Lymphedema pp 29-39 | Cite as

Hereditary and Familial Lymphedema

  • Kimberly A. Jones
  • Marlys H. Witte


Just 10 years ago, a chapter could not have been written about the genetic basis of familial or hereditary lymphedema. Whereas the familial or hereditary occurrence of peripheral lymphedema has been described for at least 150 years in the literature, along with numerous syndromes listed in the database Online Mendelian inheritance in Man (OMIM™),1 it was not until 2000 that the first of a series of unrelated “lymphedema genes” was discovered. The location had been identified on the long arm of chromosome 5 two years earlier by three independent research groups, but was not pinpointed.2-4 In a few of the other described syndromes, genes contributing to the disease now have been identified using new molecular tools. Together with advances in understanding the growth and development of the lymphatic vasculature (lymphvasculogenesis and lymphangiogenesis) and diverse lymphatic functions, which have uncovered an array of candidate genes underlying these processes, the field is advancing at a much faster pace. Some of the genes identified to date seem to have a clear function related to the lymphatic system such as the mutation in the FLT4 gene, which encodes the vascular endothelial growth factor receptor-3 gene (VEGFR3), important in lymphatic vessel development and function. Other genes (e.g., FOXC2) have identified proteins important in lymphatic structures as well as other organs, thus explaining the unique and at times baffling phenotypes of and within these syndromes. Some gene discoveries have been the stimulus to look at new pathways or to fill in steps or interrelationships in established pathways in lymphatic growth, development, and function. Detailed description and improved classification and reporting of these syndromes and further imaging studies to more precisely define lymphatic phenotypes (including carriers who may not exhibit overt lymphedema, but have structurally/functionally abnormal lymphatic vessels) will allow use of more precise molecular tools to continue to help identify specific loci responsible for these often multi-system disorders and to carry out pre-natal or ­post-natal screening for detection. Moreover, once the molecular defects are uncovered and understood, more targeted therapeutic agents are likely to be developed.


Turner Syndrome Lymphatic Endothelial Cell Pubertal Onset Lymphatic Vasculature Epigenetic Influence 



Arizona Disease Control Research Commission Contract #9002, I-103, NIH HL 71206, and the International Society of Lymphology.


  1. 1.
    Online Mendelian Inheritance in Man, OMIM (™). Johns Hopkins University, Baltimore, MD. MIM Number: World Wide Web URL:
  2. 2.
    Evans AL, Brice G, Sotirova V, et al. Mapping of primary congenital lymphedema to the 5q35.3 region. Am J Hum Genet. 1999;64(2):547-555.PubMedCrossRefGoogle Scholar
  3. 3.
    Witte MH, Erickson R, Bernas M, et al. Phenotypic and genotypic heterogeneity in familial Milroy lymphedema. Lymphology. 1998;31(4):145-155.PubMedGoogle Scholar
  4. 4.
    Karkkainen MJ, Ferrell RE, Lawrence EC, et al. Missense mutations interfere with VEGFR-3 signaling in primary lymphedema. Nat Genet. 2000;25(2):153-159.PubMedCrossRefGoogle Scholar
  5. 5.
    McNeil GC, Witte MH, Witte CL, et al. Whole-body lymphangioscintigraphy: the preferred method for the initial assessment of the peripheral lymphatic system. Radiology. 1989;172:495-502.Google Scholar
  6. 6.
    Bolinger A, Jager K, Sgier F, Seglias J. Fluorescence microlymphography. Circulation. 1981;64(6):1195-1200.CrossRefGoogle Scholar
  7. 7.
    Case TC, Witte CL, Witte MH, Unger EC, Williams WH, et al. Magnetic resonance imaging in human lymphedema: comparison with lymphangioscintigraphy. Magn Reson Imaging. 1992;10:549-558.PubMedCrossRefGoogle Scholar
  8. 8.
    Hennekam R. Syndromic lymphatic maldevelopment. In: Witte M, ed. Conquering Lymphatic Disease: Setting the Research Agenda. Tucson: University of Arizona; 2001:70-73.Google Scholar
  9. 9.
    Northup KA, Witte MH, Witte CL. Syndromic classification of hereditary lymphedema. Lymphology. 2003;36:162-189.PubMedGoogle Scholar
  10. 10.
    Irrthum A, Devriendt K, Chitayat D, et al. Mutations in the transcription factor gene SOX18 underlie recessive and dominant forms of hypotrichosis-lymphedema-telangiectasia. Am J Hum Genet. 2003;72(6):1470-1478.PubMedCrossRefGoogle Scholar
  11. 11.
    Alders M, Hogan BM, Gjini E, et al. Mutations in CCBE1 cause generalized lymph vessel dysplasia in humans. Nat Genet. 2009;41(12):1272-1274.PubMedCrossRefGoogle Scholar
  12. 12.
    Finegold DN, Schacht V, Kimak MA, et al. HGF and MET mutations in primary and secondary lymphedema. Lymphat Res Biol. 2008;6(2):65-68.PubMedCrossRefGoogle Scholar
  13. 13.
    Ferrell RE, Baty CJ, Kimak MA, et al. GJC2 missense mutations cause human lymphedema. Am J Hum Genet. 2010;86:943-948.PubMedCrossRefGoogle Scholar
  14. 14.
    Irrthum A, Karkkainen MJ, Devriendt K, Alitalo K, Vikkula M. Congenital hereditary lymphedema caused by a mutation that inactivates VEFGFR3 tyrosine kinase. Am J Hum Genet. 2000;67:295-301.PubMedCrossRefGoogle Scholar
  15. 15.
    Connell FC, Ostergaard P, Carver C, et al. Analysis of the coding regions of VEGFR3 and VEGFC in Milroy disease and other primary lymphoedemas. Hum Genet. 2009;124(6):625-631.PubMedCrossRefGoogle Scholar
  16. 16.
    Lohela M, Saaristo A, Veikkola T, Alitalo K. Lymphangiogenic growth factors, receptors, and therapies. Thromb Haemost. 2003;90(2):167-184.PubMedGoogle Scholar
  17. 17.
    Fang J, Dagenais SL, Erickson RP. Mutations in FOXC2 (MFH-1), a forkhead family transcription factor, are responsible for the hereditary lymphedema-distichiasis syndrome. Am J Hum Genet. 2000;67:1382-1388.PubMedCrossRefGoogle Scholar
  18. 18.
    Erickson RP, Dagenais SL, Caulder MS, et al. Clinical heterogeneity in lymphoedema-­distichiasis with FOXC2 truncating mutations. J Med Genet. 2001;38(11):761-766.PubMedCrossRefGoogle Scholar
  19. 19.
    Witte MH, Erickson RP, Khalil M, et al. Lymphedema-distichiasis syndrome without FOXC2 mutation: evidence for chromosome 16 duplication upstream of FOXC2. Lymphology. 2009;42:152-160.PubMedGoogle Scholar
  20. 20.
    Connell F, Kalidas K, Ostergaard P, et al. Linkage and sequence analysis indicate that CCBE1 is mutated in recessively inherited generalised lymphatic dysplasia. Hum Genet. 2010;127:231-241.PubMedCrossRefGoogle Scholar
  21. 21.
    Ferrell RE, Levinson KD, Esman JH, et al. Hereditary lymphedema: evidence for linkage and genetic heterogeneity. Hum Mol Genet. 1998;7(13):2073-2078.PubMedCrossRefGoogle Scholar
  22. 22.
    Evans AL, Bell R, Brice G, et al. Identification of eight novel VEFFR-3 mutations in families with primary lymphoedema. J Med Genet. 2003;40(9):697-703.PubMedCrossRefGoogle Scholar
  23. 23.
    Spiegel R, Ghalamkarpour A, Daniel-Spiegel E, Vikkula M, Shalev SA. Wide clinical spectrum in a family with hereditary lymphedema type I due to a novel missense mutation in VEGFR3. J Hum Genet. 2006;51(10):846-850.PubMedCrossRefGoogle Scholar
  24. 24.
    Karkkainen MJ, Haiko P, Sainio K, et al. Vascular endothelial growth factor C is required for sprouting of the first lymphatic vessels from embryonic veins. Nat Immunol. 2004;5(1):74-80.PubMedCrossRefGoogle Scholar
  25. 25.
    Meige H. Dystrophie oedemateuse hereditaire. Presse Méd. 1898;6:341-343.Google Scholar
  26. 26.
    Hoque SR, Mansour S, Mortimer PS. Yellow nail syndrome: not a genetic disorder? Eleven new cases and review of the literature. Br J Dermatol. 2007;156:1230-1234.PubMedCrossRefGoogle Scholar
  27. 27.
    Witte MH, Way DL, Witte CL, Bernas M. Lymphangiogenesis: mechanisms, significance and clinical implications. In: Goldberg ID, Rosen EM, eds. Regulation of Angiogenesis. Basel: Birkhäuser Verlag; 1997:65-112.Google Scholar
  28. 28.
    Witte MH, Bernas M. Lymphatic pathophysiology. In: Cronenwett JL, Johnston KW, eds. Rutherford’s Vascular Surgery. Philadelphia: W.B. Saunders Company; 2010:177-201.Google Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • Kimberly A. Jones
  • Marlys H. Witte
    • 1
  1. 1.Department of SurgeryUniversity of Arizona College of MedicineTucsonUSA

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