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He M, He Q, Cai X, Chen Z, Lao S, Deng H, Liu X, Zheng Y, Liu X, Liu J, Xie Z, Yao M, Liang W, He J. Role of lymphatic endothelial cells in the tumor microenvironment-a narrative review of recent advances. Transl Lung Cancer Res 2021; 10:2252-2277. [PMID: 34164274 PMCID: PMC8182726 DOI: 10.21037/tlcr-21-40] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background As lymphatic vessel is a major route for solid tumor metastasis, they are considered an essential part of tumor drainage conduits. Apart from forming the walls of lymphatic vessels, lymphatic endothelial cells (LECs) have been found to play multiple other roles in the tumor microenvironment, calling for a more in-depth review. We hope that this review may help researchers gain a detailed understanding of this fast-developing field and shed some light upon future research. Methods To achieve an informative review of recent advance, we carefully searched the Medline database for English literature that are openly published from the January 1995 to December 2020 and covered the topic of LEC or lymphangiogenesis in tumor progression and therapies. Two different authors independently examined the literature abstracts to exclude possible unqualified ones, and 310 papers with full texts were finally retrieved. Results In this paper, we discussed the structural and molecular basis of tumor-associated LECs, together with their roles in tumor metastasis and drug therapy. We then focused on their impacts on tumor cells, tumor stroma, and anti-tumor immunity, and the molecular and cellular mechanisms involved. Special emphasis on lung cancer and possible therapeutic targets based on LECs were also discussed. Conclusions LECs can play a much more complex role than simply forming conduits for tumor cell dissemination. Therapies targeting tumor-associated lymphatics for lung cancer and other tumors are promising, but more research is needed to clarify the mechanisms involved.
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Affiliation(s)
- Miao He
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qihua He
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Oncology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiuyu Cai
- Department of VIP Region, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zisheng Chen
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Respiratory Medicine, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, China
| | - Shen Lao
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hongsheng Deng
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiwen Liu
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yongmei Zheng
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoyan Liu
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jun Liu
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhanhong Xie
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Maojin Yao
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,The First People Hospital of Zhaoqing, Zhaoqing, China
| | - Jianxing He
- Department of Thoracic Surgery, China State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Chen H, Lin X, Liu H, Huang C, Li R, Ai J, Wei J, Xiao S. HMGB1 Translocation is Associated with Tumor-Associated Myeloid Cells and Involved in the Progression of Fibroblastic Sarcoma. Pathol Oncol Res 2021; 27:608582. [PMID: 34257571 PMCID: PMC8262203 DOI: 10.3389/pore.2021.608582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/26/2021] [Indexed: 11/13/2022]
Abstract
The morphological variability and genetic complexity of fibroblastic sarcoma makes its diagnosis and treatment a challenge. High-mobility group box 1 protein (HMGB1), which functions as a DNA chaperone and a prototypical damage-associated molecular pattern, plays a paradoxical role in cancer. However, the expression pattern and role of HMGB1 in fibroblastic sarcomas is ill defined. By immunostaining of 95 tissue microarray cores of fibroblastic sarcomas, HMGB1 was found to be expressed in most tumor tissues. Nuclear HMGB1 translocation to cytoplasm was observed both in tumor cells and vascular endothelial cells. A visible number of tumor-associated myeloid cells including CD68+ and CD163+ macrophages and CD33+ myeloid cells were also detected in most tumor tissues. HMGB1 translocation was not only associated with CD68, CD163, and CD33 density, but also with disease progression. These results imply that HMGB1, an important regulator of the tumor microenvironment, is associated with tumor-associated myeloid cells and involved in the progression of fibroblastic sarcomas; HMGB1 may serve as a promising prognostic biomarker and a potential therapeutic target for fibroblastic sarcoma.
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Affiliation(s)
- Huoying Chen
- Prenatal Diagnosis Center, Guangdong Second Provincial General Hospital, Guangdong Provincial Emergency Hospital, Guangzhou, China.,Department of Laboratory Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Xiaoying Lin
- Prenatal Diagnosis Center, Guangdong Second Provincial General Hospital, Guangdong Provincial Emergency Hospital, Guangzhou, China
| | - Hongbo Liu
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Cheng Huang
- Prenatal Diagnosis Center, Guangdong Second Provincial General Hospital, Guangdong Provincial Emergency Hospital, Guangzhou, China
| | - Rong Li
- Prenatal Diagnosis Center, Guangdong Second Provincial General Hospital, Guangdong Provincial Emergency Hospital, Guangzhou, China
| | - Jie Ai
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Jiaxue Wei
- Prenatal Diagnosis Center, Guangdong Second Provincial General Hospital, Guangdong Provincial Emergency Hospital, Guangzhou, China
| | - Shengjun Xiao
- Department of Pathology, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
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Tu Q, Hu C, Zhang H, Kong M, Peng C, Song M, Zhao C, Wang Y, Ma X. Development and Validation of Novel Nomograms for Predicting Specific Distant Metastatic Sites and Overall Survival of Patients With Soft Tissue Sarcoma. Technol Cancer Res Treat 2021; 20:1533033821997828. [PMID: 33706618 PMCID: PMC7958169 DOI: 10.1177/1533033821997828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose: The goal of this study is to construct nomograms to effectively predict the
distant metastatic sites and overall survival (OS) of soft tissue sarcoma
(STS) patients. Methods: STS case data between 2010 and 2015 for retrospective study were gathered
from public databases. According to the chi-square and multivariate logistic
regression analysis determined independent predictive factors of specific
metastatic sites, the nomograms based on these factors were consturced.
Subsequently, combined metastatic information a nomogram to predict 1-, 2-,
and 3-year OS of STS patients was developed. The performance of models was
validated by the area under the curve (AUC), calibration plots, and decision
curve analyses (DCA). Results: A total of 7001 STS patients were included in this retrospective study,
including 4901 cases in the training group and the remaining 2,100 patients
in the validation group. Three nomograms were established to predict lung,
liver and bone metastasis, and satisfactory results have been obtained by
internal and external validation. The AUCs for predicting lung, liver, and
bone metastases in the training cohort were 0.796, 0.799, and 0.766,
respectively, and in the validation cohort were 0.807, 0.787, and 0.775,
respectively, which means that the nomograms have good discrimination. The
calibration curves showed that the models have high precision, and the DCA
manifested that the nomograms have great clinical application prospects.
Through univariate and multivariate COX regression analyses, 8 independent
prognosis factors of age, grade, histological type, tumor size, surgery,
chemotherapy, radiatiotherapy and lung metastasis were determined. A
nomogram was then constructed to predict the 1-, 2-, and 3-years OS, which
has a good performance in both internal and external validations. Conclusion: The nomograms for predicting specific metastatic sites and OS have good
discrimination, accuracy and clinical applicability. The models could
accurately predict the metastatic risk and survival information, and help
clinical decision-making.
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Affiliation(s)
- QiHao Tu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan Hu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hao Zhang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Kong
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chen Peng
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - MengXiong Song
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chong Zhao
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - YuJue Wang
- Medical College of Qingdao University, Qingdao, Shandong, China
| | - XueXiao Ma
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Smolle MA, Herbsthofer L, Goda M, Granegger B, Brcic I, Bergovec M, Scheipl S, Prietl B, El-Heliebi A, Pichler M, Gerger A, Posch F, Tomberger M, López-García P, Feichtinger J, Baumgartner C, Leithner A, Liegl-Atzwanger B, Szkandera J. Influence of tumor-infiltrating immune cells on local control rate, distant metastasis, and survival in patients with soft tissue sarcoma. Oncoimmunology 2021; 10:1896658. [PMID: 33763294 PMCID: PMC7954425 DOI: 10.1080/2162402x.2021.1896658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Soft tissue sarcomas (STS) are considered non-immunogenic, although distinct entities respond to anti-tumor agents targeting the tumor microenvironment. This study’s aims were to investigate relationships between tumor-infiltrating immune cells and patient/tumor-related factors, and assess their prognostic value for local recurrence (LR), distant metastasis (DM), and overall survival (OS). One-hundred-eighty-eight STS-patients (87 females [46.3%]; median age: 62.5 years) were retrospectively analyzed. Tissue microarrays (in total 1266 cores) were stained with multiplex immunohistochemistry and analyzed with multispectral imaging. Seven cell types were differentiated depending on marker profiles (CD3+, CD3+ CD4+ helper, CD3+ CD8+ cytotoxic, CD3+ CD4+ CD45RO+ helper memory, CD3+ CD8+ CD45RO+ cytotoxic memory T-cells; CD20 + B-cells; CD68+ macrophages). Correlations between phenotype abundance and variables were analyzed. Uni- and multivariate Fine&Gray and Cox-regression models were constructed to investigate prognostic variables. Model calibration was assessed with C-index. IHC-findings were validated with TCGA-SARC gene expression data of genes specific for macrophages, T- and B-cells. B-cell percentage was lower in patients older than 62.5 years (p = .013), whilst macrophage percentage was higher (p = .002). High B-cell (p = .035) and macrophage levels (p = .003) were associated with increased LR-risk in the univariate analysis. In the multivariate setting, high macrophage levels (p = .014) were associated with increased LR-risk, irrespective of margins, age, gender or B-cells. Other immune cells were not associated with outcome events. High macrophage levels were a poor prognostic factor for LR, irrespective of margins, B-cells, gender and age. Thus, anti-tumor, macrophage-targeting agents may be applied more frequently in tumors with enhanced macrophage infiltration.
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Affiliation(s)
- Maria A Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | | | - Mark Goda
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Barbara Granegger
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Iva Brcic
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Marko Bergovec
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Susanne Scheipl
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Barbara Prietl
- Center for Biomarker Research in Medicine (CBmed), Graz, Austria.,Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Amin El-Heliebi
- Center for Biomarker Research in Medicine (CBmed), Graz, Austria.,Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Clinical Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Armin Gerger
- Division of Clinical Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Posch
- Division of Clinical Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | | | - Julia Feichtinger
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Claudia Baumgartner
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Bernadette Liegl-Atzwanger
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Joanna Szkandera
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
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Song SO, Kim MS, Lee KH, Choi SJ. Undifferentiated Pleomorphic Sarcoma of the Small Intestine with Distant Endobronchial Metastasis Presenting as Intussusception: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:1304-1309. [PMID: 36238390 PMCID: PMC9432362 DOI: 10.3348/jksr.2020.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/29/2020] [Accepted: 12/17/2020] [Indexed: 11/15/2022]
Abstract
미분화성 다형성 육종은 중간엽조직에서 기원하는 고등급의 연조직 육종이다. 소장에서 기원한 미분화성 다형성 육종은 매우 드물며 산발적인 증례 보고가 대부분이다. 소장 미분화성 다형성 육종의 증상은 대개는 비특이적이며, 일부에서는 장중첩증으로 발현되어 간헐적 복통을 일으키기도 한다. 미분화성 다형성 육종은 공격적인 성장을 보이는 종양으로 진단 당시에 원격 전이를 동반한 경우가 많다. 가장 흔한 원격 전이 부위는 복막이며, 그 외에도 임파선, 복강 내 고형 장기, 폐나 뇌 등으로 전이할 수 있다. 저자들이 아는 한도에서는, 기관지 내 전이는 현재까지 보고된 바 없다. 저자들은 장중첩증으로 발현한 소장의 미분화성 다형성 육종이 기관지 내로 전이한 드문 증례를 경험하였기에 이를 보고하고자 한다.
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Affiliation(s)
- Sung Oh Song
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
| | - Min Seon Kim
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
| | - Kyung Hee Lee
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
| | - Suk Jin Choi
- Department of Pathology, Inha University College of Medicine, Incheon, Korea
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McKenna KA, Spiro JD, Wu Q, Falcone TE. Metastatic Soft Tissue Sarcoma Presenting as a Subcutaneous Facial Mass. EAR, NOSE & THROAT JOURNAL 2020; 101:454-455. [PMID: 33076713 DOI: 10.1177/0145561320967731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kelly A McKenna
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jeffrey D Spiro
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of Connecticut Health, Farmington, CT, USA
| | - Qian Wu
- Department of Pathology and Laboratory Medicine, University of Connecticut Health, Farmington, CT, USA
| | - Todd E Falcone
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of Connecticut Health, Farmington, CT, USA
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Du XH, Wei H, Zhang P, Yao WT, Cai QQ. Heterogeneity of Soft Tissue Sarcomas and Its Implications in Targeted Therapy. Front Oncol 2020; 10:564852. [PMID: 33072594 PMCID: PMC7538626 DOI: 10.3389/fonc.2020.564852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022] Open
Abstract
Soft tissue sarcomas are a set of malignancies of mesenchymal origin. Due to the rarity and similarity in clinical presentation, they are grouped together and treated similarly in clinic. The response rates for current chemotherapy are around 20% and the median overall survival for advanced soft tissue sarcoma are less than 2 years. Thus, the current strategy with identical treatment for all soft tissue sarcomas is far from satisfactory. In this study, we first reviewed the current clinical and genomic findings of soft tissue sarcoma, paying special attention to the heterogeneities among different tumors. Then we reviewed the state-of-art understanding of targeted therapy in soft tissue sarcoma. We observed tremendous heterogeneity both in clinical and genomic settings between different tumors. Individualized treatment plans demonstrated better response and disease control and should be advocated. In summary, heterogeneity of soft tissue sarcomas requires the development of individualized treatment plans such as targeted therapy.
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Affiliation(s)
- Xin-Hui Du
- Department of Orthopedics, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Hua Wei
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Zhang
- Department of Orthopedics, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Wei-Tao Yao
- Department of Orthopedics, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Qi-Qing Cai
- Department of Orthopedics, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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Doxorubicin and Olaratumab Versus Doxorubicin, Ifosfamide, and Mesna for Treatment of Advanced Soft Tissue Sarcomas. Am J Clin Oncol 2020; 43:446-451. [PMID: 32235164 DOI: 10.1097/coc.0000000000000690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We compared the outcomes in soft tissue sarcoma (STS) treated with olaratumab and doxorubicin (OD) versus doxorubicin, ifosfamide, and mesna (AIM) to assess whether OD could supersede AIM in STS therapy. METHODS A single-institution, retrospective study of STS treated for advanced disease with OD or AIM in 2013 to 2017 was conducted. Demographic and clinical parameters were compared by Fisher's exact test. Kaplan-Meier and Cox analyses examined progression-free survival (PFS) and overall survival (OS). Adverse events were compared. RESULTS Thirty patients (13 OD, 17 AIM) were included. OD was administered more commonly after first-line therapy (54% OD vs. 6% AIM, P=0.0005). The 2 groups did not differ in other parameters. Median OS [OD: 14.2 mo, 95% confidence interval (CI): 7.1-not reached; AIM 19.9 mo, 95% CI 9.5-35.5; hazard ratio: 0.99, 95% CI: 0.38-2.59, P=0.99] and PFS (OD: 2.6 mo, 95% CI: 1.3-7; AIM 6.4 mo, 95% CI: 1.5-14.5; hazard ratio: 0.57, 95% CI: 0.26-1.24, P=0.16) were not statistically different, although median values favored AIM. Grade 3 to 4 neutropenia, but not febrile neutropenia, was more frequent with OD. CONCLUSIONS OD and AIM did not differ with respect to either OS or PFS. Although this study's size initially appeared the most likely explanation, lack of significant activity of olaratumab was subsequently reported in the phase III trial of OD. Our results suggest that future conditional oncology drug approvals should be accompanied by mandated registries to monitor outcomes of patients treated after conditional approval, but before full approval.
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59
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Gao Y, Liu P, Shi R. Anlotinib as a molecular targeted therapy for tumors. Oncol Lett 2020; 20:1001-1014. [PMID: 32724339 PMCID: PMC7377159 DOI: 10.3892/ol.2020.11685] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/30/2020] [Indexed: 12/24/2022] Open
Abstract
Angiogenesis has an essential role in tumor growth and metastasis, and blocking this pathway has been a successfully utilized strategy in the clinical treatment of cancer. Anlotinib (AL3818) is a novel oral receptor tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor 2 and 3, fibroblast growth factor 1-4, platelet-derived growth factor receptor α and β, c-Kit and Ret. Anlotinib exerts inhibitory effects on tumor growth and angiogenesis and received its first approval as a third-line treatment for refractory advanced non-small-cell lung cancer in May 2018 and its second approval as a second-line treatment for advanced soft-tissue sarcoma in June 2019 in the People's Republic of China. Anlotinib has encouraging efficacy and a manageable and tolerable safety profile in a broad range of malignancies, including medullary thyroid cancer, renal cell cancer, gastric cancer and esophageal squamous cell carcinoma. In the present review, the preclinical and clinical trials of anlotinib were summarized with a focus on safety evaluation and adverse event management.
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Affiliation(s)
- Yi Gao
- School of Medicine, Southeast University, Nanjing, Jiangsu 210009, P.R. China
- Department of Gastroenterology, The Jiangyin Clinical College of Xuzhou Medical University, Jiangyin, Jiangsu 214400, P.R. China
- Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, Jiangsu 215123, P.R. China
| | - Pengfei Liu
- Department of Gastroenterology, The Jiangyin Clinical College of Xuzhou Medical University, Jiangyin, Jiangsu 214400, P.R. China
- State Key Laboratory of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, Jiangsu 215123, P.R. China
| | - Ruihua Shi
- School of Medicine, Southeast University, Nanjing, Jiangsu 210009, P.R. China
- Department of Gastroenterology, Zhongda Hospital, Affiliated Hospital of Southeast University, Nanjing, Jiangsu 210009, P.R. China
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Tian Z, Zhang F, Li P, Wang J, Yang J, Zhang P, Yao W, Wang X. Albumin-bound paclitaxel and gemcitabine combination therapy in soft tissue sarcoma. BMC Cancer 2020; 20:698. [PMID: 32723378 PMCID: PMC7388541 DOI: 10.1186/s12885-020-07199-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The evidence that albumin-bound paclitaxel (nab-paclitaxel) is safe and efficacious for the treatment of many types of malignant tumors is continuously increasing. However, the evidence and clinical data of nab-paclitaxel and gemcitabine in metastatic soft tissue sarcoma (STS) treatment are rare. METHODS The clinical data of metastatic STS patients who received nab-paclitaxel/ gemcitabine chemotherapy between January 2019 and February 2020 were retrospectively analysed. All these patients were treated with nab-paclitaxel/ gemcitabine only after doxorubicin-based chemotherapy had failed. We evaluated the effectiveness and safety of nab-paclitaxel and gemcitabine in these patients. RESULTS A total of 17 patients treated with nab-paclitaxel/ gemcitabine were enrolled in this study. One patient with angiosarcoma achieved complete response, 6 patients had partial response, 5 patients achieved stable disease, and 5 patients had progressive disease. The average diameter change in target lesion from baseline was - 19.06 ± 45.74%. And median progression free survival was 6 months (95% CI, 2-9 months). Grade 3 / 4 adverse events were not common, included neutropenia (17.6%), fatigue (11.8%), anemia (11.8%), leukopenia (11.8%), nausea (5.9%), peripheral neuropathy (5.9%), diarrhea (5.9%), and thrombocytopenia (5.9%). No treatment-related deaths occurred. CONCLUSION Nab-paclitaxel/ gemcitabine combination chemotherapy is comparatively effective in the treatment of STS, demonstrates low toxicity, and is worthy of further study.
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Affiliation(s)
- Zhichao Tian
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China.
| | - Fan Zhang
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Po Li
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Jiaqiang Wang
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Jinpo Yang
- Department of Medical Oncology, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Peng Zhang
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Weitao Yao
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
| | - Xin Wang
- Department of Bone and Soft Tissue, the Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450008, Henan Province, China
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A phase II study of pazopanib as front-line therapy in patients with non-resectable or metastatic soft-tissue sarcomas who are not candidates for chemotherapy. Eur J Cancer 2020; 137:1-9. [PMID: 32712457 DOI: 10.1016/j.ejca.2020.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/06/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cytotoxic chemotherapy remains the standard of care first-line treatment for advanced and metastatic soft-tissue sarcomas (STSs). Certain patients may not be chemotherapy candidates based upon age or co-morbidities, leaving limited treatment options. Pazopanib is a multi-targeted tyrosine kinase inhibitor that is FDA-approved for metastatic STS after the first line. We proposed a phase II study evaluating pazopanib as a first-line agent in patients with advanced disease who are deemed not to be candidates for chemotherapy. METHODS Eligible patients were at least 18 years old, not candidates for chemotherapyand were treatment naive. Pazopanib was titrated from 200 mg twice daily to a goal of 800 mg daily. The primary end point was the clinical benefit rate (CBR) (CBR = completed response + partial response + stable disease per Response Evaluation Criteria in Solid Tumours [RECIST 1.1]) at 16 weeks. The sample size of 56 evaluable patients was calculated to provide 80% power to test a hypothesised CBR of ≥35% against an unfavourable CBR of ≤20%. If ≥ 17 patients achieved benefit, the null CBR of 20% would be rejected at a nominal 5% alpha level. Secondary end points included progression-free survival (PFS), overall survival (OS), quality of life and serum biomarkers. FINDINGS Fifty-six patients were enrolled from May 2015 to February 2019 and are included in the intention-to-treat analysis. Median PFS was 3.67 (2.62-7.25) months. Median OS was 14.16 (95% confidence interval [CI]: 8.4-NR) months, CBR = 39.29% (22/56) (CI = 0.265-0.533, p = 0.0007). No new or unexpected adverse events were seen. The most common grade I-II events were diarrhoea, nausea and fatigue. The most common grade III-IV events were hypertension and liver function test abnormalities. INTERPRETATION These data suggest that there is a benefit to front-line pazopanib in patients with STS who are not candidates for cytotoxic chemotherapy.
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Porcelli L, Garofoli M, Di Fonte R, Fucci L, Volpicella M, Strippoli S, Guida M, Azzariti A. The β-adrenergic receptor antagonist propranolol offsets resistance mechanisms to chemotherapeutics in diverse sarcoma subtypes: a pilot study. Sci Rep 2020; 10:10465. [PMID: 32591592 PMCID: PMC7320177 DOI: 10.1038/s41598-020-67342-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Standard chemotherapy for soft tissue sarcomas has shown limited efficacy. Here, we sought to evaluate whether β-adrenergic receptor (β-AR) signalling contributed to the progression of sarcomas and therapy resistance. To assess the translational potential of β-adrenergic receptors, we performed immunohistochemical detection of β1-AR, β2-AR and β3-AR in leiomyosarcoma, liposarcoma and angiosarcoma tissue specimens, reporting the results scored for the intensity. By using established and patient-derived sarcoma cells, we demonstrated the antitumour potential of the pharmacological targeting of β-ARs with the nonselective β-blocker propranolol in such sarcomas. Of note, pharmacological β-AR inhibition synergized with doxorubicin in inhibiting the cell viability of liposarcoma and leiomyosarcoma cells and increased the response to docetaxel in angiosarcoma- and solitary fibrous tumour (SFT)-patient-derived cells. Notably, the SFT patient was treated with the combination of propranolol and docetaxel, reporting prolonged disease control. Mechanistically, we found that propranolol reduced the activity of the multidrug resistance efflux pump P-gp, thereby increasing the intracellular doxorubicin concentration and antitumour activity. In addition, propranolol attenuated the Akt-dependent survival signal induced by doxorubicin and strongly reduced the activation of the NF-kB/COX-2 pathway, increasing cell sensitivity to docetaxel. Overall, our study highlighted the therapeutic potential of propranolol, alone or in rational combination therapies, for sarcoma treatment.
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Affiliation(s)
- Letizia Porcelli
- Experimental Pharmacology Laboratory, IRCCS Istituto Tumori Giovanni Paolo II, Viale O. Flacco, 65, 70124, Bari, Italy
| | - Marianna Garofoli
- Experimental Pharmacology Laboratory, IRCCS Istituto Tumori Giovanni Paolo II, Viale O. Flacco, 65, 70124, Bari, Italy
| | - Roberta Di Fonte
- Experimental Pharmacology Laboratory, IRCCS Istituto Tumori Giovanni Paolo II, Viale O. Flacco, 65, 70124, Bari, Italy
| | - Livia Fucci
- Histopathological Unit, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Mariateresa Volpicella
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | - Sabino Strippoli
- Medical Oncology, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Michele Guida
- Medical Oncology, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Amalia Azzariti
- Experimental Pharmacology Laboratory, IRCCS Istituto Tumori Giovanni Paolo II, Viale O. Flacco, 65, 70124, Bari, Italy.
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Nadler E, Aguilar K, Wentworth C, Boyd M, Amirian ES, Barker S, French P, Wilson T, Hess LM. Treatment Patterns and Healthcare Resource Utilization among Patients with Advanced or Metastatic Soft Tissue Sarcoma in US Community Practices. Sarcoma 2020; 2020:1765319. [PMID: 32256184 PMCID: PMC7068137 DOI: 10.1155/2020/1765319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 01/28/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION This study was designed to describe demographic and clinical characteristics of patients diagnosed with advanced or metastatic soft tissue sarcoma (STS) and to examine treatment and healthcare resource utilization patterns of this patient population in a United States (US) community-based oncology practice setting over time. METHODS AND MATERIALS A retrospective observational study was conducted within the US Oncology Network (USON). Patients were eligible if they were diagnosed with advanced or metastatic STS and were treated at a USON site between 01 July 2015 and 31 August 2018. Demographic, clinical, and treatment characteristics were described for the overall study population. Comparisons between patients by time period (prior to and after October 2016) were evaluated using the T test for continuous variables and chi-squared test for categorical variables. Data were available for analysis through 31 August 2018. RESULTS Demographic and clinical characteristics of the eligible study cohort (N = 376) were similar between patients who initiated treatment before and after October 2016 (all p > 0.05). Forty-three unique regimens were observed in the first-line setting, with the predominant regimen (gemcitabine + docetaxel) received by 33.2% (n = 125) patients. Prior to October 2016, 45.4% of patients received first-line gemcitabine + docetaxel, while 29.0% received this regimen after October 2016. CONCLUSIONS While demographic and clinical characteristics were similar, treatment patterns changed in 2016. Future research should evaluate the impact of changing drug approvals and clinical trial results on future treatment patterns.
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Affiliation(s)
| | | | | | - Marley Boyd
- McKesson Life Sciences, The Woodlands, TX 77380, USA
| | | | - Scott Barker
- Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Pearl French
- Eli Lilly and Company, Indianapolis, IN 46285, USA
| | - Thomas Wilson
- McKesson Life Sciences, The Woodlands, TX 77380, USA
| | - Lisa M. Hess
- Eli Lilly and Company, Indianapolis, IN 46285, USA
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Lee P, Malik D, Perkons N, Huangyang P, Khare S, Rhoades S, Gong YY, Burrows M, Finan JM, Nissim I, Gade TPF, Weljie AM, Simon MC. Targeting glutamine metabolism slows soft tissue sarcoma growth. Nat Commun 2020; 11:498. [PMID: 31980651 PMCID: PMC6981153 DOI: 10.1038/s41467-020-14374-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/24/2019] [Indexed: 12/19/2022] Open
Abstract
Tumour cells frequently utilize glutamine to meet bioenergetic and biosynthetic demands of rapid cell growth. However, glutamine dependence can be highly variable between in vitro and in vivo settings, based on surrounding microenvironments and complex adaptive responses to glutamine deprivation. Soft tissue sarcomas (STSs) are mesenchymal tumours where cytotoxic chemotherapy remains the primary approach for metastatic or unresectable disease. Therefore, it is critical to identify alternate therapies to improve patient outcomes. Using autochthonous STS murine models and unbiased metabolomics, we demonstrate that glutamine metabolism supports sarcomagenesis. STS subtypes expressing elevated glutaminase (GLS) levels are highly sensitive to glutamine starvation. In contrast to previous studies, treatment of autochthonous tumour-bearing animals with Telaglenastat (CB-839), an orally bioavailable GLS inhibitor, successfully inhibits undifferentiated pleomorphic sarcoma (UPS) tumour growth. We reveal glutamine metabolism as critical for sarcomagenesis, with CB-839 exhibiting potent therapeutic potential.
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Affiliation(s)
- Pearl Lee
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Dania Malik
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Institute of Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Nicholas Perkons
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Peiwei Huangyang
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sanika Khare
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Seth Rhoades
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Institute of Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yao-Yu Gong
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Michelle Burrows
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Jennifer M Finan
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Itzhak Nissim
- Division of Genetics and Metabolism, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Biochemistry, and Biophysics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Terence P F Gade
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Aalim M Weljie
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Institute of Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - M Celeste Simon
- Abramson Family Cancer Research Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
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Patterns of Care and Survival in Elderly Patients With Locally Advanced Soft Tissue Sarcoma. Am J Clin Oncol 2019; 42:749-754. [DOI: 10.1097/coc.0000000000000594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Yamada Y, Kaplan T, Soltermann A, Schmitt-Opitz I, Schneiter D, Weder W, Inci I. Surgical Outcomes and Risk Analysis of Primary Pulmonary Sarcoma. Thorac Cardiovasc Surg 2019; 69:101-108. [PMID: 31499540 DOI: 10.1055/s-0039-1695784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Primary pulmonary sarcoma (PPS) is a rare malignant lung neoplasm, and there is very little medical evidence about treatment of PPS. The aim of this study is to clarify the clinical characteristics and therapeutic outcome of patients who underwent surgical resection for PPS. METHODS We retrospectively reviewed the records of patients who underwent surgical resection for PPS in our institution between 1995 and 2014. Cases who only underwent biopsy were excluded. RESULTS A total of 24 patients (18 males, 6 females), with a median age of 60 (interquartile range: 44-67) years, were analyzed. The surgical procedures performed in these patients were pneumonectomy (n = 10), lobectomy (n = 11), and wedge resection (n = 3). Complete resection was achieved in 16 patients. The pathological stages (tumor, node, metastases lung cancer classification, 8th edition) of the patients were I (n = 4), II (n = 12), III (n = 2), and IV (n = 5), and there were four cases of lymph node metastasis. The 5-year overall survival rate of the patients was 50% (95% confidence interval [CI]: 29-72). Adverse prognostic factors for overall survival were incomplete resection (hazard ratio [HR]: 4.4, 95% CI: 2.1-42), advanced pathological stage (HR 14, 95% CI: 2.8-66), higher pathological grade (HR 4.5, 95% CI: 1.2-17), and tumor size ≥ 7 cm (HR 4.7, 95% CI: 1.1-21). CONCLUSIONS Our series of PPS revealed that incomplete resection, advanced pathological stage, higher pathological grade, and tumor size were unfavorable factors for long-term survival.
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Affiliation(s)
- Yoshito Yamada
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Tevfik Kaplan
- Department of Thoracic Surgery, Ufuk University School of Medicine, Ankara, Çankaya, Turkey
| | - Alex Soltermann
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | | | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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Thoenen E, Curl A, Iwakuma T. TP53 in bone and soft tissue sarcomas. Pharmacol Ther 2019; 202:149-164. [PMID: 31276706 DOI: 10.1016/j.pharmthera.2019.06.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/25/2019] [Indexed: 12/13/2022]
Abstract
Genomic and functional study of existing and emerging sarcoma targets, such as fusion proteins, chromosomal aberrations, reduced tumor suppressor activity, and oncogenic drivers, is broadening our understanding of sarcomagenesis. Among these mechanisms, the tumor suppressor p53 (TP53) plays significant roles in the suppression of bone and soft tissue sarcoma progression. Although mutations in TP53 were thought to be relatively low in sarcomas, modern techniques including whole-genome sequencing have recently illuminated unappreciated alterations in TP53 in osteosarcoma. In addition, oncogenic gain-of-function activities of missense mutant p53 (mutp53) have been reported in sarcomas. Moreover, new targeting strategies for TP53 have been discovered: restoration of wild-type p53 (wtp53) activity through inhibition of TP53 negative regulators, reactivation of the wtp53 activity from mutp53, depletion of mutp53, and targeting of vulnerabilities in cells with TP53 deletions or mutations. These discoveries enable development of novel therapeutic strategies for therapy-resistant sarcomas. We have outlined nine bone and soft tissue sarcomas for which TP53 plays a crucial tumor suppressive role. These include osteosarcoma, Ewing sarcoma, chondrosarcoma, rhabdomyosarcoma (RMS), leiomyosarcoma (LMS), synovial sarcoma, liposarcoma (LPS), angiosarcoma, and undifferentiated pleomorphic sarcoma (UPS).
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Affiliation(s)
- Elizabeth Thoenen
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center, Kansas City, KS 66010, USA
| | - Amanda Curl
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS 66010, USA
| | - Tomoo Iwakuma
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center, Kansas City, KS 66010, USA; Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS 66010, USA; Translational Laboratory Oncology Research, Children's Mercy Research Institute, Kansas City, MO 64108, USA.
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