Severely polarized extracellular acidity around tumour cells

Extracellular pH impacts many molecular, cellular and physiological processes, and hence is tightly regulated. Yet, in tumours, dysregulated cancer cell metabolism and poor vascular perfusion cause the tumour microenvironment to become acidic. Here by leveraging fluorescent pH nanoprobes with a transistor-like activation profile at a pH of 5.3, we show that, in cancer cells, hydronium ions are excreted into a small extracellular region. Such severely polarized acidity (pH <5.3) is primarily caused by the directional co-export of protons and lactate, as we show for a diverse panel of cancer cell types via the genetic knockout or inhibition of monocarboxylate transporters, and also via nanoprobe activation in multiple tumour models in mice. We also observed that such spot acidification in ex vivo stained snap-frozen human squamous cell carcinoma tissue correlated with the expression of monocarboxylate transporters and with the exclusion of cytotoxic T cells. Severely spatially polarized tumour acidity could be leveraged for cancer diagnosis and therapy.

STING licensing of type I dendritic cells potentiates antitumor immunity

Stimulator of interferon genes (STING) is an immune adaptor protein that senses cyclic GMP-AMP in response to self or microbial cytosolic DNA as a danger signal. STING is ubiquitously expressed in diverse cell populations, including cancer cells, with distinct cellular functions, such as activation of type I interferons, autophagy induction, or triggering apoptosis. It is not well understood whether and which subsets of immune cells, stromal cells, or cancer cells are particularly important for STING-mediated antitumor immunity. Here, using a polymeric STING-activating nanoparticle (PolySTING) with a shock-and-lock dual activation mechanism, we show that conventional type 1 dendritic cells (cDC1s) are essential for STING-mediated rejection of multiple established and metastatic murine tumors. STING status in the host but not in the cancer cells (Tmem173-/-) is important for antitumor efficacy. Specific depletion of cDC1 (Batf3-/-) or STING deficiency in cDC1 (XCR1creSTINGfl/fl) abolished PolySTING efficacy, whereas depletion of other myeloid cells had little effect. Adoptive transfer of wild-type cDC1 in Batf3-/- mice restored antitumor efficacy, whereas transfer of cDC1 with STING or IRF3 deficiency failed to rescue. PolySTING induced a specific chemokine signature in wild-type but not Batf3-/- mice. Multiplexed immunohistochemistry analysis of STING-activating cDC1s in resected tumors correlates with patient survival. Furthermore, STING-cDC1 signature was increased after neoadjuvant pembrolizumab therapy in patients with non-small cell lung cancer. Therefore, we have defined that a subset of myeloid cells is essential for STING-mediated antitumor immunity with associated biomarkers for prognosis.

An Ensemble Learning Method for Detection of Head and Neck Squamous Cell Carcinoma Using Polarized Hyperspectral Microscopic Imaging

Head and neck squamous cell carcinoma (HNSCC) has a high mortality rate. In this study, we developed a Stokes-vector-derived polarized hyperspectral imaging (PHSI) system for H&E-stained pathological slides with HNSCC and built a dataset to develop a deep learning classification method based on convolutional neural networks (CNN). We use our polarized hyperspectral microscope to collect the four Stokes parameter hypercubes (S0, S1, S2, and S3) from 56 patients and synthesize pseudo-RGB images using a transformation function that approximates the human eye's spectral response to visual stimuli. Each image is divided into patches. Data augmentation is applied using rotations and flipping. We create a four-branch model architecture where each branch is trained on one Stokes parameter individually, then we freeze the branches and fine-tune the top layers of our model to generate final predictions. Our results show high accuracy, sensitivity, and specificity, indicating that our model performed well on our dataset. Future works can improve upon these results by training on more varied data, classifying tumors based on their grade, and introducing more recent architectural techniques.

STING Licensing of Type I Dendritic Cells Potentiates Antitumor Immunity

Stimulator of interferon genes (STING) is an immune adaptor protein that senses cyclic GMP-AMP (cGAMP) in response to self or microbial cytosolic DNA as a danger signal. STING is ubiquitously expressed in diverse cell populations including cancer cells with distinct cellular functions such as activation of type I interferons, autophagy induction, or triggering apoptosis. It is not well understood whether and which subsets of immune cells, stromal cells, or cancer cells are particularly important for STING-mediated antitumor immunity. Here using a polymeric STING-activating nanoparticle (PolySTING) with a "shock-and-lock" dual activation mechanism, we show type 1 conventional dendritic cell (cDC1) is essential for STING-mediated rejection of multiple established and metastatic murine tumors. STING status in the host but not in the cancer cells ( Tmem173 -/- ) is important for antitumor efficacy. Specific depletion of cDC1 ( Batf3 -/- ) or STING deficiency in cDC1 ( XCR1 cre STING fl/fl ) abolished PolySTING efficacy, whereas depletion of other myeloid cells had little effect. Adoptive transfer of wildtype cDC1 in Batf3 -/- mice restored antitumor efficacy while transfer of cDC1 with STING or IRF3 deficiency failed to rescue. PolySTING induced a specific chemokine signature in wildtype but not Batf3 -/- mice. Multiplexed immunohistochemistry analysis of STING-activating cDC1s in resected tumors correlates with patient survival while also showing increased expressions after neoadjuvant pembrolizumab therapy in non-small cell lung cancer patients. Therefore, we have defined that a subset of myeloid cells is essential for STING-mediated antitumor immunity with associated biomarkers for prognosis.

One Sentence Summary

A "shock-and-lock" nanoparticle agonist induces direct STING signaling in type 1 conventional dendritic cells to drive antitumor immunity with defined biomarkers.

Polarized hyperspectral microscopic imaging system for enhancing the visualization of collagen fibers and head and neck squamous cell carcinoma

Significance

Polarized hyperspectral microscopes with the capability of full Stokes vector imaging have potential for many biological and medical applications.

Aim

The aim of this study is to investigate polarized hyperspectral imaging (PHSI) for improving the visualization of collagen fibers, which is an important biomarker related to tumor development, and improving the differentiation of normal and tumor cells on pathologic slides.

Approach

We customized a polarized hyperspectral microscopic imaging system comprising an upright microscope with a motorized stage, two linear polarizers, two liquid crystal variable retarders (LCVRs), and a compact SnapScan hyperspectral camera. The polarizers and LCVRs worked in tandem with the hyperspectral camera to acquire polarized hyperspectral images, which were further used to calculate four Stokes vectors: S 0 , S 1 , S 2 , and S 3 . Synthetic RGB images of the Stokes vectors were generated for the visualization of cellular components in PHSI images. Regions of interest of collagen, normal cells, and tumor cells in the synthetic RGB images were selected, and spectral signatures of the selected components were extracted for comparison. Specifically, we qualitatively and quantitatively investigated the enhanced visualization and spectral characteristics of dense fibers and sparse fibers in normal stroma tissue, fibers accumulated within tumors, and fibers accumulated around tumors.

Results

By employing our customized polarized hyperspectral microscope, we extract the spectral signatures of Stokes vector parameters of collagen as well as of tumor and normal cells. The measurement of Stokes vector parameters increased the image contrast of collagen fibers and cells in the slides.

Conclusions

With the spatial and spectral information from the Stokes vector data cubes (S 0 , S 1 , S 2 , and S 3 ), our PHSI microscope system enhances the visualization of tumor cells and tumor microenvironment components, thus being beneficial for pathology and oncology.

Efficacy and Quality-of-Life Following Involved Nodal Radiotherapy for Head and Neck Squamous Cell Carcinoma: The INRT-AIR Phase II Clinical Trial

PURPOSE

Elective neck irradiation (ENI) has long been considered mandatory when treating head and neck squamous cell carcinoma (HNSCC) with definitive radiotherapy, but it is associated with significant dose to normal organs-at-risk (OAR). In this prospective phase II study, we investigated the efficacy and tolerability of eliminating ENI and strictly treating involved and suspicious lymph nodes (LN) with intensity-modulated radiotherapy.

PATIENTS AND METHODS

Patients with newly diagnosed HNSCC of the oropharynx, larynx, and hypopharynx were eligible for enrollment. Each LN was characterized as involved or suspicious based on radiologic criteria and an in-house artificial intelligence (AI)-based classification model. Gross disease received 70 Gray (Gy) in 35 fractions and suspicious LNs were treated with 66.5 Gy, without ENI. The primary endpoint was solitary elective volume recurrence, with secondary endpoints including patterns-of-failure and patient-reported outcomes.

RESULTS

Sixty-seven patients were enrolled, with 18 larynx/hypopharynx and 49 oropharynx cancer. With a median follow-up of 33.4 months, the 2-year risk of solitary elective nodal recurrence was 0%. Gastrostomy tubes were placed in 14 (21%), with median removal after 2.9 months for disease-free patients; no disease-free patient is chronically dependent. Grade I/II dermatitis was seen in 90%/10%. There was no significant decline in composite MD Anderson Dysphagia Index scores after treatment, with means of 89.1 and 92.6 at 12 and 24 months, respectively.

CONCLUSIONS

These results suggest that eliminating ENI is oncologically sound for HNSCC, with highly favorable quality-of-life outcomes. Additional prospective studies are needed to support this promising paradigm before implementation in any nontrial setting.

Long-term Patient-Reported Outcomes in a Population-Based Cohort Following Radiotherapy vs Surgery for Oropharyngeal Cancer

Importance

Oncologic outcomes are similar for patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with primary surgery or radiotherapy. However, comparative differences in long-term patient-reported outcomes (PROs) between modalities are less well established.

Objective

To determine the association between primary surgery or radiotherapy and long-term PROs.

Design, Setting, and Participants

This cross-sectional study used the Texas Cancer Registry to identify survivors of OPSCC treated definitively with primary radiotherapy or surgery between January 1, 2006, and December 31, 2016. Patients were surveyed in October 2020 and April 2021.

Exposures

Primary radiotherapy and surgery for OPSCC.

Main Outcomes and Measures

Patients completed a questionnaire that included demographic and treatment information, the MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) module, the Neck Dissection Impairment Index (NDII), and the Effectiveness of Auditory Rehabilitation (EAR) scale. Multivariable linear regression models were performed to evaluate the association of treatment (surgery vs radiotherapy) with PROs while controlling for additional variables.

Results

Questionnaires were mailed to 1600 survivors of OPSCC identified from the Texas Cancer Registry, with 400 responding (25% response rate), of whom 183 (46.2%) were 8 to 15 years from their initial diagnosis. The final analysis included 396 patients (aged ≤57 years, 190 [48.0%]; aged >57 years, 206 [52.0%]; female, 72 [18.2%]; male, 324 [81.8%]). After multivariable adjustment, no significant differences were found between surgery and radiotherapy outcomes as measured by the MDASI-HN (β, -0.1; 95% CI, -0.7 to 0.6), NDII (β, -1.7; 95% CI, -6.7 to 3.4), and EAR (β, -0.9; 95% CI -7.7 to 5.8). In contrast, less education, lower household income, and feeding tube use were associated with significantly worse MDASI-HN, NDII, and EAR scores, while concurrent chemotherapy with radiotherapy was associated with worse MDASI-HN and EAR scores.

Conclusions and Relevance

This population-based cohort study found no associations between long-term PROs and primary radiotherapy or surgery for OPSCC. Lower socioeconomic status, feeding tube use, and concurrent chemotherapy were associated with worse long-term PROs. Further efforts should focus on the mechanism, prevention, and rehabilitation of these long-term treatment toxicities. The long-term outcomes of concurrent chemotherapy should be validated and may inform treatment decision making.

Polarized hyperspectral microscopic imaging for collagen visualization on pathologic slides of head and neck squamous cell carcinoma

We developed a polarized hyperspectral microscope to collect four types of Stokes vector data cubes (S0, S1, S2, and S3) of the pathologic slides with head and neck squamous cell carcinoma (HNSCC). Our system consists of an optical light microscope with a movable stage, two polarizers, two liquid crystal variable retarders (LCVRs), and a SnapScan hyperspectral camera. The polarizers and LCVRs work in tandem with the hyperspectral camera to acquire polarized hyperspectral images. Synthetic pseudo-RGB images are generated from the four Stokes vector data cubes based on a transformation function similar to the spectral response of human eye for the visualization of hyperspectral images. Collagen is the most abundant extracellular matrix (ECM) protein in the human body. A major focus of studying the ECM in tumor microenvironment is the role of collagen in both normal and abnormal function. Collagen tends to accumulate in and around tumors during cancer development and growth. In this study, we acquired images from normal regions containing normal cells and collagen fibers and from tumor regions containing cancerous squamous cells and collagen fibers on HNSCC pathologic slides. The preliminary results demonstrated that our customized polarized hyperspectral microscope is able to improve the visualization of collagen on HNSCC pathologic slides under different situations, including thick fibers of normal stroma, thin fibers of normal stroma, fibers of normal muscle cells, fibers accumulated in tumors, fibers accumulated around tumors. Our preliminary results also demonstrated that the customized polarized hyperspectral microscope is capable of extracting the spectral signatures of collagen based on Stokes vector parameters and can have various applications in pathology and oncology.

Patient-Reported Financial Toxicity in a Population-Based Cohort of Oropharynx Cancer Survivors

PURPOSE

Patients with oropharyngeal squamous cell carcinoma (OPSCC) are at high risk for financial toxicity (FT), but the nature, extent, and predictors of FT experienced after primary radiation therapy (RT) or surgery are poorly understood.

METHODS AND MATERIALS

We used a population-based sample of patients from the Texas Cancer Registry with stage I to III OPSCC diagnosed from 2006 to 2016 and treated with primary RT or surgery. Of 1668 eligible patients, 1600 were sampled, 400 responded, and 396 confirmed OPSCC. Measures included the MD Anderson Symptom Inventory Head and Neck, Neck Dissection Impairment Index, and a financial toxicity instrument adapted from the Individualized Cancer Care (iCanCare) study. Multivariable logistic regression evaluated associations of exposures with outcomes.

RESULTS

Of 396 analyzable respondents, 269 (68%) received primary RT and 127 (32%) surgery. The median time from diagnosis to survey was 7 years. Due to OPSCC, 54% of patients experienced material sacrifice (including 28% who reduced food spending and 6% who lost their housing), 45% worried about financial problems, and 29% experienced long-term FT. Independent factors associated with more long-term FT included female sex (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.23-2.40), Black non-Hispanic race (OR, 2.98; 95% CI, 1.26-7.09), unmarried status (OR, 1.50; 95% CI, 1.11-2.03), feeding tube use (OR, 3.98; 95% CI, 2.29-6.90), and worst versus best quartile on the MD Anderson Symptom Inventory Head and Neck (OR, 1.89; 95% CI, 1.23-2.90) and Neck Dissection Impairment Index (OR, 5.62; 95% CI, 3.79-8.34). Factors associated with less long-term FT included age >57 years (OR, 0.54; 95% CI, 0.41-0.71; P < .001) and household income ≥$80,000 (OR, 0.60; 95% CI, 0.44-0.82; P = .001). Primary RT versus surgery was not associated with long-term FT (OR, 0.92; 95% CI, 0.68-1.24).

CONCLUSIONS

Oropharynx cancer survivors experience high rates of material sacrifice and long-term FT, and we identified important risk factors. Chronic symptom burden was associated with significantly worse long-term financial status, supporting the hypothesis that toxicity mitigation strategies may reduce long-term FT.

Clinical and Biologic Characteristics and Outcomes in Young and Middle-Aged Patients With Laryngeal Cancer: A Retrospective Cohort Analysis

OBJECTIVE

To describe the clinical and biologic characteristics and outcomes of young and middle-aged (YMA; <65 years) patients according to the presence or absence of traditional risk factors for laryngeal cancer.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Single-institution academic medical center.

METHODS

Patients without a history of clinically significant tobacco use or heavy alcohol use were defined as "nontraditional": ≤5 pack-years, ≤5 years smoked, ≤14 alcoholic drinks per week, and ≥15-year interval from last tobacco abuse use to diagnosis. Remaining patients were categorized as "traditional." Select tumor samples were evaluated for bacterial and viral DNA by multiplex polymerase chain reaction.

RESULTS

Seventy-eight YMA patients with primary laryngeal squamous cell carcinoma were identified, 23% (n = 18) of whom were nontraditional. Nontraditional patients were younger than traditional patients (median age, 51 vs 59 years; P < .001). Twenty-eight tumors were prospectively tested for human papillomavirus (HPV), and nontraditional patients were more likely to exhibit high-risk HPV (57% vs 5%, P < .01). Among 17 select tumors (nontraditional, n = 8; traditional, n = 9), 35% exhibited HPV16 (nontraditional, 63%; traditional, 11%; P = .05). Other viruses were identified but did not differ according to risk status: herpesviruses (40%) and Merkel cell polyomavirus (7%). Chlamydia, β-HPV, and γ-HPV DNA was not detected in any samples. Median length of follow-up was 42 months. On adjusted analyses, nontraditional patients exhibited nonsignificantly improved overall survival (hazard ratio, 0.24 [95% CI, 0.03-1.82]; P = .17) and disease-free survival (hazard ratio, 0.34 [95% CI, 0.10-1.23]; P = .08) as compared with traditional patients.

CONCLUSION

Almost one-quarter of YMA patients lacked characteristic risk factors for laryngeal squamous cell carcinoma, and their tumors exhibited a higher prevalence of high-risk HPV. The significance of HPV16 and other tumor viruses with outcomes in nontraditional patients should be evaluated further.

Lactate increases stemness of CD8 + T cells to augment anti-tumor immunity

Lactate is a key metabolite produced from glycolytic metabolism of glucose molecules, yet it also serves as a primary carbon fuel source for many cell types. In the tumor-immune microenvironment, effect of lactate on cancer and immune cells can be highly complex and hard to decipher, which is further confounded by acidic protons, a co-product of glycolysis. Here we show that lactate is able to increase stemness of CD8+ T cells and augments anti-tumor immunity. Subcutaneous administration of sodium lactate but not glucose to mice bearing transplanted MC38 tumors results in CD8+ T cell-dependent tumor growth inhibition. Single cell transcriptomics analysis reveals increased proportion of stem-like TCF-1-expressing CD8+ T cells among intra-tumoral CD3+ cells, a phenotype validated by in vitro lactate treatment of T cells. Mechanistically, lactate inhibits histone deacetylase activity, which results in increased acetylation at H3K27 of the Tcf7 super enhancer locus, leading to increased Tcf7 gene expression. CD8+ T cells in vitro pre-treated with lactate efficiently inhibit tumor growth upon adoptive transfer to tumor-bearing mice. Our results provide evidence for an intrinsic role of lactate in anti-tumor immunity independent of the pH-dependent effect of lactic acid, and might advance cancer immune therapy.

Adherence to the American Cancer Society Head and Neck Cancer Survivorship Care Guideline According to Chart Review: A Nested Retrospective Cohort Pilot Study

OBJECTIVES

The purpose of this study was to explore adherence to the American Cancer Society (ACS) Head and Neck Cancer (HNC) Survivorship Care Guideline and their outlined 33 recommendations among posttreatment HNC survivors.

METHODS

A bi-institutional, retrospective, nested cohort study of mucosal or salivary gland HNC survivors diagnosed in 2018 was designed. Guideline adherence was assessed via retrospective chart review between 0 and 13 months after completion of oncologic treatment according to 4 categories: (1) problem assessed, (2) problem diagnosed, (3) management offered; (4) problem treated. Adherence was defined as meeting a recommendation subcategory at least once over the 13-month period.

RESULTS

Among 60 randomly selected HNC survivors, a total of 38 were included in the final cohort after exclusion of individuals with ineligible cancers and those who died or were lost to follow-up over the study period. Approximately 95% of HNC survivors were assessed for HNC recurrence and screened for lung cancer. Certain common problems such as xerostomia, dysphagia, and hypothyroidism were screened for and managed in ≥70% of eligible survivors. Conversely, screening for other second primary cancers and assessment of a majority of other physical and psychosocial harms occurred in <70% of survivors, and in many cases none to a slim minority of survivors (eg, sleep apnea and sleep disturbance, body and self-image concerns). Only 5% of survivors received a survivorship care plan.

CONCLUSION

Overall adherence to the ACS HNC Survivorship Care Guideline in early posttreatment survivors was suboptimal. Interventions are needed to better implement and operationalize these guideline recommendations.

Survival and disease progression following solitary locoregional recurrence after head and neck radiotherapy

PURPOSE

The management of solitary locoregional recurrence (sLRR) of head and neck squamous cell carcinoma (HNSCC) previously treated with radiotherapy (RT) is challenging. We aimed to identify characteristics associated with improved outcome.

METHODS

We identified patients treated with non-sinus, mucosal HNSCC who initially received IMRT. We characterized overall survival (OS) and locoregional control (LRC). Multivariable analysis (MVA) on survival and patterns-of-failure were performed using Cox and Fine-Gray competing risks analysis.

RESULTS

We identified 90 patients with available follow-up. In total, 67 (74%) patients received curative-intent salvage, while 23 (26%) received palliative care. On MVA, significantly improved OS and LRC were associated with lower initial N-classification and use of salvage total laryngectomy (TL) or neck dissection (ND).

CONCLUSION

A nontrivial number of patients with sLRR cannot undergo salvage. Among patients treated with curative intent, TL or ND were clearly associated with improved OS and LRC.

Automatic detection of head and neck squamous cell carcinoma on histologic slides using hyperspectral microscopic imaging (Erratum)

The erratum corrects the name of the first author listed in a reference cited.

Automatic detection of head and neck squamous cell carcinoma on histologic slides using hyperspectral microscopic imaging

SIGNIFICANCE

Automatic, fast, and accurate identification of cancer on histologic slides has many applications in oncologic pathology.

AIM

The purpose of this study is to investigate hyperspectral imaging (HSI) for automatic detection of head and neck cancer nuclei in histologic slides, as well as cancer region identification based on nuclei detection.

APPROACH

A customized hyperspectral microscopic imaging system was developed and used to scan histologic slides from 20 patients with squamous cell carcinoma (SCC). Hyperspectral images and red, green, and blue (RGB) images of the histologic slides with the same field of view were obtained and registered. A principal component analysis-based nuclei segmentation method was developed to extract nuclei patches from the hyperspectral images and the coregistered RGB images. Spectra-based support vector machine and patch-based convolutional neural networks (CNNs) were implemented for nuclei classification. The CNNs were trained with RGB patches (RGB-CNN) and hyperspectral patches (HSI-CNN) of the segmented nuclei and the utility of the extra spectral information provided by HSI was evaluated. Furthermore, cancer region identification was implemented by image-wise classification based on the percentage of cancerous nuclei detected in each image.

RESULTS

RGB-CNN, which mainly used the spatial information of nuclei, resulted in a 0.81 validation accuracy and 0.74 testing accuracy. HSI-CNN, which utilized the spatial and spectral features of the nuclei, showed significant improvement in classification performance and achieved 0.89 validation accuracy as well as 0.82 testing accuracy. Furthermore, the image-wise cancer region identification based on nuclei detection could generally improve the cancer detection rate.

CONCLUSIONS

We demonstrated that the morphological and spectral information contribute to SCC nuclei differentiation and that the spectral information within hyperspectral images could improve classification performance.

Pilot Study of a Wearable Activity Monitor During Head and Neck Radiotherapy to Predict Clinical Outcomes

PURPOSE

Given the established associations between performance status and survival in a variety of cancers, there is significant interest in using a biometric wearable device (WD) to predict outcomes in the oncology population. In this pilot study, we investigated the ability of a WD to predict meaningful clinical end points in patients undergoing head and neck radiotherapy.

METHODS

Patients receiving head and neck definitive chemoradiotherapy or postoperative radiotherapy/chemoradiotherapy were enrolled in this pilot study, designed to show 90% compliance with using the device. Individuals were asked to wear the WD for 23 hours a day, and hospital admissions, pain medication usage, and FACT-G quality-of-life (QoL) score were prospectively recorded.

RESULTS

Fifty-one patients were enrolled and started using the WD, but eight patients stopped wearing it, resulting in a compliance probability of only 84%. There were 15 hospital admissions, 13 of which were planned for feeding tube placement. There was no step count threshold that predicted the need for admission or more pain medications. However, among the 25 patients with a significant reduction in FACT-G score, the average reductions in daily steps during the week and weekend before the decline were 988 (P = .005) and 1,311 (P = .018), respectively, and the odds of a QoL reduction were more than 4-fold higher among patients experiencing a week-to-week reduction of at least 1,000 daily steps. There was no association between heart rate and any end point.

CONCLUSION

Although not meeting the compliance goal, the majority of patients did use the WD. The WD signal could not identify patients requiring hospitalization or significantly more pain medication, but the finding of reduced step counts before a significant reduction in QoL is provocative.

Automatic detection of head and neck squamous cell carcinoma on pathologic slides using polarized hyperspectral imaging and deep learning

The study is to incorporate polarized hyperspectral imaging (PHSI) with deep learning for automatic detection of head and neck squamous cell carcinoma (SCC) on hematoxylin and eosin (H&E) stained tissue slides. A polarized hyperspectral imaging microscope had been developed in our group. In this paper, we firstly collected the Stokes vector data cubes (S0, S1, S2, and S3) of histologic slides from 17 patients with SCC by the PHSI microscope, under the wavelength range from 467 nm to 750 nm. Secondly, we generated the synthetic RGB images from the original Stokes vector data cubes. Thirdly, we cropped the synthetic RGB images into image patches at the image size of 96×96 pixels, and then set up a ResNet50-based convolutional neural network (CNN) to classify the image patches of the four Stokes vector parameters (S0, S1, S2, and S3) by application of transfer learning. To test the performances of the model, each time we trained the model based on the image patches (S0, S1, S2, and S3) of 16 patients out of 17 patients, and used the trained model to calculate the testing accuracy based on the image patches of the rest 1 patient (S0, S1, S2, and S3). We repeated the process for 6 times and obtained 24 testing accuracies (S0, S1, S2, and S3) from 6 different patients out of the 17 patients. The preliminary results showed that the average testing accuracy (84.2%) on S3 outperformed the average testing accuracy (83.5%) on S0. Furthermore, 4 of 6 testing accuracies of S3 (96.0%, 87.3%, 82.8%, and 86.7%) outperformed the testing accuracies of S0 (93.3%, 85.2%, 80.2%, and 79.0%). The study demonstrated the potential of using polarized hyperspectral imaging and deep learning for automatic detection of head and neck SCC on pathologic slides.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis

BACKGROUND

Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood.

METHODS

National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms).

RESULTS

In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively).

CONCLUSIONS

Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

Polyvalent design in the cGAS-STING pathway

Polyvalent interactions mediate the formation of higher-order macromolecular assemblies to improve the sensitivity, specificity, and temporal response of biological signals. In host defense, innate immune pathways recognize danger signals to alert host of insult or foreign invasion, while limiting aberrant activation from auto-immunity and cellular senescence. Of recent attention are the unique higher-order assemblies in the cGAS-STING pathway. Natural stimulation of cGAS enzymes by dsDNA induces phase separation and enzymatic activation for switchlike production of cGAMP. Subsequent binding of cGAMP to STING induces oligomerization of STING molecules, offering a scaffold for kinase assembly and signaling transduction. Additionally, the discovery of PC7A, a synthetic polymer which activates STING through a non-canonical biomolecular condensation, illustrates the engineering design of agonists by polyvalency principles. Herein, we discuss a mechanistic and functional comparison of natural and synthetic agonists to advance our understanding in STING signaling and highlight the principles of polyvalency in innate immune activation. The combination of exogenous cGAMP along with synthetic PC7A stimulation of STING offers a synergistic strategy in spatiotemporal orchestration of the immune milieu for a safe and effective immunotherapy against cancer.

Extracapsular extension, pathologic node status, and adjuvant treatment in primary surgery patients with human papillomavirus-mediated oropharyngeal cancer: A national hospital-based retrospective cohort analysis

BACKGROUND

The significance of extracapsular extension (ECE) and adjuvant treatment paradigm in patients with surgically managed human papillomavirus-positive (HPV+) oropharyngeal cancer (OPC) is debated.

METHODS

National, hospital-based, retrospective cohort study of 2663 patients pN+ HPV+ OPC who underwent primary surgery.

RESULTS

Patients with ECE had a 1.74-times risk of death (95% confidence interval [CI]: 1.26-2.40, p = 0.001) compared to patients without ECE. Among patients with pN1, ECE-positive disease, risk of overall mortality was similar across treatment paradigms (surgery alone: ref; adjuvant radiation therapy [RT]: aHR: 0.81; 95% CI: 0.36-1.85; p = 0.62; adjuvant CRT: aHR: 0.66; 95% CI: 0.34-1.32; p = 0.24). Patients with pN2 ECE-positive disease treated with adjuvant RT alone exhibited similar risk of all-cause mortality (hazard ratio: 1.04, 95% CI: 0.24-4.47, p = 0.96) compared to adjuvant chemoradiation (CRT). In patients with advanced, ECE-positive disease (e.g., pT3-T4pN2), adjuvant CRT did not reduce the risk of overall mortality relative to adjuvant RT.

CONCLUSION

Although pathologic ECE negatively predicts for survival in patients with HPV+ OPC, our analyses support expansion of postoperative de-intensification clinical trial eligibility criteria in patients with ECE-positive disease.

Blood-based biomarkers of human papillomavirus-associated cancers: A systematic review and meta-analysis

BACKGROUND

Despite the significant societal burden of human papillomavirus (HPV)-associated cancers, clinical screening interventions for HPV-associated noncervical cancers are not available. Blood-based biomarkers may help close this gap in care.

METHODS

Five databases were searched, 5687 articles were identified, and 3631 unique candidate titles and abstracts were independently reviewed by 2 authors; 702 articles underwent a full-text review. Eligibility criteria included the assessment of a blood-based biomarker within a cohort or case-control study.

RESULTS

One hundred thirty-seven studies were included. Among all biomarkers assessed, HPV-16 E seropositivity and circulating HPV DNA were most significantly correlated with HPV-associated cancers in comparison with cancer-free controls. In most scenarios, HPV-16 E6 seropositivity varied nonsignificantly according to tumor type, specimen collection timing, and anatomic site (crude odds ratio [cOR] for p16+ or HPV+ oropharyngeal cancer [OPC], 133.10; 95% confidence interval [CI], 59.40-298.21; cOR for HPV-unspecified OPC, 25.41; 95% CI, 8.71-74.06; cOR for prediagnostic HPV-unspecified OPC, 59.00; 95% CI, 15.39-226.25; cOR for HPV-unspecified cervical cancer, 12.05; 95% CI, 3.23-44.97; cOR for HPV-unspecified anal cancer, 73.60; 95% CI, 19.68-275.33; cOR for HPV-unspecified penile cancer, 16.25; 95% CI, 2.83-93.48). Circulating HPV-16 DNA was a valid biomarker for cervical cancer (cOR, 15.72; 95% CI, 3.41-72.57). In 3 cervical cancer case-control studies, cases exhibited unique microRNA expression profiles in comparison with controls. Other assessed biomarker candidates were not valid.

CONCLUSIONS

HPV-16 E6 antibodies and circulating HPV-16 DNA are the most robustly analyzed and most promising blood-based biomarkers for HPV-associated cancers to date. Comparative validity analyses are warranted. Variations in tumor type-specific, high-risk HPV DNA prevalence according to anatomic site and world region highlight the need for biomarkers targeting more high-risk HPV types. Further investigation of blood-based microRNA expression profiling appears indicated.

Pixel-level Tumor Margin Assessment of Surgical Specimen with Hyperspectral Imaging and Deep Learning Classification

Surgery is a major treatment method for squamous cell carcinoma (SCC). During surgery, insufficient tumor margin may lead to local recurrence of cancer. Hyperspectral imaging (HSI) is a promising optical imaging technique for in vivo cancer detection and tumor margin assessment. In this study, a fully convolutional network (FCN) was implemented for tumor classification and margin assessment on hyperspectral images of SCC. The FCN was trained and validated with hyperspectral images of 25 ex vivo SCC surgical specimens from 20 different patients. The network was evaluated per patient and achieved pixel-level tissue classification with an average area under the curve (AUC) of 0.88, as well as 0.83 accuracy, 0.84 sensitivity, and 0.70 specificity across all the 20 patients. The 95% Hausdorff distance of assessed tumor margin in 17 patients was less than 2 mm, and the classification time of each tissue specimen took less than 10 seconds. The proposed methods can potentially facilitate intraoperative tumor margin assessment and improve surgical outcomes.

Automatic detection of head and neck squamous cell carcinoma on pathologic slides using polarized hyperspectral imaging and machine learning

The aim of this study is to incorporate polarized hyperspectral imaging (PHSI) with machine learning for automatic detection of head and neck squamous cell carcinoma (SCC) on hematoxylin and eosin (H&E) stained tissue slides. A polarized hyperspectral imaging microscope had been developed in our group. In this paper, we imaged 20 H&E stained tissue slides from 10 patients with SCC of the larynx by the PHSI microscope. Several machine learning algorithms, including support vector machine (SVM), random forest, Gaussian naive Bayes, and logistic regression, were applied to the collected image data for the automatic detection of SCC on the H&E stained tissue slides. The performance of these methods was compared among the collected PHSI data, the pseudo-RGB images generated from the PHSI data, and the PHSI data after applying the principal component analysis (PCA) transformation. The results suggest that SVM is a superior classifier for the classification task based on the PHSI data cubes compared to the other three classifiers. The incorporate of four Stokes vector parameters improved the classification accuracy. Finally, the PCA transformed image data did not improve the accuracy as it might lose some important information from the original PHSI data. The preliminary results show that polarized hyperspectral imaging can have many potential applications in digital pathology.

Hyperspectral Microscopic Imaging for the Detection of Head and Neck Squamous Cell Carcinoma on Histologic Slides

The purpose of this study is to investigate hyperspectral microscopic imaging and deep learning methods for automatic detection of head and neck squamous cell carcinoma (SCC) on histologic slides. Hyperspectral imaging (HSI) cubes were acquired from pathologic slides of 18 patients with SCC of the larynx, hypopharynx, and buccal mucosa. An Inception-based two-dimensional convolutional neural network (CNN) was trained and validated for the HSI data. The automatic deep learning method was tested with independent data of human patients. This study demonstrated the feasibility of using hyperspectral microscopic imaging and deep learning classification to aid pathologists in detecting SCC on histologic slides.

Tumor-Targeted Inhibition of Monocarboxylate Transporter 1 Improves T-Cell Immunotherapy of Solid Tumors

Export of lactic acid from glycolytic cancer cells to the extracellular tumor milieu has been reported to enhance tumor growth and suppress antitumor immunity. In this study, a pH-activatable nanodrug is reported for tumor-targeted inhibition of monocarboxylate transporter-1 (MCT1) that reverses lactic acid-induced tumor immunosuppression. The nanodrug is composed of an MCT1 inhibitor (AZD3965) loaded inside the ultra-pH-sensitive nanoparticles (AZD-UPS NPs). AZD-UPS NP is produced by a microfluidics method with improved drug loading efficiency and optimal nanoparticle size over sonication methods. The nanodrug remains as intact micelles at pH 7.4 but rapidly disassembles and releases payload upon exposure to acidic pH. When combined with anti-PD-1 therapy, AZD-UPS NP leads to potent tumor growth inhibition and increases survival in two tumor models over oral administration of AZD3965 at dramatically reduced dose (>200-fold). Safety evaluations demonstrate reduced drug distribution in heart and liver tissues with decrease in toxic biomarkers such as cardiac troponin by the nanodrug. Increased T-cell infiltration and reduced exhaustive PD1⁺ Tim3⁺ T cells are found in tumors. These data illustrate that tumor-targeted inhibition of MCT1 can reverse the immune suppressive microenvironment of solid tumors for increased safety and antitumor efficacy of cancer immunotherapy.

Factors Associated with Lymph Node Count in Mucosal Squamous Cell Carcinoma Neck Dissection

OBJECTIVE/HYPOTHESIS

Decreased lymph node count (LNC) from neck dissection (ND) for mucosal head and neck squamous cell carcinoma (HNSCC) patients is correlated with decreased survival. Advanced age and low BMI due to undernutrition from dysphagia from advanced T-stage tumors are common in patients with HNSCC. We studied the relationship between these two well-described causes for immune dysfunction and LNC in patients undergoing neck dissection.

STUDY DESIGN

We conducted a retrospective review at a single tertiary care institution of patients with HNSCC that underwent neck dissection from 2006 to 2017.

METHODS

Stepwise linear and logistic regression analyses were performed on 247 subjects to identify independent significant factors associated with 1) the LNC per neck level dissected; 2) advanced T-stage. One-way ANOVA was utilized to demonstrate differences between the p16 positive and negative subgroups.

RESULTS

Low BMI (<23 vs. ≥23) (P = .03), extra nodal extension (ENE) (P = .0178), and advanced age (P = .005) were associated with decreased LNC per neck level dissected on multivariable analysis. Higher T-stage (P = .0005) was correlated with low BMI (<23) after controlling for the effects of tobacco, smoking, sex, ECE, and p16 status. p16+ patients, on average had higher BMI, were younger and produced a higher nodal yield (P < .0001, .007, and .035).

CONCLUSIONS

Patient intrinsic factors known to correlate with decreased immune function and worse outcomes, including p16 negative status, advanced age, and low BMI from undernutrition and ENE are associated with low nodal yield in neck dissections. LNC may be a metric for anti-tumor immune function that correlates with prognosis and T-stage.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1516-1521, 2021.

Nano-Immune-Engineering Approaches to Advance Cancer Immunotherapy: Lessons from Ultra-pH-Sensitive Nanoparticles

Immunotherapy has transformed the field of oncology and patient care. By leveraging the immune system of the host, immunostimulatory compounds exert a durable, personalized response against the patient's own tumor. Despite the clinical success, the overall response rate from current therapies (e.g., immune checkpoint inhibitors) remains low (∼20%) because tumors develop multiple resistance pathways at molecular, cellular, and microenvironmental levels. Unlike other oncologic therapies, harnessing antitumor immunity requires precise activation of a complex immunological system with multiple levels of regulation over its function. This requires the ability to exert control over immune cells in both intracellular compartments and various extracellular sites, such as the tumor microenvironment, in a spatiotemporally coordinated fashion.The immune system has evolved to sense and respond to nano- and microparticulates (e.g., viruses, bacteria) as foreign pathogens. Through the versatile control of composition, size, shape, and surface properties of nanoparticles, nano-immune-engineering approaches are uniquely positioned to mount appropriate immune responses against cancer. This Account highlights the development and implementation of ultra-pH-sensitive (UPS) nanoparticles in cancer immunotherapy with an emphasis on nanoscale cooperativity. Nanocooperativity has been manifested in many biological systems and processes (e.g., protein allostery, biomolecular condensation), where the system can acquire emergent properties distinct from the sum of individual parts acting in isolation.Using UPS nanoparticles as an example, we illustrate how all-or-nothing protonation cooperativity during micelle assembly/disassembly can be leveraged to augment the cancer-immunity cycle toward antitumor immunity. The cooperativity behavior enables instant and pH-triggered payload release and dose accumulation in acidic sites (e.g., endocytic organelles of antigen presenting cells, tumor microenvironment), intercepting specific immunological and tumor pathophysiological processes for therapy. These efforts include T cell activation in lymph nodes by coordinating cytosolic delivery of tumor antigens to dendritic cells with simultaneous activation of stimulator of interferon genes (STING), or tumor-targeted delivery of acidotic inhibitors to reprogram the tumor microenvironment and overcome T cell retardation. Each treatment strategy represents a nodal intervention in the cancer-immunity cycle, featuring the versatility of UPS nanoparticles. Overall, this Account aims to highlight nanoimmunology, an emerging cross field that exploits nanotechnology's unique synergy with immunology through nano-immune-engineering, for advancing cancer immunotherapy.

Exploiting nanoscale cooperativity for precision medicine

Precise spatiotemporal control of molecular transport is vital to functional physiological systems. Nature evolved to apply macromolecular cooperativity to achieve precision over systemic delivery of important molecules. In drug delivery, conventional nanocarriers employ inert materials and rely on passive accumulation for tissue targeting and diffusion for drug release. Early clinical studies show these nanodrugs have not delivered the anticipated impact on therapy. Inspired by nature, we propose a design principle that incorporates nanoscale cooperativity and phase transition to sense and amplify physiological signals to improve the therapeutic outcome. Using ultra-pH-sensitive (UPS) nanoparticles as an example, we demonstrate how all-or-nothing protonation cooperativity during micelle assembly/disassembly can be exploited to increase dose accumulation and achieve rapid drug release in acidic microenvironments. In a separate study, we show the effectiveness of a single polymer composition to accomplish cytosolic delivery of tumor antigens with activation of stimulator of interferon genes (STING) in lymph node-resident dendritic cells for cancer immunotherapy. Molecular cooperativity is a hallmark of nanobiology that offers a valuable strategy to functionalize nanomedicine systems to achieve precision medicine.

Exploiting metabolic acidosis in solid cancers using a tumor-agnostic pH-activatable nanoprobe for fluorescence-guided surgery

Cancer cell metabolism leads to a uniquely acidic microenvironment in solid tumors, but exploiting the labile extracellular pH differences between cancer and normal tissues for clinical use has been challenging. Here we describe the clinical translation of ONM-100, a nanoparticle-based fluorescent imaging agent. This is comprised of an ultra-pH sensitive amphiphilic polymer, conjugated with indocyanine green, which rapidly and irreversibly dissociates to fluoresce in the acidic extracellular tumor microenvironment due to the mechanism of nanoscale macromolecular cooperativity. Primary outcomes were safety, pharmacokinetics and imaging feasilibity of ONM-100. Secondary outcomes were to determine a range of safe doses of ONM-100 for intra-operative imaging using commonly used fluorescence camera systems. In this study (Netherlands National Trial Register #7085), we report that ONM-100 was well tolerated, and four solid tumor types could be visualized both in- and ex vivo in thirty subjects. ONM-100 enables detection of tumor-positive resection margins in 9/9 subjects and four additional otherwise missed occult lesions. Consequently, this pH-activatable optical imaging agent may be clinically beneficial in differentiating previously unexploitable narrow physiologic differences.

It is well known that the pH of tumor tissue is lower than that of the corresponding normal adjacent tissue. Here, the authors report a clinical trial of a pH activatable nanoparticle for imaging tumours.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks

The COVID-19 pandemic demands reassessment of head and neck oncology treatment paradigms. Head and neck cancer (HNC) patients are generally at high-risk for COVID-19 infection and severe adverse outcomes. Further, there are new, multilevel COVID-19-specific risks to patients, surgeons, health care workers (HCWs), institutions and society. Urgent guidance in the delivery of safe, quality head and neck oncologic care is needed. Novel barriers to safe HNC surgery include: (1) imperfect presurgical screening for COVID-19; (2) prolonged SARS-CoV-2 aerosolization; (3) occurrence of multiple, potentially lengthy, aerosol generating procedures (AGPs) within a single surgery; (4) potential incompatibility of enhanced personal protective equipment (PPE) with routine operative equipment; (5) existential or anticipated PPE shortages. Additionally, novel, COVID-19-specific multilevel risks to HNC patients, HCWs and institutions, and society include: use of immunosuppressive therapy, nosocomial COVID-19 transmission, institutional COVID-19 outbreaks, and, at some locations, societal resource deficiencies requiring health care rationing. Traditional head and neck oncology doctrines require reassessment given the extraordinary COVID-19-specific risks of surgery. Emergent, comprehensive management of these novel, multilevel surgical risks are needed. Until these risks are managed, we temporarily favor nonsurgical therapy over surgery for most mucosal squamous cell carcinomas, wherein surgery and nonsurgical therapy are both first-line options. Where surgery is traditionally preferred, we recommend multidisciplinary evaluation of multilevel surgical-risks, discussion of possible alternative nonsurgical therapies and shared-decision-making with the patient. Where surgery remains indicated, we recommend judicious preoperative planning and development of COVID-19-specific perioperative protocols to maximize the safety and quality of surgical and oncologic care.

Detection of Lymph Node Metastases by Ultra-pH-Sensitive Polymeric Nanoparticles

Lymph node (LN) dissection followed by histological analysis is the current standard for diagnosis of LN metastasis but the method suffers from patient morbidity and low sensitivity of detection. Ultra-pH sensitive (UPS) nanoparticles show remarkable accuracy in the delineation of primary tumor margins for precision cancer surgery. Herein we investigate the effectiveness of UPS nanoparticles to detect cancer-involved LNs. Methods: We synthesized a series of indocyanine green (ICG) conjugated UPS nanoparticles with distinct pK_a (UPS_5.3, UPS_6.1, and UPS_6.9). Systemically administered UPS-ICG nanoparticles in the 4T1.2-BALB/cj mouse model were imaged with real-time, near-infrared fluorescence (NIRF) to guide removal of LNs. Ex vivo imaging of gross tissue enabled quantification of fluorescence intensity. Histological analysis was used as the gold standard diagnostic test. Results: Macrophage uptake of UPS nanoparticles elevates the background signal in benign LNs. However, cancer foci within LNs show distinctive clustering of UPS-ICG fluorescence. UPS_5.3 achieves accurate detection of metastatic LNs as shown by a receiver operating characteristic (ROC) area under the curve (AUC) of 0.96 ± 0.03. UPS_6.1 and UPS_6.9 offer decreased discriminatory power at ROC AUC of 0.73 ± 0.1 and 0.88 ± 0.07, respectively. Conclusions: All UPS compositions show cancer-specific discrimination of metastatic LNs over benign LNs with the best outcomes from UPS_5.3. Detection of micro-metastatic LNs (cancer foci < 2 mm) remains a challenge. This study provides information on the detection of LN status for image-guided resection of metastatic LNs.

Unique Patterns of Distant Metastases in HPV-Positive Head and Neck Cancer

BACKGROUND

HPV-positive head and neck squamous cell carcinoma (HPV+ HNSCC) demonstrates favorable outcomes compared to HPV-negative SCC, but distant metastases (DM) still occur. The pattern of DM in HPV+ HNSCC is unclear.

METHODS

1,494 HNSCC patients were treated from 2006 to 2012. Recurrence time and metastatic sites in HPV+ HNSCC (Group 1) were compared to patients with HPV-negative/unknown cancers arising in the hypopharynx, larynx, or glottis (Group 2) as well as to patients with HPV-negative/unknown cancers in theoral cavity, oropharynx, hard palate, or tonsil (Group 3).

RESULTS

7/109 (6.4%) patients with HPV+ HNSCC developed DM. The median time to metastases was 11 months. At a median follow-up of 18-25 months, there was no difference in the overall rate of DM for the HPV+ HNSCC group compared to Group 2 (HPV-/unknown) (p = 0.21) and Group 3 (HPV-/unknown) (p = 0.13). There was a significant difference in the rate of DM to the lung in the HPV+ HNSCC group compared to Group 2 (HPV-/unknown) (p = 0.012) and Group 3 (HPV-/unknown) (p = 0.002).

CONCLUSIONS

There was no observed difference in the time to development of DM between the HPV-/unknown and HPV+ HNSCC groups. However, the HPV+ HNSCC group showed a higher rate of DM to the lung compared to the HPV-/unknown -HNSCC group (p = 0.002).

Head and Neck Cancer Detection in Digitized Whole-Slide Histology Using Convolutional Neural Networks

Primary management for head and neck cancers, including squamous cell carcinoma (SCC), involves surgical resection with negative cancer margins. Pathologists guide surgeons during these operations by detecting cancer in histology slides made from the excised tissue. In this study, 381 digitized, histological whole-slide images (WSI) from 156 patients with head and neck cancer were used to train, validate, and test an inception-v4 convolutional neural network. The proposed method is able to detect and localize primary head and neck SCC on WSI with an AUC of 0.916 for patients in the SCC testing group and 0.954 for patients in the thyroid carcinoma testing group. Moreover, the proposed method is able to diagnose WSI with cancer versus normal slides with an AUC of 0.944 and 0.995 for the SCC and thyroid carcinoma testing groups, respectively. For comparison, we tested the proposed, diagnostic method on an open-source dataset of WSI from sentinel lymph nodes with breast cancer metastases, CAMELYON 2016, to obtain patch-based cancer localization and slide-level cancer diagnoses. The experimental design yields a robust method with potential to help create a tool to increase efficiency and accuracy of pathologists detecting head and neck cancers in histological images.

Hyperspectral Imaging of Head and Neck Squamous Cell Carcinoma for Cancer Margin Detection in Surgical Specimens from 102 Patients Using Deep Learning

Surgical resection of head and neck (H and N) squamous cell carcinoma (SCC) may yield inadequate surgical cancer margins in 10 to 20% of cases. This study investigates the performance of label-free, reflectance-based hyperspectral imaging (HSI) and autofluorescence imaging for SCC detection at the cancer margin in excised tissue specimens from 102 patients and uses fluorescent dyes for comparison. Fresh surgical specimens (n = 293) were collected during H and N SCC resections (n = 102). The tissue specimens were imaged with reflectance-based HSI and autofluorescence imaging and afterwards with two fluorescent dyes for comparison. A histopathological ground truth was made. Deep learning tools were developed to detect SCC with new patient samples (inter-patient) and machine learning for intra-patient tissue samples. Area under the curve (AUC) of the receiver-operator characteristic was used as the main evaluation metric. Additionally, the performance was estimated in mm increments circumferentially from the tumor-normal margin. In intra-patient experiments, HSI classified conventional SCC with an AUC of 0.82 up to 3 mm from the cancer margin, which was more accurate than proflavin dye and autofluorescence (both p < 0.05). Intra-patient autofluorescence imaging detected human papilloma virus positive (HPV+) SCC with an AUC of 0.99 at 3 mm and greater accuracy than proflavin dye (p < 0.05). The inter-patient results showed that reflectance-based HSI and autofluorescence imaging outperformed proflavin dye and standard red, green, and blue (RGB) images (p < 0.05). In new patients, HSI detected conventional SCC in the larynx, oropharynx, and nasal cavity with 0.85-0.95 AUC score, and autofluorescence imaging detected HPV+ SCC in tonsillar tissue with 0.91 AUC score. This study demonstrates that label-free, reflectance-based HSI and autofluorescence imaging methods can accurately detect the cancer margin in ex-vivo specimens within minutes. This non-ionizing optical imaging modality could aid surgeons and reduce inadequate surgical margins during SCC resections.

Hyperspectral imaging for head and neck cancer detection: specular glare and variance of the tumor margin in surgical specimens

Head and neck squamous cell carcinoma (SCC) is primarily managed by surgical cancer resection. Recurrence rates after surgery can be as high as 55%, if residual cancer is present. Hyperspectral imaging (HSI) is evaluated for detection of SCC in ex-vivo surgical specimens. Several machine learning methods are investigated, including convolutional neural networks (CNNs) and a spectral-spatial classification framework based on support vector machines. Quantitative results demonstrate that additional data preprocessing and unsupervised segmentation can improve CNN results to achieve optimal performance. The methods are trained in two paradigms, with and without specular glare. Classifying regions that include specular glare degrade the overall results, but the combination of the CNN probability maps and unsupervised segmentation using a majority voting method produces an area under the curve value of 0.81 [0.80, 0.83]. As the wavelengths of light used in HSI can penetrate different depths into biological tissue, cancer margins may change with depth and create uncertainty in the ground truth. Through serial histological sectioning, the variance in the cancer margin with depth is investigated and paired with qualitative classification heat maps using the methods proposed for the testing group of SCC patients. The results determined that the validity of the top section alone as the ground truth may be limited to 1 to 2 mm. The study of specular glare and margin variation provided better understanding of the potential of HSI for the use in the operating room.

Abstract CT018: Image guided surgery for tumor agnostic detection of solid tumors using the pH activated micellar imaging agent ONM-100: The Shine study

Introduction: ONM-100, an indocyanine green (ICG) conjugated, micelle-based polymer imaging agent with an exquisitely pH-sensitive binary activation mechanism, may be used for intra-operative tumor detection. Micelles dissociate in acidic environments resulting in fluorescent activation of ICG. As most solid cancer types are acidotic due to anaerobic glycolysis, the so-called Warburg effect, ONM-100 has the potential to act as a tumor agnostic imaging agent targeting a broad range of tumors. This first in-human study investigates the safety and feasibility of ONM-100 as a tumor agnostic imaging agent for intra-operative fluorescent imaging of various solid tumors.

Methods: ONM-100 was IV administered 24±8h prior to surgery in a dose escalation scheme (0.1-1.2mg/kg), and the optimal dose was further evaluated in a subsequent cohort. Patients with histopathologically confirmed breast cancer (BC), head and neck squamous cell carcinoma (HNSCC), colorectal cancer (CRC) and esophageal cancer (EC) were included. Blood was drawn to assess safety and pharmacokinetic data. Intra-operative images were collected before and after tumor excision. After excision, fluorescence images were obtained from serially sliced specimens and formalin fixated paraffin embedded tissue blocks and correlated with standard histopathological assessment.

Results: 30 patients (11 BC, 13 HNSCC, 3 EC, 3 CRC) were enrolled between March and December 2018. No ONM-100 related serious adverse events were observed and the agent was well tolerated at all the dose levels. A strong and sharply demarcated fluorescent signal was observed in all patients with vital tumor tissue (median Contrast to Noise Ratio 3.5; IQR 3.4) which correlated with tumor on final histopathology.

Pharmacokinetics showed increased tumor fluorescence in a dose and plasma concentration-dependent manner. HNSCC, superficially located BC, extraluminal CRC as well as peritoneal metastasis could be clearly visualized in vivo during surgery. In 4 patients (BC and HNSCC), perioperatively, an otherwise unnoticed tumor by the surgeon was detected on the margin or wound bed using fluorescence imaging. Additionally, 2 BC tumor lesions were detected which were missed by conventional pre-operative imaging and pathological assessment.

Conclusion: ONM-100 appears to be safe and allows fluorescent visualization of tumors both in- and ex vivo. The first in-human data demonstrates feasibility for potential use of ONM-100 for image guided surgery, detection of occult disease and margin assessment. Analysis of the microscopic biodistribution of ONM-100 is currently being performed and applications for metastatic lymph node detection will be explored.

Note: This abstract was not presented at the meeting.

Citation Format: Pieter J. Steinkamp, Floris J. Voskuil, Marjory Koller, Bert van der Vegt, Jan J. Doff, Tian Zhao, Jeffrey P. Hartung, Yalia Jayalakshmi, Baran D. Sumer, Jinming Gao, Max J. Witjes, Gooitzen M. van Dam. Image guided surgery for tumor agnostic detection of solid tumors using the pH activated micellar imaging agent ONM-100: The Shine study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT018.

Image-guided surgery for tumor agnostic detection of solid tumors using the pH-activated micellar imaging agent ONM-100

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Background: ONM-100, a micelle-based polymer imaging agent conjugated to indocyanine green (ICG) and with an exquisitely pH-sensitive binary activation mechanism, may be used for tumor detection. ONM-100 micelles dissociate in acidic environments resulting in activation of the fluorescent ICG tag. As nearly all solid cancer types are acidotic, ONM-100 has the potential to act as a broadly indicated tumor agnostic imaging agent. This first-in-human study investigates the safety and feasibility of ONM-100 as a tumor agnostic imaging agent for intra-operative fluorescent imaging of various solid tumors. Methods: ONM-100 was IV administered 24±8h prior to surgery in a dose escalation scheme (0.1-1.2mg/kg). Patients with histopathologically confirmed breast cancer (BC), head and neck squamous cell carcinoma (HNSCC), colorectal cancer (CRC) and esophageal cancer (EC) were included. Blood was drawn to assess safety and pharmacokinetic data. Intra-operative fluorescence images were collected before and after tumor excision. Post-excision fluorescence images were obtained from serially sliced specimens and correlated with standard histopathological assessment. Results: 30 patients (11 BC, 13 HNSCC, 3 EC, 3 CRC) were enrolled. No ONM-100 related serious adverse events were observed and the agent was well-tolerated. A strong and sharply demarcated fluorescent signal was observed in all patients with vital tumor tissue (median CNR ranging 1.85-14.05) which correlated with tumor on final histopathology. HNSCC and superficially located BC as well as peritoneal metastasis could be clearly visualized in vivo during surgery. In four patients (BC and HNSCC), perioperatively, tumors otherwise unnoticed by the surgeons were detected on the margin or wound bed using fluorescence imaging. Additionally, two BC tumor lesions were detected that were missed by conventional pre-operative imaging and pathological assessment. Conclusions: ONM-100 appears to be safe and enables fluorescent visualization of tumors both in vivo and ex vivo. The first-in-human data demonstrate the feasibility for potential use of ONM-100 for image guided surgery, margin assessment and detection of occult disease. Clinical trial information: NTR 7085.

Evaluating sociodemographic, behavioral and psychologic disparities in 918 head and neck cancer survivors

e17541

Background: Minority race, low-income status, tobacco dependence, alcohol abuse, and depression negatively impact overall survival among head and neck cancer (HNC) survivors. Understanding the prevalence and associations of these factors will inform the development of targeted HNC survivorship interventions. Methods: We pooled cross-sectional samples of HNC patients participating in the National Health Interview Survey from 1997-2016. Descriptive statistics were used to compare: 1) HNC survivors to age- and sex-matched adults without cancer (1:4) and 2) behavioral and psychologic conditions in HNC survivors by income status. Results: Mean age of the 918 HNC survivors was 64.8 years and 65.2% were male. Most HNC survivors were non-Hispanic white (85.3%); 7.6% were non-Hispanic black, 4.9% were Hispanic, and 2.2% were of other race and ethnicity. A substantial portion reported income below the poverty threshold (13.9%) and 5.0% consumed > 14 alcoholic drinks per week. Compared to adults without cancer (n = 3,612), a higher proportion (p < 0.05) of HNC survivors (n = 903) exhibited: current tobacco use (21.3% vs 17.4%); serious psychological distress (Kessler-6 score of ≥13; 6.9% vs 3.9%); depressive symptoms most or all of the time (14.1% vs 8.9%). There were particularly striking differences in the prevalence of these factors among HNC survivors by income. Specifically, a higher proportion of HNC survivors with income below the poverty threshold (n = 133) were non-Hispanic black (15.5% vs 5.8%) and exhibited current tobacco use (42.9% vs 18.6%), serious psychological distress (17.4% vs 5.7%) and depressive symptoms most or all of the time (25.3% vs 12.7%) compared to those at or above the poverty threshold (n = 646; all p < 0.05). Conclusions: HNC survivors experience a disproportionate burden of behavioral and psychologic health conditions compared to age- and sex-matched adults without cancer. Low-income status exacerbates these disparities. HNC survivors, especially those in low-income settings, require comprehensive survivorship care targeting these needs.

Risk of Unplanned Hospital Encounters in Patients Treated With Radiotherapy for Head and Neck Squamous Cell Carcinoma

CONTEXT

Radiotherapy is highly effective for treating squamous cell carcinoma of the head and neck but is often associated with significant toxicities and severe morbidity. Unplanned emergency department (ED) visits and hospitalizations are common during treatment and come with a substantial financial and health burden as well as the potential for impaired long-term outcomes due to treatment disruption.

OBJECTIVES

The objective of this study was to identify patient, disease, and treatment characteristics that were associated with ED encounters and admissions.

METHODS

A cohort of 462 patients with cancer of the head and neck treated with radiotherapy at UT Southwestern between 2010 and 2015 was retrospectively analyzed. The risks of ED visits, admissions, multiple admissions, and extended admissions were determined. Risk factors for an unplanned hospital encounter were analyzed using univariate and multivariate logistic regression.

RESULTS

Overall, 36% of patients had an unplanned hospital encounter during the treatment window. Patients with advanced disease, those with high comorbidity score, and those treated with concurrent chemotherapy were more likely to have unplanned admissions/ED visits. Social factors such as marital status, smoking status, and registration in the public hospital system were also strongly associated with admissions and multiple encounters.

CONCLUSION

The high rate of admissions and ED visits emphasizes the importance of anticipating and managing toxicities during treatment. Social factors have a strong association with unplanned encounters and may present opportunities for targeted interventions to reduce admissions for patients at highest risk.

Targeting NAD+ Metabolism to Enhance Radiation Therapy Responses

Nicotinamide adenine dinucleotide (NAD⁺) metabolism is integrally connected with the mechanisms of action of radiation therapy and is altered in many radiation-resistant tumors. This makes NAD⁺ metabolism an ideal target for therapies that increase radiation sensitivity and improve patient outcomes. This review provides an overview of NAD⁺ metabolism in the context of the cellular response to ionizing radiation, as well as current therapies that target NAD⁺ metabolism to enhance radiation therapy responses. Additionally, we summarize state-of-the-art methods for measuring, modeling, and manipulating NAD⁺ metabolism, which are being used to identify novel targets in the NAD⁺ metabolic network for therapeutic interventions in combination with radiation therapy.

Abstract P2-14-29: Image guided surgery for tumor detection in breast cancer using the PH activated micellar tracer ONM-100: The SHINE study

Background: Currently, no reliable intra-operative tumor detection and margin assessment technologies during breast conserving surgery are available. Fluorescence-guided surgery (FGS) using tumor specific fluorescent tracers can improve intra-operative tumor detection. However, a major limitation is the lack of broad tumor applicability due to complex oncogenotypes and histologic phenotypes. A strategy to overcome this challenge is targeting metabolic vulnerabilities that are more ubiquitous and regarded as generic hallmarks of cancer. The extracellular environment of tumors is relatively acidic compared to healthy tissue due to aerobic glycolysis, the so-called Warburg effect. ONM-100, a micellar polymer tracer labeled with the fluorescent imaging dye Indocyanine Green (ICG), has an exquisitely pH-sensitive binary on/off mechanism. The micelles dissociate in acidic environments causing the unquenching and fluorescent activation of the ICG dye. As most solid cancer types are acidotic, ONM-100 acts as a generic tracer targeting a broad range of tumors. This proof of concept, first in-human study, investigates the safety and feasibility of ONM-100 as an intra-operative fluorescent tracer in breast cancer (BC) patients.

Methods: In this phase 1 study, the pH-activated fluorescent tracer ONM-100 was administered 24±8h prior to surgery in a dose escalation scheme ranging from 0.1 mg/kg to 0.8 mg/kg in groups of 3 patients each. Patients with biopsy proven BC were included. Patients that had undergone neoadjuvant therapy were excluded. Blood was drawn up to day 10 to assess safety and pharmacokinetic data. Intra-operative images were collected of the tumor before and after excision and of the wound bed. Immediately after excision ex vivo fluorescence images were obtained from the serially sliced specimen and the formalin fixated paraffin embedded tissue blocks. Fluorescence images were correlated with histopathological assessment on Hematoxylin and Eosin (H/E) stained sections.

Results: In this ongoing clinical trial, 4 patients with BC were enrolled between March and May 2018. No tracer related (serious) adverse events were observed. A strong and sharply demarcated fluorescent signal in tumor tissue was observed in all 4 patients with in- and ex vivo imaging (median Contrast to Noise Ratio 6.5; IQR 7.25), which correlated with areas of tumor involvement on histopathology. In one BC patient, an intra-operatively unnoticed tumor positive margin was detected using fluorescence imaging. Additionally, a BC satellite lesion was detected, which was otherwise missed by the pathologist.

Conclusion: Preliminary results of this ongoing first in-human study with the pH-activated tracer ONM-100 shows that ONM-100 is well tolerated and safe and allows fluorescent tumor visualization both in- and ex vivo. Here, we provide the first data that this pH-sensitive optical tracer can be used as a tracer for FGS and for margin detection. Further analysis on microscopic biodistribution of ONM-100 is currently being performed and possibilities for metastatic lymph node detection will be explored.

Citation Format: Steinkamp PJ, Voskuil FJ, Koller M, van der Vegt B, Doff JJ, Zhao T, Hartung J, Jayalakshmi Y, Sumer BD, Gao J, Witjes MJ, van Dam GM. Image guided surgery for tumor detection in breast cancer using the PH activated micellar tracer ONM-100: The SHINE study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-29.

Detection of Squamous Cell Carcinoma in Digitized Histological Images from the Head and Neck Using Convolutional Neural Networks

Primary management for head and neck squamous cell carcinoma (SCC) involves surgical resection with negative cancer margins. Pathologists guide surgeons during these operations by detecting SCC in histology slides made from the excised tissue. In this study, 192 digitized histological images from 84 head and neck SCC patients were used to train, validate, and test an inception-v4 convolutional neural network. The proposed method performs with an AUC of 0.91 and 0.92 for the validation and testing group. The careful experimental design yields a robust method with potential to help create a tool to increase efficiency and accuracy of pathologists for detecting SCC in histological images.

Cancer Detection Using Hyperspectral Imaging and Evaluation of the Superficial Tumor Margin Variance with Depth

Head and neck squamous cell carcinoma (SCCa) is primarily managed by surgical resection. Recurrence rates after surgery can be as high as 55% if residual cancer is present. In this study, hyperspectral imaging (HSI) is evaluated for detection of SCCa in ex-vivo surgical specimens. Several methods are investigated, including convolutional neural networks (CNNs) and a spectral-spatial variant of support vector machines. Quantitative results demonstrate that additional processing and unsupervised filtering can improve CNN results to achieve optimal performance. Classifying regions that include specular glare, the average AUC is increased from 0.73 [0.71, 0.75 (95% confidence interval)] to 0.81 [0.80, 0.83] through an unsupervised filtering and majority voting method described. The wavelengths of light used in HSI can penetrate different depths into biological tissue, while the cancer margin may change with depth and create uncertainty in the ground-truth. Through serial histological sectioning, the variance in cancer-margin with depth is also investigated and paired with qualitative classification heat maps using the methods proposed for the testing group SCC patients.

Association between treatment delays and oncologic outcome in patients treated with surgery and radiotherapy for head and neck cancer

BACKGROUND

This study sought to determine the oncologic impact of delays to surgery, radiotherapy, and completion of therapy in patients with head and neck squamous cell carcinoma.

METHODS

The impact of biopsy to surgery (BTS) time, surgery to start of radiation time (STSR), and radiation treatment time (RTT) on locoregional recurrence (LRR), distant metastases (DMs), and cancer-specific mortality (CSM) was examined. The cumulative incidences (CI) of LRR, DMs, and CSM were examined using Fine-Gray testing.

RESULTS

A total of 277 patients treated with surgery and adjuvant radiotherapy were analyzed. On multivariable testing, BTS >50 days was associated with DM (P = .03), whereas RTT and STSR were not. RTT >43 days was associated with LRR (P = .02) in patients with non-p16-positive-oropharynx cancer.

CONCLUSIONS

An increase in DM appears to be the mechanism by which prolonged time to treatment initiation leads to worse overall survival. Prolonged RTT has the greatest impact on patients with non-p16 positive oropharynx cancers.