Magnetic Resonance Lymphangiography

The utility of dynamic contrast-enhanced intranodal magnetic resonance lymphangiography (MRL) in the investigation of primary lymphatic anomalies

AIM

The aim of this study was to describe the technique of DCMRL to identify central lymphatic abnormalities in patients with primary lymphatic anomalies and discuss utility of the findings.

MATERIALS AND METHODS

Twenty-eight patients with primary lymphatic abnormalities underwent dynamic magnetic resonance imaging (MRI) following injection of gadolinium directly into inguinal lymph nodes at a tertiary lymphovascular referral center.

RESULTS

Technical success was achieved in 23 patients (82.1%). Pathological imaging findings included obstructed, hypoplastic, or absent lymphatic channels with collateralization/rerouting or reflux of flow, lymphangiectasia, lymphatic pseudoaneurysms, and lymph leaks. Protocol modifications for improved imaging are highlighted including technical aspects of lymph node injection, image acquisition and MRI parameters. In two patients, imaging findings warranted embolization of the abnormal lymphatic channels with subsequent symptomatic improvement.

CONCLUSION

DCMRL has been shown to be a safe, reproducible technique in patients with primary lymphatic anomalies enabling imaging of the central lymphatic system.

Value of interventional radiology and their contributions to modern medical systems

Interventional radiology (IR) is a unique specialty that incorporates a diverse set of skills ranging from imaging, procedures, consultation, and patient management. Understanding how IR generates value to the healthcare system is important to review from various perspectives. IR specialists need to understand how to meet demands from various stakeholders to expand their practice improving patient care. Thus, this review discusses the domains of value contributed to medical systems and outlines the parameters of success. IR benefits five distinct parties: patients, practitioners, payers, employers, and innovators. Value to patients and providers is delivered through a wide set of diagnostic and therapeutic interventions. Payers and hospital systems financially benefit from the reduced cost in medical management secondary to fast patient recovery, outpatient procedures, fewer complications, and the prestige of offering diverse expertise for complex patients. Lastly, IR is a field of rapid innovation implementing new procedural technology and techniques. Overall, IR must actively advocate for further growth and influence in the medical field as their value continues to expand in multiple domains. Despite being a nascent specialty, IR has become indispensable to modern medical practice.

Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography for Diagnosis and Treatment of Chylopericardium After Cardiac Transplantation

Chylopericardium is a rare complication after cardiac transplantation. We report a case of a 69-year-old woman with persistent chylopericardium after a heart transplantation due to Chagas disease. Failure of conservative treatment led to dynamic contrast-enhanced magnetic resonance lymphangiography and percutaneous radiologic intervention of the lymphatic leakage and symptoms resolution.

State-of-the-art imaging for children with central lymphatic disorders

Lymphatic imaging plays a crucial role in novel lymphatic interventions, offering valuable insights into central lymphatic drainage. Lymphatic system abnormalities may appear in various pediatric disorders, and accurate imaging is crucial for effective diagnosis and tailored therapeutic interventions. Traditional imaging modalities have offered valuable insights, but the demand for non-invasive, high-resolution techniques has fueled the development of innovative lymphatic imaging methods. In this review, we explore the state of the art in lymphatic imaging specifically within the context of pediatric surgery.

Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement

Recent years have witnessed exponential growth in cardiac imaging technologies, allowing better visualization of complex cardiac anatomy and improved assessment of physiology. These advances have become increasingly important as more complex surgical and catheter-based procedures are evolving to address the needs of a growing congenital heart disease population. This state-of-the-art review presents advances in echocardiography, cardiac magnetic resonance, cardiac computed tomography, invasive angiography, 3-dimensional modeling, and digital twin technology. The paper also highlights the integration of artificial intelligence with imaging technology. While some techniques are in their infancy and need further refinement, others have found their way into clinical workflow at well-resourced centers. Studies to evaluate the clinical value and cost-effectiveness of these techniques are needed. For techniques that enhance the value of care for congenital heart disease patients, resources will need to be allocated for education and training to promote widespread implementation.

Future Directions in the Assessment of Axillary Lymph Nodes in Patients with Breast Cancer

Background and Objectives: Breast cancer (BC) is a leading cause of morbidity and mortality worldwide, and accurate assessment of axillary lymph nodes (ALNs) is crucial for patient management and outcomes. We aim to summarize the current state of ALN assessment techniques in BC and provide insights into future directions. Materials and Methods: This review discusses various imaging techniques used for ALN evaluation, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. It highlights advancements in these techniques and their potential to improve diagnostic accuracy. The review also examines landmark clinical trials that have influenced axillary management, such as the Z0011 trial and the IBCSG 23-01 trial. The role of artificial intelligence (AI), specifically deep learning algorithms, in improving ALN assessment is examined. Results: The review outlines the key findings of these trials, which demonstrated the feasibility of avoiding axillary lymph node dissection (ALND) in certain patient populations with low sentinel lymph node (SLN) burden. It also discusses ongoing trials, including the SOUND trial, which investigates the use of axillary ultrasound to identify patients who can safely avoid sentinel lymph node biopsy (SLNB). Furthermore, the potential of emerging techniques and the integration of AI in enhancing ALN assessment accuracy are presented. Conclusions: The review concludes that advancements in ALN assessment techniques have the potential to improve patient outcomes by reducing surgical complications while maintaining accurate disease staging. However, challenges such as standardization of imaging protocols and interpretation criteria need to be addressed. Future research should focus on large-scale clinical trials to validate emerging techniques and establish their efficacy and cost-effectiveness. Over-all, this review provides valuable insights into the current status and future directions of ALN assessment in BC, highlighting opportunities for improving patient care.

Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment

Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.

Improving protocols for whole-body magnetic resonance imaging: oncological and inflammatory applications

Whole-body MRI is increasingly used in the evaluation of a range of oncological and non-oncological diseases in infants, children and adolescents. Technical innovation in MRI scanners, coils and sequences have enabled whole-body MRI to be performed more rapidly, offering large field-of-view imaging suitable for multifocal and multisystem disease processes in a clinically useful timeframe. Together with a lack of ionizing radiation, this makes whole-body MRI especially attractive in the pediatric population. Indications include lesion detection in cancer predisposition syndrome surveillance and in the workup of children with known malignancies, and diagnosis and monitoring of a host of infectious and non-infectious inflammatory conditions. Choosing which patients are most likely to benefit from this technology is crucial, but so is adjusting protocols to the patient and disease to optimize lesion detection. The focus of this review is on protocols and the elements impacting image acquisition in pediatric whole-body MRI. We consider the practical aspects, from scanner and coil selection to patient positioning, single-center generic and indication-specific protocols with technical parameters, motion reduction strategies and post-processing. When optimized, collectively these lead to better standardization of whole-body MRI, and when married to systematic analysis and interpretation, they can improve diagnostic accuracy.

Imaging of fluorescent polymer dots in relation to channels and immune cells in the lymphatic system

Polymer dots (Pdots) have been applied to imaging lymph nodes (LNs) and lymphatic vessels (LVs) in living mice and rats. However, the mechanism of absorption, distribution, metabolism, and excretion of Pdots in LNs and LVs is still unclear. Therefore, the relationship between Pdots and immune cells, LVs and collagen fibers in lymphatics was studied by multiple in vivo and ex vivo microscopic imaging methods and detection techniques. Flow cytometry showed that Pdots could be phagocytosed by macrophages and monocytes, and had no relationship with B cells, T cells and dendric cells in LNs. Silver staining, immunofluorescence and two-photon microscope showed that Pdots gathered in collagen fibers and LVs of LNs. Furthermore, immunofluorescence imaging results verified that Pdots were distributed in the extracellular space of collecting LVs endothelial cells. In addition, Pdots in the collecting LVs were basically cleared by leaking into the surrounding tissue or draining LNs after 21 days of injection. During the long-time observation, Pdots also helped monitor the contraction frequency and variation range of LV. Our study lays a foundation on the research of Pdots as the carrier to study lymphatic structure and function in the future.

Imaging biomarkers for diagnosis and treatment response in patients with lymphedema

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.

Biology of Lymphedema

Simple Summary

Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy.

Abstract

This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.