1
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Chen JJ, Lee CK, Yang CY. High-Grade Malignant Peripheral Nerve Sheath Tumor Arising From Common Peroneal Nerve Neurofibroma. Cureus 2024; 16:e59607. [PMID: 38832183 PMCID: PMC11144666 DOI: 10.7759/cureus.59607] [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] [Accepted: 05/01/2024] [Indexed: 06/05/2024] Open
Abstract
This article presents a case report of a 45-year-old male with neurofibromatosis type I (NF1) who developed a high-grade malignant peripheral nerve sheath tumor (MPNST) originating from a neurofibroma within the common peroneal nerve over popliteal fossa. MPNSTs are aggressive tumors associated with NF1, causing significant mortality. The patient underwent tumor resection surgery and received postoperative radiation therapy. Follow-up examinations showed no impairment of motor function and no tumor recurrence after regular MRI evaluation for four years. This article explores the challenges of distinguishing benign neurofibromas from malignant MPNST via MRI image and biopsy, and achieving a balance between tumor excision and preserving nerve functionality during surgical treatment. However, caution is warranted due to the risk of recurrence.
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Affiliation(s)
- Jian-Jiun Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, TWN
| | - Chien-Kuan Lee
- Department of Pathology, Kuang Tien General Hospital, Taichung, TWN
| | - Chen-Yuan Yang
- Department of Orthopedic Surgery, Kuang Tien General Hospital, Taichung, TWN
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2
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Lalvani S, Brown RM. Neurofibromatosis Type 1: Optimizing Management with a Multidisciplinary Approach. J Multidiscip Healthc 2024; 17:1803-1817. [PMID: 38680880 PMCID: PMC11055545 DOI: 10.2147/jmdh.s362791] [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: 12/10/2023] [Accepted: 04/09/2024] [Indexed: 05/01/2024] Open
Abstract
Neurofibromatosis Type I (NF1) is a complex genetic condition that affects multiple organ systems and presents a unique set of challenges for clinicians in its management. NF1 is a tumor predisposition syndrome that primarily affect the peripheral and central nervous systems via the impact of haploinsufficiency upon neural crest lineage cells including Schwann cells, melanocytes, fibroblasts, etc. NF1 can further lead to pathology of the skin, bones, visual system, and cardiovascular system, all of which can drastically reduce a patient's quality of life (QOL). This review provides a comprehensive examination of the many specialties required for the care of patients with Neurofibromatosis Type 1 (NF1). We delve into the pathogenesis and clinical presentation of NF1, highlighting its diverse manifestations and the challenges they pose in management. The review underscores the importance of a multidisciplinary approach to NF1, emphasizing how such an approach can significantly improve patient outcomes and overall QOL. Central to this approach is the role of the NF expert, who guides a multidisciplinary team (MDT) comprising healthcare professionals from many areas of expertise. The MDT collaboratively addresses the multifaceted needs of NF1 patients, ensuring comprehensive and personalized care. This review highlights the need for further investigation to optimize the workflow for NF1 patients in an MDT setting, and to improve implementation and efficacy.
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Affiliation(s)
- Shaan Lalvani
- Department of Neurology, The Mount Sinai Hospital, New York, NY, USA
| | - Rebecca M Brown
- Department of Neurology, The Mount Sinai Hospital, New York, NY, USA
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3
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Merker VL, Thompson HL, Wolters PL, Buono FD, Hingtgen CM, Rosser T, Barton B, Barnett C, Smith T, Haberkamp D, McManus ML, Baldwin A, Moss IP, Röhl C, Martin S. Recommendations for assessing appearance concerns related to plexiform and cutaneous neurofibromas in neurofibromatosis 1 clinical trials. Clin Trials 2024; 21:6-17. [PMID: 38140900 PMCID: PMC10922038 DOI: 10.1177/17407745231205577] [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] [Indexed: 12/24/2023]
Abstract
BACKGROUND/AIMS Individuals with neurofibromatosis 1 may experience changes in their appearance due to physical manifestations of the disorders and/or treatment sequelae. Appearance concerns related to these physical changes can lead to psychological distress and poorer quality of life. While many neurofibromatosis 1 clinical trials focus on assessing changes in tumor volume, evaluating patients' perspectives on corresponding changes in symptoms such as physical appearance can be key secondary outcomes. We aimed to determine whether any existing patient-reported outcome measures are appropriate for evaluating changes in appearance concerns within neurofibromatosis 1 clinical trials. METHODS After updating our previously published systematic review process, we used it to identify and rate existing patient-reported outcome measures related to disfigurement and appearance. Using a systematic literature search and initial triage process, we focused on identifying patient-reported outcome measures that could be used to evaluate changes in appearance concerns in plexiform or cutaneous neurofibroma clinical trials in neurofibromatosis 1. Our revised Patient-Reported Outcome Rating and Acceptance Tool for Endpoints then was used to evaluate each published patient-reported outcome measures in five domains, including (1) respondent characteristics, (2) content validity, (3) scoring format and interpretability, (4) psychometric data, and (5) feasibility. The highest-rated patient-reported outcome measures were then re-reviewed in a side-by-side comparison to generate a final consensus recommendation. RESULTS Eleven measures assessing appearance concerns were reviewed and rated; no measures were explicitly designed to assess appearance concerns related to neurofibromatosis 1. The FACE-Q Craniofacial Module-Appearance Distress scale was the top-rated measure for potential use in neurofibromatosis 1 clinical trials. Strengths of the measure included that it was rigorously developed, included individuals with neurofibromatosis 1 in the validation sample, was applicable to children and adults, covered item topics deemed important by neurofibromatosis 1 patient representatives, exhibited good psychometric properties, and was feasible for use in neurofibromatosis 1 trials. Limitations included a lack of validation in older adults, no published information regarding sensitivity to change in clinical trials, and limited availability in languages other than English. CONCLUSION The Response Evaluation in Neurofibromatosis and Schwannomatosis patient-reported outcome working group currently recommends the FACE-Q Craniofacial Module Appearance Distress scale to evaluate patient-reported changes in appearance concerns in clinical trials for neurofibromatosis 1-related plexiform or cutaneous neurofibromas. Additional research is needed to validate this measure in people with neurofibromatosis 1, including older adults and those with tumors in various body locations, and explore the effects of nontumor manifestations on appearance concerns in people with neurofibromatosis 1 and schwannomatosis.
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Affiliation(s)
- Vanessa L Merker
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA, USA
| | - Heather L Thompson
- Department of Communication Sciences and Disorders, California State University, Sacramento, Sacramento, CA, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Frank D Buono
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Tena Rosser
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Belinda Barton
- Faculty of Health, Discipline of Psychology, Southern Cross University, Coffs Harbour, NSW, Australia
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Taylor Smith
- Department of Psychology and Child Development, California Polytechnic State University, San Luis Obispo, CA, USA
| | | | | | - Andrea Baldwin
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - Claas Röhl
- NF Kinder, NF Patients United, Vienna, Austria
| | - Staci Martin
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD, USA
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4
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Saleh M, Dib A, Beaini S, Saad C, Faraj S, El Joueid Y, Kotob Y, Saoudi L, Emmanuel N. Neurofibromatosis type 1 system-based manifestations and treatments: a review. Neurol Sci 2023; 44:1931-1947. [PMID: 36826455 DOI: 10.1007/s10072-023-06680-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Neurofibromatosis type 1 (NF1) is a genetic disorder caused by a mutation in the NF1 gene. This disease presents with various system-based manifestations, including cardiac, musculoskeletal, and neuronal issues, which have been well-studied in previous research and have prompted the development of current and emerging treatments. These treatments, mainly medications targeting specific manifestations of NF1, aim to mitigate the negative impacts of the disease on patients' lives. NF1 is associated with an increased risk of malignancy and a significant decrease in life expectancy. In this paper, we review the current and emerging treatments for NF1 in relation to its system-based manifestations. METHODS We conducted an extensive literature search using specific keywords through databases such as PubMed, Scopus, and Cochrane. The articles we found were compiled and subjected to strict inclusion and exclusion criteria. RESULTS Pharmacological advances have led to the development of products that hold promise as future treatments for NF1. Given the diverse manifestations that can affect multiple organ systems in patients with NF1, it is important to consider a variety of treatment options to achieve optimal results. However, one of the major challenges in diagnosing and treating NF1 is that patients present asymptomatically, making it necessary to rely on clinical features for diagnosis. CONCLUSION In conclusion, NF1 is a complex disease with varying manifestations and a growing field of pharmacologic treatments. The information presented in this article synthesizes current knowledge and available therapies for NF1.
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Affiliation(s)
- Mustafa Saleh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - AlFadel Dib
- Faculty of Medicine & Medical Sciences, University of Balamand, Koura, Lebanon
| | - Sarah Beaini
- Faculty of Medicine, Université Saint Joseph de Beirut, Damascus Street, Lebanon
| | - Charbel Saad
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Sary Faraj
- Department of Anatomy, Cell Biology, and Physiological Cell Sciences, AUB- FM and MC, Beirut, Lebanon
| | - Youssef El Joueid
- Department of Medicine, School of Health Sciences, University of Georgia, Tbilisi, Georgia
| | - Yasmine Kotob
- Faculty of Medicine, Université Saint Joseph de Beirut, Damascus Street, Lebanon
| | - Lara Saoudi
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Nancy Emmanuel
- Department of Dermatology, Faculty of Medicine of the University of São Paulo, São Paulo, Brazil.
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5
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Fleming J, Morgan O, Wong C, Schlub TE, Berman Y. Characterization of health concerns in people with neurofibromatosis type 1. Mol Genet Genomic Med 2022; 11:e2077. [PMID: 36444392 PMCID: PMC9834143 DOI: 10.1002/mgg3.2077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Neurofibromatosis 1 (NF1) is a common cancer predisposition syndrome. Affected individuals require lifelong surveillance and often suffer progressive disfigurement due to cutaneous neurofibromas. The aim of this research was to characterize health concerns and quality of life (QOL) in a population cohort. METHODS An online survey was completed by 68 adults and 32 parents of children with NF1, and 60 controls. The survey included the Skindex-29 QOL scale, 5D-itch scale, and additional health questions. RESULTS Frequency of itch was high in children (50%) and adults (69%), with most expressing interest in treatment for itch. The presence of itch and increased visibility of NF1 were predictors of poorer QoL. Many adults (53%) and parents (44%) desired access to treatment to improve cosmetic appearance. Muscle weakness/tiredness was also prevalent amongst (60-70%) adults and children with NF1. Two-thirds of adults with NF1 reported limited awareness of NF1 services and poor knowledge of surveillance, particularly breast screening in young women. CONCLUSION This study highlights the impact of NF1-related itch and visibility in adults and children with a need for cosmetic and itch treatment. The findings emphasize a need for strategies to promote awareness, and access to management and treatment of NF1 in adults.
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Affiliation(s)
- Jane Fleming
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia
| | - Oliver Morgan
- Faculty of Health and MedicineUniversity of Sydney, Northern Clinical SchoolSydneyNew South WalesAustralia
| | - Claire Wong
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia,Department of Clinical GeneticsThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Timothy E. Schlub
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Yemima Berman
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia
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6
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Somatilaka BN, Sadek A, McKay RM, Le LQ. Malignant peripheral nerve sheath tumor: models, biology, and translation. Oncogene 2022; 41:2405-2421. [PMID: 35393544 PMCID: PMC9035132 DOI: 10.1038/s41388-022-02290-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 01/29/2023]
Abstract
Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive, invasive cancer that comprise around 10% of all soft tissue sarcomas and develop in about 8-13% of patients with Neurofibromatosis Type 1. They are associated with poor prognosis and are the leading cause of mortality in NF1 patients. MPNSTs can also develop sporadically or following exposure to radiation. There is currently no effective targeted therapy to treat MPNSTs and surgical removal remains the mainstay treatment. Unfortunately, surgery is not always possible due to the size and location of the tumor, thus, a better understanding of MPNST initiation and development is required to design novel therapeutics. Here, we provide an overview of MPNST biology and genetics, discuss findings regarding the developmental origin of MPNST, and summarize the various model systems employed to study MPNST. Finally, we discuss current management strategies for MPNST, as well as recent developments in translating basic research findings into potential therapies.
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Affiliation(s)
- Bandarigoda N. Somatilaka
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Ali Sadek
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Renee M. McKay
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Lu Q. Le
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,Simmons Comprehensive Cancer Center, University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,UTSW Comprehensive Neurofibromatosis Clinic, University of
Texas Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,Hamon Center for Regenerative Science and Medicine,
University of Texas Southwestern Medical Center at Dallas, Dallas, Texas,
75390-9069, USA,O’Donnell Brain Institute, University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
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7
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Spoorthy B, Jartarkar S, Kareddy S. Solitary neurofibroma over lower lip: A rare manifestation. J Cutan Aesthet Surg 2022; 15:189-192. [PMID: 35965910 PMCID: PMC9364456 DOI: 10.4103/jcas.jcas_100_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurofibromas are common nerve sheath tumors, occurring either sporadically or associated with Von Recklinghausen’s disease. Only 6.5% of solitary lesions are seen to involve the oral cavity without any features of neurofibromatosis type 1 (NF-1). It presents as a soft, skin-colored nodule with a characteristic buttonhole invagination. Histologically, it is an unencapsulated lesion consisting of proliferated neural elements, with a background of mucin and mast cells. Surgical excision is the treatment of choice. A 49-year-old female patient presented with a 35-year history of single, asymptomatic lesion over the lower lip, with no features of NF-1. On the basis of the history, histopathological findings, and dermoscopy, a diagnosis of neurofibroma was made and the lesion was excised, with no recurrence over a period of 1 year. The present case report has been reported for its interesting presentation and unusual site of involvement.
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8
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Pak KY, Pun S, Cassarino DS. Case of Symptomatic Dermal Neurofibroma With Microcystic Features. Am J Dermatopathol 2021; 43:e290-e292. [PMID: 33989218 DOI: 10.1097/dad.0000000000001961] [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: 11/26/2022]
Abstract
ABSTRACT A neurofibroma is a benign neural tumor arising within a peripheral nerve sheath composed of Schwann cells, fibroblasts, and immune cells involved in the nerve. Microcystic elements have been rarely described in these tumors. Neurofibromas are classically described as unencapsulated tumors of interspersed spindle cells and mast cells in a hypocellular, myxoid stroma. These tumors are most commonly dermal and seen in almost all patients with neurofibromatosis type 1; however, they may also occur sporadically, as seen in our case here. We report a 23-year-old patient with no significant medical history who presented with a dome-shaped papule on her cheek. This slow-growing mass had been present for multiple years and was soft, inflamed, and painful. Shave biopsy was collected and sent for evaluation. The shave biopsy diagnosed a benign neural tumor with features of a rare microcystic neurofibroma. This unencapsulated tumor consisted of microcystic spaces lined by oval-shaped to spindle-shaped cells in a matrix of myxoid to collagenous-like areas. Scattered lymphocytes and mast cells were noted, with few true vessels enclosing red blood cells. The stromal cells and cells lining the microcystic spaces stained S100 and SOX-10 positive. These cells had limited CD34 staining; however, most microcystic spaces were negative. Only the few true vessels stained CD31 positive. It is important to distinguish the prominent microcystic features in neurofibromas versus schwannomas by the lack of encapsulation or Antoni A features with Verocay bodies, which are typical of the latter. Further differentiating neurofibromas versus malignant peripheral nerve sheath tumors is required, where the latter should exhibit much greater nuclear atypic, higher cellularity, necrosis, hemorrhage, and increased mitotic activity. Excision of this benign microcystic neurofibroma was not deemed necessary because of lack of clinical concern and recurrent lesions.
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Affiliation(s)
- Kaitlynne Y Pak
- Wright State University Boonshoft School of Medicine, Dayton, OH; and
| | - Stacey Pun
- Departments of Dermatology and Pathology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - David S Cassarino
- Departments of Dermatology and Pathology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
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9
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Amaravathi A, Oblinger JL, Welling DB, Kinghorn AD, Chang LS. Neurofibromatosis: Molecular Pathogenesis and Natural Compounds as Potential Treatments. Front Oncol 2021; 11:698192. [PMID: 34604034 PMCID: PMC8485038 DOI: 10.3389/fonc.2021.698192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
The neurofibromatosis syndromes, including NF1, NF2, and schwannomatosis, are tumor suppressor syndromes characterized by multiple nervous system tumors, particularly Schwann cell neoplasms. NF-related tumors are mainly treated by surgery, and some of them have been treated by but are refractory to conventional chemotherapy. Recent advances in molecular genetics and genomics alongside the development of multiple animal models have provided a better understanding of NF tumor biology and facilitated target identification and therapeutic evaluation. Many targeted therapies have been evaluated in preclinical models and patients with limited success. One major advance is the FDA approval of the MEK inhibitor selumetinib for the treatment of NF1-associated plexiform neurofibroma. Due to their anti-neoplastic, antioxidant, and anti-inflammatory properties, selected natural compounds could be useful as a primary therapy or as an adjuvant therapy prior to or following surgery and/or radiation for patients with tumor predisposition syndromes, as patients often take them as dietary supplements and for health enhancement purposes. Here we review the natural compounds that have been evaluated in NF models. Some have demonstrated potent anti-tumor effects and may become viable treatments in the future.
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Affiliation(s)
- Anusha Amaravathi
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Janet L Oblinger
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - D Bradley Welling
- Department of Otolaryngology Head & Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, and Massachusetts General Hospital, Boston, MA, United States
| | - A Douglas Kinghorn
- Division of Medicinal Chemistry and Pharmacognosy, The Ohio State University College of Pharmacy, Columbus, OH, United States
| | - Long-Sheng Chang
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.,Department of Otolaryngology-Head & Neck Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
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10
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Ozarslan B, Russo T, Argenziano G, Santoro C, Piccolo V. Cutaneous Findings in Neurofibromatosis Type 1. Cancers (Basel) 2021; 13:463. [PMID: 33530415 PMCID: PMC7865571 DOI: 10.3390/cancers13030463] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/02/2021] [Accepted: 01/14/2021] [Indexed: 12/15/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is a complex autosomal dominant disorder associated with germline mutations in the NF1 tumor suppressor gene. NF1 belongs to a class of congenital anomaly syndromes called RASopathies, a group of rare genetic conditions caused by mutations in the Ras/mitogen-activated protein kinase pathway. Generally, NF1 patients present with dermatologic manifestations. In this review the main features of café-au-lait macules, freckling, neurofibromas, juvenile xanthogranuloma, nevus anemicus and other cutaneous findings will be discussed.
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Affiliation(s)
| | - Teresa Russo
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80100 Naples, Italy; (T.R.); (G.A.)
| | - Giuseppe Argenziano
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80100 Naples, Italy; (T.R.); (G.A.)
| | - Claudia Santoro
- Department of Woman, Neurofibromatosis Referral Centre, Child and of General and Specialised Surgery, University of Campania Luigi Vanvitelli, 80100 Naples, Italy;
| | - Vincenzo Piccolo
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80100 Naples, Italy; (T.R.); (G.A.)
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