Anti-Ku antibody-positive systemic sclerosis and idiopathic inflammatory myopathies overlap syndrome in children: a report of two cases and a review of the literature.

The occurrence of anti-Ku antibody-positive idiopathic inflammatory myopathy (IIM) in pediatric patients is rare, and therefore, the clinical phenotypes of this disease in such patients remain obscure. We herein report two cases of Japanese female pediatric patients with anti-Ku antibody-positive IIM. One case was unique in that it was complicated by pericardial effusion. Another patient had severe and refractory myositis with immune-mediated necrotizing myopathy. In addition, we reviewed literatures involving a total of 11 pediatric patients with anti-Ku antibody-positive IIM. The median age of the patients was 11 years, and most of them were girls. Skin rash, including erythematous nodules, malar rash, multiple brownish plaques, butterfly rash, heliotrope rash, periorbital edema, and Gottron's papules, was observed in 54.5% of the patients, scleroderma in 81.8%, and skin ulcer in 18.2%. Their serum creatine kinase level ranged from 504 to 10,840 IU/L. Furthermore, joint involvement was observed in 91% of the patients, interstitial lung disease in 18.2%, and esophageal involvement in 9.1%. All patients were treated with corticosteroids in combination with immunosuppressants. Pediatric patients with anti-Ku antibody-positive IIM had unique characteristics compared to adult patients. Skin manifestations, joint involvement and elevation of serum CK levels were more common in children than in adults. In contrast, ILD and esophageal involvement were less common in children than in adults. Although pediatric cases of anti-Ku antibody-positive IIM are rare, patients with IIM need to be tested for the presence of anti-Ku antibodies.

Novel TENM3-ALK fusion is an alternate mechanism for ALK activation in neuroblastoma.

The identification of molecular events underlying the pathogenesis of neuroblastoma can likely result in improved clinical outcomes for this disease. In this study, a translocation within chromosome 2p and 4q was found to bring about the formation of an in-frame fusion gene that was composed of portions of the teneurin transmembrane protein 3 (TENM3, also known as ODZ3) gene and the anaplastic lymphoma kinase (ALK) gene in tumor cells from patients with neuroblastoma. Expression of the full length TENM3-ALK cDNA in NIH-3T3 cells led to the formation of a fusion protein that: (1) possesses constitutive tyrosine kinase activity, (2) induces strong activation of the downstream targets of extracellular signal-regulated kinase (ERK), protein kinase B (a.k.a. AKT), and signal transducer and activator of transcription 3 (STAT3), (3) provokes oncogenic transformation in NOD.Cg-PrkdcscidIl2rgtm1Sug/ShiJic mice, and (4) possesses sensitivity to ALK inhibitors in vitro and in vivo. Our findings demonstrated that patients with neuroblastoma may express a transforming fusion kinase, which is a promising candidate for a therapeutic target and a diagnostic molecular marker for neuroblastoma. The in-frame 5' partner gene that fuses with ALK has not been reported previously in neuroblastoma. Our data provide novel biological insights into the mechanism of ALK activation due to translocation, with implications for neuroblastoma tumorigenesis, and could be useful as a vital marker for the accurate diagnosis of this type of neuroblastoma.

Differential Diagnosis of Histiocytic Necrotizing Lymphadenitis and Malignant Lymphoma with Simple Clinical Findings.

It is desirable that noninvasive differential diagnosis takes place without lymph node biopsy for histiocytic necrotizing lymphadenitis (HNL) or malignant lymphoma (ML). In this study, we propose a novel scoring model for the differential diagnosis of these diseases using clinical information and clinical findings. We retrospectively analyzed the data from 15 HNL and 13 ML pediatric patients. First, a univariate analysis identified 14 clinical factors with significant differences. Second, a subsequent analysis using receiver operating characteristic (ROC) curve analysis identified three factors among them with area under the ROC curve values of >0.95: body temperature (°C), maximum lymph node size (cm), and serum ß2-microglobulin level (mg/L). Finally, the cut-off values of each of these three factors were determined and examined for the 28 cases. All 15 HNL cases were within 2-3 of the cut-off values among the three factors, no ML case was within two or more cut-off values. Thus, the diagnostic sensitivity and specificity of this novel scoring system were both 100%, indicating that clinical scoring with body temperature, maximum lymph node size, and ß2-microglobulin are useful for distinguishing between HNL and ML.

Superiority of Cystatin C over Creatinine for Early Diagnosis of Acute Kidney Injury in Pediatric Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma.

The exact incidence of acute kidney injury (AKI) during chemotherapy for acute lymphoblastic leukemia (ALL)/lymphoblastic lymphoma (LBL) is unknown. Furthermore, childhood cancer survivors are at risk of AKI-chronic kidney disease transition. Thus, early diagnosis of AKI is crucial. This study aimed to elucidate the incidence of AKI in patients undergoing chemotherapy for pediatric ALL/LBL and to compare the usefulness of serum cystatin C (CysC)- and creatinine (Cr)-based estimated glomerular filtration rate (eGFR) as diagnostic measures. Data of 16 patients with ALL/LBL treated with a total of 75 courses of chemotherapy were retrospectively analyzed. CysC- and Cr-based eGFR were measured before and three times per week during therapy. To calculate the eGFR, an equation for Japanese children was used. AKI was diagnosed when eGFR dropped by ≥ 25% from the highest eGFR value obtained during the latest 2 weeks since the start of chemotherapy. AKI was graded based on the pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease scale. All patients developed AKI during chemotherapy; however, more than 90% of the cases were mild and eventually recovered. No significant differences were found in the incidence of AKI between CysC- and Cr-based eGFR (p = 0.104). The median time to AKI diagnosis was significantly shorter in the CysC-based eGFR than in the Cr-based eGFR (8 vs. 17 days, p < 0.001). In this study, all patients with pediatric ALL/LBL could develop mild AKI during treatment. CysC-based eGFR is a more effective measure than Cr-based eGFR for the early diagnosis of AKI.

Resection of Oculomotor Nerve Lesions Using Continuous Stimulation of the Oculomotor Nerve Proximal to the Lesion: A Technical Report.

BACKGROUND: We describe a continuous monitoring method aimed at preserving nerve function during biopsy of lesions on the oculomotor nerve using stimulation of the oculomotor nerve proximal to the lesion. CASE DESCRIPTION: A 5-year-old girl with a recurrent left oculomotor nerve palsy and contrast-enhancing left oculomotor nerve mass on magnetic resonance imaging underwent a biopsy of the lesion to aid in its diagnosis. At the time of surgery, needle electrodes were inserted into the superior and inferior rectus muscles percutaneously, and cotton-covered electrodes were implanted into the oculomotor nerve proximal to the lesion. Compound muscle action potentials of the oculomotor nerve were measured continuously by monopolar stimulation. The lesion was mapped by direct stimulation, and the unresponsive area was excised. The amplitude of the compound muscle action potentials decreased during the resection but recovered postoperatively. After resection of the lesion, the compound muscle action potentials remained the same as they were preoperatively. No obvious postoperative oculomotor nerve palsy was observed. CONCLUSIONS: This method of continuous monitoring of the function of the oculomotor nerve is simple to use and is suitable for lesions in close proximity to the oculomotor nerve.

Successful combination chemotherapy involving clofarabine, cyclophosphamide, and etoposide for pediatric relapsed acute myeloid leukemia: A case report.

Limited salvage chemotherapies are available for relapsed/refractory acute myeloid leukemia. Herein, we described successful reinduction chemotherapy, involving a combination of clofarabine, cyclophosphamide, and etoposide, in a 12-year-old male with relapsed acute myeloid leukemia prior to allogeneic bone marrow transplantation from his father. Although treatment with a combination of fludarabine, cytarabine, granulocyte colony-stimulating factor, idarubicin, and gemtuzumab ozogamicin had no positive effects, the aforementioned clofarabine-based chemotherapy induced complete remission and allowed the transplantation to go ahead. The abovementioned regimen may be useful for induction chemotherapy prior to hematopoietic stem cell transplantation for refractory/relapsed acute myeloid leukemia.

Anticoagulation treatment and prophylactic edoxaban for cerebral sinus venous thrombosis in an adolescent with acute lymphoblastic leukemia.

Pediatric acute lymphoblastic leukemia regimens include large L-asparaginase dosages and steroids, which are associated with an increased risk of venous thromboemboli in adolescents and young adults. Herein, we report the case of an 18-year-old male with acute lymphoblastic leukemia, who was treated with the pediatric regimen, in which edoxaban was employed as a prophylaxis against cerebral sinus venous thrombosis. The event happened on day 20 of induction therapy, when brain magnetic resonance imaging demonstrated a cerebral sinus venous thrombosis in the superior sagittal sinus. Anticoagulation therapy was initiated, and the patient's symptoms disappeared 3 days later. The induction therapy was restarted after an interruption of 16 days, and the consolidation therapies, which included L-asparaginase and steroids, were completed. Edoxaban was administered as a prophylaxis during the consolidation therapy. There were no further adverse events. Edoxaban could be an effective prophylaxis for coagulation complications in adolescents and young adults with acute lymphoblastic leukemia.

Actuator Performance of Dielectric Elastomers Comprising Hydrogenated Carboxylated Acrylonitrile-Butadiene Rubber/Nitrile Group-Modified Titanium Oxide Particles.

We prepared a dielectric elastomer actuator composed of hydrogenated carboxylated acrylonitrile-butadiene rubber (HXNBR)/nitrile group (CN)-modified and non-modified titanium oxide (TiO2) particles with insulation properties. The CN group-containing silane coupling agent was synthesized via a thiol-ene reaction between acrylonitrile and 3-mercaptpropyltrimethoxysilane and immobilized onto the TiO2 particle surface. The HXNBR/CN-modified and non-modified TiO2 particle composite elastomer showed a high relative dielectric constant and generated stress in a low electric field. The relative dielectric constant increased proportionally with the amount of CN-modified TiO2 particles, showing a value of 22 at 100 Hz. As the dielectric constant increased, the volumetric resistivity decreased; however, the dielectric breakdown strength was maintained at 95 V/mm. The generated stress of the composite elastomer increased in proportion to the relative dielectric constant, showing a maximum of 1.9 MPa. The card-house structure of TiO2 particles in the composite elastomer is assumed to suppress the dielectric breakdown in a low electric field. Thus, we demonstrated that an elastomer containing a high dipole group on an insulating particle surface is capable of improving the power performance of soft actuators.

Actuator Performance of a Hydrogenated Carboxylated Acrylonitrile-Butadiene Rubber/Silica-Coated BaTiO3 Dielectric Elastomer.

We synthesized silica-coated barium titanate (BaTiO3) particles with different silica shell thicknesses and evaluated the effect of silica coating on the relative dielectric properties of silica-coated BaTiO3 particles. Furthermore, composite elastomers were prepared using hydrogenated carboxylated acrylonitrile-butadiene rubber (HXNBR) with a high relative dielectric constant (εr) and silica-coated BaTiO3 particles, and their performance as an actuator was evaluated. Both εr and relative dielectric loss of non-coated BaTiO3 particles increased at low frequencies (<200 Hz) associated with ionic conduction. However, εr and relative dielectric loss were reduced for the silica-coated BaTiO3 particles with thick silica shells, indicating that silica coating reduced ion migration. The dielectric breakdown strength increased with the thickness of the silica shell; it increased up to 80 V/µm for HXNBR/silica-coated BaTiO3 particles with 20 nm-thick silica shells. The maximum generated stress, strain, and output energy density of the composite elastomer with HXNBR (with a high relative constant) and silica-coated BaTiO3 were 1.0 MPa, 7.7%, and 19.4 kJ/m3, respectively. In contrast, the values of the same parameters for a reference elastomer (acrylic/BaTiO3; with low εr) were 0.4 MPa, 6.7%, and 6.8 kJ/m3 at the dielectric breakdown strength of 70 V/µm. The results indicated that the elastomers composed of HXNBR and silica-coated BaTiO3 exhibited higher generated stress, strain, and output energy density than elastomers for conventional dielectric actuators.

Relationship between the Relative Dielectric Constant and the Monomer Sequence of Acrylonitrile in Rubber.

Acrylonitrile-butadiene rubbers (NBRs) have a lower glass transition temperature (T g) and a higher dielectric constant than other rubbers. To understand how a low T g and a high dielectric constant are compatible, we focused on the acrylonitrile (AN) monomer sequence in rubber and synthesized random and alternating copolymers to evaluate the effect of the sequence. The AN monomer sequence dependence of the relative dielectric constant was investigated by the C-N stretching vibration of the nitrile group through Fourier transform infrared spectroscopy and internal rotation potential energy measurements around the C-C bond within the nitrile group based on dimer model calculations. The alternating copolymers, including NBR, showed a higher dielectric constant than random copolymers. The alternating copolymer shifted from ∼2243 cm-1 for polyAN to ∼2236 cm-1 for NBRs, while the random copolymer only shifted to ∼2239 cm-1. The peak of the C-N stretching vibration was correlated with the AN sequence. The sequence dependence of the shift can be explained by the C-N bond length calculation. The internal rotation potential energy between gauche and trans of the NBR model was the lowest, indicating that the NBR main chain is flexible and that AN in the main chain rotates easily. Therefore, NBR has a high dielectric constant and a low T g because of the presence of an alternating sequence and the flexibility of the NBR main chain.

Successful Treatment of Pediatric Refractory/Relapsed AML with KIR-Ligand-Mismatched Cord Blood Transplant after FLAG-IDA Reinduction Therapy with or without the GO Regimen.

Prognosis in pediatric patients with refractory/relapsed acute myeloid leukemia (AML) is grim, and there is no standard treatment for such patients. Combined treatment with intensive chemotherapy and gemtuzumab ozogamicin (GO), a monoclonal anti-CD33 antibody conjugated with calicheamicin, is useful as reinduction therapy in refractory/relapsed AML. Here, we describe three cases of pediatric refractory/relapsed AML that were successfully managed with FLAG-IDA (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin), with or without GO, as reinduction therapy before a KIR-ligand-mismatched cord blood transplant. This strategy relies on the fact that killer cell immunoglobulin-like receptors (KIR) on cord blood natural killer (NK) cells recognize human leukocyte antigen (HLA) class I alleles, and that donor KIR-ligand incompatibility may be associated with lower incidence of relapse and improved survival in AML, as cells that lack these inhibitory HLA ligands can activate NK cells. All three patients are currently alive and have been disease-free for 24-65 months, although one patient developed severe sinusoidal obstructive syndrome (SOS). Thus, our strategy can result in excellent outcomes in pediatric patients with refractory/relapsed AML.

Killer-cell immunoglobulin-like receptor ligand mismatch cord blood transplantation in high-risk neuroblastoma.

BACKGROUND: The prognosis of high-risk neuroblastoma stage 4 with bone marrow metastasis, MYCN amplified, or refractory neuroblastoma is poor. To date, no standard treatment has been established. In four selected cases, we challenged the killer-cell immunoglobulin-like receptor ligand mismatch cord blood transplantation in graft-versus-host disease (GVHD) with reduced-intensity conditioning. METHODS: Prior to this study, conventional chemotherapy, autologous peripheral blood stem cell transplantation with high-dose chemotherapy (busulfan and melphalan), surgery and radiation therapy were completed in every case. The status before cord blood transplantation in two cases was not complete remission (CR) and in the others it was CR. The primary site was the mediastinum, two adrenal glands and a retroperitoneum, respectively. Three patients had bone and bone marrow metastasis and one had MYCN amplification. In all cases, international neuroblastoma pathology classification was unfavorable histology. All patients were >2 years of age. RESULTS: Relapse occurred only in one patient 17 months after the last transplantation, and the other three patients maintained disease-free survival for 74, 36, and 24 months, respectively. In one case of relapse the disease could be controlled by conventional chemotherapy. Except one, all patients had no severe complications, such as acute or chronic GVHD. One patient had gastric antral vascular ectasia and hemorrhagic cystitis. CONCLUSION: This strategy might be feasible and should be investigated for efficacy in the future. No definite conclusion can be made, however, due to the very small number of patients. Further prospective studies are required to determine its efficacy.

Gastric antral vascular ectasia in a pediatric patient with neuroblastoma who underwent tandem stem cell transplantation.

Gastric antral vascular ectasia (GAVE) is an angiodysplastic disorder, which causes severe and prolonged gastric bleeding. Although GAVE has been described in adult patients treated with hematopoietic stem cell transplantation (HSCT), a few cases involving pediatric patients have also been reported. A 5-year-old boy with neuroblastoma (NB) developed severe hematemesis after undergoing tandem HSCT, i.e. autologous peripheral blood stem cell transplantation (auto-PBSCT), followed by allogeneic cord blood transplantation (allo-CBT). The patient suffered oral feeding difficulties because of the effects of chemotherapy and an unbalanced diet. Intravenous Busulfan (ivBU) was used as a conditioning regimen for the auto-PBSCT. The diagnosis of GAVE was made based on endoscopy of the upper gastrointestinal tract on day 31 after the allo-CBT. Argon plasma coagulation (APC) was performed twice, and the complete resolution of GAVE was confirmed by an endoscopic re-evaluation, conducted on day 87. GAVE in this case might have been associated with ivBU treatment. Atrophy of the gastric mucosa due to loss of appetite might also have contributed to GAVE. NB was treated using high-doses of alkylating agents, such as BU. Such treatment can cause significant mucositis of the oral cavity as well as vascular lesions and is associated with GAVE. Therefore, GAVE should be considered when gastrointestinal bleeding occurs in NB patients treated with HSCT. APC might be effective against HSCT-GAVE.

Prophylactic recombinant thrombomodulin treatment prevents hepatic sinusoidal obstruction syndrome in high-risk pediatric patients that undergo hematopoietic stem cell transplants.

Hepatic SOS is a potentially life-threatening complication of conditioning for allogeneic HSCT. rTM is a new drug for treating DIC. We report our experience of the use of rTM as a prophylaxis against SOS in high-risk pediatric patients that underwent HSCT. We evaluated the cases of 19 pediatric hematology and oncology patients who underwent HSCT at our institution between 2007 and 2016. The patients who received HSCT after 2012 (n = 8) were treated with rTM as a prophylaxis against SOS together with UDCA and LMWH, whereas the others (n = 11) were only treated with UDCA and LMWH. Although SOS occurred by post-HSCT day 35 in 3 (27%) patients in the control group, SOS was not seen in the rTM group. Two of the former three patients suffered severe SOS, and one died of the condition. The mean peak level of PAI-1 (a marker of endothelial damage) was significantly lower in the rTM group. rTM appears to be a safe prophylaxis for SOS. The present findings suggest that prophylactic rTM after HSCT might help to prevent SOS.

Rare MYC-amplified Neuroblastoma With Large Cell Histology.

Background Although MYCN (aka N-myc) amplification is reported in ∼20% of neuroblastomas, MYC (aka C-myc) amplification appears to be a rare event in this disease. As of today, only 2 MYC-amplified neuroblastomas have been briefly mentioned in the literature. Methods We studied here the clinicopathological features of 3 MYC-amplified neuroblastomas. Results All 3 patients (2 females and 1 male) had stage 4 disease. One female is currently alive and well 52 months after the diagnosis, while the other female and male patients died of disease 24 and 20 months after the diagnosis, respectively. Further analysis on 2 tumors revealed unfavorable histology with MYC protein overexpression but with neither MYCN amplification nor MYCN protein overexpression. Both of these tumors exhibited "large cell neuroblastoma" histology with enlarged, uniquely open nuclei and nucleolar hypertrophy, along with "aberrant" desmin expression. Conclusions MYC-amplified neuroblastomas are extremely rare and seem to present with distinct clinicopathological features.

[Initial presentation of lymphoblastic crisis in a pediatric chronic myelogenous leukemia patient].

A 9-year-old girl was referred to our hospital because of facial palsy. Both physical and blood examination revealed hepatosplenomegaly and leukocytosis, respectively. A bone marrow examination demonstrated marked hypercellularity involving myeloblasts and lymphoblasts. Based on these results, we suspected mixed phenotype acute leukemia. However, her leukemic blasts expressed B-cell antigens, and a chromosomal analysis of her bone marrow cells revealed the following karyotype: 46, XX, t (9;22) (q34;q11.2). All her neutrophils were positive for the breakpoint cluster region-Abelson murine leukemia viral oncogene homolog 1 fusion protein. Based on these findings, she was diagnosed with a lymphoblastic crisis of chronic myelogenous leukemia (CML). Combined chemotherapy, involving imatinib, resulted in complete molecular remission. She received cord blood transplant (CBT) during the first complete remission; she is alive and has not suffered a relapse since two years after the CBT. The sudden onset of a blastic crisis in pediatric CML is rare, and it may be difficult to distinguish such cases from de novo Ph-positive leukemia. For diagnostic purposes, it is essential to consider a patient's clinical course and blood test results.

MYC-family protein overexpression and prominent nucleolar formation represent prognostic indicators and potential therapeutic targets for aggressive high-MKI neuroblastomas: a report from the children's oncology group.

Neuroblastomas with a high mitosis-karyorrhexis index (High-MKI) are often associated with MYCN amplification, MYCN protein overexpression and adverse clinical outcome. However, the prognostic effect of MYC-family protein expression on these neuroblastomas is less understood, especially when MYCN is not amplified. To address this, MYCN and MYC protein expression in High-MKI cases (120 MYCN amplified and 121 non-MYCN amplified) was examined by immunohistochemistry. The majority (101) of MYCN-amplified High-MKI tumors were MYCN(+), leaving one MYC(+), 2 both(+), and 16 both(-)/(+/-), whereas non-MYCN-amplified cases appeared heterogeneous, including 7 MYCN(+), 36 MYC(+), 3 both(+), and 75 both(-)/(+/-) tumors. These MYC-family proteins(+), or MYC-family driven tumors, were most likely to have prominent nucleolar (PN) formation (indicative of augmented rRNA synthesis). High-MKI neuroblastoma patients showed a poor survival irrespective of MYCN amplification. However, patients with MYC-family driven High-MKI neuroblastomas had significantly lower survival than those with non-MYC-family driven tumors. MYCN(+), MYC-family protein(+), PN(+), and clinical stage independently predicted poor survival. Specific inhibition of hyperactive rRNA synthesis and protein translation was shown to be an effective way to suppress MYC/MYCN protein expression and neuroblastoma growth. Together, MYC-family protein overexpression and PN formation should be included in new neuroblastoma risk stratification and considered for potential therapeutic targets.