[Direct lymphography with special reference to peripheral lymphedema. Historical retrospect--technique--indications--alternative procedures--image documentation]. / Direkte Lymphographie unter besonderer Berücksichtigung des peripheren Lymphödems. Historischer Rückblick--Technik--Indikation--Alternativverfahren--Bilddokumentation

Indication for direct lymphography during the past forty years shows a downward tendency, mainly because of new alternative modern imaging methods. Nevertheless, in agreement with the actual literature it can be shown by own investigations with 8000 patients from 1964 to 1989 that one cannot give up lymphography totally. On principle lymphography is still carried out in case of testicular tumors, malignant lymphomas, unclear fever, lymphatic vessel injury and facultative in peripheric lymph edemas.

[Sudeck disease]. / Morbus Sudeck.

In 1900, the Hamburg surgeon P.H.M. Sudeck was the first to describe the clinical and radiological symptomatology of the disorder to which he later lent his name. He devoted his scientific career to this disorder, "acute inflammatory atrophy" of bone and soft-tissue as he called it. He elaborated the histology of the disorder with his students and advocated the pathogenic peripheral humoral theory. In later years seven further attempts to explain the pathogenesis were published. The present paper notes that this disorder, which can be divided into three distinct stages, is diagnosed mainly on the basis of clinical factors, above all in the early stage, and that x-rays in the early stages are difficult to differentiate from those of immobilisation osteoporosis since both disorders can manifest as patchy rare fraction and fibrous osteolysis in subchondral bone and old growth plates. Moreover, the author also notes that 10% of all Sudeck cases are not preceded by trauma; these must be understood as spontaneous Sudeck or as Sudeck after distant disturbances. A few sources also refer to Sudeck's dystrophy in the presence of lymphatic congestion. Another, special form of Sudeck's atrophy, is the shoulder-hand syndrome which, however, cannot always be differentiated precisely from rheumatic disorders or dystrophic contractures.

[Stewart-Treves syndrome of the edematous arm following breast cancer operation]. / Stewart-Treves-Syndrom am ödematösen Arm nach Brustkrebsoperation.

In 1948, Stewart and Treves (158) described a lymphangiosarcoma on the edematous arm for the first time with reference to six cases involving arm edema after breast cancer operation. Since their publication, a further 313 cases have become known. In 1982, with communication of one case we published a statistical compilation comprising of 248 cases (Zeitschrift für Lymphologie VI, 1982, 51-66). A statistical compilation totalling 290 observations is now presented on the basis of further studies of the older literature supplemented by observations of the last six years including two of our own cases. So far, a total of 319 single observations has become known: 21 cases of Yap et al. (182), eight cases of Oshmianskaia et al. (123) and 290 cases in the statistical compilation we have drawn up and which is the basis of this publication. By histological investigation of the tissue material taken from a female patient within six weeks (exploratory excision, radical excision), detailed information could be obtained on the histological development of the Stewart-Treves-Syndrome (STS) from a preneoplasia to a mature lymphangiosarcoma. The second female patient is a relatively rare observation of an STS of fulminant course which remained restricted to the extremity, chest wall and neighboring parts of the back during the entire course.

[Secondary leg edema--experimental study]. / Sekundäres Beinödem--experimentelle Untersuchungen.

Peripheral lymphedema can be induced experimentally by obliteration or destruction of the veins and/or lymphatics, extirpation of the lymph nodes and occlusion of lymphatics, circular incision of the soft tissues, experimentally induced thrombophlebitis and by simultaneous traumatization of the veins and lymphatics. Our own animal experiments were designed to provoke leg edema after ligation of the femoral vein and/or accompanying lymphatics below the inguinal ligament. In 23 animals, only one ligature of the femoral vein was applied, below the inguinal ligament and in 12 animals all accompanying lymphatics were ligated in addition. In all animals, the leg circumferences were measured in three precisely fixed positions before the experiments and daily for 22 days during the experiment. The greatest increase in circumference was found in the lower leg irrespective of the time of measurement. The peak increase of circumference was between the third and sixth day after the operation. Permanent lymph edema has not developed in any of the animals. At the latest after three weeks, the leg circumference has normalized. Additional ligation of the lymphatics merely led to a nonsignificant increase in circumference and to displacement of the maximum point by two to three days. Immediately after the operation, phlebographic and lymphographic control investigations were carried out in all animals.

[The value of lymphography of malignant testicular tumors]. / Der Stellenwert der Lymphographie bei malignen Hodentumoren.

Between 1965 and 1968, 6500 lymphograms were performed at the University of Göttingen. Amongst these, there were 412 patients with malignant testicular tumours. In 81 patients the results of lymphography could be checked histologically. There was agreement between the lymphographic and histological findings in 65 patients (80.3%), sensitivity of 98.1% (51 out of 52) and specificity of 48.3% (14 out of 29). In 50 patients CT was performed in addition. The findings agreed in 31 cases; in eight patients lymphangiography resulted in a false positive finding and CT was incorrect in 12 patients. In all patients with proven retroperitoneal metastases, one or the other method produced a correct diagnosis.

[Staging in non-Hodgkin's lymphomas]. / Staging bei Non-Hodgkin-Lymphomen.

In the period from 1970 to 1986, 46 patients with non-Hodgkin's lymphoma were laparotomized and splenectomized at the Surgery Division, University of Göttingen. The operation was frequently carried out in advanced or generalized stages with a therapeutic indication and served for purely diagnostic purposes in only a proportion of the cases. The Kiel classification was chosen for the histology. Accordingly, hairy-cell leukemia (14 cases) and chronic lymphatic leukemia (12 cases) were the most frequent diagnoses, followed by LP immunocytoma and centroblastic-centrocytic lymphoma (seven cases each). In four out of the 20 clinical pictures which were not already generalized by definition, i.e. in 20% of the cases, exploratory laparotomy resulted in a change of stage (comprising two improvements and two deteriorations). The spleen was affected in 41 out of the 46 patients; in addition, lymphomatous infiltrations were found in six of the 12 liver biopsies taken and in 15 out of 17 lymph node preparations taken. The average spleen weight in the NHL patients (1,623 g) was markedly higher than in a reference group of Hodgkin patients (317 g). With critical establishment of the indication, exploratory laparotomy with splenectomy in histologically verified NHL and lymphography in the clinical staging are the most precise methods of investigation in graduated diagnosis of non-Hodgkin's lymphomas.

[Staging in Hodgkin's lymphoma. Exploratory laparotomy with splenectomy]. / Staging beim Hodgkin-Lymphom. Explorative Laparotomie mit Splenektomie.

In the present paper, 66 Studies on exploratory laparotomy with splenectomy in Hodgkin's lymphoma from Western Europe and the USA are presented in tables. This statistical compilation on 7183 laparotomies shows that the spleen was involved in 39.9% (2685 out of 6900 cases investigated), the liver in only 7.7% (446 out of 5789) and the abdominal lymph nodes were involved in 30.3% (1389 out of 4578) of the cases. Altogether, laparotomy with splenectomy led to a change in staging in 33% of the patients (1892 out of 5745). In the period from 1970 to 1986, 123 patients with Hodgkin's lymphoma were laparotomized (and also splenectomied apart from one exception) at the Surgical Division, University of Göttingen. The patients comprised 52 cases in the context of primary staging and 71 cases in the context of secondary staging. In 43 cases (35.2%) the spleen was affected, in seven cases (5.7%) the liver was affected, and there was combination with spleen involvement in each case. Infiltration of abdominal lymph nodes was shown in 38.2% (26/68). Exploratory laparotomy led to a change in stage in 46 cases (37.1%) comprising 28 improvements and 18 deteriorations. Before laparotomy, 15 patients were in stage I, 29 in stage II, 44 in stage III and 21 in stage IV. After pathological staging, 14 were in stage I, 40 were in stage II, 47 were in stage II and 19 were in stage IV. Out of the 14 patients who could not be assigned to any stage before the operation, 11 could be definitively staged afterwards. In addition, lymphography was performed in 103 patients, liver and spleen scintigraphy in 51 patients, sonography in 30 patients and computer tomography in 22 patients. In the re-examination of the lymph node situation in the retroperitoneal space, lymphography attained a specificity of 48% and a sensitivity of 71.4% with a positive prediction precision of 35.7% and a negative prediction precision of 88.8%.

[Lymphography in Hodgkin's lymphoma. Diagnostic value based on the current status of experience and knowledge]. / Die Lymphographie beim Hodgkin-Lymphom. Der diagnostische Stellenwert aufgrund des heutigen Erfahrungs- und Wissensstandes.

Lymphography was carried out at least once in 355 patients with Hodgkin's lymphoma (HL). In 229 patients, there was a histological subclassification: 26 LP, 63 NS, 122 NC and 18 LD cases. The lymphographic manifestations could be subdivided empirically into two superordinate groups: 1. lymph nodes closely linked together in chains (LC) with dense structures as well as LC destructions, LC debris and 2. LC of varying size with pathological internal structure. Apart from in the NS type, a correlation between the lymphological appearance and the histological subtype could not be discerned in any other histological subgroup. After lymphography, 61.6% of stages I and II were assigned to stage III. The staging of the lymphography was: stage I 24.5%, stage II 47.3%, stage III 10% and stage IV 9%, and after lymphography: stage I 9.9%, stage II 17.7%, stage III 63.1% and stage IV 9.3%. From a qualitative point of view, lymphography is superior to all other methods in the diagnosis of malignant lymphomas and should hence be carried out obligatorily in suspicion of a malignant lymphoma.

[Lymphography in malignant testicular tumors]. / Die Lymphographie bei malignen Hodentumoren.

Experience and results are reported on the basis of more than 380 lymphographic investigations in patients with a malignant testicular tumor. In 61% of these patients, there was suspicion of a metastatic infiltration of the retroperitoneal lymph nodes. In 75 patients, histological checking of the lymphographic finding was possible on the basis of a retroperitoneal lymphadenectomy. Lymphography was shown to have a precision of 81%. Lymphography is obligatory as a complement to other techniques of investigation such as sonography and computer tomography in patients with malignant testicular tumor, since the greatest diagnostic information can be expected from combined application of all three methods.

[Roentgen anatomy of the lymphatic system]. / Röntgenanatomie des Lymphgefässsystems.

The enormous advances in medicine in the last 30-40 years are chiefly attributable to the constant technical development in imaging and investigation techniques. The instruments offered by the industry, which must be renewed every ten years, the hunger of doctors for information and not least the high expectation of the patients must be reconciled with our action. Besides this rapid technical development in the sector of instrumental medicine, diagnostic and therapeutic techniques have been established in precisely the same period since the beginning of the 1950's, even in the field of the more patient-related medicine. These have proved to be epoch-making, especially in lymphology, namely lymphography and therapeutic lymphatic drainage. There is no doubt that the introduction of modern diagnostic techniques such as computer tomography and nuclear spin tomography has resulted in reduction of the indication for lymphography. However, even today it is still irreplaceable by other methods in diseases of the lymphatic system, in testicular tumors, and also in lymphedema. For this reason, we consider that it is appropriate that lymphography be recalled to memory as a selective technique for application in the lymphatic system.

[Computed tomography and nuclear spin tomography in peripheral lymphedema]. / Computertomographie und Kernspintomographie beim peripheren Lymphödem.

The first reported findings on CT and N.M.R. in two cases of idiopathic peripheral lymphoedema are described. These methods have compared with the generally available volume estimations (volume estimation according to Kuhnke, immersion plethysmography) and have been considered in relation to visual and lymphographic examinations.

[Primary lymphedema]. / Das primäre Lymphödem.

Secondary peripheral lymphedemas (all edemas based on pontine symptoms) are very much more frequent than primary edemas which are either congenital or due to a predisposition. Of the latter, only hereditary (essential) lymphedema and idiopathic lymphedema (lymphedema praecox) play a role in clinical practise with the regard to their incidence. The exceedingly rare hereditary lymphedemas, which differ from the primary noncongenital lymphedemas only with regard to the demonstrated heritability merely have a clinical significance. Thus for example only six such cases occurred amongst our patients in the last 20 years. Most primary lymphedemas occur at the time of puberty with a time span of 10 to 30 years. Primary lymphedemas can also occur within a genuine clinical picture (flat nevi, Recklinghausen disease etc.), so that underlying symptoms must be looked for when they occur.