Congenital, low penetrance lymphedema of lower limbs maps to chromosome 6q16.2-q22.1 in an inbred Pakistani family

A Practical Approach to the Diagnosis of Lymphedema: A Narrative Review

INTRODUCTION

Lymphedema often presents as progressive, unremitting swelling and skin changes that are extremely distressing to patients. Hereditary lymphedema (HL) constitutes a type of primary lymphedema that is passed down through generations.

OBJECTIVES

The primary aims of this narrative review are to illustrate a framework to distinguish lymphedema from other causes of swelling and to differentiate the hereditary lymphedemas from each other.

RESULTS

A literature search was undertaken using relevant search terms. The articles were evaluated to generate a diagnostic algorithm to approach the swelling of an extremity using clinical and laboratory data. First, the stemmer sign should be evaluated. If it is negative, other causes should be considered. History and additional physical exam findings suggest either a primary or secondary cause of lymph-edema.

CONCLUSIONS

The hereditary lymphedemas have been classified by age of onset and then stratified by clinical criteria and genetic testing.

Resolution of Primary Lymphedema: A Case Report

Primary lymphedema is a rare, progressive disease that typically affects the lower extremity. The condition is not curable, and the limb enlarges over time because of subcutaneous fibroadipose deposition. We present a patient with clinical and radiographical evidence of resolution of primary lymphedema. This observation may provide greater insight into the pathophysiology of the disease.

Cervical Stimulation in the Treatment of Children with Lymphedema of All Four Extremities: A Case Report and Literature Review

Aim. The aim of this study is to report on the use of cervical stimulation as monotherapy to reduce swelling and normalize the size of limbs in two children with lymphedema of all four extremities. Case Presentation. One child also had hemifacial edema. In both cases, the mothers were trained to perform cervical stimulation under professional supervision. The cases of two girls, one of eight months and the other of six months, with primary congenital lymphedema are described. Outcome. After clinical diagnosis, the patients started treatment with cervical stimulation three times per week. The mothers were trained in cervical stimulation and, when the therapy team was confident about the mothers' ability to perform the technique, the children began to be treated at home. The Godoy & Godoy cervical stimulation technique consists of around 20 to 30 light stroking movements per minute in the cervical region which stimulate the lymphatics. Perimetric measurements were made of the feet, legs, and the hands. Only two points (3 and 6 cm) along the dorsum of the feet and hands and points at 5 cm intervals up the legs starting at the ankle were considered. Today, the children are 5 and 6 years of age, without edema and with a normal life, without limitations, except with respect to precautions against injuries to the limbs and against infections particularly erysipelas. Conclusion. Cervical Lymphatic Therapy as monotherapy is an option in the treatment of primary congenital lymphedema.

Genetics of hemangiomas, vascular malformations, and primary lymphedema

With improved genetic testing and genomic sequencing, abnormalities are increasingly being identified in affected or germline tissues in DNA of patients with vascular tumors, vascular malformations, and lymphedema. Recognition of the genetics of vascular anomalies should help clinicians make more specific diagnoses, anticipate diagnosis-specific morbidities, provide better genetic counseling, and have a better understanding of the pathogenesis of these anomalies. Growing pharmacologic options, including therapies targeted to specific mutations, with obvious parallels to cancer treatment now allow the pediatric hematologist-oncologist to assume a more prominent role in clinical care and research for patients with these diagnoses. We summarize genes and genetic loci that have been associated with vascular anomalies and offer guidelines for patient evaluations.

Adaptations in the treatment of congenital lymphedema centered on the quality of life

Case Description. This report describes the evolution, necessary adaptations, and complications in the treatment of a 9-year-old child with primary congenital lymphedema. Description of Intervention. The clinical treatment of lymphedema was started in the first year of the patient's life and for five years she was only treated using the Godoy & Godoy technique of cervical stimulation. Three years ago the patient was prescribed a compression stocking made from a cotton-polyester fabric (grosgrain) because of a sudden increase in the lymphedema after she started to take growth hormones. Outcome and Conclusion. The combination of cervical stimulation and a compression stocking was effective to keep the child's life relatively normal, performing all day-to-day and recreational activities.

Vascular anomalies: from genetics toward models for therapeutic trials

Vascular anomalies are localized abnormalities that occur during vascular development. Several causative genes have been identified not only for inherited but also for some sporadic forms, and the molecular pathways involved are becoming understood. This gives us the opportunity to generate animals carrying the causative genetic defects, which we hope model the phenotype seen in human patients. These models would enable us not only to test known antiangiogenic drugs, but also to develop novel approaches for treatment, directly targeting the mutated protein or molecules implicated in the pathophysiological signaling pathways.

The godoy & godoy cervical stimulation technique in the treatment of primary congenital lymphedema

THE AIM OF THE CURRENT STUDY IS TO REPORT ON THE TREATMENT OF PRIMARY LYMPHEDEMA USING A NEW FORM OF THERAPY: cervical stimulation. In a prospective cohort study, 9 boys and 5 girls with primary congenital lymphedema were evaluated over two years. Age ranged from two months to 8.5 years. After diagnosis, all mothers were trained in the new technique. The Godoy & Godoy cervical stimulation technique consists of between 20 to 30 stimuli per minute using light movements in the cervical region. All the children were submitted to perimetric evaluations of the feet and legs; however, in this study only two points, 3 and 6 cm from the base of the big toe nail, were used. The two-tailed t-test was used for statistical analysis with an alpha error of 5% (P<0.05) considered acceptable. The size of the lymphedematous feet was reduced and even normalized (P<0.0001) for all treated children. Cervical stimulation is a new option in the treatment of primary congenital lymphedema; its association with compression stockings has a synergistic effect in reducing the volume of lymphedema.

Pathogenesis of vascular anomalies

Vascular anomalies are localized defects of vascular development. Most of them occur sporadically (ie, there is no familial history of lesions, yet in a few cases clear inheritance is observed). These inherited forms are often characterized by multifocal lesions that are mainly small in size and increase in number with patients' age. The authors review the known (genetic) causes of vascular anomalies and call attention to the concept of Knudson's double-hit mechanism to explain incomplete penetrance and large clinical variation in expressivity observed in inherited vascular anomalies. The authors also discuss the identified pathophysiological pathways involved in vascular anomalies and how it has opened the doors toward a more refined classification of vascular anomalies and the development of animal models that can be tested for specific molecular therapies.

From germline towards somatic mutations in the pathophysiology of vascular anomalies

The localized structural abnormalities that arise during vasculogenesis, angiogenesis and lymphangiogenesis, the developmental processes which give rise to the adult vasculature, are collectively termed vascular anomalies. The last 2 years have seen an explosion of studies that underscore paradominant inheritance, the combination of inherited changes with somatic second-hits to the same genes, as underlying rare familial forms. Moreover, local, somatic genetic defects that cause some of the common sporadic forms of these malformations have been unraveled. This highlights the importance of assessing for tissue-based genetic changes, especially acquired genetic changes, as possible pathophysiological causes, which have been largely overlooked except in the area of cancer research. Large-scale somatic screens will therefore be essential in uncovering the nature and prevalence of such changes, and their downstream effects. The identification of disease genes combined with exhaustive, precise clinical delineations of the entire spectra of associated phenotypes guides better management and genetic counseling. Such a synthesis of information on functional and phenotypic effects will enable us to make and use animal models to test less invasive, targeted, perhaps locally administered, biological therapies.