Lymphoedema

Are Investigations Necessary ?

Usually Clinical history and examinations is enough

diagnosis of lymphoedema
In typical, mild swellings with no complications,
No Need for investigations

In atypical & Multifactorial Swelling

Help to confirm
Inform management
Provide prognostic information

Routine Tests
Full blood count
Blood Sugar level
Urea and electrolytes
Creatinine
Liver, thyroid function tests
Chest x-ray
Urine dipstick (chyluria)
Blood smear (microfilaria)

Direct Lymphangiography
In this technique,the lymphatics of the lower limb are

delineated with radio opaque dye and there is

subsequent radiographic visualization of the vessels
and nodes .
Surgically the lymphatic trunk of the dorsum of the
foot is exposed and iodized oil contrast medium
(neohydriol ultra fluid lipiodol) is injected directly in
to the trunk.
For lower limb approximately 6 ml of solution is
injected over a period of 1 hour

Direct Lymphangiography
Complications
Surgical exposure

Damage to the lymphatic endothelium by oil

Pulmonary oil embolism
Wound infection
Respiratory distress

Used in Few Cases

Preoperative MegaLymphatics considered for
bypass or fistula ligation

Lymphangiographic patterns of primary lymphedema

Patient with
congenital
lymphoedema of
the right leg. The
lymphangiogram
shows lymphatic
hypoplasia on
right side.

Lymphoedema of left leg

lymphangiographic
image depicts rarefaction
(reduced lymphnodes in
the left groin.)
normal lymphatic
drainage pattern right leg
decreased lymphatics
only one ectactic lymph
vessel
physiological venous
enhancement

Indirect Lymphangiography
Indirect lymphangiography involves the intradermal

injection of water-soluble, non-ionic contrast into a

web space, from where it is taken up by lymphatics
and then followed radiographically,
Iotrolan or Iotasol is infused by a motor pump into the
skin; 2-3ml injected intradermally, Dermal and
subcutaneous collecting lymphatics can be visualized
In the presence of incompetent valves and dermal
backflow,(proximal obliteration) lymphatic capillaries
can be seen
It shows distal lymphatics but not normally proximal
lymphatics and nodes

Contrast material
injected into a
web space

Subcutaneous lymphatics

Isotope lymphoscintigraphy
It has replaced lymphangiography and is the Gold

Standard Now.
Radioactive technetium-labelled protein or colloid
particles are injected into an interdigital web space
between 2nd and 3rd toes or fingers. limb is exercised
periodically and images are taken using a gamma
camera.
provides insight into lymph flow dynamics.
helps evaluate lymphatic truncal anatomy and
radiotracer transport.
The procedure can easily be repeated, and does not
adversely affect the lymphatic vascular endothelium.

Isotope lymphoscintigraphy
Clearance time is calculated from the regions of

lymphatics, over the nodes & it gives us the

quantitative analysis of lymphatic system
Peripheral lymphatics is grossly impaired in

lymphedema, with hypoplastic distal lymph vessels

This gives a characteristic picture at the injection site
and virtually no clearance of the tracer

39-year-old woman with right

leg lymphedema

Congenital lymphedema of
the left arm in a 3-year-old girl

CT scan
(CT) slice through the midcalf has been proposed as a

useful diagnostic test for

lymphoedema (coarse, non-enhancing, reticular
honeycomb pattern in an enlarged subcutaneous
compartment),
Venous oedema (increased volume of the muscular
compartment) and
lipoedema (increased subcutaneous fat).
CT can also be used to exclude pelvic or abdominal
mass lesions.

Primary lymphedema of the left

leg in a 42-year-old woman

MRI
Magnetic resonance Imaging
Clear Images of lymphatic Channels and lymph nodes
Useful in assessment of patients with lymphatic

hyperplasia
Distinguish between Venous and lymphatic causes of a
swollen limb.
shows tumours causing obstructions

Transaxial MRI:Chylous
reflux syndrome in a 12year-old boy.
prominent perirectal
lymphatic vessels

pubic skin with

superficial
lymphangiectasia

Ultrasound
Ultrasound can provide useful information about

venous function, including DVT and venous

abnormalities

Pathological Examination
Where Malignancy is suspected
Lymph node biopsy obtained by fine-needle

aspiration, needle core biopsy or surgical excision.

Skin Biopsy where lymphangiosarcoma is suspected

Lymph node enlargement

Blood: blood examination is essential for leucocytosis (acute

lymphadenitis),TB,lymphatic leukemia,raised ESR in

lymphosarcoma.
Aspiration: of cold abcess:acid fast bacilli or lymphogranuloma
inguinale:0.1 ml of diluted pus when injected intradermally a
reddish papule appear within 48 hrs. FREIs intradermal test.
Mantoux test for tuberculosis
Gordons biological test:hodgkins
Biopsy
Radiological :To look for enlargement of LN
Laprotomy:Hodgkins,to know the clinical staging of the disease.
It involves a wedge biopsy of liver, aortic,mesentric iliac LN
biopsy ;chip biopsy of iliac bone & splenectomy.

Hodgkins disease
Special investigations
1)Blood picture of normochromic normocytic anemia

is quiet evident and about 1/3 of cases show

leucocytosis due to increased neutrophil and
eosinophil count.
2)lymphangiography.
3)CT scan to detect involvement of retroperitoneal
and mediastinal lymph nodes.
4)Chest X ray shows mediastinal L.N enlargement.
5)Bone scan to determine bone involvement.
6)Liver and spleen scan to indicate its involvement.
7)L.N scanning with gallium 67 to detect its
involvement.

Burkitts lymphoma
Biopsy LN reveals a
typical starry sky
appreance of
primitive lymphoid
cells with large clear
histiocytes
Burkitt cell --containing
intracytoplasmic lipid
droplets

Stars

Syphilitic lymphadenitis
W.R and Khan testusually positive
Treponema pallidum may be demonstrated in

specimens obtained from genital and mucocutaneous

lesion in dark ground illumination microscopy.

Specific tests: treponemal antigen test

Treponemal haemagglutination assay
Treponema pallidum immobilization test.

Filarial lymphadenitis
Lymphangiogram for lymphangiectasis

Blood pictureeosinophilia,microfilaria

demonstrated in blood drawn at night

Biopsy L.N reveal adult filaria

Lymphangiogram
demonstrating lymphatic
reflux from dilated paraaortic vessels into the left
kidney in a patient with

filariasis who
presented with chyluria.