Validation of the Position of Injection Needles with Contrast-Enhanced Ultrasound for Dynamic Contract-Enhanced MR Lymphangiography.

PURPOSE: To assess the feasibility of validating the position of the needle in groin lymph nodes using injection of ultrasound (US) contrast prior to magnetic resonance (MR) lymphangiography. MATERIALS AND METHODS: In 28 patients (average age, 52 y; 15 women, 13 men), 25G needles were placed in bilateral groin lymph nodes using US guidance outside the MR suite. The confirmation of the position of the needles in lymph nodes and efferent lymphatic flow was performed by injecting 1 mL of the US contrast agent (Lumason) mixed with 2 mL of lidocaine and observing contrast enhancement of the efferent lymphatic ducts leading to the pelvis from the lymph node. The patients were then transferred to the MR suite, and MR lymphangiography was performed. RESULTS: In 6 patients, the needle was repositioned due to nonvisualization of the efferent lymphatic flow toward pelvis at the first attempt. MR lymphangiogram was then performed in all patients with good opacification of the central lymphatic system. No extravasation of gadolinium contrast agent was observed. CONCLUSIONS: Injection of US contrast to confirm the position of the needles inside the lymph nodes is a safe and effective technique. This technique can serve as a substitute for fluoroscopic confirmation of needle position, allowing performance of MR lymphangiography on any MR machine with a detachable table.

Label-free volumetric imaging of conjunctival collecting lymphatics ex vivo by optical coherence tomography lymphangiography.

We employ optical coherence tomography (OCT) and optical coherence microscopy (OCM) to study conjunctival lymphatics in porcine eyes ex vivo. This study is a precursor to the development of in vivo imaging of the collecting lymphatics for potentially guiding and monitoring glaucoma filtration surgery. OCT scans at 1300 nm and higher-resolution OCM scans at 785 nm reveal the lymphatic vessels via their optical transparency. Equivalent signal characteristics are also observed from blood vessels largely free of blood (and devoid of flow) in the ex vivo conjunctiva. In our lymphangiography, vessel networks were segmented by compensating the depth attenuation in the volumetric OCT/OCM signal, projecting the minimum intensity in two dimensions and thresholding to generate a three-dimensional vessel volume. Vessel segmentation from multiple locations of a range of porcine eyes (n = 21) enables visualization of the vessel networks and indicates the varying spatial distribution of patent lymphatics. Such visualization provides a new tool to investigate conjunctival vessels in tissue ex vivo without need for histological tissue processing and a valuable reference on vessel morphology for the in vivo label-free imaging studies of lymphatics to follow.

Lymphangiography for Thoracic Duct Interventions.

Lymph leaks resulting in chylous pleural effusions can be life-threatening. Minimally invasive thoracic duct embolization and disruption have been gaining acceptance as first-line treatment for these leaks. This review discusses the techniques for both pedal and intranodal lymphangiography in detail. It also discusses the use of lymphangiography as a means of targeting a retroperitoneal lymphatic to facilitate thoracic duct interventions for chyle leaks. Finally, outcomes and adverse events pertaining to these thoracic duct interventions are discussed.

Síndrome de web axilar secundario a la biopsia selectiva del ganglio centinela en cáncer de mama / Axillary web syndrome following sentinel node biopsy for breast cancer

Paciente de 49 años diagnosticada de carcinoma lobulillar infiltrante de mama derecha, intervenida mediante mastectomía y biopsia selectiva de ganglio centinela (BSGC). Los ganglios linfáticos centinela resecados fueron negativos para malignidad, motivo por el cual no fue necesaria la realización de linfadenectomía axilar. En el periodo posquirúrgico temprano la paciente presentó una sensación de tensión cutánea en el hueco axilar asociada a un cordón palpable doloroso, manifestación típica del síndrome de web axilar (SWA), una complicación poco conocida de las intervenciones quirúrgicas axilares, tanto invasivas como conservadoras. Mediante la presentación de este caso queremos centrar la atención en una entidad patológica cuya incidencia podemos estar infravalorando al no incluirla en estudios prospectivos de BSGC. Es importante que los médicos nucleares seamos conscientes de la existencia del SWA como una posible consecuencia de la BSGC, más frecuente que la infección, el seroma o el linfedema y de que debemos informar a los pacientes que firman el consentimiento (AU)

A 49 year-old woman diagnosed with infiltrating lobular breast carcinoma, underwent a right mastectomy and sentinel node biopsy (SLNB). The resected sentinel lymph nodes were negative for malignancy, with an axillary lymphadenectomy not being performed. In the early post-operative period, the patient reported an axillary skin tension sensation, associated with a painful palpable cord. These are typical manifestations of axillary web syndrome (AWS), a poorly known axillary surgery complication, from both invasive and conservative interventions. By presenting this case we want to focus the attention on a pathological condition, for which its incidence may be underestimated by not including it in SLNB studies. It is important for nuclear medicine physicians to be aware of AWS as a more common complication than infection, seroma, or lymphoedema, and to discuss this possible event with the patient who is consenting to the procedure (AU)

Lymphatic response to depilation-induced inflammation in mouse ear assessed with label-free optical lymphangiography.

BACKGROUND AND OBJECTIVES: Optical microangiography (OMAG) is a noninvasive technique capable of imaging 3D microvasculature. OMAG-based optical lymphangiography has been developed for 3D visualization of lymphatic vessels without the need for exogenous contrast agents. In this study, we utilize the optical lymphangiography to investigate dynamic changes in lymphatic response within skin tissue to depilation-induced inflammation by using mouse ear as a simple tissue model. MATERIALS AND METHODS: A spectral-domain optical coherence tomography (OCT) system is used in this study to acquire volumetric images of mouse ear. The system operates under the ultrahigh-sensitive OMAG scanning protocol with five repetitions for each B frame. An improved adaptive-threshold-based method is proposed to segment lymphatic vessels from OCT microstructure images. Depilation is achieved by placing hair removal lotion on mouse ear pinna for 5 minutes. Three acquisitions are made before depilation, 3-minute and 30-minute post-depilation, respectively. RESULTS: Right after the application of depilation lotion on the skin, we observe that the blind-ended sacs of initial lymphatics are mainly visible in a specific area of the normal tissue. At 5 minutes, more collecting lymphatic vessels start to form, evidenced by their valve structure that only exists in collecting lymphatic vessels. The lymphangiogenesis is almost completed within 8 minutes in the inflammatory tissue. CONCLUSIONS: Our experimental results demonstrate that the OMAG-based optical lymphangiography has great potential to improve the understanding of lymphatic system in response to various physiological conditions, thus would benefit the development of effective therapeutics.

Indocyanine Green Lymphography Findings in Primary Leg Lymphedema.

OBJECTIVES: Indocyanine green (ICG) lymphography has been reported to be useful for the evaluation of secondary lymphedema, but no study has reported characteristic findings of ICG lymphography in primary lymphedema. This study aimed to classify characteristic ICG lymphography patterns in primary lymphedema. METHODS: The study was a retrospective observational study. Thirty one primary lower extremity lymphedema (LEL) patients with a total of 62 legs were studied. ICG lymphography patterns were categorized according to the visibility of lymphatics and dermal backflow (DB) extension. Clinical demographics were compared with categorized ICG lymphography patterns. RESULTS: All symptomatic legs showed abnormal patterns, and all asymptomatic legs showed normal patterns on ICG lymphography. Abnormal lymphographic patterns could be classified into proximal DB (PDB), distal DB (DDB), less enhancement (LE), and no enhancement (NE) patterns. There were significant differences between PDB (16 patients), DDB (6 patients), LE (4 patients), and NE patterns (5 patients) in age (37.3 ± 18.3 vs. 61.8 ± 19.2 vs. 50.8 ± 27.7 vs. 29.2 ± 18.0 years, p = .035), onset of edema (23.9 ± 19.4 vs. 46.8 ± 27.0 vs. 43.0 ± 31.3 vs. 6.6 ± 14.2 years, p = .020), laterality (bilateral; 18.8% vs. 66.7% vs. 75.0% vs. 0%, p » .016), cellulitis history(56.3% vs. 100% vs. 25.0% vs. 0%, p » .007), and LEL index (292.2 ± 32.8 vs. 254.2 ± 28.6 vs. 243.3 ± 9.4 vs. 295.2 ± 44.8, p = .016). CONCLUSIONS: ICG lymphography findings in primary lymphedema could be classified into four patterns withdifferent patient characteristics.

Drenaje linfático aberrante en un caso de melanoma en zona epigástrica / Aberrant lymphatic drainage from a melanoma located in epigastric area

No disponible

The use of a microscope with near-infrared imaging function in indocyanine green lymphography and lymphaticovenous anastomosis.

BACKGROUND: Indocyanine green (ICG) lymphography has become an important investigation in lymphaticovenous anastomosis (LVA). Near-infrared (NIR) imaging systems are available in the market for the production of ICG lymphography. These machines, however, may be difficult to obtain owing to their costs. In our institute, these NIR imaging devices are not available. Alternatively, microscopy with NIR imaging function was used for LVA. The experiences of the production of ICG lymphography with an NIR microscope are described. METHODS: For the production of preoperative ICG lymphography, ICG solution was injected subdermally to the web spaces of the lymphoedema limb. The NIR mode of the microscope was used for the lymphatic mapping. Black and white images and videos of the ICG lymphography were then produced. Intra-operatively, the NIR function was used for the localisation of lymphatic vessels and confirmation of the patency of the LVA. RESULTS: Between February 2013 and May 2013, 24 ICG lymphographies were performed in 20 female patients as a preoperative investigation for LVA. All four ICG lymphography patterns (linear, splash, stardust and diffuse patterns) were demonstrated. CONCLUSIONS: In institutes where NIR imaging devices are not available, we believe that a microscope with an NIR imaging function is a reasonable alternative for the production of ICG lymphography.

Localization of the sentinel lymph node in tongue VX2 carcinoma via indirect CT lymphography combined with methylene blue dye injection.

CONCLUSIONS: Indirect computed tomography lymphography (CT-LG) combined with blue dye injection can locate the sentinel lymph node (SLN) in tongue carcinoma. OBJECTIVE: To localize the SLN in tongue VX2 carcinoma using indirect CT-LG combined with methylene blue injection. METHODS: Eighteen rabbits were placed into three groups: metastasis, hyperplasia, and control. Indirect CT-LG was performed with an iohexol injection into the tongue submucosa. CT images were acquired at 1, 5, and 15 min after injection. Methylene blue was injected into the same area 24 h after indirect CT-LG, followed by SLN identification and histopathological examination. RESULTS: SLNs were visualized with an identification rate of 100%. SLN location identified using CT lymphography was confirmed by methylene blue dye. Control and hyperplastic enhanced SLNs were round or oval without any filling defects. Control rabbits had enhanced SLN attenuation values of 689.2 +/- 55.4 HU, 278.4 +/- 33.5 HU, and 71.7 +/- 9.2 HU at 1, 5, and 15 min after injection, respectively. Hyperplastic rabbits had values of 877.4 +/- 69.4 HU, 352.5 +/- 43.3 HU, and 80.2 +/- 11.5 HU. Filling defects were only observed in the ipsilateral metastatic SLNs of the metastasis group. CT attenuation values of the metastatic SLNs were 687.4 +/- 55.6 HU, 535.1 +/- 86.6 HU, and 282.3 +/- 19.4 HU at 1, 5, and 15 min, respectively, after iohexol injection. Metastatic lymph node attenuation values were significantly greater than those of the control or hyperplastic nodes at 5 (p < 0.001) and 15 min (p < 0.001) after injection.

Contribución de la SPECT/CT en la detección del ganglio centinela en el carcinoma de mama / No disponible

Objetivo: Evaluar la contribución, y por tanto el impacto clínico-quirúrgico, de la SPECT/CT en la localización preoperatoria del ganglio centinela en pacientes con cáncer de mama. Pacientes y métodos: Revisión de las 240 linfogammagrafías de ganglio centinela realizadas en pacientes con cáncer de mama. Se realizaron un total de 30 SPECT/CT complementarias a las imágenes planares. Procedimiento: administración perilesional de 4 dosis de 99mTc-nanocoloides de albúmina, adquisición de imágenes precoces-tardías con técnica planar y posterior tomografía de emisión (SPECT) y transmisión (CT) con baja dosis en casos seleccionados. Localización intraoperatoria y exéresis de ganglios, completando el procedimiento según indicaciones de cada caso. Resultados: Visualización en las imágenes del 100% de los ganglios en los 30 pacientes, observando 4 casos únicamente por SPECT/CT. Ubicación anatómica exacta según profundidad y relación con otras estructuras del 100% de los ganglios en la tomografía. Migración a 14 ganglios extra-axilares, incluyendo 6 que fueron localizados por equipo híbrido. La SPECT/CT determinó correctamente el número de los ganglios, objetivando un mayor número no visualizados en las imágenes planares. Interpretación errónea por artefacto de contaminación aclarado por el equipo híbrido. Conclusión: Aunque el número de pacientes es limitado, se demostró que la identificación y localización del ganglio centinela con SPECT/CT supera a los observados en la gammagrafía convencional. Así mismo, se evidenció una exactitud mejor de la prueba en la identificación de los ganglios extra-axilares(AU)

Objective: To assess the contribution, therefore the clinical and surgical impact of SPECT/CT in the preoperative localization of the sentinel node in patients with breast cancer. Patients and methods: Review of the 240 sentinel node lymphoscintigraphy performed in patients with breast cancer. A total of 30 SPECT/CT was performed complementary to the planar images. Procedure: four doses of 99mTc-albumin nanocolloid were perilesional injected; acquisition of early-late images with planar technique, and subsequent emission tomography (SPECT) and low dose transmission (CT) in selected cases. Intraoperative localization and excision of lymph nodes, completing the procedure as indicated in each case. Results: One hundred per cent of the nodes in the 30 patients were visualized on the images, only 4 cases observed by SPECT/CT. Precise anatomical localization, as depth and relationship to other structures of 100% of the nodes in the scan. Migration to 14 extra-axillary nodes, including 6 that were found by the hybrid method. SPECT/CT correctly identified the number of nodes, detecting a higher number not observed previously on planar images. Misinterpretation by artefacts of contamination was excluded using the tomography technique. Conclusion: Although the number of patients is limited, we demonstrated a better identification and localization of the sentinel node with SPECT/CT than those observed in conventional scintigraphy. Also, we found a better accuracy of the test identifying extra-axillary nodes(AU)

A novel tool for intralymphatic injection: the modified glass hypodermic needle.

The use of contrast lymphangiography is a relatively new technique in lymphatic anatomical research, employed as a tool for evaluating lymphatic anatomy in fresh cadaveric specimens. With the use of microsurgical techniques to cannulate lymphatics, contrast media can enable the use of lymphangiography for evaluating lymphatic anatomy. However, the ability to cannulate lymphatics with diameters that are less than the smallest commercially available needles has been a significant limitation, and indeed a challenge. The smallest commercially available hypodermic needles have been 30-gauge needles, with 0.3 mm outer diameters. The lymphatics for cannulation in our studies are of the order of 0.1 mm, and other options have been required. We describe a novel technique for cannulating lymphatic vessels, creating a modified glass hypodermic needle. We have shown that these glass needles can be made with accuracy to diameters as low as 0.01 mm. Although 0.1 mm glass needles are the more commonly utilized in most dissections, we can now accurately create these glass needles to any caliber between 0.01 mm and 0.1 mm, based on the predicted lymphatic anatomy.

The use of clinical contrast media for lymphangiography in cadaveric studies.

BACKGROUND: Radiographic contrast media have not been previously used in human lymphatic cadaver studies. As these will have further clinical applications, we sought to investigate their use in this role. METHODS: Both lower legs from an unembalmed human cadaver were studied. We used hydrogen peroxide to identify the lymphatics of the dorsum of the foot, and a single lymphatic was microsurgically injected with 1 ml of 76% 'Urografin.' A series of radiographs were taken 1 min after injection and for 2.5 h until the Urografin vanished. Images were digitalized for analysis. RESULTS: The series of lymphangiograms generated showed the size, location, and course of the lymphatics in the leg. Over time, the density of the iodinated contrast in the lymphatic vessels reduced and disappeared completely after 2.5 hours postinjection. A 'digitally subtracted' image provided a clear and high-contrast lymphangiogram. The lymphatic network identified was shown to diverge and converge twice as it coursed proximally up the limb. CONCLUSION: Urografin, a clinical radiographic contrast medium, was shown to lose contrast density 2.5 h following cadaveric intralymphatic injection. The use of a new technique, that of 'digital subtraction lymphangiography,' was able to demonstrate the lymphatic vessel pathways clearly, and is a useful technique for cadaveric lymphatic studies.

[A comparative study of Gd-DTPA and HSA-Gd-DTPA in magnetic resonance lymphography].

OBJECTIVE: To compare the effects of two contrast agents, Gd-DTPA and HSA-Gd-DTPA, in magnetic resonance (MR) lymphography. METHODS: Twelve New-Zealand rabbits were randomized into Gd-DTPA and HSA-Gd-DTPA groups with subcutaneous (interdigital skin fold) injection of the two contrast agents (0.2 ml of 0.5 mmol/L Gd(3+)) for MR lymphography of the popliteal lymph nodes examined in the axial and sagital orientation. T(1)-weighted, T1-weighted fat suppressed, and T(2)-weighted spin-echo (SE) images of the lymph nodes were obtained in plain scans. The post-contrast scanning started at 30 min, 1 h and 3 h after Gd-DTPA administration and at 10 min, 30 min and 60 min after HSA-Gd-DTPA injection to obtain T(1)-weighted images with identical imaging parameters. The signal intensity of popliteal lymph node was measured and the enhancement rate calculated. RESULTS: After subcutaneous injection, Gd-DTPA quickly entered blood circulation to result in obvious enhancement of the anterior-tibial vein and the urine and also in heterogeneous enhancement of the popliteal lymph nodes. HSA-Gd-DTPA did not enter the blood, causing obvious homogeneous enhancement of the lymphatic vessels and lymph nodes. HSA-Gd-DTPA resulted in higher enhancement rate than Gd-DTPA, and the enhancement rate in Gd-DTPA group decreased with time as opposed to that of the HSA-Gd-DTPA group. CONCLUSION: HSA-Gd-DTPA has better performance than Gd-DTPA in MR lymphography after subcutaneous administration.

The feasibility of using poroelastographic techniques for distinguishing between normal and lymphedematous tissues in vivo.

Lymphedema is a common condition involving an abnormal accumulation of lymphatic fluid in the interstitial space that causes swelling, most often in the arm(s) and leg(s). Lymphedema is a significant lifelong concern that can be congenital or develop following cancer treatment or cancer metastasis. Common methods of evaluation of lymphedema are mostly qualitative making it difficult to reliably assess the severity of the disease, a key factor in choosing the appropriate treatment. In this paper, we investigate the feasibility of using novel elastographic techniques to differentiate between lymphedematous and normal tissues. This study represents the first step of a larger study aimed at investigating the combined use of elastographic and sonographic techniques for the detection and staging of lymphedema. In this preliminary study, poroelastographic images were generated from the leg (8) and arm (4) subcutis of five normal volunteers and seven volunteers having lymphedema, and the results were compared using statistical analyses. The preliminary results reported in this paper suggest that it may be feasible to perform poroelastography in different lymphedematous tissues in vivo and that poroelastography techniques may be of help in differentiating between normal and lymphedematous tissues.

Fluorescence microlymphography: diagnostic potential in lymphedema and basis for the measurement of lymphatic pressure and flow velocity.

Fluorescence microlymphography (FML) is an almost atraumatic technique used to visualize the superficial skin network of initial lymphatics through the intact skin of man. Visualization was performed with an incident light fluorescence microscope following subepidermal injection of minute amounts of FITC-dextran 150,000 using microneedles. Emanating from the bright dye depot, the surrounding network of microvessels is filled, documentation performed by photography or video film. In congenital Milroy lymphedema, a lack of microlymphatics (aplasia) is typical while in other primary lymphedemas and in secondary lymphedema after mastectomy or irradiation of proximal lymph nodes, the network remains intact but the depicted area is enlarged. Lymphatic microangiopathy characterized by obliterations of capillary meshes or mesh segments develops in phleboedema with trophic skin changes, progressive systemic sclerosis and Fabry's disease. In lipedema, lymphatic microaneurysms are stained. Microlymphatic pressure may also be measured using FML. For this purpose, glass micropipettes are inserted into the capillaries by means of a micromanipulator and pressure is determined by the servo-nulling technique. Normal subjects produced significantly lower pressure (7.9 +/- 3.4 mmHg) compared to patients with primary lymphedema (15.0 +/- 5.1 mmHg, p<0.001). This characteristic lymphatic hypertension may be improved by complex physiotherapy or local application of prostaglandins. Additionally, a modification of the FML procedure can be used to measure lymphatic capillary flow velocity in controls and patients. FML is suited to confirm the clinical diagnosis of lymphedema, contributes to distinguish among various forms of edema, and is useful in clinical research. In addition, FML has also become a tool for experimental animal studies including the depiction of gastric microlymphatics, the measurement of flow velocity in the naked mouse tail, and in evaluation of lymphangiogenesis in a model of Milroy disease.

[Interstitial T1-weighted MR lymph fistulography with Gadomer-17 in an experimental animal model]. / Interstitielle T1-gewichtete MR-Lymphfistulographie mittels Gadomer-17 im Tierexperiment.

PURPOSE: To visualize and localize fistulas of the thoracic duct with interstitial T 1 -weighted MR lymphography using Gadomer-17. MATERIALS AND METHODS: In 10 domestic pigs, leaks of the thoracic duct were created surgically or interventional-radiologically. The lymphatic leakage was located within the abdominal portion of the thoracic duct in 5 pigs, within the thoracic portion of the thoracic duct in 3 pigs, and in both, abdominal and thoracic portions of the thoracic duct, in 2 pigs. Subsequently, 10 micro mol/kg KG Gadomer-17 (1.5-1.8 ml) was administered interstitially in both hind legs of the animals. MR lymphography was performed with a 1.5 T MR unit using two different 3D gradient echo sequences before and 10 - 90 minutes after administration of contrast material. RESULTS: Leaks within the abdominal portion of the thoracic duct were directly visible as opacified fistulas. Indirect signs of active lymphatic fistulas were increasing extravasations of contrast material and free abdominal fluid. The 3D gradient echo sequence with the highest planar resolution (TR = 8,7 - 8,8 ms, TE = 4,2 - 4,3 ms, FA = 40 degrees, matrix size = 327 x 512) was best suited for distinct delineation of the lymphatic system and detailed demonstration of the thoracic duct fistulas. Intrathoracic leaks could not be demonstrated by MR lymphography due to reduced lymphatic flow or extravasated contrast medium at the abdominal puncture site. CONCLUSION: Interstitial MR lymphography with Gadomer-17 allows sensitive detection and localization of abdominally located leaks of the thoracic duct.

A surface-modified chylomicron remnant-like emulsion for percutaneous computed tomography lymphography: synthesis and preliminary imaging findings.

RATIONALE AND OBJECTIVES: To assess a surface-modified emulsion as a percutaneous CT lymphographic agent in normal dogs. METHODS: An iodinated chylomicron remnant-like microemulsion was formulated with a mean particle size of 91.3 nm and an iodine concentration of 91 mg I/mL. Contrast material (2 mL) was injected into the subcutaneous tissues of the metatarsus and metacarpus of six normal dogs to enhance popliteal and cervical lymph nodes, respectively. CT images were acquired at 0, 15, 30, 45, 60, 240, 480, and 1440 minutes. RESULTS: Significant lymph node enhancement occurred in as little as 15 minutes after injection and persisted at least 8 hours. Node opacification was most pronounced at 1 to 4 hours postinjection and exceeded 200 HU in some nodes (precontrast attenuation = 45 HU). Marked enhancement of popliteal efferent lymphatics and of iliac and sacral node groups also occurred indicating distribution to second order nodes. Attenuation of enhanced nodes reverted to precontrast levels by 24 hours. CONCLUSION: The new surface-modified, chylomicron remnant-like emulsion provided marked, selective enhancement of targeted lymph nodes after subcutaneous administration. Moreover, the formulation produced significant opacification of more distant node groups from a single injection.