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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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Champion JD, Dodd KM, Lam HC, Alzahrani MAM, Seifan S, Rad E, Scourfield DO, Fishel ML, Calver BL, Ager A, Henske EP, Davies DM, Kelley MR, Tee AR. Drug Inhibition of Redox Factor-1 Restores Hypoxia-Driven Changes in Tuberous Sclerosis Complex 2 Deficient Cells. Cancers (Basel) 2022; 14:6195. [PMID: 36551683 PMCID: PMC9776744 DOI: 10.3390/cancers14246195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/17/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Therapies with the mechanistic target of rapamycin complex 1 (mTORC1) inhibitors are not fully curative for tuberous sclerosis complex (TSC) patients. Here, we propose that some mTORC1-independent disease facets of TSC involve signaling through redox factor-1 (Ref-1). Ref-1 possesses a redox signaling activity that stimulates the transcriptional activity of STAT3, NF-kB, and HIF-1α, which are involved in inflammation, proliferation, angiogenesis, and hypoxia, respectively. Here, we demonstrate that redox signaling through Ref-1 contributes to metabolic transformation and tumor growth in TSC cell model systems. In TSC2-deficient cells, the clinically viable Ref-1 inhibitor APX3330 was effective at blocking the hyperactivity of STAT3, NF-kB, and HIF-1α. While Ref-1 inhibitors do not inhibit mTORC1, they potently block cell invasion and vasculature mimicry. Of interest, we show that cell invasion and vasculature mimicry linked to Ref-1 redox signaling are not blocked by mTORC1 inhibitors. Metabolic profiling revealed that Ref-1 inhibitors alter metabolites associated with the glutathione antioxidant pathway as well as metabolites that are heavily dysregulated in TSC2-deficient cells involved in redox homeostasis. Therefore, this work presents Ref-1 and associated redox-regulated transcription factors such as STAT3, NF-kB, and HIF-1α as potential therapeutic targets to treat TSC, where targeting these components would likely have additional benefits compared to using mTORC1 inhibitors alone.
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Affiliation(s)
- Jesse D. Champion
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Kayleigh M. Dodd
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Hilaire C. Lam
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Sara Seifan
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Ellie Rad
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | | | - Melissa L. Fishel
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brian L. Calver
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Ann Ager
- Division of Infection and Immunity, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
| | - Elizabeth P. Henske
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David Mark Davies
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
- Department of Oncology, South West Wales Cancer Centre, Singleton Hospital, Swansea SA2 8QA, UK
| | - Mark R. Kelley
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Andrew R. Tee
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
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Sadowski K, Sijko K, Domańska-Pakieła D, Borkowska J, Chmielewski D, Ulatowska A, Józwiak S, Kotulska K. Antiepileptic Effect and Safety Profile of Rapamycin in Pediatric Patients With Tuberous Sclerosis Complex. Front Neurol 2022; 13:704978. [PMID: 35572924 PMCID: PMC9100395 DOI: 10.3389/fneur.2022.704978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Epilepsy develops in 70–90% of children with Tuberous Sclerosis Complex (TSC) and is often resistant to medication. Treatment with mTOR pathway inhibitors is an important therapeutic option in drug-resistant epilepsy associated with TSC. Our study evaluated the antiepileptic effect of rapamycin in the pediatric population of patients diagnosed with TSC. Methods This single center, open-label study evaluated safety and anti-epileptic efficacy of 12 months of rapamycin treatment in 32 patients aged from 11 months to 14 years with drug-resistant TSC- associated epilepsy. Results After the first 6 months of treatment, the improvement in seizure frequency, defined as at least a 50% reduction in the number of seizures per week compared to baseline, was seen in 18 individuals (56.25%). We observed no change in 12 individuals (37.5%) and worsening, defined as increase in the number of seizures—in 2 patients (6.25%). The overall improvement defined as at least a 50% reduction in seizure frequency was found in 65.6% of all patients after 12 months with 28% of patients obtaining complete remission. Another five patients experienced at least an 80% reduction in the frequency of seizures. Concomitant treatment with vigabatrin, and to a much lesser extent topiramate and levetiracetam, was an additional favorable prognostic factor for the success of the therapy. A linear relationship between the cumulative dose of rapamycin and its therapeutic effect was observed. The safety profile of the drug was satisfactory. In none of the observed cases did the adverse events reach the level that required withdrawal of the rapamycin treatment. The reason for dropouts was insufficient drug efficacy in 3 cases. Conclusions Long-term use of rapamycin, especially in combination with vigabatrin, might be a beneficial therapeutic option in the treatment of drug-resistant epilepsy in children with TSC.
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Affiliation(s)
- Krzysztof Sadowski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- *Correspondence: Krzysztof Sadowski
| | - Kamil Sijko
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Transition Technologies, Warsaw, Poland
| | - Dorota Domańska-Pakieła
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Agata Ulatowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Sergiusz Józwiak
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
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Alshoabi SA, Hamid AM, Alhazmi FH, Qurashi AA, Abdulaal OM, Aloufi KM, Daqqaq TS. Diagnostic features of tuberous sclerosis complex: case report and literature review. Quant Imaging Med Surg 2022; 12:846-861. [PMID: 34993123 DOI: 10.21037/qims-21-412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/06/2021] [Indexed: 01/09/2023]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic syndrome that is caused by mutations in the tumour suppressor genes TSC1 or TSC2 which causes multiorgan growths. TSC presents at any age as a wide range of clinical and phenotypic manifestations with varying severity. The main goal of this article was to state two cases of TSC and review the most commonly reported major and minor diagnostic clinical features and the most common features that led to an investigation of possible TSC diagnosis. Herein, we report two cases of TSC, which both presented with seizures during the first 6 months of life. Case 1 presented with multiple types of seizures from 6 months of age and was diagnosed by multiple calcified subependymal nodules (SENs) detected by computed tomography and magnetic resonance imaging (MRI). Case 2 presented with seizures from 3 months of age and was diagnosed prenatally when a tumour was seen in her heart during antenatal ultrasonography. In conclusion, the literature review revealed that neurological manifestations (mainly seizures) were the main feature that led to investigation and diagnosis of TSC followed by abdominal manifestations (mainly renal features) and antenatal follow-up imaging. Other manifestations in skin, chest, eyes, teeth and heart rarely led to TSC diagnosis. In some cases, TSC was incidentally discovered by medical imaging. The cortical tubers, SENs, and subependymal giant cell astrocytomas brain lesions were the most commonly reported major features. Skin features including angiofibromas, ungual fibromas and shagreen patch were the second most common major features reported in the literature. However, skin manifestations were not a common led to investigation and diagnosis of TSC. Renal features, mainly angiomyolipomas (AMLs), were the third most common major feature reported. Medical imaging plays an essential role in diagnosis of TSC, and clinical features are important clues that lead to investigation for the disease.
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Affiliation(s)
- Sultan Abdulwadoud Alshoabi
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | | | - Fahad H Alhazmi
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Abdulaziz A Qurashi
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Osamah M Abdulaal
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Khaled M Aloufi
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
| | - Tareef S Daqqaq
- Radiology Department, Faculty of Medicine, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia
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Vigabatrin-Induced Encephalopathy in a 5.5-Month-Old Girl with Infantile Spasms due to Tuberous Sclerosis. Case Rep Pediatr 2019; 2019:7249237. [PMID: 31534811 PMCID: PMC6732644 DOI: 10.1155/2019/7249237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 12/29/2022] Open
Abstract
A 5.5-month-old female infant with tuberous sclerosis complex presented with infantile spasms and was treated with vigabatrin. As her condition did not improve, she was given adrenocorticotropic hormone (ACTH) intramuscularly which stopped the spasms and improved the electroencephalogram (EEG) abnormalities. However, she developed encephalopathy with apathy, drowsiness, and generalized slowing in the EEG. Discontinuation of vigabatrin quickly improved her symptoms and reversed the EEG slowing. A high index of suspicion is required in order to diagnose vigabatrin-induced encephalopathy, especially as the underlying disorders of these patients can be erroneously considered the cause of the observed encephalopathy.
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Shah PB, James S. Antiepileptic drugs for the management of epilepsy in children under 5 years with tuberous sclerosis complex. Hippokratia 2019. [DOI: 10.1002/14651858.cd013349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Pankaj B Shah
- Sri Ramachandra Institute of Higher Education & Research (SRIHER); Department of Community Medicine; Ramachandra Nagar Porur Chennai Tamil Nadu India 600116
| | - Saji James
- Sri Ramachandra Institute of Higher Education & Research (SRIHER); Department of Paediatric Medicine; Ramachandra Nagar Porur Chennai Tamil Nadu India 60116
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Factors affecting epilepsy prognosis in patients with tuberous sclerosis. Childs Nerv Syst 2019; 35:463-468. [PMID: 30673834 DOI: 10.1007/s00381-019-04066-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/16/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE We aimed to determine the characteristics of epileptic seizures that significantly affect the cognitive functions of 83 patients followed with tuberous sclerosis complex (TSC), their resistance to treatment and risk factors causing this resistance. MATERIALS-METHODS In order to determine the prognosis, the seizure-free/seizure-controlled group and the group with refractory seizures were compared. In addition, risk factors affecting cognitive functions in the patients were determined. RESULTS There was a statistical significance between the presence of a history of seizures in the neonatal period, the age of onset of seizures being less than 2 years of age, autism, status epilepticus, Lennox-Gastaut syndrome (LGS), presence of infantile spasm, generalization of the electroencephalography (EEG) findings, the number of tubers in cerebral imaging being more than three and refractory seizures (p < 0.05). Statistically significant relationship was found between presence of a history of seizures in the neonatal period, the age of onset of seizures, autism, LGS, presence of infantile spasm, presence of status epilepticus history, history of using more than three antiepileptic drugs, generalization of EEG findings, presence of SEGA in cerebral imaging, number of tubers being more than three and the patient's mental retardation (p < 0.05). CONCLUSION In logistic regression analysis, the age of the seizure onset being less than 2 years of age, the presence of autism and number of tubers being more than three in cerebral magnetic resonance imaging (MRI) are determined to be the risk factors that most likely to increase the seizures to be more resistant.
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8
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Franz DN, Lawson JA, Yapici Z, Brandt C, Kohrman MH, Wong M, Milh M, Wiemer-Kruel A, Voi M, Coello N, Cheung W, Grosch K, French JA. Everolimus dosing recommendations for tuberous sclerosis complex-associated refractory seizures. Epilepsia 2018; 59:1188-1197. [PMID: 29727013 PMCID: PMC6033043 DOI: 10.1111/epi.14085] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2018] [Indexed: 01/27/2023]
Abstract
Objective The present analysis examined the exposure‐response relationship by means of the predose everolimus concentration (Cmin) and the seizure response in patients with tuberous sclerosis complex–associated seizures in the EXIST‐3 study. Recommendations have been made for the target Cmin range of everolimus for therapeutic drug monitoring (TDM) and the doses necessary to achieve this target Cmin. Methods A model‐based approach was used to predict patients' daily Cmin. Time‐normalized Cmin (TN‐Cmin) was calculated as the average predicted Cmin in a time interval. TN‐Cmin was used to link exposure to efficacy and safety end points via model‐based approaches. A conditional logistic regression stratified by age subgroup was used to estimate the probability of response in relation to exposure. A multiplicative linear regression model was used to estimate the exposure‐response relationship for seizure frequency (SF). An extended Cox regression model was used to link exposure to the time to first adverse event. Results There was a strong, consistent, and highly significant relationship between everolimus exposure and efficacy, measured by TN‐Cmin and SF, regardless of patient's age and concomitant use of cytochrome P450 3A4 (CYP3A4) inhibitors/inducers. Results of an extended Cox regression analyses indicated that twofold increases in TN‐Cmin were not associated with statistically significant increases in the risk of stomatitis or infections. Significance The recommended TDM is to target everolimus Cmin within a range of 5‐7 ng/mL initially and 5‐15 ng/mL in the event of an inadequate clinical response, and safety is consistent with previous reports. Starting doses depend on age and the concomitant use of CYP3A4/P‐glycoprotein inducers/inhibitors.
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Affiliation(s)
- David N Franz
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John A Lawson
- Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Zuhal Yapici
- Division of Child Neurology, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Michael H Kohrman
- NeuroDevelopmental Science Center, University of Chicago, Chicago, IL, USA
| | - Michael Wong
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mathieu Milh
- Pediatric Neurology Service, Aix-Marseille University, Marseille, France
| | | | - Maurizio Voi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Neva Coello
- Novartis Pharmaceuticals AG, Basel, Switzerland
| | - Wing Cheung
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Kai Grosch
- Novartis Pharmaceuticals AG, Basel, Switzerland
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Stafstrom CE, Staedtke V, Comi AM. Epilepsy Mechanisms in Neurocutaneous Disorders: Tuberous Sclerosis Complex, Neurofibromatosis Type 1, and Sturge-Weber Syndrome. Front Neurol 2017; 8:87. [PMID: 28367137 PMCID: PMC5355446 DOI: 10.3389/fneur.2017.00087] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/24/2017] [Indexed: 01/27/2023] Open
Abstract
Neurocutaneous disorders are multisystem diseases affecting skin, brain, and other organs. Epilepsy is very common in the neurocutaneous disorders, affecting up to 90% of patients with tuberous sclerosis complex (TSC) and Sturge–Weber syndrome (SWS), for example. The mechanisms underlying the increased predisposition to brain hyperexcitability differ between disorders, yet some molecular pathways overlap. For instance, the mechanistic target of rapamycin (mTOR) signaling cascade plays a central role in seizures and epileptogenesis in numerous acquired and genetic disorders, including several neurocutaneous disorders. Potential routes for target-specific treatments are emerging as the genetic and molecular pathways involved in neurocutaneous disorders become increasingly understood. This review explores the clinical features and mechanisms of epilepsy in three common neurocutaneous disorders—TSC, neurofibromatosis type 1, and SWS.
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Affiliation(s)
- Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Verena Staedtke
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Anne M Comi
- Department of Neurology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Kingswood JC, d'Augères GB, Belousova E, Ferreira JC, Carter T, Castellana R, Cottin V, Curatolo P, Dahlin M, de Vries PJ, Feucht M, Fladrowski C, Gislimberti G, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Nabbout R, O'Callaghan F, Benedik MP, Qin J, Marques R, Sander V, Sauter M, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC. TuberOus SClerosis registry to increase disease Awareness (TOSCA) - baseline data on 2093 patients. Orphanet J Rare Dis 2017; 12:2. [PMID: 28057044 PMCID: PMC5217262 DOI: 10.1186/s13023-016-0553-5] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 12/09/2016] [Indexed: 12/31/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder. Many gaps remain in the understanding of TSC because of the complexity in clinical presentation. The TuberOus SClerosis registry to increase disease Awareness (TOSCA) is an international disease registry designed to address knowledge gaps in the natural history and management of TSC. Here, we present the baseline data of TOSCA cohort. Methods Patients of any age diagnosed with TSC, having a documented visit for TSC within the preceding 12 months, or newly diagnosed individuals were included. The registry includes a “core” section designed to record detailed background information on each patient including disease manifestations, interventions, and outcomes collected at baseline and updated annually. “Subsections” of the registry recorded additional data related to specific features of TSC. Results Baseline “core” data from 2093 patients enrolled from 170 sites across 31 countries were available at the cut-off date September 30, 2014. Median age of patients at enrollment was 13 years (range, 0–71) and at diagnosis of TSC was 1 year (range, 0–69). The occurrence rates of major manifestations of TSC included – cortical tubers (82.2%), subependymal nodules (78.2%), subependymal giant cell astrocytomas (24.4%), renal angiomyolipomas (47.2%), lymphangioleiomyomatosis (6.9%), cardiac rhabdomyomas (34.3%), facial angiofibromas (57.3%), forehead plaque (14.1%), ≥ 3 hypomelanotic macules (66.8%), and shagreen patches (27.4%). Epilepsy was reported in 1748 (83.5%) patients, of which 1372 were diagnosed at ≤ 2 years (78%). Intellectual disability was identified in 451 (54.9%) patients of those assessed. TSC-associated neuropsychiatric disorders (TAND) were diagnosed late, and not evaluated in 30–50% of patients. Conclusion TOSCA is the largest clinical case series of TSC to date. It provided a detailed description of the disease trajectory with increased awareness of various TSC manifestations. The rates of different features of TSC reported here reflect the age range and referral patterns of clinics contributing patients to the cohort. Documentation of TAND and LAM was poor. A widespread adoption of the international TSC assessment and treatment guidelines, including use of the TAND Checklist, could improve surveillance. The registry provides valuable insights into the necessity for monitoring, timing, and indications for the treatment of TSC. Electronic supplementary material The online version of this article (doi:10.1186/s13023-016-0553-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John C Kingswood
- Sussex Kidney Unit, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK.
| | | | - Elena Belousova
- Moscow Institute of Pediatrics and Pediatric Surgery, Moscow, Russian Federation
| | | | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, UK
| | - Ramon Castellana
- Novartis Farmacéutica SA, Gran Vía Corts Catalanes, Barcelona, Spain
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | | | - Maria Dahlin
- Karolinska University Hospital, Stockholm, Sweden
| | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Martha Feucht
- Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Germany
| | | | | | - Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Rima Nabbout
- Department of pediatric neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | | | | | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | | | | | | | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, 886 Urushiyama Aoi-ku, Shizuoka, Japan
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11
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Samueli S, Abraham K, Dressler A, Gröppel G, Mühlebner-Fahrngruber A, Scholl T, Kasprian G, Laccone F, Feucht M. Efficacy and safety of Everolimus in children with TSC - associated epilepsy - Pilot data from an open single-center prospective study. Orphanet J Rare Dis 2016; 11:145. [PMID: 27809914 PMCID: PMC5094073 DOI: 10.1186/s13023-016-0530-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/24/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Epilepsy occurs in up to 90 % of all individuals with tuberous sclerosis complex (TSC). In 67 % disease onset is during childhood. In ≥ 50 % seizures are refractory to currently available treatment options. The mTOR-Inhibitor Everolimus (Votubia®) was approved for the treatment of subependymal giant cell astrocytoma (SEGA) and renal angiomyolipoma (AML) in Europe in 2011. It's anticonvulsive/antiepileptic properties are promising, but evidence is still limited. Study aim was to evaluate the efficacy and safety of Everolimus in children and adolescents with TSC-associated epilepsies. METHODS Inclusion-criteria of this investigator-initiated, single-center, open, prospective study were: 1) the ascertained diagnosis of TSC; 2) age ≤ 18 years; 3) treatment indication for Votubia® according to the European Commission guidelines; 4) drug-resistant TSC-associated epilepsy, 5) prospective continuous follow-up for at least 6 months after treatment initiation and 6) informed consent to participate. Votubia® was orally administered once/day, starting with 4.5 mg/m2 and titrated to achieve blood trough concentrations between 5 and 15 ng/ml. Primary endpoint was the reduction in seizure frequency of ≥ 50 % compared to baseline. RESULTS Fifteen patients (nine male) with a median age of six (range; 1-18) years fulfilled the inclusion criteria. 26 % (4/15) had TSC1, 66 % (10/15) had TSC2 mutations. In one patient no mutation was found. Time of observation after treatment initiation was median 22 (range; 6-50) months. At last observation, 80 % (12/15) of the patients were responders, 58 % of them (7/12) were seizure free. The overall reduction in seizure frequency was 60 % in focal seizures, 80 % in generalized tonic clonic seizures and 87 % in drop attacks. The effect of Everolimus was seen already at low doses, early after treatment initiation. Loss of efficacy over time was not observed. Transient side effects were seen in 93 % (14/15) of the patients. In no case the drug had to be withdrawn. CONCLUSION Everolimus seems to be an effective treatment option not only for SEGA and AML, but also for TSC-related epilepsies. Although there are potential serious side effects, treatment was tolerated well by the majority of patients, provided that patients are under close surveillance of epileptologists who are familiar with immunosuppressive agents.
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Affiliation(s)
- Sharon Samueli
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus Abraham
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Anastasia Dressler
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gudrun Gröppel
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Theresa Scholl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Kasprian
- Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Franco Laccone
- Institute of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Long-term High Fat Ketogenic Diet Promotes Renal Tumor Growth in a Rat Model of Tuberous Sclerosis. Sci Rep 2016; 6:21807. [PMID: 26892894 PMCID: PMC4759602 DOI: 10.1038/srep21807] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 12/31/2015] [Indexed: 11/29/2022] Open
Abstract
Nutritional imbalance underlies many disease processes but can be very beneficial in certain cases; for instance, the antiepileptic action of a high fat and low carbohydrate ketogenic diet. Besides this therapeutic feature it is not clear how this abundant fat supply may affect homeostasis, leading to side effects. A ketogenic diet is used as anti-seizure therapy i.a. in tuberous sclerosis patients, but its impact on concomitant tumor growth is not known. To examine this we have evaluated the growth of renal lesions in Eker rats (Tsc2+/−) subjected to a ketogenic diet for 4, 6 and 8 months. In spite of existing opinions about the anticancer actions of a ketogenic diet, we have shown that this anti-seizure therapy, especially in its long term usage, leads to excessive tumor growth. Prolonged feeding of a ketogenic diet promotes the growth of renal tumors by recruiting ERK1/2 and mTOR which are associated with the accumulation of oleic acid and the overproduction of growth hormone. Simultaneously, we observed that Nrf2, p53 and 8-oxoguanine glycosylase α dependent antitumor mechanisms were launched by the ketogenic diet. However, the pro-cancerous mechanisms finally took the ascendency by boosting tumor growth.
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13
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Sundberg M, Sahin M. Cerebellar Development and Autism Spectrum Disorder in Tuberous Sclerosis Complex. J Child Neurol 2015; 30:1954-62. [PMID: 26303409 PMCID: PMC4644486 DOI: 10.1177/0883073815600870] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 01/08/2023]
Abstract
Approximately 50% of patients with the genetic disease tuberous sclerosis complex present with autism spectrum disorder. Although a number of studies have investigated the link between autism and tuberous sclerosis complex, the etiology of autism spectrum disorder in these patients remains unclear. Abnormal cerebellar function during critical phases of development could disrupt functional processes in the brain, leading to development of autistic features. Accordingly, the authors review the potential role of cerebellar dysfunction in the pathogenesis of autism spectrum disorder in tuberous sclerosis complex. The authors also introduce conditional knockout mouse models of Tsc1 and Tsc2 that link cerebellar circuitry to the development of autistic-like features. Taken together, these preclinical and clinical investigations indicate the cerebellum has a profound regulatory role during development of social communication and repetitive behaviors.
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Affiliation(s)
- Maria Sundberg
- The F.M. Kirby Neurobiology Center, Department of Neurology, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
| | - Mustafa Sahin
- F.M. Kirby Neurobiology Center, Department of Neurology, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
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Wheless JW. Use of the mTOR inhibitor everolimus in a patient with multiple manifestations of tuberous sclerosis complex including epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2015; 4:63-6. [PMID: 26543807 PMCID: PMC4543076 DOI: 10.1016/j.ebcr.2015.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disease in which overactivation of mechanistic target of rapamycin (mTOR) signaling leads to the growth of benign hamartomas in multiple organs, including the brain, and is associated with a high rate of epilepsy and neurological deficits. The mTOR inhibitor everolimus has been used in the treatment of subependymal giant cell astrocytomas and renal angiomyolipomas in patients with TSC. This article describes the case of a 13-year-old girl with TSC-associated epilepsy with refractory generalized seizures who initiated treatment with everolimus and experienced subsequent improvement in several TSC manifestations, including a reduction in seizure frequency from clusters of two or three daily to one every 2 to 4 weeks after 1.5 years of treatment.
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Affiliation(s)
- James W Wheless
- Le Bonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, TN, USA
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