Successful management of refractory lymphoma-associated chylothorax with CT-guided direct embolization and pleurodesis.

BACKGROUND

Lymphoma-associated chylothorax is a challenging condition in which thoracic duct embolization (TDE) has limited efficacy because lymphatic leakage is often multifocal and difficult to localize. Furthermore, TDE performed without confirmed localization of the leakage site may increase upstream intralymphatic pressure and paradoxically worsen chylous leakage. Accurate localization of the leakage site before intervention is therefore essential.

CASE PRESENTATION: A 53-year-old man with low-grade B-cell lymphoma developed refractory bilateral chylothorax during chemotherapy. Conventional intranodal lymphangiography (INL) performed on two occasions failed to identify the leakage site, yet TDE was performed at the referring institution and was followed by marked clinical deterioration. Dynamic contrast-enhanced MR lymphangiography (DCE-MRL) subsequently demonstrated active lymphatic leakage from the residual lymphoma lesion. CT-guided direct embolization with n-butyl-2-cyanoacrylate (NBCA) was performed in four sessions, followed by surgical pleurodesis for persistent right-sided chylothorax, resulting in durable resolution without recurrence during 29 months of follow-up.

CONCLUSION

This case highlights the importance of avoiding TDE without confirmed localization of the leakage site in refractory lymphoma-associated chylothorax. When conventional lymphangiography fails to identify the leakage site, DCE-MRL may facilitate targeted intervention and improve treatment planning. CT-guided direct embolization may represent a useful therapeutic option in carefully selected patients.