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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Beslow LA, Vossough A, Kim H, Nelson J, Lawton MT, Pollak J, Lin DDM, Ratjen F, Hammill AM, Hetts SW, Gossage JR, Whitehead KJ, Faughnan ME, Krings T. Brain AVM compactness score in children with hereditary hemorrhagic telangiectasia. Childs Nerv Syst 2024:10.1007/s00381-024-06366-z. [PMID: 38517485 DOI: 10.1007/s00381-024-06366-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/14/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The brain arteriovenous malformation (BAVM) nidus compactness score (CS), determined on angiography, predicts BAVM recurrence after surgical resection among children with sporadic BAVMs. We measured the angiographic CS for BAVMs among children with hereditary hemorrhagic telangiectasia (HHT) to determine CS characteristics in this population. METHODS A pediatric interventional neuroradiologist reviewed angiograms to determine the CS of BAVMs in children with HHT recruited to the BVMC. CS is based on overall nidus and perinidal anomalous vessel compactness. CS categories included 1 = diffuse nidus, 2 = intermediate nidus, and 3 = compact nidus. RESULTS Forty-eight of 78 children (61.5%) with HHT and brain vascular malformations had a conventional angiogram; 47 (97.9%) angiograms were available. Fifty-four BAVMs were identified in 40 of these 47 children (85.1%). Of 54 BAVMs in children with HHT, CS was 1 in 7 (13%), 2 in 29 (53.7%), and 3 in 18 BAVMs (33.3%) compared with CS of 1 in six (26.1%), 2 in 15 (65.2%), and 3 in 2 BAVMs (8.7%) among 23 previously reported children with sporadic BAVMs, p = 0.045 (Fisher's exact). Seven children with HHT had intracranial hemorrhage: 4 had CS = 3, 1 had CS = 2, and 2 had CS = 1. CONCLUSIONS A range of CSs exists across HHT BAVMs, suggesting it may be an angiographic measure of interest for future studies of BAVM recurrence and hemorrhage risk. Children with HHT may have more compact niduses compared to children with sporadic BAVMs. Additional research should determine whether CS affects hemorrhage risk or post-surgical recurrence risk in HHT-associated BAVMs, which could be used to direct BAVM treatment.
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Affiliation(s)
- Lauren A Beslow
- Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Penn HHT Center of Excellence and Children's Hospital of Philadelphia Hereditary Hemorrhagic Telangiectasia Program, 3401 Civic Center Boulevard, Philadelphia, 19104, PA, USA.
| | - Arastoo Vossough
- Radiology, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Anesthesia, University of California, San Francisco, CA, USA
| | - Jeffrey Nelson
- Center for Cerebrovascular Research, Anesthesia, University of California, San Francisco, CA, USA
| | | | - Jeffrey Pollak
- Vascular & Interventional Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Doris D M Lin
- Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Felix Ratjen
- Paediatrics and Paediatric Respiratory Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Adrienne M Hammill
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital Medical Center, and Division of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Steven W Hetts
- Division of Neurointerventional Radiology, University of California, San Francisco, CA, USA
| | - James R Gossage
- Departments of Critical Care Medicine and Pulmonary Medicine, Augusta University, Augusta, GA, USA
| | - Kevin J Whitehead
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Marie E Faughnan
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital and University of Toronto, Toronto, ON, Canada
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McLean TW, Borst AJ, Hammill AM, Iacobas I, Atkinson A, Shah T, Margolin JF, Bayliff SL, Blatt J. Practice Variations in Managing Infantile Hemangiomas. J Pediatr Hematol Oncol 2023; 45:452-460. [PMID: 37749794 DOI: 10.1097/mph.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/16/2023] [Indexed: 09/27/2023]
Abstract
Infantile hemangioma (IH) is the most common benign tumor of infancy. For children with IH who require treatment, propranolol and other beta blockers have been shown to be safe and effective. Although consensus guidelines for managing IH have been published, anecdotal experience suggests that there remain variations in management. This study was performed to document these variations amongst providers and to identify areas for future research. We conducted an Internet-based survey of clinicians who treat patients with IH. Hypothetical cases and management scenarios were presented. Twenty-nine respondents participated in the survey. Most respondents use generic propranolol in infants with growing IH of the head and neck, with a goal dose of 2 mg/kg/d, until ~1 year of age. A variety of management strategies were documented including which patients should be treated, optimal dose and duration of therapy, how patients should be monitored, which patients should get additional workup, how propranolol should best be discontinued, and how often to see patients in follow-up. This study demonstrates wide practice variations in managing patients with IH. Further research is indicated to address these variations and develop additional/updated evidence-based guidelines.
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Affiliation(s)
- Thomas W McLean
- Vascular Anomalies Special Interest Group of the American Society of Pediatric Hematology/Oncology and the Divisions of Pediatric Hematology/Oncology, Wake Forest University School of Medicine, Winston-Salem
| | | | - Adrienne M Hammill
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ionela Iacobas
- Department of Pediatrics, Baylor University, Texas Children's Hospital, Houston, TX
| | - Autumn Atkinson
- Department of Pediatrics, The University of Texas Health Science Center
| | - Tishi Shah
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Judith F Margolin
- Department of Pediatrics, Baylor University, Texas Children's Hospital, Houston, TX
| | | | - Julie Blatt
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
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4
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Borst AJ, Hammill AM, Crary SE, McLean TW, Felton T, Blatt J. Barriers to Genetic Testing in Vascular Malformations. JAMA Netw Open 2023; 6:e2314829. [PMID: 37219903 DOI: 10.1001/jamanetworkopen.2023.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Importance Vascular malformations (VMs) are rare disorders of vasculogenesis associated with substantial morbidity. Improved understanding of their genetic basis is increasingly guiding management, but logistical barriers to obtaining genetic testing in patients with VM may constrain treatment options. Objectives To examine the institutional mechanisms for and obstacles to obtaining genetic testing for VM. Design, Setting, and Participants This survey study invited members of the Pediatric Hematology-Oncology Vascular Anomalies Interest Group, representing 81 vascular anomaly centers (VACs) serving individuals up to 18 years of age, to complete an electronic survey. Respondents were mostly pediatric hematologists-oncologists (PHOs) but included geneticists, genetic counselors, clinic administrators, and nurse practitioners. Responses that were received between March 1 and September 30, 2022, were analyzed with descriptive methods. Requirements for genetic testing by several genetics laboratories were also reviewed. Results were stratified by size of the VAC. Main Outcomes and Measures Vascular anomaly center and associated clinician characteristics and practice patterns for ordering and obtaining insurance approval for genetic testing for VMs were collected. Results Responses were received from 55 of 81 clinicians, for a response rate of 67.9%. Most respondents were PHOs (50 [90.9%]). Most respondents (32 of 55 respondents [58.2%]) replied that they order genetic testing on 5 to 50 patients per year and reported a genetic testing volume increase of 2- to 10-fold over the past 3 years (38 of 53 respondents [71.7%]). Most testing was ordered by PHOs (35 of 53 respondents [66.0%]), followed by geneticists (28 [52.8%]) and genetic counselors (24 [45.3%]). In-house clinical testing was more common at large and medium-sized VACs. Small VACs were more likely to use oncology-based platforms, which potentially miss low-frequency allelic variants in VM. Logistics and barriers varied by size of the VAC. Obtaining prior authorization was the duty shared among PHOs, nurses, and administrative staff, but the burden of insurance denials and appeals were on PHOs (35 of 53 respondents [66.0%]). Lack of administrative support; unclear institutional, insurance, and laboratory requirements; and lack of clinician education were barriers to genetic testing at VACs of all sizes. The effort to obtain genetic testing for patients with VM, compared with patients with cancer, was perceived as excessive, despite genetic testing being considered standard of care for this population. Conclusions and Relevance Results of this survey study showed the barriers to genetic testing for VM across VACs, described differences between VACs based on size, and proposed multiple interventions to support clinicians ordering genetic testing for VM. The results and recommendations should have broader application to clinicians caring for patients for whom molecular diagnosis is important to medical management.
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Affiliation(s)
- Alexandra J Borst
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shelley E Crary
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock
| | - Thomas W McLean
- Section of Pediatric Hematology-Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Thomas Felton
- McLendon Clinical Laboratories, UNC Health, The University of North Carolina, Chapel Hill
| | - Julie Blatt
- Division of Pediatric Hematology-Oncology, The University of North Carolina, Chapel Hill
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Taylor JM, Hammill AM. The Role of Hereditary Hemorrhagic Telangiectasia in Neurologic Practice. Neurology 2023:WNL.0000000000207384. [PMID: 37085330 DOI: 10.1212/wnl.0000000000207384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 04/23/2023] Open
Affiliation(s)
- John Michael Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- HHT Center of Excellence, Cincinnati, OH
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adrienne M Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- HHT Center of Excellence, Cincinnati, OH
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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6
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McDaniel CG, Adams DM, Steele KE, Hammill AM, Merrow AC, Crane JL, Smith CL, Kozakewich HPW, Le Cras TD. Kaposiform lymphangiomatosis: Diagnosis, pathogenesis, and treatment. Pediatr Blood Cancer 2023; 70:e30219. [PMID: 36683202 PMCID: PMC10018800 DOI: 10.1002/pbc.30219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023]
Abstract
Kaposiform lymphangiomatosis (KLA) is a life-threatening rare disease that can cause substantial morbidity, mortality, and social burdens for patients and their families. Diagnosis often occurs long after initial symptoms, and there are few centers in the world with the expertise to diagnose and care for patients with the disease. KLA is a lymphatic anomaly and significant advancements have been made in understanding its pathogenesis and etiology since its first description in 2014. This review provides multidisciplinary, comprehensive, and state-of-the-art information on KLA patient presentation, diagnostic imaging, pathology, organ involvement, genetics, and pathogenesis. Finally, we describe current therapeutic approaches, important areas for research, and challenges faced by patients and their families. Further insights into the pathogenesis of KLA may advance our understanding of other vascular anomalies given that similar signaling pathways may be involved.
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Affiliation(s)
| | - Denise M. Adams
- Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Kimberley E. Steele
- Collaborative Research Advocacy for Vascular Anomalies
Network (CaRAVAN), a 501(C)(3)
| | - Adrienne M. Hammill
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - A. Carl Merrow
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
| | - Janet L. Crane
- Johns Hopkins University School of Medicine, Baltimore,
Maryland
| | | | | | - Timothy D. Le Cras
- University of Cincinnati College of Medicine, Cincinnati,
Ohio
- Cincinnati Children’s Hospital and Medical Center,
Cincinnati, Ohio
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Yeom S, Cohen B, Weiss CR, Montano C, Wohler E, Sobreira N, Hammill AM, Comi A. Genetic testing in the evaluation of individuals with clinical diagnosis of atypical Sturge-Weber syndrome. Am J Med Genet A 2023; 191:983-994. [PMID: 36710374 DOI: 10.1002/ajmg.a.63106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 01/31/2023]
Abstract
Sturge-Weber Syndrome (SWS) is a rare vascular malformation disorder characterized by abnormal blood vessels in the brain, skin, and eye. SWS is most commonly caused by a somatic mosaic GNAQ-p.Arg183Gln variant. In this series, 12 patients presented for clinical evaluation of SWS but were noted to have atypical features, and therefore germline and/or somatic genetic testing was performed. Atypical features included extensive capillary malformation on the body as well as the face, frontal bossing, macrocephaly, telangiectasia, overgrowth of extremities, absence of neurologic signs and symptoms, and family history of vascular malformations. Five patients had a somatic GNAQ or GNA11 pathogenic variant, one patient had a somatic mosaic likely-pathogenic variant in PIK3CA, and another one had a somatic mosaic deletion that disrupted PTPRD. The other five patients had germline variants in RASA1, EPHB4, or KIT. Our findings suggest that patients presenting for SWS evaluation who have atypical clinical characteristics may have pathogenic germline or somatic variants in genes other than GNAQ or GNA11. Broad germline and somatic genetic testing in these patients with atypical findings may have implications for medical care, prognosis, and trial eligibility.
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Affiliation(s)
- SangEun Yeom
- Department of Neurology and Developmental Medicine, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Bernard Cohen
- Departments of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carolina Montano
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Wohler
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nara Sobreira
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Anne Comi
- Department of Neurology and Developmental Medicine, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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8
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Setty BA, Wusik K, Hammill AM. How we approach genetics in the diagnosis and management of vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29320. [PMID: 36070212 DOI: 10.1002/pbc.29320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/04/2023]
Abstract
Vascular anomalies are a heterogeneous group of disorders that are currently classified based on their clinical and histological characteristics. Over the past decade, there have been significant advances in molecular genetics that have led to identification of genetic alterations associated with vascular tumors, vascular malformations, and syndromes. Here, we describe known genetic alterations in vascular anomalies, discuss when and how to test, and examine how identification of causative genetic mutations provides for better management of these disorders through improved understanding of their pathogenesis and increasing use of targeted therapeutic agents in order to achieve better outcomes for our patients.
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Affiliation(s)
- Bhuvana A Setty
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, and Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Katie Wusik
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Abstract
Hereditary hemorrhagic telangiectasia (HHT), the second most common inherited bleeding disorder, is associated with the development of malformed blood vessels. Abnormal blood vessels may be small and cutaneous or mucosal (telangiectasia), with frequent complications of bleeding, or large and visceral (arteriovenous malformations [AVMs]), with additional risks that can lead to significant morbidity and even mortality. HHT can present in many different ways and can be difficult to recognize, particularly in younger patients in the absence of a known family history of disease or epistaxis, its most common manifestation. HHT is commonly diagnosed using the established Curaçao clinical criteria, which include (1) family history, (2) recurrent epistaxis, (3) telangiectasia, and (4) visceral AVMs. Fulfillment of 3 or more criteria provides a definite diagnosis of HHT, whereas 2 criteria constitute a possible diagnosis of HHT. However, these criteria are insufficient in children to rule out disease due to the age-dependent development of some of these criteria. Genetic testing, when positive, can provide definitive diagnosis of HHT in all age groups. Clinical course is often complicated by significant epistaxis and/or gastrointestinal bleeding, leading to anemia in half of adult patients with HHT. The management paradigm has recently shifted from surgical approaches to medical treatments aimed at control of chronic bleeding, such as antifibrinolytic and antiangiogenic agents, combined with aggressive iron replacement with intravenous iron. Guidelines for management of HHT, including screening and treatment, were determined by expert consensus and originally published in 2009 with updates and new guidelines in 2020.
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Affiliation(s)
- Adrienne M. Hammill
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Canaud G, Hammill AM, Adams D, Vikkula M, Keppler-Noreuil KM. A review of mechanisms of disease across PIK3CA-related disorders with vascular manifestations. Orphanet J Rare Dis 2021; 16:306. [PMID: 34238334 PMCID: PMC8268514 DOI: 10.1186/s13023-021-01929-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/27/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND PIK3CA-related disorders include vascular malformations and overgrowth of various tissues that are caused by postzygotic, somatic variants in the gene encoding phosphatidylinositol-3-kinase (PI3K) catalytic subunit alpha. These mutations result in activation of the PI3K/AKT/mTOR signaling pathway. The goals of this review are to provide education on the underlying mechanism of disease for this group of rare conditions and to summarize recent advancements in the understanding of, as well as current and emerging treatment options for PIK3CA-related disorders. MAIN BODY PIK3CA-related disorders include PIK3CA-related overgrowth spectrum (PROS), PIK3CA-related vascular malformations, and PIK3CA-related nonvascular lesions. Somatic activating mutations (predominantly in hotspots in the helical and kinase domains of PIK3CA, but also in other domains), lead to hyperactivation of the PI3K signaling pathway, which results in abnormal tissue growth. Diagnosis is complicated by the variability and overlap in phenotypes associated with PIK3CA-related disorders and should be performed by clinicians with the required expertise along with coordinated care from a multidisciplinary team. Although tissue mosaicism presents challenges for confirmation of PIK3CA mutations, next-generation sequencing and tissue selection have improved detection. Clinical improvement, radiological response, and patient-reported outcomes are typically used to assess treatment response in clinical studies of patients with PIK3CA-related disorders, but objective assessment of treatment response is difficult using imaging (due to the heterogeneous nature of these disorders, superimposed upon patient growth and development). Despite their limitations, patient-reported outcome tools may be best suited to gauge patient improvement. New therapeutic options are needed to provide an alternative or supplement to standard approaches such as surgery and sclerotherapy. Currently, there are no systemic agents that have regulatory approval for these disorders, but the mTOR inhibitor sirolimus has been used for several years in clinical trials and off label to address symptoms. There are also other agents under investigation for PIK3CA-related disorders that act as inhibitors to target different components of the PI3K signaling pathway including AKT (miransertib) and PI3K alpha (alpelisib). CONCLUSION Management of patients with PIK3CA-related disorders requires a multidisciplinary approach. Further results from ongoing clinical studies of agents targeting the PI3K pathway are highly anticipated.
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Affiliation(s)
- Guillaume Canaud
- Overgrowth Syndrome and Vascular Anomalies Unit, Hôpital Necker Enfants Malades, INSERM U1151, Assistance Publique-Hôpitaux de Paris, Université de Paris, 149 rue de Sèvres, 75105, Paris, France.
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Denise Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires Saint Luc, University of Louvain, Brussels, Belgium.,VASCERN VASCA European Reference Centre, Bichat-Claude Bernard Hospital, Paris, France.,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), University of Louvain, Brussels, Belgium
| | - Kim M Keppler-Noreuil
- Division of Genetics and Metabolism, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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11
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Smegal LF, Sebold AJ, Hammill AM, Juhász C, Lo WD, Miles DK, Wilfong AA, Levin AV, Fisher B, Ball KL, Pinto AL, Comi AM. Multicenter Research Data of Epilepsy Management in Patients With Sturge-Weber Syndrome. Pediatr Neurol 2021; 119:3-10. [PMID: 33813331 PMCID: PMC8162684 DOI: 10.1016/j.pediatrneurol.2021.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epilepsy in typical Sturge-Weber syndrome (SWS) is common, and many questions remain regarding the treatment outcomes. We analyzed a large multicenter database with focus on neurological drug treatment in different demographic and SWS characteristic groups. METHODS A total of 268 patients with brain involvement and a history of seizures were selected from a research data registry generated from a multicenter cross-sectional questionnaire. We examined associations between medication use and binary variables such as sex, ethnicity, and brain, skin, and eye involvement laterality. We analyzed group differences in mean number of antiseizure medications and age at diagnosis, enrollment, and seizure onset and examined differences in median SWS neurological scores in groups of interest. RESULTS The most frequently used medications were levetiracetam (48.1%), low-dose aspirin (44.8%), oxcarbazepine (39.9%), and phenobarbital (14.9%). Lamotrigine was more frequently used in adults than in children (P = 0.001). History of neurosurgery was associated with no current antiseizure medication use (P = 0.001), whereas bilateral brain involvement and family history of seizures were associated with using a higher number of antiseizure medications (P = 0.002, P = 0.027, respectively). Subjects with bilateral brain involvement and early seizure onset were associated with using a higher number of antiseizure medications (P = 0.002) and phenobarbital use (0.003). CONCLUSIONS Levetiracetam, low-dose aspirin, and oxcarbazepine were the most frequently used medications. More severely affected patients were frequently on a greater number of antiseizure medications. Surgery for epilepsy was associated with the ability to discontinue antiseizure medication. Longitudinal studies are needed to further investigate medication use in patients with SWS.
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Affiliation(s)
- Lindsay F. Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Csaba Juhász
- Departments of Pediatrics, Neurology, and Neurosurgery, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan
| | - Warren D. Lo
- Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Daniel K. Miles
- Department of Neurology, Pediatric Epilepsy, New York University Langone Health, New York, New York
| | - Angus A. Wilfong
- Neurology, Barrow Neurological Institute, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Alex V. Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children’s Hospital, University of Rochester, Rochester, New York
| | | | | | - Anna L. Pinto
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland,Communications should be addressed to: Dr. Comi; Department of Neurology; Hugo Moser Kennedy Krieger Research Institute; Rm 553, Kennedy Krieger Outpatient Bldg, 801 North Broadway; Baltimore, MD 21205. (A.M. Comi)
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12
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Canaud G, López Gutiérrez JC, Hammill AM, Weibel L, Vincent G, Niglis S, Paul M, Adams DM. EPIK-P2: A prospective phase 2, double-blind, randomized, placebo-controlled study of alpelisib in pediatric and adult patients (Pts) with PIK3CA-related overgrowth spectrum (PROS). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps3160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS3160 Background: Somatic gain-of-function mutations in the PIK3CA gene, encoding the phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K) catalytic α subunit (p110α), can result in PI3K pathway hyperactivation. PROS is an umbrella term for rare, phenotypically varied, but overlapping features driven by PIK3CA mutations. Disease onset is often congenital or in early childhood; presentation ranges widely from localized overgrowth to pleiotropic, severe overgrowth. Complications depend on anatomical site and extent of overgrowth. Management of PROS currently involves symptomatic treatment of its manifestations; an unmet need exists for targeted, systemic therapies. Alpelisib, a PI3Kα inhibitor, has demonstrated encouraging clinical observations and a promising safety profile; after 6 mo of treatment, pediatric and adult pts with PROS experienced improvements in symptoms without requiring surgery. A low rate of side effects was observed (Venot Q, et al. Nature. 2018;558:540-6). Methods: EPIK-P2 is a prospective, phase 2, multicenter study with an upfront 16-week, randomized, double-blind, placebo-controlled period. Key eligibility criteria include male or female ≥6 yr of age with PROS and symptomatic and/or progressive overgrowth; ≥1 PROS-related measurable lesion confirmed by a Blinded Independent Review Committee (BIRC) and documented somatic PIK3CA mutation. Pts with isolated cases of macrodactyly, epidermal nevus/nevi, or macrocephaly in absence of other PROS-related lesions; previous treatment with PI3K inhibitor(s); or debulking surgery within 3 mo are not eligible. Approximately 138 pts will be enrolled into 2 groups comprising adult (age ≥18 yr) and pediatric (ages 6-17 yr) pts. Pts will be randomized 2:1 to daily oral alpelisib or matching placebo; adults will receive 125 mg and pediatric pts 50 mg. After 16 weeks, pts randomized to placebo will switch to alpelisib in a blinded fashion; pts receiving alpelisib will continue alpelisib. Treatment will continue for up to 5 yr. The primary objective is to demonstrate the efficacy of alpelisib by the proportion of pts randomized to alpelisib with a response at Week 24 in each group. Response is defined as ≥20% volume reduction in the symptomatic target lesion(s) per BIRC. The key secondary objective is to demonstrate efficacy of alpelisib vs placebo based on the proportion of pts in each group with response at Week 16. Other secondary outcomes include safety and tolerability, duration of response, overall clinical response rates, changes in symptoms and comorbidities, patient-reported outcomes, pharmacokinetics, and healthcare utilization. An exploratory group of pts (n = 12) ages 2-5 yr will be later enrolled once a starting dose of alpelisib is confirmed in these pts. Enrollment of 150 pts is anticipated. Clinical trial information: NCT04589650.
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Affiliation(s)
| | | | | | - Lisa Weibel
- University Children’s Hospital Zurich, Zurich, Switzerland
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13
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Sebold AJ, Day AM, Ewen J, Adamek J, Byars A, Cohen B, Kossoff EH, Mizuno T, Ryan M, Sievers J, Smegal L, Suskauer SJ, Thomas C, Vinks A, Zabel TA, Hammill AM, Comi AM. Sirolimus Treatment in Sturge-Weber Syndrome. Pediatr Neurol 2021; 115:29-40. [PMID: 33316689 PMCID: PMC8209677 DOI: 10.1016/j.pediatrneurol.2020.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sturge-Weber syndrome is a rare neurovascular disorder associated with capillary malformation, seizures, cognitive impairments, and stroke-like episodes (SLEs), arising from a somatic activating mutation in GNAQ. Studies suggest this mutation may cause hyperactivation of the mammalian target of rapamycin pathway. Sirolimus is an mammalian target of rapamycin inhibitor studied in other vascular anomalies and a potentially promising therapy in Sturge-Weber syndrome. METHODS Ten patients with Sturge-Weber syndrome brain involvement and cognitive impairments were enrolled. Oral sirolimus was taken for six months (maximum dose: 2 mg/day, target trough level: 4-6 ng/mL). Neuropsychological testing, electroencephalography, and port-wine score were performed at baseline and after six months on sirolimus. Neuroquality of life, adverse events, and Sturge-Weber Syndrome Neurological Score (neuroscore) were recorded at each visit. RESULTS Sirolimus was generally well tolerated; one subject withdrew early. Adverse events considered related to sirolimus were mostly (15/16) grade 1. A significant increase in processing speed was seen in the overall group (P = 0.031); five of nine patients with available data demonstrated statistically rare improvement in processing speed. Improvements were seen in the neuroquality of life subscales measuring anger (P = 0.011), cognitive function (P = 0.015), and depression (P = 0.046). Three subjects experiencing SLEs before and during the study reported shortened recovery times while on sirolimus. CONCLUSIONS Sirolimus was well tolerated in individuals with Sturge-Weber syndrome and may be beneficial for cognitive impairments, especially in patients with impaired processing speed or a history of SLE. A future, randomized, placebo-controlled trial of sirolimus in patients with Sturge-Weber syndrome is needed to further understand these potentially beneficial effects.
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Affiliation(s)
- Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Alyssa M. Day
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Joshua Ewen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Psychological and Brain Sciences, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jack Adamek
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Anna Byars
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bernard Cohen
- Division of Pediatric Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Eric H. Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew Ryan
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jacqueline Sievers
- Clinical Trials Compliance and Quality Assurance, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Lindsay Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Stacy J. Suskauer
- Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatric Rehabilitation Medicine, Krieger Institute, Baltimore, Maryland, USA,Johns Hopkins University School of Medicine, Departments of Physical Medicine and Rehabilitation, Baltimore, Maryland, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - T. Andrew Zabel
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adrienne M. Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Communications should be addressed to: Dr. Anne M. Comi; Department of Neurology, Hugo Moser Kennedy Krieger Research Institute,801 N. Broadway; Baltimore, MD, 21205. (A.M. Comi)
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14
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Ricci KW, Chute C, Hammill AM, Dasgupta R, Patel M. Retrospective study of hematologic complications in patients with slow-flow vascular malformations undergoing sclerotherapy. Pediatr Blood Cancer 2020; 67:e28277. [PMID: 32779831 DOI: 10.1002/pbc.28277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Slow-flow vascular malformations (SFVM) are associated with localized intravascular coagulopathy (LIC), which is characterized by elevated D-dimer and, when severe, hypofibrinogenemia. LIC results in intralesional clotting and hemorrhage and increases risk for significant thrombotic and bleeding complications. Sclerotherapy has been a suggested potential trigger for LIC worsening to disseminated intravascular coagulopathy. Hematologic complications of sclerotherapy in SFVM, along with low-molecular-weight heparin (LMWH) used to prevent worsening LIC, are largely unstudied. PROCEDURE Medical records of patients with SFVM and LIC who underwent sclerotherapy at Cincinnati Children's Hospital Medical Center from July 2008 to December 2016 were reviewed for periprocedural hematologic complications. LMWH dose, frequency, and course length were evaluated. RESULTS Fifty-nine patients with SFVM and LIC underwent 281 sclerotherapy procedures, of which 86% were in children. Eighty-five percent of patients received periprocedural LMWH, although at various doses and course lengths. No thrombotic complications occurred in children. One adult on LMWH developed pulmonary emboli after sclerotherapy. No major bleeding complications occurred postoperatively. In four patients, fibrinogen dropped below 100 mg/dL post-sclerotherapy, requiring cryoprecipitate. One patient required packed red blood cell (RBC) transfusion for sclerotherapy-induced hemolysis. No intraoperative bleeding or thrombotic events occurred. CONCLUSION LMWH use, at subtherapeutic dosing, was common in this patient population and did not appear to increase risk of significant bleeding before, during, or after sclerotherapy. In children with SFVM, bleeding and thrombotic complications after sclerotherapy appear rare. Although safe, prospective studies are needed to evaluate the efficacy of LMWH to prevent worsening coagulopathy with procedures.
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Affiliation(s)
- Kiersten W Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carol Chute
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adrienne M Hammill
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roshni Dasgupta
- Hemangioma and Vascular Malformation Center, Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Manish Patel
- Hemangioma and Vascular Malformation Center, Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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15
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Abstract
Overgrowth syndromes represent a diverse group of disorders with overlapping features. Interdisciplinary management by a team of experts in vascular anomalies is crucial for establishing the correct diagnosis and optimizing outcomes for these patients. Unique management considerations include increased risk for thrombosis and in some cases, cancer. In recent years, research has demonstrated that these disorders are primarily caused by somatic mutations in growth pathways, particularly the PI3K-mTOR pathway. This improved understanding had led to promising new therapies for this group of patients.
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Affiliation(s)
- Whitney Eng
- Cancer and Blood Disorders Center, Division of Hematology/Oncology, Dana Farber Cancer Institute and Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Adrienne M Hammill
- Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, United States.
| | - Denise M Adams
- Cancer Center, Division of Oncology, Director Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia, Department of Pediatrics and University of Pennsylvania Medical Center, Philadelphia, PA, United States
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16
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Le Cras TD, Goines J, Lakes N, Pastura P, Hammill AM, Adams DM, Boscolo E. Constitutively active PIK3CA mutations are expressed by lymphatic and vascular endothelial cells in capillary lymphatic venous malformation. Angiogenesis 2020; 23:425-442. [PMID: 32350708 PMCID: PMC7311380 DOI: 10.1007/s10456-020-09722-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Capillary lymphatic venous malformations (CLVM) are complex vascular anomalies characterized by aberrant and enlarged lymphatic and blood vessels. CLVM appear during fetal development and enlarge after birth, causing life-long complications such as coagulopathy, pulmonary embolism, chronic pain, and disfigurement. Treatment includes surgical debulking, amputation, and recurrent sclerotherapy. Somatic, mosaic mutations in the 110-kD catalytic α-subunit of phosphoinositide-3-kinase (PIK3CA) gene have been previously identified in affected tissues from CLVM patients; however, the cell population harboring the mutation is still unknown. In this study, we hypothesized that endothelial cells (EC) carry the PIK3CA mutations and play a major role in the cellular origin of CLVM. We isolated EC from the lesions of seven patients with CLVM and identified PIK3CA hotspot mutations. The CLVM EC exhibited constitutive phosphorylation of the PI3K effector AKT as well as hyperproliferation and increased resistance to cell death compared to normal EC. Inhibitors of PIK3CA (BYL719) and AKT (ARQ092) attenuated the proliferation of CLVM EC in a dose-dependent manner. A xenograft model of CLVM was developed by injecting patient-derived EC into the flanks of immunocompromised mice. CLVM EC formed lesions with enlarged lymphatic and vascular channels, recapitulating the patient histology. EC subpopulations were further obtained by both immunomagnetic separation into lymphatic EC (LEC) and vascular EC (VEC) and generation of clonal populations. By sequencing these subpopulations, we determined that both LEC and VEC from the same patient express the PIK3CA mutation, exhibit increased AKT activation and can form lymphatic or vascular lesions in mouse.
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Affiliation(s)
- Timothy D Le Cras
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Jillian Goines
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Nora Lakes
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Patricia Pastura
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Adrienne M Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Denise M Adams
- Boston Children's Hospital Division of Hematology/Oncology Harvard Medical School, Boston, MA, USA
| | - Elisa Boscolo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
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17
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Fernández KS, de Alarcon A, Adams DM, Hammill AM. Sirolimus for the treatment of juvenile nasopharyngeal angiofibroma. Pediatr Blood Cancer 2020; 67:e28162. [PMID: 31925925 DOI: 10.1002/pbc.28162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/25/2019] [Accepted: 12/15/2019] [Indexed: 11/06/2022]
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a pathologically benign yet locally aggressive and destructive tumor that develops in the choana and nasopharynx. Historical treatment of JNA has included embolization, surgical resection, and radiation. Here, we describe three patients who received therapy with the mTOR inhibitor sirolimus with improvement in clinical symptoms, imaging, and overall well-being.
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Affiliation(s)
- Karen S Fernández
- Solid Tumor Program, Valley Children's Hospital, Cancer and Blood Disorders Center, Stanford University, Madera, California
| | - Alessandro de Alarcon
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology - Head and Neck Surgery, Center for Pediatric Voice Disorders, University of Cincinnati, Cincinnati, Ohio
| | - Denise M Adams
- Boston Children's Hospital, Division of Hematology/Oncology, Vascular Anomalies Center (VAC), Harvard Medical School, Boston, Massachusetts
| | - Adrienne M Hammill
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Diseases Institute, Hemangioma and Vascular Malformations Center, University of Cincinnati, Cincinnati, Ohio
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18
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Polites SF, Watanabe M, Scorletti F, Patel MN, Ricci KW, Hammill AM, Dasgupta R. Single-stage embolization with n-butyl cyanoacrylate and surgical resection of venous malformations. Pediatr Blood Cancer 2020; 67:e28029. [PMID: 31749319 DOI: 10.1002/pbc.28029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/10/2019] [Accepted: 09/07/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Sclerotherapy or surgical resection is options for symptomatic venous malformations (VM). Sclerotherapy may require repetitive intervention and resection is often avoided due to operative morbidity. The purpose of this study was to report use of single-stage n-butyl cyanoacrylate glue embolization and surgical resection of focal VM. METHODS A review of patients with focal VM who underwent glue embolization followed by resection at a single tertiary care vascular malformations center was performed. All embolizations were performed with ultrasound and fluoroscopy under the same anesthetic as resection. Patient characteristics and outcomes were evaluated. RESULTS Fifteen procedures were performed in 12 patients with a total of 20 VM addressed, as several patients had multiple VM. Mean age was 16 ± 9 years. Malformation locations included scalp, hip, gluteal, labial, toe, finger, face, lip, chest, and foot and size ranged from 1.0 to 10.5 cm. Median (range) of prior sclerotherapy treatments was 3 (0-5) and three patients previously underwent surgical resection. Median blood loss was zero (0-10) mL. Surgical complications occurred after five procedures (33%) including superficial wound dehiscence and cellulitis. No complications required readmission or reoperation. At a median follow up of 195 (103-266) days, no patients have required additional treatment. CONCLUSION Glue embolization and resection of focal VM of variable size and location appears to have durable results and low surgical morbidity. This single-stage procedure, often performed as an outpatient, may be utilized as upfront treatment for symptomatic malformations or for VM refractory to other treatments.
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Affiliation(s)
- Stephanie F Polites
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Miho Watanabe
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Federico Scorletti
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manish N Patel
- Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kiersten W Ricci
- Division of Hematology, Cancer and Blood Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roshni Dasgupta
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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19
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Harmon KA, Day AM, Hammill AM, Pinto AL, McCulloch CE, Comi AM. Quality of Life in Children With Sturge-Weber Syndrome. Pediatr Neurol 2019; 101:26-32. [PMID: 31526690 PMCID: PMC7288751 DOI: 10.1016/j.pediatrneurol.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/03/2019] [Accepted: 04/10/2019] [Indexed: 11/17/2022]
Abstract
AIM We assessed the utilization of the National Institutes of Health Quality of Life in Neurological Disorders (Neuro-QoL) in pediatric patients with Sturge-Weber syndrome, a rare neurovascular disorder which frequently results in seizures, brain atrophy, calcification, and a range of neurological impairments. METHODS Subjects were seen clinically and consented for research. All 22 patients filled out the Pediatric Neuro-QoL. The Neuro-QoL subscores were converted to T-scores to compare with the referenced control population. Twenty-one participants also filled out the Brain Vascular Malformation Consortium Database Questionnaire containing data pertaining to Sturge-Weber syndrome-related medical history, medications, comorbidities, and family history. All data were analyzed with a significance threshold of P < 0.05. RESULTS Cognitive function quality of life was significantly lower (P < 0.001) in pediatric patients with Sturge-Weber syndrome compared with referenced control subjects. Male gender (P = 0.02) was associated with lower cognitive function Neuro-QoL. The extent of skin (R = -0.46, P = 0.04), total eyelid port-wine birthmark (R = -0.56, P = 0.007), eye (R = -0.58, P = 0.005), and total Sturge-Weber syndrome involvement (R = -0.63, P = 0.002) were negatively correlated with cognitive function Neuro-QoL. A younger age at seizure onset was associated with lower cognitive function Neuro-QoL (hazard ratio = 0.90, P = 0.004) even after controlling for extent of brain, skin, or eye involvement. Antidepressant use was associated with lower cognitive function Neuro-QoL (P = 0.005), and cognitive function Neuro-QoL was negatively correlated with depression Neuro-QoL; however, after adjusting for depression this relationship was no longer significant. CONCLUSIONS The results suggest targeting cognitive function Neuro-QoL in treatment trials and reiterate the prognostic value of early seizure onset. In addition, sex-related differences were noted, which should be further studied.
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Affiliation(s)
- Kelly A Harmon
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Alyssa M Day
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anna L Pinto
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Anne M Comi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
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20
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Boscolo E, Pastura P, Glaser K, Goines J, Hammill AM, Adams DM, Dickie P, Dickie BH, Le Cras TD. Signaling pathways and inhibitors of cells from patients with kaposiform lymphangiomatosis. Pediatr Blood Cancer 2019; 66:e27790. [PMID: 31045327 PMCID: PMC6588438 DOI: 10.1002/pbc.27790] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/20/2019] [Accepted: 04/17/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Kaposiform lymphangiomatosis (KLA) is a rare lymphatic anomaly with significant morbidity and mortality. KLA is characterized by diffuse multifocal lesions comprised of focal areas of "kaposiform" spindled cells accompanying malformed lymphatic channels. The goal of this study was to identify activated signaling pathways in cells isolated from three KLA patients for the purpose of testing new therapies. PROCEDURE Cells were obtained from the lungs of one patient isolated at autopsy and the spleen of two patients removed in surgery due to disease complications. A protein kinase array was performed on the KLA cell lysates and normal lymphatic endothelial cells. RESULTS Higher activation of key signaling pathways in the KLA cells, including PRAS40, AKT1/2/3, and ERK-1/2, was identified by protein kinase array and confirmed by Western blot analysis. This indicated a role for highly activated PI3K-AKT and MAPK-ERK-1/2 signaling pathways in KLA cells. Cell proliferation studies assessed PI3K inhibitors (LY294002; BYL719), AKT inhibitor ARQ092, mTOR inhibitor rapamycin, and MAPK inhibitor U0126. These studies demonstrated that PI3K-AKT-mTOR and MAPK signaling are important mediators of KLA cell proliferation. BYL719 and rapamycin were more effective at inhibiting KLA cell proliferation than U0126. CONCLUSIONS Our studies using cells from KLA patient lesions demonstrate that these cells are highly proliferative and the PI3K-AKT-mTOR and MAPK pathways are promising therapeutic targets. Development and clinical trials of PI3K, AKT, and MAPK inhibitors for cancer treatment and the data in this study lend support for early clinical trials assessing the efficacy of these inhibitors in KLA patients.
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Affiliation(s)
- Elisa Boscolo
- Division of Experimental Hematology and Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Patricia Pastura
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Pulmonary Biology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Kathryn Glaser
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jillian Goines
- Division of Experimental Hematology and Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Adrienne M. Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Hemangioma & Vascular Anomalies Center & Division of Hematology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Denise M. Adams
- Vascular Anomalies Center, Boston, MA, USA,Boston Children’s Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Peter Dickie
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Belinda Hsi Dickie
- Boston Children’s Hospital, Boston, MA, USA,Colorectal and Pelvic Malformation Center, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Timothy D. Le Cras
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Pulmonary Biology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
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21
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Ricci KW, Hammill AM, Mobberley-Schuman P, Nelson SC, Blatt J, Glade Bender JL, McCuaig CC, Synakiewicz A, Frieden IJ, Adams DM. Efficacy of systemic sirolimus in the treatment of generalized lymphatic anomaly and Gorham-Stout disease. Pediatr Blood Cancer 2019; 66:e27614. [PMID: 30672136 PMCID: PMC6428616 DOI: 10.1002/pbc.27614] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/15/2018] [Accepted: 12/28/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Generalized lymphatic anomaly (GLA) and Gorham-Stout disease (GSD) are rare complicated lymphatic malformations that occur in multiple body sites and are associated with significant morbidity and mortality. Treatment options have been limited, and conventional medical therapies have been generally ineffective. Emerging data suggest a role for sirolimus as a treatment option for complex lymphatic anomalies. PROCEDURE Disease response was evaluated by radiologic imaging, quality of life (QOL), and clinical status assessments in children and young adults with GLA and GSD from a multicenter systematic retrospective review of patients treated with oral sirolimus and the prospective phase 2 clinical trial assessing the efficacy and safety of sirolimus in complicated vascular anomalies (NCT00975819). Sirolimus dosing regimens and toxicities were also assessed. RESULTS Eighteen children and young adults with GLA (n = 13) or GSD (n = 5) received oral sirolimus. Fifteen patients (83%) had improvement in one or more aspects of their disease (QOL 78%, clinical status 72%, imaging 28%). No patients with bone involvement had progression of bone disease, and the majority had symptom or functional improvement on sirolimus. Improvement of pleural and pericardial effusion(s) occurred in 72% and 50% of affected patients; no effusions worsened on treatment. CONCLUSIONS Sirolimus appears effective at stabilizing or reducing signs/symptoms of disease in patients with GLA and GSD. Functional impairment and/or QOL improved in the majority of individuals with GLA and GSD with sirolimus treatment.
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Affiliation(s)
- Kiersten W. Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adrienne M. Hammill
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paula Mobberley-Schuman
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephen C. Nelson
- Department of Pediatric Hematology and Oncology, Children’s Minnesota Hematology Oncology, Minneapolis, Minnesota
| | - Julie Blatt
- Division of Pediatric Hematology Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Julia L. Glade Bender
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York City, New York
| | | | - Anna Synakiewicz
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ilona J. Frieden
- Department of Dermatology, University of California, San Francisco, San Francisco, California
| | - Denise M. Adams
- Vascular Anomalies Center, Division of Hematology, Cancer and Blood Disorders Center, Boston Children’s Hospital, Boston, Massachusetts
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22
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Polites SF, Watanabe M, Crafton T, Jenkins TM, Alvarez-Allende CR, Hammill AM, Dasgupta R. Surgical resection of infantile hemangiomas following medical treatment with propranolol versus corticosteroids. J Pediatr Surg 2019; 54:740-743. [PMID: 30249358 DOI: 10.1016/j.jpedsurg.2018.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 07/26/2018] [Accepted: 08/02/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been a paradigm shift from corticosteroid to propranolol treatment for infantile hemangiomas (IHs), with surgical resection reserved for complicated or persistent IHs. The purpose of this study was to determine if propranolol treatment was associated with decreased utilization of surgical resection compared to corticosteroids. METHODS A single center retrospective chart review of all corticosteroid or propranolol treated IHs between 2005 and 2014 was performed. Demographic and clinical data were collected. Both univariate and multivariate analyses were performed with the primary outcome of requiring surgical intervention. RESULTS Of 652 patients with IH, 52 were treated with oral corticosteroids and 195 with propranolol only. Surgical intervention was required in 14 (27%) of steroid patients vs 18 (9%) of propranolol patients (p < .001). On multivariable analysis patients treated with steroids had 3.3 the odds of requiring surgery when compared to propranolol patients (p = .001). Prematurity (<37 weeks) was also associated with increased odds of surgery (OR = 2.8, p = .003). CONCLUSION Patients treated with propranolol required significantly fewer surgical interventions than those treated with corticosteroids suggesting a more efficacious treatment paradigm. Prematurity increases the need for surgical intervention regardless of the modality of medical treatment. LEVEL OF EVIDENCE Level III, treatment study.
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Affiliation(s)
- Stephanie F Polites
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Miho Watanabe
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA; Pediatric Surgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-8655
| | - Thomas Crafton
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Todd M Jenkins
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Carlos R Alvarez-Allende
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Adrienne M Hammill
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Roshni Dasgupta
- Department of Pediatric Thoracic and General Surgery, Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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23
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Walkup LL, Towe CT, Bdaiwi A, Merrow AC, Hammill AM, Cleveland ZI, Woods JC. Evidence of Normal Alveolar Size in Pediatric Generalized Lymphatic Anomaly. Am J Respir Crit Care Med 2018; 198:1573-1574. [PMID: 30134116 DOI: 10.1164/rccm.201805-0855im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laura L Walkup
- Cincinnati Children's Hospital Medical Center, Pulmonary Medicine, Cincinnati, Ohio, United States
| | - Christopher T Towe
- Cincinnati Children's Hospital Medical Center, Pulmonary Medicine, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, Pediatrics, Cincinnati, Ohio, United States
| | - Abdullah Bdaiwi
- University of Cincinnati, Biomedical Engineering, Cincinnati, Ohio, United States
| | - Arnold C Merrow
- Cincinnati Children's Hospital Medical Center, 2518, Radiology, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, 12303, Radiology, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, Pediatrics, Cincinnati, Ohio, United States
| | - Adrienne M Hammill
- Cincinnati Children's Hospital Medical Center, Hematology, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, 12303, Pediatrics, Cincinnati, Ohio, United States
| | - Zackary I Cleveland
- Cincinnati Children's Hospital Medical Center, 2518, Pulmonary Medicine, Cincinnati, Ohio, United States
- Cincinnati Children's Hospital Medical Center, 2518, Radiology, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, 12303, Pediatrics, Cincinnati, Ohio, United States
- University of Cincinnati, Biomedical Engineering, Cincinnati, Ohio, United States
| | - Jason C Woods
- Cincinnati Children's Hospital Medical Center, Pulmonary Medicine, Cincinnati, Ohio, United States
- Cincinnati Children's Hospital Medical Center, 2518, Radiology, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, 12303, Pediatrics, Cincinnati, Ohio, United States
- University of Cincinnati College of Medicine, Radiology, Cincinnati, Ohio, United States ;
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24
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Mizuno T, Fukuda T, Emoto C, Mobberley-Schuman PS, Hammill AM, Adams DM, Vinks AA. Developmental pharmacokinetics of sirolimus: Implications for precision dosing in neonates and infants with complicated vascular anomalies. Pediatr Blood Cancer 2017; 64. [PMID: 28205374 DOI: 10.1002/pbc.26470] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/23/2016] [Accepted: 12/28/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sirolimus has recently been shown to be efficacious and tolerable in pediatric patients with complicated vascular anomalies. Nevertheless, dosing information remains very limited especially for neonates and infants. The purpose of this study was to develop an age-appropriate sirolimus starting dosing regimen based on the developmental changes in drug elimination capacity using data collected in neonates and infants. PROCEDURE A recently developed sirolimus maturation model [Emoto et al. CPT Pharmacometrics Syst Pharmacol, 2016] was used to simulate clearance estimates using realistic age and weight covariates for age cohorts aged 0-24 months. Next, predose concentrations at steady state were generated for each age cohort of neonates and infants. Dose requirements to attain predefined target trough concentration ranges (10-15 and 5-10 ng/ml) were simulated across the different age groups. Starting doses were chosen to maximize the likelihood of achieving sirolimus-targeted concentrations. RESULTS The trajectory of simulated sirolimus clearances increased with age and was in agreement with the previous findings in the Phase 2 study. The proposed dosing regimens covered eight age cohorts and resulted in target attainment of more than 75-95% across selected regimens. CONCLUSIONS This study identified age-appropriate sirolimus dosing regimens for neonates and infants. The algorithm in combination with therapeutic drug management will facilitate sirolimus precision dosing in young children with vascular anomalies. A prospective evaluation is being planned.
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Affiliation(s)
- Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Paula S Mobberley-Schuman
- Division of Oncology, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adrienne M Hammill
- Division of Oncology, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Denise M Adams
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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25
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Mizuno T, Emoto C, Fukuda T, Hammill AM, Adams DM, Vinks AA. Model-based precision dosing of sirolimus in pediatric patients with vascular anomalies. Eur J Pharm Sci 2017; 109S:S124-S131. [PMID: 28526601 DOI: 10.1016/j.ejps.2017.05.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
Sirolimus is the first drug to show efficacy in the treatment of patients with complicated vascular anomalies. The current study expands on the evolution of a PK model-based strategy for the precision dosing of sirolimus as part of prospective concentration controlled clinical trials in pediatric patients with vascular anomalies. Twelve month follow up data collected from 52 pediatric patients participating in the Phase 2 clinical trial were analyzed. Target attainment across the age range of 3weeks to 18years after 2-3months of therapy was 94% (49 out of 52 patients). The mean sirolimus dose to achieve the target of ~10ng/mL for patients older than 2years was 1.8mg/m2 twice daily (range 0.8-2.9), while it was 0.7 to 1.6mg/m2 twice daily for patients 3weeks of age to 2years. A total of 676 blood concentration data were used for the population PK analysis by nonlinear mixed effect modeling using NONMEM. The final model included a maturation function for sirolimus clearance and allometrically scaled body weight to account for size differences. The mean allometrically scaled sirolimus clearance estimates increased from 3.9 to 17.0L/h per 70kg with age from shortly after the birth to 2years of age while the mean estimate for patients older than 2years was 18.5L/h per 70kg. The developed model based dosing strategy provides a foundation for ongoing efforts to define the sirolimus exposure-response and clinical outcome relationships across the pediatric age spectrum from birth to adolescence.
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Affiliation(s)
- Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Denise M Adams
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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26
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Visscher MO, Burkes SA, Adams DM, Hammill AM, Wickett RR. Infant skin maturation: Preliminary outcomes for color and biomechanical properties. Skin Res Technol 2017; 23:545-551. [PMID: 28303612 DOI: 10.1111/srt.12369] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Newborn infant skin changes after birth but studies have focused on the epidermal barrier. Dermal properties are relevant for care, but literature on postnatal changes is sparse. We further characterized skin maturational changes in lightness, color and response to biomechanical stress. METHODS Normal skin sites from subsets of participants in a trial on the progression and stage of infantile hemangiomas were retrospectively examined. Standardized photographs were analyzed as L*, a*, and b* images. Biomechanics were measured with the Cutometer® . RESULTS Color changed significantly with increasing age. Skin was darker and redder at 2.0 vs. 5.4, 8.5 and 12.8 months. Yellow color increased, with higher values at 12.8 vs. 2.0, 3.5 and 5.4 months. Chest tissue was consistently more elastic than arm and face sites, with significantly higher elasticity for the youngest and oldest age groups. Biological elasticity, elastic recovery, and total recovery were significantly greater for the oldest subjects. Viscoelasticity and elastic deformation were lower at 5.5 vs. 8.8 and 17.6 months. Arm viscoelastic creep was highest at 2.8 months. CONCLUSION Skin maturation continues into year two. Increasing elasticity and decreasing viscoelasticity may reflect increased collagen structure/function. The findings have implications for prevention of skin injury associated with mechanical forces.
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Affiliation(s)
- M O Visscher
- Skin Sciences Program, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S A Burkes
- Skin Sciences Program, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - D M Adams
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A M Hammill
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R R Wickett
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
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27
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Salloum R, Fox CE, Alvarez-Allende CR, Hammill AM, Dasgupta R, Dickie BH, Mobberley-Schuman P, Wentzel MS, Chute C, Kaul A, Patel M, Merrow AC, Gupta A, Whitworth JR, Adams DM. Response of Blue Rubber Bleb Nevus Syndrome to Sirolimus Treatment. Pediatr Blood Cancer 2016; 63:1911-4. [PMID: 27273326 DOI: 10.1002/pbc.26049] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/13/2016] [Accepted: 04/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Blue rubber bleb nevus syndrome (BRBNS) is a rare multifocal venous malformation syndrome involving predominantly the skin and gastrointestinal tract. Traditional treatment modalities include corticosteroids, interferon-α, sclerotherapy, and aggressive surgical resection. Sirolimus has been used in several single case reports. PROCEDURE We performed a single-institution retrospective review of four children with BRBNS, who received sirolimus as part of their treatment regimens. A diagnosis of BRBNS was based on clinical, radiologic, and pathologic criteria. RESULTS Median age was 6.5 years (range: 2-16 years). Pathologic evaluations revealed a combined malformation with venous and lymphatic components. The novel finding of a lymphatic component was confirmed with PROX-1 immunostaining. Patients received oral sirolimus with target drug levels between 10 and 13 ng/ml. Responses to treatment were defined as stabilization/decrease in size of lesions; resolution of transfusion requirements; reduction in pain, and improvement in quality of life (QOL). Median time to response was 1.5 months (SD ± 0.96 month, range: 1-3 months). Median follow-up was 21 months (range: 18-26 months). Lesion size and characteristics improved in all patients. All patients reported decrease in pain and improvement in QOL. All three patients requiring transfusions became transfusion-independent. One patient had resolution of coagulopathy. Adverse effects of sirolimus consisted of mucositis in three patients and neutropenia in one patient. CONCLUSIONS Sirolimus is safe and efficient for the treatment of BRBNS. Further prospective studies are needed to evaluate the long-term effectiveness of this drug. This is the first report that identifies a lymphatic component as part of BRBNS.
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Affiliation(s)
- Ralph Salloum
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Courtney E Fox
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Adrienne M Hammill
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Belinda H Dickie
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Mary Sue Wentzel
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carol Chute
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manish Patel
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Arnold C Merrow
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anita Gupta
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John R Whitworth
- Division of Gastroenterology, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Denise M Adams
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
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28
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Burkes SA, Patel M, Adams DM, Hammill AM, Eaton KP, Randall Wickett R, Visscher MO. Infantile hemangioma status by dynamic infrared thermography: A preliminary study. Int J Dermatol 2016; 55:e522-32. [PMID: 27062495 PMCID: PMC5026852 DOI: 10.1111/ijd.13298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/29/2015] [Accepted: 12/28/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Infantile hemangiomas (IH) are initially warm due to increased proliferation and perfusion then involute with apoptosis and reduced perfusion. Objective quantitative evaluation of IH treatment response is essential for improving outcomes. We applied a functional imaging method, dynamic infrared (IR) thermography, to investigate IH status versus control skin and over time. MATERIALS AND METHODS A preliminary prospective observational study was conducted among 25 subjects with superficial or mixed IHs (< 19 months) over 59 clinic visits. Infrared images of IHs and control sites, standardized color images, and three-dimensional images were obtained. Tissue responses following application and removal of a cold stress were recorded with video IR thermography. Outcomes included areas under the curve during cooling (AUCcool ) and rewarming (AUCrw ) and thermal intensity distribution maps. RESULTS AUCcool and AUCrw were significantly higher and cooling rate slower for IHs versus uninvolved tissue indicating greater heat, presumably due to greater perfusion and metabolism for the IH. IR distribution maps showed specific areas of high and low temperature. Significant changes in IH thermal activity were reflected in the difference (AUCcool - AUCrw ), with 6.2 at 2.2 months increasing to 37.6 at 12.8 months. IH cooling rate increased with age, indicating slower recovery, and interpreted as reduced proliferation and/or involution. CONCLUSIONS Dynamic IR thermography was a well-tolerated, quantitative functional imaging modality appropriate for the clinic, particularly when structural changes, i.e., height, volume, color, were not readily observed. It may assist in monitoring progress, individualizing treatment, and evaluating therapies. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov (Identifier NCT02061735).
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Affiliation(s)
- Shoná A Burkes
- Skin Sciences Program, University of Cincinnati, Cincinnati, OH, USA
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Manish Patel
- Hemangioma and Vascular Malformation Center, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Denise M Adams
- Hemangioma and Vascular Malformation Center, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Adrienne M Hammill
- Hemangioma and Vascular Malformation Center, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kenneth P Eaton
- Imaging Research Center, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Randall Wickett
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Marty O Visscher
- Skin Sciences Program, University of Cincinnati, Cincinnati, OH, USA.
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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29
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Adams DM, Trenor CC, Hammill AM, Vinks AA, Patel MN, Chaudry G, Wentzel MS, Mobberley-Schuman PS, Campbell LM, Brookbank C, Gupta A, Chute C, Eile J, McKenna J, Merrow AC, Fei L, Hornung L, Seid M, Dasgupta AR, Dickie BH, Elluru RG, Lucky AW, Weiss B, Azizkhan RG. Efficacy and Safety of Sirolimus in the Treatment of Complicated Vascular Anomalies. Pediatrics 2016; 137:e20153257. [PMID: 26783326 PMCID: PMC4732362 DOI: 10.1542/peds.2015-3257] [Citation(s) in RCA: 466] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Complicated vascular anomalies have limited therapeutic options and cause significant morbidity and mortality. This Phase II trial enrolled patients with complicated vascular anomalies to determine the efficacy and safety of treatment with sirolimus for 12 courses; each course was defined as 28 days. METHODS Treatment consisted of a continuous dosing schedule of oral sirolimus starting at 0.8 mg/m(2) per dose twice daily, with pharmacokinetic-guided target serum trough levels of 10 to 15 ng/mL. The primary outcomes were responsiveness to sirolimus by the end of course 6 (evaluated according to functional impairment score, quality of life, and radiologic assessment) and the incidence of toxicities and/or infection-related deaths. RESULTS Sixty-one patients were enrolled; 57 patients were evaluable for efficacy at the end of course 6, and 53 were evaluable at the end of course 12. No patient had a complete response at the end of course 6 or 12 as anticipated. At the end of course 6, a total of 47 patients had a partial response, 3 patients had stable disease, and 7 patients had progressive disease. Two patients were taken off of study medicine secondary to persistent adverse effects. Grade 3 and higher toxicities attributable to sirolimus included blood/bone marrow toxicity in 27% of patients, gastrointestinal toxicity in 3%, and metabolic/laboratory toxicity in 3%. No toxicity-related deaths occurred. CONCLUSIONS Sirolimus was efficacious and well tolerated in these study patients with complicated vascular anomalies. Clinical activity was reported in the majority of the disorders.
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Affiliation(s)
- Denise M. Adams
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Adrienne M. Hammill
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander A. Vinks
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manish N. Patel
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Anita Gupta
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Carol Chute
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Arnold C. Merrow
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lin Fei
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lindsey Hornung
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Michael Seid
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - A. Roshni Dasgupta
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Belinda H. Dickie
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Anne W. Lucky
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brian Weiss
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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30
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Adams DM, Hammill AM, Mobberley-Schuman PS, Trenor CC. Comment on: Steroid-resistant kaposiform hemangioendothelioma: A retrospective study of 37 patients treated with vincristine and long-term follow-up. Pediatr Blood Cancer 2015; 62:2056. [PMID: 26052679 DOI: 10.1002/pbc.25609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Denise M Adams
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Adrienne M Hammill
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | | | - Cameron C Trenor
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Burkes SA, Adams DM, Hammill AM, Chute C, Eaton KP, Welge JA, Wickett RR, Visscher MO. Skin imaging modalities quantify progression and stage of infantile haemangiomas. Br J Dermatol 2015; 173:838-41. [PMID: 25975196 DOI: 10.1111/bjd.13905] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S A Burkes
- Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A.,James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, U.S.A
| | - D M Adams
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
| | - A M Hammill
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
| | - C Chute
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
| | - K P Eaton
- Imaging Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
| | - J A Welge
- Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, U.S.A
| | - R R Wickett
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, U.S.A
| | - M O Visscher
- Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, U.S.A
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Drolet BA, Trenor CC, Brandão LR, Chiu YE, Chun RH, Dasgupta R, Garzon MC, Hammill AM, Johnson CM, Tlougan B, Blei F, David M, Elluru R, Frieden IJ, Friedlander SF, Iacobas I, Jensen JN, King DM, Lee MT, Nelson S, Patel M, Pope E, Powell J, Seefeldt M, Siegel DH, Kelly M, Adams DM. Consensus-derived practice standards plan for complicated Kaposiform hemangioendothelioma. J Pediatr 2013; 163:285-91. [PMID: 23796341 DOI: 10.1016/j.jpeds.2013.03.080] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/22/2013] [Accepted: 03/29/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Beth A Drolet
- Departments of Pediatrics and Dermatology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Hammill AM, Wentzel M, Gupta A, Nelson S, Lucky A, Elluru R, Dasgupta R, Azizkhan RG, Adams DM. Sirolimus for the treatment of complicated vascular anomalies in children. Pediatr Blood Cancer 2011; 57:1018-24. [PMID: 21445948 DOI: 10.1002/pbc.23124] [Citation(s) in RCA: 385] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 02/16/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vascular anomalies comprise a diverse group of diagnoses. While infantile hemangiomas are common, the majority of these conditions are quite rare and have not been widely studied. Some of these lesions, though benign, can impair vital structures, be deforming, or even become life-threatening. Vascular tumors such as kaposiform hemangioendotheliomas (KHE) and complicated vascular malformations have proven particularly difficult to treat. PROCEDURE Here we retrospectively evaluate a series of six patients with complicated, life-threatening vascular anomalies who were treated with the mTOR inhibitor sirolimus for compassionate use at two centers after failing multiple other therapies. RESULTS These patients showed significant improvement in clinical status with tolerable side effects. CONCLUSIONS Sirolimus appears to be effective and safe in patients with life-threatening vascular anomalies and represents an important tool in treating these diseases. These findings are currently being further evaluated in a Phase II safety and efficacy trial.
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Affiliation(s)
- Adrienne M Hammill
- Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Hammill AM, Risinger MA, Joiner CH, Keddache M, Kalfa TA. Compound heterozygosity for two novel mutations in the erythrocyte protein 4.2 gene causing spherocytosis in a Caucasian patient. Br J Haematol 2011; 152:780-3. [PMID: 21275958 DOI: 10.1111/j.1365-2141.2010.08516.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Lytic viruses kill cells as a consequence of their normal replication life cycle. The idea of harnessing viruses to kill cancer cells arose over a century ago, before viruses were even discovered, from medical case reports of infections associated with cancer remissions. Since then, there has been no shortage of hype, hope, or fear regarding the prospect of oncolytic virotherapy for cancer. Early developments in the field included encouraging antitumor efficacy both in animal studies in the 1920s-1940s and in human clinical trials in the 1950s-1970s. Despite its long-standing history, oncolytic virotherapy was an idea ahead of its time. Without needed advances in molecular biology, virology, immunology, and clinical research ethics, early clinical trials resulted in infectious complications and were fraught with controversial research conduct, so that enthusiasm in the medical community waned. Oncolytic virotherapy is now experiencing a major growth spurt, having sustained numerous laboratory advances and undergone multiple encouraging adult clinical trials, and is now witnessing the emergence of pediatric trials. Here we review the history and salient biology of the field, including preclinical and clinical data, with a special emphasis on those agents now being tested in pediatric cancer patients.
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Affiliation(s)
- Adrienne M Hammill
- Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Hsueh RC, Hammill AM, Lee JA, Uhr JW, Scheuermann RH. Activation of the Syk tyrosine kinase is insufficient for downstream signal transduction in B lymphocytes. BMC Immunol 2002; 3:16. [PMID: 12470302 PMCID: PMC139997 DOI: 10.1186/1471-2172-3-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2002] [Accepted: 12/06/2002] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immature B lymphocytes and certain B cell lymphomas undergo apoptotic cell death following activation of the B cell antigen receptor (BCR) signal transduction pathway. Several biochemical changes occur in response to BCR engagement, including activation of the Syk tyrosine kinase. Although Syk activation appears to be necessary for some downstream biochemical and cellular responses, the signaling events that precede Syk activation remain ill defined. In addition, the requirements for complete activation of the Syk-dependent signaling step remain to be elucidated. RESULTS A mutant form of Syk carrying a combination of a K395A substitution in the kinase domain and substitutions of three phenylalanines (3F) for the three C-terminal tyrosines was expressed in a murine B cell lymphoma cell line, BCL1.3B3 to interfere with normal Syk regulation as a means to examine the Syk activation step in BCR signaling. Introduction of this kinase-inactive mutant led to the constitutive activation of the endogenous wildtype Syk enzyme in the absence of receptor engagement through a 'dominant-positive' effect. Under these conditions, Syk kinase activation occurred in the absence of phosphorylation on Syk tyrosine residues. Although Syk appears to be required for BCR-induced apoptosis in several systems, no increase in spontaneous cell death was observed in these cells. Surprisingly, although the endogenous Syk kinase was enzymatically active, no enhancement in the phosphorylation of cytoplasmic proteins, including phospholipase Cgamma2 (PLCgamma2), a direct Syk target, was observed. CONCLUSION These data indicate that activation of Syk kinase enzymatic activity is insufficient for Syk-dependent signal transduction. This observation suggests that other events are required for efficient signaling. We speculate that localization of the active enzyme to a receptor complex specifically assembled for signal transduction may be the missing event.
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Affiliation(s)
- Robert C Hsueh
- Laboratory of Molecular Pathology and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adrienne M Hammill
- Laboratory of Molecular Pathology and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Cell Regulation Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jamie A Lee
- Laboratory of Molecular Pathology and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan W Uhr
- Cancer Immunobiology Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Richard H Scheuermann
- Laboratory of Molecular Pathology and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Cancer Immunobiology Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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