Everolimus as a therapeutic option in refractory epilepsy in children with tuberous sclerosis: a systematic review / Everolimo como opção terapêutica na epilepsia refratária em crianças com esclerose tuberosa: uma revisão sistemática

Abstract Background Tuberous sclerosis (TS) is a multisystem genetic disease in which epilepsy is a frequent manifestation and is often difficult to control. Everolimus is a drug with proven efficacy in the treatment of other conditions related to TS, and some evidence suggests that its use benefits the treatment of refractory epilepsy in these patients. Objective To evaluate the efficacy of everolimus in controlling refractory epilepsy in children with TS. Methods A literature review was conducted in the Pubmed, BVS, and Medline databases, using the descriptors Tuberous sclerosis, Children, Epilepsy, and Everolimus. Original clinical trials and prospective studies published in Portuguese or English in the last decade that evaluated the use of everolimus as an adjuvant therapy in the control of refractory epilepsy in pediatric patients with TS were included. Results Our search screened 246 articles from electronic databases, 6 of which were chosen for review. Despite the methodological variations between the studies, most patients benefited from the use of everolimus to control refractory epilepsy, with response rates ranging from 28.6 to 100%. Adverse effects were present in all studies leading to dropouts of some patients; however, the majority were of low severity. Conclusion The selected studies suggest a beneficial effect of everolimus in the treatment of refractory epilepsy in children with TS, despite the adverse effects observed. Further studies involving a larger sample in double-blind controlled clinical trials should be performed to provide more information and statistical credibility.

Resumo Antecedentes A esclerose tuberosa (ET) é uma doença genética multissistêmica na qual a epilepsia é a manifestação neurológica mais frequente, sendo muitas vezes de difícil controle. O everolimo é uma droga com eficácia comprovada no tratamento de outras condições relacionadas à ET, e indícios sugerem benefícios de seu uso também no controle da epilepsia refratária nesses pacientes. Objetivo Avaliar a eficácia do everolimo no controle da epilepsia refratária em crianças com ET. Métodos Revisão de literatura nas bases de dados Pubmed, BVS e Medline, utilizando os descritores Tuberous sclerosis, Children, Epilepsy e Everolimus. Incluíram-se ensaios clínicos originais e estudos prospectivos publicados em português ou inglês na última década e que avaliassem o uso do everolimo como terapia adjuvante no controle da epilepsia refratária em pacientes pediátricos com ET. Resultados Nossa busca rastreou 246 artigos nas bases de dados, dos quais 6 foram escolhidos para a revisão. Apesar das variações metodológicas entre os estudos, a maioria dos pacientes tiveram benefício no uso do everolimo para controle da epilepsia refratária, com taxas de resposta variando entre 28.6 e 100%. Os efeitos adversos estiveram presentes em todos os estudos, levando à desistência de alguns pacientes, contudo a maioria foi de baixa gravidade. Conclusão Os estudos selecionados sugerem efeito benéfico do everolimo no tratamento da epilepsia refratária em crianças com ET, apesar dos efeitos adversos observados. Novos estudos envolvendo uma amostra maior em ensaios clínicos controlados duplo-cegos devem ser realizados para fornecer mais informações e credibilidade estatística.

La vía canónica PI3K/AKT/mTOR y sus alteraciones en cáncer / The PI3K/AKT/mTOR canonical pathway and its alterations in cancer

RESUMEN La vía PI3K/AKT/mTOR participa en múltiples procesos celulares fundamentales para la célula. Algunas mutaciones genéticas de los componentes de esta vía se han asociado a diversas enfermedades humanas: las más importantes son los carcinomas de mama, tiroides y endometrio, el glioblastoma multiforme, el cáncer de próstata y los linfomas. La vía canónica PI3K/AKT/mTOR se ha estudiado ampliamente en los últimos años. Sin embargo, el conocimiento de la complejidad de sus componentes principales y su interrelación con los elementos de otras vías va en aumento. Por ello, es importantes actualizar cada cierto tiempo la información disponible para la comprensión de este mecanismo. Así mismo, se están y se han desarrollado numerosos ensayos con medicinas selectivas en búsqueda de un tratamiento más inteligente para las enfermedades asociadas a alteraciones de esta vía. Por tanto, realizamos una revisión de esta vía de transducción con el objetivo de tener una visión cercana de su funcionamiento, sus alteraciones y enumerar algunas moléculas promisorias para ser utilizadas en futuros tratamientos.

ABSTRACT The PI3K/AKT/mTOR pathway is involved in multiple cellular processes which are essential for the cells. Some genetic mutations of the components of this pathway have been associated with various human diseases, the most important of which are breast, thyroid and endometrium carcinomas; glioblastoma multiforme; prostate cancer and lymphomas. The PI3K/AKT/mTOR canonical pathway has been extensively studied in recent years. However, as the complexity of its main components and their correlation with the components of other pathways are increasing, it is important to update from time to time the available information to understand this mechanism. Furthermore, many trials have been conducted with selective medicines aimed to look for a more intelligent treatment for diseases associated with alterations in this pathway. Therefore, we review this transduction pathway to take a close look at its functioning and alterations, and to list some promising molecules for future treatments.

Sarcoma de Kaposi ganglionar postrasplante renal: reporte de dos casos en un centro de trasplante colombiano Kaposi sarcoma in lymph nodes after kidney transplantation: report of two cases in a Colombian transplant center / Sarcoma de Kaposi ganglionar postrasplante renal: reporte de dos casos en un centro de trasplante colombiano Kaposi sarcoma in lymph nodes after kidney transplantation: report of two cases in a Colombian transplant center

El cáncer es una causa importante de morbilidad y mortalidad en los receptores de trasplante. La combinación de infecciones virales, terapia de inmunosupresión y la alteración en el sistema inmune en los pacientes trasplantados, contribuyen al desarrollo de cáncer. El sarcoma de Kaposi es causado por el virus herpes humano 8 (VHH-8), y aunque es raro en la población general, puede ser hasta 300 veces más frecuente en los pacientes con trasplante renal. El diagnóstico de la enfermedad se realiza a menudo con base en las características de las lesiones, pero debe ser confirmado por histología. En años recientes, los inhibidores de mTOR han mostrado ser efectivos para el control del sarcoma de Kaposi en los pacientes trasplantados, ya que se interrumpe el efecto antiapoptótico y la angiogénesis dependientes de la proteína mTOR, los cuales son esenciales para el desarrollo y la propagación de células malignas. Se presentan dos casos de pacientes con sarcoma de Kaposi ganglionar, sin lesiones en piel, en nuestro centro de trasplante, quienes respondieron de manera positiva al cambio del esquema inmunosupresor con inhibidores de mTOR

Cancer is a major cause of morbidity and mortality in transplant recipients. The combination of viral infections, immunosuppression therapy and immune system dysfunction in transplant patients contribute to the development of cancer. Kaposi sarcoma is caused by human herpes virus 8 (HHV-8) and although rare in the general population, it is reported to be up to 300 times more common in kidney transplant patients. Diagnosis of the disease is often made on the basis of the characteristic appearance of lesions, but must be confirmed by histology. In recent years, mTOR inhibitors have been shown to be effective in controlling Kaposi sarcoma in transplant patients, due to disruption of the antiapoptotic effect and angiogenesis dependent on the mTOR protein, which are essential for development and propagation of malignant cells. We present two case reports of patients with Kaposi sarcoma in lymph nodes and no skin lesions, who responded well to the immunosuppressive therapy switch with mTOR inhibitors

Overexpression of mTOR and p(240-244)S6 in IDH1 Wild-Type Human Glioblastomas Is Predictive of Low Survival.

PI3K/Akt/mTOR pathway activation is a hallmark of high-grade gliomas, which prompted clinical trials for the use of PI3K and mTOR inhibitors. However, the poor results in the original trials suggested that better patient profiling was needed for such drugs. Thus, accurate and reproducible monitoring of mTOR complexes can lead to improved therapeutic strategies. In this work, we evaluated the expression and phosphorylation of mTOR, RAPTOR, and rpS6 in 195 human astrocytomas and 30 normal brain tissue samples. The expression of mTOR increased in glioblastomas, whereas mTOR phosphorylation, expression of RAPTOR, and expression and phosphorylation of rpS6 were similar between grades. Interestingly, the overexpression of total and phosphorylated mTOR as well as phosphorylated rpS6 (residues 240-244) were associated with wild-type IDH1 only glioblastomas. The expression and phosphorylation of mTOR and phosphorylation of rpS6 at residues 240-244 were associated with a worse prognosis in glioblastomas. Our results suggest that mTOR and rpS6 could be used as markers of overactivation of the PI3K-mTOR pathway and are predictive factors for overall survival in glioblastomas. Our study thus suggests that patients who harbor IDH1 wild-type glioblastomas might have increased benefit from targeted therapy against mTOR.

Use of sirolimus in the treatment of lymphangioleiomyomatosis: favorable responses in patients with different extrapulmonary manifestations / Uso de sirolimo no tratamento de linfangioleiomiomatose: resposta favorável em pacientes com diferentes manifestações extrapulmonares

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. .

OBJETIVO: A linfangioleiomiomatose (LAM) é uma doença rara que é atualmente considerada uma neoplasia de baixo grau com potencial metastático e evolução variável. Os inibidores de mammalian target of rapamycin (mTOR), como o sirolimo e o everolimo, recentemente se tornaram uma opção para o tratamento de pacientes com LAM, especialmente daqueles com manifestações extrapulmonares. O objetivo deste estudo foi descrever quatro casos de pacientes com LAM no Brasil que apresentaram melhora, especialmente das manifestações extrapulmonares, após tratamento com sirolimo (em doses de 1-4 mg/dia). MÉTODOS: Descrevemos quatro casos de pacientes com LAM e diferentes manifestações extrapulmonares tratados com sirolimo. RESULTADOS: Após o tratamento com sirolimo por 12 meses, um paciente apresentou resolução do quilotórax de difícil manejo, um paciente teve redução significativa do volume do angiomiolipoma renal, e uma paciente apresentou regressão importante de linfangioleiomiomas retroperitoneais e linfonodomegalias abdominais. Após tratamento com sirolimo por 6 meses, um paciente apresentou redução significativa de volumoso linfangioleiomioma retroperitoneal. CONCLUSÕES: Nossos achados confirmam que os inibidores de mTOR são benéficos para pacientes com LAM, especialmente para aqueles com manifestações extrapulmonares, tais como angiomiolipomas renais, linfangioleiomiomas e derrames de origem quilosa. Entretanto, alguns pontos, tais como a dose ideal, a duração do tratamento e os efeitos adversos em longo prazo, ainda precisam ser esclarecidos para que os inibidores de mTOR possam ser incorporados na abordagem da LAM. .