Controversies in orthopaedic oncology

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Complications following surgical treatment of ankle fractures in the elderly: can they be avoided?

Background Following surgical treatment of ankle fractures, geriatric patients face high complication rates (CR) in literature. Commonly used diagnostic and treatment algorithms fail to consider requirements of ageing patients which increases the risk of postoperative complications. Objective Present study critically evaluated surgical management of ankle fractures in patients over 65 years old, with focus on identifying modifiable risk factors and effective comorbidity management strategies. Methods We conducted a retrospective single-center study on patients who underwent surgical treatment of an ankle fracture. Based on their age, participants were divided into non-geriatric patients (NGP<65y) and geriatric patients (GP≥65y). We analyzed overall CR and number of minor and major complications in relation to timing of surgery, biological sex, injury pattern, osteosynthesis, pre-existing medical conditions, and postoperative care. Results 402 patients were included. GP encountered significantly higher overall (p<0.001), minor (p<0.001) and major (p=0.003) complications. They presented more complex, displaced and open fractures. Predominant factor contributing to higher CR in NGP and markedly in GP was concomitant diseases, presenting a strong OR of 19,290 (p<0.001) and 17,022 (p<0.001). Delaying surgery and managing comorbidities preoperatively had a favorable impact. Conclusion We revealed a high significant correlation between pre-existing medical conditions and postoperative results. To ascertain viability of delayed surgery in facilitating additional diagnostics and treatment of comorbidities, further comparative trials with a larger cohort are imperative.

Semi-Supervised, Attention-Based Deep Learning for Predicting TMPRSS2:ERG Fusion Status in Prostate Cancer Using Whole Slide Images

IMPLICATIONS

Our study illuminates the potential of deep learning in effectively inferring key prostate cancer genetic alterations from the tissue morphology depicted in routinely available histology slides, offering a cost-effective method that could revolutionize diagnostic strategies in oncology.

DOLAMA 200: Effectiveness and Safety of a Dual Therapy with Dolutegravir Plus Lamivudine in Treatment-Experienced HIV-1 Infected Real World Participants in Spain

The continuous pharmacological advances in antiretroviral treatment (ART) and the increasing understanding of HIV drug resistance has led to a change in the paradigm of ART optimization in the setting of the viral suppression of treatment-experienced patients with the emerging evidence of the effectiveness and safety of dual therapies. The aim of this study is to determine the antiviral efficacy and safety of switching to Dolutegravir + Lamivudine in people living with HIV, and to analyze the rate of patients with virologic failure (VF). A total of 200 patients were included with a median age of 51 years, 189 cells/µL of nadir CD4+, 13 years on ART and four previous ART regimens. Among the 168 patients who completed a follow-up at 48 weeks, a total of five VFs occurred, resulting in a 2.98% (5/168) VF rate. The results of the intention-to-treat analysis were a VF rate of 2.54% (5/197), and the rate of patients/year with viral suppression was 98.3% (298/303) in the observed data analysis. We observed a significant improvement in mean CD4 lymphocytes, the CD4/CD8 ratio and lipid profiles. The optimization of ART to DTG plus 3TC is a cost-effective switch option for treatment-experienced HIV patients, and also improves their lipid profiles.

Effects of first year COVID-19 pandemic on urology practice in three major Arab Countries: Sub-Analysis of a survey by Arab association of urology research group

BACKGROUND AND OBJECTIVES

The World Health Organization (WHO) declared the coronavirus disease-19 (COVID-19) pandemic on March 11, 2020. The health care system faced tremendous challenges in providing ethical and high-quality care. The impact of COVID-19 on urological practices varied widely worldwide, including in Arab countries. This study aimed to compare the influence of the COVID-19 pandemic on urology practice in Egypt, the KSA, and the UAE during the first year of the pandemic.

METHODS

This sub-analysis assessed the demographics and COVID-19's effects on urological practice in terms of adjustments to hospital policy, including outpatient consultations, the management of elective and urgent surgical cases, and the continuation of education across the three countries. The availability of personal protective equipment (PPE) and urologists' emotional, physical, and verbal intimidation during COVID-19 were also compared.

RESULTS

Regarding the impact on hospital policy, consultations replaced by telemedicine were significantly higher in the KSA (36.15%), followed by the UAE (33.3%), then Egypt (10.4%) (P = 0.008). Elective cases requiring ICU admission were 65.1% in Egypt, 45.2% in the KSA, and 58.2% in the UAE and were performed only in high-risk patients. PPE was freely available in 20.8% of the Egyptian hospitals compared to 83.3% in the KSA and 81.8% in the UAE. Online courses were significantly higher in Egypt (70.8%), followed by the UAE (53%) and the KSA (41.7%) (P = 0.02). Emotional intimidation was higher than verbal intimidation, representing 80%, 75.9%, and 76% in the UAE, KSA, and Egypt, respectively.

CONCLUSION

This sub-analysis outlined significant hospital policy changes across the three Arab countries. Exposure to emotional, verbal, and physical intimidation was observed. The development of teleconsultations and online platforms for educational purposes was observed.

Distinct mesenchymal cell states mediate prostate cancer progression

In the complex tumor microenvironment (TME), mesenchymal cells are key players, yet their specific roles in prostate cancer (PCa) progression remain to be fully deciphered. This study employs single-cell RNA sequencing to delineate molecular changes in tumor stroma that influence PCa progression and metastasis. Analyzing mesenchymal cells from four genetically engineered mouse models (GEMMs) and correlating these findings with human tumors, we identify eight stromal cell populations with distinct transcriptional identities consistent across both species. Notably, stromal signatures in advanced mouse disease reflect those in human bone metastases, highlighting periostin's role in invasion and differentiation. From these insights, we derive a gene signature that predicts metastatic progression in localized disease beyond traditional Gleason scores. Our results illuminate the critical influence of stromal dynamics on PCa progression, suggesting new prognostic tools and therapeutic targets.

Drain fluid cultures can rule in but cannot rule out infection persistence after surgical treatment of periprosthetic joint infections

BACKGROUND

Periprosthetic joint infection (PJI) is one of the most common reason for implant failure in arthroplasty. Surgical therapy is essential but there is no standardized guideline to determine infection eradication in multiple-step revision surgery. To date, clinical and laboratory inflammation markers and preoperative arthrocentesis are controversial to evaluate the infection status before reimplantation and therefore are often combined. Drain fluid cultures enable a microbiological analysis without need for further invasive procedure after revision surgery. This retrospective study evaluates the diagnostic performance of drain fluid cultures in diagnosing infection persistence according to the MSIS definition of PJI.

METHODS

Drain samples have been taken after every revision surgery for microbiological testing. Afterwards, the results have been assigned to the infection status according to the diagnostic criteria of the MSIS definition of PJI.

RESULTS

1084 revision surgeries in 183 patients have been included, resulting in a total sample size of 1552 drain fluid cultures. Overall sensitivity was 36.0%, specificity was 90.7% and ROC-AUC was 0.63.

CONCLUSION

Due to a high specificity and a low sensitivity drain fluid cultures can rule in but cannot rule out infection persistence in PJI.

Can Perioperative Antibiotic Choice Impact Rates of Infectious Complications After Percutaneous Nephrolithotomy? A Single-Blind, Prospective Randomized Trial

Objective: National guidelines recommend periprocedural antibiotics before percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. We conducted a randomized trial to compare two guideline-recommended antibiotics: ciprofloxacin (cipro) vs cefazolin, on PCNL outcomes, focusing on the development of systemic inflammatory response syndrome (SIRS) criteria. Methods: Adult patients who were not considered high risk for surgical or infectious complications and undergoing PCNL were randomized to receive either cipro or cefazolin perioperatively. All had negative preoperative urine cultures. Demographic and perioperative data were collected, including SIRS criteria, intraoperative urine culture, duration of hospitalization, and need for intensive care. SIRS is defined by ≥2 of the following: body temperature <96.8°F or >100.4°F, heart rate >90 bpm, respiratory rate >20 per minute, and white blood cell count <4000 or >12,000 cells/mm3. Results: One hundred forty-seven patients were enrolled and randomized (79 cefazolin and 68 cipro). All preoperative characteristics were similar (p > 0.05), except for mean age, which was higher in the cipro group (64 vs 57 years, p = 0.03). Intra- and postoperative findings were similar, with no difference between groups (p > 0.05), except a longer mean hospital stay in the cefazolin group (2 hours longer, p = 0.02). There was no difference between SIRS episodes in both univariate and multivariate analyses. Conclusions: Despite the relatively broader coverage for urinary tract pathogens with ciprofloxacin, this prospective randomized trial did not show superiority over cefazolin. Our findings therefore support two appropriate options for perioperative antibiotic prophylaxis in patients undergoing PCNL who are nonhigh risk for infectious complications.

The prognostic significance of surgical resection margins for local recurrence, distant metastasis, and overall survival in sarcoma

BACKGROUND AND OBJECTIVES

Surgical resection with microscopically negative margins constitutes one of the key elements of a curative therapeutic approach for localized sarcomas. However, the prognostic value of quantitative margin width remains controversial. We sought to determine the prognostic significance of margin status and margin width for local recurrence (LR), distant recurrence (DR), and overall survival.

METHODS

Retrospective analysis of 210 patients undergoing resection of localized sarcoma between 1997 and 2018 at a national sarcoma reference center.

RESULTS

Logistic regression did not reveal an effect of metric margin width as a prognostic factor for LR (odds ratio [OR] = 0.98, p = 0.574), DR (OR = 1, p = 0.908), or overall survival (hazard ratio = 0.98, 95% confidence interval = 0.73-1.20, p = 0.609). Subgroup analysis revealed no differences between complete first resections (R0) and re-resections (re-R0) following unplanned R1-resections for LR (p = 0.727) and overall survival (p = 0.125), but a significantly higher DR-rate in re-R0 cases (p = 0.022).

CONCLUSIONS

Achieving a negative margin is essential in sarcoma surgery, however, metric margin width was not associated with disease-specific outcomes. Re-resection of unplanned R1-resections should be performed to control for LR and overall survival rates. As re-R0 cases were at significantly higher risk of DR, these patients should be followed up closely in standardized surveillance protocols.

[Limb-sparing resection of axillary soft tissue sarcomas]

OBJECTIVE

For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function.

INDICATIONS

Soft tissue sarcoma, metastases.

CONTRAINDICATIONS

Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care.

SURGICAL TECHNIQUE

Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus.

POSTOPERATIVE MANAGEMENT

Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up.

RESULTS

Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.

Notch-based gene signature for predicting the response to neoadjuvant chemotherapy in triple-negative breast cancer

BACKGROUND

While the efficacy of neoadjuvant chemotherapy (NACT) in treating triple-negative breast cancer (TNBC) is generally accepted, not all patients derive benefit from this preoperative treatment. Presently, there are no validated biomarkers to predict the NACT response, and previous attempts to develop predictive classifiers based on gene expression data have not demonstrated clinical utility. However, predictive models incorporating biological constraints have shown increased robustness and improved performance compared to agnostic classifiers.

METHODS

We used the preoperative transcriptomic profiles from 298 patients with TNBC to train and test a rank-based classifier, k-top scoring pairs, to predict whether the patient will have pathological complete response (pCR) or residual disease (RD) following NACT. To reduce overfitting and enhance the signature's interpretability, we constrained the training process to genes involved in the Notch signaling pathway. Subsequently, we evaluated the signature performance on two independent cohorts with 75 and 71 patients. Finally, we assessed the prognostic value of the signature by examining its association with relapse-free survival (RFS) using Kaplan‒Meier (KM) survival estimates and a multivariate Cox proportional hazards model.

RESULTS

The final signature consists of five gene pairs, whose relative ordering can be predictive of the NACT response. The signature has a robust performance at predicting pCR in TNBC patients with an area under the ROC curve (AUC) of 0.76 and 0.85 in the first and second testing cohorts, respectively, outperforming other gene signatures developed for the same purpose. Additionally, the signature was significantly associated with RFS in an independent TNBC patient cohort even after adjusting for T stage, patient age at the time of diagnosis, type of breast surgery, and menopausal status.

CONCLUSION

We introduce a robust gene signature to predict pathological complete response (pCR) in patients with TNBC. This signature applies easily interpretable, rank-based decision rules to genes regulated by the Notch signaling pathway, a known determinant in breast cancer chemoresistance. The robust predictive and prognostic performance of the signature make it a strong candidate for clinical implementation, aiding in the stratification of TNBC patients undergoing NACT.

Health research prioritization in Somalia: setting the agenda for context specific knowledge to advance universal health coverage

Introduction

Despite recognition that health research is an imperative to progress toward universal health coverage, resources for health research are limited. Yet, especially in sub-Saharan Africa, more than 85% of the resources available for health research are spent on answering less relevant research questions. This misalignment is partially due to absence of locally determined health research priorities. In this study, we identified health research priorities which, if implemented, can inform local interventions required to accelerate progress toward universal health coverage in Somalia.

Methods

We adapted the child health and nutrition research initiative method for research priority setting and applied it in 4 major phases: (1) establishment of an exercise management team, (2) a web-based survey among 84 respondents to identify health research questions; (3) categorization of identified health research questions; and (4) a workshop with 42 participants to score and rank the identified health research questions. Ethical approval was received from ethics review committee of the London School of Hygiene and Tropical Medicine (Ref:26524) and the Somali Research and Development Institute (Ref: EA0143).

Results

Two hundred and thirty-one unique health research questions were identified and categorized under health systems, services and social determinants (77), communicable diseases (54), non-communicable diseases (41) and reproductive, maternal, new-born, child, adolescent health and nutrition (59). A priority score ranging from 1 to 9 was assigned to each of the questions. For each category, a list of 10 questions with the highest priority scores was developed. Across the four categories, an overall list of 10 questions with the highest priority scores was also developed. These related to bottlenecks to accessing essential health services, use of evidence in decision making, antimicrobial resistance, distribution and risk factors for non-communicable diseases, post-traumatic stress disorder and factors associated with low antenatal care attendance among others.

Conclusion and recommendations

The developed priority research questions can be used to focus health research and to inform appropriation of health research resources to questions that contribute to generation of local health system knowledge which is required to accelerate progress toward universal health coverage in Somalia. The Somalia national institute of health should set up a consortium for provision of technical and financial support for research addressing the identified priority research questions, establish a mechanism to continuously monitor the extent to which new health interventions in Somalia are informed by knowledge generated through conducting prioritized health research and prioritize interventions aimed at strengthening the broader national health research system for Somalia.

Paracolic Gutter Routing: A Novel Retroperitoneal Extra-Anatomical Repair for Infected Aorto-Iliac Axis

OBJECTIVE

We describe and analyze outcomes of a novel extra-anatomical paracolic gutter routing technique for surgical repair of aorto-iliac infections.

METHODS

A double-center, observational, cohort study of all consecutive patients with aorto-iliac infections treated using extra-anatomical paracolic gutter technique. Between May 2015 and December 2022, six patients with aorto-iliac infections were treated with the paracolic gutter routing technique. Cases were identified retrospectively in an institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records.

RESULTS

Aorto-bifemoral vascular reconstructions were performed using this technique in six patients. During mean follow-up of 52 ± 44 months, there was one case of graft thrombosis (17%) with subsequent successful thrombectomy. Primary and secondary graft patency rates were 83% and 100%, respectively. There was one mortality (17%) due to candida sepsis. All graft prostheses were patent at last follow-up.

CONCLUSIONS

The paracolic gutter technique is a useful technique in patients with extensive aorto-iliac infections, arteriovenous and iliac-ureteric fistulas, or at a high risk of vascular graft infection and is associated with favorable reinfection and patency rates.

Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects

BACKGROUND

Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation.

METHODS

Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed.

RESULTS

Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected.

CONCLUSION

A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

HPV Infection of the Oropharyngeal, Genital and Anal Mucosa and Associated Dysplasia in People Living with HIV

BACKGROUND

The main objectives were to describe the prevalence of HPV, its genotypes and HPV-associated dysplastic lesions in the oropharyngeal mucosa of PLHIV and related factors.

MATERIAL AND METHODS

This cross-sectional prospective study consecutively enrolled PLHIV attending our specialist outpatient units. At visit, HIV-related clinical and analytical variables were gathered, and oropharyngeal mucosa exudates were taken to detect HPV and other STIs by polymerase chain reaction. Samples were also taken from the anal canal of all participants and from the genital mucosa of the women for HPV detection/genotyping and cytological study.

RESULTS

The 300 participants had a mean age of 45.1 years; 78.7% were MSM and 21.3% women; 25.3% had a history of AIDS; 99.7% were taking ART; and 27.3% had received an HPV vaccine. HPV infection prevalence in the oropharynx was 13%, with genotype 16 being the most frequent (2.3%), and none had dysplasia. Simultaneous infection with Treponema pallidum (HR: 4.02 (95% CI: 1.06-15.24)) and a history of anal HSIL or SCCA (HR: 21.52 (95% CI: 1.59-291.6)) were risk factors for oropharyngeal HPV infection, whereas ART duration (8.8 vs. 7.4 years) was a protective factor (HR: 0.989 (95% CI: 0.98-0.99)).

CONCLUSIONS

The prevalence of HPV infection and dysplasia was low in the oropharyngeal mucosae. A higher exposure to ART was protective against oral HPV infection.

Abstract 1343: Mesenchymal cell populations associated with different stages of prostate cancer progression in mice and human

Mesenchymal cells in the prostate cancer (PCa) tumor microenvironment (TME) contribute to the biological and clinical history of PCa. Indeed, mesenchymal cells heavily interact with cancer cells, immune cells, and the other cellular and non-cellular components of the TME to favor or hinder carcinogenesis and tumor progression. Using a comprehensive array of genetically engineered mouse models (GEMMs) of prostate cancer, 8 mesenchymal populations with different transcriptional programs are preferentially enriched in specific GEMMs at different stages of PCa. Here, we determine the transferability of this mesenchymal cluster designation from mice PCa models to human PCa cases. To this end, we compared: a) Tmprss2-ERG (T-ERG) mouse and ERG+ human cases; b) Pb4-Cre+/-;Ptenf/f;LSL-MYCN+/+;Rb1f/f (PRN) mouse and PCa bone metastasis. We generated scRNA-seq data for &gt; 8000 mesenchymal cells from ERG+ (n=6) and ERG- (n=3) PCa patients, and we retrieved data for bone metastasis mesenchymal cells (osteoblasts, osteoclasts, endothelial cells, pericytes; 1,872 total cells) from GSE143791. To transfer the stromal mouse clusters’ labels to human data, human gene symbols were converted to their mouse counterparts, then both datasets were restricted to overlapping genes. For the human PCa cases, label transfer was performed through ‘ingest’ using the scRNA-seq data from the mouse T-ERG model as reference for the human ERG+ cases and data from the remaining GEMMs as reference for the human ERG- cases. For bone metastases cases, mouse stromal data from all GEMMs were used to project the 8 stromal clusters to the mesenchymal cells in the bone metastases microenvironment. Not surprisingly, ERG+ human samples were enriched (&gt; 60% of total stromal cells) in mouse stroma clusters predominantly present in T-ERG mouse model, characterized by the expression of Wnt regulators and AR. Common populations to all murine models, representing myofibroblasts and immunomodulatory fibroblasts (expressing Gpx3, C3, C7, Cfh), were also commonly present in patients, irrespectively to the ERG status. In the PCa bone metastases, mesenchymal clusters enriched in the PRN model were strongly represented in human bone metastases, comprising &gt; 60% of total stromal cells. These cells were characterized by high expression of POSTN and MKI67, as well as bone-specific genes like BGN. Altogether, these findings suggest that our mesenchymal cluster designation developed using GEMMs can be meaningfully applied to human PCa, and that the different transcriptional programs we identified in distinct mesenchymal population are conserved across species. This lays the foundation for the utilization of defined genetically-engineered models in defining the interactions and cross-talks between different mesenchymal populations in relation to cancer and immune cells and other components of the TME in human prostate cancer.

Citation Format: Mohamed Omar, Hubert Pakula, Filippo Pederzoli, Giuseppe N. Fanelli, Tania Panellinni, Ryan Carelli, Silvia Rodrigues, Caroline Fidalgo-Ribeiro, Pier V. Nuzzo, Lucie V. Emmenis, Mohammad Mohammad, Madhavi Jere, Caitlin Unkenholz, David Rickman, Christopher Barbieri, Brian Robinson, Luigi Marchionni, Massimo Loda. Mesenchymal cell populations associated with different stages of prostate cancer progression in mice and human [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1343.

Abstract 5414: Automated detection of high-grade urothelial carcinoma from urine cytology slides using attention-based deep learning

Urine cytology has long been an effective and non-invasive test for the detection of bladder urothelial carcinomas (UC) routinely performed in cases of unexplained hematuria or for monitoring patients with UC. In cytopathology practice, urine cytology specimens are examined manually with a light microscope to identify morphologic features associated with different diagnostic categories based on the Paris System (TPS) for Reporting Urinary Cytology. Specifically, the diagnosis of high-grade urothelial carcinoma (HGUC) requires the identification of &gt; 5-10 cells with a nuclear/cytoplasm ratio of 0.7 or greater and hyperchromasia together with coarse chromatin or irregular nuclear membranes. However, the task of identifying HGUC involves a substantial degree of manual review and is often associated with intra-and inter-observer variability. To address this, we have designed an accurate and efficient deep learning system capable of automatically distinguishing between HGUC and non-HGUC using digitized cytology slides. Our model has been developed using a retrospective cohort of 158 digitized urine ThinPrep cytology slides consisting of HGUC (n=98) and negative for HGUC (n=60). The model was then prospectively validated on a cohort of 105 urine cytology slides that were also independently reviewed prospectively in a blinded manner by a cytopathologist and cytotechnologist. Our system uses Otsu’s method for automatic image thresholding followed by dividing images into non-overlapping tiles of 500 × 500 pixels at the highest magnification. Subsequently, we use a pre-trained ResNet50 model to extract features which are used for training our attention-based multiple instance learning framework. For the training task, our retrospective cohort (158 slides) has been divided into 10 different splits each consisting of training (70%), validation (15%), and testing (15%) sets. The training and validation sets were used for the model training and optimalization, respectively, while the testing set was used for assessing the performance. This process yielded 10 different models with an average Area Under the ROC Curve (AUC) of 0.80 in the testing set. The best performing model had an AUC of 0.90 and an accuracy of 0.88. This model was subsequently validated prospectively in an independent testing cohort with 105 slides. In the prospective testing cohort, the model was able to accurately distinguish between HGUC and non-HGUC with an AUC of 0.83, accuracy of 0.76, sensitivity of 0.89, and specificity of 0.62. Additionally, our system can detect slide regions with high attention score for HGUC which are enriched in atypical urothelial cells. These findings show that our system can be utilized to assist cytopathologists in assessing urine cytology slides and to detect regions with high-diagnostic relevance for further assessment which is expected to reduce the time needed for manual review.

Citation Format: Mohamed Omar, David Kim, Luigi Marchionni, Momin T. Siddiqui. Automated detection of high-grade urothelial carcinoma from urine cytology slides using attention-based deep learning. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5414.

Distinct mesenchymal cell states mediate prostate cancer progression

Alterations in tumor stroma influence prostate cancer progression and metastatic potential. However, the molecular underpinnings of this stromal-epithelial crosstalk are largely unknown. Here, we compare mesenchymal cells from four genetically engineered mouse models (GEMMs) of prostate cancer representing different stages of the disease to their wild-type (WT) counterparts by single-cell RNA sequencing (scRNA-seq) and, ultimately, to human tumors with comparable genotypes. We identified 8 transcriptionally and functionally distinct stromal populations responsible for common and GEMM-specific transcriptional programs. We show that stromal responses are conserved in mouse models and human prostate cancers with the same genomic alterations. We noted striking similarities between the transcriptional profiles of the stroma of murine models of advanced disease and those of of human prostate cancer bone metastases. These profiles were then used to build a robust gene signature that can predict metastatic progression in prostate cancer patients with localized disease and is also associated with progression-free survival independent of Gleason score. Taken together, this offers new evidence that stromal microenvironment mediates prostate cancer progression, further identifying tissue-based biomarkers and potential therapeutic targets of aggressive and metastatic disease.

Distinct mesenchymal cell states mediate prostate cancer progression

Alterations in tumor stroma influence prostate cancer progression and metastatic potential. However, the molecular underpinnings of this stromal-epithelial crosstalk are largely unknown. Here, we compare mesenchymal cells from four genetically engineered mouse models (GEMMs) of prostate cancer representing different stages of the disease to their wild-type (WT) counterparts by single-cell RNA sequencing (scRNA-seq) and, ultimately, to human tumors with comparable genotypes. We identified 8 transcriptionally and functionally distinct stromal populations responsible for common and GEMM-specific transcriptional programs. We show that stromal responses are conserved in mouse models and human prostate cancers with the same genomic alterations. We noted striking similarities between the transcriptional profiles of the stroma of murine models of advanced disease and those of of human prostate cancer bone metastases. These profiles were then used to build a robust gene signature that can predict metastatic progression in prostate cancer patients with localized disease and is also associated with progression-free survival independent of Gleason score. Taken together, this offers new evidence that stromal microenvironment mediates prostate cancer progression, further identifying tissue-based biomarkers and potential therapeutic targets of aggressive and metastatic disease.

Using biological constraints to improve prediction in precision oncology

Many gene signatures have been developed by applying machine learning (ML) on omics profiles, however, their clinical utility is often hindered by limited interpretability and unstable performance. Here, we show the importance of embedding prior biological knowledge in the decision rules yielded by ML approaches to build robust classifiers. We tested this by applying different ML algorithms on gene expression data to predict three difficult cancer phenotypes: bladder cancer progression to muscle-invasive disease, response to neoadjuvant chemotherapy in triple-negative breast cancer, and prostate cancer metastatic progression. We developed two sets of classifiers: mechanistic, by restricting the training to features capturing specific biological mechanisms; and agnostic, in which the training did not use any a priori biological information. Mechanistic models had a similar or better testing performance than their agnostic counterparts, with enhanced interpretability. Our findings support the use of biological constraints to develop robust gene signatures with high translational potential.

Hyaluronan driven by epithelial aPKC deficiency remodels the microenvironment and creates a vulnerability in mesenchymal colorectal cancer

Mesenchymal colorectal cancer (mCRC) is microsatellite stable (MSS), highly desmoplastic, with CD8+ T cells excluded to the stromal periphery, resistant to immunotherapy, and driven by low levels of the atypical protein kinase Cs (aPKCs) in the intestinal epithelium. We show here that a salient feature of these tumors is the accumulation of hyaluronan (HA) which, along with reduced aPKC levels, predicts poor survival. HA promotes epithelial heterogeneity and the emergence of a tumor fetal metaplastic cell (TFMC) population endowed with invasive cancer features through a network of interactions with activated fibroblasts. TFMCs are sensitive to HA deposition, and their metaplastic markers have prognostic value. We demonstrate that in vivo HA degradation with a clinical dose of hyaluronidase impairs mCRC tumorigenesis and liver metastasis and enables immune checkpoint blockade therapy by promoting the recruitment of B and CD8+ T cells, including a proportion with resident memory features, and by blocking immunosuppression.

Posterior acetabular wall morphology is an independent risk factor that affects the occurrence of acetabular wall fracture in patients with traumatic, posterior hip dislocation

PURPOSE

Smaller posterior acetabular walls have been shown to independently influence the risk for bipolar hip dislocation. We asked whether differences would also be observed in patients with traumatic posterior hip dislocation with and without posterior wall fractures.

METHODS

Between 2012 and 2020 we observed 67 traumatic posterior hip dislocations. Of these, 43 traumatic posterior hip dislocations in 41 patients met the inclusion criteria. Eighteen dislocations were excluded with an acetabular fracture other than posterior wall fracture and six dislocations had insufficient computed tomography (CT) data. The mean age was 41 ± 11 years, 32 males and nine females. We observed 26 traumatic hip dislocations with posterior wall fractures and 17 without. All patients underwent polytrauma CT scans and postoperative/postinterventional pelvic CT scans. On axial CT-scans, posterior wall determining angles were measured.

RESULTS

Patients with posterior wall fractures were not significantly older than patients without posterior wall fractures (42 ± 12 vs. 38 ± 10 years; p = 0.17). Patients without posterior wall fractures had significantly smaller posterior acetabular sector angles (84° ± 10°) than did patients with posterior wall fractures (105° ± 12°) (p < 0.01; OR 1.178). Likewise, the posterior wall angle was significantly smaller in patients without posterior wall fracture (62° ± 9°) than in those with posterior wall fractures (71° ± 8°) (p < 0.01; OR 1.141).

CONCLUSION

Both posterior acetabular sector angle and posterior wall angle are independent factors determining the posterior wall fracture morphology in patients with traumatic posterior hip dislocation. Age and the observed trauma mechanism did not differentiate between traumatic posterior hip dislocations with and without posterior wall fractures.

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study

BACKGROUND

While postoperative malrotation in the subtrochanteric region is a well-known problem, malrotation after osteosynthesis in proximal femoral fractures has not been extensively studied. In this context, many methods for perioperatively assessment of femoral torsion have been described, but none of them is applicable in the basicervical region of the proximal femur. As an important difference in femoral neck fractures, the discontinuous neck fails to serve as a significant "pointer" for measurements and malfunctions to be placed in relation to the condylar plane. Considering postoperative maltorsion at any location as a substantial negative effect on patients' outcome and functional expectations, precise and patient-friendly rotation measurement standards in femoral neck fractures are desired in clinical practice. Recently, a novel computed tomography (CT) based geometric technique was described named "direct measurement" with promising results covering this diagnostic disparity, but still requires validation. Thus, we aimed to validate the previously described technique using a controlled range of displacement in a femoral neck fracture Sawbone® model.

METHODS AND FINDINGS

A goniometer was designed to set retro- and anteversion of the proximal femur in a reproducible manner. Prospectively, all femurs underwent a CT scan and were measured 3D for displacement. The interclass correlation between the CT measurements and the goniometer measurements was calculated and was found to be very high (1.00, 95% confidence interval: 0.99-1.00; p < 0.001). For the mean of all measurements, the Pearson's correlation was 1.00 (p < 0.001). No significant differences in the measurements of both investigators were observed, with 20° of retroversion not significant (-1.20 ± 1.71; 95% confidence interval: -2.43-0.03; p = 0.054).

CONCLUSION

This CT-based 3D measurement technique may allow for perioperative malrotation assessment in basicervical femoral neck fractures and appears to be feasible in femoral neck fractures when it comes to rare cases of osteosynthesis. Further investigations are still needed to define the thresholds of malrotation provoking functional impairment after osteosynthesis in basicervical femoral neck fractures.

DNA methylation changes underlie the long-term association between periodontitis and atherosclerotic cardiovascular disease

Periodontitis, the leading cause of adult tooth loss, has been identified as an independent risk factor for cardiovascular disease (CVD). Studies suggest that periodontitis, like other CVD risk factors, shows the persistence of increased CVD risk even after mitigation. We hypothesized that periodontitis induces epigenetic changes in hematopoietic stem cells in the bone marrow (BM), and such changes persist after the clinical elimination of the disease and underlie the increased CVD risk. We used a BM transplant approach to simulate the clinical elimination of periodontitis and the persistence of the hypothesized epigenetic reprogramming. Using the low-density lipoprotein receptor knockout (LDLR^o ) atherosclerosis mouse model, BM donor mice were fed a high-fat diet to induce atherosclerosis and orally inoculated with Porphyromonas gingivalis (Pg), a keystone periodontal pathogen; the second group was sham-inoculated. Naïve LDLR ^o mice were irradiated and transplanted with BM from one of the two donor groups. Recipients of BM from Pg-inoculated donors developed significantly more atherosclerosis, accompanied by cytokine/chemokines that suggested BM progenitor cell mobilization and were associated with atherosclerosis and/or PD. Using whole-genome bisulfite sequencing, 375 differentially methylated regions (DMRs) and global hypomethylation in recipients of BM from Pg-inoculated donors were observed. Some DMRs pointed to the involvement of enzymes with major roles in DNA methylation and demethylation. In validation assays, we found a significant increase in the activity of ten-eleven translocase-2 and a decrease in the activity of DNA methyltransferases. Plasma S-adenosylhomocysteine levels were significantly higher, and the S-adenosylmethionine to S-adenosylhomocysteine ratio was decreased, both of which have been associated with CVD. These changes may be related to increased oxidative stress as a result of Pg infection. These data suggest a novel and paradigm-shifting mechanism in the long-term association between periodontitis and atherosclerotic CVD.

Design, synthetic approach, in silico molecular docking and antibacterial activity of quinazolin-2,4-dione hybrids bearing bioactive scaffolds

Antimicrobial resistance (AMR) is one of ten global public health threats facing humanity. This created the need to identify and develop effective inhibitors as antimicrobial agents. In this respect, quinazolin-2,4-dione hybrids bearing N-heterocyclic cores such as pyrrolidine-2,5-dione, pyrazole and oxadiazole and/or bioactive scaffolds such as hydrazone, amide, sulfonamide, azomethine, and thiourea linkage are described for design, synthesis, antibacterial investigation, and in silico studies. The characterization of the target compounds was accomplished by elemental analysis and various spectroscopic data like FT-IR, ¹H-NMR, ¹³C-NMR and MS. The antibacterial evaluation was achieved for the newly synthesized compounds using two G -ve bacteria (Escherichia coli ATCC 25955 and Pseudomonas aeruginosa ATCC 10145), and two G +ve bacteria (Bacillus subtilis ATCC 6633 and Staphylococcus aureus NRRL B-767). Synthesized compounds exhibited various activities against the tested pathogens, the results revealed that compound 3c exhibited a characteristic antimicrobial efficacy against all the tested pathogenic strains at a concentration lower than the tested standard drug ranging from 2.5 to 10 μg ml^-1. Moreover, the molecular docking study against the target S. aureus tyrosyl-tRNA synthetase (PDB ID: 1JIJ) was carried out to investigate the mechanism of action of the prepared compounds, which is in line with an in vitro study. Most new compounds exhibited zero violation of Lipinski's rule (Ro5). These candidate molecules have shown promising antibacterial activity. Among these molecules, compound 3c with di-hydroxyl groups on two phenyl rings at position-4 exhibited a promising potent antibacterial inhibitory effect. Further SAR analysis reveals that a greater number of hydroxyl groups in an organic compound might be crucial for antibacterial efficacy. These findings demonstrate the potential activity of compound 3c as an antibacterial agent.

ZNF92, an unexplored transcription factor with remarkably distinct breast cancer over-expression associated with prognosis and cell-of-origin

Tumor phenotype is shaped both by transforming genomic alterations and the normal cell-of-origin. We identified a cell-of-origin associated prognostic gene expression signature, ET-9, that correlates with remarkably shorter overall and relapse free breast cancer survival, 8.7 and 6.2 years respectively. The genes associated with the ET-9 signature are regulated by histone deacetylase 7 (HDAC7) partly through ZNF92, a previously unexplored transcription factor with a single PubMed citation since its cloning in 1990s. Remarkably, ZNF92 is distinctively over-expressed in breast cancer compared to other tumor types, on a par with the breast cancer specificity of the estrogen receptor. Importantly, ET-9 signature appears to be independent of proliferation, and correlates with outcome in lymph-node positive, HER2+, post-chemotherapy and triple-negative breast cancers. These features distinguish ET-9 from existing breast cancer prognostic signatures that are generally related to proliferation and correlate with outcome in lymph-node negative, ER-positive, HER2-negative breast cancers. Our results suggest that ET-9 could be also utilized as a predictive signature to select patients for HDAC inhibitor treatment.

Progress in the quality of care for newly diagnosed people with HIV in Spain (2004-2019)

BACKGROUND

We monitored the quality of care for newly diagnosed people with HIV (PWH) in Spain, including linkage to care within 1 month of HIV diagnosis (LC-1Mo) and viral suppression within 3 months of HIV diagnosis (VS-3Mo).

METHODS

Longitudinal study based on The Cohort of the Spanish AIDS Research Network (CoRIS). We used logistic regression stratified by year of HIV diagnosis (2004-2013 and 2014-2019) to assess differences by sex, country of origin, HIV risk group, age, prior AIDS, HIV Viral Load, and CD4 cell count.

RESULTS

The final analysis included 13,632 PWH: males 85%, men having sex with men (MSM) 61%, median age 35 years. LC-1Mo increased from 42% (95% CI, 38%-46%) in 2004 to 80% (95% CI, 77%-83%) in 2019 (P < 0.001). Median CD4⁺ cell counts at ART initiation increased from <250/mm3 in 2004-2005 to >350/mm3 since 2012 (P < 0.001). The percentage of initial regimens based on integrase strand transfer inhibitors (INSTI) increased from 3% in 2004 to >70% from 2016 onwards (P < 0.001). VS-3Mo increased from 6% (95% CI, 4%-8%) in 2004 to 45% (95% CI, 41%-49%) in 2019 (P < 0.001). Worst results for LC-1Mo were found among PWH acquiring HIV by injection drug use and those born in Latin American Countries across all the study period.

CONCLUSION

Care indicators have improved among newly diagnosed PWH in Spain over the last 15 years. Removal of CD4 cell counts limitations, and probably the increasing use of INSTI-based regimens was decisive for the progress made.

Abstract 3816: Functional atlas of prostate mesenchyme

Prostate cancer has a heterogeneous prognosis, and genetic alterations alone do not fully explain clinical behavior. We previously characterized the stroma of localized human prostates by Laser Capture Microdissection, and found that stroma was substantially different in prostates with and without tumor. Furthermore, a stromal gene signature reflecting bone remodeling was upregulated in high compared to low Gleason grade cases. To determine how stromal cells contribute to carcinogenesis and progression we study whether specific genetic alterations in the epithelium induce unique stromal changes. To do this, we utilized Genetically Engineered Mouse Models (GEMMs) representing common prostate cancer mutations and compared these to their wild-type conterparts: the Tmprss2-ERG fusion knock-in murine model induces histological alterations in the stroma in the absence of an epithelial phenotype; the Pten deletion mouse model (PtenKO) results in prostate intraepithelial neoplasia (PIN) but not invasive cancer; the Hi-Myc GEMM, leads to PIN and subsequently invasion; and the Pb4-Cre +/-;Pten f/f; LSL-MYCN +/+; Rb1 f/f (MNRPDKO) mouse model that leads to neuroendocrine prostate cancer (NEPC). We generated a comprehensive single-cell transcriptomic atlas of the mouse prostate cancer mesenchyme in these models. Using deep generative modeling followed by graph-based clustering and gene regulatory network inference, six (6) distinct subsets of fibroblasts and two (2) subsets of smooth muscle cells (myofibroblasts and pericytes) were identified. Notably, some subsets were common across all GEMMs and WT mice, while others aligned with specific genotypes. Moreover, we found a variable pattern of positive and negative Ar expressing cells between genotypes. Analysis by CellphoneDB of mesenchymal-epithelial communications revealed the complex cross-talk between mutated epithelial cells and the tumor microenvironment. Multiplex immunofluorescence phenotyping of mesenchymal cell confirmed the cluster subtypes by both expression and spatial location. Finally, stromal transcripts defining mesenchymal cluster subtypes associated with Tmprss2-ERG were conserved between mouse and human genotypes.This study lays the groundwork for understanding and ultimately targeting stromal-epithelial interactions in prostate cancer.

Citation Format: Hubert Pakula, Ryan Carelli, Nicolo Fanelli, Madhavi Jere, Caitlin Unkenholz, Mohamed Omar, Caroline Ribeiro- Fidalgo, Filippo Pederzoli, Cory Abate-Shen, David S. Rickman, Brian Robinson, Luigi Marchionni, Massimo Loda. Functional atlas of prostate mesenchyme [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3816.

Abstract 5858: A multi-omics signature for patients’ risk classification in prostate cancer

Background: Effective biomarkers are urgently needed in the clinical settings. However, most biomarkers are currently developed from single type of omics data. The goal of this study is to identify prognostic prostate cancer signatures using transcriptomics and metabolomics profiles jointly aiming to capture wider spectrum of biological information.

Methods: In this study, we included 94 tumor and 48 adjacency normal samples with both transcriptomics and metabolomics profiles from Dana-Farber/Harvard Cancer Center SPORE Prostate Cancer Cohort. There were 85 patients being followed up with median length of 2.02 years including 3 lethal and 8 progression cases. We first constructed a multi-omics covering network that contained minimal set of variable pairs but sufficiently rich to account for observed inter-patient variations. The network was built on known gene-metabolite interaction pairs from Pathway Commons as prior knowledge. Next, we used a diffusion process with each of connected gene-metabolite pairs as seeds to identify candidate signatures in the network. Signature sizes were controlled under 5 by adjusting the tree height during pruning. Hierarchical clustering and survival analyses were then performed to stratify patients into two risk groups for disease-free survival probability. Only the prognostic signatures with power higher than 0.9 from bootstrapping were kept for external validation and functional analyses. Since to our best knowledge, there is no publicly available dataset with both transcriptomics and metabolomics to validate the multi-omics signature we identified. We thus trained a rank-based kTSP classifier using gene expression data in SPORE cohort as a surrogate signature and validated it in TCGA prostate cancer cohort independently.

Results: Constructed covering network consisted of 12 metabolites and 54 genes with inter-patient heterogeneities being captured efficiently. We identified one high-powered multi-omics signature (Gene: EGLN3; Metabolites: succinate, trans-4-hydroxyproline) that exhibited good prognostic value where high-risk patients had significant less time of disease-free survival (log rank test: p=0.019, power: 0.974). In addition, genomic variations were observed in different percentages of patients in high and low risk groups including NCOR1(SNV, 70.6% vs 96.3% p=0.025), NKX3.1(CNV, 29.6% vs 64.7% p=0.031) and TNFRSF10C (CNV, 29.6% vs 64.7%, p=0.031). No evidence indicated the patient grouping by the signature depend on Gleason scores (p=0.44). The surrogated gene signature contained 6 pairs of genes that can effectively classify TCGA patients into two prognostic groups (log rank test: p=0.048). Still, no evidence indicated the surrogate gene signature is associated with Gleason score (p=0.23) in TCGA dataset.

Conclusions: We identified a prognostic multi-omics signature (EGLN3, succinate, trans-4-hydroxyproline) with high statistical power.

Citation Format: Zhuoran Xu, Elisa Benedetti, Ryan Carelli, Jacob Rosenthal, Hubert Pakula, Mohamed Omar, Renato Umeton, David Brundage, Jan Krumsiek, Massimo Loda, Luigi Marchionni. A multi-omics signature for patients’ risk classification in prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5858.

Abstract 462: Using attention-based deep multiple instance learning to identify key genetic alterations in prostate cancer from whole slide images

Prostate cancer (PCa) is associated with several genetic alterations which play an important role in the disease heterogeneity and clinical outcome. These alterations involve gene fusion between TMPRSS2 and members of the ETS family of transcription factors like ERG, ETV1, and ETV4 together with mutations or deletions in tumor suppressors like TP53 and PTEN. The expanding wealth of digital whole slide images (WSIs) and the increasing adoption of deep learning approaches offer a unique opportunity for pathologists to streamline the detection of these alterations. Here, we used 736 haematoxylin and eosin-stained WSIs from 494 primary PCa patients to identify several key genetic alterations including ERG, ETV1, and ETV4 fusion, PTEN loss, and TP53 and SPOP mutations. Using a custom segmentation pipeline, we identified tissue regions and tiled them into high-resolution (10X magnification) patches (256X256 pixels) which were passed to our deep multiple instance learning framework. Using a pre-trained ResNet50 model, we extracted informative features which were subsequently used for training to predict slide-level labels and to detect slide regions with high diagnostic relevance. Using a 10-folds cross validation approach, we divided the data into training (80%), validation (10%) and testing (10%) sets. The training and validation data were used for training the model and hyperparameters tuning, respectively while the testing data was used to provide an unbiased evaluation of the models’ performance using the mean Area Under the Receiver Operating Characteristic (AUROC) across the ten testing folds as evaluation metric. We managed to accurately detect key molecular alterations including ERG fusion, ETV1 fusion, ETV4 fusion, and PTEN loss. Additionally, we were able to detect mutations in TP53 and SPOP together with the presence of androgen-receptor splice variant 7 (ARv7). In addition to slide-level classification, we also identified subregions with high attention score which can help pathologists identify the distinct morphological features associated with each genetic alteration. Finally, in order to examine the cellular structure associated with each genetic alteration, we used Hover-Net model to segment and classify the nuclei in the high-attention tiles. Our work highlights the utility of using WSIs to accurately identify key molecular alteration in cancer and their associated morphological and cellular features on the slide which would streamline the diagnostic process. To the best of our knowledge, this is the first study that uses routine WSIs to predict and characterize key genetic alterations in PCa.

Citation Format: Mohamed Omar, Zhuoran Xu, Ryan Carelli, Jacob Rosenthal, David Brundage, Daniela C. Salles, Eddie L. Imada, Renato Umeton, Edward M. Schaeffer, Brian D. Robinson, Tamara L. Lotan, Massimo Loda, Luigi Marchionni. Using attention-based deep multiple instance learning to identify key genetic alterations in prostate cancer from whole slide images [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 462.

Diagnostic Accuracy for Periprosthetic Joint Infection Does Not Improve by a Combined Use of Glucose and Leukocyte Esterase Strip Reading as Diagnostic Parameters

The diagnosis of periprosthetic infections (PJI) can be challenging in clinical practice because the clinical presentations of aseptic loosening and low-grade infections are similar. Semiquantitative evaluation of leukocyte esterase (LE) in synovial fluid using a urine strip test has already established itself as a diagnostic method over the past decade. The analysis of LE in synovial fluid leads to a high number of false-positive test results. In the present study, the value of a combined semiquantitative determination of glucose and LE in synovial fluid to improve the diagnosis of PJI was investigated. Over a 4-year period, 145 synovial samples were collected from patients who developed joint effusion after arthroplasty. LE and glucose test strips were considered as an index test for the diagnosis of PJI. A ++ or +++ LE and a negative glucose test strip reading were considered as positive test results. Modified diagnostic criteria for PJI as recommended by the Musculoskeletal Infection Society (MSIS) served as the reference test, except that intraoperative findings were excluded. Forty-six out of 145 samples were classified as septic complication according to the reference test. In regard to PJI, our data showed that combined use of LE and glucose strip test reading displayed a 98.0% specificity (95% confidence interval (CI): 95.2% to 100%), a 50% sensitivity (95% CI: 35.6% to 64.4%), a 92% positive predictive value (95% CI: 81.4% to 100.0%), and an 80.3% negative predictive value (95% CI: 73.2% to 87.4%). In contrast, the exclusive analysis of LE on the urine strip to diagnose PJI demonstrated a 90.9% specificity (95% CI: 85.2% to 96.6%), a 67.4% sensitivity (95% CI: 53.8% to 80.9%), a 77.5% positive predictive value (95% CI: 64.6% to 90.4%), and an 85.7% negative predictive value (5% CI: 79.0% to 92.4%). A combination of LE and glucose test pad reading is considered superior as a potential “rule-in” method for the diagnosis of PJI compared with LE test pad analysis alone. However, combined LE and glucose synovial fluid testing also demonstrated lower test sensitivity and thus diagnostic accuracy compared with LE analysis alone. Therefore, combined glucose and LE test pad analysis does not represent a sufficient diagnostic standard to exclude PJI with certainty.

Multivariate Analysis of Agronomic Traits in Newly Developed Maize Hybrids Grown under Different Agro-Environments

Developing high-yielding maize hybrids is essential under the fast-growing global population and abrupt global climate change. Planting density is one of the imperative components for enhancing maize productivity. This study assessed newly developed maize hybrids under three planting densities on two sowing dates. The evaluated hybrids were 40 maize genotypes comprised of 36 F1-developed hybrids and 4 commercial high-yielding check hybrids. The developed hybrids were generated from selected maize inbred lines according to their adaptive traits to high planting density, such as prolificacy, erect leaves, short plants, early silking, anthesis-silking interval, and small tassel size. The applied planting densities were high, intermediate, and low, with 95,000, 75,000, and 55,000 plants/ha, respectively, under timely and late sowing. The high planting density displayed the uppermost grain yield compared with the intermediate and low densities at both sowing dates. The developed hybrid G36 exhibited the highest agronomic performance under high planting density at timely and late sowing. Additionally, G38, G16, G37, G23, G5, G31, G18, G7, G2, G20, G29, and G17 displayed high agronomic traits at both sowing dates. Joint regression and AMMI analyses revealed significant genotype, agro-environment, and genotype × agro-environment interaction effects for grain yield. The AMMI biplot displayed that G39 was closest to the ideal stable hybrid, and the hybrids G36, G18, G38, G17, G2, and G37 were considered desirable stable hybrids. Moreover, the GGE biplot indicated that a high planting density at an optimal sowing date could be considered a representative environment for discriminating high-yielding maize hybrids. The designated promising hybrids are recommended for further inclusion in maize breeding due to their stability and high yields.

Onlay Pedicled Transverse Skin Flap versus One-Stage Inlay Buccal Mucosal Graft in Penile Urethroplasty: A Prospective Matched-Pair Analysis

INTRODUCTION

The aim of this study was to compare urethroplasty using onlay pedicled transverse skin flap (PSF) versus one-stage inlay buccal mucosa graft (BMG) in repair of penile urethral strictures.

METHODS

We conducted a prospective matched-pair analysis of 44 male patients receiving penile urethroplasty between June 2016 and June 2019. There were 22 patients who received PSF and 22 patients who received BMG. Matching was performed according to stricture length. Patients with strictures caused by lichen sclerosus, prior hypospadias repair, or failed prior urethroplasty were excluded. Treatment was considered successful if no recurrence was observed. Successful repair, complication rates, patients' satisfaction, and quality of life improvement were endpoints of this study.

RESULTS

Mean follow-up was 40.3 months. PSF and BMG showed comparable success rates (90.9% vs. 86.4%, p = 0.713). Recurrent stricture occurred in 2 patients (9.1%) who received PSF and in 3 patients (13.6%) who received BMG. Operation time was significantly longer for PSF than for BMG (108.4 min vs. 78.1 min, p = 0.01). Univariable logistic regression analysis revealed no relevant risk factors for stricture recurrence.

CONCLUSION

Early results indicate comparable success rates of PSF and BMG in penile urethroplasty. Further studies with larger sample size and longer follow-up periods are required to evaluate subtle differences between both techniques.

Floor plants’ leaf shape and Phyllagathis rotundifolia’s soil organic matter in Kuala Keniam Trail, Pahang National Park

Kuala Keniam forest in the Pahang National Park is a part of the oldest and most complex ecosystem in the world with multispecies of plants and structures. Unfortunately, near to none information was documented on the geometrical aspects of leaves. Thus, this study aims to pre-document on the variety of shapes of leaves along the trail and classify them. Photographs of the plants and all site activities were taken and documented by using the digital single-lens reflex (DSLR) and smartphone-digital cameras. Secondly, this study also aims at understanding this one particular herbaceous plant, known as Phyllagathis rotundifolia (tapak sulaiman) which is commonly found along the trail, and traditionally used to relieve gastrointestinal problems and fever. The composition of the soil organic matter of the plant were collected for better understanding of the type of soil needed for mass-cultivation and medical purposes. The Walkley-Black (WB) titration method was used to analyse the soil, where the oxidation of organic matter by potassium dichromate (K2Cr2O7)-sulfuric acid mixture followed by back titration of the excessive dichromate by ferrous ammonium sulphate (Fe (NH4)2(SO4)2.6H2O) were monitored. Findings from the Kuala Keniam trails were documented and analysed. Thirty distinct-leaves have been identified and classified into 10-distinct leaf shape categories. Rich soil contents such as iron, carbon and phosphorous were also detected, thus creating Kuala Keniam as an excellent environment for the growth of beneficial shrubs and herbs

DOLAVI Real-Life Study of Dolutegravir Plus Lamivudine in Naive HIV-1 Patients (48 Weeks)

Brief: Real-world data in naïve HIV-1 patients demonstrate that dolutegravir plus lamivudine in a multiple tablet regimen is effective, safe, and satisfactory; it causes moderately increasing weight and abdominal circumference and is administrable on a test-and-treat strategy. Background: Our objectives were to determine the real-life effectiveness and safety of DT with dolutegravir (50 mg/QD) plus lamivudine (300 mg/QD) in a multiple-tablet regimen (MTR) in naïve PLHIV followed up for 48 weeks and to evaluate the compliance and satisfaction of patients. Material and methods: An open, single-arm, multicenter, non-randomized clinical trial from May 2019 through September 2020 with a 48-week follow-up. Results: The study included 88 PLHIV patients (87.5% male) with a mean age of 35.9 years; 76.1% were MSM patients. The mean baseline CD4 was 516.4 cells/uL, with a viral load (VL) of 4.49 log10, and 11.4% were in the AIDS stage. DT started within 7 days of first specialist consultation in all patients and the same day in 84.1%; 3.4% had baseline resistance mutations (K103N, V106I + E138A, and V108I); 12.5% were lost to follow-up. At week 48, 86.3% had VL < 50 cop/uL by intention-to-treat analysis and 98.7% by per-protocol (PP) analysis. Virological failure (VF) was recorded in 1.1%, with no resistance mutation. One blip was detected in 5.2% without VF. Three reported anxiety, dizziness, and cephalgia, respectively, at week 4 and one reported insomnia at week 24; none reported adverse events at week 48. The mean weight was 4 kg higher at 48 weeks (p = 0.0001) and abdominal circumference 3 cm larger at 24 weeks (p = 0.022). No forgetfulness occurred in 98.7% of patients. Patient satisfaction was 90/100 at 4, 24, and 48 weeks. Conclusion: Real-world data demonstrate that dolutegravir plus lamivudine in MTR is effective, safe, and satisfactory, moderately increasing weight and abdominal circumference and administrable on a test-and-treat strategy.

How did the first year of the COVID-19 pandemic affect urology practice in Arab countries? A cross-sectional study by the Arab Association of Urology research group

Objective:

The aim of this study was to assess of the effect of coronavirus disease 2019 (COVID-19) pandemic on urology practice in the Arab world during the first year of the crisis.

Methods:

An Internet-based questionnaire was created and sent out via email to members of the Arab Association of Urology (AAU) using ‘Google Forms’. The survey assessed participants’ demographics in terms of age, gender, country of origin, type of practice and position. Impacts of COVID-19 on urological practice were assessed in terms of the changes in hospital policies regarding consultations, and elective and emergency surgical cases. Moreover, impacts of COVID-19 on urologists were assessed.

Results:

A total of 255 AAU members across 14 Arab countries (Emirates, Egypt, Saudi Arabia, Iraq, Jordan, Algeria, Kuwait, Yemen, Qatar, Lebanon, Libya, Oman, Sudan and Syria) completed the survey; 4% were female urologists. Consultations at outpatient clinics were closed or restricted to emergency cases or replaced by telemedicine in almost 15%, 40% and 25% of hospitals, respectively. Elective surgeries were stopped or reduced to under 25% of surgical capacity in >10% and about 25% of hospitals, respectively. Almost 90% (228) reported changes in the policy for emergency theatres. Nearly 65% of hospitals offered preoperative COVID-19 testing to patients and 50% of hospitals provided personal protective equipment (PPE) to their urologists. Of 99% (253) who reported a change in urological education, 95% relied on online webinars. About 56% of respondents had their own private practice, of whom 91% continued private practice during the crisis. About 38% of participants reported exposure to intimidation (75% emotional, 20% verbal and 5% physical).

Conclusion:

The COVID-19 pandemic resulted in major changes in hospitals’ policies regarding outpatient consultations, elective and emergency operative cases, and the shift to telemedicine. Arab urologists have been facing major challenges either in both the governmental or the private sectors, and some of them were exposed to emotional, verbal and even physical intimidation.

Malleable Penile Implant Rod Diameter Predicts Complications and Patient Satisfaction

Background

One of the most common complaints after malleable prosthesis implantation (MPI) is thinning of the penis and decreasing girth. Some surgeons try to insert the largest diameter they can to improve patient satisfaction

Aim

To investigate if malleable rod diameter (MRD) has an impact on outcome and patient satisfaction

Methods

Consecutive malleable prosthesis implantation (MPI) was assessed in a high-volume center over 1 year. The same preoperative, intraoperative, and postoperative protocols were used for all patients and one brand of the malleable device was used only. We recorded MRD and length for all patients. All patients had data on comorbidities including glycated hemoglobin (HbA1c) and clinical Peyronie's disease (PD). Revision cases and those who lost for follow-up were excluded from the study. We also excluded patients operated on by low-volume surgeons. All complications, minor (edema, ecchymosis, pain), and major (infection and erosion) were recorded. After 1-year, patients were assessed and given a Likert scale from 1 to 5 where 5 is most satisfied with their MPI. We stratified patients according to MRD into 2 groups: group A for diameter 9.5 and 11 mm and group B for 13 mm.

Outcome

: Larger diameter of malleable penile implants may be associated with more complications

Results

183 patients had full data and filled the questionnaire after 1-year follow-up. All patients had Coloplast, Genesis penile implants. Major complications rate (infection, erosion, and removal) was significantly higher in group B 11% vs 1.2% in group A (P = .016). At 4 weeks postoperative visit, 90 % of group A showed no complications vs 60% only in group B that was statistically significant (P = .0003). Satisfaction rate was more in patients in group A (88.6%) compared to patients in group B (75.7%) but this did not reach to be statistically significant (P = .0519)

Clinical Implications

MRD predicts outcome.

Strengths & Limitations

The strengths of our study include that it is the first prospective study with good number of malleable implants. Limitations include: no validated satisfaction instrument and MRD choice was based on surgeon preference.

Conclusions

Larger diameter of malleable penile implants are not associated with a higher rate of patient satisfaction

Habous M, Omar M, Farag M et al. Malleable Penile Implant Rod Diameter Predicts Complications and Patient Satisfaction. Sex Med 2022;10:100486.

A224 COVID-19 INFECTION IN LIVER TRANSPLANT RECIPIENTS: CLINICAL FEATURES, HOSPITALIZATION, AND MORTALITY FROM A CANADIAN MULTICENTRE COHORT

Background

The COVID-19 pandemic has brought significant challenges to clinicians caring for liver transplant (LT) recipients. Researchers have sought to better understand the risk and clinical outcomes of LT recipients infected with COVID-19 globally, however, there is a paucity of data from within Canada.

Aims

Our multi-center study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 in Canada.

Methods

We identified a retrospective cohort of adult LT recipients with RT-PCR confirmed COVID-19 from 7 Canadian tertiary care centers between March 2020 and June 2021. Demographic and clinical data were compiled by clinicians within those centers. We identified liver enzyme profile at the time of COVID-19 infection, immunosuppression type and post-infection adjustments, rate of hospitalization, ICU admission, mechanical ventilation, and death.

Results

A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty nine patients (59%) were male, the median time from LT was 66 months (1, 128) and the median age at COVID-19 infection was 59 years (52, 65). At COVID-19 diagnosis, the median ALT was 37 U/L (21, 41), AST U/L was 34 (20, 37), ALP U/L was 156 (88, 156), Total Bilirubin was 11 umol/L (7, 14), and INR was 1.1 (1.0, 1.1). The majority of patients (92%) were on tacrolimus monotherapy or a combination of tacrolimus and mycophenolate mofetil (MMF); median tacrolimus level at COVID-19 diagnosis was 5.3 ug/L (4.0, 8.1). Immunosuppression was modified in 8 (16%) patients post-infection; either the tacrolimus dose was reduced or MMF was held. One patient developed acute cellular rejection which recovered after re-initiation of the prior regimen. Eighteen patients (37%) required hospitalization, 6 (12%) were treated with dexamethasone, and 3 (6%) required ICU admission and mechanical ventilation. Four patients (8%) died due to complications of COVID-19. On univariate analysis, neither age, sex, co-morbidities nor duration post-transplant were associated with risk of hospitalization.

Conclusions

In our national retrospective study, approximately 40% of patients required hospitalization with a mortality rate of &lt; 10%. Previous studies have shown proximity to LT as an independent factor for mortality with COVID-19; the median time from LT for our patients was 5 years, which may explain the lower mortality rate. Of note, the median tacrolimus levels were much lower in comparison to the target of 8–10 ug/L used in the first year post-transplant. As the landscape of COVID-19 changes with vaccination, evolving treatments, and increasing rates of variant transmission, additional studies are required to continue identifying trends in clinical outcomes.

Funding Agencies

None

A robust and interpretable gene signature for predicting the lymph node status of primary T1/T2 oral cavity squamous cell carcinoma

Oral cavity squamous cell carcinoma (OSCC) affects more than 30 000 individuals in the United States annually, with smoking and alcohol consumption being the main risk factors. Management of early-stage tumors usually includes surgical resection followed by postoperative radiotherapy in certain cases. The cervical lymph nodes (LNs) are the most common site for local metastasis, and elective neck dissection is usually performed if the primary tumor thickness is greater than 3.5 mm. However, postoperative histological examination often reveals that many patients with early-stage disease are negative for neck nodal metastasis, posing a pressing need for improved risk stratification to either avoid overtreatment or prevent the disease progression. To this end, we aimed to identify a primary tumor gene signature that can accurately predict cervical LN metastasis in patients with early-stage OSCC. Using gene expression profiles from 189 samples, we trained K-top scoring pairs models and identified six gene pairs that can distinguish primary tumors with nodal metastasis from those without metastasis. The signature was further validated on an independent cohort of 35 patients using real-time polymerase chain reaction (PCR) in which it achieved an area under the receiver operating characteristic (ROC) curve and accuracy of 90% and 91%, respectively. These results indicate that such signature holds promise as a quick and cost effective method for detecting patients at high risk of developing cervical LN metastasis, and may be potentially used to guide the neck treatment regimen in early-stage OSCC.

Effect of Docosahexaenoic Acid as a Chemopreventive Agent on Experimentally Induced Hamster Buccal Pouch Carcinogenesis.. [DOI: 10.20944/preprints202201.0307.v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The purpose of the current study was directed to investigate the effectiveness of docosahexaenoic acid (DHA) as a chemopreventive agent on experimentally induced hamster buccal pouch (HBP) carcinogenesis; Material and methods: 40 Syrian male hamsters, five weeks old, were divided into 4 groups of 10 animals in each as follows, GI: Topical application of liquid paraffin alone (thrice a week for 14 weeks), GII: Topical application of 7, 12 dimethyl benz[a]anthracene (DMBA) alone (0.5 % in liquid paraffin, thrice a week for 14 weeks), GIII: Topical application of DMBA (0.5 % in liquid paraffin, thrice a week for 14 weeks) + Oral administration of DHA (125 mg/kg b.w. in 1 ml distilled water by oral gavage, thrice a week for 14 weeks on alternative days of DMBA application), GIV : Oral administration of DHA alone (125 mg/kg b.w. in 1 ml distilled water by oral gavage, thrice a week for 14 weeks); Results: Gross observations and histopathological findings revealed a-GI: normal stratified squamous epithelium b- GII: well and moderately differentiated squamous cell carcinoma (SCC) c-: GIII: showed variable results ranges from hyperkeratosis, hyperkeratosis and focal hyperplasia, mild dysplasia, and well differentiated SCC with superficial invasion of tumor cells not extended to deeper areas d: GIV: normal similar to GI. Immunohistochemical results revealed that oral DHA treatment to DMBA treated hamsters restored the normal expression of bcl-2; Conclusion: DHA has the potential to be a dietary chemopreventive agent due to its capacity to improve carcinogen detoxification and to block/suppress the initiation and promotion stages of experimentally produced HBP carcinogenesis.