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Pérez S, Mulero-Soto P, Schoene A, Pereira G, Santini-Domínguez R, Martínez-Trabal J. Simultaneous rupture of two renal artery aneurysms in a patient with tuberous sclerosis complex. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:364-367. [PMID: 34136727 PMCID: PMC8176208 DOI: 10.1016/j.jvscit.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/21/2021] [Indexed: 12/01/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem neurocutaneous genetic condition. It is characterized by TSC-associated neuropsychiatric disorders, epilepsy, tumors, and angiomyolipoma in multiple organs, such as the skin, lungs, and kidneys. TSC is also associated with the development of aneurysms of the medium and large arteries, including the renal arteries. This condition will usually be diagnosed early in life, and active surveillance is required of tumor and aneurysm growth to prevent life-threatening events. We have presented the case of a 41-year-old patient with TSC that had not been previously diagnosed. The patient had presented with retroperitoneal hematoma secondary to the rupture of two left renal artery branch aneurysms that had likely developed within the angiomyolipoma.
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Affiliation(s)
- Sheila Pérez
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
| | - Patricia Mulero-Soto
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
| | - Alexandra Schoene
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
| | - Gabriel Pereira
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
| | - Rafael Santini-Domínguez
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
| | - Jorge Martínez-Trabal
- Division of Vascular Surgery, General Surgery Resident, Ponce Health Sciences University, St. Lukes Medical Center, Ponce, Puerto Rico
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Barnett JR, Grinspoon RA, Harisinghani M, Caruso PA, Thiele EA. The efficacy of cannabidiol on renal angiomyolipoma and subependymal giant cell tumor volume in tuberous sclerosis complex. J Clin Neurosci 2020; 77:85-88. [PMID: 32409220 DOI: 10.1016/j.jocn.2020.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
In patients with tuberous sclerosis complex (TSC) the upregulation of the mechanistic target of rapamycin (mTOR) pathway leads to the development and growth of subependymal giant cell tumors (SGCTs) and renal angiomyolipomas (AMLs). Drugs that inhibit the mTOR pathway, such as sirolimus, can reduce the size of both SGCTs and AMLs. Recent preclinical studies have suggested cannabidiol (CBD) may mediate the mTOR pathway, however, its exact effects are unclear. This study examines the volumes of SGCTs and renal AMLs in patients with TSC during treatment with purified CBD for refractory epilepsy. We retrospectively reviewed the medical records of patients with TSC with radiological evidence of AMLs and SGCTs who were being treated with plant-derived highly purified CBD in oral solution (Epidiolex®, GW Research Ltd) for refractory epilepsy at Massachusetts General Hospital. Patients who had surgical intervention for AMLs or SGCTS, and patients who had been treated with mTOR inhibitors were excluded. The volumes of SGCTs and dominant renal AML were measured before and after CBD initiation using abdominal and brain scans and compared. Patient demographics and CBD doses were collected from medical records. Six out of the seven dominant renal AMLs and three out of the three SGCTs increased in volume during CBD treatment. One AML had a decrease in volume after CBD initiation which was not considered significant. The results suggest that unlike mTOR inhibitors, CBD treatment does not decrease the volume of SGCTs or AMLs in TSC patients.
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Ni J, Yan F, Qin W, Yu L, Zhang G, Liu F, Yang X, Yang B, Hao C, Wang T, Liu P, Yuan J, Wu G. Mutational analysis of renal angiomyolipoma associated with tuberous sclerosis complex and the outcome of short-term everolimus therapy. Sci Rep 2019; 9:14337. [PMID: 31586081 PMCID: PMC6778095 DOI: 10.1038/s41598-019-49814-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 08/31/2019] [Indexed: 12/22/2022] Open
Abstract
To identify clinical characteristics and mutation spectra in Chinese patients with renal angiomyolipoma (AML) associated with the tuberous sclerosis complex (TSC, TSC-AML), examined the efficacy and safety of short-term everolimus therapy (12 weeks). We analyzed the frequency distribution of each TSC-related clinical feature and investigated gene mutations by genetic testing. Some subjects received everolimus for 12 weeks at a dose of 10 mg/day, and the efficacy and safety of short-term everolimus therapy were examined. Finally, 82 TSC-AML patients were enrolled for analysis in this study. Of the 47 patients who underwent genetic testing, 22 patients (46.81%) had at least one detectable mutation in the TSC1 or TSC2 gene: 7 were TSC1 gene mutations, 13 were TSC2 gene mutations, and 2 were found in both TSC1 and TSC2. Everolimus treatment had a statistically significant effect on the renal AML volume reduction during follow-up (P < 0.05), and the mean reduction rate of volume for all cases was 56.47 ± 23.32% over 12 weeks. However, 7 patients (7/25; 28.00%) experienced an increase in renal AML tumor volume within 12 weeks after discontinuation of the everolimus treatment. Although most patients (27/30, 90.00%) experienced some adverse events during the treatment period, all such events were mild, and no patients discontinued or needed dose reduction because of adverse events. Overall, in this study, the mutation rate of TSC-AML patients is much lower than other reports. Short-term everolimus treatment for TSC-AML is effective and safe, but the stability is much lower than long-term therapy.
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Affiliation(s)
- Jianxin Ni
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Fengqi Yan
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.,Department of Urology, Tang Du Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710038, China
| | - Weijun Qin
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Lei Yu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Geng Zhang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Fei Liu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Xiaojian Yang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Bo Yang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Chunlin Hao
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Teng Wang
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Pengfei Liu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China
| | - Jianlin Yuan
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.
| | - Guojun Wu
- Department of Urology, Xi Jing Hospital, the Fourth Military Medical University, Shaanxi, Xian, 710032, China.
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Abstract
Immunosuppressive drugs are used in renal transplantation to prevent and treat rejection and their use has traditionally been limited to urologists trained in transplant surgery. However, there are other urologic conditions for which these drugs have proven efficacy. Since transplant surgery has become a small niche subspecialty within urology, most urologists are unfamiliar and uncomfortable with their use. This review will focus on the use of Cyclosporine (CyA), mycophenolate mofetil (MMF), and mammalian target of rapamycin (mTOR) inhibitors in urology outside of solid organ transplant. This includes the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) with CyA as well as the role of CyA in eosinophilic cystitis (EC) and the treatment of retroperitoneal fibrosis (RF) with MMF. Also included is the utilization of mTOR inhibitors in both advanced renal cell carcinoma (RCC) and in patients with tuberous sclerosis complex (TSC) associated angiomyolipoma (AML). Available clinical data on mTOR inhibition in autosomal dominant polycystic kidney disease (ADPKD) is also briefly presented. Specific attention is given to the indications for each agent, the available evidence surrounding their use, and the most common adverse events (AEs) and their subsequent management.
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Affiliation(s)
- Alice Crane
- Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed Eltemamy
- Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Shoskes
- Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, OH, USA
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Zhao DD, Yuan J, Cheng Q, Qi YL, Lu K, Lai SS, Sun Q, Zhao Y, Fang L, Jin ML, Yu DC, Qiu YD, Li CJ, Chen J, Xue B. Evidence for a role of geranylgeranylation in renal angiomyolipoma and renal epithelioid angiomyolipoma. Oncol Lett 2019; 17:1523-1530. [PMID: 30675208 PMCID: PMC6341897 DOI: 10.3892/ol.2018.9808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/19/2018] [Indexed: 01/17/2023] Open
Abstract
Research on mevalonate kinase deficiency has revealed that it may lead to the development of renal angiomyolipomas (RAMLs). Thus, it was suspected that geranylgeranyl pyrophosphate synthase (GGPPS), a key enzyme in the mevalonate pathway, may be involved in the development of RAMLs. In the present study, the expression of GGPPS in RAMLs and renal epithelioid angiomyolipomas (REAs) was assessed, and paraffin embedded specimens from 60 patients, including 9 cases with REA and 51 cases with RAML, were examined. Immunoreactivity was evaluated semi-quantitatively according to the intensity of staining and the percentage of positively stained cells. The results indicated that GGPPS was predominantly present in the cytoplasm, and REA tissues exhibited higher expression of GGPPS in the cytoplasm compared with RAML tissues. It was also identified that GGPPS was upregulated in TSC2-null cells, and inhibition of GGPPS could induce apoptosis of TSC2-null cells by autophagy. In conclusion, the increased expression of GGPPS in RAMLs and REAs indicated that mevalonate pathways may be involved in disease progression. GGPPS may serve as a potential therapeutic target and the current results may provide a novel therapeutic strategy for RAML and lymphangioleiomyomatosis.
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Affiliation(s)
- Dan-Dan Zhao
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Research Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, P.R. China
| | - Jun Yuan
- Biochemical and Environmental Engineering School of Xiaozhuang College, Nanjing 211171, P.R. China
| | - Qi Cheng
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Ya-Ling Qi
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Ke Lu
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Shan-Shan Lai
- Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Sciences, Nanjing Normal University, Nanjing, Jiangsu 210023, P.R. China
| | - Qian Sun
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Yue Zhao
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Lei Fang
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Mei-Ling Jin
- Pulmonary Department, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - De-Cai Yu
- Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, P.R. China
| | - Yu-Dong Qiu
- Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, P.R. China
| | - Chao-Jun Li
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China
| | - Jun Chen
- Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Department of Pathology, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, P.R. China
| | - Bin Xue
- State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory of Molecular Medicine and School of Medicine, Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,Liver Disease Collaborative Research Platform of Medical School of Nanjing University, Nanjing, Jiangsu 210093, P.R. China.,State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu 210009, P.R. China
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Abstract
Angiomyolipomas (AMLs) are the most common benign renal tumours. Most of these neoplasms are found incidentally on imaging. However, symptomatic presentation does exist. Renal AMLs are typically composed of smooth muscle, blood vessels, and adipose tissue. Because of the abundant fat tissue, they give a characteristic appearance on imaging and are therefore easily diagnosed. However, sometimes they contain too little fat to be detected. This increases the difficulty in differentiating them from renal cell carcinoma (RCC). Management of AML is based on clinical presentation and should be individualized for every patient. Treatment modalities range from active surveillance to more invasive approaches.
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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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