LymphographyLymphographyByBy

Dr/ Dina MetwalyDr/ Dina Metwaly

  lymphatic systemlymphatic system

  it is part of the circulatory system, comprising a it is part of the circulatory system, comprising a

network of lymphatic vessels that carry a clear network of lymphatic vessels that carry a clear

fluid called lymph directionally towards the fluid called lymph directionally towards the

heart. heart. 

The lymphatic system consists of lymphatic The lymphatic system consists of lymphatic

organs, a conducting network of lymphatic organs, a conducting network of lymphatic

vessels, and the circulating vessels, and the circulating lymph..

The Lymphatic System functionsThe Lymphatic System functions

Slide 12.1Slide 12.1

Transport clean fluids back to the

blood

Drains excess fluids from tissues

Removes “debris” from cells of

body

Transports fats from digestive

system

Lymphatic SystemLymphatic System

Thymus Thymus Gland Gland

Lymph Lymph VesselsVessels

Lymph NodesLymph Nodes Spleen Spleen Tonsils Tonsils

Lymphatic CapillariesLymphatic Capillaries

Fluid leaks through mini-valves into lymph capillaries

Higher pressure on the inside closes mini-valves

Lymphatic VesselsLymphatic Vessels

Collects lymph from lymph

capillaries

Delivers lymph to lymph nodes

Returns fluid to circulatory

veins near the heart

Right lymphatic duct

Thoracic duct

Lymphatic System StructuresLymphatic System Structures

Lymph NodesLymph Nodes

Filter lymph before it is

returned to the blood

Defense cells in nodes:

Medulla houses macrophages

which engulf and destroy

foreign substances

Cortex nurtures lymphocytes

which provide immune

response to antigens (cortex)

Lymphoid OrgansLymphoid Organs

Several other organs

contribute to lymphatic

function

1. Spleen

2. Thymus

3. Tonsils

4. Peyer’s patchesFigure 12.5

The SpleenThe Spleen

Filters blood

Destroys worn out blood cells

Forms blood cells in the fetus

Acts as a blood reservoir

The ThymusThe Thymus

Functions at peak levels

only during childhood

Produces hormones (like

thymosin) to program

lymphocytes

TonsilsTonsils

Small masses of lymphoid

tissue around the pharynx

Trap and remove bacteria and

other foreign materials

Tonsillitis is caused by

congestion with bacteria

Peyer’s Patches Peyer’s Patches “Tonsils of the intestine” “Tonsils of the intestine”

Found in the wall of the small intestine

Capture and destroy bacteria in the

intestine

LymphographyLymphography

General term applied to the General term applied to the

radiologic examination of:radiologic examination of:

Lymph nodesLymph nodes

(lymphadenography) : (lymphadenography) :

radiographic visualization of the radiographic visualization of the

lymph nodes . lymph nodes .

Lymph Vessels: endovascular Lymph Vessels: endovascular

injection of radiopaque material injection of radiopaque material

into a lymphatic vesselinto a lymphatic vessel

Usually done to demonstrate pelvis and Usually done to demonstrate pelvis and

abdomenabdomen

Injected in footInjected in foot

For axillary, clavicular area and upper limbsFor axillary, clavicular area and upper limbs

Injected in hand Checks drainage of lymph Injected in hand Checks drainage of lymph

nodesnodes

IndicationsIndications

Edema in limbs by Edema in limbs by

Visualization of vessel Visualization of vessel

obstructionobstruction

InfectionsInfections

Rule out cancerRule out cancer

Lymphoma staging & Check Lymphoma staging & Check

for metastasisfor metastasis

Size, shape, location of Size, shape, location of

enlarged nodesenlarged nodes

Fluoroscopy guided biopsy Fluoroscopy guided biopsy

ContraindicationsContraindications

  PregnancyPregnancy

People with allergies to iodine-based People with allergies to iodine-based

contrast dyes.contrast dyes.

people with severe chronic lung, heart, people with severe chronic lung, heart,

kidney, or liver disease.kidney, or liver disease.

Pre ProcedurePre Procedure

Obtain PT history Obtain PT history

Obtain PT consentObtain PT consent

Make sure to have all supplies Make sure to have all supplies

Make sure the absence of contraindications, Make sure the absence of contraindications,

which are cardiovascular or pulmonary which are cardiovascular or pulmonary

diseasedisease

Positioning aides and comfort suppliesPositioning aides and comfort supplies

ContrastContrast

Water based (less commonly used as it diffuse in Water based (less commonly used as it diffuse in

nearby tissues).nearby tissues).

Oil based Oil based

More commonly usedMore commonly used

EthiodalEthiodal

LipodalLipodal

Dose: The total amount of oily contrast medium Dose: The total amount of oily contrast medium

injected on each side should never exceed 10 mLinjected on each side should never exceed 10 mL

Procedure of lower limb Procedure of lower limb lymphography ( pedal lymphography ( pedal lymphangiography)lymphangiography)

Injection of mixture of local anesthesia + methylene Injection of mixture of local anesthesia + methylene

blue violet on the dorsal aspect of the foot between the blue violet on the dorsal aspect of the foot between the

toes.toes.

longitudinal incision ---> isolation of lymphatic vessel longitudinal incision ---> isolation of lymphatic vessel

from the surrounding fatty tissue from the surrounding fatty tissue

visualization of superficial collectors after visualization of superficial collectors after

subcutaneous injection of contrast materialsubcutaneous injection of contrast material

1.1. into the first and second inter-metatarsal spaces into the first and second inter-metatarsal spaces

of the dorsal foot (for superficial circulation)of the dorsal foot (for superficial circulation)

oror

2.2. or lateral retro-malleolar space (for deep or lateral retro-malleolar space (for deep

circulation)circulation)

Nodes in pelvis and abdomen are demonstrated Nodes in pelvis and abdomen are demonstrated

with foot injectionwith foot injection

A needle or catheter is inserted into a lymphatic channel in A needle or catheter is inserted into a lymphatic channel in

either the foot or arm, and a contrast medium is injected either the foot or arm, and a contrast medium is injected

into the body at a very slow rate (approximately 60 to 90 into the body at a very slow rate (approximately 60 to 90

minutes for all the contrast medium to be injected).minutes for all the contrast medium to be injected).

A fluoroscope is used to follow the dye as it spreads A fluoroscope is used to follow the dye as it spreads

through the lymphatic system through the legs, into the through the lymphatic system through the legs, into the

groin, and along the back of the abdominal cavity.groin, and along the back of the abdominal cavity.

Once the contrast medium is injected, the catheter is Once the contrast medium is injected, the catheter is

removed, and the incisions are stitched and bandaged.removed, and the incisions are stitched and bandaged.

FilmingFilming

X-rays are usually taken 1 HR after pressure X-rays are usually taken 1 HR after pressure

injection that takes about 45 minutesinjection that takes about 45 minutes

After 1 hourAfter 1 hour

24 hrs24 hrs

48 hrs (if needed)48 hrs (if needed)

72hrs (if needed)72hrs (if needed)

First hourFirst hour= = Contrast in lymph ductsContrast in lymph ducts

24 hours 24 hours = = If lymph nodesIf lymph nodes

After 1 hour= After 1 hour= LymphangiogramsLymphangiograms

the first films are taken the first films are taken

usually of the lymph usually of the lymph

vesselsvessels the upper body or the upper body or

any area of interest. any area of interest.

These first flims are called These first flims are called

“Lymphangiograms”!“Lymphangiograms”!

LymphadenogramsLymphadenograms

24 hours after the 24 hours after the

Lymphangiograms Lymphangiograms

are taken the patient are taken the patient

has to come back to has to come back to

have the films taken have the films taken

of the lymph of the lymph nodes nodes

called called

“lymphadenograms!”“lymphadenograms!”

upper limb upper limb lymphography lymphography

injection of contrast agent in a collector of injection of contrast agent in a collector of

dorsal radio-carpal surface (for superficial dorsal radio-carpal surface (for superficial

circulation) or ulnar retro-styloid location circulation) or ulnar retro-styloid location

(for deep circulation) (for deep circulation)

radiography of the lymphatic channels from radiography of the lymphatic channels from

forearm to axillary lymph nodesforearm to axillary lymph nodes

Upper Limb Upper Limb LymphographyLymphography

Normal appearances and Normal appearances and variationsvariations

1.1. Normal appearance of lymph nodes.Normal appearance of lymph nodes.

a)a) Lymphogram (filling phase): shows a homogeneous Lymphogram (filling phase): shows a homogeneous appearance of the lymph nodes. appearance of the lymph nodes.

b)b) Lymphogram (nodal phase): shows a smooth peripheral Lymphogram (nodal phase): shows a smooth peripheral indentation (arrowheads), which corresponds to the hilar indentation (arrowheads), which corresponds to the hilar area. area. 

a) filling b) Nodal

Para-aortic nodes have proved to Para-aortic nodes have proved to

be the most reliable group for be the most reliable group for

showing features of high showing features of high

diagnostic accuracydiagnostic accuracy

The cisterna chyli is usually a The cisterna chyli is usually a

saccular structure less than 5 cm saccular structure less than 5 cm

in length usually lies at the in length usually lies at the

midline of the body of L1 but may midline of the body of L1 but may

also be situated on either side of also be situated on either side of

the midline. the midline. Lymphogram shows normal cisterna chyli and the abdominal segment of the thoracic duct.

The thoracic duct sharply merges into the junction of The thoracic duct sharply merges into the junction of

the left subclavian vein and left internal jugular veinthe left subclavian vein and left internal jugular vein

Some rarely seen nodes are situated extrinsically to Some rarely seen nodes are situated extrinsically to

the usual lymphographic regions, such as the the usual lymphographic regions, such as the

popliteal, posterior intercostal, mediastinal, bilateral popliteal, posterior intercostal, mediastinal, bilateral

hilar, paratracheal, and supraclavicular nodeshilar, paratracheal, and supraclavicular nodes

Figure: Lymphogram shows Normal appearance of the thoracic duct. the termination of the thoracic duct at the left subclavian-jugular venous anastomosis at the base of the neck

Iliopelvic-aortic Lymphatic Iliopelvic-aortic Lymphatic SystemSystem

Iliopelvic Abdominoaortic Iliopelvic Abdominoaortic Lymph NodesLymph Nodes

Inguinal RegionInguinal Region

LymphographyLymphography

Lipiodol lymphography: Left image: After the injection of contrast material (lymphangiographic phase) the normal lymphatic vessels of the minor pelvis are visualized. Right image: 24 hours after the injection normal inguinal, pelvic and paralumbar lymph nodes are demonstrated (nodal phase).

complicationscomplications

The major complications of lymphography are The major complications of lymphography are caused by the vital dye and contrast materials caused by the vital dye and contrast materials rather than the techniquerather than the technique

Major frequent complication: Major frequent complication:

1.1. pulmonary oil embolizationpulmonary oil embolization

2.2. Pulmonary infarctionPulmonary infarction

3.3. hypersensitivity to methylene blue dye and hypersensitivity to methylene blue dye and ethiodized oilethiodized oil

Rare complication:Rare complication:

1.1. intraalveolar hemorrhageintraalveolar hemorrhage

2.2. hypothyroidismhypothyroidism

3.3. systemic arterial embolization to the brain or systemic arterial embolization to the brain or kidneykidney

Post ProcedurePost Procedure

1.1. Watch for signs of infection Watch for signs of infection

Swelling red and warm to touchSwelling red and warm to touch

Accompanied by a feverAccompanied by a fever

Contact DR right awayContact DR right away

2.2. Drink lots of waterDrink lots of water

3.3. Major swelling in one limbMajor swelling in one limb

Especially limb injectedEspecially limb injected

ConclusionConclusion

This procedure has largely been replaced by non-This procedure has largely been replaced by non-

invasive MRI or CT procedures.invasive MRI or CT procedures.

However, lymphography has the unique capability However, lymphography has the unique capability

of demonstrating internal architectural of demonstrating internal architectural

derangements within normal-sized lymph nodes. derangements within normal-sized lymph nodes.

This highly valuable advantage makes This highly valuable advantage makes

lymphography diagnostically more accurate than CT lymphography diagnostically more accurate than CT

(which demonstrates size rather than architecture) (which demonstrates size rather than architecture)

Lymphography still has a cornerstone role in Lymphography still has a cornerstone role in

diagnosis and management of lymphatic circulatory diagnosis and management of lymphatic circulatory

disorders. disorders. 

Q & A?Q & A?