The cisterna chyli: prevalence, characteristics and predisposing factors

The cisterna chyli: a systematic review of definition, prevalence, and anatomy

The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower limbs. In addition to being an important landmark in retroperitoneal surgery, it is the key gateway for interventional radiology procedures targeting the thoracic duct. A detailed understanding of its anatomy is required to facilitate more accurate intervention, but an exhaustive summary is lacking. A systematic review was conducted, and 49 published human studies met the inclusion criteria. Studies included both healthy volunteers and patients and were not restricted by language or date. The detectability of the cisterna chyli is highly variable, ranging from 1.7 to 98%, depending on the study method and criteria used. Its anatomy is variable in terms of location (vertebral level of T10 to L3), size (ranging 2-32 mm in maximum diameter and 13-80 mm in maximum length), morphology, and tributaries. The size of the cisterna chyli increases in some disease states, though its utility as a marker of disease is uncertain. The anatomy of the cisterna chyli is highly variable, and it appears to increase in size in some disease states. The lack of well-defined criteria for the structure and the wide variation in reported detection rates prevent accurate estimation of its natural prevalence in humans.

Cisterna chyli as an optimal marker of tolvaptan response in severe cirrhotic ascites

For patients with cirrhosis, no definitive predictor of the efficacy and prognosis of tolvaptan treatment exists. We assessed the cisterna chyli's utility as an optimal marker. We retrospectively enrolled 172 patients with cirrhosis. The effect of tolvaptan was evaluated using post-treatment survival time. The overall response to tolvaptan was 52.3%. The median cisterna chyli diameter was 4.1 mm. Of 172 patients, 100 were included in the pilot set and 72 in the validation set. According to the Youden index, the cisterna chyli diameter's cutoff value was 4 mm, with a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of 92%, 83%, 86%, 91%, 5.43, and 0.09, respectively, in the pilot set. The area under the curve of the cisterna chyli diameter for evaluating tolvaptan's effect was 0.911 and 0.988 in the pilot and validation sets, respectively. During multivariate analysis, cisterna chyli narrowing and furosemide treatment were significant predictive factors for tolvaptan's insufficient effect. Cumulative liver transplantation-free survival rates were significantly higher in patients with cisterna chyli dilatation than in those without (p = 0.028). Our findings suggest a strong association of cisterna chyli with tolvaptan treatment response in patients with cirrhosis and hepatic edema.

Morphometry and Lymph Dynamics of Swine Thoracic Duct

Background: The goal of this study was to characterize the thoracic duct (TD) both morphologically and hemodynamically. Methods and Results: The lymphatic flow and pressure gradient from the cisterna chyli (CC) to the lymphovenous junction were measured in anesthetized swine (n = 9). After the animals were euthanized, the TD were harvested for histomorphometric analyses in which three samples were perfused with 9% gelatin to obtain the morphometry of the TD valve in both the open and closed configuration. Spectral analyses were performed. An afferent lymphatic vessel of the CC was accessed and cannulated after the animal was euthanized for casting (n = 3) to obtain morphometric data. The in vivo flow rate was 0.7 ± 0.49 mL/minute. Spectral analysis (Fast Fourier Transformation) showed correlation coefficients of 0.858 ± 0.063 and 0.586 ± 0.112 (p < 0.05) for the TD and JVPs, respectively. The average pressure gradient was 8.1 mmHg along the TD. The length of the TD was 35.6 ± 2.2 cm. The maximal width of the CC ranged from 11.4 to 15 mm. The diameter of the TD varied irregularly from 2 to 4.3 mm. The geometry of the TD leaflets was determined to have an area of 1.99 ± 0.53 mm², a leaflet length of 3.26 ± 0.86 mm, a packet depth of 0.66 ± 0.19 mm, and a wall length of 5.46 ± 2.16 mm. The TD media thickness was ∼7 ± 3 μm. The number of valves ranged from 9 to 13 in the full length of the TD. Conclusions: A relatively constant pressure gradient in the swine TD drives lymph flow from the CC to the jugular vein. The TD is a thin-walled vessel with valves that prevent reflux of lymph flow. This study of morphometric and lymphatic dynamics is important for interventionalists to understand the anatomy and physiology of the TD to design new diagnostic, interventional procedures, and devices.

A radio-anatomical correlation study of the cisterna chyli

Surgical laparoscopic procedures in the retroperitoneal and supramesocolic spaces are increasingly frequent. There is a high risk of iatrogenic intraoperative injury of the retroperitoneal lymphatic structures during these procedures. A precise understanding of the anatomy of the thoracic duct (TD) and the cisterna chyli (CC) is essential for safe surgical procedures in this area. However, routine imaging procedures rarely and often incorrectly visualize the CC. The objective of this study was to evaluate the feasibility of a retrograde injection of the TD to fill the CC with a contrast agent in 16 human cadavers. Both magnetic resonance lymphography (MRI) and computed tomography (CT) studies could be performed on the same anatomical specimen, using a contrast medium which hardened, allowing gross dissection. MRI and CT detectability were evaluated, and imaging results were compared with the anatomical dissection. The CC of 12/16 cadavers were successfully injected, and four were unsuccessful due to technical difficulties, showing the effectiveness of the method. This technique can improve understanding of the anatomy of the TD and CC and provides an original option to study the complex anatomy of these structures by correlating precise cadaveric dissections with cross-sectional imaging.

Morphology of the distal thoracic duct and the right lymphatic duct in different head and neck pathologies: an imaging based study

Background

The purpose of this study was to assess the influence of head and neck pathologies on the detection rate, configuration and diameter of the thoracic duct (TD) and right lymphatic duct (RLD) in computed tomography (CT) of the head and neck.

Methods

One hundred ninety-seven patients were divided into the subgroups "healthy", "benign disease" and "malignant disease". The interpretation of the images was performed at a slice thickness of 3 mm in the axial and coronal plane. In each case we looked for the distal part of the TD and RLD respectively and subsequently evaluated their configuration (tubular, sacciform, dendritic) as well as their maximum diameter and correlated the results with age, gender and diagnosis group.

Results

The detection rate in the study population was 81.2 % for the TD and 64.2 % for the RLD and did not differ significantly in any of the subgroups. The predominant configuration was tubular. The configuration distribution did not differ significantly between the diagnosis groups. The mean diameter of the TD was 4.79 ± 2.41 mm and that of the RLD was 3.98 ± 1.96 mm. No significant influence of a diagnosis on the diameter could be determined.

Conclusions

There is no significant influence of head/neck pathologies on the CT detection rate, morphology or size of the TD and RLD. However our study emphasizes that both the RLD and the TD are detectable in the majority of routine head and neck CTs and therefore reading physicians and radiologists should be familiar with their various imaging appearances.

Chest CT incidentalomas: thyroid lesions, enlarged mediastinal lymph nodes, and lung nodules

A computed tomography (CT) incidentaloma is an incidentally detected and previously unsuspected finding or abnormality that is not related to the indication for obtaining the CT examination. The aim of this article is to review the frequency of incidentalomas on chest CT scans, discuss the potential clinical significance of the findings, and suggest guidelines for reporting, further evaluation, and follow-up, with particular focus on thyroid lesions, enlarged mediastinal lymph nodes and lung nodules.

Thoracic duct and cisterna chyli: evaluation with multidetector row CT

OBJECTIVES

The aim of this study was to evaluate the normal anatomy of the thoracic duct and cisterna chyli obtained by axial and multiplanar reformation (MPR) images of 1 mm slice thickness using multidetector row CT (MDCT).

METHODS

We evaluated the ability of MDCT to examine the normal anatomy of the thoracic duct and cisterna chyli. The axial and coronal images of thoracoabdominal MDCT images obtained in 50 patients (20 females and 30 males; mean age, 63.5 years; range, 32-81 years) were reviewed between January and October 2005. We excluded patients with malignant neoplasms, inflammation or vascular diseases (e.g. aortic aneurysm, aortic dissection) and those with a history of thoracoabdominal surgery. The thoracic duct was divided into three anatomical sections: the upper, middle and lower. We evaluated the degree of visualisation and the maximum size of the thoracic duct. We also evaluated the degree of visualisation, maximum size, configuration and location of the cisterna chyli.

RESULTS

Visualisation of the thoracic duct and cisterna chyli was almost 100% on axial and coronal images. The lower section of the thoracic duct was most clearly visualised among the three sections. There was little difference in the maximum size of the thoracic duct among the three sections. The cisterna chyli was most frequently located at the Th12 or L1 level, and the most common type was the "straight thin tube type".

CONCLUSION

Axial and MPR images of 1 mm slice thickness using MDCT can clearly depict the thoracic duct and cisterna chyli.

Postural effect on the size of the cisterna chyli

BACKGROUND

The aim was to investigate the effect of patient position on the size of the cisterna chyli using positional MRI. The cisterna chyli is usually the only large lymphatic vessel that can be found on cross-sectional imaging. Not much is known about its postural behavior. However, animal studies suggest that the cisterna chyli varies in size according to physical activity.

METHODS AND RESULTS

Retrospectively, 998 MRI scans of patients referred for positional MRI were reviewed. Ten patients had acquired axial scans in at least two positions at the level T12/L1 or/and L1/2 and were included in the study. The area representing the cisterna chyli was assessed on axial images and its size was compared in different positions. The size of the cisterna chyli determined as the cross-sectional area was 14.7 mm² ± 17.3 mm² in the supine position, 43.8 mm² ± 3.1 mm² in the sitting position, and 62.9 mm² ± 42.5 mm² in the standing position. Using the t-test, a statistically significant difference was found in the size of the cistern chyli between supine and standing positions and between supine and sitting positions.

CONCLUSIONS

The size of the cisterna chyli shows postural variations. This finding is discussed in regards to possible implications of interventional procedures in the thoracic duct. Physicians reading MR images acquired in positions other than supine should be aware of these physiological changes.

Cisterna chyli in patients with malignancy--influence of cardiovascular disease on the prevalence of the cisterna

The purpose of this study was to investigate the potential correlation between the presence and size of the cisterna chyli (CC) on computed tomography (CT) and the presence of cardiovascular disease.

MATERIALS AND METHODS

Out of a 3000-patient cohort 2599 patients who received a CT examination of the chest and/or abdomen with measurable inferior vena cava and azygos vein were included in this retrospective study. To assess the presence of cardiovascular disease the following parameters were recorded from the PACS or clinical information system: diameter of vena cava and azygos vein, presence of ascitis, serum creatinine, history of congestive heart failure, coronary artery disease or arterial hypertension and medication (diuretics, beta-blocker). In addition the volume of the CC and the presence or absence of malignant disease were recorded. Mean values (vessel diameters, creatinine) or percentages were calculated and compared for the groups with (n=416) and without (n=2183) a cisterna. Multivariate logistic regression analysis was performed for all parameters to identify the potential association with the presence and size of a cisterna. In addition the simultaneous influence of the parameter malignancy, cardiovascular disease and age on presence and size of the CC was analyzed in a logistic regression model.

RESULTS

The presence or absence of a CC was not associated with any of the measured parameter. Regarding the size of the CC, there was a positive correlation with the diameter of the azygos vein, the presence of ascitis and diuretic medication. The influences of malignancy, elevated central venous pressure and age on the development of a CC proved to be highly significant but could not be separated or quantified.

CONCLUSION

The volume of the cisterna chyli is influenced by pathologic states with an increased central venous pressure, while the presence or absence of the cisterna seems to be independent of those factors.

Cisterna chyli in patients with malignancy--is there a correlation between changes in cisterna volume and progression or regression of the tumor?

The purpose of this study was to investigate the potential correlation between the size of the cisterna chyli (CC) and the tumor size in patients with malignancies on computed tomography (CT).

MATERIALS AND METHODS

Out of a 3000 patient cohort 138 patients with histologically confirmed malignant disease, a detectable CC on CT and at least two CT scans within a 6 month period were included in this retrospective study. Out of 525 scans a total of 711 lesion intervals were evaluated. The volume of the CC and all target lesions (up to three per scan) were recorded. The Pearson correlation coefficient for the two parameters of changes in lesion size and CC size was calculated for the whole cohort and for a 33 patient subgroup that included only patients with tumors that showed the closest association with large CC in a previous study.

RESULTS

The mean difference in lesion size for all 711 intervals was -1165μl. The mean difference in CC size for all 711 intervals was -46.6μl. The respective Pearson correlation coefficient was .05 with a non-significant p-value of .1823 (subgroup: r=.04, p=.6358).

CONCLUSION

No significant correlation between the progression or regression of malignant disease and the size of the cisterna chyli could be found.