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Thamkittikun C, Tovichien P. Clinical approach for pulmonary lymphatic disorders. World J Clin Cases 2024; 12:6020-6026. [DOI: 10.12998/wjcc.v12.i27.6020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/29/2024] Open
Abstract
In this editorial, we discuss the clinical implications of the article “Lymphatic plastic bronchitis and primary chylothorax: A study based on computed tomography lymphangiography” published by Li et al. Pulmonary lymphatic disorders involve abnormalities in the lymphatic tissues within the thoracic cavity. Specifically, pulmonary lymphatic perfusion syndrome describes a condition where the flow of lymphatic fluid in the lungs is redirected towards abnormally widened lymphatic vessels. Clinically, individuals with this syndrome may experience symptoms such as chyloptysis, plastic bronchitis (PB), chylothorax, chylopericardium, and interstitial lung disease. These disorders can be caused by various factors, including PB, chylothorax, and complex lymphatic malformations. Advancements in lymphatic imaging techniques, such as intranodal lymphangiography, computed tomography lymphangiography, and dynamic contrast-enhanced magnetic resonance lymphangiography, have enabled the detection of abnormal lymphatic flow. This has enhanced our understanding of the pathophysiology of these conditions. Additionally, innovative minimally invasive treatments, such as thoracic duct embolization, selective embolization of lymphatic channels, and surgical procedures aim to improve clinical condition of patients and address their dietary needs.
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Affiliation(s)
- Chalisa Thamkittikun
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Prakarn Tovichien
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Benjamin J, O'Leary C, Hur S, Gurevich A, Klein WM, Itkin M. Imaging and Interventions for Lymphatic and Lymphatic-related Disorders. Radiology 2023; 307:e220231. [PMID: 36943078 DOI: 10.1148/radiol.220231] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.
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Affiliation(s)
- Jamaal Benjamin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Cathal O'Leary
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Saebeom Hur
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Alexey Gurevich
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Willemijn M Klein
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Maxim Itkin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
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McDaniel CG, Adams DM, Steele KE, Hammill AM, Merrow AC, Crane JL, Smith CL, Kozakewich HPW, Le Cras TD. Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment. Pediatr Blood Cancer 2023; 70:e30219. [PMID: 36683202 PMCID: PMC10018800 DOI: 10.1002/pbc.30219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023]
Abstract
Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.
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Affiliation(s)
| | - Denise M. Adams
- Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Kimberley E. Steele
- Collaborative Research Advocacy for Vascular Anomalies
Network (CaRAVAN), a 501(C)(3)
| | - Adrienne M. Hammill
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - A. Carl Merrow
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - Janet L. Crane
- Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | | | | | - Timothy D. Le Cras
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
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O'Leary C, Itkin M, Roshkovan L, Katz S, Cao Q, Hershman M, Galperin-Aizenberg M. CT Features of Lymphatic Plastic Bronchitis in Adults: Correlation with Multimodality Lymphatic Imaging. Radiol Cardiothorac Imaging 2022; 4:e210048. [PMID: 35506131 DOI: 10.1148/ryct.210048] [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: 02/22/2021] [Revised: 12/05/2021] [Accepted: 03/24/2022] [Indexed: 11/11/2022]
Abstract
Purpose To distinguish CT patterns of lymphatic and nonlymphatic causes of plastic bronchitis (PB) through comparison with lymphatic imaging. Materials and Methods In this retrospective study, chest CT images acquired prior to lymphatic workup were assessed in 44 patients with PB from January 2014 to August 2020. The location and extent of ground-glass opacity (GGO) was compared with symptoms and lymphatic imaging. Statistical analysis was performed using descriptive statistics, logistic regression, Pearson correlation coefficient, and unweighted κ coefficient for interobserver agreement. Sensitivity and specificity of GGO for lymphatic PB were calculated. Results Lymphatic imaging was performed in 44 patients (median age, 52 years ± 21 [IQR]; 23 women): 35 with lymphatic PB and nine with nonlymphatic PB. GGO was more frequently observed in patients with lymphatic PB than in those with nonlymphatic PB (91% [32 of 35] vs 33% [three of nine]; P < .001). Univariate logistic regression confirmed this result by showing that GGO was a significant predictor of lymphatic PB (odds ratio, 21 (95% CI: 3.8, 159.7). The model areas under the receiver operating characteristic curve (AUCs) of GGO unadjusted and adjusted for demographics were 0.79 and 0.86, respectively. The location of GGO correlated with lymphatic imaging and bronchoscopic findings. Overall sensitivity and specificity of GGO for lymphatic PB were 91% (32 of 35; 95% CI: 76, 98) and 67% (six of nine; 95% CI: 30, 93), respectively. Conclusion Patients with lymphatic PB predominantly had multifocal GGO with or without a "crazy paving" pattern; identification of GGO should prompt lymphatic workup in this frequently misdiagnosed condition.Keywords: Lymphography, Lymphatic, CT, Tracheobronchial Tree, Thorax© RSNA, 2022See also commentary by Kligerman and White in this issue.
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Affiliation(s)
- Cathal O'Leary
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Leonid Roshkovan
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Sharyn Katz
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Quy Cao
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Michelle Hershman
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Maya Galperin-Aizenberg
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
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Sun X, Perl AK, Li R, Bell SM, Sajti E, Kalinichenko VV, Kalin TV, Misra RS, Deshmukh H, Clair G, Kyle J, Crotty Alexander LE, Masso-Silva JA, Kitzmiller JA, Wikenheiser-Brokamp KA, Deutsch G, Guo M, Du Y, Morley MP, Valdez MJ, Yu HV, Jin K, Bardes EE, Zepp JA, Neithamer T, Basil MC, Zacharias WJ, Verheyden J, Young R, Bandyopadhyay G, Lin S, Ansong C, Adkins J, Salomonis N, Aronow BJ, Xu Y, Pryhuber G, Whitsett J, Morrisey EE. A census of the lung: CellCards from LungMAP. Dev Cell 2022; 57:112-145.e2. [PMID: 34936882 PMCID: PMC9202574 DOI: 10.1016/j.devcel.2021.11.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/19/2021] [Accepted: 11/05/2021] [Indexed: 01/07/2023]
Abstract
The human lung plays vital roles in respiration, host defense, and basic physiology. Recent technological advancements such as single-cell RNA sequencing and genetic lineage tracing have revealed novel cell types and enriched functional properties of existing cell types in lung. The time has come to take a new census. Initiated by members of the NHLBI-funded LungMAP Consortium and aided by experts in the lung biology community, we synthesized current data into a comprehensive and practical cellular census of the lung. Identities of cell types in the normal lung are captured in individual cell cards with delineation of function, markers, developmental lineages, heterogeneity, regenerative potential, disease links, and key experimental tools. This publication will serve as the starting point of a live, up-to-date guide for lung research at https://www.lungmap.net/cell-cards/. We hope that Lung CellCards will promote the community-wide effort to establish, maintain, and restore respiratory health.
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Affiliation(s)
- Xin Sun
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA; Department of Biological Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Anne-Karina Perl
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Rongbo Li
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Sheila M Bell
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Eniko Sajti
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Vladimir V Kalinichenko
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Tanya V Kalin
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Ravi S Misra
- Department of Pediatrics Division of Neonatology, The University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Hitesh Deshmukh
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Geremy Clair
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Jennifer Kyle
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Laura E Crotty Alexander
- Deparment of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Jorge A Masso-Silva
- Deparment of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Joseph A Kitzmiller
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kathryn A Wikenheiser-Brokamp
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pathology & Laboratory Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Gail Deutsch
- Department of Pathology, University of Washington School of Medicine, Seattle, WA, USA; Department of Laboratories, Seattle Children's Hospital, OC.8.720, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| | - Minzhe Guo
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Yina Du
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Michael P Morley
- Penn-CHOP Lung Biology Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael J Valdez
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Haoze V Yu
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Kang Jin
- Departments of Biomedical Informatics, Developmental Biology, and Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric E Bardes
- Departments of Biomedical Informatics, Developmental Biology, and Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jarod A Zepp
- Penn-CHOP Lung Biology Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Terren Neithamer
- Penn-CHOP Lung Biology Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Maria C Basil
- Penn-CHOP Lung Biology Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - William J Zacharias
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Jamie Verheyden
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Randee Young
- Department of Pediatrics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Gautam Bandyopadhyay
- Department of Pediatrics Division of Neonatology, The University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Sara Lin
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Charles Ansong
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Joshua Adkins
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Nathan Salomonis
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bruce J Aronow
- Departments of Biomedical Informatics, Developmental Biology, and Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yan Xu
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Gloria Pryhuber
- Department of Pediatrics Division of Neonatology, The University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Jeff Whitsett
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Edward E Morrisey
- Penn-CHOP Lung Biology Institute, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Cell and Developmental Biology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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6
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McCarthy C, Gupta N, Johnson SR, Yu JJ, McCormack FX. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1313-1327. [PMID: 34461049 DOI: 10.1016/s2213-2600(21)00228-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 01/15/2023]
Abstract
Lymphangioleiomyomatosis (LAM) is a slowly progressive, low-grade, metastasising neoplasm of women, characterised by infiltration of the lung parenchyma with abnormal smooth muscle-like cells, resulting in cystic lung destruction. The invading cell in LAM arises from an unknown source and harbours mutations in tuberous sclerosis complex (TSC) genes that result in constitutive activation of the mechanistic target of rapamycin (mTOR) pathway, dysregulated cellular proliferation, and a programme of frustrated lymphangiogenesis, culminating in disordered lung remodelling and respiratory failure. Over the past two decades, all facets of LAM basic and clinical science have seen important advances, including improved understanding of molecular mechanisms, novel diagnostic and prognostic biomarkers, effective treatment strategies, and comprehensive clinical practice guidelines. Further research is needed to better understand the natural history of LAM; develop more powerful diagnostic, prognostic, and predictive biomarkers; optimise the use of inhibitors of mTOR complex 1 in the treatment of LAM; and explore novel approaches to the development of remission-inducing therapies.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St Vincent's University Hospital, University College Dublin, Dublin, Ireland.
| | - Nishant Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Simon R Johnson
- Division of Respiratory Medicine, University of Nottingham, NIHR Respiratory Biomedical Research Centre, Nottingham, UK
| | - Jane J Yu
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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7
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Gulaya K, Entezari P, Salem R, Riaz A. Trans-cervical thoracic duct embolization for post-surgical left Chylothorax in a patient with multifocal lymphatic malformations. CVIR Endovasc 2021; 4:73. [PMID: 34632559 PMCID: PMC8502719 DOI: 10.1186/s42155-021-00260-4] [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: 07/23/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background Mediastinal and abdominal lymphatic malformations may not be diagnosed until adulthood. Radiologic and pathologic diagnosis is often challenging due to the rarity of the lesion. Surgical excision of these lesions may be curative but lymphatic leak is a known complication. Lymphatic duct embolization may then be required to treat the leak. Case presentation We describe a patient with post-surgical chylothorax where thoracic duct lymphangiography and embolization was performed by catheterizing the thoracic duct at the venous angle where it drains into the subclavian vein. Conclusion Lymphatic duct embolization can be challenging in patients with lymphatic malformations. In these patients, if there is adequate visualization on ultrasound or fluoroscopy, terminal aspect of the thoracic duct can be accessed through the subclavian vein to perform the procedure.
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Affiliation(s)
- Karan Gulaya
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, 676 N St. Clair, Suite 800, Chicago, IL, 60611, USA.
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8
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Cochrane CN, Collin N, Langton Hewer SC. A breathless teenager. Breathe (Sheff) 2021; 17:210027. [PMID: 34295426 PMCID: PMC8291959 DOI: 10.1183/20734735.0027-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
A 14-year-old girl presented to hospital with breathlessness and fatigue. On admission she was hypoxaemic with oxygen saturations of 90%, tachycardic with a heart rate of 120 beats·min−1 and tachypnoeic with a respiratory rate of 40–50 breaths·min−1. In children with persistent chylothoraces of unknown origin, intranodal lymphangiography can be used to help identify the source of a leak. This may enable embolisation with glue and coils to enable resolution of the chylothoraces.https://bit.ly/3gskhgJ
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Affiliation(s)
| | - Neil Collin
- Dept of Radiology, Southmead Hospital, Bristol, UK
| | - Simon C Langton Hewer
- Dept of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
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Abstract
Lymphatic vessels maintain tissue fluid homeostasis by returning to blood circulation interstitial fluid that has extravasated from the blood capillaries. They provide a trafficking route for cells of the immune system, thus critically contributing to immune surveillance. Developmental or functional defects in the lymphatic vessels, their obstruction or damage, lead to accumulation of fluid in tissues, resulting in lymphedema. Here we discuss developmental lymphatic anomalies called lymphatic malformations and complex lymphatic anomalies that manifest as localized or multifocal lesions of the lymphatic vasculature, respectively. They are rare diseases that are caused mostly by somatic mutations and can present with variable symptoms based upon the size and location of the lesions composed of fluid-filled cisterns or channels. Substantial progress has been made recently in understanding the molecular basis of their pathogenesis through the identification of their genetic causes, combined with the elucidation of the underlying mechanisms in animal disease models and patient-derived lymphatic endothelial cells. Most of the solitary somatic mutations that cause lymphatic malformations and complex lymphatic anomalies occur in genes that encode components of oncogenic growth factor signal transduction pathways. This has led to successful repurposing of some targeted cancer therapeutics to the treatment of lymphatic malformations and complex lymphatic anomalies. Apart from the mutations that act as lymphatic endothelial cell-autonomous drivers of these anomalies, current evidence points to superimposed paracrine mechanisms that critically contribute to disease pathogenesis and thus provide additional targets for therapeutic intervention. Here, we review these advances and discuss new treatment strategies that are based on the recently identified molecular pathways.
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Affiliation(s)
- Taija Mäkinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden (T.M.)
| | - Laurence M Boon
- Division of Plastic Surgery, Center for Vascular Anomalies, Cliniques Universitaires Saint Luc, UCLouvain, Brussels, Belgium (L.M.B.).,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.)
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.).,Walloon Excellence in Lifesciences and Biotechnology, University of Louvain, Brussels, Belgium (M.V.)
| | - Kari Alitalo
- Wihuri Research Institute and Translational Cancer Medicine Program, Biomedicum, University of Helsinki, Finland (K.A.)
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10
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O'Leary CN, Khaddash T, Nadolski G, Itkin M. Abnormal Pulmonary Lymphatic Flow on Novel Lymphangiographic Imaging Supports a Common Etiology of Lymphatic Plastic Bronchitis and Nontraumatic Chylothorax. Lymphat Res Biol 2021; 20:153-159. [PMID: 34077679 DOI: 10.1089/lrb.2021.0008] [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] [Indexed: 11/13/2022] Open
Abstract
Background: This study evaluates whether dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) and thoracic duct lymphangiography (TDL) findings in adults with lymphatic plastic bronchitis (PB) and/or nontraumatic chylothorax (NTC) support a shared pathophysiology. Materials and Results: Retrospective review of clinical and imaging findings in patients who underwent DCMRL and TDL at a single institution from March 2017 to March 2019. Categorical variables were compared with Fisher's exact test. Twenty-eight patients (median age 61 ± 21 years, 15 women) presenting with lymphatic PB (n = 13), NTC (n = 10), or both (n = 5) were included. Lymphatic imaging demonstrated pulmonary lymphatic perfusion (PLP) in all patients. A patent thoracic duct (TD) with retrograde flow was seen in 53.4% (7/13) of patients with PB, 60% (6/10) of patients with NTC, and 20% (1/5) of patients with both (p = 0.69). An occluded TD with retrograde flow was seen in 30.8% (4/13) of patients with PB, 30% (3/10) of patients with NTC, and 80% (4/5) of patients with both (p = 0.12). Similar patterns of PLP between DCMRL and TDL were seen in 96.2% (25/26) of patients. Conclusions: DCMRL and TDL demonstrated similar findings in patients with lymphatic PB and/or NTC, supporting a common etiology. This supports the hypothesis that the clinical presentation depends on the proximity of abnormal lymphatic vessels to the pleural cavity, resulting in chylothorax, or bronchial mucosa, resulting in PB.
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Affiliation(s)
- Cathal N O'Leary
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Tamim Khaddash
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Gregory Nadolski
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Maxim Itkin
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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11
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Itkin M, Chidekel A, Ryan KA, Rabinowitz D. Abnormal pulmonary lymphatic flow in patients with paediatric pulmonary lymphatic disorders: Diagnosis and treatment. Paediatr Respir Rev 2020; 36:15-24. [PMID: 32792289 DOI: 10.1016/j.prrv.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
Pulmonary lymphatic disorders are characterized by the presence of the abnormal lymphatic tissues in the thoracic cavity, presenting clinically as chylothorax, chylopericardium, chyloptysis, interstitial lung disease and plastic bronchitis. These conditions include: neonatal chylothorax, cardiac and non-cardiac plastic bronchitis, non-traumatic chylothorax, post congenital cardiac surgery chylothorax and complex lymphatic malformations. Recently developed lymphatic imaging techniques, such as intranodal lymphangiography and dynamic contrast enhanced magnetic resonance lymphangiography demonstrated abnormal pulmonary lymphatic flow from thoracic duct into pulmonary parenchyma as a pathophysiological mechanism of these diseases. Novel minimally invasive lymphatic interventions, such as thoracic duct embolization, interstitial lymphatic embolization and surgical lympho-venous anastomosis, provide an effective treatment of these conditions.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Aaron Chidekel
- Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kelly A Ryan
- Cardiac Center, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Deborah Rabinowitz
- Dept of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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12
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Dellinger MT, McCormack FX. The emergence of targetable MEKanisms in sporadic lymphatic disorders. EMBO Mol Med 2020; 12:e12822. [PMID: 32945117 PMCID: PMC7539175 DOI: 10.15252/emmm.202012822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Sporadic lymphatic diseases are orphans among orphans in the medical community, a diverse collection of disorders at the intersection of cardiac, gastrointestinal, pulmonary, dermatologic, and oncologic disease that receives only passing attention in medical school and that no subspecialty in medicine fully embraces as its own. They often present in a confusing and illusive manner, with a fractured bone, expectoration of blood or a branching airway cast, a swollen limb or a collection of chylous material; protean manifestations that can challenge even the most expert diagnostician. Yet many of these acquired disorders have been discovered to have a targetable genetic basis, and as the case report of Foster et al (2020) demonstrates, the sedulous clinician–patient dyad can be rewarded with an almost miraculous result when the molecular pathogenesis of the disease is pursued and an exquisitely targeted therapy is administered.
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Affiliation(s)
- Michael T Dellinger
- Division of Surgical Oncology, Department of Surgery and the Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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13
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Chavhan GB, Lam CZ, Greer MLC, Temple M, Amaral J, Grosse-Wortmann L. Magnetic Resonance Lymphangiography. Radiol Clin North Am 2020; 58:693-706. [PMID: 32471538 DOI: 10.1016/j.rcl.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.
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Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lars Grosse-Wortmann
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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14
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Iacobas I, Adams DM, Pimpalwar S, Phung T, Blei F, Burrows P, Lopez-Gutierrez JC, Levine MA, Trenor CC. Multidisciplinary guidelines for initial evaluation of complicated lymphatic anomalies-expert opinion consensus. Pediatr Blood Cancer 2020; 67:e28036. [PMID: 31617676 DOI: 10.1002/pbc.28036] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Complicated lymphatic anomalies (CLAs) are chronic, progressive, and debilitating conditions that share clinical features, yet key elements for optimal evaluation and management have not been established. We aimed to formulate expert opinion consensus-based guidelines for comprehensive evaluation of CLAs. STUDY DESIGN Patient support groups dedicated to CLAs organized an international conference for vascular anomaly experts from 16 specialties to address the objective. Participants received a set of questions before the meeting and reviewed the literature. Data extracted from international lymphatic anomaly registries were presented and the group separated for panel discussions during the conference. The recommendations achieving consensus within the panel were presented to the entire audience. Open debate occurred until majority approval was achieved. RESULTS The expert group was composed of 52 physicians who defined the clinical elements required to evaluate and diagnose a CLA. The radiology panel established the preferred anatomical and functional imaging methods for diagnosis and the elements required to be described during interpretation. Two medical panels compiled the metabolic and hematologic tests at diagnosis and also recommended functional studies. The surgical group recommended precautions for biopsy and the pathology panel provided biopsy specimen processing guidelines. CONCLUSIONS Patients with CLAs require a comprehensive and targeted diagnostic plan for appropriate management, prevention of complications, and conservation of resources. As this population is managed by diverse medical and surgical specialties, we offer an expert multidisciplinary consensus-based opinion on the current literature and on data extracted from international lymphatic anomaly registries.
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Affiliation(s)
- Ionela Iacobas
- TCH Vascular Anomalies Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Denise M Adams
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Thuy Phung
- TCH Vascular Anomalies Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Francine Blei
- Vascular Anomalies Program, Lenox Hill Hospital, New York, New York
| | - Patricia Burrows
- Radiology Department, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Michael A Levine
- Center for Bone Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cameron C Trenor
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Abstract
RATIONALE Diffuse pulmonary lymphangiomatos (DPL) is a rare aggressive lymphatic disorder characterized by proliferation of anastomozing lymphatic vessels and extremely rare in adult patients. PATIENT CONCERNS We report a case of diffuse pulmonary lymphangiomatosis in 59-year-old man presented with cough and sputum for 2 months. DIAGNOSES Combining clinical manifestations with results of radiological, bronchoscopy, and surgical lung biopsy, it was consistent with the diagnosis of DPL. INTERVENTIONS After bronchoalveolar lavage and biopsy, symptom of cough got worse suddenly accompanied by excessive chyloptysis. The patient received an emergency surgical intervention and low fat medium chain fat treatment. OUTCOMES The patient was discharged with a much better health condition. LESSONS This case report is the oldest patient reported in the English literature, to the best of our knowledge. Serious complications of bronchoscopy should be considered, especially in DPL patients with severely enlarged mediastinum or with thin-walled translucent vesicles under endoscopy.
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Affiliation(s)
| | - Liyun Mi
- Department of Respiratory Medicine
| | | | | | - Yunqing Chen
- Department of Pathology, Affiliated Hospital of Qingdao University, Qingdao City, Shandong, China
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16
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Blue Bronchoscopy: Confirmation of Aberrant Pulmonary Lymphatic Perfusion During Lymphangiography. J Bronchology Interv Pulmonol 2019; 24:e51-e52. [PMID: 28957894 DOI: 10.1097/lbr.0000000000000388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Maisel K, Merrilees MJ, Atochina-Vasserman EN, Lian L, Obraztsova K, Rue R, Vasserman AN, Zuo N, Angel LF, Gow AJ, Kang I, Wight TN, Eruslanov E, Swartz MA, Krymskaya VP. Immune Checkpoint Ligand PD-L1 Is Upregulated in Pulmonary Lymphangioleiomyomatosis. Am J Respir Cell Mol Biol 2018; 59:723-732. [PMID: 30095976 PMCID: PMC6293078 DOI: 10.1165/rcmb.2018-0123oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/21/2018] [Indexed: 12/29/2022] Open
Abstract
Pulmonary lymphangioleiomyomatosis (LAM) is a slow-progressing metastatic disease that is driven by mutations in the tumor suppressor tuberous sclerosis complex 1/2 (TSC1/2). Rapamycin inhibits LAM cell proliferation and is the only approved treatment, but it cannot cause the regression of existing lesions and can only stabilize the disease. However, in other cancers, immunotherapies such as checkpoint blockade against PD-1 and its ligand PD-L1 have shown promise in causing tumor regression and even curing some patients. Thus, we asked whether PD-L1 has a role in LAM progression. In vitro, PD-L1 expression in murine Tsc2-null cells is unaffected by mTOR inhibition with torin but can be upregulated by IFN-γ. Using immunohistochemistry and single-cell flow cytometry, we found increased PD-L1 expression both in human lung tissue from patients with LAM and in Tsc2-null lesions in a murine model of LAM. In this model, PD-L1 is highly expressed in the lung by antigen-presenting and stromal cells, and activated T cells expressing PD-1 infiltrate the affected lung. In vivo treatment with anti-PD-1 antibody significantly prolongs mouse survival in the model of LAM. Together, these data demonstrate that PD-1/PD-L1-mediated immunosuppression may occur in LAM, and suggest new opportunities for therapeutic targeting that may provide benefits beyond those of rapamycin.
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Affiliation(s)
- Katharina Maisel
- Institute for Molecular Engineering, University of Chicago, Chicago, Illinois
| | - Mervyn J. Merrilees
- Department of Anatomy and Medical Imaging, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | | | - Lurong Lian
- Penn Center for Pulmonary Biology, Pulmonary, Allergy and Critical Care Division, and
| | - Kseniya Obraztsova
- Penn Center for Pulmonary Biology, Pulmonary, Allergy and Critical Care Division, and
| | - Ryan Rue
- Penn Center for Pulmonary Biology, Pulmonary, Allergy and Critical Care Division, and
| | | | - Ning Zuo
- Department of Anatomy and Medical Imaging, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Luis F. Angel
- New York University Langone Medical Center, New York, New York
| | - Andrew J. Gow
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey; and
| | - Inkyung Kang
- Matrix Biology Program, Benaroya Research Institute, Seattle, Washington
| | - Thomas N. Wight
- Matrix Biology Program, Benaroya Research Institute, Seattle, Washington
| | - Evgeniy Eruslanov
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Melody A. Swartz
- Institute for Molecular Engineering, University of Chicago, Chicago, Illinois
| | - Vera P. Krymskaya
- Penn Center for Pulmonary Biology, Pulmonary, Allergy and Critical Care Division, and
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18
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Gupta N, Henske EP. Pulmonary manifestations in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:326-337. [PMID: 30055039 DOI: 10.1002/ajmg.c.31638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Tuberous sclerosis complex has manifestations in many organ systems, including brain, heart, kidney, skin, and lung. The primary manifestations in the lung are lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH). LAM affects almost exclusively women, and causes cystic lung destruction, pneumothorax, and chylous pleural effusions. LAM can lead to dyspnea, oxygen dependence, and respiratory failure, with more rapid disease progression during the premenopausal years. In contrast, MMPH affects men and women equally, causing small nodular pulmonary deposits of type II pneumocytes that rarely progress to symptomatic disease. Here, we review the clinical features and pathogenesis of LAM and MMPH.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth P Henske
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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19
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Du H, Xiong M, Liao H, Luo Y, Shi H, Xie C. Chylothorax and constrictive pericarditis in a woman due to generalized lymphatic anomaly: a case report. J Cardiothorac Surg 2018; 13:59. [PMID: 29871646 PMCID: PMC5989411 DOI: 10.1186/s13019-018-0752-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background Generalized lymphatic anomaly (GLA) is characterized by diffuse or multicentric proliferation of dilated lymphatic vessels resembling common lymphatic malformations. Compared with soft tissue or bone involvement, thoracic involvement may be associated with a worse prognosis. Case presentation We reported a case of GLA with chylothorax and constrictive pericarditis in a 29-year-old woman. This patient exhibited remarkable features, including a continuously hemorrhagic chylothorax, constrictive pericarditis, and involvement of bone and neck lymph nodes. After attempting to manage her condition with conservative treatment, the patient underwent pericardial stripping surgery. Exploration revealed abundant hyperplasia of tubular tissue in the aortopulmonary window in both pleural cavities. Conclusions This case highlights the importance of maintaining the clinical suspicion of GLA during the follow-up of chylothorax patients. Aggressive pericardial surgery, which is important for both diagnosis and treatment, should be performed in patients with GLA with constrictive pericarditis.
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Affiliation(s)
- Hongchun Du
- Department of Respiratory Medicine, The First Affiliated Hospital, Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Mai Xiong
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huai Liao
- Department of Respiratory Medicine, The First Affiliated Hospital, Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Yifeng Luo
- Department of Respiratory Medicine, The First Affiliated Hospital, Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Huijuan Shi
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Canmao Xie
- Department of Respiratory Medicine, The First Affiliated Hospital, Sun Yat-sen University, No 58, Zhongshan 2nd Road, Guangzhou, 510080, China.
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20
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Weber E, Sozio F, Borghini A, Sestini P, Renzoni E. Pulmonary lymphatic vessel morphology: a review. Ann Anat 2018; 218:110-117. [PMID: 29679722 DOI: 10.1016/j.aanat.2018.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/07/2018] [Accepted: 02/28/2018] [Indexed: 01/02/2023]
Abstract
Our understanding of lymphatic vessels has been advanced by the recent identification of relatively specific lymphatic endothelium markers, including Prox-1, VEGFR3, podoplanin and LYVE-1. The use of lymphatic markers has led to the observation that, contrary to previous assumptions, human lymphatic vessels extend deep inside the pulmonary lobule, either in association with bronchioles, intralobular arterioles or small pulmonary veins. Pulmonary lymphatic vessels may thus be classified into pleural, interlobular (in interlobular septa) and intralobular. Intralobular lymphatic vessels may be further subdivided in: bronchovascular (associated with a bronchovascular bundle), perivascular (associated with a blood vessel), peribronchiolar (associated with a bronchiole), and interalveolar (in interalveolar septa). Most of the intralobular lymphatic vessels are in close contact with a blood vessel, either alone or within a bronchovascular bundle. A minority is associated with a bronchiole, and small lymphatics are occasionally present even in interalveolar septa, seemingly independent of blood vessels or bronchioles. The lymphatics of the interlobular septa often contain valves, are usually associated with the pulmonary veins, and connect with the pleural lymphatics. The large lymphatics associated with bronchovascular bundles have similar characteristics to pleural and interlobular lymphatics and may be considered conducting vessels. The numerous small perivascular lymphatics and the few peribronchiolar ones that are found inside the lobule are probably the absorbing compartment of the lung responsible for maintaining the alveolar interstitium relatively dry in order to provide a minimal thickness of the air-blood barrier and thus optimize gas diffusion. These lymphatic populations could be differentially involved in the pathogenesis of diseases preferentially involving distinct lung compartments.
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Affiliation(s)
- E Weber
- Dept. of Molecular and Developmental Medicine, University of Siena, via A.Moro 2, 53100 Siena, Italy
| | - F Sozio
- Dept. of Molecular and Developmental Medicine, University of Siena, via A.Moro 2, 53100 Siena, Italy
| | - A Borghini
- Dept. of Molecular and Developmental Medicine, University of Siena, via A.Moro 2, 53100 Siena, Italy
| | - P Sestini
- Dept. of Medicine, Surgery and Neuroscience, University of Siena, viale Bracci 16, 53100 Siena, Italy
| | - E Renzoni
- ILD Unit Royal Brompton Hpospital,Sydney Street SW3 6LR, London, UK.
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21
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Guo Y, Chen J, Xu B, Zheng Y, Shen K. Causes and manifestations of chylothorax in children in China: Experience from a children's medical center, 2007-2017. Pediatr Investig 2018; 2:8-14. [PMID: 32851223 PMCID: PMC7331315 DOI: 10.1002/ped4.12019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 03/07/2018] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Chylothorax is the most common cause of pleural effusion in neonates and relatively rare in children. It can cause significant respiratory morbidity. Many clinical entities may contribute to chylothorax. OBJECTIVE To investigate the causes and manifestations of chylothorax in infants and children in China. METHODS Case records of 107 cases with chylothorax seen in Beijing Children's Hospital from 2007 to 2017 were retrieved and analyzed; follow-up was carried out by telephone. RESULTS Of 107 cases, 58.9% (63/107) were primary chylothorax (PC) and 41.1% (44/107) were secondary chylothorax (SC). Also, 36.4% (39/107) were neonatal chylothorax (NC) and 35.5% (38/107) were postoperative chylothorax. In PC with a verified lymphatic anomaly, there was one case of diffuse pulmonary lymphangiomatosis (DPL) and six cases of generalized lymphatic anomaly (GLA), which accounted for 6.5% (7/107) of cases. In most patients, chylothorax was alleviated by conservative treatment based on total parenteral nutrition (TPN); 13.1% (14/107) of cases needed further surgery. In NC, the median duration of TPN was 9 days, but 10 of 20 cases who improved had recurrence upon re-introduction of a fat-free diet, which was alleviated by further TPN. The duration of hospitalization was (23 ± 14) days for congenital chylothorax. Upon long- term follow-up, except for GLA and DPL, most patients were doing well without recurrence. INTERPRETATION NC and postoperative chylothorax are the common subtypes. TPN is effective for most patients. Despite a prolonged and fluctuating clinical course, most patients had a good long-term prognosis.
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Affiliation(s)
- Yan Guo
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Jiehua Chen
- Department of Respiratory MedicineShenzhen Children's HospitalShenzhenChina
| | - Baoping Xu
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yuejie Zheng
- Department of Respiratory MedicineShenzhen Children's HospitalShenzhenChina
| | - Kunling Shen
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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22
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Détrée A, Picaud M, Bury Q, Chabrol J, Bart F, Faivre JB, Wallaert B. Une histoire de chyle. Rev Mal Respir 2018; 35:94-97. [DOI: 10.1016/j.rmr.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
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23
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Chavhan GB, Amaral JG, Temple M, Itkin M. MR Lymphangiography in Children: Technique and Potential Applications. Radiographics 2017; 37:1775-1790. [DOI: 10.1148/rg.2017170014] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Govind B. Chavhan
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Joao G. Amaral
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Michael Temple
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Maxim Itkin
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
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24
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Bargagli E, Piccioli C, Cavigli E, Scola M, Rosi E, Lavorini F, Novelli L, Ugolini D, Notaristefano T, Filippo P, Miele V, Comin CE, Pistolesi M, Voltolini L. Gorham-Stout Disease Management during Pregnancy. AJP Rep 2017; 7:e226-e229. [PMID: 29263942 PMCID: PMC5736391 DOI: 10.1055/s-0037-1615259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 09/12/2017] [Indexed: 10/31/2022] Open
Abstract
Gorham-Stout Disease (GSD) is a rare lymphatic disorder affecting children or young adults with no predilection of sex. It is generally associated with vanishing bone osteolytic lesions, thoracic and abdominal involvement, and diffuse pulmonary lymphangiomatosis. Chylous effusions and chylothorax, consequent to the abnormal proliferation of lymphatic vessels, may induce respiratory failure with a high mortality risk. Extrapulmonary alterations may include chylous ascites, lymphopenia, and destructing bone disease for overgrowth of lymphatic vessels. Here, we report the case of a young woman who developed a severe and recalcitrant GSD with persistent unilateral chylothorax during pregnancy. The complex management of this patient during and after pregnancy was discussed and compared with literature data to contribute to the definition of a correct diagnostic and therapeutic approach to this rare lymphatic disease.
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Affiliation(s)
- Elena Bargagli
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Caterina Piccioli
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Edoardo Cavigli
- Department of Radiodiagnostic and Emergency, Careggi University Hospital, Florence, Italy
| | - Marianna Scola
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Elisabetta Rosi
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Federico Lavorini
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Luca Novelli
- Department of Pathology, Careggi University Hospital, Florence, Italy
| | - Dario Ugolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | | | - Pieralli Filippo
- Subintentive Medicine Section, Careggi University Hospital, Florence, Italy
| | - Vittorio Miele
- Department of Radiodiagnostic and Emergency, Careggi University Hospital, Florence, Italy
| | - Camilla E Comin
- Department of Pathology, Careggi University Hospital, Florence, Italy
| | - Massimo Pistolesi
- Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
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25
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Blei F. Update June 2017. Lymphat Res Biol 2017. [DOI: 10.1089/lrb.2017.29024.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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26
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Blei F. Update September 2016. Lymphat Res Biol 2016. [DOI: 10.1089/lrb.2016.29012.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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