Marina Cestari  MD

SUMMARY

The diagnosis of lymph-oedema is essentially clinical, however, we must not ignore the accuracy of the high resolution scan when it is performed by experienced operators using high technology instruments.
We evaluated the utility of this methodology using Echo-Colour-Doppler  Sonoline Antares apparatus, in lymph-oedematous upper and lower limbs diagnostics because it is provides us with information on structural characteristics of the examined tissue, and in the ambit of personalized therapeutic strategies.

 INTRODUCTION

The first evaluation of patients with lymph-oedema, performed in a team ambit, leads to the compilation of a specific clinical report and personalized rehabilitation  project.
Among the instrumental exams requested in the specific clinical report, the Echo-Colour-Doppler is always present: a non-invasive diagnostic approach, repeatable and relatively cheap, it has proved to be indispensable both in differential diagnostics with other oedematous pathologies, both in the ambit of rehabilitative projects and in the choice of  selected  therapeutic  strategies thanks to the precise information on the structural  characteristics of the examined tissue.

This method is also used for therapeutic monitoring as verification of the validity of treatment effectuated and for follow-up

MATERIALS AND METHODS

In the ambit of instrumental diagnostics of upper and lower limb lymph-oedema, we use a Sonoline Antares Echo-Colour-Doppler instrument with high frequency (13.5 Mhz) electronic linear probe (4.5 cm), proceeding along the examined limb with longitudinal and transversal scansions; a large quantity of gel avoids pressure on the skin and a subsequent collapse of the superficial lymphatic vessels.
The instrument available is provided with the “Siescape panoramic reconstruction”  function, a system option which allows the acquisition of bi-dimensional  ultrasound images with an extended visualization field (photo 1). In order to obtain good images, the scansion must be performed slowly using a large quantity of gel to favour the movement of the probe on the skin.
Before and after the therapeutic treatment and in follow-up we use as markers:
- the same circumferential measurements (lateral, medial, anterior and posterior regions of the examined limb),
- the superficial vessels in the examined limb which prove to be a useful spy of eventual probe hyper-pressure, which would cause the collapse of vessel walls (photo 2). It is interesting to note how it is possible to observe both the calibre and the flow speed of the superficial and deep veins in the lymph-oedematous limb, proof of the venous-lymphatic twinning useful in the case of lymphatic system insufficiency; after the combined treatment, a reduction of both the parameters is evident sign of the validity of the therapeutic strategy carried out.
Obviously other points can be taken into consideration, if considered interesting on palpation, aimed with a view to therapy selection  (photo 3).

 RESULTS

Echo-Colour-Doppler diagnostics provide important indications on structural characteristics of examined tissue:
- derma layer: it is possible to identify an increased thickness with a reduced echogenicity due to the presence of interstitial oedema, or an increased echogenicity due to tissue fibrosis (photo 4)
- subcutaneous tissue: it is possible to highlight ectasia of lymphatic collectors, located at the epifascial level and in proximity of the superficial venous vessels, and the pre-collectors which can be found as anechogenic network in the adipose tissue.
Tissue compression with probe empties the lymphatic vessels which slowly fill up after its removal, differently to the lymphatic lakes, anechogenic network without evident walls, which do not respond to compression. In more advanced studies , a progressive increase of the echogenic tissue, due to the presence of fibrosis, can be noted (photo 5).
The increased thickness, easily measurable before and after rehabilitative treatment, highlights the quantity of oedematous tissue and the efficacy of the therapy applied; furthermore it is a useful parameter to monitor the evolution of lymph-oedema.
- Adipose tissue: it is possible to find a prevalence of this tissue due to hypertrophic and hyper-echogenic adipose lobes, with denser aspect of subcutaneous tissue (foto 6);
- lymph-nodes: with Echo-Colour-Doppler it is possible to identify the morphological characteristics and vascularization; in the case of inflammation for example, the hyperplasic reactive lymph-node presents an increased dimension with cortical hypertrophia and conservation of hilum.
In oncological patients, with secondary post-surgical lymph-oedema, eventual vascularized neoformations and/or regional lymph-nodes which present a reduction of the longitudinal diameter, with spherical form, and altered hilum structure, induce us not to take on the patient and to contact the patient’s oncologist for a further specialist evaluation.

 DISCUSSION

We have tried to compare the clinical impressions, based on tissue consistency on palpation, with the echo-graphic imaging highlighting three different clinical-instrumental situations, with relative prognostic implications which allow us to decide precise rehabilitation programs and therefore optimize therapeutic treatment.
1) Lymph-oedema with optimal response to therapeutic treatment:on palpation the oedema appears to be of soft consistency with pitting, while with echo-graphic examination we observe hypoanecogenic tissue due to interstitial fluid, with lymphatic collector and  pre-collector ectasia.
In this case both rehabilitative treatment (combined therapy) and pharmacological treatment with natural cumarine is carried out.
Furthermore the patient learns, if able to do so, combined self-care (self-drainage and self-bandaging with associated motorial therapy) in the ambit of self-care.
2) Lymph-oedema with poor response to therapeutic treatment:
- on palpation the oedema appears to be of hard consistency without pitting, while the echo-graphic examination highlights extended hyperechogenic tissue upon the fascia, due to fibrosis. In this clinical-instrumental situation we carry out rehabilitative treatment, with particular utilization of special manoeuvres for fibrosis, and bandaging with suitable under-bandaging (“Schneider pack”) prescribed and prepared by the physiotherapist in charge of the patient.
- on palpation oedema appears to be of hard consistency without pitting, prevalently, on echo-graphic examination, with hypertrophic and hyperechogenic adipose tissue, which would indicate an adequate liposuction  in highly specialized centres; in any case, elastic compression with personalized tutor is indispensable.
3) Lymph-oedema whose response to treatment is based on clinical-instrumental characteristics with oedema of medium consistency and mixed echo-graphic characteristics.
In these cases we refer to echo-graphic characteristics for therapeutic strategies.
Although conditioned by technical limits, being above all operator dependent, Echo-Colour-Doppler diagnostics provides important data which lead to an improvement in lymph-oedema management, helping the lymphologist and physiotherapist in the choice of precise strategies and therefore the setting up of personalized therapeutic programs, with subsequent therapeutic optimization.

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