A phase II open-label randomized clinical trial of preoperative durvalumab or durvalumab plus tremelimumab in resectable head and neck squamous cell carcinoma

PURPOSE

Clinical implications of neoadjuvant immunotherapy in patients with locally advanced but resectable head and neck squamous cell carcinoma (HNSCC) remain largely unexplored.

PATIENTS AND METHODS

Patients with resectable HNSCC were randomized to receive a single dose of preoperative durvalumab (D) with or without tremelimumab (T) before resection, followed by postoperative (chemo)radiation based on multidisciplinary discretion and 1-year D treatment. Artificial intelligence (AI)-powered spatial distribution analysis of tumor-infiltrating lymphocytes and high-dimensional profiling of circulating immune cells tracked dynamic intratumoral and systemic immune responses.

RESULTS

Of the 48 patients enrolled (D: 24 patients, D+T: 24 patients), 45 underwent surgical resection per protocol (D: 21 patients; D+T: 24 patients). D+/-T had a favorable safety profile and did not delay surgery. Distant recurrence-free survival (DRFS) was significantly better in patients treated with D+T than in those treated with D monotherapy. AI-powered whole-slide image analysis demonstrated that D+T significantly reshaped the tumor microenvironment toward immune-inflamed phenotypes, in contrast to D monotherapy or cytotoxic chemotherapy. High-dimensional profiling of circulating immune cells revealed a significant expansion of T cell subsets characterized by proliferation and activation in response to D+T therapy, which was rare following D monotherapy. Importantly, expansion of specific clusters in CD8+ T cells and non-regulatory CD4+ T cells with activation and exhaustion programs was associated with prolonged DRFS in patients treated with D+T.

CONCLUSIONS

Preoperative D+/-T is feasible and may benefit patients with resectable HNSCC. Distinct changes in the tumor microenvironment and circulating immune cells were induced by each treatment regimen, warranting further investigation.

Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery

The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.

Neutrophil-lymphocyte ratio and hypersensitive C-reaction protein are associated with miscarriage during the second trimester of pregnancy

This study investigated whether biomarkers in the second trimester of pregnancy, including the white blood cell (WBC) count, neutrophil-lymphocyte ratio (NLR), hypersensitive C-reactive protein (hs-CRP) concentration, and procalcitonin (PCT) concentration, were associated with miscarriage during the second trimester of pregnancy. Sixty-two asymptomatic patients in their second trimester of pregnancy were included in the control group (group A). Among 67 patients diagnosed with late threatened miscarriage, 46 patients with ongoing pregnancy were included in group B and 21 patients with subsequent miscarriage were included in group C. The serum of these patients was collected and the biomarkers were analyzed. A paired-samples t-test was used for the comparison between the groups before and after the miscarriage. Statistical significance was set at p<0.05. Receiver operating characteristic curve (ROC) analysis was performed to evaluate the predictive value of different biomarkers for miscarriage during the second trimester of pregnancy. WBC count, neutrophil percentage, and hs-CRP levels were significantly higher in group C than in groups A and B (p<0.05). Lymphocyte percentage and albumin levels decreased significantly from group A to group C (p<0.05). In contrast, NLR increased significantly from group A to group C (p<0.05). There was a significant decrease in the WBC count, neutrophil percentage, hemoglobin concentration, and post-miscarriage NLR among the cases with miscarriage (p<0.05). The area under the curve of WBC count, NLR, hs-CRP, and the combination of these three factors for the prediction of late miscarriage varied from 78.0% to 82.6%. The combination of these three factors had the highest specificity of 91.1%, while hs-CRP had the highest sensitivity of 88.9%. WBC count, NLR, and hs-CRP levels are strongly associated with miscarriage during the second trimester of pregnancy, indicating that they are potential predictive biomarkers.

Effect of human acellular dermal matrix (Megaderm™) on infra-auricular depressed deformities, Frey's syndrome, and first bite syndrome following parotidectomy: a multi-center prospective study

Background

Parotidectomy is the primary treatment for parotid gland tumors. However, complications may include a prominent facial scar or infra-auricular depressed deformity, Frey's syndrome, first bite syndrome, or other facial pain, numbness, and paralysis. Acellular dermal matrix (ADM) has been widely used to prevent these complications in parotid surgery, but there have been no prospective, multi-center trials documenting its efficacy. This study evaluates the effectiveness of ADM implantation in preventing infra-auricular depressed deformity, Frey's syndrome and first bite syndrome after parotidectomy.

Methods

We analyzed 51 cases of standard parotidectomy and 58 cases of parotidectomy with implantation of Megaderm™ ADM through prospective multicenter trial. Acute complications including infection, seroma, hematoma, skin necrosis, and acute parotid area pain were evaluated 1 week postoperatively. Clinician grading of Frey's syndrome and blinded clinician evaluation of infra-auricular depressed deformities were conducted at 3, 6, and 12 months. Patients evaluated subjective satisfaction with neck appearance, Frey's syndrome quality, and acute parotid area pain at 3, 6, and 12 months.

Results

There was a higher incidence of seroma in the Megaderm™ group than in the control group at week 1. The incidence and total clinician-evaluated Frey's syndrome scores were significantly lower in the Megaderm™ group than in the control group at 3, 6, and 12 months. Both the objective and subjective evaluations of the facial contour showed a better outcome in the Megaderm™ group compared to the control group at 3, 6, and 12 months. There were no significant differences between the groups in the patient-reported Frey's syndrome quality scores at 3, 6, and 12 months, but the Megaderm™ group reported significantly less acute pain than the control group.

Conclusions

ADM implantation can effectively reduce the occurrence of Frey's syndrome, infra-auricular depressed deformity, and first bite syndrome after parotidectomy. ADM may be especially advantageous in complex parotidectomy cases when significant complications are expected.

Recent Treatment Patterns of Oropharyngeal Cancer in Korea Based on the Expert Questionnaire Survey of the Korean Society for Head and Neck Oncology (KSHNO)

Purpose

The incidence of human papillomavirus (HPV)-related oropharyngeal cancer (OPC) has increased, and staging and optimal therapeutic approaches are challenging. A questionnaire survey was conducted to investigate the controversial treatment policy of stage T2 OPC according to the N category and determine the opinions of multidisciplinary experts in Korea.

Materials and Methods

Five OPC scenarios were developed by the Subcommittee on Oropharyngeal Treatment Guidelines of the Korean Society for Head and Neck Oncology and distributed to experts of multidisciplinary treatment hospitals.

Results

Sixty-five experts from 45 institutions responded. For the HPV-positive T2N0M0 scenario, 67.7% of respondents selected surgery followed by definitive concurrent chemoradiotherapy (CCRT) or radiotherapy alone. For the T2N1M0 HPV-positive scenario, there was a notable difference in the selection of primary treatment by expert specialty; 53.9% of respondents selected surgery and 39.8% selected definitive CCRT as the primary treatment. For the T2N3M0 advanced HPV-positive scenario, 50.0% of respondents selected CCRT and 33.3% considered induction chemotherapy (IC) as the primary treatment. CCRT and IC were significantly more frequently selected for the HPV-related OPC cases (p=0.010). The interdepartmental variability showed that the head and neck surgeons and medical oncologists favored surgery, whereas the radiation oncologists preferably selected definitive CCRT (p < 0.001).

Conclusion

In this study, surgery was preferred for lymph node-negative OPC, and as lymph node metastasis progressed, CCRT tended to be preferred, and IC was administered. Clinical practice patterns by stage and HPV status showed differences according to expert specialty. Multidisciplinary consensus guidelines will be essential in the future.

Effects of Intratympanic Injection of Isosorbide on the Vestibular Function of Animal Models of Endolymphatic Hydrops

Objectives

The aims of this study were to investigate the effects of intratympanic injections of isosorbide on vestibular function in animal models of endolymphatic hydrops and to find a new treatment option for the acute onset of vertigo in Ménière disease (MD).

Methods

Seventy male guinea pigs received intratympanic injection of isosorbide (IT-ISB). The animals were divided into three study groups: control, a chronic hydrops model, and an acute hydrops model. Intracochlear drug concentrations were measured using high-performance liquid chromatography. Vestibular function was analyzed using an animal rotator test with bidirectional sinusoidal harmonic acceleration before and after IT-ISB administration. Histological changes were also investigated.

Results

ISB successfully permeated the perilymph through the round window membrane (RWM) at all three concentrations (25%, 50%, and 100%). In the chronic hydrops model, while IT-ISB histologically induced a reduction of endolymphatic hydrops, vestibular function was unchanged. In the acute hydrops model, no endolymphatic hydrops was histologically observed, and vestibular symmetry was also preserved after IT-ISB.

Conclusion

ISB passed through the RWM into the perilymphatic space even at lower concentrations. IT-ISB histologically reduced hydrops in the chronic model and preserved symmetrical vestibular function in the acute model. IT-ISB could be a treatment candidate for acute attacks of vertigo in MD.

Prognostic value of trafficking of regulatory T cells to tumors in head and neck cancer patients

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Background: The prognostic value of regulatory T cells (Tregs) in head and neck squamous cell carcinoma (HNSCC) remains unknown. We analyzed the prognostic effect of Tregs in HNSCC with immune activity scores, which reflect the activity status of the seven-step cancer-immunity cycle. Methods: We correlated the 23 immune activity scores and clinicopathologic features of The Cancer Genome Atlas (TCGA) HNSCC using multivariate Cox regression analyses and Kaplan-Meier survival curves. The processed data of immune activity scores were obtained from TIP online tool and the clinicopathologic data were downloaded from TCGA HNSCC database. Results: Immune activity scores of “trafficking of Tregs to tumors” was significantly associated with overall survival (OS) and progression-free survival (PFS). Low activity scores of “trafficking of Tregs to tumors” resulted in shorter OS and PFS. In multivariate analysis, low scores predicted poor OS (adjusted HR = 1.87, 95% CI 1.34-2.60 ; P < 0.001) and were related with unfavorable PFS (adjusted HR = 2.04, 95% CI 1.45-2.86 ; P < 0.001). Conclusions: Immune activity scores of “trafficking of Tregs to tumors” was independent significant prognostic factor in HNSCC. Therefore, assessment of immune activity scores may be useful tools for predicting prognosis in these patients.

Safety of esophagogastroduodenoscopy-guided forceps biopsy and the feasibility of esophagogastroduodenoscopy for evaluation of hypopharyngeal cancer

Background

There is currently no established standard tissue sampling method for hypopharyngeal cancer. The present study aimed to evaluate the feasibility of esophagogastroduodenoscopy (EGD) for the pretreatment evaluation of hypopharyngeal cancer and the safety of EGD-guided forceps biopsy.

Methods

We reviewed nine patients with hypopharyngeal cancer who underwent EGD for the evaluation of tumor extent and tissue biopsy from March 2014 to March 2017 at International St. Mary’s Hospital. One experienced endoscopist performed all the EGD procedures in the presence of a head and neck surgeon. The procedure included determining tumor location, extent (presence of pyriform sinus apex involvement), and size, and passing the endoscope through the upper esophageal sphincter. The success rate of tissue sampling was assessed, and procedure-related complications were recorded.

Results

All patients were male, with a mean age of 69.9 ± 10.9 years (range 61–69 years). Tissue sampling using biopsy forceps was performed in 6/9 patients (66.7%). No complications related to moderate sedation or biopsy, including post-biopsy bleeding or respiratory distress, were reported. Histologic confirmation was successful in 5/6 patients (83.3%). Upper gastrointestinal lesions were evaluated in 7/9 (77.8%) patients in whom the scope passed through the lesion.

Conclusions

EGD and EGD-guided forceps biopsy may be useful for the evaluation of hypopharyngeal cancer extent and tissue sampling, respectively.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0571-z) contains supplementary material, which is available to authorized users.

Establishment of a Gallbladder Cancer-Specific Survival Model to Predict Prognosis in Non-metastatic Gallbladder Cancer Patients After Surgical Resection

BACKGROUND

Gallbladder cancer is an invasive cancer with a discouraging prognosis, and early detection and active intervention are of great value.

AIMS

To establish a more accurate and effective survival model to predict the prognosis of patients with non-metastatic gallbladder after surgical resection.

METHODS

A retrospective analysis was conducted in non-metastatic gallbladder cancer patients who were registered in the surveillance, epidemiology and end results database from 2010 to 2014. Univariate analysis and multivariate analysis were performed for the related factors that might affect the gallbladder cancer-specific survival. A prognostic gallbladder cancer-specific survival model was established using the nomogram tool. The discrimination test was measured by the c-index, and the conformance test was performed by a calibration curve.

RESULTS

In all, 1422 patients with non-metastatic gallbladder cancer were identified. The prognostic factors include age, gender, lymph node dissection, postoperative chemotherapy, tumor size, histological grading, pT stage and pN stage. The gallbladder cancer-specific survival model was established based on the prognostic factors. The model's c-index was 0.775, and the 7th AJCC staging c-index was 0.649. The calibration curves showed a good correlation between prediction and actual survival.

CONCLUSIONS

This study established the gallbladder cancer-specific survival model successfully. Compared with the 7th AJCC stage, this model refined the contribution of the pT stage, pN stage and other related factors and was demonstrated to be more accurate and reliable. More importantly, this model may allow clinicians to screen patients with a poor prognosis for closer follow-up or adjuvant treatment.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Prognostic Factors and Treatment Outcomes of Parotid Gland Cancer

Objective

To investigate the treatment outcomes of parotid gland cancer at a single center over a 10-year period and to evaluate the prognostic significance of maximum standardized uptake value.

Study Design

Retrospective case series with chart review.

Setting

Academic care center.

Subjects and Methods

Ninety-eight patients with primary parotid gland cancer who were surgically treated at Yonsei University Head & Neck Cancer Clinic between January 1999 and December 2008 were analyzed. Patient data were collected retrospectively from medical charts. The investigators analyzed the association of clinicopathological factors and maximum standardized uptake value on 18F-fluorodeoxyglucose positron emission tomography–computed tomography scan with disease-specific survival.

Results

Mean patient age was 49.7 years. Mean follow-up was 48.8 months. Thirty-three, 40, 30, and 23 patients had stage I, II, III, and IVA disease, respectively. Mucoepidermoid carcinoma was the most common histologic type (34.7%), followed by acinic cell carcinoma (27.6%). Eighteen patients (18.4%) experienced recurrences (mean recurrence gap, 20.6 months; range, 2-87 months). Five- and 10-year disease-specific survival rates were 93.6% and 81.8%, respectively. In the univariate analysis, pathologic T stage, pathologic lymph node status, resection margin, external parenchymal extension, and maximum standardized uptake value were significantly associated with disease-specific survival. Pathologic lymph node status and maximum standardized uptake value were independent prognostic factors in the multivariate analysis.

Conclusion

Our single-center experience with parotid gland cancer treatment is consistent with the literature. Cervical lymph node metastasis and high maximum standardized uptake value are associated with poor survival in parotid gland cancer.

Tetrafluoroethane (R134a) hydrate formation within variable volume reactor accompanied by evaporation and condensation

Vast size hydrate formation reactors with fast conversion rate are required for the economic implementation of seawater desalination utilizing gas hydrate technology. The commercial target production rate is order of thousand tons of potable water per day per train. Various heat and mass transfer enhancement schemes including agitation, spraying, and bubbling have been examined to maximize the production capacities in scaled up design of hydrate formation reactors. The present experimental study focused on acquiring basic knowledge needed to design variable volume reactors to produce tetrafluoroethane hydrate slurry. Test vessel was composed of main cavity with fixed volume of 140 ml and auxiliary cavity with variable volume of 0 ∼ 64 ml. Temperatures at multiple locations within vessel and pressure were monitored while visual access was made through front window. Alternating evaporation and condensation induced by cyclic volume change provided agitation due to density differences among water and vapor, liquid and hydrate R134a as well as extended interface area, which improved hydrate formation kinetics coupled with latent heat release and absorption. Influences of coolant temperature, piston stroke/speed, and volume change period on hydrate formation kinetics were investigated. Suggestions of reactor design improvement for future experimental study are also made.

Conversion of twice-daily tacrolimus to once-daily tacrolimus formulation in stable pediatric kidney transplant recipients: pharmacokinetics and efficacy

The pharmacokinetics, efficacy and safety of once-daily tacrolimus formulation (Tac-OD) were assessed in 34 stable pediatric kidney transplant recipients. Enrolled patients received their dose of twice-daily tacrolimus formulation (Tac-BID) on study Days 0 through 7. On the morning of study Day 8, the total daily doses for patients were converted to Tac-OD on a 1:1 basis and maintained on a once-daily morning dosing regimen. Tacrolimus pharmacokinetic profiles were obtained on study Days 7, 14 and 28 (after dose adjustment). Although the mean C0 concentrations (4.10 ± 1.16-3.53 ± 1.10 ng/mL, p = 0.004), and AUC0-24 (151.8 ± 41.6-129.8 ± 39.3 ng h/mL, p < 0.001) were decreased significantly after a 1:1 based conversion, there was high interindividual variability. The dose of Tac-OD was decreased in 26.5% and increased in 44.1% of patients. The resultant tacrolimus dose and pharmacokinetic profiles on study Day 28 were comparable to those on Day 7. There were no serious adverse events. In conclusion, Tac-BID can be safely converted to Tac-OD in stable pediatric kidney transplant patients with the heightened therapeutic drug monitoring. Effects of drug conversion on the cardiovascular risk factors, neurological side effects and adherence should be further evaluated.

Human antibodies targeting the C-type lectin-like domain of the tumor endothelial cell marker clec14a regulate angiogenic properties in vitro

It has been suggested that clec14a may be involved in tumor angiogenesis. However, a molecular mechanism has not been clearly identified. In this study, we show for the first time that C-type lectin-like domain (CTLD) of clec14a may be important for regulating cell migration and filopodia formation. Using phage display technology, recombinant human antibodies specific to the CTLDs of human and mouse clec14a (clec14a-CTLD (immunoglobulin G) IgG) were selected. Functional assays using the antibodies showed that clec14a-CTLD IgGs specifically blocked endothelial cell migration and tube formation without affecting cell viability or activation. Further, clec14a-CTLD IgGs inhibited clec14a-mediated cell–cell contact by blocking interaction between CTLDs. Finally, clec14a cross-linking by the clec14a-CTLD IgGs significantly downregulated clec14a expression on the surface of endothelial cells. These results strongly suggest that the clec14a-CTLD may be a key domain in angiogenesis, and that clec14a-CTLD IgGs specifically inhibit angiogenesis by modulating CTLD-mediated cell interactions and clec14a expression on the surface of endothelial cells.

Use of Pulsed Dye Laser in the Treatment of Sulcus Vocalis

Objective

The pulsed dye laser (PDL) has been shown to be effective in the treatment of hypertrophic scars and keloids in dermatology. On the basis of histopathologic similarities between sulcus vocalis and scar tissue and numerous reports on the treatment of laryngeal lesions, especially scar tissue, with PDL, we evaluated the efficacy of treating sulcus vocalis with PDL. We named this surgical procedure PDL glottoplasty.

Study Design

Case series with planned data collection.

Setting

A university-based, tertiary care medical center.

Subjects and Methods

This study was conducted on 25 patients diagnosed with sulcus vocalis by videostroboscopy at the Gangnam Severance Hospital Otorhinolaryngology Department between August 2006 and February 2012. Energy delivery was fixed at 0.75 Joules (J) per pulse, and each vocal fold was administered 60 to 110 pulses (average 72.5 pulses) during each procedure. Aerodynamic, stroboscopic, and acoustic voice analyses were performed pre- and postoperatively.

Results

Although assessment was necessarily subjective, our study indicated that vocal folds showed decreased stiffness and improved mucosal wave properties after treatment, resulting in improved vibration and dysphonia. In the objective assessments, most patients who underwent PDL glottoplasty showed improvement in several postoperative voice analysis indices. The differences between preoperative and some postoperative voice parameter indices were statistically significant.

Conclusion

We found PDL glottoplasty to be beneficial in the treatment of sulcus vocalis. Objective measurements of voice quality and normalization of vocal fold vibration improved after PDL treatment in most cases. Our results warrant further studies with larger numbers of participants and longer follow-up periods.

Gasless transaxillary robot-assisted neck dissection: a preclinical feasibility study in four cadavers

PURPOSE

We hypothesized that comprehensive neck dissection could be achieved via a gasless transaxillary approach using a robotic system. We intended to evaluate the accessibility of level I, IIB and VA nodes with transaxillary robot-assisted neck dissection of four cadavers.

MATERIALS AND METHODS

Transaxillary robotic neck dissection was performed in four cadavers through a 7-cm longitudinal incision at the anterior axilla and a 0.8-cm-sized incision in the chest wall.

RESULTS

We successfully performed neck dissection from level II to V in all four cadavers. However, dissection of levels IIB and VA, which lie on the cephalic portion of the spinal accessory nerve, was difficult. Vital structures, including the internal jugular vein, carotid artery, vagus nerve, phrenic nerve, superior thyroid artery and hypoglossal nerve, were successfully identified and preserved.

CONCLUSION

Our results demonstrate the feasibility of robot-assisted neck dissection using a transaxillary approach. We suggest that gasless, transaxillary robotic neck dissection is a promising technique for treating nodal metastasis in thyroid cancers or in selected squamous cell carcinomas of the head and neck. However, some modification of the approach might be needed when performing comprehensive neck dissections of all levels of the neck.

Early neurological outcomes according to CHADS2 score in stroke patients with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

A higher CHADS(2) score or CHA(2)DS(2)-VASc score is associated with an increased risk of ischaemic stroke in patients with non-valvular atrial fibrillation (NVAF). However, there are no data regarding early neurological outcomes after stroke according to the risk levels.

METHODS

In this study, a total of 649 stroke patients with NVAF were enrolled and categorized into three groups: low-risk (CHADS(2) score of 0-1), moderate-risk (CHADS(2) score 2-3), or high-risk group (CHADS(2) score ≥4). CHA(2)DS(2)-VASc score was divided into four groups including 0-1, 2-3, 4-5, and ≥6. We investigated whether there were differences in initial stroke severity, early neurological outcome, and infarct size according to CHADS(2) score or CHA(2)DS(2)-VASc score in stroke patients with NVAF.

RESULTS

The initial National Institutes of Health Stroke Scale (NIHSS) score was highest in high-risk group [9.5, interquartile range (IQR) 4-18], followed by moderate-risk (8, IQR 2-17) and low-risk group (6, IQR 2-15) (P=0.012). Likewise, initial stroke severity increased in a positive fashion with increasing the CHA(2)DS(2)-VASc score. During hospitalization, those in the high-risk group or higher CHA(2)DS(2)-VASc score had less improvement in their NIHSS score. Furthermore, early neurological deterioration (END) developed more frequently as CHADS(2) score or CHA(2)DS(2)-VASc score increased. Multivariate analysis showed being in the high-risk group was independently associated with END (OR 2.129, 95% CI 1.013-4.477).

CONCLUSIONS

Our data indicate that patients with NVAF and higher CHADS(2) score or CHA(2)DS(2)-VASc score are more likely to develop severe stroke and a worse clinical course is expected in these patients after stroke presentation.

Radiation Deteriorates Functional Outcome after Glossectomy

Objective: Quality of life could be deteriorated by surgical treatment of tongue cancer. Adjuvant therapy may also affect the functional outcome. Therefore, we intend to evaluate the influence of radiotherapy on the postoperative functional outcome after partial glossectomy with free flap reconstruction in early tongue cancer patients.

Method: We measured the functional outcome and reviewed the charts of 31 oral tongue cancer patients. We evaluated speech integrity with Diadochokinetic test (DDK). Mobility of tongue was checked with measurement of upward, protrusion, and lateral deviation distance. We also evaluated swallowing capacity with the M.D. Anderson Dysphagia Inventory.

Results: DDK rates of the surgery-only group and the postoperative radiotherapy group were 27.8 and 23.9, respectively, which was statistically different. Swallowing capacity was significantly superior in the surgery only group. Tongue mobility was not statistically different between the groups.

Conclusion: The functional outcome regarding speech and swallowing is negatively influenced by postoperative radiotherapy.

Endoscopic thyroidectomy via an axillo-breast approach without gas insufflation for benign thyroid nodules and micropapillary carcinomas: preliminary results

PURPOSE

To examine the feasibility of endoscopic thyroidectomy (ET) via an axillo- breast approach without gas insufflation for large thyroid tumors and micropapillary carcinomas.

MATERIALS AND METHODS

The patients in the benign group were separated into groups 1 (n=95, <4 cm in tumor diameter) and 2 (n=37, ≥4 cm in tumor diameter). Also, 57 patients in the micropapillary carcinoma group underwent an endoscopic hemithyroidectomy (HT) (group 3) and were compared with 60 patients who received conventional open HT (group 4). Postoperative functional outcome, local complications, surgical outcomes, and pathological outcomes were compared between the groups.

RESULTS

In the benign group, there was no significant difference in mean operating time, hospital stay, or overall perioperative complications between the two groups. In the micropapillary carcinoma group, mean operating time and hospital stay in group 3 were significantly longer than in group 4 (p=0.015 and p≤0.001). The overall perioperative complications did not differ significantly between the groups. The postoperative cosmetic result was better in groups 1-3 (endo group) than in group 4 (open group).

CONCLUSION

ET via a gasless axillo-breast approach seems to be a safe procedure even for benign thyroid lesions ≥4 cm and micropapillary carcinomas. Although it has the advantage of better cosmetic results over open thyroidectomy, there is room for improvement in terms of lessening its invasiveness and shortening the operative time.

Necessity of level IV dissection in cN0 hypopharyngeal carcinoma

CONCLUSIONS

We suggest that contralateral level IV dissection is not necessary in patients with cN0 hypopharyngeal squamous cell carcinoma (HPSCC).

OBJECTIVES

Elective treatment of neck nodes is very important in the management of cN0 HPSCC. A selective neck dissection neck level II to IV (SND II-IV) is widely accepted as an elective neck treatment of cN0 HPSCC. However, there has been a lot of effort to reduce the extent of surgery. Therefore, we investigated the incidence of level IV metastasis and regional recurrence in cN0 HPSCC.

METHODS

We performed a retrospective review of 40 patients who underwent SND II-IV as an elective treatment for cN0 HPSCC from 1992 to 2010.

RESULTS

In all, 30 bilateral and 10 unilateral SND II-IVs were performed in 40 patients. Of the 70 SND II-IV specimens, 15 specimens from 14 patients (21%) were revealed to have positive lymph node metastasis. Level IV was involved in 3 of 70 necks (4.2%), but no isolated or contralateral level IV metastasis was observed. Every case that had level IV metastasis also had positive nodes in level II or III. There was no case of postoperative chylous leakage and only one case of phrenic nerve palsy.

Abstract 4772: A novel agonist antibody to human death receptor 4, AY4, induces apoptotic cell death in head and neck cancer through ROS generation: in vitro and in vivo

Background : The proapoptotic tumor necrosis factor-related apoptosis inducing ligand (TRAIL) receptors death receptor (DR) 4 and DR5 are attractive targets to develop the receptorspecific agonistic monoclonal antibodies (mAb) as anticancer agents because of their tumor-selective cell death-inducing activity. Here, we describe the characterization of a novel agonistic mAb (AY4) against human DR4 and apoptosis through reactive oxygen species (ROS) production in head and neck cancer model.

Methods : The effects of AY4 in head and neck cell lines (KB, SNU899, HN9, FaDu) was studied on apoptosis using MTT assy, TUNEL, Annexin V assay and western blotting and was examed on the production of reactive oxygen species with DCFDA staining, intracellular signaling and animal model. In addition, we analyzed the anticancer effect of AY4 in nude mice xenograft model. In addition, drug toxicity (embryotoxicity and neurotoxicity) of AY4 were investigated in vivo zebrafish model.

Results: The DR4 was expressed in head and neck cancer cell lines by Flow cytometry (FACS) and western blotting. AY4 inhibited cell growth in KB and HN9 excluding SNU899 and FaDu and caused cell death via caspase-dependent apoptosis. The apoptotic cell death by AY4 decreased by N-acetylcysteine (NAC), an antioxidant, suggesting ROS generation involved in the cell death. Moreover, NAC and AY4 cotreatment augmented the reduced expression of antiapoptotic molecules, Bcl-XL and XIAP. In vivo administration of AY4 significantly inhibited tumor growth of head and neck cancer preestablished in athymic nude mice. In addition, in a zebrafish model used for toxicity testing, a considerable dose of AY4 did not result in embryotoxicity or neurotoxicity.

Conclusion : Our results demonstrates the effect of AY4 on apoptosis and tumor inhibition via ROS production and provide potential use of AY4 as an anticancer therapeutic agent in head and neck cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4772. doi:10.1158/1538-7445.AM2011-4772

Expression of the hepatitis B surface S and preS2 antigens in tubers of Solanum tuberosum

In an attempt to develop an edible vaccine, we transformed a recombinant hepatitis B virus (HBV) gene encoding the middle protein of HBV that contains the surface S and preS2 antigen into potato by Agrobacterium-mediated transformation. The HBV gene was under control of either the CaMV 35S promoter, the double 35S promoter with the AlMV 5' non-translated leader sequence, or the tuber-specific patatin promoter. HBV mRNA levels were higher with the 35S promoter than with the double 35S and patatin promoters; however, the levels of the S and preS2 antigen in the transformed tubers were higher with the patatin promoter than with the CaMV 35S and double promoters. The levels of preS2 antigen produced are the highest reported to date. Transgenic potato tubers were fed to mice, and the mice showed an immune response against the HBV S antigen.

Supplemention with tetrahydrobiopterin suppresses the development of hypertension in spontaneously hypertensive rats

It has been suggested that tetrahydrobiopterin (H(4)B), a cofactor of NO synthase, can reverse endothelial dysfunction caused by cardiovascular diseases, including atherosclerosis, coronary artery disease, and hypertension. Moreover, an impairment of H(4)B biosynthesis in spontaneously hypertensive rats (SHR) was observed. Thus, we hypothesized that the defect of the H(4)B synthesis system may play an important role in the development of hypertension in SHR. In the present study H(4)B (10 mg/kg per day IP) was used to treat SHR and Wistar-Kyoto rats (WKY) from the age of 5 through 16 weeks. Results demonstrated that chronic treatment with H(4)B significantly improved the impaired vascular responses to acetylcholine and suppressed the development of hypertension in SHR but did not affect WKY. The increase of inducible NO synthase expression, nitrotyrosine immunostaining, NO production, and superoxide anion formation in adult SHR were also significantly suppressed by chronic treatment with H(4)B. In contrast, H(4)B had no effect on WKY. In conclusion, this study demonstrated that H(4)B significantly attenuated the development of hypertension in SHR. The antihypertensive effect of H(4)B might be mediated through its direct antioxidant activity and/or decreasing oxygen free radical production from NO synthase, thereby reducing inducible NO synthase expression and peroxynitrite formation. Thus, the present study proposed that supplementation with H(4)B might be beneficial in preventing pathological conditions such as essential hypertension.

Inhibitory effect of endothelin-1 on the isoproterenol-induced chloride current in human cardiac myocytes

It is still controversial whether the cAMP-activated Cl(-) current (I(Cl,cAMP)) is expressed in human cardiomyocytes. The whole-cell configuration of the voltage-clamp technique was used to examine in detail the I(Cl,cAMP) in single human atrial and ventricular myocytes. Human cardiomyocytes were enzymatically isolated from atrial or ventricular specimens obtained from open-heart surgery or cardiac transplantation, respectively. Isoproterenol (1 microM) or forskolin (10 microM) was used to activate the cAMP second-messenger system. The isoproterenol- or forskolin-induced Cl(-) current was elicited in 12 of 54 atrial myocytes but was completely absent from ventricular myocytes. The isoproterenol-induced Cl(-) current in atrial myocytes was time-independent and had a reversal potential close to zero. Endothelin-1 (30 nM) inhibited the isoproterenol-induced Cl(-) current by 75+/-6% (n=4). This inhibitory effect of endothelin-1 was attenuated by pretreating atrial myocytes with the endothelin ET(A) receptor antagonist, BQ485, but not with the ET(B) receptor antagonist, BQ-788. The results provide evidence that the I(Cl,cAMP) exists in human atria, but not ventricle, and is inhibited by endothelin-1.

Purification and structural analysis of the hepatitis B virus preS1 expressed from Escherichia coli

The preS1 of hepatitis B virus (HBV) is located at the outermost part of the envelope protein and possesses several functionally important regions such as hepatocyte receptor-binding site and virus-neutralizing epitopes. As the first step to understand the structure-function relationship for the preS1 antigen, we have purified the preS1 and performed its structural characterization by circular dichroism (CD) spectroscopy. The preS1 was purified to near homogeneity from bacterially expressed glutathione S-transferase (GST)-preS1 fusion protein by two-step purification, affinity chromatography on glutathione-agarose column, and cation-exchange chromatography on Mono S column. The CD analysis showed that the purified preS1, which was largely unstructured in aqueous solution, acquired a significant (16%) alpha-helical structure when analyzed in 50% trifluoroethanol or 20 mM SDS. The results suggest that the preS1 assumes a mainly unstructured conformation and may form induced secondary structures upon binding to target proteins or under hydrophobic environment.

Modulation of actinorhodin biosynthesis in Streptomyces lividans by glucose repression of afsR2 gene transcription

While the biosynthetic gene cluster encoding the pigmented antibiotic actinorhodin (ACT) is present in the two closely related bacterial species, Streptomyces lividans and Streptomyces coelicolor, it normally is expressed only in S. coelicolor-generating the deep-blue colonies responsible for the S. coelicolor name. However, multiple copies of the two regulatory genes, afsR and afsR2, activate ACT production in S. lividans, indicating that this streptomycete encodes a functional ACT biosynthetic pathway. Here we report that the occurrence of ACT biosynthesis in S. lividans is determined conditionally by the carbon source used for culture. We found that the growth of S. lividans on solid media containing glucose prevents ACT production in this species by repressing the synthesis of afsR2 mRNA; a shift to glycerol as the sole carbon source dramatically relieved this repression, leading to extensive ACT synthesis and obliterating this phenotypic distinction between S. lividans and S. coelicolor. Transcription from the afsR2 promoter during growth in glycerol was dependent on afsR gene function and was developmentally regulated, occurring specifically at the time of aerial mycelium formation and coinciding temporally with the onset of ACT production. In liquid media, where morphological differentiation does not occur, ACT production in the absence of glucose increased as S. lividans cells entered stationary phase, but unlike ACT biosynthesis on solid media, occurred by a mechanism that did not require either afsR or afsR2. Our results identify parallel medium-dependent pathways that regulate ACT biosynthesis in S. lividans and further demonstrate that the production of this antibiotic in S. lividans grown on agar can be modulated by carbon source through the regulation of afsR2 mRNA synthesis.

Generation and characterization of a novel tetravalent bispecific antibody that binds to hepatitis B virus surface antigens

Hepatitis B virus (HBV) infection is a worldwide public health problem affecting about 350 million people. HBV envelope contains three surface antigens, called pre-S1, pre-S2 and S. For the prophylaxis of HBV infection, only an anti-S monoclonal antibody was tested for the protective efficacy against HBV infection, but it was shown to be incomplete. In addition, some immune escape mutants carrying mutations on the S antigen were reported. Therefore, a multivalent bispecific antibody rather than a single monoclonal antibody would be more beneficial for the prophylaxis of HBV infection. We have generated a novel tetravalent bispecific antibody with two binding sites for each of the S and pre-S2 antigens. Each of the antigen-binding sites was composed of a single-chain Fv (ScFv). The tetravalent antibody was generated by constructing a single gene encoding a single-chain protein. This protein consisted of an anti-S ScFv whose carboxyl end was tethered, through a 45 amino acid linker, to the amino terminus of anti-preS2 ScFv that in turn was joined to the hinge region of human gamma1 constant region. The single-chain protein was expressed in Chinese hamster ovary cells and secreted in culture supernatant as a homodimeric molecule. The tetravalent bispecific antibody showed both anti-S and anti-pre-S2 binding activities. In addition, the binding affinity of the bispecific antiboy for HBV particles was greater than that of either parental antibody. The tetravalent bispecific antibody is a potentially useful reagent for the prevention and treatment of HBV infection.

A humanized anti--4-1BB monoclonal antibody suppresses antigen-induced humoral immune response in nonhuman primates

The interaction of 4-1BB and its ligand plays an important role in the regulation of T-cell-mediated immune responses. In this study, the authors examined the effect of a humanized anti--4-1BB monoclonal antibody (H4B4) on ovalbumin-induced immune responses in baboons. Previously, a mouse monoclonal antibody, 4B4 against the human 4-1BB molecule, was generated and characterized. Based on this antibody, a humanized version of 4B4 monoclonal antibody was constructed and the resultant antibody, H4B4, showed full recovery of the binding activity of the original antibody 4B4: a 1.5-fold increase in affinity for 4-1BB. In addition, H4B4 mediated antibody-dependent cellular cytotoxicity of activated human peripheral blood T cells and CEM cells in a dose-dependent manner. Weekly administration of H4B4 at doses of 1 or 4 mg/kg could suppress immunoglobulin G production against ovalbumin. This was not a result of the overall immune suppression, because the numbers of B and T cells and the total immunoglobulin G production were not altered during treatment with H4B4. These findings suggest that treatment with H4B4 may be a valid therapeutic approach to control unwanted immune responses in persons with autoimmune diseases.

Fine mapping of virus-neutralizing epitopes on hepatitis B virus PreS1

We identified the epitopes on the preS1 which induce antibodies that neutralize both ad and ay subtypes of hepatitis B virus (HBV). Previously we generated murine monoclonal antibodies KR359 and KR127 that bind specifically to the preS1 of HBV. In this study we have performed fine mappings of the epitopes of the antibodies by examining their reactivity with GST fusion proteins, which contain a series of deletion mutants of the preS1. KR359 and KR127 specifically recognize aa 19-26 and 37-45 of the preS1, respectively. The antibodies neutralized both adr and ayw subtypes of the virus in an in vitro neutralization assay using in vitro infection of adult human hepatocyte primary culture by HBV. The epitopes showed little sequence divergence and the antibodies bound to the preS1 of all the HBV subtypes and variants tested.

Mouse monoclonal antibodies to hepatitis B virus preS1 produced after immunization with recombinant preS1 peptide

We have efficiently generated mouse monoclonal antibodies (MAbs), which bind specifically to amino acids 21-47 of the preS1 domain of hepatitis B virus (HBV) by immunizing mice with the preS1 peptide (amino acids, aa 1-56) conjugated to keyhole limpet hemocyanin. Hybridomas were screened by an indirect enzyme-linked immunosorbent assay (ELISA) using the purified preS1 peptide as a coated antigen. Eighteen positive hybridomas were selected and subjected to isotyping. Of these, 5 clones secreted immunoglobulin G (IgG) and 13 clones secreted IgM. Four (KR1, KR2, KR3, and KR4) of the 5 IgG MAbs bound to preS1 peptide (aa 21-47). Epitope mapping using bacterially expressed GST fusion proteins revealed that three clones (KR2, KR3, KR4) (IgG1, K) recognize aa 21-35, while KR1 (IgG2a, K) recognizes aa 35-47 of the preS1. These MAbs immunoprecipitated HBV particles, demonstrating that they bind to native HBV particles.

An 80-kilodalton protein that binds to the pre-S1 domain of hepatitis B virus

It has been suggested that hepatitis B virus (HBV) binds to a receptor on the plasma membrane of human hepatocytes via the pre-S1 domain of the large envelope protein as an initial step in HBV infection. However, the nature of the receptor remains controversial. In an attempt to identify a cell surface receptor for HBV, purified recombinant fusion protein of the pre-S1 domain of HBV with glutathione S-transferase (GST), expressed in Escherichia coli, was used as a ligand. The surface of human hepatocytes or HepG2 cells was biotinylated, and the cell lysate (precleared lysate) which did not bind to GST and glutathione-Sepharose beads was used as a source of receptor molecules. The precleared lysate of the biotinylated cells was incubated with the GST-pre-S1 fusion protein, and the bound proteins were visualized by Western blotting and enhanced chemiluminescence. An approximately 80-kDa protein (p80) was shown to bind specifically to the pre-S1 domain of the fusion protein. The receptor binding assay using serially or internally deleted segments of pre-S1 showed that amino acid residues 12 to 20 and 82 to 90 are essential for the binding of pre-S1 to p80. p80 also bound specifically to the pre-S1 of native HBV particles. Analysis of the tissue and species specificity of p80 expression in several available human primary cultures and cell lines of different tissue origin showed that p80 expression is not restricted to human hepatocytes. Taken together the results suggest that p80 may be a component of the viral entry machinery.

Expression and characterization of bioactive human thrombopoietin in the milk of transgenic mice

Human thrombopoietin (hTPO) is the primary physiological regulator of platelet production and plays a pivotal role in promoting the proliferation and maturation of megakaryocytic progenitor cells and megakaryocytes. In this study, transgenic mice were produced harboring either full-length or the erythropoietin (EPO)-like amino-terminal domain of hTPO cDNA sequences fused to the regulatory elements of the bovine beta-casein gene. The transgene RNA was expressed exclusively in the mammary glands of eight transgenic mice, and a trace amount of the transgene was also found in the lungs of one mouse. The full-length form induced efficient expression of the protein with the highest expression level of 1500 microg/ml; however, the EPO-like domain alone expressed the protein at <0.1 microg/ml. The proteins from the two recombinant cDNAs have apparent molecular weights of about 74 and 17 kDa, due to glycosylation in the case of the full-length cDNA. Cell proliferation assay in vitro indicated that both of the recombinant forms stimulated proliferation of the TPO-dependent BaF3-Mpl cells. A positive correlation appeared between the amount of TPO in the milk of lactating animals and their blood platelet levels. About a twofold increase in platelet numbers in the blood was observed after direct subcutaneous injection of the recombinant hTPO at the level of 30 microg/kg of body weight. On the basis of these results, we anticipate that the recombinant hTPO produced efficiently in milk of transgenic mice will have the same activities as the native hTPO in a few in vivo as well as in vitro biochemical aspects.

Generation and characterization of a novel single-gene-encoded single-chain immunoglobulin molecule with antigen binding activity and effector functions

Monoclonal antibody (MAb) CC49 is a murine IgG1 that reacts with tumor-associated glycoprotein (TAG)-72, a pancarcinoma antigen. Clinical trials using radiolabeled CC49 for diagnostic imaging have demonstrated specific localization of more than 90% of carcinomas. The feasibility of adopting in vivo gene inoculation methods for antibody-based immunotherapy requires introduction and expression of two genes, encoding immunoglobulin (Ig) heavy and light chains, in a single cell to generate a functional antibody. To circumvent the problems inherent in this approach, we have constructed a single-gene encoding a single-chain immunoglobulin (SCIg) that, unlike previously developed SCIgs, contains all IgG domains. To construct the novel SCIg, the carboxyl end of the constant region of the chimeric (c) CC49 kappa chain is joined, via a 30 residue Gly-Ser linker peptide, to the amino terminus of the CC49 heavy chain. To our knowledge, neither a linker peptide this long nor a linkage between the constant light (C(L)) and variable heavy domains has been reported previously. Transfectomas developed by introducing the expression construct of the amplifiable gene in dihydrofolate reductase-deficient Chinese hamster ovary (CHO dhfr-) cells secrete a 160 kDa homodimeric molecule, SCIgcCC49. The in vitro antigen binding properties of SCIgcCC49 are comparable to those of cCC49 and SCIgcCC49deltaC(H)1, a single-chain Ig deficient in constant heavy chain-1 (C(H)1) and C(L) domains. The antibody-dependent cellular cytotoxicity (ADCC) of SCIgcCC49 and cCC49 were also comparable. This single-gene approach for generating an immunoglobulin molecule may facilitate in vivo gene inoculation as well as ex vivo transfection of patients' cultured tumor-infiltrating lymphocytes for immunotherapy protocols for a variety of diseases, including cancer.

Generation of human Fab monoclonal antibodies against preS1 of hepatitis B virus using repertoire cloning

Human monoclonal antibodies (MAbs) have considerable potential in the prevention and treatment of many viral diseases. A combinatorial antibody library of heavy (Fd)- and light-chain genes derived from peripheral blood lymphocytes of a volunteer with high antibody titer to preS1 of HBV was constructed and expressed on the surface of filamentous phages. The library contained 7 x 10(9) independent clones. A phage antibody population from the third panning against preS1 was converted to one expressing soluble Fabs by removal of the g3 sequences from the pComb3 phagemid vector and subsequent transformation into E. coli TG1 cells. Screening of the library led to the identification of two clones, 3DW and 8GW, showing high reactivity toward preS1. The authenticity of the Fabs was confirmed by immunoblot analysis which yielded approximately 60 and approximately 30 kDa bands under nonreducing and reducing conditions, respectively. The soluble Fabs of 3DW and 8GW exhibited relative affinities of 6 x 10(5) and 8 x 10(6) M(-1), respectively. The sequencing results demonstrate that all Fd sequences belong to subgroup II and all light chain sequences belong to subgroup I. There are differences in CDR length and composition, especially in the FW3 and CDR3 regions of the heavy- and light-chain genes. These human Fab MAbs specific to preS1, generated from a combinatorial library, represent prototypes of passive immunotherapy candidates for viral hepatitis B.

Homology modeling of the receptor binding domain of human thrombopoietin

Platelet production in blood is regulated by a lineage specific humoral factor, thrombopoietin (TPO). The amino terminal domain of TPO (TPO-N) is responsible for the signal transduction mediated by the TPO receptor, c-mpl. From the predicted length of helices we found that TPO-N belongs to the long-chain subfamily of the four-helix bundle cytokine family. We built a three dimensional model of TPO-N by a comparative homology modeling procedure. The four helices of TPO-N with an up-up-down-down topology are stabilized by a tightly packed central hydrophobic core and the extended loop AB makes an additional hydrophobic core with helices B and D outside of the four helix bundle scaffold. An interpretation of the previous site directed mutageneses results in light of the model enabled us to identify two isolated receptor binding sites. The surface made of Lys 136, Lys 138 and Lys 140 in helix D, and Pro 42 and Glu 50 in loop AB forms the first receptor binding site, while the surface of Asp 8, Arg 10 and Lys 14 in helix A represents the second binding site for the sequential receptor oligomerization.