chemotherapy followed by high-dose therapy with autologous stem cell transplant and subsequent antidisialoganglioside antibody immunotherapy is standard of care for patients with high-risk neuroblastoma, but survival rate among these patients remains low. OBJECTIVE To determine if tandem autologous transplant improves event-free survival (EFS) compared with single transplant. DESIGN, SETTING, AND PARTICIPANTS Patients were enrolled in this randomized clinical trial from November 2007 to February 2012 at 142 Children's Oncology Group centers in the United States, Canada, Switzerland, Australia, and New Zealand. A total of 652 eligible patients aged 30 years or younger with protocol-defined high-risk neuroblastoma were enrolled and 355 were randomized. The final date of follow-up was June 29, 2017, and the data analyses cutoff date was June 30, 2017. INTERVENTIONS Patients were randomized to receive tandem transplant with thiotepa/cyclophosphamide followed by dose-reduced carboplatin/etoposide/melphalan (n = 176) or single transplant with carboplatin/etoposide/melphalan (n = 179). MAIN OUTCOMES AND MEASURES The primary outcome was EFS from randomization to the occurrence of the first event (relapse, progression, secondary malignancy, or death from any cause). The study was designed to test the 1-sided hypothesis of superiority of tandem transplant compared with single transplant. RESULTS Among the 652 eligible patients enrolled, 297 did not undergo randomization because they were nonrandomly assigned (n = 27), ineligible for randomization (n = 62), had no therapy (n = 1), or because of physician/parent preference (n = 207). Among 355 patients randomized (median diagnosis age, 36.1 months; 152 [42.8%] female), 297 patients (83.7%) completed the study and 21 (5.9%) were lost to follow-up after completing protocol therapy. Three-year EFS from the time of randomization was 61.6% (95% CI, 54.3%-68.9%) in the tandem transplant group and 48.4% (95% CI, 41.0%-55.7%) in the single transplant group (1-sided log-rank P=.006). The median (range) duration of follow-up after randomization for 181 patients without an event was 5.6 (0.6-8.9) years. The most common significant toxicities following tandem vs single transplant were mucosal (11.7% vs 15.4%) and infectious (17.9% vs 18.3%). CONCLUSIONS AND RELEVANCE Among patients aged 30 years or younger with high-risk neuroblastoma, tandem transplant resulted in a significantly better EFS than single transplant. However, because of the low randomization rate, the findings may not be representative of all patients with high-risk neuroblastoma.

The role of dihydroceramide desaturase as a key enzyme in the de-novo pathway of ceramide generation was investigated in human neuroblastoma cells (SMS-KCNR). A novel assay using water soluble analogs of dihydroceramide, dihydroceramidoids (D-e-dhCCPS analogs) was used to measure desaturase activity in-situ. Conversion of D-e-C12-dhCCPS (C12-dhCCPS) to its 4,5-desaturated counterpart: D-e-C12-CCPS (C12-CCPS) was determined by LC/MS analysis. The validity of the assay was confirmed by C8-cyclopropenylceramide, a competitive inhibitor of dihydroceramide desaturase. A human homologue (DEGS-1) of the Drosophila melanogaster degenerative-spermatocyte-gene-1 (des-1) was recently identified, and reported to have desaturase activity. Transfection of SMS-KCNR cells with siRNA to DEGS-1 significantly blocked the conversion of C12-dhCCPS to C12-CCPS. The associated accumulation of endogenous dihydroceramides confirmed DEGS-1 as the main active dihydroceramide desaturase in these cells. The partial loss of DEGS-1 inhibited cell growth with cell cycle arrest at G0/G1. This was accompanied by significant decrease in the amount of phosphorylated retinoblastoma protein (pRb). This hypophosphorylation was inhibited by tautomycin and not by okadaic acid, suggesting the involvement of protein phosphatase 1. Additionally, we found that treatment of SMS-KCNR cells with fenretinide inhibited desaturase activity in a dose dependent manner. Increase of dihydroceramides, but not ceramides, paralled this process as measured by LC/MS. There were no effects on the mRNA or protein levels of DEGS-1, suggesting that fenretinide acts at the posttranslational level as an inhibitor of this enzyme. Tautomycin was also able to block the hypophosphorylation of Rb observed with fenretinide treatment. These findings suggest a novel biologic function for dihydroceramides.Sphingolipids, in addition to their roles as structural components of cell membranes, play important roles as regulators of signal transduction in cell differentiation, cell proliferation, and apoptosis. One of the most studied sphingolipids is ceramide (1-5). Ceramide (Cer) is the central building block for sphingolipids. It serves as a precursor for the synthesis of more complex sphingolipids; and is generated in cells by multiple pathways. Ceramide can be produced de-novo from serine and palmitoyl-CoA via dihydroceramide (dhCer), followed by its desaturation to Cer by dihydroceramide desaturase. While there has been a great body of *Address correspondence to: Jacqueline M. Kraveka, Division of Pediatric Hematology-Oncology, Medical University of South Carolina, 135 Rutledge Avenue, PO Box 250558, Charleston, SC 29425. Tel: 843-792-2957; Fax: 843-792-8912; Email: kravekjm@musc.edu. Dihydroceramide desaturase is responsible for inserting the 4,5-trans-double bond to the sphingoid backbone of dhCer. The enzyme was previously characterized and an in-vitro assay was developed to determine its activity (6-9). A crude enzyme preparation was isolated from rat liver microsomes. In a...

Neuroblastoma is an embryonic tumor of the peripheral sympathetic nervous system. It is the most common extracranial solid tumor of childhood and accounts for up to 15% of all pediatric cancer fatalities. The manifestation of neuroblastoma is variable depending on the location of the tumor and on the presence or absence of paraneoplastic syndromes. The prognosis of neuroblastoma is also highly variable, ranging from spontaneous regression to widespread metastatic disease that is unresponsive to treatment. The age of the patient, stage of disease, histopathologic results, and multiple biologic factors contribute to the presurgical and pretreatment risk stratification of a patient with neuroblastoma. Multimodality anatomic imaging with ultrasonography, computed tomography, and magnetic resonance imaging, as well as functional or metabolic nuclear imaging, are essential to determining the risk status of a patient with neuroblastoma. Patients at low risk of metastasis or death receive minimal intervention and those at high risk receive multimodality treatment. New immunotherapeutic techniques and nuclear medicine-targeted therapies have emerged and are demonstrating promising response rates for patients at high risk. This article reviews updates in the diagnosis, management, and treatment of neuroblastoma that have evolved over the past 2 decades, including emphasis on presurgical risk stratification, genetic evaluation of tumors, and the use of modern, high-quality, advanced imaging modalities. RSNA, 2018.

BackgroundNeuroblastoma (NB) is the most common cancer in infancy and most frequent cause of death from extracranial solid tumors in children. Ornithine decarboxylase (ODC) expression is an independent indicator of poor prognosis in NB patients. This study investigated safety, response, pharmacokinetics, genetic and metabolic factors associated with ODC in a clinical trial of the ODC inhibitor difluoromethylornithine (DFMO) ± etoposide for patients with relapsed or refractory NB.Methods and FindingsTwenty-one patients participated in a phase I study of daily oral DFMO alone for three weeks, followed by additional three-week cycles of DFMO plus daily oral etoposide. No dose limiting toxicities (DLTs) were identified in patients taking doses of DFMO between 500-1500 mg/m2 orally twice a day. DFMO pharmacokinetics, single nucleotide polymorphisms (SNPs) in the ODC gene and urinary levels of substrates for the tissue polyamine exporter were measured. Urinary polyamine levels varied among patients at baseline. Patients with the minor T-allele at rs2302616 of the ODC gene had higher baseline levels (p=0.02) of, and larger decreases in, total urinary polyamines during the first cycle of DFMO therapy (p=0.003) and had median progression free survival (PFS) that was over three times longer, compared to patients with the major G allele at this locus although this last result was not statistically significant (p=0.07). Six of 18 evaluable patients were progression free during the trial period with three patients continuing progression free at 663, 1559 and 1573 days after initiating treatment. Median progression-free survival was less among patients having increased urinary polyamines, especially diacetylspermine, although this result was not statistically significant (p=0.056).ConclusionsDFMO doses of 500-1500mg/m2/day are safe and well tolerated in children with relapsed NB. Children with the minor T allele at rs2302616 of the ODC gene with relapsed or refractory NB had higher levels of urinary polyamine markers and responded better to therapy containing DFMO, compared to those with the major G allele at this locus. These findings suggest that this patient subset may display dependence on polyamines and be uniquely susceptible to therapies targeting this pathway.Trial RegistrationClinicaltrials.gov NCT#01059071

The dihydroceramide desaturase (DES) enzyme is responsible for inserting the 4,5-trans-double bond to the sphingolipid backbone of dihydroceramide. We previously demonstrated that fenretinide (4-HPR) inhibited DES activity in SMS-KCNR neuroblastoma cells. In this study, we investigated whether 4-HPR acted directly on the enzyme in vitro. N-C8:0-D-erythrodihydroceramide (C 8 -dhCer) was used as a substrate to study the conversion of dihydroceramide into ceramide in vitro using rat liver microsomes, and the formation of tritiated water after the addition of the tritiated substrate was detected and used to measure DES activity. NADH served as a cofactor Sphingolipids are known to be modulators of various cell functions. They are not only components of cell membranes but also play a role in cell survival, apoptosis, senescence, and differentiation (1, 2). Ceramide, a central molecule in the metabolism of sphingolipids and glycosphingolipids, is involved in these regulatory cellular events. Intracellulary, ceramide is generated by different pathways. De novo synthesis of ceramide starts with condensation of L-serine with palmitoylCoA. Further reduction and subsequent N-acylation generates dihydroceramide. Ceramide is finally generated by introduction of the 4,5-double bond into dihydroceramide by dihydroceramide desaturase (DES) 2 (3). The DES enzyme was characterized previously, and an in vitro assay was developed to determine its activity (4). In subsequent studies, a family of sphingolipid ⌬4-desaturases (homologs of the Drosophila melanogaster degenerative spermatocyte gene 1 (des-1)) were identified via a bioinformatics approach (5). These proteins contain three His-containing consensus motifs that are characteristic of a group of membrane fatty acid desaturases. The human homolog of des-1 is now referred to as DEGS-1, although it was first cloned in 1997 and named as membrane lipid desaturase because its physiologic substrate was not determined at the time (6). DEGS-1 is the only dihydroceramide desaturase reported to be present in human cells, and its mouse homolog (mDES1) was shown to have desaturase activity (7). hDES2, the human homolog of the mouse DES2 (mDes2) gene, like mDES2 has dihydroceramide hydroxylase activity (8). Although mDES2 has been reported to have both desaturase and hydroxylase activity, no desaturase activity was detected in HEK 293 human embryonic kidney cells overexpressing hDES2 (8). In this work, we refer to enzyme as DES in experiments with rat liver microsomes and as DEGS-1 in experiments with human SMS-KCNR cells.We previously developed an assay to evaluate the in situ activity of DEGS-1 using cell-permeable dihydroceramidoids (dhCCPS analogs) (9). We showed in these studies that the

The efficacy of incorporating IDM/HiDAC in the treatment plan of pediatric and adolescent patients with advanced-stage LCL was inconclusive as to its effect on EFS, regardless of the lymphoma phenotype. It cannot be excluded that with a higher number of patients, one treatment could prove superior and future studies will build on these data.

This study was designed to analyze whether ceramide, a bioeffector of growth suppression, plays a role in the regulation of telomerase activity in A549 cells. Telomerase activity was inhibited significantly by exogenous C 6 -ceramide, but not by the biologically inactive analog dihydro-C 6 -ceramide, in a time-and dose-dependent manner, with 85% inhibition produced by 20 M showing that the increased endogenous ceramide is sufficient for telomerase inhibition. Moreover, treatment of A549 cells with daunorubicin at 1 M for 6 h resulted in the inhibition of telomerase, which correlated with the elevation of endogenous ceramide levels and growth arrest. Finally, stable overexpression of human glucosylceramide synthase, which attenuates ceramide levels by converting ceramide to glucosylceramide, prevented the inhibitory effects of C 6 -ceramide and daunorubicin on telomerase. Therefore, these results provide novel data showing for the first time that ceramide is a candidate upstream regulator of telomerase.

Despite recent advances in the development of novel therapies against castration resistant prostate cancer, the advanced form of the disease remains a major treatment challenge. Aberrant sphingolipid signaling through sphingosine kinases and their product sphingosine-1-phosphate can promote proliferation, drug resistance, angiogenesis and inflammation. The sphingosine kinase 2 inhibitor ABC294640 is undergoing clinical testing in cancer patients, and in this study we investigated the effects this first-in-class inhibitor in castration resistant prostate cancer. In vitro, ABC294640 decreased prostate cancer cell viability as well as the expression of c-Myc and the androgen receptor while lysosomal acidification increased. ABC294640 also induced a greater than 3-fold increase in dihydroceramides that inversely correlated with inhibition of dihydroceramide desaturase (DEGS) activity. Expression of sphingosine kinase 2 was dispensable for the ABC294640-mediated increase in dihydroceramides. In vivo, ABC294640 diminished the growth rate of TRAMP-C2 xenografts in syngeneic hosts and elevated dihydroceramides within tumors as visualized by MALDI imaging mass spectroscopy. The plasma of ABC294640 treated mice contained significantly higher levels of C16- and C24:1-ceramides (but not dihydro-C16-ceramide) compared to vehicle treated mice. In summary, our results suggest that ABC294640 may reduce the proliferative capacity of castration resistant prostate cancer cells through both, inhibition of sphingosine kinase 2 and dihydroceramide desaturase, which provides a foundation for future exploration of this small molecule inhibitor for the treatment of advanced disease.