Procedural Recommendations for Lymphoscintigraphy in the Diagnosis of Peripheral Lymphedema: the Genoa Protocol

Abstract

Introduction Lymphoscintigraphy is the gold standard for imaging in the diagnosis of peripheral lymphedema. However, there are no clear guidelines to standardize usage across centers, and as such, large variability exists. The aim of this perspectives paper is to draw upon the knowledge and extensive experience of lymphoscintigraphy here in Genoa, Italy, from our center of excellence in the assessment and treatment of lymphatic disorders for over 30 years to provide general guidelines for nuclear medicine specialists. Method The authors describe the technical characteristics of lymphoscintigraphy in patients with limb swelling. Radioactive tracers, dosage, administration sites, and the rationale for a two-compartment protocol with the inclusion of subfascial lymphatic vessels are all given in detail.Results Examples of lymphoscintigraphic investigations with various subgroups of patients are discussed. The concept of a transport index (TI) for semi-quantitative analysis of normal/pathological lymphatic flow is introduced. Different concepts of injection techniques are outlined. Discussion It is past time that lymphoscintigraphy in the diagnosis of lymphatic disorders becomes standardized. This represents our first attempt to outline a clear protocol and delineate the relevant points for lymphoscintigraphy in this patient population.

Long‐term patency of multiple lymphatic‐venous anastomoses in cancer‐related lymphedema: A single center observational study

“…The postoperative elastic compression is required immediately after MLVA and up to 12 months because pathological findings (Boccardo, Fulcheri, et al, 2013) have shown how in lymphedema, the lymphatic collector pathways tend to lose the elastic component of the wall, losing more or less markedly the lymphatic pump capacity, and lymphoscintigraphy has demonstrated this aspect from a functional point of view. After 12 months, this functional capacity partially recovers and this aspect is demonstrated by the clinical stability of the lymphedema and by lymphoscintigraphic studies (Villa et al, 2019).…”

“…Lymphoscintigraphy is able to demonstrate the flow of lymph in both the superficial and deep lymphatic pathways and it has been shown to have high sensitivity (96%) and specificity (100%) for lymphedema (Villa et al, 2019). Lymphoscintigraphy and the interpretation of results should be done by the same nuclear physician using the same device and the same protocol, to avoid possible wrong assessments.…”

Rest/Stress Intradermal Lymphoscintigraphy for the Functional Imaging of the Lymphatic System

“…Superficial and deep collectors are functionally complementary, and the deep compartment may participate in lymph drainage of the skin. 28,29 In our center, we adopted the rest/stress intradermal lymphoscintigraphy. This method was instituted in collaboration with our surgeons and physiotherapists to evaluate patients with lymphedema.…”

Surgical research, staging-guided technical procedures and long-term clinical outcomes for the treatment of peripheral lymphedema: the Genoa Protocol

“…Microsurgical approach is planned on the guide of preoperative superfi cial and deep lymphoscintigraphy, combined with calculation of Transport Index [16][17][18].…”