M.Cestari, F.Loreti* 
Pianeta Linfedema Study Center  
*Nuclear Medicine Service - S. Maria Hospital
Terni - Italy

In our lymphology study centre, over a period of 2 years, we focused our attention on 144 all subclinical stage patients (107 lymphadenectomy and 37 sentinel lymphnode), which includes patients at risk of developing lymph stasis in the homolateral arm without clinical evidence of edema, who had undergone surgery between  6-12 months before arriving at our centre, for examination spontaneously requested by their family doctor.

Patient evaluation, inside the rehabilitative team, with the inclusion of other different disciplines outside our centre, leads to a clinical report where anamnesis and clinical examination are included,  as well as the centrimetrical evaluation of compared arms and relative volumes calculated by using the volume of a truncated cone.
A physiatric evaluation is also fundamental for eventual subsequent specific physiotherapy.

But when we talk about primary prevention lymphscintigrapy has, in our opinion, the main importance because it allows us to identify patients at risk of edema onset, those who present slower radiotracer flow, which might not otherwise be identified.
In this study nuclear M.D. had performed the exam by bilateral subcutaneous injections  (needle 28 G) of 99mTc-nanosized colloid (80 nm) in every interdigital space, without additional proximal injection, (185 MBq - 2,035 mSv).
With regards to lymphadenectomy, 39% of the patients refused the exam: patients who had undergone surgery recently because not ready to perform other exams outside the oncological field, but, above all, because the exam was against medical advice (in oncologists’ opinion lymphoscintigraphy is useless, and lymphedema is not a relevant pathology). In the exam carried out (61%) lymphscintigraphy had highlighted a normal radiotracer flow in 26% of the cases and a slower radiotracer flow in 74% of the cases (lymphnode stops 50%, initial
dermal back flow 37% or both 13%). Photo 1.
Furthermore, lymphscintigraphy with homolateral slower radiotracer flow also highlighted contralateral stops in 52% of the cases.
With regards to sentinel lymphnode, 42%, of the patients refused to undergo the exam, because it was against medical advice (sentinel lymphnode is equal to no edema), while in the exam carried out (58%) lymphscintigraphy had highlighted a normal radiotracer flow in 45% of the cases and slower radiotracer flow in 55% (lymphnode stops 67%, initial dermal back flow 25% or both 8%). Photo 2.
Furthermore lymphscintigraphy with homolateral slower radiotracer fflow also  highlighted contralateral stop in 50% of the cases.
With regards to no lymphoscintigrapy or no evidence of slower radiotracer low, only follow-up was requested (one check a year), while in homolateral
slower radiotracer flow, patients, after the opening of a rehabilitative project, were included in the early treatment  which  consisted in respiratory training, manual lymph drainage, activation of alternative pathways and isotonic gymnastic.
All patients included in the study were informed on preventive measures through individual settings whose end-point was the information on the lymphedema, the information and the acceptance of preventive measures, intended not as prohibitions, that could lead to anxiety or depression, but as a fundamental behavioural strategy. Furthermore, the psychologist listened to the woman’s problems and became available for eventual individual sittings. Until two years ago we used to organize the informative group which included patients with subclinical stage and patients affected with lymphedema: the lymphologist talked about lymphedema, a physiotherapist explained the anatomy-physiology of the lymphatic system, and highlighted the importance of the hygienic-behavioural rules and at the end, the psychologist who listened to the women’s problems.
At present we inform on preventive measures through individual sittings because we realize patient compliance was insufficient using the former method.
A brochure, which contains the above-mentioned rules, is also given to the patients.

With regards to lymphadenectomy we have observed lymphedema onset in 17% of patient: 20%  had  undergone  lymphscintigraphy that had highlighted normal
exam in 27% of the cases and  slower radiotracer flow in 75% of the cases. Photo 3.
With regards to sentinel lymphnode we observed lymphedema onset in 5% of patients: all patients had undergone lymphscintigraphy that highlighted slower
radiotracer flow in all cases. Photo 4.
In both cases edema onset always secondary to accidental or avoidable event in previously informed patients: with regards to lymphoadenectomy edema onset
after lymphangitis (insect bite, gardening without protection), heavy work (long cleaning window session, long session ironing or cooking), sunburn or
burn removing dishes from oven, while with regards to sentinel lymphnode, edema onset always after lymphangitis (cat scratch, local wound),

This study highlights the main importance of lymphoscintigraphy in primary prevention, because it allows us to identify patients at risk of edema onset, but also underlines the necessity to attain the complete compliance of the patients who have to interpret the preventive measures, particularly highlighted in the case of slower radiotracer flow, as a fundamental strategy in primary prevention.
And as rehabilitative team we continue to have a dream: not to treat lymphedema, but to prevent it though the identification of patients at risk ...also we know that it should start immediately after post-surgical period.

1.Bourgeois P.,Leduc O., Belgrado J.P., Leduc A. “Scintigraphic investigations of the superficial lymphatic system: quantitative differences between intradermal and subcutaneous injections” Nuclear Medicine Communications April 2009 - Vol 30 
2. Bourgeois P. “Scintigraphic Investigations of the Lymphatic System: The influence of Injected Volume and Quantitaty of Labeled Colloidal Tracer” - J.Nucl Med 2007; 48:693-695
3.F.Boccardo, C.Campisi e coll. ”Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer “- Lymphology Vol.42,No1 - 2009.
4. Cestari M. “Lymphedema post-mastectomy: Primary prevention - European Journal of Lymphology - vol.20.No.55.2008
3. European Consensus “Rehabilitation after breast cancer treatment” - The European  Journal of Lymphology - Vol.19.No 55. 2008
5.Vaughan Keeley “The use of lymphoscintigraphy in the management of chronic oedema” - Journal of Lymphoedema, 2006, Vol.1.No1