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LYMPHANGIOGRAMSRT 255 (rev 2010)

radiographic investigation and

demonstration of the lymphatic system

Lymphography & LymphangiogramDisease Of The Lymphatic System

Lymphatic System:Green-superficialBlack- deep

2•Lymph nodes are home to lymphocytes which help fight infections - They can become swollen if an infection is present

• http://www.youtube.com/watch?v=qEIV6c61kx4&feature=related

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Lymphatic system:Considered to be part of the circulatory system

2 Parts of Circulatory System:

Blood (Arteries/ Capillaries/ Veins)

& Lymphatics

• Lymph filters bacteria, carbon particles and malignant cells

• like which other vessels that the direction of flow goes towards the heart?

4 Lymphatic System

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6LYMPHOMAS : signs and symptoms

Painless lump or swollen

gland - enlarged lymph nodes• itching, skin rash• Drenching night sweats •Fever (100º) , fatigue •Unexplained weight loss (10%)•Coughing or breathlessness•Nausea, vomiting

Common Lymph Nodes:AdenoidsSpleen AppendixBone marrowThymusTonsils

7LYMPHOMAS : signs and symptoms

• Check for metastasis

• Edema in limbs• Obstruction

• Infections

• Rule out cancer•Looking for LYMPHOMA•Look for parasitic diseases•Find the cause for any unusual swelling in an extremity (obstruction)

8 LYMPHOMAS  risk factors

• Unknown causes

• Reduced/suppressed immune function

• as a result of organ transplantation

• HIV/AIDs pts at higher risk for NHL (50-100x)

• increased risk of exposure to infectious agents

• Occupational exposure to herbicides and other chemicals.

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History of Hodgkins lymphoma

• lymphomas are closely related to some forms of leukemia

2 catagories 

• Non- Hodgkins lymphomas (NHL)

• & Hodgkin’s disease

10 LYMPHOMAS  - 2 types HD, NHL• which together are

called lymphomas - are types of cancer. Cancer is not one condition but a word applied to many different diseases, which have diverse causes and a wide range of treatments.

• Hodgkin's disease (HD)

• Non Hodgkin's lymphomas (NHL) -• There are about

20 different types of non Hodgkins lymphoma.

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Signs and symptoms  • The first sign of this cancer is often an enlarged

lymph node which appears without a known cause

• The disease can spread to adjacent lymph nodes and later may spread outside the lymph nodes to the lungs, liver, or bone marrow.

• Main types of Lymphomas:• HD - spreads in a predicable way to each lymph

group• NHL - are found in lymph nodes or lymphatic

organs - the cause is not known• Mutations in certain genes

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Chest CT of a patient with non-Hodgkin's lymphoma (NHL) demonstrating a necrotic lymph node in the cardiophrenic angle.

Chest image shows contrast in the the largest lymph vessel in the body – the Throacic duct

13 Lymphoma

• Malignancy of lymphatic system• Either Hodgkin's or Non-Hodgkin's

• Non-Hodgkin's• Originate in parenchymal organs• 60 years of age (median)

• Hodgkin's• 90% start in lymph nodes• 15-40 years• 2nd peak: mid to late 50’s

• Can be imaged using x-ray, CT, MRI, PET, US and NM.• Modality of choice depends on location.• VERY rarely is lymphangiograms used to diagnosis this disease

anymore

14 Statistics• New cases in 2008 : 73,740

• NHL 66,120• Hodgkin's 8,220• 39,850 males : 34.490 females

• 5 year survival rate (1996-2004) • NHL 65%• Hodgkin's 86%

www.lls.org

61,000 new cases in 2002 of Non- Hodgkin’s lymphomas (NHL) & Hodgkin’s disease

15 The lymphatic system & lymphomas

The lymphatic system is part of the body's natural defense against infection. It consists of a wide network of nodes or glands, which are found all around the body, and are linked by tiny vessels (or lymphatics).

• A clear fluid called lymph circulates around the body and is drained, via the lymphatics, into the bloodstream. Lymph contains white blood cells known as lymphocytes. They play a part in protecting the body from infection. As the lymph circulates through the lymphatics it is interrupted by the lymph nodes which provide the opportunity to sieve the lymph and attack invaders.

16• The only way to tell the difference between

Hodgkins and non Hodgkins lymphomas is when the cells are looked at under the microscope. In most cases of Hodgkins disease,

• a particular cell known as the Reed-Sternberg cell is found in the biopsies.

• This cell is not usually found in other lymphomas, therefore they are called non Hodgkins lymphoma.

• This may not seem a very big difference, but it is important because the treatment for Hodgkins and non Hodgkins lymphomas can be very different.

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• Hodgkin's lymphoma is a malignancy (cancer) of lymph tissue found in the lymph nodes, spleen, liver, and bone marrow.

• A form of malignant lymphoma that is pathologically distinct from other lymphoid diseases

18 Hodgkin's disease

• Hodgkin's disease was first identified by Dr Thomas Hodgkin in 1832.

• It is characterized by particular cells seen under a micorscope- when a biopsy of an affected lymph node, or gland, is studied.

• The incidence of HD peaks at 25 = seen in the 15 – 30 age group and at 55 (all ages can)

• more men are affected than women.• Nowadays, Hodgkin's disease can be very

successfully treated and many people are completely cured.

19 History of Hodgkins lymphoma

• Cancers that involve the lymph nodes

• Lymphoma – can be applied to entire spectrum of malignant diseases

• Comprise approx 3% -4% of all malignant diseases in humans

The cause is not known

The incidence is 2 in 10,000 people

20 HODGKINS Who get’s it?

• Age:  Hodgkin's Disease most often occurs in people 15 to 34 years old and in people over 55 years old.

• Family History of Hodgkin's Disease:  Having a brother or sister with Hodgkin's Disease indicates that you may be at higher risk because of genetic factors.

• Viruses:  People who have had an infection from the Epstein-Barr virus or who have had infectious mononucleosis ("mono") are at a higher risk.

• Compromised Immune System:  AIDS, immune system suppressing drugs, and various immunodeficiency syndromes have been associated with an increased risk

21 HODGKIN’S DISEASE• STAGING

• I – only 1 lymph node involved

• II - 2 or more, same side as diaphragm

• III – both sides of diaphragm

• IV – widespread involvement

22 CANCER• The cells which make up our bodies normally divide

in a set and orderly fashion so they can repair our tissues.

• This process sometimes goes wrong and there is an uncontrolled growth of cells.

• A characteristic of all cancers is this disorderly formation of body cells, causing swellings or tumors.

• A tumor is referred to as benign when it remains contained in a localized area of the body and, on removal by surgery, does not recur.

• The term cancer is used when the tumors are malignant i.e. they spread and invade healthy tissue.

23 Non hodgkin's lymphoma

• There are many different types of non Hodgkin's lymphomas.

• Some are so mild that they require little or no treatment; some are very active.

• Broadly, NHL is divided into Low Grade (slow growing) or High Grade (the faster growing lymphomas).

• NHL is most common in people over 50 years old.

• It can also arise when the immune system has been suppressed because of other illnesses or conditions, including organ transplantation.

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Non- Hodgkin’s lymphomas (NHL) aka lymphomas

The tumors are graded according to their level of malignancy

(aggressiveness)-- low-grade, intermediate-grade or high-grade

• Low grade, intermediate

•& high grade

•determined by a lymphnode biopsy)

prognosis

2 – 3 years

1.5 – 2 yrs

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Hodgkins Disease and Non Hodgkins Lymphoma

– What’s the Difference?

• In Hodgkins disease the biopsy contains a type of cell called a Reed-Sternberg cell. This type of cell is not present in non Hodgkins lymphoma. There are quite a lot of different non Hodgkins lymphoma types.

.

26 treatment• However, all lymphomas are treated

either by radiotherapy or chemotherapy and, in some instances, both.

• The treatment given depends on the exact diagnosis so one person’s treatment may be different to another’s

27 CHILDHOOD DISEASESChildhood cancer :

• Non- Hodgkin’s lymphomas – 4%

• Hodgkin’s disease 4.5%

• may also invade bone marrow and other organs (spleen, thymus)

• may cause selling in lymph nodes of the neck axilla and groin

• general weakness and fever

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LYMPHANGIOGRAM• The test is not often done now in

the diagnosis or staging of lymphoma. 

• The test is performed by injecting a dye or contrast agent into the lymphatic vessels of the foot

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Lymphangiogram• CT and U/S have been used to successfully

stage tumors – replacing lymphangiogram• CT usually first procedure in staging, esp NHL

abnormal CT replaces lymphangiograms• Lymphangiograms - most value with Hodgkin’s

disease - (no bulky masses seen, alteration of internal architecture which cannot be detected with CT) also aids when CT is equivocal.

• gallium scan, MRI or PET scans may also be used - CT and U/S best choice

30 CT Scanning

• Still procedure of choice for staging of Hodgkin’s lymphoma *

31 Non-Hodgkin’s Lymphoma

•CT of abdomen & pelvis is used to stage disease

•Treatment consists of chemo and/or Rad therapy

•Symptoms vary•Lymphadenopathy•anemia •Hepatomegaly•Splenomegaly•Fever and weakness

32 Non-Hodgkin’s Lymphoma

33 Case study:Hodgkin’s Disease

•CT exams show enlarged retroperitoneal nodes

•Symptoms•Painless lymph node swelling in cervical area•Fever•Fatigeu•Anemia & weight loss•Coughing •breathlessness

34 Hodgkin’s Disease

Treatment includes RAD therapyAnd chemotherapy

Symptoms include malaise, fever,Anorexia, enlarged lymph nodes

35 Staging of Lymphomas

• Stage I: • One lymph node group • Only one part of a tissue • One organ

• Stage II: • Two lymph node groups on the same side • one part of a tissue or an organ and the lymph nodes near that organ• In other lymph node groups on the same side of the diaphragm

• Stage III: • In lymph nodes above and below the diaphragm.• In one part of a tissue or an organ near these lymph node groups• It may also be found in the spleen

• Stage IV:• In several parts of one or more organs or tissues• In an organ and in distant lymph nodes

36 CT: Lymphoma

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Lymphoma in a 16-year-old girl with a 3-week history of supraclavicular adenopathy

PET Lymphoma

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Diagnostic Medical Sonography: Lymphoma

39 LYMPHOMA

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LYMPHOMAS treatment

• chemotherapy

• radiation therapy combined

• possible bone marrow transplant

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Lymphedema • Symptoms:• Chronic swelling, usually of the arm or

leg

• is the clinical hallmark of lymphatic obstruction.

Lymphatic obstruction

42 Lymphography- Procedures• General term applied to the radiologic examination of:

• Lymph nodes • Lymph Vessels

• Usually done to demonstrate pelvis and abdomen

• Injected in foot

• For axillary, clavicular area and upper limbs• Injected in hand

• Checks drainage of lymph nodes• Checks for pathology

43 Pre Procedure• Obtain PT history

• Obtain PT consent

• Make sure to have all supplies

• Positioning aides and comfort supplies

44The technologist has many responsibilities during this

exam.

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Procedure

Patient prep

• Empty bladder

• long procedure (4-5 hours) over 2 days

• Special attention to patient’s physiological needs (Ca pt)

46 The technologist must: • Get a good patient history

• LMP• Any bleeding problems• Any previous allergic reactions to

contrast media

• Explain the procedure and any instructions for after the exam

• Get the consent form signed

47•Once the patient is on the table the injection site will be cleaned

•Next, a special blue dye (patent blue violet) is injected.•Methaline Blue•injected into the subcutaneous web spaces of the hand or foot about 15 min. before the test begins.

48 Procedure• Inject blue dye under skin

in between toes

• Inject small amount of contrast into the lymph vessels• Show blue tint

• Nodes in pelvis and abdomen are demonstrated with foot injection

49 Affects of the blue dye on the patient:

•The skin, stool, and urine will have a blue tint.•The lymph vessels look like thin, blue lines.•Vision can even take on a bluish tint. •The affects of the dye can last from a few hours to 48 hours.

50After the 15 minutes are up, the local anesthetic is

injected.Then a longitudinal incision is made in one of the

lymph vessels shown with the dye.

51 Procedure

• Small cut-down made on top of foot

• Slow injection of 5 – 10 ml/extremity @ 1.25 hr

• Room – radiographic (usually does not need fluoroscopic

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53 A needle/catheter is then placed in the vessel and the contrast is injected in.

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Fluoroscopy is used to see if the contrast is in the correct vessel.The progress of the contrast will be recorded under fluoro.

55 Procedure

• X-rays are usually taken 1 HR after injection• 24 hrs• 48 hrs (if needed)• 72hrs (if needed)

• First hour• Contrast in lymph ducts

• 24 hours • If lymph nodes

• After 24 hours it is indicative of cancer

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Once the contrast has been injected, the incision is sutured, and regular radiographic images are

taken within the hour.

•A second set of x-rays are taken for the lymph nodes 24 hours later.

57 Filming• Chest / abdomen / pelvis

• poss extremities – 24

hours –• Shows lymph vessels and

nodes• Follow up 48 and 72 hour

films shows nodes• Normal should not have

contrast after 24 hoursA fluoroscopy room will be used for the exam.

58 When the feet are injected the lymphatics in these areas are

seen:Lower

extremityAbdominal

areaGroinThoracic duct

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•LYMPH DUCTS•1 HOUR•BEYOND 24•SIGN OF CA•IN VESSELS

•LYMPH NODES•24 HOURS +++

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68Iliopelvic-aortic Lymphatic System

69 Lymphography

70 Other notes of interest are:

o The contrast can remain in the lymph nodes from anywhere from 3-4 weeks to 2 years.

o Exposure from this exam is about the same as what would be received from a bone study (low).

71 RADIOGRAPHIC FINDINGS

• Mediastinal lymph nodes enlargement is the most common radiographic findings in lymphoma.

• Seen with about 1/3rd with NHL and ½ with Hod Lymp

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• Pleural effusion occurs in 1/3 of the patients -

• extension of the tumor into the pericardium can cause pericardial effusion.

• 5 – 10 % have involvement of the GI tract (stomach and small bowel) – seen as large bulky polypoid mass

73 ENLARGED MEDIASTINUM

involvement of the pulmonary parenchyma and pleura usually occur due to the mediastinals lymph node enlargement=

74BEFORE: Non-Hodgkin's lymphoma in 32-year-old female.

AFTER: Resolution after 2 weeks of treatment.

75 LYMPHOMAenlargement of left hilar region

76 • may appear as a coarse interstitial pattern or solitary or

multiple ill-defined nodules or as patchy areas of infiltrates

77 Post Procedure

1. Watch for signs of infection Swelling red and warm to touch Accompanied by a fever Contact DR right away

2. Drink lots of water

3. Major swelling in one limb Especially limb injected

78•The lymph nodes and vessels cannot be seen on regular diagnostic x-ray films without the injection of contrast.•Preferred contrast is OIL based – less irritating and absorbed more slowly•Lipoidol

79 Contrast• Oil based

• More commonly used• Ethiodal• Lipodal

• Water based Iodine• Less commonly used• Ionic• Non-ionic

80 Contrast Media• Ethiodol and Lipiodal• Directly injected into a

vessel of an extremity –• Blue dye used –

absorbed by lymphatic vessel –

• Oil based usually used for lymphangio

• Water based is irritating to the lymphatic system – causes pain and burning to patient

81 Upper Limb Lymphography

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When the hands are injected the areas seen are:

Upper limbsClavicular regionAxillary region

This is skin erythema and

swelling caused by an allergic reaction

to contrast media.

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Does anyone have any questions?

Review questions on 2007

lecture