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1.  Extrarenal perivascular epithelioid cell tumors (PEComas) respond to mTOR inhibition: Clinical and molecular correlates 
Perivascular epithelioid cell tumors (PEComas) are a group of rare mesenchymal tumors that typically show both melanocytic and smooth muscle cell features. Some types of PEComa are seen at high frequency in tuberous sclerosis complex (TSC). The TSC1 and TSC2 genes are commonly mutated in both TSC-associated and sporadic PEComas, and mTOR signaling pathway activation is also common in these tumors. Preliminary reports have indicated that the mTOR inhibitors sirolimus and related drugs have activity in some patients with non-TSC-associated PEComa.
Here we report on the use of these medications in the treatment of five consecutive patients with extrarenal non-pulmonary PEComas seen at one institution. Three complete responses, one partial response and one case of progression were seen. Molecular studies identified TSC2 aberrations in four of these patients, and TFE3 translocation was excluded in the resistant case. A review of all published cases as well as those reported here indicates that partial or complete response was seen in 6 of 11 PEComas, with 5 of the 6 having a complete response. These findings highlight the consistent though incomplete activity of mTOR inhibitors in the treatment of PEComas.
PMCID: PMC3558545  PMID: 22927055
perivascular epithelioid cell tumor; PEComa; mTOR; TSC2; sirolimus; everolimus
2.  Advances in Integrative Nanomedicine for Improving Infectious Disease Treatment in Public Health 
Infectious diseases present public health challenges worldwide. An emerging integrative approach to treating infectious diseases is using nanoparticle (NP) forms of traditional and alternative medicines. Advantages of nanomedicine delivery methods include better disease targeting, especially for intracellular pathogens, ability to cross membranes and enter cells, longer duration drug action, reduced side effects, and cost savings from lower doses.
We searched Pubmed articles in English with keywords related to nanoparticles and nanomedicine. Nanotechnology terms were also combined with keywords for drug delivery, infectious diseases, herbs, antioxidants, homeopathy, and adaptation.
NPs are very small forms of material substances, measuring 1–100 nanometers along at least one dimension. Compared with bulk forms, NPs’ large ratio of surface-area-to-volume confers increased reactivity and adsorptive capacity, with unique electromagnetic, chemical, biological, and quantum properties. Nanotechnology uses natural botanical agents for green manufacturing of less toxic NPs.
Nanoparticle herbs and nutriceuticals can treat infections via improved bioavailability and antiinflammatory, antioxidant, and immunomodulatory effects. Recent studies demonstrate that homeopathic medicines may contain source and/or silica nanoparticles because of their traditional manufacturing processes. Homeopathy, as a form of nanomedicine, has a promising history of treating epidemic infectious diseases, including malaria, leptospirosis and HIV/AIDS, in addition to acute upper respiratory infections. Adaptive changes in the host’s complex networks underlie effects.
Nanomedicine is integrative, blending modern technology with natural products to reduce toxicity and support immune function. Nanomedicine using traditional agents from alternative systems of medicine can facilitate progress in integrative public health approaches to infectious diseases.
PMCID: PMC3685499  PMID: 23795222
Nanomedicine; Drug delivery systems; Medicinal plants; Herbal medicine; Antioxidants; Homeopathy; Nanoparticles; Silica; Infectious disease treatment; Adaptation; Network medicine
3.  Cixutumumab and temsirolimus for patients with bone and soft-tissue sarcoma: a multicentre, open-label, phase 2 trial 
The lancet oncology  2013;14(4):371-382.
Preclinical studies have shown synergistic antitumour activity by inhibition of insulin-like growth factor-1 receptor (IGF-1R) and mTOR. The expression of IGF-1R seems to be crucial for this effect. We investigated the safety and efficacy of the combination of the IGF-1R antibody cixutumumab and the mTOR inhibitor temsirolimus in patients with chemotherapy-refractory bone and soft-tissue sarcomas according to IGF-1R expression by immunohistochemistry.
We undertook a multicentre, open-label, phase 2 study in 19 cancer centres in the USA. Patients aged at least 16 years with a histologically confirmed diagnosis of bone or soft-tissue sarcoma were allocated on the basis of IGF-1R expression by immunohistochemistry to one of three treatment groups: IGF-1R-positive soft-tissue sarcoma (group A), IGF-1R-positive bone sarcomas (group B), or IGF-1R-negative bone and soft-tissue sarcoma (group C). Patients received weekly treatment with cixutumumab (6 mg/kg, intravenous) and temsirolimus (25 mg, intravenous flat dose) in 6-week cycles. A Simon optimal two-stage design was used for every arm. The primary endpoint was progression-free survival (PFS) at 12 weeks by intention-to-treat analysis in the first 54 patients assigned to every treatment arm. Although patients still remain on treatment, this trial has completed enrolment and this represents the final analysis. This study is registered with, number NCT01016015.
Between Nov 18, 2009, and April 11, 2012, 388 patients were screened for IGF-1R expression and 54 were assigned to each arm. 17 of 54 patients in the IGF-1R-positive soft-tissue sarcoma group (31%; one-sided 95% CI lower bound 21%; two-sided 90% CI 21–43), 19 of 54 in IGF-1R-positive bone sarcoma group (35%; one-sided 95% CI lower bound 24%; two-sided 90% CI 24–47), and 21 of 54 in the IGF-1R-negative group (39%, one-sided 95% CI lower bound 28%; two-sided 90% CI 28–51) were progression free at 12 weeks. On April 6, 2011, the protocol was amended to include three additional patients in the IGF-1R-positive soft-tissue sarcoma group (total of 57 patients) and nine more in the IGF-1R-negative group (total of 63 patients). There were 2546 adverse events reported during the study, 214 (8%) of which were grade 3–4. The most common grade 3–4 toxicities in the 174 treated patients were anaemia in 16 (9%) patients, hyperglycaemia in 18 (10%), hypophosphataemia in 16 (9%), lymphopenia in 25 (14%), oral mucositis in 19 (11%), and thrombocytopenia in 19 (11%).
The combination of cixutumumab and temsirolimus shows clinical activity in patients with sarcoma and forms a basis for future trials. However, IGF-1R expression by immunohistochemistry is not predictive of clinical outcome after treatment with this combination.
National Cancer Institute and Cycle for Survival Fund, Memorial Sloan-Kettering Cancer Center.
PMCID: PMC3766955  PMID: 23477833
4.  Central Leucine Sensing in the Control of Energy Homeostasis 
PMCID: PMC3568262  PMID: 23391241
food intake; leucine; nutrient sensing; rapamycin; S6K1; diabetes; obesity; hypothalamus; brainstem
5.  Genetic variants and non-genetic factors predict circulating vitamin D levels in Hispanic and non-Hispanic White women: the Breast Cancer Health Disparities Study 
Genome-wide association studies (GWAS) have identified common polymorphisms in or near GC, CYP2R1, CYP24A1, and NADSYN1/DHCR7 genes to be associated with circulating levels of 25-hydroxyvitamin D [25(OH)D] in European populations. To replicate these GWAS findings, we examined six selected polymorphisms from these regions and their relation with circulating 25(OH)D levels in 1,605 Hispanic women (629 U.S. Hispanics and 976 Mexicans) and 354 non-Hispanic White (NHW) women. We also assessed the potential interactions between these variants and known non-genetic predictors of 25(OH)D levels, including body mass index (BMI), sunlight exposure and vitamin D intake from diet and supplements. The minor alleles of the two GC polymorphisms (rs7041 and rs2282679) were significantly associated with lower 25(OH)D levels in both Hispanic and NHW women. The CYP2R1 polymorphism, rs2060793, also was significantly associated with 25(OH)D levels in both groups. We found no significant associations for the polymorphisms in the CYP24A1. In Hispanic controls, 25(OH)D levels were significantly associated with the rs12785878T and rs1790349G haplotype in the NADSYN1/DHCR7 region. Significant interactions between GC rs2282679 and BMI and between rs12785878 and time spent in outdoor activities were observed. These results provide further support for the contribution of common genetic variants to individual variability in circulating 25(OH)D levels. The observed interactions between SNPs and non-genetic factors warrant confirmation.
PMCID: PMC3939005  PMID: 24596595
Circulating levels; Hispanics; genetic polymorphisms; SNPs; genotype-phenotype correlation; vitamin D
6.  Low 25-Hydroxyvitamin D Predicts the Onset of Mobility Limitation and Disability in Community-Dwelling Older Adults: The Health ABC Study 
Although low 25-hydroxyvitamin D (25(OH)D) is prevalent among older adults and is associated with poor physical function, longitudinal studies examining vitamin D status and physical function are lacking. We examined the association between 25(OH)D, parathyroid hormone (PTH), and the onset of mobility limitation and disability over 6 years of follow-up in community-dwelling, initially well-functioning older adults participating in the Health, Aging and Body Composition study (n = 2,099).
Serum 25(OH)D and PTH were measured at the 12-month follow-up visit (1998–1999). Mobility limitation and disability (any/severe difficulty walking 1/4 mile or climbing 10 steps) was assessed semiannually over 6 years of follow-up. The association between 25(OH)D, PTH, and mobility limitation and disability was examined using Cox proportional hazard regression models adjusted for demographics, season, behavioral characteristics, and chronic conditions.
At baseline, 28.9% of the participants had 25(OH)D <50 nmol/L and 36.1% had 25(OH)D of 50 to <75 nmol/L. Participants with 25(OH)D <50 and 50 to <75 nmol/L were at greater risk of developing mobility limitation (HR (95% CI): 1.29 (1.04–1.61) and 1.27 (1.05–1.53), respectively) and mobility disability (HR (95% CI): 1.93 (1.32–2.81) and 1.30 (0.92–1.83), respectively) over 6 years of follow-up compared with participants with 25(OH)D ≥75 nmol/L. Elevated PTH, however, was not significantly associated with developing mobility limitation or disability.
Low 25(OH)D was associated with an increased risk of mobility limitation and disability in community-dwelling, initially well-functioning black and white older adults. Prevention or treatment of low 25(OH)D may provide a pathway for reducing the burden of mobility disability in older adults.
PMCID: PMC3598356  PMID: 22573914
25-hydroxyvitamin D; Mobility limitation; Vitamin D; Parathyroid hormone
7.  ΔNp63α Mediated Activation of Bone Morphogenetic Protein Signaling Governs Stem Cell Activity and Plasticity in Normal and Malignant Mammary Epithelial Cells 
Cancer research  2012;73(2):1020-1030.
Genetic analysis of TP63indicates that ΔNp63 isoforms are required for preservation of regenerative stasis within diverse epithelial tissues. In squamous carcinomas, TP63 is commonly amplified, and ΔNp63α confers a potent survival advantage. Genome-wide occupancy studies demonstrate that ΔNp63 promotes bidirectional target gene regulation by binding >5000 sites throughout the genome; however, the subset of targets mediating discreet activities of TP63 remains unclear. We report that ΔNp63α activates BMP signaling by inducing the expression of BMP7. Immunohistochemical analysis indicates that hyper-activation of BMP signaling is common in human breast cancers, most notably in the basal molecular subtype, as well as in several mouse models of breast cancer. Suppression of BMP signaling in vitro with LDN193189, a small molecule inhibitor of BMP Type I Receptor kinases, represses clonogenicity and diminishes the cancer stem cell enriched ALDH1+ population. Importantly, LDN193189 blocks reconstitution of mixed ALDH1+/ALDH1- cultures indicating that BMP signaling may govern aspects of cellular plasticity within tumor hierarchies. These results show that BMP signaling enables reversion of committed populations to a stem-like state, potentially supporting progression and maintenance of tumorigenesis. Treatment of a mouse model of breast cancer with LDN193189 caused reduced expression of markers associated with epithelial to mesenchymal transition (EMT). Furthermore, in vivo limiting dilution analysis assays revealed that LDN193189 treatment suppressed tumor-initiating capacity and increased tumor latency. These studies support a model in which ΔNp63α-mediated activation of BMP signaling governs epithelial cell plasticity, EMT, and tumorigenicity during breast cancer initiation and progression.
PMCID: PMC3739305  PMID: 23243027
BMP signaling; Breast Cancer; ΔNp63α; Epithelial to Mesenchymal Transition; Mammary Stem Cells
8.  Protective effects of low calcium intake and low calcium absorption vitamin D receptor genotype in the California Collaborative Prostate Cancer Study 
High calcium intake is consistently associated with increased prostate cancer risk in epidemiologic studies. We previously reported that the positive association between calcium intake and risk of aggressive prostate cancer was modified by the Vitamin D Receptor (VDR) calcium absorption genotype, Cdx2, among African American men.
We expanded our previous study to include White men, a population with a higher calcium intake and a higher prevalence of the low absorption allele. We also examined VDR polymorphisms at other loci unrelated to calcium absorption. The study included 1,857 prostate cancer cases (1,140 with advanced stage at diagnosis, 717 with localized stage) and 1,096 controls. Odds ratios (OR) were estimated using conditional logistic regression.
Among both Blacks and Whites, we observed a threshold for calcium intake (604 mg/day) below which prostate cancer risk declined sharply. Low calcium intake was most strongly associated with decreased risk among men with the VDR Cdx2 low calcium absorption genotype (p for interaction = 0.001 and p=0.06 for Whites and African Americans, respectively). Among all men with this genotype, those in the lowest quartile of calcium intake (<=604 mg/day) had a 50% reduction in risk compared to those in the upper three quartiles (OR=0.49, 95% CI=0.36–0.67). The association between calcium intake and prostate cancer risk was not modified by genotype at other VDR loci.
Conclusions and Impact
Our findings support the hypothesis that genetic determinants of calcium absorption influence prostate cancer risk and may contribute to racial disparities in prostate cancer incidence and mortality rates.
PMCID: PMC3763955  PMID: 23129590
Vitamin D receptor; calcium absorption; genetic polymorphism; prostate cancer; ethnicity
9.  25-Hydroxyvitamin D Status and Change in Physical Performance and Strength in Older Adults 
American Journal of Epidemiology  2012;176(11):1025-1034.
Low 25-hydroxyvitamin D (25(OH)D) concentrations are common among older adults and are associated with poorer physical performance and strength, but results from longitudinal studies have been inconsistent. The 25(OH)D threshold for physical performance and strength was determined, and both cross-sectional and longitudinal associations between 25(OH)D and physical performance and strength were examined, in men and women aged 71–80 years from the Health, Aging, and Body Composition Study (n = 2,641). Baseline serum 25(OH)D was measured in 1998–1999, and physical performance and strength were measured at baseline and at 2- and 4-year follow-up. Piecewise regression models were used to determine 25(OH)D thresholds. Linear regression and mixed models were used to examine cross-sectional and longitudinal associations. The 25(OH)D thresholds were 70–80 nmol/L for physical performance and 55–70 nmol/L for strength. Participants with 25(OH)D <50 nmol/L had poorer physical performance at baseline and at 2- and 4-year follow-up than participants with 25(OH)D ≥75 nmol/L (P < 0.01). Although physical performance and strength declined over 4 years of follow-up (P < 0.0001), in general, the rate of decline was not associated with baseline 25(OH)D. Older adults with low 25(OH)D concentrations had poorer physical performance over 4 years of follow-up, but low 25(OH)D concentrations were not associated with a faster rate of decline in physical performance or strength.
PMCID: PMC3571245  PMID: 23118104
aged; 25-hydroxyvitamin D; muscle strength; physical performance
10.  Comparison of Physical Therapy with Energy Healing for Improving Range of Motion in Subjects with Restricted Shoulder Mobility 
Two forms of energy healing, Reconnective Healing (RH) and Reiki, which involve light or no touch, were tested for efficacy against physical therapy (PT) for increasing limited range of motion (ROM) of arm elevation in the scapular plane. Participants were assigned to one of 5 groups: PT, Reiki, RH, Sham Healing, or no treatment. Except for no treatment, participants were blinded as to grouping. Range of Motion, self-reported pain, and heart rate variability (HRV) were assessed before and after a 10-minute session. On average, for PT, Reiki, RH, Sham Healing, and no treatment, respectively, ROM increased by 12°, 20°, 26°, 0.6°, and 3° and pain score decreased by 11.5%, 10.1%, 23.9%, 15.4%, and 0%. Physical therapy, Reiki, and RH were more effective than Sham Healing for increasing ROM (PT: F = 8.05, P = 0.008; Reiki: F = 10.48, P = 0.003; RH: F = 30.19, P < 0.001). It is possible that this improvement was not mediated by myofascial release because the subjects' HRV did not change, suggesting no significant increase in vagal activity. Sham treatment significantly reduced pain compared to no treatment (F = 8.4, P = 0.007) and was just as effective as PT, Reiki, and RH. It is the authors' opinion that the accompanying pain relief is a placebo effect.
PMCID: PMC3847956  PMID: 24327820
11.  Brainstem nutrient sensing in the nucleus of the solitary tract inhibits feeding 
Cell metabolism  2012;16(5):579-587.
Direct detection of circulating nutrients by the central nervous system has been implicated in the regulation of energy balance, and the mediobasal hypothalamus is considered the primary sensing site mediating these effects. Neurons sensitive to energy-related signals have also been identified outside the hypothalamus, particularly within the caudomedial nucleus of the solitary tract (cmNTS) in brainstem, but the consequences of direct NTS nutrient detection on energy balance remain poorly characterized. Here we determined the behavioral and metabolic consequences of direct L-leucine detection by the cmNTS and investigated the intracellular signaling and neurochemical pathways implicated in cmNTS L-leucine sensing in rats. Our results support the distributed nature of central nutrient detection, evidence a role for the cmNTS S6K1 pathway in the regulation of meal size and body weight, and suggest that the cmNTS integrates direct cmNTS nutrient detection with gut-derived, descending forebrain, and adiposity signals of energy availability to regulate food intake.
PMCID: PMC3537851  PMID: 23123165
12.  The Inverse Relationship between 25-Hydroxyvitamin D and Cancer Survival: Discussion of Causation 
Cancers  2013;5(4):1439-1455.
Cancer mortality rates vary inversely with geographic latitude and solar ultraviolet-B doses. This relationship may be due to an inhibitory role of vitamin D on cancer development. The relationship between vitamin D and cancer appears to be stronger for studies of cancer mortality than incidence. Because cancer mortality reflects both cancer incidence and survival, the difference may be due to effects of vitamin D on cancer survival. Here we review analytic epidemiologic studies investigating the relation between vitamin D, measured by circulating levels of 25-hydroxyvitamin D (25-OHD), and cancer survival. A relationship between low 25-OHD levels and poor survival is shown by most of the reviewed studies. This relationship is likely to be causal when viewed in light of most criteria for assessing causality (temporality, strength, exposure-response, biological plausibility and consistency). A serum level of 25-OHD around 50 nmol/L appears to be a threshold level. Conversely, there are several mechanisms whereby cancer could lower serum levels of 25-OHD. The severity of disease at the time of diagnosis and time of serum sampling are key factors to clarify the temporal aspect of these relationships. Evidence that vitamin D supplementation could retard the disease process or prolong survival time would be key evidence, but is difficult to generate. However, recent clinical trial results in prostate cancer support a role for vitamin D in this regard.
PMCID: PMC3875947  PMID: 24202453
vitamin D; cancer survival; causality; reverse causality; temporality
13.  Dropped head syndrome: Report of three cases during treatment with a MEK inhibitor 
Neurology  2012;79(18):1929-1931.
PMCID: PMC3525312  PMID: 23077008
14.  Central action of FGF19 reduces hypothalamic AGRP/NPY neuron activity and improves glucose metabolism★ 
Molecular Metabolism  2013;3(1):19-28.
Tight control of glucose excursions has been a long-standing goal of treatment for patients with type 2 diabetes mellitus in order to ameliorate the morbidity and mortality associated with hyperglycemia. Fibroblast growth factor (FGF) 19 is a hormone-like enterokine released postprandially that emerged as a potential therapeutic agent for metabolic disorders, including diabetes and obesity. Remarkably, FGF19 treatment has hypoglycemic actions that remain potent in models of genetic and acquired insulin resistance. Here, we provided evidence that the central nervous system responds to FGF19 administered in the periphery. Then, in two mouse models of insulin resistance, leptin-deficiency and high-fat diet feeding, third intra-cerebro-ventricular infusions of FGF19 improved glycemic status, reduced insulin resistance and potentiated insulin signaling in the periphery. In addition, our study highlights a new mechanism of central FGF19 action, involving the suppression of AGRP/NPY neuronal activity. Overall, our work unveils novel regulatory pathways induced by FGF19 that will be useful in the design of novel strategies to control diabetes in obesity.
PMCID: PMC3929918  PMID: 24567901
FGF19; Diabetes; Obesity; AGRP/NPY neurons
15.  PDGF receptor alpha is an alternative mediator of rapamycin-induced Akt activation: implications for combination targeted therapy of synovial sarcoma 
Cancer research  2012;72(17):4515-4525.
Akt activation by the IGF-1 receptor (IGF-1R) has been posited to be a mechanism of intrinsic resistance to mTORC1 inhibitors ("rapalogues") for sarcomas. Here we demonstrate that rapamycin-induced phosphorylation of Akt can occur in an IGF-1R-independent manner. Analysis of synovial sarcoma cell lines demonstrated that either the IGF-1R or the PDGF receptor alpha (PDGFRA) could mediate intrinsic resistance to rapamycin. Repressing expression of PDGFRA or inhibiting its kinase activity in synovial sarcoma cells blocked rapamycin-induced phosphorylation of Akt and decreased tumor viability. Expression profiling of clinical tumor samples revealed that PDGFRA was the most highly expressed kinase gene among several sarcoma disease subtypes, suggesting that PDGFRA may be uniquely significant for synovial sarcomas. Tumor biopsy analyses from a synovial sarcoma patient treated with the mTORC1 inhibitor everolimus and PDGFRA inhibitor imatinib mesylate confirmed that this drug combination can impact both mTORC1 and Akt signals in vivo. Together, our findings define mechanistic variations in the intrinsic resistance of synovial sarcomas to rapamycin and suggest therapeutic strategies to address them.
PMCID: PMC3432680  PMID: 22787122
mTOR; rapamycin; PDGFR; synovial sarcoma
16.  Calcium and Vitamin D Supplementation During Androgen Deprivation Therapy for Prostate Cancer: A Critical Review 
The Oncologist  2012;17(9):1171-1179.
Guidelines and studies on calcium and vitamin D supplementation in men with prostate cancer undergoing androgen deprivation therapy were reviewed. The authors conclude that the doses tested are inadequate to prevent loss of bone mineral density and that intervention studies are needed to evaluate safety and efficacy of calcium and vitamin D supplements in these men.
Learning Objectives
After completing this course, the reader will be able to: Describe the prevalence of bone loss with androgen deprivation therapy for prostate cancer.Discuss the possible increased risk of cardiovascular disease and of advanced prostate cancer with high calcium intake.
This article is available for continuing medical education credit at
Loss of bone mineral density is an unintended consequence of androgen deprivation therapy in men with prostate cancer. Supplementation with calcium and/or vitamin D in these men seems logical and is advocated by many lay and professional groups.
We reviewed guidelines for calcium and vitamin D supplementation and the results of clinical trials of calcium and vitamin D supplementation on bone mineral density in men with prostate cancer undergoing androgen deprivation therapy.
Whether supplementation of men undergoing androgen deprivation therapy with calcium and/or vitamin D results in higher bone mineral density than no supplementation has not been tested. The results of 12 clinical trials show that, at the doses commonly recommended, 500–1,000 mg calcium and 200–500 IU vitamin D per day, men undergoing androgen deprivation lose bone mineral density.
The doses of calcium and vitamin D that have been tested are inadequate to prevent loss of bone mineral density in men undergoing androgen deprivation therapy. In light of evidence that high levels of dietary calcium and calcium supplement use are associated with higher risks for cardiovascular disease and advanced prostate cancer, intervention studies should evaluate the safety as well as the efficacy of calcium and vitamin D supplementation in these men.
PMCID: PMC3448410  PMID: 22836449
Calcium; Vitamin D; Bone mineral density; Prostate cancer; Androgen deprivation therapy; Clinical trials
17.  A proof of principle clinical trial to determine whether conjugated linoleic acid modulates the lipogenic pathway in human breast cancer tissue 
Conjugated linoleic acid (CLA) is widely used as a “nutraceutical” for weight loss. CLA has anticancer effects in preclinical models, and we demonstrated in vitro that this can be attributed to the suppression of fatty acid (FA) synthesis. We tested the hypothesis that administration of CLA to breast cancer patients would inhibit expression of markers related to FA synthesis in tumor tissue, and that this would suppress tumor proliferation. Women with Stage I–III breast cancer were enrolled into an open label study and treated with CLA (1:1 mix of 9c,11t- and 10t,12c-CLA isomers, 7.5 g/d) for ≥10 days before surgery. Fasting plasma CLA concentrations measured pre- and post-CLA administration, and pre/post CLA tumor samples were examined by immunohistochemistry for Spot 14 (S14), a regulator of FA synthesis, FA synthase (FASN), an enzyme of FA synthesis, and lipoprotein lipase (LPL), the enzyme that allows FA uptake. Tumors were also analyzed for expression of Ki-67 and cleaved caspase 3. 24 women completed study treatment, and 23 tumors were evaluable for the primary endpoint. The median duration of CLA therapy was 12 days, and no significant toxicity was observed. S14 expression scores decreased (p = 0.003) after CLA administration. No significant change in FASN or LPL expression was observed. Ki-67 scores declined (p = 0.029), while cleaved caspase 3 staining was unaffected. Decrements in S14 or Ki-67 did not correlate with fasting plasma CLA concentrations at surgery. Breast tumor tissue expression of S14, but not FASN or LPL, was decreased after a short course of treatment with 7.5 g/day CLA. This was accompanied by reductions in the proliferation index. CLA consumption was well-tolerated and safe at this dose for up to 20 days. Overall, CLA may be a prototype compound to target fatty acid synthesis in breast cancers with a “lipogenic phenotype”.
PMCID: PMC3736354  PMID: 23417336
Breast cancer; Fatty acid; Metabolism; Conjugated linoleic acid
18.  Autophagy in Myf5+ progenitors regulates energy and glucose homeostasis through control of brown fat and skeletal muscle development 
EMBO Reports  2013;14(9):795-803.
Autophagy in Myf5+ progenitors regulates energy and glucose homeostasis through control of brown fat and skeletal muscle development
Atg7 deletion in Myf5+ progenitors blocks autophagy in brown adipose tissue and muscle, affecting their differentiation and function. Knockout mice have higher body temperatures and glucose intolerance, underscoring the importance of autophagy in these processes.
Macroautophagy (MA) regulates cellular quality control and energy balance. For example, loss of MA in aP2-positive adipocytes converts white adipose tissue (WAT) into brown adipose tissue (BAT)-like, enhancing BAT function and thereby insulin sensitivity. However, whether MA regulates early BAT development is unknown. We report that deleting Atg7 in myogenic Myf5+ progenitors inhibits MA in Myf5-cell-derived BAT and muscle. Knock out (KO) mice have defective BAT differentiation and function. Surprisingly, their body temperature is higher due to WAT lipolysis-driven increases in fatty acid oxidation in ‘Beige' cells in inguinal WAT, BAT and muscle. KO mice also present impaired muscle differentiation, reduced muscle mass and glucose intolerance. Our studies show that ATG7 in Myf5+ progenitors is required to maintain energy and glucose homeostasis through effects on BAT and muscle development. Decreased MA in myogenic progenitors with age and/or overnutrition might contribute to the metabolic defects and sarcopenia observed in these conditions.
PMCID: PMC3790054  PMID: 23907538
Autophagy; Myf5+ progenitors; brown fat
19.  Chemotherapy in the Management of Advanced Cutaneous Malignant Melanoma 
Clinics in dermatology  2013;31(3):290-297.
The recent past has witnessed unprecedented clinical progress in the treatment of advanced malignant melanoma through targeting of mutant BRAF in approximately 50 percent of patients and immune check point blockade in all patients. As has been well documented however, responses to targeted therapy are of limited duration and rates of clinical benefit to immunotherapy are modest. Given these factors, palliation of patients with chemotherapy remains an essential aspect of melanoma oncology. Many chemotherapeutics (and combinations with other agents such as immunotherapy) have been evaluated in melanoma however no chemotherapy regimen has been documented to provide an overall survival benefit in a prospective, randomized, well controlled phase III study. Here, we overview the development of the most common chemotherapy regimens for melanoma, discuss the clinical trial evidence supporting and contrasting them and highlight appropriate clinical situations in which they might be employed. Finally, we discuss the future of chemotherapy for melanoma, noting the potential for combinations of chemotherapy with either targeted or immunotherapeutic agents.
PMCID: PMC3709980  PMID: 23608448
20.  Identification of unique MEK-dependent genes in GNAQ mutant uveal melanoma involved in cell growth, tumor cell invasion and MEK-resistance. 
Metastatic uveal melanoma (UM) represents the most common intraocular malignancy with very poor prognosis and no effective treatments. Oncogenic mutations in the G protein alpha subunit q and 11 have been described in about 85% of uveal melanomas and confer constitutive activation. Multiple signaling pathways are induced as a consequence of GNAQ/11 activation, which include the MEK/ERK kinase cascade. We analyzed the transcriptional profile of cell lines treated with a MEK inhibitor to identify gene targets of activated GNAQ and evaluate the biological importance of these genes in UM.
Experimental Design
We performed microarray analysis of UM cell lines with GNAQ mutations treated with the MEK inhibitor selumetinib. For comparison, we used cells carrying BRAFV600E and cells without either mutation. Changes in the expression of selected genes were then confirmed by real-time qPCR and immunoblotting.
We found that GNAQ mutant cells have a MEK-dependent transcriptional output and identified a unique set of genes that are down-regulated by MEK inhibition, including the RNA helicase DDX21 and the cyclin dependent kinase regulator CDK5R1, while JUN was induced. We provide evidence that these genes are involved in cell proliferation, tumor cell invasion and drug resistance, respectively. Furthermore, we show that selumetinib treatment regulates the expression of these genes in tumor tissues of patients with metastatic GNAQ/11 mutant uveal melanoma. Conclusions: Our findings define a subset of transcriptionally regulated genes by selumetinib in GNAQ mutant cells and provide new insights into understanding the biologic effect of MEK inhibition in this disease.
PMCID: PMC3433236  PMID: 22550165
selumetinib; microarray; metastasis; JUN
Hypertension  2012;59(6):1204-1211.
To identify genes influencing blood pressure response to an angiotensin II receptor blocker, single nucleotide polymorphisms identified by genome-wide association analysis of the response to candesartan were validated by opposite direction associations with the response to a thiazide diuretic, hydrochlorothiazide. 198 White and 193 African Americans with primary hypertension were sampled from opposite tertiles of the race-sex-specific distributions of age-adjusted diastolic blood pressure response to candesartan. 285 polymorphisms associated with the response to candesartan at p<10−4 in Whites. 273 of the 285 polymorphisms, which were available for analysis in a separate sample of 196 Whites, validated for opposite direction associations with the response to hydrochlorothiazide (Fisher’s X2 1-sided p=0.02). Among the 273 polymorphisms, those in the chromosome 11q21 region were the most significantly associated with response to candesartan in Whites (e.g., rs11020821 near FUT4, p=8.98×10−7), had the strongest opposite direction associations with response to hydrochlorothiazide (e.g., rs3758785 in GPR83, p=7.10×10−3), and had same direction associations with response to candesartan in the 193 African Americans (e.g., rs16924603 near FUT4, p=1.52×10−2). Also notable among the 273 polymorphisms was rs11649420 on chromosome 16 in the amiloride-sensitive sodium channel subunit SCNN1G involved in mediating renal sodium reabsorption and maintaining blood pressure when the renin-angiotensin system is inhibited by candesartan. These results support the utility of genomewide association analyses to identify novel genes predictive of opposite direction associations with blood pressure responses to inhibitors of the renin-angiotensin and renal sodium transport systems.
PMCID: PMC3530397  PMID: 22566498
Hypertension; pharmacogenetics; diuretic; blood pressure; genome
22.  Risk factor profile for chronic kidney disease is similar to risk factor profile for small artery disease 
Journal of hypertension  2011;29(9):1796-1801.
Background and method
We investigated whether chronic kidney disease detected by increased serum creatinine (SCr) or urine albumin-to-creatinine ratio (UACR) may reflect arteriosclerosis involving the kidneys. The sample consisted of 1585 members of sibships (804 non-Hispanic whites and 781 non-Hispanic blacks) in which at least two siblings had primary hypertension. We first evaluated the correlations of increased SCr and UACR with the presence of cerebral small vessel arteriosclerosis, which was determined by increased subcortical white matter hyperintensity (WMH) volume on brain magnetic resonance imaging; and with peripheral large vessel arteriosclerosis, which was determined by decreased ankle-brachial index (ABI). After age adjustment, increased SCr and UACR correlated with increased WMH volume (0.54 and 0.52, respectively) and with decreased ABI (0.50 and 0.54, respectively; all P < 0.001). We then used logistic regression to evaluate the dependency of each measure of disease on conventional risk factors for arteriosclerosis to assess whether the risk factors’ effects were proportional across different measures of disease.
Age, race, sex, hypertension, diabetes, total cholesterol, and smoking made similar overall contributions to the prediction of each measure of disease, as judged by the model C-statistics, which varied in a narrow range from 0.84 to 0.85 (all P < 0.001). However, the relative contributions that the modifiable risk factors, including hypertension, diabetes, total cholesterol, and smoking made to prediction of increased SCr and UACR were disproportionate to their relative contributions to prediction of decreased ABI (P < 0.0001).
The findings support the view that chronic kidney disease detected by increased SCr or UACR primarily reflects small vessel arteriosclerosis involving the kidneys.
PMCID: PMC3651813  PMID: 21720267
albuminuria; ankle-brachial blood pressure index; arteriosclerosis; blood pressure; glomerular filtration rate; hypertension; subcortical white matter hyperintensity
23.  The cyclin-dependent kinase inhibitor flavopiridol potentiates doxorubicin efficacy in advanced sarcomas: preclinical investigations and results of a phase I dose escalation clinical trial 
Clinical Cancer Research  2012;18(9):2638-2647.
Dysregulated cyclin-dependent kinases (CDKs) are important to the growth of some sarcomas. Flavopiridol is a pan-CDK inhibitor that has been shown to potentiate chemotherapy. As such, we explored the potentiation of doxorubicin by flavopiridol in sarcoma, in vitro and in vivo, and performed a phase I trial of flavopiridol with doxorubicin in patients with advanced sarcomas.
Sarcoma cell lines and xenografts were treated with flavopiridol alone and in combination with doxorubicin. In the phase I study, doxorubicin and flavopiridol were administered on 2 flavopiridol schedules; a 1 hour bolus and split dosing as a 30 minute bolus followed by a 4 hour infusion.
Pre-clinically, flavopiridol potentiated doxorubicin. In vivo, doxorubicin administered 1 hour prior to flavopiridol was more active than doxorubicin alone. Clinically, 31 patients were enrolled on protocol and flavopiridol was escalated to target dose in 2 schedules (90 mg/m2 bolus; 50 mg/m2 bolus + 40 mg/m2 infusion) both in combination with doxorubicin (60 mg/m2). Dose-limiting toxicities were neutropenia, leukopenia and febrile neutropenia but no maximum tolerated dose was defined. Flavopiridol pharmacokinetics showed increasing Cmax with increasing dose. RECIST responses included 2 partial responses however stable disease was seen in 16 patients. Of 12 evaluable patients with progressive well- and de-differentiated liposarcoma, 8 had stable disease greater than 12 weeks.
The sequential combination of doxorubicin followed flavopiridol is well tolerated on both schedules. Disease control was observed in well- and de-differentiated liposarcoma specifically, a disease where CDK4 is known to be amplified.
PMCID: PMC3343204  PMID: 22374332
Flavopiridol; Sarcoma; Cyclin-dependent kinase; CDK; phase I
24.  Multiweek Resting EEG Cordance Change Patterns from Repeated Olfactory Activation with Two Constitutionally Salient Homeopathic Remedies in Healthy Young Adults 
Electroencephalography (EEG) offers psychophysiologic tools to improve sensitivity for detecting objective effects in complementary and alternative medicine. This current investigation extended prior clinical research studies to evaluate effects of one of two different homeopathic remedies on resting EEG cordance after an olfactory activation protocol on healthy young adults with remedy-relevant, self-perceived characteristics.
Ninety-seven (7) young adults (N=97, mean age 19 years, 55% women) with good self-rated global health and screened for homeopathic constitutional types consistent with one of two remedies (either Sulphur or Pulsatilla) underwent three weekly laboratory sessions. At each visit, subjects had 5-minute resting, eyes-closed EEG recordings before and after a placebo-controlled olfactory activation task with their constitutionally relevant verum remedy. One remedy potency (6c, 12c, or 30c) used per week, was presented in a randomized order over the 3 sessions. Prefrontal resting EEG cordance values at Fp1 and Fp2 were computed from artifact-free 2-minute EEG samples from the presniffing and postsniffing rest periods. Cordance derives from an algorithm that incorporates absolute and relative EEG values.
The data showed significant two-way oscillatory interactions of remedy by time for ß, α, θ, and δ cordance, controlling for gender and chemical sensitivity.
EEG cordance provided a minimally invasive technique for assessing objective nonlinear physiologic effects of two different homeopathic remedies salient to the individuals who received them. Time factors modulated the direction of effects. Given previous evidence of correlations between cordance and single-photon emission computed tomography, these findings encourage additional neuroimaging research on nonlinear psychophysiologic effects of specific homeopathic remedies.
PMCID: PMC3353816  PMID: 22594648
25.  Microwave imaging for neoadjuvant chemotherapy monitoring: initial clinical experience 
Microwave tomography recovers images of tissue dielectric properties, which appear to be specific for breast cancer, with low-cost technology that does not present an exposure risk, suggesting the modality may be a good candidate for monitoring neoadjuvant chemotherapy.
Eight patients undergoing neoadjuvant chemotherapy for locally advanced breast cancer were imaged longitudinally five to eight times during the course of treatment. At the start of therapy, regions of interest (ROIs) were identified from contrast-enhanced magnetic resonance imaging studies. During subsequent microwave examinations, subjects were positioned with their breasts pendant in a coupling fluid and surrounded by an immersed antenna array. Microwave property values were extracted from the ROIs through an automated procedure and statistical analyses were performed to assess short term (30 days) and longer term (four to six months) dielectric property changes.
Two patient cases (one complete and one partial response) are presented in detail and demonstrate changes in microwave properties commensurate with the degree of treatment response observed pathologically. Normalized mean conductivity in ROIs from patients with complete pathological responses was significantly different from that of partial responders (P value = 0.004). In addition, the normalized conductivity measure also correlated well with complete pathological response at 30 days (P value = 0.002).
These preliminary findings suggest that both early and late conductivity property changes correlate well with overall treatment response to neoadjuvant therapy in locally advanced breast cancer. This result is consistent with earlier clinical outcomes that lesion conductivity is specific to differentiating breast cancer from benign lesions and normal tissue.
PMCID: PMC3672734  PMID: 23621959

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