A Girl with Gorham-Stout Disease

A narrative review of the role of sirolimus in the treatment of congenital vascular malformations

OBJECTIVE

Vascular malformations arise from defects in the morphologic development of the vascular system and can have an impact on quality of life and/or lead to severe complications. To date, vascular malformations are frequently managed by invasive techniques, after which recurrence is common. Sirolimus, a downstream inhibitor of the phosphatidylinositol 3 kinase/AKT pathway and best known for its immunosuppressive effect, has been used off-label for lesions for which approved therapies were associated with unsatisfactory results or recurrence. The aim of this study was to review the available data on the effect of sirolimus on the size and symptoms of different types of malformations and to summarize the main safety issues.

METHODS

A literature search in Pubmed, Embase, Web of Science, and SCOPUS was performed. Case reports, case series, and clinical trials evaluating the effect of sirolimus in vascular malformations were eligible for this review. Fully terminated studies published between January 2010 and May 2019 reporting an evaluable response on size and/or symptoms were included. Relevant data on lesion size, symptoms, side effects and duration of treatment were extracted as reported in the study. Additionally, we reported 10 unpublished cases who were treated in UZ Leuven.

RESULTS

The literature review included 68 articles, describing 324 patients. The median duration of therapy was 12 months (range, 1-60 months). After 6 months of treatment, the size of the malformation had at least decreased in 67% of patients with common venous malformations (VM), in 93% of patients with blue rubber bleb nevus syndrome and in all patients with verrucous VM. The size of lymphatic malformations improved in more than 80% of the patients, even in the case of extensive involvement such as in Gorham-Stout disease and generalized lymphatic anomaly. In addition, the majority of patients with syndromic vascular malformations experienced a decrease in size and reported symptoms improved in almost all patients, regardless of the type of malformation. Side effects were common (53%) but usually mild; mucositis and bone marrow suppression were the most common. Regrowth or recurrence of symptoms occurred in 49% of patients who discontinued treatment. Comparable effects were seen in our own patients.

CONCLUSIONS

This review shows that sirolimus is effective in decreasing the size and/or symptoms of particularly lymphatic malformations as well as VMs. Although common, side effects were usually mild. Nevertheless, clinical trials are needed to confirm the safety and effectivity of sirolimus and to identify the required serum levels and duration of treatment.

Gorham-Stout disease successfully treated with sirolimus (rapamycin): a case report and review of the literature

BACKGROUND

Gorham-Stout disease (GSD) is a rare disease characterized by bone lesions and osteolysis. Therapy usually involves surgical resection. Sirolimus (Rapamycin) is used in some patients with GSD but the efficacy and safety of Sirolimus remains unclear. We propose that Sirolimus may be a novel therapeutic for GSD and present a case and review of literature that supports this.

CASE PRESENTATION

We presented a 1-year-old boy with GSD involving osteolysis of the right humerus with fracture of the left femur complicated by an effusion in the right pleural cavity. X-rays showed osteolysis in the right clavicle. A large pleural effusion was observed on the right-side, and the left lung was significantly compressed. X-rays also showed a fracture of the left femur. A femoral biopsy was performed that showed necrotic tissue in the cortical bone and a large number of irregularly shaped capillaries that proliferated within the necrotic tissue. Dilated lymphatic vessels were seen adjacent to the cortex, with fibrous tissue hyperplasia. We prescribed sirolimus, which is an oral mTOR inhibitor, for two consecutive years. The boy recovered well without other progressive bone lesions and participates in normal daily activities. His growth and development are the same as that of his peers.

DISCUSSION AND CONCLUSION

Gorham-Stout disease is a rare and enigmatic disease characterized by the presentation of an intraosseous lymphatic anomaly (LM), which results in progressive bone resorption. Based on this case report and a literature review, we conclude that sirolimus may be an effective alternative medication for GSD.

Gorham-Stout Disease of the Shoulder: Clinical, Pathologic and Therapeutic Considerations

BACKGROUND

Gorham-Stout disease (GSD) is a rare skeletal disorder characterized by massive osteolysis of a bony area in the body. When it hits the shoulder, the patient is faced with a debilitating limitation in terms of motion, stability and quality of life. GSD etiology and pathology are unknown and, as a result, therapeutic modalities remain unclear. The aim of this paper is to explore and offer medical insight into the possible etiologies, pathologies and therapeutic modalities of GSD in the shoulder.

METHODS

We explored PubMed/Medline for GSD cases in the shoulder. The search involved all articles published from database inception until February 1, 2019. Only articles published in English were included. Demographics and clinical information extrapolated from the reported cases were analyzed to deduce patterns and infer conclusions.

RESULTS

Only 32 studies met our criteria, with a total of 37 cases (n=37). Males predominated in 21 cases (57%). Twelve cases (32%) were younger than 18 years, and 18 cases (49%) were aged between 18 and 65 years. Shoulder pain was the predominant reporting symptom. The humerus was the most common shoulder site affected (54%), followed by the scapula (35%) and the clavicle (30%). Almost half of the cases affected the right shoulder (51%), the left shoulder was affected in 16 cases (43%). Conservative treatment was opted in 17 cases (46%), while surgery was performed in 13 cases (35%). Good outcomes were reported in 28 cases (76%), while death occurred twice (5%).

CONCLUSION

Understanding the demographics and clinical characteristics of GSD in the shoulder region will help in formulating better therapeutic interventions and preventive health policies.