1
|
Huerta CT, Beres AL, Englum BR, Gonzalez K, Levene T, Wakeman D, Yousef Y, Gulack BC, Chang HL, Christison-Lagay ER, Ham PB, Mansfield SA, Kulaylat AN, Lucas DJ, Rentea RM, Pennell CP, Sulkowski JP, Russell KW, Ricca RL, Kelley-Quon LI, Tashiro J, Rialon KL. Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee. J Pediatr Surg 2024:S0022-3468(24)00349-X. [PMID: 38914511 DOI: 10.1016/j.jpedsurg.2024.05.019] [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: 04/02/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
| | - Alana L Beres
- Division of Pediatric General and Thoracic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine Gonzalez
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Yasmine Yousef
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Henry L Chang
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Phillip Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Afif N Kulaylat
- Division on Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rebecca M Rentea
- Division of Pediatric Surgery, Children's Mercy- Kansas City, Kansas City, MO, USA; Department of Surgery, University of Missouri- Kansas City, Kansas City, MO, USA
| | | | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond, Richmond, VA, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Robert L Ricca
- Division of Pediatric Surgery, University of South Carolina, Greenville, SC, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
2
|
Bonilla-Velez J, Whitlock KB, Ganti S, Shivaram GM, Bly RA, Dahl JP, Manning SC, Perkins JA. Delaying Invasive Treatment in Unilateral Head and Neck Lymphatic Malformation Improves Outcomes. Laryngoscope 2023; 133:956-962. [PMID: 35657104 DOI: 10.1002/lary.30237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/21/2022] [Accepted: 05/19/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Large (De Serres stage [IV-V]) head and neck lymphatic malformations (HNLMs) often have multiple, high-risk, invasive treatments (ITs) to address functional compromise. Logically reducing HNLM ITs should reduce treatment risk. We tested whether delaying HNLM ITs reduces total IT number. MATERIALS Consecutive HNLM patients (n = 199) between 2010 and 2017, aged 0-18 years. METHODS ITs (surgery or sclerotherapy) were offered for persistent or dysfunction causing HNLMs. Treatment effectiveness categorized by IT number: optimal (0-1), acceptable (2-5), or suboptimal (>5). Clinical data were summarized, and outcome associations tested (χ2 ). Relative risk (RR) with a Poisson working model tested whether HNLM observation or IT delay (>6 months post-diagnosis) predicts treatment success (i.e., ≤1 IT). RESULTS Median age at HNLM diagnosis was 1.3 months (interquartile range [IQR] 0-45 m) with 107/199(54%) male. HNLM were stage I-III (174 [88%]), IV-V (25 [13%]). Initial treatment was observation (70 [35%]), invasive (129 [65%]). Treatment outcomes were optimal (137 [69%]), acceptable (36 [18%]), and suboptimal (26 [13%]). Suboptimal outcome associations: EXIT procedure, stage IV-V, oral location, and tracheotomy (p < 0.001). Stage I-III HNLMs were initially observed compared with stage I-III having ITs within 6 months of HNLM diagnosis, had a 82% lower relative treatment failure risk ([i.e., >1 IT], RR = 0.09, 95% CI 0.02-0.36, p < 0.001). Stage I-III HNLMs with non-delayed ITs had reduced treatment failure risk compared with IV-V (RR = 0.47, 95% CI 0.33-0.66, p < 0.001). CONCLUSION Observation and delayed IT in stage I-III HNLM ("Grade 1") is safe and reduces IT (i.e., ≤1 IT). Stage IV-V HNLMs ("Grade 2") with early IT have a greater risk of multiple ITs. LEVEL OF EVIDENCE 4 Laryngoscope, 133:956-962, 2023.
Collapse
Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Kathryn B Whitlock
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Sheila Ganti
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Giri M Shivaram
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A.,Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Randall A Bly
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Scott C Manning
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| |
Collapse
|
3
|
Richardson CM, Perkins JN, Zenner K, Bull C, Lutsky E, Jensen DM, Dmyterko V, Bennett JT, Wenger TL, Dahl JP, Bonilla-Velez J, Bly RA, Geddis AE, Perkins JA. Primary targeted medical therapy for management of bilateral head and neck lymphatic malformations in infants. Int J Pediatr Otorhinolaryngol 2023; 164:111371. [PMID: 36459725 PMCID: PMC10243723 DOI: 10.1016/j.ijporl.2022.111371] [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: 08/01/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Patients born with bilateral head and neck lymphatic malformations (BHNLMs) often require multiple invasive treatments, including tracheostomy. We hypothesized that primary targeted medical therapy (pTMT) with diagnostic needle aspiration reduces the need for invasive therapy such as surgical resection and/or sclerotherapy. METHODS Retrospective case review was performed of infants with BHNLMs (Grade 2 or De Serres stage IV and V) treated only at our institution from 2000 to 2021. Patients were divided into two cohorts: those managed with pTMT and those managed with observation, sclerotherapy, or surgical intervention (non-pTMT). Data regarding interventions, clinical outcomes, morbidity, and mortality were analyzed with descriptive statistics. RESULTS Nine children with BHNLMs met inclusion criteria. Three (33%) were in the pTMT cohort and six (66%) were non-pTMT. Eight (89%) malformations were genotyped, and all demonstrated hotspot PIK3CA variants. All pTMT patients had sirolimus initiated in the first month of life and underwent needle aspiration of malformation cyst fluid for cell-free DNA samples. All pTMT patients tolerated medical therapy. For the non-pTMT cohort, primary treatment included none (deceased, n = 1, 17%), observation with needle aspiration (n = 1, 17%), surgical resection (n = 2, 33%), or combination surgery and sclerotherapy (n = 2, 33%). Intubation duration, intensive care and initial hospital length of stay were not different between cohorts. Four non-pTMT patients (67%) required tracheostomy, and two (33%) died prior to discharge. All pTMT patients survived and none required tracheostomy. Non-pTMT patients required a median of two invasive therapies prior to discharge (IQR 1-4) and a mean total of 13 over the course of their lifetime (IQR 1-16), compared to the pTMT group who did not require any lifetime invasive therapy, even after initial pTMT and discharge home. CONCLUSION This study compares patients with BHNLMs (Grade 2) treated with pTMT versus those treated with observation or invasive therapy. Patients treated with pTMT required no surgical or invasive procedural treatment of their malformations, no tracheostomy placement, no unplanned readmissions after discharge, and had no mortalities. Needle aspiration was useful as a therapeutic adjunct for cell-free DNA diagnosis of PIK3CA variants, which guided TMT.
Collapse
Affiliation(s)
- Clare M Richardson
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA.
| | - Jonathan N Perkins
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA.
| | - Kaitlyn Zenner
- Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA.
| | - Catherine Bull
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA.
| | - Erika Lutsky
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA.
| | - Dana M Jensen
- Center for Clinical and Translational Research, Seattle Children's Hospita, USAl.
| | - Victoria Dmyterko
- Center for Clinical and Translational Research, Seattle Children's Hospita, USAl.
| | - James T Bennett
- Center for Clinical and Translational Research, Seattle Children's Hospita, USAl; Division of Genetic Medicine, Department of Pediatrics, Seattle Children's Hospital, USA.
| | - Tara L Wenger
- Division of Genetic Medicine, Department of Pediatrics, Seattle Children's Hospital, USA.
| | - John P Dahl
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospita, USAl.
| | - Juliana Bonilla-Velez
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospita, USAl.
| | - Randall A Bly
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA.
| | - Amy E Geddis
- Center for Clinical and Translational Research, Seattle Children's Hospita, USAl; Division of Hematology-Oncology, Department of Pediatrics, Seattle Children's Hospital, USA.
| | - Jonathan A Perkins
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Seattle Children's Hospital, MS OA.9.220, PO Box 5371, Seattle, WA, 98145, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 356515, Seattle, WA, 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospita, USAl.
| |
Collapse
|
4
|
Wenger TL, Ganti S, Bull C, Lutsky E, Bennett JT, Zenner K, Jensen DM, Dmyterko V, Mercan E, Shivaram GM, Friedman SD, Bindschadler M, Drusin M, Perkins JN, Kong A, Bly RA, Dahl JP, Bonilla-Velez J, Perkins JA. Alpelisib for the treatment of PIK3CA-related head and neck lymphatic malformations and overgrowth. Genet Med 2022; 24:2318-2328. [PMID: 36066547 PMCID: PMC11091962 DOI: 10.1016/j.gim.2022.07.026] [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: 05/12/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE PIK3CA-related overgrowth spectrum (PROS) conditions of the head and neck are treatment challenges. Traditionally, these conditions require multiple invasive interventions, with incomplete malformation removal, disfigurement, and possible dysfunction. Use of the PI3K inhibitor alpelisib, previously shown to be effective in PROS, has not been reported in PIK3CA-associated head and neck lymphatic malformations (HNLMs) or facial infiltrating lipomatosis (FIL). We describe prospective treatment of 5 children with PIK3CA-associated HNLMs or head and neck FIL with alpelisib monotherapy. METHODS A total of 5 children with PIK3CA-associated HNLMs (n = 4) or FIL (n = 1) received alpelisib monotherapy (aged 2-12 years). Treatment response was determined by parental report, clinical evaluation, diary/questionnaire, and standardized clinical photography, measuring facial volume through 3-dimensional photos and magnetic resonance imaging. RESULTS All participants had reduction in the size of lesion, and all had improvement or resolution of malformation inflammation/pain/bleeding. Common invasive therapy was avoided (ie, tracheotomy). After 6 or more months of alpelisib therapy, facial volume was reduced (range 1%-20%) and magnetic resonance imaging anomaly volume (range 0%-23%) were reduced, and there was improvement in swallowing, upper airway patency, and speech clarity. CONCLUSION Individuals with head and neck PROS treated with alpelisib had decreased malformation size and locoregional overgrowth, improved function and symptoms, and fewer invasive procedures.
Collapse
Affiliation(s)
- Tara L Wenger
- Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA.
| | - Sheila Ganti
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Catherine Bull
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Erika Lutsky
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - James T Bennett
- Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Center for Developmental Biology and Regenerative Medicine, Seattle Children's Hospital, Seattle, WA
| | - Kaitlyn Zenner
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Dana M Jensen
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Hospital, Seattle, WA
| | - Victoria Dmyterko
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Hospital, Seattle, WA
| | - Ezgi Mercan
- Craniofacial Center, Seattle Children's Hospital, Seattle, WA
| | - Giri M Shivaram
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | - Seth D Friedman
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Michael Bindschadler
- Division of Neurology, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Madeleine Drusin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Jonathan N Perkins
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Ada Kong
- Investigational Drug Services, Seattle Children's Hospital, Seattle, WA
| | - Randall A Bly
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - John P Dahl
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Juliana Bonilla-Velez
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| | - Jonathan A Perkins
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
5
|
Somatic activating BRAF variants cause isolated lymphatic malformations. HGG ADVANCES 2022; 3:100101. [PMID: 35373151 PMCID: PMC8972000 DOI: 10.1016/j.xhgg.2022.100101] [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: 11/08/2021] [Accepted: 03/10/2022] [Indexed: 11/20/2022] Open
Abstract
Somatic activating variants in PIK3CA, the gene that encodes the p110α catalytic subunit of phosphatidylinositol 3-kinase (PI3K), have been previously detected in ∼80% of lymphatic malformations (LMs).1,2 We report the presence of somatic activating variants in BRAF in individuals with LMs that do not possess pathogenic PIK3CA variants. The BRAF substitution p.Val600Glu (c.1799T>A), one of the most common driver mutations in cancer, was detected in multiple individuals with LMs. Histology revealed abnormal lymphatic channels with immunopositivity for BRAFV600E in endothelial cells that was otherwise indistinguishable from PIK3CA-positive LM. The finding that BRAF variants contribute to low-flow LMs increases the complexity of prior models associating low-flow vascular malformations (LM and venous malformations) with mutations in the PI3K-AKT-MTOR and high-flow vascular malformations (arteriovenous malformations) with mutations in the RAS-mitogen-activated protein kinase (MAPK) pathway.3 In addition, this work highlights the importance of genetic diagnosis prior to initiating medical therapy as more studies examine therapeutics for individuals with vascular malformations.
Collapse
|