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Postgrad Med J: first published as 10.1136/pgmj.41.478.452 on 1 August 1965. Downloaded from POSTryRAD. MED. J. (1965), 41, 452 LYMPHOGRAPHY AND THE UROLOGIST R. G. MAHAFFY, F.R.C.S.E., F.F.R. Department of Diagnostic Radiology, Royal Infirmary, Edinburgh.* VARIOUS radiological methods of demonstrating adequate in most cases, unless visualisation of lymph vessels and nodes have been utilised in the thoracic duct is required when larger the past. Interstitial injection of thorotrast amounts will be necessary. The procedure (Menville and Ane, 1932), and contrast in- should be controlled by means of an image jection into lymph nodes (Bruun and Engeset, intensifier and the injection stopped if any 1956), into body cavities (Bennet and Shivas, evidence of lymphatic obstruction is seen. 1954) and into joint spaces have all resulted At the termination of the injection a series of in some degree of visualisation of a limited films of the pelvic and lumbar regions is taken. segment of the lymphatic system. Detailed study These must include oblique and lateral views of the pelvic and abdominal lymph nodes, in order to throw the vessels off the underlying however, was not possible until Kinmonth bone and avoid superimposition of lymphatic (1952) described a practical method of intralym- structures. In this series the lymph vessels are phatic injection. He used a water soluble well shown but the nodes are only partially contrast medium to demonstrate the lymph filled with contrast. It is noteworthy that vessels of the legs in cases of lymphoedema. initially the lipiodol will flow from afferent to Such media, however, rapidly diffuse out of efferent lymphatics, via the marginal sinus of the lymphatics and for this reason are not the node, with no filling whatever of the suitable for investigation of retroperitoneal remaining nodal sinuses. 24 hours later the copyright. lymph nodes. Oily media are necessary for this series is repeated, when the nodes should be purpose and have become standard for well filled with contrast and the vessels entirely lymphography (Wallace, Jackson, Schaffer, empty. Multiple projections are important at Gould, Greening, Weiss and Kramer, 1961; this time to show all surfaces of the nodes. Ruttimann and Del Buono, 1962). Lipiodol remains in the nodes for 4-6 months and subsequent changes can be followed on Technique plain films. The technique of lymphography is now well known and requires no detailed description. http://pmj.bmj.com/ Briefly, lymphatics on the dorsum of the foot Lymphatic Anatomy are rendered visible by a subcutaneous injection One of the major contributions of lympho- of a dye such as patent blue violet. Under local graphy has been the demonstration of normal anx,sthesia a vessel is exposed and, by proximal lymphatic anatomy (Herman, Benninghoff, obstruction and manipulation of the toes, Nelson and Mellins, 1963). Two systems of distended to its maximum diameter. The vessel lymphatics occur in the leg, one accompanying may then be catheterised or a needle introduced. the long saphenous vein and the other the I have found catheterisation to be simpler and short. Injection of a long saphenous lymphatic on October 2, 2021 by guest. Protected much more stable, allowing fairly free move- at the foot results in visualisation of up to ment of the foot during the injection. A minute 20 vessels in the thigh, which drain into incision is made in the vessel, a polythene superficial inguinal lymph nodes. Short catheter (No. 45, Portland Plastics) introduced, saphenous lymphatics drain into a separate the vessel ligated round the catheter and the group of superficial inguinal nodes, and there catheter sutured to the skin edge. For visual- appears to be no communication between these isation of retroperitoneal nodes the procedure systems in the leg (Jacobsson and Johansson, must be repeated on the other foot. Warmed 1959). About a dozen nodes are seen in the ultra-fluid lipiodol is then injected bilaterally, superficial inguinal region and these are simultaneously, at a very slow speed. I have arranged in a rather haphazard manner, found 7-8 ml. lipiodol in each leg to be although two groups can be recognised, one lying transversely below the inguinal ligament *Present Address: and the other distal to this and parallel to the X-ray Department, Royal Infirmary, Aberdeen. long axis of the limb. Postgrad Med J: first published as 10.1136/pgmj.41.478.452 on 1 August 1965. Downloaded from August, 1965 MAHAFFY: Lymphography and the Urologist 453 -*0-. ., .4 o .yJ . -. 0 (. -z copyright. 0 U, o.Q ., CD -o0 http://pmj.bmj.com/ o CD on October 2, 2021 by guest. Protected CD U, 0CD Postgrad Med J: first published as 10.1136/pgmj.41.478.452 on 1 August 1965. Downloaded from 454 POSTGRADUATE MEDICAL JOURNAL Au2ust. 1965 ,,. ... t..-...C,.6...'................ .. ;<|.5.. ..............11 * .. ..}. o..pU--a kS-; copyright. FIG. 2.-Lateral pelvis film showing the medial external iliac lymphatic chain dipping deeply into the pelvis, particularly in the internal iliac region. The external iliac system is divided into three in its entirety although a few nodes are often http://pmj.bmj.com/ chains. A lateral chain lies lateral to the seen, particularly in the lateral sacral group external iliac artery, *a middle one medial to (Herman, Benninghoff, Nelson and Mellins, the artery and a medial chain behind the vein 1963). on the lateral pelvic wall (Fig. 1). In a lateral The three external iliac chains continue into view the medial chain can be seen to dip deeply the common iliac region, but there is a tendency into the pelvis (Fig. 2). The superficial in- for the medial and middle chains to unite, guinal nodes drain partly directly to the lateral so that frequently only two chains are seen and middle chains and partly via one or two in this region, one anterolateral to the vein on October 2, 2021 by guest. Protected deep inguinal nodes to the medial chain. At and one posteromedial. The medial chains of the distal ends of these chains lie the lateral, both sides form the nodes of the promontory. middle and medial retrocrural nodes, which The close relationship of the nodes to the pelvic are fairly large and constant. There is a very veins is the basis of pelvic venography as a free communication between the chains by diagnostic procedure, although I have found means of multiple, transversely arranged vessels. surprising enlargement of these nodes to be Proximal to the medial retrocrural node lies possible without producing any venographic. the 'middle' or 'principle' node which is large abnormality (Mahaffy, 1964). In the commork and constant and communicates with the and internal iliac regions the ureter is seen to obturator nodes, which as a rule are filled by come into intimate relationship with lymph lymphography carried out from the foot. nodes, enlargement of which may give rise to Owing to the valved nature of lymph vessels ureteric obstruction or displacement '(Fig. 3). retrograde flow does not normally occur. As The common iliac lymphatics drain into a a result the internal iliac system is not filled plexus which virtually surrounds the vena cava Postgrad Med J: first published as 10.1136/pgmj.41.478.452 on 1 August 1965. Downloaded from August, 1965 MAHAFFY: Lymphography and the Urologist 455 Complications and Precautions A number of patients suffer from a mild fever for 24-48 hours following lymphography. These patients are generally symptom-free and recover spontaneously. In a small number of cases, however, serious reactions have occured and Desprez-Curely, Bismuth, Laugier and Descamps (1962) report one fatality. Many patients have visible lipiodol in the lung-fields following the injection and, although I have not found reactions to be proportional to the degree of pulmonary lipiodol embolism, never- theless it must be advisable to limit the amount of contrast reaching the blood stream. For this reason the volume of contrast injected should be restricted to the minimum consistent with good radiographic detail of the lymphatic system. I stop the injection when the contrast reaches the mid-lumbar region, since I find that subsequently good filling of the upper lumbar nodes occurs by onward passage of lipiodol in the vessels at the end of the injection, and that only minimal amounts pass beyond the diaphragm. It is also necessary to follow the course of copyright. FIG. 3.-Oblique film of the pelvis showing the the lipiodol so that lymphatic obstruction at any relationship of the ureter to the pelvic lymph level may be recognised at an early stage. If nodes. evidence of this is seen the injection must be stopped since lymphatic-venous communications and aorta and is divided into four groups. may open up distal to such an obstruction, The right latero-aortic group lies on all sides allowing lipiodol to pass directly into the blood of the vena cava, but only one or two nodes stream (Bron, Baum and Abrams, 1963). are anterior to it and these occur only at its It is necessary to X-ray the chest prior to lower end. The left latero-aortic, pre-and lymphography and restrict the procedure to http://pmj.bmj.com/ retro-aortic groups lie to the left, in front of those patients whose lung-fields are clear, since and behind the aorta. Good ifilling of con- pulmonary pathology of any kind tends to tralateral para-aortic lymphatics is normally increase the effect of lipiodol embolism. obtained when unilateral lymphography is carried out, and an almost constant crossing Following radiotherapy to the abdomen or vessel is seen at the first sacral level. At the pelvis there is a reduction in the number and level of the second lumbar vertebra the para- size of lymph nodes, and these retain less aortic vessels drain into the cisterna chyli and contrast than normal, allowing larger amounts on October 2, 2021 by guest.

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