Human lymphatic pumping measured in healthy and lymphoedematous arms by lymphatic congestion lymphoscintigraphy

• Published in: The Journal of physiology Vol. 583; no. 1; pp. 271 - 285
• Main Authors: Modi, S., Stanton, A. W. B., Svensson, W. E., Peters, A. M., Mortimer, P. S., Levick, J. R.
• Format: Journal Article
• Language: English
• Published: Oxford, UK The Physiological Society 15.08.2007; Blackwell Publishing Ltd; Blackwell Science Inc
• Subjects: Adult; Arm - blood supply; Arm - physiopathology; Blood Pressure - physiology; Breast Neoplasms - radiotherapy; Breast Neoplasms - surgery; Cardiovascular; Dose-Response Relationship, Radiation; Female; Humans; Immunoglobulin G; Lymph - physiology; Lymphatic System - physiology; Lymphedema - diagnostic imaging; Lymphedema - physiopathology; Lymphoscintigraphy; Male; Middle Aged; Organotechnetium Compounds; Radionuclide Imaging - methods; Radiotherapy - adverse effects; Sphygmomanometers
• ISSN: 0022-3751; 1469-7793; 1469-7793
• DOI: 10.1113/jphysiol.2007.130401

Axillary surgery for breast cancer partially obstructs lymph outflow from the arm, chronically raising the lymphatic smooth muscle afterload. This may lead to pump failure, as in hypertensive cardiac failure, and could explain features of breast cancer treatment-related lymphoedema (BCRL) such as its delayed onset. A new method was developed to measure human lymphatic contractility non-invasively and test the hypothesis of contractile impairment. 99m Tc-human IgG (Tc-HIG), injected into the hand dermis, drained into the arm lymphatic system which was imaged using a gamma-camera. Lymph transit time from hand to axilla, t transit , was 9.6 ± 7.2 min (mean ± s.d. ) (velocity 8.9 cm min −1 ) in seven normal subjects. To assess lymphatic contractility, a sphygmomanometer cuff around the upper arm was inflated to 60 mmHg ( P cuff ) before 99m Tc-HIG injection and maintained for >> t transit . When P cuff exceeded the maximum pressure generated by the lymphatic pump ( P pump ), radiolabelled lymph was held up at the distal cuff border. P cuff was then lowered in 10 mmHg steps until 99m Tc-HIG began to flow under the cuff to the axilla, indicating P pump ≥ P cuff . In 16 normal subjects P pump was 39 ± 14 mmHg. P pump was 38% lower in 16 women with BCRL, namely 24 ± 19 mmHg ( P = 0.014, Student's unpaired t test), and correlated negatively with the degree of swelling (12–56%). Blood radiolabel accumulation proved an unreliable measure of lymphatic pump function. Lymphatic congestion lymphoscintigraphy thus provided a quantitative measure of human lymphatic contractility without surgical cut-down, and the results supported the hypothesis of lymphatic pump failure in BCRL.