Characterization of a Diverse Set of Conditionally Reprogrammed Head and Neck Cancer Cell Cultures

OBJECTIVE

To establish and characterize a diverse library of head and neck squamous cell cancer (HNSCC) cultures using conditional reprogramming (CR).

METHODS

Patients enrolled on an IRB-approved protocol to generate tumor cell cultures using CR methods. Tumor and blood samples were collected and clinical information was recorded. Successful CR cultures were validated against banked reference tumors with short tandem repeat genotyping. Cell morphology was archived with photodocumentation. Clinical and demographic factors were evaluated for associations with successful establishment of CR culture. Human papilloma virus (HPV) genotyping, clonogenic survival, MTT assays, spheroid growth, and whole exome sequencing were carried out in selected cultures.

RESULTS

Forty four patients were enrolled, with 31 (70%) successful CR cultures, 32% derived from patients who identified as Black and 61% as Hispanic. All major head and neck disease sites were represented, including 15 (48%) oral cavity and 8 (26%) p16-positive oropharynx cancers. Hispanic ethnicity and first primary tumors (vs. second primary or recurrent tumors) were significantly associated with successful CR culture. HPV expression was conserved in CR cultures, including CR-024, which carried a novel HPV-69 serotype. CR cultures were used to test cisplatin responses using MTT assays. Previous work has also demonstrated these models can be used to assess response to radiation and can be engrafted in mouse models. Whole exome sequencing demonstrated that CR cultures preserved tumor mutation burden and driver mutations.

CONCLUSION

CR culture is highly successful in propagating HNSCC cells. This study included a high proportion of patients from underrepresented minority groups.

LEVEL OF EVIDENCE

Not Applicable Laryngoscope, 134:2748-2756, 2024.

Kruppel-family zinc finger proteins as emerging epigenetic biomarkers in head and neck squamous cell carcinoma

BACKGROUND

Krüppel-type zinc finger protein genes located on chromosome 19q13 are aberrantly hypermethylated with high frequency in all anatomic sub-sites of head and neck cancers as well as other epithelial tumours resulting in decreased expression.

METHODS

We examined prognostic significance of ZNF154 and ZNF132 expression and DNA methylation in independent patient cohort of about 500 head and neck cancer patients in the Cancer Genome Atlas (TCGA). We also overexpressed these genes in HEK-293 cells, as well as the oral cancer cell line UM-SCC-1.

RESULTS

In 20 patients from the TCGA cohort of HNSCC patients where ZNF154 and ZNF132 DNA methylation and RNA expression could be compared in tumor and adjacent normal tissue, there was increased DNA methylation and decreased expression of both ZNF154 and ZNF132 in primary tumours. Low ZNF154 and low ZNF132 expression were associated with shorter overall survival in both head and neck squamous cell carcinoma (HNSCC) and lung adenocarcinoma (LUAC patients). While expression of these proteins in HEK-293 cells produced full-length protein, only truncated copies could be expressed in head and neck cancer cells (UM-SCC-1). The truncated version of ZNF154 protein increased doubling time and reduced cell migration in UM-SCC-1 cancer cells.

CONCLUSIONS

Both ZNF132 and ZNF154 represent novel clinically significant biomarkers in head and neck cancer with potential tumour suppressive properties. Future studies will address the underlying molecular mechanisms by which ZNF154 expression in HNSCC contributes to the control of cell growth and migration.

Abstract 5986: The CDK4/6 inhibitor palbociclib sensitizes oral cavity squamous cell carcinoma to navitoclax-induced apoptosis-An in vitro and in vivo study

INTRODUCTION: CDKN2A, coding for p16INK4a, a CDK4/6 inhibitory protein, is among the most commonly lost tumor suppressors in oral cavity squamous cell carcinoma (OCSCC). Drugs like palbociclib are CDK4/6 inhibitors that phenomenally also induce senescence. Senescence can be pro-tumorigenic. Studies suggests prosurvival BCL-2 family support tumor cell survival in senescent state. Agents targeting BCL-2 family e.g. navitoclax, are “senolytics” The current study examines combining palbociclib (P) with the senolytic agent navitoclax (N) as a treatment strategy. We demonstrate efficacy of combining P+N in OCSCC, and examine senescence and apoptosis processes as related mechanistic response of combination.

EXPERIMENTAL PROCEDURE: We examined cell viability after sequential treatment: 72 h P followed by 72 h N (P+N) in 2-dimensional (2D) model of immortalized cell line HN5 and 3D model of a human OCSCC patient-derived conditional reprogrammed cell line (CR18). Flow cytometry measured apoptosis with Annexin V assay in 2D. Confocal imaging in 3D spheroids corroborated pro-survival protein levels. An in vivo xenograft study was performed with HN5 in 8 weeks old male nude mice to examine tumor responses to sequential P+N treatment. 3 million cells were injected in right flank. Tumors were treated at ~300 mm3 (P-100 mg/kg o.p; N -17 mg/kg i.p). After treatment termination, Bcl-2 family proteins (BcLxl); apoptosis markers (caspase 3, Cleaved PARP) and β-galactosidase (β -gal) for senescence were evaluated with western blot. QPCR measured expression of CDK4/6 target (FOXM1) to examine senescence and pro survival genes.

RESULTS: Sequential treatment of P+N (1µM each) demonstrated consistent synergy in both 2D and 3D viability assays. Bright field images of P+N revealed senescence with P followed with apoptosis on N application. β -gal levels increased to 1.5 fold with P and Caspase 3 showed 2-fold increase with P+N. Flow cytometry data revealed 2 folds increase in the apoptotic population with P+N. Confocal imaging in organoids demonstrated increased levels of BcLxL with P, and repression of BCL-xL following N administration. Sequential P+N significantly reduced tumor growth in vivo. P+N demonstrated a robust 5-fold decrease in tumor volume (TV) with a complete cure (TV<20 mm3) in 60% population in comparison to either of the cohorts post 30 days of treatment (control: 2000 mm3, P- 1200 mm3; N- 1500 mm3, p<0.05). Compared to control sequential P+N treatment in vivo i) reduced anti-apoptotic BcLxL mRNA expression to 2.5 fold ii) Cleaved PARP increased 10 folds and iii) BcLxL levels decreased 2 fold.

CONCLUSION: Our results suggest that CDK4/6 inhibition makes OCSCC undergo senescence and make it more susceptible to apoptosis when combined with the BCL2-family inhibitor, navitoclax. We propose a sequential P+N as a rational and potentially effective treatment strategy in OCSCC.

Citation Format: Nitisha Shrivastava, Nicole Kawachi, Michael B. Prystowsky, Evripidis Gavathiotis, Chandan Guha, Thomas J. Ow. The CDK4/6 inhibitor palbociclib sensitizes oral cavity squamous cell carcinoma to navitoclax-induced apoptosis-An in vitro and in vivo study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5986.

CDK4/6 Inhibition Induces Senescence and Enhances Radiation Response by Disabling DNA Damage Repair in Oral Cavity Squamous Cell Carcinoma

Purpose: HPV(−) OCSCC resists radiation treatment. The CDKN2A gene, encoding p16INK4A, is commonly disrupted in OCSCC. p16 inhibits CDK4/CDK6, leading to cell cycle arrest, but the biological sequelae of CDK4/6 inhibition in OCSCC remains understudied. This study examines whether inhibition of CDK4/6 enhances radiation response in OCSCC. Methods: MTT assays were performed in OCSCC cell lines HN5 and CAL27following treatment with palbociclib. Clonogenic survival and synergy were analyzed after radiation (RT-2 or 4Gy), palbociclib (P) (0.5 µM or 1 µM), or concurrent combination treatment (P+RT). DNA damage/repair and senescence were examined. CDK4/6 were targeted via siRNA to corroborate P+RT effects. Three-dimensional immortalized spheroids and organoids derived from patient tumors (conditionally reprogrammed OCSCC CR-06 and CR-18) were established to further examine and validate responses to P+RT. Results: P+RT demonstrated reduced viability and synergy, increased β-gal expression (~95%), and ~two-fold higher γH2AX. Rad51 and Ku80 were reduced after P+RT, indicating impairment of both HR and NHEJ. siCDK4/6 increased senescence with radiation. Spheroids showed reduced proliferation and size with P+RT. CR-06 and CR-18 further demonstrated three-fold reduced proliferation and organoids size with P+RT. Conclusion: Targeting CDK4/6 can lead to improved efficacy when combined with radiation in OCSCC by inducing senescence and inhibiting DNA damage repair.

Establishment of a diverse head and neck squamous cancer cell bank using conditional reprogramming culture methods

Most laboratory models of head and neck squamous cell cancer (HNSCC) rely on established immortalized cell lines, which carry inherent bias due to selection and clonality. We established a robust panel of HNSCC tumor cultures using a "conditional reprogramming" (CR) method, which utilizes a rho kinase inhibitor (Y-27632) and co-culture with irradiated fibroblast (J2 strain) feeder cells to support indefinite tumor cell survival. Sixteen CR cultures were successfully generated from 19 consecutively enrolled ethnically and racially diverse patients with HNSCC at a tertiary care center in the Bronx, NY. Of the 16 CR cultures, 9/16 were derived from the oral cavity, 4/16 were derived from the oropharynx, and 3/16 were from laryngeal carcinomas. Short tandem repeat (STR) profiling was used to validate culture against patient tumor tissue DNA. All CR cultures expressed ΔNp63 and cytokeratin 5/6, which are markers of squamous identity. Human papillomavirus (HPV) testing was assessed utilizing clinical p16 staining on primary tumors, reverse transcription polymerase chain reaction (RT-PCR) of HPV16/18-specific viral oncogenes E6 and E7 in RNA extracted from tumor samples, and HPV DNA sequencing. Three of four oropharyngeal tumors were p16 and HPV-positive and maintained HPV in culture. CR cultures were able to establish three-dimensional spheroid and murine flank and orthotopic tongue models. CR methods can be readily applied to all HNSCC tumors regardless of patient characteristics, disease site, and molecular background, providing a translational research model that properly includes patient and tumor diversity.

Abstract 968: Loss of glutathione peroxidase 2 promotes epithelial to mesenchymal transition and breast cancer metastasis

The processes regulating tumor metastasis are multivariate and complex. Redox regulation of the tumor phenotype by GPx2 knockdown (KD) in breast cancer led us to uncover dramatic effects on spontaneous metastasis. Analysis of single cell RNA sequencing (scRNAseq) data from GPx2 KD tumor and control tumor, revealed that both tumors were comprised of several luminal-like tumor cell clusters and one mesenchymal-like cell cluster (cluster 3). Notably, GPx2 KD promoted a significant increase in the size of mesenchymal cells (cluster 3) relative to control, which might be due to the stimulation of epithelial-to-mesenchymal transition (EMT) in response to GPx2 loss. In support of this view, GPx2 KD stimulated an increase in mRNA expression of basal/mesenchymal (KRT5, KRT14, KRT17, Vimentin, Twist1, Twist2, CDH2) genes and a decrease in mRNA expression of epithelial/luminal (Cldn7 and Epcam) genes, especially in cluster 3. Moreover, GPx2 KD upregulated mRNA expression of basal/mesenchymal (Twist2, CDH2, and KRT14) genes in most luminal-like clusters expressing epithelial/luminal (Epcam, Cldn3/7, CDH1, KRT8/18) genes, implying these clusters may be undergoing EMT transition in a hybrid epithelial/mesenchymal state in response to GPx2 loss. Validation of these data in cell lines and tumors showed that GPx2 KD dramatically enhanced EMT via activation of ROS/HIF1α-mediated signaling. Importantly, these effects were reversed by GPx2 re-expression or HIF1α inhibition, which was capable of suppressing EMT and metastasis. Collectively, these results indicate that GPx2 loss promotes breast cancer metastasis by stimulating EMT due to HIF1α signaling, highlighting the impact of GPx2 and HIF1 on therapeutic intervention in metastasis.

Citation Format: Zuen Ren, Huizhi Liang, Malindrie Dharmaratne, Miriam Morales-Gallego, Atefeh Taherian Fard, Jessica Mar, Kimita Suyama, Outhiriaradjou Benard, Michael B. Prystowsky, Larry Norton, Rachel B. Hazan. Loss of glutathione peroxidase 2 promotes epithelial to mesenchymal transition and breast cancer metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 968.

Impact of Nonadherence to NCCN Adjuvant Radiotherapy Initiation Guidelines in Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

BACKGROUND

Nonadherence to NCCN Guidelines during time from surgery to postoperative radiotherapy (S-PORT) can alter survival outcomes in head and neck squamous cell carcinomna (HNSCC). There is a need to validate this impact in an underserved urban population and to understand risk factors and reasons for delay. We sought to investigate the impact of delayed PORT with outcomes of overall survival (OS) in HNSCC, to analyze predictive factors of delayed PORT, and to identify reasons for delay.

METHODS

We conducted a retrospective cohort study in an urban, community-based academic center. A total of 184 patients with primary HNSCC were identified through the Montefiore Medical Center cancer registry who had been treated between March 1, 2005, and March 8, 2017, and met the inclusion and exclusion criteria. The primary exposure was S-PORT. OS, recurrence, and risk factors and reasons for treatment delay were the main outcomes and measures.

RESULTS

Among 184 patients with HNSCC treated with PORT, the median S-PORT was 48.5 days (interquartile range, 41-67 days). The S-PORT threshold that optimally differentiated worse OS outcomes was >50 days (46.7% of our cohort; n=86). Independent of other relevant factors, patients with HNSCC and S-PORT >50 days had worse OS (hazard ratio, 2.30; 95% CI, 1.34-3.95) and greater recurrence (odds ratio, 3.51; 95% CI, 1.31-9.39). Predictors of delayed S-PORT included being underweight or obese, prolonged postoperative length of stay, and age >70 years. The most frequent reasons for PORT delay were complications related to surgery (22.09%), unrelated medical comorbidities (18.60%), and nonadherence/missed appointments (6.98%).

CONCLUSIONS

Delayed PORT beyond 50 days after surgery was associated with decreased OS and greater recurrence. Identification of predictive factors and reasons for treatment delay helps to target at-risk patients and facilitates interventions in underserved populations.

Abstract 1958: Inhibition of CDK4/6 in head and neck squamous cell carcinoma dismantles key DNA repair pathways in response to radiation treatment

Introduction: Conventional treatment for head and neck squamous cell carcinoma (HNSCC) relies on surgery and radiation for cure; locoregional failure is often related to recurrence after radiation. CDKN2A, coding for the CDK4/6 inhibitory protein, p16INK4a (p16), is among the most commonly lost tumor suppressors in HNSCC. Palbociclib, a chemotherapeutic agent that is FDA-approved for breast cancer, is a selective CDK4/6 inhibitor. FOXM1 is a key cell cycle regulatory protein whose activation is controlled by CDK4/6. FOXM1 controls cell proliferation, DNA damage repair and suppresses senescence. The current study examines the role of CDK4/6 and its targets in response to radiation in HNSCC. We demonstrate inhibiting CDK4/6 can synergize with radiation, partially via suppression of FOXM1 signaling and impact on senescence.

Experimental Procedure: Our study focuses on utilizing palbociclib to increase radiation response in HPV(-) oral cavity HNSCC and understanding mechanisms of potential radiosensitization. We examined cell viability after concurrent palbociclib and radiation (P+RT) application using proliferation assays in 2-dimensional (2D) and 3D organoid models of immortalized cell lines (HN5 and Cal27), and calculated synergy by Compusyn analysis. After 3-days treatment, we performed western blot to evaluate DNA damage response (DDR) proteins and β-galactosidase (β -gal) staining to evaluate the senescent phenotype. Flow cytometry studies were used to measure cell cycle arrest and QPCR to measure expression of cell cycle regulators.

Results: P+RT (1µM palbociclib + 2 or 4Gy RT) demonstrated consistent synergy in both 2D and 3D viability assays. Comparing P+RT to RT alone, flow cytometry data revealed a 2-fold increase in the G1 arrested population, and DNA damage (measured by γ-H2AX level) increased by 2.3 fold. Additionally, Rad51 and Ku80 showed a 2 and 10-fold decrease respectively, suggesting an impact on DDR repair via both the homologous recombination and non-homologous end joining pathways. On transient knockdown of CDK-4 or 6, or both, we observed that senescence was the prevailing response - concurrent inhibition of CDK4 and CDK6 was the most profound, and levels of senescence based on β -gal staining results matched that observed with palbociclib treatment. P+RT demonstrated a robust 3-fold decrease in FOXM1 mRNA level and a 10-fold decrease in protein expression. We observed a 5-fold decrease in FOXM1 levels with CDK6 inhibition compared to a 2-fold decrease with CDK4 inhibition alone. Independently, FOXM1 inhibition induced apoptosis in HNSCC to a level higher than staurosporine-control treated cells.

Conclusions: Our results suggest that palbociclib may make HNSCC more susceptible to RT via the induction of senescence related to suppressed signaling through FOXM1.We propose P+RT as a rational and potentially effective treatment strategy in HNSCC

Citation Format: Nitisha Shrivastava, Carlos Thomas, Daniel Li, Cory D. Fulcher, Michael B. Prystowsky, Indranil Basu, Chandan Guha, Thomas J. Ow. Inhibition of CDK4/6 in head and neck squamous cell carcinoma dismantles key DNA repair pathways in response to radiation treatment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1958.

Abstract 2986: Conditional reprogramming of primary head and neck tumor cells to establish consistent and diverse cell line models

Introduction

Head and neck squamous cell carcinoma (HNSCC) most commonly arise in the oral cavity, pharynx, and larynx and exhibit diverse molecular characteristics and clinical behavior across sites. Current models of HNSCC largely rely on immortalized cell lines, which suffer from selection bias and clonality. Primary cell cultures, on the other hand, are difficult to maintain and are limited by their finite ability to proliferate. Here, we describe the establishment of a robust HNSCC cell line bank using a “conditional reprogramming” (CR) method which relies on treatment with a rho kinase inhibitor (Y-27632) and co-culture with irradiated fibroblast (J2 strain) feeder cells to support indefinite tumor cell survival.

Methods

HNSCC tumors were acquired on an IRB-approved prospective tissue banking protocol. Tumor tissue and blood were collected from each patient, and tumor cells were digested and cultured using previously described CR methods. DNA was collected from tumor tissue and CR cultures and short tandem repeat (STR) profiling was used to validate culture against patient tumor tissue. To verify that the cultures were of squamous origin, western blot analysis was used to detect cytokeratin 5, cytokeratin 6 and p63. Tumor cell phenotype and growth characteristics were examined with light microscopy. HPV testing was carried out on DNA from CR cultures and matched tumor samples using PCR and specific genotyping by oligonucleotide hybridization. HPV testing was correlated with clinical p16 testing results. Whole exome sequencing was carried out on a subset of blood/tumor/CR culture samples.

Results

Eighteen CR lines were successfully cultured and validated with STR genotyping from 25 sequentially procured tumors. 10/18 were derived from oral cavity squamous cell cancers (SCCs), 5/18 were derived from oropharyngeal SCCs, and 3/18 were derived from laryngeal SCCs. 18/18 lines were found to express p63 and either cytokeratin 5 or 6, verifying these cultures contained tumor cells of squamous origin. 4/5 tumors from oropharyngeal SCCs were p16-positive on clinical testing and considered HPV-mediated. These 4 tumors all tested positive for HPV DNA in both tumor samples and CR cultures. Preliminary comparison of exome sequencing results between CR cultures and primary tumors suggests that overall mutational profiles are preserved through the tumor “conditional programming” process. Tumor heterogeneity between original tumor and CR culture is being actively compared in ongoing analyses.

Conclusion

We have consistently generated primary tumor CR cultures from patients with HNSCC arising in three major anatomical subsites of HNSCC disease, including HPV-mediated tumors. CR methods can be readily applied to all HNSCC tumors regardless of disease site and molecular background, providing a translational research model that can capture the molecular and phenotypic breadth of HNSCC disease.

Citation Format: Daniel Li, Carlos Thomas, Nitisha Shrivastava, Nicholas Gadsden, Nicole Kawachi, Bradley A. Schiff, Richard V. Smith, Nicolas F. Schlecht, Michael B. Prystowsky, Gregory Rosenblatt, Stelby Augustine, Chandan Guha, Evripidis Gavathiotis, Robert D. Burk, Vikas Mehta, Thomas J. Ow. Conditional reprogramming of primary head and neck tumor cells to establish consistent and diverse cell line models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2986.

Single-Dilution COVID-19 Antibody Test with Qualitative and Quantitative Readouts

The coronavirus disease 2019 (COVID-19) global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to place an immense burden on societies and health care systems. A key component of COVID-19 control efforts is serological testing to determine the community prevalence of SARS-CoV-2 exposure and quantify individual immune responses to prior SARS-CoV-2 infection or vaccination. Here, we describe a laboratory-developed antibody test that uses readily available research-grade reagents to detect SARS-CoV-2 exposure in patient blood samples with high sensitivity and specificity. We further show that this sensitive test affords the estimation of viral spike-specific IgG titers from a single sample measurement, thereby providing a simple and scalable method to measure the strength of an individual's immune response. The accuracy, adaptability, and cost-effectiveness of this test make it an excellent option for clinical deployment in the ongoing COVID-19 pandemic.IMPORTANCE Serological surveillance has become an important public health tool during the COVID-19 pandemic. Detection of protective antibodies and seroconversion after SARS-CoV-2 infection or vaccination can help guide patient care plans and public health policies. Serology tests can detect antibodies against past infections; consequently, they can help overcome the shortcomings of molecular tests, which can detect only active infections. This is important, especially when considering that many COVID-19 patients are asymptomatic. In this study, we describe an enzyme-linked immunosorbent assay (ELISA)-based qualitative and quantitative serology test developed to measure IgG and IgA antibodies against the SARS-CoV-2 spike glycoprotein. The test can be deployed using commonly available laboratory reagents and equipment and displays high specificity and sensitivity. Furthermore, we demonstrate that IgG titers in patient samples can be estimated from a single measurement, enabling the assay's use in high-throughput clinical environments.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Qualitative IgG Assays: The Value of Numeric Reporting

CONTEXT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG testing is used for serosurveillance and will be important to evaluate vaccination status. Given the urgency to release coronavirus disease 2019 (COVID-19) serology tests, most manufacturers have developed qualitative tests.

OBJECTIVE

To evaluate clinical performance of six different SARS-CoV-2 IgG assays and their quantitative results to better elucidate the clinical role of serology testing in COVID-19.

DESIGN

Six SARS-CoV-2 IgG assays were tested using remnant specimens from 190 patients. Sensitivity and specificity were evaluated for each assay with the current manufacturer's cutoff and a lower cutoff. A numeric result analysis and discrepancy analysis were performed Results: The specificity was >93% for all assays, and sensitivity was >80% for all assays (≥ 7 days post-polymerase chain reaction [PCR] testing). Inpatients with more severe disease had higher numeric values compared to health care workers with mild or moderate disease. Several discrepant serology results were those just below the manufacturers cutoff.

CONCLUSIONS

SARS-CoV-2 IgG antibody testing can aid in the diagnosis of COVID-19 especially with negative PCR. Quantitative COVID-19 IgG results are important to better understand the immunological response and disease course of this novel virus and to assess immunity as part of future vaccination programs.

Approaching the Interpretation of Discordances in SARS-CoV-2 Testing

The coronavirus disease 2019 pandemic has upended life throughout the globe. Appropriate emphasis has been placed on developing effective therapies and vaccines to curb the pandemic. While awaiting such countermeasures, mitigation efforts coupled with robust testing remain essential to controlling spread of the disease. In particular, serological testing plays a critical role in providing important diagnostic, prognostic, and therapeutic information. However, this information is only useful if the results can be accurately interpreted. This pandemic placed clinical testing laboratories and requesting physicians in a precarious position because we are actively learning about the disease and how to interpret serological results. Having developed robust assays to detect antibodies generated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and serving the hardest-hit areas within the New York City epicenter, we found 3 types of discordances in SARS-CoV-2 test results that challenge interpretation. Using representative clinical vignettes, these interpretation dilemmas are highlighted, along with suggested approaches to resolve such cases.

Palbociclib Renders Human Papilloma Virus-Negative Head and Neck Squamous Cell Carcinoma Vulnerable to the Senolytic Agent Navitoclax

We demonstrate that inhibition of cyclin-dependent kinases 4/6 (CDK4/6) leads to senescence in human papillomavirus (HPV)-negative (-) head and neck squamous cell carcinoma (HNSCC), but not in HPV-positive (+) HNSCC. The BCL-2 family inhibitor, navitoclax, has been shown to eliminate senescent cells effectively. We evaluated the efficacy of combining palbociclib and navitoclax in HPV^- HNSCC. Three HPV^- HNSCC cell lines (CAL27, HN31, and PCI15B) and three HPV⁺ HNSCC cell lines (UPCI-SCC-090, UPCI-SCC-154, and UM-SCC-47) were treated with palbociclib. Treatment drove reduced expression of phosphorylated Rb (p-Rb) and phenotypic evidence of senescence in all HPV^- cell lines, whereas HPV⁺ cell lines did not display a consistent response by Rb or p-Rb and did not exhibit morphologic changes of senescence in response to palbociclib. In addition, treatment of HPV^- cells with palbociclib increased both β-galactosidase protein expression and BCL-xL protein expression compared with untreated controls in HPV^- cells. Co-expression of β-galactosidase and BCL-xL occurred consistently, indicating elevated BCL-xL expression in senescent cells. Combining palbociclib with navitoclax led to decreased HPV^- HNSCC cell survival and led to increased apoptosis levels in HPV^- cell lines compared with each agent given alone. IMPLICATIONS: This work exploits a key genomic hallmark of HPV^- HNSCC (CDKN2A disruption) using palbociclib to induce BCL-xL-dependent senescence, which subsequently causes the cancer cells to be vulnerable to the senolytic agent, navitoclax.

Prioritizing the Interview in Selecting Resident Applicants: Behavioral Interviews to Determine Goodness of Fit

From our initial screening of applications, we assess that the 10% to 15% of applicants whom we will interview are all academically qualified to complete our residency training program. This initial screening to select applicants to interview includes a personality assessment provided by the personal statement, Dean's letter, and letters of recommendation that, taken together, begin our evaluation of the applicant's cultural fit for our program. While the numerical scoring ranks applicants preinterview, the final ranking into best fit categories is determined solely on the interview day at a consensus conference by faculty and residents. We analyzed data of 819 applicants from 2005 to 2017. Most candidates were US medical graduates (62.5%) with 23.7% international medical graduates, 11.7% Doctors of Osteopathic Medicine (DO), and 2.1% Caribbean medical graduates. Given that personality assessment began with application review, there was excellent correlation between the preinterview composite score and the final categorical ranking in all 4 categories. For most comparisons, higher scores and categorical rankings were associated with applicants subsequently working in academia versus private practice. We found no problem in using our 3-step process employing virtual interviews during the COVID pandemic.

The New York State SARS-CoV-2 Testing Consortium: Regional Communication in Response to the COVID-19 Pandemic

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, created an unprecedented need for comprehensive laboratory testing of populations, in order to meet the needs of medical practice and to guide the management and functioning of our society. With the greater New York metropolitan area as an epicenter of this pandemic beginning in March 2020, a consortium of laboratory leaders from the assembled New York academic medical institutions was formed to help identify and solve the challenges of deploying testing. This report brings forward the experience of this consortium, based on the real-world challenges which we encountered in testing patients and in supporting the recovery effort to reestablish the health care workplace. In coordination with the Greater New York Hospital Association and with the public health laboratory of New York State, this consortium communicated with state leadership to help inform public decision-making addressing the crisis. Through the length of the pandemic, the consortium has been a critical mechanism for sharing experience and best practices in dealing with issues including the following: instrument platforms, sample sources, test performance, pre- and post-analytical issues, supply chain, institutional testing capacity, pooled testing, biospecimen science, and research. The consortium also has been a mechanism for staying abreast of state and municipal policies and initiatives, and their impact on institutional and laboratory operations. The experience of this consortium may be of value to current and future laboratory professionals and policy-makers alike, in dealing with major events that impact regional laboratory services.

Mater Artium Necessitas: The Birth of a COVID-19 Command Center

In February of 2020, New York City was unprepared for the COVID-19 pandemic. Cases of SARS-CoV-2 infection appeared and spread rapidly. Hospitals had to repurpose staff and establish diagnostic testing for this new viral infection. In the background of the usual respiratory pathogen testing performed in the clinical laboratory, SARS-CoV-2 testing at the Montefiore Medical System grew exponentially, from none to hundreds per day within the first week of testing. The job of appropriately routing SARS-CoV-2 viral specimens became overwhelming. Additional staff was required to triage these specimens to multiple in-house testing platforms as well as external reference laboratories. Since medical school classes and many research laboratories shut down at the Albert Einstein College of Medicine and students were eager to help fight the pandemic, we seized the opportunity to engage and train senior MD-PhD students to assist in triaging specimens. This volunteer force enabled us to establish the "Pathology Command Center," staffed by these students as well as residents and furloughed dental associates. The Pathology Command Center staff were tasked with the accessioning and routing of specimens, answering questions from clinical teams, and updating ever evolving protocols developed in collaboration with a team of Infectious Disease clinicians. Many lessons were learned during this process, including how best to restructure an accessioning department and how to properly onboard students and repurpose staff while establishing safeguards for their well-being during these unprecedented times. In this article, we share some of our challenges, successes, and what we ultimately learned as an organization.

Development, clinical translation, and utility of a COVID-19 antibody test with qualitative and quantitative readouts

The COVID-19 global pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continues to place an immense burden on societies and healthcare systems. A key component of COVID-19 control efforts is serologic testing to determine the community prevalence of SARS-CoV-2 exposure and quantify individual immune responses to prior infection or vaccination. Here, we describe a laboratory-developed antibody test that uses readily available research-grade reagents to detect SARS-CoV-2 exposure in patient blood samples with high sensitivity and specificity. We further show that this test affords the estimation of viral spike-specific IgG titers from a single sample measurement, thereby providing a simple and scalable method to measure the strength of an individual's immune response. The accuracy, adaptability, and cost-effectiveness of this test makes it an excellent option for clinical deployment in the ongoing COVID-19 pandemic.

Abstract 4426: Redox regulation of tumor cell heterogeneity in the PyMT mammary tumor model revealed by single cell RNA sequencing

Tumor heterogeneity is known to drive breast cancer progression and metastasis. Current therapies target mostly inter-tumor heterogeneity (different patients) without taking into consideration intratumor heterogeneity (individual tumor). Hypoxia is a hallmark of aggressive tumors that is known to select for intratumor cells that are prone for metastasis. Here we show that knockdown of a ROS scavenging enzyme, Glutathione Peroxidase 2, in the PyMT mammary tumor model results in highly hypoxic and metastatic tumors. Single cell RNA-seq on both GPx2 knockdown and control tumors revealed a high degree of intratumor heterogeneity resulting in several clusters that were either of luminal/epithelial or basal-like/mesenchymal type shared by both tumors. Interestingly, GPx2 loss caused increases in a mesenchymal-like/quiescent and a highly proliferative luminal population, implying that GPx2 loss might drive a cancer stem-like population that is conducive of metastasis. Metascape pathway analysis of differentially expressed genes identified pathways that were significantly overrepresented in GPx2 knockdown tumors involving mitochondrial oxidative phosphorylation and response to hypoxia, consistent with the high levels of reactive oxygen species in these tumors. Finally, differential gene expression analysis on mesenchymal and luminal subpopulations predicts novel candidate gene signatures stimulated by GPx2 loss, that might be used to identify or target metastatic cells in tumors. In sum, our data imply that oxidative stress conveys a metastatic phenotype via effects on tumor cell heterogeneity.

Citation Format: Zuen Ren, Malindrie Dharmaratne, Ameya Kulkarni, Atefeh Taherian Fard, Jessica Mar, Phillip M. Galbo, Yang Liu, Deyou Zheng, Huizhi Liang, Outhiriaradjou Benard, Kimita Suyama, Michael B. Prystowsky, Larry Norton, Rachel B. Hazan. Redox regulation of tumor cell heterogeneity in the PyMT mammary tumor model revealed by single cell RNA sequencing [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4426.

Apoptosis signaling molecules as treatment targets in head and neck squamous cell carcinoma

OBJECTIVES

To evaluate BCL-2 family signaling molecules in head and neck squamous cell carcinoma (HNSCC) and examine the ability of therapeutic agents with variable mechanisms of action to induce apoptosis in HNSCC cells.

METHODS

messenger ribonculeic acid (mRNA) expression of BAK, BAX, B-cell lymphoma (Bcl-2), BCL2 Like 1 (BCL2L1), and MCL1 were measured in The Cancer Genome Atlas (TCGA) head and neck cancer dataset, as well as in a dataset from a cohort at Montefiore Medical Center (MMC). Protein expression was similarly evaluated in a panel of HNSCC cell lines (HN30, HN31, HN5, MDA686LN, UMSCC47). Cell viability and Annexin V assays were used to assess the efficacy and apoptotic potential of a variety of agents (ABT-263 [navitoclax], A-1210477, and bortezomib.

RESULTS

Expression of BAK, BAX, BCL2L1, and MCL1 were each significantly higher than expression of BCL2 in the TCGA and MMC datasets. Protein expression demonstrated the same pattern of expression when examined in HNSCC cell lines. Treatment with combined ABT-263 (navitoclax)/A-1210477 or with bortezomib demonstrated apoptosis responses that approached or exceeded treatment with staurospaurine control.

CONCLUSION

HNSCC cells rely on inhibition of apoptosis via BCL-xL and MCL-1 overexpression, and induction of apoptosis remains a potential therapeutic option as long as strategies overcome redundant anti-apoptotic signals.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2643-2649, 2020.

How to Succeed in Fellowship Acquisition: A Survey of Pathology Residents

Medical school curricula limit students’ exposure to pathology practice while pathology subspecialty training programs require residents to apply for fellowships as early as the end of their first year of training. Thus, limited exposure to pathology practice creates significant confusion and anxiety, often making the fellowship application process premature. Additionally, early focus on subspecialty training in order to acquire a fellowship adds to the initial lack of emphasis on general pathology training. We prepared a voluntary online survey with questions developed through focus groups and advice from an expert in survey design to determine which fellowships are desired and how successful residents are in their pursuit of these fellowships. The survey was distributed through the Pathology Residency Program Directors' (PRODS) listserv. Answers were solicited from pathology trainees throughout the entire training cycle. There were 141 (4.6% response rate) total respondents with each postgraduate year represented. One hundred twenty-two (95%) of 129 residents plan on completing 1 or 2 fellowships after residency training. Encouragingly, 94 (75%) of 126 pathology residents attained their desired specialty fellowship. However, 32 (32%) of 99 residents who acquired at least one fellowship chose a general surgical pathology fellowship. Furthermore, 33 (24%) respondents had already decided to pursue a specific specialty while still in medical school. An additional 32 (23%) came to their decision during postgraduate year 1. Therefore, although most residents are successful in attaining their desired fellowship, further research is needed to understand the effect of early commitment to a subspecialty and its impact on pathology education.

Association of Delayed Time to Treatment Initiation With Overall Survival and Recurrence Among Patients With Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

Importance

Delay in time to treatment initiation (TTI) can alter survival and oncologic outcomes. There is a need to characterize these consequences and identify risk factors and reasons for treatment delay, particularly in underserved urban populations.

Objectives

To investigate the association of delayed treatment initiation with outcomes of overall survival and recurrence among patients with head and neck squamous cell carcinoma (HNSCC), to analyze factors that are predictive of delayed treatment initiation, and to identify specific reasons for delayed treatment initiation.

Design, Setting, and Participants

Retrospective cohort study at an urban community-based academic center. Participants were 956 patients with primary HNSCC treated between February 8, 2005, and July 17, 2017, identified through the Montefiore Medical Center Cancer Registry.

Exposures

The primary exposure was TTI, defined as the duration between histopathological diagnosis and initial treatment. The threshold for delayed treatment initiation was determined by recursive partitioning analysis.

Main Outcomes and Measures

Overall survival, recurrence, and reasons for treatment delay.

Results

Among 956 patients with HNSCC (mean [SD] age, 60.8 [18.2] years; 72.6% male), the median TTI was 40 days (interquartile range, 28-56 days). The optimal TTI threshold to differentiate overall survival was greater than 60 days (20.8% [199 of 956] of patients in our cohort). Independent of other relevant factors, patients with HNSCC with TTI exceeding 60 days had poorer survival (hazard ratio, 1.69; 95% CI, 1.32-2.18). Similarly, TTI exceeding 60 days was associated with greater risk of recurrence (odds ratio, 1.77; 95% CI, 1.07-2.93). Predictors of delayed TTI included African American race/ethnicity, Medicaid insurance, body mass index less than 18.5, and initial diagnosis at a different institution. Commonly identified individual reasons for treatment delay were missed appointments (21.2% [14 of 66]), extensive pretreatment evaluation (21.2% [14 of 66]), and treatment refusal (13.6% [9 of 66]).

Conclusions and Relevance

Delaying TTI beyond 60 days was associated with decreased overall survival and increased HNSCC recurrence. Identification of predictive factors and reasons for treatment delay will help target at-risk patients and facilitate intervention in hospitals with underserved urban populations.

Training the Next Generation of Pathologists: A Novel Residency Program Curriculum at Montefiore Medical Center/Albert Einstein College of Medicine

Pathology residency training is currently a time-intensive process, frequently extending up to 6 years in duration as residents complete 1 or 2 fellowships following graduation. Innovative training curricula may help address the impending changes in the health-care landscape, particularly future shortfalls in pathology staffing and changing health-care models that incorporate more work within interdisciplinary teams. Montefiore has created a novel residency training program aimed at accelerating the acquisition of competency in pathology, preparing residents for independent practice at the completion of residency training, and providing residents with the requisite adaptability and consultative skills to excel wherever they choose to practice. We describe the implementation of this novel pathology residency training curriculum at Montefiore Medical Center/Albert Einstein College of Medicine and the perception of residents in both the old curriculum and the new curriculum.

Association between pretreatment obesity, sarcopenia, and survival in patients with head and neck cancer

BACKGROUND

Body mass index (BMI), sarcopenia, and obesity-related comorbidities have been associated with head and neck squamous cell carcinoma (HNSCC) progression.

METHODS

We conducted a retrospective analysis of 441 normal-weight, overweight, and obese HNSCC patients treated at Montefiore Medical Center (New York). Patients were grouped by BMI prior to treatment and assessed for differences in survival adjusting for comorbid conditions (cardiovascular disease and diabetes). Evidence of sarcopenia was also assessed using pretreatment abdominal CT scans in a subset of 113 patients.

RESULTS

Prior to treatment, 55% of HNSCC patients were overweight or obese. Overweight/obese patients had significantly better overall survival (hazard ratio [HR] = 0.4, 95% CI: 0.3-0.6) compared to normal-weight patients, independent of comorbid conditions. Patients with sarcopenia had significantly poorer survival (HR = 2.1, 95% CI: 1.1-3.9) compared to non-sarcopenic patients, with the strongest association seen among overweight/obese patients.

CONCLUSION

Our data support the importance of sarcopenia assessment, in addition to BMI, among patients with HNSCC.

Integrated Genomic and Functional microRNA Analysis Identifies miR-30-5p as a Tumor Suppressor and Potential Therapeutic Nanomedicine in Head and Neck Cancer

PURPOSE

To identify deregulated and inhibitory miRNAs and generate novel mimics for replacement nanomedicine for head and neck squamous cell carcinomas (HNSCC).

EXPERIMENTAL DESIGN

We integrated miRNA and mRNA expression, copy number variation, and DNA methylation results from The Cancer Genome Atlas (TCGA), with a functional genome-wide screen.

RESULTS

We reveal that the miR-30 family is commonly repressed, and all 5 members sharing these seed sequence similarly inhibit HNSCC proliferation in vitro. We uncover a previously unrecognized inverse relationship with overexpression of a network of important predicted target mRNAs deregulated in HNSCC, that includes key molecules involved in proliferation (EGFR, MET, IGF1R, IRS1, E2F7), differentiation (WNT7B, FZD2), adhesion, and invasion (ITGA6, SERPINE1). Reexpression of the most differentially repressed family member, miR-30a-5p, suppressed this mRNA program, selected signaling proteins and pathways, and inhibited cell proliferation, migration, and invasion in vitro. Furthermore, a novel miR-30a-5p mimic formulated into a targeted nanomedicine significantly inhibited HNSCC xenograft tumor growth and target growth receptors EGFR and MET in vivo. Significantly decreased miR-30a/e family expression was related to DNA promoter hypermethylation and/or copy loss in TCGA data, and clinically with decreased disease-specific survival in a validation dataset. Strikingly, decreased miR-30e-5p distinguished oropharyngeal HNSCC with poor prognosis in TCGA (P = 0.002) and validation (P = 0.007) datasets, identifying a novel candidate biomarker and target for this HNSCC subset.

CONCLUSIONS

We identify the miR-30 family as an important regulator of signal networks and tumor suppressor in a subset of HNSCC patients, which may benefit from miRNA replacement nanomedicine therapy.

Association of an intact E2 gene with higher HPV viral load, higher viral oncogene expression, and improved clinical outcome in HPV16 positive head and neck squamous cell carcinoma

To assess the relationship of E2 gene disruption with viral gene expression and clinical outcome in human papillomavirus (HPV) positive head and neck squamous cell carcinoma, we evaluated 31 oropharyngeal and 17 non-oropharyngeal HPV16 positive carcinomas using two PCR-based methods to test for disruption of E2, followed by Sanger sequencing. Expression of HPV16 E6, E7 and E2 transcripts, along with cellular ARF and INK4A, were also assessed by RT-qPCR. Associations between E2 disruption, E2/E6/E7 expression, and clinical outcome were evaluated by Kaplan-Meier analysis for loco-regional recurrence and disease-specific survival. The majority (n = 21, 68%) of HPV16 positive oropharyngeal carcinomas had an intact E2 gene, whereas the majority of HPV16 positive non-oropharyngeal carcinomas (n = 10, 59%) had a disrupted E2 gene. Three of the oropharyngeal tumors and two of the non-oropharyngeal tumors had deletions within E2. Detection of an intact E2 gene was associated with a higher DNA viral load and increased E2/E6/E7, ARF and INK4A expression in oropharyngeal tumors. Oropharyngeal carcinomas with an intact E2 had a lower risk of loco-regional recurrence (log-rank p = 0.04) and improved disease-specific survival (p = 0.03) compared to tumors with disrupted E2. In addition, high E7 expression was associated with lower risk of loco-regional recurrence (p = 0.004) as was high E6 expression (p = 0.006). In summary, an intact E2 gene is more common in HPV16 positive oropharyngeal than non-oropharyngeal carcinomas; the presence of an intact E2 gene is associated with higher HPV viral load, higher viral oncogene expression, and improved clinical outcome compared to patients with a disrupted E2 gene in oropharyngeal cancer.

Apolipoprotein E Promotes Invasion in Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) patients generally have a poor prognosis, because of the invasive nature of these tumors. In comparing transcription profiles between OSCC tumors with a more invasive (worst pattern of tumor invasion 5) versus a less invasive (worst pattern of tumor invasion 3) pattern of invasion, we identified a total of 97 genes that were overexpressed at least 1.5-fold in the more invasive tumor subtype. The most functionally relevant genes were assessed using in vitro invasion assays with an OSCC cell line (UM-SCC-1). Individual siRNA knockdown of 15 of these 45 genes resulted in significant reductions in tumor cell invasion compared to a nontargeting siRNA control. One gene whose knockdown had a strong effect on invasion corresponded to apolipoprotein E (APOE). Both matrix degradation and the number of mature invadopodia were significantly decreased with APOE knockdown. APOE knockdown also resulted in increased cellular cholesterol, consistent with APOE's role in regulating cholesterol efflux. APOE knockdown resulted in decreased levels of phospho-extracellular signal-regulated kinase 1/2, phospho-c-Jun N-terminal kinase, and phospho-cJun, as well as decreased activator protein 1 (AP-1) activity. Expression of matrix metalloproteinase 7 (MMP7), an AP-1 target, was also significantly decreased. Our findings suggest that APOE protein plays a significant role in OSCC tumor invasion because of its effects on cellular cholesterol and subsequent effects on cell signaling and AP-1 activity, leading to changes in the expression of invasion-related proteins, including MMP7.

Pathology Competencies for Medical Education and Educational Cases

Current medical school curricula predominantly facilitate early integration of basic science principles into clinical practice to strengthen diagnostic skills and the ability to make treatment decisions. In addition, they promote life-long learning and understanding of the principles of medical practice. The Pathology Competencies for Medical Education (PCME) were developed in response to a call to action by pathology course directors nationwide to teach medical students pathology principles necessary for the practice of medicine. The PCME are divided into three competencies: 1) Disease Mechanisms and Processes, 2) Organ System Pathology, and 3) Diagnostic Medicine and Therapeutic Pathology. Each of these competencies is broad and contains multiple learning goals with more specific learning objectives. The original competencies were designed to be a living document, meaning that they will be revised and updated periodically, and have undergone their first revision with this publication. The development of teaching cases, which have a classic case-based design, for the learning objectives is the next step in providing educational content that is peer-reviewed and readily accessible for pathology course directors, medical educators, and medical students. Application of the PCME and cases promotes a minimum standard of exposure of the undifferentiated medical student to pathophysiologic principles. The publication of the PCME and the educational cases will create a current educational resource and repository published through Academic Pathology.

miR-375 Regulates Invasion-Related Proteins Vimentin and L-Plastin

Invasion is a hallmark of advanced head and neck squamous cell carcinoma (HNSCC). We previously determined that low relative miR-375 expression was associated with poor patient prognosis. HNSCC cells with increased miR-375 expression have lower invasive properties and impaired invadopodium activity. Using stable isotope labeling with amino acids in cell culture and reverse-phase liquid chromatography mass spectrometry, we assessed the impact of miR-375 expression on protein levels in UM-SCC-1 cells. Increased miR-375 expression was associated with down-regulation of proteins involved in cellular assembly and organization, death and survival, and movement. Two invasion-associated proteins, vimentin and L-plastin, were strongly down-regulated by miR-375. Luciferase reporter assays demonstrated that high miR-375 expression reduced vimentin promoter activity, suggesting that vimentin is an indirect target of miR-375. Runt-related transcription factor 1 (RUNX1) is a potential miR-375 direct target, and its knockdown reduced vimentin and L-plastin expression. Data in The Cancer Genome Atlas HNSCC database showed a significant inverse correlation between miR-375 expression and RUNX1, vimentin, and L-plastin RNA expression. These clinical correlations validate our in vitro model findings and support a mechanism in which miR-375 suppresses RUNX1 levels, resulting in reduced vimentin and L-plastin expression. Furthermore, knockdown of RUNX1, L-plastin, and vimentin resulted in significant reductions in cell invasion in vitro, indicating the functional significance of miR-375 regulation of specific proteins involved in HNSCC invasion.

Nonpromoter methylation of the CDKN2A gene with active transcription is associated with improved locoregional control in laryngeal squamous cell carcinoma

We previously reported a novel association between CDKN2A nonpromoter methylation and transcription (ARF/INK4a) in human papillomavirus associated oropharyngeal tumors. In this study we assessed whether nonpromoter CDKN2A methylation in laryngeal squamous cell carcinomas (LXSCC) conferred a similar association with transcription that predicted patient outcome. We compared DNA methylation and ARF/INK4a RNA expression levels for the CDKN2A locus using the Illumina HumanMethylation27 beadchip and RT‐PCR in 43 LXSCC tumor samples collected from a prospective study of head and neck cancer patients treated at Montefiore Medical Center (MMC). Validation was performed using RNAseq data on 111 LXSCC tumor samples from the Cancer Genome Atlas (TCGA). The clinical relevance of combined nonpromoter CDKN2A methylation and transcription was assessed by multivariate Cox regression for locoregional recurrence on a subset of 69 LXSCC patients with complete clinicopathologic data from the MMC and TCGA cohorts. We found evidence of CDKN2A nonpromoter hypermethylation in a third of LXSCC from our MMC cohort, which was significantly associated with increased ARF and INK4a RNA expression (Wilcoxon rank‐sum, P = 0.007 and 0.003, respectively). A similar association was confirmed in TCGA samples (Wilcoxon rank‐sum test P < 0.0001 for ARF and INK4a). Patients with CDKN2A hypermethylation or high ARF/INK4a expression were significantly less likely to develop a locoregional recurrence compared to those with neither of the features, independent of other clinicopatholgic risk factors (adjusted hazard ratio=0.21, 95% confidence interval:0.05–0.81). These results support the conclusion that CDKN2A nonpromoter methylation is associated with increased ARF and INK4a RNA expression, and improved locoregional control in LXSCC.

Crumbs 3b promotes tight junctions in an ezrin-dependent manner in mammalian cells

Crumbs 3 (CRB3) is a component of epithelial junctions, which has been implicated in apical-basal polarity, apical identity, apical stability, cell adhesion, and cell growth. CRB3 undergoes alternative splicing to yield two variants: CRB3a and CRB3b. Here, we describe novel data demonstrating that, as with previous studies on CRB3a, CRB3b also promotes the formation of tight junctions (TJs). However, significantly we demonstrate that the 4.1-ezrin-radixin-moesin-binding motif of CRB3b is required for CRB3b functionality and that ezrin binds to the FBM of CRB3b. Furthermore, we show that ezrin contributes to CRB3b functionality and the correct distribution of TJ proteins. We demonstrate that both CRB3 isoforms are required for the production of functionally mature TJs and also the localization of ezrin to the plasma membrane. Finally, we demonstrate that reduced CRB3b expression in head and neck squamous cell carcinoma (HNSCC) correlates with cytoplasmic ezrin, a biomarker for aggressive disease, and shows evidence that while CRB3a expression has no effect, low CRB3b and high cytoplasmic ezrin expression combined may be prognostic for HNSCC.

Training Pathology Residents to Practice 21st Century Medicine: A Proposal

Scientific advances, open information access, and evolving health-care economics are disrupting extant models of health-care delivery. Physicians increasingly practice as team members, accountable to payers and patients, with improved efficiency, value, and quality. This change along with a greater focus on population health affects how systems of care are structured and delivered. Pathologists are not immune to these disruptors and, in fact, may be one of the most affected medical specialties. In the coming decades, it is likely that the number of practicing pathologists will decline, requiring each pathologist to serve more and often sicker patients. The demand for increasingly sophisticated yet broader diagnostic skills will continue to grow. This will require pathologists to acquire appropriate professional training and interpersonal skills. Today’s pathology training programs are ill designed to prepare such practitioners. The time to practice for most pathology trainees is typically 5 to 6 years. Yet, trainees often lack sufficient experience to practice independently and effectively. Many studies have recognized these challenges suggesting that more effective training for this new century can be implemented. Building on the strengths of existing programs, we propose a redesign of pathology residency training that will meet (and encourage) a continuing evolution of American Board of Pathology and Accreditation Council for Graduate Medical Education requirements, reduce the time to readiness for practice, and produce more effective, interactive, and adaptable pathologists. The essence of this new model is clear definition and acquisition of core knowledge and practice skills that span the anatomic and clinical pathology continuum during the first 2 years, assessed by competency-based metrics with emphasis on critical thinking and skill acquisition, followed by individualized modular training with intensively progressive responsibility during the final years of training. We anticipate that implementing some or all aspects of this model will enable residents to attain a higher level of competency within the current time-based constraints of residency training.

Onboarding for Pathology Residency Programs-The Montefiore Experience

Onboarding is a system frequently used in the corporate world as a means of orienting incoming employees to their duties and inculcating the workplace values. The program aims to facilitate transition into new work roles and improve employee retention rates. At Montefiore, we have instituted an onboarding curriculum that is given to new anatomic and clinical pathology residents about a month prior to the start of residency. The program includes an introductory video series of basic histology and a series of anatomic and clinical case studies illustrating basic laboratory principles. This didactic content is tagged to learning objectives and short self-assessment modules. In addition, content related to the work ethos at Montefiore and the role of the core competencies and milestones in residency education are included. Finally, a broader component of the onboarding gives the incoming residents a social welcome to our area, including key information about living in the area surrounding Montefiore. The program has been well received by our residents for whom the content has helped to boost confidence when starting. We feel that the program is helpful in ensuring that all incoming residents start having received the same baseline didactic content. Transmitting this didactic content via onboarding allows our residents to begin the work of learning pathology immediately, rather than spending the first weeks of residency covering remedial content such as basic histology. Such a program may be useful to other pathology residencies, most of whom have residents from a range of backgrounds and whose prior exposure to pathology may be limited.

The Pathologist Workforce in the United States: II. An Interactive Modeling Tool for Analyzing Future Qualitative and Quantitative Staffing Demands for Services

CONTEXT

Pathologists are physicians who make diagnoses based on interpretation of tissue and cellular specimens (surgical/cytopathology, molecular/genomic pathology, autopsy), provide medical leadership and consultation for laboratory medicine, and are integral members of their institutions' interdisciplinary patient care teams.

OBJECTIVE

To develop a dynamic modeling tool to examine how individual factors and practice variables can forecast demand for pathologist services.

DESIGN

Build and test a computer-based software model populated with data from surveys and best estimates about current and new pathologist efforts.

RESULTS

Most pathologists' efforts focus on anatomic (52%), laboratory (14%), and other direct services (8%) for individual patients. Population-focused services (12%) (eg, laboratory medical direction) and other professional responsibilities (14%) (eg, teaching, research, and hospital committees) consume the rest of their time. Modeling scenarios were used to assess the need to increase or decrease efforts related globally to the Affordable Care Act, and specifically, to genomic medicine, laboratory consolidation, laboratory medical direction, and new areas where pathologists' expertise can add value.

CONCLUSIONS

Our modeling tool allows pathologists, educators, and policy experts to assess how various factors may affect demand for pathologists' services. These factors include an aging population, advances in biomedical technology, and changing roles in capitated, value-based, and team-based medical care systems. In the future, pathologists will likely have to assume new roles, develop new expertise, and become more efficient in practicing medicine to accommodate new value-based delivery models.

Visualization of podocyte substructure with structured illumination microscopy (SIM): a new approach to nephrotic disease

A detailed microscopic analysis of renal podocyte substructure is essential to understand and diagnose nephrotic kidney disease. Currently only time consuming electron microscopy (EM) can resolve this substructure. We used structured illumination microscopy (SIM) to examine frozen sections of renal biopsies stained with an immunofluorescence marker for podocin, a protein localized to the perimeter of the podocyte foot processes and compared them with EM in both normal and nephrotic disease biopsies. SIM images of normal glomeruli revealed curvilinear patterns of podocin densely covering capillary walls similar to podocyte foot processes seen by EM. Podocin staining of all nephrotic disease biopsies were significantly different than normal, corresponding to and better visualizing effaced foot processes seen by EM. The findings support the first potential use of SIM in the diagnosis of nephrotic disease.

An Innovative Interactive Modeling Tool to Analyze Scenario-Based Physician Workforce Supply and Demand

Effective physician workforce management requires that the various organizations comprising the House of Medicine be able to assess their current and future workforce supply. This information has direct relevance to funding of graduate medical education. We describe a dynamic modeling tool that examines how individual factors and practice variables can be used to measure and forecast the supply and demand for existing and new physician services. The system we describe, while built to analyze the pathologist workforce, is sufficiently broad and robust for use in any medical specialty. Our design provides a computer-based software model populated with data from surveys and best estimates by specialty experts about current and new activities in the scope of practice. The model describes the steps needed and data required for analysis of supply and demand. Our modeling tool allows educators and policy makers, in addition to physician specialty organizations, to assess how various factors may affect demand (and supply) of current and emerging services. Examples of factors evaluated include types of professional services (3 categories with 16 subcategories), service locations, elements related to the Patient Protection and Affordable Care Act, new technologies, aging population, and changing roles in capitated, value-based, and team-based systems of care. The model also helps identify where physicians in a given specialty will likely need to assume new roles, develop new expertise, and become more efficient in practice to accommodate new value-based payment models.

Fibroblasts in Head and Neck Squamous Cell Carcinoma Associated With Perineural Invasion Have High-Level Nuclear Yes-Associated Protein (YAP) Expression

We retrospectively studied the expression of Yes-associated protein (YAP) using immunohistochemical staining in 10 cases of head and neck squamous cell carcinoma with associated perineural invasion. We find that fibroblasts in areas associated with perineural invasion show higher levels of nuclear YAP compared to fibroblasts in the stroma of normal mucosa, with a median cell count of 35.4 per high-power field in the former and 3.9 in the latter. No differences were observed between the expression of YAP phosphorylated at Ser127 in the tumoral stroma compared to that in the normal mucosa, with a median cell count expression of 4.9 in the former versus 5.0 in the latter. Therefore, a strong and increased nuclear YAP expression in fibroblasts associated with perineural invasion in head and neck squamous cell carcinoma suggests that YAP-mediated transcription programs in these fibroblasts may contribute to perineural invasion.

Abstract 185: MicroRNA-375 suppresses extracellular matrix degradation and invadopodial activity in head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) is a highly invasive cancer having an association with locoregional recurrence and lymph node metastasis. We previously reported that patients with lower microRNA-375 (miR-375) tumor:normal expression levels showed significantly decreased disease-specific survival, increased locoregional recurrence and distant metastasis. We also previously described that HNSCC cells with increased miR-375 showed significantly diminished invasion in vitro. The ability of cancer cells to degrade extracellular matrix (ECM) through secreted and membrane-bound proteases allows local invasion into the surrounding stroma, as well as possible metastasis. Invadopodia are specialized actin-rich structures, which mediate ECM degradation. Our objective was to determine whether elevated miR-375 expression in HNSCC cells also affects invadopodia formation and activity.

For the evaluation of the matrix degradation properties of UMSCC1 and OSC19 cell lines, an invadopodial matrix degradation assay was used. Western blot analyses were conducted to measure the total protein levels of selected invadopodia-associated proteins. The tyrosine phosphorylation states of cortactin were evaluated by immunoprecipitation experiments. For the detection of levels of secreted proteases in the conditioned cell growth medium, Human Protease Arrays were used. Quantitative RT-PCR measurements were used to evaluate the mRNA expression levels of the commonly regulated proteases.

We observed that the HNSCC cell lines with elevated miR-375 expression showed significant reductions in ECM degradation. We further identified that HNSCC cells expressing increased miR-375 expression had significantly suppressed amounts of mature invadopodia, although the levels of invadopodium precursors were not significantly altered. We determined that increased miR-375 expression in the HNSCC cell lines did not reduce cellular levels of invadopodia components, such as Tks5, cortactin and fascin. We also did not observe significant alterations to the tyrosine phosphorylation states of cortactin in the HNSCC cell lines. However, we found that the HNSCC cells with higher miR-375 expression had significant reductions in the mRNA expression and secreted levels of specific proteases, including Kallikrein 6, Kallikrein 10, and MMP-9.

In summary, we have extended our understanding of the impact of miR-375 expression levels on HNSCC invasion. We demonstrated that increased miR-375 expression in HNSCC cells reduced ECM degradation and invadopodial activity. Our data suggest that reduced miR-375 expression in HNSCC patients can contribute to the invasive properties of head and neck cancer through increased invadopodial activity.

Citation Format: Lizandra Jimenez, Ved P. Sharma, John S. Condeelis, Thomas M. Harris, Thomas J. Ow, Michael B. Prystowsky, Geoffrey J. Childs, Jeffrey E. Segall. MicroRNA-375 suppresses extracellular matrix degradation and invadopodial activity in head and neck squamous cell carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 185. doi:10.1158/1538-7445.AM2015-185

MicroRNA-375 Suppresses Extracellular Matrix Degradation and Invadopodial Activity in Head and Neck Squamous Cell Carcinoma

CONTEXT

Head and neck squamous cell carcinoma (HNSCC) is a highly invasive cancer with an association with locoregional recurrence and lymph node metastasis. We have previously reported that low microRNA-375 (miR-375) expression levels correlate with poor patient survival, increased locoregional recurrence, and distant metastasis. Increasing miR-375 expression in HNSCC cell lines to levels found in normal cells results in suppressed invasive properties. HNSCC invasion is mediated in part by invadopodia-associated degradation of the extracellular matrix.

OBJECTIVE

To determine whether elevated miR-375 expression in HNSCC cell lines also affects invadopodia formation and activity.

DESIGN

For evaluation of the matrix degradation properties of the HNSCC lines, an invadopodial matrix degradation assay was used. The total protein levels of invadopodia-associated proteins were measured by Western blot analyses. Immunoprecipitation experiments were conducted to evaluate the tyrosine phosphorylation state of cortactin. Human protease arrays were used for the detection of the secreted proteases. Quantitative real time-polymerase chain reaction measurements were used to evaluate the messenger RNA (mRNA) expression of the commonly regulated proteases.

RESULTS

Increased miR-375 expression in HNSCC cells suppresses extracellular matrix degradation and reduces the number of mature invadopodia. Higher miR-375 expression does not reduce cellular levels of selected invadopodia-associated proteins, nor is tyrosine phosphorylation of cortactin altered. However, HNSCC cells with higher miR-375 expression had significant reductions in the mRNA expression levels and secreted levels of specific proteases.

CONCLUSIONS

MicroRNA-375 regulates invadopodia maturation and function potentially by suppressing the expression and secretion of proteases.

Cancer as the Disintegration of Robustness: Population-Level Variance in Gene Expression Identifies Key Differences Between Tobacco- and HPV-Associated Oropharyngeal Carcinogenesis

CONTEXT

Oropharyngeal squamous cell carcinoma is associated both with tobacco use and with human papillomavirus (HPV) infection. It is argued that carcinogen-driven tumorigenesis is a distinct disease from its virally driven counterpart. We hypothesized that tumorigenesis is the result of a loss of genotypic robustness resulting in an increase in phenotypic variation in tumors compared with adjacent histologically normal tissues, and that carcinogen-driven tumorigenesis results in greater variation than its virally driven counterpart.

OBJECTIVES

To examine the loss of robustness in carcinogen-driven and virally driven oropharyngeal squamous cell carcinoma samples, and to identify potential pathways involved.

DESIGN

We used coefficients of variation for messenger RNA and microRNA expression to measure the loss of robustness in oropharyngeal squamous cell carcinoma samples. Tumors were compared with matched normal tissues, and were further categorized by HPV and patient smoking status. Weighted gene coexpression networks were constructed for genes with highly variable expression among the HPV⁻ tumors from smokers.

RESULTS

We observed more genes with variable messenger RNA expression in tumors compared with normal tissues, regardless of HPV and smoking status, and more microRNAs with variable expression in HPV⁻ and HPV⁺ tumors from smoking patients than from nonsmokers. For both the messenger RNA and microRNA data, we observed more variance among HPV⁻ tumors from smokers compared with HPV⁺ tumors from nonsmokers. The gene coexpression network construction highlighted pathways that have lost robustness in carcinogen-induced tumors but appear stable in virally induced tumors.

CONCLUSIONS

Using coefficients of variation and coexpression networks, we identified multiple altered pathways that may play a role in carcinogen-driven tumorigenesis.

Epigenetic changes in the CDKN2A locus are associated with differential expression of P16INK4A and P14ARF in HPV-positive oropharyngeal squamous cell carcinoma

Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is recognized as a distinct disease entity associated with improved survival. DNA hypermethylation profiles differ significantly by HPV status suggesting that a specific subset of methylated CpG loci could give mechanistic insight into HPV-driven OPSCC. We analyzed genome-wide DNA methylation of primary tumor samples and adjacent normal mucosa from 46 OPSCC patients undergoing treatment at Montefiore Medical Center, Bronx, NY using the Illumina HumanMethylation27 beadchip. For each matched tissue set, we measured differentially methylated CpG loci using a change in methylation level (M value). From these analyses, we identified a 22 CpG loci panel for HPV+ OPSCC that included four CDKN2A loci downstream of the p16(INK4A) and p14(ARF) transcription start sites. This panel was significantly associated with overall HPV detection (P < 0.05; ROC area under the curve = 0.96, 95% CI: 0.91-1.0) similar to the subset of four CDKN2A-specific CpG loci (0.90, 95% CI: 0.82-0.99) with equivalence to the full 22 CpG panel. DNA hypermethylation correlated with a significant increase in alternative open reading frame (ARF) expression in HPV+ OPSCC primary tumors, but not to the other transcript variant encoded by the CDKN2A locus. Overall, this study provides evidence of epigenetic changes to the downstream region of the CDKN2A locus in HPV+ oropharyngeal cancer that are associated with changes in expression of the coded protein products.

Proteomic analysis of oral cavity squamous cell carcinoma specimens identifies patient outcome-associated proteins

CONTEXT

Global proteomic analysis of oral cavity squamous cell carcinoma was performed to identify changes that reflect patient outcomes.

OBJECTIVES

To identify differentially expressed proteins associated with patient outcomes and to explore the use of imaging mass spectrometry as a clinical tool to identify clinically relevant proteins.

DESIGN

Two-dimensional separation of digested peptides generated from 43 specimens with high-resolution mass spectrometry identified proteins associated with disease-specific death, distant metastasis, and loco-regional recurrence. RNA expressions had been correlated to protein levels to test transcriptional regulation of clinically relevant proteins. Imaging mass spectrometry explored an alternative platform for assessing clinically relevant proteins that would complement surgical pathologic diagnosis.

RESULTS

Seventy-two peptide features were found to be associated with 3 patient outcomes: disease-specific death (9), distant metastasis (16), and loco-regional recurrence (39); 8 of them were associated with multiple outcomes. Functional ontology revealed major changes in cell adhesion and calcium binding. Thirteen RNAs showed strong correlation with their encoded proteins, implying transcriptional control. Reduction of DSP, PKP1, and TRIM29 was associated with significantly shorter time to onset of distant metastasis. Reduction of PKP1 and TRIM29 correlated with poorer disease-specific survival. Additionally, S100A8 and S100A9 reductions were verified for their association with poor prognosis using imaging mass spectrometry, a platform more adaptable for use with surgical pathology.

CONCLUSIONS

Using global proteomic analysis, we have identified proteins associated with clinical outcomes. The list of clinically relevant proteins observed will provide a means to develop clinical assays for prognosis and optimizing treatment selection.

Abstract 1452: MicroRNA-375 impairs head and neck squamous cell carcinoma invasion by suppressing invadopodia activity

Head and neck squamous cell carcinoma (HNSCC) is a highly invasive cancer, with a five-year survival rate of around 50%. Our goal is to improve patient outcome through understanding the mechanisms determining HNSCC invasiveness. Our research group previously reported that miR-375 expression levels correlate with patient survival, recurrence and distant metastasis. We have previously observed diminished HNSCC invasion in vitro correlates with increased miR-375 expression. To assess whether the miR-375 over-expressing transductant lines have reduced matrix degradation properties, a fluorescent matrix degradation assay was used. We have observed that miR-375 over-expression in HNSCC cells suppresses extracellular matrix degradation. We further determined whether miR-375 over-expressing cells show reduced invadopodium formation and maturation. We observed miR-375 expression in HNSCC cell lines reduces the number of mature invadopodia, but does not affect levels of invadopodium precursors. We examined the phosphorylation and total levels of key invadopodia components (Tks5 and cortactin) to determine whether changes in regulation or expression of these components may lead impaired matrix degradation properties. We determined that miR-375 expression in HNSCC cell lines does not reduce cellular levels of cortactin and Tks5, nor is tyrosine phosphorylation of cortactin altered. To identify candidate proteins regulated by miR-375, we are utilizing stable isotope labeling of cells in cell culture (SILAC). Candidate target proteins are being validated as targets of miR-375 and tested for involvement in the diminished invasive properties of HNSCC as a result of miR-375 expression. In conclusion, increased miR-375 expression may suppress the invasive properties of HNSCC through diminished invadopodia activity.

Citation Format: Lizandra Jimenez, Ved P. Sharma, Jihyeon Lim, Ruth Angeletti, John Condeelis, Thomas Harris, Michael B. Prystowsky, Geoffrey Childs, Jeffrey E. Segall. MicroRNA-375 impairs head and neck squamous cell carcinoma invasion by suppressing invadopodia activity. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1452. doi:10.1158/1538-7445.AM2014-1452

Abstract 3158: Identifying novel genes critical to invasion in head and neck squamous cell carcinoma

Oral squamous cell carcinomas (OSCC) have a poor patient prognosis, which is attributed to their invasive nature. Our goal was to identify specific genes that are important in OSCC invasion utilizing genome-wide expression data generated from HNSCC patient tumor samples of varying degrees of invasiveness. Invasion was assessed using the histological parameter pattern of invasion (POI), which describes the manner in which tumor cells infiltrate the normal tissue at the tumor-host interface. POI was used to categorize tumor resections into five types (1-5), type 5 being the most invasive with a “widely dispersed pattern of tumor infiltrate” and correlated significantly with the appearance of local recurrence and decreased overall survival of the patients after surgery. Global gene expression data was acquired from analysis of the surgical resections from 9 OSCC patient samples collected at Montefiore Medical Center between 2001 and 2008. Tumor cell-enriched cores from FFPE samples were used to generate global gene expression data using the Illumina® WG-DASL array to compare gene expression in four tumors that were WPOI type 5 and five tumors that were WPOI type 3. RNA extracted from flash-frozen tumor samples following surgical resection from the same patients was used to obtain global gene expression data using the Illumina® HumanHT-12 v4 Expression BeadChip. Candidate genes were assessed using in vitro invasion assays following siRNA knockdown of specific gene expression using siGENOME smart pools from Dharmacon. When both gene expression datasets were analyzed, we identified 104 genes that were overexpressed at least 1.5-fold in the WPOI type 5 tumors compared to the less invasive WPOI type 3 tumors. Fifty genes were initially tested based on functional criteria. In our initial screen, 16 of these genes showed a significant reduction in tumor cell invasion when expression was knocked down by siRNA in an OSCC cell line. The top gene from the screen, APOE, is now being further examined to determine a mechanistic explanation for its effect on invasion. Downstream signaling of APOE receptors and how this may interact with invasion are currently being assessed. This initial screen of global gene expression data in combination with pattern of invasion has revealed APOE as a novel gene that may play a critical role in OSCC invasion.

Citation Format: Sangeeta K. Jayakar, Olivier D. Loudig, Margaret Brandwein-Gensler, Ryung S. Kim, Michael B. Prystowsky, Jeffrey E. Segall, Thomas J. Belbin. Identifying novel genes critical to invasion in head and neck squamous cell carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3158. doi:10.1158/1538-7445.AM2014-3158

National standards in pathology education: developing competencies for integrated medical school curricula

CONTEXT

Medical school education has evolved from department-specific memorization of facts to an integrated curriculum presenting knowledge in a contextual manner across traditional disciplines, integrating information, improving retention, and facilitating application to clinical practice. Integration occurs throughout medical school using live data-sharing technologies, thereby providing the student with a framework for lifelong active learning. Incorporation of educational teams during medical school prepares students for team-based patient care, which is also required for pay-for-performance models used in accountable care organizations.

OBJECTIVE

To develop learning objectives for teaching pathology to medical students. Given the rapid expansion of basic science knowledge of human development, normal function, and pathobiology, it is neither possible nor desirable for faculty to teach, and students to retain, this vast amount of information. Courses teaching the essentials in context and engaging students in the learning process enable them to become lifelong learners. An appreciation of pathobiology and the role of laboratory medicine underlies the modern practice of medicine. As such, all medical students need to acquire 3 basic competencies in pathology: an understanding of disease mechanisms, integration of mechanisms into organ system pathology, and application of pathobiology to diagnostic medicine.

DESIGN

We propose the development of 3 specific competencies in pathology to be implemented nationwide, aimed at disease mechanisms/processes, organ system pathology, and application to diagnostic medicine. Each competency will include learning objectives and a means to assess acquisition, integration, and application of knowledge. The learning objectives are designed to be a living document managed (curated) by a group of pathologists representing Liaison Committee on Medical Education-accredited medical schools nationally.

CONCLUSIONS

Development of a coherent set of learning objectives will assist medical students nationally to gain the basic competencies in pathology necessary for clinical practice. Having national standards for competencies preserves schools' independence in specific curriculum design while assuring all students meet the evolving needs of medical practice.

A team-based approach to autopsy education: integrating anatomic and clinical pathology at the rotation level

CONTEXT

Pathology residency training programs should aim to teach residents to think beyond the compartmentalized data of specific rotations and synthesize data in order to understand the whole clinical picture when interacting with clinicians.

OBJECTIVE

To test a collaborative autopsy procedure at Montefiore Medical Center (Bronx, New York), linking residents and attending physicians from anatomic and clinical pathology in the autopsy process from the initial chart review to the final report. Residents consult with clinical pathology colleagues regarding key clinical laboratory findings during the autopsy. This new procedure serves multiple functions: creating a team-based, mutually beneficial educational experience; actively teaching consultative skills; and facilitating more in-depth analysis of the clinical laboratory findings in autopsies.

DESIGN

An initial trial of the team-based autopsy system was done from November 2010 to December 2012. Residents were then surveyed via questionnaire to evaluate the frequency and perceived usefulness of clinical pathology autopsy consultations.

RESULTS

Senior residents were the most frequent users of clinical pathology autopsy consultation. The most frequently consulted services were microbiology and chemistry. Eighty-nine percent of the residents found the clinical pathology consultation to be useful in arriving at a final diagnosis and clinicopathologic correlation.

CONCLUSION

The team-based autopsy is a novel approach to integration of anatomic and clinical pathology curricula at the rotation level. Residents using this approach develop a more holistic approach to pathology, better preparing them for meaningful consultative interaction with clinicians. This paradigm shift in training positions us to better serve in our increasing role as arbiters of outcomes measures in accountable care organizations.