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The diagnosis of lumbar lymph node metastases by lymphography
Clin. RadioL (1974)25, 195-201
THE DIAGNOSIS
OF LUMBAR LYMPH NODE BY LYMPHOGRAPHY
METASTASES
B. T. JACKSON and J. B. KINMONTH From the Department of Surgery, St. Thomas's Hospital Medical School, London, SE1 7EH An account is given of the various abnormal lymphographic appearances of the lumbar region when involved by metastatic carcinoma. It is suggested that lymphography should be performed more often in the management of patients with suspected malignant deposits in the lumbar region. IT is well documented that lymphography may aid in the diagnosis of metastatic spread of malignant tumours to regional lymph nodes, but most authors have been concerned with the use of lymphography in the diagnosis of inguinal or pelvic metastases, and have made few references to the lymphographic diagnosis of lumbar (paraaortic) node metastases (Collette, 1959; Averette et aL, 1962; Viamonte et al., 1962; Hreshcyshyn and Sheehan, 1964; Macdonald and Wallace, 1965; Gerteis, 1970). The diagnosis of secondary spread of malignant tumours to the lumbar lymph nodes is often difficult. Occasionally, enlarged lumbar nodes can be palpated; sometimes an intravenous pyelogram may show displacement of a ureter by enlarged nodes; sometimes an inferior venacavogram may show displacement or distortion of the cava. Usually, however, no nodes can be palpated, intravenous pyelography is normal and intravenous cavography is not performed. This paper gives an account of the varying lymphographic appearances of metastases in lumbar lymph nodes and demonstrates the value of lymphography in the diagnosis of secondary carcinoma in these nodes.
posterior, right oblique and left oblique projections were studied so as to allow suspicious nodes to be observed in more than one plane and unobscured by the vertebral column. Many of the lymphograms were normal and are reported in detail elsewhere (Jackson and Kinmonth, 1974 a & b). Lymphadenograms that appeared abnormal were compared with follow-up lymphadenograms and then correlated with the clinical history which was available in all cases. Further details of materials and methods may be found elsewhere (Jackson, 1972).
RESULTS Metastases in lumbar nodes were found to give rise to several different abnormal lymphographic appearances. Some of these abnormalities were observed in isolation, but more often they were present in combination. None of them was and, characteristic of metastatic spread from a particular primary tumour and, therefore, it was not possible to diagnose the site of an unknown primary tumour from the lymphographic appearances of the metastases. The Table lists the different lymphographic abnormalities that were observed. (A) FILLING DEFECTSIN NODES. This is the most MATERIALS AND METHODS common lymphographic abnormality. Filling A review was made of lymphograms performed defects usually appear as bites taken from the edge as part of the investigation of various primary of nodes causing an irregular outline (Fig. 1) but malignant turnouts at St. Thomas's Hospital and sometimes may be seen as a single central filling the Royal Marsden Hospital, Surrey, between the defect within the substance of the node. Central years 1963 and 1968. The 24-hour or 48-hour filling defects are particularly characteristic of lymphadenograms were studied with special secondary malignant melanoma (McPeak and reference to the appearances of the lumbar region, Constantinides, 1964) but melanoma metastases are which was defined as that area between the upper rare in the lumbar region. border of the first and the lower border of the (B) FAILURE OF NODES TO OPACIFY. - If a node fourth lumbar vertebrae. In all cases a standard is extensively replaced by tumour it may completely technique of lymphography had been used and the fail to opacify, and in the lumbar region this will radiographs had been taken in standard positions show as a filling defect in one of the chains of to prevent magnification errors. The antero- lumbar nodes. In 45 ~ of normal lymphograms, 195 -
196
CLINICAL RADIOLOGY
Mr. A.H. Age 73. Left hypernephroma. This patient presented with painless haematuria and a palpable mass in the left loin. I.V.P. confirmed a carcinoma of the kidney and nephro-ureterectomy was performed. No definiteevidence of lymph node involvement was seen at operation. Postoperative lymphography showed unequivocal lumbar node metastases and the patient was treated with local radiotherapy and systemic chemotherapy. He remained well for fourteen months before developing carcinomatosis. Lymphadenogram shows characteristic marginal filling defects in a node to the left of L3, 4 (arrowed).
FIG. 2 Mrs. A.W. Age 54. Carcinoma of left ovary. This patient presented with a pelvic mass. The diagnosis was made at laparotomy when a total hysterectomy and bilateral salpingooophorectomy was performed. At that time it was uncertain whether lymph nodes were involved. Post-operative lymphography showed lumbar node metastases confirmed by biopsy at a second laparotomy. Radiotherapy was given but the patient died eight months later. Lymphadenogram shows an abnormal filling defect in the left lumbar chain at the level of L3,4 (an'owed). Reactive hyperplasia of many nodes is also seen.
however, a discontinuous right lumbar chain is observed (Jackson & Kinmonth, 1974a) and great caution must be exercised before diagnosing metastases on the basis of a filling defect in the lower part of the right lumbar chain. A filling defect in the left lumbar chain, however, is always highly suspicious of metastases. Figure 2 shows such a tilling defect in the left lumbar chain which is highly suggestive of carcinomatous replacement. This interpretation was later confirmed at laparotomy. Gross replacement of lymph nodes by metastases
may prevent the filling of any lumbar lymph nodes despite the injection of adequate amounts of contrast medium. (C) DISPLACEMENT OF NODES. - Carcinomatous deposits may cause displacement of lymph nodes from their normal anatomical position. Figure 3 shows a displaced node of the left lumbar chain lying opposite the second lumbar vertebra in a patient with a seminoma of the left testis. Notice that the displacement is beyond the tips of the transverse processes and therefore almost certainly pathological (Jackson & Kinmonth, 1973a).
FIG. 1
THE D I A G N O S I S OF L U M B A R L Y M P H NODE METASTASES BY L Y M P H O G R A P H Y
FIG. 3 Mr. T.H. Age 48. Seminoma left testis. Left orchidectomy was performed two weeks after this patient presented with a hard swelling of the left testis. Physical examination showed no evidence of metastatic spread. Post-operative lymphography showed an unequivocal metastasis in the lumbar region, and the patient was treated with radiotherapy to the mediastinum and to the abdomen and pelvis. He has remained well for over two years. Lymphadenogram shows a lymph node of the left lumbar chain displaced laterally beyond the tips of the transverse processes. The node contains an abnormal marginal filling defect.
(D)
DISTORTED
LYMPHATIC
ANATOMY.
-
If
displacement of lymphatic tissue and filling defects in lymph nodes reach an extreme, the lymphographic appearance may be that of gross distortion of normal anatomy, as shown in Figure 4, from a patient with carcinoma of the ovary. (E)
STASIS IN
LYMPH
VESSELS.
--
Metastatic
deposits in lymph nodes often block lymph flow and thus cause stasis of contrast medium in the lymph vessels which may then be seen on the lyrnphadenogram. This appearance must be
197
FIG. 4 Miss E.H. Age 78. Carcinoma of left ovary. This patient presented with ascites. Laparotomy showed carcinoma of the left ovary with local and distant lymph node involvement. Total hysterectomy and bilateral salpingo-oophorectomy was performed. Post-operative lymphography confirmed gross lumbar node involvement and radiotherapy was given to the pelvis and abdomen. One year later the patient was well but was then lost to follow-up. Lymphadenogram shows gross distortion of lymphatic anatomy caused by filling defects, displacement of nodes, collateral vessels and lymph vessel stasis.
distinguished from extravasation. Figure 5 shows stasis of contrast medium in lymph vessels of the right lower lumbar chain in a patient who had a chorion-carcinoma of the right testis but no clinical evidence of lymph node involvement. (F) OPACIFICATION OF COLLATERAL LYMPH VESSELS. -- Obstruction to lymph flow by metastases may cause the opacification of collateral lymph vessels not normally seen by lymphography. This is well seen in Figure 6, which shows a collateral vessel passing from the left external iliac nodes to
198
CLINICAL R A D I O L O G Y
the upper lumbar nodes in a patient with a teratoma of the right testis. The isolated left lumbar node metastases are explained by crossover of tumour cells from right to left in the lumbar region (Jackson & Kinmonth, 1974b). (G) LYMPHATICO-VENOUS CONNECTIONS. -Obstruction to lymph flow by secondary deposits occasionally results in the passage of contrast medium into the veins through abnormal lymphatico-venous connections. These connections only occur under abnormal conditions such as in malignant disease or primary defects of the lymph system (Edwards & Kinmonth, 1969). Metastases in the lumbar lymph nodes may be associated with a lymphatico-portal vein connection causing the liver to become outlined by radio-opaque contrast (Fig. 6). This appearance is most commonly seen in association with a tumour of the testis. The 'hepatogram' is almost always caused by a lymphatico-portal venous connection (Kuisk, 1971) but occasionally is caused by direct opacification of hepatic lymphatics (Kinmonth, 1972). (H) THE APPEARANCE OF 'PSEUDo-LYMPHOMA'. Lymph nodes containing metastases may occasionally appear as enlarged nodes with a coarse reticular pattern, similar to that seen in malignant lymphoma. This appearance is known as 'pseudo-lymphoma' (Fig. 7). (I) DIFFERENTIAL SHRINKAGE OF INVOLVED NODES IN RESPONSE TO RADIOTHERAPY. - T h e 2 4 - h o u r
lymphadenogram may show nodes that are suggestive but not diagnostic of metastatic carcinoma. Figure 8A shows a node to the left of L3 which is displaced from the rest of the left node chain but which is not lying beyond the tips of the transverse processes. The node also shows a suspicious filling defect but the appearance is not pathognomonic of metastatic involvement. Nevertheless, the patient was treated with radiotherapy and Figure 8B shows the considerable shrinkage that occurred during the six weeks following treatment. The shrinkage confirms the diagnosis of a metastasis. Normal lymph nodes shrink in size when irradiated and it is therefore important to see differential shrinkage before making a definite diagnosis of metastases. That is, the involved node must shrink to a greater extent than the surrounding normal nodes. (J) DIFFERENTIAL ENLARGEMENT OF INVOLVED NODES
ON
FOLLOW-UP
LYMPHADENOGRAMS.
-
Metastases may also be diagnosed by differential enlargement in the absence of radiotherapy.
FIG. 5 Mr. H.L. Age 22. Chorion-carcinoma of the right testis. This patient had no clinical evidence of lumbar node involvement. Lymphography showed deposits of tumour in both
left and right lumbar chains. Treatment was by radiotherapy and chemotherapy but the patient died six months later. Lymphadenogram, left oblique projection, shows stasis of contrast medium within lymph vessels of the right lower lumbar chain.
Figure 9A shows multiple lumbar metastases in a patient with a carcinoma of the cervix. Figure 9B shows considerable diminution in the size of the involved lumbar nodes one month after radiotherapy. Ten months later a routine follow-up lymphadenogram shows enlargement of nodes in the upper lumbar chain indicating the development of metastases in this region (Fig. 9C). Soon after this radiograph was taken the patient developed
THE DIAGNOSIS OF LUMBAR LYMPH NODE METASTASES BY LYMPHOGRAPHY
FIG. 6 Mr. D.M. Age 21. Teratoma right testis. Three months after the onset of swelling of the right testis this patient had an orchidectomy. E.U.A. at this time suggested an epigastric mass. Post-operative lymphography showed unequivocal metastases in the left lumbar nodes. Chemotherapy was given as well as radiotherapy but the patient died four months later. Lymphadenogram shows a long collateral vessel (arrowed) bypassing a mass of involved nodes in the left lumbar chain. Crossover of malignant cells must have occurred. Contrast medium is seen in the liver (arrowed) suggesting the presence of a lymphatico-portal venous connection.
malignant cachexia a n d died. Post m o r t e m examination confirmed l u m b a r n o d e metastases. DISCUSSION The use of l y m p h o g r a p h y as a n aid i n the diagnosis a n d m a n a g e m e n t of metastatic c a r c i n o m a is less well established t h a n its use in patients with malignant l y m p h o m a , possibly due to inability of
199
F~G. 7 Mr. R.H. Age 47. Seminoma left testis. Orchidectomy was performed one month after the onset of swelling of the testis. There was no clinical evidence of metastatic spread. Lymphography showed lumbar and pelvic metastases and the patient was treated with radiotherapy. He died 7 months after presentation. Lymphadenogram shows considerable enlargement of nodes of the left chain, which are clearly abnormal and present a pseudo-lymphomatous appearance.
the technique to identify small metastases of only a few millimeters in diameter. False negatives are k n o w n to occur. Vuksanovic et al. (1966) report 3 false negatives i n 27 cases of c a r c i n o m a of the cervix, a n d Fein a n d T a b o r (1969) report 4 false negatives i n 50 cases of n e o p l a s m of the testis. W h e n one is experienced i n the technique, however, this source of error is n o t large a n d M a c d o n a l d (1970) claims that it is possible to give a definite
200
CLINICAL RADIOLOGY
diagnosis when metastases are less than 5 millimeters across and o f a size that would be scarcely visible on a chest radiograph. The key to successful interpretation is to ensure regular follow-up lymphadenograms on which doubtful metastases m a y be seen to enlarge. Regular follow-up lymphadenograms are essential whenever lymphography is performed in cases o f malignant disease, for information m a y be obtained a b o u t the state o f the nodes up to a year after the initial injection o f contrast medium. False positive inaccuracies m a y also occur in lymphographic interpretation o f malignant disease (Dolan & Hughes, 1964; Lecart & Lenfant, 1971). The likelihood o f such errors depends to a great extent on the experience o f the radiologist and on a detailed knowledge o f the range o f normal appearances. In the lumbar region, for example, the normal appearances o f the 'right lower lumbar g a p ' and the 'left upper l u m b a r clump' m a y be wrongly t h o u g h t to be caused by metastatic deposits (Jackson & Kinmonth, 1974a). I n doubtful cases, follow-up l y m p h a d e n o g r a p h y will almost always distinguish between malignant disease and non-malignant artefacts. L y m p h o g r a p h y can give extremely useful information about the presence o f metastases in the lumbar region. There is often no clinical suggestion of lumbar n o d e involvement and l y m p h o g r a p h y m a y demonstrate otherwise occult disease. It is suggested that this investigation should be performed more often in the investigation o f patients with malignant turnouts who are suspected o f having lumbar lymphatic involvement. N o t only will l y m p h o g r a p h y help in diagnosis but it m a y also define the extent o f the disease, help in devising a rational plan o f management in assessing the effect o f treatment, give early warning o f reactivation o f disease and sometimes m a y help the surgeon to perform an adequate excisional operation (Macdonald, 1969).
N; ¢
7
FIG. 8A Fig. 8A--Mrs. L.H. Age 57. Carcinoma of the cervix. This patient presented with an eight-month history of postmenopausal bleeding. Physical examhaation of the abdomen was unremarkable. The diagnosis was made by E.U.A. and biopsy and the patient treated with 137 Caesium insertion. Lymphography showed unequivocal pelvic node deposits and a suspicious lumbar node. Radiotherapy was given to the pelvis and abdomen. The patient was well for several months but died of carcinomatosis a year later. 24-hour lymphadenogram shows a displaced node to the left of L3 with a highly suspicious marginal filling defect on the superior border (arrowed). FIG. 8B Fig. 8B--6-week lymphadenogram shows differential shrinkage of the suspicious lumbar node in response to radiotherapy, confirming the presence of a metastasis. TABLE THE LYMPHOGRAPHIC ABNORMALITIES OBSERVED WHEN METASTASES WERE PRESENT IN LUMBAR LYMPH NODES
Filling defects in nodes Failure of nodes to opacify Displacement of nodes Gross distortion of lymphatic anatomy Stasis in lymph vessels Opacification of collateral lymph vessels Lymphatico-venous connections "Pseudo-lymphoma" Differential shrinkage of involved nodes in response to radiotherapy Differential enlargement of involved nodes on follow-up lymphadenograms
Aeknowledgements.--We would like to thank Dr. J. S. Macdonald, Consultant Radiologist, Royal Marsden Hospital, Surrey, for allowing access to lymphograms performed in his department and Mr. T. W. Brandon of the produced the illustrations.
AVERETTE, H. E., HUDSON, R. C., VIAMONTE,M., PARKS,
Edward Arnold (Publishers) Ltd. have given permission for reproduction of Figures I, 2, 3, 6 and 9, which appear in The Lymphatics: Diseases, Lymphography and Surgery, by J. B. Kinmonth.
R. E. & FERGUSON, J. H. (1962). Lymphangioadenography in the study of female genital cancer. Cancer, 15, 769-775. COLLETTE, J. M. (1958). Envahissements ganglionaires inguino-ilio-pelviens par lymphographie. Acta ~adiologica, 49, 154-165. DOLAN, P. A. & HUGHES, P. R. (1964). Lymphography in
REFERENCES
THE D I A G N O S I S OF L U M B A R L Y M P H NODE METASTASES BY L Y M P H O G R A P H Y
FIG. 9A Fig. 9A--Mrs. L.W. Age 51. Carcinoma of cervix. This patient gave a one-year history of post-coital bleeding. Physical examination of the abdomen was unremarkable. Diagnosis was made by E.U.A. and biopsy and the patient treated with a Wertheim's hysterectomy. The state of the lumbar nodes was not adequately assessed at operation. Lymphography showed gross involvement of the lumbar nodes and the patient was treated with radiotherapy to the pelvis and abdomen. She remained well for eleven months before developing carcinomatosis. 24-hour lymphadenogram shows gross bilateral metastatic involvement of the lumbar nodes. Note displacement of lymphatic tissue beyond the tips of the transverse processes.
genital cancer. Surgery, Gynaecology and Obstetrics, 118, 1286-1290. EDWARDS, J. M. & KINMONTH, J. B. (1969). Lymphovenous shunts in man. British Medical Journal, 4, 579-581, FEIN, R. L. & TABER, D. O. (1969). Foot lymphography in the testis tumour patient: a review of 50 cases. Cancer, 24, 248-255. GERTEIS, W. (1970). Indications for different methods of treatment for carcinoma of the uterus based on lymphography. In Progress in Lymphology 11. Ed., Viamonte M. Thieme, Stuttgart. HRESHCYSrlYN, M. M. & SHEEHAN, F. R. (1964). Lymphangiography in advanced gynaecologic cancer. Obstetrics and Gynaecology, 24, 525-529. JACKSON, B. T. (1972). The Lumbar Lymphatics: A lymphographic study. M.S. Thesis. University of London Library. JACKSON, B. T. & KINMONTH, J. B. (1974a). The normal lymphographic appearances of the lumbar lymphatics.
Clinical Radiology. JACKsoN, B. T. & KINMONTH, J. B. (1974b). Lumbar lymphatic crossover. Clinical Radiology. KINMONTH, J. B. (1972). The Lymphatics: Diseases, Lymphography and Surgery. Arnold, London. KuIsK, H. (1971). Technique of L ymphography and Principles
201
FIGURE 9B Fig. 9B--One-month lymphadenogram shows considerable shrinkage of lymph nodes in response to radiotherapy. Note that lymphatic tissue is no longer displaced beyond the transverse processes. Fro. 9c Fig. 9c--lO-month lymphadenogram shows enlargement of nodes to the left of L3 indicating growth of metastases in this region (arrowed). The patient was clinically free of disease at the time of this radiograph.
oflnterpretation. St. Louis, Green. LECART, C. ~; LENFANT, P. (1971). Critical appraisal of lymphangiography in cancer of the female genital tract. Lymphology, 4, 100-108. MACDONALD, J. S. (1969). The value of lymphography to the radiotherapist. Clinical Radiology, 20, 447-452. MACDONALD, J. S. (1970). Lymphography in Malignant Disease of the Urinary Tract. Proceedings of the Royal Society of 3,[ediciue, 63, 1237. MACDONALD, J. S. & WALLACE, E. N. K. (1965). Lymphangiography in tumours of the kidney, bladder and testicle. British Journal of Radiology, 38, 93. McP~AK, C. J. & CONSTANTINmES, S. C. (1964). Lymphangiography in malignant melanoma. Cancer, 17, 1586. VIAMONTE, M., MYERS, M. B., SOTO, M., KENYON, N. M. & PARKS, R. E. (1962). Lymphography: Its role in detection and therapeutic evaluation of carcinoma and neoplastic conditions of the benitourinary tract. Journal of Urology, 87, 85. VUKSANOVIC, M., VIAMONTE, M. • MARTIN, J. E. (1966). The Place of Lymphangioadonography in the Diagnosis and during the treatment of Disease. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 96, 205.
THE DIAGNOSIS
OF LUMBAR LYMPH NODE BY LYMPHOGRAPHY
METASTASES
B. T. JACKSON and J. B. KINMONTH From the Department of Surgery, St. Thomas's Hospital Medical School, London, SE1 7EH An account is given of the various abnormal lymphographic appearances of the lumbar region when involved by metastatic carcinoma. It is suggested that lymphography should be performed more often in the management of patients with suspected malignant deposits in the lumbar region. IT is well documented that lymphography may aid in the diagnosis of metastatic spread of malignant tumours to regional lymph nodes, but most authors have been concerned with the use of lymphography in the diagnosis of inguinal or pelvic metastases, and have made few references to the lymphographic diagnosis of lumbar (paraaortic) node metastases (Collette, 1959; Averette et aL, 1962; Viamonte et al., 1962; Hreshcyshyn and Sheehan, 1964; Macdonald and Wallace, 1965; Gerteis, 1970). The diagnosis of secondary spread of malignant tumours to the lumbar lymph nodes is often difficult. Occasionally, enlarged lumbar nodes can be palpated; sometimes an intravenous pyelogram may show displacement of a ureter by enlarged nodes; sometimes an inferior venacavogram may show displacement or distortion of the cava. Usually, however, no nodes can be palpated, intravenous pyelography is normal and intravenous cavography is not performed. This paper gives an account of the varying lymphographic appearances of metastases in lumbar lymph nodes and demonstrates the value of lymphography in the diagnosis of secondary carcinoma in these nodes.
posterior, right oblique and left oblique projections were studied so as to allow suspicious nodes to be observed in more than one plane and unobscured by the vertebral column. Many of the lymphograms were normal and are reported in detail elsewhere (Jackson and Kinmonth, 1974 a & b). Lymphadenograms that appeared abnormal were compared with follow-up lymphadenograms and then correlated with the clinical history which was available in all cases. Further details of materials and methods may be found elsewhere (Jackson, 1972).
RESULTS Metastases in lumbar nodes were found to give rise to several different abnormal lymphographic appearances. Some of these abnormalities were observed in isolation, but more often they were present in combination. None of them was and, characteristic of metastatic spread from a particular primary tumour and, therefore, it was not possible to diagnose the site of an unknown primary tumour from the lymphographic appearances of the metastases. The Table lists the different lymphographic abnormalities that were observed. (A) FILLING DEFECTSIN NODES. This is the most MATERIALS AND METHODS common lymphographic abnormality. Filling A review was made of lymphograms performed defects usually appear as bites taken from the edge as part of the investigation of various primary of nodes causing an irregular outline (Fig. 1) but malignant turnouts at St. Thomas's Hospital and sometimes may be seen as a single central filling the Royal Marsden Hospital, Surrey, between the defect within the substance of the node. Central years 1963 and 1968. The 24-hour or 48-hour filling defects are particularly characteristic of lymphadenograms were studied with special secondary malignant melanoma (McPeak and reference to the appearances of the lumbar region, Constantinides, 1964) but melanoma metastases are which was defined as that area between the upper rare in the lumbar region. border of the first and the lower border of the (B) FAILURE OF NODES TO OPACIFY. - If a node fourth lumbar vertebrae. In all cases a standard is extensively replaced by tumour it may completely technique of lymphography had been used and the fail to opacify, and in the lumbar region this will radiographs had been taken in standard positions show as a filling defect in one of the chains of to prevent magnification errors. The antero- lumbar nodes. In 45 ~ of normal lymphograms, 195 -
196
CLINICAL RADIOLOGY
Mr. A.H. Age 73. Left hypernephroma. This patient presented with painless haematuria and a palpable mass in the left loin. I.V.P. confirmed a carcinoma of the kidney and nephro-ureterectomy was performed. No definiteevidence of lymph node involvement was seen at operation. Postoperative lymphography showed unequivocal lumbar node metastases and the patient was treated with local radiotherapy and systemic chemotherapy. He remained well for fourteen months before developing carcinomatosis. Lymphadenogram shows characteristic marginal filling defects in a node to the left of L3, 4 (arrowed).
FIG. 2 Mrs. A.W. Age 54. Carcinoma of left ovary. This patient presented with a pelvic mass. The diagnosis was made at laparotomy when a total hysterectomy and bilateral salpingooophorectomy was performed. At that time it was uncertain whether lymph nodes were involved. Post-operative lymphography showed lumbar node metastases confirmed by biopsy at a second laparotomy. Radiotherapy was given but the patient died eight months later. Lymphadenogram shows an abnormal filling defect in the left lumbar chain at the level of L3,4 (an'owed). Reactive hyperplasia of many nodes is also seen.
however, a discontinuous right lumbar chain is observed (Jackson & Kinmonth, 1974a) and great caution must be exercised before diagnosing metastases on the basis of a filling defect in the lower part of the right lumbar chain. A filling defect in the left lumbar chain, however, is always highly suspicious of metastases. Figure 2 shows such a tilling defect in the left lumbar chain which is highly suggestive of carcinomatous replacement. This interpretation was later confirmed at laparotomy. Gross replacement of lymph nodes by metastases
may prevent the filling of any lumbar lymph nodes despite the injection of adequate amounts of contrast medium. (C) DISPLACEMENT OF NODES. - Carcinomatous deposits may cause displacement of lymph nodes from their normal anatomical position. Figure 3 shows a displaced node of the left lumbar chain lying opposite the second lumbar vertebra in a patient with a seminoma of the left testis. Notice that the displacement is beyond the tips of the transverse processes and therefore almost certainly pathological (Jackson & Kinmonth, 1973a).
FIG. 1
THE D I A G N O S I S OF L U M B A R L Y M P H NODE METASTASES BY L Y M P H O G R A P H Y
FIG. 3 Mr. T.H. Age 48. Seminoma left testis. Left orchidectomy was performed two weeks after this patient presented with a hard swelling of the left testis. Physical examination showed no evidence of metastatic spread. Post-operative lymphography showed an unequivocal metastasis in the lumbar region, and the patient was treated with radiotherapy to the mediastinum and to the abdomen and pelvis. He has remained well for over two years. Lymphadenogram shows a lymph node of the left lumbar chain displaced laterally beyond the tips of the transverse processes. The node contains an abnormal marginal filling defect.
(D)
DISTORTED
LYMPHATIC
ANATOMY.
-
If
displacement of lymphatic tissue and filling defects in lymph nodes reach an extreme, the lymphographic appearance may be that of gross distortion of normal anatomy, as shown in Figure 4, from a patient with carcinoma of the ovary. (E)
STASIS IN
LYMPH
VESSELS.
--
Metastatic
deposits in lymph nodes often block lymph flow and thus cause stasis of contrast medium in the lymph vessels which may then be seen on the lyrnphadenogram. This appearance must be
197
FIG. 4 Miss E.H. Age 78. Carcinoma of left ovary. This patient presented with ascites. Laparotomy showed carcinoma of the left ovary with local and distant lymph node involvement. Total hysterectomy and bilateral salpingo-oophorectomy was performed. Post-operative lymphography confirmed gross lumbar node involvement and radiotherapy was given to the pelvis and abdomen. One year later the patient was well but was then lost to follow-up. Lymphadenogram shows gross distortion of lymphatic anatomy caused by filling defects, displacement of nodes, collateral vessels and lymph vessel stasis.
distinguished from extravasation. Figure 5 shows stasis of contrast medium in lymph vessels of the right lower lumbar chain in a patient who had a chorion-carcinoma of the right testis but no clinical evidence of lymph node involvement. (F) OPACIFICATION OF COLLATERAL LYMPH VESSELS. -- Obstruction to lymph flow by metastases may cause the opacification of collateral lymph vessels not normally seen by lymphography. This is well seen in Figure 6, which shows a collateral vessel passing from the left external iliac nodes to
198
CLINICAL R A D I O L O G Y
the upper lumbar nodes in a patient with a teratoma of the right testis. The isolated left lumbar node metastases are explained by crossover of tumour cells from right to left in the lumbar region (Jackson & Kinmonth, 1974b). (G) LYMPHATICO-VENOUS CONNECTIONS. -Obstruction to lymph flow by secondary deposits occasionally results in the passage of contrast medium into the veins through abnormal lymphatico-venous connections. These connections only occur under abnormal conditions such as in malignant disease or primary defects of the lymph system (Edwards & Kinmonth, 1969). Metastases in the lumbar lymph nodes may be associated with a lymphatico-portal vein connection causing the liver to become outlined by radio-opaque contrast (Fig. 6). This appearance is most commonly seen in association with a tumour of the testis. The 'hepatogram' is almost always caused by a lymphatico-portal venous connection (Kuisk, 1971) but occasionally is caused by direct opacification of hepatic lymphatics (Kinmonth, 1972). (H) THE APPEARANCE OF 'PSEUDo-LYMPHOMA'. Lymph nodes containing metastases may occasionally appear as enlarged nodes with a coarse reticular pattern, similar to that seen in malignant lymphoma. This appearance is known as 'pseudo-lymphoma' (Fig. 7). (I) DIFFERENTIAL SHRINKAGE OF INVOLVED NODES IN RESPONSE TO RADIOTHERAPY. - T h e 2 4 - h o u r
lymphadenogram may show nodes that are suggestive but not diagnostic of metastatic carcinoma. Figure 8A shows a node to the left of L3 which is displaced from the rest of the left node chain but which is not lying beyond the tips of the transverse processes. The node also shows a suspicious filling defect but the appearance is not pathognomonic of metastatic involvement. Nevertheless, the patient was treated with radiotherapy and Figure 8B shows the considerable shrinkage that occurred during the six weeks following treatment. The shrinkage confirms the diagnosis of a metastasis. Normal lymph nodes shrink in size when irradiated and it is therefore important to see differential shrinkage before making a definite diagnosis of metastases. That is, the involved node must shrink to a greater extent than the surrounding normal nodes. (J) DIFFERENTIAL ENLARGEMENT OF INVOLVED NODES
ON
FOLLOW-UP
LYMPHADENOGRAMS.
-
Metastases may also be diagnosed by differential enlargement in the absence of radiotherapy.
FIG. 5 Mr. H.L. Age 22. Chorion-carcinoma of the right testis. This patient had no clinical evidence of lumbar node involvement. Lymphography showed deposits of tumour in both
left and right lumbar chains. Treatment was by radiotherapy and chemotherapy but the patient died six months later. Lymphadenogram, left oblique projection, shows stasis of contrast medium within lymph vessels of the right lower lumbar chain.
Figure 9A shows multiple lumbar metastases in a patient with a carcinoma of the cervix. Figure 9B shows considerable diminution in the size of the involved lumbar nodes one month after radiotherapy. Ten months later a routine follow-up lymphadenogram shows enlargement of nodes in the upper lumbar chain indicating the development of metastases in this region (Fig. 9C). Soon after this radiograph was taken the patient developed
THE DIAGNOSIS OF LUMBAR LYMPH NODE METASTASES BY LYMPHOGRAPHY
FIG. 6 Mr. D.M. Age 21. Teratoma right testis. Three months after the onset of swelling of the right testis this patient had an orchidectomy. E.U.A. at this time suggested an epigastric mass. Post-operative lymphography showed unequivocal metastases in the left lumbar nodes. Chemotherapy was given as well as radiotherapy but the patient died four months later. Lymphadenogram shows a long collateral vessel (arrowed) bypassing a mass of involved nodes in the left lumbar chain. Crossover of malignant cells must have occurred. Contrast medium is seen in the liver (arrowed) suggesting the presence of a lymphatico-portal venous connection.
malignant cachexia a n d died. Post m o r t e m examination confirmed l u m b a r n o d e metastases. DISCUSSION The use of l y m p h o g r a p h y as a n aid i n the diagnosis a n d m a n a g e m e n t of metastatic c a r c i n o m a is less well established t h a n its use in patients with malignant l y m p h o m a , possibly due to inability of
199
F~G. 7 Mr. R.H. Age 47. Seminoma left testis. Orchidectomy was performed one month after the onset of swelling of the testis. There was no clinical evidence of metastatic spread. Lymphography showed lumbar and pelvic metastases and the patient was treated with radiotherapy. He died 7 months after presentation. Lymphadenogram shows considerable enlargement of nodes of the left chain, which are clearly abnormal and present a pseudo-lymphomatous appearance.
the technique to identify small metastases of only a few millimeters in diameter. False negatives are k n o w n to occur. Vuksanovic et al. (1966) report 3 false negatives i n 27 cases of c a r c i n o m a of the cervix, a n d Fein a n d T a b o r (1969) report 4 false negatives i n 50 cases of n e o p l a s m of the testis. W h e n one is experienced i n the technique, however, this source of error is n o t large a n d M a c d o n a l d (1970) claims that it is possible to give a definite
200
CLINICAL RADIOLOGY
diagnosis when metastases are less than 5 millimeters across and o f a size that would be scarcely visible on a chest radiograph. The key to successful interpretation is to ensure regular follow-up lymphadenograms on which doubtful metastases m a y be seen to enlarge. Regular follow-up lymphadenograms are essential whenever lymphography is performed in cases o f malignant disease, for information m a y be obtained a b o u t the state o f the nodes up to a year after the initial injection o f contrast medium. False positive inaccuracies m a y also occur in lymphographic interpretation o f malignant disease (Dolan & Hughes, 1964; Lecart & Lenfant, 1971). The likelihood o f such errors depends to a great extent on the experience o f the radiologist and on a detailed knowledge o f the range o f normal appearances. In the lumbar region, for example, the normal appearances o f the 'right lower lumbar g a p ' and the 'left upper l u m b a r clump' m a y be wrongly t h o u g h t to be caused by metastatic deposits (Jackson & Kinmonth, 1974a). I n doubtful cases, follow-up l y m p h a d e n o g r a p h y will almost always distinguish between malignant disease and non-malignant artefacts. L y m p h o g r a p h y can give extremely useful information about the presence o f metastases in the lumbar region. There is often no clinical suggestion of lumbar n o d e involvement and l y m p h o g r a p h y m a y demonstrate otherwise occult disease. It is suggested that this investigation should be performed more often in the investigation o f patients with malignant turnouts who are suspected o f having lumbar lymphatic involvement. N o t only will l y m p h o g r a p h y help in diagnosis but it m a y also define the extent o f the disease, help in devising a rational plan o f management in assessing the effect o f treatment, give early warning o f reactivation o f disease and sometimes m a y help the surgeon to perform an adequate excisional operation (Macdonald, 1969).
N; ¢
7
FIG. 8A Fig. 8A--Mrs. L.H. Age 57. Carcinoma of the cervix. This patient presented with an eight-month history of postmenopausal bleeding. Physical examhaation of the abdomen was unremarkable. The diagnosis was made by E.U.A. and biopsy and the patient treated with 137 Caesium insertion. Lymphography showed unequivocal pelvic node deposits and a suspicious lumbar node. Radiotherapy was given to the pelvis and abdomen. The patient was well for several months but died of carcinomatosis a year later. 24-hour lymphadenogram shows a displaced node to the left of L3 with a highly suspicious marginal filling defect on the superior border (arrowed). FIG. 8B Fig. 8B--6-week lymphadenogram shows differential shrinkage of the suspicious lumbar node in response to radiotherapy, confirming the presence of a metastasis. TABLE THE LYMPHOGRAPHIC ABNORMALITIES OBSERVED WHEN METASTASES WERE PRESENT IN LUMBAR LYMPH NODES
Filling defects in nodes Failure of nodes to opacify Displacement of nodes Gross distortion of lymphatic anatomy Stasis in lymph vessels Opacification of collateral lymph vessels Lymphatico-venous connections "Pseudo-lymphoma" Differential shrinkage of involved nodes in response to radiotherapy Differential enlargement of involved nodes on follow-up lymphadenograms
Aeknowledgements.--We would like to thank Dr. J. S. Macdonald, Consultant Radiologist, Royal Marsden Hospital, Surrey, for allowing access to lymphograms performed in his department and Mr. T. W. Brandon of the produced the illustrations.
AVERETTE, H. E., HUDSON, R. C., VIAMONTE,M., PARKS,
Edward Arnold (Publishers) Ltd. have given permission for reproduction of Figures I, 2, 3, 6 and 9, which appear in The Lymphatics: Diseases, Lymphography and Surgery, by J. B. Kinmonth.
R. E. & FERGUSON, J. H. (1962). Lymphangioadenography in the study of female genital cancer. Cancer, 15, 769-775. COLLETTE, J. M. (1958). Envahissements ganglionaires inguino-ilio-pelviens par lymphographie. Acta ~adiologica, 49, 154-165. DOLAN, P. A. & HUGHES, P. R. (1964). Lymphography in
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THE D I A G N O S I S OF L U M B A R L Y M P H NODE METASTASES BY L Y M P H O G R A P H Y
FIG. 9A Fig. 9A--Mrs. L.W. Age 51. Carcinoma of cervix. This patient gave a one-year history of post-coital bleeding. Physical examination of the abdomen was unremarkable. Diagnosis was made by E.U.A. and biopsy and the patient treated with a Wertheim's hysterectomy. The state of the lumbar nodes was not adequately assessed at operation. Lymphography showed gross involvement of the lumbar nodes and the patient was treated with radiotherapy to the pelvis and abdomen. She remained well for eleven months before developing carcinomatosis. 24-hour lymphadenogram shows gross bilateral metastatic involvement of the lumbar nodes. Note displacement of lymphatic tissue beyond the tips of the transverse processes.
genital cancer. Surgery, Gynaecology and Obstetrics, 118, 1286-1290. EDWARDS, J. M. & KINMONTH, J. B. (1969). Lymphovenous shunts in man. British Medical Journal, 4, 579-581, FEIN, R. L. & TABER, D. O. (1969). Foot lymphography in the testis tumour patient: a review of 50 cases. Cancer, 24, 248-255. GERTEIS, W. (1970). Indications for different methods of treatment for carcinoma of the uterus based on lymphography. In Progress in Lymphology 11. Ed., Viamonte M. Thieme, Stuttgart. HRESHCYSrlYN, M. M. & SHEEHAN, F. R. (1964). Lymphangiography in advanced gynaecologic cancer. Obstetrics and Gynaecology, 24, 525-529. JACKSON, B. T. (1972). The Lumbar Lymphatics: A lymphographic study. M.S. Thesis. University of London Library. JACKSON, B. T. & KINMONTH, J. B. (1974a). The normal lymphographic appearances of the lumbar lymphatics.
Clinical Radiology. JACKsoN, B. T. & KINMONTH, J. B. (1974b). Lumbar lymphatic crossover. Clinical Radiology. KINMONTH, J. B. (1972). The Lymphatics: Diseases, Lymphography and Surgery. Arnold, London. KuIsK, H. (1971). Technique of L ymphography and Principles
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FIGURE 9B Fig. 9B--One-month lymphadenogram shows considerable shrinkage of lymph nodes in response to radiotherapy. Note that lymphatic tissue is no longer displaced beyond the transverse processes. Fro. 9c Fig. 9c--lO-month lymphadenogram shows enlargement of nodes to the left of L3 indicating growth of metastases in this region (arrowed). The patient was clinically free of disease at the time of this radiograph.
oflnterpretation. St. Louis, Green. LECART, C. ~; LENFANT, P. (1971). Critical appraisal of lymphangiography in cancer of the female genital tract. Lymphology, 4, 100-108. MACDONALD, J. S. (1969). The value of lymphography to the radiotherapist. Clinical Radiology, 20, 447-452. MACDONALD, J. S. (1970). Lymphography in Malignant Disease of the Urinary Tract. Proceedings of the Royal Society of 3,[ediciue, 63, 1237. MACDONALD, J. S. & WALLACE, E. N. K. (1965). Lymphangiography in tumours of the kidney, bladder and testicle. British Journal of Radiology, 38, 93. McP~AK, C. J. & CONSTANTINmES, S. C. (1964). Lymphangiography in malignant melanoma. Cancer, 17, 1586. VIAMONTE, M., MYERS, M. B., SOTO, M., KENYON, N. M. & PARKS, R. E. (1962). Lymphography: Its role in detection and therapeutic evaluation of carcinoma and neoplastic conditions of the benitourinary tract. Journal of Urology, 87, 85. VUKSANOVIC, M., VIAMONTE, M. • MARTIN, J. E. (1966). The Place of Lymphangioadonography in the Diagnosis and during the treatment of Disease. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 96, 205.