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Spörlein A, Hirche C, Berner JE, Kneser U, Will PA. Characterization of Immune Cell Infiltration and Collagen Type III Disorganization in Human Secondary Lymphedema: A Case-control Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5906. [PMID: 38911579 PMCID: PMC11191027 DOI: 10.1097/gox.0000000000005906] [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: 11/22/2023] [Accepted: 04/17/2024] [Indexed: 06/25/2024]
Abstract
Background Secondary lymphedema (SL) affects 120 million people globally, posing a lifelong burden for up to 37% of cancer survivors. Chronic inflammation and progressive fibrosis are key drivers of SL, yet detailed characterization of immune cell subpopulations across lymphedema stages is lacking. This study aimed to investigate the immunologic profile of lymphedematous skin and its association with extracellular matrix changes, which could serve as clinical biomarkers or therapeutic targets. Methods This case-control study analyzed the skin from 36 patients with and without SL, using immunofluorescence to quantify T cells, B cells, macrophages, and their subpopulations. Collagen quantity and composition were examined using picrosirius red staining, and mast cell infiltration was assessed with toluidine blue staining. Early and late SL stages were compared to identify histomorphological and immunologic correlates of stage progression. Results We found a predominance of CD4+ T cells and mast cells in SL skin (1.4/mm² versus 1.0/mm², P < 0.01; 1.2/mm² versus 0.2/mm², P < 0.0001) and a higher ratio of collagen III to collagen I fibers (51.6% versus 75.0%, P < 0.001). M2 macrophages were more abundant in late-stage than in early-stage lymphedema (1.7/mm² versus 1.0/mm², P = 0.02). Conclusions This study demonstrated a shift toward CD4+ T cell and mast cell infiltration in SL skin, correlating with extracellular matrix disorganization and an altered collagen III/I ratio. These findings enhance our understanding of the cellular and morphological changes in SL, potentially guiding future diagnostic and therapeutic strategies.
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Affiliation(s)
- Andreas Spörlein
- From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen am Rhein, Germany
- Department of Otorhinolaryngology—Head and Neck Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Hirche
- From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen am Rhein, Germany
- Department of Plastic, Hand, and Reconstructive Microsurgery, BG Unfallklinik Frankfurt am Main, Affiliated Hospital of Goethe-University, Frankfurt am Main, Germany
| | - Juan Enrique Berner
- Department of Plastic Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
- Kellogg College, University of Oxford, Oxford, United Kingdom
| | - Ulrich Kneser
- From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen am Rhein, Germany
| | - Patrick A. Will
- From the Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen am Rhein, Germany
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU University Dresden, Dresden, Germany
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Li X, Li B, Hao K, Liu M, Guo J, Zhang Y, Hao Q, Zhang Y, Sun X, Wang R. Value of the short time inversion recovery sequence of magnetic resonance imaging in the staging of Klippel-Trenaunay syndrome complicated with lymphedema. J Vasc Surg Venous Lymphat Disord 2024; 12:101746. [PMID: 38158121 DOI: 10.1016/j.jvsv.2023.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Currently, the focus on limb lymphedema (LE) is on classification and staging. However, few scholars have conducted staging for Klippel-Trenaunay syndrome complicated LE (KTS-LE). This study aimed to investigate the value of the short time inversion recovery sequence of magnetic resonance imaging (MRI) in the staging of KTS-LE. METHODS Forty-six patients who were diagnosed with KTS-LE were recruited for this retrospective study from July 2011 to November 2022. Referring to the clinical staging standard of lower extremity LE of the International Society of Lymphology in 2020, all patients were divided into three groups: stages I, II, and III. The MRI indicators of the three groups were recorded and statistically compared: LE range (unilateral bilateral, lower limbs, only thighs, only calves and ankles), abnormal parts (skin thickening, abnormal subcutaneous fat signal, abnormal muscle signal, muscle hypertrophy or contraction, abnormal bone signal, hyperostosis), and subcutaneous soft tissue signs (parallel line sign, grid sign, band sign, honeycomb sign, lymph lake sign, crescent sign, and nebula sign). RESULTS There was a significant difference in the honeycomb sign among the three periods (P = .028). There was a significant difference between stage II and stage I disease (P < .05). There was a significant difference between stage II and stage III disease (P < .05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the honeycomb sign in diagnosing KTS-LE of stage II were 87.5%, 63.2%, 33.3%, 96.0%, and 67.4%, respectively. In contrast, the other signs were not statistically significant among the three periods. CONCLUSIONS The short time inversion recovery sequence of MRI is of great value in KTS-LE. The honeycomb sign is an important imaging indicator for the diagnosis of stage II disease. It is necessary to evaluate the severity of edema with MRI for KTS-LE, which is very important for therapeutic options.
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Affiliation(s)
- Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Bin Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Jia Guo
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Yimeng Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Qi Hao
- Department Of Radiology, People's Hospital Of Peking University, The Second School Of Clinical Medicine Of Peking University, Beijing, Pr China
| | - Yan Zhang
- Department Of Radiology, Qilu Hospital, Shandong University, Shandong, Pr China
| | - Xiaoli Sun
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, Pr China.
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Goudarzi S, Whyte J, Boily M, Towers A, Kilgour RD, Rivaz H. Segmentation of Arm Ultrasound Images in Breast Cancer-Related Lymphedema: A Database and Deep Learning Algorithm. IEEE Trans Biomed Eng 2023; 70:2552-2563. [PMID: 37028332 DOI: 10.1109/tbme.2023.3253646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE Breast cancer treatment often causes the removal of or damage to lymph nodes of the patient's lymphatic drainage system. This side effect is the origin of Breast Cancer-Related Lymphedema (BCRL), referring to a noticeable increase in excess arm volume. Ultrasound imaging is a preferred modality for the diagnosis and progression monitoring of BCRL because of its low cost, safety, and portability. As the affected and unaffected arms look similar in B-mode ultrasound images, the thickness of the skin, subcutaneous fat, and muscle have been shown to be important biomarkers for this task. The segmentation masks are also helpful in monitoring the longitudinal changes in morphology and mechanical properties of tissue layers. METHODS For the first time, a publicly available ultrasound dataset containing the Radio-Frequency (RF) data of 39 subjects and manual segmentation masks by two experts, are provided. Inter- and intra-observer reproducibility studies performed on the segmentation maps show a high Dice Score Coefficient (DSC) of 0.94±0.08 and 0.92±0.06, respectively. Gated Shape Convolutional Neural Network (GSCNN) is modified for precise automatic segmentation of tissue layers, and its generalization performance is improved by the CutMix augmentation strategy. RESULTS We got an average DSC of 0.87±0.11 on the test set, which confirms the high performance of the method. CONCLUSION Automatic segmentation can pave the way for convenient and accessible staging of BCRL, and our dataset can facilitate development and validation of those methods. SIGNIFICANCE Timely diagnosis and treatment of BCRL have crucial importance in preventing irreversible damage.
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4
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Canales-Lachén E, Asunsolo Á, Manrique OJ, Blázquez J, Holguín P, Maldonado AA. The Use of Ultrasound Imaging for Upper Extremity Lymphedema after Breast Cancer: A Systematic Review. J Reconstr Microsurg 2023; 39:102-110. [PMID: 36162421 DOI: 10.1055/s-0042-1750824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The aim of this study was to analyze the different applications of ultrasound (US) in upper extremity lymphedema (UEL) after breast cancer. METHODS A systematic review of the literature was performed in line with the PRISMA statement using MEDLINE/PubMed databases from January 1970 to December 2021. Articles describing the application of US in patients with UEL after breast cancer were included. The quality of the study, the level of reproducibility, and the different applications and type of US technique were analyzed. RESULTS In total, 30 articles with 1,193 patients were included in the final review. Five different applications were found: (1) diagnosis of UEL (14 studies found a direct correlation between lymphedema and morphological and/or functional parameters); (2) staging/severity of UEL (9 studies found a direct correlation between the clinical stage and the soft-tissue stiffness/texture/thickness); (3) therapeutic assessment (3 studies found an improvement in the circulatory status or in the muscle/subcutaneous thickness after conservative treatments); (4) prognosis assessment of UEL (1 study found a correlation between the venous flow and the risk of UEL); and (5) surgical planning (3 studies determined the location of the lymphatic vessel for lymphovenous anastomosis [LVA] surgery). CONCLUSION Morphological and functional parameters have been correlated with the diagnosis, stage, therapeutic effect, prognosis of UEL, and surgical planning of LVA.
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Affiliation(s)
| | - Ángel Asunsolo
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Oscar J Manrique
- Deparment of Plastic Surgery, University of Rochester Medical Center, Rochester, New York
| | - Javier Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | | | - Andrés A Maldonado
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain.,Department of Plastic Surgery, University Hospital Getafe, Madrid, Spain.,Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Academic Hospital of the Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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5
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Ricci V, Ricci C, Gervasoni F, Andreoli A, Özçakar L. From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach. Eur J Phys Rehabil Med 2022; 58:108-117. [PMID: 33861039 PMCID: PMC9980573 DOI: 10.23736/s1973-9087.21.06853-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lymphedema is a disorder characterized by the accumulation of protein-rich lymphatic fluid in the cutaneous and subcutaneous tissue. Based on the underlying causes, it is classified into primary and secondary forms. The use of ultrasound has recently become widespread in the field of lymphedema - especially for its diagnosis and treatment planning. In this study, we briefly reviewed the anatomy and histology of the skin and subcutaneous tissue - to propose a standardized ultrasound assessment of the superficial tissues in patients with upper-/lower-limb lymphedema. We believe that identification of the sono-histological patterns of the dermo-epidermal complex and subcutaneous tissue has place to serve as a simple and reproducible strategy to evaluate their edema diseases that are often subject to an inaccurate diagnosis in daily clinical practice.
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Affiliation(s)
- Vincenzo Ricci
- Unit of Physical and Rehabilitation Medicine, "Luigi Sacco" University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy -
| | - Costantino Ricci
- Unit of Pathology, Maggiore Hospital, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Fabrizio Gervasoni
- Unit of Physical and Rehabilitation Medicine, "Luigi Sacco" University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Arnaldo Andreoli
- Unit of Physical and Rehabilitation Medicine, "Luigi Sacco" University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Levent Özçakar
- Hacettepe University Medical School, Department of Physical and Rehabilitation Medicine, Ankara, Turkey
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6
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Phillips J, Reynolds KJ, Gordon SJ. Dermal thickness and echogenicity using DermaScan C high frequency ultrasound: Methodology and reliability testing in people with and without primary lymphoedema. Skin Res Technol 2020; 26:813-823. [PMID: 32579302 DOI: 10.1111/srt.12880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND DermaScan C high frequency ultrasound was investigated for image capture and analysis of dermal measures in people with and without primary lymphoedema. METHOD Three repeated images were taken at six sites in people without lymphoedema (NLO). Intra-rater reliability was assessed by taking three sets of measures on images from 10 people and inter-session reliability by capturing three images, lifting the probe from the skin in between. Methods were adjusted, and repeated images from four sites were taken in people with primary lymphoedema (PLO) and reliability re-assessed. RESULTS Intra-rater reliability in NLO and PLO for echogenicity measures were excellent (NLO ICC(3,1) : .989; PLO .997) across all sites and specific to each site (calf: ICC(3,1) : .989; and foot: ICC(3,1) : .999, respectively). Inter-session reliability was moderate for NLO (ICC(3,1) : .727), improving after method modifications for PLO (ICC(3,1) : .916). When investigated by site, inter-session reliability was good in the foot (ICC(3,1) : .811) and moderate in the calf (ICC(3,1) : .616). Mean thickness analysed by site resulted in good inter-session reliability only in the foot (ICC(3,1) .838). CONCLUSION Intra-rater reliability was excellent using the DermaScan C for dermal measures in people with primary lymphoedema. Inter-session reliability required particular attention to method and gain settings.
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Affiliation(s)
- Jane Phillips
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University, Adelaide, SA, Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia
| | - Karen J Reynolds
- College of Science & Engineering, Medical Device Research Institute, Flinders University, Adelaide, SA, Australia
| | - Susan J Gordon
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University, Adelaide, SA, Australia
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7
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Mander A, Venosi S, Menegatti E, Byung-Boong L, Neuhardt D, Maietti E, Gianesini S. Upper limb secondary lymphedema ultrasound mapping and characterization. INT ANGIOL 2019; 38:334-342. [PMID: 31203598 DOI: 10.23736/s0392-9590.19.04176-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ultrasound investigation potentials in lymphedema are still to be fully used in everyday practice. Aim of the present study was to report the sonographic characterization of the dermo-epidermal complex (DEC) and of the subcutaneous (SUBC) tissue, assessing the feasibility of a related mapping, in upper limb secondary lymphedema. METHODS In this retrospective study 287 patients affected by monolateral upper limb post-mastectomy lymphedema (M5/F282; mean age 64±4.24) were enrolled and scanned by ultrasound, considering the healthy contralateral limb as control. In order to standardize the assessment, the limb was divided in sectors: 4 anterior, 4 posterior below the elbow, 4 anterior and 4 posterior above the elbow, plus the hand. DEC and SUBC regions B-mode appearance were reported, both in the healthy and in the pathological arms. DEC thickness was measured and compared among the same sectors of the healthy and pathological limbs. RESULTS DEC and SUBC sonographic appearance was differentiated in fluid and sclerotic. DEC included a third category characterized by differentiation loss. The different sectors showed significantly different lymphatic involvement in the affected limb. In the comparison with the contralateral unaffected segments a significantly thicker DEC was reported in the forearm affected by lymphedema (P<0.005), while no significant difference was reported at the arm level. CONCLUSIONS Traditional ultrasonography can provide a secondary upper limb lymphedema characterization with related mapping and useful data for a better lymphatic physiopathology understanding and for a properly addressed therapeutic protocol.
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Affiliation(s)
- Antonio Mander
- Unit of Oncologic and Vascular Rehabilitation, Vaclav Vojta Center, Rome, Italy
| | - Salvatore Venosi
- Unit of Vascular Surgery, Paride Stefanini Department, Sapienza University, Rome, Italy
| | - Erica Menegatti
- Unit of Translational Surgery, Vascular Disease Center, University of Ferrara, Ferrara, Italy
| | - Lee Byung-Boong
- George Washington University, Washington DC, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Diana Neuhardt
- Comprehensive Interventional Care Center, Gilbert, AZ, USA
| | - Elisa Maietti
- Department of Medical Sciences, Center for Clinical Epidemiology, University of Ferrara, Ferrara, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Sergio Gianesini
- Unit of Translational Surgery, Vascular Disease Center, University of Ferrara, Ferrara, Italy - .,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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8
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Li K, Zhang Z, Liu NF, Sadigh P, Evans VJ, Zhou H, Gao W, Zhang YX. Far-Infrared Radiation Thermotherapy Improves Tissue Fibrosis in Chronic Extremity Lymphedema. Lymphat Res Biol 2018; 16:248-257. [PMID: 28961078 DOI: 10.1089/lrb.2016.0057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ning Fei Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Parviz Sadigh
- Department of Plastic Reconstructive Surgery, The Royal London Hospital, London, United Kingdom
| | - Verity Joyce Evans
- Department of Plastic Reconstructive Surgery, The Royal London Hospital, London, United Kingdom
| | - Huihong Zhou
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Weiqing Gao
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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9
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Topical tacrolimus for the treatment of secondary lymphedema. Nat Commun 2017; 8:14345. [PMID: 28186091 PMCID: PMC5309859 DOI: 10.1038/ncomms14345] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 12/20/2016] [Indexed: 02/06/2023] Open
Abstract
Secondary lymphedema, a life-long complication of cancer treatment, currently has no cure. Lymphedema patients have decreased quality of life and recurrent infections with treatments limited to palliative measures. Accumulating evidence indicates that T cells play a key role in the pathology of lymphedema by promoting tissue fibrosis and inhibiting lymphangiogenesis. Here using mouse models, we show that topical therapy with tacrolimus, an anti-T-cell immunosuppressive drug, is highly effective in preventing lymphedema development and treating established lymphedema. This intervention markedly decreases swelling, T-cell infiltration and tissue fibrosis while significantly increasing formation of lymphatic collaterals with minimal systemic absorption. Animals treated with tacrolimus have markedly improved lymphatic function with increased collecting vessel contraction frequency and decreased dermal backflow. These results have profound implications for lymphedema treatment as topical tacrolimus is FDA-approved for other chronic skin conditions and has an established record of safety and tolerability. Secondary lymphedema is a debilitating disease with no cure. Here the authors show that topical application of an FDA-approved anti-T cell drug tacrolimus potently prevents development and alleviates pathologic changes of established lymphedema in mice, suggesting a new treatment for human patients.
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10
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Dai M, Sato A, Maeba H, Iuchi T, Matsumoto M, Okuwa M, Nakatani T, Sanada H, Sugama J. Dermal Structure in Lymphedema Patients with History of Acute Dermatolymphangioadenitis Evaluated by Histogram Analysis of Ultrasonography Findings: A Case-Control Study. Lymphat Res Biol 2016; 14:2-7. [PMID: 26982711 DOI: 10.1089/lrb.2015.0020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings. METHODS AND RESULTS This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10 cm proximal to the ulnar styloid process. We compared "skewness" of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p = 0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31). CONCLUSIONS Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.
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Affiliation(s)
- Misako Dai
- 1 Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Ishikawa Prefecture, Japan
| | - Aya Sato
- 2 Graduate School of Medical Sciences, Division of Health Science, Graduate Course of Nursing Science, Kanazawa University , Ishikawa Prefecture, Japan
| | - Hiroko Maeba
- 3 Career Design Laboratory for Gender Equality, Kanazawa University , Ishikawa Prefecture, Japan
| | - Terumi Iuchi
- 2 Graduate School of Medical Sciences, Division of Health Science, Graduate Course of Nursing Science, Kanazawa University , Ishikawa Prefecture, Japan
| | - Masaru Matsumoto
- 2 Graduate School of Medical Sciences, Division of Health Science, Graduate Course of Nursing Science, Kanazawa University , Ishikawa Prefecture, Japan
| | - Mayumi Okuwa
- 1 Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Ishikawa Prefecture, Japan
| | - Toshio Nakatani
- 1 Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Ishikawa Prefecture, Japan
| | - Hiromi Sanada
- 4 Department of Gerontological Nursing/Wound Care Management, Division of Health Science and Nursing, Graduate School of Medicine, University of Tokyo , Japan
| | - Junko Sugama
- 1 Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Ishikawa Prefecture, Japan .,5 Wellness Promotion Science Center, Kanazawa University , Ishikawa Prefecture, Japan
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11
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Preliminary evaluation of reliability and validity of head and neck external lymphedema and fibrosis assessment criteria. Eur J Oncol Nurs 2016; 22:63-70. [DOI: 10.1016/j.ejon.2016.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 01/23/2016] [Accepted: 02/01/2016] [Indexed: 11/20/2022]
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12
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Stecco A, Stern R, Fantoni I, De Caro R, Stecco C. Fascial Disorders: Implications for Treatment. PM R 2016; 8:161-8. [DOI: 10.1016/j.pmrj.2015.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 06/03/2015] [Accepted: 06/07/2015] [Indexed: 01/26/2023]
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13
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Deng J, Ridner SH, Aulino JM, Murphy BA. Assessment and measurement of head and neck lymphedema: State-of-the-science and future directions. Oral Oncol 2015; 51:431-7. [DOI: 10.1016/j.oraloncology.2015.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 01/08/2023]
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14
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Ueda-Iuchi T, Ohno N, Miyati T, Dai M, Okuwa M, Nakatani T, Sanada H, Sugama J. Assessment of the interstitial fluid in the subcutaneous tissue of healthy adults using ultrasonography. SAGE Open Med 2015; 3:2050312115613351. [PMID: 27092255 PMCID: PMC4821211 DOI: 10.1177/2050312115613351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/18/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Lymphoedema involves swelling, especially in the subcutaneous tissues. For lymphoedema management to be successful, it is necessary to remove the interstitial fluid. Subcutaneous echogenicity may be associated with interstitial fluid, but echogenicity is not an indicator for the evaluation of management because we do not directly compare echogenicity with the interstitial fluid. We aimed to identify an outcome indicator for the evaluation of interstitial fluid using ultrasonography. We assessed the correlation between echogenicity and transverse relaxation rate (R2) on magnetic resonance imaging. METHODS This was an observational study. Healthy adults with leg swelling after activity for >8 h were recruited. The legs of 13 women were evaluated using ultrasonography, magnetic resonance imaging and measurements of the limb circumference before and after an intervention to reduce the swelling. RESULTS Echogenicity in the oedema group was greater than that of the controls. Echogenicity decreased with reductions in oedema. The range of the strongest correlations with the changes in R2 occurred at echogenicity values of 48-144 (Pearson's correlation coefficient: r = -0.63 and p < 0.01). Thus, it was possible to evaluate the interstitial fluid using echogenicity. CONCLUSION The outcome indicators for the evaluation of interstitial fluid using ultrasonography were echogenicities in the range of 48-144, and these values were valid for assessing the interstitial fluid in the subcutaneous tissue.
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Affiliation(s)
- Terumi Ueda-Iuchi
- Division of Health Sciences, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Naoki Ohno
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan; Wellness Promotion Science Center, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Tosiaki Miyati
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan; Wellness Promotion Science Center, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Misako Dai
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Mayumi Okuwa
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Toshio Nakatani
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Sugama
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan; Wellness Promotion Science Center, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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15
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Gardner GC, Nickerson JP, Watts R, Nelson L, Dittus KL, O'Brien PJ. Quantitative and morphologic change associated with breast cancer-related lymphedema. Comparison of 3.0T MRI to external measures. Lymphat Res Biol 2014; 12:95-102. [PMID: 24654879 DOI: 10.1089/lrb.2013.0026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Abstract Introduction: Lymphedema is a chronic disease of increasing importance to cancer survivors. A tape measurement tool used for lymphedema relies on indirect volume calculations based on external circumference, which may not reflect the true extent of abnormal fluid accumulation accurately. Fluid-sensitive MRI sequences may be able to delineate the severity of this condition more precisely and thus also monitor response to therapy. METHODS AND RESULTS Eight patients being followed by physical therapy for clinically diagnosed breast cancer-related lymphedema were recruited to participate in this study. External measurements and upper extremity MRI were performed on all subjects. Arm circumference, arm volume, and lymphedema volumes were calculated for each method. MR imaging detected lymphedema in all study subjects. Correlation was found between external circumferential measurements and with the 3.0T MRI (r=0.9368). There was poor correlation between lymphedema volumes calculated from clinical measurements and MR imaging (r=0.5539). CONCLUSIONS External measurements were not found to be an accurate measure of lymphedema volume associated with breast cancer lymphedema. MRI is a reliable means to obtain upper extremity circumferential and volume measurements. MRI is able to evaluate morphologic change associated with breast cancer-related lymphedema. Lymphedema research requires integrated use of tools to further describe the disease process over time, quantitate the distribution of tissue changes, and improve the sensitivity and specificity of the measurements.
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Affiliation(s)
- Gregory C Gardner
- 1 Department of Radiology, Fletcher-Allen Healthcare , Burlington, Vermont
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16
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Devoogdt N, Pans S, De Groef A, Geraerts I, Christiaens MR, Neven P, Vergote I, Van Kampen M. Postoperative Evolution of Thickness and Echogenicity of Cutis and Subcutis of Patients With and Without Breast Cancer-Related Lymphedema. Lymphat Res Biol 2014; 12:23-31. [DOI: 10.1089/lrb.2013.0028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nele Devoogdt
- Department of Rehabilitation Sciences, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Physical Medicine and Rehabilitation, Leuven Lymphedema Center, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Steven Pans
- Department of Radiology, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Physical Medicine and Rehabilitation, Leuven Lymphedema Center, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Physical Medicine and Rehabilitation, Leuven Lymphedema Center, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Marie-Rose Christiaens
- Department of Oncology, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Surgical Oncology, Multidisciplinary Breast Clinic, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Neven
- Department of Oncology, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Ignace Vergote
- Department of Oncology, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Marijke Van Kampen
- Department of Rehabilitation Sciences, KU Leuven–University of Leuven, Leuven, Belgium
- Department of Physical Medicine and Rehabilitation, Leuven Lymphedema Center, Gynaecologic Oncology and Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
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17
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Newman AL, Rosenthall L, Towers A, Hodgson P, Shay CA, Tidhar D, Vigano A, Kilgour RD. Determining the precision of dual energy x-ray absorptiometry and bioelectric impedance spectroscopy in the assessment of breast cancer-related lymphedema. Lymphat Res Biol 2014; 11:104-9. [PMID: 23772720 DOI: 10.1089/lrb.2012.0020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The composition of breast cancer-related lymphedema (BCRL) has been shown to evolve from the initial accumulation of fluid to the development of fibrotic lesions and abnormal fat deposition. Therefore, precise and reliable assessments of BCRL are required to develop accurate staging and management. Although dual energy x-ray absorptiometry (DXA) and bioelectric impedance spectroscopy (BIS) have been used to assess BCRL, no study has evaluated the precision of these two modalities in the same cohort. METHODS AND RESULTS We determined the precision of DXA and BIS in lymphedematous (LE) and nonaffected (NA) arms of 24 women with Stage II unilateral BCRL. Precision was calculated from the results of paired bilateral arm measurements obtained from DXA scans measuring fat, lean, and bone mineral masses, BIS measuring extracellular fluid (ECF) and total fluid volume, and circumferential tape measurements (CM) of the arms to calculate the anatomic volume. Precision error was expressed as the root mean square (RMS) of the coefficients of variation (%CV) and standard deviations (SD). RESULTS The precisions of DXA and BIS varied from 1.16% (DXA measurements of LE arm total volume) to 1.86% (BIS LE arm total fluid volume) and from 0.95% (DXA lean mass of NA arm) to 1.72% (DXA BMC of NA arm). Precision of CM measures of arm volume were 1.71% CV for LE arm and 2.51% CV for NA arm. The fat and lean masses of the LE arm exceeded the NA arm by about 15% (p<0.0001). ECF and total fluid volume of LE arm was 22.6% and 19% greater than the NA arm (p<0.0001), respectively. CONCLUSION For BCRL, these findings suggest that DXA and BIS are two measurement instruments that provide acceptable levels of precision for the measurement of arm lean mass, fat mass and ECF volume, respectively.
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Affiliation(s)
- Anne L Newman
- Department of Exercise Science, Concordia University, Montreal, Quebec, Canada.
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18
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Wu X, Zhuo S, Chen J, Liu N. Real-time in vivo imaging collagen in lymphedematous skin using multiphoton microscopy. SCANNING 2011; 33:463-7. [PMID: 21796645 DOI: 10.1002/sca.20266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 06/16/2011] [Indexed: 05/21/2023]
Abstract
Changes of dermal collagen are characteristic for chronic lymphedema. To evaluate these changes, a real-time imaging based on two-photon excited fluorescence and second-harmonic generation was developed for investigating collagen of lymphedematous mouse and rat tail skin in vivo. Our findings showed that the technique could image the morphological changes and distribution of collagen in lymphedematous mouse and rat tail skin in vivo. More importantly, it may allow visualization of dynamic collagen alteration during the progression of lymphedema. Our findings demonstrated that multiphoton microscopy may have potential in a clinical setting as an in vivo diagnostic and monitoring system for therapy in lymphology.
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Affiliation(s)
- Xiufeng Wu
- Lymphology Center of Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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19
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Tassenoy A, De Mey J, De Ridder F, Van Schuerbeeck P, Vanderhasselt T, Lamote J, Lievens P. Postmastectomy lymphoedema: different patterns of fluid distribution visualised by ultrasound imaging compared with magnetic resonance imaging. Physiotherapy 2011; 97:234-43. [DOI: 10.1016/j.physio.2010.08.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 08/03/2010] [Indexed: 11/30/2022]
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20
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Rockson SG. The lymphaticovenous spectrum of edema. Lymphat Res Biol 2009; 7:125. [PMID: 19778198 DOI: 10.1089/lrb.2009.7301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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