F-FDG-PET imaging and RT-QuIC-Assay were able to establish the diagnosis. We conclude that in cases presenting with rapid progressive dementia secondary to sudden cortical anopsia the Heidenhain-variant of CJD should be considered.Sporadic Creutzfeldt-Jakob disease is the predominant type of human prion disease. While routine diagnostic in phenotypic cases has advanced considerably, the clinical heterogeneity and rarity of subtypes continue to constitute a major clinical and diagnostic challenge. Here, we report a peculiar case of the Heidenhain-variant of MM1 sporadic Creutzfeldt-Jakob disease presenting as a stroke mimic in an 81-year-old patient with a rapid and clinically distinct course of disease as compared to previously reported cases. While 14-3-3 protein was negative, clinical findings substantiated by 18 Sc-type 1 prion protein constitutes the predominant molecular subtype. Although the clinical characteristics of CJD are heterogeneous, they typically include rapidly progressive dementia, psychiatric disorders, ataxia, visual symptoms and an akinetic state of mutism [The rarity, multifaceted clinical presentation and heterogeneity of human prion diseases render them a major diagnostic and clinical challenge. Sporadic forms of Creutzfeldt-Jakob disease (sCJD) represent the largest group within human prion diseases wherein the MM1-subtype with a homozygous methionine at codon 129 of the PrPf mutism , which af mutism ,5.Here, we report a peculiar case of an 81 years old female patient diagnosed with MM1-sCJD presenting with an acute and isolated loss of visual acuity mimicking a stroke.Initially, an 81-year-old, Caucasian woman presented with acute loss of visual acuity accompanied by a decline in her general condition and frontotemporal cephalgia. The visual symptoms manifested acutely 2 days prior to admission. Before the onset of visual symptoms, the patient was otherwise healthy, routinely practising competitive dancing. Her medical history is unremarkable except for a pre-existing rotating vertigo which was considered Meniere’s disease earlier. The patient’s husband added progressive olfactory dysfunction during the last months and intermittent accidental falls but negated a relevant cognitive decline. The patient´s father died from an unknown rapidly progressive neurological disease at around 80 years.Sup. 1), 24-hour ECG, neurovascular ultrasound and transthoracic echocardiography did not reveal explanatory findings. The patient was admitted to the neurological ward for further diagnostics under the initial working diagnosis of ischaemic stroke in the posterior cerebral artery territory.The initial neurological examination revealed psychomotor retardation, a loss of visual acuity and raised the suspicion of a right homonymous hemianopsia. Ophthalmologic examination confirmed these findings. An explanatory pathology of the eye was not found. Cranial MRI showed left occipitomesial diffusion restriction in the DWI sequences (diffusion-weighted imaging) with a correlate in the ADC-map (apparent diffusion coefficient) matching the right-sided hemianopsia. Auxiliary findings were global brain volume loss and microangiopathic white matter changes. Other diagnostics including blood  and CSF analysis  revealed significant hypometabolism in the left occipital lobe and adjacent left parietotemporal and precuneal cortex areas but not in PSP-typical medial frontal cortex areas, providing a functional correlate for the progressive visual dysfunction (Sup. 1) did not yield aberrant findings. However, an analysis of dementia markers in CSF from a re-puncture 2.5 weeks after admission revealed a massively elevated Tau-protein (>2200 pg/ml) along with normal amyloid levels. As left frontotemporal periodical sharp waves were detected in an electroencephalogram, the new suspect diagnosis of CJD was raised. Phosphorylated neurofilament heavy chain (pNfH) in CSF was strongly elevated (2064 pg/ml). Although further analysis of CSF did not detect 14-3-3 protein, a real-time quaking-induced conversion assay (RT-QuIC) PrPSc-aggregation analysis [Sc 1 protein  was raised, when a supranuclear vertical gaze palsy together with postural instability and bradykinesia developed. However, an L-dopa test did not improve neurological symptoms and advanced function . Furtherevated 204 pg/ml.  protein . PRNP geIn the further course of the disease, the patient gradually developed spastic hypertonia, global bradykinesia and a loss of consciousness cumulating in respiratory insufficiency and ultimately death 7 weeks after hospital admission and 9 weeks after the onset of symptoms. The patient did not consent to an autopsy. Further genetic analysis excluded familial CJD.Here, we report a noteworthy presentation of the Heidenhain-variant, a phenotype constituting approximately 5% of the total sCJD cases. While visual symptoms are present in up to 20% to 35% of sCJD – more often in younger patients  – the di18F-FDG-PET imaging provided a symptom matching correlate with lesions in the parietooccipital cortex. Similar locations of hypometabolism were reported very rarely in other Heidenhain-variant cases when 18F-FDG-PET imaging was applied [18F-FDG-PET was suggested to be of diagnostic relevance in the differential diagnosis of sCJD from other forms of rapidly progressive dementia in a few cases and series. The parietooccipital cortex was mainly affected with hypometabolism in patients with visual symptoms which is in line with our findings [18F-FDG-PET imaging in differential diagnosis of Heidenhain-variant sCJD remains elusive due to a lack of prospective trials but can be considered in unclear cases of rapidly progressive dementia.In respect to the diagnostic work-up, an initial MRI revealed a hyperintense DWI-signal in the correlating cortex area compatible with sCJD, being present in up to 80% of sCJD cases . The con applied ,17,18. Bfindings ,20. HoweSup. 2) showed sensitivity rates around 95% and a specificity of 100% in retrospective and one prospective study [RT-QuIC analysis was developed to allow for a more rapid and specific discriminability between treatable and non-treatable pathologies ,21,22. Sve study –25, withve study ,27. The ve study ,28,29. GIn conclusion, we established the probable antemortem diagnosis of Heidenhain-variant sCJD with MM1 molecular subtype. Key clinical findings were an advanced age at onset combined with an accelerated course of disease mimicking an ischaemic stroke. We propose that an unusual presentation of the Heidenhain-variant might be considered as a ‘stroke-mimic’ in cases of isolated visual symptoms followed by unexplained neurological deterioration. FDG-PET imaging and CSF RT-QuIC prion protein aggregation assay have proven their diagnostic value, while we were unable to detect 14-3-3 protein. A limitation of our case is the lack of a histopathology. The clinical heterogeneity of sCJD sustains diagnostic difficulties.


The relationship between anti-estrogen drugs and macular telangiectasia type 2 (MacTel-2) remains unknown. Here we report a case with anti-estrogen maculopathy resembling MacTel-2 with improved visual function and macular morphology following cessation of anti-estrogen drugs.A 53-year-old woman presented with a 5-month history of central vision loss and anorthopia in both eyes. She had received oral tamoxifen followed by toremifene for 69 months. Funduscopy, fluorescein angiography, and optical coherence tomography (OCT) revealed MacTel-2-like findings OU. Fundus autofluorescence (FAF) showed hyper-autofluorescence at the fovea OU. Visual acuity, macular morphology on OCT, and FAF findings gradually improved after cessation of anti-estrogen drugs.In the present case, visual acuity, macular morphology, and impairment of the retinal pigment epithelium (RPE) improved following cessation of anti-estrogen drugs, suggesting the relationship between retinal toxicity of anti-estrogen drugs and the development of MacTel-2-like findings. From these results and the previous observations, toxicity of both photoreceptor and RPE cells caused by anti-estrogen drugs may contribute to the development of anti-estrogen maculopathy similar to MacTel-2. Anti-estrogen drugs are widely used to treat hormone-dependent breast cancer. Tamoxifen and toremifene rarely cause toxic retinopathy, characterized by intraretinal crystals and changes in retinal pigment epithelium (RPE) , 2. AntiFindings such as intraretinal crystals, RPE abnormality, and foveal hypo-reflective space on optical coherence tomography (OCT), as seen in patients with tamoxifen retinopathy, may also be observed in patients with macular telangiectasia type 2 (MacTel-2), showing similarity of clinical findings between the two diseases . A previWe herein report a case with anti-estrogen maculopahty resembling MacTel-2 showing improved visual acuity and macular morphology following cessation of anti-estrogen drugs.A 53-year-old woman presented with a 5-month history of central vision loss with anorthopia of both eyes. The patient received oral tamoxifen 20 mg/day for 58 months  and thereafter toremifene 40 mg/day for 11 months  for breast cancer; however, toremifene was discontinued several days prior to her first hospital visit. She had no significant personal or family medical history, except for breast cancer.Her best-corrected visual acuity (BCVA) was 0.4 OD and 0.3 OS with mild myopia. The cornea and lens were clear OU. Funduscopic examination revealed a de-pigmented lesion of the RPE at the fovea, surrounded by a gray-colored lesion OU Fig. a, b. IntThree months after the first visit, her BCVA spontaneously improved to 0.9 OD and 0.6 OS and the area of the EZ loss and the extent of the inner and outer lamellar cavities on EDI-OCT were reduced OS and remained unchanged OD Fig. c, d. SheWe encountered an anti-estrogen maculopathy case exhibiting part of typical MacTel-2 findings. Use of toremifene and marked improvements of the BCVA and macular morphology following cessation of anti-estrogen drugs were rarely described in the literature.Clinical findings in the present case resembled those of MacTel-2 at the early stage except for the absence of dye leakage at the temporal side of the macula on fluorescein angiography. In patients with MacTel-2, Müller cell dysfunction has been proposed based on histopathological examination , as beinIn mice with serine diet, elevated deoxysphingolipids were observed in the RPE as well. The elevation of the cytotoxic metabolites is theorized to affect the RPE . ActuallLittle is known about tamoxifen’s effect on Müller cells. Tamoxifen-induced abnormality of sphingolipid metabolism may possibly affect Müller cells as well as photoreceptor cells. Next, a recent study with a model of photoreceptor degeneration revealed that loss of rod cells was simultaneously associated with damage to the neurovascular unit comprising photoreceptor, RPE, and Müller glial cells , suggestThe effectiveness of intravitreal injections of triamcinolone acetonide (IVTA) has been reported in a case with tamoxifen retinopathy and an animal model of MacTel-2 , 19. TheToremifene is structurally and pharmacologically similar to tamoxifen. A previous study showed that there was no significant difference in frequency of retinopathy between patients receiving tamoxifen and toremifene three years after the start of the drugs . TherefoIn conclusion, BCVA, macular morphology, and impairment of the RPE improved following cessation of anti-estrogen drugs in an anti-estrogen maculopathy case with MacTel-2-like findings. These results suggest the relationship between retinal toxicity of anti-estrogen drugs and the development of findings resembling MacTel-2 in the present case.


In this presentation, we introduce a series of projects outlined above and share the challenges and opportunities identified in our behavioral intervention trials focused on social interaction.In our previous NIH-funded randomized controlled behavioral clinical trial, we developed a conversation-based social interaction cognitive stimulation protocol delivered by trained interviewers through webcams and a user-friendly interactive Internet interface. Daily 30 minute face-to-face video-chats were conducted for 6 weeks. Despite a short duration, this proof of concept study demonstrated high adherence among older adults (mean age 80 years) and showed improvement in cognitive domains which tap language-based executive functions and semantic memory among the experimental group compared to the control group who did not engage in any video-chats. Building on these results, we are now conducting two NIH-funded projects (


Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) have been emerged as the standard selection in non-small cell lung cancer (NSCLC) patients with EGFR sensitive mutations. However, primary or acquired resistance to EGFR-TKIs seems inevitable, especially to third-generation TKIs, which has appeared absence of effective solutions so far.Here we reported a NSCLC patient with EGFR sensitive mutation of deletion within EGFR exon 19, who had been resistant to icotinib and AZD9291 successively after a period of 18 months response duration. Next-generation sequencing (NGS) technique using plasma sample suggested an acquired EGFR Leu792H mutation, rather than C797S one. Interestingly, the patient obtained another 8 months of disease-free duration with symptoms greatly relieved after repeating icotinib administration. The overall survival of the patient has been thirty-six months and still in the extension.The presentation of the case may provide some selective therapeutic thoughts for NSCLC patients with acquired EGFR Leu792H mutation suffering resistance to the third-generation TKIs. Owing to the well-established beneficial outcomes of clinical trials, epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), have been approved as the standard regimens in patients with non-small cell lung cancer (NSCLC) harboring EGFR sensitive mutations . HoweverA 65-year old male patient was referred to our hospital with several space-occupying lesions in inferior lobe of right lung and enlarged lymph nodes in mediastinum and bilateral hilum detected occasionally by chest computed tomography (CT) scanning during the annual health examination in April 2015 Fig. a-b. The EGFR-TKI has been emerged as the standard choice for NSCLC patients with EGFR sensitive mutations, while resistant to which appears to be inevitable . EGFR C7


In vitro studies indicate that, by itself, synthetic TCAP-1 promotes neuron growth and protects cells from chemical insult. In vivo, TCAP-1 increases hippocampal neuron spine density, reduces stress-induced behavior and ablates cocaine-seeking behaviors. Together, these studies suggest that the physiological effects of TCAP-1 are a result of an inhibition of corticotropin-releasing factor (CRF) activity leading to increased energy production. This hypothesis is supported by in vivo functional positron emissions tomography studies, which demonstrate that TCAP-1 significantly increases glucose uptake in rat brain. Complimentary in vitro studies show that enhanced glucose uptake is the result of TCAP-1-induced insertion of the glucose transporter into the neuronal plasma membrane, leading to increased glucose uptake and ATP production. Interestingly, TCAP-1-mediated glucose uptake occurs through a novel insulin-independent pathway. This review will focus on examining the role of TCAP on neuronal energy metabolism in the central nervous system.Teneurin C-terminal associated peptides (TCAPs) are an evolutionarily ancient family of 40- to 41-residue bioactive peptides located on the extracellular end of each of the four teneurin transmembrane proteins. TCAP-1 may exist as a tethered peptide at the teneurin-1 carboxy end or as an independent peptide that is either released via post-transcriptional cleavage from its teneurin-1 pro-protein or independently expressed as its own mRNA. In neurons, soluble TCAP-1 acts as a paracrine factor to regulate cellular activity and neuroplastic interactions.  Drosophila, the teneurins were first thought to be related to the tenascin proteins. Baumgartner and colleagues were in search of Drosophila orthologs of the vertebrate tenascins when they identified two proteins and subsequently named them tenascin-like protein major (ten-m) and tenascin-like protein accessory (ten-a)  . At the s system . Since ts system . Subsequs system .Teneurin genes encode proteins approximately 2800 amino acids in length that contain an intracellular amino terminal, a single transmembrane region and a large conserved extracellular carboxy terminal domain . The fouin situ hybridization analyses showing TCAP mRNA expression in the murine olfactory bulb, cerebellum and brainstem -related homologs in a rainbow trout hypothalamic cDNA library using a hamster urocortin probe . A clonerainstem . Though rainstem . These sCiona intestinalis, which could represent a soluble form of its 39-amino acid TCAP  venom  venom . Upon th ) venom . They ha ) venom . Recent  ) venom . If thisFurther to these phylogenetic studies, several recent binding studies provide clear evidence that the TCAP region is required for teneurin-LPHN interaction. LPHN1 binds LPHN1-associated synaptic surface organizer (Lasso), a splice variant of teneurin-2 comprised of the protein’s distal C-terminus, including the TCAP-2 region . Full-leNumerous studies have indicated potent bioactivity for synthetic TCAP-1. Treatment of Gn11 cells with multiple doses of TCAP-1 showed that a low dose (1 nM) leads to an increase in intracellular cAMP levels whereas a high dose (100 nM) decreases cAMP . Immortain vivo study utilizing intracerebroventricular injection of TCAP-1 under unstressed and restraint conditions. Under unstressed conditions, TCAP-1 decreased dendritic branching while under stressed conditions it increased dendritic branching  insertion into the plasma membrane (In confirmation of these studies, TCAP-1 also increases glucose uptake in a hypothalamic neuron cell model. In these cells, TCAP-1 increased uptake of [membrane . Unlike membrane . The timGlucose uptake into neurons occurs by faciltated diffusion through GLUTs, and is dependent on the plasma membrane expression of GLUTs and the diffusion gradient of glucose into the cell. The actions of TCAP-1 are consistent with this mechanism. TCAP-1 increases GLUT3 transport to the plasma membrane of a hypothalamic neuronal model by 37.5% within 1 h, where the increase is maintained for up to 3 h post-treatment . In addiIncreases in intracellular glucose importation stimulate cellular energy metabolism. TCAP-1 significantly increases intracellular ATP turnover in a dose-dependent manner in an immortalized neuronal cell line, demonstrating that TCAP-1-mediated glucose uptake does, indeed, stimulate neuronal energy metabolism . This inTeneurin C-terminal associated peptide represents a bioactive region of the teneurin proteins that may act as a tethered ligand or a distinct peptide that is either cleaved from the full-length teneurin protein or expressed independently . TCAP-1 DH: analysis of energy metabolism and description of key studies. MH: interpretation of receptor interaction and associated experiments, review and editing of the manuscript. DW: overview of aerobic studies on TCAP and associated literature. TD: molecular biology of TCAP receptor interactions and associated literature. AD’A: development of key experiments associated with TCAP action. DL: supervision of research program and overview of the manuscript.DL is a co-founder of Protagenic Therapeutics, Inc., a commercial entity that may have interests in the findings of these studies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Gammaherpesviruses are important pathogens that establish latent infection in their natural host for lifelong persistence. During latency, the viral genome persists in the nucleus of infected cells as a circular episomal element while the viral gene expression program is restricted to non-coding RNAs and a few latency proteins. Among these, the genome maintenance protein (GMP) is part of the small subset of genes expressed in latently infected cells. Despite sharing little peptidic sequence similarity, gammaherpesvirus GMPs have conserved functions playing essential roles in latent infection. Among these functions, GMPs have acquired an intriguing capacity to evade the cytotoxic T cell response through self-limitation of MHC class I-restricted antigen presentation, further ensuring virus persistence in the infected host. In this review, we provide an updated overview of the main functions of gammaherpesvirus GMPs during latency with an emphasis on their immune evasion properties. Herpesvirales comprising three families: the family Malacoherpesviridae composed of viruses infecting molluscs such as oysters, the family Alloherpesviridae composed of viruses infecting fish species and amphibians, and the predominantly studied family Herpesviridae that includes viruses of mammals and birds, itself classified into the three subfamilies Alpha-, Beta-, and Gammaherpesvirinae. A hallmark of all herpesviruses is their unique capacity to induce lifelong infection through establishing and maintaining latent infection. The definition of herpesvirus latency involves: (i) the presence of the viral genome in the nucleus of the infected cell (either as an episome or integrated in cellular chromosomes), (ii) reduced viral gene expression together with the absence of virion production, and (iii) the ability of latently infected cells to reactivate lytic viral replication either in vivo and/or in vitro  establish latency in non-dividing sensory neurons through maintenance of a quiescent episomal genome and expression of viral transcripts, in the absence of viral protein detection (bovine gammaherpesvirus 4 (BoHV-4) seem to infect cells of the monocyte/macrophage lineage  created the order in vitro . In addietection . In betaetection . Gammahe lineage , 2013. T lineage .genome maintenance protein” (GMP): (i) is encoded by the genome of all described gammaherpesvirus species, (ii) is expressed during latent infection, (iii) regulates the maintenance of viral episomes in actively dividing lymphocytes through tethering the viral genome to cellular chromosomes, and (iv) evades immune detection (+ cytotoxic T cells (CTLs), during latent infection.Most significant advances in the understanding of herpesvirus latency mechanisms have been identified in gammaherpesviruses, which can probably be explained by the fact that one major latency protein, named the “etection . The maiLymphocryptovirus genus, the Rhadinovirus genus, the Percavirus genus and the Macavirus genus (human gammaherpesvirus 4 – HHV-4) (human gammaherpesvirus 8 – HHV-8) (saimiriine gammaherpesvirus 2 (or SaHV-2) also known as herpesvirus saimiri (HVS); and ateline gammaherpesvirus 3, which infects spider monkeys (murid gammaherpesvirus 4 (MuHV-4), also referred to as murine gammaherpesvirus 68 (MHV-68) is a natural pathogen of the yellow-necked field mouse (Mus musculus). Furthermore, Bovine herpesvirus 4 (BoHV-4) infection is prevalent in cows while this virus is thought to have originally evolved in another Bovinae, the African buffalo (Syncerus caffer)  and ovine gammaherpesvirus 2 (OvHV-2) naturally infect wildebeest (Connochaetes taurinus) and sheep (Ovis aries). They are responsible for wildebeest-derived and sheep-associated MCF in ruminants, respectively. The genus Percavirus is less well-defined and includes virus species infecting horses or mustelids.Based on genomic and biological characteristics, gammaherpesviruses have been classified into four genera: the us genus . Lymphoc– HHV-4) . Rhadino– HHV-8) . In addi monkeys . In addi monkeys . For insld mouse  and is l caffer) . Macavirin vivo. The former category includes MCF-inducing AlHV-1 that is responsible for the induction of a deadly peripheral T cell lymphoma-like disease in cattle caused by latently infected CD8+ T lymphocytes . GMPs are DNA-binding proteins able to bind sequences within the viral genome while at the same time interacting with cell chromosome-associated proteins, to ensure partitioning to daughter cells during mitosis. Early studies have already demonstrated that GMPs, such as EBNA-1 and LANA-1, are essential for episome persistence  and loaded on major histocompatibility class I (MHC class I) molecules to form MHC-I-peptide (MHCp) complexes. MHCp complexes are exported to the cell surface for recognition by CD8+ cytotoxic T lymphocytes (CTLs)    .The main source of viral antigens was previously thought to uniquely arise from the turnover of mature proteins. However, more recent studies highlighted an alternate hypothesis regarding the origin of MHC class I-restricted viral peptides, pointing to a major role of defective ribosomal products (DRiPs) as the main source of antigenic peptides during viral infection . DRiPs acis-acting immune evasion”  or BoHV-4 (boLANA) do not have a CR domain  (∗35:01-restricted CTL epitope (HPVGEADYFEY). Despite the potential self-protection of EBNA-1 from MHC class I antigen presentation, several studies found that EBNA-1-specific CTLs exist in EBV-seropositive patients  . The GArin (GAr) . Althougin (GAr) . In ordein (GAr) . In thespatients . Whereastability .cis-acting immune evasion of EBNA-1 is that the GAr-mediated self-inhibition of antigen presentation to CTLs is not absolute. Indeed, although reduced in presence of GAr, EBNA-1 can be immunogenic and lead to the development of EBNA-1-specific CTLs in humans  and rhesus lymphocryptovirus (rhLCV), namely baEBNA-1 and rhEBNA-1, respectively, provided conflicting data. Indeed, the first results suggested that both the ba- and rhGSAr domains were not able to prevent MHC class I restricted peptide presentation in cis , whereasrhEBNA-1 . A more operties . Both pr the GMP .cis to inhibit MHC class I-restricted epitope presentation to CTLs through involvement of the CR domain , including the initially sequenced strain, and one strain of equid gammaherpesvirus 5 (EHV-5)  . Whereas+ T lymphocytes (in cattle). During AlHV-1-associated MCF, aLANA is highly expressed  has recently been investigated experimentally . AlHV-1 xpressed . Thus, arthologs . In partrthologs . Mutant rthologs . Althougrthologs , the intrthologs . Howeverrthologs . Althougrthologs . Thus, irthologs , which rrthologs , resultirthologs , led to rthologs . These rrthologs . Then, mit model . Indeed,cis-acting immune evasion during lymphoproliferation, a hallmark of gammaherpesvirus-associated malignancies? Indeed, a recombinant strain of AlHV-1 expressing a mutated aLANA unable to self-inhibit protein processing for presentation by MHC class I was, however, fully able to induce normal MCF. Whether this observation after AlHV-1 infection represents a general rule or just an exception is unknown. Thus, it makes no doubt that understanding the degree of involvement of GMP cis-acting immune evasion during gammaherpesvirus latency will be determined depending on our understanding of latency mechanisms themselves and, for instance, how distinct are silent latency in healthy individuals and latency-dependent lymphoproliferative diseases. In other words, would self-inhibition of antigen presentation by GMP represent the essential mechanism to avoid CTL recognition during gammaherpesvirus-induced lymphoproliferation? We are eager to uncover future investigations that will clarify these questions.All sequenced gammaherpesviruses encode a GMP that tethers viral genomes to the cellular chromosomes, ensuring even segregation of viral episomes in daughter cells during cell division . BesidesAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Over the last decades, primary prostate cancer radiotherapy saw improving developments, such as more conformal dose administration and hypofractionated treatment regimens. Still, prostate cancer recurrences after whole-gland radiotherapy remain common, especially in patients with intermediate- to high-risk disease. The vast majority of these patients are treated palliatively with androgen deprivation therapy (ADT), which exposes them to harmful side-effects and is only effective for a limited amount of time. For patients with a localized recurrent tumor and no signs of metastatic disease, local treatment with curative intent seems more rational. However, whole-gland salvage treatments such as salvage radiotherapy or salvage prostatectomy are associated with significant toxicity and are, therefore, uncommonly performed. Treatments that are solely aimed at the recurrent tumor itself, thereby better sparing the surrounding organs at risk, potentially provide a safer salvage treatment option in terms of toxicity. To achieve such tumor-targeted treatment, imaging developments have made it possible to better exclude metastatic disease and accurately discriminate the tumor. Currently, focal salvage treatment is being performed with different modalities, including brachytherapy, cryotherapy, high-intensity focused ultrasound (HIFU), and stereotactic body radiation therapy (SBRT). Oncologic outcomes seem comparable to whole-gland salvage series, but with much lower toxicity rates. In terms of oncologic control, these results will improve further with better understanding of patient selection. Other developments, such as high-field diagnostic MRI and live adaptive MRI-guided radiotherapy, will further improve precision of the treatment. Prostate cancer is the most diagnosed male cancer in developed countries. Frequently diagnosed at an early stage, with opportunistic prostate-specific antigen (PSA) screening increasing the incidence, the search for optimal and patient-tailored treatment is of growing significance. In the setting of localized recurrent prostate cancer after primary whole-gland radiotherapy, the standard of care now consists of palliative androgen deprivation therapy (ADT). This only has a temporary suppressive effect and is associated with harmful side-effects. On the other hand, treatments with curative intent such as salvage prostatectomy or whole-gland radiotherapy also convey serious toxicity risks and should only be offered to highly selected patients . This leFor whole-gland treatment of intermediate- to high-risk prostate cancer in the primary setting, radiotherapy has evolved as a suitable modality. It is comparable to prostatectomy in terms of cancer control, while both are associated with their respective side-effects . SeveralWhile external beam techniques are generally delivered fractionated, internal radiation using brachytherapy is increasingly performed in a single procedure. Originally, low-dose-rate brachytherapy (using iodine-125 seeds) was mainly used for low- to intermediate-risk patients. Currently, there is an increase in the treatment of higher-risk disease with high-dose-rate brachytherapy, providing comparable cancer control rates to other primary treatments ,12,13. AAlthough dose escalation is increasingly adopted, recurrent prostate cancer after primary radiotherapy remains common. A recent series of 2694 patients treated with doses above 78 Gy revealed 10-year biochemical recurrence risks of approximately 10%, 23%, and 44% in low-, intermediate-, and high-risk patients, respectively . BiochemPrimary prostate cancer is often a multifocal process ,17, withThe treatment of prostate-confined recurrences after primary radiotherapy is called salvage and will be denoted as such in the subsequent part of this review. Within the literature, there are reasonably large series available describing the results of salvage treatments directed at the entire prostatic volume. These series include salvage radical prostatectomy (SRP) , whole-gWith recurrences often being localized and unifocal (mainly at the “index lesion” site), a salvage treatment directed solely at the recurrent tumor lesion seems rational. Especially considering the narrow therapeutic ratio (treatment efficacy versus treatment-related toxicity) in the recurrent setting, focal treatment provides a promising alternative: a second chance at achieving local control, with minimal burden to the patient in terms of side-effects.68Ga prostate-specific membrane antigen (PSMA)-PET/CT, with a radiotracer binding more specifically to a cellular protein overexpressed on 95% of prostate cancer cell membranes. High diagnostic accuracy is attained for both intra-prostatic lesions, as well as lymph node and bone metastases, even at low PSA values (<2 ng/mL) [The success of focal salvage treatment starts with adequate exclusion of metastatic disease. More dated series of whole-gland salvage treatments often show substantial failure rates due to inadequate pre-treatment diagnosis of metastases. For example, technetium-99m bone scintigraphy was often used to exclude bone metastases, which only achieves acceptable diagnostic accuracy in patients with higher-risk disease characteristics  . Further2 ng/mL) ,44. Avai2 ng/mL) , PSMA-PE2 ng/mL) . Current2 ng/mL) ,48.After exclusion of metastatic disease, assessment of intra-prostatic disease is necessary to adequately target the recurrent lesion. In the past, salvage treatments had to be aimed at the whole prostate gland since localization of the recurrent nodule was inadequate. Currently, this is possible with the use of multi-parametric MRI (mp-MRI), offering both morphological and functional information with T2-weighted, dynamic contrast-enhanced (DCE), and diffusion-weighted imaging (DWI). In the primary setting, the diagnostic accuracy of mp-MRI for the detection of clinically significant intra-prostatic disease seems adequate with a sensitivity of 93% ,50. AlthHowever, in the setting of treatment failure evaluation, the interpretation of mp-MRI is often complicated by treatment-related anatomic and functional changes. Radiologists should be familiar with the findings that are associated with the type of treatment the patient previously received. For instance, T2 hypo-intense intraprostatic lesions can be difficult to distinguish within a diffusely hypo-intense prostate caused by previous irradiation. Although there are no established guidelines for characterizing possible local tumor relapses on mp-MRI, there is an increasing amount of literature discussing the differences between normal post-treatment patterns and suspicious recurrence findings ,57,58,5968Ga-PSMA-PET/CT with mp-MRI could provide an even higher accuracy in detecting and delineating intra-prostatic disease [68Ga-PSMA-PET/CT in the recurrent setting revealed a negative predictive value (NPV) and positive predictive value (PPV) of 91.4% and 100%, detecting recurrent prostate cancer in a high number of patients [68Ga-PSMA-PET/CT in patients with recurrent prostate cancer is large, altering the therapeutic management in approximately half of all patients. Specifically, the use of dose escalation to boost the target volume and the proportion of focal salvage treatments seems to increase, while systemic treatment decreases [The combination of  disease  -guided biopsies, decrease the detection of insignificant disease, while the yield of clinically relevant cancers increases . A studyIn the radiorecurrent setting, prostate biopsy evaluation is hampered by radiation effects, which sometimes mimic higher-grade disease. Approximately 30% of indeterminate biopsies seem to resolve into negative disease status. On the other hand, local failure can also be interpreted as radiation effect, and indeterminate biopsies should, therefore, not be considered negative. Furthermore, delayed tumor regression may cause false positives. Biopsies should, therefore, not be taken before 24 months of follow-up . Even afIn case of localized recurrence, one could argue that biopsies might aid in the selection of patients for focal salvage treatment. A study comparing cognitive targeted biopsies with TPM biopsies showed that targeted biopsies had similar or at most 10% less detection rate, depending on the definition of clinically significant cancer. Targeted biopsies were efficient, requiring fewer biopsies compared to TPM biopsies for detection of clinically significant disease . However68Ga-PSMA-PET/CT and at least one mp-MRI sequence, who underwent subsequent MRI-targeted biopsies, to determine the added value of histologic verification for adequate disease assessment.With advancements in imaging modalities as outlined above, and the burden of invasive biopsy procedures on patients, it is questionable whether these biopsies are mandatory for adequate disease assessment. There is no literature describing the accuracy of combined mp-MRI and PET-CT with pathology verification in the radiorecurrent setting. Currently, we are investigating a cohort of patients with a positive recurrent lesion on Today, focal salvage treatment of radiorecurrent prostate cancer is performed with a variety of techniques: focal cryotherapy ,73,74, f68Ga-PSMA-PET/CT outperforms the other modalities in selecting patients with true localized, non-metastatic recurrence [Studies that report five-year bFFS seem to reach an approximate 50% rate , which icurrence ,86. In tWith this in mind, it is important to consider treatment-related side-effects of focal salvage treatments. Although toxicity might be underreported in many current series due to the retrospective nature of data collection, the general trend seems favorable. Severe GU and GI toxicity seem limited to a maximum of 5–10%. Potency preservation  or common terminology criteria for adverse events (CTCAE)) is observed in the majority of patients in many of the series. Treatment effects on patient-reported quality of life was only reported in focal salvage brachytherapy series, revealing no significant changes in most domains, except an increase in urinary symptoms after focal low-dose-rate brachytherapy .To determine which patients benefit the most from focal salvage treatment, it is also important to consider other patient and tumor characteristics. In the abovementioned studies, patients with stage T1–T3b recurrent tumors, total Gleason score ≤6–10, and PSA levels between 0.01 and ≥20 ng/mL were treated. This indicates that a wide range of patients, classified from (very) low-risk to high-risk disease, were included. Most studies did not report on the pre-treatment PSA doubling time (PSADT). In a Delphi consensus study among 18 experts in the field of salvage brachytherapy for radiorecurrent prostate cancer, 88% of participants indicated that stage T3b should be the maximum tumor classification to be eligible for salvage treatment. A total of 94% agreed that the Gleason score should not be used as a criterion . In terms of PSA kinetics, a maximum PSA level of 10 ng/mL and minimum PSADT of six months was preferred by most participants . A prediIt is clear that accurate targeted ablation requires precise localization of the recurrent prostatic lesion. Over the years, the use of (mp-)MRI for treatment planning substantially increased. The superior resolution of soft tissue enables more accurate delineation of the tumor volume and organs at risk . New devImaging developments are not only used for the treatment planning phase, but are also increasingly incorporated into the treatment itself. Currently, MRI guidance during treatment can be achieved using image registration of pre-operative MR images (1.5 T or 3 T) with intra-operative TRUS images (MRI/TRUS fusion). With this technique, software is used to register the pre-operatively delineated tumor location to real-time prostate images. Image registration may be either rigid (overlay of images without adjustment for possible prostate deformation during treatment) or non-rigid . Some factors that contribute to prostate deformation are unavoidable, such as swelling of the prostate due to catheter insertion during a brachytherapy implant procedure. Prostate motion can also be caused by surrounding organ movement, such as rectal distension due to flatulence or introduction of an ultrasound probe. Evidently, non-rigid registration is challenging; a variety of registration methods using different algorithms were presented in the search for the most optimal solution .The next step in the development of MRI-guided intervention is the incorporation of live MR images into the treatment workflow, thereby achieving direct treatment guidance and avoiding any registration errors. Although early experiences with real-time MRI-guided brachytherapy date back to 1997, this approach is not yet widely adopted due to logistical issues such as resource demand and procedural time prolongation . One of To overcome these shortcomings, a robotic MRI-compatible implantation device for prostate brachytherapy was developed at our institution see . The robRegarding external beam radiotherapy, MRI-guided radiotherapy systems such as the MR-Linac will provide another way of accomplishing live MRI-guided intervention. Using online fast MR-sequences for auto-contouring and auto-planning, a full MRI-based online adaptive workflow can be achieved . ChangesLocalized radiorecurrent prostate cancer seems susceptible to focal salvage treatment. Treating the tumor while sparing the surrounding healthy tissue leads to a reduction of treatment-related side-effects, where whole-gland salvage treatments or palliative ADT are often less well tolerated. Focal salvage therapy thereby provides an intermediate step between primary curative treatment and (if necessary) palliative hormonal treatment. Diagnostic innovations led to more adequate patient selection in terms of exclusion of metastatic disease and accurate tumor targeting. This is a constantly developing field, as new diagnostic techniques are warranted to provide greater insight into prostate tumor profiling. With MRI guidance, focal treatment becomes more and more precise, especially with emerging technologies enabling live and online adaptive MRI-guided radiotherapy.


A hyper-metabolic pulmonary nodule was detected on 18F-FDG PET/CT in a 65-year-old woman who had been followed up for 12 years without any complaints following treatment for papillary thyroid cancer (PTC). Wedge resection was performed to the pulmonary nodule and the pathologic examination revealed PTC metastasis. On the post-therapeutic I-131 scan after radioiodine treatment, focal I-131 uptake was detected at the site of pulmonary wedge resection. At first, this finding was thought to be related to the residual lesion but diagnostic CT demonstrated only focal traction bronchiectasis at that region. In addition, a false-positive I-131 uptake was also detected at the soft tissue just lateral to the femoral heads probably due to inflammation.


Accumulated evidence has demonstrated exosomes of cancer cells carry microRNAs (miRNAs) to non-malignant cells to induce metastasis. The present study aimed to identify crucial exosomal miRNAs for breast cancer (BC) using microarray data (GSE83669 and GSE50429) from Gene Expression Omnibus database, including exosomal samples from human BC cells  and normal mammary epithelial cell line , as well as original cell samples. Differentially expressed miRNAs (DEMs) were identified using EdgeR package, and mRNA targets were predicted using miRWalk2 database. The target genes were overlapped with BC genes from Comparative Toxicogenomics Database (CTD) to construct BC-related interaction network. Potential functions were analyzed by DAVID. The expression of crucial miRNAs and target genes were confirmed in other microarray datasets or TCGA sequencing data. Their associations with survival and other clinical characteristics were validated by Kaplan–Meier plotter and LinkedOmics database. As a result, 9 and 8 DEMs were identified to be shared in two datasets for exosomal and original cells, respectively. Further comparison showed that miR-455-5p was specifically differentially expressed in exosomes, and miR-1255a was commonly expressed in exosomal and original cells samples. miR-455-5p could interact with CDKN1B to influence cell cycle process and miR-1255a could regulate SMAD4 to participate in TGF-β signaling pathway. High expressed miR-455-5p  and miR-1255a  were associated with poor overall survival, while the high expression of their target genes was associated with excellent overall, recurrence-free or distant metastasis-free survival. In conclusion, the present study preliminarily indicates that exosomal miR-455-5p and miR-1255a may be novel therapeutic targets for BC. Breast cancer is one of the leading causes of oncological mortality for women ,2, with Recently, it has been widely considered that the development of recurrence and metastasis may be resulted from the interactions between tumor cells and non-malignant cells . ExosomeThere also several studies to investigate the exosomal miRNA expression profiles in order to screen crucial exosomal miRNAs for breast cancer progression. However, most of them focused on chemoresistance mechanisms in breast cancer cells ,15 or bihttp://www.ncbi.nlm.nih.gov/geo/) using the key word [exosomal (or exosomes) AND breast cancer] on December 2018. The cells or tissues did not undergo any treatment. Four were obtained, including GSE83669, GSE50429, GSE70432 and GSE114329, all of which analyzed the exosomal miRNAs of cell lines. GSE70432 and GSE114329 were excluded due to the lack of normal controls and the lower matching rate, respectively. Thus, only GSE83669 and GSE50429 were used in the following analysis. GSE83669 dataset contained six samples, including exosomal samples of two human breast cancer cells (MCF7 and MDA-MB-231) and one normal mammary epithelial cell line (MCF10) as well as their original cells, which were obtained on Illumina MiSeq platform (GPL15520). GSE50429 consisted of four samples, including exosomal samples of one breast cancer cell (MDA-MB-231) and one normal mammary epithelial cell line (MCF-10A) as well as their original cells, which were sequenced on Illumina Genome Analyzer IIx platform (GPL10999).Exosomal miRNA datasets of breast cancer were identified by an electronic search in GEO database (http://bioconductor.org/packages/release/bioc/html/preprocessCore.html) in R . The DEMs between normal mammary epithelial cells and breast cancer cells in exosomal and original cell samples were identified using the EdgeR package   were examined by searching the online tool, LinkedOmics database (http://www.linkedomics.org/) [The expression of crucial exosomal miRNAs were confirmed in GSE60714 (2 MDA-MB-231 exosomes versus 2 MCF10A exosomes) microarray dataset  and miRNcs.org/) .P < 0.05; while there were 23 and 24 DEMs were identified in the cancer original cells of GSE50429  were collected from the TCGA and the expression levels of crucial DEMs (miR-1255a and miR-455) and their target genes (SMAD4 and CDKN1B) were calculated. In line with our expected, miR-455 was found to be significantly up-regulated, but SMAD4 and CDKN1B were significantly down-regulated in cancer . AlthougIn the present study, we identified two important exosomal miRNAs for breast cancer, including miR-455-5p and miR-1255a. High expressed miR-455-5p may exert tumor promoting roles by inhibiting the expression of CDKN1B and influencing cell cycle, which led to poor prognosis in basal-like subtype . High expressed miR-1255a may be oncogenic by down-regulating SMAD4 and affecting TGF-β signaling pathway, which resulted in poor prognosis overall.In vitro experiments showed overexpression of miR-455-5p accelerated invasiveness and migration capabilities of breast cancer cells [Although the roles of miR-455-5p in exosomes have not been investigated previously, its tumor-promoting functions in original cancer cells may indirectly verify our results because of the similar expression trend confirmed using the TCGA data. For example, the study of Aili et al. showed miR-455-5p was significantly up-regulated in breast cancer tissues. High expressed miR-455-5p was an independent prognostic factor for poor survival for breast cancer patients. er cells . Li et aer cells . Furtherer cells , colon cer cells  and oraler cells  also verer cells ,33. Theser cells ,35. ThermiR-1255a is a shared DEM in exosomes and original cells, indicating its important roles as a therapeutic target for breast cancer. However, the expression and functions of miR-1255a in exosomes and cancer original cells have rarely been reported, except occasional identification of another miR-1255 member miR-1255b in cancer. For example, the study of Tölle et al. showed that miR-1255b-5p was significantly increased in the urine of patients with invasive bladder cancer compared with the control group. The urine miR-1255b-5p reached 68% specificity and 85% sensitivity in the diagnosis of invasive bladder cancer . Choi etin vitro and in vivo experiments  are necessary to confirm their interaction. Fourth, the exosomal mechanisms of the identified miRNAs also need wet experiments  to validate.The present study had certain limitations: First, sample size and the number of cell lines used for identification of exosomal miRNAs were relatively small, which may be the potential cause to lead to some inconsistent conclusions in different datasets. Although there were six breast cancer cell lines that were included in GSE114329 dataset, the matching rate was very low and most of the expressions of mRNAs were zero and it could not be analyzed. Second, the TCGA data did not include the exosomal miRNAs in breast cancer tissues and the associations with clinical characteristics were only the results preliminarily predicted according to their expression in original cells. Third, although our study preliminarily detected the opposite expression between miRNAs and their target genes, In conclusion, the present study preliminarily indicates that exosomal miR-455-5p and miR-1255a may be novel therapeutic targets for breast cancer. They may be transferred from the breast cancer cells to non-malignant recipient cells to inhibit the expression of CDKN1B and SMAD4 and result in poor prognosis of patients.


Gastroenteropancreatic neuroendocrine tumors are a heterogeneous group of low incidence neoplasms characterized by a low proliferative activity and slow growth. Their response to targeted therapies is heterogeneous and often does not lead to tumor shrinkage. Thus, evaluation of the therapeutic response should differ from other kind of tumors.To answer relevant questions about which techniques are best in the assessment of progression or treatment response a RAND/UCLA-based consensus process was implemented. Relevant clinical questions were listed followed by a systematic search of the literature. The expert panel answered all questions with recommendations, combining available evidence and expert opinion. Recommendations were validated through a questionnaire and a participatory meeting.Expert recommendations regarding imaging tools for tumor assessment and evaluation of progression were agreed upon. Available imaging techniques were reviewed and recommendations for best patient monitoring practice and the best way to evaluate treatment response were formulated.The online version of this article (10.1007/s12094-018-1881-9) contains supplementary material, which is available to authorized users. Neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms that arise from neuroendocrine cells and in particular, affect the gastroenteropancreatic tissue, therefore, being called gastroenteropancreatic NETs (GEP-NETs) . Along tAlthough improvements in imaging techniques have led to an increased amount of newly diagnosis of GEP-NETs in the past two decades , reporteMedical antitumor treatment for GEP-NETs is mainly based on somatostatin analogs, interferon, chemotherapy, locoregional liver therapies, peptide receptor radionuclide therapy and targeted therapies, which are currently arising . In geneDespite the current research and progress in GEP-NETs characterization and treatment, there is still a need for higher specificity in diagnosis and monitoring of patients. In an effort to provide some certainty to routine critical practice in this field a RAND/UCLA-based protocol was used to build a systematic and reproducible process. The evidence currently available concerning concrete clinical questions was collected and when no contrasted evidence was found, the participating experts provided clinical practice and expertise-based criteria. This document summarizes the results of the consensus procedure with the objective of helping professionals assessing GEP-NET progression and treatment response.This document of recommendations is the result of a consensus formal process developed following the methodological manual for the preparation of clinical practice guidelines in the spanish national health . A multi111In-DTPA-octreotide, although in the near future this might be replaced by positron emission tomography (PET) using somatostatin receptor (SR-PET), due to its high sensitivity and specificity for evaluating localized NETs in the thorax, bone and abdomen [68Gallium-DOTA-TOC/-NOC/-TATE is available .Multiphasic contrast-enhanced abdominal and pelvic computed tomography (CT) or magnetic resonance imaging (MRI) are recommended for all patients with suspected GEP-NETs . It is r abdomen . SR imag abdomen . TherefoIn the case of the thorax, abdomen and pelvis, multi-slice intravenous contrast-enhanced CT is the usual technique for evaluating extrahepatic disease , as recommended in clinical guidelines because of its efficiency and accessibility . MRI is 68Ga-DOTA peptides and WB-MRI can be considered for evaluating bone metastases in patients with spine symptoms  [18F-FDG-PET in G2 NET patients is widely debated, a multimodality diagnostic approach using both PET tracers could be useful in G2 NET patients. Well-differentiated GEP-NETs (low to intermediate grade) can differ in clinical presentation, SR expression, functionality and proliferation rate when compared to poorly differentiated (high grade) tumors and large or small cell carcinomas. Thus, the choice of the molecular imaging technique to be used depends on the proliferation rate and grade of the disease [68Ga-DOTATOC/NOC/TATE) are recommended for following-up well-differentiated GEP-NETs metastases and those expressing SR, being SR-PET preferable when available . In fact, SR-PET can be recommended to follow-up all well differentiated GEP-NETs and metastases [In patient-based analysis, PET/CT shows higher accuracy for lymph node and bone lesions, while in organ-based detection whole body MRI (WB-MRI) shows more accuracy for liver and bone metastases and PET/CT for lymph node and pulmonary lesions . The MRIRD: 5/D) , 10. SR- disease . Both SRtastases   or the appearance of new lesions. Other considerations for radiologic progression are still under investigation . In any case, the same type of radiological assessment study should be used for the follow-up of lesions, since the use of methods with different accuracy should lead to an erroneous interpretation of the appearance of new lesions or an increase in previous ones .The adequate frequency of follow-up has not been established, but it is necessary to contemplate the need to detect early progression and avoid risks  and costs caused by very frequent follow-up in stable patients. Although prospective studies analyzing benefits and hazards of frequent imaging assessment are lacking, Table 111In-Pentetreotide is more sensitive than planar or planar plus SPECT when evaluating progression in metastatic GEP-NETs [68Ga-DOTA peptides imaging is higher than 111In-Pentetreotide, even when SPECT/CT scans are used [18F-FDOPA PET is also more accurate than 111In-Pentetreotide for restaging metastatic GEP-NETs and should be performed when 68Ga-DOTA peptides are not available [68Ga- DOTA peptides when serotonin is overexpressed [Imaging using radiolabeled SSA is indicated to detect recurrent or progressive disease during the follow-up of patients with known metastatic disease . 111In-PGEP-NETs . Howeverare used . 18F-FDOvailable  and it ixpressed .18F-FDG PET should be limited to SR-negative NET patients, although G1–2 patients may also initially have 18F-FDG-positive tumors and may develop 18F-FDG-positive lesions during follow-up [The gain in glucose utilization in GEP-NETs has been found to coincide with a loss of SR expression and the higher the NET grade is, the higher its glucose metabolism . Thus, i111In-pentetreotide SPECT/CT, 68Ga-DOTATATE PET/CT detects additional lesions in 71.0% of patients and when it is compared with CT scan, additional lesions are frequently detected, having a high management impact in a significant number of patients [Compared to patients .18F-FDG and 68Ga-DOTATATE PET/CT has a significant impact on the therapeutic decision and is helpful in the individual therapeutic approach [18F-FDOPA and 18F-FDG, for routine clinical practice if available with SSA are formulated in Table High-grade, poorly differentiated NETs often have limited expression of SR , which capproach . Expert Adequate assessment of response after therapy will not only help predict prognosis, but also influence treatment decisions. Due to low proliferation rate of GEP-NETs, monitoring changes in tumor size is suboptimal to assess the response to systemic therapies, especially since they tend to stabilize the disease rather than to shrink the tumor.68Ga-labelled SSA or 18F-FDOPA was considered the best method for NET imaging in centers of excellence [68Ga-DOTATOC is a useful complement to morphologically oriented imaging methods for early assessment of progressive disease, after finalizing peptide receptor radionuclide therapy, namely in that it detects new and as-yet undiscovered lesions during whole-body PET [18F-FDG PET should be considered for tumor response assessment, especially when positive in G1 and G2 tumors, since the presence of 18F-FDG-positive tumors correlates strongly with a higher risk of progression [18F-FDOPA-PET for monitoring treatment response, especially in those patients with elevated serotonin and catecholamine pathways tumor markers in urine and plasma, regardless of the type of therapy prescribed [In GEP-NETs patients, tumor response is basically assessed through blood circulating biomarkers and imaging. According to a consensus on biomarkers, imaging was considered the best modality to measure treatment effectiveness. However, no agreement on the optimum imaging method to use in different types of tumor was achieved. CT/MRI in conjunction with SRI was appropriate as a routine measure. Within the nuclear medicine tools, PET/CT with cellence . 68Ga-DObody PET  Below is the link to the electronic supplementary material.


Rapidly developing resistance against different therapeutics is a major stumbling block in the standardization of therapy. Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL)-mediated signaling has emerged as one of the most highly and extensively studied signal transduction cascade that induces apoptosis in cancer cells. Rapidly emerging cutting-edge research has helped us to develop a better understanding of the signaling machinery involved in inducing apoptotic cell death. However, excitingly, cancer cells develop resistance against TRAIL-induced apoptosis through different modes. Loss of cell surface expression of TRAIL receptors and imbalance of stoichiometric ratios of pro- and anti-apoptotic proteins play instrumental roles in rewiring the machinery of cancer cells to develop resistance against TRAIL-based therapeutics. Natural products have shown excellent potential to restore apoptosis in TRAIL-resistant cancer cell lines and in mice xenografted with TRAIL-resistant cancer cells. Significantly refined information has previously been added and continues to enrich the existing pool of knowledge related to the natural-product-mediated upregulation of death receptors, rebalancing of pro- and anti-apoptotic proteins in different cancers. In this mini review, we will set spotlight on the most recently published high-impact research related to underlying mechanisms of TRAIL resistance and how these deregulations can be targeted by natural products to restore TRAIL-mediated apoptosis in different cancers. Cancer is a multifaceted and therapeutically challenging disease. Groundbreaking discoveries in the past few decades have enabled us to develop a sharper understanding of intra- and inter-tumor heterogeneity, loss of apoptosis, oncogenic overexpression, inactivation of tumor suppressors, and deregulation of spatio-temporally controlled signal transduction cascades which play a central role in cancer onset and progression ,2,3,4. LThere are some detailed reviews about TRAIL-mediated signaling in different cancers, but we have exclusively focused on the most recent evidence related to positive and negative regulators of TRAIL-mediated signaling in this review. We have also summarized how different natural products effectively restored apoptosis in TRAIL-resistant cancers. Before providing an overview of the natural product-mediated regulation of the TRAIL-driven pathway, we will discuss some of the most important advancements in the TRAIL-mediated signaling pathway. Overwhelmingly, increasing and continuously upgrading discoveries in the field of apoptotic cell death have enabled us to develop a better knowledge of this area. Researchers have extensively characterized two primary death-signaling cascades, the extrinsic and intrinsic pathways. When the signaling is “switched on”, it results in the activation of downstream effector molecules for both pathways that mediate apoptosis. Caspases belong to a group of cysteine proteases which proteolytically process a variety of cytoplasmic and nuclear substrates . The extActivation of the mitochondrial or intrinsic pathway is induced either through radiation or chemotherapy. Caspase-8-mediated truncation of Bid also played a dominant role in activating the mitochondrially driven pathway. Translocation of truncated Bid into mitochondria caused mitochondrial permeabilization and release of apoptogenic proteins, including cytochrome c and second mitochondrial-derived activator of caspases (SMAC) from the mitochondria into the cytosol. Cytosolic cytochrome c interacted with apoptotic protease activating factor-1 (APAF1) and formed a multimeric complex termed the apoptosome shown in . The apoBecause TRAIL-based therapies have entered into various phases of clinical trials, it is essential to drill down deep into TRAIL-mediated signaling and further unfold the mysterious aspects of this pathway. The overexpression and stabilization of anti-apoptotic proteins is necessary to induce resistance against TRAIL. Various lines of evidence have revealed that cancer cells developed resistance against TRAIL mainly through the overexpression and stabilization of anti-apoptotic proteins. We have partitioned this section into modes and strategies used by cancer cells to develop resistance against TRAIL. (1) Stabilization of anti-apoptotic proteins; (2) Noncoding RNAs also play their role in rewiring cell-signaling pathways to potentiate TRAIL resistance; (3) Ubiquitination is a very critical mechanism in the context of anti-apoptotic and pro-apoptotic protein degradations. It has been seen that pro-apoptotic proteins are degraded but anti-apoptotic proteins escape from these death-tagging molecules in TRAIL-resistant cancer cells; (4) Recent discoveries have unmasked unique locations and functionalities of death receptors. Death receptors not only activate classical pathways to induce apoptosis, but their movement has also been tracked in the nucleus to modulate miRNA biogenesis. Therefore, we will discuss these interesting topics in the upcoming section and try to critically evaluate their implications. GADD34 (growth arrest and DNA damage-inducible protein 34) overexpression resulted in an increase in MCL-1 levels. Knockdown of GADD34 resulted in marked reduction in MCL-1 levels in both SMMC-7721 and HepG2 cells . GADD34 CIB1  played a contributory role in the development of resistance against chemotherapeutics and TRAIL . IntriguOvarian adenocarcinoma-amplified lncRNA (OVAAL) has been shown to play an instrumental role in the development of resistance against TRAIL . OVAAL iDetailed mechanistic insights revealed that cytoplasmic PARP-1 was recruited into the TRA-8-activated DISC and sustained Src-mediated pro-survival signals . HoweverCullin-7 has recently been shown to physically interact with caspase-8 . CUL7 prMonocyte chemotactic protein-induced protein-1 (MCPIP1), a deubiquitinating enzyme, promoted the lysosomal degradation of DR5 . MCPIP1 Karyopherin β1 (KPNB1) played an instrumental role in the nuclear import of DR5. KPNB1 transported DR5 into the nucleus, while inhibition of KPNB1 restored DR5 levels on the cell surface of glioblastoma cells . These fIt has recently been convincingly revealed that circulating tumor cells (CTCs) demonstrated rapid autophagic flux, characterized by an accumulation of autophagosome organelles . NotablyN-acetyl-l-cysteine, severely compromised TRAIL-mediated apoptosis in RUNX3-overexpressing cancer cells [RUNX3 (RUNT-related transcription factor-3) played a central role in stimulating the expression of DR5 . DR5 waser cells . Superoxer cells . The finFucosylation is a post-translational modification of critical importance that plays a crucial role in improving TRAIL-mediated apoptosis . Stably ITCH, a homologous to the E6AP carboxyl terminus (HECT) domain E3 ligase, is reportedly involved in the negative regulation of c-FLIP . JNK phoNatural products have captivated tremendous attention because of their premium pharmacological properties. There has been a longstanding quest to identify products that can be combined with TRAIL to maximize the apoptosis in TRAIL-resistant cancers. Therefore, in this specific section, we provide an update about products obtained from natural sources which can restore apoptosis in resistant cancer cells. Cannabis plant, induced the upregulation of the protein and cell surface expression of TRAIL-R2/DR5 [Auriculasin, a prenylated isoflavone, was highly effective when used in combination with TRAIL . AuriculL-R2/DR5 . Andrographis paniculata enhanced the expression of DR4 and DR5 mainly through increasing the levels of p53 [Andrographolide isolated from s of p53 . As expes of p53 . Periplocin obtained from Cortex Periplocae led to a dose-dependent enhancement of the expression levels of DR4 and DR5 on the surface of MGC-803 and SGC-7901 cells . PeriploIn combination with TRAIL, the sesquiterpene coumarin galbanic acid, worked effectively against non-small-cell lung cancer cells . GalbaniDiallyl disulfide (DADS) and TRAIL jointly repressed Bcl-2 in colorectal cancer cells . BufalinLithospermum erythrorhizon that was shown to work effectively with TRAIL against A549 cells [Tripterygium wilfordii worked effectively with TRAIL and inhibited autophagic influx in A549 cells [Shikonin is a medicinally important product isolated from the root of 49 cells . Shikoni49 cells . Celastr49 cells . Remarkable advancements have been made in the molecular biology of autophagy, and scientists are focusing on solving questions regarding how this pathway can be harnessed to improve clinical outcomes ,33. In 2Celastrol treatment induced an increase in the levels of LC3II and p62. However, authors did not report the effects induced by combinatorial treatment with celastrol and TRAIL . It was d-glucose potentiated TRAIL-triggered apoptotic cell death, in part through suppressing JNK-mediated cytoprotective autophagic signaling in SGC7901 and MGC803 cells [2-Deoxy-03 cells . Chloroq03 cells .Excitingly, flow cytometry analyses revealed that toosendanin induced a reduction of membrane DR5 . HoweverIt is important to mention that autophagy has a dualistic role in TRAIL-mediated apoptosis. There is also sufficient evidence related to the positive regulation of TRAIL-mediated apoptosis by autophagy. Different natural products have also been shown to potentiate TRAIL-mediated apoptosis through the induction of autophagy. Ginsenosides are biologically active constituents of ginseng, and potentiate TRAIL-mediated apoptosis through the induction of autophagy . JuglaniL and re-sensitized TRAIL-resistant triple-negative breast cancer cells to apoptosis [Ursolic acid stimulated the expression of DR4 and DR5 and simultaneously downregulated c-FLIPpoptosis . Stephania cepharantha, has been shown to be effective against renal carcinoma cells [Cepharanthine, a biscoclaurine alkaloid isolated from ma cells . Cepharama cells . OverallC-27-carboxylated oleanolic acid derivatives have been shown to stimulate the expression of DR5 through CHOP . TreatmePinus koraiensis that was efficient against non-small-cell lung cancer. Lambertianic acid and TRAIL upregulated DR4. Furthermore, lambertianic acid and TRAIL markedly reduced p-NF-κB, p-IκB, and c-FLIP in A549 and H1299 cells [Lambertianic acid is a biologically active product isolated from 99 cells . The cancer genome atlas (TCGA) network groups have comprehensively reported the genomic landscape for over 30 different cancer types . More imIt seems surprising to note that although scientists have uncovered tremendous information about the TRAIL-mediated signaling pathway, we have not sufficiently investigated the natural-product-mediated regulation of the TRAIL-driven pathway. Even though we have seen that natural products triggered the upregulation of death receptors and induced the re-balancing of pro- and anti-apoptotic proteins, we still have unanswered questions and visible knowledge gaps in our understanding related to the realization of products derived from medicinally important natural sources. Different ubiquitin ligases  have been shown to ubiquitinate DR4 at 273rd lysine and induce degradation . CHIP (CAnother important and exciting area of research that needs detailed research is the microRNA regulation of the TRAIL-driven pathway. Rapidly emerging scientific reports have started to shed light on the central role of microRNAs in the modulation of the TRAIL-mediated pathway. Certain pieces of evidence have suggested that maritoclax, isolated from marine bacteria, promoted miR-708-mediated targeting of c-FLIP and restored apoptosis . InteresHowever, we have not yet witnessed considerable experimental work related to the natural-product-mediated regulation of miRNAs to restore apoptosis in TRAIL-resistant cancers. Likewise, different xenografted mice model studies are necessary for an effective evaluation of the potential of natural products in inducing tumor regression.


Aconitum have been widely used medically in many Asian countries since ancient times. These plants have been proven effective for treating several types of cancer, such as lung, stomach, and liver cancers. The main effective components of Aconitum plants are diterpenoid alkaloids—which are divided into C18-, C19-, C20-, and bis-diterpenoid alkaloids—are reportedly some of the most promising, naturally abundant compounds for treating cancer. This review focuses on the progress of diterpenoid alkaloids with different structures derived from Aconitum plants and some of their derivatives with potential anticancer activities. We hope that this work can serve as a reference for further developing Aconitum diterpenoid alkaloids as anticancer agents.Cancer is one of the most common lethal diseases, and natural products have been extensively studied as anticancer agents considering their availability, low toxicity, and economic affordability. Plants belonging to the genus  Cancer is one of the most common lethal diseases, with approximately 14 million new cases of cancer diagnosed and 8 million cancer-related deaths in 2012. This disease affects all populations in all regions according to the World Health Organization , anti-anAconitum belongs to the family Ranunculaceae, which comprises about 400 species distributed in the temperate regions of the northern hemisphere, with half of them distributed in China esters [O-(14-benzoylaconine-8-yl)]-pimelate (47), bis-[O-(14-benzoylaconine-8-yl)]-suberate (48), and bis-[O-(14-benzoylaconine-8-yl)]-azelate (49), built from the 8-O-azeloyl-14-benzoylaconine (11) skeleton, present remarkable cytotoxic activity in vitro against lung cancer A-549, colon cancer HCT-15, and breast cancer MCF-7 cells; their IC50s were <28 µM. The anticancer activities in vivo of bis-[O-(14-benzoylaconine-8-yl)]-suberate (48) was subsequently tested in immunodeficient mice transplanted with human tumors MCF-7 and HCT-15 cells because of its significant cytotoxicity in vitro. Its antitumor activity is obviously shown at a dose below the maximum tolerated dose. The impact of the alkyl-linker length of the designed bis-diterpenoid alkaloids on cytotoxicity is clearly elucidated in the study and can serve as a reference for designing novel antiproliferative agents [Three bis-[)]esters , includie agents .Aconitum plants have shown effective anticancer properties in various cancer cell lines. Such properties include inhibiting cell growth, inducing apoptosis, interfering with the cell cycle, and altering MDR. The in vitro anticancer activities  of diterpenoid alkaloids derived from Aconitum and their derivatives are presented in Diterpenoid alkaloids isolated and designed from Aconitum are C19-diterpenoid alkaloids, although derivatives of C20-diterpenoid alkaloids also have notable anticancer potential. Many diterpenoid alkaloids tend to exhibit improved activity after simple structural modification [Most of natural diterpenoid alkaloids with anticancer effect in fication , and manfication .Aconitum have great potential use as new drugs for treating cancer. This review can serve as a useful reference for researchers in their search for highly effective, low-toxicity diterpenoid alkaloids through structure modification and structure–activity analysis. We also provide a theoretical basis for safety medication in clinical settings and further development of new anticancer drugs.Diterpenoid alkaloids from


Regulation of exo- and endocytosis of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-type glutamate receptor (AMPAR) plays a critical role in the expression of synaptic plasticity such as long-term potentiation (LTP) and long-term depression (LTD) at excitatory central synapses. Enhanced AMPAR exocytosis or endocytosis has been suggested to contribute to LTP or LTD, respectively. However, several unsettled fundamental questions have remained about AMPAR exo- and endocytosis in the basal condition and during synaptic plasticity: (1) Does the size of each exo- or endocytosis event, and/or do the frequencies of these events change during LTP or LTD? If they change, what are the time courses of the respective changes? (2) Where does the exo- or endocytosis preferentially occur in each condition: inside or in the vicinity of postsynaptic membrane, or in the extrasynaptic membrane? (3) Do different types of AMPAR, such as GluA1 homo-tetramer, GluA1/2 hetero-tetramer and GluA2/3 hetero-tetramer, show distinct exo- and endocytosis changes? To address these questions, we developed new methods to observe individual events of AMPAR exo- or endocytosis with a high signal to noise (SN) ratio in a culture preparation using total internal reflection fluorescence microscopy (TIRFM). In these studies, hippocampal neurons were cultured on a neurexin (NRX)-coated glass coverslip, which induced formation of postsynaptic-like membrane (PSLM) directly on the glass surface. Then, a super-ecliptic pHluorin (SEP)-tagged AMPAR subunit such as GluA1 (GluA1-SEP) was expressed in neurons and its fluorescence changes during LTP induced by high frequency electrical field stimulation were observed with TIRFM, which showed different time courses of exocytosis changes of GluA1-, GluA2-, or GluA3-SEP in and around PSLM. In addition, a new method to detect individual endocytosis events of AMPAR was developed by combining TIFRM observation of GluA-SEP around PSLM with a rapid extracellular pH exchange method using a U-tube. Recent results on exo- and endocytosis changes of GluA-SEP during N-methyl-D-aspartate (NMDA)-induced LTD suggested that suppression of AMPAR exocytosis rather than enhancement of AMPAR endocytosis primarily contributes to LTD expression, although the NMDA application transiently enhances clathrin-dependent endocytosis of GluA1-containing AMPAR. Long-term potentiation (LTP) and long-term depression (LTD) at hippocampal glutamatergic synapses have been regarded as basic cellular mechanisms of learning and memory, and intensively studied  directly on the surface of a glass coverslip, and then studied the dynamics of GluA-SEP around PSLM during LTP or LTD expression , Neurexin (NRX), Synaptic cell adhesion molecule (SynCAM), EphrinB, leucine rich repeat transmembrane (LRRTM) and N-Cadherin. Among them presynaptic membrane protein NRX and postsynaptic membrane protein NLG have been studied extensively (Levinson and El-Husseini, NLG expressed in non-neuronal cells co-cultured with neurons induces formation of presynaptic structures in axons, while NRX when similarly expressed induces formation of postsynaptic structures in dendrites (Scheiffele et al., Glass coating with NRX was performed utilizing biotin-avidin interaction and an antibody which was described in detail elsewhere (Tanaka and Hirano, When hippocampal neurons overexpressing NLG 1 with splice insertion at site B were cultured on the NRX-coated coverslip, many punctate structures that contained PSD95, a marker protein of postsynaptic density, but that were not apposed to a presynaptic marker were observed with TIRFM Figure . Such poWe reported that high frequency electrical field stimulation used to induce LTP increases the amount of SEP-tagged GluA subunit of AMPAR in and outside PSLM in a hippocampal culture preparation Figure . The incOne possible factor contributing to the increase in the amount of GluA-SEP on the surface is enhancement of GluA-SEP exocytosis. Individual events of GluA-SEP exocytosis can be observed around PSLM by high frequency live-cell TIRFM imaging Figure . LTP-indChanges in the cell surface amounts and in the exocytosis frequencies of GluA2-SEP or GluA3-SEP also occur during LTP expression (Tanaka and Hirano, Regarding changes of AMPAR exocytosis during LTP expression, some unclear or conflicting observations have been reported about sites of exocytosis, AMPAR subtype specificity and precise time courses. Some previous studies reported different molecular regulation mechanisms between constitutive AMPAR exocytosis and regulated exocytosis during LTP induction (Ahmad et al., NMDA application induces LTD in hippocampal culture preparations, which is accompanied by a decrease in amount of cell-surface AMPAR (Lee et al., This combination method is also useful to precisely determine the amount of cell surface AMPAR, because some SEP fluorescence arises from molecules located in endoplasmic reticulum with relatively neutral luminal pH (Paroutis et al., The LTD-inducing NMDA application transiently increases the size of individual GluA1-SEP endocytic events and also the frequency of GluA1-SEP endocytosis for about 1 min. Interestingly this transiently enhanced large endocytosis is clathrin-dependent, whereas constitutive endocytosis of GluA1-SEP does not depend on clathrin (Fujii et al., Transient enhancement of GluA1-SEP endocytosis seems to be insufficient to explain slowly developing LTD expression. Considering that the cell-surface amounts of molecules are regulated by the balance of endo- and exocytosis, we examined changes of GluA1-SEP exocytosis after the LTD-inducing NMDA application (Fujii et al., 2+ permeable AMPAR lacking GluA2 (Sanderson et al., In addition, the cell-surface amount, and endo- and exocytosis of GluA2-SEP after the NMDA application were examined. We showed that GluA2-SEP exhibits different temporal profiles from those of GluA1-SEP, suggesting differential regulation of GluA2-SEP. However, how each type of AMPAR consisting of GluA1–3, such as GluA1/2 or GluA2/3 hetero-tetramer, changes during LTD has not been reported. Transient and simultaneous enhancement of both exo- and endocytosis of GluA1 after the onset of NMDA application might contribute to substitutions of AMPAR subtypes. GluA2-containing AMPAR might be replaced by CaImportantly, similar changes of GluA1-SEP dynamics during LTD expression were observed in conventional synapses. Using oblique illumination, we studied the exo- and endocytosis changes of GluA1-SEP around conventional synapses in hippocampal neurons cultured on glass that was not coated with NRX (Fujii et al., AMPAR moves around on the plasma membrane by lateral diffusion, and this movement has been studied by live-cell imaging of a fluorescent quantum dot attached to AMPAR (Bats et al., in vivo (Deng and Dunaevsky, High SN ratio images of fluorescent molecules can be obtained around PSLM with TIRFM through the reduction of background signals Figure . ParalleHowever, PSLM is certainly an artificial structure deficient in interaction with presynaptic structures, which could potentially affect some functions of postsynaptic membrane. Thus, certain care should be taken in interpretation of results obtained using PSLM. Nevertheless, PSLM retains essential properties of postsynaptic membrane, as evidenced by the accumulation of postsynaptic proteins such as PSD95 and homer, and dynamic changes of the amount of AMPAR relevant to the expression of LTP and LTD. Furthermore, it was demonstrated that exo- and endocytic changes of GluA1-SEP during LTD at conventional postsynaptic membranes were qualitatively similar to those observed at PSLM as explained above Fujii et al. . Thus, PThere are many different types of synapses. Some are excitatory, and the others are inhibitory. There are also large differences in presynaptic transmitter release probability among synapses, which is likely to affect postsynaptic properties (Konnerth et al., Over-expression of AMPAR-SEP is also artificial manipulation which could affect normal cellular processes. Overexpression of a subunit of AMPAR such as GluA1 inevitably increases its relative amount, potentially affecting normal cellular processes. Indeed, we found that GluA2-SEP behaves somewhat differently depending on whether it is co-expressed with GluA1 (Tanaka and Hirano, Development of new fluorescent proteins such as pH-sensitive red fluorescent proteins will enable us to simultaneously monitor multiple proteins, and will certainly promote the analyses (Shen et al., Another interesting extension of the culture method on the coated-glass surface is application to studies on presynaptic mechanisms. By coating glass surface with postsynaptic adhesion molecule, formation of presynaptic structure has been achieved (Funahashi et al., TH wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although multiple myeloma (MM) has become more treatable in the past decade by application of proteasome inhibitors (PI) and immunomodulatory drugs (IMiDs) , there iMacrophages mediate antibody-dependent cellular phagocytosis (ADCP) and antibody-dependent cell-mediated cytotoxicity (ADCC) but also serve in a MM-supportive role as so-called myeloma-associated macrophages (MAMs) . DespiteInterestingly, vitamin D plays a key role in regulating effector functions of human macrophages , and vitDuring the last years, we have been focusing on the tumoricidal effector functions of macrophages. Although macrophages can, in principle, target neoplastic cells and mediate ADCP, tumor-associated macrophages (TAMs) regularly fail to exert direct cytotoxic functions. The underlying mechanisms responsible for this observation remain unclear. Since vitamin D acts as a key regulator of the human macrophages’ effector functions, as well as the finding that vitamin D deficiency negatively affects treatment of high-grade NHL patients with rituximab containing chemotherapy , we specWe observed that MAMs  exhibit a defective vitamin D metabolism with reduced expression of CYP27B1 . As a coWe and others have previously shown, that vitamin D promotes the macrophages’ tumoricidal potency against lymphomas and improves the efficacy of rituximab-dependent cytotoxicity . In factTaken together, it may be postulated that reconstitution of the vitamin D metabolism in MAMs by lenalidomide and constant vitamin D supplementation of MM patients improves the therapeutic efficacy of anti-CD38 mAbs like MOR202 Figure . Our fin


In the late 1990s, tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL), a member of the TNF-family, started receiving much attention for its potential in cancer therapy, due to its capacity to induce apoptosis selectively in tumour cells in vivo. TRAIL binds to its membrane-bound death receptors TRAIL-R1 (DR4) and TRAIL-R2 (DR5) inducing the formation of a death-inducing signalling complex (DISC) thereby activating the apoptotic cascade. The ability of TRAIL to also induce apoptosis independently of p53 makes TRAIL a promising anticancer agent, especially in p53-mutated tumour entities. Thus, several so-called TRAIL receptor agonists (TRAs) were developed. Unfortunately, clinical testing of these TRAs did not reveal any significant anticancer activity, presumably due to inherent or acquired TRAIL resistance of most primary tumour cells. Since the potential power of TRAIL-based therapies still lies in TRAIL’s explicit cancer cell-selectivity, a desirable approach going forward for TRAIL-based cancer therapy is the identification of substances that sensitise tumour cells for TRAIL-induced apoptosis while sparing normal cells. Numerous of such TRAIL-sensitising strategies have been identified within the last decades. However, many of these approaches have not been verified in animal models, and therefore potential toxicity of these approaches has not been taken into consideration. Here, we critically summarise and discuss the status quo of TRAIL signalling in cancer cells and strategies to force tumour cells into undergoing apoptosis triggered by TRAIL as a cancer therapeutic approach. Moreover, we provide an overview and outlook on innovative and promising future TRAIL-based therapeutic strategies. Pharmacotherapy for cancer uses one or more chemotherapeutic drugs with either a curative aim or to prolong life and manage symptoms. Chemotherapy targets rapidly dividing cells to slow or stop their growth, conversely not distinguishing between transformed and non-transformed cells which leads to the commonly observed strong side effects in most scenarios. The last decade has seen the development and testing of targeted therapies such as small-molecule inhibitors or monoclonal antibodies. The clinical use of a substance with the ability to selectively kill tumour cells while sparing healthy cells thereby reducing severe side effects is urgently needed in pharmacological cancer therapy. This “silver bullet” against cancer seemed close at hand in 1995 when tumor necrosis factor (TNF)-related apoptosis-inducing ligand TRAIL/Apo2L) was introduced L was int,4. AfterTRAIL is a type II transmembrane protein with apoptosis-inducing capabilities, which belongs to the TNF-superfamily (TNF-SF) ,2. In huIn mice, only one death-inducing TRAIL-R is expressed, mTRAIL-R (MK) sharing 43% and 49% sequence homology with human TRAIL-R1 and TRAIL-R2, respectively . The murDespite a research history of more than 20 years, it is still puzzling why humans have evolved to express two death-inducing TRAIL-Rs ,27. In aThe induction of apoptosis can be subdivided into either intrinsic apoptosis, triggered by p53 in response to cellular injuries  or extriL/S), are recruited to TRAIL-Rs via a homotypic interaction between the death domains (DDs) within the receptor and the adapter molecule Fas-associated death domain (FADD) . C. C256]. During the last decade, research into novel anti-cancer drugs has especially revolved around the discovery of specifically-targeted, side effect-reduced approaches. In this context, the discovery of the tumour selectiveness of apoptosis induction by TRAIL in the late 90s was thought to be a breakthrough and research into TRAIL-induced signalling pathways has been intensified. Following favourable preclinical results of tumour cell-selective apoptosis induction, recombinant forms of TRAIL and TRAIL-R-targeting antibodies have been evaluated in clinical trials, though with sobering outcome in most cases. The drawbacks have been outlined above as well as strategies to overcome TRAIL resistance. Novel, highly potent TRAs have been designed. By the use of high-throughput screenings (HTS), the identification and development of these TRAs can become more efficient. Although the TRAs with improved agonistic potential may finally boast the desired antitumor effect in clinical settings, overcoming TRAIL resistance remains a struggle ahead. There is a stable demand for highly-potent and adverse effect-reduced TRAIL sensitisers without losing sight of possible, fulminant adverse effects. For more appropriate pre-clinical testing, humanised and patient-derived preclinical mouse models are warranted. Moreover, predictive biomarkers are urgently needed to identify responding patients or to follow therapy response more precisely. To date, everything suggests that CPT will perform superior to conventional chemotherapy in haematological malignancies. In case that this approach can be validated for other tumour entities, and efficient sensitisers such as SMAC and BH3 mimetics can be clinically validated in combination, targeting this receptor/ligand system might just turn out to be a “TRAILblazer” in cancer therapy.


OBJECTIVES/SPECIFIC AIMS: The goal of this study is to test the hypothesis that the adherens junctions of colon epithelial cells regulate lncRNAs levels and function via the microprocessor and RISC complexes to suppress expression of pro-tumorigenic markers and aberrant cell behavior. METHODS/STUDY POPULATION: To test this hypothesis, we used colon epithelial cancer cell lines. We performed RNA-seq following knockdown of PLEKHA7, a key component of the adherens junctions, to identify changes in lncRNA expression and downstream mRNA levels. We confirmed junctional localization of affected lncRNAs from the RNA-seq and those that we found in our preliminary study by using in situ hybridization (ISH). RESULTS/ANTICIPATED RESULTS: RNA-seq identified junction-associated lncRNAs whose expression levels are regulated by PLEKHA7. The top upregulated lncRNA upon PLEKHA7 depletion was MIR17HG, an oncogenic host transcript of a cluster of miRNAs. These mature miRNAs also co-precipitate with PLEKHA7. PLEKHA7 knockdown results in increased levels of MIR17HG, but only a subset of its hosted miRNAs . Notably, miR-19a and mir-19b are highly upregulated in colon cancer. Our data suggest that 2 PLEKHA7-associated miRNAs, miR-203a and miR-372, mediate suppression MIR17HG. Re-expression of PLEKHA7 in aggressive colon cancer cells that lack PLEKHA7 suppressed expression of MIR17HG, as well as anchorage independent growth of these cells. DISCUSSION/SIGNIFICANCE OF IMPACT: Our data point towards a novel mechanism of lncRNA regulation that tethers epithelial tissue integrity with pro-tumorigenic cell transformation. Reducing elevated MIR17HG levels, is a potential therapeutic approach to suppress the tumorigenic behavior of cells that have lost their junctional integrity and homeostasis. identify a network of miRNA-mRNA-lncRNA interactions that could be exploited for further mechanistic studies, as well as for diagnostic and therapeutic purposes in the future.


Older adults with dementia may manifest symptoms such as apathy, withdrawal, and aggressive actions . Even surrounded by people in LTC, residents with dementia may lack social engagement. Non-pharmacologic approaches are promising  and are reflected in the newer CMS F-tag guidelines , but there remains a gap in research about the most effective approaches for LTC residents. Limited research exists on animal-assisted interventions (AAI) as a non-pharmacological approach to increase engagement in people with dementia  and no known research compares equine- and canine-assisted therapy protocols. This study employed a within-subject alternating-treatments design for three single subjects. Completing the similar tasks of grooming, walking, and interaction, the independent variables are two conditions: 1) Condition A: Equine-assisted activity 2) Condition B: Canine-assisted activity. Using the Dementia Interview Rating , apathy was measured before and after each phase. During each session, three outcomes were measured: 1) Engagement in Preferred Activities Scale  was used to measure the level of engagement in the interaction; 2) Heart rate variability, a measure of coherence, was measured using the Emwave pro , and 3) targeted observed social responsiveness  using a smart tablet application. Preliminary results suggest past experience/preference impact the individual client’s response to differing protocols. Effective non-pharmacological interventions for older adults with dementia are an essential alternative to current practice.