Comparative response to PDT with methyl-aminolevulinate and temoporfin in cutaneous and oral squamous cell carcinoma cells

Cutaneous and Head and Neck squamous cell carcinoma (CSCC, HNSCC) are among the most prevalent cancers. Both types of cancer can be treated with photodynamic therapy (PDT) by using the photosensitizer Temoporfin in HNSCC and the prodrug methyl-aminolevulinate (MAL) in CSCC. However, PDT is not always effective. Therefore, it is mandatory to correctly approach the therapy according to the characteristics of the tumour cells. For this reason, we have used cell lines of CSCC (A431 and SCC13) and HNSCC (HN5 and SCC9). The results obtained indicated that the better response to MAL-PDT was related to its localization in the plasma membrane (A431 and HN5 cells). However, with Temoporfin all cell lines showed lysosome localization, even the most sensitive ones (HN5). The expression of mesenchymal markers and migratory capacity was greater in HNSCC lines compared to CSCC, but no correlation with PDT response was observed. The translocation to the nucleus of β-catenin and GSK3β and the activation of NF-κβ is related to the poor response to PDT in the HNSCC lines. Therefore, we propose that intracellular localization of GSK3β could be a good marker of response to PDT in HNSCC. Although the molecular mechanism of response to PDT needs further elucidation, this work shows that the most MAL-resistant line of CSCC is more sensitive to Temoporfin.

Changes in the Immunology of Breast Milk From Obese or Overweight Women: a Brief Review

A systematic search was carried out through search platforms and specialized databases, such as Academic Google, PubMed, and Scopus, using thesauri: breast feeding, obesity, immunology, and human milk in English and Spanish, and those articles published from January 2000 to December 2021, in both languages. Only those reports that included quantitative data on immunological components in the milk of normal-weight and overweight women were considered. The PRISMA 2020 guides were used, and a total of 306 articles were reviewed, of which a total of 33 were included, according to the basic inclusion criteria. It was observed that in obese mothers, there is an increase in certain immune cells, such as B lymphocytes, cytotoxic T lymphocytes, and NK cells, and cytokines, such as IL-6 and IFN-γ; other alterations included the bacterial population and proteins with antibacterial action. Also, a decrease in growth factors such as TGF-β and IFG-1 was documented in overweight women. Immunoglobulin concentrations did not show substantial changes. This brief review shows that maternal overweight is associated with changes in the biochemical and immunological parameters of milk.

Interaction among health workers and trans men: Findings from a qualitative study in Chile

PURPOSE

To explore trans men's access and use of healthcare services in Chile, based on the experiences of the trans men themselves, as well as of healthcare professionals.

METHODS

A qualitative study with an ethnographic approach was carried out with 30 participants: 14 trans men and 16 healthcare professionals. Semi-structured one-on-one interviews with open-ended questions were used to collect the data. A thematic analysis was carried out with the NVivo Software.

RESULTS

Three main themes were identified: (1) failures in the recognition of trans identity, (2) challenges with patient-centered care, and (3) use of other ("non-trans") health services.

CONCLUSIONS

The results suggest that not all transition processes are the same, individuals seek different ways; therefore, it is necessary to consider different body types and identities when planning programs and care for men in transition. Moreover, the accompaniment provided during the gender transition process should contemplate emotional and mental support.

CLINICAL RELEVANCE

The study outlines the need for all healthcare professionals to have training and knowledge about the transgender population, regardless of whether they are part of the teams supporting gender transition processes. The role of nurses and the contributions that can be made from nursing discipline in this research field are fundamental.

Bypassing the Need for Cell Permeabilization: Nanobody CDR3 Peptide Improves Binding on Living Bacteria

Membrane interaction constitutes to be an essential parameter in the mode of action of entities such as proteins, as well as cell-penetrating and antimicrobial peptides, resulting in noninvasive or lytic activities depending on the membrane compositions and interactions. Recently, a nanobody able to interact with the top priority, multidrug-resistant bacterial pathogen Acinetobacter baumannii was discovered, although binding took place with fixed cells only. To potentially overcome this limitation, linear peptides corresponding to the complementarity-determining regions (CDR) were synthesized and fluorescently labeled. Microscopy data indicated clear membrane interactions of the CDR3 sequence with living A. baumannii cells, indicating both the importance of the CDR3 as part of the parent nanobody paratope and the improved binding ability and thus avoiding the need for permeabilization of the cells. In addition, cyclization of the peptide with an additionally introduced rigidifying 1,2,3-triazole bridge retains its binding ability while proteolytically protecting the peptide. Overall, this study resulted in the discovery of novel peptides binding a multidrug-resistant pathogen.

Abstract 6689: Whole genome cell-free tumor DNA mutational signatures from blood for early detection of recurrence of low stage lung adenocarcinoma

Introduction: Lung cancer remains the leading cause of cancer-related deaths. Surgery is the best option for early lung cancer, and the role of adjuvant therapy remains controversial. Liquid biopsy offers a noninvasive approach to monitor cancer burden. Targeted sequencing of circulating cell free tumor DNA (ctDNA) in blood has shown success for diagnosis; however, low tumor burden and dynamic evolution of low stage disease is challenging for targeted panels. Thus, we hypothesized that a whole genome sequencing (WGS)-derived patient specific mutational signature from a matched tumor-normal WGS can provide sensitive and specific approach to detect mutations and copy numbers in ctDNA for monitoring of lung adenocarcinoma patients.

Methods: We successfully profiled 50 Stage 1 or 2 lung adenocarcinomas. ctDNA was extracted from 1-2 mL of plasma, tumor DNA was extracted from pathology tissue and normal germline DNA from the white blood cells. WGS using was performed on matched tumor and normal DNA, and ctDNA extracted from plasma. WGS coverage was 40x for matched tumor-normal and 20x for ctDNA. We derived a personalized mutational pattern for each tumor and used an AI-based error suppression model for quantification and ultra-sensitive detection of ctDNA in plasma samples. A patient-specific personalized genome-wide compendium of somatic mutations and copy numbers was established and ctDNA tested at 3 to 18 available time points during the therapy or follow up. A personalized mutational signature for detection ctDNA from WGS was quantified and the ctDNA Tumor Fraction (TF) was compared to the clinical status and time to recurrence.

Results: Tumor specific signatures were derived from matched tumor-normal samples with >5% tumor purity and <30% duplications rate. Out of all patients, 33 patients showed no recurrence and 12 recurred. Tumor-specific signatures detected the presence of the tumor signature in plasma with TF as low as 10−5. Based on positive minimal residual disease in plasma, the recurrence prediction sensitivity was 0.75 and specificity 0.82, with positive predictive value of 0.6 and negative predictive value 0.9. WGS ctDNA predicted recurrence with a median lead time of 508 days before clinical/imaging recurrence. In one case we were able to identify the second primary by deconvoluting known and novel ctDNA mutations. ctDNA mutational profiles enabled identification of smoking mutational signature matching clinical history, and APOBEC and ageing signatures as well as tumor mutational burden.

Conclusions: Patient-specific WGS tumor signature from plasma derived ctDNA enables specific and ultrasensitive tracking of minimal residual disease in low stage lung adenocarcinoma patients. Molecularly positive status can be used to predict recurrence and identify patients with clinical low stage disease that may benefit from adjuvant therapy.

Citation Format: Ivy Tran, Alejandro Vargas, Reid Wilkins, Isabella Pizzillo, Kenneth Tokoro, Danielle Afterman, Tomer Lauterman, Maja Kuzman, Santiago Gonzalez, Dunja Glavas, James Smadbeck, Dillon Maloney, Jurica Levatic, Samuel Phillips, Sunil Deochand, Michael Yahalom, Ryan Ptashkin, Iman Tavassoly, Zohar Donenhirsh, Eric White, Ravi Kandasamy, Ury Alon, Paz Polak, Boris Oklander, Asaf Zviran, Matija Snuderl, Harvey I. Pass. Whole genome cell-free tumor DNA mutational signatures from blood for early detection of recurrence of low stage lung adenocarcinoma. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6689.

Relationship between left ventriculoarterial coupling and damage stage in severe aortic stenosis

Background

In patients with severe aortic stenosis (AS), an anatomic and functional staging classification has been proposed to assess extent of cardiac chambers damage to improve the decision of aortic valve replacement based only in symptoms or ejection fraction (EF) <50%. This staging relies on the concept that left ventricular (LV) afterload secondary to AS induce LV dysfunction with progression to LV and right ventricular damage. However, afterload has valvular and vascular components, and the latter is not evaluated by the classification of stages. Characteristics of arterial vasculature can impact on LV function through the alteration in LV-VA coupling which is the relationship between effective arterial elastance (Ea) and LV end-systolic elastance (Emax).

Objective

To evaluate the relationship between LV-VA coupling and the different stages of cardiac damage in severe AS.

Methods

We studied 205 patients, age average 70±11 years, 117 men, with severe AS (AVA <1 cm2) with Doppler echocardiography. Measurements of cardiac chambers were made according to ASE/EACVI Guidelines. Ea was calculated as end-systolic pressure divided by stroke volume. End-systolic pressure was obtained from tonometry of carotid pulse. Emax was estimated by the method of Senzaki (1) as an index of LV contractility. Ea / Emax ratio was used to assess LV-VA coupling. Patients were divided in five groups according to the classification of staging cardiac damage proposed by Tasted (2): stage 0, no valvular cardiac damage; stage 1, LV damage (EF <60%); stage 2, left atrial or mitral valve damage; stage 3, pulmonary vasculature or tricuspid valve damage and stage 4, right ventricular damage, or subclinical heart failure (LV stroke volume index <30 ml/m2).

Results

Mean ± standard deviation (see Table 1). No patient was in stage 0. Symptoms was present in 40% of stage 1, 85% of stage 2 and 100% of stage 3 and 4. Ea increases from stage 2 to stage 4 while Emax did not change in those groups but decreased from stage 1 to 2. Consequently, LV-VA coupling progressively decreased from stage 1 to 4.

Conclusions

Worsening of LV-VA coupling increase with staging cardiac damage. The alteration of LV-VA coupling from stage 2 to 4 is due to an increase in Ea without significant changes in level of contractility (Emax). The progression of cardiac damage appears to be related not only to valve disease but also to the characteristics of arterial vasculature.

Funding Acknowledgement

Type of funding sources: None.

Expected Impact of the Pass/Fail Scoring System for USMLE Step 1 on the Plastic Surgery Residency Selection Process: A National Survey of Plastics Program Directors

Background: Traditionally, the United States Medical Licensing Examination (USMLE) Step 1 3-digit score has been used as a metric to stratify plastic surgery residency candidates. The transition to a pass/fail exam may impact the manner in which integrated plastic surgery residency program directors (PS-RPD) evaluate candidates. It may also limit opportunities for applicants to differentiate themselves from their counterparts.

Methods: A 14-question survey was distributed via email to 76 PS-RPDs collected from the American Medical Association (AMA) residency program site, FRIEDA. It was sent three times from March 3 - March 14, 2020. McNemar tests were performed on the current metrics of evaluation in comparison to metrics expected to be used in the absence of a 3-digit Step 1 score, assuming a P < 0.05 level for statistical significance. 

Results: Of the 76 integrated plastics programs surveyed, 24 PS-RPDs responded (31.6% response rate); 91.3% of PS-RPDs strongly disagree or disagree that Step 1 should be pass/fail; 78.3% of PS-RPDs strongly disagree or disagree that diversity will increase. The top five evaluation metrics PS-RPDs expect to utilize following the transition to pass/fail are: letters of recommendation (87.0%; CI 72% - 100%; p=0.500), Step 2 score (78.3%; CI 60% - 96%; p=0.001), research (56.5%; CI 35% - 78%; p=0.125), elective rotation (56.5%; CI 35% - 78%; p=1.000), and personal knowledge of the applicant (52.2%; CI 30% - 74%; p=0.500). 

Conclusions: In the absence of a Step 1 score, PS-RPDs may require more holistic metric(s) to evaluate the best fit for their program. This study found that PS-RPDs expect their candidate evaluation process to remain highly similar with the only statistically significant change being an increased emphasis on the candidate's Step 2 score. 

In Vivo Reflectance Confocal Microscopy of Cutaneous Acute Graft-Versus-Host Disease: Concordance with Histopathology and Interobserver Reproducibility of a Glossary with Representative Images

BACKGROUND

The reliability to noninvasively identify features of inflammatory dermatoses by reflectance confocal microscopy (RCM) remains unknown. Lack of formal training among RCM readers can result in inconsistent assessments, limiting clinical utility. Specific consensus terminology with representative images is necessary to ensure consistent feature-level interpretation among RCM readers.

OBJECTIVES

(1) Develop a glossary with representative images of RCM features of cutaneous acute graft-versus-host disease (aGVHD) for consistent interpretation among observers, (2) assess the interobserver reproducibility among RCM readers using the glossary, and (3) determine the concordance between RCM and histopathology for aGVHD features.

METHODS

Through an iterative process of refinement and discussion among five international RCM experts, we developed a glossary with representative images of RCM features of aGVHD. From April to November 2018, patients suspected of aGVHD were imaged with RCM and subsequently biopsied. 17 lesions from 12 patients had clinically and pathologically confirmed cutaneous aGVHD. For each of these lesions, four dermatopathologists and four RCM readers independently evaluated the presence of aGVHD features in scanned histopathology slides and 1.5x1.5 mm RCM submosaics at 4 depths (blockstacks), respectively. RCM cases were adjudicated by a fifth RCM expert. Interobserver reproducibility was calculated by U statistic. Concordance between modalities was determined by fraction agreement.

RESULTS

We present a glossary with representative images of 18 aGVHD features by RCM. The average interobserver reproducibility among RCM readers (75%, confidence interval, CI: 71%-79%) did not differ significantly from dermatopathologists (80%, 76%-85%). The concordance between RCM and histopathology was 59%.

CONCLUSIONS

By using the glossary, the interobserver reproducibility among RCM readers was similar to the interobserver reproducibility among dermatopathologists. There was good concordance between RCM and histopathology to visualize aGVHD features. The implementation of RCM can now be advanced in a variety of inflammatory conditions with a validated glossary and representative image set.

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality

BACKGROUND

Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).

METHODS

591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.

RESULTS

447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.

CONCLUSIONS

cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

What smell and taste disorders by SARS-CoV-2 do we know? Predictive value of the Venezuelan Olfactory Test and RT-PCR molecular analysis in COVID-19 infection

Background: Smell and taste disorders are reported very frequently and at an early stage in SARS-CoV-2 infectious disease. These symptoms could be sensitive and specific to establish possible severity of the infection, and may suggest the flow of decisions as to further therapy. Objective: We asked whether smell and taste impairment are earlier and more sensitive symptoms than the RT-PCR molecular assays for SARS-CoV-2 detection. Methods: Subjects (N=275) with a probable COVID-19 diagnosis were classified as follows: Symptomatic with chemosensory dysfunction, symptomatic without chemosensory dysfunction, and asymptomatic. Validated unbiased testing of the chemosensory dysfunction was performed by means of the Venezuelan Olfactory Test and taste test. Nasal swabs and blood samples were analyzed by RT-PCR molecular analysis a rapid diagnostic test to detect the SARS-CoV-2 virus and viral antibodies, respectively. Smell and taste testing and RT-PCR were performed every 3 to 5 days to patients until full recovery. Results: Out of 144 patients that were positive for SARS-CoV-2: 45.83% had COVID-19 symptoms, smell and taste disorders; 23.61% had COVID-19 symptoms but not smell or taste disorders, and 30.55% were asymptomatic. Mild hyposmia and hypogeusia were frequently associated with SARS-CoV-2 symptoms. Recovery from chemosensory dysfunction occurred between day 3 and 14. RT-PCR becomes negative after 21 days. The Venezuelan Olfactory Test and taste test has a 61.68% positive predictive value, 45.83% sensitivity, and 68.7% specificity for SARS-CoV-2. Conclusions: Smell and taste disorders are associated symptoms with SARS-CoV-2 infection, but not a predictor of the disease, as compared to the molecular RT-PCR test.

Comparing the effects of alcohol sclerotherapy with those of surgery on anti-Müllerian hormone and ovarian reserve after endometrioma treatment. A prospective multicenter pilot cohort study

STUDY OBJECTIVE

To compare the effects of ultrasound-guided aspiration and ethanol sclerotherapy with those of laparoscopic surgery on anti-Müllerian hormone (AMH) levels and ovarian reserve in benign-appearing ovarian endometrioma.

DESIGN

A prospective, cohort pilot study.

SETTING

Multiple centers, Spain.

PATIENTS

Forty patients with a suspected ovarian endometrioma with a maximum diameter of 35-100 mm. Serum hormonal concentrations were analyzed in 26 of these women.

INTERVENTIONS

Two groups: one that received US-guided aspiration plus alcohol sclerotherapy (n = 16) and the other that underwent laparoscopic cystectomy (n = 10).

MEASUREMENTS AND MAIN RESULTS

We studied serum hormonal concentrations (AMH, FSH and 17-β-estradiol) and antral follicle counts (AFC) in each patient at baseline, and after the procedures and pregnancies. No differences were found when comparing AMH and FSH concentrations before and after each procedure. 17-β-estradiol concentrations were significantly increased after alcohol sclerotherapy (p < 0.001). AFC recovery after 6 months seemed to be higher after sclerotherapy than after surgery. Three patients became pregnant in the sclerotherapy group.

CONCLUSION

This pilot study indicated that alcohol sclerotherapy preserves fertility in patients with endometriomas better than surgery, with significant increases in serum estradiol concentrations, possible AFC recovery and spontaneous pregnancies observed in the patients after sclerotherapy.

The evolution of relapse of adult T cell acute lymphoblastic leukemia

BACKGROUND

Adult T cell acute lymphoblastic leukemia (T-ALL) is a rare disease that affects less than 10 individuals in one million. It has been less studied than its cognate pediatric malignancy, which is more prevalent. A higher percentage of the adult patients relapse, compared to children. It is thus essential to study the mechanisms of relapse of adult T-ALL cases.

RESULTS

We profile whole-genome somatic mutations of 19 primary T-ALLs from adult patients and the corresponding relapse malignancies and analyze their evolution upon treatment in comparison with 238 pediatric and young adult ALL cases. We compare the mutational processes and driver mutations active in primary and relapse adult T-ALLs with those of pediatric patients. A precise estimation of clock-like mutations in leukemic cells shows that the emergence of the relapse clone occurs several months before the diagnosis of the primary T-ALL. Specifically, through the doubling time of the leukemic population, we find that in at least 14 out of the 19 patients, the population of relapse leukemia present at the moment of diagnosis comprises more than one but fewer than 108 blasts. Using simulations, we show that in all patients the relapse appears to be driven by genetic mutations.

CONCLUSIONS

The early appearance of a population of leukemic cells with genetic mechanisms of resistance across adult T-ALL cases constitutes a challenge for treatment. Improving early detection of the malignancy is thus key to prevent its relapse.

Ejection dynamics and valve kinetics in patients with low-gradient severe aortic stenosis with preserved ejection fraction. Comparison between normal and low-flow

Background

Studies of ejection dynamics in severe aortic stenosis and prosthetic valve obstruction had demonstrated a delay in aortic valve opening.

Purpose

The aim of this study was to compare and evaluate ejection dynamics and valve kinetics in patients with severe aortic stenosis with preserved ejection fraction with normal and low flow.

Methods

83 patients (age average 68±11 years) with severe aortic stenosis (aortic valve area &lt;1cm2) and preserved ejection fraction (≥50%) were studied with Doppler echocardiography and included prospectively. The ratio of aortic valve area measured at mid-deceleration and mid-acceleration (Md/Ma) were calculated using velocity of left ventricular outflow tract and aortic transvalvular velocity in continuity equation as an index of valvular kinetics. A ratio of Md/Ma &gt;1 indicate delay in opening of aortic valve. Assessment of ejection dynamics was evaluated with acceleration time (AT), ejection time (ET) and the ratio AT/ET estimated from aortic Doppler velocities profiles. Aortic flow was calculated as stroke volume/ET. According to stroke volume index and mean gradient patients were classified in 3 groups: normal-flow, low-gradient (NFLG) 25 patients, low-flow, low-gradient (LFLG) 28 patients and normal-flow, high-gradient (HG) 30 patients. Analysis of the variance and coefficient of correlation “r” were used for statistical evaluation. A p value &lt;0.05 was considered significant.

Results

There was no significant difference among the 3 groups with regard to ratio Md/Ma: NFLG 1.29±0.38, LFLG 1.22±0.26 and HG 1.23±0.45, NS. No difference was found in AT in the 3 groups, but ET was shorter in LFLG (310±30 ms) in comparison with NFLG (345±32 ms) and HG (361±31 ms), p&lt;0.01. Ratio AT/ET occurred in early systole in NFLG (0.27±0.07) compared with LFLG (0.32±0.07) and HG (0.39±0.07), p&lt;0.01. As expected, flow was decreased in LFLG (163±20 ml/s, p&lt;0.001) compared with NFLG (217±13 ml/s) and HG (233±44 ml/s). There was no correlation among AT/ET and aortic flow or stroke volume index.

Conclusions

There were not differences among the groups with regard to kinetic of the valve evaluated by mean of ratio Md/Ma. According to ratio AT/ET, aortic valve takes less time to open in NFLG compared with LFLG and HG independent of aortic flow suggesting a different ejection dynamics pattern in this group.

Funding Acknowledgement

Type of funding source: None

Mutational signatures are jointly shaped by DNA damage and repair

Cells possess an armamentarium of DNA repair pathways to counter DNA damage and prevent mutation. Here we use C. elegans whole genome sequencing to systematically quantify the contributions of these factors to mutational signatures. We analyse 2,717 genomes from wild-type and 53 DNA repair defective backgrounds, exposed to 11 genotoxins, including UV-B and ionizing radiation, alkylating compounds, aristolochic acid, aflatoxin B1, and cisplatin. Combined genotoxic exposure and DNA repair deficiency alters mutation rates or signatures in 41% of experiments, revealing how different DNA alterations induced by the same genotoxin are mended by separate repair pathways. Error-prone translesion synthesis causes the majority of genotoxin-induced base substitutions, but averts larger deletions. Nucleotide excision repair prevents up to 99% of point mutations, almost uniformly across the mutation spectrum. Our data show that mutational signatures are joint products of DNA damage and repair and suggest that multiple factors underlie signatures observed in cancer genomes.

Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study

STUDY OBJECTIVE

To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma.

DESIGN

Prospective, cohort pilot study.

SETTING

Multiple centers, Spain.

PATIENTS

Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria.

INTERVENTIONS

The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy.

MEASUREMENTS AND MAIN RESULTS

Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01-1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group-266 euros versus 2189 euros.

CONCLUSION

Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale1-3. Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter4; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation5,6; analyses timings and patterns of tumour evolution7; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity8,9; and evaluates a range of more-specialized features of cancer genomes8,10-18.

The evolutionary history of 2,658 cancers

Cancer develops through a process of somatic evolution1,2. Sequencing data from a single biopsy represent a snapshot of this process that can reveal the timing of specific genomic aberrations and the changing influence of mutational processes3. Here, by whole-genome sequencing analysis of 2,658 cancers as part of the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA)4, we reconstruct the life history and evolution of mutational processes and driver mutation sequences of 38 types of cancer. Early oncogenesis is characterized by mutations in a constrained set of driver genes, and specific copy number gains, such as trisomy 7 in glioblastoma and isochromosome 17q in medulloblastoma. The mutational spectrum changes significantly throughout tumour evolution in 40% of samples. A nearly fourfold diversification of driver genes and increased genomic instability are features of later stages. Copy number alterations often occur in mitotic crises, and lead to simultaneous gains of chromosomal segments. Timing analyses suggest that driver mutations often precede diagnosis by many years, if not decades. Together, these results determine the evolutionary trajectories of cancer, and highlight opportunities for early cancer detection.

Founding a USMLE Step 1 student organization: A new approach to promote student engagement and peer support in exam preparation

This article was migrated. The article was not marked as recommended. The USMLE Step 1 exam is the principal tool that US residency programs utilize to select applicants for interview. Due to the high stakes nature of the exam, both students and educators need to be informed about the most effective preparation tools and support strategies available to students. The literature has evidence to suggest that the number of board-style questions a student completes has a strong correlation with performance on the exam. Based on this premise, a group of medical students developed a USMLE step 1 preparation program to increase the number of practice questions they completed, and to foster support and comradery among students. The main contribution of this educational initiative is its structure as a registered student organization, which may help to promote the program's continuity and constant improvement as the lessons learned pass from one class of student officers to the next. This article may serve as a how-to guide to describe the steps we took to start a Step 1 registered student organization at our institution, and about how the reader may be able to apply our experiences to create their own step 1 student organization at their institution.

Genomic landscape and chronological reconstruction of driver events in multiple myeloma

The multiple myeloma (MM) genome is heterogeneous and evolves through preclinical and post-diagnosis phases. Here we report a catalog and hierarchy of driver lesions using sequences from 67 MM genomes serially collected from 30 patients together with public exome datasets. Bayesian clustering defines at least 7 genomic subgroups with distinct sets of co-operating events. Focusing on whole genome sequencing data, complex structural events emerge as major drivers, including chromothripsis and a novel replication-based mechanism of templated insertions, which typically occur early. Hyperdiploidy also occurs early, with individual trisomies often acquired in different chronological windows during evolution, and with a preferred order of acquisition. Conversely, positively selected point mutations, whole genome duplication and chromoplexy events occur in later disease phases. Thus, initiating driver events, drawn from a limited repertoire of structural and numerical chromosomal changes, shape preferred trajectories of evolution that are biologically relevant but heterogeneous across patients.

Role of boost radiotherapy for local control of pure ductal carcinoma in situ after breast-conserving surgery: a multicenter, retrospective study of 622 patients

PURPOSE

To evaluate the effect of boost radiotherapy on ipsilateral breast tumor recurrence (IBTR) for ductal carcinoma in situ (DCIS) after breast-conserving surgery and whole breast radiotherapy (WBRT) with or without boost.

METHODS AND MATERIALS

Retrospective, multicentre study of 622 patients (624 tumors) diagnosed with pure DCIS from 1993-2011.

RESULTS

Most tumors (377/624; 60.4%) received a boost. At a median follow-up of 8.8 years, IBTR occurred in 64 cases (10.3%). A higher percentage of patients with risk factors for IBTR received a boost (p < 0.05). Boost was not associated with lower rates of IBTR than WBRT alone (HR 0.75, 95% CI 0.42-1.35). On the univariate analyses, IBTR was significantly associated with tumor size (11-20 mm, HR 2.32, 95% CI 1.27-4.24; and > 20 mm, HR 2.10, 95% CI 1.14-3.88), re-excision (HR 1.76, 95% CI 1.04-2.96), and tamoxifen (HR 2.03, 95% CI 1.12-3.70). Boost dose > 16 Gy had a protective effect (HR 0.39, 95% CI 0.187-0.824). Multivariate analyses confirmed the independent associations between IBTR and 11-20 mm (p = 0.02) and > 20 mm (p = 0.009) tumours, and re-excision (p = 0.006). On the margin-stratified multivariate analysis, tamoxifen was a poor prognostic factor in the close/positive margin subgroup (HR 4.28 95% CI 1.23-14.88), while the highest boost dose ( > 16 Gy) had a significant positive effect (HR 0.34, 95% CI 0.13-0.86) in the negative margin subgroup.

CONCLUSIONS

Radiotherapy boost did not improve the risk of IBTR. Boost radiotherapy was more common in patients with high-risk disease. Tumor size and re-excision were significant independent prognostic factors.

Abundance and Biogeochemical Impact of Cable Bacteria in Baltic Sea Sediments

Oxygen depletion in coastal waters may lead to release of toxic sulfide from sediments. Cable bacteria can limit sulfide release by promoting iron oxide formation in sediments. Currently, it is unknown how widespread this phenomenon is. Here, we assess the abundance, activity, and biogeochemical impact of cable bacteria at 12 Baltic Sea sites. Cable bacteria were mostly absent in sediments overlain by anoxic and sulfidic bottom waters, emphasizing their dependence on oxygen or nitrate as electron acceptors. At sites that were temporarily reoxygenated, cable bacterial densities were low. At seasonally hypoxic sites, cable bacterial densities correlated linearly with the supply of sulfide. The highest densities were observed at Gulf of Finland sites with high rates of sulfate reduction. Microelectrode profiles of sulfide, oxygen, and pH indicated low or no in situ cable bacteria activity at all sites. Reactivation occurred within 5 days upon incubation of an intact sediment core from the Gulf of Finland with aerated overlying water. We found no relationship between cable bacterial densities and macrofaunal abundances, salinity, or sediment organic carbon. Our geochemical data suggest that cable bacteria promote conversion of iron monosulfides to iron oxides in the Gulf of Finland in spring, possibly explaining why bottom waters in this highly eutrophic region rarely contain sulfide in summer.

In Vivo Reflectance Confocal Microscopy: Emerging Role in Noninvasive Diagnosis and Monitoring of Eczematous Dermatoses

Dermatologic diagnosis and monitoring have been dependent largely on visual grading. A skin biopsy is performed in case of diagnostic uncertainty, but can be traumatic, and results are delayed due to time for specimen transport and processing. Biopsies also destroy specimens, prohibiting lesion evolution monitoring. In vivo reflectance confocal microscopy (RCM) offers a diagnostic alternative to skin biopsy. RCM captures real-time, high-resolution images, and has been piloted for the evaluation of various dermatologic conditions. Identification of unique RCM features may distinguish dermatoses with similar clinical morphologies. Allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) are diagnosed by patch testing that currently uses a subjective scoring system. RCM has increasingly been studied for early detection and severity grading of CD. Common RCM features shared by ACD and ICD are stratum corneum disruption, vesicle formation, exocytosis, spongiosis, and parakeratosis. Features unique to ACD are vasodilation, increased epidermal thickness, intercellular edema, and acanthosis. Features unique to ICD are detached corneocytes and targetoid keratinocytes. This review summarizes the use of RCM in evaluating contact eccematous conditions and aims to spark future research and interest in this promising tool.

Lectin-like transcript 1 (LLT1) expression is associated with nodal metastasis in patients with head and neck cutaneous squamous cell carcinoma

The interaction of lectin-like transcript 1 (LLT1) with CD161 inhibits Natural Killer cell activation. Overexpression of LLT1 contributes to the immunosuppressive properties of tumor cells. However, there are little data about LLT1 expression in human solid tumors. The objective of this paper is to investigate the relationship between LLT1 expression with the clinicopathologic features and its impact on the prognosis of head and neck cutaneous squamous cell carcinoma (cSCC). LLT1 expression was analyzed on paraffin-embedded tissue samples obtained from 100 patients with cSCC by immunohistochemistry. The estimator of Fine and Gray was used to estimate the cumulative incidence curves for relapse. Proportional Hazard models and Hazard ratios (HRs) were used for studying the risk of tumor relapse and mortality. LLT1 strong expression was a significant risk factor for nodal metastasis with crude and adjusted ratios (HRs) of 3.40 (95% CI 1.39-9.28) and 3.25 (95% CI 1.15-9.16); and for cSCC specific death of 6.17 (95% CI 1.79-21.2) and 6.10 (95% CI 1.45-25.7). Strong LLT1 expression is an independent predictor of nodal metastasis and poor disease-specific survival and it might be helpful for risk stratification of patients with cSCC.

Glutathione S-transferases promote proinflammatory astrocyte-microglia communication during brain inflammation

Astrocytes and microglia play critical roles in brain inflammation. Here, we report that glutathione S-transferases (GSTs), particularly GSTM1, promote proinflammatory signaling in astrocytes and contribute to astrocyte-mediated microglia activation during brain inflammation. In vivo, astrocyte-specific knockdown of GSTM1 in the prefrontal cortex attenuated microglia activation in brain inflammation induced by systemic injection of lipopolysaccharides (LPS). Knocking down GSTM1 in astrocytes also attenuated LPS-induced production of the proinflammatory cytokine tumor necrosis factor-α (TNF-α) by microglia when the two cell types were cocultured. In astrocytes, GSTM1 was required for the activation of nuclear factor κB (NF-κB) and the production of proinflammatory mediators, such as granulocyte-macrophage colony-stimulating factor (GM-CSF) and C-C motif chemokine ligand 2 (CCL2), both of which enhance microglia activation. Our study suggests that GSTs play a proinflammatory role in priming astrocytes and enhancing microglia activation in a microglia-astrocyte positive feedback loop during brain inflammation.

Unexplored Questions About Away Rotations - A Student's Perspective

This article was migrated. The article was marked as recommended. Many fourth-year medical students complete away rotations as elective courses within their specialty of choice. The popularity of away rotations is increasing and has become nearly ubiquitous in certain competitive specialties ( Higgins et al., 2016). Benefits include obtaining letters of recommendation, diversifying clinical exposure, expanding research opportunities, and establishing a connection with a residency program. Some disadvantages include cost, stress, competitive nature among applicants, and separation from personal support networks. We are writing this to bring attention to the pros and cons of away rotations, and to the absence of substantial data available in the literature to help us understand the actual impact that away rotations may have on our residency matching outcomes.

Nanoclusters of crystallographically aligned nanoparticles for magnetic thermotherapy: aqueous ferrofluid, agarose phantoms and ex vivo melanoma tumour assessment

Magnetic hyperthermia is an oncological therapy where magnetic nanostructures, under a radiofrequency field, act as heat transducers increasing tumour temperature and killing cancerous cells. Nanostructure heating efficiency depends both on the field conditions and on the nanostructure properties and mobility inside the tumour. Such nanostructures are often incorrectly bench-marketed in the colloidal state and using field settings far off from the recommended therapeutic values. Here, we prepared nanoclusters composed of iron oxide magnetite nanoparticles crystallographically aligned and their specific absorption rate (SAR) values were calorimetrically determined in physiological fluids, agarose-gel-phantoms and ex vivo tumours extracted from mice challenged with B16-F0 melanoma cells. A portable, multipurpose applicator using medical field settings; 100 kHz and 9.3 kA m^-1, was developed and the results were fully analysed in terms of nanoclusters' structural and magnetic properties. A careful evaluation of the nanoclusters' heating capacity in the three milieus clearly indicates that the SAR values of fluid suspensions or agarose-gel-phantoms are not adequate to predict the real tissue temperature increase or the dosage needed to heat a tumour. Our results show that besides nanostructure mobility, perfusion and local thermoregulation, the nanostructure distribution inside the tumour plays a key role in effective heating. A suppression of the magnetic material effective heating efficiency appears in tumour tissue. In fact, dosage had to be increased considerably, from the SAR values predicted from fluid or agarose, to achieve the desired temperature increase. These results represent an important contribution towards the design of more efficient nanostructures and towards the clinical translation of hyperthermia.

Accuracy of tele-consultation on management decisions of lesions suspect for melanoma using reflectance confocal microscopy as a stand-alone diagnostic tool

BACKGROUND

Diagnostic accuracy of reflectance confocal microscopy (RCM) as a stand-alone diagnostic tool for suspect skin lesions has not been extensively studied.

OBJECTIVE

Primary aim was to measure experts' accuracy in RCM-based management decisions. Secondary aim was to identify melanoma-specific RCM features.

METHODS

The study enrolled patients ≥18 years that underwent biopsy of skin lesions clinically suspected to be melanoma. One hundred lesions imaged by RCM were randomly selected from 439 lesions prospectively collected at four pigmented lesion clinics. The study data set included 23 melanomas, three basal cell and two squamous cell carcinomas, 11 indeterminate melanocytic lesions and 61 benign lesions including 50 nevi. Three expert RCM evaluators were blinded to clinical or dermoscopic images, and to the final histopathological diagnosis. Evaluators independently issued a binary RCM-based management decision, 'biopsy' vs. 'observation'; these decisions were scored against histopathological diagnosis, with 'biopsy' as the correct management decision for malignant and indeterminate lesions. A subset analysis of 23 melanomas and 50 nevi with unequivocal histopathological diagnosis was performed to identify melanoma-specific RCM features.

RESULTS

Sensitivity, specificity and diagnostic accuracy were 74%, 67% and 70% for reader 1, 46%, 84% and 69% for reader 2, and 72%, 46% and 56% for reader 3, respectively. The overall kappa for management decisions was 0.34. Readers had unanimous agreement on management for 50 of the 100 lesions. Non-specific architecture, non-visible papillae, streaming of nuclei, coarse collagen fibres and abnormal vasculature showed a significant association with melanoma in the evaluation of at least two readers.

CONCLUSIONS

Reflectance confocal microscopy tele-consultation of especially challenging lesions, based on image review without benefit of clinical or dermoscopy images, may be associated with limited diagnostic accuracy and interobserver agreement. Architectural and stromal criteria may emerge as potentially useful and reproducible criteria for melanoma diagnosis.

Abstract 218: The evolutionary history of 2,658 cancers

Cancer develops through a continuous process of somatic evolution. Whole genome sequencing provides a snapshot of the tumor genome at the point of sampling, however, the data can contain information that permits the reconstruction of a tumor's evolutionary past.

Here, we apply such life history analyses on an unprecedented scale, to a set of 2,658 tumors spanning 39 cancer types. We estimated the timing of large chromosomal gains during tumor evolution, by comparing the rates of doubled to non-doubled point mutations within gained regions. Although we find that such events typically occur in the second half of clonal evolution, we also observe distinctive and early chromosomal gains in some cancer types, such as gains of chromosomes 7, 19 and 20 in glioblastoma, and isochromosome 17q in medulloblastoma. By integrating these results with the qualitative timing of individual driver mutations, we obtained an overall ranking, from early to late, of frequent somatic events per cancer type, which both identified novel patterns of tumor evolution, and incorporated additional detail into known models, such as the progression of APC-KRAS-TP53 in colorectal cancer proposed by Vogelstein and Fearon.

To estimate how mutational processes acting on the tumor genome change over time, we classified mutations in each sample according to three broad time periods (early clonal, late clonal, and subclonal), and quantified the activity of mutational signatures in each period. Most mutational processes appear to remain remarkably constant, however, certain signatures show clear and consistent changes during clonal evolution. Particularly, mutational signatures associated with exposure to carcinogens, such as smoking and UV light, tend to decrease over time. In contrast, signatures associated with defective endogenous processes, such as APOBEC mutagenesis and defective double strand break repair, show an increase between early and late phases of tumor evolution.

Making use of clock-like mutational signatures, we converted mutational time estimates for large events, such as whole genome duplication (WGD), and the emergence of the most recent common ancestor (MRCA), into real time estimates, which allowed us to combine our analyses into overall timelines of cancer evolution, per tumor type. For example, the typical timeline of ovarian adenocarcinoma development shows that early tumor evolution is characterized by mutations in TP53, and widespread genome instability, with WGD events taking place on average 8 years prior to diagnosis. In later stages of evolution, signatures of defective repair processes increase, and the MRCA emerges on average 1 year before diagnosis.

Taken together, these data reveal the common and divergent evolutionary trajectories available to a cancer, which might be crucial in understanding specific tumor biology, and in providing new opportunities for early detection and cancer prevention.

Citation Format: Clemency Jolly, Moritz Gerstung, Ignaty Leshchiner, Stefan C. Dentro, Santiago Gonzalez, Thomas J. Mitchell, Yulia Rubanova, Pavana Anur, Daniel Rosebrock, Kaixian Yu, Maxime Tarabichi, Amit Deshwar, Jeff Wintersinger, Kortine Kleinheinz, Ignacio Vásquez-García, Kerstin Haase, Subhajit Sengupta, Geoff Macintyre, Salem Malikic, Nilgun Donmez, Dimitri G. Livitz, Mark Cmero, Jonas Demeulemeester, Steve Schumacher, Yu Fan, Xiaotong Yao, Juhee Lee, Matthias Schlesner, Paul C. Boutros, David D. Bowtell, Hongtu Zhu, Gad Getz, Marcin Imielinski, Rameen Beroukhim, S Cenk Sahinalp, Yuan Ji, Martin Peifer, Florian Markowetz, Ville Mustonen, Ke Juan, Wenyi Wang, Quaid D. Morris, Paul T. Spellman, David C. Wedge, Peter Van Loo, PCAWG Evolution and Heterogeneity Working Group. The evolutionary history of 2,658 cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 218.

Main problems and suggested solutions for improving radiation protection in medicine in Ibero-American countries. Summary of an International Conference held in Madrid, 2016

During the International Conference on Radiation Protection in Medicine held in Bonn in 2012, several areas for improvement were identified, including specific actions related with justification, optimization, role of manufacturers, radiation protection education and training, strategic research, data collection on medical and occupational exposures, prevention of incidents and accidents, radiation safety culture, risk-benefit dialogue and implementation of the radiation safety standards. The outcomes of the Bonn Conference were summarized in the so-called 'Bonn Call for Action', identifying 10 priority actions to enhance RP in medicine. Trying to analyse the progress in the implementation of this 'Call for Action' in the Ibero-American region, several international organizations organized the 'Ibero-American Conference on Radiation Protection in Medicine' (Conferencia Iberoamericana sobre Protección Radiológica en Medicina, CIPRaM) held in Madrid, in October 2016. CIPRaM was structured in eight thematic sessions dealing with: diagnostic and dental radiology, image guided interventional radiology, nuclear medicine, radiation therapy, health authorities and radiation protection regulators, professional associations of technologists and nurses, professional associations of medical physicists and radiation protection experts, and universities and researchers in radiation protection in medicine. This paper summarizes the main results of that Conference based on the consensus achieved about main problems, solutions, and indicators to evaluate the implementation of the proposed solutions.