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Update and audit of the St George’s classification algorithm of primary lymphatic anomalies: a clinical and molecular approach to diagnosis
  1. Kristiana Gordon1,2,
  2. Ruth Varney1,
  3. Vaughan Keeley3,
  4. Katie Riches3,
  5. Steve Jeffery4,
  6. Malou Van Zanten1,
  7. Peter Mortimer1,2,
  8. Pia Ostergaard1,
  9. Sahar Mansour1,5
  1. 1 Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
  2. 2 Dermatology & Lymphovascular Medicine, St George's Universities NHS Foundation trust, London, UK
  3. 3 Lymphedema Clinic, Derby Hospitals NHS Foundation Trust, Derby, UK
  4. 4 Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
  5. 5 SW Thames Regional Genetics Service, St George’s Hospital, London, UK
  1. Correspondence to Professor Sahar Mansour, SW Thames Regional Genetics Service, St George's Hospital, London SW17 0RE, UK; smansour{at}


Primary lymphatic anomalies may present in a myriad of ways and are highly heterogenous. Careful consideration of the presentation can lead to an accurate clinical and/or molecular diagnosis which will assist with management. The most common presentation is lymphoedema, swelling resulting from failure of the peripheral lymphatic system. However, there may be internal lymphatic dysfunction, for example, chylous reflux, or lymphatic malformations, including the thorax or abdomen. A number of causal germline or postzygotic gene mutations have been discovered. Some through careful phenotyping and categorisation of the patients based on the St George’s classification pathway/algorithm. The St George’s classification algorithm is aimed at providing an accurate diagnosis for patients with lymphoedema based on age of onset, areas affected by swelling and associated clinical features. This has enabled the identification of new causative genes. This update brings the classification of primary lymphatic disorders in line with the International Society for the Study of Vascular Anomalies 2018 classification for vascular anomalies. The St George’s algorithm considers combined vascular malformations and primary lymphatic anomalies. It divides the types of primary lymphatic anomalies into lymphatic malformations and primary lymphoedema. It further divides the primary lymphoedema into syndromic, generalised lymphatic dysplasia with internal/systemic involvement, congenital-onset lymphoedema and late-onset lymphoedema. An audit and update of the algorithm has revealed where new genes have been discovered and that a molecular diagnosis was possible in 26% of all patients overall and 41% of those tested.

  • central conducting lymphatic anomaly (CCLA)
  • lymphatic
  • generalised lymphatic anomalies (GLA)
  • primary lymphoedema

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  • Correction notice This article has been corrected since it was published Online First. Figure 1 has been replaced to correct the 'Late onset' value to '>1 y'.

  • Contributors KG: clinician, patient examination. RV: completed the audit and wrote initial draft. VK clinician, patient examination. KR: clinician, patient examination. SJ: supervises the molecular lab and edited the manuscript. MVZ: senior research coordinator. PM: clinician, patient examination. PO: supervises the molecular lab and edited the manuscript. SM: original concept, supervision of audit, revision of manuscript and clinician/patient examination.

  • Funding This study was funded by the British Heart Foundation.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Commissioned; externally peer reviewed.

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