Published online before print July 24, 2007, 10.1148/radiol.2443061518
(Radiology 2007;244:791-796.)
© RSNA, 2007
The Cisterna Chyli: Enhancement on Delayed Phase MR Images after Intravenous Administration of Gadolinium Chelate1
Sachit K. Verma, MD 2,
Donald G. Mitchell, MD,
Diane Bergin, MD,
Rashi Mehta, MD,
Sheetal Chopra, MD, and
Dongil Choi, MD, PhD 3
1 From the Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, 1094 Main Bldg, Philadelphia, PA 19107. Received September 1, 2006; revision requested October 27; revision received November 9; accepted December 18; final version accepted February 1, 2007.
Address correspondence to D.G.M. (e-mail: donald.mitchell{at}jefferson.edu).
 |
ABSTRACT
|
|---|
Purpose: To retrospectively evaluate cisterna chyli (CC) enhancement on magnetic resonance (MR) images obtained after intravenous administration of a gadolinium-based contrast agent.
Materials and Methods: This retrospective HIPAA-compliant study of 1.5-T MR imaging findings was institutional review board approved; informed patient consent was waived. All MR examinations involved the acquisition of heavily T2-weighted single-shot fast spin-echo (SSFSE) images and three-dimensional (3D) gradient-echo images obtained before and during the arterial, venous, and 3–5-minute delayed phases after intravenous bolus injection of gadopentetate dimeglumine. Included were the data of 59 patients (37 men, 22 women; mean age, 59 years) who had a CC 4 mm or greater in transverse diameter, which was identified as a tubular structure with fluid signal intensity (SI) on SSFSE images. The SI of the CC relative to the spinal canal (SC) was noted and was measured on 3D gradient-echo images obtained during all phases. The Student t test was performed for statistical evaluations.
Results: Mean CC-SC SI ratios on nonenhanced, arterial phase, venous phase, and delayed phase images were 0.92, 0.98, 0.99, and 2.13, respectively. The CC had low SI on all 3D gradient-echo images obtained during the nonenhanced, arterial, and venous phases and high SI, similar to the azygos vein SI, on all delayed phase images. The CC-SC SI ratio during the delayed phase was significantly higher than that during the other phases (P < .001).
Conclusion: The CC has minimal or no enhancement on arterial phase and venous phase images but intense enhancement—similar to the enhancement of veins—on delayed phase images. Comparison of delayed phase images with SSFSE and venous phase images may help to distinguish the CC seen on delayed phase images from lymph nodes, the azygos vein, or esophageal varices.
© RSNA, 2007
|
INTRODUCTION
|
|---|
Most investigations of lymphatic imaging have been directed at detecting metastases to the lymph nodes. Far less attention has been directed toward depicting the lymphatic channels themselves, and still even less attention has been directed toward elucidating normal or abnormal lymphatic function. The largest lymphatic channel is the cisterna chyli (CC), which is located in the retrocrural space along with the thoracic duct, retrocrural lymph nodes, aorta, and azygos and hemiazygos veins (1–10). With the heavily T2-weighted fluid-sensitive sequences currently used in many abdominal magnetic resonance (MR) imaging protocols, the CC is depicted as isointense to simple fluid (6–9); this channel was visualized with this appearance in 15% of patients in one series (6). However, to our knowledge, the enhancement pattern of lymphatic fluid within the CC at dynamic MR imaging had not been investigated other than in a single case report of a giant enhancing CC (8).
Currently used gadolinium-based contrast materials, like other water-soluble low–molecular-weight agents, rapidly diffuse across systemic capillary walls into the interstitium of most body tissues (11). Small molecules dissolved in interstitial fluid diffuse into the tissue lymphatics, where they drain into larger lymphatic channels such as the CC (12–14). We speculated that if, by way of this mechanism, the CC is sufficiently enhanced on clinical contrast material–enhanced images, it may resemble other retrocrural structures such as varices or lymph nodes. We additionally speculated that enhancement of the CC on MR images could be the basis of a technique for in vivo investigation of the dynamics of contrast material transit from vascular to interstitial to lymphatic spaces. Thus, the purpose of our study was to retrospectively evaluate CC enhancement on MR images obtained after the intravenous administration of a gadolinium-based contrast agent.
|
MATERIALS AND METHODS
|
|---|
Patients
This retrospective study was Health Insurance Portability and Accountability Act compliant and was approved by our institutional review board, which waived the requirement for informed patient consent. The medical and imaging data of 400 patients, each of whom underwent a 1.5-T abdominal MR imaging examination between July 2005 and June 2006, were included for review, without regard to patient demographics or clinical history. All MR examinations included the acquisition of heavily T2-weighted single-shot fast spin-echo images and dynamic fat-suppressed gradient-echo images before and during the arterial, venous, and delayed (3–5-minute) phases after the intravenous bolus administration of gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ).
The final study group consisted of 59 (15%) subjects (37 men, 22 women; age range, 36–87 years; mean age, 59 years) from the initial group of 400 patients. All 59 patients had a CC 4 mm or greater in diameter that was seen as fluid signal intensity in the retrocrural space on heavily T2-weighted MR images. Radiology reports and medical records were reviewed by one investigator (S.K.V.) to determine the clinical indication(s) for imaging, which included cirrhosis or hepatitis (n = 32), evaluation after liver transplantation (n = 4), evaluation after chemoembolization (n = 2), pancreatic abnormality (n = 5), hemangioma or other benign liver mass (n = 5), and unclear indication (n = 11).
MR Imaging Technique
All MR examinations were performed during suspended respiration with a 1.5-T system (Signa; GE Medical Systems, Milwaukee, Wis) and a phased-array coil. Coronal and transverse two-dimensional single-shot fast spin-echo T2-weighted (effective echo time, 180–200 msec), transverse fat-suppressed fast spin-echo T2-weighted (2500–4000/80–90 [repetition time msec/echo time msec]), and spoiled dual gradient-echo T1-weighted in-phase and out-phase (120–200/2.3 and 4.6, 90° flip angle) MR images were obtained. Parameters for two-dimensional imaging included a section thickness of 5–8 mm with an intersection gap of 0–1 mm, a 256 x (160–192) matrix, a 32-cm transverse field of view and 24-cm anteroposterior field of view, and one or fewer signals acquired. Three-dimensional (3D) contrast-enhanced spoiled gradient-echo dynamic MR images were obtained with a 5-mm section resolution in 2.5-mm increments by using zero-fill interpolation, 4–6/1.3–2.1, and a 12°–20° flip angle; parameters were otherwise similar to those for two-dimensional imaging. Twenty milliliters of gadopentetate dimeglumine was administered intravenously by using a power injector at 2 mL/sec and followed by a 20-mL saline flush.
Imaging was initiated at a time intended to optimize first-pass arterial enhancement, as determined by using a timing bolus sequence or observing the enhancement on images reconstructed in real time. In all patients, 3D gradient-echo images were obtained during a breath hold before (nonenhanced phase), immediately after (hepatic arterial phase), and 30 seconds after (portal venous phase) the injection. Delayed phase (approximately 3–5 minutes after the injection) images of the entire liver were also obtained—by using a fat-suppressed two-dimensional single-section sequence (19/2, 30° flip angle) in all patients and by using the 3D gradient-echo sequence described earlier in most (n = 41) patients. The acquisition of two-dimensional single-section delayed phase images was included in our routine protocol because these images have fewer motion artifacts and higher vascular signal intensity compared with 3D delayed phase images.
Image Analysis
MR images were interpreted independently on a teleradiology workstation monitor by one radiologist (S.K.V.) with 2 years experience in body MR imaging, without access to any clinical information. Questions involving interpretation or scoring were resolved in consensus with a second radiologist (D.G.M.) with 20 years experience in body MR imaging. The CC was first identified as a fluid signal intensity structure on transverse heavily T2-weighted single-shot fast spin-echo images and then was viewed at the corresponding location on the 3D gradient-echo images. CCs with a maximum transverse diameter of 4 mm or greater constituted the study data set, and these diameters were recorded. Smaller CCs were not evaluated owing to the limited spatial resolution of the images in this retrospective study.
Signal intensity was measured on the 3D gradient-echo images during four phases relative to the intravenous administration of gadopentetate dimeglumine: the precontrast phase, the first-pass (arterial) phase, the second-pass (venous) phase, and the delayed (3–5-minute) contrast-enhanced phase. For each phase in each patient, the signal intensity of the CC was judged to be low (similar to or lower than muscle signal intensity), intermediate (between muscle and azygos vein signal intensities), or high (similar to azygos vein signal intensity). In addition, visible enhancement was described as none, minimal, or prominent. Region-of-interest (ROI) measurements were obtained at each phase from the largest portion of the CC, and images obtained above and below the selected site were viewed to minimize partial volume artifacts. The ROI was as large as possible without extending beyond the margins of the CC, and the ROI size was constant at each phase in all patients.
To compare the dynamic images with the delayed phase images, on which the receiver gain and attenuation may have varied owing to the repeated preimaging procedure, the measured signal intensity was normalized to the average signal intensity of the spinal canal (SC) on the same image. The SC was chosen because of its consistent presence anatomically near the CC. Because of the limited spatial resolution, variable amounts of spinal cord tissue had to be included, but ROIs that excluded the dura and epidural veins were chosen. Weak enhancement of the spinal cord was anticipated owing to the blood-brain barrier. The sizes of the CC and SC ROIs ranged from 2 to 9 mm2. Normalized CC signal intensity–to–SC signal intensity ratios for the nonenhanced, arterial, venous, and delayed phases were calculated. The percentage enhancement of the CC (ECC) during the arterial, venous, and delayed phases was calculated as the percentage change in signal intensity: ECC = [(SIpost – SIpre)/SIpre] x 100, where SIpre and SIpost are the pre- and postcontrast signal intensities of the CC, respectively.
Statistical Analyses
Mean CC and SC signal intensity values ± standard deviations were calculated by using computer software (Excel XP; Microsoft, Redmond, Wash). The significance of the signal intensity change across the various phases was analyzed by using the two-tailed paired Student t test. P < .05 was considered to indicate statistical significance.
|
RESULTS
|
|---|
The CCs in the 59 study patients were 4–11 mm (mean, 6.07 mm) in diameter. The CC had low signal intensity on all 3D gradient-echo MR images obtained during the nonenhanced, arterial, and venous phases and had high signal intensity similar to that of the azygos and hemiazygos veins on the delayed phase images (Fig 1). Mean CC-SC signal intensity ratios were 0.92, 0.98, 0.99, and 2.13, respectively, on the nonenhanced, arterial phase, venous phase, and delayed (3–5-minute) phase images (Table). Percentage enhancement values for the CC and SC, respectively, were 29% and 24% during the arterial phase, 47% and 40% during the venous phase, and 243% and 50% during the delayed phase. The mean CC-SC signal intensity ratio was significantly higher on the delayed phase images than on the other phase images (P < .001).
View larger version (147K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a: Transverse MR images of CC in 56-year-old man with cirrhosis. (a) Single-shot fast spin-echo T2-weighted image (180–200-msec effective echo time) shows uniform high signal intensity of the CC (arrow)—similar to the cerebrospinal fluid signal intensity—in the right retrocrural space. (b) Nonenhanced 3D gradient-echo image (5/1.4, 12° flip angle) shows the CC (arrow) with low signal intensity. Corresponding contrast-enhanced (c) arterial phase and (d) portal venous phase images (5/1.4, 12° flip angle) show the CC (arrow) with no visible enhancement. In d, the azygos vein and tributary (arrowhead) are enhancing intensely. (e) Image obtained 3–5 minutes after gadolinium chelate injection shows the CC (arrow) with strong homogeneous enhancement, similar to the enhancement of the surrounding blood vessels.
|
|
View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b: Transverse MR images of CC in 56-year-old man with cirrhosis. (a) Single-shot fast spin-echo T2-weighted image (180–200-msec effective echo time) shows uniform high signal intensity of the CC (arrow)—similar to the cerebrospinal fluid signal intensity—in the right retrocrural space. (b) Nonenhanced 3D gradient-echo image (5/1.4, 12° flip angle) shows the CC (arrow) with low signal intensity. Corresponding contrast-enhanced (c) arterial phase and (d) portal venous phase images (5/1.4, 12° flip angle) show the CC (arrow) with no visible enhancement. In d, the azygos vein and tributary (arrowhead) are enhancing intensely. (e) Image obtained 3–5 minutes after gadolinium chelate injection shows the CC (arrow) with strong homogeneous enhancement, similar to the enhancement of the surrounding blood vessels.
|
|
View larger version (144K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1c: Transverse MR images of CC in 56-year-old man with cirrhosis. (a) Single-shot fast spin-echo T2-weighted image (180–200-msec effective echo time) shows uniform high signal intensity of the CC (arrow)—similar to the cerebrospinal fluid signal intensity—in the right retrocrural space. (b) Nonenhanced 3D gradient-echo image (5/1.4, 12° flip angle) shows the CC (arrow) with low signal intensity. Corresponding contrast-enhanced (c) arterial phase and (d) portal venous phase images (5/1.4, 12° flip angle) show the CC (arrow) with no visible enhancement. In d, the azygos vein and tributary (arrowhead) are enhancing intensely. (e) Image obtained 3–5 minutes after gadolinium chelate injection shows the CC (arrow) with strong homogeneous enhancement, similar to the enhancement of the surrounding blood vessels.
|
|
View larger version (157K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1d: Transverse MR images of CC in 56-year-old man with cirrhosis. (a) Single-shot fast spin-echo T2-weighted image (180–200-msec effective echo time) shows uniform high signal intensity of the CC (arrow)—similar to the cerebrospinal fluid signal intensity—in the right retrocrural space. (b) Nonenhanced 3D gradient-echo image (5/1.4, 12° flip angle) shows the CC (arrow) with low signal intensity. Corresponding contrast-enhanced (c) arterial phase and (d) portal venous phase images (5/1.4, 12° flip angle) show the CC (arrow) with no visible enhancement. In d, the azygos vein and tributary (arrowhead) are enhancing intensely. (e) Image obtained 3–5 minutes after gadolinium chelate injection shows the CC (arrow) with strong homogeneous enhancement, similar to the enhancement of the surrounding blood vessels.
|
|
View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1e: Transverse MR images of CC in 56-year-old man with cirrhosis. (a) Single-shot fast spin-echo T2-weighted image (180–200-msec effective echo time) shows uniform high signal intensity of the CC (arrow)—similar to the cerebrospinal fluid signal intensity—in the right retrocrural space. (b) Nonenhanced 3D gradient-echo image (5/1.4, 12° flip angle) shows the CC (arrow) with low signal intensity. Corresponding contrast-enhanced (c) arterial phase and (d) portal venous phase images (5/1.4, 12° flip angle) show the CC (arrow) with no visible enhancement. In d, the azygos vein and tributary (arrowhead) are enhancing intensely. (e) Image obtained 3–5 minutes after gadolinium chelate injection shows the CC (arrow) with strong homogeneous enhancement, similar to the enhancement of the surrounding blood vessels.
|
|
In two patients, a retroperitoneal cystic structure with a signal intensity similar to that of the CC was seen on the coronal heavily T2-weighted MR image, without apparent communication with the CC visualized on the same image. These cystic structures, which might have been lymphangiomas, did not show contrast enhancement on the delayed phase images and thus were differentiated from the enhancing CC (Fig 2).
View larger version (162K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a: (a) Coronal single-shot fast spin-echo T2-weighted MR image (180–200-msec echo time) shows a high-signal-intensity retroperitoneal cystic structure (arrow) of uncertain origin and without visible communication with the CC (arrowhead). (b) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) shows no enhancement of the cystic structure (arrow). (c) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) obtained at a level slightly higher than b shows the CC (arrowhead) enhancing intensely.
|
|
View larger version (162K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b: (a) Coronal single-shot fast spin-echo T2-weighted MR image (180–200-msec echo time) shows a high-signal-intensity retroperitoneal cystic structure (arrow) of uncertain origin and without visible communication with the CC (arrowhead). (b) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) shows no enhancement of the cystic structure (arrow). (c) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) obtained at a level slightly higher than b shows the CC (arrowhead) enhancing intensely.
|
|
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2c: (a) Coronal single-shot fast spin-echo T2-weighted MR image (180–200-msec echo time) shows a high-signal-intensity retroperitoneal cystic structure (arrow) of uncertain origin and without visible communication with the CC (arrowhead). (b) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) shows no enhancement of the cystic structure (arrow). (c) Transverse 3D gradient-echo delayed phase MR image (5/1.4, 12° flip angle) obtained at a level slightly higher than b shows the CC (arrowhead) enhancing intensely.
|
|
|
DISCUSSION
|
|---|
The appearance of the thoracic duct and CC on transverse heavily T2-weighted single-shot fast spin-echo images has been described in prior reports (6–9). Lee and Cassar-Pullicino (7) noted enhancement in a single case of giant CC 10 minutes after the intravenous administration of gadolinium-based contrast material. To our knowledge, our study is the first investigation in which the enhancement of all CCs with a diameter of 4 mm or greater is described. In all patients with such findings, we observed minimal or no enhancement on the arterial and venous phase images but intense enhancement—comparable to that of the nearby veins—on images obtained 3–5 minutes after contrast material administration.
MR methods previously used to image the lymphatic system have included interstitial injection of gadolinium chelates to deliver contrast material into the lymph nodes and thoracic duct (14). Particulate agents that induce T2* enhancement have been administered interstitially or intravenously but with limitations that included long plasma circulation times and image degradation due to the susceptibility effects of iron (15,16). It has been observed at lymphoscintigraphy and interstitial MR lymphography that a delay of 20–80 minutes after the administration of contrast material is required for optimal visualization of the abdominal lymphatic system (10,17–19).
After injection, water-soluble contrast agents such as gadopentetate dimeglumine show rapid diffusion between the intravascular and interstitial compartments (11). The intense lymphatic enhancement, comparable to the blood vessel enhancement, that we consistently observed after only 3–5 minutes presumably results from the rapid passage of gadolinium chelate molecules initially across capillary walls into interstitial fluid and then into the thin-walled, fenestrated lymphatic microvessels. The rates of contrast material transit from blood to the interstitium to lymph tissue may depend on the combined effects of pressure, osmosis, and volumes, similar to the combined effects reported for other extracellular water-soluble, low–molecular-weight solutes (11–13,20).
Compared with prior methods of lymphangiographic investigation, high-spatial-resolution volumetric MR imaging can provide more detailed information about the functional 3D anatomy of the lymphatic system. Although particulate agents are effective in enhancing functioning lymph nodes owing to the macrophage uptake of particles, water-soluble agents are probably better suited for the rapid enhancement of lymphatic channels, providing new opportunities for in vivo physiologic study of this important system, which has thus far been difficult to investigate. Although lymph nodes also enhance on delayed phase images, they can be distinguished from lymphatic channels because their blood supply causes perfusion-related enhancement on early phase images. In addition, lymph node signal intensity is usually lower than fluid signal intensity on heavily T2-weighted fast spin-echo images.
It has been suggested that an enlarged CC is more common in patients with cirrhosis; possible contributing factors include increased flow of lymph through the thoracic duct and altered portal pressure and serum albumin levels (21,22). Many of our study patients, who had a CC 4 mm or greater in diameter, had cirrhosis. However, the retrospective nature of our study, which included selection bias that was difficult to evaluate, limited our ability to compare CC characteristics between patients with cirrhosis and healthy subjects. In addition, we did not measure the portal pressure, serum albumin level, or other potentially relevant parameters.
There were other important limitations in our retrospective study. Our study patients were recruited from among subjects who were examined with MR imaging and did not represent the general population. Therefore, the 15% prevalence of CCs 4 mm or greater in diameter cannot be generalized. Our ROI enhancement measurements were limited by partial volume averaging artifacts, but our use of volumetric acquisitions with 2.5-mm increments between sections and a through-plane resolution of 5 mm reduced the prevalence of these artifacts. To reduce the incidence of subjective judgments in identifying and measuring structures with a diameter of less than 2 pixels, we restricted our analysis to CCs with an in-plane diameter of 4 mm or greater. Receiver attenuation and gain were constant through the nonenhanced, arterial, and venous phases, but they varied at the delayed phase. In a minority of examinations, the delayed phase images were acquired by using a two-dimensional rather than 3D fat-suppressed technique. To address these differences between the early and delayed contrast-enhanced images, we used visual comparisons and on all images normalized the measured signal intensity to that of the SC, a structure with minimal enhancement and that is anatomically close to the CC. Although it would have been preferable to include only the cerebrospinal fluid, spatial resolution limitations mandated that some spinal cord tissue be included. The blood-brain barrier prevents the spinal cord from enhancing intensely, however.
For more robust normalization, we could have used a phantom external to the patient or measured the noise within the air adjacent to the patient; however, owing to our use of small fields of view and an external phased-array coil to optimize the quality of the clinical images, the use of these techniques would have led to additional problems. Although these technical limitations reduced the precision of our quantitative measurements of enhancement, we believe that our measurements were adequate to confirm our visual impression of consistently intense enhancement on the delayed phase images.
In all patients in our series, the CCs 4 mm or greater in diameter enhanced intensely on images obtained 3–5 minutes after contrast material administration. Detection of the CC and knowledge of its enhancement pattern are important to avoid mistaking it for an enhancing esophageal varicosity, retrocrural lymph node, or azygos vein. Noninvasive assessment of the physiologic and pathophysiologic features of the lymphatic system might be conducted prospectively by using more frequent volumetric acquisitions throughout the first several minutes after contrast agent injection. Possible uses for optimized in vivo functional lymphography include (a) gaining greater understanding of factors that might affect the time of transit of low–molecular-weight molecules from the blood to the lymphatic fluid; (b) altering the balance of plasma, interstitial fluid, lymphatic fluid, and other extracellular fluids in disease subpopulations; and (c) elucidating the biodistribution of pharmaceutical agents.
|
ADVANCE IN KNOWLEDGE
|
|---|
- The cisterna chyli enhances intensely on T1-weighted three-dimensional gradient-echo MR images obtained 3–5 minutes after injection of gadolinium-based contrast agent.
|
IMPLICATION FOR PATIENT CARE
|
|---|
- Comparison of delayed phase images with heavily T2-weighted and venous phase MR images may help to distinguish the cisterna chyli seen on delayed phase images from lymph nodes, the azygos vein, or esophageal varices.
|
FOOTNOTES
|
|---|
Abbreviations: CC = cisterna chyli • ROI = region of interest • SC = spinal canal • 3D = three-dimensional
2 Current address: Department of Radiodiagnosis, K.G. Hospital and P.G. Medical Institute, Coimbatore, India 
3 Current address: Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Author contributions: Guarantors of integrity of entire study, S.K.V., D.G.M.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, S.K.V., D.G.M., S.C.; clinical studies, S.K.V., D.G.M., D.C.; statistical analysis, S.K.V., D.G.M.; and manuscript editing, all authors
Authors stated no financial relationship to disclose.
|
References
|
|---|
- Nasbaum M, Baum S, Hedges RC, Blakemore WS. Roentgenographic and direct visualization of thoracic duct. Arch Surg 1964;88:105–113.[Medline]
- Smith TR, Grigoropoulos J. The cisterna chyli: incidence and characteristics on CT. Clin Imaging 2002;26:18–22.[CrossRef][Medline]
- Propst-Proctor SL, Rinsky LA, Bleck EE. The cisterna chyli in orthopaedic surgery. Spine 1983;8:787–792.[Medline]
- Gollub MJ, Castellino RA. The cisterna chyli: a potential mimic of retroperitoneal lymphadenopathy on CT scans. Radiology 1996;199:477–480.[Abstract/Free Full Text]
- Erden A, Fitoz S, Yagmurlu B, Erden I. Abdominal confluence of lymph trunks: detectability and morphology on heavily T2-weighted images. AJR Am J Roentgenol 2005;184:35–40.[Abstract/Free Full Text]
- Pinto PS, Sirlin CB, Andrade-Barreto OA, Brown MA, Mindelzun RE, Mattrey RF. Cisterna chyli at routine abdominal MR imaging: a normal anatomic structure in the retrocrural space. RadioGraphics 2004;24:809–817.[Abstract/Free Full Text]
- Lee KC, Cassar-Pullicino VN. Giant cisterna chyli: MRI depiction with gadolinium-DTPA enhancement. Clin Radiol 2000;55:51–55.[CrossRef][Medline]
- Hayashi S, Miyazaki M. Thoracic duct: visualization at nonenhanced MR lymphography—initial experience. Radiology 1999;212:598–600.[Abstract/Free Full Text]
- Hvid-Jacobsen K, Nielsen SL, Jensen VJ, Thomsen HS. Demonstration of the thoracic duct by 123I heptadecanoic acid: report of a case. Acta Radiol 1987;28:783–784.[Medline]
- Rosenberger A, Abrams HL. Radiology of the thoracic duct. Am J Roentgenol Radium Ther Nucl Med 1971;111:807–820.[Medline]
- Weinmann HJ, Brasch RC, Press WR, Wesbey GE. Characteristics of gadolinium-DTPA complex: a potential NMR contrast agent. AJR Am J Roentgenol 1984;142:619–624.[Abstract/Free Full Text]
- Staatz G, Nolte-Ernsting CC, Adam GB, et al. Interstitial T1-weighted MR lymphography: lipophilic perfluorinated gadolinium chelates in pigs. Radiology 2001;220:129–134.[Abstract/Free Full Text]
- Schmid-Schonbein GW. Microlymphatics and lymph flow. Physiol Rev 1990;70:987–1028.[Abstract/Free Full Text]
- Ruehm SG, Corot C, Debatin JF. Interstitial MR lymphography with a conventional extracellular gadolinium-based agent: assessment in rabbits. Radiology 2001;218:664–669.[Abstract/Free Full Text]
- Taupitz M, Wagner S, Hamm B, Binder A, Pfefferer D. Interstitial MR lymphography with iron oxide particles: results in tumor-free and VX2 tumor-bearing rabbits. AJR Am J Roentgenol 1993;161:193–200.[Abstract/Free Full Text]
- Wagner S, Pfefferer D, Ebert W, et al. Intravenous MR lymphography with superparamagnetic iron oxide particles: experimental studies in rats and rabbits. Eur Radiol 1995;5:640–646.
- Ruehm SG, Schroeder T, Debatin JF. Interstitial MR lymphography with gadoterate meglumine: initial experience in humans. Radiology 2001;220:816–821.[Abstract/Free Full Text]
- Kettner BI, Aurisch R, Rückert JC, et al. Scintigraphic localization of lymphatic leakage site after oral administration of iodine-123-IPPA. J Nucl Med 1998;39:2141–2144.[Abstract/Free Full Text]
- Qureshy A, Kubota K, Ono S, Sato T, Fukuda H. Thoracic duct scintigraphy by orally administered I-123 BMIPP: normal findings and a case report. Clin Nucl Med 2001;26:847–855.[CrossRef][Medline]
- Meyerson HS. The physiologic importance of lymph. In: Hamilton WF, Dow P, eds. Handbook of physiology. Baltimore, Md: Williams & Wilkins, 1963; 1044–1050.
- Dumont AE, Mulholland JH. Flow rate and composition of thoracic-duct lymph in patients with cirrhosis. N Engl J Med 1960;263:471–474.[Medline]
- Takahashi H, Kuboyama S, Abe H, Aoki T, Miyazaki M, Nakata H. Clinical feasibility of noncontrast-enhanced magnetic resonance lymphography of the thoracic duct. Chest 2003;124:2136–2142.[CrossRef][Medline]
TOP
ABSTRACT
INTRODUCTION
