part of decongestive lymphatic therapy on the superficial lymphatic architecture in patients with breast cancer-related lymphoedema: A randomised controlled trial. Cancers (Basel), 2023; 15(5):1545.
48.
TV, LV, NG, et al.Protocol of a randomised controlled trial regarding the effectiveness of fluoroscopy-guided manual lymph drainage for the treatment of breast cancer-related lymphoedema (EFforT-BCRL trial). Eur J Obstet Gynecol Reprod Biol, 2018; 221:177–188.
49.
Medina-RodríguezME, de-la-Casa-AlmeidaM, MartínJG, et al.Changes in indocyanine green lymphography patterns after physical treatment in secondary upper limb lymphedema. J Clin Med, 2020; 9(2):306.
50.
LiangM, ChenQ, PengK, et al.Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore), 2020; 99(49):e23192.
51.
RidnerSH, DietrichMS, SpotanskiK, et al.A prospective study of L-Dex values in breast cancer patients pretreatment and through 12 months postoperatively. Lymphat Res Biol, 2018; 16(5):435–441.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
