Can Anal Cytology Be a Tool in Following Patients Treated for Squamous Cell Carcinoma of the Anus?

BACKGROUND: Squamous cell carcinoma of the anus (SCCA) is associated with human papillomavirus infection and preceded by high-grade squamous intraepithelial lesions (HSIL). Following successful treatment, the standard of care is to surveille for local recurrence with both anoscopy and digital rectal examination. While high-resolution anoscopy (HRA) has been shown to identify HSIL during the surveillance period, it requires specialized training and resources.1 The burden of these resources may be reduced by conducting surveillance with anal cytology. We studied 2 questions: (1) Can anal cytology identify HSIL in patients after successful treatment of SCCA? (2) Can HSIL be found with anal cytology after completion of chemoradiation for SCCA? METHODS: Patient charts were queried for diagnosis of SCCA. Patients were excluded if they were not successfully treated for cure or if patients had not been seen in the surveillance period of 5 years following treatment. Descriptive statistics were elucidated. RESULTS: 104 patient charts met inclusion criteria. 81 were surveilled using standard of care, while 23 were followed with standard of care plus anal cytology. 5 patients followed with cytology demonstrated HSIL. 2/5 were found via cytology, 1/5 via HRA, and 2/5 patients via exam under anesthesia and biopsy. DISCUSSION: This study demonstrated that HSIL was identified cytologically in the surveillance period. There may be utility in using anal cytology to identify HSIL in patients during this period in lieu of the specialized resources required for HRA. This may allow dysplasia to be treated with excision and fulguration prior to redevelopment of SCCA.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change.

BACKGROUND: Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS: Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS: After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION: Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

Tolerability of ADXS11-001 Lm-LLO Listeria-Based Immunotherapy With Mitomycin, Fluorouracil, and Radiation for Anal Cancer.

PURPOSE: To obtain safety and preliminary efficacy data of the combination of ADXS11-001, live attenuated Listeria monocytogenes bacterium, with mitomycin, 5-fluorouracil (5-FU), and intensity modulated radiation therapy in locally advanced anal cancer. PATIENTS AND METHODS: Eligibility included patients with previously untreated, nonmetastatic anal cancer with a primary tumor >4 cm or node-positive disease. Patients received 2 cycles of mitomycin and 5-FU concurrent with 54.0 Gy intensity modulated radiation therapy. One intravenous dose of ADXS11-001 (1 × 109 colony-forming units) was administered before chemoradiation; 3 additional monthly doses were given after chemoradiation. RESULTS: Ten patients were treated, including 1 with N2 and 4 with N3 disease. Two patients had grade 3 acute toxicities after the initial dose of ADXS11-001, including chills/rigors (n = 2), back pain (n = 1), and hyponatremia (n = 1). All ADXS11-001 toxicities occurred within 24 hours of administration. There was no apparent increase in chemoradiation toxicities or myelosuppression. One patient had a grade 5 cardiopulmonary event shortly after beginning 5-FU treatment. All 9 assessable patients had complete clinical responses by sigmoidoscopy. Eight of 9 patients (89%) are progression-free at a median follow-up of 42 months. CONCLUSIONS: Preliminary data show that ADXS11-001 can be safely administered with standard chemoradiation for anal cancer. Further studies of listeria-based immunotherapy with radiation are warranted.

Preclinical Development of an Anti-NaPi2b (SLC34A2) Antibody-Drug Conjugate as a Therapeutic for Non-Small Cell Lung and Ovarian Cancers.

PURPOSE: Antibody-drug conjugates (ADC) selectively deliver a cytotoxic drug to cells expressing an accessible antigenic target. Here, we have appended monomethyl auristatin E (MMAE) to an antibody recognizing the SLC34A2 gene product NaPi2b, the type II sodium-phosphate cotransporter, which is highly expressed on tumor surfaces of the lung, ovary, and thyroid as well as on normal lung pneumocytes. This study evaluated its efficacy and safety in preclinical studies. EXPERIMENTAL DESIGN: The efficacy of anti-NaPi2b ADC was evaluated in mouse ovarian and non-small cell lung cancer (NSCLC) tumor xenograft models, and its toxicity was assessed in rats and cynomolgus monkeys. RESULTS: We show here that an anti-NaPi2b ADC is effective in mouse ovarian and NSCLC tumor xenograft models and well-tolerated in rats and cynomolgus monkeys at levels in excess of therapeutic doses. Despite high levels of expression in normal lung of non-human primate, the cross-reactive ADC exhibited an acceptable safety profile with a dose-limiting toxicity unrelated to normal tissue target expression. The nonproliferative nature of normal pneumocytes, together with the antiproliferative mechanism of MMAE, likely mitigates the potential liability of this normal tissue expression. CONCLUSIONS: Overall, our preclinical results suggest that the ADC targeting NaPi2b provides an effective new therapy for the treatment of NSCLC and ovarian cancer and is currently undergoing clinical developments.

An anti-B7-H4 antibody-drug conjugate for the treatment of breast cancer.

B7-H4 has been implicated in cancers of the female reproductive system and investigated for its possible use as a biomarker for cancer, but there are no preclinical studies to demonstrate that B7-H4 is a molecular target for therapeutic intervention of cancer. We provide evidence that the prevalence and expression levels of B7-H4 are high in different subtypes of breast cancer and that only a few normal tissues express B7-H4 on the cell membrane. These profiles of low normal expression and upregulation in cancer provide an opportunity for the use of antibody-drug conjugates (ADCs), cytotoxic drugs chemically linked to antibodies, for the treatment of B7-H4 positive cancers. We have developed an ADC specific to B7-H4 that uses a linker drug consisting of a potent antimitotic, monomethyl auristatin E (MMAE), linked to engineered cysteines (THIOMAB) via a protease labile linker. We will refer to ADCs that use the THIOMAB format as TDCs to help distinguish the format from standard MC-vc-MMAE ADCs that are conjugated to the interchain disulfide bonds. Anti-B7-H4 (h1D11)-MC-vc-PAB-MMAE (h1D11 TDC) produced durable tumor regression in cell line and patient-derived xenograft models of triple-negative breast cancer. It also binds rat B7-H4 with similar affinity to human and allowed us to test for target dependent toxicity in rats. We found that our anti-B7-H4 TDC has toxicity findings similar to untargeted TDC. Our results validate B7-H4 as an ADC target for breast cancer and support the possible use of this TDC in the treatment of B7-H4(+) breast cancer.

MAPK pathway inhibition enhances the efficacy of an anti-endothelin B receptor drug conjugate by inducing target expression in melanoma.

Therapies targeting the mitogen-activated protein (MAP) kinase pathway in melanoma have produced significant clinical responses; however, duration of response is limited by acquisition of drug resistance. Rational drug combinations may improve outcomes in this setting. We assessed the therapeutic combination of an antibody-drug conjugate (ADC) targeting the endothelin B receptor (EDNRB) with small-molecule inhibitors of the MAP kinase signaling pathway in melanoma. Cell lines and tumor models containing either mutant BRAF or NRAS, or wild-type for both, were exposed to small-molecule inhibitors of BRAF and MEK. Expression of EDNRB was analyzed and the therapeutic impact of combining the anti-EDNRB ADC with the BRAF and MEK inhibitors was assessed. Increased expression of EDNRB in response to inhibition of BRAF and/or MEK was observed and augmented the antitumor activity of the ADC. Enhanced target expression and ADC antitumor activity were realized irrespective of the response of the tumor model to the BRAF or MEK inhibitors alone and could be achieved in melanoma with mutant NRAS, BRAF, or neither mutation. Cells that acquired resistance to BRAF inhibition through long-term culture retained drug-induced elevated levels of EDNRB expression. Expression of EDNRB was not enhanced in normal human melanocytes by inhibition of BRAF and the combination of the ADC with MAPK inhibitors was well-tolerated in mice. The anti-EDNRB ADC combines well with BRAF and MEK inhibitors and could have therapeutic use in the majority of human melanoma cases.

Total antibody quantification for MMAE-conjugated antibody-drug conjugates: impact of assay format and reagents.

Antibody-drug conjugates (ADCs) are target-specific anticancer agents consisting of cytotoxic drugs covalently linked to a monoclonal antibody. The number of ADCs in the clinic is growing, and therefore thorough characterization of the quantitative assays used to measure ADC concentrations in support of pharmacokinetic, efficacy, and safety studies is of increasing importance. Cytotoxic drugs such as the tubulin polymerization inhibiting auristatin, monomethyl auristatin E, have been conjugated to antibodies via cleavable linkers (MC-vc-PAB) through internal cysteines. This results in a heterogeneous mixture of antibody species with drug-to-antibody ratios (DAR) ranging from 0 to 8. In order to characterize the assays used to quantitate total MC-vc-PAB-MMAE ADCs (conjugated and unconjugated antibody), we used purified fractions with defined DARs from 6 therapeutic antibodies to evaluate different assay formats and reagents. Our investigations revealed that for quantitation of total antibody, including all unconjugated and conjugated antibody species, sandwich ELISA formats did not always allow for recovery of all purified DAR fractions (DAR 0-8) to within ±20% of the expected values at the reagent concentrations tested. In evaluating alternative approaches, we found that the recovery of DAR fractions with semihomogeneous assay (SHA) formats, in which sample, capture, and detection reagents are preincubated in solution, were less affected by the antibody's MMAE drug load as compared to traditional stepwise sandwich ELISAs. Thus, choosing the optimal assay format and reagents for total antibody assays is valuable for developing accurate quantitative assays.

Blocking NRG1 and other ligand-mediated Her4 signaling enhances the magnitude and duration of the chemotherapeutic response of non-small cell lung cancer.

Although standard chemotherapies are commonly used to treat most types of solid tumors, such treatment often results in inadequate response to, or relapse after, therapy. This is particularly relevant for lung cancer because most patients are diagnosed with advanced-stage disease and are treated with frontline chemotherapy. By studying the residual tumor cells that remain after chemotherapy in several in vivo non-small cell lung cancer models, we found that these cells have increased levels of human epidermal growth factor receptor (HER) signaling due, in part, to the enrichment of a preexisting NRG1(HI) subpopulation. Neuregulin 1 (NRG1) signaling in these models can be mediated by either the HER3 or HER4 receptor, resulting in the differential activation of downstream effectors. Inhibition of NRG1 signaling inhibits primary tumor growth and enhances the magnitude and duration of the response to chemotherapy. Moreover, we show that inhibition of ligand-mediated Her4 signaling impedes disease relapse in cases where NRG1 inhibition is insufficient. These findings demonstrate that ligand-dependent Her4 signaling plays an important role in disease relapse.

Anal incontinence-sphincter ani repair: indications, techniques, outcome.

INTRODUCTION: Fecal incontinence is a debilitating problem that has many different causes. There also are many treatments options, from behavioral modification to sphincteroplasty to artificial anal sphincter and colostomy. In a society with an aging population, fecal incontinence is an ever-increasing problem and will continue to grow. DISCUSSION: Treatment plans need to be individually tailored for each patient. The surgeon should be proficient in different types of procedures and match the procedure with the needs of the patient. Long-term follow-up of these patients must continue to help us better serve this patient population.

Current management of diverticulitis.

Diverticulitis is classified as uncomplicated or complicated, i.e., associated with perforation, fistula, or obstruction. CT allows more reliable characterization of an acute attack of diverticulitis. Medical management is reserved for uncomplicated diverticulitis and the initial phase of treatment of diverticulitis associated with abscess formation. Percutaneous abscess drainage is a major advance, which permits one-stage resection in a majority of cases. Diverticulitis associated with free perforation can be selectively managed with resection and primary anastomosis, although a Hartmann resection is likely to be performed. A fistula associated with diverticulitis can usually be managed with a one-stage resection. Obstruction can be managed selectively with resection with on-table bowel preparation, primary anastomosis, and proximal diversion. Laparoscopic techniques permit successful performance of elective resections most of the time. Hand assistance is of particular value when the patient has dense fibrosis.

Completely minimally invasive approach to restorative total proctocolectomy with j-pouch construction in children.

Restorative total proctocolectomy with J-pouch is a procedure used for children with severe ulcerative colitis or premalignant conditions like familial polyposis. The classic approach requires a laparotomy incision. Most published minimally invasive techniques still require a somewhat smaller incision to complete the procedure. We present a completely minimally invasive approach to accomplish the same goal, using a combined laparoscopic and endorectal technique and present our current clinical results with this method.

Profiling activities of transcription factors in breast cancer cell lines.

Transcription factors (TFs) are critical regulators of cell growth and differentiation, whose dysfunction is associated with many human diseases, including cancer. To facilitate the discovery of functionally altered TFs among the approximately 2,000 human TFs, we (Panomics, Inc., Fremont, CA) developed a Protein/DNA array technology that can be used to profile the activities of multiple TFs simultaneously. In this study, we applied this technology to examine the TF activities in three different breast cancer cell lines: MCF7 (estrogen receptor [ER] +, tamoxifen-sensitive), T47D (ER+, tamoxifen-resistant), and HCC1806 (ER-, tamoxifen-resistant). We compared the differences in TF activity in these cells lines following treatment with estradiol or tamoxifen. We found a number of TF activities unique to each of these cell lines. In addition to verifying previous findings, the novel findings of this study provide a more comprehensive view of the differences in the response of these cancer lines to estrogen and tamoxifen.

Protein-DNA array-based identification of transcription factor activities regulated by interaction with the glucocorticoid receptor.

The glucocorticoid receptor (GR) regulates gene expression by binding specific sequence elements within the promoters of target genes or by cross-talk with other transcription factors (TFs). For some TFs, interaction with the GR results in alteration of DNA binding and transcriptional regulation. We used a protein-DNA array, a system that facilitates simultaneous profiling of the activities of multiple transcription factors, to systematically examine the potential cross-talk of GRalpha with 149 TFs. Using this array, we identified several TFs, including IRF, E47, and COUP-TF, whose DNA binding activities were modulated by GRalpha. We then confirmed these results with in vitro electrophoretic mobility shift assays and in vivo reporter assays. In this study, IRF and E47 were identified as participants in GRalpha cross-talk for the first time. This new finding expands our understanding of the functional role of GRalpha in the context of gene expression regulation.

Laryngeal mask airway--a novel method of airway protection during ERCP: comparison with endotracheal intubation.

BACKGROUND: ERCP sometimes requires deep sedation and rarely general anesthesia with airway protection. The laryngeal mask airway device is placed perorally to create a seal over the larynx. Unlike endotracheal intubation, no tube traverses the vocal cords, thus reducing airway stimulation and obviating the need to administer muscle relaxants. The feasibility of using the laryngeal mask airway during ERCP was evaluated and recovery times compared for patients undergoing ERCP with the laryngeal mask airway versus endotracheal intubation. METHODS: In this retrospective cohort study, anesthesia records were reviewed for anesthesiologist-assisted ERCP procedures performed during a 30-month period. Demographics, procedure duration, and time from endoscope removal to extubation were abstracted. Either propofol or inhalation agents were used for anesthesia in all patients. OBSERVATIONS: Anesthesiologists administered sedation for 41 ERCPs. The airway was managed in 12 patients with endotracheal intubation and the laryngeal mask airway in 20 patients. Six patients underwent laryngeal mask airway insertion and removal while prone. A therapeutic duodenoscope was passed beyond the laryngeal mask airway with little or no resistance in all cases. Repositioning the laryngeal mask airway during the procedure was required in 1 case. Laryngeal mask airway use was associated with shorter extubation time compared with endotracheal intubation (7.2 vs. 12 min.; p = 0.004). There were no airway complications. CONCLUSION: ERCP can be performed while using the laryngeal mask airway for airway protection. The laryngeal mask airway can be placed with the patient prone, obviating the need to change position. Laryngeal mask airway shortens extubation time compared with endotracheal intubation.