Epidermal-derived factors in the treatment of a chronic leg ulcer

Vascular and cellular events in post-mastectomy seroma: an immunohistochemical study

This study aimed to describe the vascular and cellular histopathological changes that occurred in post-mastectomy seroma in an animal model. Unilateral mastectomies were conducted on 45 female albino rabbits. On day seven, the skin flap and the underlying tissues of the mastectomy regions were dissected and processed for histopathological examination using immunohistochemical staining of the T- and B-lymphocytes and macrophages (CD3, CD20, and CD68 respectively), and the vascular endothelia. The post-mastectomy regions in the seroma group showed a large number of inflammatory cells and newly formed blood vessels that lost the integrity of their endothelial cell linings, as revealed by the von Willebrand factor staining, as well the basement membrane, as revealed by the histochemical stain. The post-mastectomy seroma beds showed many CD3 and CD20+ve lymphocytes and CD68+ve macrophages. These macrophages were producing angiogenic factors, resulting in the persistent and continuous formation of new blood vessels. These new blood vessels were defective and represented an underlying cause of seroma formation.

Pro-inflammatory cytokine, matrix metalloproteinases and TIMP-1 are involved in wound healing after mastectomy in invasive breast cancer patients

BACKGROUND

Mastectomy provides a good model to study the wound healing process after surgery. The involved factors include selectins, pro-inflammatory cytokines such as interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), matrix metalloproteinases (MMPs), and their natural inhibitors (TIMPs). In the present study, we observed the kinetic changes of these factors in the process of wound healing after a mastectomy, and analyzed the relationship between these factors and the clinical outcomes.

MATERIALS AND METHODS

Twenty-nine patients, who received a modified radical mastectomy, were recruited to this study. The wound was inspected daily for the presence of flap necrosis, infection and seroma. Drain fluid was collected on days 1, 2 and 5. IL-6, P-selectin, MMP-2, 3, 9 and TIMP-1 were screened by ELISA kits for their impacts on wound healing after mastectomy.

RESULTS

IL-6 demonstrated the highest level on Day 1 after operation and was negatively correlated with MMP-2, which in turn showed a consistently negative correlation with MMP-9 for days 1, 2 and 5. Incidences of seroma formation and skin flap necrosis were 27.6% and 20.7%, respectively. Seroma formation was associated with low MMP-2 levels on Day 5. While skin flap necrosis seemed to correlate with high MMP-2 levels and low levels of MMP-9 and TIMP-1.

CONCLUSION

IL-6, P-selectin, MMP-2, MMP-3, MMP-9 and TIMP-1 are important in the process of wound healing after mastectomy. A low MMP-2 level correlates with the formation of seroma, while MMP-2, MMP-9 and TIMP-1 are associated with skin flap necrosis.

The study of cytokine dynamics at the operation site after mastectomy

Twenty-nine patients, who each received modified radical mastectomy, were recruited for this study. Wounds were inspected daily for the presence of flap necrosis, infection, and seroma. Drain fluid (20 ml) was collected at 6 a.m. on postoperative days 1, 2, and 5 and the levels of interleukin (IL)-4, IL-6, tumor necrosis factor-alpha, and interferon-gamma determined. For patients with no wound events, only IL-6 levels were elevated during the initial phase, but in the later phase the IL-6 levels dropped with a corresponding rise in tumor necrosis factor-alpha levels. In patients with flap necrosis, there was a sequential rise of IL-4 on day 1, IL-6 on day 2, and tumor necrosis factor-alpha on day 5, but only IL-4 was found to be a statistically significant factor associated with necrosis. In patients with seroma, the levels of IL-4 and interferon-gamma were persistently low and were both statistically significant. To conclude, IL-6 and tumor necrosis factor-alpha are important in normal postoperative wound healing and IL-4 and interferon-gamma may be associated with postoperative necrosis and seroma.

Proteinases, their inhibitors, and cytokine profiles in acute wound fluid

Wound healing is a complex process involving the interactions of many different cell types, matrix components and biological factors, including proteinases and cytokines. This study compared the levels of proteinases (matrix metalloproteinases and plasminogen activators), proteinase inhibitors (tissue inhibitors of metalloproteinases and plasminogen activator inhibitors), inflammatory cytokines and growth factors in acute wound fluid samples collected from the surgical drains of elective breast (n = 24) and colorectal (n = 26) patients on the first postoperative day. Gelatin zymography was used to determine matrix metalloproteinase-2 and -9 levels, quenched fluorescence substrate hydrolysis was applied for total MMP activity and enzyme-linked immunoassays were used to quantitate other factors. Colorectal wound fluid samples showed significantly (p < 0.05) greater levels of the matrix metalloproteinases (MMP-1, 2, 3, and 9), tissue inhibitor of metalloproteinases-1, urokinase plasminogen activator receptor and the inflammatory cytokines (interleukin-1beta, -6, and tumor necrosis factor-alpha); e.g., matrix metalloproteinase-3 colon; median 275 (range 11-2.530) ng/ml; breast; 530-400. However, tissue plasminogen activator and growth factor levels (epidermal growth factor, platelet-derived growth factor, basic fibroblast growth factor, transforming growth factor-beta1) were significantly greater in breast samples; e.g., epidermal growth factor breast 468 (103-1, 444) pg/ml; colon 57(1-573). There was no difference in the levels of urokinase type plasminogen activator, plasminogen activator inhibitor-1 and -2, tissue inhibitor of metalloproteinases -2 or vascular endothelial growth factor. Acute wound fluid from different surgical wounds showed different profiles of proteinases, proteinase inhibitors, and cytokines. This may lead to differences in the rate of tissue remodeling and therefore healing in these two wounds in vivo.

Innovations in leg ulcer care

This master class article discusses some of the new techniques that are currently being considered in the management of patients with leg ulcers