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, 53 (1), 47-56

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

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

G Villa et al. Nucl Med Mol Imaging.

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.

Keywords: Epifascial and subfascial lymphatic vessels; Limb swelling; Lymphoscintigraphy; Semi-quantitative transport index.

Conflict of interest statement

Giuseppe. Villa, Corrado C Campisi, Melissa Ryan, Francesco Boccardo, Pietro di Summa, Marco Frascio, Gianmario Sambuceti, and Corradino Campisi declare that they have no conflict of interest. There is no source of funding.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.The institutional board of our Institution reviewed the study and approved it as a retrospective study, waiving the need for formal consent. Although no formal consent was required, patients gave their written consent to use their anonymous data.

Figures

Fig. 1
Fig. 1
Lymphoscintigraphy with 99mTc-Nanocoll®: normal lymphoscintigraphic picture of the lower limbs, obtained 30 min after the injections (early images). Superficial circulation: anterior (a) and posterior views (b). Deep circulation: anterior (c) and posterior (d) views
Fig. 2
Fig. 2
Imaging at 2 h. In some cases, lymphatic circulation problems can be mostly confined to one compartment: left lower limb lymphedema with slight deficit of the left limb superficial circulation (a) but a severe insufficiency of the ipsilateral deep circulation (b). The dynamic node uptake of the deep circulation is shown in c with images sampled every 120 s after the subfascial injection. (Transport index (TI) scores are as follows: superficial circuit: left leg TI = 9: K − 3, D − 0, T − 0.3 (8 min), N − 3, and V − 3 and right leg TI = 1.1: K − 1, D − 0, T − 0.1 (2 min), N – 0, and V − 0. Deep circuit: left leg TI = 29.8: K − 8, D − 0, T − 4.8 (120 min), N – 8, and V − 9 and right leg TI = 1.1: K − 1, D − 0, T − 0.1 (2 min), N – 0, and V − 0. Please note that when the lymph nodes are not visualized (as in c), a T value is assigned that is equal to the time taken from injection of the tracer and the late image acquisition—120 min)
Fig. 3
Fig. 3
Scrotal edema. Slowing of lymphatic flow from the left hemiscrotum to inguinal lymph node stations. Imaging obtained after 2 h
Fig. 4
Fig. 4
SPECT/CT hybrid images where the lymph flow is in blue/yellow. Normal uptake of 99mTc-Nanocoll® by inguinal and iliac lymph nodes on the right. Lack of visualization of left iliac and inguinal lymph nodes (yellow arrow heads in b) and the presence of dermal back flow (white arrows in pictures a, b, and c) to the left flank regions and left hemithorax in a patient with left inguinal lymphodenectomy for Hodgkin’s lymphoma. NB. The red marks are not significant but simply a method of centering the two image sources in order to provide the hybrid image
Fig. 5
Fig. 5
Widespread dermal flow in bilateral lymphedema of the lower limbs resulting from inguinal lymphadenectomy and radiation treatment for cervical carcinoma (delayed imaging at 4 h)
Fig. 6
Fig. 6
Presence of “in-transit lymph nodes” in the deep lymphatic pathway of the lower left limb (2 h imaging), indicative of lymph stasis. Bilaterally visualization of popliteal nodes and shunt from deep to superficial pathways

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