The Lymphatic System

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Lymphology Quo Vadis?

Part-2

Borislav Penchev - Unitec NZ Shamim Shaikh - Unitec NZ

Lymphatic system

anatomy, physiology and pathology for MRTs

Imaging of the lymphatic system

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Out of the 215 participants in a recent survey, 12.5% could list 3 to 4 elements of the LS

Lymphatic system (LS) awareness amongst Medical Imaging students is low.

“I don’t see what the LS has to do with bones and radiography.

“I have never seen any knowledge of the LS been used in the

clinical practice”

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2. L. vessels:

- capillaries - trunks

- cisterna chily - ducts

lumbar x 2 Intestinal x 1

broncho-mediastinal x 2 subclavian

jugular

thoracic duct right lymph duct

ELEMENTS OF THE LS

1. Lymph

3. L. nodes popliteal & inguinal para iliac & para aortic

Inf. mes., celiac, sup. mes.

cubital, axillary para sternal

supra & infraclavicular cervical, mastoid……

4. L. tissue,

and organs appendix, Peyer’s patches,

tonsils, spleen, thymus

https://www.britannica.com/science/lymphoid-tissue

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http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=115885&ti=377057&searchkey=

Primary bone marrow

lymphoma

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Schuenke et al., (2006), Atlas of 5

Anatomy, Stuttgart, Thieme

20 L 18 L

1. LYMPH

https://www.researchgate.net/figure/51689813_fig2_Appearance-of- the-pleural-fluid-before-and-after-a-low-dietary-fat-intake-A-The-high

A B

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Reproduced from Hubbard & Mechan 1977 as seen in Stone, C. (1999) , Science in the art of Osteopathy.

10%

100% 90%

Henry Starling (1866-1927) - “Starling equation”

for fluid movement across capillary wall

and the formation of lymph

(Fanous et al. (2007).

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http://ars.els-cdn.com/content/image/1-s2.0-S2352345X16301035-gr2.jpg

50% of lymph is hepatic

>>> proteins 30% of lymph is intestinal

>>> fats

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http://medical-dictionary.thefreedictionary.com/thymus

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Lymphocyte

• mature in thymus

• attack intracellular antigens

http://amazingribs.com/tips_and_technique/mythbusting_bone-in_meat_is_better.html

• mature in red bone marrow

• develop memory for antigens

• become plasma cells secrete antibodies

• attack extracellular antigens

LYMPH WBCs

B lymphocytes - humoral immunity

T lymphocytes - cell immunity

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Prevent collapsing and secure absorption, even in a high-pressure environments 9

http://www.cell.com/trends/cell-biology/fulltext/S0962-8924(05)00156-X

Start as blind sacks

Capillary wall features:

- endothelial cells - no muscle layer

- no basement membrane

Marieb & Hoehn (2008)

2. LYMPHATIC VESSELS

CAPILLARIES

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LACTEAL CAPILLARIES IN INTESTINAL MUCOSA

http://www.vivo.colostate.edu/hbooks/pathp hys/digestion/smallgut/absorb_lipids.html http://friedbiochem.weebly.com/surface-area-to-volume-ratio.html

http://www.lab.anhb.uwa.edu.au/mb 140/corepages/vascular/vascular.htm

https://images.nature.com/full/natureassets/nrgastr o/journal/v13/n1/images/nrgastro.2015.201-i1.jpg

An active peristalting transporter

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http://histology.medicine.umich.edu/resource s/bone-bone-formation#learning-objectives http://www.gla.ac.uk/ibls/US/fab/tutorial/generic/bonet.html

 Where is the bone interstitium?

 Do bones have lymphatics?

Metastasis to bone do not occur via lymphatics

 No

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http://www.apsubiology.org/anatomy/2020/2020_Exam_Reviews/

Exam_2/CH20_Gross_Anatomy_of_the_Lymphatic_System.htm

http://www.sciencedirect.com/topics/page/Lymph_capillary http://www.sciencedirect.com/topics/page/Lymph_capillary

http://biomedicaloptics.spiedigitallibra ry.org/article.aspx?articleid=2488189

Muscle fibres

Frederik Ruysch (1638 – 1731)

2. LYMPHATIC DUCTS Valves

Schuenke et al., (2006), Atlas of Anatomy, Stuttgart, Thieme

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3. LYMPHATIC NODES

Average LN 0.83 gr

Function:

- filtration of lymph

- lymphocytes B & T reservoir - immune response

https://www.slideshare.net/AbinoDavid/anatomy-of-lymph-node

Average 500-700 LNs Metastatic LN 2.34 gr

8% of 0.5gr LNS are metastatic

https://www.ncbi.nlm.nih.gov/pubmed/1960454

SIZE MATTERS,

BUT NOT MUCH

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McCracken & Morris, (2001), New Atlas of Human

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Anatomy, London, Constable Publishers

LYMPH NODES MAP

Mastoid

Inframandibular Cervical

Supraclavicular Infraclavicular Axillary

Epitrochlear Inguinal

Popliteal

SUPERFICIAL

Para sternal Mediastinal Celiac

Superior mesenteric Inferior mesenteric Para aortic

Internal iliac

DEEP

Less suitable for US

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http://ultrasound-images.blogspot.co.nz/2010/09/breast-cancer-with-spread-to-lymph.html

Enlarged hypoechoic malignant LNs in

Mammography can see them

US can diagnose them

https://www.researchgate.net/figure/221869954_fig4_Fig-5-Lymph- node-and-afferent-lymphatic-vessels-the-ventral-cervical-node-left-and

SUPERFICIAL LYMPH NODES

https://www.sanovadermatology.com/skin-cancer/what-is-a-sentinel- lymph-node-biopsy-and-when-is-it-recommended-for-skin-cancer/

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http://www.radiologyassistant.nl/en/p4646f1278c26f/mediastinum-lymph-node-map.html

Sub-carinal l.n.

DEEP LYMPH NODES

https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-8-94

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4. LYMPH TISSUES AND ORGANS

DIFFUSE LYMPH TISSUE – nodules beneath mucosa and serosa

http://apchute.com/digestive/ileum2.htm https://www.hindawi.com/journals/iji/2010/823710/fig1/

Peyer’s patches in distal ileum

https://www.med-ed.virginia.edu/courses/rad/gi/smallbowel/neop02/neop022a.htm

LYMPHOMA

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LYMPH GLANDS

TONSILS & ADENOIDS

https://radiologykey.com/target-definition-and-localization/

https://openi.nlm.nih.gov/detailedresult.php?img=PMC3004499_kjped-53-863-g002&req=4

http://www.kids-ent.com/newkids800/tonsilprint.html

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LYMPH ORGANS THYMUS

http://radnet.bidmc.harvard.edu/fetalatlas/chest/thymus/thymus.html http://www.gettyimages.co.nz/detail/photo/cadaver-dissection-of-the-thoracic-cavity-high-res-stock-photography/vis300414

hypoechoic & heterogeneous

https://www.slideshare.net/Bahnassy/understanding-the-thymus

Thymus compared to thyroid:

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Sail sign

http://learningradiology.com/notes/chestnotes/thymicsailsigns.htm

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THYMUS

https://radiologykey.com/mediastinum-and-hila/

THYMOMA

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http://posterng.netkey.at/esr/viewing/index.php?module=viewing _poster&task=viewsection&pi=130844&ti=442748&searchkey=

Hyperplasia Rebound?

Normal

https://www.slideshare.net/Bahnassy/understanding-the-thymus

Malignant

THYMUS

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SPLEEN

https://s-media-cache-ak0.pinimg.com/736x/a8/7a/80/a87a80991055b6eddb9c734c31687832.jpg

https://howlingpixel.com/wiki/Liver http://web.duke.edu/anatomy/lab05/lab5.html

https://web.stanford.edu/dept/radiology/radiologysite/images/Med%20students%2014,%20kidney/

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https://radiologykey.com/spleen-and-peritoneal-cavity/

SPLENOMEGALY

https://radiopaedia.org/articles/splenomegaly

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https://upload.wikimedia.org/wikipedia/c ommons/2/2a/Dimitrie_Gerota.jpg

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Paolo Mascagni - (1755-1815) - Italian Invented dyeing of lymphatics with Mercury - a precursor of lymphangiography.

http://library.uthscsa.edu/2014/03/a-landmark-in-anatomical-

illustration-paolo-mascagni-and-the-lymphatic-system/ https://nz.pinterest.com/pin/409053578625829100/

Dimitrie Gerota (1867-1939) - the first Romanian radiologist - introduced the

Prussian blue paint / turpentine / ether mix.

Hernani Monteiro - University of Porto introduced lymphography in 1931

John Kinmonth (1916-1982) - Irish In 1952, he introduced the

contrast lymphangiography

http://accesscardiology.mhmedical.com/conte nt.aspx?bookid=1782&sectionid=121398132

http://jmg.bmj.com/content/39/7/478 https://nz.pinterest.com/pin/103512491407005239/

THE MODERN IMAGING OF LS HAS HISTORY

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Several valves prior to venous angle

Inguinal

Parailiac

Cisterna chily

Thoracic duct

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The significant variability of number, size, and appearance can simulate malignancy in this region.

http://www.ufrgs.br/imunovet/molecular_immunology/invivo.html

INGUINAL NODES

and exceptionally detailed

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 Intra-vascular

cannulation of l. vessels – already presented retrograde veno-lymphatic cannulation

From subclavian vein to l. ducts

CURRENT LYMPHANGIOGRAPHIC TECHNIQUES

 Intra-interstitial Depending on the application of the contrast include:

 Intra-nodal-US guided administration of:

- iodinated contrast - gadolinium

http://ar.iiarjournals.org/content/35/2/891/F3.large.jpg http://www.sciencedirect.com/scien

ce/article/pii/S1051044307013826

ttps://www.quora.com/What-are-the-causes-of-chylothorax http://radiology.rsna.org/content/212/2/598.long

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INTRANODAL LS MRI

http://pediatrics.aappublications.org/content/134/2/e590

Plastic bronchitis - an instant HIT

- exceptional presentation of the central LS

^{(11, 12).}

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IS ALSO A MOLECULAR IMAGING

1940s - Hand-held Geiger counters

1950 - Rectilinear scanner of Benedict Cassen 1956 - Photo scanner

1960 - Gamma camera (Scintillation camera)

1976 - John Keyes - SPECT (single photon emission computed tomography)

= Gamma camera + rotating detecting system + 99m Tc + computerising…

1978 - 18 FDG - Ido et al.

- in vivo

- visualization and measurement - of dynamic biological processes - at molecular and cellular levels - by using a radiotracer

It includes: nuclear medicine, MR imaging, MR spectroscopy, optical imaging, US, and others……

(Mankoff DA; JNM 48(6)18N, 2007)

THE CURRENT IMAGING OF LS

2000 - Fluorescence imaging - fluorescence agent + light = photons emission - Bioluminiscence imaging

- Cerenkov luminescence imaging