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Nguyen HTL, Kohl E, Bade J, Eng SE, Tosevska A, Al Shihabi A, Tebon PJ, Hong JJ, Dry S, Boutros PC, Panossian A, Gosline SJC, Soragni A. A platform for rapid patient-derived cutaneous neurofibroma organoid establishment and screening. CELL REPORTS METHODS 2024; 4:100772. [PMID: 38744290 PMCID: PMC11133839 DOI: 10.1016/j.crmeth.2024.100772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 05/16/2024]
Abstract
Localized cutaneous neurofibromas (cNFs) are benign tumors that arise in the dermis of patients affected by neurofibromatosis type 1 syndrome. cNFs are benign lesions: they do not undergo malignant transformation or metastasize. Nevertheless, they can cover a significant proportion of the body, with some individuals developing hundreds to thousands of lesions. cNFs can cause pain, itching, and disfigurement resulting in substantial socio-emotional repercussions. Currently, surgery and laser desiccation are the sole treatment options but may result in scarring and potential regrowth from incomplete removal. To identify effective systemic therapies, we introduce an approach to establish and screen cNF organoids. We optimized conditions to support the ex vivo growth of genomically diverse cNFs. Patient-derived cNF organoids closely recapitulate cellular and molecular features of parental tumors as measured by immunohistopathology, methylation, RNA sequencing, and flow cytometry. Our cNF organoid platform enables rapid screening of hundreds of compounds in a patient- and tumor-specific manner.
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Affiliation(s)
- Huyen Thi Lam Nguyen
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Emily Kohl
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jessica Bade
- Pacific Northwest National Laboratories, Seattle, WA, USA
| | - Stefan E Eng
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA, USA; Institute for Precision Health, University of California, Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anela Tosevska
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ahmad Al Shihabi
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peyton J Tebon
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jenny J Hong
- Division of Hematology-Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sarah Dry
- Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Paul C Boutros
- Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA, USA; Institute for Precision Health, University of California, Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA; Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Sara J C Gosline
- Pacific Northwest National Laboratories, Seattle, WA, USA; Department of Biomedical Engineering, Oregon Health and Sciences University, Portland, OR, USA.
| | - Alice Soragni
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA; Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, Los Angeles, CA, USA.
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Fertitta L, Sarin KY, Bergqvist C, Patel E, Peiffer B, Moryousef S, Armand ML, Jannic A, Ferkal S, Ravaud P, Tran VT, Blakeley JO, Romo CG, Ezzedine K, Wolkenstein P. cNF-Skindex in Adults Living with Neurofibromatosis 1: Severity Strata in France and Validation in United States Adults. J Invest Dermatol 2023; 143:2226-2232.e1. [PMID: 37149083 DOI: 10.1016/j.jid.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/06/2023] [Accepted: 04/14/2023] [Indexed: 05/08/2023]
Abstract
Cutaneous neurofibromas (cNF) contribute to the impairment of QOL in individuals with neurofibromatosis 1. The cNF-Skindex, validated in a French population, specifically assesses the cNF-related QOL. In this study, we first defined severity strata using an anchoring approach on the basis of patient's burden. In total, 209 patients answered the anchor question and the cNF-Skindex. We tested the agreement among the three strata, generated by all potential couples of cut-off values of the cNF-Skindex and the three strata defined in the anchor question. The cut-off values 12 and 49 provided the highest Kappa value (κ = 0.685, 95% confidence interval = 0.604-0.765). Second, we validated the score and the strata in a United States population using the answers provided by 220 French and 148 United States adults. In the multivariable linear regression analysis, the country of origin was not a factor associated with the score (P = 0.297). The number of cNF along the different severity strata was similar between the French and the United States populations. In conclusion, stratification constitutes a powerful tool to better interpret the cNF-Skindex in daily practice and in clinical trials. This study validates its use in two populations that together constitute a large cohort of patients willing to participate in clinical research.
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Affiliation(s)
- Laura Fertitta
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Inserm U955, Mondor Institute for Biomedical Research, Creteil, France.
| | - Kavita Y Sarin
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Christina Bergqvist
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Ekshika Patel
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Bastien Peiffer
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Sabine Moryousef
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Marie-Laure Armand
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Arnaud Jannic
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Salah Ferkal
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France
| | - Philippe Ravaud
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and Statistics, Paris, France
| | - Viet-Thi Tran
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and Statistics, Paris, France
| | - Jaishri O Blakeley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carlos G Romo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khaled Ezzedine
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Université Paris Est Créteil, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, National Referral Center for Neurofibromatosis, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Creteil, France; Inserm U955, Mondor Institute for Biomedical Research, Creteil, France; Université Paris Est Créteil, Créteil, France
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Blakeley JO, Le LQ, Lee SY, Ly I, Rhodes SD, Romo CG, Sarin KY, Staedtke V, Steensma MR, Wolkenstein P. A Call for Discovery and Therapeutic Development for Cutaneous Neurofibromas. J Invest Dermatol 2023:S0022-202X(23)01983-8. [PMID: 37354152 DOI: 10.1016/j.jid.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/27/2022] [Indexed: 06/26/2023]
Affiliation(s)
- Jaishri O Blakeley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Lu Q Le
- Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sang Y Lee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ina Ly
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven D Rhodes
- Division of Hematology-Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA; Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carlos G Romo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kavita Y Sarin
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Verena Staedtke
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew R Steensma
- Center for Cancer and Cell Biology, Van Andel Research Institute, Grand Rapids, Michigan, USA; Helen DeVos Children's Hospital, Spectrum Health System, Grand Rapids, Michigan, USA; College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Pierre Wolkenstein
- Department of Dermatology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, University Paris East Créteil, Créteil, France
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Li Y, Blakeley J, Ly I, Berman Y, Lau J, Wolkenstein P, Bergqvist C, Jia W, Milner TE, Katta N, Durkin AJ, Kennedy GT, Rowland R, Romo CG, Fleming J, Kelly KM. Current and Emerging Imaging Techniques for Neurofibromatosis Type 1-Associated Cutaneous Neurofibromas. J Invest Dermatol 2023:S0022-202X(23)01988-7. [PMID: 37330718 DOI: 10.1016/j.jid.2023.03.1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/25/2023] [Accepted: 03/08/2023] [Indexed: 06/19/2023]
Abstract
A consistent set of measurement techniques must be applied to reliably and reproducibly evaluate the efficacy of treatments for cutaneous neurofibromas (cNFs) in people with neurofibromatosis type 1 (NF1). cNFs are neurocutaneous tumors that are the most common tumor in people with NF1 and represent an area of unmet clinical need. This review presents the available data regarding approaches in use or development to identify, measure, and track cNFs, including calipers, digital imaging, and high-frequency ultrasound sonography. We also describe emerging technologies such as spatial frequency domain imaging and the application of imaging modalities such as optical coherence tomography that may enable the detection of early cNFs and prevention of tumor-associated morbidity.
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Affiliation(s)
- Yingjoy Li
- Department of Dermatology, School of Medicine, University of California, Irvine, California, USA
| | - Jaishri Blakeley
- Comprehensive Neurofibromatosis Center, Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ina Ly
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yemima Berman
- Department of Clinical Genetics, Royal North Shore Hospital, St Leonards, Australia
| | - Jonathan Lau
- Department of Clinical Genetics, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, The University of Sydney, Camperdown, Australia
| | - Pierre Wolkenstein
- Faculty of Medicine and Health, Université Paris-Est Créteil Val de Marne, Créteil, France; Department of Dermatology, National Referral Center for Neurofibromatoses, Henri-Mondor Hospital, Assistance Publique-Hôpital Paris (AP-HP), Créteil, France
| | - Christina Bergqvist
- Department of Dermatology, National Referral Center for Neurofibromatoses, Henri-Mondor Hospital, Assistance Publique-Hôpital Paris (AP-HP), Créteil, France
| | - Wangcun Jia
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA
| | - Thomas E Milner
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Nitesh Katta
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA
| | - Anthony J Durkin
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Gordon T Kennedy
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA
| | - Rebecca Rowland
- Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA
| | - Carlos G Romo
- Comprehensive Neurofibromatosis Center, Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jane Fleming
- Department of Clinical Genetics, Royal North Shore Hospital, St Leonards, Australia
| | - Kristen M Kelly
- Department of Dermatology, School of Medicine, University of California, Irvine, California, USA; Beckman Laser Institute & Medical Clinic, University of California, Irvine, California, USA.
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Fleming J, Morgan O, Wong C, Schlub TE, Berman Y. Characterization of health concerns in people with neurofibromatosis type 1. Mol Genet Genomic Med 2022; 11:e2077. [PMID: 36444392 PMCID: PMC9834143 DOI: 10.1002/mgg3.2077] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Neurofibromatosis 1 (NF1) is a common cancer predisposition syndrome. Affected individuals require lifelong surveillance and often suffer progressive disfigurement due to cutaneous neurofibromas. The aim of this research was to characterize health concerns and quality of life (QOL) in a population cohort. METHODS An online survey was completed by 68 adults and 32 parents of children with NF1, and 60 controls. The survey included the Skindex-29 QOL scale, 5D-itch scale, and additional health questions. RESULTS Frequency of itch was high in children (50%) and adults (69%), with most expressing interest in treatment for itch. The presence of itch and increased visibility of NF1 were predictors of poorer QoL. Many adults (53%) and parents (44%) desired access to treatment to improve cosmetic appearance. Muscle weakness/tiredness was also prevalent amongst (60-70%) adults and children with NF1. Two-thirds of adults with NF1 reported limited awareness of NF1 services and poor knowledge of surveillance, particularly breast screening in young women. CONCLUSION This study highlights the impact of NF1-related itch and visibility in adults and children with a need for cosmetic and itch treatment. The findings emphasize a need for strategies to promote awareness, and access to management and treatment of NF1 in adults.
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Affiliation(s)
- Jane Fleming
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia
| | - Oliver Morgan
- Faculty of Health and MedicineUniversity of Sydney, Northern Clinical SchoolSydneyNew South WalesAustralia
| | - Claire Wong
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia,Department of Clinical GeneticsThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Timothy E. Schlub
- Sydney School of Public Health, Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Yemima Berman
- Department of Clinical GeneticsNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia
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Hsu CK, Denadai R, Chang CS, Yao CF, Chen YA, Chou PY, Lo LJ, Chen YR. The Number of Surgical Interventions and Specialists Involved in the Management of Patients with Neurofibromatosis Type I: A 25-Year Analysis. J Pers Med 2022; 12:jpm12040558. [PMID: 35455674 PMCID: PMC9025029 DOI: 10.3390/jpm12040558] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 02/05/2023] Open
Abstract
Objective: In this study, we aim to present a single institution’s 25-year experience of employing a comprehensive multidisciplinary team-based surgical approach for treating patients with NF-1. Summary Background Data: All patients (n = 106) with a confirmed diagnosis of NF-1 who were treated using a multidisciplinary surgical treatment algorithm at Chang Gung Memorial Hospital between 1994 and 2019 were retrospectively enrolled. Patients were categorized into groups according to the anatomy involved (craniofacial and noncraniofacial groups) and the type of clinical presentation (plexiform and cutaneous neurofibromas groups) for comparative analysis. Methods: The number of surgical interventions and number of specialists involved in surgical care were assessed. Results: Most of the patients exhibited craniofacial involvement (69.8%) and a plexiform type of NF-1 (58.5%), as confirmed through histology. A total of 332 surgical interventions (3.1 ± 3.1 procedures per patient) were performed. The number of specialists involved in surgical care of the included patients was 11 (1.6 ± 0.8 specialists per patient). Most of the patients (62.3%) underwent two or more surgical interventions, and 40.6% of the patients received treatment from two or more specialists. No significant differences were observed between the craniofacial and noncraniofacial groups in terms of the average number of surgical interventions (3.3 ± 3.2 vs. 2.7 ± 2.7, respectively) and number of specialists involved (1.7 ± 0.9 vs. 1.4 ± 0.6). Patients with plexiform craniofacial involvement underwent a significantly higher average number of surgical interventions (4.3 ± 3.6 vs. 1.6 ± 1.1; p < 0.001) and received treatment by more specialists (1.9 ± 0.9 vs. 1.2 ± 0.5; p < 0.001) compared with those having cutaneous craniofacial involvement. Conclusions: In light of the potential benefits of employing the multidisciplinary team-based surgical approach demonstrated in this study, such an approach should be adopted to provide comprehensive individualized care to patients with NF-1.
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Choi J, An S, Lim SY. Current concepts of neurofibromatosis type 1: pathophysiology and treatment. Arch Craniofac Surg 2022; 23:6-16. [PMID: 35255591 PMCID: PMC8901593 DOI: 10.7181/acfs.2022.00633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/08/2022] [Accepted: 02/18/2022] [Indexed: 11/22/2022] Open
Abstract
Neurofibromatosis type 1 is the most common tumor predisposition syndrome inherited in an autosomal dominant (100% penetrance) fashion with a wide variety of expressivity. From the perspective of plastic surgery, the most significant clinical symptoms, including disfiguration, peripheral neurologic symptoms, and skeletal abnormalities, are caused by various tumors originating from the affected nerves. Surgical removal is the standard of care for these tumors. However, the outcome is frequently unsatisfactory, facilitating the search for additional therapeutic adjuvants. Current trials of molecularly targeted therapies are promising. Abbreviations: CALMs, café-au-lait macules; CNs, cutaneous neurofibromas; FDG, 18F-fluoro-deoxy-glucose; MAPK, mitogen-activated protein kinase; MPNSTs, malignant peripheral nerve sheath tumors; MRI, magnetic resonance imaging; NF1, neurofibromatosis type 1; NIH, National Institutes of Health; PET, positron emission tomography; PN, plexiform neurofibromas; TME, tumor microenvironment.
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Affiliation(s)
- Jaemin Choi
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sungbin An
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea
| | - So Young Lim
- Department of Plastic and Reconstructive Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
The neurofibromatoses are a group of genetic disorders that cause development of nervous system tumors as well as various other tumor and systemic manifestations. Neurofibromatosis type 1 is the most prevalent of these conditions and has the most variable phenotype and highest risk of malignant tumor formation. Neurofibromatosis type 2 has no associated malignant tumors but does carry significant morbidity, including deafness, facial weakness, and physical disability. Schwannomatosis is the least prevalent of these disorders and is characterized primarily by nonvestibular schwannomas and pain.
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Affiliation(s)
- Justin T Jordan
- Pappas Center for Neuro-Oncology and Family Center for Neurofibromatosis, Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
| | - Scott R Plotkin
- Pappas Center for Neuro-Oncology and Family Center for Neurofibromatosis, Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA
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Rabab’h O, Gharaibeh A, Al-Ramadan A, Ismail M, Shah J. Pharmacological Approaches in Neurofibromatosis Type 1-Associated Nervous System Tumors. Cancers (Basel) 2021; 13:cancers13153880. [PMID: 34359780 PMCID: PMC8345673 DOI: 10.3390/cancers13153880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Neurofibromatosis type 1 (NF1) is a common cancer predisposition genetic disease that is associated with significant morbidity and mortality. In this literature review, we discuss the major pathways in the nervous system that are affected by NF1, tumors that are associated with NF1, drugs that target these pathways, and genetic models of NF1. We also summarize the latest updates from clinical trials that are evaluating pharmacological agents to treat these tumors and discuss the efforts that are being made to cure the disease in the future Abstract Neurofibromatosis type 1 is an autosomal dominant genetic disease and a common tumor predisposition syndrome that affects 1 in 3000 to 4000 patients in the USA. Although studies have been conducted to better understand and manage this disease, the underlying pathogenesis of neurofibromatosis type 1 has not been completely elucidated, and this disease is still associated with significant morbidity and mortality. Treatment options are limited to surgery with chemotherapy for tumors in cases of malignant transformation. In this review, we summarize the advances in the development of targeted pharmacological interventions for neurofibromatosis type 1 and related conditions.
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Affiliation(s)
- Omar Rabab’h
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
| | - Abeer Gharaibeh
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
- Insight Institute of Neurosurgery & Neuroscience, Flint, MI 48507, USA
- Insight Surgical Hospital, Warren, MI 48091, USA
| | - Ali Al-Ramadan
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
| | - Manar Ismail
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
| | - Jawad Shah
- Insight Research Institute, Flint, MI 48507, USA; (O.R.); (A.G.); (A.A.-R.); (M.I.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
- Insight Institute of Neurosurgery & Neuroscience, Flint, MI 48507, USA
- Insight Surgical Hospital, Warren, MI 48091, USA
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
- Correspondence:
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Thalheimer RD, Merker VL, Ly KI, Champlain A, Sawaya J, Askenazi NL, Herr HP, Da JLW, Jordan JT, Muzikansky A, Pearce EM, Sakamoto FH, Blakeley JO, Anderson RR, Plotkin SR. Validating Techniques for Measurement of Cutaneous Neurofibromas: Recommendations for Clinical Trials. Neurology 2021; 97:S32-S41. [PMID: 34230197 DOI: 10.1212/wnl.0000000000012428] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the reliability and variability of digital calipers, 3D photography, and high-frequency ultrasound (HFUS) for measurement of cutaneous neurofibromas (cNF) in patients with neurofibromatosis type 1 (NF1). BACKGROUND cNF affect virtually all patients with NF1 and are a major source of morbidity. Reliable techniques for measuring cNF are needed to develop therapies for these tumors. METHODS Adults with NF1 were recruited. For each participant, 6 cNF were assessed independently by 3 different examiners at 5 different time points using digital calipers, 3D photography, and HFUS. The intraclass correlation coefficient (ICC) was used to assess intrarater and interrater reliability of linear and volumetric measurements for each technique, with ICC values >0.90 defined as excellent reliability. The coefficient of variation (CV) was used to estimate the minimal detectable difference (MDD) for each technique. RESULTS Fifty-seven cNF across 10 participants were evaluated. The ICC for image acquisition and measurement was >0.97 within and across examiners for HFUS and 3D photography. ICC for digital calipers was 0.62-0.88. CV varied by measurement tool, linear vs volumetric measurement, and tumor size. CONCLUSIONS HFUS and 3D photography demonstrate excellent reliability whereas digital calipers have good to excellent reliability in measuring cNF. The MDD for each technique was used to create tables of proposed thresholds for investigators to use as guides for clinical trials focused on cNF size. These criteria should be updated as the performance of these end points is evaluated.
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Affiliation(s)
- Raquel D Thalheimer
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vanessa L Merker
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - K Ina Ly
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amanda Champlain
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer Sawaya
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Naomi L Askenazi
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hamilton P Herr
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer L W Da
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Justin T Jordan
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alona Muzikansky
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth Morehouse Pearce
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fernanda H Sakamoto
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaishri O Blakeley
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - R Rox Anderson
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott R Plotkin
- From the Department of Neurology and Cancer Center (R.T., V.L.M., I.L., N.L.A., H.P.H., J.L.W.D., J.T.J., S.R.P.), Wellman Center for Photomedicine (A.C., J.S., E.M.P., F.H.S., R.R.A.), and Biostatistics Center (A.M.), Massachusetts General Hospital, and Department of Dermatology (A.C., J.S., E.M.P., F.H.S., R.R.A.), Harvard Medical School, Boston; and Department of Neurology, Neurosurgery, and Oncology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD.
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11
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Oliveira LB, Geller M, Cunha KS, Santos A, Bernacchi A, Rubenstein AE, Takirambudde S, Mezitis S, de Almeida Ito Brum C, Darrigo LG, Ribeiro MG. Clinical assessment of the use of topical liquid diclofenac following laser microporation of cutaneous neurofibromas in individuals with neurofibromatosis type 1. Heliyon 2021; 7:e06518. [PMID: 33817379 PMCID: PMC8010391 DOI: 10.1016/j.heliyon.2021.e06518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/16/2020] [Accepted: 03/11/2021] [Indexed: 11/03/2022] Open
Abstract
Background Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder with a prevalence of 1:3000 births and a wide variety of clinical manifestations. Cutaneous neurofibromas (cNF) are among the most common visible manifestations of NF1 and present a major clinical burden for patients. NF1 patients with cNF often report decreased quality of life, emotional well-being and physical comfort. Developing effective medical therapies for cNF has been identified as a priority for the majority of adults with NF1. Methods The study was an open, controlled and prospective proof-of-concept clinical trial. The topical treatment consisted of two steps: cNF microporation using a laser device followed by topical application of one drop of diclofenac 25 mg/mL on the surface of the cNF (T neurofibroma = treatment) or physiological saline (C neurofibroma = control) and reapplied twice daily for 3 days. Neurofibroma assessments included visual and dermatoscopy observations noting color and presence of necrosis, presence of flaccidity, measurements in two dimensions, photographs, and histopathology after excision. The primary efficacy variable was the presence of tissue necrosis. The primary safety variable was the occurrence of treatment-related adverse events. Results Six patients were included in the study. The treatment resulted in transitory topical changes (healing of the microporation grid with formation of scintillating tissue layer, hyperemia and desquamation), with no statistically significant variation in the dimensions of the T and C neurofibromas in relation to pretreatment measurements. There was no necrosis in the T or C neurofibromas. In the histopathological analysis, there was no significant difference in the distribution of chronic (lymphocytic) inflammatory infiltrate in the papillary reticular dermis (subepithelial), type of infiltrate (diffuse, perivascular, or both), presence of fibrosis, and presence of atrophy among the T and C neurofibromas. No adverse events attributable to the use of diclofenac were reported during the treatment period. Conclusions Treatment did not result in significant alterations in terms of presence of tissue necrosis, size, or histopathological features in the T neurofibromas or in comparison to the C neurofibromas. Topical diclofenac with laser microporation was well-tolerated, with no adverse events attributable to diclofenac reported. Whether these observations are due to minimal systemic and neurofibroma exposure remain to be explored in dosage studies with larger patient groups. Trial registration ClinicalTrials.gov (NCT03090971) retrospectively registered March 27, 2017.
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Affiliation(s)
- Lisa Brauer Oliveira
- Postgraduate Program in Clinical Medicine, Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro, Brazil
| | - Mauro Geller
- Medical Genetics Service, Instituto de Puericultura e Pediatria Martagão Gesteira Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.,Department of Immunology and Microbiology, Centro Universitário Serra dos Órgãos (UNIFESO), Teresópolis, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Clinical Immunology, Instituto de Pós-Graduação Médica Carlos Chagas - Rio de Janeiro, Brazil
| | - Karin Soares Cunha
- Postgraduate Program in Pathology, Universidade Federal Fluminense (UFF) Medical School, Niterói, Brazil.,Pathology Department, Faculdade de Medicina - Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Alessandra Santos
- Postgraduate Program in Clinical Medicine, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Allan Bernacchi
- Department of Plastic Surgery, Serviço Prof. Pitanguy, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Allan E Rubenstein
- Department of Neurology and Pediatrics, NYU Langone Medical Center, New York, NY, USA
| | - Sanyu Takirambudde
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Spyros Mezitis
- Department of Endocrinology/Clinical Medicine, Weill Medical College of Cornell University, New York, NY, USA.,New York Presbyterian Hospital/Cornell Medicine, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | | | - Luiz Guilherme Darrigo
- Bone Marrow Transplant Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcia Gonçalves Ribeiro
- Department of Pediatrics, Federal University of Rio de Janeiro Medical School (UFRJ), Rio de Janeiro, Brazil.,Medical Genetics Service, Instituto de Puericultura e Pediatria Martagão Gesteira, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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12
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Quirk B, Olasz E, Kumar S, Basel D, Whelan H. Photodynamic Therapy for Benign Cutaneous Neurofibromas Using Aminolevulinic Acid Topical Application and 633 nm Red Light Illumination. PHOTOBIOMODULATION PHOTOMEDICINE AND LASER SURGERY 2021; 39:411-417. [PMID: 33470897 PMCID: PMC8219184 DOI: 10.1089/photob.2020.4957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Neurofibromatosis type 1 (NF1) has no current effective treatments beyond surgery. Topical photodynamic therapy (PDT) has the potential to provide a less invasive treatment modality. Objective: Based on murine data, we hypothesized PDT could be used for the treatment of cutaneous neurofibromas (cNF). Methods and results: We conducted a phase I trial to examine absorption and conversion of topical aminolevulinic acid (ALA) in cNF and determine safety in a dose escalation study. ALA or control vehicle was applied to neurofibromas through microneedle-assisted delivery (n = 4) and excised specimens were examined 24 h later for protoporphyrin IX fluorescence. Fluorescence was detected in the tumors at 304 ± 94 U/μm2, while adjacent paralesional normal skin and vehicle-treated tumors showed no fluorescence (p < 0.0001). Subsequently, neurofibromas (n = 27) were treated with ALA and irradiated with 633 nm red light 18 h later, at escalating dosages of 50 and 100 mJ/cm2. Maximum tolerable dose was established at 100 mJ/cm2. Light microscopy study of tumors biopsied 48 h after PDT (ALA n = 14 and vehicle n = 4) showed mixed inflammatory infiltrate in the ALA, but not in the vehicle-treated tumors or perilesional normal skin. TUNEL evaluation showed 42.5 ± 19.9 apoptotic cells per visual field for ALA-treated and 1.1 ± 1.4 for vehicle-treated tumors (p = 0.002). Conclusions: In the first reported clinical trial of PDT for NF1, PDT targeted neurofibromas specifically, and may offer a normal tissue-sparing treatment modality in the future. This study is registered at Clintrials.gov (NCT01682811).
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Affiliation(s)
- Brendan Quirk
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Edit Olasz
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Suresh Kumar
- Department of Pathology & Laboratory Medicine, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Donald Basel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Harry Whelan
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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13
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Chamseddin BH, Le LQ. Management of cutaneous neurofibroma: current therapy and future directions. Neurooncol Adv 2020; 2:i107-i116. [PMID: 32642736 PMCID: PMC7317049 DOI: 10.1093/noajnl/vdz034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is a life-long neurocutaneous disorder characterized by a predisposition to tumor development, including cutaneous neurofibroma (cNF), the hallmark of the disease. cNF is a histologically benign, multicellular tumor formed in virtually most individuals with NF1. It is considered the most burdensome feature of the disorder due to their physical discomfort, cosmetically disfiguring appearance, and psychosocial burden. Management of cNF remains a challenge in the medical field. Effective medicinal treatment for cNF does not exist at this time. Trials aimed at targeting individual components of the neoplasm such as mast cells with Ketotifen have not shown much success. Physical removal or destruction has been the mainstay of therapy. Surgical removal gives excellent cosmetic results, but risk in general anesthesia may require trained specialists. Destructive laser such as CO2 laser is effective in treating hundreds of tumors at one time but has high risk of scarring hypopigmentation or hyperpigmentation that alter cosmetic outcomes. A robust, low-risk surgical technique has been developed, which may be performed in clinic using traditional biopsy tools that may be more accessible to NF1 patients worldwide than contemporary techniques including Er:YAG or Nd:YAG laser. In this review, specific recommendations for management of cNFs are made based on symptoms, clinical expertise, and available resources. Additionally, antiproliferative agents aimed at stimulating cellular quiescence are explored.
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Affiliation(s)
- Bahir H Chamseddin
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lu Q Le
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
- Hamon Center for Regenerative Science and Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Neurofibromatosis Clinic, University of Texas Southwestern Medical Center, Dallas, Texas
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14
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Guiraud M, Bouroubi A, Beauchamp R, Bocquet A, Grégoire JM, Rauly-Lestienne I, Blanco I, Wolkenstein P, Schmitt AM. Cutaneous neurofibromas: patients' medical burden, current management and therapeutic expectations: results from an online European patient community survey. Orphanet J Rare Dis 2019; 14:286. [PMID: 31801570 PMCID: PMC6894276 DOI: 10.1186/s13023-019-1265-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/26/2019] [Indexed: 11/21/2022] Open
Abstract
Background Neurofibromatosis type 1 is an inherited condition with variable phenotypic expression and a high medical and social burden. The objectives of this patient survey were to better understand the real-world experiences of patients living with cutaneous neurofibromas (cNF), to perceive their satisfaction and feelings about cNF current management (only laser and surgery are currently available), and to highlight their expectations of new therapeutic modalities. Results One hundred seventy patients from 4 European countries took part in the study, 65% (n = 110) were women and mean age was 39 years old. 96% (n = 164) of respondents have cNF on visible parts of the body and the survey confirmed that total number of cNF and visibility increase with age. Patients reported that cNF mainly impacts everyday mood, general daily life and social life. The visibility of cNF had a higher impact than their number. 92% (n = 156) of patients have a regular and multidisciplinary medical follow-up. The dermatologist is one of the most consulted healthcare professionals. 76% (n = 130) of respondents have treated their cNF: 65% (n = 111) had surgery and 38% (n = 64) had multiple laser sessions. Frequency of operations and regrowth of cNF were the two most unsatisfactory aspects with both treatments for patients. Indeed, after removal, new cNF appear in more than 75% (n = 128) of cases. As a future treatment, patients expected a topical (30%, n = 51) or oral medication (29%, n = 50). Around 2 out of 3 patients would agree to take it at least once a day or more for life but they would like a well-tolerated treatment. According to patients, the most important effectiveness criteria of a new treatment are to block cNF growth and reduce their number. 70% (n = 119) of patients would consider a future treatment moderately effective to very effective if it could clear 30% of cNF. Conclusions This first cNF European patient community survey confirmed that the visible stigma and unaesthetic aspect of cNF have an important impact on patients’ quality of life. The survey highlighted that patients were not entirely satisfied with the actual surgery and laser treatments and revealed their clear and realistic expectations for future treatment of cNF.
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Affiliation(s)
- Marlene Guiraud
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France.
| | - Athmane Bouroubi
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
| | - Roxane Beauchamp
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
| | - Arnaud Bocquet
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
| | - Jean-Marc Grégoire
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
| | - Isabelle Rauly-Lestienne
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
| | - Ignacio Blanco
- Genetic Counseling and Clinical Genetics Program, Laboratori Clínic Metropolitana Nord, Hospital Germans Tias, 08916, Badalona, Spain
| | | | - Anne-Marie Schmitt
- Institut de Recherche Pierre Fabre, Centre de Recherche et Développement, Dermatology Innovation Unit, 3 avenue Hubert Curien - BP 13562 31035, Toulouse Cedex 1, France
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15
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Abstract
Neurofibromatosis type 1 (NF1), NF2, and schwannomatosis are related, but distinct, tumor suppressor syndromes characterized by a predilection for tumors in the central and peripheral nervous systems. NF1 is one of the most common autosomal dominant conditions of the nervous system. NF1 has a high degree of variability in clinical presentation, which may include multiple neoplasms as well as cutaneous, vascular, bony, and cognitive features. Some of these manifestations overlap with other genetic conditions. Accurate diagnosis of NF1 is important for individualizing clinical care and genetic counseling. This article summarizes the clinical features, diagnostic work-up, and management of NF1.
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Affiliation(s)
- K Ina Ly
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Yawkey 9 East, 55 Fruit Street, Boston, MA 02114, USA.
| | - Jaishri O Blakeley
- Department of Neurology and Neurosurgery, Johns Hopkins University, 600 North Wolfe Street, Meyer 100, Baltimore, MD 21287, USA; Department of Oncology, Johns Hopkins University, 600 North Wolfe Street, Meyer 100, Baltimore, MD 21287, USA
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16
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Cannon A, Jarnagin K, Korf B, Widemann BC, Casey D, Ko HS, Blakeley JO, Verma SK, Pichard DC. Clinical trial design for cutaneous neurofibromas. Neurology 2019; 91:S31-S37. [PMID: 29987133 DOI: 10.1212/wnl.0000000000005790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/13/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Several clinical trials targeting cutaneous neurofibromas (cNF) have been conducted; however, none has resulted in meaningful changes to care. The Clinical Trial Design and Development subgroup's goals were to (1) define key considerations in the design of clinical trials for cNF, (2) summarize existing data in relation to these considerations, and (3) provide consensus recommendations about key elements of trial design to accelerate the clinical development of therapies for cNF. METHODS The subgroup, with experts from genetics, dermatology, neurology, oncology, and basic science, spanning academia, government research, and regulatory programs, and industry, reviewed published and unpublished data on clinical trials for cNF and other diseases in the skin. Discussions of these data resulted in formulation of a list of priority issues to address in order to develop efficient and effective clinical trials for cNF. RESULTS The subgroup identified 2 natural history studies of cNF, 4 priority outcome measures, and 6 patient-reported outcome tools for potential use in efficacy trials of cNF. Time to initiate intervention, patient eligibility, mechanism of action, route of administration, safety monitoring, and regulatory agency interactions were identified as key factors to consider when designing clinical trials for cNF. CONCLUSIONS Alignment on endpoints and methods for the measurement and quantification of cNF represent a priority for therapeutic development for cNF. Advances in technological methods and outcome tools utilized in other skin diseases may be applicable to cNF studies. Patient age is an important factor guiding trial design and clinical development path.
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Affiliation(s)
- Ashley Cannon
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kurt Jarnagin
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bruce Korf
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brigitte C Widemann
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Denise Casey
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hon-Sum Ko
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaishri O Blakeley
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sharad K Verma
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dominique C Pichard
- From the Department of Genetics (A.C., B.K.), University of Alabama at Birmingham; BioPharm Tech (K.J.), San Mateo, CA; Pediatric Oncology Branch (B.C.W.) and Dermatology Branch, Center for Cancer Research (D.C.P.), National Cancer Institute, NIH, Bethesda; Division of Oncology Products (D.C.) and Division of Dermatology and Dental Products (H.-S.K.), Food and Drug Administration, Silver Spring; and Department of Neurology (J.O.B., S.K.V.), The Neurofibromatosis Therapeutic Acceleration Program, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Chamseddin BH, Hernandez L, Solorzano D, Vega J, Le LQ. Robust surgical approach for cutaneous neurofibroma in neurofibromatosis type 1. JCI Insight 2019; 5:128881. [PMID: 31038470 PMCID: PMC6629109 DOI: 10.1172/jci.insight.128881] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/23/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cutaneous neurofibromas (cNF) are physically disfiguring, painful, and cause extensive psychologic harm in patients with neurofibromatosis type 1 (NF1). There is currently no effective medical treatment and surgical procedures are inaccessible to most NF1 patients globally. OBJECTIVE While research is underway to find an effective medical treatment for cNF, there is an urgent need to develop surgical approach that is accessible to all NF1 patients in the world with the skill set and equipment found in most general medical office settings. Here, we present a robust surgical approach to remove cNF that does not require sterile surgical field, utilizes accessible clinical equipment, and can be performed by any health care providers including family practitioners, and physician assistants. METHODS In a prospective case-series, patients with NF1 underwent this surgical procedure which removes multiple cutaneous neurofibromas. The Dermatology Life Quality Index was given to subjects before and after the procedure as surrogate for patient satisfaction. RESULTS 83 tumors were removed throughout the body from twelve individuals. Examination at follow-up visits revealed well-healed scars without infection or adverse events including aberrant scarring. Patient satisfaction with the procedure was high with significant improvements in symptoms, daily activities, leisure, personal relationships, and treatment experience (P = 0.00062). CONCLUSION This study demonstrates a robust surgical approach to management cutaneous neurofibromas which can be accessed world-wide to individuals with NF1 and performed by a wide-variety of medical specialists with high clinical efficacy and patient satisfaction.
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Affiliation(s)
| | | | | | | | - Lu Q. Le
- Department of Dermatology
- Comprehensive Neurofibromatosis Clinic, and
- Simmons Comprehensive Cancer Center, University of Texas (UT) Southwestern Medical Center, Dallas, Texas, USA
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18
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Ortonne N, Wolkenstein P, Blakeley JO, Korf B, Plotkin SR, Riccardi VM, Miller DC, Huson S, Peltonen J, Rosenberg A, Carroll SL, Verma SK, Mautner V, Upadhyaya M, Stemmer-Rachamimov A. Cutaneous neurofibromas. Neurology 2018; 91:S5-S13. [PMID: 29987130 DOI: 10.1212/wnl.0000000000005792] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/16/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo present the current terminology and natural history of neurofibromatosis 1 (NF1) cutaneous neurofibromas (cNF).MethodsNF1 experts from various research and clinical backgrounds reviewed the terms currently in use for cNF as well as the clinical, histologic, and radiographic features of these tumors using published and unpublished data.ResultsNeurofibromas develop within nerves, soft tissue, and skin. The primary distinction between cNF and other neurofibromas is that cNF are limited to the skin whereas other neurofibromas may involve the skin, but are not limited to the skin. There are important cellular, molecular, histologic, and clinical features of cNF. Each of these factors is discussed in consideration of a clinicopathologic framework for cNF.ConclusionThe development of effective therapies for cNF requires formulation of diagnostic criteria that encompass the clinical and histologic features of these tumors. However, there are several areas of overlap between cNF and other neurofibromas that make distinctions between cutaneous and other neurofibromas more difficult, requiring careful deliberation with input across the multiple disciplines that encounter these tumors and ultimately, prospective validation. The ultimate goal of this work is to facilitate accurate diagnosis and meaningful therapeutics for cNF.
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Affiliation(s)
- Nicolas Ortonne
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Pierre Wolkenstein
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK.
| | - Jaishri O Blakeley
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Bruce Korf
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Scott R Plotkin
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Vincent M Riccardi
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Douglas C Miller
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Susan Huson
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Juha Peltonen
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Andrew Rosenberg
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Steven L Carroll
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Sharad K Verma
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Victor Mautner
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Meena Upadhyaya
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
| | - Anat Stemmer-Rachamimov
- From the Departments of Pathology (N.O.) and Dermatology (P.W.), French Referral Center for Neurofibromatoses, Henri-Mondor Hospital, AP-HP, University Paris Est Créteil, France; Department of Neurology (J.O.B., S.K.V.), Johns Hopkins University School of Medicine, The Neurofibromatosis Therapuetic Acceleration Program, Baltimore, MD; University of Alabama at Birmingham (B.K.); Cancer Center and Department of Neurology (S.R.P.) and Department of Pathology, Division of Neuropathology (A.S.-R.), Massachusetts General Hospital, Boston; The Neurofibromatosis Institute (V.M.R.), La Crescenta, CA; Department of Pathology & Anatomical Sciences (D.C.M.), University of Missouri School of Medicine, Columbia; Manchester Centre for Genomic Medicine (S.H.), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, UK; Institute of Biomedicine (J.P.), University of Turku, Finland; Department of Pathology and Laboratory Medicine (A.R.), Jackson Memorial Hospital/University of Miami Miller School of Medicine, FL; Department of Pathology and Laboratory Medicine (S.L.C.), Medical University of South Carolina, Charleston; Clinics and Polyclinics of Neurology (V.M.), University Hospital Hamburg-Eppendorf, Hamburg, Germany; and Division of Cancer and Genetics (M.U.), Institute of Medical Genetics, Cardiff University, UK
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