Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization

Abstract

Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol^® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol^® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol^® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.

Keywords: Lymphocele; chylous; embolization; lymphangiography; lymphatic leakage.

Figure 1

A 43-year-old female with a symptomatic pelvic lymphocele after pelvic lymph node dissection for ovarian cancer. (A) Lymphoscintigraphy showed an increased radioactivity of the left pelvic lymphocele (open arrow); (B) an intranodal lymphangiography through an inguinal lymph node (asterisk) showed an extravasation of Lipiodol^® (arrowhead) from a medial external iliac lymph node, which was punctured with another needle under fluoroscopic guidance; (C) after embolization of the medial external iliac lymph node using diluted glue, Lipiodol^® and glue leaked into the lymphocele and collected around the drainage catheter (white arrows).

Figure 2

A 54-year-old female with chylous ascites after para-aortic lymph node dissection for ovarian cancer. (A,B) Dynamic contrast-enhanced MR lymphangiography showed the collection of the extravasated contrast agent in the retroperitoneal lymphocele (asterisk) and its leakage into the peritoneal space (arrowheads), thereby confirming that the lymphatic leakage had caused the post-operative ascites; (C) Lipiodol^® extravasated into the lymphocele, which was not fully visualized in the intranodal lymphangiography (asterisk); (D) the lymphocele (asterisk) was embolized using glue and coils, based on the confirmative MRI findings. MR, magnetic resonance; MRI, MR imaging.

Figure 3

A 22-year-old female with non-traumatic chylous ascites. (A) Mesenteric intranodal lymphangiography required open laparotomy to expose the mesentery for the US-guided access to a small mesenteric lymph node; (B) Lipiodol^® was carefully injected into the punctured lymph node (arrow) to evaluate the mesenteric lymphatic system. US, ultrasound.