An Easy Method for Diagnosis of Lymphedema Timothy Bradford Richards, MD, Mike McBiles, MD, Paul Steven Collins, MD, Presidio o f San Francisco, California
Lymphoscintigraphy has been very useful in determination of lymphatic abnormalities. However, the radioactive isotopes used have been investigational and difficult to obtain. The purpose of this study was to examine patients with extremity edema by lymphoscintigraphy using a radioactive colloid readily available in our nuclear pharmacy, Technetium 99m sulfur minicolloid. Forty limbs in 20 patients were evaluated using Technetium 99m sulfur minicoiloid iymphoscintigraphy. All patients had lower extremity edema initially attributed to a venous or lymphatic etiology. There were 12 patients with normal bilateral studies. Seven patients exhibited unilateral obstruction to lymphatic flow, and one had unilateral enhanced flow of lymph. Those with normal studies included five patients with nonspecific edema, four with varicosities, and one patient each with acute deep vein thrombosis, chylous ascites, and excision of the greater saphenous vein for arterial bypass grafting. Five patients with obstructed patterns had previous arterial bypass procedures, one had trauma to the extremity, and one had lymphedema tarda. The one enhanced lymphoscintigraphic pattern was seen in a patient with acute cellulitis. All patients had Doppler venous examinations and other studies included strain gauge phlethysmography, venograms, computed tomography, magnetic resonance imaging, and ultrasound. As with other scintigraphic imaging agents used to study lymphatic flow, Technetium 99m provides clinically useful information in evaluating the swollen extremity noninvasively. (Ann Vasc Surg 1990;4:255-259). KEY WORDS: Lymphedema; Technetium 99m sulfur minicolloid lymphoscintigraphy.
The patient with a swollen extremity poses a challenge to the medical team in determining
From the Departments of Surgery and Nuclear Medicine, Letterman Army Medical Center, Presidio of San Francisco, California. Presented at the Annual Meeting of the Peripheral Vascular Surgery Socie~', New York, New York, June 17, 1989. The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense. Reprint requests: Timothy B. Richards, MD, CPT, MC. USA, Department of General Surge~, Letterman Army Medical Center, Presidio of San Francisco, California 9412)-6700.
whether the edema is due to a venous, lymphatic, or combined process. Many methods have been devised to aid in the diagnosis, however those used to evaluate the lymphatic component of the swollen extremity have been difficult to obtain or difficult to administer. Lymphoscintigraphy has helped bridge that gap. Sherman and Ter-Pogossian first introduced this test in 1953 [1] and since that time radiocolloids have become smaller [2] and less of a radioactive risk to the patient. The purpose of this study was to evaluate Technetium 99m sulfur minicolloid (99mTc), a locally compounded radiopharmaceutical, in performing lymphoscintigraphy of the swollen lower extremity.
255
ANNALS OF VASCULAR SURGERY
D I A G N O S I S OF" L Y M P H E D E M A
256
PATIENTS AND METHODS Lymphoscintigraphy was performed on all patients presenting with lower leg edema between November 1987 and November 1988. All patients underwent deep and superficial venous examinations by either venous Doppler, strain gauge phlethysmography, or venogram in the Vascular Surgical Clinic. Patients were studied using 99mTc sulfur minicolloid using the technique first described by Dunson in 1973 [3]. Hydrogen sulfide gas is bubbled through an acidic gelatin mixture containing sodium pertechnetate (99mTc)*. A chemical reaction occurs precipitating sulfur with the pertechnetate in a small colloid form ranging from 20 to 220 nanometers in size. The colloid is then buffered to a pH of 5.0-6.0 [4]. A dose of 260 microcuries of the minicolloid in 0.5 cc normal saline was injected intradermally in each web space of the first and second toe and the fourth and fifth toe of each foot for a total of one millicurie. Using a large field of view gamma camera, the patient's extremity was. scanned immediately after injection at a frame rate of one minute per frame and the images stored in a 64 x 64 byte matrix in a computer. The extremity was scanned for 45 minutes with the patient remaining in a supine position. The patient was then allowed to ambulate, and the whole body was rescanned two and three hours later. No specific instructions for exercise of the injected limbs were given. Evaluation of lymph dynamics was performed in both limbs using the asymptomatic limb as a control. There were 20 patients in this study, l0 men and 10 women with ages ranging from 22 to 81 years with an average age of 57. Fifteen patients were white, four were black and one was Filipino. All patients had edema of one or both extremities and their symptoms ranged from two weeks to 20 years. Associated medical problems varied, including acute deep venous thrombosis (n = 1): greater saphenous vein incompetence (n = 4); nonspecific complaints with intermittent edema (n = 5); postphlebitic syndrome (n = l); edema secondary to trauma (n = I); postsurgical edema (n = 6); lymphedema tarda (n = 1); and one patient studied without edema but with a history of chytous ascites (Table I). The subsequent lymphatic drainage patterns were then evaluated by the nuclear medicine and vascular staff. Three patterns of flow were observed: normal, enhanced, and decreased [5]. A flow pattern was considered normal if there was symmetric transport of the colloid through calf and thigh lymphatic channels and there was activity in the inguinal nodes at 30 minutes (Fig. I). A pattern was *Mallincrodt Inc., St. Louis, Missouri.
TABLE I.--Lymphoscintigraphic patterns
Normal Venous edema Acute DVT* GSV t incompetence Primary edema Lymphedema tarda Secondary edema Acute celtulitis Postsurgical CAGB § GSV exc. for BPG** LN exc.*/XRT §~ Trauma Nonspecific edema Drugs Cardiac Unknown Chylous ascites Total
Abnormal Enhanced
1 4
1
2 2
1 1 2 2 1 12
7
1
*DVT - deep venous thrombosis t G S V = greater saphenous vein §CABG = coronary artery bypass graft **BPG = bypass graft *LN exc. - lymph node excision §§XRT - radiation
considered enhanced if the flow moved rapidly through lymphatic channels asymmetrically with visualization of the lymph nodes at 10 minutes (Fig. 2). Decreased flow was defined as the absence of inguinal lymph node visualization at 45 minutes or abnormal tracer pattern distribution in the lower extremities, or both (Figs. 3-5). A dermal backflow pattern occurred when the patients had lymph drainage through dermal lymph collaterals. This pattern was indicative of widespread lymphatic channel occlusion [6]. Quantification of the lymph clearance was not performed and visual interpretation of the scans has, in our experience and those of others, been highly accurate [7-10]. RESULTS There were 12 normal lymphoscintigraphic patterns, seven decreased or obstructed patterns, and one enhanced in this group of patients. No patient had bilateral abnormal scans. The group with normal patterns included five patients with nonspecific complaints and intermittent edema, four with greater saphenous vein incompetence, one patient with an acute deep venous thrombosis, one patient studied with chylous ascites, and one postsurgical patient (Table I). Obstructed patterns were found in patients who had undergone greater saphenous vein removal for coronary artery bypass grafting (n = 1) or extremity arterial bypass grafting (n = 2). Obstructed patterns were also found in patients who had undergone
DIAGNOSIS OF L YMPHEDEMA
VOLUME 4 N o 3 - 1990
257
IN AIN
L
R IN, /,~:?i :
~/i ~
:
R
L
K
il ~
A A IS Fig. 1. N o r m a l pattern. (R = right, L = left, IS = injections site, A = ankle, K = knee, IN = inguinal nodes, B = bladder, A I N = aortoiliac nodes, * = liver.)
lymph node excision with radiation therapy (n = 2). An obstructed pattern was also found in a patient who had trauma to his medial right knee resulting in a discrete occlusion to the medial lymphatics of the calf (Fig. 3). One other obstructed pattern occurred in the patient who carried the diagnosis of lymphedema tarda. The one enhanced pattern occurred in a patient with acute cellulitis and an acutely swollen extremity. Other historical variables that increased the likelihood of an abnormal pattern were a history of chronic cellulitis or a history of pelvic radiation. Two of three patients with a history of pelvic radiation had abnormal studies and three of three patients with a history of chronic cellulitis had obstructed patterns. One patient had both a history of pelvic radiation with lymph node excision and a history of chronic cellulitis (Table II).
DISCUSSION Available tests to evaluate lymphedema have included lymphangiography, nuclear magnetic res-
IS Fig. 2. E n h a n c e d pattern. I n c r e a s e d u p t a k e in right groin n o d e s on initial 10 m i n u t e scan. (R = right, L = left, IS = injection site, A = a n k l e , K = knee, iN = inguinal nodes.)
onance, computed tomography, ultrasound, protein concentration evaluation, and lymphoscintigraphy [11]. Lymphangiography is the gold standard and gives the most accurate anatomic visualization of the lymphatics. However, lymphangiography is difficult to perform. It can injure the lymphatics, and it may result in severe patient discomfort [12,13]. In addition, lymphangiography provides no information concerning the dynamic flow of lymph in the extremity. Lymphoscintigraphy provides a technique for evaluating both the anatomy of the lymphatic vessels and the dynamics of lymphatic flow. The study is easy to perform with little or no discomfort to the patient and there have been no reported complications. The whole body radiation dose is very low and considered equivalent to a chest x-ray. Local and lymph node dosimetry is higher but not considered excessive [14]. Lymphoscintigraphy historically has been performed with a variety of radiopharmaceuticals including several Technetium 99m albumin and sulfur colloids, and more recently with the investigational drug 99mTc antimony trisulfide (99mTcSb2S 3) [7].
ANNALS OF VASCULAR SURGERY
DIAGNOSIS OF L YMPHEDEMA
258
.j
IN
t R
L IN""
K •
K.
A
•
Fig. 3. Obstructed pattern. Large arrow identifies point of lymphatic obstruction secondary to trauma. (K = knee, A = ankle, IS = injection site, IN = inguinal nodes.)
This study was based on the use of Technetium 99m sulfur minicolloid, a radiopharmaceutical made available for routine use by a licensed radiopharmacist. There were no specific lymphatic flow patterns seen in this study which clearly identified the different causes of lymphedema. Most patients with nonspecific edema in their extremity and no history of trauma, surgery, or a venous disorder had normal lymphatic flow. Obstructive flow patterns were seen in all patients who had episodes of ceilulitis in their edematous extremity as well as in most of those who had radiation. This reflects obliteration of their lymphatic channels which compounds preexisting edema in their extremity, secondary to their underlying disorders. One should attempt to prevent cellulitis in the edematous extremity in order to prevent progression of the lymphatic injury. Also, patients who have undergone lymph node excision when exposed to radiation may suffer obliteration of collateral dermal lymphatic flow, thereby resulting in lower extremity edema.
CONCLUSION Technetium sulfur minicolloid (99mTc) provides accurate imaging of the lymphatics. As with other scinti-
IS Fig. 4. Obstructed pattern. Resection and radiation of left thigh sarcoma. Large arrow identifies point of lymphatic obstruction and dermal lymphatic flow is seen proximal to the obstruction. (* = liver, IN = inguinal node, K = knee, A = ankle, IS = injection site, S = stomach.)
graphic imaging, it provides information concerning the dynamics of lymphatic flow noninvasively and with a minimum of patient risk and discomfort. TABLE ll.mHistorical variables
Normal
Abnormal
1
5
Enhanced
Pelvic XRT* LN exc. t Chylous ascites Cellulitis Acute Chronic GSV exc. § CABG** Pelvic XRT, chronic cellulitis and LN excision Total
*XRT = radiation tLN exc. = lymph node excision §GSV exc. = greater saphenous vein excision **CABG = coronary artery bypass graft
1
VOLUME 4
No 3 - 1990
DIAGNOSIS OF L YMPHEDEMA
259
Q
• .-- A I N IN
IN
L
R
L
R K
A t IS Fig. 5. Obstructed pattern. Large arrow identifies dermal lymphatic backflow pattern after saphenous vein harvesting for lower extremity arterial reconstruction. (* = liver, IS = injection site, AIN = aortoiliac nodes, IN = inguinal nodes.)
REFERENCES
Fig. 6. Obstructed pattern. Dermal lymphatic flow outlining foot, calf, and thigh of right leg. Patient had malignant melanoma of groin excised with extensive pelvic lymph node dissection and radiation. (K = knee, A = ankle, IS = injection site, IN = inguinal nodes.)
8.
1. SHERMAN AL, TER-POGOSSIAN M. Lymph node concentration of radioactive colloidal gold following interstitial injection. Cancer 1953;6:1238-1240. 2. BERGQVIST L, STRAND SE, PERSSON BRR. Particle sizing and biokinetics of interstitial lymphoscintigraphic agents. Sere Nucl Med 1983;8:9-19. 3. DUNSON GL, THRALL JH, STEVENSON JS, PINSKY SM. Technetium-99m minicolloid for radionuclide lymphography. Radiology 1973;109:387-392. 4. DUNSON GL, THRALL JH, STEVENSON JS, PINSKY SM. 99mTc minicolloid for radionuclide lymphography. Radiology 1973;109:387-392. 5. NAWAZ K, HAMAD MM, SADEK S, et al. Dynamic lymph flow imaging in lymphedema, normal and abnormal patterns. Clin Nuc Med 1986;11:653--658. 6. STY JR, BOEDECKER RA, SCANLON GT, BABBITT DP. Radionuclide "dermal backflow" in lymphatic obstruction. J Nucl M e d 1979;20:905-906. 7. COLLINS PS, VILLAVICENCIO JL, ABREU SH, et al. nun
9.
10.
11.
12. 13. 14.
Abnormalities of lymphatic drainage in lower extremities: a lymphoscintigraphic study. J Vasc Surg 1989;9:145-152. STEWART C, COAUNT Jl, CROFT ON, BROWSE NL. Isotope lymphography: a new method of investigating the role of the lymphatics in chronic limb edema. Br J Surg 1985 ;72:9t)6-909. SACKS GA, SANDLER MP, BORN ML, et al. Lymphoscintigraphy as an adjunctive procedure in the perioperative assessment of patients undergoing microlymphaticovenous anastomoses. Clin Nuc Med 1983;8:309-311. GLOV1CZKI P, CALCAGNO D, SCH1RGER A, et al. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg 1989;5:683-690. CASLEY-SMITH JR, FOLDI M, RYAN TJ, et al. Summary of the 10th international congress of lymphology working group discussions and recommendations, Adelaide, Australia, August 10-17, 1985. Lymphology 1985;18:175-180. BROWSE NL. The diagnosis and management of primary lymphedema. J Vasc Surg 1986;3:181-184. KOCHLER PR. Complications of lymphography. Lymphology 1968;4:116-120. BRONSKILL MJ. Radiation dose estimates for interstitial radiocolloid tymphoscintigraphy. Sern Nucl Med 1983;8:20-25.
Lymphoscintigraphy has been very useful in determination of lymphatic abnormalities. However, the radioactive isotopes used have been investigational and difficult to obtain. The purpose of this study was to examine patients with extremity edema by lymphoscintigraphy using a radioactive colloid readily available in our nuclear pharmacy, Technetium 99m sulfur minicolloid. Forty limbs in 20 patients were evaluated using Technetium 99m sulfur minicoiloid iymphoscintigraphy. All patients had lower extremity edema initially attributed to a venous or lymphatic etiology. There were 12 patients with normal bilateral studies. Seven patients exhibited unilateral obstruction to lymphatic flow, and one had unilateral enhanced flow of lymph. Those with normal studies included five patients with nonspecific edema, four with varicosities, and one patient each with acute deep vein thrombosis, chylous ascites, and excision of the greater saphenous vein for arterial bypass grafting. Five patients with obstructed patterns had previous arterial bypass procedures, one had trauma to the extremity, and one had lymphedema tarda. The one enhanced lymphoscintigraphic pattern was seen in a patient with acute cellulitis. All patients had Doppler venous examinations and other studies included strain gauge phlethysmography, venograms, computed tomography, magnetic resonance imaging, and ultrasound. As with other scintigraphic imaging agents used to study lymphatic flow, Technetium 99m provides clinically useful information in evaluating the swollen extremity noninvasively. (Ann Vasc Surg 1990;4:255-259). KEY WORDS: Lymphedema; Technetium 99m sulfur minicolloid lymphoscintigraphy.
The patient with a swollen extremity poses a challenge to the medical team in determining
From the Departments of Surgery and Nuclear Medicine, Letterman Army Medical Center, Presidio of San Francisco, California. Presented at the Annual Meeting of the Peripheral Vascular Surgery Socie~', New York, New York, June 17, 1989. The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense. Reprint requests: Timothy B. Richards, MD, CPT, MC. USA, Department of General Surge~, Letterman Army Medical Center, Presidio of San Francisco, California 9412)-6700.
whether the edema is due to a venous, lymphatic, or combined process. Many methods have been devised to aid in the diagnosis, however those used to evaluate the lymphatic component of the swollen extremity have been difficult to obtain or difficult to administer. Lymphoscintigraphy has helped bridge that gap. Sherman and Ter-Pogossian first introduced this test in 1953 [1] and since that time radiocolloids have become smaller [2] and less of a radioactive risk to the patient. The purpose of this study was to evaluate Technetium 99m sulfur minicolloid (99mTc), a locally compounded radiopharmaceutical, in performing lymphoscintigraphy of the swollen lower extremity.
255
ANNALS OF VASCULAR SURGERY
D I A G N O S I S OF" L Y M P H E D E M A
256
PATIENTS AND METHODS Lymphoscintigraphy was performed on all patients presenting with lower leg edema between November 1987 and November 1988. All patients underwent deep and superficial venous examinations by either venous Doppler, strain gauge phlethysmography, or venogram in the Vascular Surgical Clinic. Patients were studied using 99mTc sulfur minicolloid using the technique first described by Dunson in 1973 [3]. Hydrogen sulfide gas is bubbled through an acidic gelatin mixture containing sodium pertechnetate (99mTc)*. A chemical reaction occurs precipitating sulfur with the pertechnetate in a small colloid form ranging from 20 to 220 nanometers in size. The colloid is then buffered to a pH of 5.0-6.0 [4]. A dose of 260 microcuries of the minicolloid in 0.5 cc normal saline was injected intradermally in each web space of the first and second toe and the fourth and fifth toe of each foot for a total of one millicurie. Using a large field of view gamma camera, the patient's extremity was. scanned immediately after injection at a frame rate of one minute per frame and the images stored in a 64 x 64 byte matrix in a computer. The extremity was scanned for 45 minutes with the patient remaining in a supine position. The patient was then allowed to ambulate, and the whole body was rescanned two and three hours later. No specific instructions for exercise of the injected limbs were given. Evaluation of lymph dynamics was performed in both limbs using the asymptomatic limb as a control. There were 20 patients in this study, l0 men and 10 women with ages ranging from 22 to 81 years with an average age of 57. Fifteen patients were white, four were black and one was Filipino. All patients had edema of one or both extremities and their symptoms ranged from two weeks to 20 years. Associated medical problems varied, including acute deep venous thrombosis (n = 1): greater saphenous vein incompetence (n = 4); nonspecific complaints with intermittent edema (n = 5); postphlebitic syndrome (n = l); edema secondary to trauma (n = I); postsurgical edema (n = 6); lymphedema tarda (n = 1); and one patient studied without edema but with a history of chytous ascites (Table I). The subsequent lymphatic drainage patterns were then evaluated by the nuclear medicine and vascular staff. Three patterns of flow were observed: normal, enhanced, and decreased [5]. A flow pattern was considered normal if there was symmetric transport of the colloid through calf and thigh lymphatic channels and there was activity in the inguinal nodes at 30 minutes (Fig. I). A pattern was *Mallincrodt Inc., St. Louis, Missouri.
TABLE I.--Lymphoscintigraphic patterns
Normal Venous edema Acute DVT* GSV t incompetence Primary edema Lymphedema tarda Secondary edema Acute celtulitis Postsurgical CAGB § GSV exc. for BPG** LN exc.*/XRT §~ Trauma Nonspecific edema Drugs Cardiac Unknown Chylous ascites Total
Abnormal Enhanced
1 4
1
2 2
1 1 2 2 1 12
7
1
*DVT - deep venous thrombosis t G S V = greater saphenous vein §CABG = coronary artery bypass graft **BPG = bypass graft *LN exc. - lymph node excision §§XRT - radiation
considered enhanced if the flow moved rapidly through lymphatic channels asymmetrically with visualization of the lymph nodes at 10 minutes (Fig. 2). Decreased flow was defined as the absence of inguinal lymph node visualization at 45 minutes or abnormal tracer pattern distribution in the lower extremities, or both (Figs. 3-5). A dermal backflow pattern occurred when the patients had lymph drainage through dermal lymph collaterals. This pattern was indicative of widespread lymphatic channel occlusion [6]. Quantification of the lymph clearance was not performed and visual interpretation of the scans has, in our experience and those of others, been highly accurate [7-10]. RESULTS There were 12 normal lymphoscintigraphic patterns, seven decreased or obstructed patterns, and one enhanced in this group of patients. No patient had bilateral abnormal scans. The group with normal patterns included five patients with nonspecific complaints and intermittent edema, four with greater saphenous vein incompetence, one patient with an acute deep venous thrombosis, one patient studied with chylous ascites, and one postsurgical patient (Table I). Obstructed patterns were found in patients who had undergone greater saphenous vein removal for coronary artery bypass grafting (n = 1) or extremity arterial bypass grafting (n = 2). Obstructed patterns were also found in patients who had undergone
DIAGNOSIS OF L YMPHEDEMA
VOLUME 4 N o 3 - 1990
257
IN AIN
L
R IN, /,~:?i :
~/i ~
:
R
L
K
il ~
A A IS Fig. 1. N o r m a l pattern. (R = right, L = left, IS = injections site, A = ankle, K = knee, IN = inguinal nodes, B = bladder, A I N = aortoiliac nodes, * = liver.)
lymph node excision with radiation therapy (n = 2). An obstructed pattern was also found in a patient who had trauma to his medial right knee resulting in a discrete occlusion to the medial lymphatics of the calf (Fig. 3). One other obstructed pattern occurred in the patient who carried the diagnosis of lymphedema tarda. The one enhanced pattern occurred in a patient with acute cellulitis and an acutely swollen extremity. Other historical variables that increased the likelihood of an abnormal pattern were a history of chronic cellulitis or a history of pelvic radiation. Two of three patients with a history of pelvic radiation had abnormal studies and three of three patients with a history of chronic cellulitis had obstructed patterns. One patient had both a history of pelvic radiation with lymph node excision and a history of chronic cellulitis (Table II).
DISCUSSION Available tests to evaluate lymphedema have included lymphangiography, nuclear magnetic res-
IS Fig. 2. E n h a n c e d pattern. I n c r e a s e d u p t a k e in right groin n o d e s on initial 10 m i n u t e scan. (R = right, L = left, IS = injection site, A = a n k l e , K = knee, iN = inguinal nodes.)
onance, computed tomography, ultrasound, protein concentration evaluation, and lymphoscintigraphy [11]. Lymphangiography is the gold standard and gives the most accurate anatomic visualization of the lymphatics. However, lymphangiography is difficult to perform. It can injure the lymphatics, and it may result in severe patient discomfort [12,13]. In addition, lymphangiography provides no information concerning the dynamic flow of lymph in the extremity. Lymphoscintigraphy provides a technique for evaluating both the anatomy of the lymphatic vessels and the dynamics of lymphatic flow. The study is easy to perform with little or no discomfort to the patient and there have been no reported complications. The whole body radiation dose is very low and considered equivalent to a chest x-ray. Local and lymph node dosimetry is higher but not considered excessive [14]. Lymphoscintigraphy historically has been performed with a variety of radiopharmaceuticals including several Technetium 99m albumin and sulfur colloids, and more recently with the investigational drug 99mTc antimony trisulfide (99mTcSb2S 3) [7].
ANNALS OF VASCULAR SURGERY
DIAGNOSIS OF L YMPHEDEMA
258
.j
IN
t R
L IN""
K •
K.
A
•
Fig. 3. Obstructed pattern. Large arrow identifies point of lymphatic obstruction secondary to trauma. (K = knee, A = ankle, IS = injection site, IN = inguinal nodes.)
This study was based on the use of Technetium 99m sulfur minicolloid, a radiopharmaceutical made available for routine use by a licensed radiopharmacist. There were no specific lymphatic flow patterns seen in this study which clearly identified the different causes of lymphedema. Most patients with nonspecific edema in their extremity and no history of trauma, surgery, or a venous disorder had normal lymphatic flow. Obstructive flow patterns were seen in all patients who had episodes of ceilulitis in their edematous extremity as well as in most of those who had radiation. This reflects obliteration of their lymphatic channels which compounds preexisting edema in their extremity, secondary to their underlying disorders. One should attempt to prevent cellulitis in the edematous extremity in order to prevent progression of the lymphatic injury. Also, patients who have undergone lymph node excision when exposed to radiation may suffer obliteration of collateral dermal lymphatic flow, thereby resulting in lower extremity edema.
CONCLUSION Technetium sulfur minicolloid (99mTc) provides accurate imaging of the lymphatics. As with other scinti-
IS Fig. 4. Obstructed pattern. Resection and radiation of left thigh sarcoma. Large arrow identifies point of lymphatic obstruction and dermal lymphatic flow is seen proximal to the obstruction. (* = liver, IN = inguinal node, K = knee, A = ankle, IS = injection site, S = stomach.)
graphic imaging, it provides information concerning the dynamics of lymphatic flow noninvasively and with a minimum of patient risk and discomfort. TABLE ll.mHistorical variables
Normal
Abnormal
1
5
Enhanced
Pelvic XRT* LN exc. t Chylous ascites Cellulitis Acute Chronic GSV exc. § CABG** Pelvic XRT, chronic cellulitis and LN excision Total
*XRT = radiation tLN exc. = lymph node excision §GSV exc. = greater saphenous vein excision **CABG = coronary artery bypass graft
1
VOLUME 4
No 3 - 1990
DIAGNOSIS OF L YMPHEDEMA
259
Q
• .-- A I N IN
IN
L
R
L
R K
A t IS Fig. 5. Obstructed pattern. Large arrow identifies dermal lymphatic backflow pattern after saphenous vein harvesting for lower extremity arterial reconstruction. (* = liver, IS = injection site, AIN = aortoiliac nodes, IN = inguinal nodes.)
REFERENCES
Fig. 6. Obstructed pattern. Dermal lymphatic flow outlining foot, calf, and thigh of right leg. Patient had malignant melanoma of groin excised with extensive pelvic lymph node dissection and radiation. (K = knee, A = ankle, IS = injection site, IN = inguinal nodes.)
8.
1. SHERMAN AL, TER-POGOSSIAN M. Lymph node concentration of radioactive colloidal gold following interstitial injection. Cancer 1953;6:1238-1240. 2. BERGQVIST L, STRAND SE, PERSSON BRR. Particle sizing and biokinetics of interstitial lymphoscintigraphic agents. Sere Nucl Med 1983;8:9-19. 3. DUNSON GL, THRALL JH, STEVENSON JS, PINSKY SM. Technetium-99m minicolloid for radionuclide lymphography. Radiology 1973;109:387-392. 4. DUNSON GL, THRALL JH, STEVENSON JS, PINSKY SM. 99mTc minicolloid for radionuclide lymphography. Radiology 1973;109:387-392. 5. NAWAZ K, HAMAD MM, SADEK S, et al. Dynamic lymph flow imaging in lymphedema, normal and abnormal patterns. Clin Nuc Med 1986;11:653--658. 6. STY JR, BOEDECKER RA, SCANLON GT, BABBITT DP. Radionuclide "dermal backflow" in lymphatic obstruction. J Nucl M e d 1979;20:905-906. 7. COLLINS PS, VILLAVICENCIO JL, ABREU SH, et al. nun
9.
10.
11.
12. 13. 14.
Abnormalities of lymphatic drainage in lower extremities: a lymphoscintigraphic study. J Vasc Surg 1989;9:145-152. STEWART C, COAUNT Jl, CROFT ON, BROWSE NL. Isotope lymphography: a new method of investigating the role of the lymphatics in chronic limb edema. Br J Surg 1985 ;72:9t)6-909. SACKS GA, SANDLER MP, BORN ML, et al. Lymphoscintigraphy as an adjunctive procedure in the perioperative assessment of patients undergoing microlymphaticovenous anastomoses. Clin Nuc Med 1983;8:309-311. GLOV1CZKI P, CALCAGNO D, SCH1RGER A, et al. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg 1989;5:683-690. CASLEY-SMITH JR, FOLDI M, RYAN TJ, et al. Summary of the 10th international congress of lymphology working group discussions and recommendations, Adelaide, Australia, August 10-17, 1985. Lymphology 1985;18:175-180. BROWSE NL. The diagnosis and management of primary lymphedema. J Vasc Surg 1986;3:181-184. KOCHLER PR. Complications of lymphography. Lymphology 1968;4:116-120. BRONSKILL MJ. Radiation dose estimates for interstitial radiocolloid tymphoscintigraphy. Sern Nucl Med 1983;8:20-25.
