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Lestelle F, Beigelman C, Rotzinger D, Si-Mohamed S, Nasser M, Wemeau L, Hirschi S, Prevot G, Roux A, Bunel V, Gomez E, Sohier L, Pradier HM, Gaubert MR, Gondouin A, Lazor R, Glerant JC, Bejui FT, Colombat M, Cottin V. Phenotypes and outcome of diffuse pulmonary non-amyloid light chain deposition disease. Respir Res 2024; 25:159. [PMID: 38600600 PMCID: PMC11005206 DOI: 10.1186/s12931-024-02798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/01/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Light chain deposition disease (LCDD) is a very rare entity. Clinical manifestations of LCDD vary according to the organs involved. Data on pulmonary LCDD are scarce and limited to small series or case reports. This study aimed to describe the characteristics and outcome of diffuse pulmonary non-amyloid LCDD localized to the lungs. STUDY DESIGN AND METHODS A multicenter retrospective cohort study was conducted. Clinical characteristics were collected, and chest CTs were centrally reviewed. The diagnosis of pulmonary non-amyloid LCDD was confirmed by immunohistochemistry. RESULTS Thirty-one cases were identified (68% female), with a median age at diagnosis of 50 years (IQR 20). Baseline FEV1/FVC was < 0.70 in 45% of patients. Mean (± SD) FEV1 and DLCO were 86% ± 26.2 and 52% ± 23.9, respectively. CT revealed peculiar patterns of thin-walled cysts (58%) and thin-walled cystic bronchiectases (27%). Increased serum kappa light chain was found in 87% of patients. Histological analysis showed kappa light chain deposits in all patients, except one with lambda chain deposits. Median annual FEV1 decline was 127 ml (IQR 178) and median DLCO decline was 4.3% (IQR 4.3). Sixteen patients received immunomodulatory treatment or chemotherapy; serum light chain levels decreased in 9 cases (75%), without significant improvement in FEV1 (p = 0.173). Overall, 48% of patients underwent bilateral lung transplantation. Transplant-free survival at 5 and 10 years were 70% and 30%, respectively. An annual FEV1 decline greater than 127 ml/year was associated with increased risk of death or transplantation (p = 0.005). CONCLUSIONS Diffuse pulmonary LCDD is characterised by female predominance, a peculiar imaging pattern with bronchiectasis and/or cysts, progressive airway obstruction and severe DLCO impairment, and poor outcome. Lung transplantation is a treatment of choice.
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Affiliation(s)
- François Lestelle
- Hospices Civils de Lyon, Centre de Référence Coordinateur Des Maladies Pulmonaires Rares (OrphaLung), Hôpital Louis Pradel, Service de Pneumologie, 69677, Lyon, France
| | - Catherine Beigelman
- Service de Radiologie Et de Radiologie Interventionnelle, Hôpital Universitaire de Lausanne, Université de Lausanne, Lausanne, Suisse
| | - David Rotzinger
- Service de Radiologie Et de Radiologie Interventionnelle, Hôpital Universitaire de Lausanne, Université de Lausanne, Lausanne, Suisse
| | - Salim Si-Mohamed
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Radiologie, Lyon 69677U1206, Université de Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, F-69621, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| | - Mouhamad Nasser
- Hospices Civils de Lyon, Centre de Référence Coordinateur Des Maladies Pulmonaires Rares (OrphaLung), Hôpital Louis Pradel, Service de Pneumologie, 69677, Lyon, France
| | - Lidwine Wemeau
- Centre de Référence Constitutif Des Maladies Pulmonaires Rares (OrphaLung), CHU Lille, Service de Pneumologie, Lille, France
| | - Sandrine Hirschi
- Centre de Compétence Des Maladies Pulmonaires Rares (OrphaLung), CHU Strasbourg, Service de Pneumologie, Strasbourg, France
| | - Grégoire Prevot
- Centre de Compétence Des Maladies Pulmonaires Rares (OrphaLung), CHU Toulouse, Hôpital LarreyUniversité Paul Sabatier, Toulouse, France
| | - Antoine Roux
- Service de Pneumologie Et de Transplantation Pulmonaire, Hopital Foch, Suresnes, France
| | - Vincent Bunel
- Service de Pneumologie B Et de Transplantation Pulmonaire, AP-HP, Hôpital Bichat Claude-Bernard, Inserm U1152, Paris, France
| | - Emmanuel Gomez
- Centre de Compétence Des Maladies Pulmonaires Rares (OrphaLung), CHU Nancy, Service de Pneumologie, Nancy, France
| | - Laurent Sohier
- Centre Hospitalier Bretagne Sud, Service de Pneumologie, Lorient, France
| | - Helene Morisse Pradier
- Centre de Compétence Des Maladies Pulmonaires Rares (OrphaLung), CHU Rouen, Service de Pneumologie, Rouen, France
| | - Martine Reynaud Gaubert
- Service de Pneumologie Et Transplantation Pulmonaire, CHU Marseille Nord, Aix-Marseille Université Marseille, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Anne Gondouin
- Centre de Compétence Des Maladies Pulmonaires Rares (OrphaLung), CHU Besançon, Service de Pneumologie, Besançon, France
| | - Romain Lazor
- Service de Pneumologie, Centre Hospitalier Universitaire Vaudois, Lausanne, CH, Suisse
| | - Jean-Charles Glerant
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'explorations Fonctionnelles Respiratoires, 69677, Lyon, France
| | | | - Magali Colombat
- CHU Toulouse, Institut Universitaire du Cancer de Toulouse, Service d'anatomie Et Cytologie Pathologiques, Toulouse, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Centre de Référence Coordinateur Des Maladies Pulmonaires Rares (OrphaLung), Hôpital Louis Pradel, Service de Pneumologie, 69677, Lyon, France.
- UMR754, INRAE; Member of RespiFil and ERN-LUNG, Université, Claude Bernard Lyon 1, Lyon, France.
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Tinoco EM, Bermudo G, Vicens-Zygmunt V, Luburich P, Llatjós R, Molina-Molina M. Hypersensitivity pneumonitis, a differential diagnosis of cystic lung diseases. Pulmonology 2023:S2531-0437(22)00261-6. [PMID: 36639331 DOI: 10.1016/j.pulmoe.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 01/13/2023] Open
Affiliation(s)
- E M Tinoco
- Pulmonology Department, Vila Nova de Gaia/Espinho Hospital Center, R. Conceição Fernandes S/N, Vila Nova de Gaia 4434-502, Portugal.
| | - G Bermudo
- ILD Unit, Pulmonology Department, Bellvitge University Hospital-IDIBELL, Spain
| | - V Vicens-Zygmunt
- ILD Unit, Pulmonology Department, Bellvitge University Hospital-IDIBELL, Spain
| | - P Luburich
- ILD Unit, Radiology Department, Bellvitge University Hospital-IDIBELL, Spain
| | - R Llatjós
- ILD Unit, Pathology Department, Bellvitge University Hospital-IDIBELL, Spain
| | - M Molina-Molina
- ILD Unit, Pulmonology Department, Bellvitge University Hospital-IDIBELL, Spain
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3
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Louza GF, Nobre LF, Mançano AD, Hochhegger B, Souza AS, Zanetti G, Marchiori E. Lymphocytic interstitial pneumonia: computed tomography findings in 36 patients. Radiol Bras 2020; 53:287-292. [PMID: 33071371 PMCID: PMC7545736 DOI: 10.1590/0100-3984.2019.0107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze the computed tomography (CT) findings of lymphocytic interstitial pneumonia (LIP). Materials and Methods We retrospectively reviewed the clinical and CT findings of 36 patients with LIP, including 25 women and 11 men, with a mean age of 52.5 years (age range, 22-78 years). Results The main associated diseases with LIP were Sjögren syndrome (42%), human immunodeficiency virus infection (17%), amyloidosis (17%), Sjögren syndrome associated with secondary amyloidosis (11%), idiopathic (8%), and systemic lupus erythematosus (5%). The predominant CT abnormalities were multiple cystic airspaces (n = 35), small nodules (n = 15), ground-glass opacities (n = 13), bronchiectasis and/or bronchiolectasis (n = 8), and thickening of the bronchovascular bundles (n = 8). Other CT findings included reticular opacities (n = 7), calcified nodules (n = 4), airspace consolidation (n = 4), emphysema (n = 3), honeycombing (n = 3), lymph node enlargement (n = 2), mosaic attenuation pattern (n = 1), and cavitated nodules (n = 1). Conclusion The main CT findings of LIP were multiple cysts, small nodules, and ground-glass opacities.
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Affiliation(s)
| | - Luiz Felipe Nobre
- Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | | | - Bruno Hochhegger
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Arthur Soares Souza
- Faculdade de Medicina de São José do Rio Preto (Famerp), São José do Rio Preto, SP, Brazil
| | - Gláucia Zanetti
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Edson Marchiori
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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Kodati R, Tadepalli A, Reddy C. Pulmonary tuberculosis presenting as diffuse cystic lung disease: An atypical manifestation. Indian J Tuberc 2019; 67:397-399. [PMID: 32825878 DOI: 10.1016/j.ijtb.2019.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/06/2019] [Indexed: 11/16/2022]
Abstract
Pulmonary tuberculosis has varied patterns of clinical presentation. Here, we report a case of tuberculosis in a 44 year immunocompetent female patient who presented to us with multiple cysts in the lung parenchyma. The diagnosis was confirmed by the analysis of bronchoalveolar lavage fluid. She had secondary spontaneous pneumothorax and progressive respiratory failure despite anti-tubercular therapy. Acute or sub acute onset of multiple lung cysts is usually associated with pulmonary infection. Tuberculosis presenting as cystic lung disease is less common and atypical. High index of suspicion and early initiation of therapy is pivotal in management of such cases.
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Affiliation(s)
- Rakesh Kodati
- Department of Pulmonary and Critical Care Medicine, Star Hospitals, Hyderabad, India.
| | - Anuradha Tadepalli
- Department of Pulmonary and Critical Care Medicine, Star Hospitals, Hyderabad, India
| | - Chandana Reddy
- Department of Pulmonary and Critical Care Medicine, Star Hospitals, Hyderabad, India
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Hirokawa Y, Fujikawa R, Arai Y, Otsuki Y, Nakamura T. Primary thymic MALT lymphoma in a patient with Sjögren's syndrome and multiple lung cysts: a case report. Surg Case Rep 2019; 5:138. [PMID: 31478101 PMCID: PMC6718689 DOI: 10.1186/s40792-019-0696-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 08/26/2019] [Indexed: 12/16/2022] Open
Abstract
Background Thymic mucosa-associated lymphoid tissue (MALT) lymphoma is rare and also known for its association with autoimmune diseases, especially Sjögren’s syndrome (SjS), which could affect the systemic organs, and pulmonary involvement often reveals multiple lung cysts. Case presentation A 40-year-old woman presented with an anterior mediastinal mass and multiple lung cysts on computed tomography. We suspected thymoma concomitant with lymphangioleiomyomatosis and performed a total thymectomy and wedge resection of the lung as a surgical biopsy. The histopathological diagnosis of the mediastinal mass was a MALT lymphoma, and there were no specific findings in the lung specimen. She had a history of SjS, which had been overlooked during the initial work-up. Conclusions A history of SjS should raise suspicion of a MALT lymphoma for the differential diagnosis of an anterior mediastinal mass. A precise history taking is crucial for the correct diagnosis, and we could have avoided a lung resection in our case.
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Affiliation(s)
- Yusuke Hirokawa
- Department of General Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu City, Shizuoka, 430-8558, Japan.
| | - Ryo Fujikawa
- Department of General Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu City, Shizuoka, 430-8558, Japan
| | - Yoshifumi Arai
- Department of Pathology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu City, Shizuoka, 430-8558, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu City, Shizuoka, 430-8558, Japan
| | - Toru Nakamura
- Department of General Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu City, Shizuoka, 430-8558, Japan
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Welter S, Thrull P, Westhoff M, Bach P, Popper H, Maschek HJ. Difficult diagnosis and rare morphology of lymphangioleiomyomatosis with giant cysts. Respir Med Case Rep 2019; 28:100873. [PMID: 31249775 PMCID: PMC6586772 DOI: 10.1016/j.rmcr.2019.100873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 10/29/2022] Open
Abstract
We report on a 32-year-old woman with a second manifestation of a tension pneumothorax two weeks after drainage therapy. The chest CT-scan revealed multiple large bilateral pulmonary cysts. She underwent minimally invasive wedge resection and pleurectomy for treatment. The extensive histologic evaluation revealed the diagnosis of a lymphangioleiomyomatosis (LAM) with an uncommon pattern of lung cysts. Initial staining for HMB-45 was negative. Repeated evaluation of other sections and reference pathology examination detected minimal expression of HMB-45. This case illustrates that immunohistochemistry for HMB-45 may be negative, although LAM is present and repeated immunohistochemistry may be necessary to establish the correct diagnosis.
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Affiliation(s)
- Stefan Welter
- Lung Clinic Hemer, Center for Pneumology and Thoracic Surgery, Theo-Funccius-Str. 1, 58675 Hemer, Germany
| | - Philipp Thrull
- Lung Clinic Hemer, Center for Pneumology and Thoracic Surgery, Theo-Funccius-Str. 1, 58675 Hemer, Germany
| | - Michael Westhoff
- Lung Clinic Hemer, Center for Pneumology and Thoracic Surgery, Theo-Funccius-Str. 1, 58675 Hemer, Germany.,Medical University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Peter Bach
- Lung Clinic Hemer, Center for Pneumology and Thoracic Surgery, Theo-Funccius-Str. 1, 58675 Hemer, Germany
| | - Helmut Popper
- Institute of Pathology, Medical University of Graz, Neue Stiftingtalstraße 6, 8010 Graz, Austria
| | - Hans-Jörg Maschek
- Synlab, Pathology Laboratory, Tiergartenstraße 73, 30559 Hannover, Germany
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7
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Johannesma PC, van de Beek I, van der Wel JWT, Paul MA, Houweling AC, Jonker MA, van Waesberghe JHTM, Reinhard R, Starink TM, van Moorselaar RJA, Menko FH, Postmus PE. Risk of spontaneous pneumothorax due to air travel and diving in patients with Birt-Hogg-Dubé syndrome. Springerplus 2016; 5:1506. [PMID: 27652079 PMCID: PMC5014776 DOI: 10.1186/s40064-016-3009-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 08/05/2016] [Indexed: 01/10/2023]
Abstract
Background and objectives Birt–Hogg–Dubé syndrome is an autosomal dominant disorder characterized by skin fibrofolliculomas, lung cysts, spontaneous pneumothorax and renal cell cancer due to germline folliculin (FLCN) mutations (Menko et al. in Lancet Oncol 10(12):1199–1206, 2009). The aim of this study was to evaluate the incidence of spontaneous pneumothorax in patients with BHD during or shortly after air travel and diving. Methods A questionnaire was sent to a cohort of 190 BHD patients and the medical files of these patients were evaluated. The diagnosis of BHD was confirmed by FLCN mutations analysis in all patients. We assessed how many spontaneous pneumothoraces (SP) occurred within 1 month after air travel or diving. Results In total 158 (83.2 %) patients returned the completed questionnaire. A total of 145 patients had a history of air travel. Sixty-one of them had a history of SP (42.1 %), with a mean of 2.48 episodes (range 1–10). Twenty-four (35.8 %) patients had a history of pneumothorax on both sides. Thirteen patients developed SP < 1 month after air travel (9.0 %) and two patients developed a SP < 1 month after diving (3.7 %). We found in this population of BHD patients a pneumothorax risk of 0.63 % per flight and a risk of 0.33 % per episode of diving. Symptoms possible related to SP were perceived in 30 patients (20.7 %) after air travel, respectively in ten patients (18.5 %) after diving. Conclusion Based on the results presented in this retrospective study, exposure of BHD patients to considerable changes in atmospheric pressure associated with flying and diving may be related to an increased risk for developing a symptomatic pneumothorax. Symptoms reported during or shortly after flying and diving might be related to the early phase of pneumothorax. An individualized advice should be given, taking also into account patients’ preferences and needs.
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Affiliation(s)
- P C Johannesma
- Department of Pulmonary Diseases, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - I van de Beek
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - J W T van der Wel
- Department of Pulmonary Diseases, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - M A Paul
- Department of Thoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - A C Houweling
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - M A Jonker
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - R Reinhard
- Department of Radiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Th M Starink
- Department of Dermatology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - F H Menko
- Family Cancer Clinic, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - P E Postmus
- Clatterbridge Cancer Centre, Liverpool Heart and Chest Hospital, Liverpool, UK ; Department of Thoracic Oncology, University of Liverpool, Liverpool, UK
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Mastrogiulio MG, Barone A, Disanto MG, Ginori A, Ambrosio MR, Carbone SF, Spina D. Type II congenital pulmonary airway malformation associated with intralobar pulmonary sequestration: report of a case and review of classification criteria. Pathologica 2016; 108:38-41. [PMID: 28195247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Pulmonary congenital abnormalities are rare disorders including congenital pulmonary airway malformations (CPAM) and pulmonary sequestration (PS). CPAM is a lesion characterized by the presence of anomalous bronchiolar or acinar structures, variable in size, either cystic or not cystic. PS is generally defined as nonfunctioning lung tissue that is not in normal continuity with the tracheobronchial tree and that derives its blood supply from systemic vessels. We describe a case of a baby girl with a very rare association between CPAM type 2 and intralobar pulmonary sequestration (IPS) focusing on the cystic lesions typical of CPAM and on the lymphatic and blood vessels. The cells lining the cysts often were positive for D2-40 (oncofetal protein M2A). Lymphatic endothelial cells, positive for D2-40, were widely present in the lung parenchyma and dilated lymphatic vessels were present also in the inter-alveolar septa. Moreover, we discuss the pathogenesis of CPAM and its classification criteria.
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Affiliation(s)
- M G Mastrogiulio
- Department of Medical Biotechnologies, Pathology Unit, University of Siena, Siena, Italy
| | - A Barone
- Department of Medical Biotechnologies, Pathology Unit, University of Siena, Siena, Italy
| | - M G Disanto
- Department of Medical Biotechnologies, Pathology Unit, University of Siena, Siena, Italy
| | - A Ginori
- Department of Medical Biotechnologies, Pathology Unit, University of Siena, Siena, Italy
| | - M R Ambrosio
- Department of Medical Biotechnologies, Pathology Unit, University of Siena, Siena, Italy
| | - S F Carbone
- Department of Medical and Surgical Sciences and Neurosciences, University of Siena, Siena, Italy
| | - D Spina
- Pathology Unit, "Azienda Ospedaliera Universitaria Senese", Siena, Italy
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Kennedy JC, Khabibullin D, Henske EP. Mechanisms of pulmonary cyst pathogenesis in Birt-Hogg-Dube syndrome: The stretch hypothesis. Semin Cell Dev Biol 2016; 52:47-52. [PMID: 26877139 DOI: 10.1016/j.semcdb.2016.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 12/11/2022]
Abstract
Loss-of-function mutations in the folliculin gene (FLCN) on chromosome 17p cause Birt-Hogg-Dube syndrome (BHD), which is associated with cystic lung disease. The risk of lung collapse (pneumothorax) in BHD patients is 50-fold higher than in the general population. The cystic lung disease in BHD is distinctive because the cysts tend to be basilar, subpleural and lentiform, differentiating BHD from most other cystic lung diseases. Recently, major advances in elucidating the primary functions of the folliculin protein have been made, including roles in mTOR and AMPK signaling via the interaction of FLCN with FNIP1/2, and cell-cell adhesion via the physical interaction of FLCN with plakophilin 4 (PKP4), an armadillo-repeat containing protein that interacts with E-cadherin and is a component of the adherens junctions. In addition, in just the last three years, the pulmonary impact of FLCN deficiency has been examined for the first time. In mouse models, evidence has emerged that AMPK signaling and cell-cell adhesion are involved in alveolar enlargement. In addition, the pathologic features of human BHD cysts have been recently comprehensively characterized. The "stretch hypothesis" proposes that cysts in BHD arise because of fundamental defects in cell-cell adhesion, leading to repeated respiration-induced physical stretch-induced stress and, over time, expansion of alveolar spaces particularly in regions of the lung with larger changes in alveolar volume and at weaker "anchor points" to the pleura. This hypothesis ties together many of the new data from cellular and mouse models of BHD and from the human pathologic studies. Critical questions remain. These include whether the consequences of stretch-induced cyst formation arise through a destructive/inflammatory program or a proliferative program (or both), whether cyst initiation involves a "second hit" genetic event inactivating the remaining wild-type copy of FLCN (as is known to occur in BHD-associated renal cell carcinomas), and whether cyst initiation involves exclusively the epithelial compartment versus an interaction between the epithelium and mesenchyme. Ultimately, understanding the mechanisms of cystic lung disease in BHD may help to elucidate the pathogenesis of primary spontaneous pneumothorax, with more than 20,000 cases reported annually in the United States alone.
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