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The Third Circulation: Radionuclide Lymphoscintigraphy in the Evaluation of Lymphedema^*

¹ Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
² Division of Nuclear Medicine, Stanford University School of Medicine, Stanford, California

View larger version (37K): [in a new window]   FIGURE 1. Scheme for superficial lymphatic system. Capillary density of skin lymphatic network differs in various parts of body, with higher density in face, soles of feet, and palms of hands than in trunk.

View larger version (54K): [in a new window]   FIGURE 2. Lymphedema of arm in patient after axillary dissection during breast cancer surgery. Ant = anterior.

View larger version (65K): [in a new window]   FIGURE 3. Lymphatic capillary (top), in comparison with blood capillary (bottom). Lymphatic capillary has larger diameter, no pericytes (P), and thin and porous basal membrane (BM) and is attached to surrounding tissue with anchoring filaments. Erythrocytes (E) are visible within lumen of blood capillary.

View larger version (52K): [in a new window]   FIGURE 4. Filling mechanism of initial lymphatics: interendothelial clefts. (A) Cross-sectional view shows that stretching of anchoring filaments (tissue edema, massage) pulls apart endothelial cells, allowing interstitial fluid to flow freely into lymphatic capillary. (B) Lymphatic endothelial cells are pulled apart and porous basement membrane is visible, acting as sieve for interstitial fluid entering lymphatic capillary (luminal surface of capillary).

View larger version (66K): [in a new window]   FIGURE 5. Scheme for lymph formation. A = Arterial capillary; V = venous capillary.

View larger version (67K): [in a new window]   FIGURE 6. Lower-extremity lymphoscintigram from patient with history of lymphadenitis in right groin because of herpes zoster (shingles) affecting her right buttock and inguinal area. Shown are immediate images in anterior and posterior views (left), late images (about 3 h after injection) in anterior and posterior views (middle), and superimposition of anterior emission scan on transmission scan (right). Inguinal node visualization on right and dermal backflow on medial aspect of upper thigh are minimal, suggesting lymphatic obstruction of superficial system. Ant = anterior; Post = posterior.

View larger version (50K): [in a new window]   FIGURE 7. Upper-extremity lymphoscintigram from patient who had left-sided pacemaker. Several months after pacemaker was placed, patient noticed swelling of left arm. Shown are immediate images in anterior and posterior views (left), images 2 h after injection in anterior and posterior views (middle), and images 3 h after injection in anterior and posterior views (right). Axillary nodal visualization and appearance of dermal backflow in upper portion of left arm and in area of pacemaker implantation are weak, confirming that cause of extremity edema is lymphatic obstruction, possibly related to surgical intervention. Ant = anterior; Post = posterior.