Our clinic treats patients with lymphedema based on the medical data that have been accumulated to date. We perform conservative treatment, such as compression therapy, and surgical procedures in an integrated manner, and also focus on building evidence. In cases where intensive conservative treatment is needed, we may refer patients to our affiliated health care providers or clinics. International patients who cannot have tests or examinations in their home country may do them in Japan.

 

(Note) Please treat DVT (deep vein thrombosis) and cellulitis first, before a patient travels to Japan.

 

If you have patients with lymphedema, please try to perform as many of the laboratory tests and examinations listed below as possible prior to referral to us. That will help us provide efficient care to the patients at our clinic. In addition, if any abnormalities are found in these tests or examinations, it will be preferable for you to advise the patient in question to see an internist, vascular surgeon, and so on prior to visiting us.

【The Importance of Medical Examinations Before Traveling to Japan for Lymphedema Treatment】

If the required examinations cannot be performed in your home country, we will arrange for them to be carried out at our clinic after you arrive in Japan.

 

However, if these examinations are performed only after your arrival and reveal cardiac abnormalities or significant blood test abnormalities—such as underlying heart disease or internal organ disorders—it may become medically unsafe to proceed with surgery, even for lymphaticovenous anastomosis (LVA) performed under local anesthesia.

 

For this reason, we strongly recommend that these examinations be completed before traveling to Japan, so that we can confirm in advance that surgery can be performed safely and help ensure a smooth and safe treatment process during your visit.

(1) Blood test: Blood counts, albumin, liver function, renal function, thyroid gland function, lipids, glucose, coagulability, infection (HIV, syphilis, hepatitis B, hepatitis C, etc.)

(2) Chest X-ray

(3) ECG

(4) Ultrasound examination of leg veins or CT scans of the legs

(5) ABI (Ankle Brachial Index)

(6) Lymph0scintigraphy

 

【Examinations Required at the Time of Visit】

Information for Healthcare Professionals

(Referring Physicians / Facilities Performing Examinations)

 

【Positioning of Examinations at Our Clinic】

At Mukumi Clinic, lymphedema care is conceptualized using a three-layered framework:

1.Confirmation of general systemic condition and differential diagnosis

2.Circulatory evaluation for determining indications for compression therapy and surgery

3.Assessment of lymphatic function

 

Accordingly, if the examinations listed below can be performed in advance and within feasible limits, the process of clinical evaluation and treatment decision-making will proceed more smoothly.

・If advance examinations are difficult to perform, they will be conducted or scheduled at the time of the patient’s visit to our clinic.

・Explanations of these examinations for patients are provided in the lower section of this page.

 

【List of Examinations and Their Purposes】

① Blood Tests (Standard Hematology and Biochemical Tests)

Purpose

Screening for hypoalbuminemia, thyroid dysfunction, renal disease, hepatic disease, etc.

→ Exclusion of lymphedema-mimicking conditions (systemic edema)

Evaluation of infection/inflammation and abnormalities in glucose metabolism

 

Clinical Significance

Differentiation between primary and secondary lymphedema

Safety assessment for conservative treatment and surgical intervention

 

 

② Chest X-ray

Purpose

Exclusion of heart failure, pleural effusion, mediastinal pathology, etc.

Clinical Significance

Differential diagnosis of systemic edema and venous return disorders

 

 

③ Electrocardiogram (ECG)

Purpose

Evaluation of arrhythmias and ischemic heart disease

Clinical Significance

Safety management for compression therapy and day-surgery procedures

 

 

④ Lower Extremity Venous Ultrasound

(Evaluation for DVT and Varicose Veins)

Purpose

Assessment of deep vein thrombosis (DVT) and chronic venous insufficiency

Clinical Significance

Differentiation between lymphedema and venous edema

Reference for initiation and intensity setting of compression therapy

This examination can be performed at our affiliated facility, Ochanomizu Vascular Surgery Clinic.

 

 

⑤ ABI (Ankle–Brachial Index)

Purpose

Screening for peripheral arterial disease of the lower extremities

Clinical Significance

Assessment of eligibility and safety for compression therapy

In cases with low ABI values, careful adjustment of compression conditions is required

 

 

⑥ Lymphoscintigraphy

Purpose

Global assessment of lymphatic transport capacity

Understanding the pathophysiology of primary versus secondary lymphedema

Differential diagnosis from other internal organ–related diseases

Positioning at Our Clinic

Considered an international standard examination for lymphedema

Used in conjunction with lymphatic ultrasound and ICG lymphography for a comprehensive treatment evaluation

Useful for disease staging, treatment strategy planning, and patient explanation

 

▶ Recommended Lymphoscintigraphy Protocol at Our Clinic

At our clinic, we routinely perform dual-phase imaging (15 minutes and 60 minutes).

For lower extremities, we emphasize evaluation of physiological lymphatic flow using subcutaneous injections between the toes.

 

【Recommended Lymphoscintigraphy Protocol】

(Lymphedema Clinic Tokyo) 

 

Equipment and Imaging Settings

Gamma Camera: Symbia Evo Excel

Radiopharmaceutical: 99mTc-HAS-D

Collimator: LMEGP

Matrix Size: 256 × 1024

Zoom: 1.00

 

Energy Window Preset: 99mTc ±20%, automatic proximity

Detectors: Dual-head detection

 

Scan Range

Lower extremities: From the ankles to the vertex of the head

Upper extremities: From the wrists to the vertex of the head

 

Scan Speed

Variable scan speed adjusted so that the total scan time is approximately 10 minutes

 

Example:

Height 180 cm → 18 cm/min

Height 150 cm → 15 cm/min

 

Acquisition Phases

15 minutes after injection

60 minutes after injection

After completion of the 15-minute imaging, patients are asked to leave the scanning table and wait until the 60-minute imaging while performing ankle movements, flexion–extension exercises, or gentle massage.

 

Patient Positioning

Head First

Scan Direction: Head Out

Radiotracer Dose and Injection Method

 

Dose: 150 MBq per injection

Injection Route: Subcutaneous injection

Local Anesthesia: Lidocaine (Xylocaine) used

 

Injection Sites

Lower extremities: Subcutaneous injection between the first and second toes

Upper extremities: Subcutaneous injection between the second and third fingers

 

Clinical Notes

This protocol is designed to evaluate physiological lymphatic flow and overall lymphatic transport function.

It is used as part of a comprehensive lymphedema assessment, in combination with lymphatic ultrasound and ICG lymphography, to support disease staging, treatment planning, and patient education.

 

【FAQ for Healthcare Professionals】

<Regarding Examinations Required for Clinical Management>

 

Q1. Why are these examinations reviewed in advance for lymphedema care?

A.

At our clinic, lymphedema is evaluated using the following three-layer approach:

Differential diagnosis (exclusion of systemic and venous edema)

Safety assessment for compression therapy and surgery

Evaluation of lymphatic function

Therefore, having prior information from blood tests, cardiovascular assessments, and vascular evaluations enables us to formulate a concrete treatment strategy from the initial consultation.

 

 

Q2. Which blood test parameters are particularly important?

A.

We place particular emphasis on the following:

Albumin (exclusion of malnutrition and systemic edema)

Renal function and hepatic function

Thyroid function

Inflammatory markers

Abnormalities in glucose metabolism

These parameters serve as important indicators for:

Determining whether the condition represents isolated lymphedema

Assessing the safety of conservative therapy and surgery

 

 

Q3. Are chest X-ray and ECG required for all patients?

A.

They are not mandatory in all cases; however, they are particularly useful in:

Elderly patients

Patients with a history of cardiac disease

Cases of bilateral or rapidly progressive edema

In patients where heart failure or circulatory insufficiency is involved, lymphedema treatment alone may not lead to improvement, making differential diagnosis crucial.

 

 

Q4. How does lower extremity venous ultrasound relate to lymphedema?

A.

In patients with lymphedema, concomitant conditions such as:

Chronic venous insufficiency

Varicose veins

History of DVT

are not uncommon.

Failure to identify these conditions may result in insufficient effects of compression therapy or even symptom exacerbation.

 

 

Q5. Why is ABI testing performed?

A.

ABI is regarded as an important tool for evaluating the safety of compression therapy.

Strong compression poses risks in patients with low ABI values

Adjustment of compression pressure and material selection is required

At our clinic, ABI is used not to determine whether compression can be applied, but rather how compression should be applied.

 

 

Q6. Is lymphoscintigraphy a mandatory examination?

A.

At our clinic, yes.

If lymphoscintigraphy cannot be performed at your institution, it will be scheduled during the patient’s visit to our outpatient clinic.

Additional examinations may be performed as needed:

Lymphatic ultrasound

ICG lymphography

Lymphoscintigraphy is positioned as a supplementary examination for:

Macroscopic evaluation of lymphatic transport

Understanding the pathophysiology of primary versus secondary lymphedema

Patient explanation and disease staging

 

 

Q7. What are the characteristics of the lymphoscintigraphy protocol recommended by your clinic?

A.

At our clinic, we emphasize:

Multi-phase imaging (15, 30, and 60 minutes)

Subcutaneous injection between the toes, which better reflects physiological lymphatic flow

Continuous evaluation from the entire lower limb to the trunk lymphatic flow

For detailed imaging conditions, dosage, patient positioning, and exercise loading, please refer to the separate PDF document titled “Our Recommended Protocol.”

 

 

Q8. To what extent do lymphoscintigraphy results influence surgical indication?

A.

They are not used as a sole determinant.

Surgical indications are assessed comprehensively based on:

Lymphatic vessel diameter and wall characteristics on lymphatic ultrasound

Dermal backflow patterns on ICG lymphography

Clinical symptoms and disease stage

Lymphoscintigraphy is positioned as a tool for understanding the overall background of lymphatic flow.

 

 

Q9. If examinations have already been performed at another institution, is re-examination necessary?

A.

In principle, no.

If the data are relatively recent (within one year) and clinically consistent, those results will be utilized.

Only missing information will be supplemented as necessary.

 

 

Q10. What information would you like us to share at the time of referral?

A.

The following information is particularly helpful:

Primary disease and surgical details (extent of lymph node dissection, history of radiotherapy)

Onset and clinical course of edema

Details of existing compression therapy

History of venous disease and infections (cellulitis)

Results of examinations already performed

This allows us to present concrete treatment options from the initial visit.

 

 

Q11. What is the ultimate goal of this examination framework?

A.

The ultimate goals are:

To avoid unnecessary treatments

To avoid unsafe treatments

To present the most appropriate options for each individual patient

At our clinic, our basic policy is to provide care that is not biased toward either conservative therapy or surgery.

 

【How We Approach Lymphedema Care at Our Clinic】

At our clinic, lymphedema is evaluated through a three-layered medical approach:

1.Assessment of your overall health and exclusion of other conditions

2.Circulatory evaluation to determine the safety and appropriateness of compression therapy and surgery

3.Evaluation of lymphatic function

 

Because of this approach, having certain examinations completed before your visit, whenever possible, allows us to make smoother and more accurate diagnostic and treatment decisions.

 

If it is difficult to complete these examinations in advance, they can be performed or scheduled after your visit.

A simplified explanation of these tests for patients is provided in the lower section of this page.

 

【List of Examinations and Their Purpose】

1. Blood Tests (Basic Hematology and Biochemistry)

Purpose

To check for low albumin levels, thyroid dysfunction, kidney disease, or liver disease

To exclude conditions that cause generalized swelling, which may resemble lymphedema

To assess infection, inflammation, and glucose metabolism

Clinical Significance

Differentiation between primary and secondary lymphedema

Safety assessment for conservative treatment and surgical options

 

2. Chest X-ray

Purpose

To rule out heart failure, pleural effusion, or mediastinal abnormalities

Clinical Significance

Helps distinguish systemic edema or venous circulation problems from lymphedema

 

3. Electrocardiogram (ECG)

Purpose

Evaluation of arrhythmias or ischemic heart disease

Clinical Significance

Ensures safety when considering compression therapy or day-surgery procedures

 

4. Lower Limb Venous Ultrasound (DVT / Varicose Veins)

Purpose

Assessment of deep vein thrombosis (DVT) and chronic venous insufficiency

Clinical Significance

Differentiation between lymphedema and venous edema

Helps determine whether compression therapy is appropriate and how strong it should be

This examination can be performed at our affiliated vascular clinic if needed.

 

5. ABI (Ankle-Brachial Index)

Purpose

Screening for peripheral arterial disease in the lower limbs

Clinical Significance

Safety evaluation before starting compression therapy

In patients with low ABI values, compression must be carefully adjusted

At our clinic, ABI is used not simply to decide whether compression can be applied, but how it should be applied safely.

 

6. Lymphoscintigraphy

Purpose

Evaluation of overall lymphatic transport function

Understanding the pathophysiology of primary versus secondary lymphedema

Exclusion of other internal medical conditions

 

【Role at Our Clinic】

Considered an international standard examination for lymphedema

Used in combination with lymphatic ultrasound and ICG lymphography

Helpful for disease staging, treatment planning, and patient explanation

 

Our Recommended Lymphoscintigraphy Protocol

At our clinic, we typically perform dual-phase imaging (15 minutes and 60 minutes after injection).

For lower-limb lymphedema, we emphasize subcutaneous injection between the toes, as this best reflects physiological lymphatic flow.

 

 

【FAQ for Patients】

Q1. Why are these examinations needed before lymphedema treatment?

A.

We evaluate lymphedema from three perspectives:

Excluding other causes of swelling (systemic or venous)

Ensuring the safety of compression therapy and surgery

Understanding lymphatic function

Having blood tests and circulatory evaluations in advance allows us to discuss treatment options more clearly from your first visit.

 

Q2. Which blood test items are especially important?

A.

We pay particular attention to:

Albumin (nutrition and generalized edema)

Kidney and liver function

Thyroid function

Inflammatory markers

Glucose metabolism

These help us determine whether swelling is caused by lymphedema alone and whether treatment can be performed safely.

 

Q3. Are chest X-rays and ECGs required for all patients?

A.

They are not mandatory for everyone, but are especially useful for:

Older patients

Patients with a history of heart disease

Patients with bilateral or rapidly progressing swelling

In such cases, swelling may not improve with lymphedema treatment alone, making differentiation important.

 

Q4. How is venous ultrasound related to lymphedema?

A.

Many patients with lymphedema also have:

Chronic venous insufficiency

Varicose veins

A history of DVT

If these are overlooked, compression therapy may be ineffective or may worsen symptoms.

 

Q5. Why is ABI testing important?

A.

ABI is essential for evaluating the safety of compression therapy.

Strong compression can be risky in patients with low ABI

Compression pressure and materials must be adjusted carefully

We use ABI to determine how to apply compression safely, not simply whether compression is possible.

 

Q6. Is lymphoscintigraphy mandatory?

A.

Yes, at our clinic it is considered an important examination.

If it cannot be performed at your referring institution, it will be scheduled during your visit.

Additional tests may include:

Lymphatic ultrasound

ICG lymphography

Lymphoscintigraphy provides a broad overview of lymphatic flow and supports diagnosis and patient education.

 

Q7. What are the characteristics of your lymphoscintigraphy protocol?

A.

We emphasize:

Multi-phase imaging (15, 30, and 60 minutes)

Subcutaneous injection between the toes to reflect physiological lymph flow

Continuous evaluation from the lower limb to the trunk

Detailed protocols regarding dosage, positioning, and exercise loading are provided separately.

 

Q8. How much does lymphoscintigraphy influence surgical decisions?

A.

It is not used alone.

We make decisions based on a comprehensive assessment including:

Lymphatic vessel diameter and wall condition on ultrasound

Dermal backflow patterns on ICG lymphography

Clinical symptoms and disease stage

Lymphoscintigraphy provides background understanding of overall lymphatic flow.

 

Q9. Do examinations need to be repeated if already done elsewhere?

A.

Usually not.

If results are:

Relatively recent (within one year)

Clinically consistent

we will use them. Additional tests are performed only if necessary.

 

Q10. What information is helpful when being referred?

A.

The following information is very helpful:

Underlying disease and surgical history (including lymph node dissection and radiation)

Onset and progression of swelling

Current compression therapy

History of venous disease or infections (such as cellulitis)

Results of previous examinations

This allows us to discuss treatment options from the very first visit.

 

Q11. What is the ultimate goal of this examination system?

A.

The goal is to:

Avoid unnecessary treatment

Avoid unsafe treatment

Offer the most appropriate option for each individual patient

Our clinic’s philosophy is to provide balanced care, without favoring either conservative therapy or surgery alone.