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Seyama K, Komiyama E, Tsuchihashi H, Okura MK, Sekimoto Y, Mitsuishi Y. Stepwise Incremental Dose Schedule of Sirolimus Is Successfully Tolerated by a Patient With Lymphangioleiomyomatosis Who Was Initially Allergic to mTOR Inhibitors. Cureus 2024; 16:e58805. [PMID: 38784348 PMCID: PMC11112535 DOI: 10.7759/cureus.58805] [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] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease involving the proliferation of LAM cells in the lungs and the axial lymphatic system and mechanistic target of rapamycin (mTOR) inhibitors are the only effective medicines for treating it. Patients suffering from LAM, who are allergic to mTOR inhibitors can be treated by desensitizing them to the medicine. A 39-year-old woman presented with dyspnea caused by chylous pleural effusion, ascites, and retroperitoneal lymphangioleiomyomas. She was diagnosed with LAM based on the presence of LAM cell clusters (LCCs) in chylous pleural effusion and elevated serum vascular endothelial growth factor D (VEGF-D) concentration. She was allergic to cedars and yellowtails. Although she was started on sirolimus for treating LAM, the drug had to be discontinued on day 45 because of the appearance of a skin rash on her trunk. A year later, another oral mTOR inhibitor, everolimus, was initiated but had to be discontinued because of the appearance of cutaneous reactions. Since mTOR inhibitors are the only effective molecular-target medicines for LAM, desensitization to sirolimus was attempted by initiating exposure to sirolimus at a low dose followed by stepwise dose escalation. Eventually, the patient tolerated a dose of 0.5 mg/day of sirolimus, which resulted in a trough concentration of approximately 2 ng/ml in blood, without adverse cutaneous reactions; furthermore, clinically relevant effects were observed as her LAM condition reduced and stabilized. This case study illustrates that mTOR inhibitor therapy for LAM should not be abandoned because of allergic cutaneous reactions. Physicians must find a dose that balances adverse events and therapeutic effects to ensure continued treatment for patients with LAM. Furthermore, the possible mechanisms for mTOR inhibitor-induced cutaneous reactions have been discussed.
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Affiliation(s)
- Kuniaki Seyama
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Etsuko Komiyama
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Hitoshi Tsuchihashi
- Dermatology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Makiko K Okura
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yasuhito Sekimoto
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
| | - Yoichiro Mitsuishi
- Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, JPN
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2
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Pascalau NA, Radu AF, Cseppento DCN, Andronie-Cioara FL, Jurcau A, Mos C, Bungau AF, Bungau SG. An Evidence-Based Update on the Potential Association between Rheumatoid Arthritis and Lymphangioleiomyomatosis. J Pers Med 2023; 13:jpm13040607. [PMID: 37108993 PMCID: PMC10141996 DOI: 10.3390/jpm13040607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Lymphangioleiomyomatosis (LAM) represents an uncommon disorder characterized by cystic lung destruction and chronic respiratory failure. Lung damage caused by various mechanisms may represent a hypothesis for studying the association between LAM and rheumatoid arthritis (RA), which is the most prevalent autoinflammatory rheumatic disease and may affect the lungs as an extra-articular manifestation. Despite their distinct clinical presentations, the pathophysiology of both disorders includes dysregulated immunological function, abnormal cellular development, and inflammation. Current research suggests a potential relationship between RA and LAM, as some RA patients have been reported to develop LAM. However, the association of RA and LAM raises important therapeutic dilemmas. For this reason, the trajectory of a patient who was identified in our medical records as suffering from both LAM and RA, treated with many novel molecules and biological therapy, but with a negative outcome due to respiratory and multiorgan failure, has been exemplified. The delay in the diagnosis of LAM is due to a correlation between RA and LAM, worsening the vital prognosis and also hindering pulmonary transplantation. In addition, extensive research is essential for understanding the potential connection between these two disorders and discovering any similar mechanisms involved that may underlie their occurrence. This may contribute to the development of new therapeutic options that target shared pathways implicated in the pathogenesis of RA and LAM.
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3
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Reynaud-Gaubert M, Le Pavec J, Uzunhan Y. [Lung transplantation for lymphangioleiomyomatosis]. Rev Mal Respir 2023; 40 Suppl 1:e62-e64. [PMID: 36792401 DOI: 10.1016/j.rmr.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- M Reynaud-Gaubert
- Service de pneumologie et équipe de transplantation pulmonaire, centre hospitalo-universitaire Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
| | - J Le Pavec
- Service de pneumologie et de transplantation pulmonaire, Groupe hospitalier Marie-Lannelongue-Paris Saint-Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin-Bicêtre, France; UMR_S 999, université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France
| | - Y Uzunhan
- Inserm UMR 1272, université Sorbonne Paris Nord, AP-HP, hôpital Avicenne, service de pneumologie, Bobigny, France; Service de pneumologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris, Paris, France
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4
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Warrior K, Dilling DF. Lung transplantation for lymphangioleiomyomatosis. J Heart Lung Transplant 2023; 42:40-52. [PMID: 36334961 DOI: 10.1016/j.healun.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/27/2022] [Indexed: 12/23/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease, associated with respiratory symptoms of dyspnea and spontaneous pneumothorax, along with various extra-thoracic manifestations. Often a progressive disease, albeit slowly, patients can develop chronic and severe respiratory failure and require supplemental oxygen. Lung transplantation (LTX) can offer improved duration and quality of life for patients with end-stage lung disease due to LAM. There are several unique considerations for LTX in LAM patients, and disease-specific complications of LAM prior to LTX can affect management decisions. Furthermore, there are several possible post-transplant issues specific to LAM. In this review, we discuss evaluation and management, disease-specific complications (both pre- and post-transplant), and outcomes for LAM patients undergoing lung transplantation.
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Affiliation(s)
- Krishnan Warrior
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL.
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5
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Fukui M, Seyama K, Matsunaga T, Hattori A, Takamochi K, Oh S, Kawagoe I, Suzuki K. Perioperative management of thoracic surgery in patients with lymphangioleiomyomatosis. Surg Case Rep 2022; 8:145. [PMID: 35909204 PMCID: PMC9339431 DOI: 10.1186/s40792-022-01507-5] [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: 05/16/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
General surgery for patients with lymphangioleiomyomatosis (LAM) is infrequent, however, general surgeons also occasionally experience it. Only a few reports have described the specific perioperative management appropriate for patients with LAM. Hence, in this case series, we aimed to investigate the surgical outcomes of LAM patients and their characteristics.
Case presentation
Medical records of 4482 patients who underwent thoracic surgery between 2009 and 2017 at our institution were assessed. Twelve patients were diagnosed with LAM. Details of the postoperative courses and surgical outcomes of LAM patients were retrospectively examined.
All LAM patients were female (age 41.3 ± 10.6 years). Surgeries were performed for patients undergoing biopsy (n = 4) and those with pneumothorax (n = 3), lung cancer (n = 2), and other conditions (n = 3). The mortality rate was 0% and the length of hospital stay was 27.4 ± 8.9 days. Ten postoperative complications occurred in six patients (50%): hypoxemia (n = 5), chylothorax (n = 2), and prolonged air leakage (n = 3).
Conclusions
Thoracic surgery may pose a risk of postoperative complications and long hospitalization for patients with LAM, although it lowers the risk of fatality. Management of perioperative air and chyle leakages and lymphatic stasis in the lungs is important for preventing morbidities.
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6
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Hagan M, Shenkar R, Srinath A, Romanos SG, Stadnik A, Kahn ML, Marchuk DA, Girard R, Awad IA. Rapamycin in Cerebral Cavernous Malformations: What Doses to Test in Mice and Humans. ACS Pharmacol Transl Sci 2022; 5:266-277. [PMID: 35592432 PMCID: PMC9112291 DOI: 10.1021/acsptsci.2c00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) are hemorrhagic neurovascular lesions that affect more than 1 million people in the United States. Rapamycin inhibits CCM development and bleeding in murine models. The appropriate dosage to modify disease phenotype remains unknown. Current approved indications by the U.S. Food and Drug Administration and clinicaltrials.gov were queried for rapamycin human dosing for various indications. A systematic literature search was conducted on PubMed to investigate mouse dosimetry of rapamycin. In humans, low daily doses of <2 mg/day or trough level targets <15 ng/mL were typically used for benign indications akin to CCM disease, with relatively low complication rates. Higher oral doses in humans, used for organ rejection, result in higher complication rates. Oral dosing in mice, between 2 and 4 mg/kg/day, achieved blood trough levels in the 5-15 ng/mL range, a concentration likely to be targeted in human studies to treat CCM. Preclinical studies are needed utilizing dosing strategies which achieve blood levels corresponding to likely human dosimetry.
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Affiliation(s)
- Matthew
J. Hagan
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Robert Shenkar
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Abhinav Srinath
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Sharbel G. Romanos
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Agnieszka Stadnik
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Mark L. Kahn
- Department
of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Douglas A. Marchuk
- Department
of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina 27710, United States
| | - Romuald Girard
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Issam A. Awad
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
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7
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Liu X, Xu Y, Wu X, Liu Y, Wu Q, Wu J, Zhang H, Zhou M, Qu J. Soluble Immune-Related Proteins as New Candidate Serum Biomarkers for the Diagnosis and Progression of Lymphangioleiomyomatosis. Front Immunol 2022; 13:844914. [PMID: 35300340 PMCID: PMC8923288 DOI: 10.3389/fimmu.2022.844914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background The goal of this study was to analyze serum from lymphangioleiomyomatosis (LAM) patients and healthy controls to identify novel biomarkers that could shed light on disease diagnosis and pathogenesis. Methods From April 2017 to October 2019, qualified serum samples were obtained to explore differences in 59 immune proteins between 67 LAM patients and 49 healthy controls by the Luminex method. Results We characterized 22 serum immune proteins that were differentially expressed in LAM patients compared with healthy people. Fifty-nine proteins were then classified into eight categories according to their biological function, and the results showed that LAM patients displayed significantly higher levels of growth factors (p = 0.006) and lower levels of costimulatory molecules (p = 0.008). LAG-3 was not only likely to have better predictive value than VEGF-D but also showed a significant difference between patients without elevated VEGF-D and healthy people. IL-18 was positively correlated with lung function and six-minute walk test (6MWT) distance and negatively correlated with St. George’s Respiratory Questionnaire (SGRQ) score and pulmonary artery systolic pressure (PASP), which suggested that IL-18 was related to disease severity. PD-1 was significantly different between patients with pneumothorax and/or chylothorax and those without complications. Conclusion We performed a large-scale serum immune factor analysis of LAM. Our study provides evidence that LAG-3 may be a novel candidate serum biomarker for the diagnosis of LAM. Future independent validation in prospective studies is warranted.
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Affiliation(s)
- Xuefei Liu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanping Xu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xueying Wu
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Ninth School of Clinical Medicine, Peking University, Beijing, China.,School of Oncology, Capital Medical University, Beijing, China
| | - Yanpu Liu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital, Shanghai, China
| | - Qiang Wu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital, Shanghai, China
| | - Jialiang Wu
- Department of Respiration, Xiangshan Traditional Chinese Medicine Hospital, Shanghai, China
| | - Henghui Zhang
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Ninth School of Clinical Medicine, Peking University, Beijing, China.,School of Oncology, Capital Medical University, Beijing, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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8
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McCarthy C, Gupta N, Johnson SR, Yu JJ, McCormack FX. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1313-1327. [PMID: 34461049 DOI: 10.1016/s2213-2600(21)00228-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 01/15/2023]
Abstract
Lymphangioleiomyomatosis (LAM) is a slowly progressive, low-grade, metastasising neoplasm of women, characterised by infiltration of the lung parenchyma with abnormal smooth muscle-like cells, resulting in cystic lung destruction. The invading cell in LAM arises from an unknown source and harbours mutations in tuberous sclerosis complex (TSC) genes that result in constitutive activation of the mechanistic target of rapamycin (mTOR) pathway, dysregulated cellular proliferation, and a programme of frustrated lymphangiogenesis, culminating in disordered lung remodelling and respiratory failure. Over the past two decades, all facets of LAM basic and clinical science have seen important advances, including improved understanding of molecular mechanisms, novel diagnostic and prognostic biomarkers, effective treatment strategies, and comprehensive clinical practice guidelines. Further research is needed to better understand the natural history of LAM; develop more powerful diagnostic, prognostic, and predictive biomarkers; optimise the use of inhibitors of mTOR complex 1 in the treatment of LAM; and explore novel approaches to the development of remission-inducing therapies.
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Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St Vincent's University Hospital, University College Dublin, Dublin, Ireland.
| | - Nishant Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Simon R Johnson
- Division of Respiratory Medicine, University of Nottingham, NIHR Respiratory Biomedical Research Centre, Nottingham, UK
| | - Jane J Yu
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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9
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Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 282] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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10
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Uncommon radiologic computed tomography appearances of the chest in patients with lymphangioleiomyomatosis. Sci Rep 2021; 11:7170. [PMID: 33785773 PMCID: PMC8010110 DOI: 10.1038/s41598-021-85999-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare destructive lung disease characterized by multiple thin-walled pulmonary cysts. The currently proposed diagnostic algorithm emphasizes the characteristic cystic appearance on high-resolution computed tomography (HRCT) so uncommon HRCT appearances present challenges to establishing the proper LAM diagnosis. The objective of this study is to accrue uncommon chest HRCT appearances, determine frequencies in both tuberous sclerosis complex (TSC)-associated LAM (TSC-LAM) and sporadic LAM (S-LAM) patients. 311 females referred to our hospital, including 272 S-LAM patients (mean age 39.2 years) and 39 TSC-LAM patients (mean age 38.3 years), were retrospectively evaluated. We found 2 types of radiologic findings likely to make HRCT cyst appearance atypical: characteristics of the cyst itself and uncommon findings in addition to cysts. We found that approximately 80% of LAM patients, whether TSC-associated or sporadic, showed typical HRCT appearance with mild to severe cystic destruction. The remaining 20% displayed unusual profiles in cyst appearance as well as additional findings aside from cyst: the former includes large cyst, thickened walls, and irregularly shaped whereas the latter includes ground glass attenuation and diffuse noncalcified nodules. It is important to be aware of various radiologic findings that make HRCT cystic appearance atypical of LAM.
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11
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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: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [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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12
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Saegusa C, Hosoya M, Nishiyama T, Saeki T, Fujimoto C, Okano H, Fujioka M, Ogawa K. Low-dose rapamycin-induced autophagy in cochlear outer sulcus cells. Laryngoscope Investig Otolaryngol 2020; 5:520-528. [PMID: 32596496 PMCID: PMC7314457 DOI: 10.1002/lio2.392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/02/2020] [Accepted: 04/26/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Autophagy is an intracellular housekeeping process that degrades cytoplasmic organelles, damaged molecules, and abnormal proteins or pathogens and is essential for normal hearing. Recent studies revealed the essential roles of autophagy in hearing and balance. The aim of this study was to evaluate the activation state of rapamycin-induced autophagy in cochlear outer sulcus cells (OSCs). METHODS We used autophagy reporter transgenic mice expressing the green fluorescent protein-microtubule-associated protein light chain 3 (GFP-LC3) fusion protein and counted GFP-LC3 puncta in cochlear OSCs to evaluate the activation state of autophagy after oral administration of rapamycin. RESULTS We observed basal level GFP-LC3 expression and an increase in the number of GFP-LC3 puncta in cochlear OSCs by oral administration of rapamycin. This increase was detected when the daily rapamycin intake was as low as 0.025 mg/kg, and it was dose dependent. The increased number of puncta was more at the basal turn than the apical turn. CONCLUSION Oral intake of low-dose rapamycin activates autophagy in cochlear OSCs. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Chika Saegusa
- Department of Otorhinolaryngology, Head and Neck SurgeryKeio University School of MedicineTokyoJapan
| | - Makoto Hosoya
- Department of Otorhinolaryngology, Head and Neck SurgeryKeio University School of MedicineTokyoJapan
| | - Takanori Nishiyama
- Department of Otorhinolaryngology, Head and Neck SurgeryKeio University School of MedicineTokyoJapan
| | - Tsubasa Saeki
- Department of PhysiologyKeio University School of MedicineTokyoJapan
| | - Chisato Fujimoto
- Department of Otolaryngology and Head and Neck SurgeryGraduate School of Medicine, University of TokyoTokyoJapan
| | - Hideyuki Okano
- Department of PhysiologyKeio University School of MedicineTokyoJapan
| | - Masato Fujioka
- Department of Otorhinolaryngology, Head and Neck SurgeryKeio University School of MedicineTokyoJapan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck SurgeryKeio University School of MedicineTokyoJapan
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13
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Shigeta K, Kikuchi M, Tanaka M, Takasaki S, Oishi H, Sado T, Matsuda Y, Noda M, Okada Y, Mano N, Yamaguchi H. Development of a precise quantitative method for monitoring sirolimus in whole blood using LC/ESI–MS/MS. Biomed Chromatogr 2020; 34:e4853. [DOI: 10.1002/bmc.4853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Kensuke Shigeta
- Faculty of Pharmaceutical SciencesTohoku University Sendai Japan
| | - Masafumi Kikuchi
- Faculty of Pharmaceutical SciencesTohoku University Sendai Japan
- Department of Pharmaceutical sciencesTohoku University Hospital Sendai Japan
| | - Masaki Tanaka
- Department of Pharmaceutical sciencesTohoku University Hospital Sendai Japan
| | - Shinya Takasaki
- Department of Pharmaceutical sciencesTohoku University Hospital Sendai Japan
| | - Hisashi Oishi
- Department of Thoracic SurgeryTohoku University Hospital Sendai Japan
| | - Tetsu Sado
- Department of Thoracic SurgeryTohoku University Hospital Sendai Japan
| | - Yasushi Matsuda
- Department of Thoracic SurgeryTohoku University Hospital Sendai Japan
| | - Masafumi Noda
- Department of Thoracic SurgeryTohoku University Hospital Sendai Japan
| | - Yoshinori Okada
- Department of Thoracic SurgeryTohoku University Hospital Sendai Japan
| | - Nariyasu Mano
- Faculty of Pharmaceutical SciencesTohoku University Sendai Japan
- Department of Pharmaceutical sciencesTohoku University Hospital Sendai Japan
| | - Hiroaki Yamaguchi
- Faculty of Pharmaceutical SciencesTohoku University Sendai Japan
- Department of Pharmaceutical sciencesTohoku University Hospital Sendai Japan
- Yamagata University Graduate School of Medicine/Department of PharmacyYamagata University Hospital Yamagata Japan
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14
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Taya M, Garcia-Hernandez MDLL, Rangel-Moreno J, Minor B, Gibbons E, Hammes SR. Neutrophil elastase from myeloid cells promotes TSC2-null tumor growth. Endocr Relat Cancer 2020; 27:261-274. [PMID: 32045362 PMCID: PMC7394719 DOI: 10.1530/erc-19-0431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 12/12/2022]
Abstract
Chronic inflammation promotes progression of many cancers, with circulating myeloid-derived suppressor cell (MDSC) levels correlating with poor prognosis. Here we examine effects of MDSCs on lymphangioleiomyomatosis (LAM), a rare disease occurring almost exclusively in women whereby estrogen-sensitive metastatic TSC2-null tumors grow throughout the lungs, markedly reducing pulmonary function. The LAM cell origin remains unknown; however, previous work demonstrated that Tsc2 inactivation in the mouse uterus induced estrogen-dependent myometrial tumors with nearly all features of LAM. Half of these animals developed metastatic myometrial tumors in the lungs, suggesting that LAM cells might originate from the myometrium, possibly explaining its overwhelming female prevalence and estrogen-sensitivity. Here we report that MDSC levels, and in particular granulocytic myeloid cell levels, are elevated in the periphery and in tumors of uterine-specific Tsc2-null mice. Importantly, MDSC depletion or inhibition of their recruitment impairs myometrial tumor growth. RNA and protein analysis of Tsc2-null myometrial tumors and xenografts demonstrate high expression and activity of the serine protease neutrophil elastase (NE), with selective qPCR studies indicating a stromal origin of the NE. Notably, treatment with sivelestat, a known NE inhibitor already approved for human use in some countries, reduces tumor growth similar to MDSC depletion. Furthermore, NE promotes Tsc2-null tumor cell growth, migration, and invasion in vitro. Finally, NE-expressing myeloid cells are present throughout the lungs of LAM patients but not controls. These data suggest that NE derived from granulocytic myeloid cells might directly promote LAM tumor cell progression and could be a novel therapeutic target for LAM.
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Affiliation(s)
- Manisha Taya
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Javier Rangel-Moreno
- Division of Allergy/Immunology and Rheumatology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Briaunna Minor
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Erin Gibbons
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Stephen R Hammes
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY
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15
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Salman J, Ius F, Sommer W, Siemeni T, Fleissner F, Alhadidi H, Kugler C, Avsar M, Haverich A, Warnecke G, Tudorache I, Kuhn C. Long-Term Results of Bilateral Lung Transplantation in Patients With End-Stage Pulmonary Lymphangioleiomyomatosis. Prog Transplant 2020; 29:115-121. [PMID: 31084354 DOI: 10.1177/1526924819835815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Lymphangioleiomyomatosis (LAM) is a rare disease in women, leading to progressive deterioration of lung function and respiratory failure. We describe the outcome of patients with end-stage LAM who underwent lung transplantation at our center. MATERIALS AND METHODS The records of patients with LAM transplanted at our institution between February 1997 and May 2015 were reviewed retrospectively. Morbidity and mortality were analyzed, and actuarial survival was calculated using Kaplan-Meier methods. The cumulative survival of transplant patients with LAM at our center was compared with survival after transplantation due to different diseases at our center and the results of the International Society for Heart and Lung Transplantation. Quality of life was assessed by a patient self-report at the end of the first postoperative year. RESULTS During the study period, 25 patients underwent lung transplantation for LAM. All patients were women with a mean age of 50 (9) years. Thirteen patients (52%) had undergone previous thoracotomy. All patients (100%) received bilateral lung transplantation. One (4%) case of in-hospital mortality occurred and 9 (36%) late deaths. Two (8%) cases of late death were due to chronic lung allograft dysfunction. The 1-, 3-, and 5-year survival rates were 92%, 84%, and 76%, respectively. Quality-of-life ratings were above the normal in all eight 36-Item Short Form Health Survey subscales 1 year after transplantation. CONCLUSIONS Lung transplantation offers a valuable therapy for patients with end-stage pulmonary LAM.
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Affiliation(s)
- Jawad Salman
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,2 German Centre for Lung Research, Hannover, Germany
| | - Fabio Ius
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,2 German Centre for Lung Research, Hannover, Germany
| | - Thierry Siemeni
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hani Alhadidi
- 3 Department of Thoracic Surgery, King Hussein Medical Center, Amman, Jordan
| | - Christiane Kugler
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,2 German Centre for Lung Research, Hannover, Germany
| | - Igor Tudorache
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuhn
- 1 Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,2 German Centre for Lung Research, Hannover, Germany
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16
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Wang Q, Luo M, Xiang B, Chen S, Ji Y. The efficacy and safety of pharmacological treatments for lymphangioleiomyomatosis. Respir Res 2020; 21:55. [PMID: 32059669 PMCID: PMC7023761 DOI: 10.1186/s12931-020-1316-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 02/08/2023] Open
Abstract
Background Lymphangioleiomyomatosis (LAM) is a rare, low-grade multisystem neoplastic disease. Most LAM patients are at a high risk of losing lung function at an accelerated rate and developing progressive dyspnea. Recently, several studies have reported their experience with pharmacological treatments for LAM. Therefore, we conducted a systematic review and meta-analysis to assess the efficacy and safety of these therapies. Methods PubMed (Medline), EMBASE, Cochrane Library, Web of Science and EBSCO Host were searched (until March 31, 2019) for eligible prospective studies regarding LAM patients treated with pharmacological treatments. Random effect models were used for quantitative analysis. Results Fourteen prospective studies regarding five pharmacological treatments (including sirolimus, everolimus, doxycycline, triptorelin, and a combination therapy of sirolimus and hydroxychloroquine) were enrolled in our systematic review, and ten of them were used for the meta-analysis. Seven prospective studies reported that sirolimus was effective at improving or stabilizing lung function and alleviating renal angiomyolipoma (AML) in LAM patients. Subsequent quantitative analyses showed that during sirolimus treatment, the pooled values of lung function and 6-min walk distance (6MWD) were not significantly changed (P > 0.05), with the pooled response rate of AML being 0.62 (95% confidence intervals [CIs]: 0.43 to 0.82, I2 = 65%). Regarding everolimus, three prospective studies reported similar effects to those of sirolimus with regard to preserving lung function and reducing AMLs. The meta-analysis showed that the changes in lung function during everolimus treatment were not statistically significant (P > 0.05), while the pooled response rate of AML was 0.78 (95% CI: 0.68 to 0.88, I2 = 8%). Neither the qualitative nor the quantitative results confirmed the benefits of doxycycline or triptorelin treatment, and the effects of the combination therapy were unclear in LAM patients. Most of the adverse events during pharmacological treatments were low or moderate grade and tolerable. Conclusions Overall, sirolimus and everolimus were recommended for the treatment of LAM because they could stabilize lung function and alleviate renal AML. Doxycycline and triptorelin were not recommended for the treatment of LAM because no beneficial outcomes were consistently observed. The efficacy and safety of combination therapy remain to be further explored.
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Affiliation(s)
- Qi Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Mengqi Luo
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37# Guo-Xue-Xiang, Chengdu, 610041, China.
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17
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Abstract
With the discovery of rapamycin 45 years ago, studies in the mechanistic target of rapamycin (mTOR) field started 2 decades before the identification of the mTOR kinase. Over the years, studies revealed that the mTOR signaling is a master regulator of homeostasis and integrates a variety of environmental signals to regulate cell growth, proliferation, and metabolism. Deregulation of mTOR signaling, particularly hyperactivation, frequently occurs in human tumors. Recent advances in molecular profiling have identified mutations or amplification of certain genes coding proteins involved in the mTOR pathway (eg, PIK3CA, PTEN, STK11, and RICTOR) as the most common reasons contributing to mTOR hyperactivation. These genetic alterations of the mTOR pathway are frequently observed in lung neoplasms and may serve as a target for personalized therapy. mTOR inhibitor monotherapy has met limited clinical success so far; however, rational drug combinations are promising to improve efficacy and overcome acquired resistance. A better understanding of mTOR signaling may have the potential to help translation of mTOR pathway inhibitors into the clinical setting.
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18
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Koul PA, Mehfooz N. Sirolimus in lymphangioleiomyomatosis: A case in point for research in 'orphan' diseases. Lung India 2019; 36:353-355. [PMID: 31290424 PMCID: PMC6625251 DOI: 10.4103/lungindia.lungindia_280_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Parvaiz A Koul
- Department of Internal and Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Nazia Mehfooz
- Department of Pulmonary Medicine, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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19
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Harari S, Spagnolo P, Cocconcelli E, Luisi F, Cottin V. Recent advances in the pathobiology and clinical management of lymphangioleiomyomatosis. Curr Opin Pulm Med 2019; 24:469-476. [PMID: 29927757 DOI: 10.1097/mcp.0000000000000502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Lymphangioleiomyomatosis (LAM) is a rare systemic disease that occurs almost exclusively in women. In the last few years, our understanding of disease pathobiology has improved substantially; in addition, a guideline document has recently been developed that provides recommendations for the diagnosis and clinical management of patients with LAM. Yet, significant gaps in knowledge remain. RECENT FINDINGS Groundbreaking insights into the cellular biochemistry of LAM have led to the reclassification of the disease as a low-grade, destructive, metastasizing neoplasm. In addition, recent data confirm the potential of next-generation sequencing to detect low-prevalence mutations in tuberous sclerosis (TSC) genes in sporadic LAM. A randomized, double-blind, multicentre trial has confirmed the efficacy of sirolimus in stabilizing lung function, improving functional performance and quality of life, and reducing lymphatic manifestations in patients with LAM. Accordingly, recent guidelines issued by the American Thoracic Society and the Japanese Respiratory Society recommend sirolimus treatment for patients with LAM and reduced lung function. Uncertainty remains, however, with regard to patient selection, and timing of initiation, duration and dosing of treatment. SUMMARY Significant advances have been made in the diagnosis and clinical management of patients with LAM. However, additional studies are needed to assess long-term safety and efficacy of sirolimus therapy, and to identify predictors of disease behaviour and response to treatment.
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Affiliation(s)
- Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, IRCCS MultiMedica, Milan
| | - Paolo Spagnolo
- Section of Respiratory Diseases, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Elisabetta Cocconcelli
- Section of Respiratory Diseases, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesca Luisi
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, IRCCS MultiMedica, Milan
| | - Vincent Cottin
- Hospices Civils de Lyon, Louis Pradel Hospital, National Reference Center for Rare Pulmonary Diseases, Department of Respiratory Diseases, Claude Bernard University Lyon 1, UMR754, Lyon, France
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20
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Polamreddy P, Gattu N. The drug repurposing landscape from 2012 to 2017: evolution, challenges, and possible solutions. Drug Discov Today 2019; 24:789-795. [DOI: 10.1016/j.drudis.2018.11.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/15/2018] [Accepted: 11/27/2018] [Indexed: 01/13/2023]
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21
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Sonobe S, Arai T, Tanimoto Y, Sugimoto C, Kitaichi M, Akira M, Kasai T, Hirose M, Inoue Y. Successful Sirolimus Treatment of Lymphangioleiomyomatosis in a Hepatitis B Virus Carrier. Intern Med 2019; 58:569-574. [PMID: 30333386 PMCID: PMC6421154 DOI: 10.2169/internalmedicine.1329-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 34-year-old woman experiencing shortness of breath was referred to our hospital. The patient was diagnosed with sporadic lymphangioleiomyomatosis based on the observation of bilateral diffuse multiple thin-walled cysts on computed tomography of the chest, chylous effusion, elevated serum vascular endothelial growth factor-D levels and transbronchial biopsy findings. This patient was a hepatitis B virus (HBV) carrier. Treatment with 1 mg daily of sirolimus was started after HBV DNA was brought below the cut-off level using entecavir. Sirolimus was effective, as the chylous effusion resolved completely and the dyspnea improved. The sirolimus dosage was increased to 2 mg daily without causing HBV reactivation.
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Affiliation(s)
- Shoko Sonobe
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Yasushi Tanimoto
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Japan
| | - Chikatoshi Sugimoto
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Masanori Kitaichi
- Department of Pathology, National Hospital Organization Minami Wakayama Medical Center, Japan
| | - Masanori Akira
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Takahiko Kasai
- Department of Pathology, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
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22
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Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease associated with cystic lung destruction and abdominal tumors, including lymphangioleiomyomas, which frequently occur in the retroperitoneal region. Sirolimus therapy is currently recommended for LAM patients with abnormal or declining lung function with an adjusted dose to maintain a serum trough level of 5–15 ng/mL. We describe a significant reduction of retroperitoneal lymphangioleiomyomas after treatment with low-dose sirolimus therapy (serum trough level <5 ng/mL) in a patient with sporadic LAM.
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Affiliation(s)
- Kamonpun Ussavarungsi
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Archana T Laroia
- Division of Cardiovascular and Pulmonary Imaging, Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Charles D Burger
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
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23
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Hosoya M, Saeki T, Saegusa C, Matsunaga T, Okano H, Fujioka M, Ogawa K. Estimating the concentration of therapeutic range using disease-specific iPS cells: Low-dose rapamycin therapy for Pendred syndrome. Regen Ther 2018; 10:54-63. [PMID: 30581897 PMCID: PMC6299162 DOI: 10.1016/j.reth.2018.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/28/2018] [Accepted: 11/12/2018] [Indexed: 01/31/2023] Open
Abstract
Introduction Pendred syndrome is an autosomal-recessive disease characterized by congenital hearing loss and thyroid goiter. Previously, cell stress susceptibilities were shown to increase in patient-derived cells with intracellular aggregation using an in vitro acute cochlear cell model derived from patient-specific pluripotent stem (iPS) cells. Moreover, we showed that rapamycin can relieve cell death. However, studies regarding long-term cell survival without cell stressors that mimic the natural course of disease or the rational minimum concentration of rapamycin that prevents cell death are missing. Methods In this report, we first investigated the rational minimum concentration of rapamycin using patient-specific iPS cells derived-cochlear cells with three different conditions of acute stress. We next confirmed the effects of rapamycin in long-term cell survival and phenotypes by using cochlear cells derived from three different patient-derived iPS cells. Results We found that inner ear cells derived from Pendred syndrome patients are more vulnerable than those from healthy individuals during long-term culturing; however, this susceptibility was relieved via treatment with low-dose rapamycin. The slow progression of hearing loss in patients may be explained, in part, by the vulnerability observed in patient cells during long-term culturing. We successfully evaluated the rational minimum concentration of rapamycin for treatment of Pendred syndrome. Conclusion Our results suggest that low-dose rapamycin not only decreases acute symptoms but may prevent progression of hearing loss in Pendred syndrome patients. In vitro chronic disorder model of Pendred syndrome is established. The vulnerability observed during long-term culturing explains progression of PDS. Low-dose rapamycin relief the cell vulnerability observed in PDS patients. PDS iPSCs reveal a rational treatment strategy for chronic progressive hearing loss.
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Affiliation(s)
- Makoto Hosoya
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
| | - Tsubasa Saeki
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
| | - Chika Saegusa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
| | - Tatsuo Matsunaga
- The Laboratory of Auditory Disorders and Division of Hearing and Balance Research, National Institute of Sensory Organs, National Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan.,Medical Genetics Center, National Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan
| | - Hideyuki Okano
- Department of Physiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masato Fujioka
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan
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24
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Pregnancy unmasking symptoms of undiagnosed lymphangioleiomyomatosis: Case report and review of literature. Respir Med Case Rep 2018; 26:63-67. [PMID: 30555778 PMCID: PMC6277247 DOI: 10.1016/j.rmcr.2018.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/16/2018] [Accepted: 11/17/2018] [Indexed: 11/21/2022] Open
Abstract
Cystic lung diseases are a group of disorders that appear similar on radiological studies on chest computed tomography. Each disorder is characterized by its own etiology, pathophysiology, course of progression and manifestation. Lymphangioleiomyomatosis (LAM) is one of the cystic lung diseases that can either be hereditary or sporadic. The sporadic form is a rare disease with no accurate prevalence reported but is believed to be less than 10 per million. LAM is associated with inappropriate activation of mammalian target of rapamycin (mTOR) signaling which regulates cellular growth. The sporadic form is almost confined to premenopausal female population and estrogen is believed to play an important role in the pathogenesis. Pregnancy and use of estrogen based oral contraceptives can aggravate symptoms of already existing LAM. Here we describe a case of LAM that was previously treated as asthma and was diagnosed after exacerbation of respiratory symptoms after pregnancy. We offer a review of the medical literature regarding the etiology, clinical course, diagnosis and treatment of LAM.
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25
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Yoon HY, Hwang JJ, Kim DS, Song JW. Efficacy and safety of low-dose Sirolimus in Lymphangioleiomyomatosis. Orphanet J Rare Dis 2018; 13:204. [PMID: 30428897 PMCID: PMC6236936 DOI: 10.1186/s13023-018-0946-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/30/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis is a rare disease caused by unregulated activation of mammalian target of rapamycin (mTOR) signalling pathway. Sirolimus showed efficacy in a phase 3 trial of patients with lymphangioleiomyomatosis, but the optimal dose remains unclear. METHODS We investigated the efficacy and safety of low-dose compared with conventional-dose sirolimus. Clinical data of 39 patients with lymphangioleiomyomatosis (mean age, 34.8 years; median treatment period, 29.6 months) who received sirolimus were retrospectively reviewed. Low-dose sirolimus was defined as any dose that maintained mean blood trough levels lower than those maintained with conventional doses (5-15 ng/mL). RESULTS Fifty-one percent of patients received low-dose therapy. The rate of decline in lung function decreased after treatment in the whole group (forced expiratory volume in 1 s [FEV1], - 0.12 ± 0.47 [before] vs. 0.24 ± 0.48% predicted/month [after], p = 0.027; diffusing capacity for carbon monoxide [DLco], - 0.33 ± 0.61 vs. 0.03 ± 0.26% predicted/month, p = 0.006) compared with before treatment. In the low-dose group, the rate of decline in FEV1 (- 0.08 ± 0.38 [before] vs. 0.19 ± 0.51% predicted/month [after], p = 0.264) and DLco (-0.13 ± 0.62 vs. 0.02 ± 0.28% predicted/month, p = 0.679) showed a numeric trend towards improvement after treatment; however, the conventional-dose group showed significant improvement in FEV1 (- 0.26 ± 0.54 [before] vs. 0.22 ± 0.38 [after] % predicted/month, p = 0.024) and DLco (- 0.55 ± 0.58 vs. 0.04 ± 0.25% predicted/month, p = 0.002) after treatment. Adverse events (AEs) occurred in 89.7% of patients and the most common AEs was hypercholesterolaemia (43.6%), followed by stomatitis (35.9%). The occurrences of AE were similar between the low- and conventional-dose groups (85.0% vs. 94.7%, p = 0.605). CONCLUSIONS Low-dose sirolimus may stabilise lung function decline in lymphangioleiomyomatosis patients, but its efficacy appears to be inferior to that of conventional-dose sirolimus.
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Affiliation(s)
- Hee-Young Yoon
- Departments of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jung Jin Hwang
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Dong Soon Kim
- Departments of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jin Woo Song
- Departments of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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26
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Gupta N, Henske EP. Pulmonary manifestations in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:326-337. [PMID: 30055039 DOI: 10.1002/ajmg.c.31638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Tuberous sclerosis complex has manifestations in many organ systems, including brain, heart, kidney, skin, and lung. The primary manifestations in the lung are lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH). LAM affects almost exclusively women, and causes cystic lung destruction, pneumothorax, and chylous pleural effusions. LAM can lead to dyspnea, oxygen dependence, and respiratory failure, with more rapid disease progression during the premenopausal years. In contrast, MMPH affects men and women equally, causing small nodular pulmonary deposits of type II pneumocytes that rarely progress to symptomatic disease. Here, we review the clinical features and pathogenesis of LAM and MMPH.
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Affiliation(s)
- Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth P Henske
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
Lymphangioleiomyomatosis is a rare disorder that predominantly affects women and is characterized by progressive cystic changes in the lung, leading to gradually worsening shortness of breath and lung function impairment. Pleural complications such as pneumothorax and chylothorax commonly occur in these patients. Lymphangioleiomyomatosis can occur as a form of lung involvement in tuberous sclerosis complex or as a sporadic form (without tuberous sclerosis complex). Etiology in both forms of this disease centers on mutations in the tuberous sclerosis genes. Advances in our understanding of the regulatory role of tuberous sclerosis gene products (hamartin/tuberin) in the mechanistic target of rapamycin (mTOR) signaling pathway have led to the identification of effective therapy (mTOR inhibitors) for a rare disorder, once considered uniformly fatal. Here, we summarize the evolution of current concepts regarding lymphangioleiomyomatosis with an emphasis on recent advances and unresolved issues.
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Affiliation(s)
- Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing , China
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
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Single lung transplantation for lymphangioleiomyomatosis: a single-center experience in Japan. Surg Today 2018; 48:944-950. [PMID: 29808303 DOI: 10.1007/s00595-018-1678-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/27/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Lung transplantation is accepted as an effective modality for patients with end-stage pulmonary lymphangioleiomyomatosis (LAM). Generally, bilateral lung transplantation is preferred to single lung transplantation (SLT) for LAM because of native lung-related complications, such as pneumothorax and chylothorax. It remains controversial whether SLT is a suitable surgical option for LAM. The objective of this study was to evaluate the morbidity, mortality and outcome after SLT for LAM in a lung transplant center in Japan. METHODS We reviewed the records of 29 patients who underwent SLT for LAM in our hospital between March, 2000 and November, 2017. The data collected included the pre-transplant demographics of recipients, surgical characteristics, complications, morbidity, mortality and survival after SLT for LAM. RESULTS The most common complication after SLT for LAM was contralateral pneumothorax (n = 7; 24.1%). Six of these recipients were treated successfully with chest-tube placement and none required surgery for the pneumothorax. The second-most common complication was chylous pleural effusion (n = 6; 20.7%) and these recipients were all successfully treated by pleurodesis. The 5-year survival rate after SLT for LAM was 79.5%. CONCLUSION LAM-related complications after SLT for this disease can be managed. SLT is a treatment option and may improve access to lung transplantation for patients with end-stage LAM.
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Taveira-DaSilva AM, Julien-Williams P, Jones AM, Stylianou M, Moss J. Rates of change in FEV 1 and DLCO as potential indicators for mTOR inhibitor therapy in premenopausal lymphangioleiomyomatosis patients. Eur Respir J 2018. [PMID: 29519926 DOI: 10.1183/13993003.02258-2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The value of rates of change in forced expiratory volume in 1 s (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) to predict disease progression, and initiation of mTOR (mechanistic target of rapamycin) inhibitor therapy has not been evaluated.In 84 premenopausal lymphangioleiomyomatosis patients, individual rates of change in FEV1 and DLCO and their 95% confidence intervals were used to derive subsequent lowest values of FEV1 and DLCO that would prompt initiation of sirolimus therapy. These treatment criteria were compared with a criterion based on FEV1 or DLCO ≤70% predicted. In 12 patients undergoing sirolimus therapy both methods for determining the optimal point for initiation of therapy were evaluated.27 and 35 patients who experienced greater than expected rates of change in FEV1 and DLCO, respectively, would have been excluded from therapy based on an FEV1 or DLCO >70% pred. 25 of the 84 patients were eventually treated, but only when FEV1 or DLCO were ≤70% pred. Applying such treatment criteria to 12 patients undergoing sirolimus therapy would have delayed treatment for many years.Premenopausal females in whom FEV1 or DLCO are declining at rates above the expected based on their individual rates of decline, should be considered for sirolimus therapy before the FEV1 or DLCO falls to ≤70% pred.
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Affiliation(s)
- Angelo M Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Patricia Julien-Williams
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Amanda M Jones
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Zhan Y, Shen L, Xu W, Wu X, Zhang W, Wang J, Li X, Yang Y, Tian X, Xu KF. Functional improvements in patients with lymphangioleiomyomatosis after sirolimus: an observational study. Orphanet J Rare Dis 2018; 13:34. [PMID: 29458386 PMCID: PMC5819088 DOI: 10.1186/s13023-018-0775-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/12/2018] [Indexed: 12/01/2022] Open
Abstract
Background Sirolimus has been shown to be effective in patients with lymphangioleiomyomatosis (LAM). We wish to summarize our experience using sirolimus and its effectiveness in LAM patients. Methods We analyzed data from 98 patients who were diagnosed with definite or probable sporadic LAM based on the European Respiratory Society diagnosis criteria for LAM in 2010 at Peking Union Medical College Hospital and who had received sirolimus during January 2007 to June 2015. The data before and after the initiation of sirolimus therapy included pulmonary function tests, arterial blood gas analysis, 6-min walking distance (6MWD), size of chylous effusion and renal angiomyolipomas (AML), St. George’s Respiratory Questionnaires (SGRQ) and vascular endothelial growth factor-D (VEGF-D) levels. Serum levels of sirolimus and adverse events were collected. Results Median follow-up was 2.5 years. Most patients had forced expiratory volume in 1 s (FEV1) values less than 70% predicted or symptomatic chylothorax. The mean changes before and after the initiation of sirolimus were − 31.12 ± 30.78 mL/month and 16.11 ± 36.00 mL/month (n = 18,p = 0.002) for FEV1 change, and − 0.55 ± 0.60 mmHg/month and 0.30 ± 1.19 mmHg/month (n = 17, p = 0.018) for PaO2 change. 6MWD improved from 358.8 ± 114.4 m to 415.6 ± 118.6 m (n = 46, p = 0.004) and SGRQ total score from 57.2 ± 21.0 to 47.5 ± 22.8 (n = 50, p < 0.001). The median VEGF-D concentration decreased to 1609.4 pg/mL from 3075.6 pg/mL after sirolimus therapy (n = 41, p < 0.001). Patients with sirolimus trough levels of 5–9.9 ng/mL had an increase in FEV1 (p < 0.05). Sixty-five percent of patients (13/20) had almost complete resolution of chylous effusions. The most frequent adverse events were mouth ulcers, menstrual disorder, hyperlipidemia and acneiform rash, all were mild. Conclusion Long-term use of sirolimus is safe in patients with LAM. LAM patients with FEV1 less than 70% predicted and symptomatic chylothorax are suitable for receiving sirolimus therapy. The maintaining serum trough levels of sirolimus are recommended between 5 to 9.99 ng/mL.
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Affiliation(s)
- Yongzhong Zhan
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Lisha Shen
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Wenshuai Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xiuxiu Wu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Weihong Zhang
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Jun Wang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xue Li
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yanli Yang
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xinlun Tian
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, China.
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Xu KF, Tian X, Yang Y, Zhang H. Rapamycin for lymphangioleiomyomatosis: optimal timing and optimal dosage. Thorax 2018; 73:308-310. [DOI: 10.1136/thoraxjnl-2017-211135] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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32
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Successful treatment of a patient with chyluria due to lymphangioleiomyomatosis using sirolimus. Respir Med Case Rep 2018; 23:86-89. [PMID: 29349035 PMCID: PMC5767566 DOI: 10.1016/j.rmcr.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/04/2018] [Indexed: 12/23/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare and progressive neoplastic disease of young woman, characterized by the proliferation of abnormal smooth muscle-like cells (LAM cells) in the lungs and axial lymphatics. A 44-year-old woman was referred to our hospital because pleural effusion was detected during a health checkup. She had chylothorax, chylous ascites, and chyluria, and her computed tomography scan showed a solid tumor in the pelvis. Surgical biopsy was performed; she was diagnosed as having LAM. We could not control the fluid collection and chyluria using standard medical treatments. Therefore, we chose to administer sirolimus, and her symptoms dramatically improved. The mechanism of chyluria presumably involved LAM cell infiltrates in the ureter via the lymphatic vessel flow, which causes LAM to develop because of ureter wall exposure.
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Efficacy and Safety of Long-Term Sirolimus Therapy for Asian Patients with Lymphangioleiomyomatosis. Ann Am Thorac Soc 2017; 13:1912-1922. [PMID: 27513278 DOI: 10.1513/annalsats.201605-335oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Sirolimus has been shown in a randomized, controlled clinical trial to stabilize lung function in patients with lymphangioleiomyomatosis (LAM) treated for a 12-month time period; however the pretreatment decline in lung function after the drug was discontinued indicated that continued exposure is required to suppress disease progression. OBJECTIVES To elucidate the durability and tolerability of long-term sirolimus treatment in Asian patients with LAM. METHODS We conducted a single-arm, open-label, investigator-initiated safety and efficacy study of sirolimus in 63 women with LAM at 9 sites in Japan. Subjects received sirolimus for 2 years at doses adjusted to maintain a trough blood level of 5-15 ng/ml. MEASUREMENTS AND MAIN RESULTS Fifty-two subjects (82.5%) completed the trial with mean drug compliance of more than 80% overall during the study. The number of adverse events was greatest during the initial 6 months of therapy, but they continued to occur with declining frequency throughout the 2-year study period. Of the 1,549 adverse events, 27 were classified as serious, including reversible sirolimus pneumonitis in 3 patients. New hypercholesterolemia occurred in 30 patients (48%); microcytosis in 10 patients; loss of body weight in 33 patients; and increase in blood pressure that required treatment in 5 patients. FEV1, FVC, and quality-of-life parameters were stable in the overall study cohort during the study period, but baseline to 2-year improvements in lung function occurred in the subset of patients with a prior history of chylothorax. CONCLUSIONS Although long-term sirolimus treatment of Asian patients with LAM was associated with a large number of adverse events, including three episodes of pneumonitis, most patients completed the 2-year course of medication with good drug compliance and stable quality of life and lung function.
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34
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Daccord C, Nicod L, Lazor R. Cystic Lung Disease in Genetic Syndromes with Deficient Tumor Suppressor Gene Function. Respiration 2017; 94:467-485. [DOI: 10.1159/000485106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 12/28/2022] Open
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35
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Taveira-DaSilva AM, Moss J. Addressing the challenges of lymphangioleiomyomatosis assessment in the clinic. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1400966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Angelo M. Taveira-DaSilva
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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36
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Singla A, Gupta N, Apewokin S, McCormack FX. Sirolimus for the treatment of lymphangioleiomyomatosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1391089] [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] [Indexed: 01/30/2023]
Affiliation(s)
- Abhishek Singla
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X. McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
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37
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Bee J, Fuller S, Miller S, Johnson SR. Lung function response and side effects to rapamycin for lymphangioleiomyomatosis: a prospective national cohort study. Thorax 2017; 73:369-375. [DOI: 10.1136/thoraxjnl-2017-210872] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/19/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
RationaleMechanistic target of rapamycin inhibitors reduce loss of lung function in lymphangioleiomyomatosis (LAM), although their benefit varies between individuals. We examined lung function response and side effects to rapamycin in a national cohort.MethodsSubjects were receiving rapamycin for progressive lung disease. Clinical evaluation, detailed phenotyping, serial lung function, rapamycin and safety monitoring were performed according to a clinical protocol. Lung function change, measured as FEV1 slope (ΔFEV1), was reported for those treated for 1 year or longer.ResultsRapamycin was associated with improved ΔFEV1 in 21 individuals where pretreatment data were available (p<0.0001). In 47 treated for a mean duration of 35.8 months, mean ΔFEV1 was +11 (SD 75) mL/year, although it varied from +254 to −148 mL/year. The quartile with the highest positive ΔFEV1 had greater pretreatment FEV1 (p=0.02) and shorter disease durations (p=0.02) than the lowest quartile. Serum rapamycin level was positively associated with side effects (p=0.02) but not ΔFEV1 over 1 year. Within the first month of therapy, apthous ulcers, nausea and diarrhoea were associated with higher rapamycin levels. Acne, oedema and menstrual irregularities tended to increase over the first year of therapy. At the end of observation, the prevalence of side effects was 5% or less.ConclusionsRapamycin reduces lung function loss in LAM, although in some, ΔFEV1 continues to fall at an accelerated rate. Poor response to rapamycin was associated with lower pretreatment lung function and longer disease duration but not serum level. Early intervention with low-dose rapamycin may preserve lung function and reduce side effects.
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38
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Noriega Aldave AP, Leslie JW. Transudative chylothorax in a patient with lymphangioleiomyomatosis. Respir Med Case Rep 2017; 22:271-273. [PMID: 29062682 PMCID: PMC5643078 DOI: 10.1016/j.rmcr.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/12/2017] [Accepted: 09/12/2017] [Indexed: 11/26/2022] Open
Abstract
Transudative chylothorax is a rare type of pleural effusion. It has been described to be present in the setting of liver cirrhosis, heart failure, amyloidosis, nephrotic syndrome, superior vena cava thrombosis, sclerosing mesenteritis and heart failure. We present the case of an 86-year-old woman with a right-side transudative chylothorax associated with heart failure and lymphangioleiomyomatosis.
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Affiliation(s)
- Adrian Pedro Noriega Aldave
- Department of Pulmonary and Critical Care Medicine, Carilion Clinic – Virginia Tech Carilion, Roanoke, VA, USA
- Corresponding author. Carilion Clinic – Virginia Tech Carilion, Pulmonary/Critical Care Fellowship, 1906 Belleview Ave., Roanoke, VA 24014, USA.Carilion Clinic – Virginia Tech CarilionPulmonary/Critical Care Fellowship1906 Belleview Ave.RoanokeVA24014USA
| | - John W. Leslie
- Carilion Clinic Pulmonary Medicine - New River Valley, USA
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39
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Torre O, Elia D, Caminati A, Harari S. New insights in lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis. Eur Respir Rev 2017; 26:26/145/170042. [PMID: 28954765 PMCID: PMC9488980 DOI: 10.1183/16000617.0042-2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/26/2017] [Indexed: 12/15/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) and pulmonary Langerhans cell histiocytosis (PLCH) are rare diseases that lead to progressive cystic destruction of the lungs. Despite their distinctive characteristics, these diseases share several features. Patients affected by LAM or PLCH have similar radiological cystic patterns, a similar age of onset, and the possibility of extrapulmonary involvement. In this review, the recent advances in the understanding of the molecular pathogenesis, as well as the current and most promising biomarkers and therapeutic approaches, are described. Understanding of LAM/PLCH pathogenesis has improved over the past years, leading to new therapeutic approacheshttp://ow.ly/7wjR30erSJY
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Affiliation(s)
- Olga Torre
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Davide Elia
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Antonella Caminati
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
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40
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Julian LM, Delaney SP, Wang Y, Goldberg AA, Doré C, Yockell-Lelièvre J, Tam RY, Giannikou K, McMurray F, Shoichet MS, Harper ME, Henske EP, Kwiatkowski DJ, Darling TN, Moss J, Kristof AS, Stanford WL. Human Pluripotent Stem Cell-Derived TSC2-Haploinsufficient Smooth Muscle Cells Recapitulate Features of Lymphangioleiomyomatosis. Cancer Res 2017; 77:5491-5502. [PMID: 28830860 DOI: 10.1158/0008-5472.can-17-0925] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/22/2017] [Accepted: 08/16/2017] [Indexed: 01/06/2023]
Abstract
Lymphangioleiomyomatosis (LAM) is a progressive destructive neoplasm of the lung associated with inactivating mutations in the TSC1 or TSC2 tumor suppressor genes. Cell or animal models that accurately reflect the pathology of LAM have been challenging to develop. Here, we generated a robust human cell model of LAM by reprogramming TSC2 mutation-bearing fibroblasts from a patient with both tuberous sclerosis complex (TSC) and LAM (TSC-LAM) into induced pluripotent stem cells (iPSC), followed by selection of cells that resemble those found in LAM tumors by unbiased in vivo differentiation. We established expandable cell lines under smooth muscle cell (SMC) growth conditions that retained a patient-specific genomic TSC2+/- mutation and recapitulated the molecular and functional characteristics of pulmonary LAM cells. These include multiple indicators of hyperactive mTORC1 signaling, presence of specific neural crest and SMC markers, expression of VEGF-D and female sex hormone receptors, reduced autophagy, and metabolic reprogramming. Intriguingly, the LAM-like features of these cells suggest that haploinsufficiency at the TSC2 locus contributes to LAM pathology, and demonstrated that iPSC reprogramming and SMC lineage differentiation of somatic patient cells with germline mutations was a viable approach to generate LAM-like cells. The patient-derived SMC lines we have developed thus represent a novel cellular model of LAM that can advance our understanding of disease pathogenesis and develop therapeutic strategies against LAM. Cancer Res; 77(20); 5491-502. ©2017 AACR.
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Affiliation(s)
- Lisa M Julian
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | - Sean P Delaney
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Institute of Systems Biology, Ottawa, Ontario, Canada
| | - Ying Wang
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada
| | | | - Carole Doré
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada
| | | | - Roger Y Tam
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada.,University of Toronto, Donnelly Centre for Cellular & Biomolecular Research, Boston, Massachusetts
| | - Krinio Giannikou
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fiona McMurray
- University of Ottawa, Ottawa, Ontario, Canada.,Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Health Sciences, Bethesda, Maryland
| | - Molly S Shoichet
- University of Toronto, Donnelly Centre for Cellular & Biomolecular Research, Boston, Massachusetts
| | - Mary-Ellen Harper
- University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Institute of Systems Biology, Ottawa, Ontario, Canada.,Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Health Sciences, Bethesda, Maryland
| | - Elizabeth P Henske
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Kwiatkowski
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas N Darling
- Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Joel Moss
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | - Arnold S Kristof
- Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - William L Stanford
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada. .,University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Institute of Systems Biology, Ottawa, Ontario, Canada
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McCormack FX, Gupta N, Finlay GR, Young LR, Taveira-DaSilva AM, Glasgow CG, Steagall WK, Johnson SR, Sahn SA, Ryu JH, Strange C, Seyama K, Sullivan EJ, Kotloff RM, Downey GP, Chapman JT, Han MK, D'Armiento JM, Inoue Y, Henske EP, Bissler JJ, Colby TV, Kinder BW, Wikenheiser-Brokamp KA, Brown KK, Cordier JF, Meyer C, Cottin V, Brozek JL, Smith K, Wilson KC, Moss J. Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guidelines: Lymphangioleiomyomatosis Diagnosis and Management. Am J Respir Crit Care Med 2017; 194:748-61. [PMID: 27628078 DOI: 10.1164/rccm.201607-1384st] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease that primarily affects women. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of LAM. METHODS Systematic reviews were performed to summarize evidence pertinent to our questions. The evidence was summarized and discussed by a multidisciplinary panel. Evidence-based recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS After considering the panel's confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were formulated for or against specific interventions. These included recommendations for sirolimus treatment and vascular endothelial growth factor D testing and recommendations against doxycycline and hormonal therapy. CONCLUSIONS Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.
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42
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Glasgow CG, Pacheco-Rodriguez G, Steagall WK, Haughey ME, Julien-Williams PA, Stylianou MP, Gochuico BR, Moss J. CA-125 in Disease Progression and Treatment of Lymphangioleiomyomatosis. Chest 2017; 153:339-348. [PMID: 28576630 DOI: 10.1016/j.chest.2017.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/24/2017] [Accepted: 05/16/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a destructive lung disease of women caused by proliferation of neoplastic-like LAM cells, with mutations in the TSC1/2 tumor suppressor genes. Based on case reports, levels of cancer antigen 125 (CA-125), an ovarian cancer biomarker, can be elevated in patients with LAM. We hypothesized that elevated serum CA-125 levels seen in some patients with LAM were due to LAM, not other malignancies, and might respond to sirolimus treatment. METHODS Serum CA-125 levels were measured for 241 patients at each visit. Medical records were reviewed for co-morbidities, disease progression, and response to sirolimus treatment. CA-125 expression in LAM cells was determined by using immunohistochemical analysis. RESULTS Almost 25% of patients with LAM had at least one elevated serum CA-125 measurement. Higher serum CA-125 levels correlated with lower FEV1, premenopausal status, and pleural effusion in a multivariate model (each P < .001). Serum CA-125 levels decreased following sirolimus treatment (P = .002). CA-125 and α-smooth muscle actin were co-expressed in LAM lung nodules. CONCLUSIONS Higher serum CA-125 levels were associated with pleural effusions and reduced pulmonary function and were decreased with sirolimus therapy. LAM cells express CA-125. Some elevated serum CA-125 levels may reflect serosal membrane involvement.
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Affiliation(s)
- Connie G Glasgow
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gustavo Pacheco-Rodriguez
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Wendy K Steagall
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mary E Haughey
- Office of the Clinical Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Patricia A Julien-Williams
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mario P Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bernadette R Gochuico
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
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Franz DN, Capal JK. mTOR inhibitors in the pharmacologic management of tuberous sclerosis complex and their potential role in other rare neurodevelopmental disorders. Orphanet J Rare Dis 2017; 12:51. [PMID: 28288694 PMCID: PMC5348752 DOI: 10.1186/s13023-017-0596-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/14/2017] [Indexed: 11/21/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder that affects multiple organ systems throughout the body. Dysregulation of the mammalian target of rapamycin (mTOR) pathway is implicated in the disease pathology, and evidence exists to support the use of mTOR inhibitors in treatment. The mTOR pathway has also been investigated as a potential treatment target for several other rare diseases. TSC research has highlighted the value of pursuing targeted therapies based on underlying molecular pathophysiology. One goal of current research is to identify the role of mTOR inhibition in neurologic and developmental disorders apart from TSC. There is also particular interest in the potential role of mTOR inhibitors in preventing seizures, neurodevelopmental disabilities, renal tumors, cutaneous tumors, and other manifestations typically seen in TSC. It is foreseeable that use of mTOR inhibition to prevent long-term morbidity in TSC will become mainstream therapeutic practice. This review will provide an overview of the relationship between the mTOR pathway and TSC disease pathology, summarize the clinical evidence supporting the use of mTOR inhibitors for treatment of the various manifestations of TSC, and discuss the potential therapeutic role of mTOR inhibitors in several rare diseases.
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Affiliation(s)
- David N Franz
- Department of Pediatrics, Tuberous Sclerosis Clinic, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Jamie K Capal
- Department of Neurology, Tuberous Sclerosis Clinic, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
Lymphangioleiomyomatosis is a rare multisystem disease predominantly affecting women that can occur sporadically or in association with tuberous sclerosis. Lung cysts progressively replace the lung parenchyma, which leads to dyspnea, recurrent pneumothorax, and in some cases respiratory failure. Patients may also have lymphatic disease in the thorax, abdomen, and pelvis, and renal angiomyolipomas. Treatment includes supportive care, bronchodilators, and for those with progressive disease, mammalian target of rapamycin (mTOR) inhibitors.
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Courtwright AM, Goldberg HJ, Henske EP, El-Chemaly S. The effect of mTOR inhibitors on respiratory infections in lymphangioleiomyomatosis. Eur Respir Rev 2017; 26:26/143/160004. [PMID: 28096282 DOI: 10.1183/16000617.0004-2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/25/2016] [Indexed: 11/05/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a destructive cystic lung disease. Mammalian target of rapamycin (mTOR) inhibitors are the primary treatment for LAM but it is unknown whether these immunosuppressing medications increase the risk for or the severity of respiratory infections in LAM patients.We searched multiple databases for original articles that reported the rate of respiratory infections in LAM patients treated with mTOR inhibitors or placebo. We calculated incidence rates for respiratory infections in these groups and incidence rate ratios for respiratory infections and severe respiratory infections in mTOR inhibitors treated versus placebo treated patients.11 studies were included. There were 294 patients in the treatment groups and 93 patients in the placebo groups. Among subjects in placebo arms, the incidence rate of respiratory infections was 58.8 per 100 patient-years (95% CI 35.3-82.3 per 100 patient-years). The incidence-rate ratio (IRR) for respiratory infection among treated subjects was 0.71 (95% CI 0.50-1.02; p=0.06 compared to placebo subjects). The IRR for severe respiratory infections among treated subjects was 1.56 (95% CI 0.43-8.55; p=0.52).We found that respiratory infections are common in patients with LAM. Importantly, treatment with mTOR inhibitors does not increase the incidence of these infections and may be protective.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth Petri Henske
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
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Prizant H, Taya M, Lerman I, Light A, Sen A, Mitra S, Foster TH, Hammes SR. Estrogen maintains myometrial tumors in a lymphangioleiomyomatosis model. Endocr Relat Cancer 2016; 23:265-80. [PMID: 26880751 PMCID: PMC4992946 DOI: 10.1530/erc-15-0505] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 02/15/2016] [Indexed: 12/17/2022]
Abstract
Lymphangioleiomyomatosis (LAM) is a rare disease in women. Patients with LAM develop metastatic smooth-muscle cell adenomas within the lungs, resulting in reduced pulmonary function. LAM cells contain mutations in tuberous sclerosis genes (TSC1 or TSC2), leading to up-regulation of mTORC1 activity and elevated proliferation. The origin of LAM cells remains unknown; however, inactivation of Tsc2 gene in the mouse uterus resulted in myometrial tumors exhibiting LAM features, and approximately 50% of animals developed metastatic myometrial lung tumors. This suggests that LAM tumors might originate from the uterine myometrium, possibly explaining the overwhelming prevalence of LAM in female. Here, we demonstrate that mouse Tsc2-null myometrial tumors exhibit nearly all the features of LAM, including mTORC1/S6K activation, as well as expression of melanocytic markers and matrix metalloproteinases (MMPs). Estrogen ablation reduces S6K signaling and results in Tsc2-null myometrial tumor regression. Thus, even without TSC2, estradiol is required to maintain tumors and mTORC1/S6K signaling. Additionally, we find that MMP-2 and -9, as well as neutrophil elastase (NE), are overexpressed in Tsc2-null myometrial tumors in an estrogen-dependent fashion. In vivo fluorescent imaging using MMP- or NE-sensitive optical biomarkers confirms that protease activity is specific to myometrial tumors. Similar to LAM cells, uterine Tsc2-null myometrial cells also overexpress melanocytic markers in an estrogen-dependent fashion. Finally, we identify glycoprotein NMB (GPNMB) as a melanocytic marker up-regulated in Tsc2-null mouse uteri and human LAM samples. Our data highlight the potential importance of estradiol in LAM cells, suggesting that anti-estrogen therapy may be a treatment modality. Furthermore, proteases and GPNMB might be useful LAM biomarkers.
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Affiliation(s)
- Hen Prizant
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Manisha Taya
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Irina Lerman
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Allison Light
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Aritro Sen
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Soumya Mitra
- Department of Imaging SciencesUniversity of Rochester Medical Center, Rochester, New York, USA
| | - Thomas H Foster
- Department of Imaging SciencesUniversity of Rochester Medical Center, Rochester, New York, USA
| | - Stephen R Hammes
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester Medical Center, Rochester, New York, USA
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Ando K, Fujino N, Mitani K, Ota C, Okada Y, Kondo T, Mizobuchi T, Kurihara M, Suzuki K, Hoshika Y, Ebana H, Kobayashi E, Takahashi K, Kubo H, Seyama K. Isolation of individual cellular components from lung tissues of patients with lymphangioleiomyomatosis. Am J Physiol Lung Cell Mol Physiol 2016; 310:L899-908. [PMID: 27016587 DOI: 10.1152/ajplung.00365.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/19/2016] [Indexed: 01/30/2023] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a rare neoplastic disease entailing cystic destruction of the lungs and progressive respiratory failure. LAM lungs are histologically characterized by the proliferation of smooth muscle-like cells (LAM cells) and an abundance of lymphatic vessels. To elucidate the pathophysiological processes of LAM, cell-type-specific analyses are required. However, no method exists for isolating the individual types of cells in LAM lesions. Therefore, we established a fluorescence-activated cell sorting (FACS)-based method for the direct isolation of LAM cells and other various cellular components from LAM-affected lung tissue. We obtained LAM-affected lung tissue from resections or transplant recipients and prepared single-cell suspensions. FACS, immunohistochemical, and molecular analysis were used cooperatively to isolate HMB45-positive LAM cells with tuberous sclerosis complex (TSC) 2 loss of heterozygosity (LOH). Using a combination of antibodies against an epithelial cell adhesion molecule (EpCAM) and podoplanin, we fractionated CD45-negative lung cells into three groups: lymphatic endothelial cells (LEC) (EpCAM(-)/podoplanin(hi) subset), alveolar type II cells (EpCAM(hi)/podoplanin(-) subset), and mesenchymal cells (EpCAM(-)/podoplanin(-/low) subset). During subsequent analysis of HMB45 expression, as a LAM-specific marker, we clearly identified LAM cells in the mesenchymal cell population. We then discovered that CD90(+)/CD34(-) cells in the mesenchymal cell population are not only positive for HBM45 but also had TSC2 LOH. These isolated cells were viable and subsequently amenable to cell culture. This method enables us to isolate LAM cells and other cellular components, including LAM-associated LEC, from LAM-affected lung tissues, providing new research opportunities in this field.
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Affiliation(s)
- Katsutoshi Ando
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan;
| | - Naoya Fujino
- Department of Advanced Preventive Medicine for Infectious Disease, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiko Mitani
- Division of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Chiharu Ota
- Department of Advanced Preventive Medicine for Infectious Disease, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging, and Cancer, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Takashi Kondo
- Department of Thoracic Surgery, Institute of Development, Aging, and Cancer, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Teruaki Mizobuchi
- Pneumothorax Research Center and Division of Thoracic Surgery, Nissan Tamagawa Hospital, Tokyo, Japan; and
| | - Masatoshi Kurihara
- Pneumothorax Research Center and Division of Thoracic Surgery, Nissan Tamagawa Hospital, Tokyo, Japan; and
| | - Kenji Suzuki
- Division of Thoracic Surgery, Juntendo University Faculty of Medicine and Graduate School of Medicine, Bunkyo-Ku, Tokyo, Japan
| | - Yoshito Hoshika
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Ebana
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Etsuko Kobayashi
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Kubo
- Department of Advanced Preventive Medicine for Infectious Disease, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
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Lama A, Ferreiro L, Golpe A, Gude F, Álvarez-Dobaño JM, González-Barcala FJ, Toubes ME, San José E, Rodríguez-Núñez N, Valdés L. Characteristics of Patients with Lymphangioleiomyomatosis and Pleural Effusion: A Systematic Review. Respiration 2016; 91:256-64. [DOI: 10.1159/000444264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/22/2016] [Indexed: 11/19/2022] Open
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50
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Freitas CSG, Baldi BG, Araújo MS, Heiden GI, Kairalla RA, Carvalho CRR. Use of sirolimus in the treatment of lymphangioleiomyomatosis: favorable responses in patients with different extrapulmonary manifestations. J Bras Pneumol 2016; 41:275-80. [PMID: 26176526 PMCID: PMC4541764 DOI: 10.1590/s1806-37132015000004553] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/08/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: Lymphangioleiomyomatosis (LAM) is a rare disease that is currently considered a low-grade neoplasm with metastatic potential and variable progression. Mammalian target of rapamycin (mTOR) inhibitors, such as sirolimus and everolimus, have recently become a treatment option for LAM patients, especially those with extrapulmonary manifestations. The objective of the present study was to describe a case series of four patients with LAM in Brazil who showed significant improvement, particularly in their extrapulmonary manifestations, after treatment with sirolimus (at 1-4 mg/day). METHODS: We describe four cases of LAM patients with different extrapulmonary manifestations who were treated with sirolimus. RESULTS: After treatment with sirolimus for 12 months, one patient presented resolution of severe chylothorax; one had a significant reduction in renal angiomyolipoma volume; and one showed significant regression of retroperitoneal lymphangioleiomyomas and abdominal lymph node enlargement. After treatment with sirolimus for 6 months, the remaining patient had a significant reduction in the volume of a massive retroperitoneal lymphangioleiomyoma. CONCLUSIONS: Our findings confirm that mTOR inhibitors are beneficial for patients with LAM, especially those with extrapulmonary manifestations, such as renal angiomyolipoma, lymphangioleiomyomas, and chylous effusions. However, certain aspects, such as the optimal dose, duration of treatment, and long-term adverse effects, have yet to be sufficiently clarified for mTOR inhibitors to be incorporated into LAM management protocols.
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Affiliation(s)
| | - Bruno Guedes Baldi
- Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Ronaldo Adib Kairalla
- Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
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