Rhabdomyosarcoma

Insights into medication-induced liver injury: Understanding and management strategies

Drug-induced liver injury (DILI) has increasingly become a major concern in Western countries since the late 1960s, with an estimated annual incidence of 13.9-19.1 cases per 100,000 people. DILI is a significant cause of acute liver failure, exhibiting a high mortality rate of 10-50 %. Its etiology includes medications, herbal products, and dietary supplements, exacerbated by pre-existing liver conditions, sonorities, pregnancy, and nutritional deficiencies. It is categorized into intrinsic and idiosyncratic reactions. Intrinsic DILI, dose-dependent and predictable, is primarily caused by substances like paracetamol, which leads to liver toxicity through direct metabolic pathways. In contrast, idiosyncratic DILI is less common, unpredictable, and affects susceptible individuals, with non-steroidal anti-inflammatory drugs, antibiotics, and cardiovascular agents frequently implicated in hospitals. Oxidative stress, mitochondrial dysfunction, bile salt export inhibition, and stress on the endoplasmic reticulum are some DILI-related pathophysiology. Diagnosis relies on biochemical tests, serological markers, radiological investigations, and liver biopsy. Management strategies emphasize the identification and cessation of the offending drugs, supportive care, and specific treatment options targeted to the culprit drugs. Management depends on the severity and nature of the injury.

Parameningeal Rhabdomyosarcoma-Clinical Profile, Outcomes, and Prognostic Factors in Children Treated at a Single Center Over a Decade

BACKGROUND

Parameningeal rhabdomyosarcomas (PM-RMS) in children is challenging to treat. While a 10-year event-free survival (EFS) of 62% has been reported from high-middle income countries (HMICs) for localized disease, data is limited from low-middle income countries (LMICs). We studied the clinical profile, outcomes, and prognostic factors in PM-RMS.

MATERIALS AND METHODS

Children aged 15 years or younger with PM-RMS treated on a uniform chemotherapy protocol from January 2013 to December 2021 were retrospectively analyzed. Local therapy at 10 to 12 weeks of induction was radiotherapy (RT)+/-surgery, where possible, with early RT for intracranial extension (ICE).

RESULTS

Seventy-six patients with a median age of 6.7 years (range: 3.2 to 15 y), male to female ratio of 1.8:1 formed the study cohort. Eleven patients (14.5%) had metastasis (lungs: 8, bone: 2, and bone marrow: 1) and ICE was seen in 46.1% (n=35). Twenty-five patients (49.0%) had alveolar histology with PAX3/7 positive in 17/59 (28.8%). The median tumor size (t size ) at baseline was 5.2 cm (range: 1.2 to 12.8 cm). Seventy-one patients received RT and 5 also underwent surgery. At a median follow-up of 65 months (range: 53 to 76 mo) 4 year EFS, OS of the whole cohort were 47.3% (95% CI: 34.8%-58.8%), 51.7% (95% CI: 38.0%-64.0%), respectively. Four-year EFS, OS of the localized and metastatic cohort were 54.7% (95% CI: 41.3%-68.1%), 56.0% (95% CI: 42.0%-70.0%), and 9.1% (95% CI: 0%-26.5%), 18.2% (95% CI: 0%-47.8%), respectively. Metastases (HR: 3.38, 95% CI: 1.57-7.26, and P =0.002), t size (HR: 1.17, 95% CI: 1.02-1.34, and P =0.026) were prognostic for survival on multivariate analysis.

CONCLUSIONS

Survival of children with localized PM-RMS in our study is relatively fair compared with the reported literature probably due to the application of RT in all despite higher proportion of larger tumors, unfavorable sites of primary, and intracranial extension. Identification of high-risk subsets and optimizing current treatment strategies, both systemic and local therapy may partly improve outcomes.

Intranasal kisspeptin administration rapidly stimulates gonadotropin release in humans

BACKGROUND

Kisspeptin administration by intravenous or subcutaneous routes activates hypothalamic gonadotropin-releasing hormone (GnRH) neurons and is being developed to treat reproductive disorders. However, these invasive routes markedly limit patient acceptability and clinical use. Recent rodent data has identified a large GnRH population within the olfactory system communicating directly with hypothalamic GnRH neurons. Intranasal kisspeptin administration may be able to capitalise on this novel pathway and thus offer a potential non-invasive approach to stimulate reproductive hormones. Herein, we examine intranasal kisspeptin using human, pharmaceutical, and rodent studies.

METHODS

Reproductive hormone profiles were measured after intranasal kisspeptin administration in healthy volunteers and patients with reproductive disorders as part of a randomised, double-blinded, crossover, placebo-controlled clinical study. Pharmaceutical testing evaluated the chemical stability and nasal kisspeptin delivery, and rodent studies provided mechanistic insight.

FINDINGS

Intranasal kisspeptin-54 rapidly stimulates gonadotropin release in healthy men and women, and in patients with a common reproductive disorder (hypothalamic amenorrhoea), without any side effects or adverse events encountered. Specifically, intranasal kisspeptin (at 12.8 nmol/kg) induced clinically-significant mean maximal increases above baseline in serum luteinising hormone in all study groups: 4.4 ± 0.6 IU/L (mean difference = 3.1 IU/L [95% CI, 1.2-4.9], P = 0.002 vs. placebo) in healthy men; 1.4 ± 0.3 IU/L (mean difference = 1.0 IU/L [95% CI, 0.4-1.7], P = 0.004 vs. placebo) in healthy women; 4.4 ± 0.2 IU/L (mean difference = 4.3 IU/L [95% CI, 2.7-6.0], P < 0.001 vs. placebo) in patients with hypothalamic amenorrhoea. Kisspeptin-54 was delivered effectively via nasal spray and was stable for up to 60 days at 4 °C. Mirroring the human effects, intranasal kisspeptin-54 in adult C57BL/6J male mice stimulates luteinising hormone release. Further mechanistic insights reveal the accumulation of fluorescently-tagged kisspeptin in the olfactory epithelium, as well as the presence of kisspeptin receptors in olfactory bulb GnRH neurons, implicating the involvement of these extra-hypothalamic GnRH neurons in the pathway mediating intranasal kisspeptin's effects on reproductive hormones.

INTERPRETATION

We demonstrate the clinical potential for intranasal kisspeptin delivery as the first non-invasive method to robustly and safely stimulate gonadotropins with kisspeptin and potentially transform the management of reproductive disorders.

FUNDING

National Institute for Health and Care Research (NIHR)/NIHR Imperial Biomedical Research Centre/Medical Research Council (MRC).

Development of a national Distress Brief Intervention: a multi-agency service to provide connected, compassionate support for people in distress

BACKGROUND

Mental health problems, self-harm and suicide are major public health concerns. Following national strategic commitments to improve the response and follow-up support for adults in Scotland presenting to frontline services in emotional distress, this study describes the development of the first national Distress Brief Intervention, a multi-agency service to provide connected, compassionate support for people in distress.

METHODS

The six step Intervention Mapping protocol was used to account for the complexity of the intervention and to guide development, testing and implementation. Data/information sources comprised: literature and evidence review; delivery partner and stakeholder consultations (n = 19); semi-structured interviews and/or focus-groups with frontline services staff experienced in responding to distress (n = 8); interviews and/or focus groups with adults with experience of distress (n = 9); feedback from test training for staff (n = 16); self-assessed confidence ratings provided by staff immediately before and following training (n = 388).

RESULTS

We developed a time-limited, two-level, complex intervention for adults experiencing emotional distress, provided by 'frontline' statutory services (primary and acute healthcare, police, ambulance) and third-sector community organisations in Scotland. Intervention components included competency-based training programmes for staff, information, protocols and guidance for providers, personalised distress management planning and behaviour change tools. During the development phase, 525 intervention providers (n = 472 frontline statutory service staff; n = 53 third-sector community organisation staff) completed training programmes in four pilot areas in Scotland. Training evaluations from 388 providers (74%) indicated significantly greater confidence following training on key competencies.

CONCLUSIONS

A multi-agency national Distress Brief Intervention was systematically developed and implemented in a range of non-specialist frontline and community settings in Scotland. Up-take of training and evaluations of training indicate it is highly acceptable to potential providers and improves key competencies. Following independent evaluation, the Distress Brief Intervention has been rolled out nationally across the whole of Scotland, and has significant potential as a model of care and prevention internationally, including countries with low statutory health resources.

Radiation Therapy Dose Escalation Failed to Improve Local Control for Intermediate-Risk Rhabdomyosarcoma on ARST1431: A Report From the Children's Oncology Group

PURPOSE

To evaluate local failure (LF) rates for patients with intermediate-risk rhabdomyosarcoma treated on the Children's Oncology Group ARST1431 clinical trial, the first and largest international, phase 3 randomized study to use FOXO1 fusion status for risk stratification. To improve local control, radiation therapy (RT) dose was increased to 59.4 Gy for patients with tumors >5 cm and residual gross disease at the time of RT.

METHODS AND MATERIALS

For the 297 patients included, LF was defined as progression or relapse at the primary site. The rate of LF was calculated 3-years after enrollment.

RESULTS

LF for group 3, FOXO1 fusion-positive patients (n = 58) compared with fusion-negative patients (n = 175) was 10.7% versus 21.5%, respectively (P = .08). The LF rate for patients with tumors >5 cm at diagnosis (n = 180; 24.4%) was higher than that of patients with tumors ≤5 cm at diagnosis (n = 117; 9.8%), P = .002. The risk of LF for patients who received proton (n = 99) versus photon RT (n = 126) was not different (16.1% vs 15.9%, P = .8). For the 75 patients with tumors >5 cm at diagnosis and gross disease at the time of RT, the boost to 59.4 Gy did not improve the 3-year LF rate compared with that of patients who did not receive the boost (29.7% vs 16.1%, P = .6). For patients with group 3/4 disease, those who underwent delayed primary excision (n = 72) had a lower LF rate compared with those who had RT alone (n = 151) (5.8% vs 19.7%, P < .01).

CONCLUSIONS

On ARST1431, tumors >5 cm at diagnosis had poor local control despite dose escalation to 59.4 Gy. Proton and photon RT had equivalent local control. For select patients, delayed primary excision significantly improved local control.

Diagnosis and management of intraparenchymal rhabdomyosarcoma

BACKGROUND

Intracranial rhabdomyosarcomas represent a rare condition, posing a diagnostic challenge to physicians. Brain intraparenchymal rhabdomyosarcomas are exceptionally rare with poorly understood pathogenesis.

METHODS

Here we report the first adult case of intraparenchymal rhabdomyosarcoma (RMS) with brainstem and cranial nerve involvement. We conducted a literature search using Embase, MEDLINE, and PubMed for published cases of patients with rhabdomyosarcoma of the brain. The keywords used were 'rhabdomyosarcoma' combined with 'intraparenchymal', 'parenchymal', 'cerebral' or 'brain' for title/abstract. Included cases were adult patients (>18 years of age).

RESULTS

A 59-year-old man presents with multiple cranial nerve palsies. MRI revealed a solitary pontine lesion that was not responsive to steroids. No systemic lesions were identified with an extensive imaging workup. A wide range of serum and cerebrospinal fluid tests were non-diagnostic during a ten-month workup until, ultimately, the patient died as a result of aspiration pneumonia. At autopsy, pathological examination on whole-brain autopsy revealed RMS, centred in the left side of pons with extension to the left side of the midbrain and the right side of pons with multiple cranial nerve involvement. There are only 20 adult cases of primary intraparenchymal RMS reported in the literature. Our present case is the first reported adult RMS in this location, with novel molecular information, providing some insight into the pathogenesis of this rare diagnosis.

CONCLUSIONS

Intraparenchymal rhabdomyosarcoma without evidence of systemic primary disease is extremely rare, resulting in delayed diagnosis in some cases, particularly those not amenable to biopsy. The diagnostic challenge posed by this complementary case highlights the importance of maintaining a differential of neoplasm in the face of non-diagnostic investigations to the contrary.

Rhabdomyosarcoma Surgical Update

Rhabdomyosarcoma (RMS) tumors arise from mesenchymal tissue and represent half of pediatric sarcomas, which in turn make up 7% of pediatric tumors. Advances in local control therapy of RMS have improved outcomes after surgical resection of the primary tumor, either before or after induction chemotherapy, even in the setting of metastatic disease. The utilization of diagnostic core needle and sentinel node biopsy techniques for lymph node staging are becoming more widely used. Over the past several years, refinement of prognostic factors with adoption of fusion status instead of histology, and optimized risk stratification schemas have been developed to assure appropriate therapy. There have been efforts between North American and European surgical oncology cooperative groups to standardize the care we provide, and yet there are still some philosophical differences to overcome.

Epigenetic regulation of HOXA2 expression affects tumor progression and predicts breast cancer patient survival

Accumulating evidence suggests that genetic and epigenetic biomarkers hold potential for enhancing the early detection and monitoring of breast cancer (BC). Epigenetic alterations of the Homeobox A2 (HOXA2) gene have recently garnered significant attention in the clinical management of various malignancies. However, the precise role of HOXA2 in breast tumorigenesis has remained elusive. To address this point, we conducted high-throughput RNA sequencing and DNA methylation array studies on laser-microdissected human BC samples, paired with normal tissue samples. Additionally, we performed comprehensive in silico analyses using large public datasets: TCGA and METABRIC. The diagnostic performance of HOXA2 was calculated by means of receiver operator characteristic curves. Its prognostic significance was assessed through immunohistochemical studies and Kaplan-Meier Plotter database interrogation. Moreover, we explored the function of HOXA2 and its role in breast carcinogenesis through in silico, in vitro, and in vivo investigations. Our work revealed significant hypermethylation and downregulation of HOXA2 in human BC tissues. Low HOXA2 expression correlated with increased BC aggressiveness and unfavorable patient survival outcomes. Suppression of HOXA2 expression significantly heightened cell proliferation, migration, and invasion in BC cells, and promoted tumor growth in mice. Conversely, transgenic HOXA2 overexpression suppressed these cellular processes and promoted apoptosis of cancer cells. Interestingly, a strategy of pharmacological demethylation successfully restored HOXA2 expression in malignant cells, reducing their neoplastic characteristics. Bioinformatics analyses, corroborated by in vitro experimentations, unveiled a novel implication of HOXA2 in the lipid metabolism of BC. Specifically, depletion of HOXA2 leaded to a concomitantly decreased expression of PPARγ and its target CIDEC, a master regulator of lipid droplet (LD) accumulation, thereby resulting in reduced LD abundance in BC cells. In summary, our study identifies HOXA2 as a novel prognosis-relevant tumor suppressor in the mammary gland.

Primary ocular, adnexal, and orbital rhabdomyosarcoma: A review

We review the primary orbital, ocular, and adnexal rhabdomyosarcoma (RMS) spectrum of tumors and describe its clinicoradiological and histopathological features, molecular updates, management protocols, outcomes, and challenges. Despite being a favorable site, the prognosis remains dismal for cases of relapsing, refractory, and metastatic orbital RMS. A wide heterogeneity of data exists in terms of survival rates and treatment regimens spread across various geographic locations and age groups. Molecular cytogenetics is a crucial factor in both the diagnosis and effective management of RMS. Novel targeted therapy may play an integral role in avoiding treatment-related morbidity and mortality. Large-scale studies are warranted to formulate standardized regimens and uniformity, especially for advanced and metastatic cases.

XRCC4-related microcephalic primordial dwarfism: description of a clinical series of 7 cases, phenotype expansion and new diagnostic approaches

The non-homologous end joining (NHEJ) pathway is essential to repair DNA double-strand breaks. XRCC4 acts as a stabilizer of the DNA ligase LIG4 in the NHEJ process. In humans, XRCC4 pathogenic variants are responsible for a microcephalic primordial dwarfism syndrome (MPD). Currently, 17 patients have been reported with XRCC4-related MPD and we report 7 new patients from 6 different families, including one fetus. The patients present with short stature, severe microcephaly, neurodevelopmental disorder and additional features, such as transient increase in nuchal translucency, congenital glaucoma, thumb anomalies, hepatic steatosis, seizures, essential tremor and oligodontia which have not been previously described. Hyper- and hypopigmented skin macules, dermatofibrosarcoma, mandibular osteoid osteoma and pancytopenia are also new features, reminiscent of cancer susceptibility syndromes. Functional studies were performed on two patients carrying the known pathogenic p.(Trp43Arg) variant in homozygous state, using a fast, cost-effective and non-invasive approach on PBMCs: (1) Survival analyses after ionizing radiation confirm important radiosensitivity. (2) Flow cytometry showed the lack of TCR-Va7+ T-lymphocytes, suggesting recombination defect of V(D)J coding segments. (3) This was confirmed by multiplexed RT-PCR (PROMIDISα biomarker), analyzing the diversity of V(D)J coding segments in a subset of the TCRα repertoire. We therefore extend the phenotype of XRCC4-related MPD and suggest a combination of three functional assays, based on radiosensitivity and V(D)J recombination defect, to improve the interpretation of XRCC4 variants in fast, cost-effective and non-invasive manner. These findings will improve the diagnosis, genetic counselling, follow-up and management of these patients.

Role of exosomes in diagnosis, prognostication, and treatment of pediatric solid tumors

Cancer is the second leading cause of death in children, and solid tumors make up 30% of childhood cancers. Molecular profiling of pediatric solid tumors allows a personalized approach to therapy, but this approach mostly relies on surgical biopsy, which is invasive and carries the risk of complications. Liquid biopsy serves as a reliable alternative and a minimally invasive tool for diagnosing, prognosticating, and residual disease monitoring in childhood cancers. This review outlines the potential of exosomes as informative liquid biopsies in pediatric solid tumors. Studies highlighting the potential applications and clinical utility of exosomes and their molecular constituents as prognosticators and therapies in common childhood solid tumors, including neuroblastoma, medulloblastoma, sarcoma, and hepatoblastoma, have been overviewed. We also discuss the limitations and technical challenges of utilizing exosomes for pediatric solid tumors.

Diet intake and adherence to recommendations in women with gestational diabetes mellitus

BACKGROUND/OBJECTIVES

Gestational diabetes mellitus (GDM) is best managed via lifestyle changes. We aimed at investigating to which extent women with GDM adhered to dietary recommendations and to which extent an impact was observed on the glycaemic control compared to women without GDM.

SUBJECTS/METHODS

Women with overweight/obesity (n = 349) were recruited in early pregnancy. GDM was diagnosed with a 2-h oral glucose tolerance test in mid-or-early pregnancy (median 25.9 and 14.7 gestational weeks). Dietary assessments included an index of dietary quality (good ≥ 10 and poor < 10/15 scores) and 3-day food-diaries with nutrient intake calculated and dietary patterns identified. Glucose and insulin concentrations were analysed from blood samples collected in late pregnancy (after GDM diagnosis).

RESULTS

Women with GDM (n = 98) followed more often a healthier dietary pattern (62.2%) than women without GDM (49.0%, p < 0.05), but no difference in good dietary quality was seen (53% vs. 59.8%, p = 0.071). While the majority of women with GDM adhered to some recommendations, 51% to carbohydrate, 54.1% to total fat and 69.4% to sucrose, only 16.3% adhered to the protein and 4.1% to the fibre intake recommendations. Women with GDM had lower adherence to protein, total fat and fibre recommendations but higher adherence to that of sucrose than women without GDM (p < 0.05). A good dietary quality was associated with lower insulin and HOMA2-IR values (p < 0.05).

CONCLUSIONS

Adherence to dietary recommendations, particularly fibre and protein intake, is unsatisfactory in women with GDM. Overall dietary quality is related to better control of glucose metabolism proposing a target for dietary counselling.

Rewiring the fusion oncoprotein EWS/FLI1 in Ewing sarcoma with bivalent small molecules

Deregulated transcription is a defining hallmark of cancer, especially pediatric malignancies, which are frequently driven by fusion transcription factors. Targeting transcription factors directly has been challenging as they lack druggable pockets. Recently, chemically induced proximity has enabled the rewiring of transcriptional activators to drive expression of pro-apoptotic genes using bivalent small molecules. Targeting fusion transcription factors, such as EWS/FLI1 in Ewing sarcoma, with these compounds, may open new therapeutic avenues. Here, we develop a small molecule, EB-TCIP , that recruits FKBP12 F36V -tagged EWS/FLI1 to DNA sites bound by the transcriptional regulator BCL6, leading to rapid expression of BCL6 target genes. EB-TCIP activity is dependent on ternary complex formation and specific to cells that express FKBP-EWS/FLI1. This proof-of-concept study demonstrates that EWS/FLI1 can be relocalized on chromatin to induce genes that are ordinarily regulated by a transcriptional repressor. Insights herein will guide the development of bivalent molecules that rewire fusion transcription factors.

Improving prostate brachytherapy outcomes through MRI-Assisted dominant lesion dose painting

BACKGROUND

The aim of this study was to assess the feasibility of using magnetic resonance (MR) images to implement a dose painting (DP) approach in prostate high-dose-rate brachytherapy.

METHODS

The study included 45 patients with prostate tumors of varying grades, with the tumors (DILs) manually segmented with a 0.5 cm margin on T2W MR Images. The bladder, rectum, and urethra were considered as organs at risk (OARs) and treated using LLA300-KB plastic needles and the HDRplus treatment planning system. The patients received an external dose of 45 Gy and a boost dose based on the tumor's malignancy, with the dosimetric evaluations and radiobiological analysis performed according to the RTOG protocol and using the equivalent dose in 2 Gy fractions (EQD2).

RESULTS

Our study found no statistically significant differences in dose values for the rectum between the DP methods and conventional treatment planning for tumor grades 2 to 5 (p > 0.05). However, two patients with grade 5 tumors showed rectal V75cc values exceeding the limit with the DP method and a 43 Gy boost dose, although the average V75 remained below 1 cc. The analysis revealed no significant differences in bladder dose values between conventional treatment planning and DP methods for tumor grades 2 to 4 (p > 0.05). However, the mean V75cc of the bladder in grade 5 patients with a 43 Gy boost dose exceeded the permissible limit at 1.09. There was no significant difference in urethral V125cc values for patients with tumor grades 2 and 3 between both DP methods and conventional planning (p > 0.05). However, a significant difference was observed for patients with tumor grades 4 and 5. The average V125% and V150% of the whole prostate remained within the standard range of 50-65% and 20-35% respectively for all tumor grades, and both DP methods and conventional treatment planning were within acceptable limits. However, the average V125 and V150 DILs for all tumor grades exceeded the standard limits and showed a significant difference from conventional treatment planning (p < 0.05). Our results showed a significant difference in EQD2 values for the whole prostate and DIL in the DP method for all tumor grades (P < 0.05).

CONCLUSION

The DP approach offers individualized doses but may be limited by the proximity of DILs to OARs.

App- and Wearable-Based Remote Monitoring for Patients With Myasthenia Gravis and Its Specialists: Feasibility and Usability Study

Background

Myasthenia gravis (MG) is rare, chronic autoimmune disorder of the neuromuscular junction that requires specialized care and often lifelong treatment, facing challenges due to its rarity and the limited availability of specialists. Telemedical solutions in specialized centers hold considerable promise in bridging this gap by increasing access to this care to a broader patient population in a timely manner. However, there is no research regarding interventional remote care solutions in the field of MG to date.

Objective

This study aimed to assess the feasibility and usability among patients with MG and specialists of a telemedicine platform, tailored to patients with MG and designed to facilitate remote monitoring, treated in a specialized center.

Methods

The telemedicine platform consisted of an app for patients and a web-based portal for physicians. Over a period of 3 months, 30 patients continuously monitored their vital parameters through external devices, including a digital spirometer and a wearable (activity tracker). Furthermore, patients completed 7 different patient-reported outcome measures (PROMs) through the app at predefined intervals. Specialists could review this monitoring data and adjust therapy as necessary. In addition, communication between patients and physicians was facilitated through a chat module. Feasibility was evaluated by total adherence rates for completing PROMs within the app, alongside the collection of spirometry and wearable data. Furthermore, user satisfaction was assessed among both patients with MG and physicians at the end of study.

Results

Total adherence rates ranged from 74.3% (1830/2464) to 97.9% (327/334) across all data types, with the highest adherence observed for PROMs (1139/1179, 96.6%), followed by spirometry (293/334, 87.7%) and wearables (1830/2261, 80.9%). Notably, patients wore the wearable longer than required by protocol and conducted a higher number of spirometry measurements during the study than required per protocol (median 20 h/d [IQR 15-24] vs 14 h/d and median 49 [IQR 15-59] measurements vs 11 measurements, respectively). Technical issues and discomfort with wearables were factors affecting lower adherence in some patients. The System Usability Scale yielded a median score of 85 indicating "excellent usability." In addition, results from a more detailed user evaluation questionnaire showed high levels of user satisfaction among both patients and health care professionals across diverse categories, including their experience of the care program, communication, and evaluation of the program.

Conclusions

Remote monitoring of patients with MG through the telemedical platform demonstrated good feasibility and acceptability, as evidenced by above-average adherence rates and user satisfaction for both patients and physicians. The majority of patients wanted to continue using the app. These findings highlight the potential for user-friendly digital tools to enhance care for patients with MG, although addressing technical challenges and ensuring patient comfort with wearables are essential for optimal implementation. Further research involving larger cohorts and longer study duration is warranted to validate these findings.

Rhabdomyosarcoma of the Middle Ear and Mastoid in Children: Experience of the Beijing Children's Hospital-BCH

OBJECTIVES

To conduct a retrospective analysis of the clinical characteristics and prognosis of rhabdomyosarcoma of the middle ear and mastoid (MERMS) in children.

METHODS

Treatment and outcome of 37 children with MERMS from Beijing Children's Hospital (July 2016-April 2023) were evaluated.

RESULTS

The median age of this cohort was 54 months. Initially, 9 children were misdiagnosed with otitis media and/or granulomas, whereas 11 underwent anti-infective therapy. The disease manifested with a high level of local aggressiveness (T2; 83.8%), often accompanied by meningeal invasion (MI; 27 of 37), encompassing cranial base bone erosion (CBBE; 27 of 27), intracranial extension (ICE; 14 of 27), and cranial nerve paralysis (CNP; 22 of 27), with a predominance of facial nerve involvement in CNP cases. The primary treatment modality for this region was a combination of radiation and chemotherapy. The early response to neoadjuvant chemotherapy emerged as a prognostic factor, significantly impacting 5-year event-free survival (EFS) and overall survival (OS): complete response (CR), 85.7 and 100%; partial response (PR), 43.7 and 65.2%; and progressive disease/stable disease (PD/SD), 16.7 and 16.7% (p = 0.019 and 0.001, respectively). A total of 13 patients passed away, with 4 fatalities attributed to the dissemination of tumor cells in the cerebrospinal fluid and 9 resulting from intracranial progression that impacted the central nervous system. The 5-year OS and EFS were (67.1 ± 7.8%) and (51.1 ± 9.1%), respectively.

CONCLUSION

MERMS is a highly aggressive malignancy with complex clinical manifestations and frequent cranial nerve involvement. Early recognition, aggressive multimodal treatment, and close monitoring for treatment response are crucial for improving survival outcomes.

A Report of Two Cases of Embryonal Rhabdomyosarcoma: Diagnostic Insights From Pathology

Rhabdomyosarcoma (RMS) is a family of malignant soft tissue tumors derived from undifferentiated mesoderm that fails to differentiate into skeletal muscle. Embryonal RMS (ERMS) is the most common subtype of RMS in children and adolescents, particularly those under 10 years of age. It primarily arises in the head and neck region, genitourinary tract, or extremities. Histologically, it resembles developing skeletal muscle with anaplastic features. Diagnosis relies on a combination of imaging, histopathology, immunohistochemistry, and molecular studies, with specific genetic alterations noted in the literature. Effective treatment of pediatric RMS cases requires multimodal therapy, including surgery, chemotherapy, and radiotherapy, to achieve a favorable prognosis. We report two cases of ERMS diagnosed within a four-month period, where immunohistochemistry and molecular studies contributed to the diagnosis.

Exploring cutting-edge approaches in diabetes care: from nanotechnology to personalized therapeutics

Diabetes mellitus (DM) is a persistent condition characterized by high levels of glucose in the blood due to irregularities in the secretion of insulin, its action, or both. The disease was believed to be incurable until insulin was extracted, refined, and produced for sale. In DM, insulin delivery devices and insulin analogs have improved glycemic management even further. Sulfonylureas, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones are examples of newer-generation medications having high efficacy in decreasing hyperglycemia as a result of scientific and technological advancements. Incretin mimetics, dual glucose-dependent insulinotropic polypeptide, GLP-1 agonists, PPARs, dipeptidyl peptidase-4 inhibitors, anti-CD3 mAbs, glucokinase activators, and glimins as targets have all performed well in recent clinical studies. Considerable focus was placed on free FA receptor 1 agonist, protein tyrosine phosphatase-1B inhibitors, and Sparc-related modular calcium-binding protein 1 which are still being studied. Theranostics, stem cell therapy, gene therapy, siRNA, and nanotechnology are some of the new therapeutic techniques. Traditional Chinese medicinal plants will also be discussed. This study seeks to present a comprehensive analysis of the latest research advancements, the emerging trends in medication therapy, and the utilization of delivery systems in treating DM. The objective is to provide valuable insights into the application of different pharmaceuticals in the field of diabetes mellitus treatment. Also, the therapeutic approach for diabetic patients infected with COVID-19 will be highlighted. Recent clinical and experimental studies evidence the Egyptian experience. Finally, as per the knowledge of the state of the art, our conclusion and future perspective will be declared.

DNA methylation patterns are influenced by Pax3::Foxo1 expression and developmental lineage in rhabdomyosarcoma tumours forming in genetically engineered mouse models

Rhabdomyosarcoma (RMS) is a family of phenotypically myogenic paediatric cancers consisting of two major subtypes: fusion-positive (FP) RMS, most commonly involving the PAX3::FOXO1 fusion gene, formed by the fusion of paired box 3 (PAX3) and forkhead box O1 (FOXO1) genes, and fusion-negative (FN) RMS, lacking these gene fusions. In humans, DNA methylation patterns distinguish these two subtypes as well as mutation-associated subsets within these subtypes. To investigate the biological factors responsible for these methylation differences, we profiled DNA methylation in RMS tumours derived from genetically engineered mouse models (GEMMs) in which various driver mutations were introduced into different myogenic lineages. Our unsupervised analyses of DNA methylation patterns in these GEMM tumours yielded two major clusters, corresponding to high and no/low expression of Pax3::Foxo1, which mirrored the results for human FP and FN RMS tumours. Two distinct methylation-defined subsets were found for GEMM RMS tumours with no/low Pax3::Foxo1 expression: one subset enriched in Pax7 lineage tumours and a second subset enriched in myogenic factor 5 (Myf5) lineage tumours. Integrative analysis of DNA methylation and transcriptomic data in mouse and human RMS revealed a common group of differentially methylated and differentially expressed genes, highlighting a conserved set of genes functioning in both human RMS models and GEMMs of RMS. In conclusion, these studies provide insight into the roles of oncogenic fusion proteins and developmental lineages in establishing DNA methylation patterns in FP and FN RMS respectively. © 2025 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Local characterization of collagen architecture and mechanical properties of tissue engineered atherosclerotic plaque cap analogs

Many cardiovascular events are triggered by fibrous cap rupture of an atherosclerotic plaque in arteries. However, cap rupture, including the impact of the cap's structural components, is poorly understood. To obtain better mechanistic insights in a biologically and mechanically controlled environment, we previously developed a tissue-engineered fibrous cap model. In the current study, we characterized the (local) structural and mechanical properties of these tissue-engineered cap analogs. Twenty-four collagenous cap analogs were cultured. The analogs were imaged with multiphoton microscopy with second-harmonic generation to obtain local collagen fiber orientation and dispersion. Then, the analogs were mechanically tested under uniaxial tensile loading until failure, and the local deformation (strain) and failure characteristics were analyzed. Our results demonstrated that the tissue-engineered analogs mimic the dominant (circumferential) fiber direction of human plaques. The analogs also exhibited a physiological strain stiffening response, similar to human fibrous plaque caps. Ruptures in the analogs initiated in and propagated towards local high-strain regions. The local strain values at the rupture sites were similar to the ones reported for carotid human fibrous plaque tissue. Finally, the study revealed that the rupture propagation path in the analogs followed the local fiber direction. STATEMENT OF SIGNIFICANCE: Many cardiovascular events are triggered by mechanical rupture of atherosclerotic plaque caps. Yet, cap rupture mechanics is poorly understood. This is mainly due to the scarcity of plaques for high-throughput testing and the structural complexity of plaques. To overcome this, we previously developed tissue-engineered cap analogs. The current study characterizes (local) structural and mechanical properties of these cap analogs. Our findings show that: (1) cap analogs closely mimic human fibrous caps, including fiber orientation and strain stiffening responses; (2) structural and mechanical properties of cap analogs are associated, which provides critical information for understanding plaque rupture; and (3) cap ruptures commonly start in and propagate towards high-strain areas, indicating the potential use of strain measurements for cap rupture risk assessment.

Mesenchymal Neoplasms of the Bladder and Male Genital Tract, including the Perineum and Scrotum

Mesenchymal neoplasms of the bladder and male genital tract are uncommonly encountered in routine diagnostic practice and present diagnostic challenges. Here, I systematically survey mesenchymal tumors at each body site, including the spermatic cord, scrotum, and perineum. I provide a detailed overview of tumor types that specifically or most commonly occur in the bladder and male genital tract, including pseudosarcomatous myofibroblastic neoplasm of the bladder, proliferative funiculitis, paratesticular sclerosing rhabdomyoma, penile myointimoma, and so-called prostatic stromal tumors.

Primary Conjunctival Rhabdomyosarcoma Presenting as an Enlarging Papillomatous Lesion in a 3-Year-Old

This case report describes a rapidly growing conjunctival lesion in a 3-year-old patient, which was incompletely resected and diagnosed as rhabdomyosarcoma.

Self-care and health-related quality of life in Mexican older adults with type 2 diabetes

BACKGROUND

Type 2 diabetes (T2D) is one of the most prevalent chronic diseases in the world and represents one of the main risk factors for cardiovascular diseases. The evidence suggests that inadequate self-care behavior among patients with chronic diseases might negatively affect their health-related quality of life (HRQoL); however, the evidence in older adults with diabetes is inconclusive, and the information is scarce in the Mexican context. Therefore, this study aimed to determine self-care behavior and HRQoL in Mexican older adults with T2D and evaluate the association between both variables.

MATERIALS AND METHODS

An analytical cross-sectional design was used. Participants (n = 300) were recruited at six senior centers in Hidalgo, Mexico. The Self-Care Capacity and Perception Test for Older Adults and the brief version of the World Health Organization Quality of Life Scale (WHOQOL-BREF) were used to assess self-care behavior and HRQoL, respectively. The associations between the variables of interest were evaluated by logistic regression models adjusted for confounders.

RESULTS

Older adults with inadequate self-care behavior were more likely to have poor HRQoL in all domains of the WHOQOL-BREF: physical health [adjusted odds ratio (aOR) = 4.10; 95% CI = 1.59, 10.57], psychological health (aOR = 6.98; 95% CI = 2.41, 20.19), social relationships (aOR = 7.02; 95% CI = 2.64, 18.67), and environmental health (aOR = 4.25; 95%CI = 1.43, 11.50). Partially adequate self-care behavior also showed a significant association with poor HRQoL.

CONCLUSION

Self-care behavior was independently associated with HRQoL in Mexican older adults with T2D. Thus, it is important to plan awareness-raising interventions to improve self-care behaviors in older adults with chronic conditions.

Trastuzumab Decreases the Expression of G1/S Regulators and Syndecan-4 Proteoglycan in Human Rhabdomyosarcoma

Rhabdomyosarcoma (RMS), the most common soft tissue sarcoma in children, arises from skeletal muscle cells that fail to differentiate terminally. Two subgroups of RMS, fusion-positive and fusion-negative RMS (FPRMS and FNRMS, respectively), are characterized by the presence or absence of the PAX3/7-FOXO1 fusion gene. RMSs frequently exhibit increased expression of human epidermal growth factor receptor-2 (HER2). Trastuzumab is a humanized monoclonal antibody targeting HER2, and its potential role in RMS treatment remains to be elucidated. Syndecan-4 (SDC4) is a heparan sulfate proteoglycan (HSPG) affecting myogenesis via Rac1-mediated actin remodeling. Previously, we demonstrated that the SDC4 gene is amplified in 28% of human FNRMS samples, associated with high mRNA expression, suggesting a tumor driver role. In this study, after analyzing the copy numbers and mRNA expressions of other HSPGs in human RMS samples, we found that in addition to SDC4, syndecan-1, syndecan-2, and glypican-1 were also amplified and highly expressed in FNRMS. In RD (human FNRMS) cells, elevated SDC4 expression was accompanied by low levels of phospho-Ser179 of SDC4, leading to high Rac1-GTP activity. Notably, this high SDC4 expression in RD cells decreased following trastuzumab treatment. Trastuzumab decreased the levels of G1/S checkpoint regulators cyclin E and cyclin D1 and reduced the cell number; however, it also downregulated the cyclin-dependent kinase inhibitor p21. The level of MyoD, a transcription factor essential for RMS cell survival, also decreased following trastuzumab administration. Our findings contribute to the understanding of the role of SDC4 in FNRMS. Since HER2 is expressed in about half of RMSs, the trastuzumab-mediated changes observed here may have therapeutic implications.

The midline thalamic nucleus reuniens promotes compulsive-like grooming in rodents

Obsessive-compulsive disorder (OCD), a disabling and notoriously treatment-resistant neuropsychiatric disorder, affects 2-3% of the general population and is characterized by recurring, intrusive thoughts (obsessions) and repetitive, ritualistic behaviors (compulsions). Although long associated with dysfunction within the cortico-striato-thalamic-cortical circuits, the thalamic role in OCD pathogenesis remains highly understudied in the literature. Here, we identified a rat thalamic nucleus - the reuniens (NRe) - that mediates persistent, compulsive self-grooming behavior. Optogenetic activation of this nucleus triggers immediate, excessive grooming with strong irresistibility, increases anxiety, and induces negative affective valence. A thalamic-hypothalamic pathway linking NRe to the dorsal premammillary nucleus (PMd) was discovered to mediate excessive self-grooming behavior and render it a defensive coping response to stress, mirroring the compulsions faced by OCD patients. Given the close resemblance between this self-grooming behavior and the clinical manifestations of OCD, the results from this study highlight the role of NRe in mediating OCD-like compulsive behaviors. This can be attributed to NRe's position at the nexus of an extensive frontal-striatal-thalamic network regulating cognition, emotion, and stress-related behaviors, suggesting NRe as a potential novel target for intervention.

The Emerging Role and Clinical Significance of PI3K-Akt-mTOR in Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is a common soft tissue sarcoma primarily affecting children and young adults. This disease is more prevalent in children under 15, with two main types: embryonal Rhabdomyosarcoma (eRMS), which has a better prognosis, and alveolar Rhabdomyosarcoma (aRMS), which is more aggressive and associated with specific genetic alterations. The PI3K-Akt-mTOR pathway is often hyperactivated in RMS, contributing to cell proliferation, survival, and resistance to therapies. The presence of phosphorylated components of this pathway correlates with poor survival outcomes. Here, we discuss various therapeutic approaches targeting the PI3K-Akt-mTOR pathway. These include the use of specific inhibitors (e.g., PI3K inhibitors, Akt inhibitors) and combination therapies that may enhance treatment efficacy. Dietary supplements like curcumin and repurposed drugs such as chloroquine are also mentioned for their potential to induce apoptosis in RMS cells. We also emphasize the need for innovative strategies to improve survival rates, which have remained stagnant over the years. Targeting super-enhancers and transcription factors associated with RMS may provide new therapeutic avenues. Overall, this review underscores the critical role of the PI3K-Akt-mTOR pathway in RMS and the potential for targeted therapies to improve patient outcomes.

Analysis of clinicopathological characteristics in rhabdomyosarcoma and identification of risk factors for metastasis to the lung, bone, liver, and brain: a population-based cohort study

OBJECTIVE

In light of the incompletely defined metastatic patterns inherent to rhabdomyosarcoma (RMS), our objective was to analyze the clinicopathological attributes of various metastatic sites in patients afflicted with RMS. Additionally, we sought to identify population-level risk factors that contribute to metastasis in patients.

METHODS

Utilizing data from the Surveillance, Epidemiology, and End Results (SEER) database spanning from 2000 to 2017, our study included a cohort of 1,300 patients diagnosed with RMS, each presenting with specific instances of metastasis. Statistical comparisons of categorical variables between groups were conducted using the chi-squared test or Fisher's exact test. Survival curves were constructed employing the Kaplan-Meier method and their comparative analysis was conducted using the log-rank test. Identification of the risk factors associated with site-specific metastasis in patients diagnosed with RMS was undertaken through the application of multivariate logistic regression analysis.

RESULTS

The observed incidence rates of metastasis to the lung, bone, liver, and brain among patients diagnosed with RMS were 13.1, 12.3, 2.5, and 1.2% respectively. The presence of lung, bone, liver, and brain metastases in patients with RMS was associated with a statistically significant reduction in cancer-specific survival. Factors indicative of increased risk for the development of lung metastasis in patients with RMS include male gender (in comparison to female), larger tumor volume, and tumor location in unfavorable sites (as compared to favorable sites). Risk factors for the occurrence of bone metastasis were male (as compared to female), larger tumor volume, and alveolar RMS (as compared to embryonal RMS). The median CSS for patients diagnosed with RMS and presenting with lung, bone, liver, and brain metastases were 15, 19, 5, and 8 months, respectively.

CONCLUSION

Through an analysis of site-specific metastasis in patients diagnosed with RMS, we identified risk factors associated with lung and bone metastasis. These findings are of considerable significance for clinicians, are of considerable significance during the pre-treatment evaluation phase. The application of these findings has the potential to extend the survival duration of patients with RMS.

Paediatric urachal rhabdomyosarcoma: the role of radiotherapy about a case report and review

Introduction

This report discusses the case of a 10-year-old girl diagnosed with rhabdomyosarcoma (RMS) of the urachus, a rare form of soft tissue cancer in paediatric oncology. RMS, representing 3%-4% of paediatric cancers, arises from primitive muscle cells and requires a multidisciplinary treatment approach. The goal of this case is to enhance understanding of radiotherapy's role in treating RMS in children, particularly in rare sites like the urachus.

Case

The patient, with no significant medical history, presented with right lower abdominal pain and was found to have a large abdominal mass. Imaging revealed a massive necrotic tumour and pulmonary metastases. The tumour was initially deemed unresectable, and a biopsy confirmed RMS. Chemotherapy was initiated using the RMS 2005 protocol, which resulted in a 70% tumour reduction. Surgical resection was then performed, and the patient received radiotherapy targeting both the primary tumour and metastases. The treatment showed no significant side effects and follow-up for a year showed no signs of recurrence.

Discussion

RMS is a paediatric malignancy with poor survival rates in high-risk and recurrent cases. The urachal origin of RMS is extremely rare, with few cases reported in the literature. Management includes chemotherapy, surgery and radiotherapy. While no known tumour markers exist, associations with genetic conditions like neurofibromatosis and Li-Fraumeni syndrome have been observed. Treatment aims to cure the disease while minimizing morbidity, with surgery typically preceded by chemotherapy to reduce tumour size.

Conclusion

While RMS is the most common soft tissue tumour in children, urachal RMS remains rare. Treatment involves surgery and radiotherapy, but further research is needed to establish standardized treatment protocols for such tumours.

AURKB inhibition induces rhabdomyosarcoma apoptosis and ferroptosis through NPM1/SP1/ACSL5 axis

Rhabdomyosarcoma (RMS) is one of the most common solid tumors in children and adolescents. Patients with relapsed/refractory RMS have limited treatment options, highlighting the urgency for the identification of novel therapeutic targets for RMS. In the present study, aurora kinase B (AURKB) was found to be highly expressed in RMS and associated with unfavorable prognosis of patients. Functional experiments indicated that inhibition of AURKB significantly reduced RMS cell proliferation, induced apoptosis and ferroptosis, and suppressed RMS growth in vivo. The highly expressed AURKB in RMS contributes to the apoptosis and ferroptosis resistance of tumor cells through the nucleophosmin 1 (NPM1)/Sp1 transcription factor (SP1)/acyl-CoA synthetase long-chain family member 5 (ACSL5) axis. Furthermore, inhibition of AURKB exerted an anti-RMS effect together with vincristine both in vitro and in vivo, with tolerable toxicity. The above findings provide insights we believe are new into the tumorigenesis of RMS, especially with regard to apoptosis or ferroptosis resistance, indicating that AURKB may be a potential target for clinical intervention in patients with RMS.

CAR-CIK vs. CAR-T: benchmarking novel cytokine-induced killer cells as solid tumor immunotherapy in ErbB2+ rhabdomyosarcoma

Introduction

CAR-T cell therapy, though successful in hematologic malignancies, faces challenges in solid tumors due to limitations of autologous T cells. Cytokine-induced killer (CIK) cells can be given safely across allogeneic barriers and constitute alternative effector cells generated from healthy donors. CIK cells are a heterogenous population of predominantly T cells with a mixed natural killer (NK) phenotype and combine non-MHC-restricted cytotoxicity with potent anti-tumor capacity of the adaptive immune system. Here, we characterize and compare efficacy, phenotypic subpopulations and modes of action of CAR-CIK cells and conventional CAR-T cells from same-donor samples in ErbB2+ rhabdomyosarcoma (RMS).

Methods

To benchmark CAR-CIK against conventional CAR-T cells, effector cells were generated from same-donor samples and lentivirally transduced with a second generation CD28-CD3ζ CAR. Effector subpopulations and their dynamics upon target cell exposure were phenotypically characterized by flow cytometry. Efficacy was assessed in human ErbB2+ RMS cancer cell lines and primary patient samples in vitro and ex vivo using cytotoxicity and spheroid co-incubation assays. Modes of action were assessed by comparing cytokine secretion profiles using bead-based multiplexed flow cytometry and by liquid chromatography mass spectrometry whole cell proteomics. Finally, we used an in vivo model of RMS mimicking minimal metastatic residual disease to compare anti-tumor potency of CAR-CIK vs. CAR-T cells and to assess their target organ infiltration.

Results

In vitro assays demonstrated superior cytotoxicity of CAR-CIK cells against RMS cell lines and primary tumor samples. Long-term co-incubation with tumor spheroids led to expansion of CAR-CIK cells and enrichment of CD3+CD56+ TNK cells. CAR-CIK cell cytokine signature showed significantly increased secretion of effector molecules like interferon-γ, perforin and granulysin, and lower secretion of Th2 cytokines IL-2, IL-4 and IL-10. Whole cell proteomics showed corresponding upregulation of chemokine signaling and NK-cytotoxicity pathways in CAR-CIK cells. In NSG mice xenografted with ErbB2+ RMS, a single injection of either CAR-effector cells strongly impeded metastatic tumor development and significantly improved survival.

Conclusion

Our results demonstrate that CAR-CIK cells are at least equipotent to CAR-T cells. Combined with their favorable safety profile and allogeneic applicability, these findings position CAR-CIK cells as promising immune effectors for solid tumors.

Systemic sequelae and craniofacial development in survivors of pediatric rhabdomyosarcoma

INTRODUCTION

The aim of this study was to evaluate the systemic sequelae, as well as the dental and craniofacial development, of patients with rhabdomyosarcoma in relation to the treatment received and clinical-pathological variables.

MATERIALS AND METHODS

A retrospective cross-sectional study was performed. All individuals diagnosed with RMS between 1990 and 2022 were considered eligible. Cases who survived the primary tumor were included. Data were collected from medical records, and patients were called for clinical and radiographic examinations.

RESULTS

Thirty-eight patients were assessed, with a mean disease-free survival of 216.68 months (±84.99). The primary location of the tumor was mainly the head and neck region (57.9 %). All patients received chemotherapy, and 30 (78.9 %) also underwent radiotherapy. The most frequently observed sequela was sensory impairment, which was significantly associated with tumors in the head and neck (p < 0.05), as well as with the use of radiotherapy (p = 0.034). Root formation failure was observed in 60 % of cases, microdontia in 50 %, and delayed tooth eruption in 40 %. A convex profile was predominant (80 %), along with maxillary (50 %) and mandibular (80 %) retrusion and a skeletal class II diagnosis (60 %).

CONCLUSIONS

Late systemic, dental, and craniofacial developmental sequelae are observed in pediatric rhabdomyosarcoma survivors, especially in patients who underwent radiotherapy in the head and neck region. Younger individuals at the time of treatment are at greater risk of late sequelae.

Synthetic inhibition of SREBP2 and the mevalonate pathway blocks rhabdomyosarcoma tumor growth in vitro and in vivo and promotes chemosensitization

OBJECTIVE

The aim of the present study was to investigate the effects of targeting the mevalonate pathway (MVP) in rhabdomyosarcoma (RMS), a soft tissue tumor with a prevalence in young people.

METHODS

In silico analyses of RNA datasets were performed to correlate MVP with RMS patient survival. The sensitivity of RMS cell lines to MVP inhibitors was assessed in vitro by analysis of cell growth (crystal violet and clonogenic assays), cell migration (wound healing assay), cell survival (neutral red assay), and oxidative stress (ROS assay). The effects of MVP inhibitors were tested in vivo by analyzing RMS xenografts grown in NOD/SCID mice. Quantification of protein targets was performed using immunoblotting or immunohistochemistry analyses.

RESULTS

In silico analysis showed upregulation of sterol regulatory element-binding protein 2 (SREBP2) and MVP genes, including 3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR), farnesyl-diphosphate synthase (FDPS), squalene epoxidase (SQLE), which correlated with worse overall patient survival. Targeting of MVP in human RD and RH30 lines by inhibitors of SREBP2 (fatostatin), HMGCR (lovastatin and simvastatin), and FDPS (zoledronic acid) resulted in impaired cell growth, migration, and viability, and increased oxidative cell death in combination with actinomycin D. Conversely, cholesterol (CHO) supplementation enhanced cell growth and migration. Fatostatin and lovastatin produced rapid attenuation of Erk1/2 and Akt1 signaling in RMS lines, and oral administration of lovastatin reduced tumor mass growth of xenografted RD cells in NOD/SCID mice. Finally, we found that forced Akt1 activation in RD cells was sufficient to drive SREBP2, HMGCR and SQLE protein expression, promoting increased susceptibility to MVP inhibitors.

CONCLUSIONS

These data suggest that the Akt1, SREBP2 and MVP axis is critical for RMS tumor growth, migration, and oxidative stress protection primarily through maintaining adequate CHO levels that enable proper intracellular signaling. Therefore, stimulating CHO depletion via SREBP2 and MVP inhibition may represent a viable option to improve the combination therapy protocol, especially in pAkt1-positive RMS.

Head and Neck Rhabdomyosarcoma in Pediatric Patients: An International Collaborative Study

BACKGROUND

Rhabdomyosarcoma (RMS), a rare malignant tumor, frequently affects pediatric patients, with 35%-40% occurring in the head and neck. This study analyzes the clinicopathologic profile of pediatric head and neck rhabdomyosarcomas from Brazil, Guatemala, Mexico, and South Africa.

METHODS

We reviewed 44 cases from 10 Oral and Maxillofacial Pathology services, conducting immunohistochemical analyses of desmin, myogenin, Myo-D1, and Ki67, with quantification via QuPath software. Cases with ≥ 50% myogenin expression were tested for fusion status using AP2β, NOS-1, and HMGA2. Statistical analyses included the Kruskal-Wallis test for age and marker expression comparisons, Fisher's exact test for categorical variables, Spearman's rank correlation for marker relationships, and multinomial logistic regression to assess fusion status likelihood.

RESULTS

Cases were predominantly from Brazil (40.9%), followed by South Africa (27.3%), Guatemala (22.7%), and Mexico (9.1%). Two-thirds of patients were diagnosed in their first decade with no gender predilection. Nonparameningeal sites (45.5%) were more affected than parameningeal (40.9%) and orbital sites. Microscopically, embryonal RMS (77.3%) was most common, followed by alveolar (18.2%) and spindle cell (2.3%) tumors. Immunohistochemistry revealed positivity for myogenic markers, with significant differences in myogenin expression between embryonal and alveolar RMS variants (p < 0.05). Fusion status prediction identified two potential fusion-positive alveolar RMS cases, while all embryonal RMS and one alveolar RMS case appeared fusion-negative. Significant correlation with positive fusion status was found only between AP2β and NOS1 (p < 0.05).

CONCLUSION

Although there are slight clinical-demographic variations among pediatric head and neck rhabdomyosarcomas in these regions, identifying fusion status through immunohistochemistry remains a diagnostic challenge.

Detection of brain metastases from blood using Brain nanoMET sensor: Extracellular vesicles as a dynamic marker for metastatic brain tumors

Brain metastases account for a significant number of cancer-related deaths with poor prognosis and limited treatment options. Current diagnostic methods have limitations in resolution, sensitivity, inability to differentiate between primary and metastatic brain tumors, and invasiveness. Liquid biopsy is a promising non-invasive alternative; however, current approaches have shown limited efficacy for diagnosing brain metastases due to biomarker instability and low levels of detectable tumor-specific biomarkers. This study introduces an innovative liquid biopsy technique using extracellular vesicles (EVs) as a biomarker for brain metastases, employing the Brain nanoMET sensor. The sensor was fabricated through an ultrashort femtosecond laser ablation process and provides excellent surface-enhanced Raman Scattering functionality. We developed an in vitro model of metastatic tumors to understand the tumor microenvironment and secretomes influencing brain metastases from breast and lung cancers. Molecular profiling of EVs derived from brain-seeking metastatic tumors revealed unique, brain-specific signatures, which were also validated in the peripheral circulation of brain metastasis patients. Compared to primary brain tumor EVs, we also observed an upregulation of PD-L1 marker in the metastatic EVs. A machine learning model trained on these EV molecular profiles achieved 97% sensitivity in differentiating metastatic brain cancer from primary brain cancer, with 94% accuracy in predicting the primary tissue of origin for breast metastasis and 100% accuracy for lung metastasis. The results from this pilot validation suggest that this technique holds significant potential for improving metastasis diagnosis and targeted treatment strategies for brain metastases, addressing a critical unmet need in neuro-oncology.

Characterization of a pleomorphic rhabdomyosarcoma cell line

Pleomorphic rhabdomyosarcoma (PRMS) is an extremely rare soft tissue tumor with dismal prognosis that has a higher incidence in adults compared to the other RMS subtypes. The unique PRMS cell line BH1522 was established from a pleural effusion of a lung metastasis and the characteristics of this cell line were compared to two embryonal type RMS (ERMS) cell lines. The affected patient had been treated by surgery, several cycles of chemotherapy and thoracoscopy of the lung metastases. Chemosensitivity of the PRMS cell lines was checked using cytotoxicity assays and oncogene-related and phosphoproteins by Western blot arrays. The BH1522 cell line proved to be chemosensitive to conventional chemotherapeutics and the Son of Sevenless 1 homolog (SOS1) inhibitor BAY-293 that inhibited proliferation and suppressed MYC activity. Results of the novel functional BH1522 tests corroborate published tumor sequencing data that demonstrated alterations in receptor tyrosine kinase/MAPK, PI3K/AKT and mutated p53 as suspected drivers of malignant growth.

Comfortable knowing little about lymphoedema? A qualitative study of medical interns in Australia

OBJECTIVES

Knowledgeable doctors are needed for timely assessment, diagnosis and management of lymphoedema. This qualitative study explored the thoughts and feelings of Australian interns (medical graduates in their first postgraduate year) towards (i) their understanding of the lymphatic system and lymphoedema, (ii) curricula pertaining to lymphoedema within their Australian medical degree and (iii) how they perceive that their understanding and medical training in lymphoedema influence their clinical practice.

STUDY DESIGN AND METHODS

Qualitative semistructured interviews were conducted with interns employed within their first postgraduate year in Australia. Interviews were conducted via Microsoft Teams or telephone, video-recorded, transcribed verbatim and analysed using thematic analysis. Inductive (data-driven) codes identified in the data were organised into themes.

RESULTS

The overarching theme was one of ambivalence. Participants noted that they had knowledge gaps related to lymphoedema (theme 1), but were not concerned by them, as they did not consider lymphoedema a condition they were expected to know about at medical school or in clinical practice (theme 2). Furthermore, they questioned the relevance of lymphoedema to their role (theme 3) and they considered lymphoedema care to be the responsibility of others (theme 4).

CONCLUSION

These findings suggest a discord between what interns in this study recall being taught about lymphoedema and what current literature suggests newly graduated doctors should know. Future research is needed to explore the extent to which these findings extend to the perceptions of more senior doctors and how these findings impact the unmet needs of people with lymphoedema in Australia.

Myogenesis gone awry: the role of developmental pathways in rhabdomyosarcoma

Rhabdomyosarcoma is a soft-tissue sarcoma that occurs most frequently in pediatric patients and has poor survival rates in patients with recurrent or metastatic disease. There are two major sub-types of RMS: fusion-positive (FP-RMS) and fusion-negative (FN-RMS); with FP-RMS typically containing chromosomal translocations between the PAX3/7-FOXO1 loci. Regardless of subtype, RMS resembles embryonic skeletal muscle as it expresses the myogenic regulatory factors (MRFs), MYOD1 and MYOG. During normal myogenesis, these developmental transcription factors (TFs) orchestrate the formation of terminally differentiated, striated, and multinucleated skeletal muscle. However, in RMS these TFs become dysregulated such that they enable the sustained properties of malignancy. In FP-RMS, the PAX3/7-FOXO1 chromosomal translocation results in restructured chromatin, altering the binding of many MRFs and driving an oncogenic state. In FN-RMS, re-expression of MRFs, as well as other myogenic TFs, blocks terminal differentiation and holds cells in a proliferative, stem-cell-like state. In this review, we delve into the myogenic transcriptional networks that are dysregulated in and contribute to RMS progression. Advances in understanding the mechanisms through which myogenesis becomes stalled in RMS will lead to new tumor-specific therapies that target these aberrantly expressed developmental transcriptional pathways.

PAX3-FOXO1 drives targetable cell state-dependent metabolic vulnerabilities in rhabdomyosarcoma

PAX3-FOXO1, an oncogenic transcription factor, drives a particularly aggressive subtype of rhabdomyosarcoma (RMS) by enforcing gene expression programs that support malignant cell states. Here we show that PAX3-FOXO1 + RMS cells exhibit altered pyrimidine metabolism and increased dependence on enzymes involved in de novo pyrimidine synthesis, including dihydrofolate reductase (DHFR). Consequently, PAX3-FOXO1 + cells display increased sensitivity to inhibition of DHFR by the chemotherapeutic drug methotrexate, and this dependence is rescued by provision of pyrimidine nucleotides. Methotrexate treatment mimics the metabolic and transcriptional impact of PAX3-FOXO1 silencing, reducing expression of genes related to PAX3-FOXO1-driven malignant cell states. Accordingly, methotrexate treatment slows growth of multiple PAX3-FOXO1 + tumor xenograft models, but not fusion-negative counterparts. Taken together, these data demonstrate that PAX3-FOXO1 induces cell states characterized by altered pyrimidine dependence and nominate methotrexate as an addition to the current therapeutic arsenal for treatment of these malignant pediatric tumors.

Ocular Hypertropia Mimicking Inferior Rectus Palsy as an Atypical Presentation of Parameningeal Rhabdomyosarcoma in a Child

Introduction

Rhabdomyosarcoma (RMS) originates from undifferentiated mesenchymal cells that give rise to striated muscles. The symptoms of para-meningeal RMS often resemble those of allergic rhinosinusitis, including nasal congestion, mucus discharge, headache, and occasional nosebleeds. We report a child with atypical clinical presentation of ocular hypertropia secondary to para-meningeal RMS.

Case Presentation

A child presented with an upward deviation of the left eye. He had a history of blunt trauma to the face before 5 days. Computed tomography (CT) of the head revealed a soft tissue density involving the left maxillary sinus. The magnetic resonance imaging (MRI) showed a 37.6 mm x 38.4 mm lesion within the left maxillary sinus extending to the orbit, nasal cavity, and premaxillary and retro maxillary areas with a heterogeneous signal and mild heterogeneous enhancements. A biopsy and histopathology confirmed alveolar RMS. The child was treated with chemotherapy and radiotherapy.

Conclusion

Pediatric RMS with orbital extension mimicking benign conditions is challenging to diagnose and manage. Hypertropia following eye trauma can obscure severe underlying conditions, such as para-meningeal RMS. The inferior rectus lesion mimicking inferior rectus palsy stresses a thorough evaluation, including imaging and biopsy. Early and accurate diagnosis is crucial for the effective management of children with such aggressive malignancy.

Adult and pediatric orbital rhabdomyosarcoma: comparison of characteristics and outcomes

INTRODUCTION

Rhabdomyosarcoma (RMS) is a common pediatric orbital malignancy but is extremely rare in adults. This study assesses clinical and radiographic features, management, and outcomes in adult orbital RMS patients with comparison to pediatric patients.

METHODS

A retrospective chart review from 2000-2023 at Bascom Palmer Eye Institute was conducted evaluating patients aged 0 to 100-years-old with biopsy-confirmed orbital RMS. Medical records were reviewed for demographics, clinical features, imaging, histopathology, management, and outcomes. Statistical analysis was conducted with Mann-U Whitney and chi-squared testing.

RESULTS

Twenty-four patients were included, 15 children (mean age 6.4 ± 4.4 years) and 9 adults (35.7 ± 12.4 years). Patients in both groups presented with eyelid edema followed by proptosis with similar symptom duration (p = 0.31). Lesions were frequently located medially and inferiorly in both groups. At presentation, adults had significantly more metastatic disease in addition to bone, extraocular muscle, intracranial, and parameningeal involvement. The most common pediatric RMS subtype was embryonal (80%), whereas most adults were alveolar (77.8%, p = 0.001). Treatment in both groups frequently included chemoradiation. Both groups demonstrated similar local recurrence (p = 0.72), overall survival (p = 0.86), and ophthalmologic sequelae (p = 0.45), although pediatric follow-up duration was notably longer.

CONCLUSIONS

To our knowledge, this study is the largest report of adult orbital RMS from a single institution, highlights key comparisons in features and outcomes between adult and pediatric orbital RMS, and provides an updated literature review. While pediatric and adult orbital RMS clinical presentations are similar, adult disease more often demonstrates aggressive features, including alveolar subtype, local structure involvement, and lower disease-free survival.

Developmental Heterogeneity of Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is a pediatric embryonal solid tumor and the most common pediatric soft tissue sarcoma. The histology and transcriptome of RMS resemble skeletal muscle progenitor cells that have failed to terminally differentiate. Thus, RMS is typically thought to arise from corrupted skeletal muscle progenitor cells during development. However, RMS can occur in body regions devoid of skeletal muscle, suggesting the potential for nonmyogenic cells of origin. Here, we discuss the interplay between RMS driver mutations and cell(s) of origin with an emphasis on driving location specificity. Additionally, we discuss the mechanisms governing RMS transformation events and tumor heterogeneity through the lens of transcriptional networks and epigenetic control. Finally, we reimagine Waddington's developmental landscape to include a plane of transformation connecting distinct lineage landscapes to more accurately reflect the phenomena observed in pediatric cancers.

Quality, topics, and demographic trends of animal systematic reviews - an umbrella review

BACKGROUND

Animal systematic reviews are critical to inform translational research. Despite their growing popularity, there is a notable lack of information on their quality, scope, and geographical distribution over time. Addressing this gap is important to maintain their effectiveness in fostering medical advancements.

OBJECTIVE

This study aimed to assess the quality and demographic trends of animal systematic reviews in neuroscience, including changes over time.

METHODS

We performed an umbrella review of animal systematic reviews, searching Medline and Embase for reviews until January 27, 2023. A data mining method was developed and validated to automatically evaluate the quality of these reviews.

RESULTS

From 18'065 records identified, we included 1'358 animal systematic reviews in our study. These reviews commonly focus on translational research but with notable topical gaps such as schizophrenia, other psychiatric disorders, and brain tumours. They originate from 64 countries, with the United States, China, the UK, Brazil, and Iran being the most prolific. The automated quality assessment indicated high reliability, with F1-scores over 80% for most criteria. Overall, the reviews were of high quality and the quality improved over time. However, many systematic reviews did not report a pre-registered study protocol. Reviews with a pre-registered protocol generally scored higher in quality. No significant differences in quality were observed between countries.

CONCLUSION

Animal systematic reviews in neuroscience are of overall of high quality. Our study highlights specific areas for enhancement such as the recommended pre-publication of study protocols. It also identifies under-represented topics that could benefit from further investigation to inform translational research. Such measures can contribute to the effective translation of animal research findings to clinical applications.

Trends in childhood cancer: Incidence and survival analysis over 45 years of SEER data

BACKGROUND

The SEER Registry contains U.S. cancer statistics. To assess trends in incidence and survival and the impact of demographic factors among pediatric patients with cancer, we assessed nearly 5 decades (1975-2019) of data.

METHODS

All patients below the age of 20 with histology-confirmed malignancy were studied. Kaplan-Meier survival curves were generated to evaluate survival trends across treatment periods and ICCC classes. JoinPoint analysis was conducted to identify changes in incidence and survival.

RESULTS

The incidence of childhood cancer increased from 14.23 cases per 100,000 children in 1975-1979 to 18.89 in 2010-2019, with an average annual percent change of 0.73. This rise was more pronounced in several cancers, including leukemias, lymphomas, brain tumors, hepatic tumors, and gonadal germ cell tumors. Age-adjusted cancer mortality decreased from 4.9 to 2.3 per 100,000. Cancer-related mortality was consistently higher in boys than in girls, and in Black children than in White children. Survival significantly improved, with 5- and 10-year survival rates rising from 63.1% to 85.2% and from 58.8% to 82.7%, respectively. Leukemias showed a substantial increase in 5-year survival from 48.2% ± 1.7% to 85.1% ± 0.4% in 2010-2019. Lymphomas also showed significant improvement, with survival increasing from 72.9% ± 1.7% to 94.2% ± 0.3%. Despite these improvements, the survival of CNS tumors, bone tumors, and sarcomas remained suboptimal, with 5-year survival estimates of approximately 60%. Our joinpoint analysis confirmed our findings but revealed an interesting increase in the incidence of lymphomas limited to the years between 2005 and 2014.

CONCLUSION

This research elucidates advancements in survival among pediatric patients with cancer. The results offer critical perspectives on pediatric oncology, highlighting the imperative for ongoing innovation in therapeutics. Although the increase in incidence may partially stem from enhanced diagnostic capabilities and more comprehensive registration processes, the underlying causes remain unclear.

A review of deep learning for brain tumor analysis in MRI

Recent progress in deep learning (DL) is producing a new generation of tools across numerous clinical applications. Within the analysis of brain tumors in magnetic resonance imaging, DL finds applications in tumor segmentation, quantification, and classification. It facilitates objective and reproducible measurements crucial for diagnosis, treatment planning, and disease monitoring. Furthermore, it holds the potential to pave the way for personalized medicine through the prediction of tumor type, grade, genetic mutations, and patient survival outcomes. In this review, we explore the transformative potential of DL for brain tumor care and discuss existing applications, limitations, and future directions and opportunities.

Identifying Novel Genetic Markers in Pediatric Rhabdomyosarcoma

BACKGROUND/PURPOSE

Rhabdomyosarcoma risk stratification is traditionally determined by tumor histology and staging. Recent studies revealed the importance of molecular features in predicting prognosis. We investigated prognosis by age of onset and mutation incidence in rhabdomyosarcoma tumors.

METHODS

We retrospectively extracted clinical and genomic data from the Clinomics dataset (n = 641). Inclusion criteria was tumors with at least one gene mutation with >5% mutation incidence. Exclusion criteria were unknown risk stratification and age of onset. Statistical analysis was performed using ANOVA (p < 0.05) and Tukey's HSD to compare mutation incidence, EFS, and OS among age groups.

RESULTS

Among 641 patients with rhabdomyosarcoma, 8 of 39 screened genes had >5% mutation incidence: NRAS, BCOR, NF1, TP53, FGFR4, KRAS, HRAS, and CTNNB1. The final cohort consisted of 370 patients: 51 (Age: 0-2 Years), 140 (Age: 2-5 Years), 112 (Age: 5-12 Years) and 67 (Age: 12+). Later age of onset is associated with higher incidence of BCOR and HRAS mutations (p < 0.005, p < 0.001) and poorer EFS and OS (p < 0.05, p < 0.001). In patients with BCOR mutations, later age of onset is associated with poorer EFS and OS (p < 0.005, p < 0.001). NF1 mutations are equally distributed among age groups (p = 0.82), but later age of onset is associated with poorer EFS and OS (p < 0.005, p < 0.001).

CONCLUSION

In patients with at least one mutation in BCOR, NF1, TP53, KRAS, HRAS, or CTNNB1, later age of onset is associated with poorer prognosis. In patients with mutations only in tumor suppressor genes BCOR or NF1, later age of onset is associated with poorer prognosis.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE

II.

Rhabdomyosarcoma With EWSR1::NF2 Gene Fusion: A Case Report Potentially Expanding Its Genetic Spectrum

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children, presenting with heterogeneous clinical and molecular subtypes. While gene fusions are predominantly associated with alveolar RMS, spindle cell RMS, especially congenital and intraosseous variants, are also linked to specific gene fusions. Furthermore, recently, FGFR1 kinase-driven RMSs were published. Here, we describe a case of RMS harboring an EWSR1::NF2 gene fusion, a deletion-driven genetic alteration that has not been previously documented in RMS or other soft tissue tumors. The patient was a 29-year-old female who presented with a lobulated ankle mass. Histologic examination revealed a malignant round cell tumor extensively infiltrating large nerve bundles. Immunohistochemical analysis demonstrated rhabdomyoblastic differentiation, consistent with rhabdomyosarcoma. While some areas showed features resembling the sclerosing and others the embryonal subtypes, the overall findings were considered unclassifiable. Targeted RNA sequencing revealed EWSR1(exon 9):: NF2(exon 7) gene fusion, which was confirmed on whole genome and targeted DNA sequencing. The latter did not yield specific diagnostic insights but revealed mutations in TSC2 (p.T1330M), ZFHX3 (p.A301T), and a NOTCH3 rearrangement, all of unknown oncogenic significance. MYC gene amplification was detected, but there was no evidence of chromosome 8 amplification or chromosome 11p15 loss of heterozygosity. Whole genome sequencing revealed a low tumor mutation burden (2.69/Mb) and showed no other significant potentially oncogenic events. DNA methylation studies using dimensionality reduction and unsupervised clustering placed the case within the embryonal RMS subtype. Although the absence of other oncogenic driver alterations suggests that the fusion may have played a pivotal role in pathogenesis, we cannot exclude the possibility that it represents a passenger alteration rather than a true driver mutation. If the former is true, further studies will be required to determine whether this fusion represents a novel RMS subtype or a rare driver in existing subtypes of RMS.

Dependence of PAX3-FOXO1 chromatin occupancy on ETS1 at important disease-promoting genes exposes new targetable vulnerability in Fusion-Positive Rhabdomyosarcoma

Rhabdomyosarcoma (RMS), a malignancy of impaired myogenic differentiation, is the most common soft tissue pediatric cancer. PAX3-FOXO1 oncofusions drive the majority of the clinically more aggressive fusion-positive rhabdomyosarcoma (FP-RMS). Recent studies have established an epigenetic basis for PAX3-FOXO1-driven oncogenic processes. However, details of PAX3-FOXO1 epigenetic mechanisms, including interactions with, and dependence on, other chromatin and transcription factors, are incompletely understood. We previously identified a novel disease-promoting epigenetic axis in RMS, involving the histone demethylase KDM3A and the ETS1 transcription factor, and demonstrated that this epigenetic axis interfaces with PAX3-FOXO1 both phenotypically and transcriptomically, including co-regulation of biological processes and genes important to FP-RMS progression. In this study, we demonstrate that KDM3A and ETS1 colocalize with PAX3-FOXO1 to enhancers of important disease-promoting genes in FP-RMS, including FGF8, IL4R, and MEST, as well as PODXL, which we define herein as a new FP-RMS-promoting gene. We show that ETS1, which is induced by both PAX3-FOXO1 and KDM3A, exists in complex with PAX3-FOXO1, and augments PAX3-FOXO1 chromatin occupancy. We further show that the PAX3-FOXO1/ETS1 complex can be disrupted by the clinically relevant small molecule inhibitor YK-4-279. YK-4-279 displaces PAX3-FOXO1 from chromatin and interferes with PAX3-FOXO1-dependent gene regulation, resulting in potent inhibition of growth and invasive properties in FP-RMS, along with downregulation of FGF8, IL4R, MEST and PODXL expression. We additionally show that, in some FP-RMS, KDM3A also increases PAX3-FOXO1 levels. Together, our studies illuminate mechanisms of action of the KDM3A/ETS1 regulatory module, and reveal novel targetable mechanisms of PAX3-FOXO1 chromatin complex regulation, in FP-RMS.