Intradermal-Stress-Lymphoscintigraphy for screening and early detection of breast cancer related lymphedema.

Objectives Breast cancer and axillary-lymph nodes treatments place patients at life-long risk for the development of lymphedema. Earlier lymphedema diagnosis and early treatment may result in better outcomes. Our aim was to evaluate Intradermal-Stress-Lymphoscintigraphy in screening and early detection of breast cancer related lymphedema.

Methods we imaged 45 women with breast cancer (3 bilateral), ages 51 +/-9 which accepted to undergo postoperative lymphoscintigraphy follow-up for lymphedema evaluation. The test was performed about 1 year after surgery, after completion of chemio and radiation treatments. All patients were classified as ISL clinical stages from 0 to 2. A dose of the 99mTc-HSA-nanocolloidal, 50 MBq, 0.4 mL, was injected intradermally at the first and fourth intermetacarpal space on the back of the hand, in the arm on the same side as the cancer. The patient was imaged upright, minimizing the distance from the collimator face to the upper limb. Two planar static scan at rest were acquired immediately after tracer injection (180 secs, 128x128, LEGP collimator). After weight-lifting for 2 mins, the stress scans were acquired. If lymph drainage was delayed, the patients performed muscular exercise limited by symptoms, until visualization of regional lymph nodes. A late scan was acquired at 60 mins.

Results a total of 48 upper limbs have been studied. Five patterns of lymphoscintigraphy were observed: I) Normal visualisation of lymphatic pathways in 11 arms (23%) at clinical stage 0 ; II) presence of collateral lymphatic vessels (<3) in 9 arms (19%) at clinical stage 0; III) an unusual uptake of antecubital lymph nodes in 10 arms (21%) at clinical stages between 0 and 1; IV) a lymphangiectasia in 13 arms (27%) at clinical stages between 0 and 2; V) dermal backflow in 5 arms (10%) at clinical stage 2. The mean Tracer Appearance Time was 19 +/-13 mins.

Conclusions In our experience, patients with type I pattern were completely asymptomatic. Patients with patterns type II and III had in some cases initial lymphedema-related symptoms, and best results were observed after an home-based exercise program. The pattern IV seems to be predictive of swelling of upper limb, and it was observed in patients at various clinical stage. Only 5 upper limbs showed clearly dermal backflow. The abnormal patterns found may provide the basis for a preclinical diagnosis of lymphedema in breast-cancer patients. This prophylactic strategy may optimize the treatment timing, preventive approach (therapeutic education), corrective approach (combined physical therapy and/or microsurgery) and outcomes. $$graphic_C1E0EBCD-DDBC-49D8-AB8B-CACA41915CDD$$