Response to sirolimus in capillary lymphatic venous malformations and associated syndromes: Impact on symptomatology, quality of life, and radiographic response

Elissa R. Engel, Adrienne Hammill, Denise Adams, Roderic J. Phillips, Michael Jeng, Megha M. Tollefson, Ionela Iacobas, Deborah Schiff, Shoshana Greenberger, Michael Kelly, Ilona Frieden, Nibal Zaghloul, Beth Drolet, Amy Geddis, Dov Goldenberg, Kiersten Ricci

Research output: Contribution to journalArticlepeer-review


Background: Capillary lymphatic venous malformations (CLVM) and associated syndromes, including Klippel–Trenaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformation, epidermal nevi, skeletal, and spinal syndrome (CLOVES), are underrecognized disorders associated with high morbidity from chronic pain, recurrent infections, bleeding, and clotting complications. The rarity of these disorders and heterogeneity of clinical presentations make large-scale randomized clinical drug trials challenging. Identification of PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [gene]) mutations in CLVM has made targeted medications, such as sirolimus, attractive treatment options. The aim of this study was to investigate the safety and efficacy of sirolimus therapy in CLVM. Procedure: A combined prospective and retrospective cohort of pediatric and young adult patients with CLVM treated with sirolimus was evaluated for disease response, including symptom improvement, quality of life (QOL), and radiologic response. Sirolimus dosing regimens and toxicities were also assessed. Results: Twenty-nine patients with CLVM, including KTS and CLOVES, were included. Ninety-three percent of patients reported improved QOL, and 86% had improvement in at least one symptom. Most significantly, improvement was noted in 100% of patients with bleeding and 89% with thrombotic complications with corresponding decreases in mean D-dimer (p =.008) and increases in mean fibrinogen (p =.016). No patients had progressive disease on sirolimus. Most common side effects included neutropenia, lymphopenia, infection, and aphthous ulcers/stomatitis. No toxicities were life-threatening, and none required long-term discontinuation of sirolimus. Conclusion: Sirolimus appears to be effective at reducing complications and improving QOL in patients with CLVM and associated syndromes. In this patient cohort, sirolimus was well tolerated and resulted in few treatment-related toxicities.

Original languageEnglish (US)
Article numbere30215
JournalPediatric Blood and Cancer
Issue number4
StatePublished - Apr 2023


  • Klippel–Trenaunay syndrome (KTS)
  • PIK3CA-related overgrowth spectrum (PROS)
  • capillary lymphatic venous malformation (CLVM)
  • mammalian target of rapamycin (mTOR)
  • sirolimus (rapamycin)

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Hematology
  • Oncology


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