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Imaging of Lymphatic Vessels in Breast Cancer–Related Lymphedema: Intradermal Versus Subcutaneous Injection of 99mTc-Immunoglobulin

Susan O'Mahony1,2, Chandra K. Solanki2, Robert W. Barber2, Peter S. Mortimer3, Arnie D. Purushotham1 and A. Michael Peters2,4

1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK.
2 Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge, UK.
3 Department of Medicine, St. George's Hospital, London, UK.
4 Department of Nuclear Medicine, Royal Sussex County Hospital, Eastern Rd., Brighton BN2 5BE, UK.


Figure 1
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  		Fig. 1A —Lymphoscintigraphy images of upper limb and torso in female patient. Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained 52 and 48 min after intradermal (A) and subcutaneous (B) injections, respectively. There is greater clarity and earlier visualization of lymphatic structures after intradermal injection. Left and right panels are posterior and anterior images, respectively.

 

Figure 2
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  		Fig. 1B —Lymphoscintigraphy images of upper limb and torso in female patient. Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained 52 and 48 min after intradermal (A) and subcutaneous (B) injections, respectively. There is greater clarity and earlier visualization of lymphatic structures after intradermal injection. Left and right panels are posterior and anterior images, respectively.

 

Figure 3
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  		Fig. 2A —Lymphoscintigraphy images of upper limb and torso in female patients (A–D). Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained after intradermal (A and C) and subcutaneous (B and D) injections in two patients show clear definition of proximal lymphatic vessels after intradermal injection, obtained at 50 (A) and 54 (C) min, but not after subcutaneous injection, obtained at 154 (B) and 163 (D) min. As previously shown [10], images with best definition are recorded much earlier after intradermal injection. Note presence of shoulder markers.

 

Figure 4
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  		Fig. 2B —Lymphoscintigraphy images of upper limb and torso in female patients (A–D). Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained after intradermal (A and C) and subcutaneous (B and D) injections in two patients show clear definition of proximal lymphatic vessels after intradermal injection, obtained at 50 (A) and 54 (C) min, but not after subcutaneous injection, obtained at 154 (B) and 163 (D) min. As previously shown [10], images with best definition are recorded much earlier after intradermal injection. Note presence of shoulder markers.

 

Figure 5
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  		Fig. 2C —Lymphoscintigraphy images of upper limb and torso in female patients (A–D). Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained after intradermal (A and C) and subcutaneous (B and D) injections in two patients show clear definition of proximal lymphatic vessels after intradermal injection, obtained at 50 (A) and 54 (C) min, but not after subcutaneous injection, obtained at 154 (B) and 163 (D) min. As previously shown [10], images with best definition are recorded much earlier after intradermal injection. Note presence of shoulder markers.

 

Figure 6
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  		Fig. 2D —Lymphoscintigraphy images of upper limb and torso in female patients (A–D). Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images obtained after intradermal (A and C) and subcutaneous (B and D) injections in two patients show clear definition of proximal lymphatic vessels after intradermal injection, obtained at 50 (A) and 54 (C) min, but not after subcutaneous injection, obtained at 154 (B) and 163 (D) min. As previously shown [10], images with best definition are recorded much earlier after intradermal injection. Note presence of shoulder markers.

 

Figure 7
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  		Fig. 3A —Lymphoscintigraphy images of upper limb and torso in female patient. Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images show more marked and earlier blood pool signal was obtained after intradermal (A) compared with subcutaneous (B) injection. Images at third imaging times (A = 86 min, B = 108 min) are shown.

 

Figure 8
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  		Fig. 3B —Lymphoscintigraphy images of upper limb and torso in female patient. Downward-pointing arrowheads = shoulders, lateral arrowheads = elbows, upward-pointing arrowheads = pubic bone. Images show more marked and earlier blood pool signal was obtained after intradermal (A) compared with subcutaneous (B) injection. Images at third imaging times (A = 86 min, B = 108 min) are shown.

 

Figure 9
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  		Fig. 4 —Activity within arm quantified from region-of-interest analyses from gamma camera imaging and initial phantom studies after subcutaneous injection (left graph) and after intradermal injection (right graph). Data for all six patients are shown separately as different symbols, with each symbol repeated for the same patient in Figures 5 and 6.

 

Figure 10
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  		Fig. 5 —Disappearance of activity from depot after subcutaneous injection (right graph) and after intradermal injection (left graph). Data for all six patients are shown separately. Symbols correspond to same patients shown in Figures 4 and 6. It was assumed that first probe count corresponded to 100% of injected activity.

 

Figure 11
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  		Fig. 6 —Accumulation of activity in central blood expressed as percentage of administered activity after subcutaneous injection (right graph) and after intradermal injection (left graph). Blood volume was calculated from height, weight, age, and sex [16]. Radioprotein clearance from blood was considered negligible over 3 hr [17, 18]. Data for all six patients are shown separately. Symbols correspond to same patients in Figures 4 and 5.

 

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