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Anatomic and Functional Evaluation of Central Lymphatics With Noninvasive Magnetic Resonance Lymphangiography

View Article: PubMed Central - PubMed

ABSTRACT

Accurate assessment of the lymphatic system has been limited due to the lack of optimal diagnostic methods. Recently, we adopted noncontrast magnetic resonance (MR) lymphangiography to evaluate the central lymphatic channel. We aimed to investigate the feasibility and the clinical usefulness of noninvasive MR lymphangiography for determining lymphatic disease.

Ten patients (age range 42–72 years) with suspected chylothorax (n = 7) or lymphangioma (n = 3) who underwent MR lymphangiography were included in this prospective study. The thoracic duct was evaluated using coronal and axial images of heavily T2-weighted sequences, and reconstructed maximum intensity projection. Two radiologists documented visualization of the thoracic duct from the level of the diaphragm to the thoracic duct outlet, and also an area of dispersion around the chyloma or direct continuity between the thoracic duct and mediastinal cystic mass.

The entire thoracic duct was successfully delineated in all patients. Lymphangiographic findings played a critical role in identifying leakage sites in cases of postoperative chylothorax, and contributed to differential diagnosis and confirmation of continuity with the thoracic duct in cases of lymphangioma, and also in diagnosing Gorham disease, which is a rare disorder. In patients who underwent surgery, intraoperative findings were matched with lymphangiographic imaging findings.

Nonenhanced MR lymphangiography is a safe and effective method for imaging the central lymphatic system, and can contribute to differential diagnosis and appropriate preoperative evaluation of pathologic lymphatic problems.

No MeSH data available.


Related in: MedlinePlus

Schematic illustration of the anatomical course of the thoracic duct. The thoracic duct is a continuation of the cisterna chyli from its abdominal segment into the thorax. Typically, the lymphatic pathway originates in the cisterna chyli and enters into the thoracic cavity thorough the aortic hiatus. In the thorax, the thoracic duct ascends along the right anterior surface of the vertebral column between the aorta and the azygos vein posterior to the esophagus. At the T5 to T6 vertebral level, it crosses left of the midline and extends posterior to the aortic arch. It has a close relationship with the trachea, ascends approximately 2 to 3 cm above the clavicle, and then crosses anterior to the subclavian and thyrocervical trunk, making an arch inferiorly. Finally, it terminates at the junction of the left subclavian vein and the internal jugular veins.
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Figure 4: Schematic illustration of the anatomical course of the thoracic duct. The thoracic duct is a continuation of the cisterna chyli from its abdominal segment into the thorax. Typically, the lymphatic pathway originates in the cisterna chyli and enters into the thoracic cavity thorough the aortic hiatus. In the thorax, the thoracic duct ascends along the right anterior surface of the vertebral column between the aorta and the azygos vein posterior to the esophagus. At the T5 to T6 vertebral level, it crosses left of the midline and extends posterior to the aortic arch. It has a close relationship with the trachea, ascends approximately 2 to 3 cm above the clavicle, and then crosses anterior to the subclavian and thyrocervical trunk, making an arch inferiorly. Finally, it terminates at the junction of the left subclavian vein and the internal jugular veins.

Mentions: Magnetic resonance lymphangiography provides preoperative planning information regarding the entire course of the thoracic duct and anatomical variations. Additional information such as a leak at more than 1 site can also support the decision for the level of thoracic duct ligation. In addition, if the site of extravasation of chyle is once visualized, judgment for severity of leakage or prediction of resolution can be through the assessment of the amount of leakage. The typical thoracic duct course illustrated in Figure 4 is present in only 40% to 60% of patients. There are numerous variations in intrathoracic course, number of ducts, location of tributaries, and point of termination.1,26,27 These variations may contribute to a higher incidence of postoperative chylothorax. In this study, typical configurations of thoracic duct were detected in 70% (7/10) of cases. The right-side ducts were shown in 2 patients and duplication of thoracic duct was revealed in 1 patient. Before the surgery, the awareness of right thoracic duct variation would enable the successful thoracic duct ligation without further complications. According to previous reports,27–29 the cisterna chyli and entry of the thoracic duct in the subclavian region can be imaged with radiographic lymphangiographic images using an iodine contrast agent. This study has raised concerns about optimizing lymphangiography. As with whole body angiography, whole body lymphangiographic images could contribute to noninvasive diagnosis and treatment of lymphatic disorders.


Anatomic and Functional Evaluation of Central Lymphatics With Noninvasive Magnetic Resonance Lymphangiography
Schematic illustration of the anatomical course of the thoracic duct. The thoracic duct is a continuation of the cisterna chyli from its abdominal segment into the thorax. Typically, the lymphatic pathway originates in the cisterna chyli and enters into the thoracic cavity thorough the aortic hiatus. In the thorax, the thoracic duct ascends along the right anterior surface of the vertebral column between the aorta and the azygos vein posterior to the esophagus. At the T5 to T6 vertebral level, it crosses left of the midline and extends posterior to the aortic arch. It has a close relationship with the trachea, ascends approximately 2 to 3 cm above the clavicle, and then crosses anterior to the subclavian and thyrocervical trunk, making an arch inferiorly. Finally, it terminates at the junction of the left subclavian vein and the internal jugular veins.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998379&req=5

Figure 4: Schematic illustration of the anatomical course of the thoracic duct. The thoracic duct is a continuation of the cisterna chyli from its abdominal segment into the thorax. Typically, the lymphatic pathway originates in the cisterna chyli and enters into the thoracic cavity thorough the aortic hiatus. In the thorax, the thoracic duct ascends along the right anterior surface of the vertebral column between the aorta and the azygos vein posterior to the esophagus. At the T5 to T6 vertebral level, it crosses left of the midline and extends posterior to the aortic arch. It has a close relationship with the trachea, ascends approximately 2 to 3 cm above the clavicle, and then crosses anterior to the subclavian and thyrocervical trunk, making an arch inferiorly. Finally, it terminates at the junction of the left subclavian vein and the internal jugular veins.
Mentions: Magnetic resonance lymphangiography provides preoperative planning information regarding the entire course of the thoracic duct and anatomical variations. Additional information such as a leak at more than 1 site can also support the decision for the level of thoracic duct ligation. In addition, if the site of extravasation of chyle is once visualized, judgment for severity of leakage or prediction of resolution can be through the assessment of the amount of leakage. The typical thoracic duct course illustrated in Figure 4 is present in only 40% to 60% of patients. There are numerous variations in intrathoracic course, number of ducts, location of tributaries, and point of termination.1,26,27 These variations may contribute to a higher incidence of postoperative chylothorax. In this study, typical configurations of thoracic duct were detected in 70% (7/10) of cases. The right-side ducts were shown in 2 patients and duplication of thoracic duct was revealed in 1 patient. Before the surgery, the awareness of right thoracic duct variation would enable the successful thoracic duct ligation without further complications. According to previous reports,27–29 the cisterna chyli and entry of the thoracic duct in the subclavian region can be imaged with radiographic lymphangiographic images using an iodine contrast agent. This study has raised concerns about optimizing lymphangiography. As with whole body angiography, whole body lymphangiographic images could contribute to noninvasive diagnosis and treatment of lymphatic disorders.

View Article: PubMed Central - PubMed

ABSTRACT

Accurate assessment of the lymphatic system has been limited due to the lack of optimal diagnostic methods. Recently, we adopted noncontrast magnetic resonance (MR) lymphangiography to evaluate the central lymphatic channel. We aimed to investigate the feasibility and the clinical usefulness of noninvasive MR lymphangiography for determining lymphatic disease.

Ten patients (age range 42–72 years) with suspected chylothorax (n = 7) or lymphangioma (n = 3) who underwent MR lymphangiography were included in this prospective study. The thoracic duct was evaluated using coronal and axial images of heavily T2-weighted sequences, and reconstructed maximum intensity projection. Two radiologists documented visualization of the thoracic duct from the level of the diaphragm to the thoracic duct outlet, and also an area of dispersion around the chyloma or direct continuity between the thoracic duct and mediastinal cystic mass.

The entire thoracic duct was successfully delineated in all patients. Lymphangiographic findings played a critical role in identifying leakage sites in cases of postoperative chylothorax, and contributed to differential diagnosis and confirmation of continuity with the thoracic duct in cases of lymphangioma, and also in diagnosing Gorham disease, which is a rare disorder. In patients who underwent surgery, intraoperative findings were matched with lymphangiographic imaging findings.

Nonenhanced MR lymphangiography is a safe and effective method for imaging the central lymphatic system, and can contribute to differential diagnosis and appropriate preoperative evaluation of pathologic lymphatic problems.

No MeSH data available.


Related in: MedlinePlus