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Left-Sided Cisterna Chyli

Self Defense Forces Central Hospital Tokyo 154-8532, Japan

The cisterna chyli is the dilated origin of the thoracic duct, which receives the right and left lumbar lymphatic trunks and the intestinal lymphatic trunk. In 1996, Gollub and Castellino [1] first described its appearance on CT: the cisterna chyli appears as a retrocrural tubular structure of near-water attenuation and is located to the right of the aorta and anterior to the vertebral bodies between T11 and L1. The cisterna chyli may be located to the left of the aorta.

A 49-year-old asymptomatic man was admitted for surgical treatment of gastric carcinoma that had been detected on upper gastrointestinal endoscopy during an annual checkup. CT of the upper abdomen showed neither liver metastasis nor lymph node enlargement. Incidentally found was an 8-mm round structure of low attenuation at the retrocrural space to the left of the abdominal aorta; the average attenuation was 1.5 H on unenhanced CT and 5.6 H on enhanced CT (Fig. 1A,1B).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —49-year-old man with superficially sreading gastric carcinoma. Unenhanced CT scan at level of L1 shows 8-mm rounded retrocrural structure of similar attenuation to that of water to left of aorta (arrow).

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —49-year-old man with superficially sreading gastric carcinoma. Contrast-enhanced CT scan shows no definite enhancement of this structure (arrow).

At surgery, no regional lymph nodes were grossly enlarged, and distal gastrectomy was performed. Histologic examination revealed moderately differentiated tubular adenocarcinoma confined to the submucosa and no lymph node metastasis. Follow-up CT performed 1 year later showed no change in the appearance of a left-sided retrocrural structure of low attenuation.

Although the upper and lower portions of the thoracic duct usually originate from the left and right members of a pair of the ducts, respectively, variations are not rare [2]. In a study of 104 cadavers by Kutsuna [3], the duct was found to take a typical course in 92 cadavers (88.4%); two ducts paralleling each other drained into the left subclavian vein in 11 (10.6%); and the duct was located on the left side along the entire course in one (1.0%). Therefore, the left-sided cisterna chyli appeared the least common.

The left-sided cisterna chyli would be expected to be an exact mirror image of that described by Gollub and Castellino on CT scans [1]. In our patient, it appeared as a rounded structure of near-water attenuation and was smaller than 2 cm in diameter at the retrocrural space to the left of the aorta.

The left-sided cisterna chyli may mimic the structures that the retrocrural space to the left of the aorta contains: the hemiazygos vein, lymph nodes, and sympathetic chain. An enlarged lymph node with central necrosis or cystic degeneration may mimic the cisterna chyli. A history of malignant tumor and substantial change in size suggests the diagnosis of metastatic lymphadenopathy.

Radiologists should be aware that the cisterna chyli may be depicted on CT at the retrocrural space not only to the right but also to the left of the aorta. Bilateral cisterna chyli could be encountered more frequently than a left-sided one.

References

1. 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]
2. Rosse C, Gaddum-Rosse P. Hollinsheads's textbook of anatomy, 5th ed. New York: Lippincott-Raven, 1997: 508-510
3. Kutsuna M. The anatomy of the lymphatic system in the Japanese [in Japanese]. Tokyo: Kanehara Shuppan, 1968: 219-225

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kurosaki, Y. Articles by Fujikawa, A. Search for Related Content PubMed PubMed Citation Articles by Kurosaki, Y. Articles by Fujikawa, A. Social Bookmarking                      What's this?