792
TECHNICAL NOTES
December 1979
Tolazoline-Augmented Arteriography in the Evaluation of Bone and Soft-Tissue Tumors 1 Saadoon Kadir, M.D.,2 Christos A. Athanasoulis, M.D., and Arthur C. Waltman, M.D. Twelve patients with bone tumors were prospectively evaluated by arteriography both with and without tolazoline. In general, tolazoline improved definition of tumor extent; however, in 2 patients with highly vascular tumors and 2 patients with hypovascular tumors, tolazoline did not improve visualization. In 3 of the 12 patients, the tolazoline-augmented study was less accurate than the nontolazoline study in defining tumor extent. Angiography, technique. Bone neoplasms, diagnosis. Tola(Skeletal system, angiography, 4[0].124)
INDEX TERMS:
zollne
s
Radiology 133:792-795, December 1979
Advances in surgical techniques have made possible a more aggressive approach to the management of malignant bone and soft-tissue tumors (1, 2). Although arteriography has played an important role in the preoperative evaluation of these tumors, with the introduction of pharmacological aids its role has become even more significant (3-6). We have recently re-evaluated the use of intra-arterial tolazoline'' in patients with musculoskeletal tumors and have compared its use with high-flow, high-volume arteriography. MATERIAL AND METHODS Between January 1974 and July 1978, 84 patients with bone and soft-tissue tumors of the extremities underwent preoperative arteriography. Twelve of these patients with bone tumors were evaluated prospectively. These tumors included 3 giant-cell tumors, 4 osteogenic sarcomas, 2 chondrosarcomas, and 2 fibrosarcomas. One patient who had a low-grade fibrosarcoma resected several years ago was evaluated for recurrence. AITABLE I:
Fig. 1. An 18-year-oldwoman with a giant-cell tumor of the distal humerus. A tolazoline-enhanced arteriogram shows a markedly vascular tumor with early venous drainage, and visualizes two vascular satellite lesions (arrows). though physical examination and xeroradiography demonstrated a mass, no recurrence could be demonstrated by histology. In all but 3 patients the lesions were located distal to the mid-thigh. One patient had a giant-cell tumor of the distal humerus, while
SUMMARY OF ARTERIOGRAPHIC FINDINGS WITHOUT AND WITH TOLAZOLINE IN PATIENTS WITH BONE AND SOFT-TISSUE TUMORS Before Tolazoline
No.
Tumor Type * / Location
Definition of SoftTissue Extention
Venous Opacification
+ + Absent + +++ ++ + +++ + ++ + ++ +++ +++ ++ Absent ++ ++ +++ ++++ ++++ Absent ++ ++ Absent + + Absent +++ + The + signs indicate the relative visualization, where ++++
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
F.S.lhumerus F.S.lfemur F.S.t /distal thigh G.C.T.ltalus G.C.T.lhumerus G.C.T.ltibia O.S.lfibula O.S.lfemur O.S.lfemur O.S./femur C.S.lfemur C.S.lhumerus ,
=
++ +
Arteriovenous Shunting
* F. S. fibrosarcoma, G.C.T. t Evaluation for recurrence.
Absent Absent Absent Absent
=
After Tolazoline
Visualization of Skip Lesions
Visualizatlon of Small Vessels
Absent Absent Absent Absent
++ ++ + ++ + ++ ++ ++ ++ ++ + ++
++ ++ + ++ ++ Absent Absent
++
Definition of SoftTissue Extention
+++ ++
Arteriovenous Shunting
Venous Opacification
Absent
++ ++ ++ ++++ ++++ ++++ +++ +++ ++++ ++ ++ ++
++
Absent
Absent
++++ ++++ +++ ++ + +++ ++ ++ ++
++++ ++++ +++ ++ Absent
++++ Absent Absent Absent
indicates the best visualization. giant-cell tumor, C.S. = chondrosarcoma, O.S. osteogenic sarcoma.
=
Visualization of Skip Lesions
Visualization of Small Vessels
Absent Absent Absent Absent
+++ +++ ++ ++++ ++++ +++ +++ +++ +++ +++ ++ ++++
++++ ++++ ++ +++ ++ Absent Absent
++
Technical Vol. 133
793 Notes
TECHNICAL NOTES
2a,b
Fig. 2. A 26-year~0Id woman with a giant-cell tumor of the talus. a. Nontolazoline arteriogram shows a vascular tumor with some soft-tissue extension (arrows). b. Arteriogram following bolus injection of 25 mg tolazoline in the distal superficial femoral artery. There is better tumor definition, and multiple early veins are identified (arrows).
another had a fibrosarcoma of the mid-humerus. One patient had a chondrosarcoma of the humeral head. Percutaneous femoral arteriography was performed using the technique described by Seldinger (7). For proximal lesions (thigh, knee) the contralateral femoral artery was used. For distal lesions (distal to knee) an antegrade femoral artery puncture was made. For lesions of the upper extremity the femoral artery approach was used; a 6.5-Fr H1H cameter' was placed in the axillary artery and 40 ml of contrast medturn" injected at 7 ml/sec. For lesions of the lower extremity, a multiple-hole 6.7-Fr straight catheter" was deflected over the aortic bifurcation using a handle deflector.? For distal lesions the catheter tip was placed in the distal superficial femoral artery and 40 ml of contrast medium" injected at 7 ml/sec. For proximal lesions the catheter tip was placed proximal to the common femoral bifurcation and 40 ml of contrast medium injected at 8 ml/sec. The initial arteriogram was obtained without tolazoline. Arteriography was then repeated after intra-arterial administration of a bolus of 25 mg tolazoline diluted with 2-3 ml of DsW. Films were exposed over 20 seconds with filming and exposure factors kept constant. Arteriography was performed in at least two projections using the alternating biplane technique. All arteriograms were reviewed by two vascular radiologists without prior knowledge of which study was performed with tolazoline.
RESULTS The results of the 12 patients studied are summarized in TABLE
I. Three of these patients had poorly vascularized tumors. The 1 patient who was evaluated for recurrence of his low-grade fibrosarcoma is not included here, as the histology showed no abnormal tissue. Nontolazoline arteriograms in these 3 patients showed vascular displacement with no neovascularity and poor or absent tumor stain. The tolazoline-augumeted arteriogram demonstrated normal muscle vasculature in greater detail, and in 2 patients it did not show any significant changes in the areas of the known tumor. In the 1 other patient the tumor definition was enhanced slightly. In the other 8 patients with tumors showing a moderate to high degree of vascularity, in general, tolazoline was found to be advantageous, as it: (a) improved visualization of smaller vascular structures (arteries and veins), thus improving the definition of the tumor, (b) visualized or better defined skip or satellite lesions (Fig. 1), and (c) opened the arteriovenous communications, thus opacifying early and often large draining veins. This aspect was found to be particularly helpful if the nontolazoline study showed a vascular tumor without opacification of draining veins (Fig. 2).
794
TECHNICAL NOTES
December 1979
3,4
Fig. 3. A 22-year-old man with a giant-cell tumor of the proximal fibula. Lateral projection from the nontolazinearteriogram shows the soft-tissue extent (open arrows) of the vascular tumor and an early opacifying vein (curved white arrow). Fig. 4. Same patient as in Figure 3. Lateral frame from the arteriogram obtained after intra-arterial bolus injection of 25 mg Priscoline shows poor definition of the distal margin of the tumor due to increased opacification or normal soft tissue. A central avascular area is now obvious.
In 2 patients with highly vascular tumors, tolazoline was not found to be of any advantage. In 1 patient with an osteogenic sarcoma of the distal femur (Patient 10), the nontolazoline arteriogram depicted the tumor extent and vascularity quite accurately. In the tolazoline arteriogram there was earlier opacification of tumor vessels, but tumor definition was the same. In the other patient (Patient 9) with a markedly vascular osteogenic sarcoma of the distal femur, the arteriograms showed no differences in tumor definition or early opacification of large draining veins. In 3 patients the tolazoline-augmented study would have been
disadvantageous if it had been evaluated without the nontolazoline arteriogram (Patients 7, 8, and 12). One of these patients had a vascular osteogenic sarcoma of the proximal fibula with a large soft-tissue mass which was quite accurately defined by the nontolazoline arteriogram. In addition, there was opacification of an early draining vein (Fig. 3). The repeat study after injection of 25 mg tolazollne produced dilatation of the smaller vessels of the calf which resulted in poorer definition of the tumor (Fig. 4). Furthermore, the previously identified arteriovenous shunting was no longer seen, possibly as a result of diversion of the contrast medium to the newly opened vascular bed. The
late venous phase of this study did demonstrate some venous encasement by the tumor. In addition, a skip lesion was identified over the distal thigh. The nontolazoline arteriogram demonstrated circumferential narrowing of several branches of the anterior tibial artery which could be interpreted as tumor encasement. However, the tolazoline-augmented study showed dilatation of these vessels confirming the presence of vascular spasm (Figs. 3 and 4). In the other patients with a chondrosarcoma of the humerus and osteogenic sarcoma of the femur, tumor definition was also poor following tolazoline. No systemic side effects were noted with intra-arterial tolazoline. DISCUSSION In evaluating bone and soft-tissue tumors, the role of angiography is mainly to define extent, satellite lesions, vascularity, and venous drainage. Determination of tumor extent is necessary if radical excision or resection with allograft replacement is planned. Tumor vascularity is an important indicator for the anticipated intraoperative blood loss and whether preoperative embolization should be attempted. Much importance has been attributed to the identification of any large venous structure draining the tumor, in order to facilitate early ligation and thus prevent tumor embolization during surgery (3). Pharmacoangiography utilizing tolazoline, angiotensin, epinephrine, and prostaglandins has been of considerable help in defining the abnormal vascularity and determining the extent of tumors (3,
5,6,8,9). Our observations indicate that tolazoline-augmented arteriography offers several advantages, but the use of high-flow, high-volume arteriography may accomplish the same for some tumors with a moderate to high degree of vascularity. On the other hand, in hypovascular tumors the definition of the lesion remains poor or may be obscured by the enhancement of normal soft-tissue vascularity. Therefore the initial arteriogram should
Lymphography Without the Use of Vital Dyes 1 Chandrakant C. Kapdi, M.D. Pedal lymphography was performed without the use of vital dyes in 510 patients. Lymphatic vessels were still readily identifiable by this method, due to their transparency, clarity, elasticity, distensibility, and characteristic branching pattern. Procedure time was shortened by 10-15 minutes without compromising the high success rate. INDEX TERMS:
795
TECHNICAL NOTES
Vol. 133
Lymphography, contrast media. Lymphography, technique
Radiology 133:795-796, December 1979
The use of vital dyes for lymphography has been increasingly restricted by the FDA. For the past four years, this author has successfully performed 510 consecutive pedal lymphographies without compromising the high success rate. This method has not only prevented allergic reactions which are not uncommon with color dye, but has also resulted in saving time by eliminating the period of waiting for lymphatic vessels to become visible. TECHNIQUE Patients studied ranged in age from 9 to 82 years, with diag-
Technical Notes
be without tolazoline, but if additional specific information is sought, a tolazoline-augmented arteriogram should be obtained. REFERENCES 1. Mankin HJ, Fogelson FS, Thrasher AZ, et al: Massive resection and allograft transplantation in the treatment of malignant bone tumors. N Engl J Med 294:1247-1255,3 Jun 1976 2. Fortner JG, Kim OK, Shiu MH: Limb-preserving vascular surgery for malignant tumors of the lower extremity. Arch Surg 112:391-394, Apr 1977 3. Hudson TM, Haas G, Enneking WF, et al: Angiography in the management of musculoskeletal tumors. Surg Gynecol Obstet 141: 11-21,Ju11975 4. Strickland B: The value of arteriography in the diagnosis of bone tumours. Br J RadioI32:705-713, Nov 1959 5. Hawkins IF Jr, Hudson T: Prisco line in bone and soft-tissue angiography. Radiology 110:541-546, Mar 1974 6. Ekelund L, Lunderquist A: Pharmacoangiography with angiotensin. Radiology 110:533-540, Mar 1974 7. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography. A new technique. Acta RadioI39:368-376, May 1953 8. Viamonte M Jr, Roen S, LePage J: Nonspecificity of abnormal vascularity in the angiographic diagnosis of malignant neoplasms. Radiology 106:59-63, Jan 1973 9. Jonsson K, Wallace S, Jacobson ED: The use of prostaglandin E1 for enhanced visualization of the splanchnic circulation. Radiology 125:373-378, Nov 1977 1 From the Department of Radiology,MassachusettsGeneral Hospital and Harvard Medical School, Boston, MA. Received Nov. 28, 1978, and accepted Jan. 23, 1979. 2 Reprint requests: Department of Radiology,Johns Hopkins Hospital, Baltimore, MD 21205. 3 Priscoline, Ciba-Geigy, Summit, NJ. 4 Cook Inc., Bloomington, IN. 5 Renografin 76, Squibb. 6 Cook Inc., Bloomington, IN. 7 Ibid. 8 Renografin 76, Squibb. jr
noses that included pelvic carcinoma and lymphoma. The preferred site of incision was slightly proximal to the midpoint of the first and second metatarsals. Following local infiltration with 2 ml of 2 % Xylocaine, a transverse incision of 12 to 15 mm in length was made with very gentle pressure. Lymphatic vessels were identified and isolated, then properly anchored and cannulated. Although color dye was not used, it was not difficult to identify or isolate these vessels, as they were: (a) more transparent and clear than other tubular structures such as veins or fibrous tissue; (b) more elastic than veins or fibrous tissue; (c) more distensible than veins of the same size, due to their thin walls and elasticity; and (d) not tortuous, like veins; their branching pattern differs from that of the vein in that the branches run very close and almost parallel to each other before forming a single trunk. Sometimes they are contained in the same sheath. DISCUSSION Since the original report by Kinmonth (7), most of the literature on lymphography has supported the use of vital dyes in the identification of lymphatic vessels (1, 2, 5-8, 11, 12, 14). Only one previous English language paper has discussed lymphography without the use of vital dyes, to this author's knowledge
TECHNICAL NOTES
December 1979
Tolazoline-Augmented Arteriography in the Evaluation of Bone and Soft-Tissue Tumors 1 Saadoon Kadir, M.D.,2 Christos A. Athanasoulis, M.D., and Arthur C. Waltman, M.D. Twelve patients with bone tumors were prospectively evaluated by arteriography both with and without tolazoline. In general, tolazoline improved definition of tumor extent; however, in 2 patients with highly vascular tumors and 2 patients with hypovascular tumors, tolazoline did not improve visualization. In 3 of the 12 patients, the tolazoline-augmented study was less accurate than the nontolazoline study in defining tumor extent. Angiography, technique. Bone neoplasms, diagnosis. Tola(Skeletal system, angiography, 4[0].124)
INDEX TERMS:
zollne
s
Radiology 133:792-795, December 1979
Advances in surgical techniques have made possible a more aggressive approach to the management of malignant bone and soft-tissue tumors (1, 2). Although arteriography has played an important role in the preoperative evaluation of these tumors, with the introduction of pharmacological aids its role has become even more significant (3-6). We have recently re-evaluated the use of intra-arterial tolazoline'' in patients with musculoskeletal tumors and have compared its use with high-flow, high-volume arteriography. MATERIAL AND METHODS Between January 1974 and July 1978, 84 patients with bone and soft-tissue tumors of the extremities underwent preoperative arteriography. Twelve of these patients with bone tumors were evaluated prospectively. These tumors included 3 giant-cell tumors, 4 osteogenic sarcomas, 2 chondrosarcomas, and 2 fibrosarcomas. One patient who had a low-grade fibrosarcoma resected several years ago was evaluated for recurrence. AITABLE I:
Fig. 1. An 18-year-oldwoman with a giant-cell tumor of the distal humerus. A tolazoline-enhanced arteriogram shows a markedly vascular tumor with early venous drainage, and visualizes two vascular satellite lesions (arrows). though physical examination and xeroradiography demonstrated a mass, no recurrence could be demonstrated by histology. In all but 3 patients the lesions were located distal to the mid-thigh. One patient had a giant-cell tumor of the distal humerus, while
SUMMARY OF ARTERIOGRAPHIC FINDINGS WITHOUT AND WITH TOLAZOLINE IN PATIENTS WITH BONE AND SOFT-TISSUE TUMORS Before Tolazoline
No.
Tumor Type * / Location
Definition of SoftTissue Extention
Venous Opacification
+ + Absent + +++ ++ + +++ + ++ + ++ +++ +++ ++ Absent ++ ++ +++ ++++ ++++ Absent ++ ++ Absent + + Absent +++ + The + signs indicate the relative visualization, where ++++
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
F.S.lhumerus F.S.lfemur F.S.t /distal thigh G.C.T.ltalus G.C.T.lhumerus G.C.T.ltibia O.S.lfibula O.S.lfemur O.S.lfemur O.S./femur C.S.lfemur C.S.lhumerus ,
=
++ +
Arteriovenous Shunting
* F. S. fibrosarcoma, G.C.T. t Evaluation for recurrence.
Absent Absent Absent Absent
=
After Tolazoline
Visualization of Skip Lesions
Visualizatlon of Small Vessels
Absent Absent Absent Absent
++ ++ + ++ + ++ ++ ++ ++ ++ + ++
++ ++ + ++ ++ Absent Absent
++
Definition of SoftTissue Extention
+++ ++
Arteriovenous Shunting
Venous Opacification
Absent
++ ++ ++ ++++ ++++ ++++ +++ +++ ++++ ++ ++ ++
++
Absent
Absent
++++ ++++ +++ ++ + +++ ++ ++ ++
++++ ++++ +++ ++ Absent
++++ Absent Absent Absent
indicates the best visualization. giant-cell tumor, C.S. = chondrosarcoma, O.S. osteogenic sarcoma.
=
Visualization of Skip Lesions
Visualization of Small Vessels
Absent Absent Absent Absent
+++ +++ ++ ++++ ++++ +++ +++ +++ +++ +++ ++ ++++
++++ ++++ ++ +++ ++ Absent Absent
++
Technical Vol. 133
793 Notes
TECHNICAL NOTES
2a,b
Fig. 2. A 26-year~0Id woman with a giant-cell tumor of the talus. a. Nontolazoline arteriogram shows a vascular tumor with some soft-tissue extension (arrows). b. Arteriogram following bolus injection of 25 mg tolazoline in the distal superficial femoral artery. There is better tumor definition, and multiple early veins are identified (arrows).
another had a fibrosarcoma of the mid-humerus. One patient had a chondrosarcoma of the humeral head. Percutaneous femoral arteriography was performed using the technique described by Seldinger (7). For proximal lesions (thigh, knee) the contralateral femoral artery was used. For distal lesions (distal to knee) an antegrade femoral artery puncture was made. For lesions of the upper extremity the femoral artery approach was used; a 6.5-Fr H1H cameter' was placed in the axillary artery and 40 ml of contrast medturn" injected at 7 ml/sec. For lesions of the lower extremity, a multiple-hole 6.7-Fr straight catheter" was deflected over the aortic bifurcation using a handle deflector.? For distal lesions the catheter tip was placed in the distal superficial femoral artery and 40 ml of contrast medium" injected at 7 ml/sec. For proximal lesions the catheter tip was placed proximal to the common femoral bifurcation and 40 ml of contrast medium injected at 8 ml/sec. The initial arteriogram was obtained without tolazoline. Arteriography was then repeated after intra-arterial administration of a bolus of 25 mg tolazoline diluted with 2-3 ml of DsW. Films were exposed over 20 seconds with filming and exposure factors kept constant. Arteriography was performed in at least two projections using the alternating biplane technique. All arteriograms were reviewed by two vascular radiologists without prior knowledge of which study was performed with tolazoline.
RESULTS The results of the 12 patients studied are summarized in TABLE
I. Three of these patients had poorly vascularized tumors. The 1 patient who was evaluated for recurrence of his low-grade fibrosarcoma is not included here, as the histology showed no abnormal tissue. Nontolazoline arteriograms in these 3 patients showed vascular displacement with no neovascularity and poor or absent tumor stain. The tolazoline-augumeted arteriogram demonstrated normal muscle vasculature in greater detail, and in 2 patients it did not show any significant changes in the areas of the known tumor. In the 1 other patient the tumor definition was enhanced slightly. In the other 8 patients with tumors showing a moderate to high degree of vascularity, in general, tolazoline was found to be advantageous, as it: (a) improved visualization of smaller vascular structures (arteries and veins), thus improving the definition of the tumor, (b) visualized or better defined skip or satellite lesions (Fig. 1), and (c) opened the arteriovenous communications, thus opacifying early and often large draining veins. This aspect was found to be particularly helpful if the nontolazoline study showed a vascular tumor without opacification of draining veins (Fig. 2).
794
TECHNICAL NOTES
December 1979
3,4
Fig. 3. A 22-year-old man with a giant-cell tumor of the proximal fibula. Lateral projection from the nontolazinearteriogram shows the soft-tissue extent (open arrows) of the vascular tumor and an early opacifying vein (curved white arrow). Fig. 4. Same patient as in Figure 3. Lateral frame from the arteriogram obtained after intra-arterial bolus injection of 25 mg Priscoline shows poor definition of the distal margin of the tumor due to increased opacification or normal soft tissue. A central avascular area is now obvious.
In 2 patients with highly vascular tumors, tolazoline was not found to be of any advantage. In 1 patient with an osteogenic sarcoma of the distal femur (Patient 10), the nontolazoline arteriogram depicted the tumor extent and vascularity quite accurately. In the tolazoline arteriogram there was earlier opacification of tumor vessels, but tumor definition was the same. In the other patient (Patient 9) with a markedly vascular osteogenic sarcoma of the distal femur, the arteriograms showed no differences in tumor definition or early opacification of large draining veins. In 3 patients the tolazoline-augmented study would have been
disadvantageous if it had been evaluated without the nontolazoline arteriogram (Patients 7, 8, and 12). One of these patients had a vascular osteogenic sarcoma of the proximal fibula with a large soft-tissue mass which was quite accurately defined by the nontolazoline arteriogram. In addition, there was opacification of an early draining vein (Fig. 3). The repeat study after injection of 25 mg tolazollne produced dilatation of the smaller vessels of the calf which resulted in poorer definition of the tumor (Fig. 4). Furthermore, the previously identified arteriovenous shunting was no longer seen, possibly as a result of diversion of the contrast medium to the newly opened vascular bed. The
late venous phase of this study did demonstrate some venous encasement by the tumor. In addition, a skip lesion was identified over the distal thigh. The nontolazoline arteriogram demonstrated circumferential narrowing of several branches of the anterior tibial artery which could be interpreted as tumor encasement. However, the tolazoline-augmented study showed dilatation of these vessels confirming the presence of vascular spasm (Figs. 3 and 4). In the other patients with a chondrosarcoma of the humerus and osteogenic sarcoma of the femur, tumor definition was also poor following tolazoline. No systemic side effects were noted with intra-arterial tolazoline. DISCUSSION In evaluating bone and soft-tissue tumors, the role of angiography is mainly to define extent, satellite lesions, vascularity, and venous drainage. Determination of tumor extent is necessary if radical excision or resection with allograft replacement is planned. Tumor vascularity is an important indicator for the anticipated intraoperative blood loss and whether preoperative embolization should be attempted. Much importance has been attributed to the identification of any large venous structure draining the tumor, in order to facilitate early ligation and thus prevent tumor embolization during surgery (3). Pharmacoangiography utilizing tolazoline, angiotensin, epinephrine, and prostaglandins has been of considerable help in defining the abnormal vascularity and determining the extent of tumors (3,
5,6,8,9). Our observations indicate that tolazoline-augmented arteriography offers several advantages, but the use of high-flow, high-volume arteriography may accomplish the same for some tumors with a moderate to high degree of vascularity. On the other hand, in hypovascular tumors the definition of the lesion remains poor or may be obscured by the enhancement of normal soft-tissue vascularity. Therefore the initial arteriogram should
Lymphography Without the Use of Vital Dyes 1 Chandrakant C. Kapdi, M.D. Pedal lymphography was performed without the use of vital dyes in 510 patients. Lymphatic vessels were still readily identifiable by this method, due to their transparency, clarity, elasticity, distensibility, and characteristic branching pattern. Procedure time was shortened by 10-15 minutes without compromising the high success rate. INDEX TERMS:
795
TECHNICAL NOTES
Vol. 133
Lymphography, contrast media. Lymphography, technique
Radiology 133:795-796, December 1979
The use of vital dyes for lymphography has been increasingly restricted by the FDA. For the past four years, this author has successfully performed 510 consecutive pedal lymphographies without compromising the high success rate. This method has not only prevented allergic reactions which are not uncommon with color dye, but has also resulted in saving time by eliminating the period of waiting for lymphatic vessels to become visible. TECHNIQUE Patients studied ranged in age from 9 to 82 years, with diag-
Technical Notes
be without tolazoline, but if additional specific information is sought, a tolazoline-augmented arteriogram should be obtained. REFERENCES 1. Mankin HJ, Fogelson FS, Thrasher AZ, et al: Massive resection and allograft transplantation in the treatment of malignant bone tumors. N Engl J Med 294:1247-1255,3 Jun 1976 2. Fortner JG, Kim OK, Shiu MH: Limb-preserving vascular surgery for malignant tumors of the lower extremity. Arch Surg 112:391-394, Apr 1977 3. Hudson TM, Haas G, Enneking WF, et al: Angiography in the management of musculoskeletal tumors. Surg Gynecol Obstet 141: 11-21,Ju11975 4. Strickland B: The value of arteriography in the diagnosis of bone tumours. Br J RadioI32:705-713, Nov 1959 5. Hawkins IF Jr, Hudson T: Prisco line in bone and soft-tissue angiography. Radiology 110:541-546, Mar 1974 6. Ekelund L, Lunderquist A: Pharmacoangiography with angiotensin. Radiology 110:533-540, Mar 1974 7. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography. A new technique. Acta RadioI39:368-376, May 1953 8. Viamonte M Jr, Roen S, LePage J: Nonspecificity of abnormal vascularity in the angiographic diagnosis of malignant neoplasms. Radiology 106:59-63, Jan 1973 9. Jonsson K, Wallace S, Jacobson ED: The use of prostaglandin E1 for enhanced visualization of the splanchnic circulation. Radiology 125:373-378, Nov 1977 1 From the Department of Radiology,MassachusettsGeneral Hospital and Harvard Medical School, Boston, MA. Received Nov. 28, 1978, and accepted Jan. 23, 1979. 2 Reprint requests: Department of Radiology,Johns Hopkins Hospital, Baltimore, MD 21205. 3 Priscoline, Ciba-Geigy, Summit, NJ. 4 Cook Inc., Bloomington, IN. 5 Renografin 76, Squibb. 6 Cook Inc., Bloomington, IN. 7 Ibid. 8 Renografin 76, Squibb. jr
noses that included pelvic carcinoma and lymphoma. The preferred site of incision was slightly proximal to the midpoint of the first and second metatarsals. Following local infiltration with 2 ml of 2 % Xylocaine, a transverse incision of 12 to 15 mm in length was made with very gentle pressure. Lymphatic vessels were identified and isolated, then properly anchored and cannulated. Although color dye was not used, it was not difficult to identify or isolate these vessels, as they were: (a) more transparent and clear than other tubular structures such as veins or fibrous tissue; (b) more elastic than veins or fibrous tissue; (c) more distensible than veins of the same size, due to their thin walls and elasticity; and (d) not tortuous, like veins; their branching pattern differs from that of the vein in that the branches run very close and almost parallel to each other before forming a single trunk. Sometimes they are contained in the same sheath. DISCUSSION Since the original report by Kinmonth (7), most of the literature on lymphography has supported the use of vital dyes in the identification of lymphatic vessels (1, 2, 5-8, 11, 12, 14). Only one previous English language paper has discussed lymphography without the use of vital dyes, to this author's knowledge
