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Arriola-Alvarez I, Jaunarena I, Izeta A, Lafuente H. Progenitor Cell Sources for 3D Bioprinting of Lymphatic Vessels and Potential Clinical Application. Tissue Eng Part A 2024; 30:353-366. [PMID: 37950710 DOI: 10.1089/ten.tea.2023.0204] [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: 11/13/2023] Open
Abstract
The lymphatic system maintains tissue fluid homeostasis and it is involved in the transport of nutrients and immunosurveillance. It also plays a pivotal role in both pathological and regenerative processes. Lymphatic development in the embryo occurs by polarization and proliferation of lymphatic endothelial cells from the lymph sacs, that is, lymphangiogenesis. Alternatively, lymphvasculogenesis further contributes to the formation of lymphatic vessels. In adult tissues, lymphatic formation rarely occurs under physiological conditions, being restricted to pathological processes. In lymphvasculogenesis, progenitor cells seem to be a source of lymphatic vessels. Indeed, mesenchymal stem cells, adipose stem cells, endothelial progenitor cells, and colony-forming endothelial cells are able to promote lymphatic regeneration by different mechanisms, such as direct differentiation and paracrine effects. In this review, we summarize what is known on the diverse stem/progenitor cell niches available for the lymphatic system, emphasizing the potential that these cells hold for lymphatic tissue engineering through 3D bioprinting and their translation to clinical application.
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Affiliation(s)
- Inazio Arriola-Alvarez
- Tissue Engineering Group, Biogipuzkoa Health Research Institute, Donostia-San Sebastián, Spain
| | - Ibon Jaunarena
- Gynecology Oncology Unit, Donostia University Hospital, Donostia-San Sebastián, Spain
- Obstetrics and Gynaecology Group, Biogipuzkoa Health Research Institute, Donostia-San Sebastián, Spain
- University of the Basque Country (UPV/EHU), Department of Medical Surgical Specialties, Leioa, Spain
| | - Ander Izeta
- Tissue Engineering Group, Biogipuzkoa Health Research Institute, Donostia-San Sebastián, Spain
- Department of Biomedical Engineering and Sciences, Tecnun-University of Navarra, Donostia-San Sebastián, Spain
| | - Héctor Lafuente
- Tissue Engineering Group, Biogipuzkoa Health Research Institute, Donostia-San Sebastián, Spain
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Shimizu Y, Che Y, Murohara T. Therapeutic Lymphangiogenesis Is a Promising Strategy for Secondary Lymphedema. Int J Mol Sci 2023; 24:7774. [PMID: 37175479 PMCID: PMC10178056 DOI: 10.3390/ijms24097774] [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] [Received: 03/24/2023] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Secondary lymphedema is caused by lymphatic insufficiency (lymphatic drainage failure) following lymph node dissection during the surgical treatment or radiation therapy of breast or pelvic cancer. The clinical problems associated with lymphedema are reduced quality of life in terms of appearance and function, as well as the development of skin ulcers, recurrent pain, and infection. Currently, countermeasures against lymphedema are mainly physical therapy such as lymphatic massage, elastic stockings, and skin care, and there is no effective and fundamental treatment with a highly recommended grade. Therefore, there is a need for the development of a fundamental novel treatment for intractable lymphedema. Therapeutic lymphangiogenesis, which has been attracting attention in recent years, is a treatment concept that reconstructs the fragmented lymphatic network to recover lymphatic vessel function and is revolutionary to be a fundamental cure. This review focuses on the translational research of therapeutic lymphangiogenesis for lymphedema and outlines the current status and prospects in the development of therapeutic applications.
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Affiliation(s)
- Yuuki Shimizu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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3
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Maguire G. Chronic inflammation induced by microneedling and the use of bone marrow stem cell cytokines. J Tissue Viability 2022; 31:687-692. [DOI: 10.1016/j.jtv.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 08/07/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
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4
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Zhang YD, Zhang X, Wang XY, Han DM, Du JS. Visual analysis of global research output of lymphedema based on bibliometrics. Front Oncol 2022; 12:926237. [PMID: 35992843 PMCID: PMC9389543 DOI: 10.3389/fonc.2022.926237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Globally, several generations of doctors in the field of lymphedema have created numerous publications. To date, no bibliometric analysis has been performed specifically on these publications. For the further promotion of research on lymphedema and to align with the international research frontiers, it is essential to understand the current state of Lymphedema research output. Objective This study aims to statistically and visually analyze the characteristics of publications output, distribution of contributions and development process of lymphedema, enriching the knowledge base of Lymphedema, and then seek potential research topics and collaborators. Methods Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of lymphedema, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research. Results A total of 8569 papers were retrieved from 1900-2021. The top4 journals with the most publications were LYMPHOLOGY, LYMPHATIC RESEARCH AND BIOLOGY, PLASTIC AND RECONSTRUCTIVE SURGERY and ANNALS OF SURGICAL ONCOLOGY. The top 4 countries with the most publications were USA, Japan, UK, and China. The United States dominates the total number of publications and the international cooperation network. The most productive research institution is Harvard University, and the research institution with the most collaborating institutions is Memorial Sloan Kettering Cancer Center. Mortimer, Peter S contributes the most research in this field. The research achievements of Japanese scholars in this field are of great significance. The top 5 ranked keywords are "Breast Cancer", "Health-Related Quality Of Life", "Lymphscintigraphy", "Lymphovenous Anastomosis", and "Lymphangiogenesis". Conclusion More and more scholars are devoted to the research of cancer-related Lymphedema. It is foreseeable that breast cancer-related lymphedema and lymphangiogenesis will remain a focus of future research. Advances in Lymphatic vessel imaging and the development of lymphatic microsurgery will further play a role in the clinical workup of lymphedema. Meanwhile, This study can help researchers identify potential collaborators and partner institutions and contribute to further research.
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Affiliation(s)
- Yun-dong Zhang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Xue Zhang
- Chengdu Library and Information Center, Chinese Academy of Sciences, Chengdu, China
- Department of Library, Information and Archives Management, School of Economics and Management, University of Chinese Academy of Sciences, Beijing, China
| | - Xin-yu Wang
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Dong-mei Han
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
| | - Jian-shi Du
- Department of the Lymphatic and Vascular Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
- Key Laboratory of Lymphatic Surgery Jilin Province, Engineering Laboratory of Lymphatic Surgery, Changchun, China
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5
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Ogino R, Yokooji T, Hayashida M, Suda S, Yamakawa S, Hayashida K. Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema. Int J Mol Sci 2022; 23:ijms23147614. [PMID: 35886961 PMCID: PMC9322118 DOI: 10.3390/ijms23147614] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.
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Affiliation(s)
- Ryohei Ogino
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Tomoharu Yokooji
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Maiko Hayashida
- Department of Psychiatry, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan;
| | - Shota Suda
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Sho Yamakawa
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
- Correspondence: ; Tel.: +81-853-20-2210
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Fang HA, Soto E, Pigg R, Smith M, Boyd CJ, Ananthasekar S, Fix RJ, Kilic A, Denney B, Patcha P, Myers RP, de la Torre JI, Collawn S. The Safety of Fat Grafting: An Institutional Retrospective Review. Ann Plast Surg 2022; 88:S473-S477. [PMID: 35690941 PMCID: PMC9893916 DOI: 10.1097/sap.0000000000003234] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autologous fat grafting is a popular technique for volume replacement in the breast and face. The efficacy, safety, and complication rate of this technique at the division of plastic surgery at the University of Alabama at Birmingham will be described in this review. METHODS An institutional review board-approved retrospective review of patients undergoing fat grafting procedures from January 2015 to July 2018 was performed. Records were reviewed for fat graft recipient site, donor site, amount grafted, and complications. Continuous variables were compared using either a t test or one-way analysis of variance test. Categorical data were compared using χ2 test. A P value of 0.05 or less was considered statistically significant for all comparisons. RESULTS A total of 396 patients who underwent fat grafting procedures of the face and body from January 2015 through July 2018 met inclusion criteria. Average amount of fat grafted for all grafts was 124.4 +/- 6.74 grams. Two hundred fifty of the grafts (62.7%) involved the bilateral breasts with an average of 140.6 +/- 93.97 g used, 70 per side. Of the 396 patients, 110 (27.8%) experienced complications. Forty three of the complications (10.9%) were considered to be major, which included hematomas/seromas, fat necrosis, dermatitis/cellulitis, and infection. No statistical differences were seen among recipient site complication rate. Types of minor complications were statistically significant per recipient sites with bilateral breasts more likely to experience asymmetry than the other recipient sites (20% for bilateral breasts vs 16% overall, P < 0.05). Fifty nine of the 110 patients (53.6%) had the complications reported to be resolved. CONCLUSIONS Fat grafting is a reliable method for volumization of the breasts and face. Minor complications were not infrequent in this case series; however, no life-threatening complications were observed. Continued work needs to be done to use fat grafting beyond traditional measures.
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Affiliation(s)
- Hua Amanda Fang
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Edgar Soto
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
| | - Ricky Pigg
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
| | - Metta Smith
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
| | - Carter J. Boyd
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
| | - Shivani Ananthasekar
- University of Alabama in Birmingham School of Medicine, University of Alabama in Birmingham, Birmingham, AL
| | - R. Jobe Fix
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Ali Kilic
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Brad Denney
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Prasanth Patcha
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - René P. Myers
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Jorge I. de la Torre
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
| | - Sherry Collawn
- Division of Plastic Surgery, University of Alabama in Birmingham, Birmingham, AL
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Lymphatic Tissue Bioengineering for the Treatment of Postsurgical Lymphedema. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9040162. [PMID: 35447722 PMCID: PMC9025804 DOI: 10.3390/bioengineering9040162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/17/2022] [Accepted: 03/20/2022] [Indexed: 01/28/2023]
Abstract
Lymphedema is characterized by progressive and chronic tissue swelling and inflammation from local accumulation of interstitial fluid due to lymphatic injury or dysfunction. It is a debilitating condition that significantly impacts a patient's quality of life, and has limited treatment options. With better understanding of the molecular mechanisms and pathophysiology of lymphedema and advances in tissue engineering technologies, lymphatic tissue bioengineering and regeneration have emerged as a potential therapeutic option for postsurgical lymphedema. Various strategies involving stem cells, lymphangiogenic factors, bioengineered matrices and mechanical stimuli allow more precisely controlled regeneration of lymphatic tissue at the site of lymphedema without subjecting patients to complications or iatrogenic injuries associated with surgeries. This review provides an overview of current innovative approaches of lymphatic tissue bioengineering that represent a promising treatment option for postsurgical lymphedema.
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Maita K, Garcia JP, Torres RA, Avila FR, Kaplan JL, Lu X, Manrique OJ, Ciudad P, Forte AJ. Imaging biomarkers for diagnosis and treatment response in patients with lymphedema. Biomark Med 2022; 16:303-316. [PMID: 35176878 DOI: 10.2217/bmm-2021-0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.
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Affiliation(s)
- Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Ricardo A Torres
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jamie L Kaplan
- Division of General Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Xiaona Lu
- Division of Plastic & Reconstructive Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Oscar J Manrique
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY, 14627, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive & Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
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9
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Frueh FS, Gassert L, Scheuer C, Müller A, Fries P, Boewe AS, Ampofo E, Rübe CE, Menger MD, Laschke MW. Adipose tissue-derived microvascular fragments promote lymphangiogenesis in a murine lymphedema model. J Tissue Eng 2022; 13:20417314221109957. [PMID: 35923176 PMCID: PMC9340320 DOI: 10.1177/20417314221109957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/12/2022] [Indexed: 12/22/2022] Open
Abstract
Chronic lymphedema after cancer treatment is common and there is still no cure for this disease. We herein investigated the lymphangiogenic capacity of adipose tissue-derived microvascular fragments (MVF), which contain stem cells and lymphatic vessel fragments. Secondary lymphedema was induced in the hindlimbs of C57BL/6J mice. Green fluorescence protein (GFP)+ MVF were isolated from transgenic C57BL/6Tg (CAG-EGFP)1Osb/J mice, suspended in collagen hydrogel, and injected in the lymphadenectomy defect of wild-type animals. This crossover model allowed the detection of MVF-derived blood and lymphatic vessels after transplantation. The MVF group was compared with animals receiving collagen hydrogel only or a sham intervention. Lymphangiogenic effects were analyzed using volumetry, magnetic resonance (MR) lymphography, histology, and immunohistochemistry. MVF injection resulted in reduced hindlimb volumes when compared to non-treated controls. MR lymphography revealed lymphatic regeneration with reduced dermal backflow after MVF treatment. Finally, MVF transplantation promoted popliteal angiogenesis and lymphangiogenesis associated with a significantly increased microvessel and lymphatic vessel density. These findings indicate that MVF transplantation represents a promising approach to induce therapeutic lymphangiogenesis.
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Affiliation(s)
- Florian S Frueh
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Laura Gassert
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Andreas Müller
- Clinic of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Peter Fries
- Clinic of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Anne S Boewe
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Claudia E Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg/Saar, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg/Saar, Germany
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10
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Atkinson SP. Previews. Stem Cells 2021. [DOI: 10.1002/stem.3460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Lafuente H, Jaunarena I, Ansuategui E, Lekuona A, Izeta A. Cell therapy as a treatment of secondary lymphedema: a systematic review and meta-analysis. Stem Cell Res Ther 2021; 12:578. [PMID: 34801084 PMCID: PMC8605543 DOI: 10.1186/s13287-021-02632-y] [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: 09/15/2021] [Accepted: 10/16/2021] [Indexed: 12/09/2022] Open
Abstract
Background Lymphedema, the accumulation of interstitial fluid caused by poor lymphatic drainage, is a progressive and permanent disease with no curative treatment. Several studies have evaluated cell-based therapies in secondary lymphedema, but no meta-analysis has been performed to assess their efficacy. Methods We conducted a systematic review and meta-analysis of all available preclinical and clinical studies, with assessment of their quality and risk of bias. Results A total of 20 articles using diverse cell types were selected for analysis, including six clinical trials and 14 pre-clinical studies in three species. The meta-analysis showed a positive effect of cell-based therapies on relevant disease outcomes (quantification of edema, density of lymphatic capillaries, evaluation of the lymphatic flow, and tissue fibrosis). No significant publication bias was observed. Conclusion Cell-based therapies have the potential to improve secondary lymphedema. The underlying mechanisms remain unclear. Due to relevant heterogeneity between studies, further randomized controlled and blinded studies are required to substantiate the use of these novel therapies in clinical practice.
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Affiliation(s)
- Hector Lafuente
- Tissue Engineering Group, Biodonostia Health Research Institute, 20014, San Sebastián, Spain
| | - Ibon Jaunarena
- Gynecology Oncology Unit, Donostia University Hospital, 20014, San Sebastián, Spain.,Obstetrics and Gynaecology Group, Biodonostia Health Research Institute, 20014, San Sebastián, Spain
| | - Eukene Ansuategui
- Clinical Epidemiology Group, Biodonostia Health Research Institute, 20014, San Sebastián, Spain
| | - Arantza Lekuona
- Gynecology Oncology Unit, Donostia University Hospital, 20014, San Sebastián, Spain.,Obstetrics and Gynaecology Group, Biodonostia Health Research Institute, 20014, San Sebastián, Spain
| | - Ander Izeta
- Tissue Engineering Group, Biodonostia Health Research Institute, 20014, San Sebastián, Spain. .,School of Engineering, Tecnun-University of Navarra, 20009, San Sebastián, Spain.
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12
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Martin-Almedina S, Mortimer PS, Ostergaard P. Development and physiological functions of the lymphatic system: insights from human genetic studies of primary lymphedema. Physiol Rev 2021; 101:1809-1871. [PMID: 33507128 DOI: 10.1152/physrev.00006.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary lymphedema is a long-term (chronic) condition characterized by tissue lymph retention and swelling that can affect any part of the body, although it usually develops in the arms or legs. Due to the relevant contribution of the lymphatic system to human physiology, while this review mainly focuses on the clinical and physiological aspects related to the regulation of fluid homeostasis and edema, clinicians need to know that the impact of lymphatic dysfunction with a genetic origin can be wide ranging. Lymphatic dysfunction can affect immune function so leading to infection; it can influence cancer development and spread, and it can determine fat transport so impacting on nutrition and obesity. Genetic studies and the development of imaging techniques for the assessment of lymphatic function have enabled the recognition of primary lymphedema as a heterogenic condition in terms of genetic causes and disease mechanisms. In this review, the known biological functions of several genes crucial to the development and function of the lymphatic system are used as a basis for understanding normal lymphatic biology. The disease conditions originating from mutations in these genes are discussed together with a detailed clinical description of the phenotype and the up-to-date knowledge in terms of disease mechanisms acquired from in vitro and in vivo research models.
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Affiliation(s)
- Silvia Martin-Almedina
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter S Mortimer
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St. George's Universities NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
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13
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Use of adipose-derived stem cells in lymphatic tissue engineering and regeneration. Arch Plast Surg 2021; 48:559-567. [PMID: 34583446 PMCID: PMC8490113 DOI: 10.5999/aps.2021.00339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022] Open
Abstract
The potential to differentiate into different cell lines, added to the easy and cost-effective method of extraction, makes adipose-derived stem cells (ADSCs) an object of interest in lymphedema treatment. Our study’s goal was to conduct a comprehensive systematic review of the use of ADSCs in lymphatic tissue engineering and regeneration. On July 23, 2019, using PubMed/MEDLINE, Cochrane Clinical Answers, Cochrane Central Register of Controlled Trials, and Embase databases, we conducted a systematic review of published literature on the use of ADSCs in lymphatic tissue engineering and regeneration. There were no language or time frame limitations, and the following search strategy was applied: ((Adipose stem cell) OR Adipose-derived stem cell)) AND ((Lymphedema) OR Breast Cancer Lymphedema). Only original research manuscripts were included. Fourteen studies fulfilled the inclusion criteria. Eleven studies were experimental (in vitro or in vivo in animals), and only three were clinical. Publications on the topic demonstrated that ADSCs promote lymphangiogenesis, and its effect could be enhanced by modulation of vascular endothelial growth factor-C, interleukin-7, prospero homeobox protein 1, and transforming growth factor-β1. Pilot clinical studies included 11 patients with breast cancer-related lymphedema, and no significant side effects were present at 12-month follow-up. Literature on the use of ADSCs in lymphatic tissue engineering and regeneration demonstrated promising data. Clinical evidence is still in its infancy, but the scientific community agrees that ADSCs can be useful in regenerative lymphangiogenesis. Data collected in this review indicate that unprecedented advances in lymphedema treatment can be anticipated in the upcoming years.
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14
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Maguire G. Stem cells part of the innate and adaptive immune systems as a therapeutic for Covid-19. Commun Integr Biol 2021; 14:186-198. [PMID: 34527167 PMCID: PMC8437473 DOI: 10.1080/19420889.2021.1965356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 12/17/2022] Open
Abstract
Some stem cell types not only release molecules that reduce viral replication, but also reduce the hypercytokinemia and inflammation induced by the immune system, and have been found to be part of the innate and adaptive immune systems. An important component of the stem cell's ability to ameliorate viral diseases, especially the complications post-clearance of the pathogen, is the ability of adult stem cells to reset the innate and adaptive immune systems from an inflammatory state to a repair state. Thus, the molecules released from certain stem cell types found to be safe and efficacious, may be an important new means for therapeutic development in Covid-19, especially for late-stage inflammation and tissue damage once the virus has cleared, particularly in the aged population.
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Affiliation(s)
- Greg Maguire
- Dept. of Preventative and Medicinal Chemistry, NeoGenesis Inc. And BioRegenerative Sciences Inc, San Diego, CA, USA
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Abstract
Tissue engineering has witnessed remarkable advancement in various fields of medicine and has the potential of revolutionizing the management of lymphedema. Combining approaches of biotechnology with the evolving understanding of lymphangiogenesis may offer promising treatment modalities for patients suffering from lymphedema. The strategies to lymphatic vessels tissue engineer can be grouped into four main categories: Delivery of chemokines, cytokines, and other growth factors to induce lymphangiogenesis; cell-based approach using lymphatic endothelial cells or stem-cells; scaffold-based tissue engineering; or a combination of these. This review will summarize the current approach to cancer-related lymphedema and advances in lymphatic tissue engineering strategies and the challenges facing the regeneration of lymphatic vasculature, particularly in an oncologic setting.
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Affiliation(s)
- Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Summer E Hanson
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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16
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Brix B, Sery O, Onorato A, Ure C, Roessler A, Goswami N. Biology of Lymphedema. BIOLOGY 2021; 10:biology10040261. [PMID: 33806183 PMCID: PMC8065876 DOI: 10.3390/biology10040261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
Simple Summary Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy. Abstract This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.
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Affiliation(s)
- Bianca Brix
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
| | - Omar Sery
- Faculty of Science, Masaryk University, Kotlářská 2, 61137 Brno, Czech Republic;
| | | | - Christian Ure
- Wolfsberg Clinical Center for Lymphatic Disorders, Wolfsberg State Hospital, KABEG, 9400 Wolfsberg, Austria;
| | - Andreas Roessler
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
| | - Nandu Goswami
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 3810 Graz, Austria; (B.B.); (A.R.)
- Correspondence: ; Tel.: +43-316-385-73852
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Jørgensen MG, Toyserkani NM, Jensen CH, Andersen DC, Sheikh SP, Sørensen JA. Adipose-derived regenerative cells and lipotransfer in alleviating breast cancer-related lymphedema: An open-label phase I trial with 4 years of follow-up. Stem Cells Transl Med 2021; 10:844-854. [PMID: 33594819 PMCID: PMC8133335 DOI: 10.1002/sctm.20-0394] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with breast cancer‐related lymphedema (BCRL) have reduced quality of life and arm function. Current treatments are palliative, and treatments improving lymphedema are lacking. Preclinical studies have suggested that adipose‐derived regenerative cells (ADRCs) can alleviate lymphedema. We, therefore, aimed to assess whether ADRCs can alleviate lymphedema in clinical reality with long‐term follow‐up. We treated 10 patients with BCRL using ADRCs and a scar‐releasing lipotransfer to the axillary region, and all patients were followed 1, 3, 6, 12, and 48 months after treatment. The primary endpoint was change in arm volume. Secondary endpoints were safety, change in lymphedema symptoms, quality of life, lymphedema‐associated cellulitis, and conservative treatment use. There was no significant decrease in BCRL volume after treatment. However, self‐reported upper extremity disability and arm heaviness and tension improved. Six patients reduced their use of conservative BCRL treatment. Five patients felt that their BCRL had improved substantially, and four of these would redo the treatment. We did not observe any cases of locoregional breast cancer recurrence. In this phase I study with 4 years of follow‐up, axillary delivered ADRCs and lipotransfer were safe and feasible and improved BCRL symptoms and upper extremity function. Randomized controlled trials are needed to confirm the results of this study.
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Affiliation(s)
- Mads Gustaf Jørgensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Navid Mohamadpour Toyserkani
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Department of Plastic Surgery and Burns Treatment, Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Harken Jensen
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Ditte Caroline Andersen
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Søren Paludan Sheikh
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Jens Ahm Sørensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
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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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Li ZJ, Yang E, Li YZ, Liang ZY, Huang JZ, Yu NZ, Long X. Application and prospect of adipose stem cell transplantation in treating lymphedema. World J Stem Cells 2020; 12:676-687. [PMID: 32843921 PMCID: PMC7415250 DOI: 10.4252/wjsc.v12.i7.676] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymphedema is a chronic, debilitating and incurable disease that affects 0.13%-2% of the global population. Emerging evidence indicates that adipose-derived stem cells (ADSCs) might serve as suitable seed cells for lymphatic tissue engineering and lymphedema therapy.
AIM To summarize applications of ADSCs for treating lymphedema in both animal studies and clinical trials.
METHODS A systematic search was performed on four databases – PubMed, Clinicaltrials.gov, the evidence-based Cochrane Library, and OVID – using the following search string: (“lymphedema” or “lymphoedema” or “lymphangiogenesis”) and (“adipose-derived stem cells” or “adipose-derived stromal cells” or “adipose-derived regenerative cells”). A manual search was performed by skimming the references of relevant studies. Animal studies and clinical trials using adipose-derived cells for the treatment of any kind of lymphedema were included.
RESULTS A total of eight research articles published before November 2019 were included for this analysis. Five articles focused on animal studies and another three focused on clinical trials. ADSC transplantation therapy was demonstrated to be effective against lymphedema in all studies. The animal studies found that coadministration of ADSCs and controlled-release vascular endothelial growth factor-C or platelet-rich plasma could improve the effectiveness of ADSC therapy. Three sequential clinical trials were conducted on breast cancer-related lymphedema patients, and all showed favorable results.
CONCLUSION ADSC-based therapy is a promising option for treating lymphedema. Large-scale, multicenter randomized controlled trials are needed to develop more effective and durable therapeutic strategies.
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Affiliation(s)
- Zhu-Jun Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Elan Yang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yun-Zhu Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zheng-Yun Liang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jiu-Zuo Huang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Nan-Ze Yu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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He L, Qu H, Wu Q, Song Y. Lymphedema in survivors of breast cancer. Oncol Lett 2020; 19:2085-2096. [PMID: 32194706 PMCID: PMC7039097 DOI: 10.3892/ol.2020.11307] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022] Open
Abstract
The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.
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Affiliation(s)
- Lin He
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Huili Qu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Qian Wu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Yuhua Song
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
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Forte AJ, Boczar D, Huayllani MT, Lu X, Ciudad P. Lymphoscintigraphy for Evaluation of Lymphedema Treatment: A Systematic Review. Cureus 2019; 11:e6363. [PMID: 31886094 PMCID: PMC6907718 DOI: 10.7759/cureus.6363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Lymphoscintigraphy is a well-established radiologic examination to evaluate lymphatic function. We conducted a systematic review of the use of lymphoscintigraphy for evaluation of lymphedema treatment. We hypothesized that this radiologic examination could add relevant findings of treatment outcomes of lymphedema patients. We conducted a systematic review of articles in PubMed, without any time frame or language limitations, about the use of lymphoscintigraphy for the evaluation of lymphedema treatment. Articles were excluded if they investigated other uses of lymphoscintigraphy, such as diagnosis or prevention of lymphedema. Abstracts, presentations, reviews, and meta-analyses were also excluded. Of 101 potential articles found in the literature, 5 fulfilled our study eligibility criteria, and they were all case series. These articles included a total of 327 patients, most of whom had breast cancer-related lymphedema. Interventions included lymph node or vessel transfer (3 of 5 articles), complex decongestive therapy (1 of 5), and adipose-derived stem cell injection (1 of 5). The authors of these studies used lymphoscintigraphy to investigate the treatment functional outcomes, prognostic value, and complications. Lymphoscintigraphy detected lymphangiogenesis in transferred lymph nodes, and it was able to predict patient response to complex decongestive therapy. Studies that used lymphoscintigraphy to evaluate lymphedema treatment demonstrated its flexibility to provide various types of information. We hope this review will support future studies.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Xiaona Lu
- Plastic Surgery, Yale University, New Haven, USA
| | - Pedro Ciudad
- Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, PER
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