BRCA1 and BRCA2: Cancer Risk and Genetic Testing

Key Points  (THIS BEAUTIFUL ARTICLE IS WORK OF THE NIH, PLEASE KNOW THIS!)

• BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors. Mutation of these genes has been linked to hereditary breast and ovarian cancer.
• A woman's risk of developing breast and/or ovarian cancer is greatly increased if she inherits a deleterious (harmful) BRCA1 or BRCA2 mutation. Men with these mutations also have an increased risk of breast cancer. Both men and women who have harmful BRCA1 or BRCA2 mutations may be at increased risk of other cancers.
• Genetic tests are available to check for BRCA1 and BRCA2 mutations. A blood sample is required for these tests, and genetic counseling is recommended before and after the tests.
• If a harmful BRCA1 or BRCA2 mutation is found, several options are available to help a person manage their cancer risk.
• Federal and state laws help ensure the privacy of a person’s genetic information and provide protection against discrimination in health insurance and employment practices.
• Many research studies are being conducted to find newer and better ways of detecting, treating, and preventing cancer in BRCA1 and BRCA2 mutation carriers. Additional studies are focused on improving genetic counseling methods and outcomes. Our knowledge in these areas is evolving rapidly.

1. What are BRCA1 and BRCA2?

   BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors.
   In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth. Mutation of these genes has been linked to the development of hereditary breast and ovarian cancer.
   The names BRCA1 and BRCA2 stand for breast cancer susceptibility gene 1 and breast cancer susceptibility gene 2, respectively.

2. How do BRCA1 and BRCA2 gene mutations affect a person's risk of cancer?

   Not all gene changes, or mutations, are deleterious (harmful). Some mutations may be beneficial, whereas others may have no obvious effect (neutral). Harmful mutations can increase a person’s risk of developing a disease, such as cancer.
   A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2. Such a woman has an increased risk of developing breast and/or ovarian cancer at an early age (before menopause) and often has multiple, close family members who have been diagnosed with these diseases. Harmful BRCA1 mutations may also increase a woman’s risk of developing cervical, uterine, pancreatic, and colon cancer (1, 2). Harmful BRCA2 mutations may additionally increase the risk of pancreatic cancer, stomach cancer, gallbladder and bile duct cancer, and melanoma (3).
   Men with harmful BRCA1 mutations also have an increased risk of breast cancer and, possibly, of pancreatic cancer, testicular cancer, and early-onset prostate cancer. However, male breast cancer, pancreatic cancer, and prostate cancer appear to be more strongly associated with BRCA2 gene mutations (2–4).
   The likelihood that a breast and/or ovarian cancer is associated with a harmful mutation in BRCA1 or BRCA2 is highest in families with a history of multiple cases of breast cancer, cases of both breast and ovarian cancer, one or more family members with two primary cancers (original tumors that develop at different sites in the body), or an Ashkenazi (Central and Eastern European) Jewish background (see Question 6). However, not every woman in such families carries a harmful BRCA1 or BRCA2 mutation, and not every cancer in such families is linked to a harmful mutation in one of these genes. Furthermore, not every woman who has a harmful BRCA1 or BRCA2 mutation will develop breast and/or ovarian cancer.
   According to estimates of lifetime risk, about 12.0 percent of women (120 out of 1,000) in the general population will develop breast cancer sometime during their lives compared with about 60 percent of women (600 out of 1,000) who have inherited a harmful mutation in BRCA1 or BRCA2 (4, 5). In other words, a woman who has inherited a harmful mutation in BRCA1 or BRCA2 is about five times more likely to develop breast cancer than a woman who does not have such a mutation.
   Lifetime risk estimates for ovarian cancer among women in the general population indicate that 1.4 percent (14 out of 1,000) will be diagnosed with ovarian cancer compared with 15 to 40 percent of women (150–400 out of 1,000) who have a harmful BRCA1 or BRCA2 mutation (4, 5).
   It is important to note, however, that most research related to BRCA1 and BRCA2 has been done on large families with many individuals affected by cancer. Estimates of breast and ovarian cancer risk associated with BRCA1 and BRCA2 mutations have been calculated from studies of these families. Because family members share a proportion of their genes and, often, their environment, it is possible that the large number of cancer cases seen in these families may be due in part to other genetic or environmental factors. Therefore, risk estimates that are based on families with many affected members may not accurately reflect the levels of risk for BRCA1 and BRCA2 mutation carriers in the general population. In addition, no data are available from long-term studies of the general population comparing cancer risk in women who have harmful BRCA1 or BRCA2 mutations with women who do not have such mutations. Therefore, the percentages given above are estimates that may change as more data become available.

3. Do inherited mutations in other genes increase the risk of breast and/or ovarian tumors?

   Yes. Mutations in several other genes, including TP53, PTEN, STK11/LKB1, CDH1, CHEK2, ATM, MLH1, and MSH2, have been associated with hereditary breast and/or ovarian tumors (4, 6, 7). However, the majority of hereditary breast cancers can be accounted for by inherited mutations in BRCA1 and BRCA2 (8). Overall, it has been estimated that inherited BRCA1 and BRCA2 mutations account for 5 to 10 percent of breast cancers and 10 to 15 percent of ovarian cancers among white women in the United States (6).

4. Are specific mutations in BRCA1 and BRCA2 more common in certain populations?

   Yes. For example, three specific mutations, two in the BRCA1 gene and one in the BRCA2 gene, are the most common mutations found in these genes in the Ashkenazi Jewish population. In one study, 2.3 percent of participants (120 out of 5,318) carried one of these three mutations (9). This frequency is about five times higher than that found in the general population (10). It is not known whether the increased frequency of these mutations is responsible for the increased risk of breast cancer in Jewish populations compared with non-Jewish populations.
   Other ethnic and geographic populations around the world, such as the Norwegian, Dutch, and Icelandic peoples, also have higher frequencies of specific BRCA1 and BRCA2 mutations.
   In addition, limited data indicate that the frequencies of specific BRCA1 and BRCA2 mutations may vary among individual racial and ethnic groups in the United States, including African Americans, Hispanics, Asian Americans, and non-Hispanic whites (11–13).
   This information about genetic differences between racial and ethnic groups may help health care providers in selecting the most appropriate genetic test(s) (see Question 5).

5. Are genetic tests available to detect BRCA1 and BRCA2 mutations, and how are they performed?

   Yes. Several methods are available to test for BRCA1 and BRCA2 mutations (14). Most of these methods look for changes in BRCA1 and BRCA2 DNA. At least one method looks for changes in the proteins produced by these genes. Frequently, a combination of methods is used.
   A blood sample is needed for these tests. The blood is drawn in a laboratory, doctor's office, hospital, or clinic and then sent to a laboratory that specializes in the tests. It usually takes several weeks or longer to get the test results. Individuals who decide to get tested should check with their health care provider to find out when their test results might be available.
   Genetic counseling is generally recommended before and after a genetic test. This counseling should be performed by a health care professional who is experienced in cancer genetics (see Question 17). Genetic counseling usually involves a risk assessment based on the individual’s personal and family medical history and discussions about the appropriateness of genetic testing, the specific test(s) that might be used and the technical accuracy of the test(s), the medical implications of a positive or a negative test result, the possibility that a test result might not be informative (an ambiguous result) (see below), the psychological risks and benefits of genetic test results, and the risk of passing a mutation to children.

6. How do people know if they should consider genetic testing for BRCA1 and BRCA2 mutations?

   Currently, there are no standard criteria for recommending or referring someone for BRCA1 or BRCA2 mutation testing.
   In a family with a history of breast and/or ovarian cancer, it may be most informative to first test a family member who has breast or ovarian cancer. If that person is found to have a harmful BRCA1 or BRCA2 mutation, then other family members can be tested to see if they also have the mutation.
   Regardless, women who have a relative with a harmful BRCA1 or BRCA2 mutation and women who appear to be at increased risk of breast and/or ovarian cancer because of their family history should consider genetic counseling to learn more about their potential risks and about BRCA1 and BRCA2 genetic tests.
   The likelihood of a harmful mutation in BRCA1 or BRCA2 is increased with certain familial patterns of cancer. These patterns include the following (15):
   
   • For women who are not of Ashkenazi Jewish descent:
     • two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
     • three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
     • a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
     • a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
     • a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
     • a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
     • breast cancer diagnosed in a male relative.
   • For women of Ashkenazi Jewish descent:
     • any first-degree relative diagnosed with breast or ovarian cancer; and
     • two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.
   These family history patterns apply to about 2 percent of adult women in the general population. Women who have none of these family history patterns have a low probability of having a harmful BRCA1 or BRCA2 mutation.

7. How much does BRCA1 and BRCA2 mutation testing cost?

   The cost for BRCA1 and BRCA2 mutation testing usually ranges from several hundred to several thousand dollars. Insurance policies vary with regard to whether or not the cost of testing is covered. People who are considering BRCA1 and BRCA2 mutation testing may want to find out about their insurance company’s policies regarding genetic tests.

8. What does a positive BRCA1 or BRCA2 test result mean?

   A positive test result generally indicates that a person has inherited a known harmful mutation in BRCA1 or BRCA2 and, therefore, has an increased risk of developing certain cancers, as described above. However, a positive test result provides information only about a person’s risk of developing cancer. It cannot tell whether an individual will actually develop cancer or when. Not all women who inherit a harmful BRCA1 or BRCA2 mutation will develop breast or ovarian cancer.
   A positive genetic test result may have important health and social implications for family members, including future generations. Unlike most other medical tests, genetic tests can reveal information not only about the person being tested but also about that person’s relatives. Both men and women who inherit harmful BRCA1 or BRCA2 mutations, whether they develop cancer themselves or not, may pass the mutations on to their sons and daughters. However, not all children of people who have a harmful mutation will inherit the mutation. 

9. What does a negative BRCA1 or BRCA2 test result mean?

   How a negative test result will be interpreted depends on whether or not someone in the tested person’s family is known to carry a harmful BRCA1 or BRCA2 mutation. If someone in the family has a known mutation, testing other family members for the same mutation can provide information about their cancer risk. If a person tests negative for a known mutation in his or her family, it is unlikely that they have an inherited susceptibility to cancer associated with BRCA1 or BRCA2. Such a test result is called a “true negative.” Having a true negative test result does not mean that a person will not develop cancer; it means that the person’s risk of cancer is probably the same as that of people in the general population.
   In cases in which a family has a history of breast and/or ovarian cancer and no known mutation in BRCA1 or BRCA2 has been previously identified, a negative test result is not informative. It is not possible to tell whether an individual has a harmful BRCA1 or BRCA2 mutation that was not detected by testing (a “false negative”) or whether the result is a true negative. In addition, it is possible for people to have a mutation in a gene other than BRCA1 or BRCA2 that increases their cancer risk but is not detectable by the test(s) used.

10. What does an ambiguous BRCA1 or BRCA2 test result mean?

    If genetic testing shows a change in BRCA1 or BRCA2 that has not been previously associated with cancer in other people, the person’s test result may be interpreted as “ambiguous” (uncertain). One study found that 10 percent of women who underwent BRCA1 and BRCA2 mutation testing had this type of ambiguous result (16).
    Because everyone has genetic differences that are not associated with an increased risk of disease, it is sometimes not known whether a specific DNA change affects a person’s risk of developing cancer. As more research is conducted and more people are tested for BRCA1 or BRCA2 changes, scientists will learn more about these changes and cancer risk.

11. What are the options for a person who has a positive test result?

    Several options are available for managing cancer risk in individuals who have a harmful BRCA1 or BRCA2 mutation. However, high-quality data on the effectiveness of these options are limited.
    
    • Surveillance—Surveillance means cancer screening, or a way of detecting the disease early. Screening does not, however, change the risk of developing cancer. The goal is to find cancer early, when it may be most treatable.
      Surveillance methods for breast cancer may include mammography and clinical breast exams. Studies are currently under way to test the effectiveness of other breast cancer screening methods, such as magnetic resonance imaging (MRI), in women with BRCA1 or BRCA2 mutations. With careful surveillance, many breast cancers will be diagnosed early enough to be successfully treated.
      For ovarian cancer, surveillance methods may include transvaginal ultrasound, blood tests for CA–125 antigen, and clinical exams. Surveillance can sometimes find ovarian cancer at an early stage, but it is uncertain whether these methods can help reduce a woman's chance of dying from this disease.
    • Prophylactic Surgery—This type of surgery involves removing as much of the "at-risk" tissue as possible in order to reduce the chance of developing cancer. Bilateral prophylactic mastectomy (removal of healthy breasts) and prophylactic salpingo-oophorectomy (removal of healthy fallopian tubes and ovaries) do not, however, offer a guarantee against developing cancer. Because not all at-risk tissue can be removed by these procedures, some women have developed breast cancer, ovarian cancer, or primary peritoneal carcinomatosis (a type of cancer similar to ovarian cancer) even after prophylactic surgery. In addition, some evidence suggests that the amount of protection salpingo-oophorectomy provides against the development of breast and ovarian cancer may differ between carriers of BRCA1 and BRCA2 mutations (17).
    • Risk Avoidance—Certain behaviors have been associated with breast and ovarian cancer risk in the general population (see Question 16). Research results on the benefits of modifying individual behaviors to reduce the risk of developing cancer among BRCA1 or BRCA2 mutation carriers are limited.
    • Chemoprevention—This approach involves the use of natural or synthetic substances to reduce the risk of developing cancer or to reduce the chance that cancer will come back. For example, the drug tamoxifen has been shown in numerous clinical studies to reduce the risk of developing breast cancer by about 50 percent in women who are at increased risk of this disease and to reduce the recurrence of breast cancer in women undergoing treatment for a previously diagnosed breast tumor. As a result, tamoxifen was approved by the U.S. Food and Drug Administration (FDA) as a breast cancer treatment and to reduce the risk of breast cancer development in premenopausal and postmenopausal women who are at increased risk of this disease. Few studies, however, have evaluated the effectiveness of tamoxifen in women with BRCA1 or BRCA2 mutations. Data from three studies suggest that tamoxifen may be able to help lower the risk of breast cancer in BRCA1 and BRCA2 mutation carriers (18–20). Two of these studies examined the effectiveness of tamoxifen in helping to reduce the development of cancer in the opposite breast of women undergoing treatment for an initial breast cancer (19, 20).
      Another drug, raloxifene, was shown in a large clinical trial sponsored by the National Cancer Institute (NCI) to reduce the risk of developing invasive breast cancer in postmenopausal women at increased risk of this disease by about the same amount as tamoxifen. As a result, raloxifene was approved by the FDA for breast cancer risk reduction in postmenopausal women. Since tamoxifen and raloxifene inhibit the growth of breast cancer cells in similar ways, raloxifene may be able to help reduce breast cancer risk in postmenopausal BRCA1 and BRCA2 mutation carriers. However, this has not been studied directly. 

12. What are some of the benefits of genetic testing for breast and ovarian cancer risk?

    There can be benefits to genetic testing, whether a person receives a positive or a negative result. The potential benefits of a negative result include a sense of relief and the possibility that special preventive checkups, tests, or surgeries may not be needed. A positive test result can bring relief from uncertainty and allow people to make informed decisions about their future, including taking steps to reduce their cancer risk. In addition, many people who have a positive test result may be able to participate in medical research that could, in the long run, help reduce deaths from breast cancer.

13. What are some of the risks of genetic testing for breast and ovarian cancer risk?

    The direct medical risks, or harms, of genetic testing are very small, but test results may have an effect on a person’s emotions, social relationships, finances, and medical choices.
    People who receive a positive test result may feel anxious, depressed, or angry. They may choose to undergo preventive measures, such as prophylactic surgery, that have serious long-term implications and whose effectiveness is uncertain.
    People who receive a negative test result may experience “survivor guilt,” caused by the knowledge that they likely do not have an increased risk of developing a disease that affects one or more loved ones.
    Because genetic testing can reveal information about more than one family member, the emotions caused by test results can create tension within families. Test results can also affect personal choices, such as marriage and childbearing. Issues surrounding the privacy and confidentiality of genetic test results are additional potential risks (see below).

14. What can happen when genetic test results are placed in medical records?

    Clinical test results are normally included in a person’s medical records. Consequently, individuals considering genetic testing must understand that their results might not be kept private.
    Because a person’s genetic information is considered health information, it is covered by the Privacy Rule of the Health Information Portability and Accountability Act (HIPAA) of 1996 (21). The Privacy Rule requires that health care providers and others protect the privacy of health information, sets boundaries on the use and release of health records, and empowers individuals to control certain uses and disclosures of their health-related information. Many states also have laws to protect the privacy and limit the release of genetic and other health information.
    In 2008, the Genetic Information Nondiscrimination Act (GINA) became Federal law (see Question 15). GINA prohibits discrimination based on genetic information in relation to health insurance and employment, but the law does not cover life insurance, disability insurance, and long-term care insurance. When applying for these types of insurance, people may be asked to sign forms that give an insurance company permission to access their medical records. The insurance company may take genetic test results into account when making decisions about coverage.
    Some physicians keep genetic test results out of medical records. However, even if such results are not included in a person’s medical records, information about a person’s genetic profile can sometimes be gathered from that person’s family medical history.

15. What is genetic discrimination, and are there laws to protect people from this type of discrimination?

    Genetic discrimination occurs when people are treated differently by insurance companies or employers because they have a gene mutation that increases their risk of a disease, such as cancer. However, in 2008, GINA was enacted to protect U.S. citizens against discrimination based on their genetic information in relation to health insurance and employment (22, 23). The parts of the law relating to health insurers will take effect between May 2009 and May 2010, and those relating to employers will take effect by November 2009. The law does not cover life insurance, disability insurance, and long-term care insurance. In addition, the law does not cover members of the military.
    Some of the protections under GINA with regard to health insurance include the following:
    
    • Premiums or contributions to a group health plan cannot be increased based on the genetic information of an individual(s) enrolled in the plan.
    • Insurers cannot require an individual or family member to undergo a genetic test before enrollment in a group health plan.
    • Insurers cannot request, require, or purchase genetic information about an individual before the person’s enrollment in a group health plan or in connection with that person’s enrollment in the plan.
    • Health insurers cannot use genetic information as the only basis upon which to claim a pre-existing condition is present and, therefore, to deny coverage.
    Some of the protections under GINA with regard to employment include the following:
    
    • Employers cannot refuse to hire and cannot fire individuals based on their genetic information.
    • Employers cannot discriminate against employees with regard to salary, terms and conditions of employment, privileges, and opportunities for the future because of their genetic information.
    • Employers cannot request, require, or purchase genetic information about an employee except under specific circumstances.
    • Employers cannot disclose an employee's genetic information except under specific circumstances.
    Before GINA was passed, many states enacted laws against genetic discrimination. The amount of protection provided by these laws varies widely from state to state. GINA sets a minimum standard of protection that must be met by all states. It does not weaken the protections provided by any state law.

16. In general, what factors increase or decrease the chance of developing breast cancer and/or ovarian cancer?

    The following factors have been associated with increased or decreased risk of developing breast and/or ovarian cancer in the general population. It is not yet known exactly how these factors influence risk in people with BRCA1 or BRCA2 mutations. In addition, a significant portion of hereditary breast cancers are not associated with BRCA1 or BRCA2 mutations (8).
    
    • Age—The risks of breast and ovarian cancer increase with age. Most breast and ovarian cancers occur in women over the age of 50. Women with harmful BRCA1 or BRCA2 mutations often develop breast or ovarian cancer before age 50.
    • Family History—Women who have a first-degree relative (mother, sister, or daughter) or other close relative with breast and/or ovarian cancer may be at increased risk of developing these cancers. In addition, women with relatives who have had colon cancer may be at increased risk of developing ovarian cancer.
    • Medical History—Women who have already had breast cancer are at increased risk of developing breast cancer again, or of developing ovarian cancer.
    • Hormonal Influences—Estrogen is a hormone that is naturally produced by the body and stimulates the normal growth of breast tissue. It is thought that excess estrogen may contribute to breast cancer risk because of its natural role in stimulating breast cell growth. Women who had their first menstrual period before the age of 12 or experienced menopause after age 55 have a slightly increased risk of breast cancer, as do women who had their first child after age 30. Each of these factors increases the amount of time a woman’s body is exposed to estrogen. Removal of a woman’s ovaries, which are the main source of estrogen production, reduces the risk of breast cancer. Breast-feeding also reduces breast cancer risk and is thought to exert its effects through hormonal mechanisms (24).
    • Birth Control Pills (Oral Contraceptives)—Most studies have shown a slight increase or no change in risk of breast cancer among women taking birth control pills (24). In contrast, numerous studies have shown that taking birth control pills decreases a woman’s risk of developing ovarian cancer (25). This protective benefit appears to increase with the duration of oral contraceptive use and persists up to 25 years after discontinuing use. It also appears that the use of birth control pills lowers the risk of ovarian cancer in women who carry harmful BRCA1 or BRCA2 mutations (26).
    • Hormone Replacement Therapy—Doctors may prescribe hormone replacement therapy (HRT) to reduce the discomfort of certain symptoms of menopause, such as hot flashes. However, the results of the Women’s Health Initiative (WHI), a large clinical study conducted by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health (NIH), showed that HRT with the hormones estrogen and progestin is associated with harmful side effects, including an increased risk of breast cancer and increased risks of heart attack, blood clots, and stroke. The WHI also showed that HRT with estrogen alone was associated with increased risks of blood clots and stroke, but the effect on breast cancer risk was uncertain (27). In addition, the WHI showed an increase in ovarian cancer risk among women who received estrogen and progestin HRT, but this finding was not statistically significant (28). Because of these potential harmful side effects, the FDA has recommended that HRT be used only at the lowest doses for the shortest period of time needed to achieve treatment goals.
      No data have been reported to date regarding the effects of HRT on breast cancer risk among women carrying harmful BRCA1 or BRCA2 mutations, and only limited data are available regarding HRT use and ovarian cancer risk among such women. In one study, HRT use did not appear to affect ovarian cancer risk among women with BRCA1 or BRCA2 mutations (29).
      When considering HRT use, both the potential harms and benefits of this type of treatment should be discussed carefully by a woman and her health care provider.
    • Obesity—Substantial evidence indicates that obesity is associated with an increased risk of breast cancer, especially among postmenopausal women who have not used HRT (24). Evidence also suggests that obesity is associated with increased mortality (death) from ovarian cancer (30).
    • Physical Activity—Numerous studies have examined the relationship between physical activity and breast cancer risk, and most of these studies have shown that physical activity, especially strenuous physical activity, is associated with reduced risk. This decrease in risk appears to be more pronounced in premenopausal women and women with lower-than-normal body weight (24).
    • Alcohol—There is substantial evidence that alcohol consumption is associated with increased breast cancer risk. However, it is uncertain whether reducing alcohol consumption would decrease breast cancer risk (24).
    • Dietary Fat—Although early studies suggested a possible association between a high-fat diet and increased breast cancer risk, more recent studies have been inconclusive. In the WHI, a low-fat diet did not help reduce breast cancer risk (31).

17. Where can people get more information about genetic testing for cancer risk?

    A person who is considering genetic testing should speak with a professional trained in genetics before deciding whether to be tested. These professionals may include doctors, genetic counselors, and other health care workers trained in genetics (such as nurses, psychologists, or social workers). For help finding a health care professional trained in genetics, please visit NCI’s Cancer Genetics Services Directory at http://www.cancer.gov/cancertopics/genetics/directory on the Internet. Alternatively, please contact NCI’s Cancer Information Service (CIS) (see below for contact information). The CIS can provide more information about genetic testing and help in finding a health care professional trained in genetics.

18. What research is currently being done to help individuals with harmful BRCA1 or BRCA2 mutations?

    Research studies are being conducted to find newer and better ways of detecting, treating, and preventing cancer in BRCA1 and BRCA2 mutation carriers. Additional studies are focused on improving genetic counseling methods and outcomes. Our knowledge in these areas is evolving rapidly.
    Information about active clinical trials (research studies with people) for individuals with BRCA1 or BRCA2 mutations is available on NCI’s Web site. The following links will initiate searches of NCI’s clinical trials database and retrieve lists of trials open to individuals with BRCA1 or BRCA2 mutations.
    
    • BRCA1 mutation carriers
    • BRCA2 mutation carriers
    In addition, NCI’s CIS can provide information about clinical trials and help with clinical trial searches (see below for contact information).

Selected References

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21. U.S. Department of Health and Human Services. HIPAA Frequent Questions: About the Privacy Rule FAQs. Retrieved April 20, 2009, from: http://www.hhs.gov/hipaafaq/about/354.html.
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26. Whittemore AS, Balise RR, Pharoah PDP, et al. Oral contraceptive use and ovarian cancer risk among carriers of BRCA1 or BRCA2 mutations. British Journal of Cancer 2004; 91(11):1911–1915.
27. National Heart, Lung, and Blood Institute. Women’s Health Initiative. Retrieved April 20, 2009, from: http://www.nhlbi.nih.gov/whi.
28. Anderson GL, Judd HL, Kaunitz AM, et al. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: The Women's Health Initiative randomized trial. Journal of the American Medical Association 2003; 290(13):1739–1748.
29. Kotsopoulos J, Lubinski J, Neuhausen SL, et al. Hormone replacement therapy and the risk of ovarian cancer in BRCA1 and BRCA2 mutation carriers. Gynecologic Oncology 2006; 100(1):83–88.
30. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. New England Journal of Medicine 2003; 348(17):1625–1638.
31. Prentice RL, Caan B, Chlebowski RT, et al. Low-fat dietary pattern and risk of invasive breast cancer: The Women's Health Initiative Randomized Controlled Dietary Modification Trial. Journal of the American Medical Association 2006; 295(6):629–642.

Related Resources

• Cancer Genetics
• What You Need To Know About™ Breast Cancer
• What You Need To Know About™ Ovarian Cancer

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NEWS from ASCO

*Avastin-Folfoxiri better than Avastin-Folfiri, no news there.  It is just a repeat of things we knew would happen.
*In Colon cancer patients with Wild type KRAS  Panitumumab (Vectibix) associated to 5-FU based combination gave an outcome comparable to results obtained in a different study with Avastin and 5-FU based combination.  2 phase II trials but 2 similar outcomes.   And this in first line and 2nd line.  Can't wait to see a phase III.
*40% Glioblastoma express EGFR
20% have EGFRvIII
with Lapatinip being looked at for treatment, will wait to see.
 

Expression of MTOR can be quantified by the following:

Expression of MTOR can be quantified
by following PIK
Raptor
mLst8
 Deptor
TORC2
SGK
Sin1
PRR5L

By Western Blot, Flowcytometry

Mantle Cell Lymphoma

*In Mantle cell lymphoma, Rituxan-Bendamustine beats R-CHOP
with progression  free survival of 69 months vs 31 months and with better toxicity profile
except for skin erythematous lesion often seen with Bendamustine.

*A new prognosis factor added to Metastatic Colon Cancer, STROMAL PARTICIPATION IN THE HISTOLOGY OF THE CANCER.  STRONG STROMAL PRESENCE OR INFILTRATION IMPLYING INTERCELLULAR EXCHANGE WITH THE STROMAL TISSUE, AND IS OF POORER PROGNOSIS.  THIS HAS BEEN REPORTEDLY VALIDATED.

This is an official CDC HEALTH UPDATE

 

Distributed via the CDC Health Alert Network March 4, 2013, 16:30 ET (4:30 PM ET) CDCHAN-00342

 

Notice to Clinicians: Continued Vigilance Urged for

Fungal Infections among Patients Who Received

Contaminated Steroid Injections

  Summary
CDC continues to receive new reports of fungal infection among patients who were given injections of contaminated methylprednisolone acetate (MPA¹) from the New England Compounding Center (NECC) in Framingham, Mass.   Most of these recent cases have been localized spinal or paraspinal infections (e.g., epidural abscesses) in patients, although new cases of meningitis or arachnoiditis also have been reported. Because many of these new cases are among patients with minimal symptoms, CDC is re-emphasizing the recommendation for clinicians to remain vigilant for fungal infections, especially in patients with mild or even baseline symptoms, and consider evaluation with magnetic resonance imaging (MRI) if clinically warranted. This Health Alert Network (HAN) notice provides the following:

·         Information about the current status of the outbreak;

·         Recommendations for clinical management and follow-up of exposed patients;

·         Information about new revisions to web-based interim clinical guidance (http://www.cdc.gov/hai/outbreaks/clinicians/guidance_cns.html); and

·         Notice of an upcoming CDC conference call to provide clinicians with additional diagnostic and treatment information.

 

Status of Fungal Disease Outbreak
As of March 4, 2013, a total of 720 cases, which includes 48 deaths, have been reported in 20 states. Current information about the outbreak, including case counts and distribution by state, and clinician and patient guidance, is available online at http://www.cdc.gov/hai/outbreaks/meningitis.html.

Fungal meningitis, often with a mild clinical presentation, was the predominant clinical syndrome reported among case-patients during the first several weeks of the outbreak (figure). Over the past several months, there has been a marked decrease in reports of fungal meningitis, but CDC continues to receive reports of localized spinal and paraspinal infections, which include epidural abscess, phlegmon, arachnoiditis, and discitis.  Additionally, some of these newly identified case-patients had initially tested negative for signs of a fungal infection (either by lumbar puncture or MRI) and have subsequently developed fungal infection, indicating a prolonged incubation period.

 

After the recall of NECC steroid medications on September 26, state and local health departments identified almost 14,000 people in 23 states who were potentially exposed to the implicated MPA; of these, an estimated 11,000 individuals received spinal or paraspinal injections. Through active notification by clinics with assistance from states and CDC in early October, nearly all of these exposed persons were contacted at least once and informed of their risk for fungal infection as a result of receiving injections with contaminated medication.

Despite this and subsequent patient outreach efforts, CDC and public health partners remain concerned   about the potential for some exposed patients to have localized fungal infections that have gone unrecognized. These infections may be unrecognized because some patients have not continued to receive close clinical follow-up or because they have not recognized symptoms suggestive of a localized infection, which may be difficult to distinguish from their baseline chronic pain. 

As described in CDC’s HAN update on December 20 (http://emergency.cdc.gov/HAN/han00338.asp), MRI testing was done on 128 patients in Michigan, Tennessee, and North Carolina who had no previous evidence of infection and had new or worsening symptoms at or near the site of their spinal or paraspinal injection. Of these, 67 (52%) had findings suggestive of localized infection.  In addition, of 109 different patients reporting persistent but baseline symptoms at or near the site of their spinal or paraspinal injection, 15 (14%) also had abnormal MRI findings suggestive of infection, and 27 (25%) had non-specific enhancement of soft tissue or other paraspinal structures.  The clinical significance of these findings is unclear; however, there is a theoretical risk that failure to diagnose these infections in a timely fashion could result in poor outcomes for patients (e.g., neurologic compromise, osteomyelitis, or progression to meningitis

Patient and Clinician Recommendations

Early in the outbreak, CDC advised clinicians to closely monitor and evaluate patients who received injections of implicated MPA. Additional guidance was provided in HAN updates issued on November 20 (http://emergency.cdc.gov/HAN/han00335.asp) and December 20 (http://emergency.cdc.gov/HAN/han00338.asp). Because of the possibility that some patients may have unrecognized, localized fungal infections, CDC is re-emphasizing the following recommendations for patients who received a spinal or paraspinal injection with implicated MPA: 

 

Patients

Patients who received an injection in or near their spine from one of the three implicated lots of MPA¹ and who have any symptoms at or near the site of their injection should seek evaluation by their medical provider for the possibility of a localized infection, such as an epidural abscess.  This includes patients who initially received steroid injections for pain and continue to have persistent baseline pain. 

 

Clinicians

As a part of continued monitoring of patients who received an injection with implicated MPA, clinicians should consider re-evaluating patients who received a spinal or paraspinal injection with implicated MPA for signs and symptoms suggestive of infection, including any symptoms at or near the site of their injection.  Because of the prolonged incubation period for these infections, this guidance pertains both to patients who have not been previously evaluated and to those who have already had a prior negative evaluation (e.g., normal cerebrospinal fluid profile, normal findings on MRI) but continue to have complaints:

 

-          In patients with new or worsening symptoms at or near the site of their injection, clinicians should obtain an MRI with contrast of the symptomatic area(s).

-          In patients with persistent but baseline symptoms, clinicians should consider obtaining an MRI with contrast of the symptomatic area(s) because the presentation of spinal or paraspinal infections can be subtle, and may be difficult to distinguish from a patient’s baseline chronic pain.

-          In some cases, radiologic evidence of abscess or phlegmon has become apparent on repeat MRI studies performed subsequent to an initially normal imaging procedure. Clinicians should therefore have a low threshold for repeat MRI studies in patients who continue to have symptoms localizing to the site of injection, even after a normal study. However, the optimal duration between MRI studies is unknown.

-          Clinicians should also consider reviewing MRI results with a neuroradiologist because of potential difficulties in interpreting imaging results for these patients.

 

Revised Clinical Guidance and Clinician Information Call

In response to input from expert consultants on fungal disease and physicians who have been treating patients affected by this outbreak, CDC has revised its Interim Treatment and Diagnostic Guidance for Central Nervous System and Parameningeal Infections Associated with Injection of Contaminated Steroid Products (http://www.cdc.gov/hai/outbreaks/clinicians/guidance_cns.html). The revisions include addition of new information on several topics, including:

 

-          Surgical management of parameningeal disease

-          Duration of antifungal treatment

-          Monitoring clinical status after cessation of antifungal treatment

-          Information on non-first-line medications (e.g., posaconazole or itraconazole)

 

A conference call for clinicians interested in obtaining additional information about the management and treatment of patients with fungal illness associated with this outbreak has been scheduled for March 13 at 5:00 p.m.  The presenter will be Tom Chiller, M.D., medical officer, CDC. Registration and call-in information and other details about the conference call will be available on CDC’s website http://www.cdc.gov/hai/outbreaks/clinicians/index.html.

­___________________________________________________________

¹NECC lots of methylprednisolone acetate (PF) 80mg/ml:

Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012
Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012
Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013

 

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

____________________________________________________________________________________

 

Categories of Health Alert Network messages:

Health Alert         Requires immediate action or attention; highest level of importance

Health Advisory   May not require immediate action; provides important information for a specific incident or situation

Health Update     Unlikely to require immediate action; provides updated information regarding an incident or situation

HAN Info Service                Does not require immediate action; provides general public health information

##This message was distributed to state and local health officers, public information officers, epidemiologists, HAN coordinators, and clinician organizations##

 

SUPPRESSION OF NF-kB IS ONE OF THE DOMINANT EVENT IN ACUTE MYELOID LEUKEMIA,

As we explore the major genes involved in Acute Myeloid leukemia, we quickly realize that the main initiating event is located in the Core binding factors or complex proteins located at the Histone-DNA.  At this level we already uncovered that the nature of molecule interacting and  involved are considerably important, and fundamentally different when you speak about Hematological neoplasm versus solid tumor.
Globally, they appear to be several levels of action:

1.  Nature of components of Histone (H1A, H2A etc..) as cover of DNA. 
2.  Complex involved in Histone remodeling  (H1Ax)
3.  Portion Alpha-subunit of protein complexes attached to the DNA to control its expression, and here we find the RUNX which control Hematologic differentiation
4. Portion of Alpha subunit that actually ensure just clear attachment to DNA so that the Histones do not run in the nuclear  solution.  But be careful in fact most of the time if not always, the place of attachment of histone is not random and varies according to nature of tissue involved.  That is Histones attachment contribute to gene silencing and tissue differentiation.
5. Then there Beta subunits which send tentacles dealing with
    5.1-pure Histone Deacyl transferase activity
    5-2- DNA uncoiling and coiling
    5.3- Interaction with Regulators
    5.4-Interactions with cytoplasmic  signal trasductions (MAPK, FOS/c-JUNK, RAS,PI1K ,VEGF)
    5.5-output back to the cytoplasm to inhibit or activate regulators of signal transduction.  The control of signal transduction pathways is done through enzymes production but through activation of switches (E3, SOS) and through control of Ubiquitination and the MDM2
   5.6- DNA replication controlled through P53, and check-point control molecules.
    5.7-signal to Mitochondria, the Ribosome AND AT C-MYC
  etc. (Transcription factors)
The Centrosome have a DNA attachment portion and an endonucleases portion and some endonucleases find their way to  this area of histone-DNA.

Suffice is to say that in AML, the RUNX is involved to ensure Hematologic differentiation, Many regulators are involved, but suppression of the NF-kB and therefore suppression of the TGF is an significant find!
One now speculate as to why it is so.  AND WITHOUT HESITATION, ONE CONCLUDE THAT IT IS BECAUSE AML DOES NOT NEED TO FORM A MASS!  THE SUPPRESSION OF TGF CAN BE INSUFFICIENT HOWEVER, AND A GRANULOCYTIC SARCOMA IS CREATED BUT THIS IS RARE.

(CLEARLY SOME OF THE CONCEPTS PRESENTED HAVE STILL TO BE FULLY VISITED BY RESEARCHER AND READERS-READ MORE TO ESTABLISH THIS IS SO!)

IT IS INTERESTING TO NOTE THAT WHILE IN THE STRUGGLE IS AT THE RUNX IN AML, IN BLADDER CANCER THE TGF IS IS FULL SWING, DNA REPAIR IS IN FULL SWING, BUT ALSO EVENTS AT THE HISTONE MODULATION AS ALSO IN FULL SWING

Bladder cancer in 2012:
Prevalence 73.5 Thousand patients in the USA
Deaths 14.9 thousands died with this disease.
Only 15% of patients have localized disease
50% of patients who have muscle invasion will eventually progress, Median survival in Metastatic disease is 14 months.
Smoking is an established risk factor for Bladder cancer

When the Bladder Muscle is invaded, Giving 3 cycles of chemotherapy (MVAC) before surgery is standard of care and lead to a 77 months median survival Versus 46 months with surgery alone (SWOG 8710.) . But only 20% of people receive Neoadjuvant Chemotherapy.   Mostly because the disease affect the elderly who's perfomance is judged poor for the chemotherapy, because of renal failure which preclude use of Cisplatin, and related comorbidilties which would make chemotherapy hazardous.

Genes reported in Bladder cancer:

MRE11
RAD50
NBS1
ATM
_______________________________________________-----These 4 genes all involves a close pathway.   Under chemical effect there is breakage of double chains DNA in bladder cells  The DNA Break trigger stimulate ATM by phosphorylation or similar activation, MRE1-RAD50-NBS1 is a complex molecule which must allow repair of the breakage by exposing it through "histone remodeling".  Mutations here will hamper this sequence of Activity.  "Breakage of DNA" and HOP, P53 activation is not far.  This is why intact P53 or wild type marks an early cancer. and Mutation of P53 is more a sign of an advanced Bladder cancer.
-----------------------------------------------------------------------------------------
H2AX-during Histone remodeling H2Ax replace H2A and participate in the triggering of check point arrest and therefore a key point to the Histone complex activity which is to control DNA transcription.
------------------------------------------------------------------------------------------------------
CSS (Calpain family) contain DeK1 and CysPc and other anchors/molecules (Now you are going closer to treating AML)
Resistance to Cisplatin: ERCC1
Bcl-2
Overexpression of HRAS (in early disease)
70% have Mutation in FGFR3
P53 and Rb more advanced disease
P21, and P16 are also bad prognosis predictors.

NMP22 may be identified in the Urine for early detection of superficial bladder cancer

A GOOD READING ABOUT SARCOMA

Volume 2011 (2011), Article ID 483154, 13 pages
doi:10.1155/2011/483154
Review ArticleLiposarcoma: Molecular Genetics and Therapeutics

Rachel Conyers, Sophie Young, and David M. ThomasSarcoma Genomics & Genetics, Peter MacCallum Cancer Centre, 12 St Andrews Place, East Melbourne, VIC 3002,  AustraliaReceived 16 September 2010; Accepted 29 October 2010Academic Editor: Stephen Lessnick Copyright © 2011 Rachel Conyers et al.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Sarcomas are a group of heterogeneous tumours with varying genetic basis. Cytogenetic abnormalities range from distinct genomic rearrangements such as pathognomonic translocation events and common chromosomal amplification or loss, to more complex rearrangements involving multiple chromosomes. The different subtypes of liposarcoma are spread across this spectrum and constitute an interesting tumour type for molecular review. This paper will outline molecular pathogenesis of the three main subtypes of liposarcoma: well-differentiated/dedifferentiated, myxoid/round cell, and pleomorphic liposarcoma. Both the molecular basis and future avenues for therapeutic intervention will be discussed.1. IntroductionAn estimated 13,000 people were diagnosed with soft tissue and bone sarcoma in 2009 in America, of which liposarcomas constitute 20% [1, 2]. Despite their rarity these tumours have substantial morbidity and mortality, depending on histological subtype, tumour location, and volume with retroperitoneal sarcomas having particularly poor prognosis [3–9]. Liposarcomas may be classified morphologically into 3 main subtypes consisting of:  well-differentiated liposarcoma/de-differentiated liposarcoma (WD/DDLPS), myxoid/round cell liposarcoma (MLPS) and pleomorphic liposarcoma (PLPS) [10]. The morphological diversity of liposarcoma reflects the great variation in biological behaviour ranging from tumours with low metastatic potential, that is, WDLPS, to tumours with high propensity to metastasise, that is, the round cell (RC) variant of MLPS or PLPS [11]. In addition to histological characteristics, anatomical location impacts upon prognosis, given that local control is a prime concern for curative intent. Treatment is multimodal with surgical removal and radiotherapy used as cornerstones for local control, along with chemotherapy for systemic disease. Few therapeutic options are available for aggressive local or metastatic disease. Chemotherapy sensitivity varies considerably between subtypes with higher response rates in MLPS compared with WD/DDLPS (48% versus 11%) [12]. MLPS tumours are also highly radiosensitive [13, 14]. Given the small subgroup that is chemo-sensitive, and the overriding lack of chemo-curative disease there are avenues and a need for novel molecular therapies. A recent histological and molecular review of 163 liposarcoma and lipomas at the Netherlands Cancer Institute resulted in 23% of tumours being reclassified based on cytogenetic information. This highlights the importance of molecular classification in these tumours and genetic alterations now considered an integral part of the WHO classification [15]. It is hoped that further insight into the molecular characteristics of liposarcomas will allow for accurate subclassification, whilst providing a platform for molecular therapies to be included in the current treatment approach. This paper will outline the current molecular basis of liposarcoma and potential strategies for therapeutic intervention.2. Well- and De-differentiated LiposarcomaWDLPS represents 40%–45% of all diagnosis of liposarcoma [16]. It is classified as a low-grade neoplasm; it is rarely metastatic and has a low recurrence rate (10%) occurring most often in the retroperitoneum and limbs. The World Health Organization (WHO) classifies WDLPS into three main subtypes: adipocytic, sclerosing, and inflammatory. Adipocytic (lipoma-like) liposarcoma is composed of mature adipocytes, which exhibit variation in cell size and focal nuclear atypia and hyperchromasia [16]. The sclerosing subtype shows scattered distinctive bizarre stromal cells associated with rare multivacuolated lipoblasts set in a fibrillary collagenous background [16]. Finally, the inflammatory subtype shows polyphenotypic lymphoplasmacytic infiltrate, with a B-cell predominance. Less is known about this rare subtype [16–18]. DDLPS represents progression from low grade to high-grade nonlipogenic morphology within a WDLPS. DDLPS is more aggressive and exhibits an increased rapidity of disease in contrast to WDLPS, with a metastatic rate of 10%–20% and overall mortality of 50%–75% [4, 7, 19]. In respect to tumour site, retroperitoneal tumours appear to have a worse prognosis [19]. Histologically, DDLPS consists of a WDPLS with a nonlipogenic component, either high-grade, most often resembling malignant fibrous histiocytoma (MFH), or low-grade resembling fibromatosis or low-grade myxofibrosarcoma. The presence of transition from WDLPS to DDLPS is used to differentiate between DDLPS and these other lesions [4, 7, 11, 19–21].2.1. Molecular GeneticsA characteristic feature of WD/DDLPS is the presence of supernumerary ring and/or giant rod chromosomes [22]. These chromosomes contain amplified segments from the 12q13–15 region that can be identified with fluorescence in situ hybridization (FISH) and comparative genomic hybridization (CGH) [23]. Intensive research has identified several oncogenes residing in this region including MDM2, CDK4, HMGA2, TSPAN31, OS1, OS9, CHOP and GLI1 [11, 23–25]. The most compelling evidence to date demonstrates an oncogenic role in WD/DDLPS for MDM2, CDK4, HMGA2 and TSPAN31. Additional amplification events may also play a role in liposarcoma genesis, for example, c-Jun in the de-differentiation process [26].MDM2 amplification is a key feature of WD/DDLPS and is amplified and overexpressed in a number of other cancers, highlighting its importance in tumorigenesis (as reviewed [27]). MDM2 encodes a negative regulator of the tumour suppressor, p53. MDM2 binds to the transcription activation domain of p53, within an N-terminal hydrophobic pocket [28], blocking p53-dependent transcription [29–33] and recruitment of transcription coactivators [28]. MDM2 also acts as a ubiquitin ligase targeting p53 for proteasomal degradation through both cytoplasmic and nuclear proteasomes [34–36]. MDM2 is involved in its own auto-degradation to prevent MDM2 activity inhibiting p53 during times of cellular stress [37]. Thus MDM2 maintains tight control on cellular p53 levels through multiple mechanisms (see Figure 1) [38, 39]. Therapeutically this is important, as MDM2 inhibitors aim to reactivate p53 and thus allow it to actively induce cell death in response to appropriate stressors [40]. In addition to a functional downstream p53 signalling pathway, MDM2 amplification is a predictor of sensitivity to current MDM2 antagonists [40]. Amplification of MDM2 and mutation of p53 appear to be mutually exclusive events in WDLPS, but have been reported in DDLPS [41, 42]. p53 mutations have been associated with the de-differentiation process from WDLPS to DDLPS [41].  Pilotti et al. reported upon a subgroup of WD/DDLPS tumours. Retroperitoneal WD/DDLPS demonstrate mutual exclusivity between MDM2 amplification and p53 mutation. In non-retroperitoneal DDLPS, p53 mutations occur in the absence of MDM2 amplification suggesting involvement in the de-differentiation process [41].483154.fig.001Figure 1: MDM2 binds to the transcriptional activation domain of p53, blocking transcription. MDM2 functions as a ubiquitin ligase, facilitating proteasomal degradation of p53. MDM2 releases p53 in response to cellular stress and p53 translocates to the nucleus where it acts as a transcription factor to enable growth arrest and apoptosis.MDM2 is the most frequent amplification in WD/DDLPS (close to 100%) however CDK4 is shown to be amplified in over 90% of cases [16, 43, 44]. Given its role in the cell cycle and the frequency of amplification, CDK4 has been well researched in WD/DDLPS. The CDK4 gene encodes a 33-kD protein that forms complexes with the cyclin D family, to enable G1-S transition [45]. These CDK4/Cyclin D complexes phosphorylate pRb (encoded by RB1), with resultant activation of E2F target genes including E-type cyclins (see Figure 2) [46–48]. It has been suggested that CDK4 provides a selection advantage in WD/DDLPS and may contribute to transformation as CDK4 negative WDLPS exhibit more favorable prognostic features [46]. Coamplification of MDM2 and CDK4 is a common feature of WD/DDLPS and may result in proliferation through combined effects upon p53 and the cell cycle [49, 50]. Interestingly, the rearrangements of chromosome 12 on the giant rod chromosome are discontinuous and MDM2 and CDK4 may belong to different amplicons [51, 52]. Several studies [43, 53, 54] have suggested that immunohistochemical staining for both CDK4 and MDM2 may provide a useful diagnostic marker, although FISH and quantitative polymerase chain reaction (qPCR) are more effective. Although MDM2 and CDK4 are useful markers to aid in diagnosis, overexpression of these markers is not unique to WD/DDLPS [43, 54]. Further, the amplification and over-expression of CDK4 and MDM2 does not distinguish WDLPS from DDLPS [16, 23, 41]. 483154.fig.002Figure 2: Cyclin dependent kinase CDK4 binds with cyclin D to form active complexes. This results in phosphorylation of Rb and dissociates pRb from the pRb-E2F complex. E2F binds DNA to upregulate transcription of genes required to progress to S phase.HMGA2 is similarly located on 12q and frequently amplified in WD/DDLPS. This is a member of the high-mobility group of proteins [55, 56]. Previously referred to as HMGIC, it encodes an architectural transcription factor capable of remodeling DNA [57–59]. A direct role for HMGA2 in cellular transformation is demonstrated by NIH3T3 neoplastic transformation with the overexpression of HMGA2 [60]. In human sarcomas during chromosomal rearrangement, HMGA2 is fused to distant sequences, commonly occurring on other chromosomes and loses its 3′ translated end that also contains sites for Let-7 microRNAS [57]. Further support for HMGA2 involvement in adipogenic neoplasm development includes the xenograft model by Arlotta et al. [55] that showed mice expressing C-terminal truncated HMGA2 developed lipomas. Interestingly HMGA2 is frequently coamplified with MDM2 in human malignant tumours [57, 61], particularly WDLPS and DDLPS [52]. This raises the possibility that HMGA2 and MDM2 have a cooperating role in WD/DDLPS. Also included within the chromosome 12 q13–15 region is the transmembrane superfamily gene, sarcoma amplified sequence (SAS or TSPAN31) gene [62, 63]. TSPAN31 was originally identified and cloned from an amplified sequence in a malignant fibrous histiocytoma [63]. It has been identified in other subtypes of sarcoma, particularly de-differentiated liposarcoma [64, 65], although its precise role in the de-differentiation process is not well delineated. Forus et al. [66] showed TSPAN31 was as frequently amplified as MDM2 in 98 sarcomas. Both TSPAN31 and MDM2 were amplified in 8 of 11 liposarcoma samples, with MDM2 amplified alone in one additional tumour. WDLPS and DDLPS have shown co-amplification of 1q21-q22 and/or 12q21-q22 [11, 16, 23], along with amplification of chromosome 1(1q21-q23). Chromosome 1 amplified sequences include COAS1, COAS2 and COAS3 [67]. Nilsson et al. showed co-amplification of both COAS and MDM2 in 12/18 lipomatous tumours [68].  The biological function of the COAS genes remains a subject for study.Recent studies into the WDLPS de-differentiation process have suggested a role for the c-Jun N-terminal kinase (JNK) pathway. Co-amplification of 1p32 and 6q23, that contain c-Jun, and Apoptosis Signaling Kinase 1 (ASK1), are seen in DDLPS but not WDLPS [69]. The proto-oncogene c-Jun encodes part of the activator protein transcription factor (AP-1) complex involved in cell proliferation, transformation and apoptosis [70]. ASK1 activates JNK [71, 72] ultimately leading to c-Jun activation and PPARγ inactivation. PPARγ is involved in the adipocytic differentiation process and its inhibition may result in de-differentiation. A further role for c-Jun in the de-differentiation process is demonstrated by overexpression in a 3T3-L1 adipocytic tumour xenograft model. Transfection of c-Jun into 3T3-L1 cells in vitro delays adipocytic differentiation [26].3. Myxoid LiposarcomaMLPS is the second most common subtype of liposarcoma and accounts for more than one third of liposarcomas and 10% of all adult soft tissue sarcomas. MLPS is characterized by the presence of spindle or ovoid cells set in a myxoid stroma with signet ring lipoblasts and a distinctive chicken-wire pattern vasculature. The presence of areas with greater cellularity, known as round cell (RC) de-differentiation, is associated with a worse prognosis [73]. Unusual sites of metastasis are common in MLPS with a propensity to metastasize to soft tissue and bone rather than lung [74, 75]. Thirty-one percent of MLPS patients develop metastasis with bone metastases constituting 56% of these [74]. MLPS exhibits inferior survival compared to other low-grade sarcoma subtypes with a 5-year disease survival rate of 85% [76, 77]. MLPS without RC is particularly radiosensitive with good local control rates with patients treated with adjuvant or neoadjuvant radiotherapy approaching 98% 5-year local control [13, 78].3.1. Molecular GeneticsMLPS is characterised by the recurrent translocation t(12;16)(q13;p11) that results in the FUS-CHOP gene fusion that is present in over 95% of cases [79, 80]. In most cases, the amino terminal domain of FUS (also known as TLS) is fused to C/EBP homologous protein (CHOP, also known as DDIT3 or GADD153). In rare cases, an alternative translocation event is found t(12;22)(q13;q12) that results in formation of the novel fusion oncogene where EWS takes the place of FUS [81, 82]. There is strong evidence for these translocations to be the primary oncogenic event in MLPS as these tumours have a relatively normal karyotype, the exception being a few recurrent cases of trisomy 8 [83]. In addition, several growth factor pathways have been implicated in MLPS pathogenesis [84–86].There are currently 11 different FUS-CHOP chimeras and 4 different known EWS-CHOP fusion genes. In the most common variants, a portion of the amino terminus of FUS is fused to the entire coding region of CHOP. The FUS-CHOP transcript type does not appear to have a significant impact upon clinical outcome, and RC content, necrosis and p53 expression remain stronger predictors of clinical outcome [79, 87]. There is evidence that the fusion transcript type may influence response to therapy although the studies are hindered by sample size [88–90]. Understanding how the FUS-CHOP fusion causes MLPS and uncovering any further molecular abnormalities in the disease will aid in development of novel targeted therapies.FUS belongs to the FET family of RNA-binding proteins that consists of FUS, EWS, and TAF15 as well as the closely homologous, Drosophila SARFH (Cab) [80, 91, 92]. These structurally and functionally related RNA-binding proteins are composed of an SYGQ-rich amino terminus, an RNA recognition motif, a zinc finger motif, and at least one RGG rich repeat region [93, 94]. FET proteins are expressed in most human tissues and appear to be regulated following differentiation in neuroblastoma cells and spontaneously differentiating human embryonic stem cells [95].Both FUS and EWS have been shown to localize to the nucleus and the cytoplasm, bind RNA, and are also involved in nucleo-cytoplasmic shuttling [96–98].  The FET family associate with various complexes involved in the induction of transcription, including RNA polymerase II (RNAPII), which regulates transcription and TFIID complexes, that binds DNA as part of the transcriptional machinery [91], implicating both FUS and EWS in transcriptional control. In addition, FUS has recently been shown to repress transcription of RNA polymerase III (RNAPIII), suggesting a broader role in regulation through multiple different mechanisms [99]. Noncoding RNAs are capable of allosterically modifying FUS in response to DNA damage to inhibit the transcription factor CREB-binding protein (CBP) and p300 histone acetyltransferase activity, resulting in transcriptional inhibition at the cyclin D1 promoter in cell lines and shows a further role for FUS in transcriptional control [100].  FUS has also been implicated in the DNA damage response as a downstream target of ATM, which can detect and coordinate DNA repair [101].CHOP is induced in response to endoplasmic reticular stress and is involved in mediating cell death in response to such stress stimuli [102]. CHOP also plays a role in regulating differentiation in adipocytes by interfering with the process in response to metabolic stress [103]. Adipocytic differentiation is dependent on the coordinated expression of a group of transcription factors, the CCAAT/enhancer-binding protein (C/EBP) family of proteins [104]. The C/EBP family consists of six members from C/EBPα to ζ, and they require dimerisation to bind DNA and can form homodimers or heterodimers. CHOP is capable of binding to the C/EBP family members through their highly conserved leucine zipper domain and inhibiting their function. The leucine zipper dimerization domain and the adjacent basic region in CHOP are required for NIH-3T3 transformation with FUS-CHOP, highlighting the requirement for functional DNA binding and dimerization for FUS-CHOP induced oncogenesis [105]. As C/EBPα and C/EBPβ play an important role in the adipogenic differentiation and are regulated by CHOP, it is possible FUS-CHOP may interfere in cellular differentiation. In support, various studies suggest that FUS-CHOP functions by inhibiting adipogenesis and maintaining immature adipocytes in a continuous cycle of proliferation without differentiation [106–108]. Introduction of FUS-CHOP into mice, where expression of the transgene is driven by the ubiquitously expressed elongation factor 1α (EF1α) promoter, results specifically in liposarcomas with inherent induction of adipocyte specific genes such as PPARγ [109].  Further evidence of adipogenic differentiation block resulting from FUS-CHOP expression was shown in vitro where mice expressing FUS-CHOP under the control of the aP2 promoter, which is a downstream target of PPARγ expressed in immature adipocytes, failed to develop liposarcomas, indicating interference between PPARγ and aP2 activation [107].An emerging clinically relevant targetable pathway in MLPS involves the receptor tyrosine kinases (RTKs) MET, RET, and the PI3K signaling cascade (see Figure 3).  RET is overexpressed in MLPS compared to normal fat [84] and high expression has been correlated with poor metastasis free survival in MLPS [108].  RET, IGF1R and IGF2 are highly expressed in MLPS and promote cell survival through both the PI3K/Akt and Ras-Raf-ERK/MAPK pathways [85, 86]. A panel of tyrosine kinases including PDGFRB, EGFR, MET, RET, and VEGFR2 are activated in both treated (with chemotherapy/radiotherapy or Trabectedin) and untreated cases of human MLPS [110]. In addition to activation of MET in clinical MLPS specimens, MET and the ligand HGF are potentially regulated by FUS-CHOP. Both MET and HGF are highly expressed in mesenchymal progenitor cells transfected with FUS-CHOP in a disease mimicking allograft mouse model [111]. In a small clinical cohort, specific Akt phosphorylation was observed in the RC variant and 2 treated cases that harboured PTEN mutations, implicating RTK pathways signaling through Akt in MLPS [110].  FLT1 (that encodes the VEGFR1 protein) is expressed as an indirect downstream effect of FUS-CHOP expression in both FUS-CHOP transfected HT1080 (fibrosarcoma) and MLPS cell lines however, VEGFR tyrosine kinase inhibitors did not have a notable impact on proliferation in MLPS cell lines indicating a separate role in these cells [112, 113]. 483154.fig.003Figure 3: The PI3K pathway is highly active in MLPS, and this is potentiated at least in part by overexpression, and/or activation through RTKs such as MET, RET and VEGFRs. Upon ligand binding, RTKs activate downstream activation of genes involved in multiple cell processes such as cell survival, proliferation, and angiogenesis. These signals are mediated through the PI3K/Akt pathway and also through RAS. PIK3CA and PTEN mutations and Akt activation have also been documented in MLPS.Akt activation, particularly in the RC variant, suggests a role for phosphoinositide 3-kinases (PI3K) [110]. PI3Ks are activated upon phosphorylation of membrane bound receptor tyrosine kinases. PI3K can activate many proteins including the protein serine-threonine kinase Akt, which when phosphorylated causes downstream activation and ultimately cell growth, cell cycle entry, and subsequently survival. The PI3K holoenzyme complex is composed of both a catalytic and regulatory subunit. The catalytic subunit, PIK3CA, encodes the p110α isoform and is commonly mutated in various cancer types including breast, colon, brain and gastric malignancies [114, 115]. A recent study showed 18% of MLPS patients (
   
       
           

       
   
) had PIK3CA mutations in either the helical (E542K and E545K) or kinase (H1047L and H1047R) domain. The presence of a PIK3CA mutation was associated with a shortened disease specific survival [116]. Barretina et al. also showed one tumour with a homozygous PTEN mutation. PTEN is a tumour suppressor that dephosphorylates phosphoinositide substrates to negatively regulate the Akt signaling pathway [117], demonstrating more mechanisms for perturbation of the pathway.4. Pleomorphic LiposarcomaPLPS accounts for only 5% of liposarcomas and occurs mainly within the 55–65 year-old group [8, 118, 119]. PLPS mortality is 40% with no current clinical or pathological predictors of outcome [8, 120]. Histologically PLPS are similar to MFH with the addition of lipoblasts. Histology reveals a disorderly growth pattern, extreme cellularity, and cellular pleomorphism including bizarre giant cells [121]. Lesional cells are polygonal with pale eosinophilic cytoplasm and poorly demarcated boundaries. These lesional cells are interspersed with giant lipoblasts containing enlarged hyperchromatic, angular or globular nuclei [121, 122].4.1. Molecular GeneticsMolecular studies of PLPS are limited by the scarcity of this disease. Tumours tend to show complex arrangements including gains: 1p, 1q21-q32,2q, 3p, 3q, 5p12-p15, 5q, 6p21, 7p, 7q22 (see reviews) [118, 123, 124]. reported literature shows losses i of 1q, 2q, 3p, 4q, 10q, 11q, 12p13, 13q14, 13q21-qter, 13q23-24, (see reviews) [123–125], Taylor et al. described that 60% of PLPS have a deletion of 13q14.2-q14.3, a region that includes the tumour suppressor RB1 [123]. Also amplified in PLPS, the mitotic arrest deficient (MAD2) may also play a critical role [126, 127]. As reported by Singer et al. [126], MAD2 was found to be over-expressed 13 fold in comparison to normal fat, although small sample size (
   
       
           

       
   
) must be appreciated. As reported by Taylor et al. [123] additional deletions in PLPS include 17p13 and 17q11.2, where p53 and the sarcoma associated tumour suppressor gene, neurofibromatosis type 1 (NF-1) are located. Consistent with these observations, Barretina et al. [116] showed 16.7% of PLPS cases had mutations identified in p53, which are rarely seen in MLPS and WD/DDLPS.5. Therapeutic Implications in LiposarcomaThe current modalities available  (chemotherapy, surgery and radiotherapy) for the treatment of liposarcoma are limited, creating a need to identify novel therapeutics.5.1. MDM2 AntagonistsGiven MDM2 is consistently amplified in WD/DDLPS, and sensitivity to MDM2 antagonists (such as Nutlin-3a) is predicted by MDM2 amplification and an intact wild-type p53, it is an appealing therapeutic target [40]. First generation MDM2 inhibitors work via blocking the p53/MDM2 interaction. Nutlin-3a was heralded as one of the most promising MDM2 antagonists when it was shown to activate wild type p53 and induce cell cycle arrest and apoptosis in cancer cell lines [40]. These cell lines included osteosarcoma with amplified MDM2 [40, 128]. Nutlins require wild-type p53 and a functional downstream p53 pathway to be effective [128]. Müller et al. [40]  showed downstream p53 dependent transcription and apoptosis in liposarcoma cell lines treated with Nutlin-3a [40]. Translation from in vitro to attractive in vivo therapeutic intervention requires that drugs pass Phase I requirements. Shangary et al. [129] designed spiro-oxindoles as a new class of inhibitors of the MDM2-p53 complex.  Spiro-oxindoles bind to MDM2 with high affinity and activates the p53 pathway, inhibiting the growth of neoplastic cell lines with wild-type p53 [129, 130]. MI-219, the lead compound in this class, demonstrates greater potency along with a superior pharmacokinetic profile than Nutlin-3a [129, 131]. MI-219 has been shown to stimulate rapid p53 activation in tumour xenograft tissues with resultant inhibition of cell proliferation [131]. Studies using both Nutlin-3a and MI-219 show a p53 and p21 dependent cell cycle arrest in normal cells, along with p53 dependent cell death specifically in tumour cells [128, 129, 131, 132]. The ability of Nutlin-3a to induce apoptosis in tumours is variable, and osteosarcoma cell lines lacking MDM2 amplification are resistant to apoptosis [131]. Importantly, Nutlin-3a and MI-219 do not cause visible toxicity to animals, as assessed at necropsy [128, 129, 133]. Two oral MDM2 inhibitors have recently entered the clinical setting [134], JNJ-26854165 (Ortho Biotech; Johnson & Johnson) [135] and R7112 (Hoffmann-La Roche) [136]. Both agents are available in advanced stage or refractory solid tumours Phase I trials [134]. In addition, AT-219 (a derivative of MI-219) is in preclinical studies with phase I trials planned [134]. Of relevant interest, an MDM2 antagonist RO5045337 is about to recruit for a Phase I trial in liposarcoma patients [137].5.2. CDK4 AntagonistsTargeting CDK4 is an attractive therapeutic strategy given its frequent overexpression in WD/DDLPS [138]. A number of CDK4 inhibitors are in the early pre-clinical development or Phase I and II trials [139]. First generation pan-CDK inhibitors include Flavopiridol and Seleciclib (R-Roscovitine), inhibiting CDK1, CDK2, CDK4, CDK6, CDK7, and CDK1, CDK2, CDK7 and CDK9 respectively [140].  Flavopiridol causes arrest in G1 and G2 phases in a range of solid tumour cell lines [139, 141, 142]. Flavopiridol is more potent if tumour cells are in S phase. Matranga and Shapiro [143] demonstrated recruitment to S phase using hydroxyurea, gemcitabine and cisplatin, followed by flavopiridol resulting in sequence-dependent cytotoxic synergy [143–145]. Flavopiridol and Seliciclib have been investigated in Phase I/II trials for haematological and solid tumours including sarcomas. Trials include Flavopiridol as a single agent and in combination with taxanes where synergism has been noted [141]. Both Flavopiridol and Seleciclib have shown disappointing results relating to clinical outcome and intolerable side effects [146, 147]. Newer generation CDK inhibitors include PD0332991, P27600, ZK 304709, R 547 and P1446A05.  All are available in Phase I and II solid tumour trials [146]. PD0332991 is one of two more selective CDK inhibitors specific for CDK4 and CDK6. Preclinical data showed inhibition of cell growth through G1 arrest in pRb-positive tumour cell lines and antitumorigenic effects in xenograft models of colon carcinoma [148]. PD0332991 is available in Phase I and Phase II trials for solid and haematological malignancy. Finally, P1446A05 is the only single CDK4 selective inhibitor available [146]. No pre-clinical data is publicly available for this compound; however, it has been released as a Phase I drug for refractory solid tumour and haematological malignancies [146].5.3. PPARγ Ligand AgonistsA critical regulator of terminal differentiation for the adipocytic lineage is a nuclear receptor peroxisome proliferator-activated receptor γ [149–151]. PPARγ is an attractive target in undifferentiated lipomatous tumours such as DDLPS and MLPS.  PPARγ forms a heterodimeric complex with the retinoid X receptor (RXR).  This complex regulates transcription of adipocyte-specific genes by binding sites on DNA. Agonist ligands for the PPARγ receptor have been shown to induce terminal differentiation of normal preadipocytes in human liposarcoma cells in vitro [149].    A Dana-Farber Cancer Institute Phase II clinical trial used Troglitazone, a synthetic PPARγ ligand, in patients with high-grade liposarcoma. This trial enrolled three patients. All patients showed histologic and biochemical differentiation in vivo, with reduction in immunohistochemical expression of proliferation marker Ki-67 [149]. A more recent study with 12 patients with Rosiglitazone, belonging to the same class of drugs (thiazolidinediones) as Troglitazone, was not as promising, with median progression free survival of 5.5 months. Treatment did not produce any convincing adipocytic differentiation with no correlation between the high expression of differentiation genes that was found in two patients, and clinical response [152].5.4. Trabectedin (ET-743)Trabectedin (also known as Ecteinascidin or ET-743) is an antitumor drug isolated from the Caribbean marine tunicate, Ecteinascidia turbinata [153]. Trabectedin is an approved second-line agent for advanced soft tissue sarcoma and has been shown to be exquisitely sensitive to Trabectedin in Phase II clinical trials [154, 155]. The drug is a tetrahydroisoquinoline alkaloid whose main mechanism of action is through binding to the DNA minor groove with promoter and sequence specificity; however, it has also been shown to have effects on promoters that are regulated by major groove binding transcription factors [156–158]. Trabectedin does not appear to effect transcription of FUS-CHOP, but has been shown to dissociate the aberrant transcription factor from promoters of its target genes resulting in removal of the differentiation block by activating a differentiation cascade through the C/EBPs [88]. Trabectedin relies on intact nucleotide excision repair (NER) machinery and induces lethal DNA strand breaks in a transcription-couple NER dependant manner [159–161]. It has been suggested that these breaks are repaired by homologous recombination (HR), as HR-deficient cells, such as BRCA2 mutants, are 100 fold more sensitive to Trabectedin [162]. This effect is specific to HR- mediated double strand break repair as defects in the alternative pathway using nonhomologous end joining do not result in the same degree of Trabectedin sensitivity [161, 162]. FUS-CHOP modulates immune genes by activating NF-κB controlled cytokines IL-6 and IL-8 in a C/EBPβ- dependent manner [163, 164]. Proinflammatory cytokines and growth factors such as CCL2, CXCL8, IL-6, VEGF and PTX3 are highly expressed in both xenograft MLPS models and patient tumours. Trabectedin has been shown to reduce expression and production of these immune modulators, potentially altering the tumour microenvironment in a favorable way [165].  Thus, Trabectedin appears to affect the biological activity of FUS-CHOP and so far shows promise as a therapeutic in MLPS.5.5. Receptor Tyrosine Kinase Pathway InhibitorsThe high frequency of PIK3CA and PTEN mutations suggests a role for PI3K inhibitors in MLPS. The nonisoform-specific PI3K inhibitors Wortmannin, and LY294002 have been widely used in biological research but are not particularly suited to clinical work due to their lack of specificity, Wortmannin’s instability and LY294002’s low potency (as reviewed [166]). GDC-0941 and PX-866 are promising PI3K inhibitors currently in clinical trials that have low nanomolar potency against class I isoforms of PI3K [167–169]. In lung cancer cell lines and xenograft models, PIK3CA mutants are more sensitive to GDC-0941 [170]. Similarly, PIK3CA mutant and PTEN-null tumours were sensitive to PX-866 in xenograft models, and phase I clinical trials for solid tumours are currently underway [169]. The Rapamycin derivate Everolimus inhibits the mTOR complex-1 (mTORC1), which is a downstream effector of PI3K. Both H1047R and E545K PI3K mutant cells are sensitive to Everolimus [171]. PIK3CA mutated MLPS represents an ideal candidate for PI3K inhibition.As MET is activated in MLPS and there are many MET pathway inhibitors currently in development and in clinical trials (as reviewed in [172], MLPS may be a good candidate for MET inhibition. For example, the novel and promising inhibitor Foretinib (XL880) inhibits multiple kinases including both MET and VEGFR2 and exhibits extensive biological activity and clinical efficacy in an early Phase I clinical trial in metastatic or unresectable solid tumours [173].6. ConclusionMolecular-based therapeutics are not routinely used in liposarcoma, where surgery, radiotherapy, and chemotherapy remain the mainstay of treatment. Translation of targeted molecular therapeutics in sarcoma has been successfully demonstrated with Imatinib mesylate therapy in c-Kit positive gastrointestinal stromal tumour (GIST) [174]. A major challenge with the use of molecularly targeted therapeutics is to translate disease control into disease eradication. One strategy to achieve this goal is to combine two or more independent molecularly targeted agents in a disease where all of the targets are relevant. The dependence of  WD/DDLPS on amplification of both MDM2 and CDK4 means that this disease represents an important candidate for combination therapy. Recent studies point towards RTK involvement in MLPS oncogenesis, particularly signaling through the PI3K/Akt pathway. This provides an important avenue for new research due to the large number of clinical trials currently underway that target this pathway. Although not considered a molecularly targeted therapeutic, treatment of MLPS with Trabectedin is currently in late stage clinical trials with promising results. It is hoped that emerging technologies, such as next-generation sequencing, will be fundamental in revealing new molecular targets in liposarcoma. Similarly, advances in drug development should enable improvement of molecular therapies with greater sensitivity, specificity, potency, and limited toxicity. Combining technologies in both areas will allow for efficient clinical translation.Conflicts of InterestNo potential conflict of interest is disclosed.AcknowledgmentsThe authors acknowledge Dr. Maya Kansara and Dale Garsed for reviewing the manuscript and Dr. Catherine Mitchell for reviewing the histopathology. D. M. Thomas is a recipient of a Victorian Cancer Agency clinician scientist fellowship. S. Young is a recipient of an Australian Postgraduate Award. R. Conyers is a recipient of an NHMRC Postgraduate Scholarship. R. Conyers and S. Young contributed equally to this work.A GOOD READING ABOUT SARCOMA

Molecules and Cancer Cells

Now that we know that the cell does not discriminate about what is the category of this molecule invading me as classified by humans, we are ready to suggest some unconventional combinations of chemotherapy drugs:
Nexavar-Metformin for hepatocarcinoma
anti-MEK- calcium channel blocker for K-ras expressing lung cancer
Antibiotic with impact on splicing molecule with the MTOR
(to be continued)

The AML discussion continues!

AML-1 mostly corresponds to the alpha subunit of the CBF and contains the RUNX-1 which specializes in hematologic differentiation of the cell, the other portion already contains among other things regulatory or catalytic molecules facilitating many processes of the cell combination with EVI-1 will control signal pathways and growth factors.
This type of AML, or AML in general, appears to be a disease mostly driven by dysregulation of promoters and regulator genes with global suppression of the NK-kB a nd the cyclins/TGF. 
?role of ANDROGEN, interferon and growth factor in EVI-1 positive AML can be raised as a question.  On top of standard induction chemotherapy of course!  This is where Cyclosporine and Antithymocyte Globulin could still have a role (in EVI-1 AML)

One may wonder why TGF is suppressed?  Maybe to stop the cancerous process to form a mass and stay "fluid"?   That is, in granulocytic sarcoma, TGF would be less suppressed?

*Screening for Cervical cancer through PAP smear is now for women after the age of 21 years old and should be every 3 years for women between 21 and 30 years of age.

*Screening for Cervical cancer through PAP smear is now for women after the age of 21 years old
and should be every 3 years for women between 21 and 30 years of age.
*Like other screening, the rates have been decreasing.  Also cost and over-treatment had been of concern and led to revision of the guidelines.  No comments were made about HPV immunization.
*FDA warning about new batches of counterfeit Bevacizumab put out under the label ALTUZAM 400mg/16
BATCH #B6022B01 expiring sometime this year!
* Mycobacterium Tuberculosis can hide from host immune defense in the Bone Marrow!
*successful Hearing restoration performed in Mice bearing USH1C gene mutation!
(JAMA)

Smooth Muscle Myosin & Leukemia

1.SMMHC, a Smooth Muscle Myosin related marker of differentiation, but also implying the use of multiple regulatory genes that ultimately depress P53 as a way to decrease repair of DNA and allow leukemia to proceed with proliferation. this marker is  seen in Inv-16 Leukemia.  Through interaction with SMAD3, it affects TGF driven migration of leukemic cells.  It also interfere with ACTA 2, TGFBR-2 AND FBN-1,
THIS SUGGEST THAT BLOCKING MIGRATION AND IMMUNE BETA-2 RECEPTOR OF TGF COULD ADD TO ACUTE EOSINOPHILIC LEUKEMIA.  BLOCKING NUCLEAR INTERNALIZATION OF THE BETA SUBUNIT OF THE CBF WOULD HELP IN THE CBF DRIVEN LEUKEMIA IN GENERAL.


2.HOXD3
" Mutations in this particular gene cause synpolydactyly and Brachydactyly. The product of the mouse Hoxd13 gene plays a role in axial skeleton development ...
remember the role of Anti-VEGF /MEK in people with gene that impairs morphogenesis.  leukemia with this mutation could a get a trial!

3 MEIS, a cofactor to the "soul of AML" E3
remember we discussed the AML is characterized by suppression of NF-kB
that suppression is achieved by this MEIS over-expression.  it is the over expression to 
HOS protein which is
 'The homologue of Slimb (HOS) F-box protein is a receptor of the Skp1-Cullin1-F-box protein (SCF(HOS)) E3 ubiquitin ligase, which mediates ubiquitination and degradation of beta-catenin and the inhibitor of NFkappaB, IkappaB.''

Stability of homologue of Slimb F-box protein is regulated by availability of its substrate.

Li Y, Gazdoiu S, Pan ZQ, Fuchs SY.

 You block this stuff, you release NF-kB, you slow down leukemia or at least decrease co-existing infection rates (role in transplant patients).

INCREASING NEED OF A TISSUE BANK IN EL PASO.

With the increased need for cancer genetic studies, there is an increasing need of a Tissue bank in El Paso.
This town is at the border with Mexico has somewhat of an homogeneous population of a minority population which is most of the time under-represented in most clinical trials.  Here, 80% of the population is Hispanic, therefore increasing the chance to have a nice homogenous cohort for clinical trials in a minority population.  We have completed a study on risk factors for Breast cancer as perceived by the local population.  Full Analysis is awaiting funding.  Data is still sitting in the office while we are busy seeing and helping patients to survive.  A recent Collaboration with the UTEP (University of Texas in El Paso) statistics laboratory will relaunch this and maybe we will then be able to publish the full study.
Risk perception here is very much influenced by the local culture and practices centered on "family" and "religion".
The UTEP Border Biomedical Research Center has a clean cell line maintained, but they want to do more.  But we are here in a low income city and easily ignored.  President Obama stopped by last year and the city voted for him, but nothing else has happened much since.  CPRIT gave 0.2% of its cancer research funding to the 4th largest City in Texas, EL PASO, a city of 800,000 people! That is all we get: a glance from Authorities!  El Paso is largely ignored.  El Paso Women had to organize a sit-out in protest in front of the White House last year.  They were basically ignored and dismissed with political promises that have never materialized.

We need a Tissue bank here in El Paso, everybody knows it, but brushes it off!

The city is home to Fort Bliss, undoubtedly the largest military base receiving most likely the largest portion of returning soldiers.  But the medical facilities here are rather modest, fraught with financial issues and a hesitant medical leadership!  Even the needed new Beaumont Hospital construction is tied up in court with contractors fighting over the opportunities instead of being built!

We need a tissue bank, if you know any one who can help....! call 915-307-3354

Random News: MELATONIN and NIH GrantsInfo

RANDOM NEWS

*Melatonin which helps with sleep at 3mg, was tested at 20 mg to see if it could help to stop or delay cachexia.  It was not different then placebo.  Case closed. IT FAILED!

*IT IS ESTIMATED THAT 12000 DEATHS COULD BE PREVENTED WITH AN INSTITUTION OF AN AGGRESSIVE LUNG CANCER SCREENING IN THOSE WITH HISTORY OF 1 PACK/DAY FOR 30 YEARS OF MORE!

*We have shown that in the united states more than 3000 African women could be saved yearly if the Breast cancer paradox (low incidence, but high mortality) was corrected by the institution of a comprehensive prevention program.  Well, things are getting worse as recent studies continue to show a decrease of screening in world of corruption and politics.  At CPRIT, they want Commercialization.  The NIH is heavily political.  Just look at a recent submission response:

Thank you for your e-mail to GrantsInfo at the National Institutes of Health (NIH).  We provide general information about NIH extramural medical and behavioral research, research training programs, and the grant application process.

I suggest you discuss potential funding of your project with the appropriate Scientific/Research staff linked in the announcement’s Section VII:  http://grants.nih.gov/grants/guide/pa-files/PA-11-260.html#_Section_VII._Agency

Regards from GrantsInfo
Web:   http://www.nih.gov

Linking you to NIH Funding

This is an automatic reply when you submit a project
no referral to some review board
they will keep you going here and there
leading nowhere because they have their political friends to award money to. another example, not here go somewhere else!

Dear Dr. Kankonde,

In the table shown below, you will find all currently active NIH funding opportunities related to support of tissue, specimen, and biospecimen banks.  It does not appear that there is any specific funding opportunity that will work for your purposes.  You can search further in the NIH Guide for Grants and Contracts by going to http://grants1.nih.gov/grants/guide/search_guide.htm.  You might also try to connect and collaborate with scientists and pathologists who have mutual interests to find out if your proposed tissue bank might be supported through affiliation with a large research program (e.g., medical center, cancer center, program project, clinical trials network/consortium, special program of research excellence, epidemiology/population cohort, etc.)

Good luck with your efforts.

Comment: and it goes on and on, you get nowhere and after many attempts, you just give up (but at the CRBCM, we do never give up!)

It is a rough world, and they claim to help, but indeed they try to discourage any pursuit of new research and prevention with good old political tactics!

HYPOTHESIS FOR TARGET THERAPY IN AML

Leukemic cells do not like Mesenchymal transformation, therefore MEK amplification is an absolute must in treatment.
2.  The primary dysfunction in AML is Histone Deacetylation
but Histone deacetyl transferase inhibitors will work in some cases because of the variety of deacetylation or heterogeneity of molecules involved
3.  Amplification of the NF-kB signal transduction may help some patient
4. Growth factors and Androgen  may help some patients
5. Insulin may help some subset of patients
6. we predict that MTOR inhibition will have a very limited effect (except in those with specific gene discussed yesterday)
7. Velcade will not work in patients with NACA-1

so combination of the future
chemoth and MEK amplification agents
Histone Deacetylase inhibitors and MEK amplifiers
Histone Deacetylator Androgen and MEK amplifiers
MTOR-ANDROGEN-MEK amplifier
androgen will be added to pt with TIF2

IN AML FLT3 IS NOT PREDICTIVE OF RESPONSE TO THERAPY, IT HAS ONLY PROGNOSIS VALUE.

Remember we explained that in good prognosis AML, those that involve Core Binding Factor (CBF), the disruption in this molecule appears to involve disruption of histone deacethylation primarily which an activity of the Beta subunit of the CBF and we showed that the NF-kB was suppressed.  There is an associated  significant depression of cyclins and TNF, TGF which are important for CD135 (FLT 3) receptor entrance into the cell for signal transduction flow to occur. when the FLOW of this pathway is going fine, the receptor decrease at the membrane.  But under lack of TGF, the membrane FLT3 receptor transfer into the cell or its use is decreased causing Mis-location (a well known cellular dysfunction phenomena). Too many FLT-3 lead of course to dimerization and polymerization forming "Tandem" or repeats of FLT-3.
Now FLT3 suppression by growth factor is part of the normal differentiation of cell, or aging of Hematopoietic cells.   Overexpression of the FLT3 as a result confers to the cell dediffentiation and stem cell like characteristics.
The answer of course is now to increase TGF which may not work because Nuclear substrates are already compromised in most cases.  Increase Mesenchymal transformation through MEK is the only option which secondarily will increase VEGF.  Regorafenib provide here the best alternative even though the Sutent have shown activity.  Anti-MEK is the only significant intervention in AML.
Now don't get yourself cocky.  Remember the primary event is Nuclear, so anti-MEK alone cannot solve the issue and could only be for elderly. Give Anti-MEK with the standard Induction regimen and barace yourself for a new panel of side effects.

Another option histone Deacetyl transferase inhibitor and anti-MEK, this may be the chemoth free option!
anti-MEK and Arsenic Trioxide in APL!
Target therapy is here, let's use it!

TIF 2: TRANSCRIPTION INTERMEDIATE FACTOR 2
-------------------------------------------------------------A nuclear protein complex containing a Histone deacethyl transferase and a receptor to steroids which attachs Glucocorticoid, Estrogen (BRCA-1)and facilitate DNA transcription.
Also known as Nuclear Receptor Coactivator2 NCOA-2
Overexpression of TIF or mutaion here may have an impact on one of the subunit of Cytochrome-C,
It is a ligand (other ligand SRC-1, AIB-1).  It may help in tolerance of certain stressful milieu!
Is TIF 2 a biomarker for steroid response?
does TIF2 Mutation compromise effectiveness of ATRA in APL?
what the role or interaction with NACA-1?
how does PIF2 intervene in aging of cells?
what is the role of Androgen in AML expressing TIF-2?