Epigenetic changes associated with Bacillus Calmette-Guerin (BCG) treatment in bladder cancer.

Bacillus Calmette-Guérin (BCG) treatment for non-muscle invasive bladder cancer (NMIBC) is an established immunotherapeutic, however, a significant portion of patients do not respond to treatment. Despite extensive research into the therapeutic mechanism of BCG, gaps remain in our understanding. This review specifically focuses on the epigenomic contributions in the immune microenvironment, in the context of BCG treatment for NMIBC. We also summarise the current understanding of NMIBC epigenetic characteristics, and discuss how future targeted strategies for BCG therapy should incorporate epigenomic biomarkers in conjunction with genomic biomarkers.

Development of a long term, ex vivo, patient-derived explant model of endometrial cancer.

Incidence of endometrial cancer (EC) is rising in the developed world. The current standard of care, hysterectomy, is often infeasible for younger patients and those with high body mass index. There are limited non-surgical treatment options and a lack of biologically relevant research models to investigate novel alternatives to surgery for EC. The aim of the present study was to develop a long-term, patient-derived explant (PDE) model of early-stage EC and demonstrate its use for investigating predictive biomarkers for a current non-surgical treatment option, the levonorgestrel intra-uterine system (LNG-IUS). Fresh tumour specimens were obtained from patients with early-stage endometrioid EC. Tumours were cut into explants, cultured on media-soaked gelatin sponges for up to 21 days and treated with LNG. Formalin-fixed, paraffin embedded (FFPE) blocks were generated for each explant after 21 days in culture. Tumour architecture and integrity were assessed by haematoxylin and eosin (H&E) and immunohistochemistry (IHC). IHC was additionally performed for the expression of five candidate biomarkers of LNG resistance. The developed ex vivo PDE model is capable of culturing explants from early-stage EC tumours long-term (21 Days). This model can complement existing models and may serve as a tool to validate results obtained in higher-throughput in vitro studies. Our study provides the foundation to validate the extent to which EC PDEs reflect patient response in future research.

Validating a measure of motivational climate in health science courses.

PURPOSE: The aim of the study was to examine the validity evidence for the 19-item form of the MUSIC Model of Academic Motivation Inventory (College Student version) within health science schools in three different countries. The MUSIC Inventory includes five scales that assess the motivational climate by measuring students' perceptions related to five separate constructs: empowerment, usefulness, success, interest, and caring. BACKGROUND: The 26-item form of the MUSIC Inventory has been validated for use with undergraduate students and with students in professional schools, including students at a veterinary medicine school, a pharmacy school, and a medical school. A 19-item form of the MUSIC Inventory has also been validated for use with undergraduate students, but it has not yet been validated for use with medical school students. The purpose of this study was to provide validity evidence for the use of the 19-item form in heath science schools in three different countries to determine if this version is acceptable for use in different cultures. If validated, this shorter form of the MUSIC Inventory would provide more differentiation between the Interest and Usefulness scales and could reduce respondent fatigue. METHODOLOGY: Cook et al's [1] practical guidelines were followed to implement Kane's [2] validity framework as a means to examine the evidence of validity through scoring inferences, generalization inferences, and extrapolation inferences. Students (n = 667) in health science schools within three countries were surveyed. RESULTS: The results produced evidence to support all five hypotheses related to scoring, generalization, and extrapolation inferences. CONCLUSIONS: Scores from the 19-item form of the MUSIC Inventory are valid for use in health science courses within professional schools in different countries. Therefore, the MUSIC Inventory can be used in these schools to assess students' perceptions of the motivational climate.

Chromosomal instability and its effect on cell lines.

BACKGROUND: Cancer cell lines are invaluable model systems for biomedical research because they provide an almost unlimited supply of biological materials. However, there is considerable skepticism regarding the reproducibility of data derived from these in vitro models. RECENT FINDINGS: Chromosomal instability (CIN) is one of the primary issues associated with cell lines, which can cause genetic heterogeneity and unstable cell properties within a cell population. Many of these problems can be avoided with some precautions. Here we review the underlying causes of CIN, including merotelic attachment, telomere dysfunction, DNA damage response defects, mitotic checkpoint defects and cell cycle disturbances. CONCLUSION: In this review we summarize studies highlighting the consequences of CIN in various cell lines and provide suggestions on monitoring and controlling CIN during cell culture.

LOT and HOT or not. The proliferation of clinically insignificant and poorly characterised types of renal neoplasia.

The classification of malignant tumours is influenced by both immunohistochemical and molecular genetic findings. This is highlighted in the latest World Health Organization classification of renal neoplasia, which has a tumour category of 'tumours that are molecularly defined'. This implies that the defining molecular features are integral to tumourigenesis, which may not necessarily be the case. Renal oncocytoma is recognised as a benign tumour with variable morphology and immunoexpression. A variant of these tumours is hybrid oncocytic chromophobe tumour, which has features of both oncocytoma and chromophobe renal cell carcinoma and may, on rare occasions, show malignant behaviour. Recent reports have proposed two further entities with eosinophilic cytoplasm and varying nuclear pleomorphism, designated low grade oncocytic tumour (LOT) and eosinophilic vacuolated tumour (EVT), formally known as high grade oncocytic tumour (HOT). The diagnosis of these apparently benign tumours was made on the basis of morphological and immunohistochemical features. More recently it has been claimed that the mutations in the mTOR pathway are also a diagnostic feature and it is further suggested that these mutations are key to the pathogenesis of these tumours. As is seen in oncocytoma, immunohistochemical expression of tumours included in series of LOT and EVT is variable. The mutations in the mTOR pathway, where detected, were not constant, with any combination of mTOR, TSC1 and/or TSC2 being involved. A major issue is that in many of the studies full comparative genomic hybridisation results are not presented. In addition it is well recognised that mTOR mutations are seen in a variety of renal tumours. In view of these conflicting results, the rarity of these tumours and their apparent benign nature, raises questions as to why these tumours should be considered specific entities.

Using the MUSIC Inventory to Evaluate Pathology Courses: an Exploratory Study.

Background: The MUSIC Inventory evaluates student's academic motivation across five constructs. We aimed to examine its use in undergraduate medical pathology courses. Activity: Students from three pathology courses completed questions for three factors of the MUSIC Inventory plus one open-ended question. We conducted an exploratory analysis of the survey data. Results: Results showed that the open-ended responses corresponded to differences in ratings on the MUSIC Inventory. Discussion: Combining an open-ended question with the MUSIC Inventory identified differences in student motivation plus aspects of each course that could be improved. The MUSIC Inventory is an appropriate evaluation method for pathology teaching.

Prognostic significance of percentage Gleason grade 5 prostatic adenocarcinoma in needle biopsies from patients treated by radical prostatectomy.

Previous studies have shown that the percentage of high grade prostatic adenocarcinoma (Gleason patterns 4 and 5) in a biopsy correlates with outcome parameters. It has also been shown that the percentage Gleason pattern 4/5 tumour correlates with biochemical failure and overall survival. There are little data relating to the prognostic significance of quantifying the percentage of Gleason pattern 5 in isolation. We investigated the prognostic predictive value of quantifying the percentage of Gleason pattern 5 tumour in needle biopsies from a series of 196 cases of Gleason score 4+5=9 prostate adenocarcinoma from patients who had also undergone radical prostatectomy. Division of cases according to the percentage of Gleason pattern 5 present (based upon the core with the highest grade) and analysing these with tumour grouped as Gleason score 4+5 with <5% pattern 5 (GS 4+5 <5%), Gleason score 4+5 with 5-20% pattern 5 (GS 4+5 5-20%) and Gleason score 4+5 with 21-49% pattern 5 (GS 4+5 21-49%) showed no difference in outcome determined as time interval to prostate specific antigen biochemical failure. The results showed that each of the subgroups of GS 4+5 tumours had a significantly shorter biochemical recurrence-free survival than for a control group of 179 patients with Gleason score 4+3=7 (GS 4+3) cancer. Similar results were obtained when grading was based upon percentage of Gleason pattern 5 present in all the cores taken from the same patient (case-based grade). Adverse findings at radical prostatectomy showed each of the subgroups of GS 4+5 tumours to have a higher incidence of extraprostatic extension and seminal vesicle invasion than the GS 4+3 group of controls. Further, the differences in incidence between each of the subgroups were not significant for either extraprostatic extension or seminal vesicle invasion. These observations applied to both the highest core-based grade and the case-based grade. Our study has shown that any proportion of Gleason pattern 5 tumour in a needle biopsy is associated with a worse prognosis when compared to GS4+3 tumours and that these results are similar for grading that is core- or case-based.

Molecular Profiling of Endometrial Cancer: An Exploratory Study in Aotearoa, New Zealand.

BACKGROUND: Aotearoa, New Zealand, has one of the fastest-rising rates of endometrial cancer (EC) worldwide, increasing particularly in younger Maori and Pasifika women. There is a move towards using molecular profiling to direct treatment for each EC subtype. AIM: This study aimed to explore the molecular profiling of primary EC tissue in Aotearoa. METHODS: We used the PORTEC guidelines for the molecular subtyping of 90 patients' samples into four categories: POLE-mutated, p53 abnormal, mismatch repair deficient (MMRd) and no specific molecular profile (NSMP). The CTNNB1 mutation and L1CAM expression were also included in the analysis. POLE and CTNNB1 mutations were analysed using targeted next-generation sequencing (NGS). Novel mutations were assessed using VarSome. MMRd, L1CAM and p53 abnormalities were analysed using immunohistochemistry. RESULTS: In total, 15 samples were MMRd, 9 were p53 abnormal, 8 were POLE-mutated and the rest (56) were NSMP. Eleven samples had exon 3 CTNNB1 mutations and eleven novel POLE mutations were described. CONCLUSION: Surrogate markers for POLE mutations should be investigated. The validation of POLE variants and CTNNB1 mutations as part of an Aotearoa-based molecular panel is warranted.

WGS and RNA Studies Diagnose Noncoding DMD Variants in Males With High Creatine Kinase.

OBJECTIVE: To describe the diagnostic utility of whole-genome sequencing and RNA studies in boys with suspected dystrophinopathy, for whom multiplex ligation-dependent probe amplification and exomic parallel sequencing failed to yield a genetic diagnosis, and to use remnant normal DMD splicing in 3 families to define critical levels of wild-type dystrophin bridging clinical spectrums of Duchenne to myalgia. METHODS: Exome, genome, and/or muscle RNA sequencing was performed for 7 males with elevated creatine kinase. PCR of muscle-derived complementary DNA (cDNA) studied consequences for DMD premessenger RNA (pre-mRNA) splicing. Quantitative Western blot was used to determine levels of dystrophin, relative to control muscle. RESULTS: Splice-altering intronic single nucleotide variants or structural rearrangements in DMD were identified in all 7 families. Four individuals, with abnormal splicing causing a premature stop codon and nonsense-mediated decay, expressed remnant levels of normally spliced DMD mRNA. Quantitative Western blot enabled correlation of wild-type dystrophin and clinical severity, with 0%-5% dystrophin conferring a Duchenne phenotype, 10% ± 2% a Becker phenotype, and 15% ± 2% dystrophin associated with myalgia without manifesting weakness. CONCLUSIONS: Whole-genome sequencing relied heavily on RNA studies to identify DMD splice-altering variants. Short-read RNA sequencing was regularly confounded by the effectiveness of nonsense-mediated mRNA decay and low read depth of the giant DMD mRNA. PCR of muscle cDNA provided a simple, yet informative approach. Highly relevant to genetic therapies for dystrophinopathies, our data align strongly with previous studies of mutant dystrophin in Becker muscular dystrophy, with the collective conclusion that a fractional increase in levels of normal dystrophin between 5% and 20% is clinically significant.

Brief report: Lymph node morphology in stage II colorectal cancer.

BACKGROUND: Colorectal cancer is one of the leading causes of cancer-associated morbidity and mortality worldwide. The local anti-tumour immune response is particularly important for patients with stage II where the tumour-draining lymph nodes have not yet succumbed to tumour spread. The lymph nodes allow for the expansion and release of B cell compartments such as primary follicles and germinal centres. A variation in this anti-tumour immune response may influence the observed clinical heterogeneity in stage II patients. AIM: The aim of this study was to explore tumour-draining lymph node histomorphological changes and tumour pathological risk factors including the immunomodulatory microRNA-21 (miR-21) in a small cohort of stage II CRC. METHODS: A total of 23 stage II colorectal cancer patients were included. Tumour and normal mucosa samples were analysed for miR-21 expression levels and B-cell compartments were quantified from Haematoxylin and Eosin slides of lymph nodes. These measures were compared to clinicopathological risk factors such as perforation, bowel obstruction, T4 stage and high-grade. RESULTS: We observed greater Follicle density in patients with a lower tumour T stage and higher germinal centre density in patients with higher pre-operative carcinoembryonic antigen levels. Trends were also detected between tumours with deficiency in mismatch repair proteins, lymphatic invasion and both the density and size of B-cell compartments. Lastly, elevated tumour miR-21 was associated with decreased Follicle and germinal centre size. CONCLUSION: Variation in B-cell compartments of tumour-draining lymph nodes is associated with clinicopathological risk factors in stage II CRC patients.

PeerWise and Pathology: Discontinuing a teaching innovation that did not achieve its potential.

This article was migrated. The article was marked as recommended. Introduction Writing and answering multiple choice questions (MCQs) is a learning activity that potentially engages deep learning. We conducted three year-long case studies of MCQ writing and answering in PeerWise to engage students in learning Pathology. Methods Overall, an instrumental case-study design with the structure of sequential multiple case studies was used. Across three years fourth year medical students were required to write and answer MCQs. In 2016 students were provided with advice for writing questions and were encouraged to adhere to Bloom's taxonomy. In 2017, to reduce cognitive load, students were provided with a MCQ template and allocated topics. In 2018, to encourage engagement, students were informed that the top forty MCQs would be in the final exam. Results An evaluation survey was used to measure each student's perception of the MCQ exercise. In 2016 most students had a negative opinion of the MCQ exercise. Students found writing MCQs too time consuming and demanding. In 2017 student's attitudes to the MCQ exercise were more positive. In 2018 there were insufficient responses to the survey but informal student feedback suggested the MCQ exercise was considered an inefficient use of student study time. There were minimal changes in student's activity levels from 2016 to 2017. However, in 2018 when students were informed that the top forty MCQs generated would be included in their final exam they answered a greater number of MCQs than in previous years. Conclusions Providing students with templates and assigning topics for MCQs may improve student attitudes toward MCQ writing and including student generated MCQs in the final exam encourages students to answer more MCQs. However, due to high demands on their time, medical students' prioritised efficiency and MCQ writing may not be an efficient strategy for deep learning.

Intraductal carcinoma of the prostate is an aggressive form of invasive carcinoma and should be graded.

Infiltration of the prostatic ducts by prostatic adenocarcinoma occurs relatively frequently, being most commonly associated with high grade disease. It is now recognised that intraductal carcinoma of the prostate (IDCP) has an associated poor prognosis and this is reflected in its histological, molecular and immunohistochemical features. The current recommendation of the World Health Organization is that IDCP not be taken into consideration when grading prostate adenocarcinoma. It is apparent that Gleason did not differentiate between IDCP and stromal invasive carcinoma when developing and validating his grading system, and recent studies suggest that the incorporation of IDCP grading into the overall grading of the specimen provides additional prognostic information.

Reflection on the current status of endometrial cancer in New Zealand.

Incidence of endometrial cancer is increasing rapidly in the developed world and is the most common gynaecological cancer in Australia and New Zealand. In line with obesity rates, the landscape and average age of women diagnosed with endometrial cancer are changing. There is still unmet need in early diagnosis, directed treatment, management of comorbidities and prevention strategies. This opinion piece aims to reflect on the current status of endometrial cancer in New Zealand in parallel to Australia, drawing out areas for future research and discussion.

Pathological process has a crucial role in sentinel node biopsy for vulvar cancer.

OBJECTIVES: To report the interim findings of an audit of the outcomes of sentinel node (SN) biopsy performed as a replacement for groin node dissection in women with early stage vulvar cancer in routine clinical practice in Australia and New Zealand. METHODS: A prospective multi-center study in 8 participating centers. Eligible patients had squamous cell carcinomas clinically restricted to the vulva <4 cm in diameter. SN procedures and pathological assessment were to be performed in accordance with the methods published by the GROINSS-V collaboration [1]. RESULTS: 130 women with apparent early stage vulvar cancer were enrolled. Seventeen women subsequently did not meet the eligibility criteria and were excluded. SNs were identified in 111/113 of the remaining women. Twenty-two women had positive nodes. Sixteen of these women had at least 12 months follow up and 7 (44%) had recurrent disease. Eighty-nine women had only negative nodes. Seventy-four of these women had at least 12 months follow up and 6 (8%) had recurrent disease (including 2 [2.7%] with recurrence in the groin). On subsequent review of the two women with negative SNs who had groin recurrences, it was found that the recommended pathology protocol had not been followed. In both cases, SN metastases were identified following serial sectioning of the nodes. CONCLUSIONS: SN biopsy is feasible in routine clinical practice. However, undetected metastases in a removed SN may be associated with groin recurrence. To ensure patient safety, strict adherence to the pathology protocol is an essential component in the utilization of the sentinel lymph node technique in vulvar cancer.

Utility Value Theory Underlies Students' Attitudes to Biomedical Sciences Curricula.

INTRODUCTION: The recent wave of curriculum renewal has changed biomedical sciences from standalone science courses to integrated, clinically-oriented components of the curriculum. Although integrated curricula are now common in medical schools worldwide, few studies have systematically investigated students' attitudes towards and perceived relevance of the basic sciences in these new curricula. METHODS: In a cross-sectional study, surveys were distributed to all year two to six medical students at Otago Medical School. Surveys used Likert-scale items and open-ended questions to explore students' perceived importance, relevance, value and acceptance of the current biomedical curriculum. Three focus groups were conducted to further explore students' perceptions. Transcripts of focus group discussions underwent thematic analysis using inductive coding. RESULTS: Survey responses were received from 708 of 1500 students. Medical students reported acceptance of the biomedical programme, with no difference between the year groups (χ 2(4) = 8.595, p = 0.072). Perceived value, importance and relevance of the biomedical curriculum decreased from years two to six. Two major themes were identified from focus groups; the importance of contextualising biomedical science into clinical practice and detail being delivered with a just-in-time focus. Students judged the biomedical curriculum on its utility value, focusing on its' clinical relevance and usefulness. DISCUSSION AND CONCLUSION: Although students understood the importance and relevance of biomedical sciences and believed applying biomedical science to clinical practice is a skill which should be reinforced early in the medical curriculum, the information in the current biomedical curriculum may be too detailed to be clinically useful. The linkages between biomedical teaching and clinical application can still be improved.

Medical students create multiple-choice questions for learning in pathology education: a pilot study.

BACKGROUND: Medical students facing high-stakes exams want study resources that have a direct relationship with their assessments. At the same time, they need to develop the skills to think analytically about complex clinical problems. Multiple-choice questions (MCQs) are widely used in medical education and can promote surface learning strategies, but creating MCQs requires both in-depth content knowledge and sophisticated analytical thinking. Therefore, we piloted an MCQ-writing task in which students developed MCQs for their peers to answer. METHODS: Students in a fourth-year anatomic pathology course (N = 106) were required to write MCQs using the PeerWise platform. Students created two MCQs for each of four topic areas and the MCQs were answered, rated and commented on by their classmates. Questions were rated for cognitive complexity and a paper-based survey was administered to investigate whether this activity was acceptable, feasible, and whether it promoted desirable learning behaviours in students. RESULTS: Students were able to create cognitively challenging MCQs: 313/421 (74%) of the MCQs which we rated required the respondent to apply or analyse pathology knowledge. However, students who responded to the end-of-course questionnaire (N = 62) saw the task as having little educational value. Students found PeerWise easy to use, and indicated that they read widely to prepare questions and monitored the quality of their questions. They did not, however, engage in extensive peer feedback via PeerWise. CONCLUSIONS: Our study showed that the MCQ writing task was feasible and engaged students in self-evaluation and synthesising information from a range of sources, but it was not well accepted and did not strongly engage students in peer-learning. Although students were able to create complex MCQs, they found some aspects of the writing process burdensome and tended not to trust the quality of each other's MCQs. Because of the evidence this task did promote deep learning, it is worth continuing this mode of teaching if the task can be made more acceptable to students.

NRAS and EPHB6 mutation rates differ in metastatic melanomas of patients in the North Island versus South Island of New Zealand.

Melanoma, the most aggressive skin cancer type, is responsible for 75% of skin cancer related deaths worldwide. Given that New Zealand (NZ) has the world's highest melanoma incidence, we sought to determine the frequency of mutations in NZ melanomas in recurrently mutated genes. NZ melanomas were from localities distributed between North (35°S-42°S) and South Islands (41°S-47°S). A total of 529 melanomas were analyzed for BRAF exon 15 mutations by Sanger sequencing, and also by Sequenom MelaCarta MassARRAY. While, a relatively low incidence of BRAFV600E mutations (23.4%) was observed overall in NZ melanomas, the incidence of NRAS mutations in South Island melanomas was high compared to North Island melanomas (38.3% vs. 21.9%, P=0.0005), and to The Cancer Genome Atlas database (TCGA) (38.3% vs. 22%, P=0.0004). In contrast, the incidence of EPHB6G404S mutations was 0% in South Island melanomas, and was 7.8% in North Island (P=0.0002). Overall, these data suggest that melanomas from geographically different regions in NZ have markedly different mutation frequencies, in particular in the NRAS and EPHB6 genes, when compared to TCGA or other populations. These data have implications for the causation and treatment of malignant melanoma in NZ.