Lymphangiography, Cavography, and Urography

During the past few years, interest has been increasing in lymphangiography as a method of demonstrating abnormalities in lymph nodes and lymphatic channels (8, 10, 13, 14). Oncologists have exhibited a special enthusiasm for this new procedure since it affords a graphic representation of the site and extent of pelvic and abdominal cancer. Prior to the application of lymphangiography, the presence of retroperitoneal masses not detectable on physical examination was inferred from obliteration of the psoas shadows or delineation of a soft-tissue mass on the plain films of the abdomen; the secondary changes produced in the gastrointestinal tract during the course of a barium meal; displacement of either kidney or ureter during intravenous urography; the use of retroperitoneal air insufflation (2, 6); and, more recently, the displacement of the cava as shown by inferior vena cavography (5). The ease with which most of the above procedures can be performed enhances their appeal, particularly when compared with the technical difficulties involved in lymphangiography. The present study was undertaken in an attempt to evaluate and compare the accuracy of intravenous urography (IVU), inferior vena cavography (IVC), and lymphangiography in the diagnosis of retroperitoneal cancer. Methods Lymphangiography (modified after Kinmonth et al., 7): The prelymphangiographic measures include: (a) surgical preparation and pH isohex scrub to both feet and legs; (b) Seconal, 100 mg., intramuscularly one hour prior to the procedure. One-half a cubic centimeter of equal parts of Evans blue and procaine hydrochloride is injected intradermally into the web space between the first and second toes bilaterally. Approximately fifteen minutes later a cut-down is performed on the dorsum of each foot over the first metatarsal. A lymphatic channel is isolated and cannulated with a 30-gauge needle attached to a No. 10 polyethylene catheter that has been previously fitted with a 10-c.c. syringe containing warmed Ethiodol. The needle is secured by means of a single ligature. Sterile adhesive tape is used to fasten the catheter to the patient's skin so that movement will not dislodge the needle. Ten cubic centimeters of Ethiodol are injected over a period of approximately forty-five minutes by means of a constant injector. After 5 c.c. have been introduced, a radiograph is obtained to determine the level of the contrast and to exclude the presence of lymphatic obstruction. In addition, fluoroscopic monitoring is at times employed. If any of the criteria of lymphatic obstruction are noted, the injection is discontinued, since pulmonary Ethiodol embolization is a frequent complication in this group of patients (1). The examination is carried out in the radiology department.