Invasion by Lymphatic Permeation

Lymphatic permeation plays an apparently minor role in the dissemination of secondary neoplasms of the bowel. The process refers to lymphatic-borne tumor emboli from a primary neoplasm of the bowel, which may not be arrested in the nearest lymph nodes along the chain of drainage. Rather, complete blockage of a more remote node can occur from cellular impaction, with retrograde passage along other afferent channels to involve a segment of bowel adjacent to, or at some distance from, the primary carcinoma (Fig. 4-81). It has been documented that metastatic tumor cells may be carried for considerable distances beyond the usual route by this altered lymph flow.77 This process may play a role in anastomotic recurrence following resection of the colon for carcinoma (Fig. 4-82). It appears to be a major factor in some cases of local bowel metastases.78,79

The deranged lymph flow in the initial stages may be radiologically demonstrated as edema in the wall of the bowel with mucosal thickening and luminal narrowing (Figs. 4-83 and 4-84). As the metastatic lymphatic edema increases, nodular tumor deposits occur that may be evident as "thumbprinting" in the colon and "cob-blestoning" of the small intestine (Fig. 4-85), changes mimicking inflammatory bowel disease.78 79 Radiologic demonstration of these findings indicates that extensive lymphatic permeation has occurred and that resection will not be curative.77 The process can also result in diversion of lymph flow into veins through direct lym-phaticovenous communications81 or through shared channels intrinsic to lymph nodes.82

Lymphatic permeation also explains the rare form of insidious widespread linitis plastica of the intestines that can follow carcinoma of the stomach.83

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Fig. 4—64. The gastrosplenic ligament.

CT scans on two different patients with ascites (A) demonstrate the gastrosplenic ligament (GSL) by virtue of its fatty elements and contained blood vessels. RL = right lobe of the liver; GHL = gastrohepatic ligament; GB = gallbladder; St = stomach; DU = duodenum; PB = pancreatic body; LS = lesser sac.

Gastrohepatic Ligament Ascites

Fig. 4—65. Lymphoma within the gastrosplenic ligament.

Nodal mass (M) in the gastrosplenic ligament separates the stomach (St) from the enlarged spleen (Sp).

Fig. 4—65. Lymphoma within the gastrosplenic ligament.

Nodal mass (M) in the gastrosplenic ligament separates the stomach (St) from the enlarged spleen (Sp).

Lymphatic PermeationStomach Plastic Linitis

Fig. 4-66. Extension of gastric carcinoma into gastrosplenic ligament.

(a) Upper GI series demonstrates an infiltrating carcinoma of the greater curvature of the stomach. Extramural spread cannot be determined.

(b) CT scan documents nodal metastases (M) within the gastrosplenic ligament between the thickened irregular wall of the stomach (St) and the spleen (Sp).

(Reproduced from Meyers et al.9)

Fig. 4-66. Extension of gastric carcinoma into gastrosplenic ligament.

(a) Upper GI series demonstrates an infiltrating carcinoma of the greater curvature of the stomach. Extramural spread cannot be determined.

(b) CT scan documents nodal metastases (M) within the gastrosplenic ligament between the thickened irregular wall of the stomach (St) and the spleen (Sp).

(Reproduced from Meyers et al.9)

Fig. 4—67. Spread of gastric carcinoma across the gastro-splenic ligament to the spleen.

(a) An ulcerated adenocarcinoma of the stomach (St) is shown by the marked thickening of the greater curvature. Sp = spleen.

(b) The malignancy has extended across the gastrosplenic ligament to invade the splenic hilar fat. Metastatic lymph nodes are also seen along the lesser curvature.

(Courtesy of Gary Ghahremani, M.D., Evanston Hospital, Evans-ton, IL.)

Lymphedema ScanScan Gastric Carcinoma

Fig. 4-68. Extension of gastric carcinoma to invade the spleen.

A carcinoma that diffusely involves the stomach with wall thickening and bulky mass spreads widely across the gastro-splenic ligament to infiltrate the spleen. (Courtesy of Yong Ho Auh, M.D., Asan Medical Center, Seoul, Korea.)

Fig. 4—69. Spread of gastric carcinoma across the gastrosplenic ligament to the spleen. (a and b) Tract across the gastrosplenic ligament (arrow) establishes continuity between infiltrating carcinoma of stomach (St) and abscess cavity (A) within spleen.

Fig. 4—69. Spread of gastric carcinoma across the gastrosplenic ligament to the spleen. (a and b) Tract across the gastrosplenic ligament (arrow) establishes continuity between infiltrating carcinoma of stomach (St) and abscess cavity (A) within spleen.

Gastrosplenic Ligament

Fig. 4-70. Spread of gastric lymphoma across the gas-trosplenic ligament to the spleen, (a and b) Lymphoma-tous thickening of wall of stomach (St) directly continues across gastrosplenic ligament (arrow) to the development of a large communicating abscess cavity (A) within the spleen.

Lymphatic PermeationLymphatic PermeationSplenorenal Ligament

Fig. 4—71. Spread of gastric carcinoma to gastrosplenic and splenorenal ligaments.

(a) An ulcerated carcinoma of the stomach (St) extends as a mass (M) within the gastrosplenic ligament.

(b) At a lower level, the mass continues into the splenorenal ligament to displace the pancreatic tail (PT) posteriorly away from the spleen (Sp).

Fig. 4—71. Spread of gastric carcinoma to gastrosplenic and splenorenal ligaments.

(a) An ulcerated carcinoma of the stomach (St) extends as a mass (M) within the gastrosplenic ligament.

(b) At a lower level, the mass continues into the splenorenal ligament to displace the pancreatic tail (PT) posteriorly away from the spleen (Sp).

Fig. 4-72. Continuity of gastric carcinoma into gastro-splenic and splenorenal ligaments.

(a) The mass (M) of an ulcerated carcinoma of the stomach (St) extends into the gastro-splenic ligament in relation to the spleen (Sp).

(b) Celiac arteriogram documents extension into the spleno-renal ligament by virtue of neo-plastic beading of the splenic artery (arrow).

Phrenicocolic LigamentPhrenicocolic Ligament

Fig. 4—73. The phrenicocolic ligament.

(a) Frontal drawing of the sites of the major posterior ligaments of the left upper quadrant shows that all have continuity with the phrenicocolic ligament.

(b) In a patient with ascites, CT scan demonstrates the phrenicocolic ligament (arrow) extending laterally from the region of the anatomic splenic flexure of the colon.

(Reproduced from Meyers et al.9)

Fig. 4—73. The phrenicocolic ligament.

(a) Frontal drawing of the sites of the major posterior ligaments of the left upper quadrant shows that all have continuity with the phrenicocolic ligament.

(b) In a patient with ascites, CT scan demonstrates the phrenicocolic ligament (arrow) extending laterally from the region of the anatomic splenic flexure of the colon.

(Reproduced from Meyers et al.9)

Phrenicocolic Ligament

Fig. 4-74. Spread of pancreatic carcinoma into phrenicocolic ligament.

(a) Barium enema demonstrates lateral mass impression upon the anatomic splenic flexure of the colon (arrow). Incidental diverticula are present.

(b) CT scan shows a carcinomatous mass (M) arising from the tail of the pancreas anterior to the thickened anterior renal fascia (arrow) within the splenorenal ligament approaching the spleen (Sp). A component of the mass (m) has invaded the perirenal space.

(c) At a lower level, there is spread of the mass (M) into the phrenicocolic ligament anterior to the renal fascia (arrow) pressing upon the lateral aspect of the anatomic splenic flexure of the colon (C), as indicated initially by the barium enema. A component of the mass (m) has invaded the left kidney.

Lymphatic Permeation Lymphedema ScanLymphatic Permeation

Fig. 4—75. Spread of pancreatic carcinoma into phrenicocolic ligament.

(a) CT demonstrates carcinoma of the pancreatic tail (arrow) located near the splenic flexure of the colon.

(b) Barium enema study shows serration of the wall of the splenic flexure (arrows).

(c) Endoscopic ultrasonography confirms invasion by the pancreatic carcinoma (ca) into the muscularis propria (pm) of the splenic flexure.

(Reproduced from Hirata et al.71)

Fig. 4-76. Relationships of the small bowel mesentery.

Anatomic cross-section illustrates an extension of the small bowel mesentery (SBM) suspending jejunal loops (J). Anatomic continuity is established between the extraperitoneal anterior pararenal space and the intraperitoneal small bowel mesentery. RK = right kidney; LK = left kidney; Ao = aorta; IVC = inferior vena cava. (Reproduced from Meyers et al.9)

Fig. 4-76. Relationships of the small bowel mesentery.

Anatomic cross-section illustrates an extension of the small bowel mesentery (SBM) suspending jejunal loops (J). Anatomic continuity is established between the extraperitoneal anterior pararenal space and the intraperitoneal small bowel mesentery. RK = right kidney; LK = left kidney; Ao = aorta; IVC = inferior vena cava. (Reproduced from Meyers et al.9)

Hazy Small Bowel Mesentery

Fig. 4—77. Mesenteric pathways to small bowel loops.

Sagittal ultrasound scan shows loops of small bowel (s), floating in massive ascites (A), are attached by their mesentery (m).

(Courtesy of Francis S. Weill, M.D., University Hospital, Besançon, France.)

Fig. 4—77. Mesenteric pathways to small bowel loops.

Sagittal ultrasound scan shows loops of small bowel (s), floating in massive ascites (A), are attached by their mesentery (m).

(Courtesy of Francis S. Weill, M.D., University Hospital, Besançon, France.)

Lymphatic Permeation

Fig. 4-78. CT identification of the small bowel mesentery.

Discrete vasa recta penetrate the mesenteric border of a small bowel loop (SB).

Fig. 4-78. CT identification of the small bowel mesentery.

Discrete vasa recta penetrate the mesenteric border of a small bowel loop (SB).

Online Scan Sample

Fig. 4-79. Spread of lymphoma within the mesentery.

Hodgkin's lymphoma produces stellate infiltration of the small bowel mesentery and mural thickening of the mesenteric side of an opacified loop (arrow). (From Meyers et al.9)

Stellate Mesentery

Fig. 4-80. Distinction of mesenteric and retroperitoneal masses.

(a) In a patient with lymphoma, enlarged retroperitoneal nodes (N) can be distinguished from extensive mesenteric nodal masses (M) by virtue of an intact fat plane (arrows) of the anterior pararenal space. The mesenteric masses themselves exhibit the "sandwich" sign.

(b) The distinction between anatomically distinct compartments is further confirmed at a lower level by the partial interposition of opacified small bowel loops (arrows) approaching the root of the mesentery between the ex-traperitoneal tissues and the mes-enteric mass (M). (Reproduced from Meyers et al.9).

Fig. 4-81. The mechanism of lymphatic permeation.

Tumor cells may be transported through the draining chain of lymph nodes (1,2) to impact a more central node (3), with retrograde permeation then occurring.

Side Side Ileotransverse Anastomosis

Fig. 4-82. Anastomotic recurrence.

This occurred following right hemicolectomy for carcinoma and ileotransverse colostomy. Lymphatic permeation may be a contributing factor.

Fig. 4-82. Anastomotic recurrence.

This occurred following right hemicolectomy for carcinoma and ileotransverse colostomy. Lymphatic permeation may be a contributing factor.

Transverse Colon Mucous Fistula

Fig. 4-83. Carcinoma of the cecum with lymphatic permeation.

A spot compression view of the terminal ileum shows a cecal carcinoma exhibiting a short stricture with mucosal destruction and shouldering of the margins. Retrograde lymphatic spread into the terminal ilieum results in a neoplastic mass at this site larger than the primary cecal carcinoma.

(Reproduced from Gourtsoyian-nis and Nolan.80)

Lymphatic Permeation

Fig. 4-84. Carcinoma of the cecum with lymphatic permeation.

Enteroclysis study shows thickening of the valvulae conriiventes with narrowing of the lumen of the terminal ileum. Operation disclosed an occult small carcinoma of the cecum with extensive lymphatic spread to the terminal ileum.

(Reproduced from Gourtsoyiannis and Nolan.80)

Have Another Test Barium Enema

Fig. 4—85. Carcinoma of the hepatic flexure with lymphatic permeation simulating Crohn's disease.

(a) Barium enema shows a severe long stenosis in the hepatic flexure secondary to a primary adenocarcinoma with colocolonic fistulization (arrow). "Thumbprinting" is present in the ascending colon and terminal ileum, and the appendix shows spiculation and nodularity.

(b) Small bowel examination demonstrates a "cobblestone" appearance in the terminal ileum and thickening of the ileocecal valve.

(c) Histologic findings include submucous lymphatic infiltration by carcinoma cells (arrows). Some metastatic cell groups are invading the normal intestinal mucosa in retrograde fashion (arrowheads).

(Reproduced from Perez et al. )

Fig. 4—85. Carcinoma of the hepatic flexure with lymphatic permeation simulating Crohn's disease.

(a) Barium enema shows a severe long stenosis in the hepatic flexure secondary to a primary adenocarcinoma with colocolonic fistulization (arrow). "Thumbprinting" is present in the ascending colon and terminal ileum, and the appendix shows spiculation and nodularity.

(b) Small bowel examination demonstrates a "cobblestone" appearance in the terminal ileum and thickening of the ileocecal valve.

(c) Histologic findings include submucous lymphatic infiltration by carcinoma cells (arrows). Some metastatic cell groups are invading the normal intestinal mucosa in retrograde fashion (arrowheads).

(Reproduced from Perez et al. )

Parasitic Fibroid

Fig. 4—86. Direct invasion of the sigmoid colon by a leiomyosarcoma (malignant fibroid) of the uterus.

Large pelvic mass displaces and fixes the colon, with gross distortion and tethering of the mu-cosal folds from the associated desmoplastic reaction. (Reproduced from Meyers and McSweeney. )

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  • victoria
    Have Another Test Barium Enema?
    7 years ago

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