The technique of intranodal contrast injection to visualize the lymphatic vessels, along with the use of dynamic contrast-enhanced MR lymphangiography, has led to important insights into the phenotype of patients with complex lymphatic anomalies. The pediatric patient with a complex lymphatic anomaly benefits from an integration of therapy across modalities, including supportive strategies (diet), localized therapy (drainage, embolization), and systemic therapy including targeted molecular therapy in mutation-driven complex lymphatic anomalies. A multidisciplinary collaboration, involving pediatricians, pharmacotherapeutic experts, pediatric radiologists, interventional radiologists, surgeons, geneticists, and nutritionists, is essential to tailor diagnosis to genotype and phenotype, personalize treatment, and monitor response.

Chylothorax is a severe complication of esophagectomy, frequently caused by inadvertent injury due to the high anatomical variability of the thoracic duct. Fluorescence with Indocyanine Green (ICG) facilitates its identification, but standard subcutaneous injection protocols involve long latency periods that complicate surgical logistics. This study evaluates the efficacy of an optimized intranodal injection technique. We conducted a retrospective descriptive study of a consecutive cohort of 14 patients undergoing minimally invasive esophagectomy (MIE) for esophageal cancer following neoadjuvant therapy. Bilateral ultrasound-guided inguinal intranodal injection of ICG (4 mg in each inguinal region) was performed simultaneously with anesthesia induction, consuming no surgical time. The thoracic duct identification rate, latency time (injection-to-visualization), anatomical variants, and procedure safety were analyzed. The thoracic duct identification rate was 100%. The mean latency time was 31.3 ± 4.4 minutes, allowing for immediate visualization at the start of the thoracic phase without delays. Anatomical variants (aberrant patterns) were identified in 30% of cases. Fluorescence enabled the detection and repair of inadvertent intraoperative lymphatic leaks in 40% of patients. There were no complications associated with the procedure, and the incidence of postoperative chylothorax was 0%. Intranodal lymphography with ICG integrated into anesthesia induction is a safe and efficient technique. It eliminates operating room wait times associated with the subcutaneous route and allows for the detection of variants and occult leaks, effectively preventing postoperative chylothorax.

The assessment of lymphatic drainage function is essential for understanding the role of the lymphatic system in fluid homeostasis, immunosurveillance and disease processes. Conventional methods of evaluation rely on dynamic visualization with tracers, such as X-ray lymphangiography, lymphoscintigraphy and magnetic resonance lymphangiography. However, these methods have limitations in terms of invasiveness and resolution, and other aspects. Recent advances in optical technologies and nanomaterials technology have enabled the development of noninvasive, high-precision testing methods, such as photoacoustic imaging and optical coherence tomography, which have made it possible to visualize and analyze lymphatic flow rates, tracer clearance rates and functional abnormalities. In addition, the application of artificial intelligence-assisted analysis, multimodal imaging, and targeted nanoprobes has significantly improved the precision and clinical applicability of these methods. In this article, we systematically review the principles, characteristics, clinical applications and preclinical research progress of nine classical or novel lymphatic drainage function testing techniques. We also discuss the advantages and limitations of each technique and explore the future development trend, aiming to provide insights for basic research and clinical practice.

Lymphedema arises from impaired lymphatic drainage, leading to accumulation of protein-rich fluid in the interstitium and progressive soft-tissue fibrosis. Although eyelid lymphedema is rare, it can cause marked functional and aesthetic morbidity, while often proves refractory to conservative measures. We report a case of secondary facial and eyelid lymphedema following closed head trauma, successfully treated with guided lymphagiogenesis using aligned nanofibrillar collagen scaffolds. A 44-year-old man presented with a 12-month history of non-pitting edema involving the upper and lower eyelids bilaterally and the lower frontal region, following blunt cranial trauma. Cross-sectional imaging excluded fractures or hematoma. Despite 12 months of complete decongestive therapy, there was no meaningful improvement. Indocyanine green lymphography (ICG) demonstrated a diffuse dermal backflow pattern and complete lymphatic flow blockage at both medial canthi. We implanted thread-like aligned nanofibrillar collagen scaffolds subcutaneously, from functional lymphatic collectors at the medial canthi bilateral to the ipsilateral preauricular lymph nodes, creating neocollectors to bypass the fibrotic obstructed segment. At 4 months postoperative, repeat ICG showed restoration of linear lymphatic flow along the scaffold track with drainage of the lower eyelid and zygomatic region, and clinical examination confirmed complete resolution of eyelid heaviness, pain and edema. This case illustrates that guided lymphagiogenesis using aligned nanofibrillar collagen scaffolds can restore lymphatic drainage in highly localized, post-traumatic facial lymphedema that is resistant to conservative therapy, offering a minimally invasive microsurgical alternative to debulking procedures.

The central lymphatic system plays a pivotal role in fluid homeostasis, immune regulation and macromolecular transport. In children, lymphatic flow disorders are increasingly recognized as contributors to a wide spectrum of clinical conditions, particularly in those with congenital heart disease or postsurgical single ventricle physiology. Conditions such as chylothorax, plastic bronchitis, protein-losing enteropathy and generalized lymphatic anomaly often require detailed imaging for diagnosis and therapeutic planning. Advances in cross-sectional imaging have transformed the evaluation of pediatric lymphatic disorders. Traditional techniques like lymphoscintigraphy and conventional lymphangiography offer limited anatomical detail and functional insight. In contrast, noninvasive modalities such as noncontrast MR lymphangiography, contrast-enhanced ultrasound, CT lymphangiography and dynamic contrast-enhanced MR lymphangiography now enable high-resolution visualization of central conducting lymphatics, including the thoracic duct and cisterna chyli. This review describes the current techniques used to image the central lymphatic system in children, with a focus on dynamic contrast-enhanced MR lymphangiography, which has emerged as the reference standard for both anatomical mapping and functional assessment. We review clinical indications, access techniques, protocol optimization, interpretation frameworks and technical pitfalls to facilitate broader adoption and reproducibility of these techniques.

BACKGROUND: Chyloma is a rare pseudocystic collection of chyle resulting from leakage of the thoracic duct or its branches. While sporadically reported in humans, it has not been previously described in veterinary medicine. This report describes the first case of an idiopathic mediastinal chyloma in a cat. CASE PRESENTATION: A three-year-old, castrated male, domestic shorthair cat presented with acute dyspnea and lethargy. Thoracic computed tomography (CT) revealed a well-circumscribed cystic mass in the right caudal mediastinum causing compressed the adjacent lungs and heart. The lesion was surgically excised and contained chylous fluid. Histopathological examination confirmed a fibrous-walled pseudocyst lacking an epithelial lining, supporting the diagnosis of chyloma. Clinical signs resolved after surgery. Five months later, chylothorax developed at a different site, with CT lymphangiography demonstrating thoracic duct leakage. No underlying cause was identified, and both conditions were considered idiopathic. The cat was managed conservatively with no recurrence during the six-month follow-up period. CONCLUSION: Chyloma should be considered in the differential diagnosis of mediastinal cystic lesions in cats. Surgical excision may be effective for relieving mass effect, and long-term monitoring is recommended given the potential for recurrent chyle leakage.

We report a case of idiopathic chyluria in a woman in her 70s, successfully treated by direct percutaneous puncture and embolization of the fistula site. The patient had experienced persistent milky-white urine, progressive weight loss, and voiding difficulties for >3 years. Inguinal intranodal lymphangiography identified a lymphatic-urinary fistula near the lower pole of the left renal calyx. Later, under fluoroscopic guidance, the fistula site was directly punctured and embolized using n-butyl cyanoacrylate without complications. Her symptoms resolved immediately, and there has been no recurrence over a two-year follow-up period while she remained on a regular diet. This case highlights the effectiveness of direct percutaneous embolization of the fistula site as a minimally invasive treatment option for refractory chyluria.