Procedural Recommendations for Lymphoscintigraphy in the Diagnosis of Peripheral Lymphedema: the Genoa Protocol

G. Villa & C. C. Campisi & M. Ryan & F. Boccardo & P. Di Summa & M. Frascio & G. Sambuceti & C. Campisi. Nuclear Medicine and Molecular Imaging (2019) 53:47–56

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Procedural Recommendations for Lymphoscintigraphy in the Diagnosis of Peripheral Lymphedema: the Genoa Protocol

Villa & C. C. Campisi & M. Ryan & F. Boccardo & P. Di Summa & M. Frascio & G. Sambuceti & C. Campisi. Nuclear Medicine and Molecular Imaging (2019) 53:47–56.

Introduction Lymphoscintigraphy is the gold standard for imaging in the diagnosis of peripheral lymphedema. However, there are no clear guidelines to standardize usage across centers, and as such, large variability exists. The aim of this perspectives paper is to draw upon the knowledge and extensive experience of lymphoscintigraphy here in Genoa, Italy, from our center of excellence in the assessment and treatment of lymphatic disorders for over 30 years to provide general guidelines for nuclear medicine specialists.

Method The authors describe the technical characteristics of lymphoscintigraphy in patients with limb swelling. Radioactive tracers, dosage, administration sites, and the rationale for a two-compartment protocol with the inclusion of subfascial lymphatic vessels are all given in detail.

Results Examples of lymphoscintigraphic investigations with various subgroups of patients are discussed. The concept of a transport index (TI) for semi-quantitative analysis of normal/pathological lymphatic flow is introduced. Different concepts of injection techniques are outlined.

Discussion It is past time that lymphoscintigraphy in the diagnosis of lymphatic disorders becomes standardized. This represents our first attempt to outline a clear protocol and delineate the relevant points for lymphoscintigraphy in this patient population.

Main findings

  • This paper provides the details of:
    • Preparatory procedure for lymphoscintigraphy
    • Radiopharmaceutical choice and site of administration
    • Interpretation
    • Sources of error
  • The indications for lymphoscintigraphy include primary lymphatic dysplasia, secondary lymphatic dysplasia, primary lymphedema, congenital lymphedema, secondary lymphedema, and chylous leakage (chylous ascites and chylothorax). The lymphoscintigraphy technique has also been proposed, by some authors, for the evaluation of thoracic duct abnormalities.
  • There are no absolute contraindications. Pregnancy and breastfeeding are a relative contraindication. Like all tests using ionizing radiation, a lymphoscintigraphy in pregnancy must be justified by an actual benefit to the patient without excessive risk of exposure to the fetus/infant.