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SummaryWhile the lymphatic system is increasingly associated with diseases of prevalence, study of these diseases is difficult owing to the paucity of imaging techniques with the sensitivity and temporal resolution to discriminate lymphatic function. Herein, we review the known, pertinent features of the human lymphatic system in health and disease and set the context for a number of emerging studies that use near-infrared fluorescence imaging to non-invasively assess tumor draining lymphatic basins in cancer patients, intraoperatively guide resection of first draining lymph nodes, and to interrogate the difference between normal and aberrant lymphatic structure and function.

These clinical research studies demonstrate the potential of NIR fluorescence imaging as a diagnostic measure of functional lymphatics and as a new tool in translational research studies to decipher the role of the lymphatic system in cancer and other diseases.

Near-infrared (NIR) fluorescence imaging clinical studies have been reported in the literature with six different devices that employ various doses of indocyanine green (ICG) as a non-specific contrast agent. To date, clinical applications range from (i) angiography, intraoperative assessment of vessel patency, and tumor/metastasis delineation following intravenous administration of ICG, and (ii) imaging lymphatic architecture and function following subcutaneous and intradermal ICG administration. In the latter case, NIR fluorescence imaging may enable new discoveries associated with lymphatic function due to (i) a unique niche that is not met by any other conventional imaging technology and (ii) its exquisite sensitivity enabling high spatial and temporal resolution. Herein, we (i) review the basics of clinical NIR fluorescence imaging, (ii) survey the literature on clinical application of investigational devices using ICG fluorescent contrast, (iii) provide an update of non-invasive dynamic lymphatic imaging conducted with our FDPM device, and finally, (iv) comment on the future NIR fluorescence imaging for non-invasive and intraoperative use given recent demonstrations showing capabilities for imaging following microdose administration of contrast agent.

Objective To investigate the feasibility of assessing the efficacy of manual lymphatic drainage (MLD), a method for lymphedema (LE) management, using near-infrared (NIR) fluorescence imaging. Design Exploratory pilot study. Setting Primary care unit. Intervention Indocyanine green of 25 μg in 0.1 cc each was injected intradermally in bilateral arms or legs of subjects. Diffused excitation light illuminated the limbs and NIR fluorescence images were collected using custom-built imaging systems. The subjects received MLD therapy, and imaging was performed pre- and post- therapy. Participants Ten subjects (age 18 – 68) diagnosed with Grade I or II LE and 12 normal control subjects (age 22 – 59). Main outcome measures Apparent lymph velocities and the periods between lymphatic propulsion events were computed from fluorescence images. The data collected pre- and post- MLD were compared and evaluated for differences. Results By comparing the pre- MLD lymphatic contractile function against post- MLD lymphatic function, our results show that the average apparent lymph velocity increased in both the symptomatic (+23%) and asymptomatic (+25%) limbs of LE subjects and in the control limbs (+28%) of normal subjects. The average lymphatic propulsion period decreased in the symptomatic (−9%) and asymptomatic (−20%) limbs of LE subjects, as well as in the control limbs (−23%). Conclusions We demonstrated that NIR fluorescence imaging could be used to quantify immediate benefits of lymphatic contractile function following MLD.