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Cottin V, Blanchard E, Kerjouan M, Lazor R, Reynaud-Gaubert M, Taille C, Uzunhan Y, Wemeau L, Andrejak C, Baud D, Bonniaud P, Brillet PY, Calender A, Chalabreysse L, Court-Fortune I, Desbaillets NP, Ferretti G, Guillemot A, Hardelin L, Kambouchner M, Leclerc V, Lederlin M, Malinge MC, Mancel A, Marchand-Adam S, Maury JM, Naccache JM, Nasser M, Nunes H, Pagnoux G, Prévot G, Rousset-Jablonski C, Rouviere O, Si-Mohamed S, Touraine R, Traclet J, Turquier S, Vagnarelli S, Ahmad K. French recommendations for the diagnosis and management of lymphangioleiomyomatosis. Respir Med Res 2023; 83:101010. [PMID: 37087906 DOI: 10.1016/j.resmer.2023.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The present article is an English-language version of the French National Diagnostic and Care Protocol, a pragmatic tool to optimize and harmonize the diagnosis, care pathway, management and follow-up of lymphangioleiomyomatosis in France. METHODS Practical recommendations were developed in accordance with the method for developing a National Diagnosis and Care Protocol for rare diseases of the Haute Autorité de Santé and following international guidelines and literature on lymphangioleiomyomatosis. It was developed by a multidisciplinary group, with the help of patient representatives and of RespiFIL, the rare disease network on respiratory diseases. RESULTS Lymphangioleiomyomatosis is a rare lung disease characterised by a proliferation of smooth muscle cells that leads to the formation of multiple lung cysts. It occurs sporadically or as part of a genetic disease called tuberous sclerosis complex (TSC). The document addresses multiple aspects of the disease, to guide the clinicians regarding when to suspect a diagnosis of lymphangioleiomyomatosis, what to do in case of recurrent pneumothorax or angiomyolipomas, what investigations are needed to make the diagnosis of lymphangioleiomyomatosis, what the diagnostic criteria are for lymphangioleiomyomatosis, what the principles of management are, and how follow-up can be organised. Recommendations are made regarding the use of pharmaceutical specialties and treatment other than medications. CONCLUSION These recommendations are intended to guide the diagnosis and practical management of pulmonary lymphangioleiomyomatosis.
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Affiliation(s)
- Vincent Cottin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France; UMR 754, INRAE, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France.
| | - Elodie Blanchard
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), GH Sud Haut-Lévêque, Avenue Magellan, 33600 Pessac, France
| | - Mallorie Kerjouan
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Romain Lazor
- Service de Pneumologie, Centre Hospitalier Universitaire Vaudois, BU44/07.2137, Rue du Bugnon 46, 1011 Lausanne, Suisse
| | - Martine Reynaud-Gaubert
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Nord, Chemin Bourrely, 13015 Marseille, France; URMITE-CNRS-IRD UMR 6236, Aix-Marseille Université, 51 boulevard Pierre Dramard, 13344 Marseille cedex 15, France
| | - Camille Taille
- Centre de Référence Constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France; Université Paris-Diderot, 17 rue Jean Antoine de Baïf, 75013 Paris, France
| | - Yurdagül Uzunhan
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Lidwine Wemeau
- Centre de Référence constitutif des maladies pulmonaires rares, CHRU, 5 rue Oscar Lambret, 59000 Lille, France
| | - Claire Andrejak
- Service de pneumologie, CHU Amiens, 1 Place Victor Pauchet, 80054 Amiens, France; UFR de médecine, 3 rue Louvels, 80000 Amiens, France
| | - Dany Baud
- Hôpital Suisse de Paris, 10 rue Minard, 92130 Issy les Moulineaux, France
| | - Philippe Bonniaud
- Centre de Référence constitutif des maladies pulmonaires rares, CHU de Dijon, BP 77908, 21079, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, 21000 Dijon, France
| | - Pierre-Yves Brillet
- Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France; Service de radiologie, hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Alain Calender
- Département de génétique, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; IBCP, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | - Lara Chalabreysse
- Service de pathologie, Groupe hospitalier est, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | | | | | - Gilbert Ferretti
- Pole imagerie, CHU Grenoble Alpes, Boulevard Chantourne, 38700 La Tronche, France
| | - Anne Guillemot
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Laurane Hardelin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Marianne Kambouchner
- Service d'anatomopatholologie, Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Violette Leclerc
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Mathieu Lederlin
- Service de radiologie, CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | | | - Alain Mancel
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Sylvain Marchand-Adam
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Bretonneau, CHRU Tours, 2 Boulevard Tonnellé, 37000 Tours, France; Université de Tours, CEPR INSERMU1100, 10 Boulevard Tonnellé, 37000 Tours, France
| | - Jean-Michel Maury
- Service de chirurgie thoracique, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Jean-Marc Naccache
- Service de pneumologie, Hôpital Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
| | - Mouhamad Nasser
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Hilario Nunes
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Gaële Pagnoux
- Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Grégoire Prévot
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), service de pneumologie, hôpital Larrey, 24 chemin de Pouvourville, 31059 Toulouse cedex 9, France
| | | | - Olivier Rouviere
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Salim Si-Mohamed
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service d'imagerie, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Renaud Touraine
- Laboratoire de Génétique Chromosomique et Moléculaire, CHU-Hôpital Nord, Laboratoire AURAGEN (Plan France Médecine Génomique 2025), 42270 Saint Priest en Jarest, France
| | - Julie Traclet
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Ségolène Turquier
- Service d'exploration fonctionnelle respiratoire, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Stéphane Vagnarelli
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Kaïs Ahmad
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
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Koslow M, Lynch DA, Cool CD, Groshong SD, Downey GP. Lymphangioleiomyomatosis and Other Cystic Lung Diseases. Immunol Allergy Clin North Am 2023; 43:359-377. [PMID: 37055093 PMCID: PMC10863428 DOI: 10.1016/j.iac.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Cysts and cavities in the lung are commonly encountered on chest imaging. It is necessary to distinguish thin-walled lung cysts (≤2 mm) from cavities and characterize their distribution as focal or multifocal versus diffuse. Focal cavitary lesions are often caused by inflammatory, infectious, or neoplastic processes in contrast to diffuse cystic lung diseases. An algorithmic approach to diffuse cystic lung disease can help narrow the differential diagnosis, and additional testing such as skin biopsy, serum biomarkers, and genetic testing can be confirmatory. An accurate diagnosis is essential for the management and disease surveillance of extrapulmonary complications.
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Affiliation(s)
- Matthew Koslow
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA; Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA.
| | - David A Lynch
- Department of Radiology, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Carlyne D Cool
- Department of Pathology, University of Colorado School of Medicine Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO 80045, USA; Division of Pathology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Steve D Groshong
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Gregory P Downey
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA; Department of Pediatrics, National Jewish Health; Department of Immunology and Genomic Medicine, National Jewish Health
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Abstract
Classically, both chylothorax and pseudochylothorax present as a pleural effusion with a characteristic milky white appearance to the pleural fluid. Although both are rare causes of pleural effusion, they have distinct etiologies and clinical implications, and as a result require different management strategies. Pleural fluid analysis of cholesterol and triglyceride levels is key to differentiating the 2 entities from one another and then guide the clinician to determine the best next steps in evaluation and management.
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Affiliation(s)
- Cassandra M Braun
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18 South, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18 South, 200 First Street, Southwest, Rochester, MN 55905, USA.
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McCarthy C, Gupta N, Johnson SR, Yu JJ, McCormack FX. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1313-1327. [PMID: 34461049 DOI: 10.1016/s2213-2600(21)00228-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 01/15/2023]
Abstract
Lymphangioleiomyomatosis (LAM) is a slowly progressive, low-grade, metastasising neoplasm of women, characterised by infiltration of the lung parenchyma with abnormal smooth muscle-like cells, resulting in cystic lung destruction. The invading cell in LAM arises from an unknown source and harbours mutations in tuberous sclerosis complex (TSC) genes that result in constitutive activation of the mechanistic target of rapamycin (mTOR) pathway, dysregulated cellular proliferation, and a programme of frustrated lymphangiogenesis, culminating in disordered lung remodelling and respiratory failure. Over the past two decades, all facets of LAM basic and clinical science have seen important advances, including improved understanding of molecular mechanisms, novel diagnostic and prognostic biomarkers, effective treatment strategies, and comprehensive clinical practice guidelines. Further research is needed to better understand the natural history of LAM; develop more powerful diagnostic, prognostic, and predictive biomarkers; optimise the use of inhibitors of mTOR complex 1 in the treatment of LAM; and explore novel approaches to the development of remission-inducing therapies.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St Vincent's University Hospital, University College Dublin, Dublin, Ireland.
| | - Nishant Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Simon R Johnson
- Division of Respiratory Medicine, University of Nottingham, NIHR Respiratory Biomedical Research Centre, Nottingham, UK
| | - Jane J Yu
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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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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Harari S, Torre O, Elia D, Caminati A, Pelosi G, Specchia C, Zompatori M, Cassandro R. Improving Survival in Lymphangioleio-myomatosis: A 16-Year Observational Study in a Large Cohort of Patients. Respiration 2021; 100:989-999. [PMID: 34044410 DOI: 10.1159/000516330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Over the last 2 decades, great progress has been made in the understanding of the clinical aspects and pathogenesis of lymphangioleiomyomatosis (LAM), leading to publication of guidelines and approval of an effective therapy. OBJECTIVES Aim of our study was to describe how the management and the natural history of this rare disease have changed after the publication of the ERS and American Thoracic Society/Japanese Respiratory Society guidelines and the introduction of sirolimus. METHODS We examined 162 LAM patients followed at our center between 2001 and 2017, reporting clinical characteristics and diagnostic approach. Response to sirolimus in patients undergoing long-term treatment and mortality risk, estimated in terms of cumulative incidence taking into account organ transplantation as a competing cause of the event, were evaluated. The difference in the cumulative incidence between the patients admitted to the observation before 2011 and after 2011, year of the publication of the MILES trial for the efficacy of sirolimus, has also been estimated. RESULTS Sixty-one patients had a histological diagnosis (22 from 2010 onward). 101 patients received a radiological diagnosis according to the guidelines criteria. Pulmonary function tests remained stable over a 3-year treatment period in patients who received sirolimus for over 12 months. The cumulative incidence of mortality after 10 years in the whole population was 25.5%. The cumulative incidence of mortality after 5 years was significantly lower in patients who entered the study since 2011 (after publication of the MILES trial) than in patients who entered the study before. CONCLUSIONS We provide the data supporting the long-term efficacy of sirolimus therapy in a large cohort of patients with functional impairment and other manifestations of the disease. Our results also suggest that the advent of sirolimus and the publication of international guidelines changed the natural history of the disease lowering the mortality and reducing the need of invasive diagnostic techniques.
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Affiliation(s)
- Sergio Harari
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy.,Department of Medical Sciences, San Giuseppe Hospital MultiMedica IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Olga Torre
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Davide Elia
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Antonella Caminati
- Unità di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Giuseppe Pelosi
- Servizio di Anatomia Patologica, Polo Scientifico e Tecnologico, Multimedica Srl, IRCCS, Milan, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Maurizio Zompatori
- U.O. di Radiologia Ospedale San Giuseppe - MultiMedica IRCCS, Milan, Italy
| | - Roberto Cassandro
- Unità 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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Uncommon radiologic computed tomography appearances of the chest in patients with lymphangioleiomyomatosis. Sci Rep 2021; 11:7170. [PMID: 33785773 PMCID: PMC8010110 DOI: 10.1038/s41598-021-85999-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare destructive lung disease characterized by multiple thin-walled pulmonary cysts. The currently proposed diagnostic algorithm emphasizes the characteristic cystic appearance on high-resolution computed tomography (HRCT) so uncommon HRCT appearances present challenges to establishing the proper LAM diagnosis. The objective of this study is to accrue uncommon chest HRCT appearances, determine frequencies in both tuberous sclerosis complex (TSC)-associated LAM (TSC-LAM) and sporadic LAM (S-LAM) patients. 311 females referred to our hospital, including 272 S-LAM patients (mean age 39.2 years) and 39 TSC-LAM patients (mean age 38.3 years), were retrospectively evaluated. We found 2 types of radiologic findings likely to make HRCT cyst appearance atypical: characteristics of the cyst itself and uncommon findings in addition to cysts. We found that approximately 80% of LAM patients, whether TSC-associated or sporadic, showed typical HRCT appearance with mild to severe cystic destruction. The remaining 20% displayed unusual profiles in cyst appearance as well as additional findings aside from cyst: the former includes large cyst, thickened walls, and irregularly shaped whereas the latter includes ground glass attenuation and diffuse noncalcified nodules. It is important to be aware of various radiologic findings that make HRCT cystic appearance atypical of LAM.
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Elia D, Torre O, Cassandro R, Caminati A, Harari S. Ultra-rare cystic disease. Eur Respir Rev 2020; 29:29/157/190163. [PMID: 32878971 PMCID: PMC9489057 DOI: 10.1183/16000617.0163-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/20/2020] [Indexed: 12/11/2022] Open
Abstract
Diffuse cystic lung diseases include a group of heterogeneous disorders characterised by the presence of cysts within the lung parenchyma, sometimes showing a characteristic computed tomography scan pattern that allows diagnosis. The pathogenetic mechanisms underlying cyst formation in the lung are still not clear and a number of hypotheses have been postulated according to the different aetiologies: ball-valve effect, ischaemic dilatation of small airways and alveoli related to infiltration and obstruction of small vessels and capillaries that supply the terminal bronchioles and connective tissue degradation by matrix metalloproteases. A wide number of lung cyst diseases have been classified into six diagnostic groups according to the aetiology: neoplastic, congenital/genetic, lymphoproliferative, infective, associated with interstitial lung diseases, and other causes. This article focuses on lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis and Erdheim–Chester disease, Birt–Hogg–Dubé, follicular bronchiolitis and lymphocytic interstitial pneumonia, light-chain deposition disease and amyloidosis, congenital lung disease associated with aberrant lung development and growth, and cystic lung disease associated with neoplastic lesion. These cystic diseases are epidemiologically considered as ultra-rare conditions as they affect fewer than one individual per 50 000 or fewer than 20 individuals per million. Despite the rarity of this group of disorders, the increasing use of high-resolution computed tomography has improved the diagnostic yield, even in asymptomatic patients allowing prompt and correct therapy and management without the need for a biopsy. Diffuse cystic lung diseases show a characteristic CT scan pattern that often allows for diagnosis, even in asymptomatic patients, allowing prompt correct therapy and management without the needing of a biopsyhttps://bit.ly/2wIUKet
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Cottin V, Si-Mohamed S, Ahmad K, Traclet J, Nasser M. mTOR inhibitors for the management of difficult lymphangioma in adults. Respir Med Res 2020; 77:8-10. [PMID: 31923747 DOI: 10.1016/j.resmer.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Affiliation(s)
- V Cottin
- Hospices Civils de Lyon, Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel hospital, Lyon, France; Claude-Bernard Lyon 1 University, University of Lyon, INRA, UMR754, Lyon, France.
| | - S Si-Mohamed
- Hospices Civils de Lyon, Department of Radiology, Louis-Pradel hospital, Lyon, France
| | - K Ahmad
- Hospices Civils de Lyon, Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel hospital, Lyon, France
| | - J Traclet
- Hospices Civils de Lyon, Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel hospital, Lyon, France
| | - M Nasser
- Hospices Civils de Lyon, Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel hospital, Lyon, France
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The 10,000-Piece Puzzle of Lymphangioleiomyomatosis. Chest 2019; 153:298-299. [PMID: 29406212 DOI: 10.1016/j.chest.2017.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 07/23/2017] [Indexed: 11/21/2022] Open
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Kato M, Kanehiro Y, Yoshimi K, Kodama Y, Sekiya M, Sato T, Takahashi K, Seyama K. COPD assessment test as a possible tool for evaluating health-related quality of life in lymphangioleiomyomatosis. Respir Investig 2018; 56:480-488. [PMID: 30143460 DOI: 10.1016/j.resinv.2018.07.004] [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: 02/21/2018] [Revised: 07/02/2018] [Accepted: 07/17/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a progressive, cystic lung disease that causes an obstructive ventilatory impairment similar to chronic obstructive pulmonary disease (COPD) and impairs the health-related quality of life (HRQoL). Here, we extended the use of the COPD assessment test (CAT) to patients with chronic respiratory diseases other than COPD. Specifically, the CAT was administered to patients with LAM for the first time. METHODS Using data from 25 patients with LAM at Juntendo University who participated in the Multicenter Lymphangioleiomyomatosis Sirolimus Trial for Safety (MLSTS), we evaluated changes in pulmonary function, responses to HRQoL questionnaires (the CAT, St. George׳s Respiratory Questionnaire [SGRQ], EuroQOL Visual Analogue Scale [EuroQOL-VAS], and Functional Performance Inventory [FPI]), and the association between pulmonary function and HRQoL during a 24-month period of sirolimus treatment. RESULTS Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and CAT total scores improved over the 24 months of sirolimus treatment (5.33 ± 1.20 ml/month, 2.61 ± 1.16 ml/month, and -0.127 ± 0.022 score/month, respectively), whereas SGRQ total score, EuroQOL-VAS score, and FPI score did not. Most pulmonary functions at baseline were associated with the CAT breathlessness score during the first year. Longitudinal changes in FEV1, FEV1%predicted, or FEV1/FVC correlated significantly with the scores of CAT total, CAT breathlessness, and SGRQ activity. When analyzed by stepwise multivariate regression within a linear mixed-effects model, CAT breathlessness and confidence scores were significantly associated with a change in FEV1 from the baseline value (P = 0.0011, and P = 0.0441). CONCLUSION Our results suggest that the CAT is a useful instrument for assessing HRQoL in sirolimus-treated patients with LAM.
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Affiliation(s)
- Miharu Kato
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Yumiko Kanehiro
- Clinical Research Center, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kaku Yoshimi
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Yuzo Kodama
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Mitsuaki Sekiya
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Tadashi Sato
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kazuhisa Takahashi
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kuniaki Seyama
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
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12
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Gupta N, Henske EP. Pulmonary manifestations in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:326-337. [PMID: 30055039 DOI: 10.1002/ajmg.c.31638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Tuberous sclerosis complex has manifestations in many organ systems, including brain, heart, kidney, skin, and lung. The primary manifestations in the lung are lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH). LAM affects almost exclusively women, and causes cystic lung destruction, pneumothorax, and chylous pleural effusions. LAM can lead to dyspnea, oxygen dependence, and respiratory failure, with more rapid disease progression during the premenopausal years. In contrast, MMPH affects men and women equally, causing small nodular pulmonary deposits of type II pneumocytes that rarely progress to symptomatic disease. Here, we review the clinical features and pathogenesis of LAM and MMPH.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth P Henske
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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13
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Taveira-DaSilva AM, Moss J. Addressing the challenges of lymphangioleiomyomatosis assessment in the clinic. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1400966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Angelo M. Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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14
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Glasgow CG, Pacheco-Rodriguez G, Steagall WK, Haughey ME, Julien-Williams PA, Stylianou MP, Gochuico BR, Moss J. CA-125 in Disease Progression and Treatment of Lymphangioleiomyomatosis. Chest 2017; 153:339-348. [PMID: 28576630 DOI: 10.1016/j.chest.2017.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/24/2017] [Accepted: 05/16/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a destructive lung disease of women caused by proliferation of neoplastic-like LAM cells, with mutations in the TSC1/2 tumor suppressor genes. Based on case reports, levels of cancer antigen 125 (CA-125), an ovarian cancer biomarker, can be elevated in patients with LAM. We hypothesized that elevated serum CA-125 levels seen in some patients with LAM were due to LAM, not other malignancies, and might respond to sirolimus treatment. METHODS Serum CA-125 levels were measured for 241 patients at each visit. Medical records were reviewed for co-morbidities, disease progression, and response to sirolimus treatment. CA-125 expression in LAM cells was determined by using immunohistochemical analysis. RESULTS Almost 25% of patients with LAM had at least one elevated serum CA-125 measurement. Higher serum CA-125 levels correlated with lower FEV1, premenopausal status, and pleural effusion in a multivariate model (each P < .001). Serum CA-125 levels decreased following sirolimus treatment (P = .002). CA-125 and α-smooth muscle actin were co-expressed in LAM lung nodules. CONCLUSIONS Higher serum CA-125 levels were associated with pleural effusions and reduced pulmonary function and were decreased with sirolimus therapy. LAM cells express CA-125. Some elevated serum CA-125 levels may reflect serosal membrane involvement.
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Affiliation(s)
- Connie G Glasgow
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gustavo Pacheco-Rodriguez
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Wendy K Steagall
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mary E Haughey
- Office of the Clinical Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Patricia A Julien-Williams
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mario P Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bernadette R Gochuico
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
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15
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Taveira-DaSilva AM, Jones AM, Julien-Williams P, Stylianou M, Moss J. Long-Term Effect of Sirolimus on Serum Vascular Endothelial Growth Factor D Levels in Patients With Lymphangioleiomyomatosis. Chest 2017; 153:124-132. [PMID: 28533049 DOI: 10.1016/j.chest.2017.05.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/06/2017] [Accepted: 05/09/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sirolimus reduces serum levels of vascular endothelial growth factor D (VEGF-D); the size of chylous effusions, lymphangioleiomyomas, and angiomyolipomas; and stabilizes lung function in patients with lymphangioleiomyomatosis (LAM). METHODS To determine whether reductions in VEGF-D levels are sustained over time, as well as parallel changes in lung function and lymphatic disease, we evaluated 25 patients with LAM and measured VEGF-D levels, lung function, and extent of lymphatic disease before and during sirolimus therapy. RESULTS Treatment with sirolimus stabilized FEV1 and diffusion capacity for carbon monoxide (Dlco) over a period of 4.5 ± 1.6 years, caused resolution of lymphatic disease, and reduced the size of angiomyolipomas and VEGF-D levels (3,720 ± 3,020 pg/mL to 945 ± 591 pg/mL; P < .0001). Yearly changes in FEV1 % predicted and Dlco % predicted were reduced from -7.4% ± 1.4% to -0.3% ± 0.5% (P < .001) and -6.4% ± 0.9% to -0.4% ± 0.5% (P < .001), respectively. Lower VEGF-D levels correlated with sirolimus therapy (P < .001), but no significant relationship was observed between reduction in VEGF-D levels and FEV1 and Dlco during sirolimus therapy. The magnitude of VEGF-D decline was not related to the effect on lung function. Patients with lymphatic disease had higher serum VEGF-D levels, a greater reduction in VEGF-D levels, and better long-term sustained improvement in lung function during sirolimus therapy than did those without lymphatic disease. CONCLUSIONS Sirolimus therapy stabilizes lung function over many years of therapy while producing a sustained reduction in VEGF-D levels in patients with elevated levels preceding therapy. An association was not demonstrated between the magnitude of VEGF-D decline and the beneficial effect of sirolimus on lung function. Persistent improvement in lung function was observed in patients with lymphatic disease.
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Affiliation(s)
- Angelo M Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Amanda M Jones
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Patricia Julien-Williams
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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16
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Shah A, Donovan J, Marino P, Shah PL, Devaraj A, Wechalekar K, Maher TM, Loebinger MR, Wilson R. A lesson in plasticity: a 74-year-old man with plastic bronchitis. Thorax 2017; 72:1055-1057. [PMID: 28373346 DOI: 10.1136/thoraxjnl-2017-209965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Anand Shah
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - Jackie Donovan
- Department of Biochemistry, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Phil Marino
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Pallav L Shah
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - Anand Devaraj
- Imperial College London, London, UK.,Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Kshama Wechalekar
- Imperial College London, London, UK.,Nuclear Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Toby M Maher
- Imperial College London, London, UK.,Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Michael R Loebinger
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Imperial College London, London, UK
| | - Robert Wilson
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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Abstract
The thoracic lymphatic disorders are a heterogeneous group of uncommon conditions that are associated with thoracic masses, interstitial pulmonary infiltrates, and chylous complications. Accurate diagnosis of the thoracic lymphatic disorders has important implications for the newest approaches to management, including embolization and treatment with antilymphangiogenic drugs. New imaging techniques to characterize lymphatic flow, such as dynamic contrast-enhanced magnetic resonance lymphangiogram, are redefining approaches to disease classification and therapy.
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Affiliation(s)
- Maxim Itkin
- Interventional Radiology, Hospital of the University of Pennsylvania, Penn Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, MSB 6165, 231 Albert Sabin Way, Cincinnati, OH 45267-0564, USA
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Abstract
INTRODUCTION Lymphangioleiomyomatosis (LAM) is a disease of women characterized by cystic lung destruction, lymphatic involvement, and renal angiomyolipomas. AREAS COVERED LAM is caused by proliferation of abnormal smooth muscle-like LAM cells containing mutations and perhaps epigenetic modifications of the TSC1 or TSC2 genes, which encode, respectively, hamartin and tuberin, two proteins controlling the mechanistic target of rapamycin (mTOR) signaling pathway. LAM occurs sporadically or in association with tuberous sclerosis complex. LAM may present with dyspnea, recurrent pneumothorax or chylothorax. Pulmonary function tests show reduced flow rates and lung diffusion capacity. Exercise testing may reveal hypoxemia and ventilatory limitation. The severity and progression of disease may be assessed by computer tomography, and pulmonary function and exercise testing. mTOR inhibitors, (e.g., sirolimus) are effective in stabilizing lung function, and reducing the size of chylous effusions, lymphangioleiomyomas, and angiomyolipomas. EXPERT OPINION Different clinical phenotypes including variable rates of disease progression and variable responses to therapy are seen in LAM patients. No one test is available that predicts the course of disease at the time of diagnosis. Further research regarding the molecular biology of LAM clinical phenotypes is warranted. Recent advances in the characterization of the pathogenesis of LAM are leading to the development of new therapies.
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Affiliation(s)
- Angelo M. Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 6D03, MSC 1590, Bethesda, Maryland 20892-1590, USA
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 6D03, MSC 1590, Bethesda, Maryland 20892-1590, USA
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19
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Lama A, Ferreiro L, Golpe A, Gude F, Álvarez-Dobaño JM, González-Barcala FJ, Toubes ME, San José E, Rodríguez-Núñez N, Valdés L. Characteristics of Patients with Lymphangioleiomyomatosis and Pleural Effusion: A Systematic Review. Respiration 2016; 91:256-64. [DOI: 10.1159/000444264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/22/2016] [Indexed: 11/19/2022] Open
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20
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Taveira-DaSilva AM, Jones AM, Julien-Williams P, Shawker T, Glasgow CG, Stylianou M, Moss J. Effect of fasting on the size of lymphangioleiomyomas in patients with lymphangioleiomyomatosis. Chest 2016; 148:1027-1033. [PMID: 26066372 DOI: 10.1378/chest.15-0456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomas occur in 38% of patients with sporadic lymphangioleiomyomatosis (LAM) and may cause pain and increased abdominal girth, mimicking the presence of a malignancy. Lymphatic involvement in LAM is closely associated with elevated serum levels of vascular endothelium growth factor-D (VEGF-D). Because lymphangioleiomyomas undergo diurnal variation in volume, we hypothesized that daytime ingestion of food, by increasing chyle formation and lymphatic flow, is the cause of an increase in lymphangioleiomyoma volume. METHODS Subjects had abdominopelvic sonograms and blood drawn for measurement of serum VEGF-D levels under nonfasting (day 1) and fasting (day 2) conditions. The size of the lymphangioleiomyomas was determined by a radiologist who was blinded to the subjects' status. The Wilcoxon signed rank test was used to determine whether the nonfasting tumor size was different from the fasting tumor size. RESULTS Thirty-five women were studied (aged 45.2 ± 8.5 years; FEV1, 82% ± 25%; diffusing capacity of the lung for carbon monoxide, 64% ± 25% predicted). Images suitable for volume measurements were obtained in 30 subjects. Fasting decreased the tumor size by 20.7 ± 39.3 cm3 (24% ± 40%, P < .001). Fasting VEGF-D levels (10,650 ± 900 pg/mL) were not significantly different from nonfasting values (12,100 ± 800 pg/mL, P = .56). CONCLUSIONS Lymphangioleiomyoma volume decreased during the fasting state. Conversely, a combination of food intake and decreased chyle flow through lymphatics partially obstructed by LAM cells may account for increases in lymphangioleiomyoma size. Imaging studies performed under fasting conditions may help in determining whether an abdominal tumor is a result of LAM or malignancy.
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Affiliation(s)
| | | | | | - Thomas Shawker
- Radiology and Imaging Sciences Department, National Institutes of Health, Bethesda, MD
| | | | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, Bethesda, MD
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21
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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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22
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Chebib N, Khouatra C, Lazor R, Archer F, Leroux C, Gamondes D, Thivolet-Bejui F, Cordier JF, Cottin V. [Pulmonary lymphangioleiomyomatosis: From pathogenesis to management]. Rev Mal Respir 2015; 33:718-734. [PMID: 26604019 DOI: 10.1016/j.rmr.2015.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/06/2015] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pulmonary lymphangioleiomyomatosis (LAM) is a rare disease affecting mainly young women. BACKGROUND The respiratory manifestations are characterized by a progressive cystic destruction of the lung parenchyma. Extrapulmonary involvement includes benign renal tumours called angiomyolipomas and abdominal lymphatic masses called lymphangioleiomyomas. At the pathological level, the cellular proliferation found in LAM is in part due to the presence of mutations in the tumour suppressor genes TSC1 and TSC2 (Tuberous Sclerosis Complex). These mutations lead to the activation of the mTOR pathway, which is currently the main therapeutic target. mTOR inhibitors such as sirolimus or everolimus have shown a beneficial effect on the decline in pulmonary function and a reduction of angiomyolipoma size, but are necessary in only some patients. PERSPECTIVES LAM cells have migratory properties mediated by the formation of new lymphatic vessels. They are also able to secrete metalloproteases, which enhance their invasiveness. Moreover, the expression of estrogen and progesterone receptors by LAM cells suggests a possible role for sex hormones in the pathogenesis of the disease. CONCLUSION A better understanding of mTOR-independent mechanisms would allow the development of novel therapeutic approaches.
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Affiliation(s)
- N Chebib
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - C Khouatra
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France
| | - R Lazor
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; Unité des pneumopathies interstitielles et maladies pulmonaires rares, service de pneumologie, centre hospitalier universitaire vaudois, 1011 Lausanne, Suisse
| | - F Archer
- UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - C Leroux
- UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - D Gamondes
- Service de radiologie, hôpital Louis-Pradel, hospices civils de Lyon, 69677 Lyon cedex, France
| | - F Thivolet-Bejui
- Centre de pathologie Est, groupement hospitalier Est, hospices civils de Lyon, 69677 Lyon cedex, France
| | - J F Cordier
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - V Cottin
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France.
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Harari S, Torre O, Cassandro R, Moss J. The changing face of a rare disease: lymphangioleiomyomatosis. Eur Respir J 2015; 46:1471-85. [PMID: 26405290 DOI: 10.1183/13993003.00412-2015] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 07/11/2015] [Indexed: 12/18/2022]
Abstract
Lymphangioleiomyomatosis is a rare disease characterised by cystic destruction of the lung, lymphatic abnormalities and abdominal tumours. It affects almost exclusively females and can occur sporadically or in patients with tuberous sclerosis complex. In the past decade remarkable progress has been made in understanding of the pathogenesis of this disease leading to a new therapeutic approach. This review summarises recent advances regarding pathogenic mechanisms and clinical manifestations, and highlights the current and the most promising future therapeutic strategies.
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Affiliation(s)
- Sergio Harari
- Unità Operativa di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy Both authors contributed equally
| | - Olga Torre
- Unità Operativa di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy Both authors contributed equally
| | - Roberto Cassandro
- Unità Operativa di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MA, USA
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Yao J, Taveira-DaSilva AM, Jones AM, Julien-Williams P, Stylianou M, Moss J. Sustained effects of sirolimus on lung function and cystic lung lesions in lymphangioleiomyomatosis. Am J Respir Crit Care Med 2015; 190:1273-82. [PMID: 25329516 DOI: 10.1164/rccm.201405-0918oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Sirolimus therapy stabilizes lung function and reduces the size of chylous effusions and lymphangioleiomyomas in patients with lymphangioleiomyomatosis. OBJECTIVES To determine whether sirolimus has beneficial effects on lung function, cystic areas, and adjacent lung parenchyma; whether these effects are sustained; and whether sirolimus is well tolerated by patients. METHODS Lung function decline over time, lung volume occupied by cysts (cyst score), and lung tissue texture in the vicinity of the cysts were quantified with a computer-aided diagnosis system in 38 patients. Then we compared cyst scores from the last study on sirolimus with studies done on sirolimus therapy. In 12 patients, we evaluated rates of change in lung function and cyst scores off and on sirolimus. MEASUREMENTS AND MAIN RESULTS Sirolimus reduced yearly declines in FEV1 (-2.3 ± 0.1 vs. 1.0 ± 0.3% predicted; P < 0.001) and diffusing capacity of carbon monoxide (-2.6 ± 0.1 vs. 0.9 ± 0.2% predicted; P < 0.001). Cyst scores 1.2 ± 0.8 years (30.5 ± 11.9%) and 2.5 ± 2 years (29.7 ± 12.1%) after initiating sirolimus were not significantly different from pretreatment values (28.4 ± 12.5%). In 12 patients followed for 5 years, a significant reduction in rates of yearly decline in FEV1 (-1.4 ± 0.2 vs. 0.3 ± 0.4% predicted; P = 0.025) was observed. Analyses of 104 computed tomography scans showed a nonsignificant (P = 0.23) reduction in yearly rates of change of cyst scores (1.8 ± 0.2 vs. 0.3 ± 0.3%; P = 0.23) and lung texture features. Despite adverse events, most patients were able to continue sirolimus therapy. CONCLUSIONS Sirolimus therapy slowed down lung function decline and increase in cystic lesions. Most patients were able to tolerate sirolimus therapy.
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Restrepo-Gualteros S, Rodriguez-Martinez C, Jaramillo-Barberi L, Lopez-Cadena A, Nino G. Adolescent form of sporadic lymphangioleiomyomatosis (S-LAM). Allergol Immunopathol (Madr) 2015; 43:111-4. [PMID: 24792497 DOI: 10.1016/j.aller.2013.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/02/2013] [Accepted: 10/29/2013] [Indexed: 10/25/2022]
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Taveira-DaSilva AM, Jones AM, Julien-Williams P, Yao J, Stylianou M, Moss J. Severity and outcome of cystic lung disease in women with tuberous sclerosis complex. Eur Respir J 2015; 45:171-80. [PMID: 25537563 PMCID: PMC8356806 DOI: 10.1183/09031936.00088314] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
What are the clinical features, severity, and rate of progression of lung disease in women with tuberous sclerosis and lymphangioleiomyomatosis (LAM) and how do they differ from patients with sporadic LAM? Data from 94 tuberous sclerosis/LAM and 460 sporadic LAM women were compared. 40 tuberous sclerosis/LAM and 40 sporadic LAM patients were age- and lung function-matched, and changes in volume occupied by cysts (cyst score) and pulmonary function occurring over 6.5 years were evaluated. Tuberous sclerosis/LAM patients had better lung function than sporadic LAM patients, but no difference was observed from sporadic LAM patients in yearly rates of change in forced expiratory volume in 1 s (-1.9±2.7 versus -1.9±1.9% predicted; p=0.302), diffusing capacity of the lung for CO (-2.1±2.8 versus -1.9±2.7% predicted; p=0.282) or cyst scores (+1.0±1.3 versus +1.4±1.7%, p=0.213). However, the proportion of patients with abnormal lung function and higher rates of FEV1 decline was greater in sporadic LAM. Some young tuberous sclerosis/LAM patients (mean age 25.7±3 years) progressed rapidly from minimal to severe lung disease. Tuberous sclerosis/LAM patients may experience abrupt declines in lung function. Consequently, women with tuberous sclerosis found to have lung cysts should undergo periodic functional and radiological testing to follow disease progression and determine need for therapy.
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Affiliation(s)
- Angelo M Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Institutes of Health Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Amanda M Jones
- Cardiovascular and Pulmonary Branch, National Institutes of Health Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Patricia Julien-Williams
- Cardiovascular and Pulmonary Branch, National Institutes of Health Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jianhua Yao
- Radiology and Imaging Sciences Department, National Institutes of Health, Bethesda, MD, USA
| | - Mario Stylianou
- Office of Biostatistics Research, National Institutes of Health Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Institutes of Health Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Kinoshita Y, Sakamoto A, Hidaka K. Recovery of chylous pulmonary congestion in tuberous sclerosis complex-associated lymphangioleiomyomatosis. BMJ Case Rep 2014; 2014:bcr-2014-205701. [PMID: 25326562 DOI: 10.1136/bcr-2014-205701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chyloptysis and chylous pulmonary congestion are extremely rare complications of lymphangioleiomyomatosis (LAM). We report a case of a 50-year-old woman with tuberous sclerosis complex-associated LAM, who presented with expectorating milky-white bronchial casts. She was diagnosed with chyloptysis and chylous pulmonary congestion by sputum analysis. Her symptoms and lung infiltration were improved by oral sirolimus therapy; moreover, serum Krebs von den Lungen-6 (KL-6) levels paralleled the symptoms and lung infiltration of these complications. We suggest that serum KL-6 may be a useful monitoring biomarker of chyloptysis and chylous pulmonary congestion in LAM.
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Affiliation(s)
- Yoshiaki Kinoshita
- Division of Respiratory Medicine, Department of Internal Medicine, National Hospital Organization, Kokura Medical Center, Kitakyushu, Japan
| | - Atsuhiko Sakamoto
- Division of Respiratory Medicine, Department of Internal Medicine, National Hospital Organization, Kokura Medical Center, Kitakyushu, Japan
| | - Kouko Hidaka
- Division of Respiratory Medicine, Department of Internal Medicine, National Hospital Organization, Kokura Medical Center, Kitakyushu, Japan
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Suina K, Hayashi T, Mitani K, Suzuki K, Takahashi K, Seyama K. What׳s the role of sirolimus on the treatment of lymphangioleiomyomatosis (LAM)?: Merely tuning up of LAM-associated dysfunctional lymphatic vessels rather than cytoreduction? Respir Investig 2014; 52:274-276. [PMID: 24998376 DOI: 10.1016/j.resinv.2014.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 02/22/2014] [Accepted: 02/26/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Kentaro Suina
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Takuo Hayashi
- Department of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Keiko Mitani
- Department of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Kenji Suzuki
- Department of Thoracic Surgery, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Kazuhisa Takahashi
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan; The Study Group of Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-Ku, Tokyo 158-0095, Japan.
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Efficacy of sirolimus therapy for chylous effusions in lymphangioleiomyomatosis. Ann Am Thorac Soc 2014; 10:408-9. [PMID: 23952870 DOI: 10.1513/annalsats.201212-125oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Rastogi R, Jiang Z, Ahmad N, Rosati R, Liu Y, Beuret L, Monks R, Charron J, Birnbaum MJ, Samavati L. Rapamycin induces mitogen-activated protein (MAP) kinase phosphatase-1 (MKP-1) expression through activation of protein kinase B and mitogen-activated protein kinase kinase pathways. J Biol Chem 2013; 288:33966-33977. [PMID: 24126911 DOI: 10.1074/jbc.m113.492702] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Mitogen-activated protein kinase phosphatase-1 (MKP-1), also known as dual specificity phosphatase-1 (DUSP-1), plays a crucial role in the deactivation of MAPKs. Several drugs with immune-suppressive properties modulate MKP-1 expression as part of their mechanism of action. We investigated the effect of mTOR inhibition through rapamycin and a dual mTOR inhibitor (AZD2014) on MKP-1 expression. Low dose rapamycin led to a rapid activation of both AKT and ERK pathways with a subsequent increase in MKP-1 expression. Rapamycin treatment led to phosphorylation of CREB, transcription factor 1 (ATF1), and ATF2, three transcription factors that bind to the cyclic AMP-responsive elements on the Mkp-1 promoter. Inhibition of either the MEK/ERK or the AKT pathway attenuated rapamycin-mediated MKP-1 induction. AZD2014 did not activate AKT but activated the ERK pathway, leading to a moderate MKP-1 induction. Using bone marrow-derived macrophages (BMDMs) derived from wild-type (WT) mice or mice deficient in AKT1 and AKT2 isoforms or BMDM from targeted deficiency in MEK1 and MEK2, we show that rapamycin treatment led to an increased MKP1 expression in BMDM from WT but failed to do so in BMDMs lacking the AKT1 isoform or MEK1 and MEK2. Importantly, rapamycin pretreatment inhibited LPS-mediated p38 activation and decreased nitric oxide and IL-6 production. Our work provides a conceptual framework for the observed immune modulatory effect of mTOR inhibition.
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Affiliation(s)
- Ruchi Rastogi
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine and Detroit Medical Center, Detroit, Michigan 48201
| | - Zhongliang Jiang
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine and Detroit Medical Center, Detroit, Michigan 48201
| | - Nisar Ahmad
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine and Detroit Medical Center, Detroit, Michigan 48201
| | - Rita Rosati
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine and Detroit Medical Center, Detroit, Michigan 48201
| | - Yusen Liu
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43205
| | - Laurent Beuret
- Centre de Recherche sur le Cancer de l'Université Laval, CRCHU-Q, L'Hôtel-Dieu de Québec, Québec G1R 2J6, Canada
| | - Robert Monks
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104
| | - Jean Charron
- Centre de Recherche sur le Cancer de l'Université Laval, CRCHU-Q, L'Hôtel-Dieu de Québec, Québec G1R 2J6, Canada
| | - Morris J Birnbaum
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104
| | - Lobelia Samavati
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine and Detroit Medical Center, Detroit, Michigan 48201; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, Michigan 48201.
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