Mendez U, Stroup EM, Lynch LL, Waller AB, Goldman J. A chronic and latent lymphatic insufficiency follows recovery from acute lymphedema in the rat foreleg. Am J Physiol Heart Circ Physiol 303: H1107-H1113, 2012. First published August 31, 2012; doi:10.1152/ajpheart.00522.2012.-Secondary lymphedema in humans is a common consequence of axillary lymph node dissection (ALND) to treat breast cancer. Remarkably, secondary lymphedema generally first appears following a delay of over a year and can be triggered suddenly by an inflammatory insult. However, it remains unclear why the apparently functional lymphatic system is unable to accommodate an inflammatory trigger. To provide mechanistic insight into the delayed and rapid secondary lymphedema initiation, we compared the ability of the ALND-recovered rat foreleg lymphatic system to prevent edema during an inflammatory challenge with that of the uninjured lymphatic system. At 73 days postsurgery, the forelegs of ALND Ϫ -and ALND ϩ -sensitized rats were exposed to the proinflammatory agent oxazolone, which was found to reduce fluid drainage and increase skin thickness in both ALND Ϫ and ALND ϩ forelegs (P Ͻ 0.05). However, drainage in the ALNDrecovered forelegs was more severely impaired than ALND Ϫ forelegs, as visualized by indocyanine green lymphography and quantified by interstitial transport of fluid marker (P Ͻ 0.05). Although both ALND ϩ and ALND Ϫ forelegs experienced significant inflammationinduced edema with the oxazolone exposure (P Ͻ 0.05), the peak tissue swelling in the ALND ϩ group was significantly greater than that of the ALND Ϫ forelegs (arm area peaked at ϳ13.4 vs. ϳ5.7% swelling, respectively, P Ͻ 0.005; wrist diameter peaked at 9.7 vs. 2.2% swelling, respectively, P Ͻ 0.005). The findings demonstrate that outward recovery from ALND in the rat foreleg masks an ensuing chronic and latent lymphatic insufficiency, which reduces the ability of the foreleg lymphatic system to prevent edema during an acute inflammatory process.

Secondary lymphedema in humans is a common consequence of lymph node dissection (LND) to treat breast cancer. A peculiar characteristic of the disease is that lifelong swelling often precipitously appears several years after the surgical treatment, often due to an inflammatory stimulus. Although the incidence of secondary lymphedema dramatically increases after radiation therapy, the relationship between fibrotic scarring and the eventual appearance of lymphedema remains unclear. To clarify the role of fibrosis in secondary lymphedema initiation, we chemically increased fibrosis in rodent tissues with bleomycin and assessed the ability of the local lymphatic system to prevent lymphedema, either acutely or in a chronic state induced by inflammation. We found that bleomycin injections exacerbated fibrotic matrix deposition in an acute mouse tail lymphedema model (P < 0.005), reduced wound closure (P < 0.005), and impaired the ability of tail lymphatics to regenerate (P < 0.005) and reduce the swelling (P < 0.05). When fibrosis was worsened with bleomycin after axillary LND in the rat foreleg, the ability of the foreleg lymphatic system to reduce the chronic state swelling induced by stimulated inflammation was severely impaired (P < 0.005). Indocyanine green lymphography in axillary LND-recovered rat forelegs revealed a worsened lymphatic drainage due to inflammation and bleomycin pretreatment. Although inflammation reduced the drainage of dextran fluid tracer from control forelegs (P < 0.05), the reduction in fluid drainage was more severe after axillary LND when fibrosis was first increased (P < 0.005). These findings demonstrate that fibrosis reduces the lymphatic capacity to functionally regenerate and prevent the chronic appearance of lymphedema.