Showing papers by "Stanley G. Rockson published in 2022"
TL;DR: Approval of experts’ opinions on the available literature on lymphedema while following the Delphi methodology demonstrated that lyMPhedema experts agree on the majority of the statements related to risk factors for lympherema, and the diagnostic workup for lypphedema patients.
Abstract: Background Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts’ opinions on the available literature on lymphedema while following the Delphi methodology. Methods In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. Results The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3–C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. Conclusion This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
10 citations
TL;DR: The presence or absence of a lymphatic disease significantly influences disease interrelationships in the study cohorts, suggesting that the lymphatic circulation may be an underappreciated participant in disease pathogenesis.
Abstract: Abstract Background The lymphatic contribution to the circulation is of paramount importance in regulating fluid homeostasis, immune cell trafficking/activation and lipid metabolism. In comparison to the blood vasculature, the impact of the lymphatics has been underappreciated, both in health and disease, likely due to a less well‐delineated anatomy and function. Emerging data suggest that lymphatic dysfunction can be pivotal in the initiation and development of a variety of diseases across broad organ systems. Understanding the clinical associations between lymphatic dysfunction and non‐lymphatic morbidity provides valuable evidence for future investigations and may foster the discovery of novel biomarkers and therapies. Methods We retrospectively analysed the electronic medical records of 724 patients referred to the Stanford Center for Lymphatic and Venous Disorders. Patients with an established lymphatic diagnosis were assigned to groups of secondary lymphoedema, lipoedema or primary lymphovascular disease. Individuals found to have no lymphatic disorder were served as the non‐lymphatic controls. The prevalence of comorbid conditions was enumerated. Pairwise co‐occurrence pattern analyses, validated by Jaccard similarity tests, was utilised to investigate disease–disease interrelationships. Results Comorbidity analyses underscored the expected relationship between the presence of secondary lymphoedema and those diseases that damage the lymphatics. Cardiovascular conditions were common in all lymphatic subgroups. Additionally, statistically significant alteration of disease–disease interrelationships was noted in all three lymphatic categories when compared to the control population. Conclusions The presence or absence of a lymphatic disease significantly influences disease interrelationships in the study cohorts. As a physiologic substrate, the lymphatic circulation may be an underappreciated participant in disease pathogenesis. These relationships warrant further, prospective scrutiny and study.
5 citations
TL;DR: Hypoxia is a recognized feature of inflammation, obesity, and fibrosis and understanding hypoxia-regulated pathways in lymphedema may provide new insights into the pathobiology of this chronic disorder and help develop new medicinal treatments.
Abstract: Lymphedema is a chronic inflammatory disorder characterized by edema, fat deposition, and fibrotic tissue remodeling. Despite significant advances in lymphatic biology research, our knowledge of lymphedema pathology is incomplete. Currently, there is no approved pharmacological therapy for this debilitating disease. Hypoxia is a recognized feature of inflammation, obesity, and fibrosis. Understanding hypoxia-regulated pathways in lymphedema may provide new insights into the pathobiology of this chronic disorder and help develop new medicinal treatments.
3 citations
TL;DR: Cancer-Related Lymphedema: Primary or Secondary? as discussed by the authors , Lymphatic Research and Biology, 20(6), p.579-579.2022.
Abstract: Lymphatic Research and BiologyVol. 20, No. 6 EditorialCancer-Related Lymphedema: Primary or Secondary?Stanley G. RocksonStanley G. RocksonStanford University School of Medicine, Stanford, California, USA.Search for more papers by this authorPublished Online:15 Dec 2022https://doi.org/10.1089/lrb.2022.29134.editorialAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Cancer-Related Lymphedema: Primary or Secondary?." Lymphatic Research and Biology, 20(6), p. 579FiguresReferencesRelatedDetailsCited byUpdate February 2023 Francine Blei16 February 2023 | Lymphatic Research and Biology, Vol. 21, No. 1 Volume 20Issue 6Dec 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Stanley G. Rockson.Cancer-Related Lymphedema: Primary or Secondary?.Lymphatic Research and Biology.Dec 2022.579-579.http://doi.org/10.1089/lrb.2022.29134.editorialPublished in Volume: 20 Issue 6: December 15, 2022PDF download
3 citations
TL;DR: In this article , the authors evaluated the safety and efficacy of a novel nonpneumatic compression device (NPCD) for treating lymphedema vs an advanced pneumatic device (APCD).
Abstract: ObjectiveAdvanced pneumatic compression devices (APCDs) have been shown to be an effective intervention for lymphedema when used as part of a self-care maintenance treatment regimen. However, adherence to self-care has been poor, and APCDs require patients to be immobile during treatment. We evaluated the safety and efficacy of a novel nonpneumatic compression device (NPCD) for treating lymphedema vs an APCD.MethodsA randomized, crossover head-to-head investigation was performed at five U.S. sites in 2021. The patients had been randomized to either the NPCD or a commercially available APCD. The patients used the randomly assigned initial device for 28 days with a 4-week washout period before a comparable 28-day use of the second device.ResultsData from 50 adult women with unilateral breast cancer-related lymphedema were analyzed. Compared with the APCD, the NPCD was associated with a greater mean reduction in the limb edema volume (64.6% vs 27.7%; P < .001), significantly greater mean improvements in quality of life scores, greater adherence (95.6% vs 49.8%; P < .001), and greater satisfaction with the device (90% vs 14%; P < .001). The patients indicated that use of the NPCD facilitated exercise and was convenient for travel. No adverse events were reported.ConclusionsThe results have shown that the novel NPCD is an effective maintenance treatment for reducing the limb volume in patients with breast cancer-related lymphedema. The NPCD device was more effective than an APCD and resulted in greater adherence to self-care interventions and greater patient satisfaction.
2 citations
TL;DR: Rockson et al. as discussed by the authors performed an early investigation of the Gut-Lymph concept and found that the presence of intestinal ischemia alters the composition of enteral lymph and these alterations can modify the development of organ dysfunction and associated inflammatory changes.
Abstract: Lymphatic Research and BiologyVol. 20, No. 3 EditorialFree AccessEarly Investigation of the Gut–Lymph ConceptStanley G. Rockson Editor-in-ChiefStanley G. Rockson Editor-in-ChiefStanford University School of Medicine, Stanford, California, USA.Search for more papers by this authorPublished Online:10 Jun 2022https://doi.org/10.1089/lrb.2022.29125.srAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The presence of intestinal ischemia alters the composition of enteral lymph and these alterations can modify the development of organ dysfunction and associated inflammatory changes.1–4 Although preclinical investigation of these phenomena has been relatively accessible, translation to the context of human pathology is rendered difficult through the inherent barriers to sampling human thoracic duct lymph.In this issue of Lymphatic Research and Biology, Escott and his colleagues have advanced a pilot technique that consists of intraoperative cannulation of the human thoracic duct with delayed embolization. This permits objective serial quantitation of the thoracic duct lymph pressure. The authors describe the ability to analyze lymph flow and composition in response to enteral feeding as well as to vasopressor administration.The current investigation has facilitated the analysis of three of the four patients in whom the procedure was attempted. The authors observed significant enhancement over plasma concentration of several of the measured contents of thoracic duct lymph, including lipase, interleukin-6, tumor necrosis factor-α, d-lactate, endotoxin, and intestinal fatty binding protein. These observations suggest that intestinal ischemia can be exacerbated by nonselective vasopressor administration. The authors note that, although the lymph composition altered in a time-dependent manner, and in response to feeding and vasopressor administration, there was no concurrent change in thoracic duct flow rates.The gut–lymph concept remains, as yet, in its infancy, but the current report suggests that exciting observations lie ahead. Explication of these vascular and molecular phenomena is destined to provide insights that can be implemented in the maintenance and restoration of human health.References1. Deitch EA. Gut lymph and lymphatics: A source of factors leading to organ injury and dysfunction. Ann N Y Acad Sci 2010; 1207 Suppl 1:E103–E111. Crossref, Medline, Google Scholar2. Fanous MY, Phillips AJ, Windsor JA. Mesenteric lymph: The bridge to future management of critical illness. JOP 2007; 8:374–399. Medline, Google Scholar3. Phang K, Bowman M, Phillips A, Windsor J. Review of thoracic duct anatomical variations and clinical implications. Clin Anat 2014; 27:637–644. Crossref, Medline, Google Scholar4. Landahl P, Ansari D, Andersson R. Severe acute pancreatitis: Gut barrier failure, systemic inflammatory response, acute lung injury, and the role of the mesenteric lymph. Surg Infect (Larchmt) 2015; 16:651–656. Link, Google ScholarFiguresReferencesRelatedDetailsCited byThe Impact of Dietary Fat in Lymphatic Anomalies Stanley G. Rockson22 August 2022 | Lymphatic Research and Biology, Vol. 20, No. 4 Volume 20Issue 3Jun 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Stanley G. Rockson Editor-in-Chief.Early Investigation of the Gut–Lymph Concept.Lymphatic Research and Biology.Jun 2022.247-247.http://doi.org/10.1089/lrb.2022.29125.srPublished in Volume: 20 Issue 3: June 10, 2022PDF download
1 citations
TL;DR: Rockson et al. as mentioned in this paper presented an approach for non-invasive detection and documentation of upper and lower extremity lymphedema in lymphatic research and biology.
Abstract: Lymphatic Research and BiologyVol. 20, No. 1 EditorialObjective Noninvasive Detection and Documentation of Upper and Lower Extremity LymphedemaStanley G. RocksonStanley G. RocksonStanford University School of Medicine, Stanford, California, USA.Search for more papers by this authorPublished Online:28 Feb 2022https://doi.org/10.1089/lrb.2022.29120.srAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Objective Noninvasive Detection and Documentation of Upper and Lower Extremity Lymphedema." Lymphatic Research and Biology, 20(1), pp. 1–2FiguresReferencesRelatedDetails Volume 20Issue 1Feb 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Stanley G. Rockson.Objective Noninvasive Detection and Documentation of Upper and Lower Extremity Lymphedema.Lymphatic Research and Biology.Feb 2022.1-2.http://doi.org/10.1089/lrb.2022.29120.srPublished in Volume: 20 Issue 1: February 28, 2022PDF download
01 Mar 2022
TL;DR: In this paper , the first identification of a glycocalyx-like structure in the human lymphatic endothelial cells was made using transmission electron microscopy and immunohistochemistry (IHC).
Abstract: Blood flow hemodynamics are translated into biochemical inflammatory or anti-inflammatory messages based on the type of shear stress, by means of sensitive receptors located on the endothelium lining. This process is known as “mechano-transduction” and it has been widely studied in both the arterial and venous system. The interaction of shear stress and the glycocalyx leading to cellular events is known as "mechanoglycobiology.” This phenomenon is of paramount importance for advancing our understanding of the pathophysiology processes related to vascular remodeling. The endothelial glycocalyx is a pericellular matrix, identified in both arteries and veins, made by glycoproteins, proteoglycans, and glycolipids, acting as mechanical sensors responsive to the flow changes and involved in mechano-transduction. Veins and lymphatics physiology and pathology are strictly interconnected, and to our knowledge a lymphatic glycocalyx-like structure has never been identified in humans. The objective of this investigation is to search for a glycocalyx-like structure from ex vivo lymphatic human samples utilizing transmission electron microscopy (TEM) and immunohistochemistry (IHC). Five veins and lymphatics were harvested from patients undergoing lower limb plastic surgery procedures. The samples were fixed in 2.5% glutaraldehyde containing 0.05% Alcian Blue and then analyzed by TEM and by IHC for podoplanin. TEM was set at 63,000×, 80,000×, and 100,000× magnification. The fixation technique allowed TEM identification of a glycocalyx-like ciliary structure in both veins and lymphatics samples, at all magnifications starting from 63,000×. A ciliary-like structure can be clearly detected along the surface of both veins and lymphatics endothelial cells. IHC by podoplanin successfully characterized the lymphatic structure and signature markers. To our knowledge this study is the first identification of a glycocalyx-like structure in the human lymphatic endothelial cells. Future work will investigate the interrelations between venous and lymphatic functions. Importantly, the arterial and venous glycocalyx vasculoprotective action may have implications for targeted treatment in the lymphatic system in patients affected by venous and lymphatic disorders.
TL;DR: Rockson et al. as mentioned in this paper described the management of complex Lymphatic Anomalies with severe bony involvement, which is a type of complex lymphatic abnormies with Bony Involvement.
Abstract: Lymphatic Research and BiologyVol. 20, No. 2 EditorialManagement of Complex Lymphatic Anomalies with Severe Bony InvolvementStanley G. RocksonStanley G. RocksonMD, Editor-in-Chief Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA.Search for more papers by this authorPublished Online:20 Apr 2022https://doi.org/10.1089/lrb.2022.29122.srAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Management of Complex Lymphatic Anomalies with Severe Bony Involvement." Lymphatic Research and Biology, 20(2), p. 117FiguresReferencesRelatedDetails Volume 20Issue 2Apr 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Stanley G. Rockson.Management of Complex Lymphatic Anomalies with Severe Bony Involvement.Lymphatic Research and Biology.Apr 2022.117-117.http://doi.org/10.1089/lrb.2022.29122.srPublished in Volume: 20 Issue 2: April 20, 2022PDF download
TL;DR: In this article , a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) was evaluated in the rat lymphedema model.
Abstract: Abstract Background The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. Methods Unilateral left hindlimb lymphedema was created in 15 female Sprague–Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. Results Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (−13.39 ± 8.55%) and an even greater reduction in group C (−14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. Conclusion The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.
TL;DR: In this paper , a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL was investigated.
Abstract: Abstract Lower extremity lymphedema (LEL) can result in detriments to quality of life (QOL) and impose a significant economic burden on patients and payers. A common component of treatment is pneumatic compression, which requires patients to remain immobile. We investigated a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL. We conducted a non-randomized, open-label, 12-week pilot study of adult patients with primary or secondary unilateral LEL, and measured changes in limb edema and QOL using the Lymphedema Quality of Life Questionnaire (LYMQOL). Twenty-four subjects were enrolled; the majority were female (17) with secondary lymphedema (21). Eighteen completed the study. Statistically significant improvements were observed in overall QOL, aggregated LYMQOL total score, and three of four LYMQOL subscales (Function, Appearance, Mood). The fourth (Symptoms) trended toward significant improvement (p = 0.06). The average reduction in affected limb edema was 39.4%. The novel NPCD produced statistically significant improvements in QOL, functioning, and edema volume of patients with LEL. Innovations in devices to manage LEL can be effective while allowing patients to maintain mobility and physical activity during treatment.