Abstract
Lymphatic vessels, comprising the secondary circulatory system in human body, play a multifaceted role in maintaining homeostasis among various tissues and organs. They are tasked with a serious of responsibilities, including the regulation of lymph absorption and transport, the orchestration of immune surveillance and responses. Lymphatic vessel development undergoes a series of sophisticated regulatory signaling pathways governing heterogeneous-origin cell populations stepwise to assemble into the highly specialized lymphatic vessel networks. Lymphangiogenesis, as defined by new lymphatic vessels sprouting from preexisting lymphatic vessels/embryonic veins, is the main developmental mechanism underlying the formation and expansion of lymphatic vessel networks in an embryo. However, abnormal lymphangiogenesis could be observed in many pathological conditions and has a close relationship with the development and progression of various diseases. Mechanistic studies have revealed a set of lymphangiogenic factors and cascades that may serve as the potential targets for regulating abnormal lymphangiogenesis, to further modulate the progression of diseases. Actually, an increasing number of clinical trials have demonstrated the promising interventions and showed the feasibility of currently available treatments for future clinical translation. Targeting lymphangiogenic promoters or inhibitors not only directly regulates abnormal lymphangiogenesis, but improves the efficacy of diverse treatments. In conclusion, we present a comprehensive overview of lymphatic vessel development and physiological functions, and describe the critical involvement of abnormal lymphangiogenesis in multiple diseases. Moreover, we summarize the targeting therapeutic values of abnormal lymphangiogenesis, providing novel perspectives for treatment strategy of multiple human diseases.
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Introduction
The lymphatic system is a vital component of the circulatory system and plays a crucial role in maintaining fluid homeostasis, lipid absorption and the immune response in the body. Comprising a vast network of lymphatic vessels, this intricate lymphatic system is a conduit for the transportation of lymph fluid, immune cells, and various macromolecules. Lymphatic vessels are lined with lymphatic endothelial cells (LECs) with distinct structures and functions in the hierarchical lymphatic network.1 Additionally, it is becoming increasingly clear that adult lymphatic vessels exposed to different organ-specific environments acquire distinct characteristics and in turn execute multiple tissue-specific functions. Abnormal lymphangiogenesis can be induced under pathological conditions, where it becomes an active player in the pathogenesis of several diseases, such as lymphedema, obesity and cancer.2 Recently, molecular and genetic techniques have propelled the identification of potential therapeutic targets to modulate lymphangiogenesis. In this review, we provide a comprehensive summary of lymphatic vessels, addressing their origin, heterogeneity, biological functions, and related therapeutic targets.
Historical research and milestone events of lymphangiogenesis
Milestone events of lymphatic vessel anatomy and function
The anatomy and function of lymphatic vessels have been investigated for more than 2000 years, and many researchers have contributed numerous landmark discoveries that have led to the gradual clarification of the structure and physiological function of lymphatic vessels.3,4 The earliest record of the lymphatic system is the finding of lymph nodes. In the 5th century B.C., Hippocrates first coined the term chylos (chyle) and observed lymphatic glands (lymph nodes) located in the armpits, near the ears, around jugular vessels, and spread through diverse locations in the abdominal cavity. Moreover, Hippocrates described a milky fluid, termed ichor (lymph fluid), flowing in the lumen of some vessels. Then, Aristotle (384–322 B.C.) identified some unique fibers between blood vessels and nerves that were filled with fluid, thereby first describing the anatomy of general lymphatic vessels.5 As interest increased, lymphatic vessels were clearly described in a variety of tissues. Herophilus (335–280 B.C.) and Erasistratus (304–250 B.C.) successively found chyliferous vessels inside the mesentery.6,7 In 1536, Massa (1485–1569) found some vessels (lymphatics) in fat tissue near kidneys (renal lymphatic vessels).8 Eustachi (1520–1574) found the vena alba thoracis (thoracic duct) during horse dissection but failed to identify the extended structure and function.9 In 1627, Gaspare Aselli found the venae albae aut lacteae (the gut lacteal, a specialized capillary lymphatics with a blind end that absorbs chylomicron from intestinal villi) in a dog in 1627.10 Immediately afterward, in 1628, Fabrice de Peiresc described lacteals in the human body.11
Then, researchers went beyond anatomical studies and began to investigate the role of lymphatic vessels in lymph drainage. Jean Pecquet (1624–1674) described the cisterna chyli (reservoir of the chyle) and thoracic duct and explained that lymph drained into the left subclavian vein via the thoracic duct not the liver.12 At approximately the same time, another lymphatic vessel that converge with the thoracic duct was also described. Olaus Rudbeck (1630–1702) found ducti hepatici aquosi (watery hepatic ducts), now known as hepatic lymphatic vessels. Rudbeck also found cardiac, renal, pulmonary, and peripheral lymphatic vessels in 1653.13,14 In the same year, another researcher, Thomas Bartholin (1616–1680), coined the term vasae lymphatica (lymphatics or lymphatic vessels) to describe the ducts conveying lymph fluid and distinguished mesenteric lymphatic vessels from hepatic lymphatic vessels, confirming that the lymph fluid from two different sources flows into the thoracic duct.15 Niels Stensen (1638–1686) specifically described that both the thoracic duct and left jugular lymphatic vessel delivered lymph into the angle between the duct of the left subclavian and internal jugular veins.4 Simultaneously, in 1675, Stensen also discovered cervical lymphatic vessels and lymph nodes.4 Subsequently, in 1701, Frederik Ruysch explored the morphology and function of lymphatic valves, which ensure the unidirectionality of lymph flow.16 Paolo Mascagni described lymphatic vessels in the human dura mater (meningeal lymphatic vessels) and lymph node-related lymphatic vessels in 1787.17,18
Despite the lack of advanced microscopy imaging techniques and specific lymphatic markers to stain, the striking findings and continued exploration laid the foundation for modern anatomy and knowledge about the function of lymphatic vessels. Herein, we clearly present the early research events and critical timepoints of lymphatic vessel discoveries in Fig. 1.
Milestone events of lymphatic vessel origins and development
Early studies revealed the anatomy and function of mature lymphatic vessels, while modern research has been focused on the embryonic events of lymphatic vessel formations comprising origins and development (the specific events and timepoints of their discoveries are presented in Fig. 2). In 1902, Florence Sabin discovered the origin and development of lymphatic vessels by injecting India ink into pig embryos and then proposed the venous-origin theory of lymphatic vessels, which suggests that LECs sprout from veins and form the lymph sacs involved in general lymphatic vessel development.19 This researcher was the first to visualize the origin of lymphatic vessels and the development process. In contrast, in 1910, Huntington, McClure, and Kampmeier separately proposed a nonvenous theory of lymphatic vessel origin, suggesting that lymphatic vessels concentrically grow from isolated mesenchymal lymphangioblasts, coalesce into lymphatic sacs, and then connect to the venous system.20 These origin theories have been explored and verified for nearly a century. With the application of lineage tracing and other techniques in different animal models, the diversity of lymphatic vessel origins has been gradually revealed.
Martin Schneider and Annelii Ny supported the theory that lymphatic vessels originate from nonvenous cells and found that lymphangioblasts participate in the development of lymphatic vessels in avian wing bud and Xenopus laevis tadpole models in 1999 and 2005, respectively.21,22 The zebrafish is an optimal vertebrate model owing to its fast reproduction rate and ability of researchers to visualize their internal structures. In 2006, Axel M Küchler and Karina Yaniv respectively reported development and regulatory factors of lymphatic vessels in zebrafish models and supported the theory that lymphatic vessels are derived from embryonic veins.23,24 Additionally, mice are a proper mammalian models and have been used to show the process of lymphatic vessel development in different embryonic stages. In 2007, Sathish Srinivasan demonstrated that lymphatic vessels originated from venous endothelial cells (VeECs) by establishing prospero homeobox protein 1 (PROX1)-creERT2 model mice, PROX1 mainly drives the direct reprogramming of VeECs that form the functional lymphatic system that lasts a lifetime.25,26 René Hägerling showed the detailed process of embryonic lymphangiogenesis by applying ultramicroscopy to the study of whole-mount immunostained murine embryos in 2013.27 Hägerling found that lymphatic endothelial progenitor cells were selectively located on the dorsolateral wall of the cardinal vein, indicating that specific VeECs participate in lymphangiogenesis. Using lineage tracing and whole-mount immunostaining on different embryonic days, Oliver A. Stone found that the general lymphatic endothelium was derived mainly from paraxial mesoderm not lateral plate mesoderm. He further indicated that paraxial mesoderm-derived PAX3+ VeECs transdifferentiated into PROX1+ lymphatic endothelial progenitor cells in the cardinal veins and intersomitic veins. PAX3 is a marker for identifying myogenic progenitors in a subset of the somatic paraxial mesoderm, which could differentiate into muscular tissue and endocardium.28 Genetic lineage tracing in the past decade revealed the nonvenous cellular origins of a variety of organ-specific lymphatic vessels. Ines Martinez-Corral identified an isolated cell population involved in the formation of murine lumbar and dorsal midline dermal lymphatic vessels, showing another origin of dermal lymphatic vessels in 2015.29 Three years later, by applying genetic lineage tracing, Cathy Pichol-Thievend demonstrated that this progenitor cell population originated from a blood capillary plexus.30 Moreover, in 2015, Lukas Stanczuk found a population of hemogenic endothelium-derived c-Kit+ progenitor cells that may be involved in mesenteric lymphatic vessel development was discovered.31 Cardiac lymphatic vessels have also been shown to be derived from diverse cellular sources. In 2015, by using multiple Cre-loxp system-based lineage tracing, Linda Klotz determined that multiple populations of hemogenic endothelium-derived VAV1+/PDGFRB+/CSF1R+ progenitor cell contributed to cardiac lymphatic vessel development.32 Additionally, Kazuaki Maruyama and Ghislaine Lioux separately in 2019 and 2020 identified a population of second heart field-derived ISL1+ progenitor cells that participated in the formation of ventral cardiac lymphatic vessels.33,34 Two years later, Kazuaki Maruyama found that these ISL1+ progenitor cells originating from the cardiopharyngeal mesoderm differentiated into craniofacial and cardiac LECs.35
In the 1990s, a large number of studies on the regulatory factors and markers of lymphatic vessel have begun to emerge in the research field. In 1995, Kaipainen et al. discovered FLT4 gene (encoding vascular endothelial growth factor receptor 3, VEGFR3) becomes restricted in lymphatic endothelium during embryonic development.36 Subsequently, Kari Alitalo and Vladimir Joukov were the first researchers to isolate the ligand vascular endothelial growth factor C (VEGFC), the ligand for VEGFR2/VEGFR3 and a key factor in regulating LECs sprouting by activating VEGFR3 signaling, as proven by follow-up studies.37,38 In 1999, Guillermo Oliver and Jeffrey T Wigle demonstrated that PROX1 is the master regulator of lymphatic fate and regulates the expression of other transcription factors during embryonic lymphangiogenesis.39 At the same year, Silvana Breiteneder-Geleff discovered a transmembrane glycoprotein in podocytes, podoplanin (PDPN, encoded by T1α), which was specifically expressed in the endothelium of capillary lymphatics and was, therefore, the first lymphatic marker for immunolocalization and distinguishing the blood from lymphatic vessels.40 Simultaneously, Suneale Banerji determined that lymphatic vessel endothelial hyaluronan receptor 1 (LYVE1) is another specific lymphatic marker.41
These historical studies and milestone events reveal the diversity and heterogeneity of lymphatic vessel anatomy, function, and development and demonstrate the enthusiasm of these researchers for lymphatic vessel research.
Lymphatic vessel development and related regulatory signaling pathways
Lymphatic vessels in embryos undergo a stepwise developmental process, including lymphatic endothelial progenitor cell specification, LEC migration, and lymphatic vessel assembly and maturation.42 Lymphatic vessel development involves lymphangiogenesis and lymphvasculogenesis. Lymphangiogenesis, sprouting from preexisting lymphatic vessels/embryonic veins to form new lymphatic vessels, is the main developmental mechanism underlying the formation and expansion of lymphatic networks in an embryo.43,44 Another mechanism, termed lymphvasculogenesis, is the process by which various populations of nonvenous cells de novo express lymphatic markers and directly incorporated into new lymphatic vessels.43,45 Lymphatic vessel development is a highly conserved process across multiple species and relies on a stepwise and precise regulatory program.46 Currently available studies only observe localized lymphatic vessel anatomy in human fetuses, lacking dynamic developmental process.47,48,49 However, few studies have recorded the complete process of lymphatic vessel development. Due to ethical issues in using human fetuses, most studies of lymphatic vessel development and function have been carried out with other vertebrate animals, such as mice and zebrafish, and with contributions from these studies, the regulatory map of lymphatic vessel development is gradually being completed.50,51
Murine lymphatic vessel development and regulatory signaling pathways
General lymphatic vessel development and signaling pathways
Based on diverse studies with murine embryos, the timing and processes of lymphatic vessel development have been revealed.27 On approximately embryonic day 9.5–10.5 (E9.5–E10.5), a portion of VeECs located in the cardinal vein and intersomitic veins gradually transdifferentiate into lymphatic endothelial progenitor cells, which is the initial event in lymphatic vessel development.52 SRY-box transcription factor 18 (SOX18) and the chicken ovalbumin upstream promoter transcription factor 2 (COUP-TFII, encoded by NR2F2) are initially expressed in VeECs, which could synergistically activate PROX1 expression.53,54 Furthermore, COUP-TFII cooperates with PROX1 to upregulate the expression of VEGFR3, Neuropilin 2 (NRP2, a coreceptor with VEGFR3), and LYVE1.55,56 In turn, activated VEGFR3 contributes to the consistent expression of PROX1. The regulatory feedback loop further promotes lymphatic phenotype differentiation.57
At E10.5-E15.5, VEGFR3-expressing lymphatic endothelial progenitor cells sprout and form lymph sacs in response to extracellular VEGFC signaling, which triggers tip cells to leave veins and autonomously enter the surrounding mesenchyme.58 During this period, lymphatic endothelial progenitor cells differentiate into LECs and acquire migration and tube formation abilities. VEGFC is necessary and sufficient for prompting lymphatic endothelial progenitor cell budding and directed migration.38 At this stage, collagen and calcium binding EGF domains 1 (CCBE1) and a disintegrin and metallopeptidase with thrombospondin motifs 3 (ADAMTS3) are essential for the proteolytic cleavage of the active form of VEGFC.59,60 Moreover, NRP2 and VEGFR3 can jointly respond to VEGFC binding to regulate LEC migration.56 In addition, fibroblast growth factor (FGF), Adrenomedullin, and Hippo signaling play complementary roles in LEC proliferation and migration.61,62,63 In addition to biochemical pathways, mechanical force can activate lymphangiogenesis in this stage. The expression of the zinc-finger transcription factor GATA-binding protein 2 (GATA2) enhances VEGFR3 signaling in response to changes in tissue stiffness.64 Moreover, increased fluid volume could stimulate β1 integrin-mediated VEGFR3 signaling.65 Subsequently, lymph sacs separate from the cardinal vein via the action of platelet aggregation in response to c-type lectin-like receptor 2/PDPN signaling.66 Interestingly, platelet also maintain the homeostasis of lymphovenous valves.67 Lymphovenous valves, as the only connections between the blood and lymph circulatory systems, which have been gradually characterized, maintain unidirectional lymph drainage into veins. Especially, VEGFC activates the expression of YAP and TAZ to maintain PROX1 expression, which promote the lymphovenous valves and lymphatic valves development.68
From E15.5 to the early postnatal period, the primary lymphatic plexus gradually remolds into hierarchical lymphatic vessels with different features, and these vessels are classified into capillary lymphatic vessels, pre-collecting lymphatic vessels, and collecting lymphatic vessels. The transition of intercellular junctions and changes in cell morphology are fundamental to the initial functionality of lymphatic vessels (described “Capillary lymphatics”). Additionally, the maturation of collecting lymphatic vessels involves lymphatic valve morphogenesis and smooth muscle cell recruitment, which are the structural foundations for lymph transport.69 The constant shear stress caused by lymph flow can stimulate the LEC-expressed mechanosensory receptors, such as PECAM, VE-cadherin, PIEZO1, β1 integrin, VEGFR2, and VEGFR3.70 Downstream mechanotransduction signaling maintains the expression of key transcription factors, such as PROX1, GATA2, forkhead box P2 (FOXP2), and forkhead box C1/2 (FOXC1/2), which manipulate lymphatic valve formation.71,72,73 In addition to lymphatic valves, collecting lymphatic vessels transport lymph fluid by the action of coverage of smooth muscle cells. Smooth muscle cell recruitment is regulated by the expression of platelet-derived growth factor B (PDGFB), Reelin and MCP1 in LECs.74,75 Moreover, FOXC2 and Angiopoietin 2 (ANG2) could activate downstream signaling to maintain the normal pattern of smooth muscle cell coverage of vessels.73,76 In contrast, the Sema3A/NRP1/PlexinA1 axis prevents smooth muscle cells from covering valve-forming endothelial cells.77 We depict the developmental process of general lymphatic vessels in Fig. 3.
Organ-specific lymphatic vessel development and signaling pathways
Lymphatic vessels undergo a general development process mediated through biochemical and mechanical signaling pathways and gradually form a specialized lymphatic vessel network. To adapt to the physiological needs of different organs, lymphatic vessel development involves heterogeneous processes and responses to lymphangiogenic signaling.78 Therefore, we summarize the development process of organ-specific lymphatic vessels and regulatory signaling in Table 1. We also depict schematic diagrams of the murine organ-specific lymphatic vessel anatomy in Figs. 4–6.
Zebrafish lymphatic vessel development and related signaling pathways
Because of their relatively transparent body, large number of progeny, and short developmental cycle, zebrafish have become an optimal animal model for observing the dynamic development of lymphatic vessels.79,80 Through the combined application of high-resolution imaging techniques and identification of lymphatic markers, the heterogeneous processes underlying lymphatic vessel development in zebrafish have been gradually elucidated in the past decade.79 Although the main lymphangiogenic signaling network is conserved across mammals, lymphatic vessel development is regulated by specific molecules and signaling pathways in zebrafish. Therefore, we summarize the heterogeneous development processes of lymphatic vessels (Fig. 7) and the significant molecules and signaling pathways in zebrafish (Table 2).
Early lymphatic vessel development occurs during the first day 5 postfertilization (dpf). Similar to mammals, the posterior cardinal vein is the origin of lymphangiogenesis.81 Between hour 30 and 34 postfertilization (hpf), a population of bipotential progenitor cells (also known as lymphangioblasts) generates two kinds of endothelial cells, VeECs and PROX1-expressing lymphatic endothelial progenitor cells.82 In particular, VEGFC is the key factor that regulates the division of cell identity, and it also triggers PROX1 expression.82 Moreover, the role of PROX1 in initiating the transdifferentiation of VeECs into lymphatic endothelial progenitor cells is conserved in both zebrafish and mammals.82 At 1.5 dpf-2 dpf, LECs dorsally sprout toward the horizontal myoseptum, forming a population of LECs known as parachordal lymphangioblasts (or parachordal line). CCBE1/VEGFC/VEGFR3 signaling regulates LEC sprouting and migration.83,84
At 2.5 dpf-4 dpf, lymphatic vessel sprouts from the parachordal lymphangioblasts begin to migrate dorsally and ventrally along arterial intersegmental vessels not venous intersegmental vessels, forming intersegmental lymphatic vessels.85,86 Subsequently, LECs on the dorsal and ventral sides of the intersegmental vessels migrate rostrally and caudally and ultimately interconnect, forming the two trunk lymphatic vessels, namely, the dorsal longitudinal lymphatic vessel (abutting the dorsal longitudinal anastomotic vessel) and thoracic duct (abutting the posterior cardinal vein).87,88 We show the process of mainly trunk lymphatic vessel development in Fig. 7 and describe the related regulatory signaling pathways involved in LEC sprouting and migration in Table 2.
Between 5 dpf and 7 dpf, LECs begin to emerge from the intersegmental lymphatic vessels (the third trunk lymphatic vessel) and extend rostrally and caudally along the horizontal myoseptum to gradually form parachordal lymphatic vessels.80 Subsequently, parachordal lymphatic vessels continue to expand laterally during zebrafish development and form intercostal lymphatic vessels at approximately 15 dpf.80 Parachordal lymphatic vessels and intercostal lymphatic vessels become lateral lymphatic vessels in zebrafish. Through sophisticated signaling mechanisms, VEGFC/VEGFR3 is the key interaction that triggers the signaling cascade to activate LECs continuously. Interestingly, the homeobox transcription factor HOXC9 supports the expression of stabilin 2 to maintain the normal formation of thoracic duct and parachordal lymphangioblasts, and another homologous protein, stabilin 1, plays a similar role in promoting zebrafish lymphangiogenesis in a HOXC9-independent manner.89
In this developmental period, organ-specific lymphatic vessel development simultaneously occurs in the head and intestine of zebrafish.80,90 We depict the process of organ-specific lymphatic vessels by development stages in Fig. 7. Further studies should be conducted to verify the specific function of lymphangiogenic signaling pathways in organ-specific lymphatic vessel development and biological capacity.
Biological functions of lymphatic vessels and related regulatory signaling pathways
Anatomy and structure of the lymphatic vessel network
The lymphatic system includes primary lymphoid organs (the bone marrow and thymus), secondary lymphoid organs (the lymph nodes, spleen, and mucosal-associated lymphoid tissue), and lymphatic vessels that connect all lymphoid organs.91 The lymphatic vessel network is composed of capillary lymphatics, pre-collecting and collecting lymphatics.92 Additionally, the cell-cell junctions (button- and zipper-like junctions) are important for functionally specialized capillary and collecting lymphatics (Fig. 8).
Capillary lymphatics
Capillary lymphatics (also called initial lymphatics) consist of a single layer of loosely connected LECs without a continuous basement membrane and are covered by pericytes or smooth muscle cells.93 They are blind-ended vessels and are connected by anchoring filaments to the interstitial tissue. Overlapping endothelial cells build flap-like mini-valves, ensuring one-way interstitial fluid, macromolecule, and immune cells flow into the vessels. These capillary lymphatics in the most tissues are interconnected through discontinuous button-like junctions. Additionally, the integrity of LEC junctions is regulated by two different types of cell-cell junctions: adherens junctions and tight junctions.
The button-like junctions of the capillary lymphatics are formed by adherens junction proteins, including VE-cadherin,94 p120-catenin, and catenin, which bind to each other and the actin cytoskeleton. Tight junctions are formed by transmembrane proteins, such as claudin-5 and occludin, and the cytoplasmic protein ZO-1, which regulate paracellular permeability,91 and junctional adhesion molecule and endothelial cell-selective adhesion molecule, which are involved in leukocyte transmigration. The ANG/tunica interna endothelial cell kinase 2 (TIE2) signaling pathway is indispensable for the formation of button-like junctions within capillary lymphatics.95 In lacteals, VEGFC-VEGFR2/3-delta-like 4 (DLL4)-NOTCH signaling is crucial for constant regeneration and maintenance of button junctions.96
Collecting lymphatics
Capillary lymphatics drain into pre-collecting lymphatic vessels and merge with larger collecting lymphatics. Collecting lymphatic vessels contain valves that regulate the unidirectional flow of lymph with the coordinated contraction of smooth muscle cells facilitating the transport of lymph into the bloodstream.97 Tissue fluid transported by collecting lymphatics ultimately drains into the thoracic duct and right lymphatic duct, which discharge lymph into the common opening of the jugular and subclavian veins known as the venous angle.98
In collecting lymphatics, LECs are continuously connected through zipper-like junctions and are enveloped by specialized smooth muscle cells that contract to assist lymph flow.93 During mouse embryonic development, the transformation from continuous zipper-like junctions (formed at E12.5-E16.5) to button-like junctions begins at E17.5 and is mostly complete by postnatal day (P) 28.99 Therefore, zipper-like junctions are regulated in a manner similar to that of button-like junctions, however, some mechanisms that specifically regulate zipper-like junctions are described below. RhoA/ROCK signaling is essential for LEC junction formation in lacteals, lymphatic valves, and collecting vessels. Transcription factors FOXC1 and FOXC2 are required for maintaining LEC junction integrity in lymphatic valves, collecting vessels, and dermal lymphatics.92 Recent studies identified several other major signaling pathways that control tight junction localization and lymphatic vessel integrity, including EphrinB2/EphB4 and S1PR1.91
Biological functions of lymphatic vessels
The general functions of lymphatic vessels in fluid absorption and transport, as well as immunosurveillance, are well understood. However, accumulating evidence indicates that lymphatic vessels play active and versatile roles in an organ-specific manner during homeostasis and multiple disease processes.100 We provide a brief overview of the novel discoveries of organ-specific functions of adult mammalian lymphatic vessels, including immunosurveillance after pathogen invasion, transport of dietary fat, and drainage of cerebrospinal fluid and aqueous humor.
Lymph absorption and transport
Lymphatic vessels play crucial roles in the uptake and transport of multiple substances to maintain tissue fluid homeostasis, such as lipids, proteins, and immune cells in the body, which present diverse characteristics in different organs.101 Studies have suggested that both passive paracellular and active transcellular transport mechanisms may contribute to lymph absorption.102 Moreover, lymphatic vessels have an active role in draining excess interstitial fluid from organs and serving as conduits for immune cell trafficking to lymph nodes. The lymphatic pump undergoes phasic contractions generated by lymphatic smooth muscle cells to realize lymph transport, and lymphatic valves ensure one-way lymph transport. When upstream valves open, diastolic filling causes vessel wall stretching, increasing vessel volume and pressure. Systole subsequently begins with the rapid contraction of the lymphatic muscle and closure of the upstream valve (Fig. 9). To give readers a clear understanding, we summarize the absorption and transport functions of lymphatic vessels in diverse organs as follows.
Lymph absorption and transport in meningeal lymphatic vessels
Although the brain parenchyma is devoid of lymphatic vessels, the rapid clearance of cellular debris and metabolic products in the central nervous system is attributable to the glymphatic system and meningeal lymphatic vessels.103 The glymphatic system is composed of three essential components: the para-arterial cerebrospinal fluid influx channel, the para-venous interstitial fluid efflux channel, and the water channel aquaporin-4 in astrocytes that connect these channels.103 Cerebrospinal fluid flows into the brain through the para-arterial space and exchanges with interstitial fluid via aquaporin-4; this type of exchange drives metabolite and interstitial fluid into the para-venous space and then into the cerebrospinal fluid circulatory system or directly through the capillary lymphatics into the cervical lymphatics. In particular, the glymphatic system transports lipids within the brain. Excess cholesterol in the brain is eliminated through hydroxylation to 24-hydroxycholesterol by Apolipoprotein E concentrated in astrocytes.
In addition to the glymphatic system, meningeal lymphatic vessels are involved in the elimination of cellular debris and waste products. Dorsal meningeal lymphatic vessels transport macromolecules and cells along the superior sagittal and transverse sinuses. Basal meningeal lymphatic vessels possess lymphatic valves without smooth muscle cells, thereby acquiring a pre-collector phenotype.104 Dysfunction of meningeal lymphatic vessels potentially contributes to the onset and progression of Alzheimer’s disease by disrupting the clearance of pathological proteins such as amyloid-β and tau protein, which we will discuss in “Abnormal lymphangiogenesis in human diseases”.
Lymph absorption and transport in ocular lymphatic vessels
The ocular surface lymphatic system and Schlemm’s canal regulate lymph absorption and transport in ocular lymphatic vessels. Regarding the ocular surface lymphatic system, lymphatic vessels have been identified in the corneal limbus and conjunctiva of mice and humans.105 Ocular surface lymphatic vessels are characterized by button-like junctions, an oak leaf-like shape, and luminal valves with features similar to those of capillary lymphatics and pre-collecting lymphatic vessels.106
Schlemm’s canal is an endothelial cell-lined vessel encircling the cornea and abutting the juxtacanalicular region of the trabecular meshwork.107 As a special structure regulating intraocular pressure, Schlemm’s canal drains aqueous humor into aqueous and episcleral veins.108 Yang et al. described a luminal structure called the lymphatic bridge that connects Schlemm’s canal to ocular surface lymphatic vessels, which allows aqueous humor outflow to the conjunctival lymphatic pathway. This finding suggested, for the first time, that the two lymphatic drainage systems are physically connected, expanding the knowledge of the aqueous humor pathway.109
Lymph absorption and transport in intestinal lymphatic vessels
Intestinal lymphatic vessels mediate distinct functions in fat absorption, intestinal homeostasis, and peripheral fat transport. Lymphatics continuously deliver nutrients to tissues. Dietary lipids are packaged into chylomicrons in the small intestines and transported via lacteals (capillary lymphatics in the small intestine), where they mix with lymph to become chyle. Mesenteric lymphatic vessels and cisterna chyli carry chyle through the thoracic duct and into the venous circulation.110 Defects in lacteals can cause problems with lipid uptake in the intestine. VEGFR2/VEGFR3 signaling, which is mediated through DLL4/NOTCH, is important for lacteal function maintenance. The deletion of DLL4 in lymphatics led to lacteal atrophy and an increase in the number of zipper junctions, resulting in the inability of the tissues to take up chylomicrons.111 Interestingly, VEGFA/VEGFR2 signaling also leads to a shift from the establishment of button-like junctions to that of zipper-like junctions in lacteals.112 Notably, lacteal atrophy caused by postnatal deletion of VEGFC impaired the absorption of lipids and led to steatorrhea.113
Although the small intestine is generally considered an absorptive organ, it can be induced to secrete fluids, causing diarrhea, under certain conditions.114 Intestinal lymphatics are important for fluid absorption, especially after a meal. Lymphatics also appear to participate in peripheral tissue lipid balance, and recent studies have shown that they are critical for reverse cholesterol transport. When high-density lipoprotein transports cholesterol out of cells and into peripheral tissues, lymphatic vessels conduct the particles into the bloodstream and back to the liver for excretion through feces.115 In mice, obstruction of lymphatic vessels impaired reverse cholesterol transport116 and led to increased atherosclerotic plaque formation.117
Lymphatic vessels in immunity
Lymph node lymphatic vessels in coordinating immune responses
Peripheral lymphatic vessels transport antigens and immune cells to draining lymph nodes, fostering an immune response.100 In mature lymph nodes, lymphatic vessels and specialized high endothelial venules that are indispensable for the trafficking of naïve lymphocytes into the paracortex of the lymph node,118 contributing to the adaptive immune response.119 Lymph node LECs contribute to immune response directly by antigen archiving and presentation. Antigen archiving in proliferating lymph node LECs can be directly transferred to other cells, for example, to migratory CD11c+ dendritic cells.120 Antigens can also be released from dying LECs and subsequently transferred to Batf3-dependent migratory dendritic cells. Antigens can be presented by LECs to immune cells through the MHC (comprising MHCI and MHCII).121
LECs in different regions can guide immune cell trafficking and positioning within lymph nodes by expressing specific molecules.122 For instance, LECs create a chemokine (C-C motif) ligand 21 (CCL21) gradient that facilitates the migration of dendritic cells into the lymph node medulla.123 Additionally, S1P gradients, formed by medullary LECs, are necessary for B and T-cell egress into efferent lymphatics and subsequent lymphocyte recirculation. LECs establish a niche for subcapsular sinus and medullary macrophage homing and maintenance. Lymph node LECs serve as major sources of the macrophage pro-survival factor colony-stimulating factor-1, with RANK receptor-expressing LECs inducing colony-stimulating factor-1 expression by interacting with CCL19+ marginal reticular cells, producing RANKL (Fig. 10).124
Lymphatic vessels in central nervous system immunity
Recent studies of meningeal lymphatic vessels revealed an intersection between the immune system and central nervous system.125 Meningeal lymphatic vessels may provide a route for central nervous system-derived immune cell and antigen delivery to cervical lymph nodes and thus prevent central nervous system from infection or injury. Meningeal lymphangiogenesis plays an active role in immune surveillance to protect the central nervous system. In the context of glioblastoma, VEGFC-induced meningeal lymphangiogenesis recruited CD8+ T cells into the tumor and induced a long-lasting antitumor memory response.126 In response to spinal cord injury, VEGFC/VEGFR3 signaling activation-mediated spinal lymphangiogenesis enhanced the immune response by increasing the T cell infiltration rate.127 However, studies have shown that meningeal lymphatic vessels potentially promote pathological processes under autoimmune neuroinflammatory conditions. In the multiple sclerosis context, blocking meningeal lymphatic vessels reduced disease severity and alleviated the inflammatory response, likely by interfering with the trafficking and activation of CCR7+ T cells in draining lymph nodes.128
Lymphatic vessels in gut immunity
Intestinal lymphatic vessels are important components of the gut immunosurveillance system, which promotes the mucosal immune response and tolerance. Intestinal dendritic cells present antigens in response to LEC-derived CCL21 production, which is essential for the establishment of oral tolerance.129 Intestinal dendritic cells also drive the apoptosis of intestinal epithelial cells in mesenteric lymph nodes by transmitting critical signals that induce Treg cell activation.129,130 In addition, different parts of the intestine drain to distinct mesenteric lymph nodes that are immunologically specific to the functional gut segment that they drain. Proximal small intestine-draining mesenteric lymph nodes induce tolerogenic responses, while distal mesenteric lymph nodes induce proinflammatory T cell responses.131
The capillary lymphatics in the intestine (also known as lacteals) function as a secondary barrier defending against potential bacterial infections while simultaneously serving as the primary conduit for the dissemination of pathogens, pathogen-derived toxins, and subsequently tissue-derived proinflammatory mediators. DLL4-specific deletion led to lacteal regression and weakened the local immune response, leading to susceptibility to infection and impaired dietary fat uptake.111 Additionally, lymphatic drainage can influence the composition of the gut microbiota, with increased drainage potentially promoting a healthier microbiota profile and reducing the incidence of colitis. In contrast, reduced drainage may impede pathogen dissemination and reduce proinflammatory factor levels.
Abnormal lymphangiogenesis in human diseases
In the above sections, we provided a detailed account of lymphatic vessels in physiological conditions, encompassing lymphatic vessel development and physiological functions. Furthermore, lymphatic vessels actively participate in pathological processes in human diseases. As the comprehension of lymphangiogenesis in diseases improves, the underlying molecular mechanisms have been elucidating. In this section, we provide a comprehensive elucidation of the pivotal roles of lymphangiogenesis in various prevalent diseases and associated regulatory signaling pathways. Meanwhile, lymphangiogenesis in other diseases is concisely presented in Table 3.
Lymphedema and lymphatic malformation
Lymphedema
Lymphedema is a chronic, progressive accumulation of protein-rich fluid in the interstitium due to lymphatic vessel deficiency, resulting in inflammation, fat deposition, and fibrosis. Lymphedema is classified into primary disease caused by congenital abnormalities or secondary disease caused by the injury of iatrogenesis, trauma, and infection. Primary lymphedema, a rare inherited autosomal dominant disorder, is initially characterized by mutations in FLT4 (which encodes VEGFR3). Germline mutations responsible for primary lymphedema have been identified in 28 genes that encode proteins mainly involved in VEGFR3 signaling and these encoded proteins include transcription factors such as GATA2, FOXC2, and SOX18. The majority of mutations result in reduced activation of the VEGFR3 pathway.110 Secondary lymphedema arises as a result of infection, trauma or surgery.132 Current treatment strategies include mainly physical or surgical interventions to alleviate edema and these treatments include decongestive therapy, intermittent pneumatic compression and liposuction.133 In addition, recent studies have revealed the efficacy of pharmacotherapy and cell-based therapies in the treatment of lymphedema.134,135
Lymphatic malformation
Lymphatic malformation is a benign congenital vascular disease characterized by abnormal lymphatic vessel development. It is caused by single somatic mutations, most of which are in genes encoding components of oncogenic growth factor-activated signal transduction pathways.136 The classification of lymphatic malformations is based primarily on clinical manifestations. Cystic lymphatic malformation is the most prevalent type of congenital lymphatic malformation, presenting as solitary lesions of variable sizes. Based on appearance, it is classified into macrocystic, microcystic, or mixed cystic lymphatic malformation.136 Most cystic lymphatic malformations are caused by a causative mutation in PIK3CA. Most PIK3CA mutations causing cystic lymphatic malformation activate the phosphatidylinositol-3-kinase (PI3K)/AKT/mTOR signaling cascade.137 Complex lymphatic malformations are characterized as multifocal lesions or defection occurring in central collecting lymphatic vessels and show overlapping and variable clinical features. These features include generalized lymphatic anomaly, Gorham-Stout disease, Kaposiform lymphangiomatosis, and central conducting lymphatic anomaly.138 Similar to the cause of cystic lymphatic malformation, a causative somatic PIK3CA mutation (His1047Arg) has been reported in generalized lymphatic anomaly.139 In other types of complex lymphatic malformations, mutations in genes encoding components of the RAS/MAPK pathway have been reported, including mutations in NRAS and ARAF.140,141 Furthermore, germline heterozygous kinase-dead mutations in the gene encoding EPHB4 could activate MAPK signaling in cases of central conducting lymphatic anomaly.142 The choice of therapy is based on the location and size of the malformation, and the affected tissues. Pharmacotherapy, surgical resection, sclerotherapy, and thermal ablation can be used to control and relieve symptoms of recurrent effusions, infection, and pain in lymphatic malformations.136
Lymphangiogenesis in cancer
In the past, cancer-associated lymphatic vessels were considered passive transporters of cancer cells. However, recent studies revealed that lymphatic vessels actively participate in the process of cancer metastasis through their dynamic changes, mostly mediated via lymphangiogenesis. Lymphangiogenesis requires the coordination of complex cellular events, including proliferation, sprouting, migration, and tube formation.46 Tumor-associated lymphangiogenesis, with its resultant increased permeability and enlargement of lymphatic vessels, synergistically promotes cancer metastasis.143 Depending on the type and site of a tumor, the signaling pathways for lymphangiogenesis vary. Moreover, targeting lymphangiogenesis to inhibit cancer metastasis has been proven to be a valuable therapeutic strategy. In this section, we summarize the abnormal lymphangiogenesis in various cancers (Figs. 11, 12).
Nervous system cancer
Glioma
Malignant glioma is the most common primary cancer of the central nervous system. The expression levels of lymphangiogenic factors (PDPN, VEGFC/D, VEGFR3) are increased in high-grade gliomas, with their expression significantly higher at relapse than it was in the primary tumor.144 In addition, microenvironmental stress, including hyperthermia and oxidative stress, has been reported to enhance LEDGF activity, which increases the transcription and expression of VEGFC, thereby promoting lymphangiogenesis.145 However, Hu et al. found that meningeal lymphangiogenesis mediated by VEGFC enhanced the efficacy of anti-PD-1/CTLA-4 combination therapy, which was abolished by CCL21/CCR7 blockage.146
Neuroblastoma
Neuroblastoma is one of the most common cancers in children. Lymphangiogenesis in neuroblastoma is associated with upregulated VEGFC, VEGFD, and VEGFR3, which promotes lymph node metastasis and leads to poor prognosis.147 Endogenous soluble VEGFR2 inhibits the activation of VEGFR3 by binding to VEGFC, thereby inhibiting LEC proliferation. In the context of advanced neuroblastoma, the downregulation of sVEGFR2 is correlated with the disease progression.148 Furthermore, an anti-VEGFD monoclonal antibody, cVE199, specifically binds VEGFD to inhibit the binding of VEGFD to VEGFR3, thereby significantly reducing the lymphangiogenesis in the context of primary lesions.149
Thoracic cancer
Non-small cell lung cancer
The presence of lymphangiogenesis promoting lymph node metastasis is a crucial determinant for unfavorable prognosis in patients with non-small cell lung cancer. Lymphangiogenesis, indicated by an elevated density of PDPN-positive peritumoral lymphatic vessels, has been demonstrated to be associated with cancer progression and unfavorable prognosis in patients with non-small cell lung cancer.150 Watari et al. found that highly metastatic human lung cancer cells have the capability to secrete IL-1, which induces the M2-type polarization of macrophages, augmenting VEGFC expression and subsequently increasing the lymphangiogenesis.151 In addition, the overexpression of ITGA6 enhanced the tube formation capacity of LECs, thereby promoting lymphangiogenesis and accelerating subsequent lymph node metastasis in the lung adenocarcinoma context.152 Moreover, estrogens in females promoted lymphangiogenesis through an estrogen receptor alpha-dependent pathway in Lewis lung cancer.153 Additionally, Hu’s team found that miR-128, functioning as a cancer suppressor, directly targeted VEGFC and subsequently inhibited extracellular signal-regulated kinase (ERK), AKT, and p38 signaling pathway activation to impede lymphangiogenesis in the non-small cell lung cancer context.154
Breast cancer
The dissemination of breast cancer cells is primarily mediated through lymphatic vessels. Increased lymphatic vessel density has been associated with lymph node metastasis and poorer survival in patients with breast cancer.155 The interaction between PDPN and LEC-derived galectin-8 contributed to the activation of promigratory integrin β1, thereby augmenting PDPN-expressing macrophages proximal to lymphatics, which subsequently stimulated local matrix remodeling and promoted lymphangiogenesis.156 Weichand et al. revealed that S1PR1 on tumor-associated macrophages promoted lymphangiogenesis and metastasis via NLRP3/IL-1β.157 In addition, Zheng et al. found that the hypomethylation of the long noncoding RNA (lncRNA) HUMT promoted lymphangiogenesis and metastasis by enhancing FOXK1 transcription to activated the AKT/mTOR and VEGFC signaling pathways in breast cancer cells.158 A recent study conducted by Li et al. revealed that the transcription factor ZKSCAN5 directly interacted with SETD7, forming a complex at the VEGFC promoter. This interaction effectively regulated the expression of VEGFC, inducing tube formation of LECs and promoting lymphangiogenesis.159 Furthermore, NADPH oxidase 4 promoted lymphangiogenesis via the ROS/ERK/CCL21 signaling pathway and providing the entry for metastasis of CCR7-expressing breast cancer cells.160 Nectin-4 induced chemotactic interactions between CXCR4-expressing cancer cells and CXCL12-expressing LECs, which stimulated VEGFC and LYVE1 expression to promote LEC proliferation and migration, ultimately promoting lymphangiogenesis.161 Additionally, heat shock protein 90α significantly enhanced the migration and tube formation abilities of LECs to promote lymphangiogenesis via the LRP1/AKT/CXCL8 signaling pathway.162 Chemotherapy remains an effective treatment for breast cancer, although its efficacy may be influenced by lymphangiogenesis. Harris and colleagues found that lymphangiogenesis induced by platinum chemotherapy increased the rate of lymph node metastasis in breast cancer, which was prevented by adjuvant anti-VEGFR3 therapy.163
Digestive system cancer
Hepatocellular cancer
Hepatocellular cancer is the most common type of liver cancer.164 High lymphatic vessel density has been associated with reduced survival and disease-free survival of patients with hepatocellular cancer.165 VEGFD-overexpressing hepatocellular carcinoma cells promote lymphangiogenesis, resulting in an increased rate of lymph node metastasis.166 Furthermore, lncRNA HANR, which regulates exosomal miR-296 secretion, may induce lymphangiogenesis via the EAG1/VEGFA axis in LECs.167 Targeting lymphangiogenesis has been proposed as a promising approach for suppressing hepatocellular cancer metastasis. An IgG-like fusion protein molecule (VEGF receptor 31-immunoglobulin, VEGFR31-Ig) binding VEGFC has been developed to inhibit lymphangiogenesis, thereby suppressing cancer growth and metastasis.168
Intrahepatic cholangiocarcinoma
Intrahepatic cholangiocarcinoma is an aggressive and lethal type of primary liver cancer.169 Lymphangiogenesis has been correlated with an increased risk of lymph node metastasis and reduced overall survival in patients with intrahepatic cholangiocarcinoma.170 Carpino et al. found that THB1, THBS2, and PEDF released into the intrahepatic cholangiocarcinoma stroma induced lymphangiogenesis, which contributed to preferential lymph node metastasis of intrahepatic cholangiocarcinoma.171 Furthermore, cholangiocarcinoma-derived PDGFD activated LEC-adjacent fibroblasts, which secreted VEGFC and VEGFA, resulting in lymphangiogenesis to promote cancer cell intravasation.172 Moreover, PDGF-BB secreted by cancer-associated fibroblasts activated the receptor PDGFR-β and downstream ERK1/2-JNK signaling pathways in LECs to promote lymphangiogenesis.173
Pancreatic cancer
The high lethality of pancreatic cancer stems from its propensity for rapid dissemination in the lymphatic system and distant organs, and lymph node metastasis may occur early in the course of pancreatic cancer development.174 Similar to its effect on other cancer types, VEGFC may mediate lymphangiogenesis in the context of pancreatic cancer. Under hypoxic conditions, BANCR is overexpressed in pancreatic cancer and promotes lymphangiogenesis by upregulating the HIF-1α/VEGFC/VEGFR3 pathway.175 In contrast, circular RNA (circRNA) circNFIB1 exerts a suppressive effect on lymphangiogenesis by downregulating the effect of miR-486-5p and upregulating PIK3R1 expression to inhibit VEGFC signaling.176 VEGFC could be secreted from cells in extracellular vesicles to facilitate lymphangiogenesis. Wang et al. reported that the downregulation of DUSP2 in pancreatic cancer enhanced extracellular vesicle-associated secretion of VEGFC. Thus, VEGFC enhances lymphangiogenesis and cancer cell invasion into lymphatic vessels through paracrine and autocrine mechanisms, ultimately leading to lymph node metastasis.177 Additionally, based on the aforementioned mechanism, Wang et al. reported a selective inhibitor B390 of HDAC1/2 that effectively suppressed lymphangiogenesis by reinstating DUSP2 expression.178 Other studies have been aimed at understanding lymphangiogenesis independent of VEGFC action. KRAS(G12D)-mutated pancreatic cancer cells maintained the secretion of extracellular vesicles carrying hnRNPA1 in a SUMOylation-dependent manner, thereby promoting lymphangiogenesis through the stabilization of PROX1 mRNA in vesicle-recipient LECs.179 Furthermore, Zhou et al. demonstrated that exosomes derived from pancreatic cancer cells exerted a stimulating effect on the proliferation and migration of LECs via the downregulating ABHD11-AS1 expression, to promote lymphangiogenesis.180 With the recent development of the “medicine-industry combination”, Shen et al. utilized three-dimensional imaging technology to observe the relationship between primary pancreatic cancer and lymphatic vessel networks, revealing peritumoral lymphangiogenesis, laying a technological and morphological foundation for future systematic detection and three-dimensional analysis of lymphatic invasion in tumor microenvironment (TME).181
Gastric cancer
Lymph node metastasis represents the predominant pattern of gastric cancer dissemination, with lymphangiogenesis emerging as a pivotal contributing factor. The evidence suggests that gastric cancer cells stimulate lymphangiogenesis through the secretion of VEGFC, a process typically facilitated by other regulatory factors, such as transforming growth factor β1 (TGFβ1) and MACC1, in the TME.182,183 Our recent study reported that CRIP1 reshaped the gastric TME to increase the lymphangiogenesis and lymphatic vessel permeability by increasing the amount of secreted VEGFC and CCL5.184 Additionally, tumor-associated lymphangiogenesis and lymph node metastasis is influenced by metabolic factors. Yang et al. demonstrated that the elevation of oxLDL levels in plasma induced the activation of the nuclear factor (NF)-κB pathway through binding with LOX-1, leading to the upregulation of VEGFC expression and subsequently facilitating lymphangiogenesis.185 The rate-limiting enzyme SOAT1 in the cholesterol metabolic pathway exerts effect by upregulating the SREBP1 and SREBP2 expression.186 Furthermore, recent studies have also reported several factors that impede lymphangiogenesis in gastric cancer. Among them, kallistatin exerts its inhibitory effects on lymphangiogenesis and lymphatic node metastasis by downregulating the expression and secretion of VEGFC through the LRP6/IKK/IκB/NF-κB pathway.187 Furthermore, some compounds, such as auramycin G and Babao Dan, exert inhibitory effects on lymphangiogenesis through the downregulation of VEGFC, and curcumin hinders lymphangiogenesis by targeting the HMGB1/VEGFD axis.188,189,190
Colorectal cancer
Colorectal cancer, a prevalent gastrointestinal malignancy, frequently progresses to lymph node metastasis. Lymphangiogenesis indicates a higher risk of local recurrence and poorer prognosis in patients with colorectal cancer.191 Metastasis-associated protein 1 has been demonstrated to induce VEGFC expression and promote lymphangiogenesis in colorectal cancer.192 Moreover, Xiang’s team found that colorectal cancer-derived exosomes promoted lymphangiogenesis in sentinel lymph nodes through IRF-2, which induced VEGFC expression in macrophages.193 CCBE1, expressed and secreted by colorectal cancer cells and cancer-associated fibroblasts, facilitated lymphangiogenesis through the promotion of VEGFC proteolysis and maturation, while its activity was negatively regulated by TGFβ signaling.194 The development of therapeutic approaches targeting lymphangiogenesis for the treatment of colorectal cancer is currently ongoing. Qingjie Fuzheng Granule and Pien Tze Huang exhibit inhibitory effects on tumor growth and lymphangiogenesis via the PI3K/AKT/VEGFC pathway.195,196 In addition, an ethanol extract of Hedyotis diffusa Willd suppresses VEGFC-stimulated LEC migration and tube formation while concurrently downregulating the expression of downstream molecules involved in the VEGFC/VEGFR3 signaling pathway, such as MMP2, MMP9, cyclin D1, and CDK4.197
Genitourinary cancer
Bladder cancer
Bladder cancer is a highly prevalent malignancy in the genitourinary system.164 Higher lymph vessel density has been correlated with decreased metastasis-free survival of patients with bladder cancer.198 Changhao Chen and colleagues found that the lncRNA LINC01296, termed LNMAT1, epigenetically induced CCL2 expression in bladder cancer cells, recruiting macrophages to the TME, which induced lymphangiogenesis via VEGFC secretion.199 Afterward, the team identified another lncRNA known as LNMAT2 in exosomes secreted by bladder cancer cells that stimulated LEC tube formation and migration via epigenetically acting on the PROX1 promoter to upregulate the expression.200 Subsequently, Chen et al. discovered that EV-mediated ELNAT1 also promoted lymphangiogenesis via the transcriptional upregulation of SOX18 expression in human LECs via SUMOylation motification.201 In addition, overexpression of the lncRNA BLACAT2 stimulated lymphangiogenesis by binding WDR5, the core subunit of human H3K4 methyltransferase complexes, to increase the expression of VEGFC.202 The novel circRNA circEHBP1 mediated TGFβR1 overexpression and activated the TGFβ/SMAD3 signaling pathway in bladder cancer cells, thereby promoting the secretion of VEGFD to drive lymphangiogenesis.203 The inhibition of lymphangiogenesis is a promising therapeutic strategy for impeding lymph node metastasis in patients with bladder cancer. Blocking the VEGFC/D signaling pathways by administering soluble VEGFR3 encoded by adenovirus or using clodronate liposomes for depletion of tumor-associated macrophages may markedly inhibit lymphangiogenesis in patients with bladder cancer.204
Prostate cancer
The incidence of prostate cancer is highest among all the malignancies affecting the male reproductive system. Previous studies have demonstrated that elevated lymphatic vessel density in conjunction with increased VEGFC expression was indicative of metastasis and unfavorable prognosis in patients diagnosed with prostate cancer.205 Lysophosphatidic acid increased the expression of VEGFC and promoted lymphangiogenesis by upregulating calreticulin in prostate cancer cells.206 Relevant studies are currently ongoing to investigate the potential of targeted lymphangiogenesis therapy in managing lymph node metastasis and distant metastasis of prostate cancer. The administration of a VEGFC ligand trap (soluble VEGFR3) or anti-VEGFR3 antibody (mF4-31C1) resulted in a significant reduction in the lymphangiogenesis, as well as metastasis to regional lymph nodes and distant organs.207 Yano et al. revealed that glucocorticoids suppressed lymphangiogenesis by downregulating the expression of VEGFC.208
Ovarian cancer
Ovarian cancer is one of the most aggressive gynecological cancers and is associated with poor prognosis. High lymphatic vessel density has been found to be significantly associated with lymph node metastasis and recurrence in patients with ovarian cancer.209 Sapoznik et al. found that follicle-stimulating hormone enhanced the interaction between LEDGF and the VEGFC promoter, thereby increasing VEGFC expression and promoting lymphangiogenesis.210 Additionally, the overexpression of Her-2/NEU increased the endothelial permeability and facilitated lymph node metastasis by upregulating the expression of VEGFC.211 Cheng and his colleagues found that hypoxia-induced secretion of HIF-1α facilitated lymphangiogenesis and expedited metastasis through the ALKBH5/m6A-ITGB1/FAK signaling pathway.212 Other factors modulate lymphangiogenesis to influence the rate of lymph node metastasis in ovarian cancer. For example, SPARC, a Ca2+-binding matricellular glycoprotein, has been demonstrated to inhibit lymphangiogenesis by downregulating VEGFC and VEGFD expression.213
Cervical cancer
Patients with cervical cancer and lymph node metastasis face a dismal prognosis, and lymphangiogenesis promotes the dissemination of cervical cancer cells to regional lymph nodes. Chen et al. found that TNFα promoted lymphangiogenesis by VEGFC-mediated activation of the AKT and ERK pathways, which was suppressed by MAZ51, a VEGFR3 inhibitor.214 PTPRM, which has been identified as an independent prognostic factor of patients with cervical cancer, can induce VEGFC-dependent lymphangiogenesis.215 Upregulated expression of FASN and FABP5, which both play important roles in lipid metabolism, has been positively correlated with the lymph node metastasis of cervical cancer.216,217 As a pivotal enzyme in lipid metabolism, FASN stimulated the secretion of PDGF-AA and IGFBP3 by cervical cancer cells, thereby facilitating lymphangiogenesis and promoting metastasis.216 Furthermore, the upregulation of FABP5 reprogrammed fatty acid metabolism, leading to an increase in intracellular fatty acids that activated the NF-κB pathway, resulting in lymphangiogenesis in cervical cancer.217 Additionally, exosomal miR-221-3p secreted by cervical cancer cells was transferred to LECs, thereby activating the ERK and AKT pathways through downregulation of VASH1 and promoting lymphangiogenesis.218 A recent study reported that circVPRBP interacted with RACK1 and shielded the S122 O-GlcNAcylation site, thereby inducing RACK1 degradation, which subsequently suppressed galectin 1-mediated lymphangiogenesis and lymph node metastasis in cervical cancer.219
Papillary thyroid cancer
Lymphangiogenesis has been demonstrated to facilitate lymph node metastasis in papillary thyroid cancer. Choi et al. found that increased lymphatic vessel density, as assessed by high PDPN and VEGFR3 expression, was significantly associated with the incidence of lymph node metastasis in the papillary thyroid cancer context.220 Additionally, recurrent papillary thyroid cancer exhibited higher peritumoral lymphatic vessel density than nonrecurrent thyroid cancer.221 Moreover, lncRNA MFSD4A-AS1 functioned as a competing endogenous RNA to disrupt miRNA-mediated VEGFA/C repression and activated TGFβ signaling, thereby promoting lymphangiogenesis.222
Melanoma
Melanoma is an extremely malignant cutaneous cancer with a high propensity for metastasis, predominantly through lymph node metastasis. The prognostic significance of lymphatic vessel density in melanoma has been documented, with higher densities associated with a poorer prognosis.223 Melanoma-derived melanosomes facilitate the transfer of let-7i to LECs, thereby triggering type I IFN signaling and promoting lymphangiogenesis.224 Moreover, melanoma cells secrete extracellular vesicles enriched with NGFR, which promotes lymphangiogenesis and facilitate cancer cell adhesion through the induction of ERK kinase activity, activation of NF-κB, and upregulation of ICAM-1 expression in LECs.225 The high expression of CD147 within melanoma cells has been reported to stimulate lymphangiogenesis through the upregulation of PROX1 expression.226 Additionally, both Adrenomedullin and Apelin have been demonstrated to enhance lymphangiogenesis in melanoma.227,228 In the context of melanoma, claudin-3 exerted an inhibitory effect on lymphangiogenesis through the downregulation of VEGFC and PI3K signaling pathways.229 Additionally, various inhibitors targeting lymphangiogenesis have been documented, including rapamycin and a novel 2-aminobenzimidazole derivative called MFB, which effectively suppressed lymphangiogenesis by downregulating VEGFs.230,231 Interestingly, Sasso et al. demonstrated that the induction of lymphangiogenesis through VEGFC increased the efficacy of immunotherapy, thereby presenting a novel therapeutic strategy for cancer treatment targeting lymphangiogenesis.232
Alzheimer’s disease
Alzheimer’s disease is the most common form of dementia, in which impaired amyloid-β clearance from the brain is the core etiology.233 Meningeal lymphatics are involved in the clearance of molecules, including amyloid-β (as explained in “Lymph absorption and transport in meningeal lymphatic vessels”), and their dysfunction is an aggravating factor in Alzheimer’s disease pathology.234 Modulation of lymphatic vessel function might be a novel therapeutic strategy for Alzheimer’s disease. Recent studies have shown that VEGFC treatment promoted meningeal lymphangiogenesis in transgenic mice, which decreased the level of soluble amyloid-β in cerebrospinal fluid.234,235 Moreover, the therapeutic delivery of VEGFC enhanced meningeal lymphatic function to increase the clearance rate of amyloid-β by monoclonal antibodies.236
Ocular hypertension and glaucoma
Glaucoma is the foremost cause of irreversible blindness, with elevated intraocular pressure being the most crucial risk factor. Ocular lymphatic vessels and Schlemm’s canal play pivotal roles in regulating intraocular pressure under the physiological condition (as outlined in “Lymph absorption and transport in ocular lymphatic vessels”). VEGFC/VEGFR3 plays a crucial role in the development and maintenance of Schlemm’s canal. The application of recombinant VEGFC resulted in the promotion of Schlemm’s canal growth in mice and led to a tendency toward decreased intraocular pressure.237 Kim et al. found that Schlemm’s canal integrity was maintained via the interconnected and coordinated functions of ANG/TIE2 signaling, aqueous humor outflow and PROX1 activity. Deletion of ANG1/ANG2 or TIE2 severely impaired the integrity of Schlemm’s canal, resulting in elevated intraocular pressure, retinal neuron damage, and impaired retinal ganglion cell function, all hallmarks of primary open-angle glaucoma.238 Recently, SVEP1 was identified as a modifier of TEK expression during Schlemm’s canal development and affected the penetrance and severity of primary congenital glaucoma disease.239 However, the underlying mechanism through which ocular lymphatic dysfunction contributes to the pathogenesis of glaucoma remains unclear, and further investigations are needed to gain a comprehensive understanding.
Obesity and lipedema
Obesity is characterized by excessive adipose tissue accumulation resulting from an imbalance between energy intake and expenditure.240 Adipose tissue is no longer considered solely an energy storage depot but has been recognized as an active endocrine organ that secretes numerous adipokines and proinflammatory cytokines.241 Obesity is widely acknowledged to be a significant clinical risk factor for the development of lymphedema. Obesity-induced chronic inflammation, fibrosis, and increased adipose tissue deposition detrimentally impact lymphatic vessel function, thereby exacerbating the inflammatory response and precipitating the development of lymphedema.242 A decrease in lymphatic vessel density has also been observed in murine models of obesity.243 Therefore, maintaining a normal number and function of lymphatic vessels may potentially ameliorate the metabolic disruption in obese patients. The study conducted by Chakraborty et al. substantiated this possibility, demonstrating that an increased VEGFD-induced lymphangiogenesis in adipose tissue mitigated the obesity-related immune accumulation and increased the metabolism.244 Subsequently, they observed that VEGFD-induced lymphangiogenesis in adipose tissue resulted in a decrease in the macrophage populations and accelerated systemic fatty acid utilization, thereby facilitating the remodeling of the inflammatory response.245
Lipedema, often misidentified as lymphedema or obesity, is a chronic progressive disease characterized by disproportional adipose tissue distribution and limb pain, predominantly in women. Patients with lipedema present with features of lymphedema, particularly in advanced stages, which may arise from the synergistic effects of lymphatic abnormalities and lipid accumulation. Amann et al. employed fluorescence microlymphography and thus identified beadlike dilated lymphatic vessels in individuals with lipedema.246 In addition, Lohrmann et al. revealed functional and morphological aberrations in the lymphatic vessels of lower extremities in lipedema patients.247 In terms of lymphatic abnormalities as potential etiologies for lipedema, the leakage of lymph fluid has been shown to promote adipocyte proliferation significantly.248 However, imbalanced and prolonged adipose tissue expansion may contribute to abnormal contraction of collecting lymphatic vessels, as observed by Blum et al. in mice chronically fed a high-fat diet.249 Expanded adipocytes secreted certain lymphangiogenic factors, such as VEGFC, VEGFD and ANG2.250 In light of these findings, further investigations are warranted to elucidate the intricate association between lipedema and lymphatic vessel impairment.
Diabetes mellitus
Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia and abnormal carbohydrate, fat, and protein metabolism.251 Impaired lymphangiogenesis is a complication of diabetes mellitus. Wenstedt et al. observed that salt-sensitive increases in blood pressure in individuals with Type 1 diabetes may be linked to the absence of macrophages and thus reduced lymphangiogenesis.252 Wu et al. demonstrated that diabetes-induced ROS-activated c-Src-dependent phosphorylation of VEGFR3 and upregulation of epsin expression, causing VEGFR3 degradation via the interaction between epsin and VEGFR3, ultimately leading to impaired lymphangiogenesis.253 In patients with Type 2 diabetes, increased lymphatic permeability has been demonstrated to lead to lymphatic vessel dysfunction. Scallan et al. initially identified increased permeability in the collecting lymphatic vessels in individuals with Type 2 diabetes, leading to lymphatic leakage. This outcome was attributed to the diminished bioavailability of NO, which was rectified by inhibiting the action of the NO-degrading enzyme phosphodiesterase 3.254 Similarly, Cifarelli et al. observed that the downregulation of VEGFC/VEGFR2/AKT after CD36 silencing resulted in VE cadherin degradation and subsequently increased lymphatic vessel permeability in individuals diagnosed with Type 2 diabetes.255 The prolonged hyperglycemia associated with diabetes can cause oxidative stress, advanced glycation end-product formation, and inflammation, which can lead to significant damage to various organs, such as the kidneys and eyes.256 Recent studies have demonstrated the involvement of lymphatic vessels in the pathogenesis of these complications.
Diabetic kidney disease
Hyperglycemia and other metabolic abnormalities in diabetes can lead to ultrastructural and functional changes in the glomeruli and tubules, eventually causing diabetic kidney disease.257 A study by Kim et al. showed that inhibiting lymphangiogenesis alleviated lipid overload induced by diabetic kidney disease and relieved symptoms.258 Mechanistically, this outcome was caused by lymphangiogenesis in diabetic kidney disease, which promoted tubulointerstitial fibrosis in the kidneys.259 Subsequently, Hwang et al. demonstrated that the mitigation of kidney damage in diabetic kidney disease was achievable through targeted inhibition of lymphangiogenesis using a specific VEGFR3 inhibitor.260 Collectively, these studies indicated that targeting lymphangiogenesis-related factors may be a viable therapeutic strategy for diabetic kidney disease.
Diabetic retinopathy
Diabetic retinopathy is a common ocular complication of diabetes that can eventually lead to vision loss.261 Aberrant lymphangiogenesis has been observed to be involved in the pathogenesis of diabetic retinopathy.262,263 Gucciardo et al. observed that the microenvironment of diabetic retinopathy can promote pathological lymphangiogenesis.264 Korhonen et al. identified significant enrichment of genes and signaling pathways associated with lymphatic vessel development in tissues obtained from patients diagnosed with diabetic retinopathy through mRNA sequencing and Gene Ontology and pathway enrichment analyses.265 However, the mechanisms underlying pathological lymphangiogenesis contributions to the pathogenesis of diabetic retinopathy are currently unknown, and further investigation is required.
Diabetic wound healing
Lymphatic dysfunction in diabetes mellitus may lead to the impaired transport of immune cells, growth factors, and other molecules involved in tissue regeneration, resulting in delayed wound healing.266 Several studies have shown that the activation of lymphangiogenesis facilitates diabetic wound healing.267,268 Topical simvastatin or negative-pressure wound therapy are potential therapeutic approaches to promote wound healing in people with diabetes mellitus, and the mechanisms underlying these therapies both involve the promotion of lymphangiogenesis.269,270,271 In addition, some lncRNAs have also been shown to promote diabetic wound healing by promoting lymphangiogenesis.272,273 Considering these findings, researchers engineered a new tissue material to induce lymphangiogenesis, paving the way for the development of novel strategies to facilitate diabetic wound healing.274
Wound healing
Wound healing is a complex and dynamic process that involves a series of overlapping stages to restore tissue integrity and function. It encompasses revascularization, inflammation, innervation, and remodeling.275 Activation of lymphangiogenesis pathways is considered an effective strategy to facilitate healing of chronic wounds and alleviate tissue inflammation, which is mainly induced by VEGFC/VEGFR3 signaling.276 During the wound healing process, platelets promote the release of VEGFC, thereby facilitating lymphangiogenesis. Immune cells, proteins, and fluids are transported out of the wound area through newly formed lymphatic vessels.277 Stabilized expression of HIF-1α in a wound also promotes the expression of VEGFC, thereby regulating lymphangiogenesis.278 Hosono et al. found increased expression of COX-2 and mPGES-1 at wound sites and showed that these proteins promoted the expression of VEGFC and induced lymphangiogenesis.279 Notably, impaired or insufficient lymphangiogenesis may result in hindered or incomplete wound healing.280
In addition, lymphatic vessels form a specific niche for the regeneration of diverse tissues. Dermal capillary lymphatic vessels regulate the regeneration of hair follicles by dynamically interacting with stem cells. Mechanically, activated hair follicle stem cells express ANG-like protein 4 to promote capillary lymphatic vessel remodeling and reduce lymph drainage to initiate hair follicle regeneration.281,282 Skeletal lymphatic vessels mediate the regeneration of bone and hematopoietic stem cells under genotoxic stress conditions. Biswas et al. recently found that skeletal lymphangiogenesis specifically recruited and enhanced the proliferation of mature Myh11+CXCR4+ pericytes via secreting CXCL12, inducing their differentiation into osteoblasts and contributing to bone regeneration.283 Moreover, they found through experiments that inhibition of skeletal lymphangiogenesis reduced the proportion of hematopoietic stem cells, indicating a particularly potent regenerative function of lymphatic vessels.283 Additionally, lymphatic vessels have been shown to be indispensable for heart regeneration after myocardial infarction. Gancz et al. found that the lack of cardiac lymphatic vessels impaired heart regeneration by preventing VEGFC/VEGFR3 signaling in zebrafish.284 Epicardium-derived Adrenomedullin signaling in mice stimulated regenerative cardiac lymphangiogenesis via lateralization of CX43, which is a potential therapeutic target for cardiac regeneration.285
Transplant rejection
Types of transplant rejection include host-versus-graft disease (HVGD) and graft-versus-host disease (GVHD). HVGD is an immune-mediated response wherein the recipient’s immune system discerns the transplanted organ as an exogenous entity and subsequently initiates an immunological assault against it.286 Lymphatic vessels play crucial roles as conduits for antigen-presenting cells and soluble antigens, thereby facilitating their transport. Surgical intervention resulting in disrupted lymphatic vessel integrity can lead to impaired lymphatic drainage, consequently impacting both acute and chronic rejection responses after transplantation. Moreover, lymphangiogenesis exhibits heterogeneity in transplant rejection among organs.287 During ischemia-reperfusion injury in rat heart allografts, activation of the VEGFC/VEGFR3 axis induced lymphangiogenesis and subsequently exacerbated allograft inflammation.288 After the transplantation of minor antigen sex-mismatched murine heart grafts, an increase in the lymphatic flow index was associated with higher lymphatic vessel density and inflammatory infiltration of T cells and macrophages.289 VEGFR3 is involved in the trafficking of immune cells from peripheral tissues to secondary lymphoid organs by regulating the production of CCL21 in allogeneic lymphatic vessels. Adenovirus VEGFR3-Ig inhibited lymphangiogenesis and attenuated cardiac allograft rejection by reducing the number of transported and activated antigen-presenting cells.290 Additionally, Kerjaschki et al. demonstrated that lymphangiogenesis contributed to nodular mononuclear infiltration while also played a role in sustaining a potentially detrimental alloreactive immune response in hosts after renal transplant.291 Mechanistically, the nodular infiltrates contained a significant number of CCR7-positive immune cells, which appeared to be attracted by SLC/CCL21 produced and released by LECs.291 However, it has been suggested that lymphangiogenesis plays a pivotal role in enhancing the survival of allografts. Hyaluronic acid has been identified to induce inflammation and contribute to the development of chronic allograft rejection.292 Cui et al. found that stimulation of lymphangiogenesis using VEGF-C156S, a mutant form of VEGFC selectively binding to VEGFR3, resulted in the attenuation of an established rejection response and increased the clearance of hyaluronic acid from lung allografts.293 Pedersen et al. found that lymphangiogenesis in a mouse model of renal transplant rejection extended the lifespan of the recipients, which may have been related to immune tolerance promoted by lymphangiogenesis.294
GVHD is an immune response of immunocompetent cells in the graft against histocompatibility antigens in the host, resulting in damage to the host. Acute GVHD is triggered by alloreactive T cells that damage peripheral tissues and lymphoid organs.295 Gehlsen et al. found that lymphangiogenesis is involved in the pathogenesis of ocular GVHD.296 In addition, Mertlitz et al. found that acute GVHD was associated with lymphangiogenesis in murine allo-HSCT models and in intestinal tissue biopsy samples taken from patients, while the administration of anti-VEGFR3 antibodies suppressing lymphangiogenesis ameliorated GVHD and prolonged the survival in murine models.297
Therapeutic interventions and clinical research progress of lymphangiogenesis
Many past and present efforts have been made to study and reveal the interventions of lymphangiogenesis under physiological and pathological conditions. In the following section, we summarize the known promoters and inhibitors of lymphangiogenesis, list therapeutic interventions, and describe the progress in their clinical applications.
Interventions of lymphangiogenesis
VEGFs
Agonistic effects of VEGFs
Among VEGF family members, VEGFC and VEGFD are the best-characterized and specific growth factors for lymphatic vessels. Generally, VEGFC and VEGFD function as ligands that bind receptors on the LEC membrane and then activate downstream signaling cascades to promote lymphangiogenesis. VEGFC and VEGFD both bind to the receptor VEGFR3, which is commonly expressed by LECs.298,299 After binding of VEGFC or VEGFD, VEGFR3 dimerizes and is phosphorylated, leading to the activation of its cytoplasmic tail tyrosine kinase activity. The phosphorylation of VEGFR3 leads to the recruitment of some important proteins, such as GRB2, CRK, and SHC, which mediate the activation of downstream signaling pathways, including the conserved PI3K/AKT, MAPK/ERK, and MAPK/JNK pathways, etc.300,301 Activation of these molecular signaling cascades promotes the initiation of a series of cellular biological behaviors, such as LEC proliferation and migration and vessel sprouting (Fig. 13). VEGFA has been identified as the angiogenic factor acting via VEGFR1 and VEGFR2. Some recent work revealed that VEGFA promotes LEC proliferation and migration and lympangiogenesis.302,303,304,305 On one hand, VEGFA could function on VEGFR1/2 expressed by LECs and promote lymphanigongenesis.304,305 On the other hand, VEGFA could indirectly induce lymphangiogenesis via recruitment of VEGFR1+ bone marrow-derived macrophages which in turn release both hemangiogenic and lymphangiogenic growth factors.302,303
Targeted inhibitors of VEGF signaling
Antibody drugs: Bevacizumab is a well-characterized monoclonal antibody of VEGFs and is used as an anti-angiogenic drug for various types of cancer. Moreover, some clinical trials have been carried out to evaluate its anti-lymphangiogenic effects.306 Dumond et al. reported a new VEGFC antibody named 1E9 that significantly inhibited VEGFR3 signaling activation in LECs.307 Similarly, VGX-100, another highly specific monoclonal antibody, targeted VEGFC and impaired VEGFC-VEGFR2/3 signaling activation.308 A soluble fusion protein VEGFR3-immunoglobulin that bound VEGFC and inhibited VEGFR3 signaling has also been reported, and their effects in inhibiting tumor lymphangiogenesis and metastasis were remarkable.309 To target VEGFRs, blocking VEGFR3 signaling with VEGFR3 antagonist antibodies effectively inhibited angiogenesis, lymphangiogenesis, and tumor growth in an orthotopic spontaneous breast cancer metastasis model.310
Small-molecule inhibitors: The FDA has approved several small-molecule inhibitors of VEGFRs because they significantly prolong the survival of cancer patients. For instance, pazopanib is an orally available small-molecule inhibitor of VEGFRs, including VEGFR1, VEGFR2, and VEGFR3. Pazopanib showed favorable inhibitory effects on tumor growth, lymph node metastasis, and tumor lymphangiogenesis in an orthotopic colorectal cancer model.311 Sunitinib is a small-molecule inhibitor that targets VEGFRs, PDGFRs, and c-Kit.312 Sunitinib treatment markedly reduced pathological corneal lymphangiogenesis and angiogenesis.313 However, Dufies et al. reported that sunitinib treatment also induced lymphangiogenesis in the renal cell carcinoma context by activating VEGFC transcription and stabilizing VEGFC mRNA.314
Other inhibitors: Previous studies revealed that inhibition of VEGFC with specific siRNAs reduced the lymphangiogenesis in a murine mammary tumor model.315,316 Additionally, treatment with VEGFC siRNA effectively reduced lymphangiogenesis and significantly increased the survival rate of tumor-bearing mice. Fucoxanthin, a multifunctional natural non-pro-vitamin A carotenoid, has been shown to decrease tumor-associated lymphangiogenesis, indicating a potential anti-lymphangiogenic agent for use in cancer therapy.317 Shikonin, another natural compound isolated from the traditional Chinese medicinal herb Lithospermum erythrorhizon, inhibited lymphangiogenesis in a dose- and time-dependent manner.318 Curcumin, a natural dietary compound derived from turmeric, also inhibited lymphangiogenesis in vitro and in vivo by inhibiting the expression of VEGF receptors (Table 4).319
ANG
Agonistic effects of ANG
ANG and its receptors were first found to be important modulators in blood vessel growth, maturation, and stability. The two ANG receptors, called TIE1 and TIE2, were also reported to be expressed in LECs. After interaction with TIE on LECs, ANG induced the formation of TIE receptor complexes and then mediated cell behavior via activation of the PI3K/AKT pathway. AKT subsequently phosphorylated FOXO1, causing its nuclear exclusion and reducing the expression of FOXO1 downstream genes.320 Some findings revealed that ANG1 promoted lymphangiogenesis dependent on VEGFR3, indicating a difference in effects between ANG proteins.321 Interestingly, a recent study revealed that VEGFC induced ANG2 secretion from LECs and then stabilized VEGFR3 expression via the activation of ANG2/TIE/PI3K signaling, revealing cross-talk between the VEGFC and ANG2 signaling pathways.322 Additionally, ANG2 also functioned independent of its binding to TIE receptors. In this scenario, ANG2 bound β1 integrin and activated Src and FAK, leading to RhoA activation. The activation of RhoA led to the phosphorylation of the downstream effectors ROCK and formins, thereby regulating lymphangiogenesis.323
Targeted inhibitors of ANG signaling
Antibody drugs: Considering the effects of ANG2 on angiogenesis and lymphangiogenesis, several neutralizing antibodies for this signaling pathway have been designed and synthesized. These antibodies include trebananib, CVX-060, AMG 780, MEDI3617, Nesvacumab, Aflibercept, CVX-241, AZD5180, and 18E5. Among these neutralizing antibodies, MEDI3617, AZD5180, and 18E5 have been reported to show significant inhibitory effects on lymphangiogenesis.324,325
Small-molecule inhibitors: Regorafenib is a novel oral multikinase inhibitor that can inhibit various kinases, including VEGFRs, TIE, PDGFRs, c-Kit, BRAF, etc.326 In orthotopic colon tumor models, regorafenib treatment significantly decreased the density of lymphatic vessels in tumors.327
Other inhibitors: A previous study showed that siRNA-mediated ANG2 knockdown markedly inhibited corneal lymphangiogenesis.76 Recently, some multifunctional siRNA nanocapsules have been developed to deliver siRNA for targeting ANG in glioblastoma,328,329 which may provide a new direction for delivering siRNA for the treatment of abnormal lymphangiogenesis (Table 4).
Epidermal growth factor (EGF)
Agonistic effects of EGF
EGF belongs to a group of growth factors that specifically bind EGFR and activate EGFR signaling,330 which has been reported to participate in regulating skin lymphangiogenesis. EGF notably facilitated pathological lymphangiogenesis in melanoma, thus supporting the lymph node metastasis of melanoma.331 In summary, the effects of EGF on lymphangiogenesis have been relatively less studied than the effects of other factors and remain to be further investigated in the future.
Targeted inhibitors of EGF signaling
Antibody drugs: Some preclinical evidence has shown that monoclonal antibodies targeting EGF signaling could attenuate angiogenesis during cancer progression.332,333 However, evidence showing the inhibitory role of these monoclonal antibodies on lymphangiogenesis is lacking and further exploration is needed.
Small-molecule inhibitors: Afatinib, erlotinib, gefitinib, lapatinib, and vandetanib are representative small-molecule inhibitors of EGFR that prevent signal transduction after ligand-receptor binding and EGFR dimer formation. Among these drugs, lapatinib has been reported to attenuate tumor lymphangiogenesis and angiogenesis (Table 4).334
FGF2
FGF2 has been reported to exert a profound effect on lymphangiogenesis. In the mouse cornea, FGF2 promoted lymphangiogenesis in a dose-dependent manner and enhanced the secretion of VEGFC from vascular endothelial and perivascular cells to facilitate lymphangiogenesis.335 Additionally, FGF2 functions by binding the cell membrane LYVE1 with high affinity, which subsequently induces lymphangiogenesis.336
Hepatocyte growth factor (HGF)
HGF is a heparin-binding glycoprotein that was first shown to mediate liver regeneration. HGF functions by interacting with HGFR (also known as c-Met) to regulate lymphangiogenesis. Supplementation of HGF into the LEC culture medium promoted lymphangiogenesis, while inhibition of HGFR with an antagonist reduced the lymphangiogenesis.337
PDGF
PDGFs are secreted dimeric glycoprotein ligands with biological activities mediated by three forms of tyrosine kinase receptors encoded by two gene products, PDGFR-α and PDGFR-β.338,339 PDGF-BB functions as a lymphangiogenic factor and directly binds PDGFR-β expressed on LECs to induce lymph vessel growth.340
The insulin growth factor (IGF)
IGF signaling pathway is composed mainly of IGFs (IGF1 and IGF2), IGFRs (IGFR1, and IGFR2), and IGF-binding proteins (IGFBPs).341,342 IGFs bind IGFRs to initiate their effects, while IGFBPs interact with IGFs to modulate IGF stability and activity. IGFRs are expressed by LECs in both humans and mice. In vivo, administration of IGFs stimulated lymph vessel network expansion, while in vitro treatment with IGFs increased the lymphangiogenesis via activation of downstream ERK and PI3K/AKT signaling.343 In the future, the development of IGFs, IGFRs or IGFBPs antagonists may be an important approach for treating abnormal lymphangiogenesis.
WNT
Among the WNT family members, WNT5A and WNT5B have been reported to exert a positive effect on lymphangiogenesis.344,345 WNT5A regulates dermal lymphangiogenesis mainly through the noncanonical β-catenin-independent signaling pathway.346 Cancer cell-derived WNT5B modulated lymphangiogenesis and lymphatic permeability through the activation of both canonical and noncanonical WNT signaling pathways.344
EphrinB2
EphrinB2, a transmembrane ligand of the Eph receptor EphB4, controls cell migration and cytoskeletal organization in many different cell types and tissues.347,348 Evidence has shown that EphrinB2 and EphB4 are simultaneously expressed by endothelial cells and promote sprouting behavior to induce angiogenesis and lymphangiogenesis.349,350 Mechanistically, the binding of EphrinB2 to EphB4 promoted the activation of the small GTPases Rac1, AKT, and ERK and promoted VEGFC/VEGFR3 downstream signaling. In capillary lymphatic vessels of adult mouse corneas, the EphrinB2/EphB4 axis functioned in the formation and maintenance of funnel-shaped valves, indicating that this axis might be an ideal target for regulating corneal lymphangiogenesis.351
Adrenomedullin
Adrenomedullin, a well-known vasodilator, is also an important regulator of lymphangiogenesis. Adrenomedullin functions by binding its specific receptor, CALCRL. Ablation of Adrenomedullin/CALCRL signaling impedes the activation of ERK signaling, leading to the formation of abnormal jugular lymphatic vessels.63 Blockade of Adrenomedullin/CALCRL signaling after normal lymphatic vessel formation resulted in impaired permeability and function in intestinal, corneal, and dermal lymphatic vessels.352 In several types of cancers, Adrenomedullin significantly increased tumor-associated lymphangiogenesis.353,354
Bioactive lipids
Bioactive lipids are important regulators in the body; they include 1) arachidonic acid (AA) and its metabolites, such as prostaglandins (PGs), thromboxane (TXA), and leukotrienes (LTs); 2) S1P, a metabolic product of sphingolipids; and 3) lysophosphatidic acid (LPA). These bioactive lipids have been shown to regulate lymphangiogenesis under certain pathological conditions. We summarize the function of these common bioactive lipids in lymphangiogenesis (Fig. 14).
PGs
PGs are common metabolites of AA generate through the action of phospholipase A2, cyclooxygenases (COXs), and the respective prostanoid synthases. PGs function by binding their specific receptors, which are often transmembrane G protein-coupled receptors.355,356 In an LPS-induced model of inflammation, COX2-derived PGs enhanced lymphangiogenesis.357 Similarly, in acute colitis induced by DSS, PGE2/PGE receptor (EP) 4 signaling stimulates lymphangiogenesis to repair damaged mucosa. PGE2-EP4 activation on tumor cells and TAMs increased the amount of VEGFC and VEGFD secreted from these cells and then stimulated LEC lymphangiogenesis.358 Tumor-derived PGE2 also directly acted on LECs to activate EP4 and VEGFR3 and ultimately induced lymphangiogenesis.359
TXA2
TXA2 is an unstable metabolite of AA produced by the reciprocal action of COX and TX synthase.360,361 TXA2 plays a regulatory role by binding thromboxane prostanoid (TP), a transmembrane G protein-coupled receptor. TXA2-TP signaling facilitates lymphangiogenesis by acting on macrophages and T cells during inflammation. TP-positive macrophages and T cells infiltrate inflamed tissue and produce VEGFC and VEGFD after stimulation with TXA2. These macrophage- and T-cell-derived VEGFC/D promoted lymphangiogenesis and drainage function in mice with inflammatory stress.362
LTs
LTs constitute a class of bioactive lipids derived from AA by 5-lipoxygenase (LOX5) and LOX5-activating protein.363,364 LTs also function by binding G protein-coupled receptors. Two G protein-coupled receptors, BLT1 and BLT2, are receptors for LTB4 and are expressed in macrophages, leukocytes, epidermal keratinocytes, and epithelial cells. Evidence from a lymphedema model showed that macrophages are important sources of LTB4 and that inhibition of LTB4 signaling effectively prevents edema.365,366
S1P
S1P is the phosphorylated form of sphingosine that is formed through the action of sphingosine kinase 1 (SphK1) and SphK2. S1P not only functions intracellularly as a second messenger, but also can be exported extracellularly to serve as a ligand for a family of S1P receptors.367 S1P promotes lymphangiogenesis both in vitro and in vivo through the S1P/Gi/phospholipase C/Ca2+ signaling pathways.368 In breast cancer, SphK1-mediated S1P production induced lymphangiogenesis, indicating that SphK1-S1P signaling may be a potential therapeutic target for controlling lymphangiogenesis.369
LPA
LPA is a low-molecular-weight lipid growth factor that functions by binding to Edg family members.370 LPA is generated through enzymatic cleavage of membrane phosphatidic acid. A series of studies have revealed that LPA promoted lymphangiogenesis by increasing the expression of the important prolymphangiogenic factor VEGFC in targeted cells such as tumor cells and endothelial cells.371,372
NcRNA
NcRNA transcripts constitute a recently described type of RNA that has been extensively explored in recent decades. Some ncRNAs have been reported to play a clear role in lymphangiogenesis, especially in tumor-associated lymphangiogenesis (Fig. 14).
LncRNAs
LncRNAs are RNA transcripts longer than 200 bases with low protein-coding potential.373 Some lncRNAs play a prolymphangiogenic role intracellularly to enhance the expression of VEGFC, thereby promoting lymphangiogenesis.374,375 Cancer cells also deliver lncRNA-containing exosomes to LECs. The lncRNA cargo internalized by LECs induced lymphangiogenesis both in vitro and in vivo.376 These pieces of evidence implicate lncRNAs as important therapeutic targets for controlling abnormal lymphangiogenesis in patients with cancer (Fig. 14).
CircRNAs
CircRNAs represent a type of novel ncRNA with a covalently circular structure generated from the splicing of pre-mRNAs and interlacing of the 5′ caps and 3′ poly-A tails and are specific messenger RNAs.377,378 The role of circRNAs in lymphangiogenesis was investigated recently. For instance, circEHBP1 served as a miRNA sponge for miR-130a-3p to regulate the TGFβR1/VEGFD axis, leading to increased levels of VEGFD and lymph vessel density in the context of bladder cancer.203 Additionally, some circRNAs are transported from cancer cells to LECs via exosomes. In this manner, cancer cell-derived circRNAs can directly function as intra-LECs to contribute to lymphangiogenesis.379
Clinical trials of treatments for lymphangiogenesis-related diseases
We conducted an electronic search for relevant clinical trials of lymphangiogenesis-related diseases in PubMed. Additionally, relevant clinical trial registration sites, such as ClinicalTrials.gov and Netherlands Trial Registry, were comprehensively examined. Literature retrieval was performed in duplicate by two independent reviewers. A total of ten published clinical trials were included in the analysis, and among these, seven studies mainly examined the effects of different interventions on lymphangiogenesis-related diseases in human samples, one study focused on evaluating stem cell therapy in lymphedema,380 one study focused on circulating angiogenic factors in pulmonary tuberculosis in which angiogenesis and lymphangiogenesis were classical features,381 and one study mainly examined whether PDPN expression correlated with sentinel lymph node metastasis in early squamous cell carcinomas of the oral cavity and oropharynx.382 The characteristics of these studies are listed in Supplementary Table 1.
The ten selected clinical trials had enrolled participants with eight different diseases and conditions. More than three studies enrolled participants with breast cancer, including HER2-negative breast cancer and lymph node-positive breast cancer.383,384,385 A few studies recruited participants with other diseases, including lung adenocarcinoma,386 early squamous cell carcinomas of the oral cavity and oropharynx, Type 1 diabetes,252 tongue cancer,387 lower limb lymphedema, lymphangioleiomyomatosis (LAM)388 and pulmonary tuberculosis. The study with the largest number of participants enrolled patients with centrally located squamous cell carcinoma with cavitary features, and those with brain metastases that were uncontrolled or controlled for less than 2 months were excluded (n = 440). The patients were randomly assigned in a 2-to-1 ratio to receive either 12 mg/day of anlotinib (n = 294) or a matched placebo (n = 146).
With regard to the intervention/comparison in the studies, over half of the studies (n = 5) focused on drug (anlotinib treatment for lung adenocarcinoma) and stem cell therapy (using bone marrow-derived mononuclear cells in the treatment of lower limb lymphedema), and 1 study focused on dietary interventions such as salt intake. Salt-sensitive blood pressure increases in Type 1 diabetes patients is accompanied by disturbed skin macrophage influx and lymphatic dilation. In an evaluation of the medical treatment of patients with breast cancer, two clinical trials demonstrated that treatment with sunitinib showed favorable effects on tumor vessel modulation and lymphangiogenesis and significantly decreased lymphatic vessel density, as assessed via immunohistochemistry. To assess a lung adenocarcinoma medical treatment, one clinical trial demonstrated that anlotinib suppressed lymphangiogenesis and lymphatic metastasis through a process potentially involving VEGFR3 signaling. Another clinical trial showed that in patients with lymphangioleiomyomatosis, sirolimus stabilized lung function and reduced the level of serum VEGFD, which is a lymphangiogenic growth factor implicated in the pathophysiology of LAM and was associated with a reduction in symptoms and improvement in quality of life. A study of patients with chronic lymphedema showed that cell therapy led to reduced limb circumference and increased pain relief and improved walking ability compared with the results in the control group.
Approximately 40.0% (n = 4) of published clinical trials explored the effects of lymphangiogenesis activators under pathological conditions. One study showed that HER2/neu expression correlated with VEGFC and lymphangiogenesis in lymph node-positive breast cancer patients. Another study demonstrated that pulmonary tuberculosis was associated with elevated circulating levels of VEGFA, VEGFC, and VEGFR2, and angiogenesis and lymphangiogenesis were shown to be classical features of granuloma formation. Recently, the expression of PDPN in cancer cells was demonstrated to promote tumor cell motility and tumor lymphangiogenesis in vitro, and one supplementary clinical trial showed that PDPN expression correlated with sentinel lymph node metastasis in early squamous cell carcinomas of the oral cavity and oropharynx. NRP2 plays an important role in regulating lymphangiogenesis, and findings from a clinical trial for patients with early-stage tongue cancer showed that cytoplasmic NRP2 was associated with metastasis and a poor prognosis.
Although several published clinical trials showed consistent findings and most studies suggested that drug interventions targeting activators or inhibitors suppressed lymphangiogenesis-related signaling, lymphangiogenesis activators played an important role in attenuating the pathological state. Given the substantial impact of lymphangiogenesis progression on health and disease, a larger sample, longer intervention period, and multicenter clinical trials are needed to examine the safety and efficacy of targeted interventions.
Conclusion
Since the discovery of lymphatic vessels exists in organisms, an increasing number of studies have revealed the mapping of lymphatic vessel anatomy and development. In this review, we described the general lymphatic vessel development and regulatory signaling pathways. Meanwhile, organ-specific lymphatic vessel development has also shown heterogeneous processes and signaling regulation catering to tissue development and physiological functions. However, the lymphangiogenic regulatory landscape remains a puzzle. Therefore, further mechanism studies are required to determine the phenotypic differences of lymphatic vessels in diverse developmental stages and tissues, including the key transcriptome and epigenome function. The robust lymph absorption and transport capacity of lymphatic vessels contribute to fluid homeostasis. In addition, lymphatic vessels directly or indirectly participate in immunosurveillance and immune response within diverse tissues and organs.
Lymphatic vessels are actively involved in multiple diseases in humans and alleviate or exacerbate local pathological progression through lymphangiogenesis. Notably, many studies have great interest in exploring lymphangiogenesis in tumors, which actively participates in the process of lymph node metastasis and affects the tumor prognosis and treatment. Moreover, LECs are involve in the regulation of tumor-specific immune response by affecting migration, function, and survival of immune cells. Exploration of crosstalk between LECs and immune cells may be a powerful target to enhance immunosurveillance for tumors in humans. In the future, exploration of the specific markers for tumor-associated lymphangiogenesis assists clinical tracing of metastatic lymph nodes, which may provide the specification for accurate lymph node resection. Targeting lymphangiogenesis is a potential and powerful intervention for restoring lymphatic vessel function and improving disease treatment. Based on these, we systematically review the lymphangiogenic signaling pathways, with specific inhibitors known till now. Moreover, multi-center clinical trials are being carried out to further demonstrate the feasibility and broad prospects of targeting abnormal lymphangiogenesis in a variety of diseases.
In conclusion, we have summarized the heterogeneous characteristics and functions of lymphatic vessels in health and disease conditions and expect to provide comprehensive knowledge for future research to realize translational therapy.
References
Breslin, J. W. et al. Lymphatic vessel network structure and physiology. Compr. Physiol. 9, 207–299 (2018).
Oliver, G., Kipnis, J., Randolph, G. J. & Harvey, N. L. The lymphatic vasculature in the 21st century: novel functional roles in homeostasis and disease. Cell 182, 270–296 (2020).
Natale, G., Bocci, G. & Ribatti, D. Scholars and scientists in the history of the lymphatic system. J. Anat. 231, 417–429 (2017).
Irschick, R., Siemon, C. & Brenner, E. The history of anatomical research of lymphatics—from the ancient times to the end of the European Renaissance. Ann. Anat. 223, 49–69 (2019).
Kanter, M. A. The lymphatic system: an historical perspective. Plast. Reconstr. Surg. 79, 131–139 (1987).
Sheldon, J. The history of the absorbent system part the first. Containing the chylography, or description of the human lacteal vessels, with the different methods of discovering, injecting, and preparing them, and the instruments used for these purposes. (1784).
Chikly, B. Who discovered the lymphatic system. Lymphology 30, 186–193 (1997).
Massa, N. Liber introductorius anatomiae siue dissectionis corporis humani. (1536).
Eustachius, B. Opuscula anatomica. (1564).
Anderson, H. GASPAR ASELLIUS: the discoverer of the lacteals. Can. Med. Assoc. J. 28, 666 (1933).
Gans, H. On the discovery of the lymphatic circulation. Angiology 13, 530–536 (1962).
Pecqueti, J. Experimenta nova anatomica, quibus incognitum hactenus chyli receptaculum, & ab eo per thoracem in ramos usque subclavios vasa lactea deteguntur. (1700).
Eriksson, G. Olaus Rudbeck as scientist and professor of medicine. Sven. Med. Tidskr. 8, 39–44 (2004).
Fulton, J. F. The early history of the lymphatics: with particular reference to Bartholin, Rudbeck and Joyliffe. (1938).
Bartholin, T. Vasa lymphatica: Nuper Hafniae in Animantibus inventa, Et Hepatis exseqviae. (1653).
Ruysch, F. Dilucidatio valvularum in vasis lymphaticis, et lacteis. Apud Janssonio-Waesbergios (1720).
Mascagni, P. Iconography and history of the lymphatic vessels of the human body. Siena, Italy: Pazzini Carli (1787).
Di Matteo, B. et al. Art in science: Giovanni Paolo Mascagni and the art of anatomy. Clin. Orthop. Rel. Res. 473, 783–788 (2015).
Sabin, F. R. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am. J. Anat. 1, 367–389 (1902).
Huntington, G. S. & McClure, C. F. W. The anatomy and development of the jugular lymph sacs in the domestic cat (Felis domestica). Am. J. Anat. 10, 177–312 (1910).
Ny, A. et al. A genetic Xenopus laevis tadpole model to study lymphangiogenesis. Nat. Med. 11, 998–1004 (2005).
Schneider, M., Othman-Hassan, K., Christ, B. & Wilting, J. Lymphangioblasts in the avian wing bud. Dev. Dyn. 216, 311–319 (1999).
Küchler, A. M. et al. Development of the zebrafish lymphatic system requires VEGFC signaling. Curr. Biol. 16, 1244–1248 (2006).
Yaniv, K. et al. Live imaging of lymphatic development in the zebrafish. Nat. Med. 12, 711–716 (2006).
Ducoli, L. & Detmar, M. Beyond PROX1: transcriptional, epigenetic, and noncoding RNA regulation of lymphatic identity and function. Dev. Cell 56, 406–426 (2021).
Srinivasan, R. S. et al. Lineage tracing demonstrates the venous origin of the mammalian lymphatic vasculature. Genes Dev. 21, 2422–2432 (2007).
Hägerling, R. et al. A novel multistep mechanism for initial lymphangiogenesis in mouse embryos based on ultramicroscopy. EMBO J. 32, 629–644 (2013).
Stone, O. A. & Stainier, D. Y. R. Paraxial mesoderm is the major source of lymphatic endothelium. Dev. Cell 50, 247–255.e3 (2019).
Martinez-Corral, I. et al. Nonvenous origin of dermal lymphatic vasculature. Circ. Res. 116, 1649–1654 (2015).
Pichol-Thievend, C. et al. A blood capillary plexus-derived population of progenitor cells contributes to genesis of the dermal lymphatic vasculature during embryonic development. Development 145, dev160184 (2018).
Stanczuk, L. et al. cKit lineage hemogenic endothelium-derived cells contribute to mesenteric lymphatic vessels. Cell Rep. 10, 1708–1721 (2015).
Klotz, L. et al. Cardiac lymphatics are heterogeneous in origin and respond to injury. Nature 522, 62–67 (2015).
Maruyama, K. et al. Isl1-expressing non-venous cell lineage contributes to cardiac lymphatic vessel development. Dev. Biol. 452, 134–143 (2019).
Lioux, G. et al. A second heart field-derived vasculogenic niche contributes to cardiac lymphatics. Dev. Cell 52, 350–363.e6 (2020).
Maruyama, K. et al. The cardiopharyngeal mesoderm contributes to lymphatic vessel development in mouse. Elife 11, e81515 (2022).
Kaipainen, A. et al. Expression of the fms-like tyrosine kinase 4 gene becomes restricted to lymphatic endothelium during development. Proc. Natl Acad. Sci. USA 92, 3566–3570 (1995).
Joukov, V. et al. A novel vascular endothelial growth factor, VEGF-C, is a ligand for the Flt4 (VEGFR-3) and KDR (VEGFR-2) receptor tyrosine kinases. EMBO J. 15, 1751 (1996).
Karkkainen, M. J. et al. Vascular endothelial growth factor C is required for sprouting of the first lymphatic vessels from embryonic veins. Nat. Immunol. 5, 74–80 (2004).
Wigle, J. T. & Oliver, G. Prox1 function is required for the development of the murine lymphatic system. Cell 98, 769–778 (1999).
Breiteneder-Geleff, S. et al. Angiosarcomas express mixed endothelial phenotypes of blood and lymphatic capillaries: podoplanin as a specific marker for lymphatic endothelium. Am. J. Pathol. 154, 385–394 (1999).
Banerji, S. et al. LYVE-1, a new homologue of the CD44 glycoprotein, is a lymph-specific receptor for hyaluronan. J. Cell Biol. 144, 789–801 (1999).
Yang, Y. & Oliver, G. Development of the mammalian lymphatic vasculature. J. Clin. Investig. 124, 888–897 (2014).
Jafree, D. J., Long, D. A., Scambler, P. J. & Ruhrberg, C. Mechanisms and cell lineages in lymphatic vascular development. Angiogenesis 24, 271–288 (2021).
Escobedo, N. & Oliver, G. Lymphangiogenesis: origin, specification, and cell fate determination. Annu. Rev. Cell Dev. Biol. 32, 677–691 (2016).
Ulvmar, M. H. & Mäkinen, T. Heterogeneity in the lymphatic vascular system and its origin. Cardiovasc. Res. 111, 310–321 (2016).
González-Loyola, A. & Petrova, T. V. Development and aging of the lymphatic vascular system. Adv. Drug Deliv. Rev. 169, 63–78 (2021).
Belle, M. et al. Tridimensional visualization and analysis of early human development. Cell 169, 161–173.e12 (2017).
van den Bosch, Q. C. C., van Beek, J. G. M., Kiliç, E. & Verdijk, R. M. Transient expression of lymphatic markers in retrobulbar intraconal orbital vasculature during fetal development. Invest. Ophthalmol. Vis. Sci. 61, 22 (2020).
Schlereth, S. L. et al. Absence of lymphatic vessels in the developing human sclera. Exp. Eye Res. 125, 203–209 (2014).
Geng, X., Ho, Y.-C. & Srinivasan, R. S. Biochemical and mechanical signals in the lymphatic vasculature. Cell. Mol. Life Sci. 78, 5903–5923 (2021).
La, H. et al. Role of transcriptional and epigenetic regulation in lymphatic endothelial cell development. Cells 11, 1692 (2022).
Yang, Y. et al. Lymphatic endothelial progenitors bud from the cardinal vein and intersomitic vessels in mammalian embryos. Blood 120, 2340–2348 (2012).
François, M. et al. Sox18 induces development of the lymphatic vasculature in mice. Nature 456, 643–647 (2008).
Srinivasan, R. S. et al. The nuclear hormone receptor Coup-TFII is required for the initiation and early maintenance of Prox1 expression in lymphatic endothelial cells. Genes Dev. 24, 696–707 (2010).
Lee, S. et al. Prox1 physically and functionally interacts with COUP-TFII to specify lymphatic endothelial cell fate. Blood 113, 1856–1859 (2009).
Lin, F.-J. et al. Direct transcriptional regulation of neuropilin-2 by COUP-TFII modulates multiple steps in murine lymphatic vessel development. J. Clin. Investig. 120, 1694–1707 (2010).
Srinivasan, R. S. et al. The Prox1-Vegfr3 feedback loop maintains the identity and the number of lymphatic endothelial cell progenitors. Genes Dev. 28, 2175–2187 (2014).
Zhang, Y. et al. Heterogeneity in VEGFR3 levels drives lymphatic vessel hyperplasia through cell-autonomous and non-cell-autonomous mechanisms. Nat. Commun. 9, 1296 (2018).
Jeltsch, M. et al. CCBE1 enhances lymphangiogenesis via A disintegrin and metalloprotease with thrombospondin motifs-3-mediated vascular endothelial growth factor-C activation. Circulation 129, 1962–1971 (2014).
Bos, F. L. et al. CCBE1 is essential for mammalian lymphatic vascular development and enhances the lymphangiogenic effect of vascular endothelial growth factor-C in vivo. Circ. Res. 109, 486–491 (2011).
Yu, P. et al. FGF-dependent metabolic control of vascular development. Nature 545, 224–228 (2017).
Cho, H. et al. YAP and TAZ negatively regulate Prox1 during developmental and pathologic lymphangiogenesis. Circ. Res. 124, 225–242 (2019).
Fritz-Six, K. L., Dunworth, W. P., Li, M. & Caron, K. M. Adrenomedullin signaling is necessary for murine lymphatic vascular development. J. Clin. Investig. 118, 40–50 (2008).
Frye, M. et al. Matrix stiffness controls lymphatic vessel formation through regulation of a GATA2-dependent transcriptional program. Nat. Commun. 9, 1511 (2018).
Planas-Paz, L. et al. Mechanoinduction of lymph vessel expansion. EMBO J. 31, 788–804 (2012).
Pollitt, A. Y. et al. Syk and Src family kinases regulate C-type lectin receptor 2 (CLEC-2)-mediated clustering of podoplanin and platelet adhesion to lymphatic endothelial cells. J. Biol. Chem. 289, 35695–35710 (2014).
Hess, P. R. et al. Platelets mediate lymphovenous hemostasis to maintain blood-lymphatic separation throughout life. J. Clin. Investig. 124, 273–284 (2014).
Cha, B. et al. YAP and TAZ maintain PROX1 expression in the developing lymphatic and lymphovenous valves in response to VEGF-C signaling. Development 147, dev195453 (2020).
Vittet, D. Lymphatic collecting vessel maturation and valve morphogenesis. Microvasc. Res. 96, 31–37 (2014).
Angeli, V. & Lim, H. Y. Biomechanical control of lymphatic vessel physiology and functions. Cell Mol. Immunol. 20, 1051–1062 (2023).
Norden, P. R. et al. Shear stimulation of FOXC1 and FOXC2 differentially regulates cytoskeletal activity during lymphatic valve maturation. Elife 9, e53814 (2020).
Hernández Vásquez, M. N. et al. Transcription factor FOXP2 is a flow-induced regulator of collecting lymphatic vessels. EMBO J. 40, e107192 (2021).
Sabine, A. et al. Mechanotransduction, PROX1, and FOXC2 cooperate to control connexin37 and calcineurin during lymphatic-valve formation. Dev. Cell 22, 430–445 (2012).
Wang, Y. et al. Smooth muscle cell recruitment to lymphatic vessels requires PDGFB and impacts vessel size but not identity. Development 144, 3590–3601 (2017).
Lutter, S., Xie, S., Tatin, F. & Makinen, T. Smooth muscle-endothelial cell communication activates Reelin signaling and regulates lymphatic vessel formation. J. Cell Biol. 197, 837–849 (2012).
Zheng, W. et al. Angiopoietin 2 regulates the transformation and integrity of lymphatic endothelial cell junctions. Genes Dev. 28, 1592–1603 (2014).
Bouvrée, K. et al. Semaphorin3A, Neuropilin-1, and PlexinA1 are required for lymphatic valve formation. Circ. Res. 111, 437–445 (2012).
Wong, B. W., Zecchin, A., García-Caballero, M. & Carmeliet, P. Emerging concepts in organ-specific lymphatic vessels and metabolic regulation of lymphatic development. Dev. Cell 45, 289–301 (2018).
Jung, H. M. et al. Development of the larval lymphatic system in zebrafish. Development 144, 2070–2081 (2017).
Okuda, K. S. et al. lyve1 expression reveals novel lymphatic vessels and new mechanisms for lymphatic vessel development in zebrafish. Development 139, 2381–2391 (2012).
Nicenboim, J. et al. Lymphatic vessels arise from specialized angioblasts within a venous niche. Nature 522, 56–61 (2015).
Koltowska, K. et al. Vegfc regulates bipotential precursor division and prox1 expression to promote lymphatic identity in zebrafish. Cell Rep. 13, 1828–1841 (2015).
Hogan, B. M. et al. Vegfc/Flt4 signalling is suppressed by Dll4 in developing zebrafish intersegmental arteries. Development 136, 4001–4009 (2009).
Hogan, B. M. et al. Ccbe1 is required for embryonic lymphangiogenesis and venous sprouting. Nat. Genet. 41, 396–398 (2009).
Bussmann, J. et al. Arteries provide essential guidance cues for lymphatic endothelial cells in the zebrafish trunk. Development 137, 2653–2657 (2010).
Cha, Y. R. et al. Chemokine signaling directs trunk lymphatic network formation along the preexisting blood vasculature. Dev. Cell 22, 824–836 (2012).
Shin, M. et al. Vegfc acts through ERK to induce sprouting and differentiation of trunk lymphatic progenitors. Development 143, 3785–3795 (2016).
Mulligan, T. S. & Weinstein, B. M. Emerging from the PAC: studying zebrafish lymphatic development. Microvasc. Res. 96, 23–30 (2014).
Stoll, S. J., Bartsch, S. & Kroll, J. HOXC9 regulates formation of parachordal lymphangioplasts and the thoracic duct in zebrafish via stabilin 2. PLoS One 8, e58311 (2013).
Eng, T. C. et al. Zebrafish facial lymphatics develop through sequential addition of venous and non-venous progenitors. EMBO Rep. 20, e47079 (2019).
Weigel, C., Bellaci, J. & Spiegel, S. Sphingosine-1-phosphate and its receptors in vascular endothelial and lymphatic barrier function. J. Biol. Chem. 299, 104775 (2023).
Norden, P. R. & Kume, T. Molecular mechanisms controlling lymphatic endothelial junction integrity. Front. Cell Dev. Biol. 8, 627647 (2020).
Baluk, P. et al. Functionally specialized junctions between endothelial cells of lymphatic vessels. J. Exp. Med. 204, 2349–2362 (2007).
Hägerling, R. et al. Distinct roles of VE-cadherin for development and maintenance of specific lymph vessel beds. EMBO J. 37, e98271 (2018).
Peluzzo, A. M. et al. Differential regulation of lymphatic junctional morphology and the potential effects on cardiovascular diseases. Front. Physiol. 14, 1198052 (2023).
Stritt, S., Koltowska, K. & Mäkinen, T. Homeostatic maintenance of the lymphatic vasculature. Trends Mol. Med. 27, 955–970 (2021).
Norrmén, C. et al. FOXC2 controls formation and maturation of lymphatic collecting vessels through cooperation with NFATc1. J. Cell Biol. 185, 439–457 (2009).
Johnson, O. W. et al. The thoracic duct: clinical importance, anatomic variation, imaging, and embolization. Eur. Radiol. 26, 2482–2493 (2016).
Yao, L. C. et al. Plasticity of button-like junctions in the endothelium of airway lymphatics in development and inflammation. Am. J. Pathol. 180, 2561–2575 (2012).
Petrova, T. V. & Koh, G. Y. Biological functions of lymphatic vessels. Science 369, eaax4063 (2020).
Oliver, G., Kipnis, J., Randolph, G. J. & Harvey, N. L. The lymphatic vasculature in the 21(st) century: novel functional roles in homeostasis and disease. Cell 182, 270–296 (2020).
Dixon, J. B. Lymphatic lipid transport: sewer or subway? Trends Endocrinol. Met. 21, 480–487 (2010).
Xu, Y. et al. Progress on brain and ocular lymphatic system. BioMed. Res. Int. 2022, 6413553 (2022).
Louveau, A. et al. Structural and functional features of central nervous system lymphatic vessels. Nature 523, 337–341 (2015).
Nakao, S., Hafezi-Moghadam, A. & Ishibashi, T. Lymphatics and lymphangiogenesis in the eye. J. Ophthalmol. 2012, 783163 (2012).
Subileau, M. et al. Eye lymphatic defects induced by bone morphogenetic protein 9 deficiency have no functional consequences on intraocular pressure. Sci. Rep. 10, 16040 (2020).
Dautriche, C. N., Tian, Y., Xie, Y. & Sharfstein, S. T. A closer look at Schlemm’s canal cell physiology: implications for biomimetics. J. Funct. Biomater. 6, 963–985 (2015).
Mansouri, K. & Shaarawy, T. Update on Schlemm’s canal based procedures. Middle East Afr. J. Ophthalmol. 22, 38–44 (2015).
Yang, Y. et al. Novel discovery of a lymphatic bridge connecting Schlemm’s canal to limbal and conjunctival lymphatic pathway. Ocul. Surf. 29, 272–278 (2023).
Martin-Almedina, S., Mortimer, P. S. & Ostergaard, P. Development and physiological functions of the lymphatic system: insights from human genetic studies of primary lymphedema. Physiol. Rev. 101, 1809–1871 (2021).
Bernier-Latmani, J. et al. DLL4 promotes continuous adult intestinal lacteal regeneration and dietary fat transport. J. Clin. Investig. 125, 4572–4586 (2015).
Zhang, F. et al. Lacteal junction zippering protects against diet-induced obesity. Science 361, 599–603 (2018).
Nurmi, H. et al. VEGF-C is required for intestinal lymphatic vessel maintenance and lipid absorption. EMBO Mol. Med. 7, 1418–1425 (2015).
Kvietys, P. R. & Granger, D. N. Role of intestinal lymphatics in interstitial volume regulation and transmucosal water transport. Ann. Ny. Acad. Sci. 1207, E29–E43 (2010).
Randolph, G. J. & Miller, N. E. Lymphatic transport of high-density lipoproteins and chylomicrons. J. Clin. Investig. 124, 929–935 (2014).
Lim, H. Y. et al. Lymphatic vessels are essential for the removal of cholesterol from peripheral tissues by SR-BI-mediated transport of HDL. Cell Metab. 17, 671–684 (2013).
Rademakers, T. et al. Adventitial lymphatic capillary expansion impacts on plaque T cell accumulation in atherosclerosis. Sci. Rep. 7, 45263 (2017).
Ager, A. High endothelial venules and other blood vessels: critical regulators of lymphoid organ development and function. Front. Immunol. 8, 45 (2017).
Grant, S. M. et al. The lymph node at a glance - how spatial organization optimizes the immune response. J. Cell Sci. 133, jcs241828 (2020).
Rouhani, S. J. et al. Roles of lymphatic endothelial cells expressing peripheral tissue antigens in CD4 T-cell tolerance induction. Nat. Commun. 6, 6771 (2015).
Arroz-Madeira, S., Bekkhus, T., Ulvmar, M. H. & Petrova, T. V. Lessons of vascular specialization from secondary lymphoid organ lymphatic endothelial cells. Circ. Res. 132, 1203–1225 (2023).
Randolph, G. J., Ivanov, S., Zinselmeyer, B. H. & Scallan, J. P. The lymphatic system: integral roles in immunity. Annu. Rev. Immunol. 35, 31–52 (2017).
Ulvmar, M. H. et al. The atypical chemokine receptor CCRL1 shapes functional CCL21 gradients in lymph nodes. Nat. Immunol. 15, 623–630 (2014).
Camara, A. et al. Lymph node mesenchymal and endothelial stromal cells cooperate via the RANK-RANKL cytokine axis to shape the sinusoidal macrophage niche. Immunity 50, 1467–1481.e1466 (2019).
Antila, S. et al. Development and plasticity of meningeal lymphatic vessels. J. Exp. Med. 214, 3645–3667 (2017).
Song, E. et al. Publisher Correction: VEGF-C-driven lymphatic drainage enables immunosurveillance of brain tumours. Nature 590, E34 (2021).
Jacob, L. et al. Anatomy and function of the vertebral column lymphatic network in mice. Nat. Commun. 10, 4594 (2019).
Louveau, A. et al. CNS lymphatic drainage and neuroinflammation are regulated by meningeal lymphatic vasculature. Nat. Neurosci. 21, 1380–1391 (2018).
Pabst, O. & Mowat, A. M. Oral tolerance to food protein. Mucosal Immunol. 5, 232–239 (2012).
Cummings, R. J. et al. Different tissue phagocytes sample apoptotic cells to direct distinct homeostasis programs. Nature 539, 565–569 (2016).
Esterházy, D. et al. Compartmentalized gut lymph node drainage dictates adaptive immune responses. Nature 569, 126–130 (2019).
Duhon, B. H. et al. Current mechanistic understandings of lymphedema and lipedema: tales of fluid, fat, and fibrosis. Int. J. Mol. Sci. 23, 6621 (2022).
Rockson, S. G. et al. Cancer-associated secondary lymphoedema. Nat. Rev. Dis. Prim. 5, 22 (2019).
Rockson, S. G. Advances in lymphedema. Circ. Res. 128, 2003–2016 (2021).
Ogino, R. et al. Emerging anti-inflammatory pharmacotherapy and cell-based therapy for lymphedema. Int. J. Mol. Sci. 23, 7614 (2022).
Mäkinen, T., Boon, L. M., Vikkula, M. & Alitalo, K. Lymphatic malformations: genetics, mechanisms and therapeutic strategies. Circ. Res. 129, 136–154 (2021).
Boscolo, E. et al. AKT hyper-phosphorylation associated with PI3K mutations in lymphatic endothelial cells from a patient with lymphatic malformation. Angiogenesis 18, 151–162 (2015).
Ozeki, M. & Fukao, T. Generalized lymphatic anomaly and Gorham-stout disease: overview and recent insights. Adv. Wound Care 8, 230–245 (2019).
Rodriguez-Laguna, L. et al. Somatic activating mutations in PIK3CA cause generalized lymphatic anomaly. J. Exp. Med. 216, 407–418 (2019).
Manevitz-Mendelson, E. et al. Somatic NRAS mutation in patient with generalized lymphatic anomaly. Angiogenesis 21, 287–298 (2018).
Li, D. et al. ARAF recurrent mutation causes central conducting lymphatic anomaly treatable with a MEK inhibitor. Nat. Med. 25, 1116–1122 (2019).
Li, D. et al. Pathogenic variant in EPHB4 results in central conducting lymphatic anomaly. Hum. Mol. Genet. 27, 3233–3245 (2018).
Dieterich, L. C., Tacconi, C., Ducoli, L. & Detmar, M. Lymphatic vessels in cancer. Physiol. Rev. 102, 1837–1879 (2022).
Jiang, J. et al. Immunohistochemical characterization of lymphangiogenesis-related biomarkers in primary and recurrent gliomas: a STROBE compliant article. Medicines 97, e12458 (2018).
Cohen, B. et al. Transcriptional regulation of vascular endothelial growth factor C by oxidative and thermal stress is mediated by lens epithelium-derived growth factor/p75. Neoplasia 11, 921–933, (2009).
Hu, X. et al. Meningeal lymphatic vessels regulate brain tumor drainage and immunity. Cell Res. 30, 229–243 (2020).
Ramani, P. et al. VEGF-C, VEGF-D and VEGFR-3 expression in peripheral neuroblastic tumours. Histopathology 61, 1006–1016 (2012).
Becker, J. et al. Neuroblastoma progression correlates with downregulation of the lymphangiogenesis inhibitor sVEGFR-2. Clin. Cancer Res. 16, 1431–1441 (2010).
Kashima, K. et al. Inhibition of lymphatic metastasis in neuroblastoma by a novel neutralizing antibody to vascular endothelial growth factor-D. Cancer Sci. 103, 2144–2152 (2012).
Sun, J. G. et al. Detection of lymphangiogenesis in non-small cell lung cancer and its prognostic value. J. Exp. Clin. Cancer Res. 28, 21 (2009).
Watari, K. et al. Tumor-derived interleukin-1 promotes lymphangiogenesis and lymph node metastasis through M2-type macrophages. PLoS One 9, e99568 (2014).
Ren, S. et al. Integrin α6 overexpression promotes lymphangiogenesis and lymphatic metastasis via activating the NF-κB signaling pathway in lung adenocarcinoma. Cell. Oncol. 45, 57–67 (2022).
Dubois, C. et al. Lymph/angiogenesis contributes to sex differences in lung cancer through oestrogen receptor alpha signalling. Endocr. Relat. Cancer 26, 201–216 (2019).
Hu, J. et al. microRNA-128 plays a critical role in human non-small cell lung cancer tumourigenesis, angiogenesis and lymphangiogenesis by directly targeting vascular endothelial growth factor-C. Eur. J. Cancer 50, 2336–2350 (2014).
Nakamura, Y. et al. Lymph vessel density correlates with nodal status, VEGF-C expression, and prognosis in breast cancer. Breast Cancer Res. Treat. 91, 125–132 (2005).
Bieniasz-Krzywiec, P. et al. Podoplanin-expressing macrophages promote lymphangiogenesis and lymphoinvasion in breast cancer. Cell Metab. 30, 917–936.e910 (2019).
Weichand, B. et al. S1PR1 on tumor-associated macrophages promotes lymphangiogenesis and metastasis via NLRP3/IL-1β. J. Exp. Med. 214, 2695–2713 (2017).
Zheng, S. et al. Long non-coding RNA HUMT hypomethylation promotes lymphangiogenesis and metastasis via activating FOXK1 transcription in triple-negative breast cancer. J. Hematol. Oncol. 13, 17 (2020).
Li, J. et al. ZKSCAN5 activates VEGFC expression by recruiting SETD7 to promote the lymphangiogenesis, tumour growth, and metastasis of breast cancer. Front. Oncol. 12, 875033 (2022).
Wang, X. et al. Inhibition of NADPH oxidase 4 attenuates lymphangiogenesis and tumor metastasis in breast cancer. FASEB J. 35, e21531 (2021).
Sethy, C. et al. Nectin-4 promotes lymphangiogenesis and lymphatic metastasis in breast cancer by regulating CXCR4-LYVE-1 axis. Vasc. Pharmacol. 140, 106865 (2021).
Hou, Q. et al. Extracellular Hsp90α promotes tumor lymphangiogenesis and lymph node metastasis in breast cancer. Int. J. Mol. Sci. 22, 7747 (2021).
Harris, A. R. et al. Platinum chemotherapy induces lymphangiogenesis in cancerous and healthy tissues that can be prevented with adjuvant anti-VEGFR3 therapy. Front. Oncol. 12, 801764 (2022).
Sung, H. et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA-Cancer J. Clin. 71, 209–249 (2021).
Thelen, A. et al. Tumor-associated lymphangiogenesis correlates with prognosis after resection of human hepatocellular carcinoma. Ann. Surg. Oncol. 16, 1222–1230 (2009).
Thelen, A. et al. VEGF-D promotes tumor growth and lymphatic spread in a mouse model of hepatocellular carcinoma. Int. J. Cancer 122, 2471–2481 (2008).
Shi, Y. et al. HANR promotes lymphangiogenesis of hepatocellular carcinoma via secreting miR-296 exosome and regulating EAG1/VEGFA signaling in HDLEC cells. J. Cell. Biochem. 120, 17699–17708 (2019).
Zhang, D. et al. Suppression of tumor growth and metastasis by simultaneously blocking vascular endothelial growth factor (VEGF)-A and VEGF-C with a receptor-immunoglobulin fusion protein. Cancer Res. 70, 2495–2503 (2010).
Brindley, P. J. et al. Cholangiocarcinoma. Nat. Rev. Dis. Prim. 7, 65 (2021).
Sha, M. et al. Tumor-associated lymphangiogenesis predicts unfavorable prognosis of intrahepatic cholangiocarcinoma. BMC Cancer 19, 208 (2019).
Carpino, G. et al. Thrombospondin 1 and 2 along with PEDF inhibit angiogenesis and promote lymphangiogenesis in intrahepatic cholangiocarcinoma. J. Hepatol. 75, 1377–1386 (2021).
Cadamuro, M. et al. Platelet-derived growth factor-D enables liver myofibroblasts to promote tumor lymphangiogenesis in cholangiocarcinoma. J. Hepatol. 70, 700–709 (2019).
Yan, J. et al. Cancer-associated fibroblasts promote lymphatic metastasis in cholangiocarcinoma via the PDGF-BB/PDGFR-β mediated paracrine signaling network. Aging Dis. 14, 6 (2023).
Hezel, A. F. et al. Genetics and biology of pancreatic ductal adenocarcinoma. Genes Dev. 20, 1218–1249 (2006).
Hao, S. et al. BANCR positively regulates the HIF-1α/VEGF-C/VEGFR-3 pathway in a hypoxic microenvironment to promote lymphangiogenesis in pancreatic cancer cells. Oncol. Lett. 24, 422 (2022).
Kong, Y. et al. circNFIB1 inhibits lymphangiogenesis and lymphatic metastasis via the miR-486-5p/PIK3R1/VEGF-C axis in pancreatic cancer. Mol. Cancer 19, 82 (2020).
Wang, C. A. et al. DUSP2 regulates extracellular vesicle-VEGF-C secretion and pancreatic cancer early dissemination. J. Extracell. Vesicles 9, 1746529 (2020).
Wang, C. A. et al. Suppression of extracellular vesicle VEGF-C-mediated lymphangiogenesis and pancreatic cancer early dissemination by a selective HDAC1/2 inhibitor. Mol. Cancer Ther. 20, 1550–1560 (2021).
Luo, Y. et al. KRAS mutant-driven SUMOylation controls extracellular vesicle transmission to trigger lymphangiogenesis in pancreatic cancer. J. Clin. Investig. 132, e157644 (2022).
Zhou, X. et al. Pancreatic cancer cell-derived exosomes promote lymphangiogenesis by downregulating ABHD11-AS1 expression. Cancers 14, 4612 (2022).
Shen, C. N. et al. Lymphatic vessel remodeling and invasion in pancreatic cancer progression. EBioMedicine 47, 98–113 (2019).
Pak, K. H., Park, K. C. & Cheong, J. H. VEGF-C induced by TGF- β1 signaling in gastric cancer enhances tumor-induced lymphangiogenesis. BMC Cancer 19, 799 (2019).
Sun, L. et al. Metastasis-associated in colon cancer-1 upregulates vascular endothelial growth factor-C/D to promote lymphangiogenesis in human gastric cancer. Cancer Lett. 357, 242–253 (2015).
Wu, Z. et al. CRIP1 reshapes the gastric cancer microenvironment to facilitate development of lymphatic metastasis. Adv. Sci. 10, e2303246 (2023).
Ma, C. et al. OxLDL promotes lymphangiogenesis and lymphatic metastasis in gastric cancer by upregulating VEGF‑C expression and secretion. Int. J. Oncol. 54, 572–584 (2019).
Zhu, T. et al. SOAT1 promotes gastric cancer lymph node metastasis through lipid synthesis. Front. Pharmacol. 12, 769647 (2021).
Ma, C. et al. Kallistatin inhibits lymphangiogenesis and lymphatic metastasis of gastric cancer by downregulating VEGF-C expression and secretion. Gastric Cancer 21, 617–631 (2018).
Li, H. et al. Anthracycline chemicals with anthracyclinone structure exert antitumor effects by inhibiting angiogenesis and lymphangiogenesis in a xenografted gastric tumor model. Gastric Cancer 26, 863–877 (2023).
Da, W., Zhang, J., Zhang, R. & Zhu, J. Curcumin inhibits the lymphangiogenesis of gastric cancer cells by inhibiton of HMGB1/VEGF-D signaling. Int. J. Immunopathol. Pharmacol. 33, 2058738419861600 (2019).
Guan, J. et al. Babao Dan inhibits lymphangiogenesis of gastric cancer in vitro and in vivo via lncRNA-ANRIL/VEGF-C/VEGFR-3 signaling axis. Biomed. Pharmacother. 154, 113630 (2022).
Huang, C. & Chen, Y. Lymphangiogenesis and colorectal cancer. Saudi Med. J. 38, 237–244 (2017).
Du, B. et al. Metastasis-associated protein 1 induces VEGF-C and facilitates lymphangiogenesis in colorectal cancer. World J. Gastroenterol. 17, 1219–1226, (2011).
Sun, B. et al. Colorectal cancer exosomes induce lymphatic network remodeling in lymph nodes. Int. J. Cancer 145, 1648–1659 (2019).
Song, J. et al. CCBE1 promotes tumor lymphangiogenesis and is negatively regulated by TGFβ signaling in colorectal cancer. Theranostics 10, 2327–2341 (2020).
Huang, B. et al. Qingjie Fuzheng Granule suppresses lymphangiogenesis in colorectal cancer via the VEGF-C/VEGFR-3 dependent PI3K/AKT pathway. Biomed. Pharmacother. 137, 111331 (2021).
Huang, B. et al. ANRIL promotes the regulation of colorectal cancer on lymphatic endothelial cells via VEGF-C and is the key target for Pien Tze Huang to inhibit cancer metastasis. Cancer Gene Ther. 30, 1260–1273 (2023).
Li, H. et al. Hedyotis diffusa Willd. inhibits VEGF‑C‑mediated lymphangiogenesis in colorectal cancer via multiple signaling pathways. Oncol. Rep. 42, 1225–1236 (2019).
Miyata, Y. et al. Lymphangiogenesis and angiogenesis in bladder cancer: prognostic implications and regulation by vascular endothelial growth factors-A, -C, and -D. Clin. Cancer Res. 12, 800–806 (2006).
Chen, C. et al. LNMAT1 promotes lymphatic metastasis of bladder cancer via CCL2 dependent macrophage recruitment. Nat. Commun. 9, 3826 (2018).
Chen, C. et al. Exosomal long noncoding RNA LNMAT2 promotes lymphatic metastasis in bladder cancer. J. Clin. Investig. 130, 404–421 (2020).
Chen, C. et al. SUMOylation promotes extracellular vesicle-mediated transmission of lncRNA ELNAT1 and lymph node metastasis in bladder cancer. J. Clin. Investig. 131, e146431 (2021).
He, W. et al. Long noncoding RNA BLACAT2 promotes bladder cancer-associated lymphangiogenesis and lymphatic metastasis. J. Clin. Investig. 128, 861–875 (2018).
Zhu, J. et al. circEHBP1 promotes lymphangiogenesis and lymphatic metastasis of bladder cancer via miR-130a-3p/TGFβR1/VEGF-D signaling. Mol. Ther. 29, 1838–1852 (2021).
Yang, H. et al. Soluble vascular endothelial growth factor receptor-3 suppresses lymphangiogenesis and lymphatic metastasis in bladder cancer. Mol. Cancer 10, 36 (2011).
Zeng, Y. et al. Expression of vascular endothelial growth factor receptor-3 by lymphatic endothelial cells is associated with lymph node metastasis in prostate cancer. Clin. Cancer Res. 10, 5137–5144 (2004).
Lin, Y. C. et al. LPA(1/3) signaling mediates tumor lymphangiogenesis through promoting CRT expression in prostate cancer. Biochim. Biophys. Acta Mol. Cell Biol. Lipids 1863, 1305–1315 (2018).
Burton, J. B. et al. Suppression of prostate cancer nodal and systemic metastasis by blockade of the lymphangiogenic axis. Cancer Res. 68, 7828–7837 (2008).
Yano, A. et al. Glucocorticoids suppress tumor lymphangiogenesis of prostate cancer cells. Clin. Cancer Res. 12, 6012–6017 (2006).
Sopo, M. et al. Microvessels in epithelial ovarian tumors: high microvessel density is a significant feature of malignant ovarian tumors. Anticancer Res. 40, 6923–6931 (2020).
Sapoznik, S. et al. Gonadotropin-regulated lymphangiogenesis in ovarian cancer is mediated by LEDGF-induced expression of VEGF-C. Cancer Res. 69, 9306–9314 (2009).
Hsieh, C. Y. et al. Overexpression of Her-2/NEU in epithelial ovarian carcinoma induces vascular endothelial growth factor C by activating NF-kappa B: implications for malignant ascites formation and tumor lymphangiogenesis. J. Biomed. Sci. 11, 249–259 (2004).
Sun, R. et al. ALKBH5 activates FAK signaling through m6A demethylation in ITGB1 mRNA and enhances tumor-associated lymphangiogenesis and lymph node metastasis in ovarian cancer. Theranostics 13, 833–848 (2023).
Peng, F. et al. SPARC suppresses lymph node metastasis by regulating the expression of VEGFs in ovarian carcinoma. Int. J. Oncol. 51, 1920–1928 (2017).
Chen, X. et al. Tumor necrosis factor-α promotes the tumorigenesis, lymphangiogenesis, and lymphatic metastasis in cervical cancer via activating VEGFC-mediated AKT and ERK pathways. Mediators Inflamm. 2023, 5679966 (2023).
Liu, P. et al. High expression of PTPRM predicts poor prognosis and promotes tumor growth and lymph node metastasis in cervical cancer. Cell Death Dis. 11, 687 (2020).
Du, Q. et al. FASN promotes lymph node metastasis in cervical cancer via cholesterol reprogramming and lymphangiogenesis. Cell Death Dis. 13, 488 (2022).
Zhang, C. et al. FABP5 promotes lymph node metastasis in cervical cancer by reprogramming fatty acid metabolism. Theranostics 10, 6561–6580 (2020).
Zhou, C. F. et al. Cervical squamous cell carcinoma-secreted exosomal miR-221-3p promotes lymphangiogenesis and lymphatic metastasis by targeting VASH1. Oncogene 38, 1256–1268 (2019).
Zhang, C. et al. CircVPRBP inhibits nodal metastasis of cervical cancer by impeding RACK1 O-GlcNAcylation and stability. Oncogene 42, 793–807 (2023).
Choi, Y. et al. Papillary thyroid carcinoma involving cervical neck lymph nodes: correlations with lymphangiogenesis and ultrasound features. Endocr. J. 59, 941–948 (2012).
Hakala, T. et al. Recurrent thyroid cancers have more peritumoural lymphatic vasculature than nonrecurrent thyroid cancers. Eur. J. Clin. Investig. 44, 825–832 (2014).
Liu, X. et al. Long non-coding RNA MFSD4A-AS1 promotes lymphangiogenesis and lymphatic metastasis of papillary thyroid cancer. Endocr. Relat. Cancer 30, e220221 (2023).
Špirić, Z., Vještica, M. & Erić, M. Survival prediction in patients with cutaneous melanoma by tumour lymphangiogenesis. Acta Clin. Belg. 75, 379–387 (2020).
Leichner, G. S. et al. Primary Melanoma miRNA Trafficking Induces Lymphangiogenesis. J. Investig. Dermatol. 143, 1788–1798.e1787 (2023).
García-Silva, S. et al. Melanoma-derived small extracellular vesicles induce lymphangiogenesis and metastasis through an NGFR-dependent mechanism. Nat. Cancer 2, 1387–1405 (2021).
Reger de Moura, C. et al. CD147 promotes tumor lymphangiogenesis in melanoma via PROX-1. Cancers 13, 4859 (2021).
Benyahia, Z. et al. Adrenomedullin secreted by melanoma cells promotes melanoma tumor growth through angiogenesis and lymphangiogenesis. Cancers 14, 5909 (2022).
Berta, J. et al. Apelin promotes blood and lymph vessel formation and the growth of melanoma lung metastasis. Sci. Rep. 11, 5798 (2021).
Lei, N. et al. Claudin-3 inhibits tumor-induced lymphangiogenesis via regulating the PI3K signaling pathway in lymphatic endothelial cells. Sci. Rep. 12, 17440 (2022).
Wang, M. et al. Rapamycin suppresses angiogenesis and lymphangiogenesis in melanoma by downregulating VEGF-A/VEGFR-2 and VEGF-C/VEGFR-3 expression. OncoTargets Ther. 12, 4643–4654 (2019).
Hsu, M. J. et al. Anti-angiogenetic and anti-lymphangiogenic effects of a novel 2-aminobenzimidazole derivative, MFB. Front. Oncol. 12, 862326 (2022).
Sasso, M. S. et al. Lymphangiogenesis-inducing vaccines elicit potent and long-lasting T cell immunity against melanomas. Sci. Adv. 7, eabe4362 (2021).
Mawuenyega, K. G. et al. Decreased clearance of CNS beta-amyloid in Alzheimer’s disease. Science 330, 1774 (2010).
Da Mesquita, S. et al. Functional aspects of meningeal lymphatics in ageing and Alzheimer’s disease. Nature 560, 185–191 (2018).
Wen, Y. R., Yang, J. H., Wang, X. & Yao, Z. B. Induced dural lymphangiogenesis facilities soluble amyloid-beta clearance from brain in a transgenic mouse model of Alzheimer’s disease. Neural Regen. Res. 13, 709–716 (2018).
Da Mesquita, S. et al. Meningeal lymphatics affect microglia responses and anti-Aβ immunotherapy. Nature 593, 255–260 (2021).
Aspelund, A. et al. The Schlemm’s canal is a VEGF-C/VEGFR-3-responsive lymphatic-like vessel. J. Clin. Investig. 124, 3975–3986 (2014).
Kim, J. et al. Impaired angiopoietin/Tie2 signaling compromises Schlemm’s canal integrity and induces glaucoma. J. Clin. Investig. 127, 3877–3896 (2017).
Young, T. L. et al. SVEP1 as a genetic modifier of TEK-related primary congenital glaucoma. Investig. Ophthalmol. Vis. Sci. 61, 6 (2020).
Piché, M. E., Tchernof, A. & Després, J. P. Obesity phenotypes, diabetes, and cardiovascular diseases. Circ. Res. 126, 1477–1500 (2020).
Kojta, I., Chacińska, M. & Błachnio-Zabielska, A. Obesity, bioactive lipids, and adipose tissue inflammation in insulin resistance. Nutrients 12, 1305 (2020).
Savetsky, I. L. et al. Obesity increases inflammation and impairs lymphatic function in a mouse model of lymphedema. Am. J. Physiol. Heart Circ. Physiol. 307, H165–172, (2014).
García Nores, G. D. et al. Obesity but not high-fat diet impairs lymphatic function. Int. J. Obes. 40, 1582–1590 (2016).
Chakraborty, A. et al. Vascular endothelial growth factor-D (VEGF-D) overexpression and lymphatic expansion in murine adipose tissue improves metabolism in obesity. Am. J. Pathol. 189, 924–939 (2019).
Chakraborty, A. et al. Characterizing lymphangiogenesis and concurrent inflammation in adipose tissue in response to VEGF-D. Front. Physiol. 11, 363 (2020).
Amann-Vesti, B. R., Franzeck, U. K. & Bollinger, A. Microlymphatic aneurysms in patients with lipedema. Lymphology 34, 170–175 (2001).
Lohrmann, C., Foeldi, E. & Langer, M. MR imaging of the lymphatic system in patients with lipedema and lipo-lymphedema. Microvasc. Res. 77, 335–339 (2009).
Harvey, N. L. et al. Lymphatic vascular defects promoted by Prox1 haploinsufficiency cause adult-onset obesity. Nat. Genet. 37, 1072–1081 (2005).
Blum, K. S. et al. Chronic high-fat diet impairs collecting lymphatic vessel function in mice. PLoS One 9, e94713 (2014).
Silha, J. V., Krsek, M., Sucharda, P. & Murphy, L. J. Angiogenic factors are elevated in overweight and obese individuals. Int. J. Obes. 29, 1308–1314 (2005).
Demir, S., Nawroth, P. P., Herzig, S. & Ekim Üstünel, B. Emerging targets in type 2 diabetes and diabetic complications. Adv. Sci. 8, e2100275 (2021).
Wenstedt, E. F. E. et al. Salt-sensitive blood pressure rise in type 1 diabetes patients is accompanied by disturbed skin macrophage influx and lymphatic dilation—a proof-of-concept study. Transl. Res. 217, 23–32 (2020).
Wu, H. et al. Epsin deficiency promotes lymphangiogenesis through regulation of VEGFR3 degradation in diabetes. J. Clin. Investig. 128, 4025–4043 (2018).
Scallan, J. P., Hill, M. A. & Davis, M. J. Lymphatic vascular integrity is disrupted in type 2 diabetes due to impaired nitric oxide signalling. Cardiovasc. Res. 107, 89–97 (2015).
Cifarelli, V. et al. Visceral obesity and insulin resistance associate with CD36 deletion in lymphatic endothelial cells. Nat. Commun. 12, 3350 (2021).
Cole, J. B. & Florez, J. C. Genetics of diabetes mellitus and diabetes complications. Nat. Rev. Nephrol. 16, 377–390 (2020).
Alicic, R. Z., Rooney, M. T. & Tuttle, K. R. Diabetic kidney disease: challenges, progress, and possibilities. Clin. J. Am. Soc. Nephrol. 12, 2032–2045 (2017).
Kim, Y. et al. Attenuated lymphatic proliferation ameliorates diabetic nephropathy and high-fat diet-induced renal lipotoxicity. Sci. Rep. 9, 1994 (2019).
Sakamoto, I. et al. Lymphatic vessels develop during tubulointerstitial fibrosis. Kidney Int. 75, 828–838 (2009).
Hwang, S. D. et al. Inhibition of lymphatic proliferation by the selective VEGFR-3 inhibitor SAR131675 ameliorates diabetic nephropathy in db/db mice. Cell Death Dis. 10, 219 (2019).
Cheung, N., Mitchell, P. & Wong, T. Y. Diabetic retinopathy. Lancet 376, 124–136 (2010).
Gucciardo, E., Loukovaara, S., Salven, P. & Lehti, K. Lymphatic vascular structures: a new aspect in proliferative diabetic retinopathy. Int. J. Mol. Sci. 19, 4034 (2018).
Kim, B. H. et al. Imidazole-based alkaloid derivative LCB54-0009 suppresses ocular angiogenesis and lymphangiogenesis in models of experimental retinopathy and corneal neovascularization. Br. J. Pharmacol. 172, 3875–3889 (2015).
Gucciardo, E. et al. The microenvironment of proliferative diabetic retinopathy supports lymphatic neovascularization. J. Pathol. 245, 172–185 (2018).
Korhonen, A., Gucciardo, E., Lehti, K. & Loukovaara, S. Proliferative diabetic retinopathy transcriptomes reveal angiogenesis, anti-angiogenic therapy escape mechanisms, fibrosis and lymphatic involvement. Sci. Rep. 11, 18810 (2021).
Renò, F. & Sabbatini, M. Breaking a vicious circle: lymphangiogenesis as a new therapeutic target in wound healing. Biomedicines 11, 656 (2023).
Cho, C. H. et al. COMP-angiopoietin-1 promotes wound healing through enhanced angiogenesis, lymphangiogenesis, and blood flow in a diabetic mouse model. Proc. Natl Acad. Sci. USA 103, 4946–4951 (2006).
Zhou, J., Wei, T. & He, Z. ADSCs enhance VEGFR3-mediated lymphangiogenesis via METTL3-mediated VEGF-C m(6)A modification to improve wound healing of diabetic foot ulcers. Mol. Med. 27, 146 (2021).
Wu, M. et al. Modulation of lymphangiogenesis in incisional murine diabetic wound healing using negative pressure wound therapy. Adv. Wound Care 12, 483–497 (2023).
Wu, M. et al. Negative-pressure wound therapy induces lymphangiogenesis in murine diabetic wound healing. Plast. Reconstr. Surg. 151, 779–790 (2023).
Asai, J. et al. Topical simvastatin accelerates wound healing in diabetes by enhancing angiogenesis and lymphangiogenesis. Am. J. Pathol. 181, 2217–2224 (2012).
He, Z. Y. et al. Long noncoding RNA-antisense noncoding RNA in the INK4 locus accelerates wound healing in diabetes by promoting lymphangiogenesis via regulating miR-181a/Prox1 axis. J. Cell Physiol. 234, 4627–4640 (2019).
He, Z. Y. et al. Long noncoding RNA GAS5 accelerates diabetic wound healing and promotes lymphangiogenesis via miR-217/Prox1 axis. Mol. Cell Endocrinol. 532, 111283 (2021).
Güç, E. et al. Local induction of lymphangiogenesis with engineered fibrin-binding VEGF-C promotes wound healing by increasing immune cell trafficking and matrix remodeling. Biomaterials 131, 160–175 (2017).
Eming, S. A., Martin, P. & Tomic-Canic, M. Wound repair and regeneration: mechanisms, signaling, and translation. Sci. Transl. Med. 6, 265sr266 (2014).
Brunner, L. M. et al. Promotion of lymphangiogenesis by targeted delivery of VEGF-C improves diabetic wound healing. Cells 12, 472 (2023).
Lim, L. et al. Hemostasis stimulates lymphangiogenesis through release and activation of VEGFC. Blood 134, 1764–1775 (2019).
Zampell, J. C. et al. HIF-1α coordinates lymphangiogenesis during wound healing and in response to inflammation. FASEB J. 26, 1027–1039 (2012).
Hosono, K. et al. Signaling of prostaglandin E receptors, EP3 and EP4 facilitates wound healing and lymphangiogenesis with enhanced recruitment of M2 macrophages in mice. PLoS One 11, e0162532 (2016).
Bianchi, A., Painter, K. J. & Sherratt, J. A. Spatio-temporal models of lymphangiogenesis in wound healing. Bull. Math. Biol. 78, 1904–1941 (2016).
Gur-Cohen, S. et al. Stem cell-driven lymphatic remodeling coordinates tissue regeneration. Science 366, 1218–1225 (2019).
Peña-Jimenez, D. et al. Lymphatic vessels interact dynamically with the hair follicle stem cell niche during skin regeneration in vivo. EMBO J. 38, e101688 (2019).
Biswas, L. et al. Lymphatic vessels in bone support regeneration after injury. Cell 186, 382–397.e24 (2023).
Gancz, D. et al. Distinct origins and molecular mechanisms contribute to lymphatic formation during cardiac growth and regeneration. Elife 8, e44153 (2019).
Trincot, C. E. et al. Adrenomedullin induces cardiac lymphangiogenesis after myocardial infarction and regulates cardiac edema via connexin 43. Circ. Res. 124, 101–113 (2019).
Mo, F., Mamonkin, M., Brenner, M. K. & Heslop, H. E. Taking T-cell oncotherapy off-the-shelf. Trends Immunol. 42, 261–272 (2021).
Wong, B. W. Lymphatic vessels in solid organ transplantation and immunobiology. Am. J. Transplant. 20, 1992–2000 (2020).
Dashkevich, A. et al. Ischemia-reperfusion injury enhances lymphatic endothelial VEGFR3 and rejection in cardiac allografts. Am. J. Transplant. 16, 1160–1172 (2016).
Edwards, L. A. et al. Chronic rejection of cardiac allografts is associated with increased lymphatic flow and cellular trafficking. Circulation 137, 488–503 (2018).
Nykänen, A. I. et al. Targeting lymphatic vessel activation and CCL21 production by vascular endothelial growth factor receptor-3 inhibition has novel immunomodulatory and antiarteriosclerotic effects in cardiac allografts. Circulation 121, 1413–1422 (2010).
Kerjaschki, D. et al. Lymphatic neoangiogenesis in human kidney transplants is associated with immunologically active lymphocytic infiltrates. J. Am. Soc. Nephrol. 15, 603–612 (2004).
Todd, J. L. et al. Hyaluronan contributes to bronchiolitis obliterans syndrome and stimulates lung allograft rejection through activation of innate immunity. Am. J. Respir. Crit. Care Med. 189, 556–566 (2014).
Cui, Y. et al. Therapeutic lymphangiogenesis ameliorates established acute lung allograft rejection. J. Clin. Investig. 125, 4255–4268 (2015).
Pedersen, M. S. et al. Lymphangiogenesis in a mouse model of renal transplant rejection extends life span of the recipients. Kidney Int. 97, 89–94 (2020).
Dertschnig, S. et al. Graft-versus-host disease reduces lymph node display of tissue-restricted self-antigens and promotes autoimmunity. J. Clin. Investig. 130, 1896–1911 (2020).
Gehlsen, U. et al. Ocular graft-versus-host disease in a chemotherapy-based minor-mismatch mouse model features corneal (Lymph-) angiogenesis. Int. J. Mol. Sci. 22, 6191 (2021).
Mertlitz, S. et al. Lymphangiogenesis is a feature of acute GVHD, and VEGFR-3 inhibition protects against experimental GVHD. Blood 129, 1865–1875 (2017).
Valtola, R. et al. VEGFR-3 and its ligand VEGF-C are associated with angiogenesis in breast cancer. Am. J. Pathol. 154, 1381–1390 (1999).
Zhang, Y. et al. Activation of vascular endothelial growth factor receptor-3 in macrophages restrains TLR4-NF-κB signaling and protects against endotoxin shock. Immunity 40, 501–514 (2014).
Salameh, A. et al. Direct recruitment of CRK and GRB2 to VEGFR-3 induces proliferation, migration, and survival of endothelial cells through the activation of ERK, AKT, and JNK pathways. Blood 106, 3423–3431 (2005).
Leppänen, V. M. et al. Structural and mechanistic insights into VEGF receptor 3 ligand binding and activation. Proc. Natl Acad. Sci. USA 110, 12960–12965 (2013).
Tan, K. W. et al. Neutrophils contribute to inflammatory lymphangiogenesis by increasing VEGF-A bioavailability and secreting VEGF-D. Blood 122, 3666–3677 (2013).
Wuest, T. R. & Carr, D. J. VEGF-A expression by HSV-1-infected cells drives corneal lymphangiogenesis. J. Exp. Med. 207, 101–115 (2010).
Clatworthy, M. R., Harford, S. K., Mathews, R. J. & Smith, K. G. FcγRIIb inhibits immune complex-induced VEGF-A production and intranodal lymphangiogenesis. Proc. Natl Acad. Sci. USA 111, 17971–17976 (2014).
Liu, P. I. et al. ANGPTL2 promotes VEGF-A synthesis in human lung cancer and facilitates lymphangiogenesis. Aging 15, 1652–1667 (2023).
Del Vecchio, M. et al. Bevacizumab plus fotemustine as first-line treatment in metastatic melanoma patients: clinical activity and modulation of angiogenesis and lymphangiogenesis factors. Clin. Cancer Res. 16, 5862–5872 (2010).
Dumond, A. et al. Anti-vascular endothelial growth factor C antibodies efficiently inhibit the growth of experimental clear cell renal cell carcinomas. Cells 10, 1222 (2021).
Tampellini, M., Sonetto, C. & Scagliotti, G. V. Novel anti-angiogenic therapeutic strategies in colorectal cancer. Expert. Opin. Investig. Drugs 25, 507–520 (2016).
He, Y. et al. Suppression of tumor lymphangiogenesis and lymph node metastasis by blocking vascular endothelial growth factor receptor 3 signaling. J. Natl Cancer Inst. 94, 819–825 (2002).
Roberts, N. et al. Inhibition of VEGFR-3 activation with the antagonistic antibody more potently suppresses lymph node and distant metastases than inactivation of VEGFR-2. Cancer Res. 66, 2650–2657 (2006).
Zhu, G. et al. Pazopanib inhibits tumor growth, lymph-node metastasis and lymphangiogenesis of an orthotopic mouse of colorectal cancer. Cancer Genom. Proteom. 17, 131–139 (2020).
Mäkinen, T., Norrmén, C. & Petrova, T. V. Molecular mechanisms of lymphatic vascular development. Cell Mol. Life Sci. 64, 1915–1929 (2007).
Detry, B. et al. Sunitinib inhibits inflammatory corneal lymphangiogenesis. Investig. Ophthalmol. Vis. Sci. 54, 3082–3093, (2013).
Dufies, M. et al. Sunitinib stimulates expression of VEGFC by tumor cells and promotes lymphangiogenesis in clear cell renal cell carcinomas. Cancer Res. 77, 1212–1226 (2017).
Chen, Z. et al. Down-regulation of vascular endothelial cell growth factor-C expression using small interfering RNA vectors in mammary tumors inhibits tumor lymphangiogenesis and spontaneous metastasis and enhances survival. Cancer Res. 65, 9004–9011 (2005).
Shibata, M. A., Morimoto, J., Shibata, E. & Otsuki, Y. Combination therapy with short interfering RNA vectors against VEGF-C and VEGF-A suppresses lymph node and lung metastasis in a mouse immunocompetent mammary cancer model. Cancer Gene Ther. 15, 776–786 (2008).
Wang, J. et al. Fucoxanthin inhibits gastric cancer lymphangiogenesis and metastasis by regulating Ran expression. Phytomedicine 118, 154926 (2023).
Prangsaengtong, O. et al. Shikonin suppresses lymphangiogenesis via NF-κB/HIF-1α axis inhibition. Biol. Pharm. Bull. 41, 1659–1666 (2018).
Wang, W., Sukamtoh, E., Xiao, H. & Zhang, G. Curcumin inhibits lymphangiogenesis in vitro and in vivo. Mol. Nutr. Food Res. 59, 2345–2354 (2015).
Wilhelm, K. et al. FOXO1 couples metabolic activity and growth state in the vascular endothelium. Nature 529, 216–220 (2016).
Fagiani, E., Lorentz, P., Kopfstein, L. & Christofori, G. Angiopoietin-1 and -2 exert antagonistic functions in tumor angiogenesis, yet both induce lymphangiogenesis. Cancer Res. 71, 5717–5727 (2011).
Korhonen, E. A. et al. Lymphangiogenesis requires Ang2/Tie/PI3K signaling for VEGFR3 cell-surface expression. J. Clin. Investig. 132, e155478 (2022).
Akwii, R. G. et al. Angiopoietin-2-induced lymphatic endothelial cell migration drives lymphangiogenesis via the β1 integrin-RhoA-formin axis. Angiogenesis 25, 373–396 (2022).
Le, C. T. et al. Synergistic actions of blocking angiopoietin-2 and tumor necrosis factor-α in suppressing remodeling of blood vessels and lymphatics in airway inflammation. Am. J. Pathol. 185, 2949–2968 (2015).
Zhang, L. et al. Angiopoietin-2 blockade promotes survival of corneal transplants. Investig. Ophthalmol. Vis. Sci. 58, 79–86, (2017).
Wilhelm, S. M. et al. Regorafenib (BAY 73-4506): a new oral multikinase inhibitor of angiogenic, stromal and oncogenic receptor tyrosine kinases with potent preclinical antitumor activity. Int. J. Cancer 129, 245–255 (2011).
Takigawa, H. et al. Multikinase inhibitor regorafenib inhibits the growth and metastasis of colon cancer with abundant stroma. Cancer Sci. 107, 601–608 (2016).
Tarab-Ravski, D. et al. Delivery of therapeutic RNA to the bone marrow in multiple myeloma using CD38-targeted lipid nanoparticles. Adv. Sci. 10, e2301377 (2023).
Yan, Y. et al. Nanomedicines reprogram synovial macrophages by scavenging nitric oxide and silencing CA9 in progressive osteoarthritis. Adv. Sci. 10, e2207490 (2023).
Yarden, Y. The EGFR family and its ligands in human cancer. Signalling mechanisms and therapeutic opportunities. Eur. J. Cancer 37, S3–S8 (2001).
Bracher, A. et al. Epidermal growth factor facilitates melanoma lymph node metastasis by influencing tumor lymphangiogenesis. J. Investig. Dermatol. 133, 230–238 (2013).
Cripps, C. et al. Epidermal growth factor receptor targeted therapy in stages III and IV head and neck cancer. Curr. Oncol. 17, 37–48 (2010).
Pao, W. & Chmielecki, J. Rational, biologically based treatment of EGFR-mutant non-small-cell lung cancer. Nat. Rev. Cancer 10, 760–774 (2010).
Gore, J. et al. Combined targeting of TGF-β, EGFR and HER2 suppresses lymphangiogenesis and metastasis in a pancreatic cancer model. Cancer Lett. 379, 143–153 (2016).
Cao, R. et al. Collaborative interplay between FGF-2 and VEGF-C promotes lymphangiogenesis and metastasis. Proc. Natl Acad. Sci. USA 109, 15894–15899 (2012).
Platonova, N. et al. Evidence for the interaction of fibroblast growth factor-2 with the lymphatic endothelial cell marker LYVE-1. Blood 121, 1229–1237 (2013).
Cao, R. et al. Hepatocyte growth factor is a lymphangiogenic factor with an indirect mechanism of action. Blood 107, 3531–3536 (2006).
Guérit, E. et al. PDGF receptor mutations in human diseases. Cell Mol. Life Sci. 78, 3867–3881 (2021).
Zou, X. et al. Targeting the PDGF/PDGFR signaling pathway for cancer therapy: a review. Int J. Biol. Macromol. 202, 539–557 (2022).
Cao, R. et al. PDGF-BB induces intratumoral lymphangiogenesis and promotes lymphatic metastasis. Cancer cell 6, 333–345 (2004).
Kerr, A. & Baxter, R. C. Noncoding RNA actions through IGFs and IGF binding proteins in cancer. Oncogene 41, 3385–3393 (2022).
Baxter, R. C. Signaling pathways of the insulin-like growth factor binding proteins. Endocr. Rev. 44, 753–778 (2023).
Björndahl, M. et al. Insulin-like growth factors 1 and 2 induce lymphangiogenesis in vivo. Proc. Natl Acad. Sci. USA 102, 15593–15598 (2005).
Wang, S. H. et al. Tumour cell-derived WNT5B modulates in vitro lymphangiogenesis via induction of partial endothelial-mesenchymal transition of lymphatic endothelial cells. Oncogene 36, 1503–1515 (2017).
Lutze, G. et al. Non-canonical WNT-signaling controls differentiation of lymphatics and extension lymphangiogenesis via RAC and JNK signaling. Sci. Rep. 9, 4739 (2019).
Buttler, K., Becker, J., Pukrop, T. & Wilting, J. Maldevelopment of dermal lymphatics in Wnt5a-knockout-mice. Dev. Biol. 381, 365–376 (2013).
Nunan, R. et al. Ephrin-Bs drive junctional downregulation and actin stress fiber disassembly to enable wound re-epithelialization. Cell Rep. 13, 1380–1395 (2015).
Li, L. et al. EphB4/ephrinB2 contributes to imatinib resistance in chronic myeloid leukemia involved in cytoskeletal proteins. Int. J. Med. Sci. 13, 365–373 (2016).
Wang, Y. et al. Ephrin-B2 controls VEGF-induced angiogenesis and lymphangiogenesis. Nature 465, 483–486 (2010).
Abéngozar, M. A. et al. Blocking ephrinB2 with highly specific antibodies inhibits angiogenesis, lymphangiogenesis, and tumor growth. Blood 119, 4565–4576 (2012).
Katsuta, H. et al. EphrinB2-EphB4 signals regulate formation and maintenance of funnel-shaped valves in corneal lymphatic capillaries. Investig. Ophthalmol. Vis. Sci. 54, 4102–4108 (2013).
Hoopes, S. L., Willcockson, H. H. & Caron, K. M. Characteristics of multi-organ lymphangiectasia resulting from temporal deletion of calcitonin receptor-like receptor in adult mice. PloS One 7, e45261 (2012).
Hay, D. L., Walker, C. S. & Poyner, D. R. Adrenomedullin and calcitonin gene-related peptide receptors in endocrine-related cancers: opportunities and challenges. Endocr. Relat. Cancer 18, C1–C14 (2011).
Karpinich, N. O. et al. Adrenomedullin gene dosage correlates with tumor and lymph node lymphangiogenesis. FASEB J. 27, 590–600 (2013).
Yarla, N. S. et al. Targeting arachidonic acid pathway by natural products for cancer prevention and therapy. Semin. Cancer Biol. 40-41, 48–81 (2016).
Seo, M. J. & Oh, D. K. Prostaglandin synthases: Molecular characterization and involvement in prostaglandin biosynthesis. Prog. Lipid Res. 66, 50–68 (2017).
Matsuda, H. et al. Roles of mPGES-1, an inducible prostaglandin E synthase, in enhancement of LPS-induced lymphangiogenesis in a mouse peritonitis model. Life Sci. 142, 1–7 (2015).
Lala, P. K., Nandi, P. & Majumder, M. Roles of prostaglandins in tumor-associated lymphangiogenesis with special reference to breast cancer. Cancer Metastasis Rev. 37, 369–384 (2018).
Nandi, P. et al. PGE2 promotes breast cancer-associated lymphangiogenesis by activation of EP4 receptor on lymphatic endothelial cells. BMC Cancer 17, 11 (2017).
Rocha, P. N. et al. Role of thromboxane A2 in the induction of apoptosis of immature thymocytes by lipopolysaccharide. Clin. Diagn. Lab. Immunol. 12, 896–903 (2005).
Yang, C. W. & Unanue, E. R. Neutrophils control the magnitude and spread of the immune response in a thromboxane A2-mediated process. J. Exp. Med. 210, 375–387 (2013).
Matsuda, H. et al. Roles of thromboxane receptor signaling in enhancement of lipopolysaccharide-induced lymphangiogenesis and lymphatic drainage function in diaphragm. Arterioscler. Thromb. Vasc. Biol. 41, 1390–1407 (2021).
Tian, W. et al. Leukotrienes in tumor-associated inflammation. Front. Pharmacol. 11, 1289 (2020).
Wang, B. et al. Metabolism pathways of arachidonic acids: mechanisms and potential therapeutic targets. Signal. Transduct. Target. Ther. 6, 94 (2021).
Bhusan Tripathi, Y. et al. Effect of a dietary supplement on the reduction of lymphedema-progression in mouse tail-cut model. Eur. Rev. Med. Pharmacol. Sci. 25, 56–66 (2021).
Cribb, M. T. et al. The kinetics of lymphatic dysfunction and leukocyte expansion in the draining lymph node during LTB(4) antagonism in a mouse model of lymphedema. Int. J. Mol. Sci. 22, 4455 (2021).
Pyne, S. & Pyne, N. Sphingosine 1-phosphate signalling via the endothelial differentiation gene family of G-protein-coupled receptors. Pharmacol. Ther. 88, 115–131 (2000).
Yoon, C. M. et al. Sphingosine-1-phosphate promotes lymphangiogenesis by stimulating S1P1/Gi/PLC/Ca2+ signaling pathways. Blood 112, 1129–1138 (2008).
Nagahashi, M. et al. Sphingosine-1-phosphate produced by sphingosine kinase 1 promotes breast cancer progression by stimulating angiogenesis and lymphangiogenesis. Cancer Res. 72, 726–735 (2012).
Choi, J. W. et al. LPA receptors: subtypes and biological actions. Annu. Rev. Pharmacol. Toxicol. 50, 157–186 (2010).
Wu, P. Y. et al. Mechanisms of lysophosphatidic acid-mediated lymphangiogenesis in prostate cancer. Cancers 10, 413 (2018).
Mu, H. et al. Lysophosphatidic acid induces lymphangiogenesis and IL-8 production in vitro in human lymphatic endothelial cells. Am. J. Pathol. 180, 2170–2181 (2012).
Cech, T. R. & Steitz, J. A. The noncoding RNA revolution-trashing old rules to forge new ones. Cell 157, 77–94 (2014).
Li, X. et al. Long noncoding RNA ASLNC07322 functions in VEGF-C expression regulated by smad4 during colon cancer metastasis. Mol. Ther. Nucleic Acids 18, 851–862 (2019).
Wang, Y. et al. Long noncoding RNA VESTAR regulates lymphangiogenesis and lymph node metastasis of esophageal squamous cell carcinoma by enhancing VEGFC mRNA stability. Cancer Res. 81, 3187–3199 (2021).
Zheng, H. et al. Tumor-derived exosomal BCYRN1 activates WNT5A/VEGF-C/VEGFR3 feedforward loop to drive lymphatic metastasis of bladder cancer. Clin. Transl. Med. 11, e497 (2021).
Misir, S., Wu, N. & Yang, B. B. Specific expression and functions of circular RNAs. Cell Death Differ. 29, 481–491 (2022).
Yang, L., Wilusz, J. E. & Chen, L. L. Biogenesis and regulatory roles of circular RNAs. Annu. Rev. Cell Dev. Biol. 38, 263–289 (2022).
Yao, W. et al. Exosomal circ_0026611 contributes to lymphangiogenesis by reducing PROX1 acetylation and ubiquitination in human lymphatic endothelial cells (HLECs). Cell Mol. Biol. Lett. 28, 13 (2023).
Ismail, A. M. et al. Stem cell therapy using bone marrow-derived mononuclear cells in treatment of lower limb lymphedema: a randomized controlled clinical trial. Lymphat. Res. Biol. 16, 270–277 (2018).
Kumar, N. P., Banurekha, V. V., Nair, D. & Babu, S. Circulating angiogenic factors as biomarkers of disease severity and bacterial burden in pulmonary tuberculosis. PLoS One 11, e0146318 (2016).
Huber, G. F. et al. Podoplanin expression correlates with sentinel lymph node metastasis in early squamous cell carcinomas of the oral cavity and oropharynx. Int. J. Cancer 129, 1404–1409 (2011).
Yadav, K. et al. Immunohistochemistry study of tumor vascular normalization and anti-angiogenic effects of sunitinib versus bevacizumab prior to dose-dense doxorubicin/cyclophosphamide chemotherapy in HER2-negative breast cancer. Breast Cancer Res. Treat. 192, 131–142 (2022).
Wong, A. L. et al. Phase Ib/II randomized, open-label study of doxorubicin and cyclophosphamide with or without low-dose, short-course sunitinib in the pre-operative treatment of breast cancer. Oncotarget 7, 64089–64099 (2016).
Schoppmann, S. F. et al. HER2/neu expression correlates with vascular endothelial growth factor-C and lymphangiogenesis in lymph node-positive breast cancer. Ann. Oncol. 21, 955–960 (2010).
Qin, T. et al. Anlotinib suppresses lymphangiogenesis and lymphatic metastasis in lung adenocarcinoma through a process potentially involving VEGFR-3 signaling. Cancer Biol. Med. 17, 753–767 (2020).
Ong, H. S. et al. Cytoplasmic neuropilin 2 is associated with metastasis and a poor prognosis in early tongue cancer patients. Int. J. Oral. Maxillofac. Surg. 46, 1205–1219 (2017).
McCormack, F. X. et al. Efficacy and safety of sirolimus in lymphangioleiomyomatosis. N. Engl. J. Med. 364, 1595–1606 (2011).
Choi, I. et al. Visualization of lymphatic vessels by Prox1-promoter directed GFP reporter in a bacterial artificial chromosome-based transgenic mouse. Blood 117, 362–365 (2011).
González-Hernández, S. & Mukouyama, Y.-S. Lymphatic vasculature in the central nervous system. Front. Cell Dev. Biol. 11, 1150775 (2023).
Izen, R. M. et al. Postnatal development of lymphatic vasculature in the brain meninges. Dev. Dyn. 247, 741–753 (2018).
Bálint, L. et al. Lymph flow induces the postnatal formation of mature and functional meningeal lymphatic vessels. Front. Immunol. 10, 3043 (2019).
Ahn, J. H. et al. Meningeal lymphatic vessels at the skull base drain cerebrospinal fluid. Nature 572, 62–66 (2019).
Kapiainen, E. et al. Cooperation of angiopoietin-2 and angiopoietin-4 in Schlemm’s canal maintenance. Investig. Ophthalmol. Vis. Sci. 63, 1 (2022).
Wu, Y. et al. Organogenesis and distribution of the ocular lymphatic vessels in the anterior eye. JCI Insight 5, e135121 (2020).
Kizhatil, K. et al. Schlemm’s canal is a unique vessel with a combination of blood vascular and lymphatic phenotypes that forms by a novel developmental process. PLoS Biol. 12, e1001912 (2014).
Park, D.-Y. et al. Lymphatic regulator PROX1 determines Schlemm’s canal integrity and identity. J. Clin. Invest. 124, 3960–3974 (2014).
Du, J., Thomson, B. R., Onay, T. & Quaggin, S. E. Endothelial tyrosine kinase Tie1 is required for normal schlemm’s canal development-brief report. Arterioscler. Thromb. Vasc. Biol. 42, 348–351 (2022).
Thomson, B. R. et al. Cellular crosstalk regulates the aqueous humor outflow pathway and provides new targets for glaucoma therapies. Nat. Commun. 12, 6072 (2021).
Gancz, D., Perlmoter, G. & Yaniv, K. Formation and growth of cardiac lymphatics during embryonic development, heart regeneration, and disease. Cold Spring Harb. Perspect. Biol. 12, a037176 (2020).
Harrison, M. R. et al. Late developing cardiac lymphatic vasculature supports adult zebrafish heart function and regeneration. Elife 8, e42762 (2019).
Harris, N. R. et al. VE-Cadherin is required for cardiac lymphatic maintenance and signaling. Circ. Res. 130, 5–23 (2022).
Xu, W. et al. Small GTPase Rap1A/B is required for lymphatic development and adrenomedullin-induced stabilization of lymphatic endothelial junctions. Arterioscler. Thromb. Vasc. Biol. 38, 2410–2422 (2018).
Martucciello, S. et al. A dual role for Tbx1 in cardiac lymphangiogenesis through genetic interaction with Vegfr3. FASEB J. 34, 15062–15079 (2020).
Trivedi, A. & Reed, H. O. The lymphatic vasculature in lung function and respiratory disease. Front. Med. 10, 1118583 (2023).
Yao, L.-C. et al. Pulmonary lymphangiectasia resulting from vascular endothelial growth factor-C overexpression during a critical period. Circ. Res. 114, 806–822 (2014).
Fu, S. et al. c-JUN-mediated transcriptional responses in lymphatic endothelial cells are required for lung fluid clearance at birth. Proc. Natl Acad. Sci. USA 120, e2215449120 (2023).
Bobe, S. et al. Volumetric imaging reveals VEGF-C-dependent formation of hepatic lymph vessels in mice. Front. Cell Dev. Biol. 10, 949896 (2022).
Tanaka, M. & Iwakiri, Y. The hepatic lymphatic vascular system: structure, function, markers, and lymphangiogenesis. Cell Mol. Gastroenterol. Hepatol. 2, 733–749 (2016).
Huang, S. et al. Three-dimensional mapping of hepatic lymphatic vessels and transcriptome profiling of lymphatic endothelial cells in healthy and diseased livers. Theranostics 13, 639–658 (2023).
Crosswhite, P. L. et al. CHD4-regulated plasmin activation impacts lymphovenous hemostasis and hepatic vascular integrity. J. Clin. Investig. 126, 2254–2266 (2016).
Mahadevan, A. et al. The left-right Pitx2 pathway drives organ-specific arterial and lymphatic development in the intestine. Dev. Cell 31, 690–706 (2014).
Shimoda, H. et al. Abnormal recruitment of periendothelial cells to lymphatic capillaries in digestive organs of angiopoietin-2-deficient mice. Cell Tissue Res. 328, 329–337 (2007).
Davis, R. B. et al. Lymphatic deletion of calcitonin receptor-like receptor exacerbates intestinal inflammation. JCI Insight 2, e92465 (2017).
Mouta-Bellum, C. et al. Organ-specific lymphangiectasia, arrested lymphatic sprouting, and maturation defects resulting from gene-targeting of the PI3K regulatory isoforms p85alpha, p55alpha, and p50alpha. Dev. Dyn. 238, 2670–2679 (2009).
Chen, D. et al. RASA1-dependent cellular export of collagen IV controls blood and lymphatic vascular development. J. Clin. Invest. 129, 3545–3561 (2019).
Qin, L. et al. CCM3 loss-induced lymphatic defect is mediated by the augmented VEGFR3-ERK1/2 signaling. Arterioscler. Thromb. Vasc. Biol. 41, 2943–2960 (2021).
Saharinen, P. et al. Claudin-like protein 24 interacts with the VEGFR-2 and VEGFR-3 pathways and regulates lymphatic vessel development. Genes Dev. 24, 875–880 (2010).
Kenig-Kozlovsky, Y. et al. Ascending vasa recta are angiopoietin/Tie2-dependent lymphatic-like vessels. J. Am. Soc. Nephrol. 29, 1097–1107 (2018).
Jafree, D. J. et al. Spatiotemporal dynamics and heterogeneity of renal lymphatics in mammalian development and cystic kidney disease. Elife 8, e48183 (2019).
Muley, A. et al. Unique functions for Notch4 in murine embryonic lymphangiogenesis. Angiogenesis 25, 205–224 (2022).
Niessen, K. et al. The Notch1-Dll4 signaling pathway regulates mouse postnatal lymphatic development. Blood 118, 1989–1997 (2011).
Brown, H. M. & Russell, D. L. Blood and lymphatic vasculature in the ovary: development, function and disease. Hum. Reprod. Update 20, 29–39 (2014).
Brown, H. M., Robker, R. L. & Russell, D. L. Development and hormonal regulation of the ovarian lymphatic vasculature. Endocrinology 151, 5446–5455 (2010).
Brown, H. M. et al. Requirement for ADAMTS-1 in extracellular matrix remodeling during ovarian folliculogenesis and lymphangiogenesis. Dev. Biol. 300, 699–709 (2006).
van Impel, A. et al. Divergence of zebrafish and mouse lymphatic cell fate specification pathways. Development 141, 1228–1238 (2014).
Grimm, L. et al. Single-cell analysis of lymphatic endothelial cell fate specification and differentiation during zebrafish development. EMBO J. 42, e112590 (2023).
Del Giacco, L., Pistocchi, A. & Ghilardi, A. prox1b Activity is essential in zebrafish lymphangiogenesis. PLoS One 5, e13170 (2010).
Astin, J. W. et al. Vegfd can compensate for loss of Vegfc in zebrafish facial lymphatic sprouting. Development 141, 2680–2690 (2014).
Bower, N. I. et al. Vegfd modulates both angiogenesis and lymphangiogenesis during zebrafish embryonic development. Development 144, 507–518 (2017).
Vogrin, A. J. et al. Evolutionary differences in the Vegf/Vegfr code reveal organotypic roles for the endothelial cell receptor Kdr in developmental lymphangiogenesis. Cell Rep. 28, 2023–2036.e4 (2019).
Wang, G. et al. Specific fibroblast subpopulations and neuronal structures provide local sources of Vegfc-processing components during zebrafish lymphangiogenesis. Nat. Commun. 11, 2724 (2020).
Dupont, L. et al. ADAMTS2 and ADAMTS14 can substitute for ADAMTS3 in adults for pro-VEGFC activation and lymphatic homeostasis. JCI Insight 7, e151509 (2022).
Le Guen, L. et al. Ccbe1 regulates Vegfc-mediated induction of Vegfr3 signaling during embryonic lymphangiogenesis. Development 141, 1239–1249 (2014).
Cermenati, S. et al. Sox18 genetically interacts with VegfC to regulate lymphangiogenesis in zebrafish. Arterioscler. Thromb. Vasc. Biol. 33, 1238–1247 (2013).
Das, R. N. et al. Generation of specialized blood vessels via lymphatic transdifferentiation. Nature 606, 570–575 (2022).
Gauvrit, S. et al. HHEX is a transcriptional regulator of the VEGFC/FLT4/PROX1 signaling axis during vascular development. Nat. Commun. 9, 2704 (2018).
Arnold, H. et al. mafba and mafbb differentially regulate lymphatic endothelial cell migration in topographically distinct manners. Cell Rep. 39, 110982 (2022).
Shin, M. et al. Valves are a conserved feature of the zebrafish lymphatic system. Dev. Cell 51, 374–386.e5 (2019).
Meng, Y. et al. Temporospatial inhibition of Erk signaling is required for lymphatic valve formation. Signal. Transduct. Target. Ther. 8, 342 (2023).
Peng, D. et al. Proper migration of lymphatic endothelial cells requires survival and guidance cues from arterial mural cells. Elife 11, e74094 (2022).
Dunworth, W. P. et al. Bone morphogenetic protein 2 signaling negatively modulates lymphatic development in vertebrate embryos. Circ. Res. 114, 56–66 (2014).
Pedrioli, D. M. L. et al. miR-31 functions as a negative regulator of lymphatic vascular lineage-specific differentiation in vitro and vascular development in vivo. Mol. Cell Biol. 30, 3620–3634 (2010).
Geudens, I. et al. Role of delta-like-4/Notch in the formation and wiring of the lymphatic network in zebrafish. Arterioscler. Thromb. Vasc. Biol. 30, 1695–1702 (2010).
Britto, D. D. et al. Plexin D1 negatively regulates zebrafish lymphatic development. Development 149, dev200560 (2022).
Kim, J.-D. et al. Essential role of Apelin signaling during lymphatic development in zebrafish. Arterioscler. Thromb. Vasc. Biol. 34, 338–345 (2014).
Huang, H. et al. The RAS guanyl nucleotide-releasing protein RasGRP1 is involved in lymphatic development in zebrafish. J. Biol. Chem. 288, 2355–2364 (2013).
Lei, D. et al. Noncanonical protease-activated receptor 1 regulates lymphatic differentiation in zebrafish. iScience 24, 103386 (2021).
Yan, H. et al. CD146 is required for VEGF-C-induced lymphatic sprouting during lymphangiogenesis. Sci. Rep. 7, 7442 (2017).
Hußmann, M. et al. Svep1 is a binding ligand of Tie1 and affects specific aspects of facial lymphatic development in a Vegfc-independent manner. Elife 12, e82969 (2023).
Mauri, C., van Impel, A., Mackay, E. W. & Schulte-Merker, S. The adaptor protein Grb2b is an essential modulator for lympho-venous sprout formation in the zebrafish trunk. Angiogenesis 24, 345–362 (2021).
Coxam, B. et al. Pkd1 regulates lymphatic vascular morphogenesis during development. Cell Rep. 7, 623–633 (2014).
Chau, T. C. Y. et al. Pkd1 and Wnt5a genetically interact to control lymphatic vascular morphogenesis in mice. Dev. Dyn. 251, 336–349 (2022).
Hermans, K. et al. Role of synectin in lymphatic development in zebrafish and frogs. Blood 116, 3356–3366 (2010).
Grimm, L. et al. Yap1 promotes sprouting and proliferation of lymphatic progenitors downstream of Vegfc in the zebrafish trunk. Elife 8, e42881 (2019).
Koltowska, K. et al. The RNA helicase Ddx21 controls Vegfc-driven developmental lymphangiogenesis by balancing endothelial cell ribosome biogenesis and p53 function. Nat. Cell Biol. 23, 1136–1147 (2021).
Lim, A. H. et al. Motoneurons are essential for vascular pathfinding. Development 138, 3847–3857 (2011).
Baek, S. et al. The alternative splicing regulator Nova2 constrains vascular ERK signaling to limit specification of the lymphatic lineage. Dev. Cell 49, 279–292.e5 (2019).
de Oliveira, M. B. et al. Vasohibin 1 selectively regulates secondary sprouting and lymphangiogenesis in the zebrafish trunk. Development 148, dev194993 (2021).
Chen, J. et al. MicroRNA-126a directs lymphangiogenesis through interacting with chemokine and Flt4 signaling in zebrafish. Arterioscler. Thromb. Vasc. Biol. 36, 2381–2393 (2016).
Kontarakis, Z. et al. Mir-126 is a conserved modulator of lymphatic development. Dev. Biol. 437, 120–130 (2018).
Jung, H. M. et al. MicroRNA-mediated control of developmental lymphangiogenesis. Elife 8, e46007 (2019).
Kiesow, K. et al. Junb controls lymphatic vascular development in zebrafish via miR-182. Sci. Rep. 5, 15007 (2015).
Baluk, P. et al. Pathogenesis of persistent lymphatic vessel hyperplasia in chronic airway inflammation. J. Clin. Investig. 115, 247–257 (2005).
Mori, M. et al. Increased number and altered phenotype of lymphatic vessels in peripheral lung compartments of patients with COPD. Respir. Res. 14, 65 (2013).
Shin, K. et al. TH2 cells and their cytokines regulate formation and function of lymphatic vessels. Nat. Commun. 6, 6196 (2015).
Harding, J. et al. Lymphangiogenesis is induced by mycobacterial granulomas via vascular endothelial growth factor receptor-3 and supports systemic T-cell responses against mycobacterial antigen. Am. J. Pathol. 185, 432–445 (2015).
Lerner, T. R. et al. Lymphatic endothelial cells are a replicative niche for Mycobacterium tuberculosis. J. Clin. Investig. 126, 1093–1108 (2016).
El-Chemaly, S. et al. Abnormal lymphangiogenesis in idiopathic pulmonary fibrosis with insights into cellular and molecular mechanisms. Proc. Natl Acad. Sci. USA 106, 3958–3963 (2009).
Meinecke, A.-K. et al. Aberrant mural cell recruitment to lymphatic vessels and impaired lymphatic drainage in a murine model of pulmonary fibrosis. Blood 119, 5931–5942 (2012).
Heron, C. et al. Regulation and impact of cardiac lymphangiogenesis in pressure-overload-induced heart failure. Cardiovasc. Res. 119, 492–505 (2023).
Lin, Q.-Y. et al. VEGF-C/VEGFR-3 axis protects against pressure-overload induced cardiac dysfunction through regulation of lymphangiogenesis. Clin. Transl. Med. 11, e374 (2021).
Singla, B. et al. Role of R-spondin 2 in arterial lymphangiogenesis and atherosclerosis. Cardiovasc. Res. 117, 1489–1509 (2021).
Ishikawa, Y. et al. Lymphangiogenesis in myocardial remodelling after infarction. Histopathology 51, 345–353 (2007).
Liu, X. et al. Lymphoangiocrine signals promote cardiac growth and repair. Nature 588, 705–711 (2020).
Wang, W. et al. Lymphatic endothelial transcription factor Tbx1 promotes an immunosuppressive microenvironment to facilitate post-myocardial infarction repair. Immunity 56, 2342–2357 (2023).
Tamburini, B. A. J. et al. Chronic liver disease in humans causes expansion and differentiation of liver lymphatic endothelial cells. Front. Immunol. 10, 1036 (2019).
Burchill, M. A. et al. Oxidized low-density lipoprotein drives dysfunction of the liver lymphatic system. Cell Mol. Gastroenterol. Hepatol. 11, 573–595 (2021).
Tanaka, M. et al. The sympathetic nervous system promotes hepatic lymphangiogenesis, which is protective against liver fibrosis. Am. J. Pathol. 193, 2182–2202 (2023).
Li, W.-N. et al. Extracellular vesicle-associated VEGF-C promotes lymphangiogenesis and immune cells infiltration in endometriosis. Proc. Natl Acad. Sci. USA 117, 25859–25868 (2020).
Li, J. et al. Promotion of BST2 expression by the transcription factor IRF6 affects the progression of endometriosis. Front. Immunol. 14, 1115504 (2023).
Guo, R. et al. Inhibition of lymphangiogenesis and lymphatic drainage via vascular endothelial growth factor receptor 3 blockade increases the severity of inflammation in a mouse model of chronic inflammatory arthritis. Arthritis Rheum. 60, 2666–2676 (2009).
Lin, X. et al. Targeting synovial lymphatic function as a novel therapeutic intervention for age-related osteoarthritis in mice. Arthritis Rheumatol. 75, 923–936 (2023).
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Z.N.W., Y.X.S. and Y.N.X. supervised this work. Z.L.H. and X.S.Z. wrote/revised the manuscript and designed the figures and tables. Z.H.W. checked and polished the manuscript. B.C.Q. and M.X.Y. helped search and summarize the relative literature. All authors have read and approved the article.
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Hu, Z., Zhao, X., Wu, Z. et al. Lymphatic vessel: Origin, heterogeneity, biological functions and therapeutic targets. Sig Transduct Target Ther 9, 9 (2024). https://doi.org/10.1038/s41392-023-01723-x
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DOI: https://doi.org/10.1038/s41392-023-01723-x
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