Development and pilot validation of a novel disfigurement severity scale for plexiform neurofibromas in children with neurofibromatosis type 1

BACKGROUND/AIMS

We developed an observer disfigurement severity scale for neurofibroma-related plexiform neurofibromas to assess change in plexiform neurofibroma-related disfigurement and evaluated its feasibility, reliability, and validity.

METHODS

Twenty-eight raters, divided into four cohorts based on neurofibromatosis type 1 familiarity and clinical experience, were shown photographs of children in a clinical trial (NCT01362803) at baseline and 1 year on selumetinib treatment for plexiform neurofibromas (n = 20) and of untreated participants with plexiform neurofibromas (n = 4). Raters, blinded to treatment and timepoint, completed the 0-10 disfigurement severity score for plexiform neurofibroma on each image (0 = not at all disfigured, 10 = very disfigured). Raters evaluated the ease of completing the scale, and a subset repeated the procedure to assess intra-rater reliability.

RESULTS

Mean baseline disfigurement severity score for plexiform neurofibroma ratings were similar for the selumetinib group (6.23) and controls (6.38). Mean paired differences between pre- and on-treatment ratings was -1.01 (less disfigurement) in the selumetinib group and 0.09 in the control (p = 0.005). For the disfigurement severity score for plexiform neurofibroma ratings, there was moderate-to-substantial agreement within rater cohorts (weighted kappa range = 0.46-0.66) and agreement between scores of the same raters at repeat sessions (p > 0.05). In the selumetinib group, change in disfigurement severity score for plexiform neurofibroma ratings was moderately correlated with change in plexiform neurofibroma volume with treatment (r = 0.60).

CONCLUSION

This study demonstrates that our observer-rated disfigurement severity score for plexiform neurofibroma was feasible, reliable, and documented improvement in disfigurement in participants with plexiform neurofibroma shrinkage. Prospective studies in larger samples are needed to validate this scale further.

Early detection of malignant and pre-malignant peripheral nerve tumors using cell-free DNA fragmentomics

Early detection of neurofibromatosis type 1 (NF1) associated peripheral nerve sheath tumors (PNST) informs clinical decision-making, potentially averting deadly outcomes. Here, we describe a cell-free DNA (cfDNA) fragmentomic approach which distinguishes non-malignant, pre-malignant and malignant forms of NF1 PNST. Using plasma samples from a novel cohort of 101 NF1 patients and 21 healthy controls, we validated that our previous cfDNA copy number alteration (CNA)-based approach identifies malignant peripheral nerve sheath tumor (MPNST) but cannot distinguish among benign and premalignant states. We therefore investigated the ability of fragment-based cfDNA features to differentiate NF1-associated tumors including binned genome-wide fragment length ratios, end motif analysis, and non-negative matrix factorization deconvolution of fragment lengths. Fragmentomic methods were able to differentiate pre-malignant states including atypical neurofibromas (AN). Fragmentomics also adjudicated AN cases suspicious for MPNST, correctly diagnosing samples noninvasively, which could have informed clinical management. Overall, this study pioneers the early detection of malignant and premalignant peripheral nerve sheath tumors in NF1 patients using plasma cfDNA fragmentomics. In addition to screening applications, this novel approach distinguishes atypical neurofibromas from benign plexiform neurofibromas and malignant peripheral nerve sheath tumors, enabling more precise clinical diagnosis and management.

Perceived transition readiness among adolescents and young adults with neurofibromatosis type 1 and plexiform neurofibromas: a cross-sectional descriptive study

OBJECTIVES

Neurofibromatosis type 1 (NF1) is a genetic cancer predisposition syndrome that can impact multiple organ systems and is associated with plexiform neurofibroma tumors, requiring care from birth through adulthood. Adolescents and young adults (AYAs) with NF1 face several barriers to transition from pediatric to adult care. This cross-sectional study aimed to assess transition readiness in this population and to evaluate relationships between specific NF1 symptoms and transition readiness.

METHODS

AYAs (aged 16-24) enrolled in existing studies related to NF1 were eligible. AYAs and their parents completed measures of transition readiness (Transition Readiness Assessment Questionnaire version 4 [TRAQ-4]), and AYAs also completed a transition readiness interview (UNC TRxANSITION).

RESULTS

Thirty-eight AYAs (mean age = 19.95 ± 2.68 years) participated in the study. Average TRAQ scores indicated that AYAs were still learning Self-Management skills (M = 3.37, SD = 1.08) and Self-Advocacy skills (M = 3.98, SD = 0.67). Older AYAs had higher TRAQ scores for Self-Management (r = 0.70, p < .001) and Self-Advocacy (r = 0.41, p = .011) than younger AYAs. Parents and AYAs had similar TRAQ scores. About one third of AYAs (37.8%, n = 14) expressed uncertainty about how NF1 might affect them in the future. The remaining AYAs mostly expressed concerns regarding tumor growth, pain, or cancer.

CONCLUSIONS

In this small study, preliminary findings suggest that AYAs with NF1 express confidence in many areas of transition readiness but continue to require support, particularly with Self-Management skills. Given the gaps in understanding of future health risks, AYAs with NF1 would benefit from early assessment, psychoeducation, and support for transition readiness to adult care.

Long-term safety and efficacy of selumetinib in children with neurofibromatosis type 1 on a phase 1/2 trial for inoperable plexiform neurofibromas

BACKGROUND

Selumetinib shrank inoperable symptomatic plexiform neurofibromas (PN) in children with neurofibromatosis type 1 (NF1) and provided clinical benefit for many in our previously published phase 1/2 clinical trials (SPRINT, NCT01362803). At the data cutoff (DCO) of the prior publications, 65% of participants were still receiving treatment. This report presents up to 5 years of additional safety and efficacy data from these studies.

METHODS

This manuscript includes data from the phase 1 and phase 2, stratum 1 study which included participants with clinically significant PN-related morbidity. Participants received continuous selumetinib dosing (1 cycle = 28 days). Safety and efficacy data through February 27, 2021 are included. PN response assessed by volumetric magnetic resonance imaging analysis: Confirmed partial response (cPR) ≥20% decrease from baseline on 2 consecutive evaluations. Phase 2 participants completed patient-reported outcome measures assessing tumor pain intensity (Numeric Rating Scale-11) and interference of pain in daily life (pain interference index).

RESULTS

For the 74 children (median age 10.3 years; range 3-18.5) enrolled, overall cPR rate was 70% (52/74); median duration of treatment was 57.5 cycles (range 1-100). Responses were generally sustained with 59% (44) lasting ≥ 12 cycles. Tumor pain intensity (n = 19, P = .015) and pain interference (n = 18, P = .0059) showed durable improvement from baseline to 48 cycles. No new safety signals were identified; however, some developed known selumetinib-related adverse events (AEs) for the first time after several years of treatment.

CONCLUSIONS

With up to 5 years of additional selumetinib treatment, most children with NF1-related PN had durable tumor shrinkage and sustained improvement in pain beyond that previously reported at 1 year. No new safety signals were identified; however, ongoing monitoring for known selumetinib-related AEs is needed while treatment continues.

OUP accepted manuscript

BACKGROUND

Selumetinib was recently approved for the treatment of inoperable symptomatic plexiform neurofibromas (PNs) in children with neurofibromatosis type 1 (NF1). This parallel phase II study determined the response rate to selumetinib in children with NF1 PN without clinically significant morbidity.

METHODS

Children with NF1 and inoperable PNs, which were not yet causing clinically significant morbidity but had the potential to cause symptoms, received selumetinib at 25 mg/m2 orally twice daily (1 cycle = 28 days). Volumetric magnetic resonance imaging analysis and outcome assessments, including patient-reported (PRO), observer-reported, and functional outcome measures were performed every 4 cycles for 2 years, with changes assessed over time. A confirmed partial response (cPR) was defined as PN volume decrease of ≥20% on at least 2 consecutive scans ≥3 months apart.

RESULTS

72% of subjects experienced a cPR on selumetinib. Participants received selumetinib for a median of 41 cycles (min 2, max 67) at data cutoff. Approximately half of the children rated having some target tumor pain at baseline, which significantly decreased by pre-cycle 13. Most objectively measured baseline functions, including visual, motor, bowel/bladder, or airway function were within normal limits and did not clinically or statistically worsen during treatment.

CONCLUSIONS

Selumetinib resulted in PN shrinkage in most subjects with NF1 PN without clinically significant morbidity. No new PN-related symptoms developed while on selumetinib, and PRO measures indicated declines in tumor-related pain intensity. This supports that selumetinib treatment may prevent the development of PN-related morbidities, though future prospective studies are needed to confirm these results.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT01362803.

Relationships of sire breeding values and cutting parts of progeny in Czech Fleckvieh bulls

Abstract. The aim of this study was to assess the effect of the meat yield breeding values of sires on highly valued parts of carcasses in their progeny. The study was carried out on Czech Fleckviehs, a breed dual purpose milk-beef production. Cutting parts evaluated were: round, strip loin and tender loin (first-class meat); rib, shoulder blade (boneless), fore shank, flank, chuck roll + neck (second-class meat) and separable fat. The correlation analysis showed significant negative relationships only for the relative breeding values of trading classes and the rib (r=−0.2079); relative breeding values of net daily gain with strip loin (r=−0.2433). Although strip loin is an important first-class meat cut, the correlation is rather low. Correlations between other meat cuts with breeding values were non-significant. The correlation between meat cuts and age showed the same pattern as correlations between meat cuts and weight at slaughter. Significant negative correlations were found between first-class meat and increasing age (r=−0.1979) and weight (r=−0.2884). In contrast, for second-class meat there were positive correlation with increasing age and weight (r=0.3489 for age, r=0.4495 for weight). This also corresponds with the correlation between age or weight and specific first-class meat cuts (tender loin r=−0.2804, r=−0.3413, strip loin r=−0.3710, r=−0.2012) and second-class meat (sep. fat r=+0.2360, r=+0.2951, r for correlation with age and weight respectively). Based on the calculations of canonical analysis 27.75 % explained variability was found for variables relative breeding value of net daily gain (RBVndg), relative breeding value of trading class (RBVtc), age and weight using a linear combination of variables for individual cuts. At the same time, 14.25 % explained variability was found for cut variables which can be expressed using linear combinations of RBVndg, RBVtc, age and weight.

141 EFFECT OF ENVIRONMENTAL TEMPERATURE ON EMBRYO PRODUCTION AND CONCEPTION RATES IN BEEF AND DAIRY CATTLE

The aim of this study was to evaluate the effect of environmental temperature at the time of embryo collection and transfer on embryo quality and conception rates after transfer of fresh and frozen embryos. Purebred dairy (Holstein, Czech spotted cattle, n = 174) and beef (Charolais, Blonde d’Aquitaine, Piedmontese, Hereford, Limousin and Simmental; n = 72) donors were collected during 2005 to 2007. Donor cows received one application of PGF2α and superstimulation was initiated 9 to 11 days following estrus with pFSH (Folltropin-V; Bioniche Animal Health, Belleville, ON, Canada) given twice daily for 4 days. Prostaglandin2α was given on Day 3 of the superstimulation treatment. Donors were inseminated 3 times, with 1 unit of semen on Days 5 and 6 of treatment. Embryo recovery was carried out on Day 7 after insemination. The recipients were synchronized with PGF2α and embryos were transferred on Day 7 after estrus. The effect of temperature at the time of 246 embryo recoveries and 1338 transfers (fresh and frozen embryos) was analyzed using the GLM, assuming quasi-poisson and quasi-binomial error distribution by R software (www.r-project.org). We evaluated the total number of ova/embryos collected, embryo quality, and conception rates after transfer at the environmental temperatures shown below. Temperatures were divided into the following ranges: A) from –5 to 5°C; B) from 6 to 15°C; C) from 16 to 20°C; and D) over 20°C. The average temperature values were obtained from the Czech hydrometeorological institute and corresponded to the following seasons: winter (range A and B); spring (range B and C); summer (range C and D); fall (range C and B). Dairy cows were managed intensively in barns whereas beef cows were managed in barns during the winter and on pasture from April until October. In beef donors the mean number of total ova/embryos collected and transferable embryos were 9.1 ± 7.9 and 4.2 ± 4.5, respectively and no significant effect of temperature was detected (P > 0.05). In dairy donors the mean number of total ova/embryos collected and transferable embryos were 7.9 ± 6.0 and 4.9 ± 4.5, respectively and no significant effect of temperature was detected (P = 0.27). Conception rate was greatest (P < 0.001) in temperature range D (63.64%) compared with the other temperature ranges (A = 27.66%; B = 43.65%; C = 43.21%;) in beef cows and in the range C (65.31%) than in the other temperature ranges (A = 34.7%; B = 52.67%; D = 56.25%) in dairy cows. It was concluded that temperature at the time of embryo collection did not affect embryo production and quality. However, environmental temperature did have a significant effect on conception rates in both beef and dairy recipients. Nutritional status may also have contributed to the increased conception in beef cattle during warmer temperatures. However, the optimal period for conception in dairy cows was in temperature range from 16 to 20°C, because of the potential adverse effect of heat stress in high-yielding cows. Supported by MEYS CR MSM 2678846201, LA 330; NAZV 1B44034.

The effects of inbreeding on service period and pregnancy length in Holsteins and Czech Fleckviehs after the first calving

Abstract. The effects of inbreeding level on service period (SP) and pregnancy length (PL) were monitored in Holstein and Czech Fleckvieh after the first calving. The levels of inbreeding (FX) ranged from 1.25 to 25 %. SP and PL of inbred cows were compared with their outbred equals – half-sisters, sharing the same sire (n = 1824) and their first calving happened in the same farm and at the same time (± 3 month). Database with the number of 631 810 animals (year of calving 1985–2004) was used for analyses. Inbred cows were grouped according to Fx coefficient (1.5-2.3 %; 3.0-5.0 %; 8.0-12.5 %; 25 %). The GLM with fixed effects (the breed, breeding value of the sire and monitored individual for milk production, year of calving, age at first calving) was applied to all data. The effect of inbreeding depression on SP was more pronounced at higher levels of inbreeding (+2.81; +3.35; +4.53; +8.23 d, respectively according to above mentioned Fx groups) but non-significant. Differences in PL (+0.3; +0.32; -0.08 and 1.68 d) were not significant either. Average value of PL for inbred animals was 0.43 d higher. The correlation coefficient was +0.023 for SP and +0.0658 for PL. The Fx coefficient increasing by 1 % extends the SP by 0.22 day and PL by 0.063 day. There was a higher variability of SP and PL in inbred cows. The length of calving interval between the first and second lactation is affected more by SP than PL.

Comparison of felodipine and enalapril monotherapy in essential hypertension

This study compared the efficacy and tolerability of monotherapy with felodipine and enalapril in patients with essential hypertension using a double-blind randomised crossover design. Thirty-five subjects (22 male, 13 female--ages: median 48 years, range 31-69 years) entered the randomised phases of the study and 32 subjects completed the study. Following a 4-week run-in placebo phase, the treatments were felodipine ("Plendil ER") 5-20 mg and enalapril 5-20 mg orally once daily for 8 weeks, each with matching placebos. Dose titration was at 2 and/or 4 weeks in each phase. Number of subjects with each different end-of-phase dose were for felodipine: 5 mg--8, 10 mg--11, 20 mg--13 and enalapril: 5 mg--6, 10 mg--9, 20 mg--17. Predose supine blood pressure (mean +/- SEM) was reduced in both active treatment phases compared with the run-in phase (159 + 2/101 +/- 1), but there was no significant difference in blood pressure between the active phases: felodipine 143 +/- 2/90 +/- 1 and enalapril 146 +/- 2/92 +/- 1. The most common adverse effects were for felodipine: headache, flushing, ankle swelling; and for enalapril: cough. Felodipine and enalapril as once daily monotherapy are thus of similar antihypertensive efficacy but with predictably different adverse effect profiles.

[Hepatitis B immunization--when is a booster injection necessary?]

Over 10,000 high risk individuals in the Zurich area have been vaccinated against hepatitis B with 3 initial injections of 20 micrograms H-B-Vax. The question arises whether, and if so when, booster injections should be given. Concentrations and persistence of the protective anti-HBs antibodies of 158 successfully vaccinated individuals (medical staff, patients on hemodialysis or with renal transplants) were analyzed. The anti-HBs behaved typically in most individuals, reaching maximum levels in the 7th month (1 month after the third vaccine injection) and then falling gradually, more rapidly in the next following month than later. Persistence of antibodies depended on the maximum anti-HBs concentration reached initially. Three years after the first vaccine injection anti-HBs concentrations had fallen below 10 mIU/ml in all healthy individuals with initial concentrations between 10-99 mIU/ml, in 44% vaccinees with initial titers between 100 and 499 mIU/ml, in 17% individuals with initial anti-HBs between 500 and 1499 mIU/ml but in none of the vaccinees whose antibodies had originally been higher than 1500 microIU/ml. Anti-HBs were undetectable in 6% of all medical staff members, in 30% of hemodialysis patients and in 59% of patients with renal transplants. Several policies for booster injections are discussed. One possible approach is to measure anti-HBs in all vaccinees after completion of the initial immunization, a further booster injection being recommended individually on the basis of the calculated time when anti-HBs fall lower than, for example, 10 mIU/ml having regard to the initial anti-HBs concentration.(ABSTRACT TRUNCATED AT 250 WORDS)