Transnodal lymphography in the diagnostic and treatment of genital lymphedema

Transcription

1 Transnodal lymphography in the diagnostic and treatment of genital lymphedema Poster No.: C-0699 Congress: ECR 2012 Type: Scientific Exhibit Authors: F. M. Gómez, J. J. Martínez Rodrigo, E. Santos Martín, M Lloret Larrea, D. Pérez Enguix, L. Martí-Bonmatí, R. García Marcos ; Valencia/ES, Pittsburgh, PA/US Keywords: Inflammation, Edema, Treatment effects, Technical aspects, Diagnostic procedure, Lymphography, CT, Pelvis, Lymphatic DOI: /ecr2012/C-0699 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Purpose To report the technical and clinical success of groin nodal lymphography in the diagnostic and treatment of genital lymphedema. Methods and Materials We present three consecutive cases seen in our Department. There were one female (8 years old) and two male (69 and 31 years old) patients, all with persistent genital lymphedema failing to conservative treatment. The girl also presented lymphorraghia. The institutional ethics committee approved the study and informed consent was always obtained before the patients underwent the procedure. The cases were presented at a multidisciplinary clinical session and individually assessed. Genital lymphedema was due to radical cystectomy (older man), lymphatic malformation (girl) and idiopathic lymphadenitis (younger man). All of them underwent US-guided bilateral groin lymph node puncture with a 25 G needle. Afterwards, 4 to 8 ml of Lipiodol Ultra-Fluid (Guerbet, Paris, France) were injected at a rate of 0.2 ml/sec. Lipiodol progression was assessed by means of fluoroscopy. A cone beam CT scan of the pelvis was performed immediately after the procedure on an Allura Xper FD20/20 angiography (Philips, Best, the Netherlands). Twenty-four hours after the procedure, a 64-row multidetector CT (Brilliance, Philips Medical Systems, Cleveland, USA) of the abdomen and pelvis was obtained to confirm and locate the lymphatic leak. Clinical and imaging follow-up evaluation was obtained between 5 and 11 months respectively. Technical success was considered as bilateral pelvic and abdominal filling of lymphatic vessels. Therapeutic success was considered as genital lymphedema and/ or lymphorraghia significant improvement or disappearance. Results Patient 1 An 8 years-old girl suffered from sudden genital lymphedema and lymphorraghia after a trip to Jakarta VV months before. No other significant records were found. No filariasis or other infective disease was diagnosed. Under general anaesthesia, bilateral groin lymph nodes where identified by means of US. Two 25 G needle were placed under US-guidance at the lymph nodes hilum. Then, Page 2 of 15

3 4 ml of Lipiodol Ultra-Fluid were injected at a rate of 0.2 ml/sec to avoid contrast extravasations. Lipiodol progression was assessed by means of fluoroscopy immediately after the injection to check the adequate lymphatic filling and after that, at 1, 3, 5, 10, 15, 30 and 45 minutes. At 30 and 45 minutes hypertrophy of lymphatic ducts (figure 1) and vaginal leak were observed (figure 2). The day after the procedure, a CT scan was obtained and a lymphaticopelvic fistula in the right kidney was depicted as the presence of Lipiodol within the right kidney parenchyma (figure 3). Also genital lymphatic hypertrophy arrpund the uterus and vagina was appreciated (figure 4). During the follow up period the amount of lymphorraghia was progressively reduced from the needs of diapers to just none compress. Genital lymphedema was also progressively reduced and the discomfort disappeared. After 10 months, the girl is asymptomatic with no lymphorraghia neither lymphedema. Patient 2 A 69 years old man suffering genital lymphedema was admitted to the hospital. Clinical records showed radical cystectomy for bladder cancer (pt2-n0-m0) in August 2007, malignant ureterectomy in July 2009 and pelvic floor including penis resection in January He specially complained for being unable to lay down in the prone position and in some occasions in supine position due to hypersensitivity in the scrotum. After US identification of the lymphatic nodes at both groins, 5 ml of 2% lidocaine (B-Braun Medical Inc.) were locally injected and two 23 G needles placed at the nodes hilums and 8 ml of Lipiodol Ultra-Fluid were injected at a rate of 0.2 ml/sec. Lipiodol progression was fluoroscopically assessed at the same times as in Patient 1 showing normal progression of the contrast material in the left side with difficult to progress in the right side (figure 5). The 24 hours control CT showed Lipiodol reflux to the scrotum with lymphatic leak from pelvic right vessels causing the lymphedema (figure 6). Up to 8 months follow up, the patient improved aesthetically and clinically, being able to lay down in the prone position. Patient 3 A 31 years old man suffered from genital lymphedema. The clinical record did not show significant findings. Two 23 G needles were bilaterally placed in the lymphatic nodes under US-guidance and 5 ml of Lipiodol Ultra-Fluid were injected at a rate of 0.2 ml/ sec after local anaesthesia with 2% lidocaine (B-Braun Medical Inc.). A lymphatic reflux to the scrotum was observed in the left side since 5 minutes after the injection and at the post procedure cone beam CT at the angiography suite (figures 6 and 7). On the 24 hours delayed CT, the reflux was no longer appreciated and Lipiodol was accumulated in the scrotum. At 5 month follow up, a large clinical improvement with significant pain and lymphedema reduction was confirmed. Page 3 of 15

4 Images for this section: Page 4 of 15

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6 Fig. 1: Image showing lymphatic hyperplasia in the pelvis Fig. 2: Vaginal leak consistent with lymphorrhage (arrow) Page 6 of 15

7 Fig. 3: Lipiodol within the kidney parenchima due to lymphopelvic fistula (arrow). Page 7 of 15

8 Fig. 4: Lipiodol within the kidney parenchima due to lymphopelvic fistula (arrow). Lymphatic hyperplasia in the pelvic organs (curved arrow). Page 8 of 15

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10 Fig. 5: Transnodal punction with a 23 G needle (arrow head). Normal lipiodol progression through the lymphatic system (curved arrow). Page 10 of 15

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12 Fig. 6: Lipiodol reflux to the scrotum (arrow) and difficulty to progress in the right side. Fig. 7: Left lipiodol reflux to the scrotum after direct transnodal lymphangiography (arrow) Page 12 of 15

13 Fig. 8: 3-D cone beam CT reconstruction showing left lipiodol reflux to the scrotum after direct transnodal lymphangiography (arrow.) Page 13 of 15

14 Conclusion Therapeutic lymphangiography by lymph node injection seems to be effective in the treatment of genital lymphedema. Lymph node puncture lymphangiography is feasible and less cumbersome than pedal lymphangiography. References Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol Apr 1;52(3): Rajebi MR, Chaudry G, Padua HM, Dillon B, Yilmaz S, Arnold RW, Landrigan-Ossar MF, Alomari AI. Intranodal lymphangiography: feasibility and preliminary experience in children. J Vasc Interv Radiol Sep;22(9): Kos S, Haueisen H, Lachmund U, Roeren T. Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage. Cardiovasc Intervent Radiol Sep-Oct;30(5): Itkin M, Krishnamurthy G, Naim MY, Bird GL, Keller MS. Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants. Pediatrics Jul;128(1):e Epub 2011 Jun 6. Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg Mar;139(3):584-89; discussion Epub 2009 Dec 29. Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: an old technique retains its usefulness. Radiographics NovDec;23(6): Lu Q, Bui D, Liu NF, Xu JR, Zhao XH, Zhang XF. Magnetic Resonance Lymphography at 3T: A Promising Noninvasive Approach to Characterise Inguinal Lymphatic Vessel Leakage. Eur J Vasc Endovasc Surg Jan;43(1): Epub 2011 Oct 14. Pan WR, Rozen WM, Stretch J, Thierry B, Ashton MW, Corlett RJ. Advanced imaging technologies for mapping cadaveric lymphatic anatomy: magnetic resonance and computed tomography lymphangiography. Lymphology Sep;41(3): Mukenge SM, Catena M, Negrini D, Ratti F, Moriondo A, Briganti A, Rigatti P, Cipriani F, Ferla G. Assessment and follow-up of patency after lymphovenous microsurgery for treatment of secondary lymphedema in external male genital organs. Eur Urol Nov;60(5): Epub 2010 Nov 24. Page 14 of 15

15 10. Deso S, Kabutey NK, Vilvendhan R, Kim D, Guermazi A. Lymphangiography in the diagnosis, localization, and treatment of a lymphaticopelvic fistula causing chyluria: a case report. Vasc Endovascular Surg Nov;44(8): Epub 2010 Jul Oremus M, Dayes I, Walker K, Raina P. Systematic review: conservative treatments for secondary lymphedema. BMC Cancer Jan 4;12(1):6 12. Syed LH, Georgiades CS, Hart VL. Lymphangiography: a case study. Semin Intervent Radiol (1): Yamagami T, Masunami T, Kato T, et al. Spontaneous healing of chyle leakage after lyphangiography. Br J Radiol. 2005;78(933): Personal Information Page 15 of 15