The Use of Lymphography as a Diagnostic Method

Under normal circumstances, the roentgen visualization of the deep organs and soft-tissue structure in the body is dependent on the contrast between calcium, fat, soft tissue, and air. If an organ or soft-tissue structure cannot be adequately outlined by virtue of these naturally occurring substances, an opaque medium must be introduced. Any method that permits visualization of vessels which could hitherto not be demonstrated because of their inaccessibility is bound to increase the diagnostic potentialities. Demonstration of the lymphatic system by the injection of radiopaque material is such a procedure. The lymphatic system was visualized roentgenographically as early as 1930 by the Japanese investigator, Funaoka (5), who injected mercury, lead, and iodine salts into the lymph vessels. Carvalho et al. (2) reported on the radiographic demonstration of lymphatics in 1931 and again in 1934 with Thorotrast as the contrast medium. Other opaque compounds were injected into the lymph nodes or into the region of the lymphatics by Teneff and Stoppani (15, 1932), Menville and Ané (11, 1932), Shdanow (14, 1932), and Zolotukhin (18, 1934). Bennett and Shivas (1, 1954) used Angiopac, which is a micronized aqueous suspension of ethyliodostearate, for this purpose. They observed selective necrosis of lymphoid tissue but this appeared not to be permanent. The earlier investigators worked either with animals or cadavers, and the procedure in their hands did not become a practical clinical method. In 1952, Kinmonth (9) undertook the application of lymphography to the investigation of diseases of the human lymphatic system. Since that time, interest in the roentgen study of the lymphatics has increased, and reports have been published by Collette (3), Fischer (4), ]acobsson (7), Tjernberg (16), and others (13). A symposium on the subject was held at the Ninth International Congress of Radiology in Munich, 1959, at which several investigators (8, 10, 12, 16, 17) from various countries reported their experiences. This method of examination has been used in the study of the normal anatomy of the lymphatics, in the investigation of edema, and for outlining pathological changes in the lymph nodes. Lymphography can be performed in two ways. In direct lymphography the contrast medium is injected directly into the nodes (lymphadenography) or into the lymphatic vessels (lymphangiography). In the indirect method the injection is made subcutaneously or intramuscularly into tissue adjacent to lymphatic structures. Initially we used lymphadenography, but our success was limited, and our later investigations have been carried out by lymphangiography. This latter procedure has been employed during the past year in an attempt to demonstrate pathological lymph-node involvement. As our chief interest was directed toward neoplastic and metastatic lymph-node disease in the pelvis and the retroperitoneal space, the injections were confined to the lower extremities.