EGFR Targeting of Liposomal Doxorubicin Improves Recognition and Suppression of Non-Small Cell Lung Cancer

Introduction

Despite improvements in chemotherapy and molecularly targeted therapies, the life expectancy of patients with advanced non-small cell lung cancer (NSCLC) remains less than 1 year. There is thus a major global need to advance new treatment strategies that are more effective for NSCLC. Drug delivery using liposomal particles has shown success at improving the biodistribution and bioavailability of chemotherapy. Nevertheless, liposomal drugs lack selectivity for the cancer cells and have a limited ability to penetrate the tumor site, which severely limits their therapeutic potential. Epidermal growth factor receptor (EGFR) is overexpressed in NSCLC tumors in about 80% of patients, thus representing a promising NSCLC-specific target for redirecting liposome-embedded chemotherapy to the tumor site.

Methods

Herein, we investigated the targeting of PEGylated liposomal doxorubicin (Caelyx), a powerful off-the-shelf antitumoral liposomal drug, to EGFR as a therapeutic strategy to improve the specific delivery and intratumoral accumulation of chemotherapy in NSCLC. EGFR-targeting of Caelyx was enabled through its complexing with a polyethylene glycol (PEG)/EGFR bispecific antibody fragment. Tumor targeting and therapeutic potency of our treatment approach were investigated in vitro using a panel of NSCLC cell lines and 3D tumoroid models, and in vivo in a cell line-derived tumor xenograft model.

Results

Combining Caelyx with our bispecific antibody generated uniform EGFR-targeted particles with improved binding and cytotoxic efficacy toward NSCLC cells. Effects were exclusive to cancer cells expressing EGFR, and increments in efficacy positively correlated with EGFR density on the cancer cell surface. The approach demonstrated increased penetration within 3D spheroids and was effective at targeting and suppressing the growth of NSCLC tumors in vivo while reducing drug delivery to the heart.

Conclusion

EGFR targeting represents a successful approach to enhance the selectivity and therapeutic potency of liposomal chemotherapy toward NSCLC.

Optimizing Outcomes in Lymphedema Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema.

SUMMARY

Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.

Radiation and free flaps: what is the optimal timing?

The debate over when to perform flaps in patients undergoing radiation remains an ongoing dilemma without definitive resolution. Classically, reconstructive surgeons recommended avoiding exposure of autologous flaps to radiotherapy due to concerns over surgical complications and poor aesthetic outcomes. However, delayed reconstruction carries its own risk profile and aesthetic limitations, given the irreversible changes to the breast envelope. Immediate reconstruction not only confers psychosocial benefits but allows for preservation of the native breast skin and footprint. In recent years, a growing body of evidence suggests that with modern radiation techniques, long-term outcomes of immediate vs. delayed autologous reconstruction may be more similar than previously thought. This review examines the advantages and disadvantages of each treatment algorithm and critically evaluates the existing literature on autologous breast reconstruction in the setting of post-mastectomy radiotherapy. Importantly, radiation regimens have varied widely over time and between institutions, introducing significant heterogeneity in published outcomes of flap contracture or fat necrosis after immediate reconstruction. While delayed autologous reconstruction remains a reasonable pathway, the benefits of immediate reconstruction should not be dismissed. Our findings ultimately corroborate the view that immediate flap reconstruction is a sound treatment option that can be safely offered to patients. The decision regarding which pathway to pursue should ultimately be patient-centric and driven by multidisciplinary consensus, rather than by prior dogma.

"Immediate versus delayed autologous breast reconstruction in patients undergoing post-mastectomy radiation therapy: A paradigm shift"

BACKGROUND

While negative impacts of radiation on breast reconstruction have been well accepted, timing of autologous breast reconstruction in the setting of postmastectomy radiation therapy (PMRT) is still evolving. This study aims to address the dilemma of breast reconstruction timing in patients receiving PMRT.

METHODS

A retrospective chart review was performed evaluating patients who underwent PMRT and autologous breast reconstruction. Postoperative complication and revision rates were compared.

RESULTS

Thirty-six immediate (immediate breast reconstruction [IBR]) and 89 delayed reconstructions (delayed breast reconstruction [DBR]) were included with comparable patient characteristics between groups. Overall complication rates were not significantly different, or when separately assessing for surgical site infections, wound dehiscence, fat necrosis, or substantial volume loss. No free flaps were lost in either group. Revision rates were significantly lower in the IBR group (p = 0.02). DBR resulted in appreciably larger volumes of fat grafting to the therapeutically reconstructed breast (p = 0.01) and more contralateral mastopexies (p = 0.02). No significant difference was observed in fat necrosis excision, breast reduction, or need for secondary flap reconstruction or prosthetic use for volume loss.

CONCLUSIONS

IBR in the setting of PMRT does not result in higher rates of complications and requires fewer overall revisions, making it a compelling option for patients undergoing PMRT.

Outcomes for Physiologic Microsurgical Treatment of Secondary Lymphedema Involving the Extremity

OBJECTIVE

The aim of this study was to examine the long-term impact of physiologic surgical options, including VLNT and LVB, on patients with secondary lymphedema of the upper or lower extremity (UEL/LEL).

SUMMARY BACKGROUND DATA

VLNT and LVB have become increasingly popular in the treatment of lymphedema. However, there is a paucity of long-term data on patient outcomes after use of these techniques to treat lymphedema.

METHODS

An analysis of prospectively collected data on all patients who underwent physiologic surgical treatment of secondary lymphedema over a 5.5-year period was performed. Patient demographics, surgical details, subjective reported improvements, LLIS scores, and postoperative limb volume calculations were analyzed.

RESULTS

Two hundred seventy-four patients with secondary lymphedema (197 upper, 77 lower) were included in the study. More than 87% of UEL patients and 60% of LEL patients had reduction in excess limb volume postoperatively. At 3 months postoperatively, patients with UEL had a 31.1% reduction in volume difference between limbs, 33.9% at 6 months, 25.7% at 12 months, 47.4% at 24 months and 47.7% at 4 years. The reduction in limb volume difference followed a similar pattern but was overall lower for LEL patients. Greater than 86% of UEL and 75% of LEL patients also had improvement in LLIS scores postoperatively. Fifty-nine complications occurred (12.9%); flap survival was >99%.

CONCLUSIONS

Patients with secondary UEL/LEL who undergo VLNT/LVB demonstrate improved functional status and reduced affected limb volumes postoperatively. Patients with UEL seem to have a more substantial reduction in limb volume differential compared to LEL patients.

Outcomes of progressive tension donor-site closure in abdominal-based autologous breast reconstruction

BACKGROUND

The use of progressive tension sutures (PTSs) for drain-free abdominoplasty closure has been well published in the esthetic literature and found to be effective at reducing abdominal drainage without a worse complication profile. This research aims to evaluate the outcomes of incorporating PTS into donor-site closures for abdominal-based breast reconstruction.

METHODS

A retrospective chart review was performed evaluating patients at the University of Chicago Medicine, who underwent autologous breast reconstruction and either PTS closure or standard abdominal closure between 2018 and 2021.

RESULTS

A total of 100 patients were included with 50 patients receiving PTS closure and 50 with traditional abdominal closures. Patient demographics, including age (p = 0.82), body mass index (BMI; p = 0.17), diabetes (p = 1.00), tobacco use (p = 0.15), and chemotherapy (p = 1.00) did not significantly differ. Total drain output over the first 72 h was significantly lower in the PTS group compared with the standard closure (SC) group (p = 0.00005). Mean duration of drain placement was shorter by 2 days in the PTS group, but this did not reach significance (p = 0.08). Overall complication rates were lower in the PTS group (p = 0.03), however, no difference was appreciated when separately assessing for seromas (p = 1.00), hematomas (p = 1.00), wound dehiscence (p = 0.58), or surgical-site infections (p = 1.00). More abdominal revisions were observed in the SC group, however, this did not reach significance (p = 0.15) CONCLUSION: The use of PTS with placement of a single drain is a safe option for donor-site closure, and is a compelling technique for patients undergoing abdominal-based breast reconstruction.

Plastic Surgery Away Rotations During the Coronavirus Disease Pandemic: A Virtual Experience

BACKGROUND

Plastic surgery has traditionally been a specialty that places a strong emphasis on away rotations during the final year of medical school. These rotations allow the program and residency candidates to become better acquainted and are often crucial, as a large portion of applicants match at programs where they rotated. The coronavirus disease 2019 (COVID-19) pandemic forced many institutions to modify their educational curriculums when away rotations were canceled. We present our experience creating and implementing a virtual plastic surgery rotation.

METHODS

Our virtual program was designed to mirror the in-person away rotations as much as possible. Prerotation and postrotation surveys from the students as well as feedback interviews with the students, residents, and faculty were used to gather information on the experience.

RESULTS

We created a 2-week curriculum including approximately 20 hours of lecture time, 28 hours of operating room time, 2.5 hours of one-on-one mentorship, and 3 hours of social opportunities. Students reported that they learned more about plastic surgery and the residency program, but in contrast to this, some found it difficult to make an impression.

CONCLUSIONS

We developed a novel 2-week virtual curriculum that provided visiting medical students from across the country an opportunity to learn more about plastic surgery and our residency program. Virtual learning is becoming a vital part of education, and our study provides pearls and pitfalls when structuring these experiences.

Genetic associations of T cell cancer immune response-related genes with T cell phenotypes and clinical outcomes of early-stage lung cancer

Background

Recent advances in T cell-related immunotherapy have brought remarkable progress in the treatment of non-small cell lung cancer (NSCLC). However, whether and how genetic variations of T cell cancer immune response genes can influence clinical outcomes of NSCLC patients remain obscure.

Methods

In this multiphase study, we assessed 2450 single-nucleotide polymorphisms (SNPs) from 280 T cell cancer immune response-related genes in 941 early-stage NSCLC patients (discovery n=536; validation n=405) to analyze the variants’ associations with outcomes and to observe the effects on T cell phenotypes.

Results

We found 14 SNPs in 10 genes were associated with NSCLC outcomes (p<0.05) in both phases. Among them, TRB:rs1964986 was the most significant variant associated with recurrence risk after meta-analysis (HR 1.84, 95% CI 1.35 to 2.52, p=1.15E-04), while IDO1:rs10108662 was the most significant SNP associated with death risk (HR 1.87, 95% CI 1.40 to 2.51, p=2.17E-05). Analysis of unfavorable genotypes indicated cumulative effects on death and recurrence risks. Seven treatment-specific variants were found to predict opposite outcomes in surgery-only and surgery-plus-chemotherapy subgroups. Expression quantitative trait loci analysis indicated that six SNPs significantly correlated with their corresponding gene expression. T cells from high-risk subjects displayed reduced degranulation (p=0.02) and decreased cytotoxicity against cancer cells (p<0.01). Gene expression profile indicated increased IDO1 expression and decreased IL2, PRF and GZMB expression in high-risk subjects.

Conclusions

Genetic variations in T cell cancer immune response pathways can impact outcomes and may be served as predictors for treatment efficacy in early-stage NSCLC patients. The correlation between immune genotypes and T cell antitumor immunity suggests a biological link between host immune genetics and NSCLC prognosis.

Genetic variants in epithelial-mesenchymal transition genes as predictors of clinical outcomes in localized prostate cancer

BACKGROUND

Epithelial-mesenchymal transition (EMT) plays a pivotal role in the progression of prostate cancer (PCa). However, little is known about genetic variants in the EMT pathway as predictors of aggressiveness, biochemical recurrence (BCR) and disease reclassification in localized PCa.

PATIENTS AND METHODS

In this multistage study, we evaluated 5186 single nucleotide polymorphisms (SNPs) from 264 genes related to EMT pathway to identify SNPs associated with PCa aggressiveness and BCR in the MD Anderson PCa (MDA-PCa) patient cohort (N = 1762), followed by assessment of the identified SNPs with disease reclassification in the active surveillance (AS) cohort (N = 392).

RESULTS

In the MDA-PCa cohort, 312 SNPs were associated with high D'Amico risk (P < 0.05), among which, 14 SNPs in 10 genes were linked to BCR risk. In the AS cohort, 2 of 14 identified SNPs (rs76779889 and rs7083961) in C-terminal Binding Proteins 2 gene were associated with reclassification risk. The associations of rs76779889 with different endpoints were: D'Amico high versus low, odds ratio [95% confidence interval (CI)] = 2.89 (1.32-6.34), P = 0.008; BCR, hazard ratio (HR) (95% CI) = 2.88 (1.42-5.85), P = 0.003; and reclassification, HR (95% CI) = 2.83 (1.40-5.74), P = 0.004. For rs7083961, the corresponding risk estimates were: D'Amico high versus low, odds ratio (95% CI) = 1.69 (1.12-2.57), P = 0.013; BCR, HR (95% CI) = 1.87 (1.15-3.02), P = 0.011 and reclassification, HR (95% CI) = 1.72 (1.09-2.72), P = 0.020. There were cumulative effects of these two SNPs on modulating these endpoints.

CONCLUSION

Genetic variants in EMT pathway may influence the risks of localized PCa's aggressiveness, BCR and disease reclassification, suggesting their potential role in the assessment and management of localized PCa.

Immune checkpoint-related serum proteins and genetic variants predict outcomes of localized prostate cancer, a cohort study

BACKGROUND

The clinical predictors and biological mechanisms for localized prostate cancer (PCa) outcomes remain mostly unknown. We aim to evaluate the role of serum immune-checkpoint-related (ICK) proteins and genetic variations in predicting outcomes of localized PCa.

METHODS

We profiled the serum levels of 14 ICK-related proteins (BTLA, GITR, HVEM, IDO, LAG-3, PD-1, PD-L1, PD-L2, Tim-3, CD28, CD80, 4-1BB, CD27, and CTLA-4) in 190 patients with localized PCa. The genotypes of 97 single nucleotide polymorphisms (SNPs) from 19 ICK-related genes were analyzed in an extended population (N = 1762). Meta-data from ArrayExpress and TCGA was employed to validate and to probe functional data. Patients were enrolled and tumor aggressiveness, biochemical recurrence (BCR), and progression information were obtained. Statistical analyses were performed analyzing associations between serum biomarkers, genotypes, mRNA and outcomes.

RESULTS

We showed that serum (s)BTLA and sTIM3 levels were associated with PCa aggressiveness (P < 0.05). sCD28, sCD80, sCTLA4, sGITR, sHVEM and sIDO correlated with both BCR and progression risks (all P < 0.05). We further identified ICK variants were significantly associated with aggressiveness, BCR and progression. Among them, 4 SNPs located in CD80 (rs7628626, rs12695388, rs491407, rs6804441) were not only associated with BCR and progression risk, but also correlated with sCD80 level (P < 0.01). rs491407 was further validated in an independent cohort. The CD80 mRNA expression was associated with BCR (HR, 1.85, 95% CI 1.06-3.22, P = 0.03) in meta-analysis of validation cohorts.

CONCLUSION

We highlight the prognostic value of serum ICK-related proteins for predicting aggressiveness, BCR and progression of PCa. The genetic variations and mRNA expression in CD80 could be predictors and potential targets of localized PCa.

Combined Approach to Surgical Treatment of Lymphedema

Physiologic surgical interventions, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), are increasingly being used to treat lymphedema. LVB has been shown to be effective in improving the severity of lymphedema, particularly for patients with still-functional superficial lymphatic vessels that can be identified for bypass. However, in many patients, there is a paucity of functional lymphatic vessels for bypass and, thus, they are not ideal candidates for LVB alone. Unlike LVB, VLNT does not depend on the presence of functioning lymphatic vessels, but the effects of VLNT are delayed, as the proposed mechanisms of action require more time for optimal function. The author has offered a combined approach to microsurgical treatment of lymphedema for both the upper and lower extremities. Simultaneous VLNT and LVB are safe and effective for patients with both early and advanced stages of primary and secondary lymphedema. Our experience shows that a majority of patients can expect some long-term improvement, in both overall limb volume and quality of life, after surgical intervention with LVB and/or VLNT.

A 5-microRNA signature identified from serum microRNA profiling predicts survival in patients with advanced stage non-small cell lung cancer

Circulating microRNAs (miRNAs) are potential biomarkers for cancer diagnosis, screening and prognosis. This study aimed to identify serum miRNAs as predictors of survival in patients with advanced non-small cell lung cancer (NSCLC). We profiled serum miRNAs in a pilot set of four patients with good survival (>24 months) and four patients with poor survival (<6 months). We selected 140 stably detectable miRNAs and 42 miRNAs reported in literature for further analysis. Expression of these 182 miRNAs was measured using high-throughput polymerase chain reaction assay, and their association with 3-year survival in the discovery (n = 345) and validation (n = 177) cohorts was assessed. Five serum miRNAs (miR-191, miR-28-3p, miR-145, miR-328 and miR-18a) were significantly associated with 3-year overall survival in both cohorts. A combined 5-miRNA risk score was created to assess the cumulative impact of these miRNAs on risk of death. Quartile analysis of the risk score showed significant association with 3-year death risk, with a 4.6-, 6.8- and 9.3-month reduction in median survival time for the second, third and fourth quartiles, respectively. Survival tree analysis also identified distinct risk groups with different 3-year survival durations. Data from The Cancer Genome Atlas revealed all five miRNAs were differentially expressed (P < 0.0001) in paired tumor and normal tissues. Pathway analysis indicated that target genes of these five miRNAs were mainly enriched in inflammatory/immune response pathways and pathways implicated in resistance to chemoradiotherapy and/or targeted therapy. Our results suggested that the 5-miRNA signature could serve as a prognostic predictor in patients with advanced NSCLC.

Elevated systemic inflammatory responses, factors associated with physical and mental quality of life, and prognosis of hepatocellular carcinoma

Impaired quality of life (QOL) is common in hepatocellular carcinoma (HCC) patients. In this study, we used a large hospital-based multiethnic HCC patient cohort to systematically identify factors associated with QOL and investigate the prognostic value of QOL.

The Short Form-12 questionnaire was used to assess QOL. The Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were categorized into three groups (low, medium, and high) and ordered logistic regression analysis was used to analyze the association of PCS and MCS scores with patient characteristics. The association of PCS and MCS scores with mortality was assessed by Cox regression analysis.

Notably, a panel of elevated systemic inflammatory response markers was associated with poor QOL. Other significant factors associated with QOL included age, liver function, sex, smoking, HCC etiology, and major clinical features. Patients with low (hazard ratio [95% CI], 1.72 [1.36-2.17]) and medium (1.52 [1.23-1.89]) PCS scores exhibited higher risks of death compared to patients with high PCS score. The association of MCS with the risk of death was not significant. These observations were consistent across all the different ethnicities.

The identified factors associated with QOL may help clinicians formulate interventions to improve QOL and outcomes in HCC patients.

Soluble immune checkpoint-related proteins as predictors of tumor recurrence, survival, and T cell phenotypes in clear cell renal cell carcinoma patients

Background

Immune checkpoint inhibitors have achieved unprecedented success in cancer immunotherapy. With the exception of a few candidate biomarkers, the prognostic role of soluble immune checkpoint-related proteins in clear cell renal cell cancer (ccRCC) patients is largely uninvestigated.

Methods

We profiled the circulating levels of 14 immune checkpoint-related proteins panel (BTLA, GITR, HVEM, IDO, LAG-3, PD-1, PD-L1, PD-L2, Tim-3, CD28, CD80, CD137, CD27 and CTLA-4) and their associations with the risk of recurrence and death in 182 ccRCC patients using a multiplex Luminex assay. Gene expression in tumors from a subset of participating patients (n = 47) and another 533 primary ccRCC from TCGA were analyzed to elucidate potential mechanisms. Our primary endpoint is overall survival; secondary endpoint is recurrence-free survival. Multivariate Cox proportional hazard model, unconditional logistic regression model, and Kaplan-Meier analysis were applied in the study.

Results

sTIM3 and sLAG3 were significantly associated with advanced (stage III) disease (P < 0.05). sPD-L2 was the strongest predictor of recurrence (HR 2.51, 95%CI 1.46–4.34, P = 9.33E-04), whereas high sBTLA and sTIM3 was associated with decreased survival (HR 6.02, 95%CI 2.0–18.1, P = 1.39E-03 and HR 3.12, 95%CI 1.44–6.75, P = 3.94E-03, respectively). Risk scores based on sTIM3 and sBTLA indicated that the soluble immune checkpoint-related proteins jointly predicted recurrence and death risks of ccRCC (P = 0.01 and 4.44E-04, respectively). Moreover, sLAG3 and sCD28 were found negatively correlated with cytolytic activity of T cells in tumors (rho = −0.31 and − 0.33, respectively).

Conclusions

Our study provides evidence that soluble immune checkpoint-related proteins may associate with advanced disease, recurrence and survival in ccRCC patients, which highlights the prognostic values of soluble immune checkpoint-related proteins. Future independent validation in prospective studies is warranted.

Circulating obesity-driven biomarkers are associated with risk of clear cell renal cell carcinoma: a two-stage, case-control study

Obesity is one of modifiable risk factors for clear cell renal cell cancer (ccRCC). We aim to identify the association between obesity-driven biomarkers and ccRCC risk. This is a retrospective, two-phase, case-control study involving 682 cases and 733 controls. Obesity-driven biomarkers [gastric inhibitory polypeptide (GIP), C-peptide, insulin, resistin, adipsin, peptide YY, pancreatic polypeptide, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), plasminogen activator inhibitor-1, monocyte chemoattractant protein 1, lipocalin2, leptin, adiponectin] were measured using the Milliplex method. Multivariate logistic regression was used to assess the associations between biomarkers and ccRCC risk. Results revealed that GIP, C-peptide, IL-6 and TNF-α levels were consistently distinct between cases and controls. These markers were significantly associated with ccRCC risk in both phases (except C-peptide). In the combined population, compared with individuals with low levels of the biomarkers, individuals with high level of GIP [odds ratio (OR) = 0.52, 95% confidence interval (CI): 0.40-0.67] had lower risk, whereas individuals with high levels of C-peptide (OR = 1.46, 95% CI: 1.15-1.87), IL-6 (OR = 2.20, 95% CI: 1.50-3.22), TNF-α (OR = 1.90, 95% CI: 1.49-2.43) had significantly higher risk. Stratified analysis showed consistent associations with ccRCC risk in most subgroups (P < 0.05). The risk score based on the IL-6, TNF-α and GIP was positively associated with ccRCC risk in a dose-response manner (P for trend = 2.18E-13). Data from The Cancer Genome Atlas indicate that insulin signaling, IL-6 signaling and TNF-α signaling were enhanced in tumors. Collectively, our study demonstrates the integrative effect of insulin resistance and inflammation in ccRCC development, which may elucidate the basis of association between obesity and carcinogenesis. Further confirmation in prospective cohort studies are warranted for clinical applications in prevention and precision medicine of ccRCC.

Axillary dissection in sentinel lymph node positive breast cancer: Is the staging information worthwhile for patients?

AIMS

The Z0011 randomized trial demonstrated no significant difference in axillary recurrence rate or survival with or without axillary dissection in patients with a positive sentinel node biopsy. However, there is continuing controversy regarding the generalizability of its results, and axillary dissection provides additional pathologic staging information that may guide adjuvant therapy. Thus, axillary dissection after positive sentinel node biopsy is being further investigated in an actively recruiting randomized trial. We elicited patients' preferences for axillary dissection versus no axillary dissection after positive sentinel node biopsy for early breast cancer.

METHODS

Patients who had undergone axillary dissection after positive sentinel node biopsy as part of breast conserving therapy were provided with a validated, self-rated questionnaire. The questionnaire comprised two trade-off questions to determine the maximum chance of developing arm side-effects from axillary dissection to justify the benefit of additional axillary staging information. Social, demographic, and clinical details were collected.

RESULTS

Ninety-nine of the 126 eligible patients returned the questionnaire and 76 completed the trade-off assessment. The median age of participants was 62 years. The median numbers of sentinel and axillary nodes removed were 2 and 12, respectively. Forty-seven percent of participants had arm swelling or tenderness of any severity. Seventy-five percent of participants would have axillary dissection even if the chance of arm side-effects like they had experienced was 100%.

CONCLUSION

Most patients with early breast cancer preferred axillary dissection after positive sentinel node biopsy for the additional staging information even though there was no survival benefit from axillary dissection.

Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.

A quantitative analysis of the performance of computing architectures used in neural simulations

BACKGROUND

Numerical solutions of neuron models are helping neuroscientists gain new insights into the behavior of neural systems. Although computing power is increasing, the complexity of the systems being simulated is also increasing. If the computation is not well matched to the computing hardware, simulations can take lengthy times to run, which can make it more difficult to draw inferences from those simulations and also to use them in feedback with living neurons such as in the dynamic clamp.

NEW METHOD

In this paper, we perform a quantitative analysis to get a better sense of how much impact the hardware architectures can have on simulation performance. Three different architectures are implemented on the same hardware platform and compared with respect to simulation time, error, and resources used.

RESULTS

The results indicate that a lookup table approach to evaluate functions can decrease simulation time by orders of magnitude with respect to the traditional approach of mathematical operations.

COMPARISON WITH EXISTING METHOD(S)

There are many different ways to implement a lookup table approach to evaluate a function. The method presented in this paper sacrifices some speed for greater generality and accuracy with respect to other published methods.

CONCLUSIONS

Lookup tables with 32 interpolation points can dramatically speed up computation time of neural simulations without adding significant error. In this paper linear interpolation was used, but higher order interpolation could be used to further reduce simulation time.

The Relationship Between Clinical and Indocyanine Green Staging in Lymphedema

Background: Multiple staging systems for classifying the severity of lymphedema exist. The International Society of Lymphology (ISL) stage is considered standard for clinical reporting, but the relationship between clinical and functional/imaging stage remains poorly defined. Materials and Methods: We reviewed the prospectively collected data of all patients who underwent physiologic lymphedema surgery for a 3-year period by the senior author. Patients who underwent preoperative clinical staging with limb volume calculations and intraoperative indocyanine green (ICG) staging were included. Correlations were examined between ISL stage, ICG stage, and preoperative volume difference. Results: A total of 212 patients met inclusion criteria. ISL stage and preoperative volume difference had a Pearson correlation coefficient of 0.579 [p < 0.001, 95% confidence intervals, CIs (0.479-0.664)]; ICG stage and preoperative volume difference had a Pearson correlation coefficient of 0.338 [p < 0.001, 95% CIs (0.204-0.460)]; and ISL stage and ICG stage had a Pearson correlation coefficient of 0.254 [p < 0.001, 95% CIs (0.114-0.383)]. Conclusion: Clinical ISL stage does not correlate well with ICG stage in patients undergoing physiologic lymphedema surgery.

Genetic associations of T cell cancer immune response with tumor aggressiveness in localized prostate cancer patients and disease reclassification in an active surveillance cohort

Determining prostate cancer (PCa) aggressiveness and reclassification are critical events during the treatment of localized disease and for patients undergoing active surveillance (AS). Since T cells play major roles in cancer surveillance and elimination, we aimed to identify genetic biomarkers related to T cell cancer immune response which are predictive of aggressiveness and reclassification risks in localized PCa. The genotypes of 3,586 single nucleotide polymorphisms (SNPs) from T cell cancer immune response pathways were analyzed in 1762 patients with localized disease and 393 who elected AS. The aggressiveness of PCa was defined according to pathological Gleason score (GS) and D'Amico criteria. PCa reclassification was defined according to changes in GS or tumor characteristics during subsequent surveillance biopsies. Functional characterization and analysis of immune phenotypes were also performed. In the localized PCa cohort, seven SNPs were significantly associated with the risk of aggressive disease. In the AS cohort, another eight SNPs were identified as predictors for aggressiveness and reclassification. Rs1687016 of PSMB8 was the most significant predictor of reclassification. Cumulative analysis showed that a genetic score based on the identified SNPs could significantly predict risk of D'Amico high risk disease (P-trend = 2.4E-09), GS4 + 3 disease (P-trend = 1.3E-04), biochemical recurrence (P-trend = 0.01) and reclassification (P-trend = 0.01). In addition, the rs34309 variant was associated with functional somatic mutations in the PI3K/PTEN/AKT/MTOR pathway and tumor lymphocyte infiltration. Our study provides plausible evidence that genetic variations in T cell cancer immune response can influence risks of aggressiveness and reclassification in localized PCa, which may lead to additional biological insight into these outcomes. Abbreviations: PCa, prostate cancer; AS, active surveillance; GS, Gleason score; PSA, prostate specific antigen; TCGA, The Cancer Genome Atlas; SNP, single nucleotide polymorphisms; UFG, unfavorable genotype.

Global and Targeted miRNA Expression Profiling in Clear Cell Renal Cell Carcinoma Tissues Potentially Links miR-155-5p and miR-210-3p to both Tumorigenesis and Recurrence

About 30% of patients undergoing nephrectomy for renal cell carcinoma (RCC) experience disease recurrence. We profiled miRNAs dysregulated in clear-cell (cc) RCC tumor tissues and predictive of recurrence. The expression levels of 800 miRNAs were assessed in paired tumor and normal tissues from a discovery cohort of 18 ccRCC patients. miRNAs found to be differentially expressed were examined in a validation set of 205 patients, using real-time quantitative PCR. Tumor-normal data from 64 patients in The Cancer Genome Atlas were used for external validation. Twenty-eight miRNAs were consistently dysregulated in tumor tissues. On dichotomized analysis, patients with high levels of miR-155-5p and miR-210-3p displayed an increased risk for ccRCC recurrence (hazard ratio, 2.64; 95% CI, 1.49 to 4.70; P = 0.0009; and hazard ratio, 1.80; 95% CI, 1.04 to 3.12; P = 0.036, respectively) and a shorter median recurrence-free survival time than did patients with low levels [P < 0.01 (log rank test)]. A risk score was generated based on the expression levels of miR-155-5p and miR-210-3p, and the trend test was significant (P = 0.005). On pathway analysis, target genes regulated by miR-155-5p and miR-210-3p were mainly enriched in inflammation-related pathways. We identified and validated multiple miRNAs dysregulated in ccRCC tissues; miR-155-5p and miR-210-3p were predictive of ccRCC recurrence, pointing to potential utility as biomarkers and underlying biological mechanisms.

Abstract 3011: Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma

Background Quality of life (QOL) is impaired in pancreatic cancer patients. Our aim was to investigate the determinants and prognostic value of QOL after diagnosis in a hospital-based cohort of racially/ethnically diverse patients with pancreatic ductal adenocarcinoma (PDAC). Patients and methods QOL was prospectively assessed using the Short Form-12 version 1 in 2478 PDAC patients. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were categorized into tertiles based on their distribution. Ordered logistic regression was adopted to compare the risk of having lower PCS and MCS by patient sociodemographic and clinical characteristics. The association of PCS and MCS with mortality was assessed by Cox regression. Results Compared with non-Hispanic whites, Hispanics were at significantly higher risk of having lower PCS (odds ratio [95%CI], 1.69 [1.26-2.26]; P &lt; .001) and lower MCS (1.66 [1.24-2.23]; P &lt; .001). Patients diagnosed with stage III (1.80 [1.10-2.94]; P = .02) and stage IV (2.32 [1.50-3.59]; P &lt; .001) were more likely to have lower PCS than were patients diagnosed with stage I. Other determinants included sex, age, drinking, smoking, education level, and comorbidities. The low tertile of PCS (hazard ratio [95%CI], 1.94 [1.72-2.18]; P &lt; .001) and MCS (1.42 [1.26-1.59]; P &lt; .001) were each related to poor prognosis. Similar results were found for non-Hispanic Whites as compared to African Americans/Hispanics/others. Conclusion QOL after diagnosis is a significant prognostic indicator for patients with PDAC, and multiple factors determine QOL, suggesting possible means of intervention to improve QOL and outcomes of PDAC patients.

Citation Format: Yang Deng, Huakang Tu, Jeanne A. Pierzynski, Ethan Miller, Maosheng Huang, Xiangjun Gu, David W. Chang, Yuanqing Ye, Michelle A. Hildebrandt, Alison P. Klein, Scott M. Lippman, Xifeng Wu. Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3011.

Lymphovenous Anastomosis Bypass Surgery

The field of lymphedema surgery has witnessed tremendous advancements over the years and has been coupled to the rapid growth of supermicrosurgical techniques. A lymphovenous bypass or lymphaticovenular anastomosis is a new technique that requires identification of patent, residual lymphatic channels and performing an anastomosis to a recipient venule, thereby allowing outflow of lymphatic fluid and improvement in a patient's lymphedema. This article provides a summary of the maturation of the technique, as well as the technical aspects of the approach and the current outcomes in the treatment of postmastectomy lymphedema.

Serum microRNAs as predictors of risk for non-muscle invasive bladder cancer

MicroRNAs (miRNAs) are implicated in the development of nearly all cancers and may function as promising biomarkers for early detection, diagnosis and prognosis. We sought to investigate the role of serum miRNAs as potential diagnostic biomarkers or biomarkers of risk for early-stage bladder cancer. First, we profiled global serum miRNAs in a pilot set of 10 non-muscle invasive bladder cancer (NMIBC) cases and 10 healthy controls matched on age, gender and smoking status. Eighty nine stably detectable miRNAs were selected for further testing and quantification by high-throughput Taqman analysis using the Fluidigm BioMark HD System to assess their association with NMIBC risk in both discovery and validation sets totaling 280 cases and 278 controls. We found miR-409-3p and six miRNAs expression ratios were significantly associated with risk of bladder cancer in both discovery and validation sets. Interestingly, we identified expression of miR-409-3p and miR-342-3p inversely correlated with age and age of onset of NMIBC. A risk score was generated based on the combination of three miRNA ratios (miR-29a-3p/miR-222-3p, miR-150-5p/miR-331-3p, miR-409-3p/miR-423-5p). In dichotomized analysis, we found individuals with high risk score showed increased risk of bladder cancer in the discovery, validation, and combined sets. Pathway enrichment analyses suggested altered miRNAs and cognate target genes are linked to the retinoid acid receptor (RAR) signaling pathway. Overall, these results suggested specific serum miRNA signatures may serve as noninvasive predictors of NMIBC risk. Biological insights underlying bladder cancer development based on the pathway enrichment analysis may reveal novel therapeutic targets for personalized medicine.

Genetic variations in cancer-related significantly mutated genes and lung cancer susceptibility

Background

Cancer initiation and development are driven by key mutations in driver genes. Applying high-throughput sequencing technologies and bioinformatic analyses, The Cancer Genome Atlas (TCGA) project has identified panels of somatic mutations that contributed to the etiology of various cancers. However, there are few studies investigating the germline genetic variations in these significantly mutated genes (SMGs) and lung cancer susceptibility.

Patients and methods

We comprehensively evaluated 1655 tagged single nucleotide polymorphisms (SNPs) located in 127 SMGs identified by TCGA, and test their association with lung cancer risk in large-scale case-control study. Functional effect of the validated SNPs, gene mutation frequency and pathways were analyzed.

Results

We found 11 SNPs in 8 genes showed consistent association (P < 0.1) and 8 SNPs significantly associated with lung cancer risk (P < 0.05) in both discovery and validation phases. The most significant association was rs10412613 in PPP2R1A, with the minor G allele associated with a decreased risk of lung cancer [odds ratio = 0.91, 95% confidence interval (CI): 0.87-0.96, P = 2.3 × 10-4]. Cumulative analysis of risk score built as a weight sum of the 11 SNPs showed consistently elevated risk with increasing risk score (P for trend = 9.5 × 10-9). In stratified analyses, the association of PPP2R1A:rs10412613 and lung cancer risk appeared stronger among population of younger age at diagnosis and never smokers. The expression quantitative trait loci analysis indicated that rs10412613, rs10804682, rs635469 and rs6742399 genotypes significantly correlated with the expression of PPP2R1A, ATR, SETBP1 and ERBB4, respectively. From TCGA data, expression of the identified genes was significantly different in lung tumors compared with normal tissues, and the genes' highest mutation frequency was found in lung cancers. Integrative pathway analysis indicated the identified genes were mainly involved in AKT/NF-κB regulatory pathway suggesting the underlying biological processes.

Conclusion

This study revealed novel genetic variants in SMGs associated with lung cancer risk, which might contribute to elucidating the biological network involved in lung cancer development.

Global and targeted circulating microRNA profiling of colorectal adenoma and colorectal cancer

BACKGROUND

Circulating microRNAs (miRNAs) are emerging as promising biomarkers for cancer. The objective of the current study was to investigate the potential of circulating cell-free miRNAs as biomarkers for colorectal cancer (CRC) and its precursor lesion, colorectal adenoma.

METHODS

The serum levels of 800 miRNAs were assessed in a discovery set of 21 patients with CRC, 19 patients with adenoma, and 21 healthy controls using the NanoString miRNA analysis platform. Significantly differentially expressed miRNAs were examined further in a validation cohort of 34 patients with CRC, 33 patients with adenoma, and 35 healthy controls using Fluidigm quantitative polymerase chain reaction assays.

RESULTS

The ratios between the expression values of the differentially expressed miRNAs were computed. Three miRNA ratios (miR-17-5p/miR-135b, miR-92a-3p/miR135b, and miR-451a/miR-491-5p) were validated for discriminating patients with adenoma and those with CRC from the healthy control group, and 5 miRNA ratios (let-7b/miR-367-3p, miR-130a-3p/miR-409-3p, miR-148-3p/miR-27b, miR-148a-3p/miR-409-3p, and miR-21-5p/miR-367-3p) were validated for discriminating patients with CRC from those with adenoma and healthy controls. The area under the receiver operating characteristic curve values for the 3 miRNA ratios in discriminating patients with adenoma from healthy controls were 0.831 and 0.735, respectively, in the discovery and validation sets. The area under the receiver operating characteristic curve values for the 5 miRNA ratios in discriminating patients with CRC from those with adenoma were 0.797 and 0.732, respectively, in the discovery and validation sets. Pathway analysis revealed that target genes regulated by the miRNAs from the miRNA ratios were enriched mainly in metabolism-related and inflammation-related pathways.

CONCLUSIONS

The data from the current study suggest that circulating miRNAs can distinguish patients with CRC and those with adenoma and may represent novel biomarkers for the early, noninvasive detection of CRC. Cancer 2018;124:785-96. © 2017 American Cancer Society.

Circulating metabolite profiles to predict overall survival in advanced non-small cell lung cancer patients receiving first-line chemotherapy

OBJECTIVES

The prognosis for advanced-stage non-small cell lung cancer (NSCLC) is usually poor. However, survival may be variable and difficult to predict. In the current study, we aimed to identify circulating metabolites as potential predictive biomarkers for overall survival of advanced-stage (III/IV) NSCLC patients treated with first-line platinum-based chemotherapy.

MATERIALS AND METHODS

Using two-stage study design, we performed global metabolomic profiling in blood of 220 advanced-stage NSCLC patients, including 110 with poor survival and 110 with good survival. Metabolomic profiling was conducted using Metabolon platform. The association of each metabolite with survival was assessed by Cox proportional hazard regression model with adjustment for covariates.

RESULTS AND CONCLUSION

We found levels of 4 metabolites, caffeine, paraxanthine, stachydrine, and methyl glucopyranoside (alpha+beta), differed significantly between NSCLC patients with poor and good survival in both discovery and validation phases (P<0.05). Interestingly, majority of the identified metabolites are involved in caffeine metabolism, and 2 metabolites are related to coffee intake. In fact, caffeine metabolism pathway was the only significant pathway identified which significantly differed between NSCLC patients with poor and good survival (P=1.48E-07) in the pathway analysis. We also found 4 metabolites whose levels were significantly associated with good survival in both discovery and validation phases. Strong cumulative effects on overall survival were observed for these 4 metabolites. In conclusion, we identified a panel of metabolites including metabolites in caffeine metabolism pathway that may predict survival outcome in advanced-stage NSCLC patients. The identified small metabolites may be useful biomarker candidates to help identify patients who may benefit from platinum-based chemotherapy.

Genetic variants in the inflammation pathway as predictors of recurrence and progression in non-muscle invasive bladder cancer treated with Bacillus Calmette-Guérin

Inflammation plays a critical role in the etiology of several cancers and may affect their clinical outcome. Our objective was to assess the association of genetic variants within the inflammation pathway with recurrence and progression among non-muscle invasive bladder cancer (NMIBC) patients with or without Bacillus Calmette–Guérin (BCG) treatment. We genotyped 372 single nucleotide polymorphisms (SNPs) in 27 selected genes within the inflammation pathway in 349 patients diagnosed with NMIBC, followed by internal validation in 322 additional patients. We used Cox proportional hazards regression analyses to identify SNPs as predictors for recurrence and progression. In the discovery phase, we identified 20 variants that were significantly associated with recurrence outcomes and 15 SNPs significantly associated with progression in patients treated with BCG but not in the transurethral resection (TUR)-only group. In BCG treated patients, rs7089861 was the only SNP significantly associated with risk of progression in both the discovery phase (Hazard Ratio [HR]=3.15, 95% Confidence Interval [CI]: 1.38-7.22, P<0.01) and validation phase (HR=3.84, 95% CI: 1.64-9.0, P=0.002; meta-analysis HR=3.47, 95% CI: 1.92-6.28, P<0.001). Two variants, rs1800686 and rs2071081, had probable association with HRs of the same trend in the discovery and validation groups (meta-analysis P=0.002). These findings supported the notion that genetic variation of inflammation pathway may impact clinical outcome of NMIBC patients treated with BCG immunotherapy. Further validation of these results in order to improve risk stratification to identify patients most likely to benefit from BCG treatment versus upfront radical cystectomy and future development of potential targeted therapies are warranted.

Abstract 1275: Genetic variations in cancer-related significantly mutated genes and lung cancer susceptibility

Cancer initiation and development are driven by key mutations in driver genes. Applying high-throughput sequencing technologies and bioinformatics analyses, The Cancer Genome Atlas (TCGA) project has recently identified panels of genetic mutations that contributed to or associated with the etiology of various cancers. However, there are few studies investigating the germline genetic variations in these highly mutated genes and lung cancer susceptibility. In this multi-phase study, we aimed to comprehensively evaluate the 1655 tagSNPs located in the 127 significantly mutated genes (SMGs) identified by TCGA, and test their association with risk of lung cancer in a total of 7355 patients and 7301 healthy controls. We found that 11 SNPs in 8 genes showed consistent association (P&lt;0.1) and 8 SNPs significantly associated with lung cancer risk (P&lt;0.05) in both discovery and validation phases. The most significant SNP A was associated with a decreased risk of lung cancer (OR=0.91, 95%CI: 0.87-0.96, P=2.3×10-4). Cumulative analysis of the 11 SNPs showed consistently elevated risk with increasing number of unfavorable genotypes (P for trend=1.2×10-10). In stratified analyses, the association of SNP A and lung cancer risk appeared stronger among population of younger age at diagnosis and never smokers. The eQTL-analysis indicated that genotypes of four SNPs significantly correlated with the expression of their genes respectively. From TCGA data, expression of the identified genes were significantly different in lung tumors compared with normal tissues, and the genes’ highest mutation frequency was found in lung cancers. Integrative pathway analysis (IPA) indicated the identified genes were mainly involved in major cell cycle regulatory pathway suggesting the underlying biological processes. In summary, this study revealed novel genetic variants in SMGs associated with lung cancer risk, which might contribute to elucidating the biological network involved in lung cancer development.

Citation Format: Liren Zhang, Yanwei Zhang, Rong Li, David W. Chang, Yuanqing Ye, John D. Minna, Jack A. Roth, Baohui Han, Xifeng Wu. Genetic variations in cancer-related significantly mutated genes and lung cancer susceptibility [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1275. doi:10.1158/1538-7445.AM2017-1275

Global and targeted serum metabolic profiling of colorectal cancer progression

BACKGROUND

Patients with colorectal adenoma polyps (PLPs) are at higher risk for developing colorectal cancer (CRC). However, the development of improved and robust biomarkers to enable the screening, surveillance, and early detection of PLPs and CRC continues to be a challenge. The aim of this study was to identify biomarkers of progression to CRC through metabolomic profiling of human serum samples with a multistage approach.

METHODS

Metabolomic profiling was conducted with the Metabolon platform for 30 CRC patients, 30 PLP patients, and 30 control subjects, and this was followed by the targeted validation of the top metabolites in an additional set of 50 CRC patients, 50 PLP patients, and 50 controls with liquid chromatography-tandem mass spectrometry. Unconditional multivariate logistic regression models, adjusted for covariates, were used to evaluate associations with PLP and CRC risk.

RESULTS

For the discovery phase, 404 serum metabolites were detected, with 50 metabolites showing differential levels between CRC patients, PLP patients, and controls (P for trend < .05). After validation, the 3 top metabolites (xanthine, hypoxanthine, and d-mannose) were validated: lower levels of xanthine and hypoxanthine and higher levels of d-mannose were found in PLP and CRC cases versus controls. A further exploratory analysis of metabolic pathways revealed key roles for the urea cycle and caffeine metabolism associated with PLP and CRC risk. In addition, a joint effect of the top metabolites with smoking and a significant interaction with the body mass index were observed. An analysis of the ratio of hypoxanthine levels to xanthine levels indicated an association with CRC progression.

CONCLUSIONS

These results suggest the potential utility of circulating metabolites as novel biomarkers for the early detection of CRC. Cancer 2017;123:4066-74. © 2017 American Cancer Society.

Implantable Doppler monitoring of buried free flaps during vascularized lymph node transfer

BACKGROUND AND OBJECTIVES

Reliable flap monitoring is crucial to the success of free tissue transfer, including vascularized lymph node transfer (VLNT). However, no large-scale study has examined implantable Doppler monitoring in VLNT. We aimed to determine whether an implantable Doppler system can reliably monitor flap perfusion during VLNT and also to calculate the sensitivity and specificity of this system for detecting compromise in the monitored vessel.

METHODS

An analysis of prospectively collected data of patients who underwent buried VLNT with implantable Doppler monitoring between 2014 and 2015 was performed.

RESULTS

A consecutive series of 100 patients underwent VLNT with implantable Doppler monitoring. Five cases required return to the operating room for flap exploration due to a change in Doppler signal quality. All compromised flaps were salvaged. The sensitivity of the implantable Doppler system for flap monitoring was 100%, the specificity was 97.9%, the positive predictive value was 60%, and the negative predictive value was 100%. The false-positive rate was 2%.

CONCLUSIONS

This is the largest reported series of implantable Doppler monitoring of free flap perfusion during VLNT. Our experience suggests that this is a safe and effective technique for postoperative monitoring of VLNT.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient

BACKGROUND AND OBJECTIVES

Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients.

METHODS

A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described.

RESULTS

Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy.

CONCLUSIONS

The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Latissimus dorsi flap with vascularized lymph node transfer for lymphedema treatment: Technique, outcomes, indications and review of literature

BACKGROUND AND OBJECTIVES

One of the surgical treatment options for lymphedema is vascularized lymph node transfer (VLNT). We present our experience with latissimus dorsi (LD) flap based VLNT for lymphedema treatment.

METHODS

We reviewed 14 consecutive patients treated with pedicled or free LD VLNT between 2014 and 2016 for recalcitrant upper or lower extremity lymphedema. Seven patients underwent lymphovenous bypass in addition to LD VLNT. Limb volume and quality of life scores using the Lymphedema Life Impact Scale (LLIS) were analyzed for quantitative and qualitative assessment.

RESULTS

Mean duration of lymphedema was 69 months (range 24-124 months). Follow-up ranged from 3 to 12 months (mean 6.7 month). Major complications included one free flap loss and one reoperation for thrombosis. Mean preoperative volume differential between normal and affected limb was 35% (range 3-87%). Volume differential reduction was 48%, 28%, and 46% at 3, 6, and 12 months, respectively. The LLIS score improved from mean of 46.8 before surgery to a mean of 38.6 at 12 month, demonstrating improvement in quality of life.

CONCLUSIONS

The LD VLNT provides a viable option for treatment of UE and LE lymphedema in selected patients. J. Surg. Oncol. 2017;115:72-77. © 2016 Wiley Periodicals, Inc.

Pathway analysis of bladder cancer genome-wide association study identifies novel pathways involved in bladder cancer development

Genome-wide association studies (GWAS) are designed to identify individual regions associated with cancer risk, but only explain a small fraction of the inherited variability. Alternative approach analyzing genetic variants within biological pathways has been proposed to discover networks of susceptibility genes with additional effects. The gene set enrichment analysis (GSEA) may complement and expand traditional GWAS analysis to identify novel genes and pathways associated with bladder cancer risk. We selected three GSEA methods: Gen-Gen, Aligator, and the SNP Ratio Test to evaluate cellular signaling pathways involved in bladder cancer susceptibility in a Texas GWAS population. The candidate genetic polymorphisms from the significant pathway selected by GSEA were validated in an independent NCI GWAS. We identified 18 novel pathways (P < 0.05) significantly associated with bladder cancer risk. Five of the most promising pathways (P ≤ 0.001 in any of the three GSEA methods) among the 18 pathways included two cell cycle pathways and neural cell adhesion molecule (NCAM), platelet-derived growth factor (PDGF), and unfolded protein response pathways. We validated the candidate polymorphisms in the NCI GWAS and found variants of RAPGEF1, SKP1, HERPUD1, CACNB2, CACNA1C, CACNA1S, COL4A2, SRC, and CACNA1C were associated with bladder cancer risk. Two CCNE1 variants, rs8102137 and rs997669, from cell cycle pathways showed the strongest associations; the CCNE1 signal at 19q12 has already been reported in previous GWAS. These findings offer additional etiologic insights highlighting the specific genes and pathways associated with bladder cancer development. GSEA may be a complementary tool to GWAS to identify additional loci of cancer susceptibility.