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PAST, PRESENT AND FUTURE OF PAST, PRESENT AND FUTURE OF LYMPHANGIOGRAPHYLYMPHANGIOGRAPHY
ALI AKBAR AMERI-MDALI AKBAR AMERI-MDJALAL JALAL SHOKOUHI-MDJALAL JALAL SHOKOUHI-MD
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• 5th century B.CHippocrates mentioned lymphatic system
• 1563 Eustachi described thoracic duct in horses (Vena-alba thoracis)
• Rud beck 1630-1702: discovered vessels in the liver containing no blood (clear fluid) with valve and drains into thoracic duct
• Thomas Bartholin mentioned: all body have this vessels
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Introduction:Introduction:
Lymph edema Primary
Secondary
Lymphoscintigraphy:Direct lymphography:High resolution MR lymphography:Diagnosis of lymph-edema is important but today no imaging procedure has fulfilled these criteria.
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Imaging:Imaging:X-ray Lymphangiography (patent blue, Lipiodel
ultra-fluid) For tumor staging (testis, lymphoma) and
lymphoedema, post traumatic, lymph obstruction, chilothorax
Lymphocele in post surgery and congenital lymph anomalies.
Nowadays staging is possible by U.S, X-ray CT, MRI
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High resolution MR lymphangiography:High resolution MR lymphangiography:contrast administration:contrast administration:1. Gadodiamide ,Extra cellular, Water soluble
paramagnetic contrast agent Concentration of GD (0.5 mmol) – 0.1 mmol
per/ kg of body weight equivalent to 0.2 ml/ kg Excluding patients with: Renal insufficiency
allergy to GD2. Needle 24 gauge3. 2ML mepivacaine hydrochloride 1%
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Micro-magnetic resonance Lymphangiography with GD-labeled dendrimer nanoparticle T1w 3D, fast spoiled GRE T2, T1 w 3D fast imaging employing steady-state (3D-FIESTA - C)
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Lymphoscintigraphy is primary imaging Lymphoscintigraphy is primary imaging technique but:technique but:Ionizing radiationIonizing radiationPoor spatial and temporal resolutionPoor spatial and temporal resolutionLimited value for accurate assessment of Limited value for accurate assessment of
lymphatic anatomy and functionlymphatic anatomy and function
Direct lymphography:Direct lymphography:
Provide highest accumulation of contrast agent.Provide highest accumulation of contrast agent.Long time examination- radiation-pulmonary embolism-Long time examination- radiation-pulmonary embolism-infectioninfection
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Injection method:
All divided to (10 portions)4 portions injected cutaneously to dorsal aspect of
each foot at four inter digital webs.One portion is injected medial to both first
proximal phalangesMax: 1.8 ml per portion with massage for 60
seconds (pain)
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MR examinations:MR examinations:1. Foot and lower leg (dedicated peripheral surface
coil)2. Upper leg and knee3. Pelvis and proximal upper leg (phased-array body
coil)4. Heavily T2W 3D turbo spin echo (TR/TE
2000/694) + MIP
Strongest enhancement available at 45 to 55 minutes for inguinal and external iliac 35 minutes for lymphatic pathways (do not forget massage)
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Complementary for MR-Lymphangiography:
1. CT2. PET-CT (c-choline pet) for prostate is more accurate
than MRI
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Water imaging:
• STIR• Myelogram can show lymphatic channels using
no dye
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20Ly
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Benign lymph node in prostate CA (CT)Benign lymph node in prostate CA (CT)
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Right benign node, left malignant node bladder CA Right benign node, left malignant node bladder CA (shape analysis)(shape analysis)
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Ferumoxtran: enhances (darkness)right side benign node in Ferumoxtran: enhances (darkness)right side benign node in bladder CA (MRI T2* + Ferumoxtran), left side is malignant bladder CA (MRI T2* + Ferumoxtran), left side is malignant (Signal analysis)(Signal analysis)
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Malignant nodes in 3D MR by Ferumoxtran-10 Malignant nodes in 3D MR by Ferumoxtran-10 prostate CAprostate CA
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Lecture notes for new wayLecture notes for new way
• Interstitial MR-Lymphangiography for detection of sentinel lymph node
• To assess morphology of the pre- and post-operatively cases for microsurgery reconstruction for the lumphatic vessels and stenting.
• Validation study of MR-Lymphangiography using SPIO (super para magnetic nanoparticle) contrast in bladder cancer, GU cancer and prostate CA
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Thank you for your Thank you for your attentionattention