Combining germline, tissue and liquid biopsy analysis by comprehensive genomic profiling to improve the yield of actionable variants in a real-world cancer cohort

BACKGROUND

Comprehensive next-generation sequencing is widely used for precision oncology and precision prevention approaches. We aimed to determine the yield of actionable gene variants, the capacity to uncover hereditary predisposition and liquid biopsy appropriateness instead of, or in addition to, tumor tissue analysis, in a real-world cohort of cancer patients, who may benefit the most from comprehensive genomic profiling.

METHODS

Seventy-eight matched germline/tumor tissue/liquid biopsy DNA and RNA samples were profiled using the Hereditary Cancer Panel (germline) and the TruSight Oncology 500 panel (tumor tissue/cfDNA) from 23 patients consecutively enrolled at our center according to at least one of the following criteria: no available therapeutic options; long responding patients potentially fit for other therapies; rare tumor; suspected hereditary cancer; primary cancer with high metastatic potential; tumor of unknown primary origin. Variants were annotated for OncoKB and AMP/ASCO/CAP classification.

RESULTS

The overall yield of actionable somatic and germline variants was 57% (13/23 patients), and 43.5%, excluding variants previously identified by somatic or germline routine testing. The accuracy of tumor/cfDNA germline-focused analysis was demonstrated by overlapping results of germline testing. Five germline variants in BRCA1, VHL, CHEK1, ATM genes would have been missed without extended genomic profiling. A previously undetected BRAF p.V600E mutation was emblematic of the clinical utility of this approach in a patient with a liver undifferentiated embryonal sarcoma responsive to BRAF/MEK inhibition.

CONCLUSIONS

Our study confirms the clinical relevance of performing extended parallel tumor DNA and cfDNA testing to broaden therapeutic options, to longitudinally monitor cfDNA during patient treatment, and to uncover possible hereditary predisposition following tumor sequencing in patient care.

A rare case of syncronous solitary para-pharyngeal metastasis of clear cell carcinoma in a patient with small renal mass

INTRODUCTION

Unusual metastatic sites of renal cell carcinoma (RCC) are not infrequent. We report a rare case of solitary pharyngeal metastasis as first presentation of RCC.

CASE DESCRIPTION

A 74 years-old man was referred to our hospital due to rapidly progressive dyspnoea and dysphagia. Physical examination showed a large right para-pharyngeal mass. Imaging findings showed a 5.5 cm mass, suspicious for malignancy, which extended to right para and retro-pharyngeal spaces with compression of the major right cervical vessels, C2-C3 vertebral bodies osteolysis, dural sac compression and dislocation. Futhermore, a small (2.6 × 2 cm) mass located at the upper pole of the right kidney was shown. Patient underwent partial trans-oral removal of the mass. Pathological examination and immunochemistry resulting strongly suggestive for metastatic RCC. Considering the metastatic stage of the tumour and the rapidly progressive clinical worsening with poor performance status, we offered the patient a palliative treatment with tyrosine kinase and cytoreductive radiotherapy on vertebral bodies. The patient developed a rapidly progressive multifocal metastatic disease and died 4 months after the presentation.

CONCLUSION

We think that our case is noteworthy for some aspects. Firstly, pharyngeal localizations of RCC are very rare and this is the first case of solitary pharyngeal metastasis. Secondly, this metastatic lesion was really particular because it was synchronous and twice as big than the primary tumour. Thirdly, this case is consistent with previous evidence that synchronous compared with metachronous metastasis RCC is associated with adverse effect on outcome and response to targeted treatment.

Management of Patients with Gastrointestinal Stromal Tumors: Experience from an Italian Hospital

Gastrointestinal stromal tumors are malignancies originating from stromal/mesenchymal tissues, most commonly in the stomach and small intestine, although they can be located everywhere in the gastrointestinal tract. Diagnosis is based on histological and immunohistochemical examination, and these rare tumors are characterized by c-kit (CD117) staining. Complete removal of the tumor is often curative in localized gastrointestinal stromal tumors and is always recommended. Clinically, their behavior is difficult to predict, and mitotic count and tumor size seem to be the most effective prognostic factors. We performed a retrospective analysis of clinical presentation and course, surgical management and pathological features of patients with gastrointestinal stromal tumors treated in our institution from 1995 to 2003. Twenty-two patients were enrolled in the study, and all of them underwent surgery. There were two perioperative deaths, and global morbidity was about 13%. Nineteen patients were followed (mean, 31 months): 4 patients had disease progression/recurrence and died, and one patient experienced a local recurrence and was reoperated with a curative intent; 14 patients were disease free. Our experience shows that histological and immunohistochemical examinations are fundamental for a definitive diagnosis and to assess the risk of aggressive behavior. Moreover, our results confirm that in stromal tumors complete surgical resection remains the mainstay of treatment in localized gastrointestinal stromal tumors, although the recurrence rate is relatively high. It is conceivable that treatment and prognosis of metastatic and non-resectable gastrointestinal stromal tumors, as well as the adjuvant treatment of high-risk, radically excised gastrointestinal stromal tumors will be strongly impacted by the c-kit target therapy.

Patient blood management in cardiac surgery: The "Granducato algorithm"

BACKGROUND

Patients undergoing cardiac surgery are subject to severe alterations of the coagulation system. The four cardiac surgery centers in Tuscany (Italy) structured and shared an algorithm (Granducato Patient Blood Management algorithm, G-PBMa) with predefined interventions for patient blood management. The aim of the study is to analyze the impact of that algorithm on the transfusion needs and bleeding-related outcomes in a large patient population.

METHODS

Multicenter retrospective observational study on 3839 patients undergoing cardiac surgery at the four cardiac centers in Tuscany. The G-PBMa was released at the end of 2015 and it was structured in three parts: pre-, intra-, and post-operative. The year 2014, before the G-PBMa (1955 patients) and the year 2016 (1884 patients) after the G-PBMa in place were compared. Logistic regression analyses were used.

RESULTS

The main changes introduced were the routine application of viscoelastic tests in bleeding patients (+72%) and the use of fibrinogen and prothrombin complex concentrate (+67%). The G-PBMa resulted in a significant reduction in the overall transfusion rate and in the transfusion rate of the separate blood products (relative risk for transfusions: 0.75, 95% confidence interval 0.65-0.85, P = 0.001). For preoperative hemoglobin values of between 8 and 10 g/dL, the absolute difference in RBC transfusion rate before and after the G-PBMa introduction ranged around 15%-17%. The G-PBMa introduction determined lower (P = 0.02) chest drain blood loss, lower (P = 0.001) postoperative acute kidney injury and shorter (P = 0.001) hospital stay.

CONCLUSIONS

The G-PBMa was effective in reducing blood loss, transfusion requirements, and resulted in a better outcome.

Thyroid nodules with indeterminate cytology: prospective comparison between 18F-FDG-PET/CT, multiparametric neck ultrasonography, 99mTc-MIBI scintigraphy and histology

PURPOSE

To evaluate the role of (18)F-flurodeoxiglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in predicting malignancy of thyroid nodules with indeterminate cytology.

PATIENTS AND METHODS

We analysed 87 patients who have been scheduled to undergo surgery for thyroid nodule with indeterminate cytology. All patients underwent (18)F-FDG-PET/CT, multiparametric neck ultrasonography (MPUS), and (99m)Tc-methoxyisobutylisonitrile scintigraphy ((99m)Tc-MIBI-scan). Histopathology was the standard of reference. We compared the sensitivity (SE), specificity (SP), accuracy (AC), positive (PPV) and negative predictive (NPV) values of (18)F-FDG-PET/CT with those of (99m)Tc-MIBI-scan and MPUS in detecting cancer. Univariate and multivariate analyses evaluated the association between each diagnostic tool and histopathology.

RESULTS

On histopathology, 69 out of 87 nodules were found to be benign and 18 to be malignant. The SE, SP, AC, PPV and NPV of (18)F-FDG-PET/CT were 94, 58, 66, 37 and 98% respectively. The SE, AC and NPV of (18)F-FDG-PET/CT were significantly higher than those of MPUS and (99m)Tc-MIBI-scan. The association of both positive (18)F-FDG-PET/CT and MPUS (FDG+/MPUS+) showed significantly lower SE (61% vs 94%) and NPV (88% vs 98%) than (18)F-FDG-PET/CT alone, but significantly higher SP (77% vs 58%). On univariate analysis, (18)F-FDG-PET/CT and the combination of FDG+/MPUS+ and of FDG+/MIBI- were all significantly associated with histopathology. On multivariate analysis, only FDG+/MIBI- was significantly associated with histopathology.

CONCLUSION

The AC of (18)F-FDG-PET /CT in detecting thyroid malignancy is higher than that of (99m)Tc-MIBI-scan and MPUS. A negative (18)F-FDG-PET/CT correctly predicts benign findings on histopathology. The association of FDG+/MPS+ is significantly more specific than (18)F-FDG-PET/CT alone in identifying differentiated thyroid cancer. A positive (18)F-FDG-PET/CT is significantly associated with malignancy when qualitative (99m)Tc-MIBI-scan is rated as negative.

Predictive effects of muscle strength after hospitalization in old patients

BACKGROUND AND AIMS

Frailty is a common situation that often influences clinical outcomes, disability or institutionalization. The present study aims to evaluate the weight of hand grip strength (HGS) reduction in terms of death or re-hospitalizations, at 3-month and 1-year follow-up.

METHODS

Observational study performed on hospitalized patients aged 65 years or more. The HGS was measured twice: at hospital admission and discharge. The statistical analysis was performed using SPSS, version 18 for Windows. The χ (2) test was used to evaluate the relationship between HGS and different variables. Three-month and 1-year survival and hospital re-admissions have been analyzed using Kaplan-Meier's curves. The analyses have been adjusted for age and gender.

RESULTS

A total of 201 hospitalized patients have been recruited. Of them, 76 were males. The mean age was 81.79 ± 7.409 years. Of all the patients enrolled, 66.2 and 45.3 % did not show any impairment performing activities of daily living and instrumental activities of daily living, respectively. Moreover, patients were not cognitively impaired [SPMSQ (short portable mental status questionnaire ) m ± SD = 1.47 ± 0.794]. At 3-month follow-up patients with strength reduction had a relative risk of death more than seven times higher than the others (p = 0.047). Same results were observed at 1-year follow-up (95 % CI = 1.85-9.84; p = 0.000). There was no significant relationship between HGS and hospital re-admissions.

CONCLUSIONS

Effects of strength reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. This increases the relevance of maintaining usual physical performance of patients even during hospitalization.

Can voltammetry measure nitrogen monoxide (NO) and/or nitrites?

Recently, voltammetry with carbon fibre electrodes (CFE) has been implemented for real time measurement of nitrogen monoxide (NO) indicating that it is oxidised at the potential value of nitrites, approximately +700 mV. In contrast, here we show that modified CFE can monitor NO at oxidation potentials different than that of nitrites, i.e. +550 mV. Indeed, at +550 mV a significant increase of amperometric current levels was obtained when NO but not nitrites, were added to a phosphate buffer saline solution (PBS). Differential pulse voltammetry (DPV) supports these findings as two oxidation peaks were obtained when examining air preserved NO; peak 1 at +550 mV and peak 2 at +700 mV, respectively. In contrast, only peak 2 was monitored when nitrites or a solution of NO oxidised in air was added to PBS. Biological support to these in vitro data comes from the observation that the relaxation of an adrenaline-contracted aortic ring produced via addition of NO is concomitant with peak 1 at +550 mV. The relaxation is almost completed before the appearance of peak 2 at +700 mV. Furthermore, in vivo experiments performed in the striatum of rats show that the amperometric signal monitored at +550 mV is responsive to glutamatergic stimulation or inhibition of NO synthase.

[Adenocarcinoid of the appendix: a case report and anatomo-pathological and clinico-therapeutic considerations]

The Authors underline the most important pathological, clinical and therapeutic aspects of appendiceal adenocarcinoid. Appendiceal adenocarcinoid is quite a rare tumor, presently considered as a single entity; it differs from typical carcinoid of the appendix because of its well definite histology, its aggressive behaviour and its poorer prognosis. There are no precise prognostic and therapeutic criteria to direct the operative choice between appendectomy and hemicolectomy. In particular the tumor diameter is of no use since the tumor often present diffuse rather than nodular growth. According to most Authors appendectomy is not sufficient in the following cases: liver lymph-node or retroperitoneal metastases; cecal meso-appendiceal or peritoneal spreading; histological poorly differentiated tumors, with nuclear atypia and high mitotic count. Some Authors performed hemicolectomy and bilateral oophorectomy in all case with peritoneal involvement since the ovaries are a frequent site of metastases.

[Case report of a double ano-rectal neoplasia (adenocarcinoma and melanoma)]

The association in a single organ of two neoplasms with different, histogenensis is uncommon. A dual ano-rectal neoplasms, pigmented malignant melanoma in collision with adenocarcinoma is reported, along with a discussion concerning the problems related with primary origin of the melanocytic component.

Crohn's-like colitis in glycogen storage disease Ib: a case report

Association between glycogen storage disease type Ib and Crohn's like disease is rare. We present one such case. A young woman with glycogen storage disease type Ib underwent a right hemicolectomy for stenosis and a blind fistulous tract. The histological picture of the resected bowel was consistent with the diagnosis of Crohn's like disease. A leak in the entero-colostomy occurred during medical treatment with steroids, sulfasalazine, and methronidazole. Partial ileal and colonic resection and a new anastomosis were then performed. Recombinant human colony-stimulating factor (300 mcg/die subcutaneously) was then started. The neutrophils promptly increased to a normal range, and the neutrophil function tests improved. The postoperative course was uneventful and the patient did not have a relapse of the bowel disease.

Tumor vascularity as a prognostic indicator in intermediate-thickness (0.76-4 mm) cutaneous melanoma. A quantitative assay

Tumor vascularity has been reported to be a prognostic factor in solid tumors. We studied the prognostic value of tumor vascularity in 19 primary stage I skin melanomas. Only intermediate-thickness melanomas (0.76-4.00-mm thick) were studied. They were treated surgically to provide two groups of patients. The first group of 11 patients had no evidence of metastases after a follow-up of a mean period of 72.36 months, whereas the second one developed metastases in a mean period of 46.87 months. The two groups were matched for important prognostic factors including tumor thickness, sex, and age. Vascularity was quantified by a morphometric stereological analysis on paraffin sections stained with anti CD31 monoclonal antibody. The percentage of vascular area was significantly higher in the metastasizing group than in the nonmetastasizing one. Our study suggests that increased vascularity may have a prognostic significance in intermediate-thickness melanoma.

Experimental analysis of internal rigid fixation osteosynthesis performed with titanium bone screw and plate systems

The authors report the results of an experimental analysis performed on titanium miniplates and screws in order to gain a better understanding of dynamic forces in internal rigid fixation. Ten segments of bovine scapula were prepared. Osteotomies were carried out along the minor axis, following which five were fixed with four hole straight miniplates and the other five with six hole double-Y miniplates. Each sample was fastened in a special clamp adapted to a tension test machine and shearing force was applied. Force versus time was recorded and the 50 bone fragments were examined by a pathologist. On the basis of the test results, two simple computer models were developed. No significant difference was evident between the mechanical and computed tests. The most critical sections were located near the hole proximal to the osteotomy and the microscopic findings confirmed this. On the basis of the experimental results, the authors propose a new plate design in which the area subject to most stress, proximal to the bone section, would be of miniplate thickness, the distal aspect being thinner as in a microplate. It is suggested that this design would provide sufficient stability and a high degree of anatomical adjustment of the system.

Epstein-Barr virus-related primary cutaneous amyloidosis. Successful treatment with acyclovir and interferon-alpha

Cutaneous lesions related to chronic active Epstein-Barr virus (EBV) infection have been rarely documented in immunocompetent patients. A 30-year-old woman, fulfilling the diagnostic criteria for the chronic fatigue syndrome, had a 10-year history of pruritic brownish macules and papules on her chest and back. Her EBV serology was abnormal; the EBV genome was present in the epidermis of lesions, in oral secretions, and in peripheral mononuclear cells (PMC). Her blood lymphocytes spontaneously outgrew in culture. Histology revealed deposits of amyloid in the papillary dermis. Treatment with acyclovir and interferon-alpha rapidly improved her condition, stopped the lymphocyte outgrowth in culture, and reduced the EBV DNA content in oral secretions and in PMC. These data support an endogenous reactivation of EBV infection and suggest a causal relationship with primary amyloidosis.

[Inflammatory pseudotumor of the liver: report of a case with cytological and histological findings]

The AA. report a case concerning a 58 years old woman with a large hepatic mass involving the segments V-VI-VII-VIII of the liver. The clinical and radiological findings were suggestive for primary malignant lesion. On the contrary, the cytological and histological findings allowed to diagnosis of inflammatory pseudotumor of the liver.

[Excessive reabsorption of irrigation fluid during operative hysteroscopy for uterine myoma]

Operative hysteroscopy procedures can present complications connected to necessity of kneeping, usually with low viscosity fluids, an uniform distension of uterine cavity. The instilled solutions are reabsorbed through the peritoneum and open uterine venous channels producing a hyperhydration syndrome. The case report shows the rising up of tis syndrome during a hysteroscopy for an uterine myoma resection. The physiopathology includes cardiovascular overload and haemodilution, causing pulmonary, cerebral and tissutal oedema. In this case report the volumes of arterial oxygen saturation and end tidal carbon dioxide obtained on line were the first warning signals. A high CVP value, a plasmatic reduction of Na, albumin, proteins, haemoglobin, haematocrit and osmolarity reflected the excessive fluid reabsorption. For this reason the necessity, during these surgical methods, of considering some practical indications and the absolutely necessary use of clinical and biochemical monitoring systems for these patients.

Mucin deposits in morphea and systemic scleroderma

BACKGROUND

Though rarely reported, mucin deposition may be observed in scleroderma.

OBJECTIVE

To verify the frequency of significant amounts of mucin in the biopsy specimens.

METHODS

Biopsies from 20 patients with scleroderma were reviewed and stained to verify the presence of mucin.

RESULTS

Mucin deposits were found in all of the 20 specimens.

CONCLUSION

Mucin deposition is probably a constant feature in both morphea and systemic scleroderma. Its relevance in differential diagnosis between scleredema and scleroderma is debatable.

[A case of latero-cervical cystic lymphangioma]

A case of cervical cystic lymphangioma referred to a 28-year-old woman is reported. Surgical excision remains the treatment of choice.

[Expression of P53 protein in cutaneous melanoma]

P53 protein in cutaneous melanoma. We report the results of an immunohistochemical analysis about the nuclear phosphoprotein P53 expression performed on 48 primary and 10 metastatic cutaneous melanoma in order to assess the prevalence of the expression of mutant P53 protein (m-P53) in this skin tumour. In our study m-P53 was found in about 46% of primary tumours without any significant relationship with the corresponding metastatic lesions. Therefore the P53 count in cutaneous melanoma is not a prognostic marker of tumour spread and aggressiveness.

Nucleolar organizer regions: a prognostic factor in infiltrating ductal carcinoma in the breast

By means of an AgNOR technique, the authors have carried out a retrospective study on proliferative activity in 170 cases of infiltrating ductal breast carcinoma (so-called carcinoma NOS). The follow-up period was 138 months. A statistically significant correlation was found between AgNOR score and outcome of the disease ("vital status"), clinical stage and OS respectively. By means of discriminant analysis a threshold value of AgNOR score was identified (= 9.5) which distinguished two risk groups among the cases under examination. Those cases with an average AgNOR score below the threshold value showed a favourable prognosis. The cases with an AgNOR score greater than 9.5 had an unfavourable outcome. The authors suggest that AgNOR score may be used as a prognostic parameter in breast carcinoma.

Is ethanol metabolism affected by oral administration of cimetidine and ranitidine at therapeutic doses?

The aim of this study was to compare the ethanol serum concentration curve, the area under the curve and subjective response after acute ingestion of ethanol (red wine, 13 degrees proof, at a dose of 0.8 g/kg of ideal weight in 6 healthy volunteers with a mean habitual alcohol intake of 20 g/day. All the subjects underwent the test a total of three times, after pre-treatment with cimetidine (400 mg X 2/day/7 days) and ranitidine (150 mg X 2/day/7 days), respectively, and after receiving no pre-treatment. The wine was taken orally within the space of 15 min, four hours after taking a standard-weight ham sandwich. Blood samples were drawn at the following times: 0, 30, 60, 90, 120, 180, 240 and 360 minutes. The plasma ethanol curve of the subjects pre-treated with cimetidine lies above that of the subjects pre-treated with ranitidine, and largely coincides with the curve obtained in those who received no pre-treatment, with the exception of the initial hour-and-a-half, when the later show a slightly higher mean plasma concentration. The differences between the three treatment groups are merely arithmetical, but not statistical, with respect to peak plasma ethanol concentrations, time elapsing before peaking, and areas under the curves. These results are at variance with some published data suggesting a significant interaction of cimetidine with the metabolism of alcohol by way of interference either with the hepatic oxidative metabolizing enzymes, or with the activity of alcohol dehydrogenase.

Cardiac effects of clomipramine treatment. ECG and left ventricular systolic time intervals

ECGs and left ventricular systolic time intervals were studied in 26 patients suffering from major depressive disorder treated with clomipramine. ECGs did not show, with one exception, drug-induced changes. The ratio of pre-ejection period to left ventricular ejection time, both corrected for heart rate (PEPc/LVETc), presented no significant changes, as compared with initial findings, in the group of patients considered as a whole. 27% of patients, however, showed individual percent changes greater than 8%, both increases and decreases having been observed. Cardiac findings were in no way related to clomipramine plasma levels.