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Quantitative Contrast-Enhanced Magnetic Resonance Lymphangiography of the Upper Limbs in Breast Cancer Related Lymphedema: An Exploratory Study.

Borri M, Schmidt MA, Gordon KD, Wallace TA, Hughes JC, Scurr ED, Koh DM, Leach MO, Mortimer PS - Lymphat Res Biol (2015)

Bottom Line: Both protocols provided high-resolution three-dimensional images of upper limb lymphatic vessels.CA uptake curves were utilized to distinguish between lymphatic vessels and vascular structures.This work demonstrated the feasibility of CE-MRL of the upper limbs in patients with BRCL, introducing an advanced imaging and analysis protocol suitable for anatomical and functional study of the lymphatic system.

View Article: PubMed Central - PubMed

Affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .

ABSTRACT

Background: Contrast-Enhanced Magnetic Resonance Lymphangiography (CE-MRL) presents some limitations: (i) it does not quantify lymphatic functionality; and (ii) enhancement of vascular structures may confound image interpretation. Furthermore, although CE-MRL is well described in the published literature for the lower limbs, there is a paucity of data with regards to its use in the upper limbs. In this proof-of-principle study, we propose a new protocol to perform CE-MRL in the upper limbs of patients with breast cancer-related lymphedema (BCRL) which addresses these limitations.

Methods and results: CE-MRL was performed using a previously published (morphological) protocol and the proposed protocol (quantitative) on both the ipsilateral (abnormal) and contralateral (normal) arms of patients with BCRL. The quantitative protocol employs contrast agent (CA) intradermal injections at a lower concentration to prevent T2*-related signal decay. Both protocols provided high-resolution three-dimensional images of upper limb lymphatic vessels. CA uptake curves were utilized to distinguish between lymphatic vessels and vascular structures. The quantitative protocol minimized venous enhancement and avoided spurious delays in lymphatic enhancement due to short T2* values, enabling correct CA uptake characterization. The quantitative protocol was therefore employed to measure the lymphatic fluid velocity, which demonstrated functional differences between abnormal and normal arms. The velocity values were in agreement with previously reported lymphoscintigraphy and near infra-red lymphangiography measurements.

Conclusions: This work demonstrated the feasibility of CE-MRL of the upper limbs in patients with BRCL, introducing an advanced imaging and analysis protocol suitable for anatomical and functional study of the lymphatic system.

No MeSH data available.


Related in: MedlinePlus

Evolution of the depot (hand) for the two different protocols. Images are coronal maximum intensity projections (MIP) of the original image volumes. (a) Morphological protocol (Patient 1, 49-year-old, female, ipsilateral arm). In the image acquired immediately after the injection, the depot area is affected by signal loss due to short T2* effects (yellow arrow). The graph plots the evolution of the signal with time, in a voxel within the depot area (red) selected on a later MIP. (b) Quantitative protocol (Patient 3, 50-year-old, female, ipsilateral arm). The region of interest (ROI, red) is contoured on the initial MIP and encompasses one of the four inter-digital depots. The graph shows the decrease with time of the mean signal from the ROI. (c) Expansion with time of the projected depot delineated in (b). A color version of this figure is available in the online article at www.liebertpub.com/lrb.
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f1: Evolution of the depot (hand) for the two different protocols. Images are coronal maximum intensity projections (MIP) of the original image volumes. (a) Morphological protocol (Patient 1, 49-year-old, female, ipsilateral arm). In the image acquired immediately after the injection, the depot area is affected by signal loss due to short T2* effects (yellow arrow). The graph plots the evolution of the signal with time, in a voxel within the depot area (red) selected on a later MIP. (b) Quantitative protocol (Patient 3, 50-year-old, female, ipsilateral arm). The region of interest (ROI, red) is contoured on the initial MIP and encompasses one of the four inter-digital depots. The graph shows the decrease with time of the mean signal from the ROI. (c) Expansion with time of the projected depot delineated in (b). A color version of this figure is available in the online article at www.liebertpub.com/lrb.

Mentions: With the morphological protocol (an example in Fig. 1a), it is not possible to delineate the initial depot as the injection area is non-uniformly affected by signal loss due to short T2* values (indicated by the arrow). In this area, the signal increases with time, as shown in the graph, despite the fact that the concentration of CA decreases. Progressive removal of CA results in dilution in the depot, increasing the T2* and reducing the T2*-related signal decay. In examinations undertaken with the quantitative protocol (an example in Fig. 1b), the depot area could be clearly identified in all images, indicating that T2* decay has been eliminated. The evolution of the depot with time (Fig. 1b and 1c) indicates slow removal of CA, in agreement with the expected physiological behavior.4


Quantitative Contrast-Enhanced Magnetic Resonance Lymphangiography of the Upper Limbs in Breast Cancer Related Lymphedema: An Exploratory Study.

Borri M, Schmidt MA, Gordon KD, Wallace TA, Hughes JC, Scurr ED, Koh DM, Leach MO, Mortimer PS - Lymphat Res Biol (2015)

Evolution of the depot (hand) for the two different protocols. Images are coronal maximum intensity projections (MIP) of the original image volumes. (a) Morphological protocol (Patient 1, 49-year-old, female, ipsilateral arm). In the image acquired immediately after the injection, the depot area is affected by signal loss due to short T2* effects (yellow arrow). The graph plots the evolution of the signal with time, in a voxel within the depot area (red) selected on a later MIP. (b) Quantitative protocol (Patient 3, 50-year-old, female, ipsilateral arm). The region of interest (ROI, red) is contoured on the initial MIP and encompasses one of the four inter-digital depots. The graph shows the decrease with time of the mean signal from the ROI. (c) Expansion with time of the projected depot delineated in (b). A color version of this figure is available in the online article at www.liebertpub.com/lrb.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4492592&req=5

f1: Evolution of the depot (hand) for the two different protocols. Images are coronal maximum intensity projections (MIP) of the original image volumes. (a) Morphological protocol (Patient 1, 49-year-old, female, ipsilateral arm). In the image acquired immediately after the injection, the depot area is affected by signal loss due to short T2* effects (yellow arrow). The graph plots the evolution of the signal with time, in a voxel within the depot area (red) selected on a later MIP. (b) Quantitative protocol (Patient 3, 50-year-old, female, ipsilateral arm). The region of interest (ROI, red) is contoured on the initial MIP and encompasses one of the four inter-digital depots. The graph shows the decrease with time of the mean signal from the ROI. (c) Expansion with time of the projected depot delineated in (b). A color version of this figure is available in the online article at www.liebertpub.com/lrb.
Mentions: With the morphological protocol (an example in Fig. 1a), it is not possible to delineate the initial depot as the injection area is non-uniformly affected by signal loss due to short T2* values (indicated by the arrow). In this area, the signal increases with time, as shown in the graph, despite the fact that the concentration of CA decreases. Progressive removal of CA results in dilution in the depot, increasing the T2* and reducing the T2*-related signal decay. In examinations undertaken with the quantitative protocol (an example in Fig. 1b), the depot area could be clearly identified in all images, indicating that T2* decay has been eliminated. The evolution of the depot with time (Fig. 1b and 1c) indicates slow removal of CA, in agreement with the expected physiological behavior.4

Bottom Line: Both protocols provided high-resolution three-dimensional images of upper limb lymphatic vessels.CA uptake curves were utilized to distinguish between lymphatic vessels and vascular structures.This work demonstrated the feasibility of CE-MRL of the upper limbs in patients with BRCL, introducing an advanced imaging and analysis protocol suitable for anatomical and functional study of the lymphatic system.

View Article: PubMed Central - PubMed

Affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .

ABSTRACT

Background: Contrast-Enhanced Magnetic Resonance Lymphangiography (CE-MRL) presents some limitations: (i) it does not quantify lymphatic functionality; and (ii) enhancement of vascular structures may confound image interpretation. Furthermore, although CE-MRL is well described in the published literature for the lower limbs, there is a paucity of data with regards to its use in the upper limbs. In this proof-of-principle study, we propose a new protocol to perform CE-MRL in the upper limbs of patients with breast cancer-related lymphedema (BCRL) which addresses these limitations.

Methods and results: CE-MRL was performed using a previously published (morphological) protocol and the proposed protocol (quantitative) on both the ipsilateral (abnormal) and contralateral (normal) arms of patients with BCRL. The quantitative protocol employs contrast agent (CA) intradermal injections at a lower concentration to prevent T2*-related signal decay. Both protocols provided high-resolution three-dimensional images of upper limb lymphatic vessels. CA uptake curves were utilized to distinguish between lymphatic vessels and vascular structures. The quantitative protocol minimized venous enhancement and avoided spurious delays in lymphatic enhancement due to short T2* values, enabling correct CA uptake characterization. The quantitative protocol was therefore employed to measure the lymphatic fluid velocity, which demonstrated functional differences between abnormal and normal arms. The velocity values were in agreement with previously reported lymphoscintigraphy and near infra-red lymphangiography measurements.

Conclusions: This work demonstrated the feasibility of CE-MRL of the upper limbs in patients with BRCL, introducing an advanced imaging and analysis protocol suitable for anatomical and functional study of the lymphatic system.

No MeSH data available.


Related in: MedlinePlus