Cystic renal mass screening: machine-learning-based radiomics on unenhanced computed tomography

PURPOSE

The present study compares the diagnostic performance of unenhanced computed tomography (CT) radiomics-based machine learning (ML) classifiers and a radiologist in cystic renal masses (CRMs).

METHODS

Patients with pathologically diagnosed CRMs from two hospitals were enrolled in the study. Unenhanced CT radiomic features were extracted for ML modeling in the training set (Guangzhou; 162 CRMs, 85 malignant). Total tumor segmentation was performed by two radiologists. Features with intraclass correlation coefficients of >0.75 were screened using univariate analysis, least absolute shrinkage and selection operator, and bidirectional elimination to construct random forest (RF), decision tree (DT), and k-nearest neighbor (KNN) models. External validation was performed in the Zhuhai set (45 CRMs, 30 malignant). All images were assessed by a radiologist. The ML models were evaluated using calibration curves, decision curves, and receiver operating characteristic (ROC) curves.

RESULTS

Of the 207 patients (102 women; 59.1 ± 11.5 years), 92 (41 women; 58.0 ± 13.7 years) had benign CRMs, and 115 (61 women; 59.8 ± 11.4 years) had malignant CRMs. The accuracy, sensitivity, and specificity of the radiologist's diagnoses were 85.5%, 84.2%, and 91.1%, respectively [area under the (ROC) curve (AUC), 0.87]. The ML classifiers showed similar sensitivity (94.2%-100%), specificity (94.7%-100%), and accuracy (94.3%-100%) in the training set. In the validation set, KNN showed better sensitivity, accuracy, and AUC than DT and RF but weaker specificity. Calibration and decision curves showed excellent and good results in the training and validation set, respectively.

CONCLUSION

Unenhanced CT radiomics-based ML classifiers, especially KNN, may aid in screening CRMs.

Enhanced and unenhanced: Radiomics models for discriminating between benign and malignant cystic renal masses on CT images: A multi-center study

BACKGROUND

Machine learning algorithms used to classify cystic renal masses (CRMs) nave not been applied to unenhanced CT images, and their diagnostic accuracy had not been compared against radiologists.

METHOD

This retrospective study aimed to develop radiomics models that discriminate between benign and malignant CRMs in a triple phase computed tomography (CT) protocol and compare the diagnostic accuracy of the radiomics approach with experienced radiologists. Predictive models were established using a training set and validation set of unenhanced and enhanced (arterial phase [AP] and venous phase [VP]) CT images of benign and malignant CRMs. The diagnostic capabilities of the models and experienced radiologists were compared using Receiver Operating Characteristic (ROC) curves.

RESULTS

On unenhanced, AP and VP CT images in the validation set, the AUC, specificity, sensitivity and accuracy for discriminating between benign and malignant CRMs were 90.0 (95%CI: 81-98%), 90.0%, 90.5% and 90.2%; 93.0% (95%CI: 86-99%), 86.7%, 95.2% and 88.3%; and 95.0% (95%CI: 90%-100%), 93.3%, 90.5% and 92.1%, respectively, for the radiomics models. Diagnostic accuracy of the radiomics models differed significantly on unenhanced images in the training set vs. each radiologist (p = 0.001 and 0.003) but not in the validation set (p = 0.230 and 0.590); differed significantly on AP images in the validation set vs. each radiologist (p = 0.007 and 0.007) but not in the training set (p = 0.663 and 0.663); and there were no differences on VP images in the training or validation sets vs. each radiologist (training set: p = 0.453 and 0.051, validation set: p = 0.236 and 0.786).

CONCLUSIONS

Radiomics models may have clinical utility for discriminating between benign and malignant CRMs on unenhanced and enhanced CT images. The performance of the radiomics model on unenhanced CT images was similar to experienced radiologists, implying it has potential as a screening and diagnostic tool for CRMs.

Case report: A case of duodenal adenocarcinoma achieving significantly long survival treating with immune checkpoint inhibitors and chemotherapy without positive biomarkers

Small bowel adenocarcinoma (SBA), particularly duodenal adenocarcinoma (DA), is a rare gastrointestinal cancer with a dismal prognosis. Data on SBA treatments are limited, and the therapeutic strategy remains uncertain. Currently, chemotherapy is the most used treatment; however, it has a poor median progression-free survival (mPFS) of no more than five months in the second-line setting. We report a case with DA that responded well to the immune checkpoint inhibitor (ICI) tislelizumab plus irinotecan in the second-line treatment. To our knowledge, this is the first report of administering ICIs plus chemotherapy to SBA. Despite the absence of microsatellite instability-high (MSI-H) and high tumor mutational burden (TMB), the patient with TP53/KRAS mutation achieved a significantly long PFS of 17 months, and the benefit is still ongoing. The mechanism of this remarkable efficacy might be associated with an increase in tumor immunogenicity after chemotherapy. The current study presents a promising effect of ICIs plus chemotherapy on SBA, affirming the need to investigate the clinical value of this combination in SBA and the underlying mechanism behind it.

Utility of dual-layer spectral-detector CT imaging for predicting pathological tumor stages and histologic grades of colorectal adenocarcinoma

Objectives

To assess the utility of Dual-layer spectral-detector CT (DLCT) in predicting the pT stage and histologic grade for colorectal adenocarcinoma (CRAC).

Methods

A total of 131 patients (mean 62.7 ± 12.9 years; 72 female, 59 male) with pathologically confirmed CRAC (35 pT1-2, 61 pT3, and 35 pT4; 32 high grade and 99 low grade), who received dual-phase DLCT were enrolled in this retrospective study. Normalized iodine concentration (NIC), slope of the spectral HU curve (λHU), and effective atomic number (Eff-Z) were measured for each lesion by two radiologists independently. Intraobserver reliability and interobserver agreement were assessed. The above values were compared between three pT-stage and two histologic-grade groups. The correlation between the pT stages and above values were assessed. Receiver operating characteristic (ROC) curves were calculated to evaluate the diagnostic efficacy.

Results

Intra-class correlation coefficients were ranged from 0.856 to 0.983 for all measurements. Eff-Z [7.21(0.09) vs 7.31 (0.10) vs 7.35 (0.19)], NIC_AP [0.11 (0.05) vs 0.15 (0.08) vs 0.15 (0.08)], NIC_VP [0.27 (0.06) vs 0.34 (0.11) vs 0.35 (0.12)], λHU_AP [1.20 (0.45) vs 1.93 (1.18) vs 2.37 (0.91)], and λHU_VP [2.07 (0.68) vs 2.35 (0.62) vs 3.09 (1.07)] were significantly different among pT stage groups (all P<0.001) and exhibited a positive correlation with pT stages (r= 0.503, 0.455, 0.394, 0.512, 0.376, respectively, all P<0.001). Eff-Z [7.37 (0.10) vs 7.28 (0.08)], NIC_AP[0.20 (0.10) vs 0.13 (0.08)], NIC_VP[0.35 (0.07) vs 0.31 (0.11)], and λHU_AP [2.59 (1.11) vs 1.63 (0.75)] in the high-grade group were markedly higher than those in the low-grade group (all P<0.05). For discriminating the advanced- from early-stage CARC, the AUCs of Eff-Z, NIC_AP, NIC_VP, λHU_AP, and λHU_VP were 0.83, 0.80, 0.79, 0.86, and 0.68, respectively (all P<0.001). For discriminating the high- from low-grade CARC, the AUCs of Eff-Z, NIC_AP, NIC_VP, and λHU_AP were 0.81, 0.81, 0.64, and 0.81, respectively (all P<0.05).

Conclusions

The quantitative parameters derived from DLCT may provide new markers for assessing pT stages and histologic differentiation in patients with CRAC.

Evaluation of the Modulation Effects Evoked by Different Transcutaneous Auricular Vagus Nerve Stimulation Frequencies Along the Central Vagus Nerve Pathway in Migraine: A Functional Magnetic Resonance Imaging Study

OBJECTIVES

Transcutaneous auricular vagus nerve stimulation (taVNS) is a promising treatment option for migraines. This study aims to investigate the modulation effects of different taVNS frequencies along the central vagus nerve pathway in migraineurs.

MATERIALS AND METHODS

Twenty-four migraineurs were recruited for a single-blind, crossover magnetic resonance imaging (MRI) study. The study consisted of two taVNS MRI scan sessions, in which either 1-Hz or 20-Hz taVNS was applied in a random order. Seed-based static and dynamic functional connectivity (FC) analyses were performed using two key nodes of the vagus nerve pathway, the nucleus tractus solitarius (NTS) and the locus coeruleus (LC).

RESULTS

Static FC (sFC) analysis showed that 1) continuous 1-Hz taVNS resulted in an increase of NTS/LC-occipital cortex sFC and a decrease of NTS-thalamus sFC compared with the pre-1-Hz taVNS resting state, 2) continuous 20-Hz taVNS resulted in an increase of the LC-anterior cingulate cortex (ACC) sFC compared with the pre-20-Hz taVNS resting state, 3) 1-Hz taVNS produced a greater LC-precuneus and LC-inferior parietal cortex sFC than 20 Hz, and 4) 20-Hz taVNS increased LC-ACC and LC-super temporal gyrus/insula sFC in comparison with 1 Hz. Dynamic FC (dFC) analysis showed that compared with the pre-taVNS resting state, 1-Hz taVNS decreased NTS-postcentral gyrus dFC (less variability), 20-Hz taVNS decreased dFC of the LC-superior temporal gyrus and the LC-occipital cortex. Finally, a positive correlation was found between the subjects' number of migraine attacks in the past four weeks and the NTS-thalamus sFC during pre-taVNS resting state.

CONCLUSIONS

1-Hz and 20-Hz taVNS may modulate the sFC and dFC of key nodes in the central vagus nerve pathway differently. Our findings highlight the importance of stimulation parameters (frequencies) in taVNS treatment.

Predicting response to tVNS in patients with migraine using functional MRI: A voxels-based machine learning analysis

Background

Migraine is a common disorder, affecting many patients. However, for one thing, lacking objective biomarkers, misdiagnosis, and missed diagnosis happen occasionally. For another, though transcutaneous vagus nerve stimulation (tVNS) could alleviate migraine symptoms, the individual difference of tVNS efficacy in migraineurs hamper the clinical application of tVNS. Therefore, it is necessary to identify biomarkers to discriminate migraineurs as well as select patients suitable for tVNS treatment.

Methods

A total of 70 patients diagnosed with migraine without aura (MWoA) and 70 matched healthy controls were recruited to complete fMRI scanning. In study 1, the fractional amplitude of low-frequency fluctuation (fALFF) of each voxel was calculated, and the differences between healthy controls and MWoA were compared. Meaningful voxels were extracted as features for discriminating model construction by a support vector machine. The performance of the discriminating model was assessed by accuracy, sensitivity, and specificity. In addition, a mask of these significant brain regions was generated for further analysis. Then, in study 2, 33 of the 70 patients with MWoA in study 1 receiving real tVNS were included to construct the predicting model in the generated mask. Discriminative features of the discriminating model in study 1 were used to predict the reduction of attack frequency after a 4-week tVNS treatment by support vector regression. A correlation coefficient between predicted value and actual value of the reduction of migraine attack frequency was conducted in 33 patients to assess the performance of predicting model after tVNS treatment. We vislized the distribution of the predictive voxels as well as investigated the association between fALFF change (post-per treatment) of predict weight brain regions and clinical outcomes (frequency of migraine attack) in the real group.

Results

A biomarker containing 3,650 features was identified with an accuracy of 79.3%, sensitivity of 78.6%, and specificity of 80.0% (p &lt; 0.002). The discriminative features were found in the trigeminal cervical complex/rostral ventromedial medulla (TCC/RVM), thalamus, medial prefrontal cortex (mPFC), and temporal gyrus. Then, 70 of 3,650 discriminative features were identified to predict the reduction of attack frequency after tVNS treatment with a correlation coefficient of 0.36 (p = 0.03). The 70 predictive features were involved in TCC/RVM, mPFC, temporal gyrus, middle cingulate cortex (MCC), and insula. The reduction of migraine attack frequency had a positive correlation with right TCC/RVM (r = 0.433, p = 0.021), left MCC (r = 0.451, p = 0.016), and bilateral mPFC (r = 0.416, p = 0.028), and negative with left insula (r = −0.473, p = 0.011) and right superior temporal gyrus/middle temporal gyrus (r = −0.684, p &lt; 0.001), respectively.

Conclusions

By machine learning, the study proposed two potential biomarkers that could discriminate patients with MWoA and predict the efficacy of tVNS in reducing migraine attack frequency. The pivotal features were mainly located in the TCC/RVM, thalamus, mPFC, and temporal gyrus.

Case Report: Two Cases of Soft-Tissue Sarcomas: High TMB as a Potential Predictive Biomarker for Anlotinib Combined With Toripalimab Therapy

Soft-tissue sarcomas (STS), with over 100 different histologic subtypes, are rare tumors that account for 1% of all adult malignancies. Immune checkpoint inhibitors (ICIs) display certain benefits in some subtypes, especially in undifferentiated pleomorphic sarcoma (UPS), alveolar soft part sarcoma (ASPS), and leiomyosarcoma (LMS). However, efficacy is difficult to predict. High tumor mutational burden (TMB-H) and programmed death-ligand 1 (PD-L1) expression are the strongest features associated with the efficacy of immunotherapy, although they are rarely found in STS patients. Until now, whether or not PD-L1 expression and TMB are related to the efficacy of immunotherapy has not been determined. In this study, we report data obtained from two STS patients, one ASPS and one UPS with a high TMB, that benefited from anlotinib combined with toripalimab following resistance to anlotinib monotherapy. A 26 year-old female patient was diagnosed with ASPS. PD-L1 was negative. Next generation sequencing (NSG) revealed ASPSCR1-TFE3 fusion and TMB-H. Following eight months of anlotinib monotherapy, the patient’s disease progressed but continued to benefit from subsequent use of anlotinib combined with toripalimab for 19 months. Another 63 year-old male patient was diagnosed with UPS. PD-L1 was positive and NGS revealed TMB-H. Following 19 months of anlotinib monotherapy, the patient’s disease progressed but continued to benefit from subsequent use of anlotinib combined with toripalimab. DFS is 23 months to follow-up time. The results presented are the first to report the relationship between TMB and the efficacy of immunotherapy in STS. Based on our results, we hypothesis that anlotinib combined with toripalimab is effective for the treatment of some advanced ASPS or UPS. TMB may be a potential predictive biomarker for ICI treatment and deserves additional study.

Early Fractional Amplitude of Low Frequency Fluctuation Can Predict the Efficacy of Transcutaneous Auricular Vagus Nerve Stimulation Treatment for Migraine Without Aura

Migraine is a common primary headache disorder. Transcutaneous auricular vagus nerve stimulation (taVNS) has been verified to be effective in patients with migraine without aura (MWoA). However, there are large interindividual differences in patients’ responses to taVNS. This study aimed to explore whether pretreatment fractional amplitude of low frequency fluctuation (fALFF) features could predict clinical outcomes in MWoA patients after 4-week taVNS. Sixty MWoA patients and sixty well-matched healthy controls (HCs) were recruited, and migraineurs received 4-week taVNS treatment. Resting-state functional magnetic resonance imaging (rs-fMRI) data were collected, and the significant differences of fALFF were detected between MWoA patients and HCs using two-sample t-test. A mask of these significant regions was generated and used for subsequent analysis. The abnormal fALFF in the mask was used to predict taVNS efficacy for MWoA using a support vector regression (SVR) model combining with feature select of weight based on the LIBSVM toolbox. We found that (1) compared with HCs, MWoA patients exhibited increased fALFF in the left thalamus, left inferior parietal gyrus (IPG), bilateral precentral gyrus (PreCG), right postcentral gyrus (PoCG), and bilateral supplementary motor areas (SMAs), but decreased in the bilateral precuneus and left superior frontal gyrus (SFG)/medial prefrontal cortex (mPFC); (2) after 4-week taVNS treatment, the fALFF values significantly decreased in these brain regions based on the pretreatment comparison. Importantly, the decreased fALFF in the bilateral precuneus was positively associated with the reduction in the attack times (r = 0.357, p = 0.005, Bonferroni correction, 0.05/5), whereas the reduced fALFF in the right PoCG was negatively associated with reduced visual analog scale (VAS) scores (r = −0.267, p = 0.039, uncorrected); (3) the SVR model exhibited a good performance for prediction (r = 0.411, p < 0.001),which suggests that these extracted fALFF features could be used as reliable biomarkers to predict the treatment response of taVNS for MWoA patients. This study demonstrated that the baseline fALFF features have good potential for predicting individualized treatment response of taVNS in MWoA patients, and those weight brain areas are mainly involved in the thalamocortical (TC) circuits, default mode network (DMN), and descending pain modulation system (DPMS). This will contribute to well understanding the mechanism of taVNS in treating MWoA patients and may help to screen ideal patients who respond well to taVNS treatment.

Clinicopathological characteristics and prognosis of gastrointestinal stromal tumors containing air-fluid levels

An air-fluid level within a gastrointestinal stromal tumor (GIST) is unusual and indicates the presence of a fistula within the lumen of the GI tract. Until recently, the optimal management of such patients was not clear-cut. This retrospective study investigated the clinicopathological characteristics, surgical procedures, pre-and post-operative management, and prognosis of patients with GIST containing an air-fluid level. Data of GIST patients, spanning 5 years, including 17 GIST patients with air-fluid levels in the experimental group and 34 GIST patients without air-fluid levels in the control group, were retrieved from two hospitals in China. The clinicopathological characteristics, types of surgery, management, and clinical outcomes of GIST patients were compared between the two groups. GISTs containing air-fluid levels were significantly different from GISTs without air-fluid levels regarding tumor morphology, NIH risk category, invasion of adjacent organs, and necrosis or ulceration. Most GIST patients with air-fluid levels (14/17, 82.4%) received open surgery, significantly higher than the 20.6% in the control group. Targeted therapy with Imatinib mesylate (IM) was implemented in all GIST patients in the experimental group (17/17, 100%); markedly higher than those (3/34, 8.8%) in the control group. During follow-up, recurrence and death rates (5.9% and 5.9%) in the experimental group were higher than those (2.9% and 0%) in the control group. Open surgery is commonly performed in GIST patients with air-fluid levels who also require targeted therapy with IM. The Torricelli-Bernoulli sign could be a risk factor, adversely affecting the patient’s prognosis.

Predicting Treatment Response of Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer Using Amide Proton Transfer MRI Combined With Diffusion-Weighted Imaging

Objective

To evaluate amide proton weighted (APTw) MRI combined with diffusion-weighted imaging (DWI) in predicting neoadjuvant chemoradiotherapy (NCRT) response in patients with locally advanced rectal cancer (LARC).

Methods

53 patients with LARC were enrolled in this retrospective study. MR examination including APTw MRI and DWI was performed before and after NCRT. APTw SI, ADC value, tumor size, CEA level before and after NCRT were assessed. The difference of the above parameters between before and after NCRT was calculated. The tumor regression grading (TRG) was assessed by American Joint Committee on Cancer’s Cancer Staging Manual AJCC 8th score. The Shapiro-Wilk test, paired t-test and Wilcoxon Signed Ranks test, two-sample t-test, Mann-Whitney U test and multivariate analysis were used for statistical analysis.

Results

Of the 53 patients, 19 had good responses (TRG 0-1), 34 had poor responses (TRG 2-3). After NCRT, all the rectal tumors demonstrated decreased APT values, increased ADC values, reduced tumor volumes and CEA levels (all p < 0.001). Good responders demonstrated higher pre-APT values, higher Δ APT values, lower pre- ADC values and higher Δ tumor volumes than poor responders. Pre-APT combined with pre-ADC achieved the best diagnostic performance, with AUC of 0.895 (sensitivity of 85.29%, specificity of 89.47%, p < 0.001) in predicting good response to NCRT.

Conclusion

The combination of APTw and DWI may serve as a noninvasive biomarker for evaluating and identifying response to NCRT in LARC patients.

Combination of Anti-EGFR and Anti-VEGF Drugs for the Treatment of Previously Treated Metastatic Colorectal Cancer: A Case Report and Literature Review

The standard third-line treatment of metastatic colorectal cancer (mCRC) includes the small-molecule anti-vascular drugs (Regofenib and Fruquintinib) and the chemotherapy drug trifluridine and tipiracil hydrochloride (TAS-102). There is no standard treatment for mCRC if the third-line treatment failed. Therefore, it is a pressing need to develop new therapeutic approaches to improve the survival of patients who developed drug resistance to the third-line treatment. In this study, we report a case of mCRC with RAS/BRAF wild-type, who was successfully treated using cetuximab in combination with fruquintinib after resistance to chemotherapy, bevacizumab, cetuximab and regorafenib. This patient responded to this combination regimen. Then, we discuss the mechanisms of action of this combination. Furthermore, we introduce the clinical trials on the combination regimens of anti-EGFR with anti-vascular monoclonal antibodies. Finally, we discuss the clinical explorations of using combination of anti-EGFR with small-molecule anti-VEGF drugs and their potential benefits. The clinical effects of small-molecule anti-vascular drugs in combination with anti-EGFR in the treatment of CRC warrant further explored.

Zinner syndrome: an updated pooled analysis based on 214 cases from 1999 to 2020: systematic review

Zinner syndrome (ZS) is a rare anomaly of the Wolffian duct. We searched for case reports and case series to identify the most effective methods for examination and treatment. The PubMed/Medline, Embase, and Scopus databases were searched. Our searches yielded 160 case reports/case series and included 214 patients. The mean age at diagnosis was 29.35 years. The R:L distribution was 1:1. The most common symptoms were: frequency (24.3%), dysuria (23.1%) and perineal pain (20.2%) in ZS patients with clinical symptoms. The diagnostic investigations used most frequently were magnetic resonance imaging (MRI) (67.8%) and ultrasonography (65.0%). Maximum flow rate on uroflowmetry, semen ejaculate volume, sperm count, and sperm motility were significantly lower in patients with ZS. Among 193 patients with treatment details, 65.8% underwent surgery; 9.8% underwent aspiration; 24.3% were followed with observation. Two patients died after surgery; all other patients remained asymptomatic after surgery. Fifty-two patients had complications and comorbidities. In patients with ZS, the most common symptoms are seminal vesicle cyst enlargement and compression of the bladder, ureter, and reproductive system. The diagnosis mostly depends on radiological examination. Surgery may be effective, but complications may occur.

A phaseⅠ/Ⅱa clinical study of cetuximab combined with fruquintinib in the third-line treatment of RAS/BRAF wild-type colorectal cancer

TPS151

Background: The standard third-line treatment of mCRC is regofenib, fruquintinib or TAS-102. However, the efficacy was not satisfied. Because VEGF and EGFR share the downstream signal pathway, targeting these two pathways may have synergistic efficacy. Preclinical studies have confirmed the effect of the combination of regorafenib and cetuximab. The subsequent phase Ⅰb study in advanced cancer showed the combination is effective. Fruquintinib is the same anti-VEGF drugs and was approved in China. Our department has treated one patient of advanced colorectal cancer, no standard regimen after third-line treatment. The efficacy is SD and PFS time exceeded 6 months. Therefore this study explores the safety and efficacy of fruquintinib combined with cetuximab. Methods: This is a single-center, non-random, prospective, open exploratory study. Eligible pts were diagnosed as advanced RAS/BRAF wild-type colorectal cancer and had received at least two prior regimens of standard therapies. The purpose of phase Ⅰ is to confirm the safety and the appropriate dose of fruquintinib combined with cetuximab. The phase Ⅱa investigate the safety and the efficacy of fruquintinib combined with cetuximab. Phase I: The dose of cetuximab is 500mg/m2 every two weeks which is clinically tolerable, so the dose need not be adjusted. fruquintinib is taken once daily for the first 21 days of each 28-day cycle and the dose adjustment is required due to the side effects. The standard dose of fruquintinib is 5mg/d, but the side effects are serious. The dose of 3mg/d is the minimum effective dose, therefore the initial dose of fruquintinib starts from 4mg, and three patients are enrolled. If DLT appeared in less than three patients, the dose elevated to 5mg/d. Three patients were enrolled in the 5mg/d dose group. If DLT appeared in less than three patients, the right dose of fruquintinib was 5mg/d. If DLT appeared in all three patients of the 5mg/d, fruquintinib was declined to 4mg/d combined with cetuximab to carry out a phase Ⅱa study. Fruquintinib initial dose is 4mg/d. If DLT was present in all three patients, the dose was reduced to 3mg/d. The standard dose of fruquintinib (3mg/d) was determined to be MDT, and the subsequent phase Ⅱa study was conducted by giving fruquintinib 3mg/d. The phase Ⅱa study is cetuximab 500mg/m2 biweekly combined with fruquintinib according to the confirmed dose in phase Ⅰ, taking it once daily for the first 21 days of each 28-day cycle. The number of cases is 20.Response assessment via CT/MRI is to be done q8 wks (RECIST 1.1). Continue until disease progression or unacceptable toxicity. The primary objective is to estimate safety, grade 3/4 adverse, and DLT. Secondary objectives include ORR, PFS, and OS. Final analysis to be done 6 mo after enrollment of the final pt. Clinical trial information: ChiCTR2000038227 . Research Sponsor: None

Gastric Cancer Harboring an ERBB3 Mutation Treated with a Pyrotinib-Irinotecan Combo: A Case Study

Gastric cancer is common, especially in East Asian countries, and is associated with high recurrence and mortality rates. Currently, there is no standard third-line treatment for metastatic gastric cancer. In this report, we present the case of a 69-year-old man with advanced gastric cancer, whose tumor was negative for human epidermal growth factor receptor 2 (HER2) according to immunohistochemical analysis. Next-generation sequencing performed on paraffin sections of the postoperative tumor samples indicated the presence of the ERBB3 V104L mutation. The patient received irinotecan plus pyrotinib as a third-line therapy and achieved a progression-free survival of 7.6 months with a high quality of life. Therefore, the combined administration of irinotecan and pyrotinib may improve the clinical condition of patients with gastric cancer harboring an ERBB3 mutation. Moreover, ERBB3 could be a potential therapeutic target for gastric cancer.

Development of MR-based preoperative nomograms predicting DNA copy number subtype in lower grade gliomas with prognostic implication

OBJECTIVES

We aimed to determine the value of MR-based preoperative nomograms in predicting DNA copy number (CN) subtype in lower grade glioma (LGG) patients.

METHODS

The overall survival (OS) data were analyzed. MRI data of 170 subjects were retrospectively analyzed. The correlation was explored by univariate and multivariate regression analysis.

RESULTS

CN2 subtype was associated with shortest median OS (CN2 subtype vs. others: 46.8 vs. 221.7 months, p < 0.05). The time-dependent receiver operating characteristic for the CN2 subtype was 0.80 (95% CI: 0.74-0.85) for survival at 1 year, 0.80 (95% CI: 0.75-0.85) for survival at 2 years, and 0.77 (95% CI: 0.73-0.83) for survival at 3 years. On multivariate analysis, hemorrhage (OR: 0.118; p < 0.001; 95% CI: 0.037-0.376), poorly defined margin (OR: 4.592; p < 0.001; 95% CI: 1.965-10.730), extranodular growth (OR: 0.247; p = 0.006; 95% CI: 0.091-0.671), and volume ≥ 60 cm³ (OR: 4.734.256; p < 0.001; 95% CI: 2.051-10.924) were associated with CN1 subtype (AUC: 0.781). Proportion CE tumor (OR: 5.905; p = 0.007; 95% CI: 1.622-21.493), extranodular growth (OR: 9.047; p = 0.001; 95% CI: 2.349-34.846), width ≥ median (OR: 0.231; p = 0.049; 95% CI: 0.054-0.998), and depth ≥ median (OR: 0.192; p = 0.023; 95% CI: 0.046-0.799) were associated with CN2 subtype (AUC: 0.854). Necrosis/cystic (OR: 6.128; p = 0.007; 95% CI: 1.635-22.968), hemorrhage (OR: 5.752; p = 0.002; 95% CI: 1.953-16.942), poorly defined margin (OR: 0.164; p < 0.001; 95% CI: 0.063-0.427), and volume ≥ median (OR: 4.422; p < 0.001; 95% CI: 1.925-10.160) were associated with CN3 subtype (AUC: 0.808). All three nomograms showed good discrimination and calibration. Decision curve analysis supported that all nomograms were clinically useful. The average accuracy of the tenfold cross-validation was 0.680 (CN1), 0.794 (CN2), and 0.894 (CN3), respectively.

CONCLUSIONS

The shortest OS was observed in patients with CN2 subtype. This preliminary radiogenomics analysis revealed that the MR-based preoperative nomograms provide individualized prediction of DNA copy number subtype in LGG patients.

KEY POINTS

• This preliminary radiogenomics analysis of LGG revealed that the MR-based preoperative nomograms provide individualized prediction of DNA copy number subtype in LGG patients. • The AUC for the ROC curve was 0.781 for CN1 subtype, 0.854 for CN2 subtype, and 0.808 for CN3 subtype. Decision curve analysis supported that all nomograms were clinically useful. • The sensitivity was 0.779 (CN1), 0.731 (CN2), and 0.851 (CN3), respectively. The specificity was 0.664 (CN1), 0.872 (CN2), and 0.625 (CN3), respectively. And the accuracy was 0.717 (CN1), 0.849 (CN2), and 0.692 (CN3), respectively.

A Rare EGFR-SEPT14 Fusion in a Patient with Colorectal Adenocarcinoma Responding to Erlotinib

Colorectal cancer (CRC) is the second leading cause of cancer death worldwide. Growing evidence supports gene fusions as good candidates for molecularly targeted therapy in CRC. Here we describe a case of a 63-year-old man who had a radical right hemicolectomy procedure 24 months ago. Pathological diagnosis indicated colorectal adenocarcinoma with stage pT4N2bMx. During re-examination in December 2016, positron emission tomography/computed tomography scans indicated relapse with multiple lymph nodes metastasis. Then the patient received a nine-cycle combination treatment of XELOX and bevacizumab and showed progressive disease (PD). Subsequently, the patient was treated with bevacizumab plus FOLFIRI for 2 months before discontinuation because of adverse events. Paraffin sections of postoperative colorectal tissue were subjected to next-generation sequencing, and epidermal growth factor receptor (EGFR) amplification and rare EGFR-SEPT14 fusion were identified. The patient then received erlotinib, an EGFR tyrosine kinase inhibitor (TKI), and achieved a partial response. However, the patient subsequently showed PD, and a new variant, EGFRvIII, appeared in metastasis, which may be involved in erlotinib resistance. We suggest that there is value in treating patients harboring EGFR fusions with EGFR TKI therapy, and EGFR-SEPT14 fusion may be used as a therapeutic target for CRC. KEY POINTS: To the authors' knowledge, this is the first report of EGFR-SEPT14 fusion in colorectal cancer. The patient achieved a partial response after treatment with the epidermal growth factor receptor tyrosine kinase inhibitor erlotinib. This report expands the list of gene fusions in colorectal cancer and highlights new targets for the therapeutic intervention. EGFRvIII may be involved in erlotinib resistance, which is rare in colorectal cancer.

Analgesic effects of balanced acupuncture versus body acupuncture in low-back and leg pain patients with lumbar disc herniation, as assessed by resting-state functional magnetic resonance imaging

Balanced acupuncture, a single-acupoint balance therapy, regulates the balance of the cerebral center, and is characterized by exerting quick effects and a short treatment course. A total of 20 low-back and leg pain patients with lumbar disc herniation were treated with balanced acupuncture or body acupuncture. Central mechanisms of varied acupunctures were compared using resting-state functional MRI. Patients from both groups received functional MRI before and after acupuncture. Functional connectivity in brain regions that were strongly associated with the bilateral amygdala was analyzed utilizing AFNI software. Visual analogue scale scores were greater in the balanced acupuncture group compared with the body acupuncture group. Function of the endogenous pain regulation network was enhanced in patients in the balanced acupuncture group, but was not changed in the body acupuncture group. This result indicates that the analgesic effects of body acupuncture do not work through the central nervous system. These data suggest that balanced acupuncture exerts analgesic effects on low-back and leg pain patients with lumbar disc herniation by regulating the function of the endogenous pain regulation network.

Mitigation of nutrient losses via surface runoff from rice cropping systems with alternate wetting and drying irrigation and site-specific nutrient management practices

Resource-conserving irrigation and fertilizer management practices have been developed for rice systems which may help address water quality concerns by reducing N and P losses via surface runoff. Field experiments under three treatments, i.e., farmers' conventional practice (FCP), alternate wetting and drying (AWD), and AWD integrated with site-specific nutrient management (AWD + SSNM) were carried out during two rice seasons at two sites in the southwest Yangtze River delta region. Across site years, results indicated that under AWD irrigation (i.e., AWD and AWD + SSNM), water inputs were reduced by 13.4~27.5 % and surface runoff was reduced by 30.2~36.7 % compared to FCP. When AWD was implemented alone, total N and P loss masses via surface runoff were reduced by 23.3~30.4 % and 26.9~31.7 %, respectively, compared to FCP. However, nutrient concentrations of surface runoff did not decrease under AWD alone. Under AWD + SSNM, total N and P loss masses via surface runoff were reduced to a greater extent than AWD alone (39.4~47.6 % and 46.1~48.3 % compared to FCP, respectively), while fertilizer inputs and N surpluses significantly decreased and rice grain yields increased relative to FCP. Therefore, by more closely matching nutrient supply with crop demand and reducing both surface runoff and nutrient concentrations of surface runoff, our results demonstrate that integration of AWD and SSNM practices can mitigate N and P losses via surface runoff from rice fields while maintaining high yields.

A study on a family with high incidence of leukemia

A family with a high incidence of leukemia was investigated and followed up for 10 years. Up to now, 7 of 48 members in this family had acute nonlymphocytic leukemia. Chromosomal aberration was found in 3 healthy members, 2 of whom were found to have 47, XX, +5, -8, +Mar, del (7) (q22-qter) and 45, XO, -Y chromosomes and developed this disease 5 and 7 years later respectively. Pedigree analysis suggested that the hereditary defect in the family should rest on the maternal lineage. It is considered that hereditary factors play an important part in the pathogenesis of leukemia in the family.