DOI:10.2214/AJR.07.2047
AJR 2007; 189:1051-1058
© American Roentgen Ray Society
MR Lymphography of Abdominal and Retroperitoneal Lymphatic Vessels
L. Arrivé1,
L. Azizi,
M. Lewin,
C. Hoeffel,
L. Monnier-Cholley,
C. Lacombe and
J. M. Tubiana
1 All authors: Department of Radiology, Hôpital St.-Antoine, 184 rue du
Faubourg Saint-Antoine, Paris 75012, France.
Received February 13, 2007;
accepted after revision June 7, 2007.
Address correspondence to L. Arrivé
(lionel.arrive{at}sat.aphp.fr).
Abstract
OBJECTIVE. The abdominal and retroperitoneal lymphatic system is
characterized by numerous anatomic variations. Our objective is to review MR
lymphographic features of normal anatomy and abnormal conditions.
CONCLUSION. MR lymphography is a noninvasive technique that is well
suited for the examination of abdominal and retroperitoneal lymphatic
vessels.
Keywords: abdominal imaging • flow dynamics • lymphatic system abnormalities • lymphatic system • MR lymphography • retroperitoneal imaging
Introduction
The lymphatic system that collects the lymph from various organs is a
closed network of vessels that begins with lymphatic capillaries in soft
tissues, extends to larger vessels that pass through lymph nodes, and again
collects in another network of vessels. Communication with the cardiovascular
system is through the thoracic duct
[1].
The lymphatic system is anatomically complex and difficult to image. For a
long time, lymphatic imaging was limited to the use of conventional
lymphography, which involved invasive procedures and patient discomfort
[2].
MR lymphography based on heavily T2-weighted fast spin-echo sequences and
maximum-intensity-projection reconstruction appears to be a useful noninvasive
technique to evaluate the lymphatic system
[3,
4]. In this article, we review
MR lymphographic features of normal anatomy and of various abnormal conditions
in the abdomen.
MR Lymphography Protocol
MR lymphography was performed on a 1.5-T unit (Magnetom Symphony, Siemens
Medical Solutions) with a six-channel phased-array body coil. Our protocol
includes an axial free-breathing HASTE sequence without fat suppression
(TR/TE, 1,200/114; matrix, 176 x 256; flip angle, 180°; section
thickness, 6 mm; acquisition time, 80 seconds) and a free-breathing 3D
high-spatial-resolution fast spin-echo sequence with an extremely long TE
(1,400/800; flip angle, 180°). A–90° radiofrequency pulse (the
so-called restore pulse) is applied at the end of the echo train to flip the
transverse magnetization to the longitudinal direction, shorten the spin
relaxation time, and accelerate the relaxation of the longitudinal
magnetization while maintaining the same contrast resolution and reducing the
acquisition time. The matrix is symmetric (256 x 256), the section
thickness is 1 mm, and the voxel size is 1 x 1 x 1 mm. A stack of
sections is acquired for diagnostic purposes. Postprocessing of the image data
is performed to obtain maximum-intensity-projection (MIP) images and
multiplanar reformatted images.
The typical acquisition time is 3–6 minutes for respiratory-triggered
navigator-gated acquisitions with the prospective acquisition correction
(PACE) technique. The 3D imaging technique has potential advantages over 2D
imaging, including the capacity to obtain thinner sections with no gap and a
higher signal-to-noise ratio. Because partial volume averaging effects may
obscure small structures, thin-section source images must always be reviewed.
Both sequences are based on heavily T2-weighted sequences that emphasize
static fluid signal in the fluid-containing structures such as lymphatic
vessels, whereas solid tissues and flowing blood have no signal. However,
these sequences should be performed before the IV injection of gadolinium
because gadolinium that is secreted in lymphatic vessels may result in
contrast alteration.
Anatomy of the Lymphatic System
The abdominal and retroperitoneal lymphatic system is characterized by
numerous anatomic variations
[1]. The appearance of
retroperitoneal lymph trunks markedly varies from thin or prominent thick
channels, parallel or converging channels, or a plexus
(Fig. 1). The lymph trunks
receive the lymph from the lower limbs, from the walls and viscera of the
pelvis, from the kidneys and adrenal glands, and from the deep lymphatics of
the abdominal wall. Alternating bands of constriction and dilatation are
characteristic of the appearance of lymphatic vessels. Areas of constriction
correspond to lymphatic valves
[5]. Most of the efferent
paraaortic vessels converge to form the right and left lumbar trunks, which
join the cisterna chyli (Fig.
2A,
2B).
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Fig. 1 —50-year-old woman who underwent MRI for cholestasis. Coronal
maximum-intensity-projection image shows prominent lumbar trunks
(arrows) on both right and left paravertebral areas. Abdominal
confluence of lymphatic vessels is shown as complex plexus with no saccular
formation.
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Fig. 2B —25-year-old man who underwent MRI for back pain. Coronal
maximum-intensity-projection image shows giant cisterna chyli at confluence of
left and right markedly dilated retroperitoneal trunks (arrows).
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Either a single or two mesenteric lymphatic trunks may be observed. The
mesenteric lymphatic vessels, which are very small, unite to form the
intestinal trunk, which enters the cisterna chyli (Fig.
3A,
3B,
3C). The intestinal trunk
receives the lymph from the stomach and intestine and from the pancreas,
spleen, and liver. The size of the intestinal lymphatic vessels varies
markedly depending on whether the patient is fasting
[1] (Fig.
4A,
4B,
4C,
4D,
4E).
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Fig. 3B —Axial single-shot turbo spin-echo (HASTE) sequence in
63-year-old man who underwent MRI for cholestasis. At intermediate levels,
intestinal trunks converge to form right and left intestinal trunks
(arrows).
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Fig. 3C —Axial single-shot turbo spin-echo (HASTE) sequence in
63-year-old man who underwent MRI for cholestasis. At upper level, mesenteric
trunk is shown coursing from mesentery to retroperitoneal space
(arrow).
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Fig. 4A —58-year-old woman who underwent MRI for cholangitis. Axial
single-shot turbo spin-echo (HASTE) sequence after 8 hours of fasting shows
small intestinal (arrow) and retrocrural (arrowhead)
lymphatic trunks.
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Fig. 4C —58-year-old woman who underwent MRI for cholangitis. Coronal
thin-section source images of 3D sequence show marked dilatation of lymphatic
trunks after regular meal (D) and with fasting (C).
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Fig. 4D —58-year-old woman who underwent MRI for cholangitis. Coronal
thin-section source images of 3D sequence show marked dilatation of lymphatic
trunks after regular meal (D) and with fasting (C).
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The cisterna chyli receives the two lumbar lymphatic trunks, right and
left, and the intestinal lymphatic trunk. The cisterna chyli is described in
anatomic studies as a saccular area of dilatation of the lymphatic channels
that originates at the L1–L2 level of the vertebral body and extends
5–7 cm in the caudocephalad direction. It is located in the retrocrural
space, usually to the immediate right of the abdominal aorta
[5].
Despite this classic description, the cisterna chyli has a highly variable
appearance. Complex anastomoses of lumbar lymphatics may result in a plexus
rather than a single duct (Fig.
1). Several sacculations of the convergent lymphatic channels may
be present (Fig. 5). This wide
variation of the cisterna chyli has led some authors to prefer the descriptive
term "abdominal confluence of the lymphatic trunks"
[6]. The term "cisterna
chyli" is used when a distinctly fusiform or saccular dilatation is
present. In addition, the size of the cisterna chyli is markedly variable,
with cases of very large cisterna chyli (so-called giant cisterna chyli)
reported [7] (Fig.
2A,
2B). After gadolinium
injection, contrast enhancement of the cisterna chyli may be observed on
delayed phase imaging [8] (Fig.
6A,
6B,
6C,
6D).
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Fig. 5 —19-year-old man who underwent MRI for follow-up of
biliary–enteric anastomosis. Coronal maximum-intensity-projection image
shows abdominal confluence of lymphatic vessels as bilateral right and left
saccular dilatations (arrows) that continue in cephalic direction as
thoracic duct (arrowheads).
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Fig. 6A —54-year-old woman who underwent MRI for cholestasis. Axial
single-shot turbo spin-echo (HASTE) T2-weighted image shows cisterna chyli as
uniformly high-signal-intensity saccular collection (arrows) in
prevertebral location.
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Fig. 6C —54-year-old woman who underwent MRI for cholestasis. Axial MR
images obtained at arterial (C) and delayed (D) phases show
contrast enhancement of cisterna chyli (arrows) at delayed phase
after gadolinium injection.
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Fig. 6D —54-year-old woman who underwent MRI for cholestasis. Axial MR
images obtained at arterial (C) and delayed (D) phases show
contrast enhancement of cisterna chyli (arrows) at delayed phase
after gadolinium injection.
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The cisterna chyli continues in the cephalic direction as a thoracic duct
that enters the thorax through the aortic hiatus of the diaphragm and
terminates at the junction of the left subclavian and internal jugular veins,
draining lymph into the venous circulation
[9] (Figs.
7A,
7B,
7C and
8).
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Fig. 8 —25-year-old man who underwent MRI for pancreatitis. Coronal
maximum-intensity-projection image shows right and left proximal thoracic
trunks (arrows) that join to form distal thoracic duct
(arrowhead).
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Abnormal Conditions
Dilatation of the lymphatic vessels and of the cisterna chyli may be
observed after surgical ligation of the thoracic duct during gastric or
esophageal surgery (Fig. 9A,
9B,
9C). MR lymphography easily
allows the differentiation between dilated cisterna chyli and retrocrural
lymph nodes. Lymphatic dilatation progressively resolves after the formation
of multiple collateral lymphatic pathways in the vicinity of the obstruction
[10].
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Fig. 9B —61-year-old man who underwent MRI after surgery for gastric
cancer. Axial single-shot turbo spin-echo (HASTE) (B) and coronal
maximum-intensity-projection (C) images show marked dilatation of
cisterna chyli after surgical ligation of thoracic duct.
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Fig. 9C —61-year-old man who underwent MRI after surgery for gastric
cancer. Axial single-shot turbo spin-echo (HASTE) (B) and coronal
maximum-intensity-projection (C) images show marked dilatation of
cisterna chyli after surgical ligation of thoracic duct.
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Intestinal lymphangiectasis is characterized by tortuosity and marked
dilatation of the mesenteric lymphatics (Fig.
10A,
10B,
10C,
10D). Clinically, an extreme
loss of protein in the gastrointestinal tract results in hypoalbuminemia,
edema, and pleural effusion. MR lymphography directly shows the dilatation of
mesenteric lymphatic vessels and associated lymphatic vessel
abnormalities.
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Fig. 10A —41-year-old man with intestinal lymphangiectasis and history
of chylous ascites. Axial single-shot turbo spin-echo (HASTE) images show
dilatation (arrows) of both right (A) and left (B)
intestinal lymphatic vessels.
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Fig. 10B —41-year-old man with intestinal lymphangiectasis and history
of chylous ascites. Axial single-shot turbo spin-echo (HASTE) images show
dilatation (arrows) of both right (A) and left (B)
intestinal lymphatic vessels.
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Fig. 10C —41-year-old man with intestinal lymphangiectasis and history
of chylous ascites. At upper level, marked dilatation of main intestinal trunk
is shown during its course from mesentery to retrocrural space.
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In lymphangioleiomyomatosis, proliferation of smooth-muscle cells in the
lymph vessels may produce cystic masses consistent with dilatation of the
abdominal lymph vessels due to lymphatic obstruction; these are the so-called
lymphangioleiomyomas (Fig.
11A,
11B,
11C). These
lymphangioleiomyomas are easily shown on MR lymphography
[11].
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Fig. 11B —37-year-old woman with lymphangioleiomyomatosis. Coronal true
fast imaging with steady-state free precession (B) and coronal
thin-section source image of 3D sequence (C) show marked dilatation
(arrows) of both iliac lymphatic trunks (B) (so-called
lymphangioleiomyomas) and retroperitoneal lymphatic trunks (C). B =
bladder.
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Fig. 11C —37-year-old woman with lymphangioleiomyomatosis. Coronal true
fast imaging with steady-state free precession (B) and coronal
thin-section source image of 3D sequence (C) show marked dilatation
(arrows) of both iliac lymphatic trunks (B) (so-called
lymphangioleiomyomas) and retroperitoneal lymphatic trunks (C). B =
bladder.
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After surgery involving the retroperitoneal area, such as esophageal,
gastric, or pancreatic surgery, injuries to the lymphatic vessels may be
observed [12]. These injuries
can result in small lymphoceles. In other cases, important lymphatic leaks may
result in chylous ascites (Fig.
12A). The leak may sometimes be directly shown on MR
cholangiography (Figs. 12B,
12C,
12D).
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Fig. 12A —43-year-old man who underwent MRI for chylous ascites after
cephalic pancreaticoduodenectomy for chronic pancreatitis. Coronal true fast
imaging with steady-state free precession (FISP) image shows chylous ascites
(asterisks) and retroperitoneal chylous collection
(arrows).
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Fig. 12B —43-year-old man who underwent MRI for chylous ascites after
cephalic pancreaticoduodenectomy for chronic pancreatitis. Axial true FISP
images show small leak (arrows) from retrocrural lymphatic trunk that
pierces diaphragmatic crus (B) between inferior vena cava and aorta and
diffuses in peritoneal cavity (C).
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Fig. 12C —43-year-old man who underwent MRI for chylous ascites after
cephalic pancreaticoduodenectomy for chronic pancreatitis. Axial true FISP
images show small leak (arrows) from retrocrural lymphatic trunk that
pierces diaphragmatic crus (B) between inferior vena cava and aorta and
diffuses in peritoneal cavity (C).
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Fig. 12D —43-year-old man who underwent MRI for chylous ascites after
cephalic pancreaticoduodenectomy for chronic pancreatitis. Coronal
thin-section source image of 3D sequence shows small leak (arrows)
from retroperitoneal lymphatic trunk (arrowhead).
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In summary, MR lymphography based on heavily T2-weighted fast spin-echo
sequences and MIP reconstruction appears to be a useful noninvasive technique
to evaluate the lymphatic system. It allows adequate evaluation of the
abdominal and retroperitoneal lymphatic system, which is characterized by
numerous anatomic variations. On CT images, anatomic variations such as giant
cisterna chyli or abnormal lymphatic dilatation may be mistaken for lymph
nodes or fluid collections, whereas MR lymphography easily shows the lymphatic
nature of the abnormalities.
Finally, MR lymphography is useful for evaluating patients with uncommon
diseases of the lymphatic system such as lymphedema, lymphangiectasis, and
lymphangioleiomyomatosis, or after injury of the lymphatic vessels during
surgery.
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Abstract
Introduction
