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Huo M, Zhang C, Li L, Xin J, Li X, Zhang Y, Zhang M, Sun Y, Sun L, Wang R, Yue Y. The application of non-enhanced magnetic resonance thoracic ductography combined with magnetic resonance abdominopelvic scanning in the diagnosis of chylous leakage of the female reproductive system. BMC Med Imaging 2025; 25:146. [PMID: 40319262 PMCID: PMC12049049 DOI: 10.1186/s12880-025-01689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Accepted: 04/24/2025] [Indexed: 05/07/2025] Open
Abstract
OBJECTIVE To explore the value of non-enhanced magnetic resonance thoracic ductography (NMRTD) combined with MR abdominopelvic scanning in the diagnosis of chylous leakage of the female reproductive system. METHODS A retrospective analysis was conducted on the multimodal imaging data from non-enhanced magnetic resonance thoracic ductography (NMRTD), direct lymphangiography (DLG), and abdominopelvic magnetic resonance imaging (MRI) for 18 female patients with reproductive system chylous leakage. Among these patients, 7 had vaginal chylous leakage, 10 had vulvar cutaneous chylous leakage, and 1 had both conditions.The rate of successful visualization of the thoracic duct, the consistency of the drainage directions of the outlet of the thoracic duct, and the degree of visualization of each segment of the thoracic duct by NMRTD and DLG were analyzed. A retrospective analysis was performed on the abnormal manifestations of abdominopelvic MR. RESULTS NMRTD had a significant advantage over DLG in terms of successful visualization of the thoracic duct (94.4% vs. 66.7%, P = 0.035). The display of the drainage directions in the outlet area of the thoracic duct by the two methods showed excellent consistency (kappa value = 0.815) in 12 patients whose outlet areas were visualized by both methods. The degrees of visualization of the upper, middle, and lower segments of the thoracic duct in the NMRTD group were significantly greater than those in the DLG group (P values were 0.02, 0.00 and 0.00, respectively). All 18 patients (100%) showed dilatation of the lymph vessels in the pelvic cavity and retroperitoneum on abdominopelvic MR and DLG as well as pelvic perineal reflux or leakage on DLG. MR revealed multiple-site abnormalities that could not be detected by DLG, including multiple long T1 and long T2 lesions of the spleen in 8 patients (44.4%), of the subcutaneous in 7 patients (38.9%), of the bone in 6 patients (33.3%), perineal lymphedema in 18 patients (100%), and abdominopelvic effusion in 10 patients (55.6%). CONCLUSION NMRTD combined with abdominopelvic MR has advantages in comprehensively evaluating the thoracic duct and multiple systemic abnormalities in patients with chylous leakage of the female reproductive system.
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Affiliation(s)
- Meng Huo
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Chunyan Zhang
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Ling Li
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Jianfeng Xin
- Department of Lymph Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xingpeng Li
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Yimeng Zhang
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Mingxia Zhang
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Ying Sun
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Lei Sun
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China
| | - Rengui Wang
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China.
| | - Yunlong Yue
- Department of Medical Imaging, Beijing Shijitan Hospital, Capital Medical University, Yangfangdian Tieyi Road No.10, Haidian District, Beijing, 100038, China.
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Klein WM, Papaioannou G. Magnetic resonance imaging of fetal vascular malformations. Pediatr Radiol 2025; 55:633-643. [PMID: 38980353 PMCID: PMC11982143 DOI: 10.1007/s00247-024-05983-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/17/2024] [Accepted: 06/22/2024] [Indexed: 07/10/2024]
Abstract
Vascular anomalies develop during fetal life and can be detected on prenatal ultrasonography and fetal magnetic resonance imaging. Diagnosis of lymphatic, venous, and arteriovenous malformations, as well as congenital hemangiomas and other congenital vascular tumors, may be challenging. The benign vascular anomalies may be difficult to differentiate from malignancies with a similar appearance. In this manuscript, we present a succinct overview of the congenital vascular anomalies that may present in fetal or neonatal life.
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Affiliation(s)
- Willemijn M Klein
- Department of Medical Imaging, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands.
- Expertise Center for Hemangiomas and Congenital Vascular Malformations Nijmegen (Hecovan), Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Georgia Papaioannou
- Paediatric Radiology Department, Mitera Maternity and Children's Hospital, Athens, Greece
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Zhou Z, Qiu T, Zhou J, Zhang Z, Gong X, Zhang X, Lan Y, Yang C, Zhang Y, Xiang S, Ji Y. Clinical features and current management experience in Gorham-Stout disease: a systematic review. Orphanet J Rare Dis 2025; 20:134. [PMID: 40102890 PMCID: PMC11921740 DOI: 10.1186/s13023-025-03649-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Accepted: 03/03/2025] [Indexed: 03/20/2025] Open
Abstract
BACKGROUND Gorham-Stout disease (GSD) is a rare complex lymphatic malformation. Since its initial description in 1838, only approximately 400 patients have been documented. There is currently no consensus on the diagnostic criteria or treatment options for GSD. The objective of this study was to review the clinical characteristics of patients with GSD and determine the current diagnostic and treatment models. METHODS A comprehensive search of the PubMed, Web of Science, Embase, and Cochrane Library databases was conducted to identify all relevant literature on GSD published over the decade from 2013 to 2023. The clinical information extracted from these publications was analyzed. RESULTS A total of 206 patients with GSD were included in the study, comprising 119 males, 81 females and 6 patients with unknown sex. The age of onset of patients was widely distributed, ranging from 0 to 77 years old. However, the majority of cases occurred in childhood (50.7%). Fifteen patients (10.3%) exhibited an onset age of less than 1 year. The average time from the onset of symptoms to diagnosis was 3.5 years. The number of patients with osteolysis in the axial bone was greater than that in the appendiceal bone (P < 0.05), and the number of patients with multiple osteolytic lesions was greater than that with single osteolytic lesions (77.2% vs. 22.8%). In general, GSD was more likely to occur in the spine (46.1%), ribs (28.6%), hip (23.3%), femur (18.4%), mandible (15.5%) and humerus (15.0%). Pain was the most common symptom, with 68.4% of patients reporting pain in the lesion area. Surgery (66.9%) and bisphosphonates (56.9%) are still the mainstream treatment methods, with a total of 33 (18.2%) patients receiving sirolimus. Pleural effusion was identified as a risk factor for patient mortality (P < 0.05). CONCLUSIONS GSD is most commonly observed in children, with a slight male predisposition. It commonly manifests as multiple osteolysis of the axial bone, with pain being the most common symptom. The presence of pleural effusion indicates a serious condition that requires close monitoring to prevent mortality. Despite the advent of novel therapeutic modalities, the management of GSD remains an area in need of further investigation.
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Affiliation(s)
- Zilong Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xuepeng Zhang
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Congxia Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yujia Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shanshan Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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McDaniel CG, Fox D, Pastura P, Alharbi S, Huppert SS, Cras TDL. Lyve1-Driven Nras Q61R Causes Edema, Enlarged Lymphatic Vessels, and Hepatic Vascular Defects in Embryonic Mice. Pediatr Blood Cancer 2025; 72:e31492. [PMID: 39723841 DOI: 10.1002/pbc.31492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 10/30/2024] [Accepted: 12/03/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a complex lymphatic anomaly associated with a somatic activating NRAS p.Q61R (NRASQ61R) mutation. KLA is characterized by malformed lymphatic vessels that can lead to effusions and coagulopathy. The goal of this study was to generate an in vivo mouse model to determine if prenatal expression of the NrasQ61R mutation in lymphatic endothelial cells induces disease characteristics found in KLA patients. PROCEDURE A Cre-loxP system was used to conditionally express NrasQ61R in cells expressing lymphatic vessel endothelial hyaluronan receptor 1 (Lyve1), a marker of lymphatic and other types of endothelial cells that starts being expressed at embryonic day (E) 7.5. Because pups did not survive birth, embryos were collected at E14.5, E15.5, and E18.5 for gross analysis, histology and immunostaining, and organ whole-mounts. RESULTS Staining for NRASQ61R demonstrated robust recombination in the NrasQ61R mutant embryos and localization of NrasQ61R at sites of vascular abnormalities. NrasQ61R mutant embryos had significant edema and dysmorphic jugular lymph sacs with abnormal Lyve1-positive cellular masses. The lymphatic vessel network in the back skin of the NrasQ61R mutant embryos had fewer branch points and increased vessel diameter. NrasQ61R mutant embryos had severe hepatic defects characterized by disordered and enlarged vessels. By E18.5, NrasQ61R mutant embryos were dead. CONCLUSIONS Conditional expression of NrasQ61R in Lyve1-positive cells caused edema, abnormal lymphatic development, and hepatic vascular defects in mouse embryos. These findings further support the role of NRASQ61R as a driver of the lymphatic overgrowth, vessel enlargement, and dysfunction in the pathophysiology of KLA.
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Affiliation(s)
- C Griffin McDaniel
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dermot Fox
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Patricia Pastura
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara Alharbi
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stacey S Huppert
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Timothy D Le Cras
- Division of Pulmonary Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Fernandes LM, Griswold-Wheeler D, Tresemer JD, Vallejo A, Vishlaghi N, Levi B, Shapiro A, Scallan JP, Dellinger MT. A single-cell atlas of normal and KRASG12D-malformed lymphatic vessels. JCI Insight 2025; 10:e185181. [PMID: 39874106 PMCID: PMC11949019 DOI: 10.1172/jci.insight.185181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 01/22/2025] [Indexed: 01/30/2025] Open
Abstract
Somatic activating mutations in KRAS can cause complex lymphatic anomalies (CLAs). However, the specific processes that drive KRAS-mediated CLAs have yet to be fully elucidated. Here, we used single-cell RNA sequencing to construct an atlas of normal and KrasG12D-malformed lymphatic vessels. We identified 6 subtypes of lymphatic endothelial cells (LECs) in the lungs of adult wild-type mice (Ptx3, capillary, collecting, valve, mixed, and proliferating). To determine when the LEC subtypes were specified during development, we integrated our data with data from 4 stages of development. We found that proliferating and Ptx3 LECs were prevalent during early lymphatic development and that collecting and valve LECs emerged later in development. Additionally, we discovered that the proportion of Ptx3 LECs decreased as the lymphatic network matured but remained high in KrasG12D mice. We also observed that the proportion of collecting and valve LECs was lower in KrasG12D mice than in wild-type mice. Last, we found that immature lymphatic vessels in young mice were more sensitive to the pathologic effects of KrasG12D than mature lymphatic vessels in older mice. Together, our results expand the current model for the development of the lymphatic system and suggest that KRAS mutations impair the maturation of lymphatic vessels.
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Affiliation(s)
| | | | | | | | - Neda Vishlaghi
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Levi
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Abigail Shapiro
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Joshua P. Scallan
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Michael T. Dellinger
- Hamon Center for Therapeutic Oncology Research, and
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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6
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Alkhulaifat D, Ramirez-Suarez KI, Otero HJ, Rapp JB, Srinivasan AS, Smith CL, Biko DM. Complex lymphatic anomalies. Pediatr Radiol 2025:10.1007/s00247-025-06167-9. [PMID: 39853393 DOI: 10.1007/s00247-025-06167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 12/20/2024] [Accepted: 01/02/2025] [Indexed: 01/26/2025]
Abstract
Complex lymphatic anomalies are unique diseases marked by abnormal lymphatic vessel development and growth. Imaging is crucial in the evaluation and management of complex lymphatic anomalies, with dynamic contrast-enhanced MR lymphangiography emerging as a valuable modality for visualizing abnormal lymphatic structures and informing treatment decisions. This article gives an overview of complex lymphatic anomalies and their management strategies, focusing specifically on generalized lymphatic anomaly, Gorham-Stout disease, Kaposiform lymphangiomatosis, and central conducting lymphatic anomalies. Simple lymphatic diseases are beyond the scope of this review.
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Affiliation(s)
- Dana Alkhulaifat
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | | | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Abhay S Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
- Center for Lymphatic Imaging and Interventions, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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Zhang X, Wang J, Duan S, Yan Y, Wang L. Generalized lymphatic anomaly in a pediatric patient manifesting as a rare presentation of hemorrhagic pleural effusion: a case report. BMC Pediatr 2025; 25:5. [PMID: 39762764 PMCID: PMC11702163 DOI: 10.1186/s12887-024-05350-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 12/20/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND Generalized lymphatic anomaly (GLA) is a rare congenital lymphatic malformation (LM) characterized by multiple infiltrating lymphangiomas in various tissues. Owing to its rarity, information on this disease is obtained mainly through case reports, leading to delayed diagnosis. In this study, we reported a case of generalized lymphatic anomaly in a pediatric patient manifesting as hemorrhagic pleural effusion. CASE PRESENTATION A 6-year-old female presented with abdominal pain, shortness of breath, chronic cough with yellow sputum production, and diminished respiration accompanied by pleural effusion. Imaging revealed significant left-sided pleural effusion with mediastinal involvement, left lung atelectasis, and multiple cystic lesions in both liver and spleen. Thoracoscopic exploration was conducted in response to her active intrathoracic bleeding, which identified a persistently hemorrhagic mass in the left mediastinum. The mass in the left mediastinum was removed, and pathological examination confirmed hyperplasia and expansion of the papillary endothelial cells within the lymphatic vessels. After intensive anti-infection therapy and symptomatic and supportive treatment, the patient's condition improved significantly. The regular outpatient follow-ups were continued until July 2024. Subsequent positron emission tomography (PET)CT at another hospital revealed multiple skeletal lesions in the limbs. Following treatment with sirolimus, no recurrence of pleural effusion was observed, and the patient's condition remained stable. CONCLUSION In patients with generalized lymphatic anomalies (GLAs), involvement of the thoracic cavity may lead to hemorrhagic pleural effusion, thereby broadening the landscape of GLA phenotypic presentations. Furthermore, this case highlights the importance of complete radiological evaluation of susceptible patients with GLA to avoid diagnostic delay in this morbid condition. We also review recently discovered genetic changes underlying lymphatic anomaly development and the progress of treatment.
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Affiliation(s)
- Xuehong Zhang
- Department of Pediatrics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Jiuling Wang
- Department of Pediatrics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Shouxing Duan
- Department of Pediatrics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yongping Yan
- Department of Pediatrics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Libin Wang
- Department of Pediatrics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China.
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Yang C, Qiu T, Yang M, Zhou J, Gong X, Yang K, Zhang Z, Lan Y, Zhang X, Zhou Z, Zhang Y, Xiang S, Chen S, Ji Y. Clinical characteristics and risk factors for acute abdomen in patients with abdominal lymphatic malformations. J Vasc Surg Venous Lymphat Disord 2025; 13:101969. [PMID: 39305949 PMCID: PMC11764771 DOI: 10.1016/j.jvsv.2024.101969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/12/2024] [Accepted: 09/10/2024] [Indexed: 10/28/2024]
Abstract
OBJECTIVE The diagnosis of abdominal lymphatic malformations (ALMs) is often overlooked in clinical practice. However, reports in the literature about ALMs are limited to case reports and series with small sample sizes. This study aimed to review our currently available data to describe the clinical characteristics of ALMs and evaluate the risk factors for acute abdomen caused by ALMs. METHODS We reviewed the records of patients with ALMs who were diagnosed between December 2008 and January 2023 in our institution. The associations between acute abdomen and ALMs were analyzed based on single-factor and multivariate logistic regression analyses. RESULTS This study included 345 patients with pathologically confirmed ALMs, with a slight female predominance of 1:1.4. Approximately 39.1% (135/345) of patients were asymptomatic, and 24.6% (85/345) presented with acute abdomen. Among the ALMs in the cohort, 42.6% (147/345) were retroperitoneal lymphatic malformations (LMs). The maximal lesion dimensions in patients with acute abdomen and nonacute abdomen were 10.0 cm and 7.8 cm, respectively, with no significant difference based on multivariate analyses. Children were more likely to develop acute abdomen than adults were (P = .002; odds ratio, 5.128; 95% confidence interval, 1.835-14.326). ALMs accompanying acute abdomen were more common for lesions involving the small intestinal mesentery (P = .023; odds ratio, 2.926; 95% confidence interval, 1.157-7.400). CONCLUSIONS ALMs are rare with an insidious onset, and retroperitoneal LMs are the most common ALMs, followed by jejunal mesenteric LMs. Our retrospective analysis suggested that young age and small intestinal mesenteric lymphatic malformation are independent risk factors for acute abdomen with ALMs.
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Affiliation(s)
- Congxia Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Min Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Kaiying Yang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, China
| | - Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xuepeng Zhang
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zilong Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yujia Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Shanshan Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China.
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Yuan M, Königs I, Reinshagen K, Ambs JM, Rutkowski S, Kordes UR. Rapid remission of life-threatening chylo-ascites with dabrafenib and trametinib combination in complex lymphatic anomaly with pathogenic somatic BRAF and PIK3CA co-variation. Pediatr Blood Cancer 2024; 71:e31342. [PMID: 39307987 DOI: 10.1002/pbc.31342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/05/2024] [Accepted: 09/09/2024] [Indexed: 10/25/2024]
Affiliation(s)
- Mathias Yuan
- Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ingo Königs
- Pediatric Surgery, AKK Altonaer Kinderkrankenhaus gGmbH, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jan-Malte Ambs
- Department of Pediatric Radiology, Altonaer Kinderkrankenhaus, Hamburg, Germany
| | - Stefan Rutkowski
- Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Uwe R Kordes
- Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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10
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Das K, Sheppard S, Yadav B, Turner JT, Bornhorst M, Siegel AH, Yano JC, Gomez Lobo V. Kaposiform Lymphangiomatosis as a Cause of Vaginal Bleeding & Discharge: A Case Report. J Pediatr Adolesc Gynecol 2024; 37:625-628. [PMID: 38936506 PMCID: PMC11524780 DOI: 10.1016/j.jpag.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/12/2024] [Accepted: 06/16/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Prepubertal vaginal bleeding is a common presentation for pediatric adolescent gynecologists with a broad differential diagnosis that historically may not have included complex lymphatic anomalies. However, given recent consensus criteria and imaging capabilities, this may be a condition that pediatric adolescent gynecologists see more frequently in the future. CASE We present a case of a 5-year-old pre-pubertal girl whose only presenting symptoms of a rare complex lymphatic anomaly was copious vaginal bleeding. After three vaginoscopies, two hysteroscopies, two pelvic MRIs, and a percutaneous ultrasound guided core needle biopsy, this patient was eventually diagnosed with Kaposiform lymphangiomatosis at age 9 years-old, and she is now being treated medically with sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, with improvement in her symptoms. SUMMARY AND CONCLUSION Complex lymphatic anomalies should be considered after initial and secondary workups for pre-pubertal vaginal bleeding or copious vaginal discharge are negative. Furthermore, this case illustrates the value of pelvic MRI in the setting of unknown cause of vaginal bleeding when typical workup is negative.
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Affiliation(s)
- Kirsten Das
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington.
| | - Sarah Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland
| | - Bhupender Yadav
- Pediatric Interventional Radiology, Children's National Hospital, Washington
| | - Joyce Tannenbaum Turner
- Genetics and Metabolism, Children's National Hospital, Rare Disease Institute, Bethesda, Maryland
| | - Miriam Bornhorst
- Pediatric Neurooncology, Children's National Hospital, Washington
| | - Alan H Siegel
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington
| | - Jacqueline C Yano
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington
| | - Veronica Gomez Lobo
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington
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11
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Thamkittikun C, Tovichien P. Clinical approach for pulmonary lymphatic disorders. World J Clin Cases 2024; 12:6020-6026. [PMID: 39328863 PMCID: PMC11326095 DOI: 10.12998/wjcc.v12.i27.6020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/29/2024] Open
Abstract
In this editorial, we discuss the clinical implications of the article "Lymphatic plastic bronchitis and primary chylothorax: A study based on computed tomography lymphangiography" published by Li et al. Pulmonary lymphatic disorders involve abnormalities in the lymphatic tissues within the thoracic cavity. Specifically, pulmonary lymphatic perfusion syndrome describes a condition where the flow of lymphatic fluid in the lungs is redirected towards abnormally widened lymphatic vessels. Clinically, individuals with this syndrome may experience symptoms such as chyloptysis, plastic bronchitis (PB), chylothorax, chylopericardium, and interstitial lung disease. These disorders can be caused by various factors, including PB, chylothorax, and complex lymphatic malformations. Advancements in lymphatic imaging techniques, such as intranodal lymphangiography, computed tomography lymphangiography, and dynamic contrast-enhanced magnetic resonance lymphangiography, have enabled the detection of abnormal lymphatic flow. This has enhanced our understanding of the pathophysiology of these conditions. Additionally, innovative minimally invasive treatments, such as thoracic duct embolization, selective embolization of lymphatic channels, and surgical procedures aim to improve clinical condition of patients and address their dietary needs.
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Affiliation(s)
- Chalisa Thamkittikun
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Prakarn Tovichien
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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12
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Weidner J, Fiedler K, Schulze-Becking M, Sentner CP, Korenke C, Heep A. Case Report: MDFIC gene mutation resulting in central conducting lymphatic anomaly facilitates group A Streptococcus sepsis. Front Pediatr 2024; 12:1367532. [PMID: 39386015 PMCID: PMC11461237 DOI: 10.3389/fped.2024.1367532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 09/09/2024] [Indexed: 10/12/2024] Open
Abstract
Background Central conducting lymphatic anomaly (CCLA) is a heterogeneous disorder characterized by structural anomalies in the main collecting lymphatic vasculature. These anomalies result in chronic chylous leaks, causing issues such as congenital hydrothorax and potentially impairing the normal immune response. Recently, mutations in the MyoD family inhibitor domain-containing (MDFIC) gene have been identified as a cause of CCLA. Group A Streptococcus infections are common, and timely identification of patients at risk for severe complications is crucial. Case presentation Here, we present the case of a 13-year-old female patient with CCLA associated with an MDFIC mutation, who suffered from a severe group A Streptococcus sepsis. Initially, the patient was unresponsive to aggressive fluid resuscitation. Although the course of the sepsis was severe, standardized treatment according to the surviving sepsis campaign proved effective in stabilizing the patient. Discussion The patient's MDFIC mutation may have contributed to the severe clinical course of the sepsis. It is theorized that this mutation affects the function of the immune system both indirectly, by causing CCLA, and directly, by potentially influencing transcriptional activity in immune cells. More research on the effect of MDFIC mutations on immune responses is required.
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Affiliation(s)
- Johannes Weidner
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
- School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Kai Fiedler
- Section of Neonatology and Pediatric Intensive Care, Department of Pediatrics, School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Mechthild Schulze-Becking
- Section of Neonatology and Pediatric Intensive Care, Department of Pediatrics, School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Christiaan Peter Sentner
- Section of Neonatology and Pediatric Intensive Care, Department of Pediatrics, School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Christoph Korenke
- Section of Pediatric Neurology, Department of Pediatrics, School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Axel Heep
- Section of Neonatology and Pediatric Intensive Care, Department of Pediatrics, School VI-School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
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Kothandaraman V, Wisener J, Helgerson PW. Complex lymphatic anomalies: Challenging diagnostic considerations. Clin Case Rep 2024; 12:e8370. [PMID: 38161630 PMCID: PMC10756942 DOI: 10.1002/ccr3.8370] [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: 09/13/2023] [Revised: 11/14/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Diagnosis of complex lymphatic anomalies can be difficult, and biopsies can be associated with significant morbidity. Mediastinal masses with features such as osseous involvement warrant thorough noninvasive evaluation prior to biopsy.
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Affiliation(s)
| | - John Wisener
- University of Virginia Medical CenterCharlottesvilleVirginiaUSA
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14
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Kerr AM, Lin S, Sisk BA. Mental and physical health of adult patients affected by complex vascular anomalies. PATIENT EDUCATION AND COUNSELING 2023; 117:107987. [PMID: 37769517 DOI: 10.1016/j.pec.2023.107987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/14/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE We examined care and communication factors that affect physical and mental health for patients with complex vascular anomalies (VAs). METHODS VA patients (N = 135) completed an online survey with measures of ability to navigate healthcare, quality of information exchange, perceived stigma, and demographic variables. We performed linear regression to determine if these variables were associated with mental and physical health. RESULTS Physical and mental health were associated with information exchange (β = .41, 95% CI=.12 -.69; β = .33, 95% CI=.04 -.62), stigma (β = -.49, 95% CI=-.74 to -.24; β = -.63, 95% CI=-.89 to -.38), and education (β = 4.00, 95% CI=.63 - 7.38; β = 3.44, 95% CI=.06 to 6.82). Ability to navigate healthcare was associated with health outcomes in our bivariate model, but not significant in a multivariate model. CONCLUSION The results underscore the importance of effective information exchange. Poor information exchange was associated with worse physical and mental health. VA patients with lower education levels and higher perceived stigma reported poorer health outcomes and likely face many struggles accessing care. PRACTICE IMPLICATIONS Patient-centered information exchange between clinicians and patients is needed to address unmet information needs. Clinicians can also reduce perceived stigma by validating patients, and should provide resources to reduce disparities related to education.
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Affiliation(s)
- Anna M Kerr
- Department of Primary Care, Ohio University, Dublin, OH, USA.
| | - Sunny Lin
- Informatics Institute, Department of Medicine, Washington University, St. Louis, MO, USA
| | - Bryan A Sisk
- Division of Hematology/Oncology, Washington University, St. Louis, MO, USA; Bioethics Research Center, Washington University, St. Louis, MO, USA
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15
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Navarro M, Allemang-Trivalle A, Leducq S, Jonville-Bera AP, Maurier A, Zejli T, Edée AE, Harchaoui E, Giraudeau B, Maruani A. Indication for a Pneumocystis Prophylaxis Therapy in Patients with Vascular Anomalies Treated with PIK3/AKT/mTOR Pathway Inhibitors: Experts' Opinion and Systematic Review from the Literature. Dermatology 2023; 239:942-951. [PMID: 37793356 DOI: 10.1159/000533675] [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: 11/23/2022] [Accepted: 08/14/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Vascular anomalies (VAs) are increasingly being treated with PI3K/AKT/mTOR pathway inhibitors. These drugs have immunosuppressive properties and thus theoretically overexpose patients to opportunistic infections, especially Pneumocystis jirovecii pneumonia (PJP). PJP prophylaxis use lacks consensus. We aimed to investigate the prevalence of PJP in patients receiving mTOR/PI3K/AKT inhibitors for VAs and determine any indication for pneumocystis prophylaxis in this population. METHODS The study was conducted in 2 parts: (1) we sent a survey to a panel of international experts of VAs asking about their use of pneumocystis prophylaxis drugs and (2) we performed a systematic review of the literature of all published cases of patients receiving these drugs for VA to estimate the prevalence of PJP in this population. RESULTS Answers from 68 experts were analyzed: 21 (30.9%) answered they always add PJP prophylaxis when prescribing mTOR inhibitors, 20 (29.4%) case-by-case, and 27 (39.7%) never. For the systematic review, among 3,053 reports screened, 217 were included involving 1,189 patients (1,143 received sirolimus, 38 everolimus, 4 alpelisib, 4 miransertib). Among the 1,189 cases, 2 (0.2%) PJP were reported: one under sirolimus and one under everolimus. Thus, the prevalence of PJP was estimated at 0.88 cases/1,000 patients under sirolimus (95% CI: -0.84 to 2.59) and 26.31 cases/1,000 under everolimus (95% CI: -24.58 to 77.18). Patients with PJP never received prophylaxis drugs. We found no PJP cases under alpelisib and miransertib. PJP prophylaxis was given in 218 (18.3%) cases, more frequently for children (91.3 vs. 77.2% in the non-prophylaxis group, p = 0.012), mostly trimethoprim-sulfamethoxazole (186 patients, 85.3%). CONCLUSION Our study shows that even if PJP is a rare event, it may occur in patients with VAs treated with an mTOR inhibitor. Although our results cannot allow for revising guidelines, prophylaxis with TMP-SMX might be appropriate for a subgroup of patients with risk factors for PJP.
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Affiliation(s)
- Maxime Navarro
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
| | | | - Sophie Leducq
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
| | - Annie-Pierre Jonville-Bera
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
- CHRU Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Anaïs Maurier
- CHRU Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Tarik Zejli
- CHRU Tours, Clinical Investigation Center of Tours, INSERM 1415, Bretonneau Hospital, Tours, France
| | - Afi-Emiliène Edée
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
| | - Emilie Harchaoui
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
| | - Bruno Giraudeau
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
- CHRU Tours, Clinical Investigation Center of Tours, INSERM 1415, Bretonneau Hospital, Tours, France
| | - Annabel Maruani
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
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16
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Cohen-Cutler S, Blatt J, Bayliff S, Iacobas I, Hammill A, Sisk BA. Vascular Anomalies Care in the United States: A Cross-Sectional National Survey. J Pediatr 2023; 261:113579. [PMID: 37353145 DOI: 10.1016/j.jpeds.2023.113579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To characterize the current distribution, composition, and practice patterns of multidisciplinary vascular anomalies (VAs) teams in the US. STUDY DESIGN This is a cross-sectional survey of children's hospitals in the US offering VAs care. We approached 142 children's hospitals that provided care for VAs via email. The survey evaluated VA clinic location, medical staffing, research participation, and treatments offered. The survey was administered between October 2021 and July 2022. RESULTS Participants from 95 eligible hospitals responded to the survey (response rate = 67%). Large areas of the Midwest and Northwest US had no available multidisciplinary VA teams or clinics. Most respondents worked at academic centers (89%), with 66% at a freestanding children's hospital, and 56% reported having a multidisciplinary clinic. Most common physician participants in clinic included hematology-oncology (91%), interventional radiology (87%), dermatology (85%), plastic surgery (81%), and otolaryngology (74%). Only 38% of programs included medical geneticists. Smaller hospitals had fewer medical and ancillary staff and offered fewer therapeutic options. Research was available at most larger institutions (69%) but less commonly at smaller hospitals (34%). CONCLUSIONS Major portions of the US lack multidisciplinary VA care. Furthermore, VA programs vary in composition and geneticists are absent from the majority of programs. These findings should inform efforts to address disparate access and develop standards of care for multidisciplinary VA care in the US.
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Affiliation(s)
- Sally Cohen-Cutler
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Julie Blatt
- Division of Pediatric Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sherry Bayliff
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Kentucky Chandler Medical Center, Lexington, KY
| | - Ionela Iacobas
- Department of Pediatrics, Texas Children's Vascular Anomalies Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adrienne Hammill
- Division of Hematology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, Cancer and Blood Diseases Institute, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Fernandes LM, Tresemer J, Zhang J, Rios JJ, Scallan JP, Dellinger MT. Hyperactive KRAS/MAPK signaling disrupts normal lymphatic vessel architecture and function. Front Cell Dev Biol 2023; 11:1276333. [PMID: 37842094 PMCID: PMC10571159 DOI: 10.3389/fcell.2023.1276333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Complex lymphatic anomalies (CLAs) are sporadically occurring diseases caused by the maldevelopment of lymphatic vessels. We and others recently reported that somatic activating mutations in KRAS can cause CLAs. However, the mechanisms by which activating KRAS mutations cause CLAs are poorly understood. Here, we show that KRASG12D expression in lymphatic endothelial cells (LECs) during embryonic development impairs the formation of lymphovenous valves and causes the enlargement of lymphatic vessels. We demonstrate that KRASG12D expression in primary human LECs induces cell spindling, proliferation, and migration. It also increases AKT and ERK1/2 phosphorylation and decreases the expression of genes that regulate the maturation of lymphatic vessels. We show that MEK1/2 inhibition with the FDA-approved drug trametinib suppresses KRASG12D-induced morphological changes, proliferation, and migration. Trametinib also decreases ERK1/2 phosphorylation and increases the expression of genes that regulate the maturation of lymphatic vessels. We also show that trametinib and Cre-mediated expression of a dominant-negative form of MEK1 (Map2k1 K97M) suppresses KRASG12D-induced lymphatic vessel hyperplasia in embryos. Last, we demonstrate that conditional knockout of wild-type Kras in LECs does not affect the formation or function of lymphatic vessels. Together, our data indicate that KRAS/MAPK signaling must be tightly regulated during embryonic development for the proper development of lymphatic vessels and further support the testing of MEK1/2 inhibitors for treating CLAs.
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Affiliation(s)
- Lorenzo M. Fernandes
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jeffrey Tresemer
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jing Zhang
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, United States
| | - Jonathan J. Rios
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, United States
- McDermott Center for Human Growth and Development, Dallas, TX, United States
| | - Joshua P. Scallan
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Michael T. Dellinger
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, United States
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18
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Sainz Sánchez J, Aranaz Murillo A, Andrés Villares E, García Maroto J. Generalized lymphatic anomaly in adult patients: An eminently radiological diagnosis. RADIOLOGIA 2023; 65:481-485. [PMID: 37758338 DOI: 10.1016/j.rxeng.2022.08.004] [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: 07/11/2022] [Accepted: 08/09/2022] [Indexed: 10/03/2023]
Abstract
Generalized lymphatic anomaly (GLA) is an uncommon congenital disease secondary to the proliferation of lymphatic vessels in any organ except the central nervous system. GLA has a wide spectrum of clinical and radiological presentations, among which osteolytic lesions are the most widespread, being the ribs the most commonly affected bone. GLA is diagnosed mainly in children and young adults; nevertheless, on rare occasions it can remain asymptomatic and be detected incidentally in older patients. We present an unusual case of GLA in an asymptomatic 54-year-old man who had atypically distributed, purely cystic bone lesions on CT; measuring the Hounsfield (HU) of these lesions enabled us to suspect GLA. This suspicion was confirmed with MRI, PET/CT, CT-guided fine-needle aspiration biopsy, and fluoroscopy-guided percutaneous vertebral biopsy. After surgical resection of one of the lesions, histologic study provided the definitive diagnosis.
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Affiliation(s)
- J Sainz Sánchez
- Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - A Aranaz Murillo
- Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - E Andrés Villares
- Servicio de Urgencias y Medicina Familiar y Comunitaria, Hospital Hernest Lluch, Zaragoza, Spain
| | - J García Maroto
- Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Allemang-Trivalle A, Leducq S, Maruani A, Giraudeau B. Designs used in published therapeutic studies of rare superficial vascular anomalies: a systematic literature search. BMC Med Res Methodol 2023; 23:196. [PMID: 37648985 PMCID: PMC10466846 DOI: 10.1186/s12874-023-02017-0] [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: 04/07/2022] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Rare superficial vascular anomalies represent a wide range of diseases. Their management is difficult given the broad spectrum and the lack of clinical trials assessing treatment efficacy. A randomized clinical trial of vascular anomalies is difficult because of the rarity of the diseases and is enhanced by the population of interest often being children. Therefore, suitable designs are needed. We conducted a methodological systematic literature search to identify designs implemented for investigating the treatment of rare superficial vascular anomalies. METHODS We conducted a literature search on January 25, 2021, of the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, ClinicalTrials.gov and European Union Clinical Trials Register databases. This systematic methodological literature search was registered at the Prospective Register of Systematic Reviews (PROSPERO: CRD42021232449). Randomized and non-randomized studies were included if they met the following criteria: were prospective studies of rare superficial vascular anomaly therapies, dealt with humans (adults and children) and were published in English from 2000. We excluded case reports/case series reporting fewer than 10 patients, reviews, retrospective studies, animal studies, studies of systemic or common vascular anomalies and non-therapeutic studies. We did not assess risk of bias in the included studies because our review was a methodological one focused on the design used. The review provided a descriptive analysis of relevant features of eligible research studies. RESULTS From 2046 articles identified, we included 97 studies (62 reports and 35 ongoing studies): 25 randomized controlled studies, 7 non-randomized comparative studies, 64 prospective cohorts and 1 case series. Among the 32 comparative studies included, 21 used a parallel-group design. The 11 other studies used different designs such as cross-over, randomized placebo phase, delayed-start, within-person, or challenge-dechallenge-rechallenge or used a historical control group or an observational run-in period. CONCLUSIONS Our systematic literature search highlights the lack of randomized control trials in superficial vascular anomalies due to the rarity of patients and their heterogeneity. New designs are emerging and can overcome the limitations of testing treatments in parallel groups.
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Affiliation(s)
- Aude Allemang-Trivalle
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France.
- INSERM CIC1415, CHRU de Tours, Tours, France.
| | - Sophie Leducq
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
- Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), CHRU de Tours, Tours, France
| | - Annabel Maruani
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
- INSERM CIC1415, CHRU de Tours, Tours, France
- Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), CHRU de Tours, Tours, France
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
- INSERM CIC1415, CHRU de Tours, Tours, France
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20
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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21
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Rogerson D, Alkelai A, Giordano J, Pantrangi M, Hsiao MC, Nhan-Chang CL, Motelow JE, Aggarwal V, Goldstein D, Wapner R, Shawber CJ. Investigation into the genetics of fetal congenital lymphatic anomalies. Prenat Diagn 2023; 43:703-716. [PMID: 36959127 PMCID: PMC10330091 DOI: 10.1002/pd.6345] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/10/2023] [Accepted: 03/12/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE Congenital lymphatic anomalies (LAs) arise due to defects in lymphatic development and often present in utero as pleural effusion, chylothorax, nuchal and soft tissue edema, ascites, or hydrops. Many LAs are caused by single nucleotide variants, which are not detected on routine prenatal testing. METHODS Demographic data were compared between two subcohorts, those with clinically significant fetal edema (CSFE) and isolated fetal edema. A targeted variant analysis of LA genes was performed using American College of Medical Genetics criteria on whole exome sequencing (WES) data generated for 71 fetal edema cases who remained undiagnosed after standard workup. RESULTS CSFE cases had poor outcomes, including preterm delivery, demise, and maternal preeclampsia. Pathogenic and likely pathogenic variants were identified in 7% (5/71) of cases, including variants in RASopathy genes, RASA1, SOS1, PTPN11, and a novel PIEZO1 variant. Variants of uncertain significance (VOUS) were identified in 45% (32/71) of cases. In CSFEs, VOUS were found in CELSR1, EPHB4, TIE1, PIEZO1, ITGA9, RASopathy genes, SOS1, SOS2, and RAF1. CONCLUSIONS WES identified pathogenic and likely pathogenic variants and VOUS in LA genes in 51% of fetal edema cases, supporting WES and expanded hydrops panels in cases of idiopathic fetal hydrops and fluid collections.
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Affiliation(s)
- Daniella Rogerson
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Anna Alkelai
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Giordano
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Madhulatha Pantrangi
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Meng-Chang Hsiao
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Joshua E. Motelow
- Department of Pediatrics, Columbia University Vagelos College of Physicians andSurgeons, New York, New York, USA
| | - Vimla Aggarwal
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - David Goldstein
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ron Wapner
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Carrie J. Shawber
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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22
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Qiu T, Li Y, Gong X, Zhou J, Yang K, Zhang X, Zhang Z, Lan Y, Hu F, Peng Q, Zhang Y, Kong F, Chen S, Ji Y. Oral antibiotic prophylaxis for infection in patients with vascular anomalies receiving sirolimus treatment: a multicenter retrospective study. Orphanet J Rare Dis 2023; 18:121. [PMID: 37221564 PMCID: PMC10207744 DOI: 10.1186/s13023-023-02740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES Patients with vascular anomalies (VAs) who receive oral sirolimus may be at high risk of infectious complications. Antibiotic prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) has been advocated. However, there have been few evidence-based analyses on this topic. This study assessed the effect of prophylactic TMP-SMZ on the incidence of infections in VA patients receiving sirolimus monotherapy. METHODS A retrospective, multicenter chart review was performed on all VA patients receiving sirolimus treatment from August, 2013 to January, 2021. RESULTS Before January 2017, 112 patients were treated with sirolimus without antibiotic prophylaxis. In the subsequent period, 195 patients were treated with TMP-SMZ for at least 12 months during sirolimus therapy. The percentage of patients with at least one serious infection during the initial 12 months of sirolimus treatment did not differ between the groups (difference, 1.1%; 95% CI - 7.0-8.0%). We observed no difference in the incidence of individual infection or total adverse events between the groups. The rate of sirolimus discontinuation due to adverse events did not differ significantly between groups. CONCLUSIONS We demonstrated that prophylactic TMP-SMZ does not decrease the incidence of infection or improve tolerance in VA patients receiving sirolimus monotherapy.
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Affiliation(s)
- Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xuepeng Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fan Hu
- Department of Vascular and Interventional Radiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiang Peng
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Yongbo Zhang
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, 610031, China
| | - Feiteng Kong
- Department of Pediatric Surgery, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, 610045, 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, Chengdu, 610041, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, 610041, China.
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23
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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: 14] [Impact Index Per Article: 7.0] [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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24
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Trivedi A, Reed HO. The lymphatic vasculature in lung function and respiratory disease. Front Med (Lausanne) 2023; 10:1118583. [PMID: 36999077 PMCID: PMC10043242 DOI: 10.3389/fmed.2023.1118583] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/23/2023] [Indexed: 03/18/2023] Open
Abstract
The lymphatic vasculature maintains tissue homeostasis via fluid drainage in the form of lymph and immune surveillance due to migration of leukocytes through the lymphatics to the draining lymph nodes. Lymphatic endothelial cells (LECs) form the lymphatic vessels and lymph node sinuses and are key players in shaping immune responses and tolerance. In the healthy lung, the vast majority of lymphatic vessels are found along the bronchovascular structures, in the interlobular septa, and in the subpleural space. Previous studies in both mice and humans have shown that the lymphatics are necessary for lung function from the neonatal period through adulthood. Furthermore, changes in the lymphatic vasculature are observed in nearly all respiratory diseases in which they have been analyzed. Recent work has pointed to a causative role for lymphatic dysfunction in the initiation and progression of lung disease, indicating that these vessels may be active players in pathologic processes in the lung. However, the mechanisms by which defects in lung lymphatic function are pathogenic are understudied, leaving many unanswered questions. A more comprehensive understanding of the mechanistic role of morphological, functional, and molecular changes in the lung lymphatic endothelium in respiratory diseases is a promising area of research that is likely to lead to novel therapeutic targets. In this review, we will discuss our current knowledge of the structure and function of the lung lymphatics and the role of these vessels in lung homeostasis and respiratory disease.
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Affiliation(s)
- Anjali Trivedi
- Weill Cornell Medical Center, New York, NY, United States
| | - Hasina Outtz Reed
- Weill Cornell Medical Center, New York, NY, United States
- Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Hasina Outtz Reed,
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25
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Andreoti TAA, Berg S, Holm A, Angerer M, Oberlin M, Foeldi E, Baumgartner I, Niemeyer CM, Rössler J, Kapp FG. Complex Lymphatic Anomalies: Report on a Patient Registry Using the Latest Diagnostic Guidelines. Lymphat Res Biol 2023. [PMID: 36706428 DOI: 10.1089/lrb.2022.0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective: Generalized lymphatic anomaly (GLA), Gorham-Stout disease (GSD), kaposiform lymphangiomatosis (KLA), and central conducting lymphatic anomaly (CCLA) are rare, multisystem lymphatic disorders, referred to as complex lymphatic anomalies (CLAs). Their etiology remains poorly understood; however, somatic activating mutations have recently been discovered, and the results of targeted treatments are promising. This study aimed to elaborate on the phenotypic description of CLA. Methods: Thirty-six consecutive patients were recruited for the "GLA/GSD Registry" of the University Hospital of Freiburg, Germany (2015-2021). Clinical data were prospectively collected provided that a signed informed consent form was obtained. The latest proposed diagnostic guidelines were retrospectively applied. Results: Thirty-two patients (38% males) were included in the study; 15 GLA, 10 GSD, 3 KLA, and 4 CCLA patients were identified. Eighty-four percent already had symptoms by the age of 15 years. Osteolysis and periosseous soft-tissue infiltration were associated with GSD (p < 0.001 and p = 0.011, respectively), ascites and protein-losing enteropathy with CCLA (p = 0.007 and p = 0.004, respectively), and consumption coagulopathy with KLA (p = 0.006). No statistically significant differences were found in organ involvement, distribution of osteolytic lesions, number of affected bones and fractures. Twenty-five patients had complications; one patient with GLA died despite multimodal treatment. Spontaneous regression was seen in one patient with untreated KLA. Conclusions: CLA are rare, and their overlapping clinical presentations make differential diagnosis difficult. The characterization of our case series contributes to the phenotypic description and differentiation of these four clinical entities. A further understanding of their pathogenesis is crucial for evaluating targeted therapies and optimizing medical care.
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Affiliation(s)
- Themis-Areti A Andreoti
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Sebastian Berg
- Division of Pediatric Radiology, Department of Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany
| | - Annegret Holm
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Vascular Biology Program, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marina Angerer
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Oberlin
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Foeldiclinic, Hinterzarten, Germany
| | - Etelka Foeldi
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Foeldiclinic, Hinterzarten, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Charlotte M Niemeyer
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Rössler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland.,VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich G Kapp
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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26
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Leboulanger N, Bisdorff A, Boccara O, Dompmartin A, Guibaud L, Labreze C, Lagier J, Lebrun-Vignes B, Herbreteau D, Joly A, Malloizel-Delaunay J, Martel A, Munck S, Saint-Aubin F, Maruani A. French national diagnosis and care protocol (PNDS, protocole national de diagnostic et de soins): cystic lymphatic malformations. Orphanet J Rare Dis 2023; 18:10. [PMID: 36639640 PMCID: PMC9837920 DOI: 10.1186/s13023-022-02608-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Cystic lymphatic malformations (LMs) are rare chronic conditions which management differs according to the type (macrocystic LMs, microcystic LMs or both). Studies are lacking due to rarity of the pathology. We aimed to establish a French National Diagnosis and Care Protocol (PNDS: Protocole National de Diagnostic et de Soins), to provide health professionals with free open access synthesis on optimal management and care of patients with LMs ( https://www.has-sante.fr/upload/docs/application/pdf/2021-03/malformations_lymphatiques_kystiques_-_pnds.pdf ). The process included a critical review of the literature and multidisciplinary expert consensus. LMs are congenital but are not always discovered at birth. Nearly 75% of them are located in the head and neck because of the highly dense lymphatic system in this region. Physical examination (showing painless masses with normal skin color and depressible consistency, or cutaneous/mucosal lymphangiectasia) and color Doppler ultrasonography, usually allow for diagnosis. MRI (involving T2 sequences with fat saturation in at least two spatial planes) is the tool of choice for evaluating anatomical extension, characterizing lesions (microcystic and macrocystic), and before considering therapeutic management. A biopsy, coupled to a blood sample, can also be used for molecular biology analyses, to search for activating mutations of the PIK3CA gene, particularly with LM integrating in a syndromic form (CLOVES or Klippel-Trenaunay syndrome) but also in certain isolated (or common) LMs. The spontaneous evolution of LMs, in particular microcystic forms, is often toward progressive aggravation, with an increase in the number of vesicles, thickening, increased oozing and bleeding, while pure macrocystic LMs may regress due to "natural sclerosis", i.e. fibrosis secondary to an inflammatory reorganization after common infantile infections. In case of voluminous LMs or syndromic forms, functional and psychological repercussions can be major, deteriorating the patient's quality of life. LMs must be treated by physicians integrated in multidisciplinary teams, and be personalized. Management is a life-long process that involves one or several of these therapies: conservative management, physical therapy (compression), sclerotherapy, surgery, drugs such as mTOR inhibitors (sirolimus), that has shown efficacy in decreasing the volume of LMs, and, more recently, PI3K-inhibitors in syndromic forms. Psychological and social support is necessary, taking into account the patient and his family.
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Affiliation(s)
- Nicolas Leboulanger
- Otolaryngology - Head and Neck Surgery Department. National Reference Center for Rare Otolaryngological Malformations (MALO), Necker Enfants Malades Hospital, 149 Rue de Sèvres, 75015, Paris, France. .,INSERM U955, Paris Cité University. ERN Cranio, Paris, France.
| | - Annouk Bisdorff
- grid.411296.90000 0000 9725 279XDepartment of Interventional Radiology, Lariboisière Hospital, Paris, France
| | - Olivia Boccara
- grid.412134.10000 0004 0593 9113Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Necker Enfants Malades Hospital, Paris, France
| | - Anne Dompmartin
- grid.411149.80000 0004 0472 0160Department of Dermatology, CHU Côte de Nacre, Caen, France
| | - Laurent Guibaud
- grid.413852.90000 0001 2163 3825Department of Radiology, Hôpital Mère-Enfant, CHU de Lyon, Lyon, France
| | - Christine Labreze
- grid.42399.350000 0004 0593 7118Department of Dermatology, Pellegrin Hospital, CHU de Bordeaux, Bordeaux, France
| | - Jacques Lagier
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Bénédicte Lebrun-Vignes
- grid.411439.a0000 0001 2150 9058Pharmacovigilance Unit, AP-HP, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Denis Herbreteau
- grid.411167.40000 0004 1765 1600Department of Neuroradiology and Interventional Radiology - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France
| | - Aline Joly
- grid.411167.40000 0004 1765 1600Department of Maxillofacial Surgery - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, 37044 Tours, Cedex 9 France
| | - Julie Malloizel-Delaunay
- grid.411175.70000 0001 1457 2980Department of Vascular Medicine, Rangueil Hospital, CHU de Toulouse, Toulouse, France
| | - Arnaud Martel
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Stéphane Munck
- grid.460782.f0000 0004 4910 6551Département d’enseignement et de Recherche en Médecine Générale, Retines, Healthy, Université Côte d’Azur, 06000 Nice, France
| | | | - Annabel Maruani
- grid.411167.40000 0004 1765 1600Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France ,grid.12366.300000 0001 2182 6141INSERM 1246 ‑ SPHERE, Universities of Tours and Nantes, 37000 Tours, France
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27
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An unusual cause of proteinuria: lessons for clinical nephrologists. J Nephrol 2022; 35:2403-2405. [PMID: 36151451 DOI: 10.1007/s40620-022-01457-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/28/2022] [Indexed: 10/14/2022]
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28
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Wojciechowska-Durczynska K, Zygmunt A, Mikulak M, Ludwisiak M, Lewinski A. Difficult Therapeutic Decisions in Gorham-Stout Disease-Case Report and Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191811692. [PMID: 36141975 PMCID: PMC9517245 DOI: 10.3390/ijerph191811692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/02/2022] [Accepted: 09/09/2022] [Indexed: 05/30/2023]
Abstract
Gorham-Stout disease (GSD) is a very rare, life-threatening condition characterized by the proliferation of lymphatic vessels and osteolysis. Unfortunately, no standard treatment has been determined for management of GSD. The available therapies are not equally effective and carry substantial side-effects. We report a 42-year-old female with GSD manifested in multifocal osteolysis and chronic chylothorax and ascites. The combined treatment with sirolimus and zoledronic acid due to its synergism of action was introduced. To our knowledge, this is the first Polish case report of adult patients with Gorham-Stout disease.
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Affiliation(s)
- Katarzyna Wojciechowska-Durczynska
- Department of Endocrinology and Metabolic Disease, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Endocrinology and Metabolic Disease, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland
| | - Arkadiusz Zygmunt
- Department of Endocrinology and Metabolic Disease, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Endocrinology and Metabolic Disease, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland
| | - Marta Mikulak
- Department of Endocrinology and Metabolic Disease, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland
| | - Marta Ludwisiak
- Department of Endocrinology and Metabolic Disease, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland
| | - Andrzej Lewinski
- Department of Endocrinology and Metabolic Disease, Medical University of Lodz, 93-338 Lodz, Poland
- Department of Endocrinology and Metabolic Disease, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland
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29
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Nriagu BN, Adams DM, Srinivasan A, Krishnamurthy G, Smith C, Dori Y, Snyder K. Multicompartment Dynamic Contrast Magnetic Resonance Lymphangiography in Diagnosis of Complicated Lymphatic Anomaly. Lymphat Res Biol 2022; 21:135-140. [PMID: 35984928 DOI: 10.1089/lrb.2022.0012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: To describe the dynamic contrast magnetic resonance lymphangiography (DCMRL) findings of three patients with complicated lymphatic anomaly (CLA) and protein losing enteropathy. We further discuss the importance of a multicompartment (intrahepatic [IH], intramesenteric [IM], and intranodal [IN]) DCMRL in delineating central lymphatic flow pathologies. Methods and Results: This is a retrospective study of three patients-one adult and two children who individually underwent the three-compartment DCMRL, namely IN-DCMRL, IH-DCMRL, and IM-DCMCRL. Findings from the results of the DCMRL for these three patients were obtained from the medical records and compared. Using the multicompartment imaging modalities, chylous fluid leakage into the peritoneum was observed using IM-DCMRL and IH-DCMRL but not IN-DCMRL for one of the patients in the case series. In contrast, leakage of chyle into the mediastinum was noted using IN-DCMRL but not IH-DCMRL and IM-DCMRL on another patient in this case series. Conclusion: Owing to the variability in outlining lymphatic flow pathologies, multicompartment imaging gives a more global picture of individual conduction disorders, has the potential to improve clinical assessment, and in some cases leads to a diagnosis of the abnormality and thus provides a better understanding of lymphatic flow anomalies in patients with CLAs.
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Affiliation(s)
- Bede N Nriagu
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Denise M Adams
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abhay Srinivasan
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Smith
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristen Snyder
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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30
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Ricci KW, Iacobas I. How we approach the diagnosis and management of complex lymphatic anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e28985. [PMID: 33844431 DOI: 10.1002/pbc.28985] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/29/2021] [Accepted: 02/13/2021] [Indexed: 12/26/2022]
Abstract
Complex lymphatic anomalies (CLA) are congenital diseases of the lymphatic circulation system that are associated with significant morbidity and early mortality. While guidelines for the comprehensive evaluation of the CLA were recently published, the diagnostic approach and medical management are not standardized. This article presents the clinical features of four CLA: Gorham-Stout disease, generalized lymphatic anomaly, kaposiform lymphangiomatosis, and central collecting lymphatic anomaly. We also offer three cases from the authors' practice and our views on diagnostic testing and disease management including supportive care, medical therapies, and other interventions.
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Affiliation(s)
- Kiersten W Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Hematology and Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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31
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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32
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Solorzano E, Alejo AL, Ball HC, Magoline J, Khalil Y, Kelly M, Safadi FF. Osteopathy in Complex Lymphatic Anomalies. Int J Mol Sci 2022; 23:ijms23158258. [PMID: 35897834 PMCID: PMC9332568 DOI: 10.3390/ijms23158258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/07/2022] [Accepted: 07/16/2022] [Indexed: 11/16/2022] Open
Abstract
Complex Lymphatic Anomalies (CLA) are lymphatic malformations with idiopathic bone and soft tissue involvement. The extent of the abnormal lymphatic presentation and boney invasion varies between subtypes of CLA. The etiology of these diseases has proven to be extremely elusive due to their rarity and irregular progression. In this review, we compiled literature on each of the four primary CLA subtypes and discuss their clinical presentation, lymphatic invasion, osseous profile, and regulatory pathways associated with abnormal bone loss caused by the lymphatic invasion. We highlight key proliferation and differentiation pathways shared between lymphatics and bone and how these systems may interact with each other to stimulate lymphangiogenesis and cause bone loss.
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Affiliation(s)
- Ernesto Solorzano
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Andrew L. Alejo
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Hope C. Ball
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Joseph Magoline
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Yusuf Khalil
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Michael Kelly
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Department of Pediatric Hematology Oncology and Blood, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Fayez F. Safadi
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, OH 44308, USA
- School of Biomedical Sciences, Kent State University, Kent, OH 44243, USA
- Correspondence: ; Tel.: +1-330-325-6619
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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: 13] [Impact Index Per Article: 4.3] [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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Snyder EJ, Sarma A, Borst AJ, Tekes A. Lymphatic Anomalies in Children: Update on Imaging Diagnosis, Genetics, and Treatment. AJR Am J Roentgenol 2022; 218:1089-1101. [PMID: 35043669 DOI: 10.2214/ajr.21.27200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Lymphatic anomalies comprise a spectrum of disorders ranging from common localized microcystic and macrocystic lymphatic malformations (LMs) to rare complex lymphatic anomalies, including generalized lymphatic anomaly, Kaposiform lymph-angiomatosis, central conducting lymphatic anomaly, and Gorham-Stout disease. Imaging diagnosis of cystic LMs is generally straightforward, but complex lymphatic anomalies, particularly those with multiorgan involvement or diffuse disease, may be more challenging to diagnose. Complex lymphatic anomalies are rare but associated with high morbidity. Imaging plays an important role in their diagnosis, and radiologists may be the first clinicians to suggest the diagnosis. Furthermore, radiologists are regularly involved in management given the frequent need for image-guided interventions. For these reasons, it is crucial for radiologists to be familiar with the spectrum of entities comprising complex lymphatic anomalies and their typical imaging findings. In this article, we review the imaging findings of lymphatic anomalies, including LMs and complex lymphatic anomalies. We discuss characteristic imaging findings, multimodality imaging techniques used for evaluation, pearls and pitfalls in diagnosis, and potential complications. We also review recently discovered genetic changes underlying lymphatic anomaly development and the advent of new molecularly targeted therapies.
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Affiliation(s)
- Elizabeth J Snyder
- Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232-9700
| | - Asha Sarma
- Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232-9700
| | - Alexandra J Borst
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins Hospital, Baltimore, MD
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35
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Ghorishi AR, Levin NJ, Nomula K, Green J, Eisner E. Pathologic Fracture as Presentation of Generalized Lymphangiomatosis in an Eight-Year-Old: A Case Report and Literature Review. Cureus 2022; 14:e24380. [PMID: 35619846 PMCID: PMC9126478 DOI: 10.7759/cureus.24380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 11/11/2022] Open
Abstract
Pathologic fractures commonly occur secondary to abnormal skeletal physiology in the context of benign or malignant lesions. Rarely, pathologic fractures may occur in the context of a lymphatic abnormality, such as generalized lymphangiomatosis. This rare disorder is characterized by variable presentations in a broad age range of patients. By understanding the effect of widespread lymphatic anomalies on various organ systems, clinicians will be able to make this diagnosis earlier and with more certainty.
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Byrne AB, Brouillard P, Sutton DL, Kazenwadel J, Montazaribarforoushi S, Secker GA, Oszmiana A, Babic M, Betterman KL, Brautigan PJ, White M, Piltz SG, Thomas PQ, Hahn CN, Rath M, Felbor U, Korenke GC, Smith CL, Wood KH, Sheppard SE, Adams DM, Kariminejad A, Helaers R, Boon LM, Revencu N, Moore L, Barnett C, Haan E, Arts P, Vikkula M, Scott HS, Harvey NL. Pathogenic variants in MDFIC cause recessive central conducting lymphatic anomaly with lymphedema. Sci Transl Med 2022; 14:eabm4869. [PMID: 35235341 DOI: 10.1126/scitranslmed.abm4869] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Central conducting lymphatic anomaly (CCLA), characterized by the dysfunction of core collecting lymphatic vessels including the thoracic duct and cisterna chyli, and presenting as chylothorax, pleural effusions, chylous ascites, and lymphedema, is a severe disorder often resulting in fetal or perinatal demise. Although pathogenic variants in RAS/mitogen activated protein kinase (MAPK) signaling pathway components have been documented in some patients with CCLA, the genetic etiology of the disorder remains uncharacterized in most cases. Here, we identified biallelic pathogenic variants in MDFIC, encoding the MyoD family inhibitor domain containing protein, in seven individuals with CCLA from six independent families. Clinical manifestations of affected fetuses and children included nonimmune hydrops fetalis (NIHF), pleural and pericardial effusions, and lymphedema. Generation of a mouse model of human MDFIC truncation variants revealed that homozygous mutant mice died perinatally exhibiting chylothorax. The lymphatic vasculature of homozygous Mdfic mutant mice was profoundly mispatterned and exhibited major defects in lymphatic vessel valve development. Mechanistically, we determined that MDFIC controls collective cell migration, an important early event during the formation of lymphatic vessel valves, by regulating integrin β1 activation and the interaction between lymphatic endothelial cells and their surrounding extracellular matrix. Our work identifies MDFIC variants underlying human lymphatic disease and reveals a crucial, previously unrecognized role for MDFIC in the lymphatic vasculature. Ultimately, understanding the genetic and mechanistic basis of CCLA will facilitate the development and implementation of new therapeutic approaches to effectively treat this complex disease.
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Affiliation(s)
- Alicia B Byrne
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Clinical and Health Sciences, University of South Australia, 5001 Adelaide, Australia
| | - Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium
| | - Drew L Sutton
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Jan Kazenwadel
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | | | - Genevieve A Secker
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Anna Oszmiana
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Milena Babic
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Department of Genetics and Molecular Pathology, SA Pathology, 5000 Adelaide, Australia
| | - Kelly L Betterman
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Peter J Brautigan
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Department of Genetics and Molecular Pathology, SA Pathology, 5000 Adelaide, Australia
| | - Melissa White
- Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Genome Editing Program, South Australian Health and Medical Research Institute, 5000 Adelaide, Australia.,South Australian Genome Editing Facility, University of Adelaide, 5005 Adelaide, Australia
| | - Sandra G Piltz
- Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Genome Editing Program, South Australian Health and Medical Research Institute, 5000 Adelaide, Australia.,South Australian Genome Editing Facility, University of Adelaide, 5005 Adelaide, Australia
| | - Paul Q Thomas
- Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Genome Editing Program, South Australian Health and Medical Research Institute, 5000 Adelaide, Australia.,South Australian Genome Editing Facility, University of Adelaide, 5005 Adelaide, Australia
| | - Christopher N Hahn
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Department of Genetics and Molecular Pathology, SA Pathology, 5000 Adelaide, Australia.,ACRF Cancer Genomics Facility, Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Matthias Rath
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17489 Greifswald, Germany
| | - Ute Felbor
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, 17489 Greifswald, Germany
| | - G Christoph Korenke
- Department of Neuropediatrics, University Children's Hospital, Klinikum Oldenburg, 26133 Oldenburg, Germany
| | - Christopher L Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.,Division of Cardiology, Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kathleen H Wood
- Division of Genomic Diagnostics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Sarah E Sheppard
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Denise M Adams
- Vascular Anomalies Centre, Division of Haematology/Oncology, Cancer and Blood Disorders Centre, Boston Children's Hospital, Boston, PA 02115, USA
| | | | - Raphael Helaers
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium
| | - Laurence M Boon
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Cliniques Universitaires Saint-Luc and University of Louvain, 1200 Brussels, Belgium
| | - Nicole Revencu
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Cliniques Universitaires Saint-Luc and University of Louvain, 1200 Brussels, Belgium.,Centre for Human Genetics, Cliniques Universitaires Saint-Luc and University of Louvain, 1200 Brussels, Belgium
| | - Lynette Moore
- Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Anatomical Pathology, SA Pathology, 5000 Adelaide, Australia
| | - Christopher Barnett
- Paediatric and Reproductive Genetics Unit, South Australian Clinical Genetics Service, Women's and Children's Hospital, 5006 Adelaide, South Australia, Australia
| | - Eric Haan
- Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia
| | - Peer Arts
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Cliniques Universitaires Saint-Luc and University of Louvain, 1200 Brussels, Belgium.,Centre for Human Genetics, Cliniques Universitaires Saint-Luc and University of Louvain, 1200 Brussels, Belgium.,Walloon Excellence in Life Sciences and Biotechnology, University of Louvain, 1200 Brussels, Belgium
| | - Hamish S Scott
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia.,Department of Genetics and Molecular Pathology, SA Pathology, 5000 Adelaide, Australia.,ACRF Cancer Genomics Facility, Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia
| | - Natasha L Harvey
- Centre for Cancer Biology, University of South Australia and SA Pathology, 5001 Adelaide, Australia.,Adelaide Medical School, University of Adelaide, 5005 Adelaide, Australia
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Lee E, Biko DM, Sherk W, Masch WR, Ladino-Torres M, Agarwal PP. Understanding Lymphatic Anatomy and Abnormalities at Imaging. Radiographics 2022; 42:487-505. [PMID: 35179984 DOI: 10.1148/rg.210104] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lymphatic abnormalities encompass a wide range of disorders spanning solitary common cystic lymphatic malformations (LMs) to entities involving multiple organ systems such as lymphangioleiomyomatosis. Many of these disorders are rare, yet some, such as secondary lymphedema from the treatment of malignancy (radiation therapy and/or lymph node dissection), affect millions of patients worldwide. Owing to complex and variable anatomy, the lymphatics are not as well understood as other organ systems. Further complicating this is the variability in the description of lymphatic disease processes and their nomenclature in the medical literature. In recent years, medical imaging has begun to facilitate a deeper understanding of the physiology and pathologic processes that involve the lymphatic system. Radiology is playing an important and growing role in the diagnosis and treatment of many lymphatic conditions. The authors describe both normal and common variant lymphatic anatomy. Various imaging modalities including nuclear medicine lymphoscintigraphy, conventional lymphangiography, and MR lymphangiography used in the diagnosis and treatment of lymphatic disorders are highlighted. The authors discuss imaging many of the common and uncommon lymphatic disorders, including primary LMs described by the International Society for the Study of Vascular Anomalies 2018 classification system (microcystic, mixed, and macrocystic LMs; primary lymphedema). Secondary central lymphatic disorders are also detailed, including secondary lymphedema and chylous leaks, as well as lymphatic disorders not otherwise easily classified. The authors aim to provide the reader with an overview of the anatomy, pathology, imaging findings, and treatment of a wide variety of lymphatic conditions. ©RSNA, 2022.
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Affiliation(s)
- Elizabeth Lee
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - David M Biko
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William Sherk
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William R Masch
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Maria Ladino-Torres
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Prachi P Agarwal
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
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Koerner T, Patel MD, Pai V, Indramohan G. Kaposiform lymphangiomatosis presenting with a Group A Streptococcus pericardial effusion. BMJ Case Rep 2022; 15:e246250. [PMID: 35232734 PMCID: PMC8889164 DOI: 10.1136/bcr-2021-246250] [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] [Accepted: 02/09/2022] [Indexed: 11/03/2022] Open
Abstract
A 4-year-old child was transferred to the paediatric intensive care unit with acute respiratory failure following 4 days of fever, nausea and vomiting. Chest X-ray on admission had an enlarged cardiac silhouette and transthoracic echo confirmed a large pericardial effusion. An emergent pericardiocentesis was performed at bedside which drained nearly 1000 mL of purulent fluid. Postdrainage course was complicated by acute systolic and diastolic heart failure, thrombocytopenia and acute renal failure. A chest CT and MRI were concerning for a diffuse mediastinal soft-tissue density, so the patient underwent interventional radiology-guided biopsy complicated by haemorrhage requiring mediastinal exploration and subtotal thymectomy. Histopathology revealed changes consistent with kaposiform lymphangiomatosis and MRI demonstrated involvement of the lumbar spine and right hip. Following a course of intravenous antibiotics, the patient was started on sirolimus and prednisolone and ultimately discharged home.
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Affiliation(s)
- Taylor Koerner
- Pediatrics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mehul D Patel
- Pediatric Cardiology, Pediatrics, UT Health Sciences Center at Houston, Houston, Texas, USA
| | - Vinay Pai
- Radiology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gitanjali Indramohan
- Pediatric Critical Care Medicine, Pediatrics, University of Texas McGovern Medical School, Houston, Texas, USA
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39
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Maruani A, Tavernier E, Boccara O, Mazereeuw-Hautier J, Leducq S, Bessis D, Guibaud L, Vabres P, Carmignac V, Mallet S, Barbarot S, Chiaverini C, Droitcourt C, Bursztejn AC, Lengellé C, Woillard JB, Herbreteau D, Le Touze A, Joly A, Léauté-Labrèze C, Powell J, Bourgoin H, Gissot V, Giraudeau B, Morel B. Sirolimus (Rapamycin) for Slow-Flow Malformations in Children: The Observational-Phase Randomized Clinical PERFORMUS Trial. JAMA Dermatol 2021; 157:1289-1298. [PMID: 34524406 DOI: 10.1001/jamadermatol.2021.3459] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Sirolimus is increasingly being used to treat various vascular anomalies, although evidence of its efficacy is lacking. Objective To assess the efficacy and safety of sirolimus for children with slow-flow vascular malformations to better delineate the indications for treatment. Design, Setting and Participants This multicenter, open-label, observational-phase randomized clinical trial included 59 children aged 6 to 18 years with a slow-flow vascular malformation who were recruited between September 28, 2015, and March 22, 2018, in 11 French tertiary hospital centers. Statistical analysis was performed on an intent-to-treat basis from December 4, 2019, to November 10, 2020. Interventions Patients underwent an observational period, then switched to an interventional period when they received oral sirolimus (target serum levels, 4-12 ng/mL). The switch time was randomized from month 4 to month 8, and the whole study period lasted 12 months for each patient. Main Outcomes and Measures The primary outcome was change in the volume of vascular malformations detected on magnetic resonance imaging scan (with centralized interpretation) per unit of time (ie, between the interventional period and the observational period). Secondary outcomes included subjective end points: pain, bleeding, oozing, quality of life, and safety. Results Among the participants (35 girls [59.3%]; mean [SD] age, 11.6 [3.8] years), 22 (37.3%) had a pure venous malformation, 18 (30.5%) had a cystic lymphatic malformation, and 19 (32.2%) had a combined malformation, including syndromic forms. Variations in the volume of vascular malformations detected on magnetic resonance imaging scans associated with the duration period were not overall significantly different between the interventional period and the observational period (all vascular malformations: mean [SD] difference, -0.001 [0.007]; venous malformations: mean [SD] difference, 0.001 [0.004]; combined malformations: mean [SD] difference, 0.001 [0.009]). However, a significant decrease in volume was observed for children with pure lymphatic malformations (mean [SD] difference, -0.005 [0.005]). Overall, sirolimus had positive effects on pain, especially for combined malformations, and on bleeding, oozing, self-assessed efficacy, and quality of life. During sirolimus treatment, 56 patients experienced 231 adverse events (5 serious adverse events, none life-threatening). The most frequent adverse event was an oral ulcer (29 patients [49.2%]). Conclusions and Relevance This observational-phase randomized clinical trial allows for clarifying the goals of patients and families when starting sirolimus therapy for children older than 6 years. Pure lymphatic malformations seem to be the best indication for sirolimus therapy because evidence of decreasing lymphatic malformation volume per unit of time, oozing, and bleeding and increasing quality of life was found. In combined malformations, sirolimus significantly reduced pain, oozing, and bleeding. Benefits seemed lower for pure venous malformations than for the 2 other subgroups, also based on symptoms. Trial Registration ClinicalTrials.gov Identifier: NCT02509468; clinicaltrialsregister.eu Identifier: 2015-001096-43.
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Affiliation(s)
- Annabel Maruani
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Elsa Tavernier
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Olivia Boccara
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Necker), University Hospital Necker-Enfants Malades, Paris, France
| | | | - Sophie Leducq
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Didier Bessis
- Department of Dermatology, University Hospital Center of Montpellier, Montpellier, France
| | - Laurent Guibaud
- University Hospital Center of Lyon, Consultation Multidisciplinaire Lyonnaise des Angiomes, Lyon, France
| | - Pierre Vabres
- Department of Dermatology, University Hospital Center of Dijon, Dijon, France
| | - Virginie Carmignac
- Department of Dermatology, University Hospital Center of Dijon, Dijon, France
| | - Stéphanie Mallet
- Department of Dermatology, University Hospital Center of Marseille, Marseille, France
| | - Sébastien Barbarot
- Department of Dermatology, University Hospital Center of Nantes, Nantes, France
| | | | | | | | - Céline Lengellé
- Centre Hospitalier Régional Universitaire Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Jean-Baptiste Woillard
- Centre Hospitalier Universitaire Limoges, Department of Pharmacology and Toxicology, University of Limoges, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 850, Limoges, France
| | - Denis Herbreteau
- University of Tours, Centre Hospitalier Régional Universitaire Tours, Department of Neuroradiology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Anne Le Touze
- Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Surgery, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Aline Joly
- Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Maxillofacial Surgery, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | | | - Julie Powell
- Department of Pediatric Dermatology, Hospital Sainte-Justine, Montréal, Québec, Canada
| | - Hélène Bourgoin
- Centre Hospitalier Régional Universitaire Tours, Department of Pharmacy, Tours, France
| | - Valérie Gissot
- Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Bruno Giraudeau
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Baptiste Morel
- University of Tours, Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Radiology, Tours, France
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Ji Y, Chen S, Yang K, Zhou J, Zhang X, Jiang X, Xu X, Lu G, Qiu L, Kong F, Zhang Y. A prospective multicenter study of sirolimus for complicated vascular anomalies. J Vasc Surg 2021; 74:1673-1681.e3. [PMID: 34082006 DOI: 10.1016/j.jvs.2021.04.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 04/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Complicated vascular anomalies (VAs) can be intractable and uncontrollable using conventional treatment and can result in lethal outcomes. We undertook a prospective, multicenter phase II trial to evaluate the efficacy and safety of sirolimus in pediatric patients with complicated VAs. METHODS Eligible patients were required to be aged 0 to 14 years and to have a complicated VA. The patients were treated with daily oral sirolimus for 12 months. The primary endpoint was the response, which was measured using sequential volumetric magnetic resonance imaging. The secondary endpoints were the disease severity score and quality of life. RESULTS Of 126 patients enrolled on an intention-to-treat basis, 98 (77.8%) had had an objective response to sirolimus, with a ≥20% decrease in lesion volume. Compared with those with arteriovenous malformations, the response rates were higher (>80%) for patients with common lymphatic malformations, venous malformations, kaposiform hemangioendothelioma, and combined malformations with a prominent venous and/or lymphatic component (P < .05). Improvements in the disease severity score and quality of life were obtained in 83.3% and 79.4% of patients, respectively. The most common adverse event was mucositis in 47 patients. More serious adverse events included reversible grade 4 pneumonitis in 3 patients and grade 4 upper respiratory infection in 1 patient. All these adverse events were considered at least possibly related to the treatment. CONCLUSIONS Sirolimus is an apparently effective option for pediatric patients with various types of complicated VAs. Close monitoring of possible adverse events is required. The results from the present trial are the basis for future prospective studies using new therapeutic approaches.
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Affiliation(s)
- Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xuepeng Zhang
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xian Jiang
- Department of Dermatology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xuewen Xu
- Department of Burn and Plastic Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Guoyan Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liqing Qiu
- Department of Pediatric Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
| | - Feiteng Kong
- Department of Pediatric Surgery, Sichuan Women and Children's Hospital, Chengdu, China
| | - Yongbo Zhang
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, China
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Brouillard P, Witte MH, Erickson RP, Damstra RJ, Becker C, Quéré I, Vikkula M. Primary lymphoedema. Nat Rev Dis Primers 2021; 7:77. [PMID: 34675250 DOI: 10.1038/s41572-021-00309-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.
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Affiliation(s)
- Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Marlys H Witte
- Department of Surgery, Neurosurgery, and Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert P Erickson
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert J Damstra
- VASCERN PPL European Reference Centre; Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, Netherlands
| | | | - Isabelle Quéré
- Department of Vascular Medicine, Centre de référence des Maladies Lymphatiques et Vasculaires Rares, Inserm IDESP, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium. .,VASCERN VASCA European Reference Centre; Center for Vascular Anomalies, Division of Plastic Surgery, University Clinics Saint-Luc, University of Louvain, Brussels, Belgium. .,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), de Duve Institute, University of Louvain, Brussels, Belgium.
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42
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López García IM, Lorenzo Domínguez MT, Fernández Martínez AM, Cuesta Marcos MT. Massive osteolysis in a patient with Gorham-Stout syndrome. REUMATOLOGIA CLINICA 2021; 17:485-488. [PMID: 34625153 DOI: 10.1016/j.reumae.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/15/2020] [Indexed: 06/13/2023]
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43
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Anthony MD, Swilling A, Jiwani ZM, Heym K, Margraf LR, Fierke S, Akers LJ, Ray A. Multidisciplinary Multiagent Treatment of Complex Lymphatic Anomalies with Severe Bone Disease: A Single-Site Experience. Lymphat Res Biol 2021; 20:118-124. [PMID: 34435889 DOI: 10.1089/lrb.2021.0011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Complex lymphatic anomalies (CLA) are a group of conditions that pose diagnostic and therapeutic challenges due to their rarity and overlapping clinical findings. This case series describes the complex pathology and novel combination therapies of three patients diagnosed with various types of CLA. Methods and Results: A retrospective review of medical records was performed for three patients treated for CLA between 2011 and 2019. Diagnostics, imaging, treatment, and follow-up were reviewed in the electronic medical record and combined with the literature review within the analysis. One patient had involvement of her skull base and ear canals, diagnosed after ear canal abnormalities were detected on computed tomography following meningitis. The second patient had involvement of her posterior ribs and T7-T12 vertebral bodies, with thoracic instability requiring a back brace. The third patient had involvement of his left lower extremity and hemipelvis, necessitating a left above the knee amputation. Case 1 progressed on sirolimus and pamidronate but responded to zoledronic acid (ZA). She developed flares of coagulopathy and cellulitis that required reinforcement with vincristine and steroid pulses. Similarly, case 2 progressed on sirolimus and ZA alone, but achieved stable disease with added vincristine. Upon further disease progression, stabilization was obtained by the reinforcement of ZA. Case 3 required a combination of surgery as well as medical management with sirolimus and pamidronate. All three patients now have stable disease. Conclusion: This case series depicts a multidisciplinary and multiagent approach to the management of CLA with severe bony involvement using sirolimus, bisphosphonates, vincristine, and steroids.
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Affiliation(s)
- Megan D Anthony
- Departments of Hematology/Oncology, Pathology, Radiology, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Aubrey Swilling
- Departments of Hematology/Oncology, Pathology, Radiology, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Zahra M Jiwani
- Departments of Hematology/Oncology, Pathology, Radiology, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Kenneth Heym
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | | | - Shelby Fierke
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | | | - Anish Ray
- Cook Children's Medical Center, Fort Worth, Texas, USA
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44
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Canaud G, Hammill AM, Adams D, Vikkula M, Keppler-Noreuil KM. A review of mechanisms of disease across PIK3CA-related disorders with vascular manifestations. Orphanet J Rare Dis 2021; 16:306. [PMID: 34238334 PMCID: PMC8268514 DOI: 10.1186/s13023-021-01929-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/27/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND PIK3CA-related disorders include vascular malformations and overgrowth of various tissues that are caused by postzygotic, somatic variants in the gene encoding phosphatidylinositol-3-kinase (PI3K) catalytic subunit alpha. These mutations result in activation of the PI3K/AKT/mTOR signaling pathway. The goals of this review are to provide education on the underlying mechanism of disease for this group of rare conditions and to summarize recent advancements in the understanding of, as well as current and emerging treatment options for PIK3CA-related disorders. MAIN BODY PIK3CA-related disorders include PIK3CA-related overgrowth spectrum (PROS), PIK3CA-related vascular malformations, and PIK3CA-related nonvascular lesions. Somatic activating mutations (predominantly in hotspots in the helical and kinase domains of PIK3CA, but also in other domains), lead to hyperactivation of the PI3K signaling pathway, which results in abnormal tissue growth. Diagnosis is complicated by the variability and overlap in phenotypes associated with PIK3CA-related disorders and should be performed by clinicians with the required expertise along with coordinated care from a multidisciplinary team. Although tissue mosaicism presents challenges for confirmation of PIK3CA mutations, next-generation sequencing and tissue selection have improved detection. Clinical improvement, radiological response, and patient-reported outcomes are typically used to assess treatment response in clinical studies of patients with PIK3CA-related disorders, but objective assessment of treatment response is difficult using imaging (due to the heterogeneous nature of these disorders, superimposed upon patient growth and development). Despite their limitations, patient-reported outcome tools may be best suited to gauge patient improvement. New therapeutic options are needed to provide an alternative or supplement to standard approaches such as surgery and sclerotherapy. Currently, there are no systemic agents that have regulatory approval for these disorders, but the mTOR inhibitor sirolimus has been used for several years in clinical trials and off label to address symptoms. There are also other agents under investigation for PIK3CA-related disorders that act as inhibitors to target different components of the PI3K signaling pathway including AKT (miransertib) and PI3K alpha (alpelisib). CONCLUSION Management of patients with PIK3CA-related disorders requires a multidisciplinary approach. Further results from ongoing clinical studies of agents targeting the PI3K pathway are highly anticipated.
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Affiliation(s)
- Guillaume Canaud
- Overgrowth Syndrome and Vascular Anomalies Unit, Hôpital Necker Enfants Malades, INSERM U1151, Assistance Publique-Hôpitaux de Paris, Université de Paris, 149 rue de Sèvres, 75105, Paris, France.
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Denise Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires Saint Luc, University of Louvain, Brussels, Belgium.,VASCERN VASCA European Reference Centre, Bichat-Claude Bernard Hospital, Paris, France.,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), University of Louvain, Brussels, Belgium
| | - Kim M Keppler-Noreuil
- Division of Genetics and Metabolism, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Abstract
Lymphatic vessels maintain tissue fluid homeostasis by returning to blood circulation interstitial fluid that has extravasated from the blood capillaries. They provide a trafficking route for cells of the immune system, thus critically contributing to immune surveillance. Developmental or functional defects in the lymphatic vessels, their obstruction or damage, lead to accumulation of fluid in tissues, resulting in lymphedema. Here we discuss developmental lymphatic anomalies called lymphatic malformations and complex lymphatic anomalies that manifest as localized or multifocal lesions of the lymphatic vasculature, respectively. They are rare diseases that are caused mostly by somatic mutations and can present with variable symptoms based upon the size and location of the lesions composed of fluid-filled cisterns or channels. Substantial progress has been made recently in understanding the molecular basis of their pathogenesis through the identification of their genetic causes, combined with the elucidation of the underlying mechanisms in animal disease models and patient-derived lymphatic endothelial cells. Most of the solitary somatic mutations that cause lymphatic malformations and complex lymphatic anomalies occur in genes that encode components of oncogenic growth factor signal transduction pathways. This has led to successful repurposing of some targeted cancer therapeutics to the treatment of lymphatic malformations and complex lymphatic anomalies. Apart from the mutations that act as lymphatic endothelial cell-autonomous drivers of these anomalies, current evidence points to superimposed paracrine mechanisms that critically contribute to disease pathogenesis and thus provide additional targets for therapeutic intervention. Here, we review these advances and discuss new treatment strategies that are based on the recently identified molecular pathways.
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Affiliation(s)
- Taija Mäkinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden (T.M.)
| | - Laurence M Boon
- Division of Plastic Surgery, Center for Vascular Anomalies, Cliniques Universitaires Saint Luc, UCLouvain, Brussels, Belgium (L.M.B.).,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.)
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.).,Walloon Excellence in Lifesciences and Biotechnology, University of Louvain, Brussels, Belgium (M.V.)
| | - Kari Alitalo
- Wihuri Research Institute and Translational Cancer Medicine Program, Biomedicum, University of Helsinki, Finland (K.A.)
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Itkin M, Chidekel A, Ryan KA, Rabinowitz D. Abnormal pulmonary lymphatic flow in patients with paediatric pulmonary lymphatic disorders: Diagnosis and treatment. Paediatr Respir Rev 2020; 36:15-24. [PMID: 32792289 DOI: 10.1016/j.prrv.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
Pulmonary lymphatic disorders are characterized by the presence of the abnormal lymphatic tissues in the thoracic cavity, presenting clinically as chylothorax, chylopericardium, chyloptysis, interstitial lung disease and plastic bronchitis. These conditions include: neonatal chylothorax, cardiac and non-cardiac plastic bronchitis, non-traumatic chylothorax, post congenital cardiac surgery chylothorax and complex lymphatic malformations. Recently developed lymphatic imaging techniques, such as intranodal lymphangiography and dynamic contrast enhanced magnetic resonance lymphangiography demonstrated abnormal pulmonary lymphatic flow from thoracic duct into pulmonary parenchyma as a pathophysiological mechanism of these diseases. Novel minimally invasive lymphatic interventions, such as thoracic duct embolization, interstitial lymphatic embolization and surgical lympho-venous anastomosis, provide an effective treatment of these conditions.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Aaron Chidekel
- Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kelly A Ryan
- Cardiac Center, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Deborah Rabinowitz
- Dept of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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47
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Del Vecchio A, Salerno S, Barbagallo M, Chirico G, Campoleoni M, Cannatà V, Genovese E, Granata C, Magistrelli A, Tomà P. Italian inter-society expert panel position on radiological exposure in Neonatal Intensive Care Units. Ital J Pediatr 2020; 46:159. [PMID: 33109231 PMCID: PMC7592562 DOI: 10.1186/s13052-020-00905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In the recent years, clinical progress and better medical assistance for pregnant women, together with the introduction of new complex technologies, has improved the survival of preterm infants. However, this result requires frequent radiological investigations mostly represented by thoracic and abdominal radiographs in incubators. This document was elaborated by an expert panel Italian inter-society working group (Radiologists, Paediatricians, Medical Physicists) with the aim to assist healthcare practitioners in taking choices involving radiation exposures of new-born infants and to provide practical recommendations about justification and optimization in Neonatal Intensive Care Units. The adherence to these practice recommendations could ensure a high quality and patient safety. More complex and less common radiological practice, such as CT scan or fluoroscopy have been excluded. METHODS The consensus was reached starting from current good practice evidence shared by four scientific societies panel: AIFM (Italian Association of Physics in Medicine), SIN (Italian Neonatology Society), SIP (Italian Paediatric Society), SIRM (Italian Medical Radiology Society) in order to guarantee good standard practices for every professional involved in Neonatal Intensive Care Units (NICU). The report is divided into clinical and physical-dosimetric sections: clinical Indications, good practice in radiological exposures, devices, exposure parameters and modalities, patient positioning and immobilization, Reference Diagnostic Levels, operators and patient's radiation protection. Another important topic was the evaluation of the different incubators in order to understand if the consequences of the technological evolution have had an impact on the increase of the dose to the small patients, and how to choose the best device in terms of radiation protection. At the end the working group faced the problem of setting up the correct communication between clinicians and parents following the most recent indications of the international paediatric societies. RESULTS Taking into account the experience and expertise of 10 Italian Centres, the guideline sets out the criteria to ensure a high standard of neonatal care in NICU about procedures, facilities, recommended equipment, quality assurance, radiation protection measures for children and staff members and communication on radiation risk. CONCLUSIONS This document will allow a standardization of the approach to the exposures in NICU, although oriented to a flexible methodology.
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Affiliation(s)
- Antonella Del Vecchio
- Associazione Italiana di Fisica Medica (AIFM), Milan, Italy.
- Servizio di Fisica Sanitaria, IRCCS Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy.
| | - Sergio Salerno
- Società Italiana di Radiologia Medica e Interventistica (SIRM), Milan, Italy
| | | | | | | | | | | | - Claudio Granata
- Società Italiana di Radiologia Medica e Interventistica (SIRM), Milan, Italy
| | - Andrea Magistrelli
- Società Italiana di Radiologia Medica e Interventistica (SIRM), Milan, Italy
| | - Paolo Tomà
- Società Italiana di Radiologia Medica e Interventistica (SIRM), Milan, Italy
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48
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Rabinowitz D, Itkin M. Pediatric Lymphatics Review: Current State and Future Directions. Semin Intervent Radiol 2020; 37:414-419. [PMID: 33041488 DOI: 10.1055/s-0040-1715876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Deborah Rabinowitz
- Division of Interventional Radiology, Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Radiology and Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia Pennsylvania
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49
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López García IM, Lorenzo Domínguez MT, Fernández Martínez AM, Cuesta Marcos MT. Massive Osteolysis in a Patient with Gorham-Stout Syndrome. REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30189-3. [PMID: 32868245 DOI: 10.1016/j.reuma.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/08/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
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50
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de Keyser CE, Saltzherr MS, Bos EM, Zillikens MC. A Large Skull Defect Due to Gorham-Stout Disease: Case Report and Literature Review on Pathogenesis, Diagnosis, and Treatment. Front Endocrinol (Lausanne) 2020; 11:37. [PMID: 32117063 PMCID: PMC7012895 DOI: 10.3389/fendo.2020.00037] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/20/2020] [Indexed: 11/13/2022] Open
Abstract
A 24-year old man was referred to the Erasmus MC Bone Center because of an asymptomatic increasing skull defect of the left parietal bone. The defect was first noticed at the age of six, and gradually increased over the years. His medical history was unremarkable, without any known trauma and a negative family history for bone diseases. Laboratory tests showed a low vitamin D level without other abnormalities. Particularly, there was no increase in markers of inflammation or bone turnover. CT-scans of the skull showed an osteolytic region of the parietal skull bone, with a two-centimeter increase in diameter over 9 years. Contrast enhanced MRI showed lymphangiogenic invasion, which was compatible with our suspicion of Gorham-Stout disease. The patient was referred to the neurosurgeon for treatment with a bone graft while considering additional drug treatment. Gorham-Stout or vanishing bone disease is a rare entity characterized by progressive osteolysis with lymphangiogenic bone invasion. Although already reported in 1838, currently the diagnosis and treatment of Gorham-Stout disease is still challenging. The underlying pathophysiology is not clarified yet and several theories exist. The disease usually affects persons younger than 40 years and the majority present with bone disease of the maxillofacial region, the upper extremities or the torso. The clinical presentation includes most frequently pain, swelling, and functional impairment of the affected region, but the disease can also be asymptomatic. Laboratory investigations are usually normal, and diagnosis is based upon imaging and sometimes pathology examination of affected bone tissue. Treatment is experimental and there is no general consensus about the best option due to lack of randomized controlled trials. Case reports showed patients treated with bisphosphonates, interferon-alpha, anti-VEGF therapy, mTOR inhibitors, and radiotherapy. There are some reports of surgery with prosthetic or bone grafts but no long-term follow-up data exist. This paper describes a unique case of Gorham-Stout disease of the parietal skull bone and discusses the current state of knowledge about this rare bone disease.
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Affiliation(s)
- Catherine E. de Keyser
- Department of Internal Medicine, Bone Center, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Michael S. Saltzherr
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Eelke M. Bos
- Department of Neurosurgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - M. Carola Zillikens
- Department of Internal Medicine, Bone Center, Erasmus University Medical Center, Rotterdam, Netherlands
- *Correspondence: M. Carola Zillikens
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