Supplementary Table 1 from High-Resolution Analysis of Chromosomal Breakpoints and Genomic Instability Identifies <i>PTPRD</i> as a Candidate Tumor Suppressor Gene in Neuroblastoma

Supplementary Table 2 from High-Resolution Analysis of Chromosomal Breakpoints and Genomic Instability Identifies PTPRD as a Candidate Tumor Suppressor Gene in Neuroblastoma

Supplementary Table 1 from High-Resolution Analysis of Chromosomal Breakpoints and Genomic Instability Identifies <i>PTPRD</i> as a Candidate Tumor Suppressor Gene in Neuroblastoma

Background: Dysostosis multiplex contributes substantially to morbidity in patients with Hurler syndrome (mucopolysaccharidosis type I Hurler phenotype [MPS I-H]), even after successful hematopoietic stem cell transplantation (HSCT). One of the hallmarks of dysostosis multiplex in MPS I-H is hip dysplasia, which often requires surgical intervention. We sought to describe in detail the course of hip dysplasia in this group of patients, as assessed by radiographic analysis, and to identify potential outcome predictors.Methods: Longitudinal data were obtained from digitally scored pelvic radiographs of patients with MPS I-H using OrthoGon software for parameters including, but not limited to, the acetabular index, migration percentage, Smith ratio, and neck-shaft angle. Scoring was performed independently by two blinded observers. Additional information on genotype, enzyme replacement therapy pre-HSCT, donor chimerism, and enzyme activity post-HSCT were obtained. General trends and potential correlations were calculated with mixed-model statistics.Results: Fifty-two patients (192 radiographs) were included in this analysis. Intraobserver and interobserver variation analysis showed an intraclass correlation coefficient ranging from 0.78 to 1.00. Among the twenty-one patients with follow-up beyond the age of five years, the acetabular index was in the range of severe hip dysplasia in up to 86% of the patients. Severe coxa valga was seen in 91% of the patients. Lateral and superior femoral displacement were highly prevalent, with the migration percentage outside the reference range in up to 96% of the patients. Finally, anterior pelvic tilt increased with age (p = 0.001). No correlations were identified between clinical parameters and radiographic findings.Conclusions: Our study shows that progressive acetabular dysplasia as well as coxa valga and hip displacement are highly prevalent and progressive over time in patients with MPS I-H, despite successful HSCT. These data may provide essential natural history determinations for the assessment of efficacy of new therapeutic strategies aimed at improving skeletal outcomes in patients with MPS I-H.

Neuroblastoma, a paediatric malignancy of the sympathetic nervous system, accounts for 15 % of childhood cancer deaths. Despite advances in understanding the biology, it remains one of the most difficult paediatric cancers to treat partly due to the development of multidrug resistance. There is thus a compelling demand for new treatment strategies that can bypass resistance mechanisms. The pyrrolo-1,5-benzoxazepine (PBOX) compounds are a series of novel microtubule-targeting agents that potently induce apoptosis in various tumour models. We have previously reported that PBOX compounds induce apoptosis in drug sensitive and multidrug resistant neuroblastoma cells and synergistically enhance apoptosis induced by chemotherapeutics such as carboplatin. In this study we present further data concerning the molecular basis of PBOX-induced apoptosis in neuroblastoma. We demonstrate that PBOX-6 induced AMP-activated protein kinase (AMPK) activation and downstream acetyl-CoA carboxylase phosphorylation. Increased reactive oxygen species (ROS) appeared to serve as the upstream signal for AMPK activation as pretreatment of cells with the antioxidant N-acetylcysteine inhibited both AMPK activation and PBOX-induced apoptosis. Furthermore, activation of AMPK by PBOX-6 was found to inhibit mTOR complex 1 (mTORC1) signalling. Finally, we demonstrate the efficacy of PBOX-6 in an in vivo xenograft model of neuroblastoma. This study provides new insights into understanding the molecular and cellular mechanisms involved in PBOX-induced cell death in neuroblastoma and further supports their future use as novel anti-cancer agents for the treatment of neuroblastoma.

Hurler syndrome (HS) is a lysosomal storage disease characterized by multisystem morbidity and death in early childhood. Hematopoietic stem cell transplantation (HSCT) results in long-term survival, although with significant residual disease burden. How this residual disease affects the health-related quality of life is unknown. Therefore, we conducted a multicenter cohort study on functional and psychosocial health and compared the outcomes to normative data using the Child Health Questionnaire and Pediatric Outcomes Data Collection Instrument. Perception of care was evaluated by the Measure of Processes of Care questionnaire. Sixty-three HS patients receiving HSCT with at least 3 years of follow-up after HSCT were included. The influence of potential predictors was analyzed using linear regression analysis, and correlation analysis was performed using Spearman rank correlation. Functional health of transplanted HS patients was significantly diminished compared with normative data (median physical summary z score, -2.4 [range, -3.5 to -1.6]; median global functioning z score, -3.2 [range, -4.8 to -1.8]). Psychosocial health was comparable or only slightly reduced compared with healthy peers (median psychosocial summary z score, 0.15 [range, -0.7 to 0.8]). A higher obtained lysosomal enzyme level post-HSCT predicted for superior functional health. Overall, parents were satisfied with the care received. Functional health of transplanted HS patients appeared significantly more affected than psychosocial health. To improve functional health, the use of only noncarrier donors and striving to achieve full-donor chimerism, both resulting in higher enzyme levels, is advised. Assessing the health-related quality of life could play an important role in evaluating outcomes of HS patients receiving novel (cell) therapies, including autologous gene-transduced HSCT.

Mucopolysaccharidosis type I-Hurler syndrome (MPS-IH) is a lysosomal storage disease characterized by multisystem morbidity and death in early childhood. Although hematopoietic cell transplantation (HCT) has been performed in these patients for more than 30 years, large studies on the long-term outcome of patients with MPS-IH after HCT are lacking. The goal of this international study was to identify predictors of the long-term outcome of patients with MPS-IH after successful HCT. Two hundred seventeen patients with MPS-IH successfully engrafted with a median follow-up age of 9.2 years were included in this retrospective analysis. Primary endpoints were neurodevelopmental outcomes and growth. Secondary endpoints included neurologic, orthopedic, cardiac, respiratory, ophthalmologic, audiologic, and endocrinologic outcomes. Considerable residual disease burden was observed in the majority of the transplanted patients with MPS-IH, with high variability between patients. Preservation of cognitive function at HCT and a younger age at transplantation were major predictors for superior cognitive development posttransplant. A normal α-l-iduronidase enzyme level obtained post-HCT was another highly significant predictor for superior long-term outcome in most organ systems. The long-term prognosis of patients with MPS-IH receiving HCT can be improved by reducing the age at HCT through earlier diagnosis, as well as using exclusively noncarrier donors and achieving complete donor chimerism.

Background: After successful hematopoietic stem cell transplantation, maintaining function and mobility have become key goals in the management of patients with Hurler syndrome, (mucopolysaccharoidosis type 1H). The aim of this study was to establish the functional and radiologic outcomes after hip surgery in patients with this condition who had reached skeletal maturity.Methods: We prospectively followed 13 mucopolysaccharoidosis type 1H patients with closed triradiate cartilages who had undergone hip surgery in a single institution (Our Lady's Children's Hospital, Crumlin) in early childhood, after successful hematopoietic stem cell transplantation. Functional assessment was performed using the Harris Hip Score. Acetabular and femoral head morphology were defined using a pelvic radiograph.Results: The average age at follow-up was 18.6 years (range, 13.2 to 23.8 y). The average length of follow-up from surgical intervention was 14.6 years (range, 10.3 to 21.6 y). The average Harris Hip Score at follow-up was 61.0 (range, 19 to 91). At follow-up, 4 patients were either wheelchair bound or required a walking frame to mobilize in the community. At follow-up, all hips were in-joint with an average center edge angle of 37.7 degrees (range, 0 to 63 degrees). All hips displayed characteristic medial flattening of the femoral head. Ten hips (of 26 hips) showed radiologic degenerative changes with loss of joint space < 2 mm.Conclusions: Despite the surgical provision of stable well-covered hips, active intervention did not prevent the development of radiologic deterioration and clinically significant hip arthritis. We recommend that pediatric hip surgery in Hurler syndrome be designed with the possibility of early hip replacement in mind.

Hurler syndrome (HS), the most severe phenotype of Mucopolysaccharidosis type I, is caused by a deficiency of the lysosomal enzyme alpha-L-iduronidase (IDUA). HS is clinically characterized by a progressive and ultimately fatal multi-system deterioration with involvement of the central nervous system (CNS). At present, hematopoietic cell transplantation (HCT) is the only treatment able to prevent disease progression in the CNS and therefore considered the treatment of choice in HS. However, there is a lack of long-term follow-up data on successfully transplanted HS patients as well as the factors influencing them. Therefore, this international multicenter study was initiated to identify predictors of the long-term outcome of successfully transplanted HS patients worldwide. Alive and engrafted HS patients with at least 3 years follow-up after HCT were retrospectively evaluated. The main endpoint included the neurodevelopmental outcome; secondary endpoints included the growth, neurologic, orthopedic, cardiac, respiratory, ophthalmologic, audiologic and endocrinologic outcome. The influence of patient, donor, and transplantation-related variables on these endpoints was analyzed using multivariate Cox proportional hazards, logistic regression, and linear mixed models. 197 HS patients from 10 transplantation centers within Europe and the United States were included. This is estimated to represent about 70% of the HS patients successfully transplanted worldwide till 2008. Patients had a median age of 16 (2-80) months at transplantation with a median follow-up of 8.9 (3-22.6) years after last HCT. Post-transplant leukocyte IDUA enzyme levels below the lower reference were seen in 25% of patients due to mixed-chimerism or the use of a carrier donor. Following successful HCT, the clinical course of HS patients is strikingly improved, evident in all organ systems. Residual disease burden is present in the majority of the patients with high variability between patients. A better cognitive status at HCT was a major predictor for superior cognitive development after HCT (figure 1). Significant predictors for superior long-term outcome in all organ systems were the presence of “normal IDUA enzyme levels obtained after HCT” and a “younger age at transplantation”. See the association between the leukocyte IDUA enzyme level obtained after HCT and surgical intervention for cord compression and growth, in figure 2 and 3 respectively. Although HCT significantly improved the clinical course in HS patients, residual disease burden was observed in the majority of transplanted HS patients. Using exclusively non-carrier donors and accepting only full donor-chimerism will improve the prognosis of HS patients. Reducing the age at HCT through newborn screening could further improve the outcomes of HS patients after HCT.Figure 2Occurrence of surgical intervention for cord compression estimated by the obtained leukocyte IDUA enzyme level.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Height estimated by the obtained leukocyte IDUA enzyme level.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Neuroblastoma, a malignancy of neuroectoderrmal origin, accounts for 15% of childhood cancer deaths. Despite advances in understanding the biology, it remains one of the most difficult paediatric cancers to treat. A major obstacle in the effective treatment of neuroblastoma is the development of multidrug resistance (MDR). There is thus a compelling demand for new treatment strategies for this cancer that can bypass such resistance mechanisms. The pyrrolo-1,5-benzoxazepine (PBOX) compounds are a series of novel microtubule-targeting agents that potently induce apoptosis in various cancer cell lines, ex vivo patient samples and in vivo cancer models. In this study we examined the ability of two members, PBOX-6 and -15, to exhibit anti-cancer effects in a panel of drug sensitive and MDR neuroblastoma cell lines. The PBOX compounds potently reduced the viability of all neuroblastoma cells examined and exhibited a lower fold resistance in MDR cells when compared to standard chemotherapeutics. In addition, the PBOX compounds synergistically enhanced apoptosis induced by etoposide, carboplatin and doxorubicin. Exposure of drug sensitive and resistant cell lines to PBOX-6/carboplatin induced cleavage of Bcl-2, a downregulation of Mcl-1 and a concomitant increase in Bak. Furthermore, activation of caspase-3, -8 and -9 was demonstrated. Finally, gene silencing of Mcl-1 by siRNA was shown to sensitise both drug sensitive and multidrug resistant cells to carboplatin-induced apoptosis demonstrating the importance of Mcl-1 downregulation in the apoptotic pathway mediated by the PBOX compounds in neuroblastoma. In conclusion, our findings indicate the potential of the PBOX compounds in enhancing chemosensitivity in neuroblastoma.

Introduction: The use of complementary and alternative medicine (CAM) in the Irish pediatric cancer setting has not previously been established. Methods: To investigate the prevalence and predictors of CAM use in this group of patients, an anonymous cross-sectional survey was offered to all carers of patients either on or off treatment for malignancy at a single pediatric cancer center over an 8-week period. Results: Of a total of 220 questionnaires distributed, 98 (43%) were returned. Six were excluded because of inadequate data. A total of 58% of children were male and the mean age was 9 years. The most common cancer diagnosis was leukemia (45%). Fifty-two respondents (57%) said their child had used or was using CAM, and 55% of whom had started since their cancer diagnosis. The most common types of CAM used were vitamins and minerals (18%), reflexology (11%), dietary supplements (11%), faith healers (9%), and energy therapies (9%). The most common reason for CAM use was to improve physical well-being (31%). A total of 65% of CAM users had not told their doctor that they were doing so. Of the 52 CAM users, 30 (58%) were using oral CAM medication. A total of 86% of CAM users reported benefit from the treatment, and no respondent reported side effects. There was no significant relationship between sex, tumor type, age, income, previous treatment, and CAM use. Where parents had a higher level of education, children were more likely to use CAM (P=0.035.) There was a statistically significant relationship between respondents rating of conventional therapy and CAM use (P=0.007). Interestingly, parents who were satisfied with conventional therapy were more likely to use CAM. Conclusion: The high prevalence of CAM use demonstrated in this study and particularly the high use of CAM medication therapies underlines the importance of physicians asking routinely about CAM use in this population.

Forty percent of renal cell carcinomas (RCCs) in childhood are characterized by translocation involving transcription factor E3 (TFE3) family members. Here, we describe a case of TFE3-positive RCC in which metastatic relapse to the mediastinal lymph nodes and pulmonary nodules was treated with single-agent sunitinib, a multitargeted tyrosine inhibitor. Complete radiologic remission was achieved after only 3 courses of treatment, and surgical exploration of metastases failed to identify any residual viable disease. The published experience of sunitinib in TFE-RCC is limited, and prospective evaluation of its activity in a larger number of patients is warranted.

Background: After successful hematopoietic stem cell transplantation maintaining function and mobility has become the key goal in the management of patients with mucopolysaccharoidosis type 1 (MPS-1). We detail the foot and ankle pathology in 18 patients with MPS-1 managed in our unit.Methods: Functional assessment was performed using the Oxford Foot and Ankle Questionnaire for children (OxAFQ-C). Morphologic assessment was performed by means of a mirrored foot photograph box, the Foot Posture Index (FPI), and clinical photography. Standardized radiologic investigations were sought when clinically warranted. Average lateral talus-first metatarsal angle, anteroposterior and lateral talocalcaneal angles, and lateral distal tibial angle (LDTA) were determined.Results: The average patient-reported OxAFQ-C score was 44.7 (range, 10 to 60). The average proxy-reported OxAFQ-C score was 45.7 (range, 11 to 60). Ten of the 18 patients wore customized footwear. Of the 36 feet examined 11 were found scored as "highly pronated" (FPI>+9), 12 feet had a "pronated posture" (FPI + 6 to + 9), and 13 feet were found to have a "normal posture" (FPI 0 to +5). Thirteen of the 18 (72%) patients studied had curly toes. The average talus-first metatarsal angle recorded was 10.7 degrees (range, -7 to 30 degrees). The average lateral and anteroposterior talocalcaneal angles were 45.8 degrees (range, 16 to 62 degrees) and 31 degrees (range, 1 to 51 degrees), respectively. The average LDTA was found to be 70.6 degrees (range, 48 to 82 degrees). A single-sample Student t test shows significant divergence of measured LDTA, OxAFQ-C, and FPI from normal populations (P<0.005).Conclusions: MPS-1 is associated with a significant degree of foot and ankle pathology that has not been previously described. We found a high incidence of curly toes, ankle valgus, functional foot, and ankle disability and a requirement for customized footwear among our cohort. We recommend that careful assessment of foot and ankle pathology should be routine in the interdisciplinary management of patients with MPS-1.

We report transplantation outcomes of 258 children with Hurler syndrome (HS) after a myeloablative conditioning regimen from 1995 to 2007. Median age at transplant was 16.7 months and median follow-up was 57 months. The cumulative incidence of neutrophil recovery at day 60 was 91%, acute graft-versus-host disease (GVHD) (grade II-IV) at day 100 was 25%, and chronic GVHD and 5 years was 16%. Overall survival and event-free survival (EFS) at 5 years were 74% and 63%, respectively. EFS after HLA-matched sibling donor (MSD) and 6/6 matched unrelated cord blood (CB) donor were similar at 81%, 66% after 10/10 HLA-matched unrelated donor (UD), and 68% after 5/6 matched CB donor. EFS was lower after transplantation in 4/6 matched unrelated CB (UCB) (57%; P = .031) and HLA-mismatched UD (41%; P = .007). Full-donor chimerism (P = .039) and normal enzyme levels (P = .007) were higher after CB transplantation (92% and 98%, respectively) compared with the other grafts sources (69% and 59%, respectively). In conclusion, results of allogeneic transplantation for HS are encouraging, with similar EFS rates after MSD, 6/6 matched UCB, 5/6 UCB, and 10/10 matched UD. The use of mismatched UD and 4/6 matched UCB was associated with lower EFS.

A 2-year-old female with Hurler syndrome (mucopolysaccharidosis type 1) died suddenly within 3 months of successful unrelated fully matched cord blood transplant, having received weekly enzyme replacement therapy (ERT) prior to transplant. Though an infectious aetiology was clinically suspected to be the cause of her unanticipated acute deterioration and untimely demise, autopsy findings suggested that a combination of pre-existing but sub-clinical Hurler related cardiopulmonary pathology and superimposed transplant related pulmonary venopathy as the basis of her death. This case highlights the limitations of ERT in ameliorating cardiorespiratory disease and the failure of standard pre-transplant investigations to detect significant abnormality related to her underlying condition. It also reinforces the importance of autopsy in explaining unanticipated events.

A previously healthy 9-year-old girl presented with a 10-day history of slowly progressive unsteadiness, slurred speech, and behavior change. On examination there was cerebellar ataxia and dysarthria, excessive blinking, subtle perioral myoclonus, and labile mood. The finding of oligoclonal bands in the cerebrospinal fluid prompted paraneoplastic serological evaluation and search for an occult neural crest tumor. Antineuronal nuclear autoantibody type 1 (anti-Hu) and voltage-gated potassium channel complex antibodies were detected in serum. Metaiodobenzylguanidine scan and computed tomography scan of the abdomen showed a localized abdominal mass in the region of the porta hepatis. A diagnosis of occult neuroblastoma was made. Resection of the stage 1 neuroblastoma and treatment with pulsed corticosteroids resulted in resolution of all symptoms and signs. Excessive blinking has rarely been described with neuroblastoma, and, when it is not an isolated finding, it may be a useful clue to this paraneoplastic syndrome. Although voltage-gated potassium channel complex autoimmunity has not been described previously in the setting of neuroblastoma, it is associated with a spectrum of paraneoplastic neurologic manifestations in adults, including peripheral nerve hyperexcitability disorders.