Search

Lymphatic leakage, manifesting as chylothorax or chylous ascites, arises from traumatic or nontraumatic causes and poses severe risks such as malnutrition and increased infection susceptibility. Accurate diagnosis and an effective treatment strategy necessitate comprehensive lymphatic imaging. Conventional lymphangiography and dynamic contrast-enhanced MR lymphangiography (DCMRL) have been widely used and studied as effective lymphatic imaging methods. Recently, CT lymphangiography (CTL) has been successfully implemented in animal studies and some patients, and the authors' institution now prioritizes CTL over DCMRL. Contrast-enhanced CTL offers a promising alternative, with advantages such as better accessibility and faster imaging. These advantages of CTL over traditional methods highlight its superior accessibility and fast acquisition time. Moreover, to reduce and optimize radiation dose, the stepwise propagation scanning method in CTL could be used, which is especially beneficial in pediatric patients. In this review, the authors suggest the protocol for CTL and interpretation methods for evaluation and therapeutic planning of central lymphatic disorders, focusing on the condition of lymphatic leakage. © RSNA, 2024 The slide presentation from the RSNA Annual Meeting is available for this article.

Background: The pragmatic role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) needs to be evaluated and compared across distinct lymphatic disorders. We aimed to evaluate the performance of DCMRL for identifying the underlying causes of lymphatic disorders and to define the potential benefit of DCMRL for planning lymphatic interventions., Methods: Patients who underwent DCMRL between August 2017 and July 2022 were included in this retrospective analysis. DCMRL was performed with intranodal injection of a gadolinium-based contrast medium through inguinal lymph nodes under local anesthesia. Technical success of DCMRL and feasibility of percutaneous embolization were assessed based on the lymphatic anatomy visualized by DCMRL. Based on the underlying causes, clinical outcomes were evaluated and compared., Results: Seventy consecutive patients were included. The indications were traumatic chylothorax (n = 42), traumatic chylous ascites (n = 11), and nontraumatic lymphatic leak (n = 17). The technical success rate of DCMRL was the highest in association with nontraumatic lymphatic disorders (94.1% [16/17]), followed by traumatic chylothorax (92.9% [39/42]) and traumatic chylous ascites (81.8% [9/11]). Thirty-one (47.7%) patients among 65 patients who underwent technically successful DCMRL had feasible anatomy for intervention. Clinical success was achieved in 90.3% (28/31) of patients with feasible anatomy for radiologic intervention, while 62.5% (10/16) of patients with anatomical challenges showed improvement. Most patients with traumatic chylothorax showed improvement (92.9% [39/42]), whereas only 23.5% (4/17) of patients with nontraumatic lymphatic disorders showed clinical improvement., Conclusion: DCMRL can help identify the underlying causes of lymphatic disorders. The performance of DCMRL and clinical outcomes vary based on the underlying cause. The feasibility of lymphatic intervention can be determined using DCMRL, which can help in predicting clinical outcomes., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Background:  Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL., Method:  A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA., Results:  From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments., Conclusion:  CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL., Key Points:   · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps.., Citation Format: · Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035., Competing Interests: Guerbet, Villepinte, France financially supported professional language editing. The sponsor had no influence over the content of the manuscript. All authors report no conflict of interest regarding this manuscript., (Thieme. All rights reserved.)

Objective: To review the technical aspects and categorize the imaging findings of dynamic contrast enhanced magnetic resonance lymphangiography (DCMRL) and correlate the findings with patient management options., Materials and Methods: A retrospective review of patients who underwent DCMRL between June 2012 and August 2017 at a tertiary care paediatric hospital was performed. Twenty-five DCMRL studies were performed in 23 patients (9 males, 13 females, 1 ambiguous gender) with a median age of 4 years (range: 1 month-29 years). DCMRL imaging findings were reviewed, categorized and the impact on patient management was studied., Results: DCMRL was technically successful in 23/25 (92%) studies. DCMRL findings were categorized based on the status of central conducting lymphatics (CCL) and alternate lymphatic pathways as follows: Type 1 - normal CCL with no alternate lymphatic pathways, Type 2 - partial (2a) or complete (2b) non-visualization of CCL with reflux of contrast into alternate pathways and Type 3 - normal CCL with additional filling of alternate pathways. Type 1 DCMRL patients (n = 5) were reassured and conservative management was continued, Type 2 patients (n = 10) had evidence of CCL obstruction hence thoracic duct ligation or embolization was avoided and other options such as lymphatic fluid diversion using Denver ® shunt or lympho-venous anastomosis were used, and Type 3 patients (n = 8) were evaluated for elevated central venous pressure as a cause of lymphatic backflow in addition to Denver ® shunt, lympho-venous anastomosis, thoracic duct ligation or embolization., Conclusion: DCMRL is an evolving imaging technique for understanding abnormalities of the central conducting lymphatics. Categorization of imaging findings may be helpful in guiding selection of management options., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: To evaluate the effectiveness of lymphography as a minimally invasive treatment option of lymphatic leakage in terms of local control and to investigate which parameters influence the success rate., Method: This retrospective study protocol was approved by the ethic committee. Patient history, imaging data, therapeutic options and follow-up were recorded and retrospectively analyzed. Between June 1998 and February 2013, 71 patients (m:w = 42:29, mean age, 52.4; range 42–75 years) with lymphatic leakage in form of lymphatic fistulas (n = 37), lymphocele (n = 11), chylothorax (n = 13) and chylous ascites (n = 10)underwent lymphography. Sixty-four patients (90.1%) underwent successful lymphography while lymphography failed in 7 cases. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage and to the volume of the applied iodized oil., Result: Signs of leakage or contrast extravasation were directly detected in 64 patients. Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients when the lymphatic drainage volume was less than 200 mL/day (n = 33). Even when lymphatic drainage was higher than 200 mL/day (n = 31),therapeutic lymphography was still successful in 58.1% of the patients., Conclusion: Lymphography is an effective, minimally invasive method in the detection and treatment of lymphatic leakage. The volume of lymphatic drainage per day is a significant predictor of the therapeutic success rate., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

We performed lymphoscintigraphy on 31 patients (newborns and children) affected by congenital lymphatic dysplasia according to our previously published protocol. Congenital lymphatic dysplasia may present with various degrees of clinical severity, ranging from nonimmune hydrops fetalis with visceral effusions to lymphedema alone. We recommend that lymphoscintigraphy should be strongly considered in all patients with signs of lymphatic dysplasia, including those with minimal and initial signs of lymphatic impairment, in order to obtain a very early diagnosis and to start treatment. Lymphoscintigraphy is safe and useful in the diagnosis of lymphatic dysplasia in the newborn and children. Moreover, it is well tolerated by patients and well accepted by their parents.

Background: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography., Purpose: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate., Material and Methods: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage., Results: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention., Conclusion: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.

The purpose of this study was to assess the effectiveness of lymphangiography as a treatment for various chyle leakages. Pedal lymphangiography was performed in 9 patients (6 men and 3 women; mean age, 59 years) who were unlikely to be cured only by conservative treatment - a low-fat medium-chain triglyceride diet, total parenteral nutrition and insertion of a drainage tube - and in whom chylothorax (n = 5), chylous ascites (n = 2) and lymphatic fistulae (n = 2) were refractory to conservative treatment. In 7 of these 9 patients (78%), we could detect the chyle leakage sites. In 8 of the 9 patients (89%), lymphatic leakage was stopped after lymphangiography, and surgical re-intervention was avoided. No cases had a recurrence of chyle leakage during follow-up (range, 1-54 months). Lymphangiography is effective not only for diagnosis but also as treatment for various chyle leakages. Early lymphangiography is therefore recommended for patients with chyle leakages who are unlikely to be cured by conservative treatment only.

Despite radiotherapy and chemotherapy, chylous ascites occur frequently in patients with ovarian cancer. We report a case of ovarian cancer with massive chylous ascites and describe the use of lymphoscintigraphy to demonstrate pelvic lymph nodes and lymphoid fluid leakage to the pelvic floor.

Para-aortic lymphocyst occasionally follows retroperitoneal para-aortic node dissection for neoplastic diseases. We present a case in which the leakage of chylous fluid and then a para-aortic lymphocyst followed right nephrectomy and para-aortic node dissection for kidney cancer. Our method of treatment utilized conservative management of chylous ascites and laparoscopic internal drainage of the retroperitoneal lymphocyst.

This case report demonstrates the use of lymphoscintigraphy for the localization of a pelvic lymphatic leak. The study was made before and after the operative repair of a lymphatic leak and a marked reduction in the leakage was evident postoperatively. The patient, a 38 year old woman, had a history of adenocarcinoma of the cervix, that was treated by abdominal hysterectomy and pelvic node dissection, and she subsequently developed chylous ascites that required ongoing drainage via a Tenckhoff catheter. This case study illustrates how lymphoscintigraphy aided in the localization of a lymphatic leak and the follow up of surgical repair.

Two cases of abdominal lymphatic disruption following surgery on the abdominal aorta are presented, one causing chylous ascites and the other resulting in a lymphocele. These complications have been only rarely described following abdominal vascular surgery. Both patients responded to percutaneous aspiration without recurrence. The radiologist has a major role in both the detection and management of this complication.