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Lazea C, Țaranu I, Bolboacă SD. Exploring Cardiovascular Involvement in Tuberous Sclerosis: Insights for Pediatric Clinicians. CHILDREN (BASEL, SWITZERLAND) 2024; 11:674. [PMID: 38929253 PMCID: PMC11201926 DOI: 10.3390/children11060674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Tuberous sclerosis is a rare genetic disorder involving mainly the nervous and cardiovascular systems. The early recognition of the cardiovascular manifestations by the pediatrician allows an appropriate management and therefore enhances the quality of life of the affected children. Cardiac rhabdomyomas and the associated arrhythmias are the first cardiac features and they might represent a diagnosis challenge given their wide spectrum of clinical manifestations. We aimed to provide the paediatric practitioners with current knowledge regarding the cardiovascular complications in children with tuberous sclerosis. We overviewed the antenatal and postnatal evolution of cardiovascular manifestations, the systematic screening and long-term follow-up strategy of cardiac rhabdomyomas and arrhythmias in children with tuberous sclerosis.
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Affiliation(s)
- Cecilia Lazea
- Pediatric Clinic 1, Emergency Pediatric Hospital, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania;
- Department Mother and Child, Iuliu Hațieganu University of Medicine and Pharmacy, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania
| | - Ioana Țaranu
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
| | - Sorana D. Bolboacă
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
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2
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Bolshakova AS, Maslennikov DN, Shubina J, Bystritskiy AA, Tolmacheva ER, Mukosey IS, Kochetkova TO, Vasiliev GS, Atapina EE, Sadelov IO, Zaretskaya NV, Barkov IY, Degtyarev DN, Trofimov DY. Molecular diagnosis of tuberous sclerosis complex in fetuses and infants: an institutional case series. J Clin Pathol 2023:jcp-2023-208935. [PMID: 37536923 DOI: 10.1136/jcp-2023-208935] [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: 05/25/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE We describe the clinical and genetic characteristics of fetuses and infants diagnosed with tuberous sclerosis complex (TSC) in our centre, prenatally or neonatally, for a better understanding of the benefits of early screening. METHODS In this retrospective study, we analysed the data on one fetus and nine infants with a definitive TSC diagnosis by genetic criteria (five patients carrying TSC1 variants and 5 patients carrying TSC2 variants). We explored the differences between phenotypes of patients carrying TSC1 and TSC2 pathogenic variants. RESULTS The most common initial presenting features of TSC were cardiac rhabdomyomas (CRs) that were observed in nine out of ten patients. The most common postnatal features, besides CR, were presented with subependymal nodules-in five patients, and hypomelanotic macules-in four patients. In total, 10 variants causing TSC were detected in this study, including 5 novel variants. We demonstrated that patients with TSC2 variants had earlier onset and more severe clinical manifestations compared with patients carrying TSC1 variants. CONCLUSION Early diagnosis of TSC improves genetic counselling and perinatal management.
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Affiliation(s)
- Anna S Bolshakova
- Department of Clinical Genetics, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Dmitry N Maslennikov
- Laboratory of Genomic Data Analysis, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Jekaterina Shubina
- Laboratory of Genomic Data Analysis, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Andrey A Bystritskiy
- Laboratory of Molecular Genetics Methods, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Ekaterina R Tolmacheva
- Laboratory of the Analysis of Genomic Data, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Irina S Mukosey
- Laboratory of Molecular Genetics Methods, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Taisiya O Kochetkova
- Laboratory of Molecular Genetics Methods, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Grigory S Vasiliev
- Department of Clinical Genetics, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Ekaterina E Atapina
- Laboratory of Molecular Genetics Methods, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Igor O Sadelov
- Laboratory of Genomic Data Analysis, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Nadezhda V Zaretskaya
- Department of Clinical Genetics, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Ilya Yu Barkov
- Laboratory of Prenatal DNA Screening, Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Dmitry N Degtyarev
- FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
| | - Dmitry Yu Trofimov
- Institute of Reproductive Genetics, FSBI National Medical Research Center for Obstetrics Gynecology and Perinatology named after Academician V I Kulakov, Moscow, Russian Federation
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Sugalska M, Tomik A, Jóźwiak S, Werner B. Treatment of Cardiac Rhabdomyomas with mTOR Inhibitors in Children with Tuberous Sclerosis Complex-A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4907. [PMID: 34062963 PMCID: PMC8124908 DOI: 10.3390/ijerph18094907] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiac rhabdomyomas (CRs) are the earliest sign of tuberous sclerosis complex (TSC). Most of them spontaneously regress after birth. However, multiple and/or large tumors may result in heart failure or cardiac arrhythmia. Recently, the attempts to treat CRs with mTOR inhibitors (mTORi) have been undertaken. We reviewed the current data regarding the effectiveness and safety of mTORi in the treatment of CRs in children with TSC. METHODS The review was conducted according to the PRISMA guidelines. Medline, Embase, Cochrane library, and ClinicalTrial.gov databases were searched for original, full-text articles reporting the use of mTORi (everolimus or sirolimus) in the treatment of CRs in children with TSC. RESULTS Thirty articles describing 41 patients were identified (mostly case reports, no randomized or large cohort studies). Thirty-three children (80.5%) had symptomatic CRs and mTORi therapy resulted in clinical improvement in 30 of them (90.9%). CRs size reduction was reported in 95.1%. Some CRs regrew after mTORi withdrawal but usually without clinical symptoms recurrence. The observed side effects were mostly mild. CONCLUSIONS mTORi may be considered as a temporary and safe treatment for symptomatic CRs in children with TSC, especially in high-risk or inoperable tumors. However, high-quality, randomized trials are still lacking.
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Affiliation(s)
- Monika Sugalska
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Anna Tomik
- Department of Pediatric Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.T.); (B.W.)
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Bożena Werner
- Department of Pediatric Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.T.); (B.W.)
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Silva-Sánchez MP, Alvarado-Socarras JL, Castro-Monsalve J, Meneses KM, Santiago J, Prada CE. Everolimus for severe arrhythmias in tuberous sclerosis complex related cardiac rhabdomyomas. Am J Med Genet A 2021; 185:1525-1531. [PMID: 33590972 DOI: 10.1002/ajmg.a.62120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 01/19/2023]
Abstract
Intracardiac rhabdomyoma is the most common primary cardiac tumor in children. Most cases are associated with tuberous sclerosis complex (TSC). Most of them are asymptomatic in the neonate and do not require treatment. However, some develop cardiovascular symptoms such as arrhythmias, heart failure, and ventricular inflow/outflow tract obstruction in the neonatal period with early death. Many of these tumors are not candidates for surgical resection and medical management is limited. Treatment with mammalian target of rapamycin (mTOR) inhibitor is currently approved for the management of central nervous tumors and angiomyolipoma in TSC. Two patients with malignant arrhythmias related to nonsurgical multiple rhabdomyomas associated with TSC who were successfully treated with an mTOR inhibitor were described. Everolimus therapy showed significant regression of rhabdomyomas with rapid improvement of arrhythmias and heart failure prior to tumor shrinkage.
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Affiliation(s)
| | | | | | | | - Justo Santiago
- Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Carlos E Prada
- Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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5
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Knadler JJ, Lawrence E, Iacobas I, Justino H, Sheth S. Combination percutaneous and medical management of cardiac rhabdomyomas obstructing tricuspid valve inflow: Case report. J Neonatal Perinatal Med 2021; 14:143-148. [PMID: 32333554 DOI: 10.3233/npm-190330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac rhabdomyomas can be prenatally diagnosed in patients with tuberous sclerosis complex. Many neonates require no intervention in early life other than close monitoring for regression of tumor over the period of months to years. In rare instances, cardiac rhabdomyomas can result in obstruction to blood flow or decreased ventricular function. CASE REPORT We describe the case of a neonate who was prenatally diagnosed with multiple large cardiac rhabdomyomas, one of which caused clinically significant obstruction to prograde blood flow across the tricuspid valve in the newborn period. To address the disturbance to prograde pulmonary blood flow, the patient underwent successful ductal stent placement in the neonatal period. A troponin elevation was noted shortly after birth, but no evidence of coronary compression or involvement was demonstrated by coronary angiography. The patient has subsequently been treated with sirolimus over a period of three months, with noted regression in tumors and improvement in tricuspid valve inflow. CONCLUSIONS A brief review of the literature regarding the diagnosis, treatment, and management of neonatal patients with cardiac rhabdomyomas is presented. A combined percutaneous and medical management approach may be of benefit in future cases of rhabdomyomas causing obstruction to pulmonary blood flow.
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Affiliation(s)
- J J Knadler
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - E Lawrence
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - I Iacobas
- Section of Hematology/Oncology, Vascular Anomalies Center, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - H Justino
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - S Sheth
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Shibata Y, Maruyama H, Hayashi T, Ono H, Wada Y, Fujinaga H, Fujino S, Nagasawa J, Amari S, Tsukamoto K, Ito Y. Effect and Complications of Everolimus Use for Giant Cardiac Rhabdomyomas with Neonatal Tuberous Sclerosis. AJP Rep 2019; 9:e213-e217. [PMID: 31304050 PMCID: PMC6624115 DOI: 10.1055/s-0039-1692198] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/05/2019] [Indexed: 12/16/2022] Open
Abstract
Most cardiac rhabdomyomas with tuberous sclerosis (TS) are asymptomatic and spontaneously regress. However, some cases require surgical intervention due to arrhythmia and severe obstruction of cardiac inflow or outflow. We report herein a neonatal case of giant cardiac rhabdomyomas with TS and insufficient pulmonary blood flow from the right ventricle. Lipoprostaglandin E1 was necessary to maintain patency of the ductus arteriosus. We used everolimus, a mammalian target of rapamycin inhibitor, to diminish the cardiac rhabdomyomas. After treatment, the rhabdomyomas shrank rapidly, but the serum concentration of everolimus increased sharply (maximum serum trough level: 76.1 ng/mL) and induced complications including pulmonary hemorrhage, liver dysfunction, and acne. After the everolimus level decreased, the complications resolved. Everolimus may be a viable treatment option for rhabdomyomas, but its concentration requires close monitoring to circumvent complications associated with its use.
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Affiliation(s)
- Yuka Shibata
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Hidehiko Maruyama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Taiyu Hayashi
- Division of Cardiology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Hiroshi Ono
- Division of Cardiology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Yuka Wada
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Hideshi Fujinaga
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Shuhei Fujino
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Junko Nagasawa
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Shoichiro Amari
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Keiko Tsukamoto
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Setagaya, Tokyo, Japan
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7
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Davis KA, Dodeja AK, Clark A, Hor K, Baker P, Cripe LH, Cripe TP. Use of Cardiac MRI to Assess Antitumor Efficacy of Everolimus in Sporadic Cardiac Rhabdomyoma. Pediatrics 2019; 143:peds.2018-2495. [PMID: 31088894 DOI: 10.1542/peds.2018-2495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2018] [Indexed: 11/24/2022] Open
Abstract
Cardiac rhabdomyoma is the most common neonatal cardiac tumor and is typically associated with tuberous sclerosis complex (TSC). Although these tumors may naturally regress, some patients require surgical resection because of cardiac instability. If not fully resected, patients may also require medical therapy to improve their hemodynamics. Everolimus, a mammalian target of rapamycin inhibitor, has shown promise in reducing rhabdomyoma in patients with TSC, but the drug's impact in patients without TSC has not been reported. Monitoring of tumor response has typically been limited to echocardiograms, which is not ideal given inherent difficulties in three-dimensional measurements. We report a case of sporadic cardiac rhabdomyoma in a neonate treated with everolimus resulting in tumor regression as documented by cardiac MRI. While on everolimus, our patient had an increased incidence of a preexisting arrhythmia, which resolved with planned cessation of therapy, suggesting that close monitoring is imperative in patients with arrhythmia.
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Affiliation(s)
- Kyle A Davis
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant,
| | | | | | | | - Peter Baker
- Pathology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | | | - Timothy P Cripe
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant
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8
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Saffari A, Brösse I, Wiemer-Kruel A, Wilken B, Kreuzaler P, Hahn A, Bernhard MK, van Tilburg CM, Hoffmann GF, Gorenflo M, Hethey S, Kaiser O, Kölker S, Wagner R, Witt O, Merkenschlager A, Möckel A, Roser T, Schlump JU, Serfling A, Spiegler J, Milde T, Ziegler A, Syrbe S. Safety and efficacy of mTOR inhibitor treatment in patients with tuberous sclerosis complex under 2 years of age - a multicenter retrospective study. Orphanet J Rare Dis 2019; 14:96. [PMID: 31053163 PMCID: PMC6500021 DOI: 10.1186/s13023-019-1077-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/18/2019] [Indexed: 02/07/2023] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a multisystem disease with prominent neurologic manifestations such as epilepsy, cognitive impairment and autism spectrum disorder. mTOR inhibitors have successfully been used to treat TSC-related manifestations in older children and adults. However, data on their safety and efficacy in infants and young children are scarce. The objective of this study is to assess the utility and safety of mTOR inhibitor treatment in TSC patients under the age of 2 years. Results A total of 17 children (median age at study inclusion 2.4 years, range 0–6; 12 males, 5 females) with TSC who received early mTOR inhibitor therapy were studied. mTOR inhibitor treatment was started at a median age of 5 months (range 0–19 months). Reasons for initiation of treatment were cardiac rhabdomyomas (6 cases), subependymal giant cell astrocytomas (SEGA, 5 cases), combination of cardiac rhabdomyomas and SEGA (1 case), refractory epilepsy (4 cases) and disabling congenital focal lymphedema (1 case). In all cases everolimus was used. Everolimus therapy was overall well tolerated. Adverse events were classified according to the Common Terminology Criteria of Adverse Events (CTCAE, Version 5.0). Grade 1–2 adverse events occurred in 12 patients and included mild transient stomatitis (2 cases), worsening of infantile acne (1 case), increases of serum cholesterol and triglycerides (4 cases), changes in serum phosphate levels (2 cases), increase of cholinesterase (2 cases), transient neutropenia (2 cases), transient anemia (1 case), transient lymphopenia (1 case) and recurrent infections (7 cases). No grade 3–4 adverse events were reported. Treatment is currently continued in 13/17 patients. Benefits were reported in 14/17 patients and included decrease of cardiac rhabdomyoma size and improvement of arrhythmia, decrease of SEGA size, reduction of seizure frequency and regression of congenital focal lymphedema. Despite everolimus therapy, two patients treated for intractable epilepsy are still experiencing seizures and another one treated for SEGA showed no volume reduction. Conclusion This retrospective multicenter study demonstrates that mTOR inhibitor treatment with everolimus is safe in TSC patients under the age of 2 years and shows beneficial effects on cardiac manifestations, SEGA size and early epilepsy.
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Affiliation(s)
- Afshin Saffari
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ines Brösse
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Bernd Wilken
- Department of Pediatric Neurology, Kassel Hospital, Kassel, Germany
| | - Paula Kreuzaler
- Department of Child Neurology, University Hospital, Gießen, Germany
| | - Andreas Hahn
- Department of Child Neurology, University Hospital, Gießen, Germany
| | - Matthias K Bernhard
- Department of Neuropediatrics, University Hospital of Children, Leipzig, Germany
| | - Cornelis M van Tilburg
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Gorenflo
- Department for Congenital Heart Defects/Paediatric Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Hethey
- Auf der Bult - Center for Children and Adolescents, Hannover, Germany
| | - Olaf Kaiser
- Department of Paediatrics I, Paediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Robert Wagner
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Timo Roser
- Department of Paediatric Neurology and Developmental Medicine, Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Jan-Ulrich Schlump
- Division for Children and Adolescents, Evangelical Hospital Oberhausen, Oberhausen, Germany
| | | | - Juliane Spiegler
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Ziegler
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Steffen Syrbe
- Division of Child Neurology and Metabolic Medicine, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany.
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9
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Dhulipudi B, Bhakru S, Rajan S, Doraiswamy V, Koneti NR. Symptomatic improvement using everolimus in infants with cardiac rhabdomyoma. Ann Pediatr Cardiol 2019; 12:45-48. [PMID: 30745769 PMCID: PMC6343372 DOI: 10.4103/apc.apc_79_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Cardiac rhabdomyoma (CR) often shows spontaneous regression and needs close follow-up. These tumors may be associated with tuberous sclerosis complex (TSC), caused by the disinhibition of m-TOR protein. Objective: The aim of the study is to observe the efficacy of everolimus in infants with significant CR. Materials and Methods: This is a single-center prospective observational study including infants with significant CR causing either clinical symptoms or obstruction to the blood flow. Everolimus was administered at a dose of 4.5 mg/M2/wk till the symptomatic improvement. Liver and renal function tests were monitored during treatment. Results: There were six cases of suspected CR included in the study. Median age and weight of patients were 5 days (range: 1–90 days) and 3.2 kg (range: 2.2–4.5 kg), respectively. One patient was excluded after surgical excision biopsy during concomitant closure of associated large perimembranous ventricular septal defect confirmed it as a fibroma. The remaining all five cases showed regression of tumor during mean follow-up of 6.1 ± 5.1 months. One child developed varicella infection necessitating temporary discontinuation of medicine during follow-up. One case had sudden death at 4 months of age. Conclusion: Everolimus appears to be useful in selected cases of symptomatic CR. Multicentric studies are needed to determine its safety and efficacy in larger population.
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Affiliation(s)
- Bhargavi Dhulipudi
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, Telangana, India
| | - Shweta Bhakru
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, Telangana, India
| | - Saileela Rajan
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, Telangana, India
| | - Vinoth Doraiswamy
- Department of Pediatric Cardiology, Care Hospital, Hyderabad, Telangana, India
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10
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Dragoumi P, O'Callaghan F, Zafeiriou DI. Diagnosis of tuberous sclerosis complex in the fetus. Eur J Paediatr Neurol 2018; 22:1027-1034. [PMID: 30279084 DOI: 10.1016/j.ejpn.2018.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 12/18/2022]
Abstract
Tuberous sclerosis complex is a dominantly inherited genetic disorder of striking clinical variability. It is caused by mutations in either TSC1 or TSC2 gene, which regulate cell growth and proliferation by inhibition of mTORC1 signaling. TS is characterized by the development of benign tumors in many tissues and organs and its neurological manifestations include epilepsy, autism, cognitive and behavioral dysfunction, and giant cell tumors. With mechanism-based mTOR inhibitors therapy now available for many of its manifestations, early diagnosis of TSC is very important in order to offer appropriate care, long-term surveillance and parental counseling. Fetal ultrasound and MRI imaging techniques have evolved and may capture even earlier the following TSC-associated lesions: cardiac rhabdomyomas, subependymal nodules, cortical tubers and renal cysts. Often these represent an incidental finding during a routine ultrasound. Furthermore, in the past decades prenatal molecular diagnosis of TSC has emerged as an important option for families with a known affected member; however, the existing evidence with regards to the clinical characteristics and long-term outcome of babies diagnosed prenatally with TSC is yet limited and the path that follows early TSC detection merits further research.
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Affiliation(s)
- Pinelopi Dragoumi
- 1st Department of Pediatrics, Developmental Center "A. Fokas", Aristotle University of Thessaloniki, "Hippokratio" General Hospital, Thessaloniki, Greece
| | - Finbar O'Callaghan
- University College London, Institute of Child Health, Head of Clinical Neurosciences Section, Children's Department, London, UK
| | - Dimitrios I Zafeiriou
- 1st Department of Pediatrics, Developmental Center "A. Fokas", Aristotle University of Thessaloniki, "Hippokratio" General Hospital, Thessaloniki, Greece.
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Dahdah N. Everolimus for the Treatment of Tuberous Sclerosis Complex-Related Cardiac Rhabdomyomas in Pediatric Patients. J Pediatr 2017; 190:21-26.e7. [PMID: 28888564 DOI: 10.1016/j.jpeds.2017.06.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/14/2017] [Accepted: 06/30/2017] [Indexed: 01/24/2023]
Affiliation(s)
- Nagib Dahdah
- Division of Pediatric Cardiology, CHU Sainte-Justine, University of Montreal, Quebec, Canada.
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12
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Prabhu N, Osifodunrin N, Murphy D, Butler S, Hunter LE. Innovative Strategies for the Management of a Massive Neonatal Rhabdomyoma. J Pediatr Intensive Care 2017; 7:90-93. [PMID: 31073477 DOI: 10.1055/s-0037-1606574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/09/2017] [Indexed: 09/30/2022] Open
Abstract
Rhabdomyomas are histologically benign tumors known to be associated with tuberous sclerosis. The natural history predicts the majority of tumors to be asymptomatic and regress within the first year of life. We describe a neonate presenting on day 1 of life with cardiovascular collapse secondary to a massive rhabdomyoma. Surgical resection was excluded due to the extensive nature of the lesion and oral sirolimus, a mammalian target of rapamycin inhibitor, was commenced to promote tumor regression. The patient developed intractable arrhythmias requiring extracorporeal life support during therapy.
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Affiliation(s)
- N Prabhu
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, United Kingdom
| | - N Osifodunrin
- Department of Paediatric Oncology, Royal Hospital for Children, Glasgow, United Kingdom
| | - D Murphy
- Department of Paediatric Oncology, Royal Hospital for Children, Glasgow, United Kingdom
| | - S Butler
- Department of Paediatric Radiology, Royal Hospital for Children, Glasgow, United Kingdom
| | - L E Hunter
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, United Kingdom
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Abstract
Rhabdomyoma is a well characterised entity in a neonate. Herein, we report a massive biventricular rhabdomyoma in a neonate presenting with cyanosis and congestive heart failure which was confirmed on autopsy. The report is for documentation of an unusually large tumour.
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Affiliation(s)
| | - Rimlee Dutta
- Department of Pathology, AIIMS, New Delhi, India
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Aw F, Goyer I, Raboisson MJ, Boutin C, Major P, Dahdah N. Accelerated Cardiac Rhabdomyoma Regression with Everolimus in Infants with Tuberous Sclerosis Complex. Pediatr Cardiol 2017; 38:394-400. [PMID: 27878332 DOI: 10.1007/s00246-016-1528-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 11/11/2016] [Indexed: 01/25/2023]
Abstract
Tuberous sclerosis complex is associated with benign tumors such as cardiac rhabdomyomas (RHM) caused by the disinhibition of the mammalian target of rapamycin (mTOR) protein. Recent reports on everolimus, an mTOR inhibitor, have shown size reduction of RHM. We compared cases recently treated with everolimus to historic controls whose first echocardiography was within first month of life. The largest dimension of the largest RHM was reported as a percentage compared to the earliest echocardiography study. Treatment of the four cases was started at a median age of 6.5 days (range 2-20) with an initial enteral dose of 0.1 mg daily, aiming at a therapeutic serum trough level of 5-15 ng/mL. Median duration of everolimus treatment was 73 days (range 34-138). Compared to 10 historic controls, everolimus-treated patients had 11.8 times faster RHM size regression rate (slope -0.0285 vs. -0.0024; p < 0.001). The average time to 50% size reduction was 1.13 ± 0.33 month (range 0.66-1.4 months) with everolimus versus 72.9 ± 53.03 months in controls (p = 0.026). Following treatment with everolimus, one case was operated for congenital heart disease, without requirement of RHM resection, two others had the massive left ventricle RHM shrink to non-consequential size. The latter had a disappearance of RHM, but everolimus therapy was maintained to prevent the regrowth of a significant cerebral tumor. Everolimus is efficacious for size reduction of RHM during the neonatal period. With limited safety data, this approach should be used with caution in selective cases.
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Affiliation(s)
- Fatou Aw
- Division of Pediatric Cardiology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, 3175, Côte Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
- Aristide le Dantec Hospital, Cheikh Anta Diop University, Dakar, Senegal
| | - Isabelle Goyer
- Division of Clinical Pharmacology, Department of Pharmacy, CHU Sainte-Justine, University of Montreal, Montréal, QC, Canada
| | - Marie-Josée Raboisson
- Division of Pediatric Cardiology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, 3175, Côte Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Christine Boutin
- Division of Pediatric Cardiology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, 3175, Côte Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Philippe Major
- Department of Neurological Sciences, CHU Sainte-Justine, University of Montreal, Montréal, QC, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, 3175, Côte Sainte-Catherine, Montréal, QC, H3T 1C5, Canada.
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16
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Shigemitsu Y, Baba K, Kondo M, Kurita Y, Eitoku T, Fukushima Y, Hirai K, Yoshimoto J, Washio Y, Otsuki S. Regression of Massive Cardiac Rhabdomyoma Causing Circulatory Collapse with Everolimus Therapy. ACTA ACUST UNITED AC 2016. [DOI: 10.9794/jspccs.32.439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Kenji Baba
- Okayama University Hospital, Pediatric Cardiology
| | - Maiko Kondo
- Okayama University Hospital, Pediatric Cardiology
| | | | | | | | - Kenta Hirai
- Okayama University Hospital, Pediatric Cardiology
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17
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Moavero R, Romagnoli G, Graziola F, Curatolo P. Mammalian Target of Rapamycin Inhibitors and Life-Threatening Conditions in Tuberous Sclerosis Complex. Semin Pediatr Neurol 2015; 22:282-94. [PMID: 26706015 DOI: 10.1016/j.spen.2015.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tuberous sclerosis complex (TSC) is a multisystem disease associated with an overall reduction in life expectancy due to the possible occurrence of different life-threatening conditions. Subjects affected by TSC are, in fact, at risk of hydrocephalus secondary to the growth of subependymal giant cell astrocytomas, or of sudden unexpected death in epilepsy. Other nonneurological life-threatening conditions include abdominal bleeding owing to renal angiomyolipomas rupture, renal insufficiency due to progressive parenchymal destruction by multiple cysts, pulmonary complications due to lymphangioleiomyomatosis, and cardiac failure or arrhythmias secondary to rhabdomyomas. In the last decades, there has been a great progress in understanding the pathophysiology of TSC-related manifestations, which are mainly linked to the hyperactivation of the so-called mammalian target of rapamycin (mTOR) pathway, as a consequence of the mutation in 1 of the 2 genes TSC1 or TSC2. This led to the development of new treatment strategies for this disease. In fact, it is now available as a biologically targeted therapy with everolimus, a selective mTOR inhibitor, which has been licensed in Europe and USA for the treatment of subependymal giant cell astrocytomas and angiomyolipomas in subjects with TSC. This drug also proved to benefit other TSC-related manifestations, including pulmonary lymphangioleiomyomatosis, cardiac rhabdomyomas, and presumably epileptic seizures. mTOR inhibitors are thus proving to be a systemic therapy able to simultaneously address different and potentially life-threatening complications, giving the hope of improving life expectation in individuals with TSC.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy; Child Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Gloria Romagnoli
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Federica Graziola
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
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Wagner R, Riede FT, Seki H, Hornemann F, Syrbe S, Daehnert I, Weidenbach M. Oral Everolimus for Treatment of a Giant Left Ventricular Rhabdomyoma in a Neonate-Rapid Tumor Regression Documented by Real Time 3D Echocardiography. Echocardiography 2015. [PMID: 26199144 DOI: 10.1111/echo.13015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The presented case reports on successful treatment with everolimus in a neonate with left ventricular giant rhabdomyoma. The authors used a different dosage regime compared to literature and documented rapid tumor regression by 3D echocardiography.
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Affiliation(s)
- Robert Wagner
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany
| | - Frank Thomas Riede
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany
| | - Hiroshi Seki
- Department of Cardiac Surgery, University of Leipzig, Heart Center, Leipzig, Germany
| | - Frauke Hornemann
- Department of Pediatric Neurology, University of Leipzig, Leipzig, Germany
| | - Steffen Syrbe
- Department of Pediatric Neurology, University of Leipzig, Leipzig, Germany
| | - Ingo Daehnert
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany
| | - Michael Weidenbach
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Leipzig, Germany
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