ESMO recommendations on microsatellite instability testing for immunotherapy in cancer, and its relationship with PD-1/PD-L1 expression and tumour mutational burden: a systematic review-based approach

BACKGROUND

Cancers with a defective DNA mismatch repair (dMMR) system contain thousands of mutations most frequently located in monomorphic microsatellites and are thereby defined as having microsatellite instability (MSI). Therefore, MSI is a marker of dMMR. MSI/dMMR can be identified using immunohistochemistry to detect loss of MMR proteins and/or molecular tests to show microsatellite alterations. Together with tumour mutational burden (TMB) and PD-1/PD-L1 expression, it plays a role as a predictive biomarker for immunotherapy.

METHODS

To define best practices to implement the detection of dMMR tumours in clinical practice, the ESMO Translational Research and Precision Medicine Working Group launched a collaborative project, based on a systematic review-approach, to generate consensus recommendations on the: (i) definitions related to the concept of MSI/dMMR; (ii) methods of MSI/dMMR testing and (iii) relationships between MSI, TMB and PD-1/PD-L1 expression.

RESULTS

The MSI-related definitions, for which a consensus frame-work was used to establish definitions, included: 'microsatellites', 'MSI', 'DNA mismatch repair' and 'features of MSI tumour'. This consensus also provides recommendations on MSI testing; immunohistochemistry for the mismatch repair proteins MLH1, MSH2, MSH6 and PMS2 represents the first action to assess MSI/dMMR (consensus with strong agreement); the second method of MSI/dMMR testing is represented by polymerase chain reaction (PCR)-based assessment of microsatellite alterations using five microsatellite markers including at least BAT-25 and BAT-26 (strong agreement). Next-generation sequencing, coupling MSI and TMB analysis, may represent a decisive tool for selecting patients for immunotherapy, for common or rare cancers not belonging to the spectrum of Lynch syndrome (very strong agreement). The relationships between MSI, TMB and PD-1/PD-L1 expression are complex, and differ according to tumour types.

CONCLUSIONS

This ESMO initiative is a response to the urgent questions raised by the growing success of immunotherapy and provides also important insights on the relationships between MSI, TMB and PD-1/PD-L1.

Pleomorphic Adenoma of the Parotid Gland and Ipsilateral Thyroid Incidentaloma: Report of A Rare Case With Review of Literature

BACKGROUND

Pleomorphic adenomas are benign tumors of the salivary glands that mainly affect the lower pole of the superficial lobe of the parotid gland. The term "pleomorphic" refers to the epithelial and connective origin of the mass. The clinical presentation is typically that of asymptomatic swelling which increases in volume. Therapy consists in surgical removal of the tumor mass by parotidectomy with nerve preservation.

CASE DETAILS

This clinical case describes an interesting case of pleomorphic adenoma of the parotid gland in a 62-year-old patient. The patient presented with a long history of an asymptomatic mildly worsening swelling of the left parotid region. The peculiarity of the clinical case is the dimension of the adenoma (9x5x9 cm) and the presence of a thyroid incidentaloma (TI), consisting of a thyroid multinodular goiter composed of nodules, the largest of which measured 8 cm in diameter. This mass dislocated the laryngotracheal axis, compressed the larynx and caused the reduction of the respiratory space, making orotracheal intubation difficult and determining the need to perform a tracheotomy.

CONCLUSION

Benign pleomorphic adenomas can potentially reach large sizes if untreated. Socio-economic problems may be the reason for late diagnosis.

Dietary Restriction for The Treatment of Meniere's Disease

Meniere's disease (MD) is an idiopathic inner ear disorder characterized by spontaneous recurrent vertigo, fluctuating sensorineural hearing loss (SNHL), aural fullness and tinnitus. Endolymphatic hydrops (EH) of the inner ear is currently considered the pathophysiological mechanisms that underlies typical symptoms of MD. MD diagnosis is based on the criteria of the Baràny Society. There are many therapeutic options for MD, but none is considered effective by the scientific community. The first-line treatment commonly includes dietary modification, as low salt diet and reduction of alcohol and caffeine daily intake. Although some studies showed a positive effect of these dietary restrictions, even in the prevention of recurrences, currently there is no uniform consensus on their usefulness. New dietary approach, such SPC-flakes, are being evaluated: further assessments will be needed to validate their use in clinical practice.

Sub-Clinical Effects of Chronic Noise Exposure on Vestibular System

AIM

to investigate the effect of chronic noise exposure on vestibular function of subjects without clinical evidence of vestibular disorders and with documented cochlear damage from noise.

SUBJECTS AND METHODS

25 patients with chronic noise-induced hearing loss (NIHL) and without vestibular complaints (group A) and 25 matched controls with sensorineural hearing loss without noise exposure (group B), underwent audiological and vestibular test including caloric and cervical vestibular-evoked myogenic potentials tests (cVEMPs).

RESULTS

In subjects chronically exposed to noise, similarly to that of the auditory threshold, an increase in the evocation threshold of VEMPs has been documented, statistically significant (p<0,05) and independent of the performance of the auditory threshold. p1-n1 amplitude values showed a significant difference between group A and group B. No significant difference for p1-n1 latencies between the two groups was found.

CONCLUSION

We have documented the possibility of vestibular lesion, along with cochlear damage, related to chronic acoustic trauma.

Validation of the Chronic Tinnitus Acceptance Questionnaire (CTAQ-I): the Italian version

Tinnitus is a widespread symptom that is chronically experienced by approximately 10% of the adult population. While the vast majority of individuals do not feel impaired by their ear noise, about 0.5-3% of the adult population develops severe distress and feels impaired in everyday life. The severity of the distress experienced can only partially be explained by the characteristics of the ear noise itself (e.g. objective tinnitus loudness or duration). Psychological variables such as tinnitus acceptance are being increasingly investigated by tinnitus research. The aim of this study was to analyse the psychometric quality of the Italian version of the “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I). The CTAQ-I is an adaption of the Italian “Chronic Pain Acceptance Questionnaire (CPAQ)” and altered for the study of tinnitus acceptance. This cross-sectional multicentre questionnaire study included 141 outpatients with chronic tinnitus. Sociodemographic and clinical data were assessed with the Tinnitus Sample Case History (TSCH), tinnitus acceptance with the Italian “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I), tinnitus distress with the Tinnitus Handicap Inventory (THI) and the Tinnitus Questionnaire Short Form (TQ 12-I). Furthermore, we assessed the patient’s general psychological distress (Brief Symptom Inventory - BSI) and Health Related Quality of Life (SF-36). Psychometric and factorial evaluation of the CTAQ-I were carried out. To investigate the influence of sociodemographic and numerous clinical variables on tinnitus acceptance we calculated correlation coefficients, analysis of variance and independent sample-t-tests. The factor analysis revealed a two-factor solution (“activity engagement” and “tinnitus willingness”), accounting for 41.1% of the variance. Good internal consistency for the total score (α = 0.84) and both factors (α = 0.80-0.88) was found. Moderate negative correlations with tinnitus distress indicated good validity. Tinnitus acceptance was further correlated with lower psychological distress and subjective tinnitus loudness, as well as increased emotional well-being. Tinnitus acceptance is considered to be an important source of therapeutic change in behavioural-based treatments as well as in professional counselling for tinnitus. Our study shows that the CTAQ-I is a reliable and valid instrument to measure the acceptance of patients suffering from chronic tinnitus.

The prognostic significance of E-cadherin expression in laryngeal squamous-cell carcinoma: a systematic review

The aim of this study was to systematically review publications that investigated the prognostic role of E-cadherin immunostaining in patients affected by laryngeal squamous cell carcinoma. An appropriate string was run on PubMed to retrieve articles dealing with this topic. A double cross-check was performed on citations and full-text articles by two authors independently to analyse all manuscripts and perform a comprehensive quality assessment. Among 89 abstracts identified, 13 articles were included. These studies reported on 1,121 patients with histologically confirmed diagnosis of laryngeal squamous cell carcinoma. Overall, there were 10 studies that showed a significant correlation between E-cadherin immunohistochemical expression and at least one of the clinical and histopathological parameters considered by the authors. In particular E-cadherin expression was significantly associated with N stage (five studies), grading (four studies) and disease-free survival/disease-specific survival (six studies). In conclusion, the findings of our review appear similar to the results published by other authors on the putative role of E-cadherin in progression of malignancy. In fact, for laryngeal squamous cell carcinoma it seems that lower levels of E-cadherin correlate with increased tumoural aggressiveness and worse prognosis. Nevertheless, further high-quality prospective studies should be carried out to clarify if E-cadherin expression may be considered as an independent prognostic factor for patients affected by laryngeal cancer.

Transcriptomic analysis and mutational status of IDH1 in paired primary-recurrent intrahepatic cholangiocarcinoma

Background

Effective target therapies for intrahepatic cholangiocarcinoma (ICC) have not been identified so far. One of the reasons may be the genetic evolution from primary (PR) to recurrent (REC) tumors. We aim to identify peculiar characteristics and to select potential targets specific for recurrent tumors.

Eighteen ICC paired PR and REC tumors were collected from 5 Italian Centers. Eleven pairs were analyzed for gene expression profiling and 16 for mutational status of IDH1. For one pair, deep mutational analysis by Next Generation Sequencing was also carried out. An independent cohort of patients was used for validation.

Results

Two class-paired comparison yielded 315 differentially expressed genes between REC and PR tumors. Up-regulated genes in RECs are involved in RNA/DNA processing, cell cycle, epithelial to mesenchymal transition (EMT), resistance to apoptosis, and cytoskeleton remodeling. Down-regulated genes participate to epithelial cell differentiation, proteolysis, apoptotic, immune response, and inflammatory processes. A 24 gene signature is able to discriminate RECs from PRs in an independent cohort; FANCG is statistically associated with survival in the chol-TCGA dataset. IDH1 was mutated in the RECs of five patients; 4 of them displayed the mutation only in RECs. Deep sequencing performed in one patient confirmed the IDH1 mutation in REC.

Conclusions

RECs are enriched for genes involved in EMT, resistance to apoptosis, and cytoskeleton remodeling. Key players of these pathways might be considered druggable targets in RECs. IDH1 is mutated in 30% of RECs, becoming both a marker of progression and a target for therapy.

Electronic supplementary material

The online version of this article (10.1186/s12864-018-4829-0) contains supplementary material, which is available to authorized users.

Risk of pancreatic cancer associated with family history of cancer and other medical conditions by accounting for smoking among relatives

Background

Family history (FH) of pancreatic cancer (PC) has been associated with an increased risk of PC, but little is known regarding the role of inherited/environmental factors or that of FH of other comorbidities in PC risk. We aimed to address these issues using multiple methodological approaches.

Methods

Case-control study including 1431 PC cases and 1090 controls and a reconstructed-cohort study (N = 16 747) made up of their first-degree relatives (FDR). Logistic regression was used to evaluate PC risk associated with FH of cancer, diabetes, allergies, asthma, cystic fibrosis and chronic pancreatitis by relative type and number of affected relatives, by smoking status and other potential effect modifiers, and by tumour stage and location. Familial aggregation of cancer was assessed within the cohort using Cox proportional hazard regression.

Results

FH of PC was associated with an increased PC risk [odds ratio (OR) = 2.68; 95% confidence interval (CI): 2.27-4.06] when compared with cancer-free FH, the risk being greater when ≥ 2 FDRs suffered PC (OR = 3.88; 95% CI: 2.96-9.73) and among current smokers (OR = 3.16; 95% CI: 2.56-5.78, interaction FHPC*smoking P-value = 0.04). PC cumulative risk by age 75 was 2.2% among FDRs of cases and 0.7% in those of controls [hazard ratio (HR) = 2.42; 95% CI: 2.16-2.71]. PC risk was significantly associated with FH of cancer (OR = 1.30; 95% CI: 1.13-1.54) and diabetes (OR = 1.24; 95% CI: 1.01-1.52), but not with FH of other diseases.

Conclusions

The concordant findings using both approaches strengthen the notion that FH of cancer, PC or diabetes confers a higher PC risk. Smoking notably increases PC risk associated with FH of PC. Further evaluation of these associations should be undertaken to guide PC prevention strategies.

FAM49B, a novel regulator of mitochondrial function and integrity that suppresses tumor metastasis

Mitochondrial dysregulation plays a central role in cancers and drives reactive oxygen species (ROS)-dependent tumor progression. We investigated the pro-tumoral roles of mitochondrial dynamics and altered intracellular ROS levels in pancreatic ductal adenocarcinoma (PDAC). We identified 'family with sequence similarity 49 member B' (FAM49B) as a mitochondria-localized protein that regulates mitochondrial fission and cancer progression. Silencing FAM49B in PDAC cells resulted in increased fission and mitochondrial ROS generation, which enhanced PDAC cell proliferation and invasion. Notably, FAM49B expression levels in PDAC cells were downregulated by the tumor microenvironment. Overall, the results of this study show that FAM49B acts as a suppressor of cancer cell proliferation and invasion in PDAC by regulating tumor mitochondrial redox reactions and metabolism.

Chronic subjective dizziness: Analysis of underlying personality factors

BACKGROUND

Chronic subjective dizziness (CSD) is characterized by persistent dizziness, unsteadiness, and hypersensitivity to one's own motion or exposure to complex visual stimuli. CSD may be triggered, in predisposed individuals with specific personality traits, by acute vestibular diseases. CSD is also thought to arise from failure to re-establish normal balance strategies after resolution of acute vestibular events which may be modulated by diathesis to develop anxiety and depression.

OBJECTIVE

To confirm the role of personality traits linked to anxiety and depression (i.e., neuroticism, introversion, low openness) as predisposing factors for CSD and to evaluate how individual differences in these personality traits are associated with CSD severity.

METHODS

We compared 19 CSD patients with 24 individuals who had suffered from periferal vestibular disorders (PVD) (i.e., Benign Paroxysmal Postural Vertigo or Vestibular Neuritis) but had not developed CSD as well as with 25 healthy controls (HC) in terms of personality traits, assessed via the NEO-PI-R questionnaire.

RESULTS

CSD patients, relative to PVD patients and HCs, scored higher on the anxiety facet of neuroticism. Total neuroticism scores were also significantly associated with dizziness severity in CSD patients but not PVD patients.

CONCLUSIONS

Pre-existing anxiety-related personality traits may promote and sustain the initial etiophatogenetic mechanisms linked with the development of CSD. Targeting anxiety-related mechanisms in CSD may be therefore a promising way to reduce the disability associated with CSD.

The European Society for Medical Oncology (ESMO) Precision Medicine Glossary

Background

Precision medicine is rapidly evolving within the field of oncology and has brought many new concepts and terminologies that are often poorly defined when first introduced, which may subsequently lead to miscommunication within the oncology community. The European Society for Medical Oncology (ESMO) recognises these challenges and is committed to support the adoption of precision medicine in oncology. To add clarity to the language used by oncologists and basic scientists within the context of precision medicine, the ESMO Translational Research and Personalised Medicine Working Group has developed a standardised glossary of relevant terms.

Materials and methods

Relevant terms for inclusion in the glossary were identified via an ESMO member survey conducted in Autumn 2016, and by the ESMO Translational Research and Personalised Medicine Working Group members. Each term was defined by experts in the field, discussed and, if necessary, modified by the Working Group before reaching consensus approval. A literature search was carried out to determine which of the terms, 'precision medicine' and 'personalised medicine', is most appropriate to describe this field.

Results

A total of 43 terms are included in the glossary, grouped into five main themes-(i) mechanisms of decision, (ii) characteristics of molecular alterations, (iii) tumour characteristics, (iv) clinical trials and statistics and (v) new research tools. The glossary classes 'precision medicine' or 'personalised medicine' as technically interchangeable but the term 'precision medicine' is favoured as it more accurately reflects the highly precise nature of new technologies that permit base pair resolution dissection of cancer genomes and is less likely to be misinterpreted.

Conclusions

The ESMO Precision Medicine Glossary provides a resource to facilitate consistent communication in this field by clarifying and raising awareness of the language employed in cancer research and oncology practice. The glossary will be a dynamic entity, undergoing expansion and refinement over the coming years.

Fast Chromotrope Aniline Blue Special Stain Is a Useful Tool to Assess Fibrosis on Liver Biopsy During Transplantation

BACKGROUND

Assessment of potential liver allograft donors with frozen sections has clinical relevant consequences for the transplant recipient. Several clinical risk factors have been identified that increase the risk of transplantation failure and it is critical for the pathologist to become familiar with the histologic criteria for donor liver suitability. In this setting an accurate and reliable assessment of fibrosis is crucial. We sought to report the value of the rapid chromotrope aniline blue stain (CAB) in a transplantation clinical work-flow for scoring liver fibrosis.

MATERIALS AND METHODS

Twenty consecutive intraoperative donor liver biopsy specimens were evaluated by a pathologist at the Transplant Pathology Board Room, AOUI Verona, during 24-hour on-call service. The stage of fibrosis was evaluated according to Ishak score ranging from 0 to 6 (absent to cirrhosis) using hematoxylin and eosin stain (H&E) plus rapid CAB special stain. After a 3-week washout period, only the slides stained with H&E were re-assessed for fibrosis stage by the same pathologist blinded to donor patient data.

RESULTS

Combination H&E-CAB staging fibrosis score was higher in 20%, lower in 10%, and the same in 70% of biopsy specimens as determined using only H&E stain alone. Rapid CAB stain takes 20 minutes longer than H&E stain alone.

CONCLUSIONS

CAB staining may be performed on frozen tissue from liver biopsy during a transplantation process without a significant delay in diagnosis. Combination H&E-CAB staining improves sensibility of interpretation of fibrosis.