1
|
Lee S, Hur S, Choi YH, Hwang JY, Cheon JE. MR Lymphangiography: Congenital Lymphatic Flow Disorders. Invest Radiol 2024:00004424-990000000-00244. [PMID: 39137741 DOI: 10.1097/rli.0000000000001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
ABSTRACT Congenital lymphatic flow disorders collectively refer to a heterogeneous group of diseases that manifest as chylothorax, chylous ascites, intestinal lymphangiectasia, protein-losing enteropathy, and peripheral extremity or genital lymphedema, all in the absence of identifiable injury to the lymphatic system. We have only recently begun to understand congenital lymphatic flow disorders through the ability to image lymph flow dynamically. Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) is a crucial technique for imaging lymphatic flow in pediatric patients with congenital lymphatic flow disorders. However, as lymphatic imaging is still a nascent discipline with many uncertainties regarding optimal imaging and treatment, effective patient management requires a comprehensive understanding of imaging techniques, disease pathophysiology, and multidisciplinary treatment approaches. Above all, a fundamental understanding of the physiological lymphatic flow of the central conducting lymphatics is essential for the correct interpretation of DCMRL images. This knowledge helps to avoid unnecessary examinations, erroneous diagnoses, and potentially harmful treatment approaches. This review provides an overview of the methods, advantages, and precautions for interpreting the DCMRL examination, a state-of-the-art lymphatic system imaging technique, and shares various case studies.
Collapse
Affiliation(s)
- Seunghyun Lee
- From the Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.L., S.H., Y.H.C., J.-Y.H., J.-E.C.); Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea (S.L., S.H., Y.H.C., J.-Y.H., J.-E.C.); and Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea (J.-E.C.)
| | | | | | | | | |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Arrivé L, Chekir H, El Mouhadi S. Noncontrast MR Lymphography: A Noninvasive and Useful Imaging Modality. Radiographics 2024; 44:e240054. [PMID: 38662590 DOI: 10.1148/rg.240054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Affiliation(s)
- Lionel Arrivé
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris (APHP), and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Hedi Chekir
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris (APHP), and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Sanaâ El Mouhadi
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris (APHP), and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012 Paris, France
| |
Collapse
|
4
|
Kageyama T, Shiko Y, Kawasaki Y, Miyazaki T, Sakai H, Tsukuura R, Yamamoto T. Three-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema. Magn Reson Imaging 2024; 107:24-32. [PMID: 38181836 DOI: 10.1016/j.mri.2023.12.007] [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: 09/18/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024]
Abstract
PURPOSES Non-contrast magnetic resonance lymphography (NMRL) has recently shown the capability of evaluating anatomical fluid distribution in upper extremity lymphedema (UEL). However, there is still a lack of knowledge about the correlation between the characteristic three-dimensional (3D) NMRL findings and the indocyanine green lymphography (ICG-L) findings. Our goal was to clarify the relationship between the 3D NMRL findings and the ICG-L findings. METHODS Medical charts of patients with secondary UEL who underwent NMRL and ICG-L between January 2018 to October 2021 were reviewed. The upper extremities were divided into 6 regions; the hand, elbow, and the radial and ulnar aspects of the forearm and the upper arm. We investigated the prevalence of characteristic 3D NMRL patterns (Mist/Spray/Inky) in each region based on the ICG-L stage. We also examined the association between the 3D NMRL stage which we proposed and the ICG-L stage, and other clinical factors. RESULTS A total of 150 regions of 25 patients with upper extremities lymphedema were enrolled in the study. All of the characteristic patterns increased significantly as the ICG-L stage advanced (p < 0.001, < 0.001, and < 0.001, respectively). The predominant NMRL patterns changed significantly from the Early pattern (Mist pattern) to the Advanced pattern (Inky/Spray pattern) as the ICG-L stage progressed (p < 0.001). The higher Stage of 3D NMRL was significantly associated with the progression of the ICG-L stage (rs = 0.80, p < 0.001). CONCLUSIONS Characteristic 3D NMRL patterns and the 3D NMRL Stage had a significant relationship with the ICG-L stage and other clinical parameters. This information may be an efficient tool for a more precise and objective evaluation of various treatments for UEL patients.
Collapse
Affiliation(s)
- Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama, Japan
| | - Yuki Shiko
- Research Administration Center, Saitama Medical University, Saitama, Japan
| | - Yohei Kawasaki
- Research Administration Center, Saitama Medical University, Saitama, Japan
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| |
Collapse
|
5
|
Devoogdt N, Thomis S, Belva F, Dickinson-Blok J, Fourgeaud C, Giacalone G, Karlsmark T, Kavola H, Keeley V, Marques ML, Mansour S, Nissen CV, Nørregaard S, Oberlin M, Ručigaj TP, Somalo-Barranco G, Suominen S, Van Duinen K, Vignes S, Damstra R. The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema. Eur J Med Genet 2024; 67:104905. [PMID: 38143023 DOI: 10.1016/j.ejmg.2023.104905] [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: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
Lymphoedema is caused by an imbalance between fluid production and transport by the lymphatic system. This imbalance can be either caused by reduced transport capacity of the lymphatic system or too much fluid production and leads to swelling associated with tissue changes (skin thickening, fat deposition). Its main common complication is the increased risk of developing cellulitis/erysipelas in the affected area, which can worsen the lymphatic function and can be the cause of raised morbidity of the patient if not treated correctly/urgently. The term primary lymphoedema covers a group of rare conditions caused by abnormal functioning and/or development of the lymphatic system. It covers a highly heterogeneous group of conditions. An accurate diagnosis of primary lymphoedema is crucial for the implementation of an optimal treatment plan and management, as well as to reduce the risk of worsening. Patient care is diverse across Europe, and national specialised centres and networks are not available everywhere. The European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) gathers the best expertise in Europe and provide accessible cross-border healthcare to patients with rare vascular diseases. There are six different working groups in VASCERN, which focus on arterial diseases, hereditary haemorrhagic telangiectasia, neurovascular diseases, lymphoedema and vascular anomalies. The working group Paediatric and Primary Lymphedema (PPL WG) gathers and shares knowledge and expertise in the diagnosis and management of adults and children with primary and paediatric lymphoedema. The members of PPL WG have worked together to produce this opinion statement reflecting strategies on how to approach patients with primary and paediatric lymphoedema. The objective of this patient pathway is to improve patient care by reducing the time to diagnosis, define the best management and follow-up strategies and avoid overuse of resources. Therefore, the patient pathway describes the clinical evaluation and investigations that lead to a clinical diagnosis, the genetic testing, differential diagnosis, the management and treatment options and the patient follow up at expert and local centres. Also, the importance of the patient group participation in the PPL WG is discussed.
Collapse
Affiliation(s)
- Nele Devoogdt
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Thomis
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Janine Dickinson-Blok
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Caroline Fourgeaud
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | | | - Tonny Karlsmark
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Heli Kavola
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Vaughan Keeley
- Derby Lymphedema Service, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | | | - Sahar Mansour
- Department of Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christoffer V Nissen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan Nørregaard
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Oberlin
- European Centre for Lymphology, Földi Clinic, Hinterzarten, Germany
| | | | | | - Sinikka Suominen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kirsten Van Duinen
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | - Robert Damstra
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands.
| |
Collapse
|
6
|
Carroll BJ, Singhal D. Advances in lymphedema: An under-recognized disease with a hopeful future for patients. Vasc Med 2024; 29:70-84. [PMID: 38166534 DOI: 10.1177/1358863x231215329] [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] [Indexed: 01/04/2024]
Abstract
Lymphedema has traditionally been underappreciated by the healthcare community. Understanding of the underlying pathophysiology and treatments beyond compression have been limited until recently. Increased investigation has demonstrated the key role of inflammation and resultant fibrosis and adipose deposition leading to the clinical sequelae and associated reduction in quality of life with lymphedema. New imaging techniques including magnetic resonance imaging (MRI), indocyanine green lymphography, and high-frequency ultrasound offer improved resolution and understanding of lymphatic anatomy and flow. Nonsurgical therapy with compression, exercise, and weight loss remains the mainstay of therapy, but growing surgical options show promise. Physiologic procedures (lymphovenous anastomosis and vascularized lymph node transfers) improve lymphatic flow in the diseased limb and may reduce edema and the burden of compression. Debulking, primarily with liposuction to remove the adipose deposition that has accumulated, results in a dramatic decrease in limb girth in appropriately selected patients. Though early, there are also exciting developments of potential therapeutic targets tackling the underlying drivers of the disease. Multidisciplinary teams have developed to offer the full breadth of evaluation and current management, but the development of a greater understanding and availability of therapies is needed to ensure patients with lymphedema have greater opportunity for optimal care.
Collapse
Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dhruv Singhal
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
7
|
Arrivé L, Cholley LM, El Mouhadi S. Comment to perirenal lymphatics, Abdominal Radiology 2023;48:2615-2627. Abdom Radiol (NY) 2023; 48:3780-3781. [PMID: 37740760 DOI: 10.1007/s00261-023-04065-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Affiliation(s)
- Lionel Arrivé
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris (APHP) and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | - Laurence Monnier Cholley
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris (APHP) and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Sanaâ El Mouhadi
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris (APHP) and Sorbonne University, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| |
Collapse
|
8
|
Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
Collapse
Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
| |
Collapse
|
9
|
Bianchi LMG, Irmici G, Cè M, D'Ascoli E, Della Pepa G, Di Vita F, Casati O, Soresina M, Menozzi A, Khenkina N, Cellina M. Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New? Curr Oncol 2023; 30:4512-4526. [PMID: 37232799 DOI: 10.3390/curroncol30050341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.
Collapse
Affiliation(s)
| | - Giovanni Irmici
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Maurizio Cè
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Elisa D'Ascoli
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Gianmarco Della Pepa
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Filippo Di Vita
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Omar Casati
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Natallia Khenkina
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Michaela Cellina
- Radiology Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders. Korean J Radiol 2023; 24:109-132. [PMID: 36725353 PMCID: PMC9892215 DOI: 10.3348/kjr.2022.0689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/28/2023] Open
Abstract
Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.
Collapse
Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Korea.
| | - Lakshmi Ratnam
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
12
|
Myung Y, Park S, Kim BR, Yang EJ, Park JKH, Kang Y. Validation of a Lymphedema Index Score Based on Noncontrast Magnetic Resonance Lymphangiography: Correlation with Clinical Staging and Indocyanine Green Lymphangiography. Lymphat Res Biol 2023; 21:70-77. [PMID: 35501954 DOI: 10.1089/lrb.2021.0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: A standardized lymphedema grading system is a prerequisite for accurately and objectively evaluating its severity, both preoperatively and postoperatively. The purpose of this study was to establish a clinically feasible noncontrast magnetic resonance lymphangiography (NMRL) protocol and a standardized scoring system for the evaluation of lymphedema. Methods and Results: From January 2020 to February 2021, 39 patients who had been clinically diagnosed with lymphedema and had undergone NMRL were included. The severity and circumferential extent of lymphedema were assessed using magnetic resonance imaging, and a combined index was devised as the sum of the product of the severity and extent scores determined at four different levels. A magnetic resonance imaging (MRI) stage was allocated based on the combined index score, its correlation with clinical indices was analyzed. The MR and clinical staging showed a percentage agreement of 85.9% and a kappa coefficient of 0.641, indicating moderate agreement (p < 0.001). Both the interlimb volume and interlimb impedance ratios differed significantly between groups (p < 0.001 for both). The correlation analysis revealed a significant correlation between the combined index score and the inter-limb volume ratio (r = 0.70, p < 0.001) and inter-limb impedance ratio at both 1 kHz (r = 0.71, p < 0.001) and 5 kHz (r = 0.71, p < 0.001). The interobserver agreement was moderate for the severity score, extent score, and combined score. Conclusion: The proposed standardized scoring system for evaluating lymphedema based on NMRL can reproducibly determine the severity and extent of lymphedema in both the upper and lower extremities, and correlates strongly with established clinical measures.
Collapse
Affiliation(s)
- Yujin Myung
- Department of Plastic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Seokwon Park
- Department of Plastic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Bo Ram Kim
- Department of Radiology, and Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Eun Joo Yang
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Joseph Kyu-Hyung Park
- Department of Plastic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Yusuhn Kang
- Department of Radiology, and Seoul National University Bundang Hospital, Seongnam-si, South Korea
| |
Collapse
|
13
|
Nowak S, Henkel A, Theis M, Luetkens J, Geiger S, Sprinkart AM, Pieper CC, Attenberger UI. Deep learning for standardized, MRI-based quantification of subcutaneous and subfascial tissue volume for patients with lipedema and lymphedema. Eur Radiol 2023; 33:884-892. [PMID: 35976393 PMCID: PMC9889496 DOI: 10.1007/s00330-022-09047-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/20/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To contribute to a more in-depth assessment of shape, volume, and asymmetry of the lower extremities in patients with lipedema or lymphedema utilizing volume information from MR imaging. METHODS A deep learning (DL) pipeline was developed including (i) localization of anatomical landmarks (femoral heads, symphysis, knees, ankles) and (ii) quality-assured tissue segmentation to enable standardized quantification of subcutaneous (SCT) and subfascial tissue (SFT) volumes. The retrospectively derived dataset for method development consisted of 45 patients (42 female, 44.2 ± 14.8 years) who underwent clinical 3D DIXON MR-lymphangiography examinations of the lower extremities. Five-fold cross-validated training was performed on 16,573 axial slices from 40 patients and testing on 2187 axial slices from 5 patients. For landmark detection, two EfficientNet-B1 convolutional neural networks (CNNs) were applied in an ensemble. One determines the relative foot-head position of each axial slice with respect to the landmarks by regression, the other identifies all landmarks in coronal reconstructed slices using keypoint detection. After landmark detection, segmentation of SCT and SFT was performed on axial slices employing a U-Net architecture with EfficientNet-B1 as encoder. Finally, the determined landmarks were used for standardized analysis and visualization of tissue volume, distribution, and symmetry, independent of leg length, slice thickness, and patient position. RESULTS Excellent test results were observed for landmark detection (z-deviation = 4.5 ± 3.1 mm) and segmentation (Dice score: SCT = 0.989 ± 0.004, SFT = 0.994 ± 0.002). CONCLUSIONS The proposed DL pipeline allows for standardized analysis of tissue volume and distribution and may assist in diagnosis of lipedema and lymphedema or monitoring of conservative and surgical treatments. KEY POINTS • Efficient use of volume information that MRI inherently provides can be extracted automatically by deep learning and enables in-depth assessment of tissue volumes in lipedema and lymphedema. • The deep learning pipeline consisting of body part regression, keypoint detection, and quality-assured tissue segmentation provides detailed information about the volume, distribution, and asymmetry of lower extremity tissues, independent of leg length, slice thickness, and patient position.
Collapse
Affiliation(s)
- Sebastian Nowak
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Andreas Henkel
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Maike Theis
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Julian Luetkens
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Sergej Geiger
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Alois M. Sprinkart
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Claus C. Pieper
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrike I. Attenberger
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
Rodriguez JR, Yamamoto T. A Systematic Stepwise Method to Perform a Supermicrosurgical Lymphovenous Anastomosis. Ann Plast Surg 2022; 88:524-532. [PMID: 34670962 DOI: 10.1097/sap.0000000000003023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lymphovenous anastomosis (LVA) has become an increasingly common treatment for patients with extremity lymphedema. In this article, we present our current strategy for patient selection, preoperative planning, and a series of intraoperative clues that may help to perform a supermicrosurgical LVA. Technical considerations are presented using a systematic step-by-step method to make this procedure more reproducible and straightforward. PATIENTS AND METHODS We conducted a review of patients operated between January 2015 and June 2018 using the aforementioned approach. Data were collected prospectively, and all procedures were performed by the senior author. Preoperative assessment included lymphoscintigraphy, indocyanine green lymphography, noncontrast magnetic resonance lymphography and high-frequency ultrasonography. Lymphovenous anastomosis was decomposed into a sequential 6-step approach considering the main aspects that determine a successful anastomosis. RESULTS Lymphovenous anastomosis was performed in 229 patients, including 677 anastomoses. Median follow-up was 33 months (range, 13-51 months). A median of 3.1 (range, 1-7) LVA were performed on 2.7 (range, 1-6) incision sites per patient. Median time for dissection of lymphatic(s) and vein(s) was 8.7 minutes (1-18 minutes) with a median time of 27.2 minutes (range, 13-51 minutes) for a complete LVA. Lymphatic detection rate was 100% (677 of 677) and vein detection rate was 99.7% (675 of 677), with 31.0% (210 of 677) of reflux-free veins. For upper-extremity lymphedema (47 of 229; 20.6%), volume reduction was achieved in 100% (47 of 47) of the cases, with a median volume reduction rate of 67% (range, 7-93%). In lower-extremity lymphedema (182 of 229; 79.4%), volume reduction was achieved in 86.8% (158 of 182) of the cases, with a median volume reduction rate of 41% (range, 7-81%). Cellulitis episodes decreased from 2.1 to 0.2 episodes/year after LVA (P < 0.05). CONCLUSIONS Acceptable success rates were obtained using a sequential strategy for planning and execution of supermicrosurgical LVA for secondary extremity lymphedema. We believe including a stepwise approach may help to simplify this procedure, especially for surgeons in their early practice.
Collapse
Affiliation(s)
| | - Takumi Yamamoto
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| |
Collapse
|
16
|
Cao Y, Yu J, Zhang H, Xiong J, Luo Z. Classification of hepatic cavernous hemangioma or hepatocellular carcinoma using a convolutional neural network model. J Gastrointest Oncol 2022; 13:787-791. [PMID: 35557568 PMCID: PMC9086046 DOI: 10.21037/jgo-22-197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/02/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Computed tomography (CT) is a common imaging technique for diagnosis of liver tumors. However, the intensity similarity on non-contrast CT images is small, making it difficult for radiologists to visually identify hepatic cavernous hemangioma (HCH) and hepatocellular carcinoma (HCC). Recently, convolutional neural networks (CNN) have been widely used in the study of medical image classification because more discriminative image features can be extracted than the human eye. Therefore, this study focused on developing a CNN model for identifying HCH and HCC. METHODS This study is a retrospective study. A dataset consisting of 774 non-contrast CT images was collected from 50 patients with HCC or HCH, and the ground truth was given by three radiologists based on contrast-enhanced CT. Firstly, the non-contrast CT images dataset were randomly divided into a training set (n=559) and a test set (n=215). Then, we performed preprocessing of the non-contrast CT images using pseudo-color conversion, and the proposed CNN model developed using training set. Finally, the following indicators (accuracy, precision, recall) were used to quantitatively analyze the results. RESULTS In the test set, the proposed CNN model achieved a high classification accuracy of 84.25%, precision of 81.36%, and recall of 82.18%. CONCLUSIONS The CNN model for identifying HCH and HCC improves the accuracy of diagnosis on non-contrast CT images.
Collapse
Affiliation(s)
- Yunbao Cao
- Department of Interventional Radiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Jing Yu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Hu Zhang
- Department of Interventional Radiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Jian Xiong
- Department of Interventional Radiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Zhonghua Luo
- Department of Interventional Radiology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| |
Collapse
|
17
|
Maita K, Garcia JP, Torres RA, Avila FR, Kaplan JL, Lu X, Manrique OJ, Ciudad P, Forte AJ. Imaging biomarkers for diagnosis and treatment response in patients with lymphedema. Biomark Med 2022; 16:303-316. [PMID: 35176878 DOI: 10.2217/bmm-2021-0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.
Collapse
Affiliation(s)
- Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Ricardo A Torres
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jamie L Kaplan
- Division of General Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Xiaona Lu
- Division of Plastic & Reconstructive Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Oscar J Manrique
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY, 14627, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive & Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| |
Collapse
|
18
|
Kageyama T. Characteristic non-contrast magnetic resonance lymphography findings of secondary lower extremity lymphedema. J Plast Reconstr Aesthet Surg 2021; 75:893-939. [PMID: 34866008 DOI: 10.1016/j.bjps.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
| |
Collapse
|
19
|
Kim G, Donohoe K, Smith MP, Hamaguchi R, Johnson AR, Singhal D, Tsai LL. Use of non-contrast MR in diagnosing secondary lymphedema of the upper extremities. Clin Imaging 2021; 80:400-405. [PMID: 34534773 DOI: 10.1016/j.clinimag.2021.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/29/2021] [Accepted: 08/13/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema. MATERIALS AND METHODS Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated. RESULTS Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80-1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%-99.9%], and 75.0% [47.6%-92.7%], 87.5% [74.9%-94.3%], and 92.3% [63.1%-98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001). CONCLUSIONS DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.
Collapse
Affiliation(s)
- Geunwon Kim
- Beth Israel Deaconess Medical Center, Department of Radiology, 330 Brookline Ave., Boston, MA 02215, United States of America; Atrius Health, 275 Grove Street, Newton, MA 02466, United States of America
| | - Kevin Donohoe
- Beth Israel Deaconess Medical Center, Department of Radiology, 330 Brookline Ave., Boston, MA 02215, United States of America
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Department of Radiology, 330 Brookline Ave., Boston, MA 02215, United States of America
| | - Ryoko Hamaguchi
- Harvard Medical School, Boston, MA 02215, United States of America
| | - Anna Rose Johnson
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave., Boston, MA 02215, United States of America
| | - Dhruv Singhal
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave., Boston, MA 02215, United States of America
| | - Leo L Tsai
- Beth Israel Deaconess Medical Center, Department of Radiology, 330 Brookline Ave., Boston, MA 02215, United States of America.
| |
Collapse
|
20
|
Guerrini S, Gentili F, Mazzei FG, Gennaro P, Volterrani L, Mazzei MA. Magnetic resonance lymphangiography: with or without contrast? ACTA ACUST UNITED AC 2021; 26:587-595. [PMID: 33032980 DOI: 10.5152/dir.2020.19482] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lymphedema is an important medical issue around the world, caused by an anomalous collection of fluid in soft tissue due to congenital malformations or stenosis or obstruction of lymphatic vessels. Magnetic resonance lymphangiography (MRL) is an emerging technique focused on noninvasive or minimally invasive imaging of lymphatics with the goal to diagnose and treat lymphedema. This review will briefly discuss lymphatic imaging starting with lymphography and radionuclide lymphoscintigraphy up to the newest methods, focusing on MRL, a rising technique, and highlighting the technical aspects fundamental for achieving high-resolution MRL.
Collapse
Affiliation(s)
- Susanna Guerrini
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Gentili
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Giuseppe Mazzei
- Department of Radiological Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Paolo Gennaro
- Department of Maxillofacial Surgery, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luca Volterrani
- Department of Medical, Surgical and Neurosciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medical, Surgical and Neurosciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| |
Collapse
|
21
|
Oncologic Imaging of the Lymphatic System: Current Perspective with Multi-Modality Imaging and New Horizon. Cancers (Basel) 2021; 13:cancers13184554. [PMID: 34572781 PMCID: PMC8465736 DOI: 10.3390/cancers13184554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
The lymphatic system is an anatomically complex vascular network that is responsible for interstitial fluid homeostasis, transport of large interstitial particles and cells, immunity, and lipid absorption in the gastrointestinal tract. This network of specially adapted vessels and lymphoid tissue provides a major pathway for metastatic spread. Many malignancies produce vascular endothelial factors that induce tumoral and peritumoral lymphangiogenesis, increasing the likelihood for lymphatic spread. Radiologic evaluation for disease staging is the cornerstone of oncologic patient treatment and management. Multiple imaging modalities are available to access both local and distant metastasis. In this manuscript, we review the anatomy, physiology, and imaging of the lymphatic system.
Collapse
|
22
|
Vignes S, Kaltenbach S, Garçon L, Arrivé L, Asnafi V, Guitton C, Bouligand J, Delarue A, Picard V. PIEZO1-gene gain-of-function mutations with lower limb lymphedema onset in an adult: Clinical, scintigraphic, and noncontrast magnetic resonance lymphography findings. Am J Med Genet A 2021; 188:243-248. [PMID: 34477311 DOI: 10.1002/ajmg.a.62476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022]
Abstract
Primary lymphedema, a rare disease, has a genetic cause in ~40% of patients. Recently, loss-of-function mutations in PIEZO1, which encodes the mechanotransducer protein PIEZO1, were described as causing primary lymphedema, when gain-of-function PIEZO1 mutations were attributed to dehydrated hereditary stomatocytosis type-1 (DHS), a dominant red cell hemolytic disorder, with ~20% of patients having perinatal edema. Lymphedema was diagnosed in a 36-year-old man from a three-generation DHS family, with a PIEZO1-allele harboring 3 missense mutations in cis. Four affected family members had severe fetal and neonatal edema, most severe in the proband, whose generalized edema with prevailing ascites resolved after 8 months. Our patient's intermittent lower limb-lymphedema episodes during hot periods appeared at puberty; they became persistent and bilateral at age 32. Clinical Stemmer's sign confirmed lymphedema. Lower leg lymphoscintigraphy showed substantial dermal backflow in both calves, predominantly on the right. Noncontrast magnetic resonance lymphography showed bilateral lower limb lymphedema, dilated dysplastic lymphatic iliac, and inguinal trunks. Exome-sequencing analysis identified no additional pathogenic variation in primary lymphedema-associated genes. This is the first description of well-documented lymphedema in an adult with PIEZO1-DHS. The pathophysiology of PIEZO1-associated primary lymphedema is poorly understood. Whether it infers overlapping phenotypes or different mechanisms of gain- and loss-of-function PIEZO1 mutations deserves further investigation.
Collapse
Affiliation(s)
- Stéphane Vignes
- Unité de Lymphologie, Centre de Référence des Maladies Vasculaires Rares, Hôpital Cognacq-Jay, Paris, France
| | - Sophie Kaltenbach
- Université de Paris (Descartes), Institut Necker-Enfants Malades, Institut National de la Santé et de la Recherche Médicale U1151, Paris, France.,Laboratoire d'Onco-Hématologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Necker Enfants-Malades, Paris, France
| | - Loïc Garçon
- Equipe d'Accueil 4666 HEMATIM, Université de Picardie Jules-Verne, Amiens, France.,Département d'Hématologie, Centre Hospitalier Universitaire (CHU) d'Amiens, Amiens, France
| | - Lionel Arrivé
- Service de Radiologie, APHP, CHU Saint-Antoine, Paris, France
| | - Vahid Asnafi
- Université de Paris (Descartes), Institut Necker-Enfants Malades, Institut National de la Santé et de la Recherche Médicale U1151, Paris, France.,Laboratoire d'Onco-Hématologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Necker Enfants-Malades, Paris, France
| | - Corinne Guitton
- Service de Pédiatrie, APHP, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Jérôme Bouligand
- Département de Génétique, APHP, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Audrey Delarue
- Unité de Lymphologie, Centre de Référence des Maladies Vasculaires Rares, Hôpital Cognacq-Jay, Paris, France
| | - Véronique Picard
- Service d'Hématologie Biologique, APHP, CHU Bicêtre, Le Kremlin-Bicêtre, France.,Faculté de Pharmacie, Université Paris-Saclay, Chatenay-Malabry, France
| |
Collapse
|
23
|
Cellina M, Gibelli D, Martinenghi C, Giardini D, Soresina M, Menozzi A, Oliva G, Carrafiello G. Non-contrast magnetic resonance lymphography (NCMRL) in cancer-related secondary lymphedema: acquisition technique and imaging findings. Radiol Med 2021; 126:1477-1486. [PMID: 34379302 DOI: 10.1007/s11547-021-01410-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
Cancer-related secondary lymphedema (LE) is a widespread issue, which markedly affects patients' quality of life. Its diagnosis is mainly clinical since there is no consensus on the best imaging technique that should be used to assess this pathology. Even if lymphedema treatment has been traditionally conservative and mainly based on compressive bandages and decongestive therapy, new surgical techniques are proving their effectiveness in the management of the disease and made proper assessment and characterization of lymphedema necessary. In this scenario, non-contrast magnetic resonance lymphography (NCMRL) is acquiring an increasing role, as a non-invasive imaging technique, useful for the analysis of LE. NCMRL is an effective tool in diagnosis confirmation, in providing information about the structural changes of the affected limbs, in grading this disorder, and provides a guide for LE management and treatment planning. This article aims to provide an overview of the literature regarding this examination, analyzing the acquisition technique, the interpretation of the imaging findings and their usefulness, the advantages and limits of this technique, to help the radiologist approach this relatively new investigation in cases of cancer-related LE.
Collapse
Affiliation(s)
- Michaela Cellina
- Department of Radiology, ASST Fatebenefratelli Sacco, Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milan, Italy.
| | - Daniele Gibelli
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Carlo Martinenghi
- Department of Radiology, Ospedale San Raffaele, Via Olgettina 60, 20121, Milan, Italy
| | - Denisa Giardini
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Massimo Soresina
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Andrea Menozzi
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Giancarlo Oliva
- Department of Radiology, ASST Fatebenefratelli Sacco, Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milan, Italy
| | - Gianpaolo Carrafiello
- Department of Radiology, Policlinico Di Milano Ospedale Maggiore | Fondazione IRCCS Ca' Granda, Via Francesco Sforza, 35, 20122, Milan, Italy
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Abstract
Lymphedema occurs when interstitial fluid and fibroadipose tissues accumulate abnormally because of decreased drainage of lymphatic fluid as a result of injury, infection, or congenital abnormalities of the lymphatic system drainage pathway. An accurate anatomical map of the lymphatic vasculature is needed not only for understanding the pathophysiology of lymphedema but also for surgical planning. However, because of their limited spatial resolution, no imaging modalities are currently able to noninvasively provide a clear visualization of the lymphatic vessels. Photoacoustic imaging is an emerging medical imaging technique that provides unique scalability of optical resolution and acoustic depth of penetration. Moreover, light-absorbing biomolecules, including oxy- and deoxyhemoglobin, lipids, water, and melanin, can be imaged. Using exogenous contrast agents that are taken up by lymphatic vessels, e.g., indocyanine green, photoacoustic lymphangiography, which has a higher spatial resolution than previous imaging modalities, is possible. Using a new prototype of a photoacoustic imaging system with a wide field of view developed by a Japanese research group, high-resolution three-dimensional structural information of the vasculatures was successfully obtained over a large area in both healthy and lymphedematous extremities. Anatomical information on the lymphatic vessels and adjacent veins provided by photoacoustic lymphangiography is helpful for the management of lymphedema. In particular, such knowledge will facilitate the planning of microsurgical lymphaticovenular anastomoses to bypass the excess fluid component by joining with the circulatory system peripherally. Although challenges remain to establish its implementation in clinical practice, photoacoustic lymphangiography may contribute to improved treatments for lymphedema patients in the near future.
Collapse
|
26
|
Vignes S, Albuisson J, Champion L, Constans J, Tauveron V, Malloizel J, Quéré I, Simon L, Arrault M, Trévidic P, Azria P, Maruani A. Primary lymphedema French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins). Orphanet J Rare Dis 2021; 16:18. [PMID: 33407666 PMCID: PMC7789008 DOI: 10.1186/s13023-020-01652-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/19/2020] [Indexed: 11/10/2022] Open
Abstract
Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf).
Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major,
deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.
Collapse
Affiliation(s)
- Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France.
| | | | - Laurence Champion
- Department of Nuclear Medicine, René Huguenin-Curie Hospital, 35, rue Dailly, 92210, Saint-Cloud, France
| | - Joël Constans
- Department of Vascular Medicine, Saint-André Hospital, CHU de Bordeaux, 1, rue Jean-Burguet, 33000, Bordeaux, France
| | - Valérie Tauveron
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France
| | - Julie Malloizel
- Department of Vascular Medicine, Rangueil Hospital, 1, avenue du Pr Jean-Poulhès, 31059, Toulouse, France
| | - Isabelle Quéré
- Department of Vascular Medicine and Reference Center for Rare Vascular Diseases, CHU Montpellier, 80, avenue Augustin-Fliche, 34090, Montpellier, France
| | - Laura Simon
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | - Maria Arrault
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, rue Eugène-Millon, 75015, Paris, France
| | | | - Philippe Azria
- Department of Internal Medicine, Saint-Joseph Hospital, 185, rue Raymond-Losserand, 75014, Paris, France
| | - Annabel Maruani
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU Tours, 37044, Tours Cedex 9, France.,INSERM 1246 - SPHERE, Universities of Tours and Nantes, 37000, Tours, France
| | | |
Collapse
|
27
|
Cellina M, Gibelli D, Martinenghi C, Soresina M, Menozzi A, Giardini D, Oliva G. Noncontrast Magnetic Resonance Lymphography in Secondary Lymphedema Due to Prostate Cancer. Lymphat Res Biol 2020; 19:355-361. [PMID: 33290157 DOI: 10.1089/lrb.2020.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: As survival from malignancies continues to improve, a greater emphasis is being placed on the quality of life after cancer treatments. Lymphedema (LE) represents a common and devastating sequela of neoplastic therapies, even if its incidence in patients submitted to lymphadenectomy for prostatic cancer is still poorly documented. The purpose of the current study was to analyze the imaging findings provided by noncontrast magnetic resonance (MR) lymphography in secondary lower limb LE related to prostate cancer therapies. Methods and Results: Patients with diagnosed secondary LE related to prostatic cancer treatment who underwent noncontrast MR lymphography (NCMRL) between November 2019 and February 2020 were assessed. Image datasets were retrospectively reviewed for the severity of lymphedema and characteristics of the subcutaneous tissue, muscular compartment appearance, number of iliac and inguinal lymphatics, and number of locoregional lymph nodes. Ten patients with 17 affected lower extremities, nine right extremities, and eight left extremities were included in our analysis. Magnetic resonance imaging grading was classified as one in four extremities, two in five extremities, and three in eight lower extremities. Honeycomb pattern was observed in 15 extremities, without significant correlation with MR grading (p = 0.684); dermal thickening showed correlation with MR grading (p < 0.001), as well as reduction of muscular trophism (p = 0.021). We observed a significant correlation between the number of inguinal lymph nodes and recognizable inguinal lymphatics (p = 0.039). Conclusion: NCMRL is able to provide useful information for the management of secondary lower limb LE caused by prostate cancer treatments. Clinical Trials.gov ID: n.2019/ST/187.
Collapse
Affiliation(s)
- Michaela Cellina
- Department of Radiology, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy.,Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy
| | - Daniele Gibelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | | | - Massimo Soresina
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy.,Department of Plastic Surgery, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Andrea Menozzi
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy.,Department of Plastic Surgery, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Denisa Giardini
- Lymphedema Center, Nursing Home "La Madonnina", Milan, Italy
| | - Giancarlo Oliva
- Department of Radiology, Ospedale Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| |
Collapse
|
28
|
Cholet C, Delalandre C, Monnier-Cholley L, Le Pimpec-Barthes F, El Mouhadi S, Arrivé L. Nontraumatic Chylothorax: Nonenhanced MR Lymphography. Radiographics 2020; 40:1554-1573. [PMID: 33001788 DOI: 10.1148/rg.2020200044] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Because the lymphatic system plays an essential role in fat absorption and immune response, lymphatic leak associated with chylothorax may cause life-threatening malnutrition and immunodeficiency. Chylothorax is usually described as traumatic or nontraumatic. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Lymphoma and thoracic malignancies are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. Other rare causes include primary and secondary diffuse lymphatic diseases, responsible for chylothorax by lymphatic vessel wall dysfunction. Imaging the lymphatic system remains a challenge in the days of modern imaging. Nonenhanced MR lymphography is a noninvasive technique based on heavily T2-weighted sequences, thus enabling visualization of the lymphatic circulation. This technique allows diagnosis and differential diagnosis, evaluation of disease severity, and guidance of therapeutic management in nontraumatic chylothorax. Furthermore, it may offer radiologic classification of primary lymphatic diseases on the basis of morphologic features of lymphatic vessels. The authors describe the anatomy and physiology of the thoracic lymphatic system, present the technique of nonenhanced MR lymphography, and discuss pathophysiologic mechanisms and imaging features in different causes of nontraumatic chylothorax. ©RSNA, 2020.
Collapse
Affiliation(s)
- Clément Cholet
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Coline Delalandre
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Laurence Monnier-Cholley
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Françoise Le Pimpec-Barthes
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Sanaâ El Mouhadi
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Lionel Arrivé
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| |
Collapse
|
29
|
Regional Patterns of Fluid and Fat Accumulation in Patients with Lower Extremity Lymphedema Using Magnetic Resonance Angiography. Plast Reconstr Surg 2020; 146:690e-691e. [PMID: 32852476 DOI: 10.1097/prs.0000000000007299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
30
|
Cellina M, Martinenghi C, Panzeri M, Soresina M, Menozzi A, Daniele G, Oliva G. Noncontrast MR Lymphography in Secondary Lower Limb Lymphedema. J Magn Reson Imaging 2020; 53:458-466. [PMID: 32798265 DOI: 10.1002/jmri.27328] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Invasive imaging techniques have been applied for lymphedema (LE) assessment; noncontrast MR lymphography (NCMLR) has potential as an alternative, but its performance is not known in secondary lower limb LE. PURPOSE To assess the role of NCMRL for the classification and characterization of secondary lower limb LE. STUDY TYPE Retrospective. POPULATION Fifty adults with clinically diagnosed secondary LE. FIELD STRENGTH/SEQUENCE 1.5T, 3D T2 -weighted turbo spin-echo, 3D T2 -weighted turbo spin-echo short tau inversion recovery. ASSESSMENT Three radiologists assessed the following characteristics on NCMRL: honeycomb pattern, dermal thickening, muscular abnormalities, distal dilated lymphatics, inguinal lymph node number, appearance of iliac lymphatic trunks. An LE grading based on the MR images was assigned. The relationship between imaging findings and clinical staging was evaluated, as well as between dermal backflow at lymphoscintigraphy and MR staging, and between the limb swelling duration and peripheral lymphatics dilatation. STATISTICAL TESTS Pearson's correlation test and Cramer's V coefficient were computed to measure the strength of association. The Mann-Whitney test was used to compare the limb swelling duration between patients with and without dilated distal vessels. Agreement among raters was assessed through Kendall's W coefficient of correlation. RESULTS Clinical stage and the MR grading were correlated, with Cramer's V coefficient of 1 for reader 1 (P < 0.05), 0.846 for reader 2 (P < 0.05), and 0.912 (P < 0.05) for reader 3; agreement between interraters was very good (W = 0.0.75; P = 0.05). A honeycomb pattern (P < 0.05), dermal thickening (P < 0.001), muscular abnormalities (P < 0.05), iliac lymphatic trunks appearance (P < 0.05), distal dilated vessels (P < 0.05), and lymph nodes number (P < 0.05) were significantly correlated with LE clinical stage. Dermal backflow at lymphoscintigraphy was described in 10 (20%) patients and showed a significant correlation with the MR grading (P < 0.05). DATA CONCLUSION These preliminary results suggest that NCMRL may provide information useful for the staging and management of patients affected by secondary lower limb LE. Level of Evidence 4 Technical Efficacy Stage 2 J. MAGN. RESON. IMAGING 2021;53:458-466.
Collapse
Affiliation(s)
| | | | - Marta Panzeri
- Radiology Department, San Raffaele Hospital, Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, Milan, Italy
| | - Gibelli Daniele
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Giancarlo Oliva
- Radiology Department, Fatebenefratelli Hospital, Milan, Italy
| |
Collapse
|
31
|
Non-contrast MR Lymphography of lipedema of the lower extremities. Magn Reson Imaging 2020; 71:115-124. [PMID: 32561380 DOI: 10.1016/j.mri.2020.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022]
Abstract
AIM To assess imaging findings and characteristics of the lymphatic system in patients affected by lipedema and lipolymphedema of the lower extremities on Non-Contrast MR Lymphography (NCMRL). MATERIALS AND METHODS 44 lower extremities in 11 consecutive female patients affected by lipedema, and 11 patients with lipolymphedema were examined by NCMRL. MR imaging was performed on 1.5-T system MR equipment. The examination consisted of one 3D short-tau inversion recovery (STIR) and one heavily T2-weighted 3D-Turbo Spin Echo (TSE) sequence. RESULTS All patients showed symmetrical enlargement of the lower extremities with increased subcutaneous fat tissue. The fat tissue was homogeneous, without any signs of edema in pure lipedema patients. In all the extremities with lipolymphedema, high signal intensity areas in the epifascial region could be detected on the 3D-TSE sequence (p < .001) with evidence of mild epifascial fluid collections (p < .001). No sign of honeycomb pattern fat appearance was observed. The appearance of the iliac lymphatic trunks was normal in both lipedema and lipolymphedema patients. Dilated peripheral lymphatics were observed in 2 patients affected by lipedema, indicating a subclinical status of lymphedema, and in 10 patients with lipolymphedema (p = .001). Signs of vascular stasis were observed in both groups, without statistically significant difference (p = .665). CONCLUSION NCMRL is a non-invasive imaging technique that is suitable for the evaluation of patients affected by lipedema and lipolymphedema, helping in the differential diagnosis.
Collapse
|
32
|
Chavhan GB, Lam CZ, Greer MLC, Temple M, Amaral J, Grosse-Wortmann L. Magnetic Resonance Lymphangiography. Radiol Clin North Am 2020; 58:693-706. [PMID: 32471538 DOI: 10.1016/j.rcl.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.
Collapse
Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lars Grosse-Wortmann
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| |
Collapse
|
33
|
Analysis of collateral lymphatic circulation in patients with lower limb lymphedema using magnetic resonance lymphangiography. J Vasc Surg Venous Lymphat Disord 2020; 9:471-481.e1. [PMID: 32470617 DOI: 10.1016/j.jvsv.2020.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/29/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Although the development of lymphatic collaterals is expected following lymphedema, little is known about the anatomic details of such compensatory pathways or their association with symptoms. Magnetic resonance lymphangiography (MRL) has been shown to be superior to lymphoscintigraphy and indocyanine green lymphography in visualizing lymphatics. This study aimed to analyze MRL images of lower limbs to elucidate the patterns of lymphatic collateral formation and their association with the clinical stages of lymphedema. METHODS We enrolled 56 consecutive patients (112 lower limbs) with lymphedema who underwent MRL. Two radiologists performed a consensus reading of MRL images for the presence or absence of collateral lymphatic pathways, and the results were compared with the clinical stages. Furthermore, the frequency of abnormal MRL findings in 43 asymptomatic lower limbs of patients with unilateral lymphedema was analyzed and compared with that in the 69 symptomatic lower limbs of the patients. The imaging findings were also compared with the cause of lymphedema. RESULTS All three collateral pathways (anterolateral, deep, and posteromedial lymphatics) were visualized at a higher (P < .05) frequency in stage II than in stage 0 lower limbs. The frequency of visualization of the three collaterals was significantly higher in symptomatic (stages I-III) lower limbs than in asymptomatic (stage 0) lower limbs. Most (76.8%) of the symptomatic limbs exhibited at least one of these collaterals, and the frequency was significantly higher than in the asymptomatic limbs (P < .001). Most (81.4%) of the asymptomatic (stage 0) lower limbs had at least one abnormal finding in terms of lymphatic circulation, although this proportion was significantly lower compared with the symptomatic limbs (98.6%). The collaterals tended to appear less frequently in primary lymphedema than in secondary lymphedema, reaching statistical significance in the posteromedial lymphatics. CONCLUSIONS These results suggested that the two superficial lymphatic groups and the deep lymphatic system act as major collaterals of the lower limbs in patients with lymphedema. Furthermore, MRL of most patients with unilateral lymphedema demonstrated abnormal findings, including collateral formation, not only in the affected lower limb but also in the asymptomatic lower limb. In primary lymphedema, the collaterals may appear less frequently than in secondary lymphedema. Collaterals should be taken into consideration in planning the site of lymphaticovenous anastomosis and assessing disease progression. MRL can visualize preclinical alterations in lymphatic flow and compensatory pathways; therefore, we expect that it will be useful for the early diagnosis of lymphedema.
Collapse
|
34
|
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.
Collapse
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.
| |
Collapse
|
35
|
Kim G, Smith MP, Donohoe KJ, Johnson AR, Singhal D, Tsai LL. MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements. Eur Radiol 2020; 30:4686-4694. [PMID: 32221682 DOI: 10.1007/s00330-020-06790-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/17/2020] [Accepted: 03/04/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures. METHODS Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0-3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen's kappa was calculated to compare MRI staging by two readers. RESULTS STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs = 0.63, p < 0.0001), larger % difference in limb volume (rs = 0.68, p < 0.0001), and higher L-Dex® ratio (rs = 0.84, p < 0.0001). Cohen's kappa was 0.92 (95% CI, 0.85-1.00). CONCLUSION An MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning. KEY POINTS • Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists. • MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients. • In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.
Collapse
Affiliation(s)
- Geunwon Kim
- Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA.
| | - Martin P Smith
- Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Kevin J Donohoe
- Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Anna Rose Johnson
- Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Dhruv Singhal
- Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA
| |
Collapse
|
36
|
Franconeri A, Ballati F, Panzuto F, Raciti MV, Smedile A, Maggi A, Asteggiano C, Esposito M, Stoppa D, Lungarotti L, Bortolotto C, Giardini D, De Silvestri A, Calliada F. A proposal for a semiquantitative scoring system for lymphedema using Non-contrast Magnetic Resonance Lymphography (NMRL): Reproducibility among readers and correlation with clinical grading. Magn Reson Imaging 2020; 68:158-166. [PMID: 32057940 DOI: 10.1016/j.mri.2020.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/15/2020] [Accepted: 02/08/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the ability and reproducibility of Non-contrast Magnetic Resonance Lymphography (NMRL) in detecting and quantify lymphedema, using a semiquantitative scoring system. METHODS AND MATERIAL This is a monocentric retrospective study of 134 consecutive patients with a clinical diagnosis of limb lymphedema who performed a Non-contrast Magnetic Resonance Lymphography (NMRL) at our Institution between November 2014 and February 2017. Lymphedema was classified based both on clinical and radiologic evaluation. An NMRL total score was obtained for each limb's segment and compared to the clinical grade, used as reference standard. NMRL intra-observer, inter-observer variability and intraclass correlation were calculated. NMRL sensitivity, specificity, and accuracy in identifying lymphedema were provided. Based on score distribution an NMRL four-stage system was developed. RESULTS NMRL showed 92% sensitivity, 77% specificity and 82% accuracy in identifying lymphedema. An almost perfect agreement was obtained by expert operators, while substantial agreement was obtained by non-expert operators. Substantial agreement resulted also for the inter-observer variability (Cohen's Kappa K = 0.73, CI 95% [0.69-0.78]). The intra-class correlation showed an almost perfect relationship both by expert and non-expert operators. Excellent correlation between clinical grade and NMRL score and between clinical grade and NMRL stage were found for each segment. CONCLUSIONS NMRL is a confident and reproducible exam with high sensitivity, good specificity and high accuracy in lymphedema detection; the semiquantitative NMRL score resulted a reliable and reproducible tool able to quantify lymphedema severity.
Collapse
Affiliation(s)
- Andrea Franconeri
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy.
| | - Francesco Ballati
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Fabio Panzuto
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Maria Vittoria Raciti
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Antonella Smedile
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Alessia Maggi
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Carlo Asteggiano
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Marcello Esposito
- Department of Geriatrics and Rehabilitation, University of Parma, Str. dell'Università, 12, 43121 Parma, Italy
| | - Davide Stoppa
- Department of Radiology, Civili Hospital, Corso Milano, 19, 27029 Vigevano, Italy
| | - Luca Lungarotti
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Chandra Bortolotto
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Denisa Giardini
- Lymphedema Center, Nursing home "La Madonnina", Via Quadronno, 29, 20122 Milan, Italy
| | - Annalisa De Silvestri
- Scientific Direction Clinical epidemiology and Biometry Service, - IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Fabrizio Calliada
- Department of Radiology, IRCCS Policlinico San Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy
| |
Collapse
|
37
|
|
38
|
Noncontrast Magnetic Resonance Lymphangiography in a Rare Case of Everolimus-Related Lymphedema. Ann Plast Surg 2019; 84:113-116. [DOI: 10.1097/sap.0000000000002055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
39
|
Karlsson K, Nilsson-Wikmar L, Brogårdh C, Johansson K. Palpation of Increased Skin and Subcutaneous Thickness, Tissue Dielectric Constant, and Water Displacement Method for Diagnosis of Early Mild Arm Lymphedema. Lymphat Res Biol 2019; 18:219-225. [PMID: 31596662 DOI: 10.1089/lrb.2019.0042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Early diagnosis of mild lymphedema and treatment are important to prevent its progress. The tissue dielectric constant (TDC), measuring local tissue water in the skin and upper subcutis, has neither been related to the water displacement method (WDM) nor been used to diagnose mild arm lymphedema in patients at risk. Our aims were to evaluate TDC and WDM in combination with palpation, examine the association between TDC and WDM measurements, and compare lymphedema-related factors. Methods and Results: Seventy-two women treated for breast cancer were diagnosed with mild arm lymphedema using skin palpation in combination with TDC from fixed measurement sites (threshold ratio for upper arm ≥1.45 and forearm ≥1.3) and/or WDM (lymphedema relative volume [LRV]: ≥5% to ≤8%). Results revealed that 32 (45%) women were diagnosed by TDC only, 19 (26%) by WDM only, and 21 (29%) by both TDC and WDM. TDC ratios exceeding the threshold were most frequently identified on the medial site of the arm, proximal and distal to the antecubital fossa. TDC and WDM were negatively associated; LRV (r = -0.545, p < 0.001). The women diagnosed by TDC only were diagnosed earlier after surgery (p = 0.003) and had a lower LRV (1.3%) than those diagnosed by WDM only (6.3%) or both TDC and WDM (6.2%; p < 0.001). Conclusions: TDC and WDM can be used together for early diagnosis of arm lymphedema, but TDC is the most valid method, determining the diagnosis earlier after surgery and at a lower arm volume than WDM.
Collapse
Affiliation(s)
- Katarina Karlsson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.,Physiotherapy Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Nilsson-Wikmar
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.,Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden
| | - Christina Brogårdh
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Karin Johansson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oncology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
40
|
|
41
|
Arrivé L, Monnier-Cholley L, Cazzagon N, Wendum D, Chambenois E, El Mouhadi S. Non-contrast MR lymphography of the lymphatic system of the liver. Eur Radiol 2019; 29:5879-5888. [DOI: 10.1007/s00330-019-06151-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 12/16/2022]
|
42
|
Non-contrast Magnetic Resonance Lymphangiography: an emerging technique for the study of lymphedema. Clin Imaging 2019; 53:126-133. [DOI: 10.1016/j.clinimag.2018.10.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/13/2018] [Accepted: 10/04/2018] [Indexed: 02/06/2023]
|
43
|
Crescenzi R, Marton A, Donahue PM, Mahany HB, Lants SK, Wang P, Beckman JA, Donahue MJ, Titze J. Tissue Sodium Content is Elevated in the Skin and Subcutaneous Adipose Tissue in Women with Lipedema. Obesity (Silver Spring) 2018; 26:310-317. [PMID: 29280322 PMCID: PMC5783748 DOI: 10.1002/oby.22090] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/18/2017] [Accepted: 11/07/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To test the hypothesis that tissue sodium and adipose content are elevated in patients with lipedema; if confirmed, this could establish precedence for tissue sodium and adipose content representing a discriminatory biomarker for lipedema. METHODS Participants with lipedema (n = 10) and control (n = 11) volunteers matched for biological sex, age, BMI, and calf circumference were scanned with 3.0-T sodium and conventional proton magnetic resonance imaging (MRI). Standardized tissue sodium content was quantified in the calf skin, subcutaneous adipose tissue (SAT), and muscle. Dixon MRI was employed to quantify tissue fat and water volumes of the calf. Nonparametric statistical tests were applied to compare regional sodium content and fat-to-water volume between groups (significance: two-sided P ≤ 0.05). RESULTS Skin (P = 0.01) and SAT (P = 0.04) sodium content were elevated in lipedema (skin: 14.9 ± 2.9 mmol/L; SAT: 11.9 ± 3.1 mmol/L) relative to control participants (skin: 11.9 ± 2.0 mmol/L; SAT: 9.4 ± 1.6 mmol/L). Relative fat-to-water volume in the calf was elevated in lipedema (1.2 ± 0.48 ratio) relative to control participants (0.63 ± 0.26 ratio; P < 0.001). Skin sodium content was directly correlated with fat-to-water volume (Spearman's rho = 0.54; P = 0.01). CONCLUSIONS Internal metrics of tissue sodium and adipose content are elevated in patients with lipedema, potentially providing objective imaging-based biomarkers for differentially diagnosing the under-recognized condition of lipedema from obesity.
Collapse
Affiliation(s)
- Rachelle Crescenzi
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, USA
- Corresponding author: Rachelle Crescenzi, PhD, Vanderbilt University Institute of Imaging Science, 1161 21 Avenue South, Nashville, TN 37232, USA,
| | - Adriana Marton
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paula M.C. Donahue
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Helen B. Mahany
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah K. Lants
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ping Wang
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua A. Beckman
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J. Donahue
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, USA
| | - Jens Titze
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|