To assess the impact of the lymph node dissection (LND) technique on short- and long-term complications. This retrospective review included patients who underwent hysterectomy, oophorectomy, and pelvic ± para-aortic LND...To assess the impact of the lymph node dissection (LND) technique on short- and long-term complications. This retrospective review included patients who underwent hysterectomy, oophorectomy, and pelvic ± para-aortic LND for gynecological malignancies (cervical, endometrial, and ovarian) from 2020 to 2022 in our Gynecological Oncology Surgery clinic. Among 147 patients who underwent pelvic LND for gynecological malignancy, 48 had procedures involving scissors and 99 had procedures involving unipolar cautery. There was no significant difference in the numbers of extracted pelvic and para-aortic lymph nodes between groups. The extents of LND were comparable between the scissors and unipolar cautery groups ( = 0.945). The scissors group exhibited less fluid drainage between days 2 and 5 postoperatively (1300 [600-3100] vs 1800 [600-3400]; = 0.038). In terms of primary early and late clinical outcomes, there were no significant differences in lymphocele (16.7% vs 15.2%; = 0.494) and lymphedema (18.8% vs 17.2%; = 0.491) rates between groups. After retroperitoneal LND for gynecological malignancy, early complications such as lymphocele and late complications such as lower extremity lymphedema did not significantly differ between procedures using cold scissors and procedures using unipolar cautery.
Lymphat Res Biol
· 2024 Dec · PMID 39436812
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Lymphedema is an intractable disease requiring lifelong treatment. Daily self-care by the patient is essential; however, establishing care is often difficult. Our hospital offers a short-term educational hospitalization...Lymphedema is an intractable disease requiring lifelong treatment. Daily self-care by the patient is essential; however, establishing care is often difficult. Our hospital offers a short-term educational hospitalization program that involves intensive, multidisciplinary intervention to develop self-care. This study aimed to evaluate the effectiveness of this program. Among the patients diagnosed with primary or secondary lymphedema who underwent educational hospitalization, 31 cases (33 limbs) were included in this study. The upper extremity lymphedema (UEL) index and lower extremity lymphedema (LEL) index were used for objective evaluation, and the Lymphedema Quality of Life Questionnaire was used for subjective evaluation. The therapeutic effects of educational hospitalization were examined before admission, at discharge, and at 6 months postdischarge. The UEL/LEL index significantly decreased for both the upper and lower limbs after educational hospitalization. In addition, the UEL/LEL index change rate from prehospitalization to 6 months postdischarge was compared between the continued and discontinued exercise groups; the former index showed significantly more improvement than the latter. Comparing the quality of life (QOL) assessments pre- and posthospitalization, statistically significant improvements were observed in all categories, including function, appearance, symptoms, and psychological state. Short-term educational hospitalization led to a sustained reduction in the circumference of lymphedema-affected limbs and an improvement in the QOL. The multidisciplinary approach resulted in improved self-efficacy and established daily self-care.
Liu Z, Xia S, Shen W
… +10 more, Sun Y, Xin J, Chang K, Zhu Y, Liang C, Liu X, An R, Zhou C, Zhao Z, Li P
Lymphat Res Biol
· 2024 Dec · PMID 39429051
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Chylous reflux (CR) in primary lymphedema (PL) of the lower extremities is rare and requires particular diagnostic procedures. This study aimed to determine clinical and lymphoscintigraphic traits for efficient screening...Chylous reflux (CR) in primary lymphedema (PL) of the lower extremities is rare and requires particular diagnostic procedures. This study aimed to determine clinical and lymphoscintigraphic traits for efficient screening. Pediatric patients with PL of lower extremities treated in our institution between January 2020 and December 2023 were reviewed. The medical history, lymphoscintigraphy, non-contrast MR lymphography, and direct lymphangiography were analyzed. Lymphoscintigraphic visual patterns were classified to detect CR. Patients with CR showed significantly higher proportions of childhood symptom onset (65.63% vs. 25.19%, < 0.01), genital lymphedema (62.50% vs. 19.26%, < 0.01), and proximal-to-distal swelling (31.25% vs. 8.89%, < 0.01). Eight patients without skin lesions had milk discharge after acupuncture or skin breakdown. Pattern 4 shows diffused dermal backflow of the leg and an absence of superficial lymphatic drainage, or normal initial cephalad flow with subsequent reflux of tracer into the affected limb. CR showed significantly higher percentages of pattern 4 (87.50% vs. 12.59%, < 0.01), normal/widened iliac lymphatics (78.13% vs. 11.11%, < 0.01), and thigh/calf outlining (87.50% vs. 29.63%, < 0.01). Genital swelling preceding limb swelling and genital radioactivity were more common in the CR group. CR tends to occur in childhood initially, begin centrally and progress distally, and involve genitals prior to lower extremities. Milk discharge after acupuncture or skin breakdown is important for screening CR without chylous vesicles. The patterns with typical "profiling of the leg" and normal or widened iliac lymphatic trunks strongly correlate with CR. Genital lymphedema with increased radioactivity indicates CR.
Vo TT, Bayens P, Meseeuw C
… +4 more, Frippiat J, Regnier M, Lheureux A, Deltombe T
Lymphat Res Biol
· 2024 Dec · PMID 39393927
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The aim of this prospective study was to investigate the effect of a first and repeated complex decongestive therapy (CDT) program on volume and functioning in patients with unilateral breast cancer-related lymphedema (B...The aim of this prospective study was to investigate the effect of a first and repeated complex decongestive therapy (CDT) program on volume and functioning in patients with unilateral breast cancer-related lymphedema (BCRL) and to identify whether the volume before treatment and/or the number of previous treatment influence outcomes. In total, 100 and 42 patients with BCRL treated by 499 CDT (6 hours a day during 5 consecutive days) between April 2018 and December 2021 were included. Patients were assessed using volume including percentage of excess volume and percentage reduction in excess volume and lymph-International Classification of Functioning-UL questionnaire. After CDT, a significant reduction in BCRL volume (50%) and improvement in functioning (30%) were observed. The volume reduction was greater when the BCRL volume before treatment was low (10%-20%) and when CDT was performed for the first time. The functioning improvement was identical whatever the volume is before treatment and the number of previous CDT. A greater volume reduction after CDT was obtained in BCRL with low volume before treatment and after the first CDT. Such findings support the need for early intensive BCRL treatment to control volume and improve functioning.
Lymphat Res Biol
· 2024 Dec · PMID 39381855
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Lipedema is a disease characterized by an increase in extracellular fluid. In these patients, the increase in the amount of extracellular fluid may accelerate the progression of the disease. The aim of this study is to e...Lipedema is a disease characterized by an increase in extracellular fluid. In these patients, the increase in the amount of extracellular fluid may accelerate the progression of the disease. The aim of this study is to examine the effect of complex decongestive therapy (CDT) on intracellular/extracellular fluid balance. Twenty-two female patients diagnosed with lipedema by a specialist lymphologist were included in the study. Patients were subjected to complex decongestive therapy and pneumatic compression therapy 6 days a week for 1 month. Extracellular and intracellular fluid volumes were assessed using bioimpedance spectroscopy before and after the treatment. A decrease in intracellular ( = 0.010) and extracellular ( = 0.002) fluid volumes was observed after the treatment. There is no completely curative treatment method for lipedema. Current treatments aim to slow down the progression of the disease. CDT is considered effective in reducing intracellular and extracellular fluid volume in lipedema patients. Therefore, it is thought to be effective in slowing down the progression of the disease.
Lymphat Res Biol
· 2024 Oct · PMID 39320336
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Lymphedema is a common breast cancer side effect, with an average incidence of 30%. The gold standard conservative treatment for lymphedema is complex decongestive therapy (CDT), which includes manual lymphatic drainage,...Lymphedema is a common breast cancer side effect, with an average incidence of 30%. The gold standard conservative treatment for lymphedema is complex decongestive therapy (CDT), which includes manual lymphatic drainage, compression therapy, skin care, and exercise. Lymphovenular anastomosis (LVA) is a microsurgical technique that intends to redirect excess lymphatic fluid to the venous circulation; this procedure is usually performed when conservative treatment fails. Therefore, the objective of this study is to evaluate the effectiveness of LVA and CDT for the treatment of breast cancer-related lymphedema (BCRL). The search was performed in CENTRAL, MEDLINE, Embase, PsycINFO, SCOPUS, and LILACS. Inclusion criteria were (1) population: women with BCRL; (2) intervention: treated with LVA and CDT; and (3) outcome: primary outcome was lymphedema reduction. Secondary outcome was quality of life. Risk of bias and quality of study reporting were also assessed. The search found 3872 articles, with 5 articles meeting the PICO (population, intervention, comparison, outcomes) criteria, 4 pre-post studies, and one observational cohort study. The total sample included 2763 patients. Follow-up was variable. The follow-up varies from 7.8 to 120 months, with an average of 35 months. Lymphedema reduction was obtained in the five studies. The present systematic review suggests that for patients with lymphedema secondary to breast cancer, the combination of both treatments is effective in reducing the size of the limb and improving quality of life. Low-quality evidence was found for both limb circumference reduction and quality of life. Additional research effort is needed to reduce bias and improve the quality of evidence, in order to better inform clinical practice and enhance the care and well-being of patients with BCRL.
Lymphat Res Biol
· 2024 Dec · PMID 39320331
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Lymphedema in the lower abdomen and genitals is unnoticeable and has no established diagnostic methods. In this study, we evaluated it using four examinations. We evaluated 25 patients with lymphedema in the legs, divid...Lymphedema in the lower abdomen and genitals is unnoticeable and has no established diagnostic methods. In this study, we evaluated it using four examinations. We evaluated 25 patients with lymphedema in the legs, dividing the abdomen and genitals in four areas (right and left, upper and lower). The mean age was 58.6 years. In lymphoscintigraphy and indocyanine green (ICG) lymphography, we diagnosed lymphedema when dermal backflow was observed. ICG lymphography was performed in 13 patients. In ultrasonography, we determined the presence of edema when cobblestone pattern was observed. Subcutaneous fat thickness was also measured. The patients' subjective symptoms were identified on an interview. We compared the results among the examinations. The positivity rates for lymphedema based on lymphoscintigraphy, ICG lymphography, ultrasonography, and subjective symptoms were 45.0%, 42.3%, 8.0%, and 34.0%, respectively. Two of the 13 patients who underwent all examinations complained of subjective symptoms of edema in areas that showed no abnormalities in the examinations. In contrast, 14 of the 25 patients had areas where they had no subjective symptoms despite having abnormalities in at least one of the tests. Those with subjective symptoms of edema tended to have thinner abdominal fat in both the upper and lower abdomen, but no significant difference was observed. Large differences were observed in the positive rate of edema in subjective symptoms and examinations of lymphedema in the lower abdomen and genitals. It is not important to determine which examination is best but rather to combine multiple examinations.
Lymphat Res Biol
· 2024 Oct · PMID 39279577
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Among super-microsurgical techniques, the anastomosis of vessels smaller than 0.5 mm is very difficult to perform due to the small diameter and thinness of the blood and lymphatic vessel walls. In this article, we report...Among super-microsurgical techniques, the anastomosis of vessels smaller than 0.5 mm is very difficult to perform due to the small diameter and thinness of the blood and lymphatic vessel walls. In this article, we report on the main points of super microsurgery, particularly on the anastomosis of veins and lymphatic vessels with diameters smaller than 0.5 mm. Details of anastomosis of vessels smaller than 0.5 mm. (1) The outer wall of the first blood vessel near the abrupt end hook with the tip of the needle in the needle holder. The entire abrupt end of the first blood vessel was supported by forceps in the surgeon's left-hand. (2) The surgeon decided the entry point and angle of the needle while moving the tip. After the needle was fixed, a force was applied so that the needle could pass through to the vascular wall. (3) After the needle passed through, the tip was confirmed to be located in the lumen of the first blood vessel. (4) The tip of the needle was inserted into the lumen of the second blood vessel, and the bite was adjusted while touching the second blood vessel through the endometrium. (5) Once the tip was properly positioned, counter-traction was applied by holding the entire outer wall with a left-hand forceps. (6) The needle was held near the tip and pulled out along its curvature. The anastomosis time was 11.35 minutes on average (9 to 14 minutes). The patency rate for all 20 anastomosis procedures was also 100%. The important points of LVA for lymphatic vessels and veins smaller than 0.5 mm were reported. Once the surgeons are familiarized with this anastomosis procedure, they can typically perform one anastomosis in about 10 minutes.
Thomis S, Ronsse S, Bechter-Hugl B
… +2 more, Fourneau I, Devoogdt N
Lymphat Res Biol
· 2024 Oct · PMID 39253841
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Breast cancer-related lymphedema (BCRL) is a disabling and frequently occurring condition after treatment for breast cancer. Studying lymph anatomy by means of indocyanine green (ICG) lymphography is a promising tool to...Breast cancer-related lymphedema (BCRL) is a disabling and frequently occurring condition after treatment for breast cancer. Studying lymph anatomy by means of indocyanine green (ICG) lymphography is a promising tool to help better understand BCRL. The aim of this study is to investigate the relation between ICG lymphography characteristics and the risk of developing BCRL. Patients scheduled for breast surgery with either unilateral axillary lymph node dissection or sentinel lymph node biopsy between November 2017 and May 2019 were included. Patients were assessed at baseline and up to 36 months postsurgery. BCRL was defined as an increase of ≥5% relative arm volume difference compared with the presurgical difference. In total, 128 patients were included. During 36 months of follow-up, 45 patients (35.2%) developed BCRL. The number of lymph vessels before surgery was not a statistically significant risk factor for developing BCRL ( = 0.8485). However, an increase in the number of lymph vessels compared with baseline was a significant protective factor for developing BCRL (odds ratio = 0.8). An increase of one lymph vessel corresponds to a 19% relative risk reduction of developing BCRL. The presence of lymph nodes at baseline and the change in the presence of lymph nodes compared with baseline were no predictors for the development of BCRL ( = 0.0986 and = 0.8910, respectively). An increase in the number of lymph vessels visualized by ICG lymphography compared with baseline is a protective factor for developing BCRL. Therapies with the ability to increase the number of lymph vessels can thus possibly decrease the risk of developing BCRL.
Kim JH, Choi HE, Lee JH
… +3 more, Sim YJ, Jeong HJ, Kim GC
Lymphat Res Biol
· 2024 Oct · PMID 39230429
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Complex decongestive therapy (CDT) is being used in breast cancer-related lymphedema (BCRL). The degree of initial edema and bioimpedance analysis (BIA) are known to be related with the therapeutic effect of CDT. D-dimer...Complex decongestive therapy (CDT) is being used in breast cancer-related lymphedema (BCRL). The degree of initial edema and bioimpedance analysis (BIA) are known to be related with the therapeutic effect of CDT. D-dimer can indirectly reflect lymphangiogenesis because IL-6 regulates D-dimer and vascular endothelial growth factor, which is the most important lymphangiogenic factor. We assessed whether D-dimer could be used for the prediction of therapeutic effect of CDT, as well as BIA and initial edema. The participants were patients who took inpatient treatment for BCRL from July 2016 to May 2020. Percent excess volume (PEV) was calculated by dividing the difference in volume of both arms by the edema arm, and the difference in PEV before and after 2 weeks of CDT was defined as the CDT effect. BIA and D-dimer tests were performed before treatment. The single frequency bioimpedance analysis (SFBIA) ratio and D-dimer showed significant correlations with β coefficients of 0.581 and 0.402 ( < 0.01), respectively, and the explanatory power of these models was confirmed to be 0.704.The areas under the curve of initial PEV, SFBIA ratio, D-dimer for determining the CDT effect were identified as 0.849, 0.795, and 0.725, respectively. Initial PEV, SFBIA ratio, and blood D-dimer levels could be used as predictors for CDT treatment effect. Their usefulness order was in the order of initial PEV, SFBIA ratio, and D-dimer. These factors could be used as predictors to establish therapeutic plan in patients with mild lymphedema.
Abalo-Núñez R, Cuña-Carrera ID, Alonso-Calvete A
… +2 more, Lantarón-Caeiro EM, Soto-González M
Lymphat Res Biol
· 2024 Aug · PMID 39092500
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Lymphedema is a common complication after mastectomy in women with breast cancer. Several methods have been described to assess and diagnose lymphedema, one of the most studied being the perimeter and ultrasonography. Ho...Lymphedema is a common complication after mastectomy in women with breast cancer. Several methods have been described to assess and diagnose lymphedema, one of the most studied being the perimeter and ultrasonography. However, the reliability of these methods and the correlation between them are still controversial. The aim of this study was to analyze the reliability of cytometry and ultrasound imaging in the assessment of lymphedema after mastectomy in women with breast cancer and to study the correlation between them. A cross-sectional study was conducted in 29 women with mastectomy after breast cancer. Lymphedema in the arm was measured both with cytometry and ultrasonography. Reliability was calculated with intraclass correlation coefficient. The correlation between the two methods was carried out with the Pearson correlation coefficient. Both cytometry (M1: α = 0.999, ICC = 0.996; M2: = α = 0.998, ICC = 0.994) and ultrasonography (M1: α = 0.992, ICC = 0.976; M2: = α = 0.991, ICC = 0.973) are reliable methods to assess lymphedema in the arm. No significant correlation was found between them ( > 0.05). Cytometry and ultrasonography appear to be adequate for the measurement of edema in women with breast cancer after mastectomy. However, for an accurate measurement of lymphedema, these measurements should not be used interchangeably.
Mohan G, Khan I, Diaz SM
… +9 more, Kamocka MM, Hulsman LA, Ahmed S, Neumann CR, Jorge MD, Gordillo GM, Sen CK, Sinha M, Hassanein AH
Lymphat Res Biol
· 2024 Jun · PMID 38699876
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Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel the...Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel therapeutics. Intravital microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous nonviral vector gene delivery using a chip with nanochannel poration in a rapid (<100 ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics in the live mice model. The murine tail model of lymphedema was utilized. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: TNT group receives pCMV6 (expression vector backbone alone) ( = 6); TNT group receives pCMV6- ( = 6). Lymphatic vessels (fluorescein isothiocyanate [FITC]-dextran stained) and lymphatic branch points (indicating lymphangiogenesis) were analyzed with the confocal/multiphoton microscope. The experimental group TNT exhibited reduced postsurgical tail lymphedema and increased lymphatic distribution compared to TNT group. More lymphatic branching points (>3-fold) were observed at the TNT site in TNT group. This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. IVM can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.
Sakai H, Miyazaki T, Kanasaki M
… +2 more, Tsukuura R, Yamamoto T
Lymphat Res Biol
· 2024 Jun · PMID 38662456
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Evaluation of lymph circulation is significant in lower extremity lymphedema (LEL) management. Single-photon emission computed tomography-computed tomography (SPECT-CT) has been introduced for lymphedema evaluation, but...Evaluation of lymph circulation is significant in lower extremity lymphedema (LEL) management. Single-photon emission computed tomography-computed tomography (SPECT-CT) has been introduced for lymphedema evaluation, but its characteristic findings are yet fully clarified. The purpose of this study was to reveal typical SPECT-CT findings in secondary LEL by contrasting with indocyanine green (ICG) lymphography findings. This is a single-center retrospective case-control study. Medical charts of cancer survivors who underwent SPECT-CT and ICG lymphography for secondary LEL were reviewed. Lymphedematous limbs were defined as ICG lymphography stage I-V and non-lymphedematous limbs were defined as ICG lymphography stage 0. Characteristic SPECT-CT findings were identified in early phase and delay phase, and prevalence of the findings was compared between lymphedematous limbs and non-lymphedematous limbs. Thirty-four limbs of 17 patients were included in this study; 6 (17.6%) non-lymphedematous limbs and 28 (82.4%) lymphedematous limbs. Four characteristic SPECT-CT findings were identified; delayed enhancement of the main lower leg lymphatic pathway (DML), few delayed inguinal lymph nodes enhancement (FDN), early phase discontinuous enhancement of the main lymphatic pathway (EDM), and nonenhancement of the deep lymphatic pathways in early phase (NDE). Between lymphedematous and non-lymphedematous limbs, there were statistically significant differences in FDN (64.3% vs. 0%, = 0.004) and EDM (67.9% vs. 0%, = 0.002). FDN and EDM are characteristic SPECT-CT findings in secondary LEL.
Bock KJ, Kelly K, Pospichal DR
… +2 more, Siengsukon CF, Peltzer J
Lymphat Res Biol
· 2024 Jun · PMID 38648290
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Breast cancer survivors (BCSs) have many lifelong symptoms of anxiety, depression, lymphedema, and fatigue that can be exacerbated by sleep disturbance. However, little is known about unique factors contributing to sleep...Breast cancer survivors (BCSs) have many lifelong symptoms of anxiety, depression, lymphedema, and fatigue that can be exacerbated by sleep disturbance. However, little is known about unique factors contributing to sleep disturbance among BCSs with lymphedema; this requires further investigation to offer appropriate support and treatment to these individuals. Therefore, the objective of this study was to capture perceptions and experiences of lymphedema and sleep among BCSs with lymphedema. Qualitative description guided data collection and analysis as part of a mixed-methods investigation to characterize sleep disturbance among BCSs with and without lymphedema. The participants were interviewed one-on-one using a semistructured interview guide. Inductive content analysis was completed using an iterative coding approach, condensing, and categorizing to develop four themes. Seven BCSs with lymphedema participated. From their narratives, four themes were developed: (1) mind and body fatigue are exacerbated by sleep disturbance; (2) fatigue impacted fragile coping and support systems; (3) fatigue influenced self-identity and roles in society; and (4) self-management strategies were used for sleep health. The participants' perceptions of sleep disturbances' impact on their lives endorse further investigation into optimal interventions to improve sleep quality and modify these impactful findings to create a higher quality of life for survivorship.
Recently, the usefulness of lymphatic ultrasound has been reported. It is beneficial not only to identify lymphatic vessels but also to evaluate lymphatic degeneration and diagnose lymphedema. We previously proposed D-CU...Recently, the usefulness of lymphatic ultrasound has been reported. It is beneficial not only to identify lymphatic vessels but also to evaluate lymphatic degeneration and diagnose lymphedema. We previously proposed D-CUPS (Doppler, Cross, Uncollapsible, Parallel, and Superficial fascia) to identify the lymphatic vessels on ultrasound. The purpose of this study was to clarify the sensitivity of each index of D-CUPS. We performed a retrospective study of 27 patients (44 limbs, 98 sites) with lower extremity lymphedema, who underwent lymphaticovenous anastomosis (LVA). We performed a lymphatic ultrasound the day before surgery. We used a linear probe commonly used for venous ultrasound (Noblus EUP-L65; Hitachi Medical Corp., Tokyo, Japan). We applied the D-CUPS index to identify the lymphatic vessels on ultrasound. We checked whether lymphatic vessels consistent with preoperative lymphatic ultrasound findings were observed during the LVA. We also calculated the sensitivity of each D-CUPS index. All the 27 patients were women, with a mean age of 59.7 years. Totally, 98 incisions were made (59 incisions on the thigh and 39 incisions on the lower leg). During LVA, lymphatic vessels consistent with the preoperative lymphatic ultrasound findings were observed at all the sites. The sensitivities of each indicator of D-CUPS were 100.0%, 100.0%, 68.4%, 19.4%, and 100.0%, respectively. The sensitivity was 100.0% in D, C, and S. Although each index separately was not perfect, by combining them appropriately, we were able to identify lymphatic vessels with certainty.