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Chang D, Oh T, Roland JL, Matthay KK, Vo KT, Edwards CS, Sun PP, Auguste KI, Gupta N. Pediatric neuroblastoma with intraspinal extension: the role of surgical management. J Neurosurg Pediatr 2024; 33:245-255. [PMID: 38100763 DOI: 10.3171/2023.10.peds23144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/04/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Neuroblastoma with spinal involvement accounts for up to 30% of pediatric spinal tumors and can cause profound neurological deficits. Chemotherapy is the preferred treatment option, but in select patients resection may be indicated. The goal of this study was to identify preoperative factors that led to early surgical intervention, with a specific emphasis on identifying differences on long-term neurological function and spinal deformity in the recent treatment era. METHODS A retrospective chart review was performed on all children diagnosed with neuroblastoma at a single institution from 2007 to 2020. Patient demographics, symptoms (motor deficit and sphincter dysfunction), and tumor characteristics (e.g., 123I metaiodobenzylguanidine [MIBG] avidity, MYCN amplification, chromosomal abnormality, pathology, catecholamine secretion, and stage) were recorded. Spine involvement included neural or vertebral extension, spinal cord compression, and/or T2 signal change on MRI. Survival, neurological status (motor deficit, sphincter dysfunction), and spine deformity at last follow-up were compared using univariate and multivariate analyses. The variables that contributed to neurological and deformity outcome were assessed with binomial logistic and linear regression models using R software. RESULTS Seventy-seven of the 160 patients with neuroblastoma had spinal neuroblastoma, meaning either bone metastases alone (n = 43) or intraspinal extension with or without neurological deficit (n= 34). Most patients with spinal neuroblastoma were treated with chemotherapy and/or radiation therapy (97% and 57%, respectively). Resection of the spinal tumor was performed in 14 (18%) patients, all of whom also received chemotherapy. Between the surgical and nonsurgical patients, no baseline demographic differences were found. However, surgical patients were more likely to present with either motor deficits (50% vs 5%, p = 0.0011) or bladder/bowel dysfunction (14% vs 0%, p 0.035), and a shorter median time to onset of neurological symptoms (33 vs 80 days, p = 0.0096). Surgical patients also had a significantly shorter median overall survival (33.0 vs 54 months, p = 0.014). Of the 14 patients who underwent spine surgery, 2 patients underwent surgery at the time of diagnosis while the remaining 12 underwent initial chemotherapy followed later by resection. The 2 patients who underwent initial surgery had excellent outcomes, with neither long-term motor or bowel/bladder deficits nor spinal deformity. CONCLUSIONS Surgical patients had shorter overall survival. However, the 2 patients with radiographic evidence of cord compression and acute neurological symptom onset who underwent initial, immediate surgery within 3 days of diagnosis had fewer long-term neurological deficits than surgical patients who underwent initial trials of chemotherapy. Thus, acute decompression may provide benefit in carefully selected patients with acute neurological deficits and cord compression on imaging.
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Affiliation(s)
- Diana Chang
- 1Department of Neurosurgery, University of California, Los Angeles, California
| | - Taemin Oh
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Jarod L Roland
- 3Department of Neurosurgery, Washington University in St. Louis, Missouri; and
| | - Katherine K Matthay
- 4Department of Pediatrics, Division of Oncology, University of California, San Francisco, California
| | - Kieuhoa T Vo
- 4Department of Pediatrics, Division of Oncology, University of California, San Francisco, California
| | - Caleb S Edwards
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Peter P Sun
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Kurtis I Auguste
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Nalin Gupta
- 2Department of Neurological Surgery, University of California, San Francisco, California
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Batra V, Gikandi A, Pawel B, Martinez D, Granger MM, Marachelian A, Park JR, Maris JM, Vo KT, Matthay KK, DuBois SG. Norepinephrine transporter and vesicular monoamine transporter 2 tumor expression as a predictor of response to 131 I-MIBG in patients with relapsed/refractory neuroblastoma. Pediatr Blood Cancer 2024; 71:e30743. [PMID: 37885116 PMCID: PMC10842219 DOI: 10.1002/pbc.30743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/06/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Prior studies suggest that norepinephrine transporter (NET) and vesicular monoamine transporter 2 (VMAT2) mediate meta-iodobenzylguanidine (MIBG) uptake and retention in neuroblastoma tumors. We evaluated the relationship between NET and VMAT2 tumor expression and clinical response to 131 I-MIBG therapy in patients with neuroblastoma. METHODS Immunohistochemistry (IHC) was used to evaluate NET and VMAT2 protein expression levels on archival tumor samples (obtained at diagnosis or relapse) from patients with relapsed or refractory neuroblastoma treated with 131 I-MIBG. A composite protein expression H-score was determined by multiplying a semi-quantitative intensity value (0-3+) by the percentage of tumor cells expressing the protein. RESULTS Tumor samples and clinical data were available for 106 patients, of whom 28.3% had partial response (PR) or higher. NET H-score was not significantly associated with response (≥PR), though the percentage of tumor cells expressing NET was lower among responders (median 80% for ≥PR vs. 90% for CONCLUSIONS Markers of lower NET and VMAT2 protein expression are associated with higher likelihood of response to 131 I-MIBG therapy in patients with relapsed/refractory neuroblastoma. Increased VMAT2 protein expression is associated with a more differentiated disease phenotype.
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Affiliation(s)
- Vandana Batra
- Children’s Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | - Bruce Pawel
- Department of Pathology, Children’s Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA
| | - Daniel Martinez
- Children’s Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | - Araz Marachelian
- Department of Pediatrics, Children’s Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, CA
| | - Julie R. Park
- Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA
| | - John M. Maris
- Children’s Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Kieuhoa T. Vo
- Department of Pediatrics, UCSF Benioff Children’s Hospital and UCSF School of Medicine, San Francisco, CA
| | - Katherine K. Matthay
- Department of Pediatrics, UCSF Benioff Children’s Hospital and UCSF School of Medicine, San Francisco, CA
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
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Marinoff AE, Aaronson K, Agrawal AK, Braun BS, Golden C, Huang BJ, Michlitsch J, Southworth E, Thrall A, Vo KT, Stieglitz E. Venetoclax in combination with chemotherapy as treatment for pediatric advanced hematologic malignancies. Pediatr Blood Cancer 2023; 70:e30335. [PMID: 37036306 PMCID: PMC10133180 DOI: 10.1002/pbc.30335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Venetoclax is frequently used as salvage treatment in pediatric, adolescent, and young adult (AYA) patients with advanced hematologic malignancies. However, more data are needed from real-world studies to guide the safe and appropriate use of venetoclax in this population. PROCEDURE We retrospectively reviewed the medical records of all patients diagnosed with hematologic malignancies less than 30 years of age treated with venetoclax outside of clinical trials at the University of California San Francisco Benioff Children's Hospitals from 2016 to 2022. RESULTS We identified 13 patients (acute myeloid leukemia, n = 8; B-acute lymphoblastic leukemia, n = 3; myelodysplastic syndrome, n = 2) aged 4 months to 27 years. A median of 3 prior lines of therapy weregiven (range 0-5). All patients received venetoclax in combination with either a hypomethylating agent or conventional chemotherapy. Three (23%) patients achieved complete remission (CR); two (15%) achieved partial remission (PR); 3 (23%) had stable disease (SD), and five (42%) had progressive disease. Median survival and time to progression from venetoclax initiation was 9 months (range 2.5-52 months) and 3 months (range 2 weeks to 7.5 months), respectively. Six patients (46%) developed grade 3 or higher infections while receiving venetoclax, including bacteremia due to atypical organisms, invasive pulmonary infections with Aspergillus, cytomegalovirus (CMV) viremia, skin infections, and encephalitis with bacterial brain abscesses. CONCLUSIONS Venetoclax in combination with hypomethylating agents or cytotoxic chemotherapy was effective in a subset of pediatric/AYA patients with advanced hematologic malignancies, but multiple severe infections were observed, particularly among patients who received venetoclax in combination with chemotherapy. Prospective studies will be required to determine the optimal dose and duration of venetoclax in this population.
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Affiliation(s)
- Amanda E Marinoff
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn Aaronson
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Anurag K Agrawal
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Benjamin S Braun
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Carla Golden
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Benjamin J Huang
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Michlitsch
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Erica Southworth
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Allyson Thrall
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Kieuhoa T Vo
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
| | - Elliot Stieglitz
- Department of Pediatrics, Benioff Children's Hospitals, University of California, San Francisco, San Francisco, CA, USA
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Vo KT, DuBois SG, Neuhaus J, Braunstein SE, Weil BR, Naranjo A, Irtan S, Balaguer J, Matthay KK. Pattern and predictors of sites of relapse in neuroblastoma: A report from the International Neuroblastoma Risk Group (INRG) project. Pediatr Blood Cancer 2022; 69:e29616. [PMID: 35188340 PMCID: PMC9329207 DOI: 10.1002/pbc.29616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE We sought to analyze biologic, clinical, and prognostic differences according to pattern of failure at the time of first relapse in neuroblastoma. PATIENTS AND METHODS Children <21 years diagnosed with neuroblastoma between 1989 and 2017 with known site of first relapse (isolated local vs. distant only vs. combined local and distant sites) were identified from the International Neuroblastoma Risk Group (INRG) database. Data were compared between sites of relapse according to clinical features, biologic features, initial treatment, time to first relapse, and overall survival (OS) from time of first relapse. RESULTS Pattern of first relapse among 1833 children was 19% isolated local; 65% distant only; and 16% combined sites. All evaluated clinical and biologic variables with exception of tumor diagnosis differed statistically by relapse pattern, with patients with isolated local failure having more favorable prognostic features. Patients with stage 3 disease were more likely to have isolated local failure compared to all other stages (49% vs. 16%; p < .001). OS significantly differed by relapse pattern (5-year OS ± SE): isolated local: 64% ± 3%; distant only: 23% ± 2%; and combined: 26% ± 4% (p < .001). After controlling for age, stage, and MYCN status, patients with isolated local failure (adjusted hazard ratio [HR] = 0.46; 95% confidence interval [CI]: 0.33-0.62; p < .001) and distant-only failure (adjusted HR = 0.57; 95% CI: 0.45-0.71; p < .001) remained at decreased risk for death as compared to patients with combined failure. CONCLUSION Patients with distant-only and combined failures have a higher proportion of unfavorable clinical and biological features, and a lower survival than those with isolated local relapse.
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Affiliation(s)
- Kieuhoa T. Vo
- UCSF Benioff Children’s Hospital and Departments of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA, USA
| | - John Neuhaus
- Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Steve E. Braunstein
- Radiation Oncology, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Brent R. Weil
- Department of Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Arlene Naranjo
- Department of Biostatistics, University of Florida, Children’s Oncology Group Statistics and Data Center, Gainesville, FL, USA
| | - Sabine Irtan
- Department of Pediatric Surgery, Hôpital d’enfants Armand-Trousseau, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Julia Balaguer
- Pediatric Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Katherine K. Matthay
- UCSF Benioff Children’s Hospital and Departments of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
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Liu G, Poon M, Zapala MA, Temple WC, Vo KT, Matthay KK, Mitra D, Seo Y. Incorporating Radiomics into Machine Learning Models to Predict Outcomes of Neuroblastoma. J Digit Imaging 2022; 35:605-612. [PMID: 35237892 PMCID: PMC9156639 DOI: 10.1007/s10278-022-00607-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 12/15/2022] Open
Abstract
Neuroblastoma is one of the most common pediatric cancers. This study used machine learning (ML) to predict the mortality and a few other investigated intermediate outcomes of neuroblastoma patients non-invasively from CT images. Performances of multiple ML algorithms over retrospective CT images of 65 neuroblastoma patients are analyzed. An artificial neural network (ANN) is used on tumor radiomic features extracted from 3D CT images. A pre-trained 2D convolutional neural network (CNN) is used on slices of the same images. ML models are trained for various pathologically investigated outcomes of these patients. A subspecialty-trained pediatric radiologist independently reviewed the manually segmented primary tumors. Pyradiomics library is used to extract 105 radiomic features. Six ML algorithms are compared to predict the following outcomes: mortality, presence or absence of metastases, neuroblastoma differentiation, mitosis-karyorrhexis index (MKI), presence or absence of MYCN gene amplification, and presence of image-defined risk factors (IDRF). The prediction ranges over multiple experiments are measured using the area under the receiver operating characteristic (ROC-AUC) for comparison. Our results show that the radiomics-based ANN method slightly outperforms the other algorithms in predicting all outcomes except classification of the grade of neuroblastic differentiation, for which the elastic regression model performed the best. Contributions of the article are twofold: (1) noninvasive models for the prognosis from CT images of neuroblastoma, and (2) comparison of relevant ML models on this medical imaging problem.
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Affiliation(s)
- Gengbo Liu
- Department of Computer Engineering and Sciences, Florida Institute of Technology, Melbourne, FL USA
| | - Mini Poon
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA USA
| | - Matthew A. Zapala
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA USA
| | - William C. Temple
- Department of Pediatrics, University of California, San Francisco, CA USA
| | - Kieuhoa T. Vo
- Department of Pediatrics, University of California, San Francisco, CA USA
| | | | - Debasis Mitra
- Department of Computer Engineering and Sciences, Florida Institute of Technology, Melbourne, FL USA ,Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA USA
| | - Youngho Seo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA USA
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6
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DuBois SG, Granger MM, Groshen S, Tsao-Wei D, Ji L, Shamirian A, Czarnecki S, Goodarzian F, Berkovich R, Shimada H, Villablanca JG, Vo KT, Pinto N, Mosse YP, Maris JM, Shusterman S, Cohn SL, Goldsmith KC, Weiss B, Yanik GA, Twist CJ, Irwin MS, Haas-Kogan DA, Park JR, Marachelian A, Matthay KK. Randomized Phase II Trial of MIBG Versus MIBG, Vincristine, and Irinotecan Versus MIBG and Vorinostat for Patients With Relapsed or Refractory Neuroblastoma: A Report From NANT Consortium. J Clin Oncol 2021; 39:3506-3514. [PMID: 34270348 PMCID: PMC8547934 DOI: 10.1200/jco.21.00703] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/02/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE 131I-metaiodobenzylguanidine (MIBG) is an active radiotherapeutic for neuroblastoma. The primary aim of this trial was to identify which of three MIBG regimens was likely associated with the highest true response rate. PATIENTS AND METHODS Patients 1-30 years were eligible if they had relapsed or refractory neuroblastoma, at least one MIBG-avid site, and adequate autologous stem cells. Patients received MIBG 18 mCi/kg on day 1 and autologous stem cell on day 15. Patients randomly assigned to arm A received only MIBG; patients randomly assigned to arm B received intravenous vincristine on day 0 and irinotecan daily on days 0-4; patients randomly assigned to arm C received vorinostat (180 mg/m2/dose) orally once daily on days 1 to 12. The primary end point was response after one course by New Approaches to Neuroblastoma Therapy criteria. The trial was designed with 105 patients to ensure an 80% chance that the arm with highest response rate was selected. RESULTS One hundred fourteen patients were enrolled, with three ineligible and six unevaluable, leaving 105 eligible and evaluable patients (36 in arm A, 35 in arm B, and 34 in arm C; 55 boys; and median age 6.5 years). After one course, the response rates (partial response or better) on arms A, B, and C were 14% (95% CI, 5 to 30), 14% (5 to 31), and 32% (18 to 51). An additional five, five, and four patients met New Approaches to Neuroblastoma Therapy Minor Response criteria on arms A, B, and C, respectively. On arms A, B, and C, rates of any grade 3+ nonhematologic toxicity after first course were 19%, 49%, and 35%. CONCLUSION Vorinostat and MIBG is likely the arm with the highest true response rate, with manageable toxicity. Vincristine and irinotecan do not appear to improve the response rate to MIBG and are associated with increased toxicity.
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Affiliation(s)
- Steven G. DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | | | - Susan Groshen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Denice Tsao-Wei
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lingyun Ji
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anasheh Shamirian
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Scarlett Czarnecki
- Department of Pediatrics, Loma Linda University Medical Center, Loma Linda, CA
| | - Fariba Goodarzian
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Rachel Berkovich
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Hiroyuki Shimada
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA
| | - Judith G. Villablanca
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Kieuhoa T. Vo
- Department of Pediatrics, UCSF Benioff Children's Hospital and UCSF School of Medicine, San Francisco, CA
| | - Navin Pinto
- Department of Pediatrics, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA
| | - Yael P. Mosse
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John M. Maris
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Suzanne Shusterman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Susan L. Cohn
- Department of Pediatrics, Comer Children's Hospital and University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Kelly C. Goldsmith
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Brian Weiss
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gregory A. Yanik
- Department of Pediatrics, CS Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Clare J. Twist
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Meredith S. Irwin
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daphne A. Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Julie R. Park
- Department of Pediatrics, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA
| | - Araz Marachelian
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Katherine K. Matthay
- Department of Pediatrics, UCSF Benioff Children's Hospital and UCSF School of Medicine, San Francisco, CA
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Shah AT, Azad TD, Breese MR, Chabon JJ, Hamilton EG, Straessler K, Kurtz DM, Leung SG, Spillinger A, Liu HY, Behroozfard IH, Wittber FM, Hazard FK, Cho SJ, Daldrup-Link HE, Vo KT, Rangaswami A, Pribnow A, Spunt SL, Lacayo NJ, Diehn M, Alizadeh AA, Sweet-Cordero EA. A Comprehensive Circulating Tumor DNA Assay for Detection of Translocation and Copy-Number Changes in Pediatric Sarcomas. Mol Cancer Ther 2021; 20:2016-2025. [PMID: 34353895 PMCID: PMC9307079 DOI: 10.1158/1535-7163.mct-20-0987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/09/2021] [Accepted: 06/30/2021] [Indexed: 11/16/2022]
Abstract
Most circulating tumor DNA (ctDNA) assays are designed to detect recurrent mutations. Pediatric sarcomas share few recurrent mutations but rather are characterized by translocations and copy-number changes. We applied Cancer Personalized Profiling by deep Sequencing (CAPP-Seq) for detection of translocations found in the most common pediatric sarcomas. We also applied ichorCNA to the combined off-target reads from our hybrid capture to simultaneously detect copy-number alterations (CNA). We analyzed 64 prospectively collected plasma samples from 17 patients with pediatric sarcoma. Translocations were detected in the pretreatment plasma of 13 patients and were confirmed by tumor sequencing in 12 patients. Two of these patients had evidence of complex chromosomal rearrangements in their ctDNA. We also detected copy-number changes in the pretreatment plasma of 7 patients. We found that ctDNA levels correlated with metastatic status and clinical response. Furthermore, we detected rising ctDNA levels before relapse was clinically apparent, demonstrating the high sensitivity of our assay. This assay can be utilized for simultaneous detection of translocations and CNAs in the plasma of patients with pediatric sarcoma. While we describe our experience in pediatric sarcomas, this approach can be applied to other tumors that are driven by structural variants.
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Affiliation(s)
- Avanthi Tayi Shah
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Tej D Azad
- Stanford University School of Medicine, Stanford University, Stanford, California
| | - Marcus R Breese
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Jacob J Chabon
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Emily G Hamilton
- Cancer Biology, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Krystal Straessler
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
- University of Utah School of Medicine, Salt Lake City, Utah
| | - David M Kurtz
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Stanley G Leung
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Aviv Spillinger
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Heng-Yi Liu
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Inge H Behroozfard
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Frederick M Wittber
- Department of Radiology, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Florette K Hazard
- Department of Pathology, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Soo-Jin Cho
- Departments of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Heike E Daldrup-Link
- Department of Radiology, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Kieuhoa T Vo
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Arun Rangaswami
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California
| | - Allison Pribnow
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Sheri L Spunt
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford University, Stanford, California
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Norman J Lacayo
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford University, Stanford, California
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Maximilian Diehn
- Division of Radiation Therapy, Department of Radiation Oncology, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Ash A Alizadeh
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
| | - E Alejandro Sweet-Cordero
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Fransisco, California.
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Temple WC, Vo KT, Matthay KK, Balliu B, Coleman C, Michlitsch J, Phelps A, Behr S, Zapala MA. Association of image-defined risk factors with clinical features, histopathology, and outcomes in neuroblastoma. Cancer Med 2020; 10:2232-2241. [PMID: 33314708 PMCID: PMC7982630 DOI: 10.1002/cam4.3663] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/05/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinical, molecular, and histopathologic features guide treatment for neuroblastoma, but obtaining tumor tissue may cause complications and is subject to sampling error due to tumor heterogeneity. We hypothesized that image-defined risk factors (IDRFs) would reflect molecular features, histopathology, and clinical outcomes in neuroblastoma. METHODS We performed a retrospective cohort study of 76 patients with neuroblastoma or ganglioneuroblastoma. Diagnostic CT scans were reviewed for 20 IDRFs, which were consolidated into five IDRF groups (involvement of multiple body compartments, vascular encasement, tumor infiltration of adjacent organs/structures, airway compression, or intraspinal extension). IDRF groups were analyzed for association with clinical, molecular, and histopathologic features of neuroblastoma. RESULTS Patients with more IDRF groups had a higher risk of surgical complications (OR = 3.1, p = 0.001). Tumor vascular encasement was associated with increased risk of surgical complications (OR = 5.40, p = 0.009) and increased risk of undifferentiated/poorly differentiated histologic grade (OR = 11.11, p = 0.013). Tumor infiltration of adjacent organs and structures was associated with decreased survival (HR = 8.90, p = 0.007), MYCN amplification (OR = 9.91, p = 0.001), high MKI (OR = 6.20, p = 0.003), and increased risk of International Neuroblastoma Staging System stage 4 disease (OR = 8.96, p < 0.001). CONCLUSIONS The presence of IDRFs at diagnosis was associated with high-risk clinical, molecular, and histopathologic features of neuroblastoma. The IDRF group tumor infiltration into adjacent organs and structures was associated with decreased survival. Collectively, these findings may assist surgical planning and medical management for neuroblastoma patients.
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Affiliation(s)
- William C Temple
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Kieuhoa T Vo
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Katherine K Matthay
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | | | - Christina Coleman
- Department of Hematology and Oncology, UCSF Benioff Children's Hospital, Oakland, Oakland, CA, USA
| | - Jennifer Michlitsch
- Department of Hematology and Oncology, UCSF Benioff Children's Hospital, Oakland, Oakland, CA, USA
| | - Andrew Phelps
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Spencer Behr
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew A Zapala
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
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9
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Vo KT, Michlitsch JG, Shah AT, Reid JM, Burhow SA, Graham EM, Hollinger F, Zapala MA, Long-Boyle J, Kim MO, Matthay KK, DuBois SG. Phase I trial of pazopanib in combination with irinotecan and temozolomide (PAZIT) for children and young adults with advanced sarcoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.10526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10526 Background: Pro-angiogenic factors may represent therapeutic targets in sarcoma. Preclinical studies have demonstrated a potential additive or synergistic interaction between anti-angiogenic agents and chemotherapy. The purpose of this study was to determine the maximum tolerated dose (MTD), toxicities, pharmacokinetic (PK) and pharmacodynamics (PD) effects of PAZIT in patients with advanced sarcoma. Methods: Patients 6-30 years of age with relapsed/refractory sarcomas were eligible. In the initial dose escalation plan (A), patients received pazopanib PO (225-450 mg/m2/dose) on Days 1-21 of 21-day cycles. Pazopanib was combined with fixed doses of irinotecan (IV 50 or PO 90 mg/m2/dose) and temozolomide PO 100 mg/m2/dose on Days 1-5. Due to DLTs, an amendment was made to the dose escalation plan (B) and patients received fixed doses of pazopanib PO (225 mg/m2/dose) on Days 1-21 of 21-day cycles and reduced irinotecan doses (IV 25-37.5 or PO 45-67.5 mg/m2/dose) and temozolomide PO 100 mg/m2/dose on Days 1-5. Oral cephalosporin diarrhea prophylaxis was required. Dose escalation followed a 3+3 design. Correlative studies included PK (pazopanib, irinotecan) and PD (angiogenic factors, ctDNA) effects. Results: Sixteen patients were treated (median age 16 years, range 7-21). The dose levels in the table were evaluated. First cycle DLTs occurred at all dose levels (Table) and included diarrhea, pancreatitis, colitis, neutropenia, hypertension, deep vein thrombosis, and ALT increase. Due to excessive toxicity, an MTD could not be established. One patient with osteosarcoma had a partial response. Four patients had prolonged stable disease > 4 cycles, including 2 patients with Ewing sarcoma (5 and 6 cycles), rhabdomyosarcoma (9 cycles), and desmoplastic small round cell tumor (6 cycles). Mean±SD plasma exposures to pazopanib, irinotecan, and SN-38 in patients treated on dose level 1B (n = 4) on Day 4 were 601±83, 1.4±0.2 and 0.1±0.04 ug/mL*hr, respectively. Analyses of correlative studies are ongoing. Conclusions: Combination PAZIT therapy is not tolerable as evaluated at these doses/schedules. This study provides important toxicity data to inform future clinical trials using combination anti-angiogenic strategies in sarcoma. Clinical trial information: NCT03139331. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mi-Ok Kim
- University of California, San Francisco, CA
| | | | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
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10
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Aboian MS, Huang SY, Hernandez-Pampaloni M, Hawkins RA, VanBrocklin HF, Huh Y, Vo KT, Gustafson WC, Matthay KK, Seo Y. 124I-MIBG PET/CT to Monitor Metastatic Disease in Children with Relapsed Neuroblastoma. J Nucl Med 2020; 62:43-47. [PMID: 32414950 DOI: 10.2967/jnumed.120.243139] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022] Open
Abstract
The metaiodobenzylguanidine (MIBG) scan is one of the most sensitive noninvasive lesion detection modalities for neuroblastoma. Unlike 123I-MIBG, 124I-MIBG allows high-resolution PET. We evaluated 124I-MIBG PET/CT for its diagnostic performance as directly compared with paired 123I-MIBG scans. Methods: Before 131I-MIBG therapy, standard 123I-MIBG imaging (5.2 MBq/kg) was performed on 7 patients, including whole-body (anterior-posterior) planar imaging, focused-field-of-view SPECT/CT, and whole-body 124I-MIBG PET/CT (1.05 MBq/kg). After therapy, 2 of 7 patients also completed 124I-MIBG PET/CT as well as paired 123I-MIBG planar imaging and SPECT/CT. One patient underwent 124I-MIBG PET/CT only after therapy. We evaluated all 8 patients who showed at least 1 123I-MIBG-positive lesion with a total of 10 scans. In 8 pairs, 123I-MIBG and 124I-MIBG were performed within 1 mo of each other. The locations of identified lesions, the number of total lesions, and the curie scores were recorded for the 123I-MIBG and 124I-MIBG scans. Finally, for 5 patients who completed at least 3 PET/CT scans after administration of 124I-MIBG, we estimated the effective dose of 124I-MIBG. Results: 123I-MIBG whole-body planar scans, focused-field-of-view SPECT/CT scans, and whole-body 124I-MIBG PET scans found 25, 32, and 87 total lesions, respectively. There was a statistically significant difference in lesion detection for 124I-MIBG PET/CT versus 123I-MIBG planar imaging (P < 0.0001) and 123I-MIBG SPECT/CT (P < 0.0001). The curie scores were also higher for 124I-MIBG PET/CT than for 123I-MIBG planar imaging and SPECT/CT in 6 of 10 patients. 124I-MIBG PET/CT demonstrated better detection of lesions throughout the body, including the chest, spine, head and neck, and extremities. The effective dose estimated for patient-specific 124I-MIBG was approximately 10 times that of 123I-MIBG; however, given that we administered a very low activity of 124I-MIBG (1.05 MBq/kg), the effective dose was only approximately twice that of 123I-MIBG despite the large difference in half-lives (100 vs. 13.2 h). Conclusion: The first-in-humans use of low-dose 124I-MIBG PET for monitoring disease burden demonstrated tumor detection capability superior to that of 123I-MIBG planar imaging and SPECT/CT.
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Affiliation(s)
- Mariam S Aboian
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.,Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Shih-Ying Huang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Miguel Hernandez-Pampaloni
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Randall A Hawkins
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Henry F VanBrocklin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Yoonsuk Huh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Kieuhoa T Vo
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; and
| | - W Clay Gustafson
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; and
| | - Katherine K Matthay
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; and
| | - Youngho Seo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California .,Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
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Abstract
Improvements in outcome have been seen in children and adolescents with cancer. Nevertheless, challenges remain in trying to improve the outcomes for all children diagnosed with cancer, particularly in patients with metastatic disease or with cancers that are resistant or recur after standard treatment. Precision medicine trials using individualized tumor molecular profiling for selection of targeted therapies are ongoing in adult malignancies. Similar approaches are being applied to children and adolescents with cancer. This article describes how precision medicine is being applied to pediatric oncology and the unique challenges being faced with these efforts.
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Affiliation(s)
- Kieuhoa T Vo
- Department of Pediatrics, University of California San Francisco School of Medicine, Benioff Children's Hospital, 550 16th Street, 4th Floor, Box 0434, San Francisco, CA 94158, USA
| | - D Williams Parsons
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Avenue, Suite 1030.15, Houston, TX 77030, USA
| | - Nita L Seibel
- Division of Cancer Treatment and Diagnosis, Clinical Investigations Branch, National Cancer Institute, 9609 Medical Center Drive, 5W340, MSC9737, Bethesda, MD 20892, USA.
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12
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Shulman DS, Vo KT, Fox E, Muscal JA, Walensky LD, Pikman Y, Stegmaier K, Church A, Crompton BD, Place AE, Chi SN, O'Neill AF, Kamihara J, Ezrre S, Carlowicz C, Pinchasik D, Al-Sayegh H, Ma C, London WB, DuBois SG. Abstract CT112: A Phase I multicenter trial of the dual MDM2/MDMX inhibitor ALRN-6924 in children and young adults with relapsed/refractory pediatric cancers. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: TP53 mutations are rare across pediatric cancers. Recent work using CRISPR-Cas9 screens has demonstrated that MDM2 and MDMX are strong dependencies in a range of TP53-wildtype pediatric malignancies. Increased expression of MDM2 and MDMX is a common mechanism for suppressing p53 in pediatric malignancies and can occur by copy number gain or amplification, as has been reported in retinoblastoma and hepatoblastoma. In pediatric high-grade gliomas, activating PPM1D mutations drive p53 suppression, likely through MDM2 stabilization.
ALRN-6924 is a novel, first-in-class, cell-permeating stapled peptide that disrupts the inhibitory interactions between MDM2/MDMX(MDM4) and p53. ALRN-6924 has been evaluated in two adult Phase I trials, with good tolerability and evidence of clinical activity across a range of cancer subtypes. Given the oncogenic roles of MDM2 and MDMX in pediatric malignancies, we developed a Phase I clinical trial designed to evaluate the tolerability, pharmacokinetics, and pharmacodynamic and antitumor activity of ALRN-6924.
METHODS: This is a Phase I, open-label, investigator-initiated multicenter study of ALRN-6924 in children 1-21 years of age with relapsed/refractory cancer (NCT03654716). The primary objectives are to determine the recommended phase 2 dose, and to describe toxicities and pharmacokinetic parameters of ALRN-6924 in this population. The monotherapy arm consists of two cohorts: Cohort A for patients with TP53-wildtype solid tumors and lymphomas; and Cohort B for patients with retinoblastoma, or TP53-wildtype tumors that meet any of the following criteria: hepatoblastoma, malignant rhabdoid tumor, MDM2 or MDMX amplification, TET2 loss, or PPM1D activating mutations. Patients with CNS primary tumors are only eligible for Cohort B. In Cohorts A and B, patients receive ALRN-6924 intravenously on Days 1, 4, 8 and 11 of a 21-day cycle starting at a dose of 2.2 mg/kg. An expansion cohort for patients eligible for Cohort B will open following completion of monotherapy dose escalation. Patients with relapsed/refractory leukemias enroll to Cohort C and receive ALRN-6924 in combination with low-dose cytarabine on days 1, 8 and 15 of a 28-day cycle starting at a dose of 2.7 mg/kg. Pharmacokinetic sampling and pharmacodynamic testing (serum MIC-1 modulation) is required for all patients. Correlative biology studies will include evaluation of circulating tumor DNA for TP53 mutations in patients with solid tumors and serial assessment of leukemic blasts in patients with relapsed leukemia. Enrollment began in October 2018. Up to 69 patients will be enrolled.
Citation Format: David S. Shulman, Kieuhoa T. Vo, Elizabeth Fox, Jodi A. Muscal, Loren D. Walensky, Yana Pikman, Kimberly Stegmaier, Alanna Church, Brian D. Crompton, Andrew E. Place, Susan N. Chi, Allison F. O'Neill, Junne Kamihara, Suzanne Ezrre, Cecilia Carlowicz, Dawn Pinchasik, Hasan Al-Sayegh, Clement Ma, Wendy B. London, Steven G. DuBois. A Phase I multicenter trial of the dual MDM2/MDMX inhibitor ALRN-6924 in children and young adults with relapsed/refractory pediatric cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT112.
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Affiliation(s)
| | - Kieuhoa T. Vo
- 2University of California San Francisco, San Francisco, CA
| | - Elizabeth Fox
- 3Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jodi A. Muscal
- 4Baylor College of Medicine Texas Children's Hospital, Houston, TX
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Clement Ma
- 1Dana-Farber Cancer Institute, Boston, MA
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13
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Shulman DS, Klega K, Imamovic-Tuco A, Clapp A, Nag A, Thorner AR, Van Allen E, Ha G, Lessnick SL, Gorlick R, Janeway KA, Leavey PJ, Mascarenhas L, London WB, Vo KT, Stegmaier K, Hall D, Krailo MD, Barkauskas DA, DuBois SG, Crompton BD. Correction: Detection of circulating tumour DNA is associated with inferior outcomes in Ewing sarcoma and osteosarcoma: a report from the Children's Oncology Group. Br J Cancer 2019; 120:869. [PMID: 30880335 PMCID: PMC6474275 DOI: 10.1038/s41416-019-0424-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The authors have noticed that the final paragraph of the Results section contains errors in the number of patients involved. The correct number of patients is included in the text below. These errors do not affect the Figure referenced.In osteosarcoma, we focused on 8q gain as a specific biological feature of interest. Among the 41 patients with detectable ctDNA in the osteosarcoma cohort, 8q gain was detected in 73.2% (30/41). The 3-year EFS for patients with 8q gain (n = 30) in ctDNA was 60.0% (95% CI 40.5-75.0) compared to 80.8 (95% CI 42.4-94.9) in patients without 8q gain (n = 11) in ctDNA (p = 0.18; Fig. 3).
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Affiliation(s)
- David S Shulman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Kelly Klega
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Alma Imamovic-Tuco
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Andrea Clapp
- Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anwesha Nag
- Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Aaron R Thorner
- Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eliezer Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Broad Institute, Cambridge, MA, USA
| | - Gavin Ha
- Broad Institute, Cambridge, MA, USA
| | - Stephen L Lessnick
- Center for Childhood Cancer and Blood Diseases at Nationwide Children's Hospital Research Institute and the Division of Pediatric Heme/Onc/BMT at The Ohio State University, Columbus, OH, USA
| | - Richard Gorlick
- Department of Pediatrics, MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Patrick J Leavey
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Leo Mascarenhas
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Kieuhoa T Vo
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Kimberly Stegmaier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David Hall
- Children's Oncology Group, Monrovia, CA, USA
| | - Mark D Krailo
- Children's Oncology Group, Monrovia, CA, USA.,Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Donald A Barkauskas
- Children's Oncology Group, Monrovia, CA, USA.,Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Brian D Crompton
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA. .,Broad Institute, Cambridge, MA, USA. .,Department of Pediatric Oncology, 450 Brookline Avenue, Boston, MA, USA.
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14
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Seo Y, Huh Y, Huang SY, Hernandez-Pampaloni JM, Hawkins RA, Gustafson WC, Vo KT, Matthay KK. Technical Note: Simplified and practical pretherapy tumor dosimetry - A feasibility study for 131 I-MIBG therapy of neuroblastoma using 124 I-MIBG PET/CT. Med Phys 2019; 46:2477-2486. [PMID: 30761545 DOI: 10.1002/mp.13446] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Radiation dose calculated on tumors for radiopharmaceutical therapy varies significantly from tumor to tumor and from patient to patient. Accurate estimation of radiation dose requires multiple time point measurements using radionuclide imaging modalities such as SPECT or PET. In this report, we show our technical development of reducing the number of scans needed for reasonable estimation of tumor and normal organ dose in our pretherapy imaging and dosimetry platform of 124 I-metaiodobenzylguanidine (MIBG) positron emission tomography/computed tomography (PET/CT) for 131 I-MIBG therapy of neuroblastoma. METHODS We analyzed the simplest kinetic data, areas of two-time point data for five patients with neuroblastoma who underwent 3 or 4 times of 124 I-MIBG PET/CT scan prior to 131 I-MIBG therapy. The data for which we derived areas were percent of injected activity (%IA) and standardized uptake value of tumors. These areas were correlated with time-integrated activity coefficients (TIACs) from full data (3 or 4 time points). TIACs are direct correlates with radiation dose as long as the volume and the radionuclide are known. RESULTS The areas of %IAs between data obtained from all the two-time points with time points 1 and 2 (day 0 and day 1), time points 2 and 3 (day 1 and day 2), and time points 1 and 3 (day 0 and day 2) showed reasonable correlation (Pearson's correlation coefficient |r| > 0.5) with not only tumor and organ TIACs but also tumor and organ absorbed doses. The tumor and organ doses calculated using %IA areas of time point 1 and time point 2 were our best fits at about 20% individual percent difference compared to doses calculated using 3 or 4 time points. CONCLUSIONS We could achieve reasonable accuracy of estimating tumor doses for subsequent radiopharmaceutical therapy using only the two-time point imaging sessions. Images obtained from these time points (within the 48-h after administration of radiopharmaceutical) were also viewed as useful for diagnostic reading. Although our analysis was specific to 124 I-MIBG PET/CT pretherapy imaging data for 131 I-MIBG therapy of neuroblastoma and the number of imaging datasets was not large, this feasible methodology would generally be applicable to other imaging and therapeutic radionuclides with an appropriate data analysis similar to our analysis to other imaging and therapeutic radiopharmaceuticals.
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Affiliation(s)
- Youngho Seo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA.,Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA.,Joint Graduate Group in Bioengineering, University of California, San Francisco, Berkeley, CA, USA.,Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Yoonsuk Huh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Shih-Ying Huang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | | | - Randall A Hawkins
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - W Clay Gustafson
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Kieuhoa T Vo
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine K Matthay
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
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15
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Vo KT, Karski EE, Nasholm NM, Allen S, Hollinger F, Gustafson WC, Long-Boyle JR, Shiboski S, Matthay KK, DuBois SG. Phase 1 study of sirolimus in combination with oral cyclophosphamide and topotecan in children and young adults with relapsed and refractory solid tumors. Oncotarget 2017; 8:23851-23861. [PMID: 27793021 PMCID: PMC5410349 DOI: 10.18632/oncotarget.12904] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/13/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose To determine the maximum tolerated dose (MTD), toxicities, and pharmacodynamics effects of sirolimus combined with oral metronomic topotecan and cyclophosphamide in a pediatric population. Materials and Methods Patients who were 1 to 30 years of age with relapsed/refractory solid tumors (including CNS) were eligible. Patients received daily oral sirolimus and cyclophosphamide (25-50 mg/m2/dose) on days 1-21 and oral topotecan (0.8 mg/m2/dose) on days 1-14 in 28-day cycles. Sirolimus steady-state plasma trough concentrations of 3-7.9 ng/mL and 8-12.0 ng/mL were evaluated, with dose escalation based on a 3+3 phase 1 design. Biomarkers of angiogenesis were also evaluated. Results Twenty-one patients were treated (median age 18 years; range 9-30). Dose-limiting toxicities included myelosuppression, ALT elevation, stomatitis, and hypertriglyceridemia. The MTD was sirolimus with trough goal of 8-12.0 ng/mL; cyclophosphamide 25 mg/m2/dose; and topotecan 0.8 mg/m2/dose. No objective responses were observed. Four patients had prolonged stable disease > 4 cycles (range 4-12). Correlative biomarker analyses demonstrated reductions in thrombospondin-1 (p=0.043) and soluble vascular endothelial growth factor receptor-2 plasma concentrations at 21 days compared to baseline. Conclusions The combination of oral sirolimus, topotecan, and cyclophosphamide was well tolerated and biomarker studies demonstrated modulation of angiogenic pathways with this regimen.
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Affiliation(s)
- Kieuhoa T Vo
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Erin E Karski
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Nicole M Nasholm
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Shelly Allen
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Fabienne Hollinger
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - W Clay Gustafson
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Janel R Long-Boyle
- Department of Clinical Pharmacy, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Katherine K Matthay
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Steven G DuBois
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, CA, USA
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16
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Huibregtse KE, Vo KT, DuBois SG, Fetzko S, Neuhaus J, Batra V, Maris JM, Weiss B, Marachelian A, Yanik GA, Matthay KK. Incidence and risk factors for secondary malignancy in patients with neuroblastoma after treatment with (131)I-metaiodobenzylguanidine. Eur J Cancer 2016; 66:144-52. [PMID: 27573428 DOI: 10.1016/j.ejca.2016.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/19/2016] [Accepted: 07/15/2016] [Indexed: 01/22/2023]
Abstract
Several reports of second malignant neoplasm (SMN) in patients with relapsed neuroblastoma after treatment with (131)I-MIBG suggest the possibility of increased risk. Incidence of and risk factors for SMN after (131)I-MIBG have not been defined. This is a multi-institutional retrospective review of patients with neuroblastoma treated with (131)I-MIBG therapy. A competing risk approach was used to calculate the cumulative incidence of SMN from time of first exposure to (131)I-MIBG. A competing risk regression was used to identify potential risk factors for SMN. The analytical cohort included 644 patients treated with (131)I-MIBG. The cumulative incidence of SMN was 7.6% (95% confidence interval [CI], 4.4-13.0%) and 14.3% (95% CI, 8.3-23.9%) at 5 and 10 years from first (131)I-MIBG, respectively. No increase in SMN risk was found with increased number of (131)I-MIBG treatments or higher cumulative activity per kilogram of (131)I-MIBG received (p = 0.72 and p = 0.84, respectively). Thirteen of the 19 reported SMN were haematologic. In a multivariate analysis controlling for variables with p < 0.1 (stage, age at first (131)I-MIBG, bone disease, disease status at time of first (131)I-MIBG), patients with relapsed/progressive disease had significantly lower risk of SMN (subdistribution hazard ratio 0.3, 95% CI, 0.1-0.8, p = 0.023) compared to patients with persistent/refractory neuroblastoma. The cumulative risk of SMN after (131)I-MIBG therapy for patients with relapsed or refractory neuroblastoma is similar to the greatest published incidence for high-risk neuroblastoma after myeloablative therapy, with no dose-dependent increase. As the number of patients treated and length of follow-up time increase, it will be important to reassess this risk.
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Affiliation(s)
- Kelly E Huibregtse
- University of California San Francisco Benioff Children's Hospital, USA.
| | - Kieuhoa T Vo
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, USA.
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, USA.
| | - Stephanie Fetzko
- Department of Pediatrics, Baylor University Medical Center, USA.
| | - John Neuhaus
- University of California San Francisco Benioff Children's Hospital, Department of Biostatistics, USA.
| | - Vandana Batra
- Children's Hospital of Philadelphia, Department of Pediatric Oncology, USA.
| | - John M Maris
- Children's Hospital of Philadelphia, Department of Pediatric Oncology, USA.
| | - Brian Weiss
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Oncology, USA.
| | - Araz Marachelian
- Children's Hospital of Los Angeles, New Approaches to Neuroblastoma Research, USA.
| | - Greg A Yanik
- Department of Pediatrics, University of Michigan Medical Center, USA.
| | - Katherine K Matthay
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, USA.
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Vo KT, Matthay KK, DuBois SG. Targeted antiangiogenic agents in combination with cytotoxic chemotherapy in preclinical and clinical studies in sarcoma. Clin Sarcoma Res 2016; 6:9. [PMID: 27274393 PMCID: PMC4896001 DOI: 10.1186/s13569-016-0049-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
Sarcomas are a heterogeneous group of mesenchymal malignancies. In recent years, studies have demonstrated that inhibition of angiogenic pathways or disruption of established vasculature can attenuate the growth of sarcomas. However, when used as monotherapy in the clinical setting, these targeted antiangiogenic agents have only provided modest survival benefits in some sarcoma subtypes, and have not been efficacious in others. Preclinical and early clinical data suggest that the addition of conventional chemotherapy to antiangiogenic agents may lead to more effective therapies for patients with these tumors. In the current review, the authors summarize the available evidence and possible mechanisms supporting this approach.
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Affiliation(s)
- Kieuhoa T. Vo
- />Department of Pediatrics, UCSF School of Medicine, San Francisco School of Medicine, UCSF Benioff Children’s Hospital, University of California, 550 16th Street, 4th Floor, Box 0434, San Francisco, CA 94158 USA
| | - Katherine K. Matthay
- />Department of Pediatrics, UCSF School of Medicine, San Francisco School of Medicine, UCSF Benioff Children’s Hospital, University of California, 550 16th Street, 4th Floor, Box 0434, San Francisco, CA 94158 USA
| | - Steven G. DuBois
- />Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, 450 Brookline Avenue, Dana 3, Boston, MA 02215 USA
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Davenport JR, Vo KT, Goldsby R, West DC, DuBois SG. Conditional Survival and Predictors of Late Death in Patients With Ewing Sarcoma. Pediatr Blood Cancer 2016; 63:1091-5. [PMID: 26891183 DOI: 10.1002/pbc.25945] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/12/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE Long-term survivors of Ewing sarcoma (EWS) are at considerable risk for future complications, including late relapse and death. Data on prognostic factors for late death in those who have survived beyond 5 years are lacking. METHODS We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results database. We obtained clinical features and outcome data on 1,351 patients with EWS who had survived 60 months or more. From these data, we performed univariate and multivariable analyses of overall survival (OS) using log-rank tests and Cox proportional hazard models. RESULTS Of 1,351 patients in the cohort, there were 209 deaths, 144 (69%) of which were reported to be due to EWS. The OS for 5-year survivors at 10 years was 87.5% (95% confidence interval 85.4-89.3%). Univariate adverse prognostic factors for late death in 5-year survivors included age ≥ 18 years at initial diagnosis, male sex, and axial/pelvic primary site. Initial stage was not prognostic. Independent adverse prognostic factors for late death included black race (hazard ratio [HR] 2.16, P = 0.01), age ≥ 18 years at diagnosis (HR 2.02, P < 0.001), male sex (HR 1.43, P = 0.01), and axial/pelvic primary site (HR 1.43, P = 0.02). CONCLUSIONS The majority of late deaths in 5-year survivors are due to EWS. Black race, age ≥18 at diagnosis, male sex, and axial/pelvic primary site (but not stage at diagnosis) are independently associated with increased risk of late death.
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Affiliation(s)
- Jillian R Davenport
- Department of Pediatrics, UCSF Benioff Children's Hospital and University of California, San Francisco School of Medicine, San Francisco, California
| | - Kieuhoa T Vo
- Department of Pediatrics, UCSF Benioff Children's Hospital and University of California, San Francisco School of Medicine, San Francisco, California
| | - Robert Goldsby
- Department of Pediatrics, UCSF Benioff Children's Hospital and University of California, San Francisco School of Medicine, San Francisco, California
| | - Daniel C West
- Department of Pediatrics, UCSF Benioff Children's Hospital and University of California, San Francisco School of Medicine, San Francisco, California
| | - Steven G DuBois
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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Vo KT, Edwards JV, Epling CL, Sinclair E, Hawkins DS, Grier HE, Janeway KA, Barnette P, McIlvaine E, Krailo MD, Barkauskas DA, Matthay KK, Womer RB, Gorlick RG, Lessnick SL, Mackall CL, DuBois SG. Impact of Two Measures of Micrometastatic Disease on Clinical Outcomes in Patients with Newly Diagnosed Ewing Sarcoma: A Report from the Children's Oncology Group. Clin Cancer Res 2016; 22:3643-50. [PMID: 26861456 DOI: 10.1158/1078-0432.ccr-15-2516] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/29/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Flow cytometry and RT-PCR can detect occult Ewing sarcoma cells in the blood and bone marrow. These techniques were used to evaluate the prognostic significance of micrometastatic disease in Ewing sarcoma. EXPERIMENTAL DESIGN Newly diagnosed patients with Ewing sarcoma were enrolled on two prospective multicenter studies. In the flow cytometry cohort, patients were defined as "positive" for bone marrow micrometastatic disease if their CD99(+)/CD45(-) values were above the upper limit in 22 control patients. In the PCR cohort, RT-PCR on blood or bone marrow samples classified the patients as "positive" or "negative" for EWSR1/FLI1 translocations. The association between micrometastatic disease burden with clinical features and outcome was assessed. Coexpression of insulin-like growth factor-1 receptor (IGF-1R) on detected tumor cells was performed in a subset of flow cytometry samples. RESULTS The median total bone marrow CD99(+)CD45(-) percent was 0.0012% (range 0%-1.10%) in the flow cytometry cohort, with 14 of 109 (12.8%) of Ewing sarcoma patients defined as "positive." In the PCR cohort, 19.6% (44/225) patients were "positive" for any EWSR1/FLI1 translocation in blood or bone marrow. There were no differences in baseline clinical features or event-free or overall survival between patients classified as "positive" versus "negative" by either method. CD99(+)CD45(-) cells had significantly higher IGF-1R expression compared with CD45(+) hematopoietic cells (mean geometric mean fluorescence intensity 982.7 vs. 190.9; P < 0.001). CONCLUSIONS The detection of micrometastatic disease at initial diagnosis by flow cytometry or RT-PCR is not associated with outcome in newly diagnosed patients with Ewing sarcoma. Flow cytometry provides a tool to characterize occult micrometastatic tumor cells for proteins of interest. Clin Cancer Res; 22(14); 3643-50. ©2016 AACR.
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Affiliation(s)
- Kieuhoa T Vo
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, California
| | - Jeremy V Edwards
- Department of Pediatrics, Walter Reed Army Medical Center, Washington, DC
| | - C Lorrie Epling
- Division of Experimental Medicine Core Immunology Laboratory, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, California
| | - Elizabeth Sinclair
- Division of Experimental Medicine Core Immunology Laboratory, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, California
| | - Douglas S Hawkins
- Division of Hematology/Oncology, Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
| | - Holcombe E Grier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Phillip Barnette
- Department of Pediatric Hematology/Oncology, Center for Children's Cancer Research, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Elizabeth McIlvaine
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark D Krailo
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Donald A Barkauskas
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Katherine K Matthay
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, California
| | - Richard B Womer
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard G Gorlick
- Division of Pediatric Hematology/Oncology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Stephen L Lessnick
- Center for Childhood Cancer and Blood Disorders at Nationwide Children's Hospital and the Division of Hematology, Oncology, and BMT at The Ohio State University, Columbus, Ohio
| | - Crystal L Mackall
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Steven G DuBois
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco School of Medicine, San Francisco, California.
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Thompson D, Vo KT, London WB, Fischer M, Ambros PF, Nakagawara A, Brodeur GM, Matthay KK, DuBois SG. Identification of patient subgroups with markedly disparate rates of MYCN amplification in neuroblastoma: A report from the International Neuroblastoma Risk Group project. Cancer 2015; 122:935-45. [PMID: 26709890 DOI: 10.1002/cncr.29848] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/17/2015] [Accepted: 11/17/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND MYCN gene amplification (MNA) is a hallmark of aggressive neuroblastoma. This study was performed to determine univariate and multivariate predictors of tumor MNA. METHODS Data from the International Neuroblastoma Risk Group were analyzed for a subset of 7102 patients with known MYCN status. Chi-square testing and logistic regression were used to identify univariate and multivariate predictors of MYCN status. Recursive partitioning was used to identify groups of patients with maximal differences in rates of MNA. RESULTS All clinical features (age ≥ 18 months, high ferritin levels, high lactate dehydrogenase [LDH] levels, International Neuroblastoma Staging System stage 4, and adrenal sites) and pathological/biological features (DNA index ≤ 1, high mitosis-karyorrhexis index [MKI], undifferentiated/poorly differentiated grade, unfavorable histology according to the International Neuroblastoma Pathology Classification, and segmental chromosomal aberrations [SCAs]) were significantly associated with MNA. LDH (odds ratio [OR], 8.4; P < .001) and chromosomal 1p loss of heterozygosity (OR, 19.8; P < .001) were the clinical and biological variables, respectively, most strongly associated with MNA. In logistic regression, all variables except chromosome 17q aberration and pooled SCAs were independently predictive of MNA. Recursive partitioning identified subgroups with disparate rates of MNA, including subgroups with 85.7% MNA (patients with high LDH levels who had poorly differentiated adrenal tumors with chromosome 1p deletion) and 0.6% MNA (localized tumors having hyperdiploidy and low MKIs and lacking chromosome 1p aberrations). CONCLUSIONS MNA is strongly associated with other clinical and biological variables in neuroblastoma. Recursive partitioning has identified subgroups of neuroblastoma patients with highly disparate rates of MNA. These findings can be used to inform investigations of molecular mechanisms of MNA.
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Affiliation(s)
- Daria Thompson
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California
| | - Kieuhoa T Vo
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California
| | - Wendy B London
- Dana-Farber Children's Hospital Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Matthias Fischer
- Department of Pediatric Oncology, Children's Hospital and Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Peter F Ambros
- Children's Cancer Research Institute, St. Anne Kinderkrebsforschung, Vienna, Austria
| | - Akira Nakagawara
- Department of Biochemistry, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan
| | - Garrett M Brodeur
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine K Matthay
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California
| | - Steven G DuBois
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California
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Vo KT, Matthay KK, Neuhaus J, London WB, Hero B, Ambros PF, Nakagawara A, Miniati D, Wheeler K, Pearson ADJ, Cohn SL, DuBois SG. Clinical, biologic, and prognostic differences on the basis of primary tumor site in neuroblastoma: a report from the international neuroblastoma risk group project. J Clin Oncol 2014; 32:3169-76. [PMID: 25154816 DOI: 10.1200/jco.2014.56.1621] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Neuroblastoma (NB) is a heterogeneous tumor arising from sympathetic tissues. The impact of primary tumor site in influencing the heterogeneity of NB remains unclear. PATIENTS AND METHODS Children younger than age 21 years diagnosed with NB or ganglioneuroblastoma between 1990 and 2002 and with known primary site were identified from the International Neuroblastoma Risk Group database. Data were compared between sites with respect to clinical and biologic features, as well as event-free survival (EFS) and overall survival (OS). RESULTS Among 8,369 children, 47% had adrenal tumors. All evaluated clinical and biologic variables differed statistically between primary sites. The features that were > 10% discrepant between sites were stage 4 disease, MYCN amplification, elevated ferritin, elevated lactate dehydrogenase, and segmental chromosomal aberrations, all of which were more frequent in adrenal versus nonadrenal tumors (P < .001). Adrenal tumors were more likely than nonadrenal tumors (adjusted odds ratio, 2.09; 95% CI, 1.67 to 2.63; P < .001) and thoracic tumors were less likely than nonthoracic tumors (adjusted odds ratio, 0.20; 95% CI, 0.11 to 0.39; P < .001) to have MYCN amplification after controlling for age, stage, and histologic grade. EFS and OS differed significantly according to the primary site (P < .001 for both comparisons). After controlling for age, MYCN status, and stage, patients with adrenal tumors had higher risk for events (hazard ratio, 1.13 compared with nonadrenal tumors; 95% CI, 1.03 to 1.23; P = .008), and patients with thoracic tumors had lower risk for events (HR, 0.79 compared with nonthoracic; 95% CI, 0.67 to 0.92; P = .003). CONCLUSION Clinical and biologic features show important differences by NB primary site, with adrenal and thoracic sites associated with inferior and superior survival, respectively. Future studies will need to investigate the biologic origin of these differences.
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Affiliation(s)
- Kieuhoa T Vo
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Katherine K Matthay
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - John Neuhaus
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Wendy B London
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Barbara Hero
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Peter F Ambros
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Akira Nakagawara
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Doug Miniati
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Kate Wheeler
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Andrew D J Pearson
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Susan L Cohn
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL
| | - Steven G DuBois
- Kieuhoa T. Vo, Katherine K. Matthay, John Neuhaus, and Steven G. DuBois, Benioff Children's Hospital and University of California, San Francisco, San Francisco; Doug Miniati, Kaiser Permanente Medical Center, Roseville, CA; Wendy B. London, Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA; Barbara Hero, Children's Hospital, University of Cologne, Köln, Germany; Peter F. Ambros, Children's Cancer Research Institute, St Anne Kinderkrebsforschung, Vienna, Austria; Akira Nakagawara, Chiba Cancer Center Research Institute and Chiba University, Chiba, Japan; Kate Wheeler, Oxford Children's Hospital, Oxford; Andrew D.J. Pearson, Institute of Cancer Research and Royal Marsden Hospital, Surrey, United Kingdom; Susan L. Cohn, The University of Chicago, Chicago, IL.
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Vo KT, Grooms L, Klima J, Holland-Hall C, O'Brien SH. Menstrual bleeding patterns and prevalence of bleeding disorders in a multidisciplinary adolescent haematology clinic. Haemophilia 2012; 19:71-5. [PMID: 23005346 DOI: 10.1111/hae.12012] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2012] [Indexed: 11/29/2022]
Abstract
Heavy menstrual bleeding (HMB) is a frequent complaint in adolescence. Although HMB is often caused by immaturity of the hypothalamic-pituitary-ovarian axis, bleeding disorders are another common yet often unidentified cause. The aim of this study was to examine the bleeding patterns and prevalence of inherited bleeding disorders among females referred for HMB to a multidisciplinary adolescent haematology clinic. We retrospectively reviewed the first 105 patients (ages 8-18 years) referred to this specialty clinic from February 2009 to December 2011. Using menstrual bleeding questionnaires and medical records, data were extracted regarding demographics, bleeding patterns, frequency and types of bleeding disorders identified, and prescribed interventions. Sixty-two per cent of patients were diagnosed with a bleeding disorder, including platelet storage pool deficiency (36%), von Willebrand's disease (9%), other platelet function defect (8%), Ehlers-Danlos syndrome (7%) and combined bleeding disorders (2%). Comparison of the bleeding profiles for females with and without a bleeding disorder revealed only three factors that were significantly different, including the reported regularity of patients' periods (P = 0.02), description of period flow (P = 0.04) and number of days of each period that the bleeding was described as 'heavy' (P = 0.007). Bleeding disorders are prevalent in adolescent females presenting to a specialty clinic. Specifically, a relatively high proportion of adolescents were diagnosed with platelet storage pool deficiency. In our small population, menstrual bleeding profiles, as examined by a standardized questionnaire, could not identify females with an underlying bleeding disorder, demonstrating the important role of haemostasis testing in the evaluation of adolescents with HMB.
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Affiliation(s)
- K T Vo
- Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, USA
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Herr DW, Vo KT, Morgan DL, Sills RC. Carbon disulfide neurotoxicity in rats: VI. Electrophysiological examination of caudal tail nerve compound action potentials and nerve conduction velocity. Neurotoxicology 1998; 19:129-46. [PMID: 9498229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The effects of subchronic exposure to carbon disulfide (CS2) on ventral caudal tail nerve compound nerve action potential (CNAP) amplitudes and latencies, and nerve conduction velocity (NCV) in rats were examined. Male and female Fischer 344 rats were exposed to 0, 50, 500, or 800 ppm CS2 for 6 hrs/day, 5 days/week. Using separate groups, exposure duration was 2, 4, 8, or 13 weeks. Exposure to 500 or 800 ppm CS2 for 13 weeks decreased NCV compared to the 50 ppm CS2 group. CNAP amplitudes were increased, and peak P1P2 interpeak latency decreased, after exposure to 500 or 800 ppm CS2 for 13 weeks. Most of the changes in NCV and CNAPs were not attributable to differences in tail or colonic temperature. However, the increases in peak P1 amplitude may relate to the proximity of the electrodes to the tail nerves. Assessment of tail nerve morphology after 13 weeks exposure to 800 ppm CS2 revealed only minor changes compared to the extent of axonal swelling and degeneration observed in the muscular branch of the tibial nerve and axonal swelling in the spinal cord. As anticipated, in older animals the NCV increased, the CNAP amplitudes increased, and the CNAP latencies decreased. The biological basis for the changes in CNAPs produced by CS2 is under investigation. Future studies will focus on electrophysiological evaluation of spinal nerve function, to allow better correlation with pathological and behavioral endpoints.
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Affiliation(s)
- D W Herr
- National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC 27711, USA
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Abstract
We have extended the technique of PCR-directed recombination in Saccharomyces cerevisiae to develop a simple method for plasmid or gene construction in the absence of suitable restriction sites. The DNA to be cloned is PCR-amplified with 30-40 bp of homology to a linearized yeast plasmid. Co-transformation into yeast results in homologous recombination at a position directed by the PCR oligonucleotides.
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Affiliation(s)
- K R Oldenburg
- Affymax Research Institute, 4001 Miranda Avenue, Palo Alto, CA 94304, USA
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25
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Abstract
Flash evoked potentials (FEPs) undergo within- and between-session changes and are modified by auditory white noise (26). We examined whether an auditory potential produced by the "click" associated with the strobe discharge could be recorded, and if alterations in an auditory response could explain the within- and between-session changes in FEPs. We also examined differences between a frontal cortex or a nasal reference electrode location on FEPs and auditory potentials. An auditory potential associated with the strobe discharge could be clearly recorded. This response was eliminated by the presence of 80 dB SPL masking white noise. However, the within- and between-session changes in FEPs could not be explained by modifications of the auditory potential. Animals whose ear drums were ruptured did not exhibit an auditory response, and their FEPs were similar to those of controls tested in the presence of masking white noise. A nasal reference electrode decreased the impact of auditory potentials on FEPs, but allow visual potentials (electroretinogram and optic tract activity) to influence FEPs. The data show that auditory potentials associated with the strobe discharge can be recorded from the visual cortex of rats, and that these auditory responses represent a possible confounding factor in the interpretation of toxicological studies employing FEPs.
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Affiliation(s)
- D W Herr
- National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC 27711, USA.
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Abstract
In recent years there has been an increased interest in the use of oligonucleotides as therapeutic agents. Oligonucleotide therapeutics may have significant potential over traditional drugs due to their high degree of specificity and increased affinity. The major drawbacks to the use of oligonucleotide therapeutics are the problems associated with their delivery and their relative instability in serum. The serum instability problem has been partially overcome through the use of oligonucleotides with modified backbones. Transdermal electrotransport may be used to overcome the problems associated with delivery. Here we report the use of transdermal electrotransport in the delivery of oligonucleotides across hairless mouse skin. The effects of pH, salt concentration, current density, and oligonucleotide concentration, structure, and length have been investigated.
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Affiliation(s)
- K R Oldenburg
- Affymax Research Institute, Palo Alto, CA 94304, USA
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