Lymphoscintigraphy guided MLD

It's exciting how much imaging is going on in the lymph system these days! And with this paper on lymphoscintigraphy guided MLD (1) I can see a future where we will be able to combine systems to create a 3D map of everyone's lymphatic system and know exactly where the open pathways are.

FIG. 1. Example of radioactivity quantification made on lymphatic nodes and areas of dermal backflow on axillary centered imaging (A) and forearm centered imaging (B) for one patient at the end of the third phase (1), at the end of the first MLD session (2), and after the second MLD session (3) of lymphoscintigraphy examination. MLD, manual lymphatic drainage.

This study injected a radioactive tracer into the hand of women with arm lymphedema and then used MRI to visualise areas of dermal backflow and track the uptake by axillary lymph nodes, but does not show specific lymph vessels pathways.

There were 52 women in two groups. At baseline they all had the same imaging procedure and were then treated with a standard MLD treatment using the Leduc method which was not well described. The intervention group then had a second treatment where the MLD was modified according to the individual imaging, while the control group had the same standard treatment a second time. Further imaging was done and

it's not surprising that the lymphoscintigraphy guided group had a better result.

I'm not trained in the Leduc method so all I really know about it is that it employs circular movements of the skin and has been adapted more recently by Jan Wigg and Jean Paul Belgrado to a technique now called Flush and Fill. So I'm not 100% sure what was used in this study as the specific techniques used were not stated. But I don't know that it matters much since the imaging procedures alway involve manoeuvring the tracer into the lymph vessels with retrograde massage and with skeletal muscle movements. So I never really know how much we are assessing the specific technique anyway, especially as despite between-school differences, all MLD techniques exert similar stretch and shear forces into the vessels and target tissues. What is important to note is that

visualising open areas of drainage or congestion allowed the Therapists to adapt MLD for each individual.

As always it needs to be noted that statistics in RCTs like this can't inform you on the open pathways for the client in your clinical today. You still need your training and experience in clinical assessment skills and whatever combination of measures you have available to optimise treatment planning for clients who have not had any individual mapping. I also worry that if such imaging does become routine there will be unintended consequences for some people.

Do we know the long term effects of injecting dyes and radioactive molecules into skin where the lymph system cannot adequately clear them?

I heard at a recent conference that the ICG dye injected for fluoroscopy can stay in the skin for years and leave a green spot?? So that makes me wonder if it is the same for the radioactive tracer that is left in the non-draining area after lymphoscintigraphy? (I have not done any research on that, or the ICG claim.)

Mapping the individual lymphatic system has the potential to revolutionise how we use MLD and all our lymphedema management techniques. I hope we can find ways of achieving this without injecting anything.

I heard recently about a method of visualising blood vessels using laser and acoustic ultrasound, so using light and sound waves without the need for tracer. I'd love to know if it could be adapted to visualise lymph vessels.

In the virtual world we are entering I can imagine each of us having a 3D avatar of our own organs and systems, showing me exactly where my own lymph vessels and pathway are.

In the meantime Therapists should continue to rely on their own experience and observation to devise the most effective treatment protocol they can for each individual, including any available mapping that has been done

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2023. Lymphoscintigraphy as a Therapeutic Guidance Tool Can Improve Manual Lymphatic Drainage for the Physical Treatment of Patients with Upper Limb Lymphedema: Randomized Clinical Trial.

Romain Barbieux, S. D., Agathe Pluska, Keoma Enciso, Mirela Mariana Roman, Olivier Leduc, Albert Leduc, Pierre Bourgeois, and Steven Provyn. Lymphat Res Biol, 0(0), null. doi:10.1089/lrb.2022.0056

Abstract

Background: The purpose of this study was to measure the effects of lymphoscintigraphically guided manual lymphatic drainage (LG-MLD) and to compare it with standardized manual lymphatic drainage (St-MLD).

Materials and Methods: Fifty-two patients with lymphedema of the upper limb who underwent lymphoscintigraphy were randomly allocated into two groups. Following the phase of physical activity, the control group underwent two phases of St-MLD as the experimental group underwent a first phase of St-MLD followed by a second phase of LG-MLD. Areas of interest were then selected [in particular, dermal backflow (DBF) and axillary lymph nodes (LN)], radioactive activities were quantified for each of these areas.

Results: If a first phase of St-MLD increased the LN activity by 28% on average, the findings indicated that for the second phase of DLM, LG-MLD was 19% more efficient than St-MLD in increasing LN activity. If a period of rest does not influence the lymph charge of DBF areas, physical activity leads to an average activity increase of 17%, whereas LG-MLD and St-MLD lead to an activity decrease of 11%.

Conclusions: For patients with lymphedema, the findings indicate that MLD can increase the lymphatic flow toward the lymphatic nodes by 28% on average and can decrease the charge in the areas of DBF by 11% on average. Moreover, lymphoscintigraphy can be an important therapeutic tool because LG-MLD significantly increases lymphatic flow by 19% more than St-MLD. Concerning the areas of DBF, the LG-MLD and St-MLD decrease the charge in these areas with the same intensity