Lymphedema is a chronic debilitating disease that results from chronic lymphatic insufficiency. Lymphoscintigraphy forms an authentic yet simple diagnostic and screening procedure in patients with preclinical and clinical lymphedema of different etiologies. Our study population consisted of 540 patients with diagnosed lymphedema of different etiologies and grading. Here we highlight our experience of lymphoscintigraphy in different clinical situations and staging of lymphedema. Lymphoscintigraphy is a simple, noninvasive procedure, which documents clinical diagnosis and guides the management of Lymphedema

1. LYMPHOSCINTIGRAPHY AS AN IMAGING MODALITY IN LYMPHATIC
SYSTEM

2. Original Article
205 Apollo Medicine, Vol. 7, No. 3, September 2010
LYMPHOSCINTIGRAPHYAS AN IMAGING MODALITY IN LYMPHATIC SYSTEM†
K Shilpa*, M Indirani**, S Shelley** and G Manokaran#
* Resident,**Consultant, Department of Nuclear Medicine, #
Consultant, Department of Plastic Surgery, Apollo Hospitals,
21 Greams Lane (off Greams Road),Chennai 600 006, India.
Correspondence to: Dr M Indirani, Consultant, Department of Nuclear Medicine, Apollo Hospitals, 21 Greams Lane
(off Greams Road),Chennai 600 006,India.
Lymphedema is a chronic debilitating disease that results from chronic lymphatic insufficiency.
Lymphoscintigraphy forms an authentic yet simple diagnostic and screening procedure in patients with
preclinical and clinical lymphedema of different etiologies. Our study population consisted of 540 patients with
diagnosed lymphedema of different etiologies and grading. Here we highlight our experience of
lymphoscintigraphy in different clinical situations and staging of lymphedema. Lymphoscintigraphy is a simple,
noninvasive procedure, which documents clinical diagnosis and guides the management of Lymphedema
Keywords: Lymphedema, Lymphoscintigraphy, Filariasis, Klippel-Trenaunay syndrome.
†
Presented in International Congress of Lymphology 2009,
Sydney, Australia.
INTRODUCTION
Lymphedema is a chronic debilitating disease which
affects multiple aspects of patient’s life i.e. physical,
psychological, social and economical as well. It is a
progressive condition characterized by four pathologic
features:excesstissueprotein,edema,chronicinflammation
and fibrosis [1].
Lymphedema is classified as primary or secondary,
secondary being more common. Primary lymphedema is
caused by lymphatic aplasia, hypoplasia, and hyperplasia.
Causes of secondary lymphedema are infection, inflam-
mation, trauma, malignancy, iatrogenic (such as from
surgery), and radiation induced [2]. In developing countries
like India, most common causes for lymphedema are –
infection (filariasis), post operative, and vascular disease
associated lymphedema.
Lymphedema is frequently misdiagnosed, treated too
late or not treated at all. Even mild lymphedema causes
chronic leg discomfort and problem with walking, running
and fitting shoes. Advanced lymphedema causes lifelong
disability.Earlydiagnosiscanleadtoeffectivetreatmentand
thus result in clinical improvement and prevent progression
to chronic phase of the disease [3].
An early and accurate diagnosis of lymphedema is
essential for appropriate therapy. A diagnostic tool is
required as well for monitoring and evaluation of
intervening measures in the management and to control
morbidity at an early stage. Lymphoscintigraphy offers an
objective and reliable approach to diagnose and
characterize the severity of lymphedema. This method has
largely replaced the more invasive and technically difficult
technique of lymphangiography [4]. Lymphoscintigraphy
(Fig. 1) is considered the gold standard diagnostic method
for investigation of lymphatic transport disorder [5].
Lymphoscintigraphy gives fairly good image of the
anatomicalstructuresandrevealsthefunctionoflymphatic
systemaswell.
Hence we tried to establish a scintigraphic grading
system in lymphedema. We also tested the reliability of
lymphoscintigraphy in differentiating various causes of
lymphedema.
MATERIALS AND METHODS
Retrospective analysis of the patients who presented to
our department for lymphoscintigraphy from 1995 to 2009
was done. Total of 540 (M=314, F=226) patients in the age
group of 1-70 yrs were analyzed.All patients were divided
into4groupsaccordingtoetiologyafterbeingevaluatedby
alymphologist.
- Group I - Filarial lymphedema, 424 patients (347
unilateral and 77 bilateral). Clinical grading and
examination was done by a lymphologist using
Brunner’s clinical classification [6].
- Group II - 63 patients with lymphedema associated
with vascular diseases like DVT, varicose veins, post

3. Apollo Medicine, Vol. 7, No. 3, September 2010 206
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thrombotic syndrome, etc.
- Group III - 32 post-mastectomy with axillary node
dissection patients, 7 of them had received external
radiation also.
- Group IV - 21 patients with congenital lymphedema.
The study was performed by injecting 0.5-0.75 mCi of
99mTc – antimony sulfide intradermally into the dorsum of
both feet between the 1st interdigital space for lower limb
evaluation; and in 1st dorsal web space of both hands for
upper limb evaluation. Immediate, post massage (30
minutes) and delayed (3 hours) sweep images were
acquired in anterior and posterior views with the help of
SIEMENS-ECAM dual headed gamma camera with low
energy all purpose (LEAP) collimator.
Interpretation and staging was done according to the
observed patterns such as delay to flow, visualization of
lymph nodes, flow through deeper lymphatic system and
dermal back flow. Patients were classified into four grades
as follows.
Grade I - Multiple or dilated lymphatic channels or delay
to visualize lymph nodes in immediate images (Fig. 2).
Grade II – In addition to Grade I findings, flow through
deeper lymphatic system (popliteal/elbow lymph nodes)
(Fig. 3).
Grade III - Tracer stasis or dermal backflow in the
delayed images. Lymph nodes visualized in delayed
images (Fig. 4).
Grade IV - Grade I, II and III with non visualization of
lymph nodes (Fig. 5).
OBSERVATIONS
In Group I - Out of the 424 patients (i.e. 848 filarial
limbs) evaluated by us, clinically 347 limbs were non-
affected, 268 were grade I, 147 were grade II, 83 were
grade III and 3 were grade IV (Table 1). Abnormal
lympho-scintigraphic findings were seen in 61% [212/
347] of the clinically non affected limbs (Table 2). Of
these 212 limbs 51% had grade I lymphedema, 9% had
grade II and 1% had grade III lymphedema. Furthermore
in clinically affected limbs, 2.6% of grade I, 2.7% of grade
II and 1.2% of grade III limbs were found to have a higher
grade on lymphoscintigraphy (Table 3).
In Group II - we assessed a total of 63 patients with
various vascular etiologies like DVT (Fig.6), post-
thrombotic syndrome, thrombophlebitis syndrome &
varicose veins. Lymphoscintigraphy showed dilated and
prominent lymphatic channels in these patients however
Fig. 1. Lymphoscintigraphy of normal lower limbs.
Immediate Post exercise Delayed
Immediate Post exercise Delayed
Fig. 2. Grade I- Early pitting oedema of the left lower limb
completely reversible on elevation.
Immediate Post exercise Delayed
Fig. 3. Grade II- Pitting oedema partially reversible on elevation
of the lower limb without skin changes.

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207 Apollo Medicine, Vol. 7, No. 3, September 2010
Fig. 4. Grade III- Irreversible non pitting oedema of the right
lower limb with skin thickening.
Immediate Post exercise Delayed
Immediate Post exercise Delayed
Fig. 5. Grade IV- Irreversible non pitting oedema of both the
lower limbs with papillary and nodular growth.
Table 1. Scintigraphic grading as compared to
clinical grading in total patient population
Clinical Scintigraphic Not corresponding
grading gading to clinical grading
Clinically Non- Normal- 135 212 (61%)
affected- 347
Grade I- 268 Grade I- 258 10 (2.6%)
Grade II- 147 Grade II- 143 04 (2.7%)
Grade III- 83 Grade III- 82 01 (1.2%)
Grade IV- 3 Grade IV- 3 –
Table 2. Lymphoscintigraphic grading in clinically
non-affected limbs
Clinical Lymphoscintigraphic Number of
grade grade limbs (out of 347)
Non-affected Normal 135 (39%)
Non-affected I 176 (51%)
Non-affected II 33 (9%)
Non-affected III 3 (1%)
Table 3. Change in scintigraphic grading of
lymphedema in clinically affected limbs
Clinical Lymphoscintigraphic Number of
grade grade limbs upgraded
(out of 501)
I II 8
I III 2
II III 4
III IV 1
no dermal backflow was observed. Hence all limbs were
graded as grade I or II lymphoscintigraphically.
In Group III i.e. post mastectomy patients; all the
affected upper limbs (100% i.e. 32/32) showed
scintigraphic evidence of dermal backflow and 4 of them
showed residual (post-axillary nodal clearance) axillary
lymph nodes (Fig. 7).
In Group IV patients with congenital lymphedema, we
observed various patterns such as tapering channels, no
channels, no nodes, dermal back-flow and lymph lakes. In
a patient having Klippel-Trenaunay Syndrome (Fig. 8)
who presented with slowly increasing swelling of left
lower limb with patches of discoloration on abdomen and
thighs; the scan showed dermal backflow of tracer
throughout the lower limb up to lower abdomen.
DISCUSSION
Though clinical examination is sufficient for diagnosis,
lymphoscintigraphy is a simple procedure which provides
functional as well as anatomical information and
characterizesseveritybymappingtheflowoftracerthrough
thelymphaticsystem.
In group I - Filarial lymphedema: Clinical grading I, II,
III and IV correlated well with scintigraphic grading with
minor variations which were not statistically significant.
But change in grading was observed in significant number
of patients (61%) of filariasis in clinically non affected
limbs. Patterns observed were multiple tortuous lymphatic
channels or delay to flow of tracer. Thus most of the
clinically non-affected limbs were upgraded to Grade I
(51%). These scintigraphic changes could be secondary to

5. Apollo Medicine, Vol. 7, No. 3, September 2010 208
Original Article
subclinical lymphedema. This correlates with the findings
of Pani, et al. who reported that pathological changes do
occur at a very early stage in filarial lymphedema but
remain subclinical for a very long time [7]. Similar results
were observed in a previous study published by our
department in 2006 [8]. Hence, it can be affirmed that
lymphoscintigraphy diagnoses pathological changes
earlier than clinical examination. In such patients early
preventive measures can retard disease progression &
limit morbidity. Thus lymphoscintigraphy can act as an
effective screening tool in suitable patient population.
In group II - Lymphedema associated with vascular
disease: Lymphoscintigraphy showed dilated and
prominent lymphatic channels in this patient group with
no dermal backflow seen. These findings indicate
compen-satory overload on lymphatic system secondary
to vascular insufficiency [9]. These scintigraphic findings
help to differentiate lymphoedema of vascular origin from
other etiologies. Even though other investigations of
choice are available, lymphoscintigraphy would be
complementary to these.
In group III - Post operative lymphedema: The
incidence of upper limb lymphedema following treatment
of breast carcinoma is 20.7% [10]. Bourgeois et al
concluded that when axillary node dissection is
performed, the post-operative lymphoscintigraphic
investigation of the upper limbs is indicated. This
technique will allow defining the cases where the surgery
has interrupted the normal lymphatic pathways draining
the limb. Lymphoscintigraphy in the early post surgical
period will identify patients with preclinical
lymphoedema. These patients must be managed more
carefully than others. Early identification of these patients
will allow specific implementation of preventive
strategies to minimize the risk of lymphedema, to reduce
morbidity and to improve quality of life. They also
concluded that when a patient presents with upper limb
lymphoedema; inclusion of lymphoscintigraphic investi-
gation of the upper limb(s) is indicated. These techniques
characterize the edema morphologically and functionally.
They will also direct the treatments to be applied, and, in
many cases, they will allow a good assessment of the
therapeutic responses [11].
Pecking, et al. demonstrated that postoperative
lymphoscintigraphy can identify patients with high risk of
development of extremity lymphedema. They studied 60
women treated with surgical axillary lymph node
dissection and radiation therapy for breast cancer and
demonstrated that an abnormal lymphoscintigram 6
months after radiation therapy predicted the development
of arm lymphedema [12].
Fig. 6. Post DVT lymphoscintigraphy.
Immediate Post exercise Delayed
Immediate Delayed
Fig. 7. Lymphoscintigraphy of upper limbs in patient with breast
carcinoma post axillary lymph node dissection.
Immediate Post exercise Delayed
Fig. 8. Klippel-Trenaunay Syndrome

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209 Apollo Medicine, Vol. 7, No. 3, September 2010
Our findings were consistent with these studies.
Characterization of lymph flow and early detection of
interruptionoflymphaticchannelswaseasilydemonstrated
bythistechnique.Thescintigraphicfindingswerehelpfulin
early decision making in these patients and effectively
guided the treatment.
In group IV - Congenital lymphedema: Various
scintigraphic patterns such as tapering channels, no
channels,nonodes,dermalback-flowandlymphlakeswere
observed. This provided an anatomical and physiological
patternofthelymphaticswhichwasofhelptothephysician
for deciding the management.
We had a case of Klippel - Trenaunay syndrome. This
syndrome is characterized by vascular malformation of the
capillaries, veins, and lymphatics with limb hypertrophy.
Lymphatic system in such cases, many a times, is not
imaged and documented. Extent of lymph vessel anomaly
over the lower abdominal wall was demonstrated as shown
in Fig. 8. Lymphoscintigraphy has a potential and pivotal
role in diagnostic work up as well as management of
patients with congenital lymphedema.
Lymphoscintigraphy has been widely used in the
assessment of therapeutic interventions for lymphedema,
ranging from microsurgery [13,14] and manual lymphatic
massage [15], pneumatic compression [16]. At our center,
we have used lymphoscintigraphy to assess the response to
therapy in cases of lymphedema as shown in Fig. 9 and 10.
Lymphoscintigraphy was very useful for assessment of
response to therapy.
CONCLUSION
The results and analyses of data from our study allowed
us to conclude that; there is a good correlation between
clinical grading and lymphoscintigraphic grading of
lymphedema. Lymphoscintigraphy can detect pathological
changesinlymphaticsearlierthanclinicalexamination,and
allows for upgrading most of the subclinical cases.
Lymphoscintigraphy can be used as a baseline screening
procedure in filarial & post mastectomy patients, so that
subclinical lymphoedema can be detected and treated on
time. Also these scans are able to help in differentiating
various etiologies by its characteristic patterns which are
easily identifiable. Lymphoscintigraphy plays pivotal role
in therapy planning as well as monitoring the therapy
response. Hence this imaging modality should be at the
forefront in management of various lymphatic system
disorders.
Fig. 9 Pre-therapy scan of lower limbs show multiple lymphatic channels with dermal backflow.
Fig.10 Lymphoscintigraphy of lower limbs in same patient after therapy.
Immediate Post exercise Delayed

7. Apollo Medicine, Vol. 7, No. 3, September 2010 210
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REFERENCES
1. Casley-Smith JR. Foldi M, Ryan TJ, et al. Lymphedema:
summary of the 10th Intemnational Congress of
Lymphology: Working Group Discussions and
Recommendations, Adelaide, Australia, August 10-17,
1985. Lymphology 1985; 18:175-180.
2. Alok Tiwari, et al. Differential diagnosis, investigations,
and current treatment of lower limb lymphedema. Arch.
Surg. 2003; 138: 152-161.
3. Andrez Szuba, William.S. Shin, Willium Strauss. The
third circulation – Radionuclide lymphoscintigraphy in
the evaluation of lymphoedema. Journal of Nuclear
Medicine. January 2003; 44(1): 43-57.
4. The Diagnosis and Treatment of peripheral
lymphoedema .Consensus document of the International
Society of Lymphology. 2003;36:84-91.
5. Proby C.M. Investigation of swollen limb with isotopic
lymphography.Br.J.Dermatol. 1990;12: 29-37.
6. Russell RCG, NS Wiliiams, CJK Bulstrode (Eds.). Bailey
and Love’s Short Practice of Surgery. 24th edition.
Hodder education publishers, 2004.
7. Pani SP, Srividya A, Rajagopalan PK. Clinical
Manifestationsof bancroftian filariasis in relation to
microfilareimia & DEC therapy.National Medical Journal
of India.4: 9-14.
8. S Shelley, et al. Lymphoscintigraphy as a diagnostic tool
in patients with lymphedema of filarial origin- An Indian
Study. Lymphology 2006; 39: 69-75.
9. A Cavezzi, S Michelini. Phlebolymphoedema- From
Diagnosis to Therapy. T R Communications, Italy. Sept
1998.
10. Clark B, Sitzia I , Harlow W. Incidence and risk of arm
edema following treatment for breast cancer : 3 years
follow up study.QJM 2005; 98 (5):343-348.
11. Bourgeois P, Leduc O, Leduc A. Imaging techniques in
the management and prevention of posttherapeutic
upper limb edemas. Cancer. 1998; 83: 2805-2813.
12. Pecking A, Lasry S BA, Floiras J, Rambert P, Gue´rin P,
eds. Post Surgical Physiotherapeutic Treatment: Interest
in Secondary Upper Limb Lymphedemas Prevention.
Amsterdam, The Netherlands: Elsevier Science; 1988.
13. Campisi C. Lymphoedema: modern diagnostic and
therapeutic aspects. Int Angiol. 1999;18:14-24.
14. Gloviczki P, Fisher J, Hollier LH, et al. Microsurgical
lymphovenous anastomosis for treatment of
lymphedema: a critical review. J Vasc Surg. 1988;7:647-
652.
15. Leduc O, Bourgeois P, Leduc A. Manual lymphatic
drainage: scintigraphic demonstration of its efficacy on
colloidal protein reabsorption. In Partsch H, ed. Progress
in Lymphology. Amsterdam, The Netherlands: Elsevier
Science; 1988: 551-554.
16. Baulieu F, Baulieu JL, Secchi V, et al. Factorial analysis
of dynamic lymphoscintigraphy in lower limb
lymphoedema. Nucl Med Commun. 1989;10:109-119.

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