title: Quantitative Contrast-Enhanced Magnetic Resonance Lymphangiography of the Upper Limbs in Breast Cancer Related Lymphedema: An Exploratory Study.
abstract: BACKGROUND
  Contrast-Enhanced Magnetic Resonance Lymphangiography (CE-MRL) presents some limitations: (i) it does not quantify lymphatic functionality; and (ii) enhancement of vascular structures may confound image interpretation. Furthermore, although CE-MRL is well described in the published literature for the lower limbs, there is a paucity of data with regards to its use in the upper limbs. In this proof-of-principle study, we propose a new protocol to perform CE-MRL in the upper limbs of patients with breast cancer-related lymphedema (BCRL) which addresses these limitations.
  
  
  RESULTS
  CE-MRL was performed using a previously published (morphological) protocol and the proposed protocol (quantitative) on both the ipsilateral (abnormal) and contralateral (normal) arms of patients with BCRL. The quantitative protocol employs contrast agent (CA) intradermal injections at a lower concentration to prevent T2*-related signal decay. Both protocols provided high-resolution three-dimensional images of upper limb lymphatic vessels. CA uptake curves were utilized to distinguish between lymphatic vessels and vascular structures. The quantitative protocol minimized venous enhancement and avoided spurious delays in lymphatic enhancement due to short T2* values, enabling correct CA uptake characterization. The quantitative protocol was therefore employed to measure the lymphatic fluid velocity, which demonstrated functional differences between abnormal and normal arms. The velocity values were in agreement with previously reported lymphoscintigraphy and near infra-red lymphangiography measurements.
  
  
  CONCLUSIONS
  This work demonstrated the feasibility of CE-MRL of the upper limbs in patients with BRCL, introducing an advanced imaging and analysis protocol suitable for anatomical and functional study of the lymphatic system.
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Marco
authors.initials: M
authors.lastname: Borri
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Maria A
authors.initials: MA
authors.lastname: Schmidt
authors.affiliation: 2 Skin Unit, Royal Marsden NHS Foundation Trust. Sutton, United Kingdom .|3 St. George's, University of London , Cardiac and Vascular Sciences, London, United Kingdom .
authors.forename: Kristiana D
authors.initials: KD
authors.lastname: Gordon
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Toni A
authors.initials: TA
authors.lastname: Wallace
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Julie C
authors.initials: JC
authors.lastname: Hughes
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Erica D
authors.initials: ED
authors.lastname: Scurr
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Dow-Mu
authors.initials: DM
authors.lastname: Koh
authors.affiliation: 1 CR-UK Cancer Imaging Centre, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, United Kingdom .
authors.forename: Martin O
authors.initials: MO
authors.lastname: Leach
authors.affiliation: 2 Skin Unit, Royal Marsden NHS Foundation Trust. Sutton, United Kingdom .|3 St. George's, University of London , Cardiac and Vascular Sciences, London, United Kingdom .
authors.forename: Peter S
authors.initials: PS
authors.lastname: Mortimer
mesh_terms: D001943:Breast Neoplasms / Q000150:complications*; D003287:Contrast Media; D005260:Female; D006801:Humans; D007089:Image Enhancement; D007091:Image Processing, Computer-Assisted; D042601:Lymphatic Vessels / Q000473:pathology; D008209:Lymphedema / Q000175:diagnosis* / Q000209:etiology*; D008220:Lymphography / Q000379:methods*; D018810:Magnetic Resonance Angiography; D008875:Middle Aged; D034941:Upper Extremity / Q000473:pathology*
chemical_list: D003287:Contrast Media