Lymphography Research Articles

Comparison of lymphangiography and computed tomography scanning in evaluating abdominal disease in stages III and IV Hodgkin's disease: A southwest oncology group study

The authors reviewed the records of 139 patients who had laparotomy plus computed tomography (CT) and/or lymphangiograms (LAG) as part of a their staging workup for Hodgkin's disease, in accordance with Southwest Oncology Group (SWOG) protocol 7808. They evaluated the relative ability of CT and LAG to detect disease in the abdomen. Two regions of the abdomen were designated, the upper and the lower, to further examine the capabilities of CT and LAG in the lower abdomen and CT in the upper abdomen. A LAG was more sensitive (P less than 0.05) than CT in detecting positive lower abdominal nodes. In the upper abdomen, CT scan had low sensitivity for detecting positive nodes, liver, or spleen. This study suggests that LAG of the lower abdomen provided more information than CT, and therefore should not be abandoned as a valid method for detecting nodal disease.

The Role of Bipedal Lymphangiography in Testicular Seminoma

Determining the extent of intra-abdominal spread of testicular seminoma by radiographic studies is an essential step in planning rational treatment following orchidectomy. CT scanning is generally accepted as being superior to lymphangiography in assessing the retroperitoneal space. We reviewed the relative contribution of these two procedures in a retrospective analysis of 73 consecutive patients with testicular seminoma managed at Westmead Hospital between January 1980 and September 1987. Abdominal CT scans and bipedal lymphangiography (LAG) were carried out in 72 and 51 patients respectively, 50 patients undergoing both procedures. We found concordance between the two techniques to be 88%. Upstaging occurred in 5 patients using CT (10%), 7 patients using LAG (14%), and in 8 patients (16%) when both tests were utilised. Four patients were upstaged by both techniques while the remaining 4 patients were upstaged using one technique alone. Serum beta-HCG was not a reliable screen for residual disease. Residual disease in the few patients with an elevated serum beta-HCG was easily detected by CT scanning. We conclude that there is a continuing role for LAG in assessing patients with clinical Stage I seminoma when the abdominal CT scan is equivocal or normal.

Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: Extended diagnostic evaluation for paraaortic node metastasis—A Gynecologic Oncology Group study

Three hundred twenty patients were entered into GOG Protocol 63, a clinical-pathologic study of stage IIB, III, and IVA cervical carcinoma. Following the completion of FIGO staging prerequisites, patients had computerized tomography (CT), a lymphangiogram (LAG), and an ultrasound (US) of the aortic area. If any study was positive, a cytologic or histologic evaluation by fine-needle aspiration or selective paraaortic lymphadenectomy was performed. Paraaortic node dissection was mandated for patients with negative extended staging studies. Results of extended staging evaluations were compared with histologic or cytologic results. Two hundred sixty-four patients were eligible and evaluable. One hundred sixty-seven patients (63%) were stage IIB, 89 (34%) were stage III, and 8 (3%) were stage IVA. Positive paraaortic nodes occurred in 21% of stage IIB, 31% of stage III, and 13% of stage IVA. LAG sensitivity was 79% with a specificity of 73%. Sensitivity of CT and US was 34 and 19%, respectively, with specificities of 96 and 99%, respectively. The frequency of false-negative results with LAG for patients with stage IIB disease was 6%. This decrease is consistent with a stable sensitivity and specificity. These findings suggest that a negative LAG may be adequate to eliminate surgical staging in subgroups with low risk of metastasis to the aortic nodes. Until new noninvasive testing methods are developed, LAG appears to be the most reliable noninvasive examination to evaluate spread of cervical cancer to aortic nodes.

Adenocarcinoma of the uterine cervix prognosis and patterns of failure in 367 cases

Between 1965 and 1985, 367 patients received initial treatment for adenocarcinoma of the uterine cervix at the M. D. Anderson Cancer Center (MDACC). Of the 334 patients treated with curative intent, 223 had International Federation of Gynecology and Obstetrics (FIGO) Stage I, 60 had Stage II, and 51 had Stage III/IV disease. The 5-year and 10-year relapse-free survival (RFS) rates for all patients treated for Stage I disease were 73% and 70%, respectively. RFS was strongly correlated with initial bulk of disease (P = 0.002), although locoregional control (LRC) was good in all groups: 91 patients with a normal-sized cervix (tumor less than 3 cm) had a 5-year RFS rate of 88% and an actuarial LRC rate of 94%; 102 patients with lesions 3 to 5.9 cm in diameter had an RFS rate of 64% and an LRC rate of 82%; and 22 patients with bulky lesions greater than 6 cm in diameter had a comparable LRC rate of 81%, but an RFS rate of only 45%. Decreased RFS also was strongly correlated with positive lymphangiogram (LAG) results (P = 0.02) and poorly differentiated lesions (P = 0.0014). When initial primary tumor size was taken into account, there was no significant difference in RFS or LRC between patients treated with radiation (RT) alone or RT plus extrafascial hysterectomy (R + S). The 5-year and 10-year RFS rates of 60 patients who received curative therapy for Stage II disease were 32% and 25%, respectively, with an LRC rate of 62% at 5 years. Patients with bulky Stage II disease did particularly poorly, with a 5-year RFS rate of 15%. Decreased RFS was correlated with positive LAG results and poorly differentiated tumors. Most Stage II patients whose disease relapsed died with distant metastases (73%). Forty-eight patients with Stage III/IV disease treated with curative intent had a 5-year survival rate of 31% and a 5-year pelvic disease control rate of 52%. In summary, patients with small volume Stage IB lesions have excellent LRC and survival with RT alone. RT achieves good LRC of bulkier Stage I lesions, but survival decreases with increasing primary tumor size. R + S holds no apparent advantage over RT alone. Patients with more advanced disease have a high rate of relapse with frequent distant metastasis. In particular, the survival of patients with FIGO Stage II disease is much lower than what we have observed after treatment of comparable stage squamous carcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

Iliopelvic lymphoscintigraphy with99mTc-dextran in malignant lymphoma

99mTc-Dextran (99mTc-D) was evaluated as an iliopelvic lymphoscintigraphic agent in 49 patients with malignant lymphoma and the results were compared with ultrasound (US), lymphangiography (LA) and CT where available. Scintigrams were obtained by a gamma camera at 2 h postinjection and evaluated by comparing opposite sides. In 29 of 49 patients, normal lymphoscintigrams of excellent quality, deliniating the iliopelvic and paraaortic lymph nodes bilaterally were obtained. In 20 patients lymphoscintigraphy (LS) was positive. US was performed in 46 patients, 20 had positive and 26 negative findings. There was one false positive and one false negative in LS compared to US. Ten patients had LA and 3 had CT. These results were in complete agreement with LS. There was also a positive correlation between the clinical stages and the results of LS. This study showed that 99mTc-D is an excellent radiopharmaceutical for the visualization of the lymph system with high correlation with other imaging modalities.

Staging, treatment, and results in testicular seminoma A 12‐year report

Sixty-one patients with histologically confirmed seminoma of the testis were treated by radiotherapy at The Johns Hopkins Hospital from 1975 to 1987. Fifty-seven patients remain disease-free, three patients died of intercurrent disease, and one patient (Stage IIB) died of widespread seminoma. Median follow-up for these patients is 5.5 years. Using a modified M.D. Anderson Hospital clinical staging system, 42 (69%) were Stage I, 16 (26%) were Stage IIA, and three (5%) were Stage IIB. Radiologic staging included both lymphangiogram (LAG) and abdominal computed tomography (CT) scan. Among Stage I disease, nine patients had false-positive CT scans, determined by negative LAG. Six patients had false-negative CT scans and were upstaged to Stage IIA by LAG. Treatment portals were altered in 15 of the 39 patients (38%) who had both LAG and CT scan. Overall actuarial survival (Kaplan-Meier method) was 97% at 5 years and 92% at 10 years. Five-year survival corrected for intercurrent disease was 100% for Stage I, 100% for Stage IIA, and two of three in Stage IIB patients. There were two distant treatment failures among the entire cohort. One patient who had Stage I disease was salvaged with local-field radiation and chemotherapy and is now without evidence of disease for 6 years. The second patient with Stage IIB seminoma receiving the same treatments disseminated and died. There were no significant acute toxicities or serious complications. In summary, proper staging with information gained from LAG and adequate radiation dose led to a 92% 10-year disease-free survival.

Impact of surgical staging in evaluating the radiotherapeutic outcome in rtog phase III study for A 2 and B prostate carcinoma

Radiation Therapy Oncology Group (RTOG) protocol 7706 was a randomized Phase III study designed to test the value of elective (prophylactic) pelvic irradiation in addition to prostatic irradiation in patients with carcinoma of the prostate with no clinical evidence of tumor extension through the capsule. Eligible patients were those who had clinical Stage T1bNOM0 (A 2) or T2NOMO (B), who did not have curative surgery, and who had no evidence of lymph node metastases. Assessment of the regional lymphatics was mandatory but, at the discretion of the investigator, lymphangiography (LAG) or staging lymphadenectomy (SL) could be used. A total of 445 eligible and analyzable patients were entered in the study between 1978 and 1983 when the study was closed. The median follow-up was 7 years; minimum follow-up was 5 years. There were no significant differences in survival or local control whether treatment was administered to the prostate or to the prostate and pelvic lymph nodes. The nodal status for 117 (26%) patients was assessed by staging lymphadenectomy (SL) whereas for 328 (74%) patients it was assessed by lymphangiography (LAG). Pretreatment characteristics felt to have impact on survival were evaluated and found to be free of serious imbalance between the staging lymphadenectomy and lymphangiography groups. Compared to the lymphangiography group, the staging lymphadenectomy group showed better overall survival (87% to 76% at 5 years, p = .02), better disease-free survival (76% to 63% at 5 years, p = .008) and better metastases-free survival (88% to 82% at 5 years, p = .04). There was no difference between the groups in local control. The lymphangiography evaluation of pelvic nodes was clearly inferior for demonstration of the absence of pelvic node metastasis as reflected by reduced survival and increased metastasis.

Clinical and radiologic staging of locally advanced and inoperable bladder carcinoma

Twenty-seven patients with locally advanced and inoperable bladder carcinoma (LABCa) were referred for chemotherapy. All were staged by cytoscopy, examination under anesthesia, and computed tomography (CT), and 18 also had bipedal lymphangiography (LAG). In 16 patients (56%), there was agreement between the clinical and the CT staging of the primary bladder tumor. In four of these 16 patients, CT detected lymphadenopathy in three and demonstrated pelvic bone invasion in one. Of the remaining 11 patients, CT underestimated the local extent of the bladder tumor in nine and over-estimated in two. Lymphangiography was abnormal in nine patients (50%), in four of whom the abnormality was not seen on CT scan. Among the ten patients with normal LAG, six had abnormal pelvic nodes detected by CT. The LAG affected the overall staging of the tumor in five patients (16.6%). The total incidence of nodal metastasis as seen on CT, LAG, or both was 72%. Although CT and LAG may not add significantly to the clinical staging of the primary tumor in LABCa, they will affect the overall staging of the tumor by detecting lymphadenopathy. Accurate staging of these patients is important because, with aggressive chemotherapy, some of these patients might become candidates for more radical treatment such as surgery or radiotherapy.

Surveillance for stage I non-seminomatous germ cell tumours of the testis: the optimal protocol has not yet been defined.

Forty-six patients with clinical stage I testicular non-seminomatous germ cell tumours were followed up according to a protocol of active surveillance between 1979 and 1987. The median follow-up time was 40+ months. Thirteen patients (28%) relapsed, predominantly in retroperitoneum and/or lung. Ten of these relapses (76%) occurred within 8 months of orchiectomy. Relapses occurred in 7/35 T1 tumours and 5/10 T2 to T4 tumours. No correlation was detected between the histological type and relapse rate. Three late relapses were diagnosed at 23, 29 and 36 months. Eleven of the relapsed patients remain in prolonged complete remission after PVB chemotherapy +/- surgery; one patient, who initially refused treatment at the time of relapse, has died. Another relapsed with predominant elements of rhabdomyosarcoma intermingled with malignant teratoma in a bone metastasis. He had a partial response to PVB chemotherapy but subsequently died. Thirty-four patients (74%) did not undergo lymphography (LG) and had a higher relapse rate (11/34) than those who had LG (2/12); this was not a statistically significant difference in this small series. The policy of active surveillance is not yet the "state of the art" and should be under constant scrutiny with respect to safety and practice.

Value of gallium scans and lymphangiography in non-Hodgkin's lymphoma of the Waldeyer's ring.

In 37 patients with seemingly localized non-Hodgkin's lymphoma of the Waldeyer's ring (WR-NHL), lymphangiography (LAG) and/or gallium-67 scans (Ga-67 scans) were done. Before these procedures, 20 patients were diagnosed as Stage I, and 17 as Stage II. LAG was done for 30, and Ga-67 scans for 32, 25 of whom had both. Five patients (16%) were upstaged to Stage III or IV by Ga-67 scans. Only one (3%) had abnormal LAG findings, in whom Ga-67 scans also showed abnormal accumulation in the para-aortic region. Because of this low positive rate, LAG is not recommended for staging of WR-NHL.

Book ReviewLymphatic Imaging: Lymphography, computed tomography and scintigraphy

Book ReviewLymphatic Imaging: Lymphography, computed tomography and scintigraphy

Treatment of Persistent Lymphocele Following Saphenous Vein Harvesting: A Case Report

A case of lymphocele in the lower thigh, following removal of the saphenous vein, is presented. The pathophysiology and surgical treatment are described. Lymphatic complications after removal of saphenous veins are uncommon. Most of these consist of a temporary leak or subcutaneous collection of lymph. Persistent collection of lymph in the thigh may require an operation. Such a case, successfully treated by an operation, is described. The value of lymphan giogram, both in diagnosis and as an aid in the operation, is discussed.

Lymphangiography and abdominal computerized tomography in persistent generalized lymphadenopathy.

Lymphangiography (LAG) and abdominal computed tomography (CT) were performed on 13 intravenous drug (heroin) abusers with persistent generalized lymphadenopathy (PGL). All 12 LAG performed were abnormal with a repetitive pattern of diffuse abnormalities of internal structures with small filling defects of both pelvic and abdominal lymph nodes. In 12/13 (92%) of the patients, lymphadenopathy was evidenced by CT scan as well. Retroperitoneal lymph nodes were always abnormal, mesenteric and pelvic nodes in 7 patients each. In 9/13 (69%) of the patients, the spleen was found to be moderately enlarged. The LAG films of our first 2 patients referred to us with an erroneous histologic diagnosis of malignant lymphoma were read to be consistent with involvement by lymphoma. Considering that patients with PGL are at risk for transformation to malignant lymphoma, the LAG and CT findings of PGL should be kept in mind when transformation to malignant lymphoma occurs and staging is performed.

Lymphographic findings in prostatic carcinoma with distant metastases

From January 1976 to December 1981, 25 patients with prostatic carcinoma and distant metastases had lymphangiography (LAG) in their initial workup either to obtain a more precise definition of tumor extension or because at the time of LAG asymptomatic metastases had not yet been detected. In 18 patients extensive bone metastases were present while in seven the only indicator of bone metastases was bone scan (limited bone disease). Positivity rate was 48% (20% in T2 cases, 53% in T3-T4; 29% in limited bone disease, 53% in extensive bone metastases). No correlation was found between LAG positivity and degree of differentiation. Patients with N0 survived longer than patients with N2-N4; however, the difference in survival is not significant and seems to be linked to the extent of bone metastases. Our data substantiate that LAG is of no value in the staging of metastatic prostatic carcinoma.

Ultrasonography in the Staging of Hodgkin's disease: Lymphangiographic correlation

The contribution of ultrasonography (US) to the staging of Hodgkin's disease was studied in 45 patients. US findings were compared with lymphangiograms (LAG) performed in the same period. In 93% of the patients there was good correlation between the two examinations. In 7% (three patients) there was a discrepancy: LAG showed retroperitoneal node involvement while with US this was negative. There were no false-positive US examinations. We therefore suggest that US be used as the primary method in the initial evaluation of Hodgkin's disease and LAG be performed only when US is negative.

Relative role of abdominal pelvic CT and lymphangiography in staging of testicular seminoma.

Sixty patients with testicular seminoma were reviewed regarding the evaluation of the retroperitoneal lymph nodes. Thirty-four of these patients had both abdominal pelvic computerized tomography (APCT) scan and bipedal lymphangiography (LAG). In 21 patients, the results of the two studies were in agreement. However, 11 patients had positive LAG and negative APCT, while only 2 had a positive APCT and negative LAG. We recommend that patients with testicular seminoma have an APCT. If findings are negative, LAG should be done.

直腸リンパ節のラジオアイソトープリンパ造影

直腸癌リンパ節転移の術前診療法において, 従来施行されている方法 (Kinmonth法) では主たる転移経路である上方および側方経路の転移状況を明確にすることは出来ない.私達は直腸癌23例, S状結腸癌9例に対して, 経肛門的RI lymphographyを施行し, 直腸領域のリンパ流の画像上の検索を行い, 病理学的診断と対比検討した.直腸リンパ流がほぼ正常と考えられる no 直腸癌症例およびS状結腸癌症例では, 上方経路, 側方経路のscintigram上の描出率は各々100%, 88%であった.上方経路, 側方経路リンパ節に転移が著明で, リンパ流のブロックをおこしていると考えられる症例では, negative patternとしてscintigram上で診断可能であった.また上方経路のscintigram 上の描出を認めない症例は, 同経路のリンパ節の転移度が高い傾向を認めた.

The use of para-aortic radiation therapy based on lymphangiogram interpretation in uterine cervical carcinoma

From January, 1965, to June, 1979, 79 nonrandomized patients with carcinoma of the uterine cervix had a bipedal lymphangiogram (LAG) prior to radiotherapy at the Stanford University Medical Center. In 32 patients the LAGs were interpreted as normal. Of the remaining 47 patients, 28 had LAGs interpreted as positive for metastatic involvement of pelvic nodes alone, 11 as positive for pelvic and para-aortic (PA) metastasis, and 8 as positive in PA nodes alone. Five-year survival and freedom from relapse (FFR) were found to be similar for patients with LAGs interpreted as normal or positive in pelvic nodes only (all stages combined). The addition of elective PA irradiation in those patients with positive pelvic nodes alone (median 5000 rad/5 weeks) did not enhance either survival or FFR in this group. The 19 patients with positive PA nodes had significantly worse survival and FFR when compared with the other groups. Survival was not enhanced by the addition of therapeutic PA irradiation (median 5000 rad/5 weeks) and the 7 patients in this group so treated appeared to have a reduced FFR when compared to the 12 untreated patients. Irrespective of the location of nodal abnormality on LAG and regardless of stage, the majority of relapses ( 16 23 ) occurred either centrally or at the pelvic sidewalls. It is concluded that the LAG is a good predictor of subsequent relapse and survival, but that the addition of either elective or therapeutic PA radiotherapy based on LAG interpretation does not affect survival of FFR and should, therefore, be considered for investigational or palliative use only.

Survival, prognostic factors, and relapse patterns in uterine cervical carcinoma.

Between 1965 and 1979, 295 evaluable patients were treated with radiotherapy and/or surgery for invasive cervical carcinoma at the Stanford University Medical Center. The records of these patients were analyzed retrospectively with regard to survival, possible prognostic factors of freedom-from-relapse, and relapse patterns. Survival for the entire population at 5 years was 67%, with a median follow-up of 5 years. Five-year freedom-from-relapse (FFR) rates for stages I-IV were 88%, 61%, 33%, and 11%, respectively. Eighty-eight percent of all relapses occurred within 5 years. Several possible prognostic factors of FFR--including stage, histology, tumor differentiation, lymphangiogram status, treatment modality, age, presence of cervical stump, and initial serum hemoglobin value--were evaluated with a multivariate analysis. Stage was the best predictor of FFR, and lymphangiogram (LAG) status was the next most important covariate: 13 of 19 patients who showed involvement of paraaortic nodes on LAG relapsed within 1 year. There was no difference in survival or FFR between adenocarcinoma or squamous cell histologies. FFR in stage IB patients was independent of treatment modality; i.e., radiotherapy alone, surgery alone, or combined therapy. Initial serum hemoglobin (less than 12 vs. greater than 12) was not predictive of FFR or survival. Stage for stage, patients over 57 years of age tended to have better FFR than younger patients. The majority of relapses occurred centrally or at the pelvic sidewalls (58%), and future attempts to improve local control rates will rely more heavily on the individualized use of interstitial template applicators.

The lymphatics: Surgery, lymphography, and diseases of the chyle and lymph systems. 2nd ed: By J. B. Kinmonth. 428 pp., $149.50 Edward Arnold, Publisher, Baltimore, Maryland, 1982

The lymphatics: Surgery, lymphography, and diseases of the chyle and lymph systems. 2nd ed: By J. B. Kinmonth. 428 pp., $149.50 Edward Arnold, Publisher, Baltimore, Maryland, 1982