Arborizing pulmonary embolization following lymphangiography. Report of three cases and an experimental study.

Abstract

With the increasingly wide application of lymphangiography to the diagnosis of malignant disease, the hazards of the method have been a major focus of interest and concern (2, 3, 13–15, 19). The most frequent complication has been pulmonary oil embolism in the form of fine stippling observed on chest roentgenograms, with or without associated pyrexia, cough, dyspnea, chest pain, or palpitation of a minor degree. Pathologic changes in the lungs following intravenous injection of Ethiodol in animals have been described by Guiney et al. (8) and Hallgrimsson and Clouse (9). The degree to which oil may accumulate in the small arteries has received relatively little attention. The purpose of this paper is to report three instances of unique arborizing pulmonary embolization related to lymphangiography in man and to describe studies in dogs following the deliberate production of such cylindrical emboli. Clinical Material The lymphangiographic technic employed has been described elsewhere (1). Chest examinations were performed routinely prior to, immediately after, and twenty-four hours after the procedure on all patients. The chest films on 550 patients who had undergone lymphangiography were reviewed: in three, arborizing embolization was noted. In all three cases, 10 cc of Ethiodol was injected into each leg, using a gravity pressure injector. Case I (Fig. 1): J. B., a 30-year-old white female, was referred to the Stanford Medical Center for further evaluation and treatment of Hodgkin's disease. One and a half years before, she received radiation therapy for right axillary masses which had been diagnosed on biopsy as Hodgkin's paragranuloma. She had done well without systemic symptoms or recurrent masses until two months before admission, when she noted a mass in the left supraclavicular region. This continued to show slight but progressive enlargement. On physical examination, there was a 2.5 × 2 × 1.5 cm, nontender, movable mass along the lower sternocleidomastoid muscle on the left. Two small palpable lymph nodes were also noted in the left supraclavicular fossa. In the right axilla there was a small, movable, and nontender node. The spleen tip was palpable. The remainder of the physical examination and the laboratory studies were normal. The patient tolerated well both a lymphangio-graphic examination (Fig. 1, A) and inferior vena cavography.