Do we really need fine-needle biopsy needle for an ultrasound-guided biopsy of pancreatic adenocarcinoma? A retrospective study

OBJECTIVE

Endoscopic ultrasound (EUS)-guided FNB was not demonstrated to be better than EUS fine-needle aspiration (FNA) to obtain adequate samples for diagnosis of pancreatic tumors. We report our experience using a 22-gauge needle aspiration to obtain both cytologic and histologic samples.

PATIENTS AND METHODS

In a total of 232 patients (51% men), 22-gauge needles (Cook Medical) were used to obtain a cytological sample (between 2008 and 2016, Cohort A) and a cytologic and a histologic sample (between 2016 and 2019, Cohort B) to evaluate the usability of this needle to collect material for cytologic and histologic examination. MOSE was used.

RESULTS

Pancreatic adenocarcinoma was diagnosed in 76/113 (68%) patients in Cohort A and in 88/119 (74%) in Cohort B. Non-diagnostic sampling occurred in 30/113 (26%) patients in Cohort A and in 25/119 (21%) in Cohort B. The median number of passages was three in both cohorts. Lesions were in the head/uncinated process 57% vs. 51% and body/tail 43% vs. 49% in Cohorts A and B, respectively; the mean tumor size was 34.5 mm (SD 10.7) in Cohort A and 35.4 mm (SD 14.7) in Cohort B.

CONCLUSIONS

FNA needle (22-gauge) with adequate passes, MOSE determination and adequate processing of specimens, provided FNA and FNB specimen collection.

Abstract P2-04-03: Epigenomic analysis of cancer stem cell (CSC)-enriched triple-negative breast cancer (TNBC) populations reveals gene regulatory circuitry and novel tumor cell vulnerabilities

Tumor-initiating cells (TICs), also termed cancer stem cells (CSCs) are involved in breast cancer chemoresistance, metastasis and disease progression. To pinpoint tumor cell vulnerabilities and transcriptional drivers of therapeutic relevance, we have characterized the triple negative breast cancer (TNBC) CSC transcriptional landscape using epigenome mapping and nucleosome occupancy determination. We identify a set of transcriptional regulators and signaling mediators that enforce the cancer stem cell state and instruct potential therapeutic strategies.

The basal epithelial marker, integrin-β4 (ITGB4), can be used to stratify mesenchymal-like triple-negative breast cancer (TNBC) cells into populations of low and high tumor-initiating ability in vivo. We used ChIP-seq to measure H3K27ac occupancy and map the transcriptional enhancers in SUM159 cells segregated into ITGB4HI (High tumor initiating ability) and ITGB4LOW (Low tumor initiating ability) populations. Gene-enhancer linking and comparative analysis of enhancer usage revealed an epigenomically defined set of genes that are candidate drivers of the CSC cell state, including GSK3β, DNA-binding transcription factors and cellular adhesion proteins. To further define the chromatin architecture and transcriptional regulatory circuitry that underlies CSC state, we deployed ATAC-seq (Assay for Transposase-Accessible Chromatin with high throughput sequencing) within ITGB4HI and ITGB4LOW populations. By pairing nucleosome occupancy and transcription factor kinetics, we created enhancer-linked transcriptional regulatory circuitry of these tumor-initiating cells.

Together, the isolation of partially mesenchymal ITGB4HI CSCs, coupled with enhancer mapping and distillation of transcriptional regulatory circuitry from these cells enable the identification of cancer vulnerabilities and therapeutic opportunities for high-risk patients with TNBC.

Citation Format: Guenther MG, Lambert AW, Chen MW, Fiore C, Eaton M, Orlando D, Bierie B, Weinberg RA, Fritz CC, Olson ER. Epigenomic analysis of cancer stem cell (CSC)-enriched triple-negative breast cancer (TNBC) populations reveals gene regulatory circuitry and novel tumor cell vulnerabilities [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-04-03.

Abstract P1-09-08: BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines

Effective therapies for TNBC remain elusive. As such, TNBCs are associated with a high risk of relapse and short progression free- and overall-survival. Recent studies showed that TNBC cells are highly dependent on the transcriptional regulator CDK7, and suggest that the mitochondrial apoptosis pathway is important in mediating cell survival in CDK7-dependent cells. Further, TNBC has been shown to have a distinct epigenetic and transcriptional program, with super-enhancers (SE) mediating the expression of key oncogenic drivers such as MYC. SY-1365, a covalent and selective inhibitor of CDK7, was developed to exploit dysregulated programs thought to drive SE-mediated transcriptional-dependencies in TNBC and other cancers. To identify potential biomarkers predictive of sensitivity to SY-1365, we evaluated SY-1365 inhibitory activity in a large panel of human tumor cell lines, including TNBC lines, and correlated sensitivity with RNA expression and epigenetic profiles.

SY-1365 dose-response curves were measured using the ATP-lite assay in a panel of 406 human tumor cell lines, including 19 TNBC cell lines. Clustering of growth-rate adjusted dose response curves of cell-lines treated with SY-1365 allowed the classification of cell-lines into low and high response groups. An unbiased genome wide approach was used to compare response classification to RNA expression data across all cell lines to identify gene expression markers predictive of sensitivity to SY-1365. Furthermore, a hypothesis driven approach was followed to interrogate whether the MYC SE predicted sensitivity to SY-1365.

Twenty-five genes were differentially expressed between SY-1365-sensitive and -insensitive tumor lines (FDR<0.05). Lower expression of BCL2L1, which encodes the mitochondrial apoptosis regulator BCL-XL, was identified as the most predictive expression biomarker of sensitivity across all profiled cell lines, strongly separating the two classes of sensitivity (Accuracy=70%, FDR<0.005). Further, this predictive power of lower BCL2L1 expression was maintained in an analysis restricted to the subset of TNBC cell-lines (Accuracy=73%).

Expanding beyond expression analysis, we also found that the strength of the MYC SE (as defined by H3K27Ac) was predictive of response to SY-1365 in TNBC (Accuracy=86%, FDR<0.05).

In this study, we show for the first time that SY-1365 induced differential responses across a large panel of human tumor cell lines derived from multiple indications. We also show that in this panel of cell lines the response could be predicted in an “indication agnostic” manner by the level of expression of BCL2L1. Finally, in line with prior reports, in TNBC cell lines, MYC SE was significantly associated with sensitivity to SY-1365. These observations have generated strong hypotheses for selection strategies aimed at identifying patients with tumors particularly sensitive to CDK7 inhibition with SY-1365, and warrant further investigation with respect to predictive biomarkers of response in patients. SY-1365 is currently being assessed in a phase 1 trial in adult patients with advanced solid tumors, including a planned expansion cohort enriching for patients with TNBC (NCT03134638).

Citation Format: Rajagopal N, Hodgson G, Hu S, McKeown M, Bush A, Fritz C, Orlando D, Olson E, di Tomaso E. BCL2L1 (BCL-XL) expression and MYC super-enhancer positivity predict sensitivity to the covalent CDK7 inhibitor SY-1365 in triple negative breast cancer (TNBC) cell lines [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-09-08.

Abstract P6-11-18: A novel subgroup of estrogen receptor positive breast cancer may benefit from super-enhancer guided patient selection for retinoic acid receptor α agonist treatment

Endocrine-resistance remains a major challenge for treatment of breast cancer. Multiple mechanisms for endocrine resistance have been proposed, including altered expression of ER co-regulators such as Retinoic Acid Receptor Alpha (RARα). Furthermore, crosstalk between estradiol and RA signaling is known and upregulation of RARα has been observed in tamoxifen resistance. We propose a novel treatment paradigm for a newly-defined subset of HR+ patients based on our discovery of a super-enhancer (SE) associated with the RARA locus. SEs are large, highly active chromatin regions that pinpoint cancer vulnerabilities. The RARA SE-identified vulnerability can be targeted using the potent, selective, and metabolically stable RARα agonist SY-1425 (tamibarotene). SY-1425 is approved in Japan to treat Acute Promyelocytic Leukemia, has a well-established efficacy and safety profile, and may enhance response to hormonal therapy (HT) in this newly-defined subset of HR+ patients potentially delaying the need for alternate treatment.

Tumor samples from 42 breast cancer patients were analyzed across a range of molecular subtypes. We identified an SE linked to the RARA gene in 54.5% of the hormone positive patient samples. RARA SEs predicted sensitivity to SY-1425 in 12 breast cancer cell lines confirming their functional role, and showed a correlation with RARA gene expression. A panel of 37 breast cancer cell lines was tested for SY-1425 anti-proliferative activity and gene expression levels, and identified RARA as the single best predictor of response. Proliferation of RARA-high cells was inhibited by SY-1425 with low nanomolar EC50s. Transcriptional profiling was performed on 4 HR+ and 3 HER2+/HR- breast cancer cell lines and analyzed by GSEA to examine the molecular response to SY-1425. Signatures for growth including E2F, MYC, DNA replication, and cell cycle were significantly downregulated while retinol metabolism and luminal signaling were upregulated. Estrogen signaling was also significantly altered by SY-1425, supporting known crosstalk between RARα and ER. Consistent with differentiation, CYP26A1 and VE-Cadherin were induced and Actin and Ki67 were diminished at relevant concentrations of SY-1425 and could serve as pharmacodynamic markers of response.

To test responses to SY-1425 in vivo, two cell line-derived models and two patient-derived breast cancer models (one RARA-high, and one RARA-low each) were treated with SY-1425. SY-1425 inhibited tumor growth in the RARA-high models, but not the RARA-low models (43% versus 0% TGI). Consistent with the observed changes in transcription, SY-1425 in combination with tamoxifen synergistically inhibited proliferation of RARA-high breast cancer cell lines.

Although a few clinical studies have investigated the use of ATRA in HR+ breast cancer without success, our results suggest that patient selection based on the RARA SE may predict which HR+ breast cancer patients could derive benefit by adding an RARα agonist to HT. The potential to prolong or increase the clinical effect of anti-estrogen therapy with SY-1425, which has improved potency, selectivity, and PK stability versus ATRA, would be an attractive strategy to explore.

Gut Microbiota: A Key Modulator of Intestinal Healing in Inflammatory Bowel Disease

Mucosal healing (MH) represents a crucial factor for maintaining gut homeostasis. Indeed, in inflammatory bowel disease, MH has become the standard therapeutical target, because it is associated with more effective disease control, more frequent steroid-free remission, lower rates of hospitalization and surgery, and improved quality of life. In this scenario, gut microbiota is a crucial player in modulating intestinal repair and regeneration process. It can act on the tumor necrosis factor-α production, modulation of reactive oxygen and nitrogen species, activity of matrix metalloproteinases and on many other mechanisms strictly involved in restoring gut health. In this review, we analyze and review the literature on the role of gut microbiota in sustaining mucosal injury and achieving MH.

Carotid intima-media thickness measurement through semi-automated detection software and analysis of vascular walls

AIM

The aim of the present study was to compare the semi-automatic measurement of carotid intima thickness (RFQIMT - Esaote, Italy), with the conventional method.

METHODS

We enrolle 81 patients, mean age 46 years ±15, with no history of cardio-cerebrovascular events and we assessed the traditional cardiovascular risk factors. We examined the IMT of the common carotid artery with manual and RFQIMT method (based on the "Radio Frequency" signal), according to the ASE protocol.

RESULTS

Semi-automatic measurement was on average lower than manual measurement (617 μm ±191 vs. 676 μm ± 222) with a statistically significant difference (P<0.01). In agreement with manual measurements, the values of RFQIMT increased with increasing age and presence of cardiovascular risk factors.

CONCLUSION

The RFQIMT measurement was, on average, lower than manual measurement, this means that probably, age- and gender-related reference values of RFQIMT need to be revised.

National prevalence of larval echinococcosis in sheep in slaughtering plants Ovis aries as an indicator in control programmes in Uruguay

Diagnostic surveys carried out on ovine larval echinococcosis in slaughtering plants at a national level in 1998 made it possible to meet several objectives, i.e. to estimate the existing levels of prevalence, to evaluate the effectiveness of the control actions applied by the Programme against Hydatidosis and to contribute to the improvement of the health information systems for epidemiological surveillance. The work included sheep (Ovis aries), both lambs (2-4 teeth) and adults (6-8 teeth). A random sample was performed among sheep from the plants that slaughter the majority of animals in the country. The sample included 22 animals per herd, and it involved removing their offal (liver, lungs and heart) and processing serial sections at the laboratory. The histopathological studies were performed on the lesions that could not be adequately identified at gross examination, and those that were so small that had to be submitted for confirmation of the diagnosis. Of the 2035 animals that were examined, 1019 were lambs (2-4 teeth) and 1016 were adults (6-8 teeth). The prevalence of larval echinococcosis was 7.7% in lambs and 18.0% in adults. The overall prevalence in the liver was 8.5 and 8.0% in the lungs. As to the characteristics of the morphologic structures of the larvae, in younger animals 29% of the lesions were calcified, and 71.0% were hyaline, while in older animals the proportions were 34.4% calcified versus 65.6% hyaline. Other conditions found in the liver parenchyma included: white stain (0.8%), caseous lymphadenitis (3.0%), abscess (0.4%), larvae of Taenia hydatigena (5.1%), Fasciola hepatica (3.9%). And 1.7% of the animals presented larvae of Taenia ovis in the cardiac muscle. Previous surveys carried out in 1994 using the same methodology showed a prevalence of 15.2% in 2-4 teethed animals and 33.9% in 6-8 teethed animals, thus confirming that rates have decreased by 49.6 and 47.0%, respectively. The data obtained reflect the reduction of areas contaminated with eggs of Echinococcus granulosus, which would cause a loss in immunity against this parasite after a certain time. Prevalence of larvae T. hydatigena and T. ovis could change if more sites were considered, a fact that was confirmed in studies carried out in our country. The species O. aries must be used as an indicator in the control programmes, especially in the category of 2-4 teethed lambs. The fact they are not as frequent in our market must be considered; in 1998 they accounted for only 3.0% of the total numbers of animals.

[Ascites as preeminent manifestation of primary hypothyroidism. Clinical case]

The case of an adult male who came to clinical evaluation because of an abundant ascites without any obvious cardiac or hepatic explanation is reported. The exudative characteristics of the ascitic fluid, the elevated serum-ascites albumin gradient, some electrocardiographic anomalies, hypercholesterolemia and a slight macrocytic anemia prompted a clinical diagnosis of probable hypothyroidism. This was also due to an anamnesis of remote antithyroid radiometabolic treatment. The serum hormone levels and the ultrasonogram of the gland confirmed the diagnosis. Hormonal substitutive therapy led to thyroid-stimulating hormone normalization and to a progressive decrease of the ascites, that eventually disappeared. This case, which involves a rare manifestation of hypothyroidism, underscores the need to consider thyroid diseases in the differential diagnosis of ascites and to include thyroid-stimulating hormone dosage among the laboratory tests to be ordered when suspicious clinical or biochemical data are present (mainly, the exudative aspect of the ascites).

Inactivation of individual mammalian cells by single alpha-particles

PURPOSE

To measure clonogenic death of Chinese hamster V79 cells following exposure to a defined number of 4.3 MeV alpha-particles (track-averaged LET = 105 keV/micron).

MATERIALS AND METHODS

Cells were irradiated at the radiobiological facility installed at the TTT-3 Tandem accelerator in Naples by using a 'Biostack' approach, which allows the positions of incident tracks relative to cells to be carefully determined. Subcellular structure was identified by fluorescence microscopy, while tracks were visualized by LR-115 solid state nuclear track detectors.

RESULTS

Particle hits in the cytoplasm did not significantly affect cell survival, yet survival probability decreased exponentially as a function of the number of nuclear traversals. Measured probability of surviving to exactly one 4.3 MeV alpha-particle traversal in the cell nucleus was 0.67 +/- 0.10. Inactivation cross-section was substantially higher than expected from conventional survival curves. However, folding of the data with Poisson statistics showed that survival level expected if a mean of one alpha-particle goes through a nucleus is higher than the measured value after exactly one particle traversal.

CONCLUSIONS

V79 cells have about 67% probability to survive a single alpha-particle traversal in the cell nucleus. Single-particle survival curves are consistent with conventional dose-survival relationships, once Poisson distribution of traversals is taken into account.

Neoplastic phlebothrombosis from renal vein to right atrium: a case report

The authors present an atypical case of neoplastic thrombosis of the great abdominal veins, evaluated with echo-Doppler duplex scanner and computed tomographic scan with contrast enhancement. In this report the authors stress again the diagnostic accuracy of echo-Doppler methods in the study of such a phlebopathy. They describe its sonographic differential diagnosis from acute or chronic idiopathic phlebothrombosis.

[Role of non-invasive vascular diagnosis in the study of "diabetic foot"]

The Authors examine the possibilities of instrumental diagnosis in patients with the "diabetic foot" syndrome. The lack of clinical relevance of the so called "microangiopathy" is stressed, because. Indeed, either the "macroangiopathy" or the diabetic neuropathy are responsible for almost all the symptoms of this syndrome. In the differential diagnosis between these two major sequelae of diabetes, with consequently wide differences in the therapeutic choices, the Doppler ultrasound examination has been of paramount usefulness, because it is very sensitive and specific in detecting and localizing any lesion suggestive of macroangiopathy.

[Hyponatremia in cirrhosis with ascites]

Hyponatremia complicates ascitic hepatic cirrhosis with frequency and gravity related to the gravity of the cirrhosis itself. When hyponatremia develops, it worsens the already present secondary hyperaldosteronism and makes therapy with spironolactone inefficacious. From a pathophysiologic viewpoint a pathogenetic role in determining hyponatremia is attributable to the reduced plasmatic renal perfusion; in several patients a syndrome of inappropriate ADH secretion develops. Other neurohormonal systems (catecholamines, prostaglandins, natriuretic hormones) are probably very important in modifying renal hemodynamics and renal tubular function. In some patients a causative role for hyponatremia is attributable to iatrogenic factors (e.g.: diuretics). From a therapeutic viewpoint, we examine some schedules, pharmacologic or not, that, however, are far from being useful for all patients. We discuss, mainly, water restriction, osmotic diuretics with or without loop diuretics, loop diuretics followed by sodium reintegration and concentration-reinfusion of ascites or application of peritoneovenous shunt.

[Electrophysiological analysis of various brain stem reflexes in multiple sclerosis]

An electrophysiological study of "blink reflex" and "jaw reflex" was carried out on 20 sicilian patients with "definited" Multiple Sclerosis. The R1 component of the "blink reflex" was abnormal in 13 patients on 20 (65%), the R2 component in 8 patients on 20 (40%). Considering together the R1 and R2 responses, the abnormal percentage was 75%. The "jaw reflex" showed abnormal responses in 5 patients on 20 (25%). Considering both the "blink reflex" and "jaw reflex", the pathological percentage was 75%, in order that no patients had isolated changes of the "jaw reflex". The simultaneous study of the two reflexes does not increase the probability to prove pathological responses. The frequency of the clinically silent brain-stem lesions in our patients was not substantially different from that showed by other authors on different populations.

Factor VII Activity and Antigen in Hemophilia B Variants

In 23 patients with Hemophilia B (variants: II B-, 5 BR and 7 B+) factor VII Activity (VII:C) and Antigen (VII:Ag), in correlation with Thrombotest were measured. Thrombotest was found prolonged in 14 patients (in 8 > x+3SD and in 6 >x+2SD). Factor VII:C was found reduced in 1/11 B-, in 2/5 BR and in 4/7 B+ variants. Factor VII:Ag was normal in all but one patient (a 5 years old boy). The ratio VII:C/VII:Ag was abnormal in 8 patients. In these patients factors II and X activities were always within the normal range. The discrepances between VII:C and VII:Ag may be due to: 1) very minor vitamin K deficiency (presence of small amounts of PIVKA-II), 2) an inhibition of factor VII activation by a factor IX “abnormal” molecule, and 3) the synthesis of an abnormal molecule of factor VII.