Variations in permeability along individually perfused capillaries of the frog mesentery

Randomized comparison of near-infrared fluorescence imaging using indocyanine green and 99(m) technetium with or without patent blue for the sentinel lymph node procedure in breast cancer patients

Background

Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has the potential to improve sentinel lymph node (SLN) mapping of breast cancer. We performed a randomized clinical trial to assess the value of blue dyes when used in combination with NIR fluorescence. We also preliminarily examined the possibility of performing SLN mapping without radiotracers.

Methods

Clinical trial subjects were 24 consecutive breast cancer patients scheduled to undergo SLN biopsy. All patients received standard of care using 99^m technetium-nanocolloid and received 1.6 mL of 500 μM ICG injected periareolarly. Patients were randomly assigned to undergo SLN biopsy with or without patent blue. To assess the need for radiocolloids to localize the SLN or SLNs, the surgeon did not use the handheld gamma probe during the first 15 min after the axillary skin incision.

Results

SLN mapping was successful in 23 of the 24 patients. No significant difference was found in signal-to-background ratio between the groups with and without patent blue (8.3 ± 3.8 vs. 10.3 ± 5.7, respectively, P = 0.32). In both groups, 100 % of SLNs were radioactive and fluorescent, and in the patent blue group, only 84 % of SLNs were stained blue. In 25 % of patients, the use of the gamma probe was necessary to localize the SLN within the first 15 min.

Conclusions

This study shows that there is no benefit of using patent blue for SLN mapping in breast cancer patients when using NIR fluorescence and 99^m technetium-nanocolloid. NIR fluorescence imaging outperformed patent blue in all patients.

Inside-out cannulation of fine lymphatic trunks used to quantify coupling between transsynovial flow and lymphatic drainage from rabbit knees

The coupling of periarticular lymph flow to transsynovial flow from a joint cavity, i.e., fluid load, is essential to avoid periarticular edema, which is associated with arthritic morning stiffness. To study coupling in swollen joints, a new method, "inside-out" cannulation, which eliminates dead space, resistance and cutout, was used to collect lymph from fine femoral lymph trunks in anesthetised rabbits while the knee joint cavity was infused with Evans blue albumin (EVA) at controlled intraarticular pressure and transsynovial drainage rates. The amount of joint lymph in femoral lymph (volume fraction V(v)) was calculated by EVA analysis. Joint lymph flow and EVA clearance was 1.5 +/- 0.4 microl min(-1) (mean +/- SEM, n = 62) at mean trans-synovial flow, 23 microl min(-1), and increased with pressure. Volume fraction increased from 16% at 10 cmH(2)O to 43% at 41 cmH(2)O. The increase in lymph flow with pressure, 0.052 +/- 0.025 microl min(-1) cmH(2)O(-1) (n = 61) was much smaller than the increase in transsynovial flow (periarticular fluid load) with pressure, 0.71 +/- 0.14 microl min(-1) cmH(2)O(-1) (P < 0.001). Their ratio, the coupling coefficient, was only 0.06-0.11. Thus, although up to 43% of femoral lymph could stem from a single swollen joint, this drained away only a small fraction of the transsynovial filtrate. The study showed that joint lymphatic drainage is coupled to joint pressure and transsynovial flow; but the coupling is insufficient to prevent periarticular fluid accumulation under conditions of joint volume expansion and limb immobility. This may contribute to the periarticular edema of arthritis.

Capillary permeability and how it may change

Images

Steady-state fluid filtration at different capillary pressures in perfused frog mesenteric capillaries

1. The theory of steady-state filtration through capillary walls (Michel, 1984) has been developed and investigated in experiments on single capillaries of the frog mesentery perfused with Ringer solutions containing bovine serum albumin (BSA) and Ficoll 70. 2. In each experiment, the micro-occlusion technique of Michel, Mason, Curry, Tooke & Hunter (1974) has been used to investigate the relation between fluid movements per unit area of capillary wall (Jv/A) and capillary pressure (Pc) under two sets of conditions in the same vessel. First, the relation has been determined following brief perfusions, where the difference in oncotic pressure across the capillary wall approximated to the perfusate oncotic pressure at all values of Pc. These results are referred to as the transient data. Secondly, the relation was investigated by estimating Jv/A at values of Pc which had been maintained constant during at least 2 min of perfusion prior to the measurement. Under these conditions the concentration of macromolecules in the pericapillary fluid was determined by the steady-state composition of the filtrate passing through the capillary wall, and these results are referred to as steady-state data. 3. In all fifteen capillaries investigated, the relationship between Jv/A and Pc was linear for the transient data and conspicuously non-linear in the steady state. When Pc exceeded the oncotic pressure of the perfusate, steady-state values for Jv/A lay slightly above but parallel to the transient values for the same vessel. At values of Pc less than the perfusate oncotic pressure, the transient data showed reabsorption of fluid from the tissues, but in the steady state either fluid movements were so small as to be undetected or slight filtration was observed. The steady-state data followed the pattern predicted by theory. 4. The transient data were used to estimate the reflection coefficient of the capillary wall (sigma) to the macromolecular solute. In seven vessels, the mean sigma to BSA was 0.76 (S.E. of mean +/- 0.04) and in eight different vessels mean sigma to Ficoll 70 in the presence of BSA (10 mg ml-1) was 0.98 (S.E. of mean +/- 0.05). The steady-state data were consistent with the prediction that the oncotic pressure opposing high filtration rates approximates to sigma 2 pi c in the steady state, where pi c is the perfusate oncotic pressure.(ABSTRACT TRUNCATED AT 400 WORDS)

Spatial heterogeneity and microvascular fluid exchange: a simple macroscopic equation

The effect of the spatial distribution of capillary membrane "pores" on the estimate for the hydraulic conductivity (Lp) and the reflection coefficient (sigma s) in the presence of an axial gradient in the hydrostatic pressure difference (delta P) is examined. The differential fluid balance is integrated along the length of the capillary and a simple analytic solution is obtained for a capillary membrane of arbitrary structure. The effective hydrostatic pressure difference, (delta P)eff, is not simply the average of the arterial [(delta P)a] and venous [(delta P)v] pressure differences but is instead found to be (delta P)eff identical to [(delta P)a + (delta P)v]/2 + kappa [(delta P)a - (delta P)v]/2, where kappa identical to 1 - 2 (Lp1/Lp). The two macroscopic coefficients, Lp and Lp1, are related to integrals of the pore density along the length of the capillary. Failure to account for spatial heterogeneity may lead to an incorrect interpretation of the experimental data, e.g., the estimate for sigma s could be greater than 1 or less than 0 depending on the pore distribution and pressure gradient along the capillary. The single capillary hydraulic conductivity measurements of Gore [1982), Amer. J. Physiol. 242, H268-H287) and data on the microvascular pressure distributions (Bohlen and Gore (1977), Microvasc. Res. 14, 251-264) are used to estimate the magnitude of these effects.

Surgical exposure induces formation of an arteriovenous permeability gradient for macromolecules in the microcirculation of muscle

Rous and his colleagues (P. Rous, H. P. Gilding, and F. Smith, 1930, J. Exp. Med. 51, 807-830, F. Smith and P. Rous, 1931, J. Exp. Med. 53, 195-217) uncovered evidence for an arteriovenous gradient of permeability in exchange vessels of muscle. After injecting vital dyes intravenously in laboratory animals, including mice and rats, they examined escape of the dyes from exchange vessels of abdominal muscles, prepared for observation by reflection of the overlying skin. They noted that a particular class of dyes, termed "poorly diffusible," escapes from venules but not from arterioles and capillaries a few minutes after injection. We now assume that the "poor" diffusibility of the dyes stems from their binding to plasma proteins. We repeated similar experiments in mice and rats, using Evans blue as tracer, and also observed leakage of Evans blue from venules but not from other exchange vessels. We made three additional observations. (1) Evans blue leaks from venules only after the skin overlying the abdominal muscles is reflected. (2) Reflection of the skin initiates degranulation of mast cells in the muscles. (3) Leakage of Evans blue from venules is inhibited by administration of promethazine, a histamine and serotonin antagonist, to the animals prior to reflection of the skin. On the basis of our observations, we conclude that the arteriovenous permeability gradient for poorly diffusible dyes in the microcirculation of muscle represents response to tissue injury resulting from reflection of overlying skin.

Electrical resistance of arterioles and venules in the hamster cheek pouch

The electrical resistance of the vascular endothelium was determined on single microvessels in the hamster cheek pouch in order to obtain information about this variable in a mammalian preparation. So far, the technique has only been applied to frog microvessels. The technique consists of injection of current into the vascular lumen via a microelectrode and recording of the ensuing intravascular potential distribution by a second microelectrode. Cable theory was used for the analysis. The average diameter of the vessels under study was 41 micron for arterioles and 28 micron for venules. The average resistance of the vessel wall at 37 degrees C was 19 omega cm2 and 3.3 omega cm2, respectively. For the venules this is somewhat lower than what has been recorded on muscle capillaries (Olesen & Crone 1983) in the frog at room temperature, whilst the values on arterioles are rather similar. The calculated sodium permeabilities, PNa+, were for arterioles 4 X 10(-5) cm X s-1 and for venules 23 X 10(-5) cm X s-1. The high permeability values for arterioles and venules indicate that the vascular exchange function may not be limited to capillaries only.

Filtration coefficients and osmotic reflexion coefficients of the walls of single frog mesenteric capillaries

1. Single capillaries in the mesentery of pithed frogs were perfused with frog Ringer solutions containing various concentrations of bovine serum albumin and myoglobin. Filtration coefficients (Lp) of the capillary wall were determined from measurements of fluid filtration rate at a series of different capillary pressures (Michel, Mason, Curry & Tooke, 1974). The osmotic reflexion coefficients (sigma) to albumin and myoglobin were determined by comparing the effective osmotic pressure exerted by these solutes across the capillary walls with their osmotic pressures in a membrane osmometer. 2. Lp and sigma to albumin were measured in eighteen vessels at different sites in the capillary bed with the tissue temperature in the range of 20-24 degrees C. Lp varied from 1.5 x 10(-3) to 15 x 10(-3) micrometer sec-1 cm H2O-1 having a higher mean value in nine venous capillaries (11.33 x 10(-3) micrometer sec-1 cm H2O-1) than in nine arterial and mid-capillaries (4.83 x 10(-3) micrometer sec-1 cm H2O-1). For all eighteen vessels sigma to albumin had a mean value of 0.816 (S.E. of mean +/- 0.027). There was no correlation between Lp and sigma. The mean value of sigma for the venous capillaries was 0.841 (S.E. of mean +/- 0.04) and the other nine vessels 0.802 (S.E. of mean +/- 0.034). 3. The osmotic reflexion coefficient to myoglobin was measured in seven different capillaries and found to have a mean value of 0.348 (S.E. of mean +/- 0.012) at 20-24 degrees C. The Lp of the capillaries varied from 3.0 x 10(-3) to 10.5 x 10(-3) micrometer sec-1 cm H2O-1. There was no correlation between sigma for myoglobin and Lp. 4. The method of Curry, Mason & Michel (1976) was used to measure sigma for urea in eight capillaries at 20-24 degrees C (sigma for albumin was also measured in two of these vessels). The mean value of sigma for urea was 0.061 (S.E. of mean +/- 0.012). The exclusive water channel (Curry et al. 1976) was calculated to have a value of 0.209 x 10(-3) micrometer sec-1 H2O-1. 5. The effects of temperature on Lp were investigated in a further seven capillaries. It was found that when tissue temperature changed slowly (less than 2 degrees C min-1) the changes of Lp were similar to the reciprocal changes in the viscosity of water. 6. The estimates of Lp and sigma for myoglobin and serum albumin are discussed in terms of the classical pore theory and in terms of a theory that the molecular sieving properties of the capillary wall reside in a matrix of molecular fibres which covers the endothelial cells and fills the channels through or between them. A quantitative theory of a fibre matrix membrane is given in the Appendix.

Multiple pathways of capillary permeability

Morphological and physiological studies indicate multiple routes for transport across capillary endothelium. However, the identification of the morphological counterparts of specific transport processes (or the assignment of specific transport roles to morphologically identifiable pathways) has been only partly achieved: the contribution of endothelial cell membranes to transport of water and small, lipid-insoluble molecules needs to be evaluated. The identification of the "small pore" pathway for water and lipid-insoluble molecules with the intercellular junctions still remains questionable. The contributions to total macromolecular transport of junctions, single vesicles (pinocytosis, cytopempsis), chains of vesicles, and fenestrae are not yet known.