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Champion ML, Maier JG, Bushman ET, Barney JB, Casey BM, Sinkey RG. Systematic Review of Lymphangioleiomyomatosis Outcomes in Pregnancy and a Proposed Management Guideline. Am J Perinatol 2024; 41:e1508-e1520. [PMID: 36898409 PMCID: PMC10582203 DOI: 10.1055/a-2051-8395] [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] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Lymphangioleiomyomatosis (LAM) is a rare, multisystem disease that primarily affects women of reproductive age. Disease progression has been linked to estrogen exposure, and as such many patients are advised to avoid pregnancy. Data are limited regarding the interaction between LAM and pregnancy, and as such we performed a systematic review to summarize available literature reporting outcomes of pregnancies complicated by maternal LAM. STUDY DESIGN This was a systematic review including randomized controlled trials, observational studies, systematic reviews, case reports, clinical practice guidelines, and quality improvement studies with full-text manuscripts or abstracts in the English language with primary data on pregnant or postpartum patients with LAM. The primary outcome was maternal outcomes during pregnancy as well as pregnancy outcomes. Secondary outcomes were neonatal outcomes and long-term maternal outcomes. This search occurred in July 2020 and included MEDLINE, Scopus, clinicaltrials.gov, Embase, and Cochrane Central. Risk of bias was ascertained using the Newcastle-Ottawa Scale. Our systematic review was registered with PROSPERO as protocol number CRD 42020191402. RESULTS A total of 175 publications were identified in our initial search; ultimately 31 studies were included. Six (19%) studies were retrospective cohort studies and 25 (81%) studies were case reports. Patients diagnosed during pregnancy had worse pregnancy outcomes compared to those diagnosed with LAM prior to pregnancy. Multiple studies reported a significant risk of pneumothoraces during pregnancy. Other significant risks included preterm delivery, chylothoraces, and pulmonary function deterioration. A proposed strategy for preconception counseling and antenatal management is provided. CONCLUSION Patients diagnosed with LAM during pregnancy generally experience worse outcomes including recurrent pneumothoraces and preterm delivery as compared to patients with a LAM diagnosis prior to pregnancy. Given that there are limited studies available, and that the majority are low-quality evidence and subject to bias, further investigation of the interaction between LAM and pregnancy is warranted to guide patient care and counseling. KEY POINTS · Data are limited on the effects of lymphangioleiomyomatosis on pregnancy outcomes.. · We performed a systematic review to summarize pregnancy outcomes complicated by LAM.. · Patients diagnosed with LAM during pregnancy experience worse outcomes..
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Affiliation(s)
- Macie L. Champion
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Julia G. Maier
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Elisa T. Bushman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph B. Barney
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel G. Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, Alabama
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Rebaine Y, Nasser M, Girerd B, Leroux C, Cottin V. Tuberous sclerosis complex for the pulmonologist. Eur Respir Rev 2021; 30:30/161/200348. [PMID: 34348978 PMCID: PMC9488995 DOI: 10.1183/16000617.0348-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/20/2021] [Indexed: 12/18/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disorder affecting almost all organs with no sex predominance. TSC has an autosomal-dominant inheritance and is caused by a heterozygous mutation in either the TSC1 or TSC2 gene leading to hyperactivation of the mammalian target of rapamycin (mTOR). TSC is associated with several pulmonary manifestations including lymphangioleiomyomatosis (LAM), multifocal micronodular pneumocyte hyperplasia (MMPH) and chylous effusions. LAM is a multisystem disorder characterised by cystic destruction of lung parenchyma, and may occur in either the setting of TSC (TSC-LAM) or sporadically (S-LAM). LAM occurs in 30–40% of adult females with TSC at childbearing age and is considered a nonmalignant metastatic neoplasm of unknown origin. TSC-LAM is generally milder and, unlike S-LAM, may occur in males. It manifests as multiple, bilateral, diffuse and thin-walled cysts with normal intervening lung parenchyma on chest computed tomography. LAM is complicated by spontaneous pneumothoraces in up to 70% of patients, with a high recurrence rate. mTOR inhibitors are the treatment of choice for LAM with moderately impaired lung function or chylous effusion. MMPH, manifesting as multiple solid and ground-glass nodules on high-resolution computed tomography, is usually harmless with no need for treatment. Tuberous sclerosis complex is associated with diverse pulmonary manifestations including LAM, multiple micronodular pneumocyte hyperplasia and chylous effusions. LAM occurs in 30–40% of adult females with tuberous sclerosis complex.https://bit.ly/3iLqZ08
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Affiliation(s)
- Yasmine Rebaine
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Division of Pulmonology, Dept of Medicine, Hôpital Charles-LeMoyne, Montréal, QC, Canada.,Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Both authors contributed equally
| | - Mouhamad Nasser
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Both authors contributed equally
| | - Barbara Girerd
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,AP-HP, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Caroline Leroux
- Université Claude Bernard Lyon 1, Université de Lyon, INRAE, UMR754, Member of ERN-LUNG, RespiFil, OrphaLung, Lyon, France
| | - Vincent Cottin
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France .,Université Claude Bernard Lyon 1, Université de Lyon, INRAE, UMR754, Member of ERN-LUNG, RespiFil, OrphaLung, Lyon, France
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Faverio P, De Giacomi F, Bonaiti G, Stainer A, Sardella L, Pellegrino G, Sferrazza Papa GF, Bini F, Bodini BD, Carone M, Annoni S, Messinesi G, Pesci A. Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights. Int J Med Sci 2019; 16:967-980. [PMID: 31341410 PMCID: PMC6643124 DOI: 10.7150/ijms.32752] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/05/2019] [Indexed: 01/11/2023] Open
Abstract
Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Federica De Giacomi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Bonaiti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Anna Stainer
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Luca Sardella
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Pellegrino
- Casa di Cura del Policlinico, Dipartimento di Scienze Neuroriabilitative, Milan, Italy
| | | | - Francesco Bini
- UOC Pulmonology, Department of Internal Medicine, Ospedale ASST-Rhodense, Garbagnate Milanese, Italy
| | - Bruno Dino Bodini
- Pulmonology Unit, Ospedale Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Mauro Carone
- UOC Pulmonology and Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS di Cassano Murge (BA), Italy
| | - Sara Annoni
- Physical therapy and Rehabilitation Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Grazia Messinesi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Alberto Pesci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
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Torre O, Elia D, Caminati A, Harari S. New insights in lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis. Eur Respir Rev 2017; 26:26/145/170042. [PMID: 28954765 PMCID: PMC9488980 DOI: 10.1183/16000617.0042-2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/26/2017] [Indexed: 12/15/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) and pulmonary Langerhans cell histiocytosis (PLCH) are rare diseases that lead to progressive cystic destruction of the lungs. Despite their distinctive characteristics, these diseases share several features. Patients affected by LAM or PLCH have similar radiological cystic patterns, a similar age of onset, and the possibility of extrapulmonary involvement. In this review, the recent advances in the understanding of the molecular pathogenesis, as well as the current and most promising biomarkers and therapeutic approaches, are described. Understanding of LAM/PLCH pathogenesis has improved over the past years, leading to new therapeutic approacheshttp://ow.ly/7wjR30erSJY
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Affiliation(s)
- Olga Torre
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Davide Elia
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Antonella Caminati
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
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Abstract
Lymphangioleiomyomatosis (LAM) is a rare neoplastic disease affecting predominantly young women. Clinical symptoms of this progressive disease include dyspnoea, cough, recurrent pneumothorax, hemoptysis and chylothorax. LAM is generally aggressive in nature and ultimately results in respiratory failure. Important hallmark features of this metastatic disease include the formation of lesions of abnormal smooth muscle cells, cystic destruction of the lung tissue and lymphangiogenesis affecting the lungs, abdomen and lymphatics. Research over the last 10-15 years has significantly enhanced our understanding of the molecular and cellular processes associated with LAM. These processes include mutational inactivation of the tuberous sclerosis complex genes, TSC1 and TSC2, activation of the mammalian target of rapamycin (mTOR) pathway, enhanced cell proliferation and migration, lymphangiogenesis, metastatic spread through the blood and lymphatic circulations, sex steroid sensitivity and dysregulated autophagy. Despite this increased knowledge there is currently no cure for LAM and treatment options remain limited. Whilst the mTOR inhibitor rapamycin has shown some benefit in patients with LAM, with stabilisation of lung function and improved quality of life, cessation of treatment results in recurrence of the disease progression. This highlights the urgent need to identify novel targets and new treatment regimens. The focus of this review is to summarise our current understanding of the cellular and molecular processes associated with LAM and highlight emerging treatments.
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Affiliation(s)
- Lyn M Moir
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; Discipline of Pharmacology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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Chen R, Lin L, Tian JW, Zeng B, Zhang L, Chen X, Yan HY. Predictors of dynamic hyperinflation during the 6-minute walk test in stable chronic obstructive pulmonary disease patients. J Thorac Dis 2015; 7:1142-50. [PMID: 26380729 DOI: 10.3978/j.issn.2072-1439.2015.07.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/27/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Dynamic hyperinflation (DH) is a major contributor to exercise limitation in chronic obstructive pulmonary disease (COPD). Therefore, we aimed to elucidate the physiological factors responsible for DH development during the 6-minute walk test (6MWT) in COPD patients and compare ventilatory response to the 6MWT in hyperinflators and non-hyperinflators. METHODS A total of 105 consecutive subjects with stable COPD underwent a 6MWT, and the Borg dyspnea scale, oxygen saturation (SpO2), breathing pattern, and inspiratory capacity (IC) were recorded before and immediately after walking. The change in IC was measured, and subjects were divided into hyperinflators (ΔIC >0.0 L) and non-hyperinflators (ΔIC ≤0.0 L). Spirometry, the Modified Medical Research Council (MMRC) dyspnea scale and St George's Respiratory Questionnaire (SGRQ) were also assessed. RESULTS DH was present in 66.67% of subjects. ΔIC/IC was significantly and negatively correlated with the small airway function. On multiple stepwise regression analysis forced expiratory flow after exhaling 50% of the forced vital capacity (FEF50%) was the only predictor of ΔIC/IC. Non-hyperinflators had a higher post-walking VT (t=2.419, P=0.017) and post-walking VE (t=2.599, P=0.011) than the hyperinflators did. Age and resting IC were independent predictors of the 6-minute walk distance (6MWD) in hyperinflators. CONCLUSIONS DH was considerably common in subjects with COPD. Small airway function may partly contribute to the DH severity during walking. The ventilator response to the 6MWT differed between hyperinflators and non-hyperinflators. Resting hyperinflation is an important predictor of functional exercise capacity in hyperinflators.
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Affiliation(s)
- Rui Chen
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Lin Lin
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Jing-Wei Tian
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Bin Zeng
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Lei Zhang
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Xin Chen
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Hai-Yan Yan
- 1 Department of Respiratory Diseases, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 2 Laboratory of Rehabilitation, Guangdong Provincial Hospital, Guangzhou 510055, China ; 3 Department of Respiratory Diseases, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China ; 4 Department of Clinical Laboratory, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
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El-Chemaly S, Henske EP. The next breakthrough in LAM clinical trials may be their design: challenges in design and execution of future LAM clinical trials. Expert Rev Respir Med 2015; 9:195-204. [PMID: 25757365 DOI: 10.1586/17476348.2015.1024663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The past decade has resulted in stunning progress in the pathogenesis and therapy of lymphangioleiomyomatosis (LAM), culminating in the pivotal 'MILES' trial, the first-ever randomized, placebo-controlled trial in LAM, demonstrating the efficacy of sirolimus in 2011. Here, we review clinical progress since 2011, focusing on new therapeutic and observational trials. These trials include the second randomized, placebo-controlled trial, a 2-year study of doxycycline effectiveness in LAM. Other clinical studies have addressed lower-dose sirolimus and treatment of pulmonary hypertension. An improved understanding of LAM pathogenesis is essential to future therapeutic breakthroughs. Critical questions that remain to be addressed include the role of estrogen and lymphangiogenesis in LAM pathogenesis and therapy, mechanisms of cystic lung destruction, the role of autophagy and pro-survival pathways in LAM cell survival. Ultimately, achieving future 'breakthroughs' in LAM will require continued rigorous basic and preclinical investigation, innovative clinical trial design and robust biomarkers.
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Affiliation(s)
- Souheil El-Chemaly
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, One Blackfan Circle, Karp 6th Floor, Boston, MA 02115, USA
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Abstract
INTRODUCTION Pulmonary lymphangioleiomyomatosis (LAM) is a rare progressive lung disease affecting almost exclusively women. Neoplastic growth of atypical smooth muscle-like cells in the lung induces destruction of lung parenchyma leading to the formation of lung cysts, rupture of which results in spontaneous pneumothorax. LAM occurs sporadically or in association with inherited hamartoma syndrome tuberous sclerosis complex (TSC). Progression of LAM often results in loss of pulmonary function and death. Increasing understanding of neoplastic LAM cell growth is driving the development of therapeutic approaches targeting the disease progression. AREAS COVERED This review provides background to understand the rationale for current treatments used in patients with LAM, to critically appraise the evidence for these treatments, and to discuss future treatment approaches. The literature review includes publications from PubMed and clinicaltrials.gov/. EXPERT OPINION Targeting mTOR activation with rapamycin analogs sirolimus and everolimus are awaiting approval by the FDA for treatment of LAM. A number of other treatment options have been investigated and are currently tested in clinical trials to target LAM cell survival and metastasis. Key remaining and poorly understood areas for development and validation of therapeutic targeting in LAM are destruction of lungs, pathological lymphangiogenesis, and hormonal regulation. Future will reveal whether they could be targeted therapeutically.
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Affiliation(s)
- Vera P Krymskaya
- Airway Biology Initiative, Pulmonary, Allergy & Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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