Autologous Lymph Node Transplantation Research Articles

Effect of cryopreservation on lymph node fragment regeneration after autologous transplantation in the minipig model.

Introduction:Lymphoedema is a worldwide pandemic causing swelling of tissues due to dysfunctional transport of lymph fluid. Present management concepts are based in conservative palliation of symptoms through manual lymphatic drainage, use of compression garments, manual lymph drainage, exercise, and skin care. Nevertheless, some curative options as autologous lymph node transplantation were shown to reduce lymphoedema in selected cases. Lately, some concern has arisen due to reports of donor site morbidity. A possible solution could be the development of artificial lymph node scaffolds as niches of lymphatic regeneration. Engineering these scaffolds has included cryopreservation of lymph node stroma. However, the effects of cryopreservation on the regeneration capacities of these organs were unknown.Materials and methods:Here, we used the minipig animal model to assess lymphatic regeneration processes after cryopreservation of autologous lymph nodes. Superficial inguinal lymph nodes were excised and conserved at −80°C for 1 month. Thereafter, lymph node fragments were transplanted in the subcutaneous tissue.Results:Regeneration of the lymph nodes was assessed five months after transplantation. We show that lymph node fragment regeneration takes place in spite of former cryopreservation. Transplanted fragments presented typical histological appearance. Their draining capacity was documented by macroscopic transport of Berlin Blue dye as well as through SPECT-CT hybrid imaging.Discussion:In conclusion, our results suggest that processes of cryopreservation can be used in the creation of artificial lymph node scaffolds without major impairment of lymph node fragments regeneration.

Combined Surgical Treatment in Breast Cancer-Related Lymphedema.

Lymphedema is a well-known sequela of breast but no consensus has been reached about the ideal treatment. Surgical approaches, however, are receiving increased attention. Various microsurgical reconstructive techniques aim to restore anatomy and function of the lymphatic system in upper limb breast cancer-related lymphedema (BCRL). We combined two techniques, lymphaticovenous anastomosis (LVA) and autologous lymph node transplantation (ALNT) after carefully selecting those who may benefit from the surgery. We called this the "combined surgical treatment (CST)" approach. From June 2007 to December 2011, we performed CST in 106 patients with upper limb BCRL. Clinical evaluation and diagnostic imaging studies were performed preoperatively in all the patients. CST was offered to patients with stage I/II lymphedema, according to the criteria of the International Society of Lymphology (ISL). Overall 59 of the 106 patients underwent LVA, 7 underwent ALNT, and 40 underwent both the techniques. All 47 lymph node (LN)-flaps survived but 11 (22%) required surgical revision within 3 days. A total of 21 LN-flaps (45%) showed no radiotracer uptake at 1 year. Around 1 to 7 LVAs for each patient (average 3.4) were performed. Preoperative versus postoperative excess circumference decreased between 12 and 86.7% (average 39.72%). Arm circumference decreased between 0.9 and 6.1 cm (average 2.75 cm). The number of episodes of lymphangitis per year decreased from 1.8 to 0.2. Preoperative assessment is essential to select patients who can benefit from surgery for lymphedema and to choose the best surgical approach in each case. Our satisfactory results in well-selected cases encourage further research into surgical treatment for BCRL.

Vascularized Lymph Node Transfer for Patients with Secondary Inferior Limb Lymphedema

INTRODUCTION: Lymphedema affects as much as 28 a 47% of patients treated for gynaecological cancer.1 New reconstructive approaches to the lymphatic system have been gaining a lot of interest by a growing number of microsurgeons.2 Authors have reported the use of free lymphatic flap transfer to treat secondary lymphedema of the upper limb.3 METHODS: Files from 38 patients with secondary inferior limb lymphedema submitted to autologous lymph node transplantation at the senior author‘s (C.B.) practice were retrospectively reviewed. Data related to the lymphedema diagnosis and history, surgical treatment and clinical assessment were collected. Surgical technique and flap anatomy have been previously described.4 Records of limb perimetry measured at 6 different levels during pre-operative and follow-up consultations were used to estimate the approximate volume of the leg with the truncated cone formula.5 (Figure 1)Figure 1: Truncated cone formula.RESULTS: Thirty-four women and 4 men were treated. The average age at the time of the procedure was 52,1±12,4 years and patients had been suffering with lymphedema for an average of 9,1±7,3 years. Thirty-five patients presented with unilateral lymphedema while 3 patients had both limbs affected, with a total of 41 limbs treated. Hysterectomy for uterine cancer was the leading cause of secondary lymphedema (57,9%). Eleven patients (28,9%) presented with minor complications (seromas or hematomas), of either the donor or recipient sites, which were treated conservatively. No major complications were seen on this series. Files from twenty patients presented enough data to follow limb volume evolution after the procedure. Total volume reduction in eight legs (2 patients with no measures of the healthy limb and 3 bilateral) ranged from no improvement (3 legs in 2 patients) to 17%, with an average reduction of 12%. Nine of 15 patients with unilateral lymphedema and measurements of the contralateral healthy limbs presented with a reduction of more than 30% of the excess volume of the affected leg. All of these patients had a lymphedematous limb volume that would not exceed 50% of the healthy leg, while 4 of the 6 remaining patients had more than 50% excess volume. CONCLUSION: Patients with secondary leg lymphedema can benefit from autologous lymphnode transplantation. Results in patients with mild presentations seem to be more expressive that in more severe cases.

Double autologous lymph node transplantation (ALNT) at the level of the knee and inguinal region for advanced lymphoedema of the lower limb (elephantiasis)

Primary lower-limb lymphoedema is a chronic, progressive and debilitating condition with a difficult management, especially in advanced cases (elephantiasis). Recently, autologous lymph node transplantation (ALNT) appears to be a promising treatment for extremity lymphoedema. A case of a double ALNT for an advanced primary lower-limb lymphoedema is here reported: a contralateral inguinal lymph node flap was transferred to the knee and, in a second surgery, a thoracic lymph node flap was transplanted to the inguinal region. Clinical outcomes at 5 months postoperatively are very satisfactory with reduction in limb circumferences and improvement in skin quality and social impairment.

Response to commentary on ‘Angiosarcoma as a Potential Consequence of Autologous Lymph Node Transplantation for Lymphoedema’

Authors reported the occurrence of angiosarcoma in a patient with lower limb primary lymphoedema. Two ALNT were practiced 7 and 14 years before angiosarcoma onset. Angiosarcoma may occur in patient with primary lymphoedema.1Laskas J.J. Shelley W.B. Wood M.G. Lymphangiosarcoma arising in congenital lymphedema.Arch Dermatol. 1975; 111: 86-89Crossref PubMed Scopus (23) Google Scholar, 2Offori T.W. Platt C.C. Stephens M. Hopkinson G.B. Angiosarcoma in congenital hereditary lymphoedema (Milroy's disease)-diagnostic beacons and a review of the literature.Clin Exp Dermatol. 1993; 18: 174-177Crossref PubMed Scopus (41) Google Scholar, 3Dürr H.R. Pellengahr C. Nerlich A. Baur A. Maier M. Jansson V. Stewart-Treves syndrome as a rare complication of a hereditary lymphedema.Vasa. 2004; 33: 42-45Crossref PubMed Scopus (17) Google Scholar It is possible that angiosarcoma is fortuitous and not related to previous ALNT. Angiosarcoma as a Potential Consequence of Autologous Lymph Node Transplantation for LymphoedemaEuropean Journal of Vascular and Endovascular SurgeryVol. 45Issue 5PreviewWith high interest have we read the article by Vignes et al., recording complications (lymphoedema, lymphocoele, hydrocoele and donor-site pain) in patients undergoing autologous lymph node transplantation (ALNT) for limb lymphoedema.1 In addition, we recently witnessed a fatal case of angiosarcoma in a 21-year-old woman. We were amazed by the unusual presentation of this aggressive tumour in such a young otherwise healthy woman, located in the right groin exactly at the site of ALNT performed 14 and 7 years before. Full-Text PDF Open Archive

Angiosarcoma as a Potential Consequence of Autologous Lymph Node Transplantation for Lymphoedema

Angiosarcoma as a Potential Consequence of Autologous Lymph Node Transplantation for Lymphoedema

Complications of Autologous Lymph-node Transplantation for Limb Lymphoedema

This study aims to assess potential complications of autologous lymph-node transplantation (ALNT) to treat limb lymphoedema. Prospective, observational study. All limb-lymphoedema patients, followed up in a single lymphology department, who decided to undergo ALNT (January 2004-June 2012) independently of our medical team, were included. Among the 26 patients (22 females, four males) included, 14 had secondary upper-limb lymphoedema after breast-cancer treatment and seven had secondary and five primary lower-limb lymphoedema. Median (interquartile range, IQR) ages at primary lower-limb lymphoedema and secondary lymphoedema onset were 18.5 (13-30) and 47.4 (35-58) years, respectively. Median body mass index (BMI) was 25.9 (22.9-29.3) kg m⁻². For all patients, median pre-surgery lymphoedema duration was 37 (24-90) months. Thirty-four ALNs were transplanted into the 26 patients, combined with liposuction in four lower-limb-lymphoedema patients. Ten (38%) patients developed 15 complications: six, chronic lymphoedema (four upper limb, two lower limb), defined as ≥2-cm difference versus the contralateral side, in the limb on the donor lymph-node-site territory, persisting for a median of 40 months post-ALNT; four, post-surgical lymphocoeles; one testicular hydrocoele requiring surgery; and four with persistent donor-site pain. Median (IQR) pre- and post-surgical lymphoedema volumes, calculated using the formula for a truncated cone, were, respectively, 1023 (633-1375) ml (median: 3 (1-6) months) and 1058 (666-1506) ml (median: 40 (14-72) months; P = 0.73). ALNT may engender severe, chronic complications, particularly persistent iatrogenic lymphoedema. Further investigations are required to evaluate and clearly determine its indications.

Autologus groin lymph node transfer for “sentinel lymph network” reconstruction after head‐and‐neck cancer resection and neck lymph node dissection: A case report

Local or distant metastatic recurrence after therapy is observed in 20–30% of cases of head-and-neck cancer. An unfavorable course may occur after cervical lymph node dissection due to loss of immunoprotective lymph nodes in the head-and-neck region. To overcome this problem, we performed autologous lymph node transplantation from the groin after head-and-neck cancer resection and cervical lymph node dissection. The patient was a 63-year-old man with squamous cell carcinoma in the mesopharyngeal lateral wall. After tumor resection and right cervical lymph node dissection, a lymph node-containing superficial circumflex iliac artery perforator flap was transplanted from the left groin. Pathological examination showed that cancer had invaded the primary tumor tissue stump. Thus, radiotherapy (66 Gy) was performed for the residual tumor from days 28 to 84 after surgery. At 12 months after surgery, no recurrent lesion or has developed. The biopsy of flap and lymphatic vessel endothelial hyaluronan receptor-1 (LYVE1) immunostaining shows creditable lymph network in the flap, compared with normal free flap. This case suggests that autologous lymph node transplantation may keep watch on cancer recurrence by reconstruction of the lymph node system in the resected region, and we suggest that this approach may be very useful in cancer therapy.

An algorithm for screening and treatment of breast cancer-related lymphedema.

256 Background: Currently, there is no clear-cut regimen for the treatment of breast cancer related lymphedema. There is evidence advocating both conservative and micro surgical therapy, with treatment effectiveness being dependent on the lymphedema stage. We propose a multidisciplinary screening program with the aim of preventing breast cancer related lymphedema progression and ensure disease regression by early identification and treatment initiation. This approach would ultimately reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema. Methods: All women with early stage breast cancer are included in this screening program. We use preoperative and sequential postoperative bilateral upper limb circumference measurements and patient perception to identify lymphedema. A difference of > 2cm between post-operative and baseline circumference and patient perception of (refractory) swelling constitutes a diagnosis of lymphedema. Upon lymphedema diagnosis, patients are referred to a lymph therapist for initiation of conservative therapy in the form of complex decongestive physiotherapy. Therapy effect is evaluated after 1 month. In case of unsatisfactory symptom or limb circumference reduction, the patient is considered for surgical treatment. A plastic surgeon evaluates the possibility of microsurgical lymph vessel repair in the form of lymphatic-venous anastomoses or lymphatic-venous-lymphatic anastomoses. This minimal invasive surgery can improve lymph flow in the affected limb. If despite this, symptom improvement and patient satisfaction remains minimal, autologous lymph node transplantation is considered. Results: The aimed outcome parameters are 1) limb circumference reduction, 2) perceived symptom improvement: (refractory) swelling, 3) quality of life improvement, 4) limb range of motion improvement, 5) strength and sensory improvement, 6) restoration/improvement of lymph flow visualized by lymphoscintigraphy. Conclusions: A structured approach for a multidisciplinary treatment of breast cancer related lymphedema is proposed to reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema.

Experimental Assessment of Autologous Lymph Node Transplantation as Treatment of Postsurgical Lymphedema

Experimental Assessment of Autologous Lymph Node Transplantation as Treatment of Postsurgical Lymphedema

Experimental assessment of pro-lymphangiogenic growth factors in the treatment of post-surgical lymphedema following lymphadenectomy

IntroductionLymphedema is a frequent consequence of lymph node excision during breast cancer surgery. Current treatment options are limited mainly to external compression therapies to limit edema development. We investigated previously, postsurgical lymphedema in a sheep model following the removal of a single lymph node and determined that autologous lymph node transplantation has the potential to reduce or prevent edema development. In this report, we examine the potential of lymphangiogenic therapy to restore lymphatic function and reduce postsurgical lymphedema.MethodsLymphangiogenic growth factors (vascular endothelial growth factor C (VEGF-C)) and angiopoietin-2 (ANG-2) were loaded into a gel-based drug delivery system (HAMC; a blend of hyaluronan and methylcellulose). Drug release rates and lymphangiogenic signaling in target endothelial cells were assessed in vitro and vascular permeability biocompatibility tests were examined in vivo. Following, the removal of a single popliteal lymph node, HAMC with the growth factors was injected into the excision site. Six weeks later, lymphatic functionality was assessed by injecting 125Iodine radiolabeled bovine serum albumin (125I-BSA) into prenodal vessels and measuring its recovery in plasma. Circumferential leg measurements were plotted over time and areas under the curves used to quantify edema formation.ResultsThe growth factors were released over a two-week period in vitro by diffusion from HAMC, with 50% being released in the first 24 hr. The system induced lymphangiogenic signaling in target endothelial cells, while inducing only a minimal inflammatory response in sheep. Removal of the node significantly reduced lymphatic functionality (nodectomy 1.9 ± 0.9, HAMC alone 1.7 ± 0.8) compared with intact groups (3.2 ± 0.7). In contrast, there was no significant difference between the growth factor treatment group (2.3 ± 0.73) and the intact group indicating improved function with the molecular factors. An increase in the number of regenerated lymphatic vessels at treatment sites was observed with fluoroscopy. Groups receiving HAMC plus growth factors displayed significantly reduced edema (107.4 ± 51.3) compared with nontreated groups (nodectomy 219.8 ± 118.7 and HAMC alone 162.6 ± 141).ConclusionsGrowth factor therapy has the potential to increase lymphatic function and reduce edema magnitude in an animal model of lymphedema. The application of this concept to lymphedema patients warrants further examination.

Experimental Assessment of Autologous Lymph Node Transplantation as Treatment of Postsurgical Lymphedema

The authors' objective was to test whether the transplantation of an autologous lymph node into a nodal excision site in sheep would restore lymphatic transport function and reduce the magnitude of postsurgical lymphedema. As a measure of lymph transport, iodine-125 human serum albumin was injected into prenodal vessels at 8 and 12 weeks after surgery, and plasma levels of the protein were used to calculate the transport rate of the tracer to blood (percent injected per hour). Edema was quantified from the circumferential measurement of the hind limbs. The transplantation of avascular lymph nodes at 8 (n = 6) and 12 weeks (n = 6) produced lymphatic function levels of 12.3 +/- 0.5 and 12.6 +/- 0.8, respectively. These values were significantly less (p < 0.001) than those measured at similar times in the animals receiving sham surgical procedures (16.6 +/- 0.7, n = 6; and 16.1 +/- 0.7, n = 6, respectively). When vascularized transplants were performed, lymphatic function was similar to the sham controls and significantly greater (p < 0.001) than that of the avascular group (8 weeks, 15.8 +/- 0.9, n = 8; 12 weeks, 15.7 +/- 1.0, n = 10). Lymph transport correlated significantly with the health of the transplanted nodes (scaled with histologic analysis) (p < 0.0001). The vascularized node transplants (n = 18) were associated with the greatest clinical improvement, with the magnitude of edema in these limbs exhibiting significantly lower levels of edema (p = 0.039) than nontreated limbs (n = 18). The successful reimplantation of a lymph node into a nodal excision site has the potential to restore lymphatic function and facilitate edema resolution. This result has important conceptual implications in the treatment of postsurgical lymphedema.

Effects of autotransplanted lymph node fragments on the lymphatic system in the pig model

Secondary lymphedema often develops after removal of lymph nodes in combination with radiation therapy, in particular in patients with breast cancer, inguinal cancer, cervical cancer and melanoma. No convincing treatment for the prevention and therapy of acquired lymphedema exists so far, therefore we wanted to show the reintegration of transplanted avascular lymph node fragments in the lymphatic system and positive effects of the transplanted fragments on the restoration of the lymphatic flow in this study. A total of 26 minipigs underwent lymphadenectomy of both groins. A minimum of one lymph node was retransplanted. The lymph nodes were cut into small pieces and retransplanted in the left groin (n = 17) or in both groins (n = 9). Different retransplantation techniques were investigated, transplantation of large versus small fragments, with and without capsule. The lymph flow was evaluated 5 and 8 months after surgery, using SPECT/CT and Berlin Blue. The results were confirmed by dissection. The lymph node transplants were assessed histologically. In contrast to the lymph flow in the transplanted groin, the lymph flow in the non-transplanted groin was often malfunctioning. Large lymph node fragments were found reintegrated in the lymphatic system more often than small slices of lymph node fragments. About 5 months after surgery impairment of lymph flow was seen especially after retransplantation of small slices of lymph node fragments. In seven out of eight minipigs a dermal backflow developed in the non-transplanted groin, 8 months after surgery. Only one minipig of these groups developed dermal backflow in both groins. All lymph node fragments showed an organized structure histologically. Autologous lymph node transplantation has positive effects on the regeneration of lymph vessels and restoration of lymph flow after lymphadenectomy.

SPECT-CT: a valuable method to document the regeneration of lymphatics and autotransplanted lymph node fragments

The transplantation of lymph node fragments and stimulation of lymph vessel regeneration seems to be a promising model to prevent lymphoedema in patients after mammary tumour excision combined with axillary lymph node dissection and irradiation. This study evaluated the advantages of SPECT-CT in studying the regeneration of lymph vessels and lymphoid tissue after autologous lymph node transplantation. Five minipigs underwent autologous lymph node transplantation in the left groin. The lymph node was excised, cut into six pieces and embedded into two newly created subcutaneous pouches on this side. The superficial lymph node of the right groin was removed as a control. Five months after surgery the lymph flow of both legs was investigated using conventional lymphoscintigraphy and SPECT-CT with 10 MBq(99m)Tc-nanocolloid in combination with Berlin Blue injected subcutaneously into the draining area. The integration of the transplanted lymph node fragments was shown. The SPECT-CT results correlated with the in situ findings observed at dissection. Afferent and efferent lymph flow could be followed up to the lumbar trunks. The use of SPECT-CT allowed exact localisation of the lymph node fragments in three-dimensional space and the regeneration of the lymph node fragments was documented histologically. SPECT-CT is a good method to evaluate lymphatic flow and document lymph node regeneration. The data suggest that autologous lymph node transplantation is a promising model for prevention of lymphoedema.