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Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Because the lymphatic system plays an essential role in fat absorption and immune response, lymphatic leak associated with chylothorax may cause life-threatening malnutrition and immunodeficiency. Chylothorax is usually described as traumatic or nontraumatic. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Lymphoma and thoracic malignancies are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. Other rare causes include primary and secondary diffuse lymphatic diseases, responsible for chylothorax by lymphatic vessel wall dysfunction. Imaging the lymphatic system remains a challenge in the days of modern imaging. Nonenhanced MR lymphography is a noninvasive technique based on heavily T2-weighted sequences, thus enabling visualization of the lymphatic circulation. This technique allows diagnosis and differential diagnosis, evaluation of disease severity, and guidance of therapeutic management in nontraumatic chylothorax. Furthermore, it may offer radiologic classification of primary lymphatic diseases on the basis of morphologic features of lymphatic vessels. The authors describe the anatomy and physiology of the thoracic lymphatic system, present the technique of nonenhanced MR lymphography, and discuss pathophysiologic mechanisms and imaging features in different causes of nontraumatic chylothorax. ©RSNA, 2020.

Background & Aims Primary sclerosing cholangitis (PSC) has a variable, often progressive, course. Magnetic resonance cholangiography (MRC) is used in the diagnosis of PSC. Magnetic resonance risk scoring systems, called Anali without and with gadolinium, are used to predict disease progression, determined by radiologic factors. We aimed to assess the prognostic value of Anali scores in patients with PSC and validate our findings in a separate cohort. Methods We performed a retrospective study of patients with large-duct PSC (internal cohort, 119 patients in France; external cohort, 119 patients in Canada, Italy, and the United Kingdom). All the first-available MRC results were reviewed by 2 radiologists and the Anali scores were calculated as follows: Anali without gadolinium = (1× dilatation of intrahepatic bile ducts) + (2× dysmorphy) + (1× portal hypertension); Anali with gadolinium = (1× dysmorphy) + (1× parenchymal enhancement heterogeneity). The primary end point was survival without liver transplantation or cirrhosis decompensation. The prognostic value of Anali scores was assessed by Cox regression modeling. Results During a total of 549 patient-years for the internal cohort and 497 patient-years for the external cohort, we recorded 2 and 8 liver transplantations, 4 and 3 liver-related deaths, and 26 and 25 cirrhosis decompensations, respectively. In the univariate analysis, factors associated with survival without liver transplantation or cirrhosis decompensation in the internal cohort were as follows: serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, alkaline phosphatase, albumin, and Anali scores. Anali scores without and with gadolinium identified patients' survival without liver transplantation or cirrhosis decompensation with a c-statistic of 0.89 (95% CI, 0.84–0.95) and 0.75 (95% CI, 0.64–0.87), respectively. Independent prognostic factors identified by multivariate analysis were Anali scores and bilirubinemia. The prognostic value of Anali scores was confirmed in the external cohort. Conclusions In internal and external cohorts, we found that Anali scores, determined from MRC, were associated with outcomes of patients with PSC. These scores might be used as prognostic factors.

Magnetic resonance (MR) risk scores and liver stiffness (LS) have individually been shown to predict clinical outcomes in primary sclerosing cholangitis (PSC). The aim of this study was to assess their complementary prognostic value.Patients with PSC from 3 European centers with a 3-dimensional MR cholangiography available for central reviewing and a valid LS measurement assessed by vibration-controlled transient elastography by FibroScan performed within a 6-month interval were included in a longitudinal retrospective study. The MR score (Anali) without gadolinium (Gd) was calculated according to the formula: (1 × dilatation of intrahepatic bile ducts) + (2 × dysmorphy) + (1 × portal hypertension). The primary end point was survival without liver transplantation or cirrhosis decompensation. The prognostic values of LS and Anali score without Gd were assessed using Cox proportional hazard models.One hundred sixty-two patients were included. Over a total follow-up of 753 patient-years, 40 patients experienced an adverse outcome (4 liver transplantations, 6 liver-related deaths, and 30 cirrhosis decompensations). LS and Anali score without Gd were significantly correlated (ρ = 0.51, P0.001) and were independently associated with the occurrence of an adverse outcome. Optimal prognostic thresholds were 10.5 kPa for LS and 2 for the Anali score without Gd. Hazard ratios (95% confidence interval) were 2.07 (1.06-4.06) and 3.78 (1.67-8.59), respectively. The use in combination of these 2 thresholds allowed us to separate patients into low-, medium-, and high-risk groups for developing adverse outcomes. The 5-year cumulative rates of adverse outcome in these 3 groups were 8%, 16%, and 38% (P0.001), respectively.The combined use of MRI and vibration-controlled transient elastography permits easy risk stratification of patients with PSC.

International audience; Background: The aim of this study was to identify predictive criteria of improvement after endoscopic treatment (ET) for severe strictures of extrahepatic bile ducts in patients with primary sclerosing cholangitis (PSC).Methods: PSC patients who had at least one ET for severe stricture were included. Features of magnetic resonance cholangiography (MRC), performed before ET, were evaluated according to a standard model of interpretation, and a radiologic qualitative score of probability of improvement after ET was built. Score 3 (likely) was given in case of severe common bile duct (CBD) stricture with marked dilatation without severe strictures of upstream ducts, Score 1 (unlikely) was given in case of severe multiple strictures of secondary ducts without biliary dilatation and Score 2 (undeterminate) was given to an intermediate pattern. The response to ET was assessed at 2 months (T2-response) from the last ET and at 12 months (T12-response) from inclusion.Results: Thirty-one patients were included. All had severe stricture (reduction ≥ 75% of the diameter) of CBD and 50% had severe stricture of right and/or left hepatic duct (LHD) at MRC before ET. According to the qualitative score, 16 patients had Score 3, 7 had Score 1 and 9 had Score 2. T12-response was obtained in 50% of patients. In univariate analysis, short LHD strictures, bilirubin, transaminases, pruritus and Score 3 were associated with T12-response. Increased bilirubin and transaminases were independent predictive factors of T12-response (HR 24, 95% CI: 3.4–170.4, P = 0.001 and 23.8, 95% CI: 3.4–169.4, P = 0.002, respectively).Conclusion: MRC, together with biochemical features, may contribute to identify the PSC patients who are likely to be improved after ET for severe strictures of extrahepatic bile ducts.

To evaluate the prognostic value of cystic dilatation (CD) of the intrahepatic biliary ducts in patients with primary sclerosing cholangitis (PSC). A single-center cohort of 205 patients with PSC from 2003 to 2016 was analysed. CD was defined by quantitative and qualitative criteria. Radiological and clinical courses were assessed. A Kaplan-Meier analysis was used to estimate cumulative survival without liver transplantation (LT) from the date of PSC diagnosis. A log-rank test was performed to compare survival time of PSC patients with and without CD. A total of 15 (7.3%) PSC patients (12 males) with a median age of 23 years at diagnosis had CD. Five patients had one CD; seven patients had two or three CDs; and three patients had diffuse CD. CDs ranged in small diameter size from 12 to 32 mm. Radiological evolution of CD was markedly variable. However, a radiological worsening of PSC over time was observed in all patients. The clinical course was characterized by the occurrence of complications in most patients. Half of the patients with CD underwent LT at a median time of 40 months from diagnosis of CD and the median survival time from PSC diagnosis was significantly lower than in PSC without CD (10.7 vs. 23.4 years; HR 3.8, 95% confidence interval: 1.7–8.3, p = 0.001). CD in PSC is an unusual condition that mostly affects young patients. It is characterized by a rapid, unfavorable course and constitutes a significant prognostic factor. • Cystic dilatation of the intrahepatic biliary ducts affects young patients with primary sclerosing cholangitis and is characterized by a markedly variable radiological evolution. • Biliary wall inflammation, found in explanted livers, could be a key feature in the pathogenesis of cystic dilatation. • Cystic dilatation of the intrahepatic biliary ducts is characterized by an unfavorable course and constitutes a significant prognostic factor of primary sclerosing cholangitis.

Background Different imaging techniques have been used for the investigation of the lymphatic channels and lymph glands. Noncontrast magnetic resonance (MR) lymphography has significant advantages in comparison with other imaging modalities. Methods Noncontrast MR lymphography uses very heavily T2-weighted fast spin echo sequences which obtain a nearly complete signal loss in tissue background and specific display of lymphatic vessels with a long T2 relaxation time. The raw data can be processed with different algorithms such as maximum intensity projection algorithm to obtain an anatomic representation. Results Standard T2-weighted MR images easily demonstrate the location of edema. It appears as subcutaneous infiltration of soft tissue with a classical honeycomb pattern. True collection around the muscular area may be demonstrated in case of severe lymphedema. Lymph nodes may be normal in size, number, and signal intensity; in other cases, lymph nodes may be smaller in size or number of lymph nodes may be restricted. MR lymphography allows a classification of lymphedema in aplasia (no collecting vessels demonstrated); hypoplasia (a small number of lymphatic vessels), and numerical hyperplasia or hyperplasia (with an increased number of lymphatic vessels of greater and abnormal diameter). Conclusion Noncontrast MR lymphography is a unique noninvasive imaging modality for the diagnosis of lymphedema. It can be used for positive diagnosis, differential diagnosis, and specific evaluation of lymphedema severity. It may also be used for follow-up evaluation after treatment.

Resume Objectif L’objectif etait d’evaluer la qualite des comptes rendus radiologiques des examens tomodensitometriques realises pour bilan d’evaluation oncologique avant et apres intervention correctrice. Materiels et methodes Notre objectif etait d’evaluer la presence de differents items au sein des comptes rendus radiologiques realises pour evaluation tumorale de facon formelle c’est-a-dire sans verifier l’exactitude des items releves. Dix items simples ont ete evalues avant et apres une intervention correctrice correspondant a une information orale puis ecrite relative a la technique d’evaluation tumorale en tomodensitometrie. Resultats Les resultats etaient variables en fonction des items mesures. La plupart des criteres ont ete ameliores apres intervention correctrice. Mais pour certains items le resultat restait mediocre voire tres mediocre comme le choix adequat de l’examen de comparaison (baseline ou nadir). Conclusion En l’absence d’utilisation de compte rendu type, l’evaluation de la qualite des comptes rendus radiologiques des examens tomodensitometriques pour evaluation tumorale montre que la qualite des comptes rendus radiologiques reste largement sous optimale meme apres intervention correctrice.

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

Primary chylous vaginal discharge is rare. It can be associated with lower limb, pelvic, or vulvar lymphedema or cutaneous vesicles in the perineum, labia, or legs. An analysis of vaginal discharge is helpful to reveal milky fluid with chylomicrons and a triglyceride rate greater than 11 mL/L [1]. In the present case, chylous vaginal discharge was due to a hyperplasia–dysplasia of lymphatics in the pelvis abutting the uterus, cervix, and vagina. This article is protected by copyright. All rights reserved.

International audience; Magnetic resonance cholangiography (MRC) has become the standard of reference for imaging of the biliary ducts. The use of three-dimensional (3D) sequences has resulted in improved spatial resolution with virtually isotropic voxel and improved signal/noise ratio. In addition to MRC images, 3D fat suppressed T1-weighted MR images should be systematically obtained to search for intrahepatic calculi. MRC plays a major role in the diagnosis of cholangiocarcinoma and assessment of its resectability. With modern MR systems the performance of MR is basically the same that of CT for evaluation of arterial and portal vein extent. MRC is a key imaging modality for the diagnosis of primary sclerosing cholangitis. Different imaging patterns may be observed including multifocal intra- and extrahepatic strictures alternating with slightly dilated ducts. Focal signal abnormality of the liver parenchyma and focal parenchymal atrophy represent the consequences of biliary duct obstruction on liver parenchyma. Diagnosis of biliary lithiasis is performed by combination of MRC and T1-weighted MR imaging. MRC can be performed for the diagnosis of secondary cholangitis including ascending cholangitis, ischemic cholangitis and IgG4-related sclerosing cholangitis. Hepatobiliary contrast agents could be used for demonstrating the site of biliary duct leakage after surgery and for functional imaging. MR imaging can also be used to determine the prognosis of PSC. The inherent limitations of MRC of bile ducts are still the suboptimal spatial resolution for evaluation of distal intrahepatic biliary ducts.

Resume L’osteosarcome costal primitif est exceptionnel chez l’adulte. Sa presentation sous la forme d’une masse mammaire isolee n’a jamais ete decrite dans la litterature. Les auteurs rapportent le cas d’une patiente de 49 ans, presentant une masse mammaire isolee et chez qui l’imagerie a permis d’affirmer son origine costale. La biopsie de cette masse a revele un osteosarcome costal envahissant secondairement le sein.

Our purpose was to assess the quality of radiologic reports of CT scans performed for tumor response evaluation before and after corrective procedure.Our objective was to assess the presence of different items in radiologic reports of CT scans performed for tumor response evaluation. The present evaluation was formal, that is to say without checking the accuracy of the items identified. Ten simple items were evaluated before and after corrective procedure corresponding to an oral and written information concerning the tumor response evaluation technique with CT.The results were variable depending on the items measured. Most of the criteria were improved after corrective procedure. But for some items the result remained poor or very poor as the appropriate choice of comparison review (baseline or nadir).In the absence of use of the standard form, the feedback of the quality of radiologic reports of CT scans performed for tumor response evaluation shows that the quality remains largely suboptimal even after corrective procedure.

OBJECTIVE. The purpose of this article is to describe CT and MRI features of normal anatomy, variants, and pathologic conditions of different ileostomies.CONCLUSION. Multiplanar imaging techniques are useful to identify the complications related to stoma construction and preexisting disease. Understanding the indications for ileostomy construction, surgical techniques, and postoperative anatomy is important for differentiating normal and abnormal imaging features.

We report a case of chyluria with magnetic resonance (MR) imaging demonstrating communication of lymphatic vessels with the renal pelvis.