淋巴显像评估妇科肿瘤治疗后下肢淋巴系统损伤

Lymphoscintigraphy in patients with lymphedema after gynecological cancer treatment： assessment of injury of the lower limb lymphatic system

目的分析妇科肿瘤治疗后淋巴水肿患者淋巴显像的影像特点，建立评估下肢淋巴系统损伤的方法。方法166例连续陛病例（332个肢体）双足第1，2趾间皮下注射99Tcm-DX111—185MBq（0．1～0．15m1）后行淋巴显像。根据显像结果，以淋巴管完整程度和淋巴皮下返流状况为指标，将下肢淋巴系统损伤分为0，1，2和3级。根据国际淋巴学会淋巴水肿临床分期标准，将淋巴水肿分为0，I，Ⅱa，Ⅱb和Ⅲ期。列联表，检验比较2种分类方法间的相关关系。矿检验分析淋巴系统损伤分级的临床特征。结果妇科肿瘤治疗后患者淋巴显像表现包括：下肢、盆腔和腹腔区域的淋巴管中断、皮下淋巴返流、淋巴管和淋巴结不显影、淋巴囊肿和淋巴瘘等。332个肢体，水肿分期为0，I，Ⅱa，Ⅱb和Ⅲ期的分别为65（19．6％），71（21．4％），131（39．5％），62（18．7％）和3（0．9％）个，淋巴显像损伤分级为0，1，2和3级的数量分别为36（10．8％），79（23．8％），116（34．9％）和101（30．4％）个。统计学分析表明，2者间有良好的相关性（x2=313．483，P〈0．001）。临床分析表明，2和3级损伤所占比例放疗组高于非放疗组，分别为70．5％（158／224）和54．6％（59／108）,x2=9．662，P=0．022；有丹毒病史者3级损伤比例也高于无丹毒者，分别为73．1％（38／52）和43．9％（50／144）,x2=12．238，P〈0．001。随着淋巴水肿病程进展，3级损伤肢体数所占百分比逐渐增高、病程〈1．5年者为36．6％（34／93），病程1．5～5年者为72．3％（34／47），病程〉5年者为76．9％（20／26）（x2=23．123，P〈0．001）。不同类型妇科肿瘤（x2=4．000，P=0．676）、是否化疗（x2=0．411，P=0．938）对淋巴系统损伤分级无明显影响。结论淋巴显像损伤分级方法有助于评估妇科肿瘤治疗后患者的淋巴系统损伤程度，可为治疗后淋巴水肿的临床诊断和预防提供客观依据。

Objective To evaluate the lymphoscintigraphic imaging characteristics for the patients with lower limb lymphedema and to establish a novel grading system for the injury to lower limb lymphatic system. Methods One hundred and sixty six consecutive patients （332 lower limbs） with lower limb lymphedema after surgical and（or） radiotherapy treatment for gynecological cancer were recruited into this retrospective study. The lymphoscintigraphy studies were performed after subcutaneous injection of 111 ~ 185 MBq （0.1 ~ 0.15 ml） of 99Tcm-DX into the webbed space between the first and second toes of both feet. Based on the integrity of lymphatic vessel and the extension of dermal diffusion on lymphoscintigram, the lymphatic injury to the lower limb was graded as 0,1,2 and 3 respectively. The lymphedema of the limb was staged as 0, Ⅰ , Ⅱ a, Ⅱb,Ⅲ by the standard of Consensus Document of the International Society of Lymphology （ISL）. Chi square test was carried out to validate the established grading system for the assessment of the injury to the lower limb lymphatic system. Results The lymphoscintigraphic imaging characteristics included lymphatic blockage, dermal backflow, no visualization of lymphatic or lymph node, lymphocele and lymph fistula in the lower limb, pelvis and abdomen. There were 65 （ 19.6% ）, 71 （21.4%）, 131 （39.5%）, 62 （18.7%） and 3 （0.9%） limbs staged as 0, Ⅰ , Ⅱ a, Ⅱb and Ⅲ for lymphedema while 36（ 10.8% ）, 79（23.8% ）, 116（34.9% ） and 101 （30.4%） limbs graded as 0, 1, 2, and 3 for lymphatic injury. There was a statistically significant correlation between the grading methods （X2 =313.483, P 〈 0. 001 ）. The patients who underwent radiotherapy had a higher incidence rate of grade 2 and 3（70.5% , 158/224） than those who underwent surgery （53.6%, 59/108） （X2 =9. 662, P =0. 022）. The patients with erysipelas had a higher incidence rate of grade 3 （73.1%, 38/52 ） than those without erysipelas （43.9%, 50/114） （X2 = 12. 238, P 〈 0. 001 ）. The incidence rate of grade 3 increased with the duration of lymphedema after treatment ： 36.6% （34/93） for less than 1.5 years, 72.3 % （34/47） for be- tween 1.5 to 5 years, and 76.9% （20/26） for more than 5 years （X2 =23. 123, P 〈0. 001 ）. The grade of lymphatic injury showed no significant difference among 3 types of gynecological cancers （X2 = 4. 000, P = 0. 676）, or between the patients with and without chemotherapy （Xz = 0.411, P = 0.938 ）. Conclusions Lymphoseintigraphy is a reliable modality to diagnose lower limb lymphedema after treatment for gynecological cancer. The injury grading system could provide objective assessment of the lymphatic damage.