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Background Lymphaticovenous anastomosis (LVA) surgery is an effective surgical treatment of secondary lymphedema in the extremities, but indocyanine green (ICG) fluorescent lymphography, the reference standard for imaging target lymphatic vessels, has several limitations. More effective methods are needed for preoperative planning. Purpose To evaluate whether contrast-enhanced US (CEUS) can be used to identify target lymphatic vessels for LVA surgery in patients with secondary upper extremity lymphedema and compare the results with those from ICG fluorescent lymphography. Materials and Methods In this single-center retrospective review, CEUS with intradermal injection of microbubbles was performed in patients before LVA surgery in the upper extremities between October 2019 and September 2021. All patients had secondary upper extremity lymphedema from breast cancer treatment. Technical success rate was defined as lymphatic vessels identified with use of CEUS that led to successful LVAs. Descriptive statistics were used. Results All 11 patients were women (mean age, 56 years ± 8 [SD]). The median number of microbubble injection sites was 11 (range, 8-14). CEUS helped identify lymphatic vessels in all 11 women, including in six women in whom ICG fluorescent lymphography could not be performed or failed to help identify any targets. Thirty-five explorations (median, three per patient; range, two to four) were performed, and 24 LVAs (median, three per patient; range, zero to four) were created. Of the anastomoses, 33% (eight of 24) were mapped with use of both CEUS and ICG fluorescent lymphography, 58% (14 of 24) with CEUS only, and 8% (two of 24) with ICG fluorescent lymphography only. Among the 33 explorations on targets mapped with CEUS, an anastomosis could be made at 22 sites, for a technical success rate of 67%. Seven women had at least one additional LVA created from the use of CEUS. Conclusion Contrast-enhanced US is a promising tool for identifying lymphatic vessels in the upper extremities, especially when indocyanine green fluorescent lymphography fails to depict targets or cannot be used. Published under a CC BY 4.0 license.

Background Dynamic contrast-enhanced MR lymphangiography (DCMRL) is the reference standard used to diagnose various thoracic lymphatic disorders, such as traumatic chylothorax and plastic bronchitis. However, accessibility and logistical challenges have prevented the wide dissemination of this technology. Purpose To evaluate the feasibility of intranodal CT lymphangiography (ICTL) in the diagnosis and planning of subsequent intervention in patients with thoracic lymphatic disorders. Materials and Methods In this retrospective review, five women suspected of having lymphatic abnormalities (ranging from traumatic chylothorax to plastic bronchitis) and with contraindications to MRI underwent ICTL from September 2019 to May 2020. Needles (25 gauge) were placed in the bilateral inguinal lymph nodes with US guidance, and water-soluble iodinated contrast material was injected. CT fluoroscopy was used to monitor the opacification of the cisterna chyli to determine the timing of CT. After ICTL, the thoracic duct was catheterized, and lymphangiography was performed through the thoracic duct catheter. The ICTL and subsequent lymphangiographic findings were then visually compared by using three-dimensional reconstructions. Results Intranodal injection of water-soluble contrast medium was successful in all patients evaluated (five women; mean age, 68 years ± 11 [standard deviation]; range, 53-83 years). The central lymphatics were opacified in four of the five women, demonstrating abnormal pulmonary lymphatic flow from the thoracic duct into the lung parenchyma. In one of the five women, thoracic duct injection showed successful ligation of the thoracic duct. The time elapsed from injection of contrast medium to visualization of the thoracic duct ranged from 2 to 27 minutes. ICTL and lymphangiographic findings matched well. Conclusion Intranodal CT lymphangiography sufficiently depicted central lymphatic anatomy in patients with lymphatic abnormalities, thereby demonstrating its use as a feasible alternative to more technically challenging methods, such as dynamic contrast-enhanced MR lymphangiography. © RSNA, 2021.

Background Detailed visualization of the lymphatic vessels would greatly assist in the diagnosis and monitoring of lymphatic diseases and aid in preoperative planning of lymphedema surgery and postoperative evaluation. Purpose To evaluate the usefulness of photoacoustic imaging (PAI) for obtaining three-dimensional images of both lymphatic vessels and surrounding venules. Materials and Methods In this prospective study, the authors recruited healthy participants from March 2018 to January 2019 and imaged lymphatic vessels in the lower limbs. Indocyanine green (5.0 mg/mL) was injected into the subcutaneous tissue of the first and fourth web spaces of the toes and below the lateral malleolus. After confirmation of the lymphatic flow with near-infrared fluorescence (NIRF) imaging as the reference standard, PAI was performed over a field of view of 270 × 180 mm. Subsequently, the number of enhancing lymphatic vessels was counted in both proximal and distal areas of the calf and compared between PAI and NIRF. Results Images of the lower limbs were obtained with PAI and NIRF in 15 participants (three men, 12 women; average age, 42 years ± 12 [standard deviation]). All participants exhibited a linear pattern on NIRF images, which is generally considered a reflection of good lymphatic function. A greater number of lymphatic vessels were observed with PAI than with NIRF in both the distal (mean: 3.6 vessels ± 1.2 vs 2.0 vessels ± 1.1, respectively; P < .05) and proximal (mean: 6.5 vessels ± 2.6 vs 2.6 vessels ± 1.6; P < .05) regions of the calf. Conclusion Compared with near-infrared fluorescence imaging, photoacoustic imaging provided a detailed, three-dimensional representation of the lymphatic vessels and facilitated an increased understanding of their relationship with the surrounding venules. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Lillis and Krishnamurthy in this issue.

Background Most lymphatic imaging examinations of the lower limb require intradermal or subcutaneous injection of tracer material into the foot to demonstrate the lymphatic vessels; however, no standard protocol exists, and single or multiple injections are applied at different sites. Purpose To determine the three-dimensional relationships between each lymphatic group of the lower limb and corresponding regional lymph nodes. Materials and Methods A total of 130 lower limbs (55 from men and 75 from women) from 83 fresh human cadavers were studied. Lymphatic vessels were first visualized by using indocyanine green fluorescent lymphography with 19 injection sites in the foot, classified into four distinct lymphatic groups (anteromedial, anterolateral, posteromedial, and posterolateral); dilute oil-based contrast material was then injected. Next, specimens were scanned with CT and three-dimensional images were analyzed. Results The anteromedial and anterolateral lymphatic groups of the lower-leg lymphatic vessels were independent of each other and connected to different regional lymph nodes in the inguinal region. The posteromedial group and the anteromedial group in the lower leg drained to the same inguinal lymph nodes. Only the posterolateral group of lymphatic vessels in the lower leg drained to the popliteal lymph nodes. Leg lymphatic drainage pathways were independent of genital pathways. Conclusion Standard injection sites at the web spaces between the toes did not help visualize some lymph nodes of the lower leg. Additional injection sites in the medial, lateral, and posterior aspect of the foot would be better for evaluating the whole lymphatic pathways and regional lymph nodes and for improving understanding of leg lymphedema. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Weiss and Liddel in this issue.

To validate the usefulness of a newly developed tracer for preoperative gastric sentinel lymph node (LN) (SLN) mapping and intraoperative navigation after a single preoperative submucosal injection in rat and beagle models.This study was approved by the Experimental Animal Ethical Committee of Yonsei University College of Medicine according to the eighth edition of the Guide for the Care and Use of Laboratory Animals published in 2011. An emulsion was developed that contained indocyanine green in iodized oil, which can be visualized with both computed tomography (CT) and near-infrared (NIR) optical imaging and has the property of delayed washout. This emulsion was injected into the footpad of rats (n = 6) and the gastric submucosa of beagles (n = 8). CT lymphography was performed. The degree of enhancement of popliteal LNs was measured in rats, and the enhancing LNs were identified and the degree of enhancement of the enhancing LNs was measured in beagles. Next, NIR imaging was performed in beagles during open, laparoscopic, and robotic surgery to identify LNs containing the fluorescent signals of indocyanine green. The enhanced LNs detected with CT lymphography and NIR imaging were matched to see if they corresponded.Preoperative CT lymphography facilitated SLN mapping, and 26 SLNs were identified in eight beagles. NIR imaging enabled high-spatial-resolution visualization of both SLNs and the intervening lymphatic vessels and was useful for intraoperative SLN navigation.SLN mapping with fluorescent iodized oil emulsion is effective and feasible for both CT and NIR imaging.

To describe a dynamic magnetic resonance (MR) lymphangiography technique after intranodal injection of gadolinium-based contrast agent and to assess its feasibility for evaluation of the central conducting lymphatics (CCL) in patients with pathologic disorders that involve the CCL.A retrospective evaluation of experience with the dynamic MR lymphangiographic technique in six consecutive patients was performed after institutional review board approval. Written informed consent for the percutaneous procedure was obtained from the patient, parent, or the legally responsible guardian. The dynamic MR lymphangiographic technique involves ultrasonographically guided intranodal injection of gadolinium-based contrast material into the inguinal lymph nodes, combined with sequential imaging of the chest and abdomen with a three-dimensional sequence optimized for soft tissue with high spatial resolution that provides time-resolved imaging of lymphatic transit through the CCL. Qualitative assessment of the images was performed for reliability of CCL visualization and for associated findings that could explain the clinical symptoms, including lymphangiectasia, chylolymphatic reflux, and chylous leak.The procedure was technically successful in all six patients. The dynamic MR lymphangiographic findings confirmed the presence of normal CCL morphologic structure in two patients and provided a possible explanation for clinical manifestations in the remaining four patients. The dynamic MR lymphangiographic procedure led to a change in management in two patients, continuation of conservative treatment in three patients, and confirmation of an alternative nonlymphatic diagnosis in one patient. Image quality for visualization of the CCL was considered good in all cases by the two readers. There were no known adverse effects related to the procedure.The dynamic MR lymphangiographic technique with intranodal injection of gadolinium-based contrast material is feasible and can provide useful information in a variety of lymphatic flow abnormalities involving the CCL.

Purpose To evaluate the clinical performance of dual-agent relaxation contrast (DARC) magnetic resonance (MR) lymphangiography compared with that of conventional MR lymphangiography in the creation of isolated lymphatic maps in patients with secondary lymphedema. Materials and Methods This retrospective study was approved by the institutional review board. The diagnostic quality of 42 DARC MR lymphangiographic studies was compared with that of 42 conventional MR lymphangiographic studies. Two independent readers rated venous contamination as absent, mild, or moderate to severe. Interreader agreement on venous contamination grades was assessed by using the linearly weighted Cohen κ statistic. The Mann-Whitney U test was used to compare the distribution of grades at each station between conventional MR lymphangiography and DARC MR lymphangiography for each reader separately. Results DARC MR lymphangiography had significantly less venous contamination than did conventional MR lymphangiography (P.001). The two radiologists rated venous contamination as moderate to severe in 64% (27 of 42) and 69% (29 of 42) of distal limbs, 23% (10 of 42) of midlimbs, and 2% (one of 42) and 9% (four of 42) of proximal limbs at conventional MR lymphangiography compared with 0% (0 of 42) of distal limbs, 2% (one of 42) of midlimbs, and 0% (0 of 42) of proximal limbs at DARC MR lymphangiography. Lymphatic signal was partially attenuated (median 45% decrease) when longer echo times were used for venous suppression, but it did not subjectively degrade diagnostic quality. Conclusion DARC MR lymphangiography yields isolated lymphatic maps through nulling of venous contamination, thereby simplifying diagnostic interpretation and communication with surgical colleagues.

To prospectively compare findings of magnetic resonance (MR) lymphangiography with those of lymphoscintigraphy, evaluate the pattern and delay of lymphatic drainage, compare typical findings, and investigate discrepancies between the techniques.This prospective study was performed according to the Declaration of Helsinki and was approved by the local ethics committee. Thirty consecutive patients with uni- or bilateral lymphedema and lymph vessel transplants of the lower extremities were examined with 3.0-T fat-saturated three-dimensional gradient-echo MR after gadopentetate dimeglumine injection. Results of all examinations were correlated with corresponding results of lymphoscintigraphy examinations. Results of both techniques were separately reviewed in consensus by a radiologist and a nuclear physician, who rated delay and pattern of drainage, number of enhancing levels, and quality of conspicuity of the depiction of lymph nodes and lymph vessels. Sensitivity and specificity were calculated by using combined results of both techniques and clinical presentation findings as reference standard. Correlation was calculated with weighted k coefficients.Weak lymphatic drainage at lymphoscintigraphy correlated with lymphangiectasia at MR lymphangiography (13 of 33 affected extremities). Lymph vessels were clearly visualized with MR lymphangiography (five of 24 affected extremities), while they were not detectable with lymphoscintigraphy. Depiction of inguinal lymph nodes was clearer with lymphoscintigraphy (five of 60 extremities). Correlation of both techniques was excellent for delay (κ=0.93) and pattern (κ=0.84) of drainage, good for depiction of lymph nodes (κ=0.67) and number of enhancing levels (κ=0.77), and moderate for depiction of lymph vessels (κ=0.50). Sensitivity and specificity for delay and pattern of drainage were concordant, whereas MR lymphangiography showed a higher sensitivity for lymph vessel abnormalities (100% vs 79%) and lower specificity for lymph node abnormalities (78% vs 100%).Imaging findings of MR lymphangiography and lymphoscintigraphy show a clear concordance. With lymphoscintigraphy, better visualization of inguinal lymph nodes was achieved, whereas with MR lymphangiography, better depiction of lymph vessels and morphologic features of lymph vessel abnormalities were achieved.

To evaluate sentinel lymph node (SLN) mapping with interstitial computed tomographic (CT) lymphography with small volumes of iopamidol for direction of SLN biopsy in breast cancer.Thin-section transverse and three-dimensional CT images that included the breast and axilla were acquired at multi-detector row helical CT in 17 patients with operable breast cancer before subcutaneous injection of 2 mL of undiluted iopamidol into peritumoral and periareolar areas and 1-5 minutes after massage of injection sites. Location and size of SLNs were assessed at CT lymphography and were compared with SLNs at standard axillary lymph node dissection with blue dye staining.CT lymphography allowed localization of SLNs in all patients by means of visualization of a direct connection between an SLN and its afferent lymphatic vessels draining from the injection sites. Afferent vessels were joined and drained into a single axillary SLN, except in four patients with two or three SLNs, including a parasternal one. SLNs did not enhance because of rerouting of lymph flow in four patients. At surgery, SLNs that were stained or not stained with blue dye were easily found with CT lymphographic guidance. Tumoral infiltration was not evident in any resected nodes, except for infiltration in one patient with micrometastasis in SLN alone and infiltration in four patients with massive metastasis in both SLN and distant nodes.Because preoperative CT lymphography-guided SLN mapping provides SLN position with detailed lymphatic anatomy, it may be useful for the direction of breast SLN biopsy.

To investigate the enhancement of the regional lymph nodes, lymphatic vessels, and thoracic duct after interstitial administration of lymphotropic perfluorinated gadolinium chelates at magnetic resonance (MR) imaging.Two perfluorinated gadolinium chelates, gadofluoramide and gadofluorine 8, were injected subcutaneously into the hind legs of 10 pigs, respectively. Both contrast media were studied at doses of 10 and 25 micromol per kilogram of body weight. T1-weighted three-dimensional gradient-echo and maximum intensity projection images were obtained at 1.5 T between 1 and 210 minutes and 24 hours after injection. The contrast agents were qualitatively compared regarding enhancement and depiction of the regional lymph nodes, lymphatic vessels, and thoracic duct.The inguinal and iliac lymph nodes and lymphatic vasculature enhanced substantially within 10 minutes after subcutaneous administration of both lymphotropic contrast agents. Gadofluorine 8 showed a lymphographic effect superior to that of gadofluoramide. The paraaortic lymph nodes and thoracic duct were best visualized 10--50 minutes after injection of 25 micromol/kg of gadofluorine 8. Lymphatic system enhancement diminished after 2 hours, and the liver and bowel tract enhanced within 24 hours.Interstitial administration of perfluorinated gadolinium chelates offers great potential for T1-weighted MR lymphography with positive enhancement of the lymph nodes and lymphatic vasculature.

To evaluate the feasibility of CT lymphography with ethiodized oil for sentinel node mapping in porcine stomachs and in patients with early gastric cancer.Approval for the animal study was obtained from the authors' institutional animal use and care administrative advisory committee, the clinical study was approved by the institutional review board, and informed consent was obtained from each participant. Five pigs underwent CT lymphography 1 hour after gastric subserosal injection of 1 mL ethiodized oil and sentinel node mapping with injection of 1 mL methylene blue. Ethiodized oil retention nodes were identified on the radiographic images of the gastric specimen and removed for histopathologic examination. In addition, 10 patients with early gastric cancer underwent CT lymphography with peritumoral injection of 1 mL ethiodized oil, followed by sentinel basin extirpation with CT and routine nodal dissection. The removed sentinel basins were examined by radiography. Histopathologic examination was performed for dissected nodes, including sentinel nodes.In each of the five pigs, CT showed one perigastric ethiodized oil retention node. After harvesting the ethiodized oil retention node, blue-stained areas were identified in the five removed nodes and intranodal ethiodized oil was detected on histopathologic examination. In all 10 patients, CT lymphography with ethiodized oil successfully defined the sentinel basin with ethiodized oil retention nodes. CT lymphography revealed 20 ethiodized oil retention nodes. After basin extirpation, 28 and 46 nodes were detected on radiographic and histopathologic examinations. Histopathologic examination revealed that one patient had micrometastases at two sentinel nodes and another patient had isolated tumor cells at one sentinel node. No patient had metastasis in nonsentinel nodes.CT lymphography with ethiodized oil may be a feasible method for sentinel node mapping in patients with early gastric cancer.

To examine the extracellular (dispersed particles) and intracellular (phagocytosed particles) colloidal particle transport from subcutaneous tissue into the lymphatic system.Perfluorocarbon emulsions LA11063 (mean particle diameter, 0.34 micron) and ZY12149 (mean particle diameter, 0.06 micron) were individually injected into the dorsal skin of the hind foot of rabbits. Lymph flow rates and particle concentrations were determined in prenodal lymph fluid after injection, with and without massage of the skin over the injection site.In the first 24 hours after injection, extracellular colloid flux was substantially larger than intracellular flux. Lymph flow rates and colloid concentrations increased substantially with massage. Extracellular LA11063 flux was smaller than ZY12149 flux, whereas intracellular LA11063 flux exceeded ZY12149 flux.Transport of colloids into lymphatic vessels is dependent on particle size. Both extracellular and intracellular pathways are utilized. External tissue movement contributes substantially to the rate of particle uptake via both pathways.

To evaluate the feasibility of an endoscopic computed tomographic (CT) lymphography technique with submucosal injection of iopamidol for direct visualization of lymphatic drainage pathways in dogs and in patients with operable esophageal cancer.With institutional animal committee approval, a total of 2 mL of undiluted iopamidol was injected into the esophageal (n = 6) or gastric (n = 3) submucosa in nine dogs by using a flexible endoscope. Multi-detector row CT images (section thickness, 1.25 mm) were obtained before contrast material injection and during the 10 minutes after injection. The animals were euthanized so that their lymphatic anatomy could be examined. With ethical committee approval and patient informed consent, nine patients with esophageal cancer also underwent CT lymphography with peritumoral injection of 2 mL of iopamidol, followed by esophagectomy and regional lymph node dissection with CT lymphographic guidance. The histopathologic features of dissected nodes, including sentinel lymph nodes (SLNs), were examined.CT lymphography depicted the direct connection of lymphatic drainage vessels with enhanced and/or unenhanced nodes (ie, SLNs) as early as within 5 minutes after contrast material injection in all subjects. All 13 SLNs in dogs (1.4 nodes per animal) and 18 SLNs in patients (two nodes per patient) were found and dissected at the correct location by using CT lymphographic guidance. In patients, histopathologic examination revealed the high predictive value of CT lymphographic-guided SLN biopsy: Only one of the preoperatively identified SLNs in three patients and both SLNs and adjacent nodes in two patients were positive for metastasis; all resected nodes in the remaining four patients were negative.Endoscopic CT lymphography is a feasible method for visualizing the direct connection between and the accurate anatomic location of SLNs and lymphatic drainage vessels.

An unusual case of lipid embolization to brain and kidney after lymphography in a patient with non-Hodgkin lymphoma of the upper anterior mediastinum is reported. Contrast material-enhanced echocardiography demonstrated a right-to-left shunt to the left atrium without evidence of a patent foramen ovale. Echo contrast particles were transiently present within the tumor surrounding the great vessels.

To review past and possible future management of localized carcinoma of the prostate.Cases were reviewed of 963 patients with localized carcinoma of the prostate treated with external irradiation between 1967 and 1992.In 287 patients who underwent pretreatment pedal lymphangiography, there was a positive but not statistically significant correlation between normal or abnormal findings and 10-year disease-free survival (DFS) with clinical stage A (T1a-T1c), B (T2), or C (T3) disease. In 483 patients who underwent pretreatment computed tomography (CT) of the pelvis and abdomen, there was no correlation between radiologic findings and outcome for stage A2 and B disease. With stage C disease and no evidence of positive pelvic lymph nodes, 10-year DFS was 50%. No patients with positive lymph nodes survived. With stage C disease and periprostatic or seminal vesicle involvement, 10-year DFS was 19%, and it was 42% without those findings (Por = .01).Prospective clinical trials must be performed to help define optimal management of prostatic cancer.

PURPOSE: To evaluate the usefulness of lymphangiography in the staging of Hodgkin disease. MATERIALS AND METHODS: The authors retrospectively evaluated the lymphangiograms of 39 previously untreated patients with Hodgkin disease (clinical stage, 1-2A). The patients had no evidence of bulky mediastinal nodal disease, and results of abdominal and pelvic computed tomographic examination were negative for parenchymal organ disease and retroperitoneal and mesenteric node involvement. The studies were officially interpreted as normal or abnormal. No attempt was made to differentiate benign reactive changes from tumor infiltration. All patients underwent confirmatory staging laparotomy. RESULTS: Of the 39 patients, 29 had normal lymphangiograms. All 29 had normal lymph nodes at laparotomy. Of the 10 patients with abnormal lymphangiograms, only two had malignant infiltration of lymph nodes at laparotomy. The other eight showed benign reactive hyperplasia. CONCLUSION: Lymphangiography has no place in the managemen...

PURPOSE: To evaluate the imaging efficacy of percutaneous lymphography performed with injection of perflubron emulsions and computed tomography (CT). MATERIALS AND METHODS: Thin-section CT was used to image lymph nodes in 116 rabbits and six monkeys. Quantitative measures of regional lymph node enhancement were obtained 4 hours to 21 days after subcutaneous injection of perflubron (0.1-0.5 mL per injection site). Lymph node enhancement was calculated in Hounsfield units and converted to bromine concentration with standards that were imaged at the same time. RESULTS: Excellent enhancement of regional lymph nodes in both groups of animals was obtained. Nodal enhancement was linearly related to dose and was sustained for 20 days; maximum enhancement was seen 2 days after injection. Massage of the injection site increased delivery of the perflubron emulsion to regional lymph nodes. CONCLUSION: In rabbits and monkeys, percutaneous CT lymphography effectively depicts the intranodal distribution of macrophages i...

A retrospective study was performed to assess whether lymphangiography and gallium-67 scanning were complementary to computed tomography (CT) in abdominal staging of disease in 94 patients with early-stage thoracic Hodgkin disease. In 51 patients with surgical or follow-up correlation, the spleen was involved in 16% (n = 8), the spleen and lymph nodes in 22% (n = 11), and only lymph nodes in 2% (n = 1). In these 51 patients, none of the imaging modalities had greater than 50% sensitivity for the detection of nodal involvement. The overall accuracy was similar (71%-82%) for each modality. Analysis of subgroups of patients with lymph nodes measuring less than 10 mm, 10-19 mm, or 20 mm or greater at CT revealed that lymphangiography and gallium scanning added little to the positive or negative predictive values of CT. The sensitivity of CT for detection of splenic disease was 11% (two of 19). On the basis of surgical or follow-up correlation in 51 patients, the authors conclude that lymphangiography and gallium scanning offer minimal or no complementary benefit.

This study was designed to assess the complications of angiography, including transfemoral, transaxillary, and translumbar approaches. Detailed questionnaires were completed by radiologists at 514 of the 2,066 hospitals surveyed. The radiologists reported on the complications of 118,591 examinations. The overall arteriography complication rates were: transfemoral 1.73%, translumbar 2.89%, and transaxillary 3.29%. Thirty deaths were reported, eight of which were caused by aortic dissection or aneurysm rupture. Among the three techniques, there was no difference in the incidence of cardiac complications. There were significantly more neurologic complications, including seizures, in the transaxillary group than there were in either the transfemoral or translumbar groups. Similarly, hemorrhage, arterial obstruction, and pseudoaneurysms were more common with the transaxillary technique than with either of the other approaches. Vessel perforation and extraluminal contrast material were seen most frequently with the translumbar technique. Overall, between the two selective approaches, the transfemoral route carried a significantly smaller risk of complications than the transaxillary approach. There was an inverse relationship between complication rate and the annual number of arteriograms obtained. This was most striking in hospitals without residency training programs. The complications of adrenal venography, peripheral venography, pedal lymphography, and of studies for suspected pheochromocytoma were also assessed.

Lymphangiography was performed on 40 adult cats, 39 dogs, 20 rabbits, and 12 rats of mixed sex using Ethiodoi® or radiopaque perfluorocarbon (RPC). Ethiodoi was more radio-dense than RPC, but imaging of lymph channels and nodes was satisfactory with the latter. RPC could be infused rapidly, while Ethiodoi infusion was time consuming. RPC was biologically inert; Ethiodoi produced both local and systemic inflammatory reactions. The lymph node distribution with RPC was more uniform and persisted for longer periods. It was concluded that RPC was an improvement over Ethiodoi for lymphangiography.

A prospective study of the yield of various routinely performed radiographic examinations in the initial evaluation of 93 patients with previously untreated non-Hodgkin's lymphoma was undertaken. Of these, 69 patients underwent staging laparotomy and, where pathologic correlation was possible, the lymphogram showed a 92% accuracy. Chest radiography, lymphography, and excretory urography are valuable routine procedures. Barium gastrointestinal studies should be employed if specific symptoms are present. Skeletal surveys had a very low yield. The staging laparotomy provides reliable information regarding involvement of spleen, liver, and mesenteric lymph nodes.

In the 150 years since the first description of Hodgkin's disease, treatment methods have become increasingly sophisticated and effective. We now know that relapses are concentrated within the first five years after treatment. Accordingly, anyone who survives the first five years has a 95% chance of cure. Modern techniques in diagnosis, staging, and combined chemotherapy and irradiation have brought us within sight of total therapeutic conquest of this once inexorably fatal malady.

A roentgenographic-pathologic correlation study was done on 372 normal and 134 abnormal lymphograms. Contrast medium in the sinusoids was seen either as radiopaque rings around lucent lymph follicles or as radiopaque dots. Some nodes showed mainly the ring, others the mixed pattern. In visualized lymph nodes involved with Hodgkin's disease, most subtypes demonstrated irregular filling defects. Most forms of non-Hodgkin's lymphoma, especially the lymphocytic and mixed cell types, present a homogeneous appearance, all abnormal nodes exhibiting similar abnormal filling defects.

This prospective study assesses the contribution of lymphography (LAG), abdominal-pelvic computed tomography (CT), and bone marrow biopsy to the staging and management of 168 consecutive cases of newly diagnosed non-Hodgkin lymphoma (NHL). LAG and/or CT influenced Ann Arbor clinical stage (CS) in 39 patients (23%) and Ann Arbor pathologic stage (PS) in 23 patients (14%) by detection of clinically inapparent retroperitoneal adenopathy and/or extranodal disease. LAG findings raised the CS in eight patients and the PS in six of the eight by showing adenopathy when the CT results were negative. By depicting extranodal disease, CT resulted in the CS being raised in an additional ten patients and the PS in six of the ten. Of the diagnostic tests assessed, bone marrow biopsy and/or cytology had the greatest influence on staging. Clinical staging that included LAG/CT resulted in the identification of only 30 patients with CS IV disease, whereas an additional 53 CS I through CS III patients had their disease stage raised to PS IV due to positive bone marrow biopsy/cytology results. However, 42 of the 53 patients already had advanced (CS III) disease. Initial case management was influenced by LAG, CT, or bone marrow biopsy/cytology results in 27 of 168 patients. LAG/CT results influenced management in 20 of 27 cases, while bone marrow biopsy/cytology results caused initial management changes in only seven of the 27 cases.

One hundred thirty-nine patients with pelvic cancers (101 bladder carcinomas, 27 prostatic carcinomas, and 11 testicular tumors) considered for radical surgery were studied with lymphography and percutaneous fine-needle aspiration (FNA) biopsy, and the results were correlated with lymphadenectomy. Adequate material for FNA was obtained in 97%, 88%, and 100% of the bladder, prostatic, and testicular tumors, respectively. For bladder carcinoma, the global accuracy was 58% for lymphography and 93% for FNA; the high false-negative rate for lymphography (48%) was lowered to 25% with FNA, providing that the obturator nodes were punctured. For prostatic carcinomas, it was not possible to evaluate the true-positive rate because the patients with positive FNA results did not under-go surgery. For testicular tumors, lymphography and FNA had almost the same global accuracy (73% and 75%), but FNA had a better specificity (100%) than lymphography (86%). FNA had no false-positive results, which means that positive biopsy results obviate radical surgery; when FNA results are negative a lymphadenectomy should be performed. With its mild morbidity, FNA has a role in the preoperative staging of pelvic carcinomas.

Between 1957 and 1972, 384 patients with bladder cancers were treated initially with megavoltage radiation therapy. Actuarial five-year survival ranged from 35 to 42% for Stages A and B1 tumors, and was 35, 22 and 7%, respectively, for Stages B2, C and D carcinomas. Approximately 30-40% of deeply invasive tumors confined to the bladder can be controlled with radiation therapy alone, directed solely to the bladder itself.

In 20 patients with congenital and acquired lymphedema in either upper or lower extremities and in four patients without extremity edema, human serum albumin labeled with technetium-99m was injected intradermally into a digital web space of the hand or foot. With a digital gamma camera that permitted a "sweep" of the torso, serial extremity and whole-body lymphagioscintigraphy (LAS) of the peripheral lymphatic system was performed. In 11 patients with acquired lymphedema, a well-defined obstructive pattern was seen, characterized by discrete peripheral lymphatic trunks, delayed or absent depiction of regional nodes, and delayed but extensive soft-tissue tracer extravasation. Five of nine patients with congenital lymphedema showed hypoplasia characterized by poorly defined lymphatic trunks, delayed depiction of regional nodes, and early and extensive extravasation of tracer. The other four patients showed aplasia, with absence of trunks, no depiction of nodes, and little or no tracer extravasation. LAS is technically simple to perform and requires no special training. Radiation exposure is minuscule, and the procedure is safe and without apparent side effects. For these reasons, whole-body LAS should be the preferred method for the initial assessment of congenital or acquired lymphedema.

The authors studied the computed tomographic (CT) images obtained in 56 patients with pathologically proved biliary cancer and 75 patients with no evidence of biliary disease, attempting to define the normal anatomy of the lymphatic system draining the bile ducts and the prevalence of extrahepatic spread of primary biliary cancer into these retroperitoneal planes. Of 20 patients with gallbladder cancer, 14 (70%) had proved adenopathy and nine (45%) had peritoneal spread at presentation, and another three later developed carcinomatosis. Of 22 patients with proximal cholangiocarcinoma, 16 (73%) had nodal involvement at presentation, four later developed adenopathy, and five had peritoneal dissemination. Distal or diffuse cholangiocarcinomas were less associated with metastatic nodes or peritoneal spread. For all biliary cancers, the nodes most commonly involved were the node of the foramen of Winslow, the superior pancreatoduodenal node, and the posterior pancreatoduodenal chain. Extrahepatic tumor spread produced proximal intestinal obstruction in 13 patients (23%). CT reliably demonstrates lymphatic or other extrahepatic spread of biliary cancers, which may have an important bearing on management decisions.

The initial radiographs of 51 consecutive, previously untreated children with non-Hodgkin's lymphoma were reviewed. The chest radiograph was abnormal in 37%, with pleural effusions seen in 14% of patients. Lymphography, readily performed in children, was positive in 30% of the successful studies. There was a high incidence of bone lesions (18% of patients), due in large part to involvement of the facial bones; all were symptomatic and/or seen on the routine chest and abdominal radiographs. Intrinsic disease of the small bowel (10%) and colon (8%) was also associated with symptoms, so that the value of routine barium studies in asymptomatic children is questioned.

Two cases of pulmonary lymphangiectasia associated with Noonan's syndrome are described. Chest films showed diffuse pulmonary intersitial infiltrates from infancy. Lymphangiograms demonstrated obstructive changes and collateral formation in the retroperitoneal, mediastinal, pulmonary, and cervical lymphatics and extensive opacification of the pulmonary and visceral pleural lymphatics. Possible mechanisms and causes of the lymphatic malformation are discussed.

Of 59 patients undergoing lymphography as part of staging for urologic tumor (bladder carcinoma, prostate carcinoma, seminomatous and nonseminomatous testicular tumors), histological material was obtained in 38. Lymphography was shown to have a specificity of 95%, a sensitivity of 81%, and an overall accuracy of 89%. When lymph node regions were considered, the specificity was 99.2%, sensitivity 59%, and overall accuracy 91%. Causes of discrepancies between radiography and histology are evaluated and receiver operating characteristic curves are demonstrated.

A review of 339 cases of uterine cervix carcinoma revealed lumbar spine involvement characterized by unilateral destruction or sclerosis of contiguous vertebrae, often with disk narrowing and accompanied by high ureteral obstruction. The left side is usually involved probably due to direct invasion from tumor-containing lymph nodes.

A comparison was made between post-lymphangiogram abdominal radiographs and computed tomographic (CT) scans in 18 lymphoma patients. When radiographs were obtained more than one year after the original lymphangiogram, only a small percentage of the patients had adequate contrast medium remaining in the lymph nodes for a definitive diagnosis. In three cases with apparently adequate residual contrast material, the radiograph did not provide accurate information on the presence or extent of recurrent lymphoma. The authors conclude that CT is the preferred method for the initial staging of patients with lymphoma, as well as for follow-up studies after one year.

If costs of medical care are to be reduced, the choice of which imaging modality to use must be made as carefully as possible. This study was done to show how radiological modalities were used to evaluate patients with Hodgkin disease and non-Hodgkin lymphoma. We kept a record of every radiological study performed on 66 children with both diseases seen in the past 6 1/3 years. The results of these studies were analyzed to see which areas of the body were studied, which imaging modality was used, how frequently the studies were repeated, and how frequently the studies gave abnormal results. Our findings disclosed that radiological studies have been appropriately performed in anatomic regions of the body in which disease is present. New imaging modalities have been introduced, and the use of some of the older modalities has been decreased. With some modalities, such as skeletal survey, liver/spleen scan, whole-lung tomography, contrast studies of the bowel, and excretory urography, utilization is higher than it ought to be in view of the fact that the yield of positive results is low and the information is obtainable in many cases from other more sensitive procedures. These studies should not be performed as a routine on initial evaluation or follow-up of all patients with Hodgkin or non-Hodgkin lymphomas. On initial presentation all patients should undergo chest radiography and CT scanning of both chest and abdomen. A problem area is that the timing of follow-up studies has been somewhat erratic, with some inappropriate studies particularly 3 or 4 years after diagnosis. Too many imaging procedures have probably been done in follow-up of our patients.

Two cases of pulmonary lymphatic opacification during lymphangiography in the presence of a normal thoracic duct are reported. The most likely route of filling of the pulmonary lymphatics in the lower lobes is by reversed flow from the thoracic duct through the inferior pulmonary ligament lymphatics. Retrograde flow from the bronchomediastinal trunk is unlikely.

In recent years various efforts have been made to outline the lymphatics roentgenographically. The first really successful technic was that described by Kinmonth, Taylor, and Kemp Harper in 1955 (2). In attempting to visualize the lymphatics of the bronchopulmonary system, however, one encounters difficulty when using the standard procedures. While the lymphatics of the bronchopulmonary system have been described, notably by Rouviere, there is little in the literature on their radiologic appearance (6, 7). Because roentgenography of the bronchopulmonary lymphatics cannot be accomplished with direct cannulation to the peripheral lymphatics as devised by Kinmonth, an indirect method which was attempted experimentally by earlier investigators (4) was re-examined. The purpose of our study was to develop a new technic of clinical bronchopulmonary lymphography. Experimental Investigations Method and Materials: Contrast media: Crystalloids (water-soluble materials) which are miscible in lymph drain rapidly from ...

Since 1955, when Kinmonth and his co-workers (8) described a practical method for the intralymphatic injection of contrast substance, lymphangiography has come into widespread use. The procedure is being employed in diagnosis, in radiotherapy, and in the study of the physiology of the lymphatic system in various diseases (1, 4, 6, 7, 9, and 11). Despite this extensive use of Ethiodol in the procedures mentioned, there has been little detailed investigation of the metabolic fate of the medium in either man or animals. This problem became of interest when the frequent radiographic appearance of oil in the lungs was noted after diagnostic procedures (2, 13). Because of this, it was concluded that the oil did not remain confined to the lymphatic system and possibly was widely distributed throughout the body. Knowledge of its distribution became of more practical significance with the advent of the therapeutic use of the medium (1, 12). It was believed that studies with radioactive tracer technics in dogs unde...

Lymphography, despite some difficulties in performance and uncertainties in interpretation, has become accepted and is being more and more widely used in the clinical investigation of numerous diagnostic problems. I t is a valuable procedure in the staging of lymphomas, the search for metastases in cases of known carcinoma, and the elucidation of puzzling clinical problems. The best demonstration of both lymphatic vessels and nodes is achieved by the injection of Ethiodol,2 a contrast material with an oil vehicle. The medium eventually finds its way into the blood stream, either via the cisterna chyli and thoracic duct (Fig. 1) or, occasionally, via lymphaticovenous anastomoses (Fig. 2). In addition to the usual complications of intravascular introduction of foreign materials, including allergic reactions, the medium might be expected to cause difficulty because of microembolization consequent on its physical properties (Fig. 3). In practice, in our hands the side-effects have been minimal and have not ca...

Although rare, lymphangiomatosis should be considered as a possibility in children with osteolytic skeletal lesions. This diagnosis can be made from the lymphogram without need for biopsy. Radiographic features include an avascular lesion affecting both the cortex and spongiosa of the bone that may present as a pathological fracture; few normal lymph nodes in the affected area; and, frequently, swelling due to soft-tissue lymphangiomas and lymphatic stasis. Contrast medium may be visualized within the lesion for many months following injection. A representative case is presented.

In an attempt to evaluate the relative merits of early extensive radiotherapy of localized lymphoma, it occurred to us that it would be desirable to classify with greater accuracy those cases which could truly be called “localized.” This problem seemed particularly important when the inguinal and femoral areas were believed to be the only sites involved, since there was no good method for delineating enlarged pelvic and lumbar lymph nodes. Bruun and Engeset, in an article entitled “Lymphadenography” (1), described the results of injecting contrast material directly into an enlarged lymph node. Modifying their technic, we carried out a series of experiments to visualize lymph nodes and lymph channels. After a trial of various radiopaque media, a method was devised which successfully outlined chains of lymph nodes. Materials and Methods3 The skin overlying an accessible lymph node was carefully cleansed with alcohol. As in venipuncture, the injection of the radiopaque material was carried out without premed...

The complications of lymphangiography have been of particular interest with the increasing application of this technic on a large scale to the study of the lymphatics in man. The reactions reported have been primarily respiratory in character, although other types have been described (2–6). In a series of 400 lymphangiographic studies performed in the Stanford University Department of Radiology, 4 instances of severe complicating dermatitis have been observed. Three of these cases are reported in this article because of their uniqueness and because of the desirability of documenting all possible complications. The technic employed has already been described elsewhere (2) and did not vary in the 3 patients. In each, the injection was terminated when the contrast material reached the cisterna chyli or following the injection of 10 cc. The injection time was always at least fortyfive minutes. Case Reports Case I: G. E. The patient was a 56-year-old white woman admitted for evaluation of eight months of exten...