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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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Zhao Q, Sun X, Liu K, Peng Y, Jin D, Shen W, Wang R. Correlation between capsule endoscopy classification and CT lymphangiography of primary intestinal lymphangiectasia. Clin Radiol 2023; 78:219-226. [PMID: 36509551 DOI: 10.1016/j.crad.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/21/2022] [Accepted: 10/05/2022] [Indexed: 12/13/2022]
Abstract
AIM To investigate the correlation between capsule endoscopy (CE) classification of primary intestinal lymphangiectasia (PIL) and computed tomography (CT) lymphangiography (CTL). MATERIALS AND METHODS A total of 52 patients with diagnosed PIL were enrolled. All patients were examined using CTL and small intestinal CE before surgery. CE assessments included the morphology, scope, colour, and size of lesions. CTL assessments included intestinal wall, lymphatic vessel dilatation, lymph fluid reflux, and lymphatic fistula. Patients were divided into three groups according to type diagnosed by CE, and the CTL characteristics were analysed among the groups. RESULTS CE showed 15 patients with type I, 27 with II, and 10 with type III. Intestinal wall thickening was observed in 15 type I, 21 type II, and seven type III. Pericardial effusion was observed in only three type I patients; the difference among types was statistically significant (p=0.02). Abnormal contrast agent distribution in the intestinal wall and mesentery was observed in 15 type II patients, and the difference was significantly greater than that of types I and III (p=0.02). Abnormal contrast agent distribution in the abdominal cavity was observed in 12 type II, and the difference was statistically significant (p=0.03). CONCLUSION The CE PIL classification reflects the extent and scope of intestinal mucosa lesions; CTL more systematically demonstrates abnormal lymphatic vessels or reflux, and its manifestations of PIL are related to the CE classification. The combination of CTL with CE is useful for accurately evaluating PIL, and provides guidance for preoperative assessment and treatment management of PIL patients.
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Affiliation(s)
- Q Zhao
- Department of Radiology, Peking University Ninth School of Clinical Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - X Sun
- Department of Radiology, Peking University Ninth School of Clinical Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - K Liu
- Department of Gastroenterology, Peking University Ninth School of Clinical Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Y Peng
- Beijing Jiaotong University, China
| | - D Jin
- Peking University Third Hospital, China
| | - W Shen
- Department of Lymph Surgery, Peking University Ninth School of Clinical Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - R Wang
- Department of Radiology, Peking University Ninth School of Clinical Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
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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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Ur Rehman K, Sivakumar P. Non-traumatic chylothorax: diagnostic and therapeutic strategies. Breathe (Sheff) 2022; 18:210163. [PMID: 36337134 PMCID: PMC9584559 DOI: 10.1183/20734735.0163-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/31/2022] [Indexed: 12/04/2022] Open
Abstract
Non-traumatic chylothorax refers to accumulation of chyle in the pleural space in the absence of any traumatic disruption to the thoracic duct. Chyle originates from the intestines and is transported via the thoracic duct into systemic circulation. The anatomical course of the thoracic duct is complex with considerable variation; therefore, development of chylothorax is dependent on the site and level of the thoracic duct defect. Non-traumatic chylothorax is associated with a wide range of medical disorders, but malignancy accounts for three-quarters of cases. In up to 9% of cases, the aetiology remains unknown (termed idiopathic chylothorax). Gross appearance of pleural fluid is neither sensitive nor specific enough to diagnose chylothorax; therefore, biochemical analysis of the pleural fluid is required. Pleural fluid triglyceride level >1.24 mmol·L−1 (110 mg·dL−1) with a cholesterol level <5.18 mmol·L−1 (200 mg·dL−1) is diagnostic of chylothorax. In borderline cases, lipoprotein electrophoresis can help confirm the diagnosis by detecting chylomicrons in the pleural fluid. Once the diagnosis of chylothorax is confirmed, the next step is to find the cause and identify the leakage point, for which various lymphatic specific radiological investigations may have an important role. There is paucity of data on the most suitable approach to manage non-traumatic chylothoraces and treatment often depends on the underlying cause. In general, conservative treatment is tried first, usually for a limited time, before considering more invasive measures. A multidisciplinary approach is recommended with close liaison among the respiratory physicians, thoracic surgeons, oncologists, interventional radiologists, dietitians and pharmacists. Non-traumatic chylothorax is associated with a myriad of medical disorders. Lipid analysis of pleural fluid is required to confirm the diagnosis. A multidisciplinary approach is recommended for the effective management of non-traumatic chylothorax. https://bit.ly/3Nssb7n
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Pan F, Loos M, Do TD, Richter GM, Kauczor HU, Hackert T, Sommer CM. The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series. CVIR Endovasc 2020; 3:79. [PMID: 33085018 PMCID: PMC7578215 DOI: 10.1186/s42155-020-00146-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/03/2020] [Indexed: 01/30/2023] Open
Abstract
In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.
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Affiliation(s)
- F Pan
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany.,Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - M Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - T D Do
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - G M Richter
- Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - H U Kauczor
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - C M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany. .,Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
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González García FJ, Baamonde Laborda C, Muñoz Fos A, Moreno Casado P, Redel Montero J, Algar Algar J, Cerezo Madueño F, Poveda Chaves D, Ruiz López E, Salvatierra Velázquez Á, Álvarez Kindelán A. Tratamiento quirúrgico de quilotórax postrasplante pulmonar por linfangioleiomiomatosis. Arch Bronconeumol 2020. [DOI: 10.1016/j.arbres.2019.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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González García FJ, Baamonde Laborda C, Muñoz Fos A, Moreno Casado P, Redel Montero J, Algar Algar J, Cerezo Madueño F, Poveda Chaves D, Ruiz López E, Salvatierra Velázquez Á, Álvarez Kindelán A. Surgical Treatment of Chylothorax After Lung Transplantation for Lymphangioleiomyomatosis. Arch Bronconeumol 2020; 56:335-336. [PMID: 35373745 DOI: 10.1016/j.arbr.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/13/2019] [Indexed: 06/14/2023]
Affiliation(s)
| | | | - Anna Muñoz Fos
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
| | - Paula Moreno Casado
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
| | - Javier Redel Montero
- Servicio de Neumología y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
| | - Javier Algar Algar
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
| | | | - David Poveda Chaves
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
| | - Eloisa Ruiz López
- Servicio de Cirugía Torácica y Trasplante Pulmonar, Hospital Reina Sofía, Córdoba, Spain
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Jin D, Sun X, Shen W, Zhao Q, Wang R. Diagnosis of Lymphangiomatosis: A Study Based on CT Lymphangiography. Acad Radiol 2020; 27:219-226. [PMID: 31076330 DOI: 10.1016/j.acra.2019.03.024] [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] [Received: 09/28/2018] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 11/15/2022]
Abstract
RATIONALE AND OBJECTIVES Lymphangiomatosis is a rare disease characterized by the widespread presence of lymphangiomas in any part of the body. In previous studies, lymphatic vessel abnormalities in lymphangiomatosis have only rarely been mentioned. The objective of this paper is to discuss the imaging features of lymphangiomatosis, including cystic lesions and lymphatic abnormalities, on computed tomography lymphangiography (CTL). MATERIALS AND METHODS All 34 patients who were diagnosed with lymphangiomatosis underwent direct lymphangiography followed by CTL. The CTL images were independently analyzed by two experienced radiologists. The CTL image analyses included assessment of the features of cystic lesions and lymphatic vessel abnormalities. RESULTS (i) CTL revealed several cystic lesions ranging in size from 3 mm to 14 cm; the lesions were located in the neck and shoulders (61.8%), mediastinum (52.9%), retroperitoneum (70.6%), and pelvis and perineum (64.7%). (ii) Approximately 29.4% of patients showed abnormal contrast medium accumulation in cystic masses. (iii) Approximately 67.6% of patients showed lymphatic reflux. (iv) Dilated lymphatic vessels were distributed in the mediastinum (38.2%), retroperitoneum (50.0%), pelvis and lower limbs (47.1%). (v) Finally, 8.8% of patients had perineal lymphatic fistulae, and 2.9% of patients had chyluria. CONCLUSION Lymphangiomatosis is a type of systemic lymphatic abnormality that is accompanied by multiple cystic lesions. The therapeutic measures for lymphangiomatosis are determined by the size of the cystic lesions. Furthermore, the prognosis of lymphangiomatosis is affected by lymphatic abnormalities.
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Affiliation(s)
- Dan Jin
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Capital Medical University, No. 10 Tieyi St, Haidian District, Beijing 100038, PR China
| | - Xiaoli Sun
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Capital Medical University, No. 10 Tieyi St, Haidian District, Beijing 100038, PR China
| | - Wenbin Shen
- Department of Lymph Surgery, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Capital Medical University, Beijing, PR China
| | - Qingqing Zhao
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Capital Medical University, No. 10 Tieyi St, Haidian District, Beijing 100038, PR China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Capital Medical University, No. 10 Tieyi St, Haidian District, Beijing 100038, PR China.
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Asao S, Lombard CM, Tsau P. Pulmonary lymphangioleiomyomatosis with parietal pleural involvement: A case report and discussion of pathogenesis using pulmonary lymphangitic carcinomatosis as a model. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2018.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Lymphangioleiomyomatosis is a rare disorder that predominantly affects women and is characterized by progressive cystic changes in the lung, leading to gradually worsening shortness of breath and lung function impairment. Pleural complications such as pneumothorax and chylothorax commonly occur in these patients. Lymphangioleiomyomatosis can occur as a form of lung involvement in tuberous sclerosis complex or as a sporadic form (without tuberous sclerosis complex). Etiology in both forms of this disease centers on mutations in the tuberous sclerosis genes. Advances in our understanding of the regulatory role of tuberous sclerosis gene products (hamartin/tuberin) in the mechanistic target of rapamycin (mTOR) signaling pathway have led to the identification of effective therapy (mTOR inhibitors) for a rare disorder, once considered uniformly fatal. Here, we summarize the evolution of current concepts regarding lymphangioleiomyomatosis with an emphasis on recent advances and unresolved issues.
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Affiliation(s)
- Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
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