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Kelly B, Thorup L, Telinius N, Mohanakumar S, Ringgaard S, Poulsen SH, Jensen JK, Hjortdal VE. Lymphatic morphology and function in chronic right heart failure due to secondary tricuspid valve regurgitation. Int J Cardiol 2024; 413:132399. [PMID: 39069092 DOI: 10.1016/j.ijcard.2024.132399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/11/2024] [Accepted: 07/25/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND In heart failure, the capacity of the lymphatic system dictates symptoms of circulatory congestion. This study aimed at describing structural and functional changes of the lymphatic system in patients with chronic right-sided heart failure. METHODS Individuals with long-standing severe tricuspid valve regurgitation and symptoms of heart failure were compared with age- gender- and weight-matched controls. Lymphatic structure and function were examined using non-contrast MR lymphangiography and near-infrared fluorescence imaging. Microvascular fluid dynamics and distribution were evaluated using strain gauge plethysmography and bio-impedance. RESULTS In total nine patients and nine controls were included. Lymphatic morphology was unchanged in cases compared to controls with similar thoracic duct diameters 3.1(2.1-3.5) mm vs. 2.0(1.8-2.4) mm (p-value = 0.11), similar lymphatic classifications (p-value 0.34), and an identical number of lymphatic vessels in the legs 6 ± 1 vs. 6 ± 3 vessels/field (p-value = 0.72). Lymphatic function was comparable with contraction frequencies of 0.5 ± 0.2 and 0.5 ± 0.3 /min (p-value = 0.52) and a maximal lymphatic pumping pressure of 60 ± 13 and 57 ± 12 mmHg (p-value = 0.59) for cases and controls respectively. Finally, microvascular capillary filtration, isovolumetric threshold, and fluid distribution were similar between groups (p-value≥0.16 for all comparisons). CONCLUSION In this small exploratory study, individuals with severe secondary tricuspid valve regurgitation and right-sided heart failure displayed a largely similar lymphatic anatomy and function. Thoracic duct diameter displayed a trend towards increased size in the patient group. We speculate that cases were indeed stable and optimally treated at the time of examination, and with a lymphatic system largely unaffected by any of the current or prior hemodynamic changes.
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Affiliation(s)
- Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark.; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Lene Thorup
- The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niklas Telinius
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Steffen Ringgaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Steen H Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vibeke E Hjortdal
- The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
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van Heumen S, Riksen JJM, Bramer WM, van Soest G, Vasilic D. Imaging of the Lymphatic Vessels for Surgical Planning: A Systematic Review. Ann Surg Oncol 2023; 30:462-479. [PMID: 36171528 PMCID: PMC9726677 DOI: 10.1245/s10434-022-12552-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Secondary lymphedema is a common complication after surgical or radiotherapeutic cancer treatment. (Micro) surgical intervention such as lymphovenous bypass and vascularized lymph node transfer is a possible solution in patients who are refractory to conventional treatment. Adequate imaging is needed to identify functional lymphatic vessels and nearby veins for surgical planning. METHODS A systematic literature search of the Embase, MEDLINE ALL via Ovid, Web of Science Core Collection and Cochrane CENTRAL Register of Trials databases was conducted in February 2022. Studies reporting on lymphatic vessel detection in healthy subjects or secondary lymphedema of the limbs or head and neck were analyzed. RESULTS Overall, 129 lymphatic vessel imaging studies were included, and six imaging modalities were identified. The aim of the studies was diagnosis, severity staging, and/or surgical planning. CONCLUSION Due to its utility in surgical planning, near-infrared fluorescence lymphangiography (NIRF-L) has gained prominence in recent years relative to lymphoscintigraphy, the current gold standard for diagnosis and severity staging. Magnetic resonance lymphography (MRL) gives three-dimensional detailed information on the location of both lymphatic vessels and veins and the extent of fat hypertrophy; however, MRL is less practical for routine presurgical implementation due to its limited availability and high cost. High frequency ultrasound imaging can provide high resolution imaging of lymphatic vessels but is highly operator-dependent and accurate identification of lymphatic vessels is difficult. Finally, photoacoustic imaging (PAI) is a novel technique for visualization of functional lymphatic vessels and veins. More evidence is needed to evaluate the utility of PAI in surgical planning.
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Affiliation(s)
- Saskia van Heumen
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,MSc Educational Program Technical Medicine, Leiden University Medical Center, Delft University of Technology and Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jonas J M Riksen
- Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gijs van Soest
- Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Savla JJ, Kelly B, Krogh E, Smith CL, Krishnamurthy G, Glatz AC, DeWitt AG, Pinto EM, Ravishankar C, Gillespie MJ, O’Byrne ML, Escobar FA, Rome JJ, Hjortdal V, Dori Y. Occlusion Pressure of the Thoracic Duct in Fontan Patients With Lymphatic Failure: Does Dilatation Challenge Contractility? World J Pediatr Congenit Heart Surg 2022; 13:737-744. [DOI: 10.1177/21501351221119394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Fontan circulation challenges the lymphatic system. Increasing production of lymphatic fluid and impeding lymphatic return, increased venous pressure may cause lymphatic dilatation and decrease lymphatic contractility. In-vitro studies have reported a lymphatic diameter-tension curve, with increasing passive stretch affecting the intrinsic contractile properties of each thoracic duct segment. We aimed to describe thoracic duct occlusion pressure and asses if thoracic duct dilation impairs contractility in individuals with a Fontan circulation and lymphatic failure. Methods Central venous pressure and thoracic duct measurements were retrospectively collected from 31 individuals with a Fontan circulation. Thoracic duct occlusion pressure was assessed during a period of external manual compression and used as an indicator of lymphatic vessel contractility. Measurements of pressure were correlated with measurements of the thoracic duct diameter in images obtained by dynamic contrast-enhanced MR lymphangiography. Results The average central venous pressure and average pressure of the thoracic duct were 17 mm Hg. During manual occlusion, the thoracic duct pressure significantly increased to 32 mm Hg. The average thoracic duct diameter was 3.3 mm. Thoracic duct diameter correlated closely with the central venous pressure. The rise in pressure following manual occlusion showed an inverse correlation with the diameter of the thoracic duct. Conclusion Higher central venous pressures are associated with increasing diameters of the thoracic duct. When challenged by manual occlusion, dilated thoracic ducts display a decreased ability to increase pressure. Dilatation and a resulting decreased contractility may partly explain the challenged lymphatic system in individuals with a Fontan circulation.
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Affiliation(s)
- Jill J. Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Krogh
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher L. Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron G. DeWitt
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin M. Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Matthew J. Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A. Escobar
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Aarhus, Denmark
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
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Lymphatic Function Decreases over Time in the Arms of Breast Cancer Patients following Treatment. Plast Reconstr Surg Glob Open 2022; 10:e4507. [PMID: 36128434 PMCID: PMC9481438 DOI: 10.1097/gox.0000000000004507] [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: 03/10/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
In patients with breast cancer-related lymphedema, distinct lymphatic patterns and changed lymphatic contractile function have been described, but it is unknown how these characteristics change over time and to what extent they appear before clinical edema is detectable. Recently, we described the lymphatic morphology and function in a cohort of breast cancer patients shortly after radiation therapy (RT). In the current study, we investigate lymphatic function and morphology in the same cohort after 1 year of follow-up. Methods The study population consisted of 28 breast cancer patients investigated 12 months after adjuvant locoregional RT. Lymphatic contraction frequency (CF), propulsion velocity, and the morphology of lymphatic vessels in the upper extremities were described in vivo using near-infrared fluorescence imaging. Lymphatic stress test was performed using hyperthermia. Results At 1 year after RT, (n = 28) 46% of the patients presented with lymphatic morphological abnormalities with a degree of dermal backflow and 21% had developed clinical breast cancer-related lymphedema. In the ipsilateral arm, CF was 23% lower than in the contralateral arm (P = 0.04). Since primary examination, CF in the ipsilateral arm decreased by 40% (P = 0.03), whereas no change was observed in the contralateral arm. During hyperthermia, the ipsilateral arms with lymphatic complications were not able to increase CF as the remaining subgroups. Conclusions Lymphatic function in the ipsilateral arm deteriorated over time after adjuvant breast cancer therapy. Furthermore, the presence of abnormal torturous lymphatic vessels in asymptomatic arms appeared to be associated with weak lymphatic reserve pumping capacity.
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Ohhashi T, Kawai Y, Hayashi M, Watanabe-Asaka T. Estimation of the Lymph Flow Through Thoracic Duct in Human Subjects Using the Urine Osmolarity: Applicable for Evaluating the Effectiveness of Manual Lymph Drainage. Lymphat Res Biol 2021; 20:282-289. [PMID: 34724800 DOI: 10.1089/lrb.2020.0138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Currently, there are many methods to evaluate the effectiveness of manual lymph drainage in the treatment of lymphedema, that is, limb volume measurement, bio-electrical impedance measurement, computer tomography, and ultrasound imaging. However, it is difficult for these methods to accurately address the lymph flow generated by manual lymph drainage. Therefore, we aimed at developing a concise and accurate method to measure the lymph flow through the thoracic duct in human subjects, which is applicable for evaluating the effectiveness of manual lymph drainage. In the present mini-review, we demonstrate the developed method in detail and its scientific evidence for the effectiveness obtained with animal and human clinical experiments. In rat in vivo experiments, intragastric administration of distilled water significantly increased mesenteric flow, which was transported via the cisterna chyli and then the thoracic duct. The manual massage on the cisterna chyli in the anesthetized rabbit significantly accelerated the lymph flow through the thoracic duct, resulting in marked hemodilution. Abdominal respiration in the supine position in human subjects produced similar hemodilution, with a marked decrease in the concentration of vasopressin in the blood. On this basis, we developed a new method to accurately measure the lymph flow through the thoracic duct by using changes in the concentration of vasopressin in the blood. In addition, with changes in urine osmolarity depending on the concentration of vasopressin in the blood, we developed a more concise and noninvasive method for evaluating the lymph flow through the thoracic duct in human subjects. These methods may be applicable for evaluating the effectiveness for the manual lymph drainage in the patients with lymphedema.
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Affiliation(s)
- Toshio Ohhashi
- Department of Innovation of Medical and Health Sciences Research, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiko Kawai
- Department of Innovation of Medical and Health Sciences Research, Shinshu University School of Medicine, Matsumoto, Japan.,Division of Physiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Moyuru Hayashi
- Department of Innovation of Medical and Health Sciences Research, Shinshu University School of Medicine, Matsumoto, Japan.,Division of Physiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Tomomi Watanabe-Asaka
- Department of Innovation of Medical and Health Sciences Research, Shinshu University School of Medicine, Matsumoto, Japan.,Division of Physiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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Lymphatic Function in the Arms of Breast Cancer Patients-A Prospective Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3779. [PMID: 34476161 PMCID: PMC8386902 DOI: 10.1097/gox.0000000000003779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 12/09/2022]
Abstract
Background: Lymphedema is a highly feared complication of breast cancer treatment, but the underlying complex mechanisms are still unknown. Thus, we investigated the lymphatic morphology and contractility in the lymphatic vessels of arms of high-risk breast cancer patients treated for node-positive early breast cancer. Methods: In this prospective cohort study 32 women treated for unilateral node-positive breast cancer were enrolled and studied 36 ± 23 days after loco-regional radiotherapy. Near-infrared fluorescence imaging was used to assess morphology and function of the superficial lymphatic vessels. Strain-gauge plethysmography was performed to evaluate the capillary filtration of fluid. Both arms were investigated, with the non-treated arm acting as control. The patients were questioned about the presence of lymphedema yearly and finally 574 ± 118 days after ended radiotherapy. Results: Morphologically, 25% of the treated arms expressed lymphatic vessel abnormalities compared to the control arms (p = 0.0048). No difference in functional parameters (maximal pumping pressure, p = 0.20; contraction frequency, p = 0.63; contraction velocity, p = 0.55) was found between the treated and control arms. Patients who later developed lymphedema had a difference in velocity compared to those who did not develop lymphedema (p = 0.02). The capillary filtration rate was similar between the two arms (p = 0.18). Conclusions: Peripheral lymphatic vessels were morphologically changed in the ipsilateral arm in 25% of the patients and patients who later developed lymphedema showed an early increase in velocity. Other functional parameters and capillary filtration were unchanged in this early phase. These discrete changes might be early indicators of later development of lymphedema.
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Abstract
Lymphedema is a common, complex, and inexplicably underappreciated human disease. Despite a history of relative neglect by health care providers and by governmental health care agencies, the last decade has seen an explosive growth of insights into, and approaches to, the problem of human lymphedema. The current review highlights the significant advances that have occurred in the investigative and clinical approaches to lymphedema, particularly over the last decade. This review summarizes the progress that has been attained in the realms of genetics, lymphatic imaging, and lymphatic surgery. Newer molecular insights are explored, along with their relationship to future molecular therapeutics. Growing insights into the relationships among lymphedema, obesity, and other comorbidities are important to consider in current and future responses to patients with lymphedema.
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Affiliation(s)
- Stanley G Rockson
- Allan and Tina Neill Professor of Lymphatic Research and Medicine, Stanford University School of Medicine, Stanford, CA
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Mohanakumar S, Kelly B, Turquetto ALR, Alstrup M, Amato LP, Barnabe MSR, Silveira JBD, Amaral F, Manso PH, Jatene MB, Hjortdal VE. Functional lymphatic reserve capacity is depressed in patients with a Fontan circulation. Physiol Rep 2021; 9:e14862. [PMID: 34057301 PMCID: PMC8165731 DOI: 10.14814/phy2.14862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background Lymphatic abnormalities play a role in effusions in individuals with a Fontan circulation. Recent results using near‐infrared fluorescence imaging disclosed an increased contraction frequency of lymphatic vessels in Fontan patients compared to healthy controls. It is proposed that the elevated lymphatic pumping seen in the Fontan patients is necessary to maintain habitual interstitial fluid balance. Hyperthermia has previously been used as a tool for lymphatic stress test. By increasing fluid filtration in the capillary bed, the lymphatic workload and contraction frequency are increased accordingly. Using near‐infrared fluorescence imaging, the lymphatic functional reserve capacity in Fontan patients were explored with a lymphatic stress test. Methods Fontan patients (n = 33) were compared to a group of 15 healthy individuals of equal age, weight, and gender. The function of the superficial lymphatic vessels in the lower leg during rest and after inducing hyperthermia was investigated, using near‐infrared fluorescence imaging. Results Baseline values in the Fontan patients showed a 57% higher contraction frequency compared to the healthy controls (0.4 ± 0.3 min−1 vs. 0.3 ± 0.2 min−1, p = 0.0445). After inducing stress on the lymphatic vessels with hyperthermia the ability to increase contraction frequency was decreased in the Fontan patients compared to the controls (0.6 ± 0.5 min−1 vs. 1.2 ± 0.8 min−1, p = 0.0102). Conclusions Fontan patients had a higher lymphatic contraction frequency during normal circumstances. In the Fontan patients, the hyperthermia response is dampened indicating that the functional lymphatic reserve capacity is depressed. This diminished reserve capacity could be part of the explanation as to why some Fontan patients develop late‐onset lymphatic complications.
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Affiliation(s)
- Sheyanth Mohanakumar
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Mathias Alstrup
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | | | - Fernando Amaral
- Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil.,Pediatric and Adult Congenital Heart Disease Unit, Hospital das Clínicas, Ribeirão Preto, Brazil
| | - Paulo Henrique Manso
- Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil.,Pediatric and Adult Congenital Heart Disease Unit, Hospital das Clínicas, Ribeirão Preto, Brazil
| | | | - Vibeke Elisabeth Hjortdal
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
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Polomska AK, Proulx ST. Imaging technology of the lymphatic system. Adv Drug Deliv Rev 2021; 170:294-311. [PMID: 32891679 DOI: 10.1016/j.addr.2020.08.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/16/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022]
Abstract
The lymphatic system plays critical roles in tissue fluid homeostasis and immunity and has been implicated in the development of many different pathologies, ranging from lymphedema, the spread of cancer to chronic inflammation. In this review, we first summarize the state-of-the-art of lymphatic imaging in the clinic and the advantages and disadvantages of these existing techniques. We then detail recent progress on imaging technology, including advancements in tracer design and injection methods, that have allowed visualization of lymphatic vessels with excellent spatial and temporal resolution in preclinical models. Finally, we describe the different approaches to quantifying lymphatic function that are being developed and discuss some emerging topics for lymphatic imaging in the clinic. Continued advancements in lymphatic imaging technology will be critical for the optimization of diagnostic methods for lymphatic disorders and the evaluation of novel therapies targeting the lymphatic system.
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Affiliation(s)
- Anna K Polomska
- ETH Zürich, Institute of Pharmaceutical Sciences, Vladimir-Prelog Weg 1-5/10, 8093 Zürich, Switzerland
| | - Steven T Proulx
- University of Bern, Theodor Kocher Institute, Freiestrasse 1, 3012 Bern, Switzerland.
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