Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases

BACKGROUND

Vision loss secondary to aesthetic filler treatment is a rare but disastrous complication.

OBJECTIVES

The aim was to update the published cases of blindness after filler injection that have occurred since our group published reviews of 98 cases in 2015 and an additional 48 cases in 2019.

METHODS

A literature review was performed to identify all cases of visual complications caused by filler injection published between September 2018 and March 2023. The cases were analyzed independently and in combination with previously reviewed cases. Analyses are based on the number of cases with data available.

RESULTS

365 new cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nose (40.6%), forehead (27.7%), and glabella (19.0%). The filler injected was hyaluronic acid in 79.6% of cases. The most common associated signs were ptosis (56.2%), ophthalmoplegia (44.1%), pain (31.2%), and skin changes (73.2%). Stroke-like features were seen in 19.2% of cases. Of the cases reporting visual outcomes (318), 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery. Partially preserved visual acuity at onset was a significant predictor of visual improvement (p < .001). The three most common treatments were subcutaneous hyaluronidase at or near the filler site (70.1%), systemic steroids (57.3%), and intra-arterial thrombolytic therapy (56.0%). No treatments were significantly associated with visual improvement (p > .05).

CONCLUSIONS

Although blindness and stroke from fillers is a rare complication, practitioners who inject filler should have a thorough knowledge of prevention and management strategies.

The Mutographs biorepository: A unique genomic resource to study cancer around the world

Large-scale biorepositories and databases are essential to generate equitable, effective, and sustainable advances in cancer prevention, early detection, cancer therapy, cancer care, and surveillance. The Mutographs project has created a large genomic dataset and biorepository of over 7,800 cancer cases from 30 countries across five continents with extensive demographic, lifestyle, environmental, and clinical information. Whole-genome sequencing is being finalized for over 4,000 cases, with the primary goal of understanding the causes of cancer at eight anatomic sites. Genomic, exposure, and clinical data will be publicly available through the International Cancer Genome Consortium Accelerating Research in Genomic Oncology platform. The Mutographs sample and metadata biorepository constitutes a legacy resource for new projects and collaborations aiming to increase our current research efforts in cancer genomic epidemiology globally.

Evaluating enteric methane emissions within a herd of genetically divergent grazing dairy cows

Enteric methane (CH4) emissions of 3 genetic groups (GG) of dairy cows were recorded across the grazing season (early March to late October). The 3 GG were (1) high economic breeding index (EBI) Holstein-Friesian (HF) representative of the top 1% of dairy cows in Ireland at the time of the study (elite), (2) national average (NA) EBI, which were representative of the average HF dairy cow in Ireland, and (3) purebred Jersey (JE) cows. Enteric CH4 was recorded using GreenFeed technology. Seasonal variation in CH4 was observed, with the lowest daily CH4 emissions and CH4 expressed per unit of dry matter intake occurring in spring (253 g/d and 15.56 g/kg, respectively), intermediate in summer (303 g/d and 18.26 g/kg, respectively), and greatest in autumn (324 g/d and 19.80 g/kg, respectively). Seasonal variation was also observed in the proportion of gross energy intake converted to CH4 (Ym); in the spring the Ym was lowest at 0.046, increasing to 0.053 and 0.058 in the summer and autumn, respectively. There was no difference in daily CH4 between the elite and NA, whereas JE had lower CH4 emissions compared with the elite. When expressed per unit of milk solids (fat + protein yield; MS), the elite and JE produced 6.8% and 9.7% less CH4 per kilogram of MS, respectively, compared with NA. There was no difference between the GG for CH4 per unit of DMI or the Ym. This research emphasizes the variation in CH4 emissions across the grazing season and among cows of differing genetic merit for CH4 emission intensities but not for CH4 per unit of DMI or the Ym.

Organic Electronic Platform for Real-Time Phenotypic Screening of Extracellular-Vesicle-Driven Breast Cancer Metastasis

Tumor-derived extracellular vesicles (TEVs) induce the epithelial-to-mesenchymal transition (EMT) in nonmalignant cells to promote invasion and cancer metastasis, representing a novel therapeutic target in a field severely lacking in efficacious antimetastasis treatments. However, scalable technologies that allow continuous, multiparametric monitoring for identifying metastasis inhibitors are absent. Here, the development of a functional phenotypic screening platform based on organic electrochemical transistors (OECTs) for real-time, noninvasive monitoring of TEV-induced EMT and screening of antimetastatic drugs is reported. TEVs derived from the triple-negative breast cancer cell line MDA-MB-231 induce EMT in nonmalignant breast epithelial cells (MCF10A) over a nine-day period, recapitulating a model of invasive ductal carcinoma metastasis. Immunoblot analysis and immunofluorescence imaging confirm the EMT status of TEV-treated cells, while dual optical and electrical readouts of cell phenotype are obtained using OECTs. Further, heparin, a competitive inhibitor of cell surface receptors, is identified as an effective blocker of TEV-induced EMT. Together, these results demonstrate the utility of the platform for TEV-targeted drug discovery, allowing for facile modeling of the transient drug response using electrical measurements, and provide proof of concept that inhibitors of TEV function have potential as antimetastatic drug candidates.

Development and validation of a novel risk prediction algorithm to estimate 10-year risk of oesophageal cancer in primary care: prospective cohort study and evaluation of performance against two other risk prediction models

Background

Methods to identify patients at increased risk of oesophageal cancer are needed to better identify those for targeted screening. We aimed to derive and validate novel risk prediction algorithms (CanPredict) to estimate the 10-year risk of oesophageal cancer and evaluate performance against two other risk prediction models.

Methods

Prospective open cohort study using routinely collected data from 1804 QResearch® general practices. We used 1354 practices (12.9 M patients) to develop the algorithm. We validated the algorithm in 450 separate practices from QResearch (4.12 M patients) and 355 Clinical Practice Research Datalink (CPRD) practices (2.53 M patients). The primary outcome was an incident diagnosis of oesophageal cancer found in GP, mortality, hospital, or cancer registry data. Patients were aged 25-84 years and free of oesophageal cancer at baseline. Cox proportional hazards models were used with prediction selection to derive risk equations. Risk factors included age, ethnicity, Townsend deprivation score, body mass index (BMI), smoking, alcohol, family history, relevant co-morbidities and medications. Measures of calibration, discrimination, sensitivity, and specificity were calculated in the validation cohorts.

Finding

There were 16,384 incident cases of oesophageal cancer in the derivation cohort (0.13% of 12.9 M). The predictors in the final algorithms were: age, BMI, Townsend deprivation score, smoking, alcohol, ethnicity, Barrett's oesophagus, hiatus hernia, H. pylori infection, use of proton pump inhibitors, anaemia, lung and blood cancer (with breast cancer in women). In the QResearch validation cohort in women the explained variation (R2) was 57.1%; Royston's D statistic 2.36 (95% CI 2.26-2.46); C statistic 0.859 (95% CI 0.849-0.868) and calibration was good. Results were similar in men. For the 20% at highest predicted risk, the sensitivity was 76%, specificity was 80.1% and the observed risk at 10 years was 0.76%. The results from the CPRD validation were similar.

Interpretation

We have developed and validated a novel prediction algorithm to quantify the absolute risk of oesophageal cancer. The CanPredict algorithms could be used to identify high risk patients for targeted screening.

Funding

Innovate UK and CRUK (grant 105857).

Genome-wide analyses characterize shared heritability among cancers and identify novel cancer susceptibility regions

BACKGROUND

The shared inherited genetic contribution to risk of different cancers is not fully known. In this study, we leverage results from 12 cancer genome-wide association studies (GWAS) to quantify pairwise genome-wide genetic correlations across cancers and identify novel cancer susceptibility loci.

METHODS

We collected GWAS summary statistics for 12 solid cancers based on 376 759 participants with cancer and 532 864 participants without cancer of European ancestry. The included cancer types were breast, colorectal, endometrial, esophageal, glioma, head and neck, lung, melanoma, ovarian, pancreatic, prostate, and renal cancers. We conducted cross-cancer GWAS and transcriptome-wide association studies to discover novel cancer susceptibility loci. Finally, we assessed the extent of variant-specific pleiotropy among cancers at known and newly identified cancer susceptibility loci.

RESULTS

We observed widespread but modest genome-wide genetic correlations across cancers. In cross-cancer GWAS and transcriptome-wide association studies, we identified 15 novel cancer susceptibility loci. Additionally, we identified multiple variants at 77 distinct loci with strong evidence of being associated with at least 2 cancer types by testing for pleiotropy at known cancer susceptibility loci.

CONCLUSIONS

Overall, these results suggest that some genetic risk variants are shared among cancers, though much of cancer heritability is cancer-specific and thus tissue-specific. The increase in statistical power associated with larger sample sizes in cross-disease analysis allows for the identification of novel susceptibility regions. Future studies incorporating data on multiple cancer types are likely to identify additional regions associated with the risk of multiple cancer types.

OGC O02 The prognostic effect of pathological lymph node regression after neoadjuvant chemotherapy for oesophageal adenocarcinoma – a multicentre study

Background

The prognostic benefits of primary tumour and lymph node (LN) downstaging after neoadjuvant chemotherapy for oesophageal adenocarcinoma are well described. Pathological primary tumour regression grading (TRG) is widely used in the assessment of response to chemotherapy and has been shown to have prognostic value in this patient group. However, there is a lack of robust evidence regarding the prognostic effect of pathological response in LN despite emerging evidence of a discrepancy, up to 25% of patients in some studies, between TRG in the primary tumour and response in regional LNs. Although primary tumour regression is routinely documented as part of the standard pathological reporting of oesophagectomy specimens, LN regression is generally overlooked despite it's potential prognostic value. The aim of this study was to investigate the relationship between pathological response in LN, tumour recurrence and survival.

Methods

Multicentre cohort study including 763 patients with oesophageal adenocarcinoma treated with neoadjuvant chemotherapy followed by surgery at Guy's and St Thomas’ NHS Foundation Trust (NHS-FT), The Royal Marsden NHS-FT, University Hospitals Birmingham NHS-FT, University Hospital Southampton NHS-FT and Belfast Health and Social Care Trust. Tumour regression was assessed in the primary tumour (as described by Mandard) and, retrospectively, in LNs retrieved from oesophagectomy specimens. LN were graded according to the proportion of fibrosis and residual tumour providing a LN regression score (LNRS). LNRS 1, complete response; LNRS 2, &lt; 10% remaining tumour; LNRS 3, 10–50% remaining tumour; LNRS 4, &gt; 50% viable tumour; LNRS 5, no evidence of response. Regression was defined as a LNRS of 1–3. Patients were classified as LN negative (no evidence of tumour or regression in any LN), complete LN-responders (evidence of regression ≥1 LN, no residual tumour in any LN), partial LN-responders (evidence of regression ≥1 LN with residual tumour ≥1 LN) and LN non-responders (no or minimal regression in any LN). Survival analysis was performed using multivariable Cox regression providing hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, gender, chemotherapy regimen, clinical stage, tumour grade, lympho-vascular invasion and primary tumour response.

Results

Mean age was 63 years with the majority male (86.2%). In total, 17,930 LN from 763 patients were analysed for evidence of response to chemotherapy. Overall, 243 (31.8%) patients were classified as LN negative, 62 (8.1%) as complete LN-responders, 155 (20.3%) as partial LN-responders and 303 (39.7%) as LN non-responders. Less than half (322/763, 42.2%) of patients demonstrated a pathological response in the primary tumour (Mandard score 1–3). Some patients had a LN response in the absence of a response in the primary tumour (97/431, 22.5%). Multivariable Cox regression survival analysis demonstrated improved overall survival in complete LN-responders (HR 0.37 95% CI 0.24–0.58), partial LN-responders (HR 0.70 95% CI 0.55–0.89) and LN negative patients (HR 0.34 95% CI 0.26–0.44) compared to LN non-responders. Similar results were observed for disease-free survival (complete LN-responders, HR 0.34 95% CI 0.22–0.53; partial LN-responders, HR 0.74 95% CI 0.58–0.93; LN negative, HR 0.33 95% CI 0.25–0.42). Rates of tumour recurrence were lower in patients who demonstrated a LN response or had negative LN (LN negative 23.0% vs complete LN-responders 19.4% vs partial LN-responders 50.3% vs LN non-responders 66.7%, p&lt;0.001).

Conclusions

In this cohort of patients with oeosphageal adenocarcinoma treated with neoadjuvant chemotherapy prior to surgical resection, LN regression was a strong predictive factor for better survival. This relationship was independent of primary tumour response, which was discordant in a significant number of patients. Complete LN-responders had equivalent survival to those with negative LN. Complete and partial LN-responders had better survival than LN non-responders. Evaluation and documentation of LN regression should be considered during the standard pathological reporting of oesophagectomy specimens.

OGC P04 Spatial sampling of Barrett's oesophagus reveals that tumour heterogeneity is not a useful predictor of progression to cancer

Background

Intra-tumour heterogeneity has been well-described in oesophageal adenocarcinoma and Barrett's oesophagus (BE) segments also consist of multiple clones (groups of cells which share mutations). In BE there is some suggestion that the number of individual genetic clones within the segment and the diversity of the segment can be predictors of progression to cancer. However, this was with pre- whole genome sequencing (WGS) methods. In this study we consider the detailed spatial maps of ten patients with different disease trajectories, using WGS, to determine the heterogeneity and correlate it with their progression.

Methods

We performed WGS (50x) on 35 high-quality, frozen, endoscopic biopsies taken spatially from ten cases (8 males, 2 females, median age 75 (range 31–83). This included 4 long-term non-dysplastic (ND) patients with long BE segments and 6 patients with dysplasia. We used the copy number and purity information (from Battenberg) and the somatic mutation clustering information (from DPClust) to infer the clonal and subclonal architecture of individual biopsies and looked at the spatial relationship between biopsies within the segment.

Results

In both ND and dysplastic BE we saw cells with unrelated patterns of mutations, or clones, implying completely separate origins for different parts of the segments. This suggests independent or parallel evolution. There was a higher burden of shared (truncal) mutations in the dysplastic biopsies (p=0.049), indicating a more recent clonal sweep with some clones being outcompeted. Dysplastic samples had more subclonal copy number aberrations and more clonal driver mutations. In addition, most of the driver gene alterations in the dysplastic trees occurred early, whereas CDKN2A, the p16 locus, was the only truncal mutation found on the ND clone trees. We did not find the number of clones or the diversity of the segment to differ between the two groups.

Conclusions

Each individual patient showed complex, distinct genomic features and evolutionary trajectories. Some cases arose from a single ancestral clone, while others had few shared mutational variants suggesting multiple clones. Importantly, in this sample of cases we did not see any trend that the clonal diversity or number of clones correlated with progression to cancer. This is different to previous studies and highlights the importance of multiple sampling to determine the propensity for cancer progression even if the samples look similar histologically.

295 SPEP IT UP! DEVELOPING AN ALGORITHM FOR ABNORMAL SERUM PLASMA ELECTROPHORESIS RESULTS IN HIP FRACTURE PATIENTS

Background

Hip fracture is a common manifestation of osteoporosis. All patients who sustain a hip fracture should receive a specialist bone health assessment, including Serum Protein Electrophoresis (SPEP) because plasma cell disorders such as multiple myeloma are an important differential diagnosis. SPEP results can be challenging to interpret without training and expertise. We aimed to review the proportion of abnormal SPEP results in hip fracture patients and used a newly developed algorithm to assess urgency of referral to haematology.

Methods

The Orthogeriatrics and Haematology teams collaborated to develop an algorithm to help facilitate decision making in hip fracture patients with abnormal SPEP results. A retrospective study was then conducted using data from the local Hip Fracture Database from Quarters 1 and 3 in 2020, and the hospital electronic laboratory system. The algorithm was used to retrospectively determine which patients warranted haematology review. The electronic appointment system was then accessed to review whether those who warranted haematology referral had appointments on the system.

Results

Of 270 hip fracture presentations, 19 duplicate records were excluded. Five patients had no data and three patients had passed away. Of the remaining 243 patients, 193 (79.42%) had SPEP’s sent. Abnormalities were detected in 116 patients (47.74%). According to the SPEP referral pathway, two patients warranted routine referral and one patient required an urgent referral, none of whom appeared to have been referred to haematology. Two patients who did not warrant haematology referral were already under haematology for different conditions.

Conclusion

Not all patients who sustain acute osteoporotic fractures with an abnormal SPEP result require haematology referral. The need for an urgent or routine haematology can be guided by the SPEP result along with other clinical features. With the introduction of this pathway, it is proposed that all hip fracture patients will be triaged in a timely, appropriate, and consistent manner.

O086 Genomic analysis of response to neoadjuvant chemotherapy in oesophageal adenocarcinoma

Introduction

Oesophageal adenocarcinoma (OAC) is the ninth most common cancer worldwide with a mortality of over 500,000 deaths yearly. Neoadjuvant chemotherapy (NAC) followed by surgery is the standard of care (SOC) for locally advanced OAC. Although almost all patients receive chemotherapy as SOC, fewer than 20% obtain a clinically meaningful response and benefit before surgery. The OAC genome is complex and heterogeneous between patients, and it is not yet understood whether specific mutational patterns result in chemotherapy sensitivity or resistance.

Methods

To identify associations between genomic events and response to NAC in OAC, a comparative genomic analysis was performed in 65 patients using whole-genome sequencing. We defined response to NAC using Mandard Tumour Regression Grade TRG), with responders classified as TRG1-2 (n=27) and non-responders classified as TRG4- 5 (n=38).

Results

We report a higher non-synonymous mutation burden in responders (median 2.08/Mb vs 1.70/Mb, P=0.036) and elevated copy number variation (CNV) in non-responders (282 vs 136/patient, P&lt;0.001). We identified CNVs unique to each group, with cell cycle (CDKN2A, CCND1), c-Myc (MYC), RTK/PIK3 (KRAS, EGFR) and gastrointestinal differentiation (GATA6) pathway genes being specifically altered in non-responders. Of particular interest was the identification of the Neuron Navigator-3 (NAV3), a known tumour suppressor downstream of EGFR, which was mutated exclusively in 22% of non-responders.

Conclusion

We characterise genetic features and mutations that are uniquely associated with response to NAC. We envision a treatment pipeline that incorporates driver mutation profiling in OAC, combining response prediction with targeted therapies enhancing response to NAC and improving survival outcomes.

Take-home message

Developing a method of determining an OAC patient's response to neoadjuvant chemotherapy before treatment is administered is desperately needed and will improve patient outcome and quality of life. We identified a number of aberrations in the genome that were unique to non-responders to chemotherapy compared to responders, particularly a known tumour suppressor gene namely Neuron Navigator-3, suggesting that these events may contribute to chemoresistance in these patients. Our work characterises pre-existing genomic alterations that have potential as biomarkers for resistance or sensitivity to NAC.

Multiparametric High-Content Cell Painting Identifies Copper Ionophores as Selective Modulators of Esophageal Cancer Phenotypes

Esophageal adenocarcinoma is of increasing global concern due to increasing incidence, a lack of effective treatments, and poor prognosis. Therapeutic target discovery and clinical trials have been hindered by the heterogeneity of the disease, the lack of "druggable" driver mutations, and the dominance of large-scale genomic rearrangements. We have previously undertaken a comprehensive small-molecule phenotypic screen using the high-content Cell Painting assay to quantify the morphological response to a total of 19,555 small molecules across a panel of genetically distinct human esophageal cell lines to identify new therapeutic targets and small molecules for the treatment of esophageal adenocarcinoma. In this current study, we report for the first time the dose-response validation studies for the 72 screening hits from the target-annotated LOPAC and Prestwick FDA-approved compound libraries and the full list of 51 validated esophageal adenocarcinoma-selective small molecules (71% validation rate). We then focus on the most potent and selective hit molecules, elesclomol, disulfiram, and ammonium pyrrolidinedithiocarbamate. Using a multipronged, multitechnology approach, we uncover a unified mechanism of action and a vulnerability in esophageal adenocarcinoma toward copper-dependent cell death that could be targeted in the future.

Abstract PL01-03: From population to personalized prevention: Lessons from Barrett's esophagus

Cancer medicine is undergoing a radical shift away from a reactive approach in patients presenting with symptomatic disease towards a more proactive approach aimed at early diagnosis, including at the pre-cancerous stage. Oesophageal adenocarcinoma develops gradually from the pre-malignant condition Barrett’s oesophagus which presents an opportunity to radically improve outcomes from this highly aggressive cancer. Work to unravel the: clinical-demographic and inherited risk factors; the cell of origin of this disease; and the molecular landscape of Barrett’s samples over time and space, in patients with different outcomes, is shedding light on the disease pathogenesis. Our improved understanding of the disease can be used to develop novel approaches to risk-based population screening and personalised prevention. One emerging paradigm is a triage system that comprises a risk assessment, followed by targeted screening using novel non-endoscopic detection devices coupled with molecular biomarkers to identify individuals at high risk of invasive cancer needing monitoring or preventative treatment. In patients with a Barrett’s lesion undergoing monitoring, molecular strategies can further distinguish between those with indolent disease versus those likely to progress. As we redesign clinical pathways for this disease we must be sure to maximise patient and clinician acceptability, affordability and ease of access to a given technology while balancing the risks for over-diagnosis and over-treatment.

Citation Format: Rebecca Fitzgerald. From population to personalized prevention: Lessons from Barrett's esophagus [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 PL01-03.

Multitrait genetic association analysis identifies 50 new risk loci for gastro-oesophageal reflux, seven new loci for Barrett's oesophagus and provides insights into clinical heterogeneity in reflux diagnosis

OBJECTIVE

Gastro-oesophageal reflux disease (GERD) has heterogeneous aetiology primarily attributable to its symptom-based definitions. GERD genome-wide association studies (GWASs) have shown strong genetic overlaps with established risk factors such as obesity and depression. We hypothesised that the shared genetic architecture between GERD and these risk factors can be leveraged to (1) identify new GERD and Barrett's oesophagus (BE) risk loci and (2) explore potentially heterogeneous pathways leading to GERD and oesophageal complications.

DESIGN

We applied multitrait GWAS models combining GERD (78 707 cases; 288 734 controls) and genetically correlated traits including education attainment, depression and body mass index. We also used multitrait analysis to identify BE risk loci. Top hits were replicated in 23andMe (462 753 GERD cases, 24 099 BE cases, 1 484 025 controls). We additionally dissected the GERD loci into obesity-driven and depression-driven subgroups. These subgroups were investigated to determine how they relate to tissue-specific gene expression and to risk of serious oesophageal disease (BE and/or oesophageal adenocarcinoma, EA).

RESULTS

We identified 88 loci associated with GERD, with 59 replicating in 23andMe after multiple testing corrections. Our BE analysis identified seven novel loci. Additionally we showed that only the obesity-driven GERD loci (but not the depression-driven loci) were associated with genes enriched in oesophageal tissues and successfully predicted BE/EA.

CONCLUSION

Our multitrait model identified many novel risk loci for GERD and BE. We present strong evidence for a genetic underpinning of disease heterogeneity in GERD and show that GERD loci associated with depressive symptoms are not strong predictors of BE/EA relative to obesity-driven GERD loci.

Submental Fat Reduction Using Sequential Treatment Approach with Cryolipolysis and ATX‐101

Background

Submental fat (SMF) detracts from facial aesthetics and negatively impacts self‐image.

Aims

To evaluate safety, effectiveness, and satisfaction of cryolipolysis and ATX‐101 used sequentially to reduce SMF.

Methods

A prospective, open‐label, interventional, single‐site study enrolling 22‐ to 65‐year‐old participants rated as Grade 4 (extreme) on the Clinician‐Rated SMF Rating Scale (CR‐SMFRS). Co‐primary effectiveness endpoints were proportions of participants with ≥1‐grade and ≥2‐grade improvement on CR‐SMFRS at 12 weeks post final treatment. Additional assessments included ultrasound measurement of fat thickness and Subject Self‐Rating Scale (SSRS) scores at 12 weeks post final treatment. Safety was assessed throughout the study.

Results

Of 16 enrolled participants, 62.5% were female, mean age of 43, and mean body mass index of 31.8 kg/m². 100% of participants achieved ≥1‐grade improvement, and 71.4% achieved ≥2‐grade CR‐SMFRS improvement. Mean (SD) reduction in SMF thickness was 0.2 mm (1.3), and SSRS scores ≥4 (slightly to extremely satisfied) were reported by 71.4% of participants. Adverse events (AEs) were mild and resolved by study end. No unanticipated adverse device effects or serious or unexpected AEs occurred.

Conclusion

Sequential treatment with cryolipolysis and ATX‐101 was found safe and effective for reducing extreme SMF, resulting in approximately a 2‐grade improvement.

O-OGC06 Genomic analysis of response to neoadjuvant chemotherapy in oesophageal adenocarcinoma

Background

Oesophageal adenocarcinoma (OAC) is the ninth most common cancer worldwide, with an estimated mortality of over 500,000 deaths yearly. Neoadjuvant chemotherapy (NAC) followed by surgery is the standard of care (SOC) for locally advanced OAC. Although almost all patients receive chemotherapy as SOC, fewer than 20% obtain a clinically meaningful response and benefit before surgery. The OAC genome is complex and heterogeneous between patients, and it is not yet understood whether specific mutational patterns may result in chemotherapy sensitivity or resistance.

Methods

To identify associations between genomic events and response to NAC in OAC, a comparative genomic analysis was performed in 65 patients using whole-genome sequencing.  We defined response to NAC using Mandard Tumour Regression Grade (TRG), with responders classified as TRG1-2 (n = 27) and non-responders classified as TRG4-5 (n = 38).

Results

We report a higher non-synonymous mutation burden in responders (median 2.08/Mb vs 1.70/Mb, P = 0.036) and elevated copy number variation (CNV) in non-responders (282 vs 136/patient, P&lt;0.001). We identified CNVs unique to each group, with cell cycle (CDKN2A, CCND1), c-Myc (MYC), RTK/PIK3 (KRAS, EGFR) and gastrointestinal differentiation (GATA6) pathway genes being specifically altered in non-responders. Of particular interest was the identification of the Neuron Navigator-3 (NAV3), a known tumour suppressor downstream of EGFR, which was mutated exclusively in non-responders with a frequency of 22%.

Conclusions

Our work characterises genetic features and mutations that are uniquely associated with response to NAC. We envision a treatment pipeline that incorporates driver mutation profiling in OAC, combining response prediction with targeted therapies to enhance response to NAC and improve survival outcomes.

P-OGC44 Multi-omic cohort study of Barrett’s oesophagus reveals structural variation and retrotransposon activity to occur early in cancer evolution

Background

Barrett’s oesophagus (BE) is the main risk factor for the development of oesophageal adenocarcinoma (OAC), yet few patients ever go on to progress to cancer. The acquisition of events during the metaplasia-dysplasia-cancer sequence is poorly characterised. We present a large, unbiased, multi-omics analysis of a cross-sectional cohort of pre-cancer samples, with the aim of providing a comprehensive insight into the diversity and molecular changes driving the disease to cancer.

Methods

We generated and integrated the genomic (50x), transcriptomic and epigenomic (850K EPIC array) landscapes of snap-frozen endoscopic biopsies from 146 patients with a range of outcomes (27 long-standing non-dysplastic; 12 prior to progression to dysplasia; 14 low-grade; 25 high-grade; 21 intramucosal carcinoma; 47 cases of BE taken adjacent to OAC) and 642 person years of follow-up. All biopsies were reviewed independently by 3 pathologists and had associated annotation with detailed clinical information.

Results

The total number of structural variants (SV) captured the most variance between samples. Complex SVs and LINE-1 retrotransposon activity were observed even before dysplasia had developed and increased with progression. Increasing SV burden was associated with chromothripsis (12%, 18/146) and breakage-fusion bridges (BFBs; 8%, 13/146). In more than 50% of these, the BFBs were in chromosome 17, harbouring the oncogenes ERBB2 and CDK12, for which expression was significantly higher. With progression there was increased expression of genes related to cell-cycle checkpoint, DNA repair and chromosomal instability, and the epigenetic silencing of genes in WNT-signalling and cell-cycle pathways.

Conclusions

Genomic complexity occurs very early in the natural history of BE and increasing genomic instability appears to tip the balance towards cancer. This may inform the potential for progression to cancer beyond the clinically discernible phenotype. Efforts to better understand the triggers for chromosomal breakages and rearrangements that underly progression will aid clinical prediction and prevention strategies.

P-OGC39 The smell of oesophageal adenocarcinoma: opportunities for tests and treatments

Background

Exhaled breath analysis is a promising approach for oesophageal adenocarcinoma (OAC) early detection. The biomarkers of interest are low molecular weight metabolites including volatile aldehydes. In this translational study we investigated whether these metabolites originated from a tumoral source, and how this might impact the diagnosis and treatment of OAC patients.

Methods

The investigative strategy was directed by an unbiased informatics screen of metabolic reprogramming in OAC, and validated using complimentary gene expression assays (n = 638, including controls). Mass spectrometric methods were used to quantify corresponding metabolites and putative source compounds at a tissue level (n = 158), and also in exhaled breath for correlative purposes. Targeted in vitro experiments were performed to demonstrate the cause and effect of the proposed model of metabolic reprogramming in OAC. 

Results

The unbiased screen and subsequent validation found that reduced aldehyde detoxification is an OAC hallmark. In vitro and in vivo this was associated with endogenous aldehyde accumulation. OAC tissue was generally enriched for volatile aldehydes, including the genotoxins formaldehyde, acetaldehyde, 4-hydroxy-2-nonenal and 2-butenal, and the exhaled biomarker decanal (all P &lt; 0.0001). Decanal concentrations correlated with exhaled concentrations. Considering potential aldehyde sources, the OAC phospholipidome was characterised by desaturated and longer lipid acyls, and these spontaneously generated biomarker aldehyde species at ambient conditions. Enriched genotoxic aldehydes were detectable in base-pairing positions in DNA; this genotoxicity was therapeutically targetable with aldehyde scavengers in vitro.

Conclusions

These data support a model for enriched exhaled aldehydes based on increased production from an altered lipid phenotype, and reduced detoxification. Some aldehydes are non-reactive and thus support non-invasive detection. Others react with DNA and increase local genotoxicity; this process is druggable. These findings have implications for OAC early diagnosis and chemoprevention.

Effect of Urate-Elevating Inosine on Early Parkinson Disease Progression: The SURE-PD3 Randomized Clinical Trial

Importance

Urate elevation, despite associations with crystallopathic, cardiovascular, and metabolic disorders, has been pursued as a potential disease-modifying strategy for Parkinson disease (PD) based on convergent biological, epidemiological, and clinical data.

Objective

To determine whether sustained urate-elevating treatment with the urate precursor inosine slows early PD progression.

Design, Participants, and Setting

Randomized, double-blind, placebo-controlled, phase 3 trial of oral inosine treatment in early PD. A total of 587 individuals consented, and 298 with PD not yet requiring dopaminergic medication, striatal dopamine transporter deficiency, and serum urate below the population median concentration (<5.8 mg/dL) were randomized between August 2016 and December 2017 at 58 US sites, and were followed up through June 2019.

Interventions

Inosine, dosed by blinded titration to increase serum urate concentrations to 7.1-8.0 mg/dL (n = 149) or matching placebo (n = 149) for up to 2 years.

Main Outcomes and Measures

The primary outcome was rate of change in the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS; parts I-III) total score (range, 0-236; higher scores indicate greater disability; minimum clinically important difference of 6.3 points) prior to dopaminergic drug therapy initiation. Secondary outcomes included serum urate to measure target engagement, adverse events to measure safety, and 29 efficacy measures of disability, quality of life, cognition, mood, autonomic function, and striatal dopamine transporter binding as a biomarker of neuronal integrity.

Results

Based on a prespecified interim futility analysis, the study closed early, with 273 (92%) of the randomized participants (49% women; mean age, 63 years) completing the study. Clinical progression rates were not significantly different between participants randomized to inosine (MDS-UPDRS score, 11.1 [95% CI, 9.7-12.6] points per year) and placebo (MDS-UPDRS score, 9.9 [95% CI, 8.4-11.3] points per year; difference, 1.26 [95% CI, -0.59 to 3.11] points per year; P = .18). Sustained elevation of serum urate by 2.03 mg/dL (from a baseline level of 4.6 mg/dL; 44% increase) occurred in the inosine group vs a 0.01-mg/dL change in serum urate in the placebo group (difference, 2.02 mg/dL [95% CI, 1.85-2.19 mg/dL]; P<.001). There were no significant differences for secondary efficacy outcomes including dopamine transporter binding loss. Participants randomized to inosine, compared with placebo, experienced fewer serious adverse events (7.4 vs 13.1 per 100 patient-years) but more kidney stones (7.0 vs 1.4 stones per 100 patient-years).

Conclusions and Relevance

Among patients recently diagnosed as having PD, treatment with inosine, compared with placebo, did not result in a significant difference in the rate of clinical disease progression. The findings do not support the use of inosine as a treatment for early PD.

Trial Registration

ClinicalTrials.gov Identifier: NCT02642393.

Greenhouse gas emissions and nitrogen efficiency of dairy cows of divergent economic breeding index under seasonal pasture-based management

Greenhouse gas (GHG) emissions and nitrogen (N) efficiencies were modeled for 2 genetic groups (GG) of Holstein-Friesian cows across 3 contrasting feeding treatments (FT). The 2 GG were (1) high economic breeding index (EBI) animals representative of the top 5% of cows nationally (elite) and (2) EBI representative of the national average (NA). The FT represented (1) generous feeding of pasture, (2) a slight restriction in pasture allowance, and (3) a high-concentrate feeding system with adequate pasture allowance. Greenhouse gas and N balance models were parameterized using outputs generated from the Moorepark Dairy Systems model, a stochastic budgetary simulation model, having integrated biological data pertaining to the 6 scenarios (2 GG × 3 FT) obtained from a 4-yr experiment conducted between 2013 and 2016. On a per hectare basis, total system GHG emissions were similar for both elite and NA across the 3 FT. Per unit of product, however, the elite group had 10% and 11% lower GHG emissions per kilogram of fat- and protein-corrected milk and per kilogram of milk solids (MSO; fat + protein kg), respectively, compared with the NA across the 3 FT. The FT incorporating high concentrate supplementation had greater absolute GHG emissions per hectare as well as GHG per kilogram of fat- and protein-corrected milk and MSO. The elite group had a slightly superior N use efficiency (N output/N input) and lower N surplus (N input - N output) compared with the NA group. The high concentrate FT had an inferior N use efficiency and a higher N surplus. The results of the current study demonstrate that breeding for increased EBI will lead to a general improvement in GHG emissions per unit of product as well as improved N efficiency. The results also illustrate that reducing concentrate supplementation will reduce GHG emissions, GHG emissions intensity, while improving N efficiency in the context of pasture-based dairy production.

Descriptive Analysis of 213 Positive Blood Aspiration Cases When Injecting Facial Soft Tissue Fillers

BACKGROUND

Pre-injection aspiration procedures could increase safety during soft tissue filler injections. However, various influencing factors have been detected in vitro that could result in false negative aspiration results.

OBJECTIVE

A case series was retrospectively investigated to identify factors contributing to positive blood aspiration procedures in vivo.

METHODS

This study evaluated 213 clinical cases positive for blood aspiration documented in an Asian population: 208 females (43.8 ± 7.2 years old) and 5 males (46.8 ± 7.8 years old) during soft tissue filler injections. Injection location, layer (depth) of injection, product injected, size of utilized needle (gauge), length of needle (inch), priming of needle (yes/no), injection angle (degree), and time until blood was visible in the needle hub (seconds) were evaluated.

RESULTS

The most frequent location where a positive aspiration was observed was the pyriform fossa (n = 56; 26.3%), the most frequent plane was the supra-periosteal plane (n = 195; 91.5%), and the most frequent needle utilized was a 27G needle (n = 125; 58.7%). Statistically significantly more positive cases were identified when the needle was primed compared with an unprimed needle (P < 0.001, which was independent of the product). The estimated incidence rate was 0.04% to 0.9% for having positive aspiration procedures per total performed injection procedures.

CONCLUSIONS

Pre-injection aspiration could be a valuable tool to prevent accidental intravascular injection of soft tissue filler. The results of the present investigation show that aspiration can be performed with an acceptable aspiration time, that is, less than 2 seconds, if a suitable product/needle combination is chosen.

LEVEL OF EVIDENCE: 4

Somatic mutation distributions in cancer genomes vary with three-dimensional chromatin structure

Somatic mutations in driver genes may ultimately lead to the development of cancer. Understanding how somatic mutations accumulate in cancer genomes and the underlying factors that generate somatic mutations is therefore crucial for developing novel therapeutic strategies. To understand the interplay between spatial genome organization and specific mutational processes, we studied 3,000 tumor-normal-pair whole-genome datasets from 42 different human cancer types. Our analyses reveal that the change in somatic mutational load in cancer genomes is co-localized with topologically-associating-domain boundaries. Domain boundaries constitute a better proxy to track mutational load change than replication timing measurements. We show that different mutational processes lead to distinct somatic mutation distributions where certain processes generate mutations in active domains, and others generate mutations in inactive domains. Overall, the interplay between three-dimensional genome organization and active mutational processes has a substantial influence on the large-scale mutation-rate variations observed in human cancers.

Caspase-4: A Therapeutic Target for Peptic Ulcer Disease

Peptic ulcers are caused by the interaction between bacterial and host factors. This study demonstrates enhanced expression of caspase-4 in peptic ulcer patient biopsies, indicating that pyroptosis and noncanonical inflammasome activity may be processes involved in peptic ulcer disease. We show that primary murine macrophages infected with Helicobacter pylori upregulate caspase-11 (the ortholog of human caspase-4), activate caspase-1, and secrete IL-1β. We demonstrate that misoprostol (a stable PGE₁ analogue) decreased IL-1β secretion and delayed lethality in vivo in a murine peritonitis model. PGE₂ was shown to inhibit caspase-11-driven pyroptosis and IL-1β secretion in macrophages. Overall, we provide evidence for a pathological role of caspase-4/11 in peptic ulcer disease and propose that targeting caspase-4 or inhibiting pyroptosis may have therapeutic potential in the management of peptic ulcers.

Determination of the half-life and the absolute photon emission intensities for the main gamma-ray energies of 124I

The National Institute of Standards and Technology (NIST) performed new standardization measurements for ¹²⁴I. As part of this work the absolute photon emission intensity for the main gamma-rays of ¹²⁴I were determined using several high-purity germanium (HPGe) detectors. In addition, the half-life for ¹²⁴I was also determined using an HPGe detector. Ionization chamber measurements were performed for additional sources, but it was not possible to obtain a precise half-life value.

The next generation of current measurement for ionization chambers

Re-entrant ionization chambers (ICs) are essential to radionuclide metrology and nuclear medicine for maintaining standards and measuring half-lives. The requirements of top-level metrology demand that systems must be precise and stable to 0.1 % over many years, and linear from 10^-14 A to 10^-8 A. Thus, laboratories depend on bespoke current measurement systems and often rely on sealed sources to generate reference currents. To maintain and improve present capabilities, metrologists need to overcome two looming challenges: ageing electronics and decreasing availability of sealed sources. Possible solutions using Ultrastable Low-Noise Current Amplifiers (ULCAs), resistive-feedback electrometers, and (quantum) single-electron pumps are reviewed. Broader discussions of IC design and methodology are discussed. ULCAs show promise and resistive-feedback systems which take advantage of standard resistor calibrations offer an alternative.

Subunit Approach to Facelifting and Facial Rejuvenation

Facial analysis techniques traditionally separate the upper, middle, and lower facial thirds as distinct entities without guidance in achieving aesthetic youthfulness. There is now an opportunity to develop better analytical tools and specific algorithms to help create an overall harmony to the face and restore a youthful appearance. Facial anatomic subunits have similar three-dimensional qualities based on underlying anatomic structures, craniofacial skeletal modeling, superficial and deep facial fat compartments, skin thickness, facial muscle activity, and curvature (flat, convex, concave). This article discusses using the relationships of the facial anatomic subunits to obtain more consistent and natural facial rejuvenation outcomes.

Determination of the internal pair production branching ratio of 90Y

The National Institute of Standards and Technology (NIST) measured the internal pair production branching ratio of ⁹⁰Y using two sources and four high purity germanium (HPGe) detectors to detect the resulting annihilation radiation. The internal pair production branching ratio determined from these measurements, (32.0 ± 1.5) × 10^-6 (k = 1), agrees within 1 standard uncertainty with the recommended value of (32.6 ± 0.7) × 10^-6 (k = 1) from the DDEP database.

Reproductive efficiency and survival of Holstein-Friesian cows of divergent Economic Breeding Index, evaluated under seasonal calving pasture-based management

The objective of the current study was to examine phenotypic fertility performance and survival, and to gain insight into underlying factors that may contribute to greater fertility performance in 2 divergent genetic groups (GG) of Holstein-Friesian, selected using the Irish Economic Breeding Index (EBI). The GG were evaluated across 3 spring calving pasture-based feeding treatments (FT) over 4 yr. The 2 divergent GG were (1) high EBI; representative of the top 5% nationally (elite), and (2) EBI representative of the national average (NA). In each year, 90 elite and 45 NA cows were randomly allocated to 1 of 3 FT: control, lower grass allowance, and high concentrate. No interaction between GG and FT was observed for any of the measures of fertility investigated. The elite cows achieved significantly greater pregnancy rate to first service (+14.9 percentage points), and significantly greater pregnancy rates after 21, 42, and 84 d of breeding (+17.3, +15.2, and +9.6 percentage points, respectively) compared with NA. The number of services per cow was fewer for elite (1.57) compared with NA (1.80). The interval from mating start date to pregnancy was significantly shorter for elite cows compared with NA. The elite cows maintained greater mean body condition score than NA throughout the study (2.91 vs. 2.72), and had greater body condition score at calving, artificial insemination, and drying off compared with NA. The elite cows had greater mean circulating concentrations of insulin-like growth factor-1 compared with NA. No significant effect was observed of GG on commencement of luteal activity, or progesterone profile variables. Greater survival to the start of fifth lactation was observed for elite cows. The elite cows were 43% less likely to be culled than NA by the beginning of the fifth lactation. The results highlight the success of the Economic Breeding Index to deliver reproductive performance and longevity consistent with industry targets across a range of seasonal pasture-based FT. The results also clearly demonstrate the potential of appropriate genetic selection to reverse negative fertility trends incurred during previous decades of selection for milk production alone.

High-Fat Diet Accelerates Carcinogenesis in a Mouse Model of Barrett's Esophagus via Interleukin 8 and Alterations to the Gut Microbiome

BACKGROUND & AIMS

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Progression from BE to cancer is associated with obesity, possibly due to increased abdominal pressure and gastroesophageal reflux disease, although this pathogenic mechanism has not been proven. We investigated whether environmental or dietary factors associated with obesity contribute to the progression of BE to EAC in mice.

METHODS

Tg(ED-L2-IL1RN/IL1B)#Tcw mice (a model of BE, called L2-IL1B mice) were fed a chow (control) or high-fat diet (HFD) or were crossbred with mice that express human interleukin (IL) 8 (L2-IL1B/IL8 mice). Esophageal tissues were collected and analyzed for gene expression profiles and by quantitative polymerase chain reaction, immunohistochemistry, and flow cytometry. Organoids were established from BE tissue of mice and cultured with serum from lean or obese individuals or with neutrophils from L2-IL1B mice. Feces from mice were analyzed by 16s ribosomal RNA sequencing and compared to 16s sequencing data from patients with dysplasia or BE. L2-IL1B were mice raised in germ-free conditions.

RESULTS

L2-IL1B mice fed an HFD developed esophageal dysplasia and tumors more rapidly than mice fed the control diet; the speed of tumor development was independent of body weight. The acceleration of dysplasia by the HFD in the L2-IL1B mice was associated with a shift in the gut microbiota and an increased ratio of neutrophils to natural killer cells in esophageal tissues compared with mice fed a control diet. We observed similar differences in the microbiomes from patients with BE that progressed to EAC vs patients with BE that did not develop into cancer. Tissues from dysplasias of L2-IL1B mice fed the HFD contained increased levels of cytokines that are produced in response to CXCL1 (the functional mouse homolog of IL8, also called KC). Serum from obese patients caused organoids from L2-IL1B/IL8 mice to produce IL8. BE tissues from L2-IL1B mice fed the HFD and from L2-IL1B/IL8 mice contained increased numbers of myeloid cells and cells expressing Cxcr2 and Lgr5 messenger RNAs (epithelial progenitors) compared with mice fed control diets. BE tissues from L2-IL1B mice raised in germ-free housing had fewer progenitor cells and developed less dysplasia than in L2-IL1 mice raised under standard conditions; exposure of fecal microbiota from L2-IL1B mice fed the HFD to L2-IL1B mice fed the control diet accelerated tumor development.

CONCLUSIONS

In a mouse model of BE, we found that an HFD promoted dysplasia by altering the esophageal microenvironment and gut microbiome, thereby inducing inflammation and stem cell expansion, independent of obesity.

An approach to structural facial rejuvenation with fillers in women

Newer understanding of volume loss as a critical component of facial aging and the integration of volume replacement into the surgical and nonsurgical therapeutic algorithm is arguably the most significant recent development in the field of facial rejuvenation. As all structural tissues play a role in the aging face, restoring youthful characteristics (or establishing them where they are congenitally absent) starts from the skeletal framework and builds progressively to the canvas of the face. The purpose of this article is to provide an introduction and brief summary of some of the current concepts concerning facial anatomy and the anatomy of facial aging, which serve as the basis for predictable and reproducible results with the use of injectable fillers. This article does not include the various types of fillers or techniques of filler injection, but covers how to decide where to use the filler and why, in different faces, as a result of the recognition and targeted correction of currently recognized specific anatomic deficiencies.

Standardization of 64Cu activity

The complex decay scheme that makes 64Cu promising as both an imaging and therapeutic agent in medicine also makes the absolute measurement of its activity challenging. The National Institute of Standards and Technology (NIST) has completed a primary activity standardization of a 64CuCl2 solution using the 4πβ(LS)-γ(NaI) live-timed anticoincidence (LTAC) counting method with a combined standard uncertainty of 0.51 %. Two liquid scintillation (LS) counting methods were employed for confirmatory measurements. Secondary measurements were made by high-purity germanium detectors, pressurized ionization chambers (IC), and a well-type NaI(Tl) counter. Agreement between the LTAC-based standard and standards from other laboratories was established via IC calibration factors. Poor agreement between methods and with theoretical IC responses may indicate a need for improved β+/- branching probabilities and a better treatment of β+/- spectra.

Expanding Treatment Options for Injectable Agents

Loss of facial volume and soft-tissue support are common to types of facial aging. Restoration of a youthful appearance relies upon correction of this loss, and can be achieved in various capacities through use of biostimulatory or hyaluronic acids (HA) injectable fillers. Here, the authors discuss the versatility of calcium hydroxylapatite (CaHA) in volume replacement and the applications and facial regions for which CaHA, poly-L-lactic acid (PLLA), and HA fillers are best suited.

Differentiating Nonpermanent Injectable Fillers: Prevention and Treatment of Filler Complications

Though the incidence of complications and adverse events with dermatological fillers is inherently low, practitioners should be well versed in both prevention of filler complications and the treatment algorithms for addressing "granulomas," nodules, infection, and vascular compromise. Appropriate preventative measures, coupled with timely and effective treatment, are critically important for patient safety and satisfaction. In addition to the preventive measures and treatment algorithms outlined here, the authors emphasize that the broad classification and treatment of nodules as "granulomas" is likely to lead to ineffective treatment, or worse, unnecessary exposure to incorrect treatment. In practice, nodules are classified and treated based on clinical manifestation (eg, late vs early or noninflammatory vs inflammatory) rather than on histology. Indeed, classification of a nodule as a granuloma requires a histological examination, rarely available (or necessary) in clinical practice to guide treatment. Thus, the apparent inflammatory nature of the nodule and the time of onset should drive treatment approach. The treatment algorithms presented here are based on these clinically meaningful parameters.