Reconstructive Microsurgery and Tissue Engineering in Musculo-Skeletal Oncology - Innovative Techniques

Tumors involving bone and soft tissues are extremely challenging situations. With the recent advances of multi-modal treatment, not only the type of surgery has moved from amputation to limb-sparing procedures, but also the survivorship has improved considerably and reconstructive techniques have the goal to allow a considerably higher quality of life. In bone reconstruction, tissue engineering strategies are the main area of research. Re-vascularization and re-vitalisation of a massive allograft would considerably improve the outcome of biological reconstructions. Using a rabbit animal model, in this study we showed that, by implanting a vascular pedicle inside a weight bearing massive cortical allograft, the bone regeneration inside the allograft was higher compared to the non-vascularized implants, given the patency of the vascular pedicle. Improvement in the animal model and the addition of Stem Cells and Growth factors will allow a further improvement in the results. In soft tissue tumors, free and pedicled flaps have been proven to be of great help as reconstruction strategies. In this study we analyzed the functional and overall outcome of 14 patients who received a re-innervated vascularized flap. We have demonstrated that the use of the innovative technique of motor re-innervated muscular flaps is effective when the resection involves important functional compartments of the upper or lower limb, with no increase of post-operative complications. Although there was no direct comparison between this type of reconstruction and the standard non-innervated reconstruction, we underlined the remarkable high overall functional scores and patient satisfaction following this procedure.

Immunohistochemical and Molecular Prognostic/Predictive Markers in Neoplastic Diseases

Traditional morphological examinations are not anymore sufficient for a complete evaluation of tumoral tissue and the use of neoplastic markers is of utmost importance. Neoplastic markers can be classified in: diagnostic, prognostic and predictive markers. Three markers were analyzed. 1) Insulin-like growth factor binding protein 2 (IGFBP2) was immunohistochemically examined in prostatic tissues: 40 radical prostatectomies from hormonally untreated patients with their preoperative biopsies, 10 radical prostatectomies from patients under complete androgen ablation before surgery and 10 simple prostatectomies from patients with bladder outlet obstruction. Results were compared with α-methylacyl-CoA racemase (AMACR). IGFBP2 was expressed in the cytoplasm of untreated adenocarcinomas and, to a lesser extent, in HG-PIN; the expression was markedly lower in patients after complete androgen ablation. AMACR was similarly expressed in both adenocarcinoma and HG-PIN, the level being similar in both lesions; the expression was slightly lower in patients after complete androgen ablation. IGFBP2 may be used a diagnostic marker of prostatic adenocarcinomas. 2) Heparan surface proteoglycan immunohistochemical expression was examined in 150 oral squamous cell carcinomas. Follow up information was available in 93 patients (range: 6-34 months, mean: 19±7). After surgery, chemotherapy was performed in 8 patients and radiotherapy in 61 patients. Multivariate and univariate overall survival analyses showed that high expression of syndecan-1 (SYN-1) was associated with a poor prognosis. In patients treated with radiotherapy, such association was higher. SYN-1 is a prognostic marker in oral squamous cell carcinomas; it may also represent a predictive factor for responsiveness to radiotherapy. 3) EGFR was studied in 33 pulmonary adenocarcinomas with traditional DNA sequencing methods and with two mutation-specific antibodies. Overall, the two antibodies had 61.1% sensitivity and 100% specificity in detecting EGFR mutations. EGFR mutation-specific antibodies may represent a predictive marker to identify patients candidate to tyrosine kinase inhibitors therapy.

Stereotactict body radiotherapy (SBRT)

Purpose: evaluation and comparison of volumetric modulated RapidarcTM radiotherapy (RA-IMRT) vs linac based Stereotactic body radiotherapy (SBRT) in the salvage treatment of isolated lymph node recurrences in patients affected by gynaecological cancer. Materials and Methods From January 2010 to September 2011, 15 patients affected by isolated lymph nodes recurrence of gynaecological cancer underwent salvage radiotherapy after conventional imaging staging with CT and 18-FDG-PET/CT. Two different radiotherapy techniques were used in this study: RA-IMRT (RapidarcTM implemented radiotherapy Varian Medical System, Palo Alto, CA, USA) or SBRT (BrainLAB, Feldkirchen, Germany). Five patients underwent CT scan and all patients underwent 18FDG-PET/CT for pre-treatment evaluation and staging. The mean total dose delivered was 54.3 Gy (range 50-60 Gy with conventional fractionation and 27.4 Gy (range 12-40 Gy hypofractionation) for RA-IMRT and SBRT respectively. The mean number of fractions was 27.6 fractions (range 25-31) and 3-4 fractions , the mean overall treatment duration was 40.5 days (range 36-45) and 6.5 days (range 5-8 days) for RA-IMRT and SBRT respectively. Results: At the time of the analysis, October 2011, the overall survival was 92.3 % (80% for RA-IMRT and 100% for SBRT). Six patients are alive with no evidence of disease and also six patients are alive with clinically evident disease in other sites (40% and 50% patients RA-IMRT vs SBRT respectively, one patient died for systemic progression of disease and two patient were not evaluable at this time. Conclusions: Our preliminary results showed that, the use of RA-IMRT and SBRT are an excellent local therapy for isolated lymph nodes recurrences of gynaecological cancer with a good toxicity profile and local control rate, even if any long term survivors would be expected. New treatment modalities like Cyberknife are also being implemented.

Valutazione preclinica di nuovi potenziali bersagli terapeutici per la cura del medulloblastoma.

Il medulloblastoma (MB) è il tumore più comune del sistema nervoso centrale. Attualmente si riesce a curare solo il 50-60% dei pazienti che tuttavia presentano gravi effetti collaterali dovuti alle cure molto aggressive. Una recente classificazione molecolare ha ridistribuito le varianti più comuni di MB in quattro distinti gruppi. In particolare, il gruppo SHH e D sono caratterizzati da un’ alta espressione di MYCN ed associati a prognosi sfavorevole. MYCN è coinvolto nella regolazione della proliferazione cellulare, differenziazione, apoptosi, angiogenesi e metastasi. L’obiettivo di questo lavoro è la valutazione dell’attività antitumorale di oligonucleotidi diretti contro MYCN, sia in vitro su diverse linee cellulari di MB che in vivo in modelli murini xenograft ortotopici di MB. I risultati hanno dimostrato un’ottima inibizione della crescita in linee cellulari di MB, accompagnata da una riduzione della trascrizione genica e dei livelli proteici di MYCN. Inoltre, sono stati confermati tramite RT-PCR alcuni dei geni trovati significativamente variati nell’esperimento di microarray , dopo il trattamento. Molto interessanti sono stati geni quali BIRC5, che risulta down regolato mentre il gene p21 risulta up regolato in tutte le linee cellulari di MB utilizzate. Inoltre, sono stati generati modelli murini di MB utilizzando cellule precedentemente trasfettate per esprimere il gene della luciferasi e valutarne così la crescita tumorale tramite imaging bioluminescente in vivo (BLI), al fine di poter testare l’attività antitumorale data dagli oligonucleotidi. I risultati hanno dimostrato una buona risposta al trattamento come rilevato dalla tecnica di BLI. I dati preliminari prodotti, dimostrano che MYCN potrebbe esser un buon target per la terapia del MB nei casi in cui è overespresso. In particolare, una sua inibizione potrebbe presentare effetti indesiderati moderati in quanto è poco espresso dopo la nascita.

A novel specific genetic translocation in epithelioid hemangioendotelioma, showing a fusion of the WWTR1 and CAMTA1 genes, supports the monoclonality of multifocal epithelioid hemangioendotelioma.

Like other vascular tumors, epithelioid hemangioendothelioma (EHE) is multifocal in approximately 50% of cases, and it is unclear whether the separate lesions represent multifocal disease or metastases. We hypothesized that the identification of an identical WWTR1-CAMTA1 rearrangement in different EHEs from the same patient supports the monoclonal origin of EHE. To test our hypothesis, we undertook a molecular analysis of two multicentric EHEs of the liver, including separate tumor samples from each patient. Matherial and Methods: We retrieved two cases of EHE with available tissue for molecular analysis. In both cases, fluorescence in situ hybridization (FISH) was performed to identify the presence of the WWTR1-CAMTA1 rearrangement to confirm the histologic diagnosis of EHE, as previously described. The reverse transcription-polymerase chain reaction (RT-PCR) products were analyzed by electrophoresis and the RT-PCR–amplified products were sequenced using the Sanger method. Results: FISH analysis revealed signal abnormalities in both WWTR1 and CAMTA1. Combined results confirmed the presence of the t(1;3)(1p36.23;3q25.1) translocation in both cases of EHE. Using RT-PCR analysis, we found that the size of the rearranged bands was identical in the different tumors from each patient. The sequence of the fusion gene confirmed a different WWTR1-CAMTA1 rearrangement in each patient, but an identical WWTR1-CAMTA1 rearrangement in the different lesions from each patient. Discussion: Because of its generally indolent clinical course, EHE is commonly classified as a multifocal, rather than metastatic, disease. In this study, we examined two cases of multifocal liver EHE and found an identical WWTR1-CAMTA1 rearrangement in each lesion from the same patient, but not between the two patients. These findings suggest that multifocal EHE arises from metastasis of the same neoplastic clone rather than from the simultaneous formation of multiple neoplastic clones, which supports the monoclonal origin of multifocal EHE.

Analisi del profilo tossicologico e cancerogeno del particolato atmosferico e identificazione dei rischi per la salute umana correlati all'esposizione

Gli impianti di incenerimento di rifiuti solidi suscitano preoccupazione nella popolazione per i possibili effetti avversi associati all’esposizione. Gli effetti delle polveri sottili (PM2.5), generate dai processi di combustione, sulla salute umana includono l’insorgenza di patologie a carico del sistema respiratorio e cardiovascolare e l’aumento della mortalità per malattie polmonari e probabilmente cancro al polmone. Lo scopo della tesi è quello di valutare il profilo tossicologico e cancerogeno del particolato atmosferico in prossimità dell’inceneritore di Bologna rispetto alle aree adiacenti mediante l’utilizzo di test alternativi alle metodologie in vivo, come il test di trasformazione cellulare e approcci di tossicogenomica (soprattutto trascrittomica) oltre alla valutazione della variazione del rischio cancerogeno indotto dall’esposizione di PM2.5 in diversi siti (massima ricaduta, controllo, fondo urbano e fondo rurale) e in differenti periodi di campionamento (estate 2008 e inverno 2009). Gli estratti di PM2.5 relativi alla stagione invernale sono risultati più tossici rispetto ai campioni estivi, che inducono tossicità soprattutto alle alte dosi. Per i campioni invernali il numero medio di colonie di cellule BALB/c 3T3 A31-1-1 risulta ridotto in modo significativo anche per le dosi più basse saggiate indipendentemente dal sito di provenienza. Tutti i campioni analizzati sono risultati negativi nel test di trasformazione cellulare in vitro. L’analisi dell’espressione genica delle cellule BALB/c 3T3 A31-1-1, in seguito all’esposizione agli estratti di PM2.5, ha mostrato un effetto stagionale evidente. Relativamente ai campioni invernali è stato evidenziato un maggior effetto tossico da parte del sito di controllo rispetto alla massima ricaduta, poiché nel sito di controllo risultano attivati marcatori di morte cellulare per apoptosi. La valutazione del rischio cancerogeno in tutti i siti valutati non mostra situazioni preoccupanti legate alla predizione di eccessi di rischio di tumori imputabili all’attività dell’inceneritore in quanto le stime di rischio non eccedono mai il valore limite riportato in letteratura.

mRNAs translation and tumorigenesis

Translational control has a direct impact on cancer development and progression. Quantitative and qualitative changes of cap-dependent translation initiation contribute to neoplastic transformation and progression. However, the idea that “alternative” mechanisms of translation initiation, such as IRES-dependent translation, can be involved in the tumorigenesis is emerging. Because the relevance of this kind of translation initiation in cancer progression is not so well clarified, the purpose of my work was to study the impact of IRES-dependent mRNA translation on tumourigenesis and cancer progression with particular regard for breast cancer. The data obtained clarify the function of cap-independent translation in cancer. Particularly they suggested that the deregulation of IRES-dependent translation can be considered a sort of pro-oncogenic stimulus characterized by the inhibition of the expression of some proteins that block cell growth and proliferation and by the over expression of other proteins that contributed to cell survival. In addition, under stress condition, such as a hypoxia, in immortalized epithelial cell lines, changes in cap-independent translation are associated with an induction of expression of stem cell markers, and with the selection of a sub group of cells that have an increased ability to self-renewing and therefore in the acquisition of a more aggressive phenotype.

Marcatori molecolari circolanti: quale ruolo nei pazienti con tumori solidi?

Background: Circulating tumor cells (CTCs) and circulating free plasma DNA (FPDNA) have been proposed as biomarkers predictive of outcome and response to therapy in solid tumors. We investigated the multiple associations of the presence of CTC and the levels of FPDNA with the outcome and/or the response to chemotherapy in patients with localized breast cancer (LBC), metastatic breast cancer (MBC) and advanced ovarian cancer (AOC). Experimental Design: Blood samples were collected before (baseline), during and after therapy in 40 LBC and 50 AOC patients treated with neo-adjuvant chemotherapy. In 20 MBC patients blood was sampled at baseline and every each cycle of adjuvant chemotherapy. Real time PCR was applied to quantify FPDNA using the Quantifiler Human Quantification kit and CTCs through the detection of tumor-cell specific mRNA levels with or without epithelial enrichment. Results: At baseline CTCs were detected in 90% MBC, 42.5% LBC and 33% AOC patients respectively. The presence of baseline CTC was significantly associated with shorter overall survival (OS) in MBC and AOC patients, and shorter progression free survival (PFS) in LBC patients. Presence of CTCs at the end of neo-adjuvant chemotherapy was detected in 42% LBC and 18% AOC patients and was associated with shorter PFS and OS only in LBC. Increased FPDNA levels at baseline were found in 65% MBC, 17.5% LBC and 76% AOC patients but never related to OS. Baseline FPDNA high levels were associated with shorter PFS only in LBC patients. High FPDNA levels after neo-adjuvant chemotherapy were detected in 57% LBC and 48% AOC patients. Increased FPDNA after neo-adjuvant was associated with response to therapy and shorter PFS in AOC patients. Conclusions: Detection of CTCs may represent a prognostic and predictive biomarker in LBC, MBC and AOC. Quantification of FPDNA could be useful for monitoring response to therapy in AOC patients.

Farmacogenomica della Clofarabina nel trattamento delle Leucemie Acute pediatriche: identificazione di nuovi bersagli molecolari e del profilo genomico associato all’efficacia terapeutica del farmaco antitumorale

In quest’ultimi decenni si è assistito ad un notevole miglioramento nella terapia delle Leucemie Acute (LA) pediatriche, nonostante tutto si assiste oggi ad una fase di plateau della curva di sopravvivenza e le leucemie continuano a costituire la principale causa di morte pediatrica per malattia. Ulteriori progressi nel trattamento delle LA potrebbero essere ottenuti mediante studi di farmacogenomica che, identificando le componenti genetiche associate alla risposta individuale ai trattamenti farmacologici, consentono il disegno di terapie personalizzate e tumore-specifiche, ad alta efficacia e bassa tossicità per ciascun paziente. Il lavoro svolto è stato, dunque, finalizzato allo studio della farmacogenomica del farmaco antitumorale Clofarabina (CLO) nel trattamento delle LA pediatriche al fine di identificare marcatori genetici predittivi di risposta delle cellule leucemiche al farmaco, delucidare i meccanismi di resistenza cellulare ed individuare nuovi bersagli verso cui indirizzare terapie più mirate ed efficaci. L’analisi in vitro della sensibilità alla CLO di blasti provenienti da pazienti pediatrici affetti da Leucemia Acuta Linfoblastica (LAL) e Mieloide (LAM) ha consentito l’identificazione di due sottopopolazioni di cellule LAL ad immunofenotipo T a diversa sensibilità alla CLO. Mediante DNA-microarrays, si è identificata la “signature” genetica specificamente associata alla diversa risposta delle cellule LAL-T al farmaco. Successivamente, la caratterizzazione funzionale dei geni differenziali e l’analisi dei pathways hanno consentito l’identificazione specifica di potenziali biomarcatori di risposta terapeutica aprendo nuove prospettive per la comprensione dei meccanismi di resistenza cellulare alla CLO e suggerendo un nuovo bersaglio terapeutico per le forme LAL-T a bassa sensibilità al farmaco. In conclusione, nel lavoro svolto si sono identificati set di geni e pathways di rilievo biologico per la risposta delle cellule LAL-T alla CLO suggerendo marcatori genetici in grado di identificare i soggetti eleggibili per il trattamento o verso cui disegnare terapie innovative. Il lavoro è paradigma per l’applicazione della farmacogenomica in altre neoplasie.

Immunoconiugati contenenti tossine vegetali o siRNA per la deplezione selettiva di cellule leucemiche. Preparazione, citotossicità e studi di mutagenesi sito-specifica.

CD33 is a myeloid cell surface marker absent on normal hematopoietic stem cells and normal tissues but present on leukemic blasts in 90% of adult and paediatric acute myeloid leukaemia (AML) cases. By virtue of its expression pattern and its ability to be rapidly internalized after antibody binding, CD33 has become an attractive target for new immunotherapeutic approaches to treat AML. In this study two immunoconjugates were constructed to contain a humanised single-chain fragment variable antibody (scFv) against CD33 in order to create new antibody-derived therapeutics for AML. The first immunoconjugate was developed to provide targeted delivery of siRNAs as death effectors into leukemic cells. To this purpose, a CD33-specific scFv, modified to include a Cys residue at its C-terminal end (scFvCD33-Cys), was coupled through a disulphide bridge to a nona-d-arginine (9R) peptide carrying a free Cys to the N-terminal. The scFvCD33-9R was able to completely bind siRNAs at a protein to nucleic acid ratio of about 10:1, as confirmed by electrophoretic gel mobility-shift assay. The conjugate was unable to efficiently transduce cytotoxic siRNA (siTox) into the human myeloid cell line U937. We observed slight reductions in cell viability, with a reduction of 25% in comparison to the control group only at high concentration of siTox (300 nM). The second immunoconjugate was constructed by coupling the scFvCD33-Cys to the type 1 ribosome inactivating protein Dianthin 30 (DIA30) through a chemical linking The resulting immunotoxin scFvCD33-DIA30 caused the rapid arrest of protein synthesis, inducing apoptosis and leading ultimately to cell death. In vitro dose-dependent cytotoxicity assays demonstrated that scFvCD33-DIA30 was specifically toxic to CD33-positive cell U937. The concentration needed to reach 50 % of maximum killing efficiency (EC50) was approximately 0.3 nM. The pronounced antigen-restricted cytotoxicity of this novel agent makes it a candidate for further evaluation of its therapeutic potential.

Down Syndrome: Neuropsychological phenotype and mitochondrial DNA

Introduction. Down Syndrome (DS) is the most known autosomal trisomy, due to the presence in three copies of chromosome 21. Many studies were designed to identify phenotypic and clinical consequences related to the triple gene dosage. However, the general conclusion is a senescent phenotype; in particular, the most features of physiological aging, such as skin and hair changes, vision and hearing impairments, thyroid dysfunction, Alzheimer-like dementia, congenital heart defects, gastrointestinal malformations, immune system changes, appear in DS earlier than in normal age-matched subjects. The only established risk factor for the DS is advanced maternal age, responsible for changes in the meiosis of oocytes, in particular the meiotic nondisjunction of chromosome 21. In this process mitochondria play an important role since mitochondrial dysfunction, due to a variety of extrinsic and intrinsic influences, can profoundly influence the level of ATP generation in oocytes, required for a correct chromosomal segregation. Aim. The aim of this study is to investigate an integrated set of molecular genetic parameters (sequencing of complete mtDNA, heteroplasmy of the mtDNA control region, genotypes of APOE gene) in order to identify a possible association with the early neurocognitive decline observed in DS. Results. MtDNA point mutations do not accumulate with age in our study sample and do not correlate with early neurocognitive decline of DS subjects. It seems that D-loop heteroplasmy is largely not inherited and tends to accumulate somatically. Furthermore, in our study sample no association of cognitive impairment and ApoE genotype is found. Conclusions. Overall, our data cast some doubts on the involvement of these mutations in the decline of cognitive functions observed in DS.