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. 2013 Jul 5;8(7):e69701.
doi: 10.1371/journal.pone.0069701. Print 2013.

Imaging lymphatic system in breast cancer patients with magnetic resonance lymphangiography

Qing Lu  1 , Jia Hua, Mohammad M Kassir, Zachary Delproposto, Yongming Dai, Jingyi Sun, Mark Haacke, Jiani Hu
Affiliations

Imaging lymphatic system in breast cancer patients with magnetic resonance lymphangiography

Qing Lu et al. PLoS One. .

Abstract

Objective: To investigate the feasibility of gadolinium (Gd) contrast-enhanced magnetic resonance lymphangiography (MRL) in breast cancer patients within a typical clinical setting, and to establish a Gd-MRL protocol and identify potential MRL biomarkers for differentiating metastatic from non-metastatic lymph nodes.

Materials and methods: 32 patients with unilateral breast cancer were enrolled and divided into 4 groups of 8 patients. Groups I, II, and III received 1.0, 0.5, and 0.3 ml of intradermal contrast; group IV received two 0.5 ml doses of intradermal contrast. MRL images were acquired on a 3.0 T system and evaluated independently by two radiologists for the number and size of enhancing lymph nodes, lymph node contrast uptake kinetics, lymph vessel size, and contrast enhancement patterns within lymph nodes.

Results: Group III patients had a statistically significant decrease in the total number of enhancing axillary lymph nodes and lymphatic vessels compared to all other groups. While group IV patients had a statistically significant faster time to reach the maximum peak enhancement over group I and II (by 3 minutes), there was no other statistically significant difference between imaging results between groups I, II, and IV. 27 out of 128 lymphatic vessels (21%) showed dilatation, and all patients with dilated lymphatic vessels were pathologically proven to have metastases. Using the pattern of enhancement defects as the sole criterion for identifying metastatic lymph nodes during Gd-MRL interpretation, and using histopathology as the gold standard, the sensitivity and specificity were estimated to be 86% and 95%, respectively.

Conclusion: Gd-MRL can adequately depict the lymphatic system, can define sentinel lymph nodes, and has the potential to differentiate between metastatic and non-metastatic lymph nodes in breast cancer patients.

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Conflict of interest statement

Competing Interests: The authors have read the journal's policy and have the following conflicts: author Yongming Dai is currently employed by MR Business, Philips Healthcare. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

Figures

Figure 1
Figure 1. Diagrammatic representation of axillary lymph node levels.
Lymph nodes were classified as Level 1, Level 2, or Level 3 based on anatomic location. Level I: latissimus dorsi to lateral pectoralis minor; level II: posterior to pectoralis minor; level III: medial pectoralis minor to thoracic inlet.
Figure 2
Figure 2. MRL images of breast lymph nodes at different levels.
(A) (coronal plane) and (B) (transversal plane) show typical MRL images illustrating breast lymph node enhancement at different nodal levels. Arrowhead: Level 1 axillary lymph nodes. Arrows: Level 2 axillary lymph nodes.
Figure 3
Figure 3. MRL images of breast lymph nodes at different levels.
A typical MRL image shows enhancing breast lymph nodes at different nodal levels. Arrowhead: Level 1 lymph nodes. Arrow: Level 3 lymph nodes.
Figure 4
Figure 4. Axillary lymph nodes contrast-uptake kinetics of the four patient groups.
Graph of enhancement profile over time as determined with signal-to-noise ratio (SNR) measurements in the axillary lymph node shows a different contrast -uptake kinetics of the four patient groups. ANOVA test results show that the SNR (at the maximum enhancement height) of the lymph nodes in group 1, 2 and 4 was significantly higher than that in group 3 (SNR: F ratio=17.613, p<0.001), though there was no significant difference between groups 1, 2 and 4. Error bars represent standard errors of the mean.
Figure 5
Figure 5. MRL images of breast normally-sized metastatic lymph nodes.
Example of normally-sized metastatic lymph nodes with an abnormal nodal enhancement pattern and lymphatic vasculature. Arrowheads: enhancement defects within non-enlarged lymph nodes. Long arrows: lymphatic vessels. Short arrows: veins.
Figure 6
Figure 6. MRL of enlarged metastatic lymph nodes.
Arrowhead: Irregular enlarged lymph nodes with enhancement (or contrast filling) defect pattern. Long thin arrows: enhancing and dilated lymphatic vessels. Short fat arrow: enhancing normal lymphatic vessels with a beaded appearance. Short arrows: vein. Hollow arrows: injection sites.
See this image and copyright information in PMC

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