Abstracts LymphForsch 2/2009

Neoangiogenesis of lymphatics in tumor tissue, results of an immune-histochemical pilot study

C. Brück, D. Zielinski, J. Rüschoff, H. Zöltzer LymphForsch 2009;13 (2):6-14

Summary

Objective:
The lymphatics play a key role in the metastasis of malignant tumors. If a tumor exceeds a critical size of approx. 2-3 mm, it requires its own bloodvessels for the supply of nutrients and removal of metabolic waste. The secretion of angiogenic factors by the tumor triggers the formation of new blood vessels. The present study investigated whether in addition to the formation of new blood vessels, neoangiogenesis of the lymphatics in the tumor region occurs. It also addressed the question as to whether lymph vessels identified in and around the tumor tissue are evidence of tumor-associated lymphangiogenesis or whether the tumor's growth compresses and ultimately opens up the already existing lymph vessels, thus allowing the tumor cells to enter the lymphatic system.

Methods:
Using conventional stains and immunohistochemistry (LYVE-1, podoplanin,neuropilin-2), lymph vessels in normal tissue, tumor and surrounding tissue were detected. Melanomas and carcinomas of the lung, breast and colon were used for the study. 
Results: Newly formed lymph vessels could be equivocally identified in the tumor region for each type of cancer. However, for the melanoma in particular, there were also signs that the tumor had already surrounded and subsequently opened existing “mature” lymph vessels during its growth phase.

Conclusions:
In tumor tissue, both tumor-associated lymphangiogenesis may occur as well as the opening of old, already existing lymph vessels through which metastasis can occur. The latter route appears to occur frequently in rapidly growing tumors. 

Keywords: lymph vessels, tumor, neoangiogenesis, immunohistochemistry

Arguments in favor of fluorescence microlymphangiography

A. Amann-Vesti LymphForsch 2009;13 (2):22-23

Summary
Fluorescence microlymphangiography (FML) is a minimally invasive technique for visualizing lymphatics of the skin that is easy to perform. It allows differentiation of lymphogenic and non-lymphogenic edema that is highly sensitive and specific. Some types of lymphedema present specific changes of the skin lymphatic. Thus, in some cases, FML also permitts conclusions about the etiology of the lymphedema to be drawn. Since FML is performed without irradiation, it is also well-suited for follow-up and scientific studies.

Keywords: fluorescence microlymphangiography, initial lymphatics of the skin, minimally invasive technique, lymphedema, differential diagnosis of edema

Arguments against fluorescence microlymphangiography

I. Stöberl LymphForsch 2009;13 (2):24-26

Summary
Fluorescence microlymphangiography and indirect lymphography are compared and analyzed with regard to their practicability for everyday use in the diagnosis of lymphedema. Aspects speaking against fluorescence microlymphangiography include the following:
In order to perform fluorescence microlymphangiography equipment is required only available in specialized departments. Diagnosis of lymphedema carried out by fluorescence microlymphangiography is based on one parameter only which is the diameter of the containing the fluorescent tracer. The sensitivity of fluorescence microlymphangiography ( 83 %) is considerable lower then the sensitivity of indirect lymphography (97 %). 

Keywords: fluorescence microlymphangiography, indirect lymphography, lymphedema, diagnosis

Direct lymphography: Still state of art?

A. Weissleder LymphForsch 2009;13 (2):27-29

Summary
Despite the availability of modern imaging methods such as ultrasound, CT and MRI, conventional lymphographic examinations using oily contrast agent are still useful. For treatment of lymph fistulas or lymphoceles, the method is superior for localizing the defect, e.g. in patients with chylothorax or chyluria. When percutaneous thoracic duct embolization is planned, conventional lymphography is used to localize the cisterna chyli.

Keywords: conventional lymphography, lymphangiography, oily contrast agent, thoracic duct, lymph fistula

Vacuum Assisted Closure for a large posttraumatic leg ulcer in a patient with lipolymphedema

U. Wollina , B. Heinig, G. Hansel, C. Krönert LymphForsch 2009;13 (2):30-33

Summary
Chronic lower leg ulcers are a common finding in dermatology. Especially in cases of concomitant lipedema and lymphedema, all therapeutic options should be used to clean wounds and improve granulation. Vacuum assisted closure is considered to be an established method among conservative and pre- and postoperative treatment concepts for chronic wounds. In addition to the specific dermatological wound therapy and adjuvant physical applications, this method clearly improves and accelerates the wound- healing process. An actual case of a 52-year-old female patient is an example of successful treatment using vacuum assisted closure in a post-traumatic lipolymphedematous leg ulcer.

Keywords: lipolymphedema, vacuum assisted closure, decongestive therapy, leg ulcer

Diagnosing obesity in lymphology

U. Herpertz LymphForsch 2009;13 (2):34-37

Summary
Body mass index (BM I) is the most common anthropometric method for diagnosis and classification of obesity. Selected cases are used to show that BM I is unhelpful in patients with severe edema and lymphedema. For these patients, calculation of waist-to-height ratio (WHtR) is the only reasonable method Keywords: body mass index, BM I, waist-to-height ratio, WHtR, edema, lymphology.

Lipedema and liposuction: Experience with the medical service of the German social health system

W. Schmeller, I. Meier-Vollrath LymphForsch 2009;13 (2):39-46

Summary
The Medical Service of the Statutory Health Insurance Funds "(MDK)", a medical monitoring institution of the German health insurance system, is tasked with advising the health insurance companies on whether a particular therapy is necessary or not. However, in our experience with liposuction in patients with lipedema it can be said that in most cases, assessment by the MDK is not correct and not objective. Unfortunately, many of the MDK physicians do not have sufficient knowledge of lipedema. In addition, scientific facts and current guidelines are ignored. Often surgical therapy is rejected on the basis of the claim that conservative therapy has not yet been performed adequately. Such incompetent statements deprive patients of surgical treatment that is in line with established guidelines and can improve their lives.

Keywords: lipedema, liposuction, medical monitoring institution (MDK), German health insurance system

Updates in lymphological research and treatment3

A. Weissleder LymphForsch 2009;13 (2):47-50

Summary
Literature review of selected, practice-relevant articles published in the last two years (PubMed search). 1. Indocyanine green (ICG) fluorescence lymphography, a new diagnostic imaging technique, enables the visualization of subcutaneous lymph vessels of the extremities and can be used as a screening test in out-patient practice. 2. An animal model of postoperative lymphedema that would permit quantification of edema and lymphatic function (restoration of approx. 80% of original function) after the removal of a single popliteal lymph node in sheep has been demonstrated. 3. Multifocal/multicentric breast cancers may lead to diagnostic problems if exclusively mammography and ultrasound are used as “imaging methods.” Additional newer imaging procedures may improve results in the future. 4. Recalcitrant malignant lymphedema is a disorder seen in palliative care. External drainage of the accumulated interstitial fluid is an alternative option in cases ofineffective conservative treatment. This kind of palliative therapy can be helpful in reducing acute symptoms, thus improving patients’ quality of life. 5. The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. According to the recent literature, in the US, lymphedema can be expected in up to 70% of patients with morbid obesity (BMI >40).

Keywords: ICG lymphography, regeneration of lymph vessels, lymphedema, morbid obesity