1
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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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2
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Kriti B, Bains A, Lahoria U, Panda A, Khera S. Violaceous plaque with lower limb paresis in an adolescent male. Pediatr Dermatol 2024; 41:753-755. [PMID: 38621692 DOI: 10.1111/pde.15610] [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: 10/10/2023] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Bhat Kriti
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Jodhpur, India
| | - Anupama Bains
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Jodhpur, India
| | - Utkrist Lahoria
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ananya Panda
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Sudeep Khera
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Jodhpur, India
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3
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Mohammed KAK, Madeddu P, Avolio E. MEK inhibitors: a promising targeted therapy for cardiovascular disease. Front Cardiovasc Med 2024; 11:1404253. [PMID: 39011492 PMCID: PMC11247000 DOI: 10.3389/fcvm.2024.1404253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/13/2024] [Indexed: 07/17/2024] Open
Abstract
Cardiovascular disease (CVD) represents the leading cause of mortality and disability all over the world. Identifying new targeted therapeutic approaches has become a priority of biomedical research to improve patient outcomes and quality of life. The RAS-RAF-MEK (mitogen-activated protein kinase kinase)-ERK (extracellular signal-regulated kinase) pathway is gaining growing interest as a potential signaling cascade implicated in the pathogenesis of CVD. This pathway is pivotal in regulating cellular processes like proliferation, growth, migration, differentiation, and survival, which are vital in maintaining cardiovascular homeostasis. In addition, ERK signaling is involved in controlling angiogenesis, vascular tone, myocardial contractility, and oxidative stress. Dysregulation of this signaling cascade has been linked to cell dysfunction and vascular and cardiac pathological remodeling, which contribute to the onset and progression of CVD. Recent and ongoing research has provided insights into potential therapeutic interventions targeting the RAS-RAF-MEK-ERK pathway to improve cardiovascular pathologies. Preclinical studies have demonstrated the efficacy of targeted therapy with MEK inhibitors (MEKI) in attenuating ERK activation and mitigating CVD progression in animal models. In this article, we first describe how ERK signaling contributes to preserving cardiovascular health. We then summarize current knowledge of the roles played by ERK in the development and progression of cardiac and vascular disorders, including atherosclerosis, myocardial infarction, cardiac hypertrophy, heart failure, and aortic aneurysm. We finally report novel therapeutic strategies for these CVDs encompassing MEKI and discuss advantages, challenges, and future developments for MEKI therapeutics.
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Affiliation(s)
- Khaled A K Mohammed
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Department of Cardiothoracic Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Paolo Madeddu
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Elisa Avolio
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Mansur A, Radovanovic I. Defining the Role of Oral Pathway Inhibitors as Targeted Therapeutics in Arteriovenous Malformation Care. Biomedicines 2024; 12:1289. [PMID: 38927496 PMCID: PMC11201820 DOI: 10.3390/biomedicines12061289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Arteriovenous malformations (AVMs) are vascular malformations that are prone to rupturing and can cause significant morbidity and mortality in relatively young patients. Conventional treatment options such as surgery and endovascular therapy often are insufficient for cure. There is a growing body of knowledge on the genetic and molecular underpinnings of AVM development and maintenance, making the future of precision medicine a real possibility for AVM management. Here, we review the pathophysiology of AVM development across various cell types, with a focus on current and potential druggable targets and their therapeutic potentials in both sporadic and familial AVM populations.
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Affiliation(s)
- Ann Mansur
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON M5S 1A8, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
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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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6
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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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7
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Seebauer CT, Wiens B, Hintschich CA, Platz Batista da Silva N, Evert K, Haubner F, Kapp FG, Wendl C, Renner K, Bohr C, Kühnel T, Vielsmeier V. Targeting the microenvironment in the treatment of arteriovenous malformations. Angiogenesis 2024; 27:91-103. [PMID: 37733132 PMCID: PMC10881762 DOI: 10.1007/s10456-023-09896-3] [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: 07/12/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Extracranial arteriovenous malformations (AVMs) are regarded as rare diseases and are prone to complications such as pain, bleeding, relentless growth, and high volume of shunted blood. Due to the high vascular pressure endothelial cells of AVMs are exposed to mechanical stress. To control symptoms and lesion growth pharmacological treatment strategies are urgently needed in addition to surgery and interventional radiology. AVM cells were isolated from three patients and exposed to cyclic mechanical stretching for 24 h. Thalidomide and bevacizumab, both VEGF inhibitors, were tested for their ability to prevent the formation of circular networks and proliferation of CD31+ endothelial AVM cells. Furthermore, the effect of thalidomide and bevacizumab on stretched endothelial AVM cells was evaluated. In response to mechanical stress, VEGF gene and protein expression increased in patient AVM endothelial cells. Thalidomide and bevacizumab reduced endothelial AVM cell proliferation. Bevacizumab inhibited circular network formation of endothelial AVM cells and lowered VEGF gene and protein expression, even though the cells were exposed to mechanical stress. With promising in vitro results, bevacizumab was used to treat three patients with unresectable AVMs or to prevent regrowth after incomplete resection. Bevacizumab controlled bleeding, pulsation, and pain over the follow up of eight months with no patient-reported side effects. Overall, mechanical stress increases VEGF expression in the microenvironment of AVM cells. The monoclonal VEGF antibody bevacizumab alleviates this effect, prevents circular network formation and proliferation of AVM endothelial cells in vitro. The clinical application of bevacizumab in AVM treatment demonstrates effective symptom control with no side effects.
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Affiliation(s)
- Caroline T Seebauer
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Benedikt Wiens
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Constantin A Hintschich
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Katja Evert
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Friedrich G Kapp
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Heiliggeiststr. 1, 79106, Freiburg im Breisgau, Germany
| | - Christina Wendl
- Institute of Radiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Kathrin Renner
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Thomas Kühnel
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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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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Sisk B, Lin S, Kerr AM. Factors affecting the ability of patients with complex vascular anomalies to navigate the healthcare system. Orphanet J Rare Dis 2024; 19:18. [PMID: 38238812 PMCID: PMC10797881 DOI: 10.1186/s13023-024-03018-y] [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: 12/16/2022] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Vascular anomalies (VAs) are rare congenital disorders that can cause pain, disfigurement, coagulopathy, asymmetric growth, and disability. Patients with complex VAs experience multiple barriers to accessing expert care. It is imperative to understand which factors support these patients' ability to navigate the healthcare system. RESULTS We surveyed adult patients with VAs using previously validated measures, recruiting participants from five patient advocacy groups and multidisciplinary VA clinics. The primary outcome was self-reported ability to access needed medical care, using the "Navigating the Healthcare System" subscale of the Health Literacy Questionnaire. We evaluated factors associated with the ability to navigate the healthcare system using multivariate linear regression (n = 136). We also performed an exploratory model that included the primary care doctor's knowledge of VAs for the subset of participants with a primary care doctor (n = 114). Participants were predominantly women (n = 90, 66%), White and non-Hispanic (n = 109, 73%), and college-educated (n = 101, 73%). Most participants had PIK3CA-Related Overgrowth Spectrum (n = 107, 78%). Most participants reported that navigating the healthcare system was "sometimes" or "usually difficult" (mean score 16.4/30, standard deviation 5.6). In multivariate linear regression, ability to navigate the healthcare system was associated positively with quality of information exchange (β = 0.38, 95% Confidence Interval (CI) 0.22 to 0.55, p <.001) and whether patients had VA specialists (β = 2.31, 95% CI 0.35 to 4.28, p =.021), but not associated with patient self-advocacy, anxiety, education, age, race and ethnicity, gender, or having a primary care doctor. In exploratory analysis of participants with primary care doctors, ability to navigate the healthcare system was positively associated with quality of information exchange (β = 0.27, 95% CI 0.09 to 0.45, p =.004), having a VA specialist (β = 2.31, 95% CI 0.22 to 4.39, p =.031), and primary care doctors' VA knowledge (β = 0.27, 95% CI 0.04 to 0.50, p =.023). CONCLUSION Patients with VAs struggle to navigate the healthcare system. High-quality information from clinicians and more knowledgeable primary care doctors might help patients to access needed care. Relying on patient self-advocacy is insufficient. Future efforts should focus on patient-directed and clinician-directed educational interventions. Additionally, future work should assess the structural barriers that impede healthcare access for these patients.
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Affiliation(s)
- Bryan Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Sunny Lin
- Informatics Institute, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Anna M Kerr
- Department of Primary Care, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA.
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Ricciardelli AR, Robledo A, Fish JE, Kan PT, Harris TH, Wythe JD. The Role and Therapeutic Implications of Inflammation in the Pathogenesis of Brain Arteriovenous Malformations. Biomedicines 2023; 11:2876. [PMID: 38001877 PMCID: PMC10669898 DOI: 10.3390/biomedicines11112876] [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: 08/29/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/26/2023] Open
Abstract
Brain arteriovenous malformations (bAVMs) are focal vascular lesions composed of abnormal vascular channels without an intervening capillary network. As a result, high-pressure arterial blood shunts directly into the venous outflow system. These high-flow, low-resistance shunts are composed of dilated, tortuous, and fragile vessels, which are prone to rupture. BAVMs are a leading cause of hemorrhagic stroke in children and young adults. Current treatments for bAVMs are limited to surgery, embolization, and radiosurgery, although even these options are not viable for ~20% of AVM patients due to excessive risk. Critically, inflammation has been suggested to contribute to lesion progression. Here we summarize the current literature discussing the role of the immune system in bAVM pathogenesis and lesion progression, as well as the potential for targeting inflammation to prevent bAVM rupture and intracranial hemorrhage. We conclude by proposing that a dysfunctional endothelium, which harbors the somatic mutations that have been shown to give rise to sporadic bAVMs, may drive disease development and progression by altering the immune status of the brain.
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Affiliation(s)
- Ashley R. Ricciardelli
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ariadna Robledo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.R.)
| | - Jason E. Fish
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada;
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5G 2N2, Canada
| | - Peter T. Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.R.)
| | - Tajie H. Harris
- Department of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA 22903, USA;
- Brain, Immunology, and Glia (BIG) Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Joshua D. Wythe
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA 22903, USA;
- Brain, Immunology, and Glia (BIG) Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
- Robert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
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11
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Sudduth CL, Smits PJ, Vivero MP, Cheng YS, Ad M, Konczyk DJ, Bischoff J, Warman ML, Greene AK. Arteriovenous malformation Map2k1 mutation affects vasculogenesis. Sci Rep 2023; 13:11074. [PMID: 37422456 PMCID: PMC10329712 DOI: 10.1038/s41598-023-35301-6] [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: 12/20/2022] [Accepted: 05/16/2023] [Indexed: 07/10/2023] Open
Abstract
Somatic activating MAP2K1 mutations in endothelial cells (ECs) cause extracranial arteriovenous malformation (AVM). We previously reported the generation of a mouse line allowing inducible expression of constitutively active MAP2K1 (p.K57N) from the Rosa locus (R26GT-Map2k1-GFP/+) and showed, using Tg-Cdh5CreER, that EC expression of mutant MAP2K1 is sufficient for the development of vascular malformations in the brain, ear, and intestines. To gain further insight into the mechanism by which mutant MAP2K1 drives AVM development, we induced MAP2K1 (p.K57N) expression in ECs of postnatal-day-1 pups (P1) and investigated the changes in gene expression in P9 brain ECs by RNA-seq. We found that over-expression of MAP2K1 altered the transcript abundance of > 1600 genes. Several genes had > 20-fold changes between MAP2K1 expressing and wild-type ECs; the highest were Col15a1 (39-fold) and Itgb3 (24-fold). Increased expression of COL15A1 in R26GT-Map2k1-GFP/+; Tg-Cdh5CreER+/- brain ECs was validated by immunostaining. Ontology showed that differentially expressed genes were involved in processes important for vasculogenesis (e.g., cell migration, adhesion, extracellular matrix organization, tube formation, angiogenesis). Understanding how these genes and pathways contribute to AVM formation will help identify targets for therapeutic intervention.
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Affiliation(s)
- Christopher L Sudduth
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Patrick J Smits
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Matthew P Vivero
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Yu Sheng Cheng
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Michal Ad
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Dennis J Konczyk
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Joyce Bischoff
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew L Warman
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA.
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12
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Bertino FJ, Hawkins CM. Contemporary management of extracranial vascular malformations. Pediatr Radiol 2023; 53:1600-1617. [PMID: 37156889 DOI: 10.1007/s00247-023-05670-1] [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: 11/15/2022] [Revised: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
Vascular malformations are congenital vascular anomalies that originate because of disorganized angiogenesis, most commonly from spontaneous somatic genetic mutations. The modern management of vascular malformations requires a multidisciplinary team that offers patients the gamut of medical, surgical, and percutaneous treatment options with supportive care. This manuscript discusses the standard and contemporary management strategies surrounding extracranial vascular malformations and overgrowth syndromes.
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Affiliation(s)
- Frederic J Bertino
- Department of Radiology, Interventional Radiology Section, NYU Langone Health/NYU Grossman School of Medicine, 2nd Floor Radiology-Tisch Hospital, 550 First Avenue, New York, NY, 10016, USA.
| | - C Matthew Hawkins
- Department of Radiology, Division of Interventional Radiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA, USA
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13
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Kahle KT, Duran D, Smith ER. Increasing precision in the management of pediatric neurosurgical cerebrovascular diseases with molecular genetics. J Neurosurg Pediatr 2023; 31:228-237. [PMID: 36609371 DOI: 10.3171/2022.12.peds22332] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023]
Abstract
Recent next-generation DNA and RNA sequencing studies of congenital and pediatric cerebrovascular anomalies such as moyamoya disease, arteriovenous malformations, vein of Galen malformations, and cavernous malformations have shed new insight into the genetic regulation of human cerebrovascular development by implicating multiple novel disease genes and signaling pathways in the pathogenesis of these disorders. These diseases are now beginning to be categorized by molecular disruptions in canonical signaling pathways that impact the differentiation and proliferation of specific venous, capillary, or arterial cells during the hierarchical development of the cerebrovascular system. Here, the authors discuss how the continued study of these and other congenital cerebrovascular conditions has the potential to replace the current antiquated, anatomically based disease classification systems with a molecular taxonomy that has the potential to increase precision in genetic counseling, prognostication, and neurosurgical and endovascular treatment stratification. Importantly, the authors also discuss how molecular genetic data are already informing clinical trials and catalyzing the development of targeted therapies for these conditions historically considered as exclusively neurosurgical lesions.
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Affiliation(s)
- Kristopher T Kahle
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
- 2Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston
- 3Division of Genetics and Genomics, Boston Children's Hospital, Boston
- 4Broad Institute of MIT and Harvard, Cambridge, Massachusetts; and
| | - Daniel Duran
- 5Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Edward R Smith
- 2Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston
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14
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Aw WY, Cho C, Wang H, Cooper AH, Doherty EL, Rocco D, Huang SA, Kubik S, Whitworth CP, Armstrong R, Hickey AJ, Griffith B, Kutys ML, Blatt J, Polacheck WJ. Microphysiological model of PIK3CA-driven vascular malformations reveals a role of dysregulated Rac1 and mTORC1/2 in lesion formation. SCIENCE ADVANCES 2023; 9:eade8939. [PMID: 36791204 PMCID: PMC9931220 DOI: 10.1126/sciadv.ade8939] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/13/2023] [Indexed: 05/09/2023]
Abstract
Somatic activating mutations of PIK3CA are associated with development of vascular malformations (VMs). Here, we describe a microfluidic model of PIK3CA-driven VMs consisting of human umbilical vein endothelial cells expressing PIK3CA activating mutations embedded in three-dimensional hydrogels. We observed enlarged, irregular vessel phenotypes and the formation of cyst-like structures consistent with clinical signatures and not previously observed in cell culture models. Pathologic morphologies occurred concomitant with up-regulation of Rac1/p21-activated kinase (PAK), mitogen-activated protein kinase cascades (MEK/ERK), and mammalian target of rapamycin (mTORC1/2) signaling networks. We observed differential effects between alpelisib, a PIK3CA inhibitor, and rapamycin, an mTORC1 inhibitor, in mitigating matrix degradation and network topology. While both were effective in preventing vessel enlargement, rapamycin failed to reduce MEK/ERK and mTORC2 activity and resulted in hyperbranching, while inhibiting PAK, MEK1/2, and mTORC1/2 mitigates abnormal growth and vascular dilation. Collectively, these findings demonstrate an in vitro platform for VMs and establish a role of dysregulated Rac1/PAK and mTORC1/2 signaling in PIK3CA-driven VMs.
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Affiliation(s)
- Wen Yih Aw
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
- UNC Catalyst for Rare Diseases, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Crescentia Cho
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
| | - Hao Wang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
| | - Anne Hope Cooper
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
| | - Elizabeth L. Doherty
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
- UNC Catalyst for Rare Diseases, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David Rocco
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Stephanie A. Huang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
| | - Sarah Kubik
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
| | - Chloe P. Whitworth
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
- Department of Genetics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Ryan Armstrong
- Department of Physics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony J. Hickey
- UNC Catalyst for Rare Diseases, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Boyce Griffith
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
- Department of Mathematics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Computational Medicine Program, University of North Carolina, Chapel Hill, NC, USA
- McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew L. Kutys
- Department of Cell and Tissue Biology, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Blatt
- Department of Pediatrics (Division of Pediatric Hematology Oncology), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William J. Polacheck
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA and North Carolina State University, Raleigh, NC, USA
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
- McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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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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16
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Nguyen HL, Boon LM, Vikkula M. Trametinib as a promising therapeutic option in alleviating vascular defects in an endothelial KRAS-induced mouse model. Hum Mol Genet 2023; 32:276-289. [PMID: 35972810 DOI: 10.1093/hmg/ddac169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 01/18/2023] Open
Abstract
Somatic activating Kirsten rat sarcoma viral oncogene homologue (KRAS) mutations have been reported in patients with arteriovenous malformations. By producing LSL-Kras (G12D); Cdh5 (PAC)-CreERT2 [iEC-Kras (G12D*)] mice, we hoped to activate KRAS within vascular endothelial cells (ECs) to generate an arteriovenous malformation mouse model. Neonatal mice were treated daily with tamoxifen from postnatal (PN) days 1-3. Mortality and phenotypes varied amongst iEC-Kras (G12D*) pups, with only 31.5% surviving at PN14. Phenotypes (focal lesions, vessel dilations) developed in a consistent manner, although with unpredictable severity within multiple soft tissues (such as the brain, liver, heart and brain). Overall, iEC-Kras (G12D*) pups developed significantly larger vascular lumen areas compared with control littermates, beginning at PN8. We subsequently tested whether the MEK inhibitor trametinib could effectively alleviate lesion progression. At PN16, iEC-Kras (G12D*) pup survival improved to 76.9%, and average vessel sizes were closer to controls than in untreated and vehicle-treated mutants. In addition, trametinib treatment helped normalize iEC-Kras (G12D*) vessel morphology in PN14 brains. Thus, trametinib could act as an effective therapy for KRAS-induced vascular malformations in patients.
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Affiliation(s)
- Ha-Long Nguyen
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium
| | - Laurence M Boon
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, 1200 Brussels, Belgium
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, 1200 Brussels, Belgium
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17
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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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18
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Shimano KA, Eng W, Adams DM. How we approach the use of sirolimus and new agents: Medical therapy to treat vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29603. [PMID: 35253343 DOI: 10.1002/pbc.29603] [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: 09/19/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Vascular anomalies (VAs) are a heterogeneous group of primarily congenital tumors and malformations. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis. Recent discoveries evaluating the genetic causes of VAs have revealed that they are due to mutations in cancer pathways, including the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. These discoveries have led to improved phenotype-genotype correlation and have expanded medical therapy for this group of unique disorders.
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Affiliation(s)
- Kristin A Shimano
- Division of Allergy, Immunology, and Bone Marrow Transplant, UCSF Benioff Children's Hospital, University of California, San Francisco, California, USA
| | - Whitney Eng
- Division of Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Denise M Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program/Frontier Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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19
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Dawkins D, Motiwala M, Peterson J, Gleysteen J, Fowler B, Arthur A, Elijovich L. Head and neck arteriovenous malformations: University of Tennessee experience, 2012–2022. Neurosurg Focus 2022; 53:E17. [DOI: 10.3171/2022.4.focus22123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Head and neck arteriovenous malformations (AVMs) are complex lesions that represent a subset of vascular anomalies (VAs). The authors present an analysis of their institutional experience managing these lesions as a multidisciplinary team.
METHODS
A retrospective chart review was performed of head and neck AVM patients treated at the authors’ institution from 2012 to 2022. Recorded data included patient demographic characteristics, details of clinical presentation, Schöbinger clinical scale and Yakes AVM classification results, and details of all endovascular and surgical treatments. The primary outcome of the study was clinical response to treatment. Angiographic occlusion and complication rates were reported. Chi-square tests were used for comparative statistics.
RESULTS
Sixteen patients (9 female, 56%) with AVMs of the head and neck presented from age 3 to 77 years. The Schöbinger stage was stage II in 56% of patients (n = 9) and stage III in 44% of patients (n = 7). The Yakes AVM classification was nidus type (2a, 2b, or 4) in 7 patients (43%) and fistula type (1, 3a, or 3b) in 9 patients (57%). The majority of patients (n = 11, 69.0%) were managed with embolization as the only treatment modality, with an average of 1.5 embolizations/patient (range 1–3). Surgical resection was employed in 5 patients (4 in combination with embolization). Symptom resolution and symptom control were achieved in 69% and 31% of patients, respectively, in the entire cohort. A radiographic cure was demonstrated in 50% of patients. There were no statistical differences in clinical outcomes or radiographic cure rates between patients treated with different modalities.
CONCLUSIONS
Head and neck AVMs can be treated successfully with a primarily endovascular management strategy by a multidisciplinary team with the goal of symptomatic control.
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Affiliation(s)
- Demi Dawkins
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Mustafa Motiwala
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Jeremy Peterson
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | - Adam Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, Tennessee
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20
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Winkler EA, Pacult MA, Catapano JS, Scherschinski L, Srinivasan VM, Graffeo CS, Oh SP, Lawton MT. Emerging pathogenic mechanisms in human brain arteriovenous malformations: a contemporary review in the multiomics era. Neurosurg Focus 2022; 53:E2. [DOI: 10.3171/2022.4.focus2291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/18/2022] [Indexed: 11/06/2022]
Abstract
A variety of pathogenic mechanisms have been described in the formation, maturation, and rupture of brain arteriovenous malformations (bAVMs). While the understanding of bAVMs has largely been formulated based on animal models of rare hereditary diseases in which AVMs form, a new era of “omics” has permitted large-scale examinations of contributory genetic variations in human sporadic bAVMs. New findings regarding the pathogenesis of bAVMs implicate changes to endothelial and mural cells that result in increased angiogenesis, proinflammatory recruitment, and breakdown of vascular barrier properties that may result in hemorrhage; a greater diversity of cell populations that compose the bAVM microenvironment may also be implicated and complicate traditional models. Genomic sequencing of human bAVMs has uncovered inherited, de novo, and somatic activating mutations, such as KRAS, which contribute to the pathogenesis of bAVMs. New droplet-based, single-cell sequencing technologies have generated atlases of cell-specific molecular derangements. Herein, the authors review emerging genomic and transcriptomic findings underlying pathologic cell transformations in bAVMs derived from human tissues. The application of multiple sequencing modalities to bAVM tissues is a natural next step for researchers, although the potential therapeutic benefits or clinical applications remain unknown.
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Affiliation(s)
- Ethan A. Winkler
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - Mark A. Pacult
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - Joshua S. Catapano
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - Lea Scherschinski
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - Visish M. Srinivasan
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - Christopher S. Graffeo
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
| | - S. Paul Oh
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
- Barrow Aneurysm and AVM Research Center, Department of Translational Neuroscience, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix; and
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21
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Coulie J, Boon L, Vikkula M. Molecular Pathways and Possible Therapies for Head and Neck Vascular Anomalies. J Oral Pathol Med 2022; 51:878-887. [PMID: 35610188 DOI: 10.1111/jop.13318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
Vascular Anomalies are a heterogenous group of vascular lesions that can be divided, according to the International Society for the Study of Vascular Anomalies Classification, into two main groups : Vascular Tumors and Vascular Malformations. Vascular Malformations can be further subdivided into slow-flow and fast-flow malformations. This clinical and radiological classification allows for a better understanding of vascular anomalies and aims to offer a more precise final diagnosis. Correct diagnosis is essential to propose the best treatment, which traditionally consists of surgery, embolization or sclerotherapy. Since a few years, medical treatment has become an important part of multidisciplinary treatment. Genetic and molecular knowledge of vascular anomalies are increasing rapidly and opens the door for a molecular classification of vascular anomalies according to the underlying pathways involved. The main pathways seem to be: PI3K/AKT/mTOR (PIKopathies) and RAS/RAF/MEK/ERK (RASopathies). Knowing the underlying molecular cascades allows us to use targeted medical therapies. The first part of this article aims to review the vascular anomalies seen in the head and neck region and their underlying molecular causes and involved pathways. The second part will propose an overview of the available targeted therapies based on the affected molecular cascade. This article summarizes theragnostic treatments available in vascular anomalies.
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Affiliation(s)
- Julien Coulie
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Laurence Boon
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Miikka Vikkula
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
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22
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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23
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El Sissy FN, Wassef M, Faucon B, Salvan D, Nadaud S, Coulet F, Adle-Biassette H, Soubrier F, Bisdorff A, Eyries M. Somatic Mutational Landscape of Extracranial Arteriovenous Malformations and Phenotypic Correlations. J Eur Acad Dermatol Venereol 2022; 36:905-912. [PMID: 35238086 DOI: 10.1111/jdv.18046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Somatic genetic variants may be the cause of extracranial arteriovenous malformations, but few studies have explored these genetic anomalies, and no genotype-phenotype correlations have been identified. OBJECTIVES To characterize the somatic genetic landscape of extracranial arteriovenous malformations and correlate these findings with the phenotypic characteristics of these lesions. METHODS This study included twenty-three patients with extracranial arteriovenous malformations that were confirmed clinically and treated by surgical resection, and for whom frozen tissue samples were available. Targeted next-generation sequencing analysis of tissues was performed using a gene panel that included vascular disease-related genes and tumor-related genes. RESULTS We identified a pathogenic variant in 18 out of 23 samples (78.3%). Pathogenic variants were mainly located in MAP2K1 (n=7) and KRAS (n=6), and more rarely in BRAF (n=2) and RASA1 (n=3). KRAS variants were significantly (p<0.005) associated with severe extended facial arteriovenous malformations, for which relapse after surgical resection is frequently observed, while MAP2K1 variants were significantly (p<0.005) associated with less severe, limited arteriovenous malformations located on the lips. CONCLUSIONS Our study highlights a high prevalence of pathogenic somatic variants, predominantly in MAP2K1 and KRAS, in extracranial arteriovenous malformations. In addition, our study identifies for the first time a correlation between the genotype, clinical severity and angiographic characteristics of extracranial arteriovenous malformations. The RAS/MAPK variants identified in this study are known to be associated with malignant tumors for which targeted therapies have already been developed. Thus, identification of these somatic variants could lead to new therapeutic options to improve the management of patients with extracranial arteriovenous malformations.
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Affiliation(s)
- F N El Sissy
- Sorbonne Université, Département de génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France.,Department of Pathology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, Faculty of Medicine, Paris, France
| | - M Wassef
- Department of Pathology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, Faculty of Medicine, Paris, France
| | - B Faucon
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - D Salvan
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - S Nadaud
- Sorbonne Université, INSERM, UMR_S1166, Unité de recherche sur les maladies cardiovasculaires, ICAN, le métabolisme et la nutrition, Paris, France
| | - F Coulet
- Sorbonne Université, Département de génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
| | - H Adle-Biassette
- Department of Pathology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, Faculty of Medicine, Paris, France
| | - F Soubrier
- Sorbonne Université, Département de génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France.,Sorbonne Université, INSERM, UMR_S1166, Unité de recherche sur les maladies cardiovasculaires, ICAN, le métabolisme et la nutrition, Paris, France
| | - A Bisdorff
- Department of Neuroradiology, Lariboisère Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Eyries
- Sorbonne Université, Département de génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France.,Sorbonne Université, INSERM, UMR_S1166, Unité de recherche sur les maladies cardiovasculaires, ICAN, le métabolisme et la nutrition, Paris, France
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24
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Somatic activating BRAF variants cause isolated lymphatic malformations. HGG ADVANCES 2022; 3:100101. [PMID: 35373151 PMCID: PMC8972000 DOI: 10.1016/j.xhgg.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/10/2022] [Indexed: 11/20/2022] Open
Abstract
Somatic activating variants in PIK3CA, the gene that encodes the p110α catalytic subunit of phosphatidylinositol 3-kinase (PI3K), have been previously detected in ∼80% of lymphatic malformations (LMs).1,2 We report the presence of somatic activating variants in BRAF in individuals with LMs that do not possess pathogenic PIK3CA variants. The BRAF substitution p.Val600Glu (c.1799T>A), one of the most common driver mutations in cancer, was detected in multiple individuals with LMs. Histology revealed abnormal lymphatic channels with immunopositivity for BRAFV600E in endothelial cells that was otherwise indistinguishable from PIK3CA-positive LM. The finding that BRAF variants contribute to low-flow LMs increases the complexity of prior models associating low-flow vascular malformations (LM and venous malformations) with mutations in the PI3K-AKT-MTOR and high-flow vascular malformations (arteriovenous malformations) with mutations in the RAS-mitogen-activated protein kinase (MAPK) pathway.3 In addition, this work highlights the importance of genetic diagnosis prior to initiating medical therapy as more studies examine therapeutics for individuals with vascular malformations.
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25
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Systemic Therapy for Vascular Anomalies and the Emergence of Genotype-Guided Management. Dermatol Clin 2022; 40:127-136. [DOI: 10.1016/j.det.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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26
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Ng AT, Tower RL, Drolet BA. Targeted treatment of vascular anomalies. Int J Womens Dermatol 2022; 7:636-639. [PMID: 35024417 PMCID: PMC8721128 DOI: 10.1016/j.ijwd.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022] Open
Abstract
Vascular anomalies comprise an array of congenital developmental disorders that can lead to significant disfigurement and physiologic disarray. The vast multitude of clinical phenotypes has inherently led to misdiagnosis and patients and families enduring long diagnostic odysseys of medical care. Although the observed variation in disease manifestations remains poorly understood, targeted next-generation sequencing has pivoted our understanding of the pathobiology of vascular anomalies and, for the first time, uncovered potential pharmacologic targets for these disorders. In this review article, we highlight current and developing targeted therapies for vascular anomalies, namely phosphoinositide 3-kinase and mitogen-activated protein kinase pathway inhibitors, and discuss the future directions of targeted therapies.
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Affiliation(s)
- Ashley T Ng
- Department of Dermatology School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Richard L Tower
- Department of Pediatrics, Medical College of Wisconsin, Madison, Wisconsin
| | - Beth A Drolet
- Department of Dermatology School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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27
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Pan P, Weinsheimer S, Cooke D, Winkler E, Abla A, Kim H, Su H. Review of treatment and therapeutic targets in brain arteriovenous malformation. J Cereb Blood Flow Metab 2021; 41:3141-3156. [PMID: 34162280 PMCID: PMC8669284 DOI: 10.1177/0271678x211026771] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
Brain arteriovenous malformations (bAVM) are an important cause of intracranial hemorrhage (ICH), especially in younger patients. The pathogenesis of bAVM are largely unknown. Current understanding of bAVM etiology is based on studying genetic syndromes, animal models, and surgically resected specimens from patients. The identification of activating somatic mutations in the Kirsten rat sarcoma viral oncogene homologue (KRAS) gene and other mitogen-activated protein kinase (MAPK) pathway genes has opened up new avenues for bAVM study, leading to a paradigm shift to search for somatic, de novo mutations in sporadic bAVMs instead of focusing on inherited genetic mutations. Through the development of new models and understanding of pathways involved in maintaining normal vascular structure and functions, promising therapeutic targets have been identified and safety and efficacy studies are underway in animal models and in patients. The goal of this paper is to provide a thorough review or current diagnostic and treatment tools, known genes and key pathways involved in bAVM pathogenesis to summarize current treatment options and potential therapeutic targets uncovered by recent discoveries.
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Affiliation(s)
- Peipei Pan
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Shantel Weinsheimer
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Daniel Cooke
- Department of Radiology, University of California, San Francisco, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California, San Francisco, USA
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
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28
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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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29
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Durán-Romero AJ, Hernández-Rodríguez JC, Ortiz-Álvarez J, Domínguez-Cruz JJ, Monserrat-García MT, Conejo-Mir Sánchez J, Bernabeu-Wittel J. Efficacy and safety of oral sirolimus for high-flow vascular malformations in real clinical practice. Clin Exp Dermatol 2021; 47:57-62. [PMID: 34240451 DOI: 10.1111/ced.14841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Vascular malformations are a complex pathology with few treatment options. In previously published studies, oral sirolimus (rapamycin) has shown promising results in the treatment of low-flow vascular malformations, but its usefulness in high-flow vascular malformations is controversial. AIM To evaluate the efficacy and safety of sirolimus for the treatment of high-flow vascular malformations in real-life practice. METHODS In a unit specializing in vascular anomalies, patients treated with oral sirolimus for high-flow vascular malformations were located by consulting the drug dispensations. Reviewing the electronic medical records, data on patient demographics, vascular malformation characteristics, treatments, toxicity and clinical course were collected and statistically analysed. RESULTS Nine patients with vascular malformations were included: eight had arteriovenous malformation and one had arteriovenous fistula. Six of these malformations were isolated while three were part of a syndrome. Sirolimus was initiated at a dosage of 1-4 mg/day to be taken as a single dose. Partial response was observed in eight of the nine patients (88.9%) with high-flow vascular malformation, while worsening was observed in the remaining patient. The treatment was well tolerated and at the most recent follow-up, five patients remained on treatment with oral sirolimus. CONCLUSION Our results show that oral sirolimus is a well-tolerated therapeutic option, with an excellent safety profile, which can be useful in the long-term stabilization of patients with high-flow vascular malformations. Single-daily dosage may improve long-term adherence to treatment without worsening its effectiveness.
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Affiliation(s)
- A J Durán-Romero
- Department of Dermatology, University Hospital Virgen del Rocío, Seville, Spain
| | | | - J Ortiz-Álvarez
- Department of Dermatology, University Hospital Virgen del Rocío, Seville, Spain
| | - J J Domínguez-Cruz
- Department of Dermatology, University Hospital Virgen del Rocío, Seville, Spain
| | | | | | - J Bernabeu-Wittel
- Department of Dermatology, University Hospital Virgen del Rocío, Seville, Spain
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30
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Affiliation(s)
- Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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31
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Muster R, Ko N, Smith W, Su H, Dickey MA, Nelson J, McCulloch CE, Sneed PK, Clarke JL, Saloner DA, Eisenmenger L, Kim H, Cooke DL. Proof-of-concept single-arm trial of bevacizumab therapy for brain arteriovenous malformation. BMJ Neurol Open 2021; 3:e000114. [PMID: 34189463 PMCID: PMC8204171 DOI: 10.1136/bmjno-2020-000114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/13/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are relatively rare, although their potential for secondary intracranial haemorrhage (ICH) makes their diagnosis and management essential to the community. Currently, invasive therapies (surgical resection, stereotactic radiosurgery and endovascular embolisation) are the only interventions that offer a reduction in ICH risk. There is no designated medical therapy for bAVM, although there is growing animal and human evidence supporting a role for bevacizumab to reduce the size of AVMs. In this single-arm pilot study, two patients with large bAVMs (deemed unresectable by an interdisciplinary team) received bevacizumab 5 mg/kg every 2 weeks for 12 weeks. Due to limitations of external funding, the intended sample size of 10 participants was not reached. Primary outcome measure was change in bAVM volume from baseline at 26 and 52 weeks. No change in bAVM volume was observed 26 or 52 weeks after bevacizumab treatment. No clinically important adverse events were observed during the 52-week study period. There were no observed instances of ICH. Sera vascular endothelial growth factor levels were reduced at 26 weeks and returned to baseline at 52 weeks. This pilot study is the first to test bevacizumab for patients with bAVMs. Bevacizumab therapy was well tolerated in both subjects. No radiographic changes were observed over the 52-week study period. Subsequent larger clinical trials are in order to assess for dose-dependent efficacy and rarer adverse drug effects. Trial registration number: NCT02314377.
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Affiliation(s)
- Rachel Muster
- School of Medicine, UCSF, San Francisco, California, USA
| | - Nerissa Ko
- Neurology, UCSF, San Francisco, California, USA
| | - Wade Smith
- Neurology, UCSF, San Francisco, California, USA
| | - Hua Su
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | - Melissa A Dickey
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Jeffrey Nelson
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | | | | | | | - David A Saloner
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | | | - Helen Kim
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | - Daniel L Cooke
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
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32
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Raper DMS, Winkler EA, Rutledge WC, Cooke DL, Abla AA. An Update on Medications for Brain Arteriovenous Malformations. Neurosurgery 2021; 87:871-878. [PMID: 32433738 DOI: 10.1093/neuros/nyaa192] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/17/2020] [Indexed: 02/07/2023] Open
Abstract
Despite a variety of treatment options for brain arteriovenous malformations (bAVMs), many lesions remain challenging to treat and present significant ongoing risk for hemorrhage. In Vitro investigations have recently led to a greater understanding of the formation, growth, and rupture of bAVMs. This has, in turn, led to the development of therapeutic targets for medications for bAVMs, some of which have begun testing in clinical trials in humans. These include bevacizumab, targeting the vascular endothelial growth factor driven angiogenic pathway; thalidomide or lenalidomide, targeting blood-brain barrier impairment; and doxycycline, targeting matrix metalloproteinase overexpression. A variety of other medications appear promising but either requires adaptation from other disease states or development from early bench studies into the clinical realm. This review aims to provide an overview of the current state of development of medications targeting bAVMs and to highlight their likely applications in the future.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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33
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Gallant SC, Chewning RH, Orbach DB, Trenor CC, Cunningham MJ. Contemporary Management of Vascular Anomalies of the Head and Neck-Part 1: Vascular Malformations: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:197-206. [PMID: 33237296 DOI: 10.1001/jamaoto.2020.4353] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options. Observations Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype. Conclusions and Relevance Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists-head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.
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Affiliation(s)
- Sara C Gallant
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
| | - Rush H Chewning
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Darren B Orbach
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cameron C Trenor
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Cunningham
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
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34
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Bameri O, Salarzaei M, Parooie F. KRAS/BRAF mutations in brain arteriovenous malformations: A systematic review and meta-analysis. Interv Neuroradiol 2021; 27:539-546. [PMID: 33401991 DOI: 10.1177/1591019920982810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Somatic KRAS mutations have been identified in the majority of brain arteriovenous malformations (AVM) specimens. The aim of our study was to evaluate the prevalence of Kirsten rat sarcoma (KRAS)/murine sarcoma viral oncogene homolog B1 (BRAF) mutations in brain AVM. METHODS A systematic literature review was performed in November 2019. We reviewed MEDLINE/PubMed, Cochrane Library, and ClinicalTrials.gov for citation or ongoing trials from January 2010 to March 2020. RESULTS 6 studies were identified as meeting the inclusion criteria of this review. The total frequency of KRAS mutations in 1726 patients with AVM was 55%. The prevalence of BRAF mutation was 7.5%. The prevalence of AVMs with grade 2 was the most (39%). Frontal and parietal lobes were the commonest sites of AVMs (21%). the most prevalent presentation of patients with AVM was hemorrhage (62%). CONCLUSION Our findings support a high prevalence of somatic activating mutations in KRAS and less commonly, BRAF in the overwhelming majority of brain AVMs. Practically and importantly, this pathway homogeneity in CNS arteriovenous malformations also supports the development of targeted therapies with RAS/RAF pathway inhibitors. However, more studies are needed to confirm this hypothesis.
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Affiliation(s)
- Omid Bameri
- Department of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Morteza Salarzaei
- Department of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Fateme Parooie
- Department of Medicine, Zabol University of Medical Sciences, Zabol, Iran
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35
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Narsinh KH, Gautam A, Baker A, Cooke DL, Dowd CF. Vascular anomalies: Classification and management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:345-360. [PMID: 33272404 DOI: 10.1016/b978-0-444-64034-5.00003-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Vascular anomalies are broadly classified into two major categories: vascular tumors and vascular malformations. Most vascular anomalies are caused by sporadic mosaic gene mutations, and recent genetic studies have advanced our understanding of the molecular pathways involved in their pathogenesis. These findings have suggested new therapeutic approaches to vascular anomalies, focusing on their pathogenetic mechanism. This chapter seeks to integrate an improved molecular understanding within the updated classification system of the International Society for Study of Vascular Anomalies. We emphasize the genetic, radiologic, and interventional aspects of diagnosis and management in hopes of allowing improved multidisciplinary collaboration surrounding these complex and interesting anomalies.
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Affiliation(s)
- Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Ayushi Gautam
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Christopher F Dowd
- Departments of Radiology and Biomedical Imaging, Neurological Surgery, Neurology, and Anesthesia and Perioperative Care, University of California San Francisco, School of Medicine, San Francisco, CA, United States.
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36
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Hoeger PH. Genes and phenotypes in vascular malformations. Clin Exp Dermatol 2020; 46:495-502. [PMID: 33368487 DOI: 10.1111/ced.14513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022]
Abstract
Vascular malformations (VMs) are caused by localized defects of vascular development. Most VMs are due to sporadic, postzygotic mutations, while some are the result of autosomal dominant germline mutations. Genotype-phenotype correlation is influenced by many factors. Individual genes can induce different phenotypes (pleiotropy), and similar phenotypes can be due to different genes/mutations (redundancy). The phenotypic spectrum of somatic mutations is wide, and depends on variant allele frequency, timing during embryogenesis, cell type(s) involved and type of mutation. The phenotype of germline mutations is determined by penetrance and expressivity, and is influenced by epigenetic factors (DNA methylation, histone modification) or 'second-hit' somatic mutations. Except for disorders with pathognomonic phenotypes such as Proteus syndrome or a characteristic constellation of symptoms such as CLOVES [congenital lipomatous (fatty) overgrowth, vascular malformations, epidermal naevi and scoliosis/skeletal/spinal anomalies] or PIK3CA-related overgrowth spectrum syndrome, differential diagnosis of VM is therefore difficult. It will be greatly facilitated with increasing analytic sensitivity of sequencing techniques such as next-generation sequencing. High-sensitivity molecular techniques are a prerequisite for targeted pharmacotherapy, i.e. selective therapeutic inhibition of activating mutations underlying VM, which has shown promising results in preliminary studies.
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Affiliation(s)
- P H Hoeger
- Department of Paediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
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Höger PH. Vaskuläre Malformationen: neue Behandlungsansätze. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01096-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Harwin J, Sugi MD, Hetts SW, Conrad MB, Ohliger MA. The Role of Liver Imaging in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113750. [PMID: 33233377 PMCID: PMC7700186 DOI: 10.3390/jcm9113750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder characterized by spontaneous epistaxis, telangiectasia, and visceral vascular malformations. Hepatic vascular malformations are common, though a minority are symptomatic. Symptoms are dependent on the severity and exact type of shunting caused by the hepatic malformation: Arteriosystemic shunting leads to manifestations of high output cardiac failure, and arterioportal shunting leads to portal hypertension. Radiologic imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), is an important tool for assessing liver involvement. Doppler ultrasonography is the first-line screening modality for HHT-related liver disease, and it has a standardized scale. Imaging can determine whether shunting is principally to the hepatic vein or the portal vein, which can be a key determinant of patients’ symptoms. Liver-related complications can be detected, including manifestations of portal hypertension, focal liver masses as well as ischemic cholangiopathy. Ultrasound and MRI also have the ability to quantify blood flow through the liver, which in the future may be used to determine prognosis and direct antiangiogenic therapy.
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Affiliation(s)
- Joelle Harwin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
| | - Mark D. Sugi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Miles B. Conrad
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael A. Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Correspondence:
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