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Analysis of Lymphatic Drainage in Various Forms of Leg Edema Using Two Compartment Lymphoscintigraphy

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Analysis of Lymphatic Drainage in Various Forms of Leg Edema Using Two Compartment Lymphoscintigraphy 43 Lymphology 31 (1998) 43-55 ANALYSIS OF LYMPHATIC DRAINAGE IN VARIOUS FORMS OF LEG EDEMA USING TWO COMPARTMENT LYMPHOSCINTIGRAPHY P. Brautigam, E. FOldi, I. Schaiper, T. Krause, W. Vanscheidt, E. Moser Abteilung Nuklearmedizin, Radiol. University Klinik Freiburg (PB,TK,EM), FOldiklinik, Fachklinik ftir lymphologische Erkrankungen, Hinterzarten (EF), Zentrum ftir Nuklearmedizin, Paracelsus- Klinik Osnabrtick (IS), and Universitats-Hautklinik, Freiburg (WV), Germany ABSTRACT was reduced. Patients with lipedema (obesity) scintigraphically showed no alteration in The anatomical and functional status lymphatic transport. of the epifascial and subfascial lymphatic This study demonstrates that lymphatic compartments was analyzed using two drainage is notably affected (except in obesity compartment lymphoscintigraphy in five termed lipedema) in various edemas of the leg. groups of patients (total 55) with various Lymphatic drainage varied depending on the forms of edema of the lower extremities. specific compartment and the pathophysiologic Digital whole body scintigraphy enabled mechanism accounting for the edema. Two semiquantitative estimation of radio tracer compartment lymphoscintigraphy is a valuable transport with comparison of lymphatic diagnostic tool for accurate assessment of leg drainage between those individuals without edema of known and unknown origin. (normal) and those with leg edema by calculating the uptake of the radiopharma- The lymphatic system is deranged in ceutical transported to regional lymph nodes. various forms of leg edema of both lymphatic A visual assessment of the lymphatic drainage and non-lymphatic origin including venous- pathways of the legs was also performed. lymphedema, cyclic idiopathic edema, and In patients with cyclic idiopathic edema, lipedema (obesity) (1,2). As no discrete an accelerated rate of lymphatic transport differences exist on clinical grounds among was detected (high lymph volume overload or the various edema syndromes, differential dynamic insufficiency). In those with venous diagnosis and identification of the main (phlebo )edemas, high volume lymphatic pathophysiologic factors may be difficult or overload (dynamic insufficiency) of the impossible (1). epifascial compartment was scintigraphically Cyclic idiopathic edema of women entails detected by increased tracer uptake in regional much more than manifestations of the nodes. In patients with deep femoral venous premenstrual syndrome. Because of increased occlusion (post-thrombotic syndrome), permeability of the blood capillaries, both subfasciallymphatic transport was uniformly plasma proteins and great quantities of fluid markedly reduced (safety valve lymphatic (6-8 liters) may accumulate in the inter- insufficiency). On the other hand, in the stitium within a few days. As a result, the epifascial compartment, lymph transport was lymphatic system is overloaded (high volume accelerated. In those patients with recurrent insufficiency) with anasarca and in rare or extensive skin ulceration, lymph transport instances, even pulmonary edema (2). Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY . 44 In phleboedema, the venous and capillary Group 1: Eighteen patients (10 female, hydrostatic pressure are increased and the 8 male; age 19-48 years) had localized demand for lymphatic drainage increases (2). malignant melanoma of the skin proximal to Over time, the lymphatic system becomes the umbilicus. Accordingly, involvement of functionally insufficient, the lymph transport the lymphatic drainage of the lower extremity capacity decreases, and edema ensues was deemed unlikely. Two compartment (termed safety valve lymphatic insufficiency) lymphoscintigraphy was carried out and the (2). In more chronic venous insufficiency, results were used to define normal values. lymph flow is also impaired (lymphedema). In lipedema or obesity, the pathophysiology Group 2: Ten women (age 21-41 years) of lymphatic drainage is less clear. Stallworth had cyclic idiopathic edema likely from et al (3) claims that the lymphatics, arteries, increased microvascular permeability (8). and veins are unaltered. Herpertz (4), on the Fluid retention consisted of swelling of the other hand, suggests a slight mechanical face, breast, abdomen, and legs which drainage blockage to lymph capillaries, worsened as the day advanced. A diurnal precollectors, and collectors secondary to weight variation of more than 1.4 kg daily increased pressure of the excess fatty tissue. was considered abnormal. A modified FOidi et al (2) emphasizes a combination of Streeten test (9) was also used and was contributions to leg enlargement including considered positive if the renal excretion of lipedema + lymphedema and lipedema + an oral fluid load (20 mllkg body weight) was cyclic idiopathic edema. In the clinical pre- less than 60% after 4 hours of orthostasis. sentation of patients with lipedema (pressure sensitive edema and a supramalleolar fat Group 3: Seven patients (4 male, 3 collar), both edema of the top of the foot and female; age 36-64 years) with primary venous a positive Stemmer's thickened skin fold sign varicosities of the greater saphenous vein (signs of lymphedema) are present as well. (phleboedema) (stage IV according to Hach) Two compartment lymphoscintigraphy (10) underwent lymphoscintigraphy to is a useful method to quantify lymphatic exclude occult lymphedema before excision drainage in the epifascial and subfascial and ligation of varicose veins. Functionally compartment of the legs (5-7). This study and morphologically, the femoral (deep) analyzed the lymphatic drainage in the venous system was intact according to previously mentioned forms of leg edema as Doppler sonography and phlebography. well as in deep venous occlusion (post- thrombotic syndrome) using two compart- Group 4: Eleven patients (6 male, 5 ment lymphoscintigraphy. Of special interest female; age 45-68 years) had deep vein was the contribution of this scintiscan thrombosis (from 1-19 years) (post- technique in the differential diagnosis in leg thrombotic syndrome) before lymphoscinti- edema of uncertain origin. graphy. Clinical complications included dermatoliposclerosis and recurrent skin ulcerations. MATERIAL AND METHODS Group 5: Five of 9 women (age 23-37 Patients years) showed considerable fat changes of the upper and lower legs (lipedema). In the other Between 1990 and 1996, 55 patients four patients, "edema" was seen only in the clinically separated into five groups were upper leg. Stemmer's skin fold sign was subjected to two compartment absent in all patients and lipedema had been lymphoscintigraphy. present for over 5 years. Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY . 45 Fig. 1. Injection of the radio tracer into the lateral aspect of the side of the foot at a depth of 1.5 cm ensures drainage by the sUbfasciallymphatics. Lymphoscintigraphy To examine the epifascial compartment, a second study using identical lymphatic Subjasciai compartment: 4x20 MBq 99m stimulation and acquisition was performed Tc of labeled human albumin nanocolloid was after disappearance of residual tracer activity injected into the dorsolateral muscles of the (at least 2 days later) but the radiopharma- sole of the foot (Fig. 1). Standardized stimu- ceutical was injected subcutaneously between lation of lymph flow followed using bicycle the first and third toes. ergometry at a low level of intensity (25 Watt) Lymphatic function was assessed by in 2 phases. After 20 minutes the first whole analyzing the uptake of the radiopharma- body scintigram was performed using a single ceutical into the lymph nodes. For this head gamma camera (Diacam®, Siemens purpose, regions of interest (ROI) were Company). After another 30 minutes of drawn, one over the inguinal and parailiac bicycle ergometry and a recovery phase, a lymph nodes (ROIl)' and a second over the second scintigram was obtained at 2 hours. injection site and the lymph vessels (R0I2). Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY . 46 50 50 50 50 50 •• 40 40 40 40 40 ••• •• • 1i. • • • ...';30 30 • 30 • 30 30 :l Q. ::::I • • Gi .:-. .., • • • • • g 20 • 20 20 • 20 20 • 0 •••• • •• '6.. • • • •••••• a:: :• •• .-.... : ........ • 10 - -.::.- .. 10 10 10 10 - •••••.-. • • • .:.• 0 0 0 0 0 Cyclic Postthrombo- Lipedema Controls idiopathic Phlebedema tic Syndrome Edema Fig. 2. Lymph node radiotracer uptake (%) for each patient in the epifascial compartment. Percent uptake was calculated as RESULTS (R0I1)/{R0I1 + R0I2) x 100. Lymphatic transport was also visually The radiotracer uptake values for each evaluated. Reduced or absent radiotracer patient are shown in Fig. 2 (epifascial activity in regional lymph nodes represented compartment) and Fig. 3 (subfascial impaired lymphatic drainage. The compartment). In cyclic idiopathic edema appearance of 99m Tc nanocolloid in the and lipedema, the uptake values are shown proximal portion of the thoracic duct was for both legs. In phleboedema and deep interpreted as physiologic lymph pooling venous occlusion (post-thrombotic syndrome), before entry into the venous system and only the uptake values for the affected thought to represent accelerated lymphatic (edematous) side are shown. The median, the transport (high lymph volume overload or 5th and the 95th percentiles of each patient dynamic
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