Immunomodulatory effects of low dose chemotherapy and perspectives of its combination with immunotherapy

Given that cancer is one of the main causes of death worldwide, many efforts have been directed toward discovering new treatments and approaches to cure or control this group of diseases. Chemotherapy is the main treatment for cancer; however, a conventional schedule based on maximum tolerated dose (MTD) shows several side effects and frequently allows the development of drug resistance. On the other side, low dose chemotherapy involves antiangiogenic and immunomodulatory processes that help host to fight against tumor cells, with lower grade of side effects. In this review, we present evidence that metronomic chemotherapy, based on the frequent administration of low or intermediate doses of chemotherapeutics, can be better than or as efficient as MTD. Finally, we present some data indicating that noncytotoxic concentrations of antineoplastic agents are able to both up-regulate the immune system and increase the susceptibility of tumor cells to cytotoxic T lymphocytes. Taken together, data from the literature provides us with sufficient evidence that low concentrations of selected chemotherapeutic agents, rather than conventional high doses, should be evaluated in combination with immunotherapy. Copyright © 2012 UICC.

N-4-Phenyl-substituted 2-acetylpyridine thiosemicarbazones: Cytotoxicity against human tumor cells, structure-activity relationship studies and investigation on the mechanism of action

N-4-Phenyl 2-acetylpyridine thiosemicarbazone (H2Ac4Ph; N-(phenyl)-2-(1-(pyridin-2-yl)ethylidene) hydrazinecarbothioamide) and its N-4-ortho-, -meta- and -para-fluorophenyl (H2Ac4oFPh, H2Ac4mFPh, H2Ac4pFPh), N-4-ortho-, -meta- and -para-chlorophenyl (H2Ac4oClPh, H2Ac4mClPh, H2Ac4pClPh), N-4-ortho-, -meta- and -para-iodophenyl (H2Ac4oIPh, H2Ac4mIPh, H2Ac4pIPh) and N-4-ortho-, -meta- and -para-nitrophenyl (H2Ac4oNO(2)Ph, H2Ac4mNO(2)Ph, H2Ac4pNO(2)Ph) derivatives were assayed for their cytotoxicity against human malignant breast (MCF-7) and glioma (T98G and U87) cells. The compounds were highly cytotoxic against the three cell lineages (IC50: MCF-7, 52-0.16 nM; T98G, 140-1.0 nM; U87, 160-1.4 nM). All tested thiosemicarbazones were more cytotoxic than etoposide and did not present any haemolytic activity at up to 10(-5) M. The compounds were able to induce programmed cell death. H2Ac4pClPh partially inhibited tubulin assembly at high concentrations and induced cellular microtubule disorganization. (C) 2012 Elsevier Ltd. All rights reserved.

Schwerionenbestrahlung zwei- und dreidimensionaler Zellsysteme

Aufgaben der vorliegenden Untersuchungen waren die Etablierung von planaren Multilayern aus mensch­lichen Tumorzellen (WiDr und SiHa) und die Testung dieses Zellsystems als Bestrahlungsmodell solider Tumoren. Neben der konventionellen Röntgenbestrahlung (250 kV) wurde auch das Überle­ben nach Schwerionenbestrahlung (12C6+) und nach Behandlung mit dem Chemotherapeutikum Etoposid unter­sucht. Multilayer aus beiden Zelllinien zeigten ein geringeres Überleben nach Röntgen- und Schwerionenbestrah­lung als die entsprechenden Monolayer. Die hier beschriebene multizelluläre Sensitivierung steht aller­dings im Ge­gensatz zu der in der Literatur beschriebenen multizellulären Resistenz der Sphäroide, dem sog. Kontakteffekt. Nach durchflußzytometrischen Mes­sungen arretierten die bestrahlten SiHa-Zellen in der G2/M-Phase. Im Gegen­satz zum transienten Block der Monolayer verweilten die Multilayer in einem per­manenten Arrest. Im Vergleich zur Röntgenbe­strahlung verlän­gerte sich die Arrestzeit der Mono­layer nach Schwerionenbestrahlung im Bragg-Peak um 12-24 h. Auch waren mehr Zellen betroffen. Im Gegensatz dazu war kein Unterschied zwischen beiden Bestrahlungsmo­dalitäten bei den Multi­layern bis zum Ende des Beobachtungszeit­raumes zu verzeichnen. Nach Etoposid-Behandlung verhielten sich die Multilayer deutlich resistenter als die Monolayer. Somit zeigten Multilayer interessan­terweise nach Bestrahlung eine Sensitivierung und nach Etoposid-Behandlung eine Resistenz. Die Unterschiede im Überleben der beiden Kultivierungs­formen beruhen zum Großteil auf den Differenzen in der Zellzyk­lusverteilung. Besonders deutlich wurde dieser Zusam­men­hang zwischen Überleben und Zell­zyklusvertei­lung durch Wie­deraussaat- und Synchronisations-Experi­mente.

Untersuchungen zur Rolle des BH3-only-Proteins Bid bei der Stress-induzierten Apoptose in Karzinomzelllinien

Als BH3-only Protein gehört Bid zu den proapoptotischen Mitgliedern der Bcl-2 Familie, die während der Apoptose die Freisetzung Caspase-aktivierender Proteine aus den Mitochondrien kontrollieren. Bid zählt zu den potentesten BH3-only Proteinen und wird von vielen transformierten und nichttransformierten Zellen konstitutiv exprimiert. Ziel dieser Arbeit war es, Bid durch RNA-Interferenz stabil zu depletieren, um Bid-abhängige Apoptosewege in HeLa Zervixkarzinomzellen zu identifizieren, die von intrinsischen Stressstimuli sowie von konventionellen und neuartigen Chemotherapeutika induziert werden. Da Bid im Todesrezeptor-vermittelten Signalweg der Apoptose durch Caspase-8 gespalten und aktiviert wird, waren die Bid-depletierten Zellen signifikant vor der Fas/CD95-, TRAIL- oder TNF-α-induzierten Apoptose geschützt und zeigten nach Exposition mit allen drei Todesrezeptorliganden eine drastisch reduzierte Effektorcaspase-Aktivität und eine höhere Proliferationsrate als die Kontrollzellen. Eine ektopische Bidexpression in Bid knock down (kd) Zellen hob die Protektion vor der Fas- und TRAIL-induzierten Apoptose auf. Der Proteasominhibitor Epoxomicin, der Proteinkinase-Inhibitor Staurosporin oder die ER Stress-induzierenden Agenzien Tunicamycin, Thapsigargin und Brefeldin A lösten hingegen einen Bid-unabhängigen Zelltod aus. Allerdings konnten subletale Tunicamycin- oder Thapsigarginkonzentrationen HeLa Zellen für die TRAIL-induzierte Apoptose sensitivieren. Da der Synergieeffekt auf einer ER Stress-vermittelten Amplifizierung des Todesrezeptorwegs beruhte, zu der eine Tunicamycin-induzierte Steigerung der Expression des Todesrezeptors DR5 signifikant beitrug, erfolgte diese Sensitivierung nur in Bid-profizienten Zellen. Bid war in HeLa Zellen außerdem an der apoptotischen Signalkaskade beteiligt, die von den DNA-schädigenden Agenzien Etoposid, Doxorubicin und Oxaliplatin (Oxa) ausgelöst wird. Nach Behandlung mit Oxa zeigten die Bid kd Zellen eine verzögerte Caspase-2, -3, -8 und -9 Aktivierung, einen geringeren Verlust des mitochondrialen Membranpotentials sowie eine reduzierte Apoptose- und eine höhere Proliferationsrate als Bid-profiziente Zellen. Neben Bid war ein weiteres BH3-only Protein, Puma, an der Oxa-induzierten Effektorcaspase-Aktivierung beteiligt, da eine Puma-spezifische siRNA unabhängig vom Bidstatus der Zellen antiapoptotisch wirkte. Im letzten Teil der Arbeit wurde untersucht, welche Proteasen für die durch gentoxische Agenzien induzierte Spaltung und Aktivierung von Bid verantwortlich sind. Obwohl Caspasen für die Exekutionphase der Oxa-induzierten Apoptose notwendig waren, trugen sie weder zur initialen Bidaktivierung noch zur mitochondrialen Depolarisierung bei, da sie erst postmitochondrial aktiviert wurden. Konventionelle Calpaine hingegen wurden nach DNA-Schädigung bereits stromaufwärts der Mitochondrien aktiviert und der Calpaininhibitor Calpeptin reduzierte nicht nur die Bid- und Caspasespaltung, sondern auch die mitochondriale Depolarisierung signifikant. Diese Protektion durch Calpeptin fiel in Bid-depletierten Zellen signifikant geringer als in Bid-profizienten Kontrollzellen aus. Auch war in Oxa-behandelten Bid kd Zellen, die eine durch Caspase-2, -3 und -8 nicht spaltbare Bidmutante exprimierten, trunkiertes Bid nachweisbar, dessen Generierung durch Calpain-, aber nicht durch Caspaseinhibierung verhindert werden konnte. Zusammenfassend deuten diese Ergebnisse auf eine Calpain-abhängige Bidaktivierung stromaufwärts der Mitochondrien hin und zeigen, dass die BH3-only Proteine Bid und Puma wichtige Vermittler der Oxa-induzierten Apoptose in HeLa Zellen darstellen.

Etablierung eines high content imaging-basierten in vitro Testsystems zur Evaluierung genotoxischer Substanzen

Zur Registrierung von Pharmazeutika ist eine umfassende Analyse ihres genotoxischen Potentials von Nöten. Aufgrund der Vielzahl genotoxischer Mechanismen und deren resultierenden Schäden wird ein gestaffeltes Testdesign durch die ICH-Richtlinie S2(R1) „Guidance on genotoxicity testing and data interpretation for pharmaceuticals intended for human use S2(R1)“ definiert, um alle genotoxischen Substanzen zu identifizieren. Die Standardtestbatterie ist in der frühen Phase der Arzneimittelentwicklung aufgrund des geringen Durchsatzes und des Mangels an verfügbarer Substanzmenge vermindert anwendbar. Darüber hinaus verfügen in vitro Genotoxizitätstests in Säugerzellen über eine relativ geringe Spezifität. Für eine vollständige Sicherheitsbeurteilung wird eine in vivo Testung auf Kanzerogenität benötigt. Allerdings sind diese Testsysteme kosten- und zeitintensiv. Aufgrund dessen zielen neue Forschungsansätze auf die Verbesserung der Prädiktivität und die Erfassung des genotoxischen Potentials bereits in der frühen Phase der Arzneimittelentwicklung ab. Die high content imaging (HCI)-Technologie offeriert einen Ansatz zur Verbesserung des Durchsatzes verglichen mit der Standardtestbatterie. Zusätzlich hat ein Zell-basiertes Modell den Vorteil Daten relativ schnell bei gleichzeitig geringem Bedarf an Substanzmenge zu generieren. Demzufolge ermöglichen HCI-basierte Testsysteme eine Prüfung in der frühen Phase der pharmazeutischen Arzneimittelentwicklung. Das Ziel dieser Studie ist die Entwicklung eines neuen, spezifischen und sensitiven HCI-basierten Testsytems für Genotoxine und Progenotoxine in vitro unter Verwendung von HepG2-Zellen gewesen. Aufgrund ihrer begrenzten metabolischen Kapazität wurde ein kombiniertes System bestehend aus HepG2-Zellen und einem metabolischen Aktivierungssystem zur Testung progenotoxischer Substanzen etabliert. Basierend auf einer vorherigen Genomexpressionsprofilierung (Boehme et al., 2011) und einer Literaturrecherche wurden die folgenden neun unterschiedlichen Proteine der DNA-Schadensantwort als putative Marker der Substanz-induzierten Genotoxizität ausgewählt: p-p53 (Ser15), p21, p-H2AX (Ser139), p-Chk1 (Ser345) p-ATM (Ser1981), p-ATR (Ser428), p-CDC2 (Thr14/Tyr15), GADD45A und p-Chk2 (Thr68). Die Expression bzw. Aktivierung dieser Proteine wurde 48 h nach Behandlung mit den (pro-) genotoxischen Substanzen (Cyclophosphamid, 7,12-Dimethylbenz[a]anthracen, Aflatoxin B1, 2-Acetylaminofluoren, Methylmethansulfonat, Actinomycin D, Etoposid) und den nicht-genotoxischen Substanzen (D-Mannitol, Phenforminhydrochlorid, Progesteron) unter Verwendung der HCI-Technologie ermittelt. Die beste Klassifizierung wurde bei Verwendung der folgenden fünf der ursprünglichen neun putativen Markerproteine erreicht: p-p53 (Ser15), p21, p-H2AX (Ser139), p-Chk1 (Ser345) und p-ATM (Ser1981). In einem zweiten Teil dieser Arbeit wurden die fünf ausgewählten Proteine mit Substanzen, welche von dem European Centre for the Validation of Alternative Methods (ECVAM) zur Beurteilung der Leistung neuer oder modifizierter in vitro Genotoxizitätstests empfohlen sind, getestet. Dieses neue Testsystem erzielte eine Sensitivität von 80 % und eine Spezifität von 86 %, was in einer Prädiktivität von 84 % resultierte. Der synergetische Effekt dieser fünf Proteine ermöglicht die Identifizierung von genotoxischen Substanzen, welche DNA-Schädigungen durch eine Vielzahl von unterschiedlichen Mechanismen induzieren, mit einem hohen Erfolg. Zusammenfassend konnte ein hochprädiktives Prüfungssystem mit metabolischer Aktivierung für ein breites Spektrum potenziell genotoxischer Substanzen generiert werden, welches sich aufgrund des hohen Durchsatzes, des geringen Zeitaufwandes und der geringen Menge benötigter Substanz zur Substanzpriorisierung und -selektion in der Phase der Leitstrukturoptimierung eignet und darüber hinaus mechanistische Hinweise auf die genotoxische Wirkung der Testsubstanz liefert.

Autologous peripheral blood stem cell transplantation for acute myeloid leukemia

We report the results of a prospective, randomized phase 3 trial evaluating autologous peripheral blood stem cell transplantation (ASCT) versus intensive consolidation chemotherapy in newly diagnosed AML patients in complete remission (CR1). Patients with AML (16-60 years) in CR1 after 2 cycles of intensive chemotherapy and not eligible for allogeneic SCT were randomized between intensive chemotherapy with etoposide and mitoxantrone or ASCT ater high-dose cyclophosphamide and busulfan. Of patients randomized (chemotherapy, n = 259; ASCT, n = 258), more than 90% received their assigned treatment. The 2 groups were comparable with regard to prognostic factors. The ASCT group showed a markedly reduced relapse rate (58% vs 70%, P = .02) and better relapse-free survival at 5 years (38% vs 29%, P = .065, hazard ratio = 0.82; 95% confidence interval, 0.66-1.1) with nonrelapse mortality of 4% versus 1% in the chemotherapy arm (P = .02). Overall survival was similar (44% vs 41% at 5 years, P = .86) because of more opportunities for salvage with second-line chemotherapy and stem cell transplantation in patients relapsing on the chemotherapy arm. This large study shows a relapse advantage for ASCT as postremission therapy but similar survival because more relapsing patients on the chemotherapy arm were salvaged with a late transplantation for relapse. This trial is registered at www.trialregister.nl as #NTR230 and #NTR291.

Proapoptotic BH3-only protein Bid is essential for death receptor-induced apoptosis of pancreatic beta-cells

OBJECTIVE: Apoptosis of pancreatic beta-cells is critical in both diabetes development and failure of islet transplantation. The role in these processes of pro- and antiapoptotic Bcl-2 family proteins, which regulate apoptosis by controlling mitochondrial integrity, remains poorly understood. We investigated the role of the BH3-only protein Bid and the multi-BH domain proapoptotic Bax and Bak, as well as prosurvival Bcl-2, in beta-cell apoptosis. RESEARCH DESIGN AND METHODS: We isolated islets from mice lacking Bid, Bax, or Bak and those overexpressing Bcl-2 and exposed them to Fas ligand, tumor necrosis factor (TNF)-alpha, and proinflammatory cytokines or cytotoxic stimuli that activate the mitochondrial apoptotic pathway (staurosporine, etoposide, gamma-radiation, tunicamycin, and thapsigargin). Nuclear fragmentation was measured by flow cytometry. RESULTS: Development and function of islets were not affected by loss of Bid, and Bid-deficient islets were as susceptible as wild-type islets to cytotoxic stimuli that cause apoptosis via the mitochondrial pathway. In contrast, Bid-deficient islets and those overexpressing antiapoptotic Bcl-2 were protected from Fas ligand-induced apoptosis. Bid-deficient islets were also resistant to apoptosis induced by TNF-alpha plus cycloheximide and were partially resistant to proinflammatory cytokine-induced death. Loss of the multi-BH domain proapoptotic Bax or Bak protected islets partially from death receptor-induced apoptosis. CONCLUSIONS: These results demonstrate that Bid is essential for death receptor-induced apoptosis of islets, similar to its demonstrated role in hepatocytes. This indicates that blocking Bid activity may be useful for protection of islets from immune-mediated attack and possibly also in other pathological states in which beta-cells are destroyed.

AKT/mTOR pathway activation and BCL-2 family proteins modulate the sensitivity of human small cell lung cancer cells to RAD001

PURPOSE: The Akt/mammalian target of rapamycin (mTOR) pathway is frequently activated in human cancers and plays an important role in small cell lung cancer (SCLC) biology. We investigated the potential of targeting mTOR signaling as a novel antitumor approach in SCLC. EXPERIMENTAL DESIGN: The expression of mTOR in patient specimens and in a panel of SCLC cell lines was analyzed. The effects on SCLC cell survival and downstream signaling were determined following mTOR inhibition by the rapamycin derivative RAD001 (Everolimus) or down-regulation by small interfering RNA. RESULTS: We found elevated expression of mTOR in patient specimens and SCLC cell lines, compared with normal lung tissue and normal lung epithelial cells. RAD001 treatment impaired basal and growth factor-stimulated cell growth in a panel of SCLC cell lines. Cells with increased Akt pathway activation were more sensitive to RAD001. Accordingly, a constitutive activation of the Akt/mTOR pathway was sufficient to sensitize resistant SCLC cells to the cytotoxic effect of RAD001. In the sensitive cells, RAD001 showed a strong additive effect to the proapoptotic action of the chemotherapeutic agent etoposide. Intriguingly, we observed low Bcl-2 family proteins levels in the SCLC cells with a constitutive Akt pathway activation, whereas an increased expression was detected in the RAD001-resistant SCLC cells. An antisense construct targeting Bcl-2 or a Bcl-2-specific inhibitor was able to sensitize resistant SCLC cells to RAD001. Moreover, SCLC tumor growth in vivo was significantly inhibited by RAD001. CONCLUSION: Together, our data show that inhibiting mTOR signaling with RAD001 potently disrupts growth and survival signaling in human SCLC cells.

The tumor suppressor gene hypermethylated in cancer 1 is transcriptionally regulated by E2F1

The Hypermethylated in Cancer 1 (HIC1) gene encodes a zinc finger transcriptional repressor that cooperates with p53 to suppress cancer development. We and others recently showed that HIC1 is a transcriptional target of p53. To identify additional transcriptional regulators of HIC1, we screened a set of transcription factors for regulation of a human HIC1 promoter reporter. We found that E2F1 strongly activates the full-length HIC1 promoter reporter. Promoter deletions and mutations identified two E2F responsive elements in the HIC1 core promoter region. Moreover, in vivo binding of E2F1 to the HIC1 promoter was shown by chromatin immunoprecipitation assays in human TIG3 fibroblasts expressing tamoxifen-activated E2F1. In agreement, activation of E2F1 in TIG3-E2F1 cells markedly increased HIC1 expression. Interestingly, expression of E2F1 in the p53(-/-) hepatocellular carcinoma cell line Hep3B led to an increase of endogenous HIC1 mRNA, although bisulfite genomic sequencing of the HIC1 promoter revealed that the region bearing the two E2F1 binding sites is hypermethylated. In addition, endogenous E2F1 induced by etoposide treatment bound to the HIC1 promoter. Moreover, inhibition of E2F1 strongly reduced the expression of etoposide-induced HIC1. In conclusion, we identified HIC1 as novel E2F1 transcriptional target in DNA damage responses.

RNA interference-mediated c-MYC inhibition prevents cell growth and decreases sensitivity to radio- and chemotherapy in childhood medulloblastoma cells

BACKGROUND: With current treatment strategies, nearly half of all medulloblastoma (MB) patients die from progressive tumors. Accordingly, the identification of novel therapeutic strategies remains a major goal. Deregulation of c-MYC is evident in numerous human cancers. In MB, over-expression of c-MYC has been shown to cause anaplasia and correlate with unfavorable prognosis. METHODS: To study the role of c-MYC in MB biology, we down-regulated c-MYC expression by using small interfering RNA (siRNA) and investigated changes in cellular proliferation, cell cycle analysis, apoptosis, telomere maintenance, and response to ionizing radiation (IR) and chemotherapeutics in a representative panel of human MB cell lines expressing different levels of c-MYC (DAOY wild-type, DAOY transfected with the empty vector, DAOY transfected with c-MYC, D341, and D425). RESULTS: siRNA-mediated c-MYC down-regulation resulted in an inhibition of cellular proliferation and clonogenic growth, inhibition of G1-S phase cell cycle progression, and a decrease in human telomerase reverse transcriptase (hTERT) expression and telomerase activity. On the other hand, down-regulation of c-MYC reduced apoptosis and decreased the sensitivity of human MB cells to IR, cisplatin, and etoposide. This effect was more pronounced in DAOY cells expressing high levels of c-MYC when compared with DAOY wild-type or DAOY cells transfected with the empty vector. CONCLUSION: In human MB cells, in addition to its roles in growth and proliferation, c-MYC is also a potent inducer of apoptosis. Therefore, targeting c-MYC might be of therapeutic benefit when used sequentially with chemo- and radiotherapy rather than concomitantly.

Effect of initial treatment strategy on survival of patients with advanced-stage Hodgkin's lymphoma: a systematic review and network meta-analysis

BACKGROUND Several treatment strategies are available for adults with advanced-stage Hodgkin's lymphoma, but studies assessing two alternative standards of care-increased dose bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPescalated), and doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD)-were not powered to test differences in overall survival. To guide treatment decisions in this population of patients, we did a systematic review and network meta-analysis to identify the best initial treatment strategy. METHODS We searched the Cochrane Library, Medline, and conference proceedings for randomised controlled trials published between January, 1980, and June, 2013, that assessed overall survival in patients with advanced-stage Hodgkin's lymphoma given BEACOPPbaseline, BEACOPPescalated, BEACOPP variants, ABVD, cyclophosphamide (mechlorethamine), vincristine, procarbazine, and prednisone (C[M]OPP), hybrid or alternating chemotherapy regimens with ABVD as the backbone (eg, COPP/ABVD, MOPP/ABVD), or doxorubicin, vinblastine, mechlorethamine, vincristine, bleomycin, etoposide, and prednisone combined with radiation therapy (the Stanford V regimen). We assessed studies for eligibility, extracted data, and assessed their quality. We then pooled the data and used a Bayesian random-effects model to combine direct comparisons with indirect evidence. We also reconstructed individual patient survival data from published Kaplan-Meier curves and did standard random-effects Poisson regression. Results are reported relative to ABVD. The primary outcome was overall survival. FINDINGS We screened 2055 records and identified 75 papers covering 14 eligible trials that assessed 11 different regimens in 9993 patients, providing 59 651 patient-years of follow-up. 1189 patients died, and the median follow-up was 5·9 years (IQR 4·9-6·7). Included studies were of high methodological quality, and between-trial heterogeneity was negligible (τ(2)=0·01). Overall survival was highest in patients who received six cycles of BEACOPPescalated (HR 0·38, 95% credibility interval [CrI] 0·20-0·75). Compared with a 5 year survival of 88% for ABVD, the survival benefit for six cycles of BEACOPPescalated is 7% (95% CrI 3-10)-ie, a 5 year survival of 95%. Reconstructed individual survival data showed that, at 5 years, BEACOPPescalated has a 10% (95% CI 3-15) advantage over ABVD in overall survival. INTERPRETATION Six cycles of BEACOPPescalated significantly improves overall survival compared with ABVD and other regimens, and thus we recommend this treatment strategy as standard of care for patients with access to the appropriate supportive care.

ATG5 is induced by DNA-damaging agents and promotes mitotic catastrophe independent of autophagy

Anticancer drug therapy activates both molecular cell death and autophagy pathways. Here we show that even sublethal concentrations of DNA-damaging drugs, such as etoposide and cisplatin, induce the expression of autophagy-related protein 5 (ATG5), which is both necessary and sufficient for the subsequent induction of mitotic catastrophe. We demonstrate that ATG5 translocates to the nucleus, where it physically interacts with survivin in response to DNA-damaging agents both in vitro and in carcinoma tissues obtained from patients who had undergone radiotherapy and/or chemotherapy. As a consequence, elements of the chromosomal passenger complex are displaced during mitosis, resulting in chromosome misalignment and segregation defects. Pharmacological inhibition of autophagy does not prevent ATG5-dependent mitotic catastrophe, but shifts the balance to an early caspase-dependent cell death. Our data suggest a dual role for ATG5 in response to drug-induced DNA damage, where it acts in two signalling pathways in two distinct cellular compartments, the cytosol and the nucleus.

Medulloblastomas overexpress the p53-inactivating oncogene WIP1/PPM1D.

Medulloblastoma is the most common malignant brain tumor of childhood. Despite numerous advances, clinical challenges range from recurrent and progressive disease to long-term toxicities in survivors. The lack of more effective, less toxic therapies results from our limited understanding of medulloblastoma growth. Although TP53 is the most commonly altered gene in cancers, it is rarely mutated in medulloblastoma. Accumulating evidence, however, indicates that TP53 pathways are disrupted in medulloblastoma. Wild-type p53-induced phosphatase 1 (WIP1 or PPM1D) encodes a negative regulator of p53. WIP1 amplification (17q22-q23) and its overexpression have been reported in diverse cancer types. We examined primary medulloblastoma specimens and cell lines, and detected WIP1 copy gain and amplification prevalent among but not exclusively in the tumors with 17q gain and isochromosome 17q (i17q), which are among the most common cytogenetic lesions in medulloblastoma. WIP1 RNA levels were significantly higher in the tumors with 17q gain or i17q. Immunoblots confirmed significant WIP1 protein in primary tumors, generally higher in those with 17q gain or i17q. Under basal growth conditions and in response to the chemotherapeutic agent, etoposide, WIP1 antagonized p53-mediated apoptosis in medulloblastoma cell lines. These results indicate that medulloblastoma express significant levels of WIP1 that modulate genotoxic responsiveness by negatively regulating p53.

Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids.

BACKGROUND Pulmonary carcinoids (PCs) are rare tumors. As there is a paucity of randomized studies, this expert consensus document represents an initiative by the European Neuroendocrine Tumor Society to provide guidance on their management. PATIENTS AND METHODS Bibliographical searches were carried out in PubMed for the terms 'pulmonary neuroendocrine tumors', 'bronchial neuroendocrine tumors', 'bronchial carcinoid tumors', 'pulmonary carcinoid', 'pulmonary typical/atypical carcinoid', and 'pulmonary carcinoid and diagnosis/treatment/epidemiology/prognosis'. A systematic review of the relevant literature was carried out, followed by expert review. RESULTS PCs are well-differentiated neuroendocrine tumors and include low- and intermediate-grade malignant tumors, i.e. typical (TC) and atypical carcinoid (AC), respectively. Contrast CT scan is the diagnostic gold standard for PCs, but pathology examination is mandatory for their correct classification. Somatostatin receptor imaging may visualize nearly 80% of the primary tumors and is most sensitive for metastatic disease. Plasma chromogranin A can be increased in PCs. Surgery is the treatment of choice for PCs with the aim of removing the tumor and preserving as much lung tissue as possible. Resection of metastases should be considered whenever possible with curative intent. Somatostatin analogs are the first-line treatment of carcinoid syndrome and may be considered as first-line systemic antiproliferative treatment in unresectable PCs, particularly of low-grade TC and AC. Locoregional or radiotargeted therapies should be considered for metastatic disease. Systemic chemotherapy is used for progressive PCs, although cytotoxic regimens have demonstrated limited effects with etoposide and platinum combination the most commonly used, however, temozolomide has shown most clinical benefit. CONCLUSIONS PCs are complex tumors which require a multidisciplinary approach and long-term follow-up.

Fatal hyperammonemia and carbamoyl phosphate synthetase 1 (CPS1) deficiency following high-dose chemotherapy and autologous hematopoietic stem cell transplantation

Fatal hyperammonemia secondary to chemotherapy for hematological malignancies or following bone marrow transplantation has been described in few patients so far. In these, the pathogenesis of hyperammonemia remained unclear and was suggested to be multifactorial. We observed severe hyperammonemia (maximum 475 μmol/L) in a 2-year-old male patient, who underwent high-dose chemotherapy with carboplatin, etoposide and melphalan, and autologous hematopoietic stem cell transplantation for a neuroblastoma stage IV. Despite intensive care treatment, hyperammonemia persisted and the patient died due to cerebral edema. The biochemical profile with elevations of ammonia and glutamine (maximum 1757 μmol/L) suggested urea cycle dysfunction. In liver homogenates, enzymatic activity and protein expression of the urea cycle enzyme carbamoyl phosphate synthetase 1 (CPS1) were virtually absent. However, no mutation was found in CPS1 cDNA from liver and CPS1 mRNA expression was only slightly decreased. We therefore hypothesized that the acute onset of hyperammonemia was due to an acquired, chemotherapy-induced (posttranscriptional) CPS1 deficiency. This was further supported by in vitro experiments in HepG2 cells treated with carboplatin and etoposide showing a dose-dependent decrease in CPS1 protein expression. Due to severe hyperlactatemia, we analysed oxidative phosphorylation complexes in liver tissue and found reduced activities of complexes I and V, which suggested a more general mitochondrial dysfunction. This study adds to the understanding of chemotherapy-induced hyperammonemia as drug-induced CPS1 deficiency is suggested. Moreover, we highlight the need for urgent diagnostic and therapeutic strategies addressing a possible secondary urea cycle failure in future patients with hyperammonemia during chemotherapy and stem cell transplantation.