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McMeekin HJ, Peters AM, Burniston MT, Vadrucci M. Quantitative lymphoscintigraphy of the lower limbs for the diagnosis of phlebolymphoedema. Nucl Med Commun 2023; 44:1080-1086. [PMID: 37779454 DOI: 10.1097/mnm.0000000000001769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Phlebolymphoedema is caused by the interaction of the venous and lymphatic systems in a state of chronic venous insufficiency in which increased microvascular filtration causes an increased rate of lymph production. Lymphatic drainage rate increases in response, but this is unsustainable and can cause lymphatic failure and oedema. We hypothesise that in phlebolymphoedema we could measure unusually high lymphatic drainage while the lymph system is still fully functional. METHOD Patients referred for lymphoscintigraphic investigation of swollen legs between April 2021 and December 2022 were reviewed. Quantitative lymphoscintigraphy was performed following the technique of Keramida et al . (2017) and ilio-inguinal nodal uptake (IIQ%) was calculated. The presence of scintigraphic features of increased lymph production was noted for each limb. RESULTS A total of 39 patients were reviewed (78 limbs, 29F, 10M). Seven limbs were identified with supranormal lymphatic function (IIQ > 30%) plus three borderline. Of these 10 limbs, all had at least two scintigraphic features of increased lymph production. CONCLUSION Quantitative lymphoscintigraphy, although developed for diagnosing abnormally low lymphatic function, may also have utility at the upper end of the spectrum for identifying chronic venous insufficiency. An IIQ% upper normal limit of 30% could be used to diagnose venous insufficiency as the cause for limb swelling. This is of note for patients of large body habitus in whom venous ultrasound is difficult.
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Affiliation(s)
| | - A Michael Peters
- Department of Nuclear Medicine, King's College Hospitals,
- Molecular Imaging Centre and
| | | | - Manuela Vadrucci
- Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
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Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders. Korean J Radiol 2023; 24:109-132. [PMID: 36725353 PMCID: PMC9892215 DOI: 10.3348/kjr.2022.0689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/28/2023] Open
Abstract
Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Korea.
| | - Lakshmi Ratnam
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Martin-Almedina S, Mortimer PS, Ostergaard P. Development and physiological functions of the lymphatic system: insights from human genetic studies of primary lymphedema. Physiol Rev 2021; 101:1809-1871. [PMID: 33507128 DOI: 10.1152/physrev.00006.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary lymphedema is a long-term (chronic) condition characterized by tissue lymph retention and swelling that can affect any part of the body, although it usually develops in the arms or legs. Due to the relevant contribution of the lymphatic system to human physiology, while this review mainly focuses on the clinical and physiological aspects related to the regulation of fluid homeostasis and edema, clinicians need to know that the impact of lymphatic dysfunction with a genetic origin can be wide ranging. Lymphatic dysfunction can affect immune function so leading to infection; it can influence cancer development and spread, and it can determine fat transport so impacting on nutrition and obesity. Genetic studies and the development of imaging techniques for the assessment of lymphatic function have enabled the recognition of primary lymphedema as a heterogenic condition in terms of genetic causes and disease mechanisms. In this review, the known biological functions of several genes crucial to the development and function of the lymphatic system are used as a basis for understanding normal lymphatic biology. The disease conditions originating from mutations in these genes are discussed together with a detailed clinical description of the phenotype and the up-to-date knowledge in terms of disease mechanisms acquired from in vitro and in vivo research models.
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Affiliation(s)
- Silvia Martin-Almedina
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter S Mortimer
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St. George's Universities NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
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Peters AM, Mortimer PS. "Latent" and "constitutional" lymphedema, useful terms to complement the terms "primary" and "secondary" lymphedema. J Vasc Surg Venous Lymphat Disord 2021; 9:1089-1092. [PMID: 34399938 DOI: 10.1016/j.jvsv.2021.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- A Michael Peters
- King's College London, University of London, London, United Kingdom.
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Absence of hepatic activity in lymphoscintigraphy performed with Tc-99m-Nanoscan. Nucl Med Commun 2020; 41:505-509. [DOI: 10.1097/mnm.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sadeghi R, Ravari H. Lymphoscintigraphy in the Management of Lymphatic Disorders. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sarica M, Gordon K, van Zanten M, Heenan SD, Mortimer PS, Irwin AG, Ramachandra V, Ostergaard P, Mansour S. Lymphoscintigraphic Abnormalities Associated with Milroy Disease and Lymphedema-Distichiasis Syndrome. Lymphat Res Biol 2019; 17:610-619. [DOI: 10.1089/lrb.2019.0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Muberra Sarica
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Kristiana Gordon
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
- Department of Dermatology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Malou van Zanten
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Susan D. Heenan
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter S. Mortimer
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Andrew G. Irwin
- Department of Medical Physics and Clinical Engineering, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Vijaya Ramachandra
- Department of SW Thames Regional Genetics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Sahar Mansour
- Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
- Department of SW Thames Regional Genetics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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Cousins E, Cintolesi V, Vass L, Stanton AWB, Irwin A, Heenan SD, Mortimer PS. A Case-Control Study of the Lymphatic Phenotype of Yellow Nail Syndrome. Lymphat Res Biol 2019; 16:340-346. [PMID: 30130162 DOI: 10.1089/lrb.2018.0009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Yellow nail syndrome (YNS) is a rare disease manifesting as a triad of yellow-green dystrophic nails, lymphedema, and chronic respiratory disease. The etiology of YNS is obscure and investigations are few. A single lymphatic pathogenesis has been proposed to account for all the associated features, and despite the lack of evidence for a unifying lymphatic mechanism, this hypothesis prevails. The objective was to explore the lymphatic phenotype in YNS and to establish whether lymphatic dysfunction could be a major contributing factor to the disease process. METHODS AND RESULTS Four-limb lymphoscintigraphy was performed on patients with YNS and on healthy, age-matched controls. All 17 patients had lower limb swelling, and 14 (82%) had upper limb swelling also, including 5 (29%) with hand involvement. None of the YNS lymph scans was completely normal. Combined qualitative and quantitative assessment showed that 67% of YNS scans were clearly abnormal compared with 36% of healthy control scans. Mean axillary and ilio-inguinal nodal tracer uptakes were 41%-44% lower in the YNS group than in the controls (p < 0.0001). CONCLUSIONS YNS is a lymphatic phenotype because lymphatic insufficiency was found to exist in all patients and the insufficiency was widespread (upper and lower limbs), with a common mechanistic fault of poor transport. The origin of the lymphatic fault is unclear. In healthy individuals, lymphatic abnormalities may be relatively common in the fifth decade of life onward.
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Affiliation(s)
- Emma Cousins
- 1 Molecular and Clinical Sciences Research Institute (Dermatology Unit), St George's, University of London , London, United Kingdom
| | - Viviana Cintolesi
- 1 Molecular and Clinical Sciences Research Institute (Dermatology Unit), St George's, University of London , London, United Kingdom
| | - Laurence Vass
- 2 Department of Medical Physics and Clinical Engineering, St George's University Hospitals NHS Foundation Trust , London, United Kingdom
| | - Anthony W B Stanton
- 1 Molecular and Clinical Sciences Research Institute (Dermatology Unit), St George's, University of London , London, United Kingdom
| | - Andrew Irwin
- 2 Department of Medical Physics and Clinical Engineering, St George's University Hospitals NHS Foundation Trust , London, United Kingdom
| | - Susan D Heenan
- 3 Department of Radiology, St George's University Hospitals NHS Foundation Trust , London, United Kingdom
| | - Peter S Mortimer
- 1 Molecular and Clinical Sciences Research Institute (Dermatology Unit), St George's, University of London , London, United Kingdom .,4 Department of Dermatology, St George's University Hospitals NHS Foundation Trust , London, United Kingdom
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Keramida G, Wroe E, Winterman N, Aplin M, Peters AM. Lymphatic drainage efficiency: a new parameter of lymphatic function. Acta Radiol 2018; 59:1097-1101. [PMID: 29216739 DOI: 10.1177/0284185117744226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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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Affiliation(s)
- Georgia Keramida
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Emma Wroe
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Nicola Winterman
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Mark Aplin
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - A Michael Peters
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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