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© Schattauer 2014 Nuklearmedizin 5/2014
190Original article
Keywords
Lymphoscintigraphy, MR-lymphangiography,
magnet resonance imaging, lymphoedema,
lymphatic disorders
Summary
Purpose: To compare the diagnostic accuracy
of magnetic resonance imaging (MR-lym-
phangiography) and lymphoscintigraphy for
assessment of focal lesions of the peripheral
lymphatic system. Patients with focal lym-
phatic transport disorders might benefit from
surgi-cal interventions. Patients, methods: We
examined by lymphoscintigraphy and MR-
lymphangiography a total of 85 lower limbs
in 46 consecutive patients (33 women; mean
age 41 years; range 9-79 years) presenting
with uni- or bilateral lymphedema. MR-lym-
phangiographies were obtained at isotropic
sub-millimeter resolution with a 3.0 Tesla
magnet after injection of gadolinium
contrast medium. MR-lymphangiography
was reviewed by radiologists, whereas lymp-
hoscintigraphy was reviewed by nuclear
medicine physicians. The images were exam-
ined for localization and distribution of any
focal lesions of the lymphatic vessel system.
Diagnostic accuracy of the MR-approach was
calculated relative to the lymphoscintigraphy
gold standard. Results: There was substantial
correlation of results by the two modalities (
κ
= 0.62). MR-lymphangiography had sensitivity
of 68%, specificity of 91%, positive predictive
value of 82%, and negative predictive value of
83%. Conclusions: Imaging findings of both
lymphoscintigraphy and MR-lymph -
angiography showed good diagnostic accu-
racy. MR-lymphangiography proved more in-
formation about anatomic location of focal
lesions of the lymphatic vessels, but use of
MR-lymphangiography is currently con-
strained due to the requirement for off-label
subcutaneous injection of gadolinium che-
lates. Consequently, and due to its superior
sensitivity lymphoscintigraphy remains the
most common imaging method to assess func-
tional lymphatic disorders of the lower limb.
Schlüsselwörter
Lymphszintigraphie, MR-Lymphangiographie,
Kernspintomographie, Lymphödem, Lymph-
transportstörung
Zusammenfassung
Ziel war es die diagnostische Genauigkeit der
Kernspintomographie (MR-Lymphangiogra-
phie) und Lymphszintigraphie zur Einschät-
zung fokaler Läsionen des peripheren Lymph-
systems zu vergleichen. Patienten mit foka-
len lymphatischen Transportstörungen kön-
nen von chirurgischen Interventionen profi-
tieren. Patienten, Methoden: Wir untersuch-
ten insgesamt 85 untere Extremitäten bei 46
konsekutiven Patienten (33 Frauen, Durch-
schnittsalter 41 Jahre, Range 9–79 Jahre) mit
uni- oder bilateralem Lymphödem mittels
Lymphszintigraphie und MR-Lymphangiogra-
phie. Die MR-Lymphangiographien wurden
mittels isotroper Submillimeter-Auflösung an
einem 3,0-Tesla-Magneten nach Applikation
von Gadolinium-Kontrastmittel durchgeführt.
Die MR-Lymphangiographien wurde von Ra-
diologen beurteilt, die Lymphszintigraphien
von Nuklearmedizinern. Die Aufnahmen wur-
den nach Lokalisation und Verteilung um-
schriebener Läsionen des Lymphgefäßsys-
tems beurteilt. Die Genauigkeit der MR-Un-
tersuchung wurde dabei relativ zur Lymph-
szintigraphie als Goldstandard berechnet. Er-
gebnisse: Es bestand eine gute Korrelation
der Ergebnisse beider Modalitäten (
κ
= 0,62).
Die MR-Lymphangiographie zeigte eine Sen-
sitivität von 68%, eine Spezifität von 91%,
einen positiven Vorhersagewert von 82%
und einen negativen Vorhersagewert von
83%. Schlussfolgerungen: Die Ergebnisse
beider Methoden, Lymphszintigraphie und
MR-Lymphangiographie, zeigten eine gute
diagnostische Genauigkeit. Die MR-Lymph -
Correspondence to:
Mayo Weiss MD
Department of Nuclear Medicine, Ludwig-Maximilians-
University of Munich, Marchioninistr.15
81377 Muenchen, Germany
Tel. +49/(0)89/70 95 76 38
E-mail: mayo.weiss@med.uni-muenchen.de
Kernspintomographie versus Lymphszintigraphie
zur Beurteilung fokaler Lymphtransportstörungen
der unteren Extremitäten
Erste Erfahrungen
Nuklearmedizin 2014; 53: 190–196
http://dx.doi.org/10.3413/Nukmed-0649-14-03
received: March 12, 2014
accepted in revised form: June 13, 2014
epub ahead of print: July 7, 2014
Magnetic resonance imaging versus
lymphoscintigraphy for the assess-
ment of focal lymphatic transport
disorders of the lower limb
First experiences
M. Weiss1; C. Burgard2; R. Baumeister3; F. Strobl2; A. Rominger1; P. Bartenstein1;
J. Wallmichrath3; A. Frick3; M. Notohamiprodjo2
1Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Germany; 2Department of Clinical
Radiology , Ludwig-Maximilians-University of Munich, Germany; 3Department of Micro-, Hand- and Reconstructive
Surgery, Ludwig-Maximilians-University of Munich, Germany
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191 M. Weiss et al.: MRI versus lymphoscintigraphy
Introduction
Peripheral lymphoedema is caused by in-
sufficiency of lymph circulation, frequently
in the lymphatic system of the lower limbs.
The diagnosis is usually based on clinical
findings, but imaging studies permit objec-
tive confirmation of the extent of lym-
phatic dysfunction. In general, diagnostic
imaging of lymphatic function is obtained
directly by means of lymphoscintigraphy
or indocyanine green lymphography,
whereas secondary morphological dis-
orders such as fibrotic tissues are best de-
tected by computed tomography, and oede-
ma in fat tissue is detected by magnetic res-
onance imaging (MR-lymphangiography).
Beyond its efficacy in adipose tissue, MR-
lymphangiography has proven to be
beneficial in the assessment of primary or
secondary lymphoedema; it appears to
provide additional anatomic information
about the impaired lymphatic vessels, and
can depict lymphoceles and postoperative
lymphatic vessel leakage (8–10).
Lymphoscintigraphy performed with
subcutaneously injected 99mTc-labeled
nano colloids remains the primary imaging
modality for the diagnosis of peripheral
lymphoedema. Due to inherent limitations
of the spatial resolution of lymphoscinti-
graphy, the anatomical localization of dis-
eased lymphatic vessels can be unsatisfac-
tory (7, 16, 19). For examination of the pe-
ripheral lymphatic vessel system in cases of
primary or secondary lymphoedema, MR-
lymphangiography with extracellular Ga-
dolinium chelates shows considerable
promise (7–10, 12). The entire limb can be
examined by MR-lymphangiography with
high spatial and temporal resolution (10),
and without exposure of the patient to ion-
izing radiation. Furthermore, dynamic
MR-acquisitions can show the uptake rate
of the contrast agent into inguinal lymph
nodes (9). At field strengths of at least 3
Tesla, spatial resolution in the sub-milli-
meter range can be achieved, while retain-
ing tissue contrast, such that precise con-
figuration and distribution of lymph
vessels is readily identified (12).
Since gadolinium chelates are water sol-
uble, following subcutaneous injection they
reach the lymphatic vessels and also the ve-
nous vessels by simple diffusion through
the interstitial space. Consequently, there
arises the possibility of venous interference
in the identification of lymph vessels by
MR-lymphangiography (12). Here, the ap-
plication of scintigraphy with 99m
Tc-labeled
colloids confers an advantage due its spe-
cificity for the lymphatic vessel system (17).
Lymphoscintigraphy also reliably provides
information about lymph transport, fil-
tration, and reticuloendothelial function.
Therefore, scintigraphy and MR-based
methods both entail certain advantages
and disadvantages in the assessment of the
peripheral lymphatic vessel system.
With insufficiency of the peripheral
lymphatic system, the phenomenon of
“dermal backflow” can occur, resulting in
diffuse lymph transport by superficial lym-
phatic vessels. In this circumstance, focal
lymph leakage into the surrounding tissue
can occur; a focal insufficiency of the lym-
phatic collectors can exist despite intact
lymph drainage in distal vessels (15). Pa-
tients with focal lymphatic transport dis-
orders might benefit from microsurgical
interventions in cases of a lymphocele or
fistula.
To the best of our knowledge, the diag-
nostic values of lymphoscintigraphy and
MR-lymphangiography have not be com-
pared for detecting focal lymphatic leakage.
Therefore, we compared the diagnostic ac-
curacies of the two imaging modalities for
assessment of focal lesions of the peripheral
lymphatic system.
Patients, material, methods
This prospective study was approved by the
Institutional Review Board (IRB) of Lud-
wig-Maximilians-University Munich and
was conducted according to the principles
expressed in the Declaration of Helsinki.
All patients gave written, informed consent
to participate in the off-label MR study. A
total of 85 lower extremities in 46 consecu-
tive patients (33 women; mean age 41
years, range 9–79 years) were examined by
lymphoscintigraphy and MR-lymphangi-
ography. Diagnosis of lymphoedema had
first been established according to clinical
criteria of the International Society of
Lymphology classification of 2003 (5).
Exclusion criteria were typical contraindi-
cations to lymphoscintigraphy, such as
pregnancy and breastfeeding, and con-
traindications for MR-imaging such as
claustrophobia and incompatible metallic
devices, or factors related to contrast media
application, such as allergy, or renal insuffi-
ciency as defined by glomerular filtration
rate <30 ml/min. The scintigraphic and
MR-imaging tests were performed in all
patients following removal of any com-
pressive bandages.
MR imaging
All MR examinations were performed with
a 3.0 Tesla magnet (Magnetom Verio;
Siemens Healthcare Sector Erlangen, Ger-
many). For signal reception, we used a
12-element body coil for the pelvis and
36-element coil for the lower limb, also
from Siemens. Before injection of the
contrast medium, a rapid T2-weighted ac-
quisition with relaxation enhancement
(RARE) for fluid detection was obtained in
the coronal orientation of the lower limb
for the assessment of subcutaneous lymph -
oedema. MR-lymphangiography was per-
formed with a coronal T1-weighted
3D-gradient-echo sequence with spectral
fat saturation. Sequence parameters were
as follows: 4.13/1.47; flip angle, 25°;
number of sections, 176; number of signals
acquired, three; section thickness, 0.8 mm;
intersection gap, 0.16 mm; bandwidth, 340
Hz/pixel; field of view, 380 mm; matrix,
448 × 448; in-plane resolution, 0.8 × 0.8
mm2; and acquisition time, 149 seconds.
angiographie zeigte mehr Information über
die anatomische Lokalisation der umschrie-
benen Läsionen des Lymphgefäßsystems,
wobei der Einsatz der MR-Lymphangio -
graphie aufgrund der fehlenden Zulassung
für die subkutane Applikation des Gadolini-
um-Kontrastmittels eingeschränkt ist. Kon-
sequenterweise und aufgrund ihrer höheren
Sensitivität bleibt die Lymphszintigraphie
die bevorzugte Methode zur Untersuchung
funktioneller Lymphtransportstörungen der
unteren Extremitäten.
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192M. Weiss et al.: MRI versus lymphoscintigraphy
1 ml portions of a mixture consisting of
gadopentetate dimeglumine (Magnevist
Bayer Schering, Leverkusen, Germany)
along with mepivacaine (Scandicain, As-
traZeneca, London, England) for local an-
aesthesia were injected intracutaneously in
the first three interdigital spaces of the
forefoot of the affected limb using
24-gauge-needles. Upon injection, the in-
terdigital spaces were massaged for about
two minutes and MR-lymphangiography
was started immediately thereafter. Four
anatomical levels (feet, shank, thigh, and
pelvis) were examined consecutively in an
examination lasting 10 minutes, which was
repeated a further two times for a total of
40 minutes.
Lymphoscintigraphy
Technetium-99m-labelled human serum
albumin (Nanocoll; GE Healthcare, Mu-
nich, Germany) was administered at a dose
of 100.3 MBq in the mean (median 109;
range 39–145 MBq) in a volume of 0.3 ml
(1); mean left and right leg doses were
nearly identical. The radiopharmaceutical
was administered by injection with a
27-Gauge-needle into the subcutaneous
tissue of the first interdigital space of the
foot, strictly avoiding intravascular appli-
cation. Because lymphatic flow in lower
limbs at rest is low, patients were asked to
stimulate lymphatic drainage by walking
for ten minutes after radiopharmaceutical
injection. Beginning at 10 minutes after in-
jection, sequential images of the affected
Fig. 2 Woman (age: 57 years) with lymphoedema of the lower right leg; discrepancy in interpretation
of lymphatic lesion:
A) In lymphoscintigraphy the lesion was evaluated as being diffuse in (black arrow) and the inguinal
lymph nodes are depicted.
B) In MR-lymphangiography (white arrow) the identical lesion was assessed with a Likert score of D.
Fig. 1 Woman (age: 52 years) with focal
“dermal backflow” at the lower right leg due to
lymphatic leakage from a coexistent crural ulcer
A) In lymphoscintigraphy the lymphatic lesion is
properly detected (black arrow).
B, C) In MR-lymphangiography imaging is equally
well (white arrow). The MR method provides
additional information by depiction of afferent
lymph vessels and 3D-reconstruction in which
focal “dermal backflow” is readily discerned (C,
white arrow), as well as revealing a small lympho-
cele (B, full arrow).
D) The patient’s situs in which the extent of focal
“dermal backflow” is marked by patent blue dye
(full white arrow) which is also transported in
lymph. The area of backflow correlates with the
results from lymphoscintigraphy and MR- lymph -
angiography.
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193 M. Weiss et al.: MRI versus lymphoscintigraphy
limb were acquired using a gamma camera
with a low-energy-high-resolution colli-
mator (e.cam; Siemens Healthcare Sector,
Erlangen, Germany). The image matrices
measured (256 x 1024), and were acquired
at a scanning speed of 5 cm/min, extending
from feet to liver. The acquisition was re-
peated at intervals of about 60 minutes,
and ended either when inguinal lymph
nodes were detected, or by default at five
hours after tracer administration.
Image and statistical analysis
The MR-lymphangiography data were ana-
lyzed by experienced radiologists, and
lymphoscintigraphy results were analyzed
by experienced nuclear medicine phys-
icians. The readers knew it was lymphatic
disease but were blinded to the findings
and diagnosis based on the other modality.
The presence or absence of focal lesions of
the lymphatic system, such as lymphoceles
or focal “dermal backflow”, not caused by
the tracer applications, was recorded for
each examined limb, and a five-point
Likert scale was used to assess the exten-
sion of the lesions:
A = circumscribed;
B = 25%,
C = 50%,
D = 75% of the thigh or the shank;
E = the entire thigh or shank.
Lymphoscintigraphy was chosen as the
standard of reference, as it is widely used
for decades for assessment of peripheral
lymphoedema. We calculated sensitivity
and specificity as well as positive and
negative predictive value for the presence
of focal lesions detected by MR-lymphangi-
ography and lymphoscintigraphy. The cal-
culation was based on the number of
lesions. Statistical analysis was performed
with Excel (Microsoft, Excel for Mac 2011,
Version 14.3.9). The overall correlation of
the two techniques was determined with
weighted-ê-coefficients (IBM, SPSS Stat-
istics, New York, NY).
Fig. 3 Woman (age: 30 years) with a distinct lymphoedema on both sides of the lower extremities:
An area of focal “dermal backflow” could be detected clearly in the right lower leg by both imaging
modalities (black and white arrows).
A) Lymphoscintigraphy (A) shows tracer uptake of popliteal and inguinal lymph nodes (not covered in
the 15 mm MR-maximum intensity projection).
B) In MR-lymphangiography, afferent lymph vessels could be visualized precisely.
C) 3D-reconstruction of the patient’s right lower leg with clear evidence of focal “dermal backflow”
(white arrows). On the left side, “dermal backflow” was also noted, but is excluded from the analysis as
it is directly originates from the site of injection.
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194M. Weiss et al.: MRI versus lymphoscintigraphy
Fig. 4 Woman (age 46 years) with lymphoedema of the lower left leg: revised depiction of lymphatic
vessels with MR-lymphangiography
A, B) Lymphoscintigraphy (A) and MR-lymphangiography (B) detect focal “dermal backflow” (black and
white arrows). The MR lymphangiographic image shows clearly the afferent lymph vessel. Lymphoscinti-
graphy (A) also depicts inguinal lymph nodes
C) In the 3D-reconstruction of the patient’s left lower leg (white arrows) it is also seen, whereas the
presence of this vessel can only be assumed in lymphoscintigraphy (A).
Results
A total of 83/85 lower extremities in 45/46
patients who underwent lymphoscinti-
graphy and MR-lymphangiography could
be analyzed. The MR-dataset of patient #27
(both lower extremities) had to be excluded
due to its unsatisfactory diagnostic image
quality because of deficient fat saturation.
This is a problem in MR-lymphoscinti-
graphy which occurs very rarely. We re-
ported or observed no negative side effects
or adverse reactions related to the injection
of the radiopharmaceutical for lympho -
scintigraphy or the contrast medium or
MR-lymphangiography. The Table presents
patient data, clinical information, as well as
the scintigraphic and MR-lymphangio-
graphic findings in detail (
▶
www.nuklear
medizin-online.de). We found that 27/45
patients presented with primary lymph -
oedema and 18/45 with secondary lymph -
oedema. There was a median time interval
of four days between performing lympho -
scintigraphy and MR-lymphangio graphy
(range, 0–118 days).
The overall correlation of results by the
two modalities was κ = 0.62. Lymphoscinti-
graphy detected a total of 59 focal accumu-
lations of the radiopharmaceutical. Of
these, 18 (31%) were interpreted as physio-
logical lymph nodes, and were therefore
excluded from the analysis. Pathological
focal lymphatic drainage pattern was de-
tected in 28/45 patients (41 lesions in 28/83
extremities) by lymphoscintigraphy and in
22/45 patients (34 lesions in 26/83 extrem-
ities) by MR-lymphangiography. Represen-
tative examples are depicted in the figures
1–5. Relative to the lymphoscintigraphy
standard, MR-lymphangiography had sen-
sitivity of 68%, specificity of 91%, a positive
predictive value of 82%, and a negative pre-
dictive value of 83%.
Discussion
Regarding depiction of the general pattern
of lymphatic drainage or lymphatic trans-
port delay, promising results have been re-
ported for MR-lymphangiography of the
lower limbs (13). In our study, we analyzed
the diagnostic accuracy of the MR method,
and calculated the correlation of results
with the two different imaging modalities
in patients presenting with focal lesions of
the lymphatic vessel system of lower ex-
tremities. To our knowledge, this is the lar-
gest study assessing diagnostic accuracy of
MR-lymphangiography relative to lympho -
scintigraphy, serving as the reference stan-
dard. In general, both imaging methods
readily depicted focal lymph vessel lesions
such as “dermal backflow” or lymphoceles
(
▶
Fig. 1), such that there was a good cor-
relation by method. 31% of the focal lesions
detected by lymphoscintigraphy were inter-
preted as physiological lymph nodes, and
were therefore excluded from the analysis,
although popliteal lymph nodes uptake
during lymphoscintigraphy for clinical
lymphoedema of the lower limb might in-
dicate lymph rerouting through the deep
lymph vessel system (6). The most com-
mon reason in cases of imperfect concord-
ance was the diversity of valid interpre-
tations. For example, in one case a lesion of
the lymphatic vessel system was assessed
with a score of D in MR-lymphangi-
ography, but was identified as a diffuse
lesion to lymphoscintigraphy (
▶
Fig. 2).
Such reasons may account for the some-
what lesser diagnostic accuracy of MR-
lymphangiography compared to lympho -
scintigraphy.
In planar lymphoscintigraphy, the in-
herent lack of detailed spatial and anatomi-
cal information can lead to misinterpre-
tation of focal tracer accumulation, such as
misattribution of uptake in the popliteal
lymph nodes (
▶
Fig. 3). In the case of MR-
lymphangiography, there can arise techni-
cal problems such as inhomogeneity of the
magnetic field, insufficient fat saturation
(as in one of our cases) or compression of
the examined tissue, any of which may
hamper the detection of focal extravasation
of the MR contrast agent. Theoretically, the
differing kinetics of the two tracer may also
lead to misinterpretation; whereas the
water-soluble gadolinium-based contrast
agent used in MR-lymphangiography is
transported from the intradermal injection
site into deep subcutaneous levels by super-
ficial lymphatic capillaries (13). However,
imperfect application of the contrast agent
imparts a certain risk of venous enhance-
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195 M. Weiss et al.: MRI versus lymphoscintigraphy
ment, which may interfere with diagnostics
(12). However, this potential problem did
not arise in our patient group.
As noted, some studies have demon-
strated the potential of MR-lymphangi-
ography to detect focal lymphatic leakage
or “dermal backflow“ (
▶
Fig. 4). However,
these reports either lack the present direct
correlation of MR-lymphangiography ver-
sus lymphoscintigraphy, or included con-
siderably fewer patients than in the present
study. Based on other recent studies, MR-
lymphangiography emerges as an effective
diagnostic tool for the detection of lymph
node metastases in patients with different
types of cancer” (4, 7, 11). Despite these
properties, MR-lymphangiography yet to
become a routine diagnostic tool in the as-
sessment of peripheral lymphoedema in
part due to the inexperience among radiol-
ogy physicians in the performance and
evaluation of the method, and also the
requirement for off-label use of gadolin-
ium-chelates. Perivascular injection with
this kind of contrast agent has proven safe
in previous studies and in the present co-
hort, although rare cases of adverse side ef-
fects such as haemorrhage, oedema or
moderate necrosis have been reported (2,
3, 14).
In our hands, MR-lymphangiography
proved to have lower diagnostic accuracy
than did standard scintigraphy (
▶
Fig. 5).
Our results suggest that MR-lymphangi-
ography is best used as a complimentary
method to lymphoscintigraphy, delivering
additional anatomical information to the
more sensitive method. Nonetheless, we
note the outstanding depiction of lymph
vessels by MR-lymphangiography. This
made it possible to visualize in three di-
mensions “dermal backflow” in lymphatic
vessels. Furthermore, the high spatial resol-
ution and anatomical information pro-
vided by MR-lymphangiography is benefi-
cial for planning microsurgical therapies,
for example in aiding the identification of
afferent vessels in lymphoceles, or for locat-
ing donor lymph vessels intended for auto-
logous lymph vessel transplantations (8,
13).
Lymphoscintigraphy cannot provide
these special kinds of morphological infor-
mation. On the other hand, the use of la-
belled albumin in lymphoscintigraphy re-
liably provides information about lymph
transport, filtration, and reticuloendothe-
lial function, unperturbed by venous up-
take. The scintigraphy procedure is techni-
cally easy to perform, and only a single
subcutaneous injection per limb is
required, which causes minimal discom-
fort, and rarely any adverse effects for pa-
tients. A limitation of our study is that we
did not utilize the SPECT/CT-technique,
which would combine the superior func-
tional imaging capabilities of SPECT with
the anatomical overlay of CT. We expect
that hybrid imaging should have even
better diagnostic value than planar
lympho scintigraphy, and anticipate that
SPECT/CT will find use in assessing lym-
phatic function. This would present the
particular advantages of improved anat-
omic localization of lymphatic transport,
and tomographic separation of overlapping
sources, thus enabling differentiation of
tracer uptake in lymph nodes versus
lympho celes (18).
Conclusions
The results of our study show that MR-
lymphangiography serves to provide addi-
tional morphological information in the
assessment of peripheral lymphoedema, es-
pecially for patients with focal lymphatic
lesions such as “dermal backflow”. An im-
portant constraint of MR-lymphangi-
ography arises from the present require-
Fig. 5 Woman (age: 48 years) with bilateral lymphoedema
A) Lymphoscintigraphy shows clear enhancement (black arrow) and furthermore depicts additional
enhancement of inguinal lymph nodes.
B) MR-lymphangiography: depiction of an abnormal focal lymphatic lesion in the inner face of the right
thigh (white arrow). However, it does not depict any lesion of the lymph vessel system.
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196M. Weiss et al.: MRI versus lymphoscintigraphy
ment for off-label intracutaneous injection
of gadolinium chelates. As such, and due to
its superior sensitivity lymphoscintigraphy
remains the preferred diagnostic method
to assess functional lymphatic disorders of
the lower limb.
Acknowledgments
Critical reading and textual revisions of the
manuscript were provided by Inglewood
Biomedical Editing (www.inglewoodbio
medediting.com). All the authors have
made substantial contributions to the
study, and have approved the final manu-
script.
Conflict of interest
The authors declare that they have no con-
flict of interest.
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MR lymphangiography. J Vasc Interv Radiol 2006;
17: 1057–1062.
10. Lu Q, Bui D, Liu NF et al. Magnetic resonance
lymphography at 3T: a promising noninvasive ap-
proach to characterise inguinal lymphatic vessel
leakage. Eur J Vasc Endovasc Surg 2012; 43:
106–111.
11. Meijer HJ et al. Geographical distribution of
lymph node metastases on MR lymphography in
prostate cancer patients. Radiother Oncol 2013;
106: 59–63.
12. Notohamiprodjo M, Baumeister RG, Jakobs TF et
al. MR-lymphangiography at 3.0 T – a feasibility
study. Eur Radiol 2009; 19: 2771–2778.
13. Notohamiprodjo M, Weiss M, Baumeister RG et
al. MR lymphangiography at 3.0 T: correlation
with lymphoscintigraphy. Radiology 2012; 264:
78–87.
14. Runge VM, Dickey KM, Williams NM, Peng X.
Local tissue toxicity in response to extravascular
extravasation of magnetic resonance contrast
media. Invest Radiol 2002; 37: 393–398.
15. Strobl FF, Weiss M, Wallmichrath J et al. MR lym-
phangiography for assessment of focal dermal
backflow for presurgical work-up in patients with
peripheral lymphoedema. Handchir Mikrochir
Plast Chir 2012; 44: 329–333.
16. Weiss M, Baumeister RG, Hahn K. Dynamic
lymph flow imaging in patients with oedema of
the lower limb for evaluation of the functional out-
come after autologous lymph vessel transplan-
tation: an 8-year follow-up study. Eur J Nucl Med
Mol Imaging. 2003;30:202–206.
17. Weiss M, Gildehaus FJ, Brinkbäumer K et al.
Lymph kinetics with technetium-99m labeled
radiopharmaceuticals – Animal studies. Nuklear-
medizin 2005; 44: 156–165.
18. Weiss M, Landrock S, Wallmichrath J et al. The
clinical yield of SPECT/CT for the assessment of
lymphatic transport disorders. First experiences.
Nuklearmedizin 2013; 52: 235–243.
19. Weissleder H, Weissleder R. Lymphedema: evalu-
ation of qualitative and quantitative lymphoscinti-
graphy in 238 patients. Radiology 1988; 167:
729–735.
For personal or educational use only. No other uses without permission. All rights reserved.
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M. Weiss et al.: MRI versus lymphoscintigraphy
pa-
tient
1
2
3
4
5
6
7
8
9
10
* day of performance of scintigraphic tests in relation to MR-lymphangiography
sex
female
female
female
female
female
male
female
female
female
female
age
(years)
61
25
49
28
58
50
23
47
25
39
clinical information
swelling suspicious for secondary
lymphoedema following ovariectomy
primary lymphoedema, lymph vessel
trans plantation
swelling suspicious for primary
lymphoedema
swelling suspicious for primar y
lymphoedema
uterus exstirpation, secondary
lymphoedema
soft tissue tumour, postoperatively
secondary lymphoedema
swelling suspicious for primary
lymphoedema
primary lymphoedema, lymph vessel
transplantation
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
appl. dose
(MBq)
right
95
112
60
121
107
103
120
113
122
left
96
112
65
109
110
102
114
114
110
121
scintigraphic findings
leg
right
left
right
left
right
left
right
left
right
left
right
left
right
left
left
right
left
right
left
focal
lesions
detected
0
1
1
1
1
0
0
1
1
1
1
1
0
1
1
1
1
1
1
0
0
0
1
1
0
0
0
0
included
in the
analysis
0
1
0
0
1
0
0
1
0
1
1
1
0
1
0
0
1
1
1
0
0
0
1
1
0
0
0
0
exten-
sion
A
A
A
A
B
A
A
C
C
C
B
B
localisation
prox. thigh li
knee
knee
prox. shank
knee
prox. shank
knee
pretibial
knee
middle shank
knee
knee
middle shank
distal thigh
distal thigh
distal thigh
prox. thigh
interpre-
tation
lymph node
lymph node
lymph node
lymph node
lymph node
MR-lymphangiographic findings
leg
right
left
right
left
right
left
right
left
right
left
right
left
right
left
left
right
left
right
left
focal
lesions
0
1
0
0
0
0
0
1
0
0
1
0
0
1
1
0
1
1
0
0
0
1
1
0
0
0
0
0
exten-
sion
A
A
B
B
A
B
C
A
B
localisation
thigh
knee
knee
shank
thigh
knee
middle thigh
distal shank
distal thigh
time*
intervall
(days):
SZ vs MRT
22
0
16
1
30
40
20
118
80
4
Table Patients’ data (sex, age, clinical question / information, dose, focal lesions): scintigraphic and MR-lymphangiographic findings, extension of the lesions and localization
For personal or educational use only. No other uses without permission. All rights reserved.
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M. Weiss et al.: MRI versus lymphoscintigraphy
pa-
tient
11
12
13
14
15
16
17
18
19
* day of performance of scintigraphic tests in relation to MR-lymphangiography
sex
female
male
male
female
female
female
male
female
female
age
(years)
34
41
42
32
15
48
65
31
44
clinical information
swelling suspicious for primary
lymphoedema
recurrent erysipelas, swelling
suspicious for primary lymphoedema
trauma right knee secondary
lymphoedema
swelling suspicious for rarefication of
inguinal lymph nodes
swelling suspicious for primary
lymphoedema, lymph vessel trans-
plantation
cervix cancer, secondary lymphoede-
ma, lymph vessel transplantation
haematoma removal, lymphoedema,
lymph vessel transplantation
elephantiasis
cervix cancer, secondary lymphoede-
ma, lymph vessel transplantation
appl. dose
(MBq)
right
121
109
145
76
91
108
120
114
110
left
116
109
140
85
86
117
118
scintigraphic findings
leg
right
left
right
left
right
left
right
left
right
left
left
right
right
left
right
focal
lesions
detected
0
0
1
1
1
1
1
1
1
1
1
1
0
0
0
1
1
0
0
0
1
1
1
included
in the
analysis
0
0
0
0
0
1
0
0
0
0
1
1
0
0
0
1
1
0
0
0
1
1
1
exten-
sion
C
A
E
D
D
D
E
D
localisation
knee
knee
knee
Shank
knee
knee
knee
knee
knee
shank
middle shank
thigh
shank
shank
shank / thigh
interpre-
tation
lymph node
lymph node
lymph node
lymph node
lymph node
lymph node
lymph node
MR-lymphangiographic findings
leg
right
left
right
left
right
left
right
left
right
left
left
right
right
left
right
focal
lesions
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
1
0
1
exten-
sion
B
A
D
C
D
localisation
shank
knee
thigh
shank
shank / thigh
time*
intervall
(days):
SZ vs MRT
1
1
0
0
13
18
5
1
43
Table Continued
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M. Weiss et al.: MRI versus lymphoscintigraphy
pa-
tient
20
21
22
23
24
25
26
27
28
29
* day of performance of scintigraphic tests in relation to MR-lymphangiography
sex
female
female
female
female
female
female
male
female
male
female
age
(years)
44
42
45
45
47
55
79
63
18
39
clinical information
secondary lymphoedema following
varices ectomy
liposarcoma, primary lymphoedema
swelling suspicious for primary
lymphoedema
swelling suspicious for secondary
lymphoedema following lymph node
exstirpation
lymph fistula following resection of
angiosarcoma
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
rectum prolapse surgery, secondary
lymphoedema, lymph vessel trans-
plantation
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
appl. dose
(MBq)
right
105
110
80
72
93
112
98
113
109
95
left
112
105
106
77
91
116
81
119
107
77
scintigraphic findings
leg
right
left
right
left
right
left
right
left
right
left
right
left
right
left
right
left
right
left
focal
lesions
detected
1
1
0
0
0
0
1
1
0
1
1
0
0
0
0
0
0
0
1
1
1
0
included
in the
analysis
0
0
0
0
0
0
1
1
0
0
1
0
0
0
0
0
0
0
1
1
1
0
exten-
sion
E
C
C
A
A
A
localisation
knee
knee
middle thigh
knee
middle shank
interpre-
tation
lymph node
lymph node
lymph node
MR-lymphangiographic findings
leg
right
left
right
left
right
left
right
left
right
left
right
left
right
left
not of diagnostic image quality because
of deficient fat saturation
right
left
right
left
focal
lesions
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
1
1
1
0
exten-
sion
C
B
localisation
shank
thigh
lymph node
knee
time*
intervall
(days):
SZ vs MRT
1
0
23
25
10
2
3
1
1
1
Table Continued
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M. Weiss et al.: MRI versus lymphoscintigraphy
pa-
tient
30
31
32
33
34
35
36
37
38
39
40
* day of performance of scintigraphic tests in relation to MR-lymphangiography
sex
female
female
female
female
female
male
female
male
male
male
female
age
(years)
27
42
58
48
58
49
45
32
9
31
12
clinical information
myositis ossificans, secondary
lymphoedema following surgery
swelling suspicious for primary
lymphoedema
secondary lymphoedema following
varices ectomy, lymph vessel trans-
plantation
swelling suspicious for primary
lymphoedema
cervix cancer, secondary lymphoede-
ma, lymph vessel transplantation
secondary lymphoedema following
abscess removal
secondary lymphoedema following
variceal-seroma removal
recurrent erysipelas, swelling
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
appl. dose
(MBq)
right
114
95
112
120
112
108
104
39
86
40
left
115
85
112
110
96
115
96
41
92
42
scintigraphic findings
leg
right
left
right
left
right
right
left
right
right
left
right
left
right
left
right
left
right
left
left
right
left
focal
lesions
detected
1
0
0
0
0
0
1
0
0
0
0
1
1
1
0
1
0
1
0
1
1
1
1
0
included
in the
analysis
1
0
0
0
0
0
1
0
0
0
0
1
1
1
0
0
0
1
0
1
1
0
0
0
exten-
sion
A
A
B
B
E
A
C
localisation
prox. thigh
distal shank
diffus
dist shank
middle shank
distal shank
knee
thigh
thigh
shank
knee
knee
interpre-
tation
lymph node
diffuse
lymph node
lymph node
MR-lymphangiographic findings
leg
right
left
right
left
right
left
right
left
right
right
left
right
left
right
left
right
left
right
left
right
left
focal
lesions
1
0
0
0
0
0
1
0
1
1
0
0
1
1
0
0
0
1
0
1
1
0
0
0
exten-
sion
A
D
A
B
A
D
B
localisation
thigh
shank
shank
thigh
shank
shank
thigh
shank
time*
intervall
(days):
SZ vs MRT
1
31
4
114
36
0
42
49
0
0
1
Table Continued
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pa-
tient
41
42
43
44
45
46
* day of performance of scintigraphic tests in relation to MR-lymphangiography
sex
male
female
female
male
female
female
age
(years)
79
21
27
70
28
21
clinical information
swelling suspicious for primary
lymphoedema
swelling suspicious for primary
lymphoedema
skin grafting, lymphocele
liposarcoma inguinal, secondary
lymphoedema, lymph vessel trans-
plantation
swelling suspicious for primary
lymphoedema
primary lymphoedema, lymph vessel
transplantation
appl. dose
(MBq)
right
57
83
111
120
110
left
61
82
109
110
100
scintigraphic findings
leg
right
left
right
left
right
left
right
right
left
left
focal
lesions
detected
1
1
1
0
0
0
0
1
1
0
0
1
1
included
in the
analysis
1
1
1
0
0
0
0
1
1
0
0
1
1
exten-
sion
B
A
A
B
B
B
D
localisation
prox. shank
middle shank
prox. thigh
middle shank
middle shank
middle thigh
middle shank
interpre-
tation
MR-lymphangiographic findings
leg
right
left
right
left
right
left
right
right
left
left
focal
lesions
1
1
1
0
0
0
0
1
0
0
0
1
1
exten-
sion
C
B
C
D
B
localisation
shank
thigh
shank
shank
thigh
time*
intervall
(days):
SZ vs MRT
50
3
0
22
2
1
Table Continued
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