FLT4 Mutations Are Associated with Segmental Lymphatic Dysfunction and Initial Lymphatic Aplasia in Patients with Milroy Disease.

This study explored mutations in the Fms-related tyrosine kinase 4/vascular endothelial growth factor receptor 3 gene (FLT4) and lymphatic defects in patients with Milroy disease (MD). Twenty-nine patients with lower limb lymphedema were enrolled. Sixteen patients had a familial history of MD, while 13 patients exhibited sporadic MD. Clinical signs, FLT4 mutations, indocyanine green (ICG) lymphography findings, and skin tissue immunohistochemical staining results were evaluated. Twenty-eight variants in FLT4 were identified. Twelve of these have previously been reported, while 16 are novel. Of the 28 variants, 26 are missense mutations, and the remaining two comprise a splicing mutation and a non-frame shift mutation. Twenty-five variants are located in the intracellular protein tyrosine kinase domain; three are located in the extracellular immunoglobulin domain. Substantially delayed contrast-enhanced tortuous lymphatic vessels were visualized to the ankle or knee level in 15 of 23 patients who underwent ICG lymphography. No initial lymphatic vessels were visualized in skin specimens from four patients who did not exhibit lymphatic vessels during imaging analyses. No specific variant was identified in relation to the unique clinical phenotype. Segmental dysfunction of lymphatic vessels and initial lymphatic aplasia are present in MD patients with FLT4 mutations.

Dysfunction of dermal initial lymphatics of the arm and upper body quadrant causes congenital arm lymphedema.

OBJECTIVE: The objective of this study was to explore the pathologic process underlying primary lymphedema. METHODS: Twenty-seven patients with unilateral congenital arm lymphedema who visited our clinic from January 1, 2014, to May 30, 2019, were enrolled. The patients' clinical signs and the findings of indocyanine green (ICG) lymphography, skin tissue immunohistochemical staining, and whole exome sequencing of tissue and blood were evaluated. RESULTS: Among the 27 patients, 11 were diagnosed with stage II and 16 were diagnosed with stage III lymphedema. No lymphatic vessels were visualized in the affected arm in 25 of 27 (93%) patients who underwent ICG lymphography; likewise, no lymphatics were found in the territories of axillary lymph node drainage in the trunk, irrespective of any anomalies of the axillary lymph nodes. In only two (7%) patients, an unclear lymphatic trunk gradually appeared in the dorsum of the affected hand. The number of initial lymphatics was increased in the skin specimens of all nine patients in whom lymphatics were not demonstrated by ICG lymphography. Among 14 tested patients, we found compound heterozygote variants in the PIEZO1 gene in only one (7%) patient. Two missense variants, c.4072C>T; p.Arg1358Cys and c.5033C>T; p. Ala1678Val, were identified and found to have been inherited from the father and mother, respectively. No other pathogenic or likely pathogenic variants of currently known lymphedema-related genes were identified in the remaining 13 patients. No genetic difference was found between the lymphedematous and nonedematous healthy skin tissue of the same person. CONCLUSIONS: Segmental or regional dysfunction of the dermal initial lymphatics causes congenital arm lymphedema and may have implications for clinical treatment.

Assessment of Skin Properties in Chronic Lymphedema: Measurement of Skin Stiffness, Percentage Water Content, and Transepidermal Water Loss.

Background: Lymphedema (LE) is a chronic progressive protein-rich edema of the soft tissues. Measurement of extracellular fluid of the affected limbs is widely used in detecting LE; however, quantification of the skin alterations and early tissue changes in LE lacks approaches. Methods and Results: Ninety-one patients with LE were assessed. Measurement of transepidermal water loss (TEWL), skin stiffness (SF), and percentage water content (PWC) was assessed on five predetermined skin sites. The value of TEWL, SF, and PWC increased significantly in lymphedematous skin compare with controls, indicating damaged function and texture of the affected skin. Both PWC ratio and SF ratio strongly correlated with LE stage. High correlations were found among instruments assessing tissue fluid. Conclusions: Assessment of the skin parameters has contributed new information about the functional and structural alterations in chronic lymphedematous skin. Quantification of skin properties changes could be a valuable supplement to diagnosis and evaluation of chronic LE.

Prefabricated Cervical Skin Flaps for Hemi-Facial Resurfacing: Elucidating the Natural History of Postoperative Edema Using Indocyanine Green.

BACKGROUND: The increases in capillary wall permeability and capillary hydrostatic pressure are considered to be the causes for the acute swelling seen in flaps; however, disruption of the circulating flap lymphatics could be another contributory factor. In this study we monitor the development of flap edema in a series of 18 prefabricated flaps and aim to delineate the natural history of this phenomenon by use of lymphography. METHODS: Postoperative swelling was monitored in a series of 18 pre-expanded prefabricated cervical skin flaps used for hemi-facial burns-scar resurfacing. Time to spontaneous resolution, presence or absence of venous congestion, and clinical outcome were recorded. In two cases, indocyanine-green (ICG) lymphography was used to monitor the dermal backflow pattern until swelling had completely resolved. Average moving velocity of ICG after injection as well as flap thickness was also recorded over the follow-up period. RESULTS: The average moving velocity of ICG in the flap lymphatics improved from 0.48 cm/min to 1.5 cm/min in the first 12 days after flap transfer. The dermal backflow pattern was stardust in the first 12 days, indicating moderate lymphedema, transforming to splash from week three, and a robust collecting lymphatic vessel occurring from the fifth month, indicating mild lymphedema and lymphatic channel recovery, respectively. CONCLUSION: Transient swelling was observed in all prefabricated flaps in our series. We postulate that this is mostly secondary to lymphatic disruption that subsides as lymphangiogenesis takes place. ICG lymphography is an inexpensive, safe, and easy-to-use imaging technology that could be used in the monitoring of postoperative lymphedema seen in prefabricated flaps.

Blockade of angiopoietin-2/Tie2 signaling pathway specifically promotes inflammation-induced angiogenesis in mouse cornea.

AIM: To investigate angiopoietin-2 (Ang-2)/Tie2 signaling pathway involving in inflammatory angiogenesis. METHODS: Three interrupted 11-0 nylon sutures were placed into the corneal stroma of BALB/c mice (6wk old) to induce inflammatory neovascularization. Expression of Ang-2 and Tie2 protein on neovascularization were examined by immunofluorescence. The dynamic expression of Ang-2 mRNA on neovascularization was examined by quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Finally, the mouse model of suture-induced corneal neovascularization was used to assess the role of Ang-2/Tie2 signaling pathway in inflammatory angiogenesis by systemic application of L1-10, an Ang-2 specific inhibitor. Mouse corneal hemangiogenesis were evaluated by whole mount immunofluorescence. RESULTS: Both Ang-2 and Tie2 were expressed on newly generated blood vessels in inflammatory cornea. Ang-2 expression was gradually upregulated around 2wk following injury, which was concurrent with an increased number of blood vessels. Blockade of Ang-2/Tie2 signaling pathway obviously promoted angiogenesis in inflammatory cornea. CONCLUSION: Ang-2/Tie2 signaling pathway seems to play an important role during angiogenesis in inflammatory cornea. This may open new therapeutic applications in pathological processes such as corneal graft survival, wound healing and carcinogenesis.

The Value of Using a SkinFibroMeter for Diagnosis and Assessment of Secondary Lymphedema and Associated Fibrosis of Lower Limb Skin.

BACKGROUND: Skin fibrosis is a clinically serious pathological process of secondary lymphedema (SLE). The detection of latent or incipient skin fibrosis, including early tissue changes, using sensitive diagnostic equipment is essential. The SkinFibroMeter has been used in skin care; however, its ability to assess skin fibrosis in patients with SLE of the lower limb has not been explored. METHODS AND RESULTS: In this study, 45 female patients with secondary unilateral lower limb LE and 15 healthy female volunteers were enrolled. The skin stiffness values of affected and healthy limbs were measured by using the SkinFibroMeter, and skin samples were assayed by Masson staining. The circumference and interstitial fluid of limbs were also measured and analyzed. Increasing skin stiffness with increasing severity of SLE of the lower limb and skin stiffness significantly positively correlated with stage of lower limb SLE. CONCLUSIONS: Our results demonstrate that the SkinFibroMeter is very sensitive and accurate for detecting skin fibrosis of edematous limb. Therefore, this new instrument is a promising prospect for diagnosis and assessment of skin fibrosis in patients with lower limb SLE.

Pathological Changes of Lymphedematous Skin: Increased Mast Cells, Related Proteases, and Activated Transforming Growth Factor-ß1.

BACKGROUND: Skin fibrosis is a clinically serious pathological process of secondary lymphedema (SLE). Previous studies have shown that mast cells (MCs) are involved in lymphedema (LE) and play a key role in the pathological process of skin fibrosis. However, the role of the protease chymase and transforming growth factor-ß1 (TGF-ß1) secreted by MCs in the fibrotic skins of patients with secondary lower limb LE has not been explored. METHODS AND RESULTS: In this study, full-thickness skin biopsies of lymphedematous limbs from seven SLE patients and control samples from seven healthy controls were harvested. The skin samples were assayed by Masson, immunohistochemical, and immunofluorescence staining and were analyzed by western blot and enzyme-linked immunosorbent assay. The number of MCs and the expression of proteases, TGF-ß1, and latency-associated peptide TGF-ß1 (LAP TGF-ß1) were analyzed. The number of MCs and the expression of chymase, TGF-ß1, and LAP TGF-ß1 were increased in fibrotic skin compared with normal skin. The increased expression of TGF-ß1 on lymphatic vessels, endothelial cells, and in skin interstitial tissues overlapped with chymase expression. CONCLUSIONS: Our results demonstrate that chymase and TGF-ß1 expression was significantly increased in the fibrotic skin of secondary lower limb LE. The increased expression of chymase in the skin may play an important role in the development fibrosis in the lymphedematous skin. We speculate that chymase may facilitate the release of LAP TGF-ß1 to generate activated TGF-ß1, and the upregulation of active TGF-ß1 can promote fibrosis in the SLE skin.

Abnormal mural cell recruitment in lymphatic capillaries: a common pathological feature in chronic lymphedematous skin?

OBJECTIVES: This study aimed to explore the structural and functional characteristics of dermal lymphatic capillaries in patients with chronic LE, specifically focused on the mural cells that are associated with skin lymphatics. METHODS: Forty-four patients (30 primary LE and 14 secondary LE) and eight healthy controls were enrolled in this study. Genetic analysis of the FOXC2 was performed in 18 patients with primary LE. Full-thickness skin was excised and immunohistologically stained for podoplanin and α-SMA. The proportions of α-SMA+ Lv (α-SMA+ Lv%) were calculated. Lymphatic vascular function was assessed by indocyanine green lymphography. RESULTS: Analysis of FOXC2 revealed two mutations in two patients with LDs. Histologically, thirty-nine patients exhibited increased α-SMA+ mural cell coverage of lymphatic capillaries. The α-SMA+ Lv% values in the superficial and deep dermis in patients with primary and secondary LE were significantly higher than in the control group. Compared with imaging findings in healthy limbs, in which the collecting lymphatics were clearly visualized, lymphedematous extremities all exhibited dermal backflow. CONCLUSIONS: Abnormal recruitment of mural cells in dermal lymphatic capillaries is a common pathological event in chronic LE, and may play a role in disease evolution.

Heating and Compression Bandage Treatment Is Effective for Chronic Lymphedema with Dermatolymphangioadenitis-A Case-Controlled Study.

BACKGROUND: To investigate the therapeutic effect of far infrared rays and compression bandaging in the treatment of chronic lymphedema with dermatolymphangioadenitis (DLA). METHODS: Between 2005 and 2013, 106 patients with chronic lymphedema with DLA treated at the Shanghai Ninth People's Hospital were retrospectively reviewed. These patients were divided into an infrared and a bandaging group (80 patients, group 1) and bandaging only group (26 patients, group 2). Outcome measures include DLA frequency, patients' subjective feedback with regards to their symptoms, and the relationship between continuous elastic compression bandaging and relapse of DLA. RESULTS: The frequency of DLA in group 1 and group 2 were significantly reduced after treatment (p = 0.000 and 0.004, respectively). Seventy five percent (60) of patients in group 1 and 19% (5) of patients in group 2 suffered no further episodes of DLA during the follow-up period. In group 1, over 90% of patients reported a subjective improvement in their symptoms and the relapse rate was shown to be lower using elastic compression bandaging when higher pressures were applied. CONCLUSION: Heating with compression bandaging can be an effective treatment strategy to reduce DLA and improve the quality of life for those patients with chronic lymphedema associated with DLA.

Magnetic Resonance Lymphangiography for the Study of Lymphatic System in Lymphedema.

BACKGROUND: Imaging of the lymphatic system is difficult because of its structural and anatomical characteristics, and the conventional diagnostic method, radionuclide-based imaging, has the disadvantage of poor resolution. Magnetic resonance (MR) imaging has been shown the capability of depicting lymphatic channels in lymphedema recently. The purpose of this study was to evaluate the imaging of MR lymphangiography (MRL) in diagnosis of limb lymphedema and its possible role in the microsurgical management of lymphedema. METHODS: A total of 710 patients with primary lymphedema (n = 378), secondary lymphedema (n = 332), were enrolled in the study. Contrast-enhanced lymphangiography was performed with 3.0 T MR unit (Philips Medical Systems, Best, The Netherlands) after intracutaneously injection of gadobenate dimeglumine. Kinetic of enhanced lymph flow within lymphatics and lymph nodes as well as the morphological abnormalities of lymphatic system were evaluated. RESULTS: MRL was able to display the detailed anatomical changes in the vessels and nodes. In primary lymphedema, there are three major types of lymphatic system malformation: (1) only lymph nodes affected, (2) only lymph vessels affected, and (3) both lymph vessels and lymph nodes affected. In secondary lymphedema MRL clearly demonstrated tortuous and dilated collecting lymphatics in lymphedemtous limbs. MRL also provided information concerning the functional status of lymph transport in lymphatic vessels and nodes by real-time visualization of enhanced lymph flow in lymphatic channels and within lymph nodes. CONCLUSION: Contrast MRL was capable of evaluating the anatomical and functional status of lymphatic vessels and lymph nodes in lymphedematous limb. This new imaging shows good potential for use in the diagnosis and surgical management of lymphedema.

[Therapeutic effect of heating and bandage treatment for chronic lymphedema of extremities accompanied with erysipelas: a report of 80 cases].

OBJECTIVE: To investigate the therapeutic effect of heating and bandage treatment for chronic lymphedema of extremities accompanied with erysipelas. METHODS: From March 2004 to March 2013, 80 patients with chronic lymphedema of extremities accompanied with erysipelas were analyzed retrospectively. The patients underwent heating treatment (42 degree centigrade) with infrared light machine made by Shanghai Ninth People's Hospital, 2 hours a day, 20 hours for a session. Bandage treatment was adopted after heating treatment. 1 or 2 sessions were performed for each patient every year. The erysipelas occurring frequency, patients subjective feeling, treatment sessions and elastic material usage was recorded during the follow-up period. The erysipelas occurring frequency was tested by the method of rank and inspection. SPSS 17. 0 was used for statistical analysis. RESULTS: After heating and bandage treatment, the occurrence frequency of erysipelas was obviously controlled (Z = 7.598, P = 0.000). Erysipelas was not occurred any more in 60 (75%)patients. Remarkable reduction of occurrence frequency of erysipelas caused by various reasons was showed after treatment. Primary and secondary lymphedema after treatment were compared with those before treatment respectively, showing statistical difference (Z = 3.417 and 5.009, P = 0.001 and 0.000). Most of patients felt better subjectively. The relapse rate of erysipelas and lymphedema was lower if keeping using elastic material to give more pressure on extremities after therapy. CONLUSIONS: Heating and bandage treatment can obviously reduce the occurrence frequency of erysipelas. It can improve the quality of patients' lives. Simultaneously, the subsequent elastic material pressure therapy is essential.

Functional lymphatic collectors in breast cancer-related lymphedema arm.

BACKGROUND: The pathophysiology of breast cancer-related lymphedema (BCRL) is poorly understood. The present study evaluated the lymphatic collectors in the arms of patients with BCRL. METHODS AND RESULTS: In total, 123 patients with ipsilateral BCRL who had undergone magnetic resonance lymphangiography using gadobenate dimeglumine as a contrast agent were enrolled in this study. Morphological changes and the numbers of collecting lymphatic vessels were recorded. Associations between the number of visualized lymphatic collectors and edema accumulation, subcutis thickness, and the BCRL duration and latency were analyzed. Tortuous and significantly dilated lymphatic collectors were visualized in the lymphedematous arms of 104 patients (85%). The median number of visualized lymphatic collectors was four. The duration of BCRL was weakly but significantly correlated with the number of lymphatic collectors (rs=0.2054, p=0.0226). The differences in the tissue water content and thickness of the subcutis between the bilateral arms demonstrated moderate correlations with the number of collecting lymphatics (rs=0.31 and 0.35, respectively; p<0.01). More lymphatic collectors tended to be seen in more advanced cases. There was no statistical difference in the amount of lymphatic vessels among different breast cancer treatment methods. CONCLUSIONS: The number of functional remaining lymphatic collectors increases with the prolongation and severity of BCRL. This may imply persistent reactions of lymphatic collectors in response to lymphostasis.

Diagnosis of inguinal lymph node metastases using contrast enhanced high resolution MR lymphangiography.

RATIONALE AND OBJECTIVES: Inguinal lymph nodes can be the first or the only clinical signs of tumor metastases. The aim of the study was to evaluate the role of contrast-enhanced high-resolution magnetic resonance (MR) lymphangiography in diagnosis of inguinal lymph node metastases. MATERIALS AND METHODS: The study enrolled 26 patients with inguinal lymph node metastases. Contrast-enhanced lymphangiography was performed using a 3.0T MR unit after intracutaneous injection of gadobenate dimeglumine into the interdigital webs of the dorsal foot. Images of inguinal lymph nodes were acquired before and after contrast injection. RESULTS: All patients exhibited edema in the subcutaneous layer with significant dilatation of lymphatic collectors in the affected lower limbs on MR images. Before contrast injection, the outline and structure of the affected nodes were unclear on T2 weighted images. Structural changes became evident on postinjection T1-weighted images. Nodal involvement on contrast enhanced MR lymphangiograms was characterized as: 1) heterogeneous structure with partial or marginal enhancement of the node indicating partial occupation by tumor; 2) homogeneous structure of the node without contrast enhancement, indicating total occupation with metastasis, with increase or no change in size; and 3) heterogeneous structure with punctiform nodal enhancement indicating diffuse growth of tumor within the node. Further examinations confirmed the diagnoses of inguinal lymph node metastases of either regional or distal tumors. CONCLUSIONS: Contrast-enhanced high-resolution MR lymphangiography was a sensitive modality in the diagnosis of malignant peripheral lymphedema and the identification of inguinal lymph node metastasis in patients with various tumor origins.

MR lymphography of lymphatic vessels in lower extremity with gynecologic oncology-related lymphedema.

OBJECTIVE: To characterize lymphatic vessel morphology in lower extremity lymphedema using MR lymphography at 3T. STUDY DESIGN: Forty females with lower extremity lymphedema secondary to gynecologic carcinoma treatment underwent MR lymphography (MRL) at 3T. Lymphatic vessel morphology in normal and affected limbs was compared. RESULTS: The median diameter of the lymphatic vessels in swollen calf and thigh were significantly larger than that in the contralateral calf and thigh, respectively (p<0.05). The median number of lymphatic vessels visualized in normal calf was less than that in the lymphedematous calf (p<0.01), while no significant difference was found between the normal thigh and swollen thigh. Lymphatic vessel number in the affected calf was significantly greater than that in affected thigh and the mean diameter of affected calf was also significantly wider than that of affected thigh (p<0.01). Mean diameter of lymphatic vessels in the affected calf was significantly different between stage I and stage III (p<0.05), but not significantly different between stages I and II, and between stages II and III (p>0.05). The median number of lymphatic vessels for affected calf showed significant difference between stage I and stage III, and between stage II and stage III (p<0.05), but no significant difference between stage I and stage II (p>0.05). There was no significant difference in mean diameter or median number of lymphatic vessels in the affected thigh found between different stages (p>0.05). CONCLUSION: There are significant differences in the number or diameter of lymphatic vessels between normal and affected limbs and there are significant differences for affected calf between early and late stages of lymphedema; therefore, MR lymphography can be helpful in diagnosis or clinical staging for lower extremity with gynecologic oncology-related lymphedema.

Comparison of approaches for microscopic imaging of skin lymphatic vessels.

Assessment of skin lymphatic vessels is of great significance in understanding their roles in many pathological conditions. Our aim was to identify the optimal approach for investigation of cutaneous lymphatic system. We performed comparative studies on skin lymphatic vessels using immunohistochemistry of tissue sections, computer graphic reconstruction method together with immunohistochemically stained serial sections and whole mount fluorescence in human lower limb. Lymphatic vessels were identified with podoplanin antibody. The relative merits and drawbacks of each method in evaluation of structure, spatial organization, and distribution of cutaneous lymphatic vessels were described. Immunohistology of tissue sections enabled the investigation of the structure and distribution of the whole cutaneous lymphatic system in two-dimensional slices, whereas three-dimensional morphology of only the most superficial lymph capillary network immediately under the epidermis could be evaluated with the whole mount technique. Meanwhile, only little segmentation of skin lymphatic vessel from five immunohistochemically stained serial sections was reconstructed and evaluated due to expense and special skills required using computer graphic three-dimensional reconstruction. Furthermore, a great number of artifacts and special skills required in its processes leaded to less accurate structure of skin lymphatic vessels. Our findings demonstrated that the use of either of the proposed techniques alone could not allow a comprehensive analysis of the skin lymphatic system due to their relative drawbacks. Combination of immunohistology of tissue sections and three-dimensional whole-mount preparations appears to be the best candidate for comprehensive evaluation of skin lymphatic system.

Angiopoietin-2 promotes inflammatory lymphangiogenesis and its effect can be blocked by the specific inhibitor L1-10.

Angiopoietin (Ang)-2, a ligand of the receptor tyrosine kinase Tie2, is known to be involved in the regulation of embryonic lymphangiogenesis. However, the role of Ang-2 in postnatal pathological lymphangiogenesis, such as inflammation, is largely unknown. We used a combination of imaging, molecular, and cellular approaches to investigate whether Ang-2 is involved in inflammatory lymphangiogenesis. We observed strong and continuous expression of Ang-2 on newly generated lymphatic vessels for 2 wk in sutured corneas of BALB/c mice. This expression was concurrent with an increased number of lymphatic vessels. TNF-α expression also increased, with peak TNF-α expression occurring before peak Ang-2 expression was reached. In vitro experiments showed that TNF-α stimulates Ang-2 and Tie2 and ICAM-1 expression on human lymphatic endothelial cells (LECs) and blood vascular endothelial cells (BECs). Ang-2 alone did not affect the biological behavior of LECs, whereas Ang-2 combined with TNF-α significantly promoted the proliferation of LECs but not BECs. In mouse models, blockade of Ang-2 with L1-10, an Ang-2-specific inhibitor, significantly inhibited lymphangiogenesis but promoted angiogenesis. These results clearly indicate that Ang-2 acts as a crucial regulator of inflammatory lymphangiogenesis by sensitizing the lymphatic vasculature to inflammatory stimuli, thereby directly promoting lymphangiogenesis. The involvement of Ang-2 in inflammatory lymphangiogenesis provides a strong rationale for the exploitation of anti-Ang-2 treatment in the prevention and treatment of tumor metastasis and transplant rejection.

[Comparison study of radionuclide lymphoscintigraphy and dynamic magnetic resonance lymphangiography for the diagnosis of extremity lymphedema].

OBJECTIVE: To compare the role of radionuclide lymphoscintigraphy and dynamic magnetic resonance lymphangiography (MRL) for the diagnosis of extremity lymphedema. METHODS: Sixteen patients with primary extremity lymphedema and two with Klippel-Trenaunay syndrome combined with lymphedema were examined by lymphoscintigraphy using the tracer 99Tc-labelled dextran, and also by MRL using gadobenate dimeglumine as contrast agent. The results of morphological abnormalities and functional state of the lymphatic system at affected limbs from the two imaging methods were compared. RESULTS: Lymphatic vessels were imaged in 14 of 18 limbs with lymphedema using MRL, compared with one of 18 using lymphoscintigraphy. MRL detected the inguinal nodes in 16 of 17 patients, whereas lymphoscintigraphy revealed inguinal nodes in only nine cases. MRL revealed more precise information about structural and functional abnormalities of lymph vessels and nodes than lymphoscintigraphy by real-time measurement of lymph flow in vessels and nodes. CONCLUSIONS: Dynamic MRL is more sensitive and accurate than lymphoscintigraphy in the detection of anatomical and functional abnormalities in the lymphatic system in patients with extremity lymphedema.

Real-time in vivo imaging collagen in lymphedematous skin using multiphoton microscopy.

Changes of dermal collagen are characteristic for chronic lymphedema. To evaluate these changes, a real-time imaging based on two-photon excited fluorescence and second-harmonic generation was developed for investigating collagen of lymphedematous mouse and rat tail skin in vivo. Our findings showed that the technique could image the morphological changes and distribution of collagen in lymphedematous mouse and rat tail skin in vivo. More importantly, it may allow visualization of dynamic collagen alteration during the progression of lymphedema. Our findings demonstrated that multiphoton microscopy may have potential in a clinical setting as an in vivo diagnostic and monitoring system for therapy in lymphology.

[Treatment of chronic extremity lymphedema with manual lymph drainage].

OBJECTIVE: To evaluate the effect of manual lymph drainage on chronic extremity lymphedema. METHODS: Fifty patients with chronic lymphedema of extremity were treated with manual lymph drainage (MLD) complex decongestion therapy. Among them, 29 had primary lymphedema, 21 had secondary lymphedema. 42 had lymphedema of lower extremity and 8 had lymphedema of upper limb. The result of treatment was evaluated with measurement of circumference of extremities and edema fluid in tissue with Multiple-frequency bioelectrical impedance analysis. RESULTS: After 1-2 treatment courses, all 50 patients showed significant decrease of circumference of lymphomatous limbs (P < 0.05) and remarkable reduction of accumulated edema fluid in tissue (P < 0. 05). There was highly correlation between the decrease of limb circumference and edema fluid in tissue (r(s) = 0.774, P < 0.01). CONCLUSIONS: MLD complex decongestion therapy is effective for the treatment of chronic lymphedema of extremity.

[Diagnosis of peripheral lymph circulation disorders with contrast MR lymphangiography].

OBJECTIVE: To evaluate anatomical and functional images of contrast MR lymphangiography in the diagnosis of limb lymphatic circulation disorders. METHODS: 30 patients with limb lymphedema were enrolled in the study. There were 27 patients of primary lymphedema and 3 of secondary lymphedema. Contrast enhanced lymphangiography was performed with 3.0 T MR Unit after intracutaneous injection of gadobenate dimeglumine into the interdigital webs of the dorsal foot and hand. The kinetics of enhanced lymph flow within the lymphatics were calculated using the formula: Speed (cm) = total length of visualized lymph vessel (cm)/ inspection time (minutes) and by comparing dynamic nodal enhancement and time-signal intensity curves between edematous and contralateral limbs. Morphological abnormalities of the lymphatic system were also evaluated. RESULTS: Following injection of the contrast agent enhanced lymphatic channels were consistently visualized in all clinical lymphedematous limbs and five contralateral limbs of unilateral lymphedema cases. The speed of enhanced flow within the lymphatics of lymphedematous limbs ranged from 0.30 to 1.48 cm/min. The contrast enhancement in inguinal nodes of edematous limbs was significantly lower than that of contralateral limbs (P < 0.01). Dynamic measurement of contrast enhancement showed a remarkable lowering of peak time (P < 0.01) and peak enhancement (P < 0.01) and a delay in outflow in inguinal nodes of affected limbs compared with that of control limbs. Post-contrast MR imaging also depicted varied distribution patterns of lymphatics and abnormal lymph flow pathways within lymph nodes in the limbs with lymphatic circulation disorders. CONCLUSIONS: Contrast MR lymphangiography with gadobenate dimeglumine was able to visualize the precise anatomy of lymphatic vessels and lymph nodes in lymphedematous limbs. It also provided comprehensive information about the functional status of lymph flow transportation in lymphatics and lymph nodes.