Abstract P5-04-21: FGFR4 is a novel druggable target for recurrent ER-positive breast cancers

Background

Breast cancer recurrence is a major clinical problem for estrogen receptor positive (ER+) disease, even decades after initial surgery. These long-term recurrences are a challenge for invasive ductal carcinoma (IDC), and are particularly frequent for the histological subtype of invasive lobular carcinoma (ILC). To study the long-term endocrine resistance seen in ILC patients, our lab recently generated six long-term estrogen deprivation (LTED) models of ILC cells and performed RNA-Sequencing to identify differentially expressed genes that ostensibly allow these cells to grow in the absence of estrogen. We overlapped these results with a previously published microarray dataset of tamoxifen-resistant cells, and found that FGFR4 is the most consistently overexpressed gene in the setting of acquired resistance to endocrine therapy in ILC cells. From a recent publication of RNA-Seq from other LTED models, FGFR4 RNA overexpression is also seen in all five IDC cell lines.

Hypothesis

FGFR4 is an important mediator of acquired endocrine resistance in breast cancer.

Methods

To study the role of FGFR4 in vitro, we used multiple shRNAs and specific small molecule inhibition for growth assays. To study the role of FGFR4 in de novo resistance to endocrine therapy, we collected 129 well curated ER+ ILC tumor specimens and performed gene expression analysis on the pre-treatment samples using a custom NanoString panel. To study the role of FGFR4 in acquired resistance, we collected over 50 pairs of primary-metastatic ER+ tumors and performed exon capture based RNA-Sequencing.

Results

FGFR4 inhibition decreases parental and LTED cell growth in classic 2D conditions and in colony formation assays. The LTED cells, with higher FGFR4 expression, are more sensitive to its inhibition. For the parental cells, combination FGFR4 and ER-targeting drugs results in synergistic decreases in growth. In our database of primary ILC clinical samples, increased expression of FGFR4 is predictive of shorter time to distant recurrence. Among primary-recurrent tumor pairs, FGFR4 is an outlier expression gain in 20/50 (40%), spanning all recurrence sites studied (i.e. local recurrences, and metastases to the brain, bone, ovaries, and GI tract). Finally, in analyzing large cohorts of metastatic tumors, there is a significant enrichment of hotspot FGFR4 mutations in tumors originating in the breast, with >2% of metastatic ILC tumors containing such a mutation.

Conclusion/Future studies

FGFR4 may play an important role in de novo resistance to endocrine therapy in ILC and acquired resistance in both ILC and IDC. Ongoing studies include overexpression of wild-type and FGFR4 hotspot mutations in ILC and IDC cell lines to determine growth and metastatic phenotypes.

Citation Format: Levine KM, Ding K, Priedigkeit N, Sikora MJ, Tasdemir N, Zhu L, Tseng GC, Jankowitz RC, Dabbs DJ, McAuliffe PF, Lee AV, Oesterreich S. FGFR4 is a novel druggable target for recurrent ER-positive breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-21.

Abstract P2-01-09: ESR1 mutations drive breast cancer metastasis by context-dependent alterations in adhesive and migratory properties

Background: Estrogen receptor alpha (ERα/ESR1) is mutated in 30-40% of endocrine resistant ER+ breast cancer. These mutations, primarily located in the ligand binding domain, are associated with worse outcome in patients, and preclinical studies have shown that they cause ligand independent growth. An open question is whether these mutations contribute to actual metastatic process, or merely endocrine resistance.

Methods: Using Y537S and D538G genome-edited MCF7 and T47D cells, 3D growth was assessed in ultralow attachment plates. Cell-cell adhesion was determined using calcein-labelled adhesion assay and quantitative microfluidic fluorescence microscope (qMFM). Collagen-based adhesion and spheroid invasion assays were used to test adhesive and invasive properties. Wound scratching, spheroid collective migration and Boyden chamber transwell assays were applied to monitor cell migratory phenotypes. Mutated ER cistromes were profiled using ChIP-sequencing. ESR1 mutations in clinical samples were characterized using ddPCR.

Results: Visual inspection of cells grown in suspension culture revealed more compressed multicellular spheroids in ESR1 mutant cells, indicative of increased cell-cell interactions. This observation was confirmed in both static and microfluidic conditions. This effect was more pronounced in MCF7 than T47D cells, correlating with increased expression of desmosome and gap junction genes. Pharmacological blockade of gap junctions decreased cell-cell adhesion. Decreased attachment and increased invasion to collagen were discerned in all mutant cell types. Further functional analysis identified alterations in the TIMP3-MMP axis causing these phenotypes. The cell-cell adhesion phenotypes were restricted to MCF7-Y537S/D538G and T47D-Y537S, whereas T47D-D538G cells showed significantly increased migration. A GSEA screen identified Wnt signaling as uniquely induced in this context, and combination treatment using the Wnt inhibitor LGK974 and Fulvestrant led to synergistic inhibition of migration. ChIP-seq identified mutation-specific cistromes with an overall increased ligand-independent ER binding. However, it did not reveal binding sites in any candidate metastases genes, suggesting secondary epigenetic mechanisms. The motif analysis revealed the enrichment of FOXA1 motifs in mutated ER cistromes except T47D-D538G cells. However, knockdown of FOXA1 induced significantly higher inhibition of T47D-D538G migration than Fulvestrant treatment alone, indicating a FOXA1-dominated mechanism. Collectively, these data show that ESR1 mutant cells gain metastatic properties, in addition to endocrine resistance. To prove this using clinical samples, we measured ESR1 mutations in a well-defined cohort of endocrine resistant local or distant recurrence. Significant enrichment of ESR1 mutations in distant (9/55) vs local (0/27) recurrences confirms critical role of mutant ERα in metastases.

Conclusion: Further analysis of context dependent changes in cell-cell adhesion and migration of ESR1 mutant cells might guide the design and development of drugs targeting ERα-mutant tumors, such as inhibitors of gap junction, FOXA1, MMP, and Wnt signaling pathways.

Disclosure: The authors declare no conflict of interest.

Citation Format: Li Z, Bahreini A, Levine KM, Wang P, Tasdemir N, Montanez MA, Sundd P, Wallace CT, Watkins SC, Chu D, Park BH, Hou W, Mooring MS, Zhu L, Tseng GC, Carroll JS, Atkinson JM, Lee AV, Oesterreich S. ESR1 mutations drive breast cancer metastasis by context-dependent alterations in adhesive and migratory properties [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-09.

Abstract PD4-09: Combination FGFR4 and ER-targeted therapy for invasive lobular carcinoma

Background

Invasive Lobular Carcinoma (ILC) is an understudied subtype of breast cancer that requires novel therapies in the advanced setting. Distinctive properties of ILC include growth patterns, metastatic behavior, and receptor status (almost universally estrogen receptor (ER) positive). Our lab recently generated six long-term estrogen deprivation (LTED) models of ILC cells and performed RNA-Sequencing to identify differentially expressed genes compared to their parental cells cultured with estrogen. We overlapped these results with a previously published microarray dataset and found that FGFR4 is the most consistently overexpressed gene in the setting of acquired resistance to endocrine therapy in ILC cells.

Hypothesis

FGFR4 is an important mediator of resistance to endocrine therapy in ILC.

Methods

To study the role of FGFR4 in vitro, we used multiple shRNAs and specific small molecule inhibition for growth assays of ILC cells. To study the role of FGFR4 in de novo resistance to endocrine therapy, we collected 129 well curated ER+ ILC tumor specimens and performed gene expression analysis on the pre-treatment samples using a custom NanoString panel. To study the role of FGFR4 in acquired resistance, we collected over 50 pairs of primary-metastatic ER+ tumors and performed exon capture based RNA-Sequencing.

Results

FGFR4 inhibition decreases parental and LTED ILC cell growth in classic 2D conditions, in the setting of ultra-low attachment, and in colony formation assays. The LTED cells, with higher FGFR4 expression, are more sensitive to its inhibition. For the parental cells, combination FGFR4 and ER-targeting drugs results in synergistic decreases in growth. In our database of primary ILC clinical samples, increased expression of FGFR4 is predictive of shorter time to distant recurrence. For our collection of 50 paired, primary-metastatic ER+ tissues, FGFR4 expression increases on average >2.5 fold in the metastatic setting, with large gains even in ductal carcinoma cases. Finally, in analyzing recently published cohorts of metastatic tumors, there is a significant enrichment of hotspot FGFR4 mutations in tumors originating in the breast, with >2% of metastatic ILC tumors containing such a mutation.

Conclusion

FGFR4 may play an important role in both acquired and de novo resistance to endocrine therapy in ILC.

Citation Format: Levine KM, Chen J, Sikora MJ, Tasdemir N, Priedigkeit N, Tseng GC, Puhalla SL, Jankowitz RC, Dabbs DJ, McAuliffe PF, Lee AV, Oesterreich S. Combination FGFR4 and ER-targeted therapy for invasive lobular carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD4-09.

Abstract P1-03-03: Invasive lobular carcinoma and invasive ductal carcinoma differ in immune response, translation efficiency and metabolic rate

Background

Invasive lobular carcinoma (ILC) is the second most common histological subtype of breast cancer after invasive ductal carcinoma (IDC). ILC differs from IDC in pathologic, molecular, and clinical features. ILC tumors are most often characterized as luminal A by PAM50 analysis, suggestive of an indolent disease. Yet, when matched for receptor status and tumor grade, patients with ILC tend to have worse long-term outcomes than patients with IDC. The main distinguishing molecular feature of ILC is the loss of functional E-cadherin, and yet, beyond that loss, the mechanisms underlying the differences between ILC and IDC are largely unknown. We examined the RNA expression profiles of ILC and IDC tumors to assess if there may be underlying vulnerabilities of ILC tumors to novel therapeutic strategies.

Methods

Differential expression analysis was performed on 159 luminal A (LumA) ILC tumors versus 311 LumA IDC tumors from The Cancer Genome Atlas (TCGA). The METABRIC cohort (65 LumA ILC and 533 LumA IDC) was used as a validation dataset. Pathway enrichment analysis was performed to identify potential differences in biological processes, and these potential differences were then tested in a series of in vitro experiments, using 3 ER+ ILC (MDA-MB-134VI, SUM44PE, and MDA-MB-330) and 3 ER+ IDC (MCF7, T47D, and ZR75.1) cell lines.

Results

Pathway analysis led to the identification of three main signaling differences between LumA ILC and LumA IDC: immune regulation, translation, and metabolism. A series of immune pathways, including Immunological Synapse, Biocarta IL17 pathway, and Response to Wounding were up-regulated in ILC tumors. We examined specific cell type markers, and found that ILC tumors have a higher activity of nearly all immune cell types, including CD4+ T cells, CD8+ T cells, B cells, NK cells, dendritic cells, M1 macrophages, and M2 macrophages. These results were surprising, since ILC tumors have a lower incidence of stromal inflammation, as defined by H&E staining, suggesting a unique immune regulatory mechanism in ILC.

Next, we examined the translational regulation in ILC vs IDC tumors by comparing RNA expression and protein quantities as determined by RPPA analysis. ILC tumors have a lower protein:RNA ratio, suggesting a lower translation efficiency. This was reflected in the RPPA data by lower protein expression of eIF4G, ribosome protein S6 (S6) and p70-S6K in ILC tumors. Phosphorylation of 4E-BP1 (Ser65), eEF2, S6 (Ser235/236, Ser240/244), and mTOR (Ser2448) were also significantly lower in LumA ILCs. This lower translation efficiency was then validated in cell lines by O-propargyl-puromycin treatment.

Finally, the pathway analysis suggested lower rates of metabolism in lobular tumors. Comparative studies of OXPHOS and glycolysis with a Seahorse analyzer confirmed this finding.

Conclusions

ILC tumors have a higher immune activity than IDC tumors, even with lower rates of stromal inflammation, suggesting a potential for differential response to immunotherapy. The lower rates of translation and metabolism, which are general identifiers of tumor dormancy, could enable ILC to escape from cytotoxic therapies, and may play an important role in the late recurrence of ILC.

Citation Format: Levine KM, Du T, Zhu L, Tasdemir N, Lee AV, Van Houten B, Tseng GC, Oesterreich S. Invasive lobular carcinoma and invasive ductal carcinoma differ in immune response, translation efficiency and metabolic rate [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-03-03.

Abstract PD2-08: Potential role of prolactin signaling in development and growth of the lobular subtype of breast cancer

Invasive lobular carcinoma (ILC) is the eighth most frequently diagnosed cancer in any organ, and accounts for 8-11% of breast cancer. This histological subtype is characterized by loss of E-cadherin, and favorable prognostic factors, such as low Ki67 and high rates of ER/PR-positive tumors. Only recently is the lobular subtype gaining recognition as a distinct disease, displaying a unique growth pattern, unique molecular changes in addition to loss of E-cadherin, and evidence for late recurrences and reduced response to targeted endocrine therapy. It is widely accepted that a late age at first full term birth (FFTB) increases a women's risk for breast cancer. Interestingly, several published epidemiological studies have shown that the increased risk after a late age at FFTB is preferential for the lobular subtype of breast cancer compared to the ductal subtype. We therefore hypothesized that pregnancy hormones like prolactin play an integral role in the development and progression of ILC. Interrogation of the Cancer Genome Atlas (TCGA) data revealed a high expression of milk protein genes as well as prolactin signaling molecules, specifically Stat5a and Stat5b in lobular carcinomas compared to ductal carcinomas. We developed a lactation score including 7 milk protein genes and found that in the TCGA data set ILC tumors have a significantly higher lactation score than IDC tumors. Additionally, we found that ILC cell lines express increased prolactin receptor mRNA and protein levels compared to IDC cell lines. Prolactin treatment in ILC and IDC cells reveals divergent signaling pathways - prolactin stimulates ERK activation in IDC but not ILC cells. We are currently further delineating the prolactin signaling pathways, and resulting phenotypes, comparing ILC and IDC cells. We expect these experiments to move the field forward by establishing a relationship between prolactin and lobular carcinoma.

Citation Format: Oesterreich S, Katz TA, Logan G, Levine K, Nagle A, Huo Z, Tseng GC, Rui H, Lee AV, Butler LM. Potential role of prolactin signaling in development and growth of the lobular subtype of breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-08.

Abstract P4-05-03: Unique genetic, epigenetic, and transcriptomic changes in premenopausal breast cancer suggest novel strategies for therapy

Breast cancer in premenopausal women (preM) is frequently associated with worse prognosis compared to that in postmenopausal women (postM) even when controlling for prognostic variables. In particular, preM ER+ tumors have a poor prognosis on endocrine therapy. There is, however, a paucity of studies characterizing molecular alterations in premenopausal tumors, a potential avenue for finding personalized therapies for this group of women.

We analyzed gene expression, CNV, methylation, and somatic mutations in tumors from preM (≤45; ER+ n = 110, and ER- n = 39) and postM (≥55, ER+ n = 392, and ER- n = 102) women in The Cancer Genome Atlas (TCGA). Unbiased hierarchical clustering of 2,900 most variably expressed genes (using both RNA-seq and Agilent expression array data) in the whole dataset (n = 643) identified four major subtypes which correlated highly with the PAM50 defined subtypes LumA, LumB, Basal and HER2; however, there wasn't any separation between preM and postM samples. Similarly, principal component analysis using 10,000 genes with the highest inter-quartile range (IQR) demonstrated high similarity across preM and postM samples. Direct examination of gene expression differences between PreM and PostM ER+ tumors using unpaired t-test (5% FDR) identified 3,044 differentially expressed genes. The genes most upregulated in premenopausal tumors included AREG, TFPI2, MSMB, TCN1, and GLRA3. Ingenuity Pathway Analysis revealed a highly significant enrichment for TGFb (p<1.9E-16) pathway activity in preM tumors. Intriguingly, no significant gene expression differences between preM and postM ER- tumors were identified. We thus then focused on genetic and epigenetic alterations that may underlie these transcriptomic changes in ER+ preM tumors.

Comparison of methylation (450K Illumina array) between preM and postM ER+ tumors showed a difference in 1% (n = 1,738) of the probes. Genes with the largest difference included ESR1, SIM2, and KLF6. Significant differences in DNA copy number variation (Affymetrix SNP 6.0 array) were also identified in ER+ preM tumors. A number of somatic mutations were significantly enriched in preM ER+ tumors including DSPP and GATA3. Integrated analysis also showed that approximately half of the observed differences in gene expression are driven by CNVs.

Conclusion: Our in silico study has identified a number of genes and pathways which are significantly altered between preM and postM ER+ breast cancer. Distinct genetic and epigenetic differences suggest unique etiology for some preM tumors. Currently ongoing Paradigm analysis, and confirmatory studies using METABRIC data are expected to further identify pathways that could specifically be targeted in premenopausal breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-05-03.

Comparison of two-phase (201)Tl SPECT with chest CT to differentiate thoracic malignancies from benign lesions

AIM

This study was conducted to compare the performance of (201)Tl single photon emission computed tomography ((201)Tl SPECT) with chest computed tomography (CT) in differentiating thoracic malignancies from benign lesions.

METHODS

One hundred and seventy patients with confirmed diagnostic thoracic lesions found in chest radiographs were prospectively examined by (201)Tl SPECT. The performance of (201)Tl SPECT in differentiating thoracic malignancies from benign lesions was evaluated in 161 patients with a measurable retention index (RI), using the region-of-interest method. Chest CT scans were retrospectively collected from 165 patients and were interpreted by two independent observers.

RESULTS

The areas under the receiver operating characteristics curves were 0.85 using the RI value to differentiate thoracic malignancies from benign lesions. The sensitivity, specificity, and accuracy were 71.9%, 83.1%, and 76.4%, respectively, with a cutoff level for the RI set at 20%. Similarly, the sensitivity, specificity and accuracy of chest CT scans to differentiate malignancies from benign lesions were 78.2%, 69.7% and 74.9%, respectively. Focusing on patients with concordant results in both (201)Tl SPECT and chest CT scans, we can differentiate thoracic malignancies from benign lesions with a sensitivity of 89.1%, a specificity of 90%, and an accuracy of 89.4%.

CONCLUSION

Both (201)Tl SPECT and chest CT scans are useful imaging tools in differentiating thoracic malignancies from benign lesions, with an accuracy of around 75%. By combining these two image modalities, the accuracy improves to 89.4%, which may circumvent the need for invasive procedures for certain equivocal cases, using either single image alone.

Lack of serotonin1B receptor expression leads to age-related motor dysfunction, early onset of brain molecular aging and reduced longevity

Normal aging of the brain differs from pathological conditions and is associated with increased risk for psychiatric and neurological disorders. In addition to its role in the etiology and treatment of mood disorders, altered serotonin (5-HT) signaling is considered a contributing factor to aging; however, no causative role has been identified in aging. We hypothesized that a deregulation of the 5-HT system would reveal its contribution to age-related processes and investigated behavioral and molecular changes throughout adult life in mice lacking the regulatory presynaptic 5-HT(1B) receptor (5-HT(1B)R), a candidate gene for 5-HT-mediated age-related functions. We show that the lack of 5-HT(1B)R (Htr1b(KO) mice) induced an early age-related motor decline and resulted in decreased longevity. Analysis of life-long transcriptome changes revealed an early and global shift of the gene expression signature of aging in the brain of Htr1b(KO) mice. Moreover, molecular changes reached an apparent maximum effect at 18-months in Htr1b(KO) mice, corresponding to the onset of early death in that group. A comparative analysis with our previous characterization of aging in the human brain revealed a phylogenetic conservation of age-effect from mice to humans, and confirmed the early onset of molecular aging in Htr1b(KO) mice. Potential mechanisms appear independent of known central mechanisms (Bdnf, inflammation), but may include interactions with previously identified age-related systems (IGF-1, sirtuins). In summary, our findings suggest that the onset of age-related events can be influenced by altered 5-HT function, thus identifying 5-HT as a modulator of brain aging, and suggesting age-related consequences to chronic manipulation of 5-HT.

MCM7 amplification and overexpression are associated with prostate cancer progression

The genomic DNA profiles of prostate cancers with aggressive features were compared to the profiles of matched normal DNA to identify genes that are selectively amplified in the cancer cells. One of the identified genes, MCM7, which is a component of the DNA replication licensing complex, has been studied extensively both at the DNA and protein levels in human prostate tissues. Approximately half of the prostate cancer specimens studied showed MCM7 gene amplification, and 60% of the aggressive prostate cancer specimens had increased MCM7 protein expression. Amplification or overexpression of MCM7 was significantly associated with relapse, local invasion and a worse tumor grade. Constitutive expression of MCM7 in a human prostate cancer cell line, DU145, resulted in markedly increased DNA synthesis and cell proliferation compared to vector-only controls, and an increased cell invasion in vitro. Indeed, MCM7 overexpression produced primary tumors 12 times larger than vector-only controls and resulted in a rapid demise of mice bearing those tumors. These studies implicate MCM7, and the DNA replication licensing gene family, in prostate cancer progression, growth and invasion.

Issues in cDNA microarray analysis: quality filtering, channel normalization, models of variations and assessment of gene effects

We consider the problem of comparing the gene expression levels of cells grown under two different conditions using cDNA microarray data. We use a quality index, computed from duplicate spots on the same slide, to filter out outlying spots, poor quality genes and problematical slides. We also perform calibration experiments to show that normalization between fluorescent labels is needed and that the normalization is slide dependent and non-linear. A rank invariant method is suggested to select non-differentially expressed genes and to construct normalization curves in comparative experiments. After normalization the residuals from the calibration data are used to provide prior information on variance components in the analysis of comparative experiments. Based on a hierarchical model that incorporates several levels of variations, a method for assessing the significance of gene effects in comparative experiments is presented. The analysis is demonstrated via two groups of experiments with 125 and 4129 genes, respectively, in Escherichia coli grown in glucose and acetate.

Endometrial stromal sarcoma of twenty cases

BACKGROUND

Endometrial stromal sarcoma is a rare neoplasm. We reviewed twenty cases to study the characteristics of this disease.

METHODS

Twenty cases of endometrial stromal sarcoma were treated at our hospital. The clinical stage, treatment and outcome were retrospectively analyzed.

RESULTS

Endometrial stromal sarcoma comprised 4.3% of corpus cancers and 46.4% of uterine sarcomas at our hospital. Seven cases were stage I, one was stage II, ten were stage III, and two were stage IV at the time of diagnosis. Histopathologically, seventeen cases were classified as low-grade sarcoma and three were high-grade sarcoma. Seven patients had recurrence and five of them had already died of disease. Among these recurrent patients, one was stage II and six were stage III. All three patients with high-grade sarcoma and four with low-grade sarcoma had recurrence.

CONCLUSIONS

We think mitotic count is an important prognostic factor in low-grade endometrial stromal sarcoma and high-grade endometrial stromal sarcoma has a poor prognosis even with post-operative adjuvant treatment.

Scalene lymph node metastases with the negative pelvic nodes in invasive cervical carcinoma

Cervical carcinoma spreads predominantly by lymphatic routes and lymph node metastases may occur even in early stages of disease. Metastases usually first appear in pelvic lymph nodes, then disseminate along the efferent lymphatic chain to the extrapelvic lymph nodes. Cases of positive lymph node metastases with negative pelvic nodes in invasive cervical carcinoma are extremely rare. We report a 50-year-old woman with bulky stage IIA cervical carcinoma who had scalene lymph node metastases in the absence of pelvic lymph node metastases after radical hysterectomy and postoperative pelvic irradiation. This rare "skipping" nodal metastasis was probably via posterior trunk lymphatic drainage of the bulky cervical carcinoma which mainly invaded the posterior vaginal cuff. Neoadjuvant or adjuvant chemotherapy is recommended to prolong survival of patients in such cases.

Congenital nephrotic syndrome with microcephaly: report of a case

Congenital nephrotic syndrome is an uncommon disease with variable etiology, course and prognosis; its association with microcephaly is even more unusual. A case is reported here of congenital nephrotic syndrome because of focal glomerulosclerosis in a three-month-old female infant with microcephaly since birth. There were no known renal diseases nor hereditary disorders in her family. The serologic tests for syphilis, toxoplasmosis, rubella, and cytomegalovirus infections were negative. Magnetic resonance imaging of the brain showed diffuse atrophic change of the cerebral hemispheres and brain stem with a remarkable increase of extracerebral space. The infant died at the age of four months without any clinical cause other than congenital nephrotic syndrome. These findings, including congenital nephrotic syndrome and microcephaly accompanied by various other clinical symptoms, have been described as a clinical entity with an autosomal recessive mode of inheritance.