Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution.

Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African-American race (odds ratio [OR] 1.33; 95% CI: 1.17-1.51), Medicaid insurance (OR 1.59; 1.36-1.87), no insurance (OR 1.66; 1.32-2.10) and rural residence (OR 1.78; 1.49-2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.

Platelet and hemoglobin count at diagnosis are associated with survival in African American and Caucasian patients with colorectal cancer.

BACKGROUND: African Americans (AAs) compared to Caucasian Americans (CAs) with colorectal cancer (CRC) have lower stage-specific survival. CRC patients often present with several hematopathologies (such as thrombocytosis, thrombocytopenia, anemia) at diagnosis, which is associated with poorer survival. However, whether these measures impact the racial disparity in survival is not known. METHODS: The study population was composed of 581 histologically confirmed CRCs at the Medical University of South Carolina (393 CA, 188 AA) diagnosed between 01/01/2000 and 06/30/2013. We used Cox proportional hazards regression to estimate the association between thrombocytosis, thrombocytopenia, or anemia at diagnosis and risk of death by race. This analysis was adjusted for age, sex, stage and first-line treatment. RESULTS: In all patients combined, thrombocytosis, thrombocytopenia, and anemia (vs. the normal ranges) were associated with significantly higher risks of death. In the race-specific analyses, AAs (HR 2.51 [95 % CI: 1.52-4.15]) vs. CAs (HR 1.15 [95 % CI: 0.75-1.75]) with thrombocytosis compared to normal had a higher risk of death (p for difference = 0.03). CONCLUSIONS: Abnormal thrombocyte and hemoglobin levels at diagnosis were associated with poorer survival. AAs compared to CAs with elevated platelets at diagnosis had a higher risk of death. Our study is the first to examine the role of race, hematologic measures at diagnosis, and risk of death in colorectal cancer patients. These results suggest that the racial differences in the immune response may contribute to the racial disparity in survival.

Shorter survival and later stage at diagnosis among unmarried patients with cutaneous melanoma: A US national and tertiary care center study.

BACKGROUND: Addressing risk factors of delayed melanoma detection minimizes disparities in outcome. OBJECTIVE: To elucidate the significance of marital status in melanoma outcomes across anatomic sites. METHODS: Retrospective cohort study of 73,558 patients from the Surveillance, Epidemiology, and End Results (SEER) program and 2992 patients at Johns Hopkins University. Patients were stratified by marital status, anatomic site, age, and sex. Endpoints were prevalence of advanced melanoma (stages III or IV) and survival. RESULTS: In the SEER cohort, single patients were more likely than married patients to present in stages III or IV among both men (prevalence ratio [PR], 1.45; 95% confidence interval [CI], 1.37-1.53) and women (PR, 1.28; 95% confidence interval, 1.18-1.39). This trend was consistent across all anatomic sites and in all age groups, particularly in those 18 to 68 years old. Overall and cancer-specific survival times were shorter in unmarried patients. Similarly, at Johns Hopkins, single patients had increased prevalence of advanced melanoma (PR, 1.54; 95% CI, 1.21-1.94) and experienced shorter overall survival (hazard ratio, 1.51; 95% CI, 1.15-1.99). LIMITATIONS: The anatomic sites were not very specific, and this was a retrospective study. CONCLUSIONS: Unmarried patients, especially men and those younger than 68 years, are diagnosed at more advanced stages, even in readily visible sites such as the face. They also experience worse survival independent of stage.

Thrombin contributes to cancer immune evasion via proteolysis of platelet-bound GARP to activate LTGF-ß.

Cancer-associated thrombocytosis and high concentrations of circulating transforming growth factor-ß1 (TGF-ß1) are frequently observed in patients with progressive cancers. Using genetic and pharmacological approaches, we show a direct link between thrombin catalytic activity and release of mature TGF-ß1 from platelets. We found that thrombin cleaves glycoprotein A repetitions predominant (GARP), a cell surface docking receptor for latent TGF-ß1 (LTGF-ß1) on platelets, resulting in liberation of active TGF-ß1 from the GARP-LTGF-ß1 complex. Furthermore, systemic inhibition of thrombin obliterates TGF-ß1 maturation in platelet releasate and rewires the tumor microenvironment toward favorable antitumor immunity, which translates into efficient cancer control either alone or in combination with programmed cell death 1-based immune checkpoint blockade therapy. Last, we demonstrate that soluble GARP and GARP-LTGF-ß1 complex are present in the circulation of patients with cancer. Together, our data reveal a mechanism of cancer immune evasion that involves thrombin-mediated GARP cleavage and the subsequent TGF-ß1 release from platelets. We propose that blockade of GARP cleavage is a valuable therapeutic strategy to overcome cancer's resistance to immunotherapy.

Preoperative platelet counts and postoperative outcomes in cancer surgery: a multicenter, retrospective cohort study.

Platelets play roles in malignancy, wound healing, and immunity. Nevertheless, their significance in postoperative outcomes is not established. This is a retrospective cohort study of 100,795 patients undergoing cancer surgery in 2010 and 2014 in >500 hospitals. Patients were stratified into five groups based on preoperative platelet counts. Multivariable logistic regression was used to determine the risk of 30-day mortality, morbidities, readmission, and prolonged hospitalization using the mid-normal group as a reference. We adjusted for demographic variables, comorbidities, and operation complexity. In the 2014 cohort, multivariable analysis showed that mortality was higher in patients with thrombocytopenia (OR 1.49, 95% CI [1.23-1.81]), high-normal platelets (OR 1.29, [1.06-1.55]), and thrombocytosis (OR 1.78, [1.45-2.19]). Composite postoperative morbidity followed a similar trend with thrombocytopenia (OR 1.34, [1.25-1.43]), high-normal counts (OR 1.41, [1.33-1.49]), and thrombocytosis (OR 2.20, [2.05-2.36]). Concordantly, the risks of prolonged hospitalization and 30-day readmission followed the same pattern. These results were validated in a large colon cancer cohort from the 2010 database. In conclusion, platelet count is a prognostic indicator in cancer surgeries. This could be related to the role of platelets in wound healing and immunity on one hand, and propagating malignancy on the other.

Platelet count correlates with stage and predicts survival in melanoma.

Cancer is a chronic inflammatory state which is often associated with increased platelet counts. Cancer cells induce thrombopoiesis and activate platelets, which in turn facilitate cancer invasion and metastasis. In this study, we investigate the correlation between platelet counts with each of stage and overall survival in melanoma. This is a retrospective cohort study of 642 melanoma patients diagnosed or treated at a tertiary medical center between 2000 and 2016. Multivariable analysis adjusted for age, sex, stage, and treatment modality. Using multivariable analysis, patients with thrombocytosis around time of diagnosis were more likely to present with distant metastasis (Prevalence Ratio 3.5, 95% CI 2.35-5.22). In patients with metastatic disease and in all stages combined, thrombocytosis predicted decreased 5-year overall survival in univariate and multivariable analysis, and this was most pronounced during the first year after diagnosis. Finally, we show that mice with thrombocytopenia due to the lack of heat shock protein gp96 in their megakaryocytes are protected from melanoma dissemination to the lungs. These findings are concordant with preclinical studies showing a role for platelets in cancer metastasis and suppression of antitumor immunity, further supporting targeting platelets as an adjuvant to immunotherapy in melanoma.

Postdiagnosis aspirin use and overall survival in patients with melanoma.

BACKGROUND: Mouse studies show that tumor-derived prostaglandins and platelets promote melanoma progression and immune evasion. OBJECTIVE: Determine whether aspirin confers longer survival in patients with melanoma. METHODS: A retrospective cohort study of 1522 patients at Indiana University Health who had melanoma diagnosed between 2000 and 2014 and were followed up through September 2016. RESULTS: Aspirin use was associated with longer overall survival in univariate analysis and after controlling for age, sex, stage, and treatment modalities (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.45-0.75). Aspirin use was not associated with survival in patients with in situ and stage I melanoma but was associated with better survival in stages II (HR, 0.45; 95% CI, 0.24-0.82) and III (HR, 0.57; 95% CI; 0.34-0.96). No statistical significance was observed in stage IV patients (HR, 0.55; 95% CI, 0.27-1.13). In turn, melanoma in patients using aspirin before diagnosis was less likely to be diagnosed in stages III or IV. LIMITATIONS: Observational study. CONCLUSIONS: Aspirin could provide a survival advantage in melanoma. Clinical trials investigating the therapeutic potential of aspirin are warranted.

Platelets subvert T cell immunity against cancer via GARP-TGFß axis.

Cancer-associated thrombocytosis has long been linked to poor clinical outcome, but the underlying mechanism is enigmatic. We hypothesized that platelets promote malignancy and resistance to therapy by dampening host immunity. We show that genetic targeting of platelets enhances adoptive T cell therapy of cancer. An unbiased biochemical and structural biology approach established transforming growth factor ß (TGFß) and lactate as major platelet-derived soluble factors to obliterate CD4+ and CD8+ T cell functions. Moreover, we found that platelets are the dominant source of functional TGFß systemically as well as in the tumor microenvironment through constitutive expression of the TGFß-docking receptor glycoprotein A repetitions predominant (GARP) rather than secretion of TGFß per se. Platelet-specific deletion of the GARP-encoding gene Lrrc32 blunted TGFß activity at the tumor site and potentiated protective immunity against both melanoma and colon cancer. Last, this study shows that T cell therapy of cancer can be substantially improved by concurrent treatment with readily available antiplatelet agents. We conclude that platelets constrain T cell immunity through a GARP-TGFß axis and suggest a combination of immunotherapy and platelet inhibitors as a therapeutic strategy against cancer.

Mapping the Interactome of a Major Mammalian Endoplasmic Reticulum Heat Shock Protein 90.

Up to 10% of cytosolic proteins are dependent on the mammalian heat shock protein 90 (HSP90) for folding. However, the interactors of its endoplasmic reticulum (ER) paralogue (gp96, Grp94 and HSP90b1) has not been systematically identified. By combining genetic and biochemical approaches, we have comprehensively mapped the interactome of gp96 in macrophages and B cells. A total of 511 proteins were reduced in gp96 knockdown cells, compared to levels observed in wild type cells. By immunoprecipitation, we found that 201 proteins associated with gp96. Gene Ontology analysis indicated that these proteins are involved in metabolism, transport, translation, protein folding, development, localization, response to stress and cellular component biogenesis. While known gp96 clients such as integrins, Toll-like receptors (TLRs) and Wnt co-receptor LRP6, were confirmed, cell surface HSP receptor CD91, TLR4 pathway protein CD180, WDR1, GANAB and CAPZB were identified as potentially novel substrates of gp96. Taken together, our study establishes gp96 as a critical chaperone to integrate innate immunity, Wnt signaling and organ development.

Surface Expression of TGFß Docking Receptor GARP Promotes Oncogenesis and Immune Tolerance in Breast Cancer.

GARP encoded by the Lrrc32 gene is the cell surface docking receptor for latent TGFß, which is expressed naturally by platelets and regulatory T cells (Treg). Although Lrrc32 is amplified frequently in breast cancer, the expression and relevant functions of GARP in cancer have not been explored. Here, we report that GARP exerts oncogenic effects, promoting immune tolerance by enriching and activating latent TGFß in the tumor microenvironment. We found that human breast, lung, and colon cancers expressed GARP aberrantly. In genetic studies in normal mammary gland epithelial and carcinoma cells, GARP expression increased TGFß bioactivity and promoted malignant transformation in immunodeficient mice. In breast carcinoma-bearing mice that were immunocompetent, GARP overexpression promoted Foxp3+ Treg activity, which in turn contributed to enhancing cancer progression and metastasis. Notably, administration of a GARP-specific mAb limited metastasis in an orthotopic model of human breast cancer. Overall, these results define the oncogenic effects of the GARP-TGFß axis in the tumor microenvironment and suggest mechanisms that might be exploited for diagnostic and therapeutic purposes. Cancer Res; 76(24); 7106-17. ©2016 AACR.

CD24 blunts oral squamous cancer development and dampens the functional expansion of myeloid-derived suppressor cells.

CD24 expression has been implicated in the oncogenesis of multiple types of cancer and high tumor expression is considered a poor prognosis factor; however, the role of CD24 in oral cancer progression is unknown. Unlike other cancer types, we found that higher CD24 levels in human oral cancers are correlated to lower clinical stage and better overall survival. We then dissected the role of CD24 and mechanisms in oral cancer pathogenesis in mice using a genetic strategy and demonstrated that CD24 deficiency increased the oral cavity tumor burden in response to the carcinogen 4-nitroquioline 1-oxide (4-NQO). Immune profile analysis showed a significant expansion as well as increased suppressive function of myeloid-derived suppressor cells (MDSCs) in CD24-/- mice, but no apparent impairment in T cells, B cells, or dendritic cells. Further, studies with an orthotopically transplanted syngeneic squamous carcinoma model in the tongue of CD24-/- and CD24+/- mice confirmed the protective roles of CD24 against cancer. Moreover, the difference in tumor growth between CD24-/- and CD24+/- mice was blunted by immunodepletion of MDSCs. We conclude that CD24 expression impedes MDSC expansion and function, and thus slows oral cancer oncogenesis. This study is the first to examine the role of CD24 in a de novo oral cancer model, and it highlights the need to consider the immune regulatory roles of CD24 in the development of CD24-targeted therapy for cancer.

Intramuscular myxoma of the paraspinal muscles: A case report and systematic review of the literature.

Intramuscular myxoma (IM) is a rare mesenchymal tumor of the head and neck region. The current study reports a case of a 45-year-old man who presented with a painless neck mass. Imaging showed involvement of the levator scapulae and scalene muscles. Core needle biopsy was consistent with intramuscular myxoma. Surgical excision was performed and follow-up for 30 months showed no recurrence. The present study includes a systematic review of head and neck IMs, with a summary of the clinical and demographic parameters of all reported cases in the head and neck region. Surgery was curative in 28 of the 29 published cases, as well as in the current case (96.7%), with the lone recurrent tumor cured following re-resection. Females constituted 57% of the cases and the mean age was 49.7±20.4 years. Although uncommon, IM should be considered in the differential diagnosis of deep neck masses, and surgical excision is the treatment of choice with a low risk of recurrence.

Neutrophil-to-lymphocyte ratio and overall survival in all sites of head and neck squamous cell carcinoma.

BACKGROUND: Current prognostic criteria are insufficient in predicting outcomes in head and neck cancer, necessitating new, readily available biomarkers. METHODS: Pretreatment neutrophil and lymphocyte counts and their ratio (NLR) were retrospectively investigated for correlation with overall survival while controlling for demographic and clinical confounders. RESULTS: Patients in the highest tertile of neutrophil counts and those in the lowest tertile of lymphocytes experienced shorter survival than the rest of the population. Patients in the highest tertile of the NLR were at a higher risk compared with those in the lowest tertile after multivariate analysis (hazard ratio [HR] = 2.39; p = .0001). Additionally, NLR was lower in patients with human papillomavirus (HPV)-positive tumors compared to HPV-negative tumors and predicted survival in both tumor types. CONCLUSION: Neutrophil and lymphocyte counts are strong biomarkers with opposing prognostic significance and the NLR is a robust predictor of overall survival in oral, pharyngeal, and laryngeal squamous cell carcinomas. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1068-E1074, 2016.

Melanotic Neuroectodermal Tumor of Infancy: A Systematic Review.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, usually diagnosed within the first year of age, with a predilection for the maxilla. Although the tumor is usually benign, its rapidly growing nature and ability to cause major deformities in surrounding structures necessitate early diagnosis and intervention. It is important that medical and dental specialists are prepared to make the diagnosis and proceed with appropriate intervention. The authors performed a systematic review of the 472 reported cases from 1918 through 2013 and provided a comprehensive update on this rare entity that can have devastating effects on young patients. This investigation uncovered age at diagnosis as an important prognostic indicator, because younger age correlated with a higher recurrence rate. The authors also present a case report of a 5-month-old girl diagnosed with MNTI and review her clinical presentation and imaging and histopathologic findings.

GP96 is a GARP chaperone and controls regulatory T cell functions.

Molecular chaperones control a multitude of cellular functions via folding chaperone-specific client proteins. CD4+FOXP3+ Tregs play key roles in maintaining peripheral tolerance, which is subject to regulation by multiple molecular switches, including mTOR and hypoxia-inducible factor. It is not clear whether GP96 (also known as GRP94), which is a master TLR and integrin chaperone, controls Treg function. Using murine genetic models, we demonstrated that GP96 is required for Treg maintenance and function, as loss of GP96 resulted in instability of the Treg lineage and impairment of suppressive functions in vivo. In the absence of GP96, Tregs were unable to maintain FOXP3 expression levels, resulting in systemic accumulation of pathogenic IFN-γ-producing and IL-17-producing T cells. We determined that GP96 serves as an essential chaperone for the cell-surface protein glycoprotein A repetitions predominant (GARP), which is a docking receptor for latent membrane-associated TGF-ß (mLTGF-ß). The loss of both GARP and integrins on GP96-deficient Tregs prevented expression of mLTGF-ß and resulted in inefficient production of active TGF-ß. Our work demonstrates that GP96 regulates multiple facets of Treg biology, thereby placing Treg stability and immunosuppressive functions strategically under the control of a major stress chaperone.

Endoplasmic reticulum heat shock protein gp96 maintains liver homeostasis and promotes hepatocellular carcinogenesis.

BACKGROUND & AIMS: gp96, or grp94, is an endoplasmic reticulum (ER)-localized heat shock protein 90 paralog that acts as a protein chaperone and plays an important role for example in ER homeostasis, ER stress, Wnt and integrin signaling, and calcium homeostasis, which are vital processes in oncogenesis. However, the cancer-intrinsic function of gp96 remains controversial. METHODS: We studied the roles of gp96 in liver biology in mice via an Albumin promoter-driven Cre recombinase-mediated disruption of gp96 gene, hsp90b1. The impact of gp96 status on hepatic carcinogenesis in response to diethyl-nitrosoamine (DENA) was probed. The roles of gp96 on human hepatocellular carcinoma cells (HCC) were also examined pharmacologically with a targeted gp96 inhibitor. RESULTS: We demonstrated that gp96 maintains liver development and hepatocyte function in vivo, and its loss genetically promotes adaptive accumulation of long chain ceramides, accompanied by steatotic regeneration of residual gp96+ hepatocytes. The need for compensatory expansion of gp96+ cells in the gp96- background predisposes mice to develop carcinogen-induced hepatic hyperplasia and cancer from gp96+ but not gp96- hepatocytes. We also found that genetic and pharmacological inhibition of gp96 in human HCCs perturbed multiple growth signals, and attenuated proliferation and expansion. CONCLUSIONS: gp96 is a pro-oncogenic chaperone and an attractive therapeutic target for HCC.

Lower circulating platelet counts and antiplatelet therapy independently predict better outcomes in patients with head and neck squamous cell carcinoma.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) mortality rates have not shown significant reduction in decades. Platelets are being implicated in having cancer-promoting roles, an observation supported by the adverse outcomes associated with thrombocytosis in many malignancies associated with thrombocytosis. However, the prognostic significance of platelet counts in HNSCC is unknown. Here, we comprehensively investigate the predictive value of platelet counts at diagnosis and post-diagnosis antiplatelet treatment in the overall survival of HNSCC patients. METHODS: The study population consists of 1051 pathologically confirmed HNSCC cases diagnosed between years 2000 and 2012 in a tertiary medical center. Platelet count was investigated as a predictor of survival by fitting Cox Proportional Hazards (CPH) regression models to generate Hazard Ratios (HR) and 95% confidence intervals (CI), while adjusting for age, sex, race, stage, treatment and smoking status. Finally, we evaluated the association between overall survival and antiplatelet medication intake after diagnosis. RESULTS: Multivariable analysis showed an increased death rate in patients with thromobocytosis [HR 2.37, 95% CI 1.60-3.50)] and high normal platelet counts [HR 2.20, 95% CI 1.58-3.05] compared to the reference middle normal group. Post-diagnosis treatment with antiplatelet medications was inversely associated with death rate [HR 0.76, 95% CI 0.58-0.99]. CONCLUSIONS: Higher platelet counts were associated with poorer prognosis in HNSCC patients, whereas antiplatelet agents were associated with better prognosis. Antiplatelet agents warrant evaluation in preclinical and clinical settings as a way to improve survival in HNSCC.

Immune chaperone gp96 drives the contributions of macrophages to inflammatory colon tumorigenesis.

Macrophages are important drivers in the development of inflammation-associated colon cancers, but the mechanistic underpinnings for their contributions are not fully understood. Furthermore, Toll-like receptors have been implicated in colon cancer, but their relevant cellular sites of action are obscure. In this study, we show that the endoplasmic reticulum chaperone gp96 is essential in tumor-associated macrophages (TAM) to license their contributions to inflammatory colon tumorigenesis. Mice where gp96 was genetically deleted in a macrophage-specific manner exhibited reduced colitis and inflammation-associated colon tumorigenesis. Attenuation of colon cancer in these mice correlated strikingly with reduced mutation rates of ß-catenin, increased efficiency of the DNA repair machinery, and reduced expression of proinflammatory cytokines, including interleukin (IL)-17 and IL-23 in the tumor microenvironment. The genotoxic nature of TAM-associated inflammation was evident by increased expression of genes in the DNA repair pathway. Our work deepens understanding of how TAM promote oncogenesis by altering the molecular oncogenic program within epithelial cells, and it identifies gp96 as a lynchpin chaperone needed in TAM to license their function and impact on expression of critical inflammatory cytokines in colon tumorigenesis.