title: Role of lymphoscintigraphy in diagnosis and management of patients with leg swelling of unclear etiology.
abstract: BACKGROUND
  To study the utility of lymphoscintigraphy in detection of lymphatic obstruction in patients with leg swelling of unclear etiology, selection of site for nodo venous shunt procedure, and follow-up lymphoscintigraphic documentation of improved lymph flow in surgically treated limb.
  
  
  METHODS
  Twenty four consecutive patients with leg swelling, 10 male, 14 female with mean age 47 years, range from 13 years to 74 years underwent lymphoscintigraphy. All patients were referred from Department of Plastic Surgery, after initial work-up, and routine investigations to rule out the other causes of leg swelling. Both clinical and scintigraphic staging performed for all patients. All clinically and scintigraphically positive patients treated with decongestive lymphatic therapy (DLT). In addition to the DLT, those patients positive for unilateral or bilateral lymphedema, consented for surgical intervention, nodo venous shunt (NVS) in their only affected or one of the two affected lower limbs. Follow-up lymphoscintigraphy performed in operated cases after 3 months to 6 months of surgery, lymphoscintigraphy images of each patient in pre and post-surgery compared.
  
  
  RESULTS
  In 20/24 cases (83%) of clinically positive leg swelling were found to be positive for lymphedema on lymphoscintigraphy and remaining, 4/24 were scintigraphically normal. Based on the clinical and lymphoscintigraphy staging, 03/20 cases (15%) had Grade I lymphedema, 01/20 (5%) Grade II lymphedema, 06/20 (30%) Grade III and remaining 10/20 (50%) had Grade IV lymphedema. 11/20 cases of Lymphedema (55%) were managed conservatively by only DLT and in remaining 09/20 cases (45%), who were case of Grade IV, lymphedema (five patients with unilateral and four patients with bilateral disease) initially treated with DLT, and on completion of DLT, undergone for NVS procedure, in their unilaterally affected lower limb or one of the two diseased lower limbs. All nine patients showed remarkable clinical improvement in leg swelling and their follow-up lymphoscintigraphy showed normal visualization of lymphatic channels. No patient developed any recurrence.
  
  
  CONCLUSIONS
  Pre-operative functional evaluation of lymphatic channels using lymphoscintigraphy, is a widely available, simple imaging test and highly useful for documentation of lymphedema in patients with leg swelling of unclear etiology and also for exact localization of inguinal lymph nodes to perform the NVS procedure. Further, it can play important role for follow-up of patients receiving DLT or DLT with surgical intervention that provides early relief from clinical symptoms.
authors.affiliation: Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India.
authors.forename: Tek Chand
authors.initials: TC
authors.lastname: Kalawat
authors.forename: Ravi Kumar
authors.initials: RK
authors.lastname: Chittoria
authors.forename: Praveen Kumar
authors.initials: PK
authors.lastname: Reddy
authors.forename: Batchu
authors.initials: B
authors.lastname: Suneetha
authors.forename: Ravishwar
authors.initials: R
authors.lastname: Narayan
authors.forename: Parthsarthi
authors.initials: P
authors.lastname: Ravi
keywords: Leg swelling; lymphedema; lymphoscintigraphy; nodo venous shunt
references.citation: Radiology. 1995 Jul;196(1):107-13
references.pmid: 7784553
references.citation: Nucl Med Commun. 1995 Aug;16(8):683-6
references.pmid: 7491181
references.citation: Radiology. 2001 Sep;220(3):816-21
references.pmid: 11526287
references.citation: Hosp Pract (Off Ed). 1989 May 30;24(5A):109-10, 113-4, 116
references.pmid: 2498344
references.citation: Lymphology. 2005 Sep;38(3):122-9
references.pmid: 16353489
references.citation: J Nucl Med. 1986 Jul;27(7):1125-30
references.pmid: 3723188
references.citation: Lymphat Res Biol. 2004;2(1):32-7
references.pmid: 15609925
references.citation: Radiology. 1988 Jun;167(3):729-35
references.pmid: 3363131
references.citation: Lymphology. 2003 Jun;36(2):84-91
references.pmid: 12926833
references.citation: Plast Reconstr Surg. 1994 Nov;94(6):841-7; discussion 848-9
references.pmid: 7972431
references.citation: Clin Med (Lond). 2002 Jan-Feb;2(1):28-31
references.pmid: 11871635
references.citation: J Gen Intern Med. 1997 Jun;12(6):374-83
references.pmid: 9192256
references.citation: Clin Dermatol. 1995 Sep-Oct;13(5):445-50
references.pmid: 8665455
references.citation: J Nucl Med. 2003 Jan;44(1):43-57
references.pmid: 12515876