Vol. 118, October Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
PULMONARY DYSFUNCTION AFTER LYMPHANGIOGRAPHY JEFFREY R. WOODSIDE, THOMAS W. CHICK
AND
PETER W. BERGREEN
From the Division of Urology, University of New Mexico School of Medicine and the Department of Medicine, Veterans Administration Hospital, Albuquerque, New Mexico
ABSTRACT
Pulmonary function tests were done on 15 patients before and after bipedal lymphangiography. Lymphangiography was associated with an approximate 10 per cent reduction in lung volume. This phenomenon persisted for 48 to 72 hours. The probable mechanism for this reduction is closure of terminal airways or alveolar ducts or both and is reversible by beta-adrenergic drugs. The reduction does not correlate with the severity of pre-existing pulmonary disease. The degree of pulmonary impairment can be assessed roughly by measurement of the vital capacity. An operation can be performed safely 3 to 5 days after lymphangiography. Bipedal lymphangiography was introduced by Kinmonth and associates in 1955 1 and first used primarily for detecting retroperitoneal lymph node metastases in patients with Hodgkin's disease and lymphoma. Since then, lymphangiography has been used more widely to evaluate patients with other malignancies. Specifically, this modality has been used as a parameter for patients with bladder and prostatic carcinoma with rather accurate results. 2• 3 Not uncommonly, radiologists are reluctant to do lymphangiography in patients with preexisting pulmonary disease, fearing that pulmonary embolization of the contrast agent will further compromise pulmonary function. Also, surgical procedures are often empirically delayed for at least 2 weeks after lymphangiography for the same reason. Since we were impressed with the lack of pulmonary symptoms in our patients we decided to investigate the specific changes that occur in pulmonary function after lymphangiography and to examine the significance of any such changes.
the vital capacity was restored to the control value at all intervals after lymphangiography. FEV 1 , V50 and V25 were all reduced in proportion to the reduction in the vital capacity and, therefore, there is no evidence of air flow obstruction at any time after lymphangiography. At 2 to 4 hours post-lymphangiography the diffusing capacity was reduced by 11 per cent (p less than 0.005) (fig. 2, A). It was reduced by 11 per cent (p less than 0.05) at 48 hours. When expressed as diffusing capacity per unit alveolar volume (Dd VA) the mean values were reduced at all intervals post-lymNS
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MATERIAL AND METHODS
i:n
The 15 men who underwent bipedal lymphangiography for staging purposes ranged between the ages of 54 and 72 years and had stage B or C adenocarcinoma of the prostate or transitional cell carcinoma of the bladder. According to the technique of Kinmonth and associates a maximum total dose of 14 cc ethiodol was injected slowly under fluoroscopic control. 1 Radiograms, including tomograms as indicated, were done during the next 24 to 72 hours. Chest x-rays and pulmonary function tests were done the day before and 2 to 4 hours after lymphangiography and daily for 2 to 3 days. To measure pulmonary function, maximal expiratory flow volume curves were obtained. From these curves the vital capacity and 3 parameters of airway obstruction were derived: FEV 1 and instantaneous flows at 50 per cent (\\ 0) and 25 per cent (V25 ) of exhaled vital capacity. Single breath carbon monoxide diffusing capacity (DLco) was determined by standard techniques. 4 The diffusing capacity per unit alveolar volume (DL/VA) was calculated by dividing the DLrn by the helium dilution alveolar volume.
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0
RESULTS
The vital capacity was decreased from control vital capacity by 9 per cent (370 ml.) at 2 to 4 hours, 5 per cent (170 ml.) at 24 hours and 4 per cent (130 ml.) at 48 hours (fig. 1). The changes at 2 to 4 and 24 hours were statistically significant, whereas the 48-hour changes were not. After isoproterenol nebulization Accepted for publication January 28, 1977. Read at annual meeting of South Central Section, American Urological Association, San Antonio, Texas, September 12-16, 1976. 618
60
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.
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2-4
24
48
FIG. 1. Vital capacity (VC) after lymphangiography
phangiography (fig. 2, B). However, there was wide variation and the changes did not attain statistical significance. The change in diffusing capacity at 2 to 4 hours correlated with the change in vital capacity at that interval (r equals 0.59, p less than 0.05). To investigate whether pre-existing pulmonary disease predisposed patients to impairment oflung function after lymphangiography, they were classified on the basis of the FEV1.o as a per cent of the vital capacity into the following categories of pulmonary impairment: none (more than 75 per cent), mild (65 to 75 per cent), moderate (50 to 65
LYMPHANGIOGRAPHY
per cent) and severe (less than 50 per cent). This classification was correlated with the percentage reduction in vital capacity at 2 to 4 hours post-lymphangiography. This analysis indicated no significant correlation between pre-existing lung dysfunction and further lung impairment by lymphangiography (p more than 0.05). - On all films contrast material was seen in the thoracic or mediastinal lymph nodes. There were no abnormalities of the lung parenchyma in 12 patients. In 2 ,-,wu,vuuu there was a slight increase in interstitial markings on first c-uws,cwcn day only. One patient had definite fluffy left lung for 2 days post-injection and this the greatest decline in lung function (fig. 3): decreased by 32 per cent and DL 20 per cent. DISCUSSION
such as local pain, wound infection, and iodine sialitis, are not unusual after lymFever as a pyrogenic reaction to the contrast agent common and 4 of our patients had a temperature as as 100.4 within 6 hours of the injection. The most serious ""''~•.,u,vu is cerebral embolization of ethiodized with 3 of 19 cases r
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THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
PULMONARY DYSFUNCTION AFTER LYMPHANGIOGRAPHY JEFFREY R. WOODSIDE, THOMAS W. CHICK
AND
PETER W. BERGREEN
From the Division of Urology, University of New Mexico School of Medicine and the Department of Medicine, Veterans Administration Hospital, Albuquerque, New Mexico
ABSTRACT
Pulmonary function tests were done on 15 patients before and after bipedal lymphangiography. Lymphangiography was associated with an approximate 10 per cent reduction in lung volume. This phenomenon persisted for 48 to 72 hours. The probable mechanism for this reduction is closure of terminal airways or alveolar ducts or both and is reversible by beta-adrenergic drugs. The reduction does not correlate with the severity of pre-existing pulmonary disease. The degree of pulmonary impairment can be assessed roughly by measurement of the vital capacity. An operation can be performed safely 3 to 5 days after lymphangiography. Bipedal lymphangiography was introduced by Kinmonth and associates in 1955 1 and first used primarily for detecting retroperitoneal lymph node metastases in patients with Hodgkin's disease and lymphoma. Since then, lymphangiography has been used more widely to evaluate patients with other malignancies. Specifically, this modality has been used as a parameter for patients with bladder and prostatic carcinoma with rather accurate results. 2• 3 Not uncommonly, radiologists are reluctant to do lymphangiography in patients with preexisting pulmonary disease, fearing that pulmonary embolization of the contrast agent will further compromise pulmonary function. Also, surgical procedures are often empirically delayed for at least 2 weeks after lymphangiography for the same reason. Since we were impressed with the lack of pulmonary symptoms in our patients we decided to investigate the specific changes that occur in pulmonary function after lymphangiography and to examine the significance of any such changes.
the vital capacity was restored to the control value at all intervals after lymphangiography. FEV 1 , V50 and V25 were all reduced in proportion to the reduction in the vital capacity and, therefore, there is no evidence of air flow obstruction at any time after lymphangiography. At 2 to 4 hours post-lymphangiography the diffusing capacity was reduced by 11 per cent (p less than 0.005) (fig. 2, A). It was reduced by 11 per cent (p less than 0.05) at 48 hours. When expressed as diffusing capacity per unit alveolar volume (Dd VA) the mean values were reduced at all intervals post-lymNS
P
NS
100 UJ
V,
.,
+I
::,
!l!llll •••••••••
;;; 80
>
.
E
MATERIAL AND METHODS
i:n
The 15 men who underwent bipedal lymphangiography for staging purposes ranged between the ages of 54 and 72 years and had stage B or C adenocarcinoma of the prostate or transitional cell carcinoma of the bladder. According to the technique of Kinmonth and associates a maximum total dose of 14 cc ethiodol was injected slowly under fluoroscopic control. 1 Radiograms, including tomograms as indicated, were done during the next 24 to 72 hours. Chest x-rays and pulmonary function tests were done the day before and 2 to 4 hours after lymphangiography and daily for 2 to 3 days. To measure pulmonary function, maximal expiratory flow volume curves were obtained. From these curves the vital capacity and 3 parameters of airway obstruction were derived: FEV 1 and instantaneous flows at 50 per cent (\\ 0) and 25 per cent (V25 ) of exhaled vital capacity. Single breath carbon monoxide diffusing capacity (DLco) was determined by standard techniques. 4 The diffusing capacity per unit alveolar volume (DL/VA) was calculated by dividing the DLrn by the helium dilution alveolar volume.
"' C .c "'C.
0
RESULTS
The vital capacity was decreased from control vital capacity by 9 per cent (370 ml.) at 2 to 4 hours, 5 per cent (170 ml.) at 24 hours and 4 per cent (130 ml.) at 48 hours (fig. 1). The changes at 2 to 4 and 24 hours were statistically significant, whereas the 48-hour changes were not. After isoproterenol nebulization Accepted for publication January 28, 1977. Read at annual meeting of South Central Section, American Urological Association, San Antonio, Texas, September 12-16, 1976. 618
60
E
>,
~
a. 0 40
c., u
:;;
a.
.
0 Hours
2-4
24
48
FIG. 1. Vital capacity (VC) after lymphangiography
phangiography (fig. 2, B). However, there was wide variation and the changes did not attain statistical significance. The change in diffusing capacity at 2 to 4 hours correlated with the change in vital capacity at that interval (r equals 0.59, p less than 0.05). To investigate whether pre-existing pulmonary disease predisposed patients to impairment oflung function after lymphangiography, they were classified on the basis of the FEV1.o as a per cent of the vital capacity into the following categories of pulmonary impairment: none (more than 75 per cent), mild (65 to 75 per cent), moderate (50 to 65
LYMPHANGIOGRAPHY
per cent) and severe (less than 50 per cent). This classification was correlated with the percentage reduction in vital capacity at 2 to 4 hours post-lymphangiography. This analysis indicated no significant correlation between pre-existing lung dysfunction and further lung impairment by lymphangiography (p more than 0.05). - On all films contrast material was seen in the thoracic or mediastinal lymph nodes. There were no abnormalities of the lung parenchyma in 12 patients. In 2 ,-,wu,vuuu there was a slight increase in interstitial markings on first c-uws,cwcn day only. One patient had definite fluffy left lung for 2 days post-injection and this the greatest decline in lung function (fig. 3): decreased by 32 per cent and DL 20 per cent. DISCUSSION
such as local pain, wound infection, and iodine sialitis, are not unusual after lymFever as a pyrogenic reaction to the contrast agent common and 4 of our patients had a temperature as as 100.4 within 6 hours of the injection. The most serious ""''~•.,u,vu is cerebral embolization of ethiodized with 3 of 19 cases r
I
I
C
~
u
