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Garlisi Torales LD, Sempowski BA, Krikorian GL, Woodis KM, Paulissen SM, Smith CL, Sheppard SE. Central conducting lymphatic anomaly: from bench to bedside. J Clin Invest 2024; 134:e172839. [PMID: 38618951 PMCID: PMC11014661 DOI: 10.1172/jci172839] [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: 04/16/2024] Open
Abstract
Central conducting lymphatic anomaly (CCLA) is a complex lymphatic anomaly characterized by abnormalities of the central lymphatics and may present with nonimmune fetal hydrops, chylothorax, chylous ascites, or lymphedema. CCLA has historically been difficult to diagnose and treat; however, recent advances in imaging, such as dynamic contrast magnetic resonance lymphangiography, and in genomics, such as deep sequencing and utilization of cell-free DNA, have improved diagnosis and refined both genotype and phenotype. Furthermore, in vitro and in vivo models have confirmed genetic causes of CCLA, defined the underlying pathogenesis, and facilitated personalized medicine to improve outcomes. Basic, translational, and clinical science are essential for a bedside-to-bench and back approach for CCLA.
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Affiliation(s)
- Luciana Daniela Garlisi Torales
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Benjamin A. Sempowski
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Georgia L. Krikorian
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Kristina M. Woodis
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Scott M. Paulissen
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Christopher L. Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E. Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
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Negm AS, Collins JD, Bendel EC, Takahashi E, Knavel Koepsel EM, Gehling KJ, Burke CE, Barker DR, Stenzel WS, Bathke AM, Polites SF, Abcejo AS, Morris JM, Favazza C, Lu A, François CJ, Young P, Thompson SM. MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development. Radiographics 2024; 44:e230075. [PMID: 38271257 DOI: 10.1148/rg.230075] [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: 01/27/2024]
Abstract
Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Ahmed S Negm
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Jeremy D Collins
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Emily C Bendel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Edwin Takahashi
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Erica M Knavel Koepsel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Kathleen J Gehling
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Courtney E Burke
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Devin R Barker
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Wayne S Stenzel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Angela M Bathke
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Stephanie F Polites
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Arnoley S Abcejo
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Jonathan M Morris
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Christopher Favazza
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Aiming Lu
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Christopher J François
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Phillip Young
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Scott M Thompson
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
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Suzuki S, Kodama Y, Kuraoka A, Hara T, Ishikawa Y, Nakano T, Sagawa K. Lymphoscintigraphy Findings are Associated with Outcome in Children with Chylothorax After Cardiac Surgery. Pediatr Cardiol 2024; 45:150-155. [PMID: 37870602 DOI: 10.1007/s00246-023-03303-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/08/2023] [Indexed: 10/24/2023]
Abstract
Postoperative chylothorax in patients with congenital heart diseases (CHD) results in poor outcomes if anatomical and functional abnormalities of the lymphatic system are present. While these abnormalities are typically diagnosed by intranodal lymphangiography and dynamic contrast magnetic resonance lymphangiography, the usefulness of lymphoscintigraphy in these patients has not been evaluated. Between January 2019 and December 2021, 28 lymphoscintigraphies were performed in our institution for investigating prolonged pleural effusion after cardiac surgery. The images were assessed by three board-certified pediatric cardiologists retrospectively to determine the likelihood of a central lymphatic flow disorder. The likelihood was scored (range 1-3) based on structural abnormalities and congestive flow in the lymphatic system. Those scores were summed and the likelihood was categorized as low to intermediate (< 8 points) or high (8 or 9 points). Median age at lymphoscintigraphy was 129 days (IQR, 41-412 days), it was performed at a median of 22 days (IQR, 17-43) after surgery, and median score was 6 points (IQR, 4-7.5). Kendall's coefficient of concordance (0.867; p < 0.05) indicated high inter-rater reliability. Overall survival at 6 months after surgery was 92.5% in the low-to-intermediate group but 68.6% in the high group (p < 0.05), and duration of postoperative thoracic drainage was 27 and 58 days, respectively (p < 0.05). Lymphatic abnormalities detected by lymphoscintigraphy were associated with poorer outcomes. Lymphoscintigraphy was thought to be useful in assessing anatomic and functional lymphatic abnormalities, despite its minimal invasiveness.
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Affiliation(s)
- Sayo Suzuki
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan.
- Division of Pediatrics, Department of Developmental and Urological-Reproductive Medicine, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan.
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Takuya Hara
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Toshihide Nakano
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
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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.
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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
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Tomasulo CE, Dori Y, Smith CL. Understanding the next circulation: lymphatics and what the future holds. Curr Opin Cardiol 2023; 38:369-374. [PMID: 37195304 DOI: 10.1097/hco.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW The lymphatic system was previously considered the forgotten circulation because of an absence of adequate options for imaging and intervention. However, recent advances over the last decade have improved management strategies for patients with lymphatic disease, including chylothorax, plastic bronchitis, ascites, and protein-losing enteropathy. RECENT FINDINGS New imaging modalities have enabled detailed visualization of lymphatic vessels to allow for a better understanding of the cause of lymphatic dysfunction in a variety of patient subsets. This sparked the development of multiple transcatheter and surgery-based techniques tailored to each patient based on imaging findings. In addition, the new field of precision lymphology has added medical management options for patients with genetic syndromes, who have global lymphatic dysfunction and typically do not respond as well to the more standard lymphatic interventions. SUMMARY Recent developments in lymphatic imaging have given insight into disease processes and changed the way patients are managed. Medical management has been enhanced and new procedures have given patients more options, leading to better long-term results.
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Affiliation(s)
| | - Yoav Dori
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Benjamin J, O'Leary C, Hur S, Gurevich A, Klein WM, Itkin M. Imaging and Interventions for Lymphatic and Lymphatic-related Disorders. Radiology 2023; 307:e220231. [PMID: 36943078 DOI: 10.1148/radiol.220231] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.
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Affiliation(s)
- Jamaal Benjamin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Cathal O'Leary
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Saebeom Hur
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Alexey Gurevich
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Willemijn M Klein
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Maxim Itkin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
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7
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Pan F, Do TD, Schmitt N, Vollherbst DF, Möhlenbruch M, Tinoush P, Brobeil A, Koch V, Richter GM, Pereira PL, Kauczor HU, Sommer CM. Standardizing lymphangiography and lymphatic interventions: a preclinical in vivo approach with detailed procedural steps. CVIR Endovasc 2023; 6:21. [PMID: 36995443 PMCID: PMC10063775 DOI: 10.1186/s42155-023-00364-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
PURPOSE To present a preclinical in vivo approach for standardization and training of lymphangiography and lymphatic interventions using a pictorial review. MATERIALS AND METHODS Different lipiodol- and gadolinium-based lymphangiography and lymphatic interventions were performed in twelve (12) landrace pigs with a mean bodyweight of 34 ± 2 kg using various imaging and guiding modalities, similar to the procedures used in humans. The techniques used were explicitly introduced and illustrated. The potential applications of each technique in preclinical training were also discussed. RESULTS By applying visual, ultrasonography, fluoroscopy, CT, cone-beam CT, and/or MRI examination or guidance, a total of eleven techniques were successfully implemented in twelve pigs. The presented techniques include inguinal postoperative lymphatic leakage (PLL) establishment, interstitial dye test, five types of lymphangiography [incl. lipiodol-based translymphatic lymphangiography (TL), lipiodol-based percutaneous intranodal lymphangiography (INL), lipiodol-based laparotomic INL, lipiodol-based interstitial lymphangiography, and interstitial magnetic resonance lymphangiography (MRL)], and four types of percutaneous interventions in the treatment of PLL [incl. thoracic duct embolization (TDE), intranodal embolization (INE), afferent lymphatic vessel sclerotherapy (ALVS), and afferent lymphatic vessel embolization (ALVE)]. CONCLUSION This study provides a valuable resource for inexperienced interventional radiologists to undergo the preclinical training in lymphangiography and lymphatic interventions using healthy pig models.
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Affiliation(s)
- Feng Pan
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Thuy D Do
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Parham Tinoush
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Brobeil
- General Pathology and Pathological Anatomy, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Pathological Institute, NCT Tissue Bank, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Vitali Koch
- Institute for Diagnostic and Interventional Radiology, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Götz M Richter
- Clinic of Diagnostic and Interventional Radiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Philippe L Pereira
- Clinic for Radiology, Minimally-Invasive Therapies and Nuclearmedicine, SLK-Kliniken GmbH, Heilbronn, Germany
| | - Hans U Kauczor
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
- Clinic of Neuroradiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
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8
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Tanahashi Y, Shoda S, Kawada H, Ando T, Nagata S, Takasu M, Hyodo F, Goshima S, Mori T, Matsuo M. Intranodal dynamic contrast-enhanced CT lymphangiography and dynamic contrast-enhanced MR lymphangiography in microminipig. Eur Radiol 2023; 33:3165-3171. [PMID: 36814031 DOI: 10.1007/s00330-023-09463-w] [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: 05/13/2022] [Revised: 11/29/2022] [Accepted: 01/22/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To evaluate the feasibility and image quality of intranodal dynamic contrast-enhanced CT lymphangiography (DCCTL) and dynamic contrast-enhanced MR lymphangiography (DCMRL) in microminipigs. METHODS Our institution's committee for animal research and welfare provided approval. Three microminipigs underwent DCCTL and DCMRL after inguinal lymph node injection of 0.1 mL/kg contrast media. Mean CT values on DCCTL and signal intensity (SI) on DCMRL were measured at the venous angle and thoracic duct (TD). The contrast enhancement index (CEI; increase in CT values pre- to post-contrast) and signal intensity ratio (SIR; SI of lymph divided by SI of muscle) were evaluated. The morphologic legibility, visibility, and continuity of lymphatics were qualitatively evaluated using a 4-point scale. Two microminipigs underwent DCCTL and DCMRL after lymphatic disruption and the detectability of lymphatic leakage was evaluated. RESULTS The CEI peaked at 5-10 min in all microminipigs. The SIR peaked at 2-4 min in two microminipigs and at 4-10 min in one microminipig. The peak CEI and SIR values were 235.6 HU and 4.8 for venous angle, 239.4 HU and 2.1 for upper TD, and 387.3 HU and 2.1 for middle TD. The visibility and continuity of upper-middle TD scores were 4.0 and 3.3-3.7 for DCCTL, and 4.0 and 4.0 for DCMRL. In the injured lymphatic model, both DCCTL and DCMRL demonstrated lymphatic leakage. CONCLUSIONS DCCTL and DCMRL in a microminipig model enabled excellent visualization of central lymphatic ducts and lymphatic leakage, indicating the research and clinical potential of both modalities. KEY POINTS • Intranodal dynamic contrast-enhanced computed tomography lymphangiography showed a contrast enhancement peak at 5-10 min in all microminipigs. • Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography showed a contrast enhancement peak at 2-4 min in two microminipigs and at 4-10 min in one microminipig. • Both intranodal dynamic contrast-enhanced computed tomography lymphangiography and dynamic contrast-enhanced magnetic resonance lymphangiography demonstrated the central lymphatic ducts and lymphatic leakage.
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Affiliation(s)
- Yukichi Tanahashi
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan. .,Department of Radiology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Shinichi Shoda
- Radiology Service, Gifu University Hospital, Gifu, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomohiro Ando
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shoma Nagata
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masaki Takasu
- Joint Department of Veterinary Medicine, Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
| | - Fuminori Hyodo
- Department of Radiology, Frontier Science for Imaging, School of Medicine, Gifu University, Gifu, Japan
| | - Satoshi Goshima
- Department of Radiology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Takashi Mori
- Joint Department of Veterinary Medicine, Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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9
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Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part I. History, Anatomy, Physiology, and Diagnostic Imaging of the Lymphatic System. Korean J Radiol 2023; 24:95-108. [PMID: 36725352 PMCID: PMC9892216 DOI: 10.3348/kjr.2022.0688] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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
Recent advances in lymphatic imaging have provided novel insights into the lymphatic system. Interventional radiology has played a significant role in the development of lymphatic imaging techniques and modalities. Radiologists should be familiar with the basic physiology and anatomy of the lymphatic system to understand the imaging features of lymphatic disorders, which reflect their pathophysiology. This study comprehensively reviews the physiological and anatomical aspects of the human lymphatic system as well as the latest lymphatic imaging techniques.
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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
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10
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Bauer C, Dori Y, Scala M, Tulzer A, Tulzer G. Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome. Front Pediatr 2023; 11:1058567. [PMID: 36911024 PMCID: PMC9999027 DOI: 10.3389/fped.2023.1058567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria.,Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Andreas Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
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11
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Savla JJ, Kelly B, Krogh E, Smith CL, Krishnamurthy G, Glatz AC, DeWitt AG, Pinto EM, Ravishankar C, Gillespie MJ, O’Byrne ML, Escobar FA, Rome JJ, Hjortdal V, Dori Y. Occlusion Pressure of the Thoracic Duct in Fontan Patients With Lymphatic Failure: Does Dilatation Challenge Contractility? World J Pediatr Congenit Heart Surg 2022; 13:737-744. [DOI: 10.1177/21501351221119394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Fontan circulation challenges the lymphatic system. Increasing production of lymphatic fluid and impeding lymphatic return, increased venous pressure may cause lymphatic dilatation and decrease lymphatic contractility. In-vitro studies have reported a lymphatic diameter-tension curve, with increasing passive stretch affecting the intrinsic contractile properties of each thoracic duct segment. We aimed to describe thoracic duct occlusion pressure and asses if thoracic duct dilation impairs contractility in individuals with a Fontan circulation and lymphatic failure. Methods Central venous pressure and thoracic duct measurements were retrospectively collected from 31 individuals with a Fontan circulation. Thoracic duct occlusion pressure was assessed during a period of external manual compression and used as an indicator of lymphatic vessel contractility. Measurements of pressure were correlated with measurements of the thoracic duct diameter in images obtained by dynamic contrast-enhanced MR lymphangiography. Results The average central venous pressure and average pressure of the thoracic duct were 17 mm Hg. During manual occlusion, the thoracic duct pressure significantly increased to 32 mm Hg. The average thoracic duct diameter was 3.3 mm. Thoracic duct diameter correlated closely with the central venous pressure. The rise in pressure following manual occlusion showed an inverse correlation with the diameter of the thoracic duct. Conclusion Higher central venous pressures are associated with increasing diameters of the thoracic duct. When challenged by manual occlusion, dilated thoracic ducts display a decreased ability to increase pressure. Dilatation and a resulting decreased contractility may partly explain the challenged lymphatic system in individuals with a Fontan circulation.
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Affiliation(s)
- Jill J. Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Krogh
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher L. Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron G. DeWitt
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin M. Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Matthew J. Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A. Escobar
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Aarhus, Denmark
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
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12
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Simon M, Dori Y, Smith CL, Biko DM, Surrey LF, Adams DM, Krishnamurthy G, Rapp JB. Alternative Evaluation of the Right Axillary Lymphatic Pathway by Using Dynamic Contrast-enhanced MR Lymphangiography. Radiol Cardiothorac Imaging 2022; 4:e220035. [PMID: 36339058 PMCID: PMC9627229 DOI: 10.1148/ryct.220035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/02/2022] [Accepted: 10/06/2022] [Indexed: 01/25/2023]
Abstract
The lymphatic system plays an integral part in fluid homeostasis. Disturbances in lymphatic pathways are congenital, posttraumatic, or posttreatment related, such as after Fontan palliation. Lymphatic pathway evaluation is challenging because of the difficulty in introducing contrast material into the lymphatics. Intranodal, intramesenteric, and intrahepatic dynamic contrast-enhanced MR lymphangiography (DCMRL) offer better visualization of major lymphatic pathways. However, these techniques exclude pathways outside the central conduction system, preventing the visualization of abnormalities and, thus, administration of treatment. The authors describe alternative imaging of an axillary pathway via DCMRL in a patient with a symptomatic chylous effusion not previously assessed with current techniques. Keywords: Lymphatic, MR-Dynamic Contrast Enhanced, Pediatrics, Thorax, Pleura Supplemental material is available for this article. © RSNA, 2022.
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13
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Liu M, Smith CL, Biko DM, Li D, Pinto E, O'Connor N, Skraban C, Zackai EH, Hakonarson H, Dori Y, Sheppard SE. Genetics etiologies and genotype phenotype correlations in a cohort of individuals with central conducting lymphatic anomaly. Eur J Hum Genet 2022; 30:1022-1028. [PMID: 35606495 PMCID: PMC9436962 DOI: 10.1038/s41431-022-01123-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/09/2022] Open
Abstract
Central conducting lymphatic anomaly (CCLA) is a heterogenous disorder caused by disruption of central lymphatic flow that may result in dilation or leakage of central lymphatic channels. There is also a paucity of known genetic diagnoses associated with CCLA. We hypothesized that specific genetic syndromes would have distinct lymphatic patterns and this would allow us to more precisely define CCLA. As a first step toward "precision lymphology", we defined the genetic conditions associated with CCLA by performing a retrospective cohort study. Individuals receiving care through the Jill and Mark Fishman Center for Lymphatic Disorders at the Children's Hospital of Philadelphia between 2016 and 2019 were included if they had a lymphangiogram and clinical genetic testing performed and consented to a clinical registry. In our cohort of 115 participants, 26% received a molecular diagnosis from standard genetic evaluation. The most common genetic etiologies were germline and mosaic RASopathies, chromosomal abnormalities including Trisomy 21 and 22q11.2 deletion syndrome, and PIEZO1-related lymphatic dysplasia. Next, we analyzed the dynamic contrast magnetic resonance lymphangiograms and found that individuals with germline and mosaic RASopathies, mosaic KRASopathies, PIEZO1-related lymphatic dysplasia, and Trisomy 21 had distinct central lymphatic flow phenotypes. Our research expands the genetic conditions associated with CCLA and genotype-lymphatic phenotype correlations. Future descriptions of CCLA should include both genotype (if known) and phenotype to provide more information about disease (gene-CCLA). This should be considered for updated classifications of CCLA by the International Society of Vascular Anomalies.
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Affiliation(s)
- Mandi Liu
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dong Li
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Pinto
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nora O'Connor
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cara Skraban
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah E Sheppard
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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14
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Sun JD, Shum T, Behzadi F, Hammer MM. Imaging Findings of Thoracic Lymphatic Abnormalities. Radiographics 2022; 42:1265-1282. [PMID: 35960666 DOI: 10.1148/rg.220040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The lymphatic system plays an important role in balancing fluid compartments in the body. It is disrupted by various disease processes in the thorax, including injury to the thoracic lymphatic duct after surgery, as well as malignancy and heart failure. Because of the small size of lymphatic vessels, imaging of the lymphatics is relatively difficult, and effective imaging methods are still being optimized and developed. The standard of reference for lymphatic imaging has been conventional lymphangiography for several decades. Other modalities such as CT, noncontrast or contrast-enhanced MRI, and lymphoscintigraphy can also demonstrate lymphatic abnormalities and help in treatment planning. Imaging findings associated with lymphatic abnormalities can be seen in the pulmonary parenchyma, pleural space, and mediastinum. In the pulmonary parenchyma, common findings include interlobular septal thickening as well as reversal of lymphatic flow with intravasation of contrast material into pulmonary lymphatics. In the pleural space, findings include chylous pleural effusion and occasionally nonchylous pleural effusion. In the mediastinum, thoracic duct leak, plexiform thoracic duct, lymphatic malformations, and lymphangiectasis may occur. Management of chylothorax includes conservative or medical treatment, surgery, and interventional radiology procedures. The authors discuss thoracic lymphatic anatomy, imaging manifestations of lymphatic abnormalities in the various anatomic compartments, and interventional radiology treatment of chylothorax. Radiologists should be familiar with these imaging findings for diagnosis and to help guide appropriate management. ©RSNA, 2022.
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Affiliation(s)
- Jingshuo Derek Sun
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Thomas Shum
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Fardad Behzadi
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Mark M Hammer
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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15
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Ricci KW, Iacobas I. How we approach the diagnosis and management of complex lymphatic anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e28985. [PMID: 33844431 DOI: 10.1002/pbc.28985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/29/2021] [Accepted: 02/13/2021] [Indexed: 12/26/2022]
Abstract
Complex lymphatic anomalies (CLA) are congenital diseases of the lymphatic circulation system that are associated with significant morbidity and early mortality. While guidelines for the comprehensive evaluation of the CLA were recently published, the diagnostic approach and medical management are not standardized. This article presents the clinical features of four CLA: Gorham-Stout disease, generalized lymphatic anomaly, kaposiform lymphangiomatosis, and central collecting lymphatic anomaly. We also offer three cases from the authors' practice and our views on diagnostic testing and disease management including supportive care, medical therapies, and other interventions.
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Affiliation(s)
- Kiersten W Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Hematology and Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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16
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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17
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Solari E, Marcozzi C, Ottaviani C, Negrini D, Moriondo A. Draining the Pleural Space: Lymphatic Vessels Facing the Most Challenging Task. BIOLOGY 2022; 11:biology11030419. [PMID: 35336793 PMCID: PMC8945018 DOI: 10.3390/biology11030419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/25/2022] [Accepted: 03/08/2022] [Indexed: 01/06/2023]
Abstract
Simple Summary Fluid drainage operated by lymphatic vessels is crucial for a proper volume homeostasis of body compartments. This role is particularly relevant for the pleural cavity, where the hydraulic pressure of the pleural liquid is very subatmospheric and fluid filtering from the blood capillaries into the pleural space must be continuously removed to keep the pleural space volume low and to prevent accumulation of liquid causing impairments of the respiratory mechanics. In order to accomplish this task, lymphatic vessels of the pleural side of the diaphragm and those lying on the pleural surface of the chest wall must possess a negative intraluminal pressure which has to vary during the respiratory cycle to follow the similar variations occurring to the pressure of pleural liquid. This review focuses on the in vivo pressure measurements performed in sedated animal models to understand how these lymphatic networks can accomplish this complex but pivotal role. Abstract Lymphatic vessels exploit the mechanical stresses of their surroundings together with intrinsic rhythmic contractions to drain lymph from interstitial spaces and serosal cavities to eventually empty into the blood venous stream. This task is more difficult when the liquid to be drained has a very subatmospheric pressure, as it occurs in the pleural cavity. This peculiar space must maintain a very low fluid volume at negative hydraulic pressure in order to guarantee a proper mechanical coupling between the chest wall and lungs. To better understand the potential for liquid drainage, the key parameter to be considered is the difference in hydraulic pressure between the pleural space and the lymphatic lumen. In this review we collected old and new findings from in vivo direct measurements of hydraulic pressures in anaesthetized animals with the aim to better frame the complex physiology of diaphragmatic and intercostal lymphatics which drain liquid from the pleural cavity.
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18
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Dori Y, Smith CL. Lymphatic Disorders in Patients With Single Ventricle Heart Disease. Front Pediatr 2022; 10:828107. [PMID: 35757132 PMCID: PMC9226478 DOI: 10.3389/fped.2022.828107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Lymphatic abnormalities in patients with single ventricle physiology can lead to early Fontan failure and severe Fontan complications, such as protein-losing enteropathy (PLE), plastic bronchitis (PB), chylothorax, and edema. Recent developments in lymphatic imaging and interventions have shed new light on the lymphatic dysfunction in this patient population and the role of the lymphatic circulation in PLE, PB, and chylothorax. In this study, we reviewed some of the latest developments in this field and discuss new treatment options for these patients.
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Affiliation(s)
- Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher L Smith
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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20
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Lee S, Hur S, Suh DI, Moon JS, Moon J, Kim MJ, Cheon JE, Kim WS. Transcatheter Dynamic Contrast-Enhanced MR Lymphangiography for Nontraumatic Lymphatic Disorders: Technical Feasibility and Imaging Findings. J Vasc Interv Radiol 2021; 32:1654-1660.e2. [PMID: 34844704 DOI: 10.1016/j.jvir.2021.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/19/2021] [Accepted: 08/29/2021] [Indexed: 12/01/2022] Open
Abstract
This study aimed to evaluate the feasibility and added value of transcatheter dynamic contrast-enhanced magnetic resonance (MR) lymphangiography for nontraumatic lymphatic disorders. Five patients (2 males and 3 females; median age, 16.0 years; range, 3-74 years) who underwent both intranodal and transcatheter dynamic contrast-enhanced MR lymphangiography for suspected nontraumatic lymphatic leakages from June 2017 to January 2020 were included in this retrospective study. The imaging findings of both dynamic contrast-enhanced MR lymphangiography techniques were assessed for the presence of chylolymphatic reflux or direct sign of leakage. Intranodal dynamic contrast-enhanced MR lymphangiography demonstrated chylolymphatic reflux into the thoracic area in 2 patients (40%) but no direct evidence of leakage in any of the 5 patients. Transcatheter dynamic contrast-enhanced MR lymphangiography revealed chylolymphatic reflux and extravasation of the contrast agent in all 5 patients (100%). In conclusion, transcatheter dynamic contrast-enhanced MR lymphangiography may reveal additional signs of reflux and extravasation even when the findings of intranodal dynamic contrast-enhanced MR lymphangiography are negative.
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Affiliation(s)
- Seunghyun Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jangsup Moon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Genomic Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Man Jin Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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21
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Non-Traumatic Chylothorax and Chylopericardium: Diagnosis and Treatment Using an Algorithmic Approach Based on Novel Lymphatic Imaging. Ann Am Thorac Soc 2021; 19:756-762. [PMID: 34797746 DOI: 10.1513/annalsats.202103-262oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Outcomes of interventional lymphangiographic treatment of nontraumatic chylous pleural effusions using traditional approaches have been highly variable. Recent advances in lymphatic imaging have revealed variations in underlying pathophysiology enabling improved targeting of therapeutic interventions. OBJECTIVE To assess outcomes of an algorithm for management of nontraumatic chylous pleural effusions based on advanced MR identification of various abnormalities in the thoracoabdominal lymphatic network that give rise to chylothorax. METHODS Novel lymphatic MR imaging was performed in 52 patients ages 11 to 89 years. Three distinct pathophysiological patterns were found: (1) abnormal pulmonary lymphatic flow from the thoracic duct only; (2) abnormal pulmonary lymphatic flow from retroperitoneal lymphatic networks with or without involvement of the thoracic duct; and (3) chylous ascites presenting as chylous pleural effusion. Lymphatic interventions were individualized to the underlying pathophysiological patterns. RESULTS In 41/52 (79%) patients, imaging revealed abnormal pulmonary lymphatic flow from the thoracic duct and/or retroperitoneal lymphatic networks. Thoracic duct embolization and/or interstitial embolization of retroperitoneal lymphatic resulted in resolution of chylothorax in this group in 38/41 (93%) of those patients. Five patients experienced Grade 1 or 2 complications. One patient succumbed to post-operative stress-induced cardiomyopathy and pulmonary embolism. Chylous ascites was the cause of chylothorax in 11/52 (21%) patients. Eight chose to undergo interventions for chylous ascites with clinical success in 6/8 (75%). CONCLUSIONS Application of MRI-guided intervention algorithm resulted in successful control of non-traumatic chylothorax in 93% patients with abnormal pulmonary lymphatic flow. Appropriate treatment of chylous ascites presenting as a pleural effusion requires systematic evaluation and diagnosis prior to potential treatments.
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22
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Patel S, Hur S, Khaddash T, Simpson S, Itkin M. Intranodal CT Lymphangiography with Water-soluble Iodinated Contrast Medium for Imaging of the Central Lymphatic System. Radiology 2021; 302:228-233. [PMID: 34698570 DOI: 10.1148/radiol.2021210294] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Dynamic contrast-enhanced MR lymphangiography (DCMRL) is the reference standard used to diagnose various thoracic lymphatic disorders, such as traumatic chylothorax and plastic bronchitis. However, accessibility and logistical challenges have prevented the wide dissemination of this technology. Purpose To evaluate the feasibility of intranodal CT lymphangiography (ICTL) in the diagnosis and planning of subsequent intervention in patients with thoracic lymphatic disorders. Materials and Methods In this retrospective review, five women suspected of having lymphatic abnormalities (ranging from traumatic chylothorax to plastic bronchitis) and with contraindications to MRI underwent ICTL from September 2019 to May 2020. Needles (25 gauge) were placed in the bilateral inguinal lymph nodes with US guidance, and water-soluble iodinated contrast material was injected. CT fluoroscopy was used to monitor the opacification of the cisterna chyli to determine the timing of CT. After ICTL, the thoracic duct was catheterized, and lymphangiography was performed through the thoracic duct catheter. The ICTL and subsequent lymphangiographic findings were then visually compared by using three-dimensional reconstructions. Results Intranodal injection of water-soluble contrast medium was successful in all patients evaluated (five women; mean age, 68 years ± 11 [standard deviation]; range, 53-83 years). The central lymphatics were opacified in four of the five women, demonstrating abnormal pulmonary lymphatic flow from the thoracic duct into the lung parenchyma. In one of the five women, thoracic duct injection showed successful ligation of the thoracic duct. The time elapsed from injection of contrast medium to visualization of the thoracic duct ranged from 2 to 27 minutes. ICTL and lymphangiographic findings matched well. Conclusion Intranodal CT lymphangiography sufficiently depicted central lymphatic anatomy in patients with lymphatic abnormalities, thereby demonstrating its use as a feasible alternative to more technically challenging methods, such as dynamic contrast-enhanced MR lymphangiography. © RSNA, 2021.
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Affiliation(s)
- Suhag Patel
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Saebeom Hur
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Tamim Khaddash
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Scott Simpson
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Maxim Itkin
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
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23
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Lemley BA, Biko DM, Dewitt AG, Glatz AC, Goldberg DJ, Saravanan M, O'Byrne ML, Pinto E, Ravishankar C, Rome JJ, Smith CL, Dori Y. Intrahepatic Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein-Losing Enteropathy in Congenital Heart Disease. J Am Heart Assoc 2021; 10:e021542. [PMID: 34569246 PMCID: PMC8649156 DOI: 10.1161/jaha.121.021542] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Protein‐losing enteropathy (PLE) is a significant cause of morbidity and mortality in congenital heart disease patients with single ventricle physiology. Intrahepatic dynamic contrast‐enhanced magnetic resonance lymphangiography (IH‐DCMRL) is a novel diagnostic technique that may be useful in characterizing pathologic abdominal lymphatic flow in the congenital heart disease population and in diagnosing PLE. The objective of this study was to characterize differences in IH‐DCMRL findings in patients with single ventricle congenital heart disease with and without PLE. Methods and Results This was a single‐center retrospective study of IH‐DCMRL findings and clinical data in 41 consecutive patients, 20 with PLE and 21 without PLE, with single ventricle physiology referred for lymphatic evaluation. There were 3 distinct duodenal imaging patterns by IH‐DCMRL: (1) enhancement of the duodenal wall with leakage into the lumen, (2) enhancement of the duodenal wall without leakage into the lumen, and (3) no duodenal involvement. Patients with PLE were more likely to have duodenal involvement on IH‐DCMRL than patients without PLE (P<0.001). Conclusions IH‐DCMRL findings of lymphatic enhancement of the duodenal wall and leakage of lymph into the duodenal lumen are associated with PLE. IH‐DCMRL is a useful new modality for characterizing pathologic abdominal lymphatic flow in PLE and might be useful as a risk‐assessment tool for PLE in at‐risk patients.
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Affiliation(s)
- Bethan A Lemley
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Dave M Biko
- Department of Radiology Children's Hospital of Philadelphia Philadelphia PA.,Department of Radiology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Aaron G Dewitt
- Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA.,Division of Critical Care The Children's Hospital of Philadelphiae Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - David J Goldberg
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Madhumitha Saravanan
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Erin Pinto
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Chitra Ravishankar
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Christopher L Smith
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- Division of Cardiology The Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine, University of Pennsylvania Philadelphia PA
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24
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Martin-Almedina S, Mortimer PS, Ostergaard P. Development and physiological functions of the lymphatic system: insights from human genetic studies of primary lymphedema. Physiol Rev 2021; 101:1809-1871. [PMID: 33507128 DOI: 10.1152/physrev.00006.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary lymphedema is a long-term (chronic) condition characterized by tissue lymph retention and swelling that can affect any part of the body, although it usually develops in the arms or legs. Due to the relevant contribution of the lymphatic system to human physiology, while this review mainly focuses on the clinical and physiological aspects related to the regulation of fluid homeostasis and edema, clinicians need to know that the impact of lymphatic dysfunction with a genetic origin can be wide ranging. Lymphatic dysfunction can affect immune function so leading to infection; it can influence cancer development and spread, and it can determine fat transport so impacting on nutrition and obesity. Genetic studies and the development of imaging techniques for the assessment of lymphatic function have enabled the recognition of primary lymphedema as a heterogenic condition in terms of genetic causes and disease mechanisms. In this review, the known biological functions of several genes crucial to the development and function of the lymphatic system are used as a basis for understanding normal lymphatic biology. The disease conditions originating from mutations in these genes are discussed together with a detailed clinical description of the phenotype and the up-to-date knowledge in terms of disease mechanisms acquired from in vitro and in vivo research models.
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Affiliation(s)
- Silvia Martin-Almedina
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter S Mortimer
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St. George's Universities NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
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25
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Intranodal lymphangiography and interstitial lymphatic embolization to treat chyluria caused by a lymphatic malformation in a pediatric patient. Pediatr Radiol 2021; 51:1762-1765. [PMID: 33638694 DOI: 10.1007/s00247-021-05007-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
Chyluria is characterized by chyle in the urinary tract and often presents as milky-white urine. We present a case of chyluria from a lymphatic malformation in a 13-year-old boy diagnosed using dynamic intranodal contrast-enhanced magnetic resonance (MR) lymphangiography. This report demonstrates the utility of intranodal lymphangiography and interstitial lymphatic embolization to treat a pediatric patient presenting with persistent chyluria. Glue migration into the urinary collecting system is a potential complication of this procedure that can be mitigated by adjusting the n-butyl cyanoacrylate dilution with Lipiodol.
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26
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RochéRodríguez M, DiNardo JA. The Lymphatic System in the Fontan Patient-Pathophysiology, Imaging, and Interventions: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2021; 36:2669-2678. [PMID: 34446325 DOI: 10.1053/j.jvca.2021.07.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/28/2021] [Indexed: 01/30/2023]
Abstract
The Fontan surgery was developed as a palliative intervention for congenital heart disease (CHD) patients with single-ventricle physiology who are not candidates for a biventricular repair. Improvements in the surgery and medical management of these patients have increased survival, yet this population remains at risk for complications and end-organ dysfunction due to Fontan failure. Lymphatic vessels maintain a fluid balance within the extracellular space, participate in fat reabsorption from the small intestine, and play an important role in the body's immune response. Altered Starling forces at the capillary level, capillary leak, and lymphatic obstruction contribute to lymphatic dysfunction in patients with Fontan physiology. These lymphatic complications include edema, pleural effusions, plastic bronchitis (PB), and protein-losing enteropathy (PLE). Over the past decade, there have been innovations in lymphatic imaging. These new imaging techniques include noncontrast magnetic resonance (MR) lymphangiography, intranodal lymphangiography (IL), dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), and liver lymphangiography. These imaging techniques help in delineating anatomy and guiding the appropriate therapeutic approach. Lymphatic interventions then may be performed to decompress the lymphatic system or to identify and occlude abnormal lymphatic vessels and drainage pathways. The anesthesiologist should have an understanding of the effects of lymphatic disorders on the Fontan circulation and apply appropriate management techniques for the associated interventions. The Fontan surgery was developed as a palliative intervention for CHD patients with single-ventricle physiology who are not candidates for a biventricular repair. The surgery creates a series systemic and pulmonary circulation with the energy necessary to provide gradient-driven pulmonary blood flow generated by the ventricle.1 In the past decades, improvements in the surgery and medical management of these patients have increased survival, with 30-year survival rates close to 85%.2 Despite these improvements, this population remains at risk for complications and end-organ dysfunction due to Fontan failure, which is characterized by elevated systemic venous pressures and low cardiac output. These complications include arrhythmias, cardiac dysfunction, ascites, liver fibrosis/cirrhosis, renal dysfunction, pulmonary failure, and lymphatic complications such as edema, pleural effusions, PB, and PLE. Complications ultimately contribute to increased risk for hospitalization, death, and need for heart transplantation.3,4 For this reason, there has been increasing interest in the role of abnormal lymphatic circulation in the genesis of Fontan failure. The authors characterize the lymphatic pathophysiology associated with Fontan physiology and review the imaging and interventional strategies used to treat these patients.
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Affiliation(s)
- Maricarmen RochéRodríguez
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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27
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Itkin M, Rockson SG, Burkhoff D. Pathophysiology of the Lymphatic System in Patients With Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:278-290. [PMID: 34266581 DOI: 10.1016/j.jacc.2021.05.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022]
Abstract
The removal of interstitial fluid from the tissues is performed exclusively by the lymphatic system. Tissue edema in congestive heart failure occurs only when the lymphatic system fails or is overrun by fluid leaving the vascular space across the wall of the capillaries into the interstitial space. This process is driven by Starling forces determined by hydrostatic and osmotic pressures and organ-specific capillary permeabilities to proteins of different sizes. In this review, we summarize current knowledge of the generation of lymph in different organs, the mechanics by which lymph is returned to the circulation, and the consequences of the inadequacy of lymph flow. We review recent advances in imaging techniques that have allowed for new research, diagnostic, and therapeutic approaches to the lymphatic system. Finally, we review how efforts to increase lymph flow have demonstrated potential as a viable therapeutic approach for refractory heart failure.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Stanley G Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, New York, USA. https://twitter.com/burkhoffmd
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28
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Sinha S, Lee EW, Dori Y, Katsuhide M. Advances in lymphatic imaging and interventions in patients with congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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29
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Berger JH, Jones A, Fainberg N, Smith C, Ravishankar C. A Previously Healthy Teenager with Anasarca. Pediatr Rev 2021; 42:153-157. [PMID: 33648995 PMCID: PMC8034987 DOI: 10.1542/pir.2020-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Nina Fainberg
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
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30
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Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg 2021; 10:1260-1267. [PMID: 33842273 DOI: 10.21037/gs-2019-ursoc-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Hoyong Jun
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yoon Soo Jeong
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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31
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Gooty VD, Veeram Reddy SR, Greer JS, Blair Z, Zahr RA, Arar Y, Castellanos DA, Pimplawar S, Greil GF, Dillenbeck J, Hussain T. Lymphatic pathway evaluation in congenital heart disease using 3D whole-heart balanced steady state free precession and T2-weighted cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2021; 23:16. [PMID: 33641664 PMCID: PMC7919323 DOI: 10.1186/s12968-021-00707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Due to passive blood flow in palliated single ventricle, central venous pressure increases chronically, ultimately impeding lymphatic drainage. Early visualization and treatment of these malformations is essential to reduce morbidity and mortality. Cardiovascular magnetic resonance (CMR) T2-weighted lymphangiography (T2w) is used for lymphatic assessment, but its low signal-to-noise ratio may result in incomplete visualization of thoracic duct pathway. 3D-balanced steady state free precession (3D-bSSFP) is commonly used to assess congenital cardiac disease anatomy. Here, we aimed to improve diagnostic imaging of thoracic duct pathway using 3D-bSSFP. METHODS Patients underwent CMR during single ventricle or central lymphatic system assessment using T2w and 3D-bSSFP. T2w parameters included 3D-turbo spin echo (TSE), TE/TR = 600/2500 ms, resolution = 1 × 1 × 1.8 mm, respiratory triggering with bellows. 3D-bSSFP parameters included electrocardiogram triggering and diaphragm navigator, 1.6 mm isotropic resolution, TE/TR = 1.8/3.6 ms. Thoracic duct was identified independently in T2w and 3D-bSSFP images, tracked completely from cisterna chyli to its drainage site, and classified based on severity of lymphatic abnormalities. RESULTS Forty-eight patients underwent CMR, 46 of whom were included in the study. Forty-five had congenital heart disease with single ventricle physiology. Median age at CMR was 4.3 year (range 0.9-35.1 year, IQR 2.4 year), and median weight was 14.4 kg (range, 7.9-112.9 kg, IQR 5.2 kg). Single ventricle with right dominant ventricle was noted in 31 patients. Thirty-eight patients (84%) were status post bidirectional Glenn and 7 (16%) were status post Fontan anastomosis. Thoracic duct visualization was achieved in 45 patients by T2w and 3D-bSSFP. Complete tracking to drainage site was attained in 11 patients (24%) by T2w vs 25 (54%) by 3D-bSSFP and in 28 (61%) by both. Classification of lymphatics was performed in 31 patients. CONCLUSION Thoracic duct pathway can be visualized by 3D-bSSFP combined with T2w lymphangiography. Cardiac triggering and respiratory navigation likely help retain lymphatic signal in the retrocardiac area by 3D-bSSFP. Visualizing lymphatic system leaks is challenging on 3D-bSSFP images alone, but 3D-bSSFP offers good visualization of duct anatomy and landmark structures to help plan interventions. Together, these sequences can define abnormal lymphatic pathway following single ventricle palliative surgery, thus guiding lymphatic interventional procedures.
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Affiliation(s)
- Vasu D Gooty
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 49N Dunlap Street, 3rd Floor, Memphis, TN, 38015, USA.
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA.
| | - Surendranath R Veeram Reddy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Joshua S Greer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Zachary Blair
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Riad Abou Zahr
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Yousef Arar
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Daniel A Castellanos
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Sheena Pimplawar
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Gerald F Greil
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Jeanne Dillenbeck
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Tarique Hussain
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
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Itkin M, Rockson SG, Witte MH, Burkhoff D, Phillips A, Windsor JA, Kassab GS, Hur S, Nadolski G, Pabon-Ramos WM, Rabinowitz D, White SB. Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2021; 32:762.e1-762.e7. [PMID: 33610432 DOI: 10.1016/j.jvir.2021.01.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/06/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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Affiliation(s)
- Maxim Itkin
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Stanley G Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marlys H Witte
- University of Arizona College of Medicine Tucson Arizona, International Society of Lymphology, Tuscon, Arizona
| | | | - Anthony Phillips
- Applied Surgery and Metabolism Laboratory, Surgical and Translational Research Centre, School of Biological Sciences & Dept. of Surgery, Auckland University, Auckland, New Zealand
| | - John A Windsor
- Surgery and Director Surgical and Translational Research Centre, University of Auckland, New Zealand
| | | | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Gregory Nadolski
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Waleska M Pabon-Ramos
- Pediatric Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Debbie Rabinowitz
- Department of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Radiology and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware
| | - Sarah B White
- Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Lymphatic Disorders and Management in Patients with Congenital Heart Disease. Ann Thorac Surg 2020; 113:1101-1111. [PMID: 33373590 DOI: 10.1016/j.athoracsur.2020.10.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
Congenital heart disease can lead to significant lymphatic complications such as chylothorax, plastic bronchitis, protein losing enteropathy and ascites. Recent improvements in lymphatic imaging and the development of new lymphatic procedures can help alleviate symptoms and improve outcomes.
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Mi H, Chi J, Zhao X, Lu Q. A case report of generalized lymphangiomatosis with chylopericardium: the crucial role of magnetic resonance lymphangiography. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 33204977 PMCID: PMC7649488 DOI: 10.1093/ehjcr/ytaa294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/23/2020] [Accepted: 08/04/2020] [Indexed: 12/03/2022]
Abstract
Background Chylopericardium due to generalized lymphangiomatosis is a rare clinical entity. Its aetiology and treatment remain unclear. Case summary We report one case of a 51-year-old man who was diagnosed with generalized lymphangiomatosis with idiopathic chylopericardium by bilateral inguinal intranodal contrast-enhanced magnetic resonance lymphangiography. Magnetic resonance lymphangiography demonstrated abnormal communications between the pericardial sac and the thoracic duct. The patient with idiopathic chylopericardium was therefore successfully treated by exclusive surgical ligation of the abnormal communications and partial pericardiectomy by thoracotomy. The patient’s postoperative recovery was uneventful, and no recurrence of pericardial effusion occurred during the 13-month follow-up. Discussion Magnetic resonance lymphangiography showed a good capability for evaluating the extent of generalized lymphangiomatosis and therefore is helpful for delineating the anatomy of the thoracic duct and identifying chyle leakage and abnormal communications between the thoracic duct and the pericardial sac. This makes a simple ligature of the abnormal communications, instead of thoracic duct mass ligation possible in the treatment of chylopericardium.
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Affiliation(s)
- Honglan Mi
- Department of Radiology, Shanghai Jiao Tong University School of Medicine affiliated Renji Hospital, No. 160 Pujian Road, Shanghai 2000127, China
| | - Jiachang Chi
- Department of Intervention, Shanghai Jiao Tong University School of Medicine affiliated Renji Hospital, No. 160 Pujian Road, Shanghai 2000127, China
| | - Xiaojing Zhao
- Department of Cardiothoracic, Shanghai Jiao Tong University School of Medicine affiliated Renji Hospital, No. 160 Pujian Road, Shanghai 2000127, China
| | - Qing Lu
- Department of Radiology, Shanghai Jiao Tong University School of Medicine affiliated Renji Hospital, No. 160 Pujian Road, Shanghai 2000127, China
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Mejia EJ, Otero HJ, Smith CL, Shipman M, Liu M, Pinto E, DeWitt A, Rome JJ, Dori Y, Biko DM. Use of Contrast-Enhanced Ultrasound to Determine Thoracic Duct Patency. J Vasc Interv Radiol 2020; 31:1670-1674. [PMID: 32919824 DOI: 10.1016/j.jvir.2020.05.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/24/2020] [Accepted: 05/17/2020] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to determine the feasibility of using contrast-enhanced ultrasound (CEUS) evaluation to determine thoracic duct (TD) outlet patency. Nine patients referred for lymphatic imaging and intervention underwent percutaneous intranodal ultrasound contrast injection and conventional lymphangiography (CL). Eight of 9 patients had a patent TD by CEUS and CL. One patient did not have a patent TD. There was 100% agreement between CEUS and CL. These results suggest that CEUS is an imaging modality that might be as accurate as CL in determining TD patency.
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Affiliation(s)
- Erika J Mejia
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104.
| | - Hansel J Otero
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Christopher L Smith
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Molly Shipman
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Mandi Liu
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Erin Pinto
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Aaron DeWitt
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Jonathan J Rome
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Yoav Dori
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - David M Biko
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
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AlShehri E, Lam CZ, Kamath BM, Chavhan GB. Abdominal lymphatic system visibility, morphology, and abnormalities in children as seen on routine MCRP and its association with immune-mediated diseases. Eur Radiol 2020; 31:292-301. [PMID: 32797311 DOI: 10.1007/s00330-020-07152-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/08/2020] [Accepted: 08/05/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE (1) To assess the visibility and diameters of the thoracic duct (TD) and cisterna chyli (CC) on MR cholangiopancreatography (MRCP) in children. (2) To evaluate for the presence of any lymphatic abnormalities and assess their association with diseases in which the immune system is implicated in etiopathogenesis. METHODS This retrospective study included 142 MRCPs performed in children 8-17 years old and without prior surgeries. Two radiologists reviewed all exams for visibility and diameters of the TD and CC, and presence of abnormal lymphatic collaterals. TD and CC diameters in various disease processes were compared using Student's t tests. The association of collaterals with immune-mediated diseases was assessed using Fisher's exact tests. RESULTS The TD and CC were seen in 134/142 (93.7%) cases with mean diameter of 3.25 ± 1.07 mm and 126/142 (88.7%) cases with mean diameter of 4.55 ± 1.37 mm respectively. The mean diameter of CC was larger in patients with portal hypertension (p = 0.021). There were no significant differences in the TD and CC diameters between immune-mediated and non-immune-mediated diseases. Retroperitoneal collaterals were seen in 41/142 (28.8%) of cases and were associated with both portal hypertension (p = 0.0019) and immune-mediated diseases (p = 0.0083). CONCLUSION The TD and CC can be visualized in the majority of children on routine MRCP images, and CC has larger diameter in patients with portal hypertension. The association of collaterals with immune-mediated diseases supports a potential role of the lymphatic system in the etiopathogenesis of immune-mediated diseases. KEY POINTS • The lymphatic system has been increasingly implicated in a number of inflammatory and immune-mediated diseases. • The abdominal lymphatic system can be visualized in the majority of children above 8 years on routine MRCP images. Similar to adult studies, the cisterna chyli is significantly larger in children with portal hypertension. • Retroperitoneal lymphatic collaterals, seen in 29% children, are associated with immune-mediated diseases, which supports the potential role of the lymphatic system in the pathogenesis of immune-mediated diseases.
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Affiliation(s)
- Ebtehaj AlShehri
- 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
| | - Binita M Kamath
- Department of Gastroenterology Hepatology and Nutrition, The Hospital For Sick Children, University Of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - 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.
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37
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Santos E, Moussa AM. Chylous Ascites and Lymphoceles: Evaluation and Interventions. Semin Intervent Radiol 2020; 37:274-284. [PMID: 32773953 DOI: 10.1055/s-0040-1713445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.
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Affiliation(s)
- Ernesto Santos
- Department of Radiology, Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amgad M Moussa
- Department of Radiology, Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, New York
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38
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Goity LD, Itkin M, Nadolski G. An Algorithmic Approach to Minimally Invasive Management of Nontraumatic Chylothorax. Semin Intervent Radiol 2020; 37:269-273. [PMID: 32773952 DOI: 10.1055/s-0040-1713444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chylothorax is a rare condition characterized by lymph accumulation in the pleural space. When it occurs independent of trauma, it is even more rare and difficult to treat as identification of lymphatic leak is unpredictable. In addition, treatment of this condition with conventional lymphangiography and thoracic duct embolization may not result in positive outcomes. As such, the role of contrast-enhanced dynamic magnetic resonance lymphangiography to guide treatment is key to maximizing success with the advantage of localizing the site of lymphatic leak. Herein, we summarize etiologies of nontraumatic chylothorax, offer an updated treatment algorithm to stratify affected patients and determine appropriate treatment options, and review procedural techniques critical to efficient and effective treatment.
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Affiliation(s)
- Luis D Goity
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Nadolski
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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39
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Pieper CC. Nodal and Pedal MR Lymphangiography of the Central Lymphatic System: Techniques and Applications. Semin Intervent Radiol 2020; 37:250-262. [PMID: 32773950 DOI: 10.1055/s-0040-1713442] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Novel lymphatic imaging and interventional techniques are increasingly used in the diagnostic workup and treatment of pathologies of the central lymphatic system and have opened a new field of interventional radiology. The mainstay of lymphatic imaging today is magnetic resonance lymphangiography (MRL). It provides information on the anatomy of the central lymphatic system, lymphatic flow, as well as lymphatic pathologies and therefore is a valuable tool for treatment planning. There are two techniques to perform contrast-enhanced MRL: nodal dynamic contrast-enhanced MRL (nodal DCE-MRL) and interstitial transpedal MRL (tMRL). Nodal DCE-MRL yields superior information on lymphatic flow dynamics and is therefore best suited for suspected lymphatic flow pathologies and lymphatic malformations. tMRL is a technically simpler alternative for central lymphatic visualization without the need for sonographically guided lymph node cannulation. This review article describes current MRL techniques with a focus on contrast-enhanced MRL, their specific advantages, and possible clinical applications in patients suffering from pathologies of the central lymphatic system.
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Affiliation(s)
- Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital Bonn, Bonn, Germany
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40
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Tanahashi Y, Iwasaki R, Shoda S, Kawada H, Ando T, Takasu M, Hyodo F, Goshima S, Mori T, Matsuo M. Dynamic contrast-enhanced computed tomography lymphangiography with intranodal injection of water-soluble iodine contrast media in microminipig: imaging protocol and feasibility. Eur Radiol 2020; 30:5913-5922. [PMID: 32591882 DOI: 10.1007/s00330-020-07031-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/15/2020] [Accepted: 06/12/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the optimal imaging protocol and the feasibility of intranodal dynamic contrast-enhanced computed tomography lymphangiography (DCCTL) in microminipigs. METHODS The Committee for Animal Research and Welfare provided university approval. Five female microminipigs underwent DCCTL after inguinal lymph node injection of 0.1 mL/kg of iodine contrast media at a rate of 0.3 mL/min with three different iodine concentrations: group 1, 75 mgI/mL; group 2, 150 mgI/mL; and group 3, 300 mgI/mL. The CT values of the venous angle, thoracic duct (TD), cisterna chyli, iliac lymphatic duct, and iliac lymph node were measured; increases in CT values pre- to post-contrast were assessed as the contrast-enhanced index (CEI). Multi-detector row CT (MDCT) and volume rendering images showing the highest CEI were qualitatively evaluated. RESULTS The CEI of all lymphatics peaked at 5-10 min. The mean CEI of TD at 10 min of group 2 (193.0 HU) and group 3 (201.5 HU) were significantly higher than that of group 1 (70.7 HU) (p = 0.024). The continuity and overall diagnostic acceptability of all lymphatic system components were better in group 3 (3.6 and 3.0, respectively) than group 1 (2.6 and 1.6) and group 2 (3.0 and 2.6) (p = 0.249 and 0.204). CONCLUSIONS The optimal imaging protocol for intranodal DCCTL could be dual-phase imaging at 5 and 10 min after the injection of 300 mgI/mL iodinated contrast media. DCCTL provided good images of lymphatics and is potentially feasible in clinical settings. KEY POINTS • Dynamic contrast-enhanced computed tomography lymphangiography with intranodal injection of water-soluble iodine contrast media showed the highest enhancement of all lymphatics at scan delays of 5 and 10 min. • The optimal iodine concentration for intranodal dynamic contrast-enhanced computed tomography lymphangiography might be 300 mgI/mL. • Intranodal dynamic contrast-enhanced computed tomography lymphangiography provided good images of all the lymphatic system components and is potentially feasible in clinical settings.
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Affiliation(s)
- Yukichi Tanahashi
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
- Department of Diagnostic Radiology and Nuclear Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Ryota Iwasaki
- Animal Medical Center, Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
| | - Shinichi Shoda
- Radiology Service, Gifu University Hospital, Gifu, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomohiro Ando
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masaki Takasu
- Joint Department of Veterinary Medicine, Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
| | - Fuminori Hyodo
- Department of Frontier Science for Imaging, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Goshima
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
- Department of Diagnostic Radiology and Nuclear Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Takashi Mori
- Joint Department of Veterinary Medicine, Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
- Center for Highly Advanced Integration of Nano and Life Sciences, Gifu University (G-CHAIN), Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
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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.
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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
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42
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Dori Y, Smith CL, DeWitt AG, Srinivasan A, Krishnamurthy G, Escobar FA, Biko DM. Intramesenteric dynamic contrast pediatric MR lymphangiography: initial experience and comparison with intranodal and intrahepatic MR lymphangiography. Eur Radiol 2020; 30:5777-5784. [PMID: 32462442 DOI: 10.1007/s00330-020-06949-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/24/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To report on our initial experience with intramesenteric (IM) dynamic contrast magnetic resonance lymphangiography (DCMRL) for evaluation of the lymphatics in patients with concern for mesenteric lymphatic flow disorders and to compare IM-DCMRL with intrahepatic (IH) and intranodal (IN) DCMRL. METHODS This is a retrospective review of imaging findings in 15 consecutive patients who presented with protein losing enteropathy (PLE) and/or ascites undergoing IM-DCMRL, IH-DCMRL, and IN-DCMRL. The IM-DCMRL technique involves the injection of a gadolinium contrast agent into the mesenteric lymphatic ducts or lymph nodes followed by imaging of the abdomen and chest with dynamic time-resolved MR lymphangiography. RESULTS IM-DCMRL was successfully performed in 14/15 (93%) of the patients. When comparing IN-DCMRL with IM-DCMRL, there was a significant difference in the visualization of dermal backflow (p = 0.014), duodenal perfusion (p = 0.003), duodenal leak (p = 0.014), and peritoneal leak (p = 0.003). IM-DCMRL demonstrated peritoneal leak in 7 patients in contrast to IH-DCMRL which demonstrated leak in 4 patients and IN-DCMRL which did not demonstrate any peritoneal leaks. Duodenal leaks were seen by IH-DCMRL in 9 patients versus 5 with IM-DCMRL and none with IN-DCMRL. In one patient with congenital PLE, the three modalities showed different disconnected flow patterns with duodenal leak only seen by IM-DCMRL. There were no short-term complications from the procedures. CONCLUSIONS IM-DCMRL is a feasible imaging technique for evaluation of the mesenteric lymphatics. In certain mesenteric lymphatic flow abnormalities, such as PLE and ascites, this imaging may be helpful for diagnosis and the planning of interventions and warrants further studies. KEY POINTS • Intramesenteric dynamic contrast magnetic resonance lymphangiography (IM-DCMRL) is a new imaging technique to evaluate mesenteric lymphatic flow disorders such as ascites. • IM-DCMRL is able to image lymphatic leaks in patients with ascites and protein losing enteropathy not seen with intranodal (IN-DCMRL) imaging.
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Affiliation(s)
- Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Chris L Smith
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Aaron G DeWitt
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Fernando A Escobar
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Pieper CC, Feisst A, Schild HH. Contrast-enhanced Interstitial Transpedal MR Lymphangiography for Thoracic Chylous Effusions. Radiology 2020; 295:458-466. [PMID: 32208098 DOI: 10.1148/radiol.2020191593] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Abnormalities of the central lymphatic system (CLS) are increasingly treated by interventional radiology approaches. Planning of these procedures, however, is challenging because of the lack of clinical imaging tools. Purpose To evaluate the clinical usefulness of contrast agent-enhanced interstitial transpedal MR lymphangiography in the preinterventional workup of lymphatic interventions in patients with thoracic chylous effusions. Materials and Methods Patients with chylous effusions evaluated from January 2014 and December 2017 were included in this retrospective analysis of transpedal MR lymphangiography. Indications were chylothorax (n = 19; 76%), cervical lymphatic fistula (n = 2; 8%), and combined chylothorax and chylous ascites (n = 4; 16%). Patients underwent transpedal MR lymphangiography at 1.5 T with T1-weighted imaging after interstitial pedal of gadolinium-based contrast medium under local anesthesia. Contrast-enhanced MRI was evaluated for technical success, depiction of pathologic abnormalities of the CLS, and access site for lymphatic interventions (ie, clinically useful examination). Reader agreement for image quality and overall degree of visualization was assessed with weighted κ. Interrelations between overall image quality and degree of visualization of CLS structures were assessed by Spearman ρ. Efficacy of transpedal MR lymphangiography was calculated by using radiographic lymphangiography as the reference standard. Results Twenty-five patients (mean age, 54 years ± 18 [standard deviation]; 13 men) were evaluated. Eight percent (two of 25) of examinations failed (lymphoma in one patient and technical failure in one patient). Contrast agent injection was well tolerated without complications. Interrater agreement of image quality was excellent (κ = 0.96). The degree of CLS visualization correlated with overall image quality (ρ = 0.71; P < .001). Retroperitoneal lymphatics, cisterna chyli, and thoracic duct were viewed with an accuracy of 23 of 25 (92%), 24 of 25 (96%), and 23 of 25 (92%), respectively. Anatomic variations, a lymphatic pathologic abnormality, and interventional access routes were identified with an accuracy of 22 of 25 (88%), 23 of 25 (92%), and 24 of 25 (96%), respectively. Overall, 23 of 25 (92%) transpedal MR lymphangiograms provided clinically useful information. Conclusion Transpedal interstitial MR lymphangiography was well tolerated by the patient and identified specific pathologic abnormalities causing thoracic chylous leakages before lymphatic intervention. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Maki and Itkin in this issue.
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Affiliation(s)
- Claus C Pieper
- From the Department of Radiology, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Andreas Feisst
- From the Department of Radiology, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Hans H Schild
- From the Department of Radiology, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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Abstract
Single-ventricle physiology occurs in patients with hypoplastic ventricular heart defects, either on the right or left, who have undergone stepwise palliation surgeries ending with the Fontan procedure. After Fontan completion, these patients are dependent on passive venous return to the pulmonary circulation. The implications of passive flow are potentially devastating to the patient. We discuss some of the basic changes to the patient’s experience after a Fontan procedure, as well as the common complications. We also touch on some of the emerging management strategies for the common complications.
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Affiliation(s)
| | - Tabitha Moe
- Arizona Cardiology Group, Phoenix, AZ; Phoenix Children’s Hospital, Phoenix, AZ
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Vargas P, Horwitz B, Zamboni GP, Hasson D, Faure M, Soffia P, Salinas C. A Novel Technique for Thoracic Duct Access through MR Imaging/Ultrasound Fusion: Successful Percutaneous Embolization of Pulmonary Lymphatic Vessels. J Vasc Interv Radiol 2019; 31:184-187. [PMID: 31780196 DOI: 10.1016/j.jvir.2019.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/25/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Patricio Vargas
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Benjamin Horwitz
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Gian Paolo Zamboni
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Daniel Hasson
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Maria Faure
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Pablo Soffia
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
| | - Cesar Salinas
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, 7650568 Santiago, Chile
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Pan HP, Lao Q, Fei ZH, Yang L, Zhou HC, Lai C. MR Lymphangiography for Focal Disruption of the Thoracic Duct in Chylothorax of an Infant: a Case Report and Literature Review. ACTA ACUST UNITED AC 2019; 32:265-268. [PMID: 29301603 DOI: 10.24920/j1001-9294.2017.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chylothorax is a rare cause of pleural effusion in children, and it is usually difficult to identify the location of chyle leakage due to the small size of the thoracic duct in children. Herein we report an infant case with chylothorax whose leakage of the thoracic duct was successfully located by magnetic resonance lymphangiography (MRL) using pre-contrast MR cholangiopancreatography (MRCP) and gadodiamide-enhanced spectral presaturation inversion recovery (SPIR) T1-weighted imaging, which demonstrate the imaging method is easy and effective for detecting the focal disruption of the thoracic duct in children with chylothorax and younger than 8 months old.
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Affiliation(s)
- Hai-Peng Pan
- Department of Radiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China; Department of Radiology, Hangzhou Children's Hospital, Hangzhou 310014, China
| | - Qun Lao
- Department of Radiology, Hangzhou Children's Hospital, Hangzhou 310014, China
| | - Zheng-Hua Fei
- Department of Radiology, Huzhou Maternity & Child Care Hospital, Huzhou, Zhejiang 313000, China
| | - Li Yang
- Department of Radiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052
| | - Hai-Chun Zhou
- Department of Radiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052
| | - Can Lai
- Department of Radiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052
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47
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Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography and Percutaneous Lymphatic Embolization for the Diagnosis and Treatment of Recurrent Chyloptysis. J Vasc Interv Radiol 2019; 30:1135-1139. [DOI: 10.1016/j.jvir.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/23/2017] [Accepted: 11/05/2017] [Indexed: 11/21/2022] Open
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Ricci KW, Hammill AM, Mobberley-Schuman P, Nelson SC, Blatt J, Glade Bender JL, McCuaig CC, Synakiewicz A, Frieden IJ, Adams DM. Efficacy of systemic sirolimus in the treatment of generalized lymphatic anomaly and Gorham-Stout disease. Pediatr Blood Cancer 2019; 66:e27614. [PMID: 30672136 PMCID: PMC6428616 DOI: 10.1002/pbc.27614] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/15/2018] [Accepted: 12/28/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Generalized lymphatic anomaly (GLA) and Gorham-Stout disease (GSD) are rare complicated lymphatic malformations that occur in multiple body sites and are associated with significant morbidity and mortality. Treatment options have been limited, and conventional medical therapies have been generally ineffective. Emerging data suggest a role for sirolimus as a treatment option for complex lymphatic anomalies. PROCEDURE Disease response was evaluated by radiologic imaging, quality of life (QOL), and clinical status assessments in children and young adults with GLA and GSD from a multicenter systematic retrospective review of patients treated with oral sirolimus and the prospective phase 2 clinical trial assessing the efficacy and safety of sirolimus in complicated vascular anomalies (NCT00975819). Sirolimus dosing regimens and toxicities were also assessed. RESULTS Eighteen children and young adults with GLA (n = 13) or GSD (n = 5) received oral sirolimus. Fifteen patients (83%) had improvement in one or more aspects of their disease (QOL 78%, clinical status 72%, imaging 28%). No patients with bone involvement had progression of bone disease, and the majority had symptom or functional improvement on sirolimus. Improvement of pleural and pericardial effusion(s) occurred in 72% and 50% of affected patients; no effusions worsened on treatment. CONCLUSIONS Sirolimus appears effective at stabilizing or reducing signs/symptoms of disease in patients with GLA and GSD. Functional impairment and/or QOL improved in the majority of individuals with GLA and GSD with sirolimus treatment.
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Affiliation(s)
- Kiersten W. Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adrienne M. Hammill
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paula Mobberley-Schuman
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephen C. Nelson
- Department of Pediatric Hematology and Oncology, Children’s Minnesota Hematology Oncology, Minneapolis, Minnesota
| | - Julie Blatt
- Division of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Julia L. Glade Bender
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York City, New York
| | | | - Anna Synakiewicz
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ilona J. Frieden
- Department of Dermatology, University of California, San Francisco, San Francisco, California
| | - Denise M. Adams
- Vascular Anomalies Center, Division of Hematology, Cancer and Blood Disorders Center, Boston Children’s Hospital, Boston, Massachusetts
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Iwamura R, Sakamoto M, Mori S, Kodama T. Imaging of the Mouse Lymphatic Sinus during Early Stage Lymph Node Metastasis Using Intranodal Lymphangiography with X-ray Micro-computed Tomography. Mol Imaging Biol 2019; 21:825-834. [DOI: 10.1007/s11307-018-01303-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Geanacopoulos AT, Savla JJ, Pogoriler J, Piccione J, Phinizy P, DeWitt AG, Blinder JJ, Pinto E, Itkin M, Dori Y, Goldfarb SB. Bronchoscopic and histologic findings during lymphatic intervention for plastic bronchitis. Pediatr Pulmonol 2018; 53:1574-1581. [PMID: 30207430 PMCID: PMC6309194 DOI: 10.1002/ppul.24161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/13/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Percutaneous lymphatic intervention (PCL) is a promising new therapy for plastic bronchitis (PB). We characterized bronchoalveolar lavage (BAL) and cast morphology in surgically repaired congenital heart disease (CHD) patients with PB during PCL. We quantified respiratory and bronchoscopic characteristics and correlated them with post-intervention respiratory outcomes. METHODS We retrospectively reviewed patients with PB and surgically repaired CHD undergoing PCL and bronchoscopy at our institution. Pre-intervention characteristics, bronchoscopy notes, BAL cell counts, virology, and cultures were collected. A pathologist blinded to clinical data reviewed cast specimens. Respiratory outcomes were evaluated through standardized telephone questionnaire. RESULTS Sixty-two patients were included with a median follow-up of 20 months. No patients experienced airway bleeding, obstruction, or prolonged intubation related to bronchoscopy. Of BAL infectious studies, the positive results were 4 (8%) fungal, 6 (11%) bacterial, and 6 (14%) viral. Median BAL count per 100 cells for neutrophils, lymphocytes, and eosinophils were 13, 10, and 0, respectively. Of 23 bronchial casts analyzed, all contained lymphocytes, and 19 (83%) were proteinaceous, with 14 containing neutrophils and/or eosinophils. Median BAL neutrophil count was greater in patients with proteinaceous neutrophilic or eosinophilic casts compared to casts without neutrophils or lymphocytes (P = 0.030). Post-intervention, there was a significant reduction in respiratory medications and support and casting frequency. CONCLUSIONS The predominance of neutrophilic proteinaceous casts and high percentage of positive BAL infectious studies support short-term fibrinolytic and anti-infective therapies in PB in select patients. Flexible bronchoscopy enables safe assessment of cast burden. PCL effectively treats PB and reduces respiratory therapies.
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Affiliation(s)
| | - Jill J Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer Pogoriler
- Division of Anatomic Pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Piccione
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pelton Phinizy
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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