European Journal of Radiology 101 (2018) 129–135

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Dynamic contrast enhanced magnetic resonance lymphangiography: T

Categorization of imaging findings and correlation with patient
management
⁎
Sheena Pimpalwara, , Ponraj Chinnaduraib, Alex Chaua, Mercedes Pereyrac, Daniel Ashtona,
Prakash Masandc, Rajesh Krishnamurthyd, Siddharth Jadhavc
a
Division of Interventional Radiology, Department of Radiology, Texas Children’s Hospital, 6621 Fannin Street, Houston, TX 77030, USA
b
Advanced Therapies, Siemens Medical Solutions USA Inc., Hoffman Estates, IL, USA
c
Department of Radiology, Texas Children’s Hospital, 6621 Fannin Street, Houston, TX 77030, USA
d
Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To review the technical aspects and categorize the imaging findings of dynamic contrast enhanced
MR lymphangiography magnetic resonance lymphangiography (DCMRL) and correlate the findings with patient management options.
Intra-nodal lymphangiography Materials and methods: A retrospective review of patients who underwent DCMRL between June 2012 and
Central conducting lymphatics August 2017 at a tertiary care paediatric hospital was performed. Twenty-five DCMRL studies were performed in
Chylothorax
23 patients (9 males, 13 females, 1 ambiguous gender) with a median age of 4 years (range: 1 month–29 years).
Chylous ascites
DCMRL imaging findings were reviewed, categorized and the impact on patient management was studied.
Results: DCMRL was technically successful in 23/25 (92%) studies. DCMRL findings were categorized based on
the status of central conducting lymphatics (CCL) and alternate lymphatic pathways as follows: Type 1 – normal
CCL with no alternate lymphatic pathways, Type 2 – partial (2a) or complete (2b) non-visualization of CCL with
reflux of contrast into alternate pathways and Type 3 – normal CCL with additional filling of alternate pathways.
Type 1 DCMRL patients (n = 5) were reassured and conservative management was continued, Type 2 patients
(n = 10) had evidence of CCL obstruction hence thoracic duct ligation or embolization was avoided and other
options such as lymphatic fluid diversion using Denver® shunt or lympho-venous anastomosis were used, and
Type 3 patients (n = 8) were evaluated for elevated central venous pressure as a cause of lymphatic backflow in
addition to Denver® shunt, lympho-venous anastomosis, thoracic duct ligation or embolization.
Conclusion: DCMRL is an evolving imaging technique for understanding abnormalities of the central conducting
lymphatics. Categorization of imaging findings may be helpful in guiding selection of management options.

1. Introduction
Disorders of the lymphatic system present as a wide clinical spec-
trum from self-limiting traumatic leaks easily managed by conservative
methods to multi-system disorders that are progressive, unresponsive to
currently available treatment options and often result in death from
malnutrition or infection. Imaging techniques of the central conducting
lymphatics (CCL) have undergone major developments in the recent
years since the first application of intra-nodal injection of contrast
agents for dynamic study of the CCL [1–10]. The combination of intra-
nodal injection of gadolinium and simultaneous dynamic acquisition of
MR images of the chest and abdomen has led to a new lymphatic
imaging technique called dynamic contrast enhanced magnetic re-
sonance lymphangiography (DCMRL). This technique provides a time
resolved study of lymphatic flow with good spatial resolution. It is
particularly useful in patients with right-to-left intra- and extra-cardiac
shunts who could develop cerebral embolism from the use of conven-
tional iodinated oil-based contrast agent for lymphatic imaging [4].
Since the utilization of this technique has increased, new insights into
patterns of lymphatic flow in different clinical conditions and their
implications on patient management are evolving [8,9]. The purpose of
this study is to retrospectively review technical aspects, categorize

⁎
Corresponding author at: 3765 Drummond Street, Houston, TX 77025, USA.
E-mail addresses: pimpalwars@health.missouri.edu (S. Pimpalwar), ponraj.chinnadurai@siemens.com (P. Chinnadurai), axchau@texaschildrens.org (A. Chau),
mmpereyr@texaschildrens.org (M. Pereyra), djashton@texaschildrens.org (D. Ashton), pmmasand@texaschildrens.org (P. Masand),
rajesh.krishnamurthy@nationwidechildrens.org (R. Krishnamurthy), spjadhav@texaschildrens.org (S. Jadhav).

https://doi.org/10.1016/j.ejrad.2018.02.021
Received 15 January 2018; Received in revised form 12 February 2018; Accepted 14 February 2018
0720-048X/ © 2018 Elsevier B.V. All rights reserved.
 S. Pimpalwar et al.

Table 1
Clinical diagnosis, DCMRL indication, DCMRL type, patient management and outcome in 23 patients.

Patient Clinical diagnosis Indication for DCMRL DCMRL Type Patient management Outcome

1 post resection of pancreatic SPEN PLE, lymphedema 1 SMV stent for stenosis, SMV bypass graft unchanged PLE and lymphedema
tumor
2 abdominal chylous LM failed sclerotherapy 1 Sirolimus, Sorafenib metastatic angiosarcoma, died in 9 months
3 lymphedema lymphedema 1 compression stocking, lymphatic massage unchanged lymphedema
4 Nemaline myopathy chylothorax 1 chest tube resolution of chylothorax
5 ASD, PDA, pulmonary valve stenosis post-op chylothorax 1 TPN, chest tube resolution of chylothorax
6 prematurity, congenital heart disease chylous ascites 2a TPN, Sirolimus, abdominal drainage unchanged ascites
7 heterotaxy, TAPVR, single ventricle, chylothorax, chylous ascites, plastic bronchitis, PLE 2a TPN, chest tube orthotopic heart transplant
Fontan
8 Single ventricle, Glenn (12 mmHg), post-op chylothorax 2a TPN, chest tube resolution of chylothorax
PHT, CHF
9 GLA chylothorax, chylous ascites, PLE, lymphedema, 2a compression stocking, lymphatic massage, improvement in chylothorax,lymphedema and PLE
Sirolimus, LVA
10 GLA, post TD ligation and pleurodesis chylothorax, lymphedema 2a diuretics, TPN, chest tube progressive disease, died in 30 months
11 lymphedema post liver transplant lymphedema 2a compression stocking, lymphatic massage, unchanged lymphedema
Sirolimus, LVA evaluation

130
12 lymphedema lymphedema 2b compression stocking, lymphatic massage, LVA unchanged lymphedema
evaluation
13 GLA (2 DCMRL studies) abdominal wall edema, lymphorrea from labia 2b (n = 2) sclerotherapy, Sirolimus, Interferon, Denver® Shunt cessation of lymphorrea
14 GLA chylothorax, chylous ascites, lymphedema, scrotal 2b lymphatic massage, Sirolimus, Interferon, LVA cessation of lymphorrea, persistent chylothorax and chylous
wall lymphorrea evaluation ascites
15 HLHS, Fontan (18 mmHg), PHT post-op chylothorax 3 TPN, Octreotide, chest tube resolution of chylothorax
16 HLHS, Glenn, (15–22 mmHg) PHT, post-op chylothorax 3 TPN, chest tube, central venous thrombectomy and resolution of chylothorax
CVT angioplasty
17 Orthotopic heart transplant, PHT, post-op chylothorax 3 TPN, venous angiolasty, pleurodesis,TDE resolution of chylothorax
CHF, CVT
18 GLA chylothorax PLE 3 TPN, Sirolimus, chest tube progressive disease, died in 9 months
19 GLA (2 DCMRL studies) chylothorax, chylopericardium 3 (n = 2) TPN, chest tube, Sirolimus, Denver® Shunt progressive disease, died in 15 months
20 lymphedema lymphedema, lymphorrea right groin 3 compression stocking, lymphatic massage improvement in lymphedema, occasional lymphorrea
21 Single ventricle, Glenn (11 mmHg) chylothorax 3 TPN, chest tube improvement in chylothorax
22 Weaver syndrome chylothorax Technical failure low fat diet, chest tube resolution of chylothorax
23 Pulmonary atresia, Glenn post-op chylothorax Technical failure TPN, chest tube, pleurodesis resolution of chylothorax

Abbreviations;: SPEN: Solid pseudopapillary epithelial neoplasm, SMV: superior mesenteric vein, GLA: Generalized lymphatic anomaly, LM: lymphatic malformation, PLE: protein losing enteropathy, PHT: pulmonary hypertension; CHF: congestive
heart failure; CVT: central venous thrombosis; post-op: post operative, TPN: total parenteral nutrition, TD: thoracic duct, TDE: thoracic duct embolization, LVA: lympho-venous anastomosis, HLHS: Hypoplastic left heart syndrome, ASD: atrial septal,
defect, PDA: patent ductus arteriosus, TAPVR: total anomalous pulmonary venous return.
European Journal of Radiology 101 (2018) 129–135
S. Pimpalwar et al. European Journal of Radiology 101 (2018) 129–135

Table 2
Contrast transit time, DCMRL imaging time and total procedure time in 23 technically successful DCMRL studies.

DCMRL study # DCMRL Type Transit time to lumbar Transit time to cisterna Transit time to TD entry into MRI imaging time Total procedure time
lymphatics (min) chyli (min) venous angle (min) (min) (min)

1 1 15 15 15 43 191*
2 1 3 4 8 35 272*
3 1 4 5 6 33 215
4 1 2 3 5 31 167
5 1 12 18 26 50 234
6 2a 13 19 obstructed at diaphragm 49 120
7 2a 7 12 obstructed at mid-thoracic level 57 162
8 2a 6 6 6 36 237
9 2a 1 1 obstructed at mid-thoracic level 32 133
10 2a 4 4 obstructed at diaphragm 59 178*
11 2a 1 9 obstructed at mid-thoracic level 61 151
12 2b not seen not seen not seen 61 111
13 2b not seen not seen not seen 50 169
14 2b not seen not seen not seen 48 144
15 2b not seen not seen not seen 40 131
16 3 12 13 13 66 272
17 3 1 1 3 33 166
18 3 3 4 6 36 196
19 3 1 4 4 48 108
20 3 5 8 8 51 177*
21 3 10 10 10 67 191*
22 3 8 13 13 64 159
23 3 11 11 11 44 140

* Studies with additional MR imaging.

imaging findings of DCMRL and correlate the findings with patient

management options.

2. Materials and methods

A retrospective chart review of all patients who underwent DCMRL

between June 2012 and August 2017 at a tertiary care paediatric hos-
pital was performed after institutional review board approval. Twenty-
five DCMRL studies were performed in 23 patients (9 males, 13 females,
1 ambiguous gender) with a median age of 4 years (range: 1 month–29
years). Ten out of 25 (40%) studies were performed in patients with
right-to-left intra- or extra-cardiac shunts. Clinical diagnosis, DCMRL
indication, DCMRL type, patient management and outcome are sum-
marized in Table 1.

2.1. DCMRL technique

All studies were performed on 1.5T MRI (Magnetic Resonance

Fig. 1. 20-year-old-girl presented with lymphedema of the hands and feet and protein
losing enteropathy 11 years after resection of pancreatic tumor. Coronal MIP re-
construction of DCMRL image shows lumbar lymphatics, cisterna chyli and thoracic duct
with no filling of alternate pathways suggestive of Type 1 DCMRL.
Imaging) scanner (Achieva® or Ingenia®, Philips Healthcare, Best,
Netherlands) using previously described technique and imaging pro-
tocol [5]. The patient was positioned on a dockable table atop the
posterior coil just outside the MRI scanner room. Either unilateral
(n = 5) or bilateral (n = 20) inguinal nodes were accessed with 25G
needles using ultrasound guidance under local (n = 2) or general an-
esthesia (n = 23). The anterior coil was placed on a dome shaped
plastic shield over the patient to protect the sterile field and to prevent
needle dislodgement. The patient was then transferred to the MRI
scanner room and a baseline coronal 3D THRIVE® (T1 weighted high
resolution imaging with volume excitation) sequence was performed
with breath hold (by anesthesiologist inside the MRI scanner room).
This was followed by slow intermittent intra-nodal hand injection of 1:1
or 1:2 saline diluted gadopentetate dimeglumine (0.1–0.2 mmol/kg;
Magnevist®, Bayer HealthCare Pharmaceuticals, Wayne, NJ) and si-
multaneous acquisitions of 3D THRIVE® sequences at 1–2 min intervals
until visualization of the thoracic duct (TD) entry into the venous angle.
Additional MRI sequences were obtained to supplement DCMRL as
needed (0.2 mmol/kg gadolinium was divided equally between the two
studies if contrast was needed for the additional imaging).
Findings of DCMRL such as visualization of CCL (lumbar

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Fig. 2. 11-year-old boy with heterotaxy, single ventricle, post Fontan surgery presented with chylothorax, chylous ascites, protein losing enteropathy and plastic bronchitis. Coronal MIP
reconstruction of DCMRL images shows progressive filling of lumbar lymphatics (black arrows) and thoracic duct, duct obstruction at mid-thoracic level (white arrows) and alternate
pathways such as peri-hilar and peri-bronchial lymphatics (black asterisks) suggestive of Type 2a DCMRL. The time interval between intra-nodal contrast injection and image acquisition
is shown on the top of each image.

Fig. 3. 6-year-old girl with Generalized Lymphatic Anomaly presented with pitting edema of the lower abdominal wall and chylorrhea from hypertrophied left labia majora. a) Coronal
MIP reconstruction of DCMRL images shows complete lack of visualization of central conducting lymphatics and filling of dilated lymphatics within the abdominal wall (white arrow) and
labia (white arrowhead) suggestive of Type 2b DCMRL. b–d) Coronal MIP reconstruction of DCMRL images after placement of a Denver® shunt shows internal drainage of contrast into the
peritoneal cavity (white asterisk).

lymphatics, cisterna chyli and TD), alternate lymphatic pathways and
contrast leak into the pleura or peritoneum were reviewed and cate-
gorized using Vitrea® (Vital images, MN) and syngo X-workplace®
(Siemens Medical Solutions USA Inc., IL) by two radiologists (in con-
sensus) blinded to the clinical indication. To understand the dynamicity
of lymphatic flow, contrast transit time defined as the time interval be-
tween intra-nodal contrast injection and visualization of CCL was re-
corded. To understand the impact on scanner utilization, DCMRL ima-
ging time (time between survey scan and last DCMRL acquisition) and
total procedure time was recorded. DCMRL imaging findings were ca-
tegorized based on the status of CCL and alternate lymphatic pathways
and the impact on patient management was observed.
3. Results
Since ultrasound performed after aborting both studies revealed un-
changed intra-nodal needle position, the cause of extravasation was
thought to be secondary to capsular rupture from volume or pressure
overload of the accessed inguinal lymph node. Contrast transit time,
DCMRL imaging time and total procedure time are summarized in
Table 2. The median transit time from injection of intra-nodal contrast
to visualization of lumbar lymphatics in 19/23 studies was 5 min
(range: 1–15), cisterna chyli in 19/23 studies was 8 min (range: 1–19)
and TD entry into the venous angle in 14/23 studies was 8 min (range:
3–26). The median imaging time for DCMRL was 48 min (range: 31–67)
and the median total procedure time was 167 min (range: 108–272).
Additional imaging such as MR angiography of the chest (n = 2), MRI
abdomen (n = 1), MR venography of the abdomen (n = 1) and MRI of
extremity bone lesions (n = 1) was performed during the same session
in 5/23 studies.

DCMRL was technically successful in 23 out of 25 (92%) studies.

Two technical failures were due to extra-nodal contrast extravasation.

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S. Pimpalwar et al.
3.1. Categorization of DCMRL imaging findings
DCMRL imaging findings were categorized into three types based on
the status of CCL and alternate lymphatic pathways:
Type 1 (n = 5) – normal visualization of CCL and absence of filling
of alternate lymphatic pathways (Fig. 1);
Type 2 – partial or complete non-visualization of CCL further sub-
divided into: Type 2a (n = 6) – partial non-visualization of CCL with
reflux of contrast into alternate pathways such as mediastinal, peri-
hilar, pleural, pericardial, intercostal, cervical, peri-portal, chest or
abdominal wall lymphatics (Fig. 2 and Video S1) and Type 2b (n = 4) –
complete non-visualization of CCL with filling of abnormally dilated
lymphatics in the body wall, pelvis or retroperitoneum (Fig. 3);
Type 3 (n = 8) – normal visualization of CCL with additional filling
of alternate lymphatic pathways (Fig. 4).
Alternate lymphatic pathways such as cervical (n = 7), mediastinal
(n = 14), peri-bronchial (n = 4), pericardial (n = 6), intercostal
(n = 5), diaphragmatic (n = 4), peri-portal (n = 1), retroperitoneal
(n = 7), chest or abdominal wall (n = 6) were visualized in patients
with Type 2 or Type 3 DCMRL (Fig. 5). The right lymphatic duct was
seen in 5/23 studies (Fig. 5). Contrast extravasation into the pleural
space was seen in 5/15 studies performed for chylothorax (Fig. 5).
3.2. Correlation of imaging findings and patient management
DCMRL findings were correlated with the selection of patient
management options (Table 3). Patients with Type 1 DCMRL were re-
assured and conservative management was continued. This included
low fat medium-chain triglyceride diet, total parenteral nutrition, in-
travenous octreotide, external drainage of chylous fluid, medical
management of protein, fluid and electrolyte balance, compression
stockings and lymphatic massage depending on the clinical presenta-
tion. Patients with Type 2 DCMRL demonstrated obstruction of the CCL,
hence further interruption of the CCL with TD ligation or embolization
was considered as a relative contraindication. These patients were
managed with internal drainage using Denver® shunt or surgical
lympho-venous anastomosis in addition to above mentioned
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European Journal of Radiology 101 (2018) 129–135
Fig. 4. 1.5-month old girl post orthotopic heart transplant presented with
bilateral chylothorax. Coronal MIP reconstruction of DCMRL (performed
via right inguinal node access) shows normal filling of thoracic duct (white
arrow) and additional filling of alternate lymphatics such as cervical (black
asterisk), and intercostal (black arrowhead) lymphatics suggestive of Type 3
DCMRL. Note extravasation of contrast into the right pleural space.
conservative measures. Patients with Type 3 DCMRL were considered
candidates for TD ligation or embolization when conservative man-
agement failed. Furthermore, patients with Type 3 DCMRL with single
ventricle physiology or heart transplant were also evaluated and man-
aged for congestive heart failure, central venous obstruction, pul-
monary hypertension and elevated Glenn or Fontan pressures as a cause
of lymphatic backflow into collateral pathways.
4. Discussion
Imaging of the CCL using DCMRL is a novel technique that has
evolved in the recent years [7–9,11,12]. Dori et al. first demonstrated
the feasibility of DCMRL in a swine model using intra-nodal injection of
gadopentetate dimeglumine [13]. Their study showed dynamic images
of the central lymphatic system, and demonstrated the time course of
flow of contrast agent within the central lymphatic ducts. Krishna-
murthy et al. demonstrated their technique and first clinical application
of DCMRL in six patients [5]. Time resolved images of lymphatic transit
through the CCL obtained using this DCMRL technique was helpful in
clinical decision making. Dori et al. further elucidated the spectrum of
findings on DCMRL and their utilization for planning lymphatic inter-
ventions [12]. The authors described the findings of DCMRL in trau-
matic and non-traumatic chylous leaks, and lymphatic conduction
disorders such as plastic bronchitis, pulmonary lymphatic perfusion
syndrome, neonatal chylothorax and congenital lymphatic dysplasia in
their review.
In the present study, a few repetitive patterns of DCMRL imaging
findings were recognized despite a wide spectrum of clinical indications
and presentations. These findings were categorized and correlated with
patient management. This image-based categorization could help with
formulation of an approach towards selection of patient management
options. This method could also complement the pathology based
classification described by Dori et al. [12].
In the DCMRL study on swine by Dori et al., the median time for
flow of the contrast to the TD entry into the venous angle was 244 s
(range, 201–387 s) [13]. Chavhan et al. reported typical visualization of
retroperitoneal lymphatics at the aortic bifurcation at approximately
S. Pimpalwar et al. European Journal of Radiology 101 (2018) 129–135

Fig. 5. Alternate lymphatic pathways visualized by DCMRL.

a) Coronal MIP reconstruction image of Type 2a DCMRL shows peri-portal (white arrowhead), and diaphragmatic (black arrowhead) lymphatics. Note the abdominal wall lymphatics (white
asterisks) and drainage into left axillary lymph node. b) Coronal MIP reconstruction image of Type 3 DCMRL shows thoracic duct and right lymphatic duct (white arrow). Note the reflux
into right retroperitoneal lymphatics (black arrow). c) Coronal MIP reconstruction image of Type 2a DCMRL shows peri-bronchial reflux in a patient with plastic bronchitis. d) Coronal
MIP reconstruction image of Type 3 DCMRL shows bilateral pleural contrast extravasation.

Table 3
Correlation of DCMRL types and selection of patient management options.

S. No Patient Management Options Type 1 Type 2a Type 2b Type 3

1 Continue conservative management. + + + +

2 Diversion of lymphatic fluid using Denver shunt. – + + +
3 Diversion of lymphatic fluid using lympho-venous anastomosis. – + + –
4 Recanalization and reconstruction of obstructed CCL – + + –
5 Imaging, evaluation and management of central venous obstruction – – – +
6 Imaging, evaluation and management of elevated central venous pressure – – – +
7 Thoracic duct ligation or embolization – x x +

+ (considered), − (not-considered), x (contra-indicated).

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S. Pimpalwar et al.
2 min and cisterna chyli at 3–6 min after the initiation of intra-nodal
contrast injection. In their experience, TD entry into the venous angle
was typically visualized within 2–3 min after visualization of the cis-
terna chyli [10]. In the present study there was a wide variation of
transit times (Table 2) precluding interpretation of normal versus ab-
normal transit times. Further studies with larger sample sizes would be
helpful in defining normal range of transit times of lymphatic flow. This
dynamic information of lymphatic flow could help with further opti-
mization of image acquisition techniques. In the present study, the total
procedure was an average of 2.5 h due to multiple reasons such as
administration of general anesthesia, lymph node cannulation using
sterile technique, careful patient positioning with needles in situ into
the MRI scanner and optimization of imaging parameters on the base-
line scan. Since the technique is operator dependent, a dedicated team
of diagnostic radiologist, interventional radiologist and MRI technolo-
gist is helpful in successful performance of the procedure and may re-
duce total procedure time.
Alternate lymphatic pathways were seen in both Types 2 and 3
DCMRL. The proposed role of these pathways is to provide collateral
circulation in patients with Type 2 DCMRL who have either anomalous
development or acquired obstruction of the CCL. In patients with Type 3
DCMRL, these pathways likely fill secondary to lymphatic backflow
from elevated systemic venous pressures, pulmonary hypertension or
congestive heart failure in patients with single ventricle physiology post
Glenn or Fontan surgery. When these later patients present with post-
operative chylothorax, it may be difficult to ascertain the cause of the
chylothorax between lymphatic backflow and post surgical disruption
of normal lymphatics. A pre-operative baseline DCMRL may be helpful
in this scenario, and could be considered before surgery in these pa-
tients. The alternate lymphatic pathways in patients with Generalized
Lymphatic Anomaly or Gorham Stout disease who demonstrate Type 3
DCMRL represent part of their multi-system lymphatic abnormalities.
The DCMRL technique for imaging CCL has several advantages: (a)
As compared with heavily T2 weighted non-contrast imaging of the CCL
[11], gadolinium based contrast agent provides high signal intensity
within the lymphatics allowing them to be distinguished from the
surrounding soft tissue. In addition DCMRL provides dynamic lym-
phatic flow information within normal and alternate lymphatic path-
ways and is helpful in localizing the site of lymphatic leak, (b) As
compared with two-dimensional intra-nodal fluoroscopic lymphangio-
graphy using oil-based contrast agent, three-dimensional volumetric
data with time information from DCMRL is helpful in understanding
lymphatic flow patterns and pathways. In addition, this dynamic ima-
ging technique may further bolster the development of minimally in-
vasive lymphatic interventions, (c) the lack of exposure to ionizing
radiation is an advantage in the paediatric population, (d) DCMRL is
helpful in patients with intra- or extra-cardiac right-to-left shunts who
would be at high risk of cerebral embolism from traditional fluoro-
scopic lymphangiogram using oil-based contrast, (e) even when uni-
lateral inguinal lymph node is identified, a successful DCMRL study
could be performed.
The following limitations of DCMRL were evident during this study:
(a) need for general anesthesia to allow for breath hold during imaging
and to prevent needle dislodgement from the lymph node, (b) need for
an interventional radiologist for lymph node cannulation and intra-
nodal contrast injection, (c) need for a diagnostic radiologist to opti-
mize imaging parameters and to decide intra-nodal injection start and
end times, number of and interval between individual acquisitions and
need for additional MRI sequences based on DCMRL findings, (d) pos-
sibility of technical failure due to extra-nodal contrast extravasation.
Contrast extravasation could occur due to either needle dislodgement or
lymph node capsular rupture from volume or pressure overload during
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European Journal of Radiology 101 (2018) 129–135
injection. Contrast extravasation is difficult to diagnose on DCMRL
because signal drop out occurs at the injection site in all studies due to
high local concentration of gadolinium. In addition, the groins may be
partially excluded from the imaging field of view in taller patients.
In conclusion, DCMRL is a useful technique for dynamic imaging of
the CCL. Understanding the dynamicity of lymphatic flow and cate-
gorization of imaging findings may be helpful in guiding selection of
management options. Although the present study is limited by its small
sample size and retrospective design, it provides insights into under-
standing of normal and alternate lymphatic pathways that could aug-
ment diagnosis and promote development of newer interventional
treatment options for lymphatic disorders.
Disclosures
Ponraj Chinnadurai is a full-time research scientist for Siemens
Medical Solutions USA Inc., Hoffman Estates, United States. Sheena
Pimpalwar, Mercedes Pereyra, Prakash Masand, Alex Chau, Daniel
Ashton, Rajesh Krishnamurthy, Siddharth Jadhav have no disclosures
or conflict of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.ejrad.2018.02.021.
References
[1] M.R. Rajebi, G. Chaudry, H.M. Padua, B. Dillon, S. Yilmaz, R.W. Arnold,
M.F. Landrigan-Ossar, A.I. Alomari, Intranodal lymphangiography: feasibility and
preliminary experience in children, J. Vasc. Interv. Radiol. 22 (2011) 1300–1305,
http://dx.doi.org/10.1016/j.jvir.2011.05.003.
[2] G.J. Nadolski, M. Itkin, Feasibility of ultrasound-guided intranodal lymphangio-
gram for thoracic duct embolization, J. Vasc. Interv. Radiol. 23 (2012) 613–616,
http://dx.doi.org/10.1016/j.jvir.2012.01.078.
[3] R.K. Kerlan, J.M. Laberge, Intranodal lymphangiography: coming soon to a hospital
near you, J. Vasc. Interv. Radiol. 23 (2012) 617, http://dx.doi.org/10.1016/j.jvir.
2012.03.003.
[4] M.S. Stecker, C.M. Fan, Lymphangiography for thoracic duct interventions, Tech.
Vasc. Interv. Radiol. 19 (2016) 277–285, http://dx.doi.org/10.1053/j.tvir.2016.10.
010.
[5] R. Krishnamurthy, A. Hernandez, S. Kavuk, A. Annam, S. Pimpalwar, Imaging the
central conducting lymphatics: initial experience with dynamic MR lymphangio-
graphy, Radiology 274 (2015) 871–878, http://dx.doi.org/10.1148/radiol.
14131399.
[6] A. Parvinian, G.C. Mohan, R.C. Gaba, D.F. Saldanha, M.G. Knuttinen, J.T. Bui,
J. Minocha, Ultrasound-guided intranodal lymphangiography followed by thoracic
duct embolization for treatment of postoperative bilateral chylothorax, Head Neck
36 (2014), http://dx.doi.org/10.1002/hed.23425.
[7] V. Pamarthi, W.M. Pabon-Ramos, V. Marnell, L.M. Hurwitz, MRI of the central
lymphatic system: indications, imaging technique, and pre-procedural planning,
Top. Magn. Reson. Imaging 26 (2017) 175–180, http://dx.doi.org/10.1097/RMR.
0000000000000130.
[8] M. Itkin, G.J. Nadolski, Modern techniques of lymphangiography and interventions:
current status and future development, Cardiovasc. Intervent. Radiol. 41 (3) (2018)
366–376, http://dx.doi.org/10.1007/s00270-017-1863-2.
[9] F.G. Mazzei, F. Gentili, S. Guerrini, N. Cioffi Squitieri, D. Guerrieri, P. Gennaro,
M. Scialpi, L. Volterrani, M.A. Mazzei, MR lymphangiography a practical guide to
perform it and a brief review of the literature from a technical point of view,
Biomed. Res. Int. 2017 (2017), http://dx.doi.org/10.1155/2017/2598358.
[10] G.B. Chavhan, J.G. Amaral, M. Temple, M. Itkin, MR lymphangiography in children:
technique and potential applications, Radiographics 37 (2017) 1775–1790.
[11] E.Y. Kim, H.S. Hwang, H.Y. Lee, J.H. Cho, H.K. Kim, K.S. Lee, Y.M. Shim, J. Zo,
Anatomic and functional evaluation of central lymphatics with noninvasive mag-
netic resonance lymphangiography, Medicine (Baltimore) 95 (2016) e3109, http://
dx.doi.org/10.1097/MD.0000000000003109.
[12] Y. Dori, Novel lymphatic imaging techniques, Tech. Vasc. Interv. Radiol. 19 (2016)
255–261, http://dx.doi.org/10.1053/j.tvir.2016.10.002.
[13] Y. Dori, M.M. Zviman, M. Itkin, Dynamic contrast-enhanced MR lymphangio-
graphy: feasibility study in swine, Radiology 273 (2014) 410–416, http://dx.doi.
org/10.1148/radiol.14132616.