BackgroundDespite advances in molecular medicine over recent decades, there has been little advancement in the treatment of osteosarcoma. We performed comprehensive molecular profiling in two cases of metastatic and chemotherapy-refractory osteosarcoma to guide molecularly targeted therapy.Patients and MethodsHybridization capture of >300 cancer-related genes plus introns from 28 genes often rearranged or altered in cancer was applied to >50 ng of DNA extracted from tumor samples from two patients with recurrent, metastatic osteosarcoma. The DNA from each sample was sequenced to high, uniform coverage. Immunohistochemical probes and morphoproteomics analysis were performed, in addition to fluorescence in situ hybridization. All analyses were performed in CLIA-certified laboratories. Molecularly targeted therapy based on the resulting profiles was offered to the patients. Biomedical analytics were performed using QIAGEN's Ingenuity® Pathway Analysis.ResultsIn Patient #1, comprehensive next-generation exome sequencing showed MET amplification, PIK3CA mutation, CCNE1 amplification, and PTPRD mutation. Immunohistochemistry-based morphoproteomic analysis revealed c-Met expression [(p)-c-Met (Tyr1234/1235)] and activation of mTOR/AKT pathway [IGF-1R (Tyr1165/1166), p-mTOR [Ser2448], p-Akt (Ser473)] and expression of SPARC and COX2. Targeted therapy was administered to match the P1K3CA, c-MET, and SPARC and COX2 aberrations with sirolimus+ crizotinib and abraxane+ celecoxib. In Patient #2, aberrations included NF2 loss in exons 2–16, PDGFRα amplification, and TP53 mutation. This patient was enrolled on a clinical trial combining targeted agents temsirolimus, sorafenib and bevacizumab, to match NF2, PDGFRα and TP53 aberrations. Both the patients did not benefit from matched therapy.ConclusionsRelapsed osteosarcoma is characterized by complex signaling and drug resistance pathways. Comprehensive molecular profiling holds great promise for tailoring personalized therapies for cancer. Methods for such profiling are evolving and need to be refined to better assist clinicians in making treatment decisions based on the large amount of data that results from this type of testing. Further research in this area is warranted.

SummaryThe degree of somatic hypermutation, determined as percent deviation of immunoglobulin heavy chain gene variable region sequence from the germline (IGHV%), is an important prognostic factor in chronic lymphocytic leukaemia (CLL). Currently, a cut-off of 2% deviation or 98% sequence identity to germline in IGHV sequence is routinely used to dichotomize CLL patients into mutated and unmutated groups. Because dissimilar IGHV% cut-offs of 1-5% were identified in different studies, we wondered whether no cut-off should be applied and IGHV% treated as a continuous variable. We analysed the significance of IGHV% in 203 CLL patients enrolled on the original frontline fludarabine, cyclophosphamide and rituximab (FCR) trial with a median of 10 years follow-up. Using the Cox Proportional Hazard model, IGHV% was identified as a continuous variable that is significantly associated with progression-free (PFS) and overall survival (OS) (P < 0Á001). Furthermore, we validated this finding in 323 patients treated with FCR off-protocol and in the total cohort (n = 535). Multivariate analysis revealed a continuous trend. Higher IGHV% levels were incrementally associated with favorable PFS and OS in both FCR-treated cohorts (P < 0Á001, both cohorts). Taken together, our data suggest that IGHV% is a continuous variable in CLL patients treated with FCR.Keywords: CLL, FCR, IGHV gene, immunoglobulin heavy chain gene.The mutation status of the immunoglobulin heavy chain variable region gene (IGHV) is an established prognostic factor in patients with chronic lymphocytic leukaemia (CLL). Fais et al (1998) identified the presence of somatic hypermutation (SHM) in CLL cells and the prognostic significance of the percent of SHM deviation from the germline sequence (IGHV%) in patients with CLL was described the following year (Damle et al, 1999;Hamblin et al, 1999). In recent years a cut-off value of 2% deviation from the germline sequence of IGHV (i.e. 98% identity) has been commonly used in clinical practice and, according to the current dogma, CLL patients with ≥2% deviation, or otherwise ≤98% identity, are considered 'mutated' (M-CLL), whereas CLL patients with <2% IGHV% deviation or >98% identity are considered research paper ª

Mast cell leukemia (MCL) is a very rare subtype of systemic mastocytosis (SM). We have identified 13 such patients (5.9%) among 218 patients with SM seen at our institution between 1994 and 2016. Patients with MCL had poor survival (median 31.6 months); response to various therapies was rare and not durable. Clinical course may be affected by concurrent associated hematologic neoplasm and different genetic profiles. More research is required to decipher this rare and enigmatic SM subtype.

BackgroundChronic Epstein Barr virus (EBV) infection in an immunocompetent host has been described however it is not a common entity. It has been linked to many lymphoproliferative disorders and achieves such via many molecular mechanisms, some of which are poorly understood. In addition to infectious mononucleosis, the EBV is linked to various other hematological pathologies and autoimmune disorders.Case presentationWe describe the case of an elderly immunocompetent female who presented with non-specific symptomatology, lymphadenopathy, cytopenias, elevated autoantibody titers and a crescent EBV viral load that were suggestive of a multisystemic inflammatory disease related to EBV. Extensive work up including multiple bone marrow biopsy and lymphoid tissue procedures ultimately led to the diagnosis of Hodgkin lymphoma.ConclusionEBV-related lymphomagenesis is complex and through the utilization of its nuclear antigens and latent membrane proteins the virus is able to shape the microenvironment to promote the various pathologies seen. Moreover, the diagnosis of EBV-associated lymphoproliferative disorders might be challenging when they present in immunocompetent individuals. Our case also represents an emphatic reminder for clinicians that spontaneous regression of lymphadenopathy is not exclusive of low-grade lymphoid malignancies.

The XPO1 (exportin) gene (also referred to as chromosome region maintenance 1; CRM1) is a karyopherin that exports proteins and RNA fragments from the nucleus into the cytoplasm.1,2 The human XPO1 gene, located on chromosome 2 (2p15), is believed to encode an oncogenic protein since many of the molecules exported by XPO1 into the cytoplasm are associated with either known tumor-suppressor genes, such as TP53 or FOXO3A, or transcription factors that contribute to cell proliferation and survival such as IkB-α3 or STAT34 whose accumulation in the nucleus results in cell death. The binding of XPO1 to various proteins is mediated by recognizing the leucine-rich nuclear export signals (LR-NES) on the N-terminus of snurportin 1 (SNUPN) forming a nuclear pore complex or a cargo, thereby transporting proteins out of the nuclear membrane. Overexpression, deregulation, or dysfunction of XPO1 has been reported in various types of cancer.5 XPO1 is a therapeutic target in CLL,6 and selective inhibitors of nuclear transport (SINE) such as selinexor are now being investigated in clinical trials in CLL.