1
|
Kane G, Fernandez-Pineda I. Targeted therapies for vascular malformations. Front Med (Lausanne) 2024; 11:1446046. [PMID: 39290395 PMCID: PMC11405217 DOI: 10.3389/fmed.2024.1446046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 08/12/2024] [Indexed: 09/19/2024] Open
Abstract
Targeted medical therapies for the treatment of vascular malformations is an exciting and evolving area of research. As the identification of specific causative genetic mutations involved in vascular malformations becomes more accessible and inexpensive, the development of targeted therapies to address these genetic anomalies becomes all the more enticing. It is an excellent example of the potential of translational research where basic science discoveries are translated to clinical practise from 'bench to bedside'. In this mini-review we aim to synopsise some of the recent studies published in this area with specific focus on the paediatric population. We also aim to highlight the growing demand for future research in the field to elucidate further the optimum duration of treatments, strategies for discontinuation, potential for combination of therapies and the effects of prolonged use of these medications.
Collapse
Affiliation(s)
- Gavin Kane
- Children's Health Ireland, Dublin, Ireland
| | | |
Collapse
|
2
|
Dong S, Li L, Xu J, Han Z, Zheng X. Rapid response with good toleration of sirolimus for life-threatening neonatal lymphatic malformations. Pediatr Investig 2023; 7:206-211. [PMID: 37736365 PMCID: PMC10509387 DOI: 10.1002/ped4.12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/24/2023] [Indexed: 09/23/2023] Open
Abstract
Introduction Lymphatic malformations (LMs) are rare vascular anomalies predominantly affecting infants, which can be debilitating or life-threatening when complicated with intralesional bleeding or infection. Effective and safe management strategies are essential in such cases. Case presentation We report a case series involving four Chinese neonates with life-threatening LMs, initially treated with oral sirolimus. All patients achieved rapid relief and sustained remission, using a lower sirolimus dosage than previously recommended. Furthermore, adverse events were rarely recorded during follow-up. Conclusion Sirolimus can be considered a promising choice for neonates with intricate and life-threatening LMs. Initiation with a reduced sirolimus dose is advisable.
Collapse
Affiliation(s)
- Shixiao Dong
- Department of Neonatology, Neonatal Center, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Li Li
- Department of Dermatology, Plastic Surgery HospitalChinese Academy of Medical SciencesBeijingChina
| | - Jiaosheng Xu
- Department of Dermatology, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Zhonglong Han
- Department of Radiology, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Xia Zheng
- Department of Neonatology, Neonatal Center, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| |
Collapse
|
3
|
Gkalonaki I, Anastasakis M, Patoulias I. Atypical locations for cystic lymphangiomas. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
4
|
Shimano KA, Eng W, Adams DM. How we approach the use of sirolimus and new agents: Medical therapy to treat vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29603. [PMID: 35253343 DOI: 10.1002/pbc.29603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Vascular anomalies (VAs) are a heterogeneous group of primarily congenital tumors and malformations. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis. Recent discoveries evaluating the genetic causes of VAs have revealed that they are due to mutations in cancer pathways, including the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. These discoveries have led to improved phenotype-genotype correlation and have expanded medical therapy for this group of unique disorders.
Collapse
Affiliation(s)
- Kristin A Shimano
- Division of Allergy, Immunology, and Bone Marrow Transplant, UCSF Benioff Children's Hospital, University of California, San Francisco, California, USA
| | - Whitney Eng
- Division of Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Denise M Adams
- Division of Oncology, Comprehensive Vascular Anomalies Program/Frontier Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Efficacy of sirolimus in children with lymphatic malformations of the head and neck. Eur Arch Otorhinolaryngol 2022; 279:3801-3810. [PMID: 35526176 PMCID: PMC9249683 DOI: 10.1007/s00405-022-07378-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Abstract
Purpose Children with extensive lymphatic malformations of the head and neck often suffer from functional impairment and aesthetic deformity which significantly affect the quality of life and may be life-threatening. Treatment with sirolimus has the potential to improve symptoms and downsize lymphatic malformations. This systematic review summarizes the current information about sirolimus treatment of lymphatic malformations of the head and neck in children, its efficacy and side effects. Methods A systematic search of the literature regarding studies on sirolimus treatment of children with lymphatic malformations of the head and neck was performed in PubMed, Embase, and Google Scholar up to July 2021 with the search terms “lymphatic malformation”, “lymphangioma”, “cystic hygroma”, “low-flow malformation”, “sirolimus”, “rapamycin”, “mTOR inhibitor” and “children”. Results In all, 28 studies including 105 children from newborn to 17 years treated with sirolimus for lymphatic malformations of the head and neck were analyzed. The most frequent initial dose was 0.8 mg/m2 per dose, twice daily at 12-h interval. The target blood level differed between studies, 10–15 ng/mL and 5–15 ng/mL were most often used. More than 91% of the children responded to sirolimus treatment which lasts from 6 months to 4 years. Typical side effects were hyperlipidemia, neutropenia and infections. Methods Sirolimus could be an effective treatment for children with large complicated lymphatic malformations of the head and neck. As not all patients will benefit from treatment, the decision to treat sirolimus should be made by a multidisciplinary team.
Collapse
|
6
|
Al-Samkari H, Eng W. A precision medicine approach to hereditary hemorrhagic telangiectasia and complex vascular anomalies. J Thromb Haemost 2022; 20:1077-1088. [PMID: 35343049 PMCID: PMC10044495 DOI: 10.1111/jth.15715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Abstract
Vascular anomalies represent a diverse group of disorders classified broadly as malformations or tumors and include the second most common hereditary bleeding disorder worldwide, hereditary hemorrhagic telangiectasia (HHT). Patients with HHT and other vascular anomalies suffer morbid consequences of these diseases, including bleeding, thrombosis, anemia, localized intravascular coagulation, tissue overgrowth, infections, and other complications. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis, and the treatments for vascular anomalies are rapidly evolving. Recent discoveries have elucidated the molecular basis of a number of common and uncommon vascular anomalies. HHT occurs due to mutations in the transforming growth factor beta (TGF-β) pathway, resulting in vascular endothelial growth factor excess. Complex vascular anomalies including Klippel-Trénaunay syndrome (KTS) and arteriovenous malformation (AVM) may occur due to mutations in the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. The discovery of the pathophysiologic mechanisms driving these diseases has led to improved phenotype-genotype correlation and the opportunity to target molecular pathways with medical therapies. Therefore, targeted agents have quickly become a standard of care in the treatment of vascular disorders (particularly HHT). Herein, we provide a case-based approach to the use of antiangiogenic therapies including bevacizumab and pazopanib for the treatment of bleeding in HHT and the use of mammalian target of rapamycin (sirolimus), PIK3CA (alpelisib), and MEK (trametinib) inhibitors in the treatment of complex vascular anomalies.
Collapse
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Whitney Eng
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| |
Collapse
|
7
|
AlGhamdi A, AlBaqami M. Lymphangioma of the tongue in a pediatric patient. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
8
|
Chouchene F, Masmoudi F, Baaziz A, Maatouk F, Ghedira H. Oral manifestations and dental care management of a young patient with lymphangioma of the tongue: A case report. Clin Case Rep 2021; 9:e04537. [PMID: 34322267 PMCID: PMC8299271 DOI: 10.1002/ccr3.4537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
Children with lymphangioma of the tongue may require a close collaboration between physician and dentist to establish preventive, conservative approaches, and eradicate any sources of dental infections before undertaking immunosuppressive therapy.
Collapse
Affiliation(s)
- Farah Chouchene
- Pediatric and Preventive Dentistry DepartmentFaculty of Dental Medicine of MonastirMonastirTunisia
- Laboratory of Biological, Clinical and Dento‐Facial ApproachUniversity of MonastirMonastirTunisia
| | - Fatma Masmoudi
- Pediatric and Preventive Dentistry DepartmentFaculty of Dental Medicine of MonastirMonastirTunisia
- Laboratory of Biological, Clinical and Dento‐Facial ApproachUniversity of MonastirMonastirTunisia
| | - Ahlem Baaziz
- Pediatric and Preventive Dentistry DepartmentFaculty of Dental Medicine of MonastirMonastirTunisia
- Laboratory of Biological, Clinical and Dento‐Facial ApproachUniversity of MonastirMonastirTunisia
| | - Fethi Maatouk
- Pediatric and Preventive Dentistry DepartmentFaculty of Dental Medicine of MonastirMonastirTunisia
- Laboratory of Biological, Clinical and Dento‐Facial ApproachUniversity of MonastirMonastirTunisia
| | - Hichem Ghedira
- Pediatric and Preventive Dentistry DepartmentFaculty of Dental Medicine of MonastirMonastirTunisia
- Laboratory of Biological, Clinical and Dento‐Facial ApproachUniversity of MonastirMonastirTunisia
| |
Collapse
|
9
|
Geeurickx M, Labarque V. A narrative review of the role of sirolimus in the treatment of congenital vascular malformations. J Vasc Surg Venous Lymphat Disord 2021; 9:1321-1333. [PMID: 33737259 DOI: 10.1016/j.jvsv.2021.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/04/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Vascular malformations arise from defects in the morphologic development of the vascular system and can have an impact on quality of life and/or lead to severe complications. To date, vascular malformations are frequently managed by invasive techniques, after which recurrence is common. Sirolimus, a downstream inhibitor of the phosphatidylinositol 3 kinase/AKT pathway and best known for its immunosuppressive effect, has been used off-label for lesions for which approved therapies were associated with unsatisfactory results or recurrence. The aim of this study was to review the available data on the effect of sirolimus on the size and symptoms of different types of malformations and to summarize the main safety issues. METHODS A literature search in Pubmed, Embase, Web of Science, and SCOPUS was performed. Case reports, case series, and clinical trials evaluating the effect of sirolimus in vascular malformations were eligible for this review. Fully terminated studies published between January 2010 and May 2019 reporting an evaluable response on size and/or symptoms were included. Relevant data on lesion size, symptoms, side effects and duration of treatment were extracted as reported in the study. Additionally, we reported 10 unpublished cases who were treated in UZ Leuven. RESULTS The literature review included 68 articles, describing 324 patients. The median duration of therapy was 12 months (range, 1-60 months). After 6 months of treatment, the size of the malformation had at least decreased in 67% of patients with common venous malformations (VM), in 93% of patients with blue rubber bleb nevus syndrome and in all patients with verrucous VM. The size of lymphatic malformations improved in more than 80% of the patients, even in the case of extensive involvement such as in Gorham-Stout disease and generalized lymphatic anomaly. In addition, the majority of patients with syndromic vascular malformations experienced a decrease in size and reported symptoms improved in almost all patients, regardless of the type of malformation. Side effects were common (53%) but usually mild; mucositis and bone marrow suppression were the most common. Regrowth or recurrence of symptoms occurred in 49% of patients who discontinued treatment. Comparable effects were seen in our own patients. CONCLUSIONS This review shows that sirolimus is effective in decreasing the size and/or symptoms of particularly lymphatic malformations as well as VMs. Although common, side effects were usually mild. Nevertheless, clinical trials are needed to confirm the safety and effectivity of sirolimus and to identify the required serum levels and duration of treatment.
Collapse
Affiliation(s)
- Marlies Geeurickx
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Veerle Labarque
- Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Leuven, Belgium; Catholic University Leuven, Center for Molecular and Vascular Biology, Leuven, Belgium.
| |
Collapse
|
10
|
Cryer R, Gera S, Gera P. Multi-disciplinary treatment of retroperitoneal lymphatic malformations. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
11
|
Abstract
Vascular malformations are inborn errors of vascular morphogenesis and consist of localized networks of abnormal blood and/or lymphatic vessels with weak endothelial cell proliferation. They have historically been managed by surgery and sclerotherapy. Extensive insight into the genetic origin and molecular mechanism of development has been accumulated over the last 20 years. Since the discovery of the first somatic mutations in a vascular anomaly 10 years ago, it is now recognized that they are perhaps all caused by inherited or somatic mutations in genes that hyperactivate two major intracellular signaling pathways: the RAS/MAPK/ERK and/or the phosphatidylinositol 3 kinase (PIK3)/protein kinase B/mammalian target of rapamycin (mTOR) pathway. Several targeted molecular inhibitors of these pathways have been developed, mostly for the treatment of cancers that harbor mutations in the same pathways. The mTOR inhibitor sirolimus is the most studied compound for the treatment of venous, lymphatic, and complex malformations. Disease responses of vascular malformations to sirolimus have now been reported in several studies in terms of clinical changes, quality of life, functional and radiological outcomes, and safety. Other targeted treatment strategies, such as the PIK3CA inhibitor alpelisib for PIK3CA-mutated vascular malformations, are also emerging. Repurposing of cancer drugs has become a major focus in this rapidly evolving field.
Collapse
|
12
|
|
13
|
Liviskie CJ, Brennan CC, McPherson CC, Vesoulis ZA. Propranolol for the Treatment of Lymphatic Malformations in a Neonate - A Case Report and Review of Literature. J Pediatr Pharmacol Ther 2020; 25:155-162. [PMID: 32071591 DOI: 10.5863/1551-6776-25.2.155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lymphatic malformations in neonates often manifest as a chylothorax, and although rare, morbidity and mortality can be significant. First-line treatment with medium-chain triglyceride-enriched formulas, or enteric rest with total parenteral nutrition, are not always successful. We describe the case of a premature neonate with trisomy 21 who presented with bilateral pleural effusions and a pericardial effusion that worsened with the initiation of enteral nutrition. Clinical improvement was not seen until the initiation of treatment with oral propranolol at a maximum dosage of 0.5 mg/kg/day divided every 8 hours with extubation 8 days after propranolol initiation. Two case reports have described the use of propranolol in similar patients receiving 2 mg/kg/day; however, our experience is the first to report treatment success at a much lower dose. A review of the literature for alternative medication treatments uncovered numerous case reports and series documenting variable results with incongruent definitions of treatment success in a diverse patient population. The rarity of this disease state makes accrual of patients difficult and more robust treatment data unlikely. Therefore, selection of the optimal adjunctive treatment must be based on individual patient and disease state characteristics as well as safety and efficacy profile of the medication.
Collapse
|
14
|
Honnorat M, Viremouneix L, Ayari S, Guibaud L, Coste K, Claris O, Butin M. Early Adjuvant Medication With the mTOR Inhibitor Sirolimus in a Preterm Neonate With Compressive Cystic Lymphatic Malformation. Front Pediatr 2020; 8:418. [PMID: 32850534 PMCID: PMC7399047 DOI: 10.3389/fped.2020.00418] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/17/2020] [Indexed: 12/02/2022] Open
Abstract
Cystic lymphatic malformations result from an abnormal embryological development of the lymphatic structures. Here we report on a case of a preterm female baby, born at 34 weeks of gestation, with a voluminous cervicofacial cystic lymphatic malformation responsible for an airway obstruction. An mTOR inhibitor, sirolimus, was started from the first day of life, and was combined with iterative sclerotherapy procedures. This case illustrates a safe and successful early administration of sirolimus in a preterm neonate.
Collapse
Affiliation(s)
- Marion Honnorat
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France
| | - Loïc Viremouneix
- Centre de Compétence des Anomalies Vasculaires Superficielles FAVA-Multi Network, HFME, Hospices Civils de Lyon, Bron, France.,Service de Radiologie Pédiatrique, HFME, Hospices Civils de Lyon, Bron, France
| | - Sonia Ayari
- Service de Chirurgie ORL, HFME, Hospices Civils de Lyon, Bron, France
| | - Laurent Guibaud
- Centre de Compétence des Anomalies Vasculaires Superficielles FAVA-Multi Network, HFME, Hospices Civils de Lyon, Bron, France.,Service de Radiologie Pédiatrique, HFME, Hospices Civils de Lyon, Bron, France
| | - Karen Coste
- Service de Réanimation Pédiatrique et Néonatale, CHU ESTAING, Clermont-Ferrand, France.,Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Olivier Claris
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France.,Université Claude Bernard, Villeurbanne, France
| | - Marine Butin
- Service de Réanimation Néonatale, HFME, Hospices Civils de Lyon, Bron, France.,INSERM U1111, Centre International de Recherche en Infectiologie, Equipe "Pathogénèse des Infections à Staphylocoques", Lyon, France
| |
Collapse
|
15
|
Pandey V, Tiwari P, Sharma SP, Kumar R, Panigrahi P, Singh OP, Patne S. Development of a biomarker of efficacy in second-line treatment for lymphangioma of the tongue: a pilot study. Br J Oral Maxillofac Surg 2019; 57:1137-1142. [PMID: 31727434 DOI: 10.1016/j.bjoms.2019.10.303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 10/11/2019] [Indexed: 02/07/2023]
Abstract
Lymphangioma of the tongue is a rare lymphatic malformation, and various authors have reported the successful use of sirolimus for its treatment. However, the safety of sirolimus in children needs further evaluation so that those who do not respond are not necessarily exposed to its potential adverse effects. We hypothesised that assessment of lymphangiogenesis can be used to predict whether the patient will respond to sirolimus, so we organised a prospective study after ethics committee approval had been given. After clinical and histological diagnoses of lymphangioma of the tongue had been confirmed, 16 patients were given sirolimus 0.8mg/day in three divided doses. Clinical response was assessed and compared with lymphatic microvessel density (LMVD), which was calculated immunohistochemically using the monoclonal antibody D2-40 as the lymphatic endothelial marker. Nine patients responded well, five partially, and two failed to respond. Mean (SD) LVD among the good responders was 21.00 (3.74), whereas among non-responders it was 8.00 (4.24). There was a significant difference in mean LVD between good responders, partial responders, and non-responders (p=0.04). Sirolimus is effective in treating children with lymphangioma of the tongue, and lymphangiogenesis is a useful therapeutic predictive marker.
Collapse
Affiliation(s)
- V Pandey
- Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India.
| | - P Tiwari
- Department of Oral and Maxillofacial Surgery, Faculty of Dental sciences, Institute of Medical Sciences, Banaras Hindu University.
| | - S P Sharma
- Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India
| | - R Kumar
- Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India.
| | - P Panigrahi
- Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India.
| | - O P Singh
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University.
| | - S Patne
- Department of Pathology, Institute of Medical Sciences, Banaras Hindu University.
| |
Collapse
|
16
|
Abiramalatha T, Johnson T, Balakrishnan U, Amboiram P. Novel clinical phenotype of generalised lymphatic dysplasia in a neonate: a missed diagnosis. BMJ Case Rep 2019; 12:12/8/e229260. [PMID: 31471355 DOI: 10.1136/bcr-2019-229260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a preterm neonate who had a large cervical cystic hygroma and right chylothorax. She was operated on day-21 and a near-complete resection of cystic hygroma was done. She developed refractory hypoxemia and shock post surgery and died after 24 hours. During autopsy, the chest cavity was found to be filled with chyle. Histopathological examination showed dilated lymphatics in the pleura, hepatic capsule, serosa of stomach and intestines, peri-pancreatic regions, peri-renal capsule and peri-adrenal tissues suggestive of generalised lymphatic dysplasia. Clinical exome sequencing did not reveal any pathogenic mutation in the genes involved in primary lymphatic dysplasia, noonan syndrome or rasopathies.
Collapse
Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Thanka Johnson
- Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Prakash Amboiram
- Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| |
Collapse
|
17
|
|
18
|
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] [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.
Collapse
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
| |
Collapse
|
19
|
Ghariani Fetoui N, Boussofara L, Gammoudi R, Belajouza C, Ghariani N, Denguezli M. Efficacy of sirolimus in the treatment of microcystic lymphatic malformation of the tongue. J Eur Acad Dermatol Venereol 2019; 33:e336-e337. [DOI: 10.1111/jdv.15628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- N. Ghariani Fetoui
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - L. Boussofara
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - R. Gammoudi
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - C. Belajouza
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - N. Ghariani
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| | - M. Denguezli
- Department of Dermatology Farhat Hached University Hospital Sousse Tunisia
| |
Collapse
|
20
|
Elbow Cystic Lymphangioma in an 8-Month-Old Boy. Case Rep Orthop 2019; 2019:8762614. [PMID: 30886754 PMCID: PMC6388320 DOI: 10.1155/2019/8762614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/29/2019] [Indexed: 12/02/2022] Open
Abstract
Cystic lymphangiomas are benign tumors originating mainly in the head and neck of the pediatric population. The authors report a rare case of cystic lymphangioma in the right elbow of an 8-month-old baby treated successfully by complete surgical resection.
Collapse
|
21
|
García-Montero P, del Boz J, Baselga-Torres E, Azaña-Defez JM, Alcaraz-Vera M, Tercedor-Sánchez J, Noguera-Morel L, Vera-Casaño Á. Use of topical rapamycin in the treatment of superficial lymphatic malformations. J Am Acad Dermatol 2019; 80:508-515. [PMID: 30296533 DOI: 10.1016/j.jaad.2018.09.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/26/2018] [Accepted: 09/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The superficial lymphatic component of vascular malformations poses a significant treatment challenge. It is responsible for the majority of symptoms presented, and to date, there is no consensus regarding treatment. OBJECTIVE To evaluate the effectiveness of topical rapamycin in treating superficial lymphatic malformations (LM). METHODS A case series study was performed of patients with superficial LM, treated with topical rapamycin. The clinical characteristics of patients and the concentration and application mode of the drug were recorded. The changes in the signs and symptoms observed and associated adverse effects were noted and analyzed. RESULTS The study population consisted of 11 patients of an average age of 10.5 years. All were treated with topical rapamycin: 6 patients with a 1% concentration, 1 with a 0.8% concentration, and 4 with a 0.4% concentration. Changes in the clinical appearance of the lesions were observed in all patients. The associated symptoms, present in 9 of 11 patients, improved in every case. The mean follow-up time was 16.1 months. LIMITATIONS This study is retrospective, with a small sample size and considerable heterogeneity of lesions and treatment approaches. CONCLUSION Treatment with topical rapamycin modifies the clinical appearance and alleviates symptoms of superficial LM.
Collapse
|
22
|
Wiegand S, Wichmann G, Dietz A. Treatment of Lymphatic Malformations with the mTOR Inhibitor Sirolimus: A Systematic Review. Lymphat Res Biol 2018; 16:330-339. [PMID: 29924669 DOI: 10.1089/lrb.2017.0062] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Extensive lymphatic malformations are low-flow vascular malformations that can cause devastating complications. Treatment of these malformations is challenging. This systematic review presents current use of sirolimus in patients with extensive lymphatic malformations. METHODS MEDLINE and Google scholar search was conducted for studies on sirolimus treatment of lymphatic malformations up to July 2017. Search items included "lymphatic malformation," "lymphangioma," "cystic hygroma," "vascular malformation," "low-flow malformation," "sirolimus," "rapamycin," and "mTOR inhibitor." RESULTS Twenty studies, including 71 patients receiving sirolimus, were included into this review. Forty-five patients had lymphatic malformations, eight patients venolymphatic malformations, and 19 patients capillary-lymphatico-venous malformations. Sirolimus led to a partial remission of disease in 60 patients, three patients had a progressive disease, and the outcome of eight patients was not reported. Dosing, target trough level, and duration of treatment differed between the studies. Common adverse effects were hyperlipidemia and neutropenia. CONCLUSIONS Available literature indicated that sirolimus therapy might be effective for lymphatic malformations. However, further randomized controlled studies are required to analyze the efficacy and long-term adverse events and to clarify the potential role for sirolimus in the management of lymphatic malformations.
Collapse
Affiliation(s)
- Susanne Wiegand
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
| | - Gunnar Wichmann
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
| | - Andreas Dietz
- Department of Otolaryngology, Head and Neck Surgery, University of Leipzig , Leipzig, Germany
| |
Collapse
|
23
|
Zhang B, Ma L. Updated classification and therapy of vascular malformations in pediatric patients. Pediatr Investig 2018; 2:119-123. [PMID: 32851245 PMCID: PMC7331351 DOI: 10.1002/ped4.12043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/13/2018] [Indexed: 12/12/2022] Open
Abstract
Vascular malformations (VMs) comprise a diverse group of diagnoses. They are classified by the type of vessel involved, including capillaries, veins, arteries, lymphatic vessels, or combinations of these. Complex VMs, although benign, can impair vital structures, cause deformations, or even threaten the child's life. Although multimodal treatment of VMs in children with disease include a wide variety of options such as observation, laser therapy, sclerotherapy, surgical resection, radiofrequency ablation, and medical therapy, the management of VMs necessitates a multifocal and multidisciplinary method with the patient's quality of life as the priority.
Collapse
Affiliation(s)
- Bin Zhang
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Lin Ma
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| |
Collapse
|
24
|
Abstract
BACKGROUND Oral propranolol has become first-line intervention for problematic infantile hemangioma (IH) that is not amenable to topical or intralesional therapies. Consensus data supporting its efficacy for other vascular anomalies does not exist. The purpose of this study was to determine the frequency and causes of propranolol use for vascular lesions other than IH. METHODS Referrals to our Vascular Anomalies Center between 2008 and 2017 were reviewed for patients treated with propranolol at an outside institution. Patient history, photographs, imaging studies, and/or histopathology were evaluated by an interdisciplinary team to diagnose the vascular anomaly. Our center's diagnosis was compared to the referral diagnosis to categorize patients into 3 groups: Group 1 (patients were appropriately labeled with an IH); Group 2 (individuals were erroneously diagnosed with IH); and Group 3 (subjects were diagnosed with a vascular anomaly other than IH). RESULTS Two hundred thirty-six patients met inclusion criteria. Group 1 (39%; n = 91) had an IH and were treated appropriately. Group 2 (20%; n = 49) was misdiagnosed with IH and incorrectly received propranolol. Group 3 (41%; n = 96) was given propranolol to treat another vascular anomaly. Propranolol did not have efficacy for vascular anomalies other than IH. CONCLUSIONS Propranolol commonly is used to treat lesions other than IH; misdiagnosis of a lesion as IH is a common cause. Propranolol should be used with caution to treat other types of vascular anomalies because patients are subjected to the risks of the drug without data supporting its efficacy.
Collapse
|
25
|
Nasser M, Ahmad K, Cottin V. Mediastinal lymphangioma in an adult. J Thorac Cardiovasc Surg 2018; 155:e195-e197. [PMID: 29397964 DOI: 10.1016/j.jtcvs.2017.12.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/14/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Mouhamad Nasser
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Hospices Civils de Lyon, Lyon, France
| | - Kais Ahmad
- Claude Bernard Lyon 1 University, University of Lyon, INRA, UMR754, Lyon, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Center for Rare Pulmonary Diseases, Hospices Civils de Lyon, Lyon, France; Claude Bernard Lyon 1 University, University of Lyon, INRA, UMR754, Lyon, France.
| |
Collapse
|
26
|
Heredea R, Cimpean AM, Cerbu S, Popoiu CM, Jitariu AA, Raica M. New Approach to Rare Pediatric Multicystic Mesenteric Lymphangioma; Would It Guide the Development of Targeted Therapy? Front Pediatr 2018; 6:223. [PMID: 30131951 PMCID: PMC6090038 DOI: 10.3389/fped.2018.00223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/19/2018] [Indexed: 11/13/2022] Open
Abstract
In children, lymphangiomas are extremely rare pathologic entities that are characterized by unusual locations. The mesenteric localization is extremely rare in children, and the clinical signs usually mimic an acute abdominal syndrome. For most of the cases, their diagnosis is established by the radiologist, and the main therapeutic option is represented by surgery for lesion removal. We hereby describe the case of a 4 year old girl admitted to the pediatric emergency department for continuous abdominal pain, more intense in the orthostatic position, associated with abdominal distension, nausea, and vomiting. These symptoms raised the clinical suspicion of acute abdominal syndrome. The patient had no previous clinically significant events. Radiologic examination suggested a mesenteric multicystic lymphangioma certified by surgical and histopathological evaluation. No specific targeted therapy is currently available; moreover, no specific criteria for recurrences have been stated. A new approach of infantile lymphangiomas following surgery, regarding the use of specific lymphatic markers panel including D2-40, Prox-1, VEGFR-3, PDGFs, and Ki67 may improve the characterization of such lesions regarding their prognosis, recurrence rate and targeted therapy implementation especially for those with a more aggressive or recurrent behavior.
Collapse
Affiliation(s)
- Rodica Heredea
- Department of Pathology, "Louis Turcanu" Children's Clinical Emergency Hospital, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Anca M Cimpean
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Simona Cerbu
- Department of Radiology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Calin M Popoiu
- Department of Pediatric Surgery, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Adriana A Jitariu
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Marius Raica
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| |
Collapse
|
27
|
Amodeo I, Colnaghi M, Raffaeli G, Cavallaro G, Ciralli F, Gangi S, Leva E, Pignataro L, Borzani I, Pugni L, Mosca F. The use of sirolimus in the treatment of giant cystic lymphangioma: Four case reports and update of medical therapy. Medicine (Baltimore) 2017; 96:e8871. [PMID: 29390423 PMCID: PMC5758125 DOI: 10.1097/md.0000000000008871] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Lymphatic malformations (LMs) are rare and benign anomalies resulting from the defective embryological development of the primordial lymphatic structures. Due to their permeative growth throughout all tissue layers, treatment is often challenging. Small asymptomatic lesions can be conservatively managed, while symptomatic lesions require active management. Surgery has been historically considered the treatment of choice, but today less invasive therapeutic options are preferred (sclerotherapy, laser therapy, oral medications). However, there are not uniform therapeutic protocols. Sirolimus is an oral medication that has been reported to be effective in the recent literature. Here we present the case of 4 newborns with giant multicystic lymphangioma treated with oral sirolimus after surgical resection had failed. PATIENT CONCERNS At birth the LMs were clinically appreciated as giant masses involving different organs and structures. DIAGNOSES All patients had a prenatal diagnosis of giant multicystic lymphangioma confirmed at histological and cytological analysis. INTERVENTIONS Patients were treated with oral sirolimus after unsuccessful surgical resection. OUTCOMES In all patients, sirolimus determined an overall reduction of the mass and a global involution from the macro- to the microcystic composition. Sirolimus was safe and poor disadvantages had been observed. The main and isolated adverse effect at laboratory analysis was progressive dyslipidemia, with increasing levels of total cholesterol and triglycerides. LESSONS To date, our experience with sirolimus in the management of LMs is favorable. We recommend the use of sirolimus after unsuccessful surgical excision have been tried or when the surgical approach is not feasible. A multidisciplinary follow-up is needed to monitor disease evolution.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | | |
Collapse
|
28
|
Abstract
Vascular anomalies comprise a spectrum of diseases that are broadly classified as tumors and malformations. Diagnosis is often challenging, given a wide range of clinical presentations with overlapping signs and symptoms. Accurate diagnosis is critical to determine prognosis and to generate a management plan, which frequently involves multiple subspecialists during different phases of treatment. An updated classification system provides structure and clear, consistent terminology, allowing for improved diagnosis, provider communication, and collaboration. Historically, treatment of vascular anomalies was primarily surgical and medical therapies were limited or ineffective. Recent discoveries of pharmacologic agents effective in treating vascular anomalies have broadened our medical therapeutic options, limiting the need for unnecessary or high-risk procedures and improving patients' quality of life.
Collapse
Affiliation(s)
- Kiersten W Ricci
- Division of Hematology, Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
29
|
Tu JH, Tafoya E, Jeng M, Teng JM. Long-Term Follow-Up of Lymphatic Malformations in Children Treated with Sildenafil. Pediatr Dermatol 2017; 34:559-565. [PMID: 28884903 DOI: 10.1111/pde.13237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/OBJECTIVES Lymphatic malformations (LMs) are challenging to treat. Reports on the benefits of sildenafil for LM management have been mixed. This study evaluated long-term clinical outcomes of pediatric LM patients after sildenafil treatment. METHODS A retrospective chart review was performed on pediatric LM patients treated with sildenafil in the past 5 years. Patients were also contacted to complete a survey of comprehensive questions about their LM after sildenafil and subsequent interventions. RESULTS Of 12 patients identified, 10 (83.3%) participated in the follow-up survey. The average age was 8 years (range 4-16 yrs), median treatment duration was 9 months, and the average time of follow-up after sildenafil was 4 years; one patient is still taking sildenafil. Ten patients surveyed (83.3%) reported positive therapeutic response, with improvement in the size and compressibility of their LM during posttreatment clinical visits. Six received additional interventions (four sirolimus, one sclerotherapy, one surgery) after sildenafil was discontinued, with all but one reporting a positive response to subsequent interventions. Minor side effects at the time of sildenafil treatment included mild flushing, dizziness, and transient nausea, but no adverse effects were reported at the long-term follow-up. CONCLUSION This is the first report of long-term follow-up of pediatric LM patients treated with sildenafil. Our findings suggest that sildenafil is beneficial for the symptomatic treatment of LMs. Additional analysis on the role of sildenafil as adjuvant therapy is necessary to optimize the use of this medication in the management of complex LMs.
Collapse
Affiliation(s)
- Joanna H Tu
- College of Physicians and Surgeons, Columbia University, New York, New York.,Department of Dermatology, Stanford University, Stanford, California
| | - Elidia Tafoya
- Department of Dermatology, Stanford University, Stanford, California
| | - Michael Jeng
- Department of Hematology and Oncology, Stanford University, Stanford, California
| | - Joyce M Teng
- Department of Dermatology, Stanford University, Stanford, California
| |
Collapse
|
30
|
Abstract
BACKGROUND Blue rubber bleb nevus syndrome is a rare disease involving venous malformations. CASE CHARACTERISTICS We present a 6-year-old female with the syndrome, and consumptive coagulopathy. INTERVENTION/OUTCOME After management with sirolimus, symptoms resolved. MESSAGE Sirolimus may be a valuable option for reducing bleeding complications and cosmetic sequelae for the patients with this syndrome.
Collapse
|
31
|
Wu JK, Hooper ED, Laifer-Narin SL, Simpson LL, Kandel J, Shawber CJ. Initial Experience With Propranolol Treatment of Lymphatic Anomalies: A Case Series. Pediatrics 2016; 138:peds.2015-4545. [PMID: 27561730 PMCID: PMC5005016 DOI: 10.1542/peds.2015-4545] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 11/24/2022] Open
Abstract
Lymphatic malformations (LMs) are congenital lymphatic lesions that impose significant and costly morbidities on affected patients. Treatment options are limited due to incomplete understanding of LM pathobiology. Expression of an activated β2-adrenergic receptor has been described in LM tissue, suggesting that this pathway may contribute to the clinical manifestations of LM. We hypothesized that propranolol, a β-adrenergic receptor antagonist, might improve symptoms of patients with LMs and lymphatic anomalies. A retrospective chart review of patients treated with propranolol as an adjunct therapy was conducted; analyses included demographic characteristics, clinical features, and response to propranolol. Three patients with cystic and noncystic LMs displayed clinical improvement at a minimum dose of 0.7 mg/kg/d, whereas symptomatic relapses were observed when propranolol doses dropped below this threshold. Two patients with Klippel-Trenaunay syndrome demonstrated partial clinical responses with reduced edema. The fetus of a mother treated with propranolol from a gestational age of 35 weeks through delivery displayed arrested growth of a cervicofacial LM. Our retrospective review suggests that propranolol improved symptoms in a subset of patients with lymphatic anomalies. Propranolol treatment may also limit the growth of congenital LMs in utero.
Collapse
Affiliation(s)
| | | | | | - Lynn L. Simpson
- Obstetrics & Gynecology, College of Physicians and Surgeons, New York, New York; and
| | - Jessica Kandel
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Carrie J. Shawber
- Departments of Surgery,,Obstetrics & Gynecology, College of Physicians and Surgeons, New York, New York; and
| | | |
Collapse
|
32
|
Lerat J, Mounayer C, Scomparin A, Orsel S, Bessede JP, Aubry K. Head and neck lymphatic malformation and treatment: Clinical study of 23 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133:393-396. [PMID: 27497629 DOI: 10.1016/j.anorl.2016.07.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Head and neck lymphatic malformation is a rare benign tumor, mainly affecting children under 1 year of age. Total resection is often difficult, and recurrence is frequent. Functional and esthetic sequelae are a major issue. MATERIALS AND METHODS A single-center retrospective study recruited patients with head and neck lymphatic malformation managed surgically, with or without associated sclerosis by alcohol, bleomycin or aetoxisclerol, between January 1, 2004 and December 31, 2013. Local control, recurrence and complications rates were analyzed, as were swallowing disorder, tracheostomy and impaired phonation. RESULTS Twenty-three patients, with a mean age of 15.80 years, were included. Location was suprahyoid in 17 cases (73.91%) and infrahyoid in 6 (26.09%). There were 11 macrocysts (47.82%), 2 microcysts (8.70%) and 10 mixed lesions (43.48%). Three patients showed spontaneous resolution; 12 patients (52.17%) underwent a single surgical procedure, 2 (8.7%) multiple procedures, 2 (8.7%) 1 surgical procedure and 1 sclerosis, 2 (8.7%) 1 surgical procedure and multiple scleroses, and 2 (8.7%) multiple procedures and multiple scleroses. The local control rate was 69.56%. There were 8 recurrences (34.78%), all in suprahyoid microcystic or mixed lesions. There were 2 complications (8.7%): 1 severe upper cervical edema following sclerosis of the floor of the mouth, and 1 postsurgical palsy of the marginal mandibular branch of the facial nerve. In 1 case (4.35%), a nasogastric tube was required for 6 days, without tracheostomy. CONCLUSION Recurrence was frequent, with non-negligible functional and esthetic impact, especially in case of suprahyoid and microcystic lesion.
Collapse
Affiliation(s)
- J Lerat
- CHU Dupuytren, Service ORL et Chirurgie Cervico-Faciale, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
| | - C Mounayer
- CHU Dupuytren, Service de Neuroradiologie Interventionnelle, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - A Scomparin
- CHU Dupuytren, Service ORL et Chirurgie Cervico-Faciale, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - S Orsel
- CHU Dupuytren, Service ORL et Chirurgie Cervico-Faciale, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - J-P Bessede
- CHU Dupuytren, Service ORL et Chirurgie Cervico-Faciale, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - K Aubry
- CHU Dupuytren, Service ORL et Chirurgie Cervico-Faciale, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| |
Collapse
|
33
|
Linnaus ME, Notrica DM. Infected cystic hygroma resulting in septic shock and respiratory failure: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
34
|
Defnet AM, Bagrodia N, Hernandez SL, Gwilliam N, Kandel JJ. Pediatric lymphatic malformations: evolving understanding and therapeutic options. Pediatr Surg Int 2016; 32:425-33. [PMID: 26815877 DOI: 10.1007/s00383-016-3867-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 12/12/2022]
Abstract
Multimodal treatment of lymphatic malformations continues to expand as new information about the biology and genetics of these lesions is discovered, along with knowledge gained from clinical practice. A patient-centered approach, ideally provided by a multidisciplinary medical and surgical team, should guide timing and modality of treatment. Current treatment options include observation, surgery, sclerotherapy, radiofrequency ablation, and laser therapy. New medical and surgical therapies are emerging, and include sildenafil, propranolol, sirolimus, and vascularized lymph node transfer. The primary focus of management is to support and optimize these patients' quality of life. Researchers continue to study lymphatic malformations with the goal of increasing therapeutic options and developing effective clinical pathways for these complicated lesions.
Collapse
Affiliation(s)
- Ann M Defnet
- Department of Surgery, Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5839 S. Maryland, Suite A-426, MC 4062, Chicago, IL, 60637, USA
| | - Naina Bagrodia
- Department of Surgery, Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5839 S. Maryland, Suite A-426, MC 4062, Chicago, IL, 60637, USA
| | - Sonia L Hernandez
- Department of Surgery, Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5839 S. Maryland, Suite A-426, MC 4062, Chicago, IL, 60637, USA
| | - Natalie Gwilliam
- Department of Surgery, Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5839 S. Maryland, Suite A-426, MC 4062, Chicago, IL, 60637, USA
| | - Jessica J Kandel
- Department of Surgery, Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine and Biological Sciences, 5839 S. Maryland, Suite A-426, MC 4062, Chicago, IL, 60637, USA.
| |
Collapse
|
35
|
An Interesting Association of Cystic Hygroma of the Neck and Lymphangioma Causing a Paediatric Swollen Tongue. Case Rep Pediatr 2016; 2016:7930945. [PMID: 27069707 PMCID: PMC4812285 DOI: 10.1155/2016/7930945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/27/2016] [Accepted: 02/08/2016] [Indexed: 11/17/2022] Open
Abstract
Up to 75% of lymphatic malformations occur in the head and neck region. Of these, cystic hygromas and lymphangiomas have been widely reported; however they rarely occur in the same patient. We report the case of a 5-year-old girl who presented to the Department of Paediatrics of a district general hospital with a short history of recurrent, painful swelling of the anterior one-third of her tongue. She was reviewed under the joint care of the Oral and Maxillofacial Surgery and Otolaryngology Teams. Relevant past medical history included a previously excised cystic hygroma from her right neck when she was aged 2 years. Diagnosis of lymphangioma was made and of the potential management options available active monitoring was favoured due to the patient's age. To our knowledge the occurrence of both tongue lymphangioma and cystic hygroma has not been previously reported in a paediatric patient. This case report therefore shows a rare association between a cystic hygroma of the neck and lymphangioma of the tongue.
Collapse
|
36
|
Ersoy AO, Oztas E, Saridogan E, Ozler S, Danisman N. An Unusual Origin of Fetal Lymphangioma Filling Right Axilla. J Clin Diagn Res 2016; 10:QD09-11. [PMID: 27134953 PMCID: PMC4843338 DOI: 10.7860/jcdr/2016/18516.7513] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 01/27/2016] [Indexed: 01/30/2023]
Abstract
Fetal lymphangioma is a hamartomatous congenital anomaly of the lymphatic system, which is embracing the fetal skin (sometimes mucous membranes) and the subcutaneous tissue. The general consensus is that it occurs as a result of failure in lymphatic drainage. A 36-year-old pregnant woman was referred to our perinatology clinic at 22 weeks' gestation, because of a fetal right-sided axillary mass revealed by ultrasonography. The mass measuring 5x7x7cm in three dimensions had a multilocular structure without colour Doppler flow and well-circumscribed borders. Amniocentesis revealed a normal constitutional karyotyping. Lymphangioma was considered as prediagnosis. A healthy female baby weighing 3470 grams was delivered at term. Neonatal examination and the postnatal MRI confirmed the diagnosis. The baby is still on follow-up with the medical treatment of Sirolimus an anti-proliferative drug, and the mass got smaller significantly in 8 months after delivery.
Collapse
Affiliation(s)
- Ali Ozgur Ersoy
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Efser Oztas
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Erdinc Saridogan
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Sibel Ozler
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Nuri Danisman
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
37
|
Abstract
Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").
Collapse
Affiliation(s)
- Andreas Pfleger
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Austria.
| |
Collapse
|
38
|
Díaz Marugán VM, Lopez-Gutierrez JC. Primary Intestinal Lymphangiectasia and its Association With Generalized Lymphatic Anomaly. JOURNAL OF PEDIATRICS REVIEW 2016. [DOI: 10.17795/jpr-4790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
39
|
Laforgia N, Schettini F, De Mattia D, Martinelli D, Ladisa G, Favia V. Lymphatic Malformation in Newborns as the First Sign of Diffuse Lymphangiomatosis: Successful Treatment with Sirolimus. Neonatology 2016; 109:52-5. [PMID: 26506225 DOI: 10.1159/000440939] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/07/2015] [Indexed: 12/14/2022]
Abstract
Cystic hygroma and lymphangioma, currently defined as 'lymphatic malformations', are developmental abnormalities of the lymphoid system with potential for rapid expansion. The management of these abnormalities depends on the site and extent of the lesion. A different disease is diffuse lymphangiomatosis. It is very rare at birth and its treatment remains controversial. A lymphatic malformation (cystic hygroma) of the neck of a newborn girl as the first sign of diffuse lymphangiomatosis and treatment of the latter condition with sirolimus are presented. A newborn girl with a presumed isolated lymphatic malformation of the neck and significant respiratory involvement was diagnosed via total-body nuclear magnetic resonance imaging to be affected by diffuse lymphangiomatosis; she was treated with sirolimus. The treatment with sirolimus was found to be very effective, with complete resolution of the disease, good tolerability, and no side effects. This report suggests the need to explore the possibility of diffuse lymphangiomatosis in neonates with apparently isolated lymphatic malformations. In the presence of clinical deterioration, sirolimus treatment may achieve excellent results with no adverse events.
Collapse
Affiliation(s)
- Nicola Laforgia
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | | | | | | | | | | |
Collapse
|
40
|
Olive A, Moldenhauer JS, Laje P, Johnson MP, Coleman BG, Victoria T, Flake AW, Adzick NS. Axillary lymphatic malformations: Prenatal evaluation and postnatal outcomes. J Pediatr Surg 2015; 50:1711-5. [PMID: 25959530 DOI: 10.1016/j.jpedsurg.2015.03.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 03/18/2015] [Accepted: 03/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study is to describe the prenatal findings and postnatal outcomes of fetuses with axillary lymphatic malformations. METHODS Retrospective chart review of fetuses with the prenatal diagnosis of isolated axillary lymphatic malformation detected between 2009 and 2013. RESULTS There were 8 fetuses diagnosed with isolated axillary lymphatic malformation. Median gestational age at diagnosis was 20.5 (19-28) weeks. All fetuses were evaluated by serial ultrasound and ultrafast fetal MRI. Two pregnancies were electively terminated. All continued pregnancies reached term, and all fetuses were delivered by cesarean section. None of the fetuses developed polyhydramnios or hydrops fetalis. Only one patient had an associated malformation (coarctation of the aorta). All patients were evaluated postnatally by MRI. Treatment included sclerotherapy only (1), sclerotherapy followed by surgical resection (1), surgical resection only (3), and observation (1). The median postnatal hospital stay was 8 (6-15) days. Three cases recurred after the initial treatment, two after surgery and one after sclerotherapy. On a median follow up of 2.1 years, all patients have some degree of visible residual disease. There were no deaths. CONCLUSIONS Prenatal diagnosis of axillary lymphatic malformation is increasing with improved technology. Axillary lymphatic malformations are usually isolated developmental anomalies that do not affect fetal health. Postnatal management options include surgery, sclerotherapy, and observation. Recurrences and residual disease after all types of treatment are frequent. This should be communicated to the parents at the time of prenatal counseling.
Collapse
Affiliation(s)
- Aliza Olive
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pablo Laje
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Beverly G Coleman
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Teresa Victoria
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| |
Collapse
|
41
|
Abstract
PURPOSE OF REVIEW To review the literature on lymphatic malformations and to provide current opinion about the management of these lesions. RECENT FINDINGS Current treatment options include nonoperative management, surgery, sclerotherapy, radiofrequency ablation, and laser therapy. New therapies are emerging, including sildenafil, propranolol, sirolimus, and vascularized lymph node transfer. The primary focus of management centers on the patient's quality of life. SUMMARY Multimodal treatment of lymphatic malformations continues to expand as new information about the biology and genetics of these lesions is discovered, in addition to knowledge gained from clinical practice. A patient-centered approach should guide timing and modality of treatment. Continued study of lymphatic malformations will increase and solidify a treatment algorithm for these complicated lesions.
Collapse
|
42
|
Yesil S, Bozkurt C, Tanyildiz HG, Tekgunduz SA, Candir MO, Toprak S, Sahin G. Successful Treatment of Macroglossia Due to Lymphatic Malformation With Sirolimus. Ann Otol Rhinol Laryngol 2015; 124:820-3. [DOI: 10.1177/0003489415583330] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To evaluate the effectiveness and safety of sirolimus therapy in a child with macroglossia due to lymphatic malformation. Methods: Sirolimus treatment was applied to the patient with an initial dosing of 0.8 mg/m2 per dose, administered orally, twice daily at approximately 12-hour intervals. Results: After 9 months of sirolimus therapy, there was a nearly complete resolution of lymphatic malformation. The last evaluation was performed 6 months after withdrawal of treatment, and the lesion had almost completely resolved. Conclusion: This article presents a novel approach to the treatment of lymphatic malformation of the tongue using sirolimus, which appears to be safe and effective for the management of complex cases.
Collapse
Affiliation(s)
- Sule Yesil
- Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Ceyhun Bozkurt
- Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | | | | | - Mehmet Onur Candir
- Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Sule Toprak
- Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Gurses Sahin
- Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| |
Collapse
|
43
|
Abstract
Complex lymphatic anomalies include several diagnoses with overlapping patterns of clinical symptoms, anatomic location, imaging features, hematologic alterations, and complications. Lymphatic malformations likely arise through anomalous embryogenesis of the lymphatic system. Analysis of clinical, imaging, histologic, and hematologic features is often needed to reach a diagnosis. Aspiration of fluid collections can readily define fluid as chylous or not. The presence of chyle indicates dysfunction at the mesenteric or retroperitoneal level or above the cisterna chyli due to reflux. The imaging patterns of generalized lymphatic anomaly (GLA) and Gorham-Stout disease have been segregated with distinctive bone lesions and peri-osseous features. More aggressive histology (spindled lymphatic endothelial cells), clinical progression, hemorrhage, or moderate hematologic changes should raise suspicion for kaposiform lymphangiomatosis. Biopsy may be needed for diagnosis, though avoidance of rib biopsy is advised to prevent iatrogenic chronic pleural effusion. Lymphangiography can visualize the anatomy and function of the lymphatic system and may identify dysfunction of the thoracic duct in central conducting lymphatic anomalies. Local control and symptom relief are targeted by resection, laser therapy, and sclerotherapy. Emerging data suggest a role for medical therapies for complications of complex lymphatic anomalies. Outcomes include recurrent effusion, infection, pain, fracture, mortality, and rarely, malignancy. Complex lymphatic anomalies present significant diagnostic and therapeutic challenges. Results from a phase 2 study of sirolimus in these and other conditions are expected in 2014. Improved characterization of natural history, predictors of poor outcomes, responses to therapy, and further clinical trials are needed for complex lymphatic anomalies.
Collapse
Affiliation(s)
- Cameron C Trenor
- Division of Pediatric Hematology/Oncology, Boston Children׳s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 300 Longwood Ave, Boston, Massachusetts 02115.
| | - Gulraiz Chaudry
- Division of Interventional Radiology, Boston Children׳s Hospital, Harvard Medical School, Boston, Massachusetts 02115
| |
Collapse
|