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Kane G, Fernandez-Pineda I. Targeted therapies for vascular malformations. Front Med (Lausanne) 2024; 11:1446046. [PMID: 39290395 PMCID: PMC11405217 DOI: 10.3389/fmed.2024.1446046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 08/12/2024] [Indexed: 09/19/2024] Open
Abstract
Targeted medical therapies for the treatment of vascular malformations is an exciting and evolving area of research. As the identification of specific causative genetic mutations involved in vascular malformations becomes more accessible and inexpensive, the development of targeted therapies to address these genetic anomalies becomes all the more enticing. It is an excellent example of the potential of translational research where basic science discoveries are translated to clinical practise from 'bench to bedside'. In this mini-review we aim to synopsise some of the recent studies published in this area with specific focus on the paediatric population. We also aim to highlight the growing demand for future research in the field to elucidate further the optimum duration of treatments, strategies for discontinuation, potential for combination of therapies and the effects of prolonged use of these medications.
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Affiliation(s)
- Gavin Kane
- Children's Health Ireland, Dublin, Ireland
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2
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Gourmel A, Kleiber N, Kokta V, Bergeron M, McCuaig C, Doré-Bergeron MJ, Simpson E, Renaud C, Roy JP, Zysman-Colman Z, Cao Y, Théorêt Y, Powell J, Dubois J, Tran TH. Multimodal therapeutic approach for a severe case of kaposiform lymphangiomatosis from procedural interventions to targeted therapies. Pediatr Blood Cancer 2024; 71:e31079. [PMID: 38753412 DOI: 10.1002/pbc.31079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Antoine Gourmel
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Niina Kleiber
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Clinical Pharmacology Unit, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
| | - Victor Kokta
- Department of Pathology and Clinical Laboratory Medicine, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Mathieu Bergeron
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Catherine McCuaig
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Marie-Joelle Doré-Bergeron
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Ewurabena Simpson
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Christian Renaud
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Division of Pediatric Infectious Diseases, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Jean-Philippe Roy
- Division of Nephrology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Zofia Zysman-Colman
- Division of Respiratory Medicine, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Yang Cao
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Yves Théorêt
- Clinical Pharmacology Laboratory, OPTILAB and Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Julie Powell
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Josée Dubois
- Department of Medical Imaging, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
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3
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Folpe AL. Vascular tumors of intermediate malignancy: An update. Hum Pathol 2024; 147:114-128. [PMID: 38360216 DOI: 10.1016/j.humpath.2024.01.014] [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: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/17/2024]
Abstract
The term "hemangioendothelioma" is used for endothelial neoplasms of intermediate malignancy and describes a group of rare neoplasms having biologic behavior falling in between that of the benign hemangiomas and fully malignant angiosarcomas. The hemangioendotheliomas fall into several specific, clinicopathologically and genetically distinct entities, specifically epithelioid hemangioendothelioma, kaposiform hemangioendothelioma, papillary intralymphatic angioendothelioma and retiform hemangioendothelioma (hobnailed hemangioendothelioma), pseudomyogenic hemangioendothelioma, composite hemangioendothelioma, and YAP1::TFE3-fused hemangioendothelioma. The clinical, morphologic, immunohistochemical, and genetic features, and the differential diagnosis of each of these rare entities are discussed in this review.
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Affiliation(s)
- Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55902, United States.
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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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5
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Garlisi Torales LD, Sempowski BA, Krikorian GL, Woodis KM, Paulissen SM, Smith CL, Sheppard SE. Central conducting lymphatic anomaly: from bench to bedside. J Clin Invest 2024; 134:e172839. [PMID: 38618951 PMCID: PMC11014661 DOI: 10.1172/jci172839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Central conducting lymphatic anomaly (CCLA) is a complex lymphatic anomaly characterized by abnormalities of the central lymphatics and may present with nonimmune fetal hydrops, chylothorax, chylous ascites, or lymphedema. CCLA has historically been difficult to diagnose and treat; however, recent advances in imaging, such as dynamic contrast magnetic resonance lymphangiography, and in genomics, such as deep sequencing and utilization of cell-free DNA, have improved diagnosis and refined both genotype and phenotype. Furthermore, in vitro and in vivo models have confirmed genetic causes of CCLA, defined the underlying pathogenesis, and facilitated personalized medicine to improve outcomes. Basic, translational, and clinical science are essential for a bedside-to-bench and back approach for CCLA.
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Affiliation(s)
- Luciana Daniela Garlisi Torales
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Benjamin A. Sempowski
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Georgia L. Krikorian
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Kristina M. Woodis
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Scott M. Paulissen
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Christopher L. Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E. Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
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Imamura M, Shin C, Ozeki M, Matsuoka K, Saitoh A, Imai C. Regression of kaposiform lymphangiomatosis and chronic disseminated intravascular coagulation after inhaled budesonide-formoterol treatment. Pediatr Blood Cancer 2024; 71:e30907. [PMID: 38296836 DOI: 10.1002/pbc.30907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 01/24/2024] [Indexed: 02/02/2024]
Affiliation(s)
- Masaru Imamura
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chansu Shin
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Akihiko Saitoh
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Crary SE, Mack JM. Anticoagulation and vascular anomalies. Res Pract Thromb Haemost 2024; 8:102402. [PMID: 38694837 PMCID: PMC11060946 DOI: 10.1016/j.rpth.2024.102402] [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: 01/09/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 05/04/2024] Open
Abstract
A State of the Art lecture titled "Anticoagulation and Vascular Anomalies" was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2023. Vascular anomalies have been classified by the International Society for the Study of Vascular Anomalies into vascular tumors and vascular malformations. Although some vascular tumors, such as tufted angioma and kaposiform hemangioendothelioma, and other vascular malformations can present with coagulation aberrancies, these are not generally managed with anticoagulation. A subclassification of vascular malformations includes slow-flow vascular malformations. It is this subgroup specifically that has a high risk of venous thromboembolism (VTE) and morbidity associated with coagulopathy that may be present. In these select cases, anticoagulation may be indicated to reduce the risk of VTE, treat VTE, or manage localized thrombosis in the malformation that causes significant pain and reduced quality of life. There are established risk factors for VTE in these patients that will be reviewed. Finally, we summarize relevant new data on this topic presented during the 2023 ISTH Congress.
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Affiliation(s)
- Shelley E. Crary
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Joana M. Mack
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
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8
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Gatts J, Chandra S, Krishnan D, Ricci K. Medical Management of Nonmalignant Vascular Tumors of the Head and Neck: Part 1. Oral Maxillofac Surg Clin North Am 2024; 36:103-113. [PMID: 37875385 DOI: 10.1016/j.coms.2023.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Vascular anomalies, broadly classified as nonmalignant tumors and malformations, consist of a multitude of disorders that have a wide range of symptoms and complications as well as overlapping clinical, radiologic, and histologic findings. Although usually difficult, distinguishing between nonmalignant vascular tumors and malformations, as well as the precise diagnosis within these distinctions, is critical because prognosis, therapy, and chronicity of care vary greatly. In contrast to normal endothelial turnover in vascular malformations, vascular tumors are characterized by the abnormal proliferation of endothelial cells and aberrant blood vessels.
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Affiliation(s)
- Jorie Gatts
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
| | - Srinivasa Chandra
- Department of Oral and Maxillofacial Surgery-Head and Neck Oncology and Microvascular Reconstruction, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Deepak Krishnan
- Department of Surgery, Section of Oral & Maxillofacial Surgery, University of Cincinnati, 200 Albert Sabin Way, ML 0461, Cincinnati, OH 45219, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, 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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9
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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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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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11
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Mehrara BJ, Radtke AJ, Randolph GJ, Wachter BT, Greenwel P, Rovira II, Galis ZS, Muratoglu SC. The emerging importance of lymphatics in health and disease: an NIH workshop report. J Clin Invest 2023; 133:e171582. [PMID: 37655664 PMCID: PMC10471172 DOI: 10.1172/jci171582] [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: 09/02/2023] Open
Abstract
The lymphatic system (LS) is composed of lymphoid organs and a network of vessels that transport interstitial fluid, antigens, lipids, cholesterol, immune cells, and other materials in the body. Abnormal development or malfunction of the LS has been shown to play a key role in the pathophysiology of many disease states. Thus, improved understanding of the anatomical and molecular characteristics of the LS may provide approaches for disease prevention or treatment. Recent advances harnessing single-cell technologies, clinical imaging, discovery of biomarkers, and computational tools have led to the development of strategies to study the LS. This Review summarizes the outcomes of the NIH workshop entitled "Yet to be Charted: Lymphatic System in Health and Disease," held in September 2022, with emphasis on major areas for advancement. International experts showcased the current state of knowledge regarding the LS and highlighted remaining challenges and opportunities to advance the field.
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Affiliation(s)
- Babak J. Mehrara
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrea J. Radtke
- Lymphocyte Biology Section and Center for Advanced Tissue Imaging, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Gwendalyn J. Randolph
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brianna T. Wachter
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Patricia Greenwel
- Division of Digestive Diseases & Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, and
| | - Ilsa I. Rovira
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Zorina S. Galis
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Selen C. Muratoglu
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
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12
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Soszyn N, Leahy R, Morgan GJ. The novel use of an advanced thrombectomy system to manage a complex pericardial effusion associated with kaposiform lymphangiomatosis. Cardiol Young 2023; 33:1760-1762. [PMID: 36999364 DOI: 10.1017/s104795112300032x] [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] [Indexed: 04/01/2023]
Abstract
A 4-year-old boy presented to our institution with pancytopenia, consumptive coagulopathy, hepatosplenomegaly and recurrent complex pericardial effusion secondary to kaposiform lymphagiomatosis. Due to extensive loculation, conventional drainage was minimally effective. As an adjunct to medical therapy, the Indigo™ aspiration system was used to remove thrombus within the pericardial space. Our patient had good medium-term results with complete resolution of his pericardial effusion at 4 months.
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Affiliation(s)
- Natalie Soszyn
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045-2560, USA
| | - Ryan Leahy
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045-2560, USA
| | - Gareth J Morgan
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045-2560, USA
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13
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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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14
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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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15
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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: 6] [Impact Index Per Article: 6.0] [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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16
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Das A, Goyal A, Sangwan A, Kumar A, Bhalla AS, Kandasamy D, Chauhan S. Vascular anomalies: diagnostic features and step-wise approach. Acta Radiol 2023; 64:850-867. [PMID: 35300505 DOI: 10.1177/02841851221085379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The first part of this review article emphasized correct nomenclature, classification systems, and imaging algorithm of vascular anomalies. The second part of the review discusses the individual entities, highlighting the characteristic clinico-radiological features of the commonly encountered ones. A step-wise algorithmic approach is also proposed for the evaluation of a suspected case of vascular anomaly.
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Affiliation(s)
- Abanti Das
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Sangwan
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Chauhan
- Department of Plastic Reconstructive Surgery, 28730All India Institute of Medical Sciences, New Delhi, India
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17
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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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18
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Pereira-Nunes J, Madureira M, Dinis A, Barroca H, Lima J, do Bom-Sucesso M. Kaposiform Lymphangiomatosis in a Male Adolescent: A Clinical Challenge and the Role of Genetics. J Investig Med High Impact Case Rep 2023; 11:23247096231166678. [PMID: 37148180 PMCID: PMC10164843 DOI: 10.1177/23247096231166678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare and aggressive generalized lymphatic anomaly (GLA), with distinctive clinical, radiology, morphologic, and genetic features. It does not have a current standard treatment and presents poor overall prognosis. Somatic mutations in the RAS pathway were reported as the likely driver for the majority of patients. We report a case of a 17-year-old male adolescent who was referred to the emergency department due to a severe anemia. Laboratory workup confirmed the anemia and revealed coagulation factor consumption and fibrinolysis. Chest-abdomen-pelvis computed tomography revealed an extensive cervical, mediastinal, abdominal and retroperitoneal "hematoma." During admission, progressive pancytopenia, and disseminated intravascular coagulation were observed, and the hypothesis of a tumor/neoplastic etiology was considered. A thoracoscopy revealed a moderate hemorrhagic pleural effusion and a mediastinal mass resembling a "hemolymphangiomatosis" malformation, which was biopsied. Histology displayed a lymphatic-venous malformation. The patient was presented at the multidisciplinary Vascular Anomalies Center and, due to the complex vascular anomaly diagnosis, oral sirolimus monotherapy was initiated. Four years later, the patient remains clinically stable, with stability of the lesion's dimensions and characteristics. A p.Q61R variant in the NRAS gene [NM_002524.4: c.182A>G, p.(Gln61Arg)], with 5% allelic fraction and 1993x coverage was detected. In conjunction with clinical and pathological findings, it allowed KLA final diagnosis. This case reinforces the importance of a high index of clinical suspicion and highlights the need of referring these cases to referral to Vascular Anomalies Centers.
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Affiliation(s)
- Joana Pereira-Nunes
- Centro Hospitalar Universitário de São João, Porto, Portugal
- Porto University, Porto, Portugal
| | | | - Alexandra Dinis
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Helena Barroca
- Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jorge Lima
- Porto University, Porto, Portugal
- Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Maria do Bom-Sucesso
- Centro Hospitalar Universitário de São João, Porto, Portugal
- Porto University, Porto, Portugal
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19
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Naumchik B, Weigel BJ, Murati MA, Rudzinski E, Paulson V, Lockwood CM, Dolan M, Flanagan S, Luquette M. Congenital Infantile Fibrosarcoma Involving Pelvic Wall and Thigh Soft Tissues and Placenta, Presenting with Coagulopathy. Pediatr Dev Pathol 2022; 25:656-660. [PMID: 35834223 DOI: 10.1177/10935266221114017] [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] [Indexed: 12/14/2022]
Abstract
Infantile fibrosarcoma (IF) is a well characterized pediatric malignancy marked by gene rearrangements involving members of the NTRK family. In this report, we present a case of IF that presented in the inguinal region-proximal thigh and was initially thought to be a kaposiform hemangioendothelioma (KHE) because it presented with a bleeding diathesis thought to be Kasabach-Merritt phenomenon (KMP). Subsequently, the placental examination showed a neoplasm in the perivascular-subendothelial space of stem villi, initially thought to be myofibromatosis. Ultimately, a biopsy of the thigh mass showed IF with an NTRK3-ETV6 fusion. Subsequent FISH analysis of the placenta showed an ETV6 rearrangement confirming that it was also IF. Review of the laboratory studies suggests that disseminated intravascular coagulation may have been more likely than KMP, highlighting the difficulty in making this distinction in some cases. We believe this to be the first report of an IF presenting in a soft tissue site and the placenta, and discuss the possible mechanisms that could have allowed the IF in the leg to spread to the placenta.
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Affiliation(s)
- Brianna Naumchik
- Pathology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Brenda J Weigel
- Pediatrics, Division of Pediatric Hematology and Oncology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Michael A Murati
- Radiology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Erin Rudzinski
- Pathology, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Vera Paulson
- Laboratory Medicine and Pathology, 7284University of Washington, Seattle, WA, USA
| | - Christina M Lockwood
- Laboratory Medicine and Pathology, 7284University of Washington, Seattle, WA, USA
| | - Michelle Dolan
- Pathology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Siobhan Flanagan
- Interventional Radiology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Mark Luquette
- Pediatric and Perinatal Pathology, 5635University of Minnesota Twin Cities, Minneapolis, MN, USA
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20
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Cohen OG, Florez-Pollack S, Finn LS, Larijani M, Jen M, Treat J, Adams DM, Acord MR. Multifocal Kaposiform Hemangioendothelioma in a Newborn With Confirmatory Histopathology. Pediatrics 2022; 150:189664. [PMID: 36193691 DOI: 10.1542/peds.2022-056293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
Kaposiform hemangioendothelioma is classified as a locally aggressive vascular tumor of childhood resulting from abnormal angiogenesis and lymphangiogenesis. Most commonly, KHE presents as a single tissue mass, ranging from an erythematous papule to a violaceous indurated tumor. Definitive diagnosis requires tissue sampling with the demonstration of ill-defined nodules and fascicles of spindle-shaped D2-40 positive endothelial cells, forming slit-like vascular channels. This newborn presented with multifocal cutaneous Kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon confirmed on histopathology with immunostaining.
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Affiliation(s)
| | | | - Laura S Finn
- Departments of Pathology and Laboratory Medicine
| | | | | | - James Treat
- Section of Dermatology.,Comprehensive Vascular Anomaly Program
| | - Denise M Adams
- Comprehensive Vascular Anomaly Program.,Division of Oncology
| | - Michael R Acord
- University of Pennsylvania Perelman School of Medicine.,Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Fedidat R, Elia A, Hershko A, Fridlender Z. Recurrent haemoptysis: a rare diagnosis of kaposiform lymphangiomatosis and review of literature. BMJ Case Rep 2022; 15:e250825. [PMID: 36171013 PMCID: PMC9528592 DOI: 10.1136/bcr-2022-250825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare clinicopathological entity among lymphatic anomalies. The main involved sites are the mediastinum and the lungs but the disease can also affect multiple extrathoracic organs. Little is known about the pathophysiology, the natural history, the treatment response and the long-term outcome of this disorder. KLA is typically diagnosed in childhood. We present here the case of an adult man with 13 years recurrent episodes of haemoptysis who was finally found to suffer from KLA. Following this, we present a comprehensive review of the literature.
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Affiliation(s)
| | - Anna Elia
- Pathology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Alon Hershko
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Clinical Immunology, Hadassah Medical Center, Jerusalem, Israel
| | - Zvi Fridlender
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Pulmonology, Hadassah Medical Center, Jerusalem, Israel
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22
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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: 16] [Impact Index Per Article: 8.0] [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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23
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Mack JM, Crary SE. How we approach coagulopathy with vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29353. [PMID: 36070211 DOI: 10.1002/pbc.29353] [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: 04/07/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 01/19/2023]
Abstract
Some vascular anomalies can present with challenging hematologic aberrations. Kaposiform hemangioendothelioma (KHE) may be complicated with Kasabach-Merritt phenomenon (KMP) and stagnant blood flow in slow-flow malformations can promote activation and consumption of coagulation factors, which results in bleeding and clotting known as localized intravascular coagulopathy (LIC). These patients can experience significant morbidity secondary to pain due to thrombosis and are at higher risk of hematologic complications during surgical procedures. No standard of care has been established to prevent or manage these complications. This review focuses on the management of coagulopathy in children and adults with vascular anomalies.
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Affiliation(s)
- Joana M Mack
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Shelley E Crary
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
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24
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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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25
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Geng X, Srinivasan RS. Molecular Mechanisms Driving Lymphedema and Other Lymphatic Anomalies. Cold Spring Harb Perspect Med 2022; 12:a041272. [PMID: 35817543 PMCID: PMC9341459 DOI: 10.1101/cshperspect.a041272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Lymphatic vasculature regulates fluid homeostasis by absorbing interstitial fluid and returning it to blood. Lymphatic vasculature is also critical for lipid absorption and inflammatory response. Lymphatic vasculature is composed of lymphatic capillaries, collecting lymphatic vessels, lymphatic valves, and lymphovenous valves. Defects in any of these structures could lead to lymphatic anomalies such as lymphedema, cystic lymphatic malformation, and Gorham-Stout disease. Basic research has led to a deeper understanding of the stepwise development of the lymphatic vasculature. VEGF-C and shear stress signaling pathways have evolved as critical regulators of lymphatic vascular development. Loss-of-function and gain-of-function mutations in genes that are involved in these signaling pathways are associated with lymphatic anomalies. Importantly, drugs that target these molecules are showing outstanding efficacy in treating certain lymphatic anomalies. In this article, we summarize these exciting developments and highlight the future challenges.
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Affiliation(s)
- Xin Geng
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73013, USA
| | - R Sathish Srinivasan
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73013, USA
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73117, USA
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Shaheen MF, Tse JY, Sokol ES, Masterson M, Bansal P, Rabinowitz I, Tarleton CA, Dobroff AS, Smith TL, Bocklage TJ, Mannakee BK, Gutenkunst RN, Bischoff J, Ness SA, Riedlinger GM, Groisberg R, Pasqualini R, Ganesan S, Arap W. Genomic landscape of lymphatic malformations: a case series and response to the PI3Kα inhibitor alpelisib in an N-of-1 clinical trial. eLife 2022; 11:e74510. [PMID: 35787784 PMCID: PMC9255965 DOI: 10.7554/elife.74510] [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: 10/07/2021] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Lymphatic malformations (LMs) often pose treatment challenges due to a large size or a critical location that could lead to disfigurement, and there are no standardized treatment approaches for either refractory or unresectable cases. Methods We examined the genomic landscape of a patient cohort of LMs (n = 30 cases) that underwent comprehensive genomic profiling using a large-panel next-generation sequencing assay. Immunohistochemical analyses were completed in parallel. Results These LMs had low mutational burden with hotspot PIK3CA mutations (n = 20) and NRAS (n = 5) mutations being most frequent, and mutually exclusive. All LM cases with Kaposi sarcoma-like (kaposiform) histology had NRAS mutations. One index patient presented with subacute abdominal pain and was diagnosed with a large retroperitoneal LM harboring a somatic PIK3CA gain-of-function mutation (H1047R). The patient achieved a rapid and durable radiologic complete response, as defined in RECIST1.1, to the PI3Kα inhibitor alpelisib within the context of a personalized N-of-1 clinical trial (NCT03941782). In translational correlative studies, canonical PI3Kα pathway activation was confirmed by immunohistochemistry and human LM-derived lymphatic endothelial cells carrying an allele with an activating mutation at the same locus were sensitive to alpelisib treatment in vitro, which was demonstrated by a concentration-dependent drop in measurable impedance, an assessment of cell status. Conclusions Our findings establish that LM patients with conventional or kaposiform histology have distinct, yet targetable, driver mutations. Funding R.P. and W.A. are supported by awards from the Levy-Longenbaugh Fund. S.G. is supported by awards from the Hugs for Brady Foundation. This work has been funded in part by the NCI Cancer Center Support Grants (CCSG; P30) to the University of Arizona Cancer Center (CA023074), the University of New Mexico Comprehensive Cancer Center (CA118100), and the Rutgers Cancer Institute of New Jersey (CA072720). B.K.M. was supported by National Science Foundation via Graduate Research Fellowship DGE-1143953. Clinical trial number NCT03941782.
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Affiliation(s)
- Montaser F Shaheen
- University of Arizona Cancer CenterTucsonUnited States
- Division of Hematology/Oncology, Department of Medicine, University of Arizona College of MedicineTucsonUnited States
| | - Julie Y Tse
- Foundation Medicine, IncCambridgeUnited States
| | | | - Margaret Masterson
- Rutgers Cancer Institute of New JerseyNew BrunswickUnited States
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical SchoolNew BrunswickUnited States
| | - Pranshu Bansal
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Division of Hematology/Oncology, Department of Internal Medicine, University of New Mexico School of MedicineAlbuquerqueUnited States
| | - Ian Rabinowitz
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Division of Hematology/Oncology, Department of Internal Medicine, University of New Mexico School of MedicineAlbuquerqueUnited States
| | - Christy A Tarleton
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico School of MedicineAlbuquerqueUnited States
| | - Andrey S Dobroff
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico School of MedicineAlbuquerqueUnited States
| | - Tracey L Smith
- Rutgers Cancer Institute of New JerseyNewarkUnited States
- Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical SchoolNewarkUnited States
| | - Thèrése J Bocklage
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Department of Pathology, University of Kentucky College of Medicine and Markey Cancer CenterLexingtonUnited States
| | - Brian K Mannakee
- University of Arizona Cancer CenterTucsonUnited States
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of ArizonaTucsonUnited States
| | - Ryan N Gutenkunst
- University of Arizona Cancer CenterTucsonUnited States
- Department of Molecular and Cellular Biology, College of Science, University of ArizonaTucsonUnited States
| | - Joyce Bischoff
- Vascular Biology Program, Boston Children’s HospitalBostonUnited States
- Department of Surgery, Harvard Medical SchoolBostonUnited States
| | - Scott A Ness
- University of New Mexico Comprehensive Cancer CenterAlbuquerqueUnited States
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico School of MedicineAlbuquerqueUnited States
| | - Gregory M Riedlinger
- Rutgers Cancer Institute of New JerseyNew BrunswickUnited States
- Department of Pathology, Rutgers Robert Wood Johnson Medical SchoolNew BrunswickUnited States
| | - Roman Groisberg
- Rutgers Cancer Institute of New JerseyNew BrunswickUnited States
- Division of Medical Oncology, Department of Medicine, Rutgers Robert Wood Johnson Medical SchoolNew BrunswickUnited States
| | - Renata Pasqualini
- Rutgers Cancer Institute of New JerseyNewarkUnited States
- Division of Cancer Biology, Department of Radiation Oncology, Rutgers New Jersey Medical SchoolNewarkUnited States
| | - Shridar Ganesan
- Rutgers Cancer Institute of New JerseyNew BrunswickUnited States
- Division of Medical Oncology, Department of Medicine, Rutgers Robert Wood Johnson Medical SchoolNew BrunswickUnited States
| | - Wadih Arap
- Rutgers Cancer Institute of New JerseyNewarkUnited States
- Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical SchoolNewarkUnited States
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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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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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29
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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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30
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Cai Y, Li J, Yang W, Zhang N, Sun H, Zhang W, Ge M. Case Report: Congenital Intracranial Kaposiform Hemangioendothelioma Treated With Surgical Resection. Front Surg 2022; 9:831190. [PMID: 35433800 PMCID: PMC9012330 DOI: 10.3389/fsurg.2022.831190] [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: 12/23/2021] [Accepted: 02/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background Kaposiform hemangioendothelioma (KHE) is a locally aggressive but non-metastatic vascular neoplasm. Most studies have been restricted to small case series of limited generalizability. Intracranial KHE is extremely rare with only three cases reported in the literature. Here, we report a case of congenital intracranial KHE who underwent surgical resection, and no lesion recurrence was seen during the follow-up period of 13 months. Case Description A 2-month-old boy initially presented with a left temporal mass following birth. Antenatal ultrasound at 36 weeks of gestation demonstrated a hyperechoic signal present in the left frontal lobe, with clear borders and irregular morphology. There were neither cutaneous abnormalities nor other neurologic examination abnormalities. No laboratory abnormality was identified. Computed tomography (CT) scans suggested that a massive hematoma was noted under the left frontal skull plate, with a little subdural hemorrhage in the adjacent temporal area. The adjacent meninges enhanced and thickened on contrasted T1 magnetic resonance (MR). After the multidisciplinary diagnostic assessment, the surgery was performed by the left frontotemporal craniotomy approach. The operation was extremely difficult. We completely removed the tumor, and the involved dura and brain tissue were resected with the lesion in a piecemeal fashion. On postoperative-day (POD) 3 and POD 14, the head CT re-examination revealed that cerebral perfusion improved gradually. The MRI of 6- and 12-month after operation showed no local recurrence or metastasis. Conclusions Intracranial KHE is difficult to diagnose early and the prognosis has been uniformly poor. We supposed that meticulous intraoperative hemostasis is the key for a successful operation, and the radical resection of the tumor and involved structures are essential to reduce recurrence.
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Affiliation(s)
- Yingjie Cai
- National Center for Children's Health, Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiayi Li
- Graduate School, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wei Yang
- National Center for Children's Health, Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Nan Zhang
- National Center for Children's Health, Department of Pathology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Hailang Sun
- National Center for Children's Health, Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Weiping Zhang
- Graduate School, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
- *Correspondence: Weiping Zhang
| | - Ming Ge
- National Center for Children's Health, Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
- Ming Ge
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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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Allen-Rhoades W, Al-Ibraheemi A, Kohorst M, Tollefson M, Hull N, Polites S, Folpe AL. Cellular Variant of Kaposiform Lymphangiomatosis: A Report of Three Cases, Expanding the Morphologic and Molecular Genetic Spectrum of this Rare Entity. Hum Pathol 2022; 122:72-81. [PMID: 35202617 DOI: 10.1016/j.humpath.2022.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/12/2022] [Indexed: 11/04/2022]
Abstract
Kaposiform lymphangiomatosis (KLA) is a very rare form of generalized lymphatic anomaly, consisting of a diffuse proliferation of abnormal, dilated lymphatics and small fascicles of hemosiderin-laden spindled lymphatic endothelial cells. KLA occurs in children and young adults and may present with multicentric disease, pleural and pericardial effusions, and life-threatening coagulopathy. Genetically, KLA most often harbor somatic activating mutations in NRAS. We recently encountered 3 cases of KLA with cellular features, resembling kaposiform hemangioendothelioma (KHE) and studied their clinicopathologic, radiologic and molecular genetic features. The patients (1 male, 2 females; ages 2 years, 2 months, 4 years) presented with multicentric disease involving skin, soft tissue, bone and spleen, and thrombocytopenia/coagulopathy. Advanced imaging studies confirmed multicentric disease. Biopsies (skin, soft tissue, bone, spleen) demonstrated both conventional KLA and much more cellular foci, consisting of sheets, nodules, glomeruloid structures, and "sieve-like" arrays of lymphatic endothelial cells (positive for CD31 and D2-40). Cellular areas superficially resembled KHE but displayed more epithelioid cytology and lacked surrounding hyaline fibrosis and minute platelet aggregates. Molecular genetic studies demonstrated NRAS c.181C>A p.Q61K (Gln61Lys) in 2 specimens from one patient and HRAS p.A59_Q61delinsGGSIL in another. Two patients were treated with sirolimus; all are currently alive with stable disease. We conclude that cellular morphology in KLA, a previously undescribed feature, does not appear to be associated with clinical features, site of disease, mutation type, response to sirolimus, or outcome. Although cellular KLA may mimic KHE, there are sufficient clinical, morphologic, and genetic differences such that these are likely unrelated diseases.
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Affiliation(s)
- Wendy Allen-Rhoades
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology & Oncology, Rochester, MN USA 55905
| | | | - Mira Kohorst
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology & Oncology, Rochester, MN USA 55905
| | - Megha Tollefson
- Mayo Clinic, Departments of Dermatology and Pediatric and Adolescent Medicine, Rochester, MN USA 55905
| | - Nathan Hull
- Mayo Clinic, Department of Radiology, Rochester, MN USA 55905
| | - Stephanie Polites
- Mayo Clinic, Department of Surgery, Division of Pediatric Surgery, Rochester, MN USA 55905
| | - Andrew L Folpe
- Mayo Clinic, Department Laboratory Medicine and Pathology, Rochester, MN USA 55905.
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Genetic and Molecular Determinants of Lymphatic Malformations: Potential Targets for Therapy. J Dev Biol 2022; 10:jdb10010011. [PMID: 35225964 PMCID: PMC8883961 DOI: 10.3390/jdb10010011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 12/15/2022] Open
Abstract
Lymphatic malformations are fluid-filled congenital defects of lymphatic channels occurring in 1 in 6000 to 16,000 patients. There are various types, and they often exist in conjunction with other congenital anomalies and vascular malformations. Great strides have been made in understanding these malformations in recent years. This review summarize known molecular and embryological precursors for lymphangiogenesis. Gene mutations and dysregulations implicated in pathogenesis of lymphatic malformations are discussed. Finally, we touch on current and developing therapies with special attention on targeted biotherapeutics.
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Angiopoietin-2-induced lymphatic endothelial cell migration drives lymphangiogenesis via the β1 integrin-RhoA-formin axis. Angiogenesis 2022; 25:373-396. [PMID: 35103877 DOI: 10.1007/s10456-022-09831-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 11/08/2021] [Indexed: 11/01/2022]
Abstract
Lymphangiogenesis is an essential physiological process but also a determining factor in vascular-related pathological conditions. Angiopoietin-2 (Ang2) plays an important role in lymphatic vascular development and function and its upregulation has been reported in several vascular-related diseases, including cancer. Given the established role of the small GTPase RhoA on cytoskeleton-dependent endothelial functions, we investigated the relationship between RhoA and Ang2-induced cellular activities. This study shows that Ang2-driven human dermal lymphatic endothelial cell migration depends on RhoA. We demonstrate that Ang2-induced migration is independent of the Tie receptors, but dependent on β1 integrin-mediated RhoA activation with knockdown, pharmacological approaches, and protein sequencing experiments. Although the key proteins downstream of RhoA, Rho kinase (ROCK) and myosin light chain, were activated, blockade of ROCK did not abrogate the Ang2-driven migratory effect. However, formins, an alternative target of RhoA, were identified as key players, and especially FHOD1. The Ang2-RhoA relationship was explored in vivo, where lymphatic endothelial RhoA deficiency blocked Ang2-induced lymphangiogenesis, highlighting RhoA as an important target for anti-lymphangiogenic treatments.
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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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36
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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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37
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Nozawa A, Ozeki M, Yasue S, Endo S, Noguchi K, Kanayama T, Tomita H, Aoki Y, Ohnishi H. Characterization of kaposiform lymphangiomatosis tissue-derived cells. Pediatr Blood Cancer 2021; 68:e29086. [PMID: 33913609 DOI: 10.1002/pbc.29086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/22/2021] [Accepted: 04/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a recently characterized systemic lymphatic anomaly. Activation of RAS/MAPK and PI3K/AKT/mTOR pathways may affect KLA pathogenesis, but the cellular basis of KLA is unclear. Abnormal-spindle endothelial cells that express lymphatic endothelial cell (LEC) markers are characteristic of KLA histopathology. This study evaluated patient-derived KLA cells to establish their morphological and biological characteristics. PROCEDURE We established cell lines from primary KLA tissues of two patients with KLA and examined their morphological and functional characteristics, messenger RNA and protein expression profiles, gene mutations, and responses to inhibitors of the RAS/MAPK and PI3K/AKT/mTOR pathways. RESULTS Both KLA cell lines showed spindle-shaped morphology, stained positive for podoplanin (PDPN), and exhibited impaired tube-formation properties. They expressed LEC marker PDPN and mesenchymal stem cell markers (CD90, CD105) in the absence of endothelial cell markers (CD34, CD31, VWF), per real-time polymerase chain reaction. Both mTOR inhibitor rapamycin and MEK inhibitor trametinib inhibited growth of the two cell lines. A NRAS p.Q61R variant was found in one of two independent KLA tissue samples, but not in the KLA cells (per targeted next-generation sequencing); and KLA cells with this variant had elevated AKT phosphorylation levels. ERK phosphorylation levels were undetectable in both KLA cell lines. CONCLUSIONS Inhibition of the RAS/MAPK and PI3K/AKT/mTOR pathways may represent potential therapeutic targets in KLA. These patient-derived KLA cell lines will be useful research tools to elucidate KLA etiology, and could pave the way for basic, translational, and preclinical studies of this disease.
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Affiliation(s)
- Akifumi Nozawa
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan.,Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kei Noguchi
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tomohiro Kanayama
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
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38
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Nakamura F, Kato H, Ozeki M, Matsuo M. CT and MRI Findings of Focal Splenic Lesions and Ascites in Generalized Lymphatic Anomaly, Kaposiform Lymphangiomatosis, and Gorham-Stout Disease. J Clin Imaging Sci 2021; 11:44. [PMID: 34513208 PMCID: PMC8422418 DOI: 10.25259/jcis_101_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022] Open
Abstract
Objectives: This study aimed to evaluate the CT and MRI findings of focal splenic lesions and ascites in generalized lymphatic anomaly (GLA), kaposiform lymphangiomatosis (KLA), and Gorham-Stout disease (GSD). Material and Methods: Twenty-three patients (10 with GLA, 5 with KLA, and 8 with GSD) who underwent abdominal CT and/or MRI before treatment were included in this study, and their imaging findings were retrospectively evaluated. Results: Focal splenic lesions were observed in nine patients; these lesions were observed frequently in GLA (n = 5; 50%) or KLA (n = 3; 60%) compared with GSD (n = 1; 13%); however, no significant differences were found between the three groups (P = 0.190). On CT images among eight patients (4 with GLA, 3 with KLA, and 1 with GSD) with focal splenic lesions who underwent CT, the number of focal splenic lesions per patient ranged from 2 to 189 (mean, 42) and the maximum diameter of focal splenic lesions ranged from 2 to 39 mm (mean, 8 mm), while more than 30 focal splenic lesions per patient were observed in 2 (50%) GLA and focal splenic lesions with maximum diameters of ≥10 mm were observed in 4 (100%) GLA but not in KLA or GSD. Ascites was observed in five patients; significant differences were observed among KLA (n = 4; 80%), GLA (n = 1; 10%), and GSD (n = 0; 0%) (P < 0.01). Ascites was significantly more frequent in KLA than in GSD (P < 0.05). Conclusion: More than 30 focal splenic lesions per patient and/or focal splenic lesions with maximum diameters of ≥10 mm were observed only in GLA. Focal splenic lesions tended to be less frequent in GSD, whereas ascites tended to be frequent in KLA.
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Affiliation(s)
| | - Hiroki Kato
- Department of Radiology, Gifu University, Gifu, Japan
| | - Michio Ozeki
- Department of Radiology, Gifu University, Gifu, Japan
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39
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Abstract
Vascular anomalies are composed of tumors and malformations and with overlapping histologies, thus are often misdiagnosed or labeled with imprecise terminology. Lesions are common and usually diagnosed during infancy or childhood; the estimated prevalence is 4.5%. Vascular tumors rapidly enlarge postnatally and demonstrate endothelial proliferation. Malformations are errors in vascular development with stable endothelial turnover; they are typically named based on the primary vessel that is malformed (capillary, arterial, venous, lymphatic). This article reviews the pathologic and molecular genetic characteristics for select recently described vascular anomalies.
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Affiliation(s)
- Alyaa Al-Ibraheemi
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3027, Boston, MA 02115, USA.
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40
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AlTeneiji M, Brundler MA, Noseworthy M, Kurek KC. Unilateral congenital pulmonary lymphangiectasis presenting with pneumothorax and an NRAS variant. Pediatr Pulmonol 2021; 56:2374-2376. [PMID: 33852777 DOI: 10.1002/ppul.25401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/15/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Majid AlTeneiji
- Section of Pediatric Respirology, Department of Pediatrics, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| | - Marie-Anne Brundler
- Department of Pediatrics, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada.,Department of Pathology and Laboratory Medicine, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| | - Mary Noseworthy
- Section of Pediatric Respirology, Department of Pediatrics, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
| | - Kyle C Kurek
- Department of Pathology and Laboratory Medicine, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada.,Department of Medical Genetics, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
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41
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Zhou J, Yang K, Chen S, Ji Y. Sirolimus in the treatment of kaposiform lymphangiomatosis. Orphanet J Rare Dis 2021; 16:260. [PMID: 34103076 PMCID: PMC8186093 DOI: 10.1186/s13023-021-01893-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA), which is a new subtype of generalized lymphatic anomaly, is a rare disease with a poor prognosis. Currently, there is no standard treatment due to the poor understanding of KLA. Sirolimus, which is an inhibitor of mammalian target of rapamycin, has been shown to have promising potential in the treatment of complicated vascular anomalies. The aim of this study was to introduce the use of sirolimus for the treatment of KLA and to highlight the challenges of managing this refractory disease. RESULTS We reported seven patients with KLA who received sirolimus therapy in our center. Combined with previously reported cases, 58.3% achieved a partial response, 25.0% had stable disease, and 16.7% experienced disease progression. No severe sirolimus-related adverse events occurred during treatment. CONCLUSIONS This study suggests that sirolimus is currently an option for the treatment of KLA, and it is hoped that more specific therapies will be developed in the future. Rapid advances in basic science and clinical practice may facilitate the development of important new treatments for KLA.
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Affiliation(s)
- Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
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42
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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: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [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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43
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Zhu K, Gu W, Wang L, Wang J, Tang H, Shen H, Jiang K, Shu Q. A 6-Year-Old Boy With a Mediastinal Mass. Chest 2021; 158:e317-e321. [PMID: 33280776 DOI: 10.1016/j.chest.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 06/10/2020] [Accepted: 07/04/2020] [Indexed: 11/16/2022] Open
Abstract
CASE PRESENTATION A 6-year-old boy was referred to our hospital with an anterior mediastinal mass. This was discovered by chest radiography performed when the boy was examined after being caught by an elevator door about 2 weeks earlier. The patient had been born full term without any complications during pregnancy or delivery. No clinical symptoms were observed during this presentation, and he had no history of previous infections.
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Affiliation(s)
- Kun Zhu
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weizhong Gu
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Larry Wang
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jinhu Wang
- Department of Surgical Oncology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hongfeng Tang
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hongqiang Shen
- Clinical Laboratory Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Kewen Jiang
- Biobank Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiang Shu
- Department of Thoracic and Cardiovascular Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.
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44
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Elbaaly H, Piché N, Rypens F, Kleiber N, Lapierre C, Dubois J. Intra-abdominal lymphatic malformation management in light of the updated International Society for the Study of Vascular Anomalies classification. Pediatr Radiol 2021; 51:760-772. [PMID: 33559726 DOI: 10.1007/s00247-020-04930-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/26/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The International Society for the Study of Vascular Anomalies (ISSVA) classification distinguishes between common lymphatic malformations and complex lymphatic anomalies. These entities have overlapping features but differing responses to treatment. Surgery has been the mainstream treatment in intra-abdominal lymphatic malformation, with variable reported success in the literature. OBJECTIVE The aim of this study was to review the outcome of different treatments for intra-abdominal lymphatic malformations in children. MATERIALS AND METHODS We retrospectively reviewed all intra-abdominal lymphatic malformations from 1999 to 2019 in children treated by the surgical team or followed in the vascular anomalies clinic of our institution. Children were classified into one of three groups: group A, isolated intra-abdominal lymphatic malformation; group B, common lymphatic malformation in continuity with other regions; or group C, intra-abdominal involvement as part of a complex lymphatic anomaly or associated syndrome. RESULTS Fifty intra-abdominal lymphatic malformations were diagnosed; five of these were excluded. In group A (n=28), the treatment was surgical resection (n=26) or sclerosing treatment (n=1), with one case of spontaneous regression; no recurrence was observed in 25 patients. In group B (n=7), three patients had partial resection and all had recurrence; four had sclerotherapy alone with good response. In group C (n=10), therapeutic options included surgery, sclerosing treatment and pharmacotherapy, with variable outcomes. CONCLUSION The management of intra-abdominal malformations requires a team approach. Sclerotherapy is successful in treating macrocystic lymphatic malformation. Surgery is successful in treating isolated intra-abdominal common lymphatic malformation, albeit at times at the cost of intestinal resection, which could be avoided by combining surgery with preoperative sclerotherapy. With surgery there is often limited resectability, and therefore recurrence in intra-abdominal lymphatic malformations that are part of complex lymphatic anomalies associated with syndromes, or in common lymphatic malformations in continuity with other regions. Sclerotherapy is an effective modality in these instances along with pharmacotherapy.
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Affiliation(s)
- Heba Elbaaly
- Medical Imaging Department, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Nelson Piché
- Surgery Department, CHU Sainte-Justine, Montreal, QC, Canada
| | - Françoise Rypens
- Medical Imaging Department, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Niina Kleiber
- Pediatrics Department, CHU Sainte-Justine, Montreal, QC, Canada
| | - Chantale Lapierre
- Medical Imaging Department, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Josée Dubois
- Medical Imaging Department, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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45
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Soderlund KA, Mamlouk MD, Shah VN, Roland JL, Dillon WP. Cerebrospinal fluid-lymphatic fistula causing spontaneous intracranial hypotension in a child with kaposiform lymphangiomatosis. Pediatr Radiol 2021; 51:2093-2097. [PMID: 34286352 PMCID: PMC8294238 DOI: 10.1007/s00247-021-05132-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/04/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
Spontaneous intracranial hypotension is an uncommon etiology of secondary headaches in children. We report a unique case of a girl with kaposiform lymphangiomatosis who developed postural headaches and imaging features of spontaneous intracranial hypotension without a spinal extradural collection. The girl underwent dynamic computed tomography myelography which revealed a cerebrospinal fluid (CSF)-lymphatic fistula related to a lymphatic malformation associated with the right T10 nerve. She underwent surgical ligation of the CSF-lymphatic fistula, resulting in resolution of the headaches. Spinal CSF-lymphatic fistulas are rare and have previously been reported in two patients with Gorham-Stout disease. The current report suggests that patients with systemic lymphatic anomalies who develop postural headaches should undergo evaluation for spontaneous intracranial hypotension and a CSF-lymphatic fistula. If discovered, surgical ligation is a potential treatment.
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Affiliation(s)
- Karl A Soderlund
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave., Room L352, San Francisco, CA, 94143, USA.
| | - Mark D Mamlouk
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave., Room L352, San Francisco, CA, 94143, USA
- Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, CA, USA
| | - Vinil N Shah
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave., Room L352, San Francisco, CA, 94143, USA
| | - Jarod L Roland
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - William P Dillon
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave., Room L352, San Francisco, CA, 94143, USA
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46
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Abstract
Lymphangioma is a common type of congenital vascular disease in children with a broad spectrum of clinical manifestations. The current classification of lymphangioma by International Society for the Study of Vascular Anomalies is largely based on the clinical manifestations and complications and is not sufficient for selection of therapeutic strategies and prognosis prediction. The clinical management and outcome of lymphangioma largely depend on the clinical classification and the location of the disease, ranging from spontaneous regression with no treatment to severe sequelae even with comprehensive treatment. Recently, rapid progression has been made toward elucidating the molecular pathology of lymphangioma and the development of treatments. Several signaling pathways have been revealed to be involved in the progression and development of lymphangioma, and specific inhibitors targeting these pathways have been investigated for clinical applications and clinical trials. Some drugs already currently in clinical use for other diseases were found to be effective for lymphangioma, although the mechanisms underlying the anti-tumor effects remain unclear. Molecular classification based on molecular pathology and investigation of the molecular mechanisms of current clinical drugs is the next step toward developing more effective individualized treatment of children with lymphangioma with reduced side effects.
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Affiliation(s)
- Xiaowei Liu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Cheng Cheng
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Kai Chen
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Yeming Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
| | - Zhixiang Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
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47
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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: 1.0] [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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48
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Foster JB, Li D, March ME, Sheppard SE, Adams DM, Hakonarson H, Dori Y. Kaposiform lymphangiomatosis effectively treated with MEK inhibition. EMBO Mol Med 2020; 12:e12324. [PMID: 32894644 PMCID: PMC7539180 DOI: 10.15252/emmm.202012324] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 01/10/2023] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare lymphatic anomaly primarily affecting the mediastinum with high mortality rate. We present a patient with KLA and significant disease burden harboring a somatic point mutation in the Casitas B lineage lymphoma (CBL) gene. She was treated with MEK inhibition with complete resolution of symptoms, near-complete resolution of lymphatic fluid burden, and remodeling of her lymphatic system. While patients with KLA have been reported to harbor mutations in NRAS, here we report for the first time a causative mutation in the CBL gene in a patient with KLA, successfully treated with Ras pathway inhibition.
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Affiliation(s)
- Jessica B Foster
- Division of OncologyChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Dong Li
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Michael E March
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Sarah E Sheppard
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Divisions of Human Genetics and Pulmonary MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Denise M Adams
- Vascular Anomalies CenterBoston Children's HospitalBostonMAUSA
| | - Hakon Hakonarson
- Center for Applied GenomicsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Divisions of Human Genetics and Pulmonary MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Yoav Dori
- Center for Lymphatic Imaging and InterventionsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
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49
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Chen G, Graf NS, Pang T. Isolated abdominal kaposiform lymphangiomatosis: a novel presentation of a rare entity. Pathology 2020; 53:279-282. [PMID: 33036770 DOI: 10.1016/j.pathol.2020.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- George Chen
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia.
| | - Nicole S Graf
- The Children's Hospital Westmead, Westmead, NSW, Australia
| | - Tony Pang
- The University of Sydney, Sydney, NSW, Australia
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50
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Abstract
Vascular anomalies, comprised of vascular tumors and malformations, are frequently associated with coagulopathy. Recognition of and familiarity with these vascular anomaly-associated hematologic abnormalities prior to surgery or interventional procedures is essential for pre-operative pre-operative planning. Complicated coagulopathies present within the framework of either Kasabach-Merritt phenomenon (KMP) or localized intravascular coagulopathy (LIC), and their management benefits from the expertise of a hematologist for optimal intra- and peri‑operative care. Furthermore, with the recent broadening of understanding of vascular anomalies and the addition of new classification sub-groups, distinctions of these two classic coagulopathy phenotypes have been recognized. This review summarizes the main features of these coagulopathies, described according to their vascular anomaly type, highlighting clinical aspects relevant to surgical management.
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Affiliation(s)
- Kiersten W Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7015, Cincinnati 45229, OH, United States.
| | - Leonardo R Brandão
- The Hospital for Sick Children, Division of Haematology-Oncology, Toronto, Ontario, Canada
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