Characterization of DNA Damage Response-Associated Somatic Mutations in Borderline Resectable and Locally Advanced Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The role of radiation for pancreatic cancer remains controversial, with recent studies showing conflicting results, highlighting the need to develop biomarkers of radiation response. Despite its potential utility in predicting radiosensitivity, the landscape of somatic mutations in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), as related to DNA damage response (DDR), has not been well characterized. This study aimed to characterize the frequency of such mutations in a cohort of patients with BRPC/LAPC treated with neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Mutational data was collected from patients with BRPC/LAPC treated at a single institution with neoadjuvant chemotherapy and SBRT, followed by surgical resection from 2016-2021. Chemotherapy consisted of modified FOLFIRINOX or gemcitabine/nab-paclitaxel, and patients were treated with SBRT in 33 Gy in 5 fractions. Genomic data was obtained from either endoscopic biopsy or surgical specimens, and next-generation sequencing was performed either in-house with a Solid Tumor Panel or with FoundationOne CDx. Specific emphasis was placed on the characterization of double-strand DNA break (DSB) repair genes, as this is the type of tumor cell damage traditionally induced by radiation therapy. Genes associated with the two main pathways of DSB repair, non-homologous end joining (NHEJ) and homologous repair (HR), were analyzed. Specific HR pathway mutations assessed were BLM, BRCA1/2, MRE11, NBN, PALB2, RAD50, RAD51B-D, and RAD54L, while PRKDC mutations were assessed for the NHEJ pathway. Mutations in ATM, an important initiator of DDR pathways, were also analyzed. Additionally, the frequency of mutations in TP53, CDKN2A and SMAD4 in patients with concomitant KRAS mutations was assessed.

RESULTS

Eighty-five patients were included in the study. Five (5.9%) patients had mutations in the NHEJ pathway of the PRKDC gene. Twenty (23.5%) patients had mutations in the HR pathway, including BRCA2 (10/85; 11.8%), PALB2 (5/85; 5.9%), BRCA1 (3/85; 3.5%), and RAD50 (1/85; 1.2%). Six (7.1%) patients had mutations in ATM. No patients were found to have mutations in BLM, RAD51B-D, RAD54L, or NBN. Amongst patients with KRAS mutations (72/85), concomitant mutations were observed in TP53 (47/85; 55.3%), CDKN2A (16/85; 18.8%), and SMAD4 (9/85; 10.6%).

CONCLUSION

Herein, we characterized the frequency of somatic mutations associated with DSB repair genes in patients with BRPC/LAPC. Data analysis on outcomes related to radiation response in patients with mutations in DDR pathways is ongoing, but will likely also benefit from multi-institutional efforts to increase the power to answer this question.

Comprehensive mutational analysis of primary and relapse acute promyelocytic leukemia

Acute promyelocytic leukemia (APL) is a subtype of myeloid leukemia characterized by differentiation block at the promyelocyte stage. Besides the presence of chromosomal rearrangement t(15;17), leading to the formation of PML-RARA (promyelocytic leukemia-retinoic acid receptor alpha) fusion, other genetic alterations have also been implicated in APL. Here, we performed comprehensive mutational analysis of primary and relapse APL to identify somatic alterations, which cooperate with PML-RARA in the pathogenesis of APL. We explored the mutational landscape using whole-exome (n=12) and subsequent targeted sequencing of 398 genes in 153 primary and 69 relapse APL. Both primary and relapse APL harbored an average of eight non-silent somatic mutations per exome. We observed recurrent alterations of FLT3, WT1, NRAS and KRAS in the newly diagnosed APL, whereas mutations in other genes commonly mutated in myeloid leukemia were rarely detected. The molecular signature of APL relapse was characterized by emergence of frequent mutations in PML and RARA genes. Our sequencing data also demonstrates incidence of loss-of-function mutations in previously unidentified genes, ARID1B and ARID1A, both of which encode for key components of the SWI/SNF complex. We show that knockdown of ARID1B in APL cell line, NB4, results in large-scale activation of gene expression and reduced in vitro differentiation potential.

Acne conglobata and adalimumab: use of tumour necrosis factor-α antagonists in treatment-resistant acne conglobata, and review of the literature

Acne conglobata (AC) is a chronic, severe, inflammatory variant of acne characterized by development of cystic nodules, abscesses and sinus tracts. AC may prove resistant to conventional acne therapy. The off-label use of adalimumab for the treatment of AC has been reported recently. We present a 26-year-old man with AC resistant to conventional treatment, who was treated with 40 mg adalimumab every other week, with significant clinical improvement. We review the evidence for the use of tumour necrosis factor antagonists in AC and related conditions. This case provides further evidence supporting the role of adalimumab in the treatment of AC.

NF-κB/STAT5/miR-155 network targets PU.1 in FLT3-ITD-driven acute myeloid leukemia

Almost 30% of all acute myeloid leukemias (AML) are associated with an internal tandem duplication (ITD) in the juxtamembrane domain of FMS-like tyrosine kinase 3 receptor (FLT3). Patients with FLT3-ITD mutations tend to have a poor prognosis. MicroRNAs (miRNAs) have a pivotal role in myeloid differentiation and leukemia. MiRNA-155 (MiR-155) was found to be upregulated in FLT3-ITD-associated AMLs. In this study, we discovered that FLT3-ITD signaling induces the oncogenic miR-155. We show in vitro and in vivo that miR-155 expression is regulated by FLT3-ITD downstream targets nuclear factor-κB (p65) and signal transducer and activator of transcription 5 (STAT5). Further, we demonstrate that miR-155 targets the myeloid transcription factor PU.1. Knockdown of miR-155 or overexpression of PU.1 blocks proliferation and induces apoptosis of FLT3-ITD-associated leukemic cells. Our data demonstrate a novel network in which FLT3-ITD signaling induces oncogenic miR-155 by p65 and STAT5 in AML, thereby targeting transcription factor PU.1.

Treatment of refractory keloids with pulsed dye laser alone and with rotational pulsed dye laser and intralesional corticosteroids: A retrospective case series

BACKGROUND AND AIMS

The limited available effective treatments make the management of keloids challenging. Intralesional triamcinolone and pulsed dye laser have been used for the treatment of keloids. We sought to assess the efficacy of a treatment regime using rotational intralesional triamcinolone and pulsed dye laser in the management of keloids. Materials (Subjects) and Methods: Case notes and photographic records of 99 patients with keloids treated with pulsed dye laser (PDL) alone or rotational PDL and intralesional triamcinolone (ILT) at our centre between 2005 and 2010 were reviewed. Patients with raised, erythematous and/or symptomatic keloids unresponsive to ILT alone (usually 6 treatments) are referred for consideration of PDL. Patients are offered repeated rotational treatments of three PDL (4-15 J/cm(2), 7 mm spot, 1.5 msec pulse duration, 595 nm wavelength, DCD, 30 msec spray: 20 msec delay; spaced at 6-8 weeks intervals) followed by one ILT (10 mg or 40 mg/dl). ILT-treated flat but erythematous and/or symptomatic keloids are treated with PDL alone at 6-8 week intervals. Response after each laser treatment is documented as a percentage improvement from baseline. Based on the improvement in redness, thickness and pruritus the operator classified the response to treatment as mild (0-49%), moderate (50-75%) or excellent (>75%). Patients are reviewed at 6 months following last treatment. A patient satisfaction questionnaire was also sent out to all patients who received treatments between 2005 and 2010 and this was compared with the information gathered from the notes.

RESULTS

Of the 99 patients, 58 were women and 41 were men and most were Caucasian (n=84). A total of 755 keloids were treated. The average number of PDL treatments to achieve a moderate-excellent result was 14 in male and 12 in females. Moderate-excellent improvement was seen in 76% patients. The average number of ILT required to achieve a moderate-excellent result was 5 in males and 4 in females. All patients were sent a satisfaction questionnaire and 33 responses were received wherein patients reported an average of 70% improvement in the redness and thickness of the keloids. Localised cutaneous atrophy, self-limiting erythema and injection site discomfort were noted in 3 female patients whilst no side-effects noted in the male cohort.

CONCLUSIONS

Pulsed dye laser with or without intralesional triamcinolone is a moderately effective treatment of keloid scars with a very good side-effect profile and high patient satisfaction.

Left renal cyst - left duplex kidney with compromised superior renal unit and ectopic ureteral orifice in the prostatic urethra

The urinary abnormalities are an important health problem. If they are not recognized in due time, they usually lead to the loss of the renal unit function. In many cases, the diagnosis is late and incidental.

CASE PRESENTATION

We present the case of M.I., a 74-year-old male admitted in our surgical unit with diffuse left lumbar pain, low urinary tract symptoms and slow increase in abdomen volume in the past 4 years. Computer tomography scan and ecography showed a large left lumbar cyst like mass with a dilated supernumerary ureter with ectopic ureteral orifice in the prostatic urethra and apparently normal anatomic inferior renal unit. The goal was the excision of the "cyst like" mass (superior left renal unit) but because of the anatomical particularities (extensive fibrosis and local topographical changes) total nephrectomy was performed.

CONCLUSIONS

Given a normal contralateral kidney, the discovery of a urinary abnormality can be a real challenge, their evolution being a silent one. This type of disease can be suspected only with the development of clinical symptoms. The anatomic particularities (duplex kidney) together with the long evolution of the disease changed the local topography making the preservation of the inferior left renal unit a difficult, almost impossible task for the surgeon.

Muckle-Wells syndrome/neonatal-onset multisystem inflammatory disease overlap associated with myelodysplasia and cerebrovascular accident

We describe a patient with overlapping clinical features of Muckle-Wells syndrome and neonatal-onset multisystem inflammatory disease with an absence of mutation in exon 3 of the CIAS1 ⁄ PYPAF1 ⁄ NALP3 gene. Myelodysplasia and cerebrovascular accident were additional features in this patient, which to our knowledge have not been previously described in association with these disorders. The urticarial rash, myelodysplasia and raised inflammatory markers responded to treatment with the interleukin-1 receptor antagonist, anakinra.

Inflammatory epidermolysis bullosa acquisita mimicking toxic epidermal necrolysis and dermatitis herpetiformis

We report a patient with a spectrum of clinical features simulating toxic epidermal necrolysis, bullous erythema multiforme and later, dermatitis herpetiformis (DH). The histological features were suggestive of DH, bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA). Direct immunofluorescence results suggested BP or EBA. Indirect immunofluorescence on salt-split skin and immunoblotting analysis on normal human dermal extracts gave results that were diagnostic for EBA.

Defining cancer risk in dermatomyositis. Part II. Assessing diagnostic usefulness of myositis serology

In part 1 of this review, we examined the evidence behind the association between idiopathic inflammatory myopathies (IIM) and cancers. In view of the well-recognized association between cancer and myositis (hence the term cancer-associated myositis, or CAM), clinicians responsible for the management of patients with myositis must make important decisions regarding how intensively they undertake searches for malignancy. Clinicians must also decide how often such searches are repeated, and again how intensively, to optimize both cancer detection and treatment, and thus patient survival. As the risks of CAM are greatest in dermatomyositis, this is an issue of obvious importance to dermatologists. In this second of two reviews, we examine the role of autoantibodies as potential predictors of cancer risk in patients with IIM.

Efficacy of topical tacrolimus 0.3% in clobetasol propionate 0.05% ointment in therapy-resistant cutaneous lupus erythematosus: a cohort study

BACKGROUND

Despite a range of available topical and systemic therapies, treatment of cutaneous lupus erythematosus (CLE) can be challenging. Objectives. To evaluate the efficacy of a specially formulated preparation of tacrolimus 0.3% in clobetasol propionate 0.05% ointment (TCPO) in the treatment of CLE.

METHODS

Case notes of 13 patients with treatment-resistant CLE (11 discoid LE, 1 systemic LE and 1 subacute cutaneous LE) who had used twice-daily TCPO (TCPO group) were reviewed. These were compared with five similar patients with resistant CLE who had been given 0.1% tacrolimus ointment alone (TO group).

RESULTS

In the TCPO group (mean treatment duration 20 months, range 1-72), a good or excellent response was seen in five and six patients, respectively; one patient showed slight improvement. Telangiectasia and acne were observed in two patients. No systemic side-effects were noted. In the TO group (mean treatment duration 6 months, range 1-24), one patient showed good improvement and two showed slight improvement.

CONCLUSION

The results of our small retrospective study suggest that TCPO may be more effective than either 0.1% tacrolimus or clobetasol propionate 0.05% ointment monotherapy in the treatment of recalcitrant CLE. Randomized controlled trials are needed to confirm these preliminary findings.

Defining cancer risk in dermatomyositis. Part I

The idiopathic inflammatory myopathies (IIMs) comprise polymyositis, myositis overlapping with another connective tissue disease, dermatomyositis (DM) and inclusion-body myositis (IBM). IIMs are characterized by the presence of proximal muscle weakness, increased levels of muscle-specific enzymes, specific electromyographic abnormalities, and the presence of inflammatory cell infiltrates in skeletal muscle. Clinical, serological and histological criteria can be used to define individual IIM subtypes. In the first of this two-part review series, we examine the evidence for the existence of cancer-associated myositis (CAM), and in part 2, we discuss recent discoveries that provide insight into identification of patients with DM, who may be most at risk of developing CAM.

Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic and often a recalcitrant inflammatory skin condition.

OBJECTIVES

To present the results of carbon dioxide (CO2) laser treatment of recalcitrant HS in nine patients who had failed to improve on medical and other surgical treatments.

METHODS

HS lesions consisting of abscesses, sinuses and granulation tissue were completely excised using the cutting mode of a CO2 laser, leaving only healthy residual subcutaneous fat. The wounds were closed by primary intention where possible and left to granulate otherwise. Outcomes were determined by clinical review and questionnaire.

RESULTS

Twenty-seven sites were treated in 19 sessions on nine patients. Seven procedures were performed under general anaesthesia and 12 under local. All patients rated their postoperative discomfort as less or equal to their preoperative state. Seven of the nine patients had complete remission for 12 months or longer after their last laser treatment and ceased all medications. High levels of patient satisfaction were reported with CO2 laser treatment. The main complication was axillary scar contracture in two patients but this was insufficient to limit limb movement.

CONCLUSIONS

CO2 laser treatment should be considered as a treatment option in recalcitrant HS, where multiple medical treatments have been ineffective.

Notes concerning the peritonitis of urinary aetiology

Urinary peritonitis (the uroperitoneum) is categorized as a difficult to diagnose clinical entity due to its poor manifestations. Vesical trauma following pelvis bone fracture is the most frequently involved in the uroperitoneum aetiology, followed by spontaneous vesical rupture and intraoperative iatrogenic lesions. One of the most important and constant signs that can occur is diffuse abdominal tension, without tenderness. The imagistic procedure that sets the diagnosis is retrograde cystography showing intraperitoneal urine effusion. Vesical rupture is a surgical emergency. The uroperitoneum is a particular type of peritonitis that has hidden and misleading symptoms which can delay the diagnosis long enough to endanger the patient's life.

Systemic ciclosporin and tacrolimus in dermatology

Ciclosporin and tacrolimus are calcineurin inhibiting immunosuppressant agents useful in the treatment of immune-mediated inflammatory dermatoses. Available data and clinical experience demonstrate ciclosporin's efficacy in treating psoriasis, atopic dermatitis, pyoderma gangrenosum, lichen planus, autoimmune bullous disease (in combination with corticosteroids), recalcitrant chronic idiopathic urticaria, and chronic dermatitis of the hands and feet. Although the role of topical tacrolimus in atopic dermatitis is well established, such experience with the oral formulation of tacrolimus has been limited. However, there are several case studies and anecdotal reports of the successful use of oral tacrolimus in various dermatoses. In this article we discuss the utility of systemic ciclosporin and tacrolimus in dermatology.