Use of non-contrast MR in diagnosing secondary lymphedema of the upper extremities

Published:September 09, 2021DOI:


      • A combination of thickened skin and honeycombing pattern of fluid infiltration in the subcutaneous fat on noncontrast MRI, termed “dermal rim sign” (DRS), can predict dermal backflow as seen on lymphoscintigraphy with 88% PPV and 98% NPV.
      • The presence of DRS is associated with worse ICG lymphography and bioimpedance and more severe MRI lymphedema stage.
      • Fluid sensitive MR sequences without contrast of the upper extremity obtained for any reason may help identify patients who would benefit from dedicated exams, such as lymphoscintigraphy and ICG lymphography.



      The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema.

      Materials and methods

      Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated.


      Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80–1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%–99.9%], and 75.0% [47.6%–92.7%], 87.5% [74.9%–94.3%], and 92.3% [63.1%–98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001).


      DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.


      DRS (dermal rim sign), STIR (short-tau inversion recovery), PPV (positive predictive value), NPV (negative predictive value), ICG (indocyanine green)


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