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Yanagisawa A, Takimoto T, Kurahara Y, Tsuyuguchi K, Yoshida S, Hirose M, Inoue Y, Arai T. Lymphangioleiomyomatosis Showing the Development of Mycobacterium abscessus subsp. massiliense Infection during Sirolimus Therapy. Intern Med 2024; 63:2043-2047. [PMID: 38008448 PMCID: PMC11309859 DOI: 10.2169/internalmedicine.2847-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/03/2023] [Indexed: 11/28/2023] Open
Abstract
Among nontuberculous mycobacterial pulmonary diseases (NTM-PDs), Mycobacterium abscessus species pulmonary disease (MABS-PD) is one of the most severe and intractable infections. We herein report a 45-year-old woman with advanced lymphangioleiomyomatosis (LAM) who developed MABS-PD while undergoing sirolimus therapy. MABS-PD was immediately controlled using antibiotic therapy, although the patient's lung transplant registration was significantly delayed. To our knowledge, this is the first case report on the development of NTM-PD in a patient with LAM before lung transplantation. This case suggests that the early diagnosis and optimal treatment of NTM-PD are crucial in patients with advanced LAM.
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Affiliation(s)
- Atsushi Yanagisawa
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Takayuki Takimoto
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Yu Kurahara
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Kazunari Tsuyuguchi
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Shiomi Yoshida
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
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Sakurai T, Kanou T, Funaki S, Fukui E, Kimura T, Ose N, Inoue Y, Shintani Y. Effect of mTOR inhibitors on the mortality and safety of patients with lymphangioleiomyomatosis on the lung transplantation waitlist: A retrospective cohort study. Respir Investig 2024; 62:657-662. [PMID: 38761480 DOI: 10.1016/j.resinv.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Although lung transplantation (LTx) is the last resort for patients with end-stage lymphangioleiomyomatosis (LAM), the high waitlist mortality is a source of concern in Japan. Discontinuation of mechanistic target of rapamycin (mTOR) inhibitors prior to LTx is recommended due to the incidence of severe adverse events. Therefore, we hypothesized that mTOR inhibitors may affect the mortality of patients with LAM on the LTx waitlist. METHODS We retrospectively compared the characteristics of consecutive patients with LAM on the LTx waitlist who were and were not receiving mTOR inhibitors. RESULTS Twenty-nine consecutive patients with LAM who listed our center between January 2004 and December 2021 were selected from the database and enrolled in the present study. Seventeen patients (58.6%) were receiving a mTOR inhibitor, sirolimus (treatment group). During a median listing period of 1277 days, 12 patients (41.4%) were hospitalized, six patients (20.7%) died from disease before LTx, and 15 patients underwent LTx. Among the deceased patients, four patients (66.6%) had pneumothoraces. The waitlist mortality in the treatment group was significantly lower than that in the non-treatment group (p = 0.03). Among the six patients who discontinued sirolimus in the treatment group, four patients (66.6%) were hospitalized with respiratory complications after the discontinuation of sirolimus. No mTOR inhibitor-related complications arose in the treatment group undergoing LTx (n = 7), including those on a reduced sirolimus dose. CONCLUSIONS Administration of an mTOR inhibitor until LTx may decrease waitlist mortality. Due to life-threatening events after discontinuing sirolimus pre-LTx, a reduced dose until LTx is permissible.
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Affiliation(s)
- Teiko Sakurai
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
| | - Takashi Kanou
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan.
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
| | - Eriko Fukui
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
| | - Toru Kimura
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
| | - Naoko Ose
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8555, Japan; Department of Internal Medicine, Osaka Anti-tuberculosis Association Osaka Fukujuji Hospital, 3-10 Uchiagetakatsuka, Neyagawa, Osaka, 572-0859, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Graduate School of Medicine, Osaka University, Yamadagaoka 2-2(L5), Suita, Osaka, 565-0871, Japan
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Seyama K, Komiyama E, Tsuchihashi H, Okura MK, Sekimoto Y, Mitsuishi Y. Stepwise Incremental Dose Schedule of Sirolimus Is Successfully Tolerated by a Patient With Lymphangioleiomyomatosis Who Was Initially Allergic to mTOR Inhibitors. Cureus 2024; 16:e58805. [PMID: 38784348 PMCID: PMC11112535 DOI: 10.7759/cureus.58805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease involving the proliferation of LAM cells in the lungs and the axial lymphatic system and mechanistic target of rapamycin (mTOR) inhibitors are the only effective medicines for treating it. Patients suffering from LAM, who are allergic to mTOR inhibitors can be treated by desensitizing them to the medicine. A 39-year-old woman presented with dyspnea caused by chylous pleural effusion, ascites, and retroperitoneal lymphangioleiomyomas. She was diagnosed with LAM based on the presence of LAM cell clusters (LCCs) in chylous pleural effusion and elevated serum vascular endothelial growth factor D (VEGF-D) concentration. She was allergic to cedars and yellowtails. Although she was started on sirolimus for treating LAM, the drug had to be discontinued on day 45 because of the appearance of a skin rash on her trunk. A year later, another oral mTOR inhibitor, everolimus, was initiated but had to be discontinued because of the appearance of cutaneous reactions. Since mTOR inhibitors are the only effective molecular-target medicines for LAM, desensitization to sirolimus was attempted by initiating exposure to sirolimus at a low dose followed by stepwise dose escalation. Eventually, the patient tolerated a dose of 0.5 mg/day of sirolimus, which resulted in a trough concentration of approximately 2 ng/ml in blood, without adverse cutaneous reactions; furthermore, clinically relevant effects were observed as her LAM condition reduced and stabilized. This case study illustrates that mTOR inhibitor therapy for LAM should not be abandoned because of allergic cutaneous reactions. Physicians must find a dose that balances adverse events and therapeutic effects to ensure continued treatment for patients with LAM. Furthermore, the possible mechanisms for mTOR inhibitor-induced cutaneous reactions have been discussed.
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Affiliation(s)
- Kuniaki Seyama
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Etsuko Komiyama
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Hitoshi Tsuchihashi
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Makiko K Okura
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yasuhito Sekimoto
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yoichiro Mitsuishi
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
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Szalai F, Sztankovics D, Krencz I, Moldvai D, Pápay J, Sebestyén A, Khoor A. Rictor-A Mediator of Progression and Metastasis in Lung Cancer. Cancers (Basel) 2024; 16:543. [PMID: 38339294 PMCID: PMC10854599 DOI: 10.3390/cancers16030543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Lung carcinoma is one of the most common cancer types for both men and women. Despite recent breakthroughs in targeted therapy and immunotherapy, it is characterized by a high metastatic rate, which can significantly affect quality of life and prognosis. Rictor (encoded by the RICTOR gene) is known as a scaffold protein for the multiprotein complex mTORC2. Among its diverse roles in regulating essential cellular functions, mTORC2 also facilitates epithelial-mesenchymal transition and metastasis formation. Amplification of the RICTOR gene and subsequent overexpression of the Rictor protein can result in the activation of mTORC2, which promotes cell survival and migration. Based on recent studies, RICTOR amplification or Rictor overexpression can serve as a marker for mTORC2 activation, which in turn provides a promising druggable target. Although selective inhibitors of Rictor and the Rictor-mTOR association are only in a preclinical phase, they seem to be potent novel approaches to reduce tumor cell migration and metastasis formation. Here, we summarize recent advances that support an important role for Rictor and mTORC2 as potential therapeutic targets in the treatment of lung cancer. This is a traditional (narrative) review based on Pubmed and Google Scholar searches for the following keywords: Rictor, RICTOR amplification, mTORC2, Rictor complexes, lung cancer, metastasis, progression, mTOR inhibitors.
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Affiliation(s)
- Fatime Szalai
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Dániel Sztankovics
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Ildikó Krencz
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Dorottya Moldvai
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Judit Pápay
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Anna Sebestyén
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Üllői út 26, H-1085 Budapest, Hungary; (F.S.); (D.S.); (I.K.); (D.M.); (J.P.); (A.S.)
| | - Andras Khoor
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Xu W, Yang C, Cheng C, Wang Y, Hu D, Huang J, He Y, Wang J, Chen K, Yang L, Zhou W, Zhang T, Liu S, Dai J, Meng S, Li X, Yang Y, Wang ST, Feng R, Zhang W, Zhang H, Wang L, Tian X, Xu KF. Determinants of Progression and Mortality in Lymphangioleiomyomatosis. Chest 2023:S0012-3692(23)00272-6. [PMID: 36801466 DOI: 10.1016/j.chest.2023.02.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/03/2023] [Accepted: 02/14/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis is a progressive diffuse cystic lung disease with approximately 85% survival at 10 years. The determinants of disease progression and mortality after the introduction of sirolimus therapy and vascular endothelial growth factor D (VEGF-D) as a biomarker have not been well defined. RESEARCH QUESTION Which factors, including VEGF-D and sirolimus therapy, influence disease progression and survival prognosis in patients with lymphangioleiomyomatosis? STUDY DESIGN AND METHODS The progression dataset and the survival dataset included 282 and 574 patients, respectively, from Peking Union Medical College Hospital, Beijing, China. A mixed-effects model was used to compute the rate of decline in FEV1, and generalized linear models were used to identify variables affecting FEV1 decline. A Cox proportional hazards model was used to explore the association between clinical variables and the outcomes of death or lung transplantation in patients with lymphangioleiomyomatosis. RESULTS VEGF-D levels and sirolimus treatment were associated with FEV1 changes and survival prognosis. Compared with patients with VEGF-D of < 800 pg/mL at baseline, patients with VEGF-D of ≥ 800 pg/mL lost FEV1 faster (SE, -38.86 mL/y; 95% CI, -73.90 to -3.82 mL/y; P = .031). The 8-year cumulative survival rates of patients with VEGF-D of ≥ 2,000 pg/mL and < 2,000 pg/mL were 82.9% and 95.1%, respectively (P = .014). The generalized linear regression model also demonstrated the benefit of delaying the decline of FEV1 by 65.56 mL/y (95% CI, 29.06-102.06 mL/y) in patients treated with sirolimus compared with those without sirolimus (P < .001). The 8-year risk of death was reduced by 85.1% (hazard ratio, 0.149; 95% CI, 0.075-0.299) after sirolimus treatment. After inverse treatment probability weighting, the risks of death in the sirolimus group were reduced by 85.6%. CT scan results of grade III severity were associated with worse progression than results of grades I or II severity. Patients with baseline FEV1 of 70% predicted or St. George's Respiratory Questionnaire Symptoms domain 50 or higher predicted a higher risk of worse survival. INTERPRETATION Serum VEGF-D levels, a biomarker of lymphangioleiomyomatosis, are associated with disease progression and survival. Sirolimus therapy is associated with slower disease progression and better survival in patients with lymphangioleiomyomatosis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03193892; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Wenshaui Xu
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenlu Yang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Chongsheng Cheng
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yani Wang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Danjing Hu
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiannan Huang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yudi He
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jun Wang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Keqi Chen
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Luning Yang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wangji Zhou
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Tengyue Zhang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Song Liu
- Center of Medical Research, State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinrong Dai
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shuzhen Meng
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xue Li
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanli Yang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shao-Ting Wang
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weihong Zhang
- Department of Radiology, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongbing Zhang
- Department of Physiology, Institutes of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Xinlun Tian
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kai-Feng Xu
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Long-term clinical course and progression of lymphangioleiomyomatosis in a single lung transplant referral centre in Korea. Sci Rep 2022; 12:8260. [PMID: 35585116 PMCID: PMC9117329 DOI: 10.1038/s41598-022-12314-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/26/2022] [Indexed: 11/09/2022] Open
Abstract
We aimed to describe the clinical features of lymphangioleiomyomatosis (LAM) in Korean patients and identify factors associated with progressive disease (PD). Clinical features of 54 patients with definite or probable LAM from 2005 to 2018 were retrospectively analysed. Common features were pneumothorax (66.7%) and abdominal lymphadenopathy (50.0%). Twenty-three (42.6%) patients were initially treated with mechanistic target of rapamycin (mTOR) inhibitors. Lung transplantation (LT) was performed in 13 (24.1%) patients. Grouped based on the annual decline in forced expiratory volume in 1 s (FEV1) from baseline and LT, 36 (66.7%) patients exhibited stable disease (SD). All six deaths (11.1%) occurred in PD. Proportion of SD was higher in those treated initially with mTOR inhibitors than in those under observation (p = 0.043). Univariate analysis revealed sirolimus use, and baseline forced vital capacity, FEV1, and diffusing capacity of the lungs for carbon monoxide are associated with PD. Multivariate analysis showed that only sirolimus use (odds ratio 0.141, 95% confidence interval 0.021-0.949, p = 0.044) reduced PD. Kaplan-Meier analysis estimates overall survival of 92.0% and 74.7% at 5 and 10 years, respectively. A considerable proportion of LAM patients remain clinically stable without treatment. LT is an increasingly viable option for patients with severe lung function decline.
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Isozaki Y, Kato M, Fujita N, Tojo S, Fujiki M, Watanabe A, Watanabe S. A case of topical rapamycin effective for postsurgical hypertrophic scar of superficial lymphatic malformation with possible quality-of-life improvement. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2022. [DOI: 10.4103/jdds.jdds_38_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sakurai T, Arai T, Hirose M, Kojima K, Sakamoto T, Matsuda Y, Sugimoto C, Yoon HE, Inoue Y. Reduced risk of recurrent pneumothorax for sirolimus therapy after surgical pleural covering of entire lung in lymphangioleiomyomatosis. Orphanet J Rare Dis 2021; 16:466. [PMID: 34732225 PMCID: PMC8567719 DOI: 10.1186/s13023-021-02081-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Patients with lymphangioleiomyomatosis (LAM) frequently experience pneumothorax. Although sirolimus is the standard therapy for LAM, its effect on pneumothorax is controversial. Recently, total pleural covering (TPC) and modified TPC (mTPC) were introduced as surgical treatment options for pneumothorax for patients with LAM. However, the effect of sirolimus on the recurrence of pneumothorax in patients who underwent the treatments is still uncertain. We hypothesized that some clinical factors including sirolimus treatment could predict postoperative recurrence of pneumothorax. In order to clarify this hypothesis, we retrospectively analyzed the clinical data from 18 consecutive patients with LAM who underwent 24 surgical pleural covering of entire lung (SPC) as 17 TPC and 7 mTPC against pneumothoraces from surgical database between January 2005 and January 2019, and we determined the predictors of postoperative recurrence. Results Of the 24 surgeries of SPC, 14 surgeries (58.3%) had a history of two or more ipsilateral pneumothoraces, and 11 surgeries (45.8%) had a history of ipsilateral pleural procedures before SPC. Sixteen surgeries (66.6%) in 12 patients received treatment of sirolimus after SPC (sirolimus group). With a median follow-up time of 69.0 months after SPC, four surgeries (16.6%) in three patients had a postoperative recurrence, and the 5-year recurrence-free survival (RFS) after SPC was 82.9%. In patients with postoperative recurrence, serum level of vascular endothelial growth factors D was significantly higher than that in those with non-recurrence (3260.5 vs. 892.7 pg/mL, p = 0.02), and the rate of sirolimus treatment in the recurrence group was significantly lower than that in the no-recurrence group (0 vs. 80%, p = 0.006). The log-rank test showed that the RFS of the sirolimus group (sirolimus use after SPC) was significantly better than that of the non-sirolimus group (p = 0.001), and no significant difference was observed for other factors. Conclusion We first reported sirolimus might effectively suppress the recurrence of pneumothoraces in LAM patients who received SPC. Sirolimus induction after SPC (TPC or mTPC) might be a feasible option for frequent pneumothorax in LAM. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02081-z.
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Affiliation(s)
- Teiko Sakurai
- Department of General Thoracic Surgery, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Kensuke Kojima
- Department of General Thoracic Surgery, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Tetsuki Sakamoto
- Department of General Thoracic Surgery, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Hyung-Eun Yoon
- Department of General Thoracic Surgery, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Nagasone-cho 1180, Sakai, Osaka, 591-8555, Japan.
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McCarthy C, Gupta N, Johnson SR, Yu JJ, McCormack FX. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1313-1327. [PMID: 34461049 DOI: 10.1016/s2213-2600(21)00228-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 01/15/2023]
Abstract
Lymphangioleiomyomatosis (LAM) is a slowly progressive, low-grade, metastasising neoplasm of women, characterised by infiltration of the lung parenchyma with abnormal smooth muscle-like cells, resulting in cystic lung destruction. The invading cell in LAM arises from an unknown source and harbours mutations in tuberous sclerosis complex (TSC) genes that result in constitutive activation of the mechanistic target of rapamycin (mTOR) pathway, dysregulated cellular proliferation, and a programme of frustrated lymphangiogenesis, culminating in disordered lung remodelling and respiratory failure. Over the past two decades, all facets of LAM basic and clinical science have seen important advances, including improved understanding of molecular mechanisms, novel diagnostic and prognostic biomarkers, effective treatment strategies, and comprehensive clinical practice guidelines. Further research is needed to better understand the natural history of LAM; develop more powerful diagnostic, prognostic, and predictive biomarkers; optimise the use of inhibitors of mTOR complex 1 in the treatment of LAM; and explore novel approaches to the development of remission-inducing therapies.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St Vincent's University Hospital, University College Dublin, Dublin, Ireland.
| | - Nishant Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Simon R Johnson
- Division of Respiratory Medicine, University of Nottingham, NIHR Respiratory Biomedical Research Centre, Nottingham, UK
| | - Jane J Yu
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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Goldklang M. Raising the Flag for Mast Cells as a Novel Target in Lymphangioleiomyomatosis. Am J Respir Crit Care Med 2021; 204:387-389. [PMID: 33951405 PMCID: PMC8480237 DOI: 10.1164/rccm.202104-0872ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rebaine Y, Nasser M, Girerd B, Leroux C, Cottin V. Tuberous sclerosis complex for the pulmonologist. Eur Respir Rev 2021; 30:30/161/200348. [PMID: 34348978 PMCID: PMC9488995 DOI: 10.1183/16000617.0348-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/20/2021] [Indexed: 12/18/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disorder affecting almost all organs with no sex predominance. TSC has an autosomal-dominant inheritance and is caused by a heterozygous mutation in either the TSC1 or TSC2 gene leading to hyperactivation of the mammalian target of rapamycin (mTOR). TSC is associated with several pulmonary manifestations including lymphangioleiomyomatosis (LAM), multifocal micronodular pneumocyte hyperplasia (MMPH) and chylous effusions. LAM is a multisystem disorder characterised by cystic destruction of lung parenchyma, and may occur in either the setting of TSC (TSC-LAM) or sporadically (S-LAM). LAM occurs in 30–40% of adult females with TSC at childbearing age and is considered a nonmalignant metastatic neoplasm of unknown origin. TSC-LAM is generally milder and, unlike S-LAM, may occur in males. It manifests as multiple, bilateral, diffuse and thin-walled cysts with normal intervening lung parenchyma on chest computed tomography. LAM is complicated by spontaneous pneumothoraces in up to 70% of patients, with a high recurrence rate. mTOR inhibitors are the treatment of choice for LAM with moderately impaired lung function or chylous effusion. MMPH, manifesting as multiple solid and ground-glass nodules on high-resolution computed tomography, is usually harmless with no need for treatment. Tuberous sclerosis complex is associated with diverse pulmonary manifestations including LAM, multiple micronodular pneumocyte hyperplasia and chylous effusions. LAM occurs in 30–40% of adult females with tuberous sclerosis complex.https://bit.ly/3iLqZ08
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Affiliation(s)
- Yasmine Rebaine
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Division of Pulmonology, Dept of Medicine, Hôpital Charles-LeMoyne, Montréal, QC, Canada.,Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Both authors contributed equally
| | - Mouhamad Nasser
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Both authors contributed equally
| | - Barbara Girerd
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,AP-HP, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Caroline Leroux
- Université Claude Bernard Lyon 1, Université de Lyon, INRAE, UMR754, Member of ERN-LUNG, RespiFil, OrphaLung, Lyon, France
| | - Vincent Cottin
- Dept of Respiratory Medicine, National Reference Coordinating Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France .,Université Claude Bernard Lyon 1, Université de Lyon, INRAE, UMR754, Member of ERN-LUNG, RespiFil, OrphaLung, Lyon, France
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12
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Revilla-López E, Berastegui C, Méndez A, Sáez-Giménez B, Ruiz de Miguel V, López-Meseguer M, Monforte V, Bravo C, Pujana MA, Ramon MA, Gómez-Ollés S, Roman A. Long-term results of sirolimus treatment in lymphangioleiomyomatosis: a single referral centre experience. Sci Rep 2021; 11:10171. [PMID: 33986388 PMCID: PMC8119464 DOI: 10.1038/s41598-021-89562-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 04/12/2021] [Indexed: 11/18/2022] Open
Abstract
There are few published data on long-term treatment with sirolimus in lymphangioleiomyomatosis (LAM). The objective of this study was to describe the long-term effect of sirolimus in a series of LAM patients followed up in a referral centre, focusing on pulmonary function. We retrospectively reviewed a series of 48 patients with LAM diagnosed, followed up and treated with sirolimus in a single centre. Response to sirolimus was evaluated at 1 and 5 years. A negative sirolimus response was defined as an FEV1 decline greater than - 75 ml/year. A mixed-effects model was used to estimate the longitudinal changes in FEV1 (average slope), both as absolute (ml/year) and as predicted values (%predicted/year). From a total of 48 patients, 9 patients underwent lung transplantation and 4 died during the study. Mean (95% CI) FEV1 slope over 5 years was - 0.14 (- 26.13 to 25.85) ml/year in the whole LAM group, 42.55 (14.87 to 70.22) ml/year in the responder group, - 54.00 (- 71.60 to - 36.39) ml/year in the partial responder group and - 84.19 (- 113.5 to - 54.0) ml/year in the non-responder group. After 5 years of sirolimus treatment 59% had a positive response, 30% had a partial response and 11% had a negative response. Our study found that sirolimus treatment had a positive long-term effect on most LAM patients.
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Affiliation(s)
- Eva Revilla-López
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Cristina Berastegui
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Alejandra Méndez
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Berta Sáez-Giménez
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Victoria Ruiz de Miguel
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Manuel López-Meseguer
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Victor Monforte
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Bravo
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Angel Pujana
- Program Against Cancer Therapeutic Resistance (ProCURE), Breast Cancer and Systems Biology, Catalan Institute of Oncology (ICO), Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet del Llobregat, Catalonia, Spain
| | - Maria Antonia Ramon
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Susana Gómez-Ollés
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Antonio Roman
- Lung Transplant Program, Department of Pulmonology, Departament de Medicina, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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13
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Koga T, Takemori S, Hagimori N, Morimoto S, Sumiyoshi R, Shimizu T, Hosogaya N, Fukushima C, Yamamoto H, Kawakami A. An open-label continuation trial of sirolimus for tocilizumab-refractory idiopathic multicentric Castleman disease: Study protocol for an investigator-initiated, multicenter, open-label trial (SPIRIT compliant). Medicine (Baltimore) 2020; 99:e23291. [PMID: 33327255 PMCID: PMC7738043 DOI: 10.1097/md.0000000000023291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Interleukin 6 (IL-6) inhibitors are the first-line treatment for idiopathic multicentric Castleman disease (iMCD); however, there is no established treatment for cases that are resistant to IL-6 inhibitors. Although sirolimus, a mammalian target of rapamycin inhibitor, has been suggested to be effective in patients with iMCD, the long-term safety and efficacy of sirolimus on individuals with IL-6 inhibitor-resistant iMCD have not been evaluated. METHODS/DESIGN In this investigator-initiated, multicenter, open-label trial, the long-term safety of sirolimus will be evaluated in patients participating in a placebo-controlled, randomized, double-blind, parallel-group trial on tocilizumab (TCZ)-resistant iMCD. The study will be conducted in 7 centers in Japan. This trial will be promptly started after the evaluation and examination for 16 weeks in the preceding study. The trial will be completed by the time the drug is approved for iMCD treatment in Japan. The primary endpoint is the incidence of adverse events. The secondary endpoints include the following: the levels of hemoglobin, albumin, and C-reactive protein; change in CHAP score; physician global assessment (100-mm visual analog scale); patient global assessment (100-mm visual analog scale); and lymph node changes in subjects with lymphadenopathy. DISCUSSION This clinical trial will provide evidence regarding the long-term safety of sirolimus as a potential novel therapeutic agent for patients with tocilizumab-resistant iMCD. TRIAL REGISTRATION NUMBER jRCT2051200050.
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Affiliation(s)
- Tomohiro Koga
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Sachiko Takemori
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Naoko Hagimori
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Japan
| | - Shimpei Morimoto
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Remi Sumiyoshi
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Toshimasa Shimizu
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Naoki Hosogaya
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Chizu Fukushima
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Hiroshi Yamamoto
- Nagasaki University Hospital, Clinical Research Center, Nagasaki
| | - Atsushi Kawakami
- Division of Advanced Preventive Medical Sciences, Department of Immunology and Rheumatology
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14
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Koga T, Hagimori N, Takemori S, Morimoto S, Sumiyoshi R, Shimizu T, Hosogaya N, Fukushima C, Yamamoto H, Kawakami A. Randomized, double-blind, placebo-controlled, parallel-group trial of sirolimus for tocilizumab-resistant idiopathic multicentric Castleman disease: Study protocol for clinical trial. Medicine (Baltimore) 2020; 99:e20710. [PMID: 32791665 PMCID: PMC7387047 DOI: 10.1097/md.0000000000020710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Idiopathic multicentric Castleman disease (iMCD) is a rare lymphoproliferative disorder of unknown etiology with systemic symptoms that include fever, night sweats, weight loss, and fatigue. Although tocilizumab (TCZ), which is a recombinant, humanized, anti-human interleukin 6 receptor monoclonal antibody, has been recommended to treat patients with iMCD, 40% of patients with iMCD do not achieve complete remission with TCZ treatment. METHODS/DESIGN In this phase II, investigator-initiated, multicenter, double-blind, randomized, parallel-group trial, the efficacy and safety of sirolimus will be compared with placebo in patients with TCZ-resistant iMCD. The study will be conducted in 8 centers in Japan. Participants (n = 20) will be randomly assigned to receive 2 mg of oral sirolimus (n = 10) or placebo (n = 10) once daily for 16 weeks. The primary endpoint is a decrease in CHAP score by ≥1 from baseline at 16 weeks. Secondary endpoints include levels of hemoglobin, albumin, and C-reactive protein; change in CHAP score; SF-36 Health Survey Questionnaire; physician global assessment (100 mm visual analog scale); patient global assessment (100 mm visual analog scale) at 2, 4, 8, 12, and 16 weeks; change in lymphadenopathy at 16 weeks; and pharmacodynamic assessment, including the measurement of whole blood sirolimus level. DISCUSSION This clinical trial will provide evidence of efficacy and safety of sirolimus as a potential new therapeutic agent for patients with TCZ-resistant iMCD. TRIAL REGISTRATION This study was registered with the Japan Registry of Clinical Trials as jRCT2071190029 on October 8, 2019.
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Affiliation(s)
- Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Naoko Hagimori
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Sachiko Takemori
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Shimpei Morimoto
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Remi Sumiyoshi
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Naoki Hosogaya
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Chizu Fukushima
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Hiroshi Yamamoto
- Nagasaki University Hospital, Clinical Research Center, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences
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15
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Kelchtermans J, Chang J, Glaberson W, DeFreitas M, Alba-Sandoval M, Chandar J. A Pediatric Case of Sirolimus-Associated Pneumonitis After Kidney Transplantation. J Pediatr Pharmacol Ther 2020; 25:459-464. [PMID: 32641918 DOI: 10.5863/1551-6776-25.5.459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sirolimus is an immunosuppressive medication often used in solid organ transplantation. It has been associated with severe side effects, including pulmonary toxicity. In adult patients, a single center study found that 14% of those treated with sirolimus developed pulmonary pneumonitis; however, the incidence in the pediatric population is not known. Most reports in adult patients indicate that elevated drug concentrations and a prolonged duration of use are associated with pulmonary toxicity. We report a case of a 17-year-old male kidney transplant recipient who developed rapid-onset respiratory failure, necessitating mechanical ventilation and acute renal replacement therapy for ultrafiltration secondary to sirolimus-induced pneumonitis. He had been treated for acute rejection with corticosteroids 17 days prior to the development of pneumonitis. His symptoms developed within 1 week of initiation of sirolimus and with a serum concentration of 1.1 ng/mL. Sirolimus was discontinued, and, following aggressive diuresis and ventilatory support, his respiratory status returned to baseline. Sirolimus-induced pneumonitis is an important diagnosis to be considered in any transplant recipient receiving sirolimus with new onset fever, cough, or dyspnea without an identifiable source, especially if there is a preceding history of treatment with high-dose corticosteroids.
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16
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Wang Q, Luo M, Xiang B, Chen S, Ji Y. The efficacy and safety of pharmacological treatments for lymphangioleiomyomatosis. Respir Res 2020; 21:55. [PMID: 32059669 PMCID: PMC7023761 DOI: 10.1186/s12931-020-1316-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 02/08/2023] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) is a rare, low-grade multisystem neoplastic disease. Most LAM patients are at a high risk of losing lung function at an accelerated rate and developing progressive dyspnea. Recently, several studies have reported their experience with pharmacological treatments for LAM. Therefore, we conducted a systematic review and meta-analysis to assess the efficacy and safety of these therapies. Methods PubMed (Medline), EMBASE, Cochrane Library, Web of Science and EBSCO Host were searched (until March 31, 2019) for eligible prospective studies regarding LAM patients treated with pharmacological treatments. Random effect models were used for quantitative analysis. Results Fourteen prospective studies regarding five pharmacological treatments (including sirolimus, everolimus, doxycycline, triptorelin, and a combination therapy of sirolimus and hydroxychloroquine) were enrolled in our systematic review, and ten of them were used for the meta-analysis. Seven prospective studies reported that sirolimus was effective at improving or stabilizing lung function and alleviating renal angiomyolipoma (AML) in LAM patients. Subsequent quantitative analyses showed that during sirolimus treatment, the pooled values of lung function and 6-min walk distance (6MWD) were not significantly changed (P > 0.05), with the pooled response rate of AML being 0.62 (95% confidence intervals [CIs]: 0.43 to 0.82, I2 = 65%). Regarding everolimus, three prospective studies reported similar effects to those of sirolimus with regard to preserving lung function and reducing AMLs. The meta-analysis showed that the changes in lung function during everolimus treatment were not statistically significant (P > 0.05), while the pooled response rate of AML was 0.78 (95% CI: 0.68 to 0.88, I2 = 8%). Neither the qualitative nor the quantitative results confirmed the benefits of doxycycline or triptorelin treatment, and the effects of the combination therapy were unclear in LAM patients. Most of the adverse events during pharmacological treatments were low or moderate grade and tolerable. Conclusions Overall, sirolimus and everolimus were recommended for the treatment of LAM because they could stabilize lung function and alleviate renal AML. Doxycycline and triptorelin were not recommended for the treatment of LAM because no beneficial outcomes were consistently observed. The efficacy and safety of combination therapy remain to be further explored.
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Affiliation(s)
- Qi Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Mengqi Luo
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
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17
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Krymskaya VP, Courtwright AM, Fleck V, Dorgan D, Kotloff R, McCormack FX, Kreider M. A phase II clinical trial of the Safety Of Simvastatin (SOS) in patients with pulmonary lymphangioleiomyomatosis and with tuberous sclerosis complex. Respir Med 2020; 163:105898. [PMID: 32125970 DOI: 10.1016/j.rmed.2020.105898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 01/20/2023]
Abstract
INRODUCTION The mechanistic target of rapamycin inhibitors (mTORi) sirolimus and everolimus stabilize lung function in patients with pulmonary lymphangioleiomyomatosis (LAM) but do not induce remission. Pre-clinical studies suggest that simvastatin in combination with sirolimus induces LAM cell death. The objective of this study was to assess the safety of simvastatin with either sirolimus or everolimus in LAM patients. METHODS This was a phase II single arm trial evaluating the safety of escalating daily simvastatin (20-40 mg) in LAM patients already treated with sirolimus or everolimus. Adverse events and changes in lipid panel profile, pulmonary function tests, and VEGF-D were assessed. RESULTS Ten LAM patients on a stable dose of mTORi for >3 months were treated with 20 mg simvastatin for two months followed by 40 mg for two months. The most common adverse events were peripheral edema (30%), cough (30%), and diarrhea (30%). No patients withdrew or had a reduction in simvastatin dose because of adverse events. Two patients required sirolumus dose reduction for supratherapeutic trough levels following simvastatin initiation. Total cholesterol and low density lipoproteins declined over the study period (-46.0 mg/dL±20.8, p = 0.008; -41.9 mg/dL±22.0, p = 0.01, respectively). There was also a decline in FEV1 (-82.0 mL±86.4, p = 0.02) but no significant change in FVC, DLCO, or VEGF-D. CONCLUSIONS The combination of simvastatin with mTORi in LAM patients is safe and well-tolerated from an adverse events perspective. The addition of simvastatin, however, was associated with decline in FEV1 and the efficacy of this combination should be explored in larger trials.
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Affiliation(s)
- Vera P Krymskaya
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew M Courtwright
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Victoria Fleck
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniel Dorgan
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert Kotloff
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Maryl Kreider
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA.
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Ko Y, Asakawa K, Tobino K, Oguma T, Hirai T, Takada T, Takahashi K, Seyama K. Quantitative analysis of computed tomography of the lungs in patients with lymphangioleiomyomatosis treated with sirolimus. Heliyon 2020; 6:e03345. [PMID: 32072050 PMCID: PMC7011043 DOI: 10.1016/j.heliyon.2020.e03345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/03/2019] [Accepted: 01/30/2020] [Indexed: 01/30/2023] Open
Abstract
Objectives We aimed to study sirolimus-related lung parenchymal changes by quantitative analysis of computed tomography (CT) of the lungs in patients with lymphangioleiomyomatosis (LAM). Methods We studied 20 participants from the Multicenter Lymphangioleiomyomatosis Sirolimus Trial for Safety study, who had undergone both thin-section CT scans and pulmonary function tests at baseline, 12, and 24 months. Quantitative CT parameters such as CT-derived total lung capacity, percentage of low attenuation area (LAA%), lung density histogram, fractal property of low attenuation area, and airway dimensions were analyzed, and correlations were conducted between the longitudinal change in each quantitative CT measurement and changes in pulmonary function were examined. Among 20 participants, pre-trial (n = 8) and post-trial (n = 16) CT data were also analyzed to deduce pathophysiologic implications of the serial changes in CT parameters during trial periods. Results FEV1 significantly increased from baseline to 24 months (slope 3.71 ± 1.50 ml/month) whereas FVC didn't during sirolimus therapy. Strikingly, LAA%, and skewness and kurtosis of density histogram significantly increased from baseline to 24 months, while mean and mode CT values significantly decreased from baseline to 24 months. Statistically significant positive correlations were found between ΔFEV1 and Δskewness (r = 0.465, p = 0.045). Taking the changes in lung density during pre-trial period into consideration, sirolimus decreases the area of -800 to -750 Housefield unit (HU) density and inhibits the decrease of -950 to -800 HU area during treatment, then producing the increased LAA% during the trial and post-trial periods. Given few sirolimus-related changes in airway dimensions, possible changes in lung mechanics may have contributed to increased FEV1. Conclusion Our study suggests that the lung density histogram parameters, kurtosis, and skewness, may be useful as indicators of the efficacy of sirolimus.
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Affiliation(s)
- Yuki Ko
- Division of Respiratory Medicine, Iizuka Hospital, Yoshio-Machi 3-83, Iizuka-Shi, Fukuoka 820-8505, Japan.,Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Hongo 3-1-3, Bunkyo-Ku, Tokyo 113-8421, Japan
| | - Katsuaki Asakawa
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Asahi-Dori 1-754, Chyuo-Ku, Niigata, 951-8520, Japan
| | - Kazunori Tobino
- Division of Respiratory Medicine, Iizuka Hospital, Yoshio-Machi 3-83, Iizuka-Shi, Fukuoka 820-8505, Japan.,Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Hongo 3-1-3, Bunkyo-Ku, Tokyo 113-8421, Japan
| | - Tsuyoshi Oguma
- Division of Respiratory Medicine, Kyoto University Faculty of Medicine and Graduate School of Medicine, Kawara-Machi 54, Seigoin, Sakyo-Ku, Kyoto 606-8507, Japan
| | - Toyohiro Hirai
- Division of Respiratory Medicine, Kyoto University Faculty of Medicine and Graduate School of Medicine, Kawara-Machi 54, Seigoin, Sakyo-Ku, Kyoto 606-8507, Japan
| | - Toshinori Takada
- Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Urasa 4132, Minami-Uonuma, Niigata, 949-7302, Japan
| | - Kazuhisa Takahashi
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Hongo 3-1-3, Bunkyo-Ku, Tokyo 113-8421, Japan
| | - Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Hongo 3-1-3, Bunkyo-Ku, Tokyo 113-8421, Japan
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Zhang L, Wang MJ, Wang W, Zhao JY, Wu JL, Liu YP, Zhu H, Qu JM, Zhou M. Identification of driver genes and somatic mutations in cell-free DNA of patients with pulmonary lymphangioleiomyomatosis. Int J Cancer 2019; 146:103-114. [PMID: 31199508 DOI: 10.1002/ijc.32511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 01/10/2023]
Abstract
Next-generation sequencing of cell-free circulating DNA (cfDNA) has emerged as promising technique for identifying minimally invasive genomic profiling of tumor cells recently. However, it remains relatively unknown in LAM disease. In our study, paired cfDNA and genomic DNA (gDNA) in blood samples were obtained from 23 LAM patients and seven healthy controls to explore mutations profiles of targeted 70 cancer-related genes. As results, log2-based allele frequencies of mutations in cfDNA were significantly different from those of gDNA. By comparing the mutual mutations identified both in cfDNA and gDNA, a significant correlation was also observed. After removing mutations in gDNA, distinct somatic mutation profiles of cfDNA were observed in LAM patients. Forty of 70 targeted genes had recurrent mutations, of which ATM, BRCA2 and APC showed the highest frequency. Based on the mutation, correlation network constructed of 40 mutated genes, 11 hub genes bearing intensive interactions were highlighted, including BRCA1, BRCA2, RAD50, RB1, NF1, APC, MLH3, ATM, PDGFRA, PALB2 and BLM. Expression of the hub genes showed significant clusters between LAM patients and controls and that RAD50 and BRCA2 had the strongest associations with subject phenotypes. Myogenesis and estrogen response were confirmed to be positively regulated in LAM patients. Collectively, our study provided a landscape of genomic alterations in LAM and discovered several potential driver genes, that is, BRCA2 and RAD50, which shed a substantial light on the clinical application of key molecular markers and potential therapy targets for precision diagnosis and treatment in the future.
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Affiliation(s)
- Li Zhang
- Department of Pulmonary and Critical Care Medicine, Shanghai Institute of Respiratory Disease, Ruijin Hospital, Shanghai Jiaotong University school of Medicine, Shanghai, China
| | - Ming-Jie Wang
- Research Laboratory of Clinical Virology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital Huangpu District, Shanghai, China
| | - Jing-Ya Zhao
- Department of Pulmonary and Critical Care Medicine, Shanghai Institute of Respiratory Disease, Ruijin Hospital, Shanghai Jiaotong University school of Medicine, Shanghai, China
| | - Jia-Liang Wu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital Huangpu District, Shanghai, China
| | - Yan-Pu Liu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital Huangpu District, Shanghai, China
| | - Hong Zhu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital Huangpu District, Shanghai, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Shanghai Institute of Respiratory Disease, Ruijin Hospital, Shanghai Jiaotong University school of Medicine, Shanghai, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Shanghai Institute of Respiratory Disease, Ruijin Hospital, Shanghai Jiaotong University school of Medicine, Shanghai, China
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Deceased Donor Renal Transplantation Combined with Bilateral Nephrectomy in a Patient with Tuberous Sclerosis and Renal Failure. Case Rep Transplant 2019; 2019:2172163. [PMID: 30963017 PMCID: PMC6431358 DOI: 10.1155/2019/2172163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/14/2019] [Accepted: 01/30/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction A 27-year-old female patient with known tuberous sclerosis complex (TSC), polycystic kidneys with multiple large bilateral angiomyolipomas, and failing renal functions with prehemodialysis values (urea: 19 mmol/L; creatinine: 317 μmol/L; CKD-EPI 0,27) was admitted to our department for pre-renal transplant evaluation. The patient was placed on the transplant waiting list as the living donor did not pass pretransplant workup and was subsequently contraindicated. Patient was placed on the “cadaverous kidney transplant waiting list”. Method Computed tomography angiography revealed symptomatic PSA in the right kidney angiomyolipoma (AML). The patient underwent urgent transarterial embolisation of the PSA's feeding vessel in the right kidney AML. Based on the “kidney transplant waiting list” order patient underwent a bilateral nephrectomy combined with transperitoneal renal allotransplantation of a cadaverous kidney graft through midline laparotomy, appendectomy, and cholecystectomy. Results Postoperative period was complicated by delayed graft function caused by acute tubular necrosis requiring postoperative hemodialysis. The patient was discharged on the 17th postoperative day with a good renal graft function. Patient's follow-up is currently 23 months with good graft function (urea: 9 mmol/L; creatinine: 100 μmol/L). Conclusion Renal transplantation combined with radical nephrectomy provides a definitive treatment for TSC renal manifestations.
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Gupta N, Lee HS, Young LR, Strange C, Moss J, Singer LG, Nakata K, Barker AF, Chapman JT, Brantly ML, Stocks JM, Brown KK, Lynch JP, Goldberg HJ, Downey GP, Taveira-DaSilva AM, Krischer JP, Setchell K, Trapnell BC, Inoue Y, McCormack FX. Analysis of the MILES cohort reveals determinants of disease progression and treatment response in lymphangioleiomyomatosis. Eur Respir J 2019; 53:13993003.02066-2018. [PMID: 30846465 DOI: 10.1183/13993003.02066-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/19/2019] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The Multicenter International Lymphangioleiomyomatosis (LAM) Efficacy of Sirolimus (MILES) trial revealed that sirolimus stabilised lung function in patients with moderately severe LAM. The purpose of this study was to further examine the MILES cohort for the effects of racial, demographic, clinical and physiological patient characteristics on disease progression and treatment response in LAM. METHODS MILES subjects were stratified on the basis of menopausal status (pre-menopausal/post-menopausal), race (Asian/Caucasian), bronchodilator responsiveness (present/absent), initial forced expiratory volume in 1 s (FEV1; 51-70% versus ≤50% predicted) and tuberous sclerosis complex (TSC) association (yes/no). A linear mixed effects model was used to compare slope differences, and nonparametric tests were used to compare medians and proportions between treatment groups in each stratum. RESULTS In the MILES placebo group, pre-menopausal patients declined 5-fold faster than post-menopausal patients (mean±se FEV1 slope -17±3 versus -3±3 mL·month-1; p=0.003). Upon treatment with sirolimus, both the pre-menopausal (-17±3 versus -1±2 mL·month-1; p<0.0001) and post-menopausal patients (-3±3 versus 6±3 mL·month-1; p=0.04) exhibited a beneficial response in mean±se FEV1 slope compared with the placebo group. Race, LAM subtype, bronchodilator responsiveness or baseline FEV1 did not impact the rate of disease progression in the placebo group or treatment response in the sirolimus group. Menopausal status and race had differential effects on the adverse event profile of sirolimus. Baseline serum vascular endothelial growth factor (VEGF)-D >600 pg·mL-1 identified subgroups of patients who were more likely to decline on placebo and respond to treatment with sirolimus. CONCLUSIONS In LAM patients, treatment with sirolimus is beneficial regardless of menopausal status, race, bronchodilator responsiveness, baseline FEV1 or TSC association. Serum VEGF-D and menopausal status can help inform therapeutic decisions.
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Affiliation(s)
| | | | - Lisa R Young
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joel Moss
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Koh Nakata
- Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Alan F Barker
- Oregon Health and Science University, Portland, OR, USA
| | | | | | - James M Stocks
- University of Texas Health Sciences Center, Tyler, TX, USA
| | - Kevin K Brown
- National Jewish Health and the University of Colorado, Denver, CO, USA
| | | | | | - Gregory P Downey
- National Jewish Health and the University of Colorado, Denver, CO, USA
| | | | | | - Kenneth Setchell
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bruce C Trapnell
- University of Cincinnati, Cincinnati, OH, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yoshikazu Inoue
- National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
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22
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2019; 68:e1-e47. [PMID: 30566567 PMCID: PMC6653685 DOI: 10.1093/cid/ciy866] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital
- University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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23
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2019; 68. [PMID: 30566567 PMCID: PMC6653685 DOI: 10.1093/cid/ciy866 10.1093/cid/ciz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital
- University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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24
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Hirose M, Matsumuro A, Arai T, Sugimoto C, Akira M, Kitaichi M, Young LR, McCormack FX, Inoue Y. Serum vascular endothelial growth factor-D as a diagnostic and therapeutic biomarker for lymphangioleiomyomatosis. PLoS One 2019; 14:e0212776. [PMID: 30818375 PMCID: PMC6395035 DOI: 10.1371/journal.pone.0212776] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In lymphangioleiomyomatosis (LAM), tuberous sclerosis gene mutations activate the mechanistic target of the rapamycin pathway, resulting in vascular endothelial growth factor-D (VEGF-D) overproduction. While the utility of serum VEGF-D testing for the diagnosis of LAM is outlined in ATS/JRS LAM Guidelines, the assay has not been fully validated for Asian populations. Our aims were to validate serum VEGF-D testing in Japan, by directly comparing measurements in Japan and the U.S., determining the diagnostic cut-off for serum VEGF-D levels among the Japanese women with typical thin walled cystic change on CT, and determining the performance of VEGF-D as a prognostic biomarker. SUBJECTS AND METHODS We determined serum VEGF-D levels from 108 LAM patients, 14 disease controls, and 51 healthy volunteers from the Japanese population. Measurements of 61 LAM patients were compared to those from the principal VEGF-D laboratory in the U.S at Cincinnati Children's Hospital Medical Center. We correlated baseline serum VEGF-D levels with baseline and longitudinal clinical data to determine how pregnancy, sirolimus or gonadotrophin-releasing hormone (GnRH) agonists influence serum VEGF-D levels. RESULTS Serum VEGF-D measurements in Japan and the U.S. were very similar. Baseline serum VEGF-D levels effectively distinguished LAM from other diseases and healthy volunteers at a cut-off level of 645 pg/ml and were diagnostically specific at 800 pg/ml, consistent with the recommendations of the ATS/JRS LAM Guidelines. Baseline serum VEGF-D correlated negatively with the DLco baseline % predicted and with the annual decrease in DLco % predicted. There was no significant association between baseline serum VEGF-D level and the outcomes of death or transplant. Serum VEGF-D levels markedly decreased during treatment with sirolimus, but not with GnRH analogues. Serum VEGF-D levels of most LAM patients did not increase over time, and neither pregnancy nor menopause significantly modulated serum VEGF-D levels. CONCLUSIONS Serum VEGF-D is a useful diagnostic and therapeutic biomarker for LAM. Satisfactory precision and international inter-laboratory agreement of the clinical assay support VEGF-D recommendations in the ATS/JRS LAM Guidelines for the Japanese population.
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Affiliation(s)
- Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Akiko Matsumuro
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Masanori Akira
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Masanori Kitaichi
- Department of Pathology, National Hospital Organization Minami Wakayama Medical Center, Tanabe, Wakayama, Japan
| | - Lisa R. Young
- Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Francis X. McCormack
- University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
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25
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Eriksson P, Wallin P, Sjöwall C. Clinical Experience of Sirolimus Regarding Efficacy and Safety in Systemic Lupus Erythematosus. Front Pharmacol 2019; 10:82. [PMID: 30787878 PMCID: PMC6372521 DOI: 10.3389/fphar.2019.00082] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/21/2019] [Indexed: 12/28/2022] Open
Abstract
New treatment options constitute unmet needs for patients diagnosed with systemic lupus erythematosus (SLE). Inhibition of the mammalian target of rapamycin (mTOR) pathway by sirolimus, a drug approved and in clinical use to prevent transplant rejection, has shown promising effects in lupus animal models as well as in patients with both antiphospholipid syndrome and SLE. Sirolimus inhibits antigen-induced T cell proliferation and increases the number of circulating regulatory T cells. Recently, sirolimus was tested in an open label phase 1/2 trial, including 43 patients with active SLE, resistant or intolerant to conventional medications. The results were encouraging showing a progressive improvement, including mucocutaneous and musculoskeletal manifestations. At our university unit, we have more than 16 years' experience of sirolimus as treatment for non-renal manifestations of SLE. Herein, we retrospectively evaluated data on tolerance, dosage, affected organ systems, disease activity measures, corticosteroid reduction, concomitant immunosuppressive therapies, and patient-reported outcome measures (PROMs) such as pain intensity, fatigue, well-being and quality-of-life (QoL) in 27 Caucasian patients with mildly active SLE. Musculoskeletal manifestation was the main reason for sirolimus treatment followed by skin involvement and leukocytopenia. Mean time on sirolimus was 47.1 (range 2-140) months. Decreasing global disease activity was observed, as measured by the clinical SLE disease activity index-2000, with a mean reduction of 2.5 points (range -10 to 0) and a corresponding mean reduction of the physician's global assessment (0-4) of 0.64 (range -2 to 0). The mean daily dose of corticosteroids (prednisolone) was reduced by 3.3 mg (-12.5 to 0). Non-significant trends toward improvements of QoL and pain intensity were found. Serious side-effects were not seen during sirolimus treatment, but early withdrawal due to nausea (n = 4) and non-serious infections (n = 2) appeared. This observational study, including longtime real-life use of sirolimus in SLE, is the largest to date and it essentially confirms the results of the recent phase 1/2 trial. Our data indicate that sirolimus is efficient in patients with musculoskeletal SLE manifestations, particularly arthritis and tendinitis. Further randomized controlled trials evaluating the potential benefits of sirolimus in SLE are warranted, but should aim to enroll patients with shorter disease duration, less accrued damage, and more diverse ethnicities.
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Affiliation(s)
- Per Eriksson
- Rheumatology/Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Philip Wallin
- Rheumatology/Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Rheumatology/Division of Neuro and Inflammation Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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26
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Futami S, Arai T, Hirose M, Sugimoto C, Ikegami N, Akira M, Kasai T, Kitaichi M, Hayashi S, Inoue Y. Comorbid connective tissue diseases and autoantibodies in lymphangioleiomyomatosis: a retrospective cohort study. Orphanet J Rare Dis 2018; 13:182. [PMID: 30342527 PMCID: PMC6195983 DOI: 10.1186/s13023-018-0933-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) and connective tissue diseases (CTDs) occur more frequently among women than men. We investigated the frequency of comorbid CTD and positive serum autoantibody findings in patients with LAM. METHODS A total of 152 patients with LAM were prospectively and consecutively registered in the National Hospital Organization Kinki-Chuo Chest Medical Centre cohort. The clinical data were retrospectively analysed, and patients were categorised into the following three groups: a CTD group, a non-CTD-autoantibody-positive group, and a non-CTD-autoantibody-negative group. RESULTS All patients were women. We identified five patients with comorbid CTDs (3.3%): Sjögren's syndrome (SjS) (n = 3), systemic lupus erythematosus (n = 1), and rheumatoid arthritis (n = 1). One patient with SjS was also diagnosed with antiphospholipid antibody syndrome. The positive rate for anti nuclear antibody was 31.5% and 6.9% at dilution of 1:40 or higher, and those of 1:160 or higher, respectively. It tended to be lower in patients with LAM than in healthy women. The positive rate for anti-SS-A and anti-SS-B antibody was 7.9% and 1.8%, respectively. No significant differences in age, type of LAM, smoking status, serum vascular endothelial growth factor D level, respiratory function, treatment, or prognosis were observed among the three groups. CONCLUSIONS Comorbid CTDs, especially SjS, in LAM patients should be considered.
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Affiliation(s)
- Shinji Futami
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Centre, Sakai City, Osaka, Japan
| | - Toru Arai
- Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, 1180 Nagasone-cho, Kita-ku, Sakai City, Osaka, 591-8555, Japan
| | - Masaki Hirose
- Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, 1180 Nagasone-cho, Kita-ku, Sakai City, Osaka, 591-8555, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, 1180 Nagasone-cho, Kita-ku, Sakai City, Osaka, 591-8555, Japan
| | - Naoya Ikegami
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Centre, Sakai City, Osaka, Japan
| | - Masanori Akira
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Centre, Sakai City, Osaka, Japan
| | - Takahiko Kasai
- Department of Laboratory Medicine and Pathology, National Hospital Organization Kinki-Chuo Chest Medical Centre, Sakai City, Osaka, Japan
| | - Masanori Kitaichi
- Department of Laboratory Medicine and Pathology, National Hospital Organization Minami Wakayama Medical Centre, Tanabe City, Wakayama, Japan
| | - Seiji Hayashi
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Centre, Sakai City, Osaka, Japan
| | - Yoshikazu Inoue
- Clinical Research Centre, National Hospital Organization Kinki-Chuo Chest Medical Centre, 1180 Nagasone-cho, Kita-ku, Sakai City, Osaka, 591-8555, Japan.
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Kato M, Kanehiro Y, Yoshimi K, Kodama Y, Sekiya M, Sato T, Takahashi K, Seyama K. COPD assessment test as a possible tool for evaluating health-related quality of life in lymphangioleiomyomatosis. Respir Investig 2018; 56:480-488. [PMID: 30143460 DOI: 10.1016/j.resinv.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/02/2018] [Accepted: 07/17/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a progressive, cystic lung disease that causes an obstructive ventilatory impairment similar to chronic obstructive pulmonary disease (COPD) and impairs the health-related quality of life (HRQoL). Here, we extended the use of the COPD assessment test (CAT) to patients with chronic respiratory diseases other than COPD. Specifically, the CAT was administered to patients with LAM for the first time. METHODS Using data from 25 patients with LAM at Juntendo University who participated in the Multicenter Lymphangioleiomyomatosis Sirolimus Trial for Safety (MLSTS), we evaluated changes in pulmonary function, responses to HRQoL questionnaires (the CAT, St. George׳s Respiratory Questionnaire [SGRQ], EuroQOL Visual Analogue Scale [EuroQOL-VAS], and Functional Performance Inventory [FPI]), and the association between pulmonary function and HRQoL during a 24-month period of sirolimus treatment. RESULTS Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and CAT total scores improved over the 24 months of sirolimus treatment (5.33 ± 1.20 ml/month, 2.61 ± 1.16 ml/month, and -0.127 ± 0.022 score/month, respectively), whereas SGRQ total score, EuroQOL-VAS score, and FPI score did not. Most pulmonary functions at baseline were associated with the CAT breathlessness score during the first year. Longitudinal changes in FEV1, FEV1%predicted, or FEV1/FVC correlated significantly with the scores of CAT total, CAT breathlessness, and SGRQ activity. When analyzed by stepwise multivariate regression within a linear mixed-effects model, CAT breathlessness and confidence scores were significantly associated with a change in FEV1 from the baseline value (P = 0.0011, and P = 0.0441). CONCLUSION Our results suggest that the CAT is a useful instrument for assessing HRQoL in sirolimus-treated patients with LAM.
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Affiliation(s)
- Miharu Kato
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Yumiko Kanehiro
- Clinical Research Center, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kaku Yoshimi
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Yuzo Kodama
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Mitsuaki Sekiya
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Tadashi Sato
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kazuhisa Takahashi
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
| | - Kuniaki Seyama
- Divisions of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-Ku, Tokyo 113-8431, Japan.
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Gao N, Zhang T, Ji J, Xu KF, Tian X. The efficacy and adverse events of mTOR inhibitors in lymphangioleiomyomatosis: systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:134. [PMID: 30107845 PMCID: PMC6092843 DOI: 10.1186/s13023-018-0874-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/10/2018] [Indexed: 11/29/2022] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) is a rare lung disease and the mammalian target of the rapamycin (mTOR) inhibitors has been used as an effective therapy. Here we conducted a systematic review and meta-analysis with the aims to quantify the efficacy and safety of mTOR inhibitors in LAM patients. Methods The following databases were searched for clinical trials regarding LAM patients treated with mTOR inhibitors until December 2017: Pubmed, Embase, Cochrane Library and OVID medicine. Random effect models were used for the quantitative analysis. Results Nine eligible studies were included in our systematic review, 7 of which were used for the meta-analysis. In LAM patients, mTOR inhibitors improved forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) significantly, with the weighted mean difference (WMD) 0.15 L (95%CI: 0.08 to 0.22, P < 0.01, I2 = 0%) and 0.22 L (95%: 0.11 to 0.32, P < 0.01, I2 = 0%) respectively. There was no significant change in neither the diffusing capacity for carbon monoxide (WMD: 0.51 ml/mm Hg/min, 95%CI: -0.48 to 1.49, P = 0.31, I2 = 0%) nor 6-min walking distance (WMD: 5.29 m, 95%CI: -18.01 to 28.59, P = 0.66, I2 = 1%). The weighted partial response rate was 0.68 (95%CI: 0.53 to 0.84, P < 0.01, I2 = 72%) for renal angiomylipoma. The cumulative incidence rates of common safety events were 50, 40, 23, 20 and 19% for oral mucositis, hyperlipidemia, headache, bone marrow suppression, and diarrhea, respectively. And most events were low grade and tolerant. Conclusions In LAM patients, there are improvements of FEV1 and FVC after the application of mTOR inhibitors and over a half achieved the shrinkage of renal angiomyolipoma. Trial registration PROSPERO registration number: CRD42018085470. Registered 22 January 2018. Electronic supplementary material The online version of this article (10.1186/s13023-018-0874-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nannan Gao
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Tengyue Zhang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiadong Ji
- School of Statistics, Shandong University of Finance and Economics, Jinan, China
| | - Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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Gupta N, Henske EP. Pulmonary manifestations in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:326-337. [PMID: 30055039 DOI: 10.1002/ajmg.c.31638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Tuberous sclerosis complex has manifestations in many organ systems, including brain, heart, kidney, skin, and lung. The primary manifestations in the lung are lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH). LAM affects almost exclusively women, and causes cystic lung destruction, pneumothorax, and chylous pleural effusions. LAM can lead to dyspnea, oxygen dependence, and respiratory failure, with more rapid disease progression during the premenopausal years. In contrast, MMPH affects men and women equally, causing small nodular pulmonary deposits of type II pneumocytes that rarely progress to symptomatic disease. Here, we review the clinical features and pathogenesis of LAM and MMPH.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth P Henske
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Roles of human epidermal growth factor receptor family in pulmonary lymphangioleiomyomatosis. Hum Pathol 2018; 81:121-130. [PMID: 30030119 DOI: 10.1016/j.humpath.2018.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/14/2022]
Abstract
Lymphangioleiomyomatosis (LAM) is a rare and refractory disease that affects women of reproductive age. Several target therapies are used to manage LAM, but no curative modes of treatment have been reported yet. Therefore, in this study, we focused on targeting human epidermal growth factor receptor (HER) family proteins as a treatment strategy for LAM. In antibody array analysis, HER signaling was detected in the proteins extracted from LAM tissues. We then evaluated the expression of HER family members in 34 pulmonary LAM specimens using both immunohistochemistry and quantitative reverse-transcription polymerase chain reaction. Hierarchical clustering analysis was performed to classify the cases based on the immunohistochemistry results. Both epidermal growth factor receptor (EGFR) and HER4 were expressed in all 34 cases. HER3 was expressed in 25 of 34 cases, but HER2 was not expressed in any case. In addition, results of quantitative reverse-transcription polymerase chain reaction analysis confirmed the expression of EGFR and HER4 expression in LAM cells. Patients with HER3- or HER4-positive tissues were younger and had a history of pneumothorax. The cases were classified into 4 different clusters based on the results of hierarchical cluster analysis. One of these clusters was associated with EGFR, HER3, and HER4; the patients in this cluster were significantly younger and had a history of pneumothorax. These results indicated that HER family could contribute to the progression of pulmonary LAM, and treatments targeted against HER family might be effective for treating pulmonary LAM.
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Gupta N, Lee HS, Ryu JH, Taveira-DaSilva AM, Beck GJ, Lee JC, McCarthy K, Finlay GA, Brown KK, Ruoss SJ, Avila NA, Moss J, McCormack FX. The NHLBI LAM Registry: Prognostic Physiologic and Radiologic Biomarkers Emerge From a 15-Year Prospective Longitudinal Analysis. Chest 2018; 155:288-296. [PMID: 29940164 DOI: 10.1016/j.chest.2018.06.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/17/2018] [Accepted: 06/01/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The natural history of lymphangioleiomyomatosis (LAM) is mainly derived from retrospective cohort analyses, and it remains incompletely understood. A National Institutes of Health LAM Registry was established to define the natural history and identify prognostic biomarkers that can help guide management and decision-making in patients with LAM. METHODS A linear mixed effects model was used to compute the rate of decline of FEV1 and to identify variables affecting FEV1 decline among 217 registry patients who enrolled from 1998 to 2001. Prognostic variables associated with progression to death/lung transplantation were identified by using a Cox proportional hazards model. RESULTS Mean annual decline of FEV1 was 89 ± 53 mL/year and remained remarkably constant regardless of baseline lung function. FEV1 decline was more rapid in those with greater cyst profusion on CT scanning (P = .02) and in premenopausal subjects (118 mL/year) compared with postmenopausal subjects (74 mL/year) (P = .003). There were 26 deaths and 43 lung transplantations during the evaluation period. The estimated 5-, 10-, 15-, and 20-year transplant-free survival rates were 94%, 85%, 75%, and 64%, respectively. Postmenopausal status (hazard ratio, 0.30; P = .0002) and higher baseline FEV1 (hazard ratio, 0.97; P = .008) or diffusion capacity of lung for carbon monoxide (hazard ratio, 0.97; P = .001) were independently associated with a lower risk of progression to death or lung transplantation. CONCLUSIONS The median transplant-free survival in patients with LAM is > 20 years. Menopausal status, as well as structural and physiologic markers of disease severity, significantly affect the rate of decline of FEV1 and progression to death or lung transplantation in LAM.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH; Medical Service, Veterans Affairs Medical Center, Cincinnati, OH.
| | - Hye-Seung Lee
- Department of Pediatrics, Health Informatics Institute, University of South Florida, Tampa, FL
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Angelo M Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jar-Chi Lee
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Kevin McCarthy
- Formerly at Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Geraldine A Finlay
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO
| | - Stephen J Ruoss
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nilo A Avila
- Radiology Service, Veterans Affairs Medical Center, Washington, DC
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH; Medical Service, Veterans Affairs Medical Center, Cincinnati, OH
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Abstract
Lymphangioleiomyomatosis is a rare disorder that predominantly affects women and is characterized by progressive cystic changes in the lung, leading to gradually worsening shortness of breath and lung function impairment. Pleural complications such as pneumothorax and chylothorax commonly occur in these patients. Lymphangioleiomyomatosis can occur as a form of lung involvement in tuberous sclerosis complex or as a sporadic form (without tuberous sclerosis complex). Etiology in both forms of this disease centers on mutations in the tuberous sclerosis genes. Advances in our understanding of the regulatory role of tuberous sclerosis gene products (hamartin/tuberin) in the mechanistic target of rapamycin (mTOR) signaling pathway have led to the identification of effective therapy (mTOR inhibitors) for a rare disorder, once considered uniformly fatal. Here, we summarize the evolution of current concepts regarding lymphangioleiomyomatosis with an emphasis on recent advances and unresolved issues.
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Affiliation(s)
- Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
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Krencz I, Sebestyen A, Papay J, Jeney A, Hujber Z, Burger CD, Keller CA, Khoor A. In situ analysis of mTORC1/2 and cellular metabolism-related proteins in human Lymphangioleiomyomatosis. Hum Pathol 2018; 79:199-207. [PMID: 29885404 DOI: 10.1016/j.humpath.2018.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/11/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
Lymphangioleiomyomatosis (LAM) is a rare progressive cystic lung disease with features of a low-grade neoplasm. It is primarily caused by mutations in TSC1 or TSC2 genes. Sirolimus, an inhibitor of mTOR complex 1 (mTORC1), slows down disease progression in some, but not all patients. Hitherto, other potential therapeutic targets such as mTOR complex 2 (mTORC2) and various metabolic pathways have not been investigated in human LAM tissues. The aim of this study was to assess activities of mTORC1, mTORC2 and various metabolic pathways in human LAM tissues through analysis of protein expression. Immunohistochemical analysis of p-S6 (mTORC1 downstream protein), Rictor (mTORC2 scaffold protein) as well as GLUT1, GAPDH, ATPB, GLS, MCT1, ACSS2 and CPT1A (metabolic pathway markers) were performed on lung tissue from 11 patients with sporadic LAM. Immunoreactivity was assessed in LAM cells with bronchial smooth muscle cells as controls. Expression of p-S6, Rictor, GAPDH, GLS, MCT1, ACSS2 and CPT1A was significantly higher in LAM cells than in bronchial smooth muscle cells (P<.01). No significant differences were found between LAM cells and normal bronchial smooth muscle cells in GLUT1 and ATPB expression. The results are uniquely derived from human tissue and indicate that, in addition to mTORC1, mTORC2 may also play an important role in the pathobiology of LAM. Furthermore, glutaminolysis, acetate utilization and fatty acid β-oxidation appear to be the preferred bioenergetic pathways in LAM cells. mTORC2 and these preferred bioenergetic pathways appear worthy of further study as they may represent possible therapeutic targets in the treatment of LAM.
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Affiliation(s)
- Ildiko Krencz
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Anna Sebestyen
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Judit Papay
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Andras Jeney
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Zoltan Hujber
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, H-1085 Budapest, Hungary
| | - Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Cesar A Keller
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL 32224, United States; Division of Transplant Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Andras Khoor
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Jacksonville, FL 32224, United States.
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Zhan Y, Shen L, Xu W, Wu X, Zhang W, Wang J, Li X, Yang Y, Tian X, Xu KF. Functional improvements in patients with lymphangioleiomyomatosis after sirolimus: an observational study. Orphanet J Rare Dis 2018; 13:34. [PMID: 29458386 PMCID: PMC5819088 DOI: 10.1186/s13023-018-0775-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/12/2018] [Indexed: 12/01/2022] Open
Abstract
Background Sirolimus has been shown to be effective in patients with lymphangioleiomyomatosis (LAM). We wish to summarize our experience using sirolimus and its effectiveness in LAM patients. Methods We analyzed data from 98 patients who were diagnosed with definite or probable sporadic LAM based on the European Respiratory Society diagnosis criteria for LAM in 2010 at Peking Union Medical College Hospital and who had received sirolimus during January 2007 to June 2015. The data before and after the initiation of sirolimus therapy included pulmonary function tests, arterial blood gas analysis, 6-min walking distance (6MWD), size of chylous effusion and renal angiomyolipomas (AML), St. George’s Respiratory Questionnaires (SGRQ) and vascular endothelial growth factor-D (VEGF-D) levels. Serum levels of sirolimus and adverse events were collected. Results Median follow-up was 2.5 years. Most patients had forced expiratory volume in 1 s (FEV1) values less than 70% predicted or symptomatic chylothorax. The mean changes before and after the initiation of sirolimus were − 31.12 ± 30.78 mL/month and 16.11 ± 36.00 mL/month (n = 18,p = 0.002) for FEV1 change, and − 0.55 ± 0.60 mmHg/month and 0.30 ± 1.19 mmHg/month (n = 17, p = 0.018) for PaO2 change. 6MWD improved from 358.8 ± 114.4 m to 415.6 ± 118.6 m (n = 46, p = 0.004) and SGRQ total score from 57.2 ± 21.0 to 47.5 ± 22.8 (n = 50, p < 0.001). The median VEGF-D concentration decreased to 1609.4 pg/mL from 3075.6 pg/mL after sirolimus therapy (n = 41, p < 0.001). Patients with sirolimus trough levels of 5–9.9 ng/mL had an increase in FEV1 (p < 0.05). Sixty-five percent of patients (13/20) had almost complete resolution of chylous effusions. The most frequent adverse events were mouth ulcers, menstrual disorder, hyperlipidemia and acneiform rash, all were mild. Conclusion Long-term use of sirolimus is safe in patients with LAM. LAM patients with FEV1 less than 70% predicted and symptomatic chylothorax are suitable for receiving sirolimus therapy. The maintaining serum trough levels of sirolimus are recommended between 5 to 9.99 ng/mL.
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Affiliation(s)
- Yongzhong Zhan
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Lisha Shen
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Wenshuai Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xiuxiu Wu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Weihong Zhang
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Jun Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xue Li
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yanli Yang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China.
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Xu KF, Tian X, Yang Y, Zhang H. Rapamycin for lymphangioleiomyomatosis: optimal timing and optimal dosage. Thorax 2018; 73:308-310. [DOI: 10.1136/thoraxjnl-2017-211135] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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36
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Daccord C, Nicod L, Lazor R. Cystic Lung Disease in Genetic Syndromes with Deficient Tumor Suppressor Gene Function. Respiration 2017; 94:467-485. [DOI: 10.1159/000485106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 12/28/2022] Open
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Taveira-DaSilva AM, Moss J. Addressing the challenges of lymphangioleiomyomatosis assessment in the clinic. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1400966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Angelo M. Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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38
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Mittal S, Jain A, Arava S, Hadda V, Mohan A, Guleria R, Madan K. A 26-year-old man with dyspnea and chest pain. Lung India 2017; 34:562-566. [PMID: 29099006 PMCID: PMC5684818 DOI: 10.4103/lungindia.lungindia_111_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.
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Affiliation(s)
- Saurabh Mittal
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Akanksha Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer Arava
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
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Singla A, Gupta N, Apewokin S, McCormack FX. Sirolimus for the treatment of lymphangioleiomyomatosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1391089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Abhishek Singla
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X. McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
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40
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Bee J, Fuller S, Miller S, Johnson SR. Lung function response and side effects to rapamycin for lymphangioleiomyomatosis: a prospective national cohort study. Thorax 2017; 73:369-375. [DOI: 10.1136/thoraxjnl-2017-210872] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/19/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
RationaleMechanistic target of rapamycin inhibitors reduce loss of lung function in lymphangioleiomyomatosis (LAM), although their benefit varies between individuals. We examined lung function response and side effects to rapamycin in a national cohort.MethodsSubjects were receiving rapamycin for progressive lung disease. Clinical evaluation, detailed phenotyping, serial lung function, rapamycin and safety monitoring were performed according to a clinical protocol. Lung function change, measured as FEV1 slope (ΔFEV1), was reported for those treated for 1 year or longer.ResultsRapamycin was associated with improved ΔFEV1 in 21 individuals where pretreatment data were available (p<0.0001). In 47 treated for a mean duration of 35.8 months, mean ΔFEV1 was +11 (SD 75) mL/year, although it varied from +254 to −148 mL/year. The quartile with the highest positive ΔFEV1 had greater pretreatment FEV1 (p=0.02) and shorter disease durations (p=0.02) than the lowest quartile. Serum rapamycin level was positively associated with side effects (p=0.02) but not ΔFEV1 over 1 year. Within the first month of therapy, apthous ulcers, nausea and diarrhoea were associated with higher rapamycin levels. Acne, oedema and menstrual irregularities tended to increase over the first year of therapy. At the end of observation, the prevalence of side effects was 5% or less.ConclusionsRapamycin reduces lung function loss in LAM, although in some, ΔFEV1 continues to fall at an accelerated rate. Poor response to rapamycin was associated with lower pretreatment lung function and longer disease duration but not serum level. Early intervention with low-dose rapamycin may preserve lung function and reduce side effects.
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Kitamura N, Seyama K, Inoue Y, Nagai K, Suzuki M, Moriyama H, Takada T, Tazawa R, Hirai T, Mishima M, Hayashida M, Hirose M, Arai T, Sugimoto C, Hattori N, Watanabe K, Tamada T, Akazawa K, Tanaka T, Nakata K. Risk factors for stomatitis in patients with lymphangioleiomyomatosis during treatment with sirolimus: A multicenter investigator-initiated prospective study. Pharmacoepidemiol Drug Saf 2017; 26:1182-1189. [PMID: 28752672 DOI: 10.1002/pds.4259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 05/06/2017] [Accepted: 06/08/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE Lymphangioleiomyomatosis is a rare lung disease caused by proliferation of abnormal smooth muscle-like cells and typically occurs in premenopausal women. Sirolimus is now the first-line drug for the treatment of lymphangioleiomyomatosis. Sirolimus-induced stomatitis is the most frequent adverse event experienced during treatment. To identify risk factors, we investigated the association of stomatitis incidence with patient background data and treatment parameters, using data from the multicenter long-term sirolimus trial. METHODS Subjects received sirolimus for 2 years at doses adjusted to maintain a trough blood level of 5 to 15 ng/mL. The incidence of stomatitis was correlated with baseline demographics, clinical characteristics, and changes in the longitudinal data. Risk factors at baseline were assessed by using univariate and multivariate analyses. RESULTS The most frequent adverse event was stomatitis, with the cumulative rate reaching 88.9% by 9 months, higher than that reported in postrenal transplant patients. The repetition, the duration, and the severity of stomatitis events were variable among patients. We found that patients with low hemoglobin (Hb) (<14.5 g/dL) showed significantly higher incidence than those with high Hb (≥14.5 g/dL, P < .01). The cumulative rate for stomatitis incidence was significantly associated with a decrease in the mean corpuscular volume, while the Hb level was constant; thus, red blood cell count in patients increased during the study. CONCLUSIONS Baseline Hb levels and a decrease in mean corpuscular volume during treatment were correlated with the incidence of stomatitis.
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Affiliation(s)
- Nobutaka Kitamura
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kuniaki Seyama
- Department of Respiratory Medicine, School of Medicine, Juntendo University, Tokyo, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Katsura Nagai
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Masaru Suzuki
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Moriyama
- Division of Respiratory Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Toshinori Takada
- Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Ryushi Tazawa
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mie Hayashida
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Watanabe
- Department of Respiratory Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tsutomu Tamada
- Department of Respiratory Medicine, Tohoku University Graduate school of Medicine, Miyagi, Japan
| | - Kohei Akazawa
- Department of Medical Informatics, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takahiro Tanaka
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koh Nakata
- Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
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