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Gourmel A, Kleiber N, Kokta V, Bergeron M, McCuaig C, Doré-Bergeron MJ, Simpson E, Renaud C, Roy JP, Zysman-Colman Z, Cao Y, Théorêt Y, Powell J, Dubois J, Tran TH. Multimodal therapeutic approach for a severe case of kaposiform lymphangiomatosis from procedural interventions to targeted therapies. Pediatr Blood Cancer 2024; 71:e31079. [PMID: 38753412 DOI: 10.1002/pbc.31079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Antoine Gourmel
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Niina Kleiber
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Clinical Pharmacology Unit, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
| | - Victor Kokta
- Department of Pathology and Clinical Laboratory Medicine, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Mathieu Bergeron
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Catherine McCuaig
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Marie-Joelle Doré-Bergeron
- Division of General Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Ewurabena Simpson
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Christian Renaud
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
- Division of Pediatric Infectious Diseases, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Jean-Philippe Roy
- Division of Nephrology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Zofia Zysman-Colman
- Division of Respiratory Medicine, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Yang Cao
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Yves Théorêt
- Clinical Pharmacology Laboratory, OPTILAB and Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Julie Powell
- Division of Dermatology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Josée Dubois
- Department of Medical Imaging, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montréal, Quebec, Canada
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2
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Kapp FG, Bazgir F, Mahammadzade N, Mehrabipour M, Vassella E, Bernhard SM, Döring Y, Holm A, Karow A, Seebauer C, Platz Batista da Silva N, Wohlgemuth WA, Oppenheimer A, Kröning P, Niemeyer CM, Schanze D, Zenker M, Eng W, Ahmadian MR, Baumgartner I, Rössler J. Somatic RIT1 delins in arteriovenous malformations hyperactivate RAS-MAPK signaling amenable to MEK inhibition. Angiogenesis 2024:10.1007/s10456-024-09934-8. [PMID: 38969873 DOI: 10.1007/s10456-024-09934-8] [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: 01/19/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
Arteriovenous malformations (AVM) are benign vascular anomalies prone to pain, bleeding, and progressive growth. AVM are mainly caused by mosaic pathogenic variants of the RAS-MAPK pathway. However, a causative variant is not identified in all patients. Using ultra-deep sequencing, we identified novel somatic RIT1 delins variants in lesional tissue of three AVM patients. RIT1 encodes a RAS-like protein that can modulate RAS-MAPK signaling. We expressed RIT1 variants in HEK293T cells, which led to a strong increase in ERK1/2 phosphorylation. Endothelial-specific mosaic overexpression of RIT1 delins in zebrafish embryos induced AVM formation, highlighting their functional importance in vascular development. Both ERK1/2 hyperactivation in vitro and AVM formation in vivo could be suppressed by pharmacological MEK inhibition. Treatment with the MEK inhibitor trametinib led to a significant decrease in bleeding episodes and AVM size in one patient. Our findings implicate RIT1 in AVM formation and provide a rationale for clinical trials with targeted treatments.
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Affiliation(s)
- Friedrich G Kapp
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany.
| | - Farhad Bazgir
- Institute of Biochemistry and Molecular Biology II, Medical Faculty and University Hospital, Heinrich-Heine University, Düsseldorf, Germany
| | - Nagi Mahammadzade
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany
| | - Mehrnaz Mehrabipour
- Institute of Biochemistry and Molecular Biology II, Medical Faculty and University Hospital, Heinrich-Heine University, Düsseldorf, Germany
| | - Erik Vassella
- Institute of Pathology and Tissue Medicine, University of Bern, Bern, Switzerland
| | - Sarah M Bernhard
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Yvonne Döring
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians University Munich, Pettenkoferstr 9, 80336, Munich, Germany
| | - Annegret Holm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany
- Vascular Biology Program, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Axel Karow
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054, Erlangen, Germany
| | - Caroline Seebauer
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Walter A Wohlgemuth
- University Clinic and Policlinic of Radiology at the Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Aviv Oppenheimer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany
| | - Pia Kröning
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Charlotte M Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany
| | - Denny Schanze
- Institute of Human Genetics, University Hospital Magdeburg, 39120, Magdeburg, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, 39120, Magdeburg, Germany
| | - Whitney Eng
- Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mohammad R Ahmadian
- Institute of Biochemistry and Molecular Biology II, Medical Faculty and University Hospital, Heinrich-Heine University, Düsseldorf, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Jochen Rössler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, VASCERN VASCA European Reference Centre, 79106, Freiburg, Germany.
- Department of Vascular Medicine, National Reference Center of Rare Lymphatic and Vascular Diseases, UA11 INSERM - UM IDESP, Campus Santé, Montpellier Cedex 5, France.
- Division of Paediatric Hematology and Oncology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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3
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Das K, Sheppard S, Yadav B, Turner JT, Bornhorst M, Siegel AH, Yano JC, Gomez Lobo V. Kaposiform Lymphangiomatosis as a Cause of Vaginal Bleeding & Discharge: A Case Report. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00235-3. [PMID: 38936506 DOI: 10.1016/j.jpag.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 06/12/2024] [Accepted: 06/16/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Prepubertal vaginal bleeding is a common presentation for pediatric adolescent gynecologists with a broad differential diagnosis that historically may not have included complex lymphatic anomalies. However, given recent consensus criteria and imaging capabilities, this may be a condition that pediatric adolescent gynecologists see more frequently in the future. CASE We present a case of a 5-year-old pre-pubertal girl whose only presenting symptoms of a rare complex lymphatic anomaly was copious vaginal bleeding. After three vaginoscopies, two hysteroscopies, two pelvic MRIs, and a percutaneous ultrasound guided core needle biopsy, this patient was eventually diagnosed with Kaposiform lymphangiomatosis at age 9 years-old, and she is now being treated medically with sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, with improvement in her symptoms. SUMMARY AND CONCLUSION Complex lymphatic anomalies should be considered after initial and secondary workups for pre-pubertal vaginal bleeding or copious vaginal discharge are negative. Furthermore, this case illustrates the value of pelvic MRI in the setting of unknown cause of vaginal bleeding when typical workup is negative.
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Affiliation(s)
- Kirsten Das
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington.
| | - Sarah Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland
| | - Bhupender Yadav
- Pediatric Interventional Radiology, Children's National Hospital, Washington
| | - Joyce Tannenbaum Turner
- Genetics and Metabolism, Children's National Hospital, Rare Disease Institute, Bethesda, Maryland
| | - Miriam Bornhorst
- Pediatric Neurooncology, Children's National Hospital, Washington
| | - Alan H Siegel
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington
| | - Jacqueline C Yano
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington
| | - Veronica Gomez Lobo
- Department of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland; Children's National Hospital, Pediatric and Adolescent Gynecology Program, Washington
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4
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Jung R, Trivedi CM. Congenital Vascular and Lymphatic Diseases. Circ Res 2024; 135:159-173. [PMID: 38900856 PMCID: PMC11192239 DOI: 10.1161/circresaha.124.323181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Over the past several centuries, the integration of contemporary medical techniques and innovative technologies, like genetic sequencing, have played a pivotal role in enhancing our comprehension of congenital vascular and lymphatic disorders. Nonetheless, the uncommon and complex characteristics of these disorders, especially considering their formation during the intrauterine stage, present significant obstacles in diagnosis and treatment. Here, we review the intricacies of these congenital abnormalities, offering an in-depth examination of key diagnostic approaches, genetic factors, and therapeutic methods.
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Affiliation(s)
- Roy Jung
- Division of Cardiovascular Medicine, UMass Chan Medical School, Worcester, MA 01605 USA
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605 USA
- Translational Science Program, Morningside Graduate School of Biomedical Sciences, UMass Chan Medical School, Worcester, MA 01605 USA
| | - Chinmay M. Trivedi
- Division of Cardiovascular Medicine, UMass Chan Medical School, Worcester, MA 01605 USA
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01605 USA
- Translational Science Program, Morningside Graduate School of Biomedical Sciences, UMass Chan Medical School, Worcester, MA 01605 USA
- Department of Molecular, Cell, and Cancer Biology, UMass Chan Medical School; Worcester, MA 01605 USA
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5
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Gazzin A, Fornari F, Cardaropoli S, Carli D, Tartaglia M, Ferrero GB, Mussa A. Exploring New Drug Repurposing Opportunities for MEK Inhibitors in RASopathies: A Comprehensive Review of Safety, Efficacy, and Future Perspectives of Trametinib and Selumetinib. Life (Basel) 2024; 14:731. [PMID: 38929714 PMCID: PMC11204468 DOI: 10.3390/life14060731] [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: 04/23/2024] [Revised: 05/29/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
The RASopathies are a group of syndromes caused by genetic variants that affect the RAS-MAPK signaling pathway, which is essential for cell response to diverse stimuli. These variants functionally converge towards the overactivation of the pathway, leading to various constitutional and mosaic conditions. These syndromes show overlapping though distinct clinical presentations and share congenital heart defects, hypertrophic cardiomyopathy (HCM), and lymphatic dysplasia as major clinical features, with highly variable prevalence and severity. Available treatments have mainly been directed to target the symptoms. However, repurposing MEK inhibitors (MEKis), which were originally developed for cancer treatment, to target evolutive aspects occurring in these disorders is a promising option. Animal models have shown encouraging results in treating various RASopathy manifestations, including HCM and lymphatic abnormalities. Clinical reports have also provided first evidence supporting the effectiveness of MEKi, especially trametinib, in treating life-threatening conditions associated with these disorders. Nevertheless, despite notable improvements, there are adverse events that occur, necessitating careful monitoring. Moreover, there is evidence indicating that multiple pathways can contribute to these disorders, indicating a current need to more accurate understand of the underlying mechanism of the disease to apply an effective targeted therapy. In conclusion, while MEKi holds promise in managing life-threatening complications of RASopathies, dedicated clinical trials are required to establish standardized treatment protocols tailored to take into account the individual needs of each patient and favor a personalized treatment.
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Affiliation(s)
- Andrea Gazzin
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, 10126 Turin, Italy;
- Clinical Pediatrics Genetics Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy
| | - Federico Fornari
- Postgraduate School of Pediatrics, Department of Public Health and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Simona Cardaropoli
- Postgraduate School of Pediatrics, Department of Public Health and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Diana Carli
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Marco Tartaglia
- Molecular Genetics and Functional Genomics, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy
| | | | - Alessandro Mussa
- Clinical Pediatrics Genetics Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy
- Postgraduate School of Pediatrics, Department of Public Health and Pediatrics, University of Turin, 10126 Turin, Italy
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6
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Borst AJ, Britt A, Adams DM. Complex lymphatic anomalies: Molecular landscape and medical management. Semin Pediatr Surg 2024; 33:151422. [PMID: 38833763 DOI: 10.1016/j.sempedsurg.2024.151422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
The lymphatic system is one of the most essential and complex systems in the human body. Disorders that affect the development or function of the lymphatic system can lead to multi-system complications and life-long morbidity. The past two decades have seen remarkable progress in our knowledge of the basic biology and function of the lymphatic system, the molecular regulators of lymphatic development, and description of disorders associated with disrupted lymphangiogensis. In this chapter we will touch on the clinical features of complex lymphatic anomalies, new molecular knowledge of the drivers of these disorders, and novel developmental therapeutics for lymphatic disease.
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Affiliation(s)
- Alexandra J Borst
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Allison Britt
- Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Denise M Adams
- Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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Revencu N, Eijkelenboom A, Bracquemart C, Alhopuro P, Armstrong J, Baselga E, Cesario C, Dentici ML, Eyries M, Frisk S, Karstensen HG, Gene-Olaciregui N, Kivirikko S, Lavarino C, Mero IL, Michiels R, Pisaneschi E, Schönewolf-Greulich B, Wieland I, Zenker M, Vikkula M. Assessment of gene-disease associations and recommendations for genetic testing for somatic variants in vascular anomalies by VASCERN-VASCA. Orphanet J Rare Dis 2024; 19:213. [PMID: 38778413 PMCID: PMC11110196 DOI: 10.1186/s13023-024-03196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/19/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Vascular anomalies caused by somatic (postzygotic) variants are clinically and genetically heterogeneous diseases with overlapping or distinct entities. The genetic knowledge in this field is rapidly growing, and genetic testing is now part of the diagnostic workup alongside the clinical, radiological and histopathological data. Nonetheless, access to genetic testing is still limited, and there is significant heterogeneity across the approaches used by the diagnostic laboratories, with direct consequences on test sensitivity and accuracy. The clinical utility of genetic testing is expected to increase progressively with improved theragnostics, which will be based on information about the efficacy and safety of the emerging drugs and future molecules. The aim of this study was to make recommendations for optimising and guiding the diagnostic genetic testing for somatic variants in patients with vascular malformations. RESULTS Physicians and lab specialists from 11 multidisciplinary European centres for vascular anomalies reviewed the genes identified to date as being involved in non-hereditary vascular malformations, evaluated gene-disease associations, and made recommendations about the technical aspects for identification of low-level mosaicism and variant interpretation. A core list of 24 genes were selected based on the current practices in the participating laboratories, the ISSVA classification and the literature. In total 45 gene-phenotype associations were evaluated: 16 were considered definitive, 16 strong, 3 moderate, 7 limited and 3 with no evidence. CONCLUSIONS This work provides a detailed evidence-based view of the gene-disease associations in the field of vascular malformations caused by somatic variants. Knowing both the gene-phenotype relationships and the strength of the associations greatly help laboratories in data interpretation and eventually in the clinical diagnosis. This study reflects the state of knowledge as of mid-2023 and will be regularly updated on the VASCERN-VASCA website (VASCERN-VASCA, https://vascern.eu/groupe/vascular-anomalies/ ).
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Affiliation(s)
- Nicole Revencu
- Center for Human Genetics, Cliniques universitaires Saint-Luc, University of Louvain, VASCERN VASCA European Reference Centre, Brussels, Belgium
| | - Astrid Eijkelenboom
- Department of Pathology, Radboud University Medical Center, VASCERN VASCA European Reference Centre, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Claire Bracquemart
- Normandie Univ, UNICAEN, Service de Génétique, CHU Caen Normandie, BIOTARGEN EA 7450, VASCERN VASCA European Reference Centre, Caen, 14000, France
| | - Pia Alhopuro
- HUS Diagnostic Center, Laboratory of Genetics, University of Helsinki and Helsinki University Hospital, VASCERN VASCA European Reference Centre, Helsinki, Finland
| | - Judith Armstrong
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, CIBER-ER (Biomedical Network Research Center for Rare Diseases), Instituto de Salud Carlos III (ISCIII), Madrid, and Genomic Unit, Molecular and Genetic Medicine Section, Hospital Sant Joan de Déu, VASCERN VASCA European Reference Centre, Barcelona, Spain
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, VASCERN VASCA European Reference Centre, Barcelona, Spain
| | - Claudia Cesario
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children Hospital and Research Institute, IRCCS, VASCERN VASCA European Reference Centre, Rome, Italy
| | - Maria Lisa Dentici
- Medical Genetics Unit, Bambino Gesù Children's Hospital, IRCCS, VASCERN VASCA European Reference Centre, 00165, Rome, Italy
| | - Melanie Eyries
- Sorbonne Université, Département de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, VASCERN VASCA European Reference Centre, Paris, France
| | - Sofia Frisk
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Clinical Genetics, Karolinska University Hospital, VASCERN VASCA European Reference Centre, Stockholm, Sweden
| | - Helena Gásdal Karstensen
- Department of Genetics, Center of Diagnostics, Copenhagen University Hospital - Rigshospitalet, VASCERN VASCA European Reference Centre, Copenhagen, Denmark
| | - Nagore Gene-Olaciregui
- Laboratory of Molecular Oncology, Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu, VASCERN VASCA European Reference Centre, Barcelona, Spain
| | - Sirpa Kivirikko
- Department of Clinical Genetics, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, VASCERN VASCA European Reference Centre, Helsinki, Finland
| | - Cinzia Lavarino
- Laboratory of Molecular Oncology, Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu, VASCERN VASCA European Reference Centre, Barcelona, Spain
| | - Inger-Lise Mero
- Department of Medical Genetics, Oslo University Hospital, VASCERN VASCA European Reference Centre, Oslo, Norway
| | - Rodolphe Michiels
- Center for Human Genetics, Cliniques universitaires Saint-Luc, University of Louvain, VASCERN VASCA European Reference Centre, Brussels, Belgium
| | - Elisa Pisaneschi
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children Hospital and Research Institute, IRCCS, VASCERN VASCA European Reference Centre, Rome, Italy
| | - Bitten Schönewolf-Greulich
- Department of Genetics, Center of Diagnostics, Copenhagen University Hospital - Rigshospitalet, VASCERN VASCA European Reference Centre, Copenhagen, Denmark
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital Otto-Von-Guericke-University, Magdeburg, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Otto-Von-Guericke-University, Magdeburg, Germany
| | - Miikka Vikkula
- Center for Vascular Anomalies, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
- Human Molecular Genetics , de Duve Institute, University of Louvain, VASCERN VASCA European Reference Centre, Brussels, Belgium.
- WELBIO Department, WEL Research Institute, Avenue Pasteur, 6, 1300, Wavre, Belgium.
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8
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Seront E, Froidure A, Revencu N, Dekeuleneer V, Clapuyt P, Dumitriu D, Vikkula M, Boon LM. Targeted treatment in complex lymphatic anomaly: a case of synergistic efficacy of trametinib and sirolimus. Orphanet J Rare Dis 2024; 19:199. [PMID: 38750525 PMCID: PMC11097431 DOI: 10.1186/s13023-024-03211-z] [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: 04/20/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
Repurposing anticancer drugs to vascular malformations has significantly improved patient outcomes. Complex Lymphatic Anomalies (CLA) are part of the spectrum of lymphatic malformations (LMs) that share similar oncogenic mutations to cancer. We report the case of a young patient with highly symptomatic CLA who was initially treated with sirolimus, due to the frequent involvement of the PI3K-AKT-mTOR pathway in CLA pathogenesis. Despite an initial reduction in symptoms, sirolimus progressively lost its effectiveness. After an unsuccessful attempt with trametinib alone, sirolimus was added to trametinib and resulted in a significant, rapid and sustained improvement in symptoms. This suggests that, contrary to current dogmas, combination therapy using sub-therapeutic doses targeting both the PI3K and RAS pathways retains efficacy without generating the toxicity known for combination therapies, and is beneficial in the management of CLAs and potentially other vascular anomalies.
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Affiliation(s)
- Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Brussels, Belgium
| | - Antoine Froidure
- Department of Pneumology, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Brussels, Belgium
| | - Nicole Revencu
- Center for Human Genetics, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Brussels, Belgium
| | - Valerie Dekeuleneer
- Division of Plastic Surgery, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Cliniques Universitaires St Luc, Avenue Hippocrate 10, Brussels, B-1200, Belgium
| | - Philippe Clapuyt
- Department of Pediatric Radiology, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Brussels, Belgium
| | - Dana Dumitriu
- Department of Pediatric Radiology, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Brussels, Belgium
| | - Miikka Vikkula
- Human Molecular Genetics, De Duve Institute, UCLouvain, Brussels, Belgium
- WELBIO Department, WEL Research Institute, Avenue Pasteur, 6, Wavre, 1300, Belgium
| | - Laurence M Boon
- Division of Plastic Surgery, Center for Vascular Anomalies, Saint-Luc University Hospital, VASCERN VASCA European Reference Centre, UCLouvain, Cliniques Universitaires St Luc, Avenue Hippocrate 10, Brussels, B-1200, Belgium.
- Human Molecular Genetics, De Duve Institute, UCLouvain, Brussels, Belgium.
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9
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Bhari N, Agarwal A, Asritha CVV, Panda M, Mahajan R. Vascular Malformations. Indian Dermatol Online J 2024; 15:415-430. [PMID: 38845674 PMCID: PMC11152494 DOI: 10.4103/idoj.idoj_633_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/19/2023] [Accepted: 12/24/2023] [Indexed: 06/09/2024] Open
Abstract
Vascular malformations are intricate anomalies of the circulatory system, presenting a diverse array of clinical manifestations, and posing significant challenges in diagnosis and treatment. The pathogenesis of vascular malformations is explored through the lens of genetic and molecular mechanisms, shedding light on the pivotal role of somatic mutations and dysregulated signaling pathways. Clinical presentations of vascular malformations are widely variable, ranging from cosmetic concerns to life-threatening complications. The utility of imaging techniques, such as magnetic resonance imaging (MRI), computed tomography (CT), and angiography, are discussed in detail, emphasizing their role in precise delineation and characterization. Therapeutic strategies for vascular malformations are multifaceted, considering factors such as lesion size, location, potential complications, and patient-specific factors. Traditional interventions, including surgical excision and embolization, are appraised alongside emerging approaches like targeted molecular therapies and minimally invasive procedures. The manuscript underscores the need for an individualized treatment approach, optimizing outcomes while minimizing risks and complications. In summation, this manuscript offers a comprehensive analysis of vascular malformations, encompassing their underlying pathogenesis, clinical nuances, diagnostic methods, and therapeutic considerations. By synthesizing current knowledge and highlighting gaps in understanding, this review serves as a valuable resource for clinicians, researchers, and medical practitioners, fostering an enhanced comprehension of vascular malformations and paving the way for improved patient care and innovative research endeavors.
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Affiliation(s)
- Neetu Bhari
- Department of Dermatology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Akash Agarwal
- Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - C. V. V. Asritha
- Department of Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Maitreyee Panda
- Department of Dermatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Rahul Mahajan
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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10
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Folpe AL. Vascular tumors of intermediate malignancy: An update. Hum Pathol 2024; 147:114-128. [PMID: 38360216 DOI: 10.1016/j.humpath.2024.01.014] [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: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/17/2024]
Abstract
The term "hemangioendothelioma" is used for endothelial neoplasms of intermediate malignancy and describes a group of rare neoplasms having biologic behavior falling in between that of the benign hemangiomas and fully malignant angiosarcomas. The hemangioendotheliomas fall into several specific, clinicopathologically and genetically distinct entities, specifically epithelioid hemangioendothelioma, kaposiform hemangioendothelioma, papillary intralymphatic angioendothelioma and retiform hemangioendothelioma (hobnailed hemangioendothelioma), pseudomyogenic hemangioendothelioma, composite hemangioendothelioma, and YAP1::TFE3-fused hemangioendothelioma. The clinical, morphologic, immunohistochemical, and genetic features, and the differential diagnosis of each of these rare entities are discussed in this review.
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Affiliation(s)
- Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55902, United States.
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11
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Hammill AM, Boscolo E. Capillary malformations. J Clin Invest 2024; 134:e172842. [PMID: 38618955 PMCID: PMC11014659 DOI: 10.1172/jci172842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Capillary malformation (CM), or port wine birthmark, is a cutaneous congenital vascular anomaly that occurs in 0.1%-2% of newborns. Patients with a CM localized on the forehead have an increased risk of developing a neurocutaneous disorder called encephalotrigeminal angiomatosis or Sturge-Weber syndrome (SWS), with complications including seizure, developmental delay, glaucoma, and vision loss. In 2013, a groundbreaking study revealed causative activating somatic mutations in the gene (GNAQ) encoding guanine nucleotide-binding protein Q subunit α (Gαq) in CM and SWS patient tissues. In this Review, we discuss the disease phenotype, the causative GNAQ mutations, and their cellular origin. We also present the endothelial Gαq-related signaling pathways, the current animal models to study CM and its complications, and future options for therapeutic treatment. Further work remains to fully elucidate the cellular and molecular mechanisms underlying the formation and maintenance of the abnormal vessels.
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Affiliation(s)
- Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Elisa Boscolo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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12
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Imamura M, Shin C, Ozeki M, Matsuoka K, Saitoh A, Imai C. Regression of kaposiform lymphangiomatosis and chronic disseminated intravascular coagulation after inhaled budesonide-formoterol treatment. Pediatr Blood Cancer 2024; 71:e30907. [PMID: 38296836 DOI: 10.1002/pbc.30907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 01/24/2024] [Indexed: 02/02/2024]
Affiliation(s)
- Masaru Imamura
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chansu Shin
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Akihiko Saitoh
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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13
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Petkova M, Ferby I, Mäkinen T. Lymphatic malformations: mechanistic insights and evolving therapeutic frontiers. J Clin Invest 2024; 134:e172844. [PMID: 38488007 PMCID: PMC10940090 DOI: 10.1172/jci172844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Abstract
The lymphatic vascular system is gaining recognition for its multifaceted role and broad pathological significance. Once perceived as a mere conduit for interstitial fluid and immune cell transport, recent research has unveiled its active involvement in critical physiological processes and common diseases, including inflammation, autoimmune diseases, and atherosclerosis. Consequently, abnormal development or functionality of lymphatic vessels can result in serious health complications. Here, we discuss lymphatic malformations (LMs), which are localized lesions that manifest as fluid-filled cysts or extensive infiltrative lymphatic vessel overgrowth, often associated with debilitating, even life-threatening, consequences. Genetic causes of LMs have been uncovered, and several promising drug-based therapies are currently under investigation and will be discussed.
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Affiliation(s)
- Milena Petkova
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Ingvar Ferby
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Taija Mäkinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Wihuri Research Institute, Biomedicum Helsinki, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
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14
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Gatts J, Chandra SR, Ricci K. Medical Management and Therapeutic Updates on Vascular Anomalies of the Head and Neck: Part 2. Oral Maxillofac Surg Clin North Am 2024; 36:115-123. [PMID: 37981343 DOI: 10.1016/j.coms.2023.09.012] [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] [Indexed: 11/21/2023]
Abstract
Discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved understanding of vascular anomalies and changed the treatment paradigm. With aim of minimizing need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for non-malignant vascular tumors and vascular malformations in addition to medical management of associated hematologic abnormalities.
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Affiliation(s)
- Jorie Gatts
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Srinivasa R Chandra
- Department of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA.
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
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15
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Ricci K. Medical Therapeutics for the Treatment of Vascular Anomalies: Part 3. Oral Maxillofac Surg Clin North Am 2024; 36:125-136. [PMID: 37872048 DOI: 10.1016/j.coms.2023.09.013] [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] [Indexed: 10/25/2023]
Abstract
The discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved the understanding of vascular anomalies and changed the treatment paradigm. With the aim of minimizing the need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for nonmalignant vascular tumors and vascular malformations.
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Affiliation(s)
- Kiersten Ricci
- Division of Hematology, Cancer and Blood Diseases Institute, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA.
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16
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Woodis KM, Garlisi Torales LD, Wolf A, Britt A, Sheppard SE. Updates in Genetic Testing for Head and Neck Vascular Anomalies. Oral Maxillofac Surg Clin North Am 2024; 36:1-17. [PMID: 37867039 PMCID: PMC11092895 DOI: 10.1016/j.coms.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Vascular anomalies include benign or malignant tumors or benign malformations of the arteries, veins, capillaries, or lymphatic vasculature. The genetic etiology of the lesion is essential to define the lesion and can help navigate choice of therapy. . In the United States, about 1.2% of the population has a vascular anomaly, which may be underestimating the true prevalence as genetic testing for these conditions continues to evolve.
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Affiliation(s)
- Kristina M Woodis
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute for Child Health and Human Development, 10 Center Drive, MSC 1103, Bethesda, MD 20892-1103, USA
| | - Luciana Daniela Garlisi Torales
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute for Child Health and Human Development, 10 Center Drive, MSC 1103, Bethesda, MD 20892-1103, USA
| | - Alejandro Wolf
- Department of Pathology and ARUP Laboratories, University of Utah, 2000 Circle of Hope, Room 3100, Salt Lake City, UT 84112, USA
| | - Allison Britt
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah E Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute for Child Health and Human Development, 10 Center Drive, MSC 1103, Bethesda, MD 20892-1103, USA.
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17
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Chowers G, Abebe-Campino G, Golan H, Vivante A, Greenberger S, Soudack M, Barkai G, Fox-Fisher I, Li D, March M, Battig MR, Hakonarson H, Adams D, Dori Y, Dagan A. Treatment of severe Kaposiform lymphangiomatosis positive for NRAS mutation by MEK inhibition. Pediatr Res 2023; 94:1911-1915. [PMID: 35246606 PMCID: PMC9440952 DOI: 10.1038/s41390-022-01986-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/22/2021] [Accepted: 01/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a complex lymphatic anomaly involving most commonly the mediastinum, lung, skin and bones with few effective treatments. In recent years, RAS-MAPK pathway mutations were shown to underlie the pathogenesis of several complex lymphatic anomalies. Specifically, an activating NRAS mutation (p.Q61R) was found in the majority of KLA patients. Recent reports demonstrated promising results of treatment with the MEK inhibitor, Trametinib, in patients with complex lymphatic anomalies harboring gain of function mutations in ARAF and SOS1, as well as loss of function mutation in the CBL gene, a negative regulator of the RAS-MAPK pathway. We present a 9-year-old child with a severe case of KLA harboring the typical NRAS (p.Q61R) mutation detected by plasma-derived cell free DNA, responsive to trametinib therapy. METHODS The NRAS somatic mutation was detected from plasma cfDNA using droplet digital PCR. Concurrent in-vitro studies of trametinib activity on mutant NRAS affected lymphatic endothelial cells were performed using a three-dimensional spheroid sprouting assay. RESULTS Trametinib treatment lead to resolution of lifelong thrombocytopenia, improvement of pulmonary function tests and wellbeing, as well as weaning from prolonged systemic steroid treatment. Concurrent studies of mutant NRAS-expressing cells showed enhanced lymphangiogenic capacity along with over activation of the RAS-MAPK and PI3K-AKT-mTOR pathways, both reversed by trametinib. CONCLUSIONS Trametinib treatment can substantially change the prognosis of patients with RAS pathway associated lymphatic anomalies. IMPACT This is the first description of successful trametinib treatment of a patient with KLA harboring the most characteristic NRAS p.Q61R mutation. Treatment can significantly change the prognosis of patients with RAS pathway-associated lymphatic anomalies. We devised an in vitro model of KLA enabling a reproducible method for the continued study of disease pathogenesis. Mutated NRAS p.Q61R cells demonstrated increased lymphangiogenic capacity.
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Affiliation(s)
- Guy Chowers
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Gadi Abebe-Campino
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Hana Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Oncology division, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Asaf Vivante
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Nephrology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Shoshana Greenberger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Dermatology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Michalle Soudack
- Pediatric Imaging Unit, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Galia Barkai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Diseases Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Ilana Fox-Fisher
- Department of Developmental Biology and Cancer Research, The Institute for Medical Research Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Dong Li
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael March
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark R Battig
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Divisions of Human Genetics and Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Adams
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Jill and Mark Fishman Center for Lymphatic Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adi Dagan
- Pediatrics B, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Pulmonary Unit and the National Center for Cystic Fibrosis, Edmond and Lili Safra Children's Hospital, Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel.
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18
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McCarter AL, Dellinger MT. Trametinib inhibits lymphatic vessel invasion of bone in a mouse model of Gorham-Stout disease. JOURNAL OF VASCULAR ANOMALIES 2023; 4:e070. [PMID: 38737531 PMCID: PMC11086970 DOI: 10.1097/jova.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Objective Gorham-Stout disease (GSD) is a rare lymphatic anomaly that can be caused by somatic activating mutations in KRAS. This discovery has led investigators to suggest that MEK inhibitors could be a novel treatment for GSD. However, the effect of MEK inhibitors on bone disease in animal models of GSD has not been investigated. We recently reported that Osx-tTA;TetO-Vegfc mice exhibit a phenotype that resembles GSD. Osx-tTA;TetO-Vegfc mice overexpress VEGF-C in bone, which stimulates the development of lymphatic vessels in bone and the gradual loss of cortical bone. The objective of this study was to characterize the effect of trametinib, an FDA-approved MEK1/2 inhibitor, on lymphangiogenesis and osteolysis in Osx-tTA;TetO-Vegfc mice. Methods Immunoblotting was performed to assess the effect of trametinib on VEGF-C-induced phosphorylation of ERK1/2, AKT, and S6 in primary human lymphatic endothelial cells (LECs). Prevention and intervention experiments were performed to determine the effect of trametinib on lymphangiogenesis and osteolysis in Osx-tTA;TetO-Vegfc mice. Results We found that trametinib blocked VEGF-C-induced phosphorylation of ERK1/2 in primary human LECs. We also found that trametinib prevented VEGF-C-induced lymphatic invasion of bone and cortical bone loss in Osx-tTA;TetO-Vegfc mice. Additionally, trametinib slowed the progression of disease in Osx-tTA;TetO-Vegfc mice with established disease. However, it did not reverse disease in Osx-tTA;TetO-Vegfc mice. Conclusion Our results show trametinib impacts bone disease in Osx-tTA;TetO-Vegfc mice. These findings further support the testing of MEK inhibitors in patients with GSD and other RAS pathway-driven complex lymphatic anomalies with bone involvement.
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Affiliation(s)
- Anna L. McCarter
- Division of Surgical Oncology, Department of Surgery and the Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, USA
| | - Michael T. Dellinger
- Division of Surgical Oncology, Department of Surgery and the Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Molecular Biology and the Hamon Center for Regenerative Science and Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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D'Onofrio G, Delrue MA, Lortie A, Marquis C, Striano P, Jaworski M, Andelfinger G, Perreault S. Treatment of Refractory Epilepsy With MEK Inhibitor in Patients With RASopathy. Pediatr Neurol 2023; 148:148-151. [PMID: 37722300 DOI: 10.1016/j.pediatrneurol.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/18/2023] [Accepted: 08/14/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Several specific syndromes within the RASopathies spectrum lead to an increased risk of seizures up to developing refractory epileptic encephalopathy. Management remains symptomatic. METHODS Here we report two patients treated with trametinib, a MEK1-2 inhibitor, as a precision strategy for drug-resistant epilepsy. Patient 1 is a six-year-old girl with cardiofaciocutaneous syndrome (BRAF p.F595L, germline mutation), and Patient 2 is a 14-month-old boy with Schimmelpenning syndrome (KRAS p.G12D, postzygotic somatic mutation). Trametinib was initiated at a dosage of 0.025 mg/kg/day. RESULTS Patient 1 had multiple seizures per day, multifocal motor to bilateral tonic-clonic. Electroencephalography (EEG) showed a dramatic reduction in EEG discharges three months after trametinib onset, while a marked clinical improvement occurred after about five months, at the same dosage, and the girl is currently seizure-free for more than six months. Patient 2 had left cerebral hemiatrophy leading to right focal motor seizures, multiple per week to multiple per day, since the age of three months. On trametinib, he experienced an early benefit, remaining seizure-free for more than three months. However, after six months we observed recurrence of seizures. After 22 months of treatment, trametinib was discontinued because of a suspected drug-induced inflammatory colitis. After discontinuation, we observed a significant clinical and EEG "rebound effect." CONCLUSIONS We provide proof of concept that MEK inhibition is a promising approach for the treatment of patients with refractory epilepsy with selected germline and mosaic RASopathies. Future trials are encouraged to better investigate their potentials and limitations.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Division of Pediatric Neurology, Department of Neurosciences, CHU Sainte-Justine, Montreal, QC, Canada
| | - Marie-Ange Delrue
- Division of Medical Genetics, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Anne Lortie
- Division of Pediatric Neurology, Department of Neurosciences, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Genoa, Italy
| | - Magdalena Jaworski
- Department of Pediatrics, Developmental Pediatrics Division, CHU Sainte-Justine
| | - Gregor Andelfinger
- Division of Cardiology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Sebastien Perreault
- Division of Pediatric Neurology, Department of Neurosciences, CHU Sainte-Justine, Montreal, QC, Canada.
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Hägerling R, Van Zanten M, Behncke RY, Ulferts S, Hansmeier NR, Märkl B, Witzel C, Ho B, Keeley V, Riches K, Mansour S, Gordon K, Ostergaard P, Mortimer PS. Erythematous capillary-lymphatic malformations mimicking blood vascular anomalies. JCI Insight 2023; 8:e172179. [PMID: 37698920 PMCID: PMC10619487 DOI: 10.1172/jci.insight.172179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Superficial erythematous cutaneous vascular malformations are assumed to be blood vascular in origin, but cutaneous lymphatic malformations can contain blood and appear red. Management may be different and so an accurate diagnosis is important. Cutaneous malformations were investigated through 2D histology and 3D whole-mount histology. Two lesions were clinically considered as port-wine birthmarks and another 3 lesions as erythematous telangiectasias. The aims were (i) to demonstrate that cutaneous erythematous malformations including telangiectasia can represent a lymphatic phenotype, (ii) to determine if lesions represent expanded but otherwise normal or malformed lymphatics, and (iii) to determine if the presence of erythrocytes explained the red color. Microscopy revealed all lesions as lymphatic structures. Port-wine birthmarks proved to be cystic lesions, with nonuniform lymphatic marker expression and a disconnected lymphatic network suggesting a lymphatic malformation. Erythematous telangiectasias represented expanded but nonmalformed lymphatics. Blood within lymphatics appeared to explain the color. Blood-lymphatic shunts could be detected in the erythematous telangiectasia. In conclusion, erythematous cutaneous capillary lesions may be lymphatic in origin but clinically indistinguishable from blood vascular malformations. Biopsy is advised for correct phenotyping and management. Erythrocytes are the likely explanation for color accessing lymphatics through lympho-venous shunts.
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Affiliation(s)
- René Hägerling
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Malou Van Zanten
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rose Yinghan Behncke
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Sascha Ulferts
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Nils R. Hansmeier
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Clinic Augsburg, Augsburg, Germany
| | - Christian Witzel
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernard Ho
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Vaughan Keeley
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Katie Riches
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Sahar Mansour
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- SW Thames Regional Centre for Genomics, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Kristiana Gordon
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
| | - Peter S. Mortimer
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
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21
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Fernandes LM, Tresemer J, Zhang J, Rios JJ, Scallan JP, Dellinger MT. Hyperactive KRAS/MAPK signaling disrupts normal lymphatic vessel architecture and function. Front Cell Dev Biol 2023; 11:1276333. [PMID: 37842094 PMCID: PMC10571159 DOI: 10.3389/fcell.2023.1276333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Complex lymphatic anomalies (CLAs) are sporadically occurring diseases caused by the maldevelopment of lymphatic vessels. We and others recently reported that somatic activating mutations in KRAS can cause CLAs. However, the mechanisms by which activating KRAS mutations cause CLAs are poorly understood. Here, we show that KRASG12D expression in lymphatic endothelial cells (LECs) during embryonic development impairs the formation of lymphovenous valves and causes the enlargement of lymphatic vessels. We demonstrate that KRASG12D expression in primary human LECs induces cell spindling, proliferation, and migration. It also increases AKT and ERK1/2 phosphorylation and decreases the expression of genes that regulate the maturation of lymphatic vessels. We show that MEK1/2 inhibition with the FDA-approved drug trametinib suppresses KRASG12D-induced morphological changes, proliferation, and migration. Trametinib also decreases ERK1/2 phosphorylation and increases the expression of genes that regulate the maturation of lymphatic vessels. We also show that trametinib and Cre-mediated expression of a dominant-negative form of MEK1 (Map2k1 K97M) suppresses KRASG12D-induced lymphatic vessel hyperplasia in embryos. Last, we demonstrate that conditional knockout of wild-type Kras in LECs does not affect the formation or function of lymphatic vessels. Together, our data indicate that KRAS/MAPK signaling must be tightly regulated during embryonic development for the proper development of lymphatic vessels and further support the testing of MEK1/2 inhibitors for treating CLAs.
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Affiliation(s)
- Lorenzo M. Fernandes
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jeffrey Tresemer
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jing Zhang
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Madison, WI, United States
| | - Jonathan J. Rios
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, United States
- McDermott Center for Human Growth and Development, Dallas, TX, United States
| | - Joshua P. Scallan
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Michael T. Dellinger
- Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, TX, United States
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, United States
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22
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Clapp A, Shawber CJ, Wu JK. Pathophysiology of Slow-Flow Vascular Malformations: Current Understanding and Unanswered Questions. JOURNAL OF VASCULAR ANOMALIES 2023; 4:e069. [PMID: 37662560 PMCID: PMC10473035 DOI: 10.1097/jova.0000000000000069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/13/2023] [Indexed: 09/05/2023]
Abstract
Background Slow-flow vascular malformations include venous, lymphatic, and lymphaticovenous malformations. Recent studies have linked genetic variants hyperactivating either the PI3K/AKT/mTOR and/or RAS/RAF/MAPK signaling pathways with slow-flow vascular malformation development, leading to the use of pharmacotherapies such as sirolimus and alpelisib. It is important that clinicians understand basic and translational research advances in slow-flow vascular malformations. Methods A literature review of basic science publications in slow-flow vascular malformations was performed on Pubmed, using search terms "venous malformation," "lymphatic malformation," "lymphaticovenous malformation," "genetic variant," "genetic mutation," "endothelial cells," and "animal model." Relevant publications were reviewed and summarized. Results The study of patient tissues and the use of primary pathogenic endothelial cells from vascular malformations shed light on their pathological behaviors, such as endothelial cell hyperproliferation and disruptions in vessel architecture. The use of xenograft and transgenic animal models confirmed the pathogenicity of genetic variants and allowed for preclinical testing of potential therapies. These discoveries underscore the importance of basic and translational research in understanding the pathophysiology of vascular malformations, which will allow for the development of improved biologically targeted treatments. Conclusion Despite basic and translation advances, a cure for slow-flow vascular malformations remains elusive. Many questions remain unanswered, including how genotype variants result in phenotypes, and genotype-phenotype heterogeneity. Continued research into venous and lymphatic malformation pathobiology is critical in understanding the mechanisms by which genetic variants contribute to vascular malformation phenotypic features.
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Affiliation(s)
- Averill Clapp
- Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Carrie J. Shawber
- Department of Obstetrics and Gynecology, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - June K. Wu
- Department of Obstetrics and Gynecology, Department of Surgery, Columbia University Irving Medical Center, New York, NY
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23
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Lan Y, Zhou J, Qiu T, Gong X, Ji Y. Refractory kaposiform lymphangiomatosis relieved by splenectomy. Front Pediatr 2023; 11:1203336. [PMID: 37664553 PMCID: PMC10469894 DOI: 10.3389/fped.2023.1203336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Kaposiform lymphangiomatosis (KLA) is a rare and complex lymphatic anomaly with a poor prognosis. There is no standard treatment, and drug therapies are the most common therapeutic method. However, some patients' symptoms become gradually aggravated despite medical treatment. Splenectomy may be an alternative option when pharmacological therapies are ineffective. Materials and Methods We reviewed and evaluated the cases of 3 patients with KLA who ultimately underwent splenectomy. Results: The lesions were diffusely distributed and involved the lungs and spleens of the 3 patients. Laboratory examinations revealed that all three patients had thrombocytopenia and reduced fibrinogen levels. All patients underwent symptomatic splenectomy after the medication failed. Surprisingly, their symptoms greatly improved. Histopathological investigation of the splenic lesions of the three patients confirmed the diagnosis of KLA. Immunohistochemical staining showed positivity for CD31, CD34, podoplanin, Prox-1 and angiopoietin 2 (Ang-2). Discussion This study aimed to review the features of KLA patients treated by splenectomy and explore the underlying link between splenectomy and prognosis. The reason for the improvement after splenectomy may be related to increased Ang-2 levels and platelet activation in patients with KLA. Future research should seek to develop more targeted drugs based on molecular findings, which may give new hope for the treatment of KLA.
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Affiliation(s)
| | | | | | | | - Yi Ji
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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24
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Apsel Winger B, Devine WP, Hsiao EC, Zapala M, Van Ziffle J, Gupta N, Frieden IJ, Shimano KA. EML4::ALK fusions in complex lymphatic malformations. Pediatr Blood Cancer 2023:e30516. [PMID: 37377128 DOI: 10.1002/pbc.30516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
Gorham-Stout disease (GSD) and generalized lymphatic anomaly (GLA) are subtypes of complex lymphatic malformations (CLMs) with osseous involvement that cause significant complications, including pain and pathologic fractures. As with other vascular anomalies, somatic mosaic mutations in oncogenes are often present, and the mTOR inhibitor sirolimus alleviates symptoms in some, but not all, patients. We describe two patients, one with GSD and one with GLA, found to have EML4::ALK fusions. This report of a targetable, oncogenic fusion in vascular malformations expands our understanding of the genetic basis for CLMs and suggests additional targeted therapies could be effective.
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Affiliation(s)
- Beth Apsel Winger
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, California, USA
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Walter Patrick Devine
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Edward C Hsiao
- Department of Medicine, and the Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
| | - Matthew Zapala
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jessica Van Ziffle
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ilona J Frieden
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Kristin A Shimano
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, California, USA
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25
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Li D, Sheppard SE, March ME, Battig MR, Surrey LF, Srinivasan AS, Matsuoka LS, Tian L, Wang F, Seiler C, Dayneka J, Borst AJ, Matos MC, Paulissen SM, Krishnamurthy G, Nriagu B, Sikder T, Casey M, Williams L, Rangu S, O'Connor N, Thomas A, Pinto E, Hou C, Nguyen K, Pellegrino da Silva R, Chehimi SN, Kao C, Biroc L, Britt AD, Queenan M, Reid JR, Napoli JA, Low DM, Vatsky S, Treat J, Smith CL, Cahill AM, Snyder KM, Adams DM, Dori Y, Hakonarson H. Genomic profiling informs diagnoses and treatment in vascular anomalies. Nat Med 2023; 29:1530-1539. [PMID: 37264205 PMCID: PMC11184491 DOI: 10.1038/s41591-023-02364-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/24/2023] [Indexed: 06/03/2023]
Abstract
Vascular anomalies are malformations or tumors of the blood or lymphatic vasculature and can be life-threatening. Although molecularly targeted therapies can be life-saving, identification of the molecular etiology is often impeded by lack of accessibility to affected tissue samples, mosaicism or insufficient sequencing depth. In a cohort of 356 participants with vascular anomalies, including 104 with primary complex lymphatic anomalies (pCLAs), DNA from CD31+ cells isolated from lymphatic fluid or cell-free DNA from lymphatic fluid or plasma underwent ultra-deep sequencing thereby uncovering pathogenic somatic variants down to a variant allele fraction of 0.15%. A molecular diagnosis, including previously undescribed genetic causes, was obtained in 41% of participants with pCLAs and 72% of participants with other vascular malformations, leading to a new medical therapy for 63% (43/69) of participants and resulting in improvement in 63% (35/55) of participants on therapy. Taken together, these data support the development of liquid biopsy-based diagnostic techniques to identify previously undescribed genotype-phenotype associations and guide medical therapy in individuals with vascular anomalies.
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Affiliation(s)
- Dong Li
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sarah E Sheppard
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael E March
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark R Battig
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lea F Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abhay S Srinivasan
- Division of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Leticia S Matsuoka
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lifeng Tian
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fengxiang Wang
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christoph Seiler
- Zebrafish Core, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jill Dayneka
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra J Borst
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mary C Matos
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott M Paulissen
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Ganesh Krishnamurthy
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bede Nriagu
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tamjeed Sikder
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Casey
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lydia Williams
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sneha Rangu
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nora O'Connor
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandria Thomas
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Pinto
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cuiping Hou
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kenny Nguyen
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Samar N Chehimi
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charlly Kao
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren Biroc
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Allison D Britt
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maria Queenan
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Janet R Reid
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph A Napoli
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Low
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Seth Vatsky
- Division of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James Treat
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Division of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristen M Snyder
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise M Adams
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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26
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Grenier JM, Borst AJ, Sheppard SE, Snyder KM, Li D, Surrey LF, Al-Ibraheemi A, Weber DR, Treat JR, Smith CL, Laje P, Dori Y, Adams DM, Acord M, Srinivasan AS. Pathogenic variants in PIK3CA are associated with clinical phenotypes of kaposiform lymphangiomatosis, generalized lymphatic anomaly, and central conducting lymphatic anomaly. Pediatr Blood Cancer 2023; 70:e30419. [PMID: 37194624 PMCID: PMC11340265 DOI: 10.1002/pbc.30419] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/05/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Abstract
Complex lymphatic anomalies are debilitating conditions characterized by aberrant development of the lymphatic vasculature (lymphangiogenesis). Diagnosis is typically made by history, examination, radiology, and histologic findings. However, there is significant overlap between conditions, making accurate diagnosis difficult. Recently, genetic analysis has been offered as an additional diagnostic modality. Here, we describe four cases of complex lymphatic anomalies, all with PIK3CA variants but with varying clinical phenotypes. Identification of PIK3CA resulted in transition to a targeted inhibitor, alpelisib. These cases highlight the genetic overlap between phenotypically diverse lymphatic anomalies.
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Affiliation(s)
- Jeremy M. Grenier
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexandra J. Borst
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E. Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Kristen M. Snyder
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dong Li
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lea F. Surrey
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alyaa Al-Ibraheemi
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - David R. Weber
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James R. Treat
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L. Smith
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pablo Laje
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Denise M. Adams
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Acord
- Division of Interventional Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abhay S. Srinivasan
- Comprehensive Vascular Anomaly Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Interventional Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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27
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Sheppard SE, March ME, Seiler C, Matsuoka LS, Kim SE, Kao C, Rubin AI, Battig MR, Khalek N, Schindewolf E, O’Connor N, Pinto E, Priestley JR, Sanders VR, Niazi R, Ganguly A, Hou C, Slater D, Frieden IJ, Huynh T, Shieh JT, Krantz ID, Guerrero JC, Surrey LF, Biko DM, Laje P, Castelo-Soccio L, Nakano TA, Snyder K, Smith CL, Li D, Dori Y, Hakonarson H. Lymphatic disorders caused by mosaic, activating KRAS variants respond to MEK inhibition. JCI Insight 2023; 8:e155888. [PMID: 37154160 PMCID: PMC10243805 DOI: 10.1172/jci.insight.155888] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/17/2023] [Indexed: 05/10/2023] Open
Abstract
Central conducting lymphatic anomaly (CCLA) due to congenital maldevelopment of the lymphatics can result in debilitating and life-threatening disease with limited treatment options. We identified 4 individuals with CCLA, lymphedema, and microcystic lymphatic malformation due to pathogenic, mosaic variants in KRAS. To determine the functional impact of these variants and identify a targeted therapy for these individuals, we used primary human dermal lymphatic endothelial cells (HDLECs) and zebrafish larvae to model the lymphatic dysplasia. Expression of the p.Gly12Asp and p.Gly13Asp variants in HDLECs in a 2‑dimensional (2D) model and 3D organoid model led to increased ERK phosphorylation, demonstrating these variants activate the RAS/MAPK pathway. Expression of activating KRAS variants in the venous and lymphatic endothelium in zebrafish resulted in lymphatic dysplasia and edema similar to the individuals in the study. Treatment with MEK inhibition significantly reduced the phenotypes in both the organoid and the zebrafish model systems. In conclusion, we present the molecular characterization of the observed lymphatic anomalies due to pathogenic, somatic, activating KRAS variants in humans. Our preclinical studies suggest that MEK inhibition should be studied in future clinical trials for CCLA due to activating KRAS pathogenic variants.
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Affiliation(s)
| | | | - Christoph Seiler
- Zebrafish Core, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Adam I. Rubin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment and
| | | | | | - Erin Pinto
- Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Rojeen Niazi
- Genetic Diagnostic Laboratory, Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arupa Ganguly
- Genetic Diagnostic Laboratory, Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Joseph T. Shieh
- Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Ian D. Krantz
- Division of Human Genetics, and
- Roberts Individualized Medical Genetics Center, Division of Human Genetics
| | | | | | | | | | - Leslie Castelo-Soccio
- Dermatology Section, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Taizo A. Nakano
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Kristen Snyder
- Division of Oncology, Cancer Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L. Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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28
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McDaniel CG, Adams DM, Steele KE, Hammill AM, Merrow AC, Crane JL, Smith CL, Kozakewich HPW, Le Cras TD. Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment. Pediatr Blood Cancer 2023; 70:e30219. [PMID: 36683202 PMCID: PMC10018800 DOI: 10.1002/pbc.30219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023]
Abstract
Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.
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Affiliation(s)
| | - Denise M. Adams
- Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Kimberley E. Steele
- Collaborative Research Advocacy for Vascular Anomalies
Network (CaRAVAN), a 501(C)(3)
| | - Adrienne M. Hammill
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - A. Carl Merrow
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - Janet L. Crane
- Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | | | | | - Timothy D. Le Cras
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
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29
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Mansur A, Radovanovic I. Vascular malformations: An overview of their molecular pathways, detection of mutational profiles and subsequent targets for drug therapy. Front Neurol 2023; 14:1099328. [PMID: 36846125 PMCID: PMC9950274 DOI: 10.3389/fneur.2023.1099328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/25/2023] [Indexed: 02/12/2023] Open
Abstract
Vascular malformations are anomalies in vascular development that portend a significant risk of hemorrhage, morbidity and mortality. Conventional treatments with surgery, radiosurgery and/or endovascular approaches are often insufficient for cure, thereby presenting an ongoing challenge for physicians and their patients. In the last two decades, we have learned that each type of vascular malformation harbors inherited germline and somatic mutations in two well-known cellular pathways that are also implicated in cancer biology: the PI3K/AKT/mTOR and RAS/RAF/MEK pathways. This knowledge has led to recent efforts in: (1) identifying reliable mechanisms to detect a patient's mutational burden in a minimally-invasive manner, and then (2) understand how cancer drugs that target these mutations can be repurposed for vascular malformation care. The idea of precision medicine for vascular pathologies is growing in potential and will be critical in expanding the clinician's therapeutic armamentarium.
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Affiliation(s)
- Ann Mansur
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada,Krembil Brain Institute, University Health Network, Toronto, ON, Canada,*Correspondence: Ivan Radovanovic ✉
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30
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Andreoti TAA, Berg S, Holm A, Angerer M, Oberlin M, Foeldi E, Baumgartner I, Niemeyer CM, Rössler J, Kapp FG. Complex Lymphatic Anomalies: Report on a Patient Registry Using the Latest Diagnostic Guidelines. Lymphat Res Biol 2023. [PMID: 36706428 DOI: 10.1089/lrb.2022.0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective: Generalized lymphatic anomaly (GLA), Gorham-Stout disease (GSD), kaposiform lymphangiomatosis (KLA), and central conducting lymphatic anomaly (CCLA) are rare, multisystem lymphatic disorders, referred to as complex lymphatic anomalies (CLAs). Their etiology remains poorly understood; however, somatic activating mutations have recently been discovered, and the results of targeted treatments are promising. This study aimed to elaborate on the phenotypic description of CLA. Methods: Thirty-six consecutive patients were recruited for the "GLA/GSD Registry" of the University Hospital of Freiburg, Germany (2015-2021). Clinical data were prospectively collected provided that a signed informed consent form was obtained. The latest proposed diagnostic guidelines were retrospectively applied. Results: Thirty-two patients (38% males) were included in the study; 15 GLA, 10 GSD, 3 KLA, and 4 CCLA patients were identified. Eighty-four percent already had symptoms by the age of 15 years. Osteolysis and periosseous soft-tissue infiltration were associated with GSD (p < 0.001 and p = 0.011, respectively), ascites and protein-losing enteropathy with CCLA (p = 0.007 and p = 0.004, respectively), and consumption coagulopathy with KLA (p = 0.006). No statistically significant differences were found in organ involvement, distribution of osteolytic lesions, number of affected bones and fractures. Twenty-five patients had complications; one patient with GLA died despite multimodal treatment. Spontaneous regression was seen in one patient with untreated KLA. Conclusions: CLA are rare, and their overlapping clinical presentations make differential diagnosis difficult. The characterization of our case series contributes to the phenotypic description and differentiation of these four clinical entities. A further understanding of their pathogenesis is crucial for evaluating targeted therapies and optimizing medical care.
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Affiliation(s)
- Themis-Areti A Andreoti
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Sebastian Berg
- Division of Pediatric Radiology, Department of Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany
| | - Annegret Holm
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Vascular Biology Program, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marina Angerer
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Oberlin
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Foeldiclinic, Hinterzarten, Germany
| | - Etelka Foeldi
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Foeldiclinic, Hinterzarten, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Charlotte M Niemeyer
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Rössler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland.,VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich G Kapp
- VASCERN (European Network of rare vascular diseases) HCP (Health Care Provider) Freiburg-Hinterzarten, Germany.,Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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31
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Pereira-Nunes J, Madureira M, Dinis A, Barroca H, Lima J, do Bom-Sucesso M. Kaposiform Lymphangiomatosis in a Male Adolescent: A Clinical Challenge and the Role of Genetics. J Investig Med High Impact Case Rep 2023; 11:23247096231166678. [PMID: 37148180 PMCID: PMC10164843 DOI: 10.1177/23247096231166678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare and aggressive generalized lymphatic anomaly (GLA), with distinctive clinical, radiology, morphologic, and genetic features. It does not have a current standard treatment and presents poor overall prognosis. Somatic mutations in the RAS pathway were reported as the likely driver for the majority of patients. We report a case of a 17-year-old male adolescent who was referred to the emergency department due to a severe anemia. Laboratory workup confirmed the anemia and revealed coagulation factor consumption and fibrinolysis. Chest-abdomen-pelvis computed tomography revealed an extensive cervical, mediastinal, abdominal and retroperitoneal "hematoma." During admission, progressive pancytopenia, and disseminated intravascular coagulation were observed, and the hypothesis of a tumor/neoplastic etiology was considered. A thoracoscopy revealed a moderate hemorrhagic pleural effusion and a mediastinal mass resembling a "hemolymphangiomatosis" malformation, which was biopsied. Histology displayed a lymphatic-venous malformation. The patient was presented at the multidisciplinary Vascular Anomalies Center and, due to the complex vascular anomaly diagnosis, oral sirolimus monotherapy was initiated. Four years later, the patient remains clinically stable, with stability of the lesion's dimensions and characteristics. A p.Q61R variant in the NRAS gene [NM_002524.4: c.182A>G, p.(Gln61Arg)], with 5% allelic fraction and 1993x coverage was detected. In conjunction with clinical and pathological findings, it allowed KLA final diagnosis. This case reinforces the importance of a high index of clinical suspicion and highlights the need of referring these cases to referral to Vascular Anomalies Centers.
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Affiliation(s)
- Joana Pereira-Nunes
- Centro Hospitalar Universitário de São João, Porto, Portugal
- Porto University, Porto, Portugal
| | | | - Alexandra Dinis
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Helena Barroca
- Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jorge Lima
- Porto University, Porto, Portugal
- Instituto de Patologia e Imunologia Molecular da Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Maria do Bom-Sucesso
- Centro Hospitalar Universitário de São João, Porto, Portugal
- Porto University, Porto, Portugal
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32
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Carli D, Resta N, Ferrero GB, Ruggieri M, Mussa A. Mosaic RASopathies: A review of disorders caused by somatic pathogenic variants in the genes of the RAS/MAPK pathway. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:520-529. [PMID: 36461154 DOI: 10.1002/ajmg.c.32021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
Mosaic RASopathies are a heterogeneous group of diseases characterized by the presence at birth or early onset of congenital anomalies, cutaneous and vascular anomalies, segmental overgrowth, and increased cancer risk. They are caused by somatic pathogenic variants of the genes belonging the RAt Sarcoma Mitogen-activated protein kinase (RAS/MAPK) pathway causing its hyperactivation. Here, we review the clinical and molecular characteristics of this heterogeneous group of diseases, including the possibilities of molecular diagnosis and new therapeutic perspectives.
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Affiliation(s)
- Diana Carli
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.,Pediatric Onco-Hematology, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Nicoletta Resta
- Division of Medical Genetics, Department of Biomedical Sciences and Human Oncology (DIMO), University of Bari "Aldo Moro", Bari, Italy
| | | | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandro Mussa
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.,Pediatric Clinical Genetics Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza, Torino, Italy
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33
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DeMaio A, New C, Bergmann S. Medical Treatment of Vascular Anomalies. Dermatol Clin 2022; 40:461-471. [DOI: 10.1016/j.det.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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34
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Fedidat R, Elia A, Hershko A, Fridlender Z. Recurrent haemoptysis: a rare diagnosis of kaposiform lymphangiomatosis and review of literature. BMJ Case Rep 2022; 15:e250825. [PMID: 36171013 PMCID: PMC9528592 DOI: 10.1136/bcr-2022-250825] [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] [Indexed: 11/03/2022] Open
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare clinicopathological entity among lymphatic anomalies. The main involved sites are the mediastinum and the lungs but the disease can also affect multiple extrathoracic organs. Little is known about the pathophysiology, the natural history, the treatment response and the long-term outcome of this disorder. KLA is typically diagnosed in childhood. We present here the case of an adult man with 13 years recurrent episodes of haemoptysis who was finally found to suffer from KLA. Following this, we present a comprehensive review of the literature.
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Affiliation(s)
| | - Anna Elia
- Pathology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Alon Hershko
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Clinical Immunology, Hadassah Medical Center, Jerusalem, Israel
| | - Zvi Fridlender
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Internal Medicine & Pulmonology, Hadassah Medical Center, Jerusalem, Israel
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35
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Phung TL. Histopathology of Vascular Malformations. Dermatol Clin 2022; 40:345-355. [DOI: 10.1016/j.det.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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36
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Setty BA, Wusik K, Hammill AM. How we approach genetics in the diagnosis and management of vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29320. [PMID: 36070212 DOI: 10.1002/pbc.29320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/04/2023]
Abstract
Vascular anomalies are a heterogeneous group of disorders that are currently classified based on their clinical and histological characteristics. Over the past decade, there have been significant advances in molecular genetics that have led to identification of genetic alterations associated with vascular tumors, vascular malformations, and syndromes. Here, we describe known genetic alterations in vascular anomalies, discuss when and how to test, and examine how identification of causative genetic mutations provides for better management of these disorders through improved understanding of their pathogenesis and increasing use of targeted therapeutic agents in order to achieve better outcomes for our patients.
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Affiliation(s)
- Bhuvana A Setty
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, and Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Katie Wusik
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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37
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Ricci KW, Iacobas I. How we approach the diagnosis and management of complex lymphatic anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e28985. [PMID: 33844431 DOI: 10.1002/pbc.28985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/29/2021] [Accepted: 02/13/2021] [Indexed: 12/26/2022]
Abstract
Complex lymphatic anomalies (CLA) are congenital diseases of the lymphatic circulation system that are associated with significant morbidity and early mortality. While guidelines for the comprehensive evaluation of the CLA were recently published, the diagnostic approach and medical management are not standardized. This article presents the clinical features of four CLA: Gorham-Stout disease, generalized lymphatic anomaly, kaposiform lymphangiomatosis, and central collecting lymphatic anomaly. We also offer three cases from the authors' practice and our views on diagnostic testing and disease management including supportive care, medical therapies, and other interventions.
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Affiliation(s)
- Kiersten W Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Hematology and Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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38
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Solorzano E, Alejo AL, Ball HC, Magoline J, Khalil Y, Kelly M, Safadi FF. Osteopathy in Complex Lymphatic Anomalies. Int J Mol Sci 2022; 23:ijms23158258. [PMID: 35897834 PMCID: PMC9332568 DOI: 10.3390/ijms23158258] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/07/2022] [Accepted: 07/16/2022] [Indexed: 11/16/2022] Open
Abstract
Complex Lymphatic Anomalies (CLA) are lymphatic malformations with idiopathic bone and soft tissue involvement. The extent of the abnormal lymphatic presentation and boney invasion varies between subtypes of CLA. The etiology of these diseases has proven to be extremely elusive due to their rarity and irregular progression. In this review, we compiled literature on each of the four primary CLA subtypes and discuss their clinical presentation, lymphatic invasion, osseous profile, and regulatory pathways associated with abnormal bone loss caused by the lymphatic invasion. We highlight key proliferation and differentiation pathways shared between lymphatics and bone and how these systems may interact with each other to stimulate lymphangiogenesis and cause bone loss.
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Affiliation(s)
- Ernesto Solorzano
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Andrew L. Alejo
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Hope C. Ball
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Joseph Magoline
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Yusuf Khalil
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
| | - Michael Kelly
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Department of Pediatric Hematology Oncology and Blood, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Fayez F. Safadi
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA; (E.S.); (A.L.A.); (H.C.B.); (J.M.); (Y.K.); (M.K.)
- Musculoskeletal Research Group, Northeast Ohio Medical University (NEOMED), Rootstown, OH 44272, USA
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, OH 44308, USA
- School of Biomedical Sciences, Kent State University, Kent, OH 44243, USA
- Correspondence: ; Tel.: +1-330-325-6619
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39
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Geng X, Srinivasan RS. Molecular Mechanisms Driving Lymphedema and Other Lymphatic Anomalies. Cold Spring Harb Perspect Med 2022; 12:a041272. [PMID: 35817543 PMCID: PMC9341459 DOI: 10.1101/cshperspect.a041272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Lymphatic vasculature regulates fluid homeostasis by absorbing interstitial fluid and returning it to blood. Lymphatic vasculature is also critical for lipid absorption and inflammatory response. Lymphatic vasculature is composed of lymphatic capillaries, collecting lymphatic vessels, lymphatic valves, and lymphovenous valves. Defects in any of these structures could lead to lymphatic anomalies such as lymphedema, cystic lymphatic malformation, and Gorham-Stout disease. Basic research has led to a deeper understanding of the stepwise development of the lymphatic vasculature. VEGF-C and shear stress signaling pathways have evolved as critical regulators of lymphatic vascular development. Loss-of-function and gain-of-function mutations in genes that are involved in these signaling pathways are associated with lymphatic anomalies. Importantly, drugs that target these molecules are showing outstanding efficacy in treating certain lymphatic anomalies. In this article, we summarize these exciting developments and highlight the future challenges.
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Affiliation(s)
- Xin Geng
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73013, USA
| | - R Sathish Srinivasan
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma 73013, USA
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73117, USA
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40
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Perez-Atayde AR, Debelenko L, Al-Ibraheemi A, Eng W, Ruiz-Gutierrez M, O'Hare M, Croteau SE, Trenor CC, Boyer D, Balkin DM, Barclay SF, Hsi Dickie B, Liang MG, Chaudry G, Alomari AI, Mulliken JB, Adams DM, Kurek KC, Fishman SJ, Kozakewich HPW. Kaposiform Lymphangiomatosis: Pathologic Aspects in 43 Patients. Am J Surg Pathol 2022; 46:963-976. [PMID: 35385405 DOI: 10.1097/pas.0000000000001898] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Kaposiform lymphangiomatosis is an uncommon generalized lymphatic anomaly with distinctive clinical, radiologic, histopathologic, and molecular findings. Herein, we document the pathology in 43 patients evaluated by the Boston Children's Hospital Vascular Anomalies Center from 1999 to 2020. The most frequent presentations were respiratory difficulty, hemostatic abnormalities, and a soft tissue mass. Imaging commonly revealed involvement of some combination of mediastinal, pulmonary, pleural, and pericardial compartments and most often included spleen and skeleton. Histopathology was characterized by dilated, redundant, and abnormally configured lymphatic channels typically accompanied by dispersed clusters of variably canalized, and often hemosiderotic, spindled lymphatic endothelial cells that were immunopositive for D2-40, PROX1, and CD31. An activating lesional NRAS variant was documented in 9 of 10 patients. The clinical course was typically aggressive, marked by hemorrhage, thrombocytopenia, diminished fibrinogen levels, and a mortality rate of 21%.
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Affiliation(s)
| | - Larisa Debelenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | | | | | - Melisa Ruiz-Gutierrez
- Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute
| | | | - Stacy E Croteau
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - Cameron C Trenor
- Dana-Farber/Boston Children's Hospital Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | | | | | - Sarah F Barclay
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | - Ahmad I Alomari
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School
| | | | - Denise M Adams
- Division of Oncology, Department of Pediatrics, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Kyle C Kurek
- Departments of Pathology & Laboratory Medicine
- Medical Genetics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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41
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Wolter JK, Valencia-Sama I, Osborn AJ, Propst EJ, Irwin MS, Papsin B, Wolter NE. Combination mTOR and SHP2 inhibitor treatment of lymphatic malformation endothelial cells. Microvasc Res 2022; 143:104397. [PMID: 35671835 DOI: 10.1016/j.mvr.2022.104397] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/27/2022] [Accepted: 06/01/2022] [Indexed: 12/13/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors are clinically effective at treating some complex lymphatic malformations (LM). The mTOR inhibitor rapamycin blocks the phosphoinositide 3-kinase (PI3K) pathway, which is commonly mutated in this condition. Although rapamycin is effective at controlling symptoms of LM, treatment courses are long, not all LMs respond to treatment, and many patients relapse after treatment has stopped. Concurrent rat sarcoma virus (RAS) pathway abnormalities have been identified in LM, which may limit the effectiveness of rapamycin. Protein tyrosine phosphatase-2 (SHP2) controls the RAS pathway upstream, and SHP2 inhibitors are being investigated for treatment of various tumors. The objective of this study was to determine the impact of SHP2 inhibition in combination with rapamycin on LM growth in vitro. Using primary patient cells isolated from a surgically resected LM, we found that combination treatment with rapamycin and the SHP2 inhibitor SHP099 caused a synergistic reduction in cell growth, migration and lymphangiogenesis. These results suggest that combination treatment targeting the PI3K and RAS signaling pathways may result in effective treatment of LMs of the head and neck.
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Affiliation(s)
- Jennifer K Wolter
- Department of Otolaryngology, Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Alex J Osborn
- Department of Otolaryngology, Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology, Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Meredith S Irwin
- Cell Biology Program, The Hospital for Sick Children, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Blake Papsin
- Department of Otolaryngology, Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology, Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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42
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Boscolo E, Pastura P, Schrenk S, Goines J, Kang R, Pillis D, Malik P, Le Cras TD. NRAS Q61R mutation in human endothelial cells causes vascular malformations. Angiogenesis 2022; 25:331-342. [PMID: 35391614 DOI: 10.1007/s10456-022-09836-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/22/2022] [Indexed: 11/27/2022]
Abstract
Somatic mutations in NRAS drive the pathogenesis of melanoma and other cancers but their role in vascular anomalies and specifically human endothelial cells is unclear. The goals of this study were to determine whether the somatic-activating NRASQ61R mutation in human endothelial cells induces abnormal angiogenesis and to develop in vitro and in vivo models to identify disease-causing pathways and test inhibitors. Here, we used mutant NRASQ61R and wild-type NRAS (NRASWT) expressing human endothelial cells in in vitro and in vivo angiogenesis models. These studies demonstrated that expression of NRASQ61R in human endothelial cells caused a shift to an abnormal spindle-shaped morphology, increased proliferation, and migration. NRASQ61R endothelial cells had increased phosphorylation of ERK compared to NRASWT cells indicating hyperactivation of MAPK/ERK pathways. NRASQ61R mutant endothelial cells generated abnormal enlarged vascular channels in a 3D fibrin gel model and in vivo, in xenografts in nude mice. These studies demonstrate that NRASQ61R can drive abnormal angiogenesis in human endothelial cells. Treatment with MAP kinase inhibitor U0126 prevented the change to a spindle-shaped morphology in NRASQ61R endothelial cells, whereas mTOR inhibitor rapamycin did not.
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Affiliation(s)
- Elisa Boscolo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
| | - Patricia Pastura
- Division of Pulmonary Biology, Cincinnati Children's Hospital, Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Sandra Schrenk
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jillian Goines
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Rachael Kang
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Devin Pillis
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Punam Malik
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Timothy D Le Cras
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Pulmonary Biology, Cincinnati Children's Hospital, Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA.
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43
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Allen-Rhoades W, Al-Ibraheemi A, Kohorst M, Tollefson M, Hull N, Polites S, Folpe AL. Cellular Variant of Kaposiform Lymphangiomatosis: A Report of Three Cases, Expanding the Morphologic and Molecular Genetic Spectrum of this Rare Entity. Hum Pathol 2022; 122:72-81. [PMID: 35202617 DOI: 10.1016/j.humpath.2022.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/12/2022] [Indexed: 11/04/2022]
Abstract
Kaposiform lymphangiomatosis (KLA) is a very rare form of generalized lymphatic anomaly, consisting of a diffuse proliferation of abnormal, dilated lymphatics and small fascicles of hemosiderin-laden spindled lymphatic endothelial cells. KLA occurs in children and young adults and may present with multicentric disease, pleural and pericardial effusions, and life-threatening coagulopathy. Genetically, KLA most often harbor somatic activating mutations in NRAS. We recently encountered 3 cases of KLA with cellular features, resembling kaposiform hemangioendothelioma (KHE) and studied their clinicopathologic, radiologic and molecular genetic features. The patients (1 male, 2 females; ages 2 years, 2 months, 4 years) presented with multicentric disease involving skin, soft tissue, bone and spleen, and thrombocytopenia/coagulopathy. Advanced imaging studies confirmed multicentric disease. Biopsies (skin, soft tissue, bone, spleen) demonstrated both conventional KLA and much more cellular foci, consisting of sheets, nodules, glomeruloid structures, and "sieve-like" arrays of lymphatic endothelial cells (positive for CD31 and D2-40). Cellular areas superficially resembled KHE but displayed more epithelioid cytology and lacked surrounding hyaline fibrosis and minute platelet aggregates. Molecular genetic studies demonstrated NRAS c.181C>A p.Q61K (Gln61Lys) in 2 specimens from one patient and HRAS p.A59_Q61delinsGGSIL in another. Two patients were treated with sirolimus; all are currently alive with stable disease. We conclude that cellular morphology in KLA, a previously undescribed feature, does not appear to be associated with clinical features, site of disease, mutation type, response to sirolimus, or outcome. Although cellular KLA may mimic KHE, there are sufficient clinical, morphologic, and genetic differences such that these are likely unrelated diseases.
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Affiliation(s)
- Wendy Allen-Rhoades
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology & Oncology, Rochester, MN USA 55905
| | | | - Mira Kohorst
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology & Oncology, Rochester, MN USA 55905
| | - Megha Tollefson
- Mayo Clinic, Departments of Dermatology and Pediatric and Adolescent Medicine, Rochester, MN USA 55905
| | - Nathan Hull
- Mayo Clinic, Department of Radiology, Rochester, MN USA 55905
| | - Stephanie Polites
- Mayo Clinic, Department of Surgery, Division of Pediatric Surgery, Rochester, MN USA 55905
| | - Andrew L Folpe
- Mayo Clinic, Department Laboratory Medicine and Pathology, Rochester, MN USA 55905.
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44
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Lymphatic Anomalies in Children: Update on Imaging Diagnosis, Genetics and Treatment. AJR Am J Roentgenol 2022; 218:1089-1101. [PMID: 35043669 DOI: 10.2214/ajr.21.27200] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Lymphatic anomalies comprise a spectrum of disorders ranging from common localized microcystic and macrocystic lymphatic malformations (LMs) to rare complex lymphatic anomalies, including generalized lymphatic anomaly, Kaposiform lymphangiomatosis, central conducting lymphatic anomaly, and Gorham-Stout disease. Imaging diagnosis of cystic LMs is generally straightforward, but complex lymphatic anomalies, particularly those with multi-organ involvement or diffuse disease, may be more challenging to diagnose. Complex lymphatic anomalies are rare but associated with high morbidity. Imaging plays an important role in their diagnosis, and radiologists may be the first clinicians to suggest the diagnosis. Furthermore, radiologists are regularly involved in management given the frequent need for image-guided interventions. For these reasons, it is crucial for radiologists to be familiar with the spectrum of entities comprising complex lymphatic anomalies and their typical imaging findings. In this article, we review the imaging findings of lymphatic anomalies, including LMs and complex lymphatic anomalies. We discuss characteristic imaging findings, multimodality imaging techniques used for evaluation, pearls and pitfalls in diagnosis, and potential complications. We also review recently discovered genetic changes underlying lymphatic anomaly development and the advent of new molecularly targeted therapies.
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45
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Brouillard P, Witte MH, Erickson RP, Damstra RJ, Becker C, Quéré I, Vikkula M. Primary lymphoedema. Nat Rev Dis Primers 2021; 7:77. [PMID: 34675250 DOI: 10.1038/s41572-021-00309-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.
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Affiliation(s)
- Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Marlys H Witte
- Department of Surgery, Neurosurgery, and Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert P Erickson
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert J Damstra
- VASCERN PPL European Reference Centre; Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, Netherlands
| | | | - Isabelle Quéré
- Department of Vascular Medicine, Centre de référence des Maladies Lymphatiques et Vasculaires Rares, Inserm IDESP, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium. .,VASCERN VASCA European Reference Centre; Center for Vascular Anomalies, Division of Plastic Surgery, University Clinics Saint-Luc, University of Louvain, Brussels, Belgium. .,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), de Duve Institute, University of Louvain, Brussels, Belgium.
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46
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Homayun-Sepehr N, McCarter AL, Helaers R, Galant C, Boon LM, Brouillard P, Vikkula M, Dellinger MT. KRAS-driven model of Gorham-Stout disease effectively treated with trametinib. JCI Insight 2021; 6:e149831. [PMID: 34156985 PMCID: PMC8410066 DOI: 10.1172/jci.insight.149831] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/17/2021] [Indexed: 12/23/2022] Open
Abstract
Gorham-Stout disease (GSD) is a sporadically occurring lymphatic disorder. Patients with GSD develop ectopic lymphatics in bone, gradually lose bone, and can have life-threatening complications, such as chylothorax. The etiology of GSD is poorly understood, and current treatments for this disease are inadequate for most patients. To explore the pathogenesis of GSD, we performed targeted high-throughput sequencing with samples from a patient with GSD and identified an activating somatic mutation in KRAS (p.G12V). To characterize the effect of hyperactive KRAS signaling on lymphatic development, we expressed an active form of KRAS (p.G12D) in murine lymphatics (iLECKras mice). We found that iLECKras mice developed lymphatics in bone, which is a hallmark of GSD. We also found that lymphatic valve development and maintenance was altered in iLECKras mice. Because most iLECKras mice developed chylothorax and died before they had significant bone disease, we analyzed the effect of trametinib (an FDA-approved MEK1/2 inhibitor) on lymphatic valve regression in iLECKras mice. Notably, we found that trametinib suppressed this phenotype in iLECKras mice. Together, our results demonstrate that somatic activating mutations in KRAS can be associated with GSD and reveal that hyperactive KRAS signaling stimulates the formation of lymphatics in bone and impairs the development of lymphatic valves. These findings provide insight into the pathogenesis of GSD and suggest that trametinib could be an effective treatment for GSD.
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Affiliation(s)
- Nassim Homayun-Sepehr
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Anna L McCarter
- Division of Surgical Oncology, Department of Surgery and Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Raphaël Helaers
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | | | - Laurence M Boon
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium.,Division of Plastic Surgery, Cliniques universitaires Saint-Luc, University of Louvain, European Reference Network for Rare Multisystemic Vascular Diseases, Vascular Anomalies Working Group, European Reference Centre, Brussels, Belgium
| | - Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium.,Division of Plastic Surgery, Cliniques universitaires Saint-Luc, University of Louvain, European Reference Network for Rare Multisystemic Vascular Diseases, Vascular Anomalies Working Group, European Reference Centre, Brussels, Belgium.,Walloon Excellence in Life Sciences and Biotechnology, University of Louvain, Brussels, Belgium
| | - Michael T Dellinger
- Division of Surgical Oncology, Department of Surgery and Hamon Center for Therapeutic Oncology Research, UT Southwestern Medical Center, Dallas, Texas, USA.,Department of Molecular Biology and Hamon Center for Regenerative Science and Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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47
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Bell LM, Holm A, Matysiak U, Driever W, Rößler J, Schanze D, Wieland I, Niemeyer CM, Zenker M, Kapp FG. Functional assessment of two variants of unknown significance in TEK by endothelium-specific expression in zebrafish embryos. Hum Mol Genet 2021; 31:10-17. [PMID: 34254124 DOI: 10.1093/hmg/ddab196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/07/2021] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
Vascular malformations are most often caused by somatic mutations of the PI3K/mTOR and the RAS signaling pathways, which can be identified in the affected tissue. Venous malformations commonly harbor PIK3CA and TEK mutations, whereas arteriovenous malformations are usually caused by BRAF, RAS, or MAP2K1 mutations. Correct identification of the underlying mutation is of increasing importance, since targeted treatments are becoming more and more relevant, especially in patients with extensive vascular malformations. However, variants of unknown significance are often identified and their pathogenicity and response to targeted therapy cannot be precisely predicted. Here we show, that zebrafish embryos can be used to rapidly assess the pathogenicity of novel variants of unknown significance in TEK, encoding for the receptor TIE2, present on endothelial cells of venous malformations. Endothelium-specific overexpression of TEK mutations leads to robust induction of venous malformations whereas MAP2K1 mutations cause arteriovenous malformations in our zebrafish model. TEK mutations are often found as double mutations in cis; using our model, we show that double mutations have an additive effect in inducing venous malformations compared to the respective single variants. The clinically established mTOR-inhibitor sirolimus (rapamycin) efficiently abrogates the development of venous malformations in this zebrafish model. In summary, endothelium-specific overexpression of patient-derived TEK variants in the zebrafish model allows assessment of their pathogenic significance as well as testing of candidate drugs in a personalized and mutation-specific approach.
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Affiliation(s)
- Lorenz M Bell
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.,VASCERN VASCA European Reference Centre
| | - Annegret Holm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.,VASCERN VASCA European Reference Centre
| | - Uta Matysiak
- Pediatric Genetics Section, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Wolfgang Driever
- Developmental Biology, Institute Biology I, Faculty of Biology, CIBSS and BIOSS - Centres for Biological Signalling Studies, Albert-Ludwigs-University of Freiburg, 79104 Freiburg, Germany
| | - Jochen Rößler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.,Division of Pediatric Hematology and Oncology, University Children's Hospital Bern, 3010 Bern, Switzerland.,VASCERN VASCA European Reference Centre
| | - Denny Schanze
- Institute of Human Genetics, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Charlotte M Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.,VASCERN VASCA European Reference Centre
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Friedrich G Kapp
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.,VASCERN VASCA European Reference Centre
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48
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Abstract
Vascular and lymphatic malformations represent a challenge for clinicians. The identification of inherited and somatic mutations in important signaling pathways, including the PI3K (phosphoinositide 3-kinase)/AKT (protein kinase B)/mTOR (mammalian target of rapamycin), RAS (rat sarcoma)/RAF (rapidly accelerated fibrosarcoma)/MEK (mitogen-activated protein kinase kinase)/ERK (extracellular signal-regulated kinases), HGF (hepatocyte growth factor)/c-Met (hepatocyte growth factor receptor), and VEGF (vascular endothelial growth factor) A/VEGFR (vascular endothelial growth factor receptor) 2 cascades has led to the evaluation of tailored strategies with preexisting cancer drugs that interfere with these signaling pathways. The era of theranostics has started for the treatment of vascular anomalies. Registration: URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2015-001703-32.
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Affiliation(s)
- Angela Queisser
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (A.Q., L.M.B., M.V.), University of Louvain, Brussels, Belgium (M.V.)
| | - Emmanuel Seront
- Centre for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires Saint-Luc Brussels, Belgium (E.S., L.M.B., M.V.).,Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium (E.S.).,VASCERN VASCA European Reference Centre Cliniques Universitaires Saint-Luc, Brussels, Belgium (E.S., L.M.B., M.V.)
| | - Laurence M Boon
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (A.Q., L.M.B., M.V.), University of Louvain, Brussels, Belgium (M.V.).,Centre for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires Saint-Luc Brussels, Belgium (E.S., L.M.B., M.V.).,VASCERN VASCA European Reference Centre Cliniques Universitaires Saint-Luc, Brussels, Belgium (E.S., L.M.B., M.V.)
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (A.Q., L.M.B., M.V.), University of Louvain, Brussels, Belgium (M.V.).,Centre for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires Saint-Luc Brussels, Belgium (E.S., L.M.B., M.V.).,University of Louvain, Brussels, Belgium (M.V.).,University of Louvain, Brussels, Belgium (M.V.).,Walloon Excellence in Life Sciences and Biotechnology (WELBIO), University of Louvain, Brussels, Belgium (M.V.).,VASCERN VASCA European Reference Centre Cliniques Universitaires Saint-Luc, Brussels, Belgium (E.S., L.M.B., M.V.)
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49
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Abstract
Lymphatic vessels maintain tissue fluid homeostasis by returning to blood circulation interstitial fluid that has extravasated from the blood capillaries. They provide a trafficking route for cells of the immune system, thus critically contributing to immune surveillance. Developmental or functional defects in the lymphatic vessels, their obstruction or damage, lead to accumulation of fluid in tissues, resulting in lymphedema. Here we discuss developmental lymphatic anomalies called lymphatic malformations and complex lymphatic anomalies that manifest as localized or multifocal lesions of the lymphatic vasculature, respectively. They are rare diseases that are caused mostly by somatic mutations and can present with variable symptoms based upon the size and location of the lesions composed of fluid-filled cisterns or channels. Substantial progress has been made recently in understanding the molecular basis of their pathogenesis through the identification of their genetic causes, combined with the elucidation of the underlying mechanisms in animal disease models and patient-derived lymphatic endothelial cells. Most of the solitary somatic mutations that cause lymphatic malformations and complex lymphatic anomalies occur in genes that encode components of oncogenic growth factor signal transduction pathways. This has led to successful repurposing of some targeted cancer therapeutics to the treatment of lymphatic malformations and complex lymphatic anomalies. Apart from the mutations that act as lymphatic endothelial cell-autonomous drivers of these anomalies, current evidence points to superimposed paracrine mechanisms that critically contribute to disease pathogenesis and thus provide additional targets for therapeutic intervention. Here, we review these advances and discuss new treatment strategies that are based on the recently identified molecular pathways.
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Affiliation(s)
- Taija Mäkinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden (T.M.)
| | - Laurence M Boon
- Division of Plastic Surgery, Center for Vascular Anomalies, Cliniques Universitaires Saint Luc, UCLouvain, Brussels, Belgium (L.M.B.).,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.)
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium (L.M.B., M.V.).,Walloon Excellence in Lifesciences and Biotechnology, University of Louvain, Brussels, Belgium (M.V.)
| | - Kari Alitalo
- Wihuri Research Institute and Translational Cancer Medicine Program, Biomedicum, University of Helsinki, Finland (K.A.)
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50
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Zhou J, Yang K, Chen S, Ji Y. Sirolimus in the treatment of kaposiform lymphangiomatosis. Orphanet J Rare Dis 2021; 16:260. [PMID: 34103076 PMCID: PMC8186093 DOI: 10.1186/s13023-021-01893-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA), which is a new subtype of generalized lymphatic anomaly, is a rare disease with a poor prognosis. Currently, there is no standard treatment due to the poor understanding of KLA. Sirolimus, which is an inhibitor of mammalian target of rapamycin, has been shown to have promising potential in the treatment of complicated vascular anomalies. The aim of this study was to introduce the use of sirolimus for the treatment of KLA and to highlight the challenges of managing this refractory disease. RESULTS We reported seven patients with KLA who received sirolimus therapy in our center. Combined with previously reported cases, 58.3% achieved a partial response, 25.0% had stable disease, and 16.7% experienced disease progression. No severe sirolimus-related adverse events occurred during treatment. CONCLUSIONS This study suggests that sirolimus is currently an option for the treatment of KLA, and it is hoped that more specific therapies will be developed in the future. Rapid advances in basic science and clinical practice may facilitate the development of important new treatments for KLA.
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Affiliation(s)
- Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Kaiying Yang
- 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, #37# Guo-Xue-Xiang, Chengdu, 610041, 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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