IntradermalIntradermal LymphoscintigraphyLymphoscintigraphy at Rest and after a Quick Exercise, in the functional at Rest and after a Quick Exercise, in the functional

assessment of the lymph drainage in secondary assessment of the lymph drainage in secondary lymphoedemalymphoedema patients.patients.Girolamo Tartaglione 1, Marco Pagan 1, Alessandro Scoppola 2, Carlo Capalbo 2, Vincenzo Picone 2, Christiana Zorika Di Rocco 2, Maria Francesca Morelli 2, Federica De Galitis 2, Roberto Bartoletti 3,

and Paolo Marchetti 4

1 Nuclear Medicine, Cristo Re Hospital, Rome, ITALY, 2 Oncology, IDI-IRCCS, Rome, ITALY, 3 Rehabilitation, IDI-IRCCS, Rome, ITALY, 4 Oncology, University Sant'Andrea Hospital, Rome, ITALY.

Aim of this study was to evaluate the Intra-Dermal Injection (IDI) Lymphoscintigraphy at rest and after a quick muscular

exercising or walking, on the functional assessment of lymph drainage in patients with secondary lymphoedema.

Methods: We selected 40 patients (30 f, 10 m) with secondary lymphoedema after lymph nodedissection for melanoma or breast cancer. A dose of 99mTc-albumin-nanocolloid, 50 MBq, 0.3-0.4 mL, was given By Intra IDI at the top in the first inter-digital space of hands or feet. • Two planar static scans were takenimmediately afterwards (LEAP collimator, acquisition matrix 128x128, anterior and posteriorviews, pre-set time 5 minutes)• If lymph drainage were slow or absent, the patients would be asked to walk or exercisefor 2 minutes. • A post-exercise scan was then performed tomonitor and record the tracer pathway and the Tracer Appearance Time (TAT) in the mainlymph node basin.

Results: In normal limbs the lymph pathwaydrainage was along the main vein (TAT <10 mins). In limbs with delayed lymph drainage anisotonic muscular exercise for 2 minutescounteracted the increased gradient pressure of the lymphatic system accelerating lymphdrainage. The post-exercise scans revealed that:1) 7 limbs had lymph stagnation points; 2) 13 limbs presented a superficial collaterallymph drainage pathway; 3) 12 limbs showed a lymph drainage towardsthe deeper subfascial lymphaticcompartment, confirmed by an unusualuptake of the popliteal or elbow lymph nodes; 4) 12 limbs had a “dermal backflow”; 5) 3 limbs had a lymph drainage failure.

Conclusions: A quick isotonic exercise (for 2 minutes) accelerated tracer drainage, revealingseveral compensatory mechanisms of lymphoedema. In patients with lymphoedema, the 2-min exercise was also found to be veryuseful, allowing us to distinguish whether the compensatory mechanism involves the superficial or the deep lymphatic system, as thismay have a significant effect on furthermanagement.

Email: gtartaglione@hotmail.comP627P627

REST

REST POST EXERCISE

POST EXERCISE

R R

REST POST EXERCISE

REST POST EXERCISE

REST POST EXERCISE POST EXERCISEREST

C.L., 80y, female

November 2007:Left leg melanoma 1,4 mm Breslow, IV Clark, SN+Left groin lymphadenectomy(17 nodes)

C.E., 48y, female

June 2009: Right breast cancer, axillary lymphadenectomy (26 nodes)

A.E. , 46y, female2009: Left Leg Melanoma, 6,2 mm

Breslow, V Clark, SN+, Left groin

lymphadenectomy (7 nodes).

L.W., 73 y, female

March 2008Right leg melanoma, 0,5 mm BreslowSN - (1 node)

A.E., 85 y, male

August 2009:Dorsal melanoma 0,4 mm Breslow, IV Clark, SN+Right axillary limphadenectomy(27 nodes)

REST

POST EXERCISE

P.E., 44y, female

August 2008: Left leg melanoma, 2,4 mm Breslow, III Clark, SN+ Left groin lymphadenectomy (15 nodes)

Intradermal

injection for

lower limb

lymphoscinti

graphy.

See the tiny

blister at

injection

point in the

skin.

L

RR

Thighs AnteriorLegs Anterior

RR

V Gasbarro, S Michelini, PL Antignani, E Tsolaki, M Ricci, C Allegra:

The CEAP-L classification for lymphedemas of the limbs: the Italian experience

International Angiology 2009; 28, 4: 315-324

Thighs

L

Thighs Anterior

Legs

Legs

Thighs

R

R

R

R

R

R

R R

R

Forearm

Forearm Arm

Arm

Symptomatology

1Symptomatic

0AsymptomaticS0S1

C + L + Ly + E + D + S = Severity Score

3Serious disability (patient needs full and continous helpD32Moderate disability (patient needs external help)D21Light disability (patient needs minimal helps for some activities)D10No disabilityD0

Grade of Disability

2Heavy exudationE21Light exudation (drops)E10No exudationE0

Exudation

2>3 episodesLy211-3 episodesLy10No episodesLy0

Lymphagitis

2Shoulder, Genital ,TrunkL2Lower Limb: Foot, Leg, Thigh

1Upper Limb: Hand, Forearm, Arm

L1

Limb Extension

4Elephantiasis with skin lesionsC43Fibrotic EodemaC32Oedema that persists during night restC21Oedema that disappear with night restC10No OedemaC0

PointsTHE CLASSIFICATION OF LYMPHOEDEMA DISEASE (ITALIAN EXPERIENCE)

CEAP- L

Oct 09

Nov 08

Apr 08

L

Oct 09

R

Apr 08

Oct 09 Oct 09

October 2008:C0 L0 Ly0 E0 D0 S0 = 1/18Chemiotherapywithout CPT (Complex Phisical Therapy))

September 2010:C1 L1 Ly0 E0 D0 S0 = 3/18

Apr 08

Oct 09

R R

April 2008C2 L2 Ly0 E0 D0 S1 = 6/20CPT 1 cycle

September 2010C2 L1 Ly0 E0 D0 S0 = 4/20

September 2009C0 L0 Ly0 E0 D0 S0 = 1/18without CPT

July 2010C0 L0 Ly0 E0 D0 S0 = 1/18

April 2008C2 L2 Ly1 E0 D0 S1 = 6/20CPT 1 cycle

September 2010 C1 L1 Ly1 E0 D0 S0 = 4/20

October 2009C2 L2 Ly0 E0 D1 S1 = 6/20 CPT 1 cycle

July 2010C2 L1 Ly0 E0 D0 S1 = 5/20

November 2008

C2 L4 Ly0 E0 D0 S1 = 7/20

CPT 1 cycle

September 2010

C2 L2 Ly0 E0 D0 S0 = 5/20