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    Scale up of nanolipomer microfluidic production for potential clinical trials
    (2018-03-14) Johnson, Kaitlyn; Shah, Sunil; Gryczynski, Ignacy; Vishwanatha, Jamboor; Ranjan, Amalendu; Gdowski, Andrew
    Purpose: The process of optimization and fabrication of nanoparticle synthesis for preclinical studies can be challenging and time consuming. Traditional small scale laboratory synthesis techniques suffer from batch to batch variability. Additionally, the parameters used in the original formulation must be re-optimized due to differences in fabrication techniques for clinical production. Several low flow microfluidic synthesis processes have been reported in recent years for developing nanoparticles that are a hybrid between polymeric nanoparticles and liposomes. However, use of high flow microfluidic synthetic techniques has not been described for this type of nanoparticle system, which we will term as nanolipomer. We hypothesize that it is possible to manufacture nanolipomers in large batches using a high flow microfluidic synthesis method and these nanoplipomers will maintain optimal physico-chemical and functional parameters. Methods: Nanolipomers were synthesized through a microfluidic process utilizing the Nanoassembler platform. Nanolipomer size and zeta potential were measured through dynamic light scattering techniques. Time resolved lifetime and anisotropy experiments were performed to verify drug loading. MTT assay was performed on C4-2B prostate cancer cells to assess cell viability after treatment with nanolipomers. Nude mice were intravenously injected with nanolipomers to determine in vivo biocompatibility. Results: The optimal total flow rate for synthesis of these nanolipomers was found to be 12 ml/min and flow rate ratio 1:1 (organic phase: aqueous phase). The PLGA polymer concentration of 10 mg/ml and a DSPE-PEG lipid concentration of 10% w/v provided optimal size, PDI and stability. Drug loading and encapsulation of a representative hydrophobic small molecule drug, curcumin, was optimized and found that high encapsulation efficiency of 58.8% and drug loading of 4.4% was achieved at 7.5% w/w initial concentration of curcumin/ PLGA polymer. The final size and polydispersity index of the optimized nanolipomer was 102.11 nm and 0.126, respectively. Functional assessment of uptake of the nanolipomers in C4-2B prostate cancer cells showed uptake at 1 hour and increased uptake at 24 hours. The nanolipomer was more effective in the cell viability assay compared to free drug. Finally, assessment of in vivo retention in mice of these nanolipomers revealed retention for up to 2 hours and were completely cleared at 24 hours. Conclusions: In this study, we have demonstrated that a nanolipomer formulation can be successfully synthesized and easily scaled up through a high flow microfluidic system with optimal characteristics. The process of developing nanolipomers using this methodology is significant as the same optimized parameters used for small batches could be translated into manufacturing large scale batches for clinical trials through parallel flow systems.
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    Nutrition Intervention in Pediatric Acute Lymphoblastic Leukemia Patients with Down Syndrome
    (2018-03-14) Hamby, Tyler; Hill, Rachel; Bricker, Madeleine
    Abstract: Purpose: Children and adolescents with Down Syndrome (DS) are more likely to become overweight or obese than those without DS. Additionally, children with DS develop acute lymphoblastic leukemia (ALL) at higher rates than the general population, and pediatric ALL treatment is associated with excessive weight gain. Despite DS-ALL patients’ increased risk for obesity and its complications, there remains a lack of research on preventing weight gain in this specific population. Our objective was to determine if a three-visit nutritional intervention in maintenance therapy was effective at reducing weight gain in DS-ALL patients. Methods: In a retrospective analysis, medical records of the intervention group were compared to historical controls on the same ALL treatment protocol. Anthropometrics were collected throughout intensive therapy and at every monthly visit during the 12 months of maintenance therapy. Results: Nine patients met the inclusion criteria: 5 males, 7 Caucasian and 2 Hispanic, and 5 on high risk protocols. The median age was 4.07 years (range, 1.60-14.26). Three and five patients had unhealthy BMIs at diagnosis and month 12 of maintenance, respectively. When comparing patients who had healthy BMIs at diagnosis, the intervention group had smaller increases in BMI than the control group. However, patients who had unhealthy BMIs at diagnosis had unhealthy BMIs at month 12 of maintenance therapy, regardless of intervention. Conclusions: These results provide evidence that DS patients do tend to gain weight during treatment for ALL, but the data were insufficient to determine whether the nutrition intervention was successful for this population. To our knowledge, this is the first study to investigate obesity prevention in DS-ALL patients. One approach for future studies is an inter-institutional collaboration to obtain a sample size large enough to draw conclusions using inferential statistics.
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    Does the Relationship Between Skin Cancer and Obesity Differ Between Young Adult Males Versus Elderly Males?
    (2018-03-14) Ly, Ashley; Chuen, Joyce; Dao, Alejandra; Hartos, Jessica; Hamid, Kanwal
    Purpose: Obesity is an established risk factor for several cancer types, but there are conflicting findings about the relationship between obesity and skin cancer especially in males. Therefore, the purpose of this study was to explore whether the relationship between obesity and skin cancer differs between young adult males and elderly males. Methods: This cross-sectional analysis used 2015 BRFSS data for males ages 18-40 and ages 65 and older from Alabama, Kentucky, Tennessee, and West Virginia. Multiple logistic regression analysis was used to assess the relationship between skin cancer and obesity while controlling for age, White ethnicity/race, educational level, tobacco use, alcohol use, healthy eating, and routine checkups. Results: Few participants reported ever being diagnosed with skin cancer (13-17%) and about one-third reported being obese (28-33%). Results of adjusted analysis indicated that skin cancer and obesity were not significantly related in any state, but skin cancer differed by age and ethnicity/race (large effect sizes) in all four states. Conclusions: Overall, obesity was not related to skin cancer in any of the four states in young and elderly males, but skin cancer differed by age and ethnicity/race in all four states. Although this study was restricted to a single time-point survey, the broad range of the BRFSS survey allows the results to generalize to the general population in the primary care setting. Due to the low to moderate prevalence of obesity, primary care providers should educate patients on its harmful effects while the low prevalence of skin cancer indicates providers should only screen patients with symptoms. Since there is no association between obesity and skin cancer, these conditions should be considered separately.
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    Evaluation of Stability and Anti-cancer activity of Copper(II) Tolfenamic Acid with an emphasis on Pancreatic
    (2018-03-14) Sankpal, Umesh; Patel, Rafid; Chhabra, Jaya; Brown, Deondra; Gurung, Raj; Holder, Alvin; Rajasekhar, Maram; Basha, Riyaz; Hurtado, Myrna
    Purpose: Tolfenamic acid (TA) acts as an anti-cancer agent in several cancer models via down-regulating transcription factors Sp1 and Sp3, and an inhibitor of apoptotic protein, survivin. Copper (Cu) is an important element with multiple biological functions and has gained interest in medical applications. Recently, Cu-TA has been synthesized and tested for enhanced therapeutic activity. In this study, Cu-TA was investigated for its stability and anti-cancer activity using several cancer cell lines and mouse model for pancreatic cancer (PC). Method: Cu-TA was synthesized and characterized by UV visible spectroscopy and Fourier-transform infrared spectroscopy (FTIR). Anti-proliferative activity was evaluated against twelve cell lines representing six (breast, colon, glioblastoma, medulloblastoma, pancreatic and prostate) cancers using the CellTiter-Glo kit and compared with TA. Further studies were performed using PC cells. The expression of Sp1, Sp3 and survivin was determined by Western blot and qPCR. The stability of Cu-TA was determined using 8-12 month-old powder and six-month-old stock solution. Cardiomyocytes (H9C2) were used to test the cytotoxicity in non-malignant cells. Athymic mice were injected with PC cells and treated with vehicle (control) or 25 or 50 mg/kg of Cu-TA 3 times/week and the effect on tumor growth was monitored for 4 weeks Animals body weight changes were also observed to determine overt toxicity. Results: Cu-TA significantly more effective than TA against all tested cancer cells. The IC50 values of Cu-TA were 30 to 80% less when compared with TA. Comparison of the twelve-month-old powder and six-month-old stock solution using the Panc1 cells showed similar IC50values ( Conclusion: These in vitro and in vivo studies demonstrate that Cu-TA is more effective than TA and potentially useful as an effective anti-cancer agent.
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    Slow-growing benign tumors with potential for functional disability in Neuroblastoma: a case study.
    (2018-03-14) Rapisand, Stefanie; Bowman, Paul; Finger, Nicolet
    Background: Neuroblastoma (NBL) is the most common malignant extracranial tumor in pediatrics and may mature into ganglioneuroma (GN). Though GN is benign, it has the potential to cause severe symptoms related to adjacent structures or organs. Cases of GN causing complications such as scoliosis and hydronephrosis have been reported. We report a rare case of stage IV neuroblastoma which, over the course of 19 years, has presented as numerous GN tumors causing a striking number of complications. Case information: A 7 month-old male presented with stage IV NBL disseminated to his face, groin area, and testicles. The primary tumor was resected after chemotherapy treatment. Despite treatment efforts, disease spread to the bone marrow and numerous tumors appeared throughout the body. At the current age of 19, the patient has endured a lifetime of complications due to tumors in the face, spine, intestine, groin, and testicles. These complications include scoliosis, bowel obstruction, severe abdominal pain, hydronephrosis, varicocele, and neurologic symptoms. Conclusions: In more than half of patients, NBL is widely metastatic by the time it is diagnosed. Recurrence of NBL or GN is infrequent with complete tumor excision. However, due to the invasive character of NBL, it is difficult to ensure complete elimination of tumor cells. It is possible that the recurrent GN tumors appearing in this patient are the result of the maturation of what was initially metastasized, microscopic NBL lesions. Due to the rarity of such extensive GN dissemination, the pathology and management strategy of this condition is still being understood. Treatment of patients with NBL requires long-term, multidisciplinary management by experienced providers. Emphasis should be placed on quality of life. In addition, transfer of these patients from pediatric care to adult care requires extensive communication and education between the patient, family members, and all involved medical providers.
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    Copper Tolfenamic acid induces anti-proliferative activity effective against Medulloblastoma cells
    (2018-03-14) Sankpal, Umesh; Bowman, W. Paul; Basha, Riyaz; Arechiga, Bianca
    Purpose: Medulloblastoma (MB) is the most common pediatric malignant brain tumor, comprising 20% of all childhood brain tumors. Between 250-500 children per year are diagnosed in the US alone. Standard therapies result in severe long-term morbidities. Therefore, there is an urgent need for inventing novel effective treatment strategies with lower side-effects. Our laboratory showed anti-cancer activity of Tolfenamic acid (TA) in pre-clinical model for MB. Recent studies showed higher pharmacological effect of TA when synthesized as a complex with copper (Copper-TA, Cu-TA). Our aim was to investigate the anti-cancer activity of Cu-TA against MB cell lines. We hypothesize that Cu-TA presents higher anti-cancer activity and is more effective than TA to induce cytotoxicity against MB cells. Methods: DAOY and D283 cells were obtained from ATCC and grown following standard cell culture conditions. Cells were treated with TA or Cu-TA and the cell viability was measured at 24 and 48 h post-treatment using a CellTiter-Glo kit. The induction of apoptosis was investigated by studying caspase activation using the Caspase 3/7-Glo kit. In addition, reactive oxygen species (ROS) involvement was measured by flow cytometry. Results: Both Cu-TA and TA treatment resulted in decreased cell viability. However, when compared to TA, Cu-TA was more effective at inducing anti-proliferative activity in MB cells. Cu-TA induces increased production of ROS. The anti-proliferative activity of Cu-TA was accompanied by an increase in Caspase 3/7 activity, suggesting the induction of apoptosis. Conclusions: Cu-TA was more effective than TA. Therefore, it has potential as an effective anti-cancer agent for inhibiting MB cell growth. Further studies are needed to better understand Cu-TA’s mechanism of action.
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    Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner’s Syndrome and Facial Neuralgia: A Case Report
    (2018-03-14) Homewood, Tyler; Baker, Terry; Baker, Austin
    Background: Schwannomas of the carotid sheath are rare neoplasms and schwannomas of the cervical sympathetic chain are the least common subtype. Despite predictive radiologic patterns, Cervical sympathetic chain schwannomas (CSCS) have been known to masquerade as other neoplasms on CT and MRI making preoperative diagnosis difficult. Postoperative complications are common. We present a rare case of a misdiagnosed CSCS with unusual complications of permanent Horner’s syndrome and facial neuralgia. Case Information: A 36-year-old female presented with a right neck mass. CT and MRI confirmed the mass in the parapharyngeal space. The positioning of the mass in conjunction with the common carotid artery and the internal jugular vein lead to a diagnosis of vagus nerve schwannoma (VNS). During surgical treatment, dissection to the mass revealed the preoperative diagnosis of VNS to be incorrect as the mass was found to be involved with the cervical sympathetic chain. A new diagnosis of CSCS was made and the nerve was enucleated along with the mass. The patient presented postoperatively with Horner’s syndrome and severe facial neuralgia. Despite maximal medical management for two years, these complications have proved permanent. Conclusions: Imaging is the mainstay for preoperative diagnosis of CSCS. While imaging trends allowing distinction between VNS, CSCS, and other tumors are helpful, recent studies have shown considerable variability in these trends making preoperative diagnosis difficult. Our case reflects this difficulty as preoperative imaging led to an incorrect diagnosis. In addition, post-operative complications, such as temporary Horner’s syndrome are common in CSCS. The patient in our case presented with more severe and unique complications of facial neuralgia and permanent Horner’s syndrome. These complications are not often seen in the literature. Future research should be undertaken to determine if a link between an incorrect preoperative diagnosis and an increased complication rate exists. In addition, this case serves to heighten clinician consciousness of a rare but important diagnosis and the difficulties involved with initial diagnosis and potential complications. We hope that such knowledge will prompt physicians to prepare thoroughly for possibly alternative diagnoses during surgical intervention which may lead to improved patient outcomes.
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    Two Tumors in One: Mixed Malignant Germ Cell Tumor with Rhabdomyosarcomatous Malignant Transformation in a Pediatric Patient
    (2018-03-14) Margraf, Linda; Ray, Anish; Pham, Robin
    Background Testicular germ cell tumors (GCT) are the most common malignancy in males aged 15-34. The transformation of GCTs into secondary somatic-type malignancies is rare, and the lack of clear treatment guidelines presents a clinical challenge for treating physicians especially when chemosensitivities do not overlap. This report will focus on one case of a mixed malignant GCT with a secondary somatic-type malignancy. We highlight our experience in diagnosing and treating this tumor, and through literature review suggest treatment guidelines for treating a pediatric patient with similar tumor presentation. Case Information We report a 15-year-old male previously in good health who complained of a painless hard mass involving his right testicle following surgical repair of bilateral varicocele. A right radical orchiectomy was performed, and surgical resection was achieved with negative margins. Histopathological examination of the mass showed a mixed non-seminomatous malignant GCT with an embryonal rhabdomyosarcoma component that made up more than half of the primary tumor. Our greatest challenge in treating this tumor was understanding how to target the disparate components. The two major components of the tumor were staged and treated separately. The GCT component was deemed low risk, and following surgery, active surveillance strategies were utilized. The rhabdomyosarcoma component, also characterized as low risk, was targeted with chemotherapy in a 24 week therapy schedule with 4 cycles of vincristine, dactinomycin, and cyclophosphamide followed by 4 cycles of vincristine and dactinomycin. The patient completed therapy without complications. 34 months post therapy he remains in good health and has shown no evidence of tumor recurrence. Conclusion Cases such as these remain challenging given the lack of consensus in treating two malignancies whose chemosensitivities do not overlap. There is little debate that successful surgical resection aimed towards securing negative margin remains key in adequate treatment of those with localized disease. With regard to choice of chemotherapy postoperatively, there is some suggestion that malignant transformation of GCT responds poorly to cisplatin based therapy. In treating a pediatric patient with similar tumor presentation, we suggest that choice of chemotherapy agents should be influenced by the transformed histological element as the transformed element may not be responsive to cisplatin-based therapy.
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    Recurrence of Sub-Acute Methotrexate Neurotoxicity in a 16-year-old Female Undergoing Therapy for Precursor B-cell ALL
    (2018-03-14) Torres, Jordan; Chaphekar, Anita V.
    Introduction: Methotrexate, an anti-folate, is commonly used in treatment for acute lymphoblastic leukemia. Neurotoxicity is a known complication of methotrexate and can present as acute, sub-acute, and long-term neurotoxicities. Sub-acute methotrexate neurotoxicity can be seen as late as two weeks after methotrexate administration and can present as stroke-like symptoms, seizures, aphasia, and encephalopathy.Patients who develop methotrexate neurotoxicity can be safely re-challenged with the drug, although there are reports of recurrent neurotoxicity occurring. Patients who develop methotrexate neurotoxicity often have MRI findings of white matter hyper-intensities known as leukoencephalopathy. These changes are usually transient and can be present in an asymptomatic patient being treated with methotrexate. Case Presentation: This case was identified and reviewed using electronic medical records and imaging. Details of the case were also supplied by the patient herself during interview. A 16-year-old female presented to her outside pediatrician with several months of headaches, one week history of loose stools, and two-day history of bruising to the back of the hands. A complete blood count revealed anemia, thrombocytopenia, and leukocytosis. The patient was sent to Cook Children’s Emergency Room. A diagnosis of precursor B-cell Acute Lymphoblastic Leukemia, High Risk was established. Patient was enrolled in the COG protocol AALLO8B1 for biology and tissue banking and treatment protocol AALL1131. Induction began as planned. The patient was given intrathecal methotrexate on day 8 and 29 without problems. However, her minimal residual disease at the end of induction was 0.2%. Due to this, the patient was switched to the very high-risk arm of protocol AALL1131.The Consolidation phase consisted of weekly intrathecal methotrexate, intravenous cyclophosphamide, intravenous cytarabine, and 6-mercaptopurine. During the first few days of consolidation the patient began complaining of trouble with concentration and memory. Approximately eleven days after intrathecal methotrexate administration, the patient reported to the Cook Children’s Emergency Department with complaints of pain in her mouth, difficulty swallowing, and a fever of 101.9 degrees Fahrenheit. The patient also had weakness in her right upper extremity, slurred speech, and she could not write with her right hand. Physical exam in the emergency department was remarkable for right facial hemiparesis and asymmetry. She was somnolent and lethargic. The right upper extremity had decreased tone and strength compared to the left upper extremity. The patient exhibited aphasia. Cranial nerve seven demonstrated a right central palsy, but all other cranial nerves were intact. Blood cultures were negative. The patient had to be intubated and transferred to the PICU due to loss of gag reflex and inability to keep her airway open. MRI showed bilateral periventricular white matter and centrum semiovale diffusion restriction with no mass effect consistent with acute methotrexate toxicity. Decadron and Leucovorin were started. She was extubated on PICU day 4. The patient returned to the oncology clinic a few days after discharge and was doing well overall. During this clinic visit, she received a re-challenge of 15 mg of intrathecal methotrexate. Approximately one week after this methotrexate administration, the patient returned to the emergency department with recurrent methotrexate encephalopathy. She complained of a left lower facial palsy, left arm weakness, and difficulty with speech. She was afebrile and physical exam did not show any major neurological abnormalities, An MRI of the brain showed diffusion restriction in bilateral centrum semiovale and supratentorial periventricular white matter with right more than left side. This was deemed to be consistent with methotrexate neurotoxicity. MRA showed no vascular deficit. The patient was switched from intrathecal methotrexate to intrathecal cytarabine for maintenance therapy. She tolerated this well, although she did have some delayed clearance of the methotrexate requiring a longer hospital stay. Conclusion: Although re-challenge is considered safe, it is important to be aware of the possibility of a second episode of methotrexate neurotoxicity occurring as seen in this patient. The patient had stroke-like symptoms that resolved in a few days in both instances. Additionally, her MRI findings are consistent with leukoencephalopathy. She continues to receive intravenous methotrexate but is given intrathecal cytarabine rather than intrathecal methotrexate.
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    Current landscape of immunotherapy clinical trials in prostate cancer
    (2018-03-14) Gdowski, Andrew; Lampe, Jana B.; Ranjan, Amalendu; Vishwanatha, Jamboor; Gorman, Brendan
    Purpose The number of immunotherapies that have been approved in recent years has generated a lot of enthusiasm in the field of oncology. This success has come on the results of approvals for immunotherapy drugs and the expansion of indications for a variety of hematological and solid malignancies. However, very few immunotherapies have demonstrated improved overall survival in treating patients with prostate cancer. This is due to several factors including tumor heterogeneity, limited prostate tumor-associated antigens, and an immunosuppressive environment. Despite these challenges, numerous clinical trial efforts are ongoing to determine outcomes of immunotherapies in prostate cancer, and many are in the context of combination strategies. The purpose of this project was to identify and categorize the current landscape of immunotherapies that are in clinical trials for prostate cancer. Methods An extensive evaluation of the all currently registered clinical trials in the United States of immunotherapies in the setting of prostate cancer was performed utilizing on 1-20-18. The following search parameters were used: Condition/disease: “prostate cancer” Other terms: “immunotherapy”, “CAR-T cell therapy”, “monoclonal antibody”, “checkpoint inhibitors”, and “vaccine”. Results The query resulted in a total of 215 registered clinical trials. Most of these trials (84%) were in the context of vaccine therapy against prostate cancer, 12% of trials involved checkpoint inhibitors, and 4% were testing CAR-T cell therapy. Only 6% of the trials were in the phase 3 setting while 32% and 60% were in phase I or phase II, respectively (the remainder were not categorized into a phase). The majority of these trials used combination strategies. Conclusion The slow-growing nature of prostate cancer in many patients makes this cancer uniquely suitable for utilizing immunotherapies that may need time to allow for an immune response to mount against cancer cells. There is a tremendous amount of clinical trials that are currently being performed on prostate cancer with a variety of immunotherapeutic strategies. Although more research needs to be done, the potential of a durable and sustained response with immunotherapies is encouraging in the setting of prostate cancer.
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    Bone Sectioning Technique for 3D Confocal Image Resolution and Capture of Dye-Loaded Nanotherapeutics
    (2018-03-14) Gdowski, Andrew; Ranjan, Amalendu; Vishwanatha, Jamboor; Lampe, Jana B.
    ABSTRACT Purpose:Capturing detailed images of bone architecture has unique challenges and conventional procedures have proved to be insufficient for molecular 3D imaging. Furthermore, traditional 2D immunohistochemistry provides limited information for assessing therapeutic localization in the bone. In addition, techniques such as thin paraffin sections visualized by immunofluorescence microscopy or transmission electron microscopy, require prolonged exposure to damaging decalcification reagents. These chemicals have destructive effects on bone morphology and limit the capture of proteins. The objective of this project was to develop an adapted protocol for bone tissue preparation prior to sectioning and immunohistochemical (IHC) staining. This method enables ultra-thick sections for enhanced Z-stacking, enables the generation of high-resolution 3D images that map the bone tissue, and provides oseo-spatial detection of our dye-loaded nanotherapeutics. Methods:Bones were decalcified then incubated in cryoprotectant before emersion in the embedding solution. Samples were frozen at -80. Ultra-thick sections were made on a Thermo Fisher Cryostar NX70 Cryostat (75 – 100 m) and placed on polar slides. Immunohistochemical staining was applied to the slides, which were imaged with a Zeiss LSM 510 confocal microscope. Our therapeutic was labeled with near fluorescent dye.Results:High-fidelity, 3D images of mouse tibia and femur were imaged. Furthermore, visualization of nuclear staining, bone epithelial cells, and the fluorescently labeled therapeutics were easily detected. Thick sectioning provided us with a more robust, tomographic image, allowing for more thorough mapping and analysis of the nanotherapeutics in the bone. Conclusions:Our modified protocol for processing and imaging bone is an effective approach to bone handling, confocal imaging, and detecting bone and dye-labeled nanotherapeutics. This approach will provide benefits for facilitating our understanding of the significance that drug localization has on the bone microenvironment and its impact on therapeutic efficacy.
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    Diffuse Large B cell Lymphoma presenting as Acute Pancreatitis
    (2018-03-14) Mohanaselvan, Arvind; Patel, Aman; Makhni, Manmeet; Jipescu, Daniel
    Background: Diffuse large B cell Lymphoma (DLBCL), not otherwise specified (NOS) is the most common type of lymphoma in the world accounting for 25–30% of Non-Hodgkin lymphomas (NHL). It is more common in the elderly but occurs in all age groups and predominantly affect the male.Most common sites of involvement include lymph nodes or extranodal sites (bone, skin, thyroid, gastrointestinal tract and lung).1 Only 1.25% to 2.2% of all patients with NHL have pancreatic involvement at presentation.2,3 Primary pancreatic lymphoma (PPL) rarely presents with the typical B symptoms observed in lymphoma (ie, weight loss, fever, or night sweats).4–6 Here we report an unusual and rare case of PPL which was first diagnosed as acute biliary pancreatitis that was later found to be Pancreatic Adenocarcinoma and later confirmed on biopsy as DLBCL-NOS. Case Report: An 80-years-old caucasian male presented to the ER with complaints of abdominal pain for one day, generalized weakness and shortness of breath for two weeks. ROS otherwise unremarkable. Vitals showed elevated blood pressure otherwise unremarkable. Physical exam was positive for epigastric tenderness radiating to the back without any signs of peritonitis and labs showed TBili-5.4, DBili-3.6, AST-440, ALT-502, AlkPhos-372, LDH-388, Amylase-268, Lipase-4403. Beta-2-microglobulin-2.4, AFP-1.5, CEA-0.7, CA 19-9-178. Patient had a prior history of Prostate CA status-post radiation. CT Abdomen showing a pancreatic mass with biliary and duodenal obstruction suggestive of a tumor. CT Abdomen and pelvis with contrast was suggestive of Pancreatic Adenocarcinoma. Patient was diagnosed with acute biliary pancreatitis and was started IVF and pain medication. He subsequently underwent placement with a biliary drain to relieve obstruction. Biopsy was suggestive of DLBCL-NOS. Patient was started on CHOP-R regimen and advised to have a close follow up with oncologist as an outpatient. As treatment progresses, biliary drain will be replaced by indwelling stents to relieve the obstructions. Discussion: PPL is a rare neoplasm that can mimic pancreatic adenocarcinoma in many aspects. Arriving to a proper diagnosis using both biochemical and tissue biopsy is very essential as it carries excellent prognosis if diagnosed early. The best therapeutic option as per the study by Behrns et al and many other recent studies is chemotherapy CHOP-R with or without surgical resection and radiotherapy depending on the Ann Arbor staging and is associated with increased long-term survival of PPL.7-8
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    Suppression of glycosidase NGLY1 induces multifaceted anticancer responses.
    (2018-03-14) Mishra, Nigam; Lin, Victor; Ho, Yin; Hayatshahi, Hamed; Parab, Abhishek; Sampat, Rohit; Liao, Xiaoyan; Hoffmann, Peter; Liu, Jin; Emmitte, Kyle; Wang, Yu-chieh; Zolekar, Ashwini
    Purpose: NGLY1 is a pivotal enzyme that catalyzes the deglycosylation of denatured glycoproteins and facilitates proteasome-mediated protein degradation. However, there is limited information regarding the responses of human normal and cancer cells to NGLY1 suppression. The objective of our study is to determine the significance of NGLY1 for melanoma cell viability and how it may be exploited as a novel anticancer target. Methods: We used cellular and molecular biology tools such as Crispr-Cas9-mediated gene editing and shRNA for NGLY1 suppression. Computational modelling and a rational design approach was used to design and synthesize novel small molecules that can covalently modify NGLY1 to irreversibly inhibit its activity. We also used systems biology approaches including global gene expression profiling and proteomics analysis to uncover mechanisms through which inhibition of NGLY1 preferentially leads to cancer suppression. Results: Compared with normal cells, NGLY1 was upregulated in melanoma cell lines and patient tumor samples. NGLY1 knockdown caused melanoma cell death in vitro and tumor growth retardation in vivo. Mechanistically, NGLY1 suppression induced pleiotropic responses which can synergize with the anti-melanoma activity of chemotherapy and targeted therapy agents. We have discovered a series of novel small-molecule inhibitors of human NGLY1. Both pharmacological and molecular biology tools that inhibit NGLY1 elicited highly similar responses in melanoma cells. Unlike normal cells, melanoma cells presented distinct responses and high vulnerability to NGLY1 suppression. Conclusion: Our work represents the first comprehensive characterization of multifaceted anti-melanoma responses by targeting NGLY1. This study revealed the biological significance of NGLY1 in melanoma cells and provided mechanistic insights regarding how NGLY1 inactivation preferentially leads to eradication of melanoma with limited impact on normal cells. Collectively, our findings attest that the inactivation of NGLY1 represents a novel and promising anti-melanoma strategy.
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    Evaluation of Metformin as an anti-cancer agent in Medulloblastoma
    (2018-03-14) Basha, Riyaz; Bowman, W. Paul; Sankpal, Umesh; Payne, Kristen
    Evaluation of Metformin as an anti-cancer agent in Medulloblastoma Purpose: Medulloblastoma (MB) is the most common malignant brain tumor in children under 16 years of age. Standard treatment, including surgery, chemotherapy, and radiation, is successful for most; however, survivors often suffer from long-term neurocognitive and growth potential related sequelae. Therefore, there is a need to understand the molecular processes regulating MB growth to find less toxic therapies. Survivin is a protein in the Inhibitor of Apoptosis Protein (IAP) family that inhibits caspase activity. Survivin is highly expressed in MB and associated with a poor prognosis. Specificity protein 1 (Sp1) is a transcription factor regulating survivin expression and is overexpressed in many cancers. Interestingly, the use of Metformin (MET), an anti-diabetic drug, correlated with decreased occurrence of several cancers. Previous studies have demonstrated its anti-cancer activity in breast cancer cells as well. The objective of this study is to test the effect of MET on MB cells in vitro. Hypothesis: We hypothesize that MET treatment decreases the growth of MB cells in a dose and time-dependent manner, possibly inhibiting the expression of survivin via downregulating Sp1. Methods: DAOY (MB cell line from American Type Culture Collection) cells were treated with increasing concentrations of MET (0, 1, 5, 10, and 20 mM). Cell viability was assessed at 24 and 48 hours post-treatment using the CellTiter-Glo cell viability assay. Survivin and Sp1 expression in MET treated cells was determined by Western blot analysis. Potential mechanism of cell proliferation inhibition was investigated by measuring the induction of reactive oxygen species (ROS) through Flowcytometry. Results: MET treatment resulted in decreased cell viability in a dose and time dependent manner. MET treatment also decreased Sp1 and survivin expression indicating that the effect of MET is mediated via Sp1 transcription factor. We also observed MET induced cellular ROS formation, which could be a potential anti-cancer mechanism. Conclusion: Our data demonstrates that MET can inhibit MB cell growth, possibly via targeting Sp1 to down-regulate survivin and inducing ROS. We conclude that MET has the potential to be used in the treatment of MB. Due to limitations of using Metformin alone as an anti-cancer agent, additional experiments are underway to determine its use in conjunction with MB specific chemotherapeutic agents.
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    Blocking LLT1-CD161 interaction enhances natural killer cell-mediated lysis of triple-negative breast cancer cells
    (2018-03-14) Mathew, Stephen O.; Chaudhary, Pankaj; Mathew, Porunelloor A.; Marrufo, Armando M.
    Purpose: Triple-negative breast cancer (TNBC) accounts for 20 percent of all breast cancer cases and is known to be the most invasive form of breast cancer. TNBC’s absence of estrogen, progesterone, and human epidermal growth factor-2 receptors makes utilizing hormonal treatments ineffective in suppressing tumor growth. TNBC is associated with poorer prognosis and higher incidences of relapse. Therefore, natural killer cell-mediated immunotherapy shows potential as a treatment option for TNBC. Natural killer cells (NK) are innate lymphoid cells that serves its role in the immune system to eradicate infected and tumor cells. NK cell function is regulated through its receptors interacting with activating and inhibitory ligands on target cells. Lectin-like Transcript-1 (LLT1, CLEC2D) is a counter-receptor that interacts with CD161 (NKRP1A) and inhibits NK cell activation. Our study demonstrated that by blocking TNBC’s LLT1 interaction with CD161 with antibodies increases lysis of TNBCs by NK cells. Methods: We have identified the expression and function of LLT1 on TNBC cell lines MDA-MB-231 and MDA-MB-436 by flow cytometry, western blot, immunofluorescent microscopy, and chromium-release assay. LLT1 expression at the cell surface was decreased through gene knockdown with small interference RNA (siRNA) transfection. Primary NK cells were isolated from peripheral blood mononuclear cells from healthy individuals and then were co-incubated with chromium-labeled TNBCs for quantification of specific lysis of TNBCs by NK cells. Results: Our results have demonstrated a higher expression of LLT1 on TNBCs than non-tumorigenic breast cell line MCF10A. We have shown that blocking LLT1 interaction with CD161 with antibodies on TNBCs have increased lysis of TNBCs by primary NK cells. We have also shown that gene knockdown of LLT1 decreases cell surface expression of LLT1 on TNBCs and increases lysis of TNBCs by NK cells. Conclusions: LLT1 expressed on TNBCs is a ligand that interacts with NK receptor CD161 and sends an inhibitory signal to the NK cell thus serving its role for TNBCs to evade immunosurveillance. Respectively, blocking LLT1 with antibodies on TNBCs and decreasing expression of LLT1 by gene knockdown increases susceptibility of TNBCs to NK cell-mediated lysis. Blocking interaction between LLT1 and CD161 with antibodies activates lysis by NK cells and will open a possible new immunotherapeutic strategy for patients diagnosed with TNBC.
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    A Literature Review of Exercise in the Pediatric Oncology Population
    (2018-03-14) Nguyen, Peter; Salem, Yasser; Liu, Howe; Becnel, Kelsey
    Title: A Literature Review of Exercise in the Pediatric Oncology Population The advances in treatment of children with cancer have been improved in recent years. This has resulted in an increase in the number of pediatric cancer survivors. Several research studies have shown that the medical condition and its related disorders is associated with impaired growth and development, decreased strength, fatigue, cognitive dysfunction, cardiopulmonary compromise, impaired physical fitness, musculoskeletal complications and decreased quality of life. There is growing evidence that lack of participation in physical activity in children with disability including children with pediatric oncology may result in several negative effects and decrease quality of life. In recent years, several exercise programs have been implemented for pediatric oncology. Purpose The purpose of this literature review is to examine evidence regarding the potential benefits of exercise for children with pediatric oncology. Safety, benefits, and application are addressed. Methods This systematic review identified 18 articles that met our inclusion criteria. Electronic databases used were PubMed, Physiotherapy Evidence Database (PEDro), CINAHL, Rehabilitation Oncology Journal, and Scopus. Key words included pediatric, children, oncology, exercise, and rehabilitation. Our initial search yielded 271 potential articles, which we screened for selection criteria. In total, 751 children with cancer were studied in our final research articles. Results In total, 18 research studies were examined and met our inclusion criteria for aerobic exercise in pediatric oncology patients. Of the included articles, 12 were randomized controlled trials, 2 were quasi-experimental design, 3 were cohort studies, and 1 were clinical trial. Across all 18 studies, 751 children with pediatric oncology were participants. Sample size for each study ranged between 7 and 150 children. All studies showed beneficial effects of exercise training for children with pediatric cancer. Discussion and Conclusion This systematic review adds to the body of literature that supports exercise training for individuals with pediatric oncology. Studies included support the beneficial effects of exercises for children with cancer. Further studies are needed to determine long term effects of any intervention. Available literature on exercise in children with pediatric oncology suggests that there are beneficial effects without adverse outcomes.
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    Cell surface PCNA is a marker of pancreatic and colon cancer stem cells and inhibits NK cell effector function.
    (2018-03-14) Mathew, Porunelloor A.; Malaer, Joseph
    Purpose: Cancer stem cells (CSC), a unique subset of tumor cells, possess a stem-cell-like phenotype and are thought to facilitate metastasis by escaping NK cell effector function. There are numerous markers used to identify CSC; of which include surface markers CD44 and CD133, and transcription factors NANOG, SOX2, and Oct-4. NK cells participate in the innate immune response against cancer without prior sensitization. NK cell function depends on a balance of signals transmitted from activating and inhibitory receptors interacting with ligands on the surface of target cells. Cancer cells may evade NK-mediated killing by expressing or secreting ligands for NK cell inhibitory receptors. NKp44 can function as an activating receptor that induces NK cell cytotoxicity or an inhibitory receptor depending on ligand interaction. Proliferating cell nuclear antigen (PCNA) associates with Human Leukocyte Antigen I (HLA I) and forms the inhibitory ligand for NKp44, resulting in the inhibition of NK function. We hypothesize surface PCNA is a marker for CSC in pancreatic and colon cancer. Methods: Pancreatic (Panc-1) and colon (HCT 116) cancer cells were labeled with antibodies against PCNA, CD44, and CD133 and flow cytometry was performed to determine surface expression. Cells were labeled and sorted for cell surface PCNA expression via fluorescence activated cell sorting; NANOG, SOX2, and Oct-4 were analyzed by qRT-PCR from sorted cells. NK receptor-ligand interactions were blocked by incubating cells with anti-PCNA or control antibodies and a chromium release killing assay was performed. Results: In both Panc-1 and HCT 116 cells, a PCNA+CD44+CD133+ population was detected. Furthermore, cell sorting and qRT-PCR confirmed cells with cell surface PCNA have increased expression of CSC transcription factors compared to PCNA- cells. Blocking the interaction of NKp44 and PCNA enhanced the specific lysis of cells by primary NK cells. Conclusions: Cell surface PCNA is associated with co-expression of CD44 and CD133 as well as increased CSC transcription factor expression. Collectively these data demonstrate that surface PCNA is a marker of pancreatic and colon CSC. Additionally, cell surface PCNA on CSC facilitate escape from NK cell killing by interacting with NKp44 and transmission of an inhibitory signal. Our research implicates that blocking NKp44-PCNA interaction may provide novel immunotherapeutic targets for pancreatic and colon cancer stem cells and prevent metastasis.
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    Challenges of Medical Decision-Making in an Autistic Pediatric Patient with Retinoblastoma and Osteosarcoma: A Case Study
    (2018-03-14) Rapisand, Stefanie; Hamby, Tyler; Bowman, Paul; Shum, Kathy
    Background: In oncology, one of the most crucial decisions is whether it is appropriate to discontinue chemotherapy before the full course of treatment. Medical professionals must consider the risks versus the benefits, the patient’s quality of life, the appropriate role of chemotherapy, and the patient’s preference. The decision is difficult in pediatric patients who have encountered multiple malignancies while suffering from the untoward effects of chemotherapy. It is especially difficult in malignancies such as osteosarcoma where successful treatment involves the full course of systemic chemotherapy. Case Information: A 9-year-old autistic male with a history of retinoblastoma presented with pain in the right leg and an abnormal gait. A biopsy confirmed the diagnosis of high grade osteosarcoma. Neoadjuvant chemotherapy (protocol AOST 0331) was initiated with the administration of Cisplatin and Adriamycin, but was complicated by nausea, vomiting, febrile pancytopenia, and multiple life threatening infections. Nausea and vomiting was so severe that a feeding tube was placed for feedings and medication administration. After hip disarticulation amputation, chemotherapy was resumed, but was suspended at week 15 of treatment due to multiple life-threatening complications such as nephrotoxicity, endocarditis, and staphylococcus and streptococcus mitis infections. Discussion: The decision to discontinue chemotherapy early was not an easy one. The patient suffers from severe autism, is non-verbal, blind, intellectually disabled, and suffered many complications from his first and second pediatric malignancies. After considering the patient’s long battle with two pediatric malignancies and the numerous challenges he has had from undergoing chemotherapy, the patient’s parents and physicians agreed to discontinue chemotherapy. The patient is now receiving palliative care. Conclusion: Our case illustrates the importance of an individualized treatment plan when working with complicated patients. When physicians are faced with challenging medical decisions, it is important to remember, that with the help of their medical team and open communication with patients and their family members, making these decisions may not be as difficult and may be beneficial to everyone involved.
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    The Involvement of S6 Kinase-2 in Breast Cancer
    (2018-03-14) Basu, Alakananda; Joshi, Rohan
    Purpose: Breast cancer is the second leading cause of cancer death in women. Triple negative breast cancer is characterized by the lack of estrogen receptor, progesterone receptor, and HER2/neu and hence poses a problem for targeted therapy. Thus there is an urgent need to identify a suitable molecular target. The 40S ribosomal protein S6 kinase (S6K) acts downstream of mTOR, which plays important roles in cell proliferation, protein translation, and cell survival and is a potential target for cancer therapy. S6K exists as two homologues, S6K-1 and S6K-2, but little is known about the function of S6K-2. Although Akt is believed to act upstream of mTOR, persistent inhibition of S6K-1 can activate Akt via a negative feedback loop. In the present study, we have examined the effects of S6K-2 on Bcl-2. Bcl-2 is in the Bcl-2 family of proteins and is an anti-apoptotic protein. Methods: The breast cancer cell lines ZR-75 and MCF-7 were used. These cells were transfected using siRNAs which were either control non-targeting or target-specific. The extent of gene knockdown was determined by Western blot analysis. The proteins from the cell extract were visualized using SDS-PAGE gel electrophoresis and enhanced chemiluminescence. Yo-Pro staining was used to visualize apoptotic cells. Results: It was noted that S6K-2 knockdown lead to a decrease in Bcl-2, this occurred concurrently with an increase in cell death. Silencing of S6K-2 caused a decrease in Bcl-2 via Akt. Conclusion: Targeting S6K-2 may be an effective therapeutic strategy to treat breast cancer.
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    Prevalence and Risk Factors for Malnutrition during Pediatric Acute Lymphoblastic Leukemia Induction Therapy
    (2018-03-14) Ali, Mir; Hill, Rachel; Hamby, Tyler; Johnson, Danielle; Ray, Anish MD; Boren, Charles
    Purpose It is well documented that pediatric patients with acute lymphoblastic leukemia (ALL) often experience significant weight gain during induction therapy and later struggle with obesity. However, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes unnoticed or undertreated. Although malnutrition is reported to be associated with decreased survival, increased risk of infection and loss of lean body mass, there remains a scarcity of in depth analysis of prevalence and risk factors that contribute to this problem. Our study attempts to address this critical yet unmet need. Our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric ALL. Design/Method This was a retrospective chart review of patients between 2 and 20 years of age diagnosed with ALL at Cook Children’s Medical Center from 4/1/14 to 3/31/17. For each patient, we collected height, weight, age, body mass index (BMI) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. Patients with a BMI z-score [greater than] 85th percentile at diagnosis were categorized as being overweight or obese. Using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in BMI z-score throughout induction. A critical alpha level of 0.05 indicated statistical significance. Results Ninety-six patients met our inclusion criteria. Of these, 40% experienced a decrease in BMI during induction therapy. Compared to patients whose BMI increased during induction, patients with a decrease in BMI were more likely to be overweight or obese at diagnosis (55% vs. 22%; p Conclusion This research highlights a risk not previously identified in the literature that may impact outcomes. Patients treated on high- or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥10 years old at diagnosis should be monitored closely for weight loss during induction therapy. Patients who experience weight loss should receive prompt intervention. It is our hope that this information can be used for future prospective studies and help develop evidence-based guidelines.