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Keskinoglu A, Tekgül H, Kabasakal C. Renal involvement in children with tuberous sclerosis. NEUROL SCI NEUROPHYS 2021. [DOI: 10.4103/nsn.nsn_35_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Xu Z, Wu J, Xu G, Luo H. Abdominal ultrasonographic manifestations in pediatric patients with tuberous sclerosis complex. Transl Pediatr 2020; 9:757-767. [PMID: 33457297 PMCID: PMC7804489 DOI: 10.21037/tp-20-150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare genetic disease which leads to formation of benign tumors in the brain and other organs of the body. Ultrasound (US) can detect the location, quantity, size and internal echo of TSC-associated renal diseases, liver angiomyolipoma (AML), and co-existing lesions, providing important diagnostic basis for clinical diagnosis. The aim of the present study was to investigate the abdominal ultrasonographic features of pediatric TSC and explore the advantages of abdominal ultrasonography in clinical practice. METHODS Data of children with TSC, who presented to the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, between January 2016 and November 2018, were analyzed by a retrospective chart review. The cases were identified from electronic medical records (EMR) system and underwent ultrasonography, we yielded a total of 12 patients. RESULTS The 12 pediatric patients, including 5 boys and 7 girls, ranged in age from 9 months to 13 years old. And they all had a history of epilepsy. All the patients underwent brain magnetic resonance imaging (MRI) or computed tomography (CT) examination, which revealed a scattered distribution of multiple hyperintense nodules. Of the 12 patients, 10 had TSC-associated bilateral renal AMLs, 5 had hepatic AML, and 4 had renal cysts. CONCLUSIONS US is a useful and non-invasive tool for the detection of TSC-associated renal and liver lesions and for clinical follow-up among pediatric patients.
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Affiliation(s)
- Zhihua Xu
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Junbo Wu
- Department of Ultrasound Imaging, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guimin Xu
- Department of Anesthesia, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hongxia Luo
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
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Li G, Wang M, Caulk AW, Cilfone NA, Gujja S, Qin L, Chen PY, Chen Z, Yousef S, Jiao Y, He C, Jiang B, Korneva A, Bersi MR, Wang G, Liu X, Mehta S, Geirsson A, Gulcher JR, Chittenden TW, Simons M, Humphrey JD, Tellides G. Chronic mTOR activation induces a degradative smooth muscle cell phenotype. J Clin Invest 2020; 130:1233-1251. [PMID: 32039915 DOI: 10.1172/jci131048] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 12/03/2019] [Indexed: 01/01/2023] Open
Abstract
Smooth muscle cell (SMC) proliferation has been thought to limit the progression of thoracic aortic aneurysm and dissection (TAAD) because loss of medial cells associates with advanced disease. We investigated effects of SMC proliferation in the aortic media by conditional disruption of Tsc1, which hyperactivates mTOR complex 1. Consequent SMC hyperplasia led to progressive medial degeneration and TAAD. In addition to diminished contractile and synthetic functions, fate-mapped SMCs displayed increased proteolysis, endocytosis, phagocytosis, and lysosomal clearance of extracellular matrix and apoptotic cells. SMCs acquired a limited repertoire of macrophage markers and functions via biogenesis of degradative organelles through an mTOR/β-catenin/MITF-dependent pathway, but were distinguishable from conventional macrophages by an absence of hematopoietic lineage markers and certain immune effectors even in the context of hyperlipidemia. Similar mTOR activation and induction of a degradative SMC phenotype in a model of mild TAAD due to Fbn1 mutation greatly worsened disease with near-uniform lethality. The finding of increased lysosomal markers in medial SMCs from clinical TAAD specimens with hyperplasia and matrix degradation further supports the concept that proliferation of degradative SMCs within the media causes aortic disease, thus identifying mTOR-dependent phenotypic modulation as a therapeutic target for combating TAAD.
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Affiliation(s)
- Guangxin Li
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Breast and Thyroid Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Mo Wang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alexander W Caulk
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA
| | - Nicholas A Cilfone
- Computational Statistics and Bioinformatics Group, Advanced Artificial Intelligence Research Laboratory, WuXi NextCODE, Cambridge, Massachusetts, USA
| | - Sharvari Gujja
- Computational Statistics and Bioinformatics Group, Advanced Artificial Intelligence Research Laboratory, WuXi NextCODE, Cambridge, Massachusetts, USA
| | - Lingfeng Qin
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Zehua Chen
- Computational Statistics and Bioinformatics Group, Advanced Artificial Intelligence Research Laboratory, WuXi NextCODE, Cambridge, Massachusetts, USA
| | - Sameh Yousef
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yang Jiao
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Changshun He
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bo Jiang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arina Korneva
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA
| | - Matthew R Bersi
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA
| | | | - Xinran Liu
- Cell Biology, Yale School of Medicine, New Haven, Connecticut, USA.,Center for Cellular and Molecular Imaging, EM Core Facility, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Arnar Geirsson
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.,Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey R Gulcher
- Computational Statistics and Bioinformatics Group, Advanced Artificial Intelligence Research Laboratory, WuXi NextCODE, Cambridge, Massachusetts, USA
| | - Thomas W Chittenden
- Computational Statistics and Bioinformatics Group, Advanced Artificial Intelligence Research Laboratory, WuXi NextCODE, Cambridge, Massachusetts, USA
| | - Michael Simons
- Internal Medicine.,Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA.,Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA
| | - George Tellides
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.,Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
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54
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Liu Z, Zou Y, Lv T, Guan H, Fan Z. Spontaneous rupture of enormous renal angiomyolipoma in a pregnant tuberous sclerosis patient: a rare case. BMC Nephrol 2020; 21:455. [PMID: 33129297 PMCID: PMC7603716 DOI: 10.1186/s12882-020-02124-w] [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: 05/01/2020] [Accepted: 10/26/2020] [Indexed: 11/12/2022] Open
Abstract
Background Renal angiomyolipoma (RAML) is a rare benign kidney tumour comprised of adipose tissue, smooth muscle, and blood vessels. It can cause fatal complications if it ruptures. Although there have been reports of RAMLs rupturing, it is unusual to see RAMLs rupture during pregnancy, especially in pregnant women with tuberous sclerosis (TSC). Moreover, we reported a rare complication after selective arterial embolization (SAE) for the first time, which called aseptic liquefaction necrosis. Case presentation The case is a 16-week-pregnant woman with TSC who presented with severe flank pain, which was secondary to the rupture of a large, previously unknown RAML. This was confirmed by emergency computed tomography and successfully treated with selective arterial embolization after the patient received counselling and provided prior informed written consent for medical termination of pregnancy (MTP). The patient underwent abortion 3 weeks after the SAE. The patient required drainage 2 months after the SAE because of aseptic liquefaction necrosis. During follow-up, the patient’s lesion remained stable. Conclusion RAML rupture is a rare but rather serious complication in pregnant tuberous sclerosis patients. Selective arterial embolization (SAE) should be performed immediately, and the status of the pregnancy needs to be assessed by a multidisciplinary team. We also report for the first time the rare complication of aseptic liquefaction necrosis after SAE of RAML, for which percutaneous drainage is effective.
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Affiliation(s)
- Zechuan Liu
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Yinghua Zou
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, China.
| | - Tianshi Lv
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Haitao Guan
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Zeyang Fan
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, China
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Frassanito P, Noya C, Tamburrini G. Current trends in the management of subependymal giant cell astrocytomas in tuberous sclerosis. Childs Nerv Syst 2020; 36:2527-2536. [PMID: 32978642 DOI: 10.1007/s00381-020-04889-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The management of subependymal giant cells astrocytomas (SEGAs) has been traditionally represented by surgical treatment through an open craniotomic approach. Though open surgery still represents a major option in the management of this kind of tumors, the introduction of mTOR inhibitors in the clinical practice, technological advances in neuroendoscopy and the more recent use of laser interstitial therapy have significantly enlarged the range of available management opportunities. METHODS A thorough review of the literature has been performed. Accordingly, current views in open surgical treatment, medical therapy, endoscopic tumor removal and new trends (such as laser interstitial thermal therapy) are discussed. RESULTS The risk of significant neurological morbidity (5-50%) complicating open surgery has been for a long time representing a main drawback in the management of SEGAs. More recent series report a significant reduction of morbidity and mortality. The mTOR inhibitors have demonstrated efficacy in both warranting a tumor reduction by up to 60% of the tumor size and helping the control of seizures. However, the reported rate of side effects is as high as 30% and tumor recurrence is a documented occurrence at the time of mTOR inhibitor discontinuation. Endoscopic tumor removal has been more extensively considered an option due to the acquisition of new tools. Limits are still represented by tumor size (< 3 cm) and broad attachment of the tumor to the basal ganglia. Laser interstitial thermal therapy (LITT) is the more recently considered option. Though promising, only short follow-up is available so far, while data on medium- and long-term results of this treatment are completely lacking to date. CONCLUSIONS Surgical treatment remains a mainstay of the management of SEGAs. The indication for an open craniotomic approach should be balanced with an endoscopic tumor removal or LITT according to patient conditions, presence or not of an active hydrocephalus and extension of the attachment of the tumor to the basal ganglia. The mTOR inhibitors do have a definite role both as primary and as adjuvant treatment, but consistent limitations are represented up to now by a not negligible rate of complications and the uncertainties related to the possibility of tumor recurrence once the medical treatment is discontinued.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.
| | - Carolina Noya
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
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Ryoo JS, Khalid SI, Chaker AN, Behbahani M, Nunna RS, Mehta AI. Trends in survival and treatment of SEGA: National Cancer Database Analysis. Neurooncol Pract 2020; 8:98-105. [PMID: 33664974 DOI: 10.1093/nop/npaa060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background SEGA is a rare, slow-growing CNS neoplasm that has historically been treated by surgical resection. However, the advent of a mammalian target of rapamycin complex-1 inhibitor, everolimus, has shown promising results in recent clinical trials. We sought to provide an analysis of epidemiological and survival risk factors in this rare tumor entity, while comparing trends in surgical management before and after introduction of everolimus in SEGAs. Methods Patients with SEGA were queried from the National Cancer Database between 2004 and 2015. Standard statistical analysis was conducted to assess variables associated with the odds of performing surgery and survival, while controlling for confounding variables. Results A total of 460 patients were diagnosed with SEGA. Multivariable analysis of survival demonstrated that increased age was associated with decreased survival (HR, 1.05; P < .0001). Multivariable analysis of surgery showed increased age (odds ratio [OR], 1.02, P = .04) and tumor size 20 mm or larger (OR, 9.52-16.75, P < .0001 for all) to be associated with higher odds of performing surgery. The use of radiotherapy (OR, 0.12, P = .008) or chemotherapy (OR, 0.21, P = .008) was associated with lower odds of surgery. A comparison of surgical rates between 2004 and 2010 and 2011 and 2015 was found to be significantly different, with a lower rate of surgery seen after 2011 (60.63% vs 48.06%, P = .007). Conclusion Our analysis of SEGAs demonstrated that age was the only variable affecting overall survival. Surgical resection was performed in older patients with larger tumors (> 20 mm) as a primary mode of treatment, without chemoradiotherapy. Expectedly, rates of surgical resection were found to have decreased since 2011, after FDA approval of everolimus for SEGA treatment.
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Affiliation(s)
- James S Ryoo
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
| | - Syed I Khalid
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Anisse N Chaker
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
| | - Ravi S Nunna
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
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Chu WCY, Chiang LLW, Chan DCC, Wong WHS, Chan GCF. Prevalence, mortality and healthcare economic burden of tuberous sclerosis in Hong Kong: a population-based retrospective cohort study (1995-2018). Orphanet J Rare Dis 2020; 15:264. [PMID: 32988393 PMCID: PMC7523393 DOI: 10.1186/s13023-020-01517-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022] Open
Abstract
Background We aim to elucidate the disease impact by accounting the prevalence, survival rate, genetics, mTOR inhibitor use and direct costs of tuberous sclerosis complex (TSC) in our local setting. TSC patients with documented visits to our local public hospitals in 1995–2018 were identified. The public hospitals captured most if not all local TSC patients. Demographics such as age, sex, death, genetic profiles were retrieved from the central electronic database. Data including prevalence, age distribution and survival rate were analysed. Direct cost was calculated with reference to the drug use and number of visits to various public hospital facilities. Results We identified 284 surviving TSC patients (55.3% male) in Hong Kong. The age range was from 4.5 months to 89.9 years, with a median age of 27.2 years. Paediatrics (< 18 years) to adult (≥18 years) ratio was 1:2.84. The overall prevalence of TSC patients was 3.87 in 100,000 (i.e. 1 in 25,833). Genetically, TSC1:TSC2 ratio is 1:2.7. Thirty seven patients died within the study period. The age of death ranged from 7.6 years to 77.8 years, with a median age of death at 36.6 years (IQR: 24.7–51.1 years). Most patients survived till adulthood. Survival rate at 20 and 50 years follow-up was 98.6 and 79.5% respectively. Two hundred and twenty nine TSC patients (71.3%) had neurological manifestations, sixteen patients (5.0%) had chronic kidney diseases and five patients (1.6%) had pulmonary lymphangioleiomyomatosis. Forty seven (16.5%) TSC patients were prescribed with mTOR inhibitors within the study period. Healthcare facility utilization was further analysed in the 2008–2018 cohort. In particular, the mean number of specialist out-patient clinic visits per patient-year was 9.23 per patient-year, which was 4.91 times more than that of local general population. Conclusions Prevalence of local TSC patients is within the range of that reported in the literature. Local TSC patients have fair long term survival, but they require disproportionally high healthcare cost when compared with the general population, particularly in terms of outpatient (OP) visits. Although effective disease-modifying agent (i.e. mTOR inhibitor) is available, it was not widely used yet in Hong Kong despite the fact that Government approved and supported its use recently. Further research on quality of life and setting up a comprehensive patient registry are necessary for more accurate assessment of cost and benefit.
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Affiliation(s)
- William Ching-Yuen Chu
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Lorraine Lok-Wing Chiang
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Dorothy Chi-Ching Chan
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Wilfred Hing-Sang Wong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Godfrey Chi-Fung Chan
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, SAR, People's Republic of China.
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58
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Kingswood JC, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, Beaure d'Augères G, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC, Sauter M. Renal Manifestations of Tuberous Sclerosis Complex: Key Findings From the Final Analysis of the TOSCA Study Focussing Mainly on Renal Angiomyolipomas. Front Neurol 2020; 11:972. [PMID: 33041968 PMCID: PMC7526256 DOI: 10.3389/fneur.2020.00972] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/24/2020] [Indexed: 12/18/2022] Open
Abstract
Renal angiomyolipomas are one of the most common renal manifestations in patients with tuberous sclerosis complex (TSC), with potentially life-threatening complications and a poor prognosis. Despite the considerable progress in understanding TSC-associated renal angiomyolipomas, there are no large scale real-world data. The aim of our present study was to describe in detail the prevalence and outcome of renal angiomyolipomas in patients with TSC, enrolled into the TuberOus SClerosis registry to increase disease Awareness (TOSCA) from 170 sites across 31 countries worldwide. We also sought to evaluate the relationship of TSC-associated renal angiomyolipomas with age, gender and genotype. The potential risk factors for renal angiomyolipoma-related bleeding and chronic kidney disease (CKD) were studied in patients who participated in the TOSCA renal angiomyolipoma substudy. Of the 2,211 eligible patients, 1,062 (48%) reported a history of renal angiomyolipomas. The median age of TSC diagnosis for the all subjects (n = 2,211) was 1 year. The median age of diagnosis of renal angiomyolipoma in the 1,062 patients was 13 years. Renal angiomyolipomas were significantly more prevalent in female patients (p < 0.0001). Rates of angiomyolipomas >3 cm (p = 0.0119), growing lesions (p = 0.0439), and interventions for angiomyolipomas (p = 0.0058) were also higher in females than males. Pre-emptive intervention for renal angiomyolipomas with embolisation, surgery, or mammalian target of rapamycin (mTOR) inhibitor may have abolished the gender difference in impaired renal function, hypertension, and other complications. The rate of interventions for angiomyolipomas was less common in children than in adults, but interventions were reported in all age groups. In the substudy of 76 patients the complication rate was too low to be useful in predicting risk for more severe CKD. In addition, in this substudy no patient had a renal hemorrhage after commencing on an mTOR inhibitor. Our findings confirmed that renal angiomyolipomas in subjects with TSC1 mutations develop on average at the later age, are relatively smaller in size and less likely to be growing; however, by age 40 years, no difference was observed in the percentage of patients with TSC1 and TSC2 mutations needing intervention. The peak of appearance of new renal angiomyolipomas was observed in patients aged between 18 and 40 years, but, given that angiomyolipomas can occur later, lifelong surveillance is necessary. We found that pre-emptive intervention was dramatically successful in altering the outcome compared to historical controls; with high pre-emptive intervention rates but low rates of bleeding and other complications. This validates the policy of surveillance and pre-emptive intervention recommended by clinical guidelines.
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Affiliation(s)
- J Chris Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, United Kingdom
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Mirjana P Benedik
- Child Neurology Department, SPS Pediatrična Klinika, Ljubljana, Slovenia
| | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Neuropediatric Department, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Neurology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Medical University of Vienna, Universitätsklinik für Kinder-und Jugendheilkunde, Affiliated Partner of the ERN EpiCARE, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, Dattein, Germany
| | - Christoph Hertzberg
- Zentrum für Neuropädiatrie und Sozialpädiatrie, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Pediatric Neurology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of Leon, León, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | - Valentin Sander
- Department of Neurology and Rehabilitation, Tallinn Children Hospital, Tallinn, Estonia
| | - Seema Shah
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint-Étienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, Athens University, St. Sophia Children's Hospital, Athens, Greece
| | - Bernard Zonnenberg
- Department of Internal Medicine, University Medical Center, Utrecht, Netherlands
| | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel VUB, Brussels, Belgium
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Tsc1 Regulates the Proliferation Capacity of Bone-Marrow Derived Mesenchymal Stem Cells. Cells 2020; 9:cells9092072. [PMID: 32927859 PMCID: PMC7565438 DOI: 10.3390/cells9092072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022] Open
Abstract
TSC1 is a tumor suppressor that inhibits cell growth via negative regulation of the mammalian target of rapamycin complex (mTORC1). TSC1 mutations are associated with Tuberous Sclerosis Complex (TSC), characterized by multiple benign tumors of mesenchymal and epithelial origin. TSC1 modulates self-renewal and differentiation in hematopoietic stem cells; however, its effects on mesenchymal stem cells (MSCs) are unknown. We investigated the impact of Tsc1 inactivation in murine bone marrow (BM)-MSCs, using tissue-specific, transgelin (Tagln)-mediated cre-recombination, targeting both BM-MSCs and smooth muscle cells. Tsc1 mutants were viable, but homozygous inactivation led to a dwarfed appearance with TSC-like pathologies in multiple organs and reduced survival. In young (28 day old) mice, Tsc1 deficiency-induced significant cell expansion of non-hematopoietic BM in vivo, and MSC colony-forming potential in vitro, that was normalized upon treatment with the mTOR inhibitor, everolimus. The hyperproliferative BM-MSC phenotype was lost in aged (1.5 yr) mice, and Tsc1 inactivation was also accompanied by elevated ROS and increased senescence. ShRNA-mediated knockdown of Tsc1 in BM-MSCs replicated the hyperproliferative BM-MSC phenotype and led to impaired adipogenic and myogenic differentiation. Our data show that Tsc1 is a negative regulator of BM-MSC proliferation and support a pivotal role for the Tsc1-mTOR axis in the maintenance of the mesenchymal progenitor pool.
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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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61
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Maulaz P, Malinge MC, Farges D, Ingster O, Azzouzi AR, Bigot P. [Prevalence of the tuberous sclerosis complex at patients taken care for a renal angiomyolipoma]. Prog Urol 2020; 30:500-506. [PMID: 32718886 DOI: 10.1016/j.purol.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 06/28/2019] [Accepted: 05/12/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Bourneville's tuberous sclerosis or Tuberous Sclerosis Complex (TSC) is an autosomal dominant hereditary phakomatosis associated with angiomyolipomas (AML) of the kidney. The aim of this study was to identify the prevalence of TSC in patients diagnosed and cared for AML in our department of urology. MATERIALS AND METHODS All the patients with AML were included between March 2009 and June 2016 in a French university hospital. Each patient was reviewed in consultation with a clinical examination and imaging. Specific clinical criteria were used to refer patients to genetic analysis. Patients with a high TSC probability had a genetic analysis to search TSC1 and TSC2 genes mutations. RESULTS In all, 28 patients were included and 3 (11%) were diagnosed TSC. The median age of the patients was 62 years (36-82 years). The most frequent clinical criteria were facial angiofibromas in 7 patients (25%). Among the 8 patients (29%) with evocative clinical criteria, a mutation of the TSC1 and TSC2 genes was identified in 3 patients (11%) with a diagnosis of TSC made before the AML diagnosis. CONCLUSION In this study, 8 patients (29%) presented clinical criteria suggestive of TSC, preferentially dermatological. The diagnosis was confirmed by screening TSC1 and TSC2 genes mutations in 3 patients (11%), nevertheless prevalence of TSC is most probably underestimated by the genetic mosaïcisme of this pathology.
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Affiliation(s)
- P Maulaz
- Service d'urologie, CHU Angers, 4, rue Larrey, 49100, Angers, France.
| | - M C Malinge
- Département de génétique, CHU Angers, 4, rue Larrey, 49100, Angers, France.
| | - D Farges
- Département de génétique, CHU Angers, 4, rue Larrey, 49100, Angers, France.
| | - O Ingster
- Département de génétique, CHU Angers, 4, rue Larrey, 49100, Angers, France.
| | - A R Azzouzi
- Service d'urologie, CHU Angers, 4, rue Larrey, 49100, Angers, France.
| | - P Bigot
- Service d'urologie, CHU Angers, 4, rue Larrey, 49100, Angers, France.
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Padureanu V, Dragoescu O, Stoenescu VE, Padureanu R, Pirici I, Cimpeanu RC, Dalia D, Mihailovici AR, Tomescu P. Management of a Patient with Tuberous Sclerosis with Urological Clinical Manifestations. MEDICINA-LITHUANIA 2020; 56:medicina56080369. [PMID: 32718027 PMCID: PMC7466204 DOI: 10.3390/medicina56080369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 11/18/2022]
Abstract
The tuberous sclerosis complex (TSC) is highly variable as far as its clinical presentation is concerned. For the implementation of appropriate medical surveillance and treatment, an accurate diagnosis is compulsory. TSC may affect the heart, skin, kidneys, central nervous system (epileptic seizures and nodular intracranial tumors—tubers), bones, eyes, lungs, blood vessels and the gastrointestinal tract. The aim of this paper is to report renal manifestations as first clinical signs suggestive of TSC diagnosis. A 20-year-old patient was initially investigated for hematuria, dysuria and colicky pain in the left lumbar region. The ultrasound examination of the kidney showed bilateral hyperechogenic kidney structures and pyelocalyceal dilatation, both suggestive of bilateral obstructive lithiasis, complicated by uretero-hydronephrosis. The computer tomography (CT) scan of the kidney showed irregular kidney margins layout, undifferentiated images between cortical and medullar structures, with non-homogenous round components, suggestive of kidney angiomyolipomas, bilateral renal cortical retention cysts, images of a calculous component in the right middle calyceal branches and a smaller one on the left side. The clinical manifestations and imaging findings (skull and abdominal and pelvis CT scans) sustained the diagnosis.
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Affiliation(s)
- Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
| | - Octavian Dragoescu
- Department of Urology, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania; (O.D.); (V.E.S.); (P.T.)
| | - Victor Emanuel Stoenescu
- Department of Urology, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania; (O.D.); (V.E.S.); (P.T.)
| | - Rodica Padureanu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (R.P.); (I.P.)
| | - Ionica Pirici
- Department of Anatomy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (R.P.); (I.P.)
| | | | - Dop Dalia
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | | | - Paul Tomescu
- Department of Urology, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania; (O.D.); (V.E.S.); (P.T.)
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63
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Nechama M, Makayes Y, Resnick E, Meir K, Volovelsky O. Rapamycin and dexamethasone during pregnancy prevent tuberous sclerosis complex-associated cystic kidney disease. JCI Insight 2020; 5:136857. [PMID: 32484794 DOI: 10.1172/jci.insight.136857] [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] [Received: 02/03/2020] [Accepted: 05/27/2020] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease is the main cause of mortality in patients with tuberous sclerosis complex (TSC) disease. The mechanisms underlying TSC cystic kidney disease remain unclear, with no available interventions to prevent cyst formation. Using targeted deletion of TSC1 in nephron progenitor cells, we showed that cysts in TSC1-null embryonic kidneys originate from injured proximal tubular cells with high mTOR complex 1 activity. Injection of rapamycin to pregnant mice inhibited the mTOR pathway and tubular cell proliferation in kidneys of TSC1-null offspring. Rapamycin also prevented renal cystogenesis and prolonged the life span of TSC newborns. Gene expression analysis of proximal tubule cells identified sets of genes and pathways that were modified secondary to TSC1 deletion and rescued by rapamycin administration during nephrogenesis. Inflammation with mononuclear infiltration was observed in the cystic areas of TSC1-null kidneys. Dexamethasone administration during pregnancy decreased cyst formation by not only inhibiting the inflammatory response, but also interfering with the mTORC1 pathway. These results reveal mechanisms of cystogenesis in TSC disease and suggest interventions before birth to ameliorate cystic disease in offspring.
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Affiliation(s)
| | | | | | - Karen Meir
- Department of Pathology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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64
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Lymphangioleiomyomatosis Mortality in Patients with Tuberous Sclerosis Complex. Ann Am Thorac Soc 2020; 16:509-512. [PMID: 30571922 DOI: 10.1513/annalsats.201807-471rl] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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65
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Takahashi Y, Hayakawa A, Sano R, Fukuda H, Kubo R, Kominato Y, Kimura S, Takada A, Saito K, Takei H, Awata S, Tokue H. Tuberous sclerosis related-lesions detected by postmortem computed tomography. FORENSIC IMAGING 2020. [DOI: 10.1016/j.fri.2020.200376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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66
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Pfirmann P, Aupy J, Jambon E, Idier L, Prezelin-Reydit M, Fermis M, Devillard R, Grenier N, Combe C, Rigothier C. Description of a multidisciplinary model of care in a French cohort of adult patients with tuberous sclerosis complex. J Med Genet 2020; 58:25-31. [PMID: 32409510 DOI: 10.1136/jmedgenet-2019-106607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/07/2020] [Accepted: 03/29/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder. Due to the various manifestations of TSC and their potential complications, a multidisciplinary care approach is recommended by consensus guidelines. OBJECTIVES Our study aimed to give a complete description of our TSC adult cohort and to evaluate the multidisciplinary and interdisciplinary management model. METHODS Data on each adult patient diagnosed with TSC, including disease manifestations, interventions and outcomes, were collected at baseline and updated annually. A multidisciplinary TSC approach with all the recommended explorations was carried out annually. RESULTS 90 patients were enrolled in Centre Hospitalier Universitaire de Bordeaux, between January 2000 and September 2018. Median age of patients at inclusion was 37 years (range, 27-47) and 20 years old at diagnosis of TSC. Regarding the occurrence of TSC manifestations, 97% of the patients had cutaneous lesions, 89% had neurological manifestations, 83% had renal manifestations and 100% had dental lesions with pits. More than half the patients had sclerotic bone lesions (68%), TSC-associated neuropsychiatric disorders (64%) and lymphangioleiomyomatosis (59%). A TSC multidisciplinary approach was developed including a global follow-up and an evaluation of TSC targeting organs, according to the recommendations. A satisfaction survey revealed global and entire satisfaction of patients with TSC. CONCLUSION We obtained an accurate description of a cohort of adult patients with TSC. Our multidisciplinary approach model allowed us to provide optimal management of patients with TSC with a high level of patient satisfaction.
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Affiliation(s)
- Pierre Pfirmann
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France .,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
| | - Jerome Aupy
- Service de Neurologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Eva Jambon
- Service d'Imagerie Médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Laetitia Idier
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Association pour l'Utilisation du Rein Artificiel a Domicile en Aquitaine, Gradignan, France
| | - Mathilde Prezelin-Reydit
- Association pour l'Utilisation du Rein Artificiel a Domicile en Aquitaine, Gradignan, France.,ISPED, INSERM, Bordeaux Population Health Research Center, Bordeaux, France
| | - Marine Fermis
- Service de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Raphael Devillard
- Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France.,Service de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Nicolas Grenier
- Service d'Imagerie Médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Christian Combe
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
| | - Claire Rigothier
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
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67
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Giordano F, Moscheo C, Lenge M, Biagiotti R, Mari F, Sardi I, Buccoliero AM, Mongardi L, Aronica E, Guerrini R, Genitori L. Neurosurgical treatment of subependymal giant cell astrocytomas in tuberous sclerosis complex: a series of 44 surgical procedures in 31 patients. Childs Nerv Syst 2020; 36:951-960. [PMID: 31853898 DOI: 10.1007/s00381-019-04449-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Subependymal giant cell astrocytomas (SEGA) are benign tumors characteristic of tuberous sclerosis complex (TSC) that may cause hydrocephalus. Various treatments are nowadays available as mTOR inhibitors or surgery. Surgery is still a valid option especially for symptomatic and larger tumors. METHODS From January 1994 to December 2015, 31 TSC patients harboring SEGA underwent surgery at the Department of Neurosurgery of the Meyer Pediatric Hospital, Florence. Indications for surgery were tumor size and location, growth and cystization/hemorrhage, and hydrocephalus. Clinical data, preoperative and postoperative MRI, recurrence rate, further surgical procedures, and related complications were analyzed. RESULTS A total of 44 surgeries were performed in 31 TSC patients affected by SEGA, achieving gross total removal (GTR) and subtotal removal (STR), respectively, in 36 and 8 patients. Recurrences occurred in 11 patients; 9 of them underwent further surgical procedures and 2 were treated with mTOR pathway inhibitors. Surgical morbidity and mortality were, respectively, 22.7% and 2.3%. After a mean follow-up of 4.9 years, 90% of patients were tumor-free with good neurological status in 93.3%; twelve (40%) had a ventriculo-peritoneal shunt (VPS) for hydrocephalus. CONCLUSIONS The present series confirms that the surgical approach, combined with mTOR inhibitors, is still a valid option for the treatment of SEGAs.
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Affiliation(s)
- Flavio Giordano
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy.
| | - Carla Moscheo
- Neuro-oncology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Matteo Lenge
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy.,3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Roberto Biagiotti
- Division of Prenatal Diagnosis, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Francesco Mari
- 3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Iacopo Sardi
- Neuro-oncology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Anna Maria Buccoliero
- Pathology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Lorenzo Mongardi
- Neurosurgery, Sant'Anna Hospital, Via Aldo Moro, Ferrara, 44124, Italy
| | - Eleonora Aronica
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Renzo Guerrini
- 3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Lorenzo Genitori
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
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68
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Hastings B, Mortele K, Lee EY. Genetic Syndromes Affecting Both Children and Adults: A Practical Guide to Imaging-based Diagnosis, Management, and Screening Recommendations for General Radiologists. Radiol Clin North Am 2020; 58:619-638. [PMID: 32276707 DOI: 10.1016/j.rcl.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Genetic syndromes are an infrequently encountered but challenging group of conditions for both pediatric and adult radiologists given the multitude of possible findings and important complications associated with these syndromes. This article reviews characteristic syndromic imaging features, as well as discussing important complications and screening recommendations for a selected group of clinically relevant genetic syndromes affecting both pediatric and adult populations.
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Affiliation(s)
- Bradford Hastings
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | | | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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69
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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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70
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From tuberous sclerosis complex to end stage renal disease: who are these patients? J Nephrol 2020; 34:607-615. [PMID: 32130718 DOI: 10.1007/s40620-020-00714-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/15/2020] [Indexed: 10/24/2022]
Abstract
In patients with tuberous sclerosis complex (TSC), renal complications are not limited to bleeding angiomyolipoma (AML); although rare, end-stage renal disease (ESRD) may occur. New treatments (e.g., mammalian target of rapamycin (m-Tor) inhibitors) for AML might influence the epidemiology of ESRD in patients with TSC. In France, 99 patients with TSC from the Renal Epidemiology and Information Network (REIN) registry and having undergone renal replacement therapy (RRT) between 2002 and 2016 were included in the present study. Additional data were collected from the patients' medical charts. The mean ± standard deviation age at RRT initiation was 48.4 ± 16.4 and 73.8% had a neurologic impairment. Fifty-four patients underwent kidney transplantation after an average of 23 ± 12.3 months on dialysis. Among the 61 patients with additional data the most common renal lesion was AML: 26.2% of the patients had isolated AML, and 26.2% had AML and renal cysts, 65.6% of patients had undergone nephrectomy, and 16.4% had undergone at least one embolization. None of the patients had been treated with an m-Tor inhibitor before dialysis. The graft survival rate was 92.5% at 5 years and 70.2% at 10 years. The present cohort study is the first to have assessed TSC patients on RRT from a national registry. Nephrectomy or embolization due to AML was the leading cause of ESRD in our cohort. By reducing the size of the AML, m-tor inhibitors might lower the risk of complications and thus reduce the number of patients with TSC requiring RRT.
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71
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Bardawil T, El Jamal L, Abbas O, Kurban M. Tuberous sclerosis with two unusual findings: cutaneous rhabdomyoma and chronic myelogenous leukaemia. Clin Exp Dermatol 2020; 45:799-801. [PMID: 32097503 DOI: 10.1111/ced.14187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 11/27/2022]
Affiliation(s)
- T Bardawil
- Department of Dermatology, American University of Beirut, Beirut, Lebanon
| | - L El Jamal
- American University of Beirut Medical School, Beirut, Lebanon
| | - O Abbas
- Department of Dermatology and Dermatopathology, American University of Beirut, Beirut, Lebanon
| | - M Kurban
- Department of Dermatology, American University of Beirut, Beirut, Lebanon.,Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon.,Dermatology Unit, Keserwan Medical Center, Ghazir, Lebanon
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72
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Wu CQ, Wolf DS, Smith EA. Fate of Pediatric Renal Angiomyolipoma During mTOR Inhibitor Treatment in Tuberous Sclerosis Complex. Urology 2020; 139:161-167. [PMID: 32081671 DOI: 10.1016/j.urology.2019.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the clinical and radiographic follow-up of renal angiomyolipoma (AML) in pediatric patients with tuberous sclerosis complex (TSC) on mTOR inhibitors. METHODS We performed retrospective chart review of children who were diagnosed with TSC between 2000 and 2019 and prescribed everolimus at age ≤18 years. Treatment assessment was performed in patients who were medically-compliant by serum drug trough levels and who had at least a baseline and one subsequent renal imaging study. RESULTS Nineteen patients were analyzed. Average age of everolimus initiation was 9 years, and indication was neurologic in 17 (90%). Fourteen patients (73.6%) had AML with average size of 1.9 (0.4-5) cm. Medication was discontinued due to side effects in 3 (16%) patients. Treatment assessment was analyzed for 15 patients with median medication exposure 5.1 (0.8-8.5) years. Among 13 with AML, the dominant lesion decreased in size in 9 (69%) and stayed stable in 4 (31%). Greatest absolute size decrease was seen for lesions ≥2 cm. No new AML lesions formed during treatment. CONCLUSION Although not currently approved for this indication, everolimus appears to be well-tolerated with similar efficacy for pediatric AML as in adult AML. Use may be most warranted in children with AML ≥2 cm.
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Affiliation(s)
- Charlotte Q Wu
- Division of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
| | - David S Wolf
- Division of Pediatric Neurology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Edwin A Smith
- Division of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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Zöllner JP, Franz DN, Hertzberg C, Nabbout R, Rosenow F, Sauter M, Schubert-Bast S, Wiemer-Kruel A, Strzelczyk A. A systematic review on the burden of illness in individuals with tuberous sclerosis complex (TSC). Orphanet J Rare Dis 2020; 15:23. [PMID: 31964424 PMCID: PMC6975094 DOI: 10.1186/s13023-019-1258-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/19/2019] [Indexed: 01/10/2023] Open
Abstract
Objective This review will summarize current knowledge on the burden of illness (BOI) in tuberous sclerosis complex (TSC), a multisystem genetic disorder manifesting with hamartomas throughout the body, including mainly the kidneys, brain, skin, eyes, heart, and lungs. Methods We performed a systematic analysis of the available literature on BOI in TSC according to the PRISMA guidelines. All studies irrespective of participant age that reported on individual and societal measures of disease burden (e.g. health care resource use, costs, quality of life) were included. Results We identified 33 studies reporting BOI in TSC patients. Most studies (21) reported health care resource use, while 14 studies reported quality of life and 10 studies mentioned costs associated with TSC. Only eight research papers reported caregiver BOI. Substantial BOI occurs from most manifestations of the disorder, particularly from pharmacoresistant epilepsy, neuropsychiatric, renal and skin manifestations. While less frequent, pulmonary complications also lead to a high individual BOI. The range for the mean annual direct costs varied widely between 424 and 98,008 International Dollar purchasing power parities (PPP-$). Brain surgery, end-stage renal disease with dialysis, and pulmonary complications all incur particularly high costs. There is a dearth of information regarding indirect costs in TSC. Mortality overall is increased compared to general population; and most TSC related deaths occur as a result of complications from seizures as well as renal complications. Long term studies report mortality between 4.8 and 8.3% for a follow-up of 8 to 17.4 years. Conclusions TSC patients and their caregivers have a high burden of illness, and TSC patients incur high costs in health care systems. At the same time, the provision of inadequate treatment that does not adhere to published guidelines is common and centralized TSC care is received by no more than half of individuals who need it, especially adults. Further studies focusing on the cost effectiveness and BOI outcomes of coordinated TSC care as well as of new treatment options such as mTOR inhibitors are necessary.
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Affiliation(s)
- Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - David Neal Franz
- Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christoph Hertzberg
- Zentrum für Sozialpädiatrie & Neuropädiatrie (DBZ), Vivantes Klinikum Neukölln, Berlin, Germany
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Imagine Institute UMR1136, Paris, France
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | | | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | | | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany. .,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany. .,Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany. .,Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
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Kingswood JC, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D' Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC. Renal angiomyolipoma in patients with tuberous sclerosis complex: findings from the TuberOus SClerosis registry to increase disease Awareness. Nephrol Dial Transplant 2019; 34:502-508. [PMID: 29697822 PMCID: PMC6399480 DOI: 10.1093/ndt/gfy063] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 02/06/2018] [Indexed: 12/31/2022] Open
Abstract
Background Renal angiomyolipoma occurs at a high frequency in patients with tuberous sclerosis complex (TSC) and is associated with potentially life-threatening complications. Despite this frequency and severity, there are no large population-based cohort studies. Here we present baseline and follow-up data of the international TuberOus SClerosis registry to increase disease Awareness (TOSCA) with an aim to provide detailed clinical characteristics of renal angiomyolipoma among patients with TSC. Methods Patients of any age with a documented clinic visit for TSC within 12 months or who were newly diagnosed with TSC before participation in the registry were eligible. Data specific to renal angiomyolipoma included physical tumour characteristics (multiple, bilateral, lesion size and growing lesions), clinical signs and symptoms, and management. The effects of age, gender and genotype on the prevalence of renal angiomyolipoma were also evaluated. Results Renal angiomyolipoma was reported in 51.8% of patients at baseline, with higher frequency in female patients (57.8% versus 42.2%). The median age at diagnosis was 12 years. Prevalence of angiomyolipoma was higher in patients with TSC2 compared with TSC1 mutations (59.2% versus 33.3%, P < 0.01). Of the 1031 patients with angiomyolipoma at baseline, multiple lesions were reported in 88.4% and bilateral in 83.9% of patients, while the size of angiomyolipoma was >3 cm in 34.3% of patients. Most patients were asymptomatic (82%). Frequently reported angiomyolipoma-related symptoms included bleeding, pain, elevated blood pressure and impaired renal function. Embolization and mammalian target of rapamycin inhibitors were the two most common treatment modalities. Conclusions The TOSCA registry highlights the burden of renal angiomyolipoma in patients with TSC and shows that renal manifestations are initially asymptomatic and are influenced by gender and genotype. Furthermore, the occurrence of significant problems from angiomyolipoma in a minority of younger patients suggests that surveillance should begin in infancy or at initial diagnosis.
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Affiliation(s)
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | | | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, UK
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Department of Pediatric Neurology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Department of Neurology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Department of Paediatrics, Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Germany
| | - Christoph Hertzberg
- Chefarzt des Zentrums für Sozial- und Neuropädiatrie, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, Australia
| | - Alfons Macaya
- Sección de Neurología Pediátrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,The Institute of Biomedicine University of Leon, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | | | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | - Valentin Sander
- Department of Neurology, Tallinn Children Hospital, Tallinn, Estonia
| | - Matthias Sauter
- Abteilung für Hygiene und Infektiologie, Klinikverbund Kempten-Oberallgäu gGmbH, Kempten, Germany
| | - Seema Shah
- Novartis Healthcare Pvt. Ltd, Hyderabad, Telangana, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama Aoi-ku Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, Athens University Medical School, St Sophia Children's Hospital, Athens, Greece
| | - Bernard Zonnenberg
- Department of Medical Oncology, University Medical Center, Utrecht, The Netherlands
| | - Anna C Jansen
- Department of Pediatrics, Pediatric Neurology Unit, UZ Brussel VUB, Brussels, Belgium
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75
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Annear NMP, Appleton RE, Bassi Z, Bhatt R, Bolton PF, Crawford P, Crowe A, Tossi M, Elmslie F, Finlay E, Gale DP, Henderson A, Jones EA, Johnson SR, Joss S, Kerecuk L, Lipkin G, Morrison PJ, O'Callaghan FJ, Cadwgan J, Ong ACM, Sampson JR, Shepherd C, Kingswood JC. Tuberous Sclerosis Complex (TSC): Expert Recommendations for Provision of Coordinated Care. Front Neurol 2019; 10:1116. [PMID: 31781016 PMCID: PMC6851053 DOI: 10.3389/fneur.2019.01116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/07/2019] [Indexed: 01/31/2023] Open
Affiliation(s)
- Nicholas M P Annear
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | | | - Zahabiyah Bassi
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Rupesh Bhatt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Patrick F Bolton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Pamela Crawford
- York Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Alex Crowe
- Wirral University Teaching Hospitals NHS Foundation Trust, Merseyside, United Kingdom
| | - Maureen Tossi
- Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom.,Tuberous Sclerosis Association, London, United Kingdom
| | - Frances Elmslie
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Eric Finlay
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Daniel P Gale
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Alex Henderson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Elizabeth A Jones
- Centre for Genomic Medicine, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.,Centre for Genomic Medicine, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Simon R Johnson
- Division of Respiratory Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom.,National Centre for Lymphangioleiomyomatosis, Nottingham, United Kingdom
| | - Shelagh Joss
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Larissa Kerecuk
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Graham Lipkin
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Patrick J Morrison
- Tuberous Sclerosis Clinic, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Finbar J O'Callaghan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jill Cadwgan
- Evelina London Children's Hospital, St. Thomas' Hospital, London, United Kingdom.,School of Life Course Sciences, King's College London, London, United Kingdom.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Albert C M Ong
- Kidney Genetics Group, Academic Nephrology Unit, University of Sheffield Medical School, Sheffield, United Kingdom.,Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - J Chris Kingswood
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom.,Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
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76
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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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77
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Jansen AC, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Kingswood JC. Clinical Characteristics of Subependymal Giant Cell Astrocytoma in Tuberous Sclerosis Complex. Front Neurol 2019; 10:705. [PMID: 31333563 PMCID: PMC6616060 DOI: 10.3389/fneur.2019.00705] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/14/2019] [Indexed: 01/10/2023] Open
Abstract
Background: This study evaluated the characteristics of subependymal giant cell astrocytoma (SEGA) in patients with tuberous sclerosis complex (TSC) entered into the TuberOus SClerosis registry to increase disease Awareness (TOSCA). Methods: The study was conducted at 170 sites across 31 countries. Data from patients of any age with a documented clinical visit for TSC in the 12 months preceding enrollment or those newly diagnosed with TSC were entered. Results: SEGA were reported in 554 of 2,216 patients (25%). Median age at diagnosis of SEGA was 8 years (range, <1–51), with 18.1% diagnosed after age 18 years. SEGA growth occurred in 22.7% of patients aged ≤ 18 years and in 11.6% of patients aged > 18 years. SEGA were symptomatic in 42.1% of patients. Symptoms included increased seizure frequency (15.8%), behavioural disturbance (11.9%), and regression/loss of cognitive skills (9.9%), in addition to those typically associated with increased intracranial pressure. SEGA were significantly more frequent in patients with TSC2 compared to TSC1 variants (33.7 vs. 13.2 %, p < 0.0001). Main treatment modalities included surgery (59.6%) and mammalian target of rapamycin (mTOR) inhibitors (49%). Conclusions: Although SEGA diagnosis and growth typically occurs during childhood, SEGA can occur and grow in both infants and adults.
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Affiliation(s)
- Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Mirjana P Benedik
- Child Neurology Department, SPS Pediatrična Klinika, Ljubljana, Slovenia
| | - Tom Carter
- Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Neuropediatric Department, Astrid Lindgren Childrens Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Neurology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Medical University of Vienna, Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Germany
| | - Christoph Hertzberg
- Zentrum für Neuropädiatrie und Sozialpädiatrie, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Pediatric Neurology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine, University of Leon, León, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Valentin Sander
- Neurology and Rehabilitation, Tallinn Children Hospital, Tallinn, Estonia
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Kempten-Oberallgäu gGmbH, Kempten, Germany
| | - Seema Shah
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, St. Sophia Children's Hospital, Athens University, Athens, Greece
| | - Bernard Zonnenberg
- Department of Internal Medicine, University Medical Center, Utrecht, Netherlands
| | - John C Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St. Georges University of London, London, United Kingdom
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78
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Bar C, Ghobeira R, Azzi R, Ville D, Riquet A, Touraine R, Chemaly N, Nabbout R. Experience of follow-up, quality of life, and transition from pediatric to adult healthcare of patients with tuberous sclerosis complex. Epilepsy Behav 2019; 96:23-27. [PMID: 31077938 DOI: 10.1016/j.yebeh.2019.04.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a multisystemic genetic disease with high clinical variability and age-related manifestations. These characteristics add to the complexity of transition to adulthood. This study aimed to explore the perception of medical follow-up and transition experience in a large group of patients with TSC who presented epilepsy in childhood. METHOD This multicenter French study included patients with TSC aged 18 years or older who developed epilepsy before the age of 16 years. A questionnaire specifically designed for the study explored patients' opinion through 270 questions covering different aspects of their social, familial, professional, and medical courses. RESULTS The questionnaire was sent to 72 patients, and 60 patients were included in the study (83% response rate) with a mean age of 32 years (18-55 years). Cognitive impairment was present in 80% of patients, and half of questionnaires were completed by the family. Pediatric care was coordinated by the child neurologist and was more regular and multidisciplinary than adult care. Epilepsy had the best follow-up followed by renal issues. Unmet needs were identified for psychiatric and behavioral disorders, both in children and adults. Respondents considered the help in achieving autonomy better in adult care. Only 50% of patients with a normal intellectual development had clear knowledge about their disease and the need for a regular monitoring. Two-thirds of respondents estimated that they had a transition experience between 16.5 and 21-year-old, considered as good in 60% of them. Seventy percent felt continuity between pediatric and adult care, and only 3% of respondents felt that their care would have been better if they were still followed in pediatric healthcare system. The change of care structure and/or caregivers was the most stressful factor during transition and transfer. CONCLUSION This study highlights persistent issues in the regularity and coordination of the follow-up of patients with TSC despite established international guidelines. Although most patients had a positive transition experience, there is still an urgent need to optimize transition programs. This would be essential to maintain care continuity between pediatric and adult health systems, especially for patients with TSC with epilepsy and high rate of cognitive and psychiatric impairments.
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Affiliation(s)
- Claire Bar
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades, AP-HP, Paris, France; Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Paris, France; Université Paris Descartes -Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Rouba Ghobeira
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades, AP-HP, Paris, France; Department of Sciences, Faculty of Sciences II, Campus Fanar, Lebanon
| | - Rita Azzi
- Department of Sciences, Faculty of Sciences II, Campus Fanar, Lebanon
| | - Dorothée Ville
- Department of Pediatric Neurology, Femme Mère Enfant University Hospital, HCL, Bron, France
| | - Audrey Riquet
- Department of Pediatric Neurology, Roger Salengro University Hospital, Lille, France
| | | | - Nicole Chemaly
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades, AP-HP, Paris, France; Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Paris, France
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades, AP-HP, Paris, France; Laboratory of Translational Research for Neurological Disorders, INSERM UMR 1163, Imagine Institute, Paris, France; Université Paris Descartes -Sorbonne Paris Cité, Imagine Institute, Paris, France.
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79
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Harari S, Spagnolo P, Cocconcelli E, Luisi F, Cottin V. Recent advances in the pathobiology and clinical management of lymphangioleiomyomatosis. Curr Opin Pulm Med 2019; 24:469-476. [PMID: 29927757 DOI: 10.1097/mcp.0000000000000502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Lymphangioleiomyomatosis (LAM) is a rare systemic disease that occurs almost exclusively in women. In the last few years, our understanding of disease pathobiology has improved substantially; in addition, a guideline document has recently been developed that provides recommendations for the diagnosis and clinical management of patients with LAM. Yet, significant gaps in knowledge remain. RECENT FINDINGS Groundbreaking insights into the cellular biochemistry of LAM have led to the reclassification of the disease as a low-grade, destructive, metastasizing neoplasm. In addition, recent data confirm the potential of next-generation sequencing to detect low-prevalence mutations in tuberous sclerosis (TSC) genes in sporadic LAM. A randomized, double-blind, multicentre trial has confirmed the efficacy of sirolimus in stabilizing lung function, improving functional performance and quality of life, and reducing lymphatic manifestations in patients with LAM. Accordingly, recent guidelines issued by the American Thoracic Society and the Japanese Respiratory Society recommend sirolimus treatment for patients with LAM and reduced lung function. Uncertainty remains, however, with regard to patient selection, and timing of initiation, duration and dosing of treatment. SUMMARY Significant advances have been made in the diagnosis and clinical management of patients with LAM. However, additional studies are needed to assess long-term safety and efficacy of sirolimus therapy, and to identify predictors of disease behaviour and response to treatment.
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Affiliation(s)
- Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, IRCCS MultiMedica, Milan
| | - Paolo Spagnolo
- Section of Respiratory Diseases, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Elisabetta Cocconcelli
- Section of Respiratory Diseases, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesca Luisi
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, IRCCS MultiMedica, Milan
| | - Vincent Cottin
- Hospices Civils de Lyon, Louis Pradel Hospital, National Reference Center for Rare Pulmonary Diseases, Department of Respiratory Diseases, Claude Bernard University Lyon 1, UMR754, Lyon, France
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80
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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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81
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Shoji T, Konno S, Niida Y, Ogi T, Suzuki M, Shimizu K, Hida Y, Kaga K, Seyama K, Naka T, Matsuno Y, Nishimura M. Familial multifocal micronodular pneumocyte hyperplasia with a novel splicing mutation in TSC1: Three cases in one family. PLoS One 2019; 14:e0212370. [PMID: 30794603 PMCID: PMC6386448 DOI: 10.1371/journal.pone.0212370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/18/2019] [Indexed: 12/16/2022] Open
Abstract
Multifocal micronodular pneumocyte hyperplasia (MMPH) is a rare pulmonary disease, generally manifesting as a tuberous sclerosis complex (TSC), characterised by multiple, small ground-glass nodular shadows on chest computed tomography (CT). Histological examination typically reveals multicentric, well-demarcated, nodular type II pneumocystic growth. Herein, we describe three cases of this rare pulmonary disease occurring within one family. Using reverse transcription polymerase chain reaction (RT-PCR) and direct DNA sequencing, we identified a novel germline mutation, a point mutation in TSC1 intron 5, which yielded a splice variant and loss of function of TSC1. Furthermore, immunohistochemical staining indicated the expression of phospho-p70S6K and phospho-4E-BP1, suggesting that TSC1 function was impaired by the novel gene mutation in MMPH cells.
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Affiliation(s)
- Tetsuaki Shoji
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
- * E-mail:
| | - Yo Niida
- Center for Clinical Genomics, Kanazawa Medical University Hospital, Ishikawa, Japan
| | - Takahiro Ogi
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yasuhiro Hida
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kichizo Kaga
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Tomoaki Naka
- Division of Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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82
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Percutaneous microwave ablation of renal angiomyolipomas in tuberous sclerosis complex to improve the quality of life: preliminary experience in an Italian center. Radiol Med 2018; 124:176-183. [DOI: 10.1007/s11547-018-0967-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/04/2018] [Indexed: 12/26/2022]
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83
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Almobarak S, Almuhaizea M, Abukhaled M, Alyamani S, Dabbagh O, Chedrawi A, Khan S, Aldhalaan H. Tuberous Sclerosis Complex: Clinical Spectrum and Epilepsy: A Retrospective Chart Review Study. Transl Neurosci 2018; 9:154-160. [PMID: 30479846 PMCID: PMC6234476 DOI: 10.1515/tnsci-2018-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/14/2018] [Indexed: 02/01/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant genetic neurocutaneous disorder, with heterogeneous manifestations. We aimed to review the clinical presentation of TSC and its association with epilepsy among Saudi population. This was a retrospective chart review study of 88 patients diagnosed with TSC with or without epilepsy. In 38.6% of patients, symptoms began before 1 year of age. The most frequent initial manifestations of TSC were new onset of seizures (68.2%), skin manifestations (46.6%) and development delay (23.9%). During the evolution of the disease 65.9% had epilepsy, 17% facial angiofibromas, 13.6% Shagreen patch, 18.2% heart rhabdomyomas and 12.5% retinal hamartomas. The genetic study for TSC diagnosis was done for 44 patients, 42 (95,4%) of them were genetically confirmed, for whom 13 patients had TSC1 mutation (29.5%), 29 patients were carrying TSC2 gene mutation (65.9%), Genetic test for TSC 1 and TSC 2 were negative for 2 patients (4.5%) despite positive gene mutation in their relative with TSC. The most common manifestations were central nervous system (predominantly epilepsy) and dermatological manifestations. Most of the patients develop epilepsy with multiple seizure types. TSC 2 mutation is more common than TSC 1 mutation.
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Affiliation(s)
- Sulaiman Almobarak
- King Faisal Specialist Hospital & Research Center Riyadh, Riyadh Saudi Arabia
| | - Mohammad Almuhaizea
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Musaad Abukhaled
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Suad Alyamani
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Omar Dabbagh
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Aziza Chedrawi
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Sameena Khan
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hesham Aldhalaan
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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84
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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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85
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Janssens P, Van Hoeve K, De Waele L, De Rechter S, Claes KJ, Van de Perre E, Wissing KM, Bammens B, Jansen A, Mekahli D. Renal progression factors in young patients with tuberous sclerosis complex: a retrospective cohort study. Pediatr Nephrol 2018; 33:2085-2093. [PMID: 29987458 DOI: 10.1007/s00467-018-4003-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 06/05/2018] [Accepted: 06/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Renal pathology in tuberous sclerosis complex (TSC) is characterized by the growth of angiomyolipoma and renal cysts, and in rare cases renal cell carcinoma. Other consequences of renal involvement in TSC, including hypertension, proteinuria, and hyperfiltration, are not well studied. We aimed to analyze the early manifestations of the renal TSC phenotype in a young TSC cohort and to explore common, modifiable risk factors. METHODS In this retrospective cohort study, TSC patients attending the TSC clinics of two tertiary hospitals were included. Data on demographics, history, genotype, kidney function, hematuria, proteinuria, blood pressure, and renal imaging were collected. RESULTS Eighty patients were included, with a median age of 0.8 years (0.0-63.0) at first presentation, and a median follow-up time of 10.2 (0.4-41.0) years. Mutation analysis was available in 64 patients (80%). Renal lesions (cysts or angiomyolipoma) were observed in 55/73 (75%). Thirty-two percent (19/60) were hypertensive, 8/51 (16%) had proteinuria, and 18/71 (25%) had hyperfiltration (median eGFR 154 ml/min/m2). Six (7.5%) patients had developed end stage renal disease at the last follow-up. No association was found between hyperfiltration, hypertension, or proteinuria and CKD ≥ 3. Cox regression showed a significant positive association between the presence of a renal intervention and CKD ≥ 3 (Hazard-Ratio 3.91, P < 0.05). CONCLUSIONS Besides renal cysts and angiomyolipoma, the modifiable progression factors hypertension, proteinuria, and hyperfiltration occur frequently and early in TSC patients. This represents a preventive treatment target.
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Affiliation(s)
- Peter Janssens
- Department of Nephrology, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium. .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Karen Van Hoeve
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth De Waele
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatric Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Stéphanie De Rechter
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen J Claes
- Department of Microbiology & Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Els Van de Perre
- Department of Nephrology, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Karl Martin Wissing
- Department of Nephrology, UZ Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Bert Bammens
- Department of Microbiology & Immunology, KU Leuven, Leuven, Belgium.,Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Anna Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Brussel, Belgium
| | - Djalila Mekahli
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
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86
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Kondo T, Niida Y, Mizuguchi M, Nagasaki Y, Ueno Y, Nishimura A. Autopsy case of right ventricular rhabdomyoma in tuberous sclerosis complex. Leg Med (Tokyo) 2018; 36:37-40. [PMID: 30336374 DOI: 10.1016/j.legalmed.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/21/2018] [Accepted: 10/08/2018] [Indexed: 11/25/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disorder characterized by widespread hamartomas in several organs, including the brain, heart, skin, eyes, kidney, lung, and liver. Rhabdomyoma is the most common cardiac tumor diagnosed in fetuses, neonates and infants, and is closely linked to TSC. Here we describe an autopsy case of right ventricular rhabdomyoma in TSC. The deceased was a 3-month-old male infant, and TSC with a cardiac tumor had been diagnosed before his death. Since the cardiac tumor had not been physically blocking the blood flow, he had not undergone surgical intervention. At autopsy, the patient's height was 62 cm and his body weight was 6 kg. The heart weighed 37.3 g and the right ventricle was filled with the tumor. The tumor measured 2.1 cm × 1.6 cm, being a fusion of multiple tumors with several attachment sites to the myocardium. Histologically, the tumor was diagnosed as a rhabdomyoma, and was positive for mammalian target of rapamycin (mTOR). The brain weighed 795.0 g, without hydrocephalus. The cut surface of the brain revealed multiple cortical tubers and subependymal nodules. Through screening for the TSC1 (hamartin) and TSC2 (tuberin) genes, a nonsense mutation, c.1108C>T:p.Gln370∗, was detected in the TSC2 gene. Immediate cause of death was determined to be ventricular obstruction by a cardiac rhabdomyoma with insidious growth. This case highlights the need for forensic pathologists to perform a complete autopsy to determine the cause of sudden death with cardiac tumor, including genetic examination.
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Affiliation(s)
- Takeshi Kondo
- Medical Examiner's Office of Hyogo Prefecture, Kobe, Japan; Division of Legal Medicine, Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yo Niida
- Division of Genomic Medicine, Department of Advanced Medicine, Medical Research Institute, Kanazawa Medical University, Uchinada, Japan
| | - Masashi Mizuguchi
- Department of Developmental Medical Sciences, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Yasuhiro Ueno
- Medical Examiner's Office of Hyogo Prefecture, Kobe, Japan; Division of Legal Medicine, Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akiyoshi Nishimura
- Medical Examiner's Office of Hyogo Prefecture, Kobe, Japan; Department of Forensic Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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87
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Peron A, Canevini MP, Ghelma F, Di Marco F, Vignoli A. Healthcare transition from childhood to adulthood in Tuberous Sclerosis Complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:355-364. [PMID: 30253036 PMCID: PMC6635672 DOI: 10.1002/ajmg.c.31653] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/12/2022]
Abstract
Healthcare transition from childhood to adulthood is required to ensure continuity of care of an increasing number of individuals with chronic conditions surviving into adulthood. The transition for patients with tuberous sclerosis complex (TSC) is complicated by the multisystemic nature of this condition, age-dependent manifestations, and high clinical variability and by the presence of intellectual disability in at least half of the individuals. In this article, we address the medical needs regarding each TSC-related manifestation in adulthood, and the services and support required. We review existing models of transition in different chronic conditions, discuss our experience in transitioning from the pediatric to the adult TSC Clinic at our Institution, and propose general rules to follow when establishing a transition program for TSC. Although a generalizable transition model for TSC is likely not feasible for all Institutions, a multidisciplinary TSC clinic is probably the best model, developed in accordance with the resources available and country-specific healthcare systems. Coordination of care and education of the adult team should be always sought regardless of the transition model.
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Affiliation(s)
- Angela Peron
- Department of Health Sciences, Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy.,Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Maria Paola Canevini
- Department of Health Sciences, Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - Filippo Ghelma
- Department of Health Sciences, Disabled Advanced Medical Assistance, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università degli Studi di Milano (Italy), Respiratory Unit ASST-Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Aglaia Vignoli
- Department of Health Sciences, Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
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88
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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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89
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Gupta N, Henske EP. Pulmonary manifestations in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:326-337. [PMID: 30055039 DOI: 10.1002/ajmg.c.31638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Tuberous sclerosis complex has manifestations in many organ systems, including brain, heart, kidney, skin, and lung. The primary manifestations in the lung are lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH). LAM affects almost exclusively women, and causes cystic lung destruction, pneumothorax, and chylous pleural effusions. LAM can lead to dyspnea, oxygen dependence, and respiratory failure, with more rapid disease progression during the premenopausal years. In contrast, MMPH affects men and women equally, causing small nodular pulmonary deposits of type II pneumocytes that rarely progress to symptomatic disease. Here, we review the clinical features and pathogenesis of LAM and MMPH.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth P Henske
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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90
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Rentz AM, Skalicky AM, Liu Z, Dunn DW, Frost MD, Nakagawa JA, Prestifilippo J, Said Q, Wheless JW. Burden of renal angiomyolipomas associated with tuberous sclerosis complex: results of a patient and caregiver survey. J Patient Rep Outcomes 2018; 2:30. [PMID: 30294710 PMCID: PMC6091699 DOI: 10.1186/s41687-018-0055-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 06/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a rare genetic disorder characterized by benign tumors in multiple organs, including non-cancerous kidney lesions known as renal angiomyolipomas. This study’s objective is to describe the age-stratified morbidity, treatment patterns, and health-related quality of life of TSC patients with renal angiomyolipomas in the United States. A cross-sectional, anonymous web-based survey was conducted with a convenience sample of TSC patients and caregivers identified through a patient advocacy organization. Results Out of the total sample of 676, 182 respondents reported having kidney complications with 33% of the pediatric group and 25% of the adult group with TSC reporting them. Of those with kidney complications, 110 (60%) reported a diagnosis of renal angiomyolipomas, of which 79 (72%) were adult patients and 31 (28%) were pediatric age patients. Eighty-four percent of the pediatric group and 76% of the adult group reported lesions on both kidneys. Of the patients experiencing involvement of only one kidney, 60% of the pediatric group and 21% of the adult group reported having multiple tumors within the affected kidney. Almost all of the sample (99%) reported seeing a physician and having a procedure or test for TSC in the past year. Less than half the respondents (44%) reported being hospitalized in the past year. Thirty-nine percent reported an emergency room visit as well. Compared to scores for patients with kidney disease, the angiomyolipoma adult patients reported significantly lower Mental Component Summary scores on the SF-12. Conclusions Renal angiomyolipomas burden leads to frequent healthcare resource use including hospitalization, invasive treatments, and surgical procedures, which result in an impaired mental health related quality of life.
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Affiliation(s)
- Anne M Rentz
- 1Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Anne M Skalicky
- 1Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | | | - David W Dunn
- 3Riley Hospital for Children, Indianapolis, IN USA
| | | | | | | | | | - James W Wheless
- 6Le Bonheur Children's Hospital and the University of Tennessee, Memphis, TN USA
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91
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Gipson TT. Consequences of delay in screening, monitoring, and treatment of angiomyolipoma and tuberous sclerosis: A case report
. Clin Nephrol 2018; 90:71-75. [PMID: 29701176 PMCID: PMC6029576 DOI: 10.5414/cn109382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 06/13/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a multisystem disorder that results in tumor growth in various organs. TSC can affect the kidneys in the form of renal angiomyolipomas and cysts that can lead to chronic kidney disease. CASE PRESENTATION A 38-year-old woman was referred to Kennedy Krieger Institute for comprehensive TSC management. Before referral, the patient had gone most of her life without a definite diagnosis of TSC despite visually-prominent signs such as forehead plaques, facial angiofibromas, and ungual fibromas. Eventually, complications of the disease led to the patient requiring hemodialysis at age 34 and a complete bilateral nephrectomy at age 36. However, the patient was not diagnosed with TSC until an evaluation at the National Institutes of Health at age 37. After becoming a patient at our clinic, a multidisciplinary approach was taken to provide comprehensive care by including various disciplines such as nephrology, neurology, pulmonology, ophthalmology, dentistry, dermatology, and cardiology. DISCUSSION AND CONCLUSION TSC consensus recommendations aid in diagnosis, monitoring, and treatment of TSC and its associated manifestations, including those involving the kidneys. Our case underscores the importance of early identification of TSC to prevent future complications and promotes use of a multidisciplinary team to provide comprehensive care.
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92
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van der Poest Clement EA, Sahin M, Peters JM. Vigabatrin for Epileptic Spasms and Tonic Seizures in Tuberous Sclerosis Complex. J Child Neurol 2018; 33:519-524. [PMID: 29687739 DOI: 10.1177/0883073818768309] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Vigabatrin is recommended as first-line treatment for infantile spasms in tuberous sclerosis complex (TSC), but other indications in children with tuberous sclerosis complex are less known. We retrospectively reviewed 201 children with tuberous sclerosis complex, and identified 21 children older than 1 year started on vigabatrin for any indication and with sufficient follow-up data. The indication for vigabatrin was epileptic spasms (n = 13), tonic seizures (n = 5), both (n = 2), and status epilepticus (n = 1). Mean age of treatment onset was 4.0 years (range 1.1-18.3). All but 1 patient had a reduction in seizures. Ten patients became seizure free and 4 had an improvement of >90%. In 9 patients, vigabatrin was tapered successfully after 8 to 33 months. Side effects reported included rash (n = 1) and behavioral decline (n = 1). No retinal toxicity was detected in 14 of 21 patients with adequate ophthalmologic surveillance data. In conclusion, vigabatrin may be an effective treatment for epileptic spasms and tonic seizures beyond the infantile age.
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Affiliation(s)
- Emma A van der Poest Clement
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical, School, Boston, MA, USA
| | - Mustafa Sahin
- 2 Department of Neurology, Translational Neuroscience Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical, School, Boston, MA, USA
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93
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Alsidawi S, Kasi PM. Exceptional response to everolimus in a novel tuberous sclerosis complex-2 mutation-associated metastatic renal-cell carcinoma. Cold Spring Harb Mol Case Stud 2018; 4:mcs.a002220. [PMID: 29610387 PMCID: PMC5880255 DOI: 10.1101/mcs.a002220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 09/28/2017] [Indexed: 01/05/2023] Open
Abstract
Everolimus, an oral inhibitor of the mammalian target of rapamycin (mTOR) pathway, is currently approved for treatment of advanced renal-cell carcinoma (RCC) after failure of initial treatment with the tyrosine kinase inhibitors. Patients with tuberous sclerosis complex (TSC) syndrome can also develop RCC primarily mediated through mTOR signaling. However, the efficacy and duration of response of mTOR inhibition in patients with TSC-associated RCC is not well known. Herein, we describe a case of a patient with TSC2-associated metastatic RCC with mutations H1620R and Y1650C who has had an exceptional response to everolimus in the frontline setting and continues to derive benefit from mTOR inhibition 2 yr into therapy. Furthermore, the alteration H1620R in exon 37 resulting in a missense mutation is likely deleterious given our findings and previous analyses of the TSC2 gene. Further studies of somatic mutations in extended responders to mTOR inhibitors will help personalize therapy for these patients. It also emphasizes the value of targeted therapies based on genomic analyses.
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Affiliation(s)
- Samer Alsidawi
- Division of Hematology/Oncology, Mayo Clinic, Rochester, Minnesota 55905, USA
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94
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Zhang L, Jiang XY, Chen N, Hao NY, Zhou D, Li JM. Progressive cystic lesion in a middle-aged patient with tuberous sclerosis complex: A case report. Medicine (Baltimore) 2018; 97:e0407. [PMID: 29642206 PMCID: PMC5908606 DOI: 10.1097/md.0000000000010407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Tuberous sclerosis complex (TSC) is an uncommon multiple systems disorder. The main characteristics of the disease in the central nervous system include cortical or subcortical tubers, subependymal nodules, and subependymal giant cell astrocytoma. However, progressive cystic lesions in the cerebral hemispheres have rarely been reported in previous studies of TSC. PATIENT CONCERNS We present the case of a 35-year-old man with TSC who was admitted to our hospital for a sudden attack of serious headache, vomiting, and left hemiplegia. Brain computerized tomography and magnetic resonance imaging (MRI) revealed multiple subependymal calcific nodes and multiple cystic lesions in the right frontal, temporal, and parietal lobes. The solid nodule in the lesion demonstrated contrast enhancement. DIAGNOSES The patient was diagnosed with TSC, but the properties of the cystic lesion in the brain were unclear and a tumor was suspected. INTERVENTIONS Emergency operation was performed immediately. Pathological examination of the lesion revealed a vascular malformation, but no tumor cells. OUTCOMES In the fourth year after the surgery, brain MRI revealed a relapse of the cystic mass and surgery was suggested again. However, the patient refused to undergo surgery again. LESSONS This case describes an atypical MRI presentation of TSC occurring in middle-age. This condition can cause a life-threatening condition and may recur after surgery. Our finding emphasizes the importance of neuroimaging surveillance in patients older than 25 years old and after lesion resection.
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Affiliation(s)
| | | | - Ni Chen
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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95
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Cockerell I, Guenin M, Heimdal K, Bjørnvold M, Selmer KK, Rouvière O. Renal manifestations of tuberous sclerosis complex: patients' and parents' knowledge and routines for renal follow-up - a questionnaire study. BMC Nephrol 2018; 19:39. [PMID: 29439672 PMCID: PMC5812037 DOI: 10.1186/s12882-018-0835-3] [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: 05/22/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Renal angiomyolipomas (AMLs) are a major clinical feature in patients with tuberous sclerosis complex (TSC). Spontaneous bleeding can be life threatening, and appropriate information and proper surveillance and management are important to limit morbidity and mortality. Because TSC is a rare disease, patients are at risk of suboptimal medical management. Our aim was to investigate patients' and parents' knowledge about renal angiomyolipomas (AMLs) in Tuberous Sclerosis Complex (TSC) and to identify current routines for renal follow-up. METHODS A questionnaire survey was initiated by the French Reference Centre on TSC. It was distributed in France through university hospitals and the patients' association (2009-2011), and to patients registered by the Norwegian National Centre for Rare Epilepsy-Related Disorders (2013-2014). Contingency tables with Chi-Square test for independence (with Yates Continuity Correction) and Pearson-Chi-Square value were used for correlation statistics. RESULTS We included 357 patients (France, n=257; Norway n=100). Most participants knew that TSC is associated with AMLs. However, 42 % did not know about the risk of AMLrelated bleeding, and 37 % had been informed about the risk of bleeding only after the age of 15 years. Furthermore, 14 % did not know whether they themselves or their child had AMLs. Patients had less knowledge than parents. Medical consultations and patient associations were the main sources of information. Among 30 % of patients, renal imaging was not received at all, or not conducted every 1-3 years, as recommended by current guidelines. Regular imaging was more frequent in patients with AMLs < 15 years, than in patients with AMLs ≥ 15 years. Ultrasound was the most frequently used imaging modality. CONCLUSIONS Knowledge of renal AML in TSC patients and their parents was lower than expected, and follow-up by renal imaging was suboptimal for a substantial proportion of patients. Patients and parents should be informed about the risk and symptoms of renal bleeding, at the latest when the patient is 15 years. Monitoring the growth of AMLs should be standardized to comply with guidelines. Transition between adolescence and adulthood is a high-risk period and ensuring appropriate follow-up at this time is particularly important.
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Affiliation(s)
- I Cockerell
- Department of Rare Disorders and Disabilities, Oslo University Hospital, National Centre for Rare Epilepsy-Related Disorders, Pb 4950, Nydalen, 0424, Oslo, Norway.
| | - M Guenin
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - K Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - M Bjørnvold
- National Centre for Epilepsy, Division for Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - K K Selmer
- Department of Rare Disorders and Disabilities, Oslo University Hospital, National Centre for Rare Epilepsy-Related Disorders, Pb 4950, Nydalen, 0424, Oslo, Norway.,Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - O Rouvière
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
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96
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Brakemeier S, Vogt L, Adams LC, Zukunft B, Diederichs G, Hamm B, Budde K, Eckardt KU, Makowski MR. Sclerotic bone lesions as a potential imaging biomarker for the diagnosis of tuberous sclerosis complex. Sci Rep 2018; 8:953. [PMID: 29343816 PMCID: PMC5772483 DOI: 10.1038/s41598-018-19399-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/29/2017] [Indexed: 01/15/2023] Open
Abstract
Tuberous-sclerosis-complex (TSC) is associated with a high lifetime risk of severe complications. Clinical manifestations are largely variable and diagnosis is often missed. Sclerotic-bone-lesions (SBL) could represent a potential imaging biomarker for the diagnosis of TSC. In this study, computed tomography (CT) data sets of 49 TSC patients (31 females) were included and compared to an age/sex matched control group. Imaging features of SBLs included frequency, size and location pattern. Sensitivities, specificities and cutoff values for the diagnosis of TSC were established for the skull, thorax, and abdomen/pelvis. In TSC patients, 3439 SBLs were detected, including 665 skull SBLs, 1426 thoracal SBLs and 1348 abdominal/pelvic SBLs. In the matched control-collective, 157 SBLs could be found. The frequency of SBLs enabled a reliable differentiation between TSC patients and the control collective with the following sensitivities and specificities. Skull: ≥5 SBLs, 0.783, 1; thorax: ≥4 SBLs, 0.967, 0.967; abdomen/pelvis: ≥5 SBLs: 0.938, 0.906. SBL size was significantly larger compared to controls (p < 0.05). Based on the frequency, size and location pattern of SBLs TSC can be suspected. SBLs may serve as a potential imaging biomarker in the workup of TSC patients.
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Affiliation(s)
- Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany.
| | - Lars Vogt
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa C Adams
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Gerd Diederichs
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Marcus R Makowski
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany.,King's College London, Division of Imaging Sciences, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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97
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Abstract
Tuberous sclerosis complex (TSC) is an autosomal-dominant or sporadic multisystem disorder that results from mutations in either TSC1 or TSC2. The primary organs affected include the brain, skin, lung, kidney, and heart, all with variable frequency, penetrance, and severity. There are over 2000 known allelic variants for TSC, including nonsense and misssense mutation, and all pathogenic mutations are inactivating, leading to loss-of-function effects on the encoded proteins, TSC1 and TSC2. These proteins form a complex to constitutively inhibit the mammalian target of rapamycin (mTOR) signaling cascade, and as a consequence, mTOR signaling is constitutively active within all TSC-associated lesions. The mTOR inhibitors rapamycin (sirolimus) and everolimus have been shown to reduce renal and brain lesion size, and improve pulmonary function in TSC, and these compounds may also decrease seizure frequency. The clinical application of mTOR inhibitors in TSC has provided one of the first examples of precision medicine in a neurodevelopmental disorder.
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Affiliation(s)
- Daphne M Hasbani
- Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Peter B Crino
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States.
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98
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Bissler JJ, Franz DN, Frost MD, Belousova E, Bebin EM, Sparagana S, Berkowitz N, Ridolfi A, Kingswood JC. The effect of everolimus on renal angiomyolipoma in pediatric patients with tuberous sclerosis being treated for subependymal giant cell astrocytoma. Pediatr Nephrol 2018; 33:101-109. [PMID: 28993887 PMCID: PMC5700234 DOI: 10.1007/s00467-017-3806-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 08/04/2017] [Accepted: 09/05/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with tuberous sclerosis complex (TSC) often have multiple TSC-associated hamartomas, particularly in the brain and kidney. METHODS This was a post hoc analysis of pediatric patients being treated for subependymal giant cell astrocytomas (SEGAs) during the phase 3, randomized, double-blind, placebo-controlled EXIST-1 trial. Patients were initially randomly assigned to receive everolimus 4.5 mg/m2/day (target blood trough 5-15 mg/dl) or placebo and could continue in an open-label extension phase. Angiomyolipoma response rates were analyzed in patients aged <18 years with ≥1 target angiomyolipoma lesion at baseline. Response was defined as the proportion of patients with a ≥50% reduction in the sum volume of target renal angiomyolipomata from baseline, in the absence of new target angiomyolipomata, a >20% increase in kidney volume from nadir, and angiomyolipoma-related bleeding ≥ grade 2. Tolerability was also assessed. RESULTS Overall, this analysis included 33 patients. Renal angiomyolipoma response was achieved by 75.8% of patients (95% confidence interval, 57.7-88.9%), with sustained mean reductions in renal angiomyolipoma volume over nearly 4 years of treatment. In addition, most (≥80%) achieved clinically relevant reductions in angiomyolipoma volume (≥50%), beginning at week 24 and continuing for the remainder of the study. Everolimus was generally well tolerated in this subgroup, with most adverse events being grade 1 or 2 in severity. CONCLUSIONS Although everolimus is currently not indicated for this use, this analysis from EXIST-1 demonstrates its long-term efficacy and safety for the treatment of renal angiomyolipoma in pediatric patients undergoing treatment for TSC-associated SEGA.
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Affiliation(s)
- John J Bissler
- Division of Nephrology, St Jude Children's Research Hospital and Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN, 38163, USA.
| | - David N Franz
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Elena Belousova
- Moscow Research Institute of Pediatrics and Pediatric Surgery, Moscow, Russia
| | - E Martina Bebin
- University of Alabama School of Medicine, Birmingham, AL, USA
| | | | - Noah Berkowitz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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99
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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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100
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Mao S, Long Q, Lin H, Liu J. Rapamycin therapy for neonatal tuberous sclerosis complex with cardiac rhabdomyomas: A case report and review. Exp Ther Med 2017; 14:6159-6163. [PMID: 29285173 PMCID: PMC5740740 DOI: 10.3892/etm.2017.5335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 07/11/2017] [Indexed: 11/19/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease that varies greatly in its expression. The current study reports a novel case of TSC caused by a TSC2 mutation (TSC2c.1642_1643insA or TSC2p.K549fsX589), in which multiple cardiac rhabdomyomas were detected by fetal echocardiography in week 31 of pregnancy. The infant was delivered successfully; however, seizures began 16 days following birth. Subsequent genetic tests confirmed a diagnosis of TSC. Rapamycin treatment resulted in regression of cardiac rhabdomyomas and controlled seizures. The current study demonstrates the value of fetal echocardiography in the diagnosis of TSC and suggests that inhibition of the mammalian target of the rapamycin (mTOR) signaling pathway may be considered as a potential antiepileptogenic therapy for neonatal TSC. In addition, it was demonstrated that rapamycin treatment was therapeutically beneficial for preventing disorders caused by abnormal mTOR signaling, such as cancer. According to the literature, cardiac rhabdomyomas, seizures and skin lesions are well established markers for TSC in neonates. MRI scans of the brain and genetic screening of TSC1 and TSC2 genes may facilitate an early diagnosis of TSC.
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Affiliation(s)
- Shanshan Mao
- Department of Neurology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Qi Long
- Department of Clinical Nutrition, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Huijia Lin
- Department of Neonatology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Jinling Liu
- Department of Pulmonology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
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