Purpose or Case Report: Dynamic Contrast Enhanced MR Lymphangiography (DCMRL) allows evaluation of the central conducting lymphatics in patients with central lymphatic flow dysfunction. Direct injection of gadolinium contrast into inguinal lymph nodes followed by serial imaging allows visualization of lymphatic channels and lymphodynamics. This study reviews the DCMRLs performed at our institution over a 2 year period including indications, findings and impact on clinical management.
Methods & Materials: 8 children, 2 to 17 years (mean 6 years), underwent DCMRL on a Siemans Prisma 3T scanner. Following cannulation of bilateral inguinal lymph nodes under ultrasound guidance, T2 3D SPACE and pre-contrast 3D T1 VIBE were followed by serial VIBE imaging during administration of 0.1 mmol/kg Gadavist. Imaging was performed until opacification of the thoracic duct was seen and until no new additional areas of contrast leak or reflux were noted. Images were reviewed for opacification and anatomy of central lymphatics (cisterna chyli and thoracic duct), contrast reflux, and lymphatic leak as well as lymphatic channel engorgement on T2. Charts were reviewed for imaging impact on clinical decision making.
Results: Indications were chylothorax (4) -- current (2) and remote (2), protein losing enteropathy (1), expansile rib lesions in a Fontan patient (1), abdominal pain and mesenteric and retroperitoneal “mass” (1), renal lymphangiectasia (1) and chylopericardium (1). Contrast opacified the central lymphatics and demonstrated their anatomy in 8/8 patients. Reflux into abnormal lymphatic beds was seen including pulmonary (4), supraclavicular (3), intercostal (3), retroperitoneal (3), mesenteric (2), and pericardial (1). Site of chyle leak in 2 patients with chylothorax and 1 patient with chylopericardium were identified. One patient underwent successful percutaneous TD embolization with cessation of chylopericardium. Two patients’ chylothoraces resolved with conservative management, and one patient avoided biopsy when rib lesions were found to be located at sites of chyle reflux. One patient with central conducting lymphatic anomaly was initiated on medical therapy with sirolimus. Two patients’ imaging served as baseline, one prior to Fontan and one with renal lymphangiectasia and hypertension prior to undergoing tonsillectomy.
Conclusions: DCMRL offers direct visualization of the central lymphatics in children with potential to visualize a variety of lymphatic dysfunctions and can positively impact medical decision making.