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Bernas M, Al-Ghadban S, Thiadens SRJ, Ashforth K, Lin WC, Safa B, Buntic R, Paukshto M, Rovnaya A, McNeely ML. Etiology and treatment of cancer-related secondary lymphedema. Clin Exp Metastasis 2024; 41:525-548. [PMID: 37777696 DOI: 10.1007/s10585-023-10232-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/28/2023] [Indexed: 10/02/2023]
Abstract
Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.
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Affiliation(s)
- Michael Bernas
- Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX, USA.
| | - Sara Al-Ghadban
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | | | - Karen Ashforth
- St. Joseph's Medical Center, University of the Pacific, Stockton, CA, USA
| | - Walter C Lin
- Buncke Clinic, San Francisco, CA, USA
- Department of Surgery, Saint Francis Memorial Hospital, San Francisco, CA, USA
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Dinnendahl R, Tschimmel D, Löw V, Cornely M, Hucho T. Non-obese lipedema patients show a distinctly altered quantitative sensory testing profile with high diagnostic potential. Pain Rep 2024; 9:e1155. [PMID: 38617100 PMCID: PMC11013692 DOI: 10.1097/pr9.0000000000001155] [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: 11/27/2023] [Revised: 01/26/2024] [Accepted: 02/20/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction and Objectives Lipedema is a widespread severe chronic disease affecting mostly women. Characterized by painful bilateral fat accumulation in extremities sparing hands and feet, objective measurement-based diagnosis is currently missing. We tested for characteristic psychometric and/or sensory alterations including pain and for their potential for medical routine diagnosis. Methods Pain psychometry was assessed using the German Pain Questionnaire. Sensory sensitivity toward painful and nonpainful stimuli was characterized in non-obese lipedema patients and matched controls using the validated quantitative sensory testing (QST) protocol of the German Research Network on Neuropathic Pain. Results Lipedema patients showed no overt psychometric abnormalities. Pain was reported as somatic rather than psychosomatic aversive. All QST measurements were normal, but the z-score of pressure pain thresholds (PPT) was twofold reduced and the z-score of vibration detection thresholds (VDT) was two and a half times increased. Both thresholds were selectively altered at the affected thigh but not the unaffected hand. Receiver operating characteristic analysis of the combination of PPT and VDT of thigh vs hand into a PVTH score (PPT, VDT, thigh, hand-score) shows high sensitivity and specificity, categorizing correctly 95.8% of the participants as lipedema patients or healthy controls. Bayesian inference analysis corroborated the diagnostic potential of such a combined PVTH score. Conclusion We propose to assess PPT and VDT at the painful thigh and the pain-free hand. Combination in a PVTH score may allow a convenient lipedema diagnosis early during disease development.
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Affiliation(s)
- Rebecca Dinnendahl
- Translational Pain Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Dominik Tschimmel
- Translational Pain Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Löw
- Pain Center, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Manuel Cornely
- CG Lympha GmbH, Cologne, Germany
- Ly.Search GmbH, Cologne, Germany
| | - Tim Hucho
- Translational Pain Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Pain Center, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
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3
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Alshomer F, Lee SJ, Kim Y, Hong DW, Pak CJ, Suh HP, Hong JP. Lipedema associated with Skin Hypoperfusion and Ulceration: Soft Tissue Debulking Improving Skin Perfusion. Arch Plast Surg 2024; 51:311-316. [PMID: 38737852 PMCID: PMC11081723 DOI: 10.1055/a-2181-8469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 09/19/2023] [Indexed: 05/14/2024] Open
Abstract
Lipedema is a progressive connective tissue disease with enlargement of adipose tissue, fibrosis, fluid collection, and dermal thickening. Herein, we present a case of lipedema associated with skin hypoperfusion and ulceration in which soft tissue debulking with liposuction improved patients' symptoms. A 39-year-old female presented with asymmetric progressive initially unilateral lower limb swelling with severe pain with subsequent skin ulceration. Conservative management failed to improve her condition. After excluding other causes and detailed radiologic investigation, lipedema was diagnosed with an associated impaired skin perfusion. Trial of local wound care and compression therapy failed to improve the condition. Subsequent soft tissue debulking with circumferential liposuction and ulcer debridement and immediate compression showed dramatic improvement of the symptoms and skin perfusion. The unique nature of this case sheds light on lipedema as a loose connective tissue disease. Inflammation and microangiopathies explain the associated pain with hypoperfusion and ulceration being quite atypical and in part might be related to the large buildups of matrix proteins and sodium contents leading to fragility in microvessels with frequent petechiae and hematoma and subsequent tissue ischemia. Conservative measures like compression therapy plays a significant role in disease course. Surgical debulking with liposuction was shown to be efficacious in reducing the soft tissue load with improvement in limb pain, edema, circumference, and skin perfusion that was seen in our patient. Lipedema is a frequently misdiagnosed condition with disabling features. Skin involvement in lipedema with potential hypoperfusion was shown and it requires further investigation.
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Affiliation(s)
- Feras Alshomer
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Seok Joon Lee
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Yeongsong Kim
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Dae Won Hong
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Republic of Korea
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Morgan S, Reid I, Bendon C, Ishaq M, Shayan R, Pope B, Park D, Karnezis T. A Family-Based Study of Inherited Genetic Risk in Lipedema. Lymphat Res Biol 2024; 22:106-111. [PMID: 38407896 PMCID: PMC11044871 DOI: 10.1089/lrb.2023.0065] [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: 02/27/2024] Open
Abstract
Background: Lipedema is a progressive condition involving excessive deposition of subcutaneous adipose tissue, predominantly in the lower limbs, which severely compromises quality of life. Despite the impact of lipedema, its molecular and genetic bases are poorly understood, making diagnosis and treatment difficult. Historical evaluation of individuals with lipedema indicates a positive family history in 60%-80% of cases; however, genetic investigation of larger family cohorts is required. Here, we report the largest family-based sequencing study to date, aimed at identifying genetic changes that contribute to lipedema. Methods and Results: DNA samples from 31 individuals from 9 lipedema families were analyzed to reveal genetic variants predicted to alter protein function, yielding candidate variants in 469 genes. We did not identify any individual genes that contained likely disease-causing variants across all participating families. However, gene ontology analysis highlighted vasopressin receptor activity, microfibril binding, and patched binding as statistically significantly overrepresented categories for the set of candidate variants. Conclusions: Our study suggests that lipedema is not caused by a single exomic genetic factor, providing support for the hypothesis of genetic heterogeneity in the etiology of lipedema. As the largest study of its kind in the lipedema field, the results advance our understanding of the disease and provide a roadmap for future research aimed at improving the lives of those affected by lipedema.
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Affiliation(s)
- Steven Morgan
- Lymphatic, Adipose and Regenerative Medicine Group, Department of O'Brien Institute, St Vincent's Institute of Medical Research, Fitzroy, Australia
| | - Isabella Reid
- Lymphatic, Adipose and Regenerative Medicine Group, Department of O'Brien Institute, St Vincent's Institute of Medical Research, Fitzroy, Australia
| | - Charlotte Bendon
- Department of Plastic and Reconstructive Surgery, West Wing, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| | - Musarat Ishaq
- Lymphatic, Adipose and Regenerative Medicine Group, Department of O'Brien Institute, St Vincent's Institute of Medical Research, Fitzroy, Australia
| | - Ramin Shayan
- Lymphatic, Adipose and Regenerative Medicine Group, Department of O'Brien Institute, St Vincent's Institute of Medical Research, Fitzroy, Australia
- Department of Medicine, St Vincent's Hospital, Fitzroy, Australia
| | - Bernard Pope
- Melbourne Bioinformatics, The University of Melbourne, Parkville, Australia
- Department of Surgery (Royal Melbourne Hospital), The University of Melbourne, Parkville, Australia
- Department of Clinical Pathology, The University of Melbourne, Parkville, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Daniel Park
- Melbourne Bioinformatics, The University of Melbourne, Parkville, Australia
- Department of Biochemistry and Pharmacology, The University of Melbourne, Parkville, Australia
| | - Tara Karnezis
- Lymphatic, Adipose and Regenerative Medicine Group, Department of O'Brien Institute, St Vincent's Institute of Medical Research, Fitzroy, Australia
- Department of Medicine, St Vincent's Hospital, Fitzroy, Australia
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Funke S, Kuhlmann C, Taha S, Fuchs B, Wiggenhauser PS, Giunta RE. [Searching for Evidence: A Systematic Review of the Pathology of Lipoedema]. HANDCHIR MIKROCHIR P 2023; 55:411-426. [PMID: 37984363 DOI: 10.1055/a-2183-7414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Lipoedema is a symmetrically localised, painful hypertrophy of subcutaneous adipose tissue in the extremities with marked disproportion to the trunk, and almost exclusively affects females. Despite being first described over 80 years ago, the aetiology and pathogenesis of the disease are largely unknown and are currently the subject of intensive research efforts. METHODS To summarise the current evidence-based literature on the cellular pathologies and aetiology of lipoedema, a PRISMA-based systematic review was conducted within the National Library of Medicine and Cochrane databases. RESULTS A total of 53 studies were identified and included in this review. The results were classified and summarised into categories. CONCLUSION Although there has been a significant increase in research activity and recent publication of extensive studies with a histological and molecular genetic focus, the fundamental aetiology and pathology of lipoedema remains largely unclear. The current data shows discrepancies across studies, particularly with regard to the "oedematous" component of lipoedema. The frequently present comorbidities "lymphoedema" and "obesity", primarily in advanced stages of lipoedema, complicate the diagnostic differentiation and clear definition of study cohorts in scientific research.
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Affiliation(s)
- Sarah Funke
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - Constanze Kuhlmann
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - Sara Taha
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - Benedikt Fuchs
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - Paul Severin Wiggenhauser
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - Riccardo E Giunta
- Abteilung für Handchirurgie, Plastische und Ästhetische Chirurgie, LMU-Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
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Chachaj A, Dudka I, Jeziorek M, Sowicz M, Adaszyńska A, Szuba A. Lymphoscintigraphic alterations in lower limbs in women with lipedema in comparison to women with overweight/obesity. Front Physiol 2023; 14:1099555. [PMID: 37101701 PMCID: PMC10123278 DOI: 10.3389/fphys.2023.1099555] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
Introduction: Lipedema is a bilateral enlargement of the legs due to abnormal depositions of subcutaneous fat. Recent studies using lymphoscintigraphy documented that lipedema associates with lymphatic alterations. It is still not known, whether non-lipedema obesity also leads to similar lymphoscintigraphic changes within lower legs. Clinically, both, lipedema and obesity may progress to secondary lymphedema. The aim of the study was to evaluate lymphoscintigraphy of lower limbs in women with lipedema in comparison to overweight/obese women. Methods: 51 women (in the mean age of 43.3 ± 13.56) with the diagnosis of lipedema and 31 women (in the mean age of 44.7 ± 13.48) with overweight/obesity were enrolled into the study. Women in both study groups had no clinical signs of lymphedema. The groups were matched by mean volume of their legs, calculated using the formula for a truncated cone. Lymphoscintigraphy was evaluated in every women qualitatively. Body composition parameters were assessed using bioelectric impedance analysis (BIA). Results: Lymphoscintigraphic alterations within lower extremities were similar in both, lipedema and overweight/obese groups and were present in majority of women in both study groups. The most common lymphoscintigraphic alteration in both groups were additional lymphatic vessels (in the lipedema group observed in 76.5% of patients and in the overweight/obesity group - in 93.5%). Visualization of popliteal lymph nodes and dermal backflow were observed respectively in 33% and in 5.9% in the group with lipedema and in 45.2% and in 9.7% in the overweight/obesity group. There were significant relationships between severity of lymphoscintigraphic alterations and weight, lean body mass (LBM), total body water (TBW), volume of both legs and thigh circumference in the lipedema group. Such relationships were absent in the overweight/obesity group. Discussion: Our study indicates that lymphatic alterations are present before development to clinically visible secondary lymphedema in both conditions, lipedema and overweight/obesity. In majority of women from both study groups they indicate rather an overload of the lymphatic system than insufficiency. Lymphoscintigraphic alterations are similar in both groups, therefore, lymphoscintigraphy is not a diagnostic tool that might distinguish lipedema from overweight/obesity.
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Affiliation(s)
- Angelika Chachaj
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Angelika Chachaj,
| | - Ilona Dudka
- Department of Chemistry, Umeå University, Umeå, Sweden
| | - Małgorzata Jeziorek
- Department of Dietetics and Bromatology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Monika Sowicz
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Adaszyńska
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
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Next-Generation Sequencing of a Large Gene Panel for Outcome Prediction of Bariatric Surgery in Patients with Severe Obesity. J Clin Med 2022; 11:jcm11247531. [PMID: 36556146 PMCID: PMC9783894 DOI: 10.3390/jcm11247531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Obesity is a chronic disease in which abnormal deposition of fat threatens health, leading to diabetes, cardiovascular diseases, cancer, and other chronic illnesses. According to the WHO, 19.8% of the adult population in Italy is obese, and the prevalence is higher among men. It is important to know the predisposition of an individual to become obese and to respond to bariatric surgery, the most up-to-date treatment for severe obesity. To this purpose, we developed an NGS gene panel, comprising 72 diagnostic genes and 244 candidate genes, and we sequenced 247 adult obese Italian patients. Eleven deleterious variants in 9 diagnostic genes and 17 deleterious variants in 11 candidate genes were identified. Interestingly, mutations were found in several genes correlated to the Bardet-Biedl syndrome. Then, 25 patients were clinically followed to evaluate their response to bariatric surgery. After a 12-month follow-up, the patients that carried deleterious variants in diagnostic or candidate genes had a reduced weight loss, as compared to the other patients. The NGS-based panel, including diagnostic and candidate genes used in this study, could play a role in evaluating, diagnosing, and managing obese individuals, and may help in predicting the outcome of bariatric surgery.
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Poojari A, Dev K, Rabiee A. Lipedema: Insights into Morphology, Pathophysiology, and Challenges. Biomedicines 2022; 10:biomedicines10123081. [PMID: 36551837 PMCID: PMC9775665 DOI: 10.3390/biomedicines10123081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022] Open
Abstract
Lipedema is an adipofascial disorder that almost exclusively affects women. Lipedema leads to chronic pain, swelling, and other discomforts due to the bilateral and asymmetrical expansion of subcutaneous adipose tissue. Although various distinctive morphological characteristics, such as the hyperproliferation of fat cells, fibrosis, and inflammation, have been characterized in the progression of lipedema, the mechanisms underlying these changes have not yet been fully investigated. In addition, it is challenging to reduce the excessive fat in lipedema patients using conventional weight-loss techniques, such as lifestyle (diet and exercise) changes, bariatric surgery, and pharmacological interventions. Therefore, lipedema patients also go through additional psychosocial distress in the absence of permanent treatment. Research to understand the pathology of lipedema is still in its infancy, but promising markers derived from exosome, cytokine, lipidomic, and metabolomic profiling studies suggest a condition distinct from obesity and lymphedema. Although genetics seems to be a substantial cause of lipedema, due to the small number of patients involved in such studies, the extrapolation of data at a broader scale is challenging. With the current lack of etiology-guided treatments for lipedema, the discovery of new promising biomarkers could provide potential solutions to combat this complex disease. This review aims to address the morphological phenotype of lipedema fat, as well as its unclear pathophysiology, with a primary emphasis on excessive interstitial fluid, extracellular matrix remodeling, and lymphatic and vasculature dysfunction. The potential mechanisms, genetic implications, and proposed biomarkers for lipedema are further discussed in detail. Finally, we mention the challenges related to lipedema and emphasize the prospects of technological interventions to benefit the lipedema community in the future.
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Duhon BH, Phan TT, Taylor SL, Crescenzi RL, Rutkowski JM. Current Mechanistic Understandings of Lymphedema and Lipedema: Tales of Fluid, Fat, and Fibrosis. Int J Mol Sci 2022; 23:6621. [PMID: 35743063 PMCID: PMC9223758 DOI: 10.3390/ijms23126621] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022] Open
Abstract
Lymphedema and lipedema are complex diseases. While the external presentation of swollen legs in lower-extremity lymphedema and lipedema appear similar, current mechanistic understandings of these diseases indicate unique aspects of their underlying pathophysiology. They share certain clinical features, such as fluid (edema), fat (adipose expansion), and fibrosis (extracellular matrix remodeling). Yet, these diverge on their time course and known molecular regulators of pathophysiology and genetics. This divergence likely indicates a unique route leading to interstitial fluid accumulation and subsequent inflammation in lymphedema versus lipedema. Identifying disease mechanisms that are causal and which are merely indicative of the condition is far more explored in lymphedema than in lipedema. In primary lymphedema, discoveries of genetic mutations link molecular markers to mechanisms of lymphatic disease. Much work remains in this area towards better risk assessment of secondary lymphedema and the hopeful discovery of validated genetic diagnostics for lipedema. The purpose of this review is to expose the distinct and shared (i) clinical criteria and symptomatology, (ii) molecular regulators and pathophysiology, and (iii) genetic markers of lymphedema and lipedema to help inform future research in this field.
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Affiliation(s)
- Bailey H. Duhon
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
| | - Thien T. Phan
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
| | - Shannon L. Taylor
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN 37232, USA;
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachelle L. Crescenzi
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN 37232, USA;
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Joseph M. Rutkowski
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
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Michelini S, Herbst KL, Precone V, Manara E, Marceddu G, Dautaj A, Maltese PE, Paolacci S, Ceccarini MR, Beccari T, Sorrentino E, Aquilanti B, Velluti V, Matera G, Gagliardi L, Miggiano GAD, Bertelli M. A Multi-Gene Panel to Identify Lipedema-Predisposing Genetic Variants by a Next-Generation Sequencing Strategy. J Pers Med 2022; 12:268. [PMID: 35207755 PMCID: PMC8877075 DOI: 10.3390/jpm12020268] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/25/2022] Open
Abstract
Lipedema is a disabling disease characterized by symmetric enlargement of the lower and/or upper limbs due to deposits of subcutaneous fat, that is easily misdiagnosed. Lipedema can be primary or syndromic, and can be the main feature of phenotypically overlapping disorders. The aim of this study was to design a next-generation sequencing (NGS) panel to help in the diagnosis of lipedema by identifying genes specific for lipedema but also genes for overlapping diseases, and targets for tailored treatments. We developed an NGS gene panel consisting of 305 genes potentially associated with lipedema and putative overlapping diseases relevant to lipedema. The genomes of 162 Italian and American patients with lipedema were sequenced. Twenty-one deleterious variants, according to 3 out of 5 predictors, were detected in PLIN1, LIPE, ALDH18A1, PPARG, GHR, INSR, RYR1, NPC1, POMC, NR0B2, GCKR, PPARA in 17 patients. This extended NGS-based approach has identified a number of gene variants that may be important in the diagnosis of lipedema, that may affect the phenotypic presentation of lipedema or that may cause disorders that could be confused with lipedema. This tool may be important for the diagnosis and treatment of people with pathologic subcutaneous fat tissue accumulation.
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Affiliation(s)
- Sandro Michelini
- Vascular Diagnostics and Rehabilitation Service, Marino Hospital, ASL Roma 6, 00047 Marino, Italy;
| | - Karen L. Herbst
- Department of Endocrinology and Research, Total Lipedema Care, Los Angeles, CA 90211, USA;
| | - Vincenza Precone
- MAGI EUREGIO, 39100 Bolzano, Italy; (V.P.); (G.M.); (E.S.); (M.B.)
| | - Elena Manara
- MAGI’S LAB, 38068 Rovereto, Italy; (E.M.); (A.D.); (P.E.M.)
| | | | - Astrit Dautaj
- MAGI’S LAB, 38068 Rovereto, Italy; (E.M.); (A.D.); (P.E.M.)
| | | | | | - Maria Rachele Ceccarini
- Department of Pharmaceutical Sciences, University of Perugia, 06123 Perugia, Italy; (M.R.C.); (T.B.)
- C.I.B., Consorzio Interuniversitario per le Biotecnologie, 34148 Trieste, Italy
| | - Tommaso Beccari
- Department of Pharmaceutical Sciences, University of Perugia, 06123 Perugia, Italy; (M.R.C.); (T.B.)
- C.I.B., Consorzio Interuniversitario per le Biotecnologie, 34148 Trieste, Italy
| | - Elisa Sorrentino
- MAGI EUREGIO, 39100 Bolzano, Italy; (V.P.); (G.M.); (E.S.); (M.B.)
| | - Barbara Aquilanti
- UOC Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (B.A.); (V.V.); (G.M.); (L.G.); (G.A.D.M.)
| | - Valeria Velluti
- UOC Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (B.A.); (V.V.); (G.M.); (L.G.); (G.A.D.M.)
| | - Giuseppina Matera
- UOC Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (B.A.); (V.V.); (G.M.); (L.G.); (G.A.D.M.)
| | - Lucilla Gagliardi
- UOC Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (B.A.); (V.V.); (G.M.); (L.G.); (G.A.D.M.)
| | - Giacinto Abele Donato Miggiano
- UOC Nutrizione Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (B.A.); (V.V.); (G.M.); (L.G.); (G.A.D.M.)
| | - Matteo Bertelli
- MAGI EUREGIO, 39100 Bolzano, Italy; (V.P.); (G.M.); (E.S.); (M.B.)
- MAGI’S LAB, 38068 Rovereto, Italy; (E.M.); (A.D.); (P.E.M.)
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Jadhav S, Diwaker C, Lila AR, Gada JV, Kale S, Sarathi V, Thadani PM, Arya S, Patil VA, Shah NS, Bandgar TR. POU1F1 mutations in combined pituitary hormone deficiency: differing spectrum of mutations in a Western-Indian cohort and systematic analysis of world literature. Pituitary 2021; 24:657-669. [PMID: 33742319 DOI: 10.1007/s11102-021-01140-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT POU1F1 mutations are prevalent in Indian CPHD cohorts. Genotype-phenotype correlation is not well-studied. AIM To describe phenotypic and genotypic spectrum of POU1F1 mutations in our CPHD cohort and present systematic review as well as genotype-phenotype analysis of all mutation-positive cases reported in world literature. METHODS Retrospective study of POU1F1 mutation-positive patients from a western-Indian center. PRISMA guidelines based pubmed search of published literature of all mutation-positive patients. RESULTS Our cohort had 15 POU1F1 mutation-positive patients (9 index, 6 relatives). All had severe GH, TSH and prolactin deficiencies (GHD, TSHD and PD). TSHD was diagnosed earliest followed by GHD (median ages: TSHD-6 months, GHD-3 years), while PD was more variable. Two sisters had central precocious puberty at 7 years of age. Pubic hair was deficient in all post-pubertal patients (females: P1-P2, males: P3-P4). Splice-site/intronic/frameshift mutations were most common, while missense/nonsense mutations were less frequent (33%). Review of world literature yielded 114 patients (82 index patients) from 58 studies. GHD was present in all patients. TSHD was spared in 12.5% and PD in 4.4% patients. Missense/nonsense mutations accounted for 75% of spectrum. Phenotype-genotype analysis revealed higher mean peak-GH levels (1.1 vs 0.2 ng/ml, p = 0.008) and lower prevalence of anterior-pituitary hypoplasia (63.6% vs 86.3%, p = 0.03) in patients with heterozygous than homozygous and compound heterozygous mutations. CONCLUSIONS We present largest series of POU1F1 mutation-positive patients. Precocious puberty and defective pubarche are lesser-appreciated phenotypic features. Our mutation spectrum is different from that of world literature. Patients with heterozygous mutations have milder phenotype.
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Affiliation(s)
- Swati Jadhav
- Department of Endocrinology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
| | - Chakra Diwaker
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Anurag R Lila
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India.
| | - Jugal V Gada
- Department of Endocrinology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Shantanu Kale
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
| | - Puja M Thadani
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Sneha Arya
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Virendra A Patil
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Nalini S Shah
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
| | - Tushar R Bandgar
- Department of Endocrinology, IndiaSeth G.S. Medical College & KEM Hospital, Parel, Mumbai, Maharashtra, 400012, India
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Vaquero Ramiro E, Gutiérrez Retortillo M, Goiri Noguera D, Morello Ostos P, Solera-Martínez M. [Diagnosis and treatment of lipedema in Spain. Results of an online survey]. Rehabilitacion (Madr) 2021; 56:108-115. [PMID: 33461763 DOI: 10.1016/j.rh.2020.12.001] [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: 08/20/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Lipedema is a chronic and progressive disease. Most studies agree that it is underdiagnosed and undertreated. The aim of this study was to identify the diagnostic characteristics and types of treatment for lipedema in the Spanish population. MATERIAL AND METHODS A cross-sectional descriptive study was carried out through an anonymous 10-item online survey in November- December 2019. The minimum sample size was calculated for a 95% confidence level and 5% margin of error. Information was collected on sociodemographic variables (age, sex, place of residence), diagnostic characteristics and perceived improvement with distinct treatment options. RESULTS A total of 463 valid responses were obtained. The mean age at first manifestation was 18.2 (SD: 9.0) years. Onset occurred between the ages of 10 and 19 years in 69% of the patients. It took an average of 19.9 (SD: 10.1) years to receive a diagnosis and 4.9 medical visits. Diagnosis was most frequently made in private clinics by surgeons. Most patients (78.4%) had tried at least three different types of treatment. Weight loss was the most frequent treatment (92%) and compression garments were perceived to be the most effective. Only 34% of respondents had access to financing for compression garments. CONCLUSIONS Currently, there is no standard treatment for lipedema and patients perceive current treatments to be unsatisfactory. Better knowledge of this entity is needed to allow early diagnosis and provide adequate treatment.
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Affiliation(s)
- E Vaquero Ramiro
- Servicio Medicina Física y Rehabilitación, Hospital Virgen de la Luz, Cuenca,España.
| | | | - D Goiri Noguera
- Servicio Medicina Física y Rehabilitación, Hospital Virgen de la Luz, Cuenca,España
| | - P Morello Ostos
- Servicio Medicina Física y Rehabilitación, Hospital Virgen de la Luz, Cuenca,España
| | - M Solera-Martínez
- Centro de Estudios Sociosanitarios, Facultad de Enfermería de Cuenca, Universidad de Castilla-La Mancha, Cuenca, España
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Michelini S, Chiurazzi P, Marino V, Dell’Orco D, Manara E, Baglivo M, Fiorentino A, Maltese PE, Pinelli M, Herbst KL, Dautaj A, Bertelli M. Aldo-Keto Reductase 1C1 ( AKR1C1) as the First Mutated Gene in a Family with Nonsyndromic Primary Lipedema. Int J Mol Sci 2020; 21:ijms21176264. [PMID: 32872468 PMCID: PMC7503355 DOI: 10.3390/ijms21176264] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022] Open
Abstract
Lipedema is an often underdiagnosed chronic disorder that affects subcutaneous adipose tissue almost exclusively in women, which leads to disproportionate fat accumulation in the lower and upper body extremities. Common comorbidities include anxiety, depression, and pain. The correlation between mood disorder and subcutaneous fat deposition suggests the involvement of steroids metabolism and neurohormones signaling, however no clear association has been established so far. In this study, we report on a family with three patients affected by sex-limited autosomal dominant nonsyndromic lipedema. They had been screened by whole exome sequencing (WES) which led to the discovery of a missense variant p.(Leu213Gln) in AKR1C1, the gene encoding for an aldo-keto reductase catalyzing the reduction of progesterone to its inactive form, 20-α-hydroxyprogesterone. Comparative molecular dynamics simulations of the wild-type vs. variant enzyme, corroborated by a thorough structural and functional bioinformatic analysis, suggest a partial loss-of-function of the variant. This would result in a slower and less efficient reduction of progesterone to hydroxyprogesterone and an increased subcutaneous fat deposition in variant carriers. Overall, our results suggest that AKR1C1 is the first candidate gene associated with nonsyndromic lipedema.
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Affiliation(s)
- Sandro Michelini
- Dipartimento di Riabilitazione, Ospedale San Giovanni Battista, A.C.I.S.M.O.M., 00148 Rome, Italy; (S.M.); (A.F.)
| | - Pietro Chiurazzi
- Istituto di Medicina Genomica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Fondazione Policlinico Universitario “A.Gemelli” IRCCS, UOC Genetica Medica, 00168 Rome, Italy
| | - Valerio Marino
- Dipartimento di Neuroscienze, Biomedicina e Movimento, Sezione di Chimica Biologica, Università di Verona, 37134 Verona, Italy; (V.M.); (D.D.)
| | - Daniele Dell’Orco
- Dipartimento di Neuroscienze, Biomedicina e Movimento, Sezione di Chimica Biologica, Università di Verona, 37134 Verona, Italy; (V.M.); (D.D.)
| | - Elena Manara
- MAGI Euregio, 39100 Bolzano, Italy; (E.M.); (M.B.)
| | | | - Alessandro Fiorentino
- Dipartimento di Riabilitazione, Ospedale San Giovanni Battista, A.C.I.S.M.O.M., 00148 Rome, Italy; (S.M.); (A.F.)
| | | | - Michele Pinelli
- Dipartimento di Scienze Mediche Traslazionali, Sezione di Pediatria, Università di Napoli Federico II, 80131 Naples, Italy;
- Telethon Institute of Genetics and Medicine (TIGEM), 80078 Pozzuoli, Italy
| | - Karen Louise Herbst
- Departments of Medicine, Pharmacy, Medical Imaging, Division of Endocrinology, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Matteo Bertelli
- MAGI Euregio, 39100 Bolzano, Italy; (E.M.); (M.B.)
- EBTNA-Lab, 38068 Rovereto, Italy;
- Correspondence:
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Buso G, Depairon M, Tomson D, Raffoul W, Vettor R, Mazzolai L. Lipedema: A Call to Action! Obesity (Silver Spring) 2019; 27:1567-1576. [PMID: 31544340 PMCID: PMC6790573 DOI: 10.1002/oby.22597] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/30/2019] [Indexed: 01/31/2023]
Abstract
Lipedema is a chronic progressive disease characterized by abnormal fat distribution resulting in disproportionate, painful limbs. It almost exclusively affects women, leading to considerable disability, daily functioning impairment, and psychosocial distress. Literature shows both scarce and conflicting data regarding its prevalence. Lipedema has been considered a rare entity by several authors, though it may be a far more frequent condition than thought. Despite the clinical impact on women's health, lipedema is in fact mostly unknown, underdiagnosed, and too often misdiagnosed with other similarly presenting diseases. Polygenic susceptibility combined with hormonal, microvascular, and lymphatic disorders may be partly responsible for its development. Furthermore, consistent information on lipedema pathophysiology is still lacking, and an etiological treatment is not yet available. Weight loss measures exhibit minimal effect on the abnormal body fat distribution, resulting in eating disorders, increased obesity risk, depression, and other psychological complaints. Surgical techniques, such as liposuction and excisional lipectomy, represent therapeutic options in selected cases. This review aims to outline current evidence regarding lipedema epidemiology, pathophysiology, clinical presentation, differential diagnosis, and management. Increased awareness and a better understanding of its clinical presentation and pathophysiology are warranted to enable clinicians to diagnose and treat affected patients at an earlier stage.
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Affiliation(s)
- Giacomo Buso
- Angiology Division, Heart and Vessel DepartmentLausanne University HospitalLausanneSwitzerland
| | - Michele Depairon
- Angiology Division, Heart and Vessel DepartmentLausanne University HospitalLausanneSwitzerland
| | - Didier Tomson
- Angiology Division, Heart and Vessel DepartmentLausanne University HospitalLausanneSwitzerland
| | - Wassim Raffoul
- Plastic Surgery Division, Locomotor System DepartmentLausanne University HospitalLausanneSwitzerland
| | - Roberto Vettor
- Department of Medicine, Center for the Study and the Integrated Management of Obesity (EASO COM)Padova University HospitalPadovaItaly
| | - Lucia Mazzolai
- Angiology Division, Heart and Vessel DepartmentLausanne University HospitalLausanneSwitzerland
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Abstract
Background Lipedema is a chronic disorder presenting in women during puberty or other times of hormonal change such as childbirth or menopause, characterized by symmetric enlargement of nodular, painful subcutaneous adipose tissue (fat) in the limbs, sparing the hands, feet and trunk. Healthcare providers underdiagnose or misdiagnose lipedema as obesity or lymphedema. Materials and methods The benefits (friend) and negative aspects (foe) of lipedema were collected from published literature, discussions with women with lipedema, and institutional review board approved evaluation of medical charts of 46 women with lipedema. Results Lipedema is a foe because lifestyle change does not reduce lipedema fat, the fat is painful, can become obese, causes gait and joint abnormalities, fatigue, lymphedema and psychosocial distress. Hypermobility associated with lipedema can exacerbate joint disease and aortic disease. In contrast, lipedema fat can be a friend as it is associated with relative reductions in obesity-related metabolic dysfunction. In new data collected, lipedema was associated with a low risk of diabetes (2%), dyslipidemia (11.7%) and hypertension (13%) despite an obese average body mass index (BMI) of 35.3 ± 1.7 kg/m2. Conclusion Lipedema is a painful psychologically distressing fat disorder, more foe than friend especially due to associated obesity and lymphedema. More controlled studies are needed to study the mechanisms and treatments for lipedema.
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Affiliation(s)
| | - Rita Wadeea
- TREAT Program, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Victoria Rosas
- Department of Biological Sciences, University of Texas at El Paso, El Paso, TX, USA
| | - Karen L Herbst
- TREAT Program, College of Medicine, University of Arizona, Tucson, AZ, USA
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Herbst KL, Ussery C, Eekema A. Pilot study: whole body manual subcutaneous adipose tissue (SAT) therapy improved pain and SAT structure in women with lipedema. Horm Mol Biol Clin Investig 2017; 33:/j/hmbci.ahead-of-print/hmbci-2017-0035/hmbci-2017-0035.xml. [PMID: 28930626 DOI: 10.1515/hmbci-2017-0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/23/2017] [Indexed: 11/15/2022]
Abstract
Background Lipedema is a common painful subcutaneous adipose tissue (SAT) disorder in women affecting the limbs. SAT therapy is a manual therapy to improve soft tissue quality. Objective Determine if SAT therapy improves pain and structure of lipedema SAT. Design Single arm prospective pilot study. Setting Academic medical center. Patients Seven women, 46 ± 5 years, weight 90 ± 19 kg, with lipedema. Intervention Twelve 90-min SAT therapy sessions over 4 weeks. Outcomes Dual X-ray absorptiometry (DXA) scans, SAT ultrasound (Vevo 2100), leg volumetrics, skin caliper assessment, tissue exam, weight, resting metabolic rate, pain assessment, lower extremity functional scale (LEFS) and body shape questionnaire (BSQ) at baseline and end of study. Results Weight, resting metabolic rate and BSQ did not change significantly. Limb fat over total body fat mass (p = 0.08) and trunk fat over total body mass trended down from baseline (p = 0.08) by DXA. Leg volume and caliper assessments in eight of nine areas (p < 0.007), LEFS (p = 0.002) and average pain (p = 0.007) significantly decreased from baseline. Fibrosis significantly decreased in the nodules, hips and groin. Ultrasound showed improved SAT structure in some subjects. Side effects included pain, bruising, itching, swelling and gastroesophageal reflux disease. All women said they would recommend SAT therapy to other women with lipedema. Limitations Small number of subjects. Conclusion SAT therapy in 4 weeks improved tissue structure, perceived leg function, and volume although shape was not affected. While side effects of SAT therapy were common, all women felt the therapy was beneficial.
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Affiliation(s)
- Karen L Herbst
- College of Medicine, College of Pharmacy, Department of Medical Imaging, University of Arizona, Tucson, AZ 85714, USA
| | | | - Alyna Eekema
- Quadrivas Clinic and Academy, 1054 AK Amsterdam, The Netherlands
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Szél E, Kemény L, Groma G, Szolnoky G. Pathophysiological dilemmas of lipedema. Med Hypotheses 2014; 83:599-606. [DOI: 10.1016/j.mehy.2014.08.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 08/01/2014] [Accepted: 08/11/2014] [Indexed: 12/31/2022]
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Forner-Cordero I, Szolnoky G, Forner-Cordero A, Kemény L. Lipedema: an overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome - systematic review. Clin Obes 2012; 2:86-95. [PMID: 25586162 DOI: 10.1111/j.1758-8111.2012.00045.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 05/20/2012] [Accepted: 06/14/2012] [Indexed: 11/29/2022]
Abstract
Lipedema is a disproportionate, symmetrical fatty swelling characterized by pain and bruising existing almost exclusively among women. We undertook a systematic review of the available literature about lipedema, given the lack of knowledge and little evidence about this disorder especially among obesity experts. Diagnosis of lipedema is usually based on clinical features. Symmetrical edema in the lower limbs with fatty deposits located to hips and thighs usually appears at puberty and often affects several members of the same family. Main disorders considered for differential diagnosis are lymphedema, obesity, lipohypertrophy and phlebedema. Treatment protocols comprise conservative (decongestive lymphatic therapy) and surgical (liposuction) approaches. Early diagnosis and treatment are mandatory for this disorder otherwise gradual enlargement of fatty deposition causes impaired mobility and further comorbidities like arthrosis and lymphatic insufficiency.
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Affiliation(s)
- I Forner-Cordero
- Lymphedema Unit, Rehabilitation Department. University Hospital La Fe, Valencia, Spain
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