Final outcomes analysis of the cell product SQZ-PBMC-HPV Phase 1 trial in incurable HPV16+ solid tumors shows improved overall survival in patients with increased CD8+ T cell tumor infiltration.

Cancer vaccines strive to induce robust, antigen-targeted, T-cell-mediated immune responses but have struggled to produce meaningful regression in solid tumors. An autologous cell vaccine, SQZ-PBMC-HPV, was developed by SQZ Biotechnologies using microfluidic squeezing technology to load PBMCs with HPV16 E6 and E7 antigens in HLA-A*02+ patients. The SQZ-PBMC-HPV-101 Phase 1 trial (NCT04084951) enrolled patients with incurable HPV16+ cancers. Here, we present a post hoc analysis of the relationship between Posttreatment CD8+ T cell infiltration and patient outcomes. SQZ-PBMC-HPV was administered as monotherapy every 3 weeks. Tumor samples were collected pre-dose and post-dose 4 weeks after treatment start. Biomarkers including CD8, MHC-I, E6, E7, GZMB, and Ki67 were evaluated by immunohistochemistry, immunofluorescence, and RNA in situ hybridization, and were correlated with clinical response, survival, and drug product composition. Eighteen patients had paired pre- and post-dose biopsies. Six (33%) had an increase in CD8+ T cell density in tumor parenchyma between screening and C2D8. Patients with increased CD8+ T cell density had improved disease control rate (66.7% vs 16.7%) and median overall survival (606.5 days vs 170.0 days, p = 0.0078). Drug product was significantly enriched for higher T cells and lower monocytes in the increased CD8+ T cell density group. In patients with incurable HPV16+ solid tumors treated with SQZ-PBMC-HPV, an increase in CD8+ T cell density within the tumor parenchyma was associated with superior disease control rate and overall survival. The product composition for patients with increased CD8+ T cell density was enriched for T cells.

Clinical and Analytical Performance of the Onclarity HPV Assay Using the VALGENT Framework.

As the demand for human papillomavirus (HPV)-related cervical screening increases, emerging HPV tests must be evaluated robustly using well-annotated samples, such as those generated in the Validation of HPV Genotyping Tests (VALGENT) framework. Through VALGENT, we assessed the performance of the BD Onclarity HPV assay, which detects 14 high-risk (HR) types and resolves six individual types and three groups of types. Consecutive samples from a screening population (n = 1,000), enriched with cytologically abnormal samples (n = 300), that had been tested previously with the GP5+/6+ PCR enzyme immunoassay (EIA) and the GP5+/6+ PCR LMNX assay (Diassay) were tested with the Onclarity assay. Type-specific HPV prevalences were analyzed according to age and cytological result. The accuracy of the Onclarity assay for the detection of cervical intraepithelial neoplasia grade 2+ (CIN2+) and CIN3+ was assessed relative to the GP5+/6+ EIA results by using noninferiority criteria. Overall agreement and type-specific agreement between the Onclarity assay and the GP5+/6+ LMNX assay were assessed. The prevalence of HPV types 16, 18, 31, and 45 increased with the severity of cytological results (P for trend, <0.05). For the detection of CIN2+, the Onclarity assay had a relative sensitivity of 1.02 (95% confidence interval [CI], 0.99 to 1.05; P < 0.001 for noninferiority) and a relative specificity of 0.99 (95% CI, 0.97 to 1.00; P = 0.186 for noninferiority). The kappa for agreement between the Onclarity assay and the GP5+/6+ LMNX assay for HR-HPV was 0.92 (95% CI, 0.89 to 0.94), and values for the six individual types ranged from 0.78 (95% CI, 0.68 to 0.87) for HPV-52 to 0.96 (95% CI, 0.93 to 0.99) for HPV-16. These data suggest that the Onclarity assay offers applications for clinical workstreams while providing genotyping information that may be useful for risk stratification beyond types 16 and 18.

Effect of glacial acetic acid pre-treatment of cervical liquid-based cytology specimens on the molecular detection of human papillomavirus.

OBJECTIVE: Cytology laboratories routinely treat cervical liquid-based cytology (LBC) specimens that are heavily contaminated with blood with glacial acetic acid (GAA) in order to lyse red blood cells and facilitate assessment. However, the impact on downstream human papillomavirus (HPV) detection is not well understood. This study examines the effect of GAA pre-treatment of ThinPrep(®) Preservcyt(®) specimens on the molecular detection of HPV. METHODS: A panel of 150 routinely collected cervical LBC specimens was tested with two commercial HPV tests, the Abbott RealTime High Risk HPV test (rtHPV) and the Qiagen Hybrid Capture 2 High Risk HPV DNA test (HC2), as aliquots before and after GAA treatment. Statistical analysis was performed using McNemars test and Bland and Altman plots. RESULTS: Agreement between the results of the rtHPV test on GAA-untreated and GAA-treated specimens was 95.7%, with no evidence of a significant difference in the distribution of the discrepant results (P = 0.414). HC2 test agreement on GAA-untreated and GAA-treated specimens was 91% at a cut-off of 1 relative light unit index (RLUI) and 92% at a cut-off of 2 RLUI. There was no evidence of a difference in the distribution of discordant results at a cut-off of 1 (P = 0.405) and 2 RLUI (P = 0.564). CONCLUSIONS: GAA pre-treatment of cervical ThinPrep Preservcyt LBC specimens had little effect on the two commercial HPV tests used in this study. The impact of GAA treatment on HPV testing should, however, be validated for all HPV tests and all LBC collection media used in each particular diagnostic setting.

A single ThinPrep slide may not be representative in all head and neck fine needle aspirate specimens.

OBJECTIVES: Ideally, head and neck aspiration should be performed by trained aspirators within the setting of a one-stop clinic, where smeared material is available for immediate assessment. However, this may not always be possible for practical reasons and the use of liquid-based techniques in head and neck cytology is increasing. Although liquid-based cytology has been extensively validated for use in gynaecological cytology, no studies have investigated whether or not a single ThinPrep slide is representative for head and neck aspirate specimens. We performed a prospective audit of head and neck fine needle aspiration specimens processed by the ThinPrep method to investigate whether a single ThinPrep slide was representative. METHODS: A prospective audit of 115 consecutive head and neck aspirates was carried out. A single ThinPrep slide was prepared and a diagnosis recorded. The remainder of the specimen was then spun down and prepared as a cell block. The ThinPrep and cell block diagnoses were compared. RESULTS: In 36 cases (31%), the cell block provided additional information that contributed to the diagnosis. In 14 (12%), the cell block was regarded as essential to the diagnosis. CONCLUSIONS: A single ThinPrep slide may not provide representative diagnostic material in all head and neck aspirates. This should be taken into consideration when contemplating the use of liquid-based methods for non-gynaecological cytology.

The use of the 'borderline' category in the reporting of cervical cytopathology in the UK: results of a survey conducted under the aegis of the British Society for Clinical Cytology.

OBJECTIVE: To determine how the 'borderline' category was used by cytopathologists in the UK when reporting cervical smears. METHODS: A questionnaire was sent by email to members of the British Society for Clinical Cytology. RESULTS: There is wide variation in the use of the 'borderline' category in the UK but the majority of respondents (77.6%) used it when reporting smears that were either on the borderline between negative and low grade squamous dyskaryosis ('borderline ?low grade'), or on the borderline between negative and high grade squamous dyskaryosis ('borderline ?high grade'), or on the borderline between negative and glandular dyskaryosis 'borderline ?glandular dyskaryosis'). A significant minority (15.7%), however, did not use 'borderline' when reporting smears that showed an abnormality that was possibly high grade squamous dyskaryosis. A majority (79.1%) of respondents thought that it would be useful to have separate reporting categories for 'borderline ?low grade' and 'borderline ?high grade'. CONCLUSIONS: There is diversity in the use of the category 'borderline' in the UK. The proposed revised BSCC terminology with separate categories for borderline ?low grade, borderline ?high grades and borderline ? glandular dyskaryosis reflects the opinion of the majority of respondents to the questionnaire.

Using a quality control approach to define an 'adequately cellular' liquid-based cervical cytology specimen.

OBJECTIVE: To define a minimum acceptable total squamous cellularity for (ThinPrep) liquid-based cervical cytology (LBC) specimens using quality control techniques. METHODS: Two hundred LBC preparations were made containing varying numbers (<200) of severely dyskaryotic squamous cells and with varying total cellularities. RESULTS: Ninety-eight per cent of the LBC preparations that were missed by one or more of three cytoscreeners had fewer than 16 abnormal objects (single dyskaryotic cells or clumps of cells) and 87 dyskaryotic cells. The minimum ratio of dyskaryotic to total squamous cells that, in a preparation of 5000 squamous cells has a probability of at least 0.98 that 87 or more dyskaryotic cells will be present is 1:47. Twenty-three preparations diagnosed as abnormal had ratios of dyskaryotic to total squamous cells of between 1:2.5 and 1:4596. There is thus no feasible minimum acceptable squamous cellularity that will give an acceptable probability of detection of all specimen vials containing abnormal cells in the observed proportions. CONCLUSIONS: It is suggested that the minimum acceptable cellularity for LBC specimens is set pragmatically by the screening programme to give a feasible percentage of repeat tests.

Can we influence medical students' approaches to learning?

Students use three approaches to learning and studying: deep, surface and strategic. These are influenced by the learning environment. In response to the General Medical Council's report 'Tomorrow's Doctors', the second year of the medical course at the University of Edinburgh was changed to promote deep learning, with learning objectives constructed according to the SOLO taxonomy, learning methods such as problem-based learning and constructively aligned written assignments and examinations. The Approaches to Study Skills Inventory for Students (ASSIST) was used to evaluate the effect of these changes. Scores were highest for deep approaches and lowest for surface approaches and showed almost no change during the course. There are various possible explanations. The students already scored highly on deep approaches at the beginning of Year 2 and it may be difficult to increase the deep scores further, particularly over the relatively short period of the study. Alternatively, the effect of the changes in learning environment may not be strong enough to change entrenched approaches which have hitherto been successful.

Efficacy and pattern of use of sputum cytology as a diagnostic test.

Sputum cytology is regarded by many clinicians as a noninvasive, cheap and simple test for the diagnosis of bronchogenic carcinoma. Since the introduction of fibre-optic bronchoscopy and more easily obtained bronchial biopsies reliance on sputum cytology has diminished. However, in Edinburgh it was perceived that sputum samples were still being sent as well as, rather than instead of, bronchoscopic specimens. This retrospective study was undertaken to determine whether or not cytological examination of sputum is an efficient and sensitive test in the investigation of patients with suspected bronchogenic carcinoma. It demonstrated that the Lothian University Hospitals NHS Trust Pathology Directorate receives many sputa from departments not specializing in respiratory disease when there is no indication for the test. In addition, we have shown that the absolute sensitivity of the test is only 5% and that when there is a strong clinical suspicion of bronchogenic carcinoma the results of sputum cytology do not play a significant role in the management of the patient. We recommend that sputum cytology is restricted to those patients under the care of Respiratory Units in whom bronchoscopy is inappropriate or unsuccessful.

Pathologists dislike sound? Evaluation of a computerised training microscope.

AIM: To evaluate the use of multimedia enhancements, using a computerised microscope, in the training of microscope skills. METHODS: The HOME microscope provides facilities to highlight features of interest in conjunction with either text display or aural presentation. A pilot study was carried out with 10 individuals, eight of whom were at different stages of pathology training. A tutorial was implemented employing sound or text, and each individual tested each version. Both the subjective impressions of users and objective measurement of their patterns of use were recorded. RESULTS: Although both versions improved learning, users took longer to work through the aural than the text version; 90% of users preferred the text only version, including all eight individuals involved in pathology training. CONCLUSIONS: Pathologists appear to prefer visual rather than aural input when using teaching systems such as the HOME microscope and sound does not give added value to the training experience.

Should the laboratory assess the sampling adequacy of cervical smears?

The results of a questionnaire answered by 14 out of the 18 NHS laboratories in Scotland reporting cervical smears showed that, since the publication of Guidelines for Judging the Adequacy of a Cervical Smear, by the British Society for Clinical Cytology (BSCC), rates of unsatisfactory smears had risen from a mean of 3.3% to 6.5%, with some laboratories reporting rates of over 10%. Four laboratories followed the guidelines closely in requiring the presence of two indicators of sampling of the transformation zone, i.e. endocervical cells, metaplastic cells or endocervical mucus. Seven laboratories required one indicator either in all smears or in a subset, whilst three did not require any indicator at all. The laboratories observing the guidelines closely had a higher mean unsatisfactory rate than those partially observing them. The main impediment to the full implementation of the BSCC guidelines appeared to be fear of an unmanageably high unsatisfactory smear rate. The accuracy of the assessment of adequacy is questioned, as is the cost effectiveness of doing so.

Interobserver variation in cell selection for DNA image cytometry.

AIMS: To describe a systematic investigation of interobserver differences in interpretation of nuclear morphology in preparations of small cell lung cancer (SCLC). METHODS: The screening/reviewing facility on the highly optimised microscope environment was used to individually tag 127 nuclei, chosen to reflect the spectrum of morphological appearances in nuclear preparations from three biopsy specimens of SCLC. Each nucleus was reviewed and labelled as control (lymphocyte), malignant or unsatisfactory by each of four observers. DNA histograms were plotted for each specimen using the nuclei identified as malignant by each participant. The histograms were compared in terms of identification of DNA stemlines and by calculation of a 5c exceeding rate (5cER). RESULTS: Interobserver variation in assessment of morphology was seen in 55.1% of nuclei. Disagreement occurred most frequently in the malignant/unsatisfactory category. Differences in morphological classification had little influence on histogram assessment by means of visual inspection but did show an effect on 5cER. CONCLUSIONS: There are significant interobserver differences in subjective assessment of nuclear morphology in cytometric preparations. This effect may seriously influence cytometric measurements.

PCR analysis of the upstream regulatory region of human papillomavirus genomes in cervical intraepithelial neoplasia and cervical carcinoma.

AIMS: To test whether human papillomavirus (HPV) variants with large scale sequence alterations to the upstream regulatory region are present in cervical intraepithelial neoplasias (CIN) and cervical carcinomas. METHODS: New PCR based assays were designed specifically to detect large scale insertion/deletion alterations in the upstream regulatory region of HPV 16 and 18. The assays were applied to 24 cases of CIN and 34 cases of cervical carcinoma previously shown to contain these two high risk HPV types. RESULTS: No large scale sequence alterations were found in any of the HPV containing CIN or carcinomas. CONCLUSIONS: These negative findings suggest that major upstream regulatory region variants of HPV 16 and 18 do not contribute to most cervical neoplasms.

A PCR approach to discriminate between integrated and episomal HPV DNA in small clinical specimens.

HPV infection has long been implicated in the development of cervical carcinoma. There is strong evidence for association of high-risk HPV types 16 and 18 with cervical intraepithelial neoplasia (CIN) grades 2 and 3, and integration of viral DNA of these types into the host genome has been suggested to play an important role in progression to invasive cervical carcinoma. However, the existing techniques for detection of integrated DNA in clinical specimens are time-consuming and require large amounts of template DNA, often unavailable for small premalignant CIN lesions. In this study, a novel, two stage PCR assay was designed to discriminate between integrated and episomal HPV 16 DNA. The first stage was designed to determine whether intact HPV genomes were present. This initial PCR analysis of the entire viral genome in eight segments was successfully applied to authentic human cervical cancers. The second stage consisted of an ANCHOR-PCR-based analysis, developed specifically to discriminate between integrated and episomal HPV DNA, that was successfully tested with cloned HPV containing plasmids used to mimic both episomal and integrated viral DNA. Further optimization and validation will be required for application of the second stage to clinical specimens. The entire assay was developed to be applicable to small colposcopic biopsies or cervical scrape samples, representative of those acquired in routine clinical investigation of CIN 2 or CIN 3, in which determination of the physical state of HPV DNA may provide prognostically valuable information.

Neuroimaging features of neurenteric cysts: analysis of nine cases and review of the literature.

PURPOSE: To gain a better understanding of neurenteric (NE) cysts via correlation of imaging findings and surgical and pathologic data. METHODS: The medical records, imaging studies, surgical information, and pathologic material were retrospectively reviewed in nine patients with NE cysts, including seven proved and two very probable cases. RESULTS: NE cysts occurred in the cerebellopontine angle in one case and extended from the cerebellopontine angle to the C2 level in a second. In the latter patient and the remaining seven with intraspinal lesions, the NE cyst was always located anterior to the spinal cord. The most common myelographic and CT myelographic appearance was that of a lobulated intradural extramedullary (IDEM) mass. Two patients had an intramedullary NE cyst with a somewhat unusual appearing exophytic IDEM-appearing expansion that can be a characteristic feature of these lesions. MR imaging demonstrated the NE cyst to be isointense to hyperintense relative to cerebrospinal fluid on long TR sequences and isointense or slightly hyperintense to cerebrospinal fluid on T1-weighted images. These signal characteristics correlate with the high-protein-content fluid within the cysts, usually described at surgery as milky or mucinous in character. CONCLUSION: The diagnosis of NE cyst should be considered when imaging studies reveal the presence of a lobulated IDEM or an exophytic intramedullary cystic mass, especially in association with anterior spina bifida or other vertebral anomalies. MR can uniquely confirm the cystic nature of these masses and is the method of choice for their imaging investigation. Because cyst recurrence can occur, MR should also be used for long-term patient follow-up.

Human papillomavirus type 18 associates with more advanced cervical neoplasia than human papillomavirus type 16.

A type-specific, sensitive, polymerase chain reaction-based assay for human papillomavirus (HPV) types 6b, 11, 16, 18, and 33 was applied to 47 cervical carcinomas, 60 cases of cervical intraepithelial neoplasia (CIN), and 24 samples of histologically normal cervix. As expected, the combined incidence of the common high-risk genital HPVs (types 16 and 18) was high in carcinomas (79%) and CIN 2/3 (60%), low in CIN 1 (25%), and nonexistent in the normal controls. Analysis of the data by viral type and pathology revealed statistically significant differences that consistently pointed to an association of HPV 18 with more advanced disease than HPV 16. This was exemplified by calculation of the relative HPV frequency in squamous cancers and CIN 2/3 lesions, which gave cancer to CIN prevalence ratios of 1.2 for HPV 16 and 2.3 for HPV 18, a twofold difference suggesting the possibility that there is a greater risk of progression or a more rapid transition to malignancy associated with HPV 18. Furthermore, HPV 16 was associated with 2.5-fold more cancers showing squamous differentiation (58%) than HPV 18 (23%), but both types showed an identical prevalence of 41% in the clinically more sinister adenocarcinomas, indicating that there may be an association between HPV type and cancer cell differentiation.

HPV in full thickness cervical biopsies: high prevalence in CIN 2 and CIN 3 detected by a sensitive PCR method.

A new type-specific, sensitive, non-radioactive assay is described for the detection of human papillomavirus (HPV) DNA in tissues. Sequences within the E6 gene were amplified by the polymerase chain reaction (PCR), using primer pairs which clearly distinguish HPV types, including those with close sequence homology such as 6b and 11. The amplified DNA products were identified by non-radioactive oligonucleotide hybridization and restriction endonuclease mapping, and the method was sufficiently sensitive to detect between 3 and 5 SiHa cells (each containing 1-2 copies of HPV 16 DNA) amongst 10,000 non-HPV-containing cells. Frozen and archival paraffin sections were equally acceptable substrates for the reaction. The assay was applied to frozen sections of full thickness cervical epithelium from 60 cases of cervical intraepithelial neoplasia (CIN) and 24 normal cervical controls. HPV DNA was detected in 60 per cent of cases of CIN 3 and CIN 2, in 25 per cent of cases of CIN 1, and in none of the normal controls. Prevalence of HPV 16 was similar (approximately 50 per cent) in both CIN 2 and CIN 3, and in the whole series HPV 16 was almost five-fold more common than HPV 18. Low-risk HPV types were present in 5 per cent of CIN 1, but 0 per cent of CIN 2 and CIN 3 biopsies. The data emphasize the biological similarity of CIN 2 and CIN 3 lesions, and their divergence from CIN 1.

The relationship of high-intensity signals on magnetic resonance images to cognitive and psychiatric state in Alzheimer's disease.

In Alzheimer's disease (AD), the relationship between white-matter changes on magnetic resonance images and behavior are unclear. Therefore, magnetic resonance images, cognition, and psychiatric state were assessed in patients with AD with depression (AD/DEP; n = 18) and without depression (AD; n = 45), older depressed patients (n = 12) and older normal individuals (n = 25). High-intensity signals in the cortex and subcortical regions were similar in number and proportions among all groups, even when hypertensive patients were excluded. No correlations to cognitive or psychiatric state were found. Periventricular signals were categorized using a 1- (absent) to 6- (thick, irregular caps and stripes) point scale. The categories were similar among groups except that patients with AD exhibited more category 5 changes than did normal subjects, neuropsychological performance was significantly worse in patients with AD who had category 5 and 6 changes when compared to those in category 1. These results suggest that periventricular changes may predict poor neuropsychological performance in patients with AD. However, neither deep white-matter lesions nor periventricular changes are useful for diagnostic purposes.