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Holm A, Mulliken JB, Bischoff J. Infantile hemangioma: the common and enigmatic vascular tumor. J Clin Invest 2024; 134:e172836. [PMID: 38618963 PMCID: PMC11014660 DOI: 10.1172/jci172836] [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
Infantile hemangioma (IH) is a benign vascular tumor that occurs in 5% of newborns. The tumor follows a life cycle of rapid proliferation in infancy, followed by slow involution in childhood. This unique life cycle has attracted the interest of basic and clinical scientists alike as a paradigm for vasculogenesis, angiogenesis, and vascular regression. Unanswered questions persist about the genetic and molecular drivers of the proliferating and involuting phases. The beta blocker propranolol usually accelerates regression of problematic IHs, yet its mechanism of action on vascular proliferation and differentiation is unclear. Some IHs fail to respond to beta blockers and regrow after discontinuation. Side effects occur and long-term sequelae of propranolol treatment are unknown. This poses clinical challenges and raises novel questions about the mechanisms of vascular overgrowth in IH.
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Affiliation(s)
- Annegret Holm
- Vascular Biology Program and Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Freiburg, VASCERN-VASCA European Reference Center, Freiburg, Germany
| | - John B. Mulliken
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Joyce Bischoff
- Vascular Biology Program and Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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2
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Rogerson D, Alkelai A, Giordano J, Pantrangi M, Hsiao MC, Nhan-Chang CL, Motelow JE, Aggarwal V, Goldstein D, Wapner R, Shawber CJ. Investigation into the genetics of fetal congenital lymphatic anomalies. Prenat Diagn 2023; 43:703-716. [PMID: 36959127 PMCID: PMC10330091 DOI: 10.1002/pd.6345] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/10/2023] [Accepted: 03/12/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE Congenital lymphatic anomalies (LAs) arise due to defects in lymphatic development and often present in utero as pleural effusion, chylothorax, nuchal and soft tissue edema, ascites, or hydrops. Many LAs are caused by single nucleotide variants, which are not detected on routine prenatal testing. METHODS Demographic data were compared between two subcohorts, those with clinically significant fetal edema (CSFE) and isolated fetal edema. A targeted variant analysis of LA genes was performed using American College of Medical Genetics criteria on whole exome sequencing (WES) data generated for 71 fetal edema cases who remained undiagnosed after standard workup. RESULTS CSFE cases had poor outcomes, including preterm delivery, demise, and maternal preeclampsia. Pathogenic and likely pathogenic variants were identified in 7% (5/71) of cases, including variants in RASopathy genes, RASA1, SOS1, PTPN11, and a novel PIEZO1 variant. Variants of uncertain significance (VOUS) were identified in 45% (32/71) of cases. In CSFEs, VOUS were found in CELSR1, EPHB4, TIE1, PIEZO1, ITGA9, RASopathy genes, SOS1, SOS2, and RAF1. CONCLUSIONS WES identified pathogenic and likely pathogenic variants and VOUS in LA genes in 51% of fetal edema cases, supporting WES and expanded hydrops panels in cases of idiopathic fetal hydrops and fluid collections.
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Affiliation(s)
- Daniella Rogerson
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Anna Alkelai
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Giordano
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Madhulatha Pantrangi
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Meng-Chang Hsiao
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Joshua E. Motelow
- Department of Pediatrics, Columbia University Vagelos College of Physicians andSurgeons, New York, New York, USA
| | - Vimla Aggarwal
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - David Goldstein
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ron Wapner
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Carrie J. Shawber
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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3
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Handal-Orefice R, Midura D, Wu JK, Parravicini E, Miller RS, Shawber CJ. Propranolol Therapy for Congenital Chylothorax. Pediatrics 2023; 151:190476. [PMID: 36651059 DOI: 10.1542/peds.2022-058555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 01/19/2023] Open
Abstract
Congenital chylothorax is a rare and often severe anomaly without well-established medical therapies. Previously, propranolol use in patients with lymphatic malformations and secondary chylothorax was associated with improvement in clinical signs. We hypothesized that propranolol treatment would be beneficial for severe congenital chylothorax. We reviewed medical records of neonates born from 2015 to 2019 at our tertiary center with a prenatal diagnosis of congenital chylothorax for whom either prenatal or postnatal propranolol therapy was initiated. Inclusion was limited to fetuses diagnosed with severe congenital chylothorax without significant genetic, infectious, or cardiac anomalies, and who underwent prenatal interventions to mitigate consequences of the condition. Propranolol was administered orally to pregnant women at 20 mg 4 times daily and increased to a maximum dose of 40 mg 4 times daily, or to infants at 0.3 mg/kg/d and increased to 1 to 2 mg/kg/d. Primary outcomes were the time course of resolution of ultrasonographical, clinical, and/or radiologic signs of chylothorax after treatment with propranolol. Four neonates met the inclusion criteria. In 2 cases, prenatal initiation of propranolol led to resolution of the chylothoraxes before delivery (38 and 32 days after treatment) on a dose of 40 mg/day 4 times daily. Neonates had a normal postnatal course. Postnatal propranolol was initiated in 2 neonates with respiratory failure when chylothoraces were refractory to standard management. Stabilization and improvement of their pleural effusion was observed by imaging at 29 and 13 days after initiation of propranolol. There were no significant maternal or neonatal complications from prenatal or postnatal propranolol use. Propranolol may be efficacious in treating severe fetal congenital chylothorax.
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Affiliation(s)
| | - Devin Midura
- Surgery.,Contributed equally as co-first authors
| | | | - Elvira Parravicini
- Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
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4
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Kim YM, Lee Y, Choi Y, Choi IH, Heo SH, Choi JM, Do HS, Jang JH, Yum MS, Yoo HW, Lee BH. Clinical and genetic analyses of patients with lateralized overgrowth. BMC Med Genomics 2022; 15:206. [PMID: 36175890 PMCID: PMC9524090 DOI: 10.1186/s12920-022-01362-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/20/2022] [Indexed: 11/14/2022] Open
Abstract
Background The genetic features and treatment strategies of lateralized overgrowth have been elusive. We performed this study to analyze the genetic characteristics and treatment results of propranolol- or alpelisib-treated patients with lateralized overgrowth. Methods Fifteen patients with lateralized overgrowth were involved. Clinical characteristics and whole-body magnetic resonance imaging (WB-MRI) findings were evaluated. Targeted exome sequencing with a gene panel of affected tissue and peripheral white blood cells was performed. Propranolol was administered and treatment results were evaluated. The PIK3CA inhibitor alpelisib was prescribed via a managed access program. Results The identified mutations were PIK3CA (n = 7), KRAS (n = 2), PTEN (n = 1), MAP2K3 (n = 1), GNAQ (n = 1), TBC1D4 (n = 1), and TEK (n = 1). Propranolol was prescribed in 12 patients, and 7 experienced mild improvement of symptoms. Alpelisib was prescribed in two patients with a PIK3CA mutation, and the reduction of proliferated masses after 1 year of treatment was proved by WB-MRI. Conclusions Targeted exome sequencing identified various genetic features of lateralized overgrowth. Propranolol could be applied as an adjuvant therapy for reducing vascular symptoms, but a PIK3CA inhibitor would be the primary therapeutic strategy for PIK3CA-related overgrowth syndrome. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01362-1.
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Affiliation(s)
- Yoon-Myung Kim
- Department of Pediatrics, Gangneung Asan Hospital, College of Medicine, University of Ulsan, Gangneung, South Korea
| | - Yena Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Yunha Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea
| | - In Hee Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Sun Hee Heo
- Asan Medical Center, Asan Institute for Life Sciences, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Jung Min Choi
- Asan Medical Center, Asan Institute for Life Sciences, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Hyo-Sang Do
- Asan Medical Center, Asan Institute for Life Sciences, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Ja-Hyun Jang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea.,Medical Genetics Center, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Beom Hee Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, South Korea. .,Medical Genetics Center, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea.
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Lympho-venous anastomosis for the treatment of congenital and acquired lesions of the central lymphatic system: a multidisciplinary treatment approach. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01926-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Wells DA, Winlaw DS. Commentary: Serendipity leads to a fresh idea for an old problem. J Thorac Cardiovasc Surg 2021; 163:1643-1644. [PMID: 34657718 DOI: 10.1016/j.jtcvs.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Dennis A Wells
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Winlaw
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Stănciulescu MC, Popoiu MC, Cîmpean AM, David VL, Heredea R, Cerbu S, Boia ES. Expression of β1 adrenergic receptor in vascular anomalies in children. J Int Med Res 2021; 49:3000605211047713. [PMID: 34590496 PMCID: PMC8489762 DOI: 10.1177/03000605211047713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Controversial, heterogeneous, and inconsistent responses to beta-blockers have been reported in some cases of infantile proliferative hemangiomas. On the basis of these clinical observations, we aimed to examine the β1 adrenergic receptor (β1-AR) protein expression distribution among different types of pediatric vascular anomalies. METHODS Immunohistochemistry (IHC) was performed for β1-AR on 43 surgical specimens. RESULTS We found positive β1-AR IHC staining in all intramuscular hemangiomas, capillary-lymphatic, lymphatic, venous, and combined malformations, and Masson's tumor cases, as well as in 7 of 10 cases of proliferative infantile hemangiomas. CONCLUSIONS Our research demonstrates, for the first time, the degree of heterogeneous expression of β1-AR among pediatric vascular malformations. Our results support the need for β1-AR assessment in pediatric vascular anomalies to select cases with a robust response to β1-selective blockers. β1-AR assessment may have a strong impact on therapeutic refinement for pediatric vascular anomalies by selecting cases with a stronger response to beta-blockers.
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Affiliation(s)
- Maria-Corina Stănciulescu
- Department of Pediatric Surgery and Orthopedics, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania
| | - Marius-Călin Popoiu
- Department of Pediatric Surgery and Orthopedics, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania
| | - Anca Maria Cîmpean
- Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania.,Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Vlad-Laurentiu David
- Department of Pediatric Surgery and Orthopedics, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania
| | - Rodica Heredea
- Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania.,Department V/Division of Clinical Practical Skills, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Simona Cerbu
- Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania.,Department of Radiology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Eugen-Sorin Boia
- Department of Pediatric Surgery and Orthopedics, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania
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8
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Corda R, Chrisomalis-Dring S, Crook S, Shawber CJ, Wu JK, Chai PJ. Propranolol treatment for chylothorax after congenital cardiac surgery. J Thorac Cardiovasc Surg 2021; 163:1630-1641.e2. [PMID: 34583843 DOI: 10.1016/j.jtcvs.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/09/2021] [Accepted: 09/01/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Postoperative chylothorax causes significant morbidities in pediatric patients with cardiac disease. New treatment approaches based on evolving understanding of underlying lymphatic dysfunction are being developed. We hypothesized that propranolol reduces morbidities and duration of chest tube requirement in high-output chylous effusion. METHODS The postoperative courses of 50 pediatric patients with cardiac disease and high-output chylous effusion (control, n = 25; propranolol-treated, n = 25) were reviewed, including morbidities, length of hospitalization, and duration of chest tube requirement. Statistical analysis was performed using Welch's t test, Kruskal-Wallis tests for continuous variables, and chi-square and Fisher exact tests for categorical variables. Univariable logistic regression was used to determine predictors of response. RESULTS Propranolol response was defined as 80% or more drainage reduction in 9 days or less. Treated patients were grouped into responders (<9 days) and nonresponders (>10 days). Neither initial amount of drainage (P = .12) nor day of propranolol initiation (P = .17) correlated with response. When compared with controls and nonresponders, responders had significantly fewer days with chest tube requirement (P < .01), infection (P < .0002), and thrombus (P = .005), and shorter hospitalization (P < .05). All patients had low serum albumin, although nonresponders had significantly decreased serum albumin when compared with responders and control patients (P < .002), and were more likely to receive albumin replacement (P < .01). Malnutrition was prevalent in all patient groups. CONCLUSIONS Responders to propranolol had significantly less morbidity and duration of chest tube requirement when compared with control patients and nonresponders. Nonresponders did not have worse outcomes than control patients. We conclude that propranolol may be an effective treatment of patients with refractory chylothorax.
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Affiliation(s)
- Rozelle Corda
- Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
| | - Sophia Chrisomalis-Dring
- Division of Pediatric Cardiology, Department of Pediatrics, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sarah Crook
- Division of Pediatric Cardiology, Department of Pediatrics, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Carrie J Shawber
- Division of Reproductive Science, Department of Ob/Gyn and Department of Surgery, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - June K Wu
- Division of Plastic Surgery, Department of Surgery, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY; Now with Division of Cardiothoracic Surgery, Department of Surgery, Children's Healthcare of Atlanta and Emory University, Atlanta, Ga
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9
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Mitchell K, Weiner A, Ramsay P, Sahni M. Use of Propranolol in the Treatment of Chylous Effusions in Infants. Pediatrics 2021; 148:peds.2020-049699. [PMID: 34187907 DOI: 10.1542/peds.2020-049699] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/24/2022] Open
Abstract
Chylothorax and chyloperitoneum are rare in infants and challenging to definitively diagnose by using current criteria extrapolated from the adult population. They can be of primary or secondary etiologies, including congenital lymphatic malformations and postoperatively, after cardiothoracic or abdominal surgery. Current first-line management consists of bowel rest, parenteral nutrition, and a modified diet of medium-chain triglycerides but can often take weeks to be effective. Off-label use of octreotide has been reported in numerous case studies for the management of chylous effusions. However, there are no definitive neonatal data available regarding dosing, safety, and efficacy; moreover, octreotide has a side effect profile that been linked to serious morbidities, such as pulmonary hypertension and necrotizing enterocolitis. Propranolol, commonly used for the treatment of infantile hemangiomas, is currently gaining interest as a novel therapy for chylous effusions. In this case series review, we describe the use of propranolol in 4 infants with presumed chylous effusions: 1 with congenital pleural effusions and 3 infants who developed postoperative chylothorax and/or chylous ascites. Clinical improvement was noted within a few days of initiating oral propranolol, and the maximum dose used in our cases was 6 mg/kg per day. In previous case reports, researchers describe the use of oral propranolol in infants with chylous effusions, with the dose used ranging from 0.5 to 4 mg/kg per day. However, this is the first case series in which researchers report its use exclusively in infants with chylothorax and chyloperitoneum. Although further research is needed to establish safety and efficacy, our experiences suggest that propranolol could be an acceptable treatment option for chylous effusions in infants.
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Affiliation(s)
- Kaitlin Mitchell
- Sunrise Children's Hospital, Pediatrix Medical Group of Nevada, Las Vegas, Nevada
| | - Angela Weiner
- Sunrise Children's Hospital, Pediatrix Medical Group of Nevada, Las Vegas, Nevada.,Department of Pediatrics, University of Nevada, Las Vegas, Nevada
| | - Patricia Ramsay
- Sunrise Children's Hospital, Pediatrix Medical Group of Nevada, Las Vegas, Nevada.,Department of Pediatrics, University of Nevada, Las Vegas, Nevada
| | - Mitali Sahni
- Sunrise Children's Hospital, Pediatrix Medical Group of Nevada, Las Vegas, Nevada .,Department of Pediatrics, University of Nevada, Las Vegas, Nevada
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Kalwani NM, Rockson SG. Management of lymphatic vascular malformations: A systematic review of the literature. J Vasc Surg Venous Lymphat Disord 2021; 9:1077-1082. [PMID: 33540133 DOI: 10.1016/j.jvsv.2021.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lymphatic malformations (LM) are common congenital vascular lesions, most often diagnosed at birth. They deform local anatomy and can be life-threatening if they compress the aerodigestive tract or other vital structures. Significant progress has been made in the treatment of LMs in the past 20 years. We conducted a systematic review of the literature on the management of LMs. METHODS On September 21, 2020, we searched PubMed/MEDLINE for studies published from 2000 to 2020 reporting outcomes of invasive and pharmacologic treatment of LMs. RESULTS A total of 251 studies met the eligibility criteria. Surgery has continued to be a mainstay in the management of LMs, especially in the treatment of microcystic and mixed lesions. Sclerotherapy has emerged as a first-line treatment of macrocystic LMs and as an adjunctive therapy used in combination with surgery for other lesions. Sirolimus, a strong inhibitor of mTOR (mechanistic target of rapamycin), has shown tremendous promise in the treatment of LMs, as both an oral and a topical agent. Recent investigations have shown the potential of targeted small molecule modulators of cellular pathways in the treatment of LMs. CONCLUSIONS Multiple invasive and pharmacologic therapies have been shown to be effective in the treatment of LMs. Future research should focus on rigorous, prospective comparisons of these treatment modalities.
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Affiliation(s)
- Neil M Kalwani
- Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Stanley G Rockson
- Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif.
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11
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Abstract
Lymphangioma is a common type of congenital vascular disease in children with a broad spectrum of clinical manifestations. The current classification of lymphangioma by International Society for the Study of Vascular Anomalies is largely based on the clinical manifestations and complications and is not sufficient for selection of therapeutic strategies and prognosis prediction. The clinical management and outcome of lymphangioma largely depend on the clinical classification and the location of the disease, ranging from spontaneous regression with no treatment to severe sequelae even with comprehensive treatment. Recently, rapid progression has been made toward elucidating the molecular pathology of lymphangioma and the development of treatments. Several signaling pathways have been revealed to be involved in the progression and development of lymphangioma, and specific inhibitors targeting these pathways have been investigated for clinical applications and clinical trials. Some drugs already currently in clinical use for other diseases were found to be effective for lymphangioma, although the mechanisms underlying the anti-tumor effects remain unclear. Molecular classification based on molecular pathology and investigation of the molecular mechanisms of current clinical drugs is the next step toward developing more effective individualized treatment of children with lymphangioma with reduced side effects.
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Affiliation(s)
- Xiaowei Liu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Cheng Cheng
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Kai Chen
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China
| | - Yeming Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
| | - Zhixiang Wu
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Division of Pediatric Oncology, Shanghai Institute of Pediatric Research, Shanghai, China.,Department of Pediatric Surgery, Children's Hospital of Soochow University, Suzhou, China
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12
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Liviskie CJ, Brennan CC, McPherson CC, Vesoulis ZA. Propranolol for the Treatment of Lymphatic Malformations in a Neonate - A Case Report and Review of Literature. J Pediatr Pharmacol Ther 2020; 25:155-162. [PMID: 32071591 DOI: 10.5863/1551-6776-25.2.155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lymphatic malformations in neonates often manifest as a chylothorax, and although rare, morbidity and mortality can be significant. First-line treatment with medium-chain triglyceride-enriched formulas, or enteric rest with total parenteral nutrition, are not always successful. We describe the case of a premature neonate with trisomy 21 who presented with bilateral pleural effusions and a pericardial effusion that worsened with the initiation of enteral nutrition. Clinical improvement was not seen until the initiation of treatment with oral propranolol at a maximum dosage of 0.5 mg/kg/day divided every 8 hours with extubation 8 days after propranolol initiation. Two case reports have described the use of propranolol in similar patients receiving 2 mg/kg/day; however, our experience is the first to report treatment success at a much lower dose. A review of the literature for alternative medication treatments uncovered numerous case reports and series documenting variable results with incongruent definitions of treatment success in a diverse patient population. The rarity of this disease state makes accrual of patients difficult and more robust treatment data unlikely. Therefore, selection of the optimal adjunctive treatment must be based on individual patient and disease state characteristics as well as safety and efficacy profile of the medication.
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13
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Medical and sclerosing agents in the treatment of orbital lymphatic malformations. Curr Opin Ophthalmol 2019; 30:380-385. [DOI: 10.1097/icu.0000000000000585] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hangul M, Kose M, Ozcan A, Unal E. Propranolol treatment for chylothorax due to diffuse lymphangiomatosis. Pediatr Blood Cancer 2019; 66:e27592. [PMID: 30609288 DOI: 10.1002/pbc.27592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/06/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Melih Hangul
- Department of Pediatrics, Division of Pediatric Pulmonology Unit Erciyes University, Kayseri, Turkey
| | - Mehmet Kose
- Department of Pediatrics, Division of Pediatric Pulmonology Unit Erciyes University, Kayseri, Turkey
| | - Alper Ozcan
- Department of Pediatrics, Division of Pediatric Hemtology Oncology Unit Erciyes University, Kayseri, Turkey
| | - Ekrem Unal
- Department of Pediatrics, Division of Pediatric Hemtology Oncology Unit Erciyes University, Kayseri, Turkey
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15
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Ghariani Fetoui N, Boussofara L, Gammoudi R, Belajouza C, Ghariani N, Denguezli M. Efficacy of sirolimus in the treatment of microcystic lymphatic malformation of the tongue. J Eur Acad Dermatol Venereol 2019; 33:e336-e337. [DOI: 10.1111/jdv.15628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- N. Ghariani Fetoui
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - L. Boussofara
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - R. Gammoudi
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - C. Belajouza
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - N. Ghariani
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - M. Denguezli
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
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16
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Cho S, Kang SR, Lee BH, Choi S. Chylous Manifestations and Management of Gorham-Stout Syndrome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:44-46. [PMID: 30834218 PMCID: PMC6383852 DOI: 10.5090/kjtcs.2019.52.1.44] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 11/16/2022]
Abstract
Gorham-Stout disease (GSD) was first described by Gorham and colleagues in 1954, but its precise mechanism and cause remain to be elucidated. In this condition, voluminous and potentially fatal chylous effusions into the thorax can occur. Herein, we describe a case of GSD in which the patient presented with massive pleural effusions and mottled osteolytic bone lesions. We performed multiple operations, including thoracic duct ligation using video-assisted thoracoscopic surgery and thoracotomic decortication, but these procedures did not succeed in preventing recurrent pleural effusion and chest wall lymphedema. After administering sirolimus (0.8 mg/m2, twice a day) and propranolol (40 mg, twice a day), the process of GSD in this patient has been controlled for more than 2 years.
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Affiliation(s)
- Sungbin Cho
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Seung Ri Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Beom Hee Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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17
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Wiegand S, Wichmann G, Dietz A. Treatment of Lymphatic Malformations with the mTOR Inhibitor Sirolimus: A Systematic Review. Lymphat Res Biol 2018; 16:330-339. [PMID: 29924669 DOI: 10.1089/lrb.2017.0062] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Extensive lymphatic malformations are low-flow vascular malformations that can cause devastating complications. Treatment of these malformations is challenging. This systematic review presents current use of sirolimus in patients with extensive lymphatic malformations. METHODS MEDLINE and Google scholar search was conducted for studies on sirolimus treatment of lymphatic malformations up to July 2017. Search items included "lymphatic malformation," "lymphangioma," "cystic hygroma," "vascular malformation," "low-flow malformation," "sirolimus," "rapamycin," and "mTOR inhibitor." RESULTS Twenty studies, including 71 patients receiving sirolimus, were included into this review. Forty-five patients had lymphatic malformations, eight patients venolymphatic malformations, and 19 patients capillary-lymphatico-venous malformations. Sirolimus led to a partial remission of disease in 60 patients, three patients had a progressive disease, and the outcome of eight patients was not reported. Dosing, target trough level, and duration of treatment differed between the studies. Common adverse effects were hyperlipidemia and neutropenia. CONCLUSIONS Available literature indicated that sirolimus therapy might be effective for lymphatic malformations. However, further randomized controlled studies are required to analyze the efficacy and long-term adverse events and to clarify the potential role for sirolimus in the management of lymphatic malformations.
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Affiliation(s)
- Susanne Wiegand
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
| | - Gunnar Wichmann
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
| | - Andreas Dietz
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
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18
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Borcyk K, Kamil A, Hagerty K, Deer M, Tomich P, Anderson Berry AL. Successful management of extremely high-output refractory congenital chylothorax with chemical pleurodesis using 4% povidone-iodine and propranolol: a case report. Clin Case Rep 2018; 6:702-708. [PMID: 29636944 PMCID: PMC5889237 DOI: 10.1002/ccr3.1449] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 02/01/2018] [Indexed: 02/06/2023] Open
Abstract
First‐line therapy for congenital chylothorax is conservative treatment. However, surgical intervention or chemical pleurodesis is required for refractory cases. With all the concerns regarding its complications, povidone–iodin provided a successful management for a high‐output congenital chylothorax. However, renal and thyroid function must be monitored during treatment.
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Affiliation(s)
- Kathleen Borcyk
- Pediatrics University of Nebraska Medical Center Omaha Nebraska
| | - Ammar Kamil
- Pediatrics University of Nebraska Medical Center Omaha Nebraska
| | | | - Melissa Deer
- Obstetrics and Gynecology University of Nebraska Medical Center Omaha Nebraska
| | - Paul Tomich
- Obstetrics and Gynecology University of Nebraska Medical Center Omaha Nebraska
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19
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Tu JH, Tafoya E, Jeng M, Teng JM. Long-Term Follow-Up of Lymphatic Malformations in Children Treated with Sildenafil. Pediatr Dermatol 2017; 34:559-565. [PMID: 28884903 DOI: 10.1111/pde.13237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/OBJECTIVES Lymphatic malformations (LMs) are challenging to treat. Reports on the benefits of sildenafil for LM management have been mixed. This study evaluated long-term clinical outcomes of pediatric LM patients after sildenafil treatment. METHODS A retrospective chart review was performed on pediatric LM patients treated with sildenafil in the past 5 years. Patients were also contacted to complete a survey of comprehensive questions about their LM after sildenafil and subsequent interventions. RESULTS Of 12 patients identified, 10 (83.3%) participated in the follow-up survey. The average age was 8 years (range 4-16 yrs), median treatment duration was 9 months, and the average time of follow-up after sildenafil was 4 years; one patient is still taking sildenafil. Ten patients surveyed (83.3%) reported positive therapeutic response, with improvement in the size and compressibility of their LM during posttreatment clinical visits. Six received additional interventions (four sirolimus, one sclerotherapy, one surgery) after sildenafil was discontinued, with all but one reporting a positive response to subsequent interventions. Minor side effects at the time of sildenafil treatment included mild flushing, dizziness, and transient nausea, but no adverse effects were reported at the long-term follow-up. CONCLUSION This is the first report of long-term follow-up of pediatric LM patients treated with sildenafil. Our findings suggest that sildenafil is beneficial for the symptomatic treatment of LMs. Additional analysis on the role of sildenafil as adjuvant therapy is necessary to optimize the use of this medication in the management of complex LMs.
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Affiliation(s)
- Joanna H Tu
- College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Dermatology, Stanford University, Stanford, California
| | - Elidia Tafoya
- Department of Dermatology, Stanford University, Stanford, California
| | - Michael Jeng
- Department of Hematology and Oncology, Stanford University, Stanford, California
| | - Joyce M Teng
- Department of Dermatology, Stanford University, Stanford, California
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