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Gourmel A, Kleiber N, Kokta V, Bergeron M, McCuaig C, Doré-Bergeron MJ, Simpson E, Renaud C, Roy JP, Zysman-Colman Z, Cao Y, Théorêt Y, Powell J, Dubois J, Tran TH. Multimodal therapeutic approach for a severe case of kaposiform lymphangiomatosis from procedural interventions to targeted therapies. Pediatr Blood Cancer 2024; 71:e31079. [PMID: 38753412 DOI: 10.1002/pbc.31079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Antoine Gourmel
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Niina Kleiber
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Clinical Pharmacology Unit, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
| | - Victor Kokta
- Department of Pathology and Clinical Laboratory Medicine, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Mathieu Bergeron
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Catherine McCuaig
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Marie-Joelle Doré-Bergeron
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Ewurabena Simpson
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Christian Renaud
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Division of Pediatric Infectious Diseases, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Jean-Philippe Roy
- Division of Nephrology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Zofia Zysman-Colman
- Division of Respiratory Medicine, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Yang Cao
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Yves Théorêt
- Clinical Pharmacology Laboratory, OPTILAB and Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Julie Powell
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Josée Dubois
- Department of Medical Imaging, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
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2
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Nozawa A, Abe T, Niihori T, Ozeki M, Aoki Y, Ohnishi H. Lymphatic endothelial cell-specific NRAS p.Q61R mutant embryos show abnormal lymphatic vessel morphogenesis. Hum Mol Genet 2024:ddae080. [PMID: 38743908 DOI: 10.1093/hmg/ddae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/14/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024] Open
Abstract
Generalized lymphatic anomaly (GLA) and kaposiform lymphangiomatosis (KLA) are rare congenital disorders that arise through anomalous embryogenesis of the lymphatic system. A somatic activating NRAS p.Q61R variant has been recently detected in GLA and KLA tissues, suggesting that the NRAS p.Q61R variant plays an important role in the development of these diseases. To address this role, we studied the effect of the NRAS p.Q61R variant in lymphatic endothelial cells (LECs) on the structure of the lymphatics during embryonic and postnatal lymphangiogenesis applying inducible, LEC-specific NRAS p.Q61R variant in mice. Lox-stop-Lox NrasQ61R mice were crossed with Prox1-CreERT2 mice expressing tamoxifen-inducible Cre recombinase specifically in LECs. Whole-mount immunostaining of embryonic back skin using an antibody against the LEC surface marker VEGFR3 showed considerably greater lymphatic vessel width in LEC-specific NRAS p.Q61R mutant embryos than in littermate controls. These mutant embryos also showed a significant reduction in the number of lymphatic vessel branches. Furthermore, immunofluorescence staining of whole-mount embryonic back skin using an antibody against the LEC-specific nuclear marker Prox1 showed a large increase in the number of LECs in LEC-specific NRAS p.Q61R mutants. In contrast, postnatal induction of the NRAS p.Q61R variant in LECs did not cause abnormal lymphatic vessel morphogenesis. These results suggest that the NRAS p.Q61R variant in LECs plays a role in development of lymphatic anomalies. While this model does not directly reflect the human pathology of GLA and KLA, there are overlapping features, suggesting that further study of this model may help in studying GLA and KLA mechanisms.
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Affiliation(s)
- Akifumi Nozawa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Taiki Abe
- Department of Medical Genetics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Sendai 980-8574, Japan
| | - Tetsuya Niihori
- Department of Medical Genetics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Sendai 980-8574, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan
- Center for One Medicine Innovative Translational Research (COMIT), Gifu University, 1-1 Yanagido,Gifu 501-1194, Japan
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Sendai 980-8574, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1194, Japan
- Center for One Medicine Innovative Translational Research (COMIT), Gifu University, 1-1 Yanagido,Gifu 501-1194, Japan
- Clinical Genetics Center, Gifu University Hospital, 1-1 Yanagido,Gifu501-1194, Japan
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3
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Abdul-Rahman T, Ghosh S, Badar SM, Nazir A, Bamigbade GB, Aji N, Roy P, Kachani H, Garg N, Lawal L, Bliss ZSB, Wireko AA, Atallah O, Adebusoye FT, Teslyk T, Sikora K, Horbas V. The paradoxical role of cytokines and chemokines at the tumor microenvironment: a comprehensive review. Eur J Med Res 2024; 29:124. [PMID: 38360737 PMCID: PMC10868116 DOI: 10.1186/s40001-024-01711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/03/2024] [Indexed: 02/17/2024] Open
Abstract
Tumor progression and eradication have long piqued the scientific community's interest. Recent discoveries about the role of chemokines and cytokines in these processes have fueled renewed interest in related research. These roles are frequently viewed as contentious due to their ability to both suppress and promote cancer progression. As a result, this review critically appraised existing literature to discuss the unique roles of cytokines and chemokines in the tumor microenvironment, as well as the existing challenges and future opportunities for exploiting these roles to develop novel and targeted treatments. While these modulatory molecules play an important role in tumor suppression via enhanced cancer-cell identification by cytotoxic effector cells and directly recruiting immunological effector cells and stromal cells in the TME, we observed that they also promote tumor proliferation. Many cytokines, including GM-CSF, IL-7, IL-12, IL-15, IL-18, and IL-21, have entered clinical trials for people with advanced cancer, while the FDA has approved interferon-alpha and IL-2. Nonetheless, low efficacy and dose-limiting toxicity limit these agents' full potential. Conversely, Chemokines have tremendous potential for increasing cancer immune-cell penetration of the tumor microenvironment and promoting beneficial immunological interactions. When chemokines are combined with cytokines, they activate lymphocytes, producing IL-2, CD80, and IL-12, all of which have a strong anticancer effect. This phenomenon opens the door to the development of effective anticancer combination therapies, such as therapies that can reverse cancer escape, and chemotaxis of immunosuppressive cells like Tregs, MDSCs, and TAMs.
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Affiliation(s)
- Toufik Abdul-Rahman
- Medical Institute, Sumy State University, Antonova 10, Sumy, 40007, Ukraine.
| | - Shankhaneel Ghosh
- Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan, Bhubaneswar, India
| | - Sarah M Badar
- The University of the West of Scotland, Lanarkshire, UK
| | | | - Gafar Babatunde Bamigbade
- Department of Food Science and Technology, College of Agriculture and Veterinary Medicine, United Arab Emirates University, Al-Ain, Abu Dhabi, United Arab Emirates
| | - Narjiss Aji
- McGill University, Faculty of Medicine and Health Sciences, Montreal, Canada
| | - Poulami Roy
- Department of Medicine, North Bengal Medical College and Hospital, Siliguri, India
| | | | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, One Medical Center Drive Stratford, Camden, NJ, 08084, USA
| | - Lukman Lawal
- Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
| | - Zarah Sophia Blake Bliss
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan, Mexico
| | | | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | | | - Tetiana Teslyk
- Medical Institute, Sumy State University, Antonova 10, Sumy, 40007, Ukraine
| | - Kateryna Sikora
- Medical Institute, Sumy State University, Antonova 10, Sumy, 40007, Ukraine
| | - Viktoriia Horbas
- Medical Institute, Sumy State University, Antonova 10, Sumy, 40007, Ukraine
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4
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Chowers G, Abebe-Campino G, Golan H, Vivante A, Greenberger S, Soudack M, Barkai G, Fox-Fisher I, Li D, March M, Battig MR, Hakonarson H, Adams D, Dori Y, Dagan A. Treatment of severe Kaposiform lymphangiomatosis positive for NRAS mutation by MEK inhibition. Pediatr Res 2023; 94:1911-1915. [PMID: 35246606 PMCID: PMC9440952 DOI: 10.1038/s41390-022-01986-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/22/2021] [Accepted: 01/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a complex lymphatic anomaly involving most commonly the mediastinum, lung, skin and bones with few effective treatments. In recent years, RAS-MAPK pathway mutations were shown to underlie the pathogenesis of several complex lymphatic anomalies. Specifically, an activating NRAS mutation (p.Q61R) was found in the majority of KLA patients. Recent reports demonstrated promising results of treatment with the MEK inhibitor, Trametinib, in patients with complex lymphatic anomalies harboring gain of function mutations in ARAF and SOS1, as well as loss of function mutation in the CBL gene, a negative regulator of the RAS-MAPK pathway. We present a 9-year-old child with a severe case of KLA harboring the typical NRAS (p.Q61R) mutation detected by plasma-derived cell free DNA, responsive to trametinib therapy. METHODS The NRAS somatic mutation was detected from plasma cfDNA using droplet digital PCR. Concurrent in-vitro studies of trametinib activity on mutant NRAS affected lymphatic endothelial cells were performed using a three-dimensional spheroid sprouting assay. RESULTS Trametinib treatment lead to resolution of lifelong thrombocytopenia, improvement of pulmonary function tests and wellbeing, as well as weaning from prolonged systemic steroid treatment. Concurrent studies of mutant NRAS-expressing cells showed enhanced lymphangiogenic capacity along with over activation of the RAS-MAPK and PI3K-AKT-mTOR pathways, both reversed by trametinib. CONCLUSIONS Trametinib treatment can substantially change the prognosis of patients with RAS pathway associated lymphatic anomalies. IMPACT This is the first description of successful trametinib treatment of a patient with KLA harboring the most characteristic NRAS p.Q61R mutation. Treatment can significantly change the prognosis of patients with RAS pathway-associated lymphatic anomalies. We devised an in vitro model of KLA enabling a reproducible method for the continued study of disease pathogenesis. Mutated NRAS p.Q61R cells demonstrated increased lymphangiogenic capacity.
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Affiliation(s)
- Guy Chowers
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Gadi Abebe-Campino
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Hana Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Asaf Vivante
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Nephrology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Shoshana Greenberger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Dermatology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Michalle Soudack
- Pediatric Imaging Unit, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Galia Barkai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Diseases Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Ilana Fox-Fisher
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Dong Li
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael March
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark R Battig
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Divisions of Human Genetics and Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Adams
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adi Dagan
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Pulmonary Unit and the National Center for Cystic Fibrosis, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
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5
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McDaniel CG, Adams DM, Steele KE, Hammill AM, Merrow AC, Crane JL, Smith CL, Kozakewich HPW, Le Cras TD. Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment. Pediatr Blood Cancer 2023; 70:e30219. [PMID: 36683202 PMCID: PMC10018800 DOI: 10.1002/pbc.30219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023]
Abstract
Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.
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Affiliation(s)
| | - Denise M. Adams
- Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Kimberley E. Steele
- Collaborative Research Advocacy for Vascular Anomalies
Network (CaRAVAN), a 501(C)(3)
| | - Adrienne M. Hammill
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - A. Carl Merrow
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - Janet L. Crane
- Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | | | | | - Timothy D. Le Cras
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
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6
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Su T, Li C, Song B, Song D, Feng Y. Case report and literature review: Giant retroperitoneal cystic lymphangioma. Front Surg 2023; 10:1074067. [PMID: 36733888 PMCID: PMC9887134 DOI: 10.3389/fsurg.2023.1074067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/02/2023] [Indexed: 01/18/2023] Open
Abstract
Background Cystic lymphangioma is a rare benign tumor of the lymphatic system, which is most commonly observed in the neck, head and armpit.Less than 5% of lymphangiomas occur in the abdominal cavity and even less in the retroperitoneum. Case description A 65-year-old male patient was diagnosed with an "abdominal mass that had persisted for 1 year, accompanied by abdominal pain, abdominal distension and dyspnea for 7 days". After abdominal computerd tomography, a giant multilobed abdominal lymphangioma was suspected, which squeezed the intestinal canal and was closely related to the inferior vena cava. The patient underwent an exploratory laparotomy, during which, it was found that the tumor formed extensive adhesions to the transverse colon, small intestine and pelvic wall, and enveloped the abdominal aorta, superior mesenteric artery, inferior mesenteric artery and inferior vena cava to varying degrees. It was diffcult to remove the cyst completely. Postoperative pathology confirmed the diagnosis of retroperitoneal cystic lymphangioma. The patient recovered well after the operation, was eating normally by 5 days postoperatively,and was discharged 10 days postoperatively.The patient was followed up 1 month after postoperatively and no evidence of recurrence was observed. Conclusion In this case, we report a patient with giant retroperitoneal cystic lymphangioma who underwent exploratory laparotomy combined with preoperative abdominal computerd tomography and acute abdominal pain, abdominal distension and dyspnea. Because of the large volume of the tumor and its close relationship with the superior mesenteric artery and other blood vessels, the surgeon used scissors to separate the tumor sharply and removed the whole tumor completely.
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Affiliation(s)
- Tieshan Su
- Departments of Gastrointestinal Colorectal Anus Surgery, China-Japan Union Hospital, Jilin University, Changchun, China
| | - Chaoyuan Li
- Departments of Orthopedics Surgery, China-Japan Union Hospital, Jilin University, Changchun, China
| | - Bin Song
- Departments of Gastrointestinal Colorectal Anus Surgery, China-Japan Union Hospital, Jilin University, Changchun, China
| | - Defeng Song
- Departments of Gastrointestinal Colorectal Anus Surgery, China-Japan Union Hospital, Jilin University, Changchun, China,Correspondence: Defeng Song Ye Feng
| | - Ye Feng
- Departments of Gastrointestinal Colorectal Anus Surgery, China-Japan Union Hospital, Jilin University, Changchun, China,Correspondence: Defeng Song Ye Feng
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7
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Fedidat R, Elia A, Hershko A, Fridlender Z. Recurrent haemoptysis: a rare diagnosis of kaposiform lymphangiomatosis and review of literature. BMJ Case Rep 2022; 15:e250825. [PMID: 36171013 PMCID: PMC9528592 DOI: 10.1136/bcr-2022-250825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare clinicopathological entity among lymphatic anomalies. The main involved sites are the mediastinum and the lungs but the disease can also affect multiple extrathoracic organs. Little is known about the pathophysiology, the natural history, the treatment response and the long-term outcome of this disorder. KLA is typically diagnosed in childhood. We present here the case of an adult man with 13 years recurrent episodes of haemoptysis who was finally found to suffer from KLA. Following this, we present a comprehensive review of the literature.
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Affiliation(s)
| | - Anna Elia
- Pathology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Alon Hershko
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Clinical Immunology, Hadassah Medical Center, Jerusalem, Israel
| | - Zvi Fridlender
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Pulmonology, Hadassah Medical Center, Jerusalem, Israel
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8
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Perez-Atayde AR, Debelenko L, Al-Ibraheemi A, Eng W, Ruiz-Gutierrez M, O'Hare M, Croteau SE, Trenor CC, Boyer D, Balkin DM, Barclay SF, Hsi Dickie B, Liang MG, Chaudry G, Alomari AI, Mulliken JB, Adams DM, Kurek KC, Fishman SJ, Kozakewich HPW. Kaposiform Lymphangiomatosis: Pathologic Aspects in 43 Patients. Am J Surg Pathol 2022; 46:963-976. [PMID: 35385405 DOI: 10.1097/pas.0000000000001898] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Kaposiform lymphangiomatosis is an uncommon generalized lymphatic anomaly with distinctive clinical, radiologic, histopathologic, and molecular findings. Herein, we document the pathology in 43 patients evaluated by the Boston Children's Hospital Vascular Anomalies Center from 1999 to 2020. The most frequent presentations were respiratory difficulty, hemostatic abnormalities, and a soft tissue mass. Imaging commonly revealed involvement of some combination of mediastinal, pulmonary, pleural, and pericardial compartments and most often included spleen and skeleton. Histopathology was characterized by dilated, redundant, and abnormally configured lymphatic channels typically accompanied by dispersed clusters of variably canalized, and often hemosiderotic, spindled lymphatic endothelial cells that were immunopositive for D2-40, PROX1, and CD31. An activating lesional NRAS variant was documented in 9 of 10 patients. The clinical course was typically aggressive, marked by hemorrhage, thrombocytopenia, diminished fibrinogen levels, and a mortality rate of 21%.
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Affiliation(s)
| | - Larisa Debelenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | | | | | - Melisa Ruiz-Gutierrez
- Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute
| | | | - Stacy E Croteau
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - Cameron C Trenor
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | | | | | - Sarah F Barclay
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | - Ahmad I Alomari
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | | | - Denise M Adams
- Division of Oncology, Department of Pediatrics, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Kyle C Kurek
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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9
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Kobialka P, Sabata H, Vilalta O, Gouveia L, Angulo-Urarte A, Muixí L, Zanoncello J, Muñoz-Aznar O, Olaciregui NG, Fanlo L, Esteve-Codina A, Lavarino C, Javierre BM, Celis V, Rovira C, López-Fernández S, Baselga E, Mora J, Castillo SD, Graupera M. The onset of PI3K-related vascular malformations occurs during angiogenesis and is prevented by the AKT inhibitor miransertib. EMBO Mol Med 2022; 14:e15619. [PMID: 35695059 PMCID: PMC9260211 DOI: 10.15252/emmm.202115619] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 12/15/2022] Open
Abstract
Low‐flow vascular malformations are congenital overgrowths composed of abnormal blood vessels potentially causing pain, bleeding and obstruction of different organs. These diseases are caused by oncogenic mutations in the endothelium, which result in overactivation of the PI3K/AKT pathway. Lack of robust in vivo preclinical data has prevented the development and translation into clinical trials of specific molecular therapies for these diseases. Here, we demonstrate that the Pik3caH1047R activating mutation in endothelial cells triggers a transcriptome rewiring that leads to enhanced cell proliferation. We describe a new reproducible preclinical in vivo model of PI3K‐driven vascular malformations using the postnatal mouse retina. We show that active angiogenesis is required for the pathogenesis of vascular malformations caused by activating Pik3ca mutations. Using this model, we demonstrate that the AKT inhibitor miransertib both prevents and induces the regression of PI3K‐driven vascular malformations. We confirmed the efficacy of miransertib in isolated human endothelial cells with genotypes spanning most of human low‐flow vascular malformations.
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Affiliation(s)
- Piotr Kobialka
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Helena Sabata
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Odena Vilalta
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Leonor Gouveia
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain.,Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - Ana Angulo-Urarte
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Laia Muixí
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Jasmina Zanoncello
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Oscar Muñoz-Aznar
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Nagore G Olaciregui
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Lucia Fanlo
- 3D Chromatin Organization, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Anna Esteve-Codina
- CNAG-CRG, Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Cinzia Lavarino
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Biola M Javierre
- 3D Chromatin Organization, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Veronica Celis
- Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Carlota Rovira
- Department of Pathology, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Susana López-Fernández
- Department of Plastic Surgery, Hospital de la Santa Creu i de Sant Pau, Barcelona, Spain
| | - Eulàlia Baselga
- Department of Dermatology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jaume Mora
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Sandra D Castillo
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Mariona Graupera
- Endothelial Pathobiology and Microenvironment, Josep Carreras Leukaemia Research Institute, Barcelona, Spain.,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
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10
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Nozawa A, Ozeki M, Yasue S, Endo S, Noguchi K, Kanayama T, Tomita H, Aoki Y, Ohnishi H. Characterization of kaposiform lymphangiomatosis tissue-derived cells. Pediatr Blood Cancer 2021; 68:e29086. [PMID: 33913609 DOI: 10.1002/pbc.29086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/22/2021] [Accepted: 04/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a recently characterized systemic lymphatic anomaly. Activation of RAS/MAPK and PI3K/AKT/mTOR pathways may affect KLA pathogenesis, but the cellular basis of KLA is unclear. Abnormal-spindle endothelial cells that express lymphatic endothelial cell (LEC) markers are characteristic of KLA histopathology. This study evaluated patient-derived KLA cells to establish their morphological and biological characteristics. PROCEDURE We established cell lines from primary KLA tissues of two patients with KLA and examined their morphological and functional characteristics, messenger RNA and protein expression profiles, gene mutations, and responses to inhibitors of the RAS/MAPK and PI3K/AKT/mTOR pathways. RESULTS Both KLA cell lines showed spindle-shaped morphology, stained positive for podoplanin (PDPN), and exhibited impaired tube-formation properties. They expressed LEC marker PDPN and mesenchymal stem cell markers (CD90, CD105) in the absence of endothelial cell markers (CD34, CD31, VWF), per real-time polymerase chain reaction. Both mTOR inhibitor rapamycin and MEK inhibitor trametinib inhibited growth of the two cell lines. A NRAS p.Q61R variant was found in one of two independent KLA tissue samples, but not in the KLA cells (per targeted next-generation sequencing); and KLA cells with this variant had elevated AKT phosphorylation levels. ERK phosphorylation levels were undetectable in both KLA cell lines. CONCLUSIONS Inhibition of the RAS/MAPK and PI3K/AKT/mTOR pathways may represent potential therapeutic targets in KLA. These patient-derived KLA cell lines will be useful research tools to elucidate KLA etiology, and could pave the way for basic, translational, and preclinical studies of this disease.
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Affiliation(s)
- Akifumi Nozawa
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan.,Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kei Noguchi
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tomohiro Kanayama
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
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11
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Zhou J, Yang K, Chen S, Ji Y. Sirolimus in the treatment of kaposiform lymphangiomatosis. Orphanet J Rare Dis 2021; 16:260. [PMID: 34103076 PMCID: PMC8186093 DOI: 10.1186/s13023-021-01893-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA), which is a new subtype of generalized lymphatic anomaly, is a rare disease with a poor prognosis. Currently, there is no standard treatment due to the poor understanding of KLA. Sirolimus, which is an inhibitor of mammalian target of rapamycin, has been shown to have promising potential in the treatment of complicated vascular anomalies. The aim of this study was to introduce the use of sirolimus for the treatment of KLA and to highlight the challenges of managing this refractory disease. RESULTS We reported seven patients with KLA who received sirolimus therapy in our center. Combined with previously reported cases, 58.3% achieved a partial response, 25.0% had stable disease, and 16.7% experienced disease progression. No severe sirolimus-related adverse events occurred during treatment. CONCLUSIONS This study suggests that sirolimus is currently an option for the treatment of KLA, and it is hoped that more specific therapies will be developed in the future. Rapid advances in basic science and clinical practice may facilitate the development of important new treatments for KLA.
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Affiliation(s)
- Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
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12
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Kalwani NM, Rockson SG. Management of lymphatic vascular malformations: A systematic review of the literature. J Vasc Surg Venous Lymphat Disord 2021; 9:1077-1082. [PMID: 33540133 DOI: 10.1016/j.jvsv.2021.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lymphatic malformations (LM) are common congenital vascular lesions, most often diagnosed at birth. They deform local anatomy and can be life-threatening if they compress the aerodigestive tract or other vital structures. Significant progress has been made in the treatment of LMs in the past 20 years. We conducted a systematic review of the literature on the management of LMs. METHODS On September 21, 2020, we searched PubMed/MEDLINE for studies published from 2000 to 2020 reporting outcomes of invasive and pharmacologic treatment of LMs. RESULTS A total of 251 studies met the eligibility criteria. Surgery has continued to be a mainstay in the management of LMs, especially in the treatment of microcystic and mixed lesions. Sclerotherapy has emerged as a first-line treatment of macrocystic LMs and as an adjunctive therapy used in combination with surgery for other lesions. Sirolimus, a strong inhibitor of mTOR (mechanistic target of rapamycin), has shown tremendous promise in the treatment of LMs, as both an oral and a topical agent. Recent investigations have shown the potential of targeted small molecule modulators of cellular pathways in the treatment of LMs. CONCLUSIONS Multiple invasive and pharmacologic therapies have been shown to be effective in the treatment of LMs. Future research should focus on rigorous, prospective comparisons of these treatment modalities.
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Affiliation(s)
- Neil M Kalwani
- Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Stanley G Rockson
- Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif.
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13
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Abstract
Lymphangioma is a common type of congenital vascular disease in children with a broad spectrum of clinical manifestations. The current classification of lymphangioma by International Society for the Study of Vascular Anomalies is largely based on the clinical manifestations and complications and is not sufficient for selection of therapeutic strategies and prognosis prediction. The clinical management and outcome of lymphangioma largely depend on the clinical classification and the location of the disease, ranging from spontaneous regression with no treatment to severe sequelae even with comprehensive treatment. Recently, rapid progression has been made toward elucidating the molecular pathology of lymphangioma and the development of treatments. Several signaling pathways have been revealed to be involved in the progression and development of lymphangioma, and specific inhibitors targeting these pathways have been investigated for clinical applications and clinical trials. Some drugs already currently in clinical use for other diseases were found to be effective for lymphangioma, although the mechanisms underlying the anti-tumor effects remain unclear. Molecular classification based on molecular pathology and investigation of the molecular mechanisms of current clinical drugs is the next step toward developing more effective individualized treatment of children with lymphangioma with reduced side effects.
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Affiliation(s)
- Xiaowei Liu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Cheng Cheng
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Kai Chen
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Yeming Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
| | - Zhixiang Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
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14
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Foster JB, Li D, March ME, Sheppard SE, Adams DM, Hakonarson H, Dori Y. Kaposiform lymphangiomatosis effectively treated with MEK inhibition. EMBO Mol Med 2020; 12:e12324. [PMID: 32894644 PMCID: PMC7539180 DOI: 10.15252/emmm.202012324] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 01/10/2023] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare lymphatic anomaly primarily affecting the mediastinum with high mortality rate. We present a patient with KLA and significant disease burden harboring a somatic point mutation in the Casitas B lineage lymphoma (CBL) gene. She was treated with MEK inhibition with complete resolution of symptoms, near-complete resolution of lymphatic fluid burden, and remodeling of her lymphatic system. While patients with KLA have been reported to harbor mutations in NRAS, here we report for the first time a causative mutation in the CBL gene in a patient with KLA, successfully treated with Ras pathway inhibition.
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Affiliation(s)
- Jessica B Foster
- Division of OncologyChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Dong Li
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Michael E March
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Sarah E Sheppard
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Divisions of Human Genetics and Pulmonary MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Denise M Adams
- Vascular Anomalies CenterBoston Children's HospitalBostonMAUSA
| | - Hakon Hakonarson
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Divisions of Human Genetics and Pulmonary MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Yoav Dori
- Center for Lymphatic Imaging and InterventionsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
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15
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Blei F. Update April 2020. Lymphat Res Biol 2020. [DOI: 10.1089/lrb.2020.29083.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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16
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Blei F. Update August 2019. Lymphat Res Biol 2019. [DOI: 10.1089/lrb.2019.29068.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Tole S, Price V, Pope E, Powell J, David M, Zwicker K, Kendrick V, Malic C, John PR, Somers GR, Dubois J, Brandão LR. Abnormal hemostasis in children with vascular anomalies, part I: Thrombocytopenias among different vascular anomalies. Thromb Res 2019; 196:626-634. [PMID: 31221393 DOI: 10.1016/j.thromres.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/31/2019] [Accepted: 06/09/2019] [Indexed: 12/18/2022]
Abstract
Long before the classification of vascular anomalies from the International Society for the Study of Vascular Anomalies (ISSVA) provided a framework to differentiate vascular anomalies, otherwise known as vascular birthmarks, it was recognized that patients with such lesions can present with acute life-threatening hemostatic and/or thrombotic complications, as well as chronic long-standing bleeding or thrombotic issues. Scenarios such as a rapidly growing vascular lesion with severe acute thrombocytopenia, a visceral hemorrhagic lesion, a lesion associated with repetitive and painful superficial thrombosis, and cases of unprovoked or post-procedural fatal pulmonary embolism highlight the wide spectrum of manifestations of abnormal coagulation in patients with vascular anomalies. The separation of vascular anomalies into two distinct groups, vascular tumors and vascular malformations, was followed by the characterization that their respective coagulopathies were due to either a derangement of platelets or to a disequilibrium of the patient's coagulation/fibrinolytic process. This configuration of coagulopathies will be the foundation for this two-chapter review series. In the initial review, coagulopathies where thrombocytopenia is the main feature will be characterized, whereas the second review will focus on vascular malformations that have a coagulation disorder secondary to some degree of coagulation consumption and/or fibrinolytic pathway derangement.
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Affiliation(s)
- Soumitra Tole
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Victoria Price
- Department of Paediatrics, Division of Haematology-Oncology, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Elena Pope
- Department of Paediatrics, Section of Dermatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Julie Powell
- Department of Pediatrics, Division of Dermatology, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Michèle David
- Department of Pediatrics, Division of Hematology, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Kelley Zwicker
- Department of Paediatrics, Division of Community Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Victoria Kendrick
- Department of Pediatrics, Division of Community Pediatrics, Calgary, AB, Canada
| | - Claudia Malic
- Division of Plastic Surgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Philip R John
- Department of Diagnostic Imaging, Division of Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gino R Somers
- Department of Paediatric Laboratory Medicine, Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Josée Dubois
- Department of Medical Imaging, CHU Sainte-Justine Mother and Child University Hospital Center, University of Montreal, Montreal, QC, Canada
| | - Leonardo R Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
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