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Histologic Analysis of the Lymphatic Vessels Used for Supermicrosurgical Lymphatico-venous Anastomoses in Lymphedema (s-LVA)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details. Identifier: NCT03465930
Recruitment Status : Recruiting
First Posted : March 15, 2018
Last Update Posted : March 15, 2018
Elisabetta Weber, MD
Information provided by (Responsible Party):
Paolo Gennaro, University of Siena

Brief Summary:
Lymphedema, primary or secondary, is a chronic disease that causes functional impairment and has an important impact on patient's quality of life. Lymphedema can be primary or secondary. Secondary lymphedema, which is more common, especially in industrialized countries, is often due to surgery and radiotherapy to treat cancer. There is no definite cure for lymphedema; conservative treatments such as elastic compression garments, bandages and manual lymphatic drainage help reducing the edema but do not resolve it. Many types of surgery have been used in the past, the most recent are lymphatic-venous anastomoses, a minimally invasive procedure that may be performed under local anesthesia. Briefly, after visualizing the lymphatic vessels with a fluorescent dye, one or more anastomosis are created between collecting lymphatic vessels and superficial veins in order to drain the lymph into the blood stream bypassing the obstacle. During this procedure, it is possible to take samples of the collecting lymphatic vessels that are to be anastomosed with veins and use them for histological and immunohistochemical studies, without causing any additional discomfort to the patient. These samples can be formalin fixed and paraffin embedded. The obtained sections will be stained with a lymphatic endothelium marker and a smooth muscle specific stain. A morphometric study will be conducted and, based on the results a statistical evaluation will be made. The analysis will be conducted on samples obtained from patients, affected by secondary or primary lymphedema willing to provide their free and informed consent. The aim of this study is to evaluate the histopathological characteristics of the collecting lymphatic vessels that have been anastomosed with adjacent veins during surgery, and relate the results with the obtained clinical response. The acquired knowledge will contribute to optimize the clinical approach to prevent and treat lymphedema, by helping to select the patients that will benefit more from the surgery, and to select vessels and anatomical sites that have better chances to provide efficient anastomoses.

Condition or disease Intervention/treatment
Lymphedema Procedure: Supermicrosurgical lymphatico-venous anastomoses

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Study Type : Observational
Estimated Enrollment : 200 participants
Observational Model: Case-Only
Time Perspective: Cross-Sectional
Official Title: Histologic Analysis of the Lymphatic Collecting Vessels Used for Minimally Invasive Supermicrosurgical Lymphatico-venous Anastomoses in the Treatment of Lymphedema
Actual Study Start Date : June 1, 2017
Estimated Primary Completion Date : December 31, 2018
Estimated Study Completion Date : December 31, 2023

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Lymphedema

Group/Cohort Intervention/treatment
Patients with lymphedema
Patients affected by primary or secondary lymphedema. The intervention will consist in supermicrosurgical lymphatico-venous anastomoses (sLVA) to allow drainage of the lymph in the venous stream distal to the obstruction. sLVA is a minimally invasive procedure performed under local anesthesia. It requires an accurate visualization of the lymphatic vessels that are still functional.
Procedure: Supermicrosurgical lymphatico-venous anastomoses
Supermicrosurgical lymphatico-venous anastomoses (sLVA) require an accurate visualization of the lymphatic vessels that are still functional. Lymphatic vessels are visualized with lymphography using a fluorescent dye, indocyanine green. Adjacent superficial veins mapping is obtained with Accuvein device.

Primary Outcome Measures :
  1. Expression of the lymphatic endothelial marker D2-40 in relation with the duration of lymphedema. [ Time Frame: Collection of samples from different sites of at least 10 patients will require at least 6 months ]
    On sections stained with D2-40, under light microscopy with the aid of the morphometric program NIS elements tracing the portions of the endothelium stained positively for this marker and comparing the sum of all positive segments of each vessel with the length of its inner profile. The duration of lymphedema in number of years can be obtained using previous medical records (e.g. lymphography or lymphoscintigraphy) when the patient comes to observation after the diagnosis has already been made or, when no previous medical record is available, through the anamnesis. The duration of lymphedema from clinical onset to the time of surgery is expressed in number of years.

Secondary Outcome Measures :
  1. Area of the vessel wall versus area of the lumen [ Time Frame: Collection of samples from different sites of at least 10 patients will require at least 6 months ]
    Subtracting the inner from the outer profile with the aid of the morphometric program NIS elements.

  2. The relative proportion of smooth muscle cells and collagen fibers in the lymphatic vessel wall. [ Time Frame: Collection of samples from different sites of at least 10 patients will require at least 6 months ]
    Staining with Trichrome stain and measuring the threshold of the stained area (threshold of red for smooth muscle cells, threshold of blue for collagen fibers).

  3. Differences in the histology of lymphatics between primary and secondary lymphedema. [ Time Frame: Since primary lymphedema is rare, collection of an adequate number of cases of primary lymphedema (at least 10) to evaluate whether there are histologic differences with secondary lymphedema will require at least three years. ]
    Histologic measurements are the same as for the primary outcome. To determine if the lymphedema is primary or secondary an accurate anamnesis is usually enough: patients report history of trauma or cancer treatment in case of secondary lymphedema, no such events in primary lymphedema.

  4. Relation between the anatomic site of the anastomosis and histologic parameters. [ Time Frame: Collection of samples from different sites of at least 10 patients will require at least 6 months. ]
    Measurement of histologic parameters as in the primary outcome, comparison between samples taken from different sites of the same patient (hand or wrist versus elbow, or more rarely arm, for the upper limb, foot or ankle versus knee or more rarely thigh, for the lower limb).

  5. Correlation between histologic modifications and morphologic appearance at lymphography and / or at MRL (Magnetic Resonance Lymphography). [ Time Frame: Collection of samples from different sites of at least 10 patients will require at least 6 months ]
    Lymphography with a fluorescent dye (indocyanine green), routinely performed prior to surgery to choose the lymphatic vessels suitable for anastomoses. In later stage lymphedemas, MRL, with gadolinium as a contrast medium, is sometimes necessary to allow visualization of lymphatic vessels thanks to the slow wash out of gadolinium. Histologic evaluation as in the primary outcome.

Biospecimen Retention:   Samples Without DNA
Biospecimens to be retained are tissue, more precisely they are segments of the lymphatic vessels which are to be anastomosed with the veins, they are therefore very small structures (maximum 0.4mm diameter, 2-5mm in length) that are removed for technical reasons in a variable number between 1 and 3 for each patient during surgery. This doesn't affect in any way the success of the surgery itself. These samples instead of being destroyed, will be formalin fixed and transported to the laboratory of Prof. Elisabetta Weber where they will be paraffin embedded. Histologic sections will be obtained and adequate staining will be made.

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Probability Sample
Study Population
All the patients affected by lymphedema that come to us to undergo s-LVA surgery, that match the eligibility criteria and give their free and informed consent. There is no restriction of sex, gender, race, ethnics, country, region, town, etc.

Inclusion Criteria:

  • age over 18 years old;
  • patients affected by primary or secondary lymphedema;
  • patients willing to give their free and informed consent.

Exclusion Criteria:

  • patients currently undergoing radiotherapy;
  • patients currently undergoing chemotherapy.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT03465930

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Contact: Paolo Gennaro, MD, PhD +390577585447
Contact: Elisabetta Weber, MD +390577234083

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Dept. of Maxillofacial Surgery, Azienda Ospedaliera Universitaria Senese Recruiting
Siena, Italy, 53100
Contact: Paolo Gennaro, MD, PhD    +390577585447   
Contact: Elisabetta Weber, MD    +390577234083   
Sub-Investigator: Virginia Barone, PhD         
Sub-Investigator: Annalisa Borghini, PhD         
Sub-Investigator: Guido Gabriele, MD         
Sub-Investigator: Erica Tedone Clemente, MD         
Sponsors and Collaborators
Paolo Gennaro
Elisabetta Weber, MD
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Study Director: Paolo Gennaro, MD, PhD Department of Biotechnology, University of Siena; Department of Maxillofacial Surgery, Azienda Ospedaliera Universitaria Senese
Principal Investigator: Elisabetta Weber, MD University of Siena, Dept. of Molecular and Developmental Medicine.
  Study Documents (Full-Text)

Documents provided by Paolo Gennaro, University of Siena:
Study Protocol  [PDF] January 26, 2018
Statistical Analysis Plan  [PDF] January 26, 2018

Publications of Results:
Other Publications:

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Responsible Party: Paolo Gennaro, MD, PhD. Associate Professor of Maxillofacial Surgery, University of Siena, University of Siena Identifier: NCT03465930    
Other Study ID Numbers: LVA2017
First Posted: March 15, 2018    Key Record Dates
Last Update Posted: March 15, 2018
Last Verified: March 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided
Plan Description: For technical reasons we do not yet know which type of data may be obtained and hence cannot make plans for data sharing.

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by Paolo Gennaro, University of Siena:
Lymphatic collecting vessels
Lymphatic-venous anastomoses
Additional relevant MeSH terms:
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Lymphatic Diseases