- Email: [email protected]
The demonstration of pulmonary lymphatics by lymphography in a patient with chylothorax
Clin. Radiol. (1966) 17, 92-94
THE
DEMONSTRATION
LYMPHOGRAPHY
OF IN
A
PULMONARY
PATIENT
WITH
LYMPHATICS
BY
CHYLOTHORAX
W. F. W H I T E a n d W. U R Q U H A R T *
From The Westminster Hospital, London, S.W.1
O b s t r u c t i o n o f the thoracic duct in the neck a n d r e t r o g r a d e flow o f contrast m e d i u m into the mediastinal a n d p u l m o n a r y lymphatics were d e m o n s t r a t e d in a case o f c h y l o t h o r a x investigated b y l y m p h o g r a p h y . A tear in the mediastinal p l e u r a was found at o p e r a t i o n a n d repair o f this resulted in cure. It is p o s t u l a t e d that the a b n o r m a l l y m p h a t i c flow was present p r i o r to the occurrence o f pleural lesion. The interest in this case lies in the d e m o n s t r a t i o n o f the p u l m o n a r y lymphatics during life.
SINCE the introduction o f oily contrast m e d i a by Wallace, Jackson, Schaffer, G o u l d , Greening, Weiss a n d K r a m e r (1961) to l y m p h o g r a p h y , it has been possible to study abnormalities o f the thoracic duct. F o l l o w i n g routine l y m p h o g r a p h y from the feet, chest x-ray often shows the p a r t i a l l y filled t h o r a c i c duct. Studies on p u l m o n a r y lymphatics are o f considerable interest a n d to date have been m a d e on post m o r t e m specimens (Trapnell, 1963). The characteristic a p p e a r a n c e s o f the lymphatics in the lungs as shown b y p o s t - m o r t e m injection studies are n o w well known. In a search o f the literature, however, we have failed to find any case where the p u l m o n a r y lymphatics have been d e m o n s t r a t e d in the living subject. The following is a case r e p o r t o f a patient with c h y l o t h o r a x investigated by l y m p h o g r a p h y . Case Report.--A male, age 38 years, was admitted for investigations following mass miniature radiography where the appearances of a large right pleural effusion were seen. He had no complaints and the only possible relevant history was of falling from his bicycle some weeks prior to admission. The only abnormal physical signs were those of a right pleural effusion. Investigations.--Hb. 113 ~, WBC. 5,000, normal differential. E.S.R. 7 mm./hr. (Wintrobe), Serum Na. 144m.Eq/litre, K. 4-7 m.Eq/litre, Bicarbonate 29m.Eq/litre, Sp.Gravity 1.0270, Urea 27 rag./ 100 ml., Alkaline Phosphatase 8 K.A. units. Bronchoscopy showed no abnormality of the cords, trachea, carina or bronchi. Pleural aspiration was performed on three occasions, a total of 7 litres of milky fluid being withdrawn. Laboratory investigation confirmed this to be chyle. Cytological examination showed the presence of numerous lymphocytes, but no polymorphs. There were a number of rnesothelial pleural cells. No cells which could be regarded as malignant were present. Radiological lnvestigations.--Chest x-ray prior to admission showed an infra-pulmonary effusion with fluid
FIG. 1 Chest x-ray showing an infra-pulmonary effusion. extending up the thoracic wall and into the horizontal fissure and greater fissure (Fig. 1). X-rays on admission showed a large right pleural effusion. The dome of the diaphragm was not elevated and there was no evidence of collapse at the right base. The lateral decubitus film confirmed the presence of the effusion with fluid passing up into the fissures. Lymphogram.--Procedure: Routine lymphogram performed from both feet following the injection of Patent Blue Violet (P.B.V.). 10 ml. Lipiodol ultra fluid were injected into each foot under fluoroscopic control. The contrast medium passed through lymphatics to normal inguinal, iliac and para-aortic nodes and entered the thoracic
*Present address, Newcastle General Hospital. 92
THE D E M O N S T R A T I O N
FiG. 2A
OF P U L M O N A R Y
FIG. 2B
LYMPHATICS
BY L Y M P H O G R A P H Y
93
FIG. 2C
FIG. 2D FIG. 2E FIG. 2A--Retrograde flow of contrast medium into medlastinum and the right hdar region, FIG. 2B--An oblique view showing the contrast medmm passing anteriorly. Fig. 2C--The thoracic duct, diverticulum and paratracheal lymphatics are shown on a later oblique view. FIG. 2D--Lateral vlew of chest showing opaclficatlon of intra-pulmonary, perlbronchial and sub-pleural lymphatics, together with a dilated tortuous internal mammary vessel, FIG, 2E The sub-pleural vessels are more clearly seen in this view,
duct. At the upper end of the thoracic duct there appeared to be an obstruction with backflow into the left supraclavicular nodes, in an amount in excess of that normally seen. A persistent collection of contrast medium, possibly a lymphatic cyst or diverticulum, was seen posterior to the termination of the thoracic duct. Fig. 2a shows retrograde flow into the mediastinum and the right hilar region; Fig. 2b, an oblique view, shows the dye passing anteriorly and Fig. 2c shows the filling of the paratracheal lymphatics and demonstrates the posterior position o f the diverticulum.
Fig. 2d shows the opacification of intrapulmonary, peribronchial and sub-pleural lymphatics together with a very dilated tortuous internal mammary vessel. Fig. 2e shows more clearly the sub-pleural vessels. Radio-opaque medium was seen at the most dependent part o f the right pleural cavity. Operation.--A right thoracotomy was performed and P.B.V. which had been previously injected subcutaneously in the left leg was present in the pleural cavity. After drainage o f the dye-coloured chyle from the pleural cavity, the
94
CLINICAL RADIOLOGY A chest x-ray taken 7 months after operation (Fig. 3) shows residual pleural thickening only, but no evidence of fluid.
CONCLUSIONS Obstruction of the upper end of the thoracic duct was shown to be present by the retrograde flow of the radio-opaque material into the mediastinum and by the absence of the characteristic mottled appearance of the contrast medium in the lungs usually seen following injection. It is thought that two pathways existed for drainage of the thoracic duct, one via the mediastinal and internal mammary lymphatics to the right subclavian lymphatics and thus back to the great veins, and an alternative pathway via the bronchial lymphatics to the pulmonary vessels and thence to the hilar region. It is postulated that trauma sustained when the patient fell from his bicycle caused rupture of the pleura overlying the mediastinum and gave rise to the chylothorax. This supposes that the abnormal lymphatic drainage existed before the injury. Closure of the pleural defect resulted in clinical cure of the chylothorax.
Fro. 3 Chest x-ray seven months after operation.
pleural lymphatics were seen to be dilated and tortuous over the mediastinal, parietal and visceral pleura. A small tear was found in the pleura low down over the mediastinum from which chyle was leaking. This tear was repaired, and a piece of parietal pleura was removed for histology. The chest wall was closed routinely. The histological report of the specimen showed the pleura to be replaced by a layer of granulation tissue, with a plaque of structureless granular material on top of that, mixed with fibrin. Frozen section showed that a substantial part of the granular material consists of extracellular lipid droplets, some of it anisotropic. The underlying granulation tissue was rich in spindleshaped histiocytes loaded with phagocytosed fatty droplets.
Aeknowledgements.--We are indebted to Mr. Charles Drew, Mr. Peter Jones and Dr. Peter Emerson for their permission to publish this case under their care and for their encouragement and help. We are also grateful to Dr. K. A. Newton and Dr. B. Strickland for their helpful suggestions in the preparation of this article, to Dr. Peter Hansell and the Photographic Department for the preparation of the photographs and to Mrs. Chatfield for her secretarial help. REFERENCES
WALLACE, S., JACKSON, L., SCHAEFER, B., GOULD, J., GREENING, R. R., WEISS, A. & KRAMER, S. (1961). Radiology, 76, 179. TRAPNELL,D. (1963). Brit. J. Radiol., 36, 660.
NOTICES NEURORADIOLOGY POSTGRADUATE C O U R S E - ALBERT EINSTEIN COLLEGE OF MEDICINE THE department of radiology of the Albert Einstein College of Medicine (affiliated hospitals--Bronx Municipal Hospital Center, The College Hospital and Montefiore Hospital & Medical Center) will hold a 5 day postgraduate course in Neuroradiology from May 16th-20th, 1966, intended for radiologists, neurologists and neurosurgeons. Guest speakers will include: Dr. James W. D. Bull, Dr. Norman E. Chase, Dr. Giovanni Di Chiro, Dr. Torgny Greitz, Dr. Colin B. Holman, Dr. Donald L. McRae, Dr. Harold O. Peterson, Dr. Joseph Ransohoff, Dr. Juan M. Taveras, Dr. Ingmar Wickbom, Dr. Bernard S. Wolf and Dr. Ernest H. Wood. For further information please write t o : - - D r . Mannie M.
Schechter, Program Director, Neuroradiology Postgraduate Course, Albert Einstein College of Medicine, New York, New York 10461.
FIFTH ROCHESTER (N.Y.) S Y M P O S I U M O N CINERADIOLOGY THE Fifth Rochester Symposium on Cineradiology will be held in Rochester, New York, on March 4 and 5, 1966. Papers are invited dealing with all aspects of motion picture radiology including television technology. Seating capacity limits registration to 200 individuals. For application forms to register or to present papers, write to Raymond Gramiak, M.D., Division of Diagnostic Radiology, University of Rochester Medical Center, Rochester, New York 14620.
THE
DEMONSTRATION
LYMPHOGRAPHY
OF IN
A
PULMONARY
PATIENT
WITH
LYMPHATICS
BY
CHYLOTHORAX
W. F. W H I T E a n d W. U R Q U H A R T *
From The Westminster Hospital, London, S.W.1
O b s t r u c t i o n o f the thoracic duct in the neck a n d r e t r o g r a d e flow o f contrast m e d i u m into the mediastinal a n d p u l m o n a r y lymphatics were d e m o n s t r a t e d in a case o f c h y l o t h o r a x investigated b y l y m p h o g r a p h y . A tear in the mediastinal p l e u r a was found at o p e r a t i o n a n d repair o f this resulted in cure. It is p o s t u l a t e d that the a b n o r m a l l y m p h a t i c flow was present p r i o r to the occurrence o f pleural lesion. The interest in this case lies in the d e m o n s t r a t i o n o f the p u l m o n a r y lymphatics during life.
SINCE the introduction o f oily contrast m e d i a by Wallace, Jackson, Schaffer, G o u l d , Greening, Weiss a n d K r a m e r (1961) to l y m p h o g r a p h y , it has been possible to study abnormalities o f the thoracic duct. F o l l o w i n g routine l y m p h o g r a p h y from the feet, chest x-ray often shows the p a r t i a l l y filled t h o r a c i c duct. Studies on p u l m o n a r y lymphatics are o f considerable interest a n d to date have been m a d e on post m o r t e m specimens (Trapnell, 1963). The characteristic a p p e a r a n c e s o f the lymphatics in the lungs as shown b y p o s t - m o r t e m injection studies are n o w well known. In a search o f the literature, however, we have failed to find any case where the p u l m o n a r y lymphatics have been d e m o n s t r a t e d in the living subject. The following is a case r e p o r t o f a patient with c h y l o t h o r a x investigated by l y m p h o g r a p h y . Case Report.--A male, age 38 years, was admitted for investigations following mass miniature radiography where the appearances of a large right pleural effusion were seen. He had no complaints and the only possible relevant history was of falling from his bicycle some weeks prior to admission. The only abnormal physical signs were those of a right pleural effusion. Investigations.--Hb. 113 ~, WBC. 5,000, normal differential. E.S.R. 7 mm./hr. (Wintrobe), Serum Na. 144m.Eq/litre, K. 4-7 m.Eq/litre, Bicarbonate 29m.Eq/litre, Sp.Gravity 1.0270, Urea 27 rag./ 100 ml., Alkaline Phosphatase 8 K.A. units. Bronchoscopy showed no abnormality of the cords, trachea, carina or bronchi. Pleural aspiration was performed on three occasions, a total of 7 litres of milky fluid being withdrawn. Laboratory investigation confirmed this to be chyle. Cytological examination showed the presence of numerous lymphocytes, but no polymorphs. There were a number of rnesothelial pleural cells. No cells which could be regarded as malignant were present. Radiological lnvestigations.--Chest x-ray prior to admission showed an infra-pulmonary effusion with fluid
FIG. 1 Chest x-ray showing an infra-pulmonary effusion. extending up the thoracic wall and into the horizontal fissure and greater fissure (Fig. 1). X-rays on admission showed a large right pleural effusion. The dome of the diaphragm was not elevated and there was no evidence of collapse at the right base. The lateral decubitus film confirmed the presence of the effusion with fluid passing up into the fissures. Lymphogram.--Procedure: Routine lymphogram performed from both feet following the injection of Patent Blue Violet (P.B.V.). 10 ml. Lipiodol ultra fluid were injected into each foot under fluoroscopic control. The contrast medium passed through lymphatics to normal inguinal, iliac and para-aortic nodes and entered the thoracic
*Present address, Newcastle General Hospital. 92
THE D E M O N S T R A T I O N
FiG. 2A
OF P U L M O N A R Y
FIG. 2B
LYMPHATICS
BY L Y M P H O G R A P H Y
93
FIG. 2C
FIG. 2D FIG. 2E FIG. 2A--Retrograde flow of contrast medium into medlastinum and the right hdar region, FIG. 2B--An oblique view showing the contrast medmm passing anteriorly. Fig. 2C--The thoracic duct, diverticulum and paratracheal lymphatics are shown on a later oblique view. FIG. 2D--Lateral vlew of chest showing opaclficatlon of intra-pulmonary, perlbronchial and sub-pleural lymphatics, together with a dilated tortuous internal mammary vessel, FIG, 2E The sub-pleural vessels are more clearly seen in this view,
duct. At the upper end of the thoracic duct there appeared to be an obstruction with backflow into the left supraclavicular nodes, in an amount in excess of that normally seen. A persistent collection of contrast medium, possibly a lymphatic cyst or diverticulum, was seen posterior to the termination of the thoracic duct. Fig. 2a shows retrograde flow into the mediastinum and the right hilar region; Fig. 2b, an oblique view, shows the dye passing anteriorly and Fig. 2c shows the filling of the paratracheal lymphatics and demonstrates the posterior position o f the diverticulum.
Fig. 2d shows the opacification of intrapulmonary, peribronchial and sub-pleural lymphatics together with a very dilated tortuous internal mammary vessel. Fig. 2e shows more clearly the sub-pleural vessels. Radio-opaque medium was seen at the most dependent part o f the right pleural cavity. Operation.--A right thoracotomy was performed and P.B.V. which had been previously injected subcutaneously in the left leg was present in the pleural cavity. After drainage o f the dye-coloured chyle from the pleural cavity, the
94
CLINICAL RADIOLOGY A chest x-ray taken 7 months after operation (Fig. 3) shows residual pleural thickening only, but no evidence of fluid.
CONCLUSIONS Obstruction of the upper end of the thoracic duct was shown to be present by the retrograde flow of the radio-opaque material into the mediastinum and by the absence of the characteristic mottled appearance of the contrast medium in the lungs usually seen following injection. It is thought that two pathways existed for drainage of the thoracic duct, one via the mediastinal and internal mammary lymphatics to the right subclavian lymphatics and thus back to the great veins, and an alternative pathway via the bronchial lymphatics to the pulmonary vessels and thence to the hilar region. It is postulated that trauma sustained when the patient fell from his bicycle caused rupture of the pleura overlying the mediastinum and gave rise to the chylothorax. This supposes that the abnormal lymphatic drainage existed before the injury. Closure of the pleural defect resulted in clinical cure of the chylothorax.
Fro. 3 Chest x-ray seven months after operation.
pleural lymphatics were seen to be dilated and tortuous over the mediastinal, parietal and visceral pleura. A small tear was found in the pleura low down over the mediastinum from which chyle was leaking. This tear was repaired, and a piece of parietal pleura was removed for histology. The chest wall was closed routinely. The histological report of the specimen showed the pleura to be replaced by a layer of granulation tissue, with a plaque of structureless granular material on top of that, mixed with fibrin. Frozen section showed that a substantial part of the granular material consists of extracellular lipid droplets, some of it anisotropic. The underlying granulation tissue was rich in spindleshaped histiocytes loaded with phagocytosed fatty droplets.
Aeknowledgements.--We are indebted to Mr. Charles Drew, Mr. Peter Jones and Dr. Peter Emerson for their permission to publish this case under their care and for their encouragement and help. We are also grateful to Dr. K. A. Newton and Dr. B. Strickland for their helpful suggestions in the preparation of this article, to Dr. Peter Hansell and the Photographic Department for the preparation of the photographs and to Mrs. Chatfield for her secretarial help. REFERENCES
WALLACE, S., JACKSON, L., SCHAEFER, B., GOULD, J., GREENING, R. R., WEISS, A. & KRAMER, S. (1961). Radiology, 76, 179. TRAPNELL,D. (1963). Brit. J. Radiol., 36, 660.
NOTICES NEURORADIOLOGY POSTGRADUATE C O U R S E - ALBERT EINSTEIN COLLEGE OF MEDICINE THE department of radiology of the Albert Einstein College of Medicine (affiliated hospitals--Bronx Municipal Hospital Center, The College Hospital and Montefiore Hospital & Medical Center) will hold a 5 day postgraduate course in Neuroradiology from May 16th-20th, 1966, intended for radiologists, neurologists and neurosurgeons. Guest speakers will include: Dr. James W. D. Bull, Dr. Norman E. Chase, Dr. Giovanni Di Chiro, Dr. Torgny Greitz, Dr. Colin B. Holman, Dr. Donald L. McRae, Dr. Harold O. Peterson, Dr. Joseph Ransohoff, Dr. Juan M. Taveras, Dr. Ingmar Wickbom, Dr. Bernard S. Wolf and Dr. Ernest H. Wood. For further information please write t o : - - D r . Mannie M.
Schechter, Program Director, Neuroradiology Postgraduate Course, Albert Einstein College of Medicine, New York, New York 10461.
FIFTH ROCHESTER (N.Y.) S Y M P O S I U M O N CINERADIOLOGY THE Fifth Rochester Symposium on Cineradiology will be held in Rochester, New York, on March 4 and 5, 1966. Papers are invited dealing with all aspects of motion picture radiology including television technology. Seating capacity limits registration to 200 individuals. For application forms to register or to present papers, write to Raymond Gramiak, M.D., Division of Diagnostic Radiology, University of Rochester Medical Center, Rochester, New York 14620.