Lipoedema is a disproportionate, symmetrical fatty swelling on the legs of unknown etiology with pain, orthostatic oedema, frequent haematomas associated, and sometimes involving arms. It affects women above all and brings a reduction in quality of life as well as psychological problems. The diagnosis is clinical, but in this study the author decided to request lymphoscintigraphy to analyze the morphological-functional features of the lymphatic system.

59 patients affected by lipoedema of the lower limbs were evaluated through a clinical examination which led to differential diagnosis versus obesity and lymphedema, as well as to 3 clinical stages. Lymphoscintigraphy was required in all patients.

Come valuta il linfologo il caso clinico che si presenta alla sua attenzione?Ovviamente attraverso una attenta valutazione clinica basata sull’anamnesi e sull’esame obiettivo.
Con l’anamnesi si indaga sulla familiarità, su eventuali traumi recenti o pregressi , su precedenti processi flogistici, sugli esiti di intervento chirurgico e/o di radioterapia, sulla terapia farmacologica in atto, ma anche sull’epoca, la modalità e la sede di insorgenza, le possibili complicazioni avvenute ed il risultato derivante da eventuali trattamenti specifici effettuati.

Venous thoracic outlet syndrome (vTOS) is a unilateral (rarely bilateral) form of thoracic outlet syndrome (approximately 4%), due to an extrinsic compression of the subclavian vein which can be divided into thrombotic and non thrombotic clinical entities.
In this study, the author underlines the usefulness of Echo-Color-Doppler diagnostic to evidence an intermittent subclavian vein compression, without intraluminal thrombus, in patients who had undergone breast surgery, with axillary lymphadenectomy, who refer homolateral positional  heaviness onset, fatigue, turgidity of the dorsal veins of the hand and cyanosis during the elevation of the homolateral arm (venous claudicatio) while performing work activities that can be resolved by resting the limb.
In this study, the subclavian venous obstacle discharge was due to impaired posture and predisposing morphotype (weak muscular support of the shoulder girdle): it was completely resolved through personalised physical therapy programme, in order to take pressure off the vein in the thoracic outlet, with complete disappearance of symptoms and consequent improvement in the performance of work activities and quality of life.
Furthermore, the resolution of non thrombotic venous thoracic outlet, through physical therapy, avoids the possibility of deep vein thrombosis onset due to the intermittent narrowing of the subclavian vein.

Il linfedema è una patologia cronica, con andamento evolutivo, e disabilitante, che richiede un team riabilitativo, con specifica preparazione linfologica, che prende in carico il paziente in modo globale ed apre un progetto riabilitativo che include un programma terapeutico personalizzato.
L’apertura di un progetto riabilitativo viene preceduta, all’interno di un team riabilitativo multidisciplinare, dalla valutazione clinica (anamnesi generale, oncologica, sociale, modalità ed insorgenza dell’edema, esame obiettivo), dalla misurazione centimetrico-volumetrica degli arti a confronto, calcolo dell’BMI, dallo staging clinico, dalla valutazione posturale e articolare-muscolare degli arti, ma anche dalla valutazione dello stato psicologico, della qualità della vita percepita e dei bisogni del paziente.

The authors confirm the usefulness of Echo-colour-doppler diagnostics, in patients affected with upper and lower limb lymphoedema.

Description of initiative
The diagnosis of lymphoedema is essentially clinical, however, we must not ignore the usefulness of Echo-colour-Doppler diagnostics, non-invasive and repeatable diagnostic approach, using adequate high linear frequency probe, in lymphological field. The instrument available is provided with the “Siescape panoramic reconstruction” function, a system option allowing the acquisition of bi-dimensional ultrasound images with an extended visualisation field.

Echo-Colour-Doppler diagnostics allows us to reach differentiated diagnoses to determine the origin of the upper and lower limbs oedema (deep venous thrombosis, post-thrombotic syndrome, Backer cist with popliteal vein compression, etc.).
It provides important indications on morphological characteristics-vascularisation of lympho-nodes, presence of vascularised neo-formations in oncological patients, subclavian-venous obstacle discharge after oncological surgery, etc.). Furthermore, it allows us to analyse the structural characteristics of oedematous tissue (thickness, echogenicity).
It is also interesting to note how it is possible to observe an increase of the calibre-flow of the superficial and deep veins in the lymphoedematous limb, proof of the venous-lymphatic twinning useful in the case of lymphatic system insufficiency.

Echo-Colour-Doppler diagnostics provides important data which lead to an improvement in lymphoedema management, helping the lymphologist and physiotherapist in the choice of precise strategies and, therefore, the setting up of personalised therapeutic programmes, with subsequent therapeutic optimisation. It also useful for therapeutic monitoring to verify the validity of treatment effectuated and in follow-up.