PAST, PRESENT AND FUTURE OF PAST, PRESENT AND FUTURE OF LYMPHANGIOGRAPHYLYMPHANGIOGRAPHY

ALI AKBAR AMERI-MDALI AKBAR AMERI-MDJALAL JALAL SHOKOUHI-MDJALAL JALAL SHOKOUHI-MD

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• 5th century B.CHippocrates mentioned lymphatic system

• 1563 Eustachi described thoracic duct in horses (Vena-alba thoracis)

• Rud beck 1630-1702: discovered vessels in the liver containing no blood (clear fluid) with valve and drains into thoracic duct

• Thomas Bartholin mentioned: all body have this vessels

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Introduction:Introduction:

Lymph edema Primary

Secondary

Lymphoscintigraphy:Direct lymphography:High resolution MR lymphography:Diagnosis of lymph-edema is important but today no imaging procedure has fulfilled these criteria.

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Imaging:Imaging:X-ray Lymphangiography (patent blue, Lipiodel

ultra-fluid) For tumor staging (testis, lymphoma) and

lymphoedema, post traumatic, lymph obstruction, chilothorax

Lymphocele in post surgery and congenital lymph anomalies.

Nowadays staging is possible by U.S, X-ray CT, MRI

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High resolution MR lymphangiography:High resolution MR lymphangiography:contrast administration:contrast administration:1. Gadodiamide ,Extra cellular, Water soluble

paramagnetic contrast agent Concentration of GD (0.5 mmol) – 0.1 mmol

per/ kg of body weight equivalent to 0.2 ml/ kg Excluding patients with: Renal insufficiency

allergy to GD2. Needle 24 gauge3. 2ML mepivacaine hydrochloride 1%

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Micro-magnetic resonance Lymphangiography with GD-labeled dendrimer nanoparticle T1w 3D, fast spoiled GRE T2, T1 w 3D fast imaging employing steady-state (3D-FIESTA - C)

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Lymphoscintigraphy is primary imaging Lymphoscintigraphy is primary imaging technique but:technique but:Ionizing radiationIonizing radiationPoor spatial and temporal resolutionPoor spatial and temporal resolutionLimited value for accurate assessment of Limited value for accurate assessment of

lymphatic anatomy and functionlymphatic anatomy and function

Direct lymphography:Direct lymphography:

Provide highest accumulation of contrast agent.Provide highest accumulation of contrast agent.Long time examination- radiation-pulmonary embolism-Long time examination- radiation-pulmonary embolism-infectioninfection

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Injection method:

All divided to (10 portions)4 portions injected cutaneously to dorsal aspect of

each foot at four inter digital webs.One portion is injected medial to both first

proximal phalangesMax: 1.8 ml per portion with massage for 60

seconds (pain)

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MR examinations:MR examinations:1. Foot and lower leg (dedicated peripheral surface

coil)2. Upper leg and knee3. Pelvis and proximal upper leg (phased-array body

coil)4. Heavily T2W 3D turbo spin echo (TR/TE

2000/694) + MIP

Strongest enhancement available at 45 to 55 minutes for inguinal and external iliac 35 minutes for lymphatic pathways (do not forget massage)

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Complementary for MR-Lymphangiography:

1. CT2. PET-CT (c-choline pet) for prostate is more accurate

than MRI

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Water imaging:

• STIR• Myelogram can show lymphatic channels using

no dye

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Benign lymph node in prostate CA (CT)Benign lymph node in prostate CA (CT)

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Right benign node, left malignant node bladder CA Right benign node, left malignant node bladder CA (shape analysis)(shape analysis)

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Ferumoxtran: enhances (darkness)right side benign node in Ferumoxtran: enhances (darkness)right side benign node in bladder CA (MRI T2* + Ferumoxtran), left side is malignant bladder CA (MRI T2* + Ferumoxtran), left side is malignant (Signal analysis)(Signal analysis)

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Malignant nodes in 3D MR by Ferumoxtran-10 Malignant nodes in 3D MR by Ferumoxtran-10 prostate CAprostate CA

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Lecture notes for new wayLecture notes for new way

• Interstitial MR-Lymphangiography for detection of sentinel lymph node

• To assess morphology of the pre- and post-operatively cases for microsurgery reconstruction for the lumphatic vessels and stenting.

• Validation study of MR-Lymphangiography using SPIO (super para magnetic nanoparticle) contrast in bladder cancer, GU cancer and prostate CA

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Thank you for your Thank you for your attentionattention