Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema

Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema.

J Vasc Surg. 2007 Mar 27

Unno N,
Inuzuka K,
Suzuki M,
Yamamoto N,
Sagara D,
Nishiyama M,
Konno H.
Division of Vascular Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan; Second Department of Surgery, Hamamatsu University School of MedicineShizuoka, Japan.

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BACKGROUND: Lymphoscintigraphy has largely been performed to diagnose lymphedema. It is, however a time-consuming and expensive technique, which has not been covered by Japanese medical insurance since the year 2002. In this report we introduce a new imaging technique of fluorescent lymphography to diagnose lymphedema.

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METHODS: Fluorescence images of subcutaneous lymphatic drainage after subcutaneous injection of indocyanine green (ICG) at the foot were obtained using a newly developed near-infrared camera system. ICG fluorescent lymphography was performed in 12 patients with secondary lymphedema and 10 healthy volunteers. The 12 patients were diagnosed with secondary lymphedema according to the medical history and lymphoscintigram, of which 11 had a history of hysterectomy with extended lymph node dissection and local radiation therapy for uterine cancer. Lymphedema developed in one patient after femorotibial artery bypass for peripheral artery occlusive disease.

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RESULTS: Four abnormal fluorescent patterns of the lymph drainage were observed in lymphedema: dermal backflow (an abnormal filling of the lymph capillaries), extended fluorescent signal at the dorsum and plantar region of the foot, dilated lymph channels with proximal obliteration, and diffuse glittering of fluorescent signals with scattered twinkling of the dye. Continuous lymph channels from the injection site of the foot to the groin were observed along the medial aspect of thigh in healthy subjects.

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CONCLUSION: ICG fluorescence lymphography is safe, simple, and minimally invasive. The device is portable and easy to use. The technique may be useful in clinical practice to identify presence of lymphatic disorder.

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PMID: 17391894 [PubMed - as supplied by publisher]

Exudative enteropathy in congenital lymphedema-lymphangiectasia syndrome

Exudative enteropathy in congenital lymphedema-lymphangiectasia syndrome


M. Heruth1, P. Müller1,3, L. Liebscher1, G. Kurze1, T. Richter2,3
1 Abt. Kinder- und Jugendmedizin, HELIOS Krankenhaus, Leisnig2 Klinik für Kinder- und Jugendmedizin, Städtisches Klinikum „St. Georg”, Leipzig3 Universitätsklinik und Poliklinik für Kinder und Jugendliche, Leipzig

Background: Congenital peripheral elephantiasiformic alterations are very rare in paediatric patients. In a patient with lymphangiectasia-lymphedema syndrome we demonstrate over a 8-year follow-up that not only cosmetic and social indications for surgical treatments but also internal care become important during the course.

Patient: We report on a boy with congenital lymphedemas of the extremities and the genital region, which were several times surgically treated. The patient became symptomatic firstly with tetanic cramps caused by malabsorption syndrome due to intestinal lymphangiectasia at the age of 6 years. Synopsis of clinical and laboratory findings and the patient's course are pointing to a mild Hennekam syndrome with still unknown aetiology.

Results: The boy developed adequately with permanent oral substitution of electrolytes and vitamins, protein-rich diet, supplementation of medium-chain fatty acids and compressing bandages. Infusions of human albumin to correct persistent hypalbuminemia as well as cytostatic treatment with cyclophosphamide as a formal trial were ineffective and are not advisable, therefore.

Key words: Hennekam syndrome - lymphangiectasia-lymphedema syndrome - exudative enteropathy

Thieme Connect

Spinal extradural arachnoid cysts associated with distichiasis and lymphedema.

Spinal extradural arachnoid cysts associated with distichiasis and lymphedema.

Yabuki S,
Kikuchi SI,
Ikegawa S.

Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.

Spinal extradural arachnoid cysts (SEDAC) are lesions communicating to the subarachnoid space of the spinal canal via a dural defect. SEDAC occupies intraspinal space and sometimes causes neurological disturbances. Although most reported cases are sporadic, several familial cases have been described, suggesting a genetic etiology. Here we report on a family with SEDAC inherited in an autosomal dominant mode. Detailed study showed that the family has the lymphedema-distichiasis syndrome. Among family members examined, a total of ten in two generations manifested all or some of the following features: SEDAC, distichiasis and lymphedema. Seven had spinal cysts, four had both SEDAC and distichiasis, and one had SEDAC distichiasis and lymphedema; three did not have SEDAC.

These findings, together with rarity of both distichiasis and lymphedema in the general population, support that all of the ten members were affected with one clinical entity, the lymphedema-distichiasis syndrome. The distribution of features illustrates the variable expressivity of clinical manifestations.

Although FOXC2 mutation analysis was not performed in our family, it is likely that SEDAC is a component manifestation of lymphedema-distichiasis syndrome and more consistent in our family than those reported. (c) 2007 Wiley-Liss, Inc.

PMID: 17366583 [PubMed - as supplied by publisher]

See Also: LYMPHEDEMA-DISTICHIASIS SYNDROME

New Procedure May Help Prevent Arm Swelling in Breast Cancer Patients

Surgeon Develops Procedure to Prevent Arm Swelling in Breast Cancer Patients

16 March 2007

Keywords: LYMPHEDEMA LYMPH NODES ARM SWELLING AXILLARY REVERSE MAPPING (ARM) BREAST CANCER BIOPSY

Description A surgeon at the University of Arkansas for Medical Sciences (UAMS) has developed a new procedure to prevent one of the most common side effects associated with breast cancer treatment - lymphedema or swelling of the arms due to faulty drainage of the lymph nodes.

Newswise - A surgeon at the University of Arkansas for Medical Sciences (UAMS) has developed a new procedure to prevent one of the most common side effects associated with breast cancer treatment - lymphedema or swelling of the arms due to faulty drainage of the lymph nodes.

V. Suzanne Klimberg, M.D., director of the UAMS breast cancer program, led a study funded by the Tenenbaum Breast Cancer Research Foundation of breast cancer patients at risk for developing lymphedema. Her findings were published in the February issue of the Annals of Surgical Oncology, and she will present the study March 17 at the Society of Surgical Oncology 60th Annual Cancer Symposium in Washington, D.C.

"The removal and analysis of the lymph nodes under the arm remains the most important factor in determining the severity of disease in breast cancer patients," Klimberg said. "In the past, surgery to remove the lymph nodes and most of the fat and tissue in the armpit often resulted in complications, including lymphedema." Five percent to 50 percent of women undergoing surgical treatment for breast cancer have developed lymphedema, mainly dependent upon the extent of surgery.

At the ACRC, surgeons determined that the draining of the first lymph node, known as the sentinel lymph node, is capable of predicting if the cancer has spread to the remaining armpit lymph nodes, known as axillary lymph nodes. This is a less invasive surgery and reduces the likelihood of complications.

However, the lymph node system is at risk of disruption during either a sentinel lymph node biopsy or an axillary lymph node dissection, which often leads to swelling in the arm.

To prevent the arm swelling, Klimberg has developed the Axillary Reverse Mapping (ARM) procedure. The new technique evaluates the ways in which fluid drains through the lymph node system in the arm through the injection of blue dye. The dye is used to map the drainage of the arm.

"Mapping the drainage of the arm decreases the chances of unintended disruption of the lymph node system during surgery and reduces the risk of developing swelling in the arm," Klimberg said. "We are the first to study lymph node drainage in the arm and are now using the ARM procedure as standard procedure at UAMS."

Klimberg will soon begin conducting training seminars on the procedure throughout the country. The seminars will be sponsored by the global medical device company Ethicon, a branch of Johnson & Johnson.

Klimberg is chief of the Division of Breast Surgical Oncology at UAMS and a professor in the Departments of Surgery and Pathology. She also is director of the Breast Cancer Program at the UAMS' Arkansas Cancer Research Center as well as director of Breast Fellowship in Diseases of the Breast at UAMS.

Additional UAMS staff members involved in the published study are Kent Westbrook, M.D.; distinguished professor; Ronda Henry-Tillman, M.D., associate professor of surgery; Margaret Thompson, fellow; Soheila Korourian, M.D., associate professor of pathology; Keiva Bland, fellow; K. Jackman, surgery resident; and Laura Adkins, data manager.

UAMS is the state's only comprehensive academic health center, with five colleges, a graduate school, a medical center, six centers of excellence and a statewide network of regional centers. UAMS has about 2,430 students and 715 medical residents. It is one of the state's largest public employers with about 9,400 employees, including nearly 1,000 physicians who provide medical care to patients at UAMS, Arkansas Children's Hospital, the VA Medical Center and UAMS' Area Health Education Centers throughout the state. UAMS and its affiliates have an economic impact in Arkansas of $5 billion a year. For more information, visit University of Arkansas Medical School

Regulation of Lymphatic Capillary Regeneration by Interstitial Flow in Skin.

Regulation of Lymphatic Capillary Regeneration by Interstitial Flow in Skin.

Goldman J,
Conley KA,
Raehl A,
Bondy DM,
Pytowski B,
Swartz MA,
Rutkowski JM,
Jaroch DB,
Ongstad EL.
Biomedical Engineering, Michigan Technological University, Houghton, Michigan, United States.

* To whom correspondence should be addressed. E-mail: jgoldman@mtu.edu

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Decreased interstitial flow (IF) in secondary lymphedema is coincident with poor physiological lymphatic regeneration. However, both the existence and direction of causality between IF and lymphangiogenesis remain unclear. This is primarily because the role of IF and its importance relative to the action of the pro-lymphangiogenic growth factor VEGF-C (which signals primarily through its receptor VEGFR-3) are poorly understood. To clarify this, we explored the cooperative roles of VEGFR-3 and IF in a mouse model of lymphangiogenesis in regenerating skin. Specifically, a region of lymphangiogenesis was created by substituting a portion of mouse tail skin with a collagen gel within which lymphatic capillaries completely regenerate over a period of 60 days. The relative importance of IF and VEGF-C signaling were evaluated by either inhibiting VEGFR-3 signaling with antagonistic antibodies or by reducing IF. In some cases, VEGF-C signaling was then increased with exogenous protein. In order to clarify the role of IF, the distribution of endogenous matrix metalloproteinases (MMPs) and VEGF-C within the regenerating region were determined. It was found that inhibition of either VEGFR-3 or IF suppressed endogenous lymphangiogenesis. Reduction of IF was found to decrease lymphatic migration and transport of endogenous MMP and VEGF-C through the regenerating region. Therapeutic VEGF-C administration restored lymphangiogenesis following inhibition of VEGFR-3 but did not increase lymphangiogenesis following inhibition of IF. These results identify IF as an important regulator of the pro-lymphangiogenic action of VEGF-C. Key words: VEGFR-3, endothelial , lymphangiogenesis, Interstitial Flow.

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