1. PAST, PRESENT AND FUTURE OF LYMPHANGIOGRAPHY ALI AKBAR AMERI-MD JALAL JALAL SHOKOUHI-MD 1

2. 5 th century B.C Hippocrates 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 2

3. 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. 3

4. 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 4

5. High resolution MR lymphangiography: 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 GD 2.Needle 24 gauge 3.2ML mepivacaine hydrochloride 1% 5

6. 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) 6

7. Lymphoscintigraphy is primary imaging technique but: Ionizing radiation Poor spatial and temporal resolution Limited value for accurate assessment of lymphatic anatomy and function Direct lymphography: Provide highest accumulation of contrast agent. Long time examination- radiation-pulmonary embolism-infection 7

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12. 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 phalanges Max: 1.8 ml per portion with massage for 60 seconds (pain) 12

13. MR examinations: 1.Foot and lower leg (dedicated peripheral surface coil) 2.Upper leg and knee 3.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) 13

14. Complementary for MR-Lymphangiography: 1.CT 2.PET-CT (c-choline pet) for prostate is more accurate than MRI 14

15. Water imaging: STIR Myelogram can show lymphatic channels using no dye 15

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20. 20 Lymph duct. stenting

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22. Benign lymph node in prostate CA (CT) 22

23. Right benign node, left malignant node bladder CA (shape analysis) 23

24. Ferumoxtran: enhances (darkness)right side benign node in bladder CA (MRI T2* + Ferumoxtran), left side is malignant (Signal analysis) 24

25. Malignant nodes in 3D MR by Ferumoxtran-10 prostate CA 25

26. Lecture 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 26

27. Thank you for your attention