Breast ductography: to do or not to do? A pictorial essay.

Nipple discharge is a frequent breast disease clinical presentation. Although most cases of nipple discharge are physiologic, pathologic nipple discharge is not uncommon. Eight to 15% of pathological nipple discharge is associated with malignancy, requiring investigation. Some specialists believe that ductography is a challenging procedure that is better to be substituted by other methods, such as MRI. However, an experienced physician can perform ductography quickly and easily and still play an essential role in some clinical scenarios. Conventional imaging, such as mammography and sonography, commonly fails to detect the underlying causes of pathological nipple discharge. MRI has limitations of low specificity, cost, lengthy exam duration, accessibility, and patient factors such as claustrophobia. In addition, we can make a specific diagnosis and appropriate treatment by coupling ductography with other methods, such as ultrasound-guided or stereotactic biopsy. This study aims to present the ductography technique, possible findings, and the clinical settings where ductography is useful.Critical relevance statement Although ductography is currently less used in breast imaging, it still plays an essential role in some clinical scenarios. These clinical scenarios include pathological nipple discharge with negative conventional imaging, contraindicated MRI, unavailable MRI, unremarkable MRI results, and multiple MRI findings.Key points• Conventional imaging commonly fails to detect the underlying causes of pathological nipple discharge.• MRI in the setting of nipple discharge has some limitations.• Ductography still plays an essential role in some clinical scenarios.• Coupling ductography with other methods helps make a specific diagnosis.

The Value of Adding Ductography to Ultrasonography for the Evaluation of Pathologic Nipple Discharge in Women with Negative Mammography.

OBJECTIVE: The optimal imaging approach for evaluating pathological nipple discharge remains unclear. We investigated the value of adding ductography to ultrasound (US) for evaluating pathologic nipple discharge in patients with negative mammography findings. MATERIALS AND METHODS: From July 2003 to December 2018, 101 women (mean age, 46.3 ± 12.2 years; range, 23-75 years) with pathologic nipple discharge were evaluated using pre-ductography (initial) US, ductography, and post-ductography US. The imaging findings were reviewed retrospectively. The standard reference was surgery (70 patients) or > 2 years of follow-up with US (31 patients). The diagnostic performances of initial US, ductography, and post-ductography US for detecting malignancy were compared using the McNemar's test or a generalized estimating equation. RESULTS: In total, 47 papillomas, 30 other benign lesions, seven high-risk lesions, and 17 malignant lesions were identified as underlying causes of pathologic nipple discharge. Only eight of the 17 malignancies were detected on the initial US, while the remaining nine malignancies were detected by ductography. Among the nine malignancies detected by ductography, eight were detected on post-ductography US and could be localized for US-guided intervention. The sensitivities of ductography (94.1% [16/17]) and post-ductography US (94.1% [16/17]) were significantly higher than those of initial US (47.1% [8/17]; p = 0.027 and 0.013, respectively). The negative predictive value of post-ductography US (96.9% [31/32]) was significantly higher than that of the initial US (83.3% [45/54]; p = 0.006). Specificity was significantly higher for initial US than for ductography and post-ductography US (p = 0.001 for all). CONCLUSION: The combined use of ductography and US has a high sensitivity for detecting malignancy in patients with pathologic nipple discharge and negative mammography. Ductography findings enable lesion localization on second-look post-ductography US, thus facilitating the selection of optimal treatment plans.

Stereotaxic Core-Needle Biopsy in Assessing Intraductal Pathologic Findings at Ductography.

Objective: The purpose of this study was to analyze the capabilities of ductography (DG) to navigate stereotactic core-needle biopsy (sCNB) for localizing and differentiating intraductal benign and malignant proliferations of the breast in patients with pathological nipple discharge (PND). Materials and Methods: Patients underwent physical, radiological, ultrasound, endoscopic and histopathological examinations. Results: The study included 183 patients. In 51, traditional DG was performed and in eight patients DG was performed using endoscopic mammoductoscopy (EMDS). A routine ductectomy labeled with methylene blue or propylene thread was performed in 81 patients. In 77 cases, a ductectomy was performed after double wire marking of intraductal proliferations (IDP) through the nipple and through the skin. In 26 patients, a preoperative sCNB under guidance of DG was performed. After sCNB 23/26 patients had benign IDP and three (11.5%) had invasive cancer. Breast surgery confirmed histology to be the gold standard in all patients, with the exception of 7 (26.9%) under the age of 45 years with benign IDP. These patients had watchful waiting and after 35 months of follow-up no signs of malignant growth were detected.DG was characterized by high (87.9%) sensitivity and low (33.3%) specificity. False positive rate was 25.9% and the cause was peripheral location of IDP (>3 cm from the nipple) in 57.1% and inadequate excision with leaving them outside the resection. Conclusion: This initial study on sCNB under the guidance of traditional or selective DG reports promising findings. Further studies are needed to determine whether preoperative histological assessment of pathologic intraductal lesions at DG would reduce the number of open surgeries with benign histology at sCNB.

The Role of Ductal Lavage Cytology in the Diagnosis of Breast Cancer.

BACKGROUND: Nipple discharge is a common finding which may be a symptom of breast cancer, but it is mostly caused by benign causes. A surgical biopsy followed by a histopathological examination is considered to be the gold standard for the diagnosis of pathological nipple discharge. Non-surgical diagnostic methods should be considered to reduce the need for intervention. Ductal lavage cytology (DLC) is performed by washing and examining the ductal discharge. The usefulness of examining spontaneous discharge is controversial. This study's aim is to evaluate the usefulness in surgical decision-making of ultrasonography (USG), mammography (MMG), magnetic resonance imaging (MRI), ductography, and DLC in patients with pathological nipple discharge. METHODS: Between 2011 and 2018, we retrospectively analyzed 141 patients with pathological nipple discharge who were planned to undergo a surgical procedure and were found to have pathology. In our study, the diagnostic efficiency of DLC for breast cancer diagnosis was compared with USG, MMG, MRI, and ductography. RESULTS: USG was performed in all patients, MMG in 51, MRI in 56, ductography in 46 patients, and cytological samples were taken from 63 patients. Twelve of 17 patients with malignant pathology were reported cytologically as suspected malignancy. The sensitivity of DLC was 70.5% (95% CI: 0.489-0.922), and its specificity was 94.1% (95% CI: 0.862-1.020). CONCLUSION: Numerous studies report that cytology is not adequate for final diagnosis. Negative cytology does not exclude the possibility of malignancy, and positive results do not help in the differential diagnosis.

Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer.

PURPOSE: The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD: A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS: The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS: This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.

Nipple Discharge: Current Clinical and Imaging Evaluation.

OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.

Combining non-contrast enhanced magnetic resonance thoracic ductography with vascular contrast-enhanced computed tomography to identify the canine thoracic duct.

Background: In humans, visualization of the thoracic duct by magnetic resonance imaging (MRI) has been attempted, and recent advances have enabled clinicians to visualize the thoracic duct configuration in a less invasive manner. Moreover, MRI does not require contrast media, and it enables visualization of morphological details of the thoracic structures. In veterinary practice, the thoracic duct has not been visualized three dimensionally in MRI. Aim: This study aimed to assess the performance of our magnetic resonance thoracic ductography (MRTD) technique to visualize the thoracic duct and the surrounding 3D anatomical structures by combining MRTD and vascular contrast-enhanced thoracic computed tomography (CT) images in dogs. Methods: Five adult male beagle dogs (11.4-12.8 kg) were included in this study. Sagittal and transverse T2-weighted images were scanned in MRI. Scanning in MRTD used a single-shot fast spin echo sequence with a respiratory gate. CT was performed after the intravenous injection of contrast medium. All MRTD and CT images were merged using a workstation. Results: The thoracic ducts were identified in MRTD images of all dogs, and the surrounding anatomical structures were located with the aid of contrast-enhanced thoracic CT. In all dogs, the thoracic ducts coursed along the right-dorsal side of the aorta, cranially from the L2 level. Thereafter, these bent to the left side at the aortic arch and curved at the left external jugular vein angle. A comparison of the number of thoracic ducts at each vertebra between transverse T2WI and MRTD did not reveal any significant differences for all vertebrae. Conclusion: The results from our study suggest that MRTD using the single-shot fast spin echo sequence could be a useful tool for visualization of the thoracic duct. Furthermore, the image merged from MRTD and vascular-enhanced images provided detailed anatomical annotation of the thorax. The MRTD protocol described in this study is safe and easily adaptable, without the need for contrast medium injection into the lymph system. In addition, the images fused from MRTD and vascular contrast-enhanced CT image of the thorax could provide detailed anatomical annotations for preoperative planning.

Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge.

PURPOSE: To compare sensitivities and specificities of ductography to noninvasive imaging studies in determining the cause of nipple discharge and assess the value of ductography on the basis of pathologic results. METHODS: In this retrospective review of women with nipple discharge who underwent ductography between January 1, 2005 and October 30, 2015, at our institution, we compared ductography with noninvasive imaging results (mammography, ultrasound, MRI) to determine its relative diagnostic sensitivity, specificity, and relative accuracy. Diagnosis was defined from pathology results, clinical notes, and minimum of 1-year follow-up monitoring. The primary endpoints include accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. The analyses were carried out in different configurations to compare results by the following pathologic categories: cancer, high-risk lesion, intraductal papilloma (IP) without atypia, and benign pathology and/or normal imaging results. RESULTS: In patients with breast cancer, ductography and noninvasive breast imaging had similar sensitivities. In patients with a high-risk lesion, ductography was significantly more sensitive than noninvasive imaging modalities. In patients with intraductal papilloma without atypia, ductography was more sensitive than noninvasive imaging, but the difference was of only borderline significance. For women with benign pathology and/or normal imaging, noninvasive imaging showed a significantly higher specificity than ductography. CONCLUSION: In the absence of standard diagnostic algorithm for patients presenting with nipple discharge, the clinician has numerous options to choose a diagnostic approach that will yield the most accurate information with the least disruption to the patient. Our results indicate the value of ductography compared to value of noninvasive imaging modalities when cancer is suspected and when high risk lesion is suspected. While we show the sensitivity of ductography is similar to noninvasive imaging modalities in the setting of cancer, the sensitivity of ductography is statistically valuable for diagnosing high-risk lesions. Our hope is that this study will emphasize more research and more understanding in clinical utility and management of high-risk lesions, leading to patient-focused algorithm for diagnosing the etiology of abnormal nipple discharge.

Is Ductography Still Warranted in the 21st century?

OBJECTIVE: To determine the utility of ductography in conjunction with mammography and ultrasound in patients with pathologic nipple discharge, and the incremental role of MRI after triple-modality evaluation. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had presented with pathologic nipple discharge and had undergone mammography and/or ultrasound and ductography between January 1, 2005, and October 31, 2010. We tested the diagnostic sensitivity, specificity and accuracy of combined triple-modality evaluation as well as of MRI performed in addition to these imaging techniques. We used the gold standard of image-guided biopsies, surgical excision, or long-term clinical and imaging follow-up. RESULTS: Among 94 study patients, benign papillomas were identified in 42 (44.7%), abscess in one (1%), duct ectasia in four (4.3%), and malignancy (invasive ductal carcinoma or ductal carcinoma in situ) or high-risk lesion (atypical ductal hyperplasia) in 10 (10.6%). Forty-six patients (49%) underwent surgical excision; 89.1% of which had presurgical planning with ductography. In 35 (37.2%) with negative imaging, resolution of nipple discharge was confirmed on median clinical and imaging follow-up of 36 months. Two patients with negative imaging were lost to follow-up. Sensitivity, specificity, PPV, and NPV for accurately demonstrating the etiology of pathologic nipple discharge were 13%, 97%, 89%, and 37% respectively for mammography; 73%, 97%, 98%, and 64% respectively for ultrasound; 76%, 72%, 84%, and 61% respectively for ductography; 86%, 70%, 85%, and 72% respectively for combined ultrasound and ductography; and 75%, 100%, 100% and 67% respectively for DCE-MRI. CONCLUSION: The combination of mammography, ultrasound and ductography is highly accurate for identifying the etiology of pathologic nipple discharge. DCE-MRI can be used as an alternate to ductography if necessary.

The Visibility of the Terminal Thoracic Duct Into the Venous System Using MR Thoracic Ductography with Balanced Turbo Field Echo Sequence.

RATIONALE AND OBJECTIVES: Magnetic resonance thoracic ductography (MRTD) with balanced turbo field echo (bTFE) can visualize both the thoracic duct and its surrounding vessels. This study aimed to investigate the visibility of the terminal thoracic duct into the venous system in the subclavian region using MRTD with bTFE. MATERIALS AND METHODS: MRTD was performed with bTFE as a preoperative workup comprising respiratory gating on a 1.5-T magnetic resonance system for patients with esophageal cancer. The portion and the number of terminal thoracic ducts into the venous system and preterminal branching in the left subclavian region were assessed using MRTD in 132 patients. The confidence level of the visibility using MRTD was also evaluated. RESULTS: The most frequent terminal portion of the thoracic duct was the jugulovenous angle (92 patients, 69.7%), followed by the subclavian vein (27 patients, 20.5%) and the internal jugular vein (8 patients, 6.1%). Four patients also exhibited double entry of the thoracic duct into the venous system. The preterminal branching was single in 96 patients (72.7%) and multiple in 36 patients (27.3%). The confidence level of the visibility of the thoracic duct using MRTD was absolutely certain in 112 patients (84.8%) and was somewhat certain in 20 patients (15.2%). CONCLUSIONS: MRTD with bTFE is a robust imaging modality to visualize the terminal portion of the thoracic duct into the venous system in the subclavian region.

Transvenous Retrograde Thoracic Ductography: Initial Experience with 13 Consecutive Cases.

PURPOSE: To report the feasibility and findings of transvenous retrograde thoracic duct cannulation. MATERIALS AND METHODS: The subjects were 13 patients who had undergone retrograde transvenous thoracic ductography. Despite conservative treatment, all required drainage for chylothorax, chylous ascites, or a chylous pericardial effusion. Lymphangiography was performed, and the junction of the thoracic duct with the vein was identified. A microcatheter was inserted into the thoracic duct retrogradely via the junction with the vein. RESULTS: The catheter could be inserted to the cervical part, thoracic part, and cisterna chyli in 12 (92.3%), nine (69.2%), and six (46.2%) patients, respectively. Successful transvenous thoracic ductography was performed in eight patients (61.5%). The cervical part of the thoracic duct was branched into a plexiform configuration beyond which the microcatheter could not be advanced to reach the thoracic part in three unsuccessful cases. The success rate of transvenous thoracic ductography was significantly higher with the simple type (80%) than with the plexiform type (0%; p = 0.035). No extravasation of contrast agent was seen in the eight patients with successful thoracic ductography. Thoracic duct embolization was performed in one patient with a chylous pericardial effusion in whom myriad lymph ducts connecting to the hilar and pericardial regions from the thoracic duct were found, and drainage was unnecessary. CONCLUSION: Transvenous retrograde thoracic ductography was successful in only eight of 13 patients (61.5%), but when the cervical part was the simple type, it was successful in eight of 10 patients (80%).

Magnetic resonance thoracic ductography assessment of serial changes in the thoracic duct after the intake of a fatty meal.

The thoracic duct, a terminal lymph vessel, is thought to dilate after the intake of a fatty meal. However, this physiological change has not been well explored in vivo. Therefore, the present study aimed to assess serial changes in the thoracic duct after the intake of a fatty meal using magnetic resonance thoracic ductography (MRTD). Eight healthy volunteers were subjected to one MRTD scan before a fatty meal and eight serial MRTD scans every hour thereafter. The cross-sectional areas of the thoracic duct were estimated using MRTD measurements of the diameters of the thoracic duct at the upper edge of the aortic arch, the tracheal bifurcation, the mid-point between the tracheal bifurcation and the left part of the diaphragm and the left part of the diaphragm. The change-rates in these areas were calculated before and after the fatty meal intake, and the maximal change-rate and timing of its achievement were determined for each subject. The summed change-rates in the four portions of the thoracic duct ranged from -40.1 to 81.3%, with maximal change-rates for each subject ranging from 22.8 to 81.3% (mean, 50.4%). Although individual variations were observed, most subjects (88.9%) exhibited a maximal change-rate at 4-6 h after meal intake, with subsequent decreases at 7-8 h. In conclusion, MRTD revealed a tendency toward thoracic duct enlargement at 4-6 h after the intake of a fatty meal, followed by contraction.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge.

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

MRI ductography of contrast agent distribution and leakage in normal mouse mammary ducts and ducts with in situ cancer.

High resolution 3D MRI was used to study contrast agent distribution and leakage in normal mouse mammary glands and glands containing in situ cancer after intra-ductal injection. Five female FVB/N mice (~19weeks old) with no detectable mammary cancer and eight C3(1) SV40 Tag virgin female mice (~15weeks old) with extensive in situ cancer were studied. A 34G, 45° tip Hamilton needle with a 25µL Hamilton syringe was inserted into the tip of the nipple and approximately 15µL of a Gadodiamide was injected slowly over 1min into the nipple and throughout the duct on one side of the inguinal gland. Following injection, the mouse was placed in a 9.4T MRI scanner, and a series of high resolution 3D T1-weighted images was acquired with a temporal resolution of 9.1min to follow contrast agent leakage from the ducts. The first image was acquired at about 12min after injection. Ductal enhancement regions detected in images acquired between 12 and 21min after contrast agent injection was five times smaller in SV40 mouse mammary ducts (p<0.001) than in non-cancerous FVB/N mouse mammary ducts, perhaps due to rapid washout of contrast agent from the SV40 ducts. The contrast agent washout rate measured between 12min and 90min after injection was ~20% faster (p<0.004) in SV40 mammary ducts than in FVB/N mammary ducts. These results may be due to higher permeability of the SV40 ducts, likely due to the presence of in situ cancers. Therefore, increased permeability of ducts may indicate early stage breast cancers.

The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.

UNLABELLED: The thoracic duct is the body's largest lymphatic conduit, draining upwards of 75 % of lymphatic fluid and extending from the cisterna chyli to the left jugulovenous angle. While a typical course has been described, it is estimated that it is present in only 40-60% of patients, often complicating already challenging interventional procedures. The lengthy course predisposes the thoracic duct to injury from a variety of iatrogenic disruptions, as well as spontaneous benign and malignant lymphatic obstructions and idiopathic causes. Disruption of the thoracic duct frequently results in chylothoraces, which subsequently cause an immunocompromised state, contribute to nutritional depletion, and impair respiratory function. Although conservative dietary treatments exist, the majority of thoracic duct disruptions require embolization in the interventional suite. This article provides a comprehensive review of the clinical importance of the thoracic duct, relevant anatomic variants, imaging, and embolization techniques for both diagnostic and interventional radiologists as well as for the general medical practitioner. KEY POINTS: • Describe clinical importance, embryologic origin, and typical course of the thoracic duct. • Depict common/lesser-known thoracic duct anatomic variants and discuss their clinical significance. • Outline the common causes of thoracic duct injury and indications for embolization. • Review the thoracic duct embolization procedure including both pedal and intranodal approaches. • Present and illustrate the success rates and complications associated with the procedure.

3D-MR Ductography and Contrast-Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study.

We evaluated contrast-enhanced magnetic resonance (ce-MR) imaging and an indirect MR galactogram (MRG) sequence against conventional galactography (CG) in women with suspicious nipple discharge who underwent histologic diagnosis. This study was Institutional Review Board approved and HIPAA compliant. Women with suspicious nipple discharge recommended for CG were recruited for our study. Patients underwent both a ce-MR as well as MRG (MRG-1 and MRG-2, variations in isotropic spatial resolution) followed by CG within 60 days. The ce-MR and MRG studies were interpreted together by a single radiologist separately from CG. Pathology was used as our gold standard and was obtained via image-guided core needle biopsy or surgery with papilloma, atypia, and malignancy considered positive. Of the 21 patients recruited for the study, 20 patients had known histology results for 26 lesions; 18 patients (90.0%) had successful CG, 20 (100.0%) ce-MRI, 20 (100.0%) MRG-1, and 19 (95.0%) MRG-2. Histology showed 5 cancers (4 women), 15 papillomas (2 with atypia) (11 women), and 6 additional benign lesions (6 women). Five patients (25.0%) had additional lesions detected by ce-MR that influenced surgical management. Sensitivity, specificity, positive (PPV), and negative predicted values (NPV) for CG, ce-MRI, MRG-1 were 65.0, 33.3, 76.5, and 22.2; 95.0, 66.7, 90.5, and 80.8; 55.0, 66.7, 84.6, and 30.8, respectively. ce-MR had the highest sensitivity, PPV, and NPV compared with CG or MRG. Our MRG protocols show promise, but were not as sensitive as ce-MRI for women with suspicious nipple discharge.

'Early' post-cardiotomy chylopericardium and the imaging value of magnetic resonance thoracic-ductography.

Isolated chylopericardium is a rare postoperative complication after cardiac surgery. A delay in diagnosis or an inappropriate management can lead to serious consequences. The treatment, which may either be conservative or surgical, is controversial and it depends on the duration and volume of effusion. We report a case of chylopericardium after atrial septal defect repair in a young woman. The patient was treated initially with total parenteral nutrition for 10 days. After drainage diminished, low fat diet containing medium chain triglyceride was instituted. Postoperatively, the role of magnetic resonance thoracic ductography was important for the assessment of the treatment strategy.