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SF 9 - The revival of lymphangiography

Friday, March 3, 08:30 - 10:00 Room: F2 Session Type: Special Focus Session Topics: Interventional Radiology, Imaging Methods Moderator: B. A. Radeleff (Heidelberg/DE) Add session to my schedule In your schedule (remove)

A-406

Chairman's introduction

B. A. Radeleff; Heidelberg/DE

Learning Objectives

1. To learn and to become familiar about the radiological diagnostic tools and therapy options (indication, technique and success) of lymphatic disease.
2. To understand the most important sequences and tricks for MR-lymphography for diagnosis and treatment steps leading to occlusion of chyle leaks.
3. To appreciate that diagnostics by non-contrast magnetic resonance lymphography in a near future could become the imaging modality of reference for investigation of lymphatic disorders.

Abstract

For decades, conventional bi-pedal lymphangiography has been considered the preferred technique for the evaluation of the lymphatic system and its disorders. Lymphangiography provides excellent architectural detail of the lymph nodes and lymphatic ducts. Intranodal lymphangiography (INL) was first reported in 1967 but the technique has been refined in the last 5 years. The lymph nodes are entered with ultrasound with a 25-23 G needle which provides an easy access to inject lipiodol and opacify the lymphatic system. This approach has simplified the technique, has shortened the time required for the procedure and, finally, has made it reproducible. Non-contrast MR lymphography is a new imaging technique and may be used for the diagnosis and classification of primary and secondary upper and lower limb lymphoedema. Therefore, it can be used for positive diagnosis, differential diagnosis and specific evaluation of lymphoedema pattern. Non-contrast MR lymphography may also be used as the modality of reference for the diagnosis of the so-called cystic lymphangioma but also for various lymphatic disorders such as lymphatic injuries resulting in chylous collections, chylous ascites and chylothorax. A postoperative (most common after oesophagectomy) or posttraumatic thoracic chyle leak is highly morbid and can carry significant mortality, if treatment is delayed. The gold standard for treatment of a chyle leak or postoperative chylothorax (e.g. after oesophagectomy) is a re-operation, either open or throracoscopic, to ligate the thoracic duct. In this talk, I will discuss the technique of thoracic duct embolisation in cases of chyle leak and chylothorax.

A-407

"Theranostic" lymphangiography

E. Santos Martín; New York/US

Learning Objectives

1. To learn and to become familiar about the indication, technique and success of intranodal lymphangiography (INL).
2. To understand that intranodal lymphangiography is an effective option for further treatment method e.g. for chyle leaks.
3. To appreciate that if conventional lymphography is impossible, percutaneous intranodal lymphangiography is a valuable alternative.

Abstract

Lymphangiography is a radiological image technique in which a radiopaque contrast medium (ethiodized oil) is injected into the lymphatic system. Lymphangiography provides excellent architectural detail of the lymph nodes and lymphatic ducts. For decades, conventional bipedal lymphangiography has been considered the preferred technique for the evaluation of the lymphatic system and its disorders, particularly in patients with lymphomas. The number of lymphographic studies performed in oncology centres has declined since the advent of simpler, less difficult and less morbid diagnostic tests (CT, MRI and PET), which have rendered the technique obsolete. Lymphangiography still has a role in the diagnosis, management and treatment of the lymphatic disorders, particularly in patients with lymphatic leaks and obstruction of the lymphatic vessels. Intranodal lymphangiography (INL) was first reported in 1967 but the technique has been refined in the last 5 years. The technique appears to be safer and faster than the old method. The lymph nodes are entered with ultrasound with a 25-23 G needle which provides an easy access to inject lipiodol and opacify the lymphatic system. This approach has simplified the technique has shortened the time required for the procedure and, finally, has made it reproducible. INL has allowed to streamline the management of the patients with chylous leaks. Due to embolic properties of the lipiodol, lymphangiography can have therapeutic properties in patients with chylous effusions, ranging from 51% to 97%. This success is linked to the volume of the lymphatic drainage per day.

A-408

MR lymphangiography

L. Arrivé; Paris/FR

Learning Objectives

1. To learn and to become familiar about the indication, technique and success of non-contrast magnetic resonance lymphography.
2. To understand the most important sequences and tricks for the non-contrast magnetic resonance lymphography.
3. To appreciate that non-contrast magnetic resonance lymphography in a near future could become the imaging modality of reference for investigation of lymphatic disorders.

Abstract

Non-contrast MR lymphography uses very heavily T2-weighted fast spin echo sequences with 3D acquisition and very thin section source images which obtain a specific display of lymphatic vessels. The raw data can be processed with different algorithms such as maximum intensity projection (MIP) algorithm. Lymphatic vessels are demonstrated with MR lymphography as alternating areas of constriction and dilatation representative of valves and contractile units. Non-contrast MR lymphography may be used in different fields. It is a unique non-invasive imaging modality for the diagnosis and classification of upper and lower limb lymphoedema. It can be used for positive diagnosis, differential diagnosis and specific evaluation of lymphoedema pattern (aplasic, hypoplasic and hyperplasic). Non-contrast MR lymphography is the modality of reference for the diagnosis of the so-called cystic lymphangioma which is a developmental abnormality characterised by lack of communications of regional lymphatic vessels resulting in marked dilatation. Non-contrast MR lymphography demonstrates that there is a continuous spectrum of change from normal variants to cystic lymphangioma. Non-contrast MR lymphography may also be used in various lymphatic disorders such as lymphatic injuries resulting in chylous collections, chylous ascites and chylothorax but also in lymphatic pathology of liver, spleen, kidney and chest. Non-contrast MR lymphography is a relative new imaging technique. The main limitation today is still the suboptimal spatial resolution. However, because of ongoing advances in software and hardware, in a near future it could become the imaging modality of reference for investigation of lymphatic pathology.

A-409

Thoracic duct embolisation

H. H. Schild; Bonn/DE

Learning Objectives

1. To learn and to become familiar about the indication, technique and success of minimal-invasive therapies for thoracic chyle leaks.
2. To understand that thoracic duct embolisation is an effective treatment method for chylothorax.
3. To appreciate that if thoracic duct embolisation is impossible, percutaneous lymphatic destruction or injection of sclerosants/tissue adhesive next to the thoracicare valuabe therapeutic alternatives.

Abstract

Interventional thoracic duct occlusion has become an established alternative to surgical thoracic duct ligation in patients with a chylothorax that does not respond to conservative treatment. The first step of the procedure involves lymphographic delineation of abdominal and thoracic lymphatics. A lymph vessel that by course and size is a suitable access route to the thoracic duct is punctured transabdominally under fluoroscopy (or CT) with a 22 G needle. After insertion of a microwire, the puncture needle is removed, and a microcatheter advanced over the guide wire into the thoracic duct. After delineation of the anatomy to exclude anatomic variants, the duct is then occluded using first coils and then tissue adhesive. If for anatomical reasons the thoracic duct cannot be entered, percutaneous destruction of lymph vessels (by “scratching”) may be performed, or it may be tried to enter the duct transvenously in a retrograde fashion. Reported clinical success rates vary between 55 and 90%, depending on anatomy and cause of the chylothorax. The complication rate of the procedure is around 7%, with major complications being rare.

Panel discussion: Lymphangiography, are you convinced?

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