Prediction of therapeutic effectiveness according to CT findings after therapeutic lymphangiography for lymphatic leakage

Purpose

To evaluate the correlation between computed tomography (CT) findings after therapeutic lymphangiography for lymphatic leakage and the clinical course of lymphatic leakage.

Materials and methods

Therapeutic lymphangiography for lymphatic leakage was performed in 14 patients. In all patients, CT was performed 0.5–26 h (mean 6.9 h) after lymphangiography and results were retrospectively evaluated.

Results

In 8 of the 14 patients (57 %), lymphatic leakage stopped after lymphangiography. Lymphatic leakage was detected on CT in 9 of the 14 patients (64 %) and had either a nodular (n = 4) or beaded appearance (n = 5). The amount of drainage had decreased the day after lymphangiography, and leakage finally stopped in all 4 patients in whom the leakage had a nodular appearance. However, leakage did not stop in 3 of the 5 patients having leakage with a beaded appearance.

Conclusion

A nodular appearance of leakage might predict success of therapeutic lymphangiography.     

Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT

The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.     

Embolization of the Neck Lymphatic Varix,Causing Periodic Neck Swelling

We report a case of a 44-year-old female patient, presented to us after years of recurrent intermittent episodes of unilateral left neck swelling. An MR lymphangiogram demonstrated a lymphatic varix at the confluence of the left upper extremity lymphatic ducts, confirmed by intranodal axillary lymphangiography. After successful catheterization of the feeding lymphatic vessels, the varix was successfully embolized with detachable microcoils and an autologous blood patch. The patient has been free from symptoms on subsequent outpatient follow-up.     

Use of Contrast-Enhanced Ultrasound to Determine Thoracic Duct Patency

The aim of this study was to determine the feasibility of using contrast-enhanced ultrasound (CEUS) evaluation to determine thoracic duct (TD) outlet patency. Nine patients referred for lymphatic imaging and intervention underwent percutaneous intranodal ultrasound contrast injection and conventional lymphangiography (CL). Eight of 9 patients had a patent TD by CEUS and CL. One patient did not have a patent TD. There was 100% agreement between CEUS and CL. These results suggest that CEUS is an imaging modality that might be as accurate as CL in determining TD patency.     

小肠淋巴管扩张症在直接淋巴管造影及造影后CT平扫中的影像表现

目的探讨小肠淋巴管扩张症在直接淋巴管造影和造影后CT检查中的影像表现,提高对此病的认识。资料与方法回顾性分析21例临床诊断为小肠淋巴管扩张症患者的临床和影像资料,所有病例均先行直接淋巴管造影后再行腹盆部CT平扫,5例在淋巴管造影前做过CT平扫加增强,3例淋巴管造影、CT平扫后进行了增强扫描,分析所有病例影像学表现。结果直接淋巴管造影显示腹膜后、髂部淋巴管走行迂曲,不同程度扩张,结构紊乱,动态观察向肠系膜反流4例,3例可见对比剂直接进入肠腔内。直接淋巴管造影后行CT平扫,21例均可见向对侧腰干反流,9例向肠干反流。15例患者有节段性肠壁增厚,8例增强扫描,显示5例小肠壁分层强化呈"晕轮征",2例增厚肠壁呈均匀性强化,1例肠壁未见增厚。结论直接淋巴管造影与造影后CT联合检查是诊断小肠淋巴管扩张症的重要方法。     

MR淋巴造影在肢体淋巴水肿诊断中的价值

目的 评估MR淋巴造影(MRL)对肢体淋巴水肿的诊断价值.方法 运用3.0T MR对582例肢体淋巴水肿患者进行MRL.并对淋巴结形态及显影情况,淋巴管数目和淋巴速度等进行评估.结果 原发性与继发性淋巴水肿淋巴回流障碍MRL均显示或为淋巴结受累、或为淋巴管受累、或为两者均受累.根据MRL显示的淋巴管数目,原发性淋巴水肿可分为淋巴系统不发育、发育不全和淋巴系统增生3类;继发性淋巴水肿可分淋巴管闭塞减少型和淋巴管开放增多型.动态MRL显示原发性淋巴水肿受累肢体淋巴回流速度平均为(1.0±0.62)cm/min,显著慢于继发性受累肢体平均流速(2.22±1.64)cm/min(P<0.01).在原发性与继发性淋巴水肿中,对侧相比患侧淋巴结MRL均表现为显影数目少、显影延迟和显影信号低.结论 动态MRL能够评估肢体淋巴水肿淋巴系统形态及功能改变,为淋巴水肿诊断提供有力影像手段.     

MR在女性生殖系统乳糜漏中的应用

目的 探讨磁共振胸导管成像(MRTD)及MR盆腔扫描在女性生殖系统乳糜漏中的应用价值.方法 收集7例影像资料完整并经手术证实的女性生殖系统乳糜漏患者资料,回顾性分析其MRTD及MR盆腔平扫的影像学表现,并与直接淋巴管造影(DLG)、核素淋巴显像及手术相对照.结果 DLG中胸导管显示率71.4%(5/7).核素淋巴显像静脉角区显影率为71.4%(5/7).MRTD胸导管显影100%(7/7),除1例未见明确异常外,余6例(85.7%)均提示胸导管出口梗阻,其中双侧引流1例,右位胸导管1例,4例伴静脉角周围多发迂曲淋巴管,1例伴左静脉角区多发淋巴管瘤.7例患者均行胸导管探查术,6例证实胸导管出口梗阻,1例未见明显异常.MRTD联合MR盆腔扫描对比DLG发现了更多淋巴管瘤,并发现了2例骨质异常.结论 MRTD结合MR盆腔扫描可对女性生殖系统乳糜漏患者作出更全面的评估,应该作为这类患者术前常规检查手段.     

Therapeutic Lymphangiography and CT-guided Sclerotherapy for the Treatment of Refractory Lymphatic Leakage

PurposeTo evaluate therapeutic lymphangiography and computed tomography (CT)–guided sclerotherapy for the treatment of refractory inguinal, pelvic, abdominal, and thoracic lymphatic leakage.Materials and MethodsBetween January 2008 and April 2011, 18 patients with refractory lymphatic leakage were treated with therapeutic lymphangiography. Additionally, 10 of these 18 patients underwent CT-guided sclerotherapy with injection of ethanol at the site of the leakage. In the delayed sclerotherapy group (n = 5), the sclerotherapy procedure was performed when the leak persisted after therapeutic lymphangiography. In the immediate sclerotherapy group (n = 5), sclerotherapy was performed on the same day as lymphangiography. The sites of the lymphatic leakage were as follows: inguinal leakage in 8 patients, pelvic leakage in 4 patients, abdominal leakage in 2 patients, and thoracic leakage in 4 patients. Data collected included technical success, clinical success, and procedural complications.ResultsLymphangiography was technically successful in all patients. In eight patients undergoing therapeutic lymphangiography alone, the clinical success rate was 75%, and the drainage catheter could be removed in six patients after the treatment. Lymphangiography followed by immediate sclerotherapy was clinically successful in four of five patients. Lymphangiography combined with delayed sclerotherapy was clinically successful in three of five patients. Overall, the clinical success rate was 72% (13 of 18 patients). One minor complication occurred.ConclusionsTherapeutic lymphangiography alone or in combination with CT-guided sclerotherapy is a promising treatment option for the management of refractory lymphatic leakage.     

Value of CT lymphangiography in the detection of lymphatic leakage: a report of nine cases

Purpose

To demonstrate the value of CT lymphangiography to detect lymphatic leakage, especially at the thoracic level, prior to therapeutic intervention.

Patients and methods

Between 2004 and 2008, nine patients underwent lymphangiography, followed by CT for the evaluation of intractable lymphatic leakage in spite of optimal medical management. Patients included seven females and two males, with age ranging between 25 and 58 years. Lymphangiography was performed after unilateral or bilateral foot injection(s) of Lipiodol ultrafluid followed by standard radiographs of the chest and abdomen and CT of the chest, abdomen and pelvis. The images were reviewed by two experienced radiologists.

Results

Lipiodol leakage was observed in six patients, while three patients showed evidence of lymphangiectasia of the abdominal and/or thoracic lymphatics. Spontaneous resolution of leakage after lymphangiography occurred in three cases.

Conclusion

CT lymphangiography allows direct evaluation of lymphatics, from pelvis to chest, in order to detect the site of leakage at the origin of a chylous effusion and assist in its management.     

A novel technique in the treatment of retroperitoneal lymphatic leakage: direct percutaneous embolization through the leakage pouch

Lymphangiography and percutaneous embolization of injured lymphatics are minimally invasive and effective techniques for the diagnosis and treatment of thoracic and retroperitoneal lymphatic leaks. We present a 58-year-old man who had abdominal chylous collection developed after multiple abdominal surgeries. Retroperitoneal lymphatic duct leakage was detected by ultrasound-guided intranodal lymphangiography and treated successfully using computed tomography (CT)-guided transabdominal embolization with percutaneous N-butyl cyanoacrylate (NBCA) glue and percutaneous NBCA glue and coil embolization by directly catheterizing the leaking lymphatic channel through the chylous collection. To the best of our knowledge, this is the first report of a lymphatic leakage case treated by percutaneous direct catheterization and embolization of leaking lymphatic channels through the chylous fluid collection.Abdominal lymphatic leakage is an unusual complication after abdominal surgery and has been reported after vascular, gastrointestinal, gynecologic, urologic surgeries, and liver and small bowel transplantations. It may cause loss of essential proteins, lipids, immunoglobulin, vitamins, electrolyte, and water, and lead to increased mortality in postoperative setting due to malnutrition, cachexia, immunosuppression, and sepsis (1, 2). The management of chylous leakage is a challenging condition and extends from conservative treatment (dietary management, medical and percutaneous drainage) to radiological intervention or surgical treatment (1–3). Bipedal or intranodal lymphangiography is the traditional imaging method for localizing the site of lymphatic leakage before surgical and endovascular treatment (3–6). In this report, we present successful treatment of abdominal collection developed after multiple abdominal surgeries using computed tomography (CT)-guided transabdominal embolization and percutaneous embolization through the leakage collection. To the best of our knowledge, this is the first report of a lymphatic leakage case treated by percutaneous embolization by catheterizing the leaking lymphatic channel through the chylous collection.     

3.0T动态增强磁共振淋巴造影对下肢淋巴水肿淋巴管功能的评估价值

目的探讨3.0 T动态增强磁共振淋巴造影在评估下肢淋巴水肿淋巴管形态及功能的应用价值。资料与方法使用Philips Achicva 3.0 T高场强超导型MR机,对25例下肢淋巴水肿患者(34侧患肢)行三维动态增强MR淋巴造影检查,观察并记录淋巴管形态改变,测量对比剂注射后5、10、15、20、25、30 min淋巴管感兴趣区相对信号强度(RSI),绘制淋巴管时间-信号强度曲线(TIC),计算峰值时间及洗净率。结果 34侧不同分期的患肢中,动态增强MR淋巴造影能显示淋巴管形态改变、确定淋巴管阻塞部位及反映淋巴管病理生理过程;淋巴管呈延迟强化,时间均超过30 min,且不同分期淋巴管强化的峰值时间、洗净率及各时间点的RSI差异有统计学意义。结论动态增强磁共振淋巴造影能为不同分期的下肢淋巴水肿患者提供淋巴管形态和功能信息,是一种安全可行的新技术。     

Intranodal Glue Embolization for the Management of Postsurgical Groin Lymphocele and Lymphorrhea

This report describes intranodal lymphatic embolization for treatment of groin lymphatic leaks following surgery or percutaneous vascular interventions. In 10 consecutive patients with groin lymphatic leak between 2015 and 2017, lymphangiography with embolization was performed by intranodal injection with dilute N-butyl cyanoacrylate (NBCA). Mean volume of dilute NBCA (1:3 with ethiodized oil) injected was 1 mL. Clinical success rate was 80%. Median time to resolution was 7 days. Intranodal lymphatic embolization for treatment of groin lymphatic leaks is a safe and effective treatment alternative to surgery resulting in a rapid time to resolution.     

Linfografía intranodal en el tratamiento de la ascitis quilosa

Chylous ascites is the presence of lymph from the thorax or bowel in the abdominal cavity. In Western countries, the most common causes of chylous ascites in adults are tumors, cirrhosis, and postoperative leakage, whereas the most common causes in children are congenital lymphatic anomalies and trauma. By contrast, in developing countries, infectious causes are responsible for most cases of chylous ascites. We present a case of chylous ascites secondary to acute necrotizing pancreatitis refractory to conservative treatment that was definitively resolved after intranodal lymphangiography with lipiodol. This is a safe and efficacious minimally invasive treatment for lymphatic leakage.     

Validation of the Position of Injection Needles with Contrast-Enhanced Ultrasound for Dynamic Contract-Enhanced MR Lymphangiography

Purpose

To assess the feasibility of validating the position of the needle in groin lymph nodes using injection of ultrasound (US) contrast prior to magnetic resonance (MR) lymphangiography.

MR imaging perfusion mismatch: a technique to verify successful targeting of liver tumors during transcatheter arterial chemoembolization

PURPOSE: To evaluate the combined use of transcatheter intraarterial perfusion (TRIP) magnetic resonance (MR) imaging and dynamic contrast-enhanced MR imaging to determine complete tumor targeting during transcatheter arterial chemoembolization (TACE) when performed within an integrated MR imaging-interventional radiology (IR) angiography suite. MATERIALS AND METHODS: Between October 2006 and March 2007, eight consecutive patients with unresectable hepatocellular carcinoma (HCC) successfully underwent TACE in a combined MR imaging-IR suite. All patients were male, with a mean age of 59 years (range, 41-71 years). Tumor enhancement on TRIP MR images before and after TACE were qualitatively compared with dynamic contrast-enhanced MR images obtained after TACE. The authors computed the prevalence of perfusion mismatch. The presence of a perfusion mismatch was judged in a binary fashion. RESULTS: A perfusion match, confirming complete tumor targeting, occurred in six of the eight patients (75%). There was a perfusion mismatch in two patients (25%). Subsequent interrogation showed that the underlying cause of the mismatch was secondary to an unexpected collateral vessel in the first patient and watershed location of the tumor in the second patient. CONCLUSIONS: Performing TACE in an MR imaging-IR suite can facilitate complete tumor targeting. By comparing perfusion images from TRIP and contrast-enhanced MR sequences, the operator gains confidence and can potentially obtain more selective catheter placement during TACE.     

Intranodal Lymphangiography with Thoracic Duct Embolization for Treatment of Chyle Leak after Thoracic Outlet Decompression Surgery

From 2015 to 2019, 9 patients underwent ultrasound-guided intranodal lymphangiography for the treatment of a chyle leak following thoracic outlet decompression surgery. Chyle leaks were identified by Lipiodol (Guerbet, Roissy, France) extravasation near the left supraclavicular surgical bed in all patients. The technical success rate of thoracic duct embolization was 67% (6 of 9), including fluoroscopic transabdominal antegrade access (n = 4) and ultrasound-guided retrograde access in the left neck (n = 2). Clinical success was achieved in 89% of patients (8 of 9). The mean interval from lymphangiography to drain removal was 6.6 days (range, 4–18 d). No patients had a chyle leak recurrence during clinical follow-up (mean, 304 d).     

CT-guided Injection of N-butyl Cyanoacrylate Glue for Treatment of Chylous Leak after Aorto-mesenteric Bypass

Lymphangiography and thoracic duct embolization are well-described techniques for the diagnosis and treatment of thoracic lymphatic leaks refractory to conservative treatment. However, thoracic duct embolization is not an option in patients with abdominal chylous leaks. The present report describes a 68-year-old man who underwent an aortomesenteric bypass complicated by a high-output postoperative chylothorax (>2,000 ml/day) and chylous ascites (>7,000 ml/paracentesis). Ultrasound-guided intranodal lymphangiography demonstrated a retroperitoneal lymphatic leak tracking along the vascular graft into the peritoneal cavity. Computed tomography-guided lymphatic duct occlusion with N-butyl cyanoacrylate glue was performed, resulting in successful treatment of both chylothorax and chylous ascites.     

Magnetic resonance lymphangiography in Klippel-Trénaunay syndrome

To date, lymphoscintigraphy and conventional, direct lymphography have been the favoured imaging modalities in assessing the lymphatic system in patients with Klippel-Trénaunay syndrome. We report on the first patient suffering from Klippel-Trénaunay syndrome whose lymphatic vasculature of the lower limbs was evaluated with MR lymphangiography.     

Factors Contributing to Successful Transvenous Retrograde Thoracic Duct Cannulation

PurposeTo identify key factors for successful transvenous retrograde cannulation (TVRC) of the thoracic duct.Materials and MethodsA total of 47 consecutive patients (62.1 ± 13.2 years; 32 men) who underwent attempted TVRC between July 2016 and July 2021 were included. Reasons for interventions were chylous leakage from the chest (n = 36), abdomen (n = 6), and other sites (n = 5). Patient age, sex, access vein (femoral vs brachial), anatomic classification (presence of dominant channel vs plexiform) of the terminal thoracic duct, and engagement of a diagnostic catheter into the jugulovenous junction were included in the analyses. Anatomic details were evaluated according to catheter-based high-pressure lymphangiography and conventional intranodal lymphangiography. The Firth bias-reduced penalized-likelihood logistic regression model was used to analyze prognostic factors.ResultsTVRC was successful in 33 of the 47 patients (70%). In univariate analysis, femoral access, diagnostic catheter engagement, and presence of dominant channel were significant positive prognostic factors (P <.05). In multivariate analysis, diagnostic catheter engagement and presence of dominant channel were significant prognostic factors (P <.05). Diagnostic catheter engagement showed the highest prognostic performance (accuracy = 0.872), followed by presence of a dominant channel. High-pressure catheter-based lymphangiographic findings showed better performance (accuracy, 0.844 vs 0.727) than intranodal lymphangiography to delineate the anatomy of the terminal thoracic duct.ConclusionsA secure selection of the jugulovenous junction and the presence of a dominant channel in the terminal portion of the thoracic duct were significant prognostic factors for successful TVRC.     

Soft-tissue tumors: value of static and dynamic gadopentetate dimeglumine-enhanced MR imaging in prediction of malignancy

PURPOSE: To prospectively evaluate static and dynamic gadopentetate dimeglumine-enhanced magnetic resonance (MR) imaging relative to nonenhanced MR imaging in differentiation of benign from malignant soft-tissue lesions and to evaluate which MR imaging parameters are most predictive of malignancy, with associated interobserver variability. MATERIALS AND METHODS: One hundred forty consecutive patients (78 male patients [median age, 51 years], 62 female patients [median age, 53 years]) with a soft-tissue mass underwent nonenhanced static and dynamic contrast material-enhanced MR imaging. Diagnosis was based on histologic findings in surgical specimens (86 of 140), findings at core-needle biopsy (43 of 140), or results of all imaging procedures with clinical follow-up (11 of 140). Multivariate logistic regression analysis was used to identify the best combination of MR imaging parameters that might be predictive of malignancy. Subjective overall performance of two observers was evaluated with receiver operating characteristic analysis. RESULTS: For subjective overall diagnosis, area under the receiver operating characteristic curve, a measure for diagnostic accuracy, was significantly larger for combined nonenhanced and contrast-enhanced MR imaging than it was for nonenhanced MR imaging alone, with no significant difference between observers. Multivariate analysis of all lesions revealed that combined nonenhanced static and dynamic contrast-enhanced MR imaging parameters were significantly superior to nonenhanced MR imaging parameters alone and to nonenhanced MR imaging parameters combined with static contrast-enhanced MR imaging parameters in prediction of malignancy. The most discriminating parameters were presence of liquefaction, start of dynamic enhancement (time interval between start of arterial and tumor enhancement), and lesion size (diameter). Results for extremity lesions were the same, with one exception: With dynamic contrast-enhanced MR imaging parameters, diagnostic performance of one observer did not improve. CONCLUSION: Static and dynamic contrast-enhanced MR imaging, when added to nonenhanced MR imaging, improved differentiation between benign and malignant soft-tissue lesions.