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

Case Report

Lymphoscintigraphy Using 99mTc 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

Lymphangiography is a radiographic examination of

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
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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 99mTc
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. 99mTc 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) Figure 2: Static Anterior & Posterior images of the thorax
Abnormal collection of tracer was noted in the right showing abnormal collection of tracer in the right hemithorax
hemithorax at 3 hours (Figure 2).A region of interest was drawn at 3 hours.
around the thoracic activity and compared with a region

Figure 3: Static image of the intercostal drain bag showing

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.
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).
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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 99mTc 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
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radiopharmaceuticals are not available, adequate studies can
be performed with filtered 99mTc 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
evaluation of the lymphatic system 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.
References
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