Download Hodgkin`s lymphomas

1
LYMPHANGIOGRAMS
RT 255
(rev 2010)
Lymphography & Lymphangiogram
Disease Of The Lymphatic System
Lymphatic System:
Green-superficial
Black- deep
radiographic investigation and
demonstration of the lymphatic system
2
•Lymph nodes are home to lymphocytes which
help fight infections - They can become swollen if
an infection is present
• http://www.youtube.com/watch?v
=qEIV6c61kx4&feature=related
3
Lymphatic system:
Considered to be part of the
circulatory system
2 Parts of Circulatory System:
Blood (Arteries/ Capillaries/ Veins)
& Lymphatics
• Lymph filters bacteria, carbon particles
and malignant cells
• like which other vessels that the
direction of flow goes towards the
heart?
4
Lymphatic System
5
6
LYMPHOMAS : signs and symptoms
Painless lump or swollen
Common Lymph Nodes:
Adenoids
Spleen
Appendix
Bone marrow
Thymus
Tonsils
gland - enlarged lymph
nodes
• itching, skin rash
• Drenching night sweats
•Fever (100º) , fatigue
•Unexplained weight loss
(10%)
•Coughing or
breathlessness
•Nausea, vomiting
7
LYMPHOMAS : signs and symptoms
• Check for metastasis
• Edema in limbs
• Obstruction
• Infections
• Rule out cancer
•Looking for LYMPHOMA
•Look for parasitic diseases
•Find the cause for any unusual
swelling in an extremity
(obstruction)
8
LYMPHOMAS
risk factors
•
•
•
•
Unknown causes
Reduced/suppressed immune function
as a result of organ transplantation
HIV/AIDs pts at higher risk for NHL (50100x)
• increased risk of exposure to infectious
agents
• Occupational exposure to herbicides
and other chemicals.
9
History of
Hodgkins lymphoma
• lymphomas are closely related to some
forms of leukemia
2 catagories
•
Non- Hodgkins lymphomas (NHL)
•
& Hodgkin’s disease
10
LYMPHOMAS - 2 types HD, NHL
• which together are
called lymphomas are types of cancer.
Cancer is not one
condition but a
word applied to
many different
diseases, which
have diverse
causes and a wide
range of
treatments.
• Hodgkin's
disease (HD)
• Non Hodgkin's
lymphomas
(NHL) • There are about
20 different types
of non Hodgkins
lymphoma.
11
Signs and symptoms
• The first sign of this cancer is often an enlarged
lymph node which appears without a known
cause
• The disease can spread to adjacent lymph
nodes and later may spread outside the lymph
nodes to the lungs, liver, or bone marrow.
• Main types of Lymphomas:
• HD - spreads in a predicable way to each lymph
group
• NHL - are found in lymph nodes or lymphatic
organs - the cause is not known
• Mutations in certain genes
12
Chest image shows contrast
in the the largest lymph
vessel in the body – the
Throacic duct
Chest CT of a patient with
non-Hodgkin's lymphoma (NHL)
demonstrating a necrotic lymph
node in the cardiophrenic angle.
13
Lymphoma
• Malignancy of lymphatic system
• Either Hodgkin's or Non-Hodgkin's
• Non-Hodgkin's
• Originate in parenchymal organs
• 60 years of age (median)
• Hodgkin's
• 90% start in lymph nodes
• 15-40 years
• 2nd peak: mid to late 50’s
• Can be imaged using x-ray, CT, MRI, PET, US and NM.
• Modality of choice depends on location.
• VERY rarely is lymphangiograms used to diagnosis this disease
anymore
14
Statistics
• New cases in 2008 : 73,740
• NHL 66,120
• Hodgkin's 8,220
• 39,850 males : 34.490 females
• 5 year survival rate (1996-2004)
• NHL 65%
• Hodgkin's 86%
61,000 new cases in 2002
of Non- Hodgkin’s lymphomas
(NHL) & Hodgkin’s disease
www.lls.org
15
The lymphatic system &
lymphomas
The lymphatic system is part of the body's
natural defense against infection. It consists
of a wide network of nodes or glands, which
are found all around the body, and are linked
by tiny vessels (or lymphatics).
• A clear fluid called lymph circulates around
the body and is drained, via the lymphatics,
into the bloodstream. Lymph contains white
blood cells known as lymphocytes. They play
a part in protecting the body from infection. As
the lymph circulates through the lymphatics it
is interrupted by the lymph nodes which
provide the opportunity to sieve the lymph
and attack invaders.
16
• The only way to tell the difference between
Hodgkins and non Hodgkins lymphomas is when
the cells are looked at under the microscope.
In most cases of Hodgkins disease,
• a particular cell known as the Reed-Sternberg
cell is found in the biopsies.
• This cell is not usually found in other
lymphomas, therefore they are called non
Hodgkins lymphoma.
• This may not seem a very big difference, but it is
important because the treatment for Hodgkins
and non Hodgkins lymphomas can be very
different.
17
• Hodgkin's lymphoma is a malignancy
(cancer) of lymph tissue found in the
lymph nodes, spleen, liver, and bone
marrow.
• A form of malignant lymphoma that is
pathologically distinct from other
lymphoid diseases
18
Hodgkin's disease
• Hodgkin's disease was first identified by Dr
Thomas Hodgkin in 1832.
• It is characterized by particular cells seen under
a micorscope- when a biopsy of an affected
lymph node, or gland, is studied.
• The incidence of HD peaks at 25 = seen in the
15 – 30 age group and at 55 (all ages can)
• more men are affected than women.
• Nowadays, Hodgkin's disease can be very
successfully treated and many people are
completely cured.
19
History of
Hodgkins lymphoma
• Cancers that involve the lymph nodes
• Lymphoma – can be applied to entire
spectrum of malignant diseases
• Comprise approx 3% -4% of all
malignant diseases in humans
The cause is not known
The incidence is 2 in 10,000
people
20
HODGKINS Who get’s it?
• Age: Hodgkin's Disease most often occurs in people 15 to 34 years old
and in people over 55 years old.
• Family History of Hodgkin's Disease: Having a brother or sister with
Hodgkin's Disease indicates that you may be at higher risk because of
genetic factors.
• Viruses: People who have had an infection from the Epstein-Barr virus
or who have had infectious mononucleosis ("mono") are at a higher risk.
• Compromised Immune System: AIDS, immune system suppressing
drugs, and various immunodeficiency syndromes have been associated
with an increased risk
21
HODGKIN’S DISEASE
• STAGING
• I – only 1 lymph node involved
• II - 2 or more, same side as diaphragm
• III – both sides of diaphragm
• IV – widespread involvement
22
CANCER
• The cells which make up our bodies normally divide
in a set and orderly fashion so they can repair our
tissues.
• This process sometimes goes wrong and there is an
uncontrolled growth of cells.
• A characteristic of all cancers is this disorderly
formation of body cells, causing swellings or tumors.
• A tumor is referred to as benign when it remains
contained in a localized area of the body and, on
removal by surgery, does not recur.
• The term cancer is used when the tumors are
malignant i.e. they spread and invade healthy tissue.
23
Non hodgkin's lymphoma
• There are many different types of non Hodgkin's
lymphomas.
• Some are so mild that they require little or no
treatment; some are very active.
• Broadly, NHL is divided into Low Grade (slow
growing) or High Grade (the faster growing
lymphomas).
• NHL is most common in people over 50 years
old.
• It can also arise when the immune system has
been suppressed because of other illnesses or
conditions, including organ transplantation.
24
Non- Hodgkin’s lymphomas (NHL)
aka lymphomas
The tumors are graded according to their level of malignancy
(aggressiveness)-- low-grade, intermediate-grade or high-grade
• Low grade,
intermediate
prognosis
2 – 3 years
•& high grade
1.5 – 2 yrs
•determined by a
lymphnode biopsy)
25
Hodgkins Disease and Non
Hodgkins Lymphoma
– What’s the Difference?
• In Hodgkins disease the biopsy
contains a type of cell called a ReedSternberg cell. This type of cell is not
present in non Hodgkins lymphoma.
There are quite a lot of different non
Hodgkins lymphoma types.
.
26
treatment
• However, all lymphomas are treated
either by radiotherapy or
chemotherapy and, in some
instances, both.
• The treatment given depends on the
exact diagnosis so one person’s
treatment may be different to
another’s
27
CHILDHOOD DISEASES
Childhood cancer :
• Non- Hodgkin’s lymphomas – 4%
• Hodgkin’s disease 4.5%
• may also invade bone marrow and other
organs (spleen, thymus)
• may cause selling in lymph nodes of the
neck axilla and groin
• general weakness and fever
28
LYMPHANGIOGRAM
• The test is not often done now in
the diagnosis or staging of
lymphoma.
• The test is performed by injecting a
dye or contrast agent into the
lymphatic vessels of the foot
29
Lymphangiogram
• CT and U/S have been used to successfully
stage tumors – replacing lymphangiogram
• CT usually first procedure in staging, esp NHL
abnormal CT replaces lymphangiograms
• Lymphangiograms - most value with Hodgkin’s
disease - (no bulky masses seen, alteration of
internal architecture which cannot be detected
with CT) also aids when CT is equivocal.
• gallium scan, MRI or PET scans may also
be used - CT and U/S best choice
30
CT Scanning
• Still procedure of choice for
staging of Hodgkin’s
lymphoma *
31
Non-Hodgkin’s Lymphoma
•CT of abdomen & pelvis is
used to stage disease
•Treatment consists of
chemo and/or Rad therapy
•Symptoms vary
•Lymphadenopathy
•anemia
•Hepatomegaly
•Splenomegaly
•Fever and weakness
32
Non-Hodgkin’s Lymphoma
Case study:
Hodgkin’s Disease
33
•CT exams show
enlarged retroperitoneal
nodes
•Symptoms
•Painless lymph node
swelling in cervical area
•Fever
•Fatigeu
•Anemia & weight loss
•Coughing
•breathlessness
34
Hodgkin’s Disease
Treatment includes RAD therapy
And chemotherapy
Symptoms include malaise, fever,
Anorexia, enlarged lymph nodes
35
Staging of Lymphomas
• Stage I:
• One lymph node group
• Only one part of a tissue
• One organ
• Stage II:
• Two lymph node groups on the same side
• one part of a tissue or an organ and the lymph nodes near that organ
• In other lymph node groups on the same side of the diaphragm
• Stage III:
• In lymph nodes above and below the diaphragm.
• In one part of a tissue or an organ near these lymph node groups
• It may also be found in the spleen
• Stage IV:
• In several parts of one or more organs or tissues
• In an organ and in distant lymph nodes
36
CT: Lymphoma
37
PET Lymphoma
Lymphoma in a 16-year-old girl with a 3week history of supraclavicular adenopathy
38
Diagnostic Medical Sonography:
Lymphoma
39
LYMPHOMA
40
LYMPHOMAS treatment
• chemotherapy
• radiation therapy
combined
• possible bone
marrow transplant
41
Lymphatic obstruction
Lymphedema
• Symptoms:
• Chronic swelling, usually of the arm or
leg
• is the clinical hallmark of lymphatic
obstruction.
42
Lymphography- Procedures
• General term applied to the radiologic examination of:
• Lymph nodes
• Lymph Vessels
• Usually done to demonstrate pelvis and abdomen
• Injected in foot
• For axillary, clavicular area and upper limbs
• Injected in hand
• Checks drainage of lymph nodes
• Checks for pathology
43
Pre Procedure
• Obtain PT history
• Obtain PT consent
• Make sure to have all supplies
• Positioning aides and comfort supplies
44
The technologist has many
responsibilities during this exam.
45
Procedure
Patient prep
• Empty bladder
• long procedure (4-5 hours)
over 2 days
• Special attention to patient’s
physiological needs (Ca pt)
46
The technologist must:
• Get a good patient history
• LMP
• Any bleeding problems
• Any previous allergic reactions to contrast
media
• Explain the procedure and any
instructions for after the exam
• Get the consent form signed
47
•Once the patient is on
the table the injection
site will be cleaned
•Next, a special blue
dye (patent blue violet)
is injected.
•Methaline Blue
•injected into the
subcutaneous web
spaces of the hand or
foot about 15 min.
before the test begins.
48
Procedure
• Inject blue dye under skin
in between toes
• Inject small amount of
contrast into the lymph
vessels
• Show blue tint
• Nodes in pelvis and
abdomen are
demonstrated with foot
injection
49
Affects of the blue dye on the patient:
•The skin, stool, and urine will have a blue
tint.
•The lymph vessels look like thin, blue lines.
•Vision can even take on a bluish tint.
•The affects of the dye can last from a few
hours to 48 hours.
50
After the 15 minutes are up, the local anesthetic is injected.
Then a longitudinal incision is made in one of the lymph
vessels shown with the dye.
51
Procedure
• Small cut-down made on top
of foot
• Slow injection of 5 – 10
ml/extremity @ 1.25 hr
• Room – radiographic (usually
does not need fluoroscopic
52
53
A needle/catheter is then placed in the vessel and the
contrast is injected in.
54
Fluoroscopy is used
to see if the contrast is
in the correct vessel.
The progress of the
contrast will be
recorded under fluoro.
Procedure
55
• X-rays are usually taken 1 HR after injection
• 24 hrs
• 48 hrs (if needed)
• 72hrs (if needed)
• First hour
• Contrast in lymph ducts
• 24 hours
• If lymph nodes
• After 24 hours it is indicative of cancer
56
Once the contrast has been injected, the incision is
sutured, and regular radiographic images are taken
within the hour.
•A second set of x-rays
are taken for the lymph
nodes 24 hours later.
57
Filming
• Chest / abdomen / pelvis
• poss extremities – 24
hours –
• Shows lymph vessels and
nodes
• Follow up 48 and 72 hour
films shows nodes
• Normal should not have
contrast after 24 hours
A fluoroscopy room will be used for
the exam.
58
When the feet are injected the
lymphatics in these areas are seen:
Lower
extremity
Abdominal area
Groin
Thoracic duct
59
60
61
62
63
64
65
•LYMPH DUCTS
•1 HOUR
•BEYOND 24
•SIGN OF CA
•IN VESSELS
•LYMPH NODES
•24 HOURS +++
66
67
68
Iliopelvic-aortic Lymphatic System
69
Lymphography
70
Other notes of interest are:
o The contrast can remain in the lymph
nodes from anywhere from 3-4 weeks
to 2 years.
o Exposure from this exam is about the
same as what would be received from a
bone study (low).
71
RADIOGRAPHIC FINDINGS
• Mediastinal lymph nodes
enlargement is the most
common radiographic
findings in lymphoma.
• Seen with about 1/3rd with
NHL and ½ with Hod Lymp
72
• Pleural effusion occurs in 1/3 of the
patients • extension of the tumor into the
pericardium can cause pericardial
effusion.
• 5 – 10 % have involvement of the GI
tract (stomach and small bowel) – seen
as large bulky polypoid mass
73
ENLARGED MEDIASTINUM
involvement of the pulmonary parenchyma and pleura usually
occur due to the mediastinals lymph node enlargement=
74
BEFORE: Non-Hodgkin's lymphoma in 32-year-old female.
AFTER: Resolution after 2 weeks of treatment.
75
LYMPHOMA
enlargement of left hilar region
76 • may appear as a coarse interstitial pattern or solitary or
multiple ill-defined nodules or as patchy areas of infiltrates
77
Post Procedure
1. Watch for signs of infection
 Swelling red and warm to touch
 Accompanied by a fever
 Contact DR right away
2. Drink lots of water
3. Major swelling in one limb
 Especially limb injected
78
•The lymph nodes and
vessels cannot be seen on
regular diagnostic x-ray
films without the injection
of contrast.
•Preferred contrast is OIL
based – less irritating and
absorbed more slowly
•Lipoidol
79
Contrast
• Oil based
• More commonly used
• Ethiodal
• Lipodal
• Water based Iodine
• Less commonly used
• Ionic
• Non-ionic
80
Contrast Media
• Ethiodol and Lipiodal
• Directly injected into a
vessel of an extremity –
• Blue dye used –
absorbed by lymphatic
vessel –
• Oil based usually used
for lymphangio
• Water based is irritating
to the lymphatic system
– causes pain and
burning to patient
81
Upper Limb Lymphography
82
When the hands are injected the
areas seen are:
Upper limbs
Clavicular region
Axillary region
This is skin erythema
and swelling caused
by an allergic reaction
to contrast media.
83
Does anyone have any
questions?
Review questions on 2007
lecture