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Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, Harimurti K, Taher A. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord 2024; 12:101863. [PMID: 38428499 DOI: 10.1016/j.jvsv.2024.101863] [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: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.
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Affiliation(s)
- Bayu Brahma
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Sonar Soni Panigoro
- Oncology Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Samuel Johny Haryono
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Prasandhya Astagiri Yusuf
- Department of Medical Physiology and Biophysics/Medical Technology IMERI, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Purnomo Sidi Priambodo
- Department of Electrical Engineering, Faculty of Engineering, Universitas Indonesia, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatrics/Clinical Epidemiological Unit, Department of Internal Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Pirincci CS, Mete O, Yasa ME, Dalyan M. A comparative evaluation of the efficacy of complete decongestive therapy in the treatment of unilateral breast cancer-related lymphedema with and without metabolic syndrome. Support Care Cancer 2024; 32:473. [PMID: 38949715 PMCID: PMC11217042 DOI: 10.1007/s00520-024-08676-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
AIM This study aimed to investigate the effect of the presence of metabolic syndrome (MetS) on the limb volume and quality of life (QoL) of patients who underwent complex decongestive therapy (CDT) due to unilateral breast cancer-related lymphedema (BCRL). METHODS Forty female patients with unilateral BCRL, of whom 20 had MetS (MetS group) and 20 did not have MetS (control group), were included in the study. The participants received CDT 5 days a week for 3 weeks. The participants' limb volume (percentage of excess volume (PEV) and percentage reduction of excess volume (PREV) was determined using a tape measure, and their QoL was assessed using the Lymphedema Quality of Life questionnaire (LYMQoL) before and after treatment. RESULTS After the treatment, the PEV and PREV values and LYMQoL-symptoms scores of the patients improved (p < 0.05); however, the LYMQoL-function, appearance/body image, mood/emotions, and overall QoL scores did not change in the MetS group (p > 0.05). In the control group, the PEV and PREV values and the LYMQoL-appearance/body image, mood/emotions, and overall QoL scores improved (p < 0.05), but the LYMQoL-symptoms and LYMQoL-function scores did not change (p > 0.05). There was a greater increase in the post-treatment PEV and PREV values of the control group compared to the MetS group (p < 0.001). CONCLUSION The study yielded that CDT was an effective treatment in BCRL with and without MetS; however, the improvement was greater in BCRL cases without MetS than in those with MetS. Therefore, the presence of MetS should be taken into account in the treatment of lymphedema in patients who develop BCRL. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT05426993. Registered 2022-06-16. https://clinicaltrials.gov/search?cond=NCT05426993.
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Affiliation(s)
- Cansu Sahbaz Pirincci
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye
| | - Oguzhan Mete
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye.
| | - Mustafa Ertugrul Yasa
- University of Health Sciences, Gulhane Faculty of Physiotherapy and Rehabilitation, Ankara, Türkiye
| | - Meltem Dalyan
- Ankara City Hospital, Physical Medicine and Rehabilitation, Ankara, Türkiye
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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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Genet M, Labropoulos N, Gasparis A, O'Donnell T, Desai K. The clinical and economic impact of chronic venous insufficiency-associated lymphedema and the prevalence of persistent edema after venous intervention. Phlebology 2024; 39:353-358. [PMID: 38345282 DOI: 10.1177/02683555241233355] [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: 05/27/2024]
Abstract
OBJECTIVES To determine the demographics, outcomes, and healthcare utilization of patients with chronic venous insufficiency-associated lymphedema (CVI-LED) and the prevalence of lymphedema-specific therapy use after venous intervention. METHODS The IBM MarketScan Commercial and Medicare Claims Databases were examined for patients with CVI-LED. Patient demographics and the use of lymphedema-specific therapy before and after venous intervention were collected. RESULTS Of 85,601 LED patients identified, 8,406 also had a diagnosis of CVI. In the CVI-LED group, 1051 underwent endovenous ablation or venous stent placement. The use of lymphedema-specific therapy before and after venous intervention was 52% and 39%, respectively (p < .05). The mean time of initiation of LED-specific therapy following venous intervention was 265 days after ablation and 347 days after stent placement. CONCLUSION Treating venous hypertension improves certain venous-related signs and symptoms of CVI. However, a significant proportion of patients have persistent edema which may reflect underlying, sub-optimally treated LED.
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Affiliation(s)
- Matthew Genet
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL, USA
| | - Nicos Labropoulos
- Department of Surgery, Stony Brook University Medical Centre, New York, NY, USA
| | - Antonios Gasparis
- Department of Surgery, Stony Brook University Medical Centre, New York, NY, USA
| | | | - Kush Desai
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL, USA
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Li XP, Sun XL, Liu X, Wen Z, Jiang LH, Fu Y, Yue YL, Wang RG. Tuberous sclerosis complex combined with primary lymphedema: A case report. World J Clin Cases 2024; 12:2642-2648. [PMID: 38817219 PMCID: PMC11135441 DOI: 10.12998/wjcc.v12.i15.2642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/08/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) and primary lymphedema (PLE) are both rare diseases, and it is even rarer for both to occur in the same patient. In this work, we have provided a detailed description of a patient's clinical presentation, imaging findings, and treatment. And a retrospective analysis was conducted on 14 published relevant case reports. CASE SUMMARY A 16-year-old male came to our hospital for treatment due to right lower limb swelling. This swelling is already present from birth. The patient's memory had been progressively declining. Seizures had occurred 1 year prior at an unknown frequency. The patient was diagnosed with TSC combined with PLE through multimodal imaging examination: Computed tomography, magnetic resonance imaging, and lymphoscintigraphy. The patient underwent liposuction. The swelling of the patient's right lower limb significantly improved after surgery. Epilepsy did not occur.after taking antiepileptic drugs and sirolimus. CONCLUSION TSC with PLE is a rare and systemic disease. Imaging can detect lesions of this disease, which are important for diagnosis and treatment.
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Affiliation(s)
- Xing-Peng Li
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Xiao-Li Sun
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Xin Liu
- Department of Lymph Surgery, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Zhe Wen
- Department of Nuclear Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Li-Hua Jiang
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Yan Fu
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Yun-Long Yue
- Department of MRI, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Ren-Gui Wang
- Department of Radiology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
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Simeroth S, Yu P. The role of lymphatic endothelial cell metabolism in lymphangiogenesis and disease. Front Cardiovasc Med 2024; 11:1392816. [PMID: 38798921 PMCID: PMC11119333 DOI: 10.3389/fcvm.2024.1392816] [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: 02/28/2024] [Accepted: 04/18/2024] [Indexed: 05/29/2024] Open
Abstract
Lymphatic endothelial cells (LECs) line lymphatic vessels, which play an important role in the transport of lymph fluid throughout the human body. An organized lymphatic network develops via a process termed "lymphangiogenesis." During development, LECs respond to growth factor signaling to initiate the formation of a primary lymphatic vascular network. These LECs display a unique metabolic profile, preferring to undergo glycolysis even in the presence of oxygen. In addition to their reliance on glycolysis, LECs utilize other metabolic pathways such as fatty acid β-oxidation, ketone body oxidation, mitochondrial respiration, and lipid droplet autophagy to support lymphangiogenesis. This review summarizes the current understanding of metabolic regulation of lymphangiogenesis. Moreover, it highlights how LEC metabolism is implicated in various pathological conditions.
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Affiliation(s)
- Summer Simeroth
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Pengchun Yu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Li X, Wen Z, Hao K, Liu M, Ren J, Guo J, Zhang Y, Hao Q, Sun X, Yue Y, Wang R. The value of the dermal rim sign on nonenhanced magnetic resonance imaging for predicting dermal backflow in patients with primary lower extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2024:101890. [PMID: 38636733 DOI: 10.1016/j.jvsv.2024.101890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/17/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE The dermal rim sign (DRS) on nonenhanced magnetic resonance imaging has been shown to predict dermal backflow (DBF) in patients with secondary upper limb lymphedema. However, whether the DRS has the same effects on primary lower extremity lymphedema (PLEL) has not been clearly reported. Therefore, this study aimed to explore whether the DRS can be used to diagnose DBF on lymphoscintigraphy in patients with PLEL. METHODS A total of 94 patients who were diagnosed with PLEL were recruited for this retrospective study from January 2022 to December 2023. All the patients were divided into two groups according to the lymphoscintigraphy findings: no DBF and DBF. The magnetic resonance imaging data of the two groups were recorded and statistically compared for the following indicators: range of lymphedema involvement (left, right, whole lower limbs, only thigh, only calf and ankle), signs of lymphedema (notable thickening of skin, parallel line sign, grid sign, honeycomb sign, band sign, lymph lake sign, crescent sign, DRS), and lymphedema measurement (skin thickness, band width). The DRS is characterized by notable thickening of the skin plus the grid sign and/or honeycomb sign, plus the band sign. RESULTS The following statistically significant differences in the following indicators were found between the two groups (P < .05): notable skin thickening, parallel line sign, grid sign, honeycomb sign, band sign, DRS, skin thickness, and band width. The sensitivity, specificity, and accuracy for predicting for DBF with the DRS was 82%, 64%, and 77%, respectively. CONCLUSIONS This study confirmed good consistency between the DRS and DBF from the perspective of imaging. This tool is suitable for children, adolescents, and patients with contraindications to lymphoscintigraphy. The DRS has important value in assessing the severity of PLEL. The DRS is suggested for the clinical use of combined surgical treatment of PLEL.
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Affiliation(s)
- Xingpeng Li
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhe Wen
- Department of Nuclear Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kun Hao
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Mengke Liu
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jie Ren
- Department of MRI, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Jia Guo
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yimeng Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Qi Hao
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Sun
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yunlong Yue
- Department of MRI, Beijing Shijitan Hospital, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Rengui Wang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
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Şahinoğlu E, Ergin G, Karadibak D. The agreement between three classification systems used to grade the severity of lymphedema in patients with upper and lower extremity lymphedema: A retrospective study. Physiother Theory Pract 2024; 40:874-879. [PMID: 36567610 DOI: 10.1080/09593985.2022.2161080] [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: 09/18/2022] [Revised: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Several classification systems are used to grade the severity of lymphedema. Their agreement with each other has not been reported. OBJECTIVE To evaluate the agreement between the American Physical Therapy Association (APTA) criteria, the criteria of Ramos et al., and the International Society of Lymphology (ISL) criteria in patients with upper and lower extremity lymphedema. METHODS A total of 156 patients (63 and 93 patients with upper and lower extremity lymphedema, respectively) were included. The circumference measurements and limb volume were measured. The severity of lymphedema of the patients was classified as mild, moderate, and severe lymphedema using the APTA criteria, the criteria of Ramos et al., and the ISL criteria. The agreement between the classification systems was assessed with Krippendorff's alpha. RESULTS An acceptable and poor agreement were found between the criteria in upper (Krippendorff's alpha > 0.667) and lower extremity lymphedema (Krippendorff's alpha < 0.667), respectively. In pairwise comparisons, an acceptable agreement was found among each comparison in upper extremity lymphedema (Krippendorff's alpha > 0.667), and a poor agreement was found among each comparison in lower extremity lymphedema (Krippendorff's alpha < 0.667) except between the APTA criteria and the criteria of Ramos et al (Krippendorff's alpha > 0.667). CONCLUSIONS Patients with upper extremity lymphedema classified according to these criteria can be assumed to be samples of the same population; however, patients with lower extremity lymphedema graded according to the ISL criteria may be included in a different classification when they grade with the APTA criteria and the criteria of Ramos et al.
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Affiliation(s)
- Ertan Şahinoğlu
- Dr. İsmail Atabek Physical Therapy and Rehabilitation Center, İzmir, Turkey
| | - Gülbin Ergin
- Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, İzmir Bakirçay University, İzmir, Turkey
| | - Didem Karadibak
- Faculty of Physical Therapy and Rehabilitation, Dokuz Eylül University, İzmir, Turkey
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Bowman C, Rockson SG. The Role of Inflammation in Lymphedema: A Narrative Review of Pathogenesis and Opportunities for Therapeutic Intervention. Int J Mol Sci 2024; 25:3907. [PMID: 38612716 PMCID: PMC11011271 DOI: 10.3390/ijms25073907] [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: 02/03/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Lymphedema is a chronic and progressive disease of the lymphatic system characterized by inflammation, increased adipose deposition, and tissue fibrosis. Despite early hypotheses identifying lymphedema as a disease of mechanical lymphatic disruption alone, the progressive inflammatory nature underlying this condition is now well-established. In this review, we provide an overview of the various inflammatory mechanisms that characterize lymphedema development and progression. These mechanisms contribute to the acute and chronic phases of lymphedema, which manifest clinically as inflammation, fibrosis, and adiposity. Furthermore, we highlight the interplay between current therapeutic modalities and the underlying inflammatory microenvironment, as well as opportunities for future therapeutic development.
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Affiliation(s)
- Catharine Bowman
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Stanley G. Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
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Jaiswal S, Madke B, Singh A, Vangala N, Jangid SD. Elephantiasis Nostras Verrucosa in a Patient With Lymphedema Tarda. Cureus 2024; 16:e56850. [PMID: 38659539 PMCID: PMC11040428 DOI: 10.7759/cureus.56850] [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: 03/01/2024] [Accepted: 03/23/2024] [Indexed: 04/26/2024] Open
Abstract
This case report presents a rare and complex clinical scenario of a 42-year-old male diagnosed with elephantiasis nostras verrucosa in the context of lymphedema tarda. The patient's seven-year history of insidious and progressively worsening swelling over the left lower limb, inguino-scrotal region, and left upper limb posed diagnostic challenges, leading to a multidisciplinary evaluation. Clinical examination, imaging studies, and laboratory investigations were integral in confirming the diagnosis. The manifestation of elephantiasis nostras verrucosa, characterized by extensive hyperkeratosis, added a unique dimension to the clinical presentation. A comprehensive treatment approach involving nutritional supplementation and pharmacological interventions was initiated to address the multifaceted aspects of lymphatic dysfunction. This case underscores the importance of a collaborative and holistic approach to managing complex lymphatic disorders, contributing valuable insights to the medical literature.
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Affiliation(s)
- Sharwari Jaiswal
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Bhushan Madke
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Adarshlata Singh
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Nitya Vangala
- Dermatology, Mahavir Institute of Medical Sciences, Vikarabad, IND
| | - Shivani D Jangid
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Markarian B, Toro C, Moreira K, Polam S, Mathew N, Mayrovitz HN. Assessment Modalities for Lower Extremity Edema, Lymphedema, and Lipedema: A Scoping Review. Cureus 2024; 16:e55906. [PMID: 38601427 PMCID: PMC11004507 DOI: 10.7759/cureus.55906] [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: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 04/12/2024] Open
Abstract
Lower extremity swelling may be broadly characterized as due to edema, lymphedema, or lipedema. Differentiation between these three conditions is important for providing appropriate treatment. This review analyzes and compares different clinical diagnostic modalities for these conditions, with the aim of assisting in the process of choosing the most appropriate diagnostic modality by highlighting the advantages and limitations of each. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic search of peer-reviewed literature, the following diagnostic methods for lower extremity swelling were investigated: (1) ultrasound (US), (2) lymphoscintigraphy (LSG), (3) computed tomography (CT), (4) bioimpedance spectroscopy (BIS), (5) tissue dielectric constant (TDC), and (6) magnetic resonance imaging (MRI), including magnetic resonance lymphangiography (MRL). The databases used in the search were PubMed, ProQuest, CINAHL Complete, Web of Science, Embase, and Biomedical Reference Collection. After retrieving 115 studies based on predetermined inclusion criteria, a total of 31 studies were critically evaluated. The main results indicate the following: duplex US is the modality of choice to initially identify lower extremity edema such as deep venous thrombosis (DVT) and venous reflux due to its high sensitivity and specificity. CT venography of the lower extremity appears to bethe preferred option for gynecologic cancer patients with lower extremity swelling post-treatment, as it measures subcutaneous tissue volumes to look for DVTs, lymphoceles, and cancer recurrence. TDC is a recommended modality for a variety of conditions, including edema and lymphedema, in part, due to its noninvasive localized assessment capabilities and ease of use. LSG emerges as an effective imaging modality for lymphedema characterization with minimal invasiveness and high sensitivity and specificity. BIS is widely used to identify and monitor lower extremity lymphedema but has been reported to have low sensitivity and lacks the ability to account for changes in tissue composition such as fibrosis. US and MRL are favored for lipedema diagnosis, with MRL providing comprehensive anatomical and functional insights, albeit with cost and accessibility limitations compared to US. While CT, MRI, US, and TDC are all useful for differentiating lymphedema from lipedema, MRI is the preferred modality due to its anatomical and functional diagnostic capabilities. However, US is a pragmatic alternative for use with obese patients or when MRI is not an option.
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Affiliation(s)
- Biura Markarian
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Carel Toro
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Karina Moreira
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Sneha Polam
- Sports Medicine, Nova Southeastern University Dr. Kiran C. Patel College Of Osteopathic Medicine, Fort Lauderdale, USA
| | - Neethu Mathew
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Harvey N Mayrovitz
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
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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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Hing JX, Chua YN, Tan PT, Tan MSL, Mok CW, Seet MYL, Lin ZC, Seah CM, Lee WP, Tan SM. Defining breast cancer-related lymphedema (BCRL) prevalence and risk factors: A pragmatic approach to lymphedema surveillance. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:80-89. [PMID: 38920232 DOI: 10.47102/annals-acadmedsg.2023264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction We presented the key findings from Singapore's Changi General Hospital Breast Centre's lymphedema surveillance strategy that used patients' reported symptoms, standard arm circumference measurements and clinical assessment in the diagnosis of breast cancer-related lymphedema (BCRL). Our secondary aim was to highlight and discuss important elements of a surveillance strategy that can be implemented to track this outcome measure of breast cancer treatment for future research. Method We conducted a cross-sectional study of 511 breast cancer patients to assess the prevalence of BCRL and its associated risk factors. We defined BCRL prevalence rates based on patients' self-reporting, objective arm circumference measure-ments and clinical diagnosis based on International Society of Lymphology (ISL) staging. Results The median follow-up of patients was 88.8 months. The cumulative prevalence rate in the cohort was 30.9%. The cohort of BCRL patients were older (58.4 versus [vs] 54.9 years), had higher mean Body Mass Index (27.7 vs 25.2), higher proportion of mastectomy (77% vs 64.3%), axillary clearance, less likely breast reconstruction, higher-grade tumour, more lymph nodes excised, more advanced nodal disease, and had undergone adjuvant chemotherapy. However, clinically apparent BCRL was only 6.5% (33 out of 511 patients). The proportion of clinically significant BCRL in patients undergoing sentinel lymph node biopsy (SLNB) or axillary sampling was 1.7% compared to 9.9% in patients who had undergone axillary clearance. Majority of the BCRL were subclinical or mild in severity. Conclusion Our study showed that our rates of BCRL were comparable to international rates and highlighted similar patient profiles who were at risk of developing the disease. Having a comprehensive lymphedema surveillance strategy is paramount in paving the way for future studies.
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Affiliation(s)
- Jun Xian Hing
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Yen Nee Chua
- Department of Nursing, Changi General Hospital, Singapore
| | - Pei Ting Tan
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | | | - Chi Wei Mok
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Melissa Yert Li Seet
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Zar Chi Lin
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Chin Mui Seah
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Wai Peng Lee
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
| | - Su-Ming Tan
- Division of Breast Surgery, Department of General Surgery, Changi General Hospital, Singapore
- SingHealth-Duke NUS Breast Centre
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14
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Alshomer F, Jeong HH, Pak CJ, Suh HP, Hong JP. Identifying Functional Lymph Nodes in Lower Extremity Lymphedema Patients: The Role of High-frequency Ultrasound. J Reconstr Microsurg 2024. [PMID: 38176427 DOI: 10.1055/a-2238-7985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Lymph nodes may play a potential role in lymphedema surgery. Radiologic evaluation of nodes may reveal the status of pathologic conditions but with limited accuracy. This study is the first to evaluate the efficacy of ultrasound in detecting functioning nodes in lymphedema patients and presents a criterion for determining the functionality of the lymph nodes. METHODS This retrospective study reviews 30 lower extremity lymphedema cases which were candidates for lymph node to vein anastomosis. Lymphoscintigraphy and magnetic resonant lymphangiography (MRL) imaging were compared with ultrasound features which were correlated to intraoperative indocyanine green (ICG) nodal uptake as an indication of functionality. RESULTS Majority were International Society of Lymphology stage 2 late (50.0%) and stage 3 (26.7%). ICG positive uptake (functioning nodes) was noted in 22 (73.3%), while 8 patients (26.6%) had negative uptake (nonfunctioning). Ultrasound had significantly the highest specificity (100%) for identifying functional nodes followed by lymphoscintigraphy (55%) and MRL (36%; p = 0.002, p < 0.001, respectively). This was associated with 100% positive predictive value compared against lymphoscintigraphy (44%) and MRL (36%; p < 0.001 for both). The identified ultrasound imaging criteria for functioning lymph node were oval lymph node shape (Solbiati Index), morphology, vascularity pattern, and vascularity quantification. CONCLUSION The use of ultrasound in nodal evaluation was proven effective in different pathologic conditions and demonstrated the best prediction for functionality of the lymph node based on the new evaluation criteria.
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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, Korea
| | - Hyung Hwa Jeong
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
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Nuwayhid R, Warg ML, Heister S, Langer S, Schulz T. Translation, Cross-Cultural Adaptation and Validation of the Lymphedema Quality of Life Questionnaire (LYMQOL) in German-Speaking Patients with Lymphedema of the Lower Limbs. Healthcare (Basel) 2024; 12:409. [PMID: 38338294 PMCID: PMC10855540 DOI: 10.3390/healthcare12030409] [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: 01/05/2024] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
The LYMQOL Leg questionnaire is the most widely used, evidence-based tool for the assessment of health-related quality of life (HRQoL) in patients with lower limb lymphedema (LLL). It has been translated into several languages, but a German version is currently lacking. The aim of our study was to validate a German translation of LYMQOL Leg. Translation and cross-cultural adaptation were performed in accordance with ISPOR principles. A total of 103 patients with LLL from Germany, Austria, and Switzerland were interviewed twice. The content and face validity assessments indicated that the German LYMQOL Leg questionnaire was acceptable for interviewing patients with lymphedema. Comparing the LYMQOL Leg with the SF-36 demonstrated good construct validity. Reliability determined by the test-retest procedure was good (intra-class-correlation coefficients 0.68-0.92). Cronbach's alpha values ranged from 0.76 to 0.90 in both interviews, showing an acceptable internal consistency. The four domains of the questionnaire reached a cumulative variance of 52.7% in the factor analysis. The association between the lymphedema stages and the LYMQOL Leg domain scores was not significant. In conclusion, the validity of the German version of LYMQOL Leg, called LYMQOL Bein, was confirmed and thus represents a suitable tool for measuring HRQoL in German-speaking patients with LLL.
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Affiliation(s)
- Rima Nuwayhid
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany (S.H.); (T.S.)
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Kim C, Ali H, Tsai LL, Bulman J, Singhal D, Carroll B, Ahmed M, Weinstein J. Evaluation of Primary Lymphedema with Intranodal Lymphangiography. Cardiovasc Intervent Radiol 2024; 47:238-244. [PMID: 37985479 DOI: 10.1007/s00270-023-03605-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE There are limited existing data on the lymphatic anatomy of patients with primary lymphedema (LED), which is caused by aberrant development of lymphatic channels. In addition, there is a paucity of contemporary studies that use groin intranodal lymphangiography (IL) to evaluate LED anatomy. The purpose of this retrospective observational study was to better delineate the disease process and anatomy of primary LED using groin IL. MATERIALS AND METHODS We identified common groin IL findings in a cohort of 17 primary LED patients performed between 1/1/2017 and 1/31/2022 at a single institution. These patients were clinically determined to have primary lymphedema and demonstrated associated findings on lower extremity MR and lymphoscintigraphy. RESULTS Ten patients (59%) demonstrated irregular lymph node morphology or a paucity of lymph nodes on the more symptomatic laterality. Eight patients (47%) demonstrated lymphovenous shunting from pre-existing anastomoses between the lymphatic and venous systems. Eight patients (47%) demonstrated passage of contrast past midline to the contralateral lymphatics. Finally, 12 patients (71%) failed to opacify the cisterna chyli and thoracic duct on their initial lymphangiograms. Delayed computed tomography of 3 patients showed eventual central lymphatic opacification up to the renal veins, but none of these patients showed central lymphatic opacification to the thorax. CONCLUSION This descriptive, exploratory study demonstrates common central groin IL findings in primary LED to highlight patterns interventional radiologists should identify and report when addressing primary LED.
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Affiliation(s)
- Charissa Kim
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Hamza Ali
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Julie Bulman
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Dhruv Singhal
- Department of Surgery/Division of Plastic Surgery, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Brett Carroll
- Department of Cardiology, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA, 02215, USA
| | - Muneeb Ahmed
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Jeffrey Weinstein
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA.
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17
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Yeo SM, Kim TK, Park SH, Lee CH. Optimal Cut-Off Value for Detecting Breast Cancer-Related Lymphedema Using Ultrasonography. Lymphat Res Biol 2024; 22:37-42. [PMID: 37971868 DOI: 10.1089/lrb.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Background: We previously devised an ultrasonographic evaluation to calculate subcutaneous tissue cross-sectional area (△CSA). The reliability and accuracy of this method were demonstrated in healthy individuals and in patients with lymphedema. The purpose of this study was to estimate the optimal cut-off value of the ratio of the △CSA of the involved side (lesion side) to the contralateral side for detecting breast cancer-related lymphedema (BCRL) using ultrasonography. Methods and Results: Ultrasonographic measurements were performed 290 times in 150 patients. BCRLD was defined as a confirmed difference of >2 cm in arm circumference. BCRL confirmed by a clinician (BCRLC) was defined as the patient group that included not only BCRLD but also patients with subcutaneous thickening and abnormal findings on lymphoscintigraphy, even if the difference in arm circumference was <2 cm. The △CSAs of both upper arms and forearms were calculated by measuring the thickness of the subcutaneous tissue at four locations using ultrasonography (superior, medial, inferior, lateral) at 10 cm above the elbow and 10 cm below the elbow. With a 1.35 △CSA ratio as the cut-off value for detecting BCRLD, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were 0.88, 0.87, and 0.95, respectively. With a 1.20 △CSA ratio as the cut-off value for detecting BCRLC, the sensitivity, specificity, and AUC were 0.92, 0.89, and 0.97, respectively. Conclusions: Our findings suggest that a 1.20 △CSA ratio as determined using ultrasonography, corresponding to a tape measurement of 1.05 cm, can be considered as a diagnostic criterion for lymphedema.
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Affiliation(s)
- Seung Mi Yeo
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Tae Kyung Kim
- Department of Physical Therapy, Youngsan University, Yangsan, Republic of Korea
| | - So Hyun Park
- Department of Physical Therapy, Youngsan University, Yangsan, Republic of Korea
| | - Chang-Hyung Lee
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Diallo LH, Mariette J, Laugero N, Touriol C, Morfoisse F, Prats AC, Garmy-Susini B, Lacazette E. Specific Circular RNA Signature of Endothelial Cells: Potential Implications in Vascular Pathophysiology. Int J Mol Sci 2024; 25:680. [PMID: 38203852 PMCID: PMC10779679 DOI: 10.3390/ijms25010680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Circular RNAs (circRNAs) are a recently characterized family of gene transcripts forming a covalently closed loop of single-stranded RNA. The extent of their potential for fine-tuning gene expression is still being discovered. Several studies have implicated certain circular RNAs in pathophysiological processes within vascular endothelial cells and cancer cells independently. However, to date, no comparative study of circular RNA expression in different types of endothelial cells has been performed and analysed through the lens of their central role in vascular physiology and pathology. In this work, we analysed publicly available and original RNA sequencing datasets from arterial, veinous, and lymphatic endothelial cells to identify common and distinct circRNA expression profiles. We identified 4713 distinct circRNAs in the compared endothelial cell types, 95% of which originated from exons. Interestingly, the results show that the expression profile of circular RNAs is much more specific to each cell type than linear RNAs, and therefore appears to be more suitable for distinguishing between them. As a result, we have discovered a specific circRNA signature for each given endothelial cell type. Furthermore, we identified a specific endothelial cell circRNA signature that is composed four circRNAs: circCARD6, circPLXNA2, circCASC15 and circEPHB4. These circular RNAs are produced by genes that are related to endothelial cell migration pathways and cancer progression. More detailed studies of their functions could lead to a better understanding of the mechanisms involved in physiological and pathological (lymph)angiogenesis and might open new ways to tackle tumour spread through the vascular system.
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Affiliation(s)
- Leïla Halidou Diallo
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
| | - Jérôme Mariette
- MIAT, University of Toulouse, INRAE, 31326 Castanet-Tolosan, France;
| | - Nathalie Laugero
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
| | - Christian Touriol
- UMR1037 INSERM, University of Toulouse, 2 Avenue Hubert Curien, 31100 Toulouse, France;
| | - Florent Morfoisse
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
| | - Anne-Catherine Prats
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
| | - Barbara Garmy-Susini
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
| | - Eric Lacazette
- U1297-I2MC, INSERM, University of Toulouse, 1 Avenue Jean Poulhes, BP 84225, 31432 Toulouse, France; (L.H.D.); (N.L.); (F.M.); (A.-C.P.); (B.G.-S.)
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Brahma B, Yamamoto T, Agdelina C, Adella D, Putri RI, Hanifah W, Sundah VH, Perdana AB, Putra MRA, Taher A, Panigoro SS. Immediate-delayed lymphatic reconstruction after axillary lymph nodes dissection for locally advanced breast cancer-related lymphedema prevention: Report of two cases. Microsurgery 2024; 44:e31033. [PMID: 36896960 DOI: 10.1002/micr.31033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023]
Abstract
Approximately 60%-70% of breast cancer patients in Indonesia are diagnosed in the locally advanced stage. The stage carries a higher risk of lymph node metastasis which increases susceptibility to lymph obstruction. Hence, breast cancer-related lymphedema (BCRL) could present before axillary lymph node dissection (ALND). The purpose of this case report is to describe immediate-delayed lymphatic reconstructions with lymphaticovenous anastomosis in two subclinical lymphedema cases that present before ALND. There were 51 and 58 years old breast cancer patients with stage IIIC and IIIB, respectively. Both had no arm lymphedema symptoms, but arm lymphatic vessel abnormalities were found during preoperative indocyanine green (ICG) lymphography. Mastectomy and ALND were performed and proceeded with lymphaticovenous anastomoses (LVA) in both cases. One LVA at the axilla (isotopic) was done in the first patient. On the second patient, 3 LVAs at the affected arm (ectopic) and 3 isotopic LVAs were created. The patients were discharged on the second day without complications during the follow-up. The intensity of dermal backflow was reduced, and no subclinical lymphedema progression occurred during 11 and 9 months follow-up, respectively. Based on these cases, BCRL screening might be recommended for the locally advanced stage before cancer treatment. Once diagnosed, immediate lymphatic reconstruction after ALND should be recommended to cure or prevent BCRL progression.
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Affiliation(s)
- Bayu Brahma
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Clarissa Agdelina
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Devina Adella
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Rizky Ifandriani Putri
- Department of Anatomical Pathology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Wardah Hanifah
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Vincentius Henry Sundah
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Adhitya Bayu Perdana
- Research and Development Department, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Mohammad Reka Ananda Putra
- Functional Medical Staff of Surgical Oncology Department, Dharmais Hospital-National Cancer Center, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Sonar Soni Panigoro
- Department of Surgery, Oncology Division, Faculty of Medicine, Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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20
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Bendon CL, Hanssen E, Nowell C, Karnezis T, Shayan R. The Arteria Lymphatica and Lymphatic Microperforators: A Dedicated Blood Supply to Collecting Lymphatics and Their Potential Implications in Lymphedema: Anatomical Description. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5547. [PMID: 38268719 PMCID: PMC10807887 DOI: 10.1097/gox.0000000000005547] [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: 08/11/2023] [Accepted: 11/17/2023] [Indexed: 01/26/2024]
Abstract
Background Lymphedema is common after lymphatic damage in cancer treatment, with negative impacts on function and quality of life. Evidence suggests that blood vessel microvasculature is sensitive to irradiation and trauma; however, despite knowledge regarding dedicated mural blood supply to arteries and veins (vasa vasorum), equivalent blood vessels supplying lymphatics have not been characterized. We studied collecting lymphatics for dedicated mural blood vessels in our series of 500 lymphaticovenous anastomosis procedures for lymphedema, and equivalent controls. Methods Microscopic images of lymphatics from lymphedema and control patients were analyzed for lymphatic wall vascular density. Collecting lymphatics from 20 patients with lymphedema and 10 control patients were sampled for more detailed analysis (podoplanin immunostaining, light/confocal microscopy, microcomputed tomography, and transmission electron microscopy) to assess lymphatic wall ultrastructure and blood supply. Results Analysis revealed elaborate, dense blood microvessel networks associating with lymphatic walls in lymphedema patients and smaller equivalent vessels in controls. These vasa vasora or "arteria lymphatica" were supplied by regular axial blood vessels, parallel to lymphatic microperforators linking dermal and collecting lymphatics. Lymphatic walls were thicker in lymphedema patients than controls, with immunohistochemistry, computed tomography, transmission electron microscopy, and confocal microscopy characterizing abnormal blood vessels (altered appearance, thickened walls, elastin loss, narrow lumina, and fewer red blood cells) on these lymphatic walls. Conclusions Dedicated blood vessels on lymphatics are significantly altered in lymphedema. A better understanding of the role of these vessels may reveal mechanistic clues into lymphedema pathophysiology and technical aspects of lymphedema microsurgery, and suggest potential novel therapeutic targets.
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Affiliation(s)
- Charlotte L. Bendon
- From The O’Brien Institute Department, St Vincent’s Institute for Medical Research, Fitzroy, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Eric Hanssen
- Advanced Microscopy Facility, Bio21 Institute of Molecular Science and Biotechnology, The University of Melbourne, Parkville, Victoria, Australia
| | - Cameron Nowell
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Tara Karnezis
- From The O’Brien Institute Department, St Vincent’s Institute for Medical Research, Fitzroy, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Ramin Shayan
- From The O’Brien Institute Department, St Vincent’s Institute for Medical Research, Fitzroy, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
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21
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Cąkała-Jakimowicz M, Domaszewska-Szostek A, Puzianowska-Kuznicka M. Interruption of Lymph Flow Worsens the Skin Inflammation Caused by Saprophytic Staphylococcus epidermidis. Biomedicines 2023; 11:3234. [PMID: 38137455 PMCID: PMC10740757 DOI: 10.3390/biomedicines11123234] [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: 10/18/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Lymphedema is often complicated by chronic inflammation, leading to fibrosis, fat deposition, and inhibition of lymphangiogenesis. This study aimed to verify whether lymphedema itself or together with commensal bacterial flora infection contributes to the severity of local inflammation. Edema was induced by interruption of the lymph flow in the rat's hind limb. Immune cell infiltrates were examined by flow cytometry and immunohistochemistry. Nine-day edema alone did not affect immune cell content in the skin but resulted in a decrease in CD4+ T helper lymphocytes and monocytes in the draining popliteal lymph nodes. In turn, local saprophytic Staphylococcus epidermidis infection of the edematous limb resulted in dense infiltrates of CD68+ macrophages and monocytes, MHC class II antigen-presenting cells, CD90+ stem cells, thymocytes, and immature B cells in the skin, accompanied by a simultaneous reduction in density of CD4+ T helper lymphocytes and monocytes, OX62+ dendritic cells, CD68+ macrophages and monocytes, HiS48+ granulocytes, CD90+ stem cells, thymocytes, and immature B cells in the draining popliteal lymph nodes. These results indicate that the combination of edema and saprophytic bacteria infection induces severe inflammation in the peripheral tissues and results in a delay of antibacterial protection processes in neighboring lymphatic organs.
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Affiliation(s)
- Marta Cąkała-Jakimowicz
- Department of Human Epigenetics, Mossakowski Medical Research Institute, Polish Academy of Sciences, 02-106 Warsaw, Poland;
| | - Anna Domaszewska-Szostek
- Department of Human Epigenetics, Mossakowski Medical Research Institute, Polish Academy of Sciences, 02-106 Warsaw, Poland;
| | - Monika Puzianowska-Kuznicka
- Department of Human Epigenetics, Mossakowski Medical Research Institute, Polish Academy of Sciences, 02-106 Warsaw, Poland;
- Department of Geriatrics and Gerontology, Medical Centre of Postgraduate Education, 01-813 Warsaw, Poland
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22
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Rizaliyana S, Dianti YS, Bogari M. Modified Seki Method for the Treatment of Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5479. [PMID: 38111721 PMCID: PMC10727643 DOI: 10.1097/gox.0000000000005479] [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: 06/19/2023] [Accepted: 10/24/2023] [Indexed: 12/20/2023]
Abstract
Lymphedema is characterized by the abnormal accumulation of lymphatic fluid in the skin and subcutaneous tissue owing to impaired lymph flow. This condition may be primary or secondary to other diseases. Most lymphedema occurs in the lower extremities, which greatly interferes with the activities of the patients, especially walking. Further, it may affect the psychological condition of patients. In Indonesia, several patients with severe lymphedema have visited our clinic. In our center, lymphography is not available. However, as our center is a provincial referral hospital, many patients with lymphedema present with severe conditions. Nonoperative and operative treatment is available, including lymphovenous anastomosis. Herein, we present the rare case of a 33-year-old man with severe lymphedema in his left leg for the past 7 years. The patient was diagnosed with stage III secondary lymphedema of the left lower extremity and underwent lymphaticovenular anastomosis using a modification of the Seki method (Seki 2015). Five large lymphatic vessels were identified using methylene blue, and a transverse incision was made approximately 2-3 cm from the skin to the fatty tissue under the superficial fascia. Lymphaticovenular anastomosis was performed using a microscope. On postoperative day 1, the edema in the leg shrank significantly, and 6 months after surgery, the patient's foot size began normalizing. The patient could wear pants and became more confident.
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Affiliation(s)
- Sitti Rizaliyana
- From the Department of Plastic and Reconstructive Surgery, Airlangga University School of Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Yuanita Safitri Dianti
- From the Department of Plastic and Reconstructive Surgery, Airlangga University School of Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Melia Bogari
- From the Department of Plastic and Reconstructive Surgery, Airlangga University School of Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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23
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Yoon HJ, Woo KJ, Kim JY, Kang SY, Moon BS, Kim BS. The added value of SPECT/CT lymphoscintigraphy in the initial assessment of secondary extremity lymphedema patients. Sci Rep 2023; 13:19494. [PMID: 37945581 PMCID: PMC10636025 DOI: 10.1038/s41598-023-44471-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023] Open
Abstract
An added value of SPECT/CT over planar lymphoscintigraphy for initial staging in patients with secondary extremity lymphedema was investigated. Furthermore, we developed a hybrid SPECT/CT classification combining dermal backflow (DBF) of SPECT and honeycomb pattern (HP) of CT, correlated it with lymphoscintigraphic staging and clinical severity. Forty-one patients with secondary extremity lymphedema who underwent lymphoscintigraphy with SPECT/CT were included retrospectively. The severity of extremity lymphedema was assessed using CT volumetry. Lymphoscintigraphic findings were evaluated using the Taiwan Lymphoscintigraphy Staging (TLS), and CT-based and SPECT-based quantitative analysis were performed. TLS was performed by planar scintigraphy only and with SPECT/CT, respectively. The SPECT/CT findings were classified into DBF-/HP-, DBF+/HP-, DBF+/HP+, and DBF-/HP+. Based on these findings, patients were categorized into five classes: Class 1 = DBF-HP- entire limb, Class 2 = DBF+/HP- proximal/distal limb without DBF+/HP+ or DBF-/HP+, Class 3 = DBF+/HP+ proximal/distal limb without DBF-/HP+, Class 4 = Mixed DBF+/HP+ and DBF-/HP+ in proximal/distal limb, Class 5 = DBF-/HP+ entire limb. Adding SPECT/CT to planar scintigraphy showed a 15.4% modification rate in lymphoscintigraphic staging. HP volume ratio significantly increased as clinical severity and lymphoscintigraphic staging increased, while DBF volume ratio increased with severity and followed expected patterns according to lymphoscintigraphic staging. Hybrid SPECT/CT lymphoscintigraphic classification showed strong positive correlation with clinical severity and TLS. Our results demonstrated substantial modification of lymphoscintigraphic staging by adding SPECT/CT to a conventional planar scintigraphy. In addition, a hybrid SPECT/CT is expected to provide new indicators reflecting lymphoscintigraphic staging and clinical severity by providing both of functional DBF and anatomical HP information.
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Affiliation(s)
- Hai-Jeon Yoon
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Kyong-Je Woo
- Department of Plastic Surgery, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Ji-Young Kim
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Seo Young Kang
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Byung Seok Moon
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Bom Sahn Kim
- Department of Nuclear Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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24
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Nishioka T, Katayama KI, Kumegawa S, Isono K, Baba T, Tsujimoto H, Yamada G, Inoue N, Asamura S. Increased infiltration of CD4 + T cell in the complement deficient lymphedema model. BMC Immunol 2023; 24:42. [PMID: 37940849 PMCID: PMC10633916 DOI: 10.1186/s12865-023-00580-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Lymphedema is an intractable disease that can be caused by injury to lymphatic vessels, such as by surgical treatments for cancer. It can lead to impaired joint mobility in the extremities and reduced quality of life. Chronic inflammation due to infiltration of various immune cells in an area of lymphedema is thought to lead to local fibrosis, but the molecular pathogenesis of lymphedema remains unclear. Development of effective therapies requires elucidation of the immunological mechanisms involved in the progression of lymphedema. The complement system is part of the innate immune system which has a central role in the elimination of invading microbes and acts as a scavenger of altered host cells, such as apoptotic and necrotic cells and cellular debris. Complement-targeted therapies have recently been clinically applied to various diseases caused by complement overactivation. In this context, we aimed to determine whether complement activation is involved in the development of lymphedema. RESULTS Our mouse tail lymphedema models showed increased expression of C3, and that the classical or lectin pathway was locally activated. Complement activation was suggested to be involved in the progression of lymphedema. In comparison of the C3 knockout (KO) mouse lymphedema model and wild-type mice, there was no difference in the degree of edema at three weeks postoperatively, but the C3 KO mice had a significant increase of TUNEL+ necrotic cells and CD4+ T cells. Infiltration of macrophages and granulocytes was not significantly elevated in C3 KO or C5 KO mice compared with in wild-type mice. Impaired opsonization and decreased migration of macrophages and granulocytes due to C3 deficiency should therefore induce the accumulation of dead cells and may lead to increased infiltration of CD4+ T cells. CONCLUSIONS Vigilance for exacerbation of lymphedema is necessary when surgical treatments have the potential to injure lymphatic vessels in patients undergoing complement-targeted therapies or with complement deficiency. Future studies should aim to elucidate the molecular mechanism of CD4+ T cell infiltration by accumulated dead cells.
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Affiliation(s)
- Toshihiko Nishioka
- Department of Plastic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
- Department of Molecular Genetics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kei-Ichi Katayama
- Department of Molecular Genetics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Shinji Kumegawa
- Department of Plastic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kyoichi Isono
- Laboratory Animal Center, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Takashi Baba
- Department of Molecular Genetics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Hiroshi Tsujimoto
- Department of Molecular Genetics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Gen Yamada
- Department of Plastic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Shinichi Asamura
- Department of Plastic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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25
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Anand NC, Campbell EH, Baum CL, Gibson LE, Todd A, Bradt JL, Alavi A. Association of Lower Extremity Lymphedema and Nonmelanoma Skin Cancers. Mayo Clin Proc 2023; 98:1653-1659. [PMID: 37923522 DOI: 10.1016/j.mayocp.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To determine whether patients with lymphedema of a lower extremity (LE) had a greater risk of skin cancer than those without lymphedema. PATIENTS AND METHODS This retrospective cohort study included patients with LE lymphedema examined at Mayo Clinic in Rochester, MN, USA, from January 1, 2000, through December 31, 2020. All patients with the phrase "lower extremity lymphedema" and a diagnostic code for lymphedema present in their electronic health record, as well as their age-, race-, and sex-matched controls without lymphedema, were included in the study. A Kaplan-Meier curve was constructed to examine the time to development of the first skin cancer for the lymphedema cohort and the controls. A Cox proportional hazards regression model was used to calculate hazard ratios. RESULTS In total, 4437 patients had lymphedema within the study period. Compared with the matched control group, the lymphedema group had a significantly increased risk of skin cancer. For the subset of patients with unilateral lymphedema, the lymphedematous extremity was 2.65 times as likely as the nonlymphedematous LE to have skin cancer, particularly basal cell carcinoma. CONCLUSION Lower extremity lymphedema appears to be a risk factor for squamous cell carcinoma, basal call carcinoma, and as expected, angiosarcoma. Clinicians caring for patients with LE lymphedema should be aware of this increased risk and monitor at-risk patients accordingly.
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Affiliation(s)
- Nimay C Anand
- Meharry Medical College, Nashville, TN, USA; Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Elliott H Campbell
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA; Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | | | - Lawrence E Gibson
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA; Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Austin Todd
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Bradt
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.
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26
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Ba-Shammakh SA, Haj-Freej HM, Al-Naggar YS, Ghanem W, Haij MZ, Al-Mohd F, Hijazi E, Amr SS. Massive Localized Lymphedema: Two Case Studies and Diagnostic Challenges. Cureus 2023; 15:e47092. [PMID: 38021692 PMCID: PMC10646702 DOI: 10.7759/cureus.47092] [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] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Massive localized lymphedema (MLL) is an emerging clinical phenomenon predominantly observed in morbidly obese individuals. It presents both diagnostic and therapeutic challenges to clinicians due to its characterization by large, pendulous masses in the abdomen or thigh. MLL may resemble malignant conditions, such as liposarcoma, leading to unnecessary invasive interventions. This study presents two case studies: a 74-year-old male who succumbed to postoperative complications and a 56-year-old female who experienced successful recovery. These cases highlight the urgent need for robust diagnostic criteria and evidence-based management approaches for MLL. In addition, further research exploring the pathogenesis, risk factors, and potential connections among MLL, hypothyroidism, and angiosarcoma is essential.
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Affiliation(s)
- Saleh A Ba-Shammakh
- Department of General Surgery, Princess Rahma Teaching Hospital, Irbid, JOR
- Department of General Surgery, The Islamic Hospital, Amman, JOR
| | - Hasn M Haj-Freej
- Department of General Surgery, Princess Rahma Teaching Hospital, Irbid, JOR
| | | | - Waleed Ghanem
- Department of General Surgery, Princess Rahma Teaching Hospital, Irbid, JOR
| | - Manal Z Haij
- Department of General Surgery, The Islamic Hospital, Amman, JOR
| | - Fahmi Al-Mohd
- Department of General Surgery, The Islamic Hospital, Amman, JOR
| | - Eman Hijazi
- Department of Pathology and Microbiology, The Islamic Hospital, Amman, JOR
| | - Samir S Amr
- Department of Pathology and Laboratory Medicine, Istishari Hospital, Amman, JOR
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27
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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28
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Cheon H, Lee SH, Kim SA, Kim B, Suh HP, Jeon JY. In Vivo Dynamic and Static Analysis of Lymphatic Dysfunction in Lymphedema Using Near-Infrared Fluorescence Indocyanine Green Lymphangiography. Arterioscler Thromb Vasc Biol 2023; 43:2008-2022. [PMID: 37615112 DOI: 10.1161/atvbaha.123.319188] [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: 02/23/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Near-infrared fluorescence indocyanine green lymphangiography, a primary modality for detecting lymphedema, which is a disease due to lymphatic obstruction, enables real-time observations of lymphatics and reveals not only the spatial distribution of drainage (static analysis) but also information on the lymphatic contraction (dynamic analysis). METHODS We have produced total lymphatic obstruction in the upper limbs of 18 Sprague-Dawley rats through the dissection of proximal (brachial and axillary) lymph nodes and 20-Gy radiation (dissection limbs). After the model formation for 1 week, 9 animal models were observed for 6 weeks using near-infrared fluorescence indocyanine green lymphangiography by injecting 6-μL ICG-BSA (indocyanine green-bovine serum albumin) solution of 20-μg/mL concentration. The drainage pattern and leakage of lymph fluid were evaluated and time-domain signals of lymphatic contraction were observed in the distal lymphatic vessels. The obtained signals were converted to frequency-domain spectrums using signal processing. RESULTS The results of both static and dynamic analyses proved to be effective in accurately identifying the extent of lymphatic disruption in the dissection limbs. The static analysis showed abnormal drainage patterns and increased leakage of lymph fluid to the periphery of the vessels compared with the control (normal) limbs. Meanwhile, the waveforms were changed and the contractile signal frequency increased by 58% in the dynamic analysis. Specifically, our findings revealed that regular lymphatic contractions, observed at a frequency range of 0.08 to 0.13 Hz in the control limbs, were absent in the dissection limbs. The contractile regularity was not fully restored for the follow-up period, indicating a persistent lymphatic obstruction. CONCLUSIONS The dynamic analysis could detect the abnormalities of lymphatic circulation by observing the characteristics of signals, and it provided additional evaluation indicators that cannot be provided by the static analysis. Our findings may be useful for the early detection of the circulation problem as a functional evaluation indicator of the lymphatic system.
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Affiliation(s)
- Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Medical Center, Seoul, Republic of Korea (H.C.)
| | - Sang-Hun Lee
- Department of Optical Engineering, Kumoh National Institute of Technology, Gyeongbuk, Republic of Korea (S.-H.L.)
| | - Sang Ah Kim
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bumchul Kim
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery (H.P.S.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine (S.A.K., B.K., J.Y.J.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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29
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Xu J, Du Y, Han T, Zhu N, Zhu S. Protein@Cyanine-Based NIR-II Lymphography Enables the Supersensitive Visualization of Lymphedema and Tumor Lymphatic Metastasis. Adv Healthc Mater 2023; 12:e2301051. [PMID: 37264990 DOI: 10.1002/adhm.202301051] [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: 04/04/2023] [Revised: 05/24/2023] [Indexed: 06/03/2023]
Abstract
Visualization of the lymphatic system is clinically indispensable for the diagnosis and/or treatment of lymphatic diseases. Although indocyanine green (ICG) lymphography becomes an alternate imaging modality compared to traditional lymphoscintigraphy, it is still far from ideal due to the insufficient detection depth and low spatiotemporal resolution. Herein, protein@cyanine probes are rationally developed to solve the limitations of the current near-infrared-I (NIR-I) lymphography. The protein@cyanine probes are synthesized following a chlorine-containing dye-labeling strategy based on structure-selectivity (facile covalent binding between the dye and protein with a 1:1 molar ratio). As expected, the probes display exceptional NIR-II imaging ability with much-improved imaging contrast/resolution and controllable pharmacokinetics, superior to the clinical ICG. The protein@cyanine probes locate lymph nodes and delineate lymphatic vessels with super-high sensitivity and signal-to-background ratio, enabling real-time diagnosing lymphatic diseases such as lymphedema and tumor lymphatic metastasis. In particular, the NIR-II lymphography provides an opportunity to discover the disparate morbidity rate of primary lymphedema in different types of mice. Given the fact of lacking clinically transferable NIR-II probes, this work not only provides a promising strategy for enriching of the current library of NIR-II probes, but also promotes the clinical translation of NIR-II lymphography technology.
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Affiliation(s)
- Jiajun Xu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Yijing Du
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Tianyang Han
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Ningning Zhu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Shoujun Zhu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
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30
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Nuri T, Jin D, Takai S, Ueda K. Tryptase-Positive Mast Cells Promote Adipose Fibrosis in Secondary Lymphedema through PDGF. Curr Issues Mol Biol 2023; 45:8027-8039. [PMID: 37886950 PMCID: PMC10605118 DOI: 10.3390/cimb45100507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Lymphedema is a chronic and progressive condition that causes physical disfigurement and psychological trauma due to the accumulation of lymphatic fluid in the interstitial space. Once it develops, lymphedema is difficult to treat because it leads to the fibrosis of adipose tissue. However, the mechanism behind this remains unclear. The purpose of this study was to investigate the involvement of mast cells (MCs) in the adipose tissues of patients with lymphedema. We found that fibrosis spread through blood vessels in the adipose tissues of lymphedema patients, and the expression of the collagen I and III genes was significantly increased compared to that of those in normal adipose tissue. Immunostaining of vimentin and α-smooth muscle actin showed that fibroblasts were the main cellular components in severely fibrotic regions. Toluidine blue staining confirmed a significant increase in the number of MCs in the adipose tissues of lymphedema patients, and immunostaining of serial sections of adipose tissue showed a significant increase in the number of tryptase-positive cells in lymphedema tissues compared with those in normal adipose tissues. Linear regression analyses revealed significant positive correlations between tryptase and the expressions of the TNF-α, platelet-derived growth factor (PDGF)-A, and PDGFR-α genes. PDGF-A-positive staining was observed in both fibroblasts and granules of tryptase-positive MCs. These results suggest that MC-derived tryptase plays a role in the fibrosis of adipose tissue due to lymphedema directly or in cooperation with other mediators.
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Affiliation(s)
- Takashi Nuri
- Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan;
| | - Denan Jin
- Department of Innovative Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (D.J.); (S.T.)
| | - Shinji Takai
- Department of Innovative Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (D.J.); (S.T.)
| | - Koichi Ueda
- Department of Plastic and Reconstructive Surgery, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan;
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31
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Anik AR, Hasan K, Islam MM, Hasan MM, Ali MF, Das SK. Non-Invasive Portable Technologies for Monitoring Breast Cancer Related Lymphedema to Facilitate Telehealth: A Scoping Review. IEEE J Biomed Health Inform 2023; 27:4524-4535. [PMID: 37247315 DOI: 10.1109/jbhi.2023.3280196] [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: 05/31/2023]
Abstract
Breast cancer related lymphedema (BCRL) is a common, debilitating condition that can affect up to one in five breast cancer surviving patients (BCSP). BCRL can significantly reduce the quality of life (QOL) of patients and poses a significant challenge to healthcare providers. Early detection and continuous monitoring of lymphedema is crucial for the development of client-centered treatment plans for post-cancer surgery patients. Therefore, this comprehensive scoping review aimed to investigate the current technology methods used for the remote monitoring of BCRL and their potential to facilitate telehealth in the treatment of lymphedema. Initially, five electronic databases were systematically searched and analyzed following the PRISMA flow diagram. Studies were included, specifically if they provided data on the effectiveness of the intervention and were designed for the remote monitoring of BCRL. A total of 25 included studies reported 18 technological solutions to remotely monitor BCRL with significant methodological variation. Additionally, the technologies were categorized by method of detection and wearability. The findings of this comprehensive scoping review indicate that state-of-the-art commercial technologies were found to be more appropriate for clinical use than home monitoring, with portable 3D imaging tools being popular (SD 53.40) and accurate (correlation 0.9, p 0.05) for evaluating lymphedema in both clinic and home settings with expert practitioners and therapists. However, wearable technologies showed the most future potential for accessible and clinical long-term lymphedema management with positive telehealth outcomes. In conclusion, the absence of a viable telehealth device highlights the need for urgent research to develop a wearable device that can effectively track BCRL and facilitate remote monitoring, ultimately improving the quality of life for patients following post-cancer treatment.
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Nikolaev VV, Trimassov IA, Amirchanov DS, Shirshin EA, Krivova NA, Beliaeva SA, Sandykova EA, Kistenev YV. An Evaluation of Lymphedema Using Optical Coherence Tomography: A Rat Limb Model Approach. Diagnostics (Basel) 2023; 13:2822. [PMID: 37685360 PMCID: PMC10486677 DOI: 10.3390/diagnostics13172822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Lymphedema is a pathology caused by poor lymphatic flow which may lead to complete disability. Currently, precise, non-invasive techniques for quantifying lymphedema are lacking. In this paper, the results of an in vivo assessment of lymphedema via a developed small-animal model using the hindlimbs of rats and an optical coherence tomography (OCT) technique are presented. This model of lymphedema was based on a surgical lymph node resection and subsequent two-step X-ray exposure. The development of lymphedema was verified via the histological examination of tissue biopsies. The properties of the lymphedematous skin were analyzed in vivo and compared with healthy skin via OCT. The main differences observed were (1) a thickening of the stratum corneum layer, (2) a thinning of the viable epidermis layer, and (3) higher signal attenuation in the dermis layer of the lymphedematous skin. Based on the distribution of the OCT signal's intensity in the skin, a machine learning algorithm was developed which allowed for a classification of normal and lymphedematous tissue sites with an accuracy of 90%. The obtained results pave the way for in vivo control over the development of lymphedema.
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Affiliation(s)
- V. V. Nikolaev
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - I. A. Trimassov
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - D. S. Amirchanov
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - E. A. Shirshin
- Faculty of Physics, Lomonosov Moscow State University, Moscow 119991, Russia;
| | - N. A. Krivova
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - S. A. Beliaeva
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - E. A. Sandykova
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
| | - Yu. V. Kistenev
- Laboratory of Laser Molecular Imaging and Machine Learning, Tomsk State University, 36, Lenin Ave., Tomsk 634050, Russia; (V.V.N.); (I.A.T.); (D.S.A.); (N.A.K.); (S.A.B.); (E.A.S.)
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [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: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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Cheng JT, Leite VF, Tennison JM, Gutierrez C, Kline-Quiroz C, Capozzi LC, Yu S, Krause KJ, Langelier D, Parke SC. Rehabilitation Interventions for Head and Neck Cancer-Associated Lymphedema: A Systematic Review. JAMA Otolaryngol Head Neck Surg 2023; 149:743-753. [PMID: 37382963 DOI: 10.1001/jamaoto.2023.1473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Importance Head and neck cancer-associated lymphedema (HNCaL) affects up to 90% of survivors of head and neck cancer and is a substantial contributor to disability following head and neck cancer treatment. Despite the prevalence and morbidity associated with HNCaL, rehabilitation interventions are not well studied. Objective To identify and appraise the current evidence for rehabilitation interventions in HNCaL. Evidence Review Five electronic databases were searched systematically from inception to January 3, 2023, for studies on HNCaL rehabilitation interventions. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Findings Of 1642 citations identified, 23 studies (1.4%; n = 2147 patients) were eligible for inclusion. Six studies (26.1%) were randomized clinical trials (RCTs) and 17 (73.9%) were observational studies. Five of the 6 RCTs were published during 2020 to 2022. Most studies had fewer than 50 participants (5 of 6 RCTs; 13 of 17 observational studies). Studies were categorized by intervention type, including standard lymphedema therapy (11 studies [47.8%]) and adjunct therapy (12 studies [52.2%]). Lymphedema therapy interventions included standard complete decongestive therapy (CDT) (2 RCTs, 5 observational studies), modified CDT (3 observational studies), therapy setting (1 RCT, 2 observational studies), adherence (2 observational studies), early manual lymphatic drainage (1 RCT), and inclusion of focused exercise (1 RCT). Adjunct therapy interventions included advanced pneumatic compression devices (APCDs) (1 RCT, 5 observational studies), kinesio taping (1 RCT), photobiomodulation (1 observational study), acupuncture/moxibustion (1 observational study), and sodium selenite (1 RCT, 2 observational studies). Serious adverse events were either not found (9 [39.1%]) or not reported (14 [60.9%]). Low-quality evidence suggested the benefit of standard lymphedema therapy, particularly in the outpatient setting and with at least partial adherence. High-quality evidence was found for adjunct therapy with kinesio taping. Low-quality evidence also suggested that APCDs may be beneficial. Conclusions and Relevance The results of this systematic review suggest that rehabilitation interventions for HNCaL, including standard lymphedema therapy with kinesio taping and APCDs, appear to be safe and beneficial. However, more prospective, controlled, and adequately powered studies are needed to clarify the ideal type, timing, duration, and intensity of lymphedema therapy components before treatment guidelines can be established.
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Affiliation(s)
- Jessica T Cheng
- Department of Supportive Care Medicine, City of Hope Orange County, Irvine, California
| | - Victor F Leite
- Rehabilitation Department, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jegy M Tennison
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Carolina Gutierrez
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Cristina Kline-Quiroz
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren C Capozzi
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Shui Yu
- Department of Rehabilitation Services, City of Hope Orange County, Irvine, California
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston
| | - David Langelier
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Sara C Parke
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Arizona, Phoenix
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Bjerre Trent PK, Nordskar NJ, Wangen KR, Engeskaug MI, Opheim MLØ, Aune G, Staff AC, Thorsen L, Falk RS, Eriksson AGZ. Self-reported lower extremity lymphedema and quality of life after surgical staging of endometrial carcinoma: A population based cross-sectional study. Gynecol Oncol 2023; 175:72-80. [PMID: 37327542 DOI: 10.1016/j.ygyno.2023.05.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Sentinel lymph node biopsy (SLN) has replaced lymphadenectomy in staging of endometrial carcinoma. The aims of the study were to explore the prevalence of self-reported lymphedema (LEL), identify factors associated with LEL, compare quality of life (QoL) scores using thresholds of clinical importance, and assess correlation between different questionnaires. METHODS Women who underwent staging for endometrial carcinoma from 2006 to 2021 were invited to complete the Lower Extremity Lymphedema Screening Questionnaire (LELSQ), EORTC QLQ-C30, QLQ-EN24 and EQ-5D-5L. RESULTS Of 2156 invited survivors, 61% participated in the study, whereof 1127 were evaluable by LELSQ. The LEL prevalence was 51%, 36% and 40% after lymphadenectomy, SLN and hysterectomy, respectively (p < 0.001). Higher BMI, undergoing lymphadenectomy and receiving adjuvant chemotherapy were associated with LEL; odds ratios 1.07 (95% CI 1.05-1.09), 1.42 (95% CI 1.03-1.97) and 1.43 (95% CI 1.08-1.89) respectively. QoL was lower for women with LEL compared to those without. In women with musculoskeletal complaints the prevalence of LEL was 59%, 50% and 53% after lymphadenectomy, SLN and hysterectomy (p = 0.115), respectively, compared to 39%, 17% and 18% (p < 0.001) in women without musculoskeletal complaints. Spearman's correlation was moderate to strong between the questionnaires. CONCLUSION SLN implementation is not associated with increased LEL prevalence compared to hysterectomy alone, but is associated with a significantly lower prevalence compared to lymphadenectomy. LEL is associated with lower QoL. Our study demonstrates moderate to strong correlation between self-reported LEL and QoL scores. Available questionnaires may not distinguish between symptoms caused by LEL and musculoskeletal disease.
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Affiliation(s)
- Pernille K Bjerre Trent
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nina Jebens Nordskar
- Section of Gynecologic Oncology, Dept. of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Knut R Wangen
- Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ms Ida Engeskaug
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Ms Linn Ø Opheim
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway; Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Guro Aune
- Section of Gynecologic Oncology, Dept. of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Cathrine Staff
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Lene Thorsen
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway; Department of Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Ragnhild S Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Ane Gerda Z Eriksson
- Department of Gynecologic Oncology, Division of Cancer Medicine, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway.
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36
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Das RK, Drolet BC, Perdikis G. Suction-assisted lipectomy and lymphatic procedures for lymphedema in the ambulatory surgery setting from 2016 to 2019. J Plast Reconstr Aesthet Surg 2023; 82:27-30. [PMID: 37148807 DOI: 10.1016/j.bjps.2023.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Rishub K Das
- Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Brian C Drolet
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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37
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Poláková N, Lederer KA, Richter B, Panáková L. A Case Report of Presumptive Primary Lymphedema Localized to the Face of a Dog. Vet Sci 2023; 10:409. [PMID: 37505815 PMCID: PMC10385117 DOI: 10.3390/vetsci10070409] [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: 05/01/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Primary lymphedema (PLE) is an uncommon diagnosis in veterinary medicine, with most of the previously described cases showing lower limb edema associated with a guarded long-term prognosis. To the authors' knowledge, this case report describes the first case of lymphedema localized unilaterally to the facial region of one-year-old German Shorthair Pointer, in which indirect CT-lymphography, combined with histopathologic examination of the skin, resulted in a tentative diagnosis of PLE.
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Affiliation(s)
- Nina Poláková
- Clinical Department for Small Animals and Horses, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - Kristina Anna Lederer
- Clinical Unit of Diagnostic Imaging, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - Barbara Richter
- Institute of Pathology, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - Lucia Panáková
- Clinical Department for Small Animals and Horses, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
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38
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Min I, Lim SJ, Cheon GJ, Suh M, Seo KS. Pneumatic Compression-Assisted Lymphoscintigraphy for Quantitative Evaluation of Breast Cancer-Related Lymphedema. Clin Nucl Med 2023; Publish Ahead of Print:00003072-990000000-00595. [PMID: 37276486 DOI: 10.1097/rlu.0000000000004722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Acquired lymphedema of upper extremity is a chronic pathologic status that frequently occurs after breast cancer treatment. Reliable and quantitative evaluation of lymphedema is crucial for successful management of patients. Although lymphoscintigraphy is the primary investigation for the confirmation and evaluation of lymphedema, the specific protocol of stress intervention is not well established. This study aims to introduce intermittent pneumatic compression (IPC) as a part of stress lymphoscintigraphy and compare the effectiveness of conventional stress lymphoscintigraphy (CSL) and pneumatic compression-assisted lymphoscintigraphy (PCAL). METHODS Our study was designed as a retrospective analysis of 85 breast cancer patients with lymphedema who underwent lymphoscintigraphy utilizing either IPC device or conventional stress maneuver and received complex decongestive therapy. The flow extent of the lymphatic fluid (FE) was evaluated using a 0- to 4-point scale based on lymphoscintigraphic images. The visualization of lymph nodes was also assessed. The clinical outcomes were evaluated by changes in side-to-side circumferential and volume differences of upper extremities and compared between groups. RESULTS Of 85 patients, 47 underwent CSL, and 38 underwent PCAL. Participants with relatively preserved flow extent of the lymphatic fluid (FE 3) showed a significant difference in percentage reduction of volume (PRV) between CSL and PCAL groups (P = 0.036). In the other groups, CSL and PCAL demonstrated comparable differences in PRV without statistical significance. CONCLUSION Our study suggests that participants in the PCAL group with relatively preserved lymphatic flow extent (FE 3) had better PRV compared with those in the CSL group. The use of IPC devices in lymphoscintigraphy with the novel stress maneuver can help in the quantitative description of lymphedema status and the selection of an appropriate treatment method.
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Affiliation(s)
- Ingi Min
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
| | - Sung Joon Lim
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Minseok Suh
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwan Sik Seo
- From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital; and
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Brown S, Campbell AC, Kuonqui K, Sarker A, Park HJ, Shin J, Kataru RP, Coriddi M, Dayan JH, Mehrara BJ. The Future of Lymphedema: Potential Therapeutic Targets for Treatment. CURRENT BREAST CANCER REPORTS 2023; 15:1-9. [PMID: 37359311 PMCID: PMC10233555 DOI: 10.1007/s12609-023-00491-5] [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] [Accepted: 05/03/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review aims to summarize the current knowledge regarding the pharmacological interventions studied in both experimental and clinical trials for secondary lymphedema. Recent Findings Lymphedema is a progressive disease that results in tissue swelling, pain, and functional disability. The most common cause of secondary lymphedema in developed countries is an iatrogenic injury to the lymphatic system during cancer treatment. Despite its high incidence and severe sequelae, lymphedema is usually treated with palliative options such as compression and physical therapy. However, recent studies on the pathophysiology of lymphedema have explored pharmacological treatments in preclinical and early phase clinical trials. Summary Many potential treatment options for lymphedema have been explored throughout the past two decades including systemic agents and topical approaches to decrease the potential toxicity of systemic treatment. Treatment strategies including lymphangiogenic factors, anti-inflammatory agents, and anti-fibrotic therapies may be used independently or in conjunction with surgical approaches.
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Affiliation(s)
- Stav Brown
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Adana C. Campbell
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Kevin Kuonqui
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Ananta Sarker
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Hyeung Ju Park
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Jinyeon Shin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Raghu P. Kataru
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Joseph H. Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
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Cai LZ, Patel AA, Thirunavu VM, Hug NF, Song S, Li J, Barghout RR, Magnani CJ, Turner BE, Steinberg JR, Lee GK. Characterizing Clinical Trials in Plastic and Reconstructive Surgery: A Systematic Review of ClinicalTrials.gov From 2007 to 2020. Ann Plast Surg 2023; 90:S287-S294. [PMID: 37227408 DOI: 10.1097/sap.0000000000003227] [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: 05/26/2023]
Abstract
BACKGROUND Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov. METHODS Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting. RESULTS A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87). CONCLUSIONS A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.
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Affiliation(s)
- Lawrence Z Cai
- From the Division of Plastic and Reconstructive Surgery, Stanford Health Care, Palo Alto, CA
| | - Ashraf A Patel
- Divison of Plastic Surgery, University of Utah Hospitals & Clinics, Salt Lake City, Utah
| | | | | | - Siyou Song
- University of California San Francisco School of Medicine, San Francisco, CA
| | | | | | | | - Brandon E Turner
- Department of Radiation Oncology, Harvard Medical School, Cambridge, MA
| | - Jecca R Steinberg
- Department of Obstetrics and Gynecology, Northwestern Medicine, Chicago, IL
| | - Gordon K Lee
- From the Division of Plastic and Reconstructive Surgery, Stanford Health Care, Palo Alto, CA
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [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: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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Bianchi LMG, Irmici G, Cè M, D'Ascoli E, Della Pepa G, Di Vita F, Casati O, Soresina M, Menozzi A, Khenkina N, Cellina M. Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New? Curr Oncol 2023; 30:4512-4526. [PMID: 37232799 DOI: 10.3390/curroncol30050341] [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: 03/14/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.
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Affiliation(s)
| | - Giovanni Irmici
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Maurizio Cè
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Elisa D'Ascoli
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Gianmarco Della Pepa
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Filippo Di Vita
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Omar Casati
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Natallia Khenkina
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Michaela Cellina
- Radiology Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
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43
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Shimizu Y, Che Y, Murohara T. Therapeutic Lymphangiogenesis Is a Promising Strategy for Secondary Lymphedema. Int J Mol Sci 2023; 24:7774. [PMID: 37175479 PMCID: PMC10178056 DOI: 10.3390/ijms24097774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Secondary lymphedema is caused by lymphatic insufficiency (lymphatic drainage failure) following lymph node dissection during the surgical treatment or radiation therapy of breast or pelvic cancer. The clinical problems associated with lymphedema are reduced quality of life in terms of appearance and function, as well as the development of skin ulcers, recurrent pain, and infection. Currently, countermeasures against lymphedema are mainly physical therapy such as lymphatic massage, elastic stockings, and skin care, and there is no effective and fundamental treatment with a highly recommended grade. Therefore, there is a need for the development of a fundamental novel treatment for intractable lymphedema. Therapeutic lymphangiogenesis, which has been attracting attention in recent years, is a treatment concept that reconstructs the fragmented lymphatic network to recover lymphatic vessel function and is revolutionary to be a fundamental cure. This review focuses on the translational research of therapeutic lymphangiogenesis for lymphedema and outlines the current status and prospects in the development of therapeutic applications.
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Affiliation(s)
- Yuuki Shimizu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Kim G, Adondakis M, Smith MP, Singhal D, Tsai LL. Rate of Incidental Edema in the Contralateral Arm of Patients with Unilateral Postsurgical Secondary Upper Extremity Lymphedema. Lymphat Res Biol 2023; 21:111-117. [PMID: 35914097 PMCID: PMC10325808 DOI: 10.1089/lrb.2021.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Secondary upper extremity lymphedema occurs after an insult such as surgery. One theory suggests underlying lymphatic dysfunction predisposing certain patients into developing secondary lymphedema. We aim to determine the rate of incidental edema in the contralateral upper extremity of patients with secondary unilateral lymphedema. Methods and Results: MRI of the upper extremities were obtained in patients with lymphedema who were referred by a lymphedema clinic from 2017 to 2019. Axial short-tau inversion recovery MR images of the symptomatic and contralateral arms were retrospectively reviewed and edema severity was graded. Interobserver agreement was calculated. Indocyanine green (ICG) lymphography was compared against MRI stage in symptomatic and contralateral. Age, symptom duration, body mass index (BMI), and history of chemotherapy were compared between patients with and without contralateral limb lymphedema. ICG severity was compared against MRI stage. Seventy-eight patients were analyzed. The MRI stages of symptomatic versus contralateral arms were 1.7 ± 1.1 versus 0.1 ± 0.4 (p < 0.00001). Interobserver agreement was 0.86 (0.79-0.94). Of the patients with MRI Stage 1 or above in the symptomatic arm (n = 64), 55 (82.1%) patients demonstrated no abnormality in the contralateral arm. Nine patients (14.1%) demonstrated asymptomatic edema (MRI Stage 1). The mean ICG lymphography stage of symptomatic versus contralateral arms was 1.83 ± 0.96 versus 0.04 ± 0.25 (p < 0.00001). There was no difference in the age, symptom duration, BMI, or history of chemotherapy between patients with or without edema in the contralateral arm. Conclusion: Asymptomatic contralateral edema was detected in 14.1% of patients with unilateral secondary upper extremity lymphedema using MRI modality.
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Affiliation(s)
- Geunwon Kim
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Atrius Health, Boston, Massachusetts, USA
| | - Michael Adondakis
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martin P. Smith
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dhruv Singhal
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Leo L. Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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A Novel Dressing Composed of Adipose Stem Cells and Decellularized Wharton's Jelly Facilitated Wound Healing and Relieved Lymphedema by Enhancing Angiogenesis and Lymphangiogenesis in a Rat Model. J Funct Biomater 2023; 14:jfb14020104. [PMID: 36826903 PMCID: PMC9960849 DOI: 10.3390/jfb14020104] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Lymphedema causes tissue swelling due to the accumulation of lymphatic fluid in the tissue, which delays the process of wound-healing. Developing effective treatment options of lymphedema is still an urgent issue. In this study, we aim to fabricate tissue-engineered moist wound dressings with adipose stem cells (ASCs) and decellularized Wharton's jelly (dWJ) from the human umbilical cord in order to ameliorate lymphedema. Rat ASCs were proliferated and an apparent layer was observed on dWJ at day 7 and 14. A rat tail lymphedema model was developed to evaluate the efficacy of the treatment. Approximately 1 cm of skin near the base of the rat tail was circularly excised. The wounds were treated by secondary healing (control) (n = 5), decellularized Wharton's jelly (n = 5) and ASC-seeded dWJ (n = 5). The wound-healing rate and the tail volume were recorded once a week from week one to week five. Angiogenesis and lymphangiogenesis were assessed by immunochemistry staining with anti-CD31 and anti-LYVE1. The results showed that the wound-healing rate was faster and the tail volume was lesser in the ASC-seeded dWJ group than in the control group. More CD31+ and LYVE-1+ cells were observed at the wound-healing area in the ASC-seeded dWJ group than in the control group. This proves that tissue-engineered moist wound dressings can accelerate wound-healing and reduce lymphedema by promoting angiogenesis and lymphangiogenesis.
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Son JH, Min JH, Kim IH, Lee SY, Lee CH. The Clinical Usefulness of Ultrasonographic Measurement Technique in Patients with Lower Extremity Lymphedema. Lymphat Res Biol 2023; 21:20-27. [PMID: 35763325 DOI: 10.1089/lrb.2021.0089] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: A previous study reported a new ultrasonography (US) measurement technique to evaluate the cross-sectional area (ΔCSA) of lymphedema in the upper extremity. This ΔCSA correlated well with parameters, such as the circumference, volumetry, and bioimpedance analysis (BIA) in healthy people and upper extremity lymphedema patients. This study examined whether a US measurement technique is clinically useful in patients with lymphedema in the lower extremity. Methods and Results: Forty patients diagnosed with unilateral lower extremity lymphedema were enrolled in this study. The subjects' leg circumference, BIA, isokinetic strength, and ΔCSA were examined on the same day. The leg circumference was measured at 15 cm above the knee (AK) and below the knee (BK) crease using a tape measure. BIA was performed by a trained physical therapist, and the data of impedance (Z) at 1 and 5 kHz of each side of the lower limbs and extracellular water (ECW) were used. A fully experienced physician measured soft tissue thickness, the distance between the skin and the fascia of the muscle, three times each at the anterior, medial, posterior, and lateral aspects of the bilateral legs by US at 15 cm AK and BK. The amount of soft tissue in the ΔCSA was calculated using the designed formula from the mean values of the thicknesses. Each parameter was calculated as the ratio of the sound side to the lesion side. The Pearson and Spearman correlation coefficients were used to assess the significance of these parameters. The ratio of ΔCSA measured at 15 cm AK and BK showed strong positive correlations with the circumference difference at the same level (rho = 0.790, p = 0.000, and rho = 0.882, p = 0.000, respectively). In addition, it showed moderate or strong correlations with the ratio of Z at 5 and 1 kHz in the BIA of the lower limbs (AK15, r = -0.511, p = 0.001 and r = -0.497, p = 0.001; BK15, r = -0.780, p = 0.000 and r = -0.756, p = 0.000, respectively). Although ECW and body mass index showed weak positive correlations with the ratio of ΔCSA measured at 15 cm BK, there was no significant correlation between the ratio of ΔCSA and the isokinetic muscle strength. Conclusion: The ΔCSA results showed moderate-to-strong correlations with other conveniently used methods except for the isokinetic muscle strength. As the US ΔCSA technique could measure lymphedema status with a structural consideration, it could also be recommended as a conventional measurement method in patients with upper and lower extremity lymphedema.
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Affiliation(s)
- Ju Hyun Son
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ji Hong Min
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - In Hye Kim
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Seo Yoon Lee
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Chang-Hyung Lee
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Lee HS, Lee HJ, Seo KS. What Should We Focus on When Managing Breast Cancer-Related Lymphedema to Improve Quality of Life? Lymphat Res Biol 2023; 21:28-33. [PMID: 35687388 DOI: 10.1089/lrb.2021.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Breast cancer-related lymphedema (BCRL) is correlated with poor quality of life (QOL). The effects of the management of lymphedema on QOL remain controversial. We analyzed the changes in QOL and identified factors associated with its improvement to improve the care of patients with BCRL. Methods and Results: A total of 194 patients with BCRL were recruited, and their medical records were reviewed regarding type of surgery, chemotherapy, and radiation. Patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires, and the volume and circumference of lymphedema were measured. Significant improvements in physical, emotional, cognitive, social, and role functioning, and future perspective were observed after BCRL management. However, the change in the size of lymphedema was not correlated with the change in QOL parameters. Conclusion: The management of BCRL has a beneficial effect on QOL. However, changes in the size of lymphedema did not reflect changes in QOL. Therefore, a comprehensive approach for the management of BCRL beyond reducing the size of lymphedema is recommended to improve QOL.
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Affiliation(s)
- Hyun Sung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Korea
| | - Hyun Jeong Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Korea
| | - Kwan Sik Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Jongno-Gu, Seoul, Korea
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Kaya B, Tang YB, Chen SH, Chen HC. Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema. Asian J Surg 2023; 46:794-800. [PMID: 35850907 DOI: 10.1016/j.asjsur.2022.07.034] [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: 05/12/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated. METHODS Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10). RESULTS In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later. CONCLUSION To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.
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Affiliation(s)
- Burak Kaya
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara University Faculty of Medicine, Ankara, Turkey; Ankara University Medical Design Application and Research Center (MEDITAM), Ankara, Turkey; China Medical University and China Medical University Hospital, Taichung, Taiwan
| | - Yueh-Bih Tang
- Department of Plastic Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung University and Medical Collage, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Chi Chen
- China Medical University and China Medical University Hospital, Taichung, Taiwan.
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49
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Meng Q, Zhang M. Clinical Significance of Serum Collagen Type IV and Procollagen Type III N-Peptide Levels in Diagnosis and Differential Diagnosis of Lymphedema. Lymphat Res Biol 2023; 21:8-14. [PMID: 35687386 DOI: 10.1089/lrb.2021.0076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphatic endothelial cells production or modification were closely related to the extracellular matrix (ECM) molecules. The serum hyaluronic acid (HA), laminin (LN), procollagen type III N-peptide (PIIINP), and collagen type IV (CGIV) levels were researched to explore the clinical significance of serum ECM proteins in the diagnosis and differentiation of lymphedema. Methods: Fifty-five patients were enrolled. They were divided into primary lymphedema (PLE), secondary lymphedema (SLE), and venous edema (VE) groups. Twenty-two healthy controls were also recruited as normal control (NC). Serum HA, LN, PIIINP, and CGIV levels of all subjects were assessed using chemiluminescence immunoassay. Statistical analysis and receiver operating characteristic (ROC) curves were used to data analysis. Results: The serum levels of CGIV were significantly decreased in both PLE and SLE groups compared with those in the NC group. Reduced serum CGIV levels were associated with the severity of lymphedema. The serum levels of CGIV and PIIINP were identified decreased in both PLE and SLE groups compared with those in the VE group. However, the levels of serum HA and LN were not observed significantly changed in both PLE and SLE groups than those in NC or VE group. Furthermore, ROC curve indicated that serum CGIV and PIIINP were capable of providing good diagnostic and differential diagnostic efficacy at the most appropriate cutoff point value. Conclusion: The serum levels of CGIV may have clinical significance in the diagnosis of lymphedema. CGIV and PIIINP may play a role in the differentiation of lymphedema from VE.
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Affiliation(s)
- Qian Meng
- Clinical Laboratory Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Clinical Laboratory Medicine, Peking University Ninth School of Clinical Medicine, Beijing, China.,Beijing Key Laboratory of Urinary Cellular Molecular Diagnostics, Beijing, China
| | - Man Zhang
- Clinical Laboratory Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Clinical Laboratory Medicine, Peking University Ninth School of Clinical Medicine, Beijing, China.,Beijing Key Laboratory of Urinary Cellular Molecular Diagnostics, Beijing, China
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50
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Nowak S, Henkel A, Theis M, Luetkens J, Geiger S, Sprinkart AM, Pieper CC, Attenberger UI. Deep learning for standardized, MRI-based quantification of subcutaneous and subfascial tissue volume for patients with lipedema and lymphedema. Eur Radiol 2023; 33:884-892. [PMID: 35976393 PMCID: PMC9889496 DOI: 10.1007/s00330-022-09047-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/20/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To contribute to a more in-depth assessment of shape, volume, and asymmetry of the lower extremities in patients with lipedema or lymphedema utilizing volume information from MR imaging. METHODS A deep learning (DL) pipeline was developed including (i) localization of anatomical landmarks (femoral heads, symphysis, knees, ankles) and (ii) quality-assured tissue segmentation to enable standardized quantification of subcutaneous (SCT) and subfascial tissue (SFT) volumes. The retrospectively derived dataset for method development consisted of 45 patients (42 female, 44.2 ± 14.8 years) who underwent clinical 3D DIXON MR-lymphangiography examinations of the lower extremities. Five-fold cross-validated training was performed on 16,573 axial slices from 40 patients and testing on 2187 axial slices from 5 patients. For landmark detection, two EfficientNet-B1 convolutional neural networks (CNNs) were applied in an ensemble. One determines the relative foot-head position of each axial slice with respect to the landmarks by regression, the other identifies all landmarks in coronal reconstructed slices using keypoint detection. After landmark detection, segmentation of SCT and SFT was performed on axial slices employing a U-Net architecture with EfficientNet-B1 as encoder. Finally, the determined landmarks were used for standardized analysis and visualization of tissue volume, distribution, and symmetry, independent of leg length, slice thickness, and patient position. RESULTS Excellent test results were observed for landmark detection (z-deviation = 4.5 ± 3.1 mm) and segmentation (Dice score: SCT = 0.989 ± 0.004, SFT = 0.994 ± 0.002). CONCLUSIONS The proposed DL pipeline allows for standardized analysis of tissue volume and distribution and may assist in diagnosis of lipedema and lymphedema or monitoring of conservative and surgical treatments. KEY POINTS • Efficient use of volume information that MRI inherently provides can be extracted automatically by deep learning and enables in-depth assessment of tissue volumes in lipedema and lymphedema. • The deep learning pipeline consisting of body part regression, keypoint detection, and quality-assured tissue segmentation provides detailed information about the volume, distribution, and asymmetry of lower extremity tissues, independent of leg length, slice thickness, and patient position.
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Affiliation(s)
- Sebastian Nowak
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Andreas Henkel
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Maike Theis
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Julian Luetkens
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Sergej Geiger
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Alois M. Sprinkart
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Claus C. Pieper
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrike I. Attenberger
- Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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