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PURPOSE: Lymphoscintigraphy has emerged as the diagnostic test of choice in patients with suspected lymphedema. To assess the lymphatic circulation of 386 extremities in 188 patients, we prospectively recorded a semiquantitative index of lymphatic transport in addition to visual evaluation of lymphoscintigraphy image patterns. METHODS: Sixty-one male and 127 female patients were studied (mean age 48 years, range 13 to 87 years). Twenty had upper extremity swelling, and 168 had lower extremity swelling. The disease was bilateral in 60 patients. Lymphoscintigraphy was performed by injecting a mean of 503 microCi of technetium 99m-antimony trisulfide colloid subcutaneously into the second interdigital space of the extremity. Time for transport to regional lymph nodes, appearance of lymph vessels and nodes and distribution pattern were scored. These scores were compiled into a modified Kleinhans transport index (TI). To assess the venous circulation, 155 patients underwent evaluation of the venous system by impedance plethysmography, ultrasonography, or contrast venography. RESULTS: The mean TI (+/- SEM) in 79 asymptomatic extremities was 2.6 +/- 0.5, with 66 (83.5%) demonstrating normal lymphoscintigraphy pattern (TI < 5). Patients with clinical diagnosis of lymphedema (n = 124) had a mean TI of 23.8 +/- 1.5; 81.5% of these were greater than 5. Fifty-six patients (30%) had primary and 68 (36%) had secondary lymphedema. (TI of 26 +/- 3.5 and 22.1 +/- 1.9, respectively, p = NS). Patients without any lymphatic transport (TI of 45) were more likely to have cellulitis in their history (p < 0.05). Contrast lymphangiography in six patients correlated with lymphoscintigraphy. Sixty-four patients (34%) had swelling without lymphedema (venous edema, cardiac edema, lipedema, etc.; TI of 1.9 +/- 0.4, p < 0.001). Of the 41 patients with abnormal venous studies, 18 (44%) had an elevated TI. CONCLUSIONS: Semiquantitative evaluation of the lymphatic transport with lymphoscintigraphy reliably depicts abnormalities in the lymphatic circulation. Lymphoscintigraphy excluded lymphedema as a cause of leg swelling in one third of our patients.

Edemas of the leg sometimes pose problems for diagnosis. Invasive procedures like lymphography or phlebography are either difficult to perform or might endanger the lymphatics. The value of magnetic resonance imaging was assessed in 20 patients with lymphedema, lipedema and phlebedema. Images of patients with lipedema showed homogenous enlarged subcutaneous tissue. In lymphedema a honeycomb pattern in the subcutaneous tissue was observed; in phlebedema there was an increase of fluid within the muscle. Magnetic resonance imaging is useful in differentiating lymphedema, lipedema or phlebedema.

Microlymphatics of human skin form two superposed networks. The superficial one located at the level of dermal papillae may be visualized by fluorescence microlymphography. Microlymphatics fill from a subepidermal depot of minute amounts of FITC-dextran 150,000. In primary lymphedema with late onset the depicted network with vessels of normal size is significantly larger than in healthy controls, whereas in congenital lymphedema (Milroy's disease) microlymphatics are aplastic or ectatic (diameter > 90 microns). Lymphatic microangiopathy with obliterations of microvessels develops in chronic venous insufficiency, in lipedema (preliminary results) and after recurrent erysipelata. In healthy controls microlymphatics are permeable to FITC-dextran 40,000 and impermeable to the larger molecule 150,000. Preserved fragments of the network in chronic venous insufficiency exhibit increased permeability to FITC-dextran 150,000. After visualization of the vessels by the fluorescent dye microlymphatic pressure may be measured by the servo-nulling technique. First results indicate that microlymphatic hypertension contributes to edema formation in patients with primary lymphedema.

The authors assessed the use of magnetic resonance imaging in differentiating lymphedema, phlebedema, and lipedema of the lower limb. They examined 14 patients: five with lipedema, five with lymphedema, and four with phlebedema. T1- and T2-weighted transaxial sequences were performed before administration of gadolinium tetraazacyclododecane-tetraacetic acid (DOTA) and T1-weighted spin-echo sequences were performed after administration of Gd-DOTA in each patient. Images of patients with lipedema showed homogeneously enlarged subcutaneous layers, with no increase in signal intensity at T2-weighted imaging or after Gd-DOTA administration. Patients with phlebedema had areas containing increased amounts of fluid within muscle and subcutaneous fat. In lymphedema, a honeycomb pattern above the fascia between muscle and subcutis was observed, with a marked increase in signal intensity at T2-weighted imaging. After Gd-DOTA administration, there was only a slight increase in signal intensity in the subcutis in lymphedema and phlebedema and a moderate increase in signal intensity in muscle in phlebedema.

Lipodystrophy, almost exclusively seen in female patients, causes psychological problems at an early age. In later life, additional complaints are heavy painful legs, edema, and varicose veins. Nearly all patients suffer from alimentary adiposity. Dermolipectomies in general are not advisable because of the resulting large scars and the risk of damaging the lymphatic system. Subcutaneous lipectomy according to the Illouz method can provide good results. Weight loss is a good alternative to liposuction of the upper legs. After sufficient weight loss, only additional liposuction of the trochanteric area and the medial side of the knee is needed. No unpleasant scarring of the leg results. Unfortunately, older patients often require a skin reduction. The results of surgery in the lower legs were, except in 2 patients, good to excellent. The results in the upper legs were disappointing because 9 of 11 patients gained weight again after surgery. Considering this, the preferable treatment now is liposuction of the lower legs, medial side of the knee, and the txochanteric area. Only in cases of ptotic skin on the medial side of the upper legs is skin reduction without lipectomy indicated. Lipodystrophy suggests a disappearance of the subcutaneous fat. When this occurs in the upper part of the body, it is called progressive lipodystrophy. Lipodystrophy is known as an abnormality of the lower half of the female body, swollen by deposition of subcutaneous fat and determined by heredity. It occurs more frequently in the lower social classes and is often accompanied by an alimentary obesity, which is a psychological reaction to the disturbed body image. Nearly all patients have severe feelings of inferiority because people mock and laugh at them; thus, the alimentary component of the obesity is a form of compensation for lack of love. By dieting, the adiposity disappears only partly because the typical deformity of lipodystrophy remains. I believe that in the lipodystrophy patient a lipedema may develop resulting from lymphatic and venous disease, which may arise later in life. Younger patients' complaints are mainly psychological and result from a disturbed body image, whereas older patients are troubled by pain and leg weariness. Treatment consists of dieting, subcutaneous lipectomy by liposuction, and prescription of elastic stockings.

An elderly patient with a swollen leg or legs can present a challenging problem in differential diagnosis. Although most swollen legs are the result of congestive heart failure, thrombophlebitis, cellulitis, or lymphedema, many other conditions should also be considered.

Lipedema is a common disease in the usual clinical practice. None organic description about the clinical symptoms and signs associated to this condition has been published. Fifty women with lipedema have been examined by the authors, and incidence rates of symptoms and signs have been emphasized. The following signs and symptoms were constantly reported: "Egyptian column", elastic edema, negative Stemmer's sign, alterated plantar support, cutaneous hypothermia. Some others were frequently found: ecchymosis, spontaneous pain, liposclerosis on the thigh, hypodermic hyperalgesia and pain on the internal face of the knee. Moreover, the two most relevant differential diagnosis as well as their two variant's clinical features (mixed lipedema and "thin women" lipedema) have been described.

The use of a single axial slice through the mid calf in the differential diagnosis of a swollen leg is described. This is a very simple quick non-invasive investigation. Venous obstruction results in an increase in the cross sectional area of the muscle compartment. The subcutaneous fat layer is normally homogeneous; in obesity or lipoedema it is increased but remains homogeneous. In lymphoedema fluid collects in the interstitial spaces which become very prominent on CT images. In chronic lymphoedema a honeycomb pattern is seen as a result of increase in the interstitial tissue due to fibrosis. Popliteal cyst extensions result in fluid collections between muscle planes. Haematomas have higher attenuation, and are intramuscular. The findings in 64 patients and 10 controls are presented and the literature is reviewed.

Leg swelling is often of edematous nature. The most important differential diagnosis lies in the distinction between venous or lymphatic forms of edema. An increased vascular permeability and alterations in blood composition have also to be taken into account. A particular entity is the lipedema. Next to an accurate history, specific inspection and palpatory criteria permit to distinguish the various forms. Tests for venous function, laboratory and technologically investigative techniques increase diagnostic accuracy. Lymphedema can only be diagnosed by an exact clinical diagnosis.

Lipodystrophy, almost exclusively seen in female patients, causes psychological problems at an early age. In later life, additional complaints are heavy painful legs, edema, and varicose veins. Nearly all patients suffer from alimentary adiposity. Dermolipectomies in general are not advisable because of the resulting large scars and the risk of damaging the lymphatic system. Subcutaneous lipectomy according to the Illouz method can provide good results. Weight loss is a good alternative to liposuction of the upper legs. After sufficient weight loss, only additional liposuction of the trochanteric area and the medial side of the knee is needed. No unpleasant scarring of the leg results. Unfortunately, older patients often require a skin reduction. The results of surgery in the lower legs were, except in 2 patients, good to excellent. The results in the upper legs were disappointing because 9 of 11 patients gained weight again after surgery. Considering this, the preferable treatment now is liposuction of the lower legs, medial side of the knee, and the trochanteric area. Only in cases of ptotic skin on the medial side of the upper legs is skin reduction without lipectomy indicated. Lipodystrophy suggests a disappearance of the subcutaneous fat. When this occurs in the upper part of the body, it is called progressive lipodystrophy. Lipodystrophy is known as an abnormality of the lower half of the female body, swollen by deposition of subcutaneous fat and determined by heredity. It occurs more frequently in the lower social classes and is often accompanied by an alimentary obesity which is a psychological reaction to the disturbed body image.(ABSTRACT TRUNCATED AT 250 WORDS)

Indirect lymphography by subepidermal infusion of newly developed nonionic, dimeric contrast media (e.g., Iotrolan) opacifies peripheral lymphatics of the skin. Using this method we examined 159 patients with primary and secondary lymphedema, chronic venous insufficiency, and lipedema and compared the findings to normal individuals. A variety of characteristic patterns were uncovered. The technique causes little patient discomfort and takes on the average only 30 minutes.

Lipedema is a hereditary disease concerning exclusively women. We discuss the characteristics of diagnosis as well as the differential diagnosis between lipedema and primary lymphedema. Therapy is effective if the lipedema resembles a lymphedema.

The role of lymphoscintigraphy, performed with 99mTc-labeled antimony sulfur colloid, in the diagnosis of lymphedema and as a test for selection of patients for microvascular operation was evaluated in 32 patients with primary and secondary lymphedema and four patients with other causes of leg edema. Lymphoscintigraphy clearly demonstrated if edema was of lymphatic origin. Five different image patterns were identified; abnormal image patterns could not be predicted from clinical history or physical findings. Quantitative evaluation of removal of the radioactive colloid from the injection site and appearance in lymph node sites and liver was of limited usefulness. Nine patients underwent various surgical procedures before or after lymphoscintigraphy. Lympho-venous anastomoses were possible only in patients who had patent lymph channels visible on lymphoscintigrams. Based on initial experience, lymphoscintigraphy seems to be useful to select patients for microvascular operation.

The microcirculation of adipose tissue is poorly understood either because of the absence of histological documents or because they fail to explain pathological conditions. However, disturbances of blood flow and parietal lesions of the microvessels are the basis for these disorders. Although we speak of disturbances of the vascular control mechanisms, these mechanisms are poorly understood and although we speak of arteriovenous short-circuits, the existence of these lesions has not been proven. In fact, classically, the circulation in the dermis and hypodermis is assured by a meshwork of arterioles, venules and capillaries, but biopsies of lateral and anterior regions of the thigh have demonstrated "block devices" in the walls of small arteries and arterioles which are able to regulate the rate of blood flow towards the capillary bed. Following contraction of these devices, the vascular lumen dilates, ensuring free circulation and when they relax, the lumen closes, resulting in decreased or no blood flow. These smooth muscle devices within the arterial wall resemble small cushions in the small arteries and more or less pedunculated polyps in the arterioles, either simple or fissured in the form of an elephant's trunk with a safety valve effect, arranged either in a single column or in two columns face to face. This provides evidence for the particularly disturbed vasculo-tissue inter-relations observed in venous insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)