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Fuster-Martínez I, Calatayud S. The current landscape of antifibrotic therapy across different organs: A systematic approach. Pharmacol Res 2024; 205:107245. [PMID: 38821150 DOI: 10.1016/j.phrs.2024.107245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
Fibrosis is a common pathological process that can affect virtually all the organs, but there are hardly any effective therapeutic options. This has led to an intense search for antifibrotic therapies over the last decades, with a great number of clinical assays currently underway. We have systematically reviewed all current and recently finished clinical trials involved in the development of new antifibrotic drugs, and the preclinical studies analyzing the relevance of each of these pharmacological strategies in fibrotic processes affecting tissues beyond those being clinically studied. We analyze and discuss this information with the aim of determining the most promising options and the feasibility of extending their therapeutic value as antifibrotic agents to other fibrotic conditions.
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Affiliation(s)
- Isabel Fuster-Martínez
- Departamento de Farmacología, Universitat de València, Valencia 46010, Spain; FISABIO (Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana), Valencia 46020, Spain.
| | - Sara Calatayud
- Departamento de Farmacología, Universitat de València, Valencia 46010, Spain; CIBERehd (Centro de Investigación Biomédica en Red - Enfermedades Hepáticas y Digestivas), Spain.
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2
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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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3
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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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4
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Brunner G, Roux MS, Falk T, Bresch M, Böhm V, Blödorn-Schlicht N, Meiners T. The Peripheral Lymphatic System Is Impaired by the Loss of Neuronal Control Associated with Chronic Spinal Cord Injury. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:1448-1457. [PMID: 35843264 DOI: 10.1016/j.ajpath.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/03/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
Spinal cord injury (SCI) is associated with venous vascular dysfunction below the level of injury, resulting in dysregulation of tissue fluid homeostasis in afflicted skin. The purpose of this study was to determine whether loss of neuronal control in chronic SCI also affects the skin lymphatic system. Morphology of lymphatics was characterized by immunohistochemistry and lymphatic gene expression profiles determined by DNA microarray analysis. In SCI, skin lymphatic function appeared to be impaired, because the ratio of functionally dilated versus collapsed lymphatic vessels was decreased 10-fold compared with control. Consequently, the average lumen area of lymphatic vessels was almost halved, possibly due to the known impaired connective tissue integrity of SCI skin. In fact, collagenases were found to be overexpressed in SCI skin, and dermal collagen structure was impaired. Molecular profiling also suggested an SCI-specific phenotype of increased connective tissue turnover and decreased lymphatic contractility. The total number of lymphatic vessels in SCI skin, however, was doubled, pointing to enhanced lymphangiogenesis. In conclusion, these data show, for the first time, that lymphatic function and development in human skin are under neuronal control. Because peripheral venous and lymphatic vascular defects are associated with disturbed fluid homeostasis, inappropriate wound healing reactions, and impaired skin immunity, they might contribute to the predisposition of afflicted individuals to pressure ulcer formation and wound healing disorders.
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Affiliation(s)
- Georg Brunner
- Center for Spinal Cord Injuries, Werner Wicker Hospital, Bad Wildungen, Germany; Department of Cancer Research, Fachklinik Hornheide, Münster, Germany.
| | - Meike S Roux
- Department of Cancer Research, Fachklinik Hornheide, Münster, Germany
| | - Thomas Falk
- Department of Dermatohistopathology, Dermatologikum Hamburg, Hamburg, Germany
| | - Martina Bresch
- Department of Dermatohistopathology, Dermatologikum Hamburg, Hamburg, Germany
| | - Volker Böhm
- Center for Spinal Cord Injuries, Werner Wicker Hospital, Bad Wildungen, Germany
| | | | - Thomas Meiners
- Center for Spinal Cord Injuries, Werner Wicker Hospital, Bad Wildungen, Germany
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5
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Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema. Int J Mol Sci 2022; 23:ijms231911359. [PMID: 36232660 PMCID: PMC9570352 DOI: 10.3390/ijms231911359] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Breast cancer-related lymphedema (BCRL) is a form of secondary lymphedema that is characterized by abnormal swelling of one or both arms due to the accumulation of lymph fluid in the interstitial tissue spaces, resulting from obstruction of the lymphatic vessels due to surgery insults, radiotherapy, or chemotherapy. Due to the multifactorial nature of this condition, the pathogenesis of secondary lymphedema remains unclear and the search for molecular factors associated with the condition is ongoing. This study aimed to identify serum microRNAs and adipokines associated with BCRL. Blood was collected from 113 breast cancer survivors and processed to obtain serum for small RNA-sequencing (BCRL vs. non-BCRL, n = 7 per group). MicroRNAs that were differentially expressed (fold change >1.5, p < 0.05) between lymphedema cases and those without lymphedema were further quantified in a validation cohort through quantitative reverse transcription PCR (BCRL n = 16, non-BCRL, n = 83). Leptin and adiponectin levels were measured in a combined cohort (BCRL n = 23, non-BCRL n = 90) using enzyme-linked immunosorbent assays. Two of the most significantly upregulated microRNAs, miR-199a-3p and miR-151a-3p, were strongly correlated with the onset of lymphedema and diabetes mellitus in the BCRL group. Leptin levels were higher in the BCRL cohort compared to the non-BCRL cohort (p < 0.05). A metabolic syndrome biomarker, the adiponectin/leptin ratio, was found to be lower in the BCRL group than in the non-BCRL group (median: 0.28 vs. 0.41, p < 0.05). Extensive studies on the mechanisms of the identified microRNAs and association of leptin with arm lymphedema may provide new insights on the potential biomarkers for lymphedema that should be followed up in a prospective cohort study.
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Ogino R, Yokooji T, Hayashida M, Suda S, Yamakawa S, Hayashida K. Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema. Int J Mol Sci 2022; 23:ijms23147614. [PMID: 35886961 PMCID: PMC9322118 DOI: 10.3390/ijms23147614] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.
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Affiliation(s)
- Ryohei Ogino
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Tomoharu Yokooji
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan; (R.O.); (T.Y.)
| | - Maiko Hayashida
- Department of Psychiatry, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan;
| | - Shota Suda
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Sho Yamakawa
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan; (S.S.); (S.Y.)
- Correspondence: ; Tel.: +81-853-20-2210
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7
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Sung C, Wang S, Hsu J, Yu R, Wong AK. Current Understanding of Pathological Mechanisms of Lymphedema. Adv Wound Care (New Rochelle) 2022; 11:361-373. [PMID: 34521256 PMCID: PMC9051876 DOI: 10.1089/wound.2021.0041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Significance: Lymphedema is a common disease that affects hundreds of millions of people worldwide with significant financial and social burdens. Despite increasing prevalence and associated morbidities, the mainstay treatment of lymphedema is largely palliative without an effective cure due to incomplete understanding of the disease. Recent Advances: Recent studies have described key histological and pathological processes that contribute to the progression of lymphedema, including lymphatic stasis, inflammation, adipose tissue deposition, and fibrosis. This review aims to highlight cellular and molecular mechanisms involved in each of these pathological processes. Critical Issues: Despite recent advances in the understanding of the pathophysiology of lymphedema, cellular and molecular mechanisms underlying the disease remains elusive due to its complex nature. Future Directions: Additional research is needed to gain a better insight into the cellular and molecular mechanisms underlying the pathophysiology of lymphedema, which will guide the development of therapeutic strategies that target specific pathology of the disease.
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Affiliation(s)
- Cynthia Sung
- Keck School of Medicine of USC, Los Angeles, California, USA.,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Sarah Wang
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Jerry Hsu
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Roy Yu
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Alex K. Wong
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Correspondence: Division of Plastic Surgery, City of Hope National Medical Center, 1500 Duarte Road, Familian Science Building 1018, Duarte, CA 91010, USA.
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8
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Duhon BH, Phan TT, Taylor SL, Crescenzi RL, Rutkowski JM. Current Mechanistic Understandings of Lymphedema and Lipedema: Tales of Fluid, Fat, and Fibrosis. Int J Mol Sci 2022; 23:6621. [PMID: 35743063 PMCID: PMC9223758 DOI: 10.3390/ijms23126621] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022] Open
Abstract
Lymphedema and lipedema are complex diseases. While the external presentation of swollen legs in lower-extremity lymphedema and lipedema appear similar, current mechanistic understandings of these diseases indicate unique aspects of their underlying pathophysiology. They share certain clinical features, such as fluid (edema), fat (adipose expansion), and fibrosis (extracellular matrix remodeling). Yet, these diverge on their time course and known molecular regulators of pathophysiology and genetics. This divergence likely indicates a unique route leading to interstitial fluid accumulation and subsequent inflammation in lymphedema versus lipedema. Identifying disease mechanisms that are causal and which are merely indicative of the condition is far more explored in lymphedema than in lipedema. In primary lymphedema, discoveries of genetic mutations link molecular markers to mechanisms of lymphatic disease. Much work remains in this area towards better risk assessment of secondary lymphedema and the hopeful discovery of validated genetic diagnostics for lipedema. The purpose of this review is to expose the distinct and shared (i) clinical criteria and symptomatology, (ii) molecular regulators and pathophysiology, and (iii) genetic markers of lymphedema and lipedema to help inform future research in this field.
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Affiliation(s)
- Bailey H. Duhon
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
| | - Thien T. Phan
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
| | - Shannon L. Taylor
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN 37232, USA;
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachelle L. Crescenzi
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN 37232, USA;
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Joseph M. Rutkowski
- Department of Medical Physiology, Texas A & M University College of Medicine, Bryan, TX 77807, USA; (B.H.D.); (T.T.P.)
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Baik JE, Park HJ, Kataru RP, Savetsky IL, Ly CL, Shin J, Encarnacion EM, Cavali MR, Klang MG, Riedel E, Coriddi M, Dayan JH, Mehrara BJ. TGF-β1 mediates pathologic changes of secondary lymphedema by promoting fibrosis and inflammation. Clin Transl Med 2022; 12:e758. [PMID: 35652284 PMCID: PMC9160979 DOI: 10.1002/ctm2.758] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/15/2022] Open
Abstract
Background Secondary lymphedema is a common complication of cancer treatment, and previous studies have shown that the expression of transforming growth factor‐beta 1 (TGF‐β1), a pro‐fibrotic and anti‐lymphangiogenic growth factor, is increased in this disease. Inhibition of TGF‐β1 decreases the severity of the disease in mouse models; however, the mechanisms that regulate this improvement remain unknown. Methods Expression of TGF‐β1 and extracellular matrix molecules (ECM) was assessed in biopsy specimens from patients with unilateral breast cancer‐related lymphedema (BCRL). The effects of TGF‐β1 inhibition using neutralizing antibodies or a topical formulation of pirfenidone (PFD) were analyzed in mouse models of lymphedema. We also assessed the direct effects of TGF‐β1 on lymphatic endothelial cells (LECs) using transgenic mice that expressed a dominant‐negative TGF‐β receptor selectively on LECs (LECDN‐RII). Results The expression of TGF‐β1 and ECM molecules is significantly increased in BCRL skin biopsies. Inhibition of TGF‐β1 in mouse models of lymphedema using neutralizing antibodies or with topical PFD decreased ECM deposition, increased the formation of collateral lymphatics, and inhibited infiltration of T cells. In vitro studies showed that TGF‐β1 in lymphedematous tissues increases fibroblast, lymphatic endothelial cell (LEC), and lymphatic smooth muscle cell stiffness. Knockdown of TGF‐β1 responsiveness in LECDN‐RII resulted in increased lymphangiogenesis and collateral lymphatic formation; however, ECM deposition and fibrosis persisted, and the severity of lymphedema was indistinguishable from controls. Conclusions Our results show that TGF‐β1 is an essential regulator of ECM deposition in secondary lymphedema and that inhibition of this response is a promising means of treating lymphedema.
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Affiliation(s)
- Jung Eun Baik
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hyeung Ju Park
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raghu P Kataru
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ira L Savetsky
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Catherine L Ly
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinyeon Shin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth M Encarnacion
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michele R Cavali
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark G Klang
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elyn Riedel
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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10
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Jiang X, Tian W, Kim D, McQuiston AS, Vinh R, Rockson SG, Semenza GL, Nicolls MR. Hypoxia and Hypoxia-Inducible Factors in Lymphedema. Front Pharmacol 2022; 13:851057. [PMID: 35450048 PMCID: PMC9017680 DOI: 10.3389/fphar.2022.851057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/14/2022] [Indexed: 12/19/2022] Open
Abstract
Lymphedema is a chronic inflammatory disorder characterized by edema, fat deposition, and fibrotic tissue remodeling. Despite significant advances in lymphatic biology research, our knowledge of lymphedema pathology is incomplete. Currently, there is no approved pharmacological therapy for this debilitating disease. Hypoxia is a recognized feature of inflammation, obesity, and fibrosis. Understanding hypoxia-regulated pathways in lymphedema may provide new insights into the pathobiology of this chronic disorder and help develop new medicinal treatments.
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Affiliation(s)
- Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
| | - Dongeon Kim
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
| | - Alexander S McQuiston
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
| | - Ryan Vinh
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
| | | | - Gregg L Semenza
- Departments of Pediatrics, Medicine, Oncology, Radiation Oncology, and Biological Chemistry, and McKusick-Nathans Institute of Genetic Medicine, Vascular Program, Institute for Cell Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mark R Nicolls
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Stanford University School of Medicine, Stanford, CA, United States
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11
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Brown S, Dayan JH, Coriddi M, Campbell A, Kuonqui K, Shin J, Park HJ, Mehrara BJ, Kataru RP. Pharmacological Treatment of Secondary Lymphedema. Front Pharmacol 2022; 13:828513. [PMID: 35145417 PMCID: PMC8822213 DOI: 10.3389/fphar.2022.828513] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/07/2022] [Indexed: 12/12/2022] Open
Abstract
Lymphedema is a chronic disease that results in swelling and decreased function due to abnormal lymphatic fluid clearance and chronic inflammation. In Western countries, lymphedema most commonly develops following an iatrogenic injury to the lymphatic system during cancer treatment. It is estimated that as many as 10 million patients suffer from lymphedema in the United States alone. Current treatments for lymphedema are palliative in nature, relying on compression garments and physical therapy to decrease interstitial fluid accumulation in the affected extremity. However, recent discoveries have increased the hopes of therapeutic interventions that may promote lymphatic regeneration and function. The purpose of this review is to summarize current experimental pharmacological strategies in the treatment of lymphedema.
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12
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Kumegawa S, Yamada G, Hashimoto D, Hirashima T, Kajimoto M, Isono K, Fujimoto K, Suzuki K, Uemura K, Ema M, Asamura S. Development of Surgical and Visualization Procedures to Analyze Vasculatures by Mouse Tail Edema Model. Biol Proced Online 2021; 23:21. [PMID: 34758723 PMCID: PMC8582144 DOI: 10.1186/s12575-021-00159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 12/02/2022] Open
Abstract
Background Because of the high frequency of chronic edema formation in the current “aged” society, analyses and detailed observation of post-surgical edema are getting more required. Post-surgical examination of the dynamic vasculature including L.V. (Lymphatic Vasculature) to monitor edema formation has not been efficiently performed. Hence, procedures for investigating such vasculature are essential. By inserting transparent sheet into the cutaneous layer of mouse tails as a novel surgery model (theTailEdema bySilicone sheet mediatedTransparency protocol; TEST), the novel procedures are introduced and analyzed by series of histological analyses including video-based L.V. observation and 3D histological reconstruction of vasculatures in mouse tails. Results The dynamic generation of post-surgical main and fine (neo) L.V. connective structure during the edematous recovery process was visualized by series of studies with a novel surgery model. Snapshot images taken from live binocular image recording for TEST samples suggested the presence of main and elongating fine (neo) L.V. structure. After the ligation of L.V., the enlargement of main L.V. was confirmed. In the case of light sheet fluorescence microscopy (LSFM) observation, such L.V. connections were also suggested by using transparent 3D samples. Finally, the generation of neo blood vessels particularly in the region adjacent to the silicone sheet and the operated boundary region was suggested in 3D reconstruction images. However, direct detection of elongating fine (neo) L.V. was not suitable for analysis by such LSFM and 3D reconstruction procedures. Thus, such methods utilizing fixed tissues are appropriate for general observation for the operated region including of L.V. Conclusions The current surgical procedures and analysis on the post-surgical status are the first case to observe vasculatures in vivo with a transparent sheet. Systematic analyses including the FITC-dextran mediated snap shot images observation suggest the elongation of fine (neo) lymphatic vasculature. Post-surgical analyses including LSFM and 3D histological structural reconstruction, are suitable to reveal the fixed structures of blood and lymphatic vessels formation. Supplementary Information The online version contains supplementary material available at 10.1186/s12575-021-00159-3.
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Affiliation(s)
- Shinji Kumegawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Medical University of Wakayama, Wakayama, Japan
| | - Gen Yamada
- Department of Developmental Genetics, Institute of Advanced Medicine, Medical University of Wakayama, Wakayama, Japan.
| | - Daiki Hashimoto
- Department of molecular Physiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tsuyoshi Hirashima
- The Hakubi Center/Graduate School of Biostudies, Kyoto University, Kyoto, Japan
| | - Mizuki Kajimoto
- Department of Developmental Genetics, Institute of Advanced Medicine, Medical University of Wakayama, Wakayama, Japan
| | - Kyoichi Isono
- Laboratory Animal Center, Wakayama Medical University, Wakayama, Japan
| | - Kota Fujimoto
- Department of Developmental Genetics, Institute of Advanced Medicine, Medical University of Wakayama, Wakayama, Japan
| | - Kentaro Suzuki
- Department of Developmental Genetics, Institute of Advanced Medicine, Medical University of Wakayama, Wakayama, Japan
| | - Kazuhisa Uemura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Medical University of Wakayama, Wakayama, Japan
| | - Masatsugu Ema
- Department of Stem Cells and Human Diseases Models, Research Center for Animal Life Science, Medical University of Shiga, Otsu, Shiga, Japan
| | - Shinichi Asamura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Medical University of Wakayama, Wakayama, Japan
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13
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Yusof KM, Groen K, Rosli R, Avery-Kiejda KA. Crosstalk Between microRNAs and the Pathological Features of Secondary Lymphedema. Front Cell Dev Biol 2021; 9:732415. [PMID: 34733847 PMCID: PMC8558478 DOI: 10.3389/fcell.2021.732415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/01/2021] [Indexed: 01/07/2023] Open
Abstract
Secondary lymphedema is characterized by lymphatic fluid retention and subsequent tissue swelling in one or both limbs that can lead to decreased quality of life. It often arises after loss, obstruction, or blockage of lymphatic vessels due to multifactorial modalities, such as lymphatic insults after surgery, immune system dysfunction, deposition of fat that compresses the lymphatic capillaries, fibrosis, and inflammation. Although secondary lymphedema is often associated with breast cancer, the condition can occur in patients with any type of cancer that requires lymphadenectomy such as gynecological, genitourinary, or head and neck cancers. MicroRNAs demonstrate pivotal roles in regulating gene expression in biological processes such as lymphangiogenesis, angiogenesis, modulation of the immune system, and oxidative stress. MicroRNA profiling has led to the discovery of the molecular mechanisms involved in the pathophysiology of auto-immune, inflammation-related, and metabolic diseases. Although the role of microRNAs in regulating secondary lymphedema is yet to be elucidated, the crosstalk between microRNAs and molecular factors involved in the pathological features of lymphedema, such as skin fibrosis, inflammation, immune dysregulation, and aberrant lipid metabolism have been demonstrated in several studies. MicroRNAs have the potential to serve as biomarkers for diseases and elucidation of their roles in lymphedema can provide a better understanding or new insights of the mechanisms underlying this debilitating condition.
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Affiliation(s)
- Khairunnisa' Md Yusof
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia.,Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Kira Groen
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia
| | - Rozita Rosli
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,UPM-MAKNA Cancer Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang, Malaysia
| | - Kelly A Avery-Kiejda
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia
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14
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Huang CW, Chang YC, Hsiao HY, Liu JW, Chang FCS, Huang JJ. Creation of a rat lymphedema model using extensive lymph node dissection and circumferential soft tissue resection: Is this a reliable model? Microsurgery 2021; 41:762-771. [PMID: 34617323 DOI: 10.1002/micr.30817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The medical demand for lymphedema treatment is huge since the disease mechanism remains unclear, and management are difficult. Our purpose was to develop a reliable lymphedema model mimicking the clinical scenario and allows a microsurgical approach. MATERIALS AND METHODS Male Lewis rats weighing 400 to 450 g were used to create lymphedema with groin and popliteal lymph node dissection and creation of 5 mm circumferential skin defect (n = 6). A skin incision was made and closed primarily for control group (n = 5). Evaluation included indocyanine green (ICG) lymphangiography 1 and 2 months postoperatively, volume difference between bilateral hindlimbs measured using micro-CT, and the skin was harvested for histological evaluation 2 months postoperatively. RESULTS Larger volume differences present in the lymphedema group (17.50 ± 7.76 vs. 3.73 ± 2.66%, p < .05). ICG lymphangiography indicated dermal backflow only in the lymphedema group. Increased thickness of the epidermis was noted in lymphedema group (28.50 ± 12.61 μm vs. 15.10 ± 5.41 μm, p < .0001). More CD45+ (35.6 ± 26.68 vs. 2.8 ± 4.23 cells/high power field [HPF], p < .0001), CD3+ (38.39 ± 20.17 vs. 9.73 ± 8.62 cells/HPF, p < .0001), and CD4+ cell infiltration (11.7 ± 7.71 vs. 2.0 ± 2.67 cells/HPF, p < .0001) were observed in the lymphedema group. Collagen type I deposition was more in the lymphedema group (0.15 ± 0.06 vs. 0.07 ± 0.03, p < .0005). CONCLUSIONS A rat lymphedema model was successfully established. The model can be applied in lymphedema related research.
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Affiliation(s)
- Chi-Wei Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Yung-Chun Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Yi Hsiao
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jia-Wei Liu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Frank Chun-Shin Chang
- Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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15
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Use of adipose-derived stem cells in lymphatic tissue engineering and regeneration. Arch Plast Surg 2021; 48:559-567. [PMID: 34583446 PMCID: PMC8490113 DOI: 10.5999/aps.2021.00339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022] Open
Abstract
The potential to differentiate into different cell lines, added to the easy and cost-effective method of extraction, makes adipose-derived stem cells (ADSCs) an object of interest in lymphedema treatment. Our study’s goal was to conduct a comprehensive systematic review of the use of ADSCs in lymphatic tissue engineering and regeneration. On July 23, 2019, using PubMed/MEDLINE, Cochrane Clinical Answers, Cochrane Central Register of Controlled Trials, and Embase databases, we conducted a systematic review of published literature on the use of ADSCs in lymphatic tissue engineering and regeneration. There were no language or time frame limitations, and the following search strategy was applied: ((Adipose stem cell) OR Adipose-derived stem cell)) AND ((Lymphedema) OR Breast Cancer Lymphedema). Only original research manuscripts were included. Fourteen studies fulfilled the inclusion criteria. Eleven studies were experimental (in vitro or in vivo in animals), and only three were clinical. Publications on the topic demonstrated that ADSCs promote lymphangiogenesis, and its effect could be enhanced by modulation of vascular endothelial growth factor-C, interleukin-7, prospero homeobox protein 1, and transforming growth factor-β1. Pilot clinical studies included 11 patients with breast cancer-related lymphedema, and no significant side effects were present at 12-month follow-up. Literature on the use of ADSCs in lymphatic tissue engineering and regeneration demonstrated promising data. Clinical evidence is still in its infancy, but the scientific community agrees that ADSCs can be useful in regenerative lymphangiogenesis. Data collected in this review indicate that unprecedented advances in lymphedema treatment can be anticipated in the upcoming years.
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16
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Scallan JP, Knauer LA, Hou H, Castorena-Gonzalez JA, Davis MJ, Yang Y. Foxo1 deletion promotes the growth of new lymphatic valves. J Clin Invest 2021; 131:e142341. [PMID: 34263740 DOI: 10.1172/jci142341] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 06/03/2021] [Indexed: 11/17/2022] Open
Abstract
Patients with congenital lymphedema suffer from tissue swelling in part due to mutations in genes regulating lymphatic valve development. Lymphatic valve leaflets grow and are maintained throughout life in response to oscillatory shear stress (OSS), which regulates gene transcription in lymphatic endothelial cells (LECs). Here, we identified the first transcription factor, Foxo1, that repressed lymphatic valve formation by inhibiting the expression of valve-forming genes. We showed that both embryonic and postnatal ablation of Foxo1 in LECs induced additional valve formation in postnatal and adult mice in multiple tissues. Our quantitative analyses revealed that after deletion, the total number of valves in the mesentery was significantly (P < 0.01) increased in the Foxo1LEC-KO mice compared with Foxo1fl/fl controls. In addition, our quantitative real-time PCR (RT-PCR) data from cultured LECs showed that many valve-forming genes were significantly (P < 0.01) upregulated upon knockdown of FOXO1. To confirm our findings in vivo, rescue experiments showed that Foxc2+/- mice, a model of lymphedema-distichiasis, had 50% fewer lymphatic valves and that the remaining valves exhibited backleak. Both valve number and function were completely restored to control levels upon Foxo1 deletion. These findings established FOXO1 as a clinically relevant target to stimulate de novo lymphatic valve formation and rescue defective valves in congenital lymphedema.
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Affiliation(s)
- Joshua P Scallan
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Luz A Knauer
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Huayan Hou
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Michael J Davis
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri, USA
| | - Ying Yang
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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17
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Forte AJ, Boczar D, Huayllani MT, Anastasiadis PZ, McLaughlin SA. Use of Vascular Endothelial Growth Factor-D As a Targeted Therapy in Lymphedema Treatment: A Comprehensive Literature Review. Lymphat Res Biol 2021; 20:3-6. [PMID: 33739868 DOI: 10.1089/lrb.2020.0011] [Citation(s) in RCA: 3] [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: Lymphangiogenic growth factors, such as vascular endothelial growth factor (VEGF)-D, are subjects of interest in studies of targeted therapies in lymphedema treatment. Methods and Results: We conducted a systematic review assessing the use of VEGF-D as a targeted therapy in lymphedema treatment. We hypothesized that VEGF-D was a promising therapy to induce lymphangiogenesis. Our search yielded 90 studies in the literature, but only 4 articles fulfilled our study eligibility criteria, and they were all experimental studies using viral gene transfer. The majority of the studies were conducted on small animals (mice) and investigated the effects of VEGF-D on lymph node transfer. All authors agreed about VEGF-D's lymphangiogenic potential, but they noticed that VEGF-C induced a superior lymphangiogenesis, and one study noticed that VEGF-D induced seroma. Conclusions: The publications assessing the use of VEGF-D as a targeted therapy in lymphedema treatment were able to demonstrate its lymphangiogenic potential. Nonetheless, further studies are still necessary to investigate VEGF-D's efficacy and safety in lymphedema treatment on patients.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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18
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Hassanein AH, Sinha M, Neumann CR, Mohan G, Khan I, Sen CK. A Murine Tail Lymphedema Model. J Vis Exp 2021:10.3791/61848. [PMID: 33645579 PMCID: PMC8056335 DOI: 10.3791/61848] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Lymphedema is extremity swelling caused by lymphatic dysfunction. The affected limb enlarges because of accumulation of fluid, adipose, and fibrosis. There is no cure for this disease. A mouse tail model that uses a focal full thickness skin excision near the base of the tail, resulting in tail swelling, has been used to study lymphedema. However, this model may result in vascular comprise and consequent tail necrosis and early tail swelling resolution, limiting its clinical translatability. The chronic murine tail lymphedema model induces sustained lymphedema over 15 weeks and a reliable perfusion to the tail. Enhancements of the traditional murine tail lymphedema model include 1) precise full thickness excision and lymphatic clipping using a surgical microscope, 2) confirmation of post-operative arterial and venous perfusion using high resolution laser speckle, and 3) functional assessment using indocyanine green near infrared laser lymphangiography. We also use tissue nanotransfection technology (TNT) for novel non-viral, transcutaneous, focal delivery of genetic cargo to the mouse tail vasculature.
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Affiliation(s)
- Aladdin H Hassanein
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine;
| | - Mithun Sinha
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine
| | - Colby R Neumann
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine
| | - Ganesh Mohan
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine
| | - Imran Khan
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine
| | - Chandan K Sen
- Department of Surgery, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine
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19
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Will PA, Rafiei A, Pretze M, Gazyakan E, Ziegler B, Kneser U, Engel H, Wängler B, Kzhyshkowska J, Hirche C. Evidence of stage progression in a novel, validated fluorescence-navigated and microsurgical-assisted secondary lymphedema rodent model. PLoS One 2020; 15:e0235965. [PMID: 32701960 PMCID: PMC7377415 DOI: 10.1371/journal.pone.0235965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022] Open
Abstract
Secondary lymphedema (SL)is a frequent and devastating complication of modern oncological therapy and filarial infections. A lack of a reliable preclinical model to investigate the underlying mechanism of clinical stage progression has limited the development of new therapeutic strategies. Current first line treatment has shown to be merely symptomatic and relies on lifetime use of compression garments and decongestive physiotherapy. In this study, we present the development of a secondary lymphedema model in 35 rats using pre- and intraoperative fluorescence-guided mapping of the lymphatics and microsurgical induction. In contrast to the few models reported so far, we decided to avoid the use of radiation for lymphedema induction. It turned out, that the model is nearly free of complications and capable of generating a statistically significant limb volume increase by water displacement measurements, sustained for at least 48 days. A translational, accurate lymphatic dysfunction was visualized by a novel VIS-NIR X-ray ICG-Clearance-Capacity imaging technology. For the first-time SL stage progression was validated by characteristic histological alterations, such as subdermal mast cell infiltration, adipose tissue deposition, and fibrosis by increased skin collagen content. Immunofluorescence confocal microscopy analysis suggested that stage progression is related to the presence of a characteristic α SMA+/HSP-47+/vimentin+ fibroblast subpopulation phenotype. These findings demonstrate that the in-vivo model is a reliable and clinically relevant SL model for the development of further secondary lymphedema therapeutic strategies and the analysis of the veiled molecular mechanisms of lymphatic dysfunction.
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Affiliation(s)
- P. A. Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - A. Rafiei
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - M. Pretze
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - E. Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - B. Ziegler
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - U. Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - H. Engel
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
- Ethianum Klinik Heidelberg, Heidelberg, Germany
| | - B. Wängler
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - J. Kzhyshkowska
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- German Red Cross Blood Service Baden-Württemberg—Hessen, Frankfurt, Germany
| | - C. Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
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20
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Azhar SH, Lim HY, Tan BK, Angeli V. The Unresolved Pathophysiology of Lymphedema. Front Physiol 2020; 11:137. [PMID: 32256375 PMCID: PMC7090140 DOI: 10.3389/fphys.2020.00137] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
Lymphedema is the clinical manifestation of impaired lymphatic transport. It remains an under-recognized and under-documented clinical condition that still lacks a cure. Despite the substantial advances in the understanding of lymphatic vessel biology and function in the past two decades, there are still unsolved questions regarding the pathophysiology of lymphedema, especially in humans. As a consequence of impaired lymphatic drainage, proteins and lipids accumulate in the interstitial space, causing the regional tissue to undergo extensive and progressive architectural changes, including adipose tissue deposition and fibrosis. These changes are also associated with inflammation. However, the temporal sequence of these events, the relationship between these events, and their interplay during the progression are not clearly understood. Here, we review our current knowledge on the pathophysiology of lymphedema derived from human and animal studies. We also discuss the possible cellular and molecular mechanisms involved in adipose tissue and collagen accumulation during lymphedema. We suggest that more studies should be dedicated to enhancing our understanding of the human pathophysiology of lymphedema to pave the way for new diagnostic and therapeutic avenues for this condition.
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Affiliation(s)
- Syaza Hazwany Azhar
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hwee Ying Lim
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bien-Keem Tan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Veronique Angeli
- Department of Microbiology and Immunology, Life Science Institute, Yoon Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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21
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Forte AJ, Boczar D, Huayllani MT, McLaughlin SA, Bagaria S. Topical Approach to Delivering Targeted Therapies in Lymphedema Treatment: A Systematic Review. Cureus 2019; 11:e6269. [PMID: 31815081 PMCID: PMC6886732 DOI: 10.7759/cureus.6269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
It is estimated that 140 to 200 million people are affected by lymphedema worldwide. Many studies have proposed targeted therapies that can be delivered systemically or locally to treat lymphedema. Since lymphedema primarily affects the skin and subcutaneous tissues, topical approaches to therapy should be considered as an attractive proposition as they can avoid systemic complications. In light of this, we conducted a systematic review of publications that analyzed the use of topical approaches to delivering targeted therapies in the treatment of lymphedema. We hypothesized that topical approaches resulted in the satisfactory treatment of lymphedema. We conducted a systematic review of publications on PubMed. The main eligibility criterion was that the articles should primarily investigate the use of topical approaches to delivering targeted therapies in the treatment of lymphedema. Consequently, we excluded papers that investigated any other delivery approaches or medical conditions. Of the 174 potential studies found in the literature, six were found to fulfill our eligibility criteria. All these studies were experimental ones on small animals (mice). The authors generally proposed different types of therapies, which could be clustered into two main groups: 1) induction of lymphangiogenesis [vascular endothelial growth factor C (VEGF-C) hydrogel or fibroblast growth factor]; and 2) modulation of inflammation (tacrolimus or topical collagen gel or troxerutin-phosphatidylcholine). All studies presented positive outcomes, demonstrating that topical therapy is a promising route for delivering growth factors and anti-inflammatory agents in the treatment of lymphedema. However, studies were conducted under heterogeneous protocols, and the safe application of these therapies in humans has not been assessed. Further studies are necessary to confirm the benefits and safety of targeted topical therapy on patients with lymphedema.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sanjay Bagaria
- Surgery, Mayo Clinic Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
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22
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Bertelli M, Kiani AK, Paolacci S, Manara E, Dautaj A, Beccari T, Michelini S. Molecular pathways involved in lymphedema: Hydroxytyrosol as a candidate natural compound for treating the effects of lymph accumulation. J Biotechnol 2019; 308:82-86. [PMID: 31794783 DOI: 10.1016/j.jbiotec.2019.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 12/14/2022]
Abstract
Lymphedema is a chronic accumulation of interstitial fluid due to inefficient lymph drainage. Major causes of lymphedema are malformations of lymphatic vessels, trauma, toxic damage and surgery. The swelling typically affects the limbs. Lymphedema may be primary, caused by genetic mutations and relatively rare, or secondary (acquired), due to external causes such as infections or surgery. Fluid accumulation induces pathological changes: activation of the inflammatory cascade, immune cell infiltration, tissue fibrosis, adipose accumulation. We focused on the inflammatory phenotype mediated by leukotriene B4, a lipid mediator of the inflammatory pathway, and the potential therapeutic effect of hydroxytyrosol. We conducted an electronic search in PubMed using "lymphedema", "lymphedema pathway", "hydroxytyrosol" as keywords. We found that lymphedema deregulates at least six molecular pathways and that hydroxytyrosol, a compound with antioxidant activity, can improve endothelial dysfunction, hemostatic and lipid profiles, and decrease oxidative stress and inflammation through inhibition of leukotriene B4 activity. This review is the first to highlight the possibility of using hydroxytyrosol to treat the secondary effects of lymphedema, especially inflammation. The possible effects of hydroxytyrosol on lymphedema should be tested in vitro and in vivo to find the best way to treat patients with lymphedema in order to improve their health status.
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Affiliation(s)
- Matteo Bertelli
- EBTNA-Lab, Via Delle Maioliche, 57/G, 38068, Rovereto, TN, Italy.
| | - Aysha Karim Kiani
- Allama Iqbal Open University, Sector H-8, 44000, Islamabad, Pakistan.
| | - Stefano Paolacci
- MAGI's Lab, Via Delle Maioliche, 57/D, 38068, Rovereto, TN, Italy.
| | - Elena Manara
- MAGI Euregio, Via Maso della Pieve, 60/A, 39100, Bolzano, Italy.
| | - Astrit Dautaj
- MAGI Balkans, Rruga Andon Zako Cajupi, 1019, Tirana, Albania.
| | - Tommaso Beccari
- Department of Pharmaceutical Sciences, University of Perugia, Via Ariodante Fabretti, 48, 06123, Perugia, Italy.
| | - Sandro Michelini
- Department of Vascular Rehabilitation, San Giovanni Battista Hospital, Via Luigi Ercole Morselli, 13, 00148, Rome, Italy.
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Forte AJ, Boczar D, Huayllani MT, McLaughlin SA, Bagaria S. Use of Gene Transfer Vectors in Lymphedema Treatment: A Systematic Review. Cureus 2019; 11:e5887. [PMID: 31772857 PMCID: PMC6837272 DOI: 10.7759/cureus.5887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Different delivery mechanisms have been proposed in the literature for targeted therapies in the treatment of lymphedema. They vary from simple and direct injection to sophisticated induction of gene expression in a targeted tissue. We conducted a systematic review of publications assessing the use of viral vectors for gene transfer in lymphedema treatment. We hypothesized that viral vectors are an effective way to deliver targeted therapy in lymphedema treatment. We conducted a comprehensive systematic review of the published literature on targeted therapies associated with lymphedema surgery using the PubMed database. Eligibility criteria excluded papers that reported use of viral vectors for other medical conditions. Abstracts, presentations, reviews, meta-analyses, and non-English language articles were also excluded. From 21 potential articles found in the literature, fourteen fulfilled study eligibility criteria. Positive outcomes in terms of lymphangiogenesis were seen. The viral vectors used included adenovirus and recombinant adeno-associated virus. Most of the genes expressed were growth factors, but expression of dominant-negative transforming growth factor-β1 receptor-II or Prox1 was also proposed. Five studies targeted genetic expression on lymphedema tissue, five on transplanted lymph nodes, two on skeletal muscle, and one on adipose-derived stem cells. Publications assessing use of viral vectors for gene transfer in lymphedema treatment demonstrated that it is an effective mechanism of delivering targeted therapies. However, to date, all studies were experimental and further studies must be performed before translating these therapies into clinical practice.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sanjay Bagaria
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
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24
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Forte AJ, Boczar D, Huayllani MT, Lu X, McLaughlin SA. Sympathetic Nerve Block in Lymphedema Treatment: A Systematic Review. Cureus 2019; 11:e5700. [PMID: 31720168 PMCID: PMC6823032 DOI: 10.7759/cureus.5700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although the sympathetic nerve system has been described as a modulator of lymphatic circulation, it has not been targeted in the treatment of lymphedema. We conducted a systematic review of publications assessing the use of sympathetic nerve block in lymphedema treatment. We hypothesized that sympathetic nerve block may be a promising treatment option for lymphedema patients. We conducted a comprehensive systematic review of the published literature on the use of sympathetic nerve block in lymphedema treatment using the PubMed database. Eligibility criteria excluded papers that reported other types of lymphedema treatment or any other anesthesiology procedure. Abstracts, presentations, reviews, and meta-analyses were also excluded. Extracted data included the year of study, country, author affiliation, type of study, patient characteristics, nerve block technique, and key findings. From 81 potential papers, eight studies fulfilled the eligibility criteria. All papers identified were clinical, reporting on a total of 187 patients. Sympathetic nerve block was proposed with local anesthetics, whether or not associated with triamcinolone. Treatment with a nerve block promoted lymphedema improvement expressed by decreased limb circumference and patient-reported outcomes. Large randomized clinical trials are still pending, but sympathetic nerve block seems to be a promising alternative for lymphedema patients who do not respond to conservative therapy.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Xiaona Lu
- Division of Plastic Surgery, Yale University, New Haven, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
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25
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Forte AJ, Boczar D, Huayllani MT, Bagaria S, McLaughlin SA. Use of Autologous Blood Components in Lymphedema Treatment: A Systematic Review. Cureus 2019; 11:e5638. [PMID: 31700741 PMCID: PMC6822891 DOI: 10.7759/cureus.5638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The main benefit of autologous therapies is its easier obtention and relatively lower concerns regarding ethical implications and patient safety. We conducted a systematic review of publications assessing the potential use of blood components (lymphocytes, red blood cells (RBCs), platelet-rich plasma (PRP)) as targeted therapy in the treatment of lymphedema. We hypothesized that blood components could be used as targeted therapy in the lymphedema treatment. We also conducted a comprehensive, systematic review of the published literature on the use of blood components as targeted therapies in the treatment of lymphedema using the PubMed database. Eligibility criteria excluded papers that aimed to investigate the correlation of inflammatory cells and the physio-pathogenesis of lymphedema. Abstracts, presentations, reviews, and meta-analyses were also excluded. From the 338 potential papers found in the literature, 11 studies fulfilled the eligibility criteria. Different types of targeted therapies were proposed, but the majority of papers investigated the potential use of lymphocytes (9/11). The use of PRP was investigated in two papers and the use of RBCs in one paper. Interestingly, six out of 11 studies were done on patients with lymphedema, but the most recent was published in 1999. The remaining publications were experimental studies on dogs, rats, or in vitro. The publications demonstrated positive outcomes for the delivery of lymphocytes and PRP in lymphedema treatment. Lymphocyte was the most common blood component investigated. Even though more than half of the papers found were conducted on patients, we noticed a scientific gap of more than 20 years on the topic.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sanjay Bagaria
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
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Forte AJ, Boczar D, Huayllani MT, Cinotto GJ, McLaughlin S. Targeted Therapies in Surgical Treatment of Lymphedema: A Systematic Review. Cureus 2019; 11:e5397. [PMID: 31431851 PMCID: PMC6697455 DOI: 10.7759/cureus.5397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although physiologic surgeries for lymphedema (i.e., lymphovenous bypass, vascularized lymph node transplantation) are becoming well established, unpredictable outcomes have still been reported in some studies. Therefore, authors have investigated ways to improve these surgery outcomes. The goal of our study was to conduct a comprehensive systematic review of targeted therapy administration in the surgical treatment of lymphedema. We conducted a comprehensive systematic review of the published literature on targeted therapies associated with lymphedema surgery using the PubMed database. Eligibility criteria excluded papers that reported surgical treatment of lymphedema without the use of targeted therapies and also papers describing targeted therapies in nonsurgical treatment of lymphedema. Abstracts, presentations, reviews, and meta-analyses were also excluded. Extracted data included the year of study, country, lymphedema model, surgical technique, targeted therapy agent, therapy delivery, findings, and outcomes. From 823 potential papers found in the literature, 10 studies fulfilled the eligibility criteria. All papers were experimental, and most of them on small animal model (7/10). Different targeted therapies were proposed, but all of them were associated with lymph node transplantation. The most common targeted therapy proposed mechanism was growth factor delivery (8/10). However, one paper used adipose-stem cell, and one paper proposed the use of sterile inflammation. The pooled publications assessing targeted therapy administration in the surgical treatment of lymphedema demonstrate encouraging data for positive outcomes. To date, all studies were experimental and related to lymph node transfer.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, USA
| | - Gabriela J Cinotto
- Plastic Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, USA
| | - Sarah McLaughlin
- Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, USA
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A novel mouse tail lymphedema model for observing lymphatic pump failure during lymphedema development. Sci Rep 2019; 9:10405. [PMID: 31320677 PMCID: PMC6639358 DOI: 10.1038/s41598-019-46797-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 07/05/2019] [Indexed: 02/07/2023] Open
Abstract
It has been suggested that many forms of secondary lymphedema in humans are driven by a progressive loss of lymphatic pump function after an initial risk-inducing event. However, the link between pump failure and disease progression has remained elusive due to experimental challenges in the clinical setting and a lack of adequate animal models. Using a novel surgical model of lymphatic injury, we track the adaptation and functional decline of the lymphatic network in response to surgery. This model mimics the histological hallmarks of the typical mouse tail lymphedema model while leaving an intact collecting vessel for analysis of functional changes during disease progression. Lymphatic function in the intact collecting vessel negatively correlated with swelling, while a loss of pumping pressure generation remained even after resolution of swelling. By using this model to study the role of obesity in lymphedema development, we show that obesity exacerbates acquired lymphatic pump failure following lymphatic injury, suggesting one mechanism through which obesity may worsen lymphedema. This lymphatic injury model will allow for future studies investigating the molecular mechanisms leading to lymphedema development.
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28
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Sauter IP, Madrid KG, de Assis JB, Sá-Nunes A, Torrecilhas AC, Staquicini DI, Pasqualini R, Arap W, Cortez M. TLR9/MyD88/TRIF signaling activates host immune inhibitory CD200 in Leishmania infection. JCI Insight 2019; 4:126207. [PMID: 31092731 DOI: 10.1172/jci.insight.126207] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 04/11/2019] [Indexed: 02/06/2023] Open
Abstract
Virulent protozoans named Leishmania in tropical and subtropical areas produce devastating diseases by exploiting host immune responses. Amastigotes of Leishmania amazonensis stimulate macrophages to express CD200, an immunomodulatory ligand, which binds to its cognate receptor (CD200R) and inhibits the inducible nitric oxide synthase and nitric oxide (iNOS/NO) signaling pathways, thereby promoting intracellular survival. However, the mechanisms underlying CD200 induction in macrophages remain largely unknown. Here, we show that phagocytosis-mediated internalization of L. amazonensis amastigotes following activation of endosomal TLR9/MyD88/TRIF signaling is critical for inducing CD200 in infected macrophages. We also demonstrate that Leishmania microvesicles containing DNA fragments activate TLR9-dependent CD200 expression, which inhibits the iNOS/NO pathway and modulates the course of L. amazonensis infection in vivo. These findings demonstrate that Leishmania exploits TLR-signaling pathways not only to inhibit macrophage microbicidal function, but also to evade host systemic immune responses, which has many implications in the severity of the disease.
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Affiliation(s)
| | | | - Josiane B de Assis
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Anderson Sá-Nunes
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Ana C Torrecilhas
- Department of Pharmaceutical Sciences, Federal University of São Paulo, São Paulo, Brazil
| | - Daniela I Staquicini
- Rutgers Cancer Institute of New Jersey and Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Renata Pasqualini
- Rutgers Cancer Institute of New Jersey and Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Wadih Arap
- Rutgers Cancer Institute of New Jersey and Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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29
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Kataru RP, Baik JE, Park HJ, Wiser I, Rehal S, Shin JY, Mehrara BJ. Regulation of Immune Function by the Lymphatic System in Lymphedema. Front Immunol 2019; 10:470. [PMID: 30936872 PMCID: PMC6431610 DOI: 10.3389/fimmu.2019.00470] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
The lymphatic vasculature has traditionally been thought to play a passive role in the regulation of immune responses by transporting antigen presenting cells and soluble antigens to regional lymph nodes. However, more recent studies have shown that lymphatic endothelial cells regulate immune responses more directly by modulating entry of immune cells into lymphatic capillaries, presenting antigens on major histocompatibility complex proteins, and modulating antigen presenting cells. Secondary lymphedema is a disease that develops when the lymphatic system is injured during surgical treatment of cancers or is damaged by infections. We have used mouse models of lymphedema in order to understand the effects of chronic lymphatic injury on immune responses and have shown that lymphedema results in a mixed T helper cell and T regulatory cell (Treg) inflammatory response. Prolonged T helper 2 biased immune responses in lymphedema regulate the pathology of this disease by promoting tissue fibrosis, inhibiting formation of collateral lymphatics, decreasing lymphatic vessel pumping capacity, and increasing lymphatic leakiness. Treg infiltration following lymphatic injury results from proliferation of natural Tregs and suppresses innate and adaptive immune responses. These studies have broad clinical relevance since understanding how lymphatic injury in lymphedema can modulate immune responses may provide a template with which we can study more subtle forms of lymphatic injury that may occur in physiologic conditions such as aging, obesity, metabolic tumors, and in the tumor microenvironment.
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Affiliation(s)
- Raghu P Kataru
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jung Eun Baik
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Hyeung Ju Park
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Itay Wiser
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sonia Rehal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jin Yeon Shin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Babak J Mehrara
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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30
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Bousseau S, Vergori L, Soleti R, Lenaers G, Martinez MC, Andriantsitohaina R. Glycosylation as new pharmacological strategies for diseases associated with excessive angiogenesis. Pharmacol Ther 2018; 191:92-122. [DOI: 10.1016/j.pharmthera.2018.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/01/2018] [Indexed: 02/07/2023]
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31
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García Nores GD, Ly CL, Cuzzone DA, Kataru RP, Hespe GE, Torrisi JS, Huang JJ, Gardenier JC, Savetsky IL, Nitti MD, Yu JZ, Rehal S, Mehrara BJ. CD4 + T cells are activated in regional lymph nodes and migrate to skin to initiate lymphedema. Nat Commun 2018; 9:1970. [PMID: 29773802 PMCID: PMC5958132 DOI: 10.1038/s41467-018-04418-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 04/19/2018] [Indexed: 12/14/2022] Open
Abstract
T cell-mediated responses have been implicated in the development of fibrosis, impaired lymphangiogenesis, and lymphatic dysfunction in secondary lymphedema. Here we show that CD4+ T cells are necessary for lymphedema pathogenesis by utilizing adoptive transfer techniques in CD4 knockout mice that have undergone tail skin and lymphatic excision or popliteal lymph node dissection. We also demonstrate that T cell activation following lymphatic injury occurs in regional skin-draining lymph nodes after interaction with antigen-presenting cells such as dendritic cells. CD4+ T cell activation is associated with differentiation into a mixed T helper type 1 and 2 phenotype, as well as upregulation of adhesion molecules and chemokines that promote migration to the skin. Most importantly, we find that blocking T cell release from lymph nodes using a sphingosine-1-phosphate receptor modulator prevents lymphedema, suggesting that this approach may have clinical utility.
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Affiliation(s)
- Gabriela D García Nores
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Catherine L Ly
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Daniel A Cuzzone
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Raghu P Kataru
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Geoffrey E Hespe
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jeremy S Torrisi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jung Ju Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jason C Gardenier
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Ira L Savetsky
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Matthew D Nitti
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Jessie Z Yu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Sonia Rehal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA
| | - Babak J Mehrara
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Suite MRI 1006, New York, NY, 10065, USA.
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32
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Olszewski WL, Zagozda M, Zaleska MT, Durlik M. Predilection to Dermato-Lymphangio-Adenitis in Obstructive Lymphedema of Lower Limbs Depending on Genetic Polymorphisms atTNFα-308G>A,CCR2-190G>A,CD14-159C>T,TLR22029C>T,TLR41063A>G,TLR41363C>T,TGFβ74G>C, andTGFβ29T>C. Lymphat Res Biol 2018; 16:109-116. [DOI: 10.1089/lrb.2016.0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | - Malgorzata Zagozda
- Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland
- Department of Surgical Research and Transplantology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Marzanna T. Zaleska
- Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland
- Department of Applied Physiology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Marek Durlik
- Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland
- Department of Surgical Research and Transplantology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
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33
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Abstract
Although nonoperative and operative treatments for lymphedema (LE) are well established, these procedures typically provide only partial relief from limb swelling, functional impairment, and the risk of cellulitis. The lack of a cure for LE, however, is due to an incomplete understanding of the underlying pathophysiological mechanisms, and current research efforts are focusing on elucidating these processes to provide new, targeted therapies for this prevalent disease for which there is no cure. This article reviews the current literature regarding the pathophysiological mechanisms that underlie LE, as well as new and emerging therapies for the condition.
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Affiliation(s)
- Mark V. Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Melissa B. Aldrich
- Center for Molecular Imaging, Brown Institute for Molecular Medicine, UT Health, Houston, Texas
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34
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Abstract
The lymphatic system is essential for the maintenance of tissue fluid homeostasis, gastrointestinal lipid absorption, and immune trafficking. Whereas lymphatic regeneration occurs physiologically in wound healing and tissue repair, pathological lymphangiogenesis has been implicated in a number of chronic diseases such as lymphedema, atherosclerosis, and cancer. Insight into the regulatory mechanisms of lymphangiogenesis and the manner in which uncontrolled inflammation promotes lymphatic dysfunction is urgently needed to guide the development of novel therapeutics: These would be designed to reverse lymphatic dysfunction, either primary or acquired. Recent investigation has demonstrated the mechanistic role of leukotriene B4 (LTB4) in the molecular pathogenesis of lymphedema. LTB4, a product of the innate immune response, is a constituent of the eicosanoid inflammatory mediator family of molecules that promote both physiological and pathological inflammation. Here we provide an overview of lymphatic development, the pathophysiology of lymphedema, and the role of leukotrienes in lymphedema pathogenesis.
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Affiliation(s)
- Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, California 94304, USA.,Stanford University School of Medicine, Stanford, California 94305, USA;
| | - Mark R Nicolls
- VA Palo Alto Health Care System, Palo Alto, California 94304, USA.,Stanford University School of Medicine, Stanford, California 94305, USA;
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, California 94304, USA.,Stanford University School of Medicine, Stanford, California 94305, USA;
| | - Stanley G Rockson
- Stanford University School of Medicine, Stanford, California 94305, USA;
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35
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Volk-Draper LD, Hall KL, Wilber AC, Ran S. Lymphatic endothelial progenitors originate from plastic myeloid cells activated by toll-like receptor-4. PLoS One 2017; 12:e0179257. [PMID: 28598999 PMCID: PMC5466303 DOI: 10.1371/journal.pone.0179257] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 05/28/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myeloid-derived lymphatic endothelial cells (M-LECP) are induced by inflammation and play an important role in adult lymphangiogenesis. However, the mechanisms driving M-LECP differentiation are currently unclear. We previously showed that activation of Toll-like receptor-4 (TLR4) induces myeloid-lymphatic transition (MLT) of immortalized mouse myeloid cells. Here the goals were to assess the potential of different TLR4 ligands to induce pro-lymphatic reprogramming in human and mouse primary myeloid cells and to identify transcriptional changes regulating this process. METHODOLOGY/PRINCIPAL FINDINGS Human and mouse myeloid cells were reprogrammed to the lymphatic phenotype by TLR4 ligands including lipopolysaccharide (LPS), recombinant high mobility group box 1 protein (HMGB1), and paclitaxel. TLR4 induced similar MLT in cells from mice of different strains and immune status. Commonly induced genes were detected by transcriptional profiling in human and mouse myeloid cells from either immunocompetent or immunodeficient mice. Shared trends included: (1) novel expression of lymphatic-specific markers vascular endothelial growth factor receptor-3 (VEGFR-3), lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1) and podoplanin (PDPN) largely absent prior to induction; (2) lack of notable changes in blood vessel-specific markers; (3) transient expression of VEGFR-3, but sustained increase of vascular endothelial growth factor-C (VEGF-C) and a variety of inflammatory cytokines; (4) dependency of VEGFR-3 upregulation and other LEC genes on NF-κB; and (5) novel expression of lymphatic-specific (e.g., PROX1) and stem/progenitor (e.g., E2F1) transcription factors known for their roles in adult and embryonic vascular formation. M-LECP generated by TLR4 ligands in vitro were functional in vivo as demonstrated by significantly increased lymphatic vessel density and lymphatic metastasis detected in orthotopic breast cancer models. CONCLUSIONS/SIGNIFICANCE We established a novel TLR4-dependent protocol for in vitro production of functionally competent M-LECP from primary human or mouse myeloid cells and identified many potential regulators of this process. This information can be further exploited for research and therapeutic purposes.
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Affiliation(s)
- Lisa D. Volk-Draper
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Kelly L. Hall
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Andrew C. Wilber
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, Springfield, IL, United States of America
- Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Sophia Ran
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, Springfield, IL, United States of America
- Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, United States of America
- * E-mail:
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36
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Ran S, Wilber A. Novel role of immature myeloid cells in formation of new lymphatic vessels associated with inflammation and tumors. J Leukoc Biol 2017; 102:253-263. [PMID: 28408396 DOI: 10.1189/jlb.1mr1016-434rr] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/14/2017] [Accepted: 03/17/2017] [Indexed: 12/18/2022] Open
Abstract
Inflammation triggers an immune cell-driven program committed to restoring homeostasis to injured tissue. Central to this process is vasculature restoration, which includes both blood and lymphatic networks. Generation of new vessels or remodeling of existing vessels are also important steps in metastasis-the major cause of death for cancer patients. Although roles of the lymphatic system in regulation of inflammation and cancer metastasis are firmly established, the mechanisms underlying the formation of new lymphatic vessels remain a subject of debate. Until recently, generation of new lymphatics in adults was thought to occur exclusively through sprouting of existing vessels without help from recruited progenitors. However, emerging findings from clinical and experimental studies show that lymphoendothelial progenitors, particularly those derived from immature myeloid cells, play an important role in this process. This review summarizes current evidence for the existence and significant roles of myeloid-derived lymphatic endothelial cell progenitors (M-LECPs) in generation of new lymphatics. We describe specific markers of M-LECPs and discuss their biologic behavior in culture and in vivo, as well as currently known molecular mechanisms of myeloid-lymphatic transition (MLT). We also discuss the implications of M-LECPs for promoting adaptive immunity, as well as cancer metastasis. We conclude that improved mechanistic understanding of M-LECP differentiation and its role in adult lymphangiogenesis may lead to new therapeutic approaches for correcting lymphatic insufficiency or excessive formation of lymphatic vessels in human disorders.
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Affiliation(s)
- Sophia Ran
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, and Simmons Cancer Institute, Springfield, Illinois, USA
| | - Andrew Wilber
- Department of Medical Microbiology, Immunology, and Cell Biology, Southern Illinois University School of Medicine, and Simmons Cancer Institute, Springfield, Illinois, USA
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Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses. Ann Plast Surg 2017; 78:184-190. [DOI: 10.1097/sap.0000000000000853] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ly CL, Kataru RP, Mehrara BJ. Inflammatory Manifestations of Lymphedema. Int J Mol Sci 2017; 18:ijms18010171. [PMID: 28106728 PMCID: PMC5297803 DOI: 10.3390/ijms18010171] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/06/2017] [Accepted: 01/12/2017] [Indexed: 12/22/2022] Open
Abstract
Lymphedema results from lymphatic insufficiency leading to a progressive inflammatory process that ultimately manifests as discomfort, recurrent infections, and, at times, secondary malignancy. Collectively, these morbidities contribute to an overall poor quality of life. Although there have been recent advances in microsurgical interventions, a conservative palliative approach remains the mainstay of treatment for this disabling disease. The absence of a cure is due to an incomplete understanding of the pathophysiological changes that result in lymphedema. A histological hallmark of lymphedema is inflammatory cell infiltration and recent studies with animal models and clinical biopsy specimens have suggested that this response plays a key role in the pathology of the disease. The purpose of this report is to provide an overview of the ongoing research in and the current understanding of the inflammatory manifestations of lymphedema.
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Affiliation(s)
- Catherine L Ly
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Raghu P Kataru
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Babak J Mehrara
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Ji RC. Lymph Nodes and Cancer Metastasis: New Perspectives on the Role of Intranodal Lymphatic Sinuses. Int J Mol Sci 2016; 18:ijms18010051. [PMID: 28036019 PMCID: PMC5297686 DOI: 10.3390/ijms18010051] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 02/07/2023] Open
Abstract
The lymphatic system is essential for transporting interstitial fluid, soluble antigen, and immune cells from peripheral tissues to lymph nodes (LNs). Functional integrity of LNs is dependent on intact lymphatics and effective lymph drainage. Molecular mechanisms that facilitate interactions between tumor cells and lymphatic endothelial cells (LECs) during tumor progression still remain to be identified. The cellular and molecular structures of LNs are optimized to trigger a rapid and efficient immune response, and to participate in the process of tumor metastasis by stimulating lymphangiogenesis and establishing a premetastatic niche in LNs. Several molecules, e.g., S1P, CCR7-CCL19/CCL21, CXCL12/CXCR4, IL-7, IFN-γ, TGF-β, and integrin α4β1 play an important role in controlling the activity of LN stromal cells including LECs, fibroblastic reticular cells (FRCs) and follicular dendritic cells (DCs). The functional stromal cells are critical for reconstruction and remodeling of the LN that creates a unique microenvironment of tumor cells and LECs for cancer metastasis. LN metastasis is a major determinant for the prognosis of most human cancers and clinical management. Ongoing work to elucidate the function and molecular regulation of LN lymphatic sinuses will provide insight into cancer development mechanisms and improve therapeutic approaches for human malignancy.
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Affiliation(s)
- Rui-Cheng Ji
- Faculty of Welfare and Health Science, Oita University, Oita 870-1192, Japan.
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High Mobility Group Box-1 Promotes Inflammation-Induced Lymphangiogenesis via Toll-Like Receptor 4-Dependent Signalling Pathway. PLoS One 2016; 11:e0154187. [PMID: 27100831 PMCID: PMC4839690 DOI: 10.1371/journal.pone.0154187] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/11/2016] [Indexed: 01/28/2023] Open
Abstract
Lymphangiogenesis in inflammation has received considerable attention in recent years. Administration of modulating lymphangiogenesis provides more possibilities of treating inflammation-associated diseases. However, the main mediators and factors governing inflammation-induced lymphangiogenesis (ILA) are yet to be defined. Here, we explored the role of HMGB1-TLR4 signalling pathway in modulating inflammation-induced lymphangiogenesis and its underlying mechanisms using an ILA mouse model and 2 cell lines. Our results show that HMGB1 promoted VEGF-C-induced HDLECs proliferation in a dose-dependent manner and TLR4 mediates HMGB1-induced LECs proliferation and tube formation in vitro. And in vivo, rHMGB1 treatment significantly promoted ILA, and the promoting effects was inhibited notably when HMGB1-TLR4 was blocked. HMGB1-associated ILA is primarily dependent on TLR4 but not on TLR2. In mechanisms, the recruitment and activation of CD11b+ cells are important cellular mechanisms in HMGB1-TLR4 associated ILA, and multiple key pro-lymphangiogenesis molecules mediates HMGB1-TLR4 associated ILA, including VEGF-C/VEGFR3, inflammatory factors IL-1β and TNF-α, MMP-2 and MMP-9 and NF-κB p65. In conclusion, HMGB1-associated ILA is primarily dependent on TLR4, and CD11b+ cells and multiple molecular mechanisms mediate HMGB1-TLR4 associated ILA. Furthermore, the ILA can be effectively modulated by HMGB1-TLR4 signalling. Consequently, administration of modulating ILA through HMGB1-TLR4 pathway may provide us more possibilities of treating inflammation and lymphangiogenesis associated diseases.
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41
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Tran CD, Grice DM, Wade B, Kerr CA, Bauer DC, Li D, Hannan GN. Gut permeability, its interaction with gut microflora and effects on metabolic health are mediated by the lymphatics system, liver and bile acid. Future Microbiol 2015; 10:1339-53. [DOI: 10.2217/fmb.15.54] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
There is evidence to link obesity (and metabolic syndrome) with alterations in gut permeability and microbiota. The underlying mechanisms have been questioned and have prompted this review. We propose that the gut barrier function is a primary driver in maintaining metabolic health with poor health being linked to ‘gut leakiness'. This review will highlight changes in intestinal permeability and how it may change gut microflora and subsequently affect metabolic health by influencing the functioning of major bodily organs/organ systems: the lymphatic system, liver and pancreas. We also discuss the likelihood that metabolic syndrome undergoes a cyclic worsening facilitated by an increase in intestinal permeability leading to gut dysbiosis, culminating in ongoing poor health leading to further exacerbated gut leakiness.
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Affiliation(s)
- Cuong D Tran
- CSIRO Food & Nutrition Flagship, Adelaide, SA 5000, Australia
| | - Desma M Grice
- CSIRO Food & Nutrition Flagship, North Ryde, NSW 2113, Australia
| | - Ben Wade
- CSIRO Biosecurity Flagship, Geelong, VIC 3219, Australia
| | - Caroline A Kerr
- CSIRO Food & Nutrition Flagship, North Ryde, NSW 2113, Australia
| | - Denis C Bauer
- CSIRO Digital Productivity & Services Flagship, North Ryde, NSW 1670, Australia
| | - Dongmei Li
- CSIRO Food & Nutrition Flagship, North Ryde, NSW 2113, Australia
| | - Garry N Hannan
- CSIRO Food & Nutrition Flagship, North Ryde, NSW 2113, Australia
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Ghanta S, Cuzzone DA, Torrisi JS, Albano NJ, Joseph WJ, Savetsky IL, Gardenier JC, Chang D, Zampell JC, Mehrara BJ. Regulation of inflammation and fibrosis by macrophages in lymphedema. Am J Physiol Heart Circ Physiol 2015; 308:H1065-77. [PMID: 25724493 DOI: 10.1152/ajpheart.00598.2014] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/19/2015] [Indexed: 12/15/2022]
Abstract
Lymphedema, a common complication of cancer treatment, is characterized by inflammation, fibrosis, and adipose deposition. We have previously shown that macrophage infiltration is increased in mouse models of lymphedema. Because macrophages are regulators of lymphangiogenesis and fibrosis, this study aimed to determine the role of these cells in lymphedema using depletion experiments. Matched biopsy specimens of normal and lymphedema tissues were obtained from patients with unilateral upper extremity breast cancer-related lymphedema, and macrophage accumulation was assessed using immunohistochemistry. In addition, we used a mouse tail model of lymphedema to quantify macrophage accumulation and analyze outcomes of conditional macrophage depletion. Histological analysis of clinical lymphedema biopsies revealed significantly increased macrophage infiltration. Similarly, in the mouse tail model, lymphatic injury increased the number of macrophages and favored M2 differentiation. Chronic macrophage depletion using lethally irradiated wild-type mice reconstituted with CD11b-diphtheria toxin receptor mouse bone marrow did not decrease swelling, adipose deposition, or overall inflammation. Macrophage depletion after lymphedema had become established significantly increased fibrosis and accumulation of CD4(+) cells and promoted Th2 differentiation while decreasing lymphatic transport capacity and VEGF-C expression. Our findings suggest that macrophages home to lymphedematous tissues and differentiate into the M2 phenotype. In addition, our findings suggest that macrophages have an antifibrotic role in lymphedema and either directly or indirectly regulate CD4(+) cell accumulation and Th2 differentiation. Finally, our findings suggest that lymphedema-associated macrophages are a major source of VEGF-C and that impaired macrophage responses after lymphatic injury result in decreased lymphatic function.
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Affiliation(s)
- Swapna Ghanta
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel A Cuzzone
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jeremy S Torrisi
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicholas J Albano
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walter J Joseph
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ira L Savetsky
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason C Gardenier
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Chang
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Jamie C Zampell
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- The Department of Surgery, Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York;
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Dixon JB, Weiler MJ. Bridging the divide between pathogenesis and detection in lymphedema. Semin Cell Dev Biol 2015; 38:75-82. [PMID: 25545813 PMCID: PMC4418628 DOI: 10.1016/j.semcdb.2014.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 12/12/2022]
Abstract
While our understanding of the lymphatic system has improved substantially in the past few decades, the translation of this knowledge into improved healthcare solutions for patients suffering from secondary lymphedema has been severely limited. The challenge facing clinicians is two-fold. First, there is no reliable, affordable, diagnostic capable of detecting the disease before symptoms of the lymphedema develop and the efficacy of treatment options becomes limited. Second, our understanding of the disease pathogenesis, its risk factors, and the underlying physiologic mechanisms is still in its infancy. These two challenges go hand in hand as limited diagnostic options have hindered our ability to understand lymphedema progression, and the lack of known underlying mechanisms involved in the disease prohibits the development of new diagnostic targets. This review serves to discuss the recent developments in clinical and lab research settings of both lymphedema diagnostic technologies and our understanding of the mechanisms driving disease risk and progression. We will show how these two lines of research are synergistically working with the ultimate goal of improving patient outcomes for those suffering from this horrible disease, identifying key areas of further research that are warranted to move the field forward and provide clinical relief for this neglected patient population.
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Affiliation(s)
- J Brandon Dixon
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, United States; Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, United States; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, United States.
| | - Michael J Weiler
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, United States; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, United States
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Chakraborty S, Davis MJ, Muthuchamy M. Emerging trends in the pathophysiology of lymphatic contractile function. Semin Cell Dev Biol 2015; 38:55-66. [PMID: 25617600 DOI: 10.1016/j.semcdb.2015.01.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 01/19/2023]
Abstract
Lymphatic contractile dysfunction is central to a number of pathologies that affect millions of people worldwide. Due to its critical role in the process of inflammation, a dysfunctional lymphatic system also compromises the immune response, further exacerbating a number of inflammation related diseases. Despite the critical physiological functions accomplished by the transport of lymph, a complete understanding of the contractile machinery of the lymphatic system lags far behind that of the blood vasculature. However, there has been a surge of recent research focusing on different mechanisms that underlie both physiological and pathophysiological aspects of lymphatic contractile function. This review summarizes those emerging paradigms that shed some novel insights into the contractile physiology of the lymphatics in normal as well as different disease states. In addition, this review emphasizes the recent progress made in our understanding of various contractile parameters and regulatory elements that contribute to the normal functioning of the lymphatics.
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Affiliation(s)
- Sanjukta Chakraborty
- Department of Medical Physiology, Cardiovascular Research Institute Division of Lymphatic Biology, Texas A&M Health Science Center College of Medicine, United States
| | - Michael J Davis
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, United States.
| | - Mariappan Muthuchamy
- Department of Medical Physiology, Cardiovascular Research Institute Division of Lymphatic Biology, Texas A&M Health Science Center College of Medicine, United States.
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Topical bFGF Improves Secondary Lymphedema through Lymphangiogenesis in a Rat Tail Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e196. [PMID: 25426379 PMCID: PMC4236357 DOI: 10.1097/gox.0000000000000154] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 06/11/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Secondary lymphedema is a common complication of cancer therapy, but options for treating lymphedema are essentially ineffective and limited. On the contrary, lymphangiogenic growth factors accelerate lymphangiogenesis and improve lymphedema. METHODS Rat tail models of lymphedema were assigned to groups that received either daily topical basic fibroblast growth factor (bFGF) or saline (control) groups. Tail volume was measured, and the function of the lymphatic system was evaluated as the fluorescence intensity of indocyanine green every 3 days. The mRNA levels of vascular endothelial growth factor (VEGF)-C and VEGF-D and the protein levels of VEGF-C were evaluated at postoperative days (PODs) 7, 14, and 28. The subcutaneous and deep areas and lymphatic vessel density were histologically determined at PODs 7, 14, and 28. RESULTS Tail volume was significantly larger in the control than in the bFGF group (P < 0.05). The intensity of indocyanine green fluorescence significantly decreased earlier in the bFGF group (P < 0.05). The mRNA and protein levels of VEGF-C were upregulated in the bFGF group at POD 14 (P < 0.01). Both subcutaneous and deep tissues gradually withered in both groups but more rapidly in the bFGF, than in the control group, reaching statistically significant differences in the subcutaneous and deeper areas at POD 14 (P < 0.05). Lymphatic vessel density was significantly higher in the bFGF than in the control group at POD 14 (P < 0.05). CONCLUSIONS Topical bFGF induces lymphangiogenesis and improves lymphedema in the rat tail model.
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Nelson TS, Akin RE, Weiler MJ, Kassis T, Kornuta JA, Dixon JB. Minimally invasive method for determining the effective lymphatic pumping pressure in rats using near-infrared imaging. Am J Physiol Regul Integr Comp Physiol 2014; 306:R281-R290. [PMID: 24430884 DOI: 10.1152/ajpregu.00369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The ability to quantify collecting vessel function in a minimally invasive fashion is crucial to the study of lymphatic physiology and the role of lymphatic pump function in disease progression. Therefore, we developed a highly sensitive, minimally invasive research platform for quantifying the pumping capacity of collecting lymphatic vessels in the rodent tail and forelimb. To achieve this, we have integrated a near-infrared lymphatic imaging system with a feedback-controlled pressure cuff to modulate lymph flow. After occluding lymphatic flow by inflating a pressure cuff on the limb or tail, we gradually deflate the cuff while imaging flow restoration proximal to the cuff. Using prescribed pressure applications and automated image processing of fluorescence intensity levels in the vessels, we were able to noninvasively quantify the effective pumping pressure (P(eff), pressure at which flow is restored after occlusion) and vessel emptying rate (rate of fluorescence clearance during flow occlusion) of lymphatics in the rat. To demonstrate the sensitivity of this system to changes in lymphatic function, a nitric oxide (NO) donor cream, glyceryl trinitrate ointment (GTNO), was applied to the tails. GTNO decreased P(eff) of the vessels by nearly 50% and the average emptying rate by more than 60%. We also demonstrate the suitability of this approach for acquiring measurements on the rat forelimb. Thus, this novel research platform provides the first minimally invasive measurements of P(eff) and emptying rate in rodents. This experimental platform holds strong potential for future in vivo studies that seek to evaluate changes in lymphatic health and disease.
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Affiliation(s)
- Tyler S Nelson
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
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Nelson TS, Akin RE, Weiler MJ, Kassis T, Kornuta JA, Dixon JB. Minimally invasive method for determining the effective lymphatic pumping pressure in rats using near-infrared imaging. Am J Physiol Regul Integr Comp Physiol 2014; 306:R281-90. [PMID: 24430884 DOI: 10.1152/ajpregu.00369.2013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The ability to quantify collecting vessel function in a minimally invasive fashion is crucial to the study of lymphatic physiology and the role of lymphatic pump function in disease progression. Therefore, we developed a highly sensitive, minimally invasive research platform for quantifying the pumping capacity of collecting lymphatic vessels in the rodent tail and forelimb. To achieve this, we have integrated a near-infrared lymphatic imaging system with a feedback-controlled pressure cuff to modulate lymph flow. After occluding lymphatic flow by inflating a pressure cuff on the limb or tail, we gradually deflate the cuff while imaging flow restoration proximal to the cuff. Using prescribed pressure applications and automated image processing of fluorescence intensity levels in the vessels, we were able to noninvasively quantify the effective pumping pressure (P(eff), pressure at which flow is restored after occlusion) and vessel emptying rate (rate of fluorescence clearance during flow occlusion) of lymphatics in the rat. To demonstrate the sensitivity of this system to changes in lymphatic function, a nitric oxide (NO) donor cream, glyceryl trinitrate ointment (GTNO), was applied to the tails. GTNO decreased P(eff) of the vessels by nearly 50% and the average emptying rate by more than 60%. We also demonstrate the suitability of this approach for acquiring measurements on the rat forelimb. Thus, this novel research platform provides the first minimally invasive measurements of P(eff) and emptying rate in rodents. This experimental platform holds strong potential for future in vivo studies that seek to evaluate changes in lymphatic health and disease.
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Affiliation(s)
- Tyler S Nelson
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia
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48
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Expansion of the lymphatic vasculature in cancer and inflammation: New opportunities for in vivo imaging and drug delivery. J Control Release 2013; 172:550-7. [DOI: 10.1016/j.jconrel.2013.04.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/26/2013] [Accepted: 04/29/2013] [Indexed: 12/30/2022]
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TLR4, rather than TLR2, regulates wound healing through TGF-β and CCL5 expression. J Dermatol Sci 2013; 73:117-24. [PMID: 24252748 DOI: 10.1016/j.jdermsci.2013.10.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 10/22/2013] [Accepted: 10/23/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Toll-like receptors (TLRs) have a crucial role in early host defense against invading pathogens. Recent studies suggest that TLRs play important roles in non-infections inflammation and tissue repair and regeneration. OBJECTIVE To determine the roles of TLR2 and TLR4 in mouse wound healing using TLR2-deficient (TLR2(-/-)), TLR4-deficient (TLR4(-/-)), and TLR2/TLR4-deficient (TLR2/4(-/-)) mice. METHODS Open wounds made in TLR2(-/-), TLR4(-/-), and TLR2/4(-/-) mice were examined clinically and histologically. Cytokine expression in the wounded skin was also investigated. TGF-β production from macrophages stimulated by hyaluronan, a ligand for TLR2 and TLR4, was evaluated by real-time PCR. RESULTS Wound areas in TLR2(-/-), TLR4(-/-), and TLR2/4(-/-) mice were larger than wild-type mice both at days 3 and 7 after wounding, accompanied by decreased numbers of infiltrating macrophages in the dermis and decreased TGF-β and CCL5 mRNA expression in the wounded skin. Immunohistochemistry showed decreased numbers of macrophages expressing TGF-β and reduced CCL5 expression by keratinocytes in the wounded skin from TLR2(-/-), TLR4(-/-), and TLR2/4(-/-) mice compared to wild-type mice. Moreover, TGF-β production from macrophages induced by hyaluronan stimulation in vitro was significantly decreased in the absence of TLRs, especially TLR4. Interestingly, macrophages and wounded skin from TLR2(-/-) mice showed decreased TLR4 mRNA expression compared to wild-type mice, suggesting that the effect of TLR2 deficiency was at least partially dependent on decrease in TLR4. Topical application of TGF-β and CCL5 significantly improved wound healing in TLR-deficient mice. CONCLUSION TLR4, rather than TLR2, regulates wound healing through TGF-β and CCL5 expression.
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50
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Weiler M, Dixon JB. Differential transport function of lymphatic vessels in the rat tail model and the long-term effects of Indocyanine Green as assessed with near-infrared imaging. Front Physiol 2013; 4:215. [PMID: 23966950 PMCID: PMC3744037 DOI: 10.3389/fphys.2013.00215] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/27/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction: Near-infrared (NIR) imaging has emerged as a novel imaging modality for assessing lymphatic function in vivo. While the technique has provided quantitative data previously unavailable, questions remain in regards to the spatiotemporal capabilities of the approach. We address three of the more important issues here using the rodent tail, one of the most widely utilized in vivo model systems in the lymphatic literature. Specifically we demonstrate (1) the transient vs. steady state response of lymphatics to tracer injection, (2) the functional characteristics of multiple collecting vessels draining the same tissue space in parallel, and (3) the long-term consequences of fluorescent tracers on lymphatic function to repeated functional measurements. Methods: Rat tails were imaged with NIR and metrics of function were calculated for both collecting vessels that drain the tail. A nitric oxide donor cream (GTNO) was applied to the tail. Additionally, two different NIR dyes, indocyanine green (ICG) and LI-COR IRDye 800CW PEG, were utilized for function imaging at the time of initial injection and at 1, 2, and 4 week follow-up time points after which both draining lymph nodes were harvested. Results and Discussion: Significant differences were found between the two collecting vessels such that the vessel first showing fluorescence (dominant) produced enhanced functional metrics compared to the second vessel (non-dominant). GTNO significantly reduced lymphatic function in the non-dominant vessel compared to the dominant. ICG remained visible in the tail for 2 weeks after injection and was accompanied by significant losses in lymphatic function and enlarged draining lymph nodes. The Licor tracer also remained visible for 2 weeks. However, the dye produced significantly lower effects on lymphatic function than ICG, and lymph nodes were not enlarged at any time point, suggesting that this may be a more appropriate contrast agent for longitudinal lymphatic imaging.
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Affiliation(s)
- Michael Weiler
- Wallace H. Coulter Department of Biomedical Engineering, George W. Woodruff School of Mechanical Engineering, Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology Atlanta, GA, USA
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