case_images: PMC10860527_01
case_images: (A) Fluoroscopic images obtained 10 min after initiating injection of the contrast agent show progression of the lipiodol through the left iliac and lumbar lymphatic ducts; however, there is no definite extravasation. (B) Fluoroscopic image obtained 25 min after the initial injection of lipiodol through the left inguinal node. Extravasation of diluted lipiodol is noticeable at the level of the first sacrum (arrowhead). A linear opacity in the midline corresponding to descending lipiodol flow was also found (white arrow). (C) Fluoroscopic image obtained 85 min after the initial injection of lipiodol shows diluted lipiodol reflux from the cisterna chyli (black arrow), descent of the anterior aspect of the lumbar spine (white arrow), and extravasation at the level of the first sacrum (arrowhead).
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case_images: PMC10860527_01_uaae004f1.jpg
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case_images: Fluoroscopy obtained 10 min after initiating injection of the contrast agent showed progression of the lipiodol through the left iliac and lumbar lymphatic ducts; however, extravasation was not observed (Figure 1A). When we punctured the right inguinal lymph node 25 min after the initial injection of lipiodol at the left inguinal node, an extravasation of diluted lipiodol was noted at the level of the first sacrum (Figure 1B). Fluoroscopy obtained 85 min after the start of left inguinal injection showed diluted lipiodol descending the anterior aspect of the lumbar spine and extravasating at the level of the first sacrum, which corresponded to the resected common iliac lymph node metastasis (Figure 1C and Supplementary Movie). Lipiodol was diluted considerably in the cisterna chyli and descended in a pulsatile fashion (Figure 1C and Supplementary Movie).
case_images: Three-dimensional volume rendering (left) shows anterograde lipiodol (yellow) and descending and refluxing lipiodol (light yellow). Cross-sectional CT images at several levels (right) show that the midline descending lipiodol corresponds to retroperitoneal paraaortic lymphatic vessels. The top image shows that lipiodol does not flow into the thoracic duct at all. The second image from the top shows the level of the cisterna chyli.
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case_images: PMC10860527_01_uaae004f2.jpg
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case_images: CT obtained 135 min after the start of left inguinal injection revealed contrast extravasation at the ventral surface of the sacrum (Figure 2).
case_images: CT obtained 40 days after surgical repair shows no ascites and an enlarged thoracic duct (arrow).
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case_images: PMC10860527_01_uaae004f3.jpg
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case_images: CT obtained 40 days after surgical repair revealed disappearance of ascites and enlargement of the thoracic duct (Figure 3).