Thoracic Duct Embolization, Unexplained Thoracic Duct Occlusions, and Lymphatic Anomalies

Abstract

To the EditorI read with interest the article by Nadolski and Itkin1Nadolski GJ Itkin M Thoracic duct embolization for non-traumatic chylous effusion: experience in 34 patients.Chest. 2013; 143: 158-163Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar in CHEST (January 2013) on thoracic duct embolization (TDE) for nontraumatic chylous effusion. The authors are to be applauded for approaching a difficult topic with poorly established standards and a high mortality rate. This is an important condition for chest physicians to understand and manage. Unfortunately, and despite the authors' vast experience in the management of >160 patients with this frequently devastating disorder, the etiology of spontaneous or idiopathic chylothorax remains unexplained. What are the mechanisms for the thoracic duct undergoing obstruction in patients with no previous disease and normal MRI thoracic examinations? Up to 20% of patients with nontraumatic chylous effusions present with lymphatic anomalies (lymphatic malformations, generalized lymphatic disease [lymphangiomatosis], or Gorham-Stout disease).2Doerr CH Allen MS Nichols III, FC Ryu JH Etiology of chylothorax in 203 patients.Mayo Clin Proc. 2005; 80: 867-870Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar Children with massive lymphatic malformations in the neck, axilla, or groin do not develop lymphatic duct obstruction with lymphedema. We do not have information regarding compared outcomes of TDE in patients with or without associated lymphatic malformations.It is evident that TDE will soon definitively replace surgical thoracic duct ligation (TDL) because morbidity is significantly reduced by using this technique. To better understand the benefits of this procedure, we need information about the routes of chyle recanalization after thoracic duct occlusion. Apparently, postoperative recurrent chylothorax or proximal chylous effusions are significantly reduced in patients undergoing TDE compared with those treated with TDL. This complication is common in patients with generalized lymphatic anomalies undergoing TDL. Are lymphatic-venous communications more easily opened and better functioning after TDE?Nontraumatic chylothorax in children aged <10 years remains an unsolved problem. Because successful TDE has been reported in the treatment of post-cardiac surgery chylothorax in small children,3Itkin M Krishnamurthy G Naim MY Bird GL Keller MS Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants.Pediatrics. 2011; 128: e237-e241Crossref PubMed Scopus (43) Google Scholar there are optimistic expectations of TDE improving the mortality rate in the pediatric population affected by pulmonary or disseminated lymphangiomatosis.4Ayuso-Velasco R López-Gutiérrez JC Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature [in Spanish].An Pediatr (Barc). 2012; 77: 83-87Crossref PubMed Scopus (3) Google Scholar We encourage pediatric interventional radiologists and thoracic surgeons involved in the management of children with chylothorax in the context of life-threatening lymphatic anomalies to develop and promote noninvasive techniques in the management of these patients. To the EditorI read with interest the article by Nadolski and Itkin1Nadolski GJ Itkin M Thoracic duct embolization for non-traumatic chylous effusion: experience in 34 patients.Chest. 2013; 143: 158-163Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar in CHEST (January 2013) on thoracic duct embolization (TDE) for nontraumatic chylous effusion. The authors are to be applauded for approaching a difficult topic with poorly established standards and a high mortality rate. This is an important condition for chest physicians to understand and manage. Unfortunately, and despite the authors' vast experience in the management of >160 patients with this frequently devastating disorder, the etiology of spontaneous or idiopathic chylothorax remains unexplained. What are the mechanisms for the thoracic duct undergoing obstruction in patients with no previous disease and normal MRI thoracic examinations? Up to 20% of patients with nontraumatic chylous effusions present with lymphatic anomalies (lymphatic malformations, generalized lymphatic disease [lymphangiomatosis], or Gorham-Stout disease).2Doerr CH Allen MS Nichols III, FC Ryu JH Etiology of chylothorax in 203 patients.Mayo Clin Proc. 2005; 80: 867-870Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar Children with massive lymphatic malformations in the neck, axilla, or groin do not develop lymphatic duct obstruction with lymphedema. We do not have information regarding compared outcomes of TDE in patients with or without associated lymphatic malformations.It is evident that TDE will soon definitively replace surgical thoracic duct ligation (TDL) because morbidity is significantly reduced by using this technique. To better understand the benefits of this procedure, we need information about the routes of chyle recanalization after thoracic duct occlusion. Apparently, postoperative recurrent chylothorax or proximal chylous effusions are significantly reduced in patients undergoing TDE compared with those treated with TDL. This complication is common in patients with generalized lymphatic anomalies undergoing TDL. Are lymphatic-venous communications more easily opened and better functioning after TDE?Nontraumatic chylothorax in children aged <10 years remains an unsolved problem. Because successful TDE has been reported in the treatment of post-cardiac surgery chylothorax in small children,3Itkin M Krishnamurthy G Naim MY Bird GL Keller MS Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants.Pediatrics. 2011; 128: e237-e241Crossref PubMed Scopus (43) Google Scholar there are optimistic expectations of TDE improving the mortality rate in the pediatric population affected by pulmonary or disseminated lymphangiomatosis.4Ayuso-Velasco R López-Gutiérrez JC Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature [in Spanish].An Pediatr (Barc). 2012; 77: 83-87Crossref PubMed Scopus (3) Google Scholar We encourage pediatric interventional radiologists and thoracic surgeons involved in the management of children with chylothorax in the context of life-threatening lymphatic anomalies to develop and promote noninvasive techniques in the management of these patients. I read with interest the article by Nadolski and Itkin1Nadolski GJ Itkin M Thoracic duct embolization for non-traumatic chylous effusion: experience in 34 patients.Chest. 2013; 143: 158-163Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar in CHEST (January 2013) on thoracic duct embolization (TDE) for nontraumatic chylous effusion. The authors are to be applauded for approaching a difficult topic with poorly established standards and a high mortality rate. This is an important condition for chest physicians to understand and manage. Unfortunately, and despite the authors' vast experience in the management of >160 patients with this frequently devastating disorder, the etiology of spontaneous or idiopathic chylothorax remains unexplained. What are the mechanisms for the thoracic duct undergoing obstruction in patients with no previous disease and normal MRI thoracic examinations? Up to 20% of patients with nontraumatic chylous effusions present with lymphatic anomalies (lymphatic malformations, generalized lymphatic disease [lymphangiomatosis], or Gorham-Stout disease).2Doerr CH Allen MS Nichols III, FC Ryu JH Etiology of chylothorax in 203 patients.Mayo Clin Proc. 2005; 80: 867-870Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar Children with massive lymphatic malformations in the neck, axilla, or groin do not develop lymphatic duct obstruction with lymphedema. We do not have information regarding compared outcomes of TDE in patients with or without associated lymphatic malformations. It is evident that TDE will soon definitively replace surgical thoracic duct ligation (TDL) because morbidity is significantly reduced by using this technique. To better understand the benefits of this procedure, we need information about the routes of chyle recanalization after thoracic duct occlusion. Apparently, postoperative recurrent chylothorax or proximal chylous effusions are significantly reduced in patients undergoing TDE compared with those treated with TDL. This complication is common in patients with generalized lymphatic anomalies undergoing TDL. Are lymphatic-venous communications more easily opened and better functioning after TDE? Nontraumatic chylothorax in children aged <10 years remains an unsolved problem. Because successful TDE has been reported in the treatment of post-cardiac surgery chylothorax in small children,3Itkin M Krishnamurthy G Naim MY Bird GL Keller MS Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants.Pediatrics. 2011; 128: e237-e241Crossref PubMed Scopus (43) Google Scholar there are optimistic expectations of TDE improving the mortality rate in the pediatric population affected by pulmonary or disseminated lymphangiomatosis.4Ayuso-Velasco R López-Gutiérrez JC Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature [in Spanish].An Pediatr (Barc). 2012; 77: 83-87Crossref PubMed Scopus (3) Google Scholar We encourage pediatric interventional radiologists and thoracic surgeons involved in the management of children with chylothorax in the context of life-threatening lymphatic anomalies to develop and promote noninvasive techniques in the management of these patients. Arrhythmias in COPD: ResponseCHESTVol. 143Issue 2PreviewWe thank Dr López-Gutiérrez for his interest in our recent work in CHEST.1 The etiology of idiopathic chylothorax has indeed been hardly investigated and in most parts remains unsolved. We suggest that all cases of idiopathic chylothorax can be divided into two major categories: (1) occlusion of the upper part of the thoracic duct (TD) with development of compensatory collaterals and (2) chylous leak in the presence of a lymphatic malformation. Full-Text PDF