Lymphatic Imaging: Current Noninvasive and Invasive Techniques

Abstract

After nearly disappearing, invasive lymphangiography not only has resurged, but new approaches have been developed to guide lymphatic interventions. At the same time, noninvasive lymphatic imaging is playing a larger role in the evaluation of lymphatic pathologies. Lymphangioscintigraphy, computed tomography lymphangiography, and magnetic resonance lymphangiography are increasingly being used as alternatives to invasive diagnostic lymphangiography. The purpose of this article is to review current invasive and noninvasive lymphatic imaging techniques.

Keywords: CT lymphangiography; MR lymphangiography; interventional radiology; lymphangiography; lymphangioscintigraphy.

Fig. 1

Bilateral lower extremity Tc99m sulfur colloid lymphangioscintigraphy. Note prompt cephalad tracer transport from foot injection sites into peripheral and central lymphatic trunks and regional inguinal and retroperitoneal lymph nodes up to the level of the cisterna chyli with demonstrable retrograde reflux of tracer (arrow) into the tracheobronchial tree and right upper lung field. Radioactive markers placed at key anatomic landmarks—knee, pubis, xiphoid, and suprasternal notch. (Reprinted with permission from Parikh et al. 25 )

Fig. 2

Volume-rendered reconstruction of a CT lymphangiography in ( a ) paracoronal and ( b ) sagittal orientation. The entire length of the thoracic duct (arrowheads) is clearly visualized from the cervical segment (arrow) to the cisterna chyli (asterisk) despite extensive spinal metal implants that would impair MR lymphangiography.

Fig. 3

Coronal heavily T2-weighted non–contrast-enhanced MR lymphangiogram shows ( a ) the upper portion of the thoracic duct (arrows) with a duplicated cervical portion (broken arrows) and ( b ) the lower portion of the thoracic duct (small arrows) and the cisterna chyli (arrowhead).

Fig. 4

Dynamic contrast-enhanced MR lymphangiography of the right lower extremity demonstrates on ( a ) coronal spoiled gradient echo, ( b ) maximum intensity projection, and ( c ) 3D volume rendering a dominant lymphatic vessel from the foot (white arrow) with branching vessels and multiple foci of lymphatic ectasia (asterisk).

Fig. 5

Photos depicting the steps of pedal lymphangiography: ( a ) appearance of the dorsum of the foot after injection of Lymphazurin blue (*, injection site; white arrow, dye in lymphatic vessel), ( b ) transverse incision on the dorsum of the foot and blunt dissection, ( c ) isolation of a pedal lymphatic vessel with silk tie, ( d ) access of a pedal lymphatic vessel with a 30-gauge lymphangiography needle, ( e ) securement of the lymphangiography needle in the lymphatic vessel by tying with the silk tie and of the silk tie to the foot with band aids, and ( f ) securement of the lymphangiography needle tubing around the toes.

Fig. 6

Excretion of green urine during and after pedal lymphangiography due to mixing of renally excreted isosulfan blue with yellow urine.

Fig. 7

Traditional lymphangiography contrast injector.

Fig. 8

Spot radiographs of the left lower extremity showing ethiodized oil opacifying ( a ) proximal calf and distal thigh lymphatic vessels and ( b ) proximal thigh, inguinal, and pelvic lymphatic vessels and lymph nodes.

Fig. 9

Spot radiographs of the ( a ) upper abdomen showing ethiodized oil opacifying an ampullaceous cisterna chyli (arrows) and ( b ) lower thorax showing extravasation of ethiodized oil (arrows) into the right hemithorax.

Fig. 10

Ultrasound images of a right inguinal lymph node showing the 25-gauge needle (white arrow) in the hilum ( a ) prior to and ( b ) after ethiodized oil injection.

Fig. 11

Spot radiographs of the right inguinal region of a pediatric patient during intranodal lymphangiography showing ( a ) needle access into a right inguinal lymph node opacified by ethiodized oil in a reticular pattern (arrow), ( b ) lobular dense focus of extravasation (arrow) developing at the needle entry site, and ( c ) worsening lobular focus of extravasation (arrow) at the needle entry site.

Fig. 12

Photo demonstrating hand injection of ethiodized oil during inguinal intranodal lymphangiography.

Fig. 13

Spot radiograph of the pelvis showing water-soluble contrast opacifying lymphatic vessels and lymph nodes in bilateral proximal thighs and inguinal regions (arrows) and lack of proximal opacification of pelvic lymph nodes and vessels.

Fig. 14

Spot radiographs of ( a ) the upper abdomen and lower thorax showing a 22-gauge Chiba needle (arrow) accessing a small fusiform cisterna chyli and ( b ) the thorax showing a microwire coursing through the thoracic duct all the way to the cervical portion of the thoracic duct (black arrow) and extravasation of contrast into the right hemithorax (white arrow).

Fig. 15

Digital subtraction ( a ) central venogram showing a 5-Fr RIM catheter (arrow) selecting the lymphovenous junction and ( b ) thoracic lymphangiogram through a microcatheter (arrow) advanced in retrograde fashion into the thoracic duct.

Fig. 16

Ultrasound images showing a micropuncture needle (arrow) accessing the cervical portion of the thoracic duct ( a ) adjacent to the left internal jugular vein (LIJ) and ( b ) through the left internal jugular vein.

Fig. 17

Spot radiographs of the left supraclavicular region showing ( a ) a micropuncture needle (arrow) accessing the cervical portion of the thoracic duct which is opacified by ethiodized oil from preceding intranodal lymphangiography, and ( b ) a 3-Fr catheter from a micropuncture kit (black arrow) in the cervical portion of the thoracic duct used to inject water-soluble contrast which reveals the lymphovenous junction (white arrow).

Fig. 18

Spot radiographs of the thorax showing ( a ) a microwire (black arrows) advanced in retrograde fashion through a micropuncture needle (white arrow) accessing the cervical portion of the thoracic duct and ( b ) retrograde water-soluble thoracic lymphangiogram (arrows).

Fig. 19

Spot radiograph of the upper abdomen during retrograde direct percutaneous lymphangiography with the tip of the microcatheter in the left lumbar trunk (black arrow) showing extravasation of contrast into the left upper quadrant (white arrows).

Fig. 20

Spot radiographs of the right upper abdominal quadrant during ( a ) transhepatic lymphangiogram and ( b ) percutaneous biliary drain placement showing contrast injection through a Chiba needle (white arrow) opacifying periportal lymphatic vessels (black arrows).