Lymphedema is always initially treated by combined decongestive physiotherapy (CDP). Those cases, refractory to CDP, may be managed by surgical therapy. One of the most used microsurgical procedures is represented by the technique of lymphatic‐venous anastomosis (LVA). But very few papers report long term results of LVA. The aim of this study is to assess the long‐term patency of multiple lymphatic‐venous anastomosis (MLVA) for the treatment of secondary lymphedemas.

Sarcoidosis is a granulomatous disease of unknown etiology. At present the best diagnostic imaging procedure to assess stage and activity of sarcoidosis is controversial. We report the case of a 50-year-old male admitted with a history of dyspnea and fatigue with past medical history negative for smoking, occupational and environmental risk factors. Physical examination, routine blood tests, and pulmonary function tests were normal except for hypercalciuria. A chest radiograph showed bilateral hilar lymphadenopathy. Single photon emission computed tomography and/or computed tomography (SPECT and/or CT) In-111 Octreotide (Octreoscan) scintigraphy confirmed morphologic involvement of bilateral hilar lymph nodes and a mediastinoscopy biopsy specimen provided diagnosis of pulmonary sarcoidosis (stage 0). This clinical case shows the effectiveness of In-111 Octreotide SPECT and/or CT in the early diagnosis of pulmonary sarcoidosis.

Authors report their pluridecennial activity (from 1973 up to today) of research, clinical experience and development of lymphatic surgery in Genoa-Italy, in close collaboration with the worldwide centers of the International Society of Lymphology. Five thousand forty-six cases of patients affected by upper and/or lower limbs, primary and secondary lymphedemas and elephantiasis, between 1973 and 2020 underwent lymphatic microsurgery; and between 2012 and 2020. fibro-lipo-lymph-aspiration. according to lymph vessel sparing procedure (FLLA-LVSP), for latest stages of lymphedema elephantiasis, previously treated by lymphatic microsurgery with partial improvement of the disease. In addition, also morbid obesity related elephantiasis, lipolympheilema/elephantiasis, chylous-lymphatic dysplastic gravitational reflux with complex related syndromes, were treated by tailored surgical procedures, properly combined with tailored medical and nutritional regimens. All patients were followed-up fora minimum of 5 years to over 20 years. Over 96% of patients with earlier stages of disease (initial lymphedema: stage IB and increasing lymphedema: stage IIA) progressively stopped using conservative therapies; and over 80% of patients with later stages (column shaped limb fibrolymphedema: stage IIB, properly called elephantiasis: stage IIIA, and extreme elephantiasis: stage IIIB), significantly decreased the frequency of physical therapies and discontinued compressive garments or stockings. Dennato-lymphangio-adenitis attacks considerably reduced by over 95%. Staging-guided treatment of peripheral lymphedema, according to authors' Genoa protocol, carries out not only the best long-lasting treatment, but also the contextual target of primary (to avoid lymphatic injuries), secondary (early-stage treatment), and tertiary (late-stage treatment) prevention in the potential worsening of the disease.

The Author ’s vast surgical experience in the treatment of primary and secondary peripheral lymphedema is reported. The objective is to describe the techniques and the long-lasting clinical outcomes based on more than 45 years research and clinical applications, with particular reference to staging-guided derivative and reconstructive lymphatic microsurgery at a single site, and to complementary, sequential, minimally invasive procedures of selective liposuction. 5.046 cases of patients (demographic characteristics are at length described) affected by upper and/or lower limb lymphedema, between 1973 and 2020, underwent lymphatic microsurgery and, between 2012 and 2020, Fibro-Lipo-Lymph-Aspiration according to Lymph Vessel Sparing Procedure (FLLA-LVSP), for latest stages of Lymphedema previously treated by Lymphatic Microsurgery with partial improvement of the disease. Derivative Multiple Lymphatic-Venous Anastomoses (MLVA) or, in selected cases of Phlebolymphedema absolutely contraindicating derivative procedures, lymphatic pathway reconstruction, using interpositioned vein grafted shunts (Multiple-Lymphatic-Venous-Lymphatic Anastomose - MLVLA), above all at lower limbs, were performed at a single site, either the brachial-axillary or inguinal-crural region.

Malignant melanoma is the most aggressive and lethal skin cancer. It can metastasize in the locoregional nodes or in distant lymph node districts following sometimes unpredictable paths. Nuclear medicine plays a key role in mapping sentinel lymph nodes and staging metastatic disease. It also provides an important contribution to the management of therapy by monitoring the response to treatment allowing a simultaneous evaluation of the metabolic and anatomical characteristics of the primary tumor and its potential local, regional and distance extension, especially in patients with high-risk disease. A variety of techniques are used including radioguided surgery and new hybrid imaging tools, such as positron emission tomography (PET/CT) with fluorine-18-fluorodeoxyglucose (18F-FDG). In this chapter, we review the clinical contribution of current nuclear medicine technologies to the management of malignant melanoma.

La linfogammagrafía representa el patrón para el diagnóstico del linfedema, pero una limitación importante es la falta de estandarización de los procedimientos. El objetivo de este panel de expertos italiano es proporcionar un estándar de procedimiento para la linfogammagrafía en la evaluación de los trastornos del sistema linfático. Se deben evitar los geles anestésicos tópicos que contengan lidocaína. Los pacientes deben retirar los apósitos compresivos. La actividad total recomendada para la administración de 99mTc-nanocoloides en adultos es de 74MBq, o 37MBq por miembro y por compartimento investigado, en alícuotas simples o múltiples. Se deben realizar 2-3 inyecciones subcutáneas (II-III±I espacio interdigital de cada mano/pie), evitando la inyección intravascular. El sistema linfático profundo de los miembros inferiores debe evaluarse en presencia de reflujo dérmico o estasis linfática (1-2 administraciones subfasciales en la región retromaleolar o plantar). Las imágenes planares deben ser tomadas desde el sitio de la inyección hasta el hígado, con adquisiciones estáticas de cuerpo entero o en serie de 20’ y 90’ después de la administración subcutánea. Se obtiene información adicional sobre las vías linfáticas después de un protocolo de ejercicio rápido y/o prolongado. Se recomienda SPECT/TC para estudiar los territorios torácicos, abdominales y pélvicos. Cuando sea necesario, el sistema linfático profundo de los miembros inferiores debe ser evaluado con adquisición estática a 90’ después de la administración subfascial. El informe debe describir el procedimiento de administración e imágenes, el protocolo de ejercicio, el análisis cualitativo y semicuantitativo (tasa de lavado, índice de transporte) y las posibles fuentes de error. Dado el papel esencial que desempeña la linfogammagrafía en el tratamiento clínico del linfedema primario y secundario, se debe hacer un esfuerzo para la estandarización de esta técnica a fin de proporcionar a los médicos una metodología técnica homogénea y fiable.

IntroductionLymphoscintigraphy is the gold standard for imaging in the diagnosis of peripheral lymphedema. However, there are no clear guidelines to standardize usage across centers, and as such, large variability exists. The aim of this perspectives paper is to draw upon the knowledge and extensive experience of lymphoscintigraphy here in Genoa, Italy, from our center of excellence in the assessment and treatment of lymphatic disorders for over 30years to provide general guidelines for nuclear medicine specialists.MethodThe authors describe the technical characteristics of lymphoscintigraphy in patients with limb swelling. Radioactive tracers, dosage, administration sites, and the rationale for a two-compartment protocol with the inclusion of subfascial lymphatic vessels are all given in detail.ResultsExamples of lymphoscintigraphic investigations with various subgroups of patients are discussed. The concept of a transport index (TI) for semi-quantitative analysis of normal/pathological lymphatic flow is introduced. Different concepts of injection techniques are outlined.DiscussionIt is past time that lymphoscintigraphy in the diagnosis of lymphatic disorders becomes standardized. This represents our first attempt to outline a clear protocol and delineate the relevant points for lymphoscintigraphy in this patient population.

Lymphoscintigraphy represents the "gold standard" for diagnosis of lymphederna, but an important limitation is the lack of procedural standardization. The aim of this Italian expert panel was to provide a procedural standard for lymphoscintigraphy in the evaluation of lymphatic system disorders. Topic anaesthetic gels containing lidocaine should be avoided. Patients should remove compressive dressings. Total recommended activity for Tc-99m-nanocolloid administration in adults is 74 MBq, or 37 MBq per limb and per investigated compartment, in single or multiple aliquots. 2-3 subcutaneous injections should be performed (II-III +/- 1) interdigital space of each hand/foot), avoiding intravascular injection. Deep lymphatic system of lower limbs should be evaluated in presence of dermal back-flow or lymphatic stasis (1-2 subfascial administrations in retro-malleolar or plantar region). Planar images should be acquired from injection site to liver with whole-body or serial static acquisitions 20' and 90' after subcutaneous administration. Additional information on lymphatic pathways is obtained after a quick and/or prolonged exercise protocol. SPELT/CT is recommended to study the thoracic, abdominal and pelvic territories. When required, deep lymphatic system of lower limbs should be evaluated with static acquisition 90' after subfascial administration. The report should describe administration and imaging procedure, exercise protocol, qualitative and semi-quantitative analysis (wash-out rate, transport index), potential sources of error. Due to the essential role fulfilled by lymphoscintigraphy in clinical management of primary and secondary lymphedema, an effort for the standardization of this technique should be made to provide the clinicians with a homogeneous and reliable technical methodology. (C) 2019 Sociedad Espanola de Medicina Nuclear e Imagen Molecular. Published by Elsevier Espana, S.L.U. All rights reserved.

Purpose The current study aimed to determine the utility of including the study of deep subfascial lymphatic vessels in a 2-compartment lymphoscintigraphy for the diagnosis of lymphedema in patients with limb swelling. Lymphoscintigraphy is a valuable imaging tool for the timely diagnosis of peripheral lymphedema. However, there is a lack of standardization in its application, especially regarding which type of lymphatic vessels to examine (superficial, deep, or both). Methods Two hundred fifty-eight patients with lymphedema underwent segmental lymphoscintigraphy. The transport index (TI) was calculated to categorize the flow of the superficial and deep vessels as normal (<10) or pathological (≥10). The scores from 248 patients (48 unilateral arm, 86 unilateral leg, 114 bilateral leg) were tested with a 3-way analysis of variance to examine the relationship between affected limb, deep or superficial pathways, and primary or secondary lymphedema. The relationship between clinical presentation and TI was also investigated. Results In general, primary and secondary lymphedema patients had similar patterns of lymphoscintigraphic lymphatic abnormalities. Patients with unilateral clinical presentation can have bilateral TI abnormalities. The vast majority of patients (88%–98%) had either the deep subfascial vessels alone, or both the superficial and deep vessels, with a pathological TI. Conclusions A 2-compartment lymphoscintigraphy is able to accurately detect lymphatic flow abnormalities in patients with limb swelling. Given that the vast majority of patients had deep lymphatic vessels abnormalities, inclusion of these vessels in the lymphoscintigraphic diagnostic protocol is recommended.

Background A side-effect of axillary lymph node excision and radiotherapy for breast cancer is arm lymphedema in about 25% patients (ranging from 13 to 52%). Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% patients (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why Axillary Reverse Mapping method (ARM) was developed aiming at identifying and preserve lymphatics draining the arm. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Based on long term experience in lymphatic-venous anastomoses (LVA) for lymphedema treatment, Authors conceived and carried out preventive LVA during nodal dissection (Lymphatic Microsurgical Preventing Healing Approach - LY.M.P.H.A. technique). Methods 78 patients underwent axillary nodal dissection for breast cancer treatment and in 74 of them LY.M.P.H.A. procedure was performed. Indications to LY.M.P.H.A. technique were based on clinical and lymphoscintigraphic parameters. All blue nodes were resected and 2 to 4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatics were introduced inside the vein cut-end by a U-shaped stitch. Volumetry was performed preoperatively in all patients and after 1, 6, 12 months and once a year. Lymphoscintigraphy was performed in 45 patients preoperatively and in 30 also postoperatively after at least over 1 year. Results Seventy-one patients had no sign of lymphedema. In 3 patients, lymphedema occurred after 8-12 months postoperatively. The incidence of secondary arm lymphedema after LY.M.P.H.A. technique was therefore 4.05%. ConclusionLVA proved not only to prevent lymphedema but also to reduce early lymphatic complications (i.e. lymphorrhea, lymphocele). LY.M.P.H.A. technique is also useful in patients with melanoma of the trunk and vulvar cancer, in whom it is possible to perform preventive LVA simultaneously with inguinal lymphadenectomy. Lymphedema is a consequence of cancer treatment. The use of the blue dye and of LVA helps to solve the problem of preventing secondary arm and leg lymphedema. LY.M.P.H.A. represents a rational approach to the prevention of lymphedema following axillary and groin surgery in the therapy of breast cancer, melanoma, vulvar cancer and other tumors.

Lymphatic complications following great and small saphenous vein surgery show a varying and non-negligible incidence in the literature. We undertook this study to investigate a new protocol to reduce lymphatic injuries in patients undergoing venous surgery. Eighty-six patients with lower limb venous insufficiency and varices were treated. Lymphoscintigraphy was performed preoperatively in 65 of them and postoperatively in 19. Blue dye was used in all patients and blue lymph nodes and lymphatics were identified intra-operatively and preserved or used to perform multiple lymphatic-venous anastomoses (MLVA). Patients were followed up fora period varying from 3 months to 6 years. Sixty-six patients were treated by greater saphenectomy and varicectomy, 12 patients had crossectomy and varicectomy, 4 patients underwent greater saphenectomy and varicectomy associated with MLVA, and 4 patients were treated by small saphenous vein stripping and varicectomy. No lymphatic complications occurred in any of the patients. A decrease of over 75% of excess volume was observed in 4 patients treated by MLVA. Lymphoscintigraphy showed normalization in the Transport Index in 4 patients treated with MLVA. Our results demonstrate that accurate diagnostic investigation and proper surgical technique is of paramount importance in the effort to avoid lymphatic complications during venous surgery.

Rationale: Hyperthermic isolated lung Perfusion (ILuP) is used to deliver high-dose chemotherapy to pulmonary metastases while sparing systemic toxicity. Accurate leakage monitoring is however necessary. This study aimed to verify the accuracy of radionuclide leakage monitoring in patients undergoing ILuP, by comparing this method with serial blood sampling.Methods: A total of 15 consecutive ILuP procedures were performed on eleven patients affected by lung metastases from soft tissue sarcoma. After establishing isolated perfusion, erythrocytes of systemic blood (SB) were labelled with 0.2 MBq/kg of Tc-99m. The baseline SB counting rate (CR) was assessed using a -probe. Subsequently, erythrocytes of the circuit blood (CB) were labelled with 2 Mbq/kg of Tc-99m. Radioactivity leakage factor (RLF) was continuously measured using a formula, accounting for CR, systemic/circuit activity ratio and total/systemic volume ratio. The TNF- concentration in SB and CB was measured by enzymelinked immunosorbent assay (ELISA) throughout the procedure.Results: RLF averaged 2.31.5%, while the systemic/circuit TNF- ratio was 0.05 +/- 0.12%. These two indices were strictly correlated in all of the procedures (average Rvalue 0.88 +/- 0.07). RLF exceeded 5% during three of 15 procedures, prompting the application of compensatory manoeuvres. ELISA confirmed a marked increase in systemic TNF- levels in these patients (2.6 +/- 3.5ng/ml). Conversely, patients whose RLF did not exceed the 5% threshold presented a mean TNF- of 0.02 +/- 0.005ng/ml (p<0.01).Conclusions: In patients submitted to ILuP, RLF monitoring is feasible and accurate. Moreover, it grants immediate results, permitting for the adoption of corrective manoeuvres for leakage, thus minimising toxicity.

LYMPHA proved to be an effective preventive procedure that contributes in giving our oncological patients a good quality of life. In this presentation, the author will report indications, technical aspects and benefits of LYMPHA technique.

Inguinofemoral lymphadenectomy carries a high risk of lower limb lymphedema. This report describes the feasibility of performing multiple lymphatic-venous anastomoses (MLVA) after inguinofemoral lymph node completion (LYMPHA technique) and the possible benefit of LYMPHA for preventing lymphedema.