Treatment of Polidocanol Sclerotherapy in Persistent Lymphatic Drainage After Radical Surgery for Endometrial cancer: A Case Report and Literature Review

Introduction

Increased pelvic lymphatic fluid and subsequent development of pelvic lymphocysts (PL) are common complications following pelvic lymphadenectomy for gynaecological malignancies. This condition primarily arises from the accumulation of lymphatic fluid together with tissue fluids and traumatic exudate after surgery.¹ The pelvic cavity serves as lymphatic distribution area, although lymphatic fluid is typically absorbed by autologous tissue in most patients, a minority experience persistent lymphatic drainage and the formation of lymphatic retention cysts. These cysts can lead to symptomatic lymphocysts, manifesting as local pain, secondary infections, lower limb edema, compression of the ureter or blood vessels, which may result in pyelonephrosis, ureteral dilation and even venous thrombosis of the lower extremities.² Current treatment modalities for this complication include expectant management, conservative treatment, interventional therapy and surgical intervention. However, no definitive treatment exists, and effective therapeutic options remain limited. In this report, we present a case of a patient who exhibited persistent lymphatic drainage following radical surgery for endometrial cancer who was successfully managed through the injection of polidocanol sclerotherapy under ultrasound-guided punctures and catheterization after failed conservative treatment. We provide a detailed discussion of the clinical characteristics, imaging features, treatment modalities, and their efficacy to offer insights into managing patients with similar complication.

Case Presentation

The patient, a 58-year-old female, was diagnosed with endometrial clear cell carcinoma (Stage IA) following diagnostic hysteroscopy and curettage due to endometrial thickening. After surgical staging, the patient experienced swelling of the left lower extremity, accompanied by pain in the left lower abdomen three weeks after surgery. Ultrasound and enhanced abdominal CT scans revealed lymphatic retention cysts near the bilateral iliac collateral vessels accompanied by compression of the left iliac vein (Figure 1). Additionally, a thrombus was identified in the distal part of the left external iliac vein at the onset of the femoral vein (Figure 2). To alleviate symptoms and improve the thrombotic state induced by venous compression, the patient underwent additional treatment involving ultrasound-guided punctures and catheterization in the bilateral lymphatic cyst cavity, meanwhile, anticoagulant therapy via subcutaneous injection of low molecular weight heparin was performed 24 hours later. Subsequently, daily drainage volume and color of lymphatic fluid were evaluated. The results showed that daily drainage volume of the right lymphatic cyst was gradually decreased, and reexamination of ultrasound showed that the lymphatic retention cyst cavity was reduced, so we pulled out the right drainage tube. However, the drainage lymphatic fluid from the left lymphatic cyst continued to increase, reaching daily fluid volumes of 600–800 mL, with no significant improvement observed following conservative treatment methods such as regular clamping of the drainage tube and external application of saltpeter. Subsequently, injections of polidocanol into the left lymph retention cyst were administered. Although there was slight improvement, the drainage fluid remained excessive. Significant improvement was observed following a secondary injection of polidocanol sclerotherapy. The daily drainage-fluid of patient’s left drainage tube gradually decreased five days after second injection of polidocanol, and ultrasound reexamination showed that the lymphatic cyst was significantly reduced, then the left drainage tube was successfully pulled out (Figure 3). In the subsequent days, the patient demonstrated a favorable recovery, and symptoms have not recurred since then (Figure 4).

Figure 1 Abdominal enhanced computed tomography findings. Both arrows points to lymphatic retention cysts near the bilateral iliac collateral vessels.

Figure 2 Abdominal enhanced computed tomography findings. The arrow points to a thrombus located at distal part of the left external iliac vein at the onset of the femoral vein.

Figure 3 Pelvic color Doppler ultrasound findings. The arrow points to the size of lymphatic cyst after second injection of polidocanol.

Figure 4 Abdominal enhanced computed tomography findings. Both arrows points to the size of lymphatic cyst 1 year after treatment.

Discussion

Lymphocyst formation is a common complication associated with radical pelvic surgery, with reported incidence rates ranging from 23% to 63%.³ It is characterized by an atypical accumulation of protein-rich lymphatic fluid that lacks a distinct epithelial lining, occurring within anatomical compartments, without eliciting an inflammatory or granulomatous response at the leakage site.^4–8 The underlying pathophysiology of lymphocyst formation involves incomplete lymphostasis, wherein postoperative lymphatic leakage surpasses the capacity for spontaneous peritoneal reabsorption, leading to lymph accumulation in the space created by the excision of lymphatic tissue.⁹ Persistent lymphatic leakage not only extends the duration of the patient’s hospitalization, but also causes some serious complications, thereby garnering increased attention from clinical surgeons. Preventative measures can be implemented to mitigate lymphatic leakage, such as employing electrocoagulation and ligation following lymph node removal during surgery. Recent studies have demonstrated that the application of vascular clips to occlude lymphatic vessels at the site of caudal lymphatic resection during surgery, or the administration of diluted pseudomonas aeruginosa injections onto the lymphatic resection wound can effectively prevent lymphatic leakage.^10,11

Despite these preventative measures, some patients still experience lymphocyst formation or lymphatic leakage, leading to clinical symptoms. The management of pelvic lymphocysts remains controversial. Among asymptomatic patients, conventional wisdom suggests that surgical decompression offers little benefit over observation.¹² Lymphatic leakage is generally a self-limiting complication, often resolving within 2–3 weeks without further intervention, as lymphatic fluid can be absorbed by the peritoneum.¹³ However, when symptoms attributable to pelvic lymphocysts are documented or when recurrence is a concern, treatment through conservative strategies or surgical intervention is warranted. Nonetheless, the optimal approach to managing lymphocysts remains contentious. Shao et al emphasized the potential benefits of conservative treatments including diet control, application of drugs, pressure dressing, paracentesis and sclerotherapy, as the preferred therapeutic options.¹⁴ On the contrary, some researchers advocate for surgical intervention such as peritoneovenous shunting, direct lymphostasis via suture ligation of the disrupted lymphatic channel, or surgery combined with fibrin glue, as the primary approach for addressing lymphatic leakage.¹⁵ This preference is based on the premise that early ligation or suturing of the leakage site can mitigate metabolic complications and shorten hospitalization days.¹⁶ Clinically, it is imperative to conduct a comprehensive evaluation of the patient’s specific condition to determine the most appropriate strategy, with the objective of alleviating symptoms and preventing further deterioration. While conservative treatments should be prioritized, surgical intervention may be warranted if conservative measures prove ineffective. In the present case, the patient developed symptomatic lymphoceles, manifesting as compression of surrounding anatomical structures, pelvic pain, leg edema and deep vein thrombosis. Consequently, targeted treatment measures are necessary for this particular case. The principle of treatment strategy for symptomatic lymphocysts involves draining the cystic fluid, alleviating compression, and closing the cystic cavity. Initially, we employed conservative approaches such as dietary management and ultrasound-guided catheterization to evacuate the cystic fluid. However, the leakage of lymphatic fluid persisted without any indication of reduction. We hypothesize that this may be attributed to factors such as irritation of the cystic cavity or siphon by the drainage tube and continuous patency of the lymphatic lumen. After thorough evaluation, we opted for administration of polidocanol sclerotherapy. As the treatment progressed, there was a marked reduction in the drainage fluid. The patient was feeling well and asymptomatic, leading to her discharge from the hospital.

Polidocanol, the sclerosing agent, possess local anesthetic, adhesive, and hemostatic properties. The mechanism of Polidocanol sclerotherapy involves the destruction of endothelial cells lining the cyst wall, thereby inhibiting their function of secretion and facilitating the closure of the cystic lumen. It has been effectively utilized in sclerotherapy of varicose veins, cysts, and vascular malformations, demonstrating significant curative effects with minimal adverse effects.^17–20 A retrospective study by Japanese scholar Yamaki et al showed that in 32 cases of lymphatic malformation patients treated with polydocanol sclerotherapy, 88% of the patients obtained good or moderate efficacy with no severe adverse events.²¹ Notably, compared with ethanol, the injection of polidocanol sclerotherapy into the cystic cavity does not induce chemical irritation or severe pain. During the procedure, a portion of the sclerosant can be retained within the cystic cavity, and no intoxication-like reaction or other toxic side effects have been observed post-operatively. This sclerosant has the clinical advantages of precise efficacy, safety and mild pain.²² However, to our knowledge, the application of polidocanol sclerotherapy in the management of persistent lymphatic drainage has been rarely reported. Our study indicates that polidocanol sclerotherapy is an effective intervention for continuous lymphatic drainage.

In summary, this preliminary investigation demonstrates that ultrasound-guided polidocanol sclerotherapy is a straightforward, safe and viable option for managing lymphocyst formation or lymphatic leakage. Its application should be tailored to the specific clinical circumstances of each patient. We hope this case study contributes to the development of new therapeutic approaches for patients with persistent lymphatic drainage after surgery for pelvic malignant tumours.