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

Cheng, Ming-Huei MD, MBA, FACS*; Pappalardo, Marco MD, MSc*,†; Lin, Chieh MD, PhD; Kuo, Chang-Fu MD, PhD§,¶; Lin, Chia-Yu MSc*; Chung, Kevin C. MD, MS||

doi: 10.1097/SLA.0000000000002917

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.

*Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan

Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy

Department of Nuclear Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan

§Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan

||Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI.

Reprints: Ming-Huei Cheng, MD, MBA, FACS, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fu-Hsing St, Kueishan, Taoyuan 333, Taiwan. E-mail:,

M-HC and MP contributed equally to this article.

Disclosures: The project was supported by the Chang Gung Memorial Hospital and University of Michigan combined project CORPG3G0131 and by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number 2 K24-AR053120-06 to Kevin C. Chung.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

M-HC received textbook royalties from Elsevier, Inc. The remaining authors report no conflicts of interest.

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