Pulmonary Lymphangioleiomyomatosis: A Case Report in Postmenopausal Woman Treated with Pleurodesis and Progesterone (Medroxyprogesterone Acetate)

Two cases of pulmonary lymphangioleiomyomatosis in postmenopausal women

Pulmonary lymphangioleiomyomatosis is a rare disease that occurs exclusively in young women, who typically present with progressive dyspnea and repeated spontaneous pneumothorax. The diagnosis of this disease in elderly women with a non-progressive clinical course is extremely rare. We herein report two incidentally discovered cases of pulmonary lymphangioleiomyomatosis in postmenopausal patients. These patients had not presented with any respiratory symptoms. Lymphangioleiomyomatosis may be related to hormonal influences; however, the etiology and pathogenesis of the pulmonary lesions that develop in postmenopausal females are unclear, even after a review of the literature.

Lymphangioleiomyomatosis: a case report

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown cause that traditionally affects young women of reproductive age. It is characterized by a proliferation of atypical smooth muscle cells, preferentially along the bronchovascular structures, that causes progressive respiratory failure. LAM is almost universally fatal without a lung transplant, although new clinical trials are ongoing. Because of its rareness and nonspecific presenting symptoms, patients often receive a missed or delayed diagnosis. We present the case of a 51-year-old postmenopausal woman who had hemoptysis ultimately determined to be due to LAM. As is common for patients with LAM, the initial chest radiograph was unremarkable, whereas subsequent computed tomography (CT) demonstrated the distinctive pulmonary parenchymal cysts. Biopsy of an HMB-45-positive, para-aortic lymphangiomyoma provided further confirmation of the diagnosis. LAM may be more common than previously recognized, and it is imperative for primary care providers to be able to recognize this disease so they can make prompt referrals to appropriate specialty centers.

Linfangioleiomiomatose: A propósito de um caso clínico

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown etiology affecting woman, primarily in their reproductive years. It is characterized by non-neoplasic proliferation of atypical smooth muscle cells that may lead to airway, lymphatic and blood vessel obstruction over time.A nine-year followed-up case of LAM is described,which presents with some unusual details as worsening haemoptysis in the setting of pregnancy and absence of cough or pneumothorax along the course of the disease. Neither haemoptysis nor gradual pulmonary function deterioration seemed to be influenced by hormone therapy. A brief re-view of the disease is then presented.

Decline in lung function in patients with lymphangioleiomyomatosis treated with or without progesterone

STUDY OBJECTIVE

Lymphangioleiomyomatosis (LAM), a disease affecting women and causing cystic lung lesions, and, in some instances, leading to respiratory failure and death, appears to be exacerbated by estrogens. Hence, hormonal therapy with progesterone is frequently employed; however, efficacy has not been demonstrated. Our aim was to determine whether progesterone administration slowed the decline in lung function in LAM.

DESIGN

Retrospective study.

SETTING

National Institutes of Health, Bethesda, MD.

DESIGN AND SUBJECTS

The study population comprised 348 patients with LAM participating in a longitudinal research protocol. Declines in diffusion capacity of the lung for carbon monoxide (Dlco) and FEV(1) were measured in 275 patients observed for approximately 4 years. The declines in Dlco and FEV(1) of patients treated with progesterone, po (n = 67) or IM (n = 72), were compared with those of untreated patients (n = 136).

MEASUREMENTS AND RESULTS

Overall yearly rates of decline in Dlco and FEV(1) were 2.4 +/- 0.4% predicted (0.69 +/- 0.07 mL/min/mm Hg) and 1.7 +/- 0.4% predicted (75 +/- 9 mL), respectively (mean +/- SEM). The most significant predictors of functional decline were initial lung function and age. After adjusting for initial FEV(1), age, and duration of disease, patients treated with IM progesterone tended to have lower rates of decline in FEV(1) than patients treated po (1.9 +/- 0.6% predicted vs 3.2 +/- 0.8% predicted, respectively; p = 0.081). However, there was no significant difference in rates of decline in FEV(1) between patients treated with IM progesterone and untreated patients (1.9 +/- 0.6% predicted vs 0.8 +/- 0.5% predicted, respectively; p = 0.520), and patients treated with po progesterone and untreated patients (3.2 +/- 0.8% predicted vs 0.8 +/- 0.5% predicted, respectively; p = 0.064). After adjusting for initial Dlco, rates of decline in Dlco were significantly higher in patients treated with po progesterone (3.6 +/- 0.7% predicted, p = 0.002) and IM progesterone (2.8 +/- 0.5% predicted, p = 0.022) than in untreated patients (1.6 +/- 0.6% predicted).

CONCLUSIONS

Within the limitations of a retrospective study, our data suggest that progesterone therapy does not slow the decline in lung function in LAM.

Linfangioleiomiomatose pulmonar

Linfangioleiomiomatose pulmonar (LAM) é uma doença rara, de etiologia desconhecida, que basicamente afeta mulheres jovens no período fértil de sua vida. Clinicamente, manifesta-se através de dispnéia progressiva, pneumotórax de repetição, tosse seca e, menos freqüentemente, por quilotórax e escarros hemoptóicos. Essas alterações surgem devido à proliferação anormal de células de músculo liso no parênquima pulmonar, linfonodos e em outros tecidos. Mais recentemente, estudos citogenéticos verificaram a presença de mutações do gene TSC-2 em células de angiomiolipoma renal e linfonodos abdominais de pacientes com LAM, indicando uma possível origem para as lesões hamartomatosas da doença. Radiologicamente, caracteriza-se pela presença de infiltrado intersticial reticulonodular e sinais de hiperinsuflação ao radiografia de tórax. Na tomografia computadorizada de alta resolução, cistos de paredes finas, localizados centralmente, são visibilizados por todo o parênquima do pulmão. O ultrassom e a tomografia de abdome podem revelar angiomiolipomas renais e linfonodomegalias retroperitoneais. Meningeomas também podem estar associados, porém a sua presença deve sempre levar à pesquisa de esclerose tuberosa. Funcionalmente, a doença caracteriza-se por um distúrbio ventilatório obstrutivo, de caráter progressivo, com hiperinsuflação pulmonar e diminuição da difusão de monóxido de carbono. Apesar da ausência de comprovação quanto à eficácia, o principal tratamento utilizado ainda é o anti-estrogênico e constitui-se de oofarectomia, progesterona contínua, tamoxifeno e análogos de GnRH. Além desse, a realização de transplantes pulmonares tem elevado para além de dez anos a sobrevida média das pacientes.

Role for activation of matrix metalloproteinases in the pathogenesis of pulmonary lymphangioleiomyomatosis

BACKGROUND

Matrix metalloproteinases (MMPs) have been shown to be involved in the pathogenesis of the destructive pulmonary lesions in patients with lymphangioleiomyomatosis (LAM); in the present report, the activation of these enzymes is examined.

OBJECTIVE

To evaluate the role of MMPs and their activating enzymes, immunohistochemical and confocalmicroscopic techniques were used to localize alpha-smooth muscle actin (alpha-SMA), HMB-45, proliferating cell nuclear antigen (PCNA), MMP-2, membrane-type 1 MMP (MT1-MMP), MT2-MMP, and MT3-MMP in lung tissues from 10 women with LAM. Tissue samples were obtained from 5 patients before treatment and in 5 patients after hormone treatment (progesterone and/or tamoxifen citrate).

RESULTS

Staining for alpha-SMA and MMP-2 was present in all the abnormal smooth muscle cells (LAM cells) in both groups. The percentages of PCNA-, MMP-2-, or MT1-MMP-positive LAM cells were much higher in the untreated group than in the treated group, whereas the percentages of HMB-45-reactive LAM cells were similar in both groups. The reactions for MT1-MMP and PCNA were preferentially localized in small spindle-shaped LAM cells; the reaction for HMB-45 was found in large epithelioid LAM cells. Many of the PCNA-positive cells were also positive for MT1-MMP. Staining for MT2-MMP and MT3-MMP was negative.

CONCLUSIONS

This study demonstrates an association between cellular proliferation and the presence of MT1-MMP in LAM cells. The activation of MMP-2 by MT1-MMP may play an important role in the destruction of lung tissue in this disorder.