Lymphocele and Cyst Drainage and Sclerosis
Danny Cheng
Parag Amin
Thuong G. Van Ha
Cystic lesions are commonly encountered on cross-sectional imaging and are usually an incidental finding without associated symptoms. They can be classified as either congenital or acquired. Cysts can occur in virtually any solid organ. When congenital, they are most common in the liver, pancreas, kidney, and ovary. Acquired cystic lesions such as lymphoceles, hematomas, seromas, urinomas, and bilomas can occur after surgery, trauma, or infection. Histologically, there are two broad categories: (a) true cysts, which are lined by epithelium, or (b) pseudocysts lined by fibrous or granulation tissue without epithelium. Symptoms may arise if they are large, complicated by hemorrhage or infection, or have undergone torsion. Excepting torsion (which should be treated surgically), single-session or multisession percutaneous aspiration and catheter drainage with or without sclerotherapy is a viable management strategy (1,2).
Percutaneous aspiration allows diagnostic analysis and can be therapeutic. When a cyst is large, catheter drainage is more efficient because a liter or more of fluid may be present (1). The catheter can be left in place for persistent drainage in the case of fluid reaccumulation. Cyst obliteration can occasionally be achieved via chronic drainage alone. If a cyst recurs after aspiration or drainage, sclerotherapy is a safe and effective option (3,4).
Sclerosants include povidone-iodine, tetracycline/doxycycline, bleomycin, cyanoacrylate, sodium tetradecyl sulfate, hypertonic saline, and acetic acid.
Although no consensus exists on sclerosant of choice, ethanol is readily available, inexpensive, and well-tolerated (2). More recently, sclerosis of lymphoceles has been performed with a fibrin-based tissue sealant (TISSEEL).
Although no consensus exists on sclerosant of choice, ethanol is readily available, inexpensive, and well-tolerated (2). More recently, sclerosis of lymphoceles has been performed with a fibrin-based tissue sealant (TISSEEL).
Indications
1. Pain/discomfort: referred or localized (5)
2. Secondary infection
3. Functional sequelae of mass effect
a. Renal cysts—hematuria, collecting system compression, hypertension (2)
b. Lymphoceles—leg swelling, thrombophlebitis, renal transplant dysfunction (6)
c. Hepatic, renal, splenic cysts—biliary (jaundice/cholestasis) or bowel obstruction (constipation/early satiety)
Contraindications
Absolute
1. Communication with vital structures such as blood vessels, biliary system, pancreatic duct, or renal collecting system
2. Communication with the peritoneal cavity/retroperitoneum (particularly in cases of prior surgery)
3. Lack of a safe window for percutaneous access
Relative
1. Coagulopathy
2. Noncompliant patient (particularly if a drain is to be left in place for multisession therapy)
Preprocedure Preparation
1. Symptom/laboratory evaluation with imaging correlation
a. Do patient symptoms (early satiety, urinary frequency, pain, etc.) correlate to site of known cystic lesion?
b. Do laboratory abnormalities (hyperbilirubinemia, elevated serum creatinine, etc.) correlate to site of known cystic lesion?
2. Imaging
a. Ultrasound, computed tomography (CT), and/or magnetic resonance (MR) imaging to characterize the lesion (simple vs. complex, soft tissue nodularity to suggest malignancy, vascularity). If lesion is large and/or poorly seen on ultrasound, obtain CT or MR imaging to fully characterize its extent and internal structure.
b. Evaluate safety/possibility of percutaneous access, adjacent vital structures, and choose mode of imaging guidance. Because most symptomatic cystic lesions are large and fluid-filled, the majority are easily accessed under sonographic guidance.
c. If cystic/necrotic neoplasm is suspected, reconsider drainage procedure and do not perform sclerosis. Drainage of cystic collections from tumor is occasionally performed for palliative purposes but sclerosis should not be considered given risk to, and likely communication with, adjacent vital structures.
3. Defining clinical expectations
a. Clarify and communicate management plan to referring physician(s) as well as the patient. Multiple sessions are often required and the need for patient cooperation (e.g., postprocedural body position changes after sclerosant injection) should be emphasized.
b. The patient should be informed that he or she may have a drainage catheter during the course of treatment for which daily outputs should be recorded.
4. Routine interventional radiology (IR) preparation
a. Baseline laboratory values: coagulation status (partial thromboplastin time [PTT], prothrombin time [PT