Sunteți pe pagina 1din 3

IJNM, 21(3): 64-66, 2006

Case Report

Lymphoscintigraphy Using 99m Tc Sulfur Colloid in Chylothorax:

A Case Report

Parul Mohan, Vivek Pathak, Parmeshwar Joshi, Romana Sehar, S. Bal*

Department of Nuclear Medicine and *Department of Thoracic Surgery, Fortis, Flt Lt. Rajan Dhall Hospital, B-1, Vasant Kunj, New Delhi-110070

A 26-y-old lady was diagnosed with afibrogenemia, increasing breathlessness and pleural effusion and underwent a right thoracotomy. Postoperatively, a recurring right pleural effusion developed. Because

an attempt at lymphangiography failed, lymphoscintigraphy using sulfur colloid was done. The study confirmed the diagnosis of chylothorax.

Key Words: chylothorax; lymphoscintigraphy; filtered sulfur colloid

Introduction

Chylous pleural effusion, or chylothorax, is defined as the accumulation of chyle-containing lymphatic fluid within the pleural space. Chylothorax is usually secondary to disruption of the thoracic duct or derangement of lymphatic flow within the thorax. Chyle is described classically as having a white, milky, or opalescent appearance.This characteristic color is seen in less than one half of patients with chylous effusion, which may cause the chylous nature of the fluid to remain unrecognized. Chylothorax has various causes and is usually attributable to 1 of 4 categories:

malignancy, trauma (including surgery), miscellaneous disorders, and idiopathic. While these entities may be challenging from a diagnostic and therapeutic standpoint, a wide variety of imaging modalities, which includes lymphangiography and lymphoscintigraphy may be used to diagnose the extent and internal structural characteristics of the abnormalities.

Correspondence to:

Dr Parul Mohan, Consultant, Department of Nuclear Medicine, Mahajan Imaging Centre, Fortis, Flt Lt. Rajan Dhall Hospital, B-1, Vasant Kunj, New Delhi-110070 E-Mail: drparulmohan@gmail.com

Lymphangiography is a radiographic examination of lymphatic vessels and nodes in which an oily contrast medium is injected into a lymphatic vessel in the foot or hand. A series of radiographs are then taken to trace the flow of the contrast medium through the lymphatic vessels. In the past lymphangiography was used to diagnose lymphatic disorders; however the oily contrast medium residue often damaged the remaining functional lymphatic vessels. The damage caused by the test often made the lymphedema worse. Besides being a non-dynamic procedure, it was also cumbersome. For these reasons, lymphangiography is no longer used in the diagnosis of disorders of lymphatic system. Lymphoscintigraphy is now widely accepted as a diagnostic test for lymphatic disorders. Lymphoscintigraphy involves the injection of a water-based radionuclide that does not damage the lymphatic tissues. The radionuclide is injected near a digit (finger or toe) on the affected limb. The flow of this radionuclide is then traced with a gamma camera and a computer is used to create images of the lymph flow and to calculate the speed of uptake. Lymphoscintigraphy is now considered to be the safest and most accepted method of diagnostic testing for lymphedema.

Case report

A 26-year-old lady presented with a 2-month history of increasing breathlessness. She was diagnosed with afibrogenemia and pleural effusion by a local hospital and a right thoracotomy was performed there. However her problems worsened and she subsequently developed a recurring right

Indian Journal of Nuclear Medicine, Vol. 21, No. 3, September 2006

sided pleural effusion and her intercostal tube drained about 900 ml of fluid daily. The drainage indicated that the right effusion was chylous, so a radiologic lymphangiogram was ordered to better evaluate the leak. Unfortunately, there was significant difficulty in cannulating the lymphatic channels and the test was not completed. Lymphoscintigraphy was suggested and, after discussion, a lymphoscintigram with 99m Tc sulfur colloid was proposed. 99m Tc sulfur colloid was made per the package insert directions from the kit (BRIT); a routine quality control (QC) procedure was performed. 99m Tc sulfur colloid was then divided into 4 insulin syringes. The patient was then injected Intradermally in the first and second web-spaces of both feet. Serial whole-body imaging was performed upto 20 min. and subsequent static images were acquired till 24 hours. Immediate upward movement of tracer was seen in both lower limbs following injection of radiotracer. The popliteal lymph nodes were well visualised at 10 minutes. Inguinal lymph nodes were well visualised at 15 minutes. Delayed images till 24 hours showed no pooling of activity anywhere in the both lower limb. Normal accumulation of tracer was seen in the liver at 20 minutes suggesting a patent thoracic duct. (Figure 1) Abnormal collection of tracer was noted in the right hemithorax at 3 hours (Figure 2).A region of interest was drawn around the thoracic activity and compared with a region

around the thoracic activity and compared with a region Figure 1: Anterior & Posterior Whole body

Figure 1: Anterior & Posterior Whole body image acquired 20 min. after injection of 99mTc sulphur colloid showing the popliteal lymph nodes. Inguinal lymph nodes and the liver suggesting a patent thoracic duct.

lymph nodes and the liver suggesting a patent thoracic duct. Figure 2: Static Anterior & Posterior

Figure 2: Static Anterior & Posterior images of the thorax showing abnormal collection of tracer in the right hemithorax at 3 hours.

collection of tracer in the right hemithorax at 3 hours. Figure 3: Static image of the

Figure 3: Static image of the intercostal drain bag showing tracer collection at 3 hours.

including the total injected activity. There was approximately 5% of injected activity present in the thorax at 3 h. Tracer activity was also noted in the drain bag at 3 hours (Figure 3).

Parul Mohan et al

No accumulation of tracer is seen anywhere in the abdomen in delayed images till 24 hours. Subsequently, a right thoracotomy, thoracic duct ligation and talc pleurodesis were done. Since this procedure, the patient has been stable with no further leakage demonstrated.

Discussion

Chylothorax, a pleural effusion containing chyle, can occur secondary to trauma, neoplasm, malformations of the lymphatic system and surgical procedures involving the pleural space. Lymphangiography is considered the gold standard in investigating chylothorax, as well as being used to assess other pathologies such as chyloperitoneum, chyluria, thoracic duct patency, abnormal leg lymphatics, and detection of abnormal retroperitoneal lymph nodes. It is a difficult procedure, requiring cannulation of the lymphatic channels that can potentially cause adverse effects such as local tissue necrosis, fat embolism to the lungs, hypersensitivity reaction or worsening of lymphedema from the contrast material. \ Lymphoscintigraphy has been described previously using radiolabeled human serum albumin, dextran or nanocolloid (1- 5).It is quick, minimally invasive, and does not have any known side effects. It has become difficult to procure human serum albumin or dextran to do these studies. An attempt was made to use 99m Tc sulfur colloid as is used in sentinel lymph node lymphoscintigraphy in melanoma or breast cancer. Although a portion of the radiopharmaceutical may have been too large subsequently being trapped in the inguinal lymph nodes, enough traveled into the thoracic duct to demonstrate the lymphatic leak. A direct comparison with other radiopharmaceuticals was not performed, but if the other

radiopharmaceuticals are not available, adequate studies can be performed with filtered 99m Tc sulfur colloid.

Conclusion

Hence, it is concluded that Radionuclide scintigraphy should be done for diagnosing any abnormal focus in the lymphatic system. Besides being safe and easy, it offers a dynamic

This functional information

provided by lymphoscintigraphy is unique and currently unattainable by using other imaging procedures. For many diseases, nuclear medicine studies yield the most useful information needed to make a diagnosis and to determine appropriate treatment, if any.

evaluation of the lymphatic system

References

1. Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax. Pui MH, Yueh TC. J Nuc Med 1998; 39(7):1292–6

2. Lymphoscintigraphy using Tc 99m human serum albumin in chylothorax. Inoue Y, Otake T, Nishikawa J, Sasaki Y. Clin Nuc Med 1997; 22(1):60.

3. Filtered Technetium-99m-Sulfur Colloid for Lymphoscintigraphy. Hung JC, Wiseman GA, Wahner HW, Mullan BP, Taggart TR and Dunn WL J Nuc Med 1995; 36(10):1895–1901.

4. A case of chylothorax diagnosed by lymphoscintigraphy using Tc- 99m HSA-DTPA. Ogi S, Fukumitsu N, Uchiyama M, Mori Y. Clin Nucl Med. 2002; 27(6):455-6.

5. Lymphoscintigraphy and Radionuclide Venography in Chylothorax. Restrepo, Jose, Vicente; Clinical Nuclear Medicine. 2004;

29(7):440-441.