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From physical to ultrasound examination in lymphedema: a novel dynamic approach

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Abstract

In daily practice, medical history and physical examination are commonly coupled with anthropometric measurements for the diagnosis and management of patients with lymphatic diseases. Herein, considering the current progress of ultrasound imaging in accurately assessing the superficial soft tissues of the human body; it is noteworthy that ultrasound examination has the potential to augment the diagnostic process. In this sense/report, briefly revisiting the most common clinical maneuvers described in the pertinent literature, the authors try to match them with possible (static and dynamic) sonographic assessment techniques to exemplify/propose an ‘ultrasound-guided’ physical examination for different tissues in the evaluation of lymphedema.

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Funding

This research received no external funding.

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Authors and Affiliations

  1. Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy

    Vincenzo Ricci, Fabrizio Gervasoni & Arnaldo Andreoli

  2. Pathology Unit, Maggiore Hospital, Bologna, Italy

    Costantino Ricci

  3. Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy

    Costantino Ricci

  4. Unit of Ultrasound in Internal Medicine, Department of Medicine and Science of Aging, G. d’Annunzio University, Chieti, Italy

    Cocco Giulio

  5. Section of Physical Medicine and Rehabilitation, Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University of Bari, Bari, Italy

    Giacomo Farì

  6. Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey

    Levent Özçakar

Authors
  1. Vincenzo Ricci
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  2. Costantino Ricci
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  3. Fabrizio Gervasoni
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  4. Cocco Giulio
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  5. Giacomo Farì
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  6. Arnaldo Andreoli
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  7. Levent Özçakar
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Correspondence to Vincenzo Ricci.

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No institutional review board (IRB) has been established to collect images necessary for the manuscript but, written permission was obtained from all the patients involved.

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Supplementary Information

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40477_2021_633_MOESM1_ESM.tif

Supplementary Fig. 1 Histological and Sonographic Features of Lymphocoele. Histological preparations show pseudo-cystic dilatations of lymphatic collectors characterized by flattened endothelium, thick and irregular fibromuscular wall, and scarce amount of erythrocytes and fibrin inside the lumen—H&E, original magnification 10 × (A), H&E, original magnification 20 × (B). Sonographic image clearly shows the lymphatic pseudocysts (inside the subcutaneous tissue) presenting with several intraluminal echoes due to the protein-rich fluid at the level of the leg (C). The trilaminar structure of the dermo-epidermal complex and the lobular architecture of the subcutis are completely lost (in the advanced stage of the disease) with an ‘undifferentiated’ pattern of the superficial tissues. [Linear Probe, 5–11 MHz] V: vein (TIF 15185 KB)

Supplementary Video 1 Sonographic Tracking of the Dermal Edema with the Gel Pad Technique. Using large amount of gel, it is possible to promptly perform dynamic sonotracking of the dermo-epidermal complex—avoiding mechanical compression of the skin surface—to check for the (hypoechoic) dermal edema. Of note, the aforementioned sono-histological pattern is not always coupled with modifications of the circumferential measurements of the limb and therefore the ultrasound examination can be considered a valuable tool for early diagnois (AVI 8888 KB)

Supplementary Video 2 Sonographic Tracking of the “Cobblestone Pattern”. Shifting the probe along the swollen segment of the limb, it is possible to promptly evaluate the spatial distribution of the dilatated lymphatic collectors of the subcutaneous tissue. Of note, the grade of dilatation of the lymphatic channels and the eventual presence of lymphatic lakes can also/easily be assessed during the dynamic assessment (AVI 12293 KB)

Supplementary Video 3 Deep Lymphatic Network: a Potential Pitfall. In patients with selective dilatation of the deep lymphatic collectors in the subcutaneous tissue, the pitting test may not be sensitive enough to evaluate the presence/amount of extra fluids (AVI 10477 KB)

Supplementary Video 4 Sonographic Tracking of the Lymphatic Lakes. Moving the probe over the swollen limb, it is possible to perform panoramic evaluation of the extension/location of the lymphatic lakes. Of note—different from the “cobblestone pattern”—normal architecture of the lymphatic collectors are completely absent and the extended fluid collections replace the subcutaneous tissue (AVI 15476 KB)

Supplementary Video 5 Sonographic Tracking of the “Snowfall Pattern”. Shifting the probe along the swollen segment of the limb, it is possible to evaluate the coarse pattern of the subcutaneous tissue—with loss of fat lobulation and blurred visibility of the fibrous scaffold. Mild dilatation of the deep lymphatic collectors is related to the high resistance of the sclero-edematous subcutis inducing secondary mechanical insufficiency of the lymphatic network (AVI 11259 KB)

Supplementary Video 6 Sonographic Tracking of the “Fibro-sclerotic Pattern”. Moving the probe over the swollen and hardened limb, it is possible to observe complete disorganization of the normal architecture of the subcutaneous tissue with small fatty lobules entrapped inside a rigid fibrous matrix (AVI 12122 KB)

Supplementary Video 7 Sonographic Tracking of the Dorsal Hump. Shifting the probe over a poorly compressible dorsal hump of the foot, high-pressure edema located in between the fatty lobules and the dorsal fascial layers is clearly visible. Of note, the dynamic assessment correctly differentiates the lymphatic collectors from the superficial dorsal venous plexus of the foot (AVI 17036 KB)

Supplementary Video 8 Sonographic Tracking of the Dermo-Hypodermal Dissociation. Selective fluid accumulation/infiltration into the dermo-hypodermal interface may be related to the early involvement of the lymphatic vessels bridging the pre-collectors of the dermis and the collectors of the subcutaneous tissue (AVI 8199 KB)

Supplementary Video 9 Ultrasound-Guided Refill Test. Dynamic assessment of dilatated lymphatic collectors (during the squeeze and refill phases) clearly shows the peculiar distribution of fluids as a web among the fatty lobules (AVI 17343 KB)

Supplementary Video 10 Sono-palpation of Lymphocoele. Dynamic assessment allows to promptly evaluate the compressibility of the lymphatic pseudocyst and the motions of intraluminal echoes in response to the compression/decompression cycles. In fact, they present swirling motions without effective propulsion (AVI 14685 KB)

Supplementary Video 11 Sonographic Tracking of the Lymphocoele. Shifting the probe along the swollen segment of the limb, it is possible to correctly evaluate the anatomical course of the lymphatic pseudocyst and to differentiate it from the surrounding superficial veins. Of note, during the dynamic assessment, the endoluminal valves of the dilatated lymphatic collectors are clearly visible (AVI 12105 KB)

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Ricci, V., Ricci, C., Gervasoni, F. et al. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound 25, 757–763 (2022). https://doi.org/10.1007/s40477-021-00633-4

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  • DOI: https://doi.org/10.1007/s40477-021-00633-4

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