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Correlation between superficial and deep lymphatic systems using magnetic resonance lymphangiography in breast cancer-related lymphedema: Clinical implications. J Plast Reconstr Aesthet Surg 2019; 73:1018-1024. [PMID: 31983664 DOI: 10.1016/j.bjps.2019.11.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/23/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Magnetic resonance lymphangiography (MRL) has increased our knowledge of lymphatic anatomy and lymphedema pathophysiology and improved the efficacy of microsurgical procedures to manage peripheral lymphedema. The aim of this study is to investigate the ability of MRL to detect communications between superficial and deep lymphatic systems in breast cancer-related lymphedema (BRCL) and to investigate whether these communications could preserve lymphatic drainage of the hand. METHODS Between 2008 and 2017 we used MRL imaging in 59 women with BCRL. Lymphedema of the arm and hand was detected in 30 patients while the hand was spared in 29. Using axial and coronal MRL reconstruction images we investigated the existence of any communication between the superficial and deep lymphatic systems. RESULTS Among the 29 patients with spared hand, MRL revealed that 24 had at least one communicating lymphatic perforator at the wrist region (p < 0.001). Lymphatic flow at the axilla was clearly visualized in 16 of the 29 patients (55.2%), no perforating lymphatic vessels were detected in the group with lymphedema in the hand (30 patients). CONCLUSIONS Communications between the deep and superficial lymphatic systems at the wrist region in BCRL patients without hand lymphedema should be considered when planning microsurgical lymphatic procedures at the wrist and in postoperative compression therapy.
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Hvidsten S, Toyserkani NM, Sørensen JA, Høilund-Carlsen PF, Simonsen JA. A Scintigraphic Method for Quantitation of Lymphatic Function in Arm Lymphedema. Lymphat Res Biol 2018; 16:353-359. [DOI: 10.1089/lrb.2017.0054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Svend Hvidsten
- Department of Nuclear Medicine, Odense University Hospital, Odense C, Denmark
| | - Navid M. Toyserkani
- Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense C, Denmark
| | - Jens A. Sørensen
- Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense C, Denmark
| | | | - Jane A. Simonsen
- Department of Nuclear Medicine, Odense University Hospital, Odense C, Denmark
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Neligan PC, Kung TA, Maki JH. MR lymphangiography in the treatment of lymphedema. J Surg Oncol 2016; 115:18-22. [DOI: 10.1002/jso.24337] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/12/2016] [Indexed: 12/21/2022]
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Soares MM, Keramida G, Glass DM, Mortimer PS, Peters AM. Lymph proteins may access peripheral blood without entering thoracic duct in patients with lymphatic dysfunction. J Vasc Surg Venous Lymphat Disord 2016; 4:215-20. [DOI: 10.1016/j.jvsv.2015.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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Devoogdt N, Van den Wyngaert T, Bourgeois P, Lambrechts M, Van Kampen M, De Groef A, Geraerts I, Neven P, Vergote I, Tjalma W, Christiaens MR, Stroobants S. Reproducibility of lymphoscintigraphic evaluation of the upper limb. Lymphat Res Biol 2014; 12:175-84. [PMID: 25144836 DOI: 10.1089/lrb.2013.0034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although reproducibility studies are missing, a lymphoscintigraphic evaluation of the upper limb is often used in routine practice to diagnose lymphedema and in clinical research, for example, to investigate the effect of a physical treatment. Therefore, the aim of the present study was to investigate the reproducibility of the lymphoscintigraphic evaluation of the upper limb. METHODS AND RESULTS In breast cancer patients, 20 lymphoscintigraphic evaluations of the upper limb were performed on two test occasions with an interval of 1 week. (99m)Tc nanocol was injected subcutaneously in the hand. A standardized protocol was applied. In the early phase, two static images of the injection places were taken and in between dynamic images of both axilla during 40 min (15 min rest, 15 min squeezing a ball, and 15 min rest). After a break of 70 min, a static image of the injection places and of the axilla was made. At the end, a partial whole body image was acquired. A strong reproducibility was found for the following quantitative variables (ICC 0.75 to 0.85): change of uptake in axilla during the break; change of extraction from hands during the break; and extraction and uptake in the late phase. The other quantitative variables (i.e., extraction form the hands in the early phase, time of arrival, accumulation rate, and uptake in axilla in the early phase) had weak to moderatie reproducibility (ICC 0.07 to 0.70). All qualitative variables (i.e., number of lymph nodes in the axilla, upper arm and elbow/lower arm, gradation of lymph collectors in upper or lower arm and of dermal backflow, and presence of lymph collaterals) had strong to very strong reproducibility (ICC 0.76 to 1.00). CONCLUSION A lymphoscintigraphy of the upper limb is a reproducible imaging tool to assess lymph transport quantitatively and qualitatively.
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Affiliation(s)
- Nele Devoogdt
- 1 Department of Physical Medicine and Rehabilitation, Rehabilitation Sciences, KU Leuven-University of Leuven, and University Hospitals Leuven , Leuven Lymphedema Center, Leuven, Belgium
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Baker A, Semple JL, Moore S, Johnston M. Lymphatic function is impaired following irradiation of a single lymph node. Lymphat Res Biol 2014; 12:76-88. [PMID: 24838016 DOI: 10.1089/lrb.2013.0036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Lymph nodes are often the target of radiotherapy procedures. Unfortunately, the impact of nodal irradiation on lymphatic function is uncertain. In this study, our aim was to quantify the impact of lymph node irradiation on lymph flow. METHODS AND RESULTS The popliteal node or the nodal excision site of rabbits was treated with four daily 8 Gy doses of radiation. A FITC-dextran tracer was infused into a prenodal popliteal lymphatic. The area under the tracer blood recovery curve (AUC) indicated lymphatic functionality and the inflow pressure versus flow rate relationship inferred resistance through the system. Fluoroscopic and histological examination provided supporting data. Radiation of intact nodes decreased lymph transport significantly at 1 week, 1 month, and 6 months post-treatment (AUCs of 207.9 ± 79.87, 191.6 ± 62.95, and 250.44 ± 46.45) in comparison to controls (667.32 ± 104.18). Surprisingly, this functional decline was similar to that detected with a combination of node removal and irradiation of the excision site. The pressure-flow relationships in all treatment groups were significantly different from controls. This may be due in part to fibrosis and the thickening of the nodal capsules and trabeculae observed at 1 and 6 months. Fluoroscopy and Evans blue dye studies revealed vigorous new lymphatic vessel growth and occasionally, vessels anastomosed with local veins. CONCLUSIONS Irradiation of the popliteal lymph node impaired lymph transport and increased the pressure required to maintain flow through the system. New vessel formation and the growth of lymph-venous anastomoses indicated the development of alternative drainage pathways as a compensatory response.
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Affiliation(s)
- Amy Baker
- 1 Sunnybrook Research Institute, Department of Laboratory Medicine and Pathobiology, Women's College Hospital, University of Toronto , Toronto, Ontario, Canada
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Abstract
AIM To investigate whether in lower extremity lymphoedema, lymph proteins enter blood before they do the thoracic duct. METHODS Retrospective analysis of routine lymphoscintigraphy in 69 adults imaged at 5, 45 and 150 min following bilateral subcutaneous web space injection of Tc-nanocolloid was carried out. Regions of interest were placed over the liver and ilioinguinal lymph nodes bilaterally on the anterior images at 45 and 150 min. Individual minor (0.5 point for each) and major (1 point for each) criteria of abnormal scintigraphy were applied to each limb and summed to give a lymphoscintigraphic abnormality score. An abnormal limb had a score ≥1. RESULTS The ratio of hepatic counts per pixel to total bilateral ilioinguinal counts (L/N ratio) was higher in patients with abnormal results on lymphoscintigraphy (median 6.2; interquartile range 4.0-15.6 pixels×10; n=48) compared with that in patients with normal lymphoscintigraphic results (2.5 [1.5-5.0] pixels×10; n=21; P<0.0002). In the abnormal group, the lymphoscintigraphic score (two limbs summed) correlated with the 150-min L/N ratio (r s=0.42; P<0.005). L/N ratios at 45 and 150 min correlated in the abnormal group (r s=0.44; P<0.005) but not in the normal group (r s=0.3; P>0.05). The 45-min activity, as a percentage of the 150-min activity, was higher in lymph nodes than in the liver in both the abnormal (35.0 [8.2-50.0] vs. 10.6 [5.8-30.0]%; P<0.0001]) and normal groups (38.3 [18.4-63.5] vs. 23.3 [12.4-33.1]%; P<0.05), and, with respect to the liver, was higher in the normal group (P<0.01). CONCLUSION In lymphoedema, more lymph proteins enter blood proximal to the thoracic duct. The time courses of nodal and hepatic activities suggest that access may occur within nodes themselves.
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Jensen MR, Simonsen L, Karlsmark T, Bülow J. The washout rate of a subcutaneous 99mTc-HSA depot in lower extremity lymphoedema. Clin Physiol Funct Imaging 2011; 32:126-32. [DOI: 10.1111/j.1475-097x.2011.01066.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jensen MR, Simonsen L, Karlsmark T, Bülow J. Lymphoedema of the lower extremities - background, pathophysiology and diagnostic considerations. Clin Physiol Funct Imaging 2010; 30:389-98. [DOI: 10.1111/j.1475-097x.2010.00969.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fowler JC, Solanki CK, Ballinger JR, Ravichandran D, Douglas-Jones A, Lawrence D, Bobrow L, Purushotham AD, Peters AM. Axillary lymph node drainage pathways from intradermal and intraparenchymal breast planes. J Surg Res 2010; 161:69-75. [PMID: 19439325 DOI: 10.1016/j.jss.2009.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 12/11/2008] [Accepted: 01/06/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND To compare functional anatomy of breast peri-areolar and peri-tumoral lymphatic drainage basins. METHODS Fifteen breast cancer patients received simultaneous peri-areolar (intradermal) and peri-tumoral (intraparenchymal) injections of human polyclonal immunoglobulin (HIG) labeled with (99m)Tc and (111)In 2 to 4 h before axillary lymph node clearance surgery. Resected nodes (range 5-20; median 16) were individually counted for (99m)Tc and (111)In in a well-counter and ranked according to activity content (echelon). Activity in distal nodes was negligible so extraction efficiency (E) of HIG in the first echelon node was calculated as counts divided by total counts in the chain. RESULTS Five- to 10-fold more activity was recovered after intradermal injection. The injection planes identified the same first echelon node in 10 patients (group 1) but different in five (group 2). In group 1, intradermal E correlated with intra-parenchymal E (r = 0.82; P < 0.01). E of intradermal first echelon nodes in group 2 was 51 (SD 13)%, similar to intradermal E in group 1 (58 [23]%). E of intraparenchymal first echelon nodes in group 2, however, was 28 (6)%, lower than intraparenchymal E in group 1 (54 [20]%; P < 0.02). CONCLUSIONS Lymph nodes extract approximately 50% of HIG. Extracted HIG does not cascade to distal nodes, validating HIG for sentinel node lymphoscintigraphy. HIG injected intradermally at the areola drains via a single route to the axilla. In two-thirds of patients, peri-tumoral HIG follows a similar route, but in one-third of patients drainage from the parenchymal plane is more complex, with more than one route to the axilla.
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Affiliation(s)
- J Charlotte Fowler
- Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom
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Delivery of radiolabelled blood cells to lymphatic vessels by intradermal injection: a means of investigating lymphovenous communications in the upper limb. Nucl Med Commun 2010; 31:121-7. [PMID: 19952856 DOI: 10.1097/mnm.0b013e328330dd14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify peripheral lymphovenous communications (LVCs) using labelled erythrocytes and intradermal injection. Intradermal injection delivers macromolecules to loco-regional lymph nodes faster than subcutaneous injection, suggesting easier lymphatic vessel access. METHODS Autologous erythrocytes labelled with 111In and 99mTc were injected into opposite hands. In four normal volunteers, the differentially labelled cells were given by intradermal injection on one side and subcutaneous injection on the other while in four breast cancer patients they were given by intradermal injection bilaterally 3 months after axillary lymph node clearance surgery. The axillae were imaged and blood samples obtained bilaterally at approximately 15, 30, 60, 120 and 180 min post-injection. Plasma activity was subtracted from whole blood activity to obtain erythrocyte-bound activity and contralateral concentrations were subtracted from ipsilateral concentrations to correct for ipsilateral recirculation. From estimated blood volume, erythrocyte and plasma activities contralateral to the injected side were calculated as percentage administered activity. Tracer concentrations in ipsilateral samples (%/l) were integrated to give total percentage administered activity, assuming a forearm blood flow of 20 ml/min. RESULTS Kinetics of plasma activity were consistent with small diffusible 99mTc complexes and protein-bound 111In. With both radionuclides, axillary nodes were visualized after intradermal but not subcutaneous injection, suggesting that nodal activity arises from erythrocytes. In one patient, 99mTc and 111In labelled erythrocytes accumulated in similar amounts ipsilaterally and contralaterally, suggesting bilateral LVCs distal to the ipsilateral sampling point. There was no evidence of LVCs in the other seven volunteers. CONCLUSION Intradermally injected erythrocytes are able to detect and potentially quantify peripheral LVCs.
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Peters AM, Fowler JC, Britton TB, Solanki CK, Ballinger JR, Ravichandran D, Mortimer PS, Purushotham AD. Functional variation in lymph node arrangements within the axilla. Lymphat Res Biol 2010; 7:139-44. [PMID: 19778201 DOI: 10.1089/lrb.2008.1021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of the project was to identify how lymphatic pathways are functionally arranged within the axilla (i.e., single linear chains, branching chains, and networks). We used ex vivo dual isotope radioassay of individual nodes resected at axillary lymphatic clearance surgery in breast cancer patients given simultaneous intradermal breast and intradermal hand injections (n = 15) or simultaneous intradermal breast and parenchymal breast injections (n = 15) of differentially labelled human immunoglobulin (Tc-99m-HIG and In-111-HIG). Nodes were ranked according to isotope content and activity-rank profiles constructed for each of the two injection sites. The majority of profiles following intradermal breast injection (17/30) were mono-exponential, consistent with a simple linear chain of nodes, with each node extracting a constant fraction of incoming HIG. In 15/17 of these, the accompanying profile from the alternative injection site was also mono-exponential and, in 11/15, essentially parallel. The profile appeared biphasic in 12/30 intradermal breast injections and of these 9/12 were accompanied by a biphasic profile (7/9 parallel) from the alternative injection site. In one patient, both profiles were polyphasic and parallel. Considering the respective shapes of paired profiles and whether the two injection sites shared the same first echelon nodes, functional lymph node arrangements are proposed. The commonest is a single linear chain, then a chain branching into two linear chains, and, least common, a network.
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Affiliation(s)
- A Michael Peters
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Fowler J, Solanki C, Guenther I, Barber R, Miller F, Bobrow L, Ravichandran D, Lawrence D, Ballinger J, Douglas-Jones A, Purushotham A, Peters A. A pilot study of dual-isotope lymphoscintigraphy for breast sentinel node biopsy comparing intradermal and intraparenchymal injection. Eur J Surg Oncol 2009; 35:1041-7. [DOI: 10.1016/j.ejso.2009.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 02/23/2009] [Accepted: 02/24/2009] [Indexed: 11/29/2022] Open
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Abstract
OBJECTIVE To determine how often the sentinel lymph node (SLN) draining the breast is the same node as the SLN draining the upper limb. A common SLN might increase the risk of upper limb breast cancer-related lymphoedema after SLN biopsy. METHODS Patients with invasive breast cancer, identified as being suitable for axillary lymph node dissection, were injected preoperatively with 40 MBq of technetium-99m (Tc)-human polyclonal immunoglobulin G intradermally into the ipsilateral breast and 3 MBq of indium-111 (In)-human polyclonal immunoglobulin G intradermally into the ipsilateral hand, or vice versa. Axillary lymph nodes were removed, separated and assayed in a well counter for Tc and In. RESULTS Fifteen patients entered the study. In 13 of 15 patients, the 'hottest' lymph node for Tc was separate from the 'hottest' lymph node for In. In two of 15 patients the 'hottest' lymph node for Tc was also the 'hottest' lymph node for In, suggesting a common drainage pathway from the ipsilateral breast and upper limb. CONCLUSION Although the majority of patients has different pathways of lymphatic drainage from the ipsilateral breast and upper limb, in a small minority of patients the drainage pathway is through a common SLN. Such patients may be at increased risk of developing upper limb breast cancer-related lymphoedema after SLN biopsy.
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Fowler JC, Solanki CK, Barber RW, Ballinger JR, Peters AM. Dual-isotope lymphoscintigraphy using albumin nanocolloid differentially labeled with 111In and 99mTc. Acta Oncol 2009; 46:105-10. [PMID: 17438712 DOI: 10.1080/02841860600635854] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of this study was to develop and evaluate 111In- and 99mTc-labeled derivatives of albumin nanocolloid (NC) for dual-label lymphoscintigraphy to allow simultaneous comparison of lymphatic flow from different tissue planes draining a tumour bed for accurate identification of sentinel lymph nodes (SLN). Using the chelator, p-isothiocyanatobenzyl-1,4,7, 10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA), 111In-DOTA-NC and 99mTc-DOTA-NC were compared in vitro with respect to stability of labeling, colloidal status and particle size, then in vivo by measuring their clearance rates from a subcutaneous injection depot. 111In-DOTA-NC and 99mTc-DOTA-NC were indistinguishable on the basis of in vitro criteria. Their in vivo clearance rates, however, were disparate (0.0015 to 0.075 min(-1) for 111In and 0.0072 to 0.067 min(-1) for 99mTc), 111In being faster in three studies and markedly slower in three. This demonstrates that even when dual-labeled radiotracers behave identically in vitro, they will not necessarily do so in vivo. Further work is needed to develop dual-labeled NC.
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Affiliation(s)
- J Charlotte Fowler
- Department of Nuclear Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom
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Modi S, Stanton A, Mortimer P, Levick J. Clinical Assessment of Human Lymph Flow Using Removal Rate Constants of Interstitial Macromolecules: A Critical Review of Lymphoscintigraphy. Lymphat Res Biol 2007; 5:183-202. [DOI: 10.1089/lrb.2007.5306] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- S. Modi
- Divisions of Cardiac & Vascular Sciences (Dermatology), University of London, United Kingdom
| | - A.W.B. Stanton
- Divisions of Cardiac & Vascular Sciences (Dermatology), University of London, United Kingdom
| | - P.S. Mortimer
- Divisions of Cardiac & Vascular Sciences (Dermatology), University of London, United Kingdom
| | - J.R. Levick
- Basic Medical Sciences (Physiology), St George's Hospital Medical School, University of London, United Kingdom
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Lane KN, Dolan LB, Worsley D, McKenzie DC. Upper extremity lymphatic function at rest and during exercise in breast cancer survivors with and without lymphedema compared with healthy controls. J Appl Physiol (1985) 2007; 103:917-25. [PMID: 17585046 DOI: 10.1152/japplphysiol.00077.2007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lymphoscintigraphy was used to measure lymphatic function at rest and during exercise in breast cancer survivors with lymphedema (BCRL, n = 10), breast cancer survivors (BC, n = 10), and controls (Cont, n = 10). After injection of 99mTc-antimony colloid to the hands, subjects rested or performed 12 repeated sets of arm cranking for 2.5 min at 0.6 W/kg followed by 2.5 min of rest. One-minute spot views were taken with a gamma-radiation camera immediately postinjection and every 10 min over 60 min to calculate clearance rate. As well, an upper body scan was taken at 65 min postinjection to measure radiopharmaceutical uptake in the axilla (Ax) and forearm (Fore). All groups displayed similar increases in clearance rate with exercise ( P = 0.000). Ax significantly increased with exercise in Cont only [Cont: (mean ± SD) 4.9 ± 2.6 vs. 7.9 ± 4.2%, P = 0.000; BCRL: 1.4 ± 1.2 vs. 1.7 ± 2.1%, P = 0.531; BC: 3.9 ± 3.4 vs. 5.2 ± 3.2%, P = 0.130], whereas Fore, indicating dermal backflow, significantly increased in BCRL only (BCRL: 2.4 ± 0.87 vs. 4.4 ± 2.0%, P = 0.004; BC: 1.1 ± 0.25 vs. 1.1 ± 0.31%, P = 0.784; Cont: 0.93 ± 0.26 vs. 1.0 ± 0.20%, P = 0.296). The results indicate that, in women with BCRL, exercise causes radiopharmaceuticals to clear from the hand at the same rate as BC and Cont, but, instead of reaching the axilla, a greater amount of activity gets trapped in the dermis of the forearm. BC, meanwhile, have similar lymphatic function as Cont; however, there is a highly variable response that may suggest that some BC subjects may be at risk for developing lymphedema.
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Affiliation(s)
- Kirstin N Lane
- Division of Sports Medicine, University of British Columbia, 3055 Wesbrook Mall, Vancouver, BC, Canada, V6T 1Z3.
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Modi S, Stanton AWB, Svensson WE, Peters AM, Mortimer PS, Levick JR. Human lymphatic pumping measured in healthy and lymphoedematous arms by lymphatic congestion lymphoscintigraphy. J Physiol 2007; 583:271-85. [PMID: 17569739 PMCID: PMC2277237 DOI: 10.1113/jphysiol.2007.130401] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Axillary surgery for breast cancer partially obstructs lymph outflow from the arm, chronically raising the lymphatic smooth muscle afterload. This may lead to pump failure, as in hypertensive cardiac failure, and could explain features of breast cancer treatment-related lymphoedema (BCRL) such as its delayed onset. A new method was developed to measure human lymphatic contractility non-invasively and test the hypothesis of contractile impairment. 99mTc-human IgG (Tc-HIG), injected into the hand dermis, drained into the arm lymphatic system which was imaged using a gamma-camera. Lymph transit time from hand to axilla, ttransit, was 9.6+/-7.2 min (mean+/-s.d.) (velocity 8.9 cm min(-1)) in seven normal subjects. To assess lymphatic contractility, a sphygmomanometer cuff around the upper arm was inflated to 60 mmHg (Pcuff) before 99mTc-HIG injection and maintained for>>ttransit. When Pcuff exceeded the maximum pressure generated by the lymphatic pump (Ppump), radiolabelled lymph was held up at the distal cuff border. Pcuff was then lowered in 10 mmHg steps until 99mTc-HIG began to flow under the cuff to the axilla, indicating Ppump>or=Pcuff. In 16 normal subjects Ppump was 39+/-14 mmHg. Ppump was 38% lower in 16 women with BCRL, namely 24+/-19 mmHg (P=0.014, Student's unpaired t test), and correlated negatively with the degree of swelling (12-56%). Blood radiolabel accumulation proved an unreliable measure of lymphatic pump function. Lymphatic congestion lymphoscintigraphy thus provided a quantitative measure of human lymphatic contractility without surgical cut-down, and the results supported the hypothesis of lymphatic pump failure in BCRL.
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Affiliation(s)
- S Modi
- Cardiac and Vascular Sciences, St George's Hospital Medical School, University of London, Cranmer Terrace, London SW17 0RE, UK
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O'Mahony S, Britton TMB, Solanki CK, Ballinger JR, Pain SJ, Mortimer PS, Purushotham AD, Peters AM. Lymphatic transfer studies with immunoglobulin scintigraphy after axillary surgery. Eur J Surg Oncol 2007; 33:1052-60. [PMID: 17499475 DOI: 10.1016/j.ejso.2007.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 03/14/2007] [Indexed: 10/23/2022] Open
Abstract
AIMS The study objective was to investigate the effects of axillary lymph node clearance surgery on the function and morphology of the lymphatic system of the upper limb in women with breast cancer. METHODS Nineteen women were studied before and 3 months after surgery. Fifteen were studied again 12 months after surgery. On each occasion, scintigraphy following intradermal hand webspace injection of Tc-99m-human polyclonal immunoglobulin was performed to include the affected upper limb and torso. RESULTS There was considerable functional variability in response to surgery. Seven patients subsequently developed breast cancer-related lymphedema (BCRL). Neither lymph re-routing (defined as a change in lymph vessel morphology or definition) nor linear velocity of protein transit up the arm was associated with the development of BCRL. Blood pool activity, judged from visual inspection of the cardiac blood pool on the whole body images, was earlier and more marked 3 and 12 months after surgery than before. The count rate (per 100 pixels/MBq injected activity), measured in a cardiac region of interest, was significantly higher after surgery than before, was higher in patients who developed BCRL and, in the patient population as a whole, correlated positively with arm swelling. CONCLUSION The consequences of axillary lymph node clearance were variable, unexpected and largely persistent. An increased rate of access of intradermally injected protein into the blood pool is significantly associated with BCRL.
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Affiliation(s)
- S O'Mahony
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Lane K, Dolan L, Worsley D, McKenzie D. Lymphoscintigraphy to Evaluate the Effect of High versus Low Intensity Upper Body Dynamic Exercise on Lymphatic Function in Healthy Females. Lymphat Res Biol 2006; 4:159-65. [PMID: 17034296 DOI: 10.1089/lrb.2006.4.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Little is known about the acute effects of exercise on the lymphatic system. Thus, the purpose was to determine the effect of low versus high intensity upper body exercise on lymphatic function in healthy females. METHODS AND RESULTS On separate days, eight females performed either HI: 12 repeated sets of arm cranking for 2.5 min at 0.6 W.kg-1, followed by 2.5 min of rest; or LO: 12 repeated sets of arm cranking for 2.5 min at 0.3 W.kg-1, followed by 2.5 min of rest. One min spot views were taken with a gamma-radiation camera immediately after injection of 99mTc-antimony colloid and every 10 min thereafter to measure the clearance rate (CR) from the first and fourth finger-web of each hand. Radiopharmaceutical uptake in the axillary regions (AX) at 65 min postinjection was also measured. Clearance from the injection sites was linear and expressed as a slope (% administered activity.min-1). HI resulted in significantly greater CR (-0.24%.min-1+/-0.06) than LO (-0.19%.min-1+/-0.05; p=0.003). A similar trend was seen in AX (HI: 6.3%+/-1.6, LO: 4.8%+/-1.1, p=0.004). CONCLUSIONS The results indicate that an arm cranking protocol of higher intensity is more effective in promoting lymphatic clearance from the hand. Further, the high intensity protocol may be useful in the functional evaluation of the lymphatic system in breast cancer survivors and warrants further investigation.
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Affiliation(s)
- Kirstin Lane
- School of Human Kinetics, Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
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O'Mahony S, Solanki CK, Barber RW, Mortimer PS, Purushotham AD, Peters AM. Imaging of lymphatic vessels in breast cancer-related lymphedema: intradermal versus subcutaneous injection of 99mTc-immunoglobulin. AJR Am J Roentgenol 2006; 186:1349-55. [PMID: 16632730 DOI: 10.2214/ajr.04.1341] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The disordered physiology that results from axillary lymph node clearance surgery for breast cancer and that leads to breast cancer-related lymphedema is poorly understood. Rerouting of lymph around the axilla or through new pathways in the axilla may protect women from breast cancer-related lymphedema. The aim of the study was to compare intradermal with subcutaneous injection of technetium-99m ((99m)Tc)-labeled human polyclonal IgG (HIG) with respect to lymphatic vessel imaging. MATERIALS AND METHODS Six women with breast cancer-related lymphedema underwent unilateral upper limb lymphoscintigraphy, using a web space injection of (99m)Tc-labeled HIG, after intradermal and subcutaneous injections on separate occasions. Multiple sequential images were obtained of the affected upper limb and torso over 3 hr on each occasion. Accumulation of activity in blood was quantified from venous blood samples taken from the opposite arm. RESULTS Imaging after intradermal injection clearly showed discrete lymphatic vessels in five of six patients, in contrast to imaging after subcutaneous injection, which did not show any discrete vessels in any patient. Intradermal injection resulted in more rapid visualization of cutaneous lymph rerouting than subcutaneous injection in six of six patients. Recovery of injected (99m)Tc-labeled HIG in venous blood was greater after intradermal injection in six of six patients. CONCLUSION In patients with breast cancer-related lymphedema, lymphatic vessels are more clearly depicted after intradermal than subcutaneous injection as a result of direct access of radiotracer to dermal lymphatics. This finding has implications for imaging lymphatic vessel regeneration and lymph rerouting.
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Affiliation(s)
- Susan O'Mahony
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK
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Stanton AWB, Modi S, Mellor RH, Peters AM, Svensson WE, Levick JR, Mortimer PS. A quantitative lymphoscintigraphic evaluation of lymphatic function in the swollen hands of women with lymphoedema following breast cancer treatment. Clin Sci (Lond) 2006; 110:553-61. [PMID: 16343054 DOI: 10.1042/cs20050277] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In BCRL (breast cancer-related lymphoedema), arm swelling is unevenly distributed and some regions are partly or entirely spared. In particular, the hand may or not be swollen, but when involved functional impairment can be substantial. We have found previously that, when the ipsilateral hand is spared of swelling (in a limb with swelling proximal to the hand), the local lymph drainage rate constant (k) is at least as high as in the contralateral hand, contrary to the traditional 'stopcock' concept of reduced lymph drainage from the whole limb. In the light of this finding, we have investigated lymph drainage in the hands of eight women with BCRL and moderate-to-severe hand swelling, using gamma-camera quantitative lymphoscintigraphy. Images showed pronounced superficial activity in the ipsilateral swollen arms of most patients, indicating dermal backflow. k for 99mTc-labelled hIgG (human IgG) measured over 5 h in the subcutis of the ipsilateral swollen hand was 34+/-24% less than in the contralateral hand (P=0.013). Activity measured in the ipsilateral swollen forearm increased progressively, but there was very little increase in the contralateral forearm, indicating retention of 99mTc-labelled hIgG in the swollen forearm. It is concluded that lymphatic function in the swollen hand is impaired, and that there appears to be two populations of women with BCRL, i.e. spared-hand and swollen-hand, irrespective of the cancer treatment received.
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Affiliation(s)
- Anthony W B Stanton
- Department of Cardiac and Vascular Sciences (Dermatology), St George's Hospital, University of London, Cranmer Terrace, London SW17 0RE, UK.
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Pain SJ, Barber RW, Solanki CK, Ballinger JR, Britton TB, Mortimer PS, Purushotham AD, Peters AM. Short-term effects of axillary lymph node clearance surgery on lymphatic physiology of the arm in breast cancer. J Appl Physiol (1985) 2005; 99:2345-51. [PMID: 16288099 DOI: 10.1152/japplphysiol.00372.2005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It is not known why some women develop breast cancer-related lymphedema (BCRL) of the arm, whereas others having similar treatment do not. We speculated that increased uptake of protein into local blood may protect against BCRL. Sixteen women were given bilateral subcutaneous hand webspace injections of polyclonal immunoglobulin (HIgG), (99m)Tc-HIgG on one side and (111)In-HIgG on the other, before and 3 mo after axillary clearance surgery. The rates of clearance of activity from the depot (k) and accumulation in central blood (b(contra)) were measured using a scintillation probe and bilateral antecubital vein blood sampling, respectively. Activity accumulating in blood ipsilateral to the injected side, in excess of central blood activity (b(ipsi)) was also calculated as a measure of local vascular uptake. The k correlated with b(contra), but neither changed in response to surgery. However, b(ipsi) for injections of (99m)Tc-HIgG into the affected arm increased in all seven patients in whom data were available (0.018 +/- 0.006 to 0.038 +/- 0.007%/min; P < 0.05); indeed, in five of these seven, b(ipsi) paradoxically exceeded b(contra), and none developed BCRL at 3-yr follow-up. We conclude that uptake of protein into local blood and/or proteolysis increases after axillary surgery and may protect against BCRL.
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Affiliation(s)
- Simon J Pain
- Cambridge Breast Unit, Addenbrooke's Hospital, UK
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Lynch PM, Schmid-Schönbein GW. Literature watch. Parker LH, Schmidt M, Jin S-W, Gray AM, Beis D, Pham T, Frantz G, Paliert S, Hillan K, Stainier DYR, de Sauvage FJ, Ye W. The endothelial-cell-derived secreted factor Egf17 regulates vascular tube formation. Nature 2004; 428(6984):754-758. Lymphat Res Biol 2005; 2:96-100. [PMID: 15615491 DOI: 10.1089/lrb.2004.2.96] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick M Lynch
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093-0412, USA
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Lane K, Worsley D, McKenzie D. Lymphoscintigraphy to Evaluate the Effects of Upper Body Dynamic Exercise and Handgrip Exercise on Radiopharmaceutical Clearance from Hands of Healthy Females. Lymphat Res Biol 2005; 3:16-24. [PMID: 15770082 DOI: 10.1089/lrb.2005.3.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Currently, there is not a standardized protocol to evaluate lymphatic function in women. Therefore, the purpose of this study was to evaluate the effects of arm crank ergometry (AC) and handgrip contractions (HG) on radiopharmaceutical clearance from the hands of six healthy females. METHODS AND RESULTS On separate days, subjects performed AC (six repeated bouts of arm cranking for 5 min at 0.6 Watts.kilogram(-1) (W.kg(-1)) followed by 5 min rest) or HG (twelve repeated bouts of 75 contractions in 2.5 min at 50% MVC followed by 2.5 min of rest). HG was done with the right hand only while the left hand served as a control (CON). Prior to the start of exercise, (99m)Tc-antimony colloid was injected into the first and fourth finger-web of each hand, and 1 min spot views were taken immediately after the injection and then again every 10 min over 60 min. Clearance from the injection sites was linear and expressed as a slope (% administered activity.min(-1)). Significantly faster clearance was observed with AC (rt = -0.27 +/- 0.03 %.min(-1); left = -0.29 +/- 0.06 %.min(-1)) compared to both HG (-0.18 +/- 0.03 %.min(-1)) and CON (-0.14 +/- 0.05 %.min(-1); p = 0.000). CONCLUSION The results indicate that AC may be more effective in promoting lymphatic clearance from the hand and may be a useful protocol to challenge the lymphatic system in breast cancer survivors.
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Affiliation(s)
- Kirstin Lane
- School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
This article summarises the current research on the lymphatic system related to exercise and critically evaluates the implications for exercise performance by breast-cancer survivors. The primary role of the lymphatic system during exercise is to assist in the regulation of tissue volume and pressure by carrying fluid and plasma proteins that have leaked into the interstitial space from tissues back to the cardiovascular system. During steady-state exercise in humans, lymph flow has been shown to increase to levels approximately 2- to 3-fold higher than at rest. Although the lymphatic system does not typically limit exercise performance in the normal population, the function of this system can be impaired in 27-49% of women who have survived breast cancer. Breast cancer-related lymphoedema (BCRL) is a chronic swelling that can occur in the ipsilateral hand or arm of women treated for breast cancer and results in a number of physical and psychological sequelae. Exercise was once believed to be a factor in the development of BCRL as it was thought that the damage to the axillary lymphatics from breast-cancer treatment resulted in a primary obstruction to lymph flow. However, the exact aetiology and pathophysiology of BCRL appears to be multi-factorial and not as simple as a 'stop-cock' effect. Furthermore, recent studies have shown that participating in vigorous, upper-body exercise is not related to an increase in arm volume, which would indicate the development of BCRL. It is still not known, though, how long-term exercise affects lymphatic system function in breast-cancer survivors with and without BCRL.
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Affiliation(s)
- Kirstin Lane
- Allan McGavin Sports Medicine Clinic, School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada.
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