Indocyanine Green Fluorescent Lymphography During Open Inguinal Hernia Repair: Relationship Between Lymphatic Vessel Injury and Postoperative Hydrocele

BACKGROUND

This prospective case series analyzed patients who underwent indocyanine green (ICG) fluorescent lymphography during open inguinal hernia repair. The aim of this study was to investigate the association between ICG leakage and postoperative hydroceles in patients who underwent inguinal hernia repair.

MATERIALS AND METHODS

Data were analyzed from 40 patients who underwent primary open hernia repair between October 2020 and June 2021 (44 cases in total). Hydroceles were categorized into two types: symptomatic and "ultrasonic" (detected only by ultrasound imaging).

RESULTS

In the univariate analysis, hernia type (p = 0.044) and ICG leakage (p = 0.007) were independent risk factors for postoperative ultrasonic hydroceles. Additionally, mesh type (p = 0.043) and ICG leakage (p = 0.025) were independent risk factors for postoperative symptomatic hydroceles. In the multivariate analysis, ICG leakage (p = 0.034) was an independent risk factor for postoperative ultrasonic hydroceles.

CONCLUSIONS

ICG leakage after inguinal hernia repair was independently associated with postoperative ultrasonic and symptomatic hydroceles. These findings suggest a relationship between lymphatic vessel injury and the incidence of postoperative hydroceles.

Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites

PURPOSE

The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil.

MATERIALS AND METHODS

Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files.

RESULTS

Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage.

CONCLUSION

L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.

Chylothorax associated with primary membranous nephropathy: a case report

BACKGROUND

Chylothorax is a state in which pleurisy is induced by chylomicron leakage due to lymphatic injury. Membranous nephropathy (MN) is one of the relatively common glomerular diseases that cause nephrotic syndrome in adults. Chylothorax at the onset of nephrotic syndrome is very rare in adult patients.

CASE DESCRIPTION

We report a case of chylothorax associated with primary MN. A 64-year-old man visited the hospital complaining of lower extremity edema and dyspnea for 4 weeks. Laboratory findings showed no azotemia but hypercholesterolemia, hypoalbuminemia, nephrotic-range proteinuria, and microscopic hematuria. Chest and abdominal computed tomography (CT) revealed no ascites, venous thrombosis, or malignancy with the presence of right-side pleurisy. Biochemical analysis of the pleural fluid was consistent with chylothorax. The patient was confirmed to have MN by percutaneous kidney biopsy. An angiotensin receptor blocker, diuretics, and a hypolipidemic agent were prescribed; non-per os, total parenteral nutrition (TPN), and subcutaneous injection of octreotide were added for management of chylothorax. As serum anti-phospholipase receptor 2 antibody (Ab) concentration increased again, immunosuppressive therapy (IST) consisting of alternating monthly cycles of glucocorticoids and oral cyclophosphamide was instituted. With no improvement in chylothorax and deteriorating nutritional status despite 3 weeks of medical therapy, lymphangiography was performed, followed by thoracic duct embolization (TDE). The patient was discharged from the hospital on day 53 with clinical improvement. At 9 months after discharge, clinical remission of primary MN was achieved without recurrence of chylothorax.

CONCLUSIONS

Patients with nephrotic syndrome may rarely exhibit refractory chylothorax without chylous ascites, increasing the risk of serious metabolic complications such as severe malnutrition. Therefore, upon confirming chylothorax associated with primary nephrotic syndrome, prompt radiologic intervention for lymphatic leakage must be considered in addition to specific IST.

[Plastic bronchitis]

Plastic bronchitis (PB) is a rare disease caused by abnormal lymphatic vessels in the thorax. These vessels drain into the bronchi creating solid casts and potential life-threatening airway obstruction. This is a case report of a 30-year-old man diagnosed with PB after several years of extensive examinations due to symptoms misconceived as non-allergic asthma. We describe the first interventional treatment in Denmark using special T2 weighed MR imaging and dynamic contrast MR lymphangiography with subsequent embolisation of abnormal lymphatic vessels in the thorax.

Intranodal lipiodol injection for the treatment of chyle leak in children - a preliminary experience

OBJECTIVE

To assess the effectiveness of intranodal lymphangiography using ethiodised oil (Lipiodol; Guerbet Japan, Tokyo, Japan) for the treatment of refractory cases of chylothorax and chylous ascites in the paediatric population.

METHODS

Between 2016 and 2020, eight children having chyle leak resistant to conservative management underwent intranodal lymphangiography using lipiodol injection. After ethical approval by the Institutional Review Board, these patients' data were retrospectively analysed. Technical success was defined by opacification of inguinal and retroperitoneal lymphatics while injection on fluoroscopy. Clinical success was defined as progressively decreasing drain output and eventual cessation of output within a week after the procedure. Long-term follow up was done as feasible.

RESULTS

Technical success was achieved in all the patients. Complete cessation of drain output was noted within 1 week of procedure in all patients indicating clinical success. One patient had recurrence of chylous leakage after an interval of 1 month and intranodal lymphangiography was repeated for that patient. The child had technical as well as clinical success after the repeat procedure. Hence a total of 9 procedures were performed in 8 patients.

CONCLUSION

Intranodal lymphangiography may prove to be a valuable minimally invasive therapeutic tool in cases of refractory chylous leakage in paediatric patients with minimal risk of complications.

ADVANCES IN KNOWLEDGE

Intranodal lymphangiography using lipiodol may prove to be a minimally invasive alternative in paediatric patients with refractory lymphatic leaks.

Real-time image-sharing to educate a patient with lymphoedema on self-care: a case study

INTRODUCTION

Compression therapy is important in oedema control in lymphoedema. However, some patients have difficulties starting compression therapy because standard self-care education does not enable them to fully understand lymphoedema and recognise it as their problem. To overcome this, real-time image-sharing education, using a combination of indocyanine green lymphography (ICG) and ultrasonography, may be used to educate patients. In this case study, real-time image-sharing education promoted decision-making and behaviour change in a patient with lower extremity lymphoedema so she would wear elastic stockings.

CASE

A 51-year-old woman with a BMI of 31.7 kg/m² and secondary lower extremity lymphoedema following cervical cancer surgery did not adhere to self-care instructions regarding wearing elastic stockings for 5 years. The oedema worsened, her limb circumference increased and she had two episodes of cellulitis within a year. Because the patient had a negative attitude towards elastic stockings, real-time image-sharing education was used to promote recognition of illness using ICG and an understanding of the condition of lymphoedema using ultrasonography. After the images were shared and explained, the patient discussed her recognition and understanding of lymphoedema, then decided to use compression stockings. She continued to wear them for 4 months, and her limb circumference decreased.

CONCLUSION

Real-time image-sharing education using ICG and ultrasonography as self-care support for a lymphoedema patient who would not start compression therapy could result in behavioural changes and the patient starting and continuing to wear elastic stockings.

Neonatal lymphatic flow disorders: central lymphatic flow disorder and isolated chylothorax, diagnosis and treatment using novel lymphatic imaging and interventions technique

PURPOSE OF REVIEW

Neonatal lymphatic disorders (NLDs) are conditions that are relatively rare and difficult to treat. The recent development of lymphatic imaging, such as Dynamic Contrast-Enhanced MR Lymphangiography and Intranodal Lymphangiography has led to a new, better understanding of the anatomical substrate and pathophysiological mechanisms of the diseases. Consequently, this has allowed the development of new targeted therapeutic interventions as well as prognostication for this population with lymphatic flow disorders.

RECENT FINDINGS

The underlying causes of all NLD is an obstruction or altered flow of the central lymphatic flow. Two types of NLD have been described: isolated neonatal chylothorax and central lymphatic flow disorder (CLFD). Isolated neonatal chylothorax can be treated successfully with oil-based contrast (lipiodol) embolization. CLFD secondary to obstruction of the thoraco-venous junction can be successfully treated with surgical thoracic duct-venous anastomosis. CLFD caused by elevated central pressure and/or thoracic duct dysplasia can be treated medically, including with new systemic therapies such as mammalian target of rapamycin inhibitors.

SUMMARY

New diagnostic and interventional tools have recently allowed for classification, prognostication, and targeted interventions for neonatal patients with lymphatic flow disorders. Further research will build on these discoveries.

Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites

Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.

[Postoperative Chylothorax Likely to be Successfully Treated by Lymphangiography;Report of a Case]

A 74-year-old man underwent right upper lobectomy and systemic lymph node dissection with video-assisted thoracoscopic surgery. Chylothorax occurred on postoperative day (POD) 1st. Under fasting management, the patient underwent pleurodesis on POD 5th and 7th, subcutaneous octreotide acetate injection on POD 6th, and lymphangiography on POD 9th. The amount of drainage decreased on POD 10th, and the drainage tube was removed on POD 12nd. Lymphangiography has been reported as one of effective procedures to treat postoperative chylothorax. The present case is also considered to be successfully treated by lymphangiography.

Restatement of Lymphography in Childhood: Experience with 413 Consecutive Patients in Ten Years

From January 1969 to June 1978, 413 children under 15 years of age underwent lymphography at the Istituto Nazionale Tumori of Milan. Successful lymphatic cannulation was accomplished in 97.7% (769/787) of the sites where it was attempted. No major or permanent complications were encountered. In those children undergoing biopsy of opacified lymph nodes, the lymphographic-histologic correlation was 94.5% (104/110). This study has shown that lymphography in childhood can be as readily performed as in the adult and that its diagnostic accuracy is acceptable. As in adults, it is useful in treatment planning, evaluating results of therapy, and detecting a recurrent tumor.

Two-Color Lymphatic Mapping Using Ig-Conjugated Near Infrared Optical Probes

To map the drainage patterns of the lymphatic system, multicolor optical probes must be developed, which can be interstitially administered. These agents must be of sufficient size to be retained by the lymphatic system and permit the conjugation or incorporation of fluorescent probes with varying emission wavelengths. Quantum dots fulfill these criteria, but their potential toxicity limits their application to research settings. Here, we describe the synthesis of lymphatic optical probes based on Igs conjugated with Cy5.5 and Cy7 and demonstrate in animal models that these agents can map the lymphatic drainage patterns within axillary nodes draining both the breast and upper extremity, cervical nodes draining both the ear and upper extremity, and sentinel lymph nodes draining different anatomic locations. The ability to separately and simultaneously visualize the drainage patterns from two separate lymphatic vessels may have implications for the preoperative mapping of lymph nodes before lymph node resection. The biocompatibility of fluorescently labeled Igs in comparison to other nanoparticulate fluorophores improves the chances of clinical translation. This noninvasive and biocompatible multicolor method of optical lymphangiography may elucidate the complex human lymphatic system and reduce the risk of lymphedema after surgery for melanoma and other cancers.

Indirect MR lymphangiography of the head and neck using conventional gadolinium contrast: a pilot study in humans

PURPOSE

To evaluate indirect magnetic resonance lymphangiography (MR-LAG) using interstitial injection of conventional gadolinium contrast (gadoteridol and gadopentetate dimeglumine) for delineating the primary lymphatic drainage of head-and-neck sites.

METHODS AND MATERIALS

We performed head-and-neck MR-LAG in 5 healthy volunteers, with injection of dermal and mucosal sites. We evaluated the safety of the procedure, the patterns of enhancement categorized by injection site and nodal level, the time course of enhancement, the optimal concentration and volume of contrast, and the optimal imaging sequence.

RESULTS

The worst side effects of interstitial contrast injection were brief, mild pain and swelling at the injected sites that were self-limited. MR-LAG resulted in consistent visualization of the primary lymphatic drainage pattern specific to each injected site, which was reproducible on repeated examinations. The best enhancement was obtained with injection of small volumes (0.3-0.5 mL) of either agent diluted, imaging within 5-15 min of injection, and a three-dimensional fast spoiled gradient echo sequence with magnetization transfer.

CONCLUSIONS

We found head-and-neck MR-LAG to be a safe, convenient imaging method that provides functional information about the lymphatic drainage of injected sites. Applied to head-and-neck cancer, it has the potential to identify sites at highest risk of occult metastatic spread for radiotherapy or surgical planning, and possibly to visualize micrometastases.

Anaphylaxis due to patent blue dye during lymphography, with negative skin prick test

We report here a case of anaphylaxis due to patent blue dye, which was administered to an adult female during a lymphographic intraoperative procedure. The patient was not atopic, and other possible causes of anaphylaxis (anesthetics, latex) had been carefully excluded through routine tests. The skin-prick test and patch test carried out with patent blue (PB) dye were negative, but the intradermal test with 100 microliters of the dye showed a remarkable positivity. There was no available commercial, specific IgE assay for PB dye, but the negativity of prick tests would exclude the involvement of an IgE-mediated mechanism. We want to highlight the possible danger derived from a dye that is considered inert, and that is now increasingly being used in surgical procedures.

Lymphangiography causes false-positive findings on 18F-FDG PET imaging

BACKGROUND

18F-FDG positron emission tomography (PET) may alter therapeutic management of patients with cervical cancer because 18F-FDG-positive pelvic and para-aortic lymph nodes are associated with lower progression-free survival and vice versa. However, the accuracy of 18F-FDG PET might be impaired by a preceding lymphangiography (LAG).

MATERIALS AND METHODS

LAG, magnetic resonance (MR)-imaging and 18F-FDG PET were performed in 6 patients with cervical cancer stage FIGO IB and II. All patients were scheduled for radical hysterectomy and pelvic and para-aortic lymphadenectomy. The results of LAG, MR-imaging and 18F-FDG PET were compared with histological findings.

RESULTS

18F-FDG PET showed false-positive foci in both patients who had LAG before PET-study but not in 4 patients who had LAG thereafter. Histology confirmed false-positive 18F-FDG accumulation in lymphnodes to be consistent with granulomateous changes as induced by foregoing LAG.

CONCLUSION

Whenever 18F-FDG PET and LAG are performed in the same patient to assess the extent of lymph-node metastases, LAG should always be done after the 18F-FDG PET study to obviate false-positive results.

Cerebral and renal embolization after lymphography in a patient with non-Hodgkin lymphoma: case report

An unusual case of lipid embolization to brain and kidney after lymphography in a patient with non-Hodgkin lymphoma of the upper anterior mediastinum is reported. Contrast material-enhanced echocardiography demonstrated a right-to-left shunt to the left atrium without evidence of a patent foramen ovale. Echo contrast particles were transiently present within the tumor surrounding the great vessels.

The influence of lymphangiography on the development of hypothyroidism in patients irradiated for Hodgkin's disease

PURPOSE

There is no consensus in the literature regarding the role of lymphangiography in promoting hypothyroidism in individuals with Hodgkin's disease irradiated with a mantle field. We sought to analyze the onset and rate of developing clinical or chemical hypothyroidism as well as possible factors related to its development in patients who received irradiation to the thyroid gland during treatment of Hodgkin's disease.

METHODS AND MATERIALS

One hundred and forty-two patients with Hodgkin's disease were treated at the Fox Chase Cancer Center between June 1967 and October 1993. All patients were treated with curative intent with radiation therapy using a mantle field. After exclusion of patients without available thyroid function tests, < 200 days of follow-up, or no radiation to the thyroid, 104 patients were eligible for analysis. Follow-up ranged from 7-170 months (median: 43 months). Sixty-seven patients had a lymphangiogram. Seventy-three patients were treated with radiation alone and 31 with radiation plus chemotherapy.

RESULTS

The actuarial 2-, and 5-year rates of biochemical hypothyroidism for all 104 patients were 18 and 37%, respectively. Forty patients developed hypothyroidism: 9 (23%) at < or = 1 year, 18 (45%) at < or = 2 years, and 33 (83%) at < or = 5 years. The actuarial 2-, and 5-year rates of biochemical hypothyroidism for patients who underwent a lymphangiogram were 23 and 42%, respectively, compared to 9 and 28%, respectively, for patients who received mantle irradiation without a lymphangiogram (p = 0.05). The effects of lymphangiogram, total thyroid dose, stage, chemotherapy, dose per fraction, energy, and age were evaluated for all patients by Cox proportional hazards regression analysis. The use of a lymphangiogram (p = 0.05) was the only variable that significantly influenced hypothyroidism.

CONCLUSIONS

This paper demonstrates in a multivariate analysis accounting for other potentially important variables the significant effect of lymphangiography and subsequent radiation therapy on the development of hypothyroidism. This information must be balanced with the fact that lymphangiograms remain a useful aid in assessing lymph node involvement, staging patients, and planning treatment fields.

[The effect of direct x-ray contrast lymphography on pulmonary perfusion function]

Overall twenty-five persons (8 males and 17 females) were enrolled in a study on the influence of straight radiopaque lymphography with an oily substance, on the condition of pulmonary microcirculation, as evidenced by perfusion pulmoscintigraphy. There was a significant decrease in the accumulation of 99m-Tc-macroaggregate (TCK-8) in lower portions of both lungs 24 hours after the lymphography and normal dispersal 10 days after the study made. The authors suggest that the radiopaque substance might stimulate the inflammatory processes in chronic nonspecific diseases of the lungs.

Role of bipedal lymphangiogram in radiation treatment planning for cervix cancer

PURPOSE

The role of bipedal lymphangiogram in tailoring radiation portals in radical radiation therapy for Stages II or III cervix cancer is investigated.

METHODS AND MATERIALS

The records and simulation films of 87 patients with Stage II or III carcinoma of the cervix treated with radical radiation therapy alone have been retrospectively reviewed.

RESULTS

Sixty-two percent of patients who had a bipedal lymphangiogram, subsequently had their radiation fields altered from a "standard portal." The most frequently altered fields were the lateral margin of the postero anterior field and the anterior margin of the lateral fields. In order to cover the lymphatic channels in the pelvis in 90% of cases as outlined by the bipedal lymphangiogram, the lateral margins of the postero anterior fields would need to be 2.5 cm lateral to the pelvic brim and the anterior border of the lateral field, 0.5 cm anterior to the pubic symphysis.

CONCLUSION

"Standard" fields adequately cover the median distribution of lymphatics, but may result in a geographic miss in some patients. Bipedal lymphangiograms allow a more accurate tailoring of pelvic lymphatic fields.

Chylous ascites in three dogs

Chylous ascites was diagnosed in 3 dogs. Mesenteric lymphangiography was performed in 2 dogs and helped delineate abnormalities of the lymphatic system. The cause of chylous ascites in each dog appeared to be different. In 1 dog, a ruptured mesenteric lymphatic was identified at surgery. Evidence of abdominal lymphatic obstruction was found in another dog. Chylous ascites in the third dog appeared to be a complication of mesenteric lymphangiography for chylothorax.

Case report: the incidental lipid embolization to the brain and kidney after lymphography in a patient with malignant lymphoma: CT findings

Lipid embolization to the brain and kidney is reported, confirmed by computed tomography (CT) following lymphography in a man with malignant lymphoma. The patient complained of headache and unstable gait and became blind and hemiplegic immediately after the examination. With supportive therapy he recovered from the complications in 5 months except for slight gait disturbance, probably explained by cerebral infarction. Mechanisms of the combined brain and renal embolization are discussed.

Postlymphography linear dermatitis

Cutaneous effects secondary to lymphography are rare events. We herein report a patient with Hodgkin's disease who developed a linear dermatitis in both lower limbs 6 days after a pedal lymphography. Histopathologic examination of the lesions demonstrated a subacute dermatitis. Patch tests with the substances used in the lymphography yielded negative results. We discuss the possible pathogenic mechanisms of this striking linear dermatitis.

[Pulmonary complications of lymphangiography]

Pulmonary complications of lymphangiography are not uncommon. Clinical manifestations vary from asymptomatic radiological pictures to severe hemorrhagic pneumonitis or a syndrome resembling massive pulmonary embolism. We report a 17-year-old girl with Hodgkin's disease who developed pneumonitis following lymphangiography.

Computed tomography of hepatic oil embolism following lymphangiography

Computed tomographic (CT) findings in two cases of hepatic oil embolism following lymphangiography are described. Both patients had lymphatic obstruction and opacification of the liver due to collateral flow of lymphangiographic contrast. Computed tomography of the liver showed a distinctive branching pattern due to the intrahepatic ethiodol.

Oil contrast lymphography and respiratory function

We reviewed our experience with direct oil contrast lymphography for pulmonary complications in more than 1500 lymphangiograms done since 1969. The vast majority of patients showed little subjective or objective (chest x-ray, pulmonary function test, and gas exchange) evidence of oil embolization even in those with mild to moderate cardiopulmonary disease. In 1% there was evidence on chest x-ray 24 hours after lymphography of tiny patchy infiltrates consistent with oil emboli. Although the indications for oil contrast lymphography have been sharply restricted with availability of newer imaging methods, it is nonetheless a safe and well-tolerated procedure even in patients with mild to moderate pulmonary dysfunction.

Reliability of diagnostic imaging after orchiectomy alone in follow-up of clinical stage I testicular carcinoma: excessive cost with potential risk

From 1981 to 1984, 86 consecutive patients with previously untreated nonseminomatous testicular carcinoma were classified as clinical radiological stage I and treated with orchiectomy alone. The follow-up program included chest x-ray and lymphangiography (LAG) every month and abdominal computed tomography (CT) bimonthly. All patients were followed for 15 to 63 months after orchiectomy (median 32 mo.). Metastases developed in 23 patients (26.7%) and in 13/23 there was retroperitoneal lymphadenopathy. Time of relapse after orchiectomy ranged from 2 to 36 months (median 7 mo.) with a shorter interval for chest (4 mo.) compared with retroperitoneal metastases (7 mo.). Lung metastases were readily identified at an early stage (less than 2 cm) whereas more than one-third of retroperitoneal nodal metastases were greater than 5 cm at time of diagnosis. LAG detected metastases in 8/11 patients (72.7%), abdominal CT in 8/10 (80%), and both together (LAG and CT) 7/8 (87.5%). In clinical stage I nonseminomatous testicular carcinoma, the high incidence of concomitant but often asymptomatic regional and distant metastases and the relatively high cost and inconvenience of follow-up using abdominal CT imaging, LAG and chest x-ray suggest that orchiectomy is best combined with retroperitoneal node dissection at time of initial presentation to insure more accurate and safe staging of tumor dissemination.

Pitfall in MR imaging of lymphadenopathy after lymphangiography

In two patients examined with magnetic resonance (MR) imaging after lymphangiography, opacified pelvic lymph nodes could not be distinguished from subcutaneous or retroperitoneal fat because of the short T1 and long T2 relaxation times of lymphangiographic contrast media. Opacified nodes removed from one patient had relaxation times similar to those of fat. Thus, assessment of lymphadenopathy with MR imaging should be performed before lymphangiography to obviate this potential pitfall.

[Acute adult respiratory distress syndrome after lymphography]

Pulmonary complications of lymphography are usually described as radiological infiltrates without clinical symptoms. However, a case is here reported of an adult respiratory distress syndrome occurring after lymphography in a 60 year old female lymphoma patient. Pulmonary oedema developed within 48 h; haemodynamic study showed a normal capillary wedge pressure. The patient died from intractable low cardiac output within 24 h. Post-mortem examination showed pulmonary lymphocytic infiltration and multiple fat emboli. The lack of lymphatic drainage was probably responsible for the intravascular passage of lipid-soluble contrast medium, this giving endothelial lesions. In such patients with preexisting lung disease or pulmonary involvement in haematological disease, lymphography has to be considered carefully.

[Lymphography without dye injection. A low-risk method with minimal patient burden]

Coloured dyes injected for demonstration of vessels during lymphography may lead to unforeseen sensitivity reactions. It is therefore recommended that the examination be done without the injection of patent blue. The techniques and problems associated with this examination are described.

The CT appearances of hepatic oil embolism following lymphography

Four instances of lymphography complicated by hepatic oil embolism are presented. The subsequent computerised tomography appearances can be misleading: the oily contrast medium mimics hepatic calcification and this may be mistakenly thought to indicate calcified hepatic metastases. The correct diagnosis will become apparent if a history of lymphography is sought, and it is important to realise that, even on conventional radiography, hepatic oily contrast medium may remain visible for several months. Computerised tomography is a much more sensitive indicator of the presence of oily contrast medium in the liver, so the absence of detectable oil on conventional radiography is unhelpful. The mechanisms which are thought to lead to hepatic oil embolism are discussed because recognition of the circumstances leading to hepatic oil embolism and appreciation of the associated findings will provide further clues to the correct diagnosis.

Mineral oil (follicular) lipidosis: II. Histologic studies of spleen, liver, lymph nodes, and bone marrow

Tissues obtained from 600 routine autopsies were studied. Mineral oil lipidosis was present in the spleen (76 per cent), liver (45 per cent), bone marrow (26 per cent), and lymph nodes; more than 50 per cent of the lymph nodes from the mesentery, porta hepatis, and mediastinum were affected. Mineral oil and its metabolic products produce a nonfibrogenic reaction in these tissues. The differential diagnosis of mineral oil lipidosis in lymph nodes with reaction to radiopaque oils and Whipple's disease is discussed. The presence of mineral oil in para-aortic (42 per cent) and internal iliac (15 per cent) lymph nodes could result in false-positive readings after lymphangiography.

[Neurologic complication of lymphography. Apropos of a case]

A lymphography was performed as a diagnostic procedure in a 69-year-old female patient hospitalized for protracted fever. Akinetic mutism with left hemiparesis occurred 10 minutes after the injection of ultrafluid lipiodol. The patient died 13 days later. Neurologic complications of lymphography are extremely rare but may be life-threatening. Speculations as to the mechanisms which may be responsible for these complications, through a modification of the usual distribution of the contrast media, include lymphovenous shunts, lymphatic vessel compression or obstruction, pulmonary arteriovenous shunts and right-to-left intracardiac shunts. These mechanisms may facilitate cerebral embolization of the contrast media. Indications of lymphography must be restricted in patients with patent lymphatic obstruction.

Thyroid damage--after treatment for Hodgkin's disease

Advances in the treatment of Hodgkin's disease in the last 20 years have led to a marked improvement in survival but also to a significant increase in treatment-related complications. Infertility, growth disturbance and carcinogenesis have attracted well deserved attention. This paper reviews the thyroid complications of treatment since these are important to patient and clinician and if missed may result in unnecessary morbidity.

Pulmonary airflow obstruction following lymphography

In a series of 27 patients a significant mean decrease of forced expiratory volume in one second (FEV1) was recorded at 1/2, 2, 4 and 24 hours after lymphography with an oily contrast medium, with a maximum mean decrease at 4 hours after injection. The decrease of FEV1 was greater in patients given large amounts of contrast medium at high injection speed. Furthermore, an excessive decrease was observed in patients with metastatic lymph nodes, while a less marked decrease of FEV1 was observed in patients treated with aspirin. No serious clinical side effects were observed. It is recommended that the injection speed and the total amount of contrast medium be limited as far as possible, especially in patients with severe airflow obstruction or with metastases in the lymphatic system. Oral administration of aspirin may limit the decrease in FEV1 following lymphography.