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Significant venous thromboembolism caused by pelvic lymphocysts: Diagnosis and management
GYNECOLOGIC
ONCOLOGY
13, 136-143 (1982)
CASE REPORT Significant Venous Thromboembolism Caused by Pelvic Lymphocysts: Diagnosis and Management’ DANIEL
L. CLARKE-PEARSON, M.D., INGRID S. SYNAN, R.N., WILLIAM T. CREASMAN, M.D.
AND
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710 Received October 13, 1981 Lymphocysts are an infrequent complication of pelvic lymphadenectomy, but may lead to serious complications. Previous reviews have discussed the etiology, diagnosis, and management of lymphocysts. We present three cases of venous thromboembolic complications secondary to venous compression and stasis from a lymphocyst. Evaluation of venous dynamics by impedance plethysmography differentiates between venous obstruction and/or lymphedema. The subsequent management of extrinsic venous obstruction with and without thrombosis is discussed.
Lymphocyst is an infrequent complication of pelvic and paraaortic lymphadenectomy. The reported incidence of lymphocysts ranges from 1 to 50% [l-6] and may be influenced by retroperitoneal suction drainage [7,8], radicality of lymphadenectomy [2,3], previous radiation therapy [2-61, lymph node metastasis [4], pregnancy [5], and low-dose heparin thromboembolis prophylaxis [9]. Most lymphocysts which are recognized clinically may be managed expectantly and resolve spontaneously [3-51. The decision to surgically drain a lymphocyst is usually based on the need to relieve pain or pressure symptoms, to drain an abscess, or to relieve urinary or GI tract obstruction. We have encountered three cases of significant venous thromboembolism secondary to lymphocyst obstruction of the pelvic veins. Based on our experience and a review of the literature, we propose that pelvic venous obstruction should also be considered an indication for lymphocyst drainage. CASE REPORTS Case 1
The patient is a 54-year-old white female who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic and pa’ Supported in part by American Cancer Society Junior Faculty Fellowship 599.
0090-8258/82/010136-08$01.00/O Copyright All rights
0 1982 by Academic Press. Inc. of reproduction in any form reserved.
136
LYMPHOCYSTS
CAUSING THROMBOEMBOLISM
137
raaortic lymphadenectomy on June 20, 1979, for a Stage IA, GI adenocarcinoma of the endometrium. The patient received perioperative prophylactic antibiotics and low-dose heparin prophylaxis. The retroperitoneal space was drained with Hemovac suction drains’ for the first 7 postoperative days. The pathology report showed bilaterally positive pelvic lymph nodes and the patient was scheduled to return for whole-pelvis radiotherapy. She was discharged on the 8th postoperative day; however, she returned on the 16th postoperative day complaining of right leg pain and edema. On examination, the lower extremity was edematous from the inguinal ligament distally and she had tenderness in the femoral triangle and over the saphenous vein. Pulses were equal and normal bilaterally. Abdominal examination revealed a well-healed midline scar with fullness and tenderness in the right lower quadrant. Pelvic examination revealed a 6 x 4-cm nontender, cystic mass arising from the right pelvic sidewall. Impedance plethysmography (IPG) was abnormal in the right leg and consistent with deep vein thrombosis and/or extrinsic venous compression. Ascending venography of the right leg showed extensive thrombosis of the deep venous system and superficial branches in the thigh and femoral vein. The iliac veins were entirely occluded by thrombus. Ultrasound examination of the pelvis revealed a 10 x 6 x 6-cm cystic right pelvic mass consistent with lymphocyst (Fig. 1). Intravenous urogram showed the right renal pelvis and right ureter to be slightly dilated with extrinsic displacement of the right lower ureter and bladder medially by the pelvic mass (Fig. 2). The patient was anticoagulated with heparin for 10 days, then placed on oral coumadin therapy for 3 months. After 1 month of anticoagulation, the lymphocyst was incised and drained without difficulty or excessive blood loss. She received 5000 rad to the whole pelvis and has been followed for 2 years with no evidence of recurrent carcinoma or rethrombosis. Case 2
The patient is an 81-year-old black female with Stage II, Grade II endometrial adenocarcinoma who underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic and paraaortic lymphadenectomy on 6/10/8 1. The retroperitoneal spaces were drained bilaterally with Hemovac suction for 7 days. Perioperative antibiotic and low-dose heparin were given for prophylaxis. Pathologic examination showed no evidence of metastatic disease to the pelvic or paraaortic lymph nodes; however, there was deep myometrial and endocervical involvement and the patient was scheduled to receive postoperative whole-pelvis radiotherapy. She was discharged on the 9th postoperative day. On the 26th postoperative day the patient presented to the clinic with a 48-hr history of right lower quadrant pain and fever. Exam revealed a 15cm tender, cystic mass in the right lower quadrant. Intravenous pyelogram showed slight medial deviation of the ureter but with no obstruction. With persistent pain, ’ Hemovac suction drain (Synder Laboratories, Inc.. New Philadelphia, Ohio 44663).
138
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
FIG. 1. Case I. Pelvic ultrasound showing urinary bladder (B) displaced by adjacent right pelvic lymphocyst (L). The lymphocyst measures IO x 6 x 6 cm.
fever, and leukocytosis the lymphocyst was incised, and a Penrose drain placed on 7/g/81. On the 4th day following lymphocyst drainage she developed right calf and inguinal pain and right lower extremity edema. Impedance plethysmography showed deep venous obstruction secondary to deep vein thrombosis and/or extrinsic compression. Ascending venography (Fig. 3) showed extensive thrombosis in the right femoral and external iliac veins and proximal extrinsic compression of the iliac vein from a persistent lymphocyst. The patient was anticoagulated and she has had no further sequelae of the venous thrombosis or lymphocyst. Five thousand rads to the whole pelvis was given without difficulty. Case 3
This 58-year-old white female underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and selective pelvic and paraaortic lymphadenectomy on 7/9/81 for a Stage 11, Grade I1 endometrial adenocarcinoma. The
LYMPHOCYSTS
CAUSING
THROMBOEMBOLISM
139
. 2. Case I. Intravenous urogram demonstrating dilatation of the right renal pelvis and upper ., and extrinsic medial displacment of the right lower ureter and bladder by the pelvic bmpklocyst. FIG
140
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
FIG. 3. Case 2. Ascending venogram of right pelvis demonstrating fresh thrombus in the external iliac and femoral vein (T) and extrinsic compression of the iliac vein proximally due to pelvic lymphocyst (L). Also note collateral venous return.
retroperitoneal spaces were drained with Hemovac suction for 6 days postoperatively. Perioperative antibiotic and low-dose heparin were given. The pathology report showed bilaterally positive pelvic lymph nodes and the patient was scheduled to return for external irradiation therapy. On the 11th postoperative day the patient developed pain and edema of the right lower extremity. Impedance plethysmography was positive on the right, consistent with deep vein thrombosis or extrinsic compression. IPG of the left leg was normal. Ascending venography of the right lower extremity (Fig. 4) showed only extrinsic compression from an otherwise asymptomatic lymphocyst. She was discharged with instructions to elevate her leg when not walking. On the 22nd postoperative day she became suddenly dyspneic with chest pain and died of a massive pulmonary embolus.
LYMPHOCYSTS CAUSING THROMBOEMBOLISM
FIG. 4. Case 3. Ascending venogram showing right external iliac vein compression by lymphocyst (L) and collateral venous return.
DISCUSSION Lymphocysts are an infrequent but sometimes significant complication of pelvic and paraaortic lymphadenectomy. The first report in the American literature by Gray et al. [3] noted an incidence of 16.4% of clinically diagnosed lymphocysts. Other reviews of that era place the incidence between 13 and 48.5% [2-61. Modern series have noted a much lower incidence of I to 4% of lymphocysts following pelvic lymphadenectomy [l]. Detection of lymphocyst in all series has been based on findings of abdominal and pelvic examination. There have been no reports utilizing pelvic ultrasonography or computerized axial tomography to prospectively screen for lymphocysts, many of which must be occult. The significant decrease in lymphocysts over the past three decades may be attributed to suction catheter drainage of the retroperitoneal spaces, improved operative techniques, the utilization of prophylactic antibiotics, and the decreased frequency of performing a pelvic lymphadenectomy following pelvic radiotherapy.
142
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
The occurrence of a lymphocyst may be influenced by a number of risk factors suggested by previous authors. Risk factors include more extended lymphadenectomy, metastasis to the lymph nodes, prior pelvic irradiation therapy, lowdose heparin thromboembolism prophylaxis, the care of ligation of the ascending lymphatic channels, and concurrent pregnancy. Pelvic suction drainage is felt by some authors to significantly reduce the incidence of lymphocyst as well as pelvic cellulitis and subsequent fistula formation [7,8]. However, other authors feel that suction drainage may actually increase the incidence of lymphocyst by encouraging continuous lymph flow [3,4,6]. While none of our patients received preoperative radiotherapy and the extent of their lymphadenectomy was not out of the usual, it should be noted that two of the three patients had metastatic tumor in pelvic lymph nodes. All patients had the retroperitoneal space drained by Hemovac suction and received prophylactic low-dose heparin and perioperative antibiotics. The time of lymphocyst detection varies from the immediate postoperative period to as long as 12 months after lymphadenectomy [3-61. Most authors, however, note the majority of lymphocysts occurring within the first 30 to 60 days postoperatively. Two of our patients were discharged prior to the detection of their lymphocyst at 16 and 26 days postoperatively (Cases 1 and 2). While the lymphocyst probably was present earlier in the postoperative course, it most likely went undetected because of other abdominal and pelvic pain attributed to surgery. Many lymphocysts are probably entirely asymptomatic and regress spontaneously. Abdominal pain, pressure symptoms from a mass encroaching on the GI or urinary tract, obstructive uropathy with secondary pyelonephritis, infection, and lower extremity edema are the most common symptoms referable to a lymphocyst. Clinical management depends primarily upon the significance of the lymphocyst, with many authors recommending conservative medical management in most cases [4-61. Most authors have emphasized that pressure symptoms, pain, urinary tract obstruction with renal compromise or subsequent pyelonephritis, or infection are all indications for incision and drainage of the lymphocyst. Extrinsic pelvic vein compression and subsequent stasis secondary to lymphocyst have been noted in two previous cases [3,4]. However, only one case developed significant venous thromboembolism secondary to venous stasis. Gray et al. [3] noted a patient who 6 weeks following extraperitoneal lymph node dissection returned in extremis and subsequently died. Autopsy showed a massive bilateral retroperitoneal lymphocyst and recent pulmonary emboli secondary to thrombosis of the pelvic veins. Considering the significant morbidity and death from thromboembolism associated with lymphocyst in our three patients we feel that an additional indication for lymphocyst incision and drainage should include pelvic venous stasis secondary to lymphocyst compression. Certainly, patients undergoing lymphadenectomy are already at high risk for thromboembolic complications and the addition of significant pelvic vein stasis only aggravates this problem. While Rutledge et al. [4] believe that “venography is not necessary to demonstrate obstruction of the pelvic veins since the edema of the lower extremities
LYMPHOCYSTS
CAUSING THROMBOEMBOLISM
143
is ample evidence that obstruction is present,” we feel it is important to differentiate between lymphedema and venous stasis secondary to lymphocyst. We have found that lymphedema is the most frequent diagnosis of patients with sympotms suggestive of deep vein thrombosis [lo]. A distinction between lymphedema and venous stasis is crucial in the clinical management of the patient with a lymphocyst. In our experience, noninvasive evaluation of the venous dynamics, including venous capacitance and outflow, is best initially evaluated by impedance plethysmography. While impedance plethysmography cannot differentiate between venous obstruction secondary to extrinsic compression or due to deep vein thrombosis, a normal impedance plethysmogram reassures us that the lymphocyst is not significantly obstructing the iliac veins. On the one hand, an abnormal impedance plethysmogram necessitates ascending venography to further evaluate the etiology of the venous obstruction. In two of our three cases venous obstruction was secondary to both the lymphocyst and deep vein thrombosis, while in one case (Case 3) venography only showed significant extrinsic compression (Fig. 4). Subsequent thrombosis and pulmonary embolus might have been prevented had this lymphocyst been drained. Should a lymphocyst and deep vein thrombosis be found to occur simultaneously, we recommend immediate anticoagulation or thrombolytic therapy followed by intravenous heparin and then maintenance on oral coumadin therapy for at least 3 months. After initially stabilizing or lysing the thrombus we then recommend drainage of the lymphocyst to relieve continued venous stasis and to prevent rethrombosis. We conclude that lymphocysts may lead to a very significant complication of venous thromboembolism. The management plan should include adequate evaluation of venous compromise, treatment of concurrent thrombi, and drainage of the lymphocyst to relieve further stasis. REFERENCES I. Creasman, W. T., and Weed, J. C., Jr. Radical hysterectomy, in Complications in obsretric and gynecologic surgery (G. Schaefer and E. A. Graber, Eds.). Harper & Row, Hagerstown, Md. (1981). 2. Mot-i, N. Clinical and experimental studies on so-called lymphocyst which develops after radical hysterectomy in cancer of uterine cervix, J. Japan. Obstet. Gynecol. Sot. 2, 178 (1955). 3. Gray, M. J., Plentl, A. A., and Taylor, H. C. The lymphocyst: A complication of pelvic lymph node dissections, Amer. J. Obster. Gynecol. 75, 1059 (1958). 4. Rutledge, F., Dodd, G. D., and Kasilag, F. B. Lymphocysts: A complication of radical pelvic surgery, Amer. J. Obstet. Gynecol. 77, II65 (1959). 5. Ferguson, J. H., and Maclure, J. G. Lymphocele following lymphadenectomy, Amer. J. Obsrer. Gynecol. 82, 783 (1961). 6. Dodd, G. D., Rutledge, F.. and Wallace. S. Postoperative pelvic lymphocysts, Amer. J. Roentgenol. 108, 312 (1970). 7. Symmonds, R. E., and Pratt, J. H. Prevention of fistulas and lymphocysts in radical hysterectomy, Obstet. Gynecol. 17, 57 (1961). 8. Helmkamp, B. F., Krebs, H. B., Isikoff, M. B., Poliakoff, S. R., and Averette, H. E. Paraaortic lymphocyst, Amer. J. Obster. Gynecol. 138, 395 (1980). 9. Catalona. W. J., Kadmon, D., and Crane, D. B. Effect of mini-dose heparin on lymphocele formation following extraperitoneal pelvic lymphadenectomy, J. Ural. 123, 890 (1980). IO. Clarke-Pearson, D. L., and Creasman, W. T. Diagnosis of deep venous thrombosis in obstetrics and gynecology by impedance phlebography, Obsrer. Gynecol. 58, 52 (1981).
ONCOLOGY
13, 136-143 (1982)
CASE REPORT Significant Venous Thromboembolism Caused by Pelvic Lymphocysts: Diagnosis and Management’ DANIEL
L. CLARKE-PEARSON, M.D., INGRID S. SYNAN, R.N., WILLIAM T. CREASMAN, M.D.
AND
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710 Received October 13, 1981 Lymphocysts are an infrequent complication of pelvic lymphadenectomy, but may lead to serious complications. Previous reviews have discussed the etiology, diagnosis, and management of lymphocysts. We present three cases of venous thromboembolic complications secondary to venous compression and stasis from a lymphocyst. Evaluation of venous dynamics by impedance plethysmography differentiates between venous obstruction and/or lymphedema. The subsequent management of extrinsic venous obstruction with and without thrombosis is discussed.
Lymphocyst is an infrequent complication of pelvic and paraaortic lymphadenectomy. The reported incidence of lymphocysts ranges from 1 to 50% [l-6] and may be influenced by retroperitoneal suction drainage [7,8], radicality of lymphadenectomy [2,3], previous radiation therapy [2-61, lymph node metastasis [4], pregnancy [5], and low-dose heparin thromboembolis prophylaxis [9]. Most lymphocysts which are recognized clinically may be managed expectantly and resolve spontaneously [3-51. The decision to surgically drain a lymphocyst is usually based on the need to relieve pain or pressure symptoms, to drain an abscess, or to relieve urinary or GI tract obstruction. We have encountered three cases of significant venous thromboembolism secondary to lymphocyst obstruction of the pelvic veins. Based on our experience and a review of the literature, we propose that pelvic venous obstruction should also be considered an indication for lymphocyst drainage. CASE REPORTS Case 1
The patient is a 54-year-old white female who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic and pa’ Supported in part by American Cancer Society Junior Faculty Fellowship 599.
0090-8258/82/010136-08$01.00/O Copyright All rights
0 1982 by Academic Press. Inc. of reproduction in any form reserved.
136
LYMPHOCYSTS
CAUSING THROMBOEMBOLISM
137
raaortic lymphadenectomy on June 20, 1979, for a Stage IA, GI adenocarcinoma of the endometrium. The patient received perioperative prophylactic antibiotics and low-dose heparin prophylaxis. The retroperitoneal space was drained with Hemovac suction drains’ for the first 7 postoperative days. The pathology report showed bilaterally positive pelvic lymph nodes and the patient was scheduled to return for whole-pelvis radiotherapy. She was discharged on the 8th postoperative day; however, she returned on the 16th postoperative day complaining of right leg pain and edema. On examination, the lower extremity was edematous from the inguinal ligament distally and she had tenderness in the femoral triangle and over the saphenous vein. Pulses were equal and normal bilaterally. Abdominal examination revealed a well-healed midline scar with fullness and tenderness in the right lower quadrant. Pelvic examination revealed a 6 x 4-cm nontender, cystic mass arising from the right pelvic sidewall. Impedance plethysmography (IPG) was abnormal in the right leg and consistent with deep vein thrombosis and/or extrinsic venous compression. Ascending venography of the right leg showed extensive thrombosis of the deep venous system and superficial branches in the thigh and femoral vein. The iliac veins were entirely occluded by thrombus. Ultrasound examination of the pelvis revealed a 10 x 6 x 6-cm cystic right pelvic mass consistent with lymphocyst (Fig. 1). Intravenous urogram showed the right renal pelvis and right ureter to be slightly dilated with extrinsic displacement of the right lower ureter and bladder medially by the pelvic mass (Fig. 2). The patient was anticoagulated with heparin for 10 days, then placed on oral coumadin therapy for 3 months. After 1 month of anticoagulation, the lymphocyst was incised and drained without difficulty or excessive blood loss. She received 5000 rad to the whole pelvis and has been followed for 2 years with no evidence of recurrent carcinoma or rethrombosis. Case 2
The patient is an 81-year-old black female with Stage II, Grade II endometrial adenocarcinoma who underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and selective pelvic and paraaortic lymphadenectomy on 6/10/8 1. The retroperitoneal spaces were drained bilaterally with Hemovac suction for 7 days. Perioperative antibiotic and low-dose heparin were given for prophylaxis. Pathologic examination showed no evidence of metastatic disease to the pelvic or paraaortic lymph nodes; however, there was deep myometrial and endocervical involvement and the patient was scheduled to receive postoperative whole-pelvis radiotherapy. She was discharged on the 9th postoperative day. On the 26th postoperative day the patient presented to the clinic with a 48-hr history of right lower quadrant pain and fever. Exam revealed a 15cm tender, cystic mass in the right lower quadrant. Intravenous pyelogram showed slight medial deviation of the ureter but with no obstruction. With persistent pain, ’ Hemovac suction drain (Synder Laboratories, Inc.. New Philadelphia, Ohio 44663).
138
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
FIG. 1. Case I. Pelvic ultrasound showing urinary bladder (B) displaced by adjacent right pelvic lymphocyst (L). The lymphocyst measures IO x 6 x 6 cm.
fever, and leukocytosis the lymphocyst was incised, and a Penrose drain placed on 7/g/81. On the 4th day following lymphocyst drainage she developed right calf and inguinal pain and right lower extremity edema. Impedance plethysmography showed deep venous obstruction secondary to deep vein thrombosis and/or extrinsic compression. Ascending venography (Fig. 3) showed extensive thrombosis in the right femoral and external iliac veins and proximal extrinsic compression of the iliac vein from a persistent lymphocyst. The patient was anticoagulated and she has had no further sequelae of the venous thrombosis or lymphocyst. Five thousand rads to the whole pelvis was given without difficulty. Case 3
This 58-year-old white female underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and selective pelvic and paraaortic lymphadenectomy on 7/9/81 for a Stage 11, Grade I1 endometrial adenocarcinoma. The
LYMPHOCYSTS
CAUSING
THROMBOEMBOLISM
139
. 2. Case I. Intravenous urogram demonstrating dilatation of the right renal pelvis and upper ., and extrinsic medial displacment of the right lower ureter and bladder by the pelvic bmpklocyst. FIG
140
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
FIG. 3. Case 2. Ascending venogram of right pelvis demonstrating fresh thrombus in the external iliac and femoral vein (T) and extrinsic compression of the iliac vein proximally due to pelvic lymphocyst (L). Also note collateral venous return.
retroperitoneal spaces were drained with Hemovac suction for 6 days postoperatively. Perioperative antibiotic and low-dose heparin were given. The pathology report showed bilaterally positive pelvic lymph nodes and the patient was scheduled to return for external irradiation therapy. On the 11th postoperative day the patient developed pain and edema of the right lower extremity. Impedance plethysmography was positive on the right, consistent with deep vein thrombosis or extrinsic compression. IPG of the left leg was normal. Ascending venography of the right lower extremity (Fig. 4) showed only extrinsic compression from an otherwise asymptomatic lymphocyst. She was discharged with instructions to elevate her leg when not walking. On the 22nd postoperative day she became suddenly dyspneic with chest pain and died of a massive pulmonary embolus.
LYMPHOCYSTS CAUSING THROMBOEMBOLISM
FIG. 4. Case 3. Ascending venogram showing right external iliac vein compression by lymphocyst (L) and collateral venous return.
DISCUSSION Lymphocysts are an infrequent but sometimes significant complication of pelvic and paraaortic lymphadenectomy. The first report in the American literature by Gray et al. [3] noted an incidence of 16.4% of clinically diagnosed lymphocysts. Other reviews of that era place the incidence between 13 and 48.5% [2-61. Modern series have noted a much lower incidence of I to 4% of lymphocysts following pelvic lymphadenectomy [l]. Detection of lymphocyst in all series has been based on findings of abdominal and pelvic examination. There have been no reports utilizing pelvic ultrasonography or computerized axial tomography to prospectively screen for lymphocysts, many of which must be occult. The significant decrease in lymphocysts over the past three decades may be attributed to suction catheter drainage of the retroperitoneal spaces, improved operative techniques, the utilization of prophylactic antibiotics, and the decreased frequency of performing a pelvic lymphadenectomy following pelvic radiotherapy.
142
CLARKE-PEARSON,
SYNAN,
AND
CREASMAN
The occurrence of a lymphocyst may be influenced by a number of risk factors suggested by previous authors. Risk factors include more extended lymphadenectomy, metastasis to the lymph nodes, prior pelvic irradiation therapy, lowdose heparin thromboembolism prophylaxis, the care of ligation of the ascending lymphatic channels, and concurrent pregnancy. Pelvic suction drainage is felt by some authors to significantly reduce the incidence of lymphocyst as well as pelvic cellulitis and subsequent fistula formation [7,8]. However, other authors feel that suction drainage may actually increase the incidence of lymphocyst by encouraging continuous lymph flow [3,4,6]. While none of our patients received preoperative radiotherapy and the extent of their lymphadenectomy was not out of the usual, it should be noted that two of the three patients had metastatic tumor in pelvic lymph nodes. All patients had the retroperitoneal space drained by Hemovac suction and received prophylactic low-dose heparin and perioperative antibiotics. The time of lymphocyst detection varies from the immediate postoperative period to as long as 12 months after lymphadenectomy [3-61. Most authors, however, note the majority of lymphocysts occurring within the first 30 to 60 days postoperatively. Two of our patients were discharged prior to the detection of their lymphocyst at 16 and 26 days postoperatively (Cases 1 and 2). While the lymphocyst probably was present earlier in the postoperative course, it most likely went undetected because of other abdominal and pelvic pain attributed to surgery. Many lymphocysts are probably entirely asymptomatic and regress spontaneously. Abdominal pain, pressure symptoms from a mass encroaching on the GI or urinary tract, obstructive uropathy with secondary pyelonephritis, infection, and lower extremity edema are the most common symptoms referable to a lymphocyst. Clinical management depends primarily upon the significance of the lymphocyst, with many authors recommending conservative medical management in most cases [4-61. Most authors have emphasized that pressure symptoms, pain, urinary tract obstruction with renal compromise or subsequent pyelonephritis, or infection are all indications for incision and drainage of the lymphocyst. Extrinsic pelvic vein compression and subsequent stasis secondary to lymphocyst have been noted in two previous cases [3,4]. However, only one case developed significant venous thromboembolism secondary to venous stasis. Gray et al. [3] noted a patient who 6 weeks following extraperitoneal lymph node dissection returned in extremis and subsequently died. Autopsy showed a massive bilateral retroperitoneal lymphocyst and recent pulmonary emboli secondary to thrombosis of the pelvic veins. Considering the significant morbidity and death from thromboembolism associated with lymphocyst in our three patients we feel that an additional indication for lymphocyst incision and drainage should include pelvic venous stasis secondary to lymphocyst compression. Certainly, patients undergoing lymphadenectomy are already at high risk for thromboembolic complications and the addition of significant pelvic vein stasis only aggravates this problem. While Rutledge et al. [4] believe that “venography is not necessary to demonstrate obstruction of the pelvic veins since the edema of the lower extremities
LYMPHOCYSTS
CAUSING THROMBOEMBOLISM
143
is ample evidence that obstruction is present,” we feel it is important to differentiate between lymphedema and venous stasis secondary to lymphocyst. We have found that lymphedema is the most frequent diagnosis of patients with sympotms suggestive of deep vein thrombosis [lo]. A distinction between lymphedema and venous stasis is crucial in the clinical management of the patient with a lymphocyst. In our experience, noninvasive evaluation of the venous dynamics, including venous capacitance and outflow, is best initially evaluated by impedance plethysmography. While impedance plethysmography cannot differentiate between venous obstruction secondary to extrinsic compression or due to deep vein thrombosis, a normal impedance plethysmogram reassures us that the lymphocyst is not significantly obstructing the iliac veins. On the one hand, an abnormal impedance plethysmogram necessitates ascending venography to further evaluate the etiology of the venous obstruction. In two of our three cases venous obstruction was secondary to both the lymphocyst and deep vein thrombosis, while in one case (Case 3) venography only showed significant extrinsic compression (Fig. 4). Subsequent thrombosis and pulmonary embolus might have been prevented had this lymphocyst been drained. Should a lymphocyst and deep vein thrombosis be found to occur simultaneously, we recommend immediate anticoagulation or thrombolytic therapy followed by intravenous heparin and then maintenance on oral coumadin therapy for at least 3 months. After initially stabilizing or lysing the thrombus we then recommend drainage of the lymphocyst to relieve continued venous stasis and to prevent rethrombosis. We conclude that lymphocysts may lead to a very significant complication of venous thromboembolism. The management plan should include adequate evaluation of venous compromise, treatment of concurrent thrombi, and drainage of the lymphocyst to relieve further stasis. REFERENCES I. Creasman, W. T., and Weed, J. C., Jr. Radical hysterectomy, in Complications in obsretric and gynecologic surgery (G. Schaefer and E. A. Graber, Eds.). Harper & Row, Hagerstown, Md. (1981). 2. Mot-i, N. Clinical and experimental studies on so-called lymphocyst which develops after radical hysterectomy in cancer of uterine cervix, J. Japan. Obstet. Gynecol. Sot. 2, 178 (1955). 3. Gray, M. J., Plentl, A. A., and Taylor, H. C. The lymphocyst: A complication of pelvic lymph node dissections, Amer. J. Obster. Gynecol. 75, 1059 (1958). 4. Rutledge, F., Dodd, G. D., and Kasilag, F. B. Lymphocysts: A complication of radical pelvic surgery, Amer. J. Obstet. Gynecol. 77, II65 (1959). 5. Ferguson, J. H., and Maclure, J. G. Lymphocele following lymphadenectomy, Amer. J. Obsrer. Gynecol. 82, 783 (1961). 6. Dodd, G. D., Rutledge, F.. and Wallace. S. Postoperative pelvic lymphocysts, Amer. J. Roentgenol. 108, 312 (1970). 7. Symmonds, R. E., and Pratt, J. H. Prevention of fistulas and lymphocysts in radical hysterectomy, Obstet. Gynecol. 17, 57 (1961). 8. Helmkamp, B. F., Krebs, H. B., Isikoff, M. B., Poliakoff, S. R., and Averette, H. E. Paraaortic lymphocyst, Amer. J. Obster. Gynecol. 138, 395 (1980). 9. Catalona. W. J., Kadmon, D., and Crane, D. B. Effect of mini-dose heparin on lymphocele formation following extraperitoneal pelvic lymphadenectomy, J. Ural. 123, 890 (1980). IO. Clarke-Pearson, D. L., and Creasman, W. T. Diagnosis of deep venous thrombosis in obstetrics and gynecology by impedance phlebography, Obsrer. Gynecol. 58, 52 (1981).