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Chae YJ, Kim KW, Kim MH, Woo CW, Kim ST, Kim JW, Shin TH, Lee DW, Kim JK, Choi Y, Woo DC. Comparison of the Pharmacokinetics of Gadolinium-Based and Iron Oxide-Based Contrast Agents inside the Lymphatic Structure using Magnetic Resonance Lymphangiography. Mol Imaging Biol 2024; 26:638-648. [PMID: 38684581 DOI: 10.1007/s11307-024-01918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Gadolinium (Gd)-based contrast agents are primarily used for contrast-enhanced magnetic resonance lymphangiography (MRL). However, overcoming venous contamination issues remains challenging. This study aims to assess the MRL efficacy of the newly developed iron-based contrast agent (INV-001) that is specially designed to mitigate venous contamination issues. The study further explores the optimal dosage, including both injection volume and concentration, required to achieve successful visualization of the popliteal lymph nodes and surrounding lymphatic vessels. PROCEDURES All animals utilized in this study were male Sprague-Dawley (SD) rats weighing between 250 and 300 g. The contrast agents prepared were injected intradermally in the fourth phalanx of both hind limbs using a 30-gauge syringe in SD rats. MRL was performed every 16 min on a coronal 3D time-of-flight sequence with saturation bands using a 9.4-T animal machine. RESULTS Contrary to Gd-DOTA, which exhibited venous contamination in most animals irrespective of injection dosages and conditions, INV-001 showed no venous contamination. For Gd-DOTA, the popliteal lymph nodes and lymphatic vessels reached peak enhancement 16 min after injection from the injection site and then rapidly washed out. However, with INV-001, they reached peak enhancement between 16 and 32 min after injection, with prolonged visualization of the popliteal lymph node and lymphatic vessels. INV-001 at 0.45 μmol (15 mM, 30 μL) and 0.75 μmol (15 mM, 50 μL) achieved high scores for qualitative image analysis, providing good visualization of the popliteal lymph nodes and lymphatic vessels without issues of venous contamination, interstitial space enhancement, or lymph node enlargement. CONCLUSION In MRL, INV-001, a novel T1 contrast agent based on iron, enables prolonged enhancement of popliteal lymph nodes and lymphatic vessels without venous contamination.
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Affiliation(s)
- Yeon Ji Chae
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
- Biomedical Research Center, Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea
- Trial Informatics Inc, Seoul, Republic of Korea
| | - Mi-Hyun Kim
- Trial Informatics Inc, Seoul, Republic of Korea
| | - Chul-Woong Woo
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Tae Kim
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | | | | | - Do-Wan Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Jeong Kon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
| | - Yoonseok Choi
- Medical Research Institute, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Gangwondo, Republic of Korea.
| | - Dong-Cheol Woo
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea.
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2
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Mills M, Brezgyte G, Ho B, Pearce J, Gordon K, Mortimer PS, Ostergaard P, Howe FA. Magnetic resonance lymphangiography: Establishing normal. J Vasc Surg Venous Lymphat Disord 2024; 12:101870. [PMID: 38513796 DOI: 10.1016/j.jvsv.2024.101870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Despite an increased interest in visualizing the lymphatic vessels with magnetic resonance lymphangiography (MRL), little literature is available describing their appearance in nonlymphedematous individuals. To determine lymphatic abnormalities, an understanding of how healthy lymphatic vessels appear and behave needs to be established. Therefore, in this study, MRL of individuals without a history of lymphatic disease was performed. METHODS A total of 25 individuals (15 women) underwent MRL of their lower limbs using a 3.0 T Philips magnetic resonance imaging scanner (Philips Medical Systems). The first nine participants were recruited to establish the concentration of gadolinium-based contrast agent (GBCA) to administer, with the remainder imaged before and after interdigital forefoot GBCA injections at the optimized dose. Outcomes, including lymphatic vessel diameter, tortuosity, and frequency of drainage via particular drainage routes, were recorded. RESULTS Healthy lymphatic vessels following the anteromedial pathway were routinely observed in post-contrast T1-weighted images (average tortuosity, 1.09 ± 0.03), with an average of 2.16 ± 0.93 lymphatic vessels with a diameter of 2.47 ± 0.50 mm crossing the anterior ankle. In six limbs, vessels following the anterolateral pathways were observed. No vessels traversing the posterior of the legs were seen. In a subset of 10 vessels, the lymphatic signal, measured at the ankle, peaked 29 minutes, 50 seconds ± 9 minutes, 29 seconds after GBCA administration. No lymphatic vessels were observed in T2-weighted images. CONCLUSIONS Contrast-enhanced MRL reliably depicts the lymphatic vessels in the legs of healthy controls. Following interdigital contrast injection, anteromedial drainage appears dominant. Quantitative measures related to lymphatic vessel size, tortuosity, and drainage rate are readily obtainable and could be beneficial for detecting even subtle lymphatic impairment.
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Affiliation(s)
- Mike Mills
- Neurosciencs and Cell Biology Research Institute, St. George's University of London, London, UK.
| | - Greta Brezgyte
- Cardiovascular and Genomics Research Institute, St. George's University of London, London, UK
| | - Bernard Ho
- Dermatology and Lymphovascular Medicine, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Julian Pearce
- Dermatology and Lymphovascular Medicine, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Kristiana Gordon
- Cardiovascular and Genomics Research Institute, St. George's University of London, London, UK; Dermatology and Lymphovascular Medicine, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter S Mortimer
- Cardiovascular and Genomics Research Institute, St. George's University of London, London, UK; Dermatology and Lymphovascular Medicine, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Pia Ostergaard
- Cardiovascular and Genomics Research Institute, St. George's University of London, London, UK
| | - Franklyn A Howe
- Neurosciencs and Cell Biology Research Institute, St. George's University of London, London, UK
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Jang JS, Kim N, Kim MH, Lee DW, Kim JW, Shin TH, Park HJ, Kim KW. Analysis on efficacy of magnetic resonance lymphangiography using INV-001 in healthy beagle dogs. Sci Rep 2024; 14:10502. [PMID: 38714849 PMCID: PMC11076550 DOI: 10.1038/s41598-024-61104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
We aimed to conduct a proof-of-concept study of INV-001 in visualizing lymphatic vessels and nodes without venous contamination and to determine the optimal dose condition of INV-001 for magnetic resonance lymphangiography (MRL) in healthy beagles. MRL was performed using a 3.0-Tesla (T) whole body clinical magnetic resonance imaging (MRI) scanner. A dose-finding study of INV-001 for MRL in beagles (N = 6) was carried out according to an adaptive optimal dose finding design. For the reproducibility study (N = 6), MRL was conducted at selected INV-001 doses (0.056 and 0.112 mg Fe/kg) with a 15 mM concentration. Additionally, an excretion study (N = 3) of INV-001 was conducted by analyzing T1, T2, and T2* maps of the liver and kidney 48 h post-administration. INV-001 administration at doses of 0.056 and 0.112 mg Fe/kg (concentration: 15 mM) consistently demonstrated the visualization of contrast-enhanced lymphatic vessels and nodes without venous contamination in the beagles. The contrast enhancement effect was highest at 30 min after INV-001 administration, then gradually decreasing. No toxicity-related issues were identified during the study. After 48 h, the T1, T2, and T2* values in the liver and both kidneys were found to be comparable to the pre-administration values, indicating thorough INV-001 excretion. The optimal dosing conditions of INV-001 for MRL for contrast-enhanced visualization of lymphatic vessels and nodes exclusively with no venous contamination in beagles was determined to be 0.056 mg Fe/kg with a 15 mM concentration.
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Affiliation(s)
- Ji Sung Jang
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Olymphic-ro 43 Gil 88, Songpa-gu, Seoul, 138-735, Republic of Korea
| | - Nari Kim
- Departments of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Hyun Kim
- Research Institute, Trial Informatics Incorporated, Seoul, Republic of Korea
- Department of Radiation Science and Technology, Jeonbuk National University, Jeonju, Republic of Korea
| | - Do-Wan Lee
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Olymphic-ro 43 Gil 88, Songpa-gu, Seoul, 138-735, Republic of Korea
| | - Ji-Wook Kim
- Inventera Incorporated, Seoul, Republic of Korea
| | | | - Hyo Jung Park
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Olymphic-ro 43 Gil 88, Songpa-gu, Seoul, 138-735, Republic of Korea
| | - Kyung Won Kim
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, Olymphic-ro 43 Gil 88, Songpa-gu, Seoul, 138-735, Republic of Korea.
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4
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Moon T, O'Donnell TF, Weycker D, Iafrati M. Lymphoscintigraphy is frequently recommended but seldom used in a "real world setting". J Vasc Surg Venous Lymphat Disord 2024; 12:101738. [PMID: 38103890 DOI: 10.1016/j.jvsv.2023.101738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Lymphedema (LED) lacks a standard, simple, guiding noninvasive diagnostic test, unlike the two other circulatory disorders-arterial or venous disease. Lymphoscintigraphy (LSG) has been recommended by several guidelines as the diagnostic test of choice for LED. Several recent expert panels, however, have suggested from anecdotal experience that LSG was used infrequently, and that the diagnosis of LED is usually based on clinical examination. METHODS To determine the use of LSG in a large real-world LED population, the International Business Machines MarketScan Research Database was examined from April 2012 to March 2020 for patients with a new diagnosis of LED (the index date). Use of LSG (LSG+) was ascertained during the period beginning 12 months prior to the initial coding of a LED diagnosis and ending 12 months after the index date based on the corresponding Current Procedural Terminology code; LSG use for sentinel node mapping at the time of oncologic surgery was excluded. Demographic profiles, comorbidities, and causes of LED among patients with and without evidence of LSG were characterized. RESULTS We identified 57,674 patients, aged ≥18 years, who had a new diagnosis of LED and health care coverage for ≥12 months before and after this index date. Only a small number (1429; 2.5%) of these patients underwent LSG during the study period. The LSG + cohort was younger (53.7 vs 60.7 years), had a higher proportion of women (91.3% vs 73.4%), but a lower percentage of diabetes (12.8% vs 27.5%), heart failure (2.2% vs 8.7%), hypertension (32.4% vs 51.0%), and obesity (15.1% vs 22.2%) compared with the LED population who did not undergo LSG (all P < .001). Most importantly, the use of LSG for diagnosis varied with the etiology of LED (LSG was most frequently utilized among patients with melanoma-LED (9.5%) and patients with breast cancer-LED (6.7%), in contrast to patients with advanced venous disease-related LED (1.1%; P < .05 for both comparisons). CONCLUSIONS Despite four guidelines recommending LSG, including the Guidelines of the American Venous Forum (Handbook of Venous and Lymphatic Disease-4th edition), which recommended LSG "for the initial evaluation of patients with LED" with a 1B recommendation, LSG plays a minor role in establishing the diagnosis of LED in the United States. This underlines the need for a better, simple diagnostic test for LED to complement clinical examination.
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Affiliation(s)
- Tina Moon
- Department of Surgery, Tufts Medical Center, Boston, MA
| | - Thomas F O'Donnell
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Mark Iafrati
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.
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5
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Salehi BP, Sibley RC, Friedman R, Kim G, Singhal D, Loening AM, Tsai LL. MRI of Lymphedema. J Magn Reson Imaging 2023; 57:977-991. [PMID: 36271779 PMCID: PMC10006319 DOI: 10.1002/jmri.28496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
Lymphedema is a devastating disease that has no cure. Management of lymphedema has evolved rapidly over the past two decades with the advent of surgeries that can ameliorate symptoms. MRI has played an increasingly important role in the diagnosis and evaluation of lymphedema, as it provides high spatial resolution of the distribution and severity of soft tissue edema, characterizes diseased lymphatic channels, and assesses secondary effects such as fat hypertrophy. Many different MR techniques have been developed for the evaluation of lymphedema, and the modality can be tailored to suit the needs of a lymphatic clinic. In this review article we provide an overview of lymphedema, current management options, and the current role of MRI in lymphedema diagnosis and management. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Betsa Parsai Salehi
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Rosie Friedman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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6
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Kim HB, Jung SS, Cho MJ, Peirera N, Pak CJ, Suh PHS, Lee SH, Hong JP. Comparative Analysis of Preoperative High Frequency Color Doppler Ultrasound versus MR Lymphangiography versus ICG Lymphography of Lymphatic Vessels in Lymphovenous Anastomosis. J Reconstr Microsurg 2023; 39:92-101. [PMID: 35426085 DOI: 10.1055/s-0042-1745745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Despite the extensive use of various imaging modalities, there is limited literature on comparing the reliability between indocyanine green (ICG) lymphography, MR Lymphangiogram (MRL), and high frequency color Doppler ultrasound (HFCDU) to identify lymphatic vessels. METHOD In this study of 124 patients, the correlation between preoperative image findings to the actual lymphatic vessel leading to lymphovenous anastomosis (LVA) was evaluated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and simple detection were calculated. Subgroup analysis was also performed according to the severity of lymphedema. RESULTS Total of 328 LVAs were performed. The HFCDU overall had significantly higher sensitivity for identifying lymphatic vessels (99%) over MRL (83.5%) and ICG lymphography (82.3%)(p < 0.0001). Both ICG lymphography and HFCDU had 100% specificity and PPV. The NPV was 3.6%, 6.5% and 57.1% respectively for MRL, ICG lymphography, and HFCDU. All modalities showed high sensitivity for early stage 2 lymphedema while HFCDU showed a significantly higher sensitivity for late stage 2 (MRL:79.7%, ICG:83.1%, HFCDU:97%) and stage 3 (MRL:79.7%, ICG:79.7%, HFCDU:100%) over the other two modalities (p < 0.0001). CONCLUSION This study demonstrated while all three modalities are able to provide good information, the sensitivity may alter as the severity of lymphedema progresses. The HFCDU will provide the best detection for lymphatic vessels throughout all stages of lymphedema. However, as each modality provides different and unique information, combining and evaluating the data according to the stage of lymphedema will be able to maximize the chance for a successful surgical outcome.
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Affiliation(s)
- Hyung Bae Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Jung
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Jeong Cho
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nicolas Peirera
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Plastic Surgery and Burns, Hospital del Trabajador, Santiago, Chile.,Department of Plastic Surgery, Clínica Las Condes, Santiago, Chile
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Peter Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Lee
- Department of Diagnostic Radiology, Asan Medical Center, University of Ulsan
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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7
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van Heumen S, Riksen JJM, Bramer WM, van Soest G, Vasilic D. Imaging of the Lymphatic Vessels for Surgical Planning: A Systematic Review. Ann Surg Oncol 2023; 30:462-479. [PMID: 36171528 PMCID: PMC9726677 DOI: 10.1245/s10434-022-12552-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Secondary lymphedema is a common complication after surgical or radiotherapeutic cancer treatment. (Micro) surgical intervention such as lymphovenous bypass and vascularized lymph node transfer is a possible solution in patients who are refractory to conventional treatment. Adequate imaging is needed to identify functional lymphatic vessels and nearby veins for surgical planning. METHODS A systematic literature search of the Embase, MEDLINE ALL via Ovid, Web of Science Core Collection and Cochrane CENTRAL Register of Trials databases was conducted in February 2022. Studies reporting on lymphatic vessel detection in healthy subjects or secondary lymphedema of the limbs or head and neck were analyzed. RESULTS Overall, 129 lymphatic vessel imaging studies were included, and six imaging modalities were identified. The aim of the studies was diagnosis, severity staging, and/or surgical planning. CONCLUSION Due to its utility in surgical planning, near-infrared fluorescence lymphangiography (NIRF-L) has gained prominence in recent years relative to lymphoscintigraphy, the current gold standard for diagnosis and severity staging. Magnetic resonance lymphography (MRL) gives three-dimensional detailed information on the location of both lymphatic vessels and veins and the extent of fat hypertrophy; however, MRL is less practical for routine presurgical implementation due to its limited availability and high cost. High frequency ultrasound imaging can provide high resolution imaging of lymphatic vessels but is highly operator-dependent and accurate identification of lymphatic vessels is difficult. Finally, photoacoustic imaging (PAI) is a novel technique for visualization of functional lymphatic vessels and veins. More evidence is needed to evaluate the utility of PAI in surgical planning.
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Affiliation(s)
- Saskia van Heumen
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,MSc Educational Program Technical Medicine, Leiden University Medical Center, Delft University of Technology and Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jonas J M Riksen
- Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gijs van Soest
- Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Mills M, van Zanten M, Borri M, Mortimer PS, Gordon K, Ostergaard P, Howe FA. Systematic Review of Magnetic Resonance Lymphangiography From a Technical Perspective. J Magn Reson Imaging 2021; 53:1766-1790. [PMID: 33625795 PMCID: PMC7611641 DOI: 10.1002/jmri.27542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clinical examination and lymphoscintigraphy are the current standard for investigating lymphatic function. Magnetic resonance imaging (MRI) facilitates three-dimensional (3D), nonionizing imaging of the lymphatic vasculature, including functional assessments of lymphatic flow, and may improve diagnosis and treatment planning in disease states such as lymphedema. PURPOSE To summarize the role of MRI as a noninvasive technique to assess lymphatic drainage and highlight areas in need of further study. STUDY TYPE Systematic review. POPULATION In October 2019, a systematic literature search (PubMed) was performed to identify articles on magnetic resonance lymphangiography (MRL). FIELD STRENGTH/SEQUENCE No field strength or sequence restrictions. ASSESSMENT Article quality assessment was conducted using a bespoke protocol, designed with heavy reliance on the National Institutes of Health quality assessment tool for case series studies and Downs and Blacks quality checklist for health care intervention studies. STATISTICAL TESTS The results of the original research articles are summarized. RESULTS From 612 identified articles, 43 articles were included and their protocols and results summarized. Field strength was 1.5 or 3.0 T in all studies, with 25/43 (58%) employing 3.0 T imaging. Most commonly, imaging of the peripheries, upper and lower limbs including the pelvis (32/43, 74%), and the trunk (10/43, 23%) is performed, including two studies covering both regions. Imaging protocols were heterogenous; however, T2 -weighted and contrast-enhanced T1 -weighted images are routinely acquired and demonstrate the lymphatic vasculature. Edema, vessel, quantity and morphology, and contrast uptake characteristics are commonly reported indicators of lymphatic dysfunction. DATA CONCLUSION MRL is uniquely placed to yield large field of view, qualitative and quantitative, 3D imaging of the lymphatic vasculature. Despite study heterogeneity, consensus is emerging regarding MRL protocol design. MRL has the potential to dramatically improve understanding of the lymphatics and detect disease, but further optimization, and research into the influence of study protocol differences, is required before this is fully realized. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Michael Mills
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Malou van Zanten
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Marco Borri
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
- Department of Neuroradiology, King’s College Hospital, London, UK
| | - Peter S. Mortimer
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Kristiana Gordon
- Lymphovascular Medicine, Dermatology Department, St George’s Hospital, London, UK
| | - Pia Ostergaard
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
| | - Franklyn A. Howe
- Molecular and Clinical Sciences Research Institute, St George’s University, London, UK
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9
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Forte AJ, Boczar D, Huayllani MT, Avila FR, Guliyeva G, Lu X, Mash WR, Kung TA. Use of magnetic resonance imaging lymphangiography for preoperative planning in lymphedema surgery: A systematic review. Microsurgery 2021; 41:384-390. [PMID: 33710683 DOI: 10.1002/micr.30731] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/04/2021] [Accepted: 03/03/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years, magnetic resonance imaging lymphangiography (MRL) has emerged as a way to predict if patients are candidates for lymphedema surgery, particularly lymphovenous anastomosis (LVA). Our goal was to conduct a systematic review of the literature on the use of MRL for preoperative planning in lymphedema surgery. We hypothesized that MRL could add valuable information to the standard preoperative evaluation of lymphedema patients. METHODS On February 17, 2020, we conducted a systematic review of the PubMed/MEDLINE, Cochrane Clinical Answers, and Embase databases, without time frame or language limitations, to identify articles on the use of MRL for preoperative planning of lymphedema surgery. We excluded studies that investigated other applications of magnetic resonance imaging, such as lymphedema diagnosis and treatment evaluation. The primary outcome was the examination capacity to identify lymphatic anatomy and the secondary outcome was the presence of adverse effects. RESULTS Of 372 potential articles identified with the search, nine studies fulfilled the eligibility criteria. A total of 334 lymphedema patients were enrolled in these studies. Two studies compared MRL findings with those of other standard examinations (indocyanine green lymphography [ICG-L] or lymphoscintigraphy). No adverse effects due to MRL were reported. A study shown that MRL had higher sensitivity to detect lymphatic vessel abnormalities compared with lymphoscintigraphy and a statistically higher chance of successful LVA was observed when the results of MRL agreed with those of ICG-L (p < .001). CONCLUSIONS MRL could be useful for preoperative planning in lymphedema surgery. The scientific evidence has been limited, so further studies with greater numbers of patients and cost analysis are necessary to justify the addition of MRL to current preoperative protocols.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Gunel Guliyeva
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - William R Mash
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore A Kung
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
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10
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Miseré RML, Wolfs JAGN, Lobbes MBI, van der Hulst RRWJ, Qiu SS. A systematic review of magnetic resonance lymphography for the evaluation of peripheral lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 8:882-892.e2. [PMID: 32417145 DOI: 10.1016/j.jvsv.2020.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/13/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Visualization of the lymphatic system is necessary for both early diagnosis and associated treatments. A promising imaging modality is magnetic resonance lymphography (MRL). The aim of this review was to summarize different MRL protocols, to assess the clinical value in patients with peripheral lymphedema, and to define minimal requirements necessary for visualization of lymphatics. METHODS A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library in December 2018. Studies performing MRL in patients with peripheral lymphedema or healthy participants were included. Study design, population, etiology, duration of lymphedema, clinical staging, contrast agent, dose, injection site, and technical magnetic resonance imaging details were analyzed. No meta-analyses were performed because of different study aims and heterogeneity of the study populations. RESULTS Twenty-five studies involving 1609 patients with both primary lymphedema (n = 669) and secondary lymphedema (n = 657) were included. Upper and lower limbs were examined in 296 and 602 patients, respectively. Twenty-two studies used a gadolinium-based contrast agent that was injected intracutaneously or subcutaneously in the interdigital web spaces. Contrast-enhanced T1-weighted combined with T2-weighted protocols were most frequently used. T1-weighted images showed lymphatics in 63.3% to 100%, even in vessels with a diameter of ≥0.5 mm. Dermal backflow and a honeycomb pattern were clearly recognized. CONCLUSIONS MRL identifies superficial lymphatic vessels with a diameter of ≥0.5 mm with high sensitivity and specificity and accurately shows abnormal lymphatics and lymphatic drainage patterns. Therefore, MRL could be of clinical value in both early and advanced stages of peripheral lymphedema. Minimum requirements of an MRL protocol should consist of a gadolinium-based contrast-enhanced T1-weighted gradient-recalled echo sequence combined with T2-weighted magnetic resonance imaging, with acquisition at least 30 minutes after injection of contrast material.
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Affiliation(s)
- Renée M L Miseré
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joost A G N Wolfs
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc B I Lobbes
- Department of Radiology, Zuyderland Medical Center, Geleen, The Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
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Shaikh R, Biko DM, Lee EY. MR Imaging Evaluation of Pediatric Lymphatics:: Overview of Techniques and Imaging Findings. Magn Reson Imaging Clin N Am 2019; 27:373-385. [PMID: 30910103 DOI: 10.1016/j.mric.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent advances in understanding lymphatic disorders have significantly improved noninvasive imaging of the lymphatic circulation, especially in pediatric patients. The ability to obtain high-quality MR imaging using 3-dimensional reconstruction has transformed the display of the lymph vessels and substantially enhanced the ability to diagnose various pediatric lymphatic disorders. Real-time dynamic imaging adds functional information to the assessment. MR imaging is increasingly used, not only to assess but also as a follow-up after lymphatic disorder treatment. This article discusses up-to-date imaging techniques and clinical applications of dynamic magnetic resonance lymphangiography for assessing central conducting lymphatic anomalies.
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Affiliation(s)
- Raja Shaikh
- Division of Interventional Radiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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12
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Evaluation of lymphedema in upper extremities by MR lymphangiography: Comparison with lymphoscintigraphy. Magn Reson Imaging 2018; 49:63-70. [DOI: 10.1016/j.mri.2017.12.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 12/29/2017] [Indexed: 11/22/2022]
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13
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Ripley B, Wilson GJ, Lalwani N, Briller N, Neligan PC, Maki JH. Initial Clinical Experience with Dual-Agent Relaxation Contrast for Isolated Lymphatic Channel Mapping. Radiology 2017; 286:705-714. [PMID: 28934015 DOI: 10.1148/radiol.2017170241] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose To evaluate the clinical performance of dual-agent relaxation contrast (DARC) magnetic resonance (MR) lymphangiography compared with that of conventional MR lymphangiography in the creation of isolated lymphatic maps in patients with secondary lymphedema. Materials and Methods This retrospective study was approved by the institutional review board. The diagnostic quality of 42 DARC MR lymphangiographic studies was compared with that of 42 conventional MR lymphangiographic studies. Two independent readers rated venous contamination as absent, mild, or moderate to severe. Interreader agreement on venous contamination grades was assessed by using the linearly weighted Cohen κ statistic. The Mann-Whitney U test was used to compare the distribution of grades at each station between conventional MR lymphangiography and DARC MR lymphangiography for each reader separately. Results DARC MR lymphangiography had significantly less venous contamination than did conventional MR lymphangiography (P < .001). The two radiologists rated venous contamination as moderate to severe in 64% (27 of 42) and 69% (29 of 42) of distal limbs, 23% (10 of 42) of midlimbs, and 2% (one of 42) and 9% (four of 42) of proximal limbs at conventional MR lymphangiography compared with 0% (0 of 42) of distal limbs, 2% (one of 42) of midlimbs, and 0% (0 of 42) of proximal limbs at DARC MR lymphangiography. Lymphatic signal was partially attenuated (median 45% decrease) when longer echo times were used for venous suppression, but it did not subjectively degrade diagnostic quality. Conclusion DARC MR lymphangiography yields isolated lymphatic maps through nulling of venous contamination, thereby simplifying diagnostic interpretation and communication with surgical colleagues. © RSNA, 2017.
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Affiliation(s)
- Beth Ripley
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
| | - Gregory J Wilson
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
| | - Neeraj Lalwani
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
| | - Noah Briller
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
| | - Peter C Neligan
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
| | - Jeffrey H Maki
- From the Department of Radiology, VA Puget Sound Health Care System, Seattle, Wash (B.R.); and Departments of Radiology (B.R., G.J.W., N.L., N.B., J.H.M.) and Plastic Surgery (P.C.N.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195-7115
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Mazzei MA, Gentili F, Mazzei FG, Gennaro P, Guerrieri D, Nigri A, Gabriele G, Weber E, Fausto A, Botta G, Volterrani L. High-resolution MR lymphangiography for planning lymphaticovenous anastomosis treatment: a single-centre experience. Radiol Med 2017; 122:918-927. [DOI: 10.1007/s11547-017-0795-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/20/2017] [Indexed: 02/06/2023]
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MR Lymphangiography: A Practical Guide to Perform It and a Brief Review of the Literature from a Technical Point of View. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2598358. [PMID: 28367439 PMCID: PMC5359436 DOI: 10.1155/2017/2598358] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/19/2017] [Indexed: 11/30/2022]
Abstract
We propose a practical approach for performing high-resolution MR lymphangiography (MRL). We shall discuss and illustrate the technical approach for the visualization of lymphatic vessels in patients suffering from lymphedema, how to distinguish lymphatic vessels from veins, and MRL role in supermicrosurgery treatment planning. A brief review of literature, from a technical point of view, is also reported.
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Hadrian R, Palmes D. Animal Models of Secondary Lymphedema: New Approaches in the Search for Therapeutic Options. Lymphat Res Biol 2017; 15:2-16. [PMID: 28128668 DOI: 10.1089/lrb.2016.0015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Secondary lymphedema is still a worldwide problem. Symptomatic approaches to lymphedema therapy have been mainly used, with complete decongestive therapy as the cornerstone. Due to a lack of regenerative therapy, researchers have established various animal models to obtain insights into pathomechanisms and to reveal the best therapeutic option. Since the first reproducible and reliable animal model of lymphedema was reported in dogs, the technique of circumferential excision of lymphatic tissue has been translated mainly to rodents to induce secondary lymphedema. In these models, various promising pharmacological and surgical approaches have been investigated to improve secondary lymphedema therapy. Imaging modalities are crucial to detect the extent of lymphatic dysfunction and decide the best therapy. The gold standard of lymphoscintigraphy is currently limited by poor spatial resolution and lack of quantification. Animal models could help to bridge a gap in improving morphological correlation and quantifying lymphatic functionality. This review summarizes the animal models used in lymphatic research and focuses on new therapeutic options and requirements for imaging modalities to visualize the lymphatic system.
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Affiliation(s)
- Rebecca Hadrian
- Department of General and Visceral Surgery, University Hospital Münster , Münster, Germany
| | - Daniel Palmes
- Department of General and Visceral Surgery, University Hospital Münster , Münster, Germany
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Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review. J Plast Reconstr Aesthet Surg 2016; 69:1234-47. [DOI: 10.1016/j.bjps.2016.06.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/18/2016] [Accepted: 06/22/2016] [Indexed: 11/17/2022]
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Maki JH, Neligan PC, Briller N, Mitsumori LM, Wilson GJ. Dark Blood Magnetic Resonance Lymphangiography Using Dual-Agent Relaxivity Contrast (DARC-MRL): A Novel Method Combining Gadolinium and Iron Contrast Agents. Curr Probl Diagn Radiol 2016; 45:174-9. [DOI: 10.1067/j.cpradiol.2015.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/08/2015] [Accepted: 08/09/2015] [Indexed: 12/28/2022]
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19
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Kim EY, Hwang HS, Lee HY, Cho JH, Kim HK, Lee KS, Shim YM, Zo J. Anatomic and Functional Evaluation of Central Lymphatics With Noninvasive Magnetic Resonance Lymphangiography. Medicine (Baltimore) 2016; 95:e3109. [PMID: 27015184 PMCID: PMC4998379 DOI: 10.1097/md.0000000000003109] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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.
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Affiliation(s)
- Eun Young Kim
- From the Department of Radiology and Center for Imaging Science (EYK, HSH, HYL, KSL); Department of Thoracic and Cardiovascular Surgery (JHC, HKK, YMS, JZ), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Radiology (EYK), Ajou University School of Medicine, Suwon, Korea
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20
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Jeon J, Lee S, Shin M, Chung H, Lee M. Three-dimensional isotropic fast spin-echo MR lymphangiography of T1-weighted and intermediate-weighted pulse sequences in patients with lymphoedema. Clin Radiol 2016; 71:e56-63. [DOI: 10.1016/j.crad.2015.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/02/2015] [Accepted: 10/14/2015] [Indexed: 11/30/2022]
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21
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Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg 2015; 261:1013-23. [PMID: 24950271 DOI: 10.1097/sla.0000000000000763] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A comprehensive literature review of VLNT with updates and comparisons on current application, techniques, results, studies and possible future implications. BACKGROUND Lymphedema is a debilitating condition that often results secondary to treatment of cancer. Unfortunately there is no cure. However, microsurgical procedures such as VLNT has gained popularity as there have been increasing reports that VLNT may help alleviate the severity of lymphedema. METHODS A review of literature was conducted over major medical indices (PubMed-MEDLINE, Factiva, Scopus, Sciencedirect, EMBASE). Search terms were focused on vascularized, lymph node transfer (also autologous, lymph node transplant) to cover both human and animal studies. Each study was verified for the nature of the procedure; a free microsurgical flap containing lymph nodes for the purpose of relieving lymphedema. RESULTS There are human and animal studies that individually report clear benefits, but because of methodological shortcomings comparative studies with uniform patient selection and monitoring are lacking. CONCLUSIONS Although the results with the use of VLNT for treatment of lymphedema have been largely positive, further exploration into standardized protocols for diagnosis, treatment optimization, and patient outcomes assessment is needed.
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22
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Mitsumori LM, McDonald ES, Wilson GJ, Neligan PC, Minoshima S, Maki JH. Mr lymphangiography: How i do it. J Magn Reson Imaging 2015; 42:1465-77. [DOI: 10.1002/jmri.24887] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 11/21/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Lee M. Mitsumori
- Department of Radiology; Straub Clinic and Hospital; Honolulu Hawaii USA
| | | | - Gregory J. Wilson
- Department of Radiology; University of Washington; Seattle Washington USA
| | - Peter C. Neligan
- Department of Plastic Surgery; University of Washington; Seattle Washington USA
| | - Satoshi Minoshima
- Department of Radiology; University of Washington; Seattle Washington USA
| | - Jeffrey H. Maki
- Department of Radiology; University of Washington; Seattle Washington USA
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White RD, Weir-McCall JR, Budak MJ, Waugh SA, Munnoch DA, Sudarshan TAP. Contrast-enhanced magnetic resonance lymphography in the assessment of lower limb lymphoedema. Clin Radiol 2014; 69:e435-44. [PMID: 25064763 DOI: 10.1016/j.crad.2014.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 06/03/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Abstract
Chronic lower limb lymphoedema is a debilitating condition that may occur as a primary disorder or secondary to other conditions. Satisfactory visualization of the lymphatic vessels to aid diagnosis and surgical planning has been problematic. Historically, direct lymphography was used to visualize lymphatic vessels, although the significant surgical risks involved led to this being largely abandoned as a technique. Technetium-99m lymphoscintigraphy has been the mainstay of diagnosis for over two decades, but is hampered by inherently poor temporal and spatial resolution and limited anatomical detail. Contrast-enhanced magnetic resonance lymphography (MRL) is a relatively new technique that shows early promise in the evaluation of chronic lymphoedema. This article provides the procedural technique for lower limb MRL at both 1.5 and 3 T, discusses pathophysiology and classifications of lymphoedema, provides an overview of relevant lower limb lymphatic anatomy using MRL imaging, compares the various techniques used in the diagnosis of lower limb lymphoedema, shows common pathological MRL imaging findings, and describes alternative uses of MRL. Utilization of this technique will allow more accurate diagnosis and classification of patients suffering from lymphoedema.
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Affiliation(s)
- R D White
- Department of Clinical Radiology, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK; Department of Clinical Radiology, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - J R Weir-McCall
- Department of Clinical Radiology, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK
| | - M J Budak
- Department of Clinical Radiology, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK
| | - S A Waugh
- Department of Clinical Radiology, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK
| | - D A Munnoch
- Department of Plastic Surgery, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK
| | - T A P Sudarshan
- Department of Clinical Radiology, Ninewells Hospital and Medical School, Ninewells Avenue, Dundee DD1 9SY, UK.
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Weiss M, Burgard C, Baumeister R, Strobl F, Rominger A, Bartenstein P, Wallmichrath J, Frick A, Notohamiprodjo M. Magnetic resonance imaging versus lymphoscintigraphy for the assessment of focal lymphatic transport disorders of the lower limb: first experiences. Nuklearmedizin 2014; 53:190-6. [PMID: 24999013 DOI: 10.3413/nukmed-0649-14-03] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 06/13/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the diagnostic accuracy of magnetic resonance imaging (MR-lymphangiography) and lymphoscintigraphy for assessment of focal lesions of the peripheral lymphatic system. Patients with focal lymphatic transport disorders might benefit from surgi-cal interventions. PATIENTS, METHODS We examined by lymphoscintigraphy and MR-lymphangiography a total of 85 lower limbs in 46 consecutive patients (33 women; mean age 41 years; range 9-79 years) presenting with uni- or bilateral lymphedema. MR-lymphangiographies were obtained at isotropic sub-millimeter resolution with a 3.0 Tesla magnet after injection of gadolinium contrast medium. MR-lymphangiography was reviewed by radiologists, whereas lymphoscintigraphy was reviewed by nuclear medicine physicians. The images were examined for localization and distribution of any focal lesions of the lymphatic vessel system. Diagnostic accuracy of the MR-approach was calculated relative to the lymphoscintigraphy gold standard. RESULTS There was substantial correlation of results by the two modalities (κ = 0.62). MR-lymphangiography had sensitivity of 68%, specificity of 91%, positive predictive value of 82%, and negative predictive value of 83%. CONCLUSIONS Imaging findings of both lymphoscintigraphy and MR-lymphangiography showed good diagnostic accuracy. MR-lymphangiography proved more information about anatomic location of focal lesions of the lymphatic vessels, but use of MR-lymphangiography is currently constrained due to the requirement for off-label subcutaneous injection of gadolinium chelates. Consequently, and due to its superior sensitivity lymphoscintigraphy remains the most common imaging method to assess functional lymphatic disorders of the lower limb.
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Affiliation(s)
- M Weiss
- Mayo Weiss MD, Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Marchioninistr.15, 81377 Muenchen, Germany, Tel. +49/(0)89/70 95 76 38, E-mail:
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Gardner GC, Nickerson JP, Watts R, Nelson L, Dittus KL, O'Brien PJ. Quantitative and morphologic change associated with breast cancer-related lymphedema. Comparison of 3.0T MRI to external measures. Lymphat Res Biol 2014; 12:95-102. [PMID: 24654879 DOI: 10.1089/lrb.2013.0026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Abstract Introduction: Lymphedema is a chronic disease of increasing importance to cancer survivors. A tape measurement tool used for lymphedema relies on indirect volume calculations based on external circumference, which may not reflect the true extent of abnormal fluid accumulation accurately. Fluid-sensitive MRI sequences may be able to delineate the severity of this condition more precisely and thus also monitor response to therapy. METHODS AND RESULTS Eight patients being followed by physical therapy for clinically diagnosed breast cancer-related lymphedema were recruited to participate in this study. External measurements and upper extremity MRI were performed on all subjects. Arm circumference, arm volume, and lymphedema volumes were calculated for each method. MR imaging detected lymphedema in all study subjects. Correlation was found between external circumferential measurements and with the 3.0T MRI (r=0.9368). There was poor correlation between lymphedema volumes calculated from clinical measurements and MR imaging (r=0.5539). CONCLUSIONS External measurements were not found to be an accurate measure of lymphedema volume associated with breast cancer lymphedema. MRI is a reliable means to obtain upper extremity circumferential and volume measurements. MRI is able to evaluate morphologic change associated with breast cancer-related lymphedema. Lymphedema research requires integrated use of tools to further describe the disease process over time, quantitate the distribution of tissue changes, and improve the sensitivity and specificity of the measurements.
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Affiliation(s)
- Gregory C Gardner
- 1 Department of Radiology, Fletcher-Allen Healthcare , Burlington, Vermont
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Zhou GX, Chen X, Zhang JH, Zhu JQ, Wang YB, Wang ZQ. MR lymphangiography at 3.0 Tesla to assess the function of inguinal lymph node in low extremity lymphedema. J Magn Reson Imaging 2013; 40:1430-6. [PMID: 24243596 DOI: 10.1002/jmri.24499] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/12/2013] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To assess the function of inguinal lymph node (ILN) in low extremity lymphedema (LEL) with dynamic enhanced MR lymphangiography (MRL). MATERIALS AND METHODS Sixty-four patients with clinically diagnosed LEL underwent MRL examinations. The lymph drainage patterns were separated into four subtypes. The peak time to enhancement and the contrast ratio of the ILN were calculated 35 min following contrast agent administration. RESULTS Dilated lymphatic vessels could be observed in all subjects. Type I-IV drainage patterns were observed 25% (16/64), 45.31% (29/64), 17.19% (11/64), and 12.5% (8/64), respectively. The ILN in the edematous limbs could be observed in 93.75% (60/64) of subjects. The peak time to enhancement was correlated with clinical stages (P < 0.001) of the disease, lymph drainage patterns (P < 0.001), and the duration of lymphedema (P < 0.001). The contrast ratios were significantly different at each time point (P < 0.001) and significantly correlated with the lymphatic drainage patterns (P < 0.001). CONCLUSION MRL could provide useful information for evaluating the functional status of the ILN. Data presented here demonstrate that the functionality of the ILN is related to the clinical stage of the disease, lymphatic drainage patterns, and the duration of lymphedema.
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Affiliation(s)
- Guo-xing Zhou
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Gogineni A, Caunt M, Crow A, Lee CV, Fuh G, van Bruggen N, Ye W, Weimer RM. Inhibition of VEGF-C modulates distal lymphatic remodeling and secondary metastasis. PLoS One 2013; 8:e68755. [PMID: 23874750 PMCID: PMC3712991 DOI: 10.1371/journal.pone.0068755] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 06/04/2013] [Indexed: 12/26/2022] Open
Abstract
Tumor-associated lymphatics are postulated to provide a transit route for disseminating metastatic cells. This notion is supported by preclinical findings that inhibition of pro-lymphangiogenic signaling during tumor development reduces cell spread to sentinel lymph nodes (SLNs). However, it is unclear how lymphatics downstream of SLNs contribute to metastatic spread into distal organs, or if modulating distal lymph transport impacts disease progression. Utilizing murine models of metastasis, longitudinal in vivo imaging of lymph transport, and function blocking antibodies against two VEGF family members, we provide evidence that distal lymphatics undergo disease course-dependent up-regulation of lymph transport coincidental with structural remodeling. Inhibition of VEGF-C activity with antibodies against VEGF-C or NRP2 prevented these disease-associated changes. Furthermore, utilizing a novel model of adjuvant treatment, we demonstrate that antagonism of VEGF-C or NRP2 decreases post SLN metastasis. These data support a potential therapeutic strategy for inhibiting distant metastatic dissemination via targeting tumor-associated lymphatic remodeling.
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Affiliation(s)
- Alvin Gogineni
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
| | - Maresa Caunt
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Ailey Crow
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Chingwei V. Lee
- Department of Antibody Engineering, Genentech Inc., South San Francisco, California, United States of America
| | - Germaine Fuh
- Department of Antibody Engineering, Genentech Inc., South San Francisco, California, United States of America
| | - Nicholas van Bruggen
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
| | - Weilan Ye
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Robby M. Weimer
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
- * E-mail:
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Lu Q, Hua J, Kassir MM, Delproposto Z, Dai Y, Sun J, Haacke M, Hu J. Imaging lymphatic system in breast cancer patients with magnetic resonance lymphangiography. PLoS One 2013; 8:e69701. [PMID: 23861979 PMCID: PMC3702586 DOI: 10.1371/journal.pone.0069701] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/17/2013] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate the feasibility of gadolinium (Gd) contrast-enhanced magnetic resonance lymphangiography (MRL) in breast cancer patients within a typical clinical setting, and to establish a Gd-MRL protocol and identify potential MRL biomarkers for differentiating metastatic from non-metastatic lymph nodes. Materials and Methods 32 patients with unilateral breast cancer were enrolled and divided into 4 groups of 8 patients. Groups I, II, and III received 1.0, 0.5, and 0.3 ml of intradermal contrast; group IV received two 0.5 ml doses of intradermal contrast. MRL images were acquired on a 3.0 T system and evaluated independently by two radiologists for the number and size of enhancing lymph nodes, lymph node contrast uptake kinetics, lymph vessel size, and contrast enhancement patterns within lymph nodes. Results Group III patients had a statistically significant decrease in the total number of enhancing axillary lymph nodes and lymphatic vessels compared to all other groups. While group IV patients had a statistically significant faster time to reach the maximum peak enhancement over group I and II (by 3 minutes), there was no other statistically significant difference between imaging results between groups I, II, and IV. 27 out of 128 lymphatic vessels (21%) showed dilatation, and all patients with dilated lymphatic vessels were pathologically proven to have metastases. Using the pattern of enhancement defects as the sole criterion for identifying metastatic lymph nodes during Gd-MRL interpretation, and using histopathology as the gold standard, the sensitivity and specificity were estimated to be 86% and 95%, respectively. Conclusion Gd-MRL can adequately depict the lymphatic system, can define sentinel lymph nodes, and has the potential to differentiate between metastatic and non-metastatic lymph nodes in breast cancer patients.
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Affiliation(s)
- Qing Lu
- Department of Radiology, Shanghai Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Hua
- Department of Radiology, Shanghai Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail: (J. Hua); (J. Hu)
| | - Mohammad M. Kassir
- Department of Radiology, Wayne State University; Michigan, United States of America
| | - Zachary Delproposto
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, United States of America
| | - Yongming Dai
- MR Business, Greater China, Philips Healthcare, Shanghai, China
| | - Jingyi Sun
- Department of Radiology, Wayne State University; Michigan, United States of America
| | - Mark Haacke
- Department of Radiology, Wayne State University; Michigan, United States of America
| | - Jiani Hu
- Department of Radiology, Wayne State University; Michigan, United States of America
- * E-mail: (J. Hua); (J. Hu)
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Liu N, Yan Z, Wu X. Classification of Lymphatic-system Malformations in Primary Lymphoedema based on MR Lymphangiography. Eur J Vasc Endovasc Surg 2012; 44:345-9. [DOI: 10.1016/j.ejvs.2012.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
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Notohamiprodjo M, Weiss M, Baumeister RG, Sommer WH, Helck A, Crispin A, Reiser MF, Herrmann KA. MR lymphangiography at 3.0 T: correlation with lymphoscintigraphy. Radiology 2012; 264:78-87. [PMID: 22523325 DOI: 10.1148/radiol.12110229] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively compare findings of magnetic resonance (MR) lymphangiography with those of lymphoscintigraphy, evaluate the pattern and delay of lymphatic drainage, compare typical findings, and investigate discrepancies between the techniques. MATERIALS AND METHODS This prospective study was performed according to the Declaration of Helsinki and was approved by the local ethics committee. Thirty consecutive patients with uni- or bilateral lymphedema and lymph vessel transplants of the lower extremities were examined with 3.0-T fat-saturated three-dimensional gradient-echo MR after gadopentetate dimeglumine injection. Results of all examinations were correlated with corresponding results of lymphoscintigraphy examinations. Results of both techniques were separately reviewed in consensus by a radiologist and a nuclear physician, who rated delay and pattern of drainage, number of enhancing levels, and quality of conspicuity of the depiction of lymph nodes and lymph vessels. Sensitivity and specificity were calculated by using combined results of both techniques and clinical presentation findings as reference standard. Correlation was calculated with weighted k coefficients. RESULTS Weak lymphatic drainage at lymphoscintigraphy correlated with lymphangiectasia at MR lymphangiography (13 of 33 affected extremities). Lymph vessels were clearly visualized with MR lymphangiography (five of 24 affected extremities), while they were not detectable with lymphoscintigraphy. Depiction of inguinal lymph nodes was clearer with lymphoscintigraphy (five of 60 extremities). Correlation of both techniques was excellent for delay (κ=0.93) and pattern (κ=0.84) of drainage, good for depiction of lymph nodes (κ=0.67) and number of enhancing levels (κ=0.77), and moderate for depiction of lymph vessels (κ=0.50). Sensitivity and specificity for delay and pattern of drainage were concordant, whereas MR lymphangiography showed a higher sensitivity for lymph vessel abnormalities (100% vs 79%) and lower specificity for lymph node abnormalities (78% vs 100%). CONCLUSION Imaging findings of MR lymphangiography and lymphoscintigraphy show a clear concordance. With lymphoscintigraphy, better visualization of inguinal lymph nodes was achieved, whereas with MR lymphangiography, better depiction of lymph vessels and morphologic features of lymph vessel abnormalities were achieved.
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Affiliation(s)
- Mike Notohamiprodjo
- Department of Clinical Radiology, Clinic of Nuclear Medicine, University Hospitals Munich, and Institute of Medical Informatics, Biometry and Epidemiology, University of Munich, Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany.
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Kamble RB, Shetty R, Diwakar N, Madhusudan G. Technical note: MRI lymphangiography of the lower limb in secondary lymphedema. Indian J Radiol Imaging 2011; 21:15-7. [PMID: 21431026 PMCID: PMC3056362 DOI: 10.4103/0971-3026.76047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We would like to describe a case of MRI lymphangiography of the left leg, performed by subcutaneous injection of gadopentetate in the foot, followed by serial acquisitions of images, in a 52-year-old female, who presented to us with progressive leg swelling following total hysterectomy and radiation therapy. Successful demonstration of lymphatic channels, along with faint visualization of the venous system, was achieved. This technique allows excellent visualization of lymphatic channels.
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Seven-Tesla micro-MRI in early detection of acute arterial ischaemia: evolution of findings in an in vivo rat model. Radiol Med 2011; 116:829-41. [PMID: 21509555 DOI: 10.1007/s11547-011-0676-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/11/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE Acute mesenteric ischaemia (AMI) is a life-threatening vascular emergency with a high mortality rate. Early diagnosis is the key to reducing its mortality rate and improving the quality of life. Although computed tomography (CT) is still the gold standard for acute intestinal disorders, over the last few years, magnetic resonance imaging (MRI) has become a useful alternative tool. An animal model of AMI was developed in order to study the effectiveness of MRI in early detection of this condition and to observe lesion evolution. METHODS Thirty Sprague Dawley rats were randomly divided into two groups (n=15): in the first group, after laparotomy, the animals underwent ligation of the superior mesenteric artery (SMA), followed by macroscopic monitoring and histological evaluation; in the second, ischaemia was induced by squeezing a loop around the SMA 3 days before evaluation with 7-T micro-MRI. RESULTS Macroscopically, a reflex spastic ileus followed by reflex hypotonic ileus and colour changes in some of the loops were detected. MRI evidenced luminal dilatation with air-fluid levels, free intraperitoneal fluid and bowelwall oedema. Histological analysis confirmed ischaemia and earlier damage involving the central portion of the ileum. CONCLUSIONS This model shows the correct sequence of events during arterial AMI and demonstrates that MRI can be recommended for early diagnosis of these lesions.
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