>>MY NAME IS
TAKEO FUJIII, WOMEN'S MALIGNANCY
BRANCH NCI. IT IS 1 P.M. SO WE
WILL START OUR SECOND LECTURE
SESSION FROM CLINICAL
(INAUDIBLE). I'M HONORED TO
MODERATE THIS SESSION AND WE
WILL START FROM DR. WARNER'S
PRESENTATION. SO LET'S INTRODUCE
DR. BLAKE WARNER. HE RECEIVED
HIS DDS Ph.D. AT THE OHIO
STATE UNIVERSITY IN SUBSEQUENTLY
COMPLETED A CLINICAL RESIDENCY
IN ORAL MAXILLO FACIAL PATHOLOGY
AT THE UNIVERSITY OF PITTSBURG
AND BOARD CERTIFIED. HE
COMPLETED THE POST-DOCTORAL
CLINICAL RESEARCH FELLOWSHIP IN
(INAUDIBLE) LAB NIDCR FOCUSED ON
TRANSLATIONAL INVESTIGATION IN
SJOGREN'S DISEASE AND RADIATION
INDUCED DYSTONIA. IN 2018 DR.
WARNER WAS APPOINTED ACTING
CHIEF OF THE SJOGREN'S DISEASE
CLINIC AND 2019 ASSOCIATE
CLINICAL INVESTIGATOR AND WAS
APPOINTED CHIEF OF THE
(INAUDIBLE) DISORDERS IN
SJOGREN'S DISEASE CLINIC. DR.
WARNER IS A MULTI-SPECIALTY
CLINIC AND ALLOWED FOCUSED ON
DEEP CHARACTERIZATION OF
SJOGREN'S DISEASE AND OTHER
PATHOLOGY, OBJECTIVE OF HIS
RESEARCH PROGRAM IS AIMED AT
DEFINE SJOGREN'S SPECIFIC SOLAR
AND MOLECULAR INTERACTIONS
BETWEEN SALIVARY EPITHELIAL AND
INFLAMMATORY CELLS POPULATION.
IN THE TRANSLATIONAL NOVEL
THERAPEUTICS STRATEGIES TO
HUMANS. SO TODAY'S DR. WARN
NEAR'S PRESENTATION TITLE IS
APPLIED OMIC IDENTIFIERS
TARGETED THERAPIES FO FOR SJOGRS
DISEASE.
>>DR. FUJIII, THANK YOU FOR
THAT WARM INTRODUCTION. AGAIN,
MY NAME IS BLAKE WARNER,
ASSISTANT CLINICAL INVESTIGATOR.
HOPEFULLY I WILL CHANGE THAT
VERY SOON TO TENURE TRACK
CLINICAL INVESTIGATOR. SO WHAT
IS AN ORAL MAX OWE FACIAL
PATHOLOGIST? LIKE MOLECULAR
PATHOLOGIST I USE PATHOLOGY OR
THE MICROSCOPE AS MY TOOL OF
CLINICAL INVESTIGATION. BUT
UNLIKE ANATOMIC PATHOLOGY I USE
CLINICAL INVESTIGATION DIRECTLY
IN THE ORAL CAVITY AND HEAD AND
NECK REGION TO UNDERSTAND
DISEASES AND DISEASE PROCESSES
THAT AFFECT THE MOUTH. I BECAME
FASCINATE WITH THE SALIVARY
GLANDS BECAUSE I SAW THE
CONNECTION BETWEEN THE FUNCTION
OF AN ORGAN, THAT IS THE
SALIVARY GLANDS AND
IMMUNOPATHOLOGY UNDERLYING THAT
DYSFUNCTION. THE SALIVARY
DISORDERS UNITS STUDIES INSULTS
AND INJURIES TO THE SALIVARY
COMPLEX. DESPITE MODERN TYPES
OF INSULTS THAT OCCUR THEY SEEM
TO MANIFEST WITH THE SAME
CLINICAL STIGMATA INCLUDING
INCREASE PROPENSITY FOR ORAL
INFECTION INCLUDING TALL CARRIES
OF ORAL CANDIDIASIS BUT ALL HAVE
UNDERLYING PATHOPHYSIOLOGIC
MECHANISMS AND TO UNDERSTAND THE
DIFFERENT MECHANISMS WE DON'T
YET HAVE ANY EFFECTIVE
MODALITIES TO PREVENT TREAT OR
REVERSAL VARY GLAND DYSFUNCT DY.
DESPITE A MULTIPLE OF DIFFERENT
CLINICAL STATES WE STUDY WE DO
FOCUS EFFORTS ON SJOGREN'S
DISEASE SPECIFICALLY IN TRYING
TO UNDERSTAND PATHOPHYSIOLOGY OF
THAT DISEASE. SJOGREN'S DISEASE
IS A SUCCINCT CHRONIC AUTOIMMUNE
DISEASE THAT AFFECTED 3 MILLION
PERSONS IN THE UNITED STATES
WHICH ARE OVERWOMENNINGLY WOMEN
WITH PREDILECTION OF 901.
INDIVIDUALS ARE DIAGNOSED OVER
AGE 40 YEARS BUT DOESN'T MEAN
DISEASE PROCESSES HAPPEN ONLY
AFTER AGE 40. THERE IS OVERLAP
WITH OTHER DISEASES SUCH AS
LUPUS AND RHEUMATOID ARTHRITIS
AND IT VARIES FROM AIN'T LENT
YET INSIDIOUS TO PATIENTS THAT
EXHIBIT RAPID PROGRESSIVE --
PROGRESSION. THIS DISEASE IS
DEFINED BY A TREMENDOUSLY
INCREASED 20 TO 44 FOLD INCREASE
RISK OF DEVELOPMENT OF LYMPHOMA
THERE ARE NO FDA APPROVED
EFFECTIVE THERAPY FOR SJOGRENS
NOT BECAUSE WE HAVEN'T TRIED BUT
MULTIPLE OF REASONS SUCH AS GAPS
UNDERSTANDING THE UNDERLYING
PATHOLOGY AND THE INTRINSIC
DISEASE HETEROGENEITY, POOR
OUTCOME MEASURES AND LACK OF
CORRELATION OF TARGET ORGAN
RESPONSE IN THOSE TRIALS MEANING
GOING AFTER THE TARGET TISSUES
IN PATIENTS ON MEDICATION. WHAT
DO I MEAN BY CLINICAL AND
BIOLOGICAL HETEROGENEITY. IN THE
SJOGREN'S LITERATURE IF YOU LOOK
AT PAPERS WITH TRANSCRIPTOMICS
OF THE SALIVARY GLANDS OR OF THE
PERIPHERAL BLOOD AND LOOK AT THE
INDIVIDUAL CLINICAL METADATA
WITH THOSE, IT IS PRETTY CLEAR
THERE IS PROBABLY FOUR GROUPS OF
PATIENTS THAT WE DEFINE AS
SJOGREN'S DISEASE. THOSE
PATIENTS WHO ARE RELATIVELY
YOUNG AT DISEASE ONSET THAT HAVE
HIGH INTERFERON SCORES AND HIGH
TITER SSA AUTOANTIBODIES
DIAGNOSTIC AUTOANTIBODY FOUND IN
SJOGRENS. THEN YOU HAVE GROUPS
RELATIVELY DIFFICULT TO
DISENTANGLE WITH LOW INTERFERON
SCORES AND MODERATE INTERFERON
SCORES. THISs PATIENTS ARE A
LITTLE BIT OLDER BUT HAVE
DISTINCT CLINICAL
MANIFESTATIONS. THEN OF COURSE
THERE IS ANOTHER GROUP THAT IS
MORE DIFFERENT THAN THOSE THREE,
PATIENTS THAT ARE SSA
AUTOANTIBODY NEGATIVE THAT HAVE
PAIN DOMINANT WITH FATIGUE AND
CLIENTS OF ORAL DRYNESS. WHAT
YOU MIGHT THINK IS THESE
INDIVIDUAL GROUPS MIGHT
REPRESENT DISTINCT CLINICAL
ENTITIES. I DON'T THINK YOU
WOULD BE WRONG. IT TELLS US
SYMPTOMS PREDICT PRECISE
THERAPIES THESE CLUSTERS MAYBE
DYNAMIC, THEY CHANGE FROM
YOUNGER TO OLDER INDIVIDUALS.
WE CAN'T THINK OF THIS AS
TREATING THE SYMPTOMS BUT CAN WE
REVERSE OR PREVENT DISEASE
PROGRESSION AND AUGMENT
FUNCTION. WHAT HAVE IS THE
PATHOLOGY OF SJOGREN'S DISEASE?
THERE ISN'T A CLEAR DEFINITION.
IT USUALLY OCCURS IN THE CONTEXT
OF ENVIRONMENTAL INSULT LIKE AS
SUCH AS VIRAL INFECTION, IN A
SUSCEPTIBILITY INDIVIDUAL WITH
BACKGROUND APPROPRIATE GENETICS
WITH HORMONAL AND IMMUNE SYSTEM
ALTERATIONS LEADING TO
INFILTRATION AND EXOCRINE ORGANS
DEATH AND DESTRUCTION OF
FUNCTIONAL PARENCHYMA AND
EXPANSION OF AN IMMUNE
INFILTRATE IN A GLAND. SO I ASK
MYSELF FOR MANY YEARS WHAT ARE
THE EFFECTOR AND TARGET CELLS IN
SJOGREN'S DISEASE SALIVARY
GLANDS? I NARROWED TO ONE ORGAN
CLINICAL ACCESSIBLE, THERE IS
ENOUGH CELLS FOR US TO ATTEMPT
TO UNDERSTAND DIRECTLY IN HUMAN
TISSUES BACK IN THE LAB WHAT IS
GOING ON IN THOSE INDIVIDUAL
GLANDS. TO DO THIS WE HAVE
CLINICAL INVESTIGATIONS
INCLUDING OBSERVATIONAL AND
INTERVENTIONAL STUDIES.
INCLUDING CROSS SECTIONAL
STUDIES WE CALL CHARACTERIZATION
OF DISEASE WITHSON GLAND
DYSFUNCTION AND PATHOGENESIS AND
NATURAL HISTORY STUDIES WHERE WE
FOLLOW PATIENTS FIVE TO TEN
YEARS. WE ALSO HAVE A SYSTEM
THAT IS CREATED TO ENTERTAIN OR
AT LEAST TEST NOVEL THERAPEUTIC
APPROACHES. WHAT WE TAKE TISSUES
AND DATA THAT WE GLEAN FROM
THESE STUDIES BACK TO LAB FOR
DIRECT INTERROGATION OF THESE
TISSUES. SO THE MODELS THAT WE
WORK WITH ARE PATIENT TISSUES.
WE INVESTIGATE THE
IMMUNOPATHOLOGY OF SJOGREN'S
DISEASE TO IDENTIFY EFFECTIVE
THERAPIES IN HUMANS AND
HOPEFULLY TRANSLATE THIS BACK TO
NOVEL CLINICAL TRIALS AN
EFFECTIVE THERAPIES. I STUDY
SALIVARY TYPE EXOCRINE ORGAN,
THE TARGET ORGANS FOR SJOGREN
DISEASE AND I HAVE A CARTOON I
CREATED TO ILLUSTRATE WHAT
HAPPENS IN THE CONTEXT OF
SJOGREN'S YOU HAVE A HEALTHY
SALIVARY GLAND, A FULLY
FUNCTIONAL SAL RARE GLAND
COMPOSED OF DIFFERENT CELL TYPES
AND SERA MUCOUS AND OVER TIME IN
THE CONTEXT OF DISEASE YOU LOSE
FUNCTIONAL PARENCHYMA AND IT IS
REPLACED BY IMMUNE INFILTRATE AS
WELL AS ELABORATION OF FIBROSIS
WHICH LEADS TO DYSFUNCTION IN
THE SALIVARY GLANDS, THIS DOES
NOT HAPPEN TO EVERY GLAND AT THE
SAME RATE. PROPERTY DID GLANDS
AND SUB MANDIBULAR GLANDS MAYBE
DIFFERENTIALLY AFFECTED. SO EASY
WAY TO LOOK AT THIS FIRST IS TO
UNDERSTAND WHAT PATHWAYS ARE
DISREGULATED. WHEN I FIRST
STARTED WE USE BULK RNA
SEQUENCING BECAUSE WE LOOKED TO
LITERATURE AND I WASN'T HAPPY
WITH THE AVAILABLE CLINICAL
METADATA ASSOCIATED WITH THESE
STUDIES THAT ALREADY BEEN
PUBLISHED. THE CONTROL GROUPS
THEY WERE USING WERE NOT ALWAYS
USING VERY PRISTINELY DEFINED
VOLUNTEERS SO THAT IS WHAT WE
DIDID. WE USE BULK RNA SEQUENCI,
PATHWAYS ENRICHED IN SJOGREN'S
VERSUS HEALTHY VOLUNTEERS.
DESPITE REDUNDANCY IN THE TOP 25
ENRICHED PATHWAYS, ONE THING
THAT JUMPS OUT ALWAYS EITHER
AMONG OUR STUDIES OR IN OTHERS
IS THAT THERE WAS THE
INVOLVEMENT OF THE JAK STAT
PATHWAY AND THE EXPRESS OF TYPE
1 AND TYPE 2 INTERFERON
STIMULATED GENES WE CAN COMPARE
THESE INDIVIDUALS PATIENTS MINOR
SALIVARY GLANDS AND THEIR
CLINICAL PATHOLOGY TO SHOW THAT
THEY ARE HIGHLY CORRELATED WITH
THE AMOUNT OF INFLAMMATION
GLANDS WE CALL THE FOCUS FORUM.
SO WE THOUGHT THIS WAS GREAT TO
LOOK AT THIS IN THE SALIVARY
GLANDS BUT WHAT IS GOING ON IN
PERIPHERAL BLOOD LOOKING AT 4
PROTEIN INTERFERON SCORE AND
PROTEOMIC DATA WITH SEE THE SAME
THING, ABOUT TWO-THIRDS OF THE
PATIENTS WITH SJOGREN'S COMPARED
TO EITHER HEALTHY VOLUNTEERS OR
NON-SJOGREN'S PATIENTS YOU HAVE
ENRICHED TYPE 1 INTERFERON
PROTEIN SCORE. WHAT IS THE JAK
STAT PATHWAY? CANONICAL JAK STAT
PATHWAY ACTIVATION IS ANY
MOLECULE SUCH AS CYTOKINES OR
GROWTH FACTORS, BINDING TO ITS
COGNATE RECEPTOR, BEING ABLE TO
TRANSMIT SIGNAL FROM AN EXTRA
CELLULAR SPACE TO INTRACELLULAR
SPACE. TO DRIVE VARIABLE
TRANSCRIPTION. IN SJOGREN'S WE
ARE THINKING ABOUT THIS FROM THE
CONTEXT OF DRIVING PATHOGENIC
CYTOKINES. LOOK AT MULTIPLE
LAYERS OF THIS PATHWAY, AS READ
OUTS OF PATHWAY ACTIVATION.
EITHER BY LOOKING DIRECTLY AT
THE EXPRESSION OF JACKS AND
STATS TO UNDERSTAND WHAT ARE THE
CELLULAR TARGETS OF CYTOKINES IN
AN EFFECTIVE TISSUE. WE CAN LOOK
AT THE ACTIVATION STATUS OF
VARIOUS STATS AND THEIR
TRANSLOCATION TO THE NUCLEUS, TO
SAY A GIVEN CELL TYPE IS
ACTIVATED OR WE CAN USE THINGS
LIKE INTERFERONS AND CYTOKINES
AS mRNA READ OUTS OR PROTEIN
READ OUTS. OF DOWNSTREAM PATHWAY
ACTIVATION. IN FACT THAT'S WHAT
WE SEE. WHEN WE LOOK AT MINOR
SALIVARY GLANDS WE SHOW
INCREASED RATES OF JAK 3 AND
STAT mRNA AND AT ALSO AT THE
PROTEIN LEVEL WE CAN SEE
INCREASE PHOSPHORYLATION OF STAT
1 AND STAT 3 SIGNIFYING DIRECTLY
ACTIVATION OF THIS PATHWAY IN
MINOR SALIVARY GLANDS FROM
SJOGREN'S PATIENTS AND AS I HAVE
SHOWED YOU WE CAN SHOW
EXPRESENCE OF INTERFERON STILL
LATED GENES. WE LENDS TO
HYPOTHESIZE WE CAN USE EXISTING
FDA APPROVED DRUGS TO MITIGATE
THE EFFECT AND HOPEFULLY USE
THESE READ OUTS IN PA HUMAN
CLINICAL TRIAL TO SHOW EFFICACY
DIRECTLY ON TARGET ORGAN. SO THE
SUMMARY OF PART 1 IS WE SHOW
IMMUNE CELLS AND EPITHELIAL
CELLS SHOW PATHOGENIC JAK STAT
ACTIVATION WHILE FINDING IS NOT
PARTICULARLY NOVEL, IT DOES
ILLUSTRATE VERY CLEARLY WE CAN
USE EXISTING DRUGS TO TREAT
SJOGREN'S POTENTIALLY. WE ALSO
SHOW THE NOVEL FINDING THAT
SJOGREN'S DISEASE ESPECIALLY IN
INFLAMED SNI INDUCTS SHOW
DEPENDENCE ON JAK 2 AND 1
SIGNALING TO TOPHI SIT ANYBODY
JACK 1 INHIBITOR. THOUGH I CAN'T
SHOW IT HERE IN FACT IN EXVIVO
MODELS TOFF RECEIVE ANYBODY
CORRECTS AND ACTIVATED JAK STAT
SIGNALING IN PBMC AND PATIENT
DERIVED SALIVARY GLAND
EPITHELIAL CELLS SO WE DESIGNED
NIDCR NEI MULTI-INSTITUTIONAL
COLLABORATIVE PHASE 1 A 2B
RANDOMIZED CONTROL TRIAL TOM
TEST KINASE INHIBITORS IN
SJOGREN'S PATIENTS. THE GOAL WAS
TO LOOK LONGITUDINALLY AT
PATIENTS TARGET ORGANS FOR
CHANGES IN THESE OUTCOMES
INCLUDING PHOSPHOSTATS IN THE
PERIPHERAL BLOOD, PHOSPHOSTATES
IN THE ORGAN AND TRANSCRIPTOMIC
CHANGES IN THAT GLAND. WE HOPE
TO SHOW THROUGH TREATMENT WITH
TOFSITNIB AND SIX MONTHS OF TIME
THAT WE CAN HOPEFULLY SHOW
REDUCTION IN INFLAMMATION DRIVEN
BY THIS PATHWAY AND A
RESTORATION OF SALIVARY GLAND
FUNCTION AS MEASURED BY SALIVA
OUTPUT FROM AT THE GLANDULAR
LEVEL AND THE WHOLE STIMULATED
FLOW LEVEL. SO SO FAR WE HAVE
ENROLLED A THIRD OF THIS TRIAL
OUT OF 30, THERE HAVE BEEN NO
LIFE THREATENING AEs AND SOME
SUBJECTS ARE REPORTING LESS
FATIGUE AND OBJECTIVELY MORE
SALIVA. THIS LED TO ANOTHER
QUESTION, YOU HAVE AN ONGOING
CLINICAL TRIAL HOW ARE YOU GOING
TO ANALYZE THE DATA YOU ARE
COLLECT SOMETHING WHILE DOING
THIS STUDY WE WERE WORKING
TRYING TO UNDERSTAND WHAT THE
POOR COMPOSITION OF THE GLANDS
ARE IN HEALTH AND ALSO IN
DISEASE. HOPEFULLY BEING ABLE
TO IDENTIFY WHAT THE CORE
EFFECTORS WERE AND WHAT THE CELL
TYPES ARE BEING TARGETED. SO WE
CREATED A SINGLE CELL RNA
SEQUENCING ATLAS OF THE SALIVARY
GLANDS WORK WITH THOMAS
(INDISCERNIBLE) WHERE WE WERE
ABLE TO ILLUSTRATE 31 DIFFERENT
CELL TYPES IN THE SALIVARY
GLANDS BUT MORE IMPORTANTLY WE
WERE ABLE TO SHOW CHANGES IN
CELLULARITY BOTH INCREASE RATES
OF GRANZYME K POSITIVE CD8
CELLS, CYTOTOXIC T-CELLS AND CD4
T-CELLS, INGREASE IN PALACENA
WELLS AND NK CELLS. NOT
SURPRISING. BUT ON THE OTHER
HAND WE SAW STATISTICALLY
SIGNIFICANT REDUCTION IN CAM
LAYERS AND SEROUS MUCOUS ACINAR
CELLS. BECAUSE SEQUENCING
CREATES A RELATIVELY SPARSE
MATRIX, YOU NEED LOTS OF
REPRESENTATION IN NUMBER O CELLS
AND INDIVIDUALS, TO REALLY
UNDERSTAND DIFFERENTIAL GENE
EXPRESSION AN INDIVIDUAL CELL
TYPE WE CHOSE TO LOOK NOT JUST
AT THE DIMENSIONALITY REDUCTION
BASED ON GENE EXPRESSION BUT WE
LOOKED AT THIS BASED ON PATHWAY
UTILIZATION. THIS IS WHERE
THINGS GOT REALLY INTERESTING.
SO WHAT WE SAW WHEN WE REFORMED
DIMENSIONALITY REDUCTION WE
STARTED INDIVIDUAL CLUSTERS OF
CELL TYPES PULLING APART FROM
THIS MAIN BODY OF MIXED CELL
TYPES. WE DIDN'T REALLY
UNDERSTAND WHAT THAT MEANT UNTIL
WE STARTED TO LOOK AT INDIVIDUAL
FEATURE ANNOTATI ANNOTATION. SOG
JUST AT DISEASE ANNOTATION YOU
CAN SEE THAT THESE INDIVIDUAL
SJOGREN'S DISEASE ASSOCIATED
CELL TYPES SEEM TO BE UTILIZING
PATHWAYS IN A DISEASE AND CELL
TYPE SPECIFIC MANNER. THAT'S
REALLY IMPORTANT. THAT EACH ONE
OF THESE CELL TYPES IN THE
IMMUNE COMPARTMENT AND EACH
THESE CELL TYPES IN THE
EPITHELIAL COMPARTMENT ARE DOING
SLIGHTLY DIFFERENT THINGS BUT
DOING THINGS THAT ARE ALSO VERY
DIFFERENT FROM WHAT THEIR
HEALTHY COUNTERPARTS ARE. IN ONE
PARTICULAR CELL TYPE WE CAN LOOK
AT SJOGREN'S T-CELLS WHICH SEEMS
TO BE DRIVING THE MOST
DIFFERENCE BETWEEN HEALTH AND
SJOGREN'S DISEASE. WE CAN FIND A
MULTITUDE OF DIFFERENT T-CELLS.
INCLUDING CD4 AND CD8 BUT THE
MOST ENRICHED TYPE OF T-CELL
WERE THESE THAT EXPRESS GRANZYME
A AND PERFORIN AND CYTOTOXIC
T-CELLS THAT EXPRESS GRANZYME B
AND PERFORIN. WHEN WE LOOK AT
PATHWAY UTILIZATION THEY SEEM
SIMILAR. THEY BOTH SEEM TO BE
ACTIVATED BUT THERE ARE ABOUT
SIX TIMES AS MANY GRANZYME A AND
K POSITIVE T-CELLS. WHEN WE
TAKE THOSE OUTS OF THE MINOR
SALIVARY GLAND AND STIMULATE
WITH ANAMICIN, WORK DONE WITH
(INDISCERNIBLE) IN THE DAN
BARBARA LAB AT NIAID, WE CAN SEE
IN FACT IT IS THE CD8 CD 107A
POSITIVE T-CELLS IN SJOGREN'S
AND NOT IN HEALTHY VOLUNTEERS
THAT SEEMED TO BE ACTIVATING.
WHEN WE LOOK DIRECTLY IN THE
GLAND FOR PATHOGENIC CELL TYPES,
IN THIS CASE AT THIS POINT WE
DID THIS WORK WE DIDN'T HAVE
REALLY GOOD GRANZYME K MARKER SO
WE ARE USING GRANZYME B AS A
NEGATIVE MARKER FOR THIS. YOU
CAN SEE THAT MOST OF THESE CD8
POSITIVE T-CELLS AT THE
INTERFACE WITH INFLAMED
EPITHELIUM THAT IS MARKED BY THE
EXPRESSION OF MHC CLASS 1 YOU
CAN SEE VERY FEW OF THEM IN
ALMOST A FOUR TO ONE RATIO ARE
CLASSIC CYTOTOXIC T-CELLS. THAT
LED US TO HYPOTHESIZE IN FACT
THE GRANZYME K THAT ARE EXERTING
FUNCTIONAL EFFECT UPON THE
SALIVARY EPITHELIUM. SO IN THIS
TIME WE WORKED WITH ANOTHER
GROUP AND WE PERFORMED A LARGER
BULK RNA SEQUENCING STUDY ON
HEALTHY VOLUNTEERS, PATIENTS
THAT DON'T MEET CLINICAL
CLASSIFICATION CRITERIA FOR
SJOGREN'S AND VERY ROBUSTLY
CHARACTERIZE SJOGREN'S PATIENTS
AND WE COMPARED EXPRESSION OF
GRANZYME K WITH BOTH CLINICAL
OUTCOMES SUCH AS WHOLE
STIMULATED SALIVA FLOW AND FOCUS
FLORA. THERE IS A SIGNIFICANT
SIGNIFICANT INVERSE CORRELATION
BETWEEN SALIVARY FLOW AND THE
AMOUNT OF GRANZYME K IN THE
SALIVARY GLANDS BUT DIRECT
CORRELATION BETWEEN FOCUS AND
GRANZYME K EXPRESSION. THIS
INDICATES THAT IN FACT WHAT IS
DRIVING A REDUCTION IN SALIVARY
FLOW IS THE INFILTRATION WITH
GRANZYME K CD8 T-CELLS. SO WE
DESIGNED A SERIES OF EXPERIMENTS
TO UNDERSTAND WHAT GRANZYME K
MIGHT BE DOING TO THE EFFECTED
EPITHELIUM SO USING A THP 1
INTERFERON STIMULATED CELLS HECK
INTERFERON ALPHA BETA RESPONSIVE
CELLS, A CELL LINE THAT IS
IMMORTALIZED THAT RECAPITULATES
ACINAR CELL DIFFERENTIATION AND
PRIMARY SALIVARY GLAND
EPITHELIAL CELLS FROM PATIENTS
AND TRANSFECTED DIRECTLY
GRANZYME K, AND B AND CONTROL
PROTEINS AND THEN LOOKED AT
MULTITUDE OF OUTCOMES. SO THE
MOST BASIC READ OUT WAS DIRECTLY
LOOKING AT WHAT HAPPENS TO THE
CELLS AND SO HERE WE ARE SHOWING
WITH MITOTRACKER MARKING
MITOCHONDRIA AND GREEN MARKING
DNA AND DAPE MARKING NUCLEUS YOU
CAN SEE CLEARLY THERE ISN'T A
WHOLE LOT OF DNA IN THE CYTOSOL
BUT WHEN YOU TRANSFECT GRANZYME
K YOU LOSE MITOCHONDRIA AND
INCREASE THE CYTOSOLIC PRESENCE
OF DNA. AND WHEN WE LOOK AT CELL
TYPES THAT ARE RESPONSE TO
STINGING A NICHE, WE SHOW DOSE
DEPENDENT INCREASE IN STING
ACTIVITY AND ALSO A DOSE
DEPENDENT INCREASE IN TYPE 1
INTERFERON ACTIVITY BUT MORE
IMPORTANTLY WHEN WE LOOK
DIRECTLY AT PHOSPHOIRF 3 WHICH
IS THE CONVERGENCE OF BOTH STING
AND RIGI PATHWAYS SHOWING
COMMITMENT TO THAT TYPE 1
INTERFERON SIGNALING WE CAN SHOW
INCREASE RATES OF PHOSPHOERK 3
IN THESE MODELS. SO SUMMARY,
HOW DOES SJOGREN'S AFFECT THE
CELLULARITY OF THE CELL
INSTITUTES OF POSITIVE GLANDS?
SJOGREN'S CELLS ARE NUMEROUS
THAN CLASSIC CYTOTOXIC T-CELLS
IN THE SALIVARY GLAND. AND THEY
HAVE AN EFFECTOR PHENOTYPE AND
EFFECTOR FUNCTION? SHOW GRAIN
SALIVARY GLANDS. SO THE FUTURE
WORK IS THINKING ABOUT CAN WE
USE STYNG ANTAGONIST TO MANAGE
SJOGREN'S DISEASE IF THIS
PHENOMENA IS IN FACT TRUE. AND
HERE WE DID PRELIMINARY WORK
LOOKING AT PHOSPHOERF 3
EXPRESSION IN SALIVARY GLANDS OF
SJOGREN OF HEALTHY VOLUNTEERS
AND YOU CAN SEE ACTIVATION OF
PHOSPHOERK 3 AND STYNG
INDICATING PATHWAY ACTIVATED. SO
THE LAST BIT TO TALK ABOUT IS WE
HAVE BEEN TALKING ABOUT THE
IMMUNOINFILTRATE AND WHAT IT
COULD DO TO THE SALIVARY GLANDS
BUT NOW I WILL SHOW YOU WHAT
HAPPENS TOESHOES FUNCTIONAL
EPITHELIAL CELLS, WHAT ARE THE
CELL TYPES AND/OR CELL STATES
TARGETED IN SALIVARY GLANDS. I
SAID YOU LOSE SERUM MUCOUS
ACINAR CELLS, TWO DIFFERENT
TYPES OF ACINAR CELLS IN THE
GLANDS. SERA MUCOUS AND MUCOUS.
WE SHOW SPECIFIC TARGETING OR
LOSS OF THOSE ACINAR CELLS. BUT
IN A MORE GRANULAR LEVEL YOU
LOSE ONE TYPE OF SORE HAVE
MUCOUS ACINAR CELL AND IT IS
THESE PR 4 POSITIVE ACINAR
CELLS. WE USE RNA VELOCITY TO
LOOK AT HOW DIFFERENTIATED THESE
CELLS ARE, WE IN FACT SHOW WHAT
IS LOST ARE THESE CST 3 PR 4
HIGH ARM OF THE TWO TYPES OF
SERUM MUCOUS ACINAR CELL. WE CAN
USE NC HYBRIDIZATION TO
DEMONSTRATE LOSS OF
HETEROGENEITY OF THE ACINAR
COMPARTMENT. THIS IS THE PLR 4
EXPRESSION IN IDEAL LOW, A
MARKER OF TERMINAL
DIFFERENTIATION OF THESE CELL
TYPES. WFDC 2 IS A MARKER OF
DUCK TILE LIKE DIFFERENTIATION,
YOU CAN SEE THAT PHENOTYPICALLY
THESE ARE ACINAR CELLS THAT
SHOULD BE THIS GOLDEN COLOR BUT
IN FACT WHAT WE HAVE IS A DUCT
LIKE ACINAR CELL AND WE SUSPECT
IS THESE ARE LESS FUNCTIONAL. SO
NOT ONLY ARE YOU LOSING CELLS AS
A DIRECT RESULT OF THAT GRANZYME
K CD8T CELL INFILTRATE BUT IT IS
SOMETHING ABILITY THE EFFECTOR
FUNCTION OF THOSE CELLS PREVENTS
OR RESTRAINS DIFFERENTIATION OF
THOSE SERUM MUCOUS ACINAR CELLS
AND HALTS THE GREATER
HETEROGENEITY OF THE ACINAR
CELLS. FUTURE WORK WILL BE
LOOKING AT THESE TYPES OF
PATHWAYS IN MAJOR SALIVARY
GLANDS. WE CAN QUANTIFY THIS,
THIS IS WORK WE DID
COLLABORATIVELY WITH THE NCI
WITH (INDISCERNIBLE) AND AFTER
SEGMENTATION OF THE SLIDES, WE
CAN ASSIGN PHENOTYPES TO EACH OF
THESE TYPES OF SERUM MUCOUS
ACINAR CELLS AND SHOW THE FULL
CHANGE IN THE SALIVARY GLANDS.
WHAT THIS ILLUSTRATES IS THAT
YOU LOSE MUCOUS ACINAR CELLS AND
PROPORTIONATELY GAIN MUCOUS
ACINAR CELLS RELATIVELY LESS
FUNCTIONAL. IN SUMMARY SHOW
DIFFERENTIATING DUCT LIKE SERUM
MUCOUS ACINAR CELLS ARE LIKELY
ONE OF THE SPECIFIC CELLULAR
TARGETS IN SJOGREN'S, A LESS OF
HETEROGENEITY NOT ONLY DIRECT
CYTOTOXICITY IS IMPLICATED IN
PANDEMIC MA LOSS AND SIGNALING
MAYBE DRIVING EPITHELIAL
DYSFUNCTION. SO IN CONCLUSION
INTEGRATED OMICS DISENTANGLE
COMPLEX TISSUE AND DISEASE
DEPENDENT ALTERATIONS TO
ILLUSTRATE DRUG L PATHWAYS THE
LOSS OF SERUM MUCOUS ACINAR
CELLS ARE LINKED TO EXPANSION OF
T-CELLS MOST SPECIFICALLY THE
CD8 GRANZYME K PHENOTYPE CELLS,
AND THESE CELLS EXERT EFFECTIVE
PHENOTYPE. LOTS OF PEOPLE TO
THANK. I WILL LEAVE HERE WHILE I
TAKE IN I QUESTIONS. THANK YOU
FOR THE OPPORTUNITY TO TALK.
[APPLAUSE]
>>OUR SECOND SPEAKER IS DR.
SARA INATI. SHE IS ADULT
NEUROLOGIST, SPECIALIZING IN
CLINICAL NEUROPHYSIOLOGY AND
EPILEPTIC PATHOLOGY. SHE CAME TO
NIH IN 2010 AND SERVED AS A
CHIEF OF THE NINDS EEG SECTION
FROM 2012 TO 2021 WHEN SHE
TRANSITIONED TO BE ASSISTANT
CLINICAL INVESTIGATOR. HER
RESEARCH IS FOCUSED ON BETTER
UNDERSTANDING THE
PATHOPHYSIOLOGY OF EPILEPSY WITH
GOAL OF IMPROVED THE TREATMENT
AND QUALITY OF LIFE OF EPILEPSY
PATIENTS. SHE SERVED AS A
PROGRAM DIRECTOR OF THE NINDS
EPILEPSY FELLOWSHIP SINCE 2016.
AND ENJOYING HELPING TO EDUCATE
THE COMMUNITY ABOUT SEIZURES AND
EPILEPSY. HER PRESENTATION TODAY
IS TRACKING SEIZURE SPREAD IN
THE BRAIN. DR. INATI.
[APPLAUSE]
>>THANK YOU SO MUCH FOR THAT
NICE INTRODUCTION AND FOR THE
INVITATION TO TALK TO Y'ALL
TODAY. THIS IS ANOTHER
OPPORTUNITY TO TELL YOU FIRST
WHAT WE ARE DOING HERE AN
EDUCATE YOU A BIT ABOUT
EPILEPSY. SO EPILEPSY IS REALLY
A COMBINATION OF DISEASE. SO
SOMETIMES REFERRED TO IT AS THE
EPILEPSIES, RANGING FROM
NEONATAL ONSET TO ONSET IN OLDER
ADULTS WHICH ARE THE TWO
POPULATIONS WHERE SEIZURES
HAPPEN THE MOST. AND SOMETIMES
IT IS A BENIGN DISORDER WITH
SELF-LIMITED SEIZURES NORMAL
DEVELOPMENT AND COKE IN ADDITION
WHICH WE PUT ON THE IDIOPATHIC
SIDE OF THIS PATHWAY. THEN THERE
IS NON-IDIOPATHIC THIS IS PARTS
OF REALLY DEVASTATING SYNDROMES
IN MY WORK I FOCUS ON ONE LITTLE
SQUARE RIGHT HERE WHICH IS THE
SYMPTOMATIC OR TRIP TOE GENIC
FOCAL EPILEPSIES. SO THIS IS A
SMALL AREA WITHIN EPILEPSY BUT
OVERALL EPILEPSY IS THREE MILL
AMERICANS AN 65 MILLION PEOPLE
WORLD WILD HAVE EPILEPSY. THAT
COMES OUT TO ONE IN 26 PEOPLE
WHO WILL DEVELOP EPILEPSY DURING
LIFETIME SO CHANCES ARE THERE'S
AT LEAST ONE OR TWO PEOPLE IN
THIS ROOM WHO HAVE HAD OR WILL
HAVE A SEIZURE AT SOME POINT IN
THEIR LIFE. AT TIMES
PARTICULARLY WHEN THEY ARE
ONGOING THEY ARE SIGNIFICANT
NEURAL PSYCHOLOGICAL
CO-MORBIDITIES AND INCREASED
MORTALITY. SO AS A CLINICAL
EPILEPSIOLOGIST, ONE MAIN
FUNCTION WITH PATIENTS IS TO
TREAT THEM MEDICALLY. SO OVER
THE LAST DECADES WE HAVE SEEN
ACTUALLY HUGE ADVANTAGES IN THE
MEDICAL TREATMENT OF EPILEPSY AS
YOU CAN SEE THERE HAS BEEN A TON
OF NEW MEDICATIONS THAT COME
OUT. THIS HAS BEEN AMAZING FOR
OUR PATIENTS. HOWEVER, THE
EFFICACY OF THESE MEDICATIONS
HAS NOT CHANGED OVER TIME. SO
WHAT IS REALLY HAPPENED IS WE
HAVE HAD ADVANCES IN
TOLERABILITY AND SAFETY OF THE
MEDICINES HOWEVER THIS STILL
HOLDS TRUE ONE DOES NOT WORK
BETTER IN THE POPULATION LEVEL
AT LEAST COMPARED TO OTHER
MEDICINES, IF YOU TAKE THE FIRST
MEDICINE HALF THE PEOPLE WILL
BECOME SEIZURE FREE, THE SECOND
MEDICINE CHANCES OF BECOMING
SEIZURE FREE GO DOWN MORE TO
ONLY ADDITIONAL 14% OF PEOPLE.
THEN WHEN AT YOUR THIRD OR
MULTIPLE MEDICATIONS THERE'S
ONLY A 4% CHANCE BECOMING
SEIZURE FREE EVEN AS YOU CYCLE
THROUGH ALL THESE NEW
MEDICATIONS. THIS IS WHY ONE OF
THE MAIN FOCUSES OF MY WORK HERE
HAS BEEN ON EPILEPSY SURGERY. SO
CLEARLY I AM NOT A SURGEON, I
WORK CLOSE WHETHER I WITH OUR
NEUROSURGEONS. WHY? ONE OF THE
MEDICAL THINGS WE TRY TO DO IS
PREVENT OUR PATIENT GETTING TO
SURGEONS BUT IN OUR CASE WHAT WE
FOUND IS A RANDOMIZE CLINICAL
TRIAL THAT SHOWED THIS IS IN
PATIENTS THAT HAVEN'T RESPONDED
TO THOSE FIRST TWO OR THREE OR
FOUR MEDICINES, THE CHANCES OF
SURGERY AND APPROPRIATELY
SELECTED PEOPLE WILL ACTUALLY
INCREASE THEIR CHANCES BECOMING
SEIZURE FREE. IN THIS LAND MARK
TRIAL THE PERCENT DAMAGE OF
PATIENTS WITHOUT SEIZURES IMPAIR
AIR WANS USNESS WAS 58% ONE YEAR
IN SURGICAL GROUP AND ONLY 8%
MEDICAL GROUP. SO THIS MEANS IF
YOU HAVE A PATIENT WHO IS A
SURGICAL CANDIDATE THIS MAY BE
THEIR BEST CHANCE FOR SEIZURE
FREEDOM. WE DIDN'T KNOW THIS FOR
SURE UNTIL RECENTLY IN 2016
THERE WAS ANOTHER STUDY THAT
SHOWED THAT THE PATIENTS THAT
DID GO ON TO HAVE BRAIN SURGERY
HAD SIGNIFICANTLY IMPROVED
MORTALITY AS WELL. THIS IS A BIG
DEAL BECAUSE MANY PATIENTS ARE
OTHERWISE RELATIVELY YOUNG AND
HEALTHY. SO THIS IS A
SIGNIFICANT UM PACT AND ACTUALLY
CHANGES HOW WE COUNCIL OUR
PATIENTS. HOWEVER, THERE HAVE
BEEN NUMEROUS ADVANCES ALONG THE
MEDICINES IN SURGICAL TREATMENT
OF EPILEPSY BUT OUTCOMES ARE
STUBBORN, ONLY ACHIEVING
SUSTAINED SEIZURE FREEDOM IN
ABOUT 67% OF OUR PATIENTS. THIS
IS FOR TEMPORAL LOBE EPILEPSY, A
GROWN WE DO THE BEST IN. THERE
IS A SUBGROUP EVERYTHING LINES
UP PERFECTLY AND HAVE GOOD --
EVEN BETTER OUTCOMES SO ABOUT
HALF -- THREE QUARTERS OF THESE
PATIENTS WILL BECOME SEIZURE
FREE AFTER SURGERY. HOWEVER
THERE IS THIS OTHER GROUP WITHIN
THIS WHERE THINGS DON'T EXACTLY
MATCH UP AND WE CALL THESE
TEMPORAL LOBE PLUS EPILEPSY, 16%
BECOME SEIZURE FREE AFTER THE
SURGERY WE DO SO THIS IS THE
THING THAT MOTIVATED MY RESEARCH
QUESTIONS. SO THE QUESTION IS,
WHY DOES THIS HAPPEN? ONE IS THE
INCOMPLETE RESECTION. SO IN A
LOT OF THESE PATIENTS, WE GOT
MOST OF THE PROBLEM BUT NOT ALL
THE PROBLEM. SO IN ABOUT HALF
MORE OR LESS OF THESE PATIENTS
IF YOU ACTUALLY REDO A SURGERY
IN THE SAME AREA, THEY WILL
ACTUALLY BECOME SEIZURE FREE.
TOTALLY DIFFERENT PROBLEM IS
INACCURATE LOCALIZATION, THIS IS
THE ONE THAT IS THE FOCUS OF
MOST OF THE REST OF MY TALK. SO
THIS IS WHEN YOU THINK FOR
EXAMPLE THAT THEY HAVE SEIZURES
COMING FROM THEIR TEMPORAL LOBE
AND TURNS OUT TO NOT BE THE
CASE. WE THINK THIS ACCOUNTS
FOR UP TO ONE FIFTH OF THE
FAILURES ONGOING SEIZURES AFTER
SURGERY AND THIS IS REALLY THE
CASE IN A LOT OF TEMPORAL PLUS
EPILEPSIES WHERE SEIZURES COME
FROM SURROUNDING YARRS, INSULA,
ORBITAL FRONTAL LOBE OR OTHER
REGIONS SO IDENTIFYING THIS IS
AN OPPORTUNITY FOR ADVANCEMENT
IN THE CAR OF PATIENTS. THEN
THE LAST IS PATIENTS DO ACTUALLY
HAVE DIFFUSE OR MULTI-FOCAL
DISEASE YOU CAN IMAGINE AFTER
TRAUMATIC BRAIN INJURIES OR
ENCEPHALITIS OR MORE DIFFUSE
GENETIC PROBLEMS IF YOU ADDRESS
ONE AREA THE SEIZURES MAYBE
COMING FROM THEY MAY GO ON IN
THE FUTURE SO IDENTIFYING WHICH
OF THESE PATIENTS IS IMPORTANT
TO IMPROVE SURGICAL OUTCOMES.
SO AS I SAID I GOT HERE IN ABOUT
2010 AND AFTER BEING HERE FOR
SEVERAL YEARS I REALIZE WE HAD
THESE AMAZING OPPORTUNITIES TO
TRY TO PURSUE SOME OF THESE
QUESTIONS HERE. SO THIS IS WHAT
OUR TYPICAL SURGICAL EVALUATION
LOOKS LIKE AND THIS WILL BE THE
TRUE IN ANY EPILEPSY CENTER
ACROSS THE COUNTRY, VERY
STANDARD YOU CLINICALLY
CHARACTERIZE THE PATIENT, DO
NEUROPSYCHOLOGICAL TESTING AND
DO EEG BETWEEN THE SEIZURES AND
DURING THE SEIZURES SO YOU CAN
SEE THESE AREAS OF IRRITABILITY
THROUGH ELECTRICAL ACTIVITY OF
THE BRAIN. THEN WE ALSO RELY
HEAVILY ON STRUCTURAL IMAGING
WHICH CAN IDENTIFY FOCAL
LESIONS, FUNCTIONAL IMAGING
THERE IS A LONG HISTORY NIH OF
DOING PET IMAGING TO IDENTIFY
ABNORMALITIES IN PATIENTS WITH
EPILEPSY. THEN FUNCTIONAL
MAPPING YOU CAN LATERALIZE AND
SOMETIMES EVEN LOCALIZE LANGUAGE
AREAS. THESE ARE ALL THE THINGS
STANDARD WE WERE DOING ALL
ALONG. THEN WE ADDED IN AS IT
BECAME AVAILABLE HIGHER FIELD
IMAGING AT 7T, WE HAVE THE
OPPORTUNITY TO ACCESS HERE, WE
ADDED ON DIFFUSION TENSOR
IMAGING TO LOOK AT STRUCTURAL
COKETIVETY AND WE ADD --
CONNECTIVITY, THEN WE ADD
PROFUSION IMAGING THAT SHOUGHS
CHANGES DURING THE COURSE OF
EPILEPSY. FINALLY WE HAVE A
REALLY INTERESTING OPPORTUNITY
IN THESE PATIENTS BECAUSE IN THE
CLINICAL CARE OF THESE PATIENTS
WE OFTENTIMES GO ON TO TRY AND
IDENTIFY WHERE SEIZURES ARE
COMING FROM USING INVASIVE EEEG
RECORDINGS, IN COLLABORATION
WITH SURGEONS HERE. SO INVASIVE
EEG RECORDINGS PUT ELECTRODES ON
THE SURFACE OF THE BRAIN OR INTO
TESTIMONY BRAIN AND RECORDS
SEIZURES FROM THERE TO HELP
GUIDE OUR SURGICAL RESECTIONS.
AND WE DO MAPPING SO WE DO DRUG
CORTICAL STIMULATION MAPPING AND
YOU CAN FIND AREAS THAT ARE
IMPORTANT FOR MOTOR OR LANGUAGE
FUNCTION. SO THIS WHOLE
SITUATION ALLOWS US TO TEST OUR
HYPOTHESES FROM THE NON-INVASIVE
IMAGING WITH INVASIVE RECORDINGS
AND OUR RESECTIONS SO IF A
PATIENT BECOMES SEIZURE FREE
AFTER A SURGERY WE CAN ASSUME WE
DID FIND THE CORRECT LOCATION
AND THEREFORE IT CAN ASSESS
WHETHER WE WERE CORRECT FOR
NON-INVASIVE IMAGING. SO I WILL
JUST TELL YOU BRIEFLY ABOUT TWO
OF THE THINGS WE HAVE DONE OVER
THE LAST FEW YEARS HERE. TO TRY
TO GET A BETTER SENSE OF WHERE
THESE SEIZURES ARE COMING FROM
IN THE BRAIN. HERE IS AN EXAMPLE
OF EPILEPTOGENIC LESION. EVEN
THOUGH WHO DON'T OFTEN LOOK AT
MRI.
IMAGINES CAN PROBABLY SEE THIS
DOESN'T LOOK LIKE THE REST OF
THE BRAIN. THIS IS A CAVRANOMA
COMMON CAUSE OF EPILEPSY IN
PATIENTS. THIS IS THE QUINT
ESSENTIAL LESION WE TALK ABOUT
ALL THE TIME IN TEMPORAL LOBE
EPILEPSY AND THIS IS ME SEW
TEMPORAL LOBE SCLEROSIS, YOU CAN
SEE THIS IS THE EPICAMPUS THE
ARROW IS POINTING TO AND WHAT
YOU CAN SEE IS THAT THE ONE
ARROW IS POINTING TO IS SMALL
AND BRIGHT ON THIS IMAGE SO THIS
IS A VERY COMMON CAUSE OF DRUG
RESISTANT EPILEPSY. IN MY
RESEARCH THE THING I'M MORE
FOCUSED ON HERE IS THE TYPE OF
LESION CALLED A FOCAL CORTICAL
DYSPLASIA. SO THESE DYSPLASIAS
AGAIN THE RED ARROW POINTING TO
THEM ARE SOMETIMES OBVIOUS ON
IMAGING BUT SOMETIMES ARE VERY
DIFFICULT TO APPRECIATE WHEN
JUST LOOKING BY EYE. THESE
AREN'T DEVELOPMENTAL
ABNORMALITIES THAT HAPPEN AT
TIME OF BIRT BIRTH. THEY DON'T D
TO SEIZURES RIGHT AWAY. A LOT OF
TIME SEIZURE ALSO COME UP IN
THEIR TEENS TO EARLY 20s WHICH
IS WHEN I SEE THEM. AND I THINK
WHAT YOU CAN SEE WITH THE ARROW
IS THAT THERE IS ON THE IMAGE ON
THE RIGHT, A FLAIR IMAGE YOU CAN
SEE THAT THERE IS A BRIGHT AREA
AND THEN ON THE IMAGE ON THE
LEFT, A T 1 IMAGE YOU CAN SEE
THAT AREA OF CORTEX IS THICKENED
AND BLURRED. THIS IS A VERY
TYPICAL CHARACTERIZATION OF
THESE. ONE THAT IS OBVIOUS LIKE
THIS I THINK WOULD USUALLY BE
SEEN BY EYE. HOWEVER, THERE ARE
OTHER PATIENTS WHERE THIS IS
HARD TO APPRECIATE. AND IN
SKIMMING THROUGH THE IMAGE MOST
PEOPLE WILL NOT IDENTIFY THIS
AND MANY RADIOLOGISTS DO NOT
IDENTIFY LESION IN THIS PATIENT.
AGAIN WITH MY RED ARROW SIGN
MAYBE YOU CAN SEE A SLIGHT BIT
OF HYPERINTENSITY IN THE IMAGE
ON THE RIGHT, A SLIGHT BIT OF
BLURRING ON THE LEFT. IMAGINE AS
YOU ARE SCROLLING THROUGH IMAGES
THESE CAN BE VERY DIFFICULT TO
FIND. THIS IS ONE OF THE MOST
COMMON PATHOLOGIES IN OUR
PATIENTS THAT ARE THOUGHT TO BE
MRI NEGATIVE. SO INTERESTINGLY
OUR SURGICAL OUTCOMES ARE BETTER
IN PATIENT WHERE IS WE CAN FIND
LESIONS AND THAT IS FOR NUMBER
OF CAUSES BUT THERE WERE SEVERAL
PROCEDURES OUT THERE DESCRIBED
TO HELP USING MACHINE LEARNING
AND IMAGE PROCESSING TO IDENTIFY
LESIONS, BUT NONE WERE PUBLICLY
AVAILABLE SO WE PROCEED OUR OWN
EFFORTS, THIS IS ONE OF THE WAYS
WE CAN MAKE THE MOST QUICKLY
BETTER FOR OUR PATIENTS. SO WHAT
YOU CAN SEE HERE IS THAT USING
OUR OWN POST PROCESSING IMAGES
WE WERE ABLE TO DEVELOP THIS
FOCAL CORTICAL DYSPLASIA OF
SIMILAR PLSIMILARITY MAP. THIS R
INTUITIVE. THESE ARE IMAGES ON
THE T 1 AND FLAIR IMAGES SEEING
RADIO LOGICALLY, THE IMAGE ON
THE RIGHT IS A BRAIN IF YOU WENT
AND FLEETED TO ALL THE CURVES
ARE GONE. SO WHAT YOU CAN SEE IS
THERE ARE PARTS OF THE BRAIN IN
THIS SIMILARITY MAP THAT
ACTUALLY TYPICALLY LOOK VERY
SIMILAR TO FOCAL CORTICAL
DYSPLASIAS AND LEAD TO SOME OF
THE PROBLEMS WITH IDENTIFYING
THEM BECAUSE SOMETIMES THEY LOOK
VERY SIMILAR TO NORMAL BRAINS.
BUT THOSE WERE IN TYPICAL
LOCATIONS MOSTLY NEAR MOTOR AND
SENSORY CORTEX AND THE INSULA.
WHEN WE USED HEALTHY VOLUNTEERS
AN CORRECTED, YOU CAN SEE THAT
OUR FOCAL CORTICAL DYSPLASIA
STANDS OUT CLEARLY. SO THIS IS
THE MASK WE DREW BY HAND AND
DETECTION WE WERE ABLE TO
ACHIEVE. SO WE STILL USE THIS
NOW GOING FORWARD IN ALL OF OUR
PATIENTS AND IN A NUMBER OF
PATIENTS IT IS HELPED TO
IDENTIFY THE ABNORMALITY AND WE
DIRECTLY BEEN ABLE TO TRANSLATE
TO IMPROVED OUTCOMES IN OUR
PATIENTS. WE HAVE THE
OPPORTUNITY TO USE 7T IMAGES AND
WE WORKED WITH (INAUDIBLE) TO
ATTEMPT TO MAKE THE IMAGES
BETTER FOR US. YOU CAN SEE
ANOTHER DYSPLASIA THAT IS
SUBTLE, THIS IS WHAT IT LOOKS ON
THE RIGHT ON 3T IMEMERGENCIENING
IMAGINING THAN THE MP --
IMAGING. WE ARE STILL WORKING
HOW TO OPTIMIZE THIS BUT SHOWS
PROMISE TO FIND THE SUBTLE
LESIONS. ALL RIGHT. SO WITH THE
TIME THAT'S LEFT, I WILL TELL
YOU MORE ABOUT
ELECTROPHYSIOLOGY. I'M AN
ELECTROPHYSIOLOGIST BY TRAINING
SO EEG IS WHAT I CAME TO ALL OF
THIS DOING. WE CAN LOOK AT IT
USING SCALP EEG STICKERS WE PUT
ON THE OUTSIDE OF THE HEAD. WE
CAN USE THIS USING MEG INSTEAD
OF ELECTRICAL ACTIVITY WE LOOK
AT MAGNETIC ACTIVITY OF THE
BRAIN AND WE CAN ALSO USE THE
INTRACRANIAL ELECTRODES WHEN WE
WORKED WITH DR. (INDISCERNIBLE)
OUR NEUROSURGEON. THERE'S TWO
WAYS TO PUT ELECTRODES IN OR ON
THE BRAIN, ONE IS SUB DO YOU
RECALL ELECTRODES UNDER THE DURA
AS YOU SUSPECT AND LIE ON THE
SURFACE OF THE BRAI BRAIN. A AND
STEREO EEG ALLOWS ELECTRODES
INTO THE BRAIN LIKE A NEEDLE
BIOPSY SO WE CAN RECORD FROM
THOSE. NO MATTER WHICH WAY WE DO
IT ON MY END, THE SQUIGGLY LINES
THEY LOOK SIMILAR SO WHAT YOU
CAN SEE HERE IS AN EXAMPLE OF
SOMEBODY WITH RIGHT AND LEFT
SIDED ELECTRODES AND YOU CAN SEE
THAT THEY GET WEAVEY HERE ON THE
RIGHT FIRST LATER SPREADS TO THE
LEFT. SO THE GOLD STANDARD RIGHT
NOW IS WHEREVER YOU SEE THE
SEIZURES START FIRST, THAT'S
WHERE WE THINK THE SEIZURES ARE
COMING FROM. THIS LED US TO THE
OUTCOMES THAT WE CURRENTLY HAVE
NOW, THE THICK THAT IS
FRUSTRATING BECAUSE YOUR
PATIENTS GO THROUGH THESE
PROCEDURES IS ON THE -- AS SOON
AS YOU REQUIRE INTRACRANIAL EEG
MONITORING YOUR OUTCOMES ARE
WORSE. WHY? BECAUSE YOU HAVE
DIFFUSE PROBLEMS MAYBE BECAUSE
YOU HAVE A HUGE OR MULTIPLE
LESIONS, MAYBE BECAUSE IT IS
HARD FOR US TO FIND. JUST
NEEDING THESE ELECTRODES MEANS
OUR OUTCOMES ARE GOING TO GO
FROM ABOUT ALMOST 80% TO ALMOST
40% SEIZURE FREEDOM. THE SECOND
PART THAT WAS POINTED OUT IN
THIS PAPER THAT CAME OUT IN 2019
I ACTUALLY RESONATED DEEPLY WITH
ME. WHEN THERE'S SLOW SPREAD OF
SEIZURES ON INTRACRANIAL EEG WE
DO REALLY WELL SO THE PATIENTS
HAVE OVER 80% SEIZURE FREEDOM.
THESE ARE REALLY DIFFERENT THAN
THE PATIENTS WHERE WE SEE THIS
REALLY RAPID SPREAD ON OUR
INTRACRANIAL EEG. WHY THAT IS IS
ONE OF THE QUESTIONS THAT
CONTINUES TO BOTHER ME AND IS
CONTINUED TO DRIVE RESEARCH WE
HAVE BEEN DOING SO HERE YOU CAN
SEE IF A SEIZURE REMAINS
CONTAINED TO THIS REGION THIS IS
SOMETHING THAT IF IT WAS SAFE WE
COULD TARGET RELATIVELY EASILY.
LACK DOWN HERE, THIS IS WITHIN
TEN SECONDS OF SEIZURES
STARTING, IF SPREAD THROUGH THE
BRAIN REGION THEN THIS IS MORE
DIFFICULT. AND LEADS YOU TO
WONDER WHAT WE ARE GETTING
WRONG. SO THERE ARE TWO REASONS
I THINK WE SOMETIMES GET IT
WRONG. ON MY SIDE OF THINGS.
ONE IS EVEN WHEN YOU PUT THESE
ELECTRODES ON THE SURFACE OF THE
BRAIN, IF YOU LOOK HERE WHEN THE
BRAIN IS ACTUALLY EXPOSED AND
YOU CAN SEE IT, IT LOOKS LIKE WE
HAVE REALLY COVERED EVERYTHING.
SO YOU SAY HOW CAN WE POSSIBLY
GET IT WRONG? THIS IS WHAT IT
LOOKS LIKE WHEN YOU PUT ON THE
SURFACE OF THE BRAIN IN OUR
IMAGES. HOWEVER, WHEN I DO THAT
INFLATED BRAIN I SHOWED YOU
BEFORE WHAT YOU SEE IS STILL
VERY SPARSE FACIAL SAMPLING SO
IN OUR BEST EFFORTS WE ONLY
COVER SMALL PER TAJES OF THE
BRAIN. IN A RECENT PAPER NO
MATTER THE METHOD WE USED OF
RECORDING IN THE REGION IN THE
FRONTAL LOBE WE ALMOST NEVER
COVER MORE THAN 3% OF THE BRAIN.
IN THE TEMPORAL LOBE, ALMOST
NEVER MORE THAN 4% OF THE BRAIN
SO NO MATTER WHAT HE DO WE ARE
UNLIKELY AT THE PLACE THE
SEIZURE STARTED. A SECOND REASON
THIS IS ACTUALLY A DIFFICULT
PROBLEM FOR US IS THAT THE
SIGNAL ON THE EEG MANY WILL SEE
THIS AND MEDICAL SCHOOL CLASSES
OR BASIC SCIENCE CLASS. YOU
NEVER APPRECIATE WHAT THIS MEANS
PRACTICALLY. WHAT THIS MEANS
PRACTICALLY, THIS IS THE
GENERATOR OF EEG, IF THESE ARE
NEURONS, THESE ARE THE DENDRITES
AND THESE ARE PLACES YOU ARE
RECEIVING ACTIVITY. WHAT HAPPENS
IN THE EEG IS WE SEE WHAT AREAS
ARE RECEIVING ACTIVITY BUT NOT
NECESSARILY WHAT REGIONS OF THE
BRAIN ARE SENDING THAT ACTIVITY.
SO WHEN LOCAL WE STILL GET IT
RIGHT BUT WHEN NOT LOCAL WE MAY
ACTUALLY BE MISLED. SO THIS IS
AN IMPORTANT CAVEAT. AS I WAS
SAYING LOCAL ACTIVITY ACTUALLY
IS A HUGE PART OF WHAT HAPPENS.
THIS IS AN ANIMAL MODEL WHERE
SOMEBODY I THINK THIS IS STILL
THE MOST ELEGANT WAY I HAVE SEEN
THIS SHOWN WHERE AS MANY OF YOU
KNOW WE MAPPED OUT VISUAL CORTEX
VERY CLEARLY, IF YOU FLASHLIGHTS
AND THIS QUADRANT WITH THIS
COLOR, IT WILL ACTIVATE THIS
PART OF THE BRAIN AND SPREAD TO
THESE OTHER PARTS OF THE BRAIN.
WHAT THEY SHOWED IN A RODENT
MODEL IF THEY SET OFF A SEIZURE
THERE IT WOULD SPREAD LOCALLY. I
TALK ABOUT THIS BEING A PEBBLE
IN A POND BUT ALSO CAN SPREAD
DISTANTLY. SO WE KNOW IF WE MAKE
USE OF ALL OF THAT, WHAT WE CAN
HAVE IF WE MODEL IN A POND
RADIAL SPREAD YOU CAN SEE IF
SEIZURE STARTED HERE IT WILL
SPREAD TO CLOSE ELECTRODES FIRST
MORE DISTANT ELECTRODES SECOND
AND YOU CAN ACTUALLY IF YOU
ASSUME IT IS SPREADING AT THE
SAME SPEED YOU CAN MODEL THIS
AND COME UP WITH THE MOST LIKELY
PLACE WHERE IT IS COMING FROM.
THIS ACTUALLY WORKS WELL AND IF
YOU HAVE MULTIPLE ELECTRODES YOU
CAN FIND INTERSECTION AND SEE
WHERE IT IS COMING FROM. THIS IS
ACTUALLY HOW THEY FIND WHERE
EARTHQUAKES ARE STARTED. SO THAT
IS -- THIS CAME OUT OF
(INAUDIBLE) LAB AND THIS IS
GREAT WORK BY JOSH DIAMOND.
THESE FOR SEIZURES THE BIGGER
RARER EVENTS. WE CAN ALSO DO IT
FOR INTERLIPI THEICAL AND HAPPEN
INTERMITTENTLY IN THE BRAIN.
THIS IS OVER SEVERAL HOURS, OVER
FOUR HOURS, THIS IS WHAT IT
LOOKS LIKE WHAT E WE CALL IT A
SPIKE ON THE SQUIGGLY LINES WE
READ. THESE ARE RECORDINGS FROM
THE ELECTRODES. YOU CAN SEE
THEY HAPPEN REALLY FREQUENTLY.
SO THEY GIVE LOTS OF
OPPORTUNITIES TO SEE THEM BUT
TEND TO HAPPEN MORE BROADLY THAN
SEIZURES. SO THEY HAPPEN IN A
STEREO TYPICAL PATTERN.
CONSISTENT WITH THE PEBBLE IN
THE POND TAKE OUT REGION IT IS
FIRST SPIKING ELECTRODE WAS,
THAT CORRELATES WITH GOOD
OUTCOMES. SO JOSH ACTUALLY
SHOWED THIS IN ANOTHER PAPER AND
HE SHOWED THAT THE LEADING
ELECTRODE AND IF YOU DO THE
DISTANCE AGAIN AND TIME OF
ARRIVAL YOU CAN ARRIVE WHERE
THEY ARE COMING FROM. AND WE --
HE ALSO SHOWED NICELY THE AREA
THAT TURNS UP IN DISCHARGES IN
BETWEEN SEIZURES CORRELATES
CLOSELY WITH WHERE THE ACTUAL
SEIZURES ARE COMING FROM. AND
BOTH OF THEM GIVE YOU A GOOD
PREDICTION OF SEIZURE OUTCOMES.
SO IF THEY ARE OUTSIDE OF THE
RESECTION, THEY TEND TO HAVE
POORER OUTCOMES. IF INSIDE THE
RESECTION THEY TEND TO HAVE
BETTER OUTCOMES. FINALLY IN THE
RECENT WORK WE JUST PUT OUT WE
SAID WHAT ABOUT THIS OTHER
MECHANISM? WHAT ABOUT THIS
SPREAD THROUGH WHITE MATTER
PATHWAYS? BEFORE ALL THE WORK WE
DID WAS IN THIS PEBBLE IN A POND
SPREADING METHOD. WE ACTUALLY
SHOWED THAT YOU GET DIFFERENT
ANSWERS. SO THIS IS THE FIRST
ELECTRODE TO SPIKE IN RED HERE
WHICH YOU CAN SEE IS THE MEDIAL
TEMPORAL LOBE. YOU CAN SEE THE
WHITE MATTER SOURCES WERE SPREAD
REALLY THROUGHOUT MUCH OF THE
TEMPORAL LOBE AND WE LOOK AT
GRAY PLUS WHITE MATTER AND PUT
THOSE TOGETHER WE ARRIVED AT A
TOTALLY DIFFERENT SOURCE WHICH
WAS IN THIS AREA WHICH IS
OUTSIDE OF THE RESECTION AND
PATIENT DIDN'T BECOME SEIZURE
FREE. YOU CAN SEE THIS IS HOW
I'M USED TO READING EEGs, WHEN
I LOOK FOR THE LEADING SPIKE.
THIS WAS VERY EYE OPENING TO ME,
IF YOU GO BACK TO MECHANISMS OF
FAILURE THIS MIGHT BE SOMETIMES
WHY WE MISLOCALLIZE SEIZURE
SOURCES. TO WRAP UP IN MY FUTURE
DIRECTIONS WE HOPE TO USE THE
MAGNETIC WAVES OF THE BRAIN,
NON-INVASIVE IMAGING TO SEE THE
SAME SPREAD PATTERN. THIS IS A
MAP IN EARLY SEIZURE SPREAD
THESE DISCRETE AREAS ARE TURNING
UP DURING OUR SPIKES AND NOT
NEAR EACH OTHER SO H IS THAT
WHITE MATTER PROPAGATION THEN
SPREADING THROUGHOUT THE BRAIN
AND SPREADING FAR AND QUICKLY
THROUGHOUT THE BRAIN. SO WE ARE
HOPING WE CAN USE THIS TO HAVE
BETTER INITIAL GUESSES AND PUT
OUR ELECTRODES IN PLACES WE CAN
GET BACK AT THESE ANSWERS. SO
ANYWAY, THIS IS MY LITTLE
JOURNEY WHERE I HAVE BEEN. GOING
THROUGH WHERE SEIZURES ARE
COMING FROM AND DIFFERENT WAYS
TO LOOK FOR STRUCTURAL LESIONS.
WE HAVE ALSO USED PROFUSION
IMAGING TO LOOK AT LOCAL EFFECTS
AND THEN ACTUALLY USING
KNOWLEDGE OF CONNECTIVITY.
THANKS TO EVERYBODY IN MY LAB,
(INAUDIBLE) BEEN HERE FOR
DECADES AND THE NEUROSURGEON AND
PEOPLE IN OUR LAB AND PATIENTS
AND FAMILY WHOSE HAVE GONE
THROUGH ALL THESE STUDIES WITH
US. THANK YOU.
[APPLAUSE]
>>QUESTION FOR YOU. CONCERNING
YOUR MRI SLIDE YOU SHOWED
EARLIER, WAS HARD TO READ. ANY
POTENTIAL FOR AI, HAVE YOU
THOUGHT ABOUT AI IN THAT?
>>ACTUALLY THE METHOD WE
INCORPORATED IS A VERY BASIC AI
APPROACH TO DOING THIS AND OTHER
CENTERS HAVE ALSO DONE HUGE
MULTI-CENTER STUDIES THEY CAN
USE MORE ADVANCE NEURAL NETWORKS
AND THINGS LIKE THAT. THIS IS
DEFINITELY THE AREA AI IS
STARTING TO MAKE AN IMPACT.
>>AS ASIDE YOU PROBABLY KNOW OF
RON SUMMERS' WORK HERE IN THE
CLINICAL CENTER ON CHEST X-RAYS,
IF X-RAYS NOT SURE BUT HE USES
AI IN IDENTIFYING TUMORS.
>>THIS IS AN INTERESTING POINT.
I THINK IF YOU HAVE HUGE NUMBERS
OF DATA POINTS AI APPROACH
BECOMES EASIER WITH THE VERY
COMPLICATED MODELS. WE TRIED TO
SAY IF YOU JUST TAKE THE
CLINICAL IMAGES THAT YOU HAVE
CAN YOU TRAIN UP THE MODEL WITH
SMALL NUMBERS OF PATIENTS?
BECAUSE A LOT OF CENTERS DON'T
HAVE HUNDREDS OF IMAGES AND THEY
HAVE DIFFERENT MRIs AND ALL
THESE OTHER THINGS SO I THINK
THE ADVANTAGE OF OUR APPROACH IS
ABOUT 15, 20 EXAMPLES TO TRAIN
IT. DEFINITELY AN AREA FOR AI.
>>ANY OTHER -- QUESTION, USE
THE MIC BECAUSE PEOPLE ARE
WATCHING ONLINE IF YOU DON'T
MIND.
>>THANK YOU SO MUCH. SO THE
MIGRATIONS THAT HOW SMALL THE
EEG CAN DETECT THE SMALL OF THE
LEAGUES EEG DETECT?
>>SORRY HOW MANY ARE WHAT?
>>THE LESION.
>>THE LESION LIKE THE FOCAL
CORTICAL DYSPLASIAS?
INTERESTINGLY WE DON'T KNOW. A
LOT OF TIME IT IS ONES WE SEE
CLEARLY ARE CENTIMETER CAN BE
LESS. A LOT OF TIME IT IS
SMALLER THEY ARE THE LESS WE
FIND THEM SO IF ON PATHOLOGY A
LOT OF TIMES JUST IN THAT SAMPLE
SO WE DON'T KNOW HOW WIDESPREAD
OR DIFFUSE UNLESS YOU CAN SEE IT
ON THE MRI SO IT IS HARD TO KNOW
HOW SMALL THEY CAN BE BUT THEY
CAN BE VERY LARGE.
>>YOU MENTIONED EEG DOESN'T DO
A GOOD JOB OF SPATIALLY
TARGETING SEIZURES BUT IT SEEMS
TO BE SOMEWHAT CLINICAL
STANDARD. DO YOU ENVISION THAT
MEG COULD REPLACE EEG IN THE
FUTURE, IS THAT SOMETHING THAT
MOTIVATES YOU?
>>I THINK THE WAY I WOULD --
EEG SCALP EEG IS REGIONAL SO BY
THE TIME WELCOME SEE IT ON THE
SCALP SURFACE, WE THINK IT
INCORPORATES SOMEWHERE ON THE
ORDER OF TEN SQUARE CENTIMETERS
OF BRAIN. DOES THAT WELL
ACTUALLY BUT CAN MISLEAD YOU
WHEN THERE'S RAPID PROPAGATION.
SO WITH ADVANCES IN IMAGING WE
HAVE GOTTEN BETTER USING EEG FOR
SOURCE LOCALIZATION. I DON'T
THINK MEG WILL EVER COMPLETELY
REPLACE IT. TESTIFY BIG
ADVANTAGE OF MEG AS FAR AS I
KNOW THERE'S 273 SENSORS THAT
YOU GET AUTOMATICALLY SO AND THE
SCALP AND PREVIOUS SURGERYINGS
AND ALL THESE OTHER THINGS DON'T
IMPACT SOURCE IMAGING AS MUCH SO
MEG HAS BIG ADVANTAGES TERMS OF
HOW TO DO THE SOURCE IMAGING BUT
WE WILL NEVER DO IT LONG ENOUGH
TO RECORD SEIZURES. SO THAT IS
STILL THE GOLD STANDARD. BUT
AGAIN, I'M VERSED IN THIS INSULA
ACTIVITY BECAUSE IT CAN BE LESS
USEFUL INFORMATION AND
(INDISCERNIBLE) ARE WORKING ON
OPMs WHICH ARE THEORETICALLY
PORTABLE SO EXCITED TO WORK WITH
THEM BECAUSE IF WE CAN HAVE A
PERSON SITTING AROUND WITH THAT
ON THEIR HEAD THAT MAY BE AN
INTERESTING DIRECTION IN THE
FUTURE. I THINK THEY BOTH HAVE
USES.
>>A LITTLE MORE GENERAL
QUESTION BUT HOW HAS INTRAMURAL
COLLABORATION IMPROVED YOUR
RESEARCH OR WHAT INSIGHTS HAVE
YOU GAINED FROM WORKING WITH
INDIVIDUALS INSIDE THE NIH
SPACE?
>>I CAN SAFELY SAY I HAVEN'T
DONE A SINGLE THING HERE WITHOUT
COLLABORATING. THE WHOLE THING
IS COLLABORATIVE. SO I CAN HAPPY
TO WORK WITH (INDISCERNIBLE) IN
THE NEUROSURGERY GROUP, I HAVE
BEEN HERE AND AMAZING
COLLABORATION. MY COLLABORATION
WITH THEODORE HELPED WITH PET
STUDIES AN FMRI AND LANGUAGE,
USING CHILDREN'S HOME AND FMRI
AND MEMORY. THE MEMORY CORES ARE
INSTRUMENTAL AND ANY IMAGING.
THE PRESENCE OF CORE FACILITIES
IS AMAZING. COLLABORATION IS
THIS IS ALL COLLABORATIVE WORK.
NOT THE TO MENTION COLLABORATION
WITH NURSING STAFF, OTHER
INSTITUTIONS SO ANYWAY, I THINK
-- THIS IS THE ONLY HOSPITAL I
HEARD FROM OF WHERE PEOPLE
AREN'T DRIVEN BY THEIR RVs SO
I THINK THAT GIVINGS AMAZING
OPPORTUNITIES TO PURSUE THINGS
WE MIGHT NOT HAVE THE FREEDOM TO
PURSUE ELSEWHERE. s SPECIALRY
PATIENTS WITH EPILEPSY WHO ARE
UNDERINSURED OR UNSURED AND
THERE'S STIGMA SO EXCITED TO
HAVE EPIPOO L THINKING ABOUT
THEIR PROBLEM AND WORKING TO
MAKE THAT BETTER.
>>OUR NEXT SPEAKER IS DR. LISA
MCREYNOLDS, GENETICS BRANCH
DIVISION OF TRANSLATIONAL
IMMUNOLOGY AND DIVISION OF NCI.
DR. MCRAY NOLS IS PEDIATRIC --
MCREYNOLDS ONCOLOGIST AND
Ph.D. IN DEVELOPMENTAL
BIOLOGY. HER WORK IS ON GENOMICS
OF INHERITED BONE MARROW FAILURE
AND MYELOID MALIGNANCY DYSPLASIA
SYNDROMES. SHE WILL BE SPEAKING
ON HETEROZYGOTE CARRIERS AND THE
TITLE OF HER PRESENTATION IS
MOVING FROM FAMILY STUDIES TO
POPULATIONS CANCER RISK IN
FANCONI ANEMIA.
>>THANK YOU SO MUCH FOR THAT
KIND INTRODUCTION. I WILL BE
SPEAKING TO INHERITED BONE HAIR
ROW SYNDROMES. SEVERAL
PATHOLOGICAL PATHWAYS UNLIED
DISORDERS SUCH AD INHERITED BONE
HAIR ROW SYNDROMES TELOMERE
BIOLOGY DISORDERS, RIBOSOME
DISORDERS E, DISORDERS BY
HEMATOID TOE POIETIC HECTOR
BIOLOGY AND CELL SIGNALING
PATHWAYS. TODAY I WILL FOCUS ON
DNA REPAIR PATHWAY DISORDERS
INCLUDING FANCONI ANEMIA.
THERE'S INHERITED BONE MARROW
FAILURE SYNDROMES, FANCONI,
INCLUDING (INDISCERNIBLE)
DIAMOND SYNDROME AND MORE RARE
INCLUDING SEVERE CONGENITAL
NEUTROPENIA, ABSENT RADII AND
CONGENITAL MEGA KARYOSITIC
CYTOPENIA. THEY ARE LINKED TO
DECREASE IN BONE MARROW OUTPUT
AND LEADING TO BONE MARROW FILE
YOUR. THE TOP TWO LEADS TO
APLASTIC ANEMIA, PATIENTS WITH
THESE DISORDERS HAVE LOSSES OF
ALL THE MAJOR BLOOD CELL
LINEAGES, WHITE, RED, AND
PLATELET LETS. IT ONLY AFFECTS
THE RED CELLS AND THE SEVERE
NEUTROPENIA ARE RELATED TO THE
NEUTROPHIL LINEAGE AND THE LAST
TWO AFFECT PLATELETS. US A THESE
INCREASE THE RISK OF PATIENTS
GETTING MYELODYSPLASTIC SYNDROME
AND ACUTE MYELOID LEUKEMIA.
INTERESTINGLY FANCONI ANEMIA AND
DYSKERATOSIS CON GENERAL TA,
THEY HAVE HIGH RISK OF
DEVELOPING HEAD AND NECK
SQUAMOUS CE CELL CARCINOMA AT YG
AGE. IT HAS A EWE PEEK
PROPENSITY TO OSTEO SARCOMA.
WITHIN THE W DIVISION OF CANCER
EPIDEMIOLOGY AND GENETICS THE
NCI INHERITED BONE MARROW
FAILURE WAS ESTABLISHED IN 2002,
THIS IS A LARGE ONGOING FAMILY
STUDY COLLECTED THE NATURAL
HISTORY OF 5,000 -- 500 FAMILIES
AND OVER 2000 INDIVIDUALS WITH
INHERITABLE MARROW FAILURE
SYNDROMES LED BY
(INDISCERNIBLE), SINCE I JOINED
CGB IN 2016 LEADING THE GENOMIC
STUDIES WITHIN THE INHERITED
BONE MARROW FAILURE STUDY. THE
FAMILY STUDY PROCESS IS COMBINED
FIELD AND CLINICAL COHORT SO
SOME COME HERE TO THE NIH TO BE
EVALUATED AT THE CLINICAL CENTER
AND SOME ARE INVOLVED REMOTELY.
FILLING OUT QUESTIONNAIRES PADS
WELL AS SUBMITTING SAMPLES AND
COLLECTING MEDICAL RECORDS SO
PATIENTS ACCRUE BY
SELF-REFERRAL, PHYSICIAN
REFERRAL, OR FINDING OUT THROUGH
THE WEB OR OTHER PATIENT
ADVOCACY ORGANIZATIONS, THEY
CALL THE STUDY WE REVIEW THERE
ELIGIBILITY CRITERIA AND THEY
ARE SENT A LARGE SEVERAL LARGE
BOOKLETS OF QUESTIONNAIRES WHICH
FAMILIES ARE AMAZINGLY WILLING
TO FILL OUT AND SEND BACK. THIS
INCLUDES FAMILY HISTORY,
INDIVIDUAL HISTORY WHICH A
PEDIGREE IS CREATED. WE COLLECT
MEDICAL RECORDS FROM ALL OVER
THE COUNTRY THAT THESE PATIENTS
HAVE AND COLLECT RESEARCH CHART.
AT THE SAME TIME THEY CAN
UNDERGO GENETIC COUNSELING AND
TESTING IF THEY HAVEN'T HAD
OUTSTANDING AND SUBMIT
BIOSPECIMENS. THE CLINICAL
COHORT WE BRING PATIENTS AND
THEIR FAMILIES HERE A WEEK LONG
EVALUATION AT THE CLINICAL
CENTER THAT INCLUDES DEEP
PHENOTYPING AND ADDITIONAL
BIOSPECIMEN COLLECTION AND
REFERRALS TO NUMBER OF SUB
SPECIALISTS HERE WITH WITHIN THE
CLINICAL CENTER INCLUDING DENTAL
GYN ENT SUBSPECIALTIES. OVER THE
LAST OVER 21 YEARS NOW THE STUDY
HAS LED TO MAJOR ADVANCES IN THE
UNDERSTANDING OF THE INHERITABLE
MARROW FAILURE, THIS INCLUDES
THE MOST IMPORTANTLY QUANTIFYING
THE RISK OF CANCER IN EACH OF
MAJOR MARROW FAILURE SYNDROMES,
IDENTIFICATION OF MORE THAN TEN
GENETIC LOW SIZE AND DESCRIBED
QUANTIFY PHENOTYPES FOR MANY OF
THE OTHER AFFECTED ORGAN SYSTEMS
AND HERE ARE A FEW PAPERS. THE
MOST IMPORTANT BEING THE
UNDERSTANDING OF THE RATE OF
CANCER WITH INHERITED BONE
MARROW FAILURE SYNDROME, PRIOR
TO STUDY WE RECOGNIZE THESE
PATIENTS HAD INCREASE RISK OF
CANCER BUT REALLY DIDN'T HAVE A
GOOD SENSE OR QUANTIFICATION HOW
MUCH CANCER THESE PATIENTS
REALLY HAD. SO IF YOU LOOK
SPECIFICALLY AT FANCONI ANEMIA,
I AM TALKING ABOUT TODAY THESE
PATIENTS GET REALLY EARLY ONSET
CANCER, UNDER THE AGE OF 40.
THIS RISK IS ACTUALLY INCREASED
AFTER HEMATOPOIETIC STEM CELL
TRANSPLANT. MORE SPECIFICALLY
RISK OF MYELODYSPLASTIC PATIENTS
IN FANCONI ANEMIA IS 5,000 FOLD
GENERAL POPULATION AND ACUTE
LEUKEMIA IS 20 FOLD. WHAT IS
FANCONI ANEMIA, A DNA REPAIR
DISORDERS, THIS IS THE PATHWAY
THAT IS INVOLVED IN THE
CORRECTION OF ENTERSTEERING
CROSS LINKS. THREE MAYOR
COMPLEXES LABELED CALLED
UPSTREAM COLLECTION, THE ID
COMPLEX AND THE DOWNSTREAM
COMPLEX, ALL ARE IMPORTANT TO
RESOLVE THIS CROSS LINK THAT CAN
BE FORMED. THESE PATIENTS HAD
UNIQUE PHYSICAL FINDINGS, SORT
OF CLASSIC ONE UNDER HEMATOLOGY
BOARD IS ABNORMAL THUMB, OFTEN
SHORT AND CLASSIC FACE, RENAL
CONGENITAL CARDIAC PROBLEMS.
THESE PATIENTS ARE IDENTIFIED BY
WHAT IS CALLED THE CHROMOSOME
BRAY DAMAGE TESTS THESE RADIALS
WHICH FORM WHEN YOU APPLY DEVICE
C OR DB, IF THESE FORM THIS IS
INDICATIVE OF FANCONI ANEMIA.
THUS FAR 22 GENES IDENTIFIED,
THEY PROBABLY ARE MORE OUT
THERE, ALL LABELED HERE, A, B,
C, SO ON, SO FORTH. THE VAST
MAJORITY ARE AUTOSOMAL RECESSIVE
BUT THERE IS A X LINK AS WELL AS
DOMINANT FORM. SO WE KNOW
INCREASE RISK OF CANCER IN
INDIVIDUALS WITH FANCONI ANEMIA.
THAT HAVE TWO ABNORMAL COPIES OF
ONE OF THE FANCONI GENES BUT
WHAT ABOUT INDIVIDUALS WITH THE
SINGLE PATHOGENIC VARIANT THAT
WE CALL CARRIERS OR
HETEROZYGOTE?
OF THE 22 FANCONI ANEMIA GENES
FIVE ARE ALREADY CANCER
PREDISPOSITION GENES ON THEIR
OWN AND AUTOSOMAL DOMINANT
FASHION IN HETEROZYGOTES
INCLUDING THE MORE COMMONLY
KNOWN ONES BRACA 1 AND 2 AS WELL
AS GROUP 1, PARB 2 AND RAD 51C,
THESE ARE THE GENE NAMES AND
FANCONI NAMES HERE. WE KNOW THAT
THESE PATIENTS HAVE INCREASE
RISK OF CANCER, IN THE
HETEROZYGOTE FORM PRIMARILY
BREAST AND OVARIAN AS WELL AS
PANCREATIC CANCER. WHAT ABOUT
INDIVIDUALS WITH SINGLE
PATHOGENIC FA VARIANT, I CAN'T
WANT, RELATIVES OF FANCONI
ANEMIA PATIENTS OR OTHER
CARRIERS SO INCREASE RISK OF
CANCER? THE FANCONI COMMUNITY
HAS ALWAYS BEEN WORRIED ABOUT
THIS AND FAMILY MEMBERS HAVE
BEEN. BUT WE SHOULD BE WORRYND
BECAUSE 3% OF THE POPULATION IS
WALKING AROUND WITH A SINGLE
PATHOGENIC VARIANT WITHIN ONE OF
THE FA GENES. SO DID THIS
QUESTION, THE NCI WE DEEM THE FA
RELATIVE STUDY WAS FORMED. WE
TOOK THE NCI COHORT OF 150 FA
FAMILIES AND COLLECTED CANCER
INFORMATION, THEIR AGE OF
DIAGNOSIS OF CANCER, CURRENT AGE
OR AGE AT DEATH, AND LOOKED AT
PARENTS AND OFFSPRING OF
PATIENTS WITH FANCONI ANEMIA WHO
ARE OBLIGATE HETEROZYGOTES AND
THEN SIBLINGS AND GRAND PARENTS
WHICH ARE GENOTYPED. WE
CALCULATED THE OBSERVED EXPECTED
CASES USING SERE AS COMPARISON
AND ADJUSTED FOR AGE SECTION AND
BIRTH COHORT. SO WE HAD 1,038
RELATIVES WHICH MAY SEEM
RELATIVELY SMALL NUMBER BUT FOR
RARE DISORDER LIKE FANCONI
ANEMIA THIS IS HIGH OF WHICH 396
INDIVIDUALS WERE HETEROZYGOTES.
SO AS I MENTION EVERYBODY WAS
GENOTYPED AND WE DETERMINED THE
OBSERVED OVEREXPECTED SHARE.
THIS IS ALL THE PEOPLE THAT WE
CHECKED HERE. 396 HETEROZYGOTES
85 KNOWN WILD TYPE AND PATIENTS
WHO WERE NOT ABLE TO GET
MATERIAL FOR BUT RELATIVES OF FA
PATIENTS. IF WE LOOK ACROSS
LOOKING AT OBSERVED OVEREXPECTED
RATIO FOR ALL RELATIVES, KNOWN
WILD TYPE RELATIVES HETEROZYGOTE
RELATIVES THERE IS NOT AN
INCREASE RISK OF CANCER. I'M
MOST INTERESTED, WE DIDN'T
OBSERVE CANCER COMMON IN FA
PATIENTS INCLUDING AML AND HEAD
AND NECK SQUAMOUS CELL CARCINOMA
AND THE CANCER WE DID OBSERVE IN
HETEROZYGOTES TYPICAL AGE OF
ONSET OF THOSE SPECIFIC CANCER
SO WE DIDN'T SEE INCREASE RISK
IN THESE HETEROZYGOTES.
PARTICULARLY THE MOST COMMON
FORMS OF FANCONI ANEMIA ARE FANC
AND FANA AND WE DIDN'T SEE
INCHRIS RISK. HOWEVER WILL
THERE'S LIMITATIONS SO DESPITE
LARGE SAMPLE SIZE WE HAD LIMITED
POWER PARTICULARLY FOR THE RARE
FA GENOTYPES. SO WE NEEDED A
SECOND VALIDATION COHORT.
HOWEVER THIS IS THE LARGEST
COLLECTION OF FA RELATIVES SO
WHERE DID WE -- WHAT DO WE DO
NEXT? TURN TO LARGE BIOBANKS AND
GENOME FIRST APPROACH. SO THERE
ARE SEVERAL ADVANTAGES TO IDENTL
PHENOTYPES PREVIOUSLY OBSERVED
IN SMALLER COHORT. SO THE
TRADITIONAL GENETIC MODEL HAS
BEEN WHAT WE CALL THE PHENOTYPE
FIRST APPROACH. SO YOU FIND
INDIVIDUALS WHO HAVE SPECIFIC
PHENOTYPE THAT YOU ARE
INTERESTED IN AND BRING THEM TO
CLINIC AND YOU DO ASSOCIATION
STUDIES AND FIND THE GENOTYPE
AND UNDERLYING CAUSATIVE GENE.
THIS IS VERY EFFECTIVE BUT THE
PROBLEM IS IT HAS BIAS TOWARDS
PEOPLE WITH SEVERE PHENOTYPE, IT
IS RELATIVELY LOW THROUGH PUT.
SO IF WE FLIP THAT MODEL ON ITS
HEAD WE CAN DO A GENOTYPE FIRST
APPROACH. SO INSTEAD OF GOING
FROM PHENOTYPE TO GENOTYPE YOU
GO GENOTYPE TO PHENOTYPE. SO
LARGE COLLECTIONS OF PEOPLE FROM
BIOBANKS USUALLY IN A --
HEALTHCARE COMBINED HEALTHCARE
SYSTEM WHICH HAS ACCESS TO
ELECTRONIC MEDICAL RECORDS AND
DO GENOTYPING AND THEN LOOK AT
THEIR PHENOTYPES. SO THIS IS
RELATIVELY HIGHER THROUGH PUT
THAN THE PHENOTYPE FIRST
APPROACH. SO FOR LOOKING AGENT
THE RISK OF CANCER IN FA
HETEROZYGOTES WE USE TWO LARGE
BIOBANKS FIRST IS GUY SINGER
COHORT OF APPROXIMATELY 175,000
INDIVIDUALS ALL CONSENTED TO
HAVE EXOME SEQUENCING,
PARTICIPANTS IN THE GUY SINGER
HEALTH SYSTEM IN NORTH EASTERN
PENNSYLVANIA AND LINKED TO THEIR
ELECTRONIC MEDICAL RECORD. AS
WELL AS THEIR TUMOR AND DEATH
REGISTRY. THIS SUB COHORT OF
INDIVIDUALS WHO HAVE BEEN EXOMED
ARE CALLED THE DISCOVER COHORT.
WE HAVE ACCESS TO THE UK BIOBANK
COHORT WHICH IS APPROXIMATELY
469,000 PEOPLE WHO HAD EXOME.
AGAIN LINKED TO THE ELECTRONIC
HEALTH REGISTRY, DEATH CANCER
REGISTRY AND NUMEROUS
QUESTIONNAIRES THESE INDIVIDUALS
UNDERGO. IF WE LOOK WE TOOK THE
DISCOVER COHORT FROM GEISINGER
AT TIME OF ANALYSIS WAS 175,300
INDIVIDUAL WHOSE HAD EXOME
SEQUENCING IDENTIFY EVERYONE WHO
HAD SINGLE PATHOGENIC VARIANT IN
ONE OF THE 22 FA GENES, WE
REMOVED ANYBODY WHO WAS
IDENTIFIED COMPOUND HETERO IS A
ZYGOTE, HOMOCYTE GOAT OR FA
VARIANT IN TWO DIFFERENT
VACCINES. SO THIS LEFT WITH 589
INDIVIDUALS, FIVE TIME MORRIS
PEOPLE THAN IN FA RELATIVE
STUDY, AND 3.4% COHORT WERE
HETEROZYGOTES. THIS IS SIMILAR
TO WHAT WE HAD PREVIOUSLY
DESCRIBED IN GENOME AD PROJECT
BUT PARTICULARLY HIGHER THAN
WHAT HAD PREVIOUSLY BEEN
DESCRIBED FOR THE RATE OF
FANCONI CARRIERS IN A POPULATION
LOOKING AT PATIENTS WHO ARE
IDENTIFIED. THIS WAS LINKED TO
THE ELECTRONIC HEALTH REGISTRY
AND MALIGNANCY ICD 10 CODES AND
COMPARE CANCER TO SERE AS WELL
AS INTERNAL COHORT AS A CONTROL
SET. THE FIRST SURPRISING THING
WAS THAT THE THERE'S SIGNIFICANT
DIFFERENCE IN THE DISTRIBUTION
OF FANCONI HETEROZYGOTES. IF YOU
TAKE ALL FANCONI ANEMIA PATIENTS
THE VAST MAJORITY OF FANC A G OR
C. LOOK AT HETEROZYGOTES WE
IDENTIFIED AND DISCOVERED THE
DISTRIBUTION ACROSS THE 22 GENES
IS QUITE DIFFERENT. YOU CAN SEE
HERE FANCA IS ONLY 13%, FANC THE
2%, FANCN IS MUCH MORE COMMON.
SECOND IS WHAT THE CANCER RATES
WERE. FIRST WE GROUPED THE GENES
WE ALREADY KNEW WERE CANCER
PRE-DISPOSITION GENES BRACA 1,
2, AND LOOKED AT THE RATE HERE.
YOU CAN SEE THAT THIS IS
SIGNIFICANTLY INCREASED RISK OF
CANCER IN THESE INDIVIDUALS,
BOTH LOOKING BY COMPARISON TO
SEER AS WELL AS COMPARED TO
INTERNAL CONTROL COHORT.
HOWEVER, IF WE LOOK AGAIN AT
JUST THE AUTOSOMAL RECESSIVE
INHERITED FANCONI GENES SUCH AS
FANC A C AND G DO NOT SEE A
SIGNIFICANTLY INCREASE RISK OF
CANCER AMONG THESE INDIVIDUALS.
SURPRISINGLY IN 3 GENES WE FOUND
SOME SIGNAL FOR INCREASE RISK OF
CANCER IN THESE THREE GENES.
HOWEVER, WHEN WE WENT TO
VALIDATE THIS FINDING WE CAN SEE
WE DID NOT SEE INCREASE RISK.
IN UK BIOBANK AMONG THESE THREE
FA GENES. SO OVERALL, WE FOUND
NO INCREASE RISK OF CANCER WAS
IDENTIFIED IN THE HETEROZYGOTE
RELATIVES OF FA ONLY MEMBERS THE
GENOME FIRST ANALYSIS IDENTIFIED
HIGHER RATES OF FA HETEROZYGOTE
MS. THE POPULATION PREVIOUSLY
DESCRIBED AND NOTABLY DIFFERENT
DISTRIBUTION OF GENES COMPARED
TO PATIENTS WITH FA. USING THE
GENOME FIRST APPROACH WE
VALIDATED STUDY FROM FA RELATIVE
AND CONFIRMED THE KNOWN CANCER
PRE-DISPOSITION GENES THE
HETEROZYGOTES HAVE INCREASE
CANCER RISK. IN CONTRAST OTHER
AUTOSOMAL INHERITED FA GENES
HETEROZYGOTES DON'T HAVE
INCREASE RISK OF CANCER AND THE
GENOME FIRST APPROACH ALLOWED
FOR STATISTICAL POWER WHEN
FAMILY STUDIES DID NOT
PARTICULARLY FOR THE FA -- THE
RARER FA GENOTYPES. SO THIS IS
COLLABORATIVE SCIENCE, LIKE TO
FIRST THANK MY MENTEES INVOLVED
IN THIS WORK, (INDISCERNIBLE)
THE ENTIRE TEAM HERE MY ACI
MENTORING COMMITTEE,
COLLABORATORS AT GEISINGER
HEALTH SYSTEM (INDISCERNIBLE)
AND SUPPORT STAFF THROUGHOUT DCG
WHO ARE AMAZING AND WONDERFUL TO
WORK WITH. THANK YOU.
[APPLAUSE]
>>ANY QUESTIONS?
SPEAKER5: GREAT. ONE OF THE
INTERESTING THINGS ABOUT DOING
GENOTYPE FIRST APPROACHES YOU
PROBABLY SHOULD COME UP WITH UP
TO A COUPLE OF HUNDRED
HOMOZYGOTES. SO THE QUESTION ARE
THERE ANY ASYMPTOMATIC OR IS
THERE EVIDENCE OF SUPPRESSER
GENES IN THE POPULATION?
>>IT IS A GREAT QUESTION SO WE
DID FIND SURPRISES IN THAT AND
WE ARE FOLLOWING UP NOW BUT WE
FIND A COUPLE OF HUNDRED PEOPLE
WHO LOOK LIKE THEY SHOULD HAVE
FANCONI ANEMIA BUT DON'T HAVE
ANY EVIDENCE OF IT IN THEIR
MEDICAL RECORDS. SO WE ARE
FOLLOWING THOSE UP NOW.
PARTICULARLY SOME SURPRISING
FINDINGS LIKE PEOPLE WHO SHOULD
HAVE VERY SEVERE FANCONI
PHENOTYPES, BUT WE DON'T SEE IT
MORE FOLLOW-UP AND WE ARE ALSO
DOING A STUDY CAN WE DETERMINE
HAVING ONE FANCA AND ONE FANCC
GIVE YOU FANCONI ANEMIA. SO FAR
NEGATIVE BUT THEY WERE HARD TO
GET AT, WE COULDN'T FIND THOSE
PEOPLE AND NOW WE HAVE WAY TO
ACCESS PEOPLE WITH THOSE
GENOTYPES.
>>WHAT FOLLOW-UP DURATION OF
THE DATA SET YOU SHOWED?
>>SO THE -- SO FOR THE
GEISINGER HEALTH SYSTEM THEY
MOVE THEIR ELECTRONIC HEALTH
RECORDS IN THE MID 90s SO WE
HAVE IT MORE THAN 20 YEARS
FOLLOW-UP. SOME OF THE PATIENTS
WHO JUST JOINED THE HEALTHCARE
SYSTEM IT IS LESS BUT THE RANGE
IS PRETTY DECENT.
>>THANK YOU.
>>THANK YOU ALL.
[APPLAUSE]
>>THE NEXT SPEAKER IS DR.
DESMOND BROWN. DR. BROWN
RECEIVED M.D. Ph.D. IN 2014
FROM RUTGERS PRINCETON
UNIVERSITY COMBINED M.D. Ph.D.
PROGRAM AND COMPLETED RESIDENCY
IN NEUROLOGICAL SURGERY
FOLLOWING FELLOWSHIP IN
NEUROSURGICAL ONCOLOGY MAYO
CLINIC IN 2021. CLINICALLY DR.
BROWN INTEREST IS COMPLEX
RESECTION OF THE INTRAAX LOW
GLAND LESIONS AWAKE RESECTIONS,
OPERATOR SPEECH AND MAPPING. DR.
BROWN'S RESEARCH PROGRAM IS
INVESTIGATING THE ROLE OF
PRIMARILY SERUM IN CANCER
MOLECULAR BIOLOGY AS SITE OF
INTEGRATION OF POPULACE.
[APPLAUSE]
I'M GOING TO TALK TO YOU TODAY ABOUT
WHAT MANY PEOPLE MIGHT THINK IS
A RATHER ESOTERIC TOPIC PRIMARY
CILIA AND TALK IN THE CONTEXT OF
GLIOBLASTGLIOBLASTOMA. NO DISCL.
PRIMARY CILIA ARE THESE
ORGANELLES THAT PROTRUDE FROM
THE CELL MEMBRANE, THEY ARE
SPECIALIZED SO MANY PEOPLE HAVE
HEARD OF THESE TUBULES THAT HAVE
THIS NINE PLUS ZERO ARRANGEMENT
AND SO THESE GROW OUT FROM THE
MOTHER CENTRIOLE AND THEY ARE
ORGANIZED IN A VERY SPECIFIC WAY
THAT WE WILL TALK ABOUT THAT GET
THEM THESE FUNCTIONS. AND THE
FUNCTION SPECIFICALLY ARE TO
REGULATE CANONICAL SIGNAL
TRANSDUCTION CASCADES, JUST
HEARD FROM LISA SHE IS A FELLOW
DEVELOPMENTAL BIOLOGIST, I ALSO
DID Ph.D. IN
NEURODEVELOPMENTAL AND MOLECULAR
BIOLOGY SO ONE OF THE HALLMARK
SIGNALING CAUSE FADES IS SONIC
HEDGEHOG SIGNALING BUT PRIMARY
CILIA ALSO REGULATE A NUMBER OF
THESE CANONICAL SIGNALING
CASCADES THAT ARE IMPORTANT IN
DEVELOPMENT AND LATER USED IN
PATHOLOGICAL PROCESSES. THEY ARE
REGULATED IN A VERY COMPLEX WAY
BECAUSE THEY GROW FROM THE
CENTRIOLE SO BASICALLY THIS
MEANS THAT THE ORGANELLES
THEMSELVES ACT AS KIND OF A G2M
CHECK POINT INHIBITOR WHICH IS
INTERESTING. SO THIS IS IMAGES
FROM OUR LAB TAKEN BY PRIOR MRA
STUDENT IN THE LAB SHOWING THAT
THE CILIA ACTUALLY AS SHOWN IN
THE CARTOON HERE FROM THIS PRIOR
REVIEW HAVE TO GET DISSOCIATED
OR DISASSEMBLED IN ORDER FOR THE
CELL TO PROGRESS THROUGH THE G2M
CHECK POINT. SO OBVIOUS THIS HAS
SOME IMPLICATIONS FOR CANCER
BROADLY BUT ALSO FOR
PROLIFERATION AND SIGNALING MORE
GENERALLY. AS A RESULT OF THE
IMPORTANCE OF THIS ORGANELLE IN
DEVELOPMENTAL CASCADES WE HAVE A
CLASS OF DISEASES REFERRED TO
BROADLY AS SILL OWEPATHYS.
THESE INCLUDE THINGS YOU HEARD
ABOUT FROM MEDICAL STUDENTS OR
OTHER PHYSICIANS, THINGS LIKE
POLYCYSTICKED KIDNEY DISEASE AND
RETINITIS PIGMENTOSA. THESE ARE
ALL DISEASES OF CELLULAR
DISREGULATION IN ONE WAY OR THE
OTHER. CILIA THEREFORE BECAUSE
OF THEIR UBIQUITOUSNESS AND
BECAUSE OF THE FACT THEY
REGULATE ALL THESE PATHWAYS,
SEVERAL PAPERS OVER THE LAST
DECADE OR SO HAVE SHOWN THESE
ARE JUST REALLY IMPORTANT FOR
NUMBER OF DIFFERENT BOTH
PHYSIOLOGIC AND PATHOLOGICAL
PROCESSES. THIS IS A PAPER THAT
IS LOOKING AT ALZHEIMER'S
DISEASE AND AGING AND SOME OF
THE NEUROPSYCHIATRIC DISORDERS
OBVIOUSLY, IT IS NOT FOR YOU TO
RECOGNIZE ANY PARTICULAR GENE,
JUST SHOWING YOU HERE THAT ALL
THESE BLUE GENES HERE ARE GENES
THAT ARE STRUCTURALLY IMPORTANT
FOR PRIMARY CILIA DEVELOPMENMEN.
ASIT IN THESE CORES OF GENES
THAT REGULATE DISEASE PROCESS
AND THINGS LIKE IN ALZHEIMER'S
DISEASE. YOU CAN SEE WHEN THEY
LOOK AT THE CILIA GENES SHOWING
RED, HOW THEY INTERACT WITH
GENES FOR EXAMPLE THAT ARE
IMPORTANT FOR THINGS LIKE AGING
AND ALZHEIMER'S DISEASE SHOWN
BETTER HERE. TRYING TO CONVINCE
YOU THIS IS A IMPORTANT THING.
BASICALLY I TOLD YOU WE TALK
ABOUT THIS IN A CONTEXT OF
GLIOBLASTOMA. THIS IS A HORRIBLE
DISEASE. I LIKE TAKING TIME AS
SARA SAID EARLIER IN HER TALK TO
TRY TO EDUCATE ESPECIALLY A ROOM
FULL OF ANYBODY I CAN GET REALLY
OF SMART PEOPLE TO UNDERSTAND
HOW DEVASTATING THIS DISEASE IS.
AND HOW LITTLE WE HAVE BEEN ABLE
TO DO COMPARATIVELY SPEAKING. TO
HELP THIS DISEASE. SO BASICALLY
WHEN SOMEONE PRESENTS WITH
GLIOBLASTOMA TO US IN CLINIC, IF
WE DIAGNOSE THEM, BUT DIDN'T DO
ANY SORT OF TREATMENT FROM THE
TIME OF SYMPTOMATIC DIAGNOSIS
WITHOUT TREATMENT LIFE
EXPECTANCY IS SOMEWHERE ON THE
ORDER OF SIX WEEKS. WITH SOME
TREATMENT MEDIAN SURVIVAL IS
NINE MONTHS OR SO. IF WE TRY TO
MAXIMIZE TREATMENT MEANING THE
MAXIMAL SAFE RESECTION FOLLOWED
BY CHEMOTHERAPY AND RADIATION
TOGETHER FOR A MONTH FOLLOWED BY
SIX MONTHS OF RADIATION, THEN WE
CAN GET TO 15 MONTHS OF LIFE
EXPECT FANCY. THAT IS WHERE WE
HAVE BEEN FOR DECADES QUITE
HONESTLY. THERE ARE NUMBER OF
REASONS WHY THIS IS SO DIFFICULT
THE TREAT. ONE IS GENETIC
HETEROGENEITY AS WE HEARD ABOUT
EARLIER CONTRIBUTES TO THAT. BUT
IN THIS CASE THE DISEASES ALSO
BEHIND THIS KIND OF FIREWALL
CALLED CENTRAL NERVOUS SYSTEM
AND BEHIND THE BLOOD BRAIN
BARRIER. SO IT IS REALLY
DIFFICULT TO GET DRUGS THAT
MIGHT OTHERWISE BE EFFECTIVE TO
GET TO TREAT THIS DISEASE. IN
ADDITION WHAT I HAVE HIGHLIGHTED
HERE WILL BE THE MEAT OF MY TALK
TODAY IS THAT THE DISEASE ALSO
IS VERY ADEPT AT MITIGATING
IMMUNE RESPONSES TUMORS
TYPICALLY GIVE TO THE IMMUNE
SYSTEM WHICH THEN TARGETS THE
CANCER. IN OTHER WORDS THE
CANCER, THIS PARTICULAR CANCER
AND SEVERAL OTHERS AS I WILL
SHOW YOU MITIGATE THE NATURAL
IMMUNITY ONE MIGHT DEVELOP
T-CELL ADAPTIVE IMMUNITY ONE
DEVELOPS TO FIGHT THE CANCER. SO
THAT IS WHAT WE ARE GOING TO BE
TALKING ABOUT A LOT TODAY. OF
COURSE THESE PRIMARY CELLULAR
CILIA ARE PRESENT IN
GLIOBLASTOMA, THIS IS ANOTHER
PICTURE FROM OUR LAB. FROM A
HUMAN SAMPLE OF GLIOBLASTOMA
SAMPLE SHOWING CLEARLY DAPI IN
BLUE ACETYLATED ALPHA TUBULIN
LOOKING AT THE MICROTUBULES AND
YOU CAN SEE THE CENTROSOME HERE
STAINED IN RED. YOU CAN SEE THIS
LOVELY MICROTUBULE STRUCTURE
GROWING OUT OF THE PRIMARY
CILIA. YOU CAN SEE THIS IS A
HUMAN SAMPLE. SO AGAIN WE HAVE
LOTS OF BIOINFORMATIC EVIDENCE
THAT THESE ORGANELLES ARE
IMPORTANT FROM THE WAY THAT THE
MOLECULAR SIGNALING OF THE
TUMORS WORK. I WILL FOCUS YOU
HERE ON THIS UPPER RIGHT PANEL
HERE BECAUSE I DON'T WANT TO
NECESSARILY TALK ABOUT THE ALL
THE GRAPH BUT SUFFICE IT TO SAY
IN THIS PAPER THEY FOUND WHICH
WERE UP OR COULDN'T REGULATED
AND DEVELOP -- DOWN REGULATED
AND DEVELOPED FROM A
MATHEMATICAL MODEL OF PREDICTING
A CILIARE SCORE. ON THE UPPER
LEFT PANEL HERE, THE GENES THAT
WERE OVEREXPRESSED OR HIGHLY
EXPRESSED THESE FUNCTIONS THAT
BECAME PART OF THIS CELLULAR
SCORE WHEN THE CILIA SCORE WAS
HIGH THE PROGNOSIS WAS EXTREMELY
POOR FOR THESE PATIENTS. THIS
IS THE TCG, CANCER GENOME ATLAS
AND IF YOU LOOK AT THE
GLIOBLASTOMA YOU CAN SEE
DIFFERENCE IN SURVIVAL WHEN YOU
LOOK AT THE CILIA SCORE. THIS IS
A BIGGER SURVIVAL DIFFERENCE
WITH CURRENT STANDARD OF CARE
THERAPY. SO REALLY IMPORTANT THE
CONSIDER. PRIMARY CILIA, THE
SIGNALING THEY OVERSEE IF YOU
WILL ARE CO-OPTED IN MANY
CANCERS SO HERE WE WILL FOCUS ON
GLIOBLASTOMA BUT PRIMARY CILIA
REPORTED TO BE INVOLVED IN
SEVERAL OTHER CANCERS SO IN OUR
LAB WE FOCUS ON A LOT OF THINGS
RELATED TO GLIOBLASTOMA PRIMARY
CILIA. IN THIS TALK WE FOCUS ON
THE IMMUNOSUPPRESSIVE PHENOTYPE
THE WAY THIS IMMUNOSUPPRESSED
PHENOTYPE IS THOUGHT TO WORK IS
ONE QUESTION SHOULD BE HOW IS IT
A TUMOR THAT I TOLD YOU IS LEFT
BEHIND THE CENTRAL NERVOUS
SYSTEM IN THE BLOOD BRAIN
BARRIER AND THE BLOOD BRAIN
BARRIER HOW TUMOR LEAD TO
SYSTEMIC IMMUNE SUPPRESSION. SO
ONE OF THE WAYS IN WHICH THIS IS
TAUGHT -- THOUGHT TO OCCUR
PRIMARILY THOUGHT TO OCCUR IS BY
THE TUMOR RELEASING THESE EXTRA
CELLULAR VESICLES WHICH THEN ARE
ABLE TO EXIT THE CENTRAL NERVOUS
SYSTEM BE PART OF THE SYSTEMIC
IMMUNE SYSTEM AT CIRCULATION AND
INTERACT WITH IMMUNE CELL
SYSTEMATICALLY CAUSING IMMUNE
SUPPRESSION. (INDISCERNIBLE) THE
SCIENTIST IN MY LAB CURRENTLY,
PUBLISHED THIS PAPER LAST YEAR
SHOWING MECHANISTICALLY MORE
DETAILS HOW THIS HAPPENS. SO WE
KNOW THINGS LIKE INTERFERON
GAMMA WILL BE UPREGULATED WHICH
LEAD TO INCREASE IN PDL 1.
ESSENTIALLY INCREASE IN PDL 1
DRIVE EXPRESSION OR INDUCTION OF
THESE VERY SPECIFIC TUMOR TYPES,
MYELOID DERIVED SUPPRESSER CELLS
WE SEE IN CANCER. IN TURN THESE
MYELOID DERIVED SUPPRESSER CELLS
ARE ABLE TO THEN REDUCE T-CELL
PROLIFERATION AND ACTIVATION
LEADING TO THE T-CELL
LYMPHOPENIA AND T-CELL
INACTIVATION THAT IS SEEN IN
PATIENTS WITH GLIOBLASTOMA IN
SOME OTHER KINDS OF CANCER. NO
LONGER ADVANCING.
>>ARROW IS MOVING.
>>CAN'T GO ANY FURTHER. HERE WE
GO. THINK IT IS STILL
DOWNLOADING. SO BASED ON THIS
WE THINK THIS PROVIDES AN
EXPLANATION FOR WHY WE HAVE SEEN
THAT INTERFERON GAMMA
UPREGULATION CORRELATE WITH
REALLY POOR SURVIVAL IN
GLIOBLASTOMA. SO WHAT IS
INTERESTING HERE ABOUT THIS
OTHER SIDE IS CHEMO RADIATION IS
HOW I TOLD YOU WE TREAT THESE
PATIENTS BUT THERE IS EVIDENCE
THAT THE VERY ACTIVE CHEMO
RADIATION INCREASES INTERFERON
GAMMA WHICH WORSENS THE
IMMUNOSUPPRESSIVE ACTIVITY OF
THE TUMORS. SO IT WILL BE THIS
KIND OF RACE BETWEEN KILLING
TUMOR CELLS WHICH WE CAN WITH
CHEMOTHERAPY AND RADIATION, AND
ALSO UPREGULATING THE INTERFERON
GAMMA WHICH MOW MIGHT HAVE A
DELETERIOUS AFFECT. SO THERE HAS
TO BE A WAY OF DOING THIS
BETTER. SO THIS IS WHAT WE ARE
SHOWING HERE THAT JUST WHEN YOU
TAKE HUMAN TUMOR GLIOBLASTOMA
CELLS. IF YOU SUBJECT THEM TOP
TMZ OR RADIATION 15 GRAY YOU CAN
SEE THAT ALONE IS ENOUGH TO
UPREGULATE PDL 1, WHICH AGAIN WE
HAVE ALREADY SHOWN HAS BEEN
IMPORTANT FOR THE INDUCTION OF
THESE MYELOID DERIVED SUPPRESSER
CELLS AND IMMUNOSUPPRESSIVE
EFFECTS. I'M GOING TO MOVE
FORWARD HERE. I'M SORRY I'M
GOING BACKWARDS. SO WE TALKED
ABOUT THESE EZVs, EXTRA
CELLULAR VESICLES A CATCH ALL
TERM FOR VESICLES RELEASED FROM
MOST CELL TYPES OF YOUR BODY.
BUT OUR REALLY PARTICULARLY
RELEASED IN REALLY LARGE VOLUMES
BY TUMOR CELLS. NOT JUST
GLIOBLASTOMAS BUT TUMOR CELLS
MORE BROADLY. WHAT THOSE ARE
ABLE TO DO BECAUSE THEY ARE
RELEASED AND THEN GO OFF INTO
THE CELLULAR MILIEU AND
SYSTEMICALLY THEY ARE ABLE TO
ESSENTIALLY COORDINATE THE
AFFECT OF THIS LOCAL EFFECT
PARACRINE EFFECT ON ADJACENT
TUMOR CELLS BUT ALSO CARRY OUT
THIS SYSTEMIC EFFECT AS WELL. WE
TALKED ABOUT THESE MYELOID
DERIVED SUPPRESSER CELLS WHICH
THEN THROUGH NUMBER OF SIGNALING
PATHWAYS THAT I WON'T GO INTO
TODAY, CAN LEAD TO BOTH
REDUCTION IN THE ACTIVITY AND
THE ACTUAL NUMBER OF THE T-CELLS
LEADING TO BOTH T-CELL
INACTIVATION AS WELL AS T-CELL
LYMPHOPENIA. AGAIN WHAT I WANT
TO HIGHLIGHT FOR YOU HERE IS
THAT THIS IS NOT A GLIOBLASTOMA
SPECIFIC PHENOMENON, THIS IS
PHENOMENON THAT INVOLVES CANCERS
MORE BROADLY. SO IN FACT, THE
IDEA TO LOOK FOR WHETHER EVs
WERE PART OF THE GLIOBLASTOMA
STORY CAME BECAUSE THIS WAS
ALREADY WORKED OUT IN SO MANY
OTHER SYSTEMIC CANCERS AND IDEA
WAS THAT WELL MAYBE EVs
PARTICIPATE IN GLIOBLASTOMAS
TOO. SO THIS IS AGAIN A REALLY
BROAD STORY HERE WITH DATA FROM
HEPATOCELLULAR CARCINOMA,
BREAST, LUNG, ET CETERA. THIS
IDEA THAT TUMORS LEAD TO BECAUSE
THEY EXPRESS THESE EPITOPES CAN
LEAD TO T-CELL ACTIVATION AND
YOUR IMMUNE SYSTEM THUS THEN
HELPS TO GIVE BENEFIT BY
TARGETING THE CANCER CELLS. IT
IS THE WHOLE POINT BEHIND CHECK
POINT THERAPY. IMMUNOTHERAPY,
WHICH THEN CAN HELP ACTIVATE
PROCESSES AND INCREASE THE
TARGETING OF THESE CANCER CELLS
HERE IS AN EXAMPLE OF THIS ONE
GROUP THAT WORKS WITH
HEPATOCELLULAR CARCINOMA, TALKED
ABOUT CCRK, CELL CYCLE RELATED
KINASE, SEEMS TO SIT AT TOP THIS
NETWORK THAT ULTIMATELY LEADS
TOICSL 6 UPREGULATION WHICH THEN
LEADS TO MYELOID DERIVED
SUPPRESSER CELL INDUCTION AND
THEN EXHAUSTION OF YOUR T-CELL.
CCRK IS ONE OF MY FAVORITE
PROTEINS, IT IS OVEREXPRESSED IN
MANY CANCER. AND ALSO I THINK
I'M PAUSED AGAIN. JUST GOT TO
WAIT ON THE SLIDE. BUT ALSO CCRK
WAS SOMETHING I SPENT A
CONSIDERABLE TIME IN GRADUATE
SCHOOL WORKING ON, WHEN I CLONED
THE FIRST CCRK KNOCK OUT MOUSE
AN CHARACTERIZED THAT. THIS IS
WHAT IS SHOWN HERE THAT WHEN WE
THEN LOOK AT THIS PHENOTYPE OF
THIS KNOCK OUT MOUSE THAT YOU
CAN SEE FOR THE DEVELOPMENTAL
BIOLOGIST IN THE ROOM YOU SHOULD
SEE A VERY FAMILIAR
CONSTELLATION OF PHENOTYPES
WHICH IS LOSS OF MID BRAIN --
POLYSYNDACTYLY, SKELETAL DEFECTS
AND TOGETHER THOSE ARE VERY MUCH
IN SYNC WITH SONIC HEDGEHOG
SIGNALING DEFEC DEFECT. SO OF CE
SONIC HEDGEHOG I TOLD YOU IS THE
SORT OF PROTOTYPE PATHWAY OF
CANONICAL SIGNALING THAT
REQUIRES PRIMARY CILIA. SO WE
LOOK AND ASKED WHETHER PRIMARY
CILIA ARE CHANGED OR AFFECTED
MORPHOLOGICALLY OR FUNCTIONALLY
IN THE CCRK KNOCKOUT MICE. I
THINK YOU CAN CLEARLY SEE FROM
THE SCANNING ELECTRON MICROSCOPY
IMAGE FROM THE NEUROEPITHELIA OF
THE DEVELOPING EMBRYOS THAT THE
PRIMARY CILIA HERE ARE CERTAINLY
MORPHOLOGICALLY ABNORMAL. ONE
THING WE THEN DECIDED TO ASK WAS
WELL, THE CCRK CONNECTION TO
IMMUNOSUPPRESSION IN CANCER, IS
THAT RELATED TO THIS AFFECT OF
CCRK IN PRIMARY CELLULAR
MORPHOLOGY OR IS THIS A
NON-CILIARE EFFECT OF CCRK THAT
DOES SOMETHING ELSE IN THE ADULT
CONTEXT? SO THAT IS WHAT WE
WANTED TO ASK. THERE ARE ALSO
OTHER REASONS TO ASK THIS
BECAUSE THERE'S SOME OTHER
PAPERS THAT HAVE SAID THAT
PRIMARY CILIA ARE PROBABLY BOTH
IMPORTANT FOR RECEIVING EV
SIGNAL AND INTERPRETING THOSE
AND ALSO MAY BE IMPORTANT FOR
RELEASING EV SIGNAL IN TO THE
TUMOR MICROENVIRONMENT AS WELL.
SO WITH ALL THESE WE THOUGHT
WELL, THIS MIGHT MAKE SENSE THE
EVs ARE DOING SOMETHING. SO
AGAIN THE MYELOID DERIVED
SUPPRESSER CELLS ARE MONOSTATTIC
RELATED CELLS THAT YOU REALLY
ONLY SEE IN CANCER THAT LEAD TO
THIS IMMUNOSUPPRESSION THROUGH
VARIETY OF PATHWAYS AND
IMMUNOSUPPRESSION OF VARIETY OF
CELL TYPES, WHAT WILL BE
FOCUSING ON HERE IS THE EFFECT
ON T-CELLS. SO WE DEVELOPED AN
ASSAY THAT ALLOWS US TO LOOK AT
THIS MYELOID DERIVED SUPPRESSER
CELL POPULATION THAT WE DEFINE
AS POPULATION OF CD 14 POSITIVE
CD 11B POSITIVE AND HLADR
NEGATIVE. WE CAN ASK QUESTIONS
LIKE SO GOING BACK TO THIS IDEA
OF WHAT DOES IRRADIATION DO,
THIS HAS NEVER BEEN SHOWN. SO WE
SHOW WHEN WE IRRADIATE THESE
HUMAN DERIVED GLIOBLASTOMA CELLS
WE CAN GET CERTAINLY INDUCTION
OF INCREASE IN INDUCTION OF
THESE MYELOID DERIVED
SUPPRESSIONER CELLS.
IMPORTANTLY, THAT INCREASE IN
THE MYELOID DERIVED SUPPRESSER
CELLS FURTHER DECREASES THE
ACTIVITY AND PROLIFERATION OF
THE T-CELLS CONSISTENT WITH WHAT
WE HAVE HYPOTHESIZE. WAITING ON
THE SLIDES AGAIN. SO THE
QUESTION NOW AGAIN BECOMES DOES
LOSS OF PRIMARY CILIA THEN
REDUCE THIS INDUCTION OF MYLID
DERIVED SUPPRESSER CELLS AND
DOES THAT IN TURN LEAD TO
RESTORATION OF THAT T-CELL
INACTIVATION? SO WE ESSENTIALLY
GOT NUMBER OF GENES THAT ARE
ESSENTIAL FOR CILIA DEVELOPMENT
BECAUSE IF I JUST SHOWED YOU
THAT WE KNOCK DOWN CCRK AND THAT
MYELOID DERIVED SUPPRESSER CELL
WENT DOWN, THE QUESTION YOU
WOULD ASK ME IS HOW DO I KNOW
THAT THAT'S CILIA RELATED OR
NOT. SO WHAT WE DID IS TOOK A
NUMBER OF OTHER GENES IN
ADDITION TO CCRK THAT ARE
ESSENTIAL FOR CILIA GENESIS AND
SAID WELL, THEN, IF THIS IS A
CILIA GENESIS ISSUE, THEN WE
SHOULD BE GETTING THE SAME
PHENOTYPE. SO WHAT YOU CAN SEE
HERE IS THAT WHEN WE KNOCK DOWN
THESE CILIA RELATED GENES IN THE
HUMAN TUMOR CELLS, HARVEST THEIR
EVs, ADD THESE EVs TO THE
MONOCYTES OF NORMAL PATIENTS
THAT WE DON'T GET THE SAME VIGOR
OF INDUCTION THAT THAT SEEMS TO
BE DEPENDENT ON FUNCTION AND
PRIMARY CILIA IN THE
GLIOBLASTOMA PATIENTS.
CONSISTENT WITH THAT, WHAT WE
SAW WAS THAT WHEN WE DO THAT,
THAT T-CELL FUNCTION IS
RESTORED. SO THIS IS CONTROL
SETTING WHERE THIS INCREASE IN
MYELOID DERIVED SUPPRESSER CELLS
LEAD TO LOSS OF DYSFUNCTION AND
RESTORED WITH CILIA BLOCKED
PRIOR TO HARVESTING THE EVs.
ALMOST DONE, JUST WAITING ON THE
SLIDES TO CHANGE. SO ONE
QUESTION WE WANTED TO ASK WAS WE
SEE THIS EFFECT. SO NOW THERE IS
A BUY LOGICAL EFFECT. THE
QUESTION, IS THIS BECAUSE WE DID
NOT MAKE EVs TO THE SAME
DEGREE OR IS THIS FOR SOME OTHER
REASON? AS I WAIT ON THE SLIDE
TO TURN BECAUSE I WILL SKIP
THROUGH ONCE IT CHANGES, THE
ANSWER IS NO, WE DID NOT SEE ANY
CHANGES IN THE QUANTITY OF THE
EV WE WERE ABLE TO GENERATE OR
IN THE SIZE OR DISTRIBUTION OF
THE EVs WE WERE ABLE TO
GENERATE. WHAT I'M SHOWING YOU
HERE IS THAT WHEN WE LOOK AT
THESE MARKERS THAT WE KNOW ARE
SPECIFIC FOR THESE EVs, THESE
TETRA SPANS WE CAN SEE THEM
PRESENT AND NEGATIVE CONTROL
RETICK LYNN WHICH SHOULD BE IN
THE CELL WE DON'T SEE THAT AND
YOU DIDN'T GET TO SEE THE VIDEO
FROM THE NANOCYTE BUT WE CAN
GENERATE PARTICLES, WE CAN
QUANTIFY THEM HERE AND WHAT WE
SEE IS THAT THE DISTRIBUTION AND
SIZE AND CONCENTRATION ARE THE
SAME. SO THAT IS NOT WHY WE SEE
THIS IN RESPONSE TO THE LOSS OF
EVs. SO WHAT WE THEN THOUGHT
IS MAYBE THE PACKAGING OF THE
EVs ARE ALTERED IN THE SETTING
OF LOSS OF CILIA. THE SHORT
ANSWER HERE IS THAT THAT'S
PRECISELY WHAT WE SAW. WHEN WE
ALTER THE PRIMARY CILIA BEFORE,
THE WAY WHICH CELLS ARE PACKA
PACKAGED, ARE COMPLETELY
DIFFERENT. WHAT YOU CAN SEE HERE
IS THIS VOLCANO PLOT SHOWING
PROFOUND DIFFERENCE IN THE
CONTENT AT THE PROTEOME LEVEL OF
EVE DERIVED FROM GLIOBLASTOMA
THE SAME PATIENT GLIOBLASTOMA IN
THE CONTEXT OF A NORMAL
FUNCTIONING CILIA OR ABSENCE OF
THE CILIA. AND INTERESTINGLY
WHAT YOU CAN SEE IS WHEN WE DO
AN IP ANALYSIS OF THIS AND WE
ARE LOOKING AT DIFFERENTIALLY
EXPRESSED PATHWAYS AND
FUNCTIONS, YOU CAN SEE WITH LOSS
OF CILIA HERE, MANY OF THESE
IMMUNE RELATED FUNCTIONS ARE
LOST AND WE SEE SO MUCH INCREASE
OF CANCER DEATH SIGNALING. BY
THE WAY I WANT TO SAY THIS
AGREES WITH THAT PAPER, I SHOW
BEFORE WITH THE CILIA SCORE
SHOWING INCREASE CILIA SCORE
WILL LEAD TO WORSENED OUTCOMES.
HOW IS THIS HAPPENING? WHAT IS
GOING ON? FIRSTLY WE SHALL DO
WHEN WE U IRRADIATE THESE CELLS
WE CAN GET INCREASE MYELOID
DERIVED SUPPRESSER CELLS, WHAT
THIS I'M SHOWING YOU HERE IS
THAT WHEN YOU RADIATE CELLS YOU
GET INCREASE IN INTERFERON GAMMA
BUT LOSS OF ANY OF THE CILIA
COMPONENTS BLOCKS THIS, IT IS
AGNOSTIC TO WHICH ONE IT IS
BLOCKING, CCRK OR FD 88, ALL
SHARE A COMMON THING THAT THEY
ARE ALL ESSENTIAL FOR CILIA
GENESIS. IN EACH CASE WHAT YOU
SEE IS THAT THE UPREGULATION OF
INTERFERON GAMMA RESPONDS TO
RADIATION IS BLOCKED. I'M ALMOST
DONE. SO WHAT YOU CAN SEE HERE
IS THAT WHEN WE LOSE THE CILIA
ULTIMATELY AS I SHOWED YOU
SHOWED EARLIER HEPATOCARCINOMA
PAPER CCRK WAS THOUGHT THE SIT
ATOP THE PATHWAY THAT LED TO
INCREASE IN IL 6. WHAT I'M
SHOWING YOU HERE IS THAT WITH
LOSS OF PRIMARY CILIA, BY ANY OF
THESE THREE GENES YOU ARE SEEING
THAT THERE IS IL 6 LOST IN EXTRA
CELLULAR VESICALES. HOWEVER,
THERE IS NO LOSS IN LEVELS OF --
SO THE IDEA IS THAT THE THOUGHT
WAS PDL 1 SOMEHOW ACTING IN THE
GLIOBLASTOMA CELLS ARE CAUSE
UPREGULATION IL 6 AND ULTIMATELY
MBSC AND WHAT THE DATA SUGGESTS
IS WHAT PDL 1 DOES IN THE
CONTEXT OF THE CANCER CELL
REQUIRES PRIMARY CILIA TO BE
PRESENT. IN FACT WHEN THE
PRIMARY CILIA ARE LOST PDL 1
LEVELS ARE INCREASED. EVEN
THOUGH YOU ARE NOT ABLE TO
SUPPRESS MYELOID DERIVED
SUPPRESSER CELLS SO IL 6 BASED
ON THIS DATA DOWNSTREAM OF THE
PRIMARY CILIA, WHEREAS PDL 1 IS
UPSTREAM AND REQUIRES PRIMARY
CILIA TO CONDUCT WHATEVER IT IS
THAT IT IS DOING. TO PROVE THIS
FURTHER WHAT WE CAN DO IS ASK IF
WE KNOCK OUT THE PRIMARY CILIA
THROUGH LOSS OF TIF 3A T KINESIN
MOTOR REQUIRED FOR CILIA
GENESIS, WHAT HAPPENS IF WE
REPLACE IL 6 IN THIS KNOCK OUT
WE SHOULD RESTORE MBSC INDUCTION
AND THAT IS PRECISELY WHAT YOU
CAN SEE HERE. SO BASED ON THIS
WHAT WE HAVE ARE COUPLE OF
THINGS THAT WE HAVE DONE IN THIS
PAPER FOR THE FIRST TIME. ONE,
THERE IS NO REPORT IN THE
LITERATURE THAT WE ARE ABLE TO
FIND ANY WAY CONNECTS PRIMARY
SIGNATURE CILIA SIGNALING TO
CANCER IMMUNE SUPPRESSION IN ANY
WAY, ONCE THE PAPER IS HOPEFULLY
ACCEPTED IT WILL BE THE FIRST TO
DO THAT. SECONDLY, THIS DATA
ALSO SUGGESTS AN UPDATED MODEL
HOW WE MIGHT THINK ABOUT THIS
CANCER MEDIATED
IMMUNOSUPPRESSION SO WHAT WE
HAVE HERE IS A GLEAM BLASTOMA
CELL WE THINK YOU CAN REPLACE
THIS WITH CANCER CELL MORE
GENERICALLY BUT IN THIS VERY
SPECIFIC CASE WE HAVE A
GLIOBLASTOMA CELL THAT HAS A
PRIMARY CILIA, AND THAT HAS A
PRIMARY CILIA SO HERE WE SHOWED
THAT THEN INTERFERON GAMMA LEADS
TO UPREGULATION OF PDL 1 WHICH
REQUIRES THE CILIA TO BE THERE.
SOMEHOW THE PRIMARY SILL YUM
INTERACTS WITH PDL 1 LEVELS
BECAUSE LOSS OF PRIMARY CILIA
LEADS TO FURTHER UPREGULATION OF
PDL 1. SO THAT MEANS THERE'S
PROBABLY SOME FEEDBACK CYCLE
BETWEEN PDL 1 AND PRIMARY CILIA
ONCE THE PDL 1 INTERACTS WITH
PRIMARY CILIA, IT LEADS TO THIS
DIFFERENTIAL PACKAGING OF EVs
AND SOME OF THE EVs MAYBE ALL
IN THAT CONTEXT WILL THEN HAVE
INTERLEUKIN 6, AND ONCE
INTERLEUKIN 6 IS PRESENT IT WILL
LEAD TO THIS UPREGULATION OR
THIS CONVERSION OF YOUR
CIRCULATING MONOCYTES IN THESE
CANCER PATIENTS, MYELOID DERIVED
SUPPRESSER CELL WHICH LEADS TO
THE INACTIVATION AND LOSS OF
PROLIFERATION OF YOUR T-CELLS. I
PUT THE STAT 3 THERE BECAUSE
MOST OF THE DATA SUGGESTS IL 6
LIKELY WORKS IN THIS INDUCTION
THROUGH STAT 3 PATHWAY. LOTS OF
QUESTIONS FOR US TO THINK ABOUT
AND FIRST TO VALIDATE, THE DATA
IS STRONG AN CONSISTENT ABOUT
THIS RELATIONSHIP BETWEEN THE
PRIMARY CILIA AND
IMMUNOSUPPRESSIVE SIGNALING. TO
SUMMARIZE PRIMARY CILIA PRESENT
IN HUMAN GLEE BLASTOMAS, THE
GLIOBLASTOMA DERIVED EVs
INDUCE MYELOID DERIVED
SUPPRESSER CELLS. THE LOSS OF
PRIMARY CILIA LEADS BLOCKS MDSC
INDUCTION AND RESTORESES T-CELL
FUNCTION AS FAR AS WE ARE ABLE
TO TELL. THE PROTEOME OF THE EV
DERIVED FROM THESE CANCER CELLS
ARE DEPENDENT ON THE PRESENCE OF
PRIMARY CILIA. PRIMARY CILIA
SEEMS TO WORK IN THE PACKAGING
OF THESE EVs IN A PROCESS THAT
I DON'T UNDERSTAND AND AGAIN
BECAUSE NO ONE ELSE HAS DONE
THIS YET I DON'T THINK ANYONE
ELSE UNDERSTANDS YET EITHER. THE
BIG POINT HERE IS THAT WE CAN
THEN THINK ABOUT HARNESSING THIS
NEW INFORMATION TO THINK ABOUT
THINGS THE CLINICAL TRIALS WE
ARE INTERESTED IN DOING. MANY
PEOPLE HAVE TRIED IMMUNE CHECK
POINT INHIBITORS FOR
GLIOBLASTOMAS, THEY FAILED ALL
THE TRIALS FAILED MISERABLY.
UNLIKE MELANOMA. IN LUNG CANCER
WHERE NOW THAT BECOMES STANDARD
OF CARE. SO IN TERMS OF CLINICAL
TRIAL DEVELOPMENT THE QUESTION
IS CAN WE COMBINE SOME OF OUR
CILIARE BLOCKADE WITH IMMUNE
CHECK POINT SIGNALING TO SEE IF
WE ARE ABLE TO GET SOME OF THOSE
EFFECTS THAT WE SEE IN OTHER
CANCERS. SO THOSE ARE SOME OF
THE THINGS WE ARE THINKING ABOUT
IN TERMS OF FUTURE DIRECTIONS.
IMMEDIATELY WE ARE WORKING ON
DEVELOPING AN ANIMAL MODEL IN AN
IMMUNE COMPETENT MODEL OF
GLIOBLASTOMA IN ORDER TO BE ABLE
TO PLAN, ASK SOME OF THOSE
CLINICAL QUEST TO FURTHER HELP
WITH CLINICAL TRIAL DEVELOPMENT.
WITH THAT TWO THINGS. MANY WERE
HELPFUL HERE AND I AM CERTAIN
MANY THAT SHOULD HAVE BEEN ON
THIS ACKNOWLEDGMENT SLIDE ARE
NOT HERE. SO I JUST WANT TO SAY
REALLY THANKS TO EVERYBODY WHO
HAS PARTNERED WITH US TO MAKE
THIS WORK HAPPEN. I STARTED HERE
IN 2021, DIDN'T HAVE A LAB FOR
SOME TIME AND GOT SLOW START. WE
REMEMBER ABLE TO ESTABLISH A LOT
IN A SHORT TIME AND I THINK THAT
IS A TESTAMENT TO THE REAL
COLLABORATIVE NATURE AND ALL THE
HELP WE HAVE GOTTEN THANKS FOR
HANGING OUT WITH ME DESPITE
TECHNICAL TROUBLES AND LAST TALK
FOR THIS SESSION. THANKS.
[APPLAUSE]
>>ANY QUESTIONS FROM OUR
AUDIENCE? NOTHING ONLINE. THANK
YOU. WAIT. QUESTION FOR YOU.
>>SORRY. I JUST FIGURED IT WAS
LATE SO PEOPLE ARE TRYING TO GET
OUT OF HERE.
>>THANK YOU FOR THE TALK. I WAS
GOING TO ASK MAYBE LIKE SO IN
TERMS OF LIKE TARGETING CILIA,
YOU MENTIONED THAT CLINICAL
TRIALS ARE GOING TO BE INTENDED
TO I GUESS TARGET CILIA AND
REDUCE CILIA. BUT I GUESS WHAT
ARE CERTAIN OBSTACLES THAT COME
WITH TREATMENTS LIKE ASSUMING
BECAUSE SO FAR DIFFERENT TYPES
OF TREATMENT SUCH AS
CHEMORADIATION OR IMMUNOTHERAPY
HAVEN'T WORKED SO WHAT CAN COME
OR HOW CAN THAT POTENTIALLY
ENHANCE AS WELL IMMUNOTHERAPIES
>>SO GREAT QUESTION. SO I HAD
THE LITTLE WHEEL, NOT GOING TO
BACK THROUGH MY SLIDES NOW
BECAUSE THEY ARE TRICKY. BUT I
HAD THAT WHEEL WHERE WE ARE
LOOKING AT GLIOBLASTOMA IN
GLIOBLASTOMA PRIMARY CILIA. WHAT
YOU CAN GARNER FROM THAT IS
PRIMARY CILIA TOUCHES ON A LOT
OF PHENOTYPES THAT ARE VERY
ADVANTAGEOUS TO CANCER BROADLY
AND GLIOBLASTOMA SPECIFICALLY.
US AND OTHERS HAVE FOUND THAT
TARGETING PRIMARY CILIA
INCREASES THE SENSITIVITY TO
THINGS LIKE CHEMORADIATION. I
HAVE SHOWN YOU THE DATA TODAY
ABOUT THE IMMUNOSUPPRESSION.
THERE IS ALSO DATA THAT SUGGEST
THAT PRIMARY CILIA BY USING SOME
OF THOSE DEVELOPMENTAL PATHWAYS
USED EARLY ON IN AXONAL GUIDANCE
IS HELPFUL TO THE TUMOR TO
SPREAD ALONG THE WHITE MATTER
TRACKS, ET CETERA. SO THE SHORT
ANSWER IS WHEN WE THINK ABOUT
TRYING TO APPLY THIS, IT IS
GOING TO BE APPLIES TO MORE THAN
JUST THE IMMUNOSUPPRESSION BUT
TRYING TO THINK THROUGH OTHER
THINGS PRIMARY CILIA MIGHT BE
INVOLVED WITH, AND SEEING HOW WE
CAN DO THA THAT. SO THAT'S ONE
THING. THE OTHER QUESTION THAT I
TYPICALLY GET WHICH I CAN GET
THE FEEL FROM YOUR QUESTION AS
WELL, IF THIS THING, PRIMARY
CILIA DO SO MANY THINGS BOTH NOT
JUST IN DEVELOPMENT BUT LATER ON
ARE YOU GOING TO HAVE A TON OF
SIDE EFFECTS IF YOU TARGET THEM?
SO FAR AT LEAST IN MICE NOT
REALLY MICE IT WILL RATE THESE
ANTI-CILIA DRUGS WELL ONCE PAST
DEVELOPMENTAL STAGES. AS A
NEUROSURGEON WE CAN THINK ABOUT
OTHER METHODS OF DELIVERY SUCH
AS LOCAL DELIVERY, WE HAVE A
TRIAL HERE DOING FOR EXAMPLE
MICROPROFUSION, THAT'S SOMETHING
WE CAN DO, MAYBE SOMETHING THAT
GOES DIRECTLY IN THE CAVITY SO
THAT YOU HAVE A LOCAL EFFECT SO
WE ARE THINKING ABOUT THOSE.
THAT IS KIND OF AN INDIRECT WAY
TO ANSWER YOUR QUESTION THAT I
KNOW MARK'S DEVELOPING A KIF 3A
INHIBITOR. WHAT IF THIS DOESN'T
CROSS BLOOD BRAIN BARRIER THIS
IS NOT HELPFUL FOR US. THESE
ARE THINGS WE CAN THINK ABOUT
LOCAL DELIVERY STRATEGIES
PUTTING IN THE CAVITY PEOPLE
HAVE DONE FOR CAVITY THAT DIDN'T
WORK WELL BUT THAT WAS A DRUG
SELECTION ISSUE. SO ON. SO
THAT'S HOW I THINK ABOUT THAT.
>>DO YOU HAVE A QUESTION
ONLINE.
>>IS IFNG ONLY COMING FROM
T-CELLS?
>>ACTUALLY THE INTERFERON GAMMA
THAT I SHOWED YOU HERE IS NOT
COMING FROM THE T-CELLS AT ALL,
THAT'S ON THE TUMOR CELLS. THIS
IS INTERFERON GAMMA THAT IS
UPREGULATED IN RESPONSE TO
CHEMORADIATION THAT IS APPLIED
TO THE TUMOR CELLS. YES THERE
MAYBE FOR EXAMPLE P -- SORRY MY
HANDS ARE LONG BUT PDL 1 MIGHT
BE IMPORTANT IN THE MONOCYTES
THEMSELVES, EVERYTHING I'M
TALKING ABOUT HERE IS UPSTREAM
SO THE WAY THESE ASSAYS ARE DONE
IS WE TAKE THE HUMAN
GLIOBLASTOMA CELLS AND TREAT
THEM CHEMOTHERAPY RADIATION, ET
CETERA, WE HAVE A CONTROL OR
BLOCK THEIR CILIA. AND THEN
THAT'S WHERE WE ARE SEEING THE
UPREGULATION OF INTERFERON GAMMA
LEADING TO UPREGULATION OF PDL 1
IN TUMOR CELLS. IN THIS PROCESS
THAT REQUIRES CILIA. AFTER WE
HARVEST THESE EVs IN THAT
CONTEXT WE MOVE THEM OVER FROM
NON-TUMOR PATIENTS TO THE
MONOCYTES OF NORMAL DONORS, WE
GO TO THE BLOOD BANK HERE
COLLECT NORMAL PATIENT APHERESIS
CONES, WE PURIFY THE MONOCYTES
AND ADD EVs FROM THE TUMOR
PATIENTS AND ASK CAN THESE TUMOR
EVs CAUSE THIS INDUCTION OF
THIS TUMOR MYELOID DERIVED
SUPPRESSER CELLS IN THESE NORMAL
PATIENTS THAT IS WHAT WE ARE
MEASURING. WE NEVER MEASURED
INTERFERON GAMMA DOWNSTREAM IN
T-CELL OR SO ON, THIS IS
UPSTREAM, GREAT QUESTION.
>>LOOK LIKE HE HAD A FOLLOW-UP
>>NK CELLS INVOLVED?
>>YES. SO MAYBE I SHOULD GO TRY
TO GO BACK. SO THIS IS WHAT IN
-- THIS IS BROADLY SPEAKING,
THIS IS JUST WHAT MYELOID
DERIVED SUPPRESSER CELLS IN
CANCER ARE THOUGHT TO DO AT
LEAST AS WE UNDERSTOOD IT IN
2012. IT IS STILL THE SAME IDEA
RIGHT NOW IN 2023 PEP FOR EACH
OF THESE THERE IS A LITTLE BIT
MORE DETAILS WORKED OUT. MYELOID
DERIVED SUPPRESSER CELLS AFFECT
DENDRITIC CELLS, INCREASE THE
IMMUNOSUPPRESSIVE T REGULATORY
CELLS, THEY BLOCK YOUR M 1
MACROPHAGE ACTIVATION. I TALKED
TODAY ABOUT BLOCKADE OF THE
T-CELL ACTIVATION AND
PROLIFERATION. AND WE KNOW
AGAIN, THE NATURAL KILLER CELLS
ARE ALSO BLOCKED BY THESE
MYELOID DERIVED SUPPRESSER
CELLS.
>>THANK YOU FOR THAT EXTRA
EFFORT. THAT IS ALL WITH THE
QUESTIONS. WE'LL CONCLUDE. ANY
CLOSING REMARKS, DR. FUJIII?
EVERYONE THERE IS A POSTER
SESSION GOING ON RIGHT NOW WITH
VARIOUS TOPICS UNTIL 4 O'CLOCK
AND THERE'S FOOD AND COFFEE IN
THERE OR THERE SHOULD BE. SO I'M
TOLD, MANY THE FAR END AS YOU
WALK IN. PLEASE ENJOY THAT.
THANK YOU EVERYONE FOR COMING.