Scintigraphic Investigations of the Deep and Superficial Lymphatic Systems in the Evaluation of Lower Limb Oedema

Abstract

The lymphoscintigraphic investigation (LySc) of the superficial lymphatic system (SLS) remains the gold standard for the diagnosis of lower limb lymphoedema. However, LySc of the deep lymphatic system (DLS) may be useful for diagnosing deep lymphatic system insufficiency in patients with lower limb oedema (LLE) but normal and/or paradoxical LySc of the SLS. The purpose of this study was therefore to evaluate a new LySc of the deep lymphatic system in patients presenting with a normal and/or paradoxical SLS exam showing LLE. In all, 15 patients with unilateral and 17 with bilateral LLE underwent 3-phased deep LySc of the lower limb via the injection of 99 mTc-labelled human serum albumin (HSA) nanocolloids in the Kager’s triangle. The absence of popliteal lymphatic node visualization after phase 2 of DLS LySc to diagnose a deep lymphatic insufficiency has a specificity and a sensitivity of 89% in patients with unilateral LLE and without associated venous symptoms. An insufficiency of the DLS was observed in 67% of cases with unilateral LLE and 59% of patients with bilateral LLE of venous and/or lymphatic origin. In conclusion, the lymphoscintigraphic visualization of the popliteal lymphatic nodes after the injection of 99 mTc-labelled HSA nanocolloids in the Kager’s triangle seems to be an effective way to diagnose DLS insufficiency in patients with LLE but normal findings in the SLS.

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

“…We suggest performing more proximal and subfascial reinjections with additional exercise to help visualize deep pathway and/or proximal tracts of superficial lymphatic collectors. [40][41][42][43] In general, we suggest reevaluating patients after adequate medical treatments and an intensive CPT program.…”

“…To better determine the extension of the damage, we recommend injecting small doses of radiotracer in different parts of the limb. We suggest performing more proximal and subfascial reinjections with additional exercise to help visualize deep pathway and/or proximal tracts of superficial lymphatic collectors 40–43 . In general, we suggest reevaluating patients after adequate medical treatments and an intensive CPT program.…”

Edemas of the face and lymphoscintigraphic examination

“…However, this specific situation might be explained by the fact that, with symptoms of left sinusal edemas, the lymphatic problem (impaired lymphatic drainage) might rather be deep than superficial and, to put it in another way, that the deep lymphatic vessels remain obliterated and/or hypo-functional after the trauma and that this increased superficial drainage may represent a compensatory situation to one increased lymph load. In case of lower limb edemas, such increased “paradoxal” superficial lymphatic drainage were recently demonstrated as a compensatory phenomenon to deep lymphatic problems 18 .…”

Lymphoscintigraphic Indications in the Diagnosis, Management and Prevention of Secondary Lymphedema

“…Lymphoscintigraphy is therefore an essential examination to establish the exact origin of the lymphatic block; this can be useful (often, indispensable) to establish the right therapy for the patient, and to agree together on a long-term maintenance path [16][17][18]. Some authors suggest that the deep circulation should also be studied with lymphoscintigraphy in patients with unilateral or bilateral lower limb lymphedema (LLE) (or sensation of LLE) without morphological or functional signs of lymphatic insufficiency, but whose history and clinical examination are indicative of the presence of lymphedema [19].…”