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Merlini A, Rabino M, Brusco S, Pavese V, Masci D, Sangiolo D, Bironzo P, Scagliotti GV, Novello S, D'Ambrosio L. Epigenetic determinants in soft tissue sarcomas: molecular mechanisms and therapeutic targets. Expert Opin Ther Targets 2024; 28:17-28. [PMID: 38234142 DOI: 10.1080/14728222.2024.2306344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/12/2024] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Soft tissue sarcomas are a group of rare, mesenchymal tumors characterized by dismal prognosis in advanced/metastatic stages. Knowledge of their molecular determinants is still rather limited. However, in recent years, epigenetic regulation - the modification of gene expression/function without DNA sequence variation - has emerged as a key player both in sarcomagenesis and sarcoma progression. AREAS COVERED Herein, we describe and review the main epigenetic mechanisms involved in chromatin remodeling and their role as disease drivers in different soft tissue sarcoma histotypes, focusing on epithelioid sarcoma, synovial sarcoma, and malignant peripheral nerve sheath tumors. Focusing on chromatin-remodeling complexes, we provide an in-depth on the role of BAF complex alterations in these soft tissue sarcoma histotypes. In parallel, we highlight current state-of-the-art and future perspectives in the development of rational, innovative treatments leveraging on epigenetic dysregulation in soft tissue sarcomas. EXPERT OPINION Therapeutic options for metastatic/advanced sarcomas are to date very limited and largely represented by cytotoxic agents, with only modest results. In the continuous attempt to find novel targets and innovative, effective drugs, epigenetic mechanisms represent an emerging and promising field of research, especially for malignant peripheral nerve sheath tumors, epithelioid and synovial sarcoma.
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Affiliation(s)
| | - Martina Rabino
- Department of Oncology, University of Turin, Orbassano (TO), Italy
| | - Silvia Brusco
- Department of Oncology, University of Turin, Orbassano (TO), Italy
- Division of Molecular Pathology, The Institute of Cancer Research Royal Cancer Hospital, London, UK
| | - Valeria Pavese
- Department of Oncology, University of Turin, Orbassano (TO), Italy
| | - Debora Masci
- Department of Oncology, University of Turin, Orbassano (TO), Italy
| | - Dario Sangiolo
- Department of Oncology, University of Turin, Orbassano (TO), Italy
| | - Paolo Bironzo
- Department of Oncology, University of Turin, Orbassano (TO), Italy
- Medical Oncology, S. Luigi Gonzaga University Hospital, Orbassano (TO), Italy
| | - Giorgio Vittorio Scagliotti
- Department of Oncology, University of Turin, Orbassano (TO), Italy
- Medical Oncology, S. Luigi Gonzaga University Hospital, Orbassano (TO), Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, Orbassano (TO), Italy
- Medical Oncology, S. Luigi Gonzaga University Hospital, Orbassano (TO), Italy
| | - Lorenzo D'Ambrosio
- Department of Oncology, University of Turin, Orbassano (TO), Italy
- Medical Oncology, S. Luigi Gonzaga University Hospital, Orbassano (TO), Italy
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2
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Black LE, Longo JF, Anderson JC, Carroll SL. Inhibition of Erb-B2 Receptor Tyrosine Kinase 3 and Associated Regulatory Pathways Potently Impairs Malignant Peripheral Nerve Sheath Tumor Proliferation and Survival. THE AMERICAN JOURNAL OF PATHOLOGY 2023; 193:1298-1318. [PMID: 37328102 PMCID: PMC10477957 DOI: 10.1016/j.ajpath.2023.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/25/2023] [Indexed: 06/18/2023]
Abstract
Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive, currently untreatable Schwann cell-derived neoplasms with hyperactive mitogen-activated protein kinase and mammalian target of rapamycin signaling pathways. To identify potential therapeutic targets, previous studies used genome-scale shRNA screens that implicated the neuregulin-1 receptor erb-B2 receptor tyrosine kinase 3 (erbB3) in MPNST proliferation and/or survival. The current study shows that erbB3 is commonly expressed in MPNSTs and MPNST cell lines and that erbB3 knockdown inhibits MPNST proliferation and survival. Kinomic and microarray analyses of Schwann and MPNST cells implicate Src- and erbB3-mediated calmodulin-regulated signaling as key pathways. Consistent with this, inhibition of upstream (canertinib, sapitinib, saracatinib, and calmodulin) and parallel (AZD1208) signaling pathways involving mitogen-activated protein kinase and mammalian target of rapamycin reduced MPNST proliferation and survival. ErbB inhibitors (canertinib and sapitinib) or erbB3 knockdown in combination with Src (saracatinib), calmodulin [trifluoperazine (TFP)], or proviral integration site of Moloney murine leukemia kinase (AZD1208) inhibition even more effectively reduces proliferation and survival. Drug inhibition enhances an unstudied calmodulin-dependent protein kinase IIα phosphorylation site in an Src-dependent manner. The Src family kinase inhibitor saracatinib reduces both basal and TFP-induced erbB3 and calmodulin-dependent protein kinase IIα phosphorylation. Src inhibition (saracatinib), like erbB3 knockdown, prevents these phosphorylation events; and when combined with TFP, it even more effectively reduces proliferation and survival compared with monotherapy. These findings implicate erbB3, calmodulin, proviral integration site of Moloney murine leukemia kinases, and Src family members as important therapeutic targets in MPNSTs and demonstrate that combinatorial therapies targeting critical MPNST signaling pathways are more effective.
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Affiliation(s)
- Laurel E Black
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jody F Longo
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Joshua C Anderson
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Steven L Carroll
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina.
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3
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Turner-Ivey B, Longo JF, Jenkins DP, Guest ST, Carroll SL. Genetic Profiling and Genome-Scale Dropout Screening to Identify Therapeutic Targets in Mouse Models of Malignant Peripheral Nerve Sheath Tumor. J Vis Exp 2023:10.3791/65430. [PMID: 37677047 PMCID: PMC11188578 DOI: 10.3791/65430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Malignant Peripheral Nerve Sheath Tumors (MPNSTs) are derived from Schwann cells or their precursors. In patients with the tumor susceptibility syndrome neurofibromatosis type 1 (NF1), MPNSTs are the most common malignancy and the leading cause of death. These rare and aggressive soft-tissue sarcomas offer a stark future, with 5-year disease-free survival rates of 34-60%. Treatment options for individuals with MPNSTs are disappointingly limited, with disfiguring surgery being the foremost treatment option. Many once-promising therapies such as tipifarnib, an inhibitor of Ras signaling, have failed clinically. Likewise, phase II clinical trials with erlotinib, which targets the epidermal growth factor (EFGR), and sorafenib, which targets the vascular endothelial growth factor receptor (VEGF), platelet-derived growth factor receptor (PDGF), and Raf, in combination with standard chemotherapy, have also failed to produce a response in patients. In recent years, functional genomic screening methods combined with genetic profiling of cancer cell lines have proven useful for identifying essential cytoplasmic signaling pathways and the development of target-specific therapies. In the case of rare tumor types, a variation of this approach known as cross-species comparative oncogenomics is increasingly being used to identify novel therapeutic targets. In cross-species comparative oncogenomics, genetic profiling and functional genomics are performed in genetically engineered mouse (GEM) models and the results are then validated in the rare human specimens and cell lines that are available. This paper describes how to identify candidate driver gene mutations in human and mouse MPNST cells using whole exome sequencing (WES). We then describe how to perform genome-scale shRNA screens to identify and compare critical signaling pathways in mouse and human MPNST cells and identify druggable targets in these pathways. These methodologies provide an effective approach to identifying new therapeutic targets in a variety of human cancer types.
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Affiliation(s)
| | - Jody Fromm Longo
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina
| | - Dorea P Jenkins
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina
| | - Stephen T Guest
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor
| | - Steven L Carroll
- Hollings Cancer Center, Medical University of South Carolina; Department of Pathology and Laboratory Medicine, Medical University of South Carolina;
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4
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Doutt SW, Longo JF, Carroll SL. LPAR1 and aberrantly expressed LPAR3 differentially promote the migration and proliferation of malignant peripheral nerve sheath tumor cells. Glia 2023; 71:742-757. [PMID: 36416236 PMCID: PMC9868101 DOI: 10.1002/glia.24308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022]
Abstract
Schwann cell-derived neoplasms known as malignant peripheral nerve sheath tumors (MPNSTs) are the most common malignancy and the leading cause of death in individuals with neurofibromatosis Type 1. Using genome-scale shRNA screens, we have previously found evidence suggesting that lysophosphatidic acid receptors (LPARs) are essential for MPNST proliferation and/or survival. Here, we examine the expression and mutational status of all six LPA receptors in MPNSTs, assess the role that individual LPA receptors play in MPNST physiology and examine their ability to activate key neurofibromin-regulated signaling cascades. We found that human Schwann cells express LPAR1 and LPAR6, while MPNST cells express predominantly LPAR1 and LPAR3. Whole exome sequencing of 16 MPNST cell lines showed no evidence of mutations in any LPAR genes or ENPP2, a gene encoding a major LPA biosynthetic enzyme. Oleoyl-LPA, an LPA variant with an unsaturated side chain, promoted MPNST cell proliferation and migration. LPAR1 knockdown ablated the promigratory effect of LPA, while LPAR3 knockdown decreased proliferation. Inhibition of R-Ras signaling with a doxycycline-inducible dominant negative (DN) R-Ras mutant, which inhibits both R-Ras and R-Ras2, blocked LPA's promigratory effect. In contrast, DN R-Ras did not affect migration induced by neuregulin-1β (NRG1β), suggesting that LPA and NRG1β promote MPNST migration via distinct pathways. LPA-induced migration was also inhibited by Y27632, an inhibitor of the ROCK1/2 kinases that mediate R-Ras effects in MPNSTs. Thus, LPAR1 and aberrantly expressed LPAR3 mediate distinct effects in MPNSTs. These receptors and the signaling pathways that they regulate are potentially useful therapeutic targets in MPNSTs.
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Affiliation(s)
- Shannon Weber Doutt
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- The Medical Scientist Training Program, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jody Fromm Longo
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Steven L Carroll
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Hiemcke-Jiwa LS, Meister MT, Martin E, Dierselhuis MP, Haveman LM, Meijers RWJ, Tops BBJ, Wesseling P, van Diest PJ, van Gorp JM, Hehir-Kwa JY, van Belzen IAEM, Bonenkamp JJ, van Noesel MM, Flucke U, Kester LA. NTRK rearrangements in a subset of NF1-related malignant peripheral nerve sheath tumors as novel actionable target. Acta Neuropathol 2023; 145:149-152. [PMID: 36331594 PMCID: PMC9807516 DOI: 10.1007/s00401-022-02515-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Affiliation(s)
- L S Hiemcke-Jiwa
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands. .,Department of Pathology, Utrecht University Hospital, Utrecht, The Netherlands.
| | - M T Meister
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Oncode Institute, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - E Martin
- Department of Reconstructive Surgery, Utrecht University Hospital, Utrecht, The Netherlands
| | - M P Dierselhuis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - L M Haveman
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - R W J Meijers
- Department of Pathology, Utrecht University Hospital, Utrecht, The Netherlands
| | - B B J Tops
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - P Wesseling
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Department of Pathology, Amsterdam University Medical Centers/Location VUmc, Amsterdam, The Netherlands
| | - P J van Diest
- Department of Pathology, Utrecht University Hospital, Utrecht, The Netherlands
| | - J M van Gorp
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Y Hehir-Kwa
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - I A E M van Belzen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - J J Bonenkamp
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M M van Noesel
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Division Imaging and Cancer, Utrecht University Hospital, Utrecht, the Netherlands
| | - U Flucke
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L A Kester
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
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Negro S, Pirazzini M, Rigoni M. Models and methods to study Schwann cells. J Anat 2022; 241:1235-1258. [PMID: 34988978 PMCID: PMC9558160 DOI: 10.1111/joa.13606] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022] Open
Abstract
Schwann cells (SCs) are fundamental components of the peripheral nervous system (PNS) of all vertebrates and play essential roles in development, maintenance, function, and regeneration of peripheral nerves. There are distinct populations of SCs including: (1) myelinating SCs that ensheath axons by a specialized plasma membrane, called myelin, which enhances the conduction of electric impulses; (2) non-myelinating SCs, including Remak SCs, which wrap bundles of multiple axons of small caliber, and perysinaptic SCs (PSCs), associated with motor axon terminals at the neuromuscular junction (NMJ). All types of SCs contribute to PNS regeneration through striking morphological and functional changes in response to nerve injury, are affected in peripheral neuropathies and show abnormalities and a diminished plasticity during aging. Therefore, methodological approaches to study and manipulate SCs in physiological and pathophysiological conditions are crucial to expand the present knowledge on SC biology and to devise new therapeutic strategies to counteract neurodegenerative conditions and age-derived denervation. We present here an updated overview of traditional and emerging methodologies for the study of SCs for scientists approaching this research field.
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Affiliation(s)
- Samuele Negro
- Department of Biomedical SciencesUniversity of PaduaPaduaItaly
| | - Marco Pirazzini
- Department of Biomedical SciencesUniversity of PaduaPaduaItaly
- CIR‐MyoCentro Interdipartimentale di Ricerca di MiologiaUniversity of PaduaPadovaItaly
| | - Michela Rigoni
- Department of Biomedical SciencesUniversity of PaduaPaduaItaly
- CIR‐MyoCentro Interdipartimentale di Ricerca di MiologiaUniversity of PaduaPadovaItaly
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7
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Silver Nanoparticles Selectively Treat Neurofibromatosis Type 1-Associated Malignant Peripheral Nerve Sheath Tumors in a Neurofibromin-Dependent Manner. J Pers Med 2022; 12:jpm12071080. [PMID: 35887576 PMCID: PMC9321475 DOI: 10.3390/jpm12071080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is among the most common neurogenic disorders, characterized by loss of function mutations in the neurofibromin gene (NF1). NF1 patients are extremely susceptible to developing neurofibromas, which can transform into deadly malignant peripheral nerve sheath tumors (MPNSTs). At the center of these tumors are NF1-null Schwann cells. Here, we found that nanomedicine shows promise in the treatment of NF1-associated MPNSTs. We assessed the cytotoxicity of silver nanoparticles (AgNPs) in NF1-null NF1-associated MPNSTs, NF1-wildtype sporadic MPNST, and normal Schwann cells. Our data show that AgNP are selectivity cytotoxic to NF1-associated MPNSTs relative to sporadic MPNST and Schwann cells. Furthermore, we found that sensitivity to AgNPs is correlated with the expression levels of functional neurofibromin. The restoration of functional neurofibromin in NF1-associated MPNSTs reduces AgNP sensitivity, and the knockdown of neurofibromin in Schwann cells increases AgNP sensitivity. This finding is unique to AgNPs, as NF1 restoration does not alter sensitivity to standard of care chemotherapy doxorubicin in NF1-associated MPNSTs. Using an in vitro model system, we then found that AgNP can selectively eradicate NF1-associated MPNSTs in co-culture with Schwann cells at doses tolerable to normal cells. AgNP represents a novel therapy for the treatment of NF1-associated MPNSTs and addresses significant unmet clinical need.
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8
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Experimental models of undifferentiated pleomorphic sarcoma and malignant peripheral nerve sheath tumor. J Transl Med 2022; 102:658-666. [PMID: 35228656 DOI: 10.1038/s41374-022-00734-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/29/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022] Open
Abstract
Undifferentiated pleomorphic sarcoma (UPS) and malignant peripheral nerve sheath tumor (MPNST) are aggressive soft tissue sarcomas that do not respond well to current treatment modalities. The limited availability of UPS and MPNST cell lines makes it challenging to identify potential therapeutic targets in a laboratory setting. Understanding the urgent need for improved treatments for these tumors and the limited cellular models available, we generated additional cell lines to study these rare cancers. Patient-derived tumors were used to establish 4 new UPS models, including one radiation-associated UPS-UPS271.1, UPS511, UPS0103, and RIS620, one unclassified spindle cell sarcoma-USC060.1, and 3 new models of MPNST-MPNST007, MPNST3813E, and MPNST4970. This study examined the utility of the new cell lines as sarcoma models by assessing their tumorigenic potential and mutation status for known sarcoma-related genes. All the cell lines formed colonies and migrated in vitro. The in vivo tumorigenic potential of the cell lines and corresponding xenografts was determined by subcutaneous injection or xenograft re-passaging into immunocompromised mice. USC060.1 and UPS511 cells formed tumors in mice upon subcutaneous injection. UPS0103 and RIS620 tumor implants formed tumors in vivo, as did MPNST007 and MPNST3813E tumor implants. Targeted sequencing analysis of a panel of genes frequently mutated in sarcomas identified TP53, RB1, and ATRX mutations in a subset of the cell lines. These new cellular models provide the scientific community with powerful tools for detailed studies of tumorigenesis and for investigating novel therapies for UPS and MPNST.
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9
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Somatilaka BN, Sadek A, McKay RM, Le LQ. Malignant peripheral nerve sheath tumor: models, biology, and translation. Oncogene 2022; 41:2405-2421. [PMID: 35393544 PMCID: PMC9035132 DOI: 10.1038/s41388-022-02290-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 01/29/2023]
Abstract
Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive, invasive cancer that comprise around 10% of all soft tissue sarcomas and develop in about 8-13% of patients with Neurofibromatosis Type 1. They are associated with poor prognosis and are the leading cause of mortality in NF1 patients. MPNSTs can also develop sporadically or following exposure to radiation. There is currently no effective targeted therapy to treat MPNSTs and surgical removal remains the mainstay treatment. Unfortunately, surgery is not always possible due to the size and location of the tumor, thus, a better understanding of MPNST initiation and development is required to design novel therapeutics. Here, we provide an overview of MPNST biology and genetics, discuss findings regarding the developmental origin of MPNST, and summarize the various model systems employed to study MPNST. Finally, we discuss current management strategies for MPNST, as well as recent developments in translating basic research findings into potential therapies.
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Affiliation(s)
- Bandarigoda N. Somatilaka
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Ali Sadek
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Renee M. McKay
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
| | - Lu Q. Le
- Department of Dermatology, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,Simmons Comprehensive Cancer Center, University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,UTSW Comprehensive Neurofibromatosis Clinic, University of
Texas Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA,Hamon Center for Regenerative Science and Medicine,
University of Texas Southwestern Medical Center at Dallas, Dallas, Texas,
75390-9069, USA,O’Donnell Brain Institute, University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas, 75390-9069, USA
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