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Traumatic brain injury (TBI) leads to delayed secondary injury events consisting of cellular and molecular cascades that exacerbate the initial injury. Human umbilical cord perivascular cells (HUCPVCs) secrete neurotrophic and prosurvival factors. In this study, we examined the effects of HUCPVC in sympathetic axon and cortical axon survival models and sought to determine whether HUCPVC provide axonal survival cues. We then examined the effects of the HUCPVC in an in vivo fluid percussion injury model of TBI. Our data indicate that HUCPVCs express neurotrophic and neural survival factors. They also express and secrete relevant growth and survival proteins when cultured alone, or in the presence of injured axons. Coculture experiments indicate that HUCPVCs interact preferentially with axons when cocultured with sympathetic neurons and reduce axonal degeneration. Nerve growth factor withdrawal in axonal compartments resulted in 66 ± 3% axon degeneration, whereas HUCPVC coculture rescued axon degeneration to 35 ± 3%. Inhibition of Akt (LY294002) resulted in a significant increase in degeneration compared with HUCPVC cocultures (48 ± 7% degeneration). Under normoxic conditions, control cultures showed 39 ± 5% degeneration. Oxygen glucose deprivation (OGD) resulted in 58 ± 3% degeneration and OGD HUCPVC cocultures reduced degeneration to 34 ± 5% (

Natural killer (NK) cells are essential for early protection against virus infection and must metabolically adapt to the energy demands of activation. Here, we found upregulation of the metabolic adaptor hypoxia-inducible factor-1α (HIF1α) is a feature of mouse NK cells during murine cytomegalovirus (MCMV) infection in vivo. HIF1α-deficient NK cells failed to control viral load, causing increased morbidity. No defects were found in effector functions of HIF1αKO NK cells; however, their numbers were significantly reduced. Loss of HIF1α did not affect NK cell proliferation during in vivo infection and in vitro cytokine stimulation. Instead, we found that HIF1α-deficient NK cells showed increased expression of the pro-apoptotic protein Bim and glucose metabolism was impaired during cytokine stimulation in vitro. Similarly, during MCMV infection HIF1α-deficient NK cells upregulated Bim and had increased caspase activity. Thus, NK cells require HIF1α-dependent metabolic functions to repress Bim expression and sustain cell numbers for an optimal virus response.

Lauron et al. demonstrate that viral MHCI inhibition within infected cells reduces local antigen-driven generation of resident memory CD8+ T cells. Additionally, resident memory CD8+ T cells are insufficient in controlling peripheral infection in the context of viral MHCI evasion., Tissue-resident memory CD8+ T cells (TRMs) confer rapid protection and immunity against viral infections. Many viruses have evolved mechanisms to inhibit MHCI presentation in order to evade CD8+ T cells, suggesting that these mechanisms may also apply to TRM-mediated protection. However, the effects of viral MHCI inhibition on the function and generation of TRMs is unclear. Herein, we demonstrate that viral MHCI inhibition reduces the abundance of CD4+ and CD8+ TRMs, but its effects on the local microenvironment compensate to promote antigen-specific CD8+ TRM formation. Unexpectedly, local cognate antigen enhances CD8+ TRM development even in the context of viral MHCI inhibition and CD8+ T cell evasion, strongly suggesting a role for in situ cross-presentation in local antigen-driven TRM differentiation. However, local cognate antigen is not required for CD8+ TRM maintenance. We also show that viral MHCI inhibition efficiently evades CD8+ TRM effector functions. These findings indicate that viral evasion of MHCI antigen presentation has consequences on the development and response of antiviral TRMs., Graphical Abstract

Vascular dysfunction arising from blood-brain barrier (BBB) breakdown after traumatic brain injury (TBI) can adversely affect neuronal health and behavioral outcome. Pericytes and endothelial cells of the neurovascular unit (NVU) function collectively to maintain strict regulation of the BBB through tight junctions. Secondary injury mechanisms, such as pro-angiogenic signals that contribute to pericyte loss, can prolong and exacerbate primary vascular injury. Human umbilical cord perivascular cells (HUCPVCs) are a source of mesenchymal stromal cells (MSCs) that have been shown to reduce vascular dysfunction after neurotrauma. We hypothesized that the perivascular properties of HUCPVCs can reduce vascular dysfunction after modeled TBI by preserving the pericyte-endothelial interactions. Rats were subjected to a moderate fluid percussion injury (FPI) and intravenously infused with 1,500,000 HUCPVCs post-injury. At acute time points (24 h and 48 h) quantitative polymerase chain reaction (qPCR) analysis demonstrated that the gene expression of angiopoietin-2 was increased with FPI and reduced with HUCPVCs. Immunofluorescent assessment of RECA-1 (endothelial cells) and platelet-derived growth factor receptors (PDGFR-β) (pericytes) revealed that capillary and pericyte densities as well as the co-localization of the two cells were decreased with FPI and preserved with HUCPVC administration. These acute HUCPVC-mediated protective effects were associated with less permeability to Evan's blue dye and increased expression of the tight junction occludin, suggesting less vascular leakage. Further, at 4 weeks post-injury, HUCPVC administration was associated with reduced anxiety and decreased β-amyloid precursor protein (β-APP) accumulation. In summary, HUCPVCs promoted pericyte-endothelial barrier function that was associated with improved long-term outcome.

Natural killer (NK) cells are essential for early protection against virus infection, and must metabolically adapt to the energy demands of activation. Here, we found upregulation of the metabolic adaptor hypoxia inducible factor-1α (HIF-1α) is a feature of NK cells during murine cytomegalovirus (MCMV) infection in vivo. HIF-1α-deficient NK cells failed to control viral load, causing increased morbidity. No defects were found in effector functions of HIF-1α KO NK cells however, their numbers were significantly reduced. Loss of HIF-1α did not affect NK cell proliferation during in vivo infection and in vitro cytokine stimulation. Instead, we found HIF1α-deficient NK cells showed increased expression of the pro-apoptotic protein Bim and glucose metabolism was impaired during cytokine stimulation in vitro. Similarly, during MCMV infection HIF1α-deficient NK cells upregulated Bim and had increased caspase activity. Thus, NK cells require HIF-1α-dependent metabolic functions to repress Bim expression and sustain cell numbers for an optimal virus response.

Overcoming drug resistance remains a key challenge to cure patients with acute and chronic B cell malignancies. Here, we describe a stromal cell–autonomous signaling pathway, which contributes to drug resistance of malignant B cells. We show that protein kinase C (PKC)–β–dependent signals from bone marrow–derived stromal cells markedly decrease the efficacy of cytotoxic therapies. Conversely, small-molecule PKC-β inhibitors antagonize prosurvival signals from stromal cells and sensitize tumor cells to targeted and nontargeted chemotherapy, resulting in enhanced cytotoxicity and prolonged survival in vivo. Mechanistically, stromal PKC-β controls the expression of adhesion and matrix proteins, required for activation of phosphoinositide 3-kinases (PI3Ks) and the extracellular signal–regulated kinase (ERK)–mediated stabilization of B cell lymphoma–extra large (BCL-X L ) in tumor cells. Central to the stroma-mediated drug resistance is the PKC-β–dependent activation of transcription factor EB, regulating lysosome biogenesis and plasma membrane integrity. Stroma-directed therapies, enabled by direct inhibition of PKC-β, enhance the effectiveness of many antileukemic therapies.

Innate lymphoid cells (ILCs) were originally classified based on their cytokine profiles, placing natural killer (NK) cells and ILC1s together, but recent studies support their separation into different lineages at steady-state. However, tumors may induce NK cell conversion into ILC1-like cells that are limited to the tumor microenvironment and whether this conversion occurs beyond this environment remains unknown. Here, we describe Toxoplasma gondii infection converts NK cells into ILC1-like cells that are distinct from both steady-state NK cells and ILC1s in uninfected mice. These cells were Eomes-dependent, indicating that NK cells can give rise to Eomes– Tbet-dependent ILC1-like cells that circulate widely and persist independent of ongoing infection. Moreover, these changes appear permanent, as supported by epigenetic analyses. Thus, these studies markedly expand current concepts of NK cells, ILCs, and their potential conversion.

Innate lymphoid cells (ILCs) were originally classified based on their cytokine profiles, placing natural killer (NK) cells and ILC1s together, but recent studies support their separation into different lineages at steady-state. However, tumors may induce NK cell conversion into ILC1-like cells that are limited to the tumor microenvironment and whether this conversion occurs beyond this environment remains unknown. Here we describeToxoplasma gondiiinfection converts NK cells into cells resembling steady-state ILC1s that are heterogeneous and distinct from both steady-state NK cells and ILC1s in uninfected mice. Most toxoplasma-induced ILC1s were Eomes-dependent, indicating that NK cells can give rise to Eomes−Tbet-dependent ILC1-like cells that circulate widely and persist independent of ongoing infection. Moreover, these changes appear permanent, as supported by epigenetic analyses. Thus, these studies markedly expand current concepts of NK cells, ILCs, and their potential conversion.

Supplemental Digital Content is available in the text., Background: Although efforts to improve access to care for patients with cleft lip in the developing world have grown tremendously, there is a dearth of data regarding aesthetic outcomes after cleft lip repairs in this setting. Defining severity-outcome relationships has the potential to improve efficiency of care delivery in resource-limited settings, and to improve overall results. In this study, we investigate the relationship between initial cleft lip severity and early aesthetic outcomes following surgical repair of primary unilateral cleft lip. Methods: Using previously validated tools to assess unilateral cleft lip severity and aesthetic outcome after repair, we evaluated 1,823 consecutive patients who underwent primary unilateral cleft lip/nose (UCL/N) repair. Three separate evaluators scored each case for a total of 5,469 total independent evaluations. Results: Our results show that with increasing severity of UCL/N deformity, there is a corresponding decrease in early aesthetic outcome scores. Using our results, we established normative early aesthetic outcomes following repair for each severity grade of UCL/N deformity. Conclusions: In conclusion, this study has achieved a standardized, timely, and cost-effective evaluation of 1,823 surgical cases of primary UCL/N repair. This data set provides a normal distribution of aesthetic results according to initial cleft severity and defines a standard of “expected” aesthetic results after primary UCL/N repair. Our results also show a clear correlation between initial severity and immediate aesthetic result after surgery, though we also show that excellent results are possible regardless of initial cleft severity.

Chronic wounds colonized with biofilm present a major burden to our healthcare system. While the current paradigm for wound healing is to maintain a moist environment, we sought to evaluate the effects of desiccation, and the ability of honey to desiccate wounds, on wound healing characteristics in Staphylococcus aureus biofilm wounds. In vivo biofilm wound healing after exposure to open-air desiccation, honey, molasses, and saline was analyzed using a rabbit ear model of S. aureus biofilm wounds previously developed by our group. Wound morphology was examined using scanning electron microscopy and granulation tissue deposition was measured using light microscopy with hematoxylin and eosin staining. Viable bacterial counts in rabbit ear biofilm wounds and scabs were measured using a drop dilution method. In vitro S. aureus growth curves were established using tryptic soy broth containing honey and glycerol. Gene expression analysis of rabbit ear wounds was performed using reverse transcription quantitative PCR. Rabbit ear S. aureus biofilm wounds exposed to open-air desiccation, honey, and molasses developed a dry scab, which displaced the majority of biofilm bacteria off of the wound bed. Wounds treated with open-air desiccation, honey, and molasses expressed lower levels of the inflammatory markers tumor necrosis factor-α and interleukin-1β at postoperative day 12 compared with wounds treated with saline, and had increased levels of granulation tissue formation. In vitro growth of S. aureus in tryptic soy broth was inhibited by the presence of honey to a greater extent than by the presence of osmolality-matched glycerol. Desiccation of chronic wounds colonized with biofilm via exposure to open air or honey leads to improved wound healing by decreasing bacterial burden and inflammation, and increasing granulation tissue formation. The ability of honey to help heal chronic wounds is at least in part due to its ability to desiccate bacterial biofilm, but other factors clearly contribute.

Novel targeted therapies have substantially improved the prognosis of patients with B cell malignancies. However, a substantial fraction of patients still relapse, even after initially achieving deep remissions. Many studies have characterized the interactions between tumor cells and their microenvironment as integral to leukemia/ lymphoma homeostasis and for the provision of survival signals, also contributing to drug resistance (referred to as environment-mediated drug resistance (EMDR)). Therapeutic efforts to antagonize microenvironment-emanating survival cues have predominantly focused on perturbation of tumour cell adhesion enabling the physical displacement from protective niches (e.g. BCR-inhibitors). In an effort to address whether direct stromal targeting could more precisely mitigate EMDR, we recently characterised the molecular mechanisms underlying tumor-stroma interactions in B cell malignancies and identified a protein kinase C-β (PKC-β) as an essential kinase, required for activation of NF-κB in mesenchymal stromal cells (Lutzny et al Cancer Cell 2013). The dependency on stroma PKC-β was uniformly found for acute (ALL) and chronic (CLL, MCL) B cell malignancies. Importantly, our data further demonstrate that targeting stroma PKC-β is of key importance for multi-drug resistance of malignant B cells and can be used for therapeutic interventions (Park et al Science Trans Med 2020). Here we demonstrate novel mechanistic insights into stroma-mediated drug resistance in B cell malignancies. We identified that stroma PKC-β drives a transcriptional program in tumor cells, dependent on the activation of TGF-β and BMP-signaling, which ultimately leads to the stabilisation of BCL-XL. Our data show that BCL-XL expression in tumor cells is associated with SMAD1-induction by cytotoxic therapies, which simultaneously suppress SMAD4 expression. Importantly, SMAD1 expression was strictly dependent on stromal PKC-β activity. Antagonizing stroma signals with TGF-β inhibitors inhibits SMAD1 induction, abrogates the up-regulation of BCL-XL and overcomes stroma-dependent resistance to Venetoclax and conventional chemotherapy. The TGF-β pathway operates in parallel to the activation of the transcription factor EB (TFEB) as a down-stream target of PKC-β. Interference with these signaling pathways impairs plasma membrane integrity of stromal cells by down-regulation of numerous adhesion and signaling molecules, such as ADAM17, required for the reciprocal stabilization of BCL-XL in tumor cells. The significance of microenvironment PKC-β for drug resistance was demonstrated in vivo, using C57B/6 mice, diseased with EμTCL-1 driven B cell tumors and treated with Venetoclax in combination with or without PKC-β inhibitors. Combined treatment significantly prolonged survival, based on PKC-β mediated impairment of EMDR. Similarly, concurrent treatment of PKC-β inhibitors with chemotherapy also improved survival in an ALL-PDx model Our data demonstrate that mitigating EMDR with small molecule inhibitors of PKC-β or TGF-β signalling enhance the effectiveness of both targeted and non-targeted chemotherapies and moreover, has the ability to overcome Venetoclax resistance in B cell malignancies. Clinical trials with repurposed drugs inhibiting the here described pathways mediating EMDR are in planning. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Midostaurin as inhibitor of stroma PKC-β

Novel targeted therapies have substantially improved the prognosis of patients with B-cell malignancies. However, a substantial fraction of patients relapse, even after initially achieving deep remissions. Many studies have characterized the interactions between tumor cells and their microenvironment as integral to leukemia/lymphoma homeostasis and for the provision of survival signals, also contributing to drug resistance (referred to as environment-mediated drug resistance [EMDR]). Therapeutic efforts to antagonize microenvironment-emanating survival cues have predominantly focused on perturbation of tumor cell adhesion enabling the physical displacement from protective niches. In an effort to address whether direct stromal targeting could more precisely mitigate EMDR, we antagonized stromal expressed PKC-beta, which we have previously shown to be a stroma-autonomous signaling pathway critical for the survival of malignant B cells (Lutzny et al., Cancer Cell 2013). The dependency on stroma PKC-b was uniformly found for acute (ALL) and chronic (CLL, MCL) B-cell malignancies. In particular, our data demonstrate that stroma PKC-b is of key importance for multidrug resistance of malignant B cells (Park et al., Science Trans Med 2020). Here we demonstrate novel mechanistic insights into stroma-mediated drug resistance in B-cell malignancies. We identified that stroma PKC-b drives a transcriptional program, activating TGF-b and BMP-signaling in tumor cells. Our data show that antagonizing stroma signals with TGF-b inhibitors abrogated upregulation of BCL-XL and overcomes stroma-dependent resistance to venetoclax. This activation operates in parallel to the activation of the transcription factor EB (TFEB) as a downstream target of PKC-b. Interference with these signaling pathways impairs plasma membrane integrity of MSCs by downregulation of numerous adhesion and signaling molecules (e.g., ADAM17), required for the reciprocal stabilization of BCL-XL in tumor cells. The significance of microenvironment PKC-b for drug resistance was demonstrated in vivo, using C57B/6 mice, diseased with EuTCL-1 driven B-cell tumors and treated with venetoclax in combination with or without enzastaurin (PKC-b inhibitor). Combined treatment significantly prolonged survival, based on PKC-b mediated impairment of lysosome biogenesis in vivo. Similarly, concurrent treatment of PKC-b inhibitors with chemotherapy also improved survival in an ALL-PDx model. Our data demonstrate that mitigating EMDR with small-molecule inhibitors of PKC-b or TGF-b signaling enhances the effectiveness of both targeted and nontargeted chemotherapies and, moreover, has the ability to overcome venetoclax resistance in B-cell malignancies in vivo. A clinical trial to test the dual inhibition of stroma and tumor cells in lymphoma patients is in preparation. Citation Format: Eugene Park, Jingyu Chen, Andrew Moore, Maurizio Mangolini, Joseph R. Byod, Hilde Schjerven, James C. Williamson, Paul J. Lehner, Michael Leitges, Alexander Egle, Marc Schmidt-Supprian, Seth Frietze, Ingo Ringshausen. Overcoming venetoclax resistance in B-cell malignancies by antagonism of stromal TGF-beta-mediated drug resistance [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr PO-62.

Objective: To evaluate complication rates following cleft lip and cleft palate repairs during the transition from mission-based care to center-based care in a developing region. Patients and Design: We performed a retrospective review of 3419 patients who underwent cleft lip repair and 1728 patients who underwent cleft palate repair in Guwahati, India between December 2010 and February 2014. Of those who underwent cleft lip repair, 654 were treated during a surgical mission and 2765 were treated at a permanent center. Of those who underwent cleft palate repair, 236 were treated during a surgical mission and 1491 were treated at a permanent center. Setting: Two large surgical missions to Guwahati, India, and the Guwahati Comprehensive Cleft Care Center (GCCCC) in Assam, India. Main Outcome Measure: Overall complication rates following cleft lip and cleft palate repair. Results: Overall complication rates following cleft lip repair were 13.2% for the first mission, 6.7% for the second mission, and 4.0% at GCCCC. Overall complication rates following cleft palate repair were 28.0% for the first mission, 30.0% for the second mission, and 15.8% at GCCCC. Complication rates following cleft palate repair by the subset of surgeons permanently based at GCCCC (7.2%) were lower than visiting surgeons ( P < .05). Conclusions: Our findings support the notion that transitioning from a mission-based model to a permanent facility-based model of cleft care delivery in the developing world can lead to decreased complication rates.

Summary:. Neuromas can be a debilitating cause of pain and often negatively affect patients’ quality of life. One effective method of treatment involves surgical resection of the painful neuroma and use of a processed nerve allograft to repair the injured nerve segment. Giving the nerve “somewhere to go and something to do” has been shown to effectively alleviate pain in upper and lower extremities. We present the first report of this concept to treat a painful neuroma of the abdominal wall that developed following a laparoscopic gastric bypass. The neuroma was excised, and the affected nerve was reconstructed using a processed nerve allograft as an interposition graft, with resolution of pain and gradual return of normal sensation. Patient-reported outcomes were measured using the Patient Reported Outcomes Measurement Information System. Neuroma excision with concurrent interposition grafting using processed nerve allografts may be a promising method of treatment for postsurgical painful neuromas of the trunk.

Background Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to increase eyelid height and improve symptoms has been described for a long time, but the optimal choice of spacer graft material is unknown. Objectives The authors reviewed the currently available evidence to determine the best available spacer graft material in terms of efficacy and complications. Methods A systematic review of all available literature published between 1985 and the present was performed using the Pubmed, Ovid MEDLINE, and Cochrane library databases. Inclusion criteria were that the studies contain original content assessing the treatment of lower eyelid retraction in humans using a spacer graft and provide quantitative outcomes data. Results One hundred and twelve articles were reviewed following an initial screen using titles, and 19 articles were chosen for inclusion in this systematic review. Analysis of these articles revealed no spacer graft material that is clearly superior to others. Conclusions Due to a lack of high quality evidence, this review did not reveal one spacer graft material that is clearly superior to others. However, a narrative summary of the available evidence reveals unique sets of advantages and disadvantages associated with the various materials currently available. Further research in the form of well-designed studies will be necessary to further clarify advantages of certain spacer graft materials over others. Level of evidence 5.

BACKGROUND: Biologic mesh is commonly used in abdominal wall reconstruction but may result in increased hernia recurrence. There are minimal data on repair of these recurrent hernias. METHODS: We conducted a retrospective chart review of 24 patients presenting to a single surgeon with recurrent ventral hernia, previously repaired with biologic mesh. RESULTS: Seventeen of 24 study patients underwent open repair, including 5 revisions of incomplete external oblique release. Mesh was polypropylene in 11 patients and fenestrated condensed polytetrafluoroethylene in 3 patients. In 1 patient, no mesh was used. In 2 patients, bridged biologic mesh was used because of risk of exposure. All biologic repairs have since recurred. Complications occurred in 3 of 15 prosthetic mesh patients and in all biologic mesh patients. CONCLUSIONS: Prior components release can be repeated if computed tomography scan reveals incomplete release. Recurrence is common after bridged biologic mesh repair. Conventional mesh can be used safely in many recurrent abdominal hernias after biologic mesh failure.

Bone marrow (BM) provides chemoprotection for acute lymphoblastic leukemia (ALL) cells, contributing to lack of efficacy of current therapies. Integrin alpha4 (alpha4) mediates stromal adhesion of normal and malignant B-cell precursors, and according to gene expression analyses from 207 children with minimal residual disease, is highly associated with poorest outcome. We tested whether interference with alpha4-mediated stromal adhesion might be a new ALL treatment. Two models of leukemia were used, one genetic (conditional alpha4 ablation of BCR-ABL1 [p210(+)] leukemia) and one pharmacological (anti-functional alpha4 antibody treatment of primary ALL). Conditional deletion of alpha4 sensitized leukemia cell to nilotinib. Adhesion of primary pre-B ALL cells was alpha4-dependent; alpha4 blockade sensitized primary ALL cells toward chemotherapy. Chemotherapy combined with Natalizumab prolonged survival of NOD/SCID recipients of primary ALL, suggesting adjuvant alpha4 inhibition as a novel strategy for pre-B ALL.

Purpose To determine the amount of shortening needed in an ulna to achieve final neutral ulnar variance in adolescents with ulnar impaction syndrome. Radiological and clinical outcomes were evaluated after ulnar shortening and after growth had stopped. Methods From February 2006 to February 2009, we prospectively followed 16 consecutive patients treated with a shortening osteotomy for positive ulnar variance. The study group included 10 boys and 6 girls with an average age of 16.1 years. The closed medial half-side of the physis of the distal radius was used to measure the variance as a reference for the ulna. Based on the radius without any growth potential, the amount of shortening was determined for the ulna with potential for further growth. The preoperative, postoperative, and final ulnar variances were evaluated. The clinical results were compared before surgery and at the time of growth termination. Results Preoperative ulnar variance was 3.4 mm ± 0.6 mm and the amount to be shortened was 6.1 mm ± 1 mm. The final ulnar variance was 0.2 mm ± 0.3 mm. The mean visual analog scale pain score improved from 6.6 ± 1.0 before surgery to 2.2 ± 0.5 after surgery. The mean range of forearm rotation increased from 132° ± 11° before surgery to 170° ± 16° at final follow-up. In addition, grip strength was 15.3 kg ± 7.6 kg (71% of grip strength on the unaffected side) before surgery and 19.8 kg ± 4.9 kg (90% of grip strength on the unaffected side) at final follow-up. The modified Mayo Wrist Score was 85 ± 8 at the final follow-up. No cases of complications or treatment failure occurred. Conclusions Ulnar shortening was considered a useful procedure for adolescents with ulnar impaction syndrome, particularly if the measurement for the shortening amount was determined using the physis of the distal radius and ulna. Type of study/level of evidence Therapeutic IV.

Primary Sjögren syndrome (pSS) is an autoimmune disease that is characterized by infiltration of lymphocytes in exocrine glands, followed by hypofunction of the glands. Dry mouth and eyes are main symptoms, but there are various extraglandular manifestations in pSS. Nine to 75% of patients have pulmonary involvement such as interstitial lung diseases. Pulmonary alveolar proteinosis (PAP) is also a kind of autoimmune disorder, characterized by the presence of anti-granulocyte/macrophage colony-stimulating factor antibody. A 45-year-old nonsmoking woman was admitted with dyspnea and dry cough. She was diagnosed as having PAP, based on characteristic computed tomography, bronchoalveolar lavage, and lung biopsy findings. At the same time, she was diagnosed with pSS, based on dry mouth, xerophthalmia, positive anti-Ro/La antibodies, and scintigraphic finding of salivary glands. Whole lung lavages and monthly intravenous cyclophosphamide had slight improvement in PAP.

Despite recent advances in the cure rate of acute lymphoblastic leukaemia (ALL), the prognosis for patients with relapsed ALL remains poor. Here we identify FOXM1 as a candidate responsible for an aggressive clinical course. We show that FOXM1 levels peak at the pre-B-cell receptor checkpoint but are dispensable for normal B-cell development. Compared with normal B-cell populations, FOXM1 levels are 2- to 60-fold higher in ALL cells and are predictive of poor outcome in ALL patients. FOXM1 is negatively regulated by FOXO3A, supports cell survival, drug resistance, colony formation and proliferation in vitro, and promotes leukemogenesis in vivo. Two complementary approaches of pharmacological FOXM1 inhibition—(i) FOXM1 transcriptional inactivation using the thiazole antibiotic thiostrepton and (ii) an FOXM1 inhibiting ARF-derived peptide—recapitulate the findings of genetic FOXM1 deletion. Taken together, our data identify FOXM1 as a novel therapeutic target, and demonstrate feasibility of FOXM1 inhibition in ALL., FOXM1, a transcription factor with roles in cell cycle progression, is highly expressed in the majority of solid tumours. Here the authors show that FOXM1 is an ideal therapeutic target in B-cell acute lymphoblastic leukaemia (ALL) due to its dispensability for normal B-cell development.

Following an initial impact after spinal cord injury (SCI), there is a cascade of downstream events termed 'secondary injury', which culminate in progressive degenerative events in the spinal cord. These secondary injury mechanisms include, but are not limited to, ischemia, inflammation, free radical-induced cell death, glutamate excitotoxicity, cytoskeletal degradation and induction of extrinsic and intrinsic apoptotic pathways. There is emerging evidence that glutamate excitotoxicity plays a key role not only in neuronal cell death but also in delayed posttraumatic spinal cord white matter degeneration. Importantly however, the differences in cellular composition and expression of specific types of glutamate receptors in grey versus white matter require a compartmentalized approach to understand the mechanisms of secondary injury after SCI. This review examines mechanisms of secondary white matter injury with particular emphasis on glutamate excitotoxicity and the potential link of this mechanism to apoptosis. Recent studies have provided new insights into the mechanisms of glutamate release and its potential targets, as well as the downstream pathways associated with glutamate receptor activation in specific types of cells. Evidence from molecular and functional expression of glutamatergic AMPA receptors in white matter glia (and possibly axons), the protective effects of AMPA/kainate antagonists in posttraumatic white matter axonal function, and the vulnerability of oligodendrocytes to excitotoxic cell death suggest that glutamate excitotoxicity is associated with oligodendrocyte apoptosis. The latter mechanism appears key to glutamatergic white matter degeneration after SCI and may represent an attractive therapeutic target.

Objective To analyze the process of urethral healing, which is the basis of urethral reconstructive surgery but remains poorly understood, we have developed a rat model of urethroplasty. Understanding this process may provide strategies to prevent aberrant urethral healing and improve the healing process. Methods We performed urethroplasties on 36 male Sprague-Dawley rats. On postoperative days 2, 4, 6, 8, 10, and 12, animals were sacrificed. The number of neutrophils, macrophages, fibroblasts, blood vessels, and Ki67 proliferative index was evaluated with immunostaining and collagen I and III contents with picrosirius staining. Expression of VEGF , PDGF , TNFα , TGFβ , and FGF was analyzed with quantitative real-time PCR. Results Urethral healing occurs in phases of inflammation, proliferation, maturation, and remodeling analogous to dermal healing, however, with extended duration of each phase. The inflammatory phase reached to postoperative day 4 being characterized by neutrophil and macrophage predominance and high levels of VEGF, PDGF, TGFβ , TNFα , and IL-10 . The proliferative phase extended until day 10 characterized by myofibroblast proliferation and angiogenesis. Maturation and remodeling started on day 10 with decreasing proliferation and angiogenesis, increasing collagen I formation, and periurethral alignment of connective tissue. The healing process involved >50% of the periurethral/spongiosum area in the inflammatory and >80% in the maturation and remodeling phase. Conclusion Urethral healing occurs in phases similar to those observed in dermal healing, however, with extension of each phase. The healing process is not limited to the site of injury but involves the vast majority of periurethral tissue and corpus spongiosum. This appears to be the result of the unique anatomical features of the urethra.

Background & Hypothesis: IFITM3 (Interferon-induced transmembrane protein 3) was identified as interferon-inducible molecule in the context of viral infection. Endosomal membrane localized IFITM3 appear to prevent fusion events of intraluminal viral particles to the endosomal membrane through accumulation of cholesterol which makes membrane more rigid. We recently found that IFITM3 is a dual-pass transmembrane protein expressed on B cell lineage ALL cells. Thereby IFITM3 is associated with known B cell co-receptors including CD19, CD81 and CD21. While the significance of this association was unknown, we found that IFITM3 is required for surface expression of the B cell antigen CD19. Although immunotherapy approaches based on CD19-specific engineered chimeric antigen receptors (CART19) have achieved spectacular successes in eliminating pre-B ALL cells based on surface expression of CD19 (Grupp et al., 2013), in some cases, CD19-specific engineered chimeric antigen receptors (CART19) treatment was followed by ALL relapse developing from clones that lacked CD19 surface expression. Results: Studying IFITM3 mRNA levels in B cell lineage ALL cells at the time of diagnosis in clinical trials for childhood (COG P9906) and adult ALL (ECOG E2993), we found that higher than median expression levels of IFITM3 predicted shorter overall and relapse-free survival (P=0.014). In addition, higher than median IFITM3 mRNA levels at the time of diagnosis were associated with a higher risk of ALL relapse and positive MRD status at the end of induction chemotherapy. To study the function of Ifitm3 in a model for human pre-B ALL, pre-B cells from Ifitm3-/- mice were transformed with BCR-ABL1 or oncogenic NRAS. Strikingly, deletion of IFITM3 resulted in loss of CD19 expression on the surface of normal and leukemic pre-B cells. Besides loss of surface expression, loss of Ifitm3 also caused impaired phosphorylation of CD19-Y513, which mediates downstream activation of PI3K signaling in both normal and malignant B cells. These changes were paralleled by G0/1 cell cycle arrest (P In mechanistic study, we identified type II transmembrane topology for IFITM3 at plasma membrane with extracellular C and intracellular N terminus which interacted with CD19, LYN, SYK, PI3K and AKT. Disruption of endocytic motif (20YEML23) by substitution of Tyr20 to Phe caused accumulation of IFITM3 at plasma membrane and led to constitutive activation of CD19/PI3K-AKT signaling. In addition to the gain-of-function mutants, extracellularly exposed C terminus was further stimulated by agonistic antibodies against IFITM3, which triggers CD19/PI3K-AKT signaling, intracellular calcium mobilization, homotypic cellular aggregation and massively increased proliferation of pre-B ALL cells. Through Filipin based cholesterol staining, we found Ifitm3-/- pre-B cells have low levels of cholesterol at plasma membrane, which causes disruption of lipid rafts formation with decreased levels of ganglioside GM1. Thereby, Inadequate CD19/BCR co-receptor signaling caused by disruption of lipid rafts homeostasis by Ifitm3 deficiency results in critical developmental defects of peritoneal B1 cell compartment in vivo. Conclusion: These findings identify novel role of the IFITM3 surface receptor maintaining lipid rafts and CD19 surface expression. IFITM3-dependent lipid raft stability and CD19 surface expression were essential for normal and oncogenic PI3K signaling. IFITM3 is a central mediator of CD19 surface trafficking and mediates the proliferation and survival signaling via PI3K in normal pre-B cells and various subtypes of human pre-B ALL. Disclosures No relevant conflicts of interest to declare.

B-cell leukemia/lymphoma 2 (BCL-2) prevents commitment to programmed cell death at the mitochondrion. It remains a challenge to identify those tumors that are best treated by inhibition of BCL-2. Here, we demonstrate that acute myeloid leukemia (AML) cell lines, primary patient samples, and murine primary xenografts are very sensitive to treatment with the selective BCL-2 antagonist ABT-199. In primary patient cells, the median IC50 was approximately 10 nmol/L, and cell death occurred within 2 hours. Our ex vivo sensitivity results compare favorably with those observed for chronic lymphocytic leukemia, a disease for which ABT-199 has demonstrated consistent activity in clinical trials. Moreover, mitochondrial studies using BH3 profiling demonstrate activity at the mitochondrion that correlates well with cytotoxicity, supporting an on-target mitochondrial mechanism of action. Our protein and BH3 profiling studies provide promising tools that can be tested as predictive biomarkers in any clinical trial of ABT-199 in AML. Significance: Although targeting BCL-2 has largely been investigated in lymphoid cancers, we present preclinical results of targeting BCL-2 in AML. These results support clinical testing of the small-molecule BCL-2 antagonist ABT-199 in AML, accompanied by testing of predictive biomarkers used in this study. Cancer Discov; 4(3); 362–75. ©2013 AACR. See related commentary by Hockenbery, p. 278 This article is highlighted in the In This Issue feature, p. 259

White matter sparing after traumatic brain injury (TBI) is an important predictor of survival and outcome. Blood vessels and axons are intimately associated anatomically and developmentally. Neural input is required for appropriate vascular patterning, and vascular signaling is important for neuron development and axon growth. Owing to this codependence between endothelial cells and axons during development and the contribution of endothelial progenitor cells (EPCs) in ischemic injury, we hypothesized that EPCs are important in axonal survival after TBI. We examined the effects of allogenic-cultured EPCs on white matter protection and microvascular maintenance after midline fluid percussion injury in adult Sprague–Dawley rats. We used two in vitro models of injury, mechanical stretch and oxygen–glucose deprivation (OGD), to examine the effects of EPCs on the mechanical and ischemic components of brain trauma, respectively. Our results indicate that EPCs improve the white matter integrity and decrease capillary breakdown after injury. Cultured cortical neurons exposed to OGD had less axon degeneration when treated with EPC-conditioned media, whereas no effect was seen in axons injured by mechanical stretch. The results indicate that EPCs are important for the protection of the white matter after trauma and represent a potential avenue for therapy.

Background Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. Methods A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. Results The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. Conclusions With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

Vascular endothelial growth factor (VEGF) plays a role in angiogenesis and has been shown to be neuroprotective following central nervous system trauma. In the present study we evaluated the pro-angiogenic and neuroprotective effects of an engineered zinc-finger protein transcription factor transactivator targeting the vascular endothelial growth factor A (VEGF-ZFP). We used two virus delivery systems, adeno-virus and adeno-associated virus, to examine the effects of early and delayed VEGF-A upregulation after brain trauma, respectively. Male Sprague-Dawley rats were subject to a unilateral fluid percussion injury (FPI) of moderate severity (2.2-2.5 atm) followed by intracerebral microinjection of either adenovirus vector (Adv) or an adeno-associated vector (AAV) carrying the VEGF-ZFP construct. Adv-VEGF-ZFP-treated animals had significantly fewer TUNEL positive cells in the injured penumbra of the cortex (p0.001) and hippocampus (p=0.001) relative to untreated rats at 72 h post-injury. Adv-VEGF-ZFP treatment significantly improved fEPSP values (p=0.007) in the CA1 region relative to injury alone. Treatment with AAV2-VEGF-ZFP resulted in improved post-injury microvascular diameter and improved functional recovery on the balance beam and rotarod task at 30 days post-injury. Collectively, the results provide supportive evidence for the concept of acute and delayed treatment following TBI using VEGF-ZFP to induce angiogenesis, reduce cell death, and enhance functional recovery.

There is strong evidence that primary blast injuries can cause neuropathological alterations in the brain. Clinical findings from war veterans indicating evidence of diffuse axonal injury have been corroborated by numerous primary blast models in animals. However, the effect of a subclinical blast (blast with no obvious sign of external trauma or lung injury) as a contributing factor to the neurological symptoms and neuropathology is less clear. Our group recently developed a model of low-level primary blast and characterized aberrant expression of white matter cytoskeletal proteins in the cortex and hippocampus following a subclinical wave shock exposure. Here we examined the susceptibility of the corpus callosum following subclinical blast. We also demonstrate that white matter dysfunction is associated with neurobehavioral deficits associated with anxiety and stress in rats. Anesthetized male Sprague-Dawley rats (~300 g) were exposed to a primary blast (approx. 28 kPa), below the threshold required to induce pulmonary trauma. Rats were evaluated on three behavioral outcome measures; the rotarod, the light/dark box and open field anxiety test. We used Western blotting to examine expression and degradation of axonally expressed αII-spectrin, NF200 and voltage-gated sodium channels (VGSC) in the corpus callosum. Acute slice preparations were used for electrophysiological analysis of evoked compound action potentials (CAPs) in the corpus callosum. There was evidence of αII-spectrin degradation in the corpus callosum at 48 h post-injury detectable up to 14 days post-injury, as well as increased heavy neurofilament expression. A reduction in VGSC expression was observed at 48 h post-blast as well as a reduction in the interaction between ankyrin G and intact αII-spectrin. Blast exposed rats had significantly lower rotarod latency times relative to sham rats (p=0.002). Increased anxiety-related and stress-related behavior were observed in blast rats relative to sham animals as indicated by the increased frequency of fecal droppings (p=0.029) and reduced exploratory activity (p=0.036) in the open-field test. Blast rats had fewer transitions and time spent in lit sections of the light/dark box. Electrophysiological recordings from the corpus callosum indicated greater deficits in unmyelinated fibers of the corpus callosum relative to myelinated fibers characterized by reduced CAP amplitude response at 14 days post-injury. Analysis of the relationship between stimulation distance to evoked response indicated an underlying abnormality in N1 myelinated fibers at close stimulation distances. Collectively, our results indicate that subclinical blast exposure can result in persistent neurological changes in cerebral white matter occurring in parallel with detectable neurobehavioral deficits.

Background and hypothesis: CD25 (IL2RA) represents the α chain of the interleukin 2 receptor on T cells and plays an important role in the maintenance of regulatory T (Treg) cells, hence preventing T cell autoimmunity. In a comprehensive gene expression analysis, we found that CD25 is specifically upregulated by pre-B cell receptor (pre-BCR) signaling during early B cell development and oncogenic tyrosine kinase that mimic pre-BCR signaling (e.g. in Ph+ ALL and Ph-like ALL). In adults with Ph+ ALL (ECOG; MDACC) and children with Ph-like ALL (P9906) patients with CD25 expression at the time of diagnosis have a particularly poor outcome (n=416; P=0.005). For these reasons, we studied the function of CD25 in B cell development and leukemia in a series of genetic experiments. Results: Unlike T cells, CD25 (IL2RA) does not function as IL2 receptor chain in B cells and B-lineage ALL: CD25 expressed on B-lineage cells did not pair with IL2Rb and g-chains and was not responsive to IL2. Il2ra-/- B cells were arrested at the pre-B cell stage with hyperactive pre-BCR downstream signaling including SRC, BTK and ERK. In the presence of CD25, Il2ra+/+ B cells responded to engagement of the pre-BCR with phosphorylation of pre-BCR downstream tyrosine kinases and coordinated release of Ca2+ from cytoplasmic stores. In the absence of CD25 (Il2ra-/-), the pre-BCR signals autonomously, resulting in uncoordinated Ca2+ oscillations of variable duration. While CD25 does not function as IL2 receptor chain in B cells, it coordinates pre-BCR-dependent signal transduction and regulates its intensity. The pre-BCR related tyrosine kinase BTK is phosphorylated by BCR-ABL1 in Ph+ ALL and other tyrosine kinase oncogenes in Ph-like ALL (Chen et al., 2015). Interestingly, overexpression of a constitutively active form of BTK resulted in strong upregulation of CD25 surface expression. Conversely, the BTK-inhibitor ibrutinib abolished CD25 expression suggesting that feedback control between pre-BCR signaling and CD25 requires BTK. The ability of CD25 to stabilize oncogenic signaling strength in Ph+ ALL and Ph-like ALL was important for leukemia-initiation and development of fatal disease. In the absence of CD25, Il2ra-/- ALL cells showed impaired proliferation and colony formation. Serial transplantation experiments revealed a profound defect of Il2ra-/- ALL cells to initiate leukemia. 100-times more cells were required to cause fatal disease. In addition, CD25 expression mediated drug-resistance in ALL cells: In patient-derived pre-B ALL cells with heterogeneous CD25 expression, vincristine selectively induced apoptosis in CD25Low cells but spared CD25High ALL cells. Combination with an anti-CD25 immunotoxin efficiently eradiated CD25High leukemia cells and sensitized the ALL cell population to treatment with vincristine. To elucidate the mechanism of how CD25 coordinates negative feedback control of pre-BCR signaling or its oncogenic mimics, we focused on its short (13aa) cytoplasmic tail, which includes two phosphorylation sites (S268 and T271) that are known substrates for serine/threonine protein kinase, PKCα. To identify cytoplasmic interaction partners of CD25, we overexpressed a Flag-tagged truncated form of CD25 including a myristoylation signal for constitutive membrane localization, transmembrane domain and cytoplasmic tail. Immunoprecipitation (IP; Flag) followed by 2D mass spectrometry revealed strong interactions of PP2A with cytoplasmic tail of CD25. Western blots showed additional strong interactions of the cytoplasmic tail of CD25 with inhibitory phosphatases PTEN, SHP1 and SHIP1. Importantly, reconstitution of myristoylated CD25 tail but not a mutant construct lacking the serine/threonine motif (S268A/T271A) rescued proliferation and survival defects of Il2ra-/- ALL cells. Conclusion: We identified CD25 as a surface receptor that mediates membrane recruitment of PP2A, PTEN, SHP1 and SHIP1, which balances fluctuations in signaling output from a pre-B cell receptor or its oncogenic mimic in ALL cells (e.g. BCR-ABL1 in Ph+ ALL). We propose that CD25-mediated negative feedback control stabilizes oncogenic tyrosine kinase signaling and mediates drug-resistance in Ph+ ALL and Ph-like ALL cells. Targeted inhibition using CD25-directed immunotoxins may be useful in new approaches to overcome drug-resistance in Ph+ ALL and Ph-like ALL. Disclosures No relevant conflicts of interest to declare.

Background & Hypothesis: IFITM3 (Interferon-induced transmembrane protein 3) also known as CD225/Leu-13 was identified as interferon-inducible molecule in the context of viral infection. IFITM3 encodes a surface receptor, basally expressed on the plasma membrane, that is associated with known B cell co-receptors including CD19, CD81 and CD21. Recent immunotherapy approaches based on CD19-specific engineered chimeric antigen receptors (CART19) have achieved spectacular successes in eliminating pre-B ALL cells based on surface expression of CD19 (Grupp et al., 2013). However, in some cases, CART19 treatment was followed by ALL relapse developing from clones that lacked CD19 surface expression. Therefore, we studied factors that regulate CD19 surface expression on human pre-B ALL cells. Results: Studying IFITM3 mRNA levels in ALL cells at the time of diagnosis in clinical trials for childhood (COG P9906) and adult ALL (ECOG E2993), we found that higher than median expression levels of IFITM3 predicted shorter overall and relapse-free survival (P=0.014). In addition, patients with higher than median IFITM3 mRNA levels at the time of diagnosis were significantly more likely to experience ALL relapse and had a higher risk of a positive MRD status at the end of induction chemotherapy. To study the function of Ifitm3 in a model for human pre-B ALL, pre-B cells from Ifitm3-/- mice were transformed with BCR-ABL1. Strikingly, deletion of IFITM3 resulted in loss of CD19 expression on the surface of normal and leukemic pre-B cells. Besides loss of surface expression, loss of Ifitm3 also caused impaired phosphorylation of CD19-Y513, which mediates downstream activation of PI3K-AKT signaling in both B cell progenitors and pre-B ALL cells. These changes were paralleled by G0/1 cell cycle arrest (P Conversely, forced expression of IFITM3 in patient-derived pre-B ALL cells increased phosphorylation of CD19-Y513 together with downstream SRC, SYK, PI3K signaling. Although human IFITM1 has known as a component of B cell receptor complex, co-immunoprecipitation experiments revealed that the cytoplasmic tail of IFITM3 interacts with CD19, LYN, SYK, PI3K p110δ and AKT. In addition, agonistic antibodies against IFITM3/CD225 trigger CD19/PI3K-AKT signaling, which caused massively increased proliferation of pre-B ALL cells. Interestingly, agonistic antibodies against CD19 had no effect on the proliferation of pre-B ALL cells despite their ability to activate CD19/PI3K-AKT signaling. These findings indicate a specific role of IFITM3 in regulating CD19/PI3K-AKT signaling in malignant pre-B ALL cells compared to their normal pre-B cell counterparts. Conclusion: These findings identify novel role of the IFITM3 (CD255) surface receptor in regulating CD19 phosphorylation and CD19-Y513 mediated PI3K-AKT signaling in pre-B ALL cells. IFITM3 is a central mediator of CD19 surface trafficking and mediates the proliferation and survival signaling via PI3K-AKT in normal pre-B cells and various subtypes of human pre-B ALL. Disclosures No relevant conflicts of interest to declare.

Shock-wave exposure from improvised explosive devices (IEDs) has been implicated as a possible contributing factor to neurological impairment reported in combat veterans. However, evidence-based substantiation of this implication, particularly for low-level exposure in the absence of external signs of trauma, remain elusive. Accordingly, we constructed an open-ended shock tube producing a short-duration, low-amplitude shockwave. Low-level (11.5 kPa static overpressure) complex shock-wave exposure in rats resulted in no histological evidence of lung injury. By contrast, delayed cytoskeletal proteolysis of αII-spectrin was detected in the cortex and hippocampus by 12 h post-injury. Cell death was minimal and localized predominantly in the corpus callosum and periventricular regions. These regions, with presumably different density interfaces, exhibit biological responses to shockwaves consistent with interface turbulence described by Richtmyer-Meshkov instability. Evoked compound action potential (CAP) recordings from the corpus callosum showed a significant increase in the duration of CAP responses at 14 and 30 days post-injury, and a gradual depression in the unmyelinated fiber amplitude. Shielding the head attenuated αII-spectrin cytoskeletal breakdown, thus directly implicating low-level shock-wave exposure as a cause of brain injury in the rat. Despite anatomical and scaling differences in rats compared to humans, the results suggest the potential for undiagnosed traumatic brain pathologies occurring in combat veterans following shock-wave exposure.

B cell lineage acute lymphoblastic leukemia (ALL) arises in virtually all cases from B cell precursors that are arrested at pre–B cell receptor–dependent stages. The Philadelphia chromosome–positive (Ph+) subtype of ALL accounts for 25–30% of cases of adult ALL, has the most unfavorable clinical outcome among all ALL subtypes and is defined by the oncogenic BCR-ABL1 kinase and deletions of the IKAROS gene in >80% of cases. Here, we demonstrate that the pre–B cell receptor functions as a tumor suppressor upstream of IKAROS through induction of cell cycle arrest in Ph+ ALL cells. Pre–B cell receptor–mediated cell cycle arrest in Ph+ ALL cells critically depends on IKAROS function, and is reversed by coexpression of the dominant-negative IKAROS splice variant IK6. IKAROS also promotes tumor suppression through cooperation with downstream molecules of the pre–B cell receptor signaling pathway, even if expression of the pre–B cell receptor itself is compromised. In this case, IKAROS redirects oncogenic BCR-ABL1 tyrosine kinase signaling from SRC kinase-activation to SLP65, which functions as a critical tumor suppressor downstream of the pre–B cell receptor. These findings provide a rationale for the surprisingly high frequency of IKAROS deletions in Ph+ ALL and identify IKAROS-mediated cell cycle exit as the endpoint of an emerging pathway of pre–B cell receptor–mediated tumor suppression.

A treatment for traumatic brain injury (TBI) remains elusive despite compelling evidence from animal models for a variety of therapeutic targets. Numerous animal models have been developed to address the wide spectrum of mechanisms involved in the progression of secondary injury after TBI. Evidence from well-established models such as the fluid percussion injury (FPI) device, cortical impact model, and the impact acceleration model has demonstrated diffuse pathophysiological mechanisms throughout various brain structures. More specifically, we have recently extended characterization of the FPI model to include pathophysiological changes in the cerebellum following unilateral fluid percussion. Data suggest that the cerebellum is susceptible to selective Purkinje cell loss as well as white matter dysfunction. Despite the cerebellum's low profile in TBI research, there is evidence to warrant further study of the cerebellum to examine mechanisms of neuronal death and traumatic axonal injury. Furthermore, evidence from clinical literature and basic science suggests that some components of TBI pathophysiology have a basis in cerebellar dysfunction. This review highlights some of the recent findings in cerebellar trauma and builds an argument for including the cerebellum as a model to assess mechanisms of secondary injury and its potential contribution to the pathology of TBI.

Evidence for diffuse traumatic axonal injury (TAI) in clinical cases and animal models of traumatic brain injury (TBI) indicate that pathophysiological mechanisms extend to regions remote from the injury epicenter. The potential for indirect cerebellar trauma contributing to TBI pathophysiology is of significance since impairment of motor function and coordination is a common consequence of TBI but is also a domain associated with cerebellar function. The relationship between cerebellar white matter structure and function following traumatic head injury has not been examined. Using the fluid percussion injury (FPI) device applied unilaterally in the forebrain, evoked compound action potential (CAP) recordings from cerebellar white matter of Sprague-Dawley rats indicated a spatial and temporal pattern of electrophysiological deficits throughout the cerebellar vermis. The posterior and middle lobules of the cerebellum exhibited significant declines in evoked CAP amplitude compared to sham controls (p=0.004, p=0.005, respectively). Duration of the CAP decay also increased, suggesting that functional white matter deficits were a combination of axonal loss and compromised axonal integrity. Functional white matter deficits persisted at 14 days post-injury in the posterior and middle regions of the cerebellum. Evidence of heavy chain neurofilament (NF200) degradation was observed at 1 day post-injury by Western blot. Immunohistochemistry labeling for NF200 indicated the presence of highly immunoreactive NF200 axonal swellings consistent with morphological features of TAI. alpha-Spectrin degradation was also observed between 1 and 14 days post-injury. This study demonstrates the electrophysiological consequences of cerebellar white matter injury and a temporal profile of NF200 and spectrin degradation following forebrain FPI.

Pathophysiological changes in the cortex, thalamus, and hippocampus have been implicated as contributors to motor and cognitive deficits in a number of animal models of traumatic brain injury (TBI). Indirect cerebellar injury may contribute to TBI pathophysiology because impairment of motor function and coordination are common consequences of TBI, but are also domains associated with cerebellar function. However, there is a lack of direct evidence to support this claim. Hence, in this study, a dose-response relationship of the cerebellum's susceptibility was determined at four grades of fluid percussion injury (1.5, 2.0, 2.5, and 3.0 atm) applied in the right lateral cerebral cortex of adult male Sprague-Dawley rats. Evidence suggests primary and secondary injury mechanisms resulting in selective cerebellar Purkinje neuron (PN) loss, whereas interneurons of the molecular layer were spared. The posterior region of the cerebellar vermis displayed significant PN loss (p = 0.001) at 1 day postinjury, whereas the gyrus of the horizontal fissure and gyrus of lobules III and IV exhibited delayed PN loss at higher levels of injury severity. Interestingly, neither terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) or cleaved caspase-3 colocalized with PNs at any time point or injury severity. Expression of calbindin-28k increased in regions of greatest PN loss, suggesting that the surviving PNs possess higher calcium-buffering capacities, which may account for their survival.

Cerebellum was shown to be vulnerable to traumatic brain injury (TBI) in experimental animals. However, the detailed pathological and functional changes within the cerebellum following TBI are not known. Using our established cerebellum fluid percussion injury (FPI) model, we characterized the temporal pattern and the nature of structural damage following FPI, as well as the functional changes of Purkinje cells in response to climbing fiber activation. Our results showed that 60% of Purkinje cells died within the first 24 h following moderate FPI. In contrast, clusters of densely stained shrunken granule cells were stained positive for terminal deoxynucleotidyl transferase-mediated UTP nick end labeling (TUNEL) in 1, 3 or 7 days following FPI animals. We also observed an accompanying structural damage to the cerebellar white matter tract. Disconnected axonal fibers appeared 1 day post-FPI, and loss of white matter fibers were visible 3 and 7 days post-FPI. Massive accumulation of beta-amyloid precursor protein (betaAPP) was found in the white matter tracts and molecular layer in the cerebellum of 1, 3 or 7 days FPI animals. Our functional study showed that the majority of Purkinje cells from 1 day and all cells from 3 to 7 days post-FPI had distorted membrane potential and synaptic responses to climbing fiber activation. These results suggested that there is a co-related structural and functional deterioration with a specific temporal pattern in the cerebellum following FPI. These observations provide a basis for future mechanistic investigations aiming to realize neuroprotection from cerebellar neuronal death and loss of cerebellar functionality.

Background: Growth arrest-specific gene 7 (Gas7) functions as an adaptor for SH2- and SH3-containing proteins, in particular in cells that undergo growth arrest. Gas7 is abundantly expressed in the brain and is involved in neuronal differentiation. Interestingly, MLL-GAS7 fusion molecules resulting from the t(11;17)(q23;p13) chromosomal translocation have been reported in treatment-related acute myeloid leukemia (AML; Megonigal et al., 2000) and in a pediatric acute lymphoblastic leukemia (ALL). While the function of MLL has been extensively studied, the role of its fusion partner GAS7 in normal hematopoiesis and leukemia has not been elucidated. Results: Studying gene expression changes during normal B cell development, we identified Gas7 as the gene with the strongest relative increase at the pre-B cell receptor checkpoint. At the transition from IL7-dependent Fraction C’ to IL7-independent small resting pre-B cells (Fraction D), GAS7 mRNA levels were upregulated by >13-fold in both human and mouse B cell progenitors. Withdrawal of IL7 cytokine signaling and Cre-mediated conditional deletion of Stat5ab recapitulated the strong increase of GAS7 expression under cell culture conditions. These finding suggest that GAS7 is part of an adaptive response of differentiating pre-B cells to attenuation of cytokine/Stat5 signaling. Consistent with this scenario, we found that Gas7-/-pre-B cells undergo accelerated differentiation, including spontaneous Ig κ light chain gene recombination and loss of Stat5-signaling. Conversely, overexpression of GAS7, reduced responsiveness of pre-B cells to normal differentiation stimuli. These findings suggest that the linker molecule GAS7 is a negative regulator of pre-B cell differentiation. Likewise, we found that tyrosine kinase inhibitor treatment of human Ph+ ALL cells resulted in a strong increased of GAS7 expression, in parallel with loss of Stat5 function. To elucidate the function of Gas7 in B cell lineage leukemia, we transformed bone marrow pre-B cells from Gas7-/- mice with BCR-ABL1. Gas7 deficient Ph+ ALL cells showed decreased proliferation with reduced S phase and increased apoptosis. In agreement with effects of Stat5 on the sensitivity of Ph+ ALL cells against tyrosine kinase inhibitors (TKIs), Gas7 deficient Ph+ ALL cells showed massively increased susceptibility to Imatinib-induced apoptosis. In addition, absence of Gas7 caused loss of self-renewal capacity and failure to form colonies in methylcellulose assay. Co-immunoprecipitation experiments with flag tagged GAS7 in patient-derived Ph+ALL cells revealed that GAS7 physically interacts with STAT5 and retains STAT5-Y694 in an active conformation.Thereby, GAS7 can propagate even weak Stat5 activity and maintain residual cytokine or BCR-ABL1 oncogenic signaling in normal and malignant pre-B cells. Conclusions: Here show that GAS7 functions as an important positive regulator of Stat5 downstream of cytokine receptors in normal pre-B cells and downstream of BCR-ABL1 and other oncogenes in leukemia. Owing to the GAS7-dependent reinforcement of Stat5-dependent survival and proliferation signaling, normal and leukemic pre-B cells can survive periods of reduced cytokine/oncogene signaling. These findings suggest that the interaction interface between GAS7 and Stat5 represents a potential target for small molecule scaffolds and peptides. Disclosures No relevant conflicts of interest to declare.

Background and hypothesis: CD25 (IL2RA, interleukin 2 receptor α chain) is a transmembrane protein with a 13aa cytoplasmic tail. CD25 cooperates with β- and γ-chains in binding IL-2, but does not contribute to cytokine signaling. During normal B cell development, CD25 is specifically upregulated on the surface of IL7-dependent pre-B cells and is also expressed on the surface of a subset of human pre-B ALL cases. CD25-expressing ALL is typically associated with poor clinical outcome. For these reasons, we studied the functional significance of CD25 expression on human pre-B ALL cells. Results: Flow cytometry and immunohistochemistry staining on a large panel of patient samples (n=416; MDACC, ECOG) revealed specific cell surface expression of CD25 in Ph+ ALL and Ph-like ALL, which are both high-risk subtypes of ALL. In agreement with selective expression on high-risk subsets, high expression levels of CD25 at the time of diagnosis were predictive of poor overall clinical outcome in these studies (P=0.005). BCR-ABL1 in Ph+ ALL and related tyrosine kinases in Ph-like ALL strongly activate STAT5, which then induces transcriptional activation of the IL2RA locus. Since Stat5 is also active during normal pre-B cell differentiation, we first analyzed B cell development in Il2ra-/- mouse bone marrow. Il2ra-/- B cell development was blocked at the pre-B cell stage, consistent with specific upregulation of CD25 on pre-B cells. In human Ph+ ALL cells, we found IL2RB and IL2RG were not co-expressed with CD25, suggesting a function of CD25 in Ph+ALL that is distinct from IL2 signaling. To test the biological significance of tyrosine kinase/STAT5-induced activation of CD25, we developed an Il2ra-/- mouse model for BCR-ABL1 pre-B ALL. Interestingly, the cytoplasmic tail of CD25 includes phosphorylation sites (S268 and T271) that are known substrates for serine/threonine phosphorylation by PKCα, which was reported to regulate protein phosphatase 2A (PP2A). To investigate interacting proteins with the cytoplasmic tail of CD25, we performed immune precipitation (IP) against the flag-tagged CD25-tail in primary Ph+ ALL cells which were transduced with either a CD25-tail-flag or an EV-flag vector. 2D mass spectrometry and Western blot on the IP products confirmed strong interactions with PKCα and PP2A. Weestern blot analysis confirmed additional interactions with inhibitory phosphatases including PTEN, PTPN6 (SHP1) and Inpp5d (SHIP1) in human Ph+ALL cells. In addition, both 2D MS and Westernblot showed recruitment of the Stat5-feedback inhibitors CISH, SOCS2 and SOCS3 at the CD25 cytoplasmic tail. Studying functional parameters of Il2ra-/-BCR-ABL1 ALL cells, we found impaired proliferation and colony formation capacity and drastically increased increased phosphorylation levels of pABLY412, pSTAT5Y694, pERKT202/Y204, pAKTS473, pP38T180/Y182 and p53. Reconstitution of CD25 expression restored normal phosphorylation levels of these molecules, as well as proliferation and colony formation.In a serial transplant setting, we observed that leukemia initiation in transplant recipients from Il2ra-/- BCR-ABL1 ALL cells required 10- to 100-times higher cell numbers, suggesting that CD25 contributes to leukemia initiation. In addition, CD25 expression is associated with a higher level of drug-resistance: In patient-derived pre-B ALL cells with mixed CD25Low and CD25High populations, the standard chemotherapy agent vincristine selectively induced apoptosis of in CD25Low but not CD25High ALL cells. An anti-CD25 immunotoxin drugs efficiently eradiated CD25High leukemia cells and thereby overcame drug-resistance against vincristine. Conclusions: Our studies identified CD25 as a surface receptor that mediates membrane recruitment of PP2A and CISH, SOCS2, negative feedback regulators of STAT5. CD25 is transcriptionally activated by STAT5 and therefore specifically expressed on high-risk ALL subtypes with oncogenic activation of the Stat5 pathway (Ph+ ALL and Ph-like ALL). We propose that CD25-mediated negative feedback control stabilizes oncogenic tyrosine kinase signaling and mediates drug-resistance in Ph+ ALL and Ph-like ALL cells. Targeted inhibition using CD25-directed immunotoxins may be useful in new approaches to overcome drug-resistance in Ph+ ALL and Ph-like ALL. Disclosures No relevant conflicts of interest to declare.

Background & Hypothesis: IFITM3 (Interferon-induced transmembrane protein 3) also known as CD225/Leu-13 was identified as interferon-inducible molecule in the context of viral infection. IFITM3 encodes a surface receptor, basally expressed on the plasma membrane, that is associated with known B cell co-receptors including CD19, CD81 and CD21 on mouse and human B cells. However, besides its interaction with CD19, specific functions of Ifitm3 in normal B cells development and, potentially leukemogenesis, are not known. Recent approaches based on CD19-specific chimeric antigen receptors (CAR) have achieved spectacular successes in eliminating pre-B ALL cells based on surface expression of CD19 (e.g. Grupp et al., N Engl J Med 2013). However, in some cases, CD19 CAR treatment was followed by ALL relapse developing from a clone that lacked CD19 surface expression. Therefore, we studied factors that can potentially regulate CD19 surface on normal and leukemic pre-B cells. Results: Studying IFITM3 mRNA levels in ALL cells at the time of diagnosis in clinical trials for childhood (COG P9906) and adult ALL (ECOG E2993), we found that higher than median expression levels of IFITM3 predicted shorter overall and relapse-free survival (P=0.014). In addition, patients with higher than median IFITM3 mRNA levels at the time of diagnosis were significantly more likely to experience ALL relapse and had a higher risk of a positive MRD status at the end of induction chemotherapy. To study the function of Ifitm3 in a model for human pre-B ALL, pre-B cells from Ifitm3-/- mice were transformed with BCR-ABL1. Strikingly, deletion of IFITM3 resulted in near-complete loss of CD19 expression on the surface of normal and leukemic pre-B cells. Besides loss of surface expression, loss of Ifitm3 also caused impaired phosphorylation of CD19-Y513, which mediates downstream activation of PI3K-AKT signaling in both B cell progenitors and pre-B ALL cells. Reconstitution of IFITM3 in patient-derived pre-B ALL cells rescued both CD19 expression and increased phosphorylation of CD19-Y513 together with downstream SRC, SYK, PI3K signaling. Co-immunoprecipitation experiments revealed that the cytoplasmic tail of IFITM3 interacts with CD19, LYN, SYK, PI3K p110δ and AKT, pointing to a central role of IFITM3 in regulating CD19/PI3K-AKT signaling in pre-B cells and pre-B ALL. Deletion of Ifitm3 also resulted in significant cell cycle arrest in the G0/G1 phase (P 4-hydroxytamoxifen (4-OHT)-inducible activation of CD19 rescued proliferative defects in Ifitm3 deficient B cell progenitors with release from G0/G1 cell cycle arrest associated with upregulation of phosphorylation of Stat5 Y694 and c-Myc expression. In addition, we found that CD19 positively regulates the surface expression of IL7R in B cell progenitors. Interestingly, CD19low population in Ifitm3 deficient B cell progenitors showed lower surface expression of IL7R compared to CD19high population. In contrast to B cell progenitors, forced expression of CD19 did not increase the proliferation of wild-type Ph+ ALL cells. Surprisingly, upregulation of CD19 induced apoptosis in Ifitm3-deficient Ph+ ALL cells with significant inhibition of BCR-ABL1 activity, phosphorylation of Stat5Y694and Bcl2 expression. Conclusion: These findings identify novel role of IFITM3 in regulating CD19 surface expression and CD19-Y513 mediated PI3K-AKT signaling in pre-B cells and pre-B ALL. Preliminary experiment showed that agonistic antibodies against IFITM3/CD225 increased CD19/PI3K-AKT signaling and proliferation in pre-B ALL cells and future studies will elucidate whether blocking antibodies (e.g. decoy Fc-fusion molecules) will have useful effects in targeting CD19/PI3K-AKT signaling in human pre-B ALL. Disclosures No relevant conflicts of interest to declare.

Background & Significance: Pre-B acute lymphoblastic leukemia (ALL) emerges in virtually all cases from B cell precursors that are arrested at the pre-B cell receptor checkpoint. In a gene expression survey of early B cell development, we found specific upregulation of FOXM1 at this developmental stage. FOXM1 belongs to the forkhead box transcription factor family and is a key regulator of cell growth by promoting cell cycle progression and has been implicated in progression of solid tumors. Therefore, we characterized the function and regulation of FOXM1 in normal B cell development as well as in pre-B ALL. Results: First, we verified the upregulation of FOXM1 during B cell development by qRT-PCR on sorted human and murine B cell progenitor populations. Then, we crossed Mb1-Cre tg mice to a Foxm1 conditional knockout mouse model (Foxm1fl/fl) and analyzed the early B cell populations according to the Hardy fractions. Despite the observed high expression of Foxm1 mRNA in fraction C’ and D, Foxm1 deletion did not alter B cell development. In order to investigate a potential role of FOXM1 in transformed B cells, we compared FOXM1 protein levels in patient-derived pre-B ALL samples with healthy B cells and B cell precursors and found 10-60-fold higher expression in the transformed B cell progenitors. To evaluate a potential predictive value of FOXM1 levels in patient-derived ALL samples, we measured FOXM1 mRNA levels at the time of diagnosis which strikingly correlate with risk stratification of ALL (intermediate-risk ALL n=31 vs. high risk ALL n=21; P=7.3e-5; BFM-REZ 2002). To further study the function and regulation of FOXM1, we cultured murine B cell precursors in the presence of IL7 and induced transformation with a retroviral BCR-ABL1 expression vector. BCR-ABL1 expression increased levels of FOXM1 compared to the normal IL7-dependent pre-B cells. Short-term inhibition of BCR-ABL1 did not affected protein levels of FOXM1. However, after 4 days of tyrosine kinase inhibition (TKI) treatment, FOXM1 protein levels were significantly downregulated in a dose-dependent manner. BCL2 overexpression prevented apoptosis induction by TKI but FOXM1 downregulation was retained. In addition, we found evidence that inactivation of FOXO factors by the PI3K/AKT pathway contributes to high FOXM1 expression in Ph+ALL. Overexpression of a constitutively active form of Akt to prevent activation of FOXO factors in the presence of TKI abrogated FOXM1 downregulation. Similarly, BCR-ABL1+ ALL derived from FOXO3a knockout mice prevented TKI-mediated FOXM1 reduction. Overexpression of a constitutively active form of FOXO3a but not FOXO1 significantly reduces levels of FOXM1 expression. In line with this, we found a significant inverse correlation of FOXM1 with FOXO3A mRNA levels in Ph+ ALL patients from the ECOG E2993 trial. However, the requirement of long-term treatment indicates, that, in addition to FOXO3a activation, epigenetic regulation of the FOXM1 promoter downstream of BCR-ABL1 is required. Consistent with this finding, the FOXM1 promoter region was found to be de-methylated in a large fraction of ALL. In order to further study FOXM1 function, we transduced pre-B cells derived from Foxm1fl/fl mice with BCR-ABL1 and with an inducible ERT2-Cre vector. Deletion of Foxm1 in BCR-ABL1-driven leukemia decreases cell viability, colony formation, and proliferative capacity in vitro as well as leukemia formation in vivo. FOXM1-deleted ALL cells revealed a strikingly higher sensitivity towards TKI-treatment compared to the control cells in Imatinib dose-response curves (IC50 EV:420 nM vs IC50 Cre-ERT2: 160 nM) as well as annexin V staining. We identified the ROS scavenger Catalase as a critical target of FOXM1 in mediating this drug resistance. As potential therapeutic agents to target FOXM1, we evaluated the effects of a previously described ARF peptide and the natural occurring antibiotic Thiostrepton. Both bind FOXM1 and inhibit its function as shown by reduced mRNA expression of FOXM1 target genes (Cyclin B1, PLK1, AURKB) and induced apoptosis in ALL and prolonged survival of patient-derived ALL transplant recipient mice. Conclusion: We have identified a critical function of the transcription factor FOXM1 in mediating proliferation and drug-resistance in B cell lineage ALL, but not in normal B cell progenitors and validated FOXM1 as a therapeutic target in a large fraction of drug-resistant B cell lineage ALL. Disclosures No relevant conflicts of interest to declare.

Background and Hypothesis: CML and Ph+ ALL are both driven by the oncogenic BCR-ABL1 tyrosine kinase and CML can progress into lymphoid blast crisis (LBC), which is clinically and biologically indistinguishable from Ph+ ALL. We hypothesize that the stark differences in phenotype and clinical outcomes between CML and Ph+ ALL/LBC are due to lineage-specific transcription factors. Our group recently identified BACH2 as a B cell-specific transcription factor that mediates negative selection at the pre-B cell receptor checkpoint and functions as a tumor suppressor in Ph+ ALL and LBC (Swaminathan et al., Nature Med 2013). Here we report the surprising finding that BACH2 mediates lineage-specific fate decisions in BCR-ABL1 driven leukemia: while a potent tumor suppressor in B cell lineage in Ph+ ALL and LBC, BACH2 is required for survival and self-renewal of myeloid lineage CML cells. Results: A gene expression analysis in 99 patients with CML (Radich et al, 2006) revealed that patients with higher blast counts showed significantly higher gene expression values of BACH2 (P=8.88 x 10-9), suggesting that BACH2 mRNA levels increase with CML progression. To determine the mechanistic role of BACH2 in the progression of CML, we studied genetic deletion of BACH2 in a CML mouse model. To this end, we transformed Lin-kit+Sca-1+(LSK) cells from Bach2+/+ and Bach2-/- bone marrow with BCR-ABL1. We compared these cells alongside with Bach2+/+ and Bach2-/- pre-B cells that were transformed with BCR-ABL1 as a model for Ph+ ALL and LBC. Bach2+/+ and Bach2-/- CML-like and Ph+ ALL/LBC-like leukemia cells were then tested in a series of functional experiments to test their ability to initiate fatal leukemia in transplant recipients. While deletion of BACH2 accelerated B cell lineage leukemia (Ph+ ALL/LBC-like) in transplant recipients, we noted the opposite outcome in transplant experiments with myeloid lineage CML cells: All mice receiving Bach2+/+BCR-ABL1-transformed LSK cells developed CML-like disease within 60 days whereas recipients of Bach2-/- cells did not develop CML-like disease (Bach2+/+ vs Bach2-/-, median survival time= 33 days vs undefined; P=0.001). Additionally, we observed that deletion of Bach2 loss reduced both the colony formation ability (P=0.0059) and the S phase proliferation potential (P=0.0075) of the CML progenitors. These results were in contrast to those observed in Ph+Bach2+/+ and Bach2-/- ALLs. Reconstitution of Bach2 in Bach2-/- CML cells rescued its colony forming ability (P= 0.023). These findings were confirmed in primary human CML cells from two patients with CML in chronic phase: Inducible overexpression of Bach2 in patient-derived CML cells conferred a selective proliferative advantage of BACH2 overexpressing cells over time, in comparison to empty vector controls. Bach2 triggered a survival program in human and mouse CML cells, in contrast to B cell lineage Ph+ ALL and LBC cells. Interestingly, Bach2 did not provide a selective growth advantage to untransformed myeloid and multi-lineage progenitor cells. This demonstrates that Bach2 drives lineage-specific fate decisions and cooperates with the transforming BCR-ABL1 oncogene. Utilizing an in vitro lineage-switch assay overexpressing CEBPα we characterized the opposing roles of BACH2 in Ph+ ALL and CML. Cell viability and colony formation assays demonstrated that absence of Bach2 results in increased survival and proliferation of Ph+ ALL cells. In striking contrast, however, CEBPα-induced myeloid reprogramming induced cell cycle arrest and suppressed colony formation in Bach2-deficient cells (P=0.0001). Conclusion: While BACH2 is primarily expressed in the B cell lineage, functioning as a tumor suppressor in Ph+ ALL, we report here the surprising finding that BACH2 is required for survival and self-renewal of myeloid lineage CML cells. BACH2 mediates lineage-specific fate decisions in BCR-ABL1 driven leukemia and represents one example of how conversion of lineage identity (e.g. from CML to LBC) may impact specific requirement for malignant transformation. For instance, deletions of BACH2 at 6q15 are common in CML at the time of LBC progression but are not found in CML chronic phase or myeloid blast crisis. Disclosures No relevant conflicts of interest to declare.

Background and hypothesis: Childhood pre-B acute lymphoblastic leukemia (ALL) can frequently be retraced to a pre-leukemic clone carrying a prenatally acquired genetic lesion (e.g. ETV6-RUNX1gene rearrangement). After birth, pre-leukemic clones can acquire secondary mutations and, hence, evolve towards overt leukemia. While this concept is well established, the mechanism(s) driving clonal evolution are not known. Epidemiological findings hint to a role of delayed childhood infections and chronic inflammation as etiologic factors of childhood ALL, but do not illuminate mechanism of clonal evolution of pre-leukemic cells. In this study, we demonstrate that cooperation between the AID cytosine deaminase and the RAG1/RAG2 V(D)J recombinase promotes acquisition of secondary genetic lesions that promote progress of pre-leukemic B cell precursors towards full-blown leukemia. Results: The enzymatic activity of RAG1/RAG2 (VDJ recombination) and AID (somatic hypermutation, class-switch recombination) are strictly segregated to early and late stages of B cell development, respectively. While RAG1 and RAG2 are actively expressed at stages of early B cell development (bone marrow and fetal liver) that give rise to pre-B ALL, little is known about the function of AID in early B-lymphopoesis. As the involvement of AID in pre-B leukemic clonal evolution is incumbent on its expression during early stages of B-lymphopoesis, we tested CD19+ pre-B cells isolated from human bone marrow (BM) for indicators of AID activity, namely, somatic hypermutation (SHM) and class switch recombination (CSR). Interestingly, most pre-B cell clones carry rearranged Ig VH region genes that are mutated at low levels (average mutation frequency 26 x 10-3 bp). Likewise, pre-B cells isolated from fetal liver tissues (three donors; 10-19 weeks of gestation) carried Ig VH region genes mutated at low levels (average mutation frequency 14 x 10-3 bp). In addition, about one third of fetal liver pre-B cells had undergone CSR to Cγ3, Cγ1 and Cα regions. These findings highlight the previously unknown function of AID in two important sites of early human B-lymphopoesis. Based on these results, we hypothesized that a specific B cell subset during early pro- and pre-B cell differentiation can concomitantly express both AID and the RAGs and, hence, would be particularly susceptible to clonal evolution of cells that carry a pre-leukemic lesion. Our subsequent studies identified late pre-B cells (Fraction D) as a natural subset of increased genetic vulnerability. Late pre-B cells downregulate IL7 receptor/Stat5 signaling, which enables expression of RAG1 and RAG2 and immunoglobulin light chain gene rearrangement. Loss of IL7 receptor/Stat5 signaling also removes an important safeguard against premature expression of AID. Therefore, late pre-B cells are poised to express AID at high levels in response to inflammatory stimuli (e.g. LPS) in concurrence with RAG1 and RAG2. Studying clonal evolution of patient-derived pre-B ALL cells, we found evidence for concomitant AID and RAG1/RAG2 activity. Further studying a genetic mouse model for pre-leukemic pre-B cells carrying ETV6-RUNX1, we found that repeated exposure to LPS can cause overt leukemia but not in the absence of either AID or Rag1. Additionally, whole exome sequencing of human B cell clones that were engineered to express AID, RAG1/RAG2 alone or in combination revealed that concurrent expression of AID with RAG1/RAG2 dramatically increased the frequency of structural chromosomal lesions. Conclusion: Consistent with epidemiological findings on the etiology of childhood ALL, we conclude that reduced cytokine signaling (here, IL7R) in late pre-B cells renders pre-leukemic clones distinctively vulnerable to genetic lesions that can be acquired in the context of repeated exposure to inflammatory stimuli (e.g. chronic and recurrent infections during childhood). Our results support a role for AID and RAGs cooperation for the generation of secondary lesions in leukemia subgroups that require additional leukemogenic events, and therefore, provide the genetic and molecular basis to support the Delayed Infections Hypothesis for leukemia progression in children. Disclosures No relevant conflicts of interest to declare.

Increasing evidence suggests that AMPA receptors (AMPARs) play a key role in mediating excitotoxic cell damage after acute spinal cord injury (SCI). However, the role of glial AMPARs in posttraumatic white matter injury requires further clarification. In the present study we examined the changes in AMPAR expression after SCI, the cellular distribution of these changes, and their association with apoptosis. Western blots revealed expression of GluR1, 3, and 4, but not GluR2, in spinal cord white matter. Immunohistochemistry was used to examine the distribution of AMPARs in spinal cord white matter. Quantification of AMPAR-expressing cells in spinal cord white matter indicated predominantly GluR3 expression in oligodendrocytes and predominantly GluR4 expression in astrocytes. A clip compression model of SCI was used to examine the changes in AMPAR expression in dorsal column white matter after injury. Quantitative analysis of GluR3 levels of expression indicated a significant decrease at 3 days postinjury compared to uninjured animals, followed by a recovery of expression by 2 weeks. GluR4 subunits followed a similar expression pattern. Gene message expression of GluR3 and GluR4 flip/flop mRNA splice variants exhibited a pattern of expression that correlated with protein expression. GluR3-expressing glia appeared to be more susceptible to apoptosis than GluR4-expressing cells. A large decline in GluR3-expressing oligodendrocytes suggests that this subunit may be associated with the induction of apoptosis in white matter glia, thus contributing to secondary injury mechanisms.

Introduction: The BCR-ABL1 tyrosine kinase induces malignant transformation of B cells at the pre-B cell checkpoint and induces Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL). In a genome-wide search, we identified FOXM1 as a transcription factor that is specifically upregulated at the pre-B cell checkpoint. FOXM1 is a forkhead box transcription factor and a key regulator of cell growth by promoting cell cycle progression. Results: We transformed murine pre-B cells with a retroviral BCR-ABL1 expression vector and observed upregulation of Foxm1 protein levels. Consistent with this, FOXM1 protein levels in patient-derived Ph+ ALL samples are ∼10-fold higher than in healthy B cells and B cell precursors (n=5; P=0.01). In a cohort of 83 Ph+ ALL patients, the FOXM1 promoter region was significantly de-methylated compared to normal pre-B cells (n=12; P=2.4x10e-7). In order to evaluate a potential predictive value of FOXM1 expression in ALL cells, we correlated FOXM1 mRNA levels with clinical outcome. High FOXM1 expression correlates with shorter overall survival in patients with ALL (n=12, P=0.05) and was predictive of a higher risk of relapse (n=21; P=7.3x10e-5). To study the functional role of FOXM1 in Ph+ ALL, we developed a genetic model for Foxm1 loss-of-function using Foxm1fl/fl mice. Cre-mediated, inducible deletion of Foxm1 decreases ALL cell viability (n=3; P=0.001) and reduced proliferative capacity (n=3; S-phase Foxm1+/+ 59% vs 42% for Foxm1-/-; P=0.0004). The ability to form colonies in vitro was significantly decreased by deletion of Foxm1 (n=3, P=8.9x10e-6). Injection of 1x10e5 Foxm1+/+ or Foxm1-/- leukemic cells into NOD/SCID mice revealed reduced leukemogenesis in vivo (n=7; P=0.0035). In contrast, normal B cell precursors were unaffected by Foxm1 deletion both, in vitro and in vivo. In addition, Foxm1-deleted ALL cells revealed a strikingly higher sensitivity towards Imatinib in dose-response curves compared to control cells (IC50=420 nM for Foxm1+/+ vs 160 nM for Foxm1-/-). Mechanistically, we found that FOXM1 decreased levels of reactive oxygen species via upregulation of the antioxidant response molecule catalase. As potential therapeutic agents to target FOXM1, we evaluated the effects of a previously described ARF peptide (AA 26-44) and the natural occurring antibiotic Thiostrepton. Both bind and inhibit the function of FOXM1, and induced apoptosis in Ph+ ALL. Patient-derived Ph+ ALL cells were xenografted into NOD/SCID recipients and then treated with Thiostrepton i.v. for 7 consecutive days. Thiostrepton-treatment resulted in significantly prolonged overall survival (29 vs 35 days; n=7; P=0.0014) and reduced leukemia burden as measured by luciferase bioimaging, as compared to vehicle controls. Conclusion: Taken together, our data identify the pre-B cell-specific transcription factor FOXM1 as a novel therapeutic target for the treatment of TKI-resistant Ph+ ALL. Citation Format: Maike V. Buchner, Eugene Park, Lars Klemm, Huimin Geng, Dragana Kopanja, Pradip Raychaudhuri, Markus Müschen. Identification of FOXM1 as therapeutic target in Philadelphia chromosome-positive acute lymphoblastic leukemia. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 484. doi:10.1158/1538-7445.AM2014-484