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Rationale for Study of the Deep Subfascial Lymphatic Vessels During Lymphoscintigraphy for the Diagnosis of Peripheral Lymphedema

Campisi, Corrado Cesare, MD, PhD, MRM*†; Ryan, Melissa, PhD*; Villa, Giuseppe, MD; Di Summa, Pietro, MD, PhD, FEBOPRAS, FMH (Plast)§; Cherubino, Mario, MD, FEBOPRAS∥¶; Boccardo, Francesco, MD, PhD, FACS*; Campisi, Corradino, MD, PhD, FACS*

doi: 10.1097/RLU.0000000000002400
Original Articles

Purpose The current study aimed to determine the utility of including the study of deep subfascial lymphatic vessels in a 2-compartment lymphoscintigraphy for the diagnosis of lymphedema in patients with limb swelling. Lymphoscintigraphy is a valuable imaging tool for the timely diagnosis of peripheral lymphedema. However, there is a lack of standardization in its application, especially regarding which type of lymphatic vessels to examine (superficial, deep, or both).

Methods Two hundred fifty-eight patients with lymphedema underwent segmental lymphoscintigraphy. The transport index (TI) was calculated to categorize the flow of the superficial and deep vessels as normal (<10) or pathological (≥10). The scores from 248 patients (48 unilateral arm, 86 unilateral leg, 114 bilateral leg) were tested with a 3-way analysis of variance to examine the relationship between affected limb, deep or superficial pathways, and primary or secondary lymphedema. The relationship between clinical presentation and TI was also investigated.

Results In general, primary and secondary lymphedema patients had similar patterns of lymphoscintigraphic lymphatic abnormalities. Patients with unilateral clinical presentation can have bilateral TI abnormalities. The vast majority of patients (88%–98%) had either the deep subfascial vessels alone, or both the superficial and deep vessels, with a pathological TI.

Conclusions A 2-compartment lymphoscintigraphy is able to accurately detect lymphatic flow abnormalities in patients with limb swelling. Given that the vast majority of patients had deep lymphatic vessels abnormalities, inclusion of these vessels in the lymphoscintigraphic diagnostic protocol is recommended.

From the *Operative Unit of General & Lymphatic Surgery, Research Center in Lymphatic Surgery, Lymphology and Microsurgery, School of Medical and Pharmaceutical Sciences–DISC, Polyclinic Hospital “San Martino” IRCCS, University of Genoa, Genoa;

ICLAS, Maria Pia Hospital, Salus Hospital, GVM Care & Research, Rapallo (GE), Turin, Reggio Emilia;

Nuclear Medicine Unit, Department of Health Sciences, Polyclinic Hospital “San Martino” IRCCS, IST, University of Genoa, Italy;

§Department of Plastic and Reconstructive Surgery, University Hospital of Lausanne, Lausanne, Switzerland; and

Division of Plastic and Reconstructive Surgery and

Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.

Received for publication May 21, 2018; revision accepted October 17, 2018.

Conflicts of interest and sources of funding: none declared.

Correspondence to: Corrado Cesare Campisi, MD, PhD, MRM, Via Assarotti 46/1, Genoa 16122, Italy. E-mail:

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