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Michalaki E, Rudd JM, Liebman L, Wadhwani R, Wood LB, Willett NJ, Dixon JB. Lentiviral overexpression of VEGFC in transplanted MSCs leads to resolution of swelling in a mouse tail lymphedema model. Microcirculation 2023; 30:e12792. [PMID: 36369987 PMCID: PMC10680019 DOI: 10.1111/micc.12792] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 10/12/2022] [Accepted: 11/08/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Dysfunction of the lymphatic system following injury, disease, or cancer treatment can lead to lymphedema, a debilitating condition with no cure. Despite the various physical therapy and surgical options available, most treatments are palliative and fail to address the underlying lymphatic vascular insufficiency driving lymphedema progression. Stem cell therapy provides a promising alternative in the treatment of various chronic diseases with a wide range of therapeutic effects that reduce inflammation, fibrosis, and oxidative stress, while promoting lymphatic vessel (LV) regeneration. Specifically, stem cell transplantation is suggested to promote LV restoration, rebuild lymphatic circulation, and thus potentially be utilized towards an effective lymphedema treatment. In addition to stem cells, studies have proposed the administration of vascular endothelial growth factor C (VEGFC) to promote lymphangiogenesis and decrease swelling in lymphedema. AIMS Here, we seek to combine the benefits of stem cell therapy, which provides a cellular therapeutic approach that can respond to the tissue environment, and VEGFC administration to restore lymphatic drainage. MATERIALS & METHODS Specifically, we engineered mesenchymal stem cells (MSCs) to overexpress VEGFC using a lentiviral vector (hVEGFC MSC) and investigated their therapeutic efficacy in improving LV function and tissue swelling using near infrared (NIR) imaging, and lymphatic regeneration in a single LV ligation mouse tail lymphedema model. RESULTS First, we showed that overexpression of VEGFC using lentiviral transduction led to an increase in VEGFC protein synthesis in vitro. Then, we demonstrated hVEGFC MSC administration post-injury significantly increased the lymphatic contraction frequency 14-, 21-, and 28-days post-surgery compared to the control animals (MSC administration) in vivo, while also reducing tail swelling 28-days post-surgery compared to controls. CONCLUSION Our results suggest a therapeutic potential of hVEGFC MSC in alleviating the lymphatic dysfunction observed during lymphedema progression after secondary injury and could provide a promising approach to enhancing autologous cell therapy for treating lymphedema.
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Affiliation(s)
- Eleftheria Michalaki
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Josephine M Rudd
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Lauren Liebman
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Rahul Wadhwani
- Neuroscience Department, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Levi B Wood
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Nick J Willett
- Phil and Penny Knight Campus for Accelerating Scientific Impact, University of Oregon, Eugene, Oregon, USA
- The Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - J Brandon Dixon
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
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Chen L, Yang J, Kim SA, Gelvosa MN, Wei P, Jeon JY, Cheon H. Anatomy and relationships of forelimb lymph nodes in Sprague-Dawley rats: A detailed dissecting approach. Front Vet Sci 2022; 9:912278. [PMID: 36090179 PMCID: PMC9453151 DOI: 10.3389/fvets.2022.912278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022] Open
Abstract
Background Constructing a reliable animal model for preclinical treatment of secondary lymphedema is challenging because the anatomical characteristics near the lymph nodes are understudied. Therefore, this study examined the detailed anatomical relationship between the axillary lymph node flaps (ALNFs) and brachial lymph node flaps (BLNFs) in the forelimb of Sprague-Dawley (SD) rats. Materials and methods Ten male rats, weighing 250–300 g, were used. The ALNFs and BLNFs on either side of the rat forelimbs were dissected. The two lymph node flaps (LNFs) were immediately harvested to analyze their physical characteristics (via imaging process software) and microscopic structure (via histology examinations). Results A total of 20 ALNFs and BLNFs from 10 rats were harvested and analyzed. ALNF dissection was simpler and lasted a shorter time than BLNF dissection (p < 0.0001). The left LNFs were more difficult to dissect than the right LNFs (p < 0.0001). In physical characteristics of LNFs, the area (p < 0.001) of LNFs and the number of lymph nodes (p < 0.0001) associated with ALNFs were greater than those associated with BLNFs, but the pedicle lengths of ALNFs were shorter than that of BLNFs (p < 0.0001). No significant difference in the diameter of the venous and arterial pedicles was noted between the two LNFs (p > 0.05). Conclusion This study reported detailed physical characteristics of ALNFs and BLNFs in SD rat forelimbs, assessing the respective area of LNFs, number of lymph nodes, and lengths and diameters of vascular pedicles. Moreover, this study suggested an efficient method to perform a study of LNFs by describing the operation process and repeatedly measuring the operation time.
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Affiliation(s)
- Linhai Chen
- Department of Plastic and Reconstructive Surgery, Ningbo First Hospital, Ningbo, China
| | - Jing Yang
- Department of Anesthesiology, The First Affiliated Hospital of Zhejiang University Medical College, Hangzhou, China
| | - Sang Ah Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ma. Nessa Gelvosa
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Peng Wei
- Department of Plastic and Reconstructive Surgery, Ningbo First Hospital, Ningbo, China
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Jae Yong Jeon
| | - Hwayeong Cheon
- Biomedical Engineering Research Center, Asan Medical Center, Asan Institute for Life Sciences, Seoul, South Korea
- *Correspondence: Hwayeong Cheon
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Mallarino-Restrepo G, Lin MCY, Cheng MH. Distal facial vein catheterization for prevention and management of thrombosis in vascularized lymph node transfers. J Surg Oncol 2022; 126:970-977. [PMID: 35811436 DOI: 10.1002/jso.26995] [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: 05/27/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND This study investigated the outcomes of the distal facial vein catheterization (DFVC) to manage venous thrombosis in vascularized submental lymph nodes (VSLN) flap transplantations. METHODS Between March 2017 and December 2020, patients who underwent VSLN flaps were divided into Group I: combined delayed primary retention sutures (DPRS) with DFVC, and Group II: DPRS alone. Primary outcomes were early (within 72 h) and late venous thrombosis. Secondary outcomes included other nonvascular complications and mechanical factors of the thrombosis. RESULTS A total of 105 patients who underwent 106 VSLN flaps, including 37 and 69 flaps in Groups I and II, respectively, were included. There were no statistically significant differences in age, body mass index, Taiwan lymphoscintigraphy staging, and surgical factors between the two groups (all p > 0.05). Early venous thrombosis requiring re-exploration developed in one (2.7%) and three (4.3%) flaps in Groups I and II, respectively (p = 0.20). One flap (2.7%) and eight (11.5%) flaps developed late venous thrombosis in Groups I and II, respectively (p < 0.01). There was no statistically significant difference in total complication rates between both groups (p = 0.9). CONCLUSION VSLN flap transplantation had a significantly higher risk of late venous thrombosis. DFVC significantly decreased the late venous thrombosis.
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Affiliation(s)
- Gonzalo Mallarino-Restrepo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Miffy C-Y Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center of Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center of Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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Yang CY, Tinhofer IE, Cheng MH. Long-term outcomes of arterial ischemia or venous occlusion on vascularized groin lymph nodes in a rat model. J Surg Oncol 2022; 126:633-639. [PMID: 35678754 DOI: 10.1002/jso.26980] [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: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study investigated the long-term effects of arterial ischemia and venous occlusion on lymph node drainage function in a rat model. METHODS Bilateral groin lymph node flaps of 18 Lewis rats were dissected. The pedicle artery was clamped for 4, 5, and 6 h (A4, A5, and A6 groups), and the vein for 3, 4, and 5 h (V3, V4, and V5 groups) in six flaps. At 4 weeks, the evaluations included gross morphomics, indocyanine green (ICG) lymphography, histological section, immunofluorescence of terminal deoxynucleotidyl transferase assay, and heme oxygenase-1 (HO-1) stain. RESULTS The lymph node flaps developed shrinkage and partial necrosis in A5, A6, V4, and V5 groups. Hemorrhage in the lymph node cortex and medulla was observed histologically in A5, A6, and V5 groups. ICG lymphography showed loss of lymphatic drainage function in 2 of 6 flaps in A6 and V5 groups. Cell death was shown partly in cortical follicles in A5 and V4 groups and completely in A6 and V5 groups. The HO-1 expression was statistically increased in A5 and V5 groups, respectively (p < 0.05). CONCLUSIONS The critical arterial ischemia and venous occlusion time were 4 h at 4 weeks of follow-up.
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Affiliation(s)
- Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria
| | - Ming-Huei Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan
- Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Plastic Surgery, Ann The University of Michigan, Arbor, Michigan, USA
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Animal Models Used in the Research of Vascularized Lymph Node Transfer: A Systematic Review. J Surg Res 2021; 272:1-8. [PMID: 34922265 DOI: 10.1016/j.jss.2021.10.021] [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: 07/23/2021] [Revised: 09/21/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lymphedema is a common adverse consequence of breast cancer therapy, while still relatively little is known about its pathophysiology. Several treatment options emerged over the past decades, and among them, vascularized lymph node transfer (VLNT) seems to be particularly promising. Animal models are indispensable to improve our understanding of the underlying processes surrounding the transplantation of a vascularized lymph node. This review aimed to systematically evaluate animal models of VLNT and compare their advantages and disadvantages. MATERIALS AND METHODS A systematic review of literature in the Scopus, Web of Science, and Ovid MEDLINE databases was conducted according to the PRISMA guidelines to identify all studies on animal models used for the research of VLNT. The algorithm used in search of articles was "Vascularized Lymph Node Transfer" AND "Model". Articles were manually verified for relevance to the topic. The resulting models were assessed for their suitability for VLNT research. RESULTS The literature search yielded a total of 233 studies after duplicates removal. Of those, 217 were excluded based on title and abstract review. Another study was excluded after reviewing the full-text article leaving 15 eligible studies to be included in this review article. CONCLUSIONS Rats were found to be the most dominantly used animal model in the VLNT research, although other models had their benefits. The main areas of study were the functionality of VLNT within or without a preinduced lymphedema, its response to ischemia, and clarification of lymphatic pathways reestablishment following VLNT.
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Yang JCS, Wu SC, Hayashi A, Lin WC, Huang GK, Tsai PY, Chien PC, Hsieh CH. Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction-A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10143121. [PMID: 34300287 PMCID: PMC8305302 DOI: 10.3390/jcm10143121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.
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Affiliation(s)
- Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8002)
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Akitatsu Hayashi
- Department of Lymphedema Center, Kameda General Hospital, Chiba 296-0041, Japan;
| | - Wei-Che Lin
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Gong-Kai Huang
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Pei-Yu Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Peng-Chen Chien
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
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Frueh FS, Jelvani B, Scheuer C, Körbel C, Kim BS, Giovanoli P, Lindenblatt N, Harder Y, Ampofo E, Menger MD, Laschke MW. Short-term molecular and cellular effects of ischemia/reperfusion on vascularized lymph node flaps in rats. PLoS One 2020; 15:e0239517. [PMID: 33021999 PMCID: PMC7537894 DOI: 10.1371/journal.pone.0239517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/08/2020] [Indexed: 11/26/2022] Open
Abstract
Vascularized lymph node (VLN) transfer is an emerging strategy to re-establish lymphatic drainage in chronic lymphedema. However, the biological processes underlying lymph node integration remain elusive. This study introduces an experimental approach facilitating the analysis of short-term molecular and cellular effects of ischemia/reperfusion on VLN flaps. Lymph node flaps were dissected pedicled on the lateral thoracic vessels in 44 Lewis rats. VLN flaps were exposed to 45 or 120 minutes ischemia by in situ clamping of the vascular pedicle with subsequent reperfusion for 24 hours. Flaps not exposed to ischemia/reperfusion served as controls. Lymph nodes and the perinodal adipose tissue were separately analyzed by Western blot for the expression of lymphangiogenic and angiogenic growth factors. Moreover, morphology, microvessel density, proliferation, apoptosis and immune cell infiltration of VLN flaps were further assessed by histology and immunohistochemistry. Ischemia for 120 minutes was associated with a markedly reduced cellularity of lymph nodes but not of the perinodal adipose tissue. In line with this, ischemic lymph nodes exhibited a significantly lower microvessel density and an increased expression of VEGF-D and VEGF-A. However, VEGF-C expression was not upregulated. In contrast, analyses of the perinodal adipose tissue revealed a more subtle decrease of microvessel density, while only the expression of VEGF-D was increased. Moreover, after 120 minutes ischemia, lymph nodes but not the perinodal adipose tissue exhibited significantly higher numbers of proliferating and apoptotic cells as well as infiltrated macrophages and neutrophilic granulocytes compared with non-ischemic flaps. Taken together, lymph nodes of VLN flaps are highly susceptible to ischemia/reperfusion injury. In contrast, the perinodal adipose tissue is less prone to ischemia/reperfusion injury.
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Affiliation(s)
- Florian S. Frueh
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Bijan Jelvani
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Christina Körbel
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Michael D. Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Matthias W. Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
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Chen K, Sinelnikov MY, Reshetov IV, Timashev P, Gu Y, Mu L, Lu P, Zhang Y. Therapeutic Potential of Mesenchymal Stem Cells for Postmastectomy Lymphedema: A Literature Review. Clin Transl Sci 2020; 14:54-61. [PMID: 33460321 PMCID: PMC7877822 DOI: 10.1111/cts.12864] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022] Open
Abstract
Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. Despite various physical therapy and surgical options available, the impaired lymph fluid drainage may be progressive due to lymphatic vascular insufficiency making treatment more difficulty. Stem cell therapy provides a promising alternative in the treatment of various chronic diseases. The wide applicability of cell therapy has been reviewed throughout literature. This review provides an overview of recent progress in the therapeutic effect of adult stem cells for primary and secondary lymphedema after breast surgery in preclinical studies and clinical cases. We start with a brief introduction about the pathophysiological mechanisms of postmastectomy lymphedema. Regarding existing treatments, we systematically summarize the benefits and limitations of recent progress. Because of their multidirectional differentiation potential and growth factor secretion, stem cell therapy shows promising results in the management of light to severe lymphedema. Increasing evidences have demonstrated a noticeable reduction in postmastectomy lymphedema and increased lymph-angiogenesis after specific stem cell therapy. Current data suggests that stem cell therapy in lymphedema treatment provides reversal of pathological reorganization associated with lymphedema progression. Finally, we propose potential strategies for overcoming the challenges in the development of multipotent progenitor cells for the treatment and prevention of lymphedema in clinical practice.
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Affiliation(s)
- Kuo Chen
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Mikhail Y Sinelnikov
- Institute for Regenerative Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Igor V Reshetov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Petr Timashev
- Institute for Regenerative Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Yuanting Gu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lan Mu
- Peking University People's Hospital, Beijing, China
| | - Pengwei Lu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanyuan Zhang
- Institute for Regenerative Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
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9
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Perrault DP, Lee GK, Bouz A, Sung C, Yu R, Pourmoussa AJ, Park SY, Kim GH, Jiao W, Patel KM, Hong YK, Wong AK. Ischemia and reperfusion injury in superficial inferior epigastric artery-based vascularized lymph node flaps. PLoS One 2020; 15:e0227599. [PMID: 31923917 PMCID: PMC6954070 DOI: 10.1371/journal.pone.0227599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 12/23/2019] [Indexed: 01/17/2023] Open
Abstract
Vascularized lymph node transfer (VLNT) is a promising treatment modality for lymphedema; however, how lymphatic tissue responds to ischemia has not been well defined. This study investigates the cellular changes that occur in lymph nodes in response to ischemia and reperfusion. Lymph node containing superficial epigastric artery-based groin flaps were isolated in Prox-1 EGFP rats which permits real time identification of lymphatic tissue by green fluorescence during flap dissection. Flaps were subjected to ischemia for either 1, 2, 4, or 8 hours, by temporarily occluding the vascular pedicle. Flaps were harvested after 0 hours, 24 hours, or 5 days of reperfusion. Using EGFP signal guidance, lymph nodes were isolated from the flaps and tissue morphology, cell apoptosis, and inflammatory cytokines were quantified and analyzed via histology, immunostaining, and rtPCR. There was a significant increase in collagen deposition and tissue fibrosis in lymph nodes after 4 and 8 hours of ischemia compared to 1 and 2 hours, as assessed by picrosirius red staining. Cell apoptosis significantly increased after 4 hours of ischemia in all harvest times. In tissue subject to 4 hours of ischemia, longer reperfusion periods were associated with increased rates of CD3+ and CD45+ cell apoptosis. rtPCR analysis demonstrated significantly increased expression of CXCL1/GRO-α with 2 hours of ischemia and increased PECAM-1 and TNF-α expression with 1 hour of ischemia. Significant cell death and changes in tissue morphology do not occur until after 4 hours of ischemia; however, analysis of inflammatory biomarkers suggests that ischemia reperfusion injury can occur with as little as 2 hours of ischemia.
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Affiliation(s)
- David P. Perrault
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Gene K. Lee
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Antoun Bouz
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Cynthia Sung
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Roy Yu
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Austin J. Pourmoussa
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Sun Young Park
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Gene H. Kim
- Departments of Pathology and Dermatology, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Wan Jiao
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Young-Kwon Hong
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Alex K. Wong
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
- * E-mail:
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10
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Cheng MH, Yang CY, Tee R, Hong YT, Lu CC. Efficacy validation of a lymphatic drainage device for lymphedema drainage in a rat model. J Surg Oncol 2019; 120:1162-1168. [PMID: 31556139 DOI: 10.1002/jso.25707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) is an effective surgery for extremity lymphedema. This study evaluated a lymphatic drainage device (LDD) for the drainage of accumulated fluid into the venous system. METHODS Micropore filtering membranes with pore sizes of 5, 0.65, and 0.22 μm polyvinylidene difluoride, and 0.8 μm Nylon Net Filter were evaluated to determine the in vitro efficiency of drainage flow of an LDD. The two superior membranes were further used for the evaluation of the inflow and outflow of the LDD in vivo using 5% albumin. RESULTS At 5 minutes, the volumes drained with 5, 0.65, and 0.22 μm polyvinylidene difluoride and 0.8 μm nylon membranes were 15.2, 2.77, 2.37, and 0.59 mL, respectively (P < .01). At 10 minutes, the collected volumes of 5 and 0.65 μm polyvinylidene difluoride were 1788 and 1051 μL (P = .3). The indocyanine green fluorescence was detected at 50 seconds for the 5 μm polyvinylidene difluoride membrane but not for the 0.65 μm membrane. CONCLUSIONS The study successfully demonstrated the proof-of-concept of the LDD prototype that mimicked VLNT with drainage of 5% albumin into the venous system in a rat model.
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Affiliation(s)
- Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Collage of Medical, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chin Yu Yang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Collage of Medical, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Richard Tee
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Collage of Medical, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yu-Ting Hong
- Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - Chih-Cheng Lu
- Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan
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Tinhofer IE, Yang CY, Chen C, Cheng MH. Impacts of arterial ischemia or venous occlusion on vascularized groin lymph nodes in a rat model. J Surg Oncol 2019; 121:153-162. [PMID: 31152457 DOI: 10.1002/jso.25518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/08/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reported ischemia time of vascularized lymph nodes was 5 hours. This study investigated the effects of arterial ischemia and venous occlusion on vascularized lymph node function in rats. METHODS Bilateral pedicled groin lymph node flaps were raised in 27 Lewis rats. Femoral artery and vein were separated and clamped for 1, 3, 4, or 5 hour(s). Lymph node flap perfusion and drainage were assessed by laser Doppler flowmetry and indocyanine green lymphography. Histologic changes were assessed using hematoxylin and eosin stain, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL), and glutathione assays. RESULTS Perfusion units of 2.84 ± 1.41, 2.46 ± 0.64, 2.42 ± 0.37, and 2.01 ± 0.90 were measured in arterial ischemia groups, and 1.71 ± 0.45, 2.20 ± 0.98, 1.49 ± 0.35, and 0.81 ± 0.20 in venous occlusion groups after 1, 3, 4, and 5 hours of clamping, respectively. Lymphatic drainage showed mean latency periods of 5.33 ± 0.88, 9.00 ± 3.21, 10.00 ± 2.08, and 24.50 ± 11.50 seconds in arterial clamping groups, and 25.00 ± 3.61, 26.00 ± 3.06, 23.33 ± 4.41, and 152.00 ± 0 seconds in venous clamping groups, respectively. Severe medullary and cortical congestion and hemorrhage on histology and cell damage by glutathione levels and TUNEL assay were found after 4 hours of venous clamping. CONCLUSIONS Arterial ischemia and venous occlusion impact the function and viability of vascularized lymph node flaps differently. The critical venous occlusion time was 4 hours.
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Affiliation(s)
- Ines E Tinhofer
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan
| | - Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Courtney Chen
- Medical student, UC San Diego School of Medicine, San Diego, California
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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