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Collins K, Bridge JA, Mehra R, Mannan R, Dickson BC, Lotan TL, Idrees MT, Ulbright TM, Acosta AM. Renal epithelioid angiomyolipomas overexpress TFE3 and the TFE3-regulated gene TRIM63 in the absence of TFE3 rearrangement. Virchows Arch 2024; 485:471-478. [PMID: 38971946 DOI: 10.1007/s00428-024-03855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/23/2024] [Accepted: 06/14/2024] [Indexed: 07/08/2024]
Abstract
Angiomyolipoma (AML) is a neoplasm within the perivascular epithelioid cell tumor family that occurs somewhat frequently in the kidney. Most are indolent and discovered incidentally, with rare tumors demonstrating malignant clinical behavior. A small subset of renal AMLs with epithelioid features are associated with aggressive behavior, and may demonstrate morphologic overlap with renal cell carcinomas (e.g., clear cell renal cell carcinoma (RCC), TFE3-rearranged RCC). Prior studies of spindle cell and epithelioid AMLs have identified rare examples with underlying TFE3 gene fusions. TFE3 protein expression (demonstrated by immunohistochemistry) with no evidence of concurrent TFE3 rearrangements has been reported previously in 4/24 AMLs (17%) (Argani et al. Am J Surg Pathol 34:1395-1406, 2010). Currently, the relationship between TFE3 protein expression, TFE3 fusions, and expression of TFE3-mediated genes remains incompletely understood in renal epithelioid AMLs. We sought to explore these relationships using TFE3 break-apart fluorescence in situ hybridization (FISH) and TRIM63 RNA in situ hybridization (ISH) on epithelioid AMLs with moderate to strong TFE3 expression by immunohistochemistry. RNA sequencing (fusion panel) was performed on two cases with negative FISH results to assess for FISH-cryptic gene fusions. The series comprised five epithelioid AMLs from four patients (three women, one man) aged 13 to 76 years. All were considered positive for TFE3 by immunohistochemistry (2 + /3 + expression). TRIM63 ISH was performed on four specimens from three patients, yielding positive results in 3/3 tumors (100%) that were successfully analyzed. TFE3 break-apart FISH was performed on all samples, demonstrating a TFE3 rearrangement in only 1/4 tumors (25%). RNA sequencing demonstrated the absence of productive TFE3 gene fusions in three tumors with negative break-apart TFE3 FISH results. This study demonstrates that renal epithelioid AMLs overexpress TFE3 and TFE3-mediated genes (TRIM63) even in the absence of TFE3 rearrangements. This finding could be explained by functional upregulation of TFE3 secondary to activation of the mammalian target of rapamycin complex 1 (mTORC1). Expression of TFE3 and TRIM63 in this tumor type represents a potential pitfall, given the morphologic and immunophenotypic overlap between epithelioid AML and TFE3-altered renal cell carcinoma.
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Affiliation(s)
- Katrina Collins
- Department of Pathology, Indiana University School of Medicine, 305 W 11 Street, Room 4080, Indianapolis, IN, USA
| | - Julia A Bridge
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
- ProPath, Division of Molecular Pathology, Dallas, TX, USA
| | - Rohit Mehra
- Department of Pathology and Michigan Center for Translational Pathology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Rahul Mannan
- Department of Pathology and Michigan Center for Translational Pathology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Brendan C Dickson
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Tamara L Lotan
- Department of PathologyDepartment of OncologyDepartment of Urology, Johns Hopkins University School of MedicineJohns Hopkins University School of MedicineJohns Hopkins University School of Medicine, Baltimore, USA
| | - Muhammad T Idrees
- Department of Pathology, Indiana University School of Medicine, 305 W 11 Street, Room 4080, Indianapolis, IN, USA
| | - Thomas M Ulbright
- Department of Pathology, Indiana University School of Medicine, 305 W 11 Street, Room 4080, Indianapolis, IN, USA
| | - Andres M Acosta
- Department of Pathology, Indiana University School of Medicine, 305 W 11 Street, Room 4080, Indianapolis, IN, USA.
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Monich AG, Bissler JJ, Barreto FC. Tuberous Sclerosis Complex and the kidneys: what nephrologists need to know. J Bras Nefrol 2024; 46:e20240013. [PMID: 38991206 PMCID: PMC11239183 DOI: 10.1590/2175-8239-jbn-2024-0013en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/24/2024] [Indexed: 07/13/2024] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disease characterized by the development of hamartomas in the central nervous system, heart, skin, lungs, and kidneys and other manifestations including seizures, cortical tubers, radial migration lines, autism and cognitive disability. The disease is associated with pathogenic variants in the TSC1 or TSC2 genes, resulting in the hyperactivation of the mTOR pathway, a key regulator of cell growth and metabolism. Consequently, the hyperactivation of the mTOR pathway leads to abnormal tissue proliferation and the development of solid tumors. Kidney involvement in TSC is characterized by the development of cystic lesions, renal cell carcinoma and renal angiomyolipomas, which may progress and cause pain, bleeding, and loss of kidney function. Over the past years, there has been a notable shift in the therapeutic approach to TSC, particularly in addressing renal manifestations. mTOR inhibitors have emerged as the primary therapeutic option, whereas surgical interventions like nephrectomy and embolization being reserved primarily for complications unresponsive to clinical treatment, such as severe renal hemorrhage. This review focuses on the main clinical characteristics of TSC, the mechanisms underlying kidney involvement, the recent advances in therapy for kidney lesions, and the future perspectives.
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Affiliation(s)
- Aline Grosskopf Monich
- Universidade Federal do Paraná, Departamento de Clínica Médica, Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Curitiba, PR, Brazil
- Hospital Universitário Evangélico Mackenzie, Serviço de Nefrologia, Curitiba, PR, Brazil
| | - John J. Bissler
- University of Tennessee, Health Science Center, Le Bonheur Children's Hospital, Department of Pediatrics, Memphis, TN, USA
- Le Bonheur Children's Hospital, Children's Foundation Research Institute, Memphis, TN, USA
- St. Jude Children’s Research Hospital, Pediatric Medicine Department, Memphis, TN, USA
| | - Fellype Carvalho Barreto
- Universidade Federal do Paraná, Departamento de Clínica Médica, Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Curitiba, PR, Brazil
- Universidade Federal do Paraná, Departamento de Clínica Médica, Serviço de Nefrologia, Curitiba, PR, Brazil
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Dun S, Wang YY, Wan L, Wang QH, Lu Q, Yang XY, Zhang Q, Chen HM, Qiu LP, Zou LP. Sirolimus can promote the disappearance of renal angiomyolipoma associated with tuberous sclerosis complex: a prospective cohort study. World J Pediatr 2024; 20:602-610. [PMID: 37773307 DOI: 10.1007/s12519-023-00751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/17/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Renal angiomyolipoma (RAML) is the most common kidney lesion in patients with tuberous sclerosis complex (TSC), affecting about 80% of patients. It is a benign tumor that grows over time, usually bilaterally, and can easily lead to kidney complications such as acute hemorrhage. Herein, we investigated the efficacy and safety of sirolimus in children with TSC-associated RAML and explored the factors affecting tumor disappearance under sirolimus treatment through subgroup analysis. METHODS A prospective cohort study was conducted. Sirolimus was initiated at 1 mg/(m2 × day), and dose adjustments were made by a 2-week titration period to attain a trough blood concentration of 5-10 ng/mL. The disappearance of RAML in children after sirolimus treatment was observed, and Cox regression was used to screen the factors affecting tumor disappearance. RESULTS One hundred and twenty-six patients who met the criteria were analyzed. After 3 months, 6 months, 12 months, and 24 months of follow-up, tumors disappeared in 18 (14.3%), 30 (23.8%), 39 (31.0%), and 42 (33.3%) children, respectively. Tumors disappeared in 50 (39.7%) children by the last visit of each individual, and 30 (60%) of them occurred within 6 months. The multivariate Cox regression analysis showed that patients with a smaller maximum tumor diameter at baseline had a higher tumor disappearance rate. Thirty-six (29%) patients had stomatitis during the entire treatment period, and no serious adverse reactions were observed. CONCLUSIONS Sirolimus could promote the disappearance of TSC-related RAML. The disappearance rate was correlated with the maximum diameter at baseline, and the smaller the tumor was, the higher the disappearance rate. It is well tolerated in the treatment of RAML associated with TSC.
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Affiliation(s)
- Shuo Dun
- Medical School of Chinese PLA, Beijing 100853, China
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yang-Yang Wang
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Lin Wan
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiu-Hong Wang
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qian Lu
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiao-Yan Yang
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi Zhang
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Hui-Min Chen
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Lu-Peng Qiu
- Medical School of Chinese PLA, Beijing 100853, China
| | - Li-Ping Zou
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China.
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing 100069, China.
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De Bock T, Brussaard C, François S, François K, Seynaeve L, Jansen A, Wissing KM, Janssens P. Prevalence of Liver Steatosis in Tuberous Sclerosis Complex Patients: A Retrospective Cross-Sectional Study. J Clin Med 2024; 13:2888. [PMID: 38792433 PMCID: PMC11122077 DOI: 10.3390/jcm13102888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Introduction: Tuberous sclerosis complex (TSC) is a genetic disease caused by pathogenetic variants in either the TSC1 or TSC2 genes. Consequently, the mechanistic target of the rapamycin complex 1 (mTORC1) pathway, a regulator of cell growth, metabolism, and survival, becomes inappropriately activated, leading to the development of benign tumors in multiple organs. The role of mTORC1 in lipid metabolism and liver steatosis in TSC patients has not been well-studied, and clinical data on liver involvement in this population are scarce. Methods: We conducted a retrospective, cross-sectional study to compare liver steatosis in TSC patients with age-, sex-, BMI-, and diabetes status-matched controls. Participants with a definite diagnosis of TSC were recruited from the TSC clinic at UZ Brussel. Liver steatosis was quantified using the fat signal fraction from in-phase and out-of-phase MRI, with a threshold of ≥5% defining the presence of steatosis. We also evaluated the prevalence of liver angiomyolipomata in the TSC group and analyzed risk factors for both liver steatosis and angiomyolipomata. Results: The study included 59 TSC patients and 59 matched controls. The mean fat signal fraction was 4.0% in the TSC group and 3.9% in the controls, showing no significant difference (two-tailed Wilcoxon signed ranks test, p = 0.950). Liver steatosis was observed in 15.3% of TSC patients compared to 23.7% of the controls, which was not statistically significant (two-tailed McNemar test, p = 0.267). Liver angiomyolipomata were identified in 13.6% of the TSC cohort. Conclusions: Our study, describing in detail the liver phenotype of TSC patients, did not reveal a significant difference in the prevalence of MRI-assessed liver steatosis in a large cohort of TSC patients compared to a closely matched control group.
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Affiliation(s)
- Thaïs De Bock
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium; (T.D.B.); (K.F.); (K.M.W.)
| | - Carola Brussaard
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium;
| | - Silke François
- Department of Gastroenterology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium;
| | - Karlien François
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium; (T.D.B.); (K.F.); (K.M.W.)
| | - Laura Seynaeve
- Department of Neurology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium;
| | - Anna Jansen
- Department of Pediatric Neurology, Universitair Ziekenhuis Antwerpen (UZA), 2650 Antwerpen, Belgium;
| | - Karl Martin Wissing
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium; (T.D.B.); (K.F.); (K.M.W.)
| | - Peter Janssens
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium; (T.D.B.); (K.F.); (K.M.W.)
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Sasongko TH, Kademane K, Chai Soon Hou S, Jocelyn TXY, Zabidi-Hussin Z. Rapamycin and rapalogs for tuberous sclerosis complex. Cochrane Database Syst Rev 2023; 7:CD011272. [PMID: 37432030 PMCID: PMC10334695 DOI: 10.1002/14651858.cd011272.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Potential benefits of rapamycin or rapalogs for treating people with tuberous sclerosis complex (TSC) have been shown. Currently everolimus (a rapalog) is only approved for TSC-associated renal angiomyolipoma and subependymal giant cell astrocytoma (SEGA), but not other manifestations of TSC. A systematic review needs to establish evidence for rapamycin or rapalogs for various manifestations in TSC. This is an updated review. OBJECTIVES To determine the effectiveness of rapamycin or rapalogs in people with TSC for decreasing tumour size and other manifestations and to assess the safety of rapamycin or rapalogs in relation to their adverse effects. SEARCH METHODS We identified relevant studies from the Cochrane-Central-Register-of-Controlled-Trials (CENTRAL), Ovid MEDLINE and ongoing trials registries with no language restrictions. We searched conference proceedings and abstract books of conferences. Date of the last searches: 15 July 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs of rapamycin or rapalogs in people with TSC. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of each study; a third review author verified the extracted data and risk of bias decisions. We assessed the certainty of the evidence using GRADE. MAIN RESULTS The current update added seven RCTs, bringing the total number to 10 RCTs (with 1008 participants aged 3 months to 65 years; 484 males). All TSC diagnoses were by consensus criteria as a minimum. In parallel studies, 645 participants received active interventions and 340 placebo. Evidence is low-to-high certainty and study quality is mixed; mostly a low risk of bias across domains, but one study had a high risk of performance bias (lack of blinding) and three studies had a high risk of attrition bias. Manufacturers of the investigational products supported eight studies. Systemic administration Six studies (703 participants) administered everolimus (rapalog) orally. More participants in the intervention arm reduced renal angiomyolipoma size by 50% (risk ratio (RR) 24.69, 95% confidence interval (CI) 3.51 to 173.41; P = 0.001; 2 studies, 162 participants, high-certainty evidence). In the intervention arm, more participants in the intervention arm reduced SEGA tumour size by 50% (RR 27.85, 95% CI 1.74 to 444.82; P = 0.02; 1 study; 117 participants; moderate-certainty evidence) ,and reported more skin responses (RR 5.78, 95% CI 2.30 to 14.52; P = 0.0002; 2 studies; 224 participants; high-certainty evidence). In one 18-week study (366 participants), the intervention led to 25% fewer seizures (RR 1.63, 95% CI 1.27 to 2.09; P = 0.0001) or 50% fewer seizures (RR 2.28, 95% CI 1.44 to 3.60; P = 0.0004); but there was no difference in numbers being seizure-free (RR 5.30, 95% CI 0.69 to 40.57; P = 0.11) (moderate-certainty evidence). One study (42 participants) showed no difference in neurocognitive, neuropsychiatry, behavioural, sensory and motor development (low-certainty evidence). Total adverse events (AEs) did not differ between groups (RR 1.09, 95% CI 0.97 to 1.22; P = 0.16; 5 studies; 680 participants; high-certainty evidence). However, the intervention group experienced more AEs resulting in withdrawal, interruption of treatment, or reduced dose (RR 2.61, 95% CI 1.58 to 4.33; P = 0.0002; 4 studies; 633 participants; high-certainty evidence and also reported more severe AEs (RR 2.35, 95% CI 0.99 to 5.58; P = 0.05; 2 studies; 413 participants; high-certainty evidence). Topical (skin) administration Four studies (305 participants) administered rapamycin topically. More participants in the intervention arm showed a response to skin lesions (RR 2.72, 95% CI 1.76 to 4.18; P < 0.00001; 2 studies; 187 participants; high-certainty evidence) and more participants in the placebo arm reported a deterioration of skin lesions (RR 0.27, 95% CI 0.15 to 0.49; 1 study; 164 participants; high-certainty evidence). More participants in the intervention arm responded to facial angiofibroma at one to three months (RR 28.74, 95% CI 1.78 to 463.19; P = 0.02) and three to six months (RR 39.39, 95% CI 2.48 to 626.00; P = 0.009; low-certainty evidence). Similar results were noted for cephalic plaques at one to three months (RR 10.93, 95% CI 0.64 to 186.08; P = 0.10) and three to six months (RR 7.38, 95% CI 1.01 to 53.83; P = 0.05; low-certainty evidence). More participants on placebo showed a deterioration of skin lesions (RR 0.27, 95% CI 0.15 to 0.49; P < 0.0001; 1 study; 164 participants; moderate-certainty evidence). The intervention arm reported a higher general improvement score (MD -1.01, 95% CI -1.68 to -0.34; P < 0.0001), but no difference specifically in the adult subgroup (MD -0.75, 95% CI -1.58 to 0.08; P = 0.08; 1 study; 36 participants; moderate-certainty evidence). Participants in the intervention arm reported higher satisfaction than with placebo (MD -0.92, 95% CI -1.79 to -0.05; P = 0.04; 1 study; 36 participants; low-certainty evidence), although again with no difference among adults (MD -0.25, 95% CI -1.52 to 1.02; P = 0.70; 1 study; 18 participants; low-certainty evidence). Groups did not differ in change in quality of life at six months (MD 0.30, 95% CI -1.01 to 1.61; P = 0.65; 1 study; 62 participants; low-certainty evidence). Treatment led to a higher risk of any AE compared to placebo (RR 1.72, 95% CI 1.10, 2.67; P = 0.02; 3 studies; 277 participants; moderate-certainty evidence); but no difference between groups in severe AEs (RR 0.78, 95% CI 0.19 to 3.15; P = 0.73; 1 study; 179 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Oral everolimus reduces the size of SEGA and renal angiomyolipoma by 50%, reduces seizure frequency by 25% and 50% and implements beneficial effects on skin lesions with no difference in the total number of AEs compared to placebo; however, more participants in the treatment group required a dose reduction, interruption or withdrawal and marginally more experienced serious AEs compared to placebo. Topical rapamycin increases the response to skin lesions and facial angiofibroma, an improvement score, satisfaction and the risk of any AE, but not severe adverse events. With caution regarding the risk of severe AEs, this review supports oral everolimus for renal angiomyolipoma, SEGA, seizure, and skin lesions, and topical rapamycin for facial angiofibroma.
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Affiliation(s)
- Teguh Haryo Sasongko
- Department of Physiology, School of Medicine, International Medical University, Kuala Lumpur, Malaysia
- Institute for Research, Development, and Innovation, International Medical University, Kuala Lumpur, Malaysia
| | - Kumaraswamy Kademane
- Department of Pharmacology, Arunai Medical College and Hospital, Tiruvannamalai, Tamilnadu, India
| | - Stanley Chai Soon Hou
- Perdana University - Royal College of Surgeons in Ireland (RCSI) School of Medicine, Kuala Lumpur, Malaysia
| | - Tan Xin Yi Jocelyn
- Perdana University - Royal College of Surgeons in Ireland (RCSI) School of Medicine, Kuala Lumpur, Malaysia
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Egami A, Takahashi S, Kokubo T, Boggarapu S, Beresford E. Topical Sirolimus 0.2% Gel for the Management of Tuberous Sclerosis Complex-Related Cutaneous Manifestations: An Interim Analysis of Postmarketing Surveillance in Japan. Dermatol Ther (Heidelb) 2023; 13:1113-1126. [PMID: 36905480 PMCID: PMC10149422 DOI: 10.1007/s13555-023-00914-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/23/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder affecting several organs, including skin. We sought to assess the real-world effectiveness and safety of a topical sirolimus 0.2% gel treatment for TSC-related cutaneous manifestations. METHODS We conducted an interim analysis of postmarketing surveillance conducted in Japan over 52 weeks. A total of 635 and 630 patients were included in the safety and efficacy analysis sets, respectively. Improvement rate of overall cutaneous manifestations, responder rate of improvement in individual lesions, adverse events (AEs), adverse drug reactions (ADRs), and patient satisfaction level of topical sirolimus 0.2% gel treatment were evaluated along with patient characteristics associated with the improvement rate of cutaneous manifestations or safety. RESULTS The mean age of the patients was 22.9 years and 46.1% were men. At week 52 of treatment, the overall improvement rate was 74.8% and the responder rate was the highest for facial angiofibroma (86.2%). Overall, the incidence rates of AEs and ADRs were 24.6% and 18.4%, respectively. Efficacy was associated with age (< 15, ≥ 15 to < 65, and ≥ 65 years, p = 0.010), duration of use (p < 0.001), and total dosage (p = 0.005). Safety was associated with age (< 15, ≥ 15 to < 65, and ≥ 65 years, p = 0.011) and duration of use (p < 0.001). However, when the broad age group (≥ 15 to < 65) was subcategorized by 10-year intervals, the incidence of ADRs was similar among the age groups with no significant differences. Hepatic or renal impairment or concomitant use of systemic mTOR inhibitors had no effect on the effectiveness or safety. Overall, 53% of patients were "very satisfied" or "satisfied" with the treatment received. CONCLUSIONS Topical sirolimus 0.2% gel is effective in the management of TSC-related cutaneous manifestations and generally well tolerated. Age and duration of usage had a significant association with the effectiveness or safety of topical sirolimus 0.2% gel, whereas total dosage had a significant association with the effectiveness.
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Bissler JJ, Batchelor D, Kingswood JC. Progress in Tuberous Sclerosis Complex Renal Disease. Crit Rev Oncog 2023; 27:35-49. [PMID: 36734871 DOI: 10.1615/critrevoncog.2022042857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder that affects both fetal development and postnatal tissue growth, resulting in altered brain structures and a tumor predisposition syndrome. Although every organ system is affected by the disease, kidney involvement is a leading cause of death in adults with TSC. Over the past decade, significant progress has been made in understanding the renal disease. This review focuses on the cystic and solid renal lesions in TSC, including their pathobiology and treatment.
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Affiliation(s)
- John J Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN 38105; Children's Foundation Research Institute (CFRI), Le Bonheur Children's Hospital, Memphis, TN 38105; Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, TN 38105
| | - Dinah Batchelor
- Johns Hopkins All Children's Hospital, St. Petersburg, FL 33702
| | - J Christopher Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St. Georges University of London, London, United Kingdom
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Lashgari NA, Roudsari NM, Zadeh SST, Momtaz S, Abbasifard M, Reiner Ž, Abdolghaffari AH, Sahebkar A. Statins block mammalian target of rapamycin pathway: a possible novel therapeutic strategy for inflammatory, malignant and neurodegenerative diseases. Inflammopharmacology 2023; 31:57-75. [PMID: 36574095 PMCID: PMC9792946 DOI: 10.1007/s10787-022-01077-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/12/2022] [Indexed: 12/28/2022]
Abstract
Inflammation plays a critical role in several diseases such as cancer, gastric, heart and nervous system diseases. Data suggest that the activation of mammalian target of rapamycin (mTOR) pathway in epithelial cells leads to inflammation. Statins, the inhibitors of the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA), seem to be able to inhibit the mTOR. Statins are considered to have favorable effects on inflammatory diseases by reducing the complications caused by inflammation and by regulating the inflammatory process and cytokines secretion. This critical review collected data on this topic from clinical, in vivo and in vitro studies published between 1998 and June 2022 in English from databases including PubMed, Google Scholar, Scopus, and Cochrane libraries.
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Affiliation(s)
- Naser-Aldin Lashgari
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Nazanin Momeni Roudsari
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | | | - Saeideh Momtaz
- Medicinal Plants Research Center, Institute of Medicinal Plants, ACECR, Tehran, Iran
- Toxicology and Diseases Group (TDG), The Institute of Pharmaceutical Sciences (TIPS), and Faculty of Pharmacy, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
- GI Pharmacology Interest Group (GPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mitra Abbasifard
- Immunology of Infectious Diseases Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Department of Internal Medicine, Ali-Ibn Abi-Talib Hospital, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Željko Reiner
- Department of Internal Medicine, School of Medicine, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Amir Hossein Abdolghaffari
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.
- Medicinal Plants Research Center, Institute of Medicinal Plants, ACECR, Tehran, Iran.
- Toxicology and Diseases Group (TDG), The Institute of Pharmaceutical Sciences (TIPS), and Faculty of Pharmacy, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran.
- GI Pharmacology Interest Group (GPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- School of Medicine, The University of Western Australia, Perth, Australia.
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Wang Z, Liu X, Wang W, Xu J, Sun H, Wei J, Yu Y, Zhao Y, Wang X, Liao Z, Sun W, Jia L, Zhang Y. UPLC-MS based integrated plasma proteomic and metabolomic profiling of TSC-RAML and its relationship with everolimus treatment. Front Mol Biosci 2023; 10:1000248. [PMID: 36891236 PMCID: PMC9986496 DOI: 10.3389/fmolb.2023.1000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
Aim: To profile the plasma proteomics and metabolomics of patients with renal cysts, sporadic angiomyolipoma (S-AML) and tuberous sclerosis complex related angiomyolipoma (TSC-RAML) before and after everolimus treatment, and to find potential diagnostic and prognostic biomarkers as well as reveal the underlying mechanism of TSC tumorigenesis. Materials and Methods: We retrospectively measured the plasma proteins and metabolites from November 2016 to November 2017 in a cohort of pre-treatment and post-treatment TSC-RAML patients and compared them with renal cyst and S-AML patients by ultra-performance liquid chromatography-mass spectrometer (UPLC-MS). The tumor reduction rates of TSC-RAML were assessed and correlated with the plasma protein and metabolite levels. In addition, functional analysis based on differentially expressed molecules was performed to reveal the underlying mechanisms. Results: Eighty-five patients with one hundred and ten plasma samples were enrolled in our study. Multiple proteins and metabolites, such as pre-melanosome protein (PMEL) and S-adenosylmethionine (SAM), demonstrated both diagnostic and prognostic effects. Functional analysis revealed many dysregulated pathways, including angiogenesis synthesis, smooth muscle proliferation and migration, amino acid metabolism and glycerophospholipid metabolism. Conclusion: The plasma proteomics and metabolomics pattern of TSC-RAML was clearly different from that of other renal tumors, and the differentially expressed plasma molecules could be used as prognostic and diagnostic biomarkers. The dysregulated pathways, such as angiogenesis and amino acid metabolism, may shed new light on the treatment of TSC-RAML.
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Affiliation(s)
- Zhan Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaoyan Liu
- School of Basic Medical College, Core facility of instrument, Institution of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenda Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiyu Xu
- School of Basic Medical College, Core facility of instrument, Institution of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Haidan Sun
- School of Basic Medical College, Core facility of instrument, Institution of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Wei
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yuncui Yu
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhangcheng Liao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Sun
- School of Basic Medical College, Core facility of instrument, Institution of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Lulu Jia
- Clinical Research Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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10
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Wang Z, Zhang W, Fan Y, Zhang X. Safety and Effectiveness of Medical Therapy and Surgical Intervention for Renal Angiomyolipoma Associated With Tuberous Sclerosis Complex. Cancer Control 2022; 29:10732748221140266. [PMID: 36471546 PMCID: PMC9730008 DOI: 10.1177/10732748221140266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Our study aimed to evaluate the effect of daily oral dose of everolimus in the treatment of patients with tuberous sclerosis complex (TSC) associated with renal angiomyolipoma (RAML), and the feasibility and safety of surgical treatment approach. METHODS We retrospectively investigated a total of 13 patients diagnosed of TSC-associated renal angiomyolipoma (TSC-RAML) who were scheduled for everolimus therapy. At 3-9 months after starting everolimus therapy, 4 of the study patients were symptomatic and underwent partial renal resection surgery. Two of these surgeries were performed open nephron sparing surgery (NSS) after TAE (Trans-arterial embolization), while the remaining 2 underwent robot-assisted partial nephrectomy (RAPN). A multi-slice helical CT scan performed among all the patients every 3 months, which was used to measure the volume and the density of the lesion. RESULTS Follow-up CT images revealed a significant reduction (P < .05) in the RAML volume, at a rate ranging from 11.6 to 42.5%, in response to everolimus therapy (10 mg/day) in TSC-RAML patients. Further, a significant decrease in the mean tumor density (P < .05), as compared to its baseline value, was also observed. Super-selective renal arterial embolization done prior to NSS was effective in reducing the intraoperative bleeding and stabilizing the patient during the NSS procedure: mean warm ischemia time was 29.5 minutes (range 18-40 minutes) and mean intraoperative bleeding volume was 275 mL (range 200-350 mL). Post-surgical (both NSS and RAPN) follow-up showed a favorable perioperative morbidity profile with good renal functional preservation. At the end of 2 years, all patients were well, with no signs of progression or recurrence of the condition, and demonstrated normal renal function. CONCLUSIONS The results suggested oral everolimus as an effective non-invasive therapy to treat TSC-RAML patients. Post mTOR inhibitor therapy, NSS and RAPN are preferred mode of surgical intervention in symptomatic patients. TAE prior to NSS is beneficial.
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Affiliation(s)
- Zhiyu Wang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Zhang
- Department of Pharmacy, Zhengzhou Orthopaedics Hospital, Zhengzhou, China
| | - Yafeng Fan
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuepei Zhang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China,Xuepei Zhang, Department of Urology, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou 450052, China.
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11
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Tibarewal P, Rathbone V, Constantinou G, Pearce W, Adil M, Varyova Z, Folkes L, Hampson A, Classen GAE, Alves A, Carvalho S, Scudamore CL, Vanhaesebroeck B. Long-term treatment of cancer-prone germline PTEN mutant mice with low-dose rapamycin extends lifespan and delays tumour development. J Pathol 2022; 258:382-394. [PMID: 36073856 PMCID: PMC9828006 DOI: 10.1002/path.6009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/19/2022] [Accepted: 09/05/2022] [Indexed: 01/19/2023]
Abstract
PTEN is one of the most commonly inactivated tumour suppressor genes in sporadic cancer. Germline heterozygous PTEN gene alterations also underlie PTEN hamartoma tumour syndrome (PHTS), a rare human cancer-predisposition condition. A key feature of systemic PTEN deregulation is the inability to adequately dampen PI3-kinase (PI3K)/mTORC1 signalling. PI3K/mTORC1 pathway inhibitors such as rapamycin are therefore expected to neutralise the impact of PTEN loss, rendering this a more druggable context compared with those of other tumour suppressor pathways such as loss of TP53. However, this has not been explored in cancer prevention in a model of germline cancer predisposition, such as PHTS. Clinical trials of short-term treatment with rapamycin have recently been initiated for PHTS, focusing on cognition and colon polyposis. Here, we administered a low dose of rapamycin from the age of 6 weeks onwards to mice with heterozygous germline Pten loss, a mouse model that recapitulates most characteristics of human PHTS. Rapamycin was well tolerated and led to a highly significant improvement of survival in both male and female mice. This was accompanied by a delay in, but not full blockade of, the development of a range of proliferative lesions, including gastro-intestinal and thyroid tumours and endometrial hyperplasia, with no impact on mammary and prostate tumours, and no effect on brain overgrowth. Our data indicate that rapamycin may have cancer prevention potential in human PHTS. This might also be the case for sporadic cancers in which genetic PI3K pathway activation is an early event in tumour development, such as endometrial cancer and some breast cancers. To the best of our knowledge, this is the first report of a long-term treatment of a germline cancer predisposition model with a PI3K/mTOR pathway inhibitor. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
| | | | | | - Wayne Pearce
- Cancer Institute, University College London, London, UK
| | - Mahreen Adil
- Cancer Institute, University College London, London, UK
| | - Zofia Varyova
- Cancer Institute, University College London, London, UK
| | - Lisa Folkes
- Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - Alix Hampson
- Oxford Institute of Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | | | - Adriana Alves
- Cancer Institute, University College London, London, UK
| | - Sara Carvalho
- Cancer Institute, University College London, London, UK
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12
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Angiotensin II receptor type 1 blockade regulates Klotho expression to induce TSC2-deficient cell death. J Biol Chem 2022; 298:102580. [DOI: 10.1016/j.jbc.2022.102580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/20/2022] [Accepted: 09/25/2022] [Indexed: 11/13/2022] Open
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The Impact of TSC-1 and -2 Mutations on Response to Therapy in Malignant PEComa: A Multicenter Retrospective Analysis. Genes (Basel) 2022; 13:genes13111932. [PMID: 36360169 PMCID: PMC9689779 DOI: 10.3390/genes13111932] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Perivascular epithelioid cell neoplasms (PEComas) are a diverse family of mesenchymal tumors with myomelanocytic differentiation that disproportionately affect women and can be associated with tuberous sclerosis (TS). Although mTOR inhibition is widely used as first-line treatment, it is unclear what genomic alterations exist in these tumors and how they influence the response to therapy. Methods: This was a multicenter study conducted at five sites within the US. The data were collected from 1 January 2004 to 31 January 2021. We conducted a retrospective analysis to identify PEComa patients with next-generation sequencing (NGS) data and compared outcomes based on mutations. Results: No significant differences in survival were identified between TSC-1 and TSC-2 mutated PEComa or TSC-1/-2 versus other mutations. No significant difference was seen in progression-free survival (PFS) after first-line therapy between mTOR inhibition versus other systemic therapies. Conclusions: We were unable to detect differences in survival based on genomic alterations or PFS between mTOR inhibition versus other systemic therapies. Future studies should seek to identify other drivers of TSC-1/-2 silencing that could predict response to mTOR inhibition.
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14
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Characterization and management of facial angiofibroma related to tuberous sclerosis complex in the United States: retrospective analysis of the natural history database. Orphanet J Rare Dis 2022; 17:355. [PMID: 36104799 PMCID: PMC9476292 DOI: 10.1186/s13023-022-02496-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Facial angiofibroma is the most predominant cutaneous manifestation of tuberous sclerosis complex (TSC), a rare autosomal dominant genetic disorder impacting the mechanistic target of rapamycin (mTOR). Facial angiofibroma can bleed spontaneously, impair eyesight, and cause aesthetic disfiguration causing psychological and social stress. To date, there is little or no evidence on the demographics, and other TSC features associated with facial angiofibroma or the use of mTOR inhibitor for the management of facial angiofibroma. This is a retrospective study of TSC Alliance’s Natural History Database aimed to characterize facial angiofibroma and to evaluate features associated with a higher risk of facial angiofibroma or the use of topical mTOR inhibitors for the management of facial angiofibroma. Data in the NHD was obtained from 18 clinical sites in the US since 2006. Results Of the 2240 patients, 2088 patients were enrolled in the US and data from 2057 patients were included in this analysis. The mean (median) age of overall TSC patients was 22.4 (19.0) years. A total of 69 patients were ≤ 5 years of age. Facial angiofibroma was noted in 1329 (64.6%) patients with TSC. Patients with facial angiofibroma were older on average (Mean: 25.9 [median, 23.0] vs. 16.0 [12.4 years] years, p < 0.0001). In patients with vs. without facial angiofibroma, TSC2 mutation (38.9% vs. 34.8%) was more common than TSC1 mutation (12.3% vs. 18.1%), and the incidence rate of most of the other TSC-related manifestations was significantly higher in patients with facial angiofibroma. Majority of patients had focal seizures (72.8% vs. 60.7%), followed by angiomyolipoma (63.7% vs. 21.8%) and renal cysts (59.4% vs. 33.5%). The age groups, 11–17 (odds ratio [OR], 2.53) and 18–45 years (5.98), TSC2 mutation (1.31), focal seizures (1.50), ADHD (1.47) angiomyolipoma (2.79), and renal cysts (2.63) were significantly associated with a higher risk of facial angiofibroma based on multivariate logistic regression. Abrasive or laser therapy was used by 17.1% and 2.6% patients, respectively. Topical mTOR inhibitor use was noted for 329 (24.8%) patients with facial angiofibroma. Overall systemic mTOR inhibitor use was observed in 399 (30.0%) patients for management of one or more TSC manifestations. Use of systemic mTOR inhibitor for facial angiofibroma was noted for 163 (12.3%) patients, among whom only 9 (0.7%) patients used exclusively for the management of facial angiofibroma. Of the patients with facial angiofibroma, 44.6% did not receive any treatment. Significantly higher use of topical mTOR inhibitor was associated with the 11–17 years age group (OR, 1.67), anxiety (1.57), angiomyolipoma (1.51), and renal cysts (1.33). Conclusions The presence of TSC2 mutations and most other TSC-related manifestations was significantly higher in patients with facial angiofibroma. About one-fourth of patients with facial angiofibroma used a topical mTOR inhibitor and use of systemic mTOR inhibitor for the management of facial angiofibroma or for the other manifestations was noted for 30.0%. About 44.6% of patients did not receive any treatment for the management of facial angiofibroma.
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Li S, Zhan M, Wu S, Liao J, Xu H, Sun D, Zhao X, Wang Y. Population Pharmacokinetic Analysis and Dosing Optimization of Sirolimus in Children With Tuberous Sclerosis Complex. J Clin Pharmacol 2022; 62:948-959. [PMID: 35094415 DOI: 10.1002/jcph.2033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/25/2022] [Indexed: 02/05/2023]
Abstract
Sirolimus is confirmed to be effective in the treatment of tuberous sclerosis complex (TSC) and related disorders. The study aims to establish a population pharmacokinetic model of oral sirolimus for children with TSC and provide an evidence-based approach for individualization of sirolimus dosing in the pediatric population. A total of 64 children were recruited in this multicenter, retrospective pharmacokinetic study. Whole-blood concentrations of sirolimus, demographic, and clinical information were collected and analyzed using a nonlinear mixed-effects population modeling method. The final model was internally and externally validated. Then Monte Carlo simulations were performed to evaluate and optimize the dosing regimens. In addition, the efficacy and safety of sirolimus therapy was assessed retrospectively in patients with epilepsy or cardiac rhabdomyomas associated with TSC. Finally, the sirolimus pharmacokinetic profile was described by a 1-compartment model with first-order absorption and elimination along with body weight and total daily dose as significant covariates. The typical population parameter estimates of apparent volume of distribution and apparent clearance were 69.48 L and 2.79 L/h, respectively. Simulations demonstrated that dosage regimens stratified by body surface area may be more appropriate for children with TSC. These findings could be used to inform individualized dosing strategies of sirolimus for pediatric patients with TSC.
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Affiliation(s)
- SiChan Li
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
| | - Min Zhan
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - SanLan Wu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - JianXiang Liao
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - Hua Xu
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Dan Sun
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
- Department of Neurology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xia Zhao
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - Yang Wang
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
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16
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Gomes I, Jesus Ribeiro J, Palavra F. Monitoring and Managing Patients with Tuberous Sclerosis Complex: Current State of Knowledge. J Multidiscip Healthc 2022; 15:1469-1480. [PMID: 35860622 PMCID: PMC9292455 DOI: 10.2147/jmdh.s266990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/29/2022] [Indexed: 12/05/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disease of autosomal dominant transmission that, in most cases, results from the presence of pathogenic variants of the TSC1 or TSC2 genes, encoding hamartin and tuberin, respectively. It is a multisystemic disease, affecting most frequently the brain, skin, kidney, and heart. The wide variety of possible clinical manifestations, given this multisystem dimension, makes the follow-up of patients with TSC an exercise of multidisciplinarity. In fact, these patients may require the intervention of various medical specialties, which thus have to combine their efforts to practice a medicine that is truly holistic. The past few years have witnessed a dramatic leap not only in the diagnosis and management of TSC patients, with standard monitoring recommendations, but also in the therapeutic field, with the use of mTORC1 inhibitors. In this article, we review the clinical manifestations associated with TSC, as well as the treatment and follow-up strategies that should be implemented, from a multidisciplinary perspective.
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Affiliation(s)
- Inês Gomes
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - Filipe Palavra
- Center for Child Development - Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Laboratory of Pharmacology and Experimental Therapeutics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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17
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Luo C, Ye WR, Shi W, Yin P, Chen C, He YB, Chen MF, Zu XB, Cai Y. Perfect match: mTOR inhibitors and tuberous sclerosis complex. Orphanet J Rare Dis 2022; 17:106. [PMID: 35246210 PMCID: PMC8895788 DOI: 10.1186/s13023-022-02266-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/20/2022] [Indexed: 12/22/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant syndrome that presents with diverse and complex clinical features and involves multiple human systems. TSC-related neurological abnormalities and organ dysfunction greatly affect the quality of life and can even result in death in patients with TSC. It is widely accepted that most TSC-related clinical manifestations are associated with hyperactivation of the mammalian target of rapamycin (mTOR) pathway caused by loss‑of‑function mutations in TSC1 or TSC2. Remarkable progress in basic and translational research has led to encouraging clinical advances. Although mTOR inhibitors (rapamycin/everolimus) demonstrate great potential in TSC management, two major concerns hamper their generalized application. One is the frequent manifestation of adverse events, such as stomatitis, infections, and menstrual disorders; and the other is the poor response in certain patients. Thus, indicators are required to effectively predict the efficacy of mTOR inhibitors. Herein, we have summarized the current utilization of mTOR inhibitors in the treatment of TSC and focused on their efficacy and safety, in an attempt to provide a reference to guide the treatment of TSC. Hyperactivation of mammalian target of rapamycin (mTOR) is essential in the
pathogenesis of tuberous sclerosis complex (TSC) and can serve as a therapeutic
target. mTOR inhibitors have shown considerable success in multiple clinical trials for the treatment of TSC, including neurological, pulmonary, cardiac, renal, and cutaneous
phenotypes. mTOR inhibitors are associated with adverse events, which should be considered
during the management of TSC. Indicators to predict mTOR inhibitor efficacy are required to select patients who
are likely to benefit from such therapy.
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Affiliation(s)
- Cong Luo
- Department of Urology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Wen-Rui Ye
- Department of Neurosurgery, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Wei Shi
- Department of Dermatology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Ping Yin
- Department of Oral and Maxillofacial Surgery, Center of Stomatology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Chen Chen
- Department of Pediatrics, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Yun-Bo He
- Department of Urology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Min-Feng Chen
- Department of Urology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Xiong-Bin Zu
- Department of Urology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, 410008, Hunan Province, People's Republic of China
| | - Yi Cai
- Department of Urology, Disorders of Tuberous Sclerosis Complex (TSC) Multidisciplinary Team, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha City, 410008, Hunan Province, People's Republic of China.
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18
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Wang W, Wang Z, Zhao Y, Wang X, Li H, Zhang Y. Analysis of serum lipid parameters predicting lipid metabolic disorders in TSC-AML patients with treatment of mTOR inhibitors. J Clin Pharm Ther 2022; 47:979-985. [PMID: 35229896 DOI: 10.1111/jcpt.13631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Patients with tuberous sclerosis complex (TSC) demonstrate disrupted lipid homeostasis before and during treatment with mammalian target of rapamycin (mTOR) inhibitor. However, few previous reports focused on if the serum lipid status at baseline would influence lipid metabolic side-effects of mTOR inhibitors for TSC associated renal angiomyolipomas (TSC-AML). The present study was designed to evaluate the predictive function of serum lipid status at baseline for hyperlipidaemia by mTOR inhibitor treatment in TSC-AML patients. METHODS The clinical data of TSC-AML patients who took mTOR inhibitors in Department of Urology of Peking Union Medical College Hospital (PUMCH) from 1 January 2014 to 1 January 2021, were retrospectively analysed. The record of lipid parameters at baseline and the highest levels of total cholesterol (TC) and triglyceride (TG) after treatment at least ≥3 months were collected. The correlation of serum lipid parameters at baseline with incidence of hyperlipidaemia during mTOR inhibitor treatment was analysed. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the ability of the serum lipid parameters in predicting hyperlipidaemia. RESULTS AND DISCUSSION 19 patients experienced hyperlipidaemia and 13 patients still had normal TC and TG levels during mTOR inhibitor treatment. The levels of high-density lipoprotein cholesterol (HDL-C) (0.98 ± 0.30 mmol/L vs. 1.23 ± 0.31 mmol/L, p = 0.030), low-density lipoprotein cholesterol (LDL-C) (2.47 ± 0.69 mmol/L vs. 1.95 ± 0.53 mmol/L, p = 0.029) and apolipoprotein B (ApoB) (0.82 ± 0.21 g/L vs. 0.65 ± 0.16 g/L, p = 0.019) are higher in the patients who experienced hyperlipidaemia during mTOR inhibition therapy. TC, TG, LDL-C, ApoB and high-sensitivity C-reactive protein (hsCRP) at baseline had positive correlation with TC after treatment; ApoB at baseline had positive correlation, while HDL-C and free fat acid (FFA) at baseline had negative correlation with TG after treatment. Therefore, ApoB concentration at baseline has statistically significant correlation with both TC (p < 0.001) and TG (p = 0.012) levels after mTOR inhibitor treatment. ROC curve and AUC revealed that ApoB with a cut-off value of 0.640g/L may be the best parameter for predicting hyperlipidaemia during mTOR inhibitor treatment in TSC-AML patients. The incidence rates of hyperlipidaemia were 27.3% and 76.2% among the patients with ApoB level ≤0.640 g/L and >0.640 g/L respectively. WHAT IS NEW AND CONCLUSION Some baseline serum lipid parameters could be used for predicting incidence of hyperlipidaemia during mTOR inhibition therapy in TSC-AML patients, and ApoB with 0.640 g/L as a cut-off value may be a potentially optimal indicator, which could help for diagnosis and treatment decision-making.
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Affiliation(s)
- Wenda Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhan Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatr Neurol 2021; 123:50-66. [PMID: 34399110 DOI: 10.1016/j.pediatrneurol.2021.07.011] [Citation(s) in RCA: 257] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease affecting multiple body systems with wide variability in presentation. In 2013, Pediatric Neurology published articles outlining updated diagnostic criteria and recommendations for surveillance and management of disease manifestations. Advances in knowledge and approvals of new therapies necessitated a revision of those criteria and recommendations. METHODS Chairs and working group cochairs from the 2012 International TSC Consensus Group were invited to meet face-to-face over two days at the 2018 World TSC Conference on July 25 and 26 in Dallas, TX, USA. Before the meeting, working group cochairs worked with group members via e-mail and telephone to (1) review TSC literature since the 2013 publication, (2) confirm or amend prior recommendations, and (3) provide new recommendations as required. RESULTS Only two changes were made to clinical diagnostic criteria reported in 2013: "multiple cortical tubers and/or radial migration lines" replaced the more general term "cortical dysplasias," and sclerotic bone lesions were reinstated as a minor criterion. Genetic diagnostic criteria were reaffirmed, including highlighting recent findings that some individuals with TSC are genetically mosaic for variants in TSC1 or TSC2. Changes to surveillance and management criteria largely reflected increased emphasis on early screening for electroencephalographic abnormalities, enhanced surveillance and management of TSC-associated neuropsychiatric disorders, and new medication approvals. CONCLUSIONS Updated TSC diagnostic criteria and surveillance and management recommendations presented here should provide an improved framework for optimal care of those living with TSC and their families.
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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The effect of sirolimus on angiomyolipoma is determined by decrease of fat-poor compartments and includes striking reduction of vascular structures. Sci Rep 2021; 11:8493. [PMID: 33875750 PMCID: PMC8055687 DOI: 10.1038/s41598-021-87930-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 04/01/2021] [Indexed: 02/02/2023] Open
Abstract
Renal angiomyolipomas hemorrhage is associated with their size and vascular constitution. The effects of sirolimus on different components of angiomyolipomas was analyzed in patients with tuberous sclerosis complex, sporadic lymphangioleiomyomatosis and multiple sporadic angiomyolipomas. Thirty angiomyolipomas from 14 patients treated with sirolimus were retrospectively evaluated. A Hounsfield-unit threshold was used to classify angiomyolipomas in fat-rich, fat-poor and intermediate-fat tumors, and to categorize tumor compartments in fat rich, fat poor, intermediate fat and highly vascularized. Diameter variations were measured to assess the effects on aneurysmatic/ectatic vascular formations. Volume reduction following treatment with sirolimus was higher in fat-poor than fat-rich angiomyolipomas. Tumor reduction was mainly determined by decrease of the fat-poor and highly-vascularized compartments while the volume of the fat-rich compartment increased. Broad liposubstitution was observed in some tumors. A median reduction of 100% (75 to 100) in the diameter of aneurysmatic/ectatic vascular structures was observed. Our study showed that sirolimus reduces the size of angiomyolipomas by decreasing primarily their highly-vascularized and fat-poor compartments. This effect is associated with a remarkable reduction of tumoral aneurysms/ectatic vessels, revealing the likely mechanism responsible for the risk-decreasing effect of mTOR inhibitors on angiomyolipoma bleeding. These findings support the role of mTOR in the development of angiomyolipoma blood vessels.
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Viswanath V, Gupte JD, Prabhu N, Gour NL. Multiple Koenen Tumors, a Rare Entity: Combination Treatment with 1% Topical Sirolimus Electrofulguration and Excision. Skin Appendage Disord 2021; 7:66-70. [PMID: 33614724 DOI: 10.1159/000511743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/20/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Koenen tumors are benign, cutaneous manifestations of tuberous sclerosis. These are disfiguring, painful, and challenging to treat as they frequently recur. We report a case of long-standing, multiple Koenen tumors affecting all twenty nails in an elderly female who was successfully treated with a combination of topical sirolimus 1%, surgical excision, and electrofulguration. Case Report A 57-year-old lady presented with multiple, asymptomatic periungual, and subungual tumors affecting all twenty nails since 27 years. Cutaneous examination revealed confetti macules, ash-leaf macule, and shagreen patch over trunk. Nail biopsy was compatible with Koenen's tumor. Computerized tomography of brain showed diffuse patchy sclerosis. The tumors were treated with topical sirolimus 1% ointment for 10 months with excellent regression. Electro-fulguration for both great toenails and surgical excision of right thumbnail periungual fibroma was done. 1% sirolimus was advised after the surgical treatment. There were no adverse effects or recurrence of tumors over a 2-year follow-up. Discussion Topical sirolimus 1% was effective in tumor regression and preventing new tumor formation. Larger tumors that interfered in daily chores were treated with excision and electrofulguration. Thus, a combination treatment for this rare presentation of tuberous sclerosis provided optimum results.
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Affiliation(s)
- Vishalakshi Viswanath
- Disha Skin and Laser Institute, Thane, India.,Rajiv Gandhi Medical College & Chhatrapati Shivaji Maharaj Hospital, Thane, India
| | - Jay D Gupte
- Disha Skin and Laser Institute, Thane, India
| | | | - Nilima L Gour
- Rajiv Gandhi Medical College & Chhatrapati Shivaji Maharaj Hospital, Thane, India
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Abstract
Tuberous sclerosis complex (TSC) is a genetic condition caused by a mutation in either the TSC1 or TSC2 gene. Disruption of either of these genes leads to impaired production of hamartin or tuberin proteins, leading to the manifestation of skin lesions, tumors, and seizures. TSC can manifest in multiple organ systems with the cutaneous and renal systems being the most commonly affected. These manifestations can secondarily lead to the development of hypertension, chronic kidney disease, and neurocognitive declines. The renal pathologies most commonly seen in TSC are angiomyolipoma, renal cysts, and less commonly, oncocytomas. In this review, we highlight the current understanding on the renal manifestations of TSC along with current diagnosis and treatment guidelines.
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Bissler JJ, Budde K, Sauter M, Franz DN, Zonnenberg BA, Frost MD, Belousova E, Berkowitz N, Ridolfi A, Christopher Kingswood J. Effect of everolimus on renal function in patients with tuberous sclerosis complex: evidence from EXIST-1 and EXIST-2. Nephrol Dial Transplant 2020; 34:1000-1008. [PMID: 30053159 PMCID: PMC6545468 DOI: 10.1093/ndt/gfy132] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Indexed: 02/06/2023] Open
Abstract
Background A reduction in renal angiomyolipoma volume observed with everolimus (EVE) treatment in patients with tuberous sclerosis complex (TSC) has been postulated to translate to clinical benefit by reducing the risk of renal hemorrhage and chronic renal failure. Methods The long-term effects of EVE on renal function (∼4 years of treatment) were examined in patients treated with EVE in the Phase 3 EXIST-1 and EXIST-2 studies. Patients in EXIST-1 had TSC and subependymal giant cell astrocytoma (SEGA), and patients in EXIST-2 had renal angiomyolipoma and a definite diagnosis of TSC or sporadic lymphangioleiomyomatosis. EVE was administered at 4.5 mg/m2/day, with adjustment to achieve target trough levels of 5–15 ng/mL in EXIST-1 and at 10 mg/day in EXIST-2. Estimated glomerular filtration rate (eGFR) and creatinine levels were assessed at baseline, at Weeks 2, 4, 6, 8, 12 and 18, then every 3 months thereafter. Proteinuria was graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. Results A total of 111 patients from EXIST-1 and 112 patients from EXIST-2 were included in this analysis. Respective mean ages at EVE initiation were 10.5 [standard deviation (SD) 6.45] and 33.2 (SD 10.29) years, and 3.6% and 37.5% of patients had undergone prior renal intervention. Mean baseline eGFR was 115 and 88 mL/min/1.73 m2 in EXIST-1 and EXIST-2, respectively. Overall, mean eGFR remained stable over time in both studies, with an decline in renal function mostly confined to some patients with severely compromised renal function before treatment. Patients with prior renal intervention exhibited low eGFR values throughout the study. The incidence of proteinuria increased after initiating treatment with EVE and was mostly Grade 1/2 in severity, with Grade 3 proteinuria reported in only two patients. Measurements of proteinuria were limited by the use of urine dipstick tests. Conclusions The use of EVE does not appear to be nephrotoxic in patients with SEGA or renal angiomyolipoma associated with TSC and may preserve renal function in most patients. ClinicalTrials.gov identifiers NCT00789828 and NCT00790400
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Affiliation(s)
- John J Bissler
- St. Jude Children's Research Hospital and Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Matthias Sauter
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - David N Franz
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Elena Belousova
- Moscow Research and Clinical Institute of Pediatrics, Moscow, Russian Federation
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Wang Q, Luo M, Xiang B, Chen S, Ji Y. The efficacy and safety of pharmacological treatments for lymphangioleiomyomatosis. Respir Res 2020; 21:55. [PMID: 32059669 PMCID: PMC7023761 DOI: 10.1186/s12931-020-1316-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 02/08/2023] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) is a rare, low-grade multisystem neoplastic disease. Most LAM patients are at a high risk of losing lung function at an accelerated rate and developing progressive dyspnea. Recently, several studies have reported their experience with pharmacological treatments for LAM. Therefore, we conducted a systematic review and meta-analysis to assess the efficacy and safety of these therapies. Methods PubMed (Medline), EMBASE, Cochrane Library, Web of Science and EBSCO Host were searched (until March 31, 2019) for eligible prospective studies regarding LAM patients treated with pharmacological treatments. Random effect models were used for quantitative analysis. Results Fourteen prospective studies regarding five pharmacological treatments (including sirolimus, everolimus, doxycycline, triptorelin, and a combination therapy of sirolimus and hydroxychloroquine) were enrolled in our systematic review, and ten of them were used for the meta-analysis. Seven prospective studies reported that sirolimus was effective at improving or stabilizing lung function and alleviating renal angiomyolipoma (AML) in LAM patients. Subsequent quantitative analyses showed that during sirolimus treatment, the pooled values of lung function and 6-min walk distance (6MWD) were not significantly changed (P > 0.05), with the pooled response rate of AML being 0.62 (95% confidence intervals [CIs]: 0.43 to 0.82, I2 = 65%). Regarding everolimus, three prospective studies reported similar effects to those of sirolimus with regard to preserving lung function and reducing AMLs. The meta-analysis showed that the changes in lung function during everolimus treatment were not statistically significant (P > 0.05), while the pooled response rate of AML was 0.78 (95% CI: 0.68 to 0.88, I2 = 8%). Neither the qualitative nor the quantitative results confirmed the benefits of doxycycline or triptorelin treatment, and the effects of the combination therapy were unclear in LAM patients. Most of the adverse events during pharmacological treatments were low or moderate grade and tolerable. Conclusions Overall, sirolimus and everolimus were recommended for the treatment of LAM because they could stabilize lung function and alleviate renal AML. Doxycycline and triptorelin were not recommended for the treatment of LAM because no beneficial outcomes were consistently observed. The efficacy and safety of combination therapy remain to be further explored.
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Affiliation(s)
- Qi Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Mengqi Luo
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
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26
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Warren H, Olsburgh J. Management of Renal Cell Carcinoma and Other Renal Masses in the Kidney Graft. Curr Urol Rep 2020; 21:8. [PMID: 32048068 DOI: 10.1007/s11934-020-0959-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Renal masses in the kidney graft pose an important clinical dilemma, balancing graft function against the need for cancer control. RECENT FINDINGS Donor origin cancers in the renal graft can be classified as 'donor transmitted' or 'donor derived'. The landmark TracerX Renal changed our understanding of renal cell carcinoma oncogenesis, demonstrating that key mutations in childhood lead to clinically apparent tumours in later life. Identified pre-operatively, contemporary evidence suggests that masses excised prior to transplantation result in acceptable oncologic safety and graft function. Identified post-operatively management mirrors that for a mass in a solitary kidney in the non-transplant population, with focus on a nephron-sparing approach. With growing number of kidney transplants each year, ageing donors, and increasing graft survival, masses in the renal graft are likely to become a more prevalent clinical conundrum.
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Affiliation(s)
- Hannah Warren
- Department of Transplant Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - Jonathon Olsburgh
- Department of Transplant Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
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27
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Bhaoighill MN, Dunlop EA. Mechanistic target of rapamycin inhibitors: successes and challenges as cancer therapeutics. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2019; 2:1069-1085. [PMID: 35582282 PMCID: PMC9019212 DOI: 10.20517/cdr.2019.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/18/2019] [Accepted: 11/26/2019] [Indexed: 12/22/2022]
Abstract
Delineating the contributions of specific cell signalling cascades to the development and maintenance of tumours has greatly informed our understanding of tumorigenesis and has advanced the modern era of targeted cancer therapy. It has been revealed that one of the key pathways regulating cell growth, the phosphatidylinositol 3-kinase/mechanistic target of rapamycin (PI3K/mTOR) signalling axis, is commonly dysregulated in cancer. With a specific, well-tolerated inhibitor of mTOR available, the impact of inhibiting this pathway at the level of mTOR has been tested clinically. This review highlights some of the promising results seen with mTOR inhibitors in the clinic and assesses some of the challenges that remain in predicting patient outcome following mTOR-targeted therapy.
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Affiliation(s)
| | - Elaine A Dunlop
- Division of Cancer and Genetics, Cardiff University, Cardiff, CF14 4XN, UK
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28
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Ni J, Yan F, Qin W, Yu L, Zhang G, Liu F, Yang X, Yang B, Hao C, Wang T, Liu P, Yuan J, Wu G. Mutational analysis of renal angiomyolipoma associated with tuberous sclerosis complex and the outcome of short-term everolimus therapy. Sci Rep 2019; 9:14337. [PMID: 31586081 PMCID: PMC6778095 DOI: 10.1038/s41598-019-49814-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 08/31/2019] [Indexed: 12/22/2022] Open
Abstract
To identify clinical characteristics and mutation spectra in Chinese patients with renal angiomyolipoma (AML) associated with the tuberous sclerosis complex (TSC, TSC-AML), examined the efficacy and safety of short-term everolimus therapy (12 weeks). We analyzed the frequency distribution of each TSC-related clinical feature and investigated gene mutations by genetic testing. Some subjects received everolimus for 12 weeks at a dose of 10 mg/day, and the efficacy and safety of short-term everolimus therapy were examined. Finally, 82 TSC-AML patients were enrolled for analysis in this study. Of the 47 patients who underwent genetic testing, 22 patients (46.81%) had at least one detectable mutation in the TSC1 or TSC2 gene: 7 were TSC1 gene mutations, 13 were TSC2 gene mutations, and 2 were found in both TSC1 and TSC2. Everolimus treatment had a statistically significant effect on the renal AML volume reduction during follow-up (P < 0.05), and the mean reduction rate of volume for all cases was 56.47 ± 23.32% over 12 weeks. However, 7 patients (7/25; 28.00%) experienced an increase in renal AML tumor volume within 12 weeks after discontinuation of the everolimus treatment. Although most patients (27/30, 90.00%) experienced some adverse events during the treatment period, all such events were mild, and no patients discontinued or needed dose reduction because of adverse events. Overall, in this study, the mutation rate of TSC-AML patients is much lower than other reports. Short-term everolimus treatment for TSC-AML is effective and safe, but the stability is much lower than long-term therapy.
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Affiliation(s)
- Jianxin Ni
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Fengqi Yan
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.,Department of Urology, Tang Du Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710038, China
| | - Weijun Qin
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Lei Yu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Geng Zhang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Fei Liu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Xiaojian Yang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Bo Yang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Chunlin Hao
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Teng Wang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Pengfei Liu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Jianlin Yuan
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.
| | - Guojun Wu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.
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Słowińska M, Jóźwiak S. Emerging treatments and therapeutic targets for tuberous sclerosis complex in children. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1662295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Monika Słowińska
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
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30
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Abstract
The discoveries of new genes underlying genetic skin diseases have occurred at a rapid pace, supported by advances in DNA sequencing technologies. These discoveries have translated to an improved understanding of disease mechanisms at a molecular level and identified new therapeutic options based on molecular targets. This article highlights just a few of these recent discoveries for a diverse group of skin diseases, including tuberous sclerosis complex, ichthyoses, overgrowth syndromes, interferonopathies, and basal cell nevus syndrome, and how this has translated into novel targeted therapies and improved patient care.
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31
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Amin S, Kingswood JC, Bolton PF, Elmslie F, Gale DP, Harland C, Johnson SR, Parker A, Sampson JR, Smeaton M, Wright I, O'Callaghan FJ. The UK guidelines for management and surveillance of Tuberous Sclerosis Complex. QJM 2019; 112:171-182. [PMID: 30247655 DOI: 10.1093/qjmed/hcy215] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/15/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The severity of Tuberous Sclerosis Complex (TSC) can vary among affected individuals. Complications of TSC can be life threatening, with significant impact on patients' quality of life. Management may vary dependent on treating physician, local and national policies, and funding. There are no current UK guidelines. We conducted a Delphi consensus process to reach agreed guidance for the management of patients with TSC in the UK. METHODS We performed a literature search and reviewed the 2012/13 international guideline for TSC management. Based on these, a Delphi questionnaire was formed. We invited 86 clinicians and medical researchers to complete an online survey in two rounds. All the people surveyed were based in the UK. Clinicians were identified through the regional TSC clinics, and researchers were identified through publications. In round one, 55 questions were asked. In round two, 18 questions were asked in order to obtain consensus on the outstanding points that had been contentious in round one. The data was analysed by a core committee and subcommittees, which consisted of UK experts in different aspects of TSC. The Tuberous Sclerosis Association was consulted. RESULTS About 51 TSC experts took part in this survey. Two rounds were required to achieve consensus. The responders were neurologists, nephrologists, psychiatrist, psychologists, oncologists, general paediatricians, dermatologist, urologists, radiologists, clinical geneticists, neurosurgeons, respiratory and neurodisability clinicians. CONCLUSIONS These new UK guidelines for the management and surveillance of TSC patients provide consensus guidance for delivery of best clinical care to individuals with TSC in the UK.
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Affiliation(s)
- S Amin
- University Hospitals Bristol, Upper Maudlin Street, Education Centre Level 6, Bristol, UK
| | - J C Kingswood
- Brighton and Sussex University Hospitals, Eastern Rd, Brighton, East Sussex, UK
| | - P F Bolton
- King's College London, Institute of Psychiatry, London, UK
| | - F Elmslie
- St George's University Hospitals, Cranmer Terrace, London, UK
| | - D P Gale
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - C Harland
- Epsom & St Helier Hospital, Wrythe Lane, Carshalton, Surrey, UK
| | - S R Johnson
- Division of Respiratory Medicine, Faculty of Medicine & Health Sciences, Nottingham University, Nottingham, UK
| | - A Parker
- Addenbrooke's Hospital, Hills Road, Cambridge, Cambridgeshire, UK
| | - J R Sampson
- Division of Cancer and Genetics, University of Cardiff, Cardiff, UK
| | - M Smeaton
- Tuberous Sclerosis Association, CAN Mezzanine, 32-36 Loman Street, London, UK
| | - I Wright
- University of Bristol, The Priory Road Complex, Priory Road, Bristol, Clifton, UK
| | - F J O'Callaghan
- UCL GOS Institute of Child Health, 41 Clinical Neurosciences Section, 4th Floor Philip Ullman Wing South, London, UK
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Wang W, Guo H, Shi B, Sun H, Li H, Zhang Y, Cai Y. CT characteristics predict the response to everolimus or sirolimus of renal angiomyolipomas in patients with tuberous sclerosis complex. Int Urol Nephrol 2019; 51:671-676. [PMID: 30756282 DOI: 10.1007/s11255-019-02093-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/30/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate factors influencing the volume response of everolimus and sirolimus in tuberous sclerosis complex (TSC) associated-angiomyolipomas (AML). METHODS A retrospective analysis of 30 cases of TSC-AML treated by mTOR inhibitors (everolimus 18 cases, and sirolimus 12 cases) between April 2014 and November 2017 at our center was carried out. Epidemiological data, therapeutic response and influence factors were reviewed and analyzed. Age, sex, associated with SEGA and/or LAM or not, plasma rapamycin concentration, AML volume at baseline, and mean CT value of AML in the maximum cross-section at baseline were analyzed as potential influencing factors. RESULTS Eighteen patients with 32 lesions in everolimus group and 12 patients with 15 lesions in sirolimus group were included. There was no statistically significant difference of baseline characteristics except for involved side (P = 0.008) between two groups. The mean volume of AML was 1000 ± 1276 cm3 at baseline and 633 ± 1121 cm3 at 6 months after treatment (P < 0.001) in everolimus group, and 1984 ± 2861 cm3 at baseline and 1733 ± 2533 cm3 at 6 months after treatment (P = 0.001) in sirolimus group, respectively. The mean volume reduction of the AML in everolimus and sirolimus groups were 55.56% ± 23.79% and 30.5% ± 22.8% (P = 0.001). Stepwise multiple linear regression analysis revealed that factors influencing the short-term volume response of everolimus and sirolimus for TSC-associated AML were AML volume at baseline (P < 0.001 and 0.038, respectively) and mean CT value at baseline (P < 0.001 and 0.020, respectively). The rates of ≥ 50% volume reduction in high CT value group was much higher than that in low CT value group (90.5% vs. 18.2%, P < 0.001). CONCLUSIONS Everolimus at 10 mg daily might be more effective than sirolimus at 2 mg daily in treatment of patients with TSC-AML. AML volume and mean CT value at baseline were factors influencing the short-term volume response of everolimus or sirolimus for TSC-AML.
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Affiliation(s)
- Wenda Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hao Guo
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Bing Shi
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hao Sun
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Yi Cai
- Department of Urology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
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Gopalakrishnan V, Yao J, Steagall WK, Avila NA, Taveira-DaSilva AM, Stylianou M, Chen MY, Moss J. Use of CT Imaging to Quantify Progression and Response to Treatment in Lymphangioleiomyomatosis. Chest 2019; 155:962-971. [PMID: 30660784 DOI: 10.1016/j.chest.2019.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/10/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In lymphangioleiomyomatosis (LAM), infiltration of the lungs with smooth muscle-like LAM cells results in cystic destruction and decline in lung function, effects stabilized by sirolimus therapy. LAM lung disease is followed, in part, by high-resolution CT scans. To obtain further information from these scans, we quantified changes in lung parenchyma by analyzing image "texture." METHODS Twenty-six texture properties were quantified by analyzing the distribution and intensity of pixels with a computer-aided system. Both cross-sectional and longitudinal studies were performed to examine the relationships between texture properties, cyst score (percentage of lung occupied by cysts), FEV1, and diffusion capacity for carbon monoxide (Dlco), and to determine the effect of sirolimus treatment. RESULTS In the cross-sectional study, 18 texture properties showed significant positive correlations with cyst score. Cyst score and 13 of the 18 texture properties showed significant differences in rates of change after sirolimus treatment; 11 also significantly predicted FEV1 and Dlco. CONCLUSIONS Increased cyst score was associated with increased texture degradation near cysts. Sirolimus treatment improved lung texture surrounding cysts and stabilized cyst score. Eleven texture properties were associated with FEV1, Dlco, cyst score, and response to sirolimus. Texture analysis may be valuable in evaluating LAM severity and treatment response.
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Affiliation(s)
- Vissaagan Gopalakrishnan
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Jianhua Yao
- Radiology and Imaging Sciences Department, National Institutes of Health, Bethesda, MD
| | - Wendy K Steagall
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Nilo A Avila
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Radiology Service, Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Angelo M Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marcus Y Chen
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
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Liu CH, Chao WT, Lin SC, Lau HY, Wu HH, Wang PH. Malignant perivascular epithelioid cell tumor in the female genital tract: Preferred reporting items for systematic reviews and meta-analyses. Medicine (Baltimore) 2019; 98:e14072. [PMID: 30633211 PMCID: PMC6336598 DOI: 10.1097/md.0000000000014072] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal tumor, located at various anatomic sites, including the female genital tract. This study aimed to evaluate the clinicopathological characteristics of patients with PEComa arising from the female genital tract. METHODS A retrospective study was conducted in Taipei Veterans General Hospital (Taipei VGH) between 2008 and 2018. All published English cases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were also included in the current review. RESULTS A total of 114 women from PRISMA and 3 women from Taipei VGH were identified. The uterus was the most commonly involved site (82/114, 71.9%), followed by the cervix (12/114, 10.5%). Immunohistochemical staining showed that nearly all gynecological PEComas were positive for human melanoma black 45 (113/114, 99.1%). More than half of the gynecological PEComas were immunoreactive for desmin (50/85, 58.8%). Multi-modality treatment, including surgery and mammalian target of rapamycin (mTOR) inhibitors as targeted therapy, provided long-term disease-free survival (cure rate ranging from 50% to 100%, based on the different anatomic sites of the female genital tract). CONCLUSION Multi-modality treatment, including cytoreductive surgery and mTOR inhibitors with/without chemotherapy and/or radiation, should be considered for the management of women with PEComas in the genital tract.
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Affiliation(s)
- Chia-Hao Liu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital
- Institute of Clinical Medicine, National Yang-Ming University
- Department of Obstetrics and Gynecology, National Yang-Ming University
| | - Wei-Ting Chao
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital
- Department of Obstetrics and Gynecology, National Yang-Ming University
- School of Medicine, Fu-Jen Catholic University, New Taipei City
| | - Shih-Chieh Lin
- Institute of Clinical Medicine, National Yang-Ming University
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, National Defense Medical Center, Taipei
| | - Hei-Yu Lau
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital
- Department of Obstetrics and Gynecology, National Yang-Ming University
- School of Medicine, China Medical University, Taichung
| | - Hua-Hsi Wu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital
- Department of Obstetrics and Gynecology, National Yang-Ming University
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital
- Institute of Clinical Medicine, National Yang-Ming University
- Department of Obstetrics and Gynecology, National Yang-Ming University
- Department of Medical Research, China Medical University Hospital, Taichung
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Volpi A, Sala G, Lesma E, Labriola F, Righetti M, Alfano RM, Cozzolino M. Tuberous sclerosis complex: new insights into clinical and therapeutic approach. J Nephrol 2018; 32:355-363. [PMID: 30406604 DOI: 10.1007/s40620-018-0547-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
Tuberous sclerosis complex (TSC) is a complex disease with many different clinical manifestations. Despite the common opinion that TSC is a rare condition, with a mean incidence of 1/6000 live births and a prevalence of 1/20,000, it is increasingly evident that in reality this is not true. Its clinical sequelae span a range of multiple organ systems, in particular the central nervous system, kidneys, skin and lungs. The management of TSC patients is heavily burdensome in terms of time and healthcare costs both for the families and for the healthcare system. Management options include conservative approaches, surgery, pharmacotherapy with mammalian target of rapamycin inhibitors and recently proposed options such as therapy with anti-EGFR antibody and ultrasound-guided percutaneous microwaves. So far, however, no systematically accepted strategy has been found that is both clinically and economically efficient. Thus, decisions are tailored to patients' characteristics, resource availability and clinical and technical expertise of each single center. This paper reviews the pathophysiology and the clinical (diagnostic-therapeutic) management of TSC.
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Affiliation(s)
- Angela Volpi
- Laboratory of Experimental Nephrology, Renal Division, Dipartimento di Scienze della Salute, San Paolo Hospital, Università di Milano, Via A. di Rudinì, 8, 20142, Milan, Italy
| | - Gabriele Sala
- Laboratory of Experimental Nephrology, Renal Division, Dipartimento di Scienze della Salute, San Paolo Hospital, Università di Milano, Via A. di Rudinì, 8, 20142, Milan, Italy
| | - Elena Lesma
- Clinical Pharmacology Unit, San Paolo Hospital, Milan, Italy
| | | | | | | | - Mario Cozzolino
- Laboratory of Experimental Nephrology, Renal Division, Dipartimento di Scienze della Salute, San Paolo Hospital, Università di Milano, Via A. di Rudinì, 8, 20142, Milan, Italy.
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Franz DN, Krueger DA. mTOR inhibitor therapy as a disease modifying therapy for tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:365-373. [PMID: 30307123 DOI: 10.1002/ajmg.c.31655] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 11/07/2022]
Abstract
Between 1993 and 2003, through experiments involving Drosophila sp., cancer biologists identified the protein kinase known as the mammalian target of rapamycin, its pathway, and its relationship to the genes responsible for tuberous sclerosis. Thereafter, clinical research has resulted in regulatory approval of mTOR inhibitors for four distinct manifestations of the disease: giant cell astrocytoma, angiomyolipoma, lymphangioleiomyomatosis, and epilepsy. These developments are summarized and the practical use of mTOR inhibitors to improve the lives of patients with tuberous sclerosis reviewed.
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Affiliation(s)
- David Neal Franz
- Department of Pediatrics, Division of Child Neurology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Darcy Andrew Krueger
- Department of Pediatrics, Division of Child Neurology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Bissler JJ, Christopher Kingswood J. Renal manifestation of tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:338-347. [PMID: 30307110 DOI: 10.1002/ajmg.c.31654] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 11/07/2022]
Abstract
Tuberous sclerosis complex (TSC) is a tumor predisposition syndrome with significant renal cystic and solid tumor disease. It commonly causes several types of cystic disease and benign tumors (angiomyolipomata) in the kidneys that can both lead to significant premature loss of glomerular filtration rate. The main risks of angiomyolipomata, severe bleeding, loss of renal function, and pulmonary lymphangioleiomyomatosis, can be ameliorated by active surveillance and preemptive therapy with mTOR inhibitors. The cystogenic mechanism may involve primary cilia, but also appears to also involve a majority of normal tubular cells and may be driven by a minority of cells with mutations inactivating both their TSC1 or TSC2 genes. Malignant tumors are rare.
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Affiliation(s)
- John J Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN
- St. Jude Children's Research Hospital, Memphis, TN
| | - J Christopher Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St. Georges University of London, London, United kingdom
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Energy Stress-Mediated Cytotoxicity in Tuberous Sclerosis Complex 2-Deficient Cells with Nelfinavir and Mefloquine Treatment. Cancers (Basel) 2018; 10:cancers10100375. [PMID: 30308940 PMCID: PMC6210998 DOI: 10.3390/cancers10100375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 12/25/2022] Open
Abstract
To find new anti-cancer drug therapies, we wanted to exploit homeostatic vulnerabilities within Tuberous Sclerosis Complex 2 (TSC2)-deficient cells with mechanistic target of rapamycin complex 1 (mTORC1) hyperactivity. We show that nelfinavir and mefloquine synergize to selectively evoke a cytotoxic response in TSC2-deficient cell lines with mTORC1 hyperactivity. We optimize the concentrations of nelfinavir and mefloquine to a clinically viable range that kill cells that lack TSC2, while wild-type cells tolerate treatment. This new clinically viable drug combination causes a significant level of cell death in TSC2-deficient tumor spheroids. Furthermore, no cell recovery was apparent after drug withdrawal, revealing potent cytotoxicity. Transcriptional profiling by RNA sequencing of drug treated TSC2-deficient cells compared to wild-type cells suggested the cytotoxic mechanism of action, involving initial ER stress and an imbalance in energy homeostatic pathways. Further characterization revealed that supplementation with methyl pyruvate alleviated energy stress and reduced the cytotoxic effect, implicating energy deprivation as the trigger of cell death. This work underpins a critical vulnerability with cancer cells with aberrant signaling through the TSC2-mTORC1 pathway that lack flexibility in homeostatic pathways, which could be exploited with combined nelfinavir and mefloquine treatment.
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Lam HC, Siroky BJ, Henske EP. Renal disease in tuberous sclerosis complex: pathogenesis and therapy. Nat Rev Nephrol 2018; 14:704-716. [DOI: 10.1038/s41581-018-0059-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Liang S, Cuellar T, Nowacki M, Nayak BK, Dong L, Li B, Sharma K, Habib SL. A new drug combination significantly reduces kidney tumor progression in kidney mouse model. Oncotarget 2018; 9:32900-32916. [PMID: 30250638 PMCID: PMC6152473 DOI: 10.18632/oncotarget.26004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 07/27/2018] [Indexed: 11/25/2022] Open
Abstract
Tuberous sclerosis complex (TSC) disease is associated with tumors in many organs, particularly angiomyolipoma (AML) in the kidneys. Loss or inactivation of TSC1/2 results in high levels of HIF-α activity and VEGF expression. mTOR inhibitor (rapamycin) and the AMPK activator 5-aminoimidazole-4-carboxamide (AICA)-riboside (AICAR) are currently used separately to treat cancer patients. Here, we investigated the effect of a novel combination of rapamycin and AICAR on tumor progression. Our data show that treatment of AML human cells with drug combinations resulted in 5-7-fold increase in cell apoptosis compared to each drug alone. In addition, drug combinations resulted in 4-5-fold decrease in cell proliferation compared to each drug alone. We found that drug combinations abolished Akt and HIF activity in AML cells. The drug combinations resulted in decrease in cell invasion and cell immigration by 70% and 84%, respectively in AML cells. The combined drugs also significantly decreased the VEGF expression compare to each drug alone in AML cells. Drug combinations effectively abolished binding of HIF-2α to the putative Akt site in the nuclear extracts isolated from AML cells. Treatment TSC mice with drug combinations resulted in 75% decrease in tumor number and 88% decrease in tumor volume compared to control TSC mice. This is first evidence that drug combinations are effective in reducing size and number of kidney tumors without any toxic effect on kidney. These data will provide evidence for initiating a new clinical trial for treatment of TSC patients.
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Affiliation(s)
- Sitai Liang
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Tiffanie Cuellar
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Maciej Nowacki
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Bijaya K. Nayak
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Lily Dong
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Boajie Li
- Shanghai Jiao Tong University, Shanghai, China
| | - Kumar Sharma
- Department of Medicine, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
| | - Samy L. Habib
- Department of Cell Systems & Anatomy, University of Texas Health Science Center at San Antonio, Bio-X Institutes, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
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Gao N, Zhang T, Ji J, Xu KF, Tian X. The efficacy and adverse events of mTOR inhibitors in lymphangioleiomyomatosis: systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:134. [PMID: 30107845 PMCID: PMC6092843 DOI: 10.1186/s13023-018-0874-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/10/2018] [Indexed: 11/29/2022] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) is a rare lung disease and the mammalian target of the rapamycin (mTOR) inhibitors has been used as an effective therapy. Here we conducted a systematic review and meta-analysis with the aims to quantify the efficacy and safety of mTOR inhibitors in LAM patients. Methods The following databases were searched for clinical trials regarding LAM patients treated with mTOR inhibitors until December 2017: Pubmed, Embase, Cochrane Library and OVID medicine. Random effect models were used for the quantitative analysis. Results Nine eligible studies were included in our systematic review, 7 of which were used for the meta-analysis. In LAM patients, mTOR inhibitors improved forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) significantly, with the weighted mean difference (WMD) 0.15 L (95%CI: 0.08 to 0.22, P < 0.01, I2 = 0%) and 0.22 L (95%: 0.11 to 0.32, P < 0.01, I2 = 0%) respectively. There was no significant change in neither the diffusing capacity for carbon monoxide (WMD: 0.51 ml/mm Hg/min, 95%CI: -0.48 to 1.49, P = 0.31, I2 = 0%) nor 6-min walking distance (WMD: 5.29 m, 95%CI: -18.01 to 28.59, P = 0.66, I2 = 1%). The weighted partial response rate was 0.68 (95%CI: 0.53 to 0.84, P < 0.01, I2 = 72%) for renal angiomylipoma. The cumulative incidence rates of common safety events were 50, 40, 23, 20 and 19% for oral mucositis, hyperlipidemia, headache, bone marrow suppression, and diarrhea, respectively. And most events were low grade and tolerant. Conclusions In LAM patients, there are improvements of FEV1 and FVC after the application of mTOR inhibitors and over a half achieved the shrinkage of renal angiomyolipoma. Trial registration PROSPERO registration number: CRD42018085470. Registered 22 January 2018. Electronic supplementary material The online version of this article (10.1186/s13023-018-0874-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nannan Gao
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Tengyue Zhang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiadong Ji
- School of Statistics, Shandong University of Finance and Economics, Jinan, China
| | - Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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Franz DN, Budde K, Kingswood JC, Belousova E, Sparagana S, de Vries PJ, Berkowitz N, Ridolfi A, Bissler JJ. Effect of everolimus on skin lesions in patients treated for subependymal giant cell astrocytoma and renal angiomyolipoma: final 4-year results from the randomized EXIST-1 and EXIST-2 studies. J Eur Acad Dermatol Venereol 2018; 32:1796-1803. [PMID: 29569806 DOI: 10.1111/jdv.14964] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder associated with tumour growth in various organs, including the brain, kidneys, heart and skin. Cutaneous lesions are prevalent manifestations of TSC, occurring in up to 90% of patients. Oral mammalian target of rapamycin inhibitors, such as everolimus, is believed to be effective for treatment of TSC-associated lesions because they act on the underlying disease pathophysiology. OBJECTIVE We evaluated the long-term effect of oral everolimus on TSC-associated skin lesions as a secondary objective in the phase III studies EXIST-1 (NCT00789828) and EXIST-2 (NCT00790400) after approximately 4 years of treatment. MATERIALS AND METHODS Everolimus was dosed 4.5 mg/m2 /day (titrated to trough 5-15 ng/mL) in patients with TSC-associated subependymal giant cell astrocytoma in EXIST-1, and 10 mg/day initially in adult patients with TSC- or sporadic lymphangioleiomyomatosis-associated renal angiomyolipoma in EXIST-2. Following positive results from the core phase, remaining patients were offered open-label everolimus in an extension. Skin lesion response rate was the proportion of patients achieving complete or partial clinical response. RESULTS A total of 105 patients in EXIST-1 and 107 in EXIST-2 received everolimus and had ≥1 skin lesion at baseline. Skin lesion response rate (95% confidence interval) was 58.1% (48.1-67.7%) in EXIST-1 and 68.2% (58.5-76.9%) in EXIST-2; most were partial responses. At week 192 (EXIST-1: n = 55; EXIST-2: n = 56), 69% and 66% had a response. Most common drug-related adverse event was stomatitis (41-45%). CONCLUSION Oral everolimus improved TSC-related skin lesions, with responses sustained over 4 years of treatment in EXIST-1 and EXIST-2.
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Affiliation(s)
- D N Franz
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K Budde
- Charité Universitätsmedizin, Berlin, Germany
| | | | - E Belousova
- Moscow Research Institute of Pediatrics & Pediatric Surgery, Moscow, Russia
| | - S Sparagana
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - P J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - N Berkowitz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - A Ridolfi
- Novartis Pharmaceuticals S.A.S., Rueil-Malmaison, France
| | - J J Bissler
- St. Jude Children's Research Hospital and Le Bonheur Children's Hospital, Memphis, TN, USA
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Loss of tuberous sclerosis complex 2 sensitizes tumors to nelfinavir-bortezomib therapy to intensify endoplasmic reticulum stress-induced cell death. Oncogene 2018; 37:5913-5925. [PMID: 29980790 DOI: 10.1038/s41388-018-0381-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/10/2018] [Accepted: 05/31/2018] [Indexed: 11/08/2022]
Abstract
Cancer cells lose homeostatic flexibility because of mutations and dysregulated signaling pathways involved in maintaining homeostasis. Tuberous Sclerosis Complex 1 (TSC1) and TSC2 play a fundamental role in cell homeostasis, where signal transduction through TSC1/TSC2 is often compromised in cancer, leading to aberrant activation of mechanistic target of rapamycin complex 1 (mTORC1). mTORC1 hyperactivation increases the basal level of endoplasmic reticulum (ER) stress via an accumulation of unfolded protein, due to heightened de novo protein translation and repression of autophagy. We exploit this intrinsic vulnerability of tumor cells lacking TSC2, by treating with nelvinavir to further enhance ER stress while inhibiting the proteasome with bortezomib to prevent effective protein removal. We show that TSC2-deficient cells are highly dependent on the proteosomal degradation pathway for survival. Combined treatment with nelfinavir and bortezomib at clinically relevant drug concentrations show synergy in selectively killing TSC2-deficient cells with limited toxicity in control cells. This drug combination inhibited tumor formation in xenograft mouse models and patient-derived cell models of TSC and caused tumor spheroid death in 3D culture. Importantly, 3D culture assays differentiated between the cytostatic effects of the mTORC1 inhibitor, rapamycin, and the cytotoxic effects of the nelfinavir/bortezomib combination. Through RNA sequencing, we determined that nelfinavir and bortezomib tip the balance of ER protein homeostasis of the already ER-stressed TSC2-deficient cells in favor of cell death. These findings have clinical relevance in stratified medicine to treat tumors that have compromised signaling through TSC and are inflexible in their capacity to restore ER homeostasis.
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Tarasewicz A, Dębska-Ślizień A, Rutkowska B, Szurowska E, Matuszewski M. Efficacy and Safety of Mammalian Target of Rapamycin Inhibitor Use-Long-term Follow-up of First Tuberous Sclerosis Complex Patient Treated De Novo With Sirolimus After Kidney Transplantation: A Case Report. Transplant Proc 2018; 50:1904-1909. [PMID: 30056926 DOI: 10.1016/j.transproceed.2018.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 02/25/2018] [Accepted: 03/06/2018] [Indexed: 01/09/2023]
Abstract
Mammalian target of rapamycin inhibitors (mTORI) are increasingly used in the treatment of tuberous sclerosis complex (TSC) and as immunosuppressants after organ transplantation. In TSC patients, mTORI are the treatment of choice after kidney transplantation. It is still under debate if benefits from long-term mTORI use will not be limited by side effects. MATERIALS AND METHODS We report long-term follow-up data of the first TSC patient after kidney transplantation treated with sirolimus de novo. In 2005, a female patient was transplanted with a kidney graft after bilateral nephrectomy due to angiomyolipoma. Initial immunosuppressive treatment consisted of antithymocyte globulin, methylprednisolone, tacrolimus, and, due to TSC diagnosis, sirolimus. Creatinine level at discharge was 1.2 mg/dL. RESULTS Long-term mTORI use resulted in skin lesion regression (angiofibromas, "confetti" skin lesions, shagreen patch) and disease stabilization in brain, abdominal, and chest magnetic resonance imaging/computed tomography scans. Pulmonary function tests showed improvement in restriction and slow deterioration in obstruction and diffusion parameters. Sirolimus related adverse reactions were hyperlipidemia and hypertriglyceridemia and respiratory and urinary tract infections. No gastrointestinal or hematologic symptoms occurred. Sirolimus concentrations ranged between 1.7 and 8.2 ng/mL (mean 4.01 ± 2.09 ng/mL). Since 2009 proteinuria and slow increase in creatinine level have been observed. No biopsy was performed to establish etiology and potential association with mTORI. In 2017 creatinine level was 2.2 mg/dL. CONCLUSION The case of the patient confirms clinical effectiveness and acceptable safety of long-term mTORI treatment. Long-term mTORI use requires meticulous patient observation to optimize dosage, achieve immunosuppressive effect, and improve TSC manifestations with minimal side effects.
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Affiliation(s)
- A Tarasewicz
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| | - A Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - B Rutkowska
- Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
| | - E Szurowska
- Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
| | - M Matuszewski
- Department of Urology, Medical University of Gdańsk, Gdańsk, Poland
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Kirste S, Kayser G, Zipfel A, Grosu AL, Brunner T. Unresectable hepatic PEComa: a rare malignancy treated with stereotactic body radiation therapy (SBRT) followed by complete resection. Radiat Oncol 2018; 13:28. [PMID: 29463266 PMCID: PMC5819697 DOI: 10.1186/s13014-018-0974-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/11/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal tumors occurring in various anatomic regions. Although diagnostic criteria and treatment management are not established, current treatment options consist of surgery and chemotherapy including mTOR inhibitors. Stereotactic body radiation therapy (SBRT) is a non-invasive ablative treatment which has shown excellent control rates for more common types of unresectable liver tumors and metastases. In this report we present a rare case of PEComa of the liver that was treated by stereotactic radiotherapy followed by resection. Staging and evaluation of treatment response was done by FDG-PET/CT. This case highlights the potential of SBRT as a neoadjuvant treatment even for rare liver malignancies. It is the first case of liver PEComa treated by SBRT and resection. CASE PRESENTATION A 52-year-old woman presented at an external hospital with abdominal pressure and pain in the right upper abdominal quadrant. A CT scan showed a 700 cm3 liver lesion in segment IV. In repeated biopsy in July 2015 histopathological workup showed a pleomorphic epitheloid tumor with small to medium sized cells expressing vimentin and melan-A while being negative for cytokeratin establishing the diagnosis of PEComa of the liver. To achieve high, ablative doses a stereotactic body radiotherapy (SBRT) technique was chosen consisting of 60Gy (biologically effective dose 105Gy) in 8 fractions of 7.5Gy. Radiotherapy planning was based on MRI resulting in a planning target volume (PTV) of 1944 cm3. Treatment toxicity was limited to a slight elevation of transaminases (grade 1 and 3). A complete resection was performed 21 weeks after radiotherapy confirmed by negative surgical margins. At last follow-up 21 months after therapy, MRI showed neither local nor distant tumor recurrence. The patient was in stable condition (ECOG 1) and without late radiation toxicity. CONCLUSIONS This is the first documented case of liver PEComa treated by SBRT and resection. A favorable post-treatment course demonstrates that SBRT is a potential neoadjuvant treatment that is capable of reducing an inoperable rare liver tumor to a resectable lesion.
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Affiliation(s)
- Simon Kirste
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Str. 6, 79106 Freiburg, Germany
- German Cancer Consortium, Partner Site Freiburg (DKTK), Freiburg, Germany
| | - Gian Kayser
- Department of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Anne Zipfel
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Str. 6, 79106 Freiburg, Germany
- German Cancer Consortium, Partner Site Freiburg (DKTK), Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Str. 6, 79106 Freiburg, Germany
- German Cancer Consortium, Partner Site Freiburg (DKTK), Freiburg, Germany
| | - Thomas Brunner
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Str. 6, 79106 Freiburg, Germany
- German Cancer Consortium, Partner Site Freiburg (DKTK), Freiburg, Germany
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A Novel Mutation in TSC2 Gene: A 34-Year-Old Female with Pulmonary Lymphangioleiomyomatosis with Concomitant Hepatic Lesions. Case Rep Pulmonol 2018; 2018:5928231. [PMID: 29666741 PMCID: PMC5832095 DOI: 10.1155/2018/5928231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/20/2017] [Indexed: 11/17/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disease resulting from mutation(s) in TSC1 or TSC2 genes. TSC is associated with the formation of hamartomas in the brain, heart, eyes, skin, kidneys, and lymphangioleiomyomatosis (LAM) of the lungs. LAM is almost restricted to women in reproductive age. Different mutations in TSC1 and TSC2 genes have been reported in the literature. Here, we present a female patient with TSC-LAM with a novel mutation in TSC2 gene. The patient also had multiple hepatic angiomyolipomas, which is a relatively less-reported manifestation of the disease. The impact of this mutation on the pattern of disease presentation and response to treatment is not clear yet.
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Liver Angiomyolipomas in Tuberous Sclerosis Complex-Their Incidence and Course. Pediatr Neurol 2018; 78:20-26. [PMID: 29249553 DOI: 10.1016/j.pediatrneurol.2017.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the epidemiology and clinical significance of hepatic angiomyolipomas in patients with tuberous sclerosis complex. METHODS We performed a retrospective analysis of clinical and imaging data from 187 patients with tuberous sclerosis complex. The prevalence, progression, and potential relationship between liver lesions and other clinical findings, including genetic associations, were assessed. RESULTS Twenty-eight of 187 patients (14.9%) had hepatic lesions. There was a predominance of female over male patients in individuals with liver lesions (17 versus 11), with statistical significance in patients under five years of age (P < 0.05). All individuals having hepatic lesions who also had available genetic testing data (n = 20) were diagnosed with a TSC2 gene mutation. All patients with liver lesions had coexisting renal angiomyolipomas (AMLs) (P < 0.05). The age of onset of renal lesions was lower and their prevalence was significantly higher in patients with liver involvement (P < 0.05). In most instances, hepatic lesions measured several millimeters in diameter and were clinically asymptomatic. Progressive lesion growth was documented in six individuals but with no clinical consequences to date. CONCLUSIONS This study confirms the association of hepatic lesions with TSC2 mutations, a common origin of liver and renal AMLs, as well as the predominance of female patients in this group. Hepatic AMLs are relatively common but mostly benign lesions.
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Brakemeier S, Vogt L, Adams L, Zukunft B, Diederichs G, Hamm B, Budde K, Makowski MR. Treatment effect of mTOR-inhibition on tissue composition of renal angiomyolipomas in tuberous sclerosis complex (TSC). PLoS One 2017; 12:e0189132. [PMID: 29232371 PMCID: PMC5726644 DOI: 10.1371/journal.pone.0189132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/20/2017] [Indexed: 11/19/2022] Open
Abstract
Purpose Tuberous sclerosis complex (TSC)-associated renal angiomyolipoma (AML) have a high lifetime risk of acute bleeding. MTOR-inhibitors are a promising novel treatment for TSC-AML, however adequate response to therapy can be difficult to assess. Early changes in MRI signal may serve as a novel early indicator for a satisfactory response to mTOR-inhibitor therapy of AML. Materials and methods Thirty-eight patients with the definite diagnosis of tuberous sclerosis receiving everolimus therapy and n = 19 patients without specific therapy were included. 1.5 Tesla MRI was performed including sequences with a selective fat suppression. Patients were investigated prior to the initiation of therapy (baseline) and after <3 months (n = 21 patients), 3 to 6 months (n = 32) and 18 to 24 months (n = 28). Signal and size changes of renal AMLs were assessed at all different timepoints. Signal-to-noise-ratio (SNR), contrast-to-noise-ratio (CNR) and size of angiomyolipomas were evaluated. Results Signal changes in 273 AMLs were evaluated. A significant and strong decrease of the CNR of AMLs following the initiation of therapy was measured in the fat-suppressed MR sequence at all time points, compared to the baseline: From 7.41±6.98 to 3.84±6.25 (p ≤ 0.05p = 0.002), 3.36±6.93 (p<0.0001), and 2.50±6.68 (p<0.0001) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively. Also, a significant, however less pronounced, reduction of angiomyolipoma size in the different groups was measured (from baseline 2022.2±2657.7 mm2 to 1854.4±1670.9 mm2 (p = 0.009), 1875.5±3190.1 mm2 (p<0.001), and 1365.8 ± 1628.8 mm2 (p<0.0001) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively). No significant changes in CNR (p>0.05) and size (p>0.05) were measured in the control group. Conclusion mTOR inhibitor therapy in TSC patients results in an early and pronounced fatty transformation of AMLs on MRI. Fatty transformation could represent a novel early indicator of response to therapy in this patient collective.
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Affiliation(s)
- Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
- * E-mail:
| | - Lars Vogt
- Department of Radiology, Charité, Berlin, Germany
| | - Lisa Adams
- Department of Radiology, Charité, Berlin, Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | | | - Bernd Hamm
- Department of Radiology, Charité, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Marcus R. Makowski
- Department of Radiology, Charité, Berlin, Germany
- King’s College London, Division of Imaging Sciences, London, United Kingdom
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Abstract
INTRODUCTION Lymphangioleiomyomatosis (LAM) is a destructive lung disease affecting primarily women. LAM is caused by inactivating mutations in the tuberous sclerosis complex (TSC) genes, resulting in hyperactivation of mechanistic/mammalian target of rapamycin complex 1 (mTORC1). Over the past five years, there have been remarkable advances in the diagnosis and therapy of LAM, including the identification of vascular endothelial growth factor D (VEGF-D) as a diagnostic biomarker and the US Food and Drug Administration approval of sirolimus as therapy for LAM. In appropriate clinical situations VEGF-D testing can make lung biopsy unnecessary to diagnose LAM. However, there remains an urgent unmet need for additional biomarkers of disease activity and/or response to therapy. Areas covered: This work reviews VEGF-D, an established LAM biomarker, and discusses emerging biomarkers, including circulating LAM cells, imaging, lipid, and metabolite biomarkers, focusing on those with the highest potential impact for LAM patients. Expert commentary: Ongoing research priorities include the development of validated biomarkers to 1) noninvasively diagnose LAM in women whose VEGF-D levels are not diagnostic, 2) accurately predict the likelihood of disease progression and 3) quantitatively measure disease activity and LAM cell burden. These biomarkers would enable personalized, precision clinical care and fast-track clinical trial implementation, with high clinical impact.
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Affiliation(s)
- Julie Nijmeh
- a Pulmonary and Critical Care Medicine, Department of Medicine , Brigham and Women's Hospital and Harvard Medical School , Boston , MA , USA
| | - Souheil El-Chemaly
- a Pulmonary and Critical Care Medicine, Department of Medicine , Brigham and Women's Hospital and Harvard Medical School , Boston , MA , USA
| | - Elizabeth P Henske
- a Pulmonary and Critical Care Medicine, Department of Medicine , Brigham and Women's Hospital and Harvard Medical School , Boston , MA , USA
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Rutkowski PL, Mullen JT. Management of the "Other" retroperitoneal sarcomas. J Surg Oncol 2017; 117:79-86. [PMID: 29127695 DOI: 10.1002/jso.24893] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/07/2017] [Indexed: 12/12/2022]
Abstract
The focus of this review is on the management of the less common sarcomas occurring in the retroperitoneal space, including solitary fibrous tumor (SFT), malignant peripheral nerve sheath tumor (MPNST), perivascular epithelioid cell tumor (PEComa), and undifferentiated pleomorphic sarcoma (UPS) of the psoas muscle. As for other retroperitoneal sarcomas, surgical resection is the mainstay of curative therapy, and multidisciplinary preoperative assessment, including percutaneous needle biopsy for histologic confirmation, is the basis for personalized management, as the surgical management, and the integration of systemic therapy and radiation therapy is unique to each histologic subtype.
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Affiliation(s)
- Piotr L Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland
| | - John T Mullen
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, Massacheusetts
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