Ann Rehabil Med.  2015 Dec;39(6):931-940. 10.5535/arm.2015.39.6.931.

Validity of Quantitative Lymphoscintigraphy as a Lymphedema Assessment Tool for Patients With Breast Cancer

• Yoo JN
• Cheong YS
• Min YS
• Lee SW
• Park HY
• Jung TD

• KMID: 2165619
• DOI: http://doi.org/10.5535/arm.2015.39.6.931

Abstract

OBJECTIVE
To evaluate the validity of quantitative lymphoscintigraphy as a useful lymphedema assessment tool for patients with breast cancer surgery including axillary lymph node dissection (ALND).
METHODS
We recruited 72 patients with lymphedema after breast cancer surgery that included ALND. Circumferences in their upper limbs were measured in five areas: 15 cm proximal to the lateral epicondyle (LE), the elbow, 10 cm distal to the LE, the wrist, and the metacarpophalangeal joint. Then, maximal circumference difference (MCD) was calculated by subtracting the unaffected side from the affected side. Quantitative asymmetry indices (QAI) were defined as the radiopharmaceutical uptake ratios of the affected side to the unaffected side. Patients were divided into 3 groups by qualitative lymphoscintigraphic patterns: normal, decreased function, and obstruction.
RESULTS
The MCD was highest in the qualitative obstruction (2.76+/-2.48) pattern with significant differences from the normal (0.69+/-0.78) and decreased function (1.65+/-1.17) patterns. The QAIs of the axillary LNs showed significant differences among the normal (0.82+/-0.29), decreased function (0.42+/-0.41), and obstruction (0.18+/-0.16) patterns. As the QAI of the axillary LN increased, the MCD decreased. The QAIs of the upper limbs were significantly higher in the obstruction (3.12+/-3.07) pattern compared with the normal (1.15+/-0.10) and decreased function (0.79+/-0.30) patterns.
CONCLUSION
Quantitative lymphoscintigraphic analysis is well correlated with both commonly used qualitative lymphoscintigraphic analysis and circumference differences in the upper limbs of patients with breast cancer surgery with ALND. Quantitative lymphoscintigraphy may be a good alternative assessment tool for diagnosing lymphedema after breast cancer surgery with ALND.

Keyword

Breast cancer; Lymph node dissection; Upper extremity; Lymphedema; Lymphoscintigraphy

MeSH Terms

Breast Neoplasms*
Breast*
Elbow
Humans
Lymph Node Excision
Lymphedema*
Lymphoscintigraphy*
Metacarpophalangeal Joint
Upper Extremity
Wrist

Figure

• 

  Fig. 1 Typical images of quantitative lymphoscintigraphic analysis of the upper limb of a patient with breast cancer surgery including axillary lymph node (LN) dissection. The axillary LN and symptomatic upper limb area were analyzed quantitatively on both the affected (arrow) and unaffected sides. (A) The normal pattern showed symmetric uptake of 99mTc phytate at the axillary LN and upper limb, (B) the decreased function pattern showed decreased uptake at both the axillary LN and upper limb (arrowhead), and (C) the obstruction pattern showed little uptake at the axillary LN and highly increased uptake in the upper limb (arrowhead).

• 

  Fig. 2 Typical images of qualitative lymphoscintigraphic patterns of the upper limb of a patient with breast cancer surgery including axillary lymph node (LN) dissection. (A) The normal pattern showed symmetric visualization of the lymphatics in the limb area, (B) the decreased function pattern showed decreased visualization of lymphatics (arrowhead), and (C) the obstruction pattern showed abnormal dermal backflow (arrow) and visualization of the collateral LN (arrowhead).

• 

  Fig. 3 Sites for measuring a patient's upper limb circumference. The five points are marked: (A) 15 cm proximal to the lateral epicondyle of humerus, (B) the elbow, specifically, the mid-point between the medial and lateral epicondyle, (C) 10 cm distal to the lateral epicondyle, (D) the wrist, specifically, the mid-point of the wrist crease, and (E) the metacarpophalangeal (MCP) joint.

• 

  Fig. 4 Correlations among the quantitative asymmetry index (QAI) and qualitative lymphoscintigraphic patterns (A, B) and maximal circumference difference (MCD) (C). (A) Asymmetry index at the axillary lymph node (LN) showed significant differences among the three qualitative patterns, (B) QAIs at the upper limb areas in the obstruction pattern were significantly higher than those in the other patterns, and (C) the MCDs between the upper limbs in the obstruction pattern were significantly different from the other patterns (*p<0.05).

• 

  Fig. 5 Correlation between quantitative asymmetry index (QAI) and maximal circumference difference (MCD) between the upper limbs. (A) Higher QAIs axillary lymph nodes showed significant inverse correlations with the MCDs between the upper limbs and (B) higher QAIs in the upper limbs were significantly correlated with the MCDs between the upper limbs (*p<0.05, **p<0.01).

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