P5-12-04: Genetic Linkage between Acquired and Primary Lymphedema Evaluated through Whole Exome Sequencing and NIR Fluorescence Lymphatic Imaging.
Authors: Sevick-Muraca EM , Gonzalez-Garay ML , Fife CE , Guilliod R , Hall O , Marshall MV , Rasmussen JC , Aldrich MB , Darne C , Zhu B , Tan I-C , Caskey CT 
Published: June 2012

Abstract
Acquired lymphedema is thought to arise from the damage of the lymphatic vasculature that transports excess fluid and macromolecules away from tissues for return to the blood vasculature. The onset of the cancer acquired disease can occur months to years after lymph node dissection and manifests itself as an accumulation of fluid and macromolecules in tissues that leads to edema and irresolvable swelling. The rare disease of primary lymphedema is identical to cancer acquired lymphedema, with the exception that there is no trauma or cancer treatment that can be attributed as its cause. Primary lymphedema has been attributed to genetic causes since the late nineteenth century. Although there are five known genetic causes of hereditary or primary lymphedema, the majority of patients with lymphedema do not possess mutations in these genes. More recently, it has been proposed that a genetic link between cancer acquired and primary lymphedema exists. If a genetic susceptibility for cancer acquired lymphedema could be found, then we could predict which survivors will encounter the disease and could develop new therapies which are more effective than the current treatments that have remained unchanged for the past 80 years.
In an FDA approved investigational study, we used near-infrared (NIR) fluorescence imaging to phenotype the lymphatic architecture of subjects with both acquired and primary lymphedema, as well as their unaffected family members. We collected blood for DNA analyses. NIR fluorescence provided the phenotype of abnormal lymphatic function while whole exome sequencing provided the genotype. Bioinformatics analyses were then used to identify causative genes using cosegregation of familial genotypes using the phentotypes found through NIR fluorescence imaging.
The first family analyzed had members with primary and acquired lymphedema in which mutations encoding for proteins that participate in the HGF/c-MET and PI3K pathways could potentially explain the inheritance of lymphedema in this family. The father and affected daughters were heterozygous for a de novo SNP HGF in the kringle binding domain that interacts with tyrosine kinase receptor c-MET. The father had a normal lymphatic phenotype. On the other hand, the mother and daughters were heterozygous for the de novo mutation of INPPL1 (SHIP-2), adjacent to the SH2 domain of the protein that is known to bind to the multifunctional docking site of c-MET and associates with proteins in the Rho pathway for cytoskeletal reorganization. The daughters possessed both HGF and INPPL1 mutations and were diagnosed with primary lymphedema while the mother, who possessed the INPPL1 mutation, was diagnosed at the time of NIR imaging with acquired lymphedema. Analyses of remaining families as well as breast cancer related lymphedema patients are underway to confirm whether INPPL1 may be a candidate susceptibility gene for acquired lymphedema. Supported in parts by R01 HL092923 and CA128919, The Texas Star Award, and the Cullen Foundation.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-12-04.