Intranodal magnetic resonance lymphangiography

1. DYNAMIC CONTRAST INTRANODAL
MAGNETIC RESONANCE
LYMPHANGIOGRAPHY
MODERATER: DR.JEEVIKA M U
PRESENTER: DR.GANESH GADAG

2. The lymphatic system is an important component of the circulatory system
Lymph constitutes the excess of tissue fluid, which is derived from blood
plasma and removed from the interstitial tissue via the lymphatic system.
Lymph contains nutrients, hormones, fatty acids, toxins, and cellular waste
products.
Most of the lymphatic system consists of a network of small vessels; hence
it is difficult to image it and especially to introduce contrast media into
these small lymphatic ducts. However, in the last few years, the lymphatic
imaging has been advanced by combining soft tissue contrast and
resolution offered by MR imaging, supplemented by the injection of
contrast media via a lymph node.
INTRODUCTION

3. Functions :
Nutrition
Fluid balance
Immunity
Clearing of waste products
The most commonly manifested clinical features of lymphatic system
disorders are
lymphedema,
ascites, and
 pleural effusion.

4. The lymphatic system consists of ,
A) Small terminal lymphatic ducts that be divided into 3 types depending on
their origin,
 Soft tissue -Lower concentration of proteins in the peripheral lymph (17%–
30%of the blood level)
 Liver - Contains the highest concentration of proteins of all lymph (80%–
90% of the blood level)
 Intestinal lymphatic ducts {higher concentration of lipids and proteins
(60% of the blood level)}-CHYLE
ANATOMY OF THE LYMPHATIC SYSTEM

5. B) Lymph nodes- Regulate the composition of lymph and mount an immune
response if pathogens are detected.

6. C) Larger lymphatic ducts-

7. METHODS OF IMAGING THE LYMPHATIC SYSTEM
Modalities of lymphatic imaging include ,
A) Lymphoscintigraphy
• Lymphoscintigraphy is performed by injection of radioactive tracers
intracutaneously or subcutaneously into the feet or hands. The tracers are
rapidly absorbed into terminal lymphatic ducts.
• Lympho-scintigraphy provides dynamic information but lacks spatial
resolution and anatomic details.
• Lymphoscintigraphy is often used to identify the sentinel lymph node, or
the first node to receive the lymph drainage from a tumor

9. B) Fluoroscopic Peripheral and central Lymphangiography
It is performed through cannulation of peripheral lymphatic ducts on the
dorsum of feet or hands, interstitial injection into interdigital web spaces,
or cannulation of lymph nodes in the groins and injection of iodized oil-
based contrast media(Lipiodol)
Advantages: Excellent spatial resolution
Disadvantages:
 Exposure to ionizing radiation
 Longer examination time than DCMRL
 Limited dynamic information due to slow movement of viscous contrast
media
 Paradoxical embolization

10. 5m 15m
1h
5h

12. C) Peripheral Magnetic Resonance Lymphangiography
• Lymphatic ducts in the lower and upper extremities can be imaged by MR
imaging using T2-weighted images or with injection of GBCM into the
dermal plane in the feet and hands on T1-weighted images
• Effectively plan treatments such as lympho-venous bypass in cases of
lymphedema

14. 45m

15. DYNAMIC INTRANODAL MAGNETIC
RESONANCE LYMPHANGIOGRAPHY

16. • Plastic bronchitis
• Congenital lymphatic dysplasia
• Traumatic /Nontraumatic chylothorax
• Traumatic /Nontraumatic Chyloperitoneum
• Protein loosing enteropathy
• Generalized lymphatic anomaly
Indications

17. • The patient is placed supine on a detachable MR imaging table, outside the
scanning room, with posterior elements of the torso coil underneath the
patient before the start of cannulation. Anterior elements of the coil are
placed when the patient is taken into the scanner, after the lymph node
cannulation.
Positioning

18. • Both inguinal regions are prepared and draped under sterile conditions.
Under ultrasound guidance, a 22- to 25-gauge needle is placed in the
medulla of an inguinal lymph node on each side.
Lymph Node Cannulation

20. • Endotracheal intubation was considered essential in all patients
because of age or coexisting morbidities that resulted in an
inability to perform repeated breath-hold sequences for 20–
30seconds, which are required for the dynamic T1-weighted
high-resolution imaging with volumetric excitation
(THRIVE)sequence.

21. • Any routinely used GBCM can be used for DCMRL.
• Dose : 0.1 mmol/kg used for routine intravenous injection. 0.2 mmol/kg
can be used occasionally in larger patients.
• Dilution: Diluted with normal saline 1:1 for older children and adults and
1:2 or 1:3 for younger children to reduce T2 effects of concentrated
gadolinium causing darkening from paramagnetic effects of undiluted
gadolinium.
• The total volume is divided and half of the amount is injected on each
side. The entire tubing is primed with contrast containing solution. A
syringe with normal saline is also attached to the 3-way stopcock on each
side to flush the system and push the contrast remaining in the tube.
Contrast Media

22. • FOV: Mid-neck to the lesser trochanter
• The 16-channel torso phased arraycoil, with a 55-cm area of coverage by
the MR coil was preferred,
• The 2 main components of central MR lymphangiography include T2-
weighted imaging and postcontrast dynamic T1-weighted imaging
(DCMRL), both acquired with fat suppression.
MR Imaging Examination

24. T2-weighted images
Advantages:
• T2-weighted images help to localize areas of lymphedema, which may
remain undetected by DCMRL.
• They also provide anatomic information of the cisterna chyli and
thoracic duct that can be complementary to DCMRL in cases where the
contrast does not propagate into the thoracic duct due to distal
obstruction or lymph leak.
• Static, noncontrast T2-weighted MR lymphangiography can be useful in
procedural planning for DCMRL and potential intervention. There are
no data on frequency of visualization of cisterna chyli and thoracic duct
on heavily T2-weighted images.

26. Limitations:
• Difficulty to visualize smaller lymphatic ducts because of insufficient
signal from small amounts of fluid within them and difficulty to
differentiate lymphatic ducts from other overlapping fluid-containing
structures and veins.
• It is a static imaging technique that lacks dynamic information,
which is important when it comes to demonstrating lymphatic reflux
or leakage

27. IMAGE ANALYSIS

28. 4m 5m 6m
7m 8m

30. CLINICAL APPLICATIONS OF INTRANODAL
DC-MRL

31. • PB is a potentially fatal condition involving airway obstruction caused by
casts that can lead to significant asphyxia.
• It is characterized by expectoration of branching bronchial casts that are
formed by exudation of proteinaceous material and sometimes cells in the
airway. PB can occur in patients,
• After single-ventricle palliation, cystic fibrosis, sickle cell anaemia, asthma,
and lymphangiomatosis.
• Fontan patients(prevalence 4%)
• Lymphatic plastic bronchitis
1) PLASTIC BRONCHITIS

34. 4.5m
5.7 m
9 m

36. 8 m 10 m 16 m

38. Chylothorax and chyloperitoneum can be congenital and isolated or
associated with lymphatic dysplasia. They can occur secondary to trauma,
surgery, severe infection such as tuberculosis or fungal infestations, as well
as malignancy
2) CHYLOTHORAX AND CHYLOPERITONEUM

39. 18 m MIP

40. 3 m 15 m

42. • Protein losing enteropathy (PLE) is characterized by rapid loss of serum
proteins into the gut lumen. The resulting hypoproteinemia can lead to
edema, ascites, pleural, and pericardial effusions due to an imbalance
between oncotic and hydrostatic pressures.
• PLE is either caused by lymphatic abnormalities or chronic mucosal injury
as occurs in inflammatory bowel disease or neoplasm.
• elevated CVP
• Abnormal lymphatic flow /lymphangectasia
3) PROTEIN LOOSING ENTEROPATHY

45. • Biko and colleagues have reported intrahepatic DCMRL that involves
injection of GBCA directly in the liver lymphatics and tracking the
passage of contrast using T1-weighted MR images
• Liver lymphangiography is performed by inserting a 25- gauge needle in
the periportal space. This technique facilitates the diagnosis of protein-
loosing enteropathy and chylous ascites.

47. 0 m 2 m 3 m
4.5 m 8 .5m 12 m

53. • Developmental lymphatic anomalies
• Cystic lymphatic malformations
• Generalized lymphatic anomalies (GLA)
• Gorham-Stout disease, channel type lymphaticmalformations, “acquired”
progressive lymphaticanomalies, and
• Variety of primary lymphedema.
4) Lymphatic Malformations

57. • DCMRL is a novel technique to image CCLs performed by injecting GBCA
into groin lymph nodes and following the passage of contrast through
the lymphatic system using T1-weighted MR images. To date, it has been
successfully applied to image and guide treatment of the lymphatic
abnormalities associated with Fontan procedure such as plastic
bronchitis. It is also useful in the assessment of chylothorax and
chyloperitoneum and their potential treatment planning. Its role in other
areas such as intestinal lymphangiectasia and lymphatic anomalies is
likely to increase.
Summary

58. References
Magnetic Resonance Lymphangiography -Govind B. Chavhan,
MD, DABR,*, Christopher Z. Lam, MD, Mary-Louise C. Greer, MD,
Michael Temple, MD, Joao Amaral, MD, Lars Grosse-Wortmann, MD
Chavhan GB, Amaral JG, Temple M, et al. MR lymph-angiography in
children: technique and potential applications. Radio graphics
2017;37(6):1775–90.
Betterman KL, Harvey NL. The lymphatic vasculature: development and
role in shaping immunity. Immunol Rev 2016;271(1):276–92.
Dori Y, Zviman MM, Itkin M. Dynamic contrast-enhanced MR
lymphangiography: feasibility study in swine. Radiology
2014;273(2):410–6.

59. THANK
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