Lymphatic Interventions in the Cancer Patient

[Lymphatic vessel imaging-Indications and clinical applications]

BACKGROUND

The armamentarium of lymphatic imaging techniques and treatment concepts available at specialized centers has significantly increased in recent years. The rarity and complexity of lymphatic vascular diseases presents the particular challenge of implementing these methods in a meaningful and targeted manner in patient care; however, there are currently no generally accepted diagnostic guidelines.

OBJECTIVE

Which lymphatic imaging technique is useful in which clinical situations?

MATERIAL AND METHODS

This article provides an overview of clinical and technical considerations that are relevant for a targeted evaluation of indications for lymphatic imaging in a multidisciplinary diagnostic and therapeutic approach.

RESULTS

The lymphatic vascular system can be affected by a wide range of primary and secondary pathologies, which often lead to relatively uniform clinical presentations (especially localized swellings, chylolymphatic effusions). In general, dedicated imaging should be discussed if a lymphatic vascular disease is suspected based on such a typical presentation. The choice of imaging strategy is then individually determined by the urgency of treatment, suspected localization and etiology of the pathology, comorbidities, specific properties of the imaging techniques, the treatment strategy pursued and local availability. When interpreting imaging and planning treatment, in addition to the large spectrum of different pathologies, the individual variability of the lymphatic system must also be taken into account.

CONCLUSION

An individual pretherapeutic assessment of lymphatic flow should nowadays be mandatory in order to be able to optimize the therapeutic approach for each patient with a suspected lymphatic vascular disease. Interdisciplinary patient care is of decisive importance.

Successful Treatment of a Refractory Lymphatic Fistula after Laparoscopic Para-Aortic Lymphadenectomy Using Dual Real-Time Lymphangiography with Indocyanine Green and a High-Fat Diet

INTRODUCTION

Postoperative lymphatic fistula is a relatively rare complication of abdominal and pelvic surgery. Lymphatic fistula is classified based on whether it contains lymphatic ascites with clear lymphatic fluid from the lumbar lymphatic trunks or chylous ascites with milky chyle fluid from the intestinal lymphatic trunk. These two lymphatic trunks eventually converge into the cisterna chyli, which is located at vertebrae T10-L3. In cases of lymphatic fistula following lymphadenectomy in this region, lymphatic leakage from either the intestinal or lumbar lymphatic trunk, or both, should be suspected. Here, we report the successful treatment of a refractory lymphatic fistula after para-aortic lymphadenectomy for rectal cancer by visualizing intestinal lymphatic leakage using enteral high-fat milk and lumbar lymphatic leakage using inguinal intranodal lymphangiography with indocyanine green (ICG).

CASE PRESENTATION

A 57-year-old male developed chylous ascites with elevated triglyceride levels after para-aortic lymphadenectomy. Conservative treatments, including dietary management with fasting, total parenteral nutrition, and administration of octreotide, were ineffective. Although lymphangiography with lipiodol identified lumbar lymphatic leakage, it failed to stop the lymphatic fistula. The intestinal lymphatic leakage site detected by enteral high-fat milk was sutured laparoscopically, and the lumbar lymphatic leakage site was glued with a fibrin sealant patch. However, persistent lymphatic leakage required repeated abdominal paracentesis. Open suturing of the lymphatic leakage site was performed using navigation with ICG and high-fat milk to resolve the lymphatic fistula completely. Lymphatic leakage from the intestinal lymphatic system was detected using enteral high-fat milk and from the lumbar lymphatic trunk using inguinal intranodal lymphangiography with ICG. A total of 5 mL of ICG (1.25 mg/mL) was injected into the inguinal lymph node. ICG leakage was identified at the lumber lymphatic trunk. The leakage site was sutured until the leakage disappeared. Four months after surgery, the ascites disappeared utterly.

CONCLUSIONS

This case demonstrates the efficacy of combining enteral high-fat milk and inguinal intranodal lymphangiography with ICG for accurate detection and differentiation of lymphatic leakage sources. Our dual lymphangiography technique aids in distinguishing leakage from either the intestinal lymphatic or lumbar lymphatic systems, which is critical for the successful treatment of complex lymphatic fistula.

Castleman disease complicated by rheumatoid arthritis and postoperative chylous leakage: A case report

RATIONALE

Castleman disease (CD) is a rare disorder characterized by nonspecific clinical presentations and imaging findings, making it prone to misdiagnosis and missed diagnosis. This report details the diagnosis and treatment process of a patient with CD complicated by rheumatoid arthritis (RA) who developed chylous leakage postoperatively, highlighting the potential risks of infection and nutritional depletion, aiming to enhance the understanding of CD.

PATIENT CONCERNS

A patient with CD complicated by RA developed chylous leakage postoperatively, which posed risks of infection and nutritional depletion.

DIAGNOSES

The patient underwent a left axillary lymph node excisional biopsy on November 13, 2019, and was diagnosed with HV-CD based on pathology.

INTERVENTIONS

No further axillary lymph node dissection or adjuvant therapy was performed. Postoperatively, the patient developed significant chylous leakage from the biopsy incision, which resolved after 2 weeks of drainage, dietary modifications, and anti-infective treatment.

OUTCOMES

Follow-up showed no disease progression, and the chylous leakage resolved with appropriate management.

LESSONS

A history of RA may be associated with the onset of CD. HV-CD generally has a favorable prognosis, and chylous leakage post-axillary lymph node biopsy, though rare, can be effectively managed with appropriate drainage, dietary control, and infection prevention.

Risk factors for lymphatic leakage following radical cystectomy and pelvic lymph node dissection in patients with muscle-invasive bladder cancer

BACKGROUND

Lymphatic leakage is a common complication after radical cystectomy and pelvic lymph node dissection (PLND) for muscle-invasive bladder cancer (MIBC).This study aimed to investigate the risk factors contributing to postoperative lymphatic leakage in patients with MIBC.

MATERIALS AND METHODS

A total of 534 patients undergoing radical cystectomy and PLND were enrolled in the retrospective study at Peking University Third Hospital from January 2010 to July 2023. Patients were categorized into lymphatic leakage(n = 254)and non-leakage groups (n = 280) and compared demographic, perioperativ and pathologic factors. Multivariate logistic regression was applied to identify risk factors for lymphatic leakage. Spearman correlation was used to analyze the relationship between lymph leakage ratio and risk factors.

RESULTS

Patients with lymphatic leakage had significantly higher rates of receiving extended PLND (19.7% vs. 11.4%, p = 0.008), higher total number of dissected lymph nodes (median 11 vs. 8, p < 0.001), longer hospital stays (median 13 vs. 11 days, p < 0.001), higher postoperative hypoalbuminemia rate (56.7% vs. 36.4%, p < 0.001) and higher fever rate (14.2% vs. 8.6%, p = 0.04) compared to the non-leakage group. On multivariate analysis, higher number of dissected lymph nodes (OR 3.278, 95% CI 1.135-9.471, p = 0.028) was found to be a independent risk factor for lymphatic leakage. Additionally, a positive correlation was observed between the numbers of dissected lymph nodes and lymphatic leakage rate (R = 0.456, p = 0.013).

CONCLUSIONS

The increased number of dissected lymph nodes is associated with a heightened risk of lymphatic leakage following radical cystectomy for MIBC.

Best evidence summary for nutritional management of cancer patients with chyle leaks following surgery

Background

Chyle leaks (CL) is a significant postoperative complication following lymph node dissection in cancer patients. Persistent CK is related to a series of adverse outcomes. Nutritional management is considered an effectively strategy that treat CL. However, the existing evidence on nutritional management for this patient cohort fails to provide actionable clinical guidance.

Aim

This study was aimed to establish an evidence-based framework for nutritional management, offering reliable basis for clinical nursing practice.

Methods

Utilizing the "6S" mode, we conducted a systematic search of UpToDate, BMJ, Best Practice, Cochrane Library, Joanna Briggs Institute (JBI) Center for Evidence-Based Health Care Database, National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Registered Nurses' Association of Ontario (RNAO), World Health Organization, Medlive, American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism (ESPEN), Web of Science, PubMed, Embase, CINAHL, China Biology Medicine (CBM), and China National Knowledge Infrastructure (CNKI) for all evidence on the nutritional management of postoperative coeliac leakage in cancer patients. This search included guidelines, evidence summaries, expert consensus, clinical decision-making, recommended practices, systematic evaluations or Meta-analyses, randomized controlled trials (RCTs), and class experiments. The search timeframe was from the library's establishment to June 2024. Quality assessment of the literature was completed independently by two researchers with professional evidence-based training and expert advice, and evidence was extracted and summarized for those that met the quality criteria.

Results

A total of 13 articles were included in the analysis, comprising two expert consensus, one guideline, one class of experimental studies, seven systematic evaluations, and two clinical decisions. We summarized 22 pieces of evidence across five categories: nutritional screening, assessment, and monitoring, timing of nutritional therapy, methods and approaches to nutritional therapy, nutrient requirements, and dietary modification strategies.

Conclusion

This study presents key evidence for nutritional management in cancer patients with CL post-surgery, emphasizing nutritional screening, assessment, timing and methods of therapy, and dietary adjustment strategies. It emphasized the necessity of thorough screening tools for the assessment of nutritional condition, and the benefits of early enteral feeding. A multidisciplinary team approach is vital for conducting personalized dietary, while sustained nutritional support, dietary fat restrictions, and medium-chain triglycerides enhance nutrient absorption. Consistent monitoring of chylous fluid output and timely dietary adjustments are crucial for improving patient outcomes and recovery.

Systematic review registration

http://ebn.nursing.fudan.edu.cn/registerResources, identifier ES20244732.

Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders

To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

ABSTRACT

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.