We read with great interest the recent article by Busetto and colleagues published in Thoracic Cancer, which addresses the management of chylothorax following thoracic surgery [1]. The authors provide valuable insights into various therapeutic approaches for postsurgical chylothorax, including both thoracic duct embolization and surgical ligation techniques. Their systematic exploration of management strategies represents an important contribution to the field.
The authors appropriately emphasize the anatomical complexity of the thoracic lymphatic system, including the presence of multiple accessory ducts and anatomical variations that can complicate surgical identification of the thoracic duct. They highlight how percutaneous interventions rely on lymphographic visualization through bi‐inguinal contrast injection, while acknowledging the inherent imaging challenges posed by the small caliber of lymphatic vessels. The authors also discuss the utility of indocyanine green (ICG) fluorescence for intraoperative identification of lymphatic structures.
While we agree with the management principles outlined by Busetto et al., we would like to highlight the potential role of unenhanced MR lymphography as a valuable diagnostic tool in the evaluation of chylothorax. This noninvasive imaging technique utilizes heavily T2‐weighted sequences with very thin source images (0.8–1 mm) acquired in a 3D format with maximum intensity projection (MIP) reconstruction, enabling detailed assessment of lymphatic abnormalities without contrast administration [2].
The technique employs a free‐breathing 3D high spatial resolution fast spin‐echo sequence, similar to that used in MR cholangiopancreatography. In our experience, unenhanced MR lymphography provides excellent spatial resolution using a 512 × 512 matrix with millimetric or submillimetric source images. The thoracic duct and adjacent lymphatic vessels are readily visualized due to their characteristic alternating pattern of constriction (representing lymphatic valves) and dilation [2]. Furthermore, this technique excels in identifying associated lymphatic anomalies, including cystic lymphangiomas, hyperplastic or dysplastic lymphatic vessels, and lymph node abnormalities.
We propose that unenhanced MR lymphography could serve as an initial non‐invasive imaging modality in the diagnostic workup of chylothorax, potentially preceding more invasive procedures such as contrast‐enhanced lymphangiography or surgical exploration. This approach offers several advantages: it requires no contrast agent administration, poses minimal patient risk, and can be readily implemented without specialized expertise [3]. Additionally, it may provide valuable anatomical information for surgical planning or guide percutaneous interventional approaches.
In conclusion, we believe that unenhanced MR lymphography represents a valuable addition to the diagnostic armamentarium for chylothorax evaluation and may enhance the comprehensive management approach described by Busetto and colleagues [1].
Conflicts of Interest
The author declares no conflicts of interest.
Funding: The author received no specific funding for this work.
References
- 1. Busetto A., Cannone G., Lione L., et al., “Chylothorax After Thoracic Surgery: How we Manage It,” Thorac Cancer 16 (2025): e70036, 10.1111/1759-7714.70036. [DOI] [PMC free article] [PubMed] [Google Scholar]
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