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Lymphography
Nikhil Bhagat, MD; Suvranu Ganguli, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        TERMINOLOGY

        • Definitions

          • Lymphography: Radiopaque contrast injection into lymphatic vessel(s) to visualize lymphatic structures
            • Historically used to assess lymph nodes/lymphatics
            • Now infrequently performed
              • Supplanted by cross-sectional imaging
                • Imaging lymphatic system remains challenging
              • Invasive, time-consuming procedure
                • Lost art; technically difficult
          • Lymphangiography: Synonym for lymphography
          • Lymphatic system
            • Key component of immune system
              • Lymphocyte, plasma cell, mastocyte production
              • Transports immune cells
            • Includes structures involved in lymphocyte circulation/production: Bone marrow, lymphoid tissue of digestive system, lymphatic vessels, spleen, thymus
            • Involved in fluid transport/regulation in body
              • Absorbs intestinal fatty acids from lacteals
              • Transports chyle/lymph
                • Lymphatic contraction, 1-way valves promote flow through lymphatic system
              • Returns interstitial proteins to blood
            • Provides filtration of fluids through lymph nodes
          • Lymphatic anatomy
            • Lymphatic capillaries in soft tissues
              • Coalesce to form lymphatic vessels
            • Lower extremity lymphatics combine in pelvis
              • Form internal and external iliac lymphatic chains
            • Common iliac lymphatics join to form paraaortic and paracaval lymphatic chains
              • Paraaortic and paracaval chains join to form cisterna chyli and thoracic duct
          • Cisterna chyli
            • Fusiform, sac-like outpouching formed by confluence of lymphatic channels
            • Usually located along right posterior aspect of abdominal aorta
            • Variable location relative to vertebral level
              • T12-L2 level most frequently
            • May not be present
            • Caudal origin of thoracic duct
          • Thoracic duct
            • Common drainage pathway of lymphatic system from abdomen, pelvis, lower extremities, left upper extremity
            • Carries 2-4 L of lymph daily
              • Proteins, lipids, lymphocytes
            • Originates at cisterna chyli
            • Courses superiorly in thoracic cavity
              • Extends from cisterna chyli level to base of neck
              • Right of midline; crosses to left at T5-T6
              • Posterior to esophagus
              • Drains into confluence of left subclavian/internal jugular vein
            • May have multiple channels, variations, duplication

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Problems

                          • Complications

                            • Expected Outcome

                              Selected References

                              1. Klotz R et al: Therapeutic lymphography for persistent chyle leak after pancreatic surgery. HPB (Oxford). 24(5):616-23, 2022
                              2. Cellina M et al: Non-contrast MR lymphography of lipedema of the lower extremities. Magn Reson Imaging. 71:115-24, 2020
                              3. Riley LE et al: Clinical approach and review of causes of a chylothorax. Respir Med. 157:7-13, 2019
                              4. Sheybani A et al: Cerebral embolization of ethiodized oil following intranodal lymphangiography. Semin Intervent Radiol. 32(1):10-3, 2015
                              5. Kariya S et al: Intranodal lymphangiogram: technical aspects and findings. Cardiovasc Intervent Radiol. 37(6):1606-10, 2014
                              6. Nadolski GJ et al: Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 23(5):613-6, 2012
                              7. Cooper K et al: Positron emission tomography (PET) and magnetic resonance imaging (MRI) for the assessment of axillary lymph node metastases in early breast cancer: systematic review and economic evaluation. Health Technol Assess. 15(4):1-134, 2011
                              8. Deso S et al: Lymphangiography in the diagnosis, localization, and treatment of a lymphaticopelvic fistula causing chyluria: a case report. Vasc Endovascular Surg. 44(8):710-3, 2010
                              9. Lu Q et al: Chronic lower extremity lymphedema: a comparative study of high-resolution interstitial MR lymphangiography and heavily T2-weighted MRI. Eur J Radiol. 73(2):365-73, 2010
                              10. Plotnik AN et al: How I do it: Lymphangiography. J Med Imaging Radiat Oncol. 54(1):43-6, 2010
                              11. Small W Jr et al: A prospective trial comparing lymphangiogram, cross-sectional imaging, and positron emission tomography scan in the detection of lymph node metastasis in locally advanced cervical cancer. Am J Clin Oncol. 33(1):89-93, 2010
                              12. Narayanan P et al: Magnetic resonance lymphography: a novel technique for lymph node assessment in gynecologic malignancies. Cancer Biomark. 5(2):81-8, 2009
                              13. Notohamiprodjo M et al: MR-lymphangiography at 3.0 T--a feasibility study. Eur Radiol. 19(11):2771-8, 2009
                              14. Guermazi A et al: Lymphography: an old technique retains its usefulness. Radiographics. 23(6):1541-58; discussion 1559-60, 2003
                              15. Witte CL et al: Advances in imaging of lymph flow disorders. Radiographics. 20(6):1697-719, 2000
                              16. North LB et al: Lymphography for staging lymphomas: is it still a useful procedure? AJR Am J Roentgenol. 161(4):867-9, 1993
                              17. Sachs PB et al: Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT. AJR Am J Roentgenol. 157(4):703-5, 1991
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    TERMINOLOGY

                                    • Definitions

                                      • Lymphography: Radiopaque contrast injection into lymphatic vessel(s) to visualize lymphatic structures
                                        • Historically used to assess lymph nodes/lymphatics
                                        • Now infrequently performed
                                          • Supplanted by cross-sectional imaging
                                            • Imaging lymphatic system remains challenging
                                          • Invasive, time-consuming procedure
                                            • Lost art; technically difficult
                                      • Lymphangiography: Synonym for lymphography
                                      • Lymphatic system
                                        • Key component of immune system
                                          • Lymphocyte, plasma cell, mastocyte production
                                          • Transports immune cells
                                        • Includes structures involved in lymphocyte circulation/production: Bone marrow, lymphoid tissue of digestive system, lymphatic vessels, spleen, thymus
                                        • Involved in fluid transport/regulation in body
                                          • Absorbs intestinal fatty acids from lacteals
                                          • Transports chyle/lymph
                                            • Lymphatic contraction, 1-way valves promote flow through lymphatic system
                                          • Returns interstitial proteins to blood
                                        • Provides filtration of fluids through lymph nodes
                                      • Lymphatic anatomy
                                        • Lymphatic capillaries in soft tissues
                                          • Coalesce to form lymphatic vessels
                                        • Lower extremity lymphatics combine in pelvis
                                          • Form internal and external iliac lymphatic chains
                                        • Common iliac lymphatics join to form paraaortic and paracaval lymphatic chains
                                          • Paraaortic and paracaval chains join to form cisterna chyli and thoracic duct
                                      • Cisterna chyli
                                        • Fusiform, sac-like outpouching formed by confluence of lymphatic channels
                                        • Usually located along right posterior aspect of abdominal aorta
                                        • Variable location relative to vertebral level
                                          • T12-L2 level most frequently
                                        • May not be present
                                        • Caudal origin of thoracic duct
                                      • Thoracic duct
                                        • Common drainage pathway of lymphatic system from abdomen, pelvis, lower extremities, left upper extremity
                                        • Carries 2-4 L of lymph daily
                                          • Proteins, lipids, lymphocytes
                                        • Originates at cisterna chyli
                                        • Courses superiorly in thoracic cavity
                                          • Extends from cisterna chyli level to base of neck
                                          • Right of midline; crosses to left at T5-T6
                                          • Posterior to esophagus
                                          • Drains into confluence of left subclavian/internal jugular vein
                                        • May have multiple channels, variations, duplication

                                    PREPROCEDURE

                                    • Indications

                                      • Contraindications

                                        • Preprocedure Imaging

                                          • Getting Started

                                            PROCEDURE

                                            • Patient Position/Location

                                              • Procedure Steps

                                                • Alternative Procedures/Therapies

                                                  POST PROCEDURE

                                                  • Things to Do

                                                    OUTCOMES

                                                    • Problems

                                                      • Complications

                                                        • Expected Outcome

                                                          Selected References

                                                          1. Klotz R et al: Therapeutic lymphography for persistent chyle leak after pancreatic surgery. HPB (Oxford). 24(5):616-23, 2022
                                                          2. Cellina M et al: Non-contrast MR lymphography of lipedema of the lower extremities. Magn Reson Imaging. 71:115-24, 2020
                                                          3. Riley LE et al: Clinical approach and review of causes of a chylothorax. Respir Med. 157:7-13, 2019
                                                          4. Sheybani A et al: Cerebral embolization of ethiodized oil following intranodal lymphangiography. Semin Intervent Radiol. 32(1):10-3, 2015
                                                          5. Kariya S et al: Intranodal lymphangiogram: technical aspects and findings. Cardiovasc Intervent Radiol. 37(6):1606-10, 2014
                                                          6. Nadolski GJ et al: Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 23(5):613-6, 2012
                                                          7. Cooper K et al: Positron emission tomography (PET) and magnetic resonance imaging (MRI) for the assessment of axillary lymph node metastases in early breast cancer: systematic review and economic evaluation. Health Technol Assess. 15(4):1-134, 2011
                                                          8. Deso S et al: Lymphangiography in the diagnosis, localization, and treatment of a lymphaticopelvic fistula causing chyluria: a case report. Vasc Endovascular Surg. 44(8):710-3, 2010
                                                          9. Lu Q et al: Chronic lower extremity lymphedema: a comparative study of high-resolution interstitial MR lymphangiography and heavily T2-weighted MRI. Eur J Radiol. 73(2):365-73, 2010
                                                          10. Plotnik AN et al: How I do it: Lymphangiography. J Med Imaging Radiat Oncol. 54(1):43-6, 2010
                                                          11. Small W Jr et al: A prospective trial comparing lymphangiogram, cross-sectional imaging, and positron emission tomography scan in the detection of lymph node metastasis in locally advanced cervical cancer. Am J Clin Oncol. 33(1):89-93, 2010
                                                          12. Narayanan P et al: Magnetic resonance lymphography: a novel technique for lymph node assessment in gynecologic malignancies. Cancer Biomark. 5(2):81-8, 2009
                                                          13. Notohamiprodjo M et al: MR-lymphangiography at 3.0 T--a feasibility study. Eur Radiol. 19(11):2771-8, 2009
                                                          14. Guermazi A et al: Lymphography: an old technique retains its usefulness. Radiographics. 23(6):1541-58; discussion 1559-60, 2003
                                                          15. Witte CL et al: Advances in imaging of lymph flow disorders. Radiographics. 20(6):1697-719, 2000
                                                          16. North LB et al: Lymphography for staging lymphomas: is it still a useful procedure? AJR Am J Roentgenol. 161(4):867-9, 1993
                                                          17. Sachs PB et al: Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT. AJR Am J Roentgenol. 157(4):703-5, 1991