Global abnormalities in lymphatic function following systemic therapy in patients with breast cancer.

BACKGROUND: Breast cancer-related lymphoedema (BCRL) is a result of interaction between several pathophysiological processes, and is not simply a 'stopcock' effect resulting from removal of axillary lymph nodes. The aim of this study was to test the hypothesis that there is a constitutional 'global' lymphatic dysfunction in patients who develop BCRL. METHODS: Lower-limb lymphoscintigraphy was performed in 30 women who had undergone axillary lymph node dissection at least 3 years previously, of whom 15 had BCRL and 15 did not. No patient had any clinical abnormality of the lower limb. The control group comprised 24 women with no history of cancer or lower-limb lymphoedema. (99m) Tc-Nanocoll was injected subcutaneously into the first webspace of each foot, followed by whole-body imaging. Scans were reported as abnormal if there was delay in lymph transport or rerouting through skin or deep system. Quantification was expressed as the percentage injected activity accumulating in ilioinguinal nodes. RESULTS: Mean(s.d.) ilioinguinal nodal accumulation at 150 min was significantly lower in women with BCRL than in those without (2·7(2·5) versus 5·9(4·8) per cent respectively; P = 0·006). Abnormal findings on lower-limb lymphoscintigraphy were observed in 17 of the 30 patients: ten of the 15 women who had BCRL and seven of the 15 who did not. None of the 24 control subjects had abnormal scan findings. CONCLUSION: Women with BCRL had reduced lower-limb lymph drainage, supporting the hypothesis of a predisposition to BCRL. A surprisingly high proportion of patients with breast cancer also demonstrated lymphatic dysfunction, despite clinically normal lower limbs. Possible explanations could be a systemic effect of breast cancer or its treatment, or an unidentified association between breast cancer and lymphatic dysfunction. REGISTRATION NUMBER: ISRCTN84866416 ( http://www.isrctn.com).

An investigation of lymphovenous communications in the upper limbs of breast cancer patients.

BACKGROUND: Approximately 25% of breast cancer patients who undergo treatment to the axilla develop breast cancer-related lymphoedema (BCRL). The aim of this study was to test the hypothesis that lymphovenous communications (LVCs) open and act as a protective mechanism against the development of BCRL. METHODS: Five patients (Group 1) received intradermal injections of (99m)Technetium-labelled autologous erythrocytes into the 2nd ipsilateral hand webspace before and 6-12 weeks following axillary node clearance surgery (ANC). Ten patients at least three years after ANC were also recruited (Group 2); seven had developed BCRL and three had not. Blood was sampled from ipsilateral and contralateral antecubital veins 5, 15, 30, 60, 120 and 180 min post-injection to assess pre-nodal shunting from lymph to blood (LVCs), since nodes block erythrocyte transit. The proportion of activity remaining in the depot was used to calculate the degree of shunting in those with evidence of LVCs. RESULTS: Significant erythrocyte-bound activity, increasing over time, was detected contralaterally in 3 of the 5 patients from Group 1 (none of whom developed BCRL) and 3 of 7 patients with BCRL from Group 2, which indicated the presence of LVCs. The degree of shunting was more marked in those patients who did not develop BCRL compared with those who did. CONCLUSIONS: The time-course of erythrocyte-bound contralateral activity indicates transit through lymphovenous communications rather than needle-induced trauma. Lymphovenous communications large enough to transmit erythrocytes are probably constitutional rather than induced. A larger study is warranted to assess any resulting protection against BCRL.

A constitutional predisposition to breast cancer-related lymphoedema and effect of axillary lymph node surgery on forearm muscle lymph flow.

AIM: The aims of this prospective study were (a) to examine the relationship between pre-operative muscle lymph flow and the predisposition to BCRL in women treated by axillary nodal surgery for breast cancer; and (b) to test the 'stopcock' hypothesis that axillary lymph node surgery impairs forearm lymph flow in the short term. METHODS: (99m)Tc-nanocoll was injected intramuscularly into both forearms of women undergoing surgery for breast cancer. Lymphatic clearance rate constant, k, representing lymph flow per unit interstitial fluid volume, was measured as the fractional disappearance rate of radioactivity from the depot site by gamma camera imaging. Axillary lymph node activity was calculated as percentage injected activity. BCRL was assessed by clinical examination and upper limb perometry. RESULTS: Of 38 pre-operative women, 33 attended at 8 ± 6 weeks post-operatively and 31 at 58 ± 9 weeks post-operatively. Seven patients (18%) developed BCRL. Prior to surgery the BCRL-destined patients had a higher mean k (0.0962 ± 0.034%/min) than non-BCRL patients (0.0830 ± 0.019%/min) (p = 0.10, unpaired t test). Post-operative k values were not significantly different from pre-operative, in either the ipsilateral (operated) or contralateral limb. Also, post-operative k values did not differ significantly between both upper limbs. Furthermore, there was no significant difference between pre- and post-operative axillary activity. CONCLUSION: Patients who develop BCRL have high lymph flow pre-surgery, which may predispose them to lymphatic overload and failure. Axillary lymph node surgery has no early, measurable effect on forearm muscle lymph flow despite surgical disruption of routes of lymph drainage.

Clinical assessment of human lymph flow using removal rate constants of interstitial macromolecules: a critical review of lymphoscintigraphy.

Edema is a common clinical problem, and the daily avoidance of edema depends critically on the lymphatic system, which clears leaked plasma proteins and fluid from the interstitial compartment. There is often confusion as to the difference between chronic edema and lymphedema. Lymphedema is by definition primarily a disease of impaired lymphatic drainage and lymph flow, and progress in lymphedema research, currently an increasingly active field, requires a clinically viable method for the quantitative assessment of lymph drainage rate in patients. Measurement of the rate of clearance of a new protein marker, radiolabelled human immunoglobulin, from skin, subcutis, and muscle provides a way of measuring human lymph flow quantitatively and is the only viable clinical method currently available. Considerable strides have been made over the last 5-10 years in evaluating the method and its pitfalls, including potential complications such as vascular clearance, peripheral lymphovenous communications and label dissociation. The review assesses critically, for the first time, the evidence relating to the method: its pitfalls; human lymph flow in various healthy and oedematous tissues; and how this is altered in hyperfiltration edemas, inflammation, vasoconstriction and various primary and secondary human lymphedemas.

Human lymphatic pumping measured in healthy and lymphoedematous arms by lymphatic congestion lymphoscintigraphy.

Axillary surgery for breast cancer partially obstructs lymph outflow from the arm, chronically raising the lymphatic smooth muscle afterload. This may lead to pump failure, as in hypertensive cardiac failure, and could explain features of breast cancer treatment-related lymphoedema (BCRL) such as its delayed onset. A new method was developed to measure human lymphatic contractility non-invasively and test the hypothesis of contractile impairment. 99mTc-human IgG (Tc-HIG), injected into the hand dermis, drained into the arm lymphatic system which was imaged using a gamma-camera. Lymph transit time from hand to axilla, ttransit, was 9.6+/-7.2 min (mean+/-s.d.) (velocity 8.9 cm min(-1)) in seven normal subjects. To assess lymphatic contractility, a sphygmomanometer cuff around the upper arm was inflated to 60 mmHg (Pcuff) before 99mTc-HIG injection and maintained for>>ttransit. When Pcuff exceeded the maximum pressure generated by the lymphatic pump (Ppump), radiolabelled lymph was held up at the distal cuff border. Pcuff was then lowered in 10 mmHg steps until 99mTc-HIG began to flow under the cuff to the axilla, indicating Ppump>or=Pcuff. In 16 normal subjects Ppump was 39+/-14 mmHg. Ppump was 38% lower in 16 women with BCRL, namely 24+/-19 mmHg (P=0.014, Student's unpaired t test), and correlated negatively with the degree of swelling (12-56%). Blood radiolabel accumulation proved an unreliable measure of lymphatic pump function. Lymphatic congestion lymphoscintigraphy thus provided a quantitative measure of human lymphatic contractility without surgical cut-down, and the results supported the hypothesis of lymphatic pump failure in BCRL.

In vivo quantification of the structural abnormalities in psoriatic microvessels before and after pulsed dye laser treatment.

BACKGROUND: Microvascular abnormalities (capillary elongation, widening and tortuosity) are a characteristic feature of psoriasis and form one of the pathological diagnostic criteria. These changes occur early in the progression of a psoriatic plaque, before there is clinical or histological evidence of epidermal hyperplasia. Treatment of psoriatic microvessels with a pulsed dye laser (PDL) has been associated with both clinical improvement and clearance of lesions. OBJECTIVES: To quantify the structural vascular abnormalities in plaque skin using noninvasive techniques in vivo. Investigations were carried out before and after PDL treatment to determine the nature of laser-induced microvascular changes and the relationship between these changes and clinical improvement. METHODS: Plaque microvessels were visualized using native capillaroscopy. Plaques were then treated three times with the PDL at 14-day intervals. Native capillaroscopy was repeated at 2 and 6 weeks after the final laser treatment. Images were analysed using a combination of nonstereological and stereological measurements. RESULTS: Whole body disease was stable. Treated plaques showed a 48% reduction in plaque severity score (P < 0.01). Native studies showed that the PDL significantly reduced plaque microvessel density (P < 0.05), image area fraction (P < 0.01), microvessel length density (P < 0.01) and vessel image width (P < 0.01). The reduction in plaque severity score (which denoted clinical improvement) was related quantitatively to the reduction in microvessel area per unit area of plaque skin, i.e. the image area fraction (correlation coefficient = 0.772, P < 0.01). The greatest response of plaque microvessels was within 2 weeks after the final laser treatment, while the greatest reduction in plaque severity score occurred between 2 and 6 weeks after the final laser treatment, i.e. clinical improvement was preceded by microvascular improvement. CONCLUSIONS: These findings indicate that there is a close correlation between the state of the superficial vasculature and the clinical status of psoriasis. The expanded superficial microvascular bed in plaque skin is a necessary component for maintaining clinical lesions and these blood vessels are thus a legitimate target for treatment.

Blood flow in psoriatic plaques before and after selective treatment of the superficial capillaries.

BACKGROUND: Blood flow is substantially raised in psoriatic plaques. In addition, mechanisms of vasoconstriction and vasodilatation (locally and neurally mediated), although intact, are altered in magnitude. The elevated blood flow is considered to be a result of abnormalities (increase in vessel number, width and length) in the superficial capillary loops rather than changes in the deeper feeding vessels (arterioles). OBJECTIVES: To determine if selective thermolysis of psoriatic capillaries with a pulsed dye laser (PDL) leads to normalization of blood flow and also if the vasoconstrictor and vasodilator responses are returned to normal magnitude. METHODS: Laser Doppler red cell flux was recorded from plaques on the forearm or elbow (untreated plaque site) and from clinically uninvolved skin at an equivalent site on the opposite limb. Plaques were treated on three occasions, at 2-weekly intervals, with a PDL. Laser Doppler red cell flux measurements were then repeated, 2 weeks after the final laser treatment was performed (treated plaque site). RESULTS: There was significant clinical improvement in plaques after treatment (P = 0.02), but complete clearance of lesions did not occur. Blood flow in plaques under basal conditions remained significantly elevated above blood flow in clinically uninvolved skin, despite laser treatment (P < 0.001). The physiological tests of resistance vessel function showed that the laser did not impair the ability of psoriatic resistance vessels to constrict and dilate. However, there was only partial resolution of the percentage responses to the provocation tests towards the values recorded in clinically uninvolved skin. CONCLUSIONS: The results indicate that it is unlikely that the reduced resistance of the expanded superficial capillary bed is solely responsible for the massively elevated blood flow in plaque skin. It is more likely that the vascular abnormalities in psoriasis also extend to involve the deeper, larger resistance vessels (arterioles).

Comparison of the microvasculature of basal cell carcinoma and actinic keratosis using intravital microscopy and immunohistochemistry.

BACKGROUND: Angiogenesis is a prerequisite for growth of invasive tumours. We hypothesized that angiogenesis would be present in invasive basal cell carcinoma (BCC) but not in a noninvasive tumour such as actinic keratosis (AK). OBJECTIVES: To investigate both types of tumour for evidence of angiogenesis. METHODS: Patients with BCC or AK underwent intravital videocapillaroscopy. Three regions were examined: the tumour, perilesional skin and a control site. Microvessel width, area fraction and length density were determined from capillaroscopy images. Biopsies were stained for CD34 and a microvessel count was performed. RESULTS: Capillaroscopy demonstrated a grossly disorganized tumour microcirculation in BCC. Compared with control skin, microvessel width was increased 2.4-fold, area fraction was increased 4.9-fold and length density was increased 5.9-fold. In AK, microvessel width was increased 1.7-fold, area fraction 2.5-fold and length density 3.4-fold. Vessel width and area fraction were significantly greater in BCC than AK. Biopsies showed significant increases in microvessel length density for both BCC and AK compared with control skin, with BCC significantly greater than AK. CONCLUSIONS: Angiogenesis was demonstrated in BCC in humans in vivo, and to a lesser extent in AK.

Impairment of lymph drainage in subfascial compartment of forearm in breast cancer-related lymphedema.

BACKGROUND: In arm lymphedema secondary to axillary surgery and radiotherapy (breast cancer-related lymphedema), the swelling is largely epifascial and lymph flow per unit epifascial volume is impaired. The subfascial muscle compartment is not measurably swollen despite the iatrogenic damage to its axillary drainage pathway, but this could be due to its low compliance. Our aim was to test the hypothesis that subfascial lymph drainage too is impaired. METHODS AND RESULTS: Quantitative lymphoscintigraphy was used to measure the removal rate constant (local lymph flow per unit distribution volume) for technetium-99m-human immunoglobulin G injected intramuscularly in the forearms of nine women with unilateral lymphedema. The removal rate constant was on average 31% lower in the ipsilateral swollen forearm than in the contralateral forearm (swollen arm: -0.096+/-0.041% min(-1), contralateral arm: -0.138+/-0.037% min(-1); mean+/-SD, p = 0.037). The decrease in subfascial rate constant correlated strongly with increase in arm volume (r = -0.88, p = 0.002), even though the swelling is mainly epifascial. There was no convincing evidence of dermal backflow. CONCLUSIONS: Lymph flow in the subfascial muscle compartment is decreased in breast cancer-related lymphedema. The correlation between impairment of subfascial drainage and epifascial arm swelling could be because both depend on the severity of axillary damage, or because loss of function in subfascial lymphatics impairs drainage from the epifascial to the subfascial system.

Evidence for dermal angiogenesis in breast cancer related lymphedema demonstrated using dual-site fluorescence angiography.

OBJECTIVE: To determine whether the skin expansion associated with breast cancer related lymphedema (BCRL) reduces microvessel density or causes a compensatory angiogenesis. METHODS: Dermal microvessel density was measured by simultaneous fluorescence video angiography in the ipsilateral and contralateral forearms of 25 patients treated for breast cancer, 12 with BCRL (excess volume 30 +/- 20%) and 13 without. RESULTS: Microvessel density was as high in the swollen arm (27.2 +/- 7.2 mm(-2)) as in the contralateral arm (24.2 +/- 6.2 mm(-2)) despite a 16 +/- 12% increase in local circumference. Total microvessels in a 1-mm annulus of skin was 30% greater in the swollen arm (752 +/- 211) than the contralateral arm (578 +/- 157; p = 0.005, t-test). Microvessel density was similar in each arm in control patients (ipsilateral 24.1 +/- 6.2 mm(-2), contralateral 26.1 +/- 8.8 mm(-2)). CONCLUSIONS: The number of microvessels increased in the expanded skin to maintain microvessel density at a normal level. Therefore, angiogenesis occurs during chronic limb swelling. The control group results indicate that angiogenesis is not caused by the cancer treatment.