The pace of progress in lymphangioleiomyomatosis (LAM) is remarkable. In the year 2000, TSC2 gene mutations were found in LAM cells; in 2001 the tuberous sclerosis complex (TSC) genes were discovered to regulate cell size in Drosophila via the kinase TOR (target of rapamycin); and in 2008 the results were published of a clinical trial of rapamycin, a specific inhibitor of TOR, in patients with TSC and LAM with renal angiomyolipomas. This interval of just 8 years between a genetic discovery for which the relevant signaling pathway was as yet unknown, to the initiation, completion, and publication of a clinical trial, is an almost unparalleled accomplishment in modern biomedical research. This robust foundation of basic, translational, and clinical research in TOR, TSC, and LAM is now poised to optimize and validate effective therapeutic strategies for LAM. An immediate challenge is to deduce the mechanisms underlying the partial response of renal angiomyolipomas to rapamycin, and thereby guide the design of combinatorial approaches. TOR complex 1 (TORC1), which is known to be active in LAM cells, is a key inhibitor of autophagy. One hypothesis, which will be explored here, is that low levels of autophagy in TSC2-null LAM cells limits their survival under conditions of bioenergetic stress. A corollary of this hypothesis is that rapamycin, by inducing autophagy, promotes the survival of LAM cells, while simultaneously arresting their growth. If this hypothesis proves to be correct, then combining TORC1 inhibition with autophagy inhibition may represent an effective clinical strategy for LAM.Keywords: tuberin; rapamycin; chloroquine; Rheb; tuberous sclerosis
LYMPHANGIOLEIOMYOMATOSIS AND THE TUBEROUS SCLEROSIS COMPLEX GENESLymphangioleiomyomatosis (LAM) is a rare lung disease affecting women, with onset typically during the childbearing years (1-3). Pathologically, LAM is characterized by two distinct components: LAM cells and cystic areas of alveolar destruction. LAM cells are smooth muscle-like, express melanocytic proteins, and grow in a diffuse pattern throughout both lungs (4-6). The relationship between the LAM cells and the regions of cystic lung degeneration is unknown, although it is believed that secretion of proteases by LAM cells is a contributing factor (6-12).LAM can occur in women with tuberous sclerosis complex (TSC), an autosomal dominant disease characterized by neurologic disease (seizures, intellectual disability, autism) and benign tumors of the brain, skin, heart, and kidneys (13). About 30% of women with TSC have evidence of cystic lung disease on CT scans and are believed to have LAM, although many of these women have mild symptoms or are asymptomatic and have not had biopsy to determine whether the cystic lesions are accompanied by LAM cells (14,15). For reasons that are not yet understood, LAM affects almost exclusively women, although a small number of men with TSC and histologically confirmed LAM have been reported (16-21).The cloning of the TSC1 and TSC2 genes in 1996 and 1993, respective...