The Unresolved Pathophysiology of Lymphedema

Characterization of Immune Cell Infiltration and Collagen Type III Disorganization in Human Secondary Lymphedema: A Case-control Study

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.

Identification Of A Higher Risk Lymphedema Phenotype And Associations With Cytokine Gene Polymorphisms

CONTEXT

Breast cancer-related lymphedema (BCRL) is chronic condition that occurs in 5% to 75% of women following treatment for breast cancer. However, little is known about the risk factors and mechanisms associated with a worse BCRL profile.

OBJECTIVES

Identify distinct BCRL profiles in women with the condition (i.e., lower vs. higher risk phenotype) and evaluate for associations with pro- and anti-inflammatory genes.

METHODS

Latent class profile analysis (LCPA) was used to identify the BCRL profiles using phenotypic characteristics evaluated prior to surgery. Candidate gene analyses were done to identify cytokine genes associated with the two BCRL profiles.

RESULTS

Of the 155 patients evaluated, 35.5% (n = 55) were in the Lower and 64.5% (n = 100) were in the Higher Risk classes. Risk factors for membership in the Higher class included: lower functional status, having sentinel lymph node biopsy, axillary lymph node dissection, mastectomy, higher number of positive lymph nodes, and receipt of chemotherapy. Polymorphisms for interleukin (IL)1-beta and IL6 were associated with membership in the Higher Risk class.

CONCLUSION

The readily available and clinically relevant phenotypic characteristics associated with a worse BCRL profile can be used by clinicians to identify higher risk patients. If confirmed, these characteristics can be tested in predictive risk models. In addition, the candidate gene findings may guide the development of mechanistically-based interventions to decrease the risk of BCRL.

Effects of complex decongestive therapy and aquatic physiotherapy on markers of the inflammatory process in individuals with lymphedema

BACKGROUND

Chronic lymphedema is a progressive and inflammatory disease caused by impaired lymphatic transport.

PURPOSE

This study evaluates the effects of complex decongestive therapy (CDT) and aquatic physiotherapy on markers of the inflammatory process and lower limb volumes in individuals with lymphedema.

METHODS

A randomized controlled clinical trial was carried out with three groups: patients with lymphedema submitted to CDT, patients with lymphedema submitted to aquatic physiotherapy, and control group of individuals without lymphedema. The evaluation was performed through blood count, CRP measurements, C3, C4 complement, measurement of serum levels of cytokines interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukins 4 (IL-4), 6 (IL-6), and 10 (IL-10), and the volume of a lower limb using the volume formula of a truncated cone. The study was registered with the Brazilian Clinical Trials Registry (RBR-4tpkszn).

RESULTS

Our work showed a reduction in the TNF-α levels of patients in the CDT group (p = .028). Significant differences were found between the control group and the CDT group for IL-10 (p = .049) and Monocytes (p = .039). No significant reduction in limb volume was found.

CONCLUSION

Our results show that CDT was able to significantly reduce the inflammatory marker TNF-α in patients with lymphedema, suggesting an anti-inflammatory effect of the therapy.

Trends in Immediate Lymphatic Reconstruction

Background and objective Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.

Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema

Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.

Editorial for the Special Issue "Vasorum Lymphaticorum: From the Discovery of the Lymphatic System to the New Perspectives in Microsurgical Reconstruction and Patient Rehabilitation"

Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...].

Breast Cancer-related Lymphedema: Recent Updates on Clinical Efficacy of Therapies and Bioengineering Approaches for a Personalized Therapy

BACKGROUND

Post-mastectomy lymphedema is a chronic progressive disease characterized by a significant reduction in quality of life and a range of complications.

AIM

To this date, no single treatment method provides pathological correction of the mechanisms associated with tissue reorganization observed in later-stage breast cancer-related lymphedema (BCRL).

METHODS

To define a personalized approach to the management of patients with iatrogenic lymphedema, we performed a systematic review of literature without a comprehensive meta-analysis to outline existing molecular- genetic patterns, overview current treatment methods and their efficacy, and highlight the specific tissue-associated changes in BCRL conditions and other bio-engineering approaches to develop personalized therapy.

RESULTS

Our results show that several tissue-specific and pathological molecular markers may be found, yet current research does not aim to define them.

CONCLUSION

As such, currently, a strong foundation for further research into molecular-genetic changes in lymphedema tissue exists, and further research should focus on finding specific targets for personalized treatment through bio-engineering approaches.

Establishment and Feasibility of an Immediate Lymphatic Reconstruction Program in a Community Health System

BACKGROUND

Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system.

PATIENTS AND METHODS

A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021.

RESULTS

Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05).

CONCLUSIONS

Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.

Sentinel node restoration by vascularized lymph node transfer in mice

BACKGROUND

Recent reports have indicated that vascularized lymph node transfer (VLNT) may improve the impaired immunity in lymphedema but there has been no report concerning anti-cancer immunity. In the early tumor immune response, dendritic cells (DCs) participate in tumor recognition and antigen presentation in local lymphatics. Here, we investigated the impact of VLNT on DC dynamics against cancer in mouse models.

METHODS

Forty-seven 8-week-old C57BL/6 N male mice were divided into three surgical groups: a VLNT model in which a vascularized inguinal lymph node (LN) flap was transferred into the ipsilateral fossa after a popliteal LN was removed; a LN dissection (LND) model in which the popliteal LN was dissected; and a control model in which a skin incision was made at the popliteal fossa and an ipsilateral inguinal LN was removed. Postoperative lymphatic flows were observed by indocyanine green lymphography and B16-F10-luc2 mouse melanoma were implanted into the ipsilateral footpad. The proportion of DCs in the transplanted nodes was measured by CD11c immunohistochemistry using digital imaging analysis 4 days after cancer implantation. Metastases to the lungs and LNs were quantitatively evaluated by luciferase assay 4 weeks after cancer implantation.

RESULTS

After VLNT, lymphatic reconnection was observed in 59.2% of mice. The proportion of DCs was significantly higher in the VLNT group with lymphatic reconnection (8.6% ± 1.0%) than in the naïve LN (4.3% ± 0.4%) (p < .001). The tumor burden of lung metastases was significantly less in the VLNT group with lymphatic reconnection compared with the LND group (p = .049).

CONCLUSIONS

Metastasis decreased in mice with reconnected lymphatics after VLNT. A possible explanation was that lymphatic restoration may have contributed to the tumor immune response by allowing DC migration to LNs.

Molecular and metabolic orchestration of the lymphatic vasculature in physiology and pathology

Lymphangiogenesis refers to the generation of new lymphatic vessels from pre-existing ones. During development and particular adult states, lymphatic endothelial cells (LEC) undergo reprogramming of their transcriptomic and signaling networks to support the high demands imposed by cell proliferation and migration. Although there has been substantial progress in identifying growth factors and signaling pathways controlling lymphangiogenesis in the last decades, insights into the role of metabolism in lymphatic cell functions are just emerging. Despite numerous similarities between the main metabolic pathways existing in LECs, blood ECs (BEC) and other cell types, accumulating evidence has revealed that LECs acquire a unique metabolic signature during lymphangiogenesis, and their metabolic engine is intertwined with molecular regulatory networks, resulting in a tightly regulated and interconnected process. Considering the implication of lymphatic dysfunction in cancer and lymphedema, alongside other pathologies, recent findings hold promising opportunities to develop novel therapeutic approaches. In this review, we provide an overview of the status of knowledge in the molecular and metabolic network regulating the lymphatic vasculature in health and disease.

Tissue Dielectric Constant and Skin Stiffness Relationships in Lower Extremity Lymphedema

Background: Lower extremity lymphedema or edema (LELE) may progressively transition from a state of excess tissue fluid to increased fat accumulation and collagen deposition, with tissue fibrosis and hardening. Such changes may lead to altered tissue water holding and thereby impact tissue dielectric constant (TDC). This study seeks to evaluate the relationship between TDC and tissue indentation force (TIF) in patients with LELE and assess the utility of the leg/arm TDC ratio (LAR) as an indicator of LELE. Methods and Results: Thirty females (49-91 years) with previously diagnosed LELE were evaluated during a scheduled session. TDC and TIF were measured 8 cm proximal to the medial malleolus on the medial and lateral aspects of both legs and on one forearm 8 cm distal to the antecubital fossa. The TDC-TIC relationship and the LAR were subsequently determined. Main results showed an absence of a significant correlation between TDC and TIF on medial or lateral leg sites but a positive correlation on the normal forearm site. Further, LAR values exceeded the published proposed threshold of 1.35 for 29/30 patients when using medial-side TDC values and 28/30 patients when using lateral-side TDC values. Conclusions: Findings suggest that for patients with LELE, TDC values are significantly elevated on medial and lateral standardized sites. The LAR determined using either medial or lateral sites that are similar to each other and have values consistent with a lymphedema threshold of 1.35. In edematous legs of the type evaluated herein, there is no apparent relationship between TDC values and indentation force.

Body image and cancer-related lymphoedema: A systematic review

OBJECTIVE

Cancer-related lymphoedema is a common side effect of cancer, affecting 24%-49% of people with cancer. Body image contributes to the well-being of individuals with this condition. This systematic review aimed to explore, for the first time, the state of the science concerning body image in cancer-related lymphoedema, including how body image is measured and variables associated with body image concerns.

METHODS

Six databases were systematically searched for peer-reviewed articles describing empirical quantitative studies where body image was measured with a reliable and valid measurement tool in adults with cancer-related lymphoedema.

RESULTS

Nine studies with 977 participants were included. The studies involved individuals who had experienced breast, head and neck, melanoma, and urogenital cancers and developed lymphoedema. There was considerable heterogeneity in body image measures used, precluding meta-analysis. The following variables were associated with increased body image concern: higher body integrity beliefs, experience of physical changes (e.g. pain) and differences in sensation and function, including changes in appearance related thoughts, feelings and emotions. Several studies described behavioural and psychological interventions which positively impacted body image outcomes in individuals with lymphoedema relating to specific cancers.

CONCLUSION

Regular screening for body image concerns could encourage more positive body image awareness in individuals with cancer-related lymphoedema and lessen some of its associated negative consequences. Future longitudinal and individual differences research in this area is important to inform intervention development. There is also need for a more standardised approach to the study and measurement of body image in people with cancer-related lymphoedema.

Outcome Analysis of Combined Surgical Approaches in Advanced-stage Upper Extremity Breast Cancer-related Lymphedema

Background

This study aimed to discuss several surgical approaches for advanced-stage breast cancer-related lymphedema and compared their treatment outcomes.

Methods

The patients who underwent surgery with International Society of Lymphology stage III lymphedema were included in this study. The three surgical methods used here were (1) suction-assisted lipectomy with lymphovenous anastomosis, (2) autologous breast reconstruction with muscle-sparing transverse rectus abdominis muscle flap combined with inguinal lymph node transfer, and (3) vascularized lymph node transfer with free omental flap. Analysis of the postoperative outcomes in the patients was based on the difference in volume between patients pre- and postoperatively, LYMPH-Q questionnaire, and bioelectrical impedance analysis.

Results

Eighty-seven patients with stage IIb or higher disease underwent surgery. 38 patients underwent suction-assisted lipectomy + lymphovenous anastomosis, 23 underwent autologous breast reconstruction with vascularized lymph node transfer + lymphovenous anastomosis, and 26 underwent right gastroepiploic omental vascularized lymph node transfer with lymphovenous anastomosis. The LYMPH-Q questionnaire, which evaluates patients' subjective satisfaction, showed that the autologous breast reconstruction group showed the greatest improvement, whereas in bioimpedance analysis, the omental flap group demonstrated the greatest postoperative improvement compared with preoperative values. However, suction-assisted lipectomy was considered the most effective surgical method for reducing limb volume in patients with high-stage lymphedema accompanied by fibrosis and volume increase.

Conclusions

We observed slightly different clinical effects for each surgical method; however, all surgical methods demonstrated a reduction in the degree of edema and an increase in patient satisfaction.

Toxicity, normal tissue and dose-volume planning parameters for radiotherapy in soft tissue sarcoma of the extremities: A systematic review of the literature

BACKGROUND

Patients with soft tissue sarcoma of the extremities (STSE) are left with high incidence of toxicities after Radiotherapy (RT). Understanding the normal tissue dose relationship with the development of long-term toxicities may enable better RT planning in order to reduce treatment toxicities for STSE. This systematic review of the literature aims at reporting the incidence of acute and late toxicities and identifying RT delineation guidance the normal tissues structures and dose-volume parameters for STSE.

METHODS

A literature search of PUBMED-MEDLINE for studies that reported data on RT toxicity outcomes, delineation guidelines and dose-volume parameters for STSE from 2000 to 2022. Data has been tabulated and reported.

RESULTS

Thirty of 586 papers were selected after exclusion criteria. External beam RT prescriptions ranged from 30 to 72 Gy. The majority of studies reported the use of Intensity Modulated RT (IMRT) (27%). Neo-adjuvant RT was used in 40%. The highest long-term toxicities were subcutaneous and lymphoedema, reported when delivering 3DCRT. IMRT had a lower incidence of toxicities. Normal tissue outlining such as weight-bearing bones, skin and subcutaneous tissue, corridor and neurovascular bundle was recommended in 6 studies. Nine studies recommended the use of dose-volume constraints, but only one recommended evidence-based dose-volume constraints.

CONCLUSION

Although the literature is replete with toxicity reports, there is a lack of evidence-based guidance on normal tissue and dose-volume parameters and strategies to reduce the normal tissues irradiation when optimising RT plans for STSE are poor compared to other tumour sites.

Biomechanical control of lymphatic vessel physiology and functions

The ever-growing research on lymphatic biology has clearly identified lymphatic vessels as key players that maintain human health through their functional roles in tissue fluid homeostasis, immunosurveillance, lipid metabolism and inflammation. It is therefore not surprising that the list of human diseases associated with lymphatic malfunctions has grown larger, including issues beyond lymphedema, a pathology traditionally associated with lymphatic drainage insufficiency. Thus, the discovery of factors and pathways that can promote optimal lymphatic functions may offer new therapeutic options. Accumulating evidence indicates that aside from biochemical factors, biomechanical signals also regulate lymphatic vessel expansion and functions postnatally. Here, we review how mechanical forces induced by fluid shear stress affect the behavior and functions of lymphatic vessels and the mechanisms lymphatic vessels employ to sense and transduce these mechanical cues into biological signals.

Attaining consensus on a core dataset for upper limb lymphoedema using the Delphi method: A foundational step in creating a clinical support system

Background: Lymphoedema is a condition of localised swelling caused by a compromised lymphatic system. The protein-rich fluid accumulating in the interstitial tissue can create inflammation and irreversible changes to the skin and underlying tissue. An array of methods has been used to assess and report these changes. Heterogeneity is evident in the clinic and in the literature for the domains assessed, outcomes and outcome measures selected, measurement protocols followed, methods of analysis, and descriptors used to report change. Objective: This study seeks consensus on the required items for inclusion in a core data set for upper limb lymphoedema to digitise the monitoring and reporting of upper limb lymphoedema. Methods: The breadth of outcomes and descriptors in common use were captured in prior studies by this research group. This list was refined by frequency and proposed to experts in the field (n = 70) through a two-round online modified Delphi study. These participants rated the importance of each item for inclusion in the dataset and identified outcomes or descriptors they felt were missing in Round 1. In Round 2, participants rated any new outcomes or descriptors proposed and preference for how numeric data is displayed. Results: The core dataset was confirmed on completion of Round 2. Interlimb difference as a percentage, and limb volume were preferred for graphed display over time; and descriptors for observed and palpated change narrowed from 42 to 20. Conclusion: This dataset provides the foundation to create a clinical support system for upper limb lymphoedema.

Effects of a lymphedema prevention program based on the theory of knowledge-attitude-practice on postoperative breast cancer patients: A randomized clinical trial

BACKGROUND

Breast cancer-related lymphedema (BCRL) is one of the common postoperative complications that severely affects the functions of the arm and quality of life. Since lymphedema is difficult to treat and prone to recurrence, early prevention of lymphedema is crucial.

METHODS

Patient diagnosed with breast cancer (N = 108) were randomized to the intervention (n = 52) or control group (n = 56). In the intervention group, patients were provided the lymphedema prevention program based on the theory of knowledge-attitude-practice during the perioperative period and the first three chemotherapy sessions (mainly includes health education, seminars, knowledge manuals, sports guidance, peer education, and WeChat group).The limb volume, handgrip strength, arm function, and quality of life were measured in all patients at the baseline, 9 weeks (T1), and 18 weeks (T2) after surgery.

RESULTS

The incidence of lymphedema in the Intervention group was numerically lower than in the control group after implementing the lymphedema prevention program, but the difference was not statistically significant (T1: 1.9% vs. 3.8%, p = 1.000; T2: 3.6% vs. 7.1%, p = 0.744). However, compared with the control group, the intervention group showed there was less deterioration in handgrip strength (T1 [t = -2.512, p < 0.05] and T2 [t = -2.538, p < 0.05]), improved postoperative upper limb dysfunction (T1 [t = 3.087, p < 0.05] and T2 [t = 5.399, p < 0.05]) and less deterioration in quality of life (T1 [p < 0.05] and T2 [p < 0.05]).

CONCLUSION

Although the investigated lymphedema prevention program improved arm function and quality of life, it did not reduce the incidence of lymphedema in postoperative breast cancer patients.

A Case Report of Presumptive Primary Lymphedema Localized to the Face of a Dog

Primary lymphedema (PLE) is an uncommon diagnosis in veterinary medicine, with most of the previously described cases showing lower limb edema associated with a guarded long-term prognosis. To the authors' knowledge, this case report describes the first case of lymphedema localized unilaterally to the facial region of one-year-old German Shorthair Pointer, in which indirect CT-lymphography, combined with histopathologic examination of the skin, resulted in a tentative diagnosis of PLE.

Tracking Symptoms of Patients With Lymphedema Before and After Power-Assisted Liposuction Surgery

PURPOSE

Lymphedema negatively impacts patients from a psychosocial standpoint and consequently affects patient's quality of life. Debulking procedures using power-assisted liposuction (PAL) are currently deemed an effective treatment for fat-dominant lymphedema and improves anthropometric measurements as well as quality of life. However, there have been no studies specifically evaluating changes in symptoms related to lymphedema after PAL. An understanding of how symptoms change after this procedure would be valuable for preoperative counseling and to guide patient expectations.

METHODS

A cross-sectional study was performed in patients with extremity lymphedema who underwent PAL from January 2018 to December 2020 at a tertiary care facility. A retrospective chart review and follow-up phone survey were conducted to compare signs and symptoms related to lymphedema before and after PAL.

RESULTS

Forty-five patients were included in this study. Of these, 27 patients (60%) underwent upper extremity PAL and 18 patients (40%) underwent lower extremity PAL. The mean follow-up time was 15.5±7.9 months. After PAL, patients with upper extremity lymphedema reported having resolved heaviness (44%), as well as improved achiness (79%) and swelling (78%). In patients with lower extremity lymphedema, they reported having improved all signs and symptoms, particularly swelling (78%), tightness (72%), and achiness (71%).

CONCLUSIONS

In patients with fat-dominant lymphedema, PAL positively impacts patient-reported outcomes in a sustained fashion over time. Continuous surveillance of postoperative studies is required to elucidate factors independently associated with the outcomes found in our study. Moreover, further studies using a mixed method approach will help us better understand patient's expectations to achieve informed decision and adequate treatment goals.

Structural and functional analysis of the newt lymphatic system

Regeneration competent vertebrates such as newts and salamanders possess a weakened adaptive immune system characterized by multiple connections between the lymphatic system and the blood vascular system called lymphatic hearts. The role of lymphatic vasculature and these lymphaticovenous connections in regeneration is unknown. We used in-vivo near-infrared lymphangiography, ultra-high frequency ultrasonography, micro-CT lymphangiography, and histological serial section 3-dimentional computer reconstruction to evaluate the lymphatic territories of Cynops pyrrhogaster. We used our model and supermicrosurgery to show that lymphatic hearts are not essential for lymphatic circulation and limb regeneration. Instead, newts possess a novel intraosseous network of lymphatics inside the bone expressing VEGFR-3, LYVE-1 and CD-31. However, we were unable to show Prox-1 expression by these vessels. We demonstrate that adult newt bone marrow functions as both a lymphatic drainage organ and fat reservoir. This study reveals the fundamental anatomical differences between the immune system of urodeles and mammals and provides a model for investigating lymphatics and regeneration.

Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New?

Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.

Under recognition and treatment of lymphedema in head and neck cancer survivors - a database study

PURPOSE

Head and neck cancer (HNC) will be diagnosed in approximately 54,000 Americans in 2022 with more than 11,000 dying as a result. The treatment of HNC often involves aggressive multimodal therapy including surgery, radiotherapy, and systemic therapy. HNC and its treatments are associated with multiple painful and function-limiting neuromusculoskeletal and visceral long-term and late effects. Among these is head and neck lymphedema (HNL), the abnormal accumulation of protein rich fluid, in as many as 90% of survivors. Though HNL is common and potentially contributory to other function-limiting issues in this population, it is notoriously understudied, underrecognized, underdiagnosed, and undertreated. This study seeks to determine the incidence of HNC-related lymphedema diagnosis and treatment in a large US healthcare claims repository database.

METHODS

A retrospective observational cohort design and data from an integrated US healthcare claims repository-the IBM MarketScan Commercial Claims and Encounters (CCAE) and Medicare Supplemental and Coordination of Benefits (MDCR) Databases spanning the period April 1, 2012 through March 31, 2020.

RESULTS

Of the 16,654 HNC patients eligible for evaluation, 1,082 (6.5%) with a diagnosis of lymphedema were identified based on eligibility criteria. Of the 521 HNC patients evaluated for lymphedema treatment, 417 (80.0%) patients received 1.5 courses of MLD, 71 (13.6%) patients were prescribed compression garments, and 45 (8.6%) patients received an advanced pneumatic compression device.

CONCLUSION

HNL in this population of HNC survivors was underdiagnosed and treated compared with contemporary assessments HNL incidence.

Lymphatic-draining nanoparticles deliver Bay K8644 payload to lymphatic vessels and enhance their pumping function

Dysfunction of collecting lymphatic vessel pumping is associated with an array of pathologies. S-(-)-Bay K8644 (BayK), a small-molecule agonist of L-type calcium channels, improves vessel contractility ex vivo but has been left unexplored in vivo because of poor lymphatic access and risk of deleterious off-target effects. When formulated within lymph-draining nanoparticles (NPs), BayK acutely improved lymphatic vessel function, effects not seen from treatment with BayK in its free form. By preventing rapid drug access to the circulation, NP formulation also reduced BayK's dose-limiting side effects. When applied to a mouse model of lymphedema, treatment with BayK formulated in lymph-draining NPs, but not free BayK, improved pumping pressure generated by intact lymphatic vessels and tissue remodeling associated with the pathology. This work reveals the utility of a lymph-targeting NP platform to pharmacologically enhance lymphatic pumping in vivo and highlights a promising approach to treating lymphatic dysfunction.

The Vicious Circle of Stasis, Inflammation, and Fibrosis in Lymphedema

SUMMARY

Lymphedema is a progressive disease of the lymphatic system arising from impaired lymphatic drainage, accumulation of interstitial fluid, and fibroadipose deposition. Secondary lymphedema resulting from cancer treatment is the most common form of the disease in developed countries, affecting 15% to 40% of patients with breast cancer after lymph node dissection. Despite recent advances in microsurgery, outcomes remain variable and, in some cases, inadequate. Thus, development of novel treatment strategies is an important goal. Research over the past decade suggests that lymphatic injury initiates a chronic inflammatory response that regulates the pathophysiology of lymphedema. T-cell inflammation plays a key role in this response. In this review, the authors highlight the cellular and molecular mechanisms of lymphedema and discuss promising preclinical therapies.

Lymphatic endothelial cell RXRα is critical for 9-cis-retinoic acid-mediated lymphangiogenesis and prevention of secondary lymphedema

Secondary lymphedema is a debilitating disease characterized by abnormal soft tissue swelling and caused by lymphatic system dysfunction. Despite a high prevalence of secondary lymphedema after cancer treatments, current management is supportive and there are no approved therapeutic agents that can thwart disease progression. We have previously demonstrated that 9-cis-retinoic acid (9-cisRA) has the potential to be repurposed for lymphedema as it mitigates disease by promoting lymphangiogenesis at the site of lymphatic injury. Although the efficacy of 9-cisRA has been demonstrated in previous studies, the mechanism of action is not completely understood. In this study, we demonstrate that when RXRα is specifically deleted in lymphatic endothelial cells, 9-cisRA fails to induce lymphangiogenesis in vitro and prevent pathologic progression of postsurgical lymphedema in vivo. These findings demonstrate that downstream nuclear receptor RXRα plays a critical role in the therapeutic efficacy of 9-cisRA in postsurgical lymphedema.

Role of Subcutaneous Adipose Tissues in the Pathophysiology of Secondary Lymphedema

Background: Secondary lymphedema (LE) occurs due to the disruption of lymphatic circulation. Lymphatic fluid accumulation in subcutaneous tissues induces adipocyte proliferation. Obesity is an important risk factor for the occurrence and deterioration of LE. Although the relationship between LE and subcutaneous adipose tissue increase has been reported clinically, their pathophysiological relationship remains unknown. Thus, we aimed to verify whether subcutaneous adipose tissue increase is involved in the pathophysiology of secondary LE. Methods and Results: The hindlimb model of secondary LE was created using male Sprague-Dawley rats (control and LE groups; n = 5 each). Skin samples were obtained on postoperative day 168. Histological examination and quantitative real-time polymerase chain reaction analysis of inflammatory adipokines, tumor necrosis factor-alpha (Tnf-α), C-C chemokine ligand 2 (Ccl2), and interleukin-6 (Il-6) were performed. Limb volume and subcutaneous adipose tissues significantly increased in the LE group compared with those in the control. Macrophages aggregated in the augmented adipose tissues, around the adipocytes, and formed crown-like structures (CLSs). The number of CLSs significantly increased in the LE group. These macrophages expressed transforming growth factor-beta 1 (TGF-β1). Inflammatory adipokine secretion was not observed. Although Il-6 expression increased in the LE group, IL-6 was expressed in subcutaneous myofibroblasts but not in subcutaneous adipocytes. Conclusion: As TGF-β1 derived from subcutaneous myofibroblasts is involved in skin fibrosis during LE, TGF-β1 derived from adipose tissues may also play a similar role. Drug treatment for subcutaneous adipose tissue reduction may improve the skin condition in secondary LE and may be a new therapeutic strategy.

Measuring Biomechanical Properties Using a Noninvasive Myoton Device for Lymphedema Detection and Tracking: A Pilot Study

Background

Improved techniques for lymphedema detection and monitoring of disease progression are needed. This study aims to use the noninvasive MyotonPRO Device to detect differences in biomechanical skin characteristics in patients with breast cancer-related lymphedema (BCRL).

Methods

The handheld Myoton device was used to measure skin parameters including dynamic skin stiffness, oscillation frequency (tone), mechanical stress relaxation time, and creep in 11 women diagnosed with BCRL. Seven anatomical sites were measured bilaterally for each participant. The average values in the affected arms were compared with those in the contralateral unaffected arms.

Results

Among the 11 female participants with unilateral BCRL Stages 0 to II, the combined averages for dynamic skin stiffness and frequency measurements were decreased in the affected arms when compared with those for the contralateral control arms (ratio < 1). The median ratio of stiffness (affected to unaffected control arm) was 0.91 (interquartile range [IQR] 0.78-1.03) while frequency was 0.94 (IQR 0.89-1.0). Skin relaxation time and creep averages were increased in the affected arms. The relaxation time median ratio (affected to unaffected control arm) was 1.07 (IQR 1.02-1.14) and the median ratio of creep was 1.06 (IQR 1.03-1.16).

Conclusions

This study suggests the Myoton can detect differences in skin biomechanical parameters of the affected and unaffected arms in patients with BCRL. Larger studies are needed to draw strong conclusions.

Acquired lymphedema: Molecular contributors and future directions for developing intervention strategies

Lymphedema is a debilitating chronic disease that mostly develops as an adverse reaction to cancer treatment modalities such as chemotherapy, surgery, and radiotherapy. Lymphedema also appears to be a deteriorating consequence of roundworm infections, as best represented by filariasis. According to its origin, lymphedema is classified as primary lymphedema and acquired lymphedema. The latter is an acquired condition that, hitherto, received a considerably low attention owing to the less number of fatal cases been reported. Notably, despite the low mortality rate in lymphedema, it has been widely reported to reduce the disease-free survival and thus the quality of life of affected patients. Hence, in this review, we focused on acquired lymphedema and orchestration of molecular interplays associated with either stimulation or inhibition of lymphedema development that were, in vast majority, clearly depicted in animal models with their specific and distinct technical approaches. We also discussed some recent progress made in phytochemical-based anti-lymphedema intervention strategies and the specific mechanisms underlying their anti-lymphedema properties. This review is crucial to understand not only the comprehensive aspects of the disease but also the future directions of the intervention strategies that can address the quality of life of affected patients rather than alleviating apparent symptoms only.

Single and combined impacts of irradiation and surgery on lymphatic vasculature and fibrosis associated to secondary lymphedema

Lymphedema (LD) refers to a condition of lymphatic dysfunction associated with excessive fluid accumulation, fibroadipose tissue deposition and swelling. In industrialized countries, LD development mainly results from a local disruption of the lymphatic network by an infection or cancer-related surgery (secondary LD). In the absence of efficient therapy, animal models are needed to decipher the cellular and molecular mechanisms underlying LD and test putative drugs. In this study, we optimized and characterized a murine model of LD that combines an irradiation of the mice hind limb and a radical surgery (lymph node resection associated to lymphatic vessel ligation). We investigated the respective roles of irradiation and surgery in LD formation by comparing their impacts, alone or in combination (with different intervention sequences), on eight different features of the pathology: swelling (paw thickness), indocyanine green (ICG) clearance, lymphatic vasculature remodeling, epidermal and dermal thickening, adipocyte accumulation, inflammatory cell infiltration and collagen deposition. This study supports the importance of radiation prior to surgery to experimentally induce a rapid, severe and sustained tissue remodeling harboring the different hallmarks of LD. We provide the first experimental evidence for an excessive deposition of periostin (POSTN) and tenascin-C (TNC) in LD. Through a computerized method of digital image quantification, we established the spatial map of lymphatic expansion, as well as collagen, POSTN and TNC deposition in papillary and reticular dermis of lymphedematous skins. This mouse model is available to study the patho-physiology of LD and test potential therapeutic targets.

Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema

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.

Outcomes of lipectomy in patients with advanced unilateral upper extremity lymphedema with regard to the difference in time required for indocyanine green to reach the axilla: A retrospective cohort study in a single center

This study aimed to compare and analyze the prognosis after lipectomy with respect to the difference in time required for indocyanine green (ICG) to reach the axilla in patients with advanced unilateral upper extremity lymphedema. The study population was divided into 2 groups, according to the time required by ICG to reach the axilla after injection, that is, <1 hour (<1 hour; n = 9) and over 1 hour (>1 hour; n = 8). The patient's arm volume was examined before surgery and up to 12 months after surgery. The volume difference between the 2 groups was compared using the excess volume ratio. Statistically significant differences were not observed before surgery (P = .847) and 1 month (P = .336), 3 months (P = .630), and 6 months after surgery (P = .124) between the excess volume ratio values of the < 1 hour and > 1 hour groups. A statistically significant difference was confirmed 12 months after surgery (P = .034). The difference in the time when ICG reached the axilla in patients with lymphedema was associated with prognosis after lipectomy. The difference in time could possibly be used as a variable to classify the progress of lymphedema in the future.

Effects of Lymphovenous Anastomosis Surgery Using Ultrasonography in Lymphedema From a Pressure Perspective

Objective

To analyze the effects of lymphovenous anastomosis (LVA) surgery after 1 year using the elastic index (EI) and volume.

Methods

This study was a retrospective study of 41 patients, with lymphedema, who underwent LVA surgery between July 2018 and June 2020. Limb circumference, used to determine the volume of the limb with lymphedema, and EI, which reflects tissue stiffness and measured using ultrasonography were measured for each patient before and 1 year after LVA surgery. To examine the effect of LVA, differences in the preoperative and 1-year postoperative volumes and EIs were analyzed using the Wilcoxon signed-rank test.

Results

The mean volume and EI of the dominant site in upper-extremity lymphedema were 2,309.4 cm³ and 1.4, respectively, preoperatively and 2,237.1 cm³ and 0.9, respectively, at 1 year postoperatively. The mean volume and EI difference of the dominant site 1 year after surgery was −16.6 cm³ (p=0.22) and −0.5 (p<0.001). The mean volume and EI of dominant site in lower-extremity lymphedema were 6,137.0 cm³ and 1.2, respectively, preoperatively, and 5,832.6 cm³ and 1.1, respectively, at 1 year postoperatively. The mean volume and EI difference of the dominant site 1 year postoperatively were −320.9 cm³ (p=0.04) and −0.2 (p=0.09), respectively.

Conclusion

LVA surgery is more effective in reducing pressure than in reducing volume, which may be helpful in preventing the progression of lymphedema.

Temporal Changes in Subcutaneous Fibrosis in Patients with Lower Extremity Lymphedema Following Surgery for Gynecologic Cancer: A Computed Tomography-Based Quantitative Analysis

Lymphedema causes inflammation, which provokes fibrosis within the epifascial tissue. Temporal change in fibrosis according to severity of the lymphedema has not been widely investigated. We aimed to study the quantitative changes in epifascial fibrosis during lymphedema treatment using computed tomography (CT). Forty-five patients (mean age: 57.75 ± 11.12 years) who developed lymphedema following gynecologic surgery were included in this retrospective study. Two weeks of complete decongestive therapy and continued self-bandaging or compression garments were prescribed under regular follow-up monitoring. Lower-extremity epifascial fibrosis was quantitatively analyzed on the initial and follow-up CT scans. Circumference, skin fibrosis, subcutaneous tissue, and fibrosis ratio were calculated in the axial scan. Based on the change in lymphedema severity, we divided subjects into ‘improved’ and ‘aggravated’ groups. The affected lower extremities showed higher circumference, more skin fibrosis and subcutaneous tissue, and higher fibrosis ratio than the unaffected sides on initial CT scan. At follow-up, compared to the aggravated group, the improved group showed significant decreases in fibrosis of skin and subcutaneous tissue and fibrosis ratio. Subcutaneous fibrosis was reversible with volume resolution of lymphedema. Therapeutic approaches should be established on the basis of the reversible nature of fibrotic changes in patients with lower extremity lymphedema.

Use of Dual-Energy X-Ray Absorptiometry to Assess Soft Tissue Composition in Breast Cancer Survivors With and Without Lymphedema

Background: In patients with lymphedema (LE), in addition to hand dominance, between-group comparisons of interlimb soft tissue differences need to account for differences in whole-body adiposity, measured directly by dual energy X-ray absorptiometry (DXA) or indirectly by body mass index. No study has evaluated the effects of hand dominance and whole-body adiposity on limb composition in patients with LE. This study's purpose was to compare soft tissue composition of affected and unaffected limbs of women with breast cancer, who did and did not have LE, controlling for dominance and percent body fat. Methods and Results: Whole-body DXA scans were acquired and included measures of percent body fat, upper limb total mass, upper limb fat mass, and upper limb fat-free mass. Participants were classified into one of three groups: women without LE; women with only subjective LE; and women with objective signs of LE at the time of assessment. Differences among the LE groups were evaluated using analysis of variance (ANOVA) and Chi-square analyses. Analysis of covariance (ANCOVA) was used to control for percent body fat and for the affected limb dominance. Compared to women without LE, women with objective signs of LE have greater total limb mass, fat mass, and fat-free mass in their affected limbs, independent of affected side dominance and percent body fat. In addition, the interlimb differences in total mass, fat mass, and fat-free mass were greater for the women with objective signs of LE, compared to the other two groups. Conclusions: DXA is useful in identifying soft tissue changes in patients with LE. Given that limb circumferences measure only changes in limb volume and that bioimpedance provides estimates of extracellular fluid, DXA has the advantage of being able to estimate the volumes of specific tissues in the limb.

Lymphatic channel sheet of polydimethylsiloxane for preventing secondary lymphedema in the rat upper limb model

Secondary lymphedema is a severe complication of cancer treatment, but there is no effective curative method yet. Lymph node dissection and radiation therapy for cancer treatment may lead to secondary lymphedema, which is a chronic disease induced by malfunction of lymphatic flow. The lymphatic channel sheet (LCS) is an artificial micro-fluidic structure that was fabricated with polydimethylsiloxane to maintain lymphatic flow and induce lymphangiogenesis. The structure has two-dimensional multichannels that increase the probability of lymphangiogenesis and allow for relatively easy application. We verified the efficacy of the lymphatic channel sheet through macroscopic and microscopic observation in small animal models, which underwent brachial lymph node dissection and irradiation. The lymphatic channel sheet enabled the successful transport of lymphatic fluid from the distal to the proximal area in place of the removed brachial lymph nodes. It prevented swelling and abnormal lymphatic drainage during the follow-up period. Lymphangiogenesis was also identified inside the channel by histological analysis after 8 weeks. According to these experimental results, we attest to the roles of the lymphatic channel sheet as a lymphatic pathway and scaffold in the rat upper limb model of secondary lymphedema. The lymphatic channel sheet maintained lymphatic flow after lymph node dissection and irradiation in an environment where lymph flow is cut off. It also relieved symptoms of secondary lymphedema by providing a lymph-friendly space and inducing lymphangiogenesis.

Current Understanding of Pathological Mechanisms of Lymphedema

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.

Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review

Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.

MRI Changes in Breast Skin Following Preoperative Therapy for Patients with Inflammatory Breast Cancer

RATIONALE AND OBJECTIVES

Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability.

MATERIALS AND METHODS

We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy.

RESULTS

Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR.

CONCLUSION

Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

Hypoxia and Hypoxia-Inducible Factors in Lymphedema

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.

Using the Indocyanine Green (ICG) Lymphography to Screen Breast Cancer Patients at High Risk for Lymphedema

Background: Indocyanine green (ICG) lymphography is a newer technique for diagnosing lymphedema. Our study aimed to find whether the abnormality of ICG lymphography can predict the occurrence of early lymphedema and then select candidates at high risk of developing lymphedema. Methods: Postoperative breast cancer patients who visited the lymphedema clinic of Peking University People’s Hospital from December 2016 to September 2019 were consecutively enrolled and received ICG lymphography and circumference measurement. Data were collected on the patients’ characteristics and correlation between ICG lymphography and the occurrence of lymphedema. Results: The analysis included 179 patients. There were 91 patients in the lymphedema group and 88 patients in the non-lymphedema group. By multivariate analysis, age, axillary surgery, radiotherapy, and time since breast cancer surgery were regarded as risk factors for lymphedema (p < 0.05). According to the results of ICG lymphography, patients in the non-lymphedema group (n = 88) were divided into ICG-positive (n = 47) and ICG-negative (n = 41) groups. The incidence of lymphedema in the ICG-positive group was significantly higher than that in the ICG-negative group (19.1% vs. 2.4%, p = 0.027). Conclusion: Lymphatic disorder can be detected before circumference change using ICG lymphography. Abnormal ICG lymphography is an independent risk factor for lymphedema. Patients with abnormal dermal backflow patterns are considered to be a high-risk group for lymphedema and should undergo early interventions to prevent lymphedema.

Indocyanine green-guided liposuction for patients presenting with residual nonpitting edema after lymphovenous anastomosis

INTRODUCTION

Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction.

PATIENTS AND METHOD

Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry.

RESULTS

The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12).

CONCLUSION

Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%.

Effect of Supervised Resistance Training on Arm Volume, Quality of Life and Physical Perfomance Among Women at High Risk for Breast Cancer-Related Lymphedema: A Study Protocol for a Randomized Controlled Trial (STRONG-B)

Objectives

To determine the preventive effects of supervised resistance training on arms volume, quality of life, physical performance, and handgrip strength in Chilean women at high risk for breast cancer-related lymphedema (BCRL) undergoing chemotherapy.

Design

Randomized control trial.

Participants

One hundred and six women at high risk for breast cancer-related lymphedema aged 18 to 70 years.

Interventions

Participants will be randomized into two groups: [a] intervention, who will receive 12 weeks of supervised resistance training (STRONG-B) during adjuvant chemotherapy; and [b] control, who will receive education to promote lymphatic and venous return, maintain range of motion, and promote physical activity.

Main Outcome Measures

The primary outcome will be arms volume measured with an optoelectric device (perometer NT1000). Secondary outcomes will be quality of life, handgrip strength, and physical performance. Primary and secondary outcomes will be measured at baseline, just after the intervention, and 3 and 6 months after. Statistical analysis will be performed following intention-to-treat and per-protocol approaches. The treatment effect will be calculated using linear mixed models.

Discussion

The STRONG-B will be a tailored supervised resistance training that attempts to prevent or mitigate BCRL in a population that, due to both intrinsic and extrinsic factors, will commonly suffer from BCRL.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04821609], identifier NCT04821609.

Multiple aspects of lymphatic dysfunction in an ApoE -/- mouse model of hypercholesterolemia

Introduction: Rodent models of cardiovascular disease have uncovered various types of lymphatic vessel dysfunction that occur in association with atherosclerosis, type II diabetes and obesity. Previously, we presented in vivo evidence for impaired lymphatic drainage in apolipoprotein E null (ApoE ^-/- ) mice fed a high fat diet (HFD). Whether this impairment relates to the dysfunction of collecting lymphatics remains an open question. The ApoE ^-/- mouse is a well-established model of cardiovascular disease, in which a diet rich in fat and cholesterol on an ApoE deficient background accelerates the development of hypercholesteremia, atherosclerotic plaques and inflammation of the skin and other tissues. Here, we investigated various aspects of lymphatic function using ex vivo tests of collecting lymphatic vessels from ApoE ^+/+ or ApoE ^-/- mice fed a HFD. Methods: Popliteal collectors were excised from either strain and studied under defined conditions in which we could quantify changes in lymphatic contractile strength, lymph pump output, secondary valve function, and collecting vessel permeability. Results: Our results show that all these aspects of lymphatic vessel function are altered in deleterious ways in this model of hypercholesterolemia. Discussion: These findings extend previous in vivo observations suggesting significant dysfunction of lymphatic endothelial cells and smooth muscle cells from collecting vessels in association with a HFD on an ApoE-deficient background. An implication of our study is that collecting vessel dysfunction in this context may negatively impact the removal of cholesterol by the lymphatic system from the skin and the arterial wall and thereby exacerbate the progression and/or severity of atherosclerosis and associated inflammation.

Autologous peripheral blood mononuclear cells for the treatment of lower extremity lymphedema: a preliminary report

Lymphedema is a chronic devastating disease characterized by the accumulation of fluid in the extremities, tissue progressive changes such as adipose tissue deposition and fibrosis. To restore the functionality and structural integrity of the damaged lymphatic vessels, autologous peripheral blood mononuclear cells (PBMNC) was implanted in 3 sessions, 4 weeks apart, in the affected limb. Each patient was followed for 6 months, monitoring changes in the limb volume. Lymphangiogenesis was evaluated by lymphoscintigraphy, and the monitoring of quality of life. A rapid reduction in the volume of the limbs was observed:  24.5% of volume reduction after the first implant, 18.5% after the second, and 15.3% at 6 months after the third (p<0.05 vs baseline). Lymphoscintigraphy showed a hyper fixation of the tracer along the ipsilateral iliac axis not appreciable at baseline. Implants of autologous PBMNC in patients with primary lower limb lymphedema seems to be a feasible, effective therapy option.

A model for self-management of chronic filarial lymphoedema with acute dermato-lymphangio-adenitis

Secondary lymphoedema due to filariasis is a leading cause of morbidity in India. We present a case of a 54-year-old female with lymphatic filariasis for 18 years, with three to four episodes of acute dermato-lymphangio-adenitis (ADLA) every year. The patient had voluntarily restricted social interaction and community participation. A combination of interventions provided in 17 physiotherapy sessions over a period of 20 days showed notable improvement, by reducing limb volume and ADLA episodes and by improving limb shape, functional capacity and quality of life. Interventions included aerobic exercise, decongestion therapy with faradism under pressure and exercises with elevation. This gain was maintained throughout the 8 months of the pandemic. Patient education and counselling along with home programme of self-bandaging and self-limb hygiene played a major role in the recovery of the patient. Self-reliance in management was important because of the pandemic, which restricted the patient from attending the outpatient department.