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Capal JK, Bernardino-Cuesta B, Horn PS, Murray D, Byars AW, Bing NM, Kent B, Pearson DA, Sahin M, Krueger DA. Influence of seizures on early development in tuberous sclerosis complex. Epilepsy Behav 2017; 70:245-252. [PMID: 28457992 PMCID: PMC5497719 DOI: 10.1016/j.yebeh.2017.02.007] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/04/2017] [Accepted: 02/04/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Epilepsy is commonly seen in Tuberous Sclerosis Complex (TSC). The relationship between seizures and developmental outcomes has been reported, but few studies have examined this relationship in a prospective, longitudinal manner. The objective of the study was to evaluate the relationship between seizures and early development in TSC. METHODS Analysis of 130 patients ages 0-36months with TSC participating in the TSC Autism Center of Excellence Network, a large multicenter, prospective observational study evaluating biomarkers predictive of autism spectrum disorder (ASD), was performed. Infants were evaluated longitudinally with standardized evaluations, including cognitive, adaptive, and autism-specific measures. Seizure history was collected continuously throughout, including seizure type and frequency. RESULTS Data were analyzed at 6, 12, 18, and 24months of age. Patients without a history of seizures performed better on all developmental assessments at all time points compared to patients with a history of seizures and exhibited normal development at 24months. Patients with a history of seizures not only performed worse, but developmental progress lagged behind the group without seizures. All patients with a history of infantile spasms performed worse on all developmental assessments at 12, 18, and 24months. Higher seizure frequency correlated with poorer outcomes on developmental testing at all time points, but particularly at 12months and beyond. Patients with higher seizure frequency during infancy continued to perform worse developmentally through 24months. A logistic model looking at the individual impact of infantile spasms, seizure frequency, and age of seizure onset as predictors of developmental delay revealed that age of seizure onset was the most important factor in determining developmental outcome. CONCLUSIONS Results of this study further define the relationship between seizures and developmental outcomes in young children with TSC. Early seizure onset in infants with TSC negatively impacts very early neurodevelopment, which persists through 24months of age.
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Affiliation(s)
- Jamie K Capal
- Department of Neurology MLC 2015, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | | | - Paul S Horn
- Department of Neurology MLC 2015, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Donna Murray
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH 45229, USA; Autism Speaks Inc, 85 Devonshire St, Boston, MA 02109, USA
| | - Anna Weber Byars
- Department of Neurology MLC 2015, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Nicole M Bing
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Bridget Kent
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Deborah A Pearson
- McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Darcy A Krueger
- Department of Neurology MLC 2015, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Emir S, Hacısalihoğlu Ş, Özyörük D, Ekici F, Değerliyurt A, Güven A, Çetin İ. Assessment of tumors in children with tuberous sclerosis: a single centre's experience. Turk Arch Pediatr 2017; 52:30-34. [PMID: 28439198 DOI: 10.5152/turkpediatriars.2017.4309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 11/02/2016] [Indexed: 11/22/2022]
Abstract
AIM As a result of mutations in TSC1 (9q34) and TSC2 (16p13.3) tumor supressor genes, the mammalian target of the rapamycin (mTor) signaling pathway is overactivated in patients with tuberous sclerosis. Abnormal cell proliferation and differentiation is responsible for the growth several different tumors. The aim of this study was to review tumors in our patients with tuberous sclerosis. MATERIAL AND METHODS Thirty-six patients with tuberous sclerosis were reviewed retrospectively in terms of age, sex, family history, clinical findings, presence of tumors, and treatments. RESULTS Our study included 36 patients (18/18:M/F) aged between two days and 17 years with a median age of 6 years. There were hypopigmented spots in 30 patients, seizures in 28 patients, and a family history in 11 patients. Tumors related to tuberous sclerosis were renal angiomyolipomas in 21 patients, cardiac rhabdomyomas in 11, subependymal giant cell astrocytomas in seven, and non renal hamartoma in one patient. Everolimus treatment was used in only two patients because of hemodynamic instability. CONCLUSIONS Tuberous sclerosis is a multisystemic disease characterized by the presence of various benign tumors and neurologic disorders. Renal angiomyolipomas, cardiac rhabdomyomas, and subependymal giant cell astrocytomas are commonly observed in patients with tuberous sclerosis. mTOR inhibitors such as everolimus and sirolimus have been increasingly used in the treatment of these tumors. However, the duration and optimal dose of mTOR inhibitors is still controversial and should be used in selected cases.
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Affiliation(s)
- Suna Emir
- Clinic of Pediatric Oncology, Ankara Children's Hematology and Oncology Education and Research Hospital, Ankara, Turkey
| | - Şadan Hacısalihoğlu
- Clinic of Pediatric Oncology, Ankara Children's Hematology and Oncology Education and Research Hospital, Ankara, Turkey
| | - Derya Özyörük
- Clinic of Pediatric Oncology, Ankara Children's Hematology and Oncology Education and Research Hospital, Ankara, Turkey
| | - Filiz Ekici
- Clinic of Pediatric Cardiology, Ankara Children's Hematology and Oncology Education and Research Hospital, Ankara, Turkey
| | - Aydan Değerliyurt
- Clinic of Pediatric Neurology, Ankara Children's Hematology and Oncology Education and Research hospital, Ankara, Turkey
| | - Alev Güven
- Clinic of Pediatric Neurology, Ankara Children's Hematology and Oncology Education and Research hospital, Ankara, Turkey
| | - İlker Çetin
- Clinic of Pediatric Cardiology, Ankara Children's Hematology and Oncology Education and Research Hospital, Ankara, Turkey
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53
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Samanta D, Bosanko KB, Zarate YA. An infant with ash-leaf and café au lait spots: a case of double phakomatosis. Acta Neurol Belg 2017; 117:323-324. [PMID: 27043227 DOI: 10.1007/s13760-016-0638-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/29/2016] [Indexed: 10/22/2022]
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54
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Rosset C, Netto CBO, Ashton-Prolla P. TSC1 and TSC2 gene mutations and their implications for treatment in Tuberous Sclerosis Complex: a review. Genet Mol Biol 2017; 40:69-79. [PMID: 28222202 PMCID: PMC5409767 DOI: 10.1590/1678-4685-gmb-2015-0321] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/01/2016] [Indexed: 01/08/2023] Open
Abstract
Tuberous sclerosis complex is an autosomal dominant disorder characterized by skin
manifestations and formation of multiple tumors in different organs, mainly in the
central nervous system. Tuberous sclerosis is caused by the mutation of one of two
tumor suppressor genes, TSC1 or TSC2. Currently,
the development of novel techniques and great advances in high-throughput genetic
analysis made mutation screening of the TSC1 and
TSC2 genes more widely available. Extensive studies of the
TSC1 and TSC2 genes in patients with TSC
worldwide have revealed a wide spectrum of mutations. Consequently, the discovery of
the underlying genetic defects in TSC has furthered our
understanding of this complex genetic disorder, and genotype-phenotype correlations
are becoming possible, although there are still only a few clearly established
correlations. This review focuses on the main symptoms and genetic alterations
described in TSC patients from 13 countries in three continents, as well as on
genotype-phenotype correlations established to date. The determination of
genotype-phenotype correlations may contribute to the establishment of successful
personalized treatment for TSC.
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Affiliation(s)
- Clévia Rosset
- Laboratório de Medicina Genômica, Centro de Pesquisa Experimental. Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Genética e Biologia Molecular, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | | | - Patricia Ashton-Prolla
- Laboratório de Medicina Genômica, Centro de Pesquisa Experimental. Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Genética e Biologia Molecular, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Departamento de Genética, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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55
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Cao J, Tyburczy ME, Moss J, Darling TN, Widlund HR, Kwiatkowski DJ. Tuberous sclerosis complex inactivation disrupts melanogenesis via mTORC1 activation. J Clin Invest 2016; 127:349-364. [PMID: 27918305 DOI: 10.1172/jci84262] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/20/2016] [Indexed: 12/20/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant tumor-suppressor gene syndrome caused by inactivating mutations in either TSC1 or TSC2, and the TSC protein complex is an essential regulator of mTOR complex 1 (mTORC1). Patients with TSC develop hypomelanotic macules (white spots), but the molecular mechanisms underlying their formation are not fully characterized. Using human primary melanocytes and a highly pigmented melanoma cell line, we demonstrate that reduced expression of either TSC1 or TSC2 causes reduced pigmentation through mTORC1 activation, which results in hyperactivation of glycogen synthase kinase 3β (GSK3β), followed by phosphorylation of and loss of β-catenin from the nucleus, thereby reducing expression of microphthalmia-associated transcription factor (MITF), and subsequent reductions in tyrosinase and other genes required for melanogenesis. Genetic suppression or pharmacological inhibition of this signaling cascade at multiple levels restored pigmentation. Importantly, primary melanocytes isolated from hypomelanotic macules from 6 patients with TSC all exhibited reduced TSC2 protein expression, and 1 culture showed biallelic mutation in TSC2, one of which was germline and the second acquired in the melanocytes of the hypomelanotic macule. These findings indicate that the TSC/mTORC1/AKT/GSK3β/β-catenin/MITF axis plays a central role in regulating melanogenesis. Interventions that enhance or diminish mTORC1 activity or other nodes in this pathway in melanocytes could potentially modulate pigment production.
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56
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Glavan N, Ljubičić-Bistrović I, Grahovac B, Traven L, Sasso A, Jonjić N. Ungual fibroma in 12-year-old boy with hypomelanotic macules, intellectual disability and attention deficit hyperactivity disorder-possible tuberous sclerosis. SAGE Open Med Case Rep 2016; 4:2050313X16666233. [PMID: 27621808 PMCID: PMC5006295 DOI: 10.1177/2050313x16666233] [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: 03/11/2016] [Accepted: 07/26/2016] [Indexed: 11/15/2022] Open
Abstract
Objective: To report a case of a 12-year-old boy with intellectual disability and attention deficit hyperactivity disorder, who came to surgery for an examination due to a minor bulge on the left thumb, which had been growing for the previous month. His mother denied any trauma. Methods: After the removal of the clinically ambiguous bulge and a pathohistological confirmation that it was a periungual fibroma, complete patient analysis was performed due to the presence of hypomelanotic macules and a suspected tuberous sclerosis. Results: Considering the presence of hypomelanotic macules, as one of the main criteria, possible TS diagnosis was set. Conclusion: Early detection of the symptoms of TS enables a timely provision of protocols for further patient monitoring, which affects the patient’s morbidity and mortality.
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Affiliation(s)
- Nedeljka Glavan
- Department of Pediatrics Surgery, University Hospital Centre Rijeka, Rijeka, Croatia
| | | | - Blaženka Grahovac
- Department of Pathology, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Luka Traven
- Department of Environmental Medicine, Medical Faculty, University of Rijeka, Rijeka, Croatia; Teaching Institute of Public Health, Rijeka, Croatia
| | - Anton Sasso
- Health Center of Primorsko-Goranska County, Medical Faculty, University of Rijeka, Rijeka, Croatia
| | - Nives Jonjić
- Department of Pathology, School of Medicine, University of Rijeka, Rijeka, Croatia
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57
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Dayal P, Prakash S. Binge drinking in tuberous sclerosis successfully treated with valproate: A case report. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.3109/14659891.2015.1065016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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58
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Baykal C, Tekturk P, Polat Ekinci A, Buyukbabani N, Baykan B, Yapici Z. Fibromatous lesion of the scalp: is it an underestimated sign of tuberous sclerosis? J Eur Acad Dermatol Venereol 2016; 31:e110-e112. [DOI: 10.1111/jdv.13853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C. Baykal
- Department of Dermatology and Venereology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - P. Tekturk
- Department of Neurology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - A. Polat Ekinci
- Department of Dermatology and Venereology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - N. Buyukbabani
- Department of Pathology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - B. Baykan
- Department of Neurology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
| | - Z. Yapici
- Department of Neurology; Istanbul Medical Faculty; Istanbul University; Istanbul Turkey
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59
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Jóźwiak S, Sadowski K, Kotulska K, Schwartz RA. Topical Use of Mammalian Target of Rapamycin (mTOR) Inhibitors in Tuberous Sclerosis Complex-A Comprehensive Review of the Literature. Pediatr Neurol 2016; 61:21-7. [PMID: 27222056 DOI: 10.1016/j.pediatrneurol.2016.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/29/2016] [Accepted: 04/05/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tuberous sclerosis complex is a genetically determined multisystem disorder that may affect almost any human organ. The discovery of the mammalian target of rapamycin (mTOR) pathway and its involvement in tuberous sclerosis complex-related pathology has led to the introduction of mTOR inhibitors into clinical practice. Topical administration of mTOR inhibitors for skin lesions related to tuberous sclerosis complex may represent a reasonable alternative for more invasive procedures. A growing number of patients have been described exhibiting positive therapeutic effects from the topical administration of these agents. The aim of this review was to systematically analyze available literature on the use of topical mTOR inhibitors to treat dermatologic lesions related to tuberous sclerosis complex. RESULTS A comprehensive review of PubMed, Medscape, and Cochrane databases between 1995 and 2015 was performed to identify available studies describing topical use of mTOR inhibitors in individuals with tuberous sclerosis complex. In most studies, topical mTOR inhibitor application proved to be effective in the treatment of skin lesions related to tuberous sclerosis complex. Facial angiofibromas were the target lesions in most instances. Few studies reported clinical improvement of hypomelanotic macules. These drugs directly address the molecular defect related to tuberous sclerosis complex manifestations. CONCLUSIONS Currently available clinical data suggest that topical application of mTOR inhibitors may be effective in the treatment of facial angiofibromas associated with tuberous sclerosis complex. Ongoing randomized clinical trials of topical mTOR inhibitors for TSC-related cutaneous lesions should add clarity to the role of these agents.
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Affiliation(s)
- Sergiusz Jóźwiak
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland; Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Robert A Schwartz
- Department of Dermatology, Rutgers University, New Jersey Medical School, Newark, New Jersey; Department of Pediatrics, Rutgers University, New Jersey Medical School, Newark, New Jersey; Department of Preventive Medicine and Community Health, Rutgers University, New Jersey Medical School, Newark, New Jersey; Rutgers University School of Public Affairs and Administration, Newark, New Jersey
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60
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Santos ACED, Heck B, Camargo BD, Vargas FR. Prevalence of Café-au-Lait Spots in children with solid tumors. Genet Mol Biol 2016; 39:232-8. [PMID: 27223488 PMCID: PMC4910556 DOI: 10.1590/1678-4685-gmb-2015-0024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 06/08/2015] [Indexed: 01/03/2023] Open
Abstract
Cafe-au-lait maculae (CALM) are frequently observed in humans, and usually are
present as a solitary spot. Multiple CALMs are present in a smaller fraction of the
population and are usually associated with other congenital anomalies as part of many
syndromes. Most of these syndromes carry an increased risk of cancer development.
Previous studies have indicated that minor congenital anomalies may be more prevalent
in children with cancer. We investigated the prevalence of CALMs in two samples of
Brazilian patients with childhood solid tumors, totaling 307 individuals.
Additionally, 176 school children without diagnosis of cancer, or of a cancer
predisposing syndrome, were investigated for the presence of CALMs. The prevalence of
solitary CALM was similar in both study groups (18% and 19%) and also in the group of
children without cancer. Multiple CALMs were more frequently observed in one of the
study groups (Z = 2.1). However, when both groups were analyzed together, the
significance disappeared (Z = 1.5). The additional morphological abnormalities in
children with multiple CALMs were analyzed and compared to the findings observed in
the literature. The nosologic entities associated with CALMs are reviewed.
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Affiliation(s)
- Anna Claudia Evangelista Dos Santos
- Departamento de Genética e Biologia Molecular, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ, Brazil.,Departamento de Genética, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, SP, Brazil
| | - Benjamin Heck
- Departamento de Pediatria, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Beatriz De Camargo
- Departamento de Pediatria, AC Camargo Cancer Center, São Paulo, SP, Brazil.,Departamento de Oncologia Pediátrica, Instituto Nacional de Cancer, Rio de Janeiro, RJ, Brazil
| | - Fernando Regla Vargas
- Departamento de Genética e Biologia Molecular, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ, Brazil.,Departamento de Genética, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, SP, Brazil.,Laboratório de Epidemiologia de Malformações Congênitas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
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61
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Strowd RE, Strowd LC, Blakeley JO. Cutaneous manifestations in neuro-oncology: clinically relevant tumor and treatment associated dermatologic findings. Semin Oncol 2016; 43:401-7. [PMID: 27178695 DOI: 10.1053/j.seminoncol.2016.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Skin findings are a rare but important aspect of the evaluation and management of patients with tumors of the nervous system. Skin findings have the highest prevalence in genetic tumor syndromes termed neuro-genodermatoses, which include neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), and tuberous sclerosis. Skin changes are observed in patients with non-syndromic nervous system malignancy, often as a result of pharmacotherapy. The skin may also manifest findings in paraneoplastic conditions that affect the nervous system, providing an early indication of underlying neoplasm, including dermatomyosistis, neuropathic itch, and brachioradial pruritus. In this article, we review the major cutaneous findings in patients with tumors of the brain, spine, and peripheral nervous system focusing on (1) cutaneous manifestations of genetic and sporadic primary nervous system tumor syndromes, and (2) paraneoplastic neurological syndromes with prominent cutaneous features.
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Affiliation(s)
- Roy E Strowd
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC; Department of Neurology and Oncology, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Lindsay C Strowd
- Department of Dermatology, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Jaishri O Blakeley
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC; Department of Neurology and Oncology, Johns Hopkins School of Medicine, Baltimore, MD
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Nathan N, Burke K, Trickett C, Moss J, Darling TN. The Adult Phenotype of Tuberous Sclerosis Complex. Acta Derm Venereol 2016; 96:278-80. [PMID: 26258325 DOI: 10.2340/00015555-2203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Neera Nathan
- Department of Dermatology, Uniformed Services University of Health Sciences, 20814 Bethesda, Maryland, USA
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63
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The spectrum of nephrocutaneous diseases and associations: Genetic causes of nephrocutaneous disease. J Am Acad Dermatol 2016; 74:231-44; quiz 245-6. [PMID: 26775773 DOI: 10.1016/j.jaad.2015.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 12/20/2022]
Abstract
There are a significant number of diseases and treatment considerations of considerable importance relating to the skin and renal systems. This emphasizes the need for dermatologists in practice or in clinical training to be aware of these associations. Part I of this 2-part continuing medical education article reviews the genetic syndromes with both renal and cutaneous involvement that are most important for the dermatologist to be able to identify, manage, and appropriately refer to nephrology colleagues. Part II reviews the inflammatory syndromes with relevant renal manifestations and therapeutic agents commonly used by dermatologists that have drug-induced effects on or require close consideration of renal function. In addition, we will likewise review therapeutic agents commonly used by nephrologists that have drug-induced effects on the skin that dermatologists are likely to encounter in clinical practice. In both parts of this continuing medical education article, we discuss diagnosis, management, and appropriate referral to our nephrology colleagues in the context of each nephrocutaneous association. There are a significant number of dermatoses associated with renal abnormalities and disease, emphasizing the need for dermatologists to be keenly aware of their presence in order to avoid overlooking important skin conditions with potentially devastating renal complications. This review discusses important nephrocutaneous disease associations with recommendations for the appropriate urgency of referral to nephrology colleagues for diagnosis, surveillance, and early management of potential renal sequelae.
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64
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Schwartz RA. Facial angiofibromas of tuberous sclerosis treated with topical sirolimus in an Indian patient (commentary on article by Resham J. Vasani). Dermatol Ther 2016; 29:70-1. [DOI: 10.1111/dth.12257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Robert A. Schwartz
- Dermatology and Pediatrics; Rutgers University New Jersey Medical School; Newark New Jersey
- Rutgers School of Public Affairs and Administration; Newark New Jersey
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65
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Nathan N, Wang JA, Li S, Cowen EW, Haughey M, Moss J, Darling TN. Improvement of tuberous sclerosis complex (TSC) skin tumors during long-term treatment with oral sirolimus. J Am Acad Dermatol 2015; 73:802-8. [PMID: 26365597 DOI: 10.1016/j.jaad.2015.07.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/09/2015] [Accepted: 07/16/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oral mechanistic target of rapamycin inhibitors have been shown to reduce visceral tumor volume in patients with tuberous sclerosis complex (TSC). OBJECTIVE We sought to evaluate the cutaneous response to oral sirolimus in patients with TSC and an indication for systemic treatment, including long-term effects. METHODS A retrospective analysis of 14 adult patients with TSC prescribed sirolimus to treat lymphangioleiomyomatosis was performed. Serial photographs of angiofibromas, shagreen patches, and ungual fibromas taken before, during, and after the treatment period were blinded, then assessed using the Physician Global Assessment of Clinical Condition (PGA). Microscopic and molecular studies were performed on skin tumors harvested before and during treatment. RESULTS Sirolimus significantly improved angiofibromas (median treatment duration 12 months; median PGA score 4.5 [range 1.5-5]; Wilcoxon signed rank test, P = .018) and shagreen patches (median treatment duration 10 months; median PGA score 4.5 [range 3.5-5]; Wilcoxon signed rank test, P = .039), whereas ungual fibromas improved in some patients (median treatment duration 6.5 months; median PGA score 4.66 [range 2.75-5]; Wilcoxon signed rank test, P = .109). Clinical, immunohistochemical, or molecular evidence of resistance was not observed (range 5-64 months of treatment). LIMITATIONS This was a retrospective analysis limited to adult women with lymphangioleiomyomatosis. CONCLUSION Oral sirolimus is an effective long-term therapy for TSC skin tumors, particularly angiofibromas, in patients for whom systemic treatment is indicated.
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Affiliation(s)
- Neera Nathan
- Department of Dermatology, Uniformed Services University of Health Sciences, Bethesda, Maryland; Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ji-an Wang
- Department of Dermatology, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Shaowei Li
- Department of Dermatology, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Mary Haughey
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Thomas N Darling
- Department of Dermatology, Uniformed Services University of Health Sciences, Bethesda, Maryland.
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66
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Abstract
Tuberous sclerosis complex is an autosomal dominant disorder that often manifests early in life with cutaneous features, and it is important that dermatologists who care for children remain up to date on its diagnosis and management. This article provides an update regarding the most recent guidelines for diagnosis published by the International Tuberous Sclerosis Complex Consensus Conference, which took place in 2012, and provides a brief literature review of the most recent developments in the treatment of skin findings.
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67
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Abstract
Acne is the most common skin disease. Distinguishing between true acne vulgaris and the various acneiform eruptions is important yet sometimes challenging. Given the common nature of acne and acneiform eruptions, the pediatrician must be aware of these lesion patterns and possess the skills to effectively evaluate the pediatric presentation of these eruptions. This article discusses several of the most common acneiform eruptions, including neonatal acne and cephalic pustulosis, periorificial dermatitis (perioral dermatitis), facial angiofibromas, iatrogenic acneiform drug eruptions, and childhood rosacea.
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Samueli S, Abraham K, Dressler A, Groeppel G, Jonak C, Muehlebner A, Prayer D, Reitner A, Feucht M. Tuberous Sclerosis Complex: new criteria for diagnostic work-up and management. Wien Klin Wochenschr 2015; 127:619-30. [PMID: 25860851 DOI: 10.1007/s00508-015-0758-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 01/27/2015] [Indexed: 12/24/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic multisystem disorder, characterized by predominantly benign tumors in potentially all organ systems. System involvement, severity of clinical symptoms and the response to treatment are age-dependent and heterogeneous. Consequently, the disorder is still not recognized in a considerable number of patients. The diagnostic criteria and the guidelines for surveillance and management of patients with TSC were revised, and the establishment of specialized TSC-centers was strongly recommended during an International Consensus Conference in 2012. TOSCA (TuberOus SClerosis registry to increase disease Awareness), an international patient registry, was started to allow new insights into the causes of different courses. Finally, there are-since the approval of the mTOR inhibitor Everolimus-promising new therapeutic approaches.This review focuses on the various TSC related symptoms occurring at different ages, the novel recommendations for diagnosis and treatment as well as the need for multidisciplinary follow-up.
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Affiliation(s)
- Sharon Samueli
- Universitätsklinik für Kinder- und Jugendheilkunde, AKH Wien, Wien, Österreich
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Schepis C, Siragusa M, Puzzo A, Amato C, Elia M. Tuberous sclerosis underlying neonatal poliosis. J Eur Acad Dermatol Venereol 2015; 29:822-3. [DOI: 10.1111/jdv.12427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C. Schepis
- Unit of Dermatology; Oasi Institute; IRCCS; Troina Italy
| | - M. Siragusa
- Unit of Dermatology; Oasi Institute; IRCCS; Troina Italy
| | - A. Puzzo
- Unit of Cardiology; Oasi Institute; IRCCS; Troina Italy
| | - C. Amato
- Unit of Neuroradiology; Oasi Institute; IRCCS; Troina Italy
| | - M. Elia
- Unit of Neurology; Oasi Institute; IRCCS; Troina Italy
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71
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Sadek AA, Abdel Samad SN, Bakheet MA, Hassan IA, Abd El-Mageed WM, Emam AM. Multidisciplinary approach for evaluation of neurocutaneous disorders in children in Sohag University Hospital, Upper Egypt. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2015. [DOI: 10.1016/j.ejmhg.2015.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mettin RR, Merkenschlager A, Bernhard MK, Elix H, Hirsch W, Kiess W, Syrbe S. Wide spectrum of clinical manifestations in children with tuberous sclerosis complex--follow-up of 20 children. Brain Dev 2014; 36:306-14. [PMID: 23751858 DOI: 10.1016/j.braindev.2013.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 11/15/2022]
Abstract
UNLABELLED TSC is a multisystem genetic disorder predisposing to multiple organ manifestations and developmental problems. Clinical follow-up of patients remains a challenge for the caring paediatrician. METHODS We performed a retrospective analysis of clinical manifestations, diagnostic and therapeutic data in 20 children with the diagnosis of tuberous sclerosis complex (TSC) to answer the following questions: are the clinical guidelines and imaging strategies appropriate to discover complications, are there significant early predictors of long-term prognosis, what is the age range for signs and symptoms to occur. RESULTS Cardiac rhabdomyoma were present in 18 children and occurred as earliest manifestation. 8 of these exhibited associated arrhythmia or congenital cardiac anomalies. Seizures combined with cortical tubers and subependymal nodules occurred in 18 patients and were most likely to start in infancy, which was associated with later cognitive impairment. Cutaneous manifestations (15 children) occurred in late childhood and school age, whilst renal angiomyolipomas (11) developed in puberty. DISCUSSION The clinical course and imaging strategies are compared with data from previous studies. A review of TSC in regard to the multiple manifestations is provided.
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Affiliation(s)
- Roland R Mettin
- Department of Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Andreas Merkenschlager
- Department of Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Matthias K Bernhard
- Department of Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Heidrun Elix
- Clinic for Paediatrics and Adolescent Medicine, Klinikum Chemnitz gGmbH, Germany
| | - Wolfgang Hirsch
- Department of Imaging and Radiotherapy, Section Paediatric Radiology, University of Leipzig, Germany
| | - Wieland Kiess
- Department of Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Steffen Syrbe
- Department of Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Germany.
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Sauter M, Sigl J, Schotten KJ, Günthner-Biller M, Knabl J, Fischereder M. Association of oestrogen-containing contraceptives with pulmonary lymphangioleiomyomatosis in women with tuberous sclerosis complex--findings from a survey. EUR J CONTRACEP REPR 2013; 19:39-44. [PMID: 24325602 DOI: 10.3109/13625187.2013.859667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES About 30-40% of women with tuberous sclerosis complex (TSC) develop pulmonary lymphangioleiomyomatosis (LAM). Oestrogen seems to be involved in LAM pathogenesis and oestrogen-containing contraception should be avoided in women with known LAM. However, there is very little data on the use of contraceptives in TSC patients. METHODS We conducted a survey on the use of contraception and disease characteristics. The questionnaire was forwarded to all adult female TSC patients listed in the database of a German patient organisation. RESULTS Data from 39 such patients could be analysed. Of these, 15 were diagnosed with LAM. Twenty-five patients (65%) confirmed current or past use of oestrogen-containing contraceptives. We found a suggestive correlation between the history of oestrogen-containing contraception, and LAM (Odds ratio: 6.500; 95% confidence interval: 1.199-35.230). However, oestrogen use was not associated with LAM complications. CONCLUSIONS Based on our findings, oestrogen-containing contraceptives should be resorted to by these patients only with great caution, and avoided whenever possible.
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Affiliation(s)
- Matthias Sauter
- * Medizinische Klinik und Poliklinik IV, Nephrologisches Zentrum, Klinikum der Universität München
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Northrup H, Krueger DA. Tuberous sclerosis complex diagnostic criteria update: recommendations of the 2012 Iinternational Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol 2013; 49:243-54. [PMID: 24053982 PMCID: PMC4080684 DOI: 10.1016/j.pediatrneurol.2013.08.001] [Citation(s) in RCA: 932] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/30/2013] [Accepted: 08/01/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tuberous sclerosis complex is highly variable in clinical presentation and findings. Disease manifestations continue to develop over the lifetime of an affected individual. Accurate diagnosis is fundamental to implementation of appropriate medical surveillance and treatment. Although significant advances have been made in the past 15 years in the understanding and treatment of tuberous sclerosis complex, current clinical diagnostic criteria have not been critically evaluated or updated since the last clinical consensus conference in 1998. METHODS The 2012 International Tuberous Sclerosis Complex Consensus Group, comprising 79 specialists from 14 countries, was organized into 12 subcommittees, each led by a clinician with advanced expertise in tuberous sclerosis complex and the relevant medical subspecialty. Each subcommittee focused on a specific disease area with important diagnostic implications and was charged with reviewing prevalence and specificity of disease-associated clinical findings and their impact on suspecting and confirming the diagnosis of tuberous sclerosis complex. RESULTS Clinical features of tuberous sclerosis complex continue to be a principal means of diagnosis. Key changes compared with 1998 criteria are the new inclusion of genetic testing results and reducing diagnostic classes from three (possible, probable, and definite) to two (possible, definite). Additional minor changes to specific criterion were made for additional clarification and simplification. CONCLUSIONS The 2012 International Tuberous Sclerosis Complex Diagnostic Criteria provide current, updated means using best available evidence to establish diagnosis of tuberous sclerosis complex in affected individuals.
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Affiliation(s)
- Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas.
| | - Darcy A. Krueger
- Division of Neurology, Department of Pediatrics, Cincinnati Children?s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Wataya-Kaneda M, Tanaka M, Hamasaki T, Katayama I. Trends in the prevalence of tuberous sclerosis complex manifestations: an epidemiological study of 166 Japanese patients. PLoS One 2013; 8:e63910. [PMID: 23691114 PMCID: PMC3656843 DOI: 10.1371/journal.pone.0063910] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 04/10/2013] [Indexed: 02/04/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder with multi-system involvement and variable manifestations. There has been significant progress in TSC research and the development of technologies used to diagnose this disorder. As a result, individuals with mild TSC are now being diagnosed, including many older adults who have not developed seizures or cognitive abnormalities. We conducted a statistical analysis of the frequency of TSC manifestations in a population of Japanese adults and children, comparing our findings with historical data. The chi-square test was used to examine the frequency of each manifestation by age. A total of 166 outpatients at the Department of Dermatology of Osaka University Hospital during the period from January 2001 to March 2011 were included in the study. Compared to previous reports, the frequency of neurologic manifestations (excepting autism) was lower in this cohort, and the frequency of skin manifestations (excepting hypomelanotic macules) was higher in this cohort. The frequencies of pulmonary lymphangioleiomyomatosis and renal manifestations were not significantly different from those previously reported. Regarding the association of each manifestation with age, the frequency of neurologic manifestations (excepting subependymal giant cell astrocytoma) was significantly higher in younger patients than in older patients. The frequency of skin manifestations and renal angiomyolipoma were significantly higher in older patients than in younger patients. Because of their high frequency and visibility, skin manifestations are useful in the diagnosis of TSC. Moreover, uterine perivascular epithelioid cell tumor was also characterized as a new findings associated with TSC.
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Affiliation(s)
- Mari Wataya-Kaneda
- Department of Dermatology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
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Schepis C. Cutaneous findings in children with intellectual disabilities. J Dermatol 2012; 40:21-6. [PMID: 22963085 DOI: 10.1111/j.1346-8138.2012.01658.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/13/2012] [Indexed: 11/30/2022]
Abstract
The link between pediatric dermatology and intellectual disabilities (ID) is revised, according to the author's personal experience and the existing published work. Cutaneous manifestations in children with ID can be: (i) a key element to reach a diagnosis, as in neurodermatoses; (ii) a peculiar sign to define a complex syndrome; (iii) linked to behavioral features; (iv) iatrogenic, caused by drugs, as a side-effect; and (v) independent from ID.
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Affiliation(s)
- Carmelo Schepis
- Unit of Dermatology, Oasi Institute (IRCCS) for Research on Intellectual Disabilities and Brain Aging, Troina, Italy.
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78
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[Neuro-encephalic features of tuberous sclerosis complex]. Rev Med Interne 2012; 33:433-8. [PMID: 22658530 DOI: 10.1016/j.revmed.2012.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 01/04/2012] [Accepted: 04/01/2012] [Indexed: 11/22/2022]
Abstract
Tuberous sclerosis is a phacomatosis resulting from an autosomal dominant inheritance. It is characterized by the presence of multiple hamartomas in various organs, especially the brain, the skin, the kidneys and the heart. The diagnosis of tuberous sclerosis is based on imaging and clinical examination, where magnetic resonance imaging constitutes the key investigation showing characteristic brain lesions. Neuro-encephalic manifestations may be particularly severe, and may even be life threatening. The authors report personal cases series and review the literature highlighting epidemiology, clinical features and imaging of neuro-encephalic tuberous sclerosis.
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Kacerovska D, Kerl K, Michal M, Filipova H, Vrtel R, Vanecek T, Zelenakova H, Kraus J, Kodet R, Kazakov DV. Giant angiofibromas in tuberous sclerosis complex: a possible role for localized lymphedema in their pathogenesis. J Am Acad Dermatol 2012; 67:1319-26. [PMID: 22552000 DOI: 10.1016/j.jaad.2012.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/25/2012] [Accepted: 03/30/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Giant angiofibromas in patients with tuberous sclerosis complex (TSC) are rare. OBJECTIVE We sought to report two patients who had TSC with unusually large and disfiguring facial angiofibromas and to identify underlying histopathologic changes that may possibly explain the clinical features. METHODS We performed a clinicopathologic, immunohistochemical, and molecular biologic study using 42 lesional specimens and peripheral blood from one of the two patients. The immunohistochemical investigations were mainly focused on the vascular moiety of the lesions. TSC1 and TSC2 alterations were studied using multiplex ligation-dependent probe amplification for large deletion/duplication mutations, whereas screening for small mutations was performed using polymerase chain reaction amplification of individual coding exons and exon-intron junctions of both genes followed by an analysis on denaturation gradient gel electrophoresis. RESULTS Histopathologic examination revealed, in addition to findings typical of angiofibroma, several unusual features including multinucleated giant cells containing multiple intracytoplasmic vacuoles, Touton-like cells, emperipolesis, pagetoid dyskeratosis, vacuolar alteration at the dermoepidermal junction, Civatte bodies, and melanophages in the subjacent dermis. Numerous dilated lymphatic vessels were detected indicating localized lymphostasis, probably caused by secondary lymphedema. The lymphatic nature of the vessels was confirmed by immunohistochemical study. Genetic testing for TSC1 and TSC2 gene mutations revealed a substitution on position c.2251C>T resulting in a nonsense mutation R751X in fragment 20.2. LIMITATIONS Histopathologic specimens and peripheral blood were available from only one patient. CONCLUSION Localized lymphedema may contribute to the formation of large disfiguring angiofibromas in patients with TSC.
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Affiliation(s)
- Denisa Kacerovska
- Sikl's Department of Pathology, Charles University in Prague, Faculty of Medicine in Pilsen, Pilsen, Czech Republic
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Numerous cortical tubers and rhabdomyomas in a case of sudden unexpected infant death. Am J Forensic Med Pathol 2011; 32:331-5. [PMID: 22101435 DOI: 10.1097/paf.0b013e3181d3dc53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sudden infant death syndrome is the leading cause of death in infants between the ages of 1 month to 1 year. Sudden infant death syndrome, a diagnosis of exclusion, can only be made after other explanations for unexpected death have been ruled out. Tuberous sclerosis complex is occasionally the findings in these patients with unexpected infant death. Here, we present a case of an unexpected infant death during sleep with multiple factors that confound the cause of death. We discuss these factors and attempt to delineate their contributions to arrive at a cause and mechanism of death.
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Abstract
BACKGROUND Neurocutaneous syndromes (NCS) are a group of genetic disorders that produce a variety of developmental abnormalities of the skin along with an increased risk of neurological complications. Cutaneous manifestations usually appear early in life and progress with time, but neurological features generally present at a later age. There is a paucity of data regarding the evolution of skin lesions and their correlation with the central nervous system involvement in children. AIM The primary objective was to track the course of skin lesions in various forms of NCS in the pediatric age group. Our secondary aim was to assess whether there was any predictive value of the lesions in relation to the neurological manifestations. MATERIALS AND METHODS This prospective longitudinal study was conducted at a tertiary care pediatric dermatology referral clinic of the Institute of Child Health, Kolkata, West Bengal. Children between the age group 0 and 12 years were included in the study on the basis of standard diagnostic criteria for different NCS, during the period from March, 2000 to February, 2004, and each of the enrolled cases were followed up for a duration of six years. RESULTS The study population comprised of 67 children (35 boys, 32 girls).The mean age of presentation was 33.8±27.8 months (range 10 days to 111 months). The various forms of NCS observed was neurofibromatosis 1(NF1) (n=33), tuberous sclerosis complex (TSC) (n=23), Sturge Weber syndrome (n=6), ataxia telangiectasia (n=2), PHACE syndrome (n=1), incontinentia pigmenti (n=1), and hypomelanosis of Ito (n=1). The presentations were varied, ranging from predominantly cutaneous to primarily neurological, depending on the disease entity and age group concerned. There was a significant increase in the number of café au lait macules (CALMs) with time (P=0.0002) in NF1, unlike that of hypopigmented macules of TSC (P=0.15). Statistically, no relation was documented between the evolution of skin lesions and neurological manifestations in the major groups. CONCLUSION As NCS is not an uncommon disease in children, it is always necessary to find out the subtle neurological signs, whenever we observe any case with cutaneous markers suggestive of NCS. In addition, it is a must to do a detailed dermatological examination in a child with central nervous system involvement, in the pediatric population. However, the neurological course cannot be predicted from skin lesions.
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Affiliation(s)
- Radheshyam Purkait
- Department of Pediatric Medicine, NRS Medical College and Hospital, Kolkata, West Bengal, India
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Folliculocystic and collagen hamartoma of tuberous sclerosis complex. J Am Acad Dermatol 2011; 66:617-21. [PMID: 21839539 DOI: 10.1016/j.jaad.2011.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 03/09/2011] [Accepted: 04/01/2011] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by tumors and hamartomas in several organs including the skin. OBJECTIVE We sought to describe a new type of complex hamartoma in patients with TSC. METHODS This was a retrospective clinical and histopathologic evaluation of 6 cases. RESULTS The skin lesions consisted of large, painless, infiltrated plaques that were first noticed at birth or during early infancy on the abdomen, thigh, back, or scalp. In time, the plaques became studded with numerous follicular comedo-like openings and cysts containing and draining a keratinous or purulent material. The main histopathologic features were: abundant collagen deposition in the dermis and extending into the underlying fat; concentric, perifollicular fibrosis surrounding hair follicles; and comedones and keratin-containing cysts lined by infundibular epithelium, some of which were ruptured with secondary granulomatous reaction. Five of the 6 patients had a clinical diagnosis of TSC. LIMITATIONS Genetic testing was performed in only one patient. CONCLUSION This distinctive folliculocystic and collagen hamartoma has not been recognized previously in association with TSC.
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Gomes AAR, Gomes YVR, Lima FB, Pessoa SGDP. Tratamento dos angiofibromas múltiplos da face com radiofrequência. An Bras Dermatol 2011; 86:S186-9. [DOI: 10.1590/s0365-05962011000700048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/28/2010] [Indexed: 11/22/2022] Open
Abstract
Esclerose tuberosa é uma doença genética rara, com herança autossômica dominante, associada à formação de hamartomas múltiplos em vários órgãos, como cérebro, pele, pulmões, rins, coração e olhos. Os autores deste estudo apresentam um caso de uma paciente do sexo feminino, com 30 anos de idade, portadora de esclerose tuberosa, apresentando múltiplos angiofibromas em face, tratada com equipamento de alta frequência (radiofrequência), e discutem as opções terapêuticas para tratamento de indivíduos portadores de esclerose tuberosa com extenso envolvimento cutâneo
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Abstract
Gelastic seizures are typically associated with hypothalamic hamartoma. Given the rarity of gelastic seizures, pathways for the motor and emotional aspects of laughter have been hypothesized but remain unclear. The authors perform a literature review to discuss what is known about these pathways. They also report a child who presented with tuberous sclerosis complex initially without cutaneous stigmata, who later developed gelastic seizures. Only 2 case reports of patients with tuberous sclerosis complex who subsequently developed gelastic epilepsy have previously been reported. In discussing his case, the authors postulate additional etiologies for gelastic seizures.
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Affiliation(s)
- Tara Cook
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Perez EG, Paranaíba LR, Bonan PR, Orsi Júnior JM, Oliveira AMD, Martelli Júnior H. [Tuberous sclerosis: evaluation of myofibroblasts in cutaneous angiofibromas - case report]. An Bras Dermatol 2010; 85:84-8. [PMID: 20464093 DOI: 10.1590/s0365-05962010000100013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 06/30/2009] [Indexed: 11/22/2022] Open
Abstract
Tuberous sclerosis is a rare autosomal dominant disorder. Myofibroblasts are cells with a hybrid phenotype between fibroblasts and smooth muscle cells. The objective of this study is to describe clinical and histopathological characteristics of tuberous sclerosis and to conduct an immunohistochemical evaluation of myofibroblasts in cutaneous angiofibromas present in this condition. Lesion sections removed were stained with hematoxylin-eosin and Masson's trichrome. Immunohistochemistry against alpha-SMA was done to determine the presence of myofibroblasts, and the reaction was negative. Since alpha-SMA is a specific marker for myofibroblasts, this result suggests that myofibroblasts are not involved in cutaneous angiofibromas present in the tuberous sclerosis case reported.
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87
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Darling TN, Pacheco-Rodriguez G, Gorio A, Lesma E, Walker C, Moss J. Lymphangioleiomyomatosis and TSC2-/- cells. Lymphat Res Biol 2010; 8:59-69. [PMID: 20235888 DOI: 10.1089/lrb.2009.0031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The cells comprising pulmonary lymphangioleiomyomatosis (LAM) and renal angiomyolipomas (AMLs) are heterogeneous, with variable mixtures of cells exhibiting differentiation towards smooth muscle, fat, and vessels. Cells grown from LAM and AMLs have likewise tended to be heterogeneous. The discovery that LAM and AMLs contain cells with mutations in the TSC1 or TSC2 genes is allowing investigators to discriminate between "two-hit" cells and neighboring cells, providing insights into disease pathogenesis. In rare cases, it has been possible to derive cells from human tumors, including AMLs and TSC skin tumors that are highly enriched for TSC2(-/-) cells. Cells derived from an Eker rat uterine leiomyoma (ELT3 cells) are Tsc2-null and these have been used in a rodent cell models for LAM. Further improvements in the ability to reliably grow well-characterized TSC2(-/-) cells from human tumors are critical to developing in vitro and in vivo model systems for studies of LAM pathogenesis and treatment.
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Affiliation(s)
- Thomas N Darling
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
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Acral lesions in tuberous sclerosis complex: insights into pathogenesis. J Am Acad Dermatol 2010; 63:244-51. [PMID: 20462663 DOI: 10.1016/j.jaad.2009.08.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with tuberous sclerosis complex (TSC) are predisposed to developing ungual fibromas and other acral lesions. OBJECTIVE We sought to determine the numbers, types, and locations of acral skin lesions in TSC. METHODS We examined and photographed 76 adult women with TSC. RESULTS The age of the patients ranged from 20 to 69 years, with a mean age of 39 +/- 11 years. Ungual fibromas were observed in 61 of 76 patients (80%). Periungual fibromas were more common than subungual fibromas, were more common on the feet than the hands, and showed the greatest frequency on the fifth toe. Longitudinal grooves in the nails occurred with or without a visible fibroma. Longitudinal short red streaks--lesions that we term "red comets"--were observed in 22 patients (29%). Longitudinal leukonychia was observed in 14 patients (18%). One patient had isolated digital overgrowth and one patient had pachydermodactyly. LIMITATIONS No men or children were included in this study. CONCLUSIONS Examination of patients for skin lesions of TSC could be improved by including inspection for longitudinal nail grooves, red comets, longitudinal leukonychia, and splinter hemorrhages in addition to ungual fibromas. The anatomic distribution of TSC ungual fibromas is not random and appears consistent with trauma-promoted tumor formation.
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90
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TSC2/PKD1 Contiguous Gene Syndrome: A Report of 2 Cases With Emphasis on Dermatopathologic Findings. Am J Dermatopathol 2009; 31:532-41. [DOI: 10.1097/dad.0b013e3181970e44] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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91
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Clinical Findings in 67 Patients With Tuberous Sclerosis. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70127-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Baskin HJ. The pathogenesis and imaging of the tuberous sclerosis complex. Pediatr Radiol 2008; 38:936-52. [PMID: 18414839 DOI: 10.1007/s00247-008-0832-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 03/03/2008] [Accepted: 03/12/2008] [Indexed: 01/08/2023]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal-dominant disorder characterized by the formation of hamartomatous lesions in multiple organ systems. It is the second most common neurocutaneous syndrome after neurofibromatosis type 1 and has been recognized since the late 1800s. Although the disease has complete penetrance, there is also high phenotypic variability: some patients have obvious signs at birth, while others remain undiagnosed for many years. In addition to skin lesions, TSC patients develop numerous brain lesions, angiomyolipoma (AMLs), lymphangiomyomatosis (LAM) in the lungs, cardiac rhabdomyomas, skeletal lesions, and vascular anomalies, all of which are well seen with medical imaging. Our knowledge of TSC genetics and pathophysiology has expanded dramatically in recent years: two genetic loci were discovered in the 1990s and recent elucidation of TSC's interaction with the mTOR pathway has changed how we manage the disease. Meanwhile, medical imaging is playing an increasingly important role in the diagnosis, management, and treatment of TSC. We provide an update on the genetics and pathophysiology of TSC, review its clinical manifestations, and explore the breadth of imaging features in each organ system, from prenatal detection of cardiac rhabdomyomas to monitoring rapamycin therapy to treatment of AMLs by interventional radiology.
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Affiliation(s)
- Henry J Baskin
- Department of Radiology, Cincinnati Children's Medical Center, 333 Burnet Ave., Cincinnati, OH 45229, USA.
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93
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Tom WL, Friedlander SF. Acne through the ages: case-based observations through childhood and adolescence. Clin Pediatr (Phila) 2008; 47:639-51. [PMID: 18698096 DOI: 10.1177/0009922808315444] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acne vulgaris is a common disorder that affects more than 17 million individuals in the United States. Knowledge of the disease is an important part of clinical practice, particularly for the pediatric practitioner. Contrary to common belief, acne is not a disease limited to adolescents and young adults but can occur at any stage of life. This article is a case-based review of acne during childhood and adolescence. Workup is based on age and concurrent physical findings, whereas therapy depends on the type of skin lesions along with patient characteristics and preferences.
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Affiliation(s)
- Wynnis L Tom
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, California 92123, USA
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94
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Abstract
Tuberous sclerosis is a genetic multisystem disorder characterised by widespread hamartomas in several organs, including the brain, heart, skin, eyes, kidney, lung, and liver. The affected genes are TSC1 and TSC2, encoding hamartin and tuberin respectively. The hamartin-tuberin complex inhibits the mammalian-target-of-rapamycin pathway, which controls cell growth and proliferation. Variations in the distribution, number, size, and location of lesions cause the clinical syndrome to vary, even between relatives. Most features of tuberous sclerosis become evident only in childhood after 3 years of age, limiting their usefulness for early diagnosis. Identification of patients at risk for severe manifestations is crucial. Increasing understanding of the molecular abnormalities caused by tuberous sclerosis may enable improved management of this disease.
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Affiliation(s)
- Paolo Curatolo
- Department of Neurosciences, Paediatric Neurology Unit, Tor Vergata University, Rome, Italy
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95
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Abstract
Tuberous sclerosis (TS), neurocutaneous disorder resulting from the mutation of 1 of 2 genes, TSC1 or TSC2, is often associated with the formation of hamartomatous lesions in various organ systems, including the skin. TS patients may present with hypomelanic macules, confetti-like spots, facial angiofibromas, ungual fibromas, shagreen patches, forehead plaques, and other dermatological signs. Some of these manifestations are pathognomic for TS and thus should be carefully evaluated when TS diagnosis is suspected. Little is known however on molecular links connecting disease pathogenesis and formation of such hamartomas. In the current review, we describe molecular pathways thought to be responsible for the development of the disease and show how their upregulation may affect the skin. Special attention is paid to protein kinase B (PKB/Akt), extracellular signal-regulated kinase, and mammalian target of rapamycin, which have recently been found to participate in the control of melanin biosynthesis through microphthalmia-associated transcription factor and tyrosinase transcription.
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96
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Mesenchymal-epithelial interactions involving epiregulin in tuberous sclerosis complex hamartomas. Proc Natl Acad Sci U S A 2008; 105:3539-44. [PMID: 18292222 DOI: 10.1073/pnas.0712397105] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Patients with tuberous sclerosis complex (TSC) develop hamartomas containing biallelic inactivating mutations in either TSC1 or TSC2, resulting in mammalian target of rapamycin (mTOR) activation. Hamartomas overgrow epithelial and mesenchymal cells in TSC skin. The pathogenetic mechanisms for these changes had not been investigated, and the existence or location of cells with biallelic mutations ("two-hit" cells) was unclear. We compared TSC skin hamartomas (angiofibromas and periungual fibromas) with normal-appearing skin of the same patient, and we observed more proliferation and mTOR activation in hamartoma epidermis. Two-hit cells were not detected in the epidermis. Fibroblast-like cells in the dermis, however, exhibited allelic deletion of TSC2, in both touch preparations of fresh tumor samples and cells grown from TSC skin tumors, suggesting that increased epidermal proliferation and mTOR activation were not caused by second-hit mutations in the keratinocytes but by mesenchymal-epithelial interactions. Gene expression arrays, used to identify potential paracrine factors released by mesenchymal cells, revealed more epiregulin mRNA in fibroblast-like angiofibroma and periungual fibroma cells than in fibroblasts from normal-appearing skin of the same patient. Elevation of epiregulin mRNA was confirmed with real-time PCR, and increased amounts of epiregulin protein were demonstrated with immunoprecipitation. Epiregulin stimulated keratinocyte proliferation and phosphorylation of ribosomal protein S6 in vitro. These results suggest that hamartomatous TSC skin tumors are induced by paracrine factors released by two-hit cells in the dermis and that proliferation with mTOR activation of the overlying epidermis is an effect of epiregulin.
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Abstract
A 41-year-old woman presented to our dermatology clinic in February 2005 with a chief complaint of numerous flesh-colored nodules on her back and abdomen. She initially noticed the lesions at age 17 years. The plaques had increased in size and number over time, but remained asymptomatic. The patient reported multiple similar lesions on a maternal uncle and a cousin. Her family history was also notable for cardiomyopathy, resulting in the death of her mother. The patient's past medical history was notable for poorly controlled type I diabetes, currently managed with an insulin pump; and coronary artery disease. The patient had undergone multiple cardiac procedures before the age of 40 years, including quadruple coronary artery bypass grafting surgery and placement of 9 cardiac stents. Her ejection fraction on cardiac catheterization in November 2004 was 65% with no wall motion abnormalities. On physical examination, numerous spongy, discrete, flesh-colored plaques and nodules were seen concentrated across the upper part of her back between the scapulae as well as underneath the breasts and across the flanks (Figure 1). All lesions were asymptomatic. Prior workup of this patient had included plain films of the long bones and hands, which were within normal limits. A biopsy from lesional skin on the back highlighted by trichome stain showed an increased number of markedly thickened and eosinophilic dermal collagen bundles compared with adjacent normal skin. Immunohistochemical studies with anticollagen type I and type III antibodies confirmed that the increased collagen material consisted of type I collagen fibers, which is the same type of collagen found in normal dermis. The elastic fibers, highlighted by Verhoeff-van Gieson stain (Figure 2), were diminished and haphazardly arranged. No increased cellular component or inflammatory infiltrate was observed. These findings were consistent with a collagenoma. Further analysis of the lesional tissue by electron microscopy revealed that the ultrastructural appearance of the collagen fibers, including arrangement and diameters, were not significantly different from that of the normal tissue (Figure 3).
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Affiliation(s)
- Marianne E Dawn
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Shave and Phenolization of Periungual Fibromas, Koenenʼs Tumors, in a Patient with Tuberous Sclerosis. Dermatol Surg 2008. [DOI: 10.1097/00042728-200801000-00024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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100
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Farrell CJ, Plotkin SR. Genetic Causes of Brain Tumors: Neurofibromatosis, Tuberous Sclerosis, von Hippel-Lindau, and Other Syndromes. Neurol Clin 2007; 25:925-46, viii. [DOI: 10.1016/j.ncl.2007.07.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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