Disorders of the Lymph System

Lymphoceles

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Lymphoceles

Definition:

The Lymphocyst (Lymphocele) was first described by Mori in 1955 1 . He analysed a large series of radical hysterectomy patients. He called these collections “ Lymphocysts “, a term that was used until the 1970s.

A lymphocele is a lymph-filled space without a distinct epithelial lining 2 . Lymphoceles are commonly seen following surgical procedures in which large amounts of lymphatic tissue are transacted. Once injured, a lymphatic vessel is quite susceptible to continued leakage. Lymph contains a low concentration of clotting factors and has no platelets. Lymphatic vessels are devoid of smooth muscle and therefore lack any constrictive properties 3 .

A Lymphocele following a blunt injury to thigh is an extremely rare entity. Only three cases have been reported in literature. The first case presented after 12 hrs of application of lower limb tourniquet for knee arthroscopy 4 . Germon published a case following pelvic fracture with crush injury which presented with swelling after a year 5 . Chaloner's patient had lymphocele following blunt war injury. His patient had received a blow from a rifle butt and presented with swelling in the thigh after about 10 weeks of trauma 6 .

The diagnosis of lymphocele is straightforward once the differential has been considered. A computed tomography (CT) scan or an ultrasound examination of the area of interest will confirm the presence and location of fluid collection.

Lymphoceles generally appear cystic but internal echoes and septations may present. Any such collections should be aspirated under radiographic guidance. The fluid should be checked for creatinine, protein, cholesterol, Triglycerides, cell count, Gram stain and culture.

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Pelvic lymphocele following radical para-aortic and pelvic lymphadenectomy for cervical carcinoma: incidence rate and percutaneous management

M Conte, PB Panici, L Guariglia, G Scambia, S Greggi, and S Mancuso

Thirty-six women, treated with radical hysterectomy (Piver types III-IV) plus systematic para-aortic and pelvic lymphadenectomy for cervical carcinoma, underwent serial postoperative ultrasound examinations to determine the incidence of lymphocele and the therapeutic efficacy of percutaneous catheter drainage. Pelvic lymphoceles, ranging in volume from 46-300 mL, occurred in eight patients (22.2%) between the 12-24th postoperative day. Percutaneous catheter drainage, inserted under local anesthesia, was used for a mean time of 14.5 days (range 4-32), resulting in a mean daily drainage of 92.2 mL and a mean total volume of 1727.5 mL per patient. Catheter drainage allowed complete clinical and sonographic remission in all cases, and only one asymptomatic recurrence was observed at 3-month and 6-month follow-up. Ultrasound-guided percutaneous catheter drainage has proved to be a well-tolerated, safe, and effective technique in the management of lymphocele that obviates the need for more invasive surgical procedures.

http://acogjnl.highwire.org/cgi/content/abstract/76/2/268

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Rakhtawane E, Chedid G, Benismaili M, Khoury R, Le Van An J.C.

Clinical History and Imaging

The patient underwent an axillary lymph node dissection for lymph node metastases. Pathology revealed carcinoma but no breast tumor was found. 4 months later a cystic mass was felt.
A mammography and MRI was performed to search for a breast tumor, but showed a large cystic mass.
A control ultrasound was performed 3 months later.

Discussion

Lymphocele is a lymphatic collection in the detachment spaces created by the ablation of lymphatic tissue from the drainage surface of a malignant tumour. It constitutes the most important complication of lymphadenectomy. The formation of this lymphocele is often in connection with the secondary appearance of a chronic lymphoedema.
The incidence has been reported to range from 5% to 35% according to Salmon, and 12% according to Salvat.
Physical examination in seated or upright position is necessary to reveal the swelling, which may remain unsuspected. To detect a small lymphocele, ultrasound is useful within one week after surgery. According to Salmon there is a positive correlation between the incidence of the lymphocele and the quantity of drained fluid, the duration of drainage and the extent of the lymph nodes dissection area, the age of the patient, obesity, arterial hypertension and breastvolume. The impact of an anticoagulant treatment by heparine has been reported. According to Flew the volume and duration of the lymphocele are decreased when the patient has no early physiotherapeutic shoulder treatment after surgery. The external postoperative radiotherapy and the tumor staging do not affect the formation of lymphocele. No treatment is recommended when the lymphoceles are quiet or less than 2 cm . For those larger or which are under tension, percutaneous aspiration, or percutaneous drainage should be performed . Spontaneous regression may be up to 15% within several months. Preventive treatment is more effective, Aitken suggested a reduction of the surgical detachment spaces as a real solution to decrease seriously the incidence.

http://www.eurorad.org/case.cfm?uid=2168

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1 From the Departments of Diagnostic Radiology (J.K.K., Y.Y.J., Y.H.K., Y.C.K., H.K.K.) and Obstetrics and Gynecology (H.S.C.), Chonnam University Medical School, 8 Hakdong, Dongku, Kwangju, 501-757 South Korea. Received May 18, 1998; revision requested July 14; revision received September 9; accepted February 12, 1999. Address reprint requests to J.K.K. (e-mail: kjkrad@chonnam.chonnam.ac.kr).

Abstract

PURPOSE: To evaluate the effectiveness of simple percutaneous catheter drainage in the treatment of postoperative lymphocele.

MATERIALS AND METHODS: Percutaneous catheter drainage of 23 symptomatic lymphoceles was performed with ultrasonographic (US) guidance in 20 patients who had undergone radical pelvic lymphadenectomy because of uterine malignancy. All lymphoceles were diagnosed on the basis of biochemical and cytologic findings in aspirated fluid. The drainage catheter was removed when the amount of daily drainage was less than 10 mL per day and when the lymphocele was seen at imaging to have resolved. Follow-up US was performed at 1, 3, and 6 months after catheter removal. The results were classified as success, partial success, or failure.

RESULTS: Lymphoceles ranged in size from 5 x 4 x 3 to 25 x 10 x 10 cm. Mean total drainage volume was 2,012 mL (range, 300–17,240 mL). Fluid from 10 lymphoceles (43%) was positive at Gram staining and bacteriologic culture; fluid from 13 (57%) was sterile. Duration of catheter drainage was 3–49 days (mean, 22 days). Twenty (87%) lymphoceles resolved completely; three (13%) recurred. Two recurrent lymphoceles were again treated with percutaneous catheter drainage; the third resolved spontaneously 5 months after catheter removal. Successful treatment was ultimately achieved in all patients. Postprocedural complications occurred in four patients. One had a secondary infection of lymphocele; one, catheter dislodgment; and two, skin infection at the site of catheter insertion.

CONCLUSION: Percutaneous catheter drainage is safe and effective for treatment of symptomatic postoperative lymphoceles.

Index terms: Cyst, percutaneous drainage, 992.1263 • Lymphatic system, interventional procedure, 992.123, 992.1263 • Lymphocele, 992.842

Complete article:

http://radiology.rsnajnls.org/cgi/content/full/212/2/390

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Prevention of postoperative lymphocele after breast amputation

Salmon RJ, Cody HS, Vedrenne JB, Asselain B, Durand JC, Pilleron JP.

Closed suction drainage is widely used after modified radical mastectomy to prevent accumulation of serum or lymph and to promote adherence of the skin flaps to the chest wall. However, between 5 and 35% of the patients develop seroma, which may prolong their stay in hospital and require more frequent post-operative outpatient visits. The prospective study reported demonstrate a significant correlation between the incidence of post-operative seromas, the duration of suction drainage and the amounts of fluid drained. The incidence of seroma also correlated significantly with the patient's age, the size of the breast removed, the presence of arterial hypertension and the post-operative use of heparin. Pre-operative radiotherapy and the TNM type of the tumour had no effect on the duration and volume of drainage nor on the occurrence of seromas. A drainage of short duration and a short stay in hospital are advocated for most mastectomy patients. Delayed mobilization of the shoulder should decrease the volume of accumulated fluid and the incidence of seromas.

PMID: 3155841 [PubMed - indexed for MEDLINE]

http://www.eurorad.org/tools/pubmed_biblio.cfm?uid=3155841

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Lymphedema and Lymphoceles

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