Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders

Abstract

To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.

Keywords: Chylothorax; Chylous ascites; Embolization; Lymphangiography; Lymphoproliferative disorders.

Fig. 1

MR lymphangiography of a 56-year-old patient with extensive retrocural lymphoma manifestation (white arrow) (a). After nodal contrast application KM ascension via enhancement of pelvic and retroperitoneal lymphatic vessels is visible; in the upper abdomen the lower part of the thoracic duct can be seen. There is no further enhancement of the thoracic duct above the lymphoma mass corresponding to lymphatic obstruction (white arrow) (b). X-ray lymphangiography  corroborated  obstructive lymphatic drainage disorder at the level of the retrocrural lymphatic mass (white arrow) and consecutive chylolymphatic reflux in the upper abdomen (c)

Fig. 2

MR (a) and X-ray lymphangiography (b) of a 52-year-old patient with DLBCL and refractory non-traumatic chylothorax. There is a marked thoracic lymphatic flow disturbance with significant thoracic duct obstruction in the upper part and chylolymphatic reflux into alternative pathways in the middle and upper thirds of the thorax. Lymphatic enhancement was first visible in the alternative pathways on the right and only secondarily and delayed of the thoracic duct