Prevalence and clinical implications of germline pathogenic variants in cancer predisposing genes in young patients across sarcoma subtypes.

BACKGROUND: Sarcomas are a rare and diverse group of cancers occurring mainly in young individuals for which an underlying germline genetic cause remains unclear in most cases. METHODS: Germline DNA from 177 children, adolescents and young adults with soft tissue or bone sarcomas was tested using multigene panels with 113 or 126 cancer predisposing genes (CPGs) to describe the prevalence of germline pathogenic/likely pathogenic variants (GPVs). Subsequent testing of a subset of tumours for loss of heterozygosity (LOH) evaluation was performed to investigate the clinical and molecular significance of these variants. RESULTS: GPVs were detected in 21.5% (38/177) of the patients (15.8% in children and 21.6% in adolescents and young adults), with dominant CPGs being altered in 15.2% overall. These variants were found in genes previously associated with the risk of developing sarcomas (TP53, RB1, NF1, EXT1/2) but also in genes where that risk is still emerging/limited (ERCC2, TSC2 and BRCA2) or unknown (PALB2, RAD50, FANCM and others). The detection rates of GPVs varied from 0% to 33% across sarcoma subtypes and GPV carriers were more likely to present more than one primary tumour than non-carriers (21.1%×6.5%; p=0.012). Loss of the wild-type allele was detected in 48% of tumours from GPV carriers, mostly in genes definitively associated with sarcoma risk. CONCLUSION: Our findings reveal that a high proportion of young patients with sarcomas presented a GPV in a CPG, underscoring the urgency of establishing appropriate genetic screening strategies for these individuals and their families.

Investigação de causas genéticas associadas ao desenvolvimento de sarcomas em idade jovem / Investigation of genetic causes associated with the development of sarcomas at young age

Os avanços recentes na genômica permitiram o reconhecimento de quase uma centena de novos genes de predisposição ao câncer (GPC). Embora o rastreamento genético de uma parte destes genes esteja atualmente bem estabelecido para os tumores hereditários mais comuns, há uma série de tumores raros, como sarcomas, que podem estar associados a síndromes de câncer hereditário, mas cuja relação genótipo-fenótipo ainda é desconhecida. Dessa forma, o presente estudo propôs-se a: definir a frequência de variantes raras germinativas patogênicas em GPCs em crianças, adolescentes e adultos jovens com sarcomas; avaliar as características moleculares dos tumores para confirmar sua causa genética em casos selecionados, realizando análise de perda de heterozigose (LOH); identificar novos genes e vias relevantes associados ao desenvolvimento de condrossarcomas e sarcomas ultrarraros. Para isso, foram rastreadas variantes germinativas em 177 pacientes jovens diagnosticados com sarcoma abaixo de 40 anos, através da análise de sequenciamento de nova geração, com painéis customizados de 113/126 GPCs. Primeiramente, foi rastreada a variante fundadora do gene TP53 mais prevalente na população brasileira (p.Arg337His) e 5/177 pacientes foram detectados como portadores e excluídos da análise de painel. No painel, foram avaliados 172 pacientes e em 33 foram detectadas variantes patogênicas (P) ou provavelmente patogênicas (PP) (18,6%), sendo estas em genes previamente associados ao risco no desenvolvimento de sarcomas, como CHEK2, EXT1, EXT2, NF1, RB1 e TP53, mas também em genes no qual esse risco ainda é desconhecido (AKT1, ERCC3, ERCC4, FANCM, MITF, MUTYH, NTHL1, SLX4 e TSC2) ou é emergente (BRCA2, ERCC2, PALB2). Cento e trinta e nove (78,5%) pacientes tiveram variantes de significado incerto ou foram negativos. Portadores de variantes P/PP foram mais propensos a apresentar mais de um tumor primário do que não portadores (21,1% X 6,5%; p=0,012). Dos 25 tumores avaliados para LOH, a perda do alelo selvagem foi detectada em nove (36%), sendo um dos genes de associação desconhecida a sarcomas (MITF). Para explorar novos genes candidatos, 9 pacientes com condrossarcomas ou sarcomas ultrarraros negativos para variantes P/PP foram incluídos em análise de sequenciamento de exoma tumoral e germinativo. Foram priorizadas na análise germinativa variantes em 10 GPCs conhecidos e 22 genes com variantes de perda de função e missenses em que a relação com câncer hereditário é desconhecida. Foi encontrada somente uma variante em um gene associado a sarcomas (RECQL4) e em um gene emergente (BRCA2). Uma variante patogênica no gene RAD50 foi detectada em um paciente com sarcoma fibromixóide. Em dois tumores distintos, foi observada alteração no gene COL7A1. Na análise somática, em três genes (TP53, PTCH1, CREBBP) foram encontradas alterações potencialmente significantes clinicamente, visto que são genes de associação conhecida a sarcomas. Também foram identificados outros genes mutados, alguns deles incluídos em vias biológicas que podem ser interessantes para sarcomas, como VPS16 e MYF6. Contudo, para que seja possível realizar associações genótipofenótipo dos dados de exoma, tanto germinativo quanto somático, outras evidências são necessárias, como análise de transcriptoma e co-segregação. Com os dados do painel, nossos resultados destacam uma alta taxa de variantes P/PP em GPCs em pacientes jovens brasileiros com sarcoma (21,5% incluindo os pacientes portadores da variante TP53 p.Arg337His), mesmo em pacientes sem história familiar de câncer. As taxas de variantes P/PP variaram de 0% a 33% entre os subtipos de sarcoma e exibiram associações específicas entre subtipos e genes. Isso aponta a urgência de implementar estratégias de triagem genética adequadas para esses indivíduos e suas famílias.

Recent advances in genomics have allowed the recognition of nearly a hundred new cancer predisposing genes (CPGs). Although genetic screening in some of these genes is currently well established for the most common hereditary tumors, there are a number of rare tumors, such as sarcomas, that may be associated with hereditary cancer syndromes, but whose genotypephenotype relationship is still unknown. Thus, the present study aimed to: define the frequency of rare pathogenic germline variants in CPGs in children, adolescents and young adults with sarcomas; assess the molecular characteristics of tumors to confirm their genetic cause in selected cases, performing loss of heterozygosity (LOH) analysis; identify novel genes and relevant pathways associated with the development of chondrosarcomas and ultra-rare sarcomas. For this, we searched for germline variants in 177 young patients diagnosed with sarcoma under 40 years old, through next-generation sequencing analysis, with customized panels of 113/126 CPGs. First, we searched for the founder variant in TP53 gene (p.Arg337His) - most prevalent in the Brazilian population - and found that 5/177 patients were detected as carriers, being excluded from the panel analysis. In the panel, 172 patients were evaluated and in 33 (18.6%) there were detected germline pathogenic variants (GPVs), occurring in genes previously associated with the risk of developing sarcomas (TP53, RB1, NF1, CHEK2, EXT1 and EXT2), but also in genes where that risk is still unknown (ERCC2/3, TSC2, RAD50, FANCM, and others) or is emerging (PALB2, BRCA2). GPVs carriers were more likely to present more than one primary tumor than non-carriers (21.1% X 6.5%; p=0.012). One hundred and thirty-nine (78.5%) patients had variants of uncertain significance or were negative. Of the 25 tumors evaluated for LOH, loss of the wild-type allele was detected in nine (36%), in which one of the genes has an unknown association with sarcomas (MITF). To explore new candidate genes, 9 patients with chondrosarcomas or ultra-rare sarcomas negative for GPVs were included in tumor exome and germline sequencing analysis. In the germline analysis, there were prioritized variants in 10 known CPGs and 22 genes with loss-of-function and missense variants in which the relationship with hereditary cancer is unknown. Only one variant was found in a sarcoma-associated gene (RECQL4) and in an emergent gene (BRCA2). A pathogenic variant in the RAD50 gene was detected in a patient with fibromyxoid sarcoma. An alteration in COL7A1 gene was observed in two different tumors. In the somatic analysis, there were found potentially clinically significant alterations in three genes (TP53, PTCH1, CREBBP), since they are genes with a known association with sarcomas. Other mutated genes were also identified, some of them included in biological pathways that may be interesting for sarcomas, such as VPS16 and MYF6. However, in order to be able to perform genotype-phenotype associations of exome data, other evidences are needed for both germline and somatic evaluation, such as transcriptome analysis and co-segregation. With panel data, our results highlight a high rate of GPVsin CPGs in young Brazilian patients with sarcoma (21.5% including patients carrying the TP53:p.Arg337His variant), even in patients with no family history of cancer. Our findings reveal that 1 in each 5 patients with sarcomas under 40 years old presented a GPV, even in patients without family history of cancer. GPVs rates varied from 0% to 33% across sarcoma subtypes and exhibited specific gene-subtypes associations. This pinpoints the urgency of implementing appropriated genetic screening strategies for these individuals and their families.

Gemcitabine, carboplatin and veliparib in multiple relapsed/refractory germ cell tumours: The GCT-SK-004 phase II trial.

Background Patients with multiple relapsed/refractory germ cell tumours (GCTs) have an extremely poor prognosis. PARP (poly-ADP-ribose polymerase) is overexpressed in GCTs compared to normal testes, and PARP overexpression is an early event in GCT development. This study aimed to determine the efficacy and toxicity of gemcitabine, carboplatin and the PARP inhibitor veliparib in patients with multiple relapsed/refractory GCTs. Methods Fifteen patients with multiple relapsed/refractory GCTs were enrolled in this phase II study from October 2016 to October 2020. Gemcitabine was administered at a dose of 800 mg/m2 on days 1 and 8 every 3 weeks; carboplatin at a target AUC of 4 on day 1 every 3 weeks; and veliparib at a dose of 250 mg b.i.d. throughout. The primary end point was 12-month progression-free survival (PFS). Results The median number of treatment cycles was 4 (range 2-8). Twelve-month PFS was achieved in 1 (6.7 %) patient. The median PFS was 3.1 months (95 % CI 2.2-3.9), and the median overall survival was 10.5 months (95 % CI 8.9-11.1). Partial remission was achieved in 4 (26.7 %) patients, and disease stabilization was observed in 5 (33.3 %) patients. A favourable response was achieved in 3 (20.0 %) patients. Treatment was well tolerated; however, 11 (73.3 %) patients experienced grade 3/4 neutropenia, 10 (66.7 %) experienced thrombocytopenia, 5 (33.3 %) anaemia and 2 (13.3 %) febrile neutropenia. Conclusions This study failed to achieve its primary endpoint, and our data suggest limited efficacy of gemcitabine, carboplatin and veliparib for multiple relapsed/refractory GCTs. ClinicalTrials.gov Identifier: NCT02860819, registered August 9, 2016.

Squamous cell carcinoma of the colon - a case report.

BACKGROUND: Primary squamous cell carcinomas (SCC) of the colon are extremely rare and occur predominantly in the fifth decade of life, with a slight prevalence in men. The most common anatomical sites are the rectum and the proximal colon. Clinical signs and common dia-gnostic methods cannot clearly distinguish SCC from adenocarcinoma. METHODS: In this case report, we present a case of a 68-year-old patient with SCC of the cecum and colon ascendens, who was treated with resection and systemic gemcitabine- and cisplatin-based chemotherapy. RESULTS: A 68-year-old patient underwent right-sided hemicolectomy for cecal and colon ascendens tumor, histologically poorly differentiated epidermoid carcinoma, grade 3 with an initial stage of pT4aN1aM0. Due to local recurrence at the resection site with suspected infiltration of straight and oblique abdominal muscles, he was treated with systemic gemcitabine and cisplatin based chemotherapy with partial remission. Subsequently, the postchemotherapeutic residual tumor was radically resected, achieving complete remission of the disease, which persists for 10 months after the surgery. CONCLUSION: The case emphasizes the need for a multidisciplinary treatment approach of this rare disease. Early surgery plays a key role. Although the standard chemotherapy regimen is not well defined, the use of a combination of cisplatin and gemcitabine resulted in partial remission in our patient, which in turn allowed a radical resection of the relapse and subsequently achieved complete remission of the disease.

Clinical and Molecular Assessment of Patients with Lynch Syndrome and Sarcomas Underpinning the Association with MSH2 Germline Pathogenic Variants.

Lynch syndrome (LS) is a hereditary cancer-predisposing syndrome associated most frequently with epithelial tumors, particularly colorectal (CRC) and endometrial carcinomas (EC). The aim of this study was to investigate the relationship between sarcomas and LS by performing clinical and molecular characterization of patients presenting co-occurrence of sarcomas and tumors from the LS spectrum. We identified 27 patients diagnosed with CRC, EC, and other LS-associated tumors who had sarcomas in the same individuals or families. Germline genetic testing, mismatch repair (MMR) protein immunohistochemistry, microsatellite instability (MSI), and other molecular analyses were performed. Five LS patients presenting personal or family history of sarcomas were identified (3 MSH2 carriers and 2 MLH1), with 2 having Muir-Torre phenotypes. For two MSH2 carriers we confirmed the etiology of the sarcomas (one liposarcoma and two osteosarcomas) as LS-related, since the tumors were MSH2/MSH6-deficient, MSI-high, or presented a truncated MSH2 transcript. Additionally, we reviewed 43 previous reports of sarcomas in patients with LS, which revealed a high frequency (58%) of MSH2 alterations. In summary, sarcomas represent a rare clinical manifestation in patients with LS, especially in MSH2 carriers, and the analysis of tumor biological characteristics can be useful for definition of tumor etiology and novel therapeutic options.

Rehabilitation and Aids during the Developing Years in Italy / 中国康复理论与实践

The rehabilitation of children with disabilities should be initiated as early as possible,as soon as problems or disorders are diagnosed in the development,to prevent or promptly counteract the consolidation of disability.In Italy the institutes involved in the rehabilitation of children with serious disability must be by law highly specialized.The devices have a key part in rehabilitation courses in developmental age.They are often planned and designed in the same rehabilitation center.La Nostra Famiglia has been in Italy one of the first specialized rehabilitation centers for children and adolescents.By La Nostra Famiglia have been designed aids for children which later became a model throughout Europe.Our National Health System provides free aids for children and adolescents and describes in detail the characteristics of great adaptability that aids for children and adolescents should have.The pressure mapping allows you to test the effects of adapted aids versus aids not properly adapted to the size and needs.

Efeito do tempo de exposiçäo na capacidade de polimerizaçäo das resinas compostas fotopolimerizáveis / Effect of exposure time in the capacity of polimerization of the photopolymerizable composite resins

Este trabalho teve como objetivo estudar através de testes de dureza, a capacidade de polimerizaçäo de resinas compostas fotopolimerizáveis com tempos de exposiçäo à luz cronometrados em 20, 40 e 60 segundos. Esta avaliaçäo foi realizada através de testes de dureza Vickers à cada milimetro de profundidade na regiäo interna dos corpos de prova. Desta maneira foi possível concluir que à medida que se aumenta o tempo de exposiçäo à luz, gradativamente melhora-se o nível de polimerizaçäo