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Using Lymphoscintigraphy to Evaluate Suspected Lymphedema of the Extremities

¹ Department of Radiology, Winthrop University Hospital, 259 First St., Mineola, NY 11501.
² Lymphedema Therapy, 77 Froehlich Farm Blvd., Woodbury, NY 11797.

View larger version (47K): [in a new window]   Fig. 1A. —37-year-old man who presented with bilateral leg edema for several years after bicycle crash but had normal findings on lymphoscintigraphy. Anterior lymphoscintigrams obtained 1 hr (A) and 3 hr (B) after injection of radionuclide show no abnormalities. Note that two main lymphatic trunks (closed arrows, A) in both calves and both thighs and ilioinguinal lymph nodes are symmetric. Artifacts (open arrows, A) related to scatter at injection sites in both feet are present. Cardiac, renal, and bladder uptake seen on B is due to free pertechnetate.

View larger version (32K): [in a new window]   Fig. 1B. —37-year-old man who presented with bilateral leg edema for several years after bicycle crash but had normal findings on lymphoscintigraphy. Anterior lymphoscintigrams obtained 1 hr (A) and 3 hr (B) after injection of radionuclide show no abnormalities. Note that two main lymphatic trunks (closed arrows, A) in both calves and both thighs and ilioinguinal lymph nodes are symmetric. Artifacts (open arrows, A) related to scatter at injection sites in both feet are present. Cardiac, renal, and bladder uptake seen on B is due to free pertechnetate.

View larger version (10K): [in a new window]   Fig. 2A. —55-year-old woman with clinically suspected lymphocele in right axilla and edema in right upper extremity but with normal findings on lymphoscintigraphy. Early lymphoscintigram of upper extremities obtained 10 min after injection of radionuclide, with patient's shoulders at top of image, shows rapid lymphatic drainage. A = level of axillae, E = level of elbows, RT = right side, LT = left side.

View larger version (45K): [in a new window]   Fig. 2B. —55-year-old woman with clinically suspected lymphocele in right axilla and edema in right upper extremity but with normal findings on lymphoscintigraphy. Delayed lymphoscintigram of both axillary regions and upper thorax shows normal bilateral axillary lymph nodes (arrows). Note absence of lymphocele or any other abnormality.

View larger version (29K): [in a new window]   Fig. 3. —34-year-old man with recurrent left foot and leg swelling and multiple episodes of left leg cellulitis. Anterior lymphoscintigram obtained 3 hr after injection of radionuclide reveals markedly delayed and diminished flow in left leg, with no lymphatic trunks or clinically relevant collaterals visualized. Note absence of radionuclide uptake in expected location of left ilioinguinal lymph nodes (thick arrow), compared with uptake on right side (thin arrow). Findings are consistent with aplasia of lymphatic vessels in left leg and primary lymphedema. LT = left side of body.

View larger version (29K): [in a new window]   Fig. 4A. —64-year-old woman who has had bilateral lower extremity swelling for 42 years (worse on left), consistent with primary lymphedema. Anterior lymphoscintigram of lower extremities obtained 1 hr after injection of radionuclide shows little lymphatic drainage. Upper marker indicates location of groin, and lower marker indicates knee.

View larger version (27K): [in a new window]   Fig. 4B. —64-year-old woman who has had bilateral lower extremity swelling for 42 years (worse on left), consistent with primary lymphedema. Lymphoscintigram obtained 3.5 hr after injection of radionuclide reveals few lymphatic channels bilaterally and marked dermal backflow (arrows) in lower calves.

View larger version (39K): [in a new window]   Fig. 5A. —30-year-old man with primary lower extremity lymphedema and Prader-Willi syndrome. Lymphoscintigram obtained 45 min after injection of radionuclide shows multiple large and tortuous lymphatic channels with multiple additional lymphatic vessels in thighs and calves. Increased numbers of bilateral ilioinguinal lymph nodes (small arrows) as well as megalymphatics (large arrows) in right calf both medially and laterally are visible.

View larger version (33K): [in a new window]   Fig. 5B. —30-year-old man with primary lower extremity lymphedema and Prader-Willi syndrome. Anterior lymphoscintigram obtained 2.5 hr after injection of radionuclide shows prominent number of fine collateral lymphatic channels (open arrow) and left dermal backflow (solid arrow).

View larger version (34K): [in a new window]   Fig. 5C. —30-year-old man with primary lower extremity lymphedema and Prader-Willi syndrome. Spot posterior lymphoscintigram obtained 3.5 hr after injection of radionuclide shows improved visualization of right collateral channels and subtle left dermal backflow (arrows). Dermal backflow is secondary effect of poor lymphatic transport. Round marker in left upper corner of image indicates level of knees. RT = right side, LT = left side.

View larger version (146K): [in a new window]   Fig. 5D. —30-year-old man with primary lower extremity lymphedema and Prader-Willi syndrome. Photographs of legs before (D) and after (E) complex lymphedema therapy. Note improvement, particularly at ankles.

View larger version (147K): [in a new window]   Fig. 5E. —30-year-old man with primary lower extremity lymphedema and Prader-Willi syndrome. Photographs of legs before (D) and after (E) complex lymphedema therapy. Note improvement, particularly at ankles.

View larger version (55K): [in a new window]   Fig. 6. —58-year-old man with left leg edema after prostate and bilateral pelvic lymph node resection. Anterior lymphoscintigram obtained 95 min after injection of radionuclide shows delayed left lower extremity lymphatic drainage with decreased left ilioinguinal lymph nodes (large arrow). Collateral lymphatic trunks are seen in left thigh and calf (small arrows). Same findings were present on image obtained 4 hr after injection (not shown).

View larger version (109K): [in a new window]   Fig. 7. —72-year-old man with secondary lymphedema in left leg after fall that injured leg several months earlier. Anterior spot lymphoscintigram of both calves obtained 3.5 hr after injection of radionuclide shows decreased number of lymphatic channels in left calf (large arrows), with associated dermal backflow (small arrows). K = level of knees, A = level of ankles, RT = right side, LT = left side.

View larger version (41K): [in a new window]   Fig. 8. —53-year-old man who fractured right ankle 1 year earlier presented with right leg swelling. Anterior lymphoscintigram obtained 3.25 hr after injection of radionuclide shows normal left lower extremity but dermal backflow (solid arrows) in right calf. Note increased number of right-sided ilioinguinal lymph nodes (open arrows) of uncertain importance.

View larger version (130K): [in a new window]   Fig. 9A. —71-year-old woman with right lower extremity edema and history of substantial injury to right knee. Anterior lymphoscintigram (composite transmission and emission image) of both calves obtained 25 min after injection of radionuclide reveals normal left leg and focal collection (arrow) in right medial calf representing lymphocele.

View larger version (52K): [in a new window]   Fig. 9B. —71-year-old woman with right lower extremity edema and history of substantial injury to right knee. Lymphoscintigram obtained 4.5 hr after injection of radionuclide reveals marked dermal backflow (arrow) in right calf, which hides focal collection visible on earlier image. Note markedly delayed lymphatic drainage in right calf.

View larger version (63K): [in a new window]   Fig. 10. —55-year-old woman who has experienced right arm edema for 1 year after removal of recurrent right axillary cysts and abscesses. Image was acquired with patient's outstretched arms placed on rectangular view camera. Early lymphoscintigram of arms shows delayed lymphatic drainage in right arm, with fewer lymph nodes in right (open arrow) than in left axilla (solid arrow) and collateral channels at level of right elbow, consistent with secondary lymphedema. Dashed arrows indicate elbow markers.

View larger version (102K): [in a new window]   Fig. 11. —66-year-old man with history of swelling in left arm after removal of left forearm melanoma and left axillary lymph node dissection. Lymphoscintigram of arms obtained 50 min after injection of radionuclide shows rapid lymphatic drainage of both forearms but decreased number of left axillary lymph nodes (small arrow) and multiple focal collections (large arrow) in left upper arm, consistent with dilated lymphatics. Findings are consistent with left axillary level obstruction from previous lymph node dissection. H = level of hands, E = level of elbows, A = level of axillae, RT = right side, LT = left side.

View larger version (98K): [in a new window]   Fig. 12A. —43-year-old woman with history of extensive travel to numerous developing countries evaluated for suspected lymphedema. Results of multiple examinations for infection—including filarial disease—were negative. Photograph of patient shows massive swelling in both thighs.

View larger version (68K): [in a new window]   Fig. 12B. —43-year-old woman with history of extensive travel to numerous developing countries evaluated for suspected lymphedema. Results of multiple examinations for infection—including filarial disease—were negative. Lymphoscintigram of lower extremities shows dermal backflow (arrow) in right calf, with otherwise prompt lymphatic drainage in both legs. No right lymphocele or other right thigh lymphatic abnormality is revealed. Left leg is unremarkable. Findings are consistent with obesity ("lipedema") with relatively minor lymphatic abnormality in right calf unrelated to obesity.

View larger version (56K): [in a new window]   Fig. 13. —41-year-old woman who had lymphangioma removed from left thigh at birth and who presented with new soft-tissue mass in left anterior thigh and edema of left lower extremity. Delayed lymphoscintigram of lower extremities reveals no lymphocele or dermal backflow but does show fewer ilioinguinal lymph nodes (arrow) on left side than on right. Latter finding may be residual effect of prior surgery, normal variant, or related to low flow obstruction.

View larger version (116K): [in a new window]   Fig. 14A. —44-year-old man who had bilateral lower extremity edema below the waist for 1 year without history of surgery or trauma. Abdominal and pelvic lymphadenopathy identified on CT was biopsied and was negative for malignancy. Cause of findings is unknown. Early anterior lymphoscintigrams of calves (A) and knees (B) show fine lymphatic collaterals (arrows), especially in left leg. R = right side, L = left side.

View larger version (105K): [in a new window]   Fig. 14B. —44-year-old man who had bilateral lower extremity edema below the waist for 1 year without history of surgery or trauma. Abdominal and pelvic lymphadenopathy identified on CT was biopsied and was negative for malignancy. Cause of findings is unknown. Early anterior lymphoscintigrams of calves (A) and knees (B) show fine lymphatic collaterals (arrows), especially in left leg. R = right side, L = left side.

View larger version (59K): [in a new window]   Fig. 14C. —44-year-old man who had bilateral lower extremity edema below the waist for 1 year without history of surgery or trauma. Abdominal and pelvic lymphadenopathy identified on CT was biopsied and was negative for malignancy. Cause of findings is unknown. Lymphoscintigram obtained 45 min after injection of radionuclide shows lymphocele or megalymphatic vessel (large arrow) in right calf, diffuse bilateral dermal backflow (small arrows), and early filling (open arrow) of abnormal structures in abdomen and pelvis, consistent with small lymph nodes and abnormal lymph vessels in mesentery.

View larger version (50K): [in a new window]   Fig. 14D. —44-year-old man who had bilateral lower extremity edema below the waist for 1 year without history of surgery or trauma. Abdominal and pelvic lymphadenopathy identified on CT was biopsied and was negative for malignancy. Cause of findings is unknown. Lymphoscintigram obtained 3.5 hr after injection of radionuclide shows diffuse bilateral dermal backflow and extravasation (small arrows) from lymphatic channels. Abnormal structures (large arrows) in abdomen and pelvis are accentuated and are also seen in thorax (open arrow).

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