Digital Commons Network^™

Diagnostic Utility Of Brain Mri Volumetry In Comparing Traumatic Brain Injury, Alzheimer Disease And Behavioral Variant Frontotemporal Dementia, Cyrus A Raji, Somayeh Meysami, Verna R Porter, David A Merrill, Mario F Mendez

2020-Current year OA Pubs

BACKGROUND: Brain MRI with volumetric quantification, MRI volumetry, can improve diagnostic delineation of patients with neurocognitive disorders by identifying brain atrophy that may not be evident on visual assessments.

OBJECTIVE: To investigate diagnostic utility of MRI volumetry in traumatic brain injury (TBI), early-onset Alzheimer disease (EOAD), late-onset Alzheimer disease, and behavioral variant frontotemporal dementia (bvFTD).

METHOD: We utilized 137 participants of TBI (n = 40), EOAD (n = 45), LOAD (n = 32), and bvFTD (n = 20). Participants had 3D T1 brain MRI imaging amendable to MRI volumetry. Scan volumes were analyzed with Neuroreader. One-way ANOVA compared brain volumes …

Variants In Lrrc7 Lead To Intellectual Disability, Autism, Aggression And Abnormal Eating Behaviors, Jana Willim, Weimin Yuan, Anika Lindsey, Omar Itani, Gary A Silverman, Stephen C Pak, Tim Schedl, Et Al.

2020-Current year OA Pubs

Members of the leucine rich repeat (LRR) and PDZ domain (LAP) protein family are essential for animal development and histogenesis. Densin-180, encoded by LRRC7, is the only LAP protein selectively expressed in neurons. Densin-180 is a postsynaptic scaffold at glutamatergic synapses, linking cytoskeletal elements with signalling proteins such as the α-subunit of Ca

Conditioning With Anti-Cd47 And Anti-Cd117 Plus Jak Inhibition Enables Toxic Payload-Free Allogeneic Transplantation, Stephen P Persaud, Aditya R Yelamali, Julie K Ritchey, John F Dipersio

2020-Current year OA Pubs

No abstract provided.

Gestational Diabetes Knowledge Improves With Interactive Online Training Modules, Petra Krutilova, Roxann Williams, Rebecca Morey, Carole Field, Veronda Byrth, Melissa Tepe, Amy Mcqueen, Cynthia Herrick

2020-Current year OA Pubs

BACKGROUND: The risk of developing type 2 diabetes mellitus (T2DM) is up to 50% among women with gestational diabetes mellitus (GDM). However, diabetes education during and after pregnancy is limited. To bridge this gap, our team developed four training modules on GDM for nurses and community health workers. This pilot study assesses changes in knowledge, self-efficacy for providing diabetes education, attitudes, and intentions to recommend diabetes prevention before and after training completion.

METHODS: Interactive online modules were disseminated to clinical staff providing care for women with GDM in the United States. Optional pre- and post-training surveys were conducted to gauge …

Smoking And Alcohol By Hpv Status In Head And Neck Cancer: A Mendelian Randomization Study, Abhinav Thakral, Laura Bierut, Et Al.

2020-Current year OA Pubs

HPV-positive and HPV-negative head and neck squamous cell carcinoma (HNSCC) are recognized as distinct entities. There remains uncertainty surrounding the causal effects of smoking and alcohol on the development of these two cancer types. Here we perform multivariable Mendelian randomization (MR) to evaluate the causal effects of smoking and alcohol on the risk of HPV-positive and HPV-negative HNSCC in 3431 cases and 3469 controls. Lifetime smoking exposure, as measured by the Comprehensive Smoking Index (CSI), is associated with increased risk of both HPV-negative HNSCC (OR = 3.03, 95%CI:1.75-5.24, P = 7.00E-05) and HPV-positive HNSCC (OR = 2.73, 95%CI:1.39-5.36, P = …

Novel Cyclic Homogeneous Oscillation Detection Method For High Accuracy And Specific Characterization Of Neural Dynamics, Hohyun Cho, Markus Adamek, Jon T Willie, Peter Brunner

2020-Current year OA Pubs

Determining the presence and frequency of neural oscillations is essential to understanding dynamic brain function. Traditional methods that detect peaks over 1/

Menopausal Hormone Therapy Use Among Postmenopausal Women, Lin Yang, Adetunji T Toriola

2020-Current year OA Pubs

IMPORTANCE: Menopausal hormone therapy (MHT) is the treatment of choice for symptoms of menopause. However, its adoption is hindered by the risk-benefit trade-off in relation to acute and chronic diseases.

OBJECTIVE: To evaluate trends in and correlates of MHT use among postmenopausal women in the US from 1999 to March 2020.

DESIGN, SETTING, AND PARTICIPANTS: This serial cross-sectional analysis of MHT use used data from the nationally representative National Health and Nutrition Examination Survey (NHANES). Participants included noninstitutionalized US postmenopausal women from 10 NHANES study cycles (1999-2000 to 2017-March 2020 [pre-COVID-19 pandemic]). Data were analyzed from December 2023 to April …

Efficacy Of Parp Inhibitor Therapy After Targeted Braf/Mek Failure In Advanced Melanoma, Jordan Phillipps, George Nassief, Renee Morecroft, Tolulope Adeyelu, Andrew Elliott, Farah Abdulla, Ari Vanderwalde, Soo Park, Omar Butt, Alice Zhou, George Ansstas

2020-Current year OA Pubs

Modern advancements in targeted therapy and immunotherapy have significantly improved survival outcomes for advanced melanoma; however, there remains a need for novel approaches to overcome disease progression and treatment resistance. In recent years, PARPi therapy has shown great promise both as a single regimen and in combination with other therapeutics in melanoma. Here, we describe three unique cases of advanced BRAF V600 mutated melanoma that progressed on targeted BRAF/MEK agents that subsequently exhibited partial to near-complete responses to combinatory PARPi and BRAF/MEK inhibitors. This highlights both a potential synergy underlying this combinatory approach and its efficacy as a treatment option …

Stat3-Mediated Atg7 Expression Regulates Anti-Tumor Immunity In Mouse Melanoma, Sarah M Zimmerman, Erin Suh, Sofia R Smith, George P Souroullas

2020-Current year OA Pubs

Epigenetic modifications to DNA and chromatin control oncogenic and tumor-suppressive mechanisms in melanoma. Ezh2, the catalytic component of the Polycomb Repressive Complex 2 (PRC2), which mediates methylation of lysine 27 on histone 3 (H3K27me3), can regulate both melanoma initiation and progression. We previously found that mutant Ezh2

Regional Desynchronization Of Microglial Activity Is Associated With Cognitive Decline In Alzheimer's Disease, Artem Zatcepin, Samira Parhizkar, Et Al.

2020-Current year OA Pubs

BACKGROUND: Microglial activation is one hallmark of Alzheimer disease (AD) neuropathology but the impact of the regional interplay of microglia cells in the brain is poorly understood. We hypothesized that microglial activation is regionally synchronized in the healthy brain but experiences regional desynchronization with ongoing neurodegenerative disease. We addressed the existence of a microglia connectome and investigated microglial desynchronization as an AD biomarker.

METHODS: To validate the concept, we performed microglia depletion in mice to test whether interregional correlation coefficients (ICCs) of 18 kDa translocator protein (TSPO)-PET change when microglia are cleared. Next, we evaluated the influence of dysfunctional microglia …

Adjunctive Intravenous Argatroban Or Eptifibatide For Ischemic Stroke, Opeolu Adeoye, Peter Panagos, Stephanie Pizzella, Et Al.

2020-Current year OA Pubs

BACKGROUND: Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear.

METHODS: We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with …

Left Coronary Artery Compression And Stent Fracture Following Self-Expanding Transcatheter Pulmonary Valve Implantation, Jeannette Wong-Siegel, Adam Naylor, David Balzer

2020-Current year OA Pubs

Coronary compression and vascular perforation have not been reported for self-expanding transcatheter pulmonary valves. We describe a patient with tetralogy of Fallot after self-expanding valve implantation who developed left coronary artery compression from the valve. In addition, a wire frame fracture resulted in perforation of the aorta.

A Genetic Screen In Drosophila Uncovers A Role For Senseless-2 In Surface Glia In The Peripheral Nervous System To Regulate Cns Morphology, Haluk Lacin, Yuqing Zhu, Jose T Dipaola, Beth A Wilson, Yi Zhu, James B Skeath

2020-Current year OA Pubs

Despite increasing in mass approximately 100-fold during larval life, the Drosophila CNS maintains its characteristic form. Dynamic interactions between the overlying basement membrane and underlying surface glia are known to regulate CNS structure in Drosophila, but the genes and pathways that establish and maintain CNS morphology during development remain poorly characterized. To identify genes that regulate CNS shape in Drosophila, we conducted an EMS-based, forward genetic screen of the second chromosome, uncovered 50 mutations that disrupt CNS structure, and mapped these alleles to 17 genes. Analysis of whole genome sequencing data wedded to genetic studies uncovered the affected gene for …

Targeting Akr1b10 By Drug Repurposing With Epalrestat Overcomes Chemoresistance In Non-Small Cell Lung Cancer Patient-Derived Tumor Organoids, Kanve N Suvilesh, Yariswamy Manjunath, Yulia I Nussbaum, Mohamed Gadelkarim, Murugesan Raju, Akhil Srivastava, Guangfu Li, Wesley C Warren, Chi-Ren Shyu, Feng Gao, Matthew A Ciorba, Jonathan B Mitchem, Satyanarayana Rachagani, Jussuf T Kaifi

2020-Current year OA Pubs

PURPOSE: Systemic treatments given to patients with non-small cell lung cancer (NSCLC) are often ineffective due to drug resistance. In the present study, we investigated patient-derived tumor organoids (PDTO) and matched tumor tissues from surgically treated patients with NSCLC to identify drug repurposing targets to overcome resistance toward standard-of-care platinum-based doublet chemotherapy.

EXPERIMENTAL DESIGN: PDTOs were established from 10 prospectively enrolled patients with non-metastatic NSCLC from resected tumors. PDTOs were compared with matched tumor tissues by histopathology/immunohistochemistry, whole exome sequencing, and transcriptome sequencing. PDTO growths and drug responses were determined by measuring 3D tumoroid volumes, cell viability, and proliferation/apoptosis. Differential …

Hierarchical Tricarboxylic Acid Cycle Regulation By Hepatocyte Arginase 2 Links The Urea Cycle To Oxidative Metabolism, Yiming Zhang, Cassandra B Higgins, Stefani Tica, Joshua A Adams, Jiameng Sun, Shannon C Kelly, Xiaoyu Zong, Dennis J Dietzen, Terri Pietka, Samuel J Ballentine, Leah P Shriver, Gary J Patti, Yin Cao, Brian J Debosch

2020-Current year OA Pubs

Urea cycle impairment and its relationship to obesity and inflammation remained elusive, partly due to the dramatic clinical presentation of classical urea cycle defects. We generated mice with hepatocyte-specific arginase 2 deletion (Arg2

Stabilization Of Interdomain Closure By A G Protein Inhibitor, Tyson D Todd, Neha Vithani, Sukrit Singh, Gregory R Bowman, Kendall J Blumer, Andrea Soranno

2020-Current year OA Pubs

Inhibitors of heterotrimeric G proteins are being developed as therapeutic agents. Epitomizing this approach are YM-254890 (YM) and FR900359 (FR), which are efficacious in models of thrombosis, hypertension, obesity, asthma, uveal melanoma, and pain, and under investigation as an FR-antibody conjugate in uveal melanoma clinical trials. YM/FR inhibits the Gq/11/14 subfamily by interfering with GDP (guanosine diphosphate) release, but by an unknown biophysical mechanism. Here, we show that YM inhibits GDP release by stabilizing closure between the Ras-like and α-helical domains of a Gα subunit. Nucleotide-free Gα adopts an ensemble of open and closed configurations, as indicated by single-molecule Förster …

Prognostic Significance And Biologic Associations Of Senescence-Associated Secretory Phenotype Biomarkers In Heart Failure, Oday Salman, Ali Javaheri, Douglas L Mann, Et Al.

2020-Current year OA Pubs

BACKGROUND: The role of cellular senescence in human heart failure (HF) remains unclear. The senescence-associated secretory phenotype (SASP) is composed of proteins released by senescent cells. We assessed the prognostic significance and biologic pathways associated with the SASP in human HF using a plasma proteomics approach.

METHODS AND RESULTS: We measured 25 known SASP proteins among 2248 PHFS (Penn HF Study) participants using the SOMAScan V4 assay. We extracted the common variance in these proteins to generate SASP factor scores and assessed the relationship between these SASP factor scores and (1) all-cause death and (2) the composite of death or …

Concurrent Ependymal And Ganglionic Differentiation In A Subset Of Supratentorial Neuroepithelial Tumors With Ewsr1-Plagl1 Rearrangement, Julieann C Lee, Sonika Dahiya, Kaleigh Roberts, Et Al.

2020-Current year OA Pubs

Neuroepithelial tumors with fusion of PLAGL1 or amplification of PLAGL1/PLAGL2 have recently been described often with ependymoma-like or embryonal histology respectively. To further evaluate emerging entities with PLAG-family genetic alterations, the histologic, molecular, clinical, and imaging features are described for 8 clinical cases encountered at St. Jude (EWSR1-PLAGL1 fusion n = 6; PLAGL1 amplification n = 1; PLAGL2 amplification n = 1). A histologic feature observed on initial resection in a subset (4/6) of supratentorial neuroepithelial tumors with EWSR1-PLAGL1 rearrangement was the presence of concurrent ependymal and ganglionic differentiation. This ranged from prominent clusters of ganglion cells within ependymoma/subependymoma-like areas, …

Use Of Palliative Care Among Adults With Newly Diagnosed Heart Failure: Insights From A Us National Insured Patient Sample, Zidong Zhang, Divya S Subramaniam, Steven W Howard, Kenton J Johnston, William H Frick, Kimberly Enard, Leslie Hinyard

2020-Current year OA Pubs

BACKGROUND: Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF.

METHODS AND RESULTS: We conducted a retrospective cohort study in a national all-payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years …

Proteomic Correlates And Prognostic Significance Of Kidney Injury In Heart Failure With Preserved Ejection Fraction, Oday Salman, Ali Javaheri, Douglas L Mann, Et Al.

2020-Current year OA Pubs

BACKGROUND: Kidney disease is common in heart failure with preserved ejection fraction (HFpEF). However, the biologic correlates and prognostic significance of kidney injury (KI), in HFpEF, beyond the estimated glomerular filtration rate (eGFR), are unclear.

METHODS AND RESULTS: Using baseline plasma samples from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial, we measured the following KI biomarkers: cystatin-C, fatty acid-binding protein-3, Beta-2 microglobulin, neutrophil gelatinase-associated lipocalin, and kidney-injury molecule-1. Factor analysis was used to extract the common variability underlying these biomarkers. We assessed the relationship between the KI-factor score and the risk of death …

Diurnal Rhythms In Varicella Vaccine Effectiveness, Dana Danino, Yoav Kalron, Jeffrey A. Haspel, Guy Hazan

2020-Current year OA Pubs

BACKGROUNDImmune processes are influenced by circadian rhythms. We evaluate the association between varicella vaccine administration time of day and vaccine effectiveness.METHODSA national cohort, children younger than 6 years, were enrolled between January 2002 and December 2023. We compared children vaccinated during morning (7:00-10:59), late morning to afternoon (11:00-15:59), or evening hours (16:00-19:59). A Cox proportional hazards regression model was used to adjust for ethnicity, sex, and comorbidities. The first varicella infection occurring at least 14 days after vaccination and a second dose administration were treated as terminal events.RESULTSOf 251,141 vaccinated children, 4,501 (1.8%) experienced breakthrough infections. Infection rates differed based …

Analysis Of Ductal Carcinoma In Situ By Self-Reported Race Reveals Molecular Differences Related To Outcome, Siri H Strand, Graham A Colditz, Et Al.

2020-Current year OA Pubs

BACKGROUND: Ductal carcinoma in situ (DCIS) is a non-obligate precursor to invasive breast cancer (IBC). Studies have indicated differences in DCIS outcome based on race or ethnicity, but molecular differences have not been investigated.

METHODS: We examined the molecular profile of DCIS by self-reported race (SRR) and outcome groups in Black (n = 99) and White (n = 191) women in a large DCIS case-control cohort study with longitudinal follow up.

RESULTS: Gene expression and pathway analyses suggested that different genes and pathways are involved in diagnosis and ipsilateral breast outcome (DCIS or IBC) after DCIS treatment in White versus …

Fetal Mavs And Type I Ifn Signaling Pathways Control Zikv Infection In The Placenta And Maternal Decidua, Yael Alippe, Leran Wang, Reyan Coskun, Stéfanie P Muraro, Fang R Zhao, Michelle Elam-Noll, J Michael White, Daiana M Vota, Vanesa C Hauk, Jeffrey I Gordon, Scott A Handley, Michael S Diamond

2020-Current year OA Pubs

The contribution of placental immune responses to congenital Zika virus (ZIKV) syndrome remains poorly understood. Here, we leveraged a mouse model of ZIKV infection to identify mechanisms of innate immune restriction exclusively in the fetal compartment of the placenta. ZIKV principally infected mononuclear trophoblasts in the junctional zone, which was limited by mitochondrial antiviral-signaling protein (MAVS) and type I interferon (IFN) signaling mechanisms. Single nuclear RNA sequencing revealed MAVS-dependent expression of IFN-stimulated genes (ISGs) in spongiotrophoblasts but not in other placental cells that use alternate pathways to induce ISGs. ZIKV infection of Ifnar1-/- or Mavs-/- placentas was associated with greater …

Psychological Aspects Of Nerve Gap Reconstruction: Addressing Patient Perspectives And Expectations, Stephen Demartini, Amanda Faust, Brendan Navarro, Christopher J Dy

2020-Current year OA Pubs

PURPOSE: Preoperative expectations play a major role in determining patient satisfaction after surgery. The aim of this study was to characterize patient's preoperative expectations and postoperative perceptions of nerve gap repair surgery.

METHODS: We conducted a search of Embase, Scopus, and Web of Science databases for peer-reviewed articles that studied patient expectations, perceptions, and impressions of nerve gap repair in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies related to lumbar plexus radiculopathy, reimplantation, or patient satisfaction scores without patient testimony were excluded. Primary and secondary outcomes were patient's preoperative expectations and postoperative perceptions of …

Pembrolizumab Plus Carboplatin And Paclitaxel As First-Line Therapy For Recurrent/Metastatic Head And Neck Squamous Cell Carcinoma (Keynote-B10): A Single-Arm Phase Iv Trial, Marcin Dzienis, Peter Oppelt, Et Al.

2020-Current year OA Pubs

PURPOSE: Standard-of-care first-line treatment for recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC) is pembrolizumab plus platinum and fluorouracil (FU). However, FU is associated with potential challenges (continuous 4-day infusion, high administration costs, and cardiovascular and gastrointestinal toxicities), creating a clinical need for alternative chemotherapy combinations. We evaluated the efficacy and safety of first-line pembrolizumab plus carboplatin and paclitaxel for R/M HNSCC in the open-label, single-arm, phase IV KEYNOTE-B10 study (ClinicalTrials.gov identifier: NCT04489888).

METHODS: Eligible adults had previously untreated, histologically or cytologically confirmed R/M HNSCC regardless of PD-L1 status, measurable disease per RECIST v1.1 by blinded independent central review …

A Novel Antigen Biomarker For Detection Of High-Level Of Loa Loa Microfilaremia, Sarah E Greene, Yuefang Huang, Kerstin Fischer, Bruce A. Rosa, John Martin, Makedonka Mitreva, Devyn Yates, Samuel Wanji, Joseph Kamgno, Philip J. Budge, Gary J. Weil, Peter U. Fischer

2020-Current year OA Pubs

BACKGROUND: Loiasis is a disease caused by the nematode Loa loa. Serious adverse events sometimes occur in people with heavy L. loa microfilaremia after ivermectin treatment. In regions of Central Africa where loiasis is endemic, this significantly impedes global elimination programs for lymphatic filariasis and onchocerciasis that use mass distribution of ivermectin. Improved diagnostic tests to identify individuals at increased risk of serious adverse events could facilitate efforts to eliminate lymphatic filariasis and onchocerciasis in this region.

METHODS AND FINDINGS: We previously identified the L. loa protein Ll-Bhp-1 in loiasis patient sera. Here, we further characterize Ll-Bhp-1 and report development …

Pulmonary Cellular Toxicity In Alpha-1 Antitrypsin Deficiency, Kristine M Abo, Carly Merritt, Maria C Basil, Susan M Lin, Edward Cantu, Michael P Morley, Pushpinder Bawa, Marissa Gallagher, Derek E Byers, Edward E Morrisey, Andrew A Wilson

2020-Current year OA Pubs

No abstract provided.

Etomoxir-Carnitine, A Novel Pharmaco-Metabolite Of Etomoxir, Inhibits Phospholipases A2 And Mitochondrial Respiration, Sung Ho Moon, Xinping Liu, Christopher M Jenkins, Beverly Gibson Dilthey, Gary J Patti, Richard W Gross

2020-Current year OA Pubs

Mitochondrial fatty acid oxidation serves as an essential process for cellular survival, differentiation, proliferation, and energy metabolism. Numerous studies have utilized etomoxir (ETO) for the irreversible inhibition of carnitine palmitoylcarnitine transferase 1 (CPT1), which catalyzes the rate-limiting step for mitochondrial long-chain fatty acid β-oxidation to examine the bioenergetic roles of mitochondrial fatty acid metabolism in many tissues in multiple diverse disease states. Herein, we demonstrate that intact mitochondria robustly metabolize ETO to etomoxir-carnitine (ETO-carnitine) prior to nearly complete ETO-mediated inhibition of CPT1. The novel pharmaco-metabolite, ETO-carnitine, was conclusively identified by accurate mass, fragmentation patterns, and isotopic fine structure. On the …

Quantitative Gradient Recalled Echo (Qgre) Mri Enables In Vivo Measurement Of Pre-Atrophic Neurodegeneration In A Mouse Model Of Alzheimer's Disease, Michal R Tomaszewski, Alexander L Sukstanskii, Hyking Haley, Xiangjun Meng, Corin O Miller, Dmitriy A Yablonskiy

2020-Current year OA Pubs

Robust methods are needed for preclinical evaluation of novel Alzheimer Disease (AD) therapies to accelerate drug discovery. Quantitative Gradient Recalled Echo (qGRE) MRI has shown promise to provide insight into neurodegeneration in AD prior to atrophy development in humans, highlighting areas of low neuronal density. In this study a novel qGRE method (20 echoes, TE=2-40ms) is shown to non-invasively measure the longitudinal neuronal loss in the hippocampus of a mouse model of AD tauopathy Tg4510. Tg4510 (n=10) and wild type (WT, n=6) mice underwent MRI (7T field strength) at 3-7 months old. 3D qGRE approach was used to generate brain-specific …

Complex Multi-Site Stereotactic Body Re-Irradiation With Ct-Guided Online Adaptive Radiotherapy, Domenic Sievert, Alden D'Souza, Xiaodong Zhao, Michael T. Prusator, Tom Mazur, Hyun Kim, Dean Hobbis

2020-Current year OA Pubs

Online adaptive radiotherapy optimizes a patient's treatment plan to their daily anatomy to account for inter-fraction motion. Daily target and organ-at-risk (OAR) delineation allows for optimized treatments and has been shown to have favorable outcomes in the abdominal region. Adaptive radiotherapy also has the potential to support fine control of dose in re-irradiation to OARs. Herein, we describe a complex multi-site re-irradiation case utilizing CT-guided adaptive radiotherapy. A 46-year-old man with metastatic hepatocellular carcinoma presented for re-irradiation of four metastatic lesions to the right acetabulum, T11, S2, and a gastrosplenic lymph node (gsLN). The right acetabulum, T11, and S2 lesions …