Limits...
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

Five-parameter logistic model10 applied to images acquired with the quantitative protocol (Patient 3, 50-year-old, female) and employed to compare the lymphatic fluid velocity between the unaffected (contralateral) and the affected (ipsilateral) arm. The plots display the signal from the selected voxels (red arrows). The curve is fitted with a modified logistic equation (black line). The five parameters (P1–P5)10 describe the shape and the timing of the curve. (a) Distribution of the parameter P3 (onset time, minutes) within a main lymphatic vessel in the contralateral arm, superimposed, with color scaling, on the maximum intensity projection (MIP). The difference in onset along the lymphatic vessel indicates that the contrast agent is perfusing the vessel. (b) Distribution of the parameter P3 within a main lymphatic vessel in the arm with impaired lymphatic function (ipsilateral), demonstrating a slower CA uptake.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4492592&req=5

f3: Five-parameter logistic model10 applied to images acquired with the quantitative protocol (Patient 3, 50-year-old, female) and employed to compare the lymphatic fluid velocity between the unaffected (contralateral) and the affected (ipsilateral) arm. The plots display the signal from the selected voxels (red arrows). The curve is fitted with a modified logistic equation (black line). The five parameters (P1–P5)10 describe the shape and the timing of the curve. (a) Distribution of the parameter P3 (onset time, minutes) within a main lymphatic vessel in the contralateral arm, superimposed, with color scaling, on the maximum intensity projection (MIP). The difference in onset along the lymphatic vessel indicates that the contrast agent is perfusing the vessel. (b) Distribution of the parameter P3 within a main lymphatic vessel in the arm with impaired lymphatic function (ipsilateral), demonstrating a slower CA uptake.

Mentions: Image processing was performed with in-house software developed in IDL (version 8.2, Exelis Visual Information Solutions, Boulder, Colorado, USA). Each post-contrast volume was subtracted from the first volume with the purpose of visualizing the CA uptake. Prior image registration across the dynamic series was required to compensate for patient motion and to avoid subtraction artifacts. This was performed by incorporating a previously reported 3D rigid body registration package9 into the software. The volume imaged at each station (hand, arm, or axilla) was then registered, assuming that each station would experience mainly rigid motion. The software was designed to visualize the entire subtracted 3D data volume, producing, for each time point, a maximum intensity projection (MIP) along a defined direction. Each voxel in the MIP was associated with the corresponding dynamic uptake curve, which plots the evolution of the signal with time. The uptake curves were fitted with a five-parameter modified logistic equation10 (see Fig. 3). This enabled identification of the onset time (time of arrival of the CA) and characterization of the shape of the curve with five numerical parameters: P1 represents the baseline signal, P2 the net enhancement, P3 the time of contrast onset, P4 the maximum slope (onset slope), and P5 the terminal slope. This semi-quantitative heuristic model is general, and has been used to describe a wide range of signal enhancement patterns.10


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)

Five-parameter logistic model10 applied to images acquired with the quantitative protocol (Patient 3, 50-year-old, female) and employed to compare the lymphatic fluid velocity between the unaffected (contralateral) and the affected (ipsilateral) arm. The plots display the signal from the selected voxels (red arrows). The curve is fitted with a modified logistic equation (black line). The five parameters (P1–P5)10 describe the shape and the timing of the curve. (a) Distribution of the parameter P3 (onset time, minutes) within a main lymphatic vessel in the contralateral arm, superimposed, with color scaling, on the maximum intensity projection (MIP). The difference in onset along the lymphatic vessel indicates that the contrast agent is perfusing the vessel. (b) Distribution of the parameter P3 within a main lymphatic vessel in the arm with impaired lymphatic function (ipsilateral), demonstrating a slower CA uptake.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

f3: Five-parameter logistic model10 applied to images acquired with the quantitative protocol (Patient 3, 50-year-old, female) and employed to compare the lymphatic fluid velocity between the unaffected (contralateral) and the affected (ipsilateral) arm. The plots display the signal from the selected voxels (red arrows). The curve is fitted with a modified logistic equation (black line). The five parameters (P1–P5)10 describe the shape and the timing of the curve. (a) Distribution of the parameter P3 (onset time, minutes) within a main lymphatic vessel in the contralateral arm, superimposed, with color scaling, on the maximum intensity projection (MIP). The difference in onset along the lymphatic vessel indicates that the contrast agent is perfusing the vessel. (b) Distribution of the parameter P3 within a main lymphatic vessel in the arm with impaired lymphatic function (ipsilateral), demonstrating a slower CA uptake.
Mentions: Image processing was performed with in-house software developed in IDL (version 8.2, Exelis Visual Information Solutions, Boulder, Colorado, USA). Each post-contrast volume was subtracted from the first volume with the purpose of visualizing the CA uptake. Prior image registration across the dynamic series was required to compensate for patient motion and to avoid subtraction artifacts. This was performed by incorporating a previously reported 3D rigid body registration package9 into the software. The volume imaged at each station (hand, arm, or axilla) was then registered, assuming that each station would experience mainly rigid motion. The software was designed to visualize the entire subtracted 3D data volume, producing, for each time point, a maximum intensity projection (MIP) along a defined direction. Each voxel in the MIP was associated with the corresponding dynamic uptake curve, which plots the evolution of the signal with time. The uptake curves were fitted with a five-parameter modified logistic equation10 (see Fig. 3). This enabled identification of the onset time (time of arrival of the CA) and characterization of the shape of the curve with five numerical parameters: P1 represents the baseline signal, P2 the net enhancement, P3 the time of contrast onset, P4 the maximum slope (onset slope), and P5 the terminal slope. This semi-quantitative heuristic model is general, and has been used to describe a wide range of signal enhancement patterns.10

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