The washout rate of a subcutaneous 99mTc-HSA depot in lower extremity lymphoedema

LYMPHOSCORE (Lymphoscintigraphy Scoring Reliability) Reliability of a New Qualitative and Semiquantitative Lymphoscintigraphy Scoring System for Primary Lymphedema

PURPOSE OF THE REPORT

Primary lymphedema (PLE) is a rare chronic disorder. Extremity lymphoscintigraphy offers access for dynamic and functional information on peripheral lymphatics and lymph nodes. We aimed to assess intraobserver and interobserver reliability of a new lymphoscintigraphy quantitative and qualitative scoring system in a homogeneous population of adult patients followed for PLE of the lower limb(s).

PATIENTS AND METHODS

This is a monocentric retrospective study. Clinical files of patients who underwent a lymphoscintigraphy were reviewed for inclusion. Lymphoscintigraphies were interpreted twice by 2 observers with a washout period. To assess intraobserver and interobserver reliability for both lower limbs, Cohen κ and Gwet's AC1 reliability coefficients were calculated with 95% confidence interval and P value of the zero-reliability comparison test. To interpret reliability coefficients, we used the orders of magnitude reported by Landis and Koch.

RESULTS

One hundred forty-four patients (288 limbs) with PLE were included. For intraobserver reliability, agreement range was 0.87-1 with an almost perfect agreement in all staging items of the score for both limbs with the lower limit of the 95% confidence interval ≥80%. Interobserver reliability was overall strong or almost perfect, ranging from 0.67 to 0.97.

CONCLUSIONS

This new scoring system demonstrated excellent intraobserver reliability and a very good interobserver reliability. Lymphoscintigraphy, when performed in a referral center and interpreted by trained nuclear medicine physicians, is a reliable means of investigation in patients with PLE of the lower limbs. This reproducibility advocates for further use of lymphoscintigraphy in multicentric cohorts of PLE patients.

The Use of Ultrasound Imaging for Upper Extremity Lymphedema after Breast Cancer: A Systematic Review

BACKGROUND

 The aim of this study was to analyze the different applications of ultrasound (US) in upper extremity lymphedema (UEL) after breast cancer.

METHODS

 A systematic review of the literature was performed in line with the PRISMA statement using MEDLINE/PubMed databases from January 1970 to December 2021. Articles describing the application of US in patients with UEL after breast cancer were included. The quality of the study, the level of reproducibility, and the different applications and type of US technique were analyzed.

RESULTS

 In total, 30 articles with 1,193 patients were included in the final review. Five different applications were found: (1) diagnosis of UEL (14 studies found a direct correlation between lymphedema and morphological and/or functional parameters); (2) staging/severity of UEL (9 studies found a direct correlation between the clinical stage and the soft-tissue stiffness/texture/thickness); (3) therapeutic assessment (3 studies found an improvement in the circulatory status or in the muscle/subcutaneous thickness after conservative treatments); (4) prognosis assessment of UEL (1 study found a correlation between the venous flow and the risk of UEL); and (5) surgical planning (3 studies determined the location of the lymphatic vessel for lymphovenous anastomosis [LVA] surgery).

CONCLUSION

 Morphological and functional parameters have been correlated with the diagnosis, stage, therapeutic effect, prognosis of UEL, and surgical planning of LVA.

[Multidisciplinary approach in the lymphedema patient: From rehabilitation to microsurgery]

Lymphedema is a chronic disease with a high incidence in our society. In this paper, we present a review with the latest advances in imaging techniques and surgical reconstructive treatment of lymphedema (lymphovenous anastomosis, vascularized lymph node transfer, and prophylactic lymphedema surgery). In addition, a protocol is established based on a multidisciplinary team (composed of physiatrists, plastic surgeons, radiologists and nuclear medicine radiologists) to optimize the treatment of these patients.

Validity of the Novel Taiwan Lymphoscintigraphy Staging and Correlation of Cheng Lymphedema Grading for Unilateral Extremity Lymphedema

OBJECTIVE

The aim was to validate the new Taiwan Lymphoscintigraphy Staging, correlate it with Cheng Lymphedema Grading (CLG) and evaluate the treatment outcomes of unilateral extremity lymphedema.

BACKGROUND

No consensus has been reached for diagnosis and staging for patients with lymphedema among medical specialties.

METHODS

We included 285 patients with unilateral extremity lymphedema using lymphoscintigraphy. Lymphoscintigraphy was correlated to clinical symptoms and signs, and classified into normal lymphatic drainage, partial obstruction, and total obstruction. Inter- and intraobserver reliability of Taiwan Lymphoscintigraphy Staging, correlation between Taiwan Lymphoscintigraphy Staging and clinical findings were conducted. Patients were categorized in "surgical" (n = 154) or "nonsurgical" (n = 131) groups for outcome evaluation.

RESULTS

Lymphoscintigraphy found 11 patients (3.9%) with normal lymphatic drainage, 128 (44.9%) with partial obstruction, and 146 (51.2%) with total obstruction. Taiwan Lymphoscintigraphy Staging showed high interobserver agreement [intraclass correlation coefficient: 0.89 (95% confidence interval, 0.82-0.94)], and significantly correlated to computed tomography volumetric difference (r = 0.66, P < 0.001) and CLG [intraclass correlation coefficient: 0.79 (95% confidence interval 0.72-0.84)]. At a mean follow-up of 31.2 ± 2.9 months, significant improvement in the circumferential difference (from 23.9% ± 17.6% to 14.6% ± 11.1%; P = 0.03) with a mean circumferential reduction rate of 40.4% ± 4.5% was found in surgical group. At a mean follow-up of 26.6 ± 8.7 months, the nonsurgical group had increase of mean circumferential difference from 24.0% ± 17.2% to 25.3% ± 19.0% (P = 0.09), with a mean circumferential reduction rate was -1.9% ± 13.0%.

CONCLUSIONS

The Taiwan Lymphoscintigraphy Staging is a reliable diagnostic tool, correlated with clinical findings and CLG, aiding in the selection of the appropriate treatment to achieve favorable long-term outcomes in unilateral extremity lymphedema.

Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.

Correlation Between Lymphedema Disease Severity and Lymphoscintigraphic Findings: A Clinical-Radiologic Study

BACKGROUND

Lymphoscintigraphy is used to confirm the diagnosis of lymphedema; pathologic findings are abnormal transit time to regional nodes and dermal backflow. A universal protocol for the test does not exist. The purpose of this study was to determine whether the clinical severity of lymphedema correlates with lymphoscintigraphy findings.

STUDY DESIGN

Patients treated in our Lymphedema Program between 2009 and 2017 were reviewed. Diagnosis of lymphedema was determined by history, physical examination, and lymphoscintigraphy. Severity was defined by increased volume of the limb as follows: mild (<20%), moderate (20% to 40%), and severe (>40%). Candidate variables included location (arm, leg), age, duration of symptoms, infection history, and lymphedema type (primary, secondary). An association between lymphedema severity and lymphoscintigraphy findings was determined using the Pearson chi-square test and multivariate logistic regression.

RESULTS

One hundred and thirty-four patients with 181 affected extremities (24 upper, 157 lower) were included. Clinical severity was as follows: 54% mild, 30% moderate, and 16% severe. Delayed tracer transit to the regional nodes was as follows: 45 minutes (34%), 2 hours (18%), and 4 hours or longer (48%). Thirty-six percent of extremities demonstrated dermal backflow. Abnormal transit time or dermal backflow was identified in 97% of extremities by 45 minutes and in 3% of limbs by 2 hours. Transit time and dermal backflow were not predictive of clinical severity when adjusting for candidate variables (p > 0.1).

CONCLUSIONS

Clinical severity of lymphedema is not associated with lymphoscintigraphy findings. A lymphoscintigram should be interpreted as normal or abnormal, and does not need to exceed 2 hours.

Gall bladder visualization in lymphoscintigraphy

BACKGROUND

The aim of this study was to evaluate gall bladder visualization in lymphoscintigraphy of extremities.

METHODS AND RESULTS

Thirteen patients who had prediagnoses of lymphedema and were referred for lower extremity lymphoscintigraphy to our department were retrospectively evaluated. Lower extremity lymphoscintigraphy with Tc-99m sulfur colloid was performed on the patients, and planar images of the lower extremity and abdominal region were taken in early phase and late phase (at the 24th hour) routinely. Lymphoscintigraphy results of eight patients were normal regarding lymphatic flow or lymph nodes; however, additional pathologic tracer accumulations in gall bladder were observed, which disappeared at 24th hour images in three patients. Five patients had various pathologies regarding lymph flow or lymph nodes. However, there were no patients with gall bladder activity except those three patients who had casual anamnesis of fasting prior to the exam.

CONCLUSION

The fasting state of the patients might be the cause of gall bladder visualization during the lymphoscintigraphy of the extremities with sulfur colloid.