MRI, clinical, and radiomic models for differentiation of uterine leiomyosarcoma and leiomyoma

PURPOSE

To assess the predictive ability of conventional MRI features and MRI texture features in differentiating uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS).

METHODS

This single-center, IRB-approved, HIPAA-compliant retrospective study included 108 patients (69 LM, 39 LMS) who had pathology, preoperative MRI, and clinical data available at our tertiary academic institution. Two radiologists independently evaluated 14 features on preoperative MRI. Texture features based on 3D segmentation were extracted from T2W-weighted MRI (T2WI) using commercially available texture software (TexRAD™, Feedback Medical Ltd., Great Britain). MRI conventional features, and clinical and MRI texture features were compared between LM and LMS groups. Dataset was randomly divided into training (86 cases) and testing (22 cases) cohorts (8:2 ratio); training cohort was further subdivided into training and validation sets using ten-fold cross-validation. Optimal radiomics model was selected out of 90 different machine learning pipelines and five models containing different combinations of MRI, clinical, and radiomics variables.

RESULTS

12/14 MRI conventional features and 2/2 clinical features were significantly different between LM and LMS groups. MRI conventional features had moderate to excellent inter-reader agreement for all but two features. Models combining MRI conventional and clinical features (AUC 0.956) and MRI conventional, clinical, and radiomics features (AUC 0.989) had better performance compared to models containing MRI conventional features alone (AUC 0.846 and 0.890) or radiomics features alone (0.929).

CONCLUSION

While multiple MRI and clinical features differed between LM and LMS groups, the model combining MRI, clinical, and radiomic features had the best predictive ability but was only marginally better than a model utilizing conventional MRI and clinical data alone.

Recurrent Loss of Heterozygosity in Pancreatic Neuroendocrine Tumors

Chromosomal aneuploidies are prognostic markers across a wide variety of tumor types, and recent literature suggests that pancreatic neuroendocrine tumors are no different. In this study 214 patients with grade 1, 2, or 3 pancreatic neuroendocrine tumors had their tissue examined for chromosomal copy number alterations using next-generation sequencing. Univariate and multivariate statistical analyses were performed with all-cause mortality and disease-specific mortality as the end comparators. As such, the cohort stratified into 3 different clinically relevant chromosomal subgroups: an indolent subgroup characterized by loss of chromosome 11 in relative isolation, an aggressive subgroup characterized by losses of chromosomes 1, 2, 3, 6, 10, 11, 16, and 22 and with no loss of chromosomes 4, 5, 7, 12, 14, 17, 19, and 20, and finally a heterogeneous third group with a subset of cases that behave even more aggressively than the aforementioned.

Molecular catastrophe, the peritoneal cavity and ovarian cancer prevention

The current theory of carcinogenesis for the deadliest of "ovarian" cancers - high-grade serous carcinoma (HGSC) - holds that the malignancy develops first in the fallopian tube and spreads to the ovaries, peritoneum and/or regional lymph nodes. This is based primarily on the observation of early forms of serous neoplasia (serous tubular intraepithelial lesions (STILs), and serous tubular intraepithelial carcinomas (STICS)) in the fimbria of women undergoing risk reduction surgery. However, these lesions are uncommon in the general population, confer a low risk (5%) of HGSC following their removal in at-risk women with germ-line BRCA1/2 mutations and require 4 or more years to recur as intraperitoneal HGSC. These features suggest that isolated STILs and STICs behave as precursors with uncertain cancer risk rather than carcinomas. Their evolution to HGSC after escape from the tube could proceed step-wise with multiple biologic events; however, it is unclear whether immediately adjacent HGSCs in the setting of advanced disease evolved in the same fashion. The latter scenario could also be explained by a "catastrophic" model in which STICs suddenly develop with invasive and metastatic potential, overwhelming or obscuring the site of origin. Moreover, a similar model might explain the sudden emergence of HGSC in the peritoneal cavity following escape of precursor cells years before. Long term follow-up data from opportunistic or prophylactic salpingectomy should shed light on where malignant transformation occurs, as well as the time-line from precursor to metastatic HGSC. This article is protected by copyright. All rights reserved.

Neoadjuvant chemotherapy induces genomic and transcriptomic changes in ovarian cancer

The growing use of neoadjuvant chemotherapy to treat advanced-stage high-grade serous ovarian cancer (HGSOC) creates an opportunity to better understand chemotherapy-induced mutational and gene expression changes. Here we performed a cohort study including 34 patients with advanced stage IIIC or IV HGSOC to assess changes in the tumor genome and transcriptome in women receiving neoadjuvant chemotherapy. RNA-sequencing and panel DNA-sequencing of 596 cancer-related genes was performed on paired FFPE specimens collected before and after chemotherapy, and differentially expressed genes (DEGs) and CNVs in pre- and post-chemotherapy samples were identified. Following tissue and sequencing quality control, the final patient cohort consisted of 32 paired DNA and 20 paired RNA samples. Genomic analysis of paired samples did not reveal any recurrent chemotherapy-induced mutations. Gene expression analyses found that most DEGs were upregulated by chemotherapy, primarily in the chemotherapy resistant specimens. AP-1 transcription factor family genes (FOS, FOSB, FRA-1) were particularly upregulated in chemotherapy resistant samples. CNV analysis identified recurrent 11q23.1 amplification, which encompasses SIK2. In vitro, combined treatment with AP-1 or SIK2 inhibitors with carboplatin or paclitaxel demonstrated synergistic effects. These data suggest that AP-1 activity and SIK2 copy number amplification are induced by chemotherapy and may represent mechanisms by which chemotherapy resistance evolves in HGSOC. AP-1 and SIK2 are druggable targets with available small molecule inhibitors and represent potential targets to circumvent chemotherapy resistance.

Next-Generation Sequencing in the Diagnosis of Metastatic Lesions: Reclassification of a Glioblastoma as an Endometrial Cancer Metastasis to the Brain

Endometrial cancer is the most common gynecologic cancer in the U.S., but metastasis to the brain is rare, and diagnosis can be challenging. Traditional tools for determining if a tumor is a primary or metastatic lesion include pan-imaging, histopathologic studies, and immunohistochemistry. Molecular testing with next-generation sequencing has been increasingly used to augment these tests. We present a case of a patient who initially presented with a brain lesion diagnosed as glioblastoma on histology and immunohistochemistry, but whose diagnosis was later changed to metastasis from an endometrial primary based on molecular findings. The two tumors shared a common microsatellite instability signature and 51 DNA variants, including oncogenic driver mutations KRAS p.G13D, PIK3CA p.E545A, and PTEN p.I135V and p.K267Rfs*9. This highlights the power of molecular analysis in making the diagnosis in cases of rare metastases. KEY POINTS: Brain metastasis from endometrial primary is rare, and histopathological features may be augmented with molecular analysis to aid in diagnosis. Comparison of the molecular makeup of the primary endometrial lesion with the metastatic lesion may reveal high-risk molecular features that may be indicative of metastatic potential.

Therapeutic plasma exchange as part of multimodal treatment of acquired hemophilia in a patient with concurrent acute intracerebral bleed and pulmonary embolism

BACKGROUND

Autoantibodies against Factor VIII (FVIII) define the rare but life-threatening bleeding disorder acquired hemophilia A (AHA). Correction of FVIII deficiency and eradication of the factor inhibitor are the ultimate therapeutic goals in this disorder. Bypassing agents such as recombinant factor VIIa (rFVIIa) or FVIII inhibitor bypassing agent are often used to control coagulopathy before the inhibitor is eradicated. Bypassing agents carry a risk of thrombosis, however.

CASE REPORT

We report a patient with newly diagnosed AHA and thalamic bleed who additionally had active atrial fibrillation and developed a segmental pulmonary embolism, limiting tolerable rFVIIa dosage. This patient with very-high-risk brain bleed and concurrent thrombosis on bypass agent represented a significant management dilemma for which we successfully utilized therapeutic plasma exchange (TPE) to reduce the inhibitor titer.

RESULTS

FVIII inhibitor was undetectable and FVIII level was above the lower limit of normal within 12.5 days from starting TPE. While the patient ultimately died 24 days from admission for reasons unrelated to bleeding, his intracerebral hemorrhage was unchanged in size and no other bleeding morbidity was observed.

CONCLUSION

This patient achieved eradication of FVIII inhibitor and did not have bleed expansion while receiving multimodal therapy including corticosteroids, rituximab, and TPE. We discuss the periprocedural risks of TPE in an acquired hemophilia patient and our multiteam management of that risk.

Joint Commission requirements for discharge instructions in patients with heart failure: is understanding important for preventing readmissions?

BACKGROUND

Many approaches have been considered to reduce heart failure (HF) readmissions. The Joint Commission on Accreditation of Health Care Organizations (JC) requires hospitals to provide patients admitted for HF with discharge instructions that address 6 topics related to HF management: diet, exercise, weight monitoring, worsening symptoms, medications, and follow-up appointments. These guidelines were developed based on expert opinion, but no one has tested whether patients' understanding of these instructions affects 30-day readmission rates.

METHODS AND RESULTS

We conducted a prospective cohort study of patients admitted for decompensated HF. Patients completed an understanding survey immediately after their nurse read their discharge papers. The survey contained 1 question for each of the 6 JC topics. Of the 145 patients in the study, only 14 (10%) understood all 6 discharge instructions. Patients with complete comprehension of their discharge instructions were significantly less likely to be readmitted within 30 days than those with nonperfect understanding (P = .044), but this association was no longer significant after controlling for level of education and use of English as a primary language.

CONCLUSIONS

HF patients' comprehension of discharge instructions is inadequate. Patients with limited education and those that do not speak English as a primary language are more likely to have poorer discharge understanding and higher rates of 30-day readmissions.

Assessing the implications of contradictory farm exposure data in an aging rural population

Occupational exposure to agriculture can be measured in a variety of ways, including a simple yes/no classification, as well as continuous measures, such as years in farming. Regardless of the exposure measure, the possibility of mismeasurement exists. This can be the result of memory decay, differential interpretation, and overly broad definitions of farming. Data from a 20-year longitudinal study were used to measure the extent of this misclassification, and also to compare results obtained from yes/no measures (ever having farmed and current farmer) versus a more refined measure (years of farming). There were 1,811 households in a rural seven-county region of central New York responding to the survey. All subjects were ≥50 as of 2009. The subjects' 2009 responses relating to agricultural exposure were validated against those given in 1989 and 1999. Subjects giving contradictory responses were contacted for clarification. Of the 445 subjects indicating any kind of agricultural exposure, 186 (41.8%) provided contradictory information. Correction of these led to a lower estimate of farming prevalence, but an increase in the mean years of farming. Contradictory responses were more common for females, subjects with partners, and those with better financial situations. For both the corrected and uncorrected data, ever farming, current farming, and years of farming were all strongly related to both farmer's lung and farm machinery injury. Contradictory information is commonly encountered when measuring agricultural exposure. However, when studying measures that are strongly related to agriculture, the extra effort devoted to clarifying these contradictions may be unnecessary. For outcomes where these relationships are more subtle, correction may be more important.

Comparison of bias resulting from two methods of self-reporting height and weight: a validation study

OBJECTIVES

To contrast the validity of two modes of self-reported height and weight data.

DESIGN

Subjects' self-reported height and weight by mailed survey without expectation of subsequent measurement. Subjects were later offered a physical exam, where they self-reported their height and weight again, just prior to measurement. Regression equations to predict actual from self-reported body mass index (BMI) were fitted for both sets of self-reported values. Residual analyses assessed bias resulting from application of each regression equation to the alternative mode of self-report. Analyses were stratified by gender.

SETTING

Upstate New York.

PARTICIPANTS

Subjects (n = 260) with survey, pre-exam and measured BMI.

MAIN OUTCOME MEASURES

Prevalence of obesity based on two modes of self-report and also measured values. Bias resulting from misapplication of correction equations.

RESULTS

Accurate prediction of measured BMI was possible for both self-report modes for men (R (2 )= 0.89 survey, 0.85 pre-exam) and women (R (2 )= 0.92 survey, 0.97 pre-exam). Underreporting of BMI was greater for survey than pre-exam but only significantly so in women. Obesity prevalence was significantly underestimated by 10.9% (p < 0.001) and 14.9% (p < 0.001) for men and 5.4% (p = 0.007) and 11.2% (p < 0.001) for women, for pre-exam and survey, respectively. Residual analyses showed that significant bias results when a regression model derived from one mode of self-report is used to correct BMI values estimated from the alternative mode.

CONCLUSIONS

Both modes significantly underestimated obesity prevalence. Underestimation of actual BMI is greater for survey than pre-exam self-report for both genders, indicating that equations adjusting for self-report bias must be matched to the self-report mode.