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2. Application of limb lymphoscintigraphy in the diagnostic workup of lymphedema
Ramin Sadeghi, M.D.
Nuclear Medicine Specialist
Associate Professor
DSNMC
Nuclear Medicine Research Center (NMRC; MUMS)

3. Lymphedema Etiology Secondary Primary The most common type
Due to surgery, radiotherapy, trauma, etc
Primary
Due to congenital abnormalities of the lymphatic system
Categorized according to the time of presentation
Congenital
Precox
Tarda

4. Stemmer’s sign: Negative

5. Stemmer’s sign: Positive

6. Technique
Sub-cutaneous injection of 1 or 2 injections of Tc-99m- Antimony Sulfide Colloid or Phytate (0.5 mCi each) in the interdigital webs
Imaging
A whole body imaging from the injection site to the liver
10-12 cm/min: Preferably faster
1 to 4 hours post injection

7. Case 1
43 y/o female patient with mild bilateral pitting edema of the lower limbs

8. Normal
Early
Delayed

9. Normal lymph flow
Symmetric visualization of the inguinal lymph nodes on the early and delayed images.
Sometimes lymph vessels can be visualized
No other abnormal activity in the limbs

10. Imaging criteria for impairment of lymphatic drainage (Lymphedema)
No lymph node visualization
Visualization of ≤3 lymph nodes in the inguinal areas on both early and delayed images
Dermal backflow
Visualization of the intercalary node (epitrochlear or politeal)
Quantitative analysis:
Significantly reduced uptake in the inguinal area (<1.5% of the injection side)
Significant asymmetry of the inguinal uptake (< 50% of the amount in the contra-lateral limb on the early or delayed images)

11. Case 2
31 y/o female with severe non pitting edema of the left lower limb started since birth

12. Lymphedema of the left lower limb No lymph node visualization
Early
Delayed

13. Primary vs. secondary lymphedema
Not possible to be distinguished by lymphoscintigraphy

14. Case
29 y/o female patient with the history of the right axillary surgery for accessory breast 8 month before. Progressive edema since then

15. Early
Delayed

16. Patient with progressive edema of the left lower limb after pelvic surgery

17. Case
39 y/o female with non-pitting edema of the right lower limb since 7 years ago and mild pitting edema of the left lower limb.

18. Bilateral lymphedema of the lower limbs
Visualization of ≤3 lymph nodes in the inguinal areas on both early and delayed images
Early
Delayed

19. Case 4
18 y/o female patient with the history of 2 year pitting edema of the right lower limb. Minimal intermittent swelling on the left side.

20. Bilateral lymphedema of the lower limbs
Visualization of the intercalary node ( politeal)
Early
Delayed

21. Case 6
40 y/o male patient with the history of left lower limb swelling since 20 years ago.

22. Lymphedema of the left lower limb
Dermal backflow
Early
Delayed

23. Case 6a
15 y/o male with progressive swelling of the lower extremities (more on the left side)

24. Bilateral Dermal backflow
Early
Delayed

25. Quantitative imaging
Significantly reduced uptake in the inguinal area (<1.5% of the injection side)
Significant asymmetry of the inguinal uptake (< 50% of the amount in the contra-lateral limb on the early or delayed images)

26. Quantitative approach
Without quantitative approach the sensitivity of lymphoscintigraphy would be low for detection of lymphedema
Inguinal to injection site ratio is important
Use the geometric or arithmetic mean for ant/post images
Values for different pathologies
Normal: >8-10%
Lipedema: 3-4%
Lymphedma: <1.5% (for lower limbs)

27. Anterior Posterior
Anterior Posterior
Early
Delayed
Left 6%
Right 2%

28. Case 7a A 60 year old patient with puffy edema of the lower limbs.
Lipedema with superimposed lymphedema

30. L: 4.5%

31. Case 8
14 y/o male with bilateral mild swelling of the limbs since 3 months ago

32. Bilateral impairment of lymphatic drainage
intercalary node
Early
Delayed

33. Normal distribution of the tracer
Tc-99m Phytate
Kidneys
Bladder
Growth plates
Tc-99m Antimony Sulfide Colloid
Less intense activity in the renal system

34. Case 9
23 y/o male with history of right lower extremity swelling since 4 years ago. No history of trauma. The swelling started proximally from the groin and scrotum.
There were small blisters on these areas and the patient reported occasional oozing of milky fluid for several days. A skin biopsy was taken from right groin and showed lymphangectasia.
Referred for diagnosis of possible lymphatic refulx

35. Injection technique?
Injection only on the non-affected side

37. Case 9 Cont.
The patient underwent surgery for ligation of the abnormal pelvic lymphatic trunks

39. Case 10a
A 7 year old child with progressive four limb edema

41. Global nature of lymphedema
Lymphedema is usually due to defect in the superficial lymphatic network and is a global disease in the body
Apparently normal limbs can have impaired lymphatic flow

42. Case 10b
A 30 year old female with right lower limb edema for 10 years.
No sign of edema on the left side

44. V.R.Dabbagh; DSNMC; www.DSNMC.ir