Inter- and intra-rater reliability of modified near-infrared camera to assess superficial lymphatic system in breast cancer-related lymphedema
DOI:
https://doi.org/10.13181/mji.oa.258234Keywords:
breast cancer-related lymphedema, fluorescence imaging, indocyanine greenAbstract
BACKGROUND Near-infrared (NIR) fluorescence imaging is one of the most useful diagnostic methods for breast cancer-related lymphedema (BCRL). It utilizes indocyanine green (ICG) lymphography, which requires a commercial camera that is not widely available. This study aimed to qualitatively assess the reliability of the modified NIR camera in diagnosing BCRL.
METHODS This prospective cross-sectional study was conducted between December 2023 and December 2024 in breast cancer (BC) patients with BCRL. A commercial mirrorless digital camera was modified by incorporating an excitation light source and spectral filters to enable NIR imaging. To evaluate the camera reliability, intra- and inter-observer agreements were assessed using Kappa analysis. Three independent observers evaluated dermal backflow patterns of lymphatic flow: linear, splash, stardust, and diffuse patterns.
RESULTS 60 BC patients with BCRL resulting in 280 images were included. The mean (standard deviation) age was 54.7 (10.1) years and body mass index were 27.1 (4.5) kg/m². Most patients had stage IIA BC (40%) and stage IV ICG lymphography (38%). Intra-observer analysis showed observers 1 and 2 of had a Kappa of 1.00 (95% confidence interval [CI]: 1.00–1.00), while observer 3 had Kappa of 0.99 (95% CI: 0.97–1.00). Inter-observer analysis between observers 1 and 2 showed Kappa 1.00 (95% CI: 1.00–1.00), while observers 1–3 and 2–3 had Kappa of 0.99 (95% CI: 0.97–1.00). Observer 3 misinterpreted 3 linear as splash patterns.
CONCLUSIONS This study showed a high inter- and intra-observer agreements making it reliable for BCRL diagnosis.
Downloads
References
Brahma B, Putri RI, Reuwpassa JO, Tuti Y, Alifian MF, Sofyan RF, et al. Lymphaticovenular anastomosis in breast cancer treatment-related lymphedema: a short-term clinicopathological analysis from Indonesia. J Reconstr Microsurg. 2021;37(8):643-54. https://doi.org/10.1055/s-0041-1723940
Jørgensen MG, Toyserkani NM, Hansen FG, Bygum A, Sørensen JA. The impact of lymphedema on health-related quality of life up to 10 years after breast cancer treatment. NPJ Breast Cancer. 2021;7(1):70. https://doi.org/10.1038/s41523-021-00276-y
Qin ES, Bowen MJ, Chen WF. Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: a retrospective cohort analysis. J Plast Reconstr Aesthet Surg. 2018;71(7):1041-50. https://doi.org/10.1016/j.bjps.2018.02.012
Figueroa BA, Lammers JD, Al-Malak M, Pandey S, Chen WF. Lymphoscintigraphy versus indocyanine green lymphography-which should be the gold standard for lymphedema imaging? Lymphatics. 2023;1:25-33. https://doi.org/10.3390/lymphatics1010004
Akita S, Nakamura R, Yamamoto N, Tokumoto H, Ishigaki T, Yamaji Y, et al. Early detection of lymphatic disorder and treatment for lymphedema following breast cancer. Plast Reconstr Surg. 2016;138(2):192e-202e. https://doi.org/10.1097/PRS.0000000000002337
Yang H, Kim J, Nam W, Kim HJ, Cha IH, Kim D. Handheld near-infrared fluorescence imaging device using modified action cameras for peri-operative guidance of microvascular flap surgery. J Clin Med. 2021;10(3):410. https://doi.org/10.3390/jcm10030410
Kwizera A, Obaid A, Tran D, Rubarth C, Preskitt JT. Use of indocyanine green for sentinel lymph node biopsy in melanoma. Proc (Bayl Univ Med Cent). 2022;36(2):201-4. https://doi.org/10.1080/08998280.2022.2147385
Pollmann L, Juratli M, Roushansarai N, Pascher A, Hölzen JP. Quantification of indocyanine green fluorescence imaging in general, visceral and transplant surgery. J Clin Med. 2023;12(10):3550. https://doi.org/10.3390/jcm12103550
Muraleedharan S, Tripathy K. Indocyanine green (ICG) angiography [Internet]. In: StatPearls. Treasure Island: StatPearls Publishing; 2025 [Updated 2023 Aug 25]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK580479/.
Aleksandrovich SA, Nikolaevich MD. Device for studying the level of blood flow and lymph flow. Russia; RU221600U1, 2023. p. 1-6.
Bertani C, Cassinotti E, Della Porta M, Pagani M, Boni L, Baldari L. Indocyanine green-a potential to explore: narrative review. Ann Laparosc Endosc Surg. 2022;7:9. https://doi.org/10.21037/ales-21-5
Brahma B, Priambodo P, Harlim H, Suryadi S, Panigoro SS, Yamamoto T, et al. 104P quantification analysis of low-cost near infrared camera for breast cancer treatment-related lymphedema fluorescence imaging. ESMO Open. 2024;9:103175. https://doi.org/10.1016/j.esmoop.2024.103175
Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53(1):3-19. https://doi.org/10.2458/lymph.4649
Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, et al. The eighth edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin. 2017;67(2):93-9. https://doi.org/10.3322/caac.21388
Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, et al. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord. 2024;12(4):101863. https://doi.org/10.1016/j.jvsv.2024.101863
Yamamoto T, Yamamoto N, Kageyama T, Sakai H, Fuse Y, Tsuihiji K, et al. Technical pearls in lymphatic supermicrosurgery. Glob Health Med. 2020;2(1):29-32. https://doi.org/10.35772/ghm.2019.01010
Wang F, Wan H, Ma Z, Zhong Y, Sun Q, Tian Y, et al. Light-sheet microscopy in the near-infrared II window. Nat Methods. 2019;16(6):545-52. https://doi.org/10.1038/s41592-019-0398-7
Li C, Chen G, Zhang Y, Wu F, Wang Q. Advanced fluorescence imaging technology in the near-infrared-ii window for biomedical applications. J Am Chem Soc. 2020;142(35):14789-804. https://doi.org/10.1021/jacs.0c07022
Gisev N, Bell JS, Chen TF. Interrater agreement and interrater reliability: key concepts, approaches, and applications. Res Social Adm Pharm. 2013;9(3):330-8. https://doi.org/10.1016/j.sapharm.2012.04.004
Jørgensen MG, Toyserkani NM, Hansen FC, Thomsen JB, Sørensen JA. Prospective validation of indocyanine green lymphangiography staging of breast cancer-related lymphedema. Cancers (Basel). 2021;13(7):1540. https://doi.org/10.3390/cancers13071540
Schmidt F, Dittberner A, Koscielny S, Petersen I, Guntinas-Lichius O. Feasibility of real-time near-infrared indocyanine green fluorescence endoscopy for the evaluation of mucosal head and neck lesions. Head Neck. 2017;39(2):234-40. https://doi.org/10.1002/hed.24570
Gençay Can A, Ekşioğlu E, Çakçı FA. Early detection and treatment of subclinical lymphedema in patients with breast cancer. Lymphat Res Biol. 2019;17(3):368-73. https://doi.org/10.1089/lrb.2018.0033
Li M, Gao Q, Yu T. Kappa statistic considerations in evaluating inter-rater reliability between two raters: which, when and context matters. BMC Cancer. 2023;23:799. https://doi.org/10.1186/s12885-023-11325-z
Ciudad P, Escandón JM, Bustos VP, Manrique OJ, Kaciulyte J. Primary prevention of cancer-related lymphedema using preventive lymphatic surgery: systematic review and meta-analysis. Indian J Plast Surg. 2022;55(1):18-25. https://doi.org/10.1055/s-0041-1740085
Liu M, Liu S, Zhao Q, Cui Y, Chen J, Wang S. Using the indocyanine green (ICG) lymphography to screen breast cancer patients at high risk for lymphedema. Diagnostics (Basel). 2022;12(4):983. https://doi.org/10.3390/diagnostics12040983
Brezgyte G, Mills M, van Zanten M, Gordon K, Mortimer PS, Ostergaard P. A systematic review of indocyanine green lymphography imaging for the diagnosis of primary lymphoedema. Br J Radiol. 2025;98(1168):517-26. https://doi.org/10.1093/bjr/tqaf006
Setyawan IB, Kurnia D, Setiaji K, Anwar SL, Purwanto DJ, Azhar Y, et al. Sociodemographic disparities associated with advanced stages and distant metastatic breast cancers at diagnosis in Indonesia: a cross-sectional study. Ann Med Surg (Lond). 2023;85(9):4211-7. https://doi.org/10.1097/MS9.0000000000001030
McDuff SG, Mina AI, Brunelle CL, Salama L, Warren LE, Abouegylah M, et al. Timing of lymphedema after treatment for breast cancer: when are patients most at risk? Int J Radiat Oncol Biol Phys. 2019;103(1):62-70. https://doi.org/10.1016/j.ijrobp.2018.08.036
Lu CH, Hsiao JK. Indocyanine green. Tzu Chi Med J. 2021;33:317-22. https://doi.org/10.4103/tcmj.tcmj_216_20
Rius M, Moawad G. New role of indocyanine green (ICG) in benign gynecology surgery. J Minim Invasive Gynecol. 2023;30(11):S58-9. https://doi.org/10.1016/j.jmig.2023.08.189
Brahma B, Putri RI, Sari L, Karsono R, Purwanto DJ, Gautama W, et al. The application of 1% methylene blue dye as a single technique in breast cancer sentinel node biopsy. J Vis Exp. 2019;(148). https://doi.org/10.3791/57201
Brahma B, Yamamoto T, Agdelina C, Adella D, Putri RI, Hanifah W, et al. Immediate-delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer-related lymphedema prevention: report of two cases. Microsurgery. 2024;44(2):e31033. https://doi.org/10.1002/micr.31033
Fransvea P, Miccini M, Rondelli F, Brisinda G, Costa A, Garbarino GM, et al. A green lantern for the surgeon: a review on the use of indocyanine green (ICG) in minimally invasive surgery. J Clin Med. 2024;13(16):4895. https://doi.org/10.3390/jcm13164895
Chen Y, Liu G, Wu Y, Cai H. Assessment of liver injury using indocyanine green fluorescence imaging. Ann Transl Med. 2021;9(14):1167. https://doi.org/10.21037/atm-21-3049
Liu YF, Liu JE, Zhu Y, Mak YW, Qiu H, Liu LH, et al. Development and validation of a nomogram to predict the risk of breast cancer-related lymphedema among Chinese breast cancer survivors. Support Care Cancer. 2021;29(9):5435-45. https://doi.org/10.1007/s00520-021-06122-y
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Bayu Brahma, Prasandhya Astagiri Yusuf, Purnomo Sidi Priambodo, Kuntjoro Harimurti, Samuel Johny Haryono, Harlim, Suryadi, Mahesa Paskahenru, Rika Lesmana, Rumuat Semuel Wullul Manangka, Akmal Taher, Sonar Soni Panigoro
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors who publish with Medical Journal of Indonesia agree to the following terms:
- Authors retain copyright and grant Medical Journal of Indonesia right of first publication with the work simultaneously licensed under a Creative Commons Attribution-NonCommercial License that allows others to remix, adapt, build upon the work non-commercially with an acknowledgment of the work’s authorship and initial publication in Medical Journal of Indonesia.
- Authors are permitted to copy and redistribute the journal's published version of the work non-commercially (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in Medical Journal of Indonesia.
