J Vasc Surg Venous Lymphat Disord. 2026 Aug 3:102592. doi: 10.1016/j.jvsv.2026.102592. Online ahead of print.
ABSTRACT
OBJECTIVE: The purpose of this systematic review was to review imaging and diagnostic modalities for their roles in (1) diagnosing upper and lower extremity lymphedema, (2) detecting subclinical disease through prospective surveillance, (3) providing anatomical assessment of the lymphatic system, and (4) guiding surgical treatment planning.
METHODS: A systematic review was conducted following the PRISMA 2020 guidelines. The search included PubMed, Embase, CENTRAL, Web of Science, and Scopus from January 2010 to April 2026. Four reviewers screened 2,847 articles using Covidence software. The inclusion criteria were studies that reported original data on one or more imaging modalities and presented diagnostic accuracy, reliability, staging parameters, or impact on surgical planning RESULTS: A total of 28 studies were included, comprising 4 RCTs, 12 prospective diagnostic studies, 6 cohort studies, 1 observational study, and 5 systematic reviews or meta-analyses. In upper extremity studies, predominantly composed of breast cancer related lymphedema (BCRL), bioimpedance spectroscopy (BIS) demonstrated sensitivity up to 100% and specificity of 98% for early detection, with the PREVENT trial showing 59% relative risk reduction in chronic BCRL through BIS triggered surveillance. ICG lymphography achieved 100% diagnostic accuracy versus 62% for lymphoscintigraphy in early disease, and UHFUS at 70 MHz achieved 94.9% sensitivity for vessel detection. In the lower extremity, MRL at 3.0 T achieved 100% sensitivity for lymph vessel abnormalities versus 79% for lymphoscintigraphy (κ = 0.93 for delayed drainage). Ultrasound achieved 95.5% sensitivity and 92.9% specificity for vessel detection. Two validated ICG based classifications, SCaT and Shinaoka, enabled lower extremity specific severity staging.
CONCLUSIONS: This systematic review identified important differences in the evidence supporting imaging and diagnostic modalities across the four clinical domains evaluated. For diagnosis and subclinical detection, BIS-triggered prospective surveillance for upper extremity lymphedema is supported by RCT evidence demonstrating significant reduction in chronic BCRL progression. However, comparable trial data for the lower extremity remains absent. For anatomical assessment, region-specific ICG classification systems (SCaT and Shinaoka) address the unique drainage patterns of the lower extremity, while MRL provides comprehensive deep and superficial system visualization across both regions. For surgical planning, the combined use of NIRF-L and MRL offers complementary information to guide microsurgical interventions.
PMID:42546876 | DOI:10.1016/j.jvsv.2026.102592