FIGURE 1 A, Number of participants by rare tumor diagnoses (N = 197). B, Diagnoses with only one participant enrolled (N = 1). C, Month of enrollment of 197 participants in 2019 and 2020, relative to the start of COVID pandemic restrictions at NIHCC in March 2020. Clinic cohort patients are shown in red and field cohort patients are in blue. More about this image found in A, Number of participants by rare tumor diagnoses (N = 19...

FIGURE 2 Variant genes found in 3 or more patients for ACC, N = 27 ( A ), GIST, N = 22 ( B ), and NEN, N = 24 ( C ). Variant genes found in 2 or more patients for MTC, N = 8 ( D ) and chordoma, N = 5 ( E ). TSO500 gene panel sequencing identified pathogenic or likely pathogenic mutations for most tumors ( F ), with NEN and chordoma showing the lowest percentage of pathogenic mutations identified. ACC and MTC tumor analysis identified the highest percentage of pathogenic mutations. G, sdGIST and MTC had the most actionable mutations in Tier 1A. Germline sequencing on participants was performed using directed variant, single gene, or small gene panels (<100 genes; hatched bars) or using comprehensive large gene panels or WES (solid bars; H ). The proportion of Path/LP mutations identified (red) varied by tumor type. I, The most common Path/LP germline mutations found were SDHA/B/C, in participants with sdGIST and their family members, and RET, in an ACC, three MTCs, and a pheochromocytoma. More about this image found in Variant genes found in 3 or more patients for ACC, N = 27 ...

FIGURE 3 Imaging and histology for 3 highlighted patients. A, Axial CT image of the abdomen showing a mass in the descending colon (arrow) in a 15-year-old male diagnosed with poorly differentiated adenocarcinoma. B, Histology shows high dysplasia and stromal microinvasion. C, MRI of the lum... More about this image found in Imaging and histology for 3 highlighted patients. A, Axial CT image of th...

FIGURE 4 Molecular analysis for 3 highlighted patients. A, Path (red), LP (gold), and VUS (Blue) variants identified by TSO500 in colon adenocarcinoma from 15-year-old male. Pathogenic germline mutations were identified in MLH1 (c.156del p.Glu53Argfs*4) and APC (c.3329C>A, p.Ser1110*) and VUS in SMAD4 (c.947A>G, p.Asn316Ser; hatched bars). B, Variants identified by TSO500 in a malignant melanotic schwannoma from a 36-year-old female, with Path mutations in NF1 (c.276dupA, p.C93fs*14) and PRKAR1A (c.207_208delGA, p.K70fs*11) and LP variant in SETD2 (c.4405dupA, p.M1469fs*6). C, Variants identified in two lymph node metastases collected 1 year apart from a carcinoma of unknown primary in a 75-year-old male (purple collected first, green collected second). VUS with higher percentage VAF (>45%) were identified in both samples (NCOR1, MST1R, ABL2, ROS1, ESR1, FAT1, POLE, NTRK3, and GEN1), as well as low VAF (∼6%) VUS in ZNF703. Pathogenicity of variants is indicated in y-axis label. More about this image found in Molecular analysis for 3 highlighted patients. A, Path (red), LP (gold), ...

FIGURE 1 Temporary reduction in p53 expression during irradiation increases sarcomagenesis. A, Schematic showing mice fed dox diet for 10 days to drive expression of shRNA to knockdown p53, irradiated with 30 or 40 Gy to the hind limb, returned to normal chow, and followed for sarcoma development and normal tissue injury in the radiation field. B, Kaplan–Meier curves show radiation-induced sarcoma-free survival of control and p53KD mice irradiated with 30 or 40 Gy to the hind limb. P value is from a log-rank test. C, Representative images of a H&E-stained radiation-induced sarcoma subtypes and table with the number of tumors from each subtype. D, Quantitation and representative IHC images of mouse muscle tissue from control and p53KD mice 4 hours after 30 Gy irradiation stained with antibodies recognizing cleaved caspase 3. The number of positive cells per tissue section is graphed. E, Representative flow cytometry dot plots of GFP+ muscle satellite cells isolated from unirradiated (left) and irradiated (right) limbs from control (top) or p53KD (bottom) mice. F, The relative ratio of GFP+ cells in the irradiated limb (30 Gy) over the unirradiated limb is graphed (±SEM). Each dot represents one mouse. P value is from a t test. G, Schematic showing that cells with functional p53 undergo apoptosis or cell-cycle arrest and repair after irradiation, while damaged cells with impaired p53 function are protected from cell death and persist. Figure generated using BioRender. More about this image found in Temporary reduction in p53 expression during irradiation increases sarcomag...

FIGURE 2 Temporary reduction of p53 during irradiation increases chronic injuries in subsets of mice. A, Kaplan–Meier curves show acute injury-free survival (score 1+) of control and p53KD male and female mice irradiated with 40 Gy to the hind limb. P value is from a log-rank test. B, Kaplan–Meier curves show acute injury-free survival (score 1+) of control and p53KD male and female mice irradiated with 30 Gy to the hind limb. P value is from a log-rank test. Kaplan–Meier curves show chronic injury-free survival from scores 1+ ( C ), 2+ ( D ), 3+ ( E ), or 4 ( F ) of control and p53KD male and female mice irradiated with 30 Gy to the hind limb. P value is from a log-rank test. More about this image found in Temporary reduction of p53 during irradiation increases chronic injuries in...

FIGURE 3 Radiation-induced chronic injuries increase the risk of sarcomagenesis. A, The final injury scores of the control and p53KD mice that received 30 or 40 Gy are plotted. The final injury scores of mice that did not develop a radiation-induced sarcoma (blue) are compared with the scores of mice that did develop a radiation-induced sarcoma (red). P value is from a t test. B, Kaplan–Meier curves show radiation-induced sarcoma-free survival of the control and p53KD mice irradiated with 30 or 40 Gy to the hind limb. Mice with chronic injury scores equal to or less than 3 are compared with mice with chronic injury scores greater than 3. P value is from a cox proportional hazards model. More about this image found in Radiation-induced chronic injuries increase the risk of sarcomagenesis. A,...

FIGURE 4 Radiation-induced sarcomas exhibit an increase in proliferative gene programs and a decrease in myogenic differentiation programs. A, Heat map of the top 75 differentially expressed genes in radiation-induced sarcomas (n = 16) versus normal muscle (n = 7). Genes (rows) are colored by scaled, normalized expression values. Both rows and columns are clustered. B, Volcano plot of log₂ fold change for all genes with base mean greater than 50 in tumor (n = 16) versus normal (n = 7). Labeled genes have a nominal −log₁₀P value greater than or equal to 30. C, Normalized enrichment scores for all FDR significant pathways for GSEA of Hallmark pathways. Points are colored by −log₁₀ (nominal P value). D, Scatter plot comparing the differentially expressed pathways between tumors that arose in irradiated tissues (Rad) versus sporadic (Spor) tumors in mouse (y-axis) and human (x-axis) datasets. The EMT pathway is highlighted with a green dot. E, Boxplot showing gene expression of EMT pathway targets in mouse radiation-induced UPS compared with p53/RB tumors (top) and in human radiation-associated undifferentiated sarcomas compared with sporadic undifferentiated sarcomas. More about this image found in Radiation-induced sarcomas exhibit an increase in proliferative gene progra...

FIGURE 5 Comparison of CNV and expression of specific oncogenes. Boxplot showing gene expression of Yap1 ( A ), Met ( B ), and Cdk4 ( C ) in radiation-induced sarcomas where the gene amplification status is known to be amplified (pink), not amplified (orange), or unknown (gray) compared with normal muscle (blue). More about this image found in Comparison of CNV and expression of specific oncogenes. Boxplot showing gen...

FIGURE 1 Swimmer plot showing time on study. Patients are grouped by dose level. Red bars indicate patients who had a CR; blue bars are patients with a PR. Black bars indicate patients with no response. Patients who had received prior treatment with RAF inhibitors are indicated with an asterisk. T... More about this image found in Swimmer plot showing time on study. Patients are grouped by dose level. Red...

FIGURE 2 Pharmacokinetics of phenformin. Pharmacokinetic results are shown for the 50 mg bid cohort ( A ), 100 mg bid cohort ( B ), 150 mg bid cohort ( C ), and the 200 mg bid cohort ( D ). Data for patients who missed a substantial number of doses due to toxicity are not shown. For the patients i... More about this image found in Pharmacokinetics of phenformin. Pharmacokinetic results are shown for the 5...

FIGURE 3 Effect of treatment on percentage of circulating MDSCs derived from flow cytometric analysis of PBMC samples from patients treated at the 150 and 200 mg bid dose level. Dotted lines indicate times when patient was not taking phenformin. bid, twice daily. More about this image found in Effect of treatment on percentage of circulating MDSCs derived from flow cy...