Non-contrast 3D MR lymphography of retroperitoneal lymphatic aneurysmal dilatation: a continuous spectrum of change from normal variants to cystic lymphangioma

Abstract

Objective: Our objective was to demonstrate the characteristic features of retroperitoneal lymphatic aneurysmal dilatation with three-dimensional (3D) magnetic resonance (MR) lymphography.

Conclusion: Three-dimensional MR lymphography demonstrates that retroperitoneal lymphatic aneurysmal dilatation exhibits a continuous spectrum of change from normal variants to lymphatic aneurysmal dilatation and so-called cystic lymphangioma.

Main message: • Non-contrast MR lymphography with very heavily T2-weighted fast spin echo sequences is a useful non-invasive technique without the need of contrast medium injection to obtain a unique evaluation of the lymphatic system • To prove the lymphatic origin of a cystic formation, it is essential to demonstrate the communication with retroperitoneal lymphatic vessels • 3D MR lymphography demonstrates that retroperitoneal lymphatic aneurysmal dilatation exhibits a continuous spectrum of change from normal variants to lymphatic aneurysmal dilatation and so-called cystic lymphangioma.

Fig. 1

A 39-year-old man with primary sclerosing cholangitis. a Axial T2-weighted MR image shows multiple high signal-intensity cystic formations (arrows) corresponding to lymphatic channels around aorta. b Coronal MIP image shows bilateral plexus of lymphatic channels (arrows) which continues with thoracic duct (arrowheads)

Fig. 2

A 25-year-old man who underwent MR imaging for back pain. a Sagittal T2-weighted MR image demonstrates a prevertebral cystic lesion (arrow) b Coronal MIP image shows giant cisterna chyli at confluence of left and right markedly dilated retroperitoneal trunks (arrows)

Fig. 3

A 37-year-old woman in which a cystic mass was discovered incidentally in a prevertebral location. Coronal MIP image shows a dilatation of cisterna chyli (arrow) and marked dilatation of both right and left retroperitoneal trunks (arrowheads)

Fig. 4

A 47-year-old woman presenting with non-specific abdominal discomfort. Axial T2-weighted images (a, b) show a retroperitoneal, round mass with thin wall and homogeneous high signal intensity corresponding to fluid content. A mass effect on the small bowel is demonstrated. Extensions are present at the bottom of the lesion (arrow) (b). MR lymphography with coronal MIP image (c) confirms the diagnosis by demonstrating extension at the bottom of the lesion that communicates with dilated lymphatic channel (arrow)

Fig. 5

A 60-year-old woman with intraductal papillary mucinous neoplasm (IPMN). Branch duct type IPMN (arrow) and two retroperitoneal cystic lesions (upper [U] and lower [L]) are demonstrated on coronal MIP image (a). Branch duct type IPMN and retroperitoneal lymphatic aneurysmal dilatation were proved at surgery. At follow-up, the second location of lymphatic aneurysmal dilatation that was not resected is well demonstrated (b). Extension of the lesion (arrow) is well demonstrated on coronal MIP image (c). Retroperitoneal trunks (arrowheads)

Fig. 6

A 41-year-old man with biopsy-proved intestinal lymphangiectasis and history of chylous ascites. On first MR examination the lesion has high signal on T2-weighted images (a). MR lymphography (b) shows the communication with dilated lymphatic channel (arrows). On first follow-up MR examination the lesion has lower signal on T2-weighted images (c) with very low signal intensity on MR lymphography on second follow-up (d). Low signal intensity on T2-weighted MR image is likely related to haemorrhage changes

Fig. 7

An 18-year-old man presenting with abdominal discomfort. CT scan (a) demonstrates a large infiltrative retroperitoneal cystic lesion. On T2-weighted MR image (b) it appears multiloculated, with thin wall and septa. The content is serous with flow phenomena, appearing as characteristically shaped signal heterogeneity on T2-weighted images. Sagittal T2-weighted MR image (c) and coronal MIP image (d) show extensions (arrow) adjacent to surrounding lymphatic channels

Fig. 8

A 60-year-old woman with non-specific abdominal pain. Axial (a) and coronal (b) T2-weighted images show a large multiloculated bulky lesion with serous content and characteristic shaped flow phenomena. Coronal MIP reconstruction of 3D MR lymphography (c) shows extensions adjacent to lymphatic vessels (arrow). Cystic lymphangioma was found at surgery

Fig. 9

A 71-year-old woman presenting with diffuse non-specific abdominal pain. CT scan (a) demonstrates an infiltrative multiloculated retroperitoneal cystic lesion. Axial T2-weighted image (b) shows infiltrative, multiloculated lesion in the right retroperitoneum with high signal intensity content. MR lymphography with MIP reconstruction (c) shows communication (arrow) between lesion and markedly dilated right iliac lymphatic vessels (arrowheads)

Fig. 10

A 25-year-old man presenting with non-specific abdominal discomfort. Two communicating cystic lesions are demonstrated. The upper lesion is a round bulky cystic lesion with mass effect on the small bowel on T2-weighted MR image (a). MR lymphography with coronal MIP image (b) demonstrates communication of the upper portion with retroperitoneal lymphatic system (arrowhead). The lower position communicates (arrow) with the lower lesion which is infiltrative and multiloculated. Communication between the two locations is also well demonstrated on MIP sagittal reconstruction (c). Lymphatic nature of the upper lesion and communication with the lower lesion was proved at surgery