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Clinical Investigations: MEDIASTINUM |

Clinical Feasibility of Noncontrast-Enhanced Magnetic Resonance Lymphography of the Thoracic Duct* FREE TO VIEW

Hiroyuki Takahashi; Shinichi Kuboyama; Hirohiko Abe; Takatoshi Aoki; Mitsue Miyazaki; Hajime Nakata
Author and Funding Information

*From the Department of Radiology (Dr. Takahashi), Japan Seamen’s Relief Association Moji Hospital, Kitakyushu-shi; Department of Internal Medicine (Drs. Kuboyama and Abe), Fukuoka Prefecture Asakura Hospital Hepato-Gastroenterology Center, Fukuoka-ken; Department of Radiology (Drs. Aoki and Nakata), University of Occupational and Environmental Health School of Medicine, Kitakyushu-shi; and MR Engineering Department (Dr. Miyazaki), Medical System R&D Center, Toshiba Corporation, Tochiji-ken, Japan.

Correspondence to: Hiroyuki Takahashi, MD, Department of Radiology, Japan Seamen’s Relief Association Moji Hospital, 1-3-1 Kiyotaki, Moji-ku, Kitakyushu-shi, 801-8550 Japan; e-mail: cbn15560@pop16.odn.ne.jp



Chest. 2003;124(6):2136-2142. doi:10.1378/chest.124.6.2136
Text Size: A A A
Published online

Study objective: The dilatation of the thoracic duct was previously demonstrated in liver cirrhosis by lymphangiography, endoscopic ultrasound, and at autopsy. The evaluation of the morphologic change of the thoracic duct may be important in assessing the altered lymphodymanics in liver cirrhosis. The objectives of this study were to determine which combination of posture and breathing phase during noncontrast-enhanced magnetic resonance lymphography (MRL) provided the clearest images, and to evaluate the morphologic changes in the thoracic duct in healthy volunteers and patients with liver disease and malignancy.

Design: Prospective study.

Setting: Community general hospital.

Design and subjects: Twenty-three healthy volunteers and 113 patients underwent the MRL examination using a three-dimensional, half-Fourier, fast spin echo sequence on a 1.5-T, whole-body magnetic resonance system. The appropriate posture and breathing phase of MRL to obtain the best visualization was first determined by trial on 14 healthy volunteers. Morphologic changes of the thoracic ducts were evaluated in 23 healthy volunteers including the 14 healthy volunteers for the first trial and 113 patients using this appropriate method. The width of the thoracic ducts in both patients and volunteers was measured.

Measurements and results: MRL with respiratory gating in the supine position depicted the thoracic duct well and was the most comfortable for the subjects. In 82 of 113 patients (72.6%), the thoracic ducts were entirely visualized from the diaphragm level to the subclavian region. The remaining 31 patients had ducts that could not be entirely visualized due to sections or short lengths that were obscured. The maximum diameter was 3.74 ± 0.81 mm in all healthy volunteers, 6.98 ± 2.77 mm in alcoholic cirrhosis, 4.12 ± 1.51 mm in nonalcoholic cirrhosis, 3.76 ± 1.10 mm in malignancy, and 3.60 ± 0.80 mm in chronic hepatitis (mean ± SD). The diameter in alcoholic cirrhosis was significantly greater than in other groups (p < 0.01).

Conclusions: Respiratory gating in the supine position is the best MRL method for acquiring the clearest images. This may be a good method of detecting morphologic changes in the thoracic duct. The patients with alcoholic cirrhosis showed a greater thoracic duct diameter than other groups.

Figures in this Article

The lymphatic system is an important circulatory system for the maintenance of an organism and its immunity. It contributes to a return of excess liquid and protein from the interstitial tissue to the circulatory system and to protection against bacteria.1 Until recently, the only methods available to examine the lymphatic system have been either by radiograph lymphography with contrast material or lymphography with radionuclides. Radiograph lymphography is an invasive procedure with drawbacks such as the use of contrast material and a long examination time.2 Lymphography with radionuclides lacks morphologic detail. More recently, endoscopic ultrasound was developed to observe the thoracic duct, but this method is semi-invasive and is unable to evaluate the entire anatomy.3 A new method of visualizing the vessel by using magnetic resonance lymphography (MRL) with three-dimensional (3D), short echo-spacing, half-Fourier, fast spin echo (FSE) sequences was reported by Hayashi and Miyazaki.4 The thoracic duct, which is the widest lymph duct in the human body, can be visualized with this technique. However, to our knowledge, neither a study examining the appropriate MRL method nor a study dealing with the feasibility of its clinical usefulness have been reported. In the present study, we set out to determine which combination of posture and breathing phase during MRL of the thoracic duct provide the clearest images, and evaluated the morphologic changes in the thoracic duct in healthy volunteers and patients with liver disease and malignancy.

Study Populations

Twenty-three healthy volunteers (18 men and 5 women; mean age, 35.7 years; age range, 26 to 48 years) and 113 patients (81 men and 32 women; mean age, 65.1 years; age range, 34 to 85 years) with liver disease and malignancy (Table 1 ) underwent MRL during the period between June 1999 and September 2002. Informed consent was obtained from each subject. The MRL for the patients was performed at the same time as the magnetic resonance examination of the liver and other organs. The total acquisition time for MRL was approximately 5 min, and the average study time for MRL was 10 min.

MRI

In the first part of this study, the appropriate posture and breathing phase to obtain the best visualization of the thoracic duct was determined by trial on 14 healthy volunteers. They were examined with four different postures and breathing methods: (1) intermittent breath-holding after expiration in the supine position, (2) intermittent breath-holding after inspiration in the supine position, (3) intermittent breath-holding after expiration in the prone position, and (4) respiratory gating in the supine position. An intermittent breath-holding was applied for each slice encoding. Each slice encoding required a breath-holding of approximately 1 s, and normal breathing was permitted during the remainder of the repetition time. This was repeated for the number of slice encodings in the 3D acquisition. After acquisition, maximum intensity projection (MIP) processing was performed. Respiratory gating parameters were adjusted for each patient individually, including respiratory cycle length, gate delay, and gate width. Prospective respiratory gating was used using the sensor that detected the motion of the body surface around the chest wall. The actual single shot acquisition time was 880 ms. A 1.5-T magnetic resonance imager (VISART EX; Toshiba; Tokyo, Japan) with a quadrature detection phased-array coil was used with a 3D, half-Fourier, FSE sequence. Coronal in-plane acquisition was performed with a resolution of 1.1 × 1.1 mm. The sequences were as follows: repetition time in milliseconds/echo times in milliseconds, 3,000 to 6,000/500 (respiratory gating), 7,000/500 (intermittent breath-holding); echo spacing, 12.5 ms; matrix size, 320 × 320; 30 slice partitions with a 2.0-mm slice thickness; and field of view, 360 × 360 mm.

Image Analysis

For the observation of the MIP images, the thoracic duct was divided into three parts: (1) upper part, from the subclavian region to the level of left main bronchus; (2) middle part, proximal half of the distance from the left main bronchus to the diaphragm; and (3) lower part, distal half of the duct. The thoracic ducts observed with the four methods were compared on the basis of the degree of visualization of the three parts. The degree of visualization was as follows: poor (the anatomic part was not or partially visible), good (the anatomic part was mostly visible), and excellent (the entire anatomic part was clearly visible). The widest portion of the thoracic ducts was measured on the MIP images after magnifying on the display, and the lateral views, slight left anterior and right anterior oblique paracoronal views, and original images were used for reference, and then statistically analyzed. At the end of the MRL examination, each volunteer was asked to answer which of the four methods was the most comfortable. All images were evaluated by two radiologists, and a final decision was reached by consensus. MRL readers were blinded to each patient’s diagnosis. After we decided on the most appropriate technique for our 14 healthy volunteers, the other 9 healthy volunteers and all patients were examined using this same technique.

As the second part of this study, morphologic change of the thoracic duct was evaluated in 23 healthy volunteers including the 14 healthy volunteers used in the first trial and 113 patients using the appropriate method. We assessed the visualization of the main thoracic duct for each part, the existence of tortuosity, the visualization of drainage into the subclavian region, and the cisterna chyli. We classified the patients into four groups: alcoholic liver cirrhosis (group 1; n = 12), nonalcoholic liver cirrhosis (group 2; n = 45), malignancy (group 3; n = 43), and chronic hepatitis (group 4; n = 13). The diagnosis of malignancy included gastric cancer (n = 24), colon cancer (n = 4), lung cancer (n = 3), gallbladder and common bile duct cancer (n = 3), pancreas cancer (n = 3), renal cancer (n = 2), esophageal cancer (n = 1), gastric malignant lymphoma (n = 1), prostatic cancer (n = 1), and breast cancer (n = 1). The widest portion of the thoracic ducts in both patients and volunteers was measured, and then statistically analyzed. Serum albumin and sodium are factors that affect hepatic lymph production, and an increased lymph production causes expansion of the thoracic duct. We examined the relation between the diameter of the thoracic duct and the serum albumin and sodium in 10 patients with alcoholic liver cirrhosis, 24 patients with nonalcoholic liver cirrhosis, 14 patients with malignancy, and 6 patients with chronic hepatitis. These tests were performed within 1 week of their MRL examinations.

Statistical Analysis

Values are expressed as means ± SD. Differences in the diameter were evaluated using the Kruskal-Wallis test. Directed paired comparisons of individual groups were conducted using the Mann-Whitney U test. Regression analysis was used to evaluate the correlation between the diameter of the thoracic duct and the serum albumin and sodium levels. The software used was StatView (Version 5.0; SAS Institute; Cary, NC); p < 0.05 was considered statistically significant.

Figure 1 shows the MRL of the thoracic duct of a healthy volunteer in the four different postures and breathing techniques. Figure 2 shows the mean maximum diameter of the thoracic duct in the four methods. Table 2 summarizes the degree of visualization in each case. The mean maximum diameter of the thoracic duct was 3.46 ± 0.56 mm in respiratory gating, 3.99 ± 0.82 mm in intermittent breath-holding after expiration in the supine position, 3.57 ± 0.77 mm in intermittent breath-holding after inspiration in the supine position, and 3.77 ± 0.60 mm in intermittent breath-holding after expiration in the prone position. The diameter of the thoracic duct in intermittent breath-holding after expiration in the supine position was significantly greater than in respiratory gating and intermittent breath-holding after inspiration in the supine position (p < 0.05). In the upper and lower parts of the thoracic duct, there was little difference in the visualization among the four methods. The middle part, however, was most clearly visualized when using the respiratory gating in the supine position. All but one volunteer reported respiratory gating was the most comfortable. The remaining volunteer reported both respiratory gating and the intermittent breath-holding method in the supine position were comfortable. We thus regarded respiratory gating in the supine position as the appropriate method for MRL of the thoracic duct.

The examination with respiratory gating in the supine position was employed on the remaining nine healthy volunteers and 113 patients. The maximum diameter of the duct ranged from 2.62 to 5.57 mm (mean, 3.74 ± 0.81 mm) in all 23 volunteers. In 82 of 113 patients (72.6%), the thoracic ducts were entirely visualized in all three parts. The remaining 31 patients had ducts that could not be entirely visualized due to sections or short lengths that were obscured. In 19 of these patients, some part of the duct was obscured due to heart compressions. In 12 of 31 patients, the thoracic duct either above or below the heart could not be seen in its entirety possibly as a result of pleural change, compression by organs, osteophytes, hiatal hernias, etc. The thoracic ducts were divided into two separate channels in 10 cases (8.85%). Sixty-five cases (57.5%) showed adequate drainage into the subclavian region. Sixty-two patients (54.9%) demonstrated a cisterna chyli or the ducts origin at the upper lumbar level. Figure 3 shows the statistical results of healthy volunteers and the four patient groups. The maximum diameters of the thoracic duct ranged from 1.44 to 10.34 mm (mean, 4.23 ± 1.76 mm) in all patients; from 3.26 to 10.34 mm (mean, 6.98 ± 2.77 mm) in group 1; from 1.44 to 9.19 mm (mean, 4.12 ± 1.51 mm) in group 2; from 2.30 to 7.47 mm (mean, 3.76 ± 1.10 mm) in group 3; and from 2.53 to 5.17 mm (mean, 3.60 ± 0.80 mm) in group 4. In 7 of 12 patients with alcoholic liver cirrhosis, in 4 of 45 patients with nonalcoholic liver cirrhosis, and in 2 of 43 patients with malignancy, the thoracic duct diameters were > 6 mm. None of the patients with chronic hepatitis nor the healthy volunteers had such wide thoracic ducts. The difference in maximum diameter among the four patient groups and healthy volunteers was significant (p < 0.01). The diameter of group 1 was significantly wider than that of healthy volunteers, and of groups 2, 3, and 4 (p < 0.01). There was no significant difference between groups 2, 3, and 4, and healthy volunteers (p > 0.1). Figure 4 shows the MRL of the thoracic duct in a 54-year-old man with alcoholic liver cirrhosis, and Figure 5 is from a 66-year-old man with nonalcoholic liver cirrhosis. Tortuous ducts were observed in 22 of 57 patients (38.6%) with liver cirrhosis. The mean serum albumin level was 3.51 ± 0.63 g/dL (mean interval, 1.90 days) in 10 patients of group 1, 3.23 ± 0.43 g/dL (mean interval, 2.53 days) in 24 patients of group 2, 3.58 ± 0.52 g/dL (mean interval, 2.21 days) in 14 patients of group 3, and 3.82 ± 0.65 g/dL (mean interval, 0.67 days) in 6 patients of group 4. The difference among the four groups was not significant (p > 0.1). The mean serum sodium levels of 10 patients of group 1, 24 patients of group 2, 14 patients of group 3, and 6 patients of group 4 were 137.90 ± 1.91 mEq/L, 137.00 ± 4.85 mEq/L, 138.29 ± 3.93 mEq/L, and 140.00 ± 4.78 mEq/L, respectively. The difference in serum sodium level among the four groups was not significant (p > 0.1). There was no correlation between the diameter of the thoracic duct and the serum albumin level or serum sodium level (p > 0.05).

The lymphatic system is an independent network for the circulation of fluid throughout the body, and it contributes to the return of excess liquid and protein from the interstitial tissue to the circulatory system.1 The thoracic duct consists of a relatively small vessel that shows slower flow than that of the cardiovascular system. Since MRL is magnetic resonance hydrography using a long repetition time and long effective echo time, this technique is particularly suitable for the delineation of the thoracic duct. In the present study, we evaluated the appropriate method of MRL for the thoracic duct and its clinical application to disease.

Hayashi and Miyazaki4 reported that the thoracic duct could be visualized in six healthy volunteers at MRL with a short spacing, 3D, half-Fourier, FSE sequence and intermittent breath-hold. However, no study examining the appropriate posture and breathing type of MRL obtaining best visualization has been reported. Since in this study we did not compare MRL with another “gold standard,” it cannot be said that this is a superior method of assessing the thoracic duct; however, we found that respiratory gating in the supine position was the best method for MRL visualization of the thoracic duct while taking into consideration the physical comfort of the patient. Pomerantz et al5 reported that the cisterna chyli and left supraclavicular lymph nodes could be observed in 35 of 98 patients (35.7%) and in 56 of 115 patients (48.7%) in radiograph lymphangiography with the use of a contrast agent, respectively. In the present study, we could image the cisterna chyli and/or their origin at the upper lumbar level in 62 of 113 cases (54.9%) and the entry of the duct into the subclavian region in 63 cases (55.8%). Divided thoracic channels were observed in 10 of 113 patients (8.9%), and divided channel was seen in one of 23 volunteers (4.4%). Rosenberger and Abrams6 reported that multiple thoracic channels were observed in 30 of 390 subjects (7.7%). The frequency of visualizing the cisterna chyli, the entry into the subclavian region, and the divided channel in the present study were similar to those reported in radiograph lymphangiography.

The maximum diameters ranged from 2.62 to 5.57 mm in healthy volunteers and 1.44 to 10.34 mm in patients. Pomerantz et al5 reported the diameter at the end of the thoracic duct varied between 0.5 mm and 12 mm in 115 cases in radiograph lymphangiography, and other studies68 documented the diameter ranging from 1 to 8 mm. The diameter of the thoracic duct in the present study concurred with these previous values, thus supporting the premise that the method in the present study appeared to measure the true diameter of the thoracic duct.

Thoracic duct dilatation has been demonstrated in portal hypertension and liver cirrhosis by lymphangiography, endoscopic ultrasound, and at autopsy.3,7,910 It was reported that enlargement of the thoracic duct in liver cirrhosis is due to an increased production of liver lymph. Thoracic duct pressure is related to the amount of duct dilatation, and cannulation of the thoracic duct with decompression produces changes similar to a portosystemic shunt.10 The production of liver lymph depends on the resultant gradient of hydrostatic and oncotic pressure differences between blood and tissues.1112 Portal pressure and serum sodium are factors involved in hydrostatic pressure, and serum albumin is a factor of oncotic pressure. According to Witte et al,1213 intrahepatic portal pressure becomes elevated and the transmural oncotic gradient in the liver increases in patients with liver cirrhosis despite hypoproteinemia. In this study, there was no correlation between the diameter of the thoracic duct and the serum albumin or sodium level. However, the meaning of this result is unclear since this measurement was performed only on a small number of patients without control of hydration. Portal hypertension, which results from the obstruction of hepatic venules, is the most significant driving force responsible for the outpouring of hepatic lymph in liver cirrhosis.7,10,1213 Vidins et al14 reported that patients with alcoholic liver disease showed a marked reduction in sinusoidal areas of their livers relative to those of patients with nonalcoholic liver disease, and that portal pressure increases inversely with the sinusoidal area when that area decreases below 20% of normal. In the present study, significant thoracic duct dilatation was only recognized in patients with alcoholic liver cirrhosis, and no correlation was observed between the diameter of the thoracic duct and serum albumin/sodium level. This may result from the difference in the hepatic architecture between alcoholic and nonalcoholic liver cirrhosis. However, we have no direct evidence to support this in the present study since no measurement of portal pressure was performed.

Though overlapping of thoracic duct sizes among patients groups occurred, all of the ducts of hepatitis patients and healthy volunteers fell < 6 mm. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value for each thoracic duct diameter to diagnose the presence of alcoholic liver cirrhosis (Table 3 ). A cut-off point of 8 mm seems to be the best diagnostic guide for the detection of alcoholic liver cirrhosis. When the criterion of 8 mm was used, sensitivity, specificity, positive predictive value, and negative predictive value were 50.0%, 98.0%, 75.0%, and 94.3%, respectively.

In conclusion, noncontrast-enhanced MRL is a safe and noninvasive method for imaging the thoracic duct. Respiratory gating in the supine position seems to be the appropriate method for MRL to obtain the best visualization. MRL may be a good method of detecting morphologic changes in the thoracic duct. MRL may be useful for a preoperative evaluation to avoid thoracic duct injury, diagnosis of chylothorax, and evaluation of lymph production.

Abbreviations: FSE = fast spin echo; MIP = maximum intensity projection; MRL = magnetic resonance lymphography; 3D = three dimensional

This work was performed at Fukuoka Prefecture Asakura Hospital Hepato-Gastroenterology Center.

Table Graphic Jump Location
Table 1. Characteristics of Patients*
* 

Data are presented as No. or mean (range).

Figure Jump LinkFigure 1. MRL of the thoracic duct in a 48-year-old healthy man. Top left: Respiratory gating in the supine position. The entire anatomic part of the thoracic duct is clearly visible. Top right: Intermittent breath-holding after expiration in the supine position. The upper and lower parts of the thoracic duct are clearly visible. Middle part is also mostly visible. Bottom left: Intermittent breath-holding method after inspiration in the supine position. The upper part of the thoracic duct is mostly visible, and lower part is clearly visible. The middle part is only partially visualized. Bottom right: Intermittent breath-holding after expiration in the prone position. The lower part of the thoracic duct is clearly visible. Only the upper part is partially visible.Grahic Jump Location
Figure Jump LinkFigure 2. Bar chart of the maximum diameters of the thoracic duct in the four different posture and breathing techniques. The diameter in intermittent breath-holding after expiration in the supine position was significantly greater than in respiratory gating and intermittent breath-holding after inspiration in the supine position (p < 0.05). Respiratory gating = respiratory gating in the supine position. After expiration = intermittent breath-holding after expiration in the supine position. After inspiration = intermittent breath-holding after inspiration in the supine position. In the prone position = intermittent breath-holding after expiration in the prone position.Grahic Jump Location
Table Graphic Jump Location
Table 2. Degree of Visualization of Each Anatomic Part of Thoracic Duct According to Method
* 

A = respiratory gating in the supine position; B = intermittent breath-holding after expiration in the supine position; C = intermittent breath-holding method after inspiration in the supine position; and D = intermittent breath-holding after expiration in the prone position.

Figure Jump LinkFigure 3. Bar chart of the maximum diameters of the thoracic duct in healthy volunteers and four patient groups. The difference in the maximum diameter among healthy volunteers and four groups was significant (p < 0.01). The diameter of group 1 was significantly wider than those of healthy volunteers, group 2, group 3, and group 4 (p < 0.01). Volunteers = all healthy volunteers (n = 23); group 1 = alcoholic liver cirrhosis (n = 12); group 2 = nonalcoholic liver cirrhosis (n = 45); group 3 = malignancy (n = 43); group 4 = chronic hepatitis (n = 13).Grahic Jump Location
Figure Jump LinkFigure 4. MRL of the thoracic duct in a 54-year-old man with alcoholic liver cirrhosis. Note the tortuous and wide thoracic duct with a maximal diameter of 10.17 mm.Grahic Jump Location
Figure Jump LinkFigure 5. MRL of the thoracic duct in a 66-year-old man with nonalcoholic liver cirrhosis. The widest portion of the thoracic duct is 9.19 mm.Grahic Jump Location
Table Graphic Jump Location
Table 3. Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for Thoracic Duct Diameter in Diagnosing the Presence of Alcoholic Liver Cirrhosis

We thank Kouji Nagata, magnetic resonance engineer, for assistance.

Gyton, AC, Hall, JE (1999)Textbook of medical physiology 9th ed. ,197-201 W. B. Saunders Company. Pennsylvania, PA: [Japanese edition; Tokyo, Japan; Igaku-shoin Ltd.]
 
Kinmonth, JB, Taylor, GW, Harper, RK Lymphangiography: a technique for its clinical use in the lower limb.BMJ1955;1,940-942. [CrossRef] [PubMed]
 
Parasher, VK, Meroni, E, Malesci, A, et al Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound.Gastrointest Endosc1998;48,588-592. [CrossRef] [PubMed]
 
Hayashi, S, Miyazaki, M Thoracic duct; visualization at nonenhanced MR lymphography-initial experience.Radiology1999;212,598-600. [PubMed]
 
Pomerantz, M, Herdt, JRL, Rockoff, SD, et al Evaluation of functional anatomy of thoracic duct by lymphangiography.J Thorac Cardiovasc Surg1963;46,568-575. [PubMed]
 
Rosenberger, A, Abrams, HL Radiology of the thoracic duct.AJR Am J Roentgenol1971;111,807-820
 
Shieber, W Lymphangiographic demonstration of thoracic duct dilatation in portal cirrhosis.Surgery1965;57,522-524. [PubMed]
 
Nusbaum, M, Baum, S, Hedges, RC, et al Roentgenographic and direct visualization of thoracic duct.Arch Surg1964;88,105-113. [CrossRef] [PubMed]
 
Dumont, AE, Mulholland, JH Flow rate and composition of thoracic duct lymph in patient with cirrhosis.N Engl J Med1960;263,471-474. [CrossRef] [PubMed]
 
Dumont, AE, Mulholland, JH Alteration in thoracic duct lymph flow in hepatic cirrhosis: significance in portal hypertension.Ann Surg1962;156,668-677. [CrossRef] [PubMed]
 
Witte, MH, Witte, CL, Dumont, AF Estimated net transcapillary water and protein flux in the liver and intestines of patients with portal hypertension from hepatic cirrhosis.Gastroenterology1981;80,265-272. [PubMed]
 
Witte, CL, Witte, MH, Dumont, AE The portal triad in hepatic cirrhosis.Surg Gynecol Obstet1978;146,965-974. [PubMed]
 
Witte, MH, Dumont, AE, Cole, WR, et al Lymph circulation in hepatic cirrhosis: effect of portacaval shunt.Ann Intern Med1969;70,303-310. [PubMed]
 
Vidins, EI, Britton, RS, Medline, A, et al Sinusoidal caliber in alcoholic and nonalcoholic liver disease: diagnostic and pathogenic implications.Hepatology1985;5,408-414. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. MRL of the thoracic duct in a 48-year-old healthy man. Top left: Respiratory gating in the supine position. The entire anatomic part of the thoracic duct is clearly visible. Top right: Intermittent breath-holding after expiration in the supine position. The upper and lower parts of the thoracic duct are clearly visible. Middle part is also mostly visible. Bottom left: Intermittent breath-holding method after inspiration in the supine position. The upper part of the thoracic duct is mostly visible, and lower part is clearly visible. The middle part is only partially visualized. Bottom right: Intermittent breath-holding after expiration in the prone position. The lower part of the thoracic duct is clearly visible. Only the upper part is partially visible.Grahic Jump Location
Figure Jump LinkFigure 2. Bar chart of the maximum diameters of the thoracic duct in the four different posture and breathing techniques. The diameter in intermittent breath-holding after expiration in the supine position was significantly greater than in respiratory gating and intermittent breath-holding after inspiration in the supine position (p < 0.05). Respiratory gating = respiratory gating in the supine position. After expiration = intermittent breath-holding after expiration in the supine position. After inspiration = intermittent breath-holding after inspiration in the supine position. In the prone position = intermittent breath-holding after expiration in the prone position.Grahic Jump Location
Figure Jump LinkFigure 3. Bar chart of the maximum diameters of the thoracic duct in healthy volunteers and four patient groups. The difference in the maximum diameter among healthy volunteers and four groups was significant (p < 0.01). The diameter of group 1 was significantly wider than those of healthy volunteers, group 2, group 3, and group 4 (p < 0.01). Volunteers = all healthy volunteers (n = 23); group 1 = alcoholic liver cirrhosis (n = 12); group 2 = nonalcoholic liver cirrhosis (n = 45); group 3 = malignancy (n = 43); group 4 = chronic hepatitis (n = 13).Grahic Jump Location
Figure Jump LinkFigure 4. MRL of the thoracic duct in a 54-year-old man with alcoholic liver cirrhosis. Note the tortuous and wide thoracic duct with a maximal diameter of 10.17 mm.Grahic Jump Location
Figure Jump LinkFigure 5. MRL of the thoracic duct in a 66-year-old man with nonalcoholic liver cirrhosis. The widest portion of the thoracic duct is 9.19 mm.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Characteristics of Patients*
* 

Data are presented as No. or mean (range).

Table Graphic Jump Location
Table 2. Degree of Visualization of Each Anatomic Part of Thoracic Duct According to Method
* 

A = respiratory gating in the supine position; B = intermittent breath-holding after expiration in the supine position; C = intermittent breath-holding method after inspiration in the supine position; and D = intermittent breath-holding after expiration in the prone position.

Table Graphic Jump Location
Table 3. Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for Thoracic Duct Diameter in Diagnosing the Presence of Alcoholic Liver Cirrhosis

References

Gyton, AC, Hall, JE (1999)Textbook of medical physiology 9th ed. ,197-201 W. B. Saunders Company. Pennsylvania, PA: [Japanese edition; Tokyo, Japan; Igaku-shoin Ltd.]
 
Kinmonth, JB, Taylor, GW, Harper, RK Lymphangiography: a technique for its clinical use in the lower limb.BMJ1955;1,940-942. [CrossRef] [PubMed]
 
Parasher, VK, Meroni, E, Malesci, A, et al Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound.Gastrointest Endosc1998;48,588-592. [CrossRef] [PubMed]
 
Hayashi, S, Miyazaki, M Thoracic duct; visualization at nonenhanced MR lymphography-initial experience.Radiology1999;212,598-600. [PubMed]
 
Pomerantz, M, Herdt, JRL, Rockoff, SD, et al Evaluation of functional anatomy of thoracic duct by lymphangiography.J Thorac Cardiovasc Surg1963;46,568-575. [PubMed]
 
Rosenberger, A, Abrams, HL Radiology of the thoracic duct.AJR Am J Roentgenol1971;111,807-820
 
Shieber, W Lymphangiographic demonstration of thoracic duct dilatation in portal cirrhosis.Surgery1965;57,522-524. [PubMed]
 
Nusbaum, M, Baum, S, Hedges, RC, et al Roentgenographic and direct visualization of thoracic duct.Arch Surg1964;88,105-113. [CrossRef] [PubMed]
 
Dumont, AE, Mulholland, JH Flow rate and composition of thoracic duct lymph in patient with cirrhosis.N Engl J Med1960;263,471-474. [CrossRef] [PubMed]
 
Dumont, AE, Mulholland, JH Alteration in thoracic duct lymph flow in hepatic cirrhosis: significance in portal hypertension.Ann Surg1962;156,668-677. [CrossRef] [PubMed]
 
Witte, MH, Witte, CL, Dumont, AF Estimated net transcapillary water and protein flux in the liver and intestines of patients with portal hypertension from hepatic cirrhosis.Gastroenterology1981;80,265-272. [PubMed]
 
Witte, CL, Witte, MH, Dumont, AE The portal triad in hepatic cirrhosis.Surg Gynecol Obstet1978;146,965-974. [PubMed]
 
Witte, MH, Dumont, AE, Cole, WR, et al Lymph circulation in hepatic cirrhosis: effect of portacaval shunt.Ann Intern Med1969;70,303-310. [PubMed]
 
Vidins, EI, Britton, RS, Medline, A, et al Sinusoidal caliber in alcoholic and nonalcoholic liver disease: diagnostic and pathogenic implications.Hepatology1985;5,408-414. [CrossRef] [PubMed]
 
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