Dimitris Dionyssiou

Regulatory T cell transfer ameliorates lymphedema and promotes lymphatic vessel function

Secondary lymphedema is a common postcancer treatment complication, but the underlying pathological processes are poorly understood and no curative treatment exists. To investigate lymphedema pathomechanisms, a top-down approach was applied, using genomic data and validating the role of a single target. RNA sequencing of lymphedematous mouse skin indicated upregulation of many T cell-related networks, and indeed depletion of CD4+ cells attenuated lymphedema. The significant upregulation of Foxp3, a transcription factor specifically expressed by regulatory T cells (Tregs), along with other Treg-related genes, implied a potential role of Tregs in lymphedema. Indeed, increased infiltration of Tregs was identified in mouse lymphedematous skin and in human lymphedema specimens. To investigate the role of Tregs during disease progression, loss-of-function and gain-of-function studies were performed. Depletion of Tregs in transgenic mice with Tregs expressing the primate diphtheria toxin receptor and green fluorescent protein (Foxp3-DTR-GFP) mice led to exacerbated edema, concomitant with increased infiltration of immune cells and a mixed TH1/TH2 cytokine profile. Conversely, expansion of Tregs using IL-2/anti-IL-2 mAb complexes significantly reduced lymphedema development. Therapeutic application of adoptively transferred Tregs upon lymphedema establishment reversed all of the major hallmarks of lymphedema, including edema, inflammation, and fibrosis, and also promoted lymphatic drainage function. Collectively, our results reveal that Treg application constitutes a potential new curative treatment modality for lymphedema.

Paramuscular and Paraneural Perforators in DIEAP Flaps: Radiographic Findings and Clinical Application

The computed tomography microangiography revolutionized the planning of abdominal flaps, and enabled us to identify perforators from the deep inferior epigastric system with a medial extramuscular or minimal medial intramuscular trajectory. We define these perforators as paramuscular and paraneural, since their main course is retromuscular and they emerge medial to the medial border of rectus muscle or medial to its motor nerve supply, respectively. Studying the different perforator distributions in the abdomen of 58 patients who underwent breast reconstruction with deep inferior epigastric artery perforator flap, we have recorded that 46.4% of the abdominal walls have a dominant paramuscular/paraneural perforator (25.8% paramuscular and 20.6% paraneural) with an average diameter 1.56 ± 0.2 mm. Although, the comparison of the rectus muscle morbidity following deep inferior epigastric artery perforator flap dissection based on paramuscular/paraneural and based on other perforator patterns, did not reveal significant differences, paraneural/paramuscular type perforators are not related anatomically to the motor nerves, and the donor site morbidity should be negligible in any operators hands.

A 35-year-old woman presenting with an unusual post-traumatic leiomyoma of the nipple: a case report

IntroductionLeiomyoma of the mammary papilla is one of the most uncommon nipple tumors with only 50 cases reported in the literature until now. To the best of our knowledge we present the first report of a nipple leiomyoma that originated from a traumatic abrasion caused by breastfeeding.Case presentationA 35-year-old healthy Caucasian female with a cauliflower-like tender and pink nodular mass that was approximately 10mm in diameter presented to our out-patients department. The patient suggested that the mass originated from a traumatic abrasion caused by breastfeeding three years ago and it has been slowly growing ever since.An excision biopsy was performed. The histological and immunohistochemical examination confirmed the diagnosis of leiomyoma. There were no postoperative complications or any sign of local recurrence four years postoperatively.ConclusionsLeiomyoma of the mammary papilla is a rare benign neoplasm that usually appears as a solid tender nodule. Differential diagnosis comprises breast carcinoma, leiomyosarcoma and myoid hamartoma. The recommended treatment is complete excision of the tumor with histologically confirmed tumor-free margins otherwise recurrence is possible. A detailed history of the patient’s disease can reveal the original etiology. This is an original case report that will have particular interest to plastic surgeons, dermatologists, and pathologists. The pathogenetic mechanism was trauma of the nipple. According to our review of the literature this particular information has never been reported and we think that it may advance our knowledge of this very infrequent tumor.

Splice-site mutations in VEGFC cause loss of function and Nonne-Milroy-like primary lymphedema.

Primary lymphedema (PLE) is phenotypically heterogeneous and partially explained by mutations in 28 genes. In Nonne-Milroy disease (OMIM 153100), PLE appears typically at birth and is autosomal dominant with incomplete penetrance. Several mutations have been discovered in VEGFR3, but only 2 in its ligand VEGFC (c.571_572insTT; p.Pro191Leufs*10 and c.628C>T; p.Arg210*; Figure 1G), causing Milroy-like disease (OMIM 615907). VEGFC regulates lymphangiogenesis upon proper activation by ADAMTS3 and CCBE1, mutations in which cause Hennekam lymphangiectasia-lymphedema syndrome . We sequenced VEGFC (NM_005429.4) in 542 index patients with any kind of PLE using Ion Torrent technology. All participants gave their informed consent, as approved by the Medical Faculty ethical committee at University of Louvain, Brussels, Belgium or local committees of collaborators. With Highlander (http://sites.uclouvain.be/highlander/), we selected variants ≤0.0014 in ExAC, not in dbSNP, and predicted to affect splicing or being damaged by at least 5 softwares (Sift (http://sift. jcvi.org), Mutation Taster (http://www.mutationtaster.org), PolyPhen2_hdiv, PolyPhen2_hvar (http://genetics.bwh.harvard.edu/pph2/), Lrt (http://www.genetics.wustl.edu/jflab/lrt_query.html) and Mutation Assessor (http://mutationassessor.org/r3/)). We identified 2 heterozygous mutations, chr4:177650901delTG (c.148-3_148-2delCA) and chr4:177648932C>T (c.552G>A), which are rare in gnomAD (7/211120 alleles and 1/242972, respectively, both predicted to alter mRNA splicing (c.552G>A is the last nucleotide of exon 3). Ten other loss-offunction VEGFC variants are reported in gnomAD. Some of these could undergo gene rescue, whereas lymphedema might be undiagnosed in other individuals. c.148-3_148-2delCA was found in a 22 years old male (LE-627III-1, Figure 1A) with no familial history of PLE. Diagnosed at 7 years of age with left lower limb swelling, he presented, 1 year later, with bilateral lower extremity lymphedema and regular episodes of lymphangitis (Figure 1B,C). At 9 years of age, he developed hydrocele, which was operated. He follows intensive physiotherapy and wears elastic garments. Lymphoscintigraphy revealed absence of lymph nodes in the right groin, suggestive of aplasia/hypoplasia, and hypoplastic lymphatics in the left limb, with backflow or rerouting in both legs, more marked on the left (Figure 1D). This had not been seen in the previously reported families. The mutation was also detected in the unaffected father, but neither in the healthy grandmother nor in the aunt who had varicose veins. Thus, penetrance was 50% in this family. c.552G>A was discovered in LE-445-V-1, 6 other affected persons and unaffected younger sister (Figure 1E). Inheritance was autosomal dominant with 87.5% penetrance. Male members were more severely affected. At birth, LE-445-V-1 had lymphedema on the dorsum of right foot. Edema of left foot appeared after a fracture. Lymphedema progressed to legs but below the knees (Figure 1F). Congenital lymphedema of right foot of his brother progressed to bilateral below knees. The granduncle, his son, and an aunt also developed lymphedema of feet and ankles. In contrast, mother and grandmother had only swollen ankles during pregnancies or warm weather. The first recorded case was the great-grandmother with lymphedema in one leg since 12 years of age, progressing to bilateral below knees. Lymphocytic mRNA of LE-627-III-1 showed a smaller amplicon (Figure 1H), corresponding to skipping of exons 2 and 3 (Figure 1I), and deletion of 135 of the 419 aa. This removes most of the propeptide and the VEGF-homology domain (VHD), namely the core for VEGFC activity after cleavage (Figure 1G). As exon 3 deletion was unexpected, we excluded a genomic deletion in the region by detecting 3 heterozygous single-nucleotide polymorphisms (Figure 1G and not shown). In LE-445V-1 RNA (Figure 1H), exon 3 was missing (Figure 1J), leading to frameshift and premature stop-codon. This truncation alters the VHD similar to previous mutations (Figure 1G). If these mutant proteins are not unstable, they would still be nonfunctional. Our novel mutations underscore VEGFC haploinsufficiency as the pathophysiological mechanism. Variable expressivity and reduced penetrance were observed in both families, albeit LE-445V-3 could develop PLE with age. Similarly, 2 individuals of the first reported family had a mutation but no clinical signs of leg edema, albeit prominent veins, or hydrocele. Thus, variants in other components of the VEGFC-VEGFR3 axis, such as ADAMTS3, or environmental factors may act as modifiers. VEGFC accounts for ~0.4% of 542 patients screened and VEGFR3 for ~10%. In several PLE genes, only few mutations have been found, underscoring pathophysiological heterogeneity. VEGFC screening should be considered for precise diagnosis, management, and counseling of patients with PLE, as well as to refine the phenotypic spectrum linked to VEGFC mutations. Received: 8 September 2017 Revised: 19 December 2017 Accepted: 21 December 2017

Soft tissue reconstruction of the thumb with the dorsoradial forearm flap

The dorsoradial flap is a recently described cutaneous flap, which is harvested from the distal forearm and indicated for covering dorsal soft tissue defects of the hand and thumb. Vascularization of the flap is assured by a cutaneous branch of the radial artery, which arises at the level of the first intermetacarpal space and supplies the skin of the distal quarter of the forearm dorsum. This area corresponds to the skin island of the dorsoradial flap. We report our clinical experience on seven patients where this flap was used for covering post-traumatic defects of the thumb. Dimensions of the defect varied from 18 to 28 cm2. The donor site was skin grafted. All flaps survived and provided satisfactory coverage of the defect. Based on a secondary vascular axis, the flap has a large skin paddle and a wide rotation arc that allows soft tissue reconstruction of the dorsal and radiopalmar areas of the thumb.

The wash-out technique in the management of delayed presentations of extravasation injuries

Late presentation of extravasation injuries from chemotherapeutic agents is not uncommon. Twenty-four patients with extravasation injuries presented with upper limb extravasation but without any skin necrosis between the second and the fourteenth day following injury day. We flushed out the infiltrated area with 300–500 ml of normal saline through multiple stab incisions. All 24 patients responded well to the procedure and no further complications occurred. The average time for the complete healing of the wounds was 15 days. All the patients were able to continue their chemotherapy treatment without delay. Patients were followed up for a mean period of 13 months. They all recovered with no functional deficit and only mild scarring. Early recognition and immediate treatment of extravasation injuries are of paramount importance. In cases with no evidence of skin necrosis, a delayed wash-out procedure appears to be very effective in removing the extravasated drug and minimizing further tissue damage.

Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients.

Sir:We read with great interest the article by Raffaini et al.1 concerning facial feminization surgery satisfaction assessment. Despite our personal high resistance in operating on transgender patients who want to undergo facial feminization, we feel that in some cases such operations are an unavoid