Real-world application of tumor mutational burden-high (TMB-high) and microsatellite instability (MSI) confirms their utility as immunotherapy biomarkers.

INTRODUCTION: Microsatellite instability (MSI) testing and tumor mutational burden (TMB) are genomic biomarkers used to identify patients who are likely to benefit from immune checkpoint inhibitors. Pembrolizumab was recently approved by the Food and Drug Administration for use in TMB-high (TMB-H) tumors, regardless of histology, based on KEYNOTE-158. The primary objective of this retrospective study was real-world applicability and use of immunotherapy in TMB/MSI-high patients to lend credence to and refine this biomarker. METHODS: Charts of patients with advanced solid tumors who had MSI/TMB status determined by next generation sequencing (NGS) (FoundationOne CDx) were reviewed. Demographics, diagnosis, treatment history, and overall response rate (ORR) were abstracted. Progression-free survival (PFS) was determined from Kaplan-Meier curves. PFS1 (chemotherapy PFS) and PFS2 (immunotherapy PFS) were determined for patients who received immunotherapy after progressing on chemotherapy. The median PFS2/PFS1 ratio was recorded. RESULTS: MSI-high or TMB-H [≥20 mutations per megabase (mut/MB)] was detected in 157 adults with a total of 27 distinct tumor histologies. Median turnaround time for NGS was 73 days. ORR for most recent chemotherapy was 34.4%. ORR for immunotherapy was 55.9%. Median PFS for patients who received chemotherapy versus immunotherapy was 6.75 months (95% confidence interval, 3.9-10.9 months) and 24.2 months (95% confidence interval, 9.6 months to not reached), respectively (P = 0.042). Median PFS2/PFS1 ratio was 4.7 in favor of immunotherapy. CONCLUSION: This real-world study reinforces the use of TMB as a predictive biomarker. Barriers exist to the timely implementation of NGS-based biomarkers and more data are needed to raise awareness about the clinical utility of TMB. Clinicians should consider treating TMB-H patients with immunotherapy regardless of their histology.

The Learning Curve in Robotic Pancreaticoduodenectomy.

BACKGROUND/PURPOSE: Few data are available on the learning curve (LC) in robot-assisted pancreaticoduodenectomy (RAPD) and no study specifically addresses the LC of a single surgeon. METHODS: The LC of a single surgeon in RAPD was determined using the cumulative sum method, based on operative time (OT). Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of index operation. RESULTS: Seventy RAPD were analyzed. One operation was converted to open surgery (1.4%). One patient died within 30 days (1.4%) and one within 90 days (2.8%). Postoperative complications occurred in 53 patients (75.7%) and exceeded Clavien-Dindo grade IIIb in 7 patients (10%). OT dropped after 33 operations from a mean of 564 ± 101.7 min to a mean of 484.1 ± 77.9 min (p = 0.0005) and was associated to reduced incidence of delayed gastric emptying (72.7 vs. 48.7%; p = 0.039). The rate of hospital readmission improved after 40 operations from 20.0 (8 of 40) to 3.3% (1 of 30) (p = 0.04). CONCLUSIONS: RAPD was safely feasible in selected patients. OT dropped after the first 33 operations and was associated with reduced rate of delayed gastric emptying. Readmission rate improved after 40 operations.

Changes in shear wave speed pre- and post-induction of labor: a feasibility study.

OBJECTIVE: To explore the feasibility of using shear wave speed (SWS) estimates to detect differences in cervical softening pre- and post-ripening in women undergoing induction of labor. METHODS: Subjects at 37-41 weeks' gestation undergoing cervical ripening before induction of labor were recruited (n = 20). Examinations, performed prior to administration of misoprostol and 4 h later included Bishop score, transvaginal ultrasound measurement of cervical length, and 10 replicate SWS measurements using an ultrasound system equipped with a prototype transducer (128 element, 3 mm diameter, 14 mm aperture) attached to the clinician's hand. Subjects were divided into two groups, 'not-in-labor' and 'marked-progression', based on cervical evaluation at the second examination. Measurements were compared via individual paired hypotheses tests and using a linear mixed model, with the latter also used to compare groups. Spearman's rank correlation coefficient was used to compare SWS with Bishop score. The linear mixed model can take into account clustered data and accommodate multiple predictors simultaneously. RESULTS: The Wilcoxon signed-rank paired test established a significant difference in pre- and post-ripening SWS, with mean SWS estimates of 2.53 ± 0.75 and 1.54 ± 0.31 m/s, respectively (P < 0.001) in the not-in-labor group (decrease in stiffness) and 1.58 ± 0.33 and 2.35 ± 0.65 m/s for the marked-progression group (increase in stiffness). The linear mixed model corroborated significant differences in pre- and post-ripening measurements in individual subjects (P < 0.001) as well as between groups (P < 0.0001). SWS estimates were significantly correlated with digitally-assessed cervical softness and marginally correlated with Bishop score as assessed by Spearman's rank correlation coefficient. CONCLUSIONS: In-vivo SWS estimates detected stiffness differences before and after misoprostol-induced softening in term pregnancies. This ultrasonic shear elasticity imaging technique shows promise for assessing cervical softness.

Estimation of shear wave speed in the human uterine cervix.

OBJECTIVES: To explore spatial variability within the cervix and the sensitivity of shear wave speed (SWS) to assess softness/stiffness differences in ripened (softened) vs unripened tissue. METHODS: We obtained SWS estimates from hysterectomy specimens (n = 22), a subset of which were ripened (n = 13). Multiple measurements were made longitudinally along the cervical canal on both the anterior and posterior sides of the cervix. Statistical tests of differences in the proximal vs distal, anterior vs posterior and ripened vs unripened cervix were performed with individual two-sample t-tests and a linear mixed model. RESULTS: Estimates of SWS increase monotonically from distal to proximal longitudinally along the cervix, they vary in the anterior compared to the posterior cervix and they are significantly different in ripened vs unripened cervical tissue. Specifically, the mid position SWS estimates for the unripened group were 3.45 ± 0.95 m/s (anterior; mean ± SD) and 3.56 ± 0.92 m/s (posterior), and 2.11 ± 0.45 m/s (anterior) and 2.68 ± 0.57 m/s (posterior) for the ripened group (P < 0.001). CONCLUSIONS: We propose that SWS estimation may be a valuable research and, ultimately, diagnostic tool for objective quantification of cervical stiffness/softness.

Pathological implications of Th1/Th2 cytokine genetic variants in Behçet's disease: Data from a pilot study in a Sicilian population.

Cytokines act as pleiotropic polypeptides able to regulate inflammatory/immune responses and to provide important signals in physiological and pathological processes. Several cytokines (Th1, Th2, and Th17) seem to be involved in the pathophysiology of Behçet's disease, a chronic immune-mediated disease characterized by oral and genital lesions and ocular inflammation. Its individual susceptibility seems to be modulated by genetic variants in genes codifying these cytokines. Th1 and Th17 seem to be involved in the disease's active phases, and Th2 seems to affect the development or severity of the disease; however, contrasting data are reported. In this study, some genetic variants of the Th1/Th2 cytokine genes were investigated in Sicilian patients and age- and gender-matched controls. Three very significant associations with Behçet's disease were detected, and combined genotypes associated with increased disease risk were identified. Results obtained point to the key role of Th1/Th2 cytokine genetic variants in disease susceptibility.

The impact of hepatic pressurization on liver shear wave speed estimates in constrained versus unconstrained conditions.

Increased hepatic venous pressure can be observed in patients with advanced liver disease and congestive heart failure. This elevated portal pressure also leads to variation in acoustic radiation-force-derived shear wave-based liver stiffness estimates. These changes in stiffness metrics with hepatic interstitial pressure may confound stiffness-based predictions of liver fibrosis stage. The underlying mechanism for this observed stiffening behavior with pressurization is not well understood and is not explained with commonly used linear elastic mechanical models. An experiment was designed to determine whether the stiffness increase exhibited with hepatic pressurization results from a strain-dependent hyperelastic behavior. Six excised canine livers were subjected to variations in interstitial pressure through cannulation of the portal vein and closure of the hepatic artery and hepatic vein under constrained conditions (in which the liver was not free to expand) and unconstrained conditions. Radiation-force-derived shear wave speed estimates were obtained and correlated with pressure. Estimates of hepatic shear stiffness increased with changes in interstitial pressure over a physiologically relevant range of pressures (0-35 mmHg) from 1.5 to 3.5 m s(-1). These increases were observed only under conditions in which the liver was free to expand while pressurized. This behavior is consistent with hyperelastic nonlinear material models that could be used in the future to explore methods for estimating hepatic interstitial pressure noninvasively.

Analysis of IL-6, IL-10 and IL-17 genetic polymorphisms as risk factors for sepsis development in burned patients.

Infection risk, sepsis and mortality after severe burn are primarily determined by patient age, burn size, and depth. Whether genetic differences contribute to otherwise unexpected variability in outcomes is unknown. We sought to determine whether there was an association between IL-6, IL-10 and IL-17 polymorphisms with cytokine production and development of sepsis. We evaluated 71 patients with burns ≥15% TBSA and 109 healthy subjects. The genotypes of IL-6 (-174C/G), IL-10 (-819C/T and -1082A/G) and IL-17 (7488T/C) polymorphisms were identified applying polymerase chain reaction protocols. The cytokine levels in serum were determined with enzyme-linked immunoabsorbent assays. Our results demonstrated no significant differences in the genotype frequencies studied between burn patients and healthy subjects. No significant associations were found among IL-6 and IL-17F genotypes and the related cytokine serum levels. Only IL-10 promoter -1082GG genotype was related to an increased IL-10 production in burned patients. In addition, septic subjects bearing -1082G/G genotype have shown the highest and non-septic bearing -1082A/* genotypes the lowest IL-10 serum levels. All together these data seem to indicate that genetically determined individual difference in IL-10 production might influence the susceptibility to septic complications in burned patients and suggest that these markers might be useful in burned patient management.

Quantifying hepatic shear modulus in vivo using acoustic radiation force.

The speed at which shear waves propagate in tissue can be used to quantify the shear modulus of the tissue. As many groups have shown, shear waves can be generated within tissues using focused, impulsive, acoustic radiation force excitations, and the resulting displacement response can be ultrasonically tracked through time. The goals of the work herein are twofold: (i) to develop and validate an algorithm to quantify shear wave speed from radiation force-induced, ultrasonically-detected displacement data that is robust in the presence of poor displacement signal-to-noise ratio and (ii) to apply this algorithm to in vivo datasets acquired in human volunteers to demonstrate the clinical feasibility of using this method to quantify the shear modulus of liver tissue in longitudinal studies. The ultimate clinical application of this work is noninvasive quantification of liver stiffness in the setting of fibrosis and steatosis. In the proposed algorithm, time-to-peak displacement data in response to impulsive acoustic radiation force outside the region of excitation are used to characterize the shear wave speed of a material, which is used to reconstruct the material's shear modulus. The algorithm is developed and validated using finite element method simulations. By using this algorithm on simulated displacement fields, reconstructions for materials with shear moduli (mu) ranging from 1.3-5 kPa are accurate to within 0.3 kPa, whereas stiffer shear moduli ranging from 10-16 kPa are accurate to within 1.0 kPa. Ultrasonically tracking the displacement data, which introduces jitter in the displacement estimates, does not impede the use of this algorithm to reconstruct accurate shear moduli. By using in vivo data acquired intercostally in 20 volunteers with body mass indices ranging from normal to obese, liver shear moduli have been reconstructed between 0.9 and 3.0 kPa, with an average precision of +/-0.4 kPa. These reconstructed liver moduli are consistent with those reported in the literature (mu = 0.75-2.5 kPa) with a similar precision (+/-0.3 kPa). Repeated intercostal liver shear modulus reconstructions were performed on nine different days in two volunteers over a 105-day period, yielding an average shear modulus of 1.9 +/- 0.50 kPa (1.3-2.5 kPa) in the first volunteer and 1.8 +/- 0.4 kPa (1.1-3.0 kPa) in the second volunteer. The simulation and in vivo data to date demonstrate that this method is capable of generating accurate and repeatable liver stiffness measurements and appears promising as a clinical tool for quantifying liver stiffness.

On the feasibility of remote palpation using acoustic radiation force.

A method of acoustic remote palpation, capable of imaging local variations in the mechanical properties of tissue, is under investigation. In this method, focused ultrasound is used to apply localized (on the order of 2 mm3) radiation force within tissue. and the resulting tissue displacements are mapped using ultrasonic correlation based methods. The tissue displacements are inversely proportional to the stiffness of the tissue, and thus a stiffer region of tissue exhibits smaller displacements than a more compliant region. In this paper, the feasibility of remote palpation is demonstrated experimentally using breast tissue phantoms with spherical lesion inclusions, and in vitro liver samples. A single diagnostic transducer and modified ultrasonic imaging system are used to perform remote palpation. The displacement images are directly correlated to local variations in tissue stiffness with higher contrast than the corresponding B-mode images. Relationships between acoustic beam parameters, lesion characteristics and radiation force induced tissue displacement patterns are investigated and discussed. The results show promise for the clinical implementation of remote palpation.

No obvious abnormality in mice deficient in receptor protein tyrosine phosphatase beta.

The development of neurons and glia is governed by a multitude of extracellular signals that control protein tyrosine phosphorylation, a process regulated by the action of protein tyrosine kinases and protein tyrosine phosphatases (PTPs). Receptor PTPbeta (RPTPbeta; also known as PTPzeta) is expressed predominantly in the nervous system and exhibits structural features common to cell adhesion proteins, suggesting that this phosphatase participates in cell-cell communication. It has been proposed that the three isoforms of RPTPbeta play a role in regulation of neuronal migration, neurite outgrowth, and gliogenesis. To investigate the biological functions of this PTP, we have generated mice deficient in RPTPbeta. RPTPbeta-deficient mice are viable, are fertile, and showed no gross anatomical alterations in the nervous system or other organs. In contrast to results of in vitro experiments, our study demonstrates that RPTPbeta is not essential for neurite outgrowth and node formation in mice. The ultrastructure of nerves of the central nervous system in RPTPbeta-deficient mice suggests a fragility of myelin. However, conduction velocity was not altered in RPTPbeta-deficient mice. The normal development of neurons and glia in RPTPbeta-deficient mice demonstrates that RPTPbeta function is not necessary for these processes in vivo or that loss of RPTPbeta can be compensated for by other PTPs expressed in the nervous system.

A finite element model of remote palpation of breast lesions using radiation force: factors affecting tissue displacement.

The early detection of breast cancer reduces patient mortality. The most common method of breast cancer detection is palpation. However, lesions that lie deep within the breast are difficult to palpate when they are small. Thus, a method of remote palpation, which may allow the detection of small lesions lying deep within the breast, is currently under investigation. In this method, acoustic radiation force is used to apply localized forces within tissue (to tissue volumes on the order of 2 mm3) and the resulting tissue displacements are mapped using ultrasonic correlation based methods. A volume of tissue that is stiffer than the surrounding medium (i.e., a lesion) distributes the force throughout the tissue beneath it, resulting in larger regions of displacement, and smaller maximum displacements. The resulting displacement maps may be used to image tissue stiffness. A finite-element-model (FEM) of acoustic remote palpation is presented in this paper. Using this model, a parametric analysis of the affect of varying tissue and acoustic beam characteristics on radiation force induced tissue displacements is performed. The results are used to evaluate the potential of acoustic remote palpation to provide useful diagnostic information in a clinical setting. The potential for using a single diagnostic transducer to both generate radiation force and track the resulting displacements is investigated.

Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears.

One hundred two type II SLAP lesions without associated anterior instability, Bankart lesion, or anterior inferior labral pathology were surgically treated under arthroscopic control. There were three distinct type II SLAP lesions based on anatomic location: anterior (37%), posterior (31%), and combined anterior and posterior (31%). Preoperatively, the Speed and O'Brien tests were useful in predicting anterior lesions, whereas the Jobe relocation test was useful in predicting posterior lesions. Rotator cuff tears were present in 31% of patients and were found to be lesion-location specific. In posterior and combined anterior-posterior lesions, a drive-through sign was always present (despite absence of anterior-inferior labral pathology or a Bankart lesion) and was eliminated by repair of the posterior component of the SLAP lesion. We conclude that SLAP lesions with a posterior component develop posterior-superior instability that manifests itself by a secondary anterior-inferior pseudolaxity (drive-through sign), and that chronic superior instability leads to secondary lesion-location-specific rotator cuff tears that begin as partial thickness tears from inside the joint.

Inflammatory pathogenesis of cortical polymicrogyria: an autopsy study.

Polymicrogyria, a cortical abnormality usually classified among neuron migration disorders, is characterized by different etiologies and pathogeneses. Recently, it has been proposed that polymicrogyria could be acquired as a consequence of a lasting damage to the developing brain. In this study, we test the hypothesis that an infection in the fetal adnexa may give rise to distant brain defects and eventually polymicrogyria. Thirty-two fetuses spontaneously aborted for extensive ascending chorioamnionitis at 15-26 wk of gestation were evaluated. Control subjects were represented by 8 fetuses aborted at 15-24 wk of gestation. A complete autopsy was carried out between 4 and 12 h after fetal expulsion. We found different histologic alterations in the primitive cortical architecture, both isolated and combined (undulation of the cortical ribbon, untimely cortical folding/molecular layer fusion, and neuronal loss). A total of 25 cases presented one or more of the above-described morphologic alterations in the brain (78%). On the contrary, similar alterations were never observed in any of the control brains (p=0.019). Our findings indicate that chorioamnionitis significantly impairs brain cortex morphogenesis. Such neuron damage may be caused by an unspecific, indirect mechanism of injury to the developing cortex involving hypoxia and free radical generation. The reported brain abnormalities may even evolve into polymicrogyria in surviving fetuses.

DNA ploidy pattern in choroidal melanoma: correlation with survival. A flow cytometry study on archival material.

BACKGROUND/AIMS: Paraffin embedded samples have provided an important source of material for retrospective cytofluorimetric studies, useful in establishing the predictive value of DNA content measurements. The aim of this study was to investigate the incidence and type of aneuploidy in choroidal malignant melanomas (CMM) and the significance in the clinical outcome (median follow up 55 months). METHODS: DNA content was quantified by flow cytometry in 61 CMM from archival material. Non-tumour ocular tissue was used as the reference diploid standard. Cases in which the coefficient of variation (CV) of the diploid peak was > 8% were excluded. The CMM were classified as spindle A, spindle B, mixed spindle and epithelioid, epithelioid, and necrotic. RESULTS: The frequency of the aneuploid DNA pattern was 38%. Necrotic tumours showed a worse clinical outcome independent of the ploidy pattern. Spindle A tumours were found to be diploid. Spindle B and mixed tumours showed a prevalent diploid and near diploid aneuploid pattern (DI < 1.3), yet aneuploidy was not correlated with a worse prognosis. The epithelioid tumours were prevalently diploid. However, 83% of the aneuploid tumours were hypodiploid (DI < 0.95), and showed the worst prognosis. CONCLUSION: These results indicate that increasing DNA abnormalities in CMM, especially in the epithelioid histotype, were associated with an increasing mortality.

Bronchopulmonary dysplasia of the premature baby: an immunohistochemical study.

Prematurely born infants who required assisted ventilation may develop chronic lung disease or bronchopulmonary dysplasia (BPD). The cells involved in the reparative process of the premature lung are not well defined. The repair of injured tissues is a highly standardized process and the most important cells are activated (modulated) fibroblasts (myofibroblasts). A key cytokine in controlling repair is transforming growth factor-beta (TGF-beta). To characterize the cells involved in the repair process of the premature lung, we employed immunocytochemical techniques and examined the lungs of 39 autopsied premature babies who had neonatal respiratory distress syndrome (RDS). All were treated in neonatal intensive care units and required mechanical ventilation and supplemental oxygen; all survived for at least 12 hours. Antibodies were employed against vimentin, alpha-smooth muscle (alpha-SM) actin, total muscle actin, desmin, MAC387, and TGF-beta. Our study indicates that myofibroblasts are normally present along terminal airways in the developing lung. These cells increase in number some days after lung injury, form bundles of cells encircling terminal air spaces, and acquire desmin contractile filaments shortly thereafter. Myofibroblasts do not lose their contractile filaments with time, suggesting a conversion to smooth muscle metaplasia. The proliferation and migration of such myofibroblasts at sites of lung injury is associated with the presence of TGF-beta. These findings suggest that myofibroblasts play an important role in premature lung repair. They may point the way to experimental and clinical trials that will identify drugs antagonistic to TGF-beta (or other cytokines). Such antagonists may protect the neonates who are at high risk of developing BPD.

Celiac disease with cerebral calcium and silica deposits: x-ray spectroscopic findings, an autopsy study.

An increased incidence of seizures and cerebral calcifications, usually bilateral and located in the occipital cortex, has been reported in celiac patients. The histology of cerebral lesions is not well defined, and their pathogenesis is only speculative. We report the autopsy results of a patient with celiac disease, seizures, and cerebral calcifications who died following a cerebral hemorrhage caused by Fisher-Evans syndrome. Calcifications were restricted to the cortical gray matter and composed of aggregates of small calcified spicules. Calcium deposition was present as psammoma-like bodies, along small vessels, and within neurons. X-ray spectroscopy of the calcified areas revealed that calcium (43%) and silica (57%) were present in the lesions. High silica content was also found in the cerebral hemorrhagic fluid. Silica toxicity has to be considered in regard to the pathogenesis of the cerebral lesions and of the seizures.

[The role of heparin sulfate in the treatment of pregnant women with circulatory deficiency syndrome]. / Ruolo dell'eparan solfato nel trattamento di pazienti gravide con sindrome da deficit circolatorio.

The syndrome from circulatory maternal, precocious and belated deficit could influence the appearance of a vast range of obstetric incluted pathology: recurrent abortions, delays of increase, pre-eclampsia, fetal and neonatal dead. The principal biochemical implicated mechanism has represented from alteration of equilibrium trombossano prostaciclina with adjunct vasoconstriction and uterum-placental hypoperfusion. In this study the authors have estimated the efficacy and the compliance of the heparan sulfate in 30 pregnant patients to risk for vascular pathology. In all these cases, the rational to the use the heparan sulfate had represented from the necessity to associate a therapy anteplatelet with associate an fibrinolitic activity. The percent of pregnancies with alive and vital fetuses was of the 90%; the collateral effects have been inconsiderable. The authors retain useful effect randomize checked studies to evaluate further the real results this therapy.