Abstract
Purpose
There are limited existing data on the lymphatic anatomy of patients with primary lymphedema (LED), which is caused by aberrant development of lymphatic channels. In addition, there is a paucity of contemporary studies that use groin intranodal lymphangiography (IL) to evaluate LED anatomy. The purpose of this retrospective observational study was to better delineate the disease process and anatomy of primary LED using groin IL.
Materials and Methods
We identified common groin IL findings in a cohort of 17 primary LED patients performed between 1/1/2017 and 1/31/2022 at a single institution. These patients were clinically determined to have primary lymphedema and demonstrated associated findings on lower extremity MR and lymphoscintigraphy.
Results
Ten patients (59%) demonstrated irregular lymph node morphology or a paucity of lymph nodes on the more symptomatic laterality. Eight patients (47%) demonstrated lymphovenous shunting from pre-existing anastomoses between the lymphatic and venous systems. Eight patients (47%) demonstrated passage of contrast past midline to the contralateral lymphatics. Finally, 12 patients (71%) failed to opacify the cisterna chyli and thoracic duct on their initial lymphangiograms. Delayed computed tomography of 3 patients showed eventual central lymphatic opacification up to the renal veins, but none of these patients showed central lymphatic opacification to the thorax.
Conclusion
This descriptive, exploratory study demonstrates common central groin IL findings in primary LED to highlight patterns interventional radiologists should identify and report when addressing primary LED.
Graphical Abstract
This is a preview of subscription content, log in via an institution to check access.
Abbreviations
- IL:
-
Intranodal lymphangiography
- LED:
-
Lymphedema
References
Warren AG, Brorson H, Borud LJ, Slavin SA. Lymphedema: a comprehensive review. Ann Plast Surg. 2007;59:464–72.
Brown S, Dayan JH, Coriddi M, et al. Pharmacological treatment of secondary lymphedema. Front Pharmacol. 2022;13:828513.
O’Donnell TF Jr, Rasmussen JC, Sevick-Muraca EM. New diagnostic modalities in the evaluation of lymphedema. J Vasc Surg Venous Lymphat Disord. 2017;5:261–73.
Buonocore E, Young JR. Lymphangiographic evaluation of lymphedema and lymphatic flow. Am J Roentgenol Radium Ther Nucl Med. 1965;95:751–65.
Edwards JM, Kinmonth JB. Lymphovenous shunts in man. Br Med J. 1969;4:579–81.
Golueke PJ, Montgomery RA, Petronis JD, Minken SL, Perler BA, Williams GM. Lymphoscintigraphy to confirm the clinical diagnosis of lymphedema. J Vasc Surg. 1989;10:306–12.
Goss JA, Maclellan RA, Greene AK. Lymphoscintigraphic evaluation of systemic tracer uptake in patients with primary lymphedema. Ann Plast Surg. 2019;82:S212–4.
Bains SK, Ballinger J, Allen S, et al. An investigation of lymphovenous communications in the upper limbs of breast cancer patients. Eur J Surg Oncol. 2015;41:433–8.
Liu J, Sato Y, Motoyama S, et al. Ultrasound-guided intranodal lipiodol lymphangiography from the groin is useful for assessment and treatment of post-esophagectomy chylothorax in three cases. Int J Surg Case Rep. 2016;29:103–7.
Patel S, Hur S, Khaddash T, Simpson S, Itkin M. Intranodal CT lymphangiography with water-soluble iodinated contrast medium for imaging of the central lymphatic system. Radiology. 2022;302:228–33.
Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 2012;23:613–6.
Pflug JJ, Calnan JS. The normal anatomy of the lymphatic system in the human leg. Br J Surg. 1971;58:925–30.
O’Mahony S, Britton TB, Ballinger JR, et al. Delivery of radiolabelled blood cells to lymphatic vessels by intradermal injection: a means of investigating lymphovenous communications in the upper limb. Nucl Med Commun. 2010;31:121–7.
Brouillard P, Witte MH, Erickson RP, et al. Primary lymphoedema. Nat Rev Dis Primers. 2021;7:77.
Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008;59:324–31.
Tucker AB, Krishnan P, Agarwal S. Lymphovenous shunts: from development to clinical applications. Microcirculation. 2021;28:e12682.
Lee E, Biko DM, Sherk W, Masch WR, Ladino-Torres M, Agarwal PP. Understanding lymphatic anatomy and abnormalities at imaging. Radiographics. 2022;42:487–505.
Mazzei FG, Gentili F, Guerrini S, et al. MR lymphangiography: a practical guide to perform it and a brief review of the literature from a technical point of view. Biomed Res Int. 2017;2017:2598358.
Garza RM, Chang DW. Lymphovenous bypass for the treatment of lymphedema. J Surg Oncol. 2018;118:743–9.
Connell FC, Gordon K, Brice G, et al. The classification and diagnostic algorithm for primary lymphatic dysplasia: an update from 2010 to include molecular findings. Clin Genet. 2013;84:303–14.
Funding
There are no funding sources for this manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None of the authors declare relevant conflicts of interest in relation to this manuscript.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Kim, C., Ali, H., Tsai, L.L. et al. Evaluation of Primary Lymphedema with Intranodal Lymphangiography. Cardiovasc Intervent Radiol 47, 238–244 (2024). https://doi.org/10.1007/s00270-023-03605-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00270-023-03605-9