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Item Brain metastases: An update on the multi-disciplinary approach of clinical management(Elsevier, 2021) Mitchell, D. K.; Kwon, H. J.; Kubica, P. A.; Huff, W. X.; O'Regan, R.; Dey, M.; Neurological Surgery, School of MedicineImportance Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. Observations The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. Conclusion With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).Item Dental X-Ray Exposure The Past has become the Future(California Dental Association, 2019) Miles, Dale A.; Yepes, Juan F.; Pediatric Dentistry, School of DentistryMost dental X-ray procedures are delegated to office staff and some recommendations and techniques, such as selection criteria and rectangular collimation for intraoral imaging, have been ignored or forgotten by some dentists. Some of the X-ray exposure recommendations, updated by the American Dental Associtation’s Science Institute in June 2018, and the need to adopt guidelines proposed by the public campaign Image Gently are discussed to help the reader develop safe X-ray protocols, from intraorals to CBCT.Item eIF3a Regulation of NHEJ Repair Protein Synthesis and Cellular Response to Ionizing Radiation(Frontiers, 2020-08-19) Tumia, Rima; Wang, Chao J.; Dong, Tianhan; Ma, Shijie; Beebe, Jenny; Chen, Juan; Dong, Zizheng; Liu, Jing-Yuan; Zhang, Jian-Ting; Pharmacology and Toxicology, School of MedicineTranslation initiation in protein synthesis regulated by eukaryotic initiation factors (eIFs) is a crucial step in controlling gene expression. eIF3a has been shown to regulate protein synthesis and cellular response to treatments by anticancer agents including cisplatin by regulating nucleotide excision repair. In this study, we tested the hypothesis that eIF3a regulates the synthesis of proteins important for the repair of double-strand DNA breaks induced by ionizing radiation (IR). We found that eIF3a upregulation sensitized cellular response to IR while its downregulation caused resistance to IR. eIF3a increases IR-induced DNA damages and decreases non-homologous end joining (NHEJ) activity by suppressing the synthesis of NHEJ repair proteins. Furthermore, analysis of existing patient database shows that eIF3a expression associates with better overall survival of breast, gastric, lung, and ovarian cancer patients. These findings together suggest that eIF3a plays an important role in cellular response to DNA-damaging treatments by regulating the synthesis of DNA repair proteins and, thus, eIIF3a likely contributes to the outcome of cancer patients treated with DNA-damaging strategies including IR.Item Incidence, Survival Analysis and Future Perspective of Primary Peritoneal Mesothelioma (PPM): A Population-Based Study from SEER Database(MDPI, 2022-02) Ullah, Asad; Waheed, Abdul; Khan, Jaffar; Mishra, Ankita; Tareen, Bisma; Nama, Noor; Karki, Nabin Raj; Panezai, Muhammad Saleem; Zarate, Luis Velasquez; White, Joseph; Cason, Frederick D.; Matolo, Nathaniel; Misra, Subhasis; Karim, Nagla Abdel; Pathology and Laboratory Medicine, School of MedicineBackground: Primary peritoneal mesothelioma (PPM) is a rare and aggressive tumor arising from the visceral and parietal peritoneum. The diagnosis and treatment of PPM are often delayed because of non-specific clinical presentation, and the prognosis is worse. The current study investigated the demographic, clinical, and pathological factors affecting patient prognosis and survival in PPM. Methods: Demographic and clinical data of 1998 patients with PPM were extracted from the Surveillance Epidemiology and End Results (SEER) database (1975–2016). The chi-square test, paired t-test, and multivariate analysis were used to analyze the data. Results: The majority of PPM patients were male (56.2%, p < 0.005) and Caucasian (90.4%, p < 0.005, with a mean age of diagnosis was 69 ± 13 years. The grading, histological, and tumor size information were classified as “Unknown” in most of the cases, but when available, poorly differentiated tumors (8.7%), malignant mesothelioma, not otherwise specified (63.4%) and tumors > 4 cm in size (8%), respectively, were most common, p < 0.005. Chemotherapy was administered to 50.6% of patients, followed by resection (29.2%) and radiation (1.5%), p < 0.001. The cohort of PPM had a five-year overall survival of 20.3% (±1.1), compared to 43.5% (±5.9), 25.9% (± 8.4), and 18.7% (±1.6) for those with surgery, radiation, or chemotherapy alone, respectively. Poor differentiation (OR = 4.2, CI = 3.3–4.9), tumor size > 4 cm (OR = 3.9, CI = 3.2–4.5), Caucasian race (OR = 2.9, CI = 2.6–4.4), and distant SEER stage (OR = 2.5, CI = 1.1–3.2) were all linked with increased mortality (p < 0.001). Conclusion: An extremely rare and aggressive peritoneal tumor, PPM may be difficult to identify at the time of diagnosis. Radiation therapy likely to have a limited function in the treatment of this condition, with surgery and chemotherapy being the primary choices. All PPM patients should be enrolled in a nationwide registry to improve our understanding of the pathogenesis and identify factors affecting survival.Item Ionizing Radiation Affects Epigenetic Programming in Adolescent Mice(Office of the Vice Chancellor for Research, 2014-04-11) Watkins, Darryl S.; Mendonca, Marc; Lossie, Amy; Zhou, Feng C.Humans are exposed to low and mild doses of radiation frequently, ranging from the natural environment to medical procedures like x-ray and CT scans. Ionizing radiation of various doses has been known to potentially cause not only cellular but also genomic changes. Here, we demonstrate that epigenetics is also altered by the radiation. Epigenetics is a chemical coding above the gene, which plays critical roles in brain development, cognitive aberrations and other neurological impairments. How radiation, as an external environmental factor, causes epigenetic change is not understood. DNA methylation, key in epigenetics, including 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) have been shown to either suppress or activate gene transcription. To aid in elucidating the role in which radiation affects epigenetic outcomes, we examined the effects of radiation on both epigenetic and phenotypic markers within the hippocampus. In this study we treated, via x-ray C57BL/6 mice, postnatal day (P) 21 with various doses (2Gy-4.5Gy) of radiation coupled with varying frequencies (0.5 Gy x 4, 1.5 Gy x 3, or 4.5Gy x 1) during a 4-week period. We used immunohistochemistry staining with cell proliferation, transcription and epigenetic markers. We found loss of 5mC in the sub-granular layer of the dentate gyrus (DG) in the upper and lower arms. Likewise a loss of 5hmC in the sub-granular layer of the DG, as well as in the cornu Ammonis (CA) layers 1 and 2. There was also loss of a transcriptional activation marker within the DG of the hippocampus. Furthermore, decreased cell proliferation in the adult neurogenesis in the hippocampus was found. Exposure to ionizing radiation altered the normal epigenetic profile of the mice. Understanding the mechanism by which ionizing radiation affects epigenetic programming will provide insight into how to develop protection against the potentially harmful risks associated with radiation exposure.Item Ionizing Radiation Affects Epigenetic Programming in Young Adult Mice(Office of the Vice Chancellor for Research, 2015-04-17) Watkins, Darryl S.; Mendonca, Marc; Lossie, Amy; Zhou, Feng C.Humans are exposed to low and mild doses of radiation frequently, ranging from the natural environment to medical procedures like x-ray and CT scans. Ionizing radiation of various doses has been known to cause not only cellular and genomic changes, but specific neurological systems such as the limbic system have been indicated to be particularly vulnerable. Here, we demonstrated that epigenetics is also altered by radiation. Epigenetics is a subtle chemical coding above the gene, which plays a critical role in brain development, and downstream can cause the onset of cognitive aberrations and other neurological impairments. How radiation as an external environmental factor causes epigenetic changes is not clearly understood. DNA methylation, including 5-methylcytosine (5M) and 5-hydroxymethylcytosine (5-hmC) have been shown to either suppress or activate gene transcription and as such are key epigenetic players. To elucidate the role of radiation in epigenetic outcomes, we examined epigenetic, phenotypic and transcriptional markers via immunohistochemistry, in the hippocampus and cortex. In this study C57BL/6 mouse (postnatal day 21 (P21)) began a 4-week radiation treatment of various doses totaling (2Gy-4.5Gy) via global head targeting CT exposure. We found a loss of 5M and 5-hmC as well as transcriptional markers within regions of the hippocampus and cortex. There was a significant decrease in cell proliferation in the hippocampus- specifically, in the region responsible for adult neurogenesis. The cingulate cortex (a region adjacent to the hippocampus) also exhibited dramatic alterations in several epigenetic and transcriptional markers, indicating the vulnerability of the limbic system in radiation exposure. Understanding the mechanism by which ionizing radiation affects epigenetic programming will provide insight into the transmissibility of external factors to biological systems. Additionally, this work can aid the development of protective strategies against the harmful risks associated with radiation exposure.Item Mitochondria as Target for Tumor Management of Hemangioendothelioma(Liebert, 2020) Gordillo, Gayle M.; Biswas, Ayan; Singh, Kanhaiya; Sen, Abhishek; Guda, Poornachander R.; Miller, Caroline; Pan, Xueliang; Khanna, Savita; Cadenas, Enrique; Sen, Chandan K.; Surgery, School of MedicineAims: Hemangioendothelioma (HE) may be benign or malignant. Mouse hemangioendothelioma endothelial (EOMA) cells are validated to study mechanisms in HE. This work demonstrates that EOMA cells heavily rely on mitochondria to thrive. Thus, a combination therapy, including weak X-ray therapy (XRT, 0.5 Gy) and a standardized natural berry extract (NBE) was tested. This NBE is known to be effective in managing experimental HE and has been awarded with the Food and Drug Administration Investigational New Drug (FDA-IND) number 140318 for clinical studies on infantile hemangioma. Results: NBE treatment alone selectively attenuated basal oxygen consumption rate of EOMA cells. NBE specifically sensitized EOMA, but not murine aortic endothelial cells to XRT-dependent attenuation of mitochondrial respiration and adenosine triphosphate (ATP) production. Combination treatment, selectively and potently, influenced mitochondrial dynamics in EOMA cells such that fission was augmented. This was achieved by lowering of mitochondrial sirtuin 3 (SIRT3) causing increased phosphorylation of AMP-activated protein kinase (AMPK). A key role of SIRT3 in loss of EOMA cell viability caused by the combination therapy was evident when pyrroloquinoline quinone, an inducer of SIRT3, pretreatment rescued these cells. Innovation and Conclusion: Mitochondria-targeting NBE significantly extended survival of HE-affected mice. The beneficial effect of NBE in combination with weak X-ray therapy was, however, far more potent with threefold increase in murine survival. The observation that safe natural products may target tumor cell mitochondria and sharply lower radiation dosage required for tumor management warrants clinical testing.Item Predictors of Nodal and Metastatic Failure in Early Stage Non-Small Cell Lung Cancer after Stereotactic Body Radiation Therapy(Elsevier, 2019) Cerra-Franco, Alberto; Liu, S.; Azar, M.; Shiue, Kevin; Freije, S.; Hinton, J.; Deig, Christopher R.; Edwards, D.; Estabrook, Neil C.; Ellsworth, S. G.; Huang, K.; Diab, K.; Langer, Mark P.; Zellars, Richard; Kong, Feng-Ming; Wan, Jun; Lautenschlaeger, Tim; Radiation Oncology, School of MedicineIntroduction/Background Many early-stage non-small cell lung cancer (ES-NSCLC) patients undergoing stereotactic body radiation therapy (SBRT) develop metastases, which is associated with poor outcomes. We sought to identify factors predictive of metastases after lung SBRT and created a risk stratification tool. Materials and Methods We included 363 patients with ES-NSCLC who received SBRT; median follow-up was 5.8 years. The following patient and tumor factors were retrospectively analyzed for their association with metastases (defined as nodal and/or distant failure): sex; age; lobe involved; centrality; previous NSCLC; smoking status; gross tumor volume (GTV); T-stage; histology; dose; minimum, maximum, and mean GTV dose; and parenchymal lung failure. A metastasis risk-score linear-model using beta coefficients from a multivariate Cox model was built. Results A total of 111/406 (27.3%) lesions metastasized. GTV volume and dose were significantly associated with metastases on univariate and multivariate Cox proportional hazards modeling (p<0.001 and HR=1.02 per mL, p<0.05 and HR=0.99 per Gy, respectively). Histology, T-stage, centrality, lung parenchymal failures, and previous NSCLC were not associated with development of metastasis. A metastasis risk-score model using GTV volume and prescription dose was built: [risk score=(0.01611 x GTV)–(0.00525 x dose (BED10))]. Two risk-score cutoffs separating the cohort into low-, medium-, and high-risk subgroups were examined. The risk-score identified significant differences in time to metastases between low-, medium-, and high-risk patients (p<0.001), with 3-year estimates of 81.1%, 63.8%, and 38%, respectively. Conclusion GTV volume and radiation dose are associated with time to metastasis and may be used to identify patients at higher risk of metastasis after lung SBRT.Item Prostaglandin E₂ promotes recovery of hematopoietic stem and progenitor cells after radiation exposure(2014-07-11) Stilger, Kayla N.; Broxmeyer, Hal E.; Kacena, Melissa A.; Srour, Edward F.; Pelus, LouisThe hematopoietic system is highly proliferative, making hematopoietic stem and progenitor cells (HSPC) sensitive to radiation damage. Total body irradiation and chemotherapy, as well as the risk of radiation accident, create a need for countermeasures that promote recovery of hematopoiesis. Substantive damage to the bone marrow from radiation exposure results in the hematopoietic syndrome of the acute radiation syndrome (HS-ARS), which includes life-threatening neutropenia, lymphocytopenia, thrombocytopenia, and possible death due to infection and/or hemorrhage. Given adequate time to recover, expand, and appropriately differentiate, bone marrow HSPC may overcome HS-ARS and restore homeostasis of the hematopoietic system. Prostaglandin E2 (PGE2) is known to have pleiotropic effects on hematopoiesis, inhibiting apoptosis and promoting self-renewal of hematopoietic stem cells (HSC), while inhibiting hematopoietic progenitor cell (HPC) proliferation. We assessed the radiomitigation potential of modulating PGE2 signaling in a mouse model of HS-ARS. Treatment with the PGE2 analog 16,16 dimethyl PGE2 (dmPGE2) at 24 hours post-irradiation resulted in increased survival of irradiated mice compared to vehicle control, with greater recovery in HPC number and colony-forming potential measured at 30 days post-irradiation. In a sublethal mouse model of irradiation, dmPGE2-treatment at 24 hours post-irradiation is associated with enhanced recovery of HSPC populations compared to vehicle-treated mice. Furthermore, dmPGE2-treatment may also act to promote recovery of the HSC niche through enhancement of osteoblast-supporting megakaryocyte (MK) migration to the endosteal surface of bone. A 2-fold increase in MKs within 40 um of the endosteum of cortical bone was seen at 48 hours post-irradiation in mice treated with dmPGE2 compared to mice treated with vehicle control. Treatment with the non-steroidal anti-inflammatory drug (NSAID) meloxicam abrogated this effect, suggesting an important role for PGE2 signaling in MK migration. In vitro assays support this data, showing that treatment with dmPGE2 increases MK expression of the chemokine receptor CXCR4 and enhances migration to its ligand SDF-1, which is produced by osteoblasts. Our results demonstrate the ability of dmPGE2 to act as an effective radiomitigative agent, promoting recovery of HSPC number and enhancing migration of MKs to the endosteum where they play a valuable role in niche restoration.Item Proton therapy for atypical meningiomas(Springer, 2015-05) McDonald, Mark W.; Plankenhorn, David A.; McMullen, Kevin P.; Henderson, Mark A.; Dropcho, Edward J.; Shah, Mitesh V.; Cohen-Gadol, Aaron A.; Department of Radiation Oncology, IU School of MedicineWe report clinical outcomes of proton therapy in patients with World Health Organization grade 2 (atypical) meningiomas. Between 2005 and 2013, 22 patients with atypical meningiomas were treated to a median dose of 63 Gy (RBE) using proton therapy, as an adjuvant therapy after surgery (n = 12) or for recurrence or progression of residual tumor (n = 10). Six patients had presumed radiation-induced meningiomas, but none had received prior radiotherapy for their meningioma. The median follow-up time after radiation was 39 months (range 7–104) and all patients remain alive at last follow-up. The 5-year estimate of local control was 71.1 % (95 % CI 49.3–92.9 %). The 5-year estimate of local control was 87.5 % following a radiation dose >60 Gy (RBE), compared to 50.0 % for ≤60 Gy (RBE) (p = 0.038). The 5-year estimate of neuraxis dissemination was 5 % (95 % CI 0–14.6 %) and 6.2 % (95 % CI 0–18.2 %) for metastases outside of the central nervous system. Radiation necrosis was observed in one patient with a history of prior cranial irradiation. Fractionated proton therapy was associated with favorable tumor control rates for grade 2 meningiomas. Prospective studies are needed to define the optimal radiation dose for high-grade meningiomas.