Castleman's disease is an uncommon lymphoproliferative disorder that can be found in both unicentric and multicentric forms. Although the multicentric form is typically seen in immunocompromised patients, the unicentric variety often presents as an asymptomatic mass in otherwise healthy patients. While these lesions are rare in the pediatric population, recognizing the potential diagnosis may help dictate pre- and intraoperative imaging and operative technique and approach.
Activated CD4+ cells comprise a large proportion of inflammatory cells involved in the development of rheumatoid arthritis (RA). Inflammatory cytokines, as tumor necrosis factor-a (TNFa), have also been implicated in the establishment and progression of joint destruction. Treatments for RA include synthetical and biological disease modifying anti-rheumatic drugs (DMARDs), as methotrexate (MTX) and TNFa-inhibitors, as infliximab. Cellular effects can be evaluated by metabolomics with measurement of ideally all endogenous metabolites.
Objectives
Evaluation in CD4+ cells, from a multiplatform metabolomic study, of MTX and infliximab treatment in order to investigate the metabolomic features.
Methods
Blood samples from 5 healthy controls were collected for metabolomic study. CD4+ cells were isolated by magnetic separation using CD4 MicroBeads from peripheral blood mononuclear cells, divided in 5 different groups and cultured for 24 hours: 1. CD4+ T cells as control, 2. CD4+ T cells treated with MTX at the dosage of 0.01 mM, 3. CD4+ T cells treated with MTX at the dosage of 0.1mM, 4. CD4+ T cells treated with infliximab at the dosage of 1 µg/ml, 5. CD4+ T cells treated with IgG1k at the dosage of 1µg/ml as control of Infliximab. A total of 25 cell samples were analysed using Metabolon's standard extraction method.
Results
Ribulose was reduced with decrease in glycolysis and inhibition of phosphofructose kinase 1 (PFK1) by MTX (p<0.05). This reflects CD4+ cells effort to increase the production of cellular reducing power (NADPH) to offset stress exerted by MTX. Isovalerylcarnitine, linked to proteolytic enzymes and calpain system, was increased by MTX (p<0.05). Both calpain and caspase systems lead to cytochrome activation and promote early apoptosis. Hypotaurine, an antioxidants in vivo, was increased by both MTX and Infliximab (p<0.05). Glutarate (pentanedioate) was reduced by infliximab(p<0.05). This agent is linked to oxidized phospholipids and proteins; measurement of protein-bound phosphate and long-chain fatty acids may be useful for assessing long-term lipid peroxidative damage to proteins in vivo. Methylphosphate was increased by MTX and infliximab (p<0.05): It reduce transcription of inflammatory genes and decrease RNAs affinity to nuclear phosphoprotein. 7 beta-hydroxycholesterol was reduced by infliximab (p<0.05). It is present at elevated concentrations in inflammatory lesions, strongly cytotoxic and pro-oxidative. Its effect is relevant on cell death and oxidative DNA damage.
Conclusions
Biochemicals involved in a number of pathways showed some promising and subtle trends and better elucidate the pathogenetic mechanisms of the disease and response to treatments. MTX and Infliximab treatment of CD4+ cells had an impact on inflammation and cellular defence. This is the first demonstration of metabolites that can be monitored for treatment efficacy and tolerability. These observations provide some insights into the potential mechanisms involved in mediating the anti-inflammatory and the immunomodulation effects of MTX and infliximab.
Abstract Relapsed high‐risk neuroblastoma has few effective therapies currently available or in development. Cabozantinib is an Food and Drug Administration approved multitargeted tyrosine kinase inhibitor for select adult malignancies with preclinical data suggesting efficacy against neuroblastoma. A safe and tolerable dose has been identified for children, but its efficacy remains unknown. We describe four children with relapsed metastatic neuroblastoma treated with cabozantinib. All four patients had extended disease control (two complete responsesfor >12 months, 2 stable disease >6 months) with manageable predictable toxicities requiring dose reduction in two patients. We discuss the potential for the use of cabozantinib in neuroblastoma.
Rhabdoid tumors (RTs) of the brain (atypical teratoid/rhabdoid tumor; AT/RT) and extracranial sites (most often the kidney; RTK) are malignant tumors predominantly occurring in children, frequently those with SMARCB1 germline alterations. Here we present data from seven RTs from three pediatric patients who all had multi-organ involvement. The tumors were analyzed using a multimodal molecular approach, which included exome sequencing of tumor and germline comparator and RNA sequencing and DNA array-based methylation profiling of tumors. SMARCB1 germline alterations were identified in all patients and in all tumors. We observed a second hit in SMARCB1 via chr22 loss of heterozygosity. By methylation profiling, all tumors were classified as rhabdoid tumors with a corresponding subclassification within the MYC, TYR, or SHH AT/RT subgroups. Using RNA-seq gene expression clustering, we recapitulated the classification of known AT/RT subgroups. Synchronous brain and kidney tumors from the same patient showed different patterns of either copy number variants, single-nucleotide variants, and/or genome-wide DNA methylation, suggestive of non-clonal origin. Furthermore, we demonstrated that a lung and abdominal metastasis from two patients shared overlapping molecular features with the patient's primary kidney tumor, indicating the likely origin of the metastasis. In addition to the SMARCB1 events, we identified other whole-chromosome events and single-nucleotide variants in tumors, but none were found to be prognostic, diagnostic, or offer therapeutic potential for rhabdoid tumors. While our findings are of biological interest, there may also be clinical value in comprehensive molecular profiling in patients with multiple rhabdoid tumors, particularly given the potential prognostic and therapeutic implications for different rhabdoid tumor subgroups demonstrated in recent clinical trials and other large cohort studies.
Anaplastic large cell lymphoma is a heterogeneous group of malignant non-Hodgkin lymphomas that occurs in up to 15% of all pediatric non-Hodgkin lymphomas. It is characterized by B-symptoms and involvement of extranodal sites such as skin, bone, and soft tissue. This brief report describes first reported case of pediatric primary testicular anaplastic large cell lymphoma in a 14-year-old boy. The presentation included acute testicular pain, fever, and vomiting. After chemotherapy and unilateral radical orchiectomy, patient continues in complete remission.
Renal masses are most common in children between ages 1 to 3 years, with less known about renal tumors in older children and young adults. The aim of this study was to review the presentation, demographics, histology, and outcomes in patients over 5 years of age with renal tumors compared with younger children. 111 renal tumors were diagnosed in patients 5 years of age and older (median, 7 y; range, 5 to 31 y) between 1950 and 2017 at a single institution. Wilms tumor (WT) was the most common histology in 84 patients (75%), followed by renal cell carcinoma in 12 patients (10.7%). Abdominal pain was the most common presenting symptom (46%) followed by hematuria (28.8%), and a palpable abdominal mass (24.3%). For WT, older children more commonly presented with advanced-stage disease (stages 3 and 4) than younger children (57.7% vs. 11.5%; P <0.001). Event-free survival (EFS) and overall survival (OS) for favorable histology WT were not different between younger and older children (OS, P =0.43; EFS, P =0.46). In this cohort, older children more frequently present with variable signs and symptoms, less common histopathologies although WT was still most frequent, and more advanced-stage disease compared with younger cohorts, but without differences in EFS or OS.
10005 Background: Neuroblastoma (NBL) is the most common extra-cranial solid tumor in children and outcomes for children with relapsed/refractory (RR) NBL remain dismal. While the combination of chemoimmunotherapy (CIT) with the anti-GD2 antibody dinutuximab as per COG protocol ANBL1221 has improved responses, this regimen is still not curative. Dinutuximab can recruit NK cells for anticancer activity, however, NK cells are depleted in NBL patients undergoing chemotherapy. We devised a method to expand allogeneic NK cells ex vivo to improve effector function and render the NK cells resistant to TGFβ-induced suppression (TGFβi). These TGFβi NK cells are expanded from a universal donor (UD) pool, enabling multiple cycles of “off-the-shelf” high-dose therapy. We hypothesize that adoptive transfer of UD-TGFβi NK cells to patients with RR NBL sequentially following CIT is safe and improves outcomes compared to CIT alone. Methods: This Phase I/II study evaluates the safety and tolerability of UD-TGFβi NK cells in combination with CIT and compares anti-cancer efficacy to CIT alone. Eligibility includes age < 30 years, RR or progressive NBL, and prior treatment with at least 4 cycles of induction chemotherapy. The treatment protocol consists of 21-day cycles of CIT as per COG protocol ANBL1221 with UD-TGFβi NK cells (1x10 8 cells/kg) infused on day 8. Up to six cycles of treatment are permitted. Overall response rates are defined using the Revised International NBL Response Criteria, with 95% confidence intervals compared to the results from ANBL1221. Progression-free and overall survival will be estimated by the Kaplan Meier method. Results: Four subjects (7 – 11 years) have been enrolled. All patients presented with high risk NBL: three with relapsed disease and one with refractory disease. All received at least one prior salvage therapy. Three patients have completed all 6 cycles of protocol therapy, and one remains on treatment. 20 NK cell infusions have been administered to date. All NK cell infusions occurred within the protocol specified window. One subject experienced grade 1 fever with two NK cell infusions. There have been no other adverse events attributable to the NK cells. Adverse events attributable to CIT were similar to those described in COG ANBL 1221. Treatment delays for cytopenias due to CIT occurred in two patients. Three patients achieved a partial response. A fourth patient attained prolonged stable disease (9 months) but experienced a skeletal recurrence. Conclusions: UD allo-TGFβi NK cells can be safely and feasibly administered to children with RR NBL after treatment with CIT, with early objective responses observed in the preliminary cohort of patients. Ongoing studies will assess markers of response, NK cell persistence, pharmacokinetics and pharmacodynamics. Clinical trial information: NCT04211675 .
Familial adenomatous polyposis (FAP) is a disease of significant morbidity and risk of early mortality caused by colorectal or periampullary cancer, or noncancerous desmoid tumors. In the pediatric and adolescent FAP population, precancerous and cancerous tumors of the colon, thyroid, liver, and central nervous system have been described, with rare reports in other locations. FAP-associated death in the pediatric and adolescent population is rare. We report a 12-year-old girl with FAP and Cushing syndrome secondary to right adrenocortical carcinoma, who died of metastatic disease unresponsive to therapy. The patient first presented for genetic screening at age 10 years and was found to have the same APC mutation as her mother, 453delA. She was lost to follow-up until the age of 12 years, when she was found to have a dramatic weight gain of 52 lb (body mass index of 34 kg/m2) and hypertension with a blood pressure of 157/89 mmHg. At endocrinology consultation, she reported daily chest and side pain with dyspnea on exertion. She was premenarchal. Physical examination revealed truncal obesity and a moon face. Her blood pressure was162/112 mmHg; height 146.6 cm; weight 72.5 kg, and growth velocity 3.7 cm/year during the last 2 years. Examination was notable for moderate acne, acanthosis nigricans, mild violaceous abdominal striae, Tanner stage-4 pubic hair, and lipomastia without true breast tissue. Abdominal examination showed no masses or organomegaly. The remainder of her physical examination was normal. Endocrine studies obtained as a result of virilization and features of Cushing syndrome showed normal electrolytes, normal thyroid-stimulating hormone, and free T4 and elevated testosterone, dehydroepiandrosterone sulfate, and androstenedione. The cortisol level did not suppress with 1 mg dexamethasone. The baseline was 18.2 μg/dL and 8 AM was 17.3 μg/dL. Computerized tomography of the abdomen/pelvis identified a right upper-quadrant suprarenal mass consistent with adrenal carcinoma measuring 14 × 10 × 8.6 cm with suspected lung metastases (Fig. 1). Further gastrointestinal evaluation was suspended at this time. Needle core biopsies of the mass showed a high-grade atypical lesion with extensive necrosis. This confirmed the diagnosis of adrenocortical carcinoma and she started receiving chemotherapy according to the Children's Oncology Group protocol, ARA0332. Her chemotherapy included cisplatin, doxorubicin, etoposide, and escalating doses of mitotane. Maintenance hydrocortisone in anticipation of the development of adrenal insufficiency secondary to mitotane therapy was also initiated.FIGURE 1: Scan at diagnosis demonstrating the right adrenal mass.Following 4 cycles of chemotherapy, she was taken to surgery for attempted gross total resection, but was found at exploration to have extensive metastatic disease to her liver, which had not been visible on preoperative imaging. She underwent right adrenalectomy with resection of the primary mass (Fig. 2). The liver metastases were biopsied, but were unresectable because of their diffusing nature. Histopathology of the primary mass showed 50% viable tumor with 50% necrosis. The pathology from the liver biopsy confirmed metastatic carcinoma. The lesional cells were highlighted by immunohistochemical stains melan A, inhibin, cytokeratin, and calretinin. The tumor cells were not highlighted by Myf-4. Disease progression was noted after 6 cycles, so she then received 2 cycles of gemcitabine, capecitabine, and mitotane. At completion of these 2 cycles, she developed cardiomyopathy with further metastatic disease progression. After further discussion with the patient and family, she was transitioned to palliative care and died 2 months later, approximately 10 months after diagnosis.FIGURE 2: Gross specimen after resection of adrenal tumor.DISCUSSION There are several well-described intestinal and extraintestinal consequences of FAP. Although surveillance recommendations for the prevention of intestinal malignancies in FAP are well established, guidelines for surveillance of the extraintestinal malignancies have not been created. Recommendations that do exist include screening children of patients with FAP for hepatoblastoma with α-fetoprotein and abdominal ultrasound, annual physical examination to evaluate for soft tissue or bone lesions, and thyroid examination to identify any nodules (1). The majority of these recommendations are nonspecific and no consensus exists regarding periodic testing. Adrenal adenomas are a frequently occurring extraintestinal manifestation of FAP, with >50 cases reported (1). Many of these patients were asymptomatic and discovered at autopsy. In a retrospective study of the FAP database at the Cleveland Clinic, Marchesa et al (2) found a 7% prevalence of "incidentalomas" in patients with FAP as compared with 3% in the general population. Smith et al (3) prospectively studied 107 patients with FAP and found the prevalence of adrenal masses to be 13%. Although adrenal adenomas are common, adrenal carcinomas in patients with FAP are rare and only a few have been reported in the literature (1–4). Of these patients, only 1 was <20 years. In the non-FAP population, adrenocortical carcinomas are rare (4–12/million) (5) and are poorly responsive to chemotherapy. The prognosis is poor, especially when metastases are present. Early discovery is imperative for complete surgical resection. Adrenocortical tumors in patients with FAP have traditionally been found incidentally when screening for other complications. The present recommendation for identification of these tumors is early recognition of the physical signs of glucocorticoid excess such as weight gain, hypertension, hypokalemia, and diabetes mellitus because nearly 20% of adults with tumors have mild hormonal dysfunction (1). Radiologic and/or hormonal surveillance is not recommended at this time (1,4). Michalkiewicz et al (6) described 254 pediatric patients with adrenal cortical tumors without FAP and found that the majority of patients younger than 20 years had clinical signs of excess virilization as the most common presenting sign. Our study indicates that children with adrenocortical tumors and FAP present with findings of both glucocorticoid and androgen excess. Unfortunately, earlier detection was not possible given our patient's poor follow-up, and she presented with advanced stage disease Adrenocortical carcinoma is a rare, often fatal entity, which has been reported in association with FAP in older adolescents and adults. Hormone-secreting adrenocortical tumors in children are usually symptomatic, indicating that clinicians caring for children with FAP should be routinely monitoring for signs such as virilization, rapid weight gain, and hypertension, with the goal of identifying these patients at an early stage when surgical resection is possible.
