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Bucan A, Frendø M, Ngo MT, Sørensen JA, Hölmich LR. Surgical lymphedema models in the mice hindlimb-A systematic review and quality assessment. Microsurgery 2024; 44:e31088. [PMID: 37665032 DOI: 10.1002/micr.31088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Lymphedema constitutes a major unsolved problem in plastic surgery. To identify novel lymphedema treatments, preclinical studies are vital. The surgical mouse lymphedema model is popular and cost-effective; nonetheless, a synthesis and overview of the literature with evidence-based guidelines is needed. The aim of this review was to perform a systematic review to establish best practice and support future high-quality animal studies exploring lymphedema treatments. METHODS We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching four databases (PubMed, Embase, Web of Science, and Scopus) from inception-September 2022. The Animals in Research Reporting In Vivo Experiments 2.0 (ARRIVE 2.0) guidelines were used to evaluate reporting quality. Studies claiming to surgically induce lymphedema in the hindlimb of mice were included. RESULTS Thirty-seven studies were included. Four main models were used. (1) Irradiation+surgery. (2) A variation of the surgery used by (1) + irradiation. (3) Surgery only (SPDF-model). (4) Surgery only (PLND-model). Remaining studies used other techniques. The most common measurement modality was the caliper. Mean quality coefficient was 0.57. Eighteen studies (49%) successfully induced sustained lymphedema. Combination of methods seemed to yield the best results, with an overrepresentation of irradiation, the removal of two lymph nodes, and the disruption of both the deep and superficial lymph vessels in the 18 studies. CONCLUSION Surgical mouse hindlimb lymphedema models are challenged by two related problems: (1) retaining lymphedema for an extended period, that is, establishing a (chronic) lymphedema model (2) distinguishing lymphedema from post-operative edema. Most studies failed to induce lymphedema and used error-prone measurements. We provide an overview of studies claiming to induce lymphedema and advocate improved research via five evidence-based recommendations to use: (1) a proven lymphedema model; (2) sufficient follow-up time, (3) validated measurement methods; (4) ARRIVE-guidelines; (5) contralateral hindlimb as control.
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Affiliation(s)
- Amar Bucan
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Martin Frendø
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, Copenhagen, Denmark
| | - Mikaella Ty Ngo
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jens Ahm Sørensen
- Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Lisbet Rosenkrantz Hölmich
- Department of Plastic Surgery, University of Copenhagen, Herlev and Gentofte Hospital, Copenhagen, Denmark
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Kawakami Z, Matsubara Y, Ogura K, Imamura S, Iizuka S, Zhang N, Matsumoto C, Fujitsuka N. Effect of Goreisan, a Traditional Japanese Medicine, on Rat Hindlimb Lymphedema. Biol Pharm Bull 2024; 47:1179-1188. [PMID: 38880626 DOI: 10.1248/bpb.b23-00829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Secondary lymphedema occurs after cancer surgery involving lymph node dissection owing to the lymphatic system dysfunction. However, the pathophysiology of lymphedema and the molecular pathways involved remain unknown. This study aimed to develop a rat hindlimb lymphedema model and investigate the mechanisms that drive pathophysiology and the effects of the traditional Japanese medicine goreisan on lymphedema. The rat lymphedema model was induced by combination surgeries of popliteal lymph node dissection, skin cautery incision, and fascial ablation coagulation in the right hindlimb using male Wistar rats. The foot volume was significantly increased, and recovery was delayed by combination surgeries. Dermal thickness and dilated lymphatic vessels of the hindlimb were observed on postoperative day 2. The number of infiltrating leukocytes (CD45+ cells), including CD4+ T-cells, increased in the lymphedema group compared with that in the sham group. The relative mRNA expression and protein levels of interleukin-6 (IL-6), CC chemokine ligand 2 (CCL2), transforming growth factor β1 (TGF-β1), and Fms-related receptor tyrosine kinase 4 (FLT4) were significantly higher in the lymphedema group than in the sham group. Foot volume was decreased by goreisan, furosemide, and prednisolone treatments. Goreisan diminished the increase in CD4+ T-cells, and the same trend was observed for CCL2 and FLT4 expression. In conclusion, the rat hindlimb lymphedema model in this study exhibited increased foot volume, skin-infiltrating cells, and pathological changes accompanied by inflammatory and fibrotic responses, suggesting that the model presented significant clinical features of lymphedema. Goreisan may exert a therapeutic effect on lymphedema by inhibiting CD4+ T-cell infiltration.
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Affiliation(s)
| | | | | | | | | | - Nana Zhang
- Tsumura Kampo Research Laboratories, Tsumura & Co
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Kim SA, Gelvosa MN, Cheon H, Jeon JY. The effects of postoperative treadmill exercise on rats with secondary lymphedema. PLoS One 2023; 18:e0285384. [PMID: 37220160 DOI: 10.1371/journal.pone.0285384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Cancer-related lymphedema (LE) is often caused by radiotherapy and surgery such as lymph node dissection (LND). Previous studies have reported that exercise is beneficial to relieve LE, but the changes in the lymphatic system following exercise are still unclear. This study aimed to examine the changes in lymphatic drainage pathways over the exercise period and beneficial effects of exercise in rats with LE. Twelve rats were randomly allocated into exercise and control groups (EG and CG; n = 6 each). To obtain LE, inguinal and popliteal LND followed by 20 Gy irradiation was performed. Treadmill exercise was 30 minutes/day, 5 days/week over the four-week period. Consecutive indocyanine green (ICG) lymphography images were collected and classified into five patterns: i) linear; ii) splash; iii) stardust; iv) diffuse, and v) none. Ankle thickness was measured weekly. Histopathological evaluation was performed to examine the skin thickness, collagen area fraction (%) and lymphatic vessel density in harvested tissue. ICG lymphography exhibited more linear and splash patterns in the EG at week 3. The difference of swelling between both groups was significantly different at week 4 (p = 0.016). Histopathologic data revealed a thinner epidermis (p = 0.041) and dermis (p = 0.002), lower collagen area fraction (%, p = 0.002), and higher lymph vessel density (p = 0.002) in the EG than the CG. In conclusion, we found that postoperative exercise can facilitate improvement in lymphatic fluid retention in the lymphedema rat model, resulting in improvement of pathological conditions in the lymphatic system.
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Affiliation(s)
- Sang Ah Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Biomedical Science, Graduate school of University of Ulsan College of Medicine, Seoul, Korea
| | - Ma Nessa Gelvosa
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sakarya AH, Huang C, Yang C, Hsiao H, Chang FC, Huang J. Vascularized lymph node transplantation successfully reverses lymphedema and maintains immunity in a rat lymphedema model. Bioeng Transl Med 2022; 7:e10301. [PMID: 36176614 PMCID: PMC9471995 DOI: 10.1002/btm2.10301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/26/2022] Open
Abstract
Vascularized lymph node transplantation (VLNT) has shown inspiring results for the treatment of lymphedema. Nevertheless, it remains unclear how VLNT restores lymphatic drainage and whether or not immunity recovers after surgery. Hindlimb lymphedema model was created using rats with extensive groin and popliteal lymph node removable following with radiotherapy, and the lymphedema was confirmed using indocyanine green (ICG) lymphangiography and micro-computer tomography for volume measurement. VLNT was performed 1 month later. Volume measurement, ICG lymphangiography, histology, and immune reaction were done 1 month after surgery. VLNT successfully reduced the volume of the lymphedema hindlimb, restored lymphatic drainage function with proven lymphatic channel, and reduced lymphedema-related inflammation and fibrosis. It promotes lymphangiogenesis shown from ICG lymphangiography, histology, and enhanced lymphangiogenesis gene expression. Dendritic cell trafficking via the regenerated lymphatic channels was successfully restored, and maintained systemic immune response was proved using dinitrofluorobenzene sensitization and challenge. VLNT effectively reduces lymphedema and promotes lymphatic regeneration in the capillary lymphatic but not the collecting lymphatic vessels. Along with the re-established lymphatic system was the restoration of immune function locally and systemically. This correlated to clinical experience regarding the reduction of swelling and infection episodes after VLNT in lymphedema patients.
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Affiliation(s)
- Ahmet Hamdi Sakarya
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Chi‐Wei Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
| | - Chin‐Yu Yang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
- Center for Tissue EngineeringChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
| | - Hui‐Yi Hsiao
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
- Center for Tissue EngineeringChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
| | - Frank Chun‐Shin Chang
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Division of Craniofacial Surgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
| | - Jung‐Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Center for Tissue EngineeringChang Gung Memorial Hospital, Linkou Medical CenterTaoyuanTaiwan
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Yang CY, Tinhofer IE, Nguyen D, Cheng MH. Enhancing lymphangiogenesis and lymphatic drainage to vascularized lymph nodes with nanofibrillar collagen scaffolds. J Surg Oncol 2022; 126:1169-1175. [PMID: 35950942 DOI: 10.1002/jso.27058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study investigated the effect of nanofibrillar collagen scaffold (BioBridge) implantation from the affected limb to the unaffected contralateral femoral vein or lymph node in a rat model. METHODS Hind limb lymphedema in Lewis rats was created with lymphadenectomy and inguinal circumcision without radiation. The volumetric difference (greater than 5%) using computed tomography and indocyanine green fluorescence evaluated the progress of lymphedema at 4 weeks. The lymphedema rats have separated into Group I: Controls; Group II: implanted BioBridge to the contralateral femoral vein; and Group III: implanted BioBridge to the contralateral inguinal lymph node. RESULTS A total of 14 of 30 (46.7%) rats developed hind limb lymphedema with a mean volume difference of 5.83 ± 0.99% and showed diffuse dermal backflow at 4 weeks postlymphadenectomy. Four weeks postimplantation of BioBridge, the mean volumetric difference was 5.62 ± 2.11%, 4.97 ± 0.59%, and -2.47 ± 2.37% in Group I, II, and III, respectively (p < 0.05). The dermal backflow on the affected limb increased in Groups I and II but decreased in Group III. CONCLUSIONS Implantation of BioBridge from the affected limb to the contralateral inguinal lymph node significantly reduced the hind limb lymphedema at 4 weeks.
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Affiliation(s)
- Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Ming-Huei Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan.,Section of Plastic Surgery, Department of Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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Blei F. Update December 2021. Lymphat Res Biol 2021; 19:585-624. [PMID: 34958250 DOI: 10.1089/lrb.2021.29113.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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