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Omar MTA, Gwada RFM, Omar GSM, El-Sabagh RM, Mersal AEAE. Low-Intensity Resistance Training and Compression Garment in the Management of Breast Cancer-Related Lymphedema: Single-Blinded Randomized Controlled Trial. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:1101-1110. [PMID: 31243692 DOI: 10.1007/s13187-019-01564-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There is limited evidence regarding the combined effect of exercise and compression garment on breast cancer-related lymphedema (BCRL). Therefore, we investigate the effect of low-intensity resistance training alone or in combination with a compression garment on lymphedema volume, self-reported lymphedema symptoms, and shoulder mobility and function. A total of 60 women with unilateral BCRL were randomly assigned to low-intensity resistance exercises (Rex group, n = 30) or exercises and compression garment (Rex-Com-group, n = 30). Both groups take part in exercises program consisted of 10-12 repetitions at 50 to 60% of one repetition maximum (IRM), three times weekly, for 8 weeks. The primary outcome was lymphedema volume determined by percentage reduction of excess limb volume (ELV). Secondary outcomes were lymphedema symptoms (pain, heaviness, and tightness) and shoulder mobility and function using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. All measurements were standardized and performed before (week 0, W0), after the intervention (week 8, W8), and at follow-up (week 12, W12). A significant reduction in percentage of ELV (p < 0.01), pain severity (p < 0.05), a sensation of heaviness (p < 0.05) and tightness (p < 0.001), and improvement in shoulder range of motion (p < 0.05) and function on DASH scores (p < 0.05) were observed at W8 and W12 in both groups. However, no between-group differences were observed over time. These findings suggest that low-intensity resistance training, irrespective of garment use, can effectively reduce limb volume and lymphedema symptoms, and increase shoulder mobility and function.
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Affiliation(s)
- Mohammed T A Omar
- Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, 7 Ahmad Al-Zayat St., Bain El-Sarayat, Giza, 12612, Egypt.
| | - Rehab F M Gwada
- Physical Therapy Department, National Heart Institute, Giza, Egypt
| | - Ghada S M Omar
- Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, 7 Ahmad Al-Zayat St., Bain El-Sarayat, Giza, 12612, Egypt
- Physical Therapy Department, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Rokia M El-Sabagh
- Physical Therapy Department, El-Mattaria Teaching Hospital, Cairo, Egypt
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Motawe ZY, Abdelmaboud SS, Breslin JW. Involvement of Sigma Receptor-1 in Lymphatic Endothelial Barrier Integrity and Bioenergetic Regulation. Lymphat Res Biol 2020; 19:231-239. [PMID: 33226886 DOI: 10.1089/lrb.2020.0060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Lymphatic endothelium plays significant roles in lymph transport and maintaining a barrier between the lymph and interstitial compartments. Lymphatic endothelial dysfunction is suspected to be a key factor in the pathogenesis of lymphatic diseases such as lymphedema. Sigma receptor-1 (σ1) was recently identified to promote endothelial-dependent production of nitric oxide and relaxation of collecting lymphatic vessels. In this study, we investigated the potential role of σ1 in lymphatic endothelial barrier function. Methods and Results: Cultured adult human dermal lymphatic endothelial cells (HDLEC) were grown into confluent monolayers. Transendothelial electrical resistance (TER) served as an index of barrier function. Glycolytic rate of HDLEC was determined with the Agilent Seahorse system. The σ1-selective agonist PRE-084 was used to test the impact of σ1 on HDLEC monolayer barrier function and endothelial bioenergetics, whereas the contribution of basal σ1 activity was assessed with small interfering RNA (siRNA)-mediated knockdown of σ1 expression. The ability of σ1 activation to counteract interleukin (IL)-1β-induced barrier dysfunction was also tested. The results show that PRE-084 increases HDLEC TER in a concentration-dependent manner, whereas reducing σ1 expression with siRNA decreases HDLEC TER. PRE-084 also enhances glycolytic rate parameters in HDLEC. Moreover, PRE-084 treatment partially counteracts IL-1β-induced HDLEC monolayer barrier dysfunction. Conclusions: Collectively, the results suggest that σ1 contributes to basal lymphatic endothelial barrier function, potentially through its ability to enhance glycolytic energy production. Our work also highlights the therapeutic potential of σ1 agonists for preventing lymphatic barrier dysfunction caused by inflammatory mediators.
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Affiliation(s)
- Zeinab Y Motawe
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Salma S Abdelmaboud
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jerome W Breslin
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Cuadrado GA, de Andrade MFC, Ariga SK, de Lima TM, Souza HP. Inflammation Precedes Fat Deposition in an Experimental Model of Lymphedema. Lymphat Res Biol 2020; 19:116-125. [PMID: 33216672 DOI: 10.1089/lrb.2020.0061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Chronic lymphedema is a common complication of lymphatic obstruction, particularly after cancer treatment, characterized by an increased volume of the affected extremity, partly caused by the accumulation of excessive adipose tissue. The relationship between lymph vessels' obstruction and fat deposit is, however, poorly understood. Objective: Our central hypothesis was that the inflammatory process caused by lymph stasis precedes the adipocyte differentiation and fat deposition. Methods and Results: We used a modified mouse tail model to produce secondary lymphedema. Animals were treated with dexamethasone, or the procedure was performed in nitric oxide synthase 2 (NOS2)-deficient mice to evaluate the role of inflammation in lymphedema formation. Adipose tissue (Lipin) and inflammatory markers (IL-6, MCP-1, and F4-80) were analyzed in histological samples and by quantitative polymerase chain reaction. We observed an increased deposition of fat into the affected area that starts 3 weeks after lymph vessel ligation; it further increased after 6 weeks. Genes involved in the inflammatory process were upregulated before adipocyte maturation. Treatment with dexamethasone or the use of inducible nitric oxide synthase knockout mice blocked the inflammatory reaction and inhibited the accumulation of fat distal to the lymphatic obstruction. Conclusion: In the modified mouse tail lymphedema, inflammation precedes adipogenesis. Our data suggest that MCP-1 and nitric oxide may be potential targets for lymphedema management.
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Affiliation(s)
- Guilherme A Cuadrado
- Emergency Medicine Department and Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Mauro F C de Andrade
- Department of Surgery, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Suely K Ariga
- Emergency Medicine Department and Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Thais M de Lima
- Emergency Medicine Department and Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Heraldo P Souza
- Emergency Medicine Department and Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
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Michelini S, Cestari M, Michelini S, Camilleri G, De Antoni L, Sonna WN, Bertelli M. Study of a supplement and a genetic test for lymphedema management. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020013. [PMID: 33170163 PMCID: PMC8023136 DOI: 10.23750/abm.v91i13-s.10658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
Malformations in the lymphatic vasculature, injury, surgery, trauma or toxic damage may lead to swelling of the limbs caused by inefficient lymphatic uptake and flow (lymphedema). Lymphedema can be congenital or acquired. Primary lymphedema is rare and caused by mutations in single genes, secondary lymphedema is more common and caused by a trauma in association with a genetic predisposition. We decided to develop a genetic test that would determine the genetic predisposition to the onset of lymphedema and to predict the course of the disease by analyzing polymorphisms involved in leukotriene B4 (LTB4) synthetic pathway, and variants involved in the onset of secondary lymphedema. There are not many compounds available for the treatment of the negative effects of lymph accumulation, we therefore designed a food supplement based on the hydroxytyrosol, that has anti-oxidant, anti-bacterial and anti-inflammatory activities.
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Affiliation(s)
- Sandro Michelini
- Department of Vascular Rehabilitation, San Giovanni Battista Hospital, Rome, Italy.
| | - Marina Cestari
- Study Centre Pianeta Linfedema, Terni, Italy; Lymphology Sector of the Rehabilitation Service, USLUmbria2, Terni, Italy.
| | - Serena Michelini
- Unit of Physical Medicine and Rehabilitation, Sant'Andrea Hospital, "Sapienza" University of Rome, Rome, Italy.
| | | | | | | | - Matteo Bertelli
- EBTNA-LAB, Rovereto (TN), Italy; MAGI EUREGIO, Bolzano, Italy; MAGI'S LAB, Rovereto (TN), Italy.
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Saternus R, Müller CSL, Heinricy L, Reichrath J, Vogt T. Elephantiasis nostras verrucosa gigantea nach nekrotisierender Fasziitis – Erfolgreiche Therapie mit Acitretin. AKTUELLE DERMATOLOGIE 2020. [DOI: 10.1055/a-1212-3230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungWir berichten über einen 54-jährigen männlichen Patienten mit einer posttraumatischen und postinflammatorischen Elephantiasis nostras verrucosa (ENV) des linken Beines. 5 Jahre zuvor war ein Arbeitsunfall vorausgegangen (Bagatellverletzung der linken Patella) mit nachfolgendem komplikationsreichen Verlauf (u. a. Entwicklung einer nekrotisierenden Fasziitis). Die dadurch entstandenen Hautdefekte wurden mittels Spalthauttransplantation versorgt. Nach initialer Einheilungstendenz kam es bei Verbandswechseln jedoch zu erheblichem Spalthautverlust mit begleitender infizierter Wundheilungsstörung. In den darauffolgenden Jahren bildeten sich eine massive Umfangsvermehrung des linken Beins sowie übel riechende, vegetierende, flächige Hyperkeratosen mit scharfer zirkulärer Demarkationslinie ca. 10 cm proximal des Kniegelenkes. Wir begannen eine Therapie mit Acitretin 40 mg/d p. o., eine intensivierte externe Therapie (stadienadaptiert antiseptisch, aggressiv keratolytisch) sowie mechanische Débridements (Skalpell, Kürette) zur Massenabtragung. Im Verlauf wurde die Acitretindosis auf 10 mg alle 2 Tage reduziert. Hierunter zeigt sich ein langfristig stabiler Befund. Pathogenetisch kann eine ENV bei einer wie im vorgestellten Fall insuffizienten Wiederherstellung des lymphatischen Abflusses nach z. B. Operationen oder Traumen mit Sistieren des Clearings relevanter Zytokine und Wachstumsfaktoren entstehen. Aufgrund der Seltenheit der ENV mit nur wenigen Fallberichten in der Literatur existiert keine standardisierte Therapie. Im hier dargestellten Fall wird über eine erfolgreiche Therapie der ENV mit Acitretin berichtet.
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Affiliation(s)
- R. Saternus
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Campus Homburg, Homburg
| | - C. S. L. Müller
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Campus Homburg, Homburg
| | - L. Heinricy
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Campus Homburg, Homburg
| | - J. Reichrath
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Campus Homburg, Homburg
| | - T. Vogt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Campus Homburg, Homburg
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Deng J, Dietrich MS, Niermann KJ, Sinard RJ, Cmelak AJ, Ridner SH, Gilbert J, Murphy BA. Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory. Int J Radiat Oncol Biol Phys 2020; 109:747-755. [PMID: 33068688 DOI: 10.1016/j.ijrobp.2020.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/22/2020] [Accepted: 10/05/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Lymphedema and fibrosis (LEF) are common yet overlooked late effects of head and neck cancer and its therapy. Lack of reliable and valid measures of head and neck LEF is a critical barrier to the timely identification and management of head and neck LEF. To fill this gap, we developed and pilot tested a 64-item patient-reported outcome measure ( Lymphedema Symptom Intensity and Distress Survey-Head and Neck, LSIDS-H&N). This article aims to report the process of further validation and refinement of the tool. METHODS AND MATERIALS A prospective, longitudinal study was conducted, and 120 patients with oral cavity and oropharyngeal cancer were recruited. Participants completed the LSIDS-H&N at pretreatment, end of treatment, and every 3 months up to 12 months after treatment. SAS PROC VARCLUS was used to generate preliminary clusters of item responses. Internal consistency of the item responses within each cluster was assessed using Cronbach's alpha. RESULTS A total of 117 patients completed the study. The participants reported that the LSIDS-H&N was easy to understand and captured their symptoms and medical conditions. However, >50% of participants indicated that the survey was burdensome due to length. Thus, we proceeded with item reduction, and the shortened tool (33-item) was named Head and Neck Lymphedema and Fibrosis Symptom Inventory (HN-LEF Symptom Inventory). The subsequent exploration of symptom clusters identified 7 symptom domain clusters (eg, soft tissue and neurologic toxicity), all of which demonstrated good internal consistency. CONCLUSIONS The HN-LEF Symptom Inventory has been carefully developed and refined to allow clinicians and researchers to capture LEF-associated symptom burden and function impairments. Additional rigorous psychometric testing of the tool is ongoing to further validate the strength and internal validity of this tool.
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Affiliation(s)
- Jie Deng
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee; Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kenneth J Niermann
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Robert J Sinard
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Sheila H Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Jill Gilbert
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
| | - Barbara A Murphy
- Vanderbilt-Ingram Cancer Center, Vanderbilt Medical Center, Nashville, Tennessee
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57
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Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients. Plast Reconstr Surg 2020; 146:402-407. [PMID: 32740596 DOI: 10.1097/prs.0000000000007021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is a risk factor for the development of secondary lymphedema after axillary lymphadenectomy and radiation therapy. The purpose of this study was to determine whether obesity influences the morbidity of lymphedema in patients who have the condition. METHODS Two cohorts of patients were compared: group 1, normal weight (body mass index ≤25 kg/m); and group 2, obese (body mass index ≥30 kg/m). Inclusion criteria were patients aged 21 years or older with lymphedema confirmed by lymphoscintigraphy. Covariates included age, sex, lymphedema type (primary or secondary), location, comorbidities, lymph node dissection, radiation therapy, lymphoscintigram result, and disease duration. Outcome variables were infection, hospitalization, and degree of limb overgrowth. The cohorts were compared using the Mann-Whitney U test, Fisher's exact test, and multivariable logistic regression. RESULTS Sixty-seven patients were included: group 1, n = 33; and group 2, n = 34. Disease duration did not differ between groups (p = 0.72). Group 2 was more likely to have an infection (59 percent), hospitalization (47 percent), and moderate or severe overgrowth (79 percent), compared to group 1 (18, 6, and 40 percent, respectively; p < 0.001). Multivariable logistic regression showed that obesity was an independent risk factor for infection (OR, 7.9; 95 percent CI, 2.5 to 26.3; p < 0.001), hospitalization (OR, 30.0; 95 percent CI, 3.6 to 150.8; p < 0.001), and moderate to severe limb overgrowth (OR, 6.7; 95 percent CI, 2.1 to 23.0; p = 0.003). CONCLUSIONS Obesity negatively affects patients with established lymphedema. Obese individuals are more likely to have infections, hospitalizations, and larger extremities compared to subjects with a normal body mass index. Patients with lymphedema should be counseled about the negative effects of obesity on their condition. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Chen K, Sinelnikov MY, Reshetov IV, Timashev P, Gu Y, Mu L, Lu P, Zhang Y. Therapeutic Potential of Mesenchymal Stem Cells for Postmastectomy Lymphedema: A Literature Review. Clin Transl Sci 2020; 14:54-61. [PMID: 33460321 PMCID: PMC7877822 DOI: 10.1111/cts.12864] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022] Open
Abstract
Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. Despite various physical therapy and surgical options available, the impaired lymph fluid drainage may be progressive due to lymphatic vascular insufficiency making treatment more difficulty. Stem cell therapy provides a promising alternative in the treatment of various chronic diseases. The wide applicability of cell therapy has been reviewed throughout literature. This review provides an overview of recent progress in the therapeutic effect of adult stem cells for primary and secondary lymphedema after breast surgery in preclinical studies and clinical cases. We start with a brief introduction about the pathophysiological mechanisms of postmastectomy lymphedema. Regarding existing treatments, we systematically summarize the benefits and limitations of recent progress. Because of their multidirectional differentiation potential and growth factor secretion, stem cell therapy shows promising results in the management of light to severe lymphedema. Increasing evidences have demonstrated a noticeable reduction in postmastectomy lymphedema and increased lymph-angiogenesis after specific stem cell therapy. Current data suggests that stem cell therapy in lymphedema treatment provides reversal of pathological reorganization associated with lymphedema progression. Finally, we propose potential strategies for overcoming the challenges in the development of multipotent progenitor cells for the treatment and prevention of lymphedema in clinical practice.
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Affiliation(s)
- Kuo Chen
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Mikhail Y Sinelnikov
- Institute for Regenerative Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Igor V Reshetov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Petr Timashev
- Institute for Regenerative Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Yuanting Gu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lan Mu
- Peking University People's Hospital, Beijing, China
| | - Pengwei Lu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanyuan Zhang
- Institute for Regenerative Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
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Hu LR, Pan J. Adipose-derived stem cell therapy shows promising results for secondary lymphedema. World J Stem Cells 2020; 12:612-620. [PMID: 32843917 PMCID: PMC7415246 DOI: 10.4252/wjsc.v12.i7.612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/29/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023] Open
Abstract
Lymphedema is mainly identified by progressive soft tissue swelling in impaired lymphatic system. Secondary lymphedema attributed to cancer therapy, parasite infection, and trauma remains a serious global disease. Patients with lymphedema suffer swelling, pain, and fatigue, with the dysfunction of the deformed extremities reducing the quality of life and increasing the risk of infection and lymphangiosarcoma. Adipose-derived stem cells (ADSCs) possess prominent regenerative potential to differentiate into multilineage cells, and produce various lymphangiogenic factors, making ADSC therapy a promising approach for lymphedema. The development of lymphedema consists of local inflammation, the fibrosis of lymphatic vessels, and the deposition of adipose fat. Existing animal models do not mimic the chronic inflammation environment, therefore suitable models are required in further studies. Some signal pathways and molecular mechanisms in physiological and pathological lymphagiogenesis remain unclear. In previous animal and human trials, ADSC therapy reduced edema in varying degrees. A larger number of trials with larger samples and longer follow-up periods are required to verify the efficiency and feasibility of ADSC therapy. ADSCs are of easy availability and immune exemption, making them a candidate for lymphedema treatment. Whether ADSCs enhance malignant characteristics or trigger the malignant change deserves further exploration and study before ADSC therapy can be made widely available.
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Affiliation(s)
- Li-Ru Hu
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jian Pan
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan Province, China
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Janssen SL, Scholbach T, Jeno S, Laurie H, Meyer M, Combs C. Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective. Eur J Case Rep Intern Med 2020; 7:001605. [PMID: 32665927 PMCID: PMC7350969 DOI: 10.12890/2020_001605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 11/16/2022] Open
Abstract
We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.
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Affiliation(s)
- Sclinda Lea Janssen
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Susan Jeno
- Department of Physical Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Mandy Meyer
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA.,Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | - Colin Combs
- Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
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O'Donnell TF, Izhakoff J, Gaebler JA, Niecko T, Iafrati MD. Correlation of disease comorbidity with prescribed treatment among insured U.S. lymphedema patients. J Vasc Surg Venous Lymphat Disord 2020; 9:461-470. [PMID: 32470618 DOI: 10.1016/j.jvsv.2020.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of this study was to define the current forms of treatment in a contemporary population of lymphedema (LED) patients for LED related to breast cancer, the most prevalently diagnosed LED comorbidity in Western countries, and phlebolymphedema with venous leg ulcer (PLEDU), a sequela of chronic venous disease. The goals of LED therapy are to reduce edema, thereby improving function and related symptoms, and to improve skin integrity to prevent development of infection. Treatment is generally nonsurgical: conservative care, including complex physical therapy, manual lymphatic drainage, and compression bandaging; or pneumatic compression device (PCD) therapy by a simple nonprogrammable device or an advanced programmable device. METHODS To determine the frequency of individual types of treatment for LED and their relationship to breast cancer-related lymphedema (BCRL) and PLEDU, we queried claims from a deidentified Health Insurance Portability and Accountability Act-compliant commercial administrative insurance database with >165 million members. A total of 26,902 patients identified with LED who had been enrolled with continuous medical benefits for 12 months before and after the index date for the complete years 2012 through 2016 were separated into four treatment categories: no treatment, conservative care, simple PCD (SPCD), and advanced PCD. LED treatment was related to the BCRL and PLEDU comorbidities. RESULTS BCRL patients, who represented 32.1% of all study patients, made up 41% of all patients receiving conservative care and 24% of patients receiving PCD therapy. By contrast, PLEDU patients (9.6% of study patients) were proportionally under-represented in the conservative care group (7.8%) but composed a disproportionately high share of the PCD therapy group (17.7%). PLEDU patients represented 23.5% of all LED patients prescribed SPCD therapy, whereas BCRL patients composed 10.3% of total LED patient SPCD prescriptions (P < .001). CONCLUSIONS Our analysis of a large health care administrative database showed clear differences between the way BCRL and PLEDU patients are treated. Compared with BCRL patients, PLEDU patients were less likely to receive conservative care and more likely to be prescribed SPCDs for pneumatic compression therapy. These differences suggest that lymphatic therapy may be undervalued for treatment of chronic venous swelling and prevention and treatment of PLEDU.
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Affiliation(s)
- Thomas F O'Donnell
- The Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Mass.
| | | | | | | | - Mark D Iafrati
- The Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
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Trinh L, Peterson P, Leander P, Brorson H, Månsson S. In vivo comparison of MRI‐based and MRS‐based quantification of adipose tissue fatty acid composition against gas chromatography. Magn Reson Med 2020; 84:2484-2494. [DOI: 10.1002/mrm.28300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/19/2020] [Accepted: 04/03/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Lena Trinh
- Medical Radiation Physics Department of Translational Medicine Lund University Skåne University Hospital Malmö Sweden
| | - Pernilla Peterson
- Medical Radiation Physics Department of Translational Medicine Lund University Skåne University Hospital Malmö Sweden
- Medical Imaging and Physiology Skåne University Hospital Lund Sweden
| | - Peter Leander
- Diagnostic Radiology Department of Translational Medicine Lund University Skåne University Hospital Malmö Sweden
| | - Håkan Brorson
- Department of Clinical Sciences Lund University Malmö Sweden
- Department of Plastic and Reconstructive Surgery Skåne University Hospital Malmö Sweden
| | - Sven Månsson
- Medical Radiation Physics Department of Translational Medicine Lund University Skåne University Hospital Malmö Sweden
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Abstract
Lymphology is evolving in search of a better management of lymphedema patients, both as to the diagnostic pathway and as to the therapeutic options. Similarly, lymphatic system is involved in a wide spectrum of pathophysiologic processes of most chronic degenerative diseases. Translational medicine integrates the interdisciplinary scientific knowledge to improve diagnostic and therapeutic options in the biomedical field. Inflammation and lymphatic function are regarded as the connecting biochemical factors in most diseases. This review focuses on the scientific publications regarding lymphatic system in connection to psycho-neuroendocrine immunology, hormesis, epigenetics and more generally nutrition and lifestyle. The interaction between lymphology and translational medicine may play a relevant role to improve management of lymphedema on the one hand, and of chronic degenerative diseases on the other.
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Affiliation(s)
- Attilio Cavezzi
- Eurocenter Venalinfa, San Benedetto del Tronto, Ascoli Piceno, Italy -
| | - Roberto Colucci
- Eurocenter Venalinfa, San Benedetto del Tronto, Ascoli Piceno, Italy
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Steele ML, Janda M, Vagenas D, Ward LC, Cornish BH, Box R, Gordon S, Matthews M, Poppitt SD, Plank LD, Yip W, Rowan A, Reul-Hirche H, Obermair A, Hayes SC. A Bioimpedance Spectroscopy-Based Method for Diagnosis of Lower-Limb Lymphedema. Lymphat Res Biol 2020; 18:101-109. [DOI: 10.1089/lrb.2018.0078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Megan L. Steele
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Monika Janda
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- Faculty of Health, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Dimitrios Vagenas
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Leigh C. Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Bruce H. Cornish
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Robyn Box
- Queensland Lymphedema & Breast Oncology Physiotherapy, Brisbane, Australia
| | - Susan Gordon
- College of Healthcare Sciences, James Cook University, Townsville, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Melanie Matthews
- College of Healthcare Sciences, James Cook University, Townsville, Australia
| | - Sally D. Poppitt
- Human Nutrition Unit, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Lindsay D. Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Wilson Yip
- Human Nutrition Unit, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Angela Rowan
- Fonterra Co-operative Group Limited, Auckland, New Zealand
| | | | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, Brisbane, Australia
| | - Sandra C. Hayes
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
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65
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Gutiérrez C, Mayrovitz HN, Naqvi SHS, Karni RJ. Longitudinal effects of a novel advanced pneumatic compression device on patient-reported outcomes in the management of cancer-related head and neck lymphedema: A preliminary report. Head Neck 2020; 42:1791-1799. [PMID: 32187788 PMCID: PMC7496342 DOI: 10.1002/hed.26110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 01/11/2020] [Accepted: 01/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background Head and neck cancer (HNC) survivors experience head and neck lymphedema (HNL), which requires treatment to prevent morbidity. We explore the self‐reported outcomes and satisfaction of patients with HNC receiving treatment for HNL with an advanced pneumatic compression device (APCD). Methods HNC survivors (n = 205) prescribed with an at‐home Flexitouch head and neck APCD completed pretreatment and posttreatment self‐reported assessments addressing efficacy, function, and symptoms. Participant average age was 60 years with 74% male. Pre‐post responses for ≥25 days of use were assessed via the non‐parametric Wilcoxon Signed Rank test. Results Analysis revealed statistically significant improvement in all symptoms and all function items (P < 0.00001). Compliance with prescribed therapy (at least 30 minutes daily) was high with 71% of participants reporting daily use and 87% reporting overall satisfaction. Conclusions The reported improvements in function and symptoms, and high compliance rate, provide a rationale for a subsequent randomized controlled trial.
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Affiliation(s)
- Carolina Gutiérrez
- Department of Physical Medicine & Rehabilitation, The University of Texas Health Science Center / McGovern Medical School, Houston, Texas.,Department of Otorhinolaryngology - Head & Neck Surgery, The University of Texas Health Science Center / McGovern Medical School, Houston, Texas
| | - Harvey N Mayrovitz
- Division of Physiology, Department of Medical Education, Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Syed Hassan Shiraz Naqvi
- Department of Otorhinolaryngology - Head & Neck Surgery, The University of Texas Health Science Center / McGovern Medical School, Houston, Texas
| | - Ron J Karni
- Division of Head & Neck Surgical Oncology, Department of Otorhinolaryngology - Head & Neck Surgery Division of Medical Oncology, The University of Texas Health Science Center / McGovern Medical School, Houston, Texas
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66
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Azhar SH, Lim HY, Tan BK, Angeli V. The Unresolved Pathophysiology of Lymphedema. Front Physiol 2020; 11:137. [PMID: 32256375 PMCID: PMC7090140 DOI: 10.3389/fphys.2020.00137] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
Lymphedema is the clinical manifestation of impaired lymphatic transport. It remains an under-recognized and under-documented clinical condition that still lacks a cure. Despite the substantial advances in the understanding of lymphatic vessel biology and function in the past two decades, there are still unsolved questions regarding the pathophysiology of lymphedema, especially in humans. As a consequence of impaired lymphatic drainage, proteins and lipids accumulate in the interstitial space, causing the regional tissue to undergo extensive and progressive architectural changes, including adipose tissue deposition and fibrosis. These changes are also associated with inflammation. However, the temporal sequence of these events, the relationship between these events, and their interplay during the progression are not clearly understood. Here, we review our current knowledge on the pathophysiology of lymphedema derived from human and animal studies. We also discuss the possible cellular and molecular mechanisms involved in adipose tissue and collagen accumulation during lymphedema. We suggest that more studies should be dedicated to enhancing our understanding of the human pathophysiology of lymphedema to pave the way for new diagnostic and therapeutic avenues for this condition.
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Affiliation(s)
- Syaza Hazwany Azhar
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hwee Ying Lim
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bien-Keem Tan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Veronique Angeli
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Vafa S, Haghighat S, Janani L, Totmaj AS, Navaei M, Amirinejad A, Emamat H, Salehi Z, Zarrati M. The effects of synbiotic supplementation on serum inflammatory markers and edema volume in breast cancer survivors with lymphedema. EXCLI JOURNAL 2020; 19:1-15. [PMID: 32038113 PMCID: PMC7003637 DOI: 10.17179/excli2019-1876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/18/2019] [Indexed: 12/17/2022]
Abstract
Breast cancer-related lymphedema (BCRL) is one of the most common complications of breast cancer treatments, which may be exacerbated by obesity. Dysbiosis may negatively impact the management of obesity and lymphedema by increasing inflammation. The objective of this study was to assess the effects of supplementation with synbiotics on inflammatory markers, serum leptin concentration and edema volume in overweight and obese BCRL women following a low-calorie diet (LCD). In a randomized double-blind controlled clinical trial, 88 breast cancer survivors with lymphedema were supplemented once a day for 10 weeks with either a synbiotic or a placebo capsule. Both groups were under a low-calorie diet (LCD). At the end of the study, synbiotic supplementation resulted in a significant reduction in leptin (P=0.003) and TNF-α (P=0.039) between the study groups. Besides, edema volume was significantly reduced within the synbiotic group after the intervention. We did not observe any significant effects of the synbiotic supplementation in hs-CRP, and IL-1β between the study groups (P=0.550, P=0.118 respectively). Conclusively, synbiotic supplementation along with an LCD program in breast cancer survivors with lymphedema had beneficial effects on the concentration of serum inflammatory markers and edema volume.
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Affiliation(s)
- Saeideh Vafa
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Shahpar Haghighat
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Leila Janani
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Saneei Totmaj
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mehraban Navaei
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Amirinejad
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hadi Emamat
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Salehi
- Immunology Department, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mitra Zarrati
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
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68
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Doruk Analan P, Kaya E. The Effect of Serum 25(OH)D3 Level on Breast Cancer-Related Lymphedema. Lymphat Res Biol 2020; 18:22-26. [DOI: 10.1089/lrb.2018.0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Pınar Doruk Analan
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Emine Kaya
- Department of Physical Medicine and Rehabilitation, Adana City Training and Research Hospital, Adana, Turkey
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69
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Lee YL, Huang YL, Chu SY, Chan WH, Cheng MH, Lin YH, Chang TY, Yeh CK, Tsui PH. Characterization of limb lymphedema using the statistical analysis of ultrasound backscattering. Quant Imaging Med Surg 2020; 10:48-56. [PMID: 31956528 PMCID: PMC6960425 DOI: 10.21037/qims.2019.10.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 10/08/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lymphedema is a disease in which tissue swelling is caused by interstitial fluid retention in subcutaneous tissue. It is caused by a compromised lymphatic system. Lymphoscintigraphy is the current and primary modality used to assess lymphatic system dysfunction. Ultrasound elastography is a complementary tool used for evaluating the tissue stiffness of the lymphedematous limb. Tissue stiffness implies the existence of changes in tissue microstructures. However, ultrasound features related to tissue microstructures are neglected in clinical assessments of lymphedematous limbs. In this study, we aimed to evaluate the lymphedematous diagnostic values of ultrasound Nakagami and entropy imaging, which are, respectively, model- and nonmodel-based backscattered statistical analysis methods for scatterer characterization. METHODS A total of 60 patients were recruited, and lymphoscintigraphy was used to score the patient's clinical severity of each of their limb lymphedema (0: normal; 1: partial lymphatic obstruction; and 2: total lymphatic obstruction). We performed ultrasound examinations to acquire ultrasound backscattered signals for B-mode, Nakagami, and entropy imaging. The envelope amplitude, Nakagami, and entropy values, as a function of the patients' lymphatic obstruction grades, were expressed in terms of their median and interquartile range (IQR). The values were then used in both an independent t test and a receiver operating characteristic (ROC) curve analysis. RESULTS For each increase in a patient's score from 0 to 2, the envelope amplitude values were 405.44 (IQR: 238.72-488.17), 411.52 (IQR: 298.53-644.25), and 476.37 (IQR: 348.86-648.16), respectively. The Nakagami parameters were 0.16 (IQR: 0.14-0.22), 0.26 (IQR: 0.23-0.34), and 0.24 (IQR: 0.16-0.36), respectively, and the entropy values were 4.55 (IQR: 4.41-4.66), 4.86 (IQR: 4.78-4.99), and 4.87 (IQR: 4.81-4.97), respectively. The P values between the normal control and lymphedema groups obtained from B-mode and Nakagami analysis were larger than 0.05; whereas that of entropy imaging was smaller than 0.05. The areas under the ROC curve for B-mode, Nakagami, and entropy imaging were 0.64 (sensitivity: 70%; specificity: 47.5%), 0.75 (sensitivity: 70%; specificity: 75%), and 0.94 (sensitivity: 95%; specificity: 87.5%), respectively. CONCLUSIONS The current findings demonstrated the diagnostic values of ultrasound Nakagami and entropy imaging techniques. In particular, the use of non-model-based entropy imaging enables for improved performance when characterizing limb lymphedema.
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Affiliation(s)
- Ya-Lun Lee
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Yen-Ling Huang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Hui Chan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Ying-Hsiu Lin
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tu-Yung Chang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Po-Hsiang Tsui
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
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Daneshgaran G, Lo AY, Paik CB, Cooper MN, Sung C, Jiao W, Park SY, Ni P, Yu RP, Vorobyova I, Jashashvili T, Hong YK, Kim GH, Conti PS, Chai Y, Wong AK. A Pre-clinical Animal Model of Secondary Head and Neck Lymphedema. Sci Rep 2019; 9:18264. [PMID: 31797883 PMCID: PMC6892928 DOI: 10.1038/s41598-019-54201-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/04/2019] [Indexed: 12/30/2022] Open
Abstract
Head and neck lymphedema (HNL) is a disfiguring disease affecting over 90% of patients treated for head and neck cancer. Animal models of lymphedema are used to test pharmacologic and microsurgical therapies; however, no animal model for HNL is described in the literature to date. In this study we describe the first reproducible rat model for HNL. Animals were subjected to two surgical protocols: (1) lymphadenectomy plus irradiation; and (2) sham surgery and no irradiation. Head and neck expansion was measured on post-operative days 15, 30 and 60. Magnetic resonance imaging (MRI) was acquired at the same time points. Lymphatic drainage was measured at day 60 via indocyanine green (ICG) lymphography, after which animals were sacrificed for histological analysis. Postsurgical lymphedema was observed 100% of the time. Compared to sham-operated animals, lymphadenectomy animals experienced significantly more head and neck swelling at all timepoints (P < 0.01). Lymphadenectomy animals had significantly slower lymphatic drainage for 6 days post-ICG injection (P < 0.05). Histological analysis of lymphadenectomy animals revealed 83% greater subcutis thickness (P = 0.008), 22% greater collagen deposition (P = 0.001), 110% greater TGFβ1+ cell density (P = 0.04), 1.7-fold increase in TGFβ1 mRNA expression (P = 0.03), and 114% greater T-cell infiltration (P = 0.005) compared to sham-operated animals. In conclusion, animals subjected to complete lymph node dissection and irradiation developed changes consistent with human clinical postsurgical HNL. This was evidenced by significant increase in all head and neck measurements, slower lymphatic drainage, subcutaneous tissue expansion, increased fibrosis, and increased inflammation compared to sham-operated animals.
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Affiliation(s)
- Giulia Daneshgaran
- Albert Einstein College of Medicine, 1300 Morris Park, Bronx, NY, 10461, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Andrea Y Lo
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Connie B Paik
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Michael N Cooper
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
- Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, 70112, USA
| | - Cynthia Sung
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Wan Jiao
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Sun Y Park
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Pauline Ni
- Department of Molecular and Cell Biology, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Roy P Yu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA
| | - Ivetta Vorobyova
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Tea Jashashvili
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Young-Kwon Hong
- Department of Surgery, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Gene H Kim
- Department of Dermatology, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA
| | - Peter S Conti
- Molecular Imaging Center, Keck School of Medicine of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Yang Chai
- Center for Craniofacial and Molecular Biology, Herman Ostrow School of Dentistry of USC, 2250 Alcazar St, Los Angeles, CA, 90089, USA
| | - Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033, USA.
- Department of Surgery, Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA, 90033, USA.
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Bertelli M, Kiani AK, Paolacci S, Manara E, Dautaj A, Beccari T, Michelini S. Molecular pathways involved in lymphedema: Hydroxytyrosol as a candidate natural compound for treating the effects of lymph accumulation. J Biotechnol 2019; 308:82-86. [PMID: 31794783 DOI: 10.1016/j.jbiotec.2019.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 12/14/2022]
Abstract
Lymphedema is a chronic accumulation of interstitial fluid due to inefficient lymph drainage. Major causes of lymphedema are malformations of lymphatic vessels, trauma, toxic damage and surgery. The swelling typically affects the limbs. Lymphedema may be primary, caused by genetic mutations and relatively rare, or secondary (acquired), due to external causes such as infections or surgery. Fluid accumulation induces pathological changes: activation of the inflammatory cascade, immune cell infiltration, tissue fibrosis, adipose accumulation. We focused on the inflammatory phenotype mediated by leukotriene B4, a lipid mediator of the inflammatory pathway, and the potential therapeutic effect of hydroxytyrosol. We conducted an electronic search in PubMed using "lymphedema", "lymphedema pathway", "hydroxytyrosol" as keywords. We found that lymphedema deregulates at least six molecular pathways and that hydroxytyrosol, a compound with antioxidant activity, can improve endothelial dysfunction, hemostatic and lipid profiles, and decrease oxidative stress and inflammation through inhibition of leukotriene B4 activity. This review is the first to highlight the possibility of using hydroxytyrosol to treat the secondary effects of lymphedema, especially inflammation. The possible effects of hydroxytyrosol on lymphedema should be tested in vitro and in vivo to find the best way to treat patients with lymphedema in order to improve their health status.
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Affiliation(s)
- Matteo Bertelli
- EBTNA-Lab, Via Delle Maioliche, 57/G, 38068, Rovereto, TN, Italy.
| | - Aysha Karim Kiani
- Allama Iqbal Open University, Sector H-8, 44000, Islamabad, Pakistan.
| | - Stefano Paolacci
- MAGI's Lab, Via Delle Maioliche, 57/D, 38068, Rovereto, TN, Italy.
| | - Elena Manara
- MAGI Euregio, Via Maso della Pieve, 60/A, 39100, Bolzano, Italy.
| | - Astrit Dautaj
- MAGI Balkans, Rruga Andon Zako Cajupi, 1019, Tirana, Albania.
| | - Tommaso Beccari
- Department of Pharmaceutical Sciences, University of Perugia, Via Ariodante Fabretti, 48, 06123, Perugia, Italy.
| | - Sandro Michelini
- Department of Vascular Rehabilitation, San Giovanni Battista Hospital, Via Luigi Ercole Morselli, 13, 00148, Rome, Italy.
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Baglivo M, Martelli F, Paolacci S, Manara E, Michelini S, Bertelli M. Electrical Stimulation in the Treatment of Lymphedema and Associated Skin Ulcers. Lymphat Res Biol 2019; 18:270-276. [PMID: 31730410 DOI: 10.1089/lrb.2019.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Lymphedema is a disorder in which lymph accumulates in the interstitial spaces due to poor lymphatic flow resulting from hypoplasia or aplasia of the lymphatic vessels, or to morpho-functional alterations that impair lymphatic flow. Lymphedema is a debilitating condition associated initially with inflammation that then degenerates into hardening of affected tissues and the formation of ulcers on the skin of affected limbs. No definitive treatment is available. The only therapy for lymphedema consists of physiotherapy, surgery, and compression to reduce impairment, which only treats the symptoms, not the causes. A possible new therapy that could reinforce the treatment of lymphedema progression and complications is electrical stimulation (ES). Many studies underline the effects of electric currents on the different cell mechanisms associated with disease. Methods and Results: In this review, we summarize the effects of ES on the molecular and cellular processes involved in the pathophysiology of lymphedema, highlighting their therapeutic potential for edema reduction, ulcer repair, and restoration of lymphatic flow in vitro and in vivo. Conclusions: ES exerts its effect on the main stages that characterize lymphedema, from its onset to ulcer formation. There are few evidences on lymphatic models and more molecular studies are needed to understand the mechanism of action of this application in the treatment of lymphedema.
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Affiliation(s)
| | - Francesco Martelli
- Department of Cardiovascular and Endocrine-Metabolic Diseases, and Ageing, National Institute of Health, Roma, Italy
| | | | - Elena Manara
- Research Unit, MAGI-Euregio, Bolzano, Italy.,Research Unit, EBTNA-Lab, Rovereto, Italy
| | - Sandro Michelini
- Department of Vascular Rehabilitation, San Giovanni Battista Hospital, Rome, Italy
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Kataru RP, Wiser I, Baik JE, Park HJ, Rehal S, Shin JY, Mehrara BJ. Fibrosis and secondary lymphedema: chicken or egg? Transl Res 2019; 209:68-76. [PMID: 31022376 PMCID: PMC7400991 DOI: 10.1016/j.trsl.2019.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 01/06/2023]
Abstract
Secondary lymphedema is a common complication of cancer treatment resulting in progressive fibroadipose tissue deposition, increased risk of infections, and, in rare cases, secondary malignancies. Until recently, the pathophysiology of secondary lymphedema was thought to be related to impaired collateral lymphatic formation after surgical injury. However, more recent studies have shown that chronic inflammation-induced fibrosis plays a key role in the pathophysiology of this disease. In this review, we will discuss the evidence supporting this hypothesis and summarize recent publications demonstrating that lymphatic injury activates chronic immune responses that promote fibrosis and lymphatic leakiness, decrease collecting lymphatic pumping, and impair collateral lymphatic formation. We will review how chronic mixed T-helper cell inflammatory reactions regulate this process and how this response may be used to design novel therapies for lymphedema.
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Affiliation(s)
- Raghu P Kataru
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Itay Wiser
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jung Eun Baik
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hyeung Ju Park
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sonia Rehal
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin Yeon Shin
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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74
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Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical Lymphoscintigraphic Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2295. [PMID: 31624689 PMCID: PMC6635205 DOI: 10.1097/gox.0000000000002295] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/17/2019] [Indexed: 12/20/2022]
Abstract
Background: The Stemmer sign is a physical examination finding used to diagnose lymphedema. If the examiner cannot pinch the skin of the dorsum of the foot or hand then this positive finding is associated with lymphedema. The purpose of the study was to determine the accuracy of the Stemmer sign to predict lymphedema. Methods: All patients referred to our Lymphedema Program between 2016 and 2018 were tested for the Stemmer sign and underwent lymphoscintigraphy to define the patient’s lymphatic function. Patient age, lymphedema type (primary and secondary), disease location (arm and leg), lymphoscintigraphy findings, stage, severity, and body mass index were recorded. Comparison of predictive variables and Stemmer sign result was performed using Fisher’s exact test and Student’s t test. Results: One hundred ten patients were studied: patients with a positive Stemmer sign (n = 87) exhibited abnormal (n = 80) or normal (n = 7) lymphatic function by lymphoscintigraphy (sensitivity = 92%). False-positive Stemmer signs included individuals with obesity (n = 6) or spinal muscle atrophy (n = 1). Subjects with a negative Stemmer sign (n = 23) had normal (n = 13) or abnormal (n = 10) lymphatic function by imaging (specificity = 57%). Patients with a false-negative Stemmer sign were more likely to have a normal body mass index (P = 0.02) and Stage 1 disease (P = 0.01). Conclusions: A positive Stemmer sign is a sensitive predictor for primary and secondary lymphedema of the arms or legs and, thus, is a useful part of the physical examination. Because the test exhibits moderate specificity, lymphoscintigraphy should be considered for patients with a high suspicion of lymphedema that have a negative Stemmer sign.
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75
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Kataru RP, Ly CL, Shin J, Park HJ, Baik JE, Rehal S, Ortega S, Lyden D, Mehrara BJ. Tumor Lymphatic Function Regulates Tumor Inflammatory and Immunosuppressive Microenvironments. Cancer Immunol Res 2019; 7:1345-1358. [PMID: 31186247 DOI: 10.1158/2326-6066.cir-18-0337] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/17/2018] [Accepted: 06/05/2019] [Indexed: 02/06/2023]
Abstract
Proliferation of aberrant, dysfunctional lymphatic vessels around solid tumors is a common histologic finding. Studies have shown that abnormalities in lymphatic function result in accumulation of inflammatory cells with an immunosuppressive profile. We tested the hypothesis that dysfunctional lymphatic vessels surrounding solid tumors regulate changes in the tumor microenvironment and tumor-specific immune responses. Using subcutaneously implanted mouse melanoma and breast cancer tumors in a lymphatic endothelial cell-specific diphtheria toxin receptor transgenic mouse, we found that local ablation of lymphatic vessels increased peritumoral edema, as compared with controls. Comparative analysis of the peritumoral fluid demonstrated increases in the number of macrophages, CD4+ inflammatory cells, F4/80+/Gr-1+ (myeloid-derived suppressor cells), CD4+/Foxp3+ (Tregs) immunosuppressive cells, and expression of inflammatory cytokines such as TNFα, IFNγ, and IL1β following lymphatic ablation. Tumors grown in lymphatic ablated mice exhibited reduced intratumoral accumulation of cytotoxic T cells and increased tumor PD-L1 expression, causing rapid tumor growth, compared with tumors grown in nonlymphatic-ablated mice. Our study suggests that lymphatic dysfunction plays a role in regulating tumor microenvironments and may be therapeutically targeted in combination with immunotherapy to prevent tumor growth and progression.
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Affiliation(s)
- Raghu P Kataru
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Catherine L Ly
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinyeon Shin
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hyeung Ju Park
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jung Eun Baik
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sonia Rehal
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sagrario Ortega
- Transgenic Mice Unit, Biotechnology Programme, Spanish National Cancer Research Center (CNIO), Madrid, Spain
| | - David Lyden
- Children's Cancer and Blood Foundation Laboratories, Departments of Pediatrics and Cell and Developmental Biology, Drukier Institute for Children's Health, Meyer Cancer Center, Weill Cornell Medicine, New York, New York
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York.
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76
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Sun Y, Armer JM. A nurse’s twenty-four-year journey with breast cancer-related lymphedema. Work 2019; 63:21-31. [DOI: 10.3233/wor-192904] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Yuanlu Sun
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO, USA
| | - Jane M. Armer
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO, USA
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T helper 2 differentiation is necessary for development of lymphedema. Transl Res 2019; 206:57-70. [PMID: 30633890 PMCID: PMC6443462 DOI: 10.1016/j.trsl.2018.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 01/16/2023]
Abstract
T cells infiltrating lymphedematous tissues have a mixed T helper 1 (Th1) and Th2 differentiation profile. Treatment with neutralizing antibodies targeting cytokines that promote Th2 differentiation (interleukin 4 [IL-4] and IL-13) decreases the severity of lymphedema in preclinical models, suggesting that Th2 cells play a key role in the pathology of this disease. However, these previous studies do not address the contribution of Th1 cells and it remains unknown if IL-4 and IL-3 blockade acts primarily on T cells or decreases the pathological changes of lymphedema by other mechanisms. Therefore, this study sought to analyze the effect of lymphatic injury in transgenic mice with mutations that cause defects in Th1 and Th2 cell generation (T-bet knockout or T-betKO and STAT6 knockout or STAT6KO mice, respectively). Using both the mouse tail and popliteal lymph node dissection models of lymphedema, we show that Th2-deficient (STAT6KO) mice are protected from developing lymphedema, have decreased fibrosis, increased collateral vessel formation, and preserved collecting lymphatic vessel pumping function. In contrast, mice with defective Th1 cell generation (T-betKO) develop disease with the same severity as wild-type controls. Taken together, our results suggest that Th2 differentiation is necessary for development of lymphedema following lymphatic injury and that Th1 differentiation does not significantly contribute to the pathology of the disease. Such findings are important as immunotherapy directed at Th2 cells has been found to be effective in well-studied Th2-mediated diseases such as asthma and atopic dermatitis and may therefore be similarly useful for lymphedema management.
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Abstract
Lymphoedema is an oedematous condition with a specific and complex tissue biology. In the clinical context of cancer, the pathogenesis of lymphoedema ensues most typically from the modalities employed to stage and treat the cancer (in particular, surgery and radiotherapy). Despite advances in cancer treatment, lifelong lymphoedema (limb swelling and the accompanying chronic inflammatory processes) affects approximately one in seven individuals treated for cancer, although estimates of lymphoedema prevalence following cancer treatment vary widely depending upon the diagnostic criteria used and the duration of follow-up. The natural history of cancer-associated lymphoedema is defined by increasing limb girth, fibrosis, inflammation, abnormal fat deposition and eventual marked cutaneous pathology, which also increases the risk of recurrent skin infections. Lymphoedema can substantially affect the daily quality of life of patients, as, in addition to aesthetic concerns, it can cause discomfort and affect the ability to carry out daily tasks. Clinical diagnosis is dependent on comparison of the affected region with the equivalent region on the unaffected side and, if available, with pre-surgical measurements. Surveillance is indicated in this high-risk population to facilitate disease detection at the early stages, when therapeutic interventions are most effective. Treatment modalities include conservative physical strategies that feature complex decongestive therapy (including compression garments) and intermittent pneumatic compression, as well as an emerging spectrum of surgical interventions, including liposuction for late-stage disease. The future application of pharmacological and microsurgical therapeutics for cancer-associated lymphoedema holds great promise.
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79
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Ly CL, Cuzzone DA, Kataru RP, Mehrara BJ. Small Numbers of CD4+ T Cells Can Induce Development of Lymphedema. Plast Reconstr Surg 2019; 143:518e-526e. [PMID: 30601329 PMCID: PMC6395505 DOI: 10.1097/prs.0000000000005322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND CD4 T cells have been implicated in the pathology of lymphedema. Interestingly, however, there have been case reports of lymphedema development in patients with low levels of CD4 T cells because of immunosuppression. In this study, the authors sought to delineate the effect of relative CD4 T-cell deficiency on the development of lymphedema in a mouse model. METHODS A mouse model of relative CD4 T-cell deficiency was created through lethal total body irradiation of wild-type mice that then underwent bone marrow transplantation with progenitors harvested from CD4 knockout mice (wild-type/CD4 knockout). Irradiated CD4 knockout mice reconstituted with wild-type mouse-derived progenitors (CD4 knockout/wild-type), and unirradiated CD4 knockout and wild-type mice were used as controls. All mice underwent tail skin and lymphatic excision to induce lymphedema, and analysis was performed 6 weeks later. RESULTS Wild-type/CD4 knockout chimeras were not protected from developing lymphedema. Despite a global deficit in CD4 T cells, these mice had swelling, fibrosis, inflammation, and impaired lymphatic transport function indistinguishable from that in wild-type and CD4 knockout/wild-type mice. In contrast, unirradiated CD4 knockout mice had no features of lymphedema after lymphatic injury. CONCLUSIONS Relatively small numbers of bone marrow and peripheral CD4 T cells are sufficient to induce the development of lymphedema. These findings suggest that lymphatic injury results in expansion of CD4 T-cell populations in lymphedematous tissues.
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Affiliation(s)
- Catherine L. Ly
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Daniel A. Cuzzone
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Raghu P. Kataru
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York 10065
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80
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Ammitzbøll G, Johansen C, Lanng C, Andersen EW, Kroman N, Zerahn B, Hyldegaard O, Wittenkamp MC, Dalton SO. Progressive resistance training to prevent arm lymphedema in the first year after breast cancer surgery: Results of a randomized controlled trial. Cancer 2019; 125:1683-1692. [PMID: 30633334 DOI: 10.1002/cncr.31962] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/16/2018] [Accepted: 12/06/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Existing research suggests that progressive resistance training (PRT) after breast cancer (BC) surgery is safe, but the preventive effect on arm lymphedema has yet to be determined. METHODS Women aged 18 to 75 years who were undergoing BC surgery with axillary lymph node dissection were eligible for the study. Recruited on the day of surgery, participants were allocated to intervention or usual care by computer randomization. The intervention consisted of PRT 3 times per week: in the first 20 weeks as a supervised group exercise and in the last 30 weeks as a self-administered exercise. The primary outcome was arm lymphedema, which was defined as a >3% increase in the interlimb volume difference by water displacement. Measurements were made at the baseline and at a 12-month follow-up by physiotherapists blinded to group allocation. Analyses of effects included t tests and regression models; missing data were addressed by multiple imputation. RESULTS Among the 158 randomized women, no mean group difference was found in arm volume (0.3%; 95% confidence interval, -1.7% to 2.3%) or lymphedema incidence (adjusted odds ratio, 1.2; 95% confidence interval, 0.5-2.8). None of the participants exited the program because of adverse events. CONCLUSIONS This study provides no evidence that PRT can prevent arm lymphedema in the first year after BC, but the results corroborate the importance and safety of resistance training for patients, including women at high risk for lymphedema.
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Affiliation(s)
- Gunn Ammitzbøll
- Survivorship Unit, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Christoffer Johansen
- Survivorship Unit, Danish Cancer Society Research Center, Copenhagen, Denmark.,CASTLE Late Effects Unit, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Lanng
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | | | - Niels Kroman
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark.,Danish Cancer Society, Copenhagen, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Ole Hyldegaard
- Section for Hyperbaric Oxygen Treatment, Department for Anesthetics and Operations, Center for Head and Orthopaedics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Merete Celano Wittenkamp
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
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81
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Rockson SG, Tian W, Jiang X, Kuznetsova T, Haddad F, Zampell J, Mehrara B, Sampson JP, Roche L, Kim J, Nicolls MR. Pilot studies demonstrate the potential benefits of antiinflammatory therapy in human lymphedema. JCI Insight 2018; 3:123775. [PMID: 30333315 DOI: 10.1172/jci.insight.123775] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Lymphedema is a common condition affecting millions around the world that still lacks approved medical therapy. Because ketoprofen, an NSAID, has been therapeutic in experimental lymphedema, we evaluated its efficacy in humans. METHODS We first performed an exploratory open-label trial. Patients with either primary or secondary lymphedema received ketoprofen 75 mg by mouth 3 times daily for 4 months. Subjects were evaluated for changes in histopathology, with skin thickness, limb volume, and tissue bioimpedance changes serving as secondary endpoints. Based on our encouraging findings, we next conducted a placebo-controlled trial, with the primary outcome defined as a change in skin thickness, as measured by skin calipers. Secondary endpoints for this second study included histopathology, limb volume, bioimpedance, and systemic inflammatory mediators. RESULTS We enrolled 21 lymphedema patients in the open-label trial, from November 2010 to July 2011. Histopathology and skin thickness were significantly improved at 4 months compared with baseline. In the follow-up, double-blind, placebo-controlled trial, we enrolled 34 patients from August 2011 to October 2015, with 16 ketoprofen recipients and 18 placebo-treated subjects. No serious adverse events occurred. The ketoprofen recipients demonstrated reduced skin thickness, as well as improved composite measures of histopathology and decreased plasma granulocyte CSF (G-CSF) expression. CONCLUSION These 2 exploratory studies together support the utility of targeted antiinflammatory therapy with ketoprofen in patients with lymphedema. Our results highlight the promise of such approaches to help restore a failing lymphatic circulation. TRIAL REGISTRATION ClinicalTrials.gov NCT02257970.
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Affiliation(s)
- Stanley G Rockson
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Wen Tian
- Department of Medicine, VA Palo Alto Health Care System/Stanford University, Palo Alto, California, USA
| | - Xinguo Jiang
- Department of Medicine, VA Palo Alto Health Care System/Stanford University, Palo Alto, California, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Francois Haddad
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jamie Zampell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Babak Mehrara
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Joshua P Sampson
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Leslie Roche
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jinah Kim
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Mark R Nicolls
- Department of Medicine, VA Palo Alto Health Care System/Stanford University, Palo Alto, California, USA
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Wu H, Rahman HA, Dong Y, Liu X, Lee Y, Wen A, To KH, Xiao L, Birsner AE, Bazinet L, Wong S, Song K, Brophy ML, Mahamud MR, Chang B, Cai X, Pasula S, Kwak S, Yang W, Bischoff J, Xu J, Bielenberg DR, Dixon JB, D’Amato RJ, Srinivasan RS, Chen H. Epsin deficiency promotes lymphangiogenesis through regulation of VEGFR3 degradation in diabetes. J Clin Invest 2018; 128:4025-4043. [PMID: 30102256 PMCID: PMC6118634 DOI: 10.1172/jci96063] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 06/26/2018] [Indexed: 12/18/2022] Open
Abstract
Impaired lymphangiogenesis is a complication of chronic complex diseases, including diabetes. VEGF-C/VEGFR3 signaling promotes lymphangiogenesis, but how this pathway is affected in diabetes remains poorly understood. We previously demonstrated that loss of epsins 1 and 2 in lymphatic endothelial cells (LECs) prevented VEGF-C-induced VEGFR3 from endocytosis and degradation. Here, we report that diabetes attenuated VEGF-C-induced lymphangiogenesis in corneal micropocket and Matrigel plug assays in WT mice but not in mice with inducible lymphatic-specific deficiency of epsins 1 and 2 (LEC-iDKO). Consistently, LECs isolated from diabetic LEC-iDKO mice elevated in vitro proliferation, migration, and tube formation in response to VEGF-C over diabetic WT mice. Mechanistically, ROS produced in diabetes induced c-Src-dependent but VEGF-C-independent VEGFR3 phosphorylation, and upregulated epsins through the activation of transcription factor AP-1. Augmented epsins bound to and promoted degradation of newly synthesized VEGFR3 in the Golgi, resulting in reduced availability of VEGFR3 at the cell surface. Preclinically, the loss of lymphatic-specific epsins alleviated insufficient lymphangiogenesis and accelerated the resolution of tail edema in diabetic mice. Collectively, our studies indicate that inhibiting expression of epsins in diabetes protects VEGFR3 against degradation and ameliorates diabetes-triggered inhibition of lymphangiogenesis, thereby providing a novel potential therapeutic strategy to treat diabetic complications.
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Affiliation(s)
- Hao Wu
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - H.N. Ashiqur Rahman
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Yunzhou Dong
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Xiaolei Liu
- Center for Vascular and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yang Lee
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Aiyun Wen
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kim H.T. To
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Li Xiao
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Amy E. Birsner
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Lauren Bazinet
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Scott Wong
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kai Song
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Megan L. Brophy
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - M. Riaj Mahamud
- Cardiovascular Biology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Baojun Chang
- Vascular Medicine Institute, Pulmonary, Allergy and Critical Care Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Xiaofeng Cai
- Cardiovascular Biology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Satish Pasula
- Cardiovascular Biology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Sukyoung Kwak
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Wenxia Yang
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Joyce Bischoff
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jian Xu
- Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Diane R. Bielenberg
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - J. Brandon Dixon
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Robert J. D’Amato
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - R. Sathish Srinivasan
- Cardiovascular Biology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Hong Chen
- Vascular Biology Program, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts, USA
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Sarimollaoglu M, Stolarz AJ, Nedosekin DA, Garner BR, Fletcher TW, Galanzha EI, Rusch NJ, Zharov VP. High-speed microscopy for in vivo monitoring of lymph dynamics. JOURNAL OF BIOPHOTONICS 2018; 11:e201700126. [PMID: 29232054 PMCID: PMC6314807 DOI: 10.1002/jbio.201700126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 11/29/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
The lymphatic system contributes to body homeostasis by clearing fluid, lipids, plasma proteins and immune cells from the interstitial space. Many studies have been performed to understand lymphatic function under normal conditions and during disease. Nevertheless, a further improvement in quantification of lymphatic behavior is needed. Here, we present advanced bright-field microscopy for in vivo imaging of lymph vessels (LVs) and automated quantification of lymphatic function at a temporal resolution of 2 milliseconds. Full frame videos were compressed and recorded continuously at up to 540 frames per second. A new edge detection algorithm was used to monitor vessel diameter changes across multiple cross sections, while individual cells in the LVs were tracked to estimate flow velocity. The system performance initially was verified in vitro using 6- and 10-μm microspheres as cell phantoms on slides and in 90-μm diameter tubes at flow velocities up to 4 cm/second. Using an in vivo rat model, we explored the mechanisms of lymphedema after surgical lymphadenectomy of the mesentery. The system revealed reductions of mesenteric LV contraction and flow rate. Thus, the described imaging system may be applicable to the study of lymphatic behavior during therapeutic and surgical interventions, and potentially during lymphatic system diseases.
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Affiliation(s)
- Mustafa Sarimollaoglu
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Amanda J. Stolarz
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Dmitry A. Nedosekin
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Brittney R. Garner
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Terry W. Fletcher
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ekaterina I. Galanzha
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Nancy J. Rusch
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Vladimir P. Zharov
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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84
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Kishimoto M, Akashi M, Kakei Y, Kusumoto J, Sakakibara A, Hasegawa T, Furudoi S, Sasaki R, Komori T. Ionizing Radiation Enhances Paracellular Permeability Through Alteration of Intercellular Junctions in Cultured Human Lymphatic Endothelial Cells. Lymphat Res Biol 2018; 16:390-396. [PMID: 29862914 DOI: 10.1089/lrb.2017.0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND A problematic complication after radiation therapy is lymphedema. Development of lymphedema is associated with an increase in lymphatic paracellular permeability. The current study investigated the effects of radiation on intercellular junctions and paracellular permeability in cultured human dermal lymphatic endothelial cells (HDLECs). METHODS AND RESULTS Double immunofluorescence staining with vascular endothelial (VE)-cadherin and actin immediately after X-ray irradiation (5 or 20 Gy) was performed. Morphological changes induced by irradiation were assessed. Cell viability and paracellular permeability after irradiation were also evaluated. Broad junctions in which VE-cadherin was accumulated at cell-cell contacts and almost colocalized with actin were significantly decreased in a dose-dependent manner in confluent and sparse irradiated HDLECs. Irradiation shortened the width of VE-cadherin-positive areas at the cell-cell contacts. Actin filaments did not colocalize with VE-cadherin after 20 Gy irradiation. Although cell viability was not affected by irradiation, paracellular permeability significantly increased in a dose-dependent manner. CONCLUSIONS A dose of 5 or 20 Gy irradiation in HDLECs does not affect cell viability, but changes VE-cadherin mediated intercellular junctions and actin structure, resulting in an increase of paracellular permeability. Further investigations on the regulatory proteins involved in radiation-induced changes, which were observed in the current study, may contribute to development of lymphedema therapy.
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Affiliation(s)
- Megumi Kishimoto
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Masaya Akashi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Yasumasa Kakei
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Junya Kusumoto
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Akiko Sakakibara
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Takumi Hasegawa
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Shungo Furudoi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Ryohei Sasaki
- 2 Department of Radiation Oncology, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Takahide Komori
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
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85
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García Nores GD, Ly CL, Cuzzone DA, Kataru RP, Hespe GE, Torrisi JS, Huang JJ, Gardenier JC, Savetsky IL, Nitti MD, Yu JZ, Rehal S, Mehrara BJ. CD4 + T cells are activated in regional lymph nodes and migrate to skin to initiate lymphedema. Nat Commun 2018; 9:1970. [PMID: 29773802 PMCID: PMC5958132 DOI: 10.1038/s41467-018-04418-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 04/19/2018] [Indexed: 12/14/2022] Open
Abstract
T cell-mediated responses have been implicated in the development of fibrosis, impaired lymphangiogenesis, and lymphatic dysfunction in secondary lymphedema. Here we show that CD4+ T cells are necessary for lymphedema pathogenesis by utilizing adoptive transfer techniques in CD4 knockout mice that have undergone tail skin and lymphatic excision or popliteal lymph node dissection. We also demonstrate that T cell activation following lymphatic injury occurs in regional skin-draining lymph nodes after interaction with antigen-presenting cells such as dendritic cells. CD4+ T cell activation is associated with differentiation into a mixed T helper type 1 and 2 phenotype, as well as upregulation of adhesion molecules and chemokines that promote migration to the skin. Most importantly, we find that blocking T cell release from lymph nodes using a sphingosine-1-phosphate receptor modulator prevents lymphedema, suggesting that this approach may have clinical utility.
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Affiliation(s)
- Gabriela D García Nores
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Catherine L Ly
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Daniel A Cuzzone
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Raghu P Kataru
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Geoffrey E Hespe
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jeremy S Torrisi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jung Ju Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jason C Gardenier
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Ira L Savetsky
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Matthew D Nitti
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jessie Z Yu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Sonia Rehal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Babak J Mehrara
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA.
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86
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Yamakawa M, Doh SJ, Santosa SM, Montana M, Qin EC, Kong H, Han KY, Yu C, Rosenblatt MI, Kazlauskas A, Chang JH, Azar DT. Potential lymphangiogenesis therapies: Learning from current antiangiogenesis therapies-A review. Med Res Rev 2018. [PMID: 29528507 DOI: 10.1002/med.21496] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, lymphangiogenesis, the process of lymphatic vessel formation from existing lymph vessels, has been demonstrated to have a significant role in diverse pathologies, including cancer metastasis, organ graft rejection, and lymphedema. Our understanding of the mechanisms of lymphangiogenesis has advanced on the heels of studies demonstrating vascular endothelial growth factor C as a central pro-lymphangiogenic regulator and others identifying multiple lymphatic endothelial biomarkers. Despite these breakthroughs and a growing appreciation of the signaling events that govern the lymphangiogenic process, there are no FDA-approved drugs that target lymphangiogenesis. In this review, we reflect on the lessons available from the development of antiangiogenic therapies (26 FDA-approved drugs to date), review current lymphangiogenesis research including nanotechnology in therapeutic drug delivery and imaging, and discuss molecules in the lymphangiogenic pathway that are promising therapeutic targets.
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Affiliation(s)
- Michael Yamakawa
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Susan J Doh
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Samuel M Santosa
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Mario Montana
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Ellen C Qin
- Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Hyunjoon Kong
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Kyu-Yeon Han
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Charles Yu
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Mark I Rosenblatt
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Andrius Kazlauskas
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Physiology and Biophysics, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jin-Hong Chang
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Dimitri T Azar
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL
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87
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Abstract
Although nonoperative and operative treatments for lymphedema (LE) are well established, these procedures typically provide only partial relief from limb swelling, functional impairment, and the risk of cellulitis. The lack of a cure for LE, however, is due to an incomplete understanding of the underlying pathophysiological mechanisms, and current research efforts are focusing on elucidating these processes to provide new, targeted therapies for this prevalent disease for which there is no cure. This article reviews the current literature regarding the pathophysiological mechanisms that underlie LE, as well as new and emerging therapies for the condition.
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Affiliation(s)
- Mark V. Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Melissa B. Aldrich
- Center for Molecular Imaging, Brown Institute for Molecular Medicine, UT Health, Houston, Texas
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88
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Urner S, Kelly-Goss M, Peirce SM, Lammert E. Mechanotransduction in Blood and Lymphatic Vascular Development and Disease. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2017; 81:155-208. [PMID: 29310798 DOI: 10.1016/bs.apha.2017.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The blood and lymphatic vasculatures are hierarchical networks of vessels, which constantly transport fluids and, therefore, are exposed to a variety of mechanical forces. Considering the role of mechanotransduction is key for fully understanding how these vascular systems develop, function, and how vascular pathologies evolve. During embryonic development, for example, initiation of blood flow is essential for early vascular remodeling, and increased interstitial fluid pressure as well as initiation of lymph flow is needed for proper development and maturation of the lymphatic vasculature. In this review, we introduce specific mechanical forces that affect both the blood and lymphatic vasculatures, including longitudinal and circumferential stretch, as well as shear stress. In addition, we provide an overview of the role of mechanotransduction during atherosclerosis and secondary lymphedema, which both trigger tissue fibrosis.
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Affiliation(s)
- Sofia Urner
- Institute of Metabolic Physiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Molly Kelly-Goss
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States
| | - Shayn M Peirce
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States
| | - Eckhard Lammert
- Institute of Metabolic Physiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute for Beta Cell Biology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.
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89
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Gjorup CA, Hendel HW, Zerahn B, Dahlstroem K, Drzewiecki KT, Klausen TW, Hölmich LR. Volume and Tissue Composition Changes Measured with Dual-Energy X-Ray Absorptiometry in Melanoma-Related Limb Lymphedema. Lymphat Res Biol 2017; 15:274-283. [DOI: 10.1089/lrb.2017.0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Caroline A. Gjorup
- Department of Plastic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Helle W. Hendel
- Department of Clinical Physiology and Nuclear Medicine, PET-Center, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Karin Dahlstroem
- Department of Plastic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Krzysztof T. Drzewiecki
- Department of Plastic Surgery, Breast Surgery and Burns Treatment, Rigshospitalet, University of Copenhagen, Herlev, Denmark
| | - Tobias W. Klausen
- Department of Hematology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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