1
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Pastura P, McDaniel CG, Alharbi S, Fox D, Coleman B, Malik P, Adams DM, Le Cras TD. NRAS Q61R mutation drives elevated angiopoietin-2 expression in human endothelial cells and a genetic mouse model. Pediatr Blood Cancer 2024; 71:e31032. [PMID: 38711167 PMCID: PMC11116044 DOI: 10.1002/pbc.31032] [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: 11/21/2023] [Revised: 03/10/2024] [Accepted: 04/10/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Angiopoietin-2 (Ang-2) is increased in the blood of patients with kaposiform lymphangiomatosis (KLA) and kaposiform hemangioendothelioma (KHE). While the genetic causes of KHE are not clear, a somatic activating NRASQ61R mutation has been found in the lesions of KLA patients. PROCEDURE Our study tested the hypothesis that the NRASQ61R mutation drives elevated Ang-2 expression in endothelial cells. Ang-2 was measured in human endothelial progenitor cells (EPC) expressing NRASQ61R and a genetic mouse model with endothelial targeted NRASQ61R. To determine the signaling pathways driving Ang-2, NRASQ61R EPC were treated with signaling pathway inhibitors. RESULTS Ang-2 levels were increased in EPC expressing NRASQ61R compared to NRASWT by Western blot analysis of cell lysates and ELISA of the cell culture media. Ang-2 levels were elevated in the blood of NRASQ61R mutant mice. NRASQ61R mutant mice also had reduced platelet counts and splenomegaly with hypervascular lesions, like some KLA patients. mTOR inhibitor rapamycin attenuated Ang-2 expression by NRASQ61R EPC. However, MEK1/2 inhibitor trametinib was more effective blocking increases in Ang-2. CONCLUSIONS Our studies show that the NRASQ61R mutation in endothelial cells induces Ang-2 expression in vitro and in vivo. In cultured human endothelial cells, NRASQ61R drives elevated Ang-2 through MAP kinase and mTOR-dependent signaling pathways.
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Affiliation(s)
- Patricia Pastura
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - C. Griffin McDaniel
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara Alharbi
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dermot Fox
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bethany Coleman
- Department of Molecular & Cellular Biosciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Punam Malik
- Division of Experimental Hematology and Cancer Biology, Cancer and Blood Disease Institute,
Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Denise M. Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Timothy D. Le Cras
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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2
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Engel ER, Le Cras TD, Ricci KW. How we use angiopoietin-2 in the diagnosis and management of vascular anomalies. Pediatr Blood Cancer 2024; 71:e30921. [PMID: 38439088 DOI: 10.1002/pbc.30921] [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: 09/14/2023] [Revised: 12/30/2023] [Accepted: 01/31/2024] [Indexed: 03/06/2024]
Abstract
The diagnosis of vascular anomalies remains challenging due to significant clinical heterogeneity and uncertain etiology. Evaluation using biopsy and/or genetic testing for somatic variants is invasive, expensive, and prone to sampling error. There is great need for noninvasive and easily measured blood laboratory biomarkers that can aid not only in diagnosis, but also management of treatments for vascular anomalies. Angiopoietin-2, a circulating blood angiogenic factor, is highly elevated in patients with kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon and kaposiform lymphangiomatosis. Here, we describe our clinical experience using serum angiopoietin-2 as a biomarker for diagnosis and monitoring response to treatment.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Timothy D Le Cras
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kiersten W Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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3
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Hammill AM, Boscolo E. Capillary malformations. J Clin Invest 2024; 134:e172842. [PMID: 38618955 PMCID: PMC11014659 DOI: 10.1172/jci172842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Capillary malformation (CM), or port wine birthmark, is a cutaneous congenital vascular anomaly that occurs in 0.1%-2% of newborns. Patients with a CM localized on the forehead have an increased risk of developing a neurocutaneous disorder called encephalotrigeminal angiomatosis or Sturge-Weber syndrome (SWS), with complications including seizure, developmental delay, glaucoma, and vision loss. In 2013, a groundbreaking study revealed causative activating somatic mutations in the gene (GNAQ) encoding guanine nucleotide-binding protein Q subunit α (Gαq) in CM and SWS patient tissues. In this Review, we discuss the disease phenotype, the causative GNAQ mutations, and their cellular origin. We also present the endothelial Gαq-related signaling pathways, the current animal models to study CM and its complications, and future options for therapeutic treatment. Further work remains to fully elucidate the cellular and molecular mechanisms underlying the formation and maintenance of the abnormal vessels.
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Affiliation(s)
- Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Elisa Boscolo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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4
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Ricci K. Medical Therapeutics for the Treatment of Vascular Anomalies: Part 3. Oral Maxillofac Surg Clin North Am 2024; 36:125-136. [PMID: 37872048 DOI: 10.1016/j.coms.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
The discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved the understanding of vascular anomalies and changed the treatment paradigm. With the aim of minimizing the need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for nonmalignant vascular tumors and vascular malformations.
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Affiliation(s)
- Kiersten Ricci
- Division of Hematology, Cancer and Blood Diseases Institute, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA.
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5
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Chowers G, Abebe-Campino G, Golan H, Vivante A, Greenberger S, Soudack M, Barkai G, Fox-Fisher I, Li D, March M, Battig MR, Hakonarson H, Adams D, Dori Y, Dagan A. Treatment of severe Kaposiform lymphangiomatosis positive for NRAS mutation by MEK inhibition. Pediatr Res 2023; 94:1911-1915. [PMID: 35246606 PMCID: PMC9440952 DOI: 10.1038/s41390-022-01986-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/22/2021] [Accepted: 01/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a complex lymphatic anomaly involving most commonly the mediastinum, lung, skin and bones with few effective treatments. In recent years, RAS-MAPK pathway mutations were shown to underlie the pathogenesis of several complex lymphatic anomalies. Specifically, an activating NRAS mutation (p.Q61R) was found in the majority of KLA patients. Recent reports demonstrated promising results of treatment with the MEK inhibitor, Trametinib, in patients with complex lymphatic anomalies harboring gain of function mutations in ARAF and SOS1, as well as loss of function mutation in the CBL gene, a negative regulator of the RAS-MAPK pathway. We present a 9-year-old child with a severe case of KLA harboring the typical NRAS (p.Q61R) mutation detected by plasma-derived cell free DNA, responsive to trametinib therapy. METHODS The NRAS somatic mutation was detected from plasma cfDNA using droplet digital PCR. Concurrent in-vitro studies of trametinib activity on mutant NRAS affected lymphatic endothelial cells were performed using a three-dimensional spheroid sprouting assay. RESULTS Trametinib treatment lead to resolution of lifelong thrombocytopenia, improvement of pulmonary function tests and wellbeing, as well as weaning from prolonged systemic steroid treatment. Concurrent studies of mutant NRAS-expressing cells showed enhanced lymphangiogenic capacity along with over activation of the RAS-MAPK and PI3K-AKT-mTOR pathways, both reversed by trametinib. CONCLUSIONS Trametinib treatment can substantially change the prognosis of patients with RAS pathway associated lymphatic anomalies. IMPACT This is the first description of successful trametinib treatment of a patient with KLA harboring the most characteristic NRAS p.Q61R mutation. Treatment can significantly change the prognosis of patients with RAS pathway-associated lymphatic anomalies. We devised an in vitro model of KLA enabling a reproducible method for the continued study of disease pathogenesis. Mutated NRAS p.Q61R cells demonstrated increased lymphangiogenic capacity.
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Affiliation(s)
- Guy Chowers
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Gadi Abebe-Campino
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Hana Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Asaf Vivante
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Nephrology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Shoshana Greenberger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Dermatology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Michalle Soudack
- Pediatric Imaging Unit, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Galia Barkai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Diseases Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Ilana Fox-Fisher
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Dong Li
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael March
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark R Battig
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Divisions of Human Genetics and Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Adams
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adi Dagan
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Pulmonary Unit and the National Center for Cystic Fibrosis, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
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6
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Lan Y, Zhou J, Qiu T, Gong X, Ji Y. Refractory kaposiform lymphangiomatosis relieved by splenectomy. Front Pediatr 2023; 11:1203336. [PMID: 37664553 PMCID: PMC10469894 DOI: 10.3389/fped.2023.1203336] [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: 04/10/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Kaposiform lymphangiomatosis (KLA) is a rare and complex lymphatic anomaly with a poor prognosis. There is no standard treatment, and drug therapies are the most common therapeutic method. However, some patients' symptoms become gradually aggravated despite medical treatment. Splenectomy may be an alternative option when pharmacological therapies are ineffective. Materials and Methods We reviewed and evaluated the cases of 3 patients with KLA who ultimately underwent splenectomy. Results: The lesions were diffusely distributed and involved the lungs and spleens of the 3 patients. Laboratory examinations revealed that all three patients had thrombocytopenia and reduced fibrinogen levels. All patients underwent symptomatic splenectomy after the medication failed. Surprisingly, their symptoms greatly improved. Histopathological investigation of the splenic lesions of the three patients confirmed the diagnosis of KLA. Immunohistochemical staining showed positivity for CD31, CD34, podoplanin, Prox-1 and angiopoietin 2 (Ang-2). Discussion This study aimed to review the features of KLA patients treated by splenectomy and explore the underlying link between splenectomy and prognosis. The reason for the improvement after splenectomy may be related to increased Ang-2 levels and platelet activation in patients with KLA. Future research should seek to develop more targeted drugs based on molecular findings, which may give new hope for the treatment of KLA.
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Affiliation(s)
| | | | | | | | - Yi Ji
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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7
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McDaniel CG, Adams DM, Steele KE, Hammill AM, Merrow AC, Crane JL, Smith CL, Kozakewich HPW, Le Cras TD. Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment. Pediatr Blood Cancer 2023; 70:e30219. [PMID: 36683202 PMCID: PMC10018800 DOI: 10.1002/pbc.30219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023]
Abstract
Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.
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Affiliation(s)
| | - Denise M. Adams
- Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Kimberley E. Steele
- Collaborative Research Advocacy for Vascular Anomalies
Network (CaRAVAN), a 501(C)(3)
| | - Adrienne M. Hammill
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - A. Carl Merrow
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - Janet L. Crane
- Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | | | | | - Timothy D. Le Cras
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
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8
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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: 3.0] [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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9
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Shimano KA, Eng W, Adams DM. How we approach the use of sirolimus and new agents: Medical therapy to treat vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29603. [PMID: 35253343 DOI: 10.1002/pbc.29603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Vascular anomalies (VAs) are a heterogeneous group of primarily congenital tumors and malformations. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis. Recent discoveries evaluating the genetic causes of VAs have revealed that they are due to mutations in cancer pathways, including the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. These discoveries have led to improved phenotype-genotype correlation and have expanded medical therapy for this group of unique disorders.
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Affiliation(s)
- Kristin A Shimano
- Division of Allergy, Immunology, and Bone Marrow Transplant, UCSF Benioff Children's Hospital, University of California, San Francisco, California, USA
| | - Whitney Eng
- Division of Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Denise M Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program/Frontier Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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10
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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: 2.0] [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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11
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Perez-Atayde AR, Debelenko L, Al-Ibraheemi A, Eng W, Ruiz-Gutierrez M, O'Hare M, Croteau SE, Trenor CC, Boyer D, Balkin DM, Barclay SF, Hsi Dickie B, Liang MG, Chaudry G, Alomari AI, Mulliken JB, Adams DM, Kurek KC, Fishman SJ, Kozakewich HPW. Kaposiform Lymphangiomatosis: Pathologic Aspects in 43 Patients. Am J Surg Pathol 2022; 46:963-976. [PMID: 35385405 DOI: 10.1097/pas.0000000000001898] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Kaposiform lymphangiomatosis is an uncommon generalized lymphatic anomaly with distinctive clinical, radiologic, histopathologic, and molecular findings. Herein, we document the pathology in 43 patients evaluated by the Boston Children's Hospital Vascular Anomalies Center from 1999 to 2020. The most frequent presentations were respiratory difficulty, hemostatic abnormalities, and a soft tissue mass. Imaging commonly revealed involvement of some combination of mediastinal, pulmonary, pleural, and pericardial compartments and most often included spleen and skeleton. Histopathology was characterized by dilated, redundant, and abnormally configured lymphatic channels typically accompanied by dispersed clusters of variably canalized, and often hemosiderotic, spindled lymphatic endothelial cells that were immunopositive for D2-40, PROX1, and CD31. An activating lesional NRAS variant was documented in 9 of 10 patients. The clinical course was typically aggressive, marked by hemorrhage, thrombocytopenia, diminished fibrinogen levels, and a mortality rate of 21%.
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Affiliation(s)
| | - Larisa Debelenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | | | | | - Melisa Ruiz-Gutierrez
- Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute
| | | | - Stacy E Croteau
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - Cameron C Trenor
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | | | | | - Sarah F Barclay
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | - Ahmad I Alomari
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | | | - Denise M Adams
- Division of Oncology, Department of Pediatrics, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Kyle C Kurek
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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12
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Boscolo E, Pastura P, Schrenk S, Goines J, Kang R, Pillis D, Malik P, Le Cras TD. NRAS Q61R mutation in human endothelial cells causes vascular malformations. Angiogenesis 2022; 25:331-342. [PMID: 35391614 DOI: 10.1007/s10456-022-09836-7] [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: 10/18/2021] [Accepted: 03/22/2022] [Indexed: 11/27/2022]
Abstract
Somatic mutations in NRAS drive the pathogenesis of melanoma and other cancers but their role in vascular anomalies and specifically human endothelial cells is unclear. The goals of this study were to determine whether the somatic-activating NRASQ61R mutation in human endothelial cells induces abnormal angiogenesis and to develop in vitro and in vivo models to identify disease-causing pathways and test inhibitors. Here, we used mutant NRASQ61R and wild-type NRAS (NRASWT) expressing human endothelial cells in in vitro and in vivo angiogenesis models. These studies demonstrated that expression of NRASQ61R in human endothelial cells caused a shift to an abnormal spindle-shaped morphology, increased proliferation, and migration. NRASQ61R endothelial cells had increased phosphorylation of ERK compared to NRASWT cells indicating hyperactivation of MAPK/ERK pathways. NRASQ61R mutant endothelial cells generated abnormal enlarged vascular channels in a 3D fibrin gel model and in vivo, in xenografts in nude mice. These studies demonstrate that NRASQ61R can drive abnormal angiogenesis in human endothelial cells. Treatment with MAP kinase inhibitor U0126 prevented the change to a spindle-shaped morphology in NRASQ61R endothelial cells, whereas mTOR inhibitor rapamycin did not.
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Affiliation(s)
- Elisa Boscolo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
| | - Patricia Pastura
- Division of Pulmonary Biology, Cincinnati Children's Hospital, Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Sandra Schrenk
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jillian Goines
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Rachael Kang
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Devin Pillis
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Punam Malik
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Timothy D Le Cras
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Pulmonary Biology, Cincinnati Children's Hospital, Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA.
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13
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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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14
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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: 4.0] [Reference Citation Analysis] [Abstract] [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 lymphangiomatosis, central conducting lymphatic anomaly, and Gorham-Stout disease. Imaging diagnosis of cystic LMs is generally straightforward, but complex lymphatic anomalies, particularly those with multi-organ 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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15
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El Amm C, Silva-Palacios F, Geng X, Srinivasan RS. Lymphatic vascular anomalies and dysfunction. THE VASCULOME 2022:301-310. [DOI: 10.1016/b978-0-12-822546-2.00025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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