The Role of Radionuclide Lymphoscintigraphy in the Diagnosis of Lymphedema of the Extremities Poster No.: C-1229 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit M. Osher 1, A. Pallas 2, X. Wang 1 ; 1 Southfield, MI/US, 2 Garden City, MI/US Edema, Diagnostic procedure, Comparative studies, Nuclear medicine conventional, Nuclear medicine, Lymph nodes, Extremities 10.1594/ecr2014/C-1229 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 7
Aims and objectives Lymphedema is a very common clinical presentation and chronic lymphatic disease that is frequently misdiagnosed. Lymphedema results from impaired lymphatic transport caused by injury of the lymphatic system after surgery or infection. The objective of our study was to evaluate radionuclide lymphoscintigraphy in the diagnosis of lymphedema of the extremities and to demonstrate the pertinent imaging findings of lymphatic obstruction. Methods and materials We retrospectively reviewed 57 patients ( 38 females and 19 males; mean age of 52.6 years; range from 32-78 years) with lymphedema. Lymphoscintigraphy was performed using 0.2 mci filtered 99m Tc sulfur colloid suspeneded in 0.10 ml of saline injected into the interdigital spaces between the first and second digits. The areas of injections were subsequently messaged. Image acquisition was obtained at 15, 60 and 120 minutes following the administration of the radionuclide. Results Eight patients who had breast cancer underwent mastectomy and lymph nodes dissection surgery revealed lymphatic obstruction in the upper extremity. Lymphatic obstruction occurred 6 months to a few years after the surgery. 25 patients demonstrated complete lymphatic obstruction with increased dermal backflow, no or delayed visualization of inguinal/axillary nodes and absence or poor visualization of lymphatic channels. 3 of 25 patients with complete obstruction showed intermediate lymph nodes (lymph nodes seen in the ankle, popliteal fossa or in the elbow). 4 patients with normal lymphoscintigraphy studies illustrated intermediate lymph nodes and/or presence of lymphatic branches. The examples cases are as follows. Case 1-58 year old female with history of right mastectomy presenting with right arm swelling. There is dermal backflow without visualization of right axillary lymph nodes or lymphatic channels. Findings are consistent with right lymphatic obstruction. Page 2 of 7
Case 2-62 year old male with complaint of left lower extremity lymphedem for two years. Lymphoscintigraphy reveals dermal backflow and few ectatic lymphatic channels in the left calf. No lymph nodes are identify in the left groin. Case 3-65 year old male with bilateral lower extremity swelling for 6 months. Lymphoscitigraphy reveals a normal exam with a non-specific lymph node in the left popliteal fossa. Images for this section: Page 3 of 7
Fig. 1: Case 1-58 year old female with history of right mastectomy presenting with right arm swelling. There is dermal backflow without visualization of right axillary lymph nodes or lymphatic channels. Findings are consistent with right lymphatic obstruction. Page 4 of 7
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Fig. 2: Case 2-62 year old male with complaint of left lower extremity lymphedem for two years. Lymphoscintigraphy reveals dermal backflow and few ectatic lymphatic channels in the left calf. No lymph nodes are identify in the left groin. Fig. 3: Case 3-65 year old male with bilateral lower extremity swelling for 6 months. Lymphoscitigraphy reveals a normal exam with a non-specific lymph node in the left popliteal fossa. Page 6 of 7
Conclusion Lymphoscintigraphy provides important diagnostic value with a minimally invasive technique. Absence or poor visualization of lymphatic channels, no or delayed visualization of draining lymph nodes and increased dermal backflow contribute to the pertinent diagnostic findings. Intermediate lymph nodes and/or visualization of lymphatic branches has little to no value in the diagnosis of lymphatic obstruction. Personal information References 1. Weissleder H, Weissleder R. Lymphedema: evaluation of qualitative and quantitative lymphoscintigraphy in 238 patients. Radiology 1988; 167:729-735 2. Williams WH, Witte CL, Witte MH, McNeill GC. Radionuclide lymphangioscintigraphy in the evaluation of peripheral lymphedema. Clin Nucl Med 2000; 25:451-464 3. Szuba A, Rockson SG. Lymphedema: classification, diagnosis, and therapy. Vasc Med 1998; 3:145-156 Page 7 of 7