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Morin CE, Morin NP, Franz DN, Krueger DA, Trout AT, Towbin AJ. Thoracoabdominal imaging of tuberous sclerosis. Pediatr Radiol 2018; 48:1307-1323. [PMID: 30078036 DOI: 10.1007/s00247-018-4123-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/02/2018] [Accepted: 03/19/2018] [Indexed: 12/19/2022]
Abstract
Imaging of tuberous sclerosis complex has rapidly evolved over the last decade in association with increased understanding of the disease process and new treatment modalities. Tuberous sclerosis complex is best known for the neurological symptoms and the associated neuroimaging findings, and children with tuberous sclerosis complex require active surveillance of associated abnormalities in the chest, abdomen and pelvis. Common findings that require regular imaging surveillance are angiomyolipomas in the kidneys and lymphangioleiomyomatosis in the chest. However multiple rarer associations have been attributed to tuberous sclerosis complex and should be considered by radiologists reviewing any imaging in these children. In this review the authors discuss the spectrum of imaging findings in people with tuberous sclerosis complex, focusing on MR imaging findings in the chest, abdomen and pelvis.
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Affiliation(s)
- Cara E Morin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH, 45229, USA
| | - Nicholas P Morin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Franz
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Darcy A Krueger
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH, 45229, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH, 45229, USA.
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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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Kızılay F, Akıncıoğlu E, Aliyev E, Şimşir A. Tüberoz skleroz ile ilişkili anjiyolipoma rüptürüne bağlı kanamada girişimsel radyoloji. EGE TIP DERGISI 2018. [DOI: 10.19161/etd.414646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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54
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Human renal angiomyolipoma cells of male and female origin can migrate and are influenced by microenvironmental factors. PLoS One 2018; 13:e0199371. [PMID: 29920561 PMCID: PMC6007918 DOI: 10.1371/journal.pone.0199371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/06/2018] [Indexed: 12/15/2022] Open
Abstract
Background Improving the knowledge of angiomyolipoma physiopathology might help in refining its pharmacological treatment. We investigated if angiomyolipoma cells have migratory properties, how their growth and motility can be influenced by the hormonal milieu, and if this can be related to a specific gender. Methods Primary cells were isolated from angiomyolipomas surgically resected for therapeutical reasons in a female and in a male patient. The genetic control demonstrated no TSC2 deletion. Bi- (wound healing) and three-dimensional (transwell assay) migration were analyzed in vitro in basal conditions and under the influence of 17- β-estradiol and SDF-1α. Results Treatment up to 72 hours with 17-β-estradiol (0.1–100 nM), tamoxifen (0.2–20 μM) or with both, does not modify angiomyolipoma cells proliferation. On the other hand, SDF-1α and 17-β-estradiol treatment induce a significant motility increase (both bi- and three-dimensional) which becomes evident already after 2 hours of incubation. Angiomyolipoma cells express mRNA coding for SDF-1α and 17-β-estradiol receptors and secrete both the metalloproteases principally involved in malignant phenotype acquisition, i.e. MMP-2 and MMP-9. Conclusion Angiomyolipoma cells behave similarly, despite their different source. Primary angiomyolipoma cells migrate in response to hormonal milieu and soluble factors, and produce active metalloproteases, both aspects being consistent with the theory claiming they can migrate to the lungs (and/or other organs) and colonizing them. No main feature, among the aspects we analyzed, seems to be referable to the gender of origin.
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55
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Woo S, Kim SY, Cho JY, Kim SH. Differentiation between papillary renal cell carcinoma and fat-poor angiomyolipoma: a preliminary study assessing detection of intratumoral hemorrhage with chemical shift MRI and T2*-weighted gradient echo. Acta Radiol 2018; 59:627-634. [PMID: 29069911 DOI: 10.1177/0284185117723371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Recent literature suggests that intratumoral hemorrhage detection may be helpful in differentiating papillary renal cell carcinoma (pRCC) from fat-poor angiomyolipoma (fpAML). Purpose To determine whether intratumoral hemorrhage detected using chemical shift magnetic resonance imaging (MRI) and T2*-weighted (T2*W) gradient echo (GRE) can be used to differentiate pRCC from fpAML. Material and Methods This retrospective study included 42 patients with pRCC (n = 28) and fpAML (n = 14) who underwent MRI followed by surgery. Two blinded radiologists independently assessed the presence of intratumoral hemorrhage using chemical shift MRI (decrease in signal intensity from opposed- to in-phase) and T2*W GRE ("blooming"). Consensus reading was determined for discrepant cases. MRI findings were compared using Chi-square test. Inter-observer agreement was assessed using kappa statistics. Results Inter-observer agreement was substantial for both sequences ( k = 0.622 and 0.793, P < 0.001). For chemical shift MRI, the prevalence of intratumoral hemorrhage was significantly greater in pRCC than in fpAML (71.4% versus 28.6%, P = 0.019 for reader 1; 64.3% versus 14.3%, P = 0.003 for reader 2; and 75% versus 21.4%, P = 0.002 for the consensus). T2*W GRE showed a similar tendency (46.4% versus 14.3%, P = 0.049 for both readers; and 50% versus 14.3%, P = 0.042 for the consensus). Using the consensus reading, sensitivity and specificity of determining pRCC were 75% and 78.6% for chemical shift MRI and 50% and 85.7% for T2*W GRE. Conclusion The prevalence of intratumoral hemorrhage identified from chemical shift MRI or T2*W GRE was significantly different between pRCC and fpAML. These hemorrhage-sensitive MRI sequences may be used as an adjunctive tool for discriminating between the two entities.
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Affiliation(s)
- Sungmin Woo
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Youn Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Seung Hyup Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Liu HJ, Lizotte PH, Du H, Speranza MC, Lam HC, Vaughan S, Alesi N, Wong KK, Freeman GJ, Sharpe AH, Henske EP. TSC2-deficient tumors have evidence of T cell exhaustion and respond to anti-PD-1/anti-CTLA-4 immunotherapy. JCI Insight 2018; 3:98674. [PMID: 29669930 DOI: 10.1172/jci.insight.98674] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/20/2018] [Indexed: 12/12/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an incurable multisystem disease characterized by mTORC1-hyperactive tumors. TSC1/2 mutations also occur in other neoplastic disorders, including lymphangioleiomyomatosis (LAM) and bladder cancer. Whether TSC-associated tumors will respond to immunotherapy is unknown. We report here that the programmed death 1 coinhibitory receptor (PD-1) is upregulated on T cells in renal angiomyolipomas (AML) and pulmonary lymphangioleiomyomatosis (LAM). In C57BL/6J mice injected with syngeneic TSC2-deficient cells, anti-PD-1 alone decreased 105K tumor growth by 67% (P < 0.0001); the combination of PD-1 and CTLA-4 blockade was even more effective in suppressing tumor growth. Anti-PD-1 induced complete rejection of TSC2-deficient 105K tumors in 37% of mice (P < 0.05). Double blockade of PD-1 and CTLA-4 induced rejection in 62% of mice (P < 0.01). TSC2 reexpression in TSC2-deficient TMKOC cells enhanced antitumor immunity by increasing T cell infiltration and production of IFN-γ/TNF-α by T cells, suggesting that TSC2 and mTORC1 play specific roles in the induction of antitumor immunity. Finally, 1 month of anti-PD-1 blockade reduced renal tumor burden by 53% (P < 0.01) in genetically engineered Tsc2+/- mice. Taken together, these data demonstrate for the first time to our knowledge that checkpoint blockade may have clinical efficacy for TSC and LAM, and possibly other benign tumor syndromes, potentially yielding complete and durable clinical responses.
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Affiliation(s)
- Heng-Jia Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick H Lizotte
- Belfer Center for Applied Cancer Science, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Heng Du
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria C Speranza
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hilaire C Lam
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Spencer Vaughan
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicola Alesi
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kwok-Kin Wong
- Belfer Center for Applied Cancer Science, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center, New York, New York, USA
| | - Gordon J Freeman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Arlene H Sharpe
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA.,Evergrande Center for Immunologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth P Henske
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Živčić-Ćosić S, Mayer K, Đorđević G, Nellist M, Hoogeveen-Westerveld M, Miletić D, Rački S, Klein HG, Trobonjača Z. Severe bleeding complications and multiple kidney transplants in a patient with tuberous sclerosis complex caused by a novel TSC2 missense variant. Croat Med J 2018; 58:416-423. [PMID: 29308833 PMCID: PMC5778681 DOI: 10.3325/cmj.2017.58.416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We presented an extremely severe case of tuberous sclerosis complex (TSC) in a female patient with recurring, life-threatening bleeding complications related to renal angiomyolipomas. Massive intratumoral hemorrhage required surgical removal of both angiomyolipomatous kidneys and kidney transplantation. During the follow-up period, the patient developed severe metrorrhagia that eventually led to hysterectomy and salpingo-oophorectomy. Bleeding from the operative sites caused the loss of the first kidney transplant received from the mother, and immediate hemorrhagic shock led to the loss of the second, cadaveric kidney allograft. The third kidney transplant had a successful outcome. Pathological analysis of all tissue specimens showed TSC-associated lesions and deformed blood vessels in the surgically removed organs. Molecular genetic analysis of TSC1 and TSC2 in the DNA of peripheral leukocytes identified a novel TSC2 c.3599G>C (p.R1200P) variant. Functional assessment confirmed the likely pathogenicity of the TSC2 c.3599G>C (p.R1200P) variant. To the best of our knowledge, this is the first report of the c.3599G>C (p.R1200P) variant in exon 29 of the TSC2 gene related to a severe clinical course and multiple kidney transplants in a patient with TSC.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Zlatko Trobonjača
- Zlatko Trobonjača, Department of Physiology and Immunology, University of Rijeka School of Medicine, Braće Branchetta 20, 51000 Rijeka, Croatia,
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58
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Lee KH, Tsai HY, Kao YT, Lin HC, Chou YC, Su SH, Chuang CK. Clinical behavior and management of three types of renal angiomyolipomas. J Formos Med Assoc 2018; 118:162-169. [PMID: 29549981 DOI: 10.1016/j.jfma.2018.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/14/2018] [Accepted: 02/23/2018] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To analyze and present the demography, clinical behavior, especially the risk factors of tumor hemorrhage and management of sporadic angiomyolipoma (SAML), tuberous sclerosis complex associated angiomyolipoma (TSCAML) and epithelioid angiomyolipoma (EAML) in our institution. METHODS A retrospective study of 587 patients who were diagnosed with renal angiomyolipoma in our institution between January 2000 and May 2015 was done. The AMLs were diagnosed by ultrasonography, CT, or MRI. EAML was confirmed by histopathology. Medical records and follow-up results were analyzed using the SPSS version 22 software. RESULTS Out of 587 cases of renal AMLs, 87.4% were SAMLs, 8.7% were TSCAMLs and 3.9% were EAMLs. Most of the AML patients were asymptomatic. The most common presenting symptoms included flank pain and abdominal pain. The median tumor size of SAML, TSCAML, EAML were 4.7, 2.7, 10.5 cm respectively. Approximately half of SAMLs were conservatively treated, almost all TSCAMLs were treated conservatively, while all EAMLs were surgically treated. The median tumor size of hemorrhagic SAML cases was 8 cm versus non-hemorrhagic cases of 4.1 cm. The optimal cut-off point on the ROC curve for predicting SAML tumor hemorrhage was 7.35 cm. CONCLUSION A larger tumor size, younger patient's age and higher BMI value correlated with a higher risk of tumor hemorrhage. For tumor sizes less than 7.35 cm, we recommend active surveillance or TAE for hemorrhage prevention. We also suggest that surgical management should be considered for patients with tumors larger than 7.35 cm, symptomatic and progressive AML, or suspicious EAML.
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Affiliation(s)
- Kun-Han Lee
- Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Han-Yu Tsai
- Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Yu-Ting Kao
- Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Hsin-Chia Lin
- Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Yi-Chun Chou
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Shih-Huan Su
- Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
| | - Cheng-Keng Chuang
- Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No.5, Fusing St., Gueishan, Taoyuan 333, Taiwan.
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Abstract
The mechanism by which TSC2 inactivation or deficiency contributes to the pathology of tuberous sclerosis complex (TSC) is not fully clear. We show that renal angiomyolipomas from TSC patients and kidney cortex from Tsc2+/− mice exhibit elevated levels of reactive oxygen species (ROS). Downregulation of tuberin (protein encoded by TSC2 gene) in renal proximal tubular epithelial cells significantly increased ROS concomitant with enhanced Nox4. Similarly, we found elevated levels of Nox4 in the renal cortex of Tsc2+/− mice and in the renal angiomyolipomas from TSC patients. Tuberin deficiency is associated with activation of mTORC1. Rapamycin, shRNAs targeting raptor, or inhibition of S6 kinase significantly inhibited the expression of Nox4, resulting in attenuation of production of ROS in tuberin-downregulated proximal tubular epithelial cells. In contrast, activation of mTORC1 increased Nox4 and ROS. These results indicate that Nox4 may be a potential target for tuberin-deficiency-derived diseases. Using a xenograft model from tuberin-null tubular cells in nude mice, both anti-sense Nox4 and GKT137831, a specific inhibitor of Nox1/4, significantly inhibited the tumor growth. Thus, our results demonstrate the presence of an antagonistic relationship between tuberin and Nox4 to drive oncogenesis in the tuberin deficiency syndrome and identify Nox4 as a target to develop a therapy for TSC.
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Ramaswamy RS, Akinwande O, Tiwari T. Renal Embolization: Current Recommendations and Rationale for Clinical Practice. Curr Urol Rep 2018; 19:5. [DOI: 10.1007/s11934-018-0756-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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61
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Factors associated with the number and size of renal angiomyolipomas in sporadic angiomyolipoma (sAML): a study of adult patients with sAML managed in a Dutch tertiary referral center. Int Urol Nephrol 2018; 50:459-467. [PMID: 29333579 PMCID: PMC5845070 DOI: 10.1007/s11255-017-1766-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/05/2017] [Indexed: 10/26/2022]
Abstract
PURPOSE To describe the patient characteristics, treatments, disease monitoring, and kidney function of patients with sporadic angiomyolipoma (sAML), stratified by the number and size of renal angiomyolipomas (AMLs). METHODS Single-center retrospective analysis of patients with sAML treated from 1990 to 2015 in a dedicated clinic for inheritable tumor syndromes in a tertiary referral center from the Netherlands. Patients' first AML assessment at the clinic was defined as the index date. Patient characteristics were measured at the index date. Treatments, disease monitoring, and kidney function were measured post-index date. RESULTS The study sample included 53 patients followed for a total of 184.6 patient-years. At the index date, the largest AML was ≥ 3.5 cm for 26 patients and < 3.5 cm for 27 patients (including six patients with five or more AMLs of < 3.5 cm). As compared to patients with AMLs < 3.5 cm, patients with largest AML ≥ 3.5 cm had higher frequency of pre-index bleeding episodes (31 vs. 4%), pre-index hypertension (35 vs. 15%), post-index nephrectomy (19 vs. 4%), post-index embolization (8 vs. 0%), and post-index renal scans (1.14 vs. 0.74 scans/year). Kidney impairment was especially pronounced in young adults with AML ≥ 3.5 cm. On average, patients with sAML developed chronic kidney disease stage two earlier than the general Dutch population (age 42 vs. 55 years), but later than the patients with tuberous sclerosis complex (35 years). CONCLUSIONS Patients with sAML, especially those with larger AMLs, have high disease burden.
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62
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[Benign mesenchymal tumors of the abdomen]. Radiologe 2018; 58:25-35. [PMID: 29318350 DOI: 10.1007/s00117-017-0338-4] [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: 10/18/2022]
Abstract
BACKGROUND Benign mesenchymal tumors of the abdomen are-except for hemangiomas-rare neoplasms that are associated with potentially life-threatening complications. Thus, awareness of the most important entities and knowledge of their imaging characteristics is fundamental for the radiologist. OBJECTIVES An overview of the most frequent benign abdominal soft tissue tumors and their common imaging features is given. Furthermore, other facts concerning the individual entities that are relevant to radiologic practice are outlined. MATERIALS AND METHODS A literature search and evaluation of the institutional image database were performed. RESULTS Hemangiomas, desmoid tumors, lipomas and lipoma variants are presented. Typical characteristics and radiological signs (e. g., iris diaphragm sign, band sign, India ink artifact) are elucidated and illustrated by image examples. CONCLUSION Despite the lack of distinctive imaging features, there are a few radiological characteristics suggestive for each of the entities that in many cases allow for correct diagnosis. In cases of doubt, biopsy or surgery is necessary to distinguish them from malignancies.
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63
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Chen SL, Hsiao WC, Tsai JD, Wang SC. Mammalian target of rapamycin inhibitor and transarterial embolization for treatment of tuberous sclerosis complex patients with renal angiomyolipoma. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_19_17] [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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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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Chemical shift magnetic resonance imaging for distinguishing minimal-fat renal angiomyolipoma from renal cell carcinoma: a meta-analysis. Eur Radiol 2017; 28:1854-1861. [PMID: 29178029 DOI: 10.1007/s00330-017-5141-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/07/2017] [Accepted: 10/17/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine the performance of chemical shift signal intensity index (CS-SII) values for distinguishing minimal-fat renal angiomyolipoma (mfAML) from renal cell carcinoma (RCC) and to assess RCC subtype characterisation. METHODS We identified eligible studies on CS magnetic resonance imaging (CS-MRI) of focal renal lesions via PubMed, Embase, and the Cochrane Library. CS-SII values were extracted by lesion type and evaluated using linear mixed model-based meta-regression. RCC subtypes were analysed. Two-sided p value <0.05 indicated statistical significance. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS Eleven articles involving 850 patients were included. Minimal-fat AML had significantly higher CS-SII value than RCC (p < 0.05); there were no significant differences between mfAML and clear cell RCC (cc-RCC) (p = 0.112). Clear cell RCC had a significantly higher CS-SII value than papillary RCC (p-RCC) (p < 0.001) and chromophobe RCC (ch-RCC) (p = 0.045). The methodological quality was relatively high, and Begg's test data points indicated no obvious publication bias. CONCLUSIONS The CS-SII value for differentiating mfAML from cc-RCC remains unproven, but is a promising method for differentiating cc-RCC from p-RCC and ch-RCC. KEY POINTS • RCC CS-SII values are significantly lower than those of mfAML overall. • CS-SII values cannot aid differentiation between mfAML and cc-RCC. • CS-SII values might help characterise RCC subtypes.
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Taveira-DaSilva AM, Moss J. Addressing the challenges of lymphangioleiomyomatosis assessment in the clinic. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1400966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Angelo M. Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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The Risks of Renal Angiomyolipoma: Reviewing the Evidence. J Kidney Cancer VHL 2017; 4:13-25. [PMID: 29090118 PMCID: PMC5644357 DOI: 10.15586/jkcvhl.2017.97] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/23/2017] [Indexed: 12/26/2022] Open
Abstract
Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.
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Diagnosis of tuberous sclerosis complex in a patient referred for uncontrolled hypertension and renal dysfunction. J Hypertens 2017; 35:2109-2114. [DOI: 10.1097/hjh.0000000000001423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kandror K. Mammalian target of rapamycin complex 1 and FoxO1 in the transcriptional control of lipolysis and de novo lipogenesis. Curr Opin Endocrinol Diabetes Obes 2017; 24:326-331. [PMID: 28841634 PMCID: PMC11210950 DOI: 10.1097/med.0000000000000352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Postprandial suppression of lipolysis in adipose tissue and stimulation of de novo lipogenesis (DNL) in the liver by insulin are essential for the metabolic homeostasis in the mammalian organism. The mechanism of coregulation of lipolysis and DNL is not clear. RECENT FINDINGS Insulin controls both lipolysis and DNL at the level of transcription via the same mammalian target of rapamycin complex 1 (mTORC1) and FoxO1-mediated signaling pathways. SUMMARY mTORC1 suppresses lipolysis in adipose tissue and activates DNL in the liver, whereas FoxO1 has the opposite effect. Individual inputs of either mTORC1 or FoxO1 in the regulation of lipid metabolism may be difficult to evaluate because of the cross talk between these pathways.
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Affiliation(s)
- K.V. Kandror
- Boston University School of Medicine, Department of Biochemistry, K123D, 715 Albany Street, Boston, MA 02118, USA. Phone: 617-638-5049
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Makki A, Graumann O, Høyer S, Solvig J, Østraat Ø, Madsen MG, Nielsen TK. Cryoablation of Renal Angiomyolipoma: An Evaluation of Safety and Efficacy. J Endourol 2017; 31:1117-1122. [PMID: 28830229 DOI: 10.1089/end.2017.0376] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Small series have reported that cryoablation (CA) is a safe and feasible minimally invasive nephron-sparing alternative for the treatment of renal angiomyolipomas (renal AMLs). The aim of the present study was to investigate the safety and efficacy of CA in patients with renal AML. MATERIALS AND METHODS A retrospective review of 19 renal AML lesions treated with CA at Aarhus University Hospital, Denmark, over a 5-year period. RESULTS The treatment was performed as laparoscopy-assisted CA on 7 lesions, and in the remaining 12 lesions CA was performed as a percutaneous ultrasound-guided CA. The mean patient age was 46 years [interquartile range (IQR) 30] and the mean tumor volume was 50.1 cm3 (IQR 53.3). In all cases, the procedure was effectively conducted with no conversion to open surgery, and no major complications were experienced. The mean follow-up time was 25 months (IQR 13). Mean maximum tumor volume was reduced from 50.1 cm3 (IQR 53.3) to 12.2 cm3 (IQR 14.1), p = 0.05. No patients presented with retroperitoneal hemorrhage or recurrence during follow-up. CONCLUSION Treating renal AMLs with CA appears to be a safe and effective nephron-sparing approach and could be a valuable alternative to other treatment modalities. The low complication rate, absence of retreatment and a good preservation of renal function might allow treatment of even subclinical renal AMLs to minimize the risk of potentially life-threatening hemorrhage.
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Affiliation(s)
- Ahmad Makki
- 1 Department of Urology, Aarhus University Hospital , Aarhus, Denmark
| | - Ole Graumann
- 2 Department of Radiology, Odense University Hospital , Odense, Denmark
| | - Søren Høyer
- 3 Department of Pathology, Aarhus University Hospital , Aarhus, Denmark
| | - Jan Solvig
- 4 Department of Radiology, Aarhus University Hospital , Aarhus, Denmark
| | - Øyvind Østraat
- 1 Department of Urology, Aarhus University Hospital , Aarhus, Denmark
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Jeong A, Wong M. mTOR Inhibitors in Children: Current Indications and Future Directions in Neurology. Curr Neurol Neurosci Rep 2017; 16:102. [PMID: 27815691 DOI: 10.1007/s11910-016-0708-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The mammalian/mechanistic target of rapamycin (mTOR) pathway is a key signaling pathway that has been implicated in genetic epilepsy syndromes, neurodegenerative diseases, and conditions associated with autism spectrum disorder and cognitive impairment. The mTOR pathway has become an exciting treatment target for these various disorders, with mTOR inhibitors such as rapamycin being studied for their potential therapeutic applications. In particular, tuberous sclerosis complex (TSC) is a genetic disorder resulting from overactivation of the mTOR pathway, and pharmacologic therapy with mTOR inhibitors has emerged as a viable treatment option for the systemic manifestations of the disease. In this review, we discuss the approved indications for mTOR inhibitors in TSC, the potential future applications of mTOR inhibitors in TSC and other neurological conditions, and the safety considerations applicable to mTOR therapy in the pediatric population.
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Affiliation(s)
- Anna Jeong
- Department of Neurology and the Hope Center for Neurological Disorders, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA
| | - Michael Wong
- Department of Neurology and the Hope Center for Neurological Disorders, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA.
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Siroky BJ, Towbin AJ, Trout AT, Schäfer H, Thamann AR, Agricola KD, Tudor C, Capal J, Dixon BP, Krueger DA, Franz DN. Improvement in Renal Cystic Disease of Tuberous Sclerosis Complex After Treatment with Mammalian Target of Rapamycin Inhibitor. J Pediatr 2017; 187:318-322.e2. [PMID: 28600153 DOI: 10.1016/j.jpeds.2017.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/01/2017] [Accepted: 05/03/2017] [Indexed: 12/18/2022]
Abstract
Renal cysts occur in approximately 50% of patients with tuberous sclerosis complex, but their clinical significance and response to treatment are unknown. Abdominal imaging of 15 patients with tuberous sclerosis complex-associated renal cystic disease who had received mammalian target of rapamycin inhibitor therapy for other tuberous sclerosis complex-related indications was evaluated. Reductions in cyst number, sum diameter, and volume were observed.
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Affiliation(s)
- Brian J Siroky
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Hannah Schäfer
- Division of Nephrology, Ludwig Maximilians University, Munich, Germany
| | - Anna R Thamann
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Karen D Agricola
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Cynthia Tudor
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jamie Capal
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley P Dixon
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Darcy A Krueger
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David N Franz
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Klover PJ, Thangapazham RL, Kato J, Wang JA, Anderson SA, Hoffmann V, Steagall WK, Li S, McCart E, Nathan N, Bernstock JD, Wilkerson MD, Dalgard CL, Moss J, Darling TN. Tsc2 disruption in mesenchymal progenitors results in tumors with vascular anomalies overexpressing Lgals3. eLife 2017; 6. [PMID: 28695825 PMCID: PMC5505700 DOI: 10.7554/elife.23202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/01/2017] [Indexed: 12/19/2022] Open
Abstract
Increased mTORC1 signaling from TSC1/TSC2 inactivation is found in cancer and causes tuberous sclerosis complex (TSC). The role of mesenchymal-derived cells in TSC tumorigenesis was investigated through disruption of Tsc2 in craniofacial and limb bud mesenchymal progenitors. Tsc2cKOPrrx1-cre mice had shortened lifespans and extensive hamartomas containing abnormal tortuous, dilated vessels prominent in the forelimbs. Abnormalities were blocked by the mTORC1 inhibitor sirolimus. A Tsc2/mTORC1 expression signature identified in Tsc2-deficient fibroblasts was also increased in bladder cancers with TSC1/TSC2 mutations in the TCGA database. Signature component Lgals3 encoding galectin-3 was increased in Tsc2-deficient cells and serum of Tsc2cKOPrrx1-cre mice. Galectin-3 was increased in TSC-related skin tumors, angiomyolipomas, and lymphangioleiomyomatosis with serum levels in patients with lymphangioleiomyomatosis correlating with impaired lung function and angiomyolipoma presence. Our results demonstrate Tsc2-deficient mesenchymal progenitors cause aberrant morphogenic signals, and identify an expression signature including Lgals3 relevant for human disease of TSC1/TSC2 inactivation and mTORC1 hyperactivity. DOI:http://dx.doi.org/10.7554/eLife.23202.001 Tuberous sclerosis complex is a genetic condition that causes non-cancerous tumours with lots of blood vessels. It is caused by mutations that inactivate either of two genes known as TSC1 and TSC2. A signalling molecule called mTOR also contributes to the disease, and drugs that block its activity provide some relief for patients. However, mTOR regulates a wide variety of molecules and so researchers are looking for which ones are responsible for the formation of the tumours. Mesenchymal cells produce bone, muscle and other structural tissues in the body. They also support the formation of blood vessels. Mice – which are often used as model animals in health research – also have mesenchymal cells and a gene that is very similar to the human TSC2 gene (known as Tsc2). Klover et al. hypothesized that disrupting the Tsc2 gene specifically in the mesenchymal cells of mice may mimic aspects of tuberous sclerosis complex in humans. The experiments show that disrupting Tsc2 in mesenchymal cells does indeed mimic features of the human disease; the mice had shorter lifespans and they developed many tumours with dilated and winding blood vessels. Treating the mice with a drug that inhibits mTOR caused the tumours to shrink. Further experiments show that the loss of Tsc2 alters the production of many proteins involved metabolism, cell growth and sensing the levels of oxygen. For example, mouse cells that lack Tsc2 produce more of a protein called galectin-3, which appears to help blood vessels and tumours to grow in cancers. Klover et al. also studied tumours from patients with tuberous sclerosis complex and a lung disease that is caused by mutations in TSC2 (called lymphangioleiomyomatosis). The experiments found that many tumours produce higher levels of galactin-3 than normal cells. Bladder cancers with mutations in TSC1 or TSC2 also had higher levels of galectin-3, suggesting that other diseases linked with mutations in these genes may also result in increased production of galectin-3. The findings of Klover et al. suggest that galectin-3 may be a useful marker to assess the severity of tuberous sclerosis complex, lymphangioleiomyomatosis and to detect cancers with mutations in TSC1 or TSC2. The next step is to investigate whether galectin-3 alters blood vessels and tumour growth in these conditions. DOI:http://dx.doi.org/10.7554/eLife.23202.002
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Affiliation(s)
- Peter J Klover
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Rajesh L Thangapazham
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Jiro Kato
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, United States
| | - Ji-An Wang
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Stasia A Anderson
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, United States
| | - Victoria Hoffmann
- Diagnostic and Research Services Branch, National Institutes of Health, Bethesda, United States
| | - Wendy K Steagall
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, United States
| | - Shaowei Li
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Elizabeth McCart
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Neera Nathan
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States.,Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, United States
| | - Joshua D Bernstock
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Matthew D Wilkerson
- Department of Anatomy Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Clifton L Dalgard
- Department of Anatomy Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, United States
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, United States
| | - Thomas N Darling
- Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, United States
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Samuels JA. Treatment of Renal Angiomyolipoma and Other Hamartomas in Patients with Tuberous Sclerosis Complex. Clin J Am Soc Nephrol 2017; 12:1196-1202. [PMID: 28302901 PMCID: PMC5498351 DOI: 10.2215/cjn.08150816] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Tuberous sclerosis complex is an autosomal dominant genetic disease characterized by growth of benign tumors (hamartomas) in multiple organs, especially the kidneys, brain, heart, lungs, and skin. Tuberous sclerosis complex is usually caused by a mutation in either the tuberous sclerosis complex 1 or tuberous sclerosis complex 2 gene, resulting in constitutive activation of mammalian target of rapamycin signaling. Currently, mammalian target of rapamycin inhibitors are recommended in adult patients with tuberous sclerosis complex for the treatment of asymptomatic, growing renal angiomyolipoma that are >3 cm in diameter and pediatric or adult patients with brain lesions (subependymal giant cell astrocytoma) that either are growing or are not amenable to surgical resection. Clinical evidence suggests that systemic administration of a mammalian target of rapamycin inhibitor may provide concurrent improvements in multiple lesions and symptoms of tuberous sclerosis complex. With the major paradigm shift in consensus guidelines toward screening at diagnosis and ongoing monitoring and with the recent availability of an effective oral treatment, it is important that nephrologists have a thorough understanding of our role in the management of patients with tuberous sclerosis complex. Because the various manifestations of tuberous sclerosis complex typically emerge at different periods during patients' lifetimes, patients will need to be followed throughout their lives. Unlike brain and cardiac lesions, renal lesions are more likely to emerge as patients age and can grow at any time. Considerations regarding long-term medication administration for the potential control of multiple tuberous sclerosis complex manifestations will need to be addressed; these include the most appropriate starting dose, appropriate doses for tumor shrinkage versus prevention of regrowth, and management of adverse events. Best practices and potential obstacles for nephrologists treating patients with tuberous sclerosis complex who have multiple manifestations are considered.
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Affiliation(s)
- Joshua A Samuels
- Renal Disease and Hypertension, Pediatric Nephrology and Hypertension, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Brakemeier S, Bachmann F, Budde K. Treatment of renal angiomyolipoma in tuberous sclerosis complex (TSC) patients. Pediatr Nephrol 2017; 32:1137-1144. [PMID: 27585680 DOI: 10.1007/s00467-016-3474-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/26/2016] [Accepted: 07/12/2016] [Indexed: 10/21/2022]
Abstract
In adult tuberous sclerosis complex (TSC) patients, renal complications are the leading cause of death. Beginning in childhood, up to 80 % of patients develop renal angiomyolipoma characterized by a size-dependent risk of life-threatening bleeding. After discovery of the two causative genes, TSC1 and TSC2, and the role of mammalian target of rapamycin (mTOR) regulation in the pathogenesis of TSC, an increasing number of clinical studies evaluating mTOR inhibition in TSC patients have shown impressive results in many organ manifestations, such as brain, lung, and kidney. For renal angiomyolipoma, mTOR inhibitor treatment fundamentally changed the approach from preventive embolization or even partial nephrectomy to everolimus treatment in order to preserve kidney function.
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Affiliation(s)
- S Brakemeier
- Department of Internal Medicine, Division of Nephrology, Charité Campus Mitte, Berlin, Germany.
| | - F Bachmann
- Department of Internal Medicine, Division of Nephrology, Charité Campus Mitte, Berlin, Germany
| | - K Budde
- Department of Internal Medicine, Division of Nephrology, Charité Campus Mitte, Berlin, Germany
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Knaup KX, Guenther R, Stoeckert J, Monti JM, Eckardt KU, Wiesener MS. HIF is not essential for suppression of experimental tumor growth by mTOR inhibition. J Cancer 2017; 8:1809-1817. [PMID: 28819378 PMCID: PMC5556644 DOI: 10.7150/jca.16486] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 03/23/2017] [Indexed: 01/18/2023] Open
Abstract
The Hypoxia Inducible Transcription Factor (HIF) is the master regulator of cellular response to hypoxic adaptation. Solid tumors inevitably harbour hypoxic regions with subsequent stabilization and activation of HIF and HIF target genes due to poor vascularization and rapid growth. The mammalian target of rapamycin (mTOR) is a global regulator of cellular growth and proliferation, which can also regulate HIF expression independantly of hypoxia via specific activation of cellular translation and transcription. An effective blockade of mTOR results in attenuation of HIF under hypoxic conditions in vitro. This mechanism could enable a simultaneous inhibition of both the mTOR- and the HIF-pathway, resulting in an effective tool for cancer targeting. We set out to analyze the effect of mTOR inhibition and the involvement of mTOR regulation on HIF in vivo in a subcutaneous xenograft model in nude mice. Our results demonstrate that mTOR inhibition in our model leads to a clear reduction in tumor growth of various cellular origins, most likely due to inhibition of cellular proliferation. Moreover, these effects can also be achieved independently of the HIF status of the tumor cells. The HIF levels per se seem to remain unaffected by mTOR inhibition, probably due to the profound hypoxic environment in these threedimensional structures, consequently leading to a strong HIF stabillization. Therefore, treatment of these experimental tumors with mTOR inhibitors is an effective tool to achieve size regression. The involvement of and the effect on HIF in this in vivo setting is nevertheless negligible.
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Affiliation(s)
- Karl X Knaup
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Regina Guenther
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Johanna Stoeckert
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Juliana M Monti
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Michael S Wiesener
- Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
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Urbano J, Paul L, Cabrera M, Alonso-Burgos A, Gómez D. Elective and Emergency Renal Angiomyolipoma Embolization with Ethylene Vinyl Alcohol Copolymer: Feasibility and Initial Experience. J Vasc Interv Radiol 2017; 28:832-839. [DOI: 10.1016/j.jvir.2017.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 01/15/2017] [Accepted: 01/26/2017] [Indexed: 01/04/2023] Open
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Sun P, Liu J, Charles H, Hulbert J, Bissler J. Outcomes of angioembolization and nephrectomy for renal angiomyolipoma associated with tuberous sclerosis complex: a real-world US national study. Curr Med Res Opin 2017; 33:821-827. [PMID: 28112545 DOI: 10.1080/03007995.2017.1286307] [Citation(s) in RCA: 7] [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] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To examine outcomes of clinical procedures for renal angiomyolipoma associated with tuberous sclerosis complex (TSC) based on US national health claims databases. METHODS This retrospective cohort study selected two cohorts of TSC patients, who underwent either embolization or nephrectomy (either partial or complete) for renal angiomyolipoma in the years from 2000 through 2011. Based on claims diagnosis codes, we estimated the prevalence rates of 10 angiomyolipoma-related conditions and 50 embolization- or nephrectomy-related conditions in the pre- and post-baseline periods respectively, and made cross-year and cross-period comparison of these rates with repeated measures analysis methods. RESULTS The embolization cohort (N = 4280) and the nephrectomy cohort (N = 3842) had mean baseline ages of 50.7 and 51.7 years with 52.5% and 51.3% males, respectively. After the intervention, the embolization cohort had statistically significant reductions (all p < .05) in gross hematuria (-27.7%), retroperitoneal hemorrhage (-8.4%), and abdominal mass (-6.9%), and increases in hypertension (15.5%), renal mass or unspecified disorder of kidney and ureter (13.8%), anemia (5.1%), and renal insufficiency (3.3%). Similarly, the nephrectomy cohort saw statistically significant reductions (all p < .05) in gross hematuria (-30.6%), flank pain (-7.5%), and abdominal mass (-6.4%), but increases in hypertension (11.9%), renal insufficiency (10.4%), and anemia (7.6%). Embolization was associated with post-procedure increases in renal mass or unspecified kidney/ureter disorder (13.9%), other disorders of kidney and ureter (3.4%), non-acute renal insufficiency (3.1%), flank pain (3.7%), renal insufficiency (3.2%), etc. (all p < .05). Nephrectomy was associated with post-procedure increases in postoperative ileus (5.3%), pain and headache (4.8%), paralytic ileus (3.6%), etc. (all p < .05). CONCLUSIONS Both embolization and nephrectomy were effective, but associated with increases in certain angiomyolipoma-related conditions. Further, the embolization effect on gross hematuria, retroperitoneal hemorrhage, and abdominal mass might subside after the intervention year.
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Affiliation(s)
- Peter Sun
- a Kailo Research Group , Indianapolis , IN , USA
| | - Jamae Liu
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | | | | | - John Bissler
- e Le Bonheur Children's Hospital and the University of Tennessee , Memphis , TN , USA
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Renal angiomyolipomas: At least two diseases. A series of patients treated at two European institutions. Eur J Surg Oncol 2017; 43:831-836. [DOI: 10.1016/j.ejso.2016.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/07/2016] [Accepted: 11/17/2016] [Indexed: 02/03/2023] Open
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Cockerell I, Guenin M, Heimdal K, Bjørnvold M, Selmer KK, Rouvière O. Prevalence of Renal Angiomyolipomas and Spontaneous Bleeding Related to Angiomyolipomas in Tuberous Sclerosis Complex Patients in France and Norway-a Questionnaire Study. Urology 2017; 104:70-76. [PMID: 28232177 DOI: 10.1016/j.urology.2017.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 02/02/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To estimate the prevalence of renal angiomyolipomas (AMLs) and AML-related bleedings among patients with tuberous sclerosis complex and to gather information about associated treatments. METHODS A questionnaire survey was undertaken by the French Reference Centre for Tuberous Sclerosis Complex and distributed through university hospitals and the patients' association (2009-2011). The questionnaire was then distributed to patients registered by the Norwegian National Centre for Rare Epilepsy-Related Disorders (2013-2014). Risk of bleeding was estimated by Kaplan-Meier analysis. RESULTS We included 357 patients (France, n = 257; Norway, n = 100); 189 (54%) reported having AMLs, 111 (32%) reported not having AMLs, and 50 (14%) reported not knowing whether they had AMLs. Twenty-five patients (France, n = 19; Norway, n = 6) reported that they have had bleeding. Age at first bleeding (known in 22 patients) was 27.6 ± 8.5 years. Fifteen patients (France, n = 11; Norway, n = 4) experienced first bleeding between 20 and 30 years. Bleeding-free survival was similar in France and Norway (P = .471). The bleeding-free survival rate at 72 years was 81% (95% confidence interval: 68-89) in the overall population and 66% (95% confidence interval: 43-82) in patients with AMLs. Bleeding treatment (known in 24 patients) consisted of conservative measures (n = 9), embolization (n = 8), nephrectomy (n = 4), embolization and nephrectomy (n = 2), or partial nephrectomy (n = 1). Fifteen French patients reported prophylactic treatment. In Norway, this information was known only in patients with renal bleeding and was reported in two. CONCLUSION Fifty-four percent of the patients reported having AMLs and 7% (25/357) reported bleeding. Sixty-eight percent of first bleedings occurred between 20 and 30 years. Bleedings were managed conservatively in 38% of the patients and 62% needed active treatment.
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Affiliation(s)
- Ine Cockerell
- National Centre for Rare Epilepsy-Related Disorders, Department of Rare Disorders and Disabilities, Oslo University Hospital, Oslo, Norway.
| | - Michel Guenin
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - Ketil Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Marit Bjørnvold
- National Centre for Epilepsy, Division for Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Kaja K Selmer
- National Centre for Rare Epilepsy-Related Disorders, Department of Rare Disorders and Disabilities, Oslo University Hospital, Oslo, Norway; Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Olivier Rouvière
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
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81
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Prischl FC, Spöttl P. Spontaneous rupture of angiomyolipoma of the kidney. Wien Klin Wochenschr 2017; 129:217-218. [PMID: 28188380 DOI: 10.1007/s00508-017-1168-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/18/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Friedrich C Prischl
- Department of Nephrology, 4th Department of Internal Medicine, Klinikum Wels-Grieskirchen, 4600, Wels, Austria.
| | - Peter Spöttl
- Department of Radiology, Klinikum Wels-Grieskirchen, Wels, Austria
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Bardin F, Chevallier O, Bertaut A, Delorme E, Moulin M, Pottecher P, Di Marco L, Gehin S, Mourey E, Cormier L, Mousson C, Midulla M, Loffroy R. Selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction. Quant Imaging Med Surg 2017; 7:8-23. [PMID: 28275556 DOI: 10.21037/qims.2017.01.02] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Angiomyolipoma (AML) is the most common renal benign tumor. Treatment should be considered for symptomatic patients or for those at risk for complications, especially retroperitoneal bleeding which is correlated to tumor size, grade of the angiogenic component and to the presence of tuberous sclerosis complex (TSC). This study reports our single-center experience with the use of selective arterial embolization (SAE) in the management of symptomatic and asymptomatic renal AMLs. METHODS In this retrospective mono-centric study, all demographic and imaging data, medical records, angiographic features, outpatient charts and follow-up visits of patients who underwent prophylactic or emergency SAE for AMLs between January 2005 and July 2016 were reviewed. Tumor size and treatment outcomes were assessed at baseline and after the procedure during follow-up. Computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography was used to evaluate AML shrinkage. Renal function was measured pre- and post-procedure. RESULTS Twenty-three patients (18 females, 5 males; median age, 45 years; range, 19-85 years) who underwent SAE either to treat bleeding AML (n=6) or as a prophylactic treatment (n=17) were included. Overall, 34 AMLs were embolized. TSC status was confirmed for 6 patients. Immediate technical success rate was 96% and 4 patients benefitted from an additional procedure. Major complications occurred in 3 patients and minor post-embolization syndrome (PES) in 14 patients. The mean AML size reduction rate was 26.2% after a mean follow-up was 20.5 months (range, 0.5-56 months), and only non-TSC status was significantly associated with better shrinkage of tumor (P=0.022). Intralesional aneurysms were significantly more frequent in patients with hemorrhagic presentation (P=0.008). There was no change in mean creatinine level after SAE. CONCLUSIONS SAE is a safe and effective technique to manage renal AMLs as a preventive treatment as well as in emergency setting, with significant reduction in tumor size during follow-up. A multidisciplinary approach remains fundamental, especially for TSC patients. In addition to size, the presence of intralesional aneurysms should be considered in any prophylactic treatment decision.
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Affiliation(s)
- Florian Bardin
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Aurélie Bertaut
- Department of Epidemiology and Biostatistics, Georges François Leclerc Center, Dijon, France
| | - Emmanuel Delorme
- Department of Urology, Sainte Marie Private Hospital, Chalon-sur-Saône, France
| | - Morgan Moulin
- Department of Urology and Andrology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Pierre Pottecher
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Lucy Di Marco
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Sophie Gehin
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Eric Mourey
- Department of Urology and Andrology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Luc Cormier
- Department of Urology and Andrology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Christiane Mousson
- Department of Nephrology and Renal Transplantation, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Dijon School of Medicine, Dijon, France;; LE2I UMR CNRS 6306, Arts et Métiers, University of Bourgogne Franche-Comté, Dijon, France
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Kaneko S, Matsumoto K, Minamida S, Hirayama T, Fujita T, Kodera Y, Iwamura M. Incremental Expression of 14-3-3 Protein Beta/Alpha in Urine Correlates with Advanced Stage and Poor Survival in Patients with Clear Cell Renal Cell Carcinoma. Asian Pac J Cancer Prev 2017; 17:1399-404. [PMID: 27039779 DOI: 10.7314/apjcp.2016.17.3.1399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We investigated the urinary levels of 14-3-3 protein beta/alpha to evaluate their diagnostic significance with regard to clear cell renal cell carcinoma (ccRCC) and angiomyolipoma (AML). Urine samples from 91 patients with ccRCC, 16 patients with AML and 24 healthy volunteers were assessed. We used an enzyme-linked immunosorbent assay (ELISA) to quantify 14-3-3 protein beta/alpha levels in urine. Values were higher in patients with ccRCC than in those with AML and in healthy volunteers. High levels were associated with pathologic stage, lymph node status, distant metastasis and poor survival. Urinary levels of 14-3-3 protein beta/alpha were significantly increased in patients with small-sized carcinoma, irrespective of being less than 4.0 cm and 2.0 cm, compared with levels in patients with AML. This study is the first to report that increased expression of 14-3- 3 protein beta/alpha in urine is associated with advanced stage and poor survival in patients with ccRCC. In addition, urinary 14-3-3 protein beta/alpha may differentiate AML from RCC, even when small sized. These results suggest that examination of urinary 14-3-3 protein beta/alpha could serve as a diagnostic and prognostic marker in patients with ccRCC.
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Affiliation(s)
- Shiho Kaneko
- Department of Urology, Kitasato University School of Science, Sagamihara, Japan E-mail :
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Trelborg K, Nielsen TK, Østraat EØ, Olsen LH. Laparoscopic cryoablation of angiomyolipomas in adolescents and young adults: A report of four cases associated with tuberous sclerosis and 1 case of sporadic origin. J Pediatr Urol 2016; 12:384.e1-384.e6. [PMID: 27346068 DOI: 10.1016/j.jpurol.2016.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 03/24/2016] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Renal angiomyolipomas (AMLs) can be of sporadic origin or associated with tuberous sclerosis (TS). TS-associated AMLs often present in childhood, tend to be bilateral and multiple, and often exhibit a faster growth rate with an increased risk of hemorrhage. Renal cryoablation is well described in adults, whereas experiences with adolescents and young adults are limited. We present here for the first time a series of renal AMLs within adolescents and young adults treated with laparoscopic assisted cryoablation (LCA). OBJECTIVE The aim was to evaluate whether LCA of AMLs in adolescents and young adults is a safe and feasible treatment modality. STUDY DESIGN From October 2009 to September 2013 a total of five patients at our institution were diagnosed with AMLs requiring treatment. Four patients had TS and one had AML of sporadic origin, all five patients underwent LCA. Data were retrospectively collected by a systematic review of patient material and reassessment of renal imaging. RESULTS The median age was 16 years (range 13-27 years). Eight AMLs with a median size of 3.9 cm (range 2.1-7.7 cm) were treated in five patients because of tumor size and rapid growth. Follow-up was a median 37 months (range 20-62 months), and all tumors showed a reduction in tumor size, and no regrowth was recognized (see summary table). The procedure was well tolerated, with only few perioperative complications and no postoperative complications. DISCUSSION When considering the indication for treating AMLs, the origin (sporadic or TS associated) and size of the tumor are the decisive factors. To preserve renal function and prevent spontaneous hemorrhage caution should be intensified when tumors reach 4 cm, particularly if TS is present. After the diagnosis is established, patients should be monitored with renal imaging at regular intervals to identify rapid-growing tumors. As an alternative to current treatment modalities such as partial nephrectomy and super selective angioembolization, cryoablation is an emerging approach, although experience with pediatric patients is limited. For patients not requiring immediate surgery, pharmacological treatment with mTOR inhibitors is now being evaluated as an alternative treatment option or as neo-adjuvant therapy to ablative techniques. CONCLUSION Prophylactic treatment of large or rapid growing AMLs with LCA appears to be a safe and feasible nephron-sparing approach in adolescents and young adults. The low perioperative complication rate and promising effect on outcome might allow treatment of subclinical AMLs in order to minimize the risk of potentially life-threatening complications and preserve renal function.
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Affiliation(s)
- Karina Trelborg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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85
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Robles NR, Peces R, Gómez-Ferrer Á, Villacampa F, Álvarez-Ossorio JL, Pérez-Segura P, Morote J, Herrera-Imbroda B, Nieto J, Carballido J, Anido U, Valero M, Meseguer C, Torra R. Everolimus safety and efficacy for renal angiomyolipomas associated with tuberous sclerosis complex: a Spanish expanded access trial. Orphanet J Rare Dis 2016; 11:128. [PMID: 27669821 PMCID: PMC5037621 DOI: 10.1186/s13023-016-0517-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/16/2016] [Indexed: 11/25/2022] Open
Abstract
Background Renal angiomyolipomas (AML) are usual manifestations of tuberous sclerosis complex (TSC) that may cause aneurism-related haemorrhages and renal impairment. Everolimus has emerged as an alternative to surgery/embolization. We provide further insight into everolimus safety and efficacy for TSC-related AML. Methods This was a Spanish expanded access trial including patients aged ≥18 years with TSC-related AML. They received 10 mg everolimus once daily until AML progression, unacceptable toxicity, death/withdrawal, commercialisation for TSC-related AML, or 1 year after first patient enrolment. The primary outcome was dose-limiting safety according to grade 3/4 adverse events, serious adverse events, or adverse events leading to treatment modification. Secondary outcomes included overall safety and efficacy. Results Nineteen patients were enrolled and received everolimus for a median of 6.6 (5.3–10.9) months. Eleven (57.9 %) remained on 10 mg/day throughout the study and eight (42.1 %) required treatment modifications due to adverse events; none permanently discontinued treatment. Adverse events were overall grade 1/2 and most frequently included aphthous stomatitis/mucosal inflammation, hypercholesterolaemia/hypertriglyceridaemia, urinary tract infection, hypertension, dermatitis acneiform, and insomnia. Four (21.1 %) patients experienced grade 3 adverse events, none was grade 4, and only one (5.3 %) was serious (pneumonia). AML volume was reduced ≥30 % in 11 (57.9 %) patients and ≥50 % in 9 (47.4 %); none progressed. Right and left kidney sizes decreased in 16 and 14 patients, respectively. Conclusions These findings support the benefit of everolimus for renal AML due to a manageable safety profile accompanied by reduced AML and kidney volumes. Trial registration EudraCT number 2012-005397-63; date of registration 22 Nov 2012.
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Affiliation(s)
- Nicolás Roberto Robles
- Department of Nephrology, Hospital Universitario Infanta Cristina, REDINREN, Avenida de Elvas, S/N, 06006, Badajoz, Spain
| | - Ramón Peces
- Department of Nephrology, Hospital Universitario La Paz, REDINREN, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Álvaro Gómez-Ferrer
- Department of Urology, Instituto Valenciano de Oncología, Calle del Profesor Beltrán Bàguena, 8, 46009, Valencia, Spain
| | - Felipe Villacampa
- Department of Urology, Hospital Universitario 12 de Octubre, Avenida de Córdoba, S/N, 28041, Madrid, Spain
| | - Jose Luis Álvarez-Ossorio
- Department of Urology, Hospital Universitario Puerta del Mar, Avenida Ana Viya, 21, 11009, Cádiz, Spain
| | - Pedro Pérez-Segura
- Department of Oncology, Hospital Universitario Clínico San Carlos, Calle del Profesor Martín Lagos, S/N, 28040, Madrid, Spain
| | - Juan Morote
- Department of Urology, Hospital Universitario Vall d'Hebron, Paseo de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Bernardo Herrera-Imbroda
- Department of Urology, Hospital Universitario Virgen de la Victoria, Campus de Teatinos, S/N, 29010, Málaga, Spain
| | - Javier Nieto
- Department of Nephrology, Hospital General Universitario de Ciudad Real, Calle del Obispo Rafael Torija, S/N, 13005, Ciudad Real, Spain
| | - Joaquín Carballido
- Department of Urology, Hospital Universitario Puerta de Hierro Majadahonda, Calle de Manuel de Falla, 1, 28222, Majadahonda, Spain
| | - Urbano Anido
- Department of Oncology, Hospital Clínico Universitario de Santiago de Compostela, Travesía de Choupana, S/N, 15706, Santiago de Compostela, Spain
| | - Marian Valero
- Department of Medical Affairs, Novartis Farmacéutica S.A, Gran Via de les Corts Catalanes, 764, 08013, Barcelona, Spain
| | - Cristina Meseguer
- Department of Medical Affairs, Novartis Farmacéutica S.A, Gran Via de les Corts Catalanes, 764, 08013, Barcelona, Spain
| | - Roser Torra
- Inherited Renal Diseases, Department of Nephrology, Fundació Puigvert, REDINREN, IIB Sant Pau, Universitat Autónoma de Barcelona, Cartagena, 340-350, 08025, Barcelona, Spain.
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Evaluation of T1-Weighted MRI to Detect Intratumoral Hemorrhage Within Papillary Renal Cell Carcinoma as a Feature Differentiating From Angiomyolipoma Without Visible Fat. AJR Am J Roentgenol 2016; 207:585-91. [DOI: 10.2214/ajr.16.16062] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Macaya A, Torra R, Ariceta G, Boronat S, Plana JC, Espinosa ÁC, García-Miñaúr S, Hernández-Martín Á, Krueger DA, López-Pisón J, Palomo Castaño YA, Hermogenes F, Crespo ER, Ruiz-Falcó Rojas ML, Serrano-Castro PJ, Auba FV. Recomendaciones para el abordaje multidisciplinar del complejo esclerosis tuberosa. Med Clin (Barc) 2016; 147:211-216. [DOI: 10.1016/j.medcli.2016.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 11/17/2022]
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Furlano M, Barreiro Y, Martí T, Facundo C, Ruiz-García C, DaSilva I, Ayasreh N, Cabrera-López C, Ballarín J, Ars E, Torra R. Renal angiomyolipoma bleeding in a patient with TSC2/PKD1 contiguous gene syndrome after 17 years of renal replacement therapy. Nefrologia 2016; 37:87-92. [PMID: 27595512 DOI: 10.1016/j.nefro.2016.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 01/17/2016] [Accepted: 04/19/2016] [Indexed: 12/15/2022] Open
Abstract
We report the case of a 32-year-old male diagnosed with TSC2/PKD1 contiguous gene syndrome, presenting with tuberous sclerosis (TS) and autosomal dominant polycystic kidney disease simultaneously. He progressed to end-stage renal disease and received a kidney transplant at the age of 12. The native kidneys presented angiomyolipomas (AML), which are common benign tumours in patients with TS. Seventeen years after transplantation, he presented with abdominal pain, anaemia and a retroperitoneal haematoma, the latter caused by renal AML bleeding. Selective embolisation was performed. Our patient could have benefited from the administration of mTOR inhibitors at transplant. This therapy is immunosuppressive and reduces the size of benign tumours in TS as well as the risk of rupture and bleeding. This patient did not receive mTOR inhibitors at the time of the transplant because the relationship between mTOR inhibitors and TS was unknown at that time. This case confirms the persistent risk of renal AML bleeding for both transplanted patients and patients on dialysis. As a result, we would recommend routine check-ups of native kidneys and nephrectomy assessment.
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Affiliation(s)
- Mónica Furlano
- Enfermedades Renales Hereditarias, Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España
| | - Yaima Barreiro
- Servicio de Hemodiálisis, Avericum S.L., Las Palmas de Gran Canaria, España
| | - Teresa Martí
- Servicio de Radiología, Fundació Puigvert, Barcelona, España
| | - Carme Facundo
- Unidad de Trasplante Renal, Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España
| | - César Ruiz-García
- Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España
| | - Iara DaSilva
- Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España
| | - Nadia Ayasreh
- Enfermedades Renales Hereditarias, Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España
| | - Cristina Cabrera-López
- Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España; Servicio de Nefrología, Hospital Moisés Broggi, Sant Joan Despí, Barcelona
| | - José Ballarín
- Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España
| | - Elisabet Ars
- Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España; Laboratorio de Biología Molecular, Fundació Puigvert, Barcelona, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Servicio de Nefrología, Fundació Puigvert, Barcelona, España; Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, España; Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, España.
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Angiomyolipoma in a Patient with Situs Inversus Totalis: Managing Two Rare Diseases. Case Reports Hepatol 2016; 2016:5060284. [PMID: 27525134 PMCID: PMC4971306 DOI: 10.1155/2016/5060284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/19/2016] [Indexed: 12/03/2022] Open
Abstract
Hepatic angiomyolipoma is an extremely rare benign hamartomatous lesion. Situs inversus totalis is a genetic condition occurring in 0.01% of the population. Following the kidney, the liver is the second most common site of angiomyolipoma. No consensus on the treatment of hepatic angiomyolipoma has been reached. However, the majority of these tumours are managed conservatively. Situs inversus totalis presents difficulties for procedures and is most commonly an incidental finding. These two conditions have not previously been reported and no genetic link has been established between them. This paper reports the association of both conditions in a 74-year-old female, reviews the literature, and presents CT imaging of the case.
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90
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Sun X, Feng R, Zhang Y, Shi J, Xu KF. Coexistence of pulmonary lymphangioleiomyomatosis and pulmonary angiomyolipoma. BMC Pulm Med 2016; 16:120. [PMID: 27527652 PMCID: PMC4986257 DOI: 10.1186/s12890-016-0286-1] [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: 04/22/2016] [Accepted: 08/11/2016] [Indexed: 01/06/2023] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) and angiomyolipoma are two different, but related rare diseases. To the best of our knowledge, pulmonary LAM and pulmonary angiomyolipoma have not previously been observed in the same patient. Case presentation A 38-year-old woman presented with a dry cough and left flank pain. She had a right nephrectomy for renal angiomyolipoma 17 years ago. A magnetic resonance imaging scan demonstrated a round mass in the left kidney. A chest computed tomography scan demonstrated scattered small thin-walled cysts and multifocal round nodules in both lungs. A lung biopsy via video-assisted thoracoscopic surgery revealed that the cysts and nodules were manifestations of LAM and angiomyolipomas, respectively. After sirolimus therapy, the renal angiomyolipoma and metastasized pulmonary angiomyolipomas shrank, but pulmonary cysts were unchanged. Conclusions LAM and angiomyolipoma are significantly associated, and may coexist in the lungs in rare cases. Sirolimus is effective for both renal angiomyolipoma and metastasized pulmonary angiomyolipomas.
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Affiliation(s)
- Xuefeng Sun
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Ye Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Juhong Shi
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, 100730, China.
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91
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Bissler JJ, Kingswood JC. Optimal treatment of tuberous sclerosis complex associated renal angiomyolipomata: a systematic review. Ther Adv Urol 2016; 8:279-290. [PMID: 27928430 PMCID: PMC5131738 DOI: 10.1177/1756287216641353] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Renal angiomyolipomata associated with tuberous sclerosis complex are often bilateral, multiple and progressive. They cause significant morbidity and mortality in older children and adults. Surveillance and pre-emptive treatment reduce this risk. Recent research suggests treatment with mammalian target of rapamycin inhibitors is better at preventing bleeding, recurrence, and preserving renal function than percutaneous embolization.
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Affiliation(s)
- John J. Bissler
- FedEx Chair of Excellence, Director, Tuberous Sclerosis Center of Excellence, Director, Division of Nephrology at St. Jude Children’s Research Hospital and LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Professor of Pediatrics, 51 North Dunlap Street, Memphis, TN 38103, USA
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Renal Angiomyolipoma: Mid- to Long-Term Results Following Embolization with Onyx. Cardiovasc Intervent Radiol 2016; 39:1759-1764. [DOI: 10.1007/s00270-016-1432-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 07/20/2016] [Indexed: 10/21/2022]
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Evidence Supporting a Lymphatic Endothelium Origin for Angiomyolipoma, a TSC2(-) Tumor Related to Lymphangioleiomyomatosis. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:1825-1836. [PMID: 27289491 DOI: 10.1016/j.ajpath.2016.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 12/27/2022]
Abstract
Angiomyolipoma (AML) is a tumor closely related to lymphangioleiomyomatosis (LAM). Both entities are characterized by the proliferation of smooth muscle actin and melanocytic glycoprotein 100 (recognized by antibody HMB-45)-positive spindle-shaped and epithelioid cells. AML and LAM are etiologically linked to mutations in the tsc2 and tsc1 genes in the case of LAM. These genes encode the proteins tuberous sclerosis complex (TSC)-1 and TSC2, which are directly involved in suppressing the mechanistic target of rapamycin cell growth signaling pathway. Although significant progress has been made in characterizing and pharmacologically slowing the progression of AML and LAM with rapamycin, our understanding of their pathogenesis lacks an identified cell of origin. We used an AML-derived cell line to determine whether TSC2 restitution brings about the cell type from which AML arises. We found that AML cells express lymphatic endothelial cell markers consistent with lymphatic endothelial cell precursors in vivo and in vitro. Moreover, on TSC2 correction, AML cells mature into adult lymphatic endothelial cells and have functional attributes characteristic of this cell lineage, suggesting a lymphatic endothelial cell of origin for AML. These effects are dependent on TSC2-mediated mechanistic target of rapamycin inactivation. Finally, we demonstrate the in vitro effectiveness of norcantharidin, a lymphangiogenesis inhibitor, as a potential co-adjuvant therapy in the treatment of AML.
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94
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Everolimus-induced near-resolution of giant cardiac rhabdomyomas and large renal angiomyolipoma in a newborn with tuberous sclerosis complex. Cardiol Young 2016; 26:1025-8. [PMID: 27055516 DOI: 10.1017/s1047951116000421] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report a case of a newborn, affected by tuberous sclerosis complex, with a prenatally diagnosed giant cardiac rhabdomyoma associated with a large renal angiomyolipoma presenting as a duct-depending lesion not treatable by surgery. After receiving everolimus, a mammalian target of rapamycin inhibitor, we observed a rapid, significant, and durable reduction of both lesions without remarkable side effects.
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95
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Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder that affects multiple organ systems and is caused by loss-of-function mutations in one of two genes: TSC1 or TSC2. The disorder can affect both adults and children. First described in depth by Bourneville in 1880, it is now estimated that nearly 2 million people are affected by the disease worldwide. The clinical features of TSC are distinctive and can vary widely between individuals, even within one family. Major features of the disease include tumours of the brain, skin, heart, lungs and kidneys, seizures and TSC-associated neuropsychiatric disorders, which can include autism spectrum disorder and cognitive disability. TSC1 (also known as hamartin) and TSC2 (also known as tuberin) form the TSC protein complex that acts as an inhibitor of the mechanistic target of rapamycin (mTOR) signalling pathway, which in turn plays a pivotal part in regulating cell growth, proliferation, autophagy and protein and lipid synthesis. Remarkable progress in basic and translational research, in addition to several randomized controlled trials worldwide, has led to regulatory approval of the use of mTOR inhibitors for the treatment of renal angiomyolipomas, brain subependymal giant cell astrocytomas and pulmonary lymphangioleiomyomatosis, but further research is needed to establish full indications of therapeutic treatment. In this Primer, we review the state-of-the-art knowledge in the TSC field, including the molecular and cellular basis of the disease, medical management, major knowledge gaps and ongoing research towards a cure.
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Affiliation(s)
- Elizabeth P Henske
- Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, Massachusetts 02115, USA
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland.,Children's Memorial Health Institute, Warsaw, Poland
| | | | - Julian R Sampson
- Institute of Medical Genetics, Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - Elizabeth A Thiele
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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96
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Bissler J, Cappell K, Charles H, Song X, Liu Z, Prestifilippo J, Gregory C, Hulbert J. Long-term Clinical Morbidity in Patients With Renal Angiomyolipoma Associated With Tuberous Sclerosis Complex. Urology 2016; 95:80-7. [PMID: 27132503 DOI: 10.1016/j.urology.2016.04.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 03/22/2016] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To estimate the incidence rates of kidney-related clinical outcomes among patients with tuberous sclerosis complex (TSC)-related angiomyolipoma (AML) compared to an age-matched control cohort in the United States. MATERIALS AND METHODS This was a retrospective, observational study. Administrative data from the MarketScan Research Databases were used to select patients with TSC and renal AML. An age-matched group with no TSC or renal AML was identified for comparison. Outcomes were incidence rates per 100 patient-years and number of months to development of hematuria, chronic kidney disease, renal hemorrhage, kidney failure, and inpatient death. RESULTS Among the commercially insured TSC-renal AML patients (N = 605) and matched controls (N = 1815), 37.2% were <18 years old. Among Medicaid TSC-renal AML patients (N = 246) and matched controls (N = 738), 38.6% were aged <18. In the commercial sample, in both age groups (<18 and ≥18), the incidence rate of each clinical outcome measured was higher in the TSC-renal AML cohort than in the control cohort, with several differences reaching statistical significance. Compared with younger patients, older TSC-renal AML patients had higher incidence rates of clinical outcomes (hematuria: 20.4 vs 8.7; chronic kidney disease: 9.6 vs 3.5; renal hemorrhage 2.7 vs 0.7; kidney failure: 1.9 vs 0.4) and took less time on average to develop each clinical outcome. A similar pattern of results was observed among patients with Medicaid insurance. CONCLUSION TSC-renal AML patients are at significantly higher risk for renal morbidity relative to the general population.
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Affiliation(s)
- John Bissler
- LeBonheur Children's Hospital and St. Jude's Children's Research Hospital, Memphis, TN
| | | | | | - Xue Song
- Truven Health Analytics Inc., Ann Arbor, MI.
| | - Zhimei Liu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
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97
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Peron A, Vignoli A, La Briola F, Volpi A, Montanari E, Morenghi E, Ghelma F, Bulfamante G, Cefalo G, Canevini MP. Do patients with tuberous sclerosis complex have an increased risk for malignancies? Am J Med Genet A 2016; 170:1538-44. [PMID: 27061015 DOI: 10.1002/ajmg.a.37644] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/20/2016] [Indexed: 02/01/2023]
Abstract
Tuberous Sclerosis Complex (TSC) is generally characterized by the presence of benign tumors, but some patients with malignancies have been reported in the literature. We examined a large Italian TSC population (240 individuals followed from 2001 to 2015, aged 3 months-74 years), assessing the frequency of malignancies to determine whether there is an increased risk for cancer in this disorder, and looking for possible features associated with the development of neoplasia. Fifteen patients had malignancies (6.25%); median age at diagnosis was 37.5 years (range of 1.6-58). Five of seven renal tumors were renal cell carcinomas. Eight patients had a non-renal malignancy (3.3%), but we did not find a more prevalent type of cancer. No patient developed more than one malignancy. The prevalence of all malignant tumors was compatible with the prevalence in the general population (5.6%, 95%CI 2.99-9.31%, vs. 4.4% in Italy). Median age at cancer diagnosis was lower (37.5 years, 95%CI 28.6-44.7, vs. 66.0 years). Two patients (13.3%) died of their cancer, while outcome was favorable in the remaining individuals. Malignant tumors were more frequently diagnosed in patients with mutations in TSC1 when compared to TSC2 and patients with no mutation identified (P = 0.032). Our study demonstrated that TSC patients do not seem to have an increased risk for malignancies besides renal cell carcinoma. However, when cancer develops, age at diagnosis is lower than in the general population, and malignant tumors are more frequently diagnosed in patients with mutations in TSC1. Further studies are needed to confirm these data. ©2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Angela Peron
- Child Neurology Unit-Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Aglaia Vignoli
- Child Neurology Unit-Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Francesca La Briola
- Child Neurology Unit-Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Angela Volpi
- Nephrology Unit, San Paolo Hospital, Milan, Italy
| | - Emanuele Montanari
- Urology Unit, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Emanuela Morenghi
- Biostatististics Unit, Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - Filippo Ghelma
- DAMA Unit (Disabled Advanced Medical Assistance), San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Gaetano Bulfamante
- Human Pathology Unit, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Graziella Cefalo
- Pediatrics Department, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Maria Paola Canevini
- Child Neurology Unit-Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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Budde K, Zonnenberg BA, Frost M, Cheung W, Urva S, Brechenmacher T, Stein K, Chen D, Kingswood JC, Bissler JJ. Pharmacokinetics and pharmacodynamics of everolimus in patients with renal angiomyolipoma and tuberous sclerosis complex or lymphangioleiomyomatosis. Br J Clin Pharmacol 2016; 81:958-70. [PMID: 26580489 DOI: 10.1111/bcp.12834] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 11/06/2015] [Accepted: 11/15/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS The purpose was to determine the exposure-response relationship of everolimus in patients with angiomyolipoma from the EXIST-2 trial and to analyze the correlation between exposure and plasma concentrations of angiogenic biomarkers in these patients. METHODS One hundred and eighteen patients with angiomyolipoma associated with tuberous sclerosis complex (TSC) or sporadic lymphangioleiomyomatosis (sLAM) were randomly assigned 2 : 1 to receive everolimus 10 mg (n = 79) or placebo (n = 39) once daily. Blood samples for determining everolimus concentration were collected at weeks 2, 4, 12, 24 and 48 during double-blind treatment. Plasma samples for biomarker analysis were collected at baseline and weeks 4, 12, 24, 36, 48 and at the end of treatment. Concentrations of eight angiogenic biomarkers associated with tumour growth were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS Peak and trough concentrations of everolimus in blood remained stable over time and similar to those reported in other indications. Substantial pharmacodynamic effects were observed in the everolimus, but not placebo, arm for three biomarkers: After 24 weeks of treatment, reduction of vascular endothelial growth factor D (VEGF-D) and collagen type IV (COL-IV) (mean fold-changes with 95% confidence intervals [CI] were 0.36 [0.33, 0.40], and 0.54 [0.51, 0.57], respectively, P < 0.001 for both), along with increased VEGF-A (mean fold-change of 1.59 [1.39, 1.80], P < 0.001), were seen. Furthermore, baseline VEGF-D and COL-IV levels were associated with angiomyolipoma size at baseline and with angiomyolipoma response to everolimus. CONCLUSIONS These findings suggest that plasma angiogenic markers may provide an objective measure of patient response to everolimus.
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Affiliation(s)
| | | | | | - Wing Cheung
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Shweta Urva
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Karen Stein
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - David Chen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - John J Bissler
- Lebonheur Children's Hospital and the University of Tennessee, Memphis, Tennessee, USA
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The clinical profile of tuberous sclerosis complex (TSC) in the United Kingdom: A retrospective cohort study in the Clinical Practice Research Datalink (CPRD). Eur J Paediatr Neurol 2016; 20:296-308. [PMID: 26706603 DOI: 10.1016/j.ejpn.2015.11.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 09/25/2015] [Accepted: 11/23/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tuberous Sclerosis Complex (TSC) is a multi-system genetic disorder characterised by the development of benign growths and diverse clinical manifestations, varying in severity, age at onset and with high clinical burden. AIMS This longitudinal study aims to describe the broad spectrum of clinical manifestation profiles in a large, representative cohort of TSC patients in the UK in order to better understand disease complexity. METHODS TSC patients in the Clinical Practice Research Datalink (CPRD) and linked Hospital Episodes Statistics (CPRD-HES) were retrospectively identified between 1987 and 2013. Available history was extracted for each patient and clinical diagnosis, procedure and medication records reviewed. A random selection of patients from the CPRD-HES was used as a Comparator cohort. RESULTS Three hundred and thirty-four TSC patients with a mean (SD) age of 30.3 (18.6) years were identified (53% female). TSC was diagnosed at mean age 3.2 (4.2) years. Epilepsy and psychiatric manifestations were reported frequently in paediatric (77% and 55%, respectively) and adult patients (66% and 68%, respectively). The prevalence of manifestations in the TSC cohort was markedly higher versus the Comparator cohort. The majority of paediatric (46%) and adult TSC patients (62%) developed clinical manifestations affecting at least three organ systems and forty-nine distinctive organ system manifestation profiles were identified. CONCLUSIONS TSC patients present with multiple and complex clinical manifestations and profiles that necessitate the co-ordinated action of a multidisciplinary team in order to improve the quality and efficiency of care.
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100
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Long-term High Fat Ketogenic Diet Promotes Renal Tumor Growth in a Rat Model of Tuberous Sclerosis. Sci Rep 2016; 6:21807. [PMID: 26892894 PMCID: PMC4759602 DOI: 10.1038/srep21807] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 12/31/2015] [Indexed: 11/29/2022] Open
Abstract
Nutritional imbalance underlies many disease processes but can be very beneficial in certain cases; for instance, the antiepileptic action of a high fat and low carbohydrate ketogenic diet. Besides this therapeutic feature it is not clear how this abundant fat supply may affect homeostasis, leading to side effects. A ketogenic diet is used as anti-seizure therapy i.a. in tuberous sclerosis patients, but its impact on concomitant tumor growth is not known. To examine this we have evaluated the growth of renal lesions in Eker rats (Tsc2+/−) subjected to a ketogenic diet for 4, 6 and 8 months. In spite of existing opinions about the anticancer actions of a ketogenic diet, we have shown that this anti-seizure therapy, especially in its long term usage, leads to excessive tumor growth. Prolonged feeding of a ketogenic diet promotes the growth of renal tumors by recruiting ERK1/2 and mTOR which are associated with the accumulation of oleic acid and the overproduction of growth hormone. Simultaneously, we observed that Nrf2, p53 and 8-oxoguanine glycosylase α dependent antitumor mechanisms were launched by the ketogenic diet. However, the pro-cancerous mechanisms finally took the ascendency by boosting tumor growth.
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