Digital Commons Network^™

Incidence And Mitigation Of Corneal Pseudomicrocysts Induced By Antibody-Drug Conjugates (Adcs), Ethan S Lindgren, Rongshan Yan, Onur Cil, Alan S Verkman, Matilda F Chan, Gerami D Seitzman, Asim V Farooq, Laura A Huppert, Hope S Rugo, Paula R Pohlmann, Janice Lu, Laura J Esserman, Neel D Pasricha

Faculty, Staff and Student Publications

Purpose of review: This study is to highlight the incidence of corneal pseudomicrocysts in FDA-approved antibody-drug conjugates (ADCs), and success of preventive therapies for pseudomicrocysts and related ocular surface adverse events (AEs).

Recent findings: ADCs are an emerging class of selective cancer therapies that consist of a potent cytotoxin connected to a monoclonal antibody (mAb) that targets antigens expressed on malignant cells. Currently, there are 11 FDA-approved ADCs with over 164 in clinical trials. Various AEs have been attributed to ADCs, including ocular surface AEs (keratitis/keratopathy, dry eye, conjunctivitis, blurred vision, corneal pseudomicrocysts). While the severity and prevalence of ADC-induced …

Automated Spontaneous Echo Contrast Detection Using A Multisequence Attention Convolutional Neural Network, Ouwen Huang, Zewei Shi, Naveen Garg, Corey Jensen, Mark L Palmeri

Faculty, Staff and Student Publications

OBJECTIVE: Spontaneous echo contrast (SEC) is a vascular ultrasound finding associated with increased thromboembolism risk. However, identification requires expert determination and clinician time to report. We developed a deep learning model that can automatically identify SEC. Our model can be applied retrospectively without deviating from routine clinical practice. The retrospective nature of our model means future works could scan archival data to opportunistically correlate SEC findings with documented clinical outcomes.

METHODS: We curated a data set of 801 archival acquisitions along the femoral vein from 201 patients. We used a multisequence convolutional neural network (CNN) with ResNetv2 backbone and visualized …

Diagnostic And Prognostic Biomarkers Of Chronic Pancreatitis: A Conceptual Framework Based On The Probe Design, Dhiraj Yadav, Darwin L Conwell, Stephen J Pandol, Hanno Steen, Ziding Feng, Liang Li

Faculty, Staff and Student Publications

No abstract provided.

Dietary Fiber And Gut Bacteria Shape Infection Susceptibility, Aqsa Mohammed, Robert R Jenq

Faculty, Staff and Student Publications

Gut microbiota composition has been reported to affect pathogen susceptibility but its specific effects, the underlying mechanisms and the potential influence of the diet remain unexplored. In their recent study, Desai and colleagues (Wolter et al, 2024), explore the complex interaction between diet, the gut microbiota and pathogen susceptibility, highlighting a diet-dependent role of the mucin-degrading microbe Akkermansia muciniphila.

Predictive Capacity Of Immune-Related Adverse Events And Cytokine Profiling In Neoadjuvant Immune Checkpoint Inhibitor Trials For Head And Neck Squamous Cell Carcinoma\, Angela E Alnemri, Sruti Tekumalla, Annie E Moroco, Ioannis Vathiotis, Madalina Tuluc, Stacey Gargano, Tingting Zhan, David M Cognetti, Joseph M Curry, Athanassios Argiris, Alban Linnenbach, Andrew P South, Larry A Harshyne, Jennifer M Johnson, Adam J Luginbuhl

Faculty, Staff and Student Publications

OBJECTIVES: Certain low-level immune-related adverse events (irAEs) have been associated with survival benefits in patients with various solid tumors on immune checkpoint inhibitors (ICIs). We aimed to investigate the association between irAEs and response to neoadjuvant ICIs in patients with head and neck squamous cell carcinoma (HNSCC) and to identify differences in circulating cytokine levels based on irAE status.

METHODS: This was a retrospective cohort study including three neoadjuvant clinical trials from July 2017 to January 2022: NCT03238365 (nivolumab ± tadalafil), NCT03854032 (nivolumab ± BMS986205), NCT03618654 (durvalumab ± metformin). The presence and type of irAEs, pathologic treatment response, and survival …

Genetic Reprogramming With Stem Cells Regenerates Glomerular Epithelial Podocytes In Alport Syndrome, Valerie S Lebleu, Keizo Kanasaki, Sara Lovisa, Joseph L Alge, Jiha Kim, Yang Chen, Yingqi Teng, Behzad Gerami-Naini, Hikaru Sugimoto, Noritoshi Kato, Ignacio Revuelta, Nicole Grau, Jonathan P Sleeman, Gangadhar Taduri, Akane Kizu, Shahin Rafii, Konrad Hochedlinger, Susan E Quaggin, Raghu Kalluri

Faculty, Staff and Student Publications

Glomerular filtration relies on the type IV collagen (ColIV) network of the glomerular basement membrane, namely, in the triple helical molecules containing the α3, α4, and α5 chains of ColIV. Loss of function mutations in the genes encoding these chains (Col4a3, Col4a4, and Col4a5) is associated with the loss of renal function observed in Alport syndrome (AS). Precise understanding of the cellular basis for the patho-mechanism remains unknown and a specific therapy for this disease does not currently exist. Here, we generated a novel allele for the conditional deletion of Col4a3 in different glomerular cell types …

Stmnd1 Is A Phylogenetically Ancient Stathmin Which Localizes To Motile Cilia And Exhibits Nuclear Translocation That Is Inhibited When Soluble Tubulin Concentration Increases, Xiang Deng, Bryan O Seguinot, Gary Bradshaw, Jong Suk Lee, Shannon Coy, Marian Kalocsay, Sandro Santagata, Timothy Mitchison

Faculty, Staff and Student Publications

Stathmins are small, unstructured proteins that bind tubulin dimers and are implicated in several human diseases, but whose function remains unknown. We characterized a new stathmin, STMND1 (Stathmin Domain Containing 1) as the human representative of an ancient subfamily. STMND1 features a N-terminal myristoylated and palmitoylated motif which directs it to membranes and a tubulin-binding stathmin-like domain (SLD) that contains an internal nuclear localization signal. Biochemistry and proximity labeling showed that STMND1 binds tubulin, and live imaging showed that tubulin binding inhibits translocation from cellular membranes to the nucleus. STMND1 is highly expressed in multiciliated epithelial cells, where it localizes …

A Bayesian Quasi-Likelihood Design For Identifying The Minimum Effective Dose And Maximum Utility Dose In Dose-Ranging Studies, Feng Tian, Ruitao Lin, Li Wang, Ying Yuan

Faculty, Staff and Student Publications

Most existing dose-ranging study designs focus on assessing the dose-efficacy relationship and identifying the minimum effective dose. There is an increasing interest in optimizing the dose based on the benefit-risk tradeoff. We propose a Bayesian quasi-likelihood dose-ranging design that jointly considers safety and efficacy to simultaneously identify the minimum effective dose and the maximum utility dose to optimize the benefit-risk tradeoff. The binary toxicity endpoint is modeled using a beta-binomial model. The efficacy endpoint is modeled using the quasi-likelihood approach to accommodate various types of data (e.g. binary, ordinal or continuous) without imposing any parametric assumptions on the dose-response curve. …

Adaptive Bayesian Information Borrowing Methods For Finding And Optimizing Subgroup-Specific Doses, Jingyi Zhang, Ruitao Lin, Xin Chen, Fangrong Yan

Faculty, Staff and Student Publications

In precision oncology, integrating multiple cancer patient subgroups into a single master protocol allows for the simultaneous assessment of treatment effects in these subgroups and promotes the sharing of information between them, ultimately reducing sample sizes and costs and enhancing scientific validity. However, the safety and efficacy of these therapies may vary across different subgroups, resulting in heterogeneous outcomes. Therefore, identifying subgroup-specific optimal doses in early-phase clinical trials is crucial for the development of future trials. In this article, we review various innovative Bayesian information-borrowing strategies that aim to determine and optimize subgroup-specific doses. Specifically, we discuss Bayesian hierarchical modeling, …

Forecasting Acute Kidney Injury And Resource Utilization In Icu Patients Using Longitudinal, Multimodal Models, Yukun Tan, Merve Dede, Vakul Mohanty, Jinzhuang Dou, Holly Hill, Elmer Bernstam, Ken Chen

Faculty, Staff and Student Publications

Background: Advances in artificial intelligence (AI) have realized the potential of revolutionizing healthcare, such as predicting disease progression via longitudinal inspection of Electronic Health Records (EHRs) and lab tests from patients admitted to Intensive Care Units (ICU). Although substantial literature exists addressing broad subjects, including the prediction of mortality, length-of-stay, and readmission, studies focusing on forecasting Acute Kidney Injury (AKI), specifically dialysis anticipation like Continuous Renal Replacement Therapy (CRRT) are scarce. The technicality of how to implement AI remains elusive.

Objective: This study aims to elucidate the important factors and methods that are required to develop effective predictive models of …

Developing A Computational Representation Of Human Physical Activity And Exercise Using Open Ontology-Based Approach: A Tai Chi Use Case, Eloisa Nguyen, Rebecca Z Lin, Yang Gong, Cui Tao, Muhammad Tuan Amith

Faculty, Staff and Student Publications

Many studies have examined the impact of exercise and other physical activities in influencing the health outcomes of individuals. These physical activities entail an intricate sequence and series of physical anatomy, physiological movement, movement of the anatomy, etc. To better understand how these components interact with one another and their downstream impact on health outcomes, there needs to be an information model that conceptualizes all entities involved. In this study, we introduced our early development of an ontology model to computationally describe human physical activities and the various entities that compose each activity. We developed an open-sourced biomedical ontology called …

Hypofractionated Radiotherapy For Glioblastoma: A Large Institutional Retrospective Assessment Of 2 Approaches, Thomas H Beckham, Michael K Rooney, Mary F Mcaleer, Amol J Ghia, Martin C Tom, Subha Perni, Susan Mcgovern, David Grosshans, Caroline Chung, Chenyang Wang, Brain De, Todd Swanson, Arnold Paulino, Wen Jiang, Sherise Ferguson, Chirag B Patel, Jing Li, Debra N Yeboa

Faculty, Staff and Student Publications

Background: Glioblastoma (GBM) poses therapeutic challenges due to its aggressive nature, particularly for patients with poor functional status and/or advanced disease. Hypofractionated radiotherapy (RT) regimens have demonstrated comparable disease outcomes for this population while allowing treatment to be completed more quickly. Here, we report our institutional outcomes of patients treated with 2 hypofractionated RT regimens: 40 Gy/15fx (3w-RT) and 50 Gy/20fx (4w-RT).

Methods: A single-institution retrospective analysis was conducted of 127 GBM patients who underwent 3w-RT or 4w-RT. Patient characteristics, treatment regimens, and outcomes were analyzed. Univariate and multivariable Cox regression models were used to estimate progression-free survival (PFS) and …

Clinical Information Retrieval: A Literature Review, Sonish Sivarajkumar, Haneef Ahamed Mohammad, David Oniani, Kirk Roberts, William Hersh, Hongfang Liu, Daqing He, Shyam Visweswaran, Yanshan Wang

Faculty, Staff and Student Publications

UNLABELLED: Clinical information retrieval (IR) plays a vital role in modern healthcare by facilitating efficient access and analysis of medical literature for clinicians and researchers. This scoping review aims to offer a comprehensive overview of the current state of clinical IR research and identify gaps and potential opportunities for future studies in this field. The main objective was to assess and analyze the existing literature on clinical IR, focusing on the methods, techniques, and tools employed for effective retrieval and analysis of medical information. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted an …

Spring Migration Ecology Of Snow Buntings In Southwest Yukon Territory, 2014-2023, Cyndi M. Smith, Julie Bauer, Terry Skjonsbert

North American Bird Bander

No abstract provided.

North American Bird Banding Program Longevity Records, Lauren Walker, Matthew Rogosky, Kyra Harvey

North American Bird Bander

No abstract provided.

Economic Impact Of A Classical Biological Control Program: Application To Diachasmimorpha Longicaudata Against Bactrocera Dorsalis Fruit Fly In Kenya, Komi Mensah Agboka, Henri E.Z. Tonnang, Beatrice W. Muriithi, Saliou Niassy, Shepard Ndlela, Elfatih M. Abdel-Rahman, Samira A. Mohamed, Sunday Ekesi

All Peer-Reviewed Publications

Classical biological control (CBC) has been exploited as a safer alternative for suppressing the oriental fruit fly, Bactrocera dorsalis, by importing, rearing, and releasing the larval parasitoid, Diachasmimorpha longicaudata. Although D. longicaudata has been released in Kenya through the Africa Fruit Fly Programme, the extent of its dispersal and subsequent economic benefits have not yet been established. This paper models the spatio-temporal dispersal of the parasitoid using the fuzzy cellular automata approaches and estimates the net benefit from each dollar invested in the CBC approach. We calculated the return on investment based on funding into the programme between 2006 and …

Asili, Husna Abubakar

Masters Theses

ASILI is a Swahili word meaning ORIGIN, SOURCE, and ESSENCE. It can also mean the fundamental principal of a culture. It is not cognitive, it is metaphysical.

The work that I do explores the preconceptual, prespatial and pretemporal organization of culture, specifically African culture and even more specifically, Swahili culture.

I use multiple techniques to interpolate a visual voice to an othered people both continental and abroad. I explore the mythoform that connects the mystical and dive into what of it that becomes a practice within Swahili culture. I take experience from my life as a Swahili woman, from the …

Variations On Noise, Clinton Van Arnam

Masters Theses

Variations on Noise is a three-part collection: an index, a set of interviews, and a perspective on a working practice in graphic design and sound.

If noise is ubiquitous in our everyday lives, how do we define it and use it as a catalyst for dissonance and change? As a designer, I use noise algorithms to generate pseudo randomness and break up repetitive textures. As a musician, I use noise to create scores and performances that challenge our perception of what is comfortable and uncomfortable.

Seven interviews with designers, artists, musicians, and a Tibetan monk offer ways to approach the …

(Matter)Ial Revolution, Aleza Epstein

Masters Theses

The (Matter)ial Revolution proposes a fundamental shift in how we approach the built environment, drawing inspiration from historical precedents like the Roman Spolia and adaptive reuse strategies of past civilizations. Instead of the conventional cycle of demolition and rebuilding, this architectural movement advocates for learning to work with existing structures and materials – re-appropriating and re-circulating them to create new forms. It demands a return to craftsmanship, methodology, materiality, and non-standardization.

Sircling The Cquare, Latika Balachander

Masters Theses

As we journey into an increasingly virtual and intangible reality, is there an opportunity for our tactile fabrics to journey with, and even reorient us? Can they exist in our future worlds to remind us of the value of current traditional, low-tech practices that we may soon forget?

Referencing the fundamental fabric languages of knitted and woven structures, this collection of garments, that I term “Earthsuits,” embody the stages of metamorphosis as we adjust to a new phase of our perceptive reality. With an emphasis on circling, we loop through virtual squares like screens and pixels, to the circles of …

House Calls, Gregory Goldstone

Masters Theses

This thesis explores the unique architectural challenges and opportunities present in rural communities, with a focus on addressing the crisis of affordable housing. Grounding the discussion in the author's personal experiences growing up in the rural town of Cambridge, New York, the thesis illuminates the diversity of identities, needs, and values that coexist within the rural context.

The thesis critically examines the architectural academy and its urban-centric biases, which have led to a neglect of rural design issues. It highlights the shortcomings of standard affordable housing approaches, such as public housing and mobile homes, in meeting the independent spirit and …

Beach Autonomous Zone, Carl Garvey

Masters Theses

This thesis project responds to issues surrounding beach erosion on Long Island’s Atlantic Coast by envisioning policy and design decisions that activate a destabilization of the shoreline and a managed retreat away from beaches. Contrasted to methods and goals of conventional coastal engineering, a beach autonomous zone sets an extended, moving setback in which coastlines are treated, in effect, as conservation easements, allowing for and encouraging beaches to return to more natural states. On four sites of different scales representing different built beachfront conditions, I visualize the negotiations between human desires and the needs of a beach that arise under …

From One Nature To Another, Sarah Mann

Masters Theses

Lichen‭, ‬fungi‭, ‬and soil each represent a microcosm of nature‭. ‬They are all quintessential examples of complex symbiosis‭, ‬yet they are often treated as lifeless materials‭. ‬But what if we took a moment to connect with each one on a daily basis‭ - ‬would that impact the way we envision the future‭? ‬

For most of us‭, ‬our homes won’t be radically changing any time soon‭; ‬therefore‭, ‬From One Nature to‭ ‬Another‭ ‬invites us to bring these entities inside and‭ ‬reflect on their possibilities as collaborators‭. ‬Each piece was carefully researched and designed to‭ ‬provide the correct atmospheric …

Better Together, Jack Dumala

Masters Theses

“Better Together” comprehensively explores the spectrum of play from early childhood to adulthood, presenting how play has always been a means of connection and communication. Although the research encompasses all age groups, particular attention is given to teenagers, a community often overlooked. The artifacts and investigations portray how a combination of purposefully designed household objects and readily available items within the home environment can be leveraged to facilitate connection through gaming and various activities. The overarching goal is to offer practical tools and insights to enhance togetherness within families with teenagers.

While We Were At Dinner, Anna Glass

Masters Theses

Mealtime is globally recognized as a time to gather, as food catalyzes connection. This project delves into this human practice of commensality and both explores and emphasizes the significance of communal eating and its benefits through designed objects. Through a collection of six designed dining experiments, this study examines the role of novel tabletop objects and unusually curated meal environments. The way these experiments are designed highlights how communal mealtime experiences can be used as tools for social engagement and disruptors of cultural norms.

Furniture and tableware designs have the power to challenge the assumed arrangement of traditional mealtime rituals, …

Utilization Of Biologic Disease-Modifying Antirheumatic Therapy In Patients With Rheumatoid Arthritis And Recently Diagnosed Breast Cancer, Juan I Ruiz, Xiudong Lei, Chi-Fang Wu, Hui Zhao, Sharon H Giordano, Suja S Rajan, Maria E Suarez-Almazor

Faculty, Staff and Student Publications

Objective: Biologic disease-modifying antirheumatic drugs (bDMARDs) are immunosuppressants, and there have been concerns that they might impact tumor immunity in patients with cancer with rheumatoid arthritis (RA). The purpose of this study was to describe the utilization trends of bDMARD in patients with RA after breast cancer (BC) diagnosis.

Methods: We performed a retrospective cohort study of adults with RA and BC (2008 onward) from Optum's de-identified Clinformatics® Data Mart Database (CDM); the Surveillance, Epidemiology, and End Results Program (SEER) Medicare; and the Texas Cancer Registry (TCR) Medicare databases. We evaluated bDMARD utilization trends during the first three years after …

Stat5b Mutations In Myeloid Neoplasms Differ By Disease Subtypes But Characterize A Subset Of Chronic Myeloid Neoplasms With Eosinophilia And/Or Basophilia, C Cameron Yin, Wayne Tam, Serena M Walker, Amandeep Kaur, Madhu M Ouseph, Wei Xie, Olga K Weinberg, Peng Li, Zhuang Zuo, Mark J Routbort, Simon Chen, L Jeffrey Medeiros, Tracy I George, Attilio Orazi, Daniel A Arber, Adam Bagg, Robert P Hasserjian, Sa A Wang

Faculty, Staff and Student Publications

STAT5B has been reported as a recurrent mutation in myeloid neoplasms with eosinophilia, but its overall frequency and importance across a spectrum of myeloid neoplasms are largely unknown. We conducted a multicenter study on a series of 82 myeloid neoplasms with STAT5B mutations detected by next-generation sequencing. The estimated frequency of STAT5B mutations in myeloid neoplasms was low, <0.5%, but mutations were detected in all categories of such neoplasms, including myelodysplastic syndrome (MDS, 28%), acute myeloid leukemia (AML, 26%), myelodysplastic/myeloproliferative neoplasm (MDS/MPN, 18%), Philadelphia chromosome-negative classic MPN (12%), systemic mastocytosis (1%), and, with a notably high frequency, chronic eosinophilic leukemia, not otherwise specified (CEL-NOS, 15%). STAT5B mutations occurred preferentially in the SH2 domain (95%), involved 12 different codons, with the N642H hotspot being the most common (78%). Co-mutations were present in all cases and clonal hierarchy analysis showed that STAT5B mutations tended to be subclonal in AML, MPN, and MDS, but frequently dominant/co-dominant in CEL-NOS (83%), followed by MDS/MPN (40%). Across the group, eosinophilia and/or basophilia were common (41%), frequently observed in cases in which STAT5B mutations were detected at initial diagnosis (P<0.0001), with a high variant allele frequency (median 42.5%, P=0.0001), as a dominant/ co-dominant clone (P<0.0001), involving the canonical N642H (P=0.0607), and associated with fewer co-mutations (P=0.0009). Our data show that the characteristics and importance of a STAT5B mutation differ among myeloid neoplasms, but if present as a dominant mutation and detected at initial diagnosis, it appears to be a driver mutation in a subgroup of chronic myeloid neoplasms, preferentially promoting a proliferation of eosinophils and basophils.

Current Methods For Hyperpolarized [1-Current Methods For Hyperpolarized [1-13c]Pyruvate Mri Human Studies, Peder E Z Larson, Jenna M L Bernard, James A Bankson, Nikolaj Bøgh, Robert A Bok, Albert P Chen, Charles H Cunningham, Jeremy W Gordon, Jan-Bernd Hövener, Christoffer Laustsen, Dirk Mayer, Mary A Mclean, Franz Schilling, James B Slater, Jean-Luc Vanderheyden, Cornelius Von Morze, Daniel B Vigneron, Duan Xu

Faculty, Staff and Student Publications

MRI with hyperpolarized (HP) 13C agents, also known as HP 13C MRI, can measure processes such as localized metabolism that is altered in numerous cancers, liver, heart, kidney diseases, and more. It has been translated into human studies during the past 10 years, with recent rapid growth in studies largely based on increasing availability of hyperpolarized agent preparation methods suitable for use in humans. This paper aims to capture the current successful practices for HP MRI human studies with [1-13C]pyruvate - by far the most commonly used agent, which sits at a key metabolic junction in glycolysis. The paper is …

Adding 6 Months Of Androgen Deprivation Therapy To Postoperative Radiotherapy For Prostate Cancer: A Comparison Of Short-Course Versus No Androgen Deprivation Therapy In The Radicals-Hd Randomised Controlled Trial, Chris C Parker, Noel W Clarke, Adrian D Cook, Howard Kynaston, Charles N Catton, William R Cross, Peter M Petersen, Rajendra A Persad, Fred Saad, Lorna C Bower, John Logue, Heather Payne, Silvia Forcat, Cindy Goldstein, Claire Murphy, Juliette Anderson, Maroie Barkati, David M Bottomley, Jennifer Branagan, Ananya Choudhury, Peter W M Chung, Lyn Cogley, Chee L Goh, Peter Hoskin, Vincent Khoo, Shawn C Malone, Lindsey Masters, Stephen L Morris, Abdenour Nabid, Aldrich D Ong, Rakesh Raman, Kathryn L Tarver, Alison C Tree, Jane Worlding, James P Wylie, Anjali M Zarkar, Wendy R Parulekar, Mahesh K B Parmar, Matthew R Sydes, Radicals Investigators

Faculty, Staff and Student Publications

BACKGROUND: Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear.

METHODS: RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy …

Contemporary Approach To Neurofibromatosis Type 1-Associated Malignant Peripheral Nerve Sheath Tumors, Angela C Hirbe, Carina A Dehner, Eva Dombi, Vanessa Eulo, Andrea M Gross, Taylor Sundby, Alexander J Lazar, Brigitte C Widemann

Faculty, Staff and Student Publications

Most malignant peripheral nerve sheath tumors (MPNSTs) are clinically aggressive high-grade sarcomas, arising in individuals with neurofibromatosis type 1 (NF1) at a significantly elevated estimated lifetime frequency of 8%-13%. In the setting of NF1, MPNSTs arise from malignant transformation of benign plexiform neurofibroma and borderline atypical neurofibromas. Composed of neoplastic cells from the Schwannian lineage, these cancers recur in approximately 50% of individuals, and most patients die within five years of diagnosis, despite surgical resection, radiation, and chemotherapy. Treatment for metastatic disease is limited to cytotoxic chemotherapy and investigational clinical trials. In this article, we review the pathophysiology of this …