World Cancer Congress 2010
Presence of Cancer-Associated Fibroblasts correlates with Microvascular Proliferation which is a Poor Prognostic Factor in Neuroblastoma Tumors
Neuroblastoma diagnosis, treatment, complications, and further management. The main contents of this review have been accessed from MedScape. Please do not reprint or copy this material without permission from the copyright owner.
Neuroblastoma diagnosis, treatment, complications, and further management. The main contents of this review have been accessed from MedScape. Please do not reprint or copy this material without permission from the copyright owner.
GROUP 1 Case 967-- A Teenage Female with an Ovarian MassCLI.docxgilbertkpeters11344
GROUP 1: Case 967-- A Teenage Female with an Ovarian Mass
CLINICAL HISTORY
A teenage female presented with secondary amenorrhea (https://www.healthline.com/health/secondary-amenorrhea#causes). The patient had 1 menstrual cycle 3 years ago and has had no menses since. Laboratory work-up was negative for pregnancy test, mildly increased calcium level (11.7 mg/dL, normal range: 8.5-10.2 mg/dL) and CA 125 (43 Units/ml, normal range: 0-20 Units/ml). Prolactin, TSH, AFP, Inhibin A, Inhibin B and CEA were normal. Imaging revealed a 13 x 11.8 x 8.6 cm, predominately cystic left pelvis mass, with multiple internal septations. Her past medical history was not contributory. Patient underwent left salpingo-oophorectomy (https://www.healthline.com/health/salpingo-oophorectomy), omentectomy (https://moffitt.org/cancers/ovarian-cancer/omentectomy/) and tumor debulking (https://en.wikipedia.org/wiki/Debulking) with intraoperative frozen section consultation.
GROSS EXAMINATION
The 930.9 g tubo-ovarian complex consisted of a 20.0 x 16.0 x 8.0 cm large mass, with no recognizable normal ovarian parenchyma grossly and an unremarkable fallopian tube. The cut surface was gray, "fish-flesh", soft with foci of hemorrhage and necrosis.
MICROSCOPIC EXAMINATION
Microscopically, the majority of main tumor was growing in large nests, sheets and cords with focal follicle-like structures and geographic areas of necrosis. It was predominantly composed of small cells with hyperchromatic nuclei, round to oval nucleus with irregular nuclear contour, inconspicuous to occasional conspicuous nucleoli and minimal cytoplasm. This component was variably admixed with a population of larger cells, which as the name implies composed of cells with abundant eosinophilic cytoplasm, with central or eccentric round to oval nuclei, pale chromatin and prominent nuclei. Both, the small and large cell components demonstrated brisk mitotic activity. All staging biopsies and omentectomy were composed of large cell component.
An extensive panel of immunohistochemical stains was performed. Overall, the staining pattern was strong and diffuse in small cell component compared to patchy weak staining pattern in the large cell component.
FINAL DIAGNOSIS
Small cell carcinoma (https://en.wikipedia.org/wiki/Small-cell_carcinoma) of the ovary, hypercalcemic type (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939673/)
DISCUSSION
Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is an aggressive and highly malignant tumor affecting the women under 40. It was first described as a distinct entity by Dickersin et al in 1982 (1). Fewer than 500 cases have been described in the literature and it accounts for less than 1% of all ovarian cancer diagnoses. Due to the initial consideration of epithelial origin, the term of SCCOHT has been used to distinguish this entity from its mimicker, the neuroendocrine or pulmonary type (2). In fact epithelial origin of SCCOHT was recently challenged as new imm.
Analysis of external adaptability (agility) as a measure of organizational Effectiveness in Higher Education and recommendation of diagnostic testing based on the performance triangle model
Zeine et al. 2011 Organizational Culture in Higher Education, in Kazeroony, H...Rana ZEINE, MD, PhD, MBA
ZEINE, R., Boglarsky, C.A., Blessinger, P., and Hamlet, M.T. Organizational Culture in Higher Education. Chapter 3 in Kazeroony, H. (Ed.), The Strategic Management of Higher Education Institutions: Serving Students as Customers for Institutional Growth, Business Expert Press, LLC, New York, NY USA, 2011, 1st edition, pp. 19-38.
DOI 10.4128/9781606491034, ISBN-13: 978-160649-366-3 (paperback),
978-1-60649-103-4 (e-book) http://www.businessexpertpress.com/books/strategic-management-higher-education-serving-students-customers-institutional-growth
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Zeine Seminar 2010, Cancer Associated Fibroblasts and Microvascular Proliferation in Neuroblastoma Tumors
1. CANCER-ASSOCIATED FIBROBLASTS and MICROVASCULAR PROLIFERATION in NEUROBLASTOMA TUMORS RANA ZEINE, M.D., Ph.D., Research Assistant Professor & Associate Director (former) Northwestern University, Chicago, IL, USA
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4. Induction of GALLBLADDER CARCINOMA Cell Invasion in a Co-Culture System with Stromal FIBROBLASTS Blocked by NK4 a specific competitive antagonist against the Hepatocyte Growth Factor – Met Receptor system Matsumoto & Nakamura, Int. J. Cancer 119, 2006 CANCER-ASSOCIATED FIBROBLASTS PROMOTE TUMOR INVASION via HGF-MET Ohnishi & Daikuhara 2003 FIBROBLASTS MOTILITY CARCINOMA
5. BREAST CARCINOMA Co-MIXED with Cancer-Associated Fibroblasts resulted in ENHANCED Xenograft Volume, Microvascular Density and Precursor Cell Recruitment over ‘Counterpart Fibroblasts’ Orimo et al. Cell 121, 2005 CANCER-ASSOCIATED FIBROBLASTS PROMOTE TUMOR GROWTH & ANGIOGENESIS via SDF1 – CXCR4 Kucia et al. 2004 Blocked by Antibody to Stromal-Derived Factor-1
6. BASAL CELL CARCINOMA GREMLIN 1 EXPRESSION in STROMAL FIBROBLASTS Sneddon et al. PNAS 103, 2006 CANCER-ASSOCIATED FIBROBLASTS MAY PROMOTE CANCER STEM CELL RENEWAL via GREMLIN ANTAGONISM of BONE MORPHOGENETIC PROTEIN (BMP)
7. EXPRESSION of EPSTI1 at EPITHELIAL – STROMAL INTERFACE in BREAST CARCINOMA De Neergaard et al. Am. J. Pathol., 2010 EPSTI1 Substitutes for fibroblasts in tumor micro-environment assays and upregulates Epithelial-Mesenchymal Transition
8. aSMA Desmin Desmin smooth muscle Myosin heavy chain SMA CANCER-ASSOCIATED FIBROBLASTS EXPRESS α SMA, sm-MYOSIN, some DESMIN in BREAST CARCINOMA Schürch, Seemayer & Gabbiani 1997 ch.7 in Sternberg (Ed.) Histology for Pathologists smooth muscle Myosin heavy chain
9. CANCER-ASSOCIATED FIBROBLASTS are NEGATIVE for hMW-CALDESMON SMA Nakayama et al. J. Clin. Pathol 55, 2002 Vessel PERICYTES hCD +ve hCD GASTRIC CARCINOMA Cancer-Associated FIBROBLASTS + PERICYTES
10. FIBROBLAST ACTIVATION PROTEIN EXPRESSION in CANCER ASSOCIATED FIBROBLASTS CORRELATION with POOR PROGNOSIS in COLON CANCER Henry et al. Clin. Cancer Res. 13, 2007 FAP / Seprase, 97-kDa Glycoprotein, Gelatinase, Dipeptidyl Peptidase
11. 3D-Reconstruction of Vasculature from Serial Sections Stained for Endothelium (CD34) Gijtenbeek et al. Angiogenesis 8, 2005 Glioblastoma Multiforme VASCULAR ARCHITECTURE APPEARS MORE TORTUOUS, DISTORTED and DISORGANIZED in AGGRESSIVE CANCER Normal Grey Matter
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13. MICROVASCULAR PROLIFERATION with Partitioning of the Lumen Glioblastoma Multiforme Montefiore Medical Center - AECOM H&E
14. Kim et al. J. Neurosurg. 74, 1991 GLOMERULOID MICROVASCULAR PROLIFERATION ASSOCIATED with SHORTER SURVIVAL in ASTROCYTOMA ‒ GLIOBLASTOMA Tumors
15. MELANOMA BREAST CARCINOMA ENDOMETRIAL CARCINOMA PROSTATE CARCINOMA MICROVASCULAR PROLIFERATION SHORTER SURVIVAL Endothelial stain FACTOR VIII Straume et al. Cancer Research 62, 2002
16. Wesseling et al. J Neuropathology and Experimental Neurology 54, 1995 EN-4 ENDOTHELIAL CELLS and -SM Actin PERICYTES Vascular Lumena Immuno-Electron Microscopy of Glomeruloid Microvascular Proliferation in GLIOBLASTOMA Multiforme
20. EVENT-FREE SURVIVAL by DIAGNOSIS (patients > 18 months; n=908) (1986-2001:CCG; POG; COG) London WB, Children’s Oncology Group, Statistics and Data Center, 2006 0 20 40 60 80 100 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Years Probability (%) Neuroblastoma (n=785) Ganglioneuroblastoma, Intermixed, (n=44) Ganglioneuroblastoma, Nodular (n=79) Kaplan-Meier Curves
21. PROGNOSTIC CATEGORIES DIAGNOSIS MITOSIS-KARYORRHEXIS INDEX (MKI) Qualman et al. Archives Pathology Laboratory Medicine 129,2005 UNFAVORABLE FAVORABLE HISTOLOGY AGE
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23. 1. To Determine the Presence and Prognostic Significance of Microvascular Proliferation in Neuroblastoma and in Relation to Schwannian Stroma and Risk Factors. 2. To Assess Cancer-Associated Fibroblasts in Neuroblastoma and in Relation to Schwannian Stroma and Microvascular Proliferation. 3. To Evaluate the Effects of Anti-Angiogenic Treatment on Tumor Microenvironment in Neuroblastoma. OBJECTIVES
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25. CASE SERIES ANALYZED for MICROVASCULAR PROLIFERATION Clinical Parameter CMH (1) CHOP GENDER M,F 23, 28 70, 73 AGE at diagnosis Age Range 16<1yr, 30>1yr 6d – 14y 90>1yr, 51<1yr 5d – 17y Dx GN, GNB, NB 5, 13, 33 12, 24, 118 STAGE 1, 2, 3, 4, 4s 18, 8, 8, 12 45, 39, 25, 27, 1 MYCN A, S, u 10, 33, 3 11, 85, 47 PROGNOSTIC F,U,u 24, 19, 3 80, 58, 5 RISK High, Low 15, 31 38, 104 Overall SURVIVAL 82 % 84 %
26. CASE SERIES ANALYZED for CANCER-ASSOCIATED FIBROBLASTS Clinical Parameter CMH (2) AGE at diagnosis 34>1yr, 19<1yr Dx GN, GNB, NB 7, 11, 42 STAGE 1+2+3, 4 34, 15 MYCN A, S, u 9, 40, 4 PROGNOSTIC F,U,u 28, 23, 2 RISK High, Low 15, 25 5-Yr Survival: Hi, Lo Risk 61%, 100% MVP Yes, No 38, 22
35. MICROVASCULAR PROLIFERATION is PRESENT in SCHWANNIAN STROMA-POOR REGIONS and TUMORS Percent of Cases 8/8 4/4 53/82 11/16 17/28 6/11 4/4 5/5 0/6 0/5 0/15 0/9 0/12 0/7 █ TMA-CHOP n=155 █ CMH n=53
36. MICROVASCULAR PROLIFERATION is ASSOCIATED with SHORTER SURVIVAL in NEUROBLASTOMA (patients all ages; n=46 CMH) Peddinti , Zeine et al. Clin. Cancer Res., 13, 2007 Kaplan-Meier Curves Log-Rank test p=0.017 Percent Survival No Microvascular Proliferation ( n=20: 13 NB, 7 GNB ) Survival in Years Microvascular Proliferation ( n=26: 20 NB, 6 GNB ) 0 2 4 6 8 10 12 14 0 20 40 60 80 100 65% ± 3 100%
37. MICROVASCULAR PROLIFERATION is ASSOCIATED with SHORTER SURVIVAL in NEUROBLASTOMA (patients all ages; n=143 CHOP) Peddinti , Zeine et al. Clin. Cancer Res., 13, 2007 No Microvascular Proliferation (n=60: 41 NB, 19 GNB) Survival in Years Percent Survival Microvascular Proliferation (n=83: 77 NB, 5 GNB) Kaplan-Meier Curves Log-rank test p=0.014 0 5 10 15 0 20 40 60 80 100 78% 95%
38. MICROVASCULAR PROLIFERATION is a POOR PROGNOSTIC FACTOR in NEUROBLASTOMA Single-Predictor Cox Regression Analysis (TMA-CHOP) RISK FACTOR ASSOCIATION with SHORTER SURVIVAL p-value Age ( ≥ 1 year vs < 1 year) 0.014 Stage (4 vs <4) <0.001 MYCN (Amplified vs Single Copy) 0.003 Prognostic Category (Unfavorable vs Favorable) <0.001 MVP (Present vs. Absent) 0.02
39. HIGH RISK NEUROBLASTOMA TUMORS are ASSOCIATED with MICROVASCULAR PROLIFERATION (143 tumors, CHOP) Peddinti, Zeine et al. Clinical Cancer Research, vol.13, June 2007 RISK FACTORS ASSOCIATION with MVP Chi-Square test p-value High-Risk Group <0.001 Unfavorable Prognosis <0.001 Advanced Stage 0.008 MYCN Amplification 0.006 Stroma-poor <0.001
47. Quantitative IHC (Clarient-Chromavision) Automated Cellular Imaging System II Scanned the SMA-stained Slides Set Color Detection Thresholds Delineated Tumor Regions Calculated Ratios of Areas Stained to Total Areas Analyzed Stain included Pericytes and Cancer Associated Fibroblasts Neuroblastoma Ganglioneuroma
48. 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% PERCENT SMA+ve REGIONS in NEUROBLASTOMA TUMORS SMA +ve AREA NBU n=5 NBPD 14 NBD 23 NGNB GNBI 7 GN 7 4 Low Med High
50. 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% GN n=7 GNBI n=7 GNBN n=4 NB (D+PD+U) n=42 INCREASED SMA +ve AREAS in SS-POOR STROMA Mean±SD - SMA POSITIVE AREA student’s t-test p<0.001 SS-Rich Tumors SS-Poor Tumors or Regions Zeine et al. Mod. Pathol. 26(4), 2009
51. INCREASED SMA +ve AREAS in NEUROBLASTOMA TUMORS with MICROVASCULAR PROLIFERATION Mean ±SD Percent -SMA POSITIVE AREA 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% GN n=7 NB+GNBI 15 NB+GNBN 38 p<0.001 student’s t-test No MVP With MVP Zeine et al. Mod. Pathol. 26(4), 2009
52. SS-Rich, No MVP, No CAFs Tumor-INHIBITORY Role SS-Poor, with MVP & CAFs Tumor-PROMOTING Role Ganglioneuroma Ganglioneuroblastoma Intermixed NB Differentiated NB Poorly Differentiated Zeine et al. Mod. Pathol. 26(4), 2009
55. Control n=9 Inside ScN. n=10 Mean ± SD SMA +ve Cells / mm 2 LESS Cancer-Associated Fibroblasts in Neuroblastoma Xenografts ENGRAFTED INSIDE the SCIATC NERVE Zeine et al. Mod. Pathol. 26(4), 2009 The Inverse Relation between Schwann Cells and Cancer-Associated Fibroblasts Suggests that the Schwannian Microenvironment might Interfere with either Fibroblast Infiltration or Activation, thus inhibiting Angiogenesis. p<0.001 *
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58. VALPROIC ACID INHIBITS TUMOR GROWTH IN VIVO DAYS Tumor Volume mm 3 Yang,… Zeine et al. Cancer Res. 26(4), 2007
59. Control SMS-KCNR Xenografts Micro-Vascular Proliferation ValproicAcid Treatment Thin Walled Vessels ANTI-ANGIOGENIC TREATMENT ABROGATES MICROVASCULAR PROLIFERATION in NB H&E Yang,… Zeine et al. Cancer Res. 26(4), 2007
60. Control NMB MICROVASCULAR PROLIFERATION Valproic Acid VASCULAR NORMALIZATION FibroCollagenous Stroma H&E Masson Trichrome Yang,… Zeine et al. Cancer Res. 26(4), 2007
61. ‘ Normalization’ of Vessels Tong et al. Cancer Research 64 (11), 2004 Murine Mammary Carcinoma Two-Photon Microscopy Control Anti-Angiogenic VEGF2R Blocker DC101 Day 0 5 1 2 3 4
62. Abrogation of Microvascular Proliferation by Anti-Angiogenic Treatment with Valproic Acid Percent of Total Vessels With Microvascular Proliferation Neuroblastoma Xenografts
63. FUNCTIONAL IMPROVEMENT LESS LEAKY Reduced Intratumoral Vessel Permeability by Anti-Angiogenic Treatment with Valproic Acid Spectrophotometric Quantitation of Evan’s Blue Extraction into formamide for 72 hr, RT 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 VPA Treated n=4 Control n=5 p=0.04 * Relative OD 620 nm Neuroblastoma SMS-KCNR Xenografts (student’s t-test) Yang,… Zeine et al. Cancer Res. 26(4), 2007 Extravasation 100 l, 0.2% Evan’s Blue by Tail-Vein Injections Let Circulate 20 min. 25 ml Saline Perfusion
64. Control SMS-KCNR Xenografts ValproicAcid Treatment LESS CANCER-ASSOCIATED FIBROBLASTS Following ANTI-ANGIOGENIC TREATMENT x200 SMA x400
65. 1- Microvacular Proliferation is a Poor Prognostic Indicator present in SS-Poor Neuroblastoma Regions. 2- Cancer-Associated Fibroblasts Colocalize with Microvacular Proliferation and are Precluded from SS-Rich Regions of Neuroblastoma Tumors. 3- It is Possible to Reduce Cancer-Associated Fibroblast Infiltration by Increasing the Schwannian Component within the Tumor Microenvironment. 4- Anti-Angiogenic Treatment Reduced Microvascular Proliferation and Cancer-Associated Fibroblasts in Neuroblastoma Xenografts. CONCLUSIONS
66.
67. ACKNOWLEDGEMENTS University of Pennsylvania (CHOP) John M. Maris, MD Kristina Cole, MD Bruce Pawel, MD Statistics (CMH and COG) Roopa Seshadri, PhD Wendy B. London, PhD Susan L. Cohn, MD Radhika Peddinti, MD Alex Chlenski, PhD Qiwei Yang, PhD Helen Salwen Yufeng Tian Lisa Guerrero Maria Tretiakova, MD, PhD Northwestern University Robert H. Lurie Comprehensive Cancer Center University of Chicago
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69.
70. STAGING SYSTEM in Neuroblastoma Brodeur et al. J Clin Oncol 11,1993 STAGE DEFINITION 1 Localized Tumor with Complete Gross Excision; -ve Nodes 2A Localized Tumor with Incomplete Gross Excision; -ve Nodes 2B Localized Tumor with +ve Ipsilateral Nodes 3 Localized Tumor with +ve Contralateral Nodes, or Unresectable Tumor; Infiltrating Across Midline 4S Localized Tumor, in Infant < 1 yr, with Dissemination Limited to Skin, Liver and/or Bone Marrow (Minimal) 4 Any Primary Tumor with Distant Metastasis (except 4S)
Zeine Thank you Dr. Zhao, Ladies and Gentlemen. 2010
Zeine Tumor Stroma provides the Microenvironment which nurtures the Growth and Progression of tumors. Stromal Cells include fibroblasts, endothelial cells, pericytes and inflammatory cells. Today we will focus on two features of Tumor Stroma, Blood Vessels and Activated Fibroblasts. 2010
Zeine Cancer-Associated Fibroblasts are believed to Originate from either Local Tissue Fibroblasts, or Bone Marrow Progenitors, or Neoplastic cells undergoing Epithelial-Mesenchymal Transition, or from Pericytes. They EXHIBIT Myofibroblastic Cytodifferentiation to become Activated Fibroblasts and ACQUIRE motility through formation of alpha-Smooth Muscle Actin Stress Fibers. They have Enhanced Proliferation, and Secrete Extracellular Matrix Proteins and Chemokines. Kalluri and Zeisberg ‘06 2010
Cancer-Associated Fibroblasts promote tumor cell invasion via the Hepatocyte Growth Factor – Met Receptor System. In this two-chamber co-culture system, presence of the fibroblasts induced Gallbladder carcinoma cells to invade matrigel; and this was blocked by NK4, a specific competitive antagonist against HGF. Matsumoto and Nakamura ’06 Zeine 2010
Cancer-Associated Fibroblasts Promote Tumor Growth and Angiogenesis via the Stromal Derived Factor 1 – CXCR4 Chemokine Receptor System. In this experiment, Breast Carcinoma Co-Mixed with Cancer-Associated Fibroblasts resulted in Enhanced Xenograft Volume, Microvascular Density and Precursor Cell Recruitment, over co-mixing with ‘Counterpart Fibroblasts’. These effects could be blocked by a neutralizing Antibody to SDF-1. Orimo et al. ’05 Zeine 2010
Cancer-Associated Fibroblasts may promote Cancer Stem Cell Renewal via Gremlin Antagonism of BMP, Bone Morphogenetic Protein. Gremlin 1 Expression is seen here in stromal fibroblasts in Basal Cell Carcinoma. Sneddon et al. ’06 Zeine 2010
More Recently De Neergaard et al. have localized Epithelial-Stromal Interface 1, a Nucleo-Cytoplasmic protein, at the junction between tumor cell nests and surrounding stroma in Breast Carcinoma; and demonstrated that it substitutes for tumor fibroblasts (morphogenesis) and up-regulates markers of epithelial-mesenchymal transition (fibronectin, integrin-alpha2-beta1) . Zeine 2010
Zeine In addition to expressing alpha SMA, Cancer-Associated Fibroblasts may express smooth muscle Myosin heavy chain, and a minority express Desmin, as seen here in breast carcinoma. They do not express Smoothelin which is the marker for mature smooth muscle cells. Gabbiani ’97 2010
Cancer-Associated Fibroblasts are negative for high molecular weight Caldesmon which distinguishes them from true Pericytes, seen here in gastric carcinoma. Nakayama et al. ’02 Zeine 2010
Zeine FIBROBLAST ACTIVATION PROTEIN, is another marker for CANCER ASSOCIATED FIBROBLASTS. FAP is a seprase, dipeptidyl peptidase, and its expression in this study on COLON Cancer reveals clinical Correlation with POOR PROGNOSIS. Henry et al. ’07 2010
Zeine Vascular Architecture Appears More Tortuous, Distorted and Disorganized in aggressive cancers, as seen here in this 3D-Reconstruction of CD34 staining in Gliobastoma Multiforme as compared to normal brain tissue. Gijtenbeek et al. ’05 2010
Zeine Scanning Electron Microscopy through blood vessels of Mouse Mammary Carcinoma reveals that ENDOTHELIAL Cells Begin to Overlap, Become Branched, Extend Multiple Projections Forming Bridges and Tunnels that Eventually Partition the Lumen. Hashizume et al. 2000. 2010
Zeine In this section from a Glioblastoma Multiforme, Partitioning of the Vascular Lumen can be Discerned on H&E. 2010
Zeine In 1991 it was reported that presence of Glomeruloid Microvascular Proliferation was Associated with Shorter Survival in Astrocytoma Tumors. Original curve was kindly provided to me by Professor Tessa Hedley-White, at Harvard, from Kim et al. ’91 2010
Zeine Subsequently, Microvascular Proliferation has been found to be a poor prognostic indicator in Melanoma, Breast, Endometrial and Prostate Carcinoma. Straume et al. ’02 2010
Zeine Immuno-Electron-microscopy revealed that both ENDOTHELIAL Cells as well as PERICYTES were present within Microvascular Proliferation, as seen here in Glioblastoma Multiforme. Wessling et al. ’95 2010
Zeine Neuroblastomas are Embryonal tumors of Migrating Neuroectodermal cells, derived from the neural crest and destined for the adrenal medulla and sympathetic nervous system. Primary Sites can be Adrenal, Abdominal, or anywhere along the Chain of Sympathetic Ganglia. 2010
Zeine Neuroblastoma constitutes 8-10% of all childhood cancers. Affecting about 8.0 children, per million per year. Median age of diagnosis is 22 months. The Male to female ratio is 1.2 to 1. 2010
Zeine There are 7 Diagnostic types of Neuroblastoma Tumors. 3 are Schwannian Stroma-Poor NEUROBASTOMAs: either Undifferentiated, Poorly Differentiated or Differentiating. 2 are Schwannian Stroma-Rich GANGLIONEUROBLASTOMAs: either Nodular or Intermixed. And 2 are Benign, Schwannian Stroma-Dominant, GANGLIONEUROMAs with either Maturing or fully Mature Nerve Fascicles. 2010
Zeine Statistical Data from the Children’s Oncology Group shows a dramatic split between Nodular and Intermixed Ganglioneuroblastoma with regards to event-free survival, whereby the Nodular Ganglioneuroblastomas have a much poorer prognosis, indeed, no better than that for the Schwannian Stroma-Poor Neuroblastoma Tumors. Original Data provided by Wendy London from COG in ’06 2010
Zeine Neuroblastoma tumors are Classified as having either Favorable or Unfavorable Prognosis based on Age, Diagnosis and Mitosis-Karyorrhexis Index. The algorithm summarized here is from Qualman et al. ‘05 2010
Zeine Furthermore, Neuroblastoma Cases are classified into 3 RISK GROUPS, Low, Intermediate or High Risk, based on MYCN Amplification Status, Ploidy, Chromosomal aberrations and Clinical parameters. 2010
Zeine Our Objectives were 1. To Determine the Presence and Prognostic Significance of Microvascular Proliferation in Neuroblastoma and in Relation to Schwannian Stroma and Risk Factors. 2. To Assess Cancer-Associated Fibroblasts in Neuroblastoma and in Relation to Schwannian Stroma and Microvascular Proliferation. 3. To Evaluate the Effects of Anti-Angiogenic Treatment on Tumor Microenvironment in Neuroblastoma. 2010
Zeine We examined archival Formalin-Fixed Paraffin-Embedded tissues from 60 tumors diagnosed at Children’s Memorial Hospital (CMH), full sections from one block per tumor, and 155 tumors on a tissue microarray constructed at Children’s Hospital of Philadelphia (CHOP), 1-4 cores per tumor. 2010
Zeine Clinical Parameters were collected for Gender, Age, Diagnosis, Stage, MYCN status, Prognostic Category, Risk Group and Survival. The Overall Survival was higher than the National Average in both series, perhaps due to selection bias for cases requiring surgical tissue for diagnosis. 2010
Zeine Cancer Associated Fibroblasts were analyzed only in the CMH series where full sections were available. 2010
Zeine In Ganglioneuroma Blood Vessels were Thin-Walled, Dilated and Capillary-Like. 2010
Zeine Immunohistochemistry revealed single layers of CD31 positive endothelial cells, and orderly coverage by alpha-SMA positive pericytes. 2010
Zeine In Ganglioneuroblastoma Intermixed, blood vessels were also of the Thin-Walled, Classic-Angiogenic type, often showing sprouting 2010
Zeine By CONTRAST, Microvascular Proliferation was seen in Ganglioneuroblastoma Nodular; note the multiple layers of plump endothelial cells and multiple microvessel lumena. 2010
Zeine We found that Microvascular Proliferation was Confined to the Schwannian Stroma-Poor Regions, and examination of the Schwannian Stroma-Rich areas revealed only Thin-Walled vessels. 2010
Zeine CD31 immunostain highlighted disorderly Endothelial cells within the microvascular proliferations. 2010
Zeine In the Schwannian-Stroma-POOR Neuroblastomas, Florid Glomeruloid Microvascular Proliferation could be seen, as shown here in Neuroblastoma Differentiating. 2010
Zeine 11/28/07 Multiple layers of pericytes were present surrounding the microvessels.
Zeine In both the CMH series and the CHOP series, Microvascular Proliferation was present only in Schwannian Stroma-Poor Regions and Tumors. Not all Neuroblastomas had Microvascular Proliferation, about 35% did not. 2010
Zeine Kaplan-Meier curves Demonstrated Shorter Survival for cases WITH Microvascular Proliferation versus those without; the difference reaching statistical significance at p-value 0.017 in the CMH series, 2010
Zeine and p-value 0.014 in the CHOP series. 2010
Zeine Univariate Regression Analysis revealed that Presence of Microvascular Proliferation was a Poor Prognostic Factor similar to the other known Risk Factors in Neuroblastoma. 2010
Zeine Furthermore, the High Risk Factors in neuroblastoma were Associated with Microvascular Proliferation at a statistically significant level in the CHOP series. 2010
Zeine There were no deaths in the subset of patients with MYCN amplified tumors that lacked Microvascular Proliferation (5 cases). The outcome was significantly better for patients with stage 4 disease who lacked Microvascular Proliferation. 2010
Zeine Fibrovascular Stroma was present In Schwannian Stroma-POOR Neuroblastoma Tumors. 2010
Zeine We then looked for Cancer-Associated Fibroblasts. 2010
Zeine No Cancer-Associated Fibroblasts were detected in Schwannian Stroma Dominant Ganglioneuroma. 2010
Zeine Few Cancer-Associated Fibroblasts were Present in Ganglioneuroblastoma Intermixed, focally in the vicinity of Neuroblasts where the Schwannian Stroma is somewhat Looser. Hi Molecular Weight Caldesmon staining reveals the Pericytes. 2010
Zeine More Cancer-Associated Fibroblasts were seen in Ganglioneuroblastoma Nodular, mainly infiltrating the Schwannian Stroma Poor Regions. Again, Pericytes are distinguished by staining for h-Caldesmon on an Adjacent Section. 2010
Zeine Abundant Cancer-Associated Fibroblasts were Present in Neuroblastoma Differentiating, and everywhere within the Fibrovascular Stroma of many of the Schwannian Stroma-Poor Neuroblastoma tumors. 2010
Zeine In order to quantitate the results, Automated Cellular Imaging System II was used. We Scanned the alpha SMA-stained Slides Set Color Detection Thresholds Delineated Tumor Regions Calculated Ratios of Areas Stained to Total Areas Analyzed Of Course, Stain included Pericytes and Cancer Associated Fibroblasts 2010
Zeine The PERCENT alpha-SMA positive Regions varied from low to high in the Neuroblastomas, but remained uniformly low in the Ganglioneuromas and Intermixed tumors. Thresholds could be defined at 1.1 and 3 Percent to designate low, medium and high levels. It is reasonable to consider that the Low levels represented mostly Pericytes, while the Medium and High Levels represented accumulation of Cancer Associated Fibroblasts. 2010
Zeine Analysis of Both the Categorical Data and the Continuous Data revealed Statistically Significant Associations of CANCER-ASSOCIATED FIBROBLASTs with SS-POOR Histology and with Microvascular Proliferation; Chi square and t-test p values less than 0.001 2010
Zeine There was an Inverse Correlation between the Levels of Alpha-SMA and the Amounts of Schwannian Stroma. 2010
Zeine And a Direct Correlation between the Levels of Alpha-SMA and the Presence of Microvascular Proliferation. 2010
Zeine Our findings are Consistent with a Pro-angiogenic / Tumor Promoting Role for Cancer-Associated Fibroblasts; and an Anti-Angiogenic / Tumor Inhibitory role for Schwannian Stroma Derived Factors. 2010
Zeine In order to Experimentally Enrich the Tumor Microenvironment for Schwannian Stroma, Neuroblastoma Xenografts were Engrafted Inside the Sciatic Nerve of Nude Mice previously in Liu et al. 2005. A MYCN Amplified cell line SMS-KCNR, Derived from Human Neuroblastoma, was used. Xenografts grown inside the Nerve were shown to have S-100 positive Schwann Cells as well as Reduced Vascular Density. Liu et al. from Sue Cohn’s lab ’05 2010
Zeine We Examined 10 of those tumors and found that as compared to controls, Cancer-Associated Fibroblasts were absent or reduced in the Schwann-Infiltrated Xenografts. 2010
Zeine The inverse relation between Schwann Cell Infiltration and Cancer-Associated Fibroblast Accumulation suggests that the Schwannian Microenvironment might interfere with either cancer-associated fibroblast migration or activation, thus Slowing down angiogenesis. 2010
Zeine For testing the effects of Anti-Angiogenic Treatment: Two, MYCN-amplified neuroblastoma Cell lines, NMB, and SMS-KCNR, were inoculated subcutaneously into female 4-6 week old Athymic Nude Mice. Treatment with 400 mg/Kg Valproic Acid was given once a day for 20 days for mice with small tumors, and for 10 days in mice with large tumors. 2010
Zeine Valproic Acid is a Branched Chain Fatty Acid; It Inhibits Histone Deacetylase (HDAC) It Inhibits Growth of Neuroblastoma and Other Cancers; and Blocks VEGF- and hypoxia-induced Angiogenesis. HDAC inhibitors are believed to exert their anti-neoplastic effects through Histone Acetylation. 2010
Zeine Treatment in vivo with VALPROIC ACID inhibited TUMOR GROWTH significantly. 2010
Zeine Valproic Acid Treatment Abrogated Microvascular Proliferation and resulted in Thin-Walled Vessels, Often Embedded in Fibrocollagenous Stroma. 2010
Zeine Masson Trichrome special stain highlighted the Fibro-Collagenous Stroma surrounding the Thin-Walled vessels found in Valproic Acid Treated Xenografts. In untreated Controls, the Majority of Vessels showed Microvascular Proliferation. 2010
Zeine Our Observations Represent the Histopathologic Counterpart of the Phenomenon of ‘Normalization’ of Vessels Demonstrated here by Tong et al. by comparing Two-Photon Microscopy on Murine Mammary Carcinoma with and without Anti-angiogenic Treatment. Tong et al. ’04 2010
Zeine Semiquantitative Analysis illustrates Abrogation of Microvascular Proliferation Following in vivo treatment with Valproic Acid in the two neuroblastoma models. 2010
Zeine Functional improvement, evidenced by Less leaky blood vessels, could be demonstrated by Spectrophotometric Quantitation of Evan’s Blue Extravasation. Mice bearing xenografts received a 0.2% solution of Evan’s Blue by tail vein injection. After 20 minutes in circulation, excess dye was removed by saline perfusion. Tumors were cut into pieces and placed in formamide for 72 hours at room temperature to facilitate dye extraction. We demonstrated a significant reduction in vessel permeability following treatment. 2010
Zeine We Also Noted Less Cancer-Associated Fibroblasts in the Valproic Acid Treated Xenografts. 2010
Zeine Conclusions: 1- Microvacular Proliferation is a Poor Prognostic Indicator present in SS-Poor Neuroblastoma Regions. 2- Cancer-Associated Fibroblasts Colocalize with Microvacular Proliferation and are Precluded from SS-Rich Regions of Neuroblastoma Tumors. 3- It is Possible to Reduce Cancer-Associated Fibroblast Infiltration by Increasing the Schwannian Component within the Tumor Microenvironment. 4- Anti-Angiogenic Treatment Reduced Microvascular Proliferation and Cancer-Associated Fibroblasts in Neuroblastoma Xenografts. 2010
Zeine Significance: Histopathologic Evaluation of Neuroblastoma Tumors for Microvascular Proliferation and Cancer-Associated Fibroblasts May Help Refine Risk Group and Prognostic Classification. May Have Impact on Eligibility Criteria for Stratification of Patients for Inclusion in Clinical Trials. May Guide Development of Novel Anti-Angiogenic and Anti-Stromal Treatment Strategies for Children with Aggressive Neuroblastoma. Results are Consistent with Tumor-Inhibitory Roles for Schwannian Derived Factors, and Tumor-Promoting Roles for Cancer-Associated Fibroblasts. 2010
Zeine I thank Sue Cohn and her lab members Radhika Peddinti, Alex Chlenski, Qiwei Yang, Helen Salwen, Yufeng Tian, Lisa Guerrero as well as the Pathcore staff at Northwestern University and University of Chicago I thank Maria Tretiakova for her help with ACIS II. We thank the statisticians Roopa Seshadri at Children’s Memorial Hospital and Wendy London of COG; and our collaborators at Children’s Hospital of Pennsylvania, John Maris, Kristina Cole and Bruce Pawel. 2010
Zeine Future Directions would be to Elucidate the Molecular Mechanisms for Tumor-Stromal Interactions and the Antagonism Between Fibrovascular Stroma and Schwannian Stroma. Discover and Identify Stromal Elements of Biologic and Clinical Significance in Cancer. Identify Cancer Stem Cells within tumors. Pursue Preclinical Testing of Therapeutic Strategies Targeting Tumor Stroma or Altering Tumor Microenvironment. 2010
Zeine Some of the Anti-Stromal Agents that are currently being Explored Experimentally include Aptenins, Phthoxazolin, Inthomycin B, Pioglitazone and Ciglitazone. Bundscherer et al. ’09, Kawada et al. ’08 and ’09 2010
Zeine The Prognosis is also impacted by Stage of Tumor; Stage 4 carrying a worse prognosis than stage 4S which was defined as dissemination limited to skin, liver and/or bone marrow in infants younger than 12 months. 2010
Zeine Masson Trichrome special stain Highlights Fibrovascular Stroma in the Schwannian-Stroma-POOR Neuroblastoma Tumors 2010