Progression Of Bone Lesions Research Articles

12214 Metastatic Functional Thyroid Carcinoma As An Unusual Cause Of Hyperthyroidism

Abstract Disclosure: S. Jimenez Salazar: None. N. Aristizabal Henao: None. C. Aguilar Londoño: None. N. Buitrago Gómez: None. S. Saldarriaga Betancur: None. D.L. Beltran: None. J.L. Torres: None. Background: Differentiated thyroid carcinoma (DTC) represents the most prevalent endocrine neoplasm. Less than 10% present distant metastases, with the lung (50%), and skeleton (25%) being the most frequently affected sites. The location of bone metastases predominates in the spine and pelvis; usually as osteolytic lesions, being more frequent in follicular thyroid cancer (FTC) (7-28%) than in patients with papillary thyroid cancer (PTC) (1.4-7%). In rare cases this metastasis can be functional and trigger a thyrotoxicosis syndrome with or without recombinant human TSH injections prior to therapy with 131-I. Clinical case: 59-year-old woman with a history of bone metastatic follicular thyroid cancer (FTC) presented with 1 month of palpitations, 4 kg weight loss, non-dysenteric diarrhea and progressive dyspnea. Her FTC had been diagnosed 8 years prior her consultation. In that time iodine refractoriness was considered due to the progression of bone lesions, and Sorafenib 800 mg per day was initiated, which was not tolerated due to severe dermatological manifestations, and the patient decided not to continue with TKI therapy. Since then, she has been treated with zoledronic acid and local radiotherapy as part of palliative care. On physical examination, she was tachycardic (150 bpm), and hypertensive (BP 160/100 mmHg). A suppressed TSH (<0.01 uUI/mL, n: 0.4-4 uUI/mL) with elevation of thyroid hormones (free T4 3.99 ng/dL, n: 0.8-2 ng/dL and total T3 480 ng/dL, n: 45-140 ng/dL) was documented, associated with a patient who had required a dose adjustment of levothyroxine from 700 mcg to 350 mcg weekly 2 months prior to admission. Additionally, she had a significantly elevated thyroglobulin (>5000 ng/mL, n: 0.1-64.1 ng/mL) with undetectable antithyroglobulin antibodies (1.09 UI/mL, n: 0-4.11 UI/mL). Considering the history of total thyroidectomy and the high tumor burden, secondary thyrotoxicosis due to functioning bone metastases of DTC was considered. Levothyroxine was discontinued, and propranolol was initiated for the control of adrenergic symptoms, along with methimazole, cholestyramine, and systemic steroids to control thyroid hormone production. 3 days after therapy adjustment dyspnea, palpitations, and thyroid function tests improved significantly (free T4 1.43 ng/dL, n: 0.8-2 ng/dL and total T3 178 ng/dL, n: 45-140 ng/dL). A new administration of therapy with 131-I 200 mCi was indicated. Antithyroid therapy and beta-blockers were continued with sustained biochemical control. Conclusion: Functional bone metastases of FTC can lead to high morbidity and mortality. Treatment consists of surgical cytoreduction of any large accessible metastatic lesion, therapy with 131-I, and high-dose antithyroid drugs to control hyperthyroidism. It is important to avoid the use of recombinant human TSH due to the risk of secondary thyrotoxicosis following its administration. Presentation: 6/2/2024

The Combined Intraosseous Administration of Orthobiologics Outperformed Isolated Intra-articular Injections in Alleviating Pain and Cartilage Degeneration in a Rat Model of MIA-Induced Knee Osteoarthritis

Background: Intra-articular (IA) platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) injections have shown efficacy and safety in treating osteoarthritis (OA). However, the effectiveness and mechanisms of combined intraosseous (IO) administration of these orthobiologics have yet to be explored. Purpose/Hypothesis: The purpose of this study was to evaluate the effect on pain, cartilage, synovium/infrapatellar fat pad (IFP), and subchondral bone in rat knee OA, comparing isolated IA with combined IA and IO (IA+IO) injections of PRP or BMAC. It was hypothesized that combined injections would be superior to sole IA injections. Study Design: Controlled laboratory study. Methods: A total of 48 rats were divided into 6 groups: sham (only joint puncture during OA induction with IA+IO saline injection treatment) and 5 groups with OA induction, control (IA+IO saline injection), PRP (IA PRP+IO saline injection), BMAC IA (IA BMAC+IO saline injection), PRP IA+IO (IA+IO PRP injection), and BMAC IA+IO (IA+IO BMAC injection). OA was induced by IA injection of monosodium iodoacetate (MIA). Rats were administered different orthobiologics according to their grouping 3 weeks after the MIA injection. Pain changes were evaluated using the weightbearing ratio assay at weeks 3, 4, 5, 7, and 9 after OA induction. Rats were euthanized at week 9 for gross, radiological, histological, immunohistochemical, and immunofluorescence assessments of cartilage, synovium, and subchondral bone. Results: Compared with the control group, all orthobiologics injection groups had reduced joint pain. Compared with IA injection, IA+IO injections provided superior pain relief by suppressing calcitonin gene-related peptide and substance P in both the synovium/IFP and subchondral bone. IA+IO injections slowed the progression of subchondral bone lesions by inhibiting CD31hiEmcnhi vessel formation and excessive osteoclast and osteoblast turnover while preserving subchondral bone microarchitecture, slowing cartilage degeneration. However, IA+IO injections did not outperform isolated IA injections in reducing synovitis and synovium/IFP fibrosis. Compared with PRP, BMAC exhibited superior inhibition of pain-related mediators, but no significant differences were observed in synovitis suppression, infrapatellar fat pad fibrosis, and subchondral bone protection. Conclusion: IA+IO injections of orthobiologics were more effective in relieving pain, slowing cartilage degeneration, and inhibiting abnormal vascularization and remodeling compared with isolated IA injections. BMAC showed superior pain relief in the synovium/IFP and subchondral bone compared with PRP. Further research is needed to optimize PRP and BMAC components for enhanced efficacy in OA management. Clinical Relevance: Our findings contribute to advancing the understanding of pain relief mechanisms and support the endorsement of IO injection of orthobiologics for the treatment of OA and joint pain.

Carboplatin in Patients With Metastatic Castration-Resistant Prostate Cancer Harboring Somatic or Germline Homologous Recombination Repair Gene Mutations: Phase II Single-Arm Trial.

Approximately 20%-25% of patients with metastatic castration-resistant prostate cancer (mCRPC) harbor a deleterious germline or somatic mutation in the homologous recombination repair (HRR) pathway genes, which is involved in the repair of double-stranded DNA damage. Half of these mutations are germline, while the remaining are exclusively somatic. While polyadenosine 5'diphosphoribose [poly (ADP-ribose)] polymerase inhibitors, such as olaparib and rucaparib, are effective in this subgroup, their widespread use is limited due to the associated high cost, especially in resource-constrained settings. Notably, platinum agents like carboplatin have exquisite sensitivity to cells with defective DNA repair machinery. Carboplatin, a conventional, inexpensive chemotherapeutic agent, offers a potential alternative treatment in such patients. Several retrospective small case series support this hypothesis. However, there are no prospective clinical trials of carboplatin in patients with mCRPC with HRR mutations. The primary objective is to assess the objective response rate of 3 weekly carboplatin treatments in patients with mCRPC harboring deleterious mutations in the HRR pathway genes and previously treated with a taxane or a novel antiandrogen agent. The secondary objectives include progression-free survival, health-related quality of life, and safety profile of carboplatin. Patients diagnosed with mCRPC harboring HRR pathway mutations previously treated with docetaxel or novel antiandrogen agents (abiraterone, enzalutamide, apalutamide, or darolutamide) or both will be eligible. Genes involved directly or indirectly in the HRR pathway will be tested. In this single-arm phase II study, we will screen approximately 200 patients to enroll 49 patients, and carboplatin (dosing at the area under curve=5) will be administered every 3 weeks until progression or intolerable side effects. The primary end point will be assessed as the proportion of patients with a reduction of serum prostate-specific antigen by more than 50% from enrollment. Secondary outcomes include progression-free survival-soft-tissue disease progression (by response evaluation criteria in solid tumors, version 1.1, and bone lesion progression using Prostate Cancer Clinical Trials Working Group 3 criteria), health-related quality of life during carboplatin treatment using the Functional Assessment of Cancer Therapy-Prostate questionnaire and the European Organisation for Research and Treatment of Cancer questionnaire and safety profile of carboplatin (National Cancer Institute's Common Terminology Criteria for Adverse Events version 5.0). The trial started enrollment in September 2023. This trial is ongoing, and 12 patients have been recruited to date. All 49 participants will be enrolled according to plan. This prospective phase II trial represents a critical step toward addressing the therapeutic gap in patients with mCRPC harboring HRR pathway mutations, particularly in demographic regions with limited access to poly (ADP-ribose) polymerase inhibitors. Outcomes from this study will inform clinical practice and guide future phase III randomized trials, ultimately improving patient outcomes globally. Clinical Trials Registry of India CTRI/2023/04/051507; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=Njc0NjU=&Enc=&userName=. DERR1-10.2196/54086.

Positron Emission Tomography-Computed Tomography and Magnetic Resonance Imaging Assessments in a Mouse Model of Implant-Related Bone and Joint Staphylococcus aureus Infection.

Osteomyelitis is an infection of the bone, associated with an inflammatory process. Imaging plays an important role in establishing the diagnosis and the most appropriate patient management. However, data are lacking regarding the use of preclinical molecular imaging techniques to assess osteomyelitis progression in experimental models. This study aimed to compare structural and molecular imaging to assess disease progression in a mouse model of implant-related bone and joint infections caused by Staphylococcus aureus. In SWISS mice, the right femur was implanted with a resorbable filament impregnated with S. aureus (infected group, n = 10) or sterile culture medium (uninfected group, n = 6). Eight animals (5 infected, 3 uninfected) were analyzed with magnetic resonance imaging (MRI) at 1, 2, and 3 weeks postintervention, and 8 mice were analyzed with [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)-computed tomography (CT) at 48 h and at 1, 2, and 3 weeks postintervention. In infected animals, CT showed bone lesion progression, mainly in the distal epiphysis, although some uninfected animals presented evident bone sequestra at 3 weeks. MRI showed a lesion in the articular area that persisted for 3 weeks in infected animals. This lesion was smaller and less evident in the uninfected group. At 48 h postintervention, FDG-PET showed higher joint uptake in the infected group than in the uninfected group (P = 0.025). Over time, the difference between groups increased. These results indicate that FDG-PET imaging was much more sensitive than MRI and CT for differentiating between infection and inflammation at early stages. FDG-PET clearly distinguished between infection and postsurgical bone healing (in uninfected animals) from 48 h to 3 weeks after implantation. IMPORTANCE Our results encourage future investigations on the utility of the model for testing different therapeutic procedures for osteomyelitis.

Breast Cancer Induced Bone Osteolysis Prediction Using Temporal Variational Autoencoders.

Objective and Impact Statement. We adopt a deep learning model for bone osteolysis prediction on computed tomography (CT) images of murine breast cancer bone metastases. Given the bone CT scans at previous time steps, the model incorporates the bone-cancer interactions learned from the sequential images and generates future CT images. Its ability of predicting the development of bone lesions in cancer-invading bones can assist in assessing the risk of impending fractures and choosing proper treatments in breast cancer bone metastasis. Introduction. Breast cancer often metastasizes to bone, causes osteolytic lesions, and results in skeletal-related events (SREs) including severe pain and even fatal fractures. Although current imaging techniques can detect macroscopic bone lesions, predicting the occurrence and progression of bone lesions remains a challenge. Methods. We adopt a temporal variational autoencoder (T-VAE) model that utilizes a combination of variational autoencoders and long short-term memory networks to predict bone lesion emergence on our micro-CT dataset containing sequential images of murine tibiae. Given the CT scans of murine tibiae at early weeks, our model can learn the distribution of their future states from data. Results. We test our model against other deep learning-based prediction models on the bone lesion progression prediction task. Our model produces much more accurate predictions than existing models under various evaluation metrics. Conclusion. We develop a deep learning framework that can accurately predict and visualize the progression of osteolytic bone lesions. It will assist in planning and evaluating treatment strategies to prevent SREs in breast cancer patients.

Follicular Lymphoma Response with CDK4/6 Inhibitor(Palbociclib) Utilized in the Setting of Metastatic Breast Cancer

INTRODUCTIONHere we report our clinical observation and first objective evidence of partial response seen in follicular lymphoma from the use of drug (palbociclib) that inhibits cyclin D-dependent kinases (CDK) CDK4 and CDK6. CASE HISTORYA 66 year old female with metastatic breast cancer in the bones and relapsing nodal follicular lymphoma (FL) was initiated on Palbocilib and fulvestrant for her breast cancer.The details of her Non-Hodgkin's lymphoma (NHL) history include her initial presentation in 2005 with large cell lymphoma. She underwent treatment with four cycles of R-CHOP and four cycles of RICE (dose of anthracycline was limited given prior exposure of doxorubicin administered for breast cancer). She achieved complete remission. The patient later relapsed with follicular lymphoma grade I/II in 2011 requiring treatment with six cycles BR(bendamustine, rituximab) followed by two years of R-maintenance. Her treatment completed in 2013. She remained in remission for the next two years and relapsed again in late 2015 with right breast mass and multiple lymph nodes above and below the diaphragm. Biopsy of breast mass and right axillary lymph nodes showed FL Grade IIIa.CD10+, Bcl-2+, Bcl-6+ and Cyclin D1 negative.The details of breast cancer include the initial diagnosis in 2003 stage T2N1 ER/PR positive (estrogen, progesterone), Her-2 was negative. She underwent treatment with lumpectomy, sentinel lymph node biopsy and axillary lymph node dissection. She also received Cyclophosphamide and doxorubicin (AC) for four cycles followed by paclitaxel for four cycles and five years of anastrazole. Later in 2013 as patient completed R-maintenance for the follicular lymphoma she presented with pathological fracture of T8 vertebral body. Biopsy confirmed metastatic breast cancer. CAT-scans showed extensive sclerotic bony metastasis consistent with metastatic breast cancer. The patient received hormonal therapy letrozole and zoledronic acid. The patient responded very well with decrease in breast tumor marker (CA 15-3) and improvement of skeletal pain.The patient progressed two years later in late 2015 with CAT-scan showing progression of sclerotic bone lesions with multiple new foci noted. The imaging also showed multiple areas of lymph nodes above and below diaphragm. Patient also developed palpable right breast mass 3cm and PET-scan showed multiple FDG-avid lymph nodes including bony sclerotic PET-avid lesion. The biopsy of breast mass and axillary lymph nodes showed FL. The radiological progression was also seen in the previously biopsy proven bony sclerotic lesion showing breast cancer. The plan was made to pursue treatment with breast cancer as patient had significant skeletal pain along with once again rise in tumor marker CA 15-3.Patient was initiated treatment on palbocilib and fulvestrant in early 2016. Three months later right breast nodal mass and axillary lymph node was not palpable. PET-scan showed decrease in the size and metabolic activity. Most of the lymph nodes showed shrinkage in size as well as SUV consistent with partial response. With respect to metastatic breast cancer tumor markers normalized and sclerotic foci in the bones also showed radiological improvement.To date patient continues to do well with respect to both malignancies. She has not required any treatment for the FL and does appear to maintain partial response from CDK4/6 inhibition. CONCLUSIONFL is a common and incurable form of NHL characterized by the translocation t (14;18) that results in increased expression of the anti-apoptotic BCL2 protein. Exactly what drives expansion of the malignant B-cells in FL is not clear. However recurrent genetic lesions targeting cell cycle control in FL have been reported including mutation in CYCLIN D3 gene, chromosomal gains of CDK4, losses of CDKN2a/b and RB1.We have seen clinical and radiological evidence of response with regard to FL while patient was on treatment with CDK4/6 inhibitor for the indication of metastatic breast cancer. Given that now we already have Bcl-2 inhibitor drug venetoclax which is approved for CLL, this early clinical observation leads us to hypothesize that it would be worth exploring the combination of CDK4/6 inhibition with BCl-2 inhibitor in FL for further exploration. DisclosuresNo relevant conflicts of interest to declare.

A possible way to prevent the progression of bone lesions in multiple myeloma via Src-homology-region-2-domain-containing-phosphatase-1 activation.

On the basis of our recent findings, in which multiple receptor-mediated mast cell functions are regulated via a common signaling cascade, we posit that the formation and functioning of osteoclasts are also controlled by a similar common mechanism. These cells are derived from the same granulocyte/monocyte progenitors and share multiple receptors except those that are cell-specific. In both types of cells, all known receptors reside in lipid rafts, form multiprotein complexes with recruited signaling molecules, and are internalized upon receptor engagement. Signal transduction proceeds in a chain of protein phosphorylations, where adaptor protein LAT (linker-for-activation-of-T-cells) plays a central role. The key kinase that associates LAT phosphorylation and lipid raft internalization is Syk (spleen-tyrosine-kinase) and/or an Src-family-kinase, most probably Lck (lymphocyte-specific-protein-tyrosine-kinase). Dephosphorylation of phosphorylated Syk and Lck by activated SHP-1 (Src-homology-region-2-domain-containing-phosphatase-1) terminates the signal transduction and endocytosis of receptors, resulting in inhibition of osteoclast differentiation and other functions. In malignant plasma cells (MM cells) too, SHP-1 plays a similar indispensable role in controlling signal transduction required for survival and proliferation, though BLNK (B-cell-linker-protein), a functional equivalent of LAT and SLP-76 (SH2-domain-containing-leukocyte-protein-of-76-kDa) in B cells, is used instead of LAT. In both osteoclasts and MM cells, therefore, activated SHP-1 acts negatively in receptor-mediated cellular functions. In osteoblasts, however, activated SHP-1 promotes differentiation, osteocalcin generation, and mineralization by preventing both downregulation of transcription factors, such as Ostrix and Runx2, and degradation of β-catenin required for activation of the transcription factors. SHP-1 is activated by tyrosine phosphorylationand micromolar doses (M-dose) of CCRI-ligand-induced SHP-1 activation. Small molecular compounds, such as A770041, Sorafenib, Nitedanib, and Dovitinib, relieve the autoinhibitory conformation. Activation of SHP-1 by M-dose CCRI ligands or the compounds described may prevent the progression of bone lesions in MM.

Implant-associated osteomyelitis: Development, characterisation, and application of a porcine model.

Implant-associated osteomyelitis: Development, characterisation, and application of a porcine model.

Survey of Post-Cranial Skeletal Pathology in Snakes

Previous reports on skeletal pathology in captive snakes did not clarify the relationship of lesions to captive or free-ranging status. In this study, post-cranial skeletons from 7,950 captive and free-ranging snakes in nine of the major North American collections were examined macroscopically, microscopically and radiologically for the presence of pathology. Micro-computerized tomography was performed on two skeletons on which surface microscopy failed to provide a definitive diagnosis. Osteomyelitis was identified in the vertebrae of 24 snakes and spondyloarthropathy in one snake. Neoplasia or congenital anomalies were not found. Osteomyelitis was four times as common in Viperidae than in Colubridae and twice as common as in Boidae, independent of captive or free-ranging status. A lytic lesion in the vertebrae of one snake was suggestive of fungal disease. The progression of bone lesions was greater in captive snakes, but the prevalence was independent of captive or free-ranging status. The results of this study indicate that bone alterations, previously proposed as neoplastic disease, in archival snake skeletons were most likely of infectious aetiology, and establish macroscopic examination as a useful technique for characterizing skeletal pathology in snakes.

Abstract P3-11-09: ARISTACAT - Aromatase inhibition plus minus saracatinib as advanced breast cancer therapy: A randomised phase II study of aromatase inhibition plus/minus the Src-inhibitor AZD0530 in post-menopausal women with advanced breast cancer

Abstract Background: Src, the first proto-oncogene to be described, is a non-receptor tyrosine kinase interacting with multiple oncogenic pathways, including cell proliferation, survival, angiogenesis and osteoclast activity. Src activation occurs in up to 40% of ER+ breast cancers, is linked with poor prognosis, and pre-clinically has been strongly implicated in endocrine resistance. Saracatinib (AZD0530) is a potent, oral selective Src inhibitor that enhances the anti-proliferative effect of endocrine agents in pre-clinical breast cancer models, preventing the development of endocrine-resistance and restoring endocrine sensitivity. In a murine model of prostate bony metastases saracatinib inhibits osteoclast activity, reducing bone resorption and the development and progression of bone lesions. Clinically, saracatinib is generally well-tolerated with mainly gastro-intestinal adverse events (AEs), clinically meaningful durations of stable disease as monotherapy, and partial responses observed in combination with other therapies. Methods: Multi-centre, placebo-controlled, double-blind, randomised phase II trial. Post-menopausal women with advanced/metastatic breast cancer suitable for 1st or 2nd second line hormonal treatment, were randomised to receive an aromatase inhibitor (AI) plus saracatinib 175mg mg/day or placebo. Patients were stratified as either (i) “AI-sensitive/naïve”, who received anastrazole 1mg daily ± saracatinib, or (ii) “prior-AI”, if they had progressed on a non-steroidal AI but were considered likely to retain some endocrine sensitivity, who received exemestane 25mg daily ± saracatinib. Other stratification factors were bone metastases, bisphosphonate use, performance status, and treatment centre. Treatment was until progression, intolerable toxicity or at the patient’s request. The primary endpoint was PFS; secondary endpoints were toxicity, ORR & OS; exploratory endpoints explored molecular correlates in on-treatment samples (including optional biopsies). Results: 140 patients were enrolled from 22 UK sites between August 2012 and April 2015 of whom 69 were in the “AI-sensitive/naïve” group and 71 in the “prior-AI” group; 134 patients were eligible for efficacy evaluation and 136 for safety. Interim safety data analyses by an IDMC identified no new safety signals. Treatment emergent AEs were generally low grade, the most frequent being fatigue (70%) and nausea (49%); AEs occurring significantly (p<0.05) more often with saracatinib were hypophosphataemia (40% vs 6%), rash (34% vs 12%), anorexia (43% vs 19%), vomiting (33% vs 15%) and diarrhoea (31% vs 16%). More patients receiving saracatinib had a dose reduction or stopped treatment due to toxicity (16% vs 10% and 5% vs 3%, respectively; n.s.). There was no indication of greater efficacy from the addition of saracatinib with respect to PFS (3.7 v 5.6 months; n.s.) or OS (24 vs 23 months; n.s.). ORR appeared lower with saracatinib (11% vs 31%) even when excluding non-evaluable patients. Effects were consistent in the “AI-sensitive/naïve” and “prior-AI” groups. Patients receiving saracatinib were no less likely to progress with bone metastases, while bisphosphonate use was associated with an increased PFS and OS across the trial population. Translational work underway includes assessing Src pathway suppression. Conclusions: Saractinib did not improve outcomes in post-menopausal women with advanced breast cancer treated with exemestane with numerically inferior p response rate and PFS, and no apparent beneficial effect on bone metastases. These data do not support further evaluation of saracatinib in combination with AIs. ARISTACAT - Abstract - San Antonio 2019 Citation Format: David Cameron, Stefan Symeonides, Murray Brunt, Peter Schmid, Simon Waters, Christopher Twelves, Peter Barrett-Lee, John Bartlett, Tammy Piper, Karen McAdam, Eve Macdonald Chisholm, Michelle Welsh, Robert Hill. ARISTACAT - Aromatase inhibition plus minus saracatinib as advanced breast cancer therapy: A randomised phase II study of aromatase inhibition plus/minus the Src-inhibitor AZD0530 in post-menopausal women with advanced breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-11-09.

Abstract 4850: The relevance of using proper preclinical models when developing therapeutics for localized or bone metastatic prostate cancer

Abstract Early stages of prostate cancer are sensitive to androgen deprivation therapy, but upon progression the disease develops to metastatic castration-resistant prostate cancer, where bone is the dominant metastatic site. Despite of recent advances in drug development, the advanced stage is still incurable. Tumor microenvironment in metastatic locations differs from the primary site and may cause resistance to used therapy and modulate tumor properties. Therefore, it is crucial to use proper models in preclinical drug development. Aim of this study was to establish predictive preclinical in vitro and in vivo prostate cancer models that can be used in drug development when targeting cancer cells or tumor microenvironment at different stages. Androgen receptor (AR) positive human prostate cancer cell line LNCaP was used in all studies. In the in vitro assay, the effects of the antiandrogen enzalutamide on viability of LNCaP cells was determined using CellTiter Glo assay in the presence and absence of a synthetic androgen R1881. In two in vivo studies, male NMRI nude mice were used. In a subcutaneous model, part of the mice received dihydrotestosterone (DHT) supplement prior to cancer cell inoculation. In a bone metastasis model, LNCaP cells were inoculated into tibia bone marrow. The mice were randomized to treatment groups based on similar serum PSA levels and cancer-induced changes in bone determined by X-ray imaging at 6 weeks after inoculation of the cancer cells. The mice were treated with 300 kBq/kg of Radium-223 dichloride or vehicle at 6 and 10 weeks. Bone lesions were followed by X-ray imaging during the study. The study was terminated at 12 weeks after inoculation of the cancer cells and the tibias were removed for histological analysis and AR staining. In the in vitro assay, 0.1 and 0.01 nM R1881 increased LNCaP cell viability, and enzalutamide reduced cell viability in the presence of R1881 compared to the group with only R1881. In the subcutaneous model, tumors formed within 2-3 weeks after inoculation and the maximum tumor volume was reached within 10-12 weeks. LNCaP tumors grew in NMRI nude mice without DHT supplement, but DHT supplement supported tumor growth. In the bone metastasis model, LNCaP tumors induced osteoblastic-mixed bone lesions without additional androgen supplement, and immunohistochemical staining demonstrated strong AR expression. Radium-223 dichloride reduced the progression of tumor-induced bone lesions, decreased serum PSA levels, and decreased tumor area analyzed by histology. This study showcases relevant models that can be used at different phases of preclinical drug development when evaluating efficacy or safety of new therapeutics as mono- or combination therapies. The choice of a preclinical model and key readouts should be carefully selected based on whether developing therapeutics for localized or metastatic prostate cancer. Citation Format: Tiina E. Kähkönen, Jenni H.E. Mäki-Jouppila, Mari I. Suominen, Jussi M. Halleen, Jenni Bernoulli. The relevance of using proper preclinical models when developing therapeutics for localized or bone metastatic prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4850.

Abstract 3936: Efficacy of single agent radium-223 in the syngeneic MBT-2 bladder cancer bone growth model in mice

Abstract Radium-223 dichloride (Ra-223, Xofigo®) is a targeted alpha therapy which prolongs the survival of castration-resistant prostate cancer (CRPC) patients with symptomatic bone metastases. As a calcium-mimetic, Ra-223 selectively binds to hydroxyapatite and targets areas of high bone turnover such as bone metastases. Here, we report the effects of Ra-223 on development and progression of osteolytic bone lesions and on survival in the syngeneic intratibial MBT-2 murine bladder cancer model in immunocompetent mice. Female 5-7-week-old C3H/HeNHsd mice were injected intratibially with 5x105 MBT-2 cells on day 0. The mice were stratified based on body weight (n=40 per group) on day 5 and Ra-223 (300 kBq/kg, i.v.) or vehicle control was administered on days 5, 33, and 61. The tumor-induced osteolytic lesion area was imaged using radiography on days 10, 18, 25, 76, and at sacrifice. The mice were sacrificed when they met the pre-defined sacrifice criteria (> 20% body weight loss, palpable tumor outgrowth from the bone or general deterioration of health status). The study was terminated on day 158. In this study, the first mice met the sacrifice criteria on study day 24 and the survival curves plateaued at 52% after 84 days in the control group and at 68% after 112 days in the Ra-223 treatment group. Survival on day 40 was significantly improved in the Ra-223 treatment group compared to the vehicle control (p< 0.001), but the effect was not statistically significant at the end of the study. Based on X-ray imaging 25 days after cancer cell inoculation, Ra-223 treatment also significantly decreased the bone lesion area compared to the vehicle treatment (p=0.0041). After initially sacrificing the mice with extensive bone lesions, tumor growth in bone was stabilized around day 25. The main reason for sacrifice at a later stage was breathing difficulties due to lung metastases, and in the Ra-223-treated mice only one mouse was sacrificed due to bone metastases. Ra-223 treatment was well-tolerated; no body weight loss was observed. In summary, radium-223 dichloride (Xofigo®) demonstrates moderate single agent in vivo efficacy in the intratibial MBT-2 murine bladder cancer model of osteolytic bone metastasis. Retaining a functional immune system in syngeneic mouse models is particularly relevant for the characterization of potential immune-stimulatory effects of Ra-223. The promising results obtained in this model warrant further investigation of Ra-223 in combination with immuno-oncological treatments like checkpoint inhibitors. Citation Format: Tiina E. Kähkönen, Mari I. Suominen, Jenni H. Mäki-Jouppila, Birgitta Sjöholm, Ilmari Ahonen, Dominik Mumberg, Karl Ziegelbauer, Jussi M. Halleen, Sanna-Maria Käkönen, Arne Scholz. Efficacy of single agent radium-223 in the syngeneic MBT-2 bladder cancer bone growth model in mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3936.

The treatment of vertebral metastases from renal cell carcinoma: a retrospective study.

Renal cell carcinoma (RCC) is among the ten most common cancers in both men and women. It comprises 2-3% of all malignancies. The most common site for metastasis from RCC is the lung (50% of patients), followed by the skeleton (20% to 50% of patients). We retrospectively reviewed our consecutive series of 63 patients surgically treated for spinal metastases from RCC. The surgical treatment for spinal metastases varied in each patient. Factors influencing the choice of surgery included age, disease status, symptoms, morbidity of the patient, the location, the number of repetitive lesions and the existence of extra-osseous metastases. For 42 patients (66.66%) the treatment included radiation two weeks after the surgical procedure. A total of 68 surgical procedures were performed in 63 patients. For all patients we collected data about type of RCC, locations of metastasis, type of spine metastasis, type of surgery and complications. In this way we had an exahustive vision of the natural history of this kind of patients. Spine metastatic RCC has a poor prognosis. The favorable prognostic factor is solitary spinal metastasis without involvement of visceral organs where the gold standard treatment is corpectomy en bloc. The negative prognostic factors are the presence of one or more pathological fractures and neurological deficits. Bisphosphonate as zoledronic acid reduce significantly skeletal morbidity and significantly prolong time to bone lesion progression in patients with spine metastases from renal cell carcinoma.

Abstract 381: PI3K inhibitor BAY 1082439 and radium-223 dichloride decrease tumor burden and tumor-induced bone formation in an established bone metastatic prostate cancer model in mice

Abstract Background and objective: Bone is the most common site of metastasis in prostate cancer (PCa) and results in significant morbidity and poor prognosis. Disseminated PCa cells conquer hematopoietic stem cell niches, and during outgrowth they induce osteoblasts to form new, disorganized bone. Also osteoclasts are activated at a varying degree. PI3K activation has important role in survival and proliferation of PCa cells, mediating critical signaling pathways involving tumor and stromal cell interaction in the bone microenvironment. BAY 1082439 is a highly selective and potent PI3K inhibitor currently in Phase I, with equipotent activity against PI3Kα and PI3Kβ isoforms. Radium-223 dichloride (ra-223/Xofigo) is alpha-emitting calcium mimetic that via efficient osteoaffinity provides targeted radiation therapy against bone metastases. We have previously reported that BAY 1082439 and ra-223 showed synergistic anti-proliferative and apoptosis-inductive effects in vitro in LNCaP PCa cells (Suominen et al, AACR Annual Meeting 2014). Here, we investigated the effects of BAY 1082439 and ra-223 as single agents and in combination in the osteoblastic LNCaP tumors in tibia of male nod.scid mice. Methods: Tumors were established 6 weeks after inoculation of LNCaP cells. Mice were randomized into four treatment groups (vehicle, ra-223; BAY 1082439 and ra-223 + BAY 1082439) based on serum PSA and bone lesion score. Treatments were continued for six weeks and the efficacy was assessed by the following endpoints biweekly and/or at the end of the study: PSA, bone formation marker PINP, bone lesions and bone volume (measured by microCT), and tumor and bone area by histological analysis. Results: Both ra-223 and BAY 1082439 monotherapies inhibited tumor growth (reduction 67.9%, p = 0.029 and 67.4%, p = 0.009, respectively). Furthermore, BAY 1082439 monotherapy treatment group displayed 68.8% of necrotic tumor, compared to 6.5% in the control group (p = 0.009). In the combination group, tumor growth was further suppressed (tumor reduction 89%, p = 0.005) and it is noteworthy that 60% of animals had no detectable tumors in histology. All treatments inhibited the tumor-induced bone formation compared to vehicle, and the combination treatment inhibited progression of bone lesions nearly completely. In conclusion, BAY 1082439 and ra-223 as monotherapies decreased tumor burden and tumor-induced bone reaction, and the observed effects were further enhanced by the combination treatment. Citation Format: Mari I. Suominen, Jukka Morko, Katja M. Fagerlund, Esa Alhoniemi, Dominik Mumberg, Karl Ziegelbauer, Jussi M. Halleen, Arne Scholz, Ningshu Liu. PI3K inhibitor BAY 1082439 and radium-223 dichloride decrease tumor burden and tumor-induced bone formation in an established bone metastatic prostate cancer model in mice. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 381.

Site‐Specific Deglucuronidation of Turmeric‐Derived Curcuminoids in Bone

IntroductionThe majority of women with advanced breast cancer (BCa) develop osteolytic bone metastases. Our laboratory has previously demonstrated that curcuminoids, bioactive components isolated from turmeric rhizomes, prevent the progression of osteolytic bone lesions in a murine xenograft model of human BCa bone metastasis and inhibit tumor cell secretion of TGFβ‐stimulated parathyroid‐related protein (PTHrP), a signaling pathway known to drive bone metastasis progression. In humans ingesting curcuminoid‐enriched turmeric dietary supplements, glucuronidated phase II metabolites of curcumin are the primary form detected in the circulation. This has given rise to the untested postulate that curcuminoids may be deglucuronidated at sites of action to form bioactive aglycone (free) curcumin. Studies were therefore performed to compare tumor cell (human MDA‐MB‐231 breast cancer cell [MDA])‐specific effects of glucuronidated curcumin (G‐CURC) vs. curcumin (CURC) in vitro and to assess site‐specific deglucuronidation of circulating G‐CURC in the bone microenvironment in the BCa bone metastases model.MethodsDose dependent effects of G‐CURC vs. CURC on Smad‐mediated TGFβ‐stimulated PTHrP secretion and their relative effects on constitutive Smad2 and 3 expression in MDA cells were determined by RIA and Western, respectively. G‐CURC and CURC levels were quantified directly, or after hydrolysis using β‐glucuronidase, by LC‐MS in either positive or negative modes in: 1) conditioned media of G‐CURC‐treated murine bone marrow (isolated from nude mice hind legs) or MDA BCa cells, or in 2) plasma and bone marrow specimens isolated from female nude mice treated in vivo with curcuminoids (100 mg/kg ip). Endogenous β‐glucuronidase enzyme was localized by immunohistochemical (IHC) staining in paraffin sections of decalcified metastases‐containing hind limbs of nude mice inoculated, via intracardiac injection 21 days previously, with MDA cells (1 × 105 cells).ResultsCURC dose‐dependently inhibited TGFβ stimulated PTHrP secretion from MDA cells and decreased constitutive Smad2 and 3 levels, while G‐CURC was without effect. G‐CURC levels in conditioned media after 4 hours of G‐CURC treatment of MDA cells were no different from levels detected in cell‐free media incubated under the same conditions. In contrast, G‐CURC levels were 37% lower (p < 0.05) in conditioned media obtained from bone marrow cells cultured under the same conditions. As has been reported in humans, the majority of circulating curcumin in mice was glucuronidated (94.5 ± 1.5%). Free curcumin levels were 4‐fold higher (p < 0.01) in the bone marrow (vs. plasma) of curcuminoid‐treated nude mice, representing 23.3 ± 5.2 % of total detectable curcumin (glucuronidated plus aglycone). Within the tumor/bone microenvironment, bone marrow cells expressed β‐glucuronidase, while MDA BCa tumor cells expressed little or no β‐glucuronidase.ConclusionResults from these studies suggest that G‐CURC may essentially act as a prodrug that is specifically activated (deconjugated) by murine bone marrow cells to form CURC, which can mediate anti‐tumor cell effects within bone that limit the progression of osteolytic human BCa metastases in turmeric‐treated mice. To our knowledge, these data provide the first evidence of bone‐specific targeting of active turmeric metabolites in vertebrates.Support or Funding InformationR01CA174926‐01, R01AT006896, and R03CA159382

Exercise intervention increases expression of bone morphogenetic proteins and prevents the progression of cartilage-subchondral bone lesions in a post-traumatic rat knee model

This study aimed to determine whether treadmill walking (TW) prevents the progression of post-traumatic osteoarthritic changes in cartilage-subchondral bone unit, and whether the exercise timing changes the exercise efficacy in destabilized medial meniscus (DMM) rat knees. Twelve-week-old male Wistar rats underwent DMM surgery on their right knees and sham surgery on their left knees and were assigned to either the sedentary (n=10) or walking (n=24) groups. The rats in the walking group were subjected to TW from day 2 through 4 weeks, from 4 through 8 weeks, or from day 2 through 8 weeks (n=8 per group). Osteoarthritic changes of cartilage and subchondral bone were assessed with micro-computed tomography, histology, and immunohistochemistry 8 weeks after surgery. TW prevented the progression of cartilage and subchondral bone lesions induced by the DMM, and increased bone morphogenetic protein (BMP)-2 and -6 expressions in superficial zone chondrocytes and bone-lining cells including osteoblasts. Furthermore, the TW-induced increase in BMPs varied with the exercise timing. Beginning TW 4 weeks after DMM surgery was the best option for increasing BMPs, coinciding with the most robust prevention of osteoarthritic changes. TW increased the expression of BMPs and prevented the progression of cartilage-subchondral bone lesions in rat knees with a DMM. Selective exercise timing may be a key factor in the development of an exercise regimen for preventing the progression of post-traumatic osteoarthritis (PTOA). Furthermore, exercise may have favorable effects even after the PTOA has been developed.

Guidelines for the management and treatment of periodic fever syndromes: Cryopyrin-associated periodic syndromes (cryopyrinopathies – CAPS)

ObjectiveTo establish guidelines based on cientific evidences for the management of cryopyrin associated periodic syndromes. Description of the evidence collection methodThe Guideline was prepared from 4 clinical questions that were structured through PICO (Patient, Intervention or indicator, Comparison and Outcome), to search in key primary scientific information databases. After defining the potential studies to support the recommendations, these were graduated considering their strength of evidence and grade of recommendation. Results1215 articles were retrieved and evaluated by title and abstract; from these, 42 articles were selected to support the recommendations. Recommendations1. The diagnosis of CAPS is based on clinical history and clinical manifestations, and later confirmed by genetic study. CAPS may manifest itself in three phenotypes: FCAS (mild form), MWS (intermediate form) and CINCA (severe form). Neurological, ophthalmic, otorhinolaryngological and radiological assessments may be highly valuable in distinguishing between syndromes; 2. The genetic diagnosis with NLRP3 gene analysis must be conducted in suspected cases of CAPS, i.e., individuals presenting before 20 years of age, recurrent episodes of inflammation expressed by a mild fever and urticaria; 3. Laboratory abnormalities include leukocytosis and elevated serum levels of inflammatory proteins; and 4. Targeted therapies directed against interleukin-1 lead to rapid remission of symptoms in most patients. However, there are important limitations on the long-term safety. None of the three anti-IL-1β inhibitors prevents progression of bone lesions.

Organ‐specific efficacy of HSP90 inhibitor in multiple‐organ metastasis model of chemorefractory small cell lung cancer

Small-cell lung cancer (SCLC) accounts for nearly 15% of lung cancer cases and exhibits aggressive clinical behavior characterized by rapid growth and metastatic spread to multiple organs. About 70% of patients with SCLC present with extensive disease and distant metastases at diagnosis. HSP90 is a 90-kDa molecular chaperone whose association is required for the stability and function of its numerous "client proteins." Here, we assessed the therapeutic potential of the HSP90 inhibitor 17-DMAG in SCLC. Notably, 17-DMAG hindered the viability of human SCLC cell lines-regardless of their chemosensitivity-via the decreased expression of client proteins, including the proto-oncogene c-Raf (also known as RAF1). In an in vivo imaging model of SCLC multiple-organ metastasis with the human SCLC cell line SBC-5, treatment with 17-DMAG remarkably inhibited the formation of metastatic sites in the liver, but was ineffective in hindering the progression of bone lesions. The latter was likely the result of activation of osteoclasts. IGF-1, which is supposed to be rich in bone environment, preserved c-Raf expression and maintained viability of SBC-5 cells treated with 17-DMAG. Furthermore, the combined use of a bisphosphonate with 17-DMAG significantly attenuated the progression of metastases in both the liver and the bone. These findings suggest that therapeutic effects of HSP90 inhibitors may be organ-specific and should be carefully monitored in SCLC clinical trials.

Diretrizes de conduta e tratamento de síndromes febris periódicas associadas à criopirina (criopirinopatias – CAPS)

ObjectiveTo establish guidelines based on cientific evidences for the management of cryopyrin associated periodic syndromes. Description of the evidence collection methodThe Guideline was prepared from 4 clinical questions that were structured through Pico (Patient, Intervention or indicator, Comparison and Outcome), to search in key primary scientific information databases. After defining the potential studies to support the recommendations, these were graduated considering their strength of evidence and grade of recommendation. Results1215 articles were retrieved and evaluated by title and abstract; from these, 42 articles were selected to support the recommendations. Recommendations1. The diagnosis of Caps is based on clinical history and clinical manifestations, and later confirmed by genetic study. Caps may manifest itself in three phenotypes: FCAS (mild form), MWS (intermediate form) and Cinca (severe form). Neurological, ophthalmic, otorhinolaryngological and radiological assessments may be highly valuable in distinguishing between syndromes; 2. The genetic diagnosis with NLRP3 gene analysis must be conducted in suspected cases of Caps, i.e., individuals presenting before 20 years of age, recurrent episodes of inflammation expressed by a mild fever and urticaria; 3. Laboratory abnormalities include leukocytosis and elevated serum levels of inflammatory proteins; 4. Targeted therapies directed against interleukin‐1 lead to rapid remission of symptoms in most patients. However, there are important limitations on the long‐term safety. None of the three anti‐IL‐1β inhibitors prevents progression of bone lesions.

Real-World Treatment Patterns in Men with Castration- Resistant Prostate Cancer Receiving Docetaxel.

Background: Docetaxel has been a standard of care for castration-resistant prostate cancer (CRPC) in the United States since 2004, yet little has been reported on its patterns of use in routine practice. To help understand these patterns, a retrospective study was conducted and is reported here. Methods: Medical records from 394 patients treated in the United States were reviewed. Data were collected by 48 physicians from oncology (patient N=344) and 8 physicians from urology (patient N=50) practices. Inclusion criteria were: CRPC diagnosed between 2004 and 2010; received docetaxel; discontinued docetaxel due to rising prostate-specific antigen (PSA), progression of bone lesions, or progression of nodal or visceral metastases. Data were collected from physicians using an internet-based case report form. We evaluated patient demographics, characteristics of the docetaxel regimen, and other treatments used until docetaxel discontinuation. Results: Patients had a mean [±SD] age of 66.5 [8.9] years, the majority (63%) were white, and geographic dispersion was similar to the US population. The majority of patients initiated docetaxel between 2008 and 2010. After CRPC diagnosis, 8% of patients had initiated another cancer-directed therapy before starting docetaxel. Most (78.9%) patients initiated docetaxel with prednisone, while 18.5% initiated docetaxel alone and 2.6% initiated with other medications. Half of patients initiated docetaxel within 1 month after CRPC diagnosis, while 25% started ≥6 months later. Other non-chemotherapy treatments used with docetaxel were hormonal therapy (22.8%), radiotherapy (17.3%), and surgery (4.1%). Most patients (75%) received ≥4 docetaxel cycles, half received ≥6 cycles, 25% received ≥8 cycles and 10% received ≥10 cycles. Increased tumor mass, with/without new bone lesions or rising PSA, was the most common reason for docetaxel discontinuation (74% of patients). Conclusions: Concordant with guidelines, docetaxel and prednisone was the preferred first-line chemotherapy regimen in CRPC patients reviewed for this study. However, one quarter of patients did not initiate docetaxel until ≥6 months after CRPC diagnosis and total exposure varied considerably, with only 10% receiving ≥10 cycles. Future studies are needed to describe specific reasons explaining timing of docetaxel initiation and duration of exposure in some CRPC patients.