Application of ultrasound-guided intranodal lymphangiography and embolisation in cancer patients with postoperative lymphatic leakage

Nodal Lymphangiography and Embolization for Postoperative Lymphatic Leakage

Intranodal lymphangiography has replaced conventional pedal lymphangiography and has advanced lymphatic intervention. In this method, a lymph node is punctured and Lipiodol is injected to visualize the subsequent lymphatic vessels. This has facilitated the widespread adoption of lymphatic interventional radiology due to the simplicity of the technique and the shortened examination time of the procedure, which allows easy mapping of lymphatic vessels and lymphatic fluid dynamics. With this technique, lymphatic embolization was achieved by injecting an embolic substance into the lymph nodes upstream of the lymphatic leak. Although complications associated with lymphangiography are rare, caution should be exercised due to potential complications associated with the use of Lipiodol. This study summarizes intranodal lymphangiography techniques, complications, and lymphatic embolization.

Multidisciplinary Treatment for Lymphorrhea and Chylorrhea Following Lymph Node Dissection for Genitourinary Cancer

BACKGROUND

Lymph node dissection (LND) is often performed in genitourinary cancer to improve accurate staging. However, the resultant lymphatic damage often leads to postoperative lymphorrhea and chylorrhea. Further, since lymphatic fluid lacks platelets, it has very few clotting factors, and it is often difficult to treat postoperative lymphatic leakage. Treatments for lymphorrhea include conservative treatment (e.g., fasting, total parenteral nutrition, and drug therapy), interventional radiology (IR) and surgical treatment. However, there is no guideline of refractory lymphorrhea, and no clear criteria for switching to the next treatment.

METHODS

We reviewed the records of 28 patients at Toho University Sakura Medical Center with postoperative lymphorrhea or chylorrhea after LND that did not improve with conservative treatment. Based on this analysis, we partially revised the treatment algorithm for lymphorrhea developed by Rose et al. Results: The cases consisted of 26 men and two women, aged 65.0 ± 9.9 years. The mean number of lymph nodes removed was 25.3 ± 15.0. Octreotide was administered in 27 patients, lymphangiography was performed in three patients, and lymphatic embolization was performed in two patients. The mean duration of octreotide administration was 9.7 ± 6.1 days, and the mean dose was 211.1 µg/day. The treatment success rates with octreotide and IR were 78.6% and 100%, respectively. The mean duration of drain placement after surgery for primary cancer was 18.3 ± 14.3 days.

CONCLUSIONS

Patients with lymphorrhea and chylorrhea should be initially treated conservatively, with IR performed if conservative treatment is unsuccessful. Surgical treatment should be a last resort.

Intranodal lymphangiography combined with foam sclerotherapy embolization of thoracic duct in the treatment of postoperative chylous leakage for thyroid carcinoma: a case report and review

Background

Chylous leakage (CL) is a rare but significant complication following cervical lymph node dissection, particularly in patients with papillary thyroid carcinoma (PTC). This condition is characterized by the leakage of lymphatic fluid, which can result in severe consequences such as malnutrition, immunosuppression, and prolonged hospital stays. Conventional treatments for CL include conservative measures and surgical interventions, but these approaches often face limitations and challenges. This case report discusses a successful treatment of CL using thoracic duct lymphangiography combined with local injection of sclerotherapy, demonstrating a novel and effective approach for managing this complication.

Case presentation

A 72-year-old female patient with PTC underwent total thyroidectomy and bilateral Level VI and left Levels II, III, IV, and V cervical lymph node dissection. Postoperatively, the patient developed milky drainage indicative of CL. Despite initial conservative treatments including pressure bandaging, negative pressure drainage, and nutritional adjustments, the patient's condition did not improve. The patient declined surgical options, leading to the decision to perform thoracic duct lymphangiography combined with local injection of sclerotherapy. Under real-time ultrasound guidance, the inguinal lymph nodes were accessed, and lipiodol was injected to visualize the thoracic duct. Subsequently, foam sclerosant was injected at the leakage site under fluoroscopic guidance. The procedure resulted in a significant reduction of chyle leakage, and the patient was discharged with no recurrence during a 1-year follow-up.

Conclusions

This case illustrates that thoracic duct angiography combined with local injection of sclerotherapy can be an effective treatment for high-output CL when conservative measures fail and surgical intervention is not preferred. The approach offers a minimally invasive alternative that can reduce complications and improve patient outcomes. The successful management of CL in this case underscores the potential of advanced interventional techniques in treating lymphatic system complications and highlights the need for further research to establish standardized treatment protocols.

Intranodal Lymphangiography and Embolization for Management of Iatrogenic Chylous Ascites after Oncological Surgery

PURPOSE

To investigate the safety and effectiveness of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of chylous ascites after oncologic surgery.

MATERIALS AND METHODS

Retrospective review of records of patients who underwent INL with or without LE from January 2017 to June 2022 was performed. Adult patients with chylous ascites after oncologic surgery referred to interventional radiology after failure of conservative treatment were included. Thirty-nine patients who underwent 55 procedures were included (34 males and 5 females). Data on patient demographics, procedural technique, outcomes, and follow-up were collected. Descriptive statistics were used to illustrate technical success, clinical success, and adverse events. Univariate logistic regression analysis was performed to evaluate factors predicting clinical success.

RESULTS

INL was technically successful in 54 of 55 procedures (98%; 95% confidence interval [CI], 90%-100%). A lymphatic leak was identified in 40 procedures, and LE was attempted in 36. LE was technically successful in 33 of the 36 procedures (92%; 95% CI, 78%-98%). Clinical success, defined as resolution of ascites with no need for peritoneovenous shunt placement or additional surgery, was achieved in 22 of 39 patients (56%; 95% CI, 40%-72%). Clinical success was achieved in 18 patients after 1 procedure, and patients who required repeat procedures were less likely to achieve clinical success (odds ratio, 0.16; 95% CI, 0.04-0.66; P = .012). Four grade 1 procedural adverse events were recorded.

CONCLUSIONS

INL with or without LE is a safe minimally invasive tool that can help patients with chylous ascites after oncologic surgery who failed conservative treatment avoid more invasive interventions.

The Delivery of mRNA Vaccines for Therapeutics

mRNA vaccines have been revolutionary in combating the COVID-19 pandemic in the past two years. They have also become a versatile tool for the prevention of infectious diseases and treatment of cancers. For effective vaccination, mRNA formulation, delivery method and composition of the mRNA carrier play an important role. mRNA vaccines can be delivered using lipid nanoparticles, polymers, peptides or naked mRNA. The vaccine efficacy is influenced by the appropriate delivery materials, formulation methods and selection of a proper administration route. In addition, co-delivery of several mRNAs could also be beneficial and enhance immunity against various variants of an infectious pathogen or several pathogens altogether. Here, we review the recent progress in the delivery methods, modes of delivery and patentable mRNA vaccine technologies.

Lymphatic Interventions in the Cancer Patient

PURPOSE OF REVIEW

The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks.

RECENT FINDINGS

Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.

Lymph Nodes as Anti-Tumor Immunotherapeutic Tools: Intranodal-Tumor-Specific Antigen-Pulsed Dendritic Cell Vaccine Immunotherapy

Simple Summary

In the field of cancer therapy, lymph nodes are important not only as targets for metastases resection but also as prudent target organs for cancer immunotherapy. Lymph nodes comprise a complete structure for the accumulation of a large number of T cells and their distribution throughout the body after antigen presentation and activation of dendritic cells. This review highlights current topics on the importance of lymph node structure in antitumor immunotherapy and intranodal-antigen-presenting mature dendritic cell vaccine therapy. We also discuss the rationale behind intranodal injection methods and their applications in neoantigen vaccine therapy, a new cancer immunotherapy.

Abstract

Hundreds of lymph nodes (LNs) are scattered throughout the body. Although each LN is small, it represents a complete immune organ that contains almost all types of immunocompetent and stromal cells functioning as scaffolds. In this review, we highlight the importance of LNs in cancer immunotherapy. First, we review recent reports on structural and functional properties of LNs as sites for antitumor immunity and discuss their therapeutic utility in tumor immunotherapy. Second, we discuss the rationale and background of ultrasound (US)-guided intranodal injection methods. In addition, we review intranodal administration therapy of tumor-specific-antigen-pulsed matured dendritic cells (DCs), including neoantigen-pulsed vaccines.