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1.  Rocaglamide, Silvestrol and Structurally Related Bioactive Compounds from Aglaia Species 
Natural product reports  2014;31(7):924-939.
Investigations on the chemistry and biology of rocaglamide, silvestrol and structurally related bioactive compounds from Aglaia species during the period 2006–2013 are reviewed. Included are new phytochemical studies of naturally occurring rocaglamide derivatives, an update on synthetic methods for cyclopenta[b]benzofurans, and a description of the recent biological evaluation and mechanism-of-action studies on compounds of this type.
PMCID: PMC4091845  PMID: 24788392
2.  Flavaglines target primitive leukemia cells and enhance anti-leukemia drug activity 
Leukemia  2014;28(10):1960-1968.
Identification of agents that target human leukemia stem cells (LSCs) is an important consideration for the development of new therapies. The present study demonstrates that rocaglamide and silvestrol, closely related natural products from the flavagline class of compounds, are able to preferentially kill functionally defined LSCs while sparing normal stem and progenitor cells. In addition to efficacy as single agents, flavaglines sensitize leukemia cells to several anti-cancer compounds, including front-line chemotherapeutic drugs used to treat leukemia patients. Mechanistic studies indicate that flavaglines strongly inhibit protein synthesis, leading to the reduction of short-lived anti-apoptotic proteins. Notably though, treatment with flavaglines alone or in combination with other drugs, yields a much stronger cytotoxic activity towards leukemia cells than the translational inhibitor temsirolimus. These results indicate that the underlying cell death mechanism of flavaglines is more complex than simply inhibiting general protein translation. Global gene expression profiling and cell biological assays identified Myc inhibition and the disruption of mitochondrial integrity to be features of flavaglines, which we propose contribute to their efficacy in targeting leukemia cells. Together, these findings indicate that rocaglamide and silvestrol are distinct from clinically available translational inhibitors and represent promising candidates for the treatment of leukemia.
PMCID: PMC4148474  PMID: 24577530
leukemia; stem cells; silvestrol; rocaglamide; flavaglines
3.  Acute phosphine poisoning on board a bulk carrier: analysis of factors leading to a fatal case 
To determine accidental factors, clinical presentation and medical care in cases of seafarers presenting phosphine poisoning symptoms on board a bulk carrier.
To consider primary prevention of this pathology, which can have extremely severe consequences.
To analyse circumstances resulting in toxic exposure to phosphine in the sea transport sector.
To obtain information from medical reports regarding the seafarer’s rescue.
To identify the causes of this accidental poisoning and how to establish an early, appropriate diagnosis thus avoiding other cases.
In February 2008, on board a bulk carrier with a cargo of peas, a 56-year-old seafarer with intense abdominal and chest pains, associated with dizziness, was rescued by helicopter 80 miles away from the coast. Despite being admitted rapidly to hospital, his heart rate decreased associated with respiratory distress. He lost consciousness and convulsed. He finally died of pulmonary oedema, major metabolic acidosis and acute multi organ failure.
The following day, the captain issued a rescue call from the same vessel for a 41-year-old man also with abdominal pain, vomiting and dizziness. The ECG only revealed type 1 Brugada syndrome.
Then 11 other seafarers were evacuated for observation. 3 showed clinical abnormalities.
Collective poisoning was suspected.
Medical team found out that aluminium phosphide pellets had been put in the ship’s hold for pest control before the vessel’s departure. Seafarers were poisoned by phosphine gas spreading through cabins above the hold. It was found that the compartments and ducts were not airtight.
Unfortunately, a seafarer on board a bulk carrier died in 2008 because of acute phosphine poisoning. Fumigation performed using this gas needs to be done with extreme care. Systematic checks need to be carried out before sailing to ensure that the vessel’s compartments are airtight.
PMCID: PMC4354992  PMID: 25763098
Phosphine; Poisoning; Seafarer; Death; Bulk carrier
4.  The multidisciplinary management of bone and soft tissue sarcoma: an essential organizational framework 
The rarity of bone and soft tissue sarcoma, the difficulty in interpretation of imaging and histology, the plethora of treatment modalities, and the complexity and intensity of the treatment contribute to the need for systematic multidisciplinary team management of patients with these diseases. An integrated multidisciplinary clinic and team with a structured sarcoma tumor board facilitate team coordination and communication. This paper reviews the rationale for multidisciplinary management of sarcoma and details the operational structure of the Multidisciplinary Sarcoma Clinic and Sarcoma Tumor Board. The structured Multidisciplinary Sarcoma Tumor Board provides opportunity for improvement in logistics, teaching, quality, and enrollment in clinical trials.
PMCID: PMC4340372  PMID: 25733913
sarcoma; sarcoma care; sarcoma tumor board; collaborative approach
5.  The translation inhibitor silvestrol exhibits direct anti-tumor activity while preserving innate and adaptive immunity against EBV-driven lymphoproliferative disease 
Oncotarget  2014;6(5):2693-2708.
Treatment options for patients with Epstein-Barr Virus-driven lymphoproliferative diseases (EBV-LPD) are limited. Chemo-immunotherapeutic approaches often lead to immune suppression, risk of lethal infection and EBV reactivation, thus it is essential to identify agents that can deliver direct anti-tumor activity while preserving innate and adaptive host immune surveillance. Silvestrol possesses direct anti-tumor activity in multiple hematologic malignancies while causing minimal toxicity to normal mononuclear cells. However, the effects of silvestrol on immune function have not been described. We utilized in vitro and in vivo models of EBV-LPD to simultaneously examine the impact of silvestrol on both tumor and normal immune function. We show that silvestrol induces direct anti-tumor activity against EBV-transformed lymphoblastoid cell lines (LCL), with growth inhibition, decreased expression of the EBV oncogene latent membrane protein-1, and inhibition of the downstream AKT, STAT1 and STAT3 signaling pathways. Silvestrol promoted potent indirect anti-tumor effects by preserving expansion of innate and EBV antigen-specific adaptive immune effector subsets capable of effective clearance of LCL tumor targets in autologous co-cultures. In an animal model of spontaneous EBV-LPD, silvestrol demonstrated significant therapeutic activity dependent on the presence of CD8-positive T-cells. These findings establish a novel immune-sparing activity of silvestrol, justifying further exploration in patients with EBV-positive malignancies.
PMCID: PMC4413611  PMID: 25393910
Lymphoproliferative disease; EBV; silvestrol; immunomodulation
6.  Potentiating Effect of the Flavonolignan (-)-Hydnocarpin in Combination with Vincristine in a Sensitive and P-gp-Expressing Acute Lymphoblastic Leukemia Cell Line 
Phytotherapy research : PTR  2012;27(11):10.1002/ptr.4903.
The potentiating action of the flavonolignan, (-)-hydnocarpin, in combination with vincristine was evaluated in the 697 acute lymphoblastic leukemia cell line and a P-gp-expressing variant, 697-R. Vincristine at 3 nM caused nearly complete growth inhibition in 697 cells, versus a 17% growth inhibition in 697-R cells. When combined with (-)-hydnocarpin at concentrations of 10 and 5 µM, vincristine-mediated growth inhibition in the 697-R cells increased significantly over the sum of the individual agents to 72% (p ≤ 0.0001), and 41% (p = 0.0256), respectively. Vincristine at 1.5 nM (66% growth inhibition) and 0.75 nM (39% growth inhibition) combined with (-)-hydnocarpin at 10 µM (42% growth inhibition) in the 697 cells, caused a significant increase in growth inhibition to 83% (p = 0.03) and to 61% (p < 0.0001), respectively, when compared to vincristine treatment as a single agent. To investigate the mechanism for the vincristine re-sensitization caused by (-)-hydnocarpin, the P-gp inhibitory effect of (-)-hydnocarpin was evaluated.
PMCID: PMC3639301  PMID: 23280566
P-glycoprotein; multidrug resistance; (-)-hydnocarpin; vincristine
7.  Bioactive Constituents of Indigofera spicata 
Journal of natural products  2013;76(8):1498-1504.
Four new flavanones, designated as (+)−5″-deacetylpurpurin (1), (+)−5-methoxypurpurin (2), (2S)-2,3-dihydrotephroglabrin (3), and (2S)-2,3-dihydrotephroapollin C (4), together with two known flavanones (5 and 6), three known rotenoids (7–9), and one known chalcone (10) were isolated from a chloroform-soluble partition of a methanol extract from the combined flowers, fruits, leaves, and twigs of Indigofera spicata, collected in Vietnam. The compounds were obtained by bioactivity-guided isolation using HT-29 human colon cancer, 697 human acute lymphoblastic leukemia, and Raji human Burkitt’s lymphoma cell lines. The structures of 1–4 were established by extensive 1D- and 2D-NMR experiments and the absolute configurations were determined by the measurement of specific rotations and CD spectra. The cytotoxic activities of the isolated compounds were tested against the HT-29, 697, Raji and the CCD-112CoN human normal colon cells. Also, the quinone reductase induction activities of the isolates were determined using the Hepa 1c1c7 murine hepatoma cell line. In addition, cis-6aβ−12aβ-hydroxyrotenone (7) was evaluated in an in vivo hollow fiber bioassay using HT-29, MCF-7 human breast cancer, and MDA-MB-435 human melanoma cells.
PMCID: PMC3806331  PMID: 23895019
8.  Standard Pentostatin Dose Reductions in Renal Insufficiency are not Adequate: Selected Patients with Steroid-Refractory Acute Graft-versus-Host Disease 
Clinical pharmacokinetics  2013;52(8):705-712.
Background and Objective
Pentostatin is an irreversible inhibitor of adenosine deaminase and has been used to prevent graft-versus-host disease (GVHD) and to treat both acute and chronic GVHD. Dose reduction equations for patients with renal insufficiency are based on few patients with limited pharmacokinetic and clinical results. This phase II study (NCT00201786) was conducted to assess pentostatin efficacy and infectious complications seen from our previous phase I study in steroid-refractory acute GVHD (aGVHD).
Patients and Methods
Hospitalized patients with steroid-refractory aGVHD were given pentostatin 1.5 mg/m2/day intravenously on days 1–3 of each 14 day cycle. Prior to each dose, dose modifications were based on Cockcroft-Gault estimated creatinine clearance (eCrCL) with 30–50 ml/min/1.73m2 leading to a 50% dose reduction and eCrCL< 30 ml/min/1.73m2 leading to study removal. Plasma pentostatin area under the concentration-time curve (AUC) and incidence of infectious complications were evaluated.
Two of the eight patients treated demonstrated excessive pentostatin exposure as determined by measurement of AUC. One of these patients had renal impairment while the other patient demonstrated borderline renal function. Despite dose reduction to 0.75 mg/m2, AUCs were significantly increased compared to the other patients in this study. Seven of eight patients treated with pentostatin had cytomegalovirus (CMV) viremia after pentostatin treatment; however none developed proven CMV disease.
A 50% dose reduction in patients with eCrCL 30–50 ml/min/1.73m2 seems reasonable. However, the eCrCL should be interpreted with extreme cautions in patients who are critically ill and/or with poor performance status. Renal function assessment based on the Cockcroft-Gault method could be significantly overestimated thus risking pentostatin over-dosing. These results imply a need to closely monitor pentostatin exposure in patients with renal insufficiency.
PMCID: PMC3720841  PMID: 23588536
9.  A Phase I/II Study of Etanercept and Rituximab in Patients with Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma 
Leukemia  2009;23(5):912-918.
Rituximab has modest activity in relapsed Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) but is associated with TNF-α release that can cause CLL proliferation and inhibit apoptosis. We examined whether disruption of TNF-α by etanercept improves response to rituximab in CLL. Eligible patients had previously treated CLL with performance status 0–3. Patients received etanercept 25 mg subcutaneously twice weekly (weeks 1–5) and rituximab 375 mg/m2 intravenously thrice weekly (weeks 2–5) using a phase I/II design. Primary endpoints were response and toxicity. The 36 enrolled patients had a median of 2 prior treatments; 50% were fludarabine-refractory, and 22% had del(17p13.1). Of the 34 response-evaluable patients, ten (29%) responded, including 9 partial responses and 1 complete remission. Response was not affected by prior rituximab nor fludarabine-refractory status, but no patients with del(17p13.1) responded. Median PFS for responders was 9.0 months (range 1–43). Ten patients have had treatment-free intervals exceeding 12 months, including four who have remained untreated for 32, 43, 46 and 56 months. Adverse events were mild, including mild infusion reactions, transient cytopenias and grade 3 infections in 14%. The combination of etanercept and thrice weekly rituximab produces durable remissions in non-del(17p13.1) CLL patients and is well tolerated.
PMCID: PMC4099250  PMID: 19225537
Rituximab; Etanercept; chronic lymphocytic leukemia
10.  Utility of a Monoclonal ERG/FLI1 Antibody for Immunohistochemical Discrimination of Ewing’s Family Tumors 
Ewing family tumors (EFTs) and prostate carcinomas (PCa) are characterized by rearrangement of ETS genes, most commonly FLI1 (EFTs) and ERG (PCa). Previously, we characterized an antibody against ERG (EPR3864) for detecting ERG-rearranged PCa. EPR3864 also cross reacts with FLI1, thus, here we evaluated the utility of EPR3864 for discriminating EFTs from other small round blue cell tumors (SRBCTs) by immunohistochemistry. Of 57 evaluable EFTs, 47 (82%) demonstrated at least moderate, diffuse, nuclear ERG/FLI1 staining (including 89% and 100% of cases with confirmed EWSR1:FLI1 and EWSR1:ERG fusions, respectively), of which 1, 3 and 43 showed negative, cytoplasmic or membranous CD99 staining, respectively. Amongst other SRBCTs (n=61 cases, 6 types), at least moderate, diffuse, nuclear EPR3864 staining was seen in all precursor-B-lymphoblastic lymphomas/leukemias and subsets of Burkitt’s lymphomas (10%) and synovial sarcomas (45%). In summary, EPR3864 may have utility for detecting EWSR1:FLI1 and EWSR1:ERG rearranged EFTs, in addition to PCa.
PMCID: PMC3662488  PMID: 23690120
EPR3864; EWSR1:FLI1; EWSR1:ERG; Ewing’s tumor
11.  Second malignancies in B-cell chronic lymphocytic leukaemia: possible association with human papilloma virus 
British journal of haematology  2010;149(3):388-390.
Second primary malignancies have long been associated with chronic lymphocytic leukaemia (CLL). We assessed secondary tumour samples from CLL and control patients for the presence of human papilloma virus (HPV). 132 CLL patients with 44 second malignancies were compared to a matched randomly-identified control population of 264 non-CLL patients with 54 solid malignancies. Polymerase chain reaction was performed with the highly conserved MY09/MY11 HPV primer. None of control samples were HPV-positive, while 53% of samples from the CLL group were positive. This report describes preliminary evidence for the presence of HPV in secondary malignancies, in patients with CLL.
PMCID: PMC4038061  PMID: 20230400
human papilloma virus; second primary malignancy; chronic lymphocytic leukaemia
12.  The Proteasome Inhibitor Carfilzomib Functions Independently of p53 To Induce Cytotoxicity and an Atypical NF-κB Response in Chronic Lymphocytic Leukemia Cells 
The proteasome consists of chymotrypsin-like (CT-L), trypsin-like, and caspase-like subunits that cleave substrates preferentially by amino acid sequence. Proteasomes mediate degradation of regulatory proteins of the p53, Bcl-2 and nuclear factor-κB (NF-κB) families that are aberrantly active in chronic lymphocytic leukemia (CLL). CLL remains an incurable disease, and new treatments are especially needed in the relapsed/refractory setting. We therefore investigated the effects of the proteasome inhibitor carfilzomib (CFZ) in CLL cells.
Experimental Design
Tumor cells from CLL patients were assayed in vitro using immunoblotting, real-time polymerase chain reaction and electrophoretic mobility shift assays. Additionally, a p53 dominant-negative construct was generated in a human B-cell line.
Unlike bortezomib, CFZ potently induces apoptosis in CLL patient cells in the presence of human serum. CLL cells have significantly lower basal CT-L activity compared to normal B and T cells, although activity is inhibited similarly in T cells vs. CLL. and the cytotoxicity of CFZ correlates with baseline CT-L activity. Co-culture of CLL cells on stroma protected from CFZ-mediated cytotoxicity; however, PI3K inhibition significantly diminished this stromal protection. CFZ-mediated cytotoxicity in leukemic B-cells is caspase-dependent and occurs irrespective of p53 status. In CLL cells, CFZ promotes atypical activation of NF-κB evidenced by loss of cytoplasmic IkBα, phosphorylation of IκBα and increased p50/p65 DNA binding, without subsequent increases in canonical NF-κB target gene transcription.
Together, these data provide new mechanistic insights into the activity of CFZ in CLL and support Phase I investigation of CFZ in this disease.
PMCID: PMC3644010  PMID: 23515408
proteasome; carfilzomib; bortezomib; p53; NF-kB
13.  Involvement of RhoH GTPase in the Development of B-Cell Chronic Lymphocytic Leukemia 
Leukemia  2009;24(1):10.1038/leu.2009.217.
RhoH is a hematopoietic-specific, GTPase-deficient member of the Rho GTPase family that functions as a regulator of thymocyte development and T-cell receptor signaling by facilitating localization of ZAP70 to the immunological synapse. Here we investigated the role of RhoH in the B-cell lineage. B-cell receptor (BCR) signaling was intact in Rhoh−/− mice. Since RhoH interacts with ZAP70, which is a prognostic factor in B-cell chronic lymphocytic leukemia (CLL), we analyzed the mRNA levels of RhoH in primary human CLL cells and demonstrated a 2.3-fold higher RhoH expression compared to normal B cells. RhoH expression in CLL positively correlated with the protein levels of ZAP70. Deletion of Rhoh in a murine model of CLL (Eμ-TCL1Tg mice) significantly delayed the accumulation of CD5+IgM+ leukemic cells in peripheral blood and the leukemic burden in the peritoneal cavity, bone marrow and spleen of Rhoh−/− mice compared with their Rhoh+/+ counterparts. Phosphorylation of AKT and ERK in response to BCR stimulation was notably decreased in Eμ-TCL1Tg;Rhoh−/− splenocytes. These data suggest that RhoH plays a role in the progression of CLL in a murine model and shows RhoH expression is altered in human primary CLL samples.
PMCID: PMC3869226  PMID: 19847197
RhoH GTPase; Chronic Lymphocytic Leukemia; TCL1; B cells; lymphopoiesis
14.  Sinonasal Lobular Capillary Hemangioma: A Clinicopathologic Study of 34 Cases Characterizing Potential for Local Recurrence 
Head and Neck Pathology  2012;7(2):129-134.
Lobular capillary hemangioma (LCH) is a specific entity among vascular lesions of the head and neck that may be diagnosed loosely as “pyogenic granuloma”. In contrast to granulation polyps and other reactive conditions, LCH is now regarded as likely a benign vascular neoplasm. Recent series assert lack of postoperative recurrence of LCH. We have observed otherwise, and to clarify this issue performed a systematic review of our institutional experience with LCH, tabulating clinicopathologic, histologic, and follow-up parameters of nasal or sinus lesions diagnosed as LCH or PG between 1989 and 2009. Lesions meeting strict criteria for LCH were included, and statistical analyses were performed using t tests, χ2 tests, and Kaplan–Meier analysis. Of cases identified, 38 of 46 (86 %) met criteria for LCH. Presenting symptoms included epistaxis (75 %), obstruction (36 %), and pain (3 %), with no sex predilection (17/17; M/F), and a median age of 39 years. Pregnancy was associated with 5/34 (15 %) cases, while antecedent trauma was reported in 4/34 (12 %). Histologically, ulceration was frequent (68 %) and mitotic activity highly variable (0–38 mitoses/10 HPF). Of cases with follow-up (31/34), we observed 13 local recurrences (42 %), including unbiopsied clinical recurrence (6/31, 19.4 %) and biopsy-documented recurrence (7/31, 22.6 %). Subjects with recurrence were significantly older (P = 0.04). Demographic, clinical, and histopathologic features were similar to prior studies; in contrast to recent series, recurrence in this cohort was frequent and comparable to that originally reported. Awareness of this may aid in avoiding misdiagnosis of these lesions as more aggressive entities such as angiofibroma and angiosarcoma.
PMCID: PMC3642257  PMID: 23184353
Lobular capillary hemangioma; Pyogenic granuloma; Sinonasal tract
15.  Molecular Inversion Probe analysis detects novel copy number alterations in Ewing Sarcoma 
Cancer genetics  2012;205(0):391-404.
Ewing sarcoma (ES) is the second most common bone tumor in children and young adults, with dismal outcomes for metastatic and relapsed disease. To better understand the molecular pathogenesis of ES and to identify new prognostic markers, we used molecular inversion probes (MIPs) to evaluate copy number alterations (CNAs) and loss of heterozygosity (LOH) in formalin-fixed paraffin-embedded (FFPE) samples which included 40 ES primary tumors and 12 ES metastatic lesions. CNAs were correlated with clinical features and outcome, and validated by immunohistochemistry (IHC). We identified previously reported CNAs, in addition to SMARCB1 (INI1/SNF5) homozygous loss and copy neutral LOH. IHC confirmed SMARCB1 protein loss in 7–10% of clinically-diagnosed ES tumors in three separate cohorts (University of Utah [N=40], Children’s Oncology Group [N=31], and University of Michigan [N=55]). A multifactor copy number (MCN)-index was highly predictive of overall survival (39% vs. 100%, P<0.001). We also identified RELN gene deletions unique to 25% of ES metastatic samples. In summary, we identified both known and novel CNAs using MIP technology for the first time in FFPE samples from patients with ES. CNAs detected by microarray correlate with outcome and may be useful for risk-stratification in future clinical trials.
PMCID: PMC3784316  PMID: 22868000
Ewing sarcoma; copy number; outcome; SMARCB1/INI1/SNF5; CEBPB
16.  Therapeutic Potential of the Translation Inhibitor Silvestrol in Hepatocellular Cancer 
PLoS ONE  2013;8(9):e76136.
Background & Aims
Although hepatocellular cancers (HCC) frequently arise in the setting of fibrosis and a hepatic regenerative response requiring new cell growth, therapeutic strategies for these cancers have not targeted protein synthesis. Silvestrol, a rocaglate isolated from Aglaiafoveolata, can inhibit protein synthesis by modulating the initiation of translation through the eukaryotic initiation factor 4A. In this study, we evaluated the therapeutic efficacy of silvestrol for HCC.
The efficacy of silvestrol was examined using human HCC cells in vitro using an orthotopic tumor cell xenograft model in a fibrotic liver. The impact of silvestrol on the liver was assessed in vivo in wild-type mice.
Silvestrol inhibited cell growth with an IC50 of 12.5-86 nM in four different HCC cell lines. In vitro, silvestrol increased apoptosis and caspase 3/7 activity accompanied by loss of mitochondrial membrane potential and decreased expression of Mcl-1 and Bcl-xL. A synergistic effect was observed when silvestrol was combined with other therapeutic agents, with a dose-reduction index of 3.42-fold with sorafenib and 1.75-fold with rapamycin at a fractional effect of 0.5. In vivo, an antitumor effect was observed with 0.4 mg/kg silvestrol compared to controls after one week, and survival of tumor-bearing mice was improved with a median survival time of 42 and 28 days in the silvestrol and control groups, respectively. The effect on survival was not observed in orthotopic xenografts in non-fibrotic livers. Silvestrol treatment in vivo did not alter liver structure.
These data identify silvestrol as a novel, structurally unique drug with potent anticancer activity for HCC and support the potential value of targeting initiation of translation in the treatment of HCC.
PMCID: PMC3784426  PMID: 24086701
17.  Long-Term Results of a Phase 2 Study of Neoadjuvant Chemotherapy and Radiotherapy in the Management of High-Risk, High-Grade, Soft Tissue Sarcomas of the Extremities and Body Wall 
Cancer  2010;116(19):4613-4621.
The use of neoadjuvant and adjuvant chemotherapy in soft tissue sarcomas is controversial. This is a report of long-term (≥5 years) follow-up in patients with high-grade, high-risk soft tissue sarcomas treated with neoadjuvant chemotherapy, preoperative radiotherapy (RT), and adjuvant chemotherapy.
Patients with high-grade soft tissue sarcoma ≥8 cm in diameter of the extremities and body wall received 3 cycles of neoadjuvant chemotherapy (mesna, doxorubicin, ifosfamide, and dacarbazine) and preoperative RT (44 grays administered in split courses), and 3 cycles of postoperative chemotherapy (mesna, doxorubicin, ifosfamide, and dacarbazine).
Sixty-four of 66 patients were analyzed. After chemotherapy and RT, 61 patients had surgery; 58 had R0 resections (5 amputations), and 3 had R1 resections. Ninety-seven percent experienced grade 3 or higher toxicity, including 3 deaths. These toxicities were short term. With a median follow-up of 7.7 years in surviving patients, the 5-year rates of locoregional failure (including amputation), and distant metastasis were 22.2% (95% confidence interval [CI], 11.8–32.6) and 28.1% (95% CI, 17.0–39.2). The most common site of metastasis was lung. Estimated 5-year rates of disease-free survival, distant disease-free survival, and overall survival were 56.1% (95% CI, 43.9–68.3), 64.1% (95% CI, 52.3–75.8), and 71.2% (95% CI, 60.0–82.5), respectively.
Although the toxicity was significant, it was limited in its course and for the most part resolved by 1 year. The long-term outcome was better than might be expected in such high-risk tumors.
PMCID: PMC3780573  PMID: 20572040
sarcoma; neoadjuvant chemotherapy; radiation
18.  Sporadic versus Radiation-Associated Angiosarcoma: A Comparative Clinicopathologic and Molecular Analysis of 48 Cases 
Sarcoma  2013;2013:798403.
Angiosarcomas are aggressive tumors of vascular endothelial origin, occurring sporadically or in association with prior radiotherapy. We compared clinicopathologic and biologic features of sporadic angiosarcomas (SA) and radiation-associated angiosarcomas (RAA). Methods. From a University of Michigan institutional database, 37 SA and 11 RAA were identified. Tissue microarrays were stained for p53, Ki-67, and hTERT. DNA was evaluated for TP53 and ATM mutations. Results. Mean latency between radiotherapy and diagnosis of RAA was 11.9 years: 6.7 years for breast RAA versus 20.9 years for nonbreast RAA (P = 0.148). Survival after diagnosis did not significantly differ between SA and RAA (P = 0.590). Patients with nonbreast RAA had shorter overall survival than patients with breast RAA (P = 0.03). The majority of SA (86.5%) and RAA (77.8%) were classified as high-grade sarcomas (P = 0.609). RAA were more likely to have well-defined vasoformative areas (55.6% versus 27%, P = 0.127). Most breast SA were parenchymal in origin (80%), while most breast RAA were cutaneous in origin (80%). TMA analysis showed p53 overexpression in 25.7% of SA and 0% RAA, high Ki-67 in 35.3% of SA and 44.4% RAA, and hTERT expression in 100% of SA and RAA. TP53 mutations were detected in 13.5% of SA and 11.1% RAA. ATM mutations were not detected in either SA or RAA. Conclusions. SA and RAA are similar in histology, immunohistochemical markers, and DNA mutation profiles and share similar prognosis. Breast RAA have a shorter latency period compared to nonbreast RAA and a significantly longer survival.
PMCID: PMC3776386  PMID: 24082817
19.  Dual Targeting of the Cyclin/Rb/E2F and Mitochondrial Pathways in Mantle Cell Lymphoma with the Translation Inhibitor Silvestrol 
During cell cycle progression, D-cyclins activate cyclin-dependent kinases (CDKs) 4/6 to inactivate Rb, permitting E2F1-mediated S-phase gene transcription. This critical pathway is typically deregulated in cancer, and novel inhibitory strategies would be effective in a variety of tumors. The protein synthesis inhibitor silvestrol has potent activity in B-cell leukemias via the mitochondrial pathway of apoptosis, and also reduces cyclin D1 expression in breast cancer and lymphoma cell lines. We hypothesized that this dual activity of silvestrol would make it especially effective in malignancies driven by aberrant cyclin D1 expression.
Experimental Design
Mantle Cell Lymphoma (MCL), characterized by elevated cyclin D1, was used as a model to test this approach. The cyclin D/Rb/E2F1 pathway was investigated in vitro using MCL cell lines and primary tumor cells. Silvestrol was also evaluated in vivo using an aggressive model of MCL.
Silvestrol showed low nanomolar potency both in MCL cell lines and primary MCL tumor cells. D-cyclins were depleted with just 10 nM silvestrol at 16 hr, with subsequent reductions of phosphorylated Rb, E2F1 protein, and E2F1 target transcription. As demonstrated in other leukemias, silvestrol caused Mcl-1 depletion followed by mitochondrial depolarization and caspase-dependent apoptosis, effects not related to inhibition of CDK4/6. Silvestrol significantly (P<0.0001) prolonged survival in a MCL xenograft model without detectable toxicity.
These data indicate that silvestrol effectively targets the cyclin/CDK/Rb pathway, and additionally induces cytotoxicity via intrinsic apoptosis. This dual activity may be an effective therapeutic strategy in MCL and other malignancies.
PMCID: PMC3677230  PMID: 22791882
translation; cyclin; Rb; lymphoma; cell cycle
20.  Variations of the ataxia telangiectasia mutated gene in patients with chronic lymphocytic leukemia lack substantial impact on progression-free survival and overall survival: a Cancer and Leukemia Group B study 
Leukemia & lymphoma  2012;53(9):1743-1748.
The impact of mutation of the ATM (ataxia telangiectasia mutated) gene in chronic lymphocytic leukemia (CLL) treatment outcome has not been examined. We studied ATM mutations in 73 patients treated with fludarabine and rituximab. ATM gene mutation analysis was performed using temperature gradient capillary electrophoresis. The impact of detected variants on overall survival (OS) and progression-free survival (PFS) was tested with proportional hazards models. None of the 73 patients demonstrated truncating ATM mutations; 17 (23%, 95% confidence interval 14 – 35%) had non-silent variants (ATM-NSVs), including 13 known ATM polymorphisms and four missense variants. ATM-NSVs were not significantly associated with any baseline characteristics including immunoglobulin heavy chain variable gene (IGVH) status. In multivariable models, no significant differences in complete response (p = 0.70), PFS (p = 0.59) or OS (p = 0.13) were observed. Our data indicate that truncating ATM mutations are rare in patients with CLL. Furthermore, in this dataset, these non-silent variants had limited impact on PFS and OS.
PMCID: PMC3724930  PMID: 22369572
Chronic lymphocytic leukemia; ATM mutation; prognosis; chemoimmunotherapy
21.  Increasing the complexity of chromatin: functionally distinct roles for replication-dependent histone H2A isoforms in cell proliferation and carcinogenesis 
Nucleic Acids Research  2013;41(20):9284-9295.
Replication-dependent histones are encoded by multigene families found in several large clusters in the human genome and are thought to be functionally redundant. However, the abundance of specific replication-dependent isoforms of histone H2A is altered in patients with chronic lymphocytic leukemia. Similar changes in the abundance of H2A isoforms are also associated with the proliferation and tumorigenicity of bladder cancer cells. To determine whether these H2A isoforms can perform distinct functions, expression of several H2A isoforms was reduced by siRNA knockdown. Reduced expression of the HIST1H2AC locus leads to increased rates of cell proliferation and tumorigenicity. We also observe that regulation of replication-dependent histone H2A expression can occur on a gene-specific level. Specific replication-dependent histone H2A genes are either up- or downregulated in chronic lymphocytic leukemia tumor tissue samples. In addition, discreet elements are identified in the 5′ untranslated region of the HIST1H2AC locus that confer translational repression. Taken together, these results indicate that replication-dependent histone isoforms can possess distinct cellular functions and that regulation of these isoforms may play a role in carcinogenesis.
PMCID: PMC3814372  PMID: 23956221
22.  Quantitative DNA Methylation Analysis Identifies a Single CpG Dinucleotide Important for ZAP-70 Expression and Predictive of Prognosis in Chronic Lymphocytic Leukemia 
Journal of Clinical Oncology  2012;30(20):2483-2491.
Increased ZAP-70 expression predicts poor prognosis in chronic lymphocytic leukemia (CLL). Current methods for accurately measuring ZAP-70 expression are problematic, preventing widespread application of these tests in clinical decision making. We therefore used comprehensive DNA methylation profiling of the ZAP-70 regulatory region to identify sites important for transcriptional control.
Patients and Methods
High-resolution quantitative DNA methylation analysis of the entire ZAP-70 gene regulatory regions was conducted on 247 samples from patients with CLL from four independent clinical studies.
Through this comprehensive analysis, we identified a small area in the 5′ regulatory region of ZAP-70 that showed large variability in methylation in CLL samples but was universally methylated in normal B cells. High correlation with mRNA and protein expression, as well as activity in promoter reporter assays, revealed that within this differentially methylated region, a single CpG dinucleotide and neighboring nucleotides are particularly important in ZAP-70 transcriptional regulation. Furthermore, by using clustering approaches, we identified a prognostic role for this site in four independent data sets of patients with CLL using time to treatment, progression-free survival, and overall survival as clinical end points.
Comprehensive quantitative DNA methylation analysis of the ZAP-70 gene in CLL identified important regions responsible for transcriptional regulation. In addition, loss of methylation at a specific single CpG dinucleotide in the ZAP-70 5′ regulatory sequence is a highly predictive and reproducible biomarker of poor prognosis in this disease. This work demonstrates the feasibility of using quantitative specific ZAP-70 methylation analysis as a relevant clinically applicable prognostic test in CLL.
PMCID: PMC3397783  PMID: 22564988
23.  Prolonged myelosuppression with clofarabine in the treatment of patients with relapsed or refractory, aggressive non-Hodgkin lymphoma 
Leukemia & lymphoma  2009;50(3):349-356.
We evaluated the safety and efficacy of the purine nucleoside analogue, clofarabine, in patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) and mantle cell lymphoma (MCL). Six patients with DLBCL (n = 5) or MCL (n = 1) and a median age of 68 years were treated with 40 mg/m2 clofarabine IV over 2 h for 5 days, repeated every 28 days, for 1–2 cycles. The overall response rate was 50% (complete response = 1, complete response unconfirmed = 1, partial response = 1). Median progression-free survival was 3.5 months (range 1.5–10 months) and the median overall survival was 7.8 months (range 3–31 months). Grade 3–4 neutropenia and thrombocytopenia was universal, with a median of 34 (range 19–55) and 77 (range 0–275) days required for neutrophil and platelet recovery. Grade 3 non-hematologic toxicities included transaminitis, febrile neutropenia, non-neutropenic infections and orthostatic hypotension. Further accrual to the study was terminated due to prolonged Grade 3–4 myelosuppression and orthostatic hypotension in five of six patients. Clofarabine exhibits evidence of single agent activity in relapsed or refractory DLBCL. However, further study with novel administration schedules that maintain this efficacy and limit toxicity is warranted.
PMCID: PMC3695225  PMID: 19263294
Clofarabine; diffuse large B cell lymphoma; mantle cell lymphoma; nucleoside analogues; myelosuppression
24.  Tetraspanin CD37 Directly Mediates Transduction of Survival and Apoptotic Signals 
Cancer Cell  2012;21(5):694-708.
Tetraspanins are commonly believed to act only as “molecular facilitators”, with no direct role in signal transduction. We herein demonstrate that upon ligation, CD37, a tetraspanin molecule expressed on mature normal and transformed B-cells, becomes tyrosine phosphorylated, associates with proximal signaling molecules, and initiates a cascade of events leading to apoptosis. Moreover, we have identified two tyrosine residues with opposing regulatory functions, one lies in the N-terminal domain of CD37 in a predicted “ITIM-like” motif and mediates SHP1-dependent death whereas the second lies in a predicted “ITAM motif” in the C-terminal domain of CD37 and counteracts death signals by mediating phosphatidylinositol 3-kinase-dependent survival.
PMCID: PMC3360882  PMID: 22624718
25.  Silvestrol exhibits significant in vivo and in vitro antileukemic activities and inhibits FLT3 and miR-155 expressions in acute myeloid leukemia 
Activating mutations [internal tandem duplication (ITD)] or overexpression of the FMS-like tyrosine kinase receptor-3 (FLT3) gene are associated with poor outcome in acute myeloid leukemia (AML) patients, underscoring the need for novel therapeutic approaches. The natural product silvestrol has potent antitumor activity in several malignancies, but its therapeutic impact on distinct molecular high-risk AML subsets remains to be fully investigated. We examined here the preclinical activity of silvestrol in FLT3-ITD and FLT3 wild-type (wt) AML.
Silvestrol in vitro anti-leukemic activity was examined by colorimetric cell viability assay, colony-forming and flow cytometry assays assessing growth inhibition and apoptosis, respectively. Pharmacological activity of silvestrol on FLT3 mRNA translation, mRNA and protein expression was determined by RNA-immunoprecipitation, qRT-PCR and immunoblot analyses, respectively. Silvestrol in vivo efficacy was investigated using MV4-11 leukemia-engrafted mice.
Silvestrol shows antileukemia activity at nanomolar concentrations both in FLT3-wt overexpressing (THP-1) and FLT3-ITD (MV4-11) expressing AML cell lines (IC50 = 3.8 and 2.7 nM, respectively) and patients’ primary blasts [IC50 = ~12 nM (FLT3-wt) and ~5 nM (FLT3-ITD)]. Silvestrol increased apoptosis (~4fold, P = 0.0001), and inhibited colony-formation (100%, P < 0.0001) in primary blasts. Silvestrol efficiently inhibited FLT3 translation reducing FLT3 protein expression by 80–90% and decreased miR-155 levels (~60%), a frequently co-regulated onco-miR in FLT3-ITD-positive AML. The median survival of silvestrol-treated vs vehicle-treated mice was 63 vs 29 days post-engraftment, respectively (P < 0.0001).
Silvestrol exhibits significant in vivo and in vitro antileukemic activities in AML through a novel mechanism resulting in inhibition of FLT3 and miR-155 expression. These encouraging results warrant a rapid translation of silvestrol for clinical testing in AML.
PMCID: PMC3623627  PMID: 23497456

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