Doctors Tame Refractory Lymphoma Chylothorax With CT-Guided Embolization After Imaging Breakthrough

A 53-year-old man with low-grade B-cell lymphoma developed refractory bilateral chylothorax during chemotherapy, and his clinicians eventually brought the condition under control through a sequence of image-guided embolization sessions followed by surgical pleurodesis, according to a case report published in CVIR Endovascular. The patient remained free of recurrence during 29 months of follow-up. The report, written by Yosuke Yamamoto, Masanori Inoue and colleagues, is presented as a letter to the editor and describes a single patient, so it cannot by itself establish how well the approach would perform across larger groups of people. Even so, the authors argue that the case carries a practical warning: thoracic duct embolization performed without first confirming where lymphatic fluid is escaping may make the problem worse rather than better.

When it arises in patients with lymphoma, it is notoriously difficult to manage because the underlying lymphatic leakage is often multifocal and hard to localize. Thoracic duct embolization, a minimally invasive procedure in which the main lymphatic vessel is deliberately occluded, has gained attention as a treatment for refractory chylothorax generally, with reported clinical success rates approaching 80 percent in technically successful cases. The authors note, however, that outcomes are considerably less favorable in lymphoma-associated chylothorax, where previous reports have described the need for repeated lymphatic interventions or substantially lower success rates, likely reflecting diffuse lymphatic abnormalities, multiple potential leakage sites and the difficulty of pinpointing the exact leak before intervening.

The patient in this report developed bilateral chylothorax during the second cycle of bendamustine chemotherapy. Although the chemotherapy reduced his tumor burden, right-sided chylothorax persisted with a daily output of approximately one liter despite conservative management that included dietary modification, total parenteral nutrition and octreotide. Intranodal lymphangiography, an imaging technique in which contrast agent is injected into lymph nodes to outline the lymphatic vessels, was performed at the referring institution but failed to identify the leakage site. Nevertheless, retrograde transvenous thoracic duct embolization with n-butyl-2-cyanoacrylate, a fast-setting medical adhesive commonly known as NBCA, was carried out via the left venous angle.

The result was a marked deterioration. Following the embolization, the bilateral chylothorax worsened substantially and the patient required drainage of both chest cavities, at which point he was referred to the authors’ institution. The authors are careful about causality, acknowledging that it cannot be established from a single case, but they offer a physiological explanation supported by prior experimental work. Maruyama and colleagues recently demonstrated that thoracic duct outflow obstruction increases thoracic duct pressure above central venous pressure, creating a state of lymphatic hypertension. In this patient, because the leakage site had never been identified before the procedure, occluding the thoracic duct may have raised pressure within disrupted lymphatic channels surrounding the residual lymphoma lesion, thereby aggravating the leakage of chyle into the pleural cavity. The authors describe these experimental findings as physiological support for the mechanism underlying their patient’s clinical deterioration.

At the new institution, a repeat intranodal lymphangiography again failed to identify a clear leakage site. The turning point came with dynamic contrast-enhanced MR lymphangiography, abbreviated DCE-MRL, a time-resolved magnetic resonance technique in which gadolinium-based contrast is tracked as it flows through the central lymphatic system. In this patient, DCE-MRL demonstrated active lymphatic leakage from the scarred lesion of the regressed lymphoma directly into the pleural cavity. Serial coronal maximum intensity projection images showed contrast accumulating first in the lumbar and para-aortic lymphatic vessels and, in later frames, extensive leakage into the right pleural cavity from the region of the residual lymphoma lesion, confirming the site of chyle extravasation.

The authors explain why DCE-MRL succeeded where conventional lymphangiography had twice failed. Because DCE-MRL uses gadolinium-based water-soluble contrast rather than oily Lipiodol, it can depict finer lymphatic structures, improving visualization of subtle or multifocal leakage. This distinction mattered enormously for treatment planning. Rather than pursuing further empirical lymphatic intervention after the deterioration, the team first prioritized precise localization of the leakage site. Identification of the residual lymphoma lesion as the source enabled targeted CT-guided direct embolization, which substantially reduced lymphatic drainage and stabilized the patient’s condition sufficiently to allow definitive surgical pleurodesis. The authors speculate that earlier localization by DCE-MRL, before the initial thoracic duct embolization, might have enabled targeted intervention as the first strategy, avoided non-targeted thoracic duct occlusion, prevented the clinical deterioration and reduced the need for subsequent surgery.

The embolization itself was performed in four sessions over two months. In each session, a 21-gauge needle was inserted directly into the residual lymphoma lesion under CT guidance, and a small amount of iodinated non-ionic contrast medium was injected to visualize the abnormal lymphatic channels within the lesion. Once these channels were opacified, and regardless of whether contrast extravasation into the pleural cavity was observed on that particular pass, a mixture of NBCA and iodized oil at a one-to-two ratio was immediately injected. The glue cast gradually outlined the lymphatic channels suspected to be the source of the chyle leak, and repeated injections across the sessions progressively covered the suspected leak points. Notably, in this case the injection of the NBCA mixture demonstrated contrast extravasation from the lesion into the pleural cavity, directly confirming that the residual lymphoma lesion was the source of the lymphatic leakage.

The response to embolization was asymmetric, and that asymmetry shaped the rest of the treatment. Pleural drainage volumes fell markedly after the embolization sessions, particularly on the left side, but persistent right-sided chylothorax remained. The authors speculate that the left-sided leakage was less extensive and therefore effectively controlled by embolization alone, whereas the right side likely involved more extensive or multiple disrupted lymphatic channels that could not be completely embolized. This partial success had a decisive practical consequence: control of the left-sided leakage made surgical pleurodesis a feasible option, whereas the initial bilateral leakage had precluded definitive surgical management. Surgical pleurodesis via thoracotomy was performed on day 61, with additional talc pleurodesis on the left side on day 75.

The timeline of the case illustrates how the combined strategy unfolded. Conservative management began with parenteral nutrition and oral nutritional supplements, moved through alternating periods of low-fat diet and parenteral nutrition, and eventually transitioned to a regular diet. Intranodal lymphangiography on day 12 identified no obvious leakage site. The four CT-guided direct embolization sessions took place between days 35 and 55, producing the marked decrease in drainage volume, especially on the left. After the thoracotomy-based pleurodesis on day 61 and the left-sided talc pleurodesis on day 75, both chest drains were removed and the patient was discharged on day 88. The combined percutaneous embolization and surgical treatment achieved durable resolution without recurrence during 29 months of follow-up.

The authors draw several cautious conclusions from this single experience. First, they emphasize the importance of avoiding thoracic duct embolization without confirmed localization of the leakage site in refractory lymphoma-associated chylothorax. Second, they suggest that when conventional lymphangiography fails to identify the leak, DCE-MRL should be considered before thoracic duct embolization to guide individualized image-guided intervention. Third, they position CT-guided direct embolization as a potentially valuable therapeutic option in carefully selected patients, while noting that direct puncture embolization of lymphomatous lesions has rarely been reported. Their conclusions align with recent multidisciplinary reviews cited in the report, which emphasize that management of this condition should be individualized using combinations of conservative, interventional and surgical approaches. As a letter describing one patient, the report does not provide efficacy data for the technique in a broader population, and the authors themselves frame the embolization approach as appropriate for carefully selected cases rather than as a general standard of care. What the case does offer is a concrete demonstration that precise imaging localization changed the trajectory of a refractory problem after an untargeted intervention had made it worse.

Subject of Research: Image-guided management of refractory lymphoma-associated chylothorax using DCE-MRL localization, CT-guided direct embolization and pleurodesis in a single case

Article Title: Successful management of refractory lymphoma-associated chylothorax with CT-guided direct embolization and pleurodesis

Article References: Yamamoto, Y., Tsukada, J., Tamura, M., Yoshikawa, H., Furukawa, Y., Ogawa, R., So, M., Miyabayashi, M., Tsuzaki, J., Nakatsuka, S., Okubo, Y., Sakurada, A., Asakura, K., Jinzaki, M., & Inoue, M. (2026). Successful management of refractory lymphoma-associated chylothorax with CT-guided direct embolization and pleurodesis. CVIR Endovascular, 9(1), Article 126. https://doi.org/10.1186/s42155-026-00780-x

Image Credits: AI Generated

DOI: 10.1186/s42155-026-00780-x

Keywords: chylothorax, lymphoma, thoracic duct embolization, DCE-MRL, MR lymphangiography, CT-guided embolization, NBCA, pleurodesis, intranodal lymphangiography, lymphatic leakage, interventional radiology, case report