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Lymphangiography in gynecology
Lymphangiography in gynecology GEORGE A. HAH!\, M.D. SIDNEY WALLACE. M.D. LAIRD JACKSO:\, M.D.* c;ERALD DODD, M.D Philadelphia, Penn.iyh ania
L Y :V1 l' H A N G l 0 G R A P H Y is the radiologic demonstration of the lymphatic system following the intralymphatic injection of radiopaque contrast material. Kinmonth 1 in 1955 developed a feasible technique for lymphangiography by using vital dyes to show the pathway of lymphatic vessels and then injecting a watcr-solublr radiopaquP material directly into the lymph channel itself. Prior to Kimnonth's work. lymphatic observations were largely confined to an indirect approach w·hereby dyes were injected into soft tissues and the dyes later concentrated in the lymphatics. Since Kinmonth's original presentation. Tjernberg.? Hreschyshyn and Sheehan:: "VVallact' and Jackson:t." Averette." and others have modified and Pxtended the method. Lymphangiography has become an important addition in the management of patients with a varietv of disorders. About 500 patients have been examined by this method by the group at thf' Jefferson Medical Colle_ge Hospital. The types of patients in whom this technique has been of special value have been
those with malignant disease and those in whom the causation and therapy of peripheral edema is a problem. Of particular value has bt>en the investigation of patients with malignancies of the extremities such as melanoma and male patients with ~enito urinary malignancy. Increasing information is being obtained in women with breast carcinoma by means of this method. In the field of gynecology more than 60 patients have been studied by the lymphangiographic technique. It has become increasingly apparent that the lymphangiogram adds so greatly to our knowledge that patients with primary pelvic malignancy should have lymphangiography as part of their routine study. When this procedure has been done the proper method of management may be more readily selected and the follm..·-up examination of these patients will become more exact. Method The technique'·;, of lymphangiography currently in use at the Jefferson Medical College Hospital is as follows: An injection of 0.25 mL of a mixture containing equal proportions of 10 per cent patent blue dye ( Alphazurine 2 G) and I pPr cent procaine hydrochloride is made intradermally into the interdigital web-space between the first and second digits of the lmver extremity. The procaine hydrochloride minimizes the transitory pain which occurs when the dye is injected alone. The blue dye is selectively absorbed by the lymphatics
Frotn the Departments of Obstetrics and Gynecolog)', Radiology, and Medicine, Jefferson Medical College Hospital. Work supported by National lnstitute.vf Health Grant No. H7158. Prl'sented at the Seuenty-third Annual AJeeting of the American Association of Obstet1·icians and Gynecologists, Hot Springs, Virginia. Sept. 6-8, 1962. *:\'ational lrntituter oi Health Fellmc.
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Fig. l. Lymphangiogram metering pump which allows pressure-controlled injection of contrast media into the lymphatic system. (Manufactured by The Holter Company, Bridgeport, Pennsylvania.)
making them readily identifiable within a few minutes. A small skin incision is then made proximal to the injection site (just lateral and distal to the first metatarsal head on the dorsum of the foot) and a lymphatic carrying the blue dye is identified and isolated. When the initial incision is made great care must be exercised to cut just subcutaneously since a deeper incision will go through the rich lymphatic layer. To identify the lymphatic channel it is helpful to "milk" the dye with the gloved hand by exerting pressure at the injection site, pushing the thumb up toward the incision. This will help force the blue dye into the exposed lymphatic making it easily recognizable. After the vessel has been identified, an instrument should be placed beneath it for stabilization and an untied ligature placed around it so that it may be temporarily obstructed and distended. The lymphatic should be carefully and thoroughly stripped of all excess tissue so that it will be easier to cannulate. A small narrow-gauge needle ( 25 to 30 depending on the caliber of the lymphatic) , which has previously been fitted to a polyethylene tube, is then threaded into the vessel. It is helpful to inject 1 per cent
procaine through the catheter and needle to distend the vessel and facilitate placing the needle about 5 mm. up into the lymphatic channel. The needle should be secured with a ligature. Ethiodol* is placed in a syringe connec ted by an adapter to the polyethylene tubing; 10 mi. of the contrast material is then injected slowly using a Holter lymphangiogram pump for steady, constant pressure (Fig. 1). The time for injection is usually about 60 minutes. This length of time will avoid undue pressure and distention so that rupture of the vessel with extravasation of the contrast material will not occur. A small amount of pressure is necessary to overcome the viscosity of the media and the resistance of the needle-catheter assembly. The patient should be kept recumbent throughout the procedure but it has not been found necessary to artificially splint the legs. The injection time may be lessened by heating the Ethiodol but this increases the discomfort to the patient. Roentgenograms are taken at the completion of the injection to demonstrate the *Ethiodol is the ethyl ester of iodi zed fatty acids of poppy seed oil containing 37 per cent iodine.
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inguinal, femoral, external iliac, and retroperitoneal lymphatics and the thoracic duct are demonstrated by this technique. The hypogastric, sacral, and obturator channels are less constantly seen . The vessels outlined are considered to be skeletal lym phatics in contradistinction to the internal iliac and sacral lymphatics which are visceral. In order properly to appreciate lymphangiography, the gynecologist must first consider normal pelvic lymphatic anatomy as seen at the operating table. Normal anatomy
Fig. 2. Lymph node drainage of the cervix, showing the three major pathways (Ackerman and del Regato: Cancer-Diagnosis, Treatment and Prognosis, ed. 3, St. Louis, 1962, The C. V. Mosby Company).
lymphatic channels. The contrast material leaves the vessels a few hours after the completion of the injection. Twenty-fourhour films are taken for best visualization of the lymph nodes themselves. By this time the lymphatics have drained and the nodes stand out very distinctly. Usually the nodes are readily demonstrable for 4 to 6 weeks but certain nodes may be identifiable for periods up to 2 years. Follow-up films may be obtained for fairly long periods of time without further injection of dye. In those patients where peripheral edema is present it may be possible to cannulate the lymphatics after: ( 1) treating the systemic cause; (2) elevating the extremity; (3) applying an elastic bandage about the leg for 24 hours; ( 4) in rare instances injecting hyaluronidase locally to relieve swelling. Normally the lymphatic vessels follow the venous system throughout the body. The lymphatics of the lower extremity, the
The plexus of lymphatics of the cervix forms into three main channels. The chief pedicle follows along the pathway of the uterine artery to the paracervical, external iliac, and obturator nodes. The second pathway follows along the uterine vein to the hypogastric nodes and the least constant route goes along the uterosacral folds to the sacral nodes (Fig. 2) . The lymphatic drainage of the uterine corpus is made up of an intercommunicating lymphatic network which is grouped in three major branches. The first channel goes by way of the broad ligament to the hilum of the oval)" then to the preaortic and lateral aortic nodes on the left and the precaval and laterocaval nodes on the right. Another less important chain goes outward to the external iliac nodes and there also is drainage from the fundus of the uterus by way of the inguinal canal to the superficial inguinal lymph nodes (Fig. 3) . The ovarian lymphatics follow an upward direction crossing the external iliac ,·essels and finally end in the lumboaortic lymph nodes. The left-sided nodes are quite compact and terminate beneath the kidney pedicle. The right-sided channels go to the precaval and laterocaval nodes. There may also be another pathway which follows the broad ligament to the external iliac nodes (Fig. 4). The vulvar area is supplied by a particularly rich network of lymphatics. The drainage is toward the superficial inguinal nodes, the deep inguinal, and the superficial femoral
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Fig. 3. Lymphatic drainage of the uterus showing : 1, the uteroovarian pedicle ; 2, the external iliac pedicle ; and 3, the round ligament pedicle leading to the inguinal nodes. (Ackerman and del Regato: Cancer-Diagnosis, Treatment and Prognosis, ed. 3, St. Louis, 1962, The C. V . Mosby Company.)
nodes. There may be drainage to the hypogastric nodes by way of the periurethral lymphatics and there is drainage to the external iliac nodes (including the node of Cloquet, which some anatomists classify as a deep femoral node ) . Since there is free anastomosis between the anterior and posterior vulvar lymphatics, cross-metastasis may readily occur (Fig. 5) .
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Fig. 4. Lymphatics of the ovary showing drainage by the para-aortic lymph nodes. On the right, the nodes extend from the kidney pedicle to the termination of the aorta. There is also inconstant drainage towa rd the external iliac nodes. (Ackerman and del R egato: Cancer-Diagnosis, Treatm ent and Prognosis, ed. 3, St. Louis, 1962, The C. V. M osby Company.)
demonstrated in the initial film . The contrast material usually leaves the lymphatics in a few hours and then settles in the nodes. The normal nodal architecture is best seen in the 24 hour film (Fig. 7). These nodes show a homogeneous reticular pattern, varying somewhat in shape but with a discrete outline. Lymphatic variants
Normal roentgen anatomy
Fig. 6 demonstrates the appearance of the normal lymphatics in a young woman. The channels leading to the inguinal, external iliac, and para-aortic areas are clearly
Fig. 8 demonstrates the lymphangiogram of a 33-year-old patient with carcinoma in situ of the uterine cervix. Preoperative films revealed a defect in one fairly large node in the left iliac area. Surgical management in-
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eluded the removal of the nodes frolll this area and pathologic examination reveale-d them to be benign in character. In reviewing the films it was considered that the hilus of the la rge iliac node was asymmetri(: in it s location and the refore produced a >light indentation radiologically . Distortion of lymphatic channels
Fig. 9 demonstrates the marked lateral displacement of the normal lymphatics which occurred in a young woman with a large tuboovarian abscess. A simi lar picture could a lso be produced by extensive endometriosis or fibrosi s wh ere fixation of the pelvic structures occurs. A frf'ely lllO\·able lesion, such as a small ovarian cys L will not bring about any significant change in the vascular or lymphatic pattern . Fig. 5. Lymphatics of the vulva leading to the superficial inguinal lymph nodes. 1, The superfi cia l femora l nodes ; 2, the deep in gu inal nodes ; 3, the node of Cloquet: and 4, the external iliac nodes. (Ac kerman and del Regato: Cancer- Diagnosis. Treatme nt and Prognosis, ed. 3, St. Louis, 196 2, The C. V . Mosby Company.)
Fig. 6. Normal lymphatics and nodes as seen on initial film . ~otc th e fine ca liber of th e channels.
Malignant disease
The chief \·alue of lymphangiography has been in the study of patients with malignant disease. Fig. 10 demonstrates the lymphangiograph ic appearance of a patient with carcinoma of the cervix uteri. The nodes are f'nlargecl. irregular, and increased in number with matting to.g ether of many of them. The margins are hazy and indistinct. This patient had a bilateral lymphadenectomy and the pathologic examination confirmed the radiolog-ic impression of nodal metastasis. Figs. 1 l and 12 represent films which were taken in the study of a patient with lymphedema of the left lower extremity. This pa tient had previou sly received radiologic therapy for an invasiw carcinoma of the cervix. Lymphangiograhpy revealed irregularity in th e left lower iliac nodes with absence of some. ThP elimination of the nodes may be due to carcinoma or may be a normal variant. In view of the irregularity of the nodes. the causation is undoubtedly malignancy. Confirmatory evidence could bc obtained hy inferior vrna cavog-raphy or by sur.gical excision. Figs. 13 and 14 show bilateral iliac nodal im·olvement in a 70-year-old patient treated 3 years pre,·iously by irradiation for a Stage
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II carcinoma of the cervix. The films confirm the clinical impression of advancing pelvic disease. A 57-year-old patient was admitted to Jefferson Hospital because of increasing right-sided discomfort. She had previously been treated by operation and irradiation for an invasive carcinoma of the cervix. Pelvic and abdominal examination disclosed a large, fixed mass in the right iliac area. Lymphangiography (Fig. 15) confirmed the clinical impression of bilateral nodal disease, more marked on the right side. Intravenous urography showed a right hydroureter and hydronephrosis. Surgical removal of the nodes was followed by relief of discomfort and, interestingly, a dramatic fall of blood pressure from a level of 270/ 140 to an average of 170/100. The patient later died from generalized disease (Fig. 16). Fig. 17 shows the relationship between radium (intrauterine tandem and Manchester ovoids) and the iliac lymph nodes in a 38-year-old patient with a Stage I carcinoma of the cervix. Lymphangiography has become an aid in the follow-up examination of patients who have been previously treated for carcinoma of the cervix. Figs. 18 and 19 show an irregular "punched-out" left iliac node at the level of the fourth lumbar vertebra. This node is above the radiation treatment portals and the patient has been admitted to the hospital for further evaluation. Fig. 20 shows obvious metastatic disease with obstruction to lymphatic channels with an attempt at collateral circulation . This patient's primary neoplastic disease was endometrial. In patients with vulvar carcinoma, lymphangiography is most helpful in evaluating the preoperative lymphatic extent of disease and the postoperative result of the surgical treatment. Fig. 21 shows bilateral nodal destruction in an 80-year-old patient with carcinoma of the vulva. Operation confirmed the radiologic diagnosis. Ovarian malignancy, when large, may produce lymphatic distortion with lateral displacement of the lymphatic channels as
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seen in Fig. 22. This appearance is not pathognomonic of ovarian malignancy but may be brought about by any fixed pelvic mass. Fig. 23 shows large iliac nodes with destruction due to metastases from ovarian carcmoma. As has been noted before,! malignant lymphoma may involve the pelvic regwn.
Fig. 7. Normal lymphatics as seen in 2+ hour film. The contrast material has left the channels and is concentrated in the nodes. The inguinal nodes ar~ prominent in this film.
Fig. 8. Twenty-four hour film showing node in left iliac area.
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Fig. 9. Lymphangiogra m showing marked lateral displacement of lymphatic structures due to large tuhoovarian abscess. (Metropolitan Hospita l. )
Fig. 10. Lymph nodes affected by metastatic carcinoma of the cervix. The nodes are large, irregular, and increased in number with peripheral filii ng defec ts.
Fig. 11. Initial film of patient with cervical carcinoma showing irregularity of nodes, particularly in the left iliac area. Note the crossing of the lymphatics to the opposite side at the sacral area. This is a normal oc
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Fig. 24 shows an appearance quite characteristic of the malignant lymphoma. This patient is an 80-year-old woman who had been treated 24 years previously for a Stage II carcinoma of the cervix. Lymphangiography was performed because of the development of nodularity in the peh-is. Fig. 25 is a film taken of a patient with generalized lymphosarcoma. The lymphangiograms in both these patients show an intrinsic lymphatic disturbance. The outer margin of the nodes is intact, but the internal nodal architecture presents a foamy or lacy pattern. There is also an increase in the nttmber and size of the nodes demonstrated. Lymphangiography is an effective way to confirm the diagnosis of lymphocyst-- a condition which is occurring more frequently with the increased emphasis on radical operation in pelvic malignancy. Reduction in the incidence of this complication may be achieved by very thoroughly ligating main lymphatic channels at the time of operation to prevent leakage of lvmph and by using extraperitoneal suction catheters in both iliac fossas during the immediate postoperative period. Fig. 26 shows the radiologic appear-
Fig. 12. Twenty-four-hour film of patient with cervical carcinoma. In addition to the irregularity of nodes, there is absence of some nodes in the left iliac area, thought to be due to carcinomatous replacement.
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ance of a lymphocyst after direct injection of contrast material into the lymphocyst cavity. Figs. 27 and 28 show the lymphangiographic appearance of lymphocysts; the first followed irradiation and radical operation for carcinoma of the cervix and the second followed radical operation including iliac node dissection for a Stage I carcinoma of the cervix. Radiologically the lymphocyst appears as a collection of contrast material which lies in close association with normal lymphatic channels. The outline is extremely well demarcated and usually remains visible for a prolonged period of time.
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Fig. 13. Initial film showing lymphatics going around defective nodes in pa tient with advanced carcinoma of the cervix.
Interpretation
The interpretation of lymphangiography must be a total interpretation and should include the correlation of all available information, clinical, laboratory, and pathologic. There must be thorough knowledge of the normal anatomic lymphatic drainage so that supposed irregularities in nodal architecture far-removed from the initial site of disease may be properly evaluated. Lymphangiography is a gross method and a negative study must be considered to be grossly negative. Microscopic study is impossible by this technique. The most frequent interpretive error occurs in the inguinal area where nodes may appear abnormal because of fibrosis and fatty replacement associated with previous inflammatory disease. Great care must be exercised in evaluating inguinal adenopathy. The changes must be definite and distinct and the nodes should be in the direct route of drainage, i.e., vulvar lymphatics would drain to the inguinal area. In the final evaluation of lymphangiographic films the initial film should be compared with the 24 hour film so that hilar areas may be properly located and not misread as pathologic deformities. In certain cases where there is questionable proof of lymphatic disease, other aids should be employed. Oblique films and planograms may give the additional evidence needed. When there is total nodal replace-
Fig. 14. Twenty-four-hour film of patient with bilateral iliac metastasis from cervical carcinoma. Note the multiple filling defects.
Fig. 15. Initial film of patient with bilateral iliac metastasis from carcinoma of the cervix. Note the almost complete obliteration of lymphatic pathways on the right side.
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ment, venocavagrams may be most helpful in correlating lymphangiographic findings. Complications
Fig. 16. Twenty-four-hour film showing absence of most of iliac nodes on the right side due to ca rcinomatous tnt'tastasis from the ce rvix.
Fig. 17. Lymphangiographic appearance of iliac lymph nodes in relation to intrauterine and paracervical radium.
When the thoracic duct is visualized it is likely that there is always some degree of pulmonary embolization. The extent of this would depend on the amount of material used and the speed of the injection. Within the first 24 hours there may be malaise, chi lls, and fever which may be due to embolus or to a "foreign body" reaction associated with th e release of iodine from the breakdown of Ethiodol. There have been no fatalities or serious complications associated with pulmomry embolus following lymphangiography. One patient developed a fairly large pulmonary embolus which cleared without serious consequence. A possible lymphatic-venous anastomosis was thought to be the l:ausc of this occurrence. Pathologic examination of nodes removed after lymphangiography has revealed changes within the nodes classified as lipogranuloma, a "foreign body" reaction due to the presence of the oil-based contrast material. A few patients have had fleeting lymphangitis with exacerbation of edema following lymphangiography. This has been seen in patients who have abnormal lymphatic
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Figs. 18 and 19. The arrow points to abnormal iliac lymph node before and after radiation therapy. Following therapy the lymph nodes are smaller and less apparent but the abnormal node is quite distinct in both films.
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Fig. 20. Bilateral involvement of pelvic nodes from endometrial carcinoma.
Fig. 21. Lymphangiogram showing marked destruction of inguinal and femoral lymph nodes in a patient with advanced vulvar carcinoma. A typical moth-eaten appearance is shown.
Fig. 22. Marked lateral displacement of lymphatics due to pressure from ovarian carcinoma. Note similarity in appearance to Fig. 9 where the displacement was due to inflammatory disease.
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structures. Local wound infection at the site of the incision may be minimized by using a pHisoHex scrub the evening prior to the procedure, strict adherence to sterile technique at the time of cannulization of the lymphatic vessel, and adequate lavage of the cannula after the completion of the lymphangiogram. Extravasation of the contrast material outside of the lymphatic vessel produces no significant clinical symptoms. This is probably due to excessive pressure at the time of injection although some authors believe this may be evidence of abnormal lymphatic structures. Pain along the distribution of tht ~ lymphatics may occur because of overdistention of the lymphatics due to too rapid a rate of injection or because too much pressure was used for the injection. These difficulties are largely obviated by using the mechanical pressure pump. The possibility of iodine sensitivity must, of course, be considered. from metastatic ovarian carcinoma. ( M. D. Anderson Hospital. )
Fig. 24. Lymphangiogram of patient with lymphoma which developed years after treatment for carcinoma of the cervix. Foamy pattern in para-aortic area is quite distin ct.
Further applications of lymphangiography
Lymphangiography may be used prior to radical operation to determine the gross lymphatic extent of malignant disease as a guide in nodal dissection. Ethiodol with chlorophyll is being used at our institution in the hope that the green dye will make it easier for the surgeon to identify lymph nodes at the operating table. Occasionally unexpected and untoward extension of disease may be detected so that radical operation will he contraindicated. At the operating table films may be made to determine the adequacy of the operation performed and later films may be made at varying intervals to follow the course of the disease. In preparing patients for external radiation therapy, lymphangiography may be used to achieve more precise portal placement. Since the contrast material will remain evident for 6 weeks to 2 years the course of the disease may be followed with better exactitude. Occasionally follow-up films will show
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that the planned therapy portals are inadequate to control the extent of the malignant lymphatic involvement. In a similar fashion, the effectiveness of chemotherapy may be readily followed by serial observations on node-bearing areas. Following treatment by radiation or chemotherapy decrease in size of lymph nodes may result, but the lymphatic channels will remain patent. With extensive fibrosis, lymphatic obstruction can occur. Intralymphatic injection of chemotherapeutic and radiotherapeutic materials has been attempted, 8 but proper evaluation is not possible at this time. According to Zeidman, Copeland, and Warren 9 carcinomatous tissue contains no lymphatics, accounting for the irregular defects seen on lymphangiography indicative of nodal destruction by malignant disease. This absence of lymphoid structure in neoplastic tissue may make the effective intralymphatic administration of cancericidal agents a most difficult problem to overcome.
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Fig. 25. Appeara nce of lymph nodes in patient with generalized lymphosarcoma. Almost all the nodes visualized show a lacy pa ttern, but the noda l margins are for the most pa rt intact.
Summary
By employing intralymphatic injection of radiopaque oil-based material the skeletal lymphatics of the pelvic area may be demonstrated. This procedure has been successfully performed in more than 500 patients, 60 of these having pelvic disorders. Normal pelvic lymphatic anatomy is briefly reviewed. Photographs of representative cases including patients with normal anatomy, carcinoma of the cervix, carcinoma of the endometrium, carcinoma of the ovary, carcinoma of the vulva, malignant lymphoma, lymphocysts, and lymphatic distortion due to benign disease are presented. In lymphangiography normal nodes exhibit a discrete outline with a homogeneous pattern. Metastatic malignancy is characterized by irregularity in the margin of the node with a "moth-eaten" aspect in the node itself. The lymphoma shows enlarged lacy nodes. Major complications are discussed and interpretive difficulties mentioned.
Fig. 26. Radiologic demonstration of large lymphocyst which followed radical operation for cervical carcinoma. Contrast ma terial has been injected directly into the cavity. (M. D. And erson Hospital. )
Fig. 27. Lymphangiographic appearance of lymphocyst following treatment for cervical carcinoma. (M. D . Anderson Hospital.)
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Conclusions
Lymphangiography is a safe, practical method to aid the gynecologist in evaluating the kind and extent of disease, and the feasibility of surgical, radiation, or chemotherapeutic management. More exact treatment fields may be outlined for radiation therapy and the follow-up care of patients becomes more effective.
Fig. 28. Pooling of contrast material in lymphocyst in right iliac area. This occurred after operation for cen •ical malignancy. (Albert Einstein Medical Ccntrr. )
W e ex press our appreciation to th e Albert Einstein M edica l Center, M. D. Anderson Hospital. }..fis eric ordia Hospital, M etropolitan Hospit al, a nd the Warner Hospital for the privilege t)f stndy ing som e of their patients.
REFERENCES
l. Kinmonth, J. B. , Taylor, G. W., and Harper, R. A. K.: Brit. M. J. 1: 940, 1955. 2. Tjcrnberg, B.: Acta Soc. med. upsal. 61: 207, 1956. 3. Hreschyshyn, M. M., and Sheehan, F. R.: Proc. Am . A. Cancer R es. 3: 121, 1960. 4. Wallan·, S., Jackson , L. , Schaffer, B., Gould, ]., Greening, R ., Weiss, A., and Kramer, S.: Radiology 76: 179, 1961. 5. Wallace, S., J ackson, L., and Greening, R .: Am. J. Roentgenol. 88: 97, 1962.
6. Averette, H . E., Hudson, R. C ., Viamonte, M. I., Jr., Parks, R . E. , and Ferguson, J. H.: Cancer 15: 769, 1962. 7. H ahn, G. A.: AM . J. OasT. & GYNEc. 75: 673 , 1958. 8. Fischer, H. W.: Radiology 79: 297, 1962. 9. Zeidman, I., Copeland, B. E., and Warrt>n, S.: Cancer 8: 123, 1955.
255 South 17th St Philadelphia 3, Penn.rylvania
Discussion DR. HowARD ULFELDER,* Boston, Massachusetts. C learly we have not yet reached the end of techniques which can help us delineate gross anatomic details in the living human subject, even though anatomy must be the most ancient of biologic sciences. Lymphatic channels and nodes were recognized long ago but the anatomic charts of the times show them as a diffuse or haphazard network. The purposefulness of their complex di stribution became apparent upon more complete dissection after the injection of colloidal dyes as markers. Drinker showed that they could be cannulated for the collection of pure lymph and stimulated other research into their function. Now we havr seen that injection of radiopaque fluids permits exquisite delinea tion of these pathways. It has been lea rned that slowly applied , stt•ady injf'ction pressure wi ll avoid rupture of the
vessels and permit distant filling. Films taken during or shortly after injection show lymphatic channels ( lymphangiograms) and nodes, while subsequent exposures will demonstrate the nodes for weeks thereafter if the injection mass had an oily base. Dr. Hahn and his colleagues have confirmed these facts and he has today illustrated through .~el ecte d cases a variety of clinica l situations where roentgen lymphnodograms were profitably employed . From the anatomic point of interest it must be noted, as Dr. Hahn says, that only the skeletal lymphatic structures arc shown by the m ethod d escribed. To date no way to isolate and inject a tributary of the visceral systrm has been reported and it is considered too hazardous in terms of extravasation and oil embolization to apply proximal pressure in the upper or mid abdomen and try to effect retrograde filling of the hypogastric, parametrial, presacral, and other
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more centrally located nodes and channels. The confluence of skeletal and visceral pathways at the level of the iliac bifurcation, however, permits the application of the method in cases of cancer of the internal genital organs whereas the immediate spread to the skeletal nodes from cancer of the vulva and anus renders it particularly useful in this situation. This patient (Fig. 1) illustrated several anatomic points of value to us. The film was taken during injection and the lymphatics are
still well filled as is the cysterna chyli. When only one extremity had been injected dye was found in channels on both sides of the aorta, indicating lymphatic crossover and the inadequacy of unilateral therapy, either by excision or radiation, for such apparently unilateral tumors as cancer of the testis. \'\' e note also that nodes in the anteroposterior view overlie the medial aspect of the kidney shadow, an area that is carefully blocked out of the usual treatment fields. In the lateral view the nodes which we can resect at
Fig. 1. Lymphangiogram taken during injec tion showing major anatomic points.
Fig. 2. Lymphangiogram after adequate surgical dissection for carcinoma.
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Fig. 3. Film of removed tissues indicating areas of remowd lymphatics.
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Fig. 4. Lymphangiogram suggestin g partial ncoplastic replacement of lymph nod e.
pelvic lymphadenectomy are seen to lie far forward and we can identify the superficial nodes of the groin. Thus we are able to translate upon the anteroposterior projection those shadows which should be missing after an adequate surgical dissection for carcinoma (Fig. 2) . A film of the removed tissues (Fig. 3) arr:.m ged roughly in their pristine relation to each ot her shows where the missing shadows have
gone. When it comes to using the method for diagnosis, all who have tried it agree there will be errors of interpretation both ways sufficiently often to prevent our depending on it as the only guide to the nature and extent of treatment. A picture like this (Fig. 4) may indicate partial neoplastic replacement and here (Fig. 5) in a film taken in the operating room a fter removal of a node for positive frozen section examination we can confirm that it was that very same node seen in the previous picture. But only <'xplorati0n could tell us tha t this was a solitary, freelying, easily removahle right obtura tor node in a patient with an early Stage II lesion that had shown a poor clinical and cytologic response to 1he first application of radium, and that extended hysterectomy and nod e dissection was, therefore, not only eminently feasible but also more likely to cure her than furth er irradiation . In patients previously treated for pelvic cancer :tnd in the evaluation of effectiveness of non>urg·ic" I t rca tnwnt in known nwtastases, roentgen
Fig. 5. Lymphangiogram of same area taken in operating room after surgical removal of involved node, confirming tentative interpreta ti on of Fig. +.
lyrnphadenography should be exceedingly helpful. Certainly as an aid to diagnosis in cases of lymphatic hlockade, lymphocyst, etc., it may offer the key items of information. All the specific indica tions lumped together, however, form a small group. Because the technique is quite safe and 1·arely fails, my r ecommendation is that lymphograms be made in the majority of patients with gynecologic cancer to accumulate experience and information and to ma intain a high level of radiologic acuity of .i nterpre-
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tation. Moreover I see in this a way to fill a void in the present-day gynecologist's awareness of the structures with which he must deal in the operating room. It is precisely this ghostliness of the intact lymphatics and nodes which has often transformed a pelvic node dissection into an anatomic demonstration of the vessels, nerves, and ureter. Any technique which lends three-dimensional substance to the routes of malignant dispersal cannot help improving both radiotherapeutic and surgical efforts to cure the disease. For this reason alone I would feel urged to practice and to preach the use of all safe methods available to show lymphatics and nodes, whether by visible dyes as Eichner and others have reported or by the method shown here today. DR. J. H. FERGUSON, Miami, Florida. There is one area in which I must disagree and that is the statement of the inability to visualize the obturator, the hypogastric, and the sacral lymph nodes when a so-called skeletal lymphatic vessel in the foot has been cannulated. We are able to do this almost uniformly, practically 100 per cent of the time. Why this difference in experience rxists, I am not certain; it may be that we have made more frequently the lateral and oblique films which can demonstrate these nodes better than the simple anteroposterior films. At the University of Miami several departments have been working together on lymphography at a pace that brings almost weekly improvements in our technique and increase in our realization of the potentialities of lymphangiography. Over 200 patients have been examined by this technique. In obstetricsgynecology we have now done over 50 studies, gradually extPnding the variety of patients as we explored the usefulness of this technique. The greatest value of lymphangiography may be in carcinoma of the cervix, where we have identified the lymphatic stmctures radiologically and by green coloration before and after either radiotherapy or radical hysterectomy. In each of these categories we see great potential for better diagnosis, better surgery, better radiotherapy, and improved follow-up of the patient. We have studied other patients, for example, ones with adenocarcinoma of the endometrium, cancer of the ovary, and benign pelvic masses. We have not been as fortunate as Dr. Hahn in avoiding febrile reactions. We have not had a typical case of lymphangitis but 22 per cent of
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the patients have had a fever of 100.4° F. after this diagnostic procedure. We have continued with radical hysterectomy when planned and without any ill effects. One patient was found 4 days after operation to have lymphoid pneumonia, which caused no symptoms and did not retard her postoperative recovery. Lymphangiography has bec>n useful in the preand post-operative study of patients who had a radical vulvectomy and in the performance of the operation. Coloration of the lymphatics permits a more rapid femoral, groin, and deep pelvic node dissection; completeness of the removal of the lymphatics appears to be assured but at the same time selectivity seems to be possible, thus avoiding unnecessary excision of tissue. This has been particularly helpful in the dissections of the groin. To the conventional x-ray films we have added cinefluoroscopy with a television monitor including a 9 inch image intensifier and an Orthicon system. This permits us to observe on the television screen the filling of different lymphatic nodes and channels. From patient to patient this filling proceeds at different rates and the lymphatic routes can vary. We feel that this technique adds to the future of lymphangiography. Today we may be in a position similar to that of the radiologists year ago when they were doing their first barium enemas and they had to wait until they accumulated the autopsy material and surgical specimens before they could interpret what they had seen. I think lymphangiography has a tremendous future for us in our specialty. At the moment I find it so useful that I would not want to do a radical hysterectomy or vulvectomy without it. Once you have tried lymphangiography I can assure you that you will not want to give it up. DR. GRAY H. TWO)fBLY,* New York, New York. Dr. Meigs's revival of radical operation for the treatment of carcinoma of the cervix has made gynecologic surgeons very much aware of the anatomy of the pelvis and has brought out many points about the lymph glands which drain the cervix. Dr. Hahn's presentation is a very good demonstration of this. If you study the position of the lymphatics, as Dr. Hahn has done, you will find that the bifurcation of the aorta lies right beneath the urn-
*By invitation.
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Hahn et ol.
bilicus and, as demonstrated in his pictures, the lymph nodes draining the cervix lie along the iliac vessels and up around the lateral margins of the bifurcation. The usual x-ray treatment portal takes in only the external iliac and the 'cry lowest of the obturator lymph nodes. It do!'~ not often reach the higher lymph nodes. Radical operation is usually able to remon: the lower lymph nodes quite readily, but the lymph nodes that lie up higher the surgeon has difficulty in getting out. When he tries to get the higher nodes, it becomes more or less a piecemeal procedure and not a block dissection at aiL We must go back to our radiotherapeutic friends and say, "Look, your treatment portals arc not right. They should go up to and include at l(·a~t the bifurcation of the aorta. The radiation you arc giving is often usdess. lt is lw]m, the n~rvix. It is down in the region that wt: can treat surgically." And the radiotherapi~t often replies that high portals will treat the small intPstinc and the small intPstine will uot take a great deal of radiotherapy. x-ray If rhere is any rationale for therap) in cancer of the cervix. it must drpcnd first of all on dirf'ctinJ" thr therap to add to this vPry interesting discussion sonw work pcPS<'ntly being done in nur institution under the direction of thf' head of the department, Dr. R. Mattingly, and one of his residt>nts, Dr. R. Pattillo. In this work. Ethindol is injected directly into thf' paracervical
\nL
\Lt1 cb Li 19b3 ,I ( >h·a S: Cym·c.
tissue of dogs. This radiopaque substallC<: was later \·isualized in the hypogastric and nbt urator glands. This preliminary work "·as follu\\Cd ou several actual women patients. Direct iujectiou of 2 c.c. of Ethiodol into the parac<'rvic.d tis:stw of the patients was followed with radiog:raphi( visualization of the hypogastric, the ohtnrator, and tlw common iliac glands. This mav lw au answer to some of tlw diflirultic~ allfl tlll<'t.'rtainties recognized b\' some im·cstigator, 1\'110 arc doing direct lymphangiography. DR. joHN G. MASTERSON/ Brooklvn, Ne11 York. During the past few years on the State University of ?\ew York GynPcological Tumor Srrvicc, we have been intcrestl'd in investigating th(' role of lymphangiography. ,\s a r.-sult uf this experience. I \\Ould certainh endorse the slatf~ments of Dr. Hahn and tlw preYi"u' discussants as to the o-.·nwndous nwrit uf this prn· Ct'dure m tlw e\'aluation of patir·nh with gynecologic mali.gnancv. ,\s n•gards the rpwstion of '' lu·thcr ·Ill<' 1s ahlt> to visualize tlw \·isct'l'al nndt'> "ith this technique, wt· think that, in most instanct:,, the visceral nodes an· filled as dearly demonstrated in ohliqtw \iews of the pdvis. ·with uhliqw' vi;•ws, you cau f('adilv s('e three distind plan"' of nod('S and we l)('lil'w that th<• innt·r plane r~'pn•sents the vi'cer;d chain of nodt:>. \'Ve haw found lnnphangiography '" h,, ,[ particular valu;· in two clinical situatinib: I In tlw who has had previou' radiation therap} for cervical malignancy and develops swdling of the lmn·r Pxtrcmitics without any palpable or other e\·id·~ncP of rccnrr('nt disease. Although we have always ron;;idcr<'d this typf' of patirnt to havf' recurrent disease, \\'t' hav•· rw\Tr been able to corroborate this without surgical exploration. ln studving; such a paticm. \H' nn\\ combint· lymphangiography \lith peh·ic art('riography. As a result, W<' han·
*Uy invitation.
Volume 85
Number6
lymphogram prior to our radical hysterectomy and lymph node dissection. On the third postoperative day, a scout film of the pelvis will disclose whether all of the lymph nodes have been removed. In those instances where we sec evidence of persistent nodes, the patient may he very promptly reoperated and the necessary dissection completed. In dosing, I would say that lymphangiography is a very useful diagnostic tool in evaluating patients with pelvic malignancy. With more experience, our interpretations will he of more value and may well eliminate the necessity of many of our present-day exploratory laparotomtcs. DR. FELIX RuTLEDGE,* Houston, Texas. \'\lc have had experience with this technique for 2 years and have been fortunate to have worked with Dr. Dodd who is now working with Dr. Hahn. We think the technique is very interesting and has a lot of possibilities. The accuracy of making a diagnosis is still variable. It is my impression that in large lymph nodes the possibility of saying they arc positive nodes is quite great, but in the smaller nodes and earlier metastases the accuracy falls off quite sharply.
*By invitation,
Lymphangiography 771
There may be some explanation for this because,
if we remove these nodes and study them routinely, we find that not all nodes do conform with the usual anatomy. They are frequently replaced by fatty tissue and have a lot of changes, such as granulomatous reactions which are hard to explain, and these rrPate defects which are difficult to interpret. DR. HAHN (Closing). I would like to emphasize a few points: It is most important that an oil base is used. All information, laboratory and anatomic, must be correlated with the radiologic findings. In the paper the usc of chlorophyll with the Ethiodol prior to operation for better visualization of the nodes is described. Even with the usc of oblique films, we have difficulty visualizing the obturator, sacral, and hypogastric nodes unless there is a lymphatic block. The placing of the portals for radiation therapy is most important. Lymphangiography is of hdp in this and we have had experience in at least one instance where the radiation fields werr too low and there were malignant nodf's present above the radiation portals.
L Y :V1 l' H A N G l 0 G R A P H Y is the radiologic demonstration of the lymphatic system following the intralymphatic injection of radiopaque contrast material. Kinmonth 1 in 1955 developed a feasible technique for lymphangiography by using vital dyes to show the pathway of lymphatic vessels and then injecting a watcr-solublr radiopaquP material directly into the lymph channel itself. Prior to Kimnonth's work. lymphatic observations were largely confined to an indirect approach w·hereby dyes were injected into soft tissues and the dyes later concentrated in the lymphatics. Since Kinmonth's original presentation. Tjernberg.? Hreschyshyn and Sheehan:: "VVallact' and Jackson:t." Averette." and others have modified and Pxtended the method. Lymphangiography has become an important addition in the management of patients with a varietv of disorders. About 500 patients have been examined by this method by the group at thf' Jefferson Medical Colle_ge Hospital. The types of patients in whom this technique has been of special value have been
those with malignant disease and those in whom the causation and therapy of peripheral edema is a problem. Of particular value has bt>en the investigation of patients with malignancies of the extremities such as melanoma and male patients with ~enito urinary malignancy. Increasing information is being obtained in women with breast carcinoma by means of this method. In the field of gynecology more than 60 patients have been studied by the lymphangiographic technique. It has become increasingly apparent that the lymphangiogram adds so greatly to our knowledge that patients with primary pelvic malignancy should have lymphangiography as part of their routine study. When this procedure has been done the proper method of management may be more readily selected and the follm..·-up examination of these patients will become more exact. Method The technique'·;, of lymphangiography currently in use at the Jefferson Medical College Hospital is as follows: An injection of 0.25 mL of a mixture containing equal proportions of 10 per cent patent blue dye ( Alphazurine 2 G) and I pPr cent procaine hydrochloride is made intradermally into the interdigital web-space between the first and second digits of the lmver extremity. The procaine hydrochloride minimizes the transitory pain which occurs when the dye is injected alone. The blue dye is selectively absorbed by the lymphatics
Frotn the Departments of Obstetrics and Gynecolog)', Radiology, and Medicine, Jefferson Medical College Hospital. Work supported by National lnstitute.vf Health Grant No. H7158. Prl'sented at the Seuenty-third Annual AJeeting of the American Association of Obstet1·icians and Gynecologists, Hot Springs, Virginia. Sept. 6-8, 1962. *:\'ational lrntituter oi Health Fellmc.
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Fig. l. Lymphangiogram metering pump which allows pressure-controlled injection of contrast media into the lymphatic system. (Manufactured by The Holter Company, Bridgeport, Pennsylvania.)
making them readily identifiable within a few minutes. A small skin incision is then made proximal to the injection site (just lateral and distal to the first metatarsal head on the dorsum of the foot) and a lymphatic carrying the blue dye is identified and isolated. When the initial incision is made great care must be exercised to cut just subcutaneously since a deeper incision will go through the rich lymphatic layer. To identify the lymphatic channel it is helpful to "milk" the dye with the gloved hand by exerting pressure at the injection site, pushing the thumb up toward the incision. This will help force the blue dye into the exposed lymphatic making it easily recognizable. After the vessel has been identified, an instrument should be placed beneath it for stabilization and an untied ligature placed around it so that it may be temporarily obstructed and distended. The lymphatic should be carefully and thoroughly stripped of all excess tissue so that it will be easier to cannulate. A small narrow-gauge needle ( 25 to 30 depending on the caliber of the lymphatic) , which has previously been fitted to a polyethylene tube, is then threaded into the vessel. It is helpful to inject 1 per cent
procaine through the catheter and needle to distend the vessel and facilitate placing the needle about 5 mm. up into the lymphatic channel. The needle should be secured with a ligature. Ethiodol* is placed in a syringe connec ted by an adapter to the polyethylene tubing; 10 mi. of the contrast material is then injected slowly using a Holter lymphangiogram pump for steady, constant pressure (Fig. 1). The time for injection is usually about 60 minutes. This length of time will avoid undue pressure and distention so that rupture of the vessel with extravasation of the contrast material will not occur. A small amount of pressure is necessary to overcome the viscosity of the media and the resistance of the needle-catheter assembly. The patient should be kept recumbent throughout the procedure but it has not been found necessary to artificially splint the legs. The injection time may be lessened by heating the Ethiodol but this increases the discomfort to the patient. Roentgenograms are taken at the completion of the injection to demonstrate the *Ethiodol is the ethyl ester of iodi zed fatty acids of poppy seed oil containing 37 per cent iodine.
756
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Hahn et al.
inguinal, femoral, external iliac, and retroperitoneal lymphatics and the thoracic duct are demonstrated by this technique. The hypogastric, sacral, and obturator channels are less constantly seen . The vessels outlined are considered to be skeletal lym phatics in contradistinction to the internal iliac and sacral lymphatics which are visceral. In order properly to appreciate lymphangiography, the gynecologist must first consider normal pelvic lymphatic anatomy as seen at the operating table. Normal anatomy
Fig. 2. Lymph node drainage of the cervix, showing the three major pathways (Ackerman and del Regato: Cancer-Diagnosis, Treatment and Prognosis, ed. 3, St. Louis, 1962, The C. V. Mosby Company).
lymphatic channels. The contrast material leaves the vessels a few hours after the completion of the injection. Twenty-fourhour films are taken for best visualization of the lymph nodes themselves. By this time the lymphatics have drained and the nodes stand out very distinctly. Usually the nodes are readily demonstrable for 4 to 6 weeks but certain nodes may be identifiable for periods up to 2 years. Follow-up films may be obtained for fairly long periods of time without further injection of dye. In those patients where peripheral edema is present it may be possible to cannulate the lymphatics after: ( 1) treating the systemic cause; (2) elevating the extremity; (3) applying an elastic bandage about the leg for 24 hours; ( 4) in rare instances injecting hyaluronidase locally to relieve swelling. Normally the lymphatic vessels follow the venous system throughout the body. The lymphatics of the lower extremity, the
The plexus of lymphatics of the cervix forms into three main channels. The chief pedicle follows along the pathway of the uterine artery to the paracervical, external iliac, and obturator nodes. The second pathway follows along the uterine vein to the hypogastric nodes and the least constant route goes along the uterosacral folds to the sacral nodes (Fig. 2) . The lymphatic drainage of the uterine corpus is made up of an intercommunicating lymphatic network which is grouped in three major branches. The first channel goes by way of the broad ligament to the hilum of the oval)" then to the preaortic and lateral aortic nodes on the left and the precaval and laterocaval nodes on the right. Another less important chain goes outward to the external iliac nodes and there also is drainage from the fundus of the uterus by way of the inguinal canal to the superficial inguinal lymph nodes (Fig. 3) . The ovarian lymphatics follow an upward direction crossing the external iliac ,·essels and finally end in the lumboaortic lymph nodes. The left-sided nodes are quite compact and terminate beneath the kidney pedicle. The right-sided channels go to the precaval and laterocaval nodes. There may also be another pathway which follows the broad ligament to the external iliac nodes (Fig. 4). The vulvar area is supplied by a particularly rich network of lymphatics. The drainage is toward the superficial inguinal nodes, the deep inguinal, and the superficial femoral
Volume 85 Number 6
Fig. 3. Lymphatic drainage of the uterus showing : 1, the uteroovarian pedicle ; 2, the external iliac pedicle ; and 3, the round ligament pedicle leading to the inguinal nodes. (Ackerman and del Regato: Cancer-Diagnosis, Treatment and Prognosis, ed. 3, St. Louis, 1962, The C. V . Mosby Company.)
nodes. There may be drainage to the hypogastric nodes by way of the periurethral lymphatics and there is drainage to the external iliac nodes (including the node of Cloquet, which some anatomists classify as a deep femoral node ) . Since there is free anastomosis between the anterior and posterior vulvar lymphatics, cross-metastasis may readily occur (Fig. 5) .
Lymphangiography 757
Fig. 4. Lymphatics of the ovary showing drainage by the para-aortic lymph nodes. On the right, the nodes extend from the kidney pedicle to the termination of the aorta. There is also inconstant drainage towa rd the external iliac nodes. (Ackerman and del R egato: Cancer-Diagnosis, Treatm ent and Prognosis, ed. 3, St. Louis, 1962, The C. V. M osby Company.)
demonstrated in the initial film . The contrast material usually leaves the lymphatics in a few hours and then settles in the nodes. The normal nodal architecture is best seen in the 24 hour film (Fig. 7). These nodes show a homogeneous reticular pattern, varying somewhat in shape but with a discrete outline. Lymphatic variants
Normal roentgen anatomy
Fig. 6 demonstrates the appearance of the normal lymphatics in a young woman. The channels leading to the inguinal, external iliac, and para-aortic areas are clearly
Fig. 8 demonstrates the lymphangiogram of a 33-year-old patient with carcinoma in situ of the uterine cervix. Preoperative films revealed a defect in one fairly large node in the left iliac area. Surgical management in-
758
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Hahn et ol.
,\Ill .
J.
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eluded the removal of the nodes frolll this area and pathologic examination reveale-d them to be benign in character. In reviewing the films it was considered that the hilus of the la rge iliac node was asymmetri(: in it s location and the refore produced a >light indentation radiologically . Distortion of lymphatic channels
Fig. 9 demonstrates the marked lateral displacement of the normal lymphatics which occurred in a young woman with a large tuboovarian abscess. A simi lar picture could a lso be produced by extensive endometriosis or fibrosi s wh ere fixation of the pelvic structures occurs. A frf'ely lllO\·able lesion, such as a small ovarian cys L will not bring about any significant change in the vascular or lymphatic pattern . Fig. 5. Lymphatics of the vulva leading to the superficial inguinal lymph nodes. 1, The superfi cia l femora l nodes ; 2, the deep in gu inal nodes ; 3, the node of Cloquet: and 4, the external iliac nodes. (Ac kerman and del Regato: Cancer- Diagnosis. Treatme nt and Prognosis, ed. 3, St. Louis, 196 2, The C. V . Mosby Company.)
Fig. 6. Normal lymphatics and nodes as seen on initial film . ~otc th e fine ca liber of th e channels.
Malignant disease
The chief \·alue of lymphangiography has been in the study of patients with malignant disease. Fig. 10 demonstrates the lymphangiograph ic appearance of a patient with carcinoma of the cervix uteri. The nodes are f'nlargecl. irregular, and increased in number with matting to.g ether of many of them. The margins are hazy and indistinct. This patient had a bilateral lymphadenectomy and the pathologic examination confirmed the radiolog-ic impression of nodal metastasis. Figs. 1 l and 12 represent films which were taken in the study of a patient with lymphedema of the left lower extremity. This pa tient had previou sly received radiologic therapy for an invasiw carcinoma of the cervix. Lymphangiograhpy revealed irregularity in th e left lower iliac nodes with absence of some. ThP elimination of the nodes may be due to carcinoma or may be a normal variant. In view of the irregularity of the nodes. the causation is undoubtedly malignancy. Confirmatory evidence could bc obtained hy inferior vrna cavog-raphy or by sur.gical excision. Figs. 13 and 14 show bilateral iliac nodal im·olvement in a 70-year-old patient treated 3 years pre,·iously by irradiation for a Stage
Volume 8j Number 6
II carcinoma of the cervix. The films confirm the clinical impression of advancing pelvic disease. A 57-year-old patient was admitted to Jefferson Hospital because of increasing right-sided discomfort. She had previously been treated by operation and irradiation for an invasive carcinoma of the cervix. Pelvic and abdominal examination disclosed a large, fixed mass in the right iliac area. Lymphangiography (Fig. 15) confirmed the clinical impression of bilateral nodal disease, more marked on the right side. Intravenous urography showed a right hydroureter and hydronephrosis. Surgical removal of the nodes was followed by relief of discomfort and, interestingly, a dramatic fall of blood pressure from a level of 270/ 140 to an average of 170/100. The patient later died from generalized disease (Fig. 16). Fig. 17 shows the relationship between radium (intrauterine tandem and Manchester ovoids) and the iliac lymph nodes in a 38-year-old patient with a Stage I carcinoma of the cervix. Lymphangiography has become an aid in the follow-up examination of patients who have been previously treated for carcinoma of the cervix. Figs. 18 and 19 show an irregular "punched-out" left iliac node at the level of the fourth lumbar vertebra. This node is above the radiation treatment portals and the patient has been admitted to the hospital for further evaluation. Fig. 20 shows obvious metastatic disease with obstruction to lymphatic channels with an attempt at collateral circulation . This patient's primary neoplastic disease was endometrial. In patients with vulvar carcinoma, lymphangiography is most helpful in evaluating the preoperative lymphatic extent of disease and the postoperative result of the surgical treatment. Fig. 21 shows bilateral nodal destruction in an 80-year-old patient with carcinoma of the vulva. Operation confirmed the radiologic diagnosis. Ovarian malignancy, when large, may produce lymphatic distortion with lateral displacement of the lymphatic channels as
Lymphangiography
759
seen in Fig. 22. This appearance is not pathognomonic of ovarian malignancy but may be brought about by any fixed pelvic mass. Fig. 23 shows large iliac nodes with destruction due to metastases from ovarian carcmoma. As has been noted before,! malignant lymphoma may involve the pelvic regwn.
Fig. 7. Normal lymphatics as seen in 2+ hour film. The contrast material has left the channels and is concentrated in the nodes. The inguinal nodes ar~ prominent in this film.
Fig. 8. Twenty-four hour film showing node in left iliac area.
dd~ct
m
760
Hahn et al.
Fig. 9. Lymphangiogra m showing marked lateral displacement of lymphatic structures due to large tuhoovarian abscess. (Metropolitan Hospita l. )
Fig. 10. Lymph nodes affected by metastatic carcinoma of the cervix. The nodes are large, irregular, and increased in number with peripheral filii ng defec ts.
Fig. 11. Initial film of patient with cervical carcinoma showing irregularity of nodes, particularly in the left iliac area. Note the crossing of the lymphatics to the opposite side at the sacral area. This is a normal oc
i\ru .
J.
:\·larch 1.) , I'163 Olw . & C ynec .
Fig. 24 shows an appearance quite characteristic of the malignant lymphoma. This patient is an 80-year-old woman who had been treated 24 years previously for a Stage II carcinoma of the cervix. Lymphangiography was performed because of the development of nodularity in the peh-is. Fig. 25 is a film taken of a patient with generalized lymphosarcoma. The lymphangiograms in both these patients show an intrinsic lymphatic disturbance. The outer margin of the nodes is intact, but the internal nodal architecture presents a foamy or lacy pattern. There is also an increase in the nttmber and size of the nodes demonstrated. Lymphangiography is an effective way to confirm the diagnosis of lymphocyst-- a condition which is occurring more frequently with the increased emphasis on radical operation in pelvic malignancy. Reduction in the incidence of this complication may be achieved by very thoroughly ligating main lymphatic channels at the time of operation to prevent leakage of lvmph and by using extraperitoneal suction catheters in both iliac fossas during the immediate postoperative period. Fig. 26 shows the radiologic appear-
Fig. 12. Twenty-four-hour film of patient with cervical carcinoma. In addition to the irregularity of nodes, there is absence of some nodes in the left iliac area, thought to be due to carcinomatous replacement.
Volume 85 Number 6
ance of a lymphocyst after direct injection of contrast material into the lymphocyst cavity. Figs. 27 and 28 show the lymphangiographic appearance of lymphocysts; the first followed irradiation and radical operation for carcinoma of the cervix and the second followed radical operation including iliac node dissection for a Stage I carcinoma of the cervix. Radiologically the lymphocyst appears as a collection of contrast material which lies in close association with normal lymphatic channels. The outline is extremely well demarcated and usually remains visible for a prolonged period of time.
Lymphangiography 761
Fig. 13. Initial film showing lymphatics going around defective nodes in pa tient with advanced carcinoma of the cervix.
Interpretation
The interpretation of lymphangiography must be a total interpretation and should include the correlation of all available information, clinical, laboratory, and pathologic. There must be thorough knowledge of the normal anatomic lymphatic drainage so that supposed irregularities in nodal architecture far-removed from the initial site of disease may be properly evaluated. Lymphangiography is a gross method and a negative study must be considered to be grossly negative. Microscopic study is impossible by this technique. The most frequent interpretive error occurs in the inguinal area where nodes may appear abnormal because of fibrosis and fatty replacement associated with previous inflammatory disease. Great care must be exercised in evaluating inguinal adenopathy. The changes must be definite and distinct and the nodes should be in the direct route of drainage, i.e., vulvar lymphatics would drain to the inguinal area. In the final evaluation of lymphangiographic films the initial film should be compared with the 24 hour film so that hilar areas may be properly located and not misread as pathologic deformities. In certain cases where there is questionable proof of lymphatic disease, other aids should be employed. Oblique films and planograms may give the additional evidence needed. When there is total nodal replace-
Fig. 14. Twenty-four-hour film of patient with bilateral iliac metastasis from cervical carcinoma. Note the multiple filling defects.
Fig. 15. Initial film of patient with bilateral iliac metastasis from carcinoma of the cervix. Note the almost complete obliteration of lymphatic pathways on the right side.
\f a re.!. ) j , 196:1 Am . .J . Ohst. & C vnec .
762 Hahn et al.
ment, venocavagrams may be most helpful in correlating lymphangiographic findings. Complications
Fig. 16. Twenty-four-hour film showing absence of most of iliac nodes on the right side due to ca rcinomatous tnt'tastasis from the ce rvix.
Fig. 17. Lymphangiographic appearance of iliac lymph nodes in relation to intrauterine and paracervical radium.
When the thoracic duct is visualized it is likely that there is always some degree of pulmonary embolization. The extent of this would depend on the amount of material used and the speed of the injection. Within the first 24 hours there may be malaise, chi lls, and fever which may be due to embolus or to a "foreign body" reaction associated with th e release of iodine from the breakdown of Ethiodol. There have been no fatalities or serious complications associated with pulmomry embolus following lymphangiography. One patient developed a fairly large pulmonary embolus which cleared without serious consequence. A possible lymphatic-venous anastomosis was thought to be the l:ausc of this occurrence. Pathologic examination of nodes removed after lymphangiography has revealed changes within the nodes classified as lipogranuloma, a "foreign body" reaction due to the presence of the oil-based contrast material. A few patients have had fleeting lymphangitis with exacerbation of edema following lymphangiography. This has been seen in patients who have abnormal lymphatic
18
19
Figs. 18 and 19. The arrow points to abnormal iliac lymph node before and after radiation therapy. Following therapy the lymph nodes are smaller and less apparent but the abnormal node is quite distinct in both films.
Volume H'J Numbe r 6
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763
Fig. 20. Bilateral involvement of pelvic nodes from endometrial carcinoma.
Fig. 21. Lymphangiogram showing marked destruction of inguinal and femoral lymph nodes in a patient with advanced vulvar carcinoma. A typical moth-eaten appearance is shown.
Fig. 22. Marked lateral displacement of lymphatics due to pressure from ovarian carcinoma. Note similarity in appearance to Fig. 9 where the displacement was due to inflammatory disease.
March i.i. 1%3 :\m . ] . Obst . & (;yner. .
764 Hahn et al.
structures. Local wound infection at the site of the incision may be minimized by using a pHisoHex scrub the evening prior to the procedure, strict adherence to sterile technique at the time of cannulization of the lymphatic vessel, and adequate lavage of the cannula after the completion of the lymphangiogram. Extravasation of the contrast material outside of the lymphatic vessel produces no significant clinical symptoms. This is probably due to excessive pressure at the time of injection although some authors believe this may be evidence of abnormal lymphatic structures. Pain along the distribution of tht ~ lymphatics may occur because of overdistention of the lymphatics due to too rapid a rate of injection or because too much pressure was used for the injection. These difficulties are largely obviated by using the mechanical pressure pump. The possibility of iodine sensitivity must, of course, be considered. from metastatic ovarian carcinoma. ( M. D. Anderson Hospital. )
Fig. 24. Lymphangiogram of patient with lymphoma which developed years after treatment for carcinoma of the cervix. Foamy pattern in para-aortic area is quite distin ct.
Further applications of lymphangiography
Lymphangiography may be used prior to radical operation to determine the gross lymphatic extent of malignant disease as a guide in nodal dissection. Ethiodol with chlorophyll is being used at our institution in the hope that the green dye will make it easier for the surgeon to identify lymph nodes at the operating table. Occasionally unexpected and untoward extension of disease may be detected so that radical operation will he contraindicated. At the operating table films may be made to determine the adequacy of the operation performed and later films may be made at varying intervals to follow the course of the disease. In preparing patients for external radiation therapy, lymphangiography may be used to achieve more precise portal placement. Since the contrast material will remain evident for 6 weeks to 2 years the course of the disease may be followed with better exactitude. Occasionally follow-up films will show
Volume 8j Number 6
that the planned therapy portals are inadequate to control the extent of the malignant lymphatic involvement. In a similar fashion, the effectiveness of chemotherapy may be readily followed by serial observations on node-bearing areas. Following treatment by radiation or chemotherapy decrease in size of lymph nodes may result, but the lymphatic channels will remain patent. With extensive fibrosis, lymphatic obstruction can occur. Intralymphatic injection of chemotherapeutic and radiotherapeutic materials has been attempted, 8 but proper evaluation is not possible at this time. According to Zeidman, Copeland, and Warren 9 carcinomatous tissue contains no lymphatics, accounting for the irregular defects seen on lymphangiography indicative of nodal destruction by malignant disease. This absence of lymphoid structure in neoplastic tissue may make the effective intralymphatic administration of cancericidal agents a most difficult problem to overcome.
lymphangiography 765
Fig. 25. Appeara nce of lymph nodes in patient with generalized lymphosarcoma. Almost all the nodes visualized show a lacy pa ttern, but the noda l margins are for the most pa rt intact.
Summary
By employing intralymphatic injection of radiopaque oil-based material the skeletal lymphatics of the pelvic area may be demonstrated. This procedure has been successfully performed in more than 500 patients, 60 of these having pelvic disorders. Normal pelvic lymphatic anatomy is briefly reviewed. Photographs of representative cases including patients with normal anatomy, carcinoma of the cervix, carcinoma of the endometrium, carcinoma of the ovary, carcinoma of the vulva, malignant lymphoma, lymphocysts, and lymphatic distortion due to benign disease are presented. In lymphangiography normal nodes exhibit a discrete outline with a homogeneous pattern. Metastatic malignancy is characterized by irregularity in the margin of the node with a "moth-eaten" aspect in the node itself. The lymphoma shows enlarged lacy nodes. Major complications are discussed and interpretive difficulties mentioned.
Fig. 26. Radiologic demonstration of large lymphocyst which followed radical operation for cervical carcinoma. Contrast ma terial has been injected directly into the cavity. (M. D. And erson Hospital. )
Fig. 27. Lymphangiographic appearance of lymphocyst following treatment for cervical carcinoma. (M. D . Anderson Hospital.)
Mard> l.'i , 1963
766 Hahn et al.
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Conclusions
Lymphangiography is a safe, practical method to aid the gynecologist in evaluating the kind and extent of disease, and the feasibility of surgical, radiation, or chemotherapeutic management. More exact treatment fields may be outlined for radiation therapy and the follow-up care of patients becomes more effective.
Fig. 28. Pooling of contrast material in lymphocyst in right iliac area. This occurred after operation for cen •ical malignancy. (Albert Einstein Medical Ccntrr. )
W e ex press our appreciation to th e Albert Einstein M edica l Center, M. D. Anderson Hospital. }..fis eric ordia Hospital, M etropolitan Hospit al, a nd the Warner Hospital for the privilege t)f stndy ing som e of their patients.
REFERENCES
l. Kinmonth, J. B. , Taylor, G. W., and Harper, R. A. K.: Brit. M. J. 1: 940, 1955. 2. Tjcrnberg, B.: Acta Soc. med. upsal. 61: 207, 1956. 3. Hreschyshyn, M. M., and Sheehan, F. R.: Proc. Am . A. Cancer R es. 3: 121, 1960. 4. Wallan·, S., Jackson , L. , Schaffer, B., Gould, ]., Greening, R ., Weiss, A., and Kramer, S.: Radiology 76: 179, 1961. 5. Wallace, S., J ackson, L., and Greening, R .: Am. J. Roentgenol. 88: 97, 1962.
6. Averette, H . E., Hudson, R. C ., Viamonte, M. I., Jr., Parks, R . E. , and Ferguson, J. H.: Cancer 15: 769, 1962. 7. H ahn, G. A.: AM . J. OasT. & GYNEc. 75: 673 , 1958. 8. Fischer, H. W.: Radiology 79: 297, 1962. 9. Zeidman, I., Copeland, B. E., and Warrt>n, S.: Cancer 8: 123, 1955.
255 South 17th St Philadelphia 3, Penn.rylvania
Discussion DR. HowARD ULFELDER,* Boston, Massachusetts. C learly we have not yet reached the end of techniques which can help us delineate gross anatomic details in the living human subject, even though anatomy must be the most ancient of biologic sciences. Lymphatic channels and nodes were recognized long ago but the anatomic charts of the times show them as a diffuse or haphazard network. The purposefulness of their complex di stribution became apparent upon more complete dissection after the injection of colloidal dyes as markers. Drinker showed that they could be cannulated for the collection of pure lymph and stimulated other research into their function. Now we havr seen that injection of radiopaque fluids permits exquisite delinea tion of these pathways. It has been lea rned that slowly applied , stt•ady injf'ction pressure wi ll avoid rupture of the
vessels and permit distant filling. Films taken during or shortly after injection show lymphatic channels ( lymphangiograms) and nodes, while subsequent exposures will demonstrate the nodes for weeks thereafter if the injection mass had an oily base. Dr. Hahn and his colleagues have confirmed these facts and he has today illustrated through .~el ecte d cases a variety of clinica l situations where roentgen lymphnodograms were profitably employed . From the anatomic point of interest it must be noted, as Dr. Hahn says, that only the skeletal lymphatic structures arc shown by the m ethod d escribed. To date no way to isolate and inject a tributary of the visceral systrm has been reported and it is considered too hazardous in terms of extravasation and oil embolization to apply proximal pressure in the upper or mid abdomen and try to effect retrograde filling of the hypogastric, parametrial, presacral, and other
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lymphangiography 767
more centrally located nodes and channels. The confluence of skeletal and visceral pathways at the level of the iliac bifurcation, however, permits the application of the method in cases of cancer of the internal genital organs whereas the immediate spread to the skeletal nodes from cancer of the vulva and anus renders it particularly useful in this situation. This patient (Fig. 1) illustrated several anatomic points of value to us. The film was taken during injection and the lymphatics are
still well filled as is the cysterna chyli. When only one extremity had been injected dye was found in channels on both sides of the aorta, indicating lymphatic crossover and the inadequacy of unilateral therapy, either by excision or radiation, for such apparently unilateral tumors as cancer of the testis. \'\' e note also that nodes in the anteroposterior view overlie the medial aspect of the kidney shadow, an area that is carefully blocked out of the usual treatment fields. In the lateral view the nodes which we can resect at
Fig. 1. Lymphangiogram taken during injec tion showing major anatomic points.
Fig. 2. Lymphangiogram after adequate surgical dissection for carcinoma.
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Hahn et al.
Fig. 3. Film of removed tissues indicating areas of remowd lymphatics.
:Ma.rh I"• , 196:1 r\m . j. Oh ~t. & (;yru.•c.
Fig. 4. Lymphangiogram suggestin g partial ncoplastic replacement of lymph nod e.
pelvic lymphadenectomy are seen to lie far forward and we can identify the superficial nodes of the groin. Thus we are able to translate upon the anteroposterior projection those shadows which should be missing after an adequate surgical dissection for carcinoma (Fig. 2) . A film of the removed tissues (Fig. 3) arr:.m ged roughly in their pristine relation to each ot her shows where the missing shadows have
gone. When it comes to using the method for diagnosis, all who have tried it agree there will be errors of interpretation both ways sufficiently often to prevent our depending on it as the only guide to the nature and extent of treatment. A picture like this (Fig. 4) may indicate partial neoplastic replacement and here (Fig. 5) in a film taken in the operating room a fter removal of a node for positive frozen section examination we can confirm that it was that very same node seen in the previous picture. But only <'xplorati0n could tell us tha t this was a solitary, freelying, easily removahle right obtura tor node in a patient with an early Stage II lesion that had shown a poor clinical and cytologic response to 1he first application of radium, and that extended hysterectomy and nod e dissection was, therefore, not only eminently feasible but also more likely to cure her than furth er irradiation . In patients previously treated for pelvic cancer :tnd in the evaluation of effectiveness of non>urg·ic" I t rca tnwnt in known nwtastases, roentgen
Fig. 5. Lymphangiogram of same area taken in operating room after surgical removal of involved node, confirming tentative interpreta ti on of Fig. +.
lyrnphadenography should be exceedingly helpful. Certainly as an aid to diagnosis in cases of lymphatic hlockade, lymphocyst, etc., it may offer the key items of information. All the specific indica tions lumped together, however, form a small group. Because the technique is quite safe and 1·arely fails, my r ecommendation is that lymphograms be made in the majority of patients with gynecologic cancer to accumulate experience and information and to ma intain a high level of radiologic acuity of .i nterpre-
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tation. Moreover I see in this a way to fill a void in the present-day gynecologist's awareness of the structures with which he must deal in the operating room. It is precisely this ghostliness of the intact lymphatics and nodes which has often transformed a pelvic node dissection into an anatomic demonstration of the vessels, nerves, and ureter. Any technique which lends three-dimensional substance to the routes of malignant dispersal cannot help improving both radiotherapeutic and surgical efforts to cure the disease. For this reason alone I would feel urged to practice and to preach the use of all safe methods available to show lymphatics and nodes, whether by visible dyes as Eichner and others have reported or by the method shown here today. DR. J. H. FERGUSON, Miami, Florida. There is one area in which I must disagree and that is the statement of the inability to visualize the obturator, the hypogastric, and the sacral lymph nodes when a so-called skeletal lymphatic vessel in the foot has been cannulated. We are able to do this almost uniformly, practically 100 per cent of the time. Why this difference in experience rxists, I am not certain; it may be that we have made more frequently the lateral and oblique films which can demonstrate these nodes better than the simple anteroposterior films. At the University of Miami several departments have been working together on lymphography at a pace that brings almost weekly improvements in our technique and increase in our realization of the potentialities of lymphangiography. Over 200 patients have been examined by this technique. In obstetricsgynecology we have now done over 50 studies, gradually extPnding the variety of patients as we explored the usefulness of this technique. The greatest value of lymphangiography may be in carcinoma of the cervix, where we have identified the lymphatic stmctures radiologically and by green coloration before and after either radiotherapy or radical hysterectomy. In each of these categories we see great potential for better diagnosis, better surgery, better radiotherapy, and improved follow-up of the patient. We have studied other patients, for example, ones with adenocarcinoma of the endometrium, cancer of the ovary, and benign pelvic masses. We have not been as fortunate as Dr. Hahn in avoiding febrile reactions. We have not had a typical case of lymphangitis but 22 per cent of
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the patients have had a fever of 100.4° F. after this diagnostic procedure. We have continued with radical hysterectomy when planned and without any ill effects. One patient was found 4 days after operation to have lymphoid pneumonia, which caused no symptoms and did not retard her postoperative recovery. Lymphangiography has bec>n useful in the preand post-operative study of patients who had a radical vulvectomy and in the performance of the operation. Coloration of the lymphatics permits a more rapid femoral, groin, and deep pelvic node dissection; completeness of the removal of the lymphatics appears to be assured but at the same time selectivity seems to be possible, thus avoiding unnecessary excision of tissue. This has been particularly helpful in the dissections of the groin. To the conventional x-ray films we have added cinefluoroscopy with a television monitor including a 9 inch image intensifier and an Orthicon system. This permits us to observe on the television screen the filling of different lymphatic nodes and channels. From patient to patient this filling proceeds at different rates and the lymphatic routes can vary. We feel that this technique adds to the future of lymphangiography. Today we may be in a position similar to that of the radiologists year ago when they were doing their first barium enemas and they had to wait until they accumulated the autopsy material and surgical specimens before they could interpret what they had seen. I think lymphangiography has a tremendous future for us in our specialty. At the moment I find it so useful that I would not want to do a radical hysterectomy or vulvectomy without it. Once you have tried lymphangiography I can assure you that you will not want to give it up. DR. GRAY H. TWO)fBLY,* New York, New York. Dr. Meigs's revival of radical operation for the treatment of carcinoma of the cervix has made gynecologic surgeons very much aware of the anatomy of the pelvis and has brought out many points about the lymph glands which drain the cervix. Dr. Hahn's presentation is a very good demonstration of this. If you study the position of the lymphatics, as Dr. Hahn has done, you will find that the bifurcation of the aorta lies right beneath the urn-
*By invitation.
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Hahn et ol.
bilicus and, as demonstrated in his pictures, the lymph nodes draining the cervix lie along the iliac vessels and up around the lateral margins of the bifurcation. The usual x-ray treatment portal takes in only the external iliac and the 'cry lowest of the obturator lymph nodes. It do!'~ not often reach the higher lymph nodes. Radical operation is usually able to remon: the lower lymph nodes quite readily, but the lymph nodes that lie up higher the surgeon has difficulty in getting out. When he tries to get the higher nodes, it becomes more or less a piecemeal procedure and not a block dissection at aiL We must go back to our radiotherapeutic friends and say, "Look, your treatment portals arc not right. They should go up to and include at l(·a~t the bifurcation of the aorta. The radiation you arc giving is often usdess. lt is lw]m, the n~rvix. It is down in the region that wt: can treat surgically." And the radiotherapi~t often replies that high portals will treat the small intPstinc and the small intPstine will uot take a great deal of radiotherapy. x-ray If rhere is any rationale for therap) in cancer of the cervix. it must drpcnd first of all on dirf'ctinJ" thr therap
\nL
\Lt1 cb Li 19b3 ,I ( >h·a S: Cym·c.
tissue of dogs. This radiopaque substallC<: was later \·isualized in the hypogastric and nbt urator glands. This preliminary work "·as follu\\Cd ou several actual women patients. Direct iujectiou of 2 c.c. of Ethiodol into the parac<'rvic.d tis:stw of the patients was followed with radiog:raphi( visualization of the hypogastric, the ohtnrator, and tlw common iliac glands. This mav lw au answer to some of tlw diflirultic~ allfl tlll<'t.'rtainties recognized b\' some im·cstigator, 1\'110 arc doing direct lymphangiography. DR. joHN G. MASTERSON/ Brooklvn, Ne11 York. During the past few years on the State University of ?\ew York GynPcological Tumor Srrvicc, we have been intcrestl'd in investigating th(' role of lymphangiography. ,\s a r.-sult uf this experience. I \\Ould certainh endorse the slatf~ments of Dr. Hahn and tlw preYi"u' discussants as to the o-.·nwndous nwrit uf this prn· Ct'dure m tlw e\'aluation of patir·nh with gynecologic mali.gnancv. ,\s n•gards the rpwstion of '' lu·thcr ·Ill<' 1s ahlt> to visualize tlw \·isct'l'al nndt'> "ith this technique, wt· think that, in most instanct:,, the visceral nodes an· filled as dearly demonstrated in ohliqtw \iews of the pdvis. ·with uhliqw' vi;•ws, you cau f('adilv s('e three distind plan"' of nod('S and we l)('lil'w that th<• innt·r plane r~'pn•sents the vi'cer;d chain of nodt:>. \'Ve haw found lnnphangiography '" h,, ,[ particular valu;· in two clinical situatinib: I In tlw who has had previou' radiation therap} for cervical malignancy and develops swdling of the lmn·r Pxtrcmitics without any palpable or other e\·id·~ncP of rccnrr('nt disease. Although we have always ron;;idcr<'d this typf' of patirnt to havf' recurrent disease, \\'t' hav•· rw\Tr been able to corroborate this without surgical exploration. ln studving; such a paticm. \H' nn\\ combint· lymphangiography \lith peh·ic art('riography. As a result, W<' han·
*Uy invitation.
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lymphogram prior to our radical hysterectomy and lymph node dissection. On the third postoperative day, a scout film of the pelvis will disclose whether all of the lymph nodes have been removed. In those instances where we sec evidence of persistent nodes, the patient may he very promptly reoperated and the necessary dissection completed. In dosing, I would say that lymphangiography is a very useful diagnostic tool in evaluating patients with pelvic malignancy. With more experience, our interpretations will he of more value and may well eliminate the necessity of many of our present-day exploratory laparotomtcs. DR. FELIX RuTLEDGE,* Houston, Texas. \'\lc have had experience with this technique for 2 years and have been fortunate to have worked with Dr. Dodd who is now working with Dr. Hahn. We think the technique is very interesting and has a lot of possibilities. The accuracy of making a diagnosis is still variable. It is my impression that in large lymph nodes the possibility of saying they arc positive nodes is quite great, but in the smaller nodes and earlier metastases the accuracy falls off quite sharply.
*By invitation,
Lymphangiography 771
There may be some explanation for this because,
if we remove these nodes and study them routinely, we find that not all nodes do conform with the usual anatomy. They are frequently replaced by fatty tissue and have a lot of changes, such as granulomatous reactions which are hard to explain, and these rrPate defects which are difficult to interpret. DR. HAHN (Closing). I would like to emphasize a few points: It is most important that an oil base is used. All information, laboratory and anatomic, must be correlated with the radiologic findings. In the paper the usc of chlorophyll with the Ethiodol prior to operation for better visualization of the nodes is described. Even with the usc of oblique films, we have difficulty visualizing the obturator, sacral, and hypogastric nodes unless there is a lymphatic block. The placing of the portals for radiation therapy is most important. Lymphangiography is of hdp in this and we have had experience in at least one instance where the radiation fields werr too low and there were malignant nodf's present above the radiation portals.