Aggressive Therapy Research Articles

The Role of Stereotactic Body Radiotherapy in Oligometastatic Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is a major cause of mortality in Canada, with many patients presenting with metastatic disease. The oligometastatic state (OM-NSCLC) may be amenable to cure using aggressive local consolidative therapies. Stereotactic body radiotherapy (SBRT), which entails the utilization of a high dose of radiation in one or few fractions, has many benefits in this setting, including its applicability in varied patient populations to ablate lesions in varied anatomical locations. It has also been demonstrated to prolong the time to next-line systemic therapy, to reduce financial burden, to improve quality-adjusted life years, and reduce adverse events caused by these lesions. This review outlines the published phase II and III trials that have already demonstrated the utility of SBRT in OM-NSCLC, as well as the many ongoing trials aiming to further define its role, including the largest phase II/III trial to date, NRG-LU002. Overall, SBRT appears to improve outcomes when combined with a broad range of standard-of-care therapies and is generally well tolerated; however, careful patient selection is necessary to maximize benefits while minimizing harm. Ongoing trials will help define the optimal patients for SBRT and the best timing for this intervention.

Leptomeningeal metastatic disease: new frontiers and future directions.

Leptomeningeal metastatic disease (LMD), encompassing entities of 'meningeal carcinomatosis', neoplastic meningitis' and 'leukaemic/lymphomatous meningitis', arises secondary to the metastatic dissemination of cancer cells from extracranial and certain intracranial malignancies into the leptomeninges and cerebrospinal fluid. The clinical burden of LMD has been increasing secondary to more sensitive diagnostics, aggressive local therapies for discrete brain metastases, and improved management of extracranial disease with targeted and immunotherapeutic agents, resulting in improved survival. However, owing to drug delivery challenges and the unique microenvironment of LMD, novel therapies against systemic disease have not yet translated into improved outcomes for these patients. Underdiagnosis and misdiagnosis are common, response assessment remains challenging, and the prognosis associated with this disease of whole neuroaxis remains extremely poor. The dearth of effective therapies is further challenged by the difficulties in studying this dynamic disease state. In this Review, a multidisciplinary group of experts describe the emerging evidence and areas of active investigation in LMD and provide directed recommendations for future research. Drawing upon paradigm-changing advances in mechanistic science, computational approaches, and trial design, the authors discuss domain-specific and cross-disciplinary strategies for optimizing the clinical and translational research landscape for LMD. Advances in diagnostics, multi-agent intrathecal therapies, cell-based therapies, immunotherapies, proton craniospinal irradiation and ongoing clinical trials offer hope for improving outcomes for patients with LMD.

Daily glucocorticoids promote glioblastoma growth and circadian synchrony to the host.

Glioblastoma (GBM) is the most common primary malignant brain tumor in adults with a poor prognosis despite aggressive therapy. Here, we hypothesized that daily host signaling regulates tumor growth and synchronizes circadian rhythms in GBM. We find daily glucocorticoids promote or suppress GBM growth through glucocorticoid receptor (GR) signaling depending on time of day and the clock genes, Bmal1 and Cry. Blocking circadian signals, like vasoactive intestinal peptide or glucocorticoids, dramatically slows GBM growth and disease progression. Analysis of human GBM samples from The Cancer Genome Atlas (TCGA) shows that high GR expression significantly increases hazard of mortality. Finally, mouse and human GBM models have intrinsic circadian rhythms in clock gene expression invitro and invivo that entrain to the host through glucocorticoid signaling, regardless of tumor type or host immune status. We conclude that GBM entrains to the circadian circuit of the brain, modulating its growth through clock-controlled cues, like glucocorticoids.

Case report: HSV lymphadenitis in immunocompromised patient with CLL

BackgroundRichter’s transformation (RT) in chronic lymphocytic leukemia (CLL) is associated with poor prognosis and requires prompt modifications in patient care. CLL patients are susceptible to severe infections due to immune dysregulation induced by their malignancy and immunosuppressive therapies.Case presentationWe present a case of a 63-year-old man with CLL who previously achieved remission and presented with a right inguinal mass. He was diagnosed with Rai Stage I CLL with del6q, without TP53 mutation, and treated with 6 cycles of fludarabine, cyclophosphamide, and rituximab (FCR) 6 years prior. Transformed CLL was suspected based on his lymphadenopathy, elevated lactate dehydrogenase, and constitutional symptoms, but excisional biopsy unexpectedly revealed herpes simplex virus (HSV)-1 and HSV-2, indicating a diagnosis of HSV lymphadenitis concurrent with CLL relapse with no transformation but acquisition of 17p deletion consistent with clonal evolution. The patient received three courses of dexamethasone and acyclovir, leading to successful clearance of the infection, evidenced by the resolution of his B symptoms. Subsequently, he was treated for the CLL recurrence with rituximab and venetoclax, demonstrating a favorable response with significant improvement in adenopathy and resolution of lymphocytosis.DiscussionThis case highlights the possibility of reactivated dormant viral infections in the context of CLL relapse, underscoring the importance of comprehensive evaluation in CLL patients presenting with lymphadenopathy. Due to immunosuppressive defects and iatrogenic hypogammaglobulinemia, patients with CLL face an increased risk of viral infections, with HSV reactivation occurring more frequently and severely in the setting of hematologic malignancies and dysregulated T-cell immunity. Timely administration of antiviral therapy is crucial for HSV lymphadenitis to prevent rapid progression and debilitating symptoms. This case demonstrates the importance of considering atypical viral infection presentations in CLL patients and emphasizes the necessity of timely and adequate biopsies to differentiate between CLL transformation, HSV lymphadenopathy, and other causes of lymphadenopathy while avoiding unnecessarily aggressive lymphoma therapy.

Iwilfin (eflornithine) approved by the FDA as the first and only oral maintenance therapy for high-risk neuroblastoma in adult and pediatric patients: Narrative review.

Neural crest progenitor cells give rise to neuroblasts, the growing nerve cells of the sympathetic nervous system. These cells can undergo changes leading to neuroblastoma, a malignancy responsible for 15% of all pediatric cancer-related deaths. The molecular pathogenesis of this pediatric cancer involves complex genetic alterations, such as MYCN amplification, chromosomal abnormalities, and gene expression changes. Despite aggressive therapies, survival rates for children with high-risk neuroblastoma (HRNB) have not improved significantly compared to those with less severe forms of the disease. This highlights the challenge of managing HRNB and underscores the need for new, effective treatments. A comprehensive treatment regimen, including immunotherapy, radiation therapy, myeloablative chemotherapy, and surgical removal, has been employed to achieve remission in HRNB patients. While dinutuximab beta immunotherapy is an effective and widely used treatment, it has several potential side effects that must be carefully monitored. New drugs are being developed to reduce these side effects without compromising efficacy. One such drug is DL-alpha-difluoromethylornithine (DFMO), approved by the FDA under the brand name Iwilfin. Numerous clinical trials have shown that DFMO, when used as maintenance therapy, significantly improves event-free survival and overall survival in neuroblastoma patients. However, DFMO has adverse effects that require continuous monitoring. Further research is needed to minimize these side effects and improve its efficacy, particularly in addressing resistance caused by long-term use.

Use of epigenetically modified bacteriophage and dual beta-lactams to treat a Mycobacterium abscessus sternal wound infection

Nontuberculous mycobacterium (NTM) infections are challenging to manage and are frequently non-responsive to aggressive but poorly-tolerated antibiotic therapies. Immunosuppressed lung transplant patients are susceptible to NTM infections and poor patient outcomes are common. Bacteriophages present an alternative treatment option and are associated with favorable clinical outcomes. Similarly, dual beta-lactam combinations show promise in vitro, but clinical use is sparse. We report here a patient with an uncontrolled Mycobacterium abscessus infection following a bilateral lung transplant and failed antibiotic therapy. Both smooth and rough colony morphotype strains were initially present, but treatment with two phages that kill the rough strain – including epigenetic-modification to overcome restriction – resulted in isolation of only the smooth strain. The rough and smooth strains have similar antibiotic susceptibilities suggesting that the phages specifically eliminated the rough strain. Dual beta-lactam therapy with meropenem and ceftazidime-avibactam provided further clinical improvement, and the phages act synergistically with meropenem in vitro.

Atypical Teratoid Rhabdoid Tumor of the Brain in a Young Adult With Down Syndrome: Case Report and Literature Review.

Atypical teratoid/rhabdoid tumor (ATRT) is an aggressive, malignant embryonal tumor with dismal long-term survival despite aggressive multimodal therapy. While this tumor typically presents in infancy or early childhood, there are published case reports of adult-onset ATRT. Making prognostic conclusions or therapeutic decisions for this older patient population remains challenging due to the paucity of these reports. A 25-year-old female with Down syndrome presented with dysphagia and facial droop and was found to have an avidly enhancing, cerebellopontine angle mass. Histology demonstrated sheets of rhabdoid cells with loss of INI1 expression, pathognomonic for ATRT. Further sequencing detected a frameshift SMARCB1 mutation and methylation profiling matched with high confidence to the MYC subclass of ATRT. The patient was treated with subtotal surgical resection and focal proton beam irradiation, followed by chemotherapy on a modified regimen due to concern for heightened risk of treatment-related toxicity. On most recent follow-up 22 months from diagnosis, the patient remains without evidence of disease. This report represents the first known case of ATRT in a young adult patient with Down syndrome, offering unique mechanistic insight into the tumorigenesis of ATRT. Further studies are needed to define an appropriate risk-adapted and standardized therapeutic approach for this patient population.

Impact of Lymphatic and Venous Invasion Patterns on Postoperative Prognosis and Distant Metastasis in Esophageal Squamous Cell Carcinoma After Preoperative Chemotherapy.

Lymphovascular invasion (LVI) is reported to correlate with postoperative prognosis in esophageal squamous cell carcinoma (ESCC). However, reports analyzing lymphatic and venous invasion separately are rare, and no studies have examined the correlation in resected specimens after neoadjuvant chemotherapy (NAC). This study evaluated the postoperative prognosis and distant metastatic recurrence patterns in ESCC patients who underwent esophagectomy after NAC. This retrospective study analyzed 427 ESCC patients who underwent radical esophagectomy after NAC. The study examined the association of LVI patterns with postoperative overall survival (OS), recurrence-free survival (RFS), and distant metastasis-free survival (DMFS). The study also evaluated the correlation with postoperative distant metastasis patterns. Multivariate analyses showed that patients with venous invasion (VI) alone had significantly worse OS (HR, 2.99; p < 0.001), RFS (HR, 2.92; p < 0.001), and DMFS (HR, 3.63; p < 0.001) than patients without LVI. Patients with both lymphatic invasion (LI) and VI had the worst OS (HR, 4.23; p < 0.001), RFS (HR, 3.38; p < 0.001), and DMFS (HR, 4.59; p < 0.001) among all groups. For the ypN0 patients, VI positivity was the only independent risk factor for DMFS (HR, 5.33; p < 0.001). Regarding distant organ metastasis, liver, brain, and bone metastasis were more frequently detected in patients with both LI and VI than in patients with other LVI patterns. The study showed that ESCC patients treated with NAC who have resected specimens positive for VI, especially those also with positive lymphatic invasion, have a worse postoperative prognosis and a higher risk for postoperative distant metastases than those without LVI. More aggressive postoperative adjuvant therapy may be suitable for improving the prognosis of such patients.

Exploiting potential molecular compounds for treating testicular seminoma by targeting immune related genes

BackgroundIn cases of advanced seminoma, up to 30% of patients may manifest cisplatin resistance, necessitating aggressive salvage therapy, with a consequent 50% risk of mortality attributable to cancer. Nevertheless, beyond chemotherapy and radiotherapy, no further therapeutic modalities have been implemented for these patients.MethodsThe study commenced with the identification of differentially expressed immune-related genes, which were subsequently subjected to clustering using WGCNA. Prognostic signature construction ensued through the execution of univariable Cox regression, lasso regression, and multivariable Cox regression analyses. To validate the prognostic signature, the TCGA-TGCT and GSE99420 cohorts were employed, with assessments conducted via PFS, C-index, DCA, and ROC analyses. Subsequent exploration of the immune landscape and potential immunotherapeutic applications was undertaken through Cibersort and TIDE analyses. Molecular docking and dynamics simulation techniques were then employed for screening potential molecular compounds. Validation of these findings was pursued through in vitro and vivo assays.ResultsCTLA4, SNX17, and TMX1 were selected to construct the signature. Patients in the high-risk group exhibited diminished progression-free survival rates. The AUC for predicting survival at 1, 3, and 5 years was 0.802, 0.899, and 0.943, respectively, surpassing those of other risk factors, such as lymphovascular invasion and T stage. The C-index for the risk score was 0.838. Decision curve analysis (DCA) suggests that incorporating lymphovascular invasion and the risk score yields the most favorable decision-making outcomes for patients. Moreover, individuals classified as high-risk may derive greater benefit from immunotherapy. Molecular compounds including Rutin, ICG-001, and Doxorubicin can selectively target CTLA4, SNX17, and TMX1, respectively, thereby inhibiting the proliferation and invasive capabilities of seminoma tumor cells in vitro and vivo.ConclusionThe signature initially constructed based on immune-related genes shows promise for predicting outcomes and assessing the efficacy of immunotherapy in seminoma patients. Rutin, ICG-001, and Doxorubicin have demonstrated potential to target these signature genes and inhibit tumor cell viability.Graphical

Bromelain augments ionizing radiation sensitivity in breast cancer cells: A synergistic approach

BackgroundRadiation-sensitizing agents, such as Bromelain (pineapple extract) have been shown to significantly impact cancer cell cycle arrest. This study investigates the anticancer properties of Bromelain on MCF-7 breast cancer cell line under both two-dimensional (2D) and three-dimensional (3D) culture conditions. MethodsBromelain enzyme was initially applied at concentrations of 75, 96, and 115 μg/ml to sensitize the MCF-7 cells under both 2D and 3D culture conditions. Following treatment, the cells were irradiated with doses of 2, 4, and 6 Gy. The synergistic effects of bromelain enzyme treatment and gamma irradiation on MCF-7 cells were assessed using the MTT assay, neutral red uptake assay, alkaline comet assay, nitric oxide (NO) release measurement, catalase activity assay, reduced glutathione quantification, and caspase 3 assay. Data were analyzed and presented as Mean ± SD using GraphPad InStat software V. 8. ResultsThe MTT assay indicated that the combination of bromelain and ionizing radiation have synergistic effects compared to cells treated with 2 Gy of X-ray alone. The results from of the MTT assay indicated showed that 75 μg/ml of bromelain did not induce exhibit significant cytotoxicity. Consistent with the MTT assay results, the Neutral red uptake assay demonstrated increased mortality in MCF-7 cells following treatment with both bromelain and ionizing radiation. Additionally, treatment with bromelain and ionizing radiation resulted in elevated levels of released NO, GSH content, and catalase enzyme activity compared to cells treated with bromelain alone. Furthermore, the Combination of ionizing radiation and bromelain synergistically enhanced caspase-3 enzyme activity and increased the number of necrotic and apoptotic cells compared to treatment with bromelain alone. ConclusionBromelain's capacity to induce apoptosis and enhance radio-sensitization offers promising potentialfor improving cancer treatment outcomes. By promoting programmed cell death and increasing the sensitivity of cancer cells to radiation, bromelain could contribute to more effective treatment regimens while potentially reducing the adverse effects associated with more aggressive therapies.

High-dose chemotherapy with autologous haematopoietic stem cell transplantation in patients with isolated vitreoretinal lymphoma: a LOC network study.

Despite its indolent evolution, vitreoretinal lymphoma (VRL) has a poor prognosis due to a major risk of relapse in the central nervous system (CNS) and may necessitate aggressive therapy. However, the use of high-dose chemotherapy with autologous stem cell transplantation (HCT-ASCT) is poorly documented. We retrospectively analysed from the French LOC network database the adult immunocompetent patients treated with HCT-ASCT for isolated VRL. Thirty-eight patients underwent consolidation with HCT-ASCT for isolated VRL between 2008 and 2019 after induction chemotherapy. Twenty patients had primary VRL, and 18 had an isolated VRL relapse of a primary CNS lymphoma. Three patients underwent HCT-ASCT in first-line treatment, 24 in second-line treatment, and 11 in subsequent lines. At HCT-ASCT, the median age was 61 years, and the median KPS was 90. Thirty-two patients (84%) received high-dose thiotepa-based HCT. One patient (3%) died from HCT-ASCT toxicity. Nineteen (50%) patients relapsed after HCT-ASCT, including 17 cases occurring in the brain. The median progression-free survival, brain-free survival and overall survival from HCT-ASCT were 96, 113 and 92 months, respectively. HCT-ASCT represents an effective therapeutic strategy for select VRL patients, with a tolerable safety profile. However, the risk of subsequent brain relapse remains significant.

Abstract PR011: Multipronged SMAD Pathway Targeting by LiPBAE miR-590-3p NanomiRs Inhibits Recurrent Glioblastoma Growth and Prolongs Survival

Abstract Despite aggressive therapy consisting of surgery followed by radio/chemotherapy Glioblastoma (GBM) recurs in almost all patients and, currently, there are no proven therapies to treat recurrent GBM (rGBM). Recent developments in nanomedicine provide new and promising opportunities to develop new targeted therapeutics to treat brain tumors. In this study we combine bioinformatics, forward-thinking understanding of miRNA biology and cutting-edge nucleic acid delivery vehicles to advance targeted therapeutics for rGBM. Bioinformatic analysis of RNA sequencing from GSCs and clinical rGBM specimens identified TGF-beta receptor II (TGFBR2) signaling as a targetable pathway in rGBM. Mechanistically, we show that alterations in chromatin state driven by stem-cell driving events are conducive to a therapy-resistant state induced by TGFBR2. We show that blocking TGFBR2 via molecular and pharmacological approaches decreases the stem cell capacity, cell viability and re-sensitizes clinical rGBM isolates to temozolomide (TMZ) in vitro. Network analysis of SMAD2/3 targets enriched in rGBM predicted a subset of miRNAs that can target multiple genes within this set. Notably, miR-590-3p was predicted to inhibit 37 SMAD 2/3 gene targets that are also enriched in rGBMs. Bioinformatics analysis also showed that expression of 24 of those 37 miR-590-3p targets are positively correlated with TGFBR2 expression in rGBM clinical specimens. Consistent with these predictions, miR-590-3p inhibited expression of 25 of the 37 targets across 3 distinct therapy-resistant GSC isolates. To translate these in vitro finding, we developed novel bioreducible Lipophilic poly(β-amino ester) nanoparticles (LiPBAEs) for in vivo miRNA delivery. Following direct intratumoral infusion, these nanomiRs efficiently distribute through the tumors and spatial transcriptomic analysis (STA) found a decrease in 34 out of the 37 miR- 590-3p targets in animals that received the active nanomiR compared to control miRNA. Furthermore, STA identified 3 cell populations with distinct transcriptomic profiles reflecting a gradient pharmacodynamic response within tumors that received miR-590-3p nanomiRs with decreasing target expression towards the core of the tumor closest to catheter tip placement. To test the effect of 590-3p nanomiR therapy on survival, animals bearing pre-established intracranial rGBM xenografts received three infusions of either control or miR-590-3p nanomiRs every other day beginning on post-implantation day 7. All 10 animals treated with control nanomiRs were either dead or premorbid requiring euthanasia by post-implantation day 23. In contrast, 3 of 10 animals treated with miR-590-3p nanomiRs remained alive and healthy by post-implantation day 45, at which time the experiment was terminated. These results show that miRNA-based targeted therapeutics provide new opportunities to treat rGBM and bypass the resistance that is developed to standard of care. Citation Format: Hernando Lopez-Bertoni, Jack Korleski, Sophie Sall, Kathryn Luly, Maya K Johnson, Amanda L Johnson, Harmon Khela, Bachchu Lal, TC Taylor, Jean Micheal Ashby, Hector Alonso, Alice Li, Stephany Tzeng, John Laterra, Jordan J Green. Multipronged SMAD Pathway Targeting by LiPBAE miR-590-3p NanomiRs Inhibits Recurrent Glioblastoma Growth and Prolongs Survival [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: RNAs as Drivers, Targets, and Therapeutics in Cancer; 2024 Nov 14-17; Bellevue, Washington. Philadelphia (PA): AACR; Mol Cancer Ther 2024;23(11_Suppl):Abstract nr PR011.

HPB SO45 - Level 1 evidence comparing aggressive versus non-aggressive intravenous fluid therapy in acute pancreatitis

Abstract Background Fluid balance in the management of acute pancreatitis (AP) is challenging and has been described as a “double-edged sword” whereby adequate fluids are required to counteract systemic hypovolaemia whilst excessive fluids may exacerbate systemic oedema. Given that data generated from randomised studies are conflicting, the optimal rate and type of fluid resuscitation for AP are yet to be determined. We aimed to perform a comprehensive meta-analysis of all existing randomized controlled trials (RCTs) to evaluate comparative outcomes of aggressive versus non-aggressive intravenous fluid (IVF) therapy in patients with AP. Method A systematic search of electronic data sources and bibliographic reference lists were conducted. All RCTs reporting outcomes of aggressive versus non-aggressive IVF therapy in AP were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random-effects modelling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. Results Ten RCTs enrolling 993 patients with AP who received aggressive (n = 475) or non-aggressive (n = 518) IVF therapy were included. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR:2.68, P=0.0005) and longer length of stay (MD:0.94, P&amp;lt;0.00001). There was no statistically significant difference in mortality (RD:0.02, P=0.31), SIRS (OR:0.93, P=0.89), respiratory failure (OR:2.81, P=0.07), pancreatic necrosis (OR:1.98, P = 0.06), clinical improvement (OR:1.12, P=0.83), severe pancreatitis (OR:1.31, P=0.38) or AKI (OR:1.06, P=0.91). Subgroup analysis demonstrated higher morbidity and mortality with aggressive fluids in severe AP. Trial sequential analysis detected risk of type 2 error. Conclusion Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non-aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs.

Diagnosis of vascular lesions in the brain – comparing T_2 and FLAIR sequences

ABSTRACT Introduction: Vascular brain lesions refer to brain damage caused by problems with blood vessels and can include various disorders such as stroke, aneurysms, blood clots, and others. Because different brain tissues have different characteristic relaxation times, and the FLAIR sequence can also be used to deal with different tissue stresses. the sequence provides high intensity while the FLAIR sequence achieves complete saturation of cerebrospinal fluid. The objectives of this study are to compare the visualization of vascular lesions using and the FLAIR sequence and to determine which sequence provides a better depiction and additional information about vascular lesions. Research Methods: The study was designed as a retrospective descriptive study, conducted at the Private Healthcare Institution 'Medical Center' in Travnik using an MRI machine: MRI Siemens Avanto A + Tim + Dot System, with a strength of 1.5 T. The study involved 50 patients diagnosed with vascular lesions. Results: In the age group from 50 to 59 years, 7 patients with FAZEKAS 0 – 1 (46.66%), 4 patients with FAZEKAS 1 (26.66%), 3 patients with FAZEKAS 2 (20%) and one patient with FAZEKAS 3 (6.66%) were diagnosed. In the age group from 60 to 69 years, 6 patients with FAZEKAS 0 – 1 (28.57%), 6 patients with FAZEKAS 1 (28.57%), 6 patients with FAZEKAS 2 and 3 patients with FAZEKAS 3 (14.28%) were diagnosed. In the 70 to 79 age group, 2 patients were diagnosed with FAZEKAS 0 – 1 (14.28%), 5 patients were diagnosed with FAZEKAS 1 (35.71%), 5 patients were diagnosed with FAZEKAS 2 (35.71%) and 2 patients were diagnosed with FAZEKAS 3 (14.28%). Discussion: Several studies have been conducted to evaluate the sensitivity of and FLAIR sequences in the diagnosis of vascular lesions in the brain. In the mentioned studies, it was found that the FLAIR sequence possesses superior capabilities in identifying and better displaying vascular lesions compared to healthy brain tissue. After measuring lesions in all 50 patients enrolled in the study, they were divided by size into three different groups: Lesions smaller than 10 millimeters; Lesions larger than 10 millimeters and smaller than 20 millimeters; Lesions larger than 20 millimeters. After statistical processing of the examined sample within this study, it was found that the FLAIR sequence provides a better representation of vascular lesions in the brain compared to the sequence in all three different groups, and it is concluded that the differences are statistically significant in favor of the FLAIR sequence in all three observed lesion sizes. The prognostic value of FLAIR vascular hyperintensity still needs to be investigated. Future studies will determine in which settings the presence of FLAIR vascular hyperintensity can be used as valuable information for the clinician. FLAIR vascular hyperintensities indicate a risk of persistent vascular stenosis or occlusion, associated with an increased risk of future stroke. They also help identify patients with favorable collateral blood flow, who could benefit from aggressive revascularization therapy. Conclusion: Statistically, there was a difference in the better presentation of vascular lesions on the FLAIR sequence compared to the sequence. In some cases, a sequence may be sufficient but in most cases a FLAIR sequence is preferable. Although the noise level is higher on the FLAIR sequence compared to the standard sequence, the FLAIR sequence is more useful in detecting vascular lesions.

Challenges in metastatic hepatocellular carcinoma: beyond tumor stage in guiding treatment.

Extrahepatic metastases in hepatocellular carcinoma (HCC) often signify a poor prognosis. This case details the five-year survival of a patient with HCC and adrenal metastasis managed with an aggressive multimodal approach, including ablation, systemic therapy, and surgical resection. Despite therapeutic advances, metastatic HCC management remains a clinical challenge, underscoring the need for individualized treatment strategies beyond traditional staging systems. Further research is essential to determine the role of surgical resection and other treatment modalities in the metastatic setting.

CNSC-29. CIRCADIAN SIGNALING IN GLIOBLASTOMA SYNCHRONIZES TUMOR DAILY RHYTHMS AND REGULATES TUMOR PROGRESSION

Abstract Glioblastoma (GBM) is the most common primary brain tumor in adults with a poor prognosis despite aggressive therapy. A recent, retrospective clinical study found that administering Temozolomide in the morning increased patient overall survival by 6 months compared to evening. Previous work has shown that murine and human models of GBM have cell-intrinsic circadian rhythms in expression of the core clock genes Bmal1 and Per2. This suggests that GBM has circadian rhythms that entrain to the hosts’ central clock. Understanding the mechanisms underlying circadian entrainment and tumor growth in GBM is essential to determine whether regulation of tumor biology and susceptibility to therapies varies with time of day. Here, we tested the hypothesis that daily host signaling regulates tumor growth and synchronizes circadian rhythms in GBM. We found that GBM cells transduced with luciferase reporters to record clock gene expression have intrinsic circadian rhythms, with Bmal1 peaking 8-12 h before Per2 in murine and human cell lines in vitro and in vivo. Further, intrinsic circadian rhythms in clock gene expression in GBM entrain to the host through glucocorticoid signaling, regardless of tumor type or host immune status. We found daily glucocorticoids (i.e., Dexamethasone) promoted or suppressed GBM growth depending on time of day of administration and on the clock gene, Bmal1. Blocking circadian signals, like VIP or glucocorticoids, dramatically slowed GBM growth and disease progression. Our results suggest that GBM tumors entrain to the circadian circuit of the brain and depend on clock-controlled cues like VIP and glucocorticoids to grow at specific times of day. This work may inform personalized circadian medicine to improve individual GBM patient outcomes.

CSIG-20. LIPOCALIN-2 DRIVES CELL-INTRINSIC FUNCTIONS IN GLIOBLASTOMA

Abstract Glioblastoma (GBM) continues to persist despite aggressive therapies, many of which are cytotoxic, and therapeutic failure is driven, in part, by the tumor cell’s ability to evade multiple forms of cell death, including ferroptosis. Lipocalin-2 (LCN2) functions to sequester iron and is considered an inflammatory marker through its function of limiting iron for bacterial usage; it has also been described to have pro and anti-tumorigenic effects depending on environmental iron status. In previously published studies in brain metastases, LCN2 promotes tumor cell proliferation by sequestering iron for cancer cells growth and survival, but the mechanisms of how LCN2 contributes to GBM progression is unknown. LCN2 expression in patient data revealed that high LCN2 expression is associated with reduced survival in GBM patients. A survey of mouse glioma models demonstrated a range of LCN2 secretion across models with KR158 and CPA being high and medium LCN2 secretors. LCN2 short hairpin knockdown of KR158 and CPA and decreased tumor cell viability and proliferation. Furthermore, when both KR158 and CPA control versus LCN2 knockdown cells were orthotopically implanted into mice, survival was increased. To understand if LCN2 impacted cell death dynamics, we investigated various cell death mechanisms and found that LCN2 knockdown increases tumor susceptibility to ferroptotic death by sensitizing cells to lipid peroxidation as well as reducing key anti-ferroptotic proteins GPX4 and xCT. To elucidate downstream mechanisms, we performed a phosphorylation array and discovered that phosphorylation of AXL, which has recently been linked to ferroptosis, is decreased with LCN2 knockdown. Moreover, AXL phosphorylation was localized to the nucleus, indicating that LCN2 knockdown attenuates AXL processing and downstream signaling. Overall, these findings indicate that LCN2 in GBM promotes tumor cell growth through AXL signaling and evasion of ferroptotic death, ultimately revealing a novel signaling network that can be leveraged for future therapeutic development.

TMIC-46. TRANSCRIPTIONAL HETEROGENEITY AND MECHANISTIC PATHWAYS OF RECURRENT GLIOBLASTOMA: INSIGHTS FROM A PRE-CLINICAL RECURRENT TUMOR MODEL

Abstract Despite aggressive therapy combining surgical resection, radiation and chemotherapy, glioblastoma (GBM) almost always recurs. Currently, there is no standard treatment for recurrent GBM, and patient inclusion in clinical trials is based on the genetic and molecular profile of the primary tumor even though the effects of chemoradiation on the transcriptional subtype in matched primary and recurrent GBM remain largely understudied. Paralleling the GLASS consortium, we sought to perform a longitudinal assessment of GBM recurrence after therapy based on molecular subtype with the hypothesis that recurrent tumors exhibit a distinct transcriptional landscape different from treatment-naive tumors. To address this, we utilized primary tumor-derived glioma stem cells (GSCs) representing classical and proneural subtypes. We then undertook in vivo intracranial implantation studies and performed standard concomitant treatment that mimics the Stupp protocol. Upon bulk RNAseq data analyses of untreated (n=21) and recurrent tumors (n=17) we identified that while the molecular subtype of recurrent tumors does not change post therapy, their transcriptional profile is more heterogenous compared to untreated tumors for both subtypes. Hierarchical cluster analyses revealed distinct sub-clusters of recurrent tumors. Common mechanisms of recurrence include upregulation of angiogenesis pathways and PI3k/Akt/mTOR signaling pathways. Interestingly, recurrent tumors exhibit upregulation of genes involved in cellular metabolism and membrane transport/ potential. The source of heterogeneity in recurrent tumors in both subtypes appears to be due to the diversity in expression of gene sets involved in hallmark of cancer pathways such as cell cycle, Notch and Wnt signaling pathways and heterogeneity in oncogenic signatures and cell states resembling fetal or neural cells. Further research into the recurrent tumor microenvironment by spatial multi-omics approaches using this pre-clinical recurrent GBM model will elucidate the linkage between cellular as well as molecular heterogeneity and enable identification of targets that can help drive therapeutic decisions for recurrent GBM patients.

Nanoconjugate Carrying pH-Responsive Transferrin Receptor-Targeted Hesperetin Triggers Triple-Negative Breast Cancer Cell Death through Oxidative Attack and Assemblage of Pro-Apoptotic Proteins.

Triple-negative breast cancer (TNBC) is recognized as a major aggressive subtype of breast cancer due to its expeditious worsening growth, extensive metastatic capability, and recalcitrance to standard current treatments. Hesperetin (HSP), a natural bioflavonoid from citrus fruits, demonstrates pronounced anticancer efficacy, but its hydrophobicity limits its clinical development. The present study reports the fabrication of a biocompatible and pH-responsive transferrin (TF) receptor-targeted HSP-loaded poly(lactic-co-glycolic acid) (PLGA) nanobioconjugate (PLGA-HSP-TF NPs) and the exploration of its in vitro and in vivo antineoplastic potential. PLGA nanoparticles (NPs), PLGA-HSP NPs, and PLGA-HSP-TF NPs were synthesized and characterized by DLS, FTIR, FE-SEM, and 1H NMR spectroscopy. The stability and in vitro release profile of nanoparticles were inspected, and anticancer efficacy was scrutinized in terms of in vitro cytotoxicity, oxidative stress and apoptosis biomarkers, and cell cycle arrest. In vivo tumor regression and host survival studies were executed in Ehrlich ascites carcinoma (EAC) cell-bearing Swiss albino mice. The drug uptake of highly stable PLGA-HSP-TF NPs was accomplished effectively in MDA-MB-231 cells and showed the pH-dependent intracellular release of HSP, which generated excessive intracellular reactive oxygen species (ROS) that led to oxidative assault to the TNBC cells. This elevated ROS dropped the mitochondrial membrane potential and triggered apoptosis-mediated cell death by arresting the cell cycle at the G0/G1 phase. Furthermore, PLGA-HSP-TF NPs unveiled significant in vivo Ehrlich ascites carcinoma regression and host survival compared to free HSP with minimum toxicity at a minimum dose of 20 mg/kg body weight. The study divulges that PLGA-HSP-TF NPs may be an astounding anticancer nanocandidate for aggressive triple-negative breast cancer therapy.

External Scaffold for Strengthening the Pulmonary Autograft in the Ross Procedure.

Despite offering several potential benefits over standard prosthetic aortic valve replacement, the use of the pulmonary autograft has been limited to date due to concerns over the risk of pulmonary autograft expansion and the need for reintervention. Several techniques using materials with biomimetic potential have been developed to reduce this complication. The incidence, risk factors, and pathophysiology of pulmonary autograft dilatation are discussed in this article. This seminar will provide an overview of the techniques of external pulmonary autograft support and their advantages and limitations. It also considers future directions for further investigation and future clinical applications of external pulmonary autograft support. Dilatation of the autograft is more likely to occur in patients with aortic regurgitation and a dilated aortic annulus. External scaffolding may prevent autograft stretching and expansion in these specific cases. However, from a biomimetic point of view, any permanent scaffold potentially restricts the movement of the autograft root. This reduces some of the benefits associated with the use of autologous tissue, which is the priority of the Ross procedure. To address this issue, several bioresorbable matrices could be used to support the root during its initial adaptive phase. Control of blood pressure with aggressive therapy is the first line to avoid this problem in the first year after pulmonary autograft implantation, together with support of the annular and sinotubular junction in some selected cases. This is the best way to maintain stable autograft root dimensions while preserving root dynamics. However, to determine the efficacy of this combined external support and best medical management, it is important to perform regular imaging and clinical follow-up.