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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

Enhancement of lymphatic vessels and veins in the forearm of Patient 2 (61-year-old, female, ipsilateral arm), for the two different protocols, and associated graphs plotting the evolution of the signal with time, including a measurement of rising time for lymphatic enhancement. Voxels belonging to the same structures are selected for both protocols; green color refers to lymphatic vessels, red to veins. Coronal maximum intensity projections (MIP) are created from image volumes at different time points, after subtracting the first post-contrast volume in order to visualize the evolution of the enhancement from the baseline. Veins are not visible in images acquired with the quantitative protocol. Lymphatic vessels have a later and slower enhancement compared with veins. The same lymphatic vessels can be identified with both protocols. (a, b) Morphological protocol: veins, lymphatic vessels; (c, d) Quantitative protocol: veins, lymphatic vessels. A color version of this figure is available in the online article at www.liebertpub.com/lrb.
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f2: Enhancement of lymphatic vessels and veins in the forearm of Patient 2 (61-year-old, female, ipsilateral arm), for the two different protocols, and associated graphs plotting the evolution of the signal with time, including a measurement of rising time for lymphatic enhancement. Voxels belonging to the same structures are selected for both protocols; green color refers to lymphatic vessels, red to veins. Coronal maximum intensity projections (MIP) are created from image volumes at different time points, after subtracting the first post-contrast volume in order to visualize the evolution of the enhancement from the baseline. Veins are not visible in images acquired with the quantitative protocol. Lymphatic vessels have a later and slower enhancement compared with veins. The same lymphatic vessels can be identified with both protocols. (a, b) Morphological protocol: veins, lymphatic vessels; (c, d) Quantitative protocol: veins, lymphatic vessels. A color version of this figure is available in the online article at www.liebertpub.com/lrb.

Mentions: Figure 2 compares the examinations performed with both protocols on the affected arm of Patient 2, showing images of enhancing vessels. The pattern of enhancement of the vessel, described by the CA uptake curve, can be used to discriminate between lymphatic vessels and veins. Veins show initial signal enhancement and subsequent signal decay due to CA wash-out (red in the plot, Fig. 2a), whereas structures that slowly take up contrast and appear bright at a later time are lymphatic vessels (green in the plot, Fig. 2b and 2d). Despite a slight difference in arm position in different examinations, the same lymphatic vessels can be identified with both protocols (Fig. 2b and 2d). In general, the enhancement of veins is negligible in all the images acquired with the quantitative protocol (an example in Fig. 2c), as predicted by the physiological modeling (Appendix 1), and the lymphatic vessels are therefore the only visible structures in these images.


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)

Enhancement of lymphatic vessels and veins in the forearm of Patient 2 (61-year-old, female, ipsilateral arm), for the two different protocols, and associated graphs plotting the evolution of the signal with time, including a measurement of rising time for lymphatic enhancement. Voxels belonging to the same structures are selected for both protocols; green color refers to lymphatic vessels, red to veins. Coronal maximum intensity projections (MIP) are created from image volumes at different time points, after subtracting the first post-contrast volume in order to visualize the evolution of the enhancement from the baseline. Veins are not visible in images acquired with the quantitative protocol. Lymphatic vessels have a later and slower enhancement compared with veins. The same lymphatic vessels can be identified with both protocols. (a, b) Morphological protocol: veins, lymphatic vessels; (c, d) Quantitative protocol: veins, lymphatic vessels. 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

f2: Enhancement of lymphatic vessels and veins in the forearm of Patient 2 (61-year-old, female, ipsilateral arm), for the two different protocols, and associated graphs plotting the evolution of the signal with time, including a measurement of rising time for lymphatic enhancement. Voxels belonging to the same structures are selected for both protocols; green color refers to lymphatic vessels, red to veins. Coronal maximum intensity projections (MIP) are created from image volumes at different time points, after subtracting the first post-contrast volume in order to visualize the evolution of the enhancement from the baseline. Veins are not visible in images acquired with the quantitative protocol. Lymphatic vessels have a later and slower enhancement compared with veins. The same lymphatic vessels can be identified with both protocols. (a, b) Morphological protocol: veins, lymphatic vessels; (c, d) Quantitative protocol: veins, lymphatic vessels. A color version of this figure is available in the online article at www.liebertpub.com/lrb.
Mentions: Figure 2 compares the examinations performed with both protocols on the affected arm of Patient 2, showing images of enhancing vessels. The pattern of enhancement of the vessel, described by the CA uptake curve, can be used to discriminate between lymphatic vessels and veins. Veins show initial signal enhancement and subsequent signal decay due to CA wash-out (red in the plot, Fig. 2a), whereas structures that slowly take up contrast and appear bright at a later time are lymphatic vessels (green in the plot, Fig. 2b and 2d). Despite a slight difference in arm position in different examinations, the same lymphatic vessels can be identified with both protocols (Fig. 2b and 2d). In general, the enhancement of veins is negligible in all the images acquired with the quantitative protocol (an example in Fig. 2c), as predicted by the physiological modeling (Appendix 1), and the lymphatic vessels are therefore the only visible structures in these images.

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