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Lovvorn HN, Pierce J, Libes J, Li B, Wei Q, Correa H, Gouffon J, Clark PE, Axt JR, Hansen E, Newton M, O'Neill JA. Genetic and chromosomal alterations in Kenyan Wilms Tumor. Genes Chromosomes Cancer 2015; 54:702-15. [PMID: 26274016 PMCID: PMC4567398 DOI: 10.1002/gcc.22281] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 12/31/2022] Open
Abstract
Wilms tumor (WT) is the most common childhood kidney cancer worldwide and poses a cancer health disparity to black children of sub-Saharan African ancestry. Although overall survival from WT at 5 years exceeds 90% in developed countries, this pediatric cancer is alarmingly lethal in sub-Saharan Africa and specifically in Kenya (36% survival at 2 years). Although multiple barriers to adequate WT therapy contribute to this dismal outcome, we hypothesized that a uniquely aggressive and treatment-resistant biology compromises survival further. To explore the biologic composition of Kenyan WT (KWT), we completed a next generation sequencing analysis targeting 10 WT-associated genes and evaluated whole-genome copy number variation. The study cohort was comprised of 44 KWT patients and their specimens. Fourteen children are confirmed dead at 2 years and 11 remain lost to follow-up despite multiple tracing attempts. TP53 was mutated most commonly in 11 KWT specimens (25%), CTNNB1 in 10 (23%), MYCN in 8 (18%), AMER1 in 5 (11%), WT1 and TOP2A in 4 (9%), and IGF2 in 3 (7%). Loss of heterozygosity (LOH) at 17p, which covers TP53, was detected in 18% of specimens examined. Copy number gain at 1q, a poor prognostic indicator of WT biology in developed countries, was detected in 32% of KWT analyzed, and 89% of these children are deceased. Similarly, LOH at 11q was detected in 32% of KWT, and 80% of these patients are deceased. From this genomic analysis, KWT biology appears uniquely aggressive and treatment-resistant.
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Affiliation(s)
- Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Janene Pierce
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Jaime Libes
- Department of Pediatrics, University of Illinois College of Medicine, Peoria, IL.,Division of Hematology/Oncology, University of Illinois College of Medicine, Peoria, IL
| | - Bingshan Li
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Qiang Wei
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Hernan Correa
- Division of Pediatric Pathology, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Peter E Clark
- Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Jason R Axt
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Erik Hansen
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Mark Newton
- Division of Pediatric Anesthesia, Vanderbilt University School of Medicine, Nashville, TN
| | - James A O'Neill
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
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Libes J, Oruko O, Abdallah F, Githanga J, Ndung’u J, Musimbi J, Njuguna F, Patel K, White J, Axt JR, O’Neill JA, Shrubsole M, Li M, Lovvorn HN. Risk factors for abandonment of Wilms tumor therapy in Kenya. Pediatr Blood Cancer 2015; 62:252-256. [PMID: 25382257 PMCID: PMC4425627 DOI: 10.1002/pbc.25312] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Survival from Wilms tumor (WT) in sub-Saharan Africa remains dismal as a result of on-therapy mortality and treatment abandonment. Review of patients diagnosed from 2008 to 2011 in our Kenyan Wilms Tumor Registry showed a loss to follow up (LTFU) rate approaching 50%. The purpose of this study was to trace those LTFU, estimate the survival rate, and identify risk factors for treatment abandonment. PROCEDURE We administered a comprehensive survey to parents of patients with WT at the two largest referral hospitals in Kenya to identify barriers to care. We also telephoned families who had abandoned care to determine vital status and identify risk factors for treatment abandonment. RESULTS Of 136 registered patients, 77 were confirmed dead (56.7%), 38 remained alive (27.9%), and the vital status of 21 patients remains unknown (15.4%). After contacting 33 of the patients who either abandoned curative treatment (n = 34) or did not attend off-therapy visits (n = 20), the best estimate of 2-year overall survival of patients with WT in Kenya approaches 36%. Sixty-three percent of parents misunderstood treatment plans and 55% encountered financial barriers. When asked how to increase comfort with the child's treatment, 27% of parents volunteered improving inefficient services and 26% volunteered reducing drug-unavailability. CONCLUSIONS Treatment abandonment remains a significant problem contributing to increased mortality from WT in developing countries. This multi-center survey identified the barriers to treatment completion from the parental perspective to be lack of education about WT and treatment, financial constraints, need for quality improvement, and drug-unavailability. Pediatr Blood Cancer 2015;62:252-256. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Jaime Libes
- Department of Pediatrics, Vanderbilt University Children’s Hospital, Nashville, TN
| | - Oliver Oruko
- Department of Human Pathology, University of Nairobi, Nairobi, Kenya
| | - Fatmah Abdallah
- Department of Haematology and Blood Transfusion, University of Nairobi, Nairobi, Kenya
| | - Jessie Githanga
- Department of Haematology and Blood Transfusion, University of Nairobi, Nairobi, Kenya
| | - James Ndung’u
- Department of Surgery, Kenyatta National Hospital, Nairobi, Kenya
| | - Joyce Musimbi
- USAID-Ampath Partnership, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Festus Njuguna
- USAID-Ampath Partnership, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Kirtika Patel
- Department of Immunology, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - John White
- Vanderbilt Epidemiology Center, Vanderbilt Institute for Medicine and Public Health, Nashville, TN, USA
| | - Jason R. Axt
- Department of Pediatric Surgery, Vanderbilt University Children’s Hospital, Nashville, TN, USA
| | - James A. O’Neill
- Department of Pediatric Surgery, Vanderbilt University Children’s Hospital, Nashville, TN, USA
| | - Martha Shrubsole
- Vanderbilt Epidemiology Center, Vanderbilt Institute for Medicine and Public Health, Nashville, TN, USA
| | - Ming Li
- Department of Biostatistics, Vanderbilt University Children’s Hospital, Nashville, TN, USA
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Children’s Hospital, Nashville, TN, USA
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Libes JM, Seeley EH, Li M, Axt JR, Pierce J, Correa H, Newton M, Hansen E, Judd A, McDonald H, Caprioli RM, Naranjo A, Huff V, O'Neill JA, Lovvorn HN. Race disparities in peptide profiles of North American and Kenyan Wilms tumor specimens. J Am Coll Surg 2014; 218:707-20. [PMID: 24655859 DOI: 10.1016/j.jamcollsurg.2013.12.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 12/15/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Wilms tumor (WT) is the most common childhood kidney cancer worldwide and arises in children of black African ancestry with greater frequency and severity than other race groups. A biologic basis for this pediatric cancer disparity has not been previously determined. We hypothesized that unique molecular fingerprints might underlie the variable incidence and distinct disease characteristics of WT observed between race groups. STUDY DESIGN To evaluate molecular disparities between WTs of different race groups, the Children's Oncology Group provided 80 favorable histology specimens divided evenly between black and white patients and matched for disease characteristics. As a surrogate of black sub-Saharan African patients, we also analyzed 18 Kenyan WT specimens. Tissues were probed for peptide profiles using matrix-assisted laser desorption ionization time of flight imaging mass spectrometry. To control for histologic variability within and between specimens, cellular regions were analyzed separately as triphasic (containing blastema, epithelia, and stroma), blastema only, and stroma only. Data were queried using ClinProTools and statistically analyzed. RESULTS Peptide profiles, detected in triphasic WT regions, recognized race with good accuracy, which increased for blastema- or stroma-only regions. Peptide profiles from North American WTs differed between black and white race groups but were far more similar in composition than Kenyan specimens. Individual peptides were identified that also associated with WT patient and disease characteristics (eg, treatment failure and stage). Statistically significant peptide fragments were used to sequence proteins, revealing specific cellular signaling pathways and candidate drug targets. CONCLUSIONS Wilms tumor specimens arising among different race groups show unique molecular fingerprints that could explain disparate incidences and biologic behavior and that could reveal novel therapeutic targets.
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Affiliation(s)
- Jaime M Libes
- Division of Pediatric Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, TN
| | - Erin H Seeley
- Department of Biochemistry, Mass Spectrometry Research Center, Tissue Core, Vanderbilt University School of Medicine, Nashville, TN
| | - Ming Li
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jason R Axt
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Janene Pierce
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Hernan Correa
- Department of Pathology, Vanderbilt University School of Medicine, Nashville, TN
| | - Mark Newton
- Division of Pediatric Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN; Kijabe Mission Hospital, Kenya
| | - Erik Hansen
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; Kijabe Mission Hospital, Kenya
| | - Audra Judd
- Department of Biochemistry, Mass Spectrometry Research Center, Tissue Core, Vanderbilt University School of Medicine, Nashville, TN
| | - Hayes McDonald
- Proteomics Laboratory, Vanderbilt University School of Medicine, Nashville, TN
| | - Richard M Caprioli
- Department of Biochemistry, Mass Spectrometry Research Center, Tissue Core, Vanderbilt University School of Medicine, Nashville, TN
| | - Arlene Naranjo
- Children's Oncology Group Statistics and Data Center, Department of Biostatistics, University of Florida, Gainseville, FL
| | - Vicki Huff
- Children's Oncology Group Statistics and Data Center, Department of Biostatistics, University of Florida, Gainseville, FL
| | - James A O'Neill
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; Kijabe Mission Hospital, Kenya
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN.
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Murphy AJ, Axt JR, Crapp SJ, Martin CA, Crane GL, Lovvorn HN. Concordance of imaging modalities and cost minimization in the diagnosis of pediatric choledochal cysts. Pediatr Surg Int 2012; 28:615-21. [PMID: 22526551 PMCID: PMC4158915 DOI: 10.1007/s00383-012-3089-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE Given evolving imaging technologies, we noted significant variation in the diagnostic evaluation of pediatric choledochal cysts (CDC). To streamline the diagnostic approach to CDC, and minimize associated expenses, we compared typing accuracy and costs of ultrasound (US), intraoperative cholangiography (IOC), and magnetic resonance cholangiopancreatography (MRCP). METHODS Records of 30 consecutive pediatric CDC patients were reviewed. Blinded to all clinical data, two pediatric radiologists reviewed all US, MRCPs, and IOCs to type CDCs according to the Todani classification. When compared with pathologic findings, the concordance between and accuracy of each diagnostic test were determined. Inflation-adjusted procedure charges and collections for imaging modalities were analyzed. RESULTS Mean typing accuracy overlapped for US, IOC, and MRCP. Inter-rater reliability was 87 % for US (κ = 0.77), 80 % for IOC (κ = 0.62), and 60 % for MRCP (κ = 0.37). MRCP procedure charges ($1204.69) and collections ($420.85) exceeded IOC and US combined ($264.80 charges, p = 0.0002; $93.40 collections, p = 0.0021). CONCLUSION Our data support the use of US alone in the diagnosis of pediatric CDC when no intrahepatic biliary ductal dilatation is visualized. However, when dilated intrahepatic ducts are encountered on US, MRCP should be utilized to distinguish a type I from a type IV CDC, which may alter the operative approach.
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Affiliation(s)
- Andrew J Murphy
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232-9780, USA.
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Axt JR, Murphy AJ, Arbogast PG, Lovvorn HN. Volume-outcome effects for children undergoing resection of renal malignancies. J Surg Res 2012; 177:e27-33. [PMID: 22541281 DOI: 10.1016/j.jss.2012.03.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/17/2012] [Accepted: 03/28/2012] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Adults undergoing oncologic resections at low-volume centers experience increased perioperative morbidity and mortality. The volume-outcome effect has not been extensively studied in pediatric oncologic resections. METHODS To clarify volume-outcome effects in pediatric oncologic resections, we analyzed resection of renal malignancies in children less than 15 y of age. We conducted a cross-sectional analysis of hospital discharges included in the health care utilization project kids' inpatient database from 1997 to 2009, examining in-hospital operative complications, length of stay (LOS), and inflation-adjusted hospital charges. Hospital volume was expressed as low (n = 1-2), medium (n = 3-4), and high (n > 4) annual volume of resections. RESULTS One thousand five hundred thirty-eight patients underwent renal malignancy resection. Of these, 527 patients had resection in low-, 422 in medium-, and 589 in high-volume hospitals. Relative to low-volume hospitals, those resected in medium-volume hospitals had an odds ratio of 0.62 (95% confidence interval 0.39-0.99, P = 0.046) for operative complication and those in high-volume hospitals had an odds ratio of 1.02 (95% confidence interval 0.63-1.65, P = 0.95). There was no detectable association with LOS (P = 0.113) or inflation-adjusted charges (P = 0.331). CONCLUSIONS The number of complications, total charges, and LOS attributable to resection of a childhood renal malignancy did not differ among high-, medium-, or low-operative volume hospitals, although oncologic outcomes could not be determined because of the limited nature of this administrative database.
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Affiliation(s)
- Jason R Axt
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee 37232-9780, USA.
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Murphy AJ, Axt JR, de Caestecker C, Pierce J, Correa H, Seeley EH, Caprioli RM, Newton MW, de Caestecker MP, Lovvorn HN. Molecular characterization of Wilms' tumor from a resource-constrained region of sub-Saharan Africa. Int J Cancer 2012; 131:E983-94. [PMID: 22437966 DOI: 10.1002/ijc.27544] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 03/05/2012] [Indexed: 11/10/2022]
Abstract
Sub-Saharan African children have an increased incidence of Wilms' tumor (WT) and experience alarmingly poor outcomes. Although these outcomes are largely due to inadequate therapy, we hypothesized that WT from this region exhibits features of biological aggressiveness that may warrant broader implementation of high-risk therapeutic protocols. We evaluated 15 Kenyan WT (KWT) for features of aggressive disease (blastemal predominance and Ki67/cellular proliferation) and treatment resistance (anaplasia and p53 immunopositivity). To explore the additional biological features of KWT, we determined the mutational status of the CTNNB1/β-catenin and WT1 genes and performed immunostaining for markers of Wnt pathway activation (β-catenin) and nephronic progenitor cell self-renewal (WT1, CITED1 and SIX2). We characterized the proteome of KWT using imaging mass spectrometry (IMS). The results were compared to histology- and age-matched North American WT (NAWT) controls. For patients with KWT, blastemal predominance was noted in 53.3% and anaplasia in 13%. We detected increased loss to follow-up (p = 0.028), disease relapse (p = 0.044), mortality (p = 0.001) and nuclear unrest (p = 0.001) in patients with KWT compared to controls. KWT and NAWT showed similar Ki67/cellular proliferation. We detected an increased proportion of epithelial nuclear β-catenin in KWT (p = 0.013). All 15 KWT specimens were found to harbor wild-type CTNNB1/β-catenin, and one contained a WT1 nonsense mutation. WT1 was detected by immunostaining in 100% of KWT, CITED1 in 80% and SIX2 in 80%. IMS revealed a molecular signature unique to KWT that was distinct from NAWT. The African WT specimens appear to express markers of adverse clinical behavior and treatment resistance and may require alternative therapies or implementation of high-risk treatment protocols.
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Affiliation(s)
- Andrew J Murphy
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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