The use of MRI for the imaging of metastatic bone lesions.

Skeletal metastatic disease accounts for significant overall morbidity in cancer patients. Accurate and accessible imaging forms an integral part of the investigation for patients with suspected or known skeletal metastatic disease; it is considered indispensable in making appropriate oncological treatment decisions. Magnetic resonance imaging (MRI) is a contemporary imaging modality that provides excellent spatial and contrast resolution for bone and soft tissues. Therefore, it is particularly useful for imaging patients suffering from metastatic skeletal disease. This review provides a fundamental overview of the physics and image generation of MRI. The most commonly used MRI sequences in the investigation of metastatic skeletal disease are also discussed. Additionally, a review of the pathophysiological basis of metastatic bone disease is presented, along with an introduction to the interpretation of MRI sequences obtained for metastatic bone disease. Finally, the strengths and drawbacks of MRI are considered in comparison to alternative imaging modalities for the investigation of this common and important oncological complication.

Non-contrast computed tomography characteristics in a large cohort of cystinuria patients.

PURPOSE: Cystine stones are widely considered hard and difficult to treat. Hounsfield Units (HU) are used in other stone types to estimate 'hardness' and treatments based on that finding. Our objective was to report mean HU of cystine stones in vivo in a large case series of cystinuria patients and assess for differences in genotype. METHODS: A prospective case series of cystinuria patients referred to a specialist centre was analysed. CT imaging was assessed by two independent radiologists to determine in vivo attenuation of cystine calculi. Mean HU was compared for both cystinuria genes (SLC3A1 and SLC7A9) using an independent t-test. RESULTS: 164 adult cystinuric patients were identified (55% male), median age 43 years (range 18-80). Median follow up was 31 months (IQR 10-62). Genetic data available for 153/164 (93%) demonstrated 97 SLC3A1 (63%) and 55 (36%) SLC7A9 mutations (39 homozygous, 16 heterozygous) and one heterozygous for both SLC3A1/SLC7A9. 107 patients had CT images available demonstrating calculi. Median HU across the cohort was 633 (5th to 95th centile 328-780). There was no difference in mean HU between SLC3A1 and SLC7A9 genotypes (p = 0.68) or homo and heterozygous SLC7A9 (p = 0.70). Mean HU correlated with stone size (Pearson correlation coefficient = 0.51, p < 0.001). CONCLUSION: In this large single centre cystinuria cohort, mean HU was low for stones that are difficult to treat. Calculi of < 800 HU should prompt consideration of a cystinuria diagnosis. Attenuation was not associated with genotype, and distinct 'smooth' and 'rough' stones were not observed. Calculi with HU > 1000 are unlikely pure cystine, and in a known cystinuric would suggest conversion to another stone type.

Intra-gastrointestinal amyloid-ß1-42 oligomers perturb enteric function and induce Alzheimer's disease pathology.

KEY POINTS: Alzheimer's disease (AD) patients and transgenic mice have beta-amyloid (Aß) aggregation in the gastrointestinal (GI) tract. It is possible that Aß from the periphery contributes to the load of Aß in the brain, as Aß has prion-like properties. The present investigations demonstrate that Aß injected into the GI tract of ICR mice is internalised into enteric cholinergic neurons; at 1 month, administration of Aß into the body of the stomach and the proximal colon was observed to partly redistribute to the fundus and jejunum; at 1 year, vagal and cerebral ß-amyloidosis was present, and mice exhibited GI dysfunction and cognitive deficits. These data reveal a previously undiscovered mechanism that potentially contributes to the development of AD. ABSTRACT: Alzheimer's disease (AD) is the most common age-related cause of dementia, characterised by extracellular beta-amyloid (Aß) plaques and intracellular phosphorylated tau tangles in the brain. Aß deposits have also been observed in the gastrointestinal (GI) tract of AD patients and transgenic mice, with overexpression of amyloid precursor protein. In the present studies, we investigate whether intra-GI administration of Aß can potentially induce amyloidosis in the central nervous system (CNS) and AD-related pathology such as dementia. We micro-injected Aß1-42 oligomers (4 µg per site, five sites) or vehicle (saline, 5 µl) into the gastric wall of ICR mice under general anaesthesia. Immunofluorescence staining and in vivo imaging showed that HiLyte Fluor 555-labelled Aß1-42 had migrated within 3 h via the submucosa to nearby areas and was internalised into cholinergic neurons. At 1 month, HiLyte Fluor 555-labelled Aß1-42 in the body of the stomach and proximal colon had partly re-distributed to the fundus and jejunum. At 1 year, the jejunum showed functional alterations in neuromuscular coupling (P < 0.001), and Aß deposits were present in the vagus and brain, with animals exhibiting cognitive impairments in the Y-maze spontaneous alteration test (P < 0.001) and the novel object recognition test (P < 0.001). We found that enteric Aß oligomers induce an alteration in gastric function, amyloidosis in the CNS, and AD-like dementia via vagal mechanisms. Our results suggest that Aß load is likely to occur initially in the GI tract and may translocate to the brain, opening the possibility of new strategies for the early diagnosis and prevention of AD.

Imidazo[1,2-a]pyridin-6-yl-benzamide analogs as potent RAF inhibitors.

A series of imidazo[1,2-a]pyridin-6-yl-benzamide analogs was designed as inhibitors of B-RAFV600E. Medicinal chemistry techniques were employed to explore the SAR for this series and improve selectivity versus P38 and VEGFR2.

Ligand efficient tetrahydro-pyrazolopyridines as inhibitors of ERK2 kinase.

A series of structure based drug design hypotheses and focused screening efforts drove improvements in the potency and lipophilic efficiency of tetrahydro-pyrazolopyridine based ERK2 inhibitors. Elaboration of a fragment chemical lead established a new lipophilic aryl-Tyr interaction resulting in a substantial potency improvement. Subsequent cleavage of the lipophilic moiety led to reconfiguration of the ligand bound binding cleft. The reconfiguration established a polar contact between a newly liberated N-H and a vicinal Asp, resulting in further improvements in lipophilic efficiency and in vitro clearance.

Tetrahydropyrrolo-diazepenones as inhibitors of ERK2 kinase.

A series of structure based drug design hypotheses and focused screening efforts led to the identification of tetrahydropyrrolo-diazepenones with striking potency against ERK2 kinase. The role of fluorination in mitigating microsomal clearance was systematically explored. Ultimately, it was found that fluorination of a cyclopentanol substructure provided significant improvement in both potency and human metabolic stability.

Potent GCN2 Inhibitor Capable of Reversing MDSC-Driven T Cell Suppression Demonstrates In Vivo Efficacy as a Single Agent and in Combination with Anti-Angiogenesis Therapy.

General control nonderepressible 2 (GCN2) protein kinase is a cellular stress sensor within the tumor microenvironment (TME), whose signaling cascade has been proposed to contribute to immune escape in tumors. Herein, we report the discovery of cell-potent GCN2 inhibitors with excellent selectivity against its closely related Integrated Stress Response (ISR) family members heme-regulated inhibitor kinase (HRI), protein kinase R (PKR), and (PKR)-like endoplasmic reticulum kinase (PERK), as well as good kinome-wide selectivity and favorable PK. In mice, compound 39 engages GCN2 at levels ≥80% with an oral dose of 15 mg/kg BID. We also demonstrate the ability of compound 39 to alleviate MDSC-related T cell suppression and restore T cell proliferation, similar to the effect seen in MDSCs from GCN2 knockout mice. In the LL2 syngeneic mouse model, compound 39 demonstrates significant tumor growth inhibition (TGI) as a single agent. Furthermore, TGI mediated by anti-VEGFR was enhanced by treatment with compound 39 demonstrating the complementarity of these two mechanisms.

The pursuit of radiology training in times of a pandemic.

The Coronavirus-19 (COVID-19) pandemic has been the greatest challenge faced by the National Health Service (NHS) in its lifetime. The crisis has seen the disruption of many long-held institutions, most critically of which is specialty training. In this article, we discuss the impact of the pandemic on Radiology training in the UK. We explore the methods that have been used to combat these difficulties and suggest workable solutions. As technology platforms become ever more integral to our daily clinical routines, we discuss how these offer a new approach to training. We argue that, of all the medical disciplines, radiologists are best placed to design and implement technology-based training, and lead other specialties in doing so. Whilst the upheaval of traditional approaches to education is a challenge, we propose that this departure from the norm offers exciting opportunities for improvement.

Immune checkpoint inhibitor induced large vessel vasculitis.

This is a case report of a 67-year-old patient with castration resistant metastatic prostate cancer who developed an immune-mediated large vessel vasculitis following treatment with ipilimumab (anti-CTLA-4) and nivolumab (anti-PD-1).

Attitudes and perceptions of UK medical students towards artificial intelligence and radiology: a multicentre survey.

OBJECTIVES: To explore the attitudes of United Kingdom (UK) medical students regarding artificial intelligence (AI), their understanding, and career intention towards radiology. We also examine the state of education relating to AI amongst this cohort. METHODS: UK medical students were invited to complete an anonymous electronic survey consisting of Likert and dichotomous questions. RESULTS: Four hundred eighty-four responses were received from 19 UK medical schools. Eighty-eight percent of students believed that AI will play an important role in healthcare, and 49% reported they were less likely to consider a career in radiology due to AI. Eighty-nine percent of students believed that teaching in AI would be beneficial for their careers, and 78% agreed that students should receive training in AI as part of their medical degree. Only 45 students received any teaching on AI; none of the students received such teaching as part of their compulsory curriculum. Statistically, students that did receive teaching in AI were more likely to consider radiology (p = 0.01) and rated more positively to the questions relating to the perceived competence in the post-graduation use of AI (p = 0.01-0.04); despite this, a large proportion of students in the taught group reported a lack of confidence and understanding required for the critical use of healthcare AI tools. CONCLUSIONS: UK medical students understand the importance of AI and are keen to engage. Medical school training on AI should be expanded and improved. Realistic use cases and limitations of AI must be presented to students so they will not feel discouraged from pursuing radiology.

Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department.

STUDY OBJECTIVES: We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations. METHODS: In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument. RESULTS: One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED. CONCLUSION: Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.

Data showing the circumvention of oxaliplatin resistance by vatalanib in colon cancer.

We have recently reported that vatalanib, an orally active small molecule multi-tyrosine kinase inhibitor (Hess-Stumpp et al., 2005 [1]), can sensitize multidrug resistant (MDR) colon cancer cells to chemotherapy under hypoxia by inhibiting two MDR transporters ABCB1 and ABCG2 (To et al., 2015 [2]). This data article describes the possible circumvention of resistance to specifically platinum (Pt)-based anticancer drugs by vatalanib via inhibition of two other efflux transporters ABCC2 and ATP7A. Data from the flow cytometric transporter efflux assay showed specific inhibition of ABCC2 activity by vatalanib in stable transfected cells and ABCC2-overexpressing oxaliplatin-resistant colon cancer cells HCT116/Oxa. We also performed the transporter ABCC2 ATPase assay and showed an increase in ATP hydrolysis by ABCC2 in the presence of vatalanib. ATP7A mRNA expression was also shown to be upregulated in HCT116/Oxa cells. Vatalanib was shown to suppress this upregulated ATP7A expression. Data from the cellular Pt accumulation assay showed a lower Pt accumulation in HCT116/Oxa cells than the parental sensitive HCT116 cells. Vatalanib was shown to increase cellular Pt accumulation in a concentration-dependent manner. Combination of oxaliplatin and vatalanib was shown to restore the suppressed apoptosis in HCT116/Oxa cells.

A platinum-based hybrid drug design approach to circumvent acquired resistance to molecular targeted tyrosine kinase inhibitors.

Three molecular targeted tyrosine kinase inhibitors (TKI) were conjugated to classical platinum-based drugs with an aim to circumvent TKI resistance, predominately mediated by the emergence of secondary mutations on oncogenic kinases. The hybrids were found to maintain specificity towards the same oncogenic kinases as the original TKI. Importantly, they are remarkably less affected by TKI resistance, presumably due to their unique structure and the observed dual mechanism of anticancer activity (kinase inhibition and DNA damage). The study is also the first to report the application of a hybrid drug approach to switch TKIs from being efflux transporter substrates into non-substrates. TKIs cannot penetrate into the brain for treating metastases because of efflux transporters at the blood brain barrier. The hybrids were found to escape drug efflux and they accumulate more than the original TKI in the brain in BALB/c mice. Further development of the hybrid compounds is warranted.

Vatalanib sensitizes ABCB1 and ABCG2-overexpressing multidrug resistant colon cancer cells to chemotherapy under hypoxia.

Cancer microenvironment is characterized by significantly lower oxygen concentration. This hypoxic condition is known to reduce drug responsiveness to cancer chemotherapy via multiple mechanisms, among which the upregulation of the ATP-binding cassette (ABC) efflux transporters confers resistance to a wide variety of structurally unrelated anticancer drugs. Vatalanib (PTK787/ZK22584) is a multitargeted tyrosine kinase inhibitor for all isoforms of VEGFR, PDGFR and c-Kit, which exhibit potent anticancer activity in vitro and in vivo. We investigated the potentiation effect of vatalanib on the anticancer activity of conventional cytotoxic drugs in colon cancer cell lines under both normoxic and hypoxic conditions. Mechanistically, vatalanib was found to inhibit ABCG2 and ABCB1 efflux activity, presumably by acting as a competitive inhibitor and interfering with their ATPase activity. Under hypoxic growth condition, ABCG2 and ABCB1-overexpressing cells sorted out by FACS technique as side population (SP) were found to be significantly more responsive to SN-38 (ABCG2 and ABCB1 substrate anticancer drug) in the presence of vatalanib. The anchorage independent soft agar colony formation capacity of the SP cells was remarkably reduced upon treatment with a combination of SN-38 and vatalanib, compared to SN-38 alone. However, vatalanib, at concentrations that produced the circumvention of the transporters-mediated resistance, did not appreciably alter ABCG2/ABCB1 mRNA or protein expression levels or the phosphorylation of Akt and extracellular signal-regulated kinase (ERK1/2). Our study thus advocates the further investigation of vatalanib for use in combination chemotherapy to eradicate drug-resistant cancer cells under hypoxia.

Pelitinib (EKB-569) targets the up-regulation of ABCB1 and ABCG2 induced by hyperthermia to eradicate lung cancer.

BACKGROUND AND PURPOSE: Pelitinib is a potent irreversible EGFR TK inhibitor currently in clinical trials for the treatment of lung cancer. Hyperthermia has been applied concomitantly with chemotherapy and radiotherapy to enhance treatment outcome. In this study, we investigated the ability of the combination of pelitinib with other conventional anticancer drugs to specifically target cancer cells with up-regulated efflux transporters ABCB1/ABCG2 after hyperthermia as a novel way to eradicate the cancer stem-like cells responsible for cancer recurrence. EXPERIMENTAL APPROACH: Alterations in intracellular topotecan accumulation, the efflux of fluorescent probe substrates, expression and ATPase activity of ABCB1/ABCG2 and tumoursphere formation capacity of side population (SP) cells sorted after hyperthermia were examined to elucidate the mechanism of pelitinib-induced chemosensitization. KEY RESULTS: While pelitinib did not modulate ABCB1/ABCG2 expressions, the combination of pelitinib with transporter substrate anticancer drugs induced more marked apoptosis, specifically in cells exposed to hyperthermia. The flow cytometric assay showed that both ABCB1- and ABCG2-mediated drug effluxes were significantly inhibited by pelitinib in a concentration-dependent manner. The inhibition kinetics suggested that pelitinib is a competitive inhibitor of ABCB1/ABCG2, which is consistent with its ability to stimulate their ATPase activity. SP cells sorted after hyperthermia were found to be more resistant to anticancer drugs, presumably due to the up-regulation of ABCB1 and ABCG2. Importantly, pelitinib specifically enhanced the chemosensitivity but reduced the tumoursphere formation capacity of these SP cells. CONCLUSIONS AND IMPLICATIONS: This study demonstrated a novel approach, exploiting drug resistance, to selectively kill cancer stem-like cells after hyperthermia.

Discovery of RAF265: A Potent mut-B-RAF Inhibitor for the Treatment of Metastatic Melanoma.

Abrogation of errant signaling along the MAPK pathway through the inhibition of B-RAF kinase is a validated approach for the treatment of pathway-dependent cancers. We report the development of imidazo-benzimidazoles as potent B-RAF inhibitors. Robust in vivo efficacy coupled with correlating pharmacokinetic/pharmacodynamic (PKPD) and PD-efficacy relationships led to the identification of RAF265, 1, which has advanced into clinical trials.

Design and Synthesis of Orally Bioavailable Benzimidazole Reverse Amides as Pan RAF Kinase Inhibitors.

Benzimidazole reverse amides were designed and synthesized as Pan RAF kinase inhibitors. Investigation of the structure-activity relationship of the compounds revealed that they were potent in vitro and exhibited desirable in vivo properties.

Correction to Design and Synthesis of Orally Bioavailable Benzimidazole Reverse Amides as Pan RAF Kinase Inhibitors.

[This corrects the article DOI: 10.1021/ml5002272.].