Importance of accurate ilio-inguinal quantification in lower extremity lymphoscintigraphy

Keramida, Georgia; Winterman, Nicola; Wroe, Emma; Aplin, Mark; Peters, A. M.

doi:10.1097/mnm.0000000000000644

Cited by 12 publications

(17 citation statements)

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“…These outcome measures were considered the most discriminating and in line with recently published criteria. 20 Quantification of uptake of tracer within a region of interest over the ilio-inguinal lymph nodes, and activity overlying the foot depot at two hours post injection, was calculated. Lymphatic transport was determined by calculating the percentage of tracer, relative to amount injected, accumulating in regional lymph nodes after 2 hours.…”

Section: Lymphoscintigraphymentioning

confidence: 99%

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Sarica

Gordon

Zanten

et al. 2019

Lymphatic Research and Biology

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Background: Primary lymphedema is genetically heterogeneous. Two of the most common forms of primary lymphedema are Milroy disease (MD) and Lymphedema-Distichiasis Syndrome (LDS). This study aims to look further into the pathogenesis of the two conditions by analyzing the lymphoscintigram images from affected individuals to ascertain if it is a useful diagnostic tool. Methods and results:The lymphoscintigrams of patients with Milroy disease and Lymphedema-Distichiasis Syndrome were analyzed, comparing the images and transport parameters of the two genotypes against a control population. Lymphoscintigrams were available for 12 MD and 16LDS patients (all genetically proven diagnoses).Eight of the twelve (67%) lymph scans performed on patients with MD demonstrated little or no uptake from the initial lymphatics and poor visualization of the inguinal lymph nodes. These changes were consistent with a "functional aplasia" i.e. the lymphatic vessels were present but appear to be ineffective in absorbing the interstitial fluid into the lymphatic system. In patients with LDS the lymphoscintigraphic appearances were different. In 12 of the 16 scans (75%), the lymph scans were highly suggestive of lymphatic collector reflux.Quantification revealed a significantly reduced uptake of tracer within the inguinal lymph nodes and a higher residual activity in the feet at 2 hours in MD compared to LDS and compared to controls. Conclusion:Lymphoscintigraphic imaging and quantification can be characteristic in specific genetic forms of primary lymphedema and may be useful as an additional tool for in-depth phenotyping, leading to a more accurate diagnosis and providing insight into the underlying mechanism of disease.

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Section: Lymphoscintigraphymentioning

confidence: 99%

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Sarica

Gordon

Zanten

et al. 2019

Lymphatic Research and Biology

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“…The lower limit of normal for IIQ using the technique described here has been reported elsewhere as 8% (6). This limit was based on the finding of a bimodal distribution of values in patients with bilaterally normal scintigraphy, which we interpreted as respectively representing abnormal and normal limbs, and in which 8% was the value separating the two modes (6). IIQ was <8% in 15/82 (18%) bilaterally scintigraphically normal limbs compared with 15/40 (38%) unilaterally normal limbs (P ¼ 0.008).…”

Section: Resultsmentioning

confidence: 92%

“…This was a prospective study of 102 consecutive patients undergoing routine lymphoscintigraphy for the investigation of lower limb swelling of unknown cause between February 2014 and September 2016. They form the population of a previous published study (6) that aimed to determine the lower limit of normal of IIQ and assess the value of intermediate post-injection time imaging (45 min) in routine lymphoscintigraphy and therefore a service improvement exercise for which ethical approval is not required. The current study was an extension of the above study.…”

Section: Methodsmentioning

confidence: 99%

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Lymphatic drainage efficiency: a new parameter of lymphatic function

et al. 2017

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Background Following convection from blood capillaries, plasma proteins are transported to loco-regional lymph nodes in two stages: first, uptake into peripheral lymphatics, and second, transport to nodes. Purpose To introduce a new parameter of lymphatic function that quantifies stage 2 - lymphatic drainage efficiency (LDE). Material and Methods Percentage injected activity (IIQ) in ilio-inguinal nodes 150 min following subcutaneous foot web-space injection of Tc-99 m-nanocolloid was measured in 102 patients undergoing lymphoscintigraphy using a method in which a standard is placed by image guidance over the nodes. Percentage activity leaving the injection depot by 150 min ( k) was measured in 60/102 patients. LDE (%) = 100 × (IIQ/ k). Abnormal lymphoscintigraphy was defined qualitatively as: (i) no activity in ilio-inguinal nodes at 45 min or negligible activity at 150 min (delay); (ii) lymph diversion through skin and/or deep system; and (iii) focal tracer accumulation suggesting cellulitis. Results Scintigraphy was bilaterally normal in 82 limbs, unilaterally normal in 40 limbs and abnormal in 82 limbs. IIQ correlated with k in bilaterally normal (r = 0.86; n = 52), unilaterally normal (r = 0.67; n = 27), and abnormal (r = 0.82; n = 41) limbs. IIQ, k, and LDE were significantly lower in unilaterally normal (9.3 ± 5.4%, 13.8 ± 7.1%, and 65 ± 30%) compared with bilaterally normal limbs (15.4 ± 8.4% [ P > 0.0001], 18.3 ± 8.9% [ P = 0.025], and 84 ± 30% [ P = 0.01]). LDE was lower in limbs displaying skin diversion and/or delay. Conclusion LDE is a new quantitative index that has potential value in clinical research but requires further clinical evaluation. Abnormal quantitative indices indicate that limbs unilaterally normal on lymphoscintigraphy are not functionally normal.

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“…If nodal uptake of tracer remains low e. g. < 3 % of injection dose at 2 hours, then lymph drainage is abnormal irrespective of the degree of venous disease. On the other hand, values of > 15 % ilio-inguinal uptake at 2 hours would suggest high capillary filtration from the veins is the dominant factor in the development of the oedema [12].…”

Section: Should Lymphatic Investigations Always Be Performed In Casesmentioning

confidence: 99%

Go with the (Lymph) Flow?

Mortimer¹

2019

Phlebologie

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My inspiration for a career in lymphatics came from two sources: the first was a visit to the Foeldi clinic and the second was a visit to Professor Fredi Bollinger’s angiology lab in Zurich. These back to back visits in 1984 gave me insight into the best practice in lymphoedema treatment at the time as well as state of the art research techniques. On my return, I unashamedly introduced the Foeldi principles of lymphoedema treatment to the UK. I also set about setting up Fluorescence microlymphangiography in my new lab. Also present during my visit to Zurich was Hugo Partsch who, as a fellow dermatologist, has been very influential ever since as a role model, mentor and friend.The idiom ‘go with the flow’ means go with the prevailing attitude or do what the majority are doing even if you disagree. There is an implication one does not really believe it is necessarily the right thing to do but it is the easiest thing to do. There is a tendency currently with interstitial fluid dynamics to ‘go with the flow’ despite overwhelming scientific evidence that the accepted direction of flow is actually incorrect. As a result, the lymphatic system has been underestimated in its importance for the understanding and treatment of peripheral oedema.

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Importance of accurate ilio-inguinal quantification in lower extremity lymphoscintigraphy

Abstract: IIQ is strongly recommended. Isolated delay at 45 min is abnormal. However, 45 min imaging is not necessary if IIQ is performed.

Cited by 12 publications

References 12 publications

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Lymphatic drainage efficiency: a new parameter of lymphatic function

Go with the (Lymph) Flow?

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Importance of accurate ilio-inguinal quantification in lower extremity lymphoscintigraphy

Abstract: IIQ is strongly recommended. Isolated delay at 45 min is abnormal. However, 45 min imaging is not necessary if IIQ is performed.

Cited by 12 publications

References 12 publications

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome

Lymphatic drainage efficiency: a new parameter of lymphatic function

﻿﻿Go with the (Lymph) Flow?

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Go with the (Lymph) Flow?