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Lymphography: An Old Technique Retains Its Usefulness¹

¹ From the Departments of Radiology (A.G.), Hematology (P.B.), Radiation Therapy (C.H.), and Surgery (E.S.), Saint-Louis University Hospital AP-HP, Paris, France. Received February 28, 2003; revision requested April 9 and received May 1; accepted May 2. Address correspondence to A.G., Department of Radiology, University of California, 350 Parnassus Ave, Suite 150, San Francisco, CA 94117 (e-mail: ali.guermazi@oarg.ucsf.edu).

View larger version (136K): [in a new window]   Figure 1a.  Pulmonary oil embolism in an 18-year-old woman with Hodgkin disease. (a) Staging chest CT scan obtained 24 hours after lymphography shows several peripheral areas of pulmonary consolidation (arrowheads), which are due to pulmonary infarction. (b) Anteroposterior chest radiograph shows subtle, asymmetric, peripheral areas of increased opacity in the lungs (greater on the left than on the right).

View larger version (181K): [in a new window]   Figure 1b.  Pulmonary oil embolism in an 18-year-old woman with Hodgkin disease. (a) Staging chest CT scan obtained 24 hours after lymphography shows several peripheral areas of pulmonary consolidation (arrowheads), which are due to pulmonary infarction. (b) Anteroposterior chest radiograph shows subtle, asymmetric, peripheral areas of increased opacity in the lungs (greater on the left than on the right).

View larger version (128K): [in a new window]   Figure 2a.  Normal appearance of lymph nodes. (a) Lymphogram obtained during the filling phase shows a homogeneous appearance of the lymph nodes. (b) Lymphogram obtained during the nodal phase shows a smooth peripheral indentation (arrowheads), which corresponds to the hilar area.

View larger version (132K): [in a new window]   Figure 2b.  Normal appearance of lymph nodes. (a) Lymphogram obtained during the filling phase shows a homogeneous appearance of the lymph nodes. (b) Lymphogram obtained during the nodal phase shows a smooth peripheral indentation (arrowheads), which corresponds to the hilar area.

View larger version (57K): [in a new window]   Figure 3a.  Anteroposterior (a) and lateral (b) drawings show the anatomy of the pelvic and retroperitoneal lymphatics.

View larger version (73K): [in a new window]   Figure 3b.  Anteroposterior (a) and lateral (b) drawings show the anatomy of the pelvic and retroperitoneal lymphatics.

View larger version (125K): [in a new window]   Figure 4.  Normal appearance of the cisterna chyli. Lymphogram shows the cisterna chyli and the abdominal segment of the thoracic duct.

View larger version (115K): [in a new window]   Figure 5.  Normal appearance of the thoracic duct. Lymphogram shows the termination of the thoracic duct at the left subclavian-jugular venous anastomosis at the base of the neck. At the termination, several powerful valves are seen.

View larger version (170K): [in a new window]   Figure 6a.  Chylous ascites in a 43-year-old human immunodeficiency virus-positive man with peritoneal tuberculosis. (a) Lymphogram obtained during the filling phase shows peritoneal extravasation of contrast material. The site of the leakage is seen immediately to the left of L4 (arrow). Multiple lympholymphatic anastomoses between both sides of the lymphatic system are also evident. (b) CT scan obtained after lymphography shows the exact level of the damage to the lymphatic vessels (arrowhead). It also shows a dysmorphic liver and ascites. (c) Lymphogram obtained during the storage phase shows extensive leakage in the form of oily droplets within the peritoneal cavity.

View larger version (134K): [in a new window]   Figure 6b.  Chylous ascites in a 43-year-old human immunodeficiency virus-positive man with peritoneal tuberculosis. (a) Lymphogram obtained during the filling phase shows peritoneal extravasation of contrast material. The site of the leakage is seen immediately to the left of L4 (arrow). Multiple lympholymphatic anastomoses between both sides of the lymphatic system are also evident. (b) CT scan obtained after lymphography shows the exact level of the damage to the lymphatic vessels (arrowhead). It also shows a dysmorphic liver and ascites. (c) Lymphogram obtained during the storage phase shows extensive leakage in the form of oily droplets within the peritoneal cavity.

View larger version (159K): [in a new window]   Figure 6c.  Chylous ascites in a 43-year-old human immunodeficiency virus-positive man with peritoneal tuberculosis. (a) Lymphogram obtained during the filling phase shows peritoneal extravasation of contrast material. The site of the leakage is seen immediately to the left of L4 (arrow). Multiple lympholymphatic anastomoses between both sides of the lymphatic system are also evident. (b) CT scan obtained after lymphography shows the exact level of the damage to the lymphatic vessels (arrowhead). It also shows a dysmorphic liver and ascites. (c) Lymphogram obtained during the storage phase shows extensive leakage in the form of oily droplets within the peritoneal cavity.

View larger version (140K): [in a new window]   Figure 7a.  Laceration of the thoracic duct in a 59-year-old woman with chylothorax after esophagectomy. (a) Lymphogram shows extravasation of contrast material from the thoracic duct with accumulation in the pleural space (arrow). (b) Chest CT scan obtained after lymphography shows extensive leakage from the thoracic duct at the T7-8 level (arrowhead) and accumulation of contrast material in the posterior right pleural space.

View larger version (158K): [in a new window]   Figure 7b.  Laceration of the thoracic duct in a 59-year-old woman with chylothorax after esophagectomy. (a) Lymphogram shows extravasation of contrast material from the thoracic duct with accumulation in the pleural space (arrow). (b) Chest CT scan obtained after lymphography shows extensive leakage from the thoracic duct at the T7-8 level (arrowhead) and accumulation of contrast material in the posterior right pleural space.

View larger version (126K): [in a new window]   Figure 8a.  Chyluria in an 84-year-old woman with W bancrofti filariasis. (a) Lymphogram obtained during   the filling phase shows numerous collateral lymphatic vessels around the left kidney. Numerous lympholymphatic anastomoses are seen between both sides of the lymphatic system, a finding indicative of stasis.     (b) Lymphogram shows that the thoracic duct is obliterated and appears tortuous and expanded. These    findings are typical of filariasis. (c) CT scan obtained after lymphography shows that contrast material has flowed off into pyelocaliceal structures and shows the exact site of the leakage at the level of the left kidney. (d) Lymphogram obtained during the nodal phase at 24 hours shows contrast material in the calices of the left kidney.

View larger version (130K): [in a new window]   Figure 8b.  Chyluria in an 84-year-old woman with W bancrofti filariasis. (a) Lymphogram obtained during   the filling phase shows numerous collateral lymphatic vessels around the left kidney. Numerous lympholymphatic anastomoses are seen between both sides of the lymphatic system, a finding indicative of stasis.     (b) Lymphogram shows that the thoracic duct is obliterated and appears tortuous and expanded. These    findings are typical of filariasis. (c) CT scan obtained after lymphography shows that contrast material has flowed off into pyelocaliceal structures and shows the exact site of the leakage at the level of the left kidney. (d) Lymphogram obtained during the nodal phase at 24 hours shows contrast material in the calices of the left kidney.

View larger version (159K): [in a new window]   Figure 8c.  Chyluria in an 84-year-old woman with W bancrofti filariasis. (a) Lymphogram obtained during   the filling phase shows numerous collateral lymphatic vessels around the left kidney. Numerous lympholymphatic anastomoses are seen between both sides of the lymphatic system, a finding indicative of stasis.     (b) Lymphogram shows that the thoracic duct is obliterated and appears tortuous and expanded. These    findings are typical of filariasis. (c) CT scan obtained after lymphography shows that contrast material has flowed off into pyelocaliceal structures and shows the exact site of the leakage at the level of the left kidney. (d) Lymphogram obtained during the nodal phase at 24 hours shows contrast material in the calices of the left kidney.

View larger version (128K): [in a new window]   Figure 8d.  Chyluria in an 84-year-old woman with W bancrofti filariasis. (a) Lymphogram obtained during   the filling phase shows numerous collateral lymphatic vessels around the left kidney. Numerous lympholymphatic anastomoses are seen between both sides of the lymphatic system, a finding indicative of stasis.     (b) Lymphogram shows that the thoracic duct is obliterated and appears tortuous and expanded. These    findings are typical of filariasis. (c) CT scan obtained after lymphography shows that contrast material has flowed off into pyelocaliceal structures and shows the exact site of the leakage at the level of the left kidney. (d) Lymphogram obtained during the nodal phase at 24 hours shows contrast material in the calices of the left kidney.

View larger version (193K): [in a new window]   Figure 9a.  External genital lymphedema of parasitic origin in a 38-year-old man. (a) Lymphogram obtained during the filling phase shows filling of the scrotum by left-sided lymphatic reflux. (b) Lymphogram obtained during the nodal phase at 24 hours shows accumulation of contrast material in the scrotum (arrowheads). The lymph nodes are normal.

View larger version (186K): [in a new window]   Figure 9b.  External genital lymphedema of parasitic origin in a 38-year-old man. (a) Lymphogram obtained during the filling phase shows filling of the scrotum by left-sided lymphatic reflux. (b) Lymphogram obtained during the nodal phase at 24 hours shows accumulation of contrast material in the scrotum (arrowheads). The lymph nodes are normal.

View larger version (144K): [in a new window]   Figure 10.  Lymphovenous shunt in a 42-year-old man with lymphedema of the right leg after surgery for a right-sided inguinocrural hernia. Lymphogram obtained during the filling phase shows complete obliteration of the right lymphatic flow at the level of the right inguinocrural region (arrow) and opacification of the inferior vena cava by contrast material (arrowheads).

View larger version (145K): [in a new window]   Figure 11a.  Primary lymphatic aplasia of the left leg in a 12-year-old girl. (a) Lymphogram obtained during the filling phase shows absence of opacification of the left abdominopelvic lymphatic system. (b) Plain radiograph centered on the left knee shows absence of lymphatic collectors in the left leg with filling of superficial lymphatic vessels in the skin (dermal reflux). These findings are consistent with lymphatic aplasia.

View larger version (91K): [in a new window]   Figure 11b.  Primary lymphatic aplasia of the left leg in a 12-year-old girl. (a) Lymphogram obtained during the filling phase shows absence of opacification of the left abdominopelvic lymphatic system. (b) Plain radiograph centered on the left knee shows absence of lymphatic collectors in the left leg with filling of superficial lymphatic vessels in the skin (dermal reflux). These findings are consistent with lymphatic aplasia.

View larger version (123K): [in a new window]   Figure 12.  Perivascular extravasation in a 28-year-old woman with edema of the left leg as a result of aplasia of the lymphatic vessels in the left leg. Lymphogram obtained immediately after administration of contrast material shows no lymphatic vessels. The contrast material is drained by the lymphatic system, mainly along the venous vessel sheaths.

View larger version (158K): [in a new window]   Figure 13a.  Pelvic lymphoceles in a 48-year-old woman after appendectomy. (a) Pelvic lymphogram obtained during the filling phase shows a right-sided pelvic cavity filled with contrast material (arrow). There is also a smaller cavity filled with contrast material (arrowhead). There is no opacification of lymphatic vessels beyond the large lymphocele. (b) CT scan obtained after lymphography shows that the lymphocele is partially filled with contrast material. (c) Pelvic lymphogram obtained during the nodal phase shows the lymphoceles. It also shows stasis of contrast material prior to the lymphoceles and no opacification of the lymph nodes beyond the large lymphocele.

View larger version (112K): [in a new window]   Figure 13b.  Pelvic lymphoceles in a 48-year-old woman after appendectomy. (a) Pelvic lymphogram obtained during the filling phase shows a right-sided pelvic cavity filled with contrast material (arrow). There is also a smaller cavity filled with contrast material (arrowhead). There is no opacification of lymphatic vessels beyond the large lymphocele. (b) CT scan obtained after lymphography shows that the lymphocele is partially filled with contrast material. (c) Pelvic lymphogram obtained during the nodal phase shows the lymphoceles. It also shows stasis of contrast material prior to the lymphoceles and no opacification of the lymph nodes beyond the large lymphocele.

View larger version (145K): [in a new window]   Figure 13c.  Pelvic lymphoceles in a 48-year-old woman after appendectomy. (a) Pelvic lymphogram obtained during the filling phase shows a right-sided pelvic cavity filled with contrast material (arrow). There is also a smaller cavity filled with contrast material (arrowhead). There is no opacification of lymphatic vessels beyond the large lymphocele. (b) CT scan obtained after lymphography shows that the lymphocele is partially filled with contrast material. (c) Pelvic lymphogram obtained during the nodal phase shows the lymphoceles. It also shows stasis of contrast material prior to the lymphoceles and no opacification of the lymph nodes beyond the large lymphocele.

View larger version (124K): [in a new window]   Figure 14a.  Hodgkin disease in a 25-year-old woman. (a) Magnified left oblique lymphogram obtained during the nodal phase shows multiple tumorous lateroaortic lymph nodes with a typical diffuse foamy appearance (arrowheads). (b) Contrast material-enhanced staging abdominal CT scan obtained 2 hours before lymphography shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes (arrowheads) at the level of L3.

View larger version (119K): [in a new window]   Figure 14b.  Hodgkin disease in a 25-year-old woman. (a) Magnified left oblique lymphogram obtained during the nodal phase shows multiple tumorous lateroaortic lymph nodes with a typical diffuse foamy appearance (arrowheads). (b) Contrast material-enhanced staging abdominal CT scan obtained 2 hours before lymphography shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes (arrowheads) at the level of L3.

View larger version (123K): [in a new window]   Figure 15a.  Hodgkin disease in a 22-year-old woman. (a) Initial lymphogram obtained during the nodal phase shows a normal appearance. (b, c) Follow-up lymphograms obtained at 6 (b) and 12 (c) months show that the lymph nodes are still opacified and have a normal appearance. (d) Follow-up lymphogram obtained at 16 months shows that the oil droplets are farther apart (arrowheads), a finding associated with abdominal recurrence, which was confirmed clinically.

View larger version (130K): [in a new window]   Figure 15b.  Hodgkin disease in a 22-year-old woman. (a) Initial lymphogram obtained during the nodal phase shows a normal appearance. (b, c) Follow-up lymphograms obtained at 6 (b) and 12 (c) months show that the lymph nodes are still opacified and have a normal appearance. (d) Follow-up lymphogram obtained at 16 months shows that the oil droplets are farther apart (arrowheads), a finding associated with abdominal recurrence, which was confirmed clinically.

View larger version (123K): [in a new window]   Figure 15c.  Hodgkin disease in a 22-year-old woman. (a) Initial lymphogram obtained during the nodal phase shows a normal appearance. (b, c) Follow-up lymphograms obtained at 6 (b) and 12 (c) months show that the lymph nodes are still opacified and have a normal appearance. (d) Follow-up lymphogram obtained at 16 months shows that the oil droplets are farther apart (arrowheads), a finding associated with abdominal recurrence, which was confirmed clinically.

View larger version (123K): [in a new window]   Figure 15d.  Hodgkin disease in a 22-year-old woman. (a) Initial lymphogram obtained during the nodal phase shows a normal appearance. (b, c) Follow-up lymphograms obtained at 6 (b) and 12 (c) months show that the lymph nodes are still opacified and have a normal appearance. (d) Follow-up lymphogram obtained at 16 months shows that the oil droplets are farther apart (arrowheads), a finding associated with abdominal recurrence, which was confirmed clinically.

View larger version (129K): [in a new window]   Figure 16a.  Hodgkin disease in a 58-year-old man. (a) Lymphogram obtained during the nodal phase shows localized involvement of the abdominoaortic lymph nodes on both sides and of the right pelvic lymph nodes. The left pelvic lymph nodes are normal. (b) Staging abdominal CT scan, obtained with intravenous contrast material 24 hours after lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L2-3 level. There was a favorable outcome at 3- and 6-month follow-up lymphography. (c) Follow-up lymphogram obtained at 12 months also shows a favorable outcome. (d) Lymphogram shows that the extent of radiation therapy is reduced to the initially involved field.

View larger version (147K): [in a new window]   Figure 16b.  Hodgkin disease in a 58-year-old man. (a) Lymphogram obtained during the nodal phase shows localized involvement of the abdominoaortic lymph nodes on both sides and of the right pelvic lymph nodes. The left pelvic lymph nodes are normal. (b) Staging abdominal CT scan, obtained with intravenous contrast material 24 hours after lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L2-3 level. There was a favorable outcome at 3- and 6-month follow-up lymphography. (c) Follow-up lymphogram obtained at 12 months also shows a favorable outcome. (d) Lymphogram shows that the extent of radiation therapy is reduced to the initially involved field.

View larger version (142K): [in a new window]   Figure 16c.  Hodgkin disease in a 58-year-old man. (a) Lymphogram obtained during the nodal phase shows localized involvement of the abdominoaortic lymph nodes on both sides and of the right pelvic lymph nodes. The left pelvic lymph nodes are normal. (b) Staging abdominal CT scan, obtained with intravenous contrast material 24 hours after lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L2-3 level. There was a favorable outcome at 3- and 6-month follow-up lymphography. (c) Follow-up lymphogram obtained at 12 months also shows a favorable outcome. (d) Lymphogram shows that the extent of radiation therapy is reduced to the initially involved field.

View larger version (137K): [in a new window]   Figure 16d.  Hodgkin disease in a 58-year-old man. (a) Lymphogram obtained during the nodal phase shows localized involvement of the abdominoaortic lymph nodes on both sides and of the right pelvic lymph nodes. The left pelvic lymph nodes are normal. (b) Staging abdominal CT scan, obtained with intravenous contrast material 24 hours after lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L2-3 level. There was a favorable outcome at 3- and 6-month follow-up lymphography. (c) Follow-up lymphogram obtained at 12 months also shows a favorable outcome. (d) Lymphogram shows that the extent of radiation therapy is reduced to the initially involved field.

View larger version (111K): [in a new window]   Figure 17a.  Hodgkin disease in a 46-year-old man. (a) Lymphogram obtained during the nodal phase shows disseminated involvement of the abdominopelvic lymph nodes. (b) Staging abdominal CT scan, obtained with intravenous contrast material 1 hour before lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L3 level. There was a favorable outcome at 2- and 6-month follow-up lymphography. (c, d) Lymphograms show that the clear demonstration of opacified lymph nodes makes design of the inverted Y field for irradiation easy and more accurate (c) and considerably reduces the field of radiation therapy (d).

View larger version (162K): [in a new window]   Figure 17b.  Hodgkin disease in a 46-year-old man. (a) Lymphogram obtained during the nodal phase shows disseminated involvement of the abdominopelvic lymph nodes. (b) Staging abdominal CT scan, obtained with intravenous contrast material 1 hour before lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L3 level. There was a favorable outcome at 2- and 6-month follow-up lymphography. (c, d) Lymphograms show that the clear demonstration of opacified lymph nodes makes design of the inverted Y field for irradiation easy and more accurate (c) and considerably reduces the field of radiation therapy (d).

View larger version (102K): [in a new window]   Figure 17c.  Hodgkin disease in a 46-year-old man. (a) Lymphogram obtained during the nodal phase shows disseminated involvement of the abdominopelvic lymph nodes. (b) Staging abdominal CT scan, obtained with intravenous contrast material 1 hour before lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L3 level. There was a favorable outcome at 2- and 6-month follow-up lymphography. (c, d) Lymphograms show that the clear demonstration of opacified lymph nodes makes design of the inverted Y field for irradiation easy and more accurate (c) and considerably reduces the field of radiation therapy (d).

View larger version (106K): [in a new window]   Figure 17d.  Hodgkin disease in a 46-year-old man. (a) Lymphogram obtained during the nodal phase shows disseminated involvement of the abdominopelvic lymph nodes. (b) Staging abdominal CT scan, obtained with intravenous contrast material 1 hour before lymphography, shows small (short-axis diameter < 10 mm) paraaortic and paracaval lymph nodes at the L3 level. There was a favorable outcome at 2- and 6-month follow-up lymphography. (c, d) Lymphograms show that the clear demonstration of opacified lymph nodes makes design of the inverted Y field for irradiation easy and more accurate (c) and considerably reduces the field of radiation therapy (d).

View larger version (131K): [in a new window]   Figure 18a.  Stage Ib cervical carcinoma in a 43-year-old woman. (a) Left oblique lymphogram obtained during the nodal phase shows filling defects in several left lateroaortic nodes. (b, c) Abdominopelvic CT scans obtained immediately after lymphography (b obtained at a higher level than c) show that the tumorous lymph nodes are too small to be positively identified.

View larger version (149K): [in a new window]   Figure 18b.  Stage Ib cervical carcinoma in a 43-year-old woman. (a) Left oblique lymphogram obtained during the nodal phase shows filling defects in several left lateroaortic nodes. (b, c) Abdominopelvic CT scans obtained immediately after lymphography (b obtained at a higher level than c) show that the tumorous lymph nodes are too small to be positively identified.

View larger version (143K): [in a new window]   Figure 18c.  Stage Ib cervical carcinoma in a 43-year-old woman. (a) Left oblique lymphogram obtained during the nodal phase shows filling defects in several left lateroaortic nodes. (b, c) Abdominopelvic CT scans obtained immediately after lymphography (b obtained at a higher level than c) show that the tumorous lymph nodes are too small to be positively identified.