16 MAST Newsletter

Since 2008, the melanoma and sarcoma programs at the University of Iowa have been rapidly growing. We have two strong teams in both programs with highly specialized scientists and physicians who are dedicated to these fields. These teams have led and opened numerous clinical trials which have enhanced research in both diseases. One of the most important resources to transpire is the

MAST (Melanoma And Sarcoma Tissue bank). The MAST is a repository of new or previously diagnosed patients with proliferative disorders of the skin, ocular or connective tissue disorders. The purpose of the MAST is to generate a comprehensive bank with biospecimen and clinical information that will contribute to the success of many multidisciplinary and translational research projects at the University of Iowa.

This is our first publication for you to meet the team at the University of Iowa for both disease types, learn about initiatives, collaborations, new research ideas and patient stories.

The MAST is possible thanks to the generosity of grateful donors who support our work and trust in our expertise to further research in these two diseases.

Mohammed M. Milhem, MDDeputy Director for Clinical Cancer ServicesHolden Comprehensive Cancer CenterUniversity of Iowa

Forewordpage 2

Patient Profiles pages 3-5

Patient Advocates page 5

Mast Posterpages 6-7

By the Numbers pages 8-9

Research Groupspage 10

Grant Recipients pages 11-12

Photospages 13-16

I N T H I S I S S U E

ISSUE NUMBER 1

Fall/Winter 2014

P H O T O S

2013

2014

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2014 Sarcoma Symposium

Melanoma Symposium

Michael Henry, Ben Miller and Mo Milhem

Nancy’s PromiseNewsletter of the University af Iowa Holden Cancer Center Melanoma and Sarcoma Tissue Bank

Nancy WhitePatient ProfilesForeword

My husband Jim White had been diagnosed with melanoma in 1999. We did not know that much about melanoma at that time. All we knew at the time was that Jim had a funny looking mole on his shoulder that they had to remove. It was stage II and after the removal he was told that everything looked clear. During the next 11 years he would be checked at his physicals routinely, but we went on with our lives and looked at this simply as Jim was a cancer survivor that had caught this in plenty of time to live a long and normal life. We had no idea what melanoma was capable of.

Then in 2010, Jim had a cough and went to his doctor, who after some tests referred him to the University of Iowa Hospital and Clinics. In late Feb on our wedding anniversary we found out Jim had recurrent melanoma, but this time it was in his bronchial area and was very serious.

So the fight began. We were a team though all of his struggles to beat melanoma. He knew I was there to pick up the fight when he had a rough day, and reached his weakest points, and that he was never alone in the fight. We could not fight this alone. Family members and friends kept us going in difficult times, and there were many.

Nikolas Jiruska – Ewing’s Sarcoma

My name is Nikolas Jiruska and I recently finished receiving chemotherapy treatments to fight a rare form of bone cancer called Ewing’s Sarcoma. This disease primarily affects children and adolescents, but I was diagnosed at the age of 20. It was a long journey, and I am fortunate enough to be able to say that I am now back at The University of Iowa nine months later and enjoying life more than ever. Now, let’s go back to April 2013 where my journey began.

I started feeling pain in my left hip towards the end of April. It was a fairly mild pain and it would come and go every so often. I thought it might have been a pulled muscle or a pinched nerve. This persisted for a few weeks before the pain started to get worse. Fortunately, the intense pain waited until I was done with my final exams for the spring 2013 semester. I went to the emergency room at St. Luke’s Hospital in Cedar Rapids the first time the pain in my leg became unbearable. It started in my hip and would send deep, pulsing pain down my entire leg. They drew blood and took X-rays of my back and hip, but were not able to draw any conclusions from this work. I received some pain medicine and was told to keep monitoring my leg.

The pain continued to grow worse and worse from then and I went to the emergency room two more times before I finally received an MRI. The ER doctor who was tending to me knew immediately that I had cancer after looking at the results of the MRI. This was the last thing I ever expected to hear, especially at age 20. The doctor arranged for me to go to The University of Iowa Hospital and Clinics immediately. My parents, girlfriend, and I left St. Luke’s and went straight to Iowa City in the middle of the night.

After a few days of various tests, I was officially diagnosed with Ewing’s Sarcoma on June 4th, which also happens to be my mother’s birthday (happy birthday, right?). Although we had the official diagnosis, there was still a lot to do to find out if

the cancer had spread anywhere else. After the initial blow from this horrifying diagnosis, we only received good news from then on. All of the tests revealed that the cancer was localized in my hip and had not spread to the brain, lungs, or bone marrow, which are three locations that this could likely spread to.

At this point, I started my chemotherapy treatments and talked with my oncologist, Dr. Mohammed Milhem (just “Mo” for every one who knows him), to get an idea of what the next few months would entail. I would receive chemotherapy treatments every two weeks, alternating between two and five-day treatments. I would have five rounds of chemotherapy and then have more scans to see how it reacted to the treatment. Shortly after, Dr. Benjamin Miller would perform surgery to remove the tumor. We thought I would have to receive a hip replacement, but there was a chance I could also have a bone allograft surgery depending on how the tumor reacted to the treatment. After the surgery, I would go on to receive nine more rounds of chemotherapy for 18 weeks.

It took me a few rounds of chemotherapy before I started to feel the effects. One of the effects that was the most difficult for me to grapple with was losing my hair. It was sort of my trademark and was a big adjustment in my life. However, a small price to pay, considering it would grow back eventually. Some of the other side effects I felt throughout my treatments were lightheadedness, fatigue, and nausea.

The first five treatments flew by much faster than I had anticipated, and all of the sudden it was August. I had my scans and my cancer had reacted very well to the chemotherapy treatments, shrinking the tumor a lot. Dr. Miller determined that I would be able to have the bone allograft surgery. There is a longer recovery time with this route, but long-term, it would be better for my leg in terms of returning to normal functionality. Dr. Miller and his team performed a successful surgery to remove my tumor on August 21st. He determined that 95% of the tumor was dead and had been removed with clean margins. This was a big step out of the way, and every-thing was downhill after that.

Perhaps it is only at this point in time that I can say that it was downhill after surgery. At the time, life was very difficult. I was not able to put weight on my left leg for three months because my bone had to heal around the graft, and when you are dealing with healing bone, everyone knows this is a very slow process. This lack of mobility along with starting my final nine rounds of chemotherapy made my choice to withdraw from school for the fall 2013 semester pretty easy.

I do not know how I would have made it through those three months without my parents and girlfriend. They went out of

their way to do things for me much more than they needed to. I am so grateful for them and what they did for me during this time, and during my whole fight. I primarily spent this time going back and forth between my apartment in Iowa City and my parents’ houses in Cedar Rapids, when I was not at UIHC for treatments. This was an uneventful time, to say the least. My days were filled with watching movies, Netflix, and playing videogames. It was the lazy time you fantasize about when you are living a normal, busy life, but believe me when I say this lifestyle gets old very fast.

After beating five video games and watching countless movies and TV shows, my three-month appointment with Dr. Miller arrived on November 14th and he gave me the OK to start bearing weight on my left leg. Goodbye, walker and crutches. I started practicing to walk immediately when I got back to my apartment after that appointment. It was an awkward and exciting feeling. I had, and still have, an overwhelming feeling of thankfulness that I have the opportunity to walk, because not everyone is fortunate enough to be able to keep their limb when they are diagnosed with Ewing’s Sarcoma.

At this point, life was getting pretty good. I was walking again and only had four more chemotherapy treatments to go. However, my last few treatments were delayed because I was really feeling the negative effects of the chemotherapy and I was not meeting the required blood counts to be able to start the next round of treatment. I had to receive a handful of blood transfusions during this time to help meet the blood count requirements. Thinking about it now, these setbacks were not a big deal at all compared to what can happen when receiving chemotherapy treatments. At the time, though, it seemed awful because I was so anxious to finish and get on with my life.

Finally, January 3rd came around and it was time to go in for my final chemotherapy treatment. Unfortunately, this had to be a five-day treatment. The longest five days of my entire life, I think. My girlfriend stayed with me every night in the hospital, as she did during my treatments in the summer months, which made everything a lot more bearable because she is a very comforting person to be around. The wonderful nurses of 4JPE in UIHC presented me a beautiful cookie cake to congratulate me on my final day. I then returned to Cedar Rapids for a couple of weeks of rest, relaxation, and relief before I would return to school. I returned to UIHC three weeks after I completed chemotherapy for a bone scan and CT scan to make sure I was clean. Sure enough, the scans were clear. We were all optimistic that this would be the case, and it was truly a wonderful feeling. Time to get back to life.

I am sitting here writing this now and I do not feel bitter about having to have endured this experience at all. I have only to be thankful that I survived it. Also, as odd as it may sound, I am sort of thankful that I went through this experience because I learned a lot about myself during this time and it strengthened my relationships with those closest to me. I want to conclude my story by saying that you should never overlook any pain or odd feeling you may experience in your body. I did not do this and the early detection of my cancer may have saved my life. I also want to give thanks to my wonderful caregivers through-out this journey, including Mo, Dr. Miller, my parents, my girlfriend, and the nurses of 4JPE, 4JPW, and 2RCW.

We discovered Care Pages at the University and that became very important therapy for Jim. He would write about his thoughts and feelings on this new, unexpected journey in life. All the inspiring responses he received back meant so much to him and helped him keep up the fight.

Through it all, Jim had a passionate doctor fighting right along his and his family’s side…Dr. Mo. Jim felt that the Holden Cancer Center was the right place for him to be during his battle. The U of I Hospital became a second home for us for over a year. It was not as overwhelming as we thought it might be, as the doctors and their teams worked together as one unit, deciding on what was the best treatment for Jim though many changes in his condition. They kept us and the family informed on everything going on so we could make the best decisions we need for Jim.

Jim passed away March 23rd, 2011. Even though Jim could not win his fight against Melanoma, it was his hope that others could learn from his struggle. Jim wanted to use the lesson learned from how his body reacted to the disease in effort to support the doctor’s and research teams when it comes to gathering data needed from his tissue samples, blood and how the cancer moved through his body. He knew towards the end that new findings would probably not benefit him directly, but wanted others with this horrible disease to be able to win this fight and have a chance to enjoy a life after a melanoma diagnosis, as well as bringing awareness to others about preventing this disease.

So to make Jim’s wish a reality his family decided to donate funds from The Jim White Foundation that was created shortly after his passing. These funds were given to the tissue and blood bank for Melanoma patients at the Holden Comprehen-sive Cancer Center. There they can learn more about melanoma’s effects on the body and how to develop new treatments, and provide more hope to future patients and their families.

With Jim’s passing a large part of me is missing. Things we thought we would experience together are no longer a reality. Now it is my retirement, not ours.

We were looking forward to spending a lot of time with our grandchildren and present for their activities and cheering them on. Now I will have to be there without Jim.

I went to a soccer game recently for one of our grandsons and as we were leaving for the game he said, “I wish grandpa could be here to go to my game.” That tore at my heart. So this is what Jim and his family do not want for other families. Our wish for them is to win their fight against melanoma and be able to share in those special moments in life together.

2 MAST Newsletter Fall/Winter 2014 3

Fall/Winter 2014 5

Patient Advocates

Nikolas Jiruska – Ewing’s Sarcoma

My name is Nikolas Jiruska and I recently finished receiving chemotherapy treatments to fight a rare form of bone cancer called Ewing’s Sarcoma. This disease primarily affects children and adolescents, but I was diagnosed at the age of 20. It was a long journey, and I am fortunate enough to be able to say that I am now back at The University of Iowa nine months later and enjoying life more than ever. Now, let’s go back to April 2013 where my journey began.

I started feeling pain in my left hip towards the end of April. It was a fairly mild pain and it would come and go every so often. I thought it might have been a pulled muscle or a pinched nerve. This persisted for a few weeks before the pain started to get worse. Fortunately, the intense pain waited until I was done with my final exams for the spring 2013 semester. I went to the emergency room at St. Luke’s Hospital in Cedar Rapids the first time the pain in my leg became unbearable. It started in my hip and would send deep, pulsing pain down my entire leg. They drew blood and took X-rays of my back and hip, but were not able to draw any conclusions from this work. I received some pain medicine and was told to keep monitoring my leg.

The pain continued to grow worse and worse from then and I went to the emergency room two more times before I finally received an MRI. The ER doctor who was tending to me knew immediately that I had cancer after looking at the results of the MRI. This was the last thing I ever expected to hear, especially at age 20. The doctor arranged for me to go to The University of Iowa Hospital and Clinics immediately. My parents, girlfriend, and I left St. Luke’s and went straight to Iowa City in the middle of the night.

After a few days of various tests, I was officially diagnosed with Ewing’s Sarcoma on June 4th, which also happens to be my mother’s birthday (happy birthday, right?). Although we had the official diagnosis, there was still a lot to do to find out if

the cancer had spread anywhere else. After the initial blow from this horrifying diagnosis, we only received good news from then on. All of the tests revealed that the cancer was localized in my hip and had not spread to the brain, lungs, or bone marrow, which are three locations that this could likely spread to.

At this point, I started my chemotherapy treatments and talked with my oncologist, Dr. Mohammed Milhem (just “Mo” for every one who knows him), to get an idea of what the next few months would entail. I would receive chemotherapy treatments every two weeks, alternating between two and five-day treatments. I would have five rounds of chemotherapy and then have more scans to see how it reacted to the treatment. Shortly after, Dr. Benjamin Miller would perform surgery to remove the tumor. We thought I would have to receive a hip replacement, but there was a chance I could also have a bone allograft surgery depending on how the tumor reacted to the treatment. After the surgery, I would go on to receive nine more rounds of chemotherapy for 18 weeks.

It took me a few rounds of chemotherapy before I started to feel the effects. One of the effects that was the most difficult for me to grapple with was losing my hair. It was sort of my trademark and was a big adjustment in my life. However, a small price to pay, considering it would grow back eventually. Some of the other side effects I felt throughout my treatments were lightheadedness, fatigue, and nausea.

The first five treatments flew by much faster than I had anticipated, and all of the sudden it was August. I had my scans and my cancer had reacted very well to the chemotherapy treatments, shrinking the tumor a lot. Dr. Miller determined that I would be able to have the bone allograft surgery. There is a longer recovery time with this route, but long-term, it would be better for my leg in terms of returning to normal functionality. Dr. Miller and his team performed a successful surgery to remove my tumor on August 21st. He determined that 95% of the tumor was dead and had been removed with clean margins. This was a big step out of the way, and every-thing was downhill after that.

Perhaps it is only at this point in time that I can say that it was downhill after surgery. At the time, life was very difficult. I was not able to put weight on my left leg for three months because my bone had to heal around the graft, and when you are dealing with healing bone, everyone knows this is a very slow process. This lack of mobility along with starting my final nine rounds of chemotherapy made my choice to withdraw from school for the fall 2013 semester pretty easy.

I do not know how I would have made it through those three months without my parents and girlfriend. They went out of

their way to do things for me much more than they needed to. I am so grateful for them and what they did for me during this time, and during my whole fight. I primarily spent this time going back and forth between my apartment in Iowa City and my parents’ houses in Cedar Rapids, when I was not at UIHC for treatments. This was an uneventful time, to say the least. My days were filled with watching movies, Netflix, and playing videogames. It was the lazy time you fantasize about when you are living a normal, busy life, but believe me when I say this lifestyle gets old very fast.

After beating five video games and watching countless movies and TV shows, my three-month appointment with Dr. Miller arrived on November 14th and he gave me the OK to start bearing weight on my left leg. Goodbye, walker and crutches. I started practicing to walk immediately when I got back to my apartment after that appointment. It was an awkward and exciting feeling. I had, and still have, an overwhelming feeling of thankfulness that I have the opportunity to walk, because not everyone is fortunate enough to be able to keep their limb when they are diagnosed with Ewing’s Sarcoma.

At this point, life was getting pretty good. I was walking again and only had four more chemotherapy treatments to go. However, my last few treatments were delayed because I was really feeling the negative effects of the chemotherapy and I was not meeting the required blood counts to be able to start the next round of treatment. I had to receive a handful of blood transfusions during this time to help meet the blood count requirements. Thinking about it now, these setbacks were not a big deal at all compared to what can happen when receiving chemotherapy treatments. At the time, though, it seemed awful because I was so anxious to finish and get on with my life.

Finally, January 3rd came around and it was time to go in for my final chemotherapy treatment. Unfortunately, this had to be a five-day treatment. The longest five days of my entire life, I think. My girlfriend stayed with me every night in the hospital, as she did during my treatments in the summer months, which made everything a lot more bearable because she is a very comforting person to be around. The wonderful nurses of 4JPE in UIHC presented me a beautiful cookie cake to congratulate me on my final day. I then returned to Cedar Rapids for a couple of weeks of rest, relaxation, and relief before I would return to school. I returned to UIHC three weeks after I completed chemotherapy for a bone scan and CT scan to make sure I was clean. Sure enough, the scans were clear. We were all optimistic that this would be the case, and it was truly a wonderful feeling. Time to get back to life.

I am sitting here writing this now and I do not feel bitter about having to have endured this experience at all. I have only to be thankful that I survived it. Also, as odd as it may sound, I am sort of thankful that I went through this experience because I learned a lot about myself during this time and it strengthened my relationships with those closest to me. I want to conclude my story by saying that you should never overlook any pain or odd feeling you may experience in your body. I did not do this and the early detection of my cancer may have saved my life. I also want to give thanks to my wonderful caregivers through-out this journey, including Mo, Dr. Miller, my parents, my girlfriend, and the nurses of 4JPE, 4JPW, and 2RCW.

Fletcher Summa – Sarcoma

In January of 2012 after shoveling my driveway, I experienced significant pain in both of my knees. We have a big driveway so I didn’t think much of my soreness. After a few days of pain, my left knee began to feel better but my right knee remained sore. I continued to wrap it for what ended up being two months. The pain did not subside, in fact it got worse. I finally asked my mom to schedule a doctor’s appoint-ment to see what could be done. I explained the soreness to the doctor and we decided that my knee was just inflamed. Luckily, as he was heading out the door, I added that a bone by my knee also ached. He sent me to get an x-ray. In a week I would learn that that decision may have saved my life. I was called into his office urgently the next week. He showed me and my mom an x-ray and pointed to an oddly shaped array known as a ‘sunburst’ (named after its resemblance to a solar flare from the sun). A ‘sunburst’ is an indicator of osteosar-coma, an aggressive bone cancer.

After an MRI confirmed my diagnosis, I was sent to the University of Iowa Hospitals and Clinicis in Iowa City. There I met Dr. Mohammed “Mo” Milhem. He was not like any doctor I’d ever met before. He was animated and funny, yet very matter of fact. I would learn that his attitude was the right one. There was no time to dwell in the negative, and there was also no need to worry, for he had a plan to cure me. The treatment was intense. Within a week or so of my diagnosis I was hooked up to bags of chemo, staying in the hospital for 3-5 days at a time. My life had been flipped upside down. The thing that kept me upbeat was the support I got from friends, family, and the wonderful staff of nurses and doctors. I would get to know the staff very well. I couldn’t imagine making it through the long days, painful procedures, and other obstacles I faced without them. I was so used to going to get treated that once I was finally done it felt like my world was flipped upside down another time. I’m very grateful for that. I can now have a life outside of a hospital and begin to pursue whatever I want. I’m a much stronger person now than I was before getting sick, and I appreciate the world around me far more.

Gilles Cochet – Melanoma

I am a French engineer living in Cedar Rapids. I was sent here four years ago to work on a 10 month mission and never left. My family and I enjoyed the life here so much that we decided to grasp the opportunity that life offered us here in Iowa. The summer of 2012 was the first time our family took a vacation in the U.S. and upon return home, I noticed a mole on my shoulder that began to change and grow. When I finally decided to go see my physician, she sent me right away to a local surgical oncologist. When the results of the biopsy came back and I was told that I have melanoma, I passed out. My brain simply couldn’t process this diagnosis. My father spent a good part of

My name is Molly (First) McDowell, the sister of Hannah First. Hannah was only 10 years old when she was diagnosed with osteosarcoma. Hannah battled many remissions of the disease for 10 years until it took her life at the age of 19 in March 2013. Hannah was my everything. She introduced me to my amazing husband, and we were able to be married in her hospital room a month before her passing. She continues to live through me every day and will forever be my hero. Since her

passing, I have completely devoted my life to spreading awareness for sarcoma research and funding. In the last year, I have become an active member of the Courage Ride, which is an annual bike ride in honor of a young man who passed away from a sarcoma. All of the funds from the Courage Ride go to the University of Iowa Holden Comprehensive Cancer Center (HCCC) towards sarcoma research. For the 2014 Courage Ride, I am in charge of collecting donations for and organizing the silent auction. This is a very rewarding experience for me because I know all of the hard work that I put into gathering donations will help destroy the disease that took my sister from me. This year, not only am I helping with organizing the silent auction, I am also planning to raise $10,000 to shave my head at the Courage Ride! The best part of it all is that Dr. Mo from the HCCC will be the one to shave it for me! This is going to be such an exciting, amazing experience for me. I love that I can do something like this in Hannah's honor. I know for sure that she is cheering me on right now. Doing such an amazing thing makes me wish that I could shave my head every year! I plan to stay incredibly active with the Courage Ride and spread sarcoma awareness in any way that I can. I am very excited to make a major difference in the world. I know that it is something Hannah would have done if she was here. I have to fight sarcoma just as she did while she was here. It is my turn to be the strong one.

When I was asked to be a patient advocate by my father's doctor, Mo, I was overwhelmed with many emotions. My father, Jim, passed away from melanoma back in March of 2011. My initial thought was “why choose me?”, as I did not personally battle cancer and I know nothing of medicine or the kinds of decisions that doctors have to make each day. But Dr. Mo encouraged me. And over dinner said something I will

never forget. "Do not overthink this, get out of your own head and simply be engaged in the moment". That was in response to me asking “what is my main responsibility as a patient advocate?”

He has encouraged me to listen, and ask questions that challenge others, no matter where they might be in their profession. It was made clear to me that I have a unique perspective of watching someone very close to me fight this disease and lose their life doing so. So if I can represent the families of the patients that struggle to understand their loved one's options, or have to make the tough call when the person dealing with cancer cannot, then maybe I can play a small role in helping others beat this horrible disease. I am honored to be a part of such an amazing movement that is taking place at the Holden Comprehensive Cancer Center at the University of Iowa Hospitals and Clinics.

his life fighting cancer and finally lost his battle a few years ago. My mother also fought cancer but was able to fight her way through it. To tell the truth, I was expecting to have cancer one day but, so soon?

Thanks to the support of my wonderful wife, I learned to accept this diagnosis. After the surgery and the removal of the lymphatic system in my right arm (where the cancer had spread), I was sent to the Holden Comprehensive Cancer Center at the University of Iowa Hospital and Clinics to start a clinical trial of ipilimumab with Dr. Mohammed Milhem. The descrip-tion of the potential side effects was pretty scary but we decided to think positively and look on the bright side. No matter what the result, my participation would help research and other people. I thought a lot about my family during this time and before I knew it, I was through with the first phase of treatment and I handled it pretty well- actually, very well.

Today, I am still afraid every time I go to the hospital but I know the place is full of incredible nice people. I still have a few infusions to go through but they are spaced out enough to give my body some time to deal with the product.

Recently, I was given the opportunity to acquire an old 1974 Corvette so I grabbed it! It’s a little boys dream to have a Corvette- life is good!

P A T I E N T P R O F I L E S

Molly McDowell Jay White

4 MAST Newsletter

Fall/Winter 2014 7

Ocular, Skin and Connective Tissue Clinical Data and Tissue Sample Collection Project (MAST)

Tina Knutson BA, Laura Jacobus MS CCRC, Helen Pope BA, Carl Sohocki BA, Aaron Bossler MD PhD, Peter Nagy MD PhD, Mohammed Milhem MBBS – Univ. of Iowa Hospitals and Clinics, Iowa City, Iowa* Supported by UI Foundation & UI Clinical Trials Support Core

ABSTRACTThe primary purpose of the MAST study is to develop and maintain a repository of new or previously diagnosed patients with proliferative disorders of skin, ocular and connective tissue disorders. MAST was initiated in April 2008, IRB approval was obtained in July 2008 and first patient enrolled in October 2008. Enrollment is ongoing and will continue until a patient expires or withdraws from the study.

A main goal of this project is to generate a comprehensive bank that will contribute to the success of many multidisciplinary and translational research projects. There are not specific research questions proposed; but rather created to build a repository of biospecimen and corresponding clinical information that will prove invaluable as investigators within the institution generate further research questions.

As part of the Biospecimen repository, serum and DNA are collected from peripheral blood samples on all returning patients. Tissue samples are collected on patients identified having a surgical procedure at UIHC. The tissue samples are flash frozen and allocated for DNA, RNA, IHC and HE processing. Several UIHC services provide a key role in the success of our sample collection process. These include: Tissue Procurement Core, Molecular Pathology and Histology Research Laboratories.

Clinical data collection includes pathological diagnostic details (subtype, anatomical site, size, labs, BMI, etc), corresponding treatment intervention (primary, adjuvant and metastatic), past medical and family histories, environmental exposure assessment, bi-annual comorbidity follow up and annual standardized quality of life assessments.

We would like to report on over 390 Melanoma patients currently enrolled in the MAST study. This review will include a clinical and biospecimen data review using data points mentioned above. Notes on obstacles overcome and future goals will also be included. This study is funded by Holden Comprehensive Cancer Center Clinical Trial Support Core and The University of Iowa Foundation.

BACKGROUND■ In Iowa alone, approximately 550 cases of Melanoma were diagnosed last year,

within the national average.

■ A need in Iowa exists for a bank of Melanoma tissue and other Melanoma biospecimens. This will provide a potential platform for a Translational bridge with Basic Scientists.

■ Provides potential banking of rare Melanoma subtypes such a Ocular, Mucosal (Vaginal) and Acral Lentiginous melanomas.

OBJECTIVESPrimary Objective:

1) Collect and maintain a Repository of Flash frozen samples isolated from fresh skin, ocular, lymph node and metastatic tissue tumor specimens from patients with proliferative disorders of skin and ocular tumors.

Tissue Collection: a. DNA extraction of tumor tissue and peripheral blood b. RNA extraction of tumor tissue available c. H&E diagnosis confirmation of sample collected d. Extra tissue flash frozen and stored for future projects2) Collect and maintain a bank of Serum specimens. Serum samples are collected at

three time points (before, during and after) each treatment a patient receives. Documented treatment includes chemotherapy, radiation, surgical excisions and observation.

3) Develop and maintain a clinical registry of subjects with proliferative disorders of skin and ocular tissue for treatments and outcome.

4) Maintain a secure database to house and track the clinical registry and specimen repository data.

Secondary Objective:1) Utilize this data for basic and translational research on Melanoma biology,

pathophysiology and epidemiology.2) Allow for procurement of fresh samples for ongoing collaborative studies that

require tissue from subjects with Proliferative disorders of skin and ocular tissue.

ELIGIBILITYMajor Inclusion Criteria

■ Male or female patients aged ≥ 18 years old with a proliferative disorder of skin or ocular tissue are eligible for full participation in the study.

■ Male or female patients aged < 17 years old with a proliferative disorder of skin or ocular tissue are eligible for limited participation in the study with parental consent.

■ Must allow storage of data, tissue and specimens for future research

Major Exclusion Criteria

■ Does not allow prisoners to be subjects

STUDY DETAILS■ Weekly screening of physician and surgeon clinic lists to determine eligibility and

sample collection

■ Consent all subtypes of Melanoma and Proliferative Tissue Disorder diagnosis

■ Abstract subject medical records for Clinical information: – Demographic – Treatments – Co-morbidities – Environmental exposures – Clinical lab values – Pathological details

■ Conduct participant follow up every six months to update clinical and Quality of Life (QOL) information. A standardized subject reported QOL survey is provided annually and includes physical, social, emotional and functional well-being details.

■ Maintain clinical registry and specimen databases

STUDY OVERVIEW & MODIFICATIONS■ Initial MAST study IRB approval received in July 2008.■ IRB approval for minor study modifications and tissue procurement received October 2008. Tissue collection limited to pilot of only 5 specimens.■ First patient enrolled in November 2008. Initial enrollment limited to Dr. Milhem’s UIHC Oncology Clinic.■ Expanded patient enrollment to other UIHC Oncology Physician Clinics.■ Approval received in March 2009 from UIHC Pathology Dept to collect additional Tissue samples■ Expanded patient enrollment to UIHC Oncology Surgical Clinics.■ Enlisted UIHC Tissue Procurement to collect “extra tissue” for MAST in November 2009.■ Pilot collection of PB-DNA for of MAST enrolled patients in limited clinical trials in May 2010.■ Expanded patient enrollment to UIHC Orthopedic Surgical Clinics in November 2010.■ Initiate collection of PB-DNA for all newly enrolled and metastatic MAST patients in March 2011.■ Addition of Laboratory Technician to screen, collect, process and enter data for all blood samples in July 2011.

FUTURE GOALS■ Involve Dermatology in early stage cancer for more accurate demographic representation■ Optimize banking per specific protocols driven by Basic Scientists

COLLABORATIVE EFFORTS■ A. Bossler: UIHC clinical review and pathologic examination of BRAF inhibitor in melanoma tissue ■ DJ Murry: UIHC examination of biomarkers of melanoma subjects.■ R Cornell: UIHC examination of biomarkers and validation of extracted RNA from melanoma tissue.

PUBLICATIONSMeng, X, Milhem, M, Knutson T, Yang S et al. Correlation of MTDH/AEG-1 and HOT AIR Expression with Metastasis and Response to Treatment in Sarcoma Patients. Journal of Cancer Science & Therapy. 2011. S5:004.

STUDY LIMITATIONS1) Early stage melanomas not banked2) Most subjects enrolled are at higher risk for relapse at UIHC3) Data is skewed toward poorer prognoses

BIOSPECIMEN DATA REVIEWTable 5. Serum and DNA samples collected

Table 6. Percent collection of total enrolled

Serum total: 624

Mid Tx 36%

Post Tx 21%

Post Excision 20%

*Pre Tx 19%

Other 3%

*Pre Excision 1%

Post- samples can often be used as *Pre- samples and is not reflected in the above data. Tx: treatment.

DNA total: 234

DNA - PB 211

DNA - Tissue 23

■ PB DNA average is 393 ug.■ Tissue DNA average is

315ug.■ Primary tissue difficult to

collect due to small size■ Sentinel lymph node

biopsies hinder collections due to high amount radioactivity present

% Population collected

Patients enrolled 402

Serum samples 63%

DNA - PB 42%

DNA - Tissue 6%

■ 256 Unique Serum samples

■ 171 Unique PB-DNA samples

■ PB - DNA collection was initiated in March 2011

CLINICAL DATA REVIEWTable 1. Enrollment of Melanoma Subtypes Per Year

Enrolled Melanoma Subtyes 2008 2009 2010 2011 2012 Total

Acral Lentginous Melanoma 1 3 1 4 9

Amelanotic Melanoma 1 1 1 1 4

Desmoplastic Melanoma 2 6 1 5 14

Lentigo Maligna Melanoma 4 7 4 2 17

Malignant Melanoma, NOS 9 35 24 18 9 95

Metastatic Melanoma 8 17 8 7 2 42

MM, Malignant Blue Nevus 1 1 2

Mucosal Melanoma 1 1 2 1 5

Nodular Melanoma 5 17 23 18 8 71

Ocular Melanoma, Chorodial 4 6 5 10 2 27

Ocular Melanoma, Ciliary Body 1 1 1 3

Ocular Melanoma, Iris 1 1 2

Ocular Melanoma, NOS 1 2 3

Other 2 2

Spindle Cell Melanoma NOS 2 2

Superficial Spreading Melanoma 3 14 35 42 10 104

Total 35 107 109 115 36 402

Enrollment began in November 2008 and actively continues in UIHC Oncology and Surgical Clinics. MM: malignant melanoma; NOS: not otherwise specified.

Table 3. Current Status of Patients Enrolled per Year

Year Passive MR Tissue ActiveEnrolled Active CTB WD Only Only WD Total

2008 12 19 2 1 1 35

2009 53 35 12 5 2 107

2010 76 27 3 2 1 109

2011 97 17 1 115

2012 33 2 1 36

Total 271 100 17 10 1 3 402

CTB: cease to breath; WD: withdraw; MR: medical record

Table 2. Survival of Enrolled MAST patients per Subtype

Enrolled Melanoma Subtypes Alive CTB Total

Acral Lentginous Melanoma 7 2 9

Amelanotic Melanoma 4 4

Desmoplastic Melanoma 11 3 14

Lentigo Maligna Melanoma 13 4 17

Malignant Melanoma, NOS 68 27 95

Metastatic Melanoma 19 23 42

MM, Malignant Blue Nevus 1 1 2

Mucosal Melanoma 5 5

Nodular Melanoma 57 14 71

Ocular Melanoma, Chorodial 23 4 27

Ocular Melanoma, Ciliary Body 2 1 3

Ocular Melanoma, Iris 2 2

Ocular Melanoma, NOS 3 3

Other 2 2

Spindle Cell Melanoma NOS 1 1 2

Superficial Spreading Melanoma 84 20 104

Total 302 100 402

Malignant melanoma , NOS (55%); Metastatic melanoma (28%), Nodular melanoma (20%) and Superficial Spreading melanoma (19%) have the highest mortality rates of those subtypes with more than 40 patients enrolled. MM: malignant melanoma; NOS: not otherwise specified; CTB: cease to breath

Table 4. Enrollment & Survival per Gender

Gender Alive CTB Total

Female 147 34 181

Male 155 66 221

Total 302 100 402

45% Females enrolled55% Males enrolled34% Females CTB66% Males CTB

6 MAST Newsletter

8 MAST Newsletter Fall/Winter 2014 9

B Y T H E N U M B E R S

Total MAST Subjects Enrolled Per Year and Current Status Year Passive MR Tissue Active Enrolled Active CTB WD Only Only WD Total

2008 12 20 1 1 1 35

2009 43 45 12 6 1 107

2010 49 39 8 11 1 1 109

2011 73 33 3 6 115

2012 96 29 1 1 1 128

2013 168 13 1 3 185

2014 23 23

Total 464 179 25 26 1 7 702

Active: Follow up done every 6 mo Passive: No active follow up x 3 pointsCTB: Cease To Breathe Active: Request to be removed from studyWD: Withdraw Tissue: Decline participation in study, MR: Medical Record but provided tissue

Gender &Mortality Data

MAST Enrolledper Year

Enrollment of Sarcoma Subtypes Enrolled Per YearMelanoma Subtype 2008 2009 2010 2011 2012 2013 2014 Total

Angiosarcoma 3 5 4 6 6 7 2 33

Carcinosarcoma (prev Mullerian) 1 4 2 5 12

Chondrosarcoma 2 5 5 5 6 2 25

Clear Cell Sarcoma 1 2 1 4

Dermatofibrosarcoma 2 3 2 1 2 10

Desmoplastic Sm Round Cell Tumor 1 1 1 3

Endometrial Stromal Sarcoma 1 1 2 4

Epithelioid Sarcoma 1 1 1 3

Ewing's Sarcoma 1 5 4 2 5 6 23

Fibrosarcoma 2 1 1 1 5

Gastrointestinal Stromal Tumor (GIST) 4 13 10 11 10 11 6 65

Giant Cell Sarcoma 1 1

Hemangioendothelioma 1 2 2 5

Kaposi's Sarcoma 1 1

Leiomyosarcoma 11 22 14 22 19 14 2 104

Liposarcoma 7 17 11 7 10 7 6 65

Malignant Fibrous Histiocytoma 2 6 4 2 1 1 16

Myxofibrosarcoma 1 6 4 6 2 11 30

Osteosarcoma 4 6 4 6 2 11 30

Other 2 4 6

Peripheral Nerve Sheath Tumor (PNST) 4 9 4 3 1 3 32

Pleomorphic Sarcoma 1 4 4 1 5 10 1 26

Rhabdomyosarcoma 1 9 1 1 2 14

Sarcoma, NOS 2 3 1 11 3 5 2 27

Solitary Fibrous Tumor 1 2 1 4

Spindle Cell Sarcoma 2 1 2 5

Synovial Sarcoma 2 3 6 5 5 3 24

Total 46 128 86 94 89 105 23 571

Enrollment of Melanoma Subtype Enrolled Per YearMelanoma Subtype 2008 2009 2010 2011 2012 2013 2014 Total

Acral Lentginous Melanoma 1 3 1 4 3 12

Amelanotic Melanoma 1 1 1 1 1 1 6

Basal Cell Carcinoma, aggress. (non-melanoma) 2 2

Desmoplastic Melanoma 2 6 1 5 1 7 1 23

Lentigo Maligna Melanoma 1 6 7 4 8 10 1 37

Malignant melanoma, MUP 1 2 3 2 10 1 19

Malignant Melanoma, NOS 4 22 20 14 22 27 1 110

Malignant melanoma, Spitzoid 1 1 1 3

Metastatic Melanoma 4 12 7 6 6 4 1 40

MM, Malignant Blue Nevus 1 1 2

Mucosal Melanoma 1 3 1 2 4 2 13

Nodular Melanoma 10 24 26 19 31 35 6 151

Ocular Melanoma, Chorodial 4 6 5 10 8 19 4 56

Ocular Melanoma, Ciliary Body 1 1 1 1 4

Ocular Melanoma, Iris 1 1 1 1 4

Ocular Melanoma, NOS 1 2 1 4

Other 2 1 1 4

Spindle Cell Melanoma NOS 2 1 3 6

Superficial Spreading Melanoma 5 20 35 42 38 60 6 206

Total 35 107 109 115 128 185 23 702

Translational Research Core

0

2008

2009

2010

2011

2012

2013

2014

50

100

150

Male

CTB

CTB

Alive

Alive

200

Female

CTB: Cease to Breathe

10 MAST Newsletter Fall/Winter 2014 11

Sarcoma Research Group

Leader: Benjamin Miller, MD, MS, Assistant Professor, Department of Orthopaedics & Rehabilitation

Co-Leader: Mo Milhem, MD, Deputy Director of Clinical Cancer Services at the Holden Comprehensive Cancer Center, Professor, Department of Internal Medicine, Division of Hematol-ogy, Oncology and Blood & Marrow Transplantation

The Sarcoma MOG (Multidisciplinary Oncology Group) meets monthly with presentations by many different facets of the cancer center. This collaboration fosters ingenuity and translational concepts in sarcoma as well as seed funding to promising ideas.

The Sarcoma Research Group had its first annual sarcoma symposium on March 8, 2013. Forty-two University of Iowa staff and faculty attended and heard presentations from 17 researchers. Five projects and seven researchers were given grants totalling $88,471.00 to support their sarcoma-related projects.

■ Jessica Geotz, PhD Awarded: $10,500.00 Project: The Effects of Radiation Dosing

Regimen on Mechanical Strength of Bone■ Lyse Norian, PhD Awarded: $20,000 Project: Elucidating Obesity-Dependent

Mechanisms of Immune Suppression in Sarcoma

■ Mitch Coleman, PhD Awarded: $19,435.00 Project: Radiosensitization of Leiomyosar-

coma and Liposarcoma via Metabolic Oxidative Stress Induced by Inhibition of Glucose Metabolism

■ Jiwoong Choi, PhD Awarded: $20,000 Project: QCT Image Matching Assessment

of Lung Biomechanical Signals of Cancer Patients

■ Darrion Mitchell, MD, PhD, Marisa Buchakjian, MD, PhD, Michael Henry, PhD Awarded: $18,536.00 Project: Developing a Model to Test

Autophagy as a Therapeutic Target in Soft-Tissue Sarcomas

■ Mission: To improve the care of patients living with sarcomas

■ Vision: To be the premier Midwest collaboration of institutions for sarcomas

■ MSTP consists of 8 medical oncologists who specialize in the treatment of sarcoma from 6 institutions in the Midwest. Together they work on creating new clinical trials.

R E S E A R C H G R O U P S & P A R T N E R S H I P S 2 0 1 3 M E L A N O M A S Y M P O S I U M S E E D G R A N T R E C I P I E N T S

Collaborating partners include:■ Mayo Clinic■ University of Iowa■ Northwestern University■ Washington University- St, Louis■ University of Wisconsin■ University of Minnesota

Melanoma Research GroupLeader: Mo Milhem, MD, Professor, Department of Internal Medicine, Division of Hematology, Oncology and Blood & Marrow Transplantation

The Melanoma MOG meets monthly to share and discuss melanoma-related projects that are being worked on at the University of Iowa. The 2nd annual Melanoma Symposium was held on February 8, 2013 and was attended by 74 staff and faculty. Twenty-nine researchers shared their melanoma-related projects with the group.

Midwest Melanoma Partnership (MMP)

■ Mission: to facilitate the sharing of ideas, clinical trials and resources in an effort to improve the diagnosis, treatment and long-term care of melanoma patients. ■ MMP consists of health care professionals including medical oncologists from 18 institutions across the United States as well as patient advocates. ■ www.midwestmelanoma.org

Midwest Sarcoma Trials Partnership (MSTP) Dr. Robert Cornell: $25,000

Project: Transgenic delivery of a transcription factor that promotes melanocyte differentiation may suppress BRAF-driven melanoma

Authors: Robert Cornell, Associate Professor, Department of Anatomy and Cell Biology

Purpose: Melanoma tumors are derived from cells in the melanocyte lineage. However, expression profile data at the NIH Cancer Genome Atlas reveals that melanoma tumors resemble neural crest, the precursor population from which melanocytes are derived, more than they do melanocytes themselves. In particular, the expression of genes that promote melanocyte differentiation, and suppress pluripotency, cell growth, and migration of neural crest, is much lower in melanoma than in melanocytes. We previously found that the transcription factor Activator Protein 2 alpha (TFAP2A) promotes differentiation of neural crest into melanocytes in zebrarish. Here we have tested the therapeutic potential of forcing expression of TFAP2A within zebrafish BRAF-driven metastatic melanoma. We injected melanoma prone zebrafish embryos with a plasmid vector that drives expression of TFAP2A specifically in cells of the melanocyte lineage. In preliminary studies, two animals injected with control vectors developed large tumors by 12 weeks post fertilization (dpf) and died by 16 weeks dpf, while an animal injected with the TFAP2A vector is alive and tumor free at 24 dpf. A replicate of the experiment with larger numbers of individuals is underway. If the trend in the results continues, further investigations of the therapeutic potential of elevating TFAP2A in melanoma tumors, and the mechanism by which doing so suppresses tumor forma-tion, are warranted. An important objective is to identify methods to elevate TFAP2A expression in melanoma; DNA methyl transfer-ase inhibitors may have this potential.

Dr. Adam Dupuy: $16,000

Project: A forward genetic approach to identify mechanisms of melanoma metastasis

Authors: Kaitlyn Zenner, Marisa Buchakjian, MD, PhD, Michael Henry, PhD, Adam J. Dupuy

Summary: Metastasis is largely responsible for melanoma associated morbidity and mortality. Fortunately the establishment of metastatic melanoma is an inefficient process — only rare disseminated melanoma cells produce metastatic lesions. Unfor-tunately, little is known about the biological mechanisms that determine which melanoma cells will produce metastases. We have developed a mouse model of melanoma in which Sleeping Beauty (SB) transposon mutagenesis is used to drive metastasis in vivo. The SB system is a powerful tool that has been used for cancer gene discovery in a variety of tumor types in mice. We have engineered the SB system components into B16-F0 melanoma cells, a spontaneous mouse melanoma cell line with very low metastatic potential. We hypothesize that the SB system will drive metastasis by generating genetic variants of B16-F0 that are capable of metastasizing to distant sites within the host animal. To test our hypothesis, engineered B16-F0 cells were subcutane-ously injected into the interscapular region of female C57B/6N mice. Two weeks after injection the primary tumors were excised, and the mice were periodically monitored for metastases to the lungs, brain, and reproductive tract. Preliminary data suggests that SB mutagenesis will produce metastatic lesions at a rate much higher than is observed using negative control cells. Our future

efforts will focus on producing a collection of SB-driven melanoma metastases. These tumors will be analyzed to identify recurrent mutations associated with a metastatic phenotype. Candidate genes will be validated using both mouse models and comparative analysis using melanoma metastases collected from human patients. Our findings could provide biological insight into the mechanisms that drive melanoma metastasis and could be used to develop therapies that specifically target these processes.

Dr. Frederick Domann: $12,000

Project: CpG methylation of PHD3 is a novel biomarker for melanoma progression

Authors: Trenton L. Place, Sabine U. Vorrink, Frederick E. Domann, PhD.

Summary: Proline hydroxylation of the hypoxia inducible factor HIF-1a is an important mode of hypoxia stimulated post-translational signal transduction. The hydroxylation reaction is accomplished by the oxygen dependent HIF-1a prolyl-4-hydroxylase family of enzymes PHD1-3. Although all three of these proteins can target HIF-1a for degradation, only PHD3 is inducible by hypoxia. Moreover, PHD3 silencing is associated with an epithelial to mesenchymal transition in several cell types. We previously showed that PHD3 silencing in a human melanoma cell line was associated with an aberrantly methylated PHD3 gene, and that PHD3 could be induced by 5-aza-deoxycytidine, a DNA methyltransferase inhibitor. Additionally, our previous bioinfor-matic searches of existing human melanoma data in the Onco-mine and TCGA databases revealed that PHD3 expression progressively deceased during melanoma progression and this was occasionally accompanied by CpG methylation in a region near the 5’ end of the PHD3 gene. The lowest expression levels of PHD3 were consistently found in distant organ metastases in contrast to primary tumors and lymph node metastases however role of DNA methylation in this phenomenon is unknown. Therefore, we aimed to determine whether aberrant cytosine methylation of the PHD3 gene contributed to the loss of its expression in melanoma metastases. We obtained 11 human metastatic melanoma samples from the Melanoma And Sarcoma Tissue (MAST) bank. Of these, 8 were lymph node metastases and 3 were organ metastases. DNA was extracted by the MAST and total RNA was isolated by the Tissue Procurement Core. From these nucleic acids we measured PHD3 mRNA expression levels by qRT-PCR and gene methylation profiles by bisulfite sequencing in each of the samples. PHD3 expression was variable and generally down-regulated across all specimens. PHD3 gene methylation was rare among these samples, with 0/8 lymph node metastases displaying PHD3 methylation. Notably however, 1/3 of the organ metastases had an aberrantly methylated PHD3 promoter. We attempted to follow-up on this observation and hopefully achieve statistical significance by obtaining additional organ met samples from the MAST but were unsuccessful due to limited sample availability. Nevertheless as additional clinical samples become available, particularly from patients before and after treatment with 5-aza-deoxycytidine. In conclusion, PHD3 is an epigenetically labile target silenced by DNA methylation in distant organ metastases; thus, acquisition of PHD3 expression following decitabine therapy could be a valuable biomarker for drug action in vivo.

Dr. Michael Schultz: $12,000

Project: Peptide Receptor Targeted Image-guided Radionuclide Therapy for Metastatic Melanomaa

Authors: Michael K. Schultz PhD and Yusuf Menda MD, Radiology; Co-Investigator Thomas Quinn PhD, University of Missouri,

Department of Biochemistry.

Background: Primary melanoma tumors identified early can be cured by surgery, but metastatic melanoma is lethal (10 yr survival < 10%). Currently, no systemic therapy provides durable benefit to metastatic melanoma patients. In fact, the standard of care for metastatic melanoma has not changed since FDA approval of the alkylating agent dacarbazine in 1975, although interleukin-2 therapy (FDA approved, 1998) shows modest improvement for a few patients. Recently approved FDA treatments appear promis-ing, but durable benefit remains elusive. Targeted radionuclide therapy has long been considered a promising therapeutic alternative for cancer treatment, but translation of discovery to clinically relevant therapies has proven challenging. On the other hand, recent successes in our laboratories and clinics not only provide preclinical evidence that targeted radionuclide therapy can circumvent resistance pathways to provide effective treatment for metastatic melanoma, but also that peptide-receptor targeted radionuclide therapy can be safely and effectively administered to provide benefit to cancer patients. Further, our team from the University of Missouri (MU) and University of Iowa (UI) has identified an innovative peptide-based ligand that not only binds with high affinity to a cell surface receptor that is upregulated in metastatic melanoma, but is also virtually undetectable in most other human tissue and organs. The molecular therapy design combines improved tumor targeting with novel alpha+beta radiation to maximize dose to tumors, while minimizing dose to healthy tissues and organs. These exciting developments and knowledge define a new paradigm for metastatic melanoma therapy based on peptide receptor targeted alpha-beta particle therapy that has yet to be explored clinically. The investigators have not only demonstrated the potential for this new patented form of treatment preclinically, but also have completed the required FDA-directed toxicity studies and have GMP-pharmaceutical grade material required for human studies in hand. There is therefore, a critical need to refine molecular targeting for radionuclide therapy of metastatic melanoma to take advantage of these developments and preliminary evidence

Objectives: Our overall objectives in this research are: (i) to develop a rhenium-cyclized lead-203 (203Pb-) labeled peptide, targeted to the melanocortin subtype 1 receptor (MC1R), for SPECT imaging of metastatic melanoma in human patients; and (ii) to develop a detailed understanding of the radiopharmaceuti-cal formulation (e.g., specific activity, radiolysis protection, etc.) that lead to a highly stable, high specific activity 212Pb labeled peptide for alpha+beta-particle therapy using 212Pb-labeled peptide. Our central hypothesis is that image-guided radionuclide therapy (using 203Pb for imaging and 212Pb for alpha+beta particle treatment) can be developed for effective treatment for metastatic melanoma. This hypothesis was formulated, in part, based on our preliminary data, which demonstrated that our 212Pb-labeled Re-cyclized peptide (ReCCMSH) cured mice bearing melanoma tumors. Further preliminary evidence demonstrated that peptide targeted radionuclide therapy is well-tolerated in human patients in our clinics. The rationale for our research is that success in our aims will lead to reliable therapy for metastatic melanoma by directing alpha+beta radiation dose precisely to tumor tissue.

Specific Aim: We have identified a clinical NIH R21 mechanism that is specifically targeted to clinical stage proposals as we expect to submit. We have further met with the NIH MD scientist-author of the RFA and discussed precisely what preliminary data we need for a strong submission. Thus, for submission to the RFA, we must optimize preparation of the 203Pb-labeled radiopharmaceutical and provide three successive preparations that meet release criteria for submission of an Investigational New Drug application. This activity is the primary focus of the research team for this research.

Potential Impact: Upon successful completion of our overall research, we expect to have demonstrated the potential of 203Pb-ReCCMSH for imaging metastatic melanoma patients. We further expect to have developed a detailed understanding of the key components and conditions for 212Pb-ReCCMSH dose preparation/ formulation that lead to optimal stability and tumor targeting for treating melanoma patients. With these advances, we anticipate identifying and optimizing a 203Pb dosimetry approach that prepares us to proceed to 212Pb therapy. The research proposed here is innovative because it would lead to the first in humans clinical trial with a 203Pb radiolabeled Re-MSH peptide (DOTA-ReCCMSH) that targets the melanocotrin 1 receptor (MC1R) for melanoma imaging and supports the advancement of an innovative MC1R targeted melanoma alpha+beta particle therapy with 212Pb.

Dr. Anthony Snow: $15,500

Project: BRAF and NRAS Mutations in Nodular and Superficial Spreading Melanoma

Authors: Anthony Snow, MD, Natasha Guseva, Nick Wilson, Tina Knutson, Anna Button, MS, Mohammed M. Milhem, MD, Aaron D. Bossler, PhD.

Departments of Pathology, Internal Medicine; and Epidemiology and Biostatistics, University of Iowa, Carver College of Medicine, Iowa City, IA. Department of Pathology, Brown University, Provi-dence, RI

Summary: Virtually all types of cancer are known to have multiple genetic defects that divert cells from a path toward development of normal tissue within the body toward one of uncontrolled growth and tumor formation. Melanoma is no exception to this rule. However, the changes in the DNA in melanoma are many and varied. Our group reviewed current literature and clinical testing options to identify gene targets that have the potential to demon-strate DNA changes that can be useful for prognostic information or for selection of therapeutic options. Typically, these changes are identified using methods that copy, or amplify, the DNA in a sequence-specific manner. This is commonly done using variations of the polymerase chain reaction (PCR) or traditional Sanger sequencing. Thanks to the generosity of the patients and families who have donated research funds, we have developed a panel of potentially clinically useful targets that can be examined at the same time from one sample. The technology is called next genera-tion sequencing and uses equipment called the Ion Torrent Personal Genome Machine. The test includes a total of 25 gene targets. Many of the targets are known to be involved in the formation of melanoma, while others are included in hopes of gaining new information about the role they may play in clinical outcome and treatment options. We have already identified mutations that were not known to be in the samples that were examined. The next step is comparing the clinical information to the test results to identify ways to use the information to improve patient care.

Pat Gavin and Cynthia Chauhan

MSTP Chicago 2013

Miller Milhem

12 MAST Newsletter Fall/Winter 2014 13

P H O T O S

Dr. Robert Cornell: $25,000

Project: Transgenic delivery of a transcription factor that promotes melanocyte differentiation may suppress BRAF-driven melanoma

Authors: Robert Cornell, Associate Professor, Department of Anatomy and Cell Biology

Purpose: Melanoma tumors are derived from cells in the melanocyte lineage. However, expression profile data at the NIH Cancer Genome Atlas reveals that melanoma tumors resemble neural crest, the precursor population from which melanocytes are derived, more than they do melanocytes themselves. In particular, the expression of genes that promote melanocyte differentiation, and suppress pluripotency, cell growth, and migration of neural crest, is much lower in melanoma than in melanocytes. We previously found that the transcription factor Activator Protein 2 alpha (TFAP2A) promotes differentiation of neural crest into melanocytes in zebrarish. Here we have tested the therapeutic potential of forcing expression of TFAP2A within zebrafish BRAF-driven metastatic melanoma. We injected melanoma prone zebrafish embryos with a plasmid vector that drives expression of TFAP2A specifically in cells of the melanocyte lineage. In preliminary studies, two animals injected with control vectors developed large tumors by 12 weeks post fertilization (dpf) and died by 16 weeks dpf, while an animal injected with the TFAP2A vector is alive and tumor free at 24 dpf. A replicate of the experiment with larger numbers of individuals is underway. If the trend in the results continues, further investigations of the therapeutic potential of elevating TFAP2A in melanoma tumors, and the mechanism by which doing so suppresses tumor forma-tion, are warranted. An important objective is to identify methods to elevate TFAP2A expression in melanoma; DNA methyl transfer-ase inhibitors may have this potential.

Dr. Adam Dupuy: $16,000

Project: A forward genetic approach to identify mechanisms of melanoma metastasis

Authors: Kaitlyn Zenner, Marisa Buchakjian, MD, PhD, Michael Henry, PhD, Adam J. Dupuy

Summary: Metastasis is largely responsible for melanoma associated morbidity and mortality. Fortunately the establishment of metastatic melanoma is an inefficient process — only rare disseminated melanoma cells produce metastatic lesions. Unfor-tunately, little is known about the biological mechanisms that determine which melanoma cells will produce metastases. We have developed a mouse model of melanoma in which Sleeping Beauty (SB) transposon mutagenesis is used to drive metastasis in vivo. The SB system is a powerful tool that has been used for cancer gene discovery in a variety of tumor types in mice. We have engineered the SB system components into B16-F0 melanoma cells, a spontaneous mouse melanoma cell line with very low metastatic potential. We hypothesize that the SB system will drive metastasis by generating genetic variants of B16-F0 that are capable of metastasizing to distant sites within the host animal. To test our hypothesis, engineered B16-F0 cells were subcutane-ously injected into the interscapular region of female C57B/6N mice. Two weeks after injection the primary tumors were excised, and the mice were periodically monitored for metastases to the lungs, brain, and reproductive tract. Preliminary data suggests that SB mutagenesis will produce metastatic lesions at a rate much higher than is observed using negative control cells. Our future

efforts will focus on producing a collection of SB-driven melanoma metastases. These tumors will be analyzed to identify recurrent mutations associated with a metastatic phenotype. Candidate genes will be validated using both mouse models and comparative analysis using melanoma metastases collected from human patients. Our findings could provide biological insight into the mechanisms that drive melanoma metastasis and could be used to develop therapies that specifically target these processes.

Dr. Frederick Domann: $12,000

Project: CpG methylation of PHD3 is a novel biomarker for melanoma progression

Authors: Trenton L. Place, Sabine U. Vorrink, Frederick E. Domann, PhD.

Summary: Proline hydroxylation of the hypoxia inducible factor HIF-1a is an important mode of hypoxia stimulated post-translational signal transduction. The hydroxylation reaction is accomplished by the oxygen dependent HIF-1a prolyl-4-hydroxylase family of enzymes PHD1-3. Although all three of these proteins can target HIF-1a for degradation, only PHD3 is inducible by hypoxia. Moreover, PHD3 silencing is associated with an epithelial to mesenchymal transition in several cell types. We previously showed that PHD3 silencing in a human melanoma cell line was associated with an aberrantly methylated PHD3 gene, and that PHD3 could be induced by 5-aza-deoxycytidine, a DNA methyltransferase inhibitor. Additionally, our previous bioinfor-matic searches of existing human melanoma data in the Onco-mine and TCGA databases revealed that PHD3 expression progressively deceased during melanoma progression and this was occasionally accompanied by CpG methylation in a region near the 5’ end of the PHD3 gene. The lowest expression levels of PHD3 were consistently found in distant organ metastases in contrast to primary tumors and lymph node metastases however role of DNA methylation in this phenomenon is unknown. Therefore, we aimed to determine whether aberrant cytosine methylation of the PHD3 gene contributed to the loss of its expression in melanoma metastases. We obtained 11 human metastatic melanoma samples from the Melanoma And Sarcoma Tissue (MAST) bank. Of these, 8 were lymph node metastases and 3 were organ metastases. DNA was extracted by the MAST and total RNA was isolated by the Tissue Procurement Core. From these nucleic acids we measured PHD3 mRNA expression levels by qRT-PCR and gene methylation profiles by bisulfite sequencing in each of the samples. PHD3 expression was variable and generally down-regulated across all specimens. PHD3 gene methylation was rare among these samples, with 0/8 lymph node metastases displaying PHD3 methylation. Notably however, 1/3 of the organ metastases had an aberrantly methylated PHD3 promoter. We attempted to follow-up on this observation and hopefully achieve statistical significance by obtaining additional organ met samples from the MAST but were unsuccessful due to limited sample availability. Nevertheless as additional clinical samples become available, particularly from patients before and after treatment with 5-aza-deoxycytidine. In conclusion, PHD3 is an epigenetically labile target silenced by DNA methylation in distant organ metastases; thus, acquisition of PHD3 expression following decitabine therapy could be a valuable biomarker for drug action in vivo.

Dr. Michael Schultz: $12,000

Project: Peptide Receptor Targeted Image-guided Radionuclide Therapy for Metastatic Melanomaa

Authors: Michael K. Schultz PhD and Yusuf Menda MD, Radiology; Co-Investigator Thomas Quinn PhD, University of Missouri,

Department of Biochemistry.

Background: Primary melanoma tumors identified early can be cured by surgery, but metastatic melanoma is lethal (10 yr survival < 10%). Currently, no systemic therapy provides durable benefit to metastatic melanoma patients. In fact, the standard of care for metastatic melanoma has not changed since FDA approval of the alkylating agent dacarbazine in 1975, although interleukin-2 therapy (FDA approved, 1998) shows modest improvement for a few patients. Recently approved FDA treatments appear promis-ing, but durable benefit remains elusive. Targeted radionuclide therapy has long been considered a promising therapeutic alternative for cancer treatment, but translation of discovery to clinically relevant therapies has proven challenging. On the other hand, recent successes in our laboratories and clinics not only provide preclinical evidence that targeted radionuclide therapy can circumvent resistance pathways to provide effective treatment for metastatic melanoma, but also that peptide-receptor targeted radionuclide therapy can be safely and effectively administered to provide benefit to cancer patients. Further, our team from the University of Missouri (MU) and University of Iowa (UI) has identified an innovative peptide-based ligand that not only binds with high affinity to a cell surface receptor that is upregulated in metastatic melanoma, but is also virtually undetectable in most other human tissue and organs. The molecular therapy design combines improved tumor targeting with novel alpha+beta radiation to maximize dose to tumors, while minimizing dose to healthy tissues and organs. These exciting developments and knowledge define a new paradigm for metastatic melanoma therapy based on peptide receptor targeted alpha-beta particle therapy that has yet to be explored clinically. The investigators have not only demonstrated the potential for this new patented form of treatment preclinically, but also have completed the required FDA-directed toxicity studies and have GMP-pharmaceutical grade material required for human studies in hand. There is therefore, a critical need to refine molecular targeting for radionuclide therapy of metastatic melanoma to take advantage of these developments and preliminary evidence

Objectives: Our overall objectives in this research are: (i) to develop a rhenium-cyclized lead-203 (203Pb-) labeled peptide, targeted to the melanocortin subtype 1 receptor (MC1R), for SPECT imaging of metastatic melanoma in human patients; and (ii) to develop a detailed understanding of the radiopharmaceuti-cal formulation (e.g., specific activity, radiolysis protection, etc.) that lead to a highly stable, high specific activity 212Pb labeled peptide for alpha+beta-particle therapy using 212Pb-labeled peptide. Our central hypothesis is that image-guided radionuclide therapy (using 203Pb for imaging and 212Pb for alpha+beta particle treatment) can be developed for effective treatment for metastatic melanoma. This hypothesis was formulated, in part, based on our preliminary data, which demonstrated that our 212Pb-labeled Re-cyclized peptide (ReCCMSH) cured mice bearing melanoma tumors. Further preliminary evidence demonstrated that peptide targeted radionuclide therapy is well-tolerated in human patients in our clinics. The rationale for our research is that success in our aims will lead to reliable therapy for metastatic melanoma by directing alpha+beta radiation dose precisely to tumor tissue.

Specific Aim: We have identified a clinical NIH R21 mechanism that is specifically targeted to clinical stage proposals as we expect to submit. We have further met with the NIH MD scientist-author of the RFA and discussed precisely what preliminary data we need for a strong submission. Thus, for submission to the RFA, we must optimize preparation of the 203Pb-labeled radiopharmaceutical and provide three successive preparations that meet release criteria for submission of an Investigational New Drug application. This activity is the primary focus of the research team for this research.

Potential Impact: Upon successful completion of our overall research, we expect to have demonstrated the potential of 203Pb-ReCCMSH for imaging metastatic melanoma patients. We further expect to have developed a detailed understanding of the key components and conditions for 212Pb-ReCCMSH dose preparation/ formulation that lead to optimal stability and tumor targeting for treating melanoma patients. With these advances, we anticipate identifying and optimizing a 203Pb dosimetry approach that prepares us to proceed to 212Pb therapy. The research proposed here is innovative because it would lead to the first in humans clinical trial with a 203Pb radiolabeled Re-MSH peptide (DOTA-ReCCMSH) that targets the melanocotrin 1 receptor (MC1R) for melanoma imaging and supports the advancement of an innovative MC1R targeted melanoma alpha+beta particle therapy with 212Pb.

Dr. Anthony Snow: $15,500

Project: BRAF and NRAS Mutations in Nodular and Superficial Spreading Melanoma

Authors: Anthony Snow, MD, Natasha Guseva, Nick Wilson, Tina Knutson, Anna Button, MS, Mohammed M. Milhem, MD, Aaron D. Bossler, PhD.

Departments of Pathology, Internal Medicine; and Epidemiology and Biostatistics, University of Iowa, Carver College of Medicine, Iowa City, IA. Department of Pathology, Brown University, Provi-dence, RI

Summary: Virtually all types of cancer are known to have multiple genetic defects that divert cells from a path toward development of normal tissue within the body toward one of uncontrolled growth and tumor formation. Melanoma is no exception to this rule. However, the changes in the DNA in melanoma are many and varied. Our group reviewed current literature and clinical testing options to identify gene targets that have the potential to demon-strate DNA changes that can be useful for prognostic information or for selection of therapeutic options. Typically, these changes are identified using methods that copy, or amplify, the DNA in a sequence-specific manner. This is commonly done using variations of the polymerase chain reaction (PCR) or traditional Sanger sequencing. Thanks to the generosity of the patients and families who have donated research funds, we have developed a panel of potentially clinically useful targets that can be examined at the same time from one sample. The technology is called next genera-tion sequencing and uses equipment called the Ion Torrent Personal Genome Machine. The test includes a total of 25 gene targets. Many of the targets are known to be involved in the formation of melanoma, while others are included in hopes of gaining new information about the role they may play in clinical outcome and treatment options. We have already identified mutations that were not known to be in the samples that were examined. The next step is comparing the clinical information to the test results to identify ways to use the information to improve patient care.

2 0 1 3 M E L A N O M A S Y M P O S I U M S E E D G R A N T R E C I P I E N T S

2013 Courage Ride, an annual bike ride honoring the courageous life of Seth Bailey (synovial sarcoma)http://www.courageride.org

2013 Miles 2 Give, a team of extreme athletes who run across the country to raise money for sarcoma http://www.miles2give.org

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P H O T O S

2014 Melanoma Monday, HCCC staff wearing black to raise melanoma awareness

2013-14 Drive Out Sarcoma, annual golf tournament in Kewanee, Illinois, in honor of Jim Burkhart (synovial sarcoma)

2013 Ride It Out for Amber, annual motorcycle ride in Polk City, Iowa, in honor of Amber Birmingham (osteosarcoma)

2014 Herky on Parade, “My Hero Herky” was designed to honor Abbey Almelien Banh (malignant peripheral nerve sheath tumor, sarcoma)

2013-14 Steve Yates Melanoma Awareness Golf Tournament , annual fundriaser in Waterloo, Iowa in honor of Steve Yateshttp://www.steveyatesmelanomaawareness.org

University of Iowa Melanoma Epigenetics Working Group

Jim Burkhart and Gang.

P H O T O S

2013

2014 Tips for Tad, annual fundraiser in honor of Tad Agnew (melanoma)

Mo with Paula Sands from the Paula Sands Live show (promoting Tips for Tad)

L to R: Dr. Frederick Domann, Dr. Aaron Bossler, Dr. Michael Henry, Jimmy Schappet, Mo, Dr. Robert Cornell, Dr. Roberto Leon-Ferre

Flyer for Tips for Tad

Marty Bunge and Jan Stewart