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Ozeki M, Endo S, Yasue S, Nozawa A, Asada R, Saito AM, Hashimoto H, Fujimura T, Yamada Y, Kuroda T, Ueno S, Watanabe S, Nosaka S, Miyasaka M, Umezawa A, Matsuoka K, Maekawa T, Hirakawa S, Furukawa T, Fumino S, Tajiri T, Takemoto J, Souzaki R, Kinoshita Y, Fujino A. Sirolimus treatment for intractable lymphatic anomalies: an open-label, single-arm, multicenter, prospective trial. Front Med (Lausanne) 2024; 11:1335469. [PMID: 38390569 PMCID: PMC10881825 DOI: 10.3389/fmed.2024.1335469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Intractable lymphatic anomalies (LAs) include cystic lymphatic malformation (LM; macrocystic, microcystic, or mixed), generalized lymphatic anomaly, and Gorham-Stout disease. LAs can present with severe symptoms and poor prognosis. Thus, prospective studies for treatments are warranted. We conducted a prospective clinical trial of sirolimus for intractable LAs. Methods This was an open-label, single-arm, multicenter, prospective trial involving five institutions in Japan. All patients with LAs received oral sirolimus once daily, and the dose was adjusted to ensure that the trough concentration remained within 5-15 ng/mL. We prospectively assessed the drug response (response rate for radiological volumetric change in target lesion), performance state, change in respiratory function, visceral impairment (pleural effusion, ascites, bleeding, pain), laboratory examination data, quality of life (QOL), and safety at 12, 24, and 52 weeks of administration. Results Eleven patients with LAs (9 generalized lymphatic anomaly, 1 cystic LM, 1 Gorham-Stout disease) were treated with sirolimus, of whom 6 (54.5%; 95% confidence interval: 23.4-83.3%) demonstrated a partial response on radiological examination at 52 weeks of administration. No patients achieved a complete response. At 12 and 24 weeks of administration, 8 patients (72.7%) already showed a partial response. However, patients with stable disease showed minor or no reduction after 12 weeks. Adverse events, such as stomatitis, acneiform dermatitis, diarrhea, and fever, were common with sirolimus. Sirolimus was safe and tolerable. Conclusion Sirolimus can reduce the lymphatic tissue volume in LAs and may lead to improvements in clinical symptoms and QOL.
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Affiliation(s)
- Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Akifumi Nozawa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Ryuta Asada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Innovative and Clinical Research Promotion Center, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroya Hashimoto
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takumi Fujimura
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shigeru Ueno
- Department of Pediatric Surgery, Tokai University School of Medicine, Hiratsuka, Japan
| | - Shoji Watanabe
- Department of Plastic Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Miyasaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiro Umezawa
- National Center for Child Health and Development, Research Institute, Tokyo, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Hirakawa
- Department of Dermatology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigehisa Fumino
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Junkichi Takemoto
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Ryota Souzaki
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Akihiro Fujino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
- Division of Surgery, Department of Surgical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
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Wm Te Loo DM, Harbers V, Vermeltfoort L, Coenen MJ. Influence of genetic variants on the pharmacokinetics and pharmacodynamics of sirolimus: a systematic review. Pharmacogenomics 2023; 24:629-639. [PMID: 37551646 DOI: 10.2217/pgs-2022-0147] [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: 08/09/2023] Open
Abstract
Sirolimus is an antiproliferative and immunosuppressive compound inhibiting the mTOR pathway, which is often activated in congenital low-flow vascular malformations. Studies have demonstrated the efficacy of sirolimus for this disease. Studies in kidney transplant patients suggest that genetic variants can influence these pharmacokinetic parameters. Therefore, a systematic literature search was performed to gain insight into pharmacogenetic studies with sirolimus. Most studies investigated CYP3A4 and CYP3A5, with inconsistent results. No pharmacogenetic studies focusing on sirolimus have been performed for low-flow vascular malformations. We analyzed two common variants of CYP3A4 and CYP3A5 (CYP3A4*22 and CYP3A5*3, respectively) in patients (n = 59) with congenital low-flow vascular malformations treated with sirolimus. No association with treatment outcome was identified in this small cohort of patients.
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Affiliation(s)
- D Maroeska Wm Te Loo
- Department of Pediatric Hematology, Amalia Children's Hospital, Radboud university medical center, Geert Grooteplein Zuid 32, Nijmegen, 6525 GA, The Netherlands
- Radboudumc Center of Expertise Hemangiomas & Congenital Vascular Malformations Nijmegen, Amalia Children's Hospital, Radboud university medical center, Rene Descartes Dreef 1, Nijmegen, 6525 GL, The Netherlands
| | - Veroniek Harbers
- Department of Medical Imaging, Radboud university medical center, Geert Grooteplein Zuid 22, Nijmegen, 6525 GA, The Netherlands
| | - Lars Vermeltfoort
- Department of Pediatric Hematology, Amalia Children's Hospital, Radboud university medical center, Geert Grooteplein Zuid 32, Nijmegen, 6525 GA, The Netherlands
| | - Marieke Jh Coenen
- Department of Clinical Chemistry, Erasmus University Medical Center, Dr Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
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Harbers VEM, Zwerink LGJM, Rongen GA, Klein WM, van der Vleuten CJM, van Rijnsoever IMP, Gerdsen-Drury L, Flucke UE, Verhoeven BH, de Laat PCJ, van der Horst CMAM, Schultze Kool LJ, Te Loo DMWM. Clinical differences in sirolimus treatment with low target levels between children and adults with vascular malformations - A nationwide trial. Clin Transl Sci 2023; 16:781-796. [PMID: 36824030 PMCID: PMC10176016 DOI: 10.1111/cts.13488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/14/2023] [Accepted: 01/27/2023] [Indexed: 02/25/2023] Open
Abstract
The clinical presentation of patients with slow-flow vascular malformations is very heterogeneous. High clinical burden and subsequent reduced health-related quality of life is something they have in common. There is an unmet medical need for these patients for whom regular treatments like surgery and embolization are either insufficient or technically impossible. Sirolimus has been reported to be effective and overall well-tolerated in most patients. However, the main limitation of sirolimus is the reported high toxicity, especially when target levels of 10-15 ng/mL are being used. We report the results of a phase IIB single-arm open-label clinical trial consisting of 68 (67 in the challenge phase and 68 in the rechallenge phase) evaluable patients (children n = 33 and adults n = 35) demonstrating that treatment with low sirolimus target levels (4-10 ng/mL) is effective in 79.1% of the patients. When sirolimus treatment was stopped, the majority of patients experienced a recurrence of symptoms, supporting prolonged or even lifelong treatment requirement. Adults experienced a higher baseline pain score compared with children, having an estimated marginal mean of 6.2 versus 4.1, p < 0.05; however, they showed a similar decrease to children. Furthermore, the pediatric population experienced less often a sirolimus-related grade I-IV adverse event (35.9% vs. 64.1%, p > 0.05) compared with adults. Additionally, response rates were higher in children compared with adults (93.8% vs. 65.7%, p < 0.05), and children responded faster (28 vs. 91 days, p < 0.05). These results suggest benefits of sirolimus in patients with slow-flow vascular malformations and support its initiation as young as possible.
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Affiliation(s)
- Veroniek E M Harbers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lilly G J M Zwerink
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerard A Rongen
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemijn M Klein
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carine J M van der Vleuten
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands.,VASCERN ERN on Rare Multisystemic Vascular Diseases, Healthcare Provider Coordinator: Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Centre de Réference (CRMR) Syndromes de Marfan et apparentés, Paris, France
| | - Ingrid M P van Rijnsoever
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lynda Gerdsen-Drury
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Uta E Flucke
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas H Verhoeven
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter C J de Laat
- Department of Pediatric Oncology, WEVAR-Team Rotterdam Erasmus MC-Sophia, Rotterdam, The Netherlands
| | - Chantal M A M van der Horst
- Department of Plastic Reconstructive and Hand Surgery, AVA-Team, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Leo J Schultze Kool
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,VASCERN ERN on Rare Multisystemic Vascular Diseases, Healthcare Provider Coordinator: Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Centre de Réference (CRMR) Syndromes de Marfan et apparentés, Paris, France
| | - D Maroeska W M Te Loo
- Radboudumc Center of Expertise HECOVAN, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatric Hematology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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