Clinical Utility of Liquid Biopsy to Identify Genomic Heterogeneity and Secondary Cancer Diagnoses: A Case Report.

Liquid biopsy is a valuable tool in advanced and metastatic cancers for detection of genomic alterations in tumors that facilitate personalized targeted therapy approaches. Analyzing circulating tumor DNA (ctDNA) using next-generation sequencing (NGS) provides an opportunity to detect tumor genomic changes during therapy and capture inter- and intra-heterogeneity of genomically divergent cancer cell evolution. Herein, we present a patient with metastatic castration-resistant prostate cancer, with progression to soft tissues, bone, and regional lymph nodes, who was treated with abiraterone plus prednisone, with excellent prostate-specific antigen response. At the time of progression, NGS analysis of ctDNA using the FoundationOne®Liquid test revealed a CHEK2 mutation and a BRAF V600E mutation, the latter being exceedingly rare in prostate cancer. At the time of biochemical recurrence, the patient was referred to hematology for evaluation of chronic but stable thrombocytopenia prior to initiating new systemic therapy. Results of a bone marrow biopsy were consistent with hairy-cell leukemia, where the BRAF V600E mutation is considered the disease-defining mutation detectable in nearly all cases at diagnosis. In this case, liquid biopsy served as a noninvasive, highly sensitive approach to help reveal tumor genomic heterogeneity but also identified an unexpected genomic alteration leading to secondary cancer diagnosis and changes to treatment-related decision-making.

Genomic trajectory in leukemogenesis of myeloproliferative neoplasms: a case report.

BACKGROUND: We report a patient with Essential Thrombocythemia (ET), subsequently diagnosed with concurrent myeloid and lymphoid leukemia. Generally, the molecular mechanisms underlying leukemic transformation of Philadelphia-negative myeloproliferative neoplasms (Ph-MPN) are poorly understood. Risk of transformation to acute myelogenous leukemia (AML) is low; transformation to both AML and acute lymphoblastic leukemia (ALL) is extremely low. Genetic defects, including allele burden, order of mutation acquisition, clonal heterogeneity and epigenetic mechanisms are important contributors to disease acceleration. CASE PRESENTATION: A 78-year-old Caucasian female originally treated for stable ET, underwent disease acceleration and transition to myeloid sarcoma and B-cell ALL. Genomic reconstruction based on targeted sequencing revealed the presence of a large del(5q) in all three malignancies and somatic driver mutations: TET2, TP53, SF3B1, and ASXL1 at high allele frequency. We propose that the combination of genetic and molecular abnormalities led to hematopoietic stem cell (HSC) injury and disease progression through sub-clone branching. We hypothesize that ancestral reconstruction of genomic data is a useful tool to uncover subclonal events leading to transformation. CONCLUSIONS: The use of ancestral reconstruction of genomic data sheds light on the unique clinical scenario described in this case report. By determining the mutational profile of tumors at several timepoints and deducing the most parsimonious relationship between them, we propose a reconstruction of their origin. We propose that blast progression originated from subclonal events with malignant potential, which coexisted with but did not originate from JAK2 p.V617F-positive ET. We conclude that the application of genomic reconstruction enhances our understanding of leukemogenesis by identifying the timing of molecular events, potentially leading to better chemotherapy choices as well as the development of new targeted therapies.

Diabetes mellitus tipo 1: edad de comienzo y presencia en familiares de primer grado / Type 1 diabetes mellitus: age of onset and presence in first-degree relatives

Introducción: la diabetes mellitus tipo 1 (DM1) se considera una enfermedad de la infancia/adolescencia, pero puede ocurrir a cualquier edad. El riesgo de desarrollar DM1 es de ocho a 15 veces mayor en parientes de primer grado. La proporción de menores de 15 años con un pariente de primer grado afectado es ≈12%. Luego de años de seguimiento, esta frecuencia puede aumentar a más del 20%. Objetivos: determinar la edad de comienzo en pacientes adultos con DM1 y su frecuencia en familiares de primer grado. Materiales y métodos: en 414 sujetos se definió diagnóstico de DM1 por fenotipo, juicio clínico y requerimiento de insulina dentro del año de diagnóstico. Se determinó edad al diagnóstico y los sujetos se dividieron en mayores y menores de 30 años al momento del debut. En ellos se evaluó y comparó: DM1 en familiares de primer grado, índice de masa corporal (IMC), circunferencia de cintura, HbA1c e hipotiroidismo. Para la comparación de variables cuantitativas de los dos grupos se usó test de t y ANOVA para grupos múltiples, y para las variables categóricas se empleó chi cuadrado con corrección de Fisher. Resultados: el debut antes de los 10 años fue de 28,2%, entre los 10 y 20 años de 36,9%, entre los 20 y 30 años de 18,8% y por encima de los 30 años de 17,1%. Hubo similar frecuencia de hipotiroidismo y familiares de primer grado con DM1 en aquellos con diagnóstico antes o después de los 30 años. Se halló presencia de DM1 en familiares de primer grado en el 17,2% (padre 3,6%, madre 3,1%, hermano 10,2%, hijo 0,5%). Conclusiones: antes de los 30 años debutó el 82,9% de los pacientes, pero hubo un 17,1% que lo hizo después. El 17,2% tenía familiares de primer grado con DM1. A diferencia de los estudios en niños y adolescentes, y al igual que los estudios que evaluron poblaciones de DM1 adultos, encontramos el mayor antecedente de DM1 entre hermanos (10,2%). Dicho patrón familiar fue similar entre DM1 con comienzo antes o después de los 30 años

Introduction: type 1 diabetes mellitus (T1DM) is a childhood and adolescence disease, but it can occur at any age. The risk of developing T1DM is 8-15 times higher in first-degree relatives of patients with T1DM. The proportion of affected first-degree relatives in children under 15 with T1DM is ≈12%. This frequency may increase to more than 20% after years of follow-up. Objectives: to determine the age of onset of T1DM in adult patients and the frequency of T1DM in their first-degree relatives. Materials and methods: a diagnosis of T1DM was defined in 414 subjects by phenotype, clinical judgment and early insulin requirement within the year of diagnosis. Age at diagnosis was determined and subjects were divided into those with debut before or after 30. The following variables were recorded and compared: presence of T1DM in first-degree relatives, body mass index (BMI), waist circumference, HbA1c and association with hypothyroidism. t test and ANOVA for two or multiple subgroups comparison and chi square test with Fisher correction for quantitative or categorical variables were used. Results: the frequency of diabetes debut before the age of 10 was 28.2%, between 10 and 20 years 36.9%, between 20 and 30 years 18.8% and above 30 years 17.1%. The frequency of hypothyroidism and first-degree relatives with T1DM was similar in those diagnosed before or after 30 years. The presence of T1DM in first-degree relatives was found in 17.2% of the patients (father 3.6%, mother 3.1%, sibling 10.2%, son 0.5%). Conclusions: in 82.9% of patients debut was before the age of 30, but it was later in 17.1%. 17.2% of patients had first-degree relatives with T1DM. We found the highest frequency of T1DM association among siblings (10.2%) similar to studies in adult T1DM populations but contrary to studies in children and adolescents. This family pattern was similar between T1DM beginning before or after 30 years

Use of prophylactic growth factors and antimicrobials in elderly patients with cancer: a review of the Medicare database.

PURPOSE: Growth factors and antimicrobials can reduce complications of chemotherapy-induced myelosuppression. Their prophylactic use in elderly patients is important given the associated comorbidity in this age group. There is a developing trend by payers to include supportive care agents in chemotherapy care bundles, which could affect clinical practice. We examined whether the febrile neutropenia (FN) risk categories can be used to describe utilization in the Centers for Medicare & Medicaid fee-for-service system in older adults. METHODS: We conducted a retrospective cohort study using the Medicare 20% sample data to describe growth factor and antimicrobial use patterns in patients receiving chemotherapy for breast cancer, lung cancer, and non-Hodgkin lymphoma (NHL). RESULTS: The highest percentage of patients receiving granulocyte colony-stimulating factor (GCSF) within the first 5 days of a chemotherapy cycle were on high-FN-risk regimens, particularly for cycle 1 (73.7%, breast cancer; 61.5%, NHL) and cycle 2 (75.9%, breast cancer; 77.5%, NHL). Chemotherapy regimens for lung cancer are less myelotoxic, and growth factor use was more likely with latter cycles. Antibiotic use was lower at 15% within a cycle and appeared to be in response to complications. CONCLUSION: Practitioners use GCSF and antibiotics for elderly patients treated with potentially toxic chemotherapy, while comorbidity burden plays a role for patients treated with less myelotoxic regimens. The complexity of these choices in clinical practice should be considered in the proposed reimbursement changes being piloted by Medicare and private insurance companies seeking treatment cost reductions, as altered use could affect safety and efficacy.

¿Sigue siendo la VDRL una prueba serológica útil para el diagnóstico para la sífilis congénita? / Is a positive VDRL test a valid evidence for congenital syphilis?

El objetivo de esta publicación fue evaluar la utilidad de la reacción VDRL como prueba de diagnóstico para la sífilis congenita (SC). Se realizó un estudio retrospectivo y longitudinal que incluyó a 36 pacientes (20 varones y 16 mujeres ) con diagnóstico de egreso hospitalario de SC. La mediana para la edad fue de 1 mes. El período de estudio abarcó desde julio de 1993 a junio de 2003. Las madres, excepto de cuatro pacientes adoptados de los que se ignoraba el antecedente materno, en su totalidad tenían serología positiva y diagnóstico de sifilis. Veinte de los 36 pacientes (56 por ciento) tenían manifestaciones clínicas y/o radiológicas de SC; todos con serología reactivaa (VDRL) y un alto porcentaje (90 por ciento), con títulos inferiores a 8 dils y sin ninguna manifestación cínica ni radiológica para SC. Siete niños (19%) con serología no reactiva fueron asumidos como SC por el antecedente de sifilis en la madre. conclusiones: Este estudio mostró que la prueba de VDRL fue siempe reactiva en pacientes con manifestaciones clínicas y/o radiológica de SC, en su mayoría con títulos altos. En los pacientes que pesentaban marcadores reactivos como única manifestación, sus títulos fueron muy bajos y probablemente debidos a pasaje de anticuerpos maternos a través de la placenta. En aquellos pacientes con marcadores serológicos no reactivos (negativos) y antecedentes maternos de Lúes, con alguna otra manifestación clínica o radiológica. el diganóstico de SC es cuestionable y amerita considerar otras etiologías. Por lo tanto, concluimos que la prueba VDRL es una herramienta útil para el diagnóstico de SC y juega un importante rol en el monitoreo de la respuesta terapéutica.

Activation of mGluR5 modulates Ca2+ currents in retinal amacrine cells from the chick.

In the inner plexiform layer, amacrine cells receive glutamatergic input from bipolar cells. Glutamate can depolarize amacrine cells by activation of ionotropic glutamate receptors or mediate potentially more diverse changes via activation of G protein-coupled metabotropic glutamate receptors (mGluR5). Here, we asked whether selective activation of metabotropic glutamate receptor 5 is linked to modulation of the voltage-gated Ca2+ channels expressed by cultured GABAergic amacrine cells. To address this, we performed whole-cell voltage clamp experiments, primarily in the perforated-patch configuration. We found that agonists selective for mGluR5, including (RS)-2-chloro-5-hydroxyphenylglycine (CHPG), enhanced the amplitude of the voltage-dependent Ca2+ current. The voltage-dependent Ca2+ current and CHPG-dependent current enhancement were blocked by nifedipine, indicating that L-type Ca2+ channels, specifically, were being modulated. We have previously shown that activation of mGluR5 produces Ca2+ elevations in cultured amacrine cells (Sosa et al., 2002). Loading the cells with 5 mM BAPTA inhibited the mGluR5-dependent enhancement, suggesting that the cytosolic Ca2+ elevations are required for modulation of the current. Although activation of mGluR5 is typically linked to activation of protein kinase C, we found that direct activation of this kinase leads to inhibition of the Ca2+ current, indicating that stimulation of this enzyme is not responsible for the mGluR5-dependent enhancement. Interestingly, direct stimulation of protein kinase A produced an enhancement of the Ca2+ current similar to that observed with activation of mGluR5. Thus, activation of mGluR5 may modulate the L-type voltage-gated Ca2+ current in these GABAergic amacrine cells via activation of protein kinase A, possibly via direct activation of a Ca2(+)-dependent adenylate cyclase.

Metabotropic glutamate receptor 5 and calcium signaling in retinal amacrine cells.

To begin to understand the modulatory role of glutamate in the inner retina, we examined the mechanisms underlying metabotropic glutamate receptor 5 (mGluR5)-dependent Ca(2+) elevations in cultured GABAergic amacrine cells. A partial sequence of chicken retinal mGluR5 encompassing intracellular loops 2 and 3 suggests that it can couple to both G(q) and G(s). Selective activation of mGluR5 stimulated Ca(2+) elevations that varied in waveform from cell to cell. Experiments using high external K(+) revealed that the mGluR5-dependent Ca(2+) elevations are distinctive in amplitude and time course from those engendered by depolarization. Experiments with a Ca(2+) -free external solution demonstrated that the variability in the time course of mGluR5-dependent Ca(2+) elevations is largely due to the influx of extracellular Ca(2+). The sensitivity of the initial phase of the Ca(2+) elevation to thapsigargin indicates that this phase of the response is due to the release of Ca(2+) from the endoplasmic reticulum. Pharmacological evidence indicates that mGluR5-mediated Ca(2+) elevations are dependent upon the activation of phospholipase C. We rule out a role for L-type Ca(2+) channels and cAMP-gated channels as pathways for Ca(2+) entry, but provide evidence of transient receptor potential (TRP) channel-like immunoreactivity, suggesting that Ca(2+) influx may occur through TRP channels. These results indicate that GABAergic amacrine cells express an avian version of mGluR5 that is linked to phospholipase C-dependent Ca(2+) release and Ca(2+) influx, possibly through TRP channels.