Call for a Multidisciplinary Effort to Map the Lymphatic System with Advanced Medical Imaging Techniques: A Review of the Literature and Suggestions for Future Anatomical Research

Abstract

This review intends to rekindle efforts to map the lymphatic system by using a more modern approach, based on medical imaging. The structure, function, and pathologies associated with the lymphatic system are first discussed to highlight the need for more accurately mapping the lymphatic system. Next, the need for an interdisciplinary approach, with a central role for the anatomist, to come up with better maps of the lymphatic system is emphasized. The current approaches on lymphatic system research involving medical imaging will be discussed and suggestions will be made for an all‐encompassing effort to thoroughly map the entire lymphatic system. A first‐hand account of our integration as anatomists in the radiotherapy department is given as an example of interdisciplinary collaboration. From this account, it will become clear that the interdisciplinary collaboration of anatomists in the clinical disciplines involved in lymphatic system research/treatment still holds great promise in terms of improving clinical regimens that are currently being employed. As such, we hope that our fellow anatomists will join us in an interdisciplinary effort to map the lymphatic system, because this could, in a relatively short timeframe, provide improved treatment options for patients with cancer or lymphatic pathologies all over the world. Anat Rec, 302:1681–1695, 2019. © 2019 American Association for Anatomy

The use of Thiel embalmed human cadavers for retrograde injection and visualization of the lymphatic system

“…Interestingly, in another recent study to visualize the cisterna chyli, using the latex and barium sulphate mixture, Renard et al showed that retrograde injection of the thoracic duct was in fact possible, despite the presence of the valves (Renard, de Mestier, et al, ). This finding is in accordance with previous findings from our research group (Degen, Van de Velde, & Van Hoof, ; Stouthandel et al, ).…”

“…T8‐T12, thoracic vertebra 8–12; VA, vena azygos; VH, vena hemi‐azygos. Adapted from Stouthandel et al ()…”

“…This ensures an efficient surgical removal of all the relevant lymphatic structures and an accurate treatment planning for radiotherapy treatment. Efficient surgical resection and radiotherapy treatment planning will in turn ensure that healthy tissue in proximity to the lymphatics is not unnecessarily resected and radiation induced side effects to organs at risk (i.e., heart and lungs in breast cancer treatment) will be kept to a minimum (Stouthandel, Veldeman, & Van Hoof, ). The location of the lymphatic system has long since been documented in anatomical atlases (Rouviere, ; Sappey, ) and these important works still play a major role in lymphatic research to this day.…”

The Lymphatic System in Breast Cancer: Anatomical and Molecular Approaches

“…The fact that mercury injections can no longer be performed, thus not allowing the replication of these historical works and the fact that historical anatomists did not have a lot of faith in microscopes yet in the 1800s, as evidenced by entries such as "his observation having been made with very high magnifying powers, are not exempt from a portion of doubt which seems almost inseparable from results so obtained" [59], would suggest that it is high time that the lymphatic system anatomy is re-evaluated. This time, the historical anatomical drawings can even be objectified by using modern medical imaging techniques that will be able to capture the contrast-filled lymphatics in relation to the regional anatomy [60].…”

“…Instead, atlas plates are likely made up of several different specimens, maybe even combining data from adult and child/foetal specimens in the same plates. As it is not possible to confirm how many specimens were used for the construction of a certain atlas plate, plates could be based on only one or two specimens and anatomical variability might be severely underrepresented, making a re-examination of these historical works all the more relevant today, now that we have the technological means to objectively capture the results [60].…”