Relationship between lymphoscintigraphy and clinical findings in lower limb lymphedema (LO): toward a comprehensive staging.

Although radionuclide lymphoscintigraphy (RNL) is widely used diagnostically for patients with lymphedema (LE), it has not been utilized for LE staging, which is still based upon clinical findings. The aim of this work is to establish whether the results of both conventional RNL and fusion imaging obtained from hybrid detectors may be used for a comprehensive clinicoimaging staging in LE. Radiolabeled nanocolloids (0.2 ml) were subcutaneously injected in 4,328 patients (23-78 years) with clinical lower limb LE and without venous disease. Patients were classified according to the ISL classification and had a minimal follow-up of 2 years. Images were taken 60 minutes after the injection as a whole body scanning and fusion images of functional SPET and anatomical CT. Clinical and RNL results were not in accordance, and a specific RNL staging was established. The association of clinical and functional staging yields a new method to grade LE patients, and this staging correlated with treatment efficacy. RNL is an important tool in lymphology, and its association with the clinical evaluation offers a new grading system which may be able to delineate patients with good prognosis, patients at risk for a complex decongestive physiotherapy (CDP) failure, and patients who may benefit from other therapeutic protocols.

Efficacy of BN165 (Ginkor Fort) in breast cancer related upper limb lymphedema: a preliminary study.

The purpose of this study was to determine whether BN165 (Ginkor Fort), which has been reported to alleviate symptoms of venous insufficiency, has a beneficial effect on lymphatic function or lymphedema symptoms. Using a 3-arm, double-blind, placebo-controlled design in 48 patients with upper extremity lymphedema secondary to breast cancer treatment, improvement in symptoms and signs as well as lymphoscintigraphic kinetic parameters (radiocolloid half-life and lymphatic migration speed) was assessed in response to treatment. A statistically significant effect on limb heaviness was noted. Lymphatic migration speed also demonstrated a significant increase at a dose of 2 active capsules per day but not at the 3 capsules per day dose, but lymphatic migration speed also improved in the placebo group. These findings in mechanical lymphatic insufficiency in breast cancer-related lymphedemas can be compared to the previously published clinical amelioration by BN165 of the subjective symptoms (heavy limbs) of dynamic lymphatic insufficiency in patients with venous insufficiency. Further studies are needed to define the possible role of BN165 in treating patients with lymphedema.

[Tests and imaging of the lymphatic system]. / Explorations et imagerie du système lymphatique.

Methods for lymphatic imaging are numerous and can be roughly classified as anatomic or functional studies. Direct or indirect lymphographies provide useful informations in case of lymphostasis. Contrast lymphangiography is the only anatomical method giving precise informations either on lymphatic ducts or lymph nodes. Nevertheless this invasive method is no more indicated in cases of limb edemas. Indirect lymphographies study the spontaneous lymphatic drainage of inert particles injected into the dermis. The blue dye test is the most simple and the oldest indirect lymphography used in the positive diagnosis of a lymphostasis. It has been replaced with the indirect radionuclide lymphography which give more reliable informations. Fluorescence microlymphoangiography is an atraumatic method which permits the visualization of skin lymphatics. Indirect lymphangiography with contrast medium give reliable informations on the status of the initial lymphatics and is the best imaging method to differentiate between lipedema and lymphedema. Indirect radionuclide lymphoscintigraphy is a safe, non invasive and physiological method for the assessment of the limb lymphatic system used for morphological studies and objective measurement of the peripheral lymphatic function necessary to assess the lymphatic variation under therapy (decongestive physiotherapy, surgery, drugs).

[Lymphedema of the lower limbs: CT staging]. / Lymphoedème des membres inférieurs: apport du scanner.

Routinely performed, CT is useful and reliable for staging lower limb lymphedema. We describe methods we utilized. We found in frequency order: skin thickening, subcutaneous tissues area increase in regard the safe limb, perimuscular aponevrosis thickening, fat infiltration: lines parallel to the skin, edematous areas along perimuscular aponevrosis, lines perpendicular to the skin. The lowest fat density is increased on the pathologic side. Subfascial compartment is slightly fattened. We found huge differences between primary and secondary lymphedema for the thigh. Same images may be generated by old or young lymphedema. Rarely useful for positive diagnosis, CT is indispensable for secondary lymphedema staging (initial staging or after a recent increase). It seems us indispensable for any pretherapeutic staging (whole objectively disorders, exact upper limit, infraclinic bilaterality).

[Results of a neurophysiologic consultation in patients with secondary lymphedema of the arm after breast cancer associated with neurological symptoms]. / Résultats d'une consultation neurophysiologique chez des patientes atteintes d'un lymphoedème secondaire du membre supérieur après cancer du sein et présentant des troubles neurologiques.

The aim of this study was to identify the nature of the nerve lesions found in patients with neurological complains and with lymphedema occurring after breast cancer treated by surgery and radiotherapy. Twelve patients treated in a specialised centre for lymphology had clinical and neurophysiological examinations. This study found 9 radiation-induced plexopathies, 1 neoplasic plexopathy, 2 carpal tunnel syndromes (one isolated), 1 cervical root disease and 1 normal examination. The radiation-induced plexopathy is characterised by a chronic neurogenic involvement and the presence of (motor and sensory) proximal persistent conduction blocks. This study demonstrated that it is essential to identify with electrodiagnosis the exact nature of the nerve lesion to determine the most appropriate and effective treatment.

Lymphedematous skin and subcutis: in vivo high resolution magnetic resonance imaging evaluation.

Physico-chemical and morphologic parameters of skin layers and subcutaneous tissue in lymphedematous limb were studied in vivo using magnetic resonance imaging. High resolution images were obtained with a depth resolution of about 70 microm, using a specific surface gradient coil specially designed for skin imaging and connected to a standard whole-body imager at 1.5 T. Twenty-one patients with unilateral lower extremity lymphedema (11 primary and 10 secondary) were examined. Skin thickness, relaxation times, and relative proton density were calculated in lymphedematous limbs and in contralateral extremities. In diseased limbs, the average skin thickness (2.17 mm) was significantly larger (p = 1.5 x 10(-4)) than that of contralateral limb (1.14 mm). Major cutaneous alterations due to lymphedema took place in dermis. In lymphedematous dermis, the significant increase of relaxation time values could be due to a shift in the equilibrium of water inside this tissue in relation to the interactions between macromolecules and water molecules. In lymphedematous epidermis our results showed an increase in the number of free water protons. Information about water and fat distribution in lymphedema was also obtained using chemical shift weighted images. Our results demonstrated a water retention diffusely spread over the entire dermis, and an important fluid retention located in the interlobular spacing and beside the superficial fascia. Inside the subcutis, the mean thickness of the superficial fat lobules was increased more than that of the deep fat lobules. From all the various measurements we could not distinguish primary from secondary lymphedema.

Treatment of secondary lymphedema of the upper limb with CYCLO 3 FORT.

Fifty seven patients with secondary lymphedema of the upper limb after previous treatment for breast cancer were treated for 3 months with an extract of Ruscus + Hesperidin Methyl Chalcone (CYCLO 3 FORT) or placebo according to a double-blind protocol in the context of a controlled clinical trial. All patients also underwent manual lymphatic drainage twice a week for at least one month. With CYCLO 3 FORT, the reduction in volume of arm edema, the main assessment criteria, was 12.9% after 3 months of treatment as compared with a placebo (p=0.009). Decreased edema tended to be more marked in the forearm compared with the upper arm where excess fat deposition seemed to dominate over excess fluid accumulation. CYCLO 3 FORT was well tolerated with minimal adverse reaction.