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McNeil C, Wong PF, Sridhar N, Wang Y, Santori C, Wu CH, Homyk A, Gutierrez M, Behrooz A, Tiniakos D, Burt AD, Pai RK, Tekiela K, Patel H, Cameron Chen PH, Fischer L, Martins EB, Seyedkazemi S, Freedman D, Kim CC, Cimermancic P. An End-to-End Platform for Digital Pathology Using Hyperspectral Autofluorescence Microscopy and Deep Learning-Based Virtual Histology. Mod Pathol 2024; 37:100377. [PMID: 37926422 DOI: 10.1016/j.modpat.2023.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Conventional histopathology involves expensive and labor-intensive processes that often consume tissue samples, rendering them unavailable for other analyses. We present a novel end-to-end workflow for pathology powered by hyperspectral microscopy and deep learning. First, we developed a custom hyperspectral microscope to nondestructively image the autofluorescence of unstained tissue sections. We then trained a deep learning model to use autofluorescence to generate virtual histologic stains, which avoids the cost and variability of chemical staining procedures and conserves tissue samples. We showed that the virtual images reproduce the histologic features present in the real-stained images using a randomized nonalcoholic steatohepatitis (NASH) scoring comparison study, where both real and virtual stains are scored by pathologists (D.T., A.D.B., R.K.P.). The test showed moderate-to-good concordance between pathologists' scoring on corresponding real and virtual stains. Finally, we developed deep learning-based models for automated NASH Clinical Research Network score prediction. We showed that the end-to-end automated pathology platform is comparable with an independent panel of pathologists for NASH Clinical Research Network scoring when evaluated against the expert pathologist consensus scores. This study provides proof of concept for this virtual staining strategy, which could improve cost, efficiency, and reliability in pathology and enable novel approaches to spatial biology research.
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Affiliation(s)
- Carson McNeil
- Verily Life Sciences LLC, South San Francisco, California.
| | - Pok Fai Wong
- Verily Life Sciences LLC, South San Francisco, California
| | | | - Yang Wang
- Verily Life Sciences LLC, South San Francisco, California
| | | | - Cheng-Hsun Wu
- Verily Life Sciences LLC, South San Francisco, California
| | - Andrew Homyk
- Verily Life Sciences LLC, South San Francisco, California
| | | | - Ali Behrooz
- Verily Life Sciences LLC, South San Francisco, California
| | - Dina Tiniakos
- Newcastle University, Newcastle upon Tyne, United Kingdom; Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Hardik Patel
- Verily Life Sciences LLC, South San Francisco, California
| | | | | | | | | | | | - Charles C Kim
- Verily Life Sciences LLC, South San Francisco, California
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2
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Martinez-Morilla S, Moutafi M, Fernandez AI, Jessel S, Divakar P, Wong PF, Garcia-Milian R, Schalper KA, Kluger HM, Rimm DL. Digital spatial profiling of melanoma shows CD95 expression in immune cells is associated with resistance to immunotherapy. Oncoimmunology 2023; 12:2260618. [PMID: 37781235 PMCID: PMC10540659 DOI: 10.1080/2162402x.2023.2260618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
Although immune checkpoint inhibitor (ICI) therapy has dramatically improved outcome for metastatic melanoma patients, many patients do not benefit. Since adverse events may be severe, biomarkers for resistance would be valuable, especially in the adjuvant setting. We performed high-plex digital spatial profiling (DSP) using the NanoString GeoMx® on 53 pre-treatment specimens from ICI-treated metastatic melanoma cases. We interrogated 77 targets simultaneously in four molecular compartments defined by S100B for tumor, CD68 for macrophages, CD45 for leukocytes, and nonimmune stromal cells defined as regions negative for all three compartment markers but positive for SYTO 13. For DSP validation, we confirmed the results obtained for some immune markers, such as CD8, CD4, CD20, CD68, CD45, and PD-L1, by quantitative immunofluorescence (QIF). In the univariable analysis, 38 variables were associated with outcome, 14 of which remained significant after multivariable adjustment. Among them, CD95 was further validated using multiplex immunofluorescence in the Discovery immunotherapy (ITX) Cohort and an independent validation cohort with similar characteristics, showing an association between high levels of CD95 and shorter progression-free survival. We found that CD95 in stroma was associated with resistance to ICI. With further validation, this biomarker could have value to select patients that will not benefit from immunotherapy.
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Affiliation(s)
| | - Myrto Moutafi
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | | | - Shlomit Jessel
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Rolando Garcia-Milian
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale School of Medicine, New Haven, CT, USA
| | - Kurt A. Schalper
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Harriet M. Kluger
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - David L. Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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3
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Vathiotis IA, Salichos L, Martinez-Morilla S, Gavrielatou N, Aung TN, Shafi S, Wong PF, Jessel S, Kluger HM, Syrigos KN, Warren S, Gerstein M, Rimm DL. Baseline gene expression profiling determines long-term benefit to programmed cell death protein 1 axis blockade. NPJ Precis Oncol 2022; 6:92. [PMID: 36522538 PMCID: PMC9755314 DOI: 10.1038/s41698-022-00330-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
Treatment with immune checkpoint inhibitors has altered the course of malignant melanoma, with approximately half of the patients with advanced disease surviving for more than 5 years after diagnosis. Currently, there are no biomarker methods for predicting outcome from immunotherapy. Here, we obtained transcriptomic information from a total of 105 baseline tumor samples comprising two cohorts of patients with advanced melanoma treated with programmed cell death protein 1 (PD-1)-based immunotherapies. Gene expression profiles were correlated with progression-free survival (PFS) within consecutive clinical benefit intervals (i.e., 6, 12, 18, and 24 months). Elastic net binomial regression models with cross validation were utilized to compare the predictive value of distinct genes across time. Lasso regression was used to generate a signature predicting long-term benefit (LTB), defined as patients who remain alive and free of disease progression at 24 months post treatment initiation. We show that baseline gene expression profiles were consistently able to predict long-term immunotherapy outcomes with high accuracy. The predictive value of different genes fluctuated across consecutive clinical benefit intervals, with a distinct set of genes defining benefit at 24 months compared to earlier outcomes. A 12-gene signature was able to predict LTB following anti-PD-1 therapy with an area under the curve (AUC) equal to 0.92 and 0.74 in the training and validation set, respectively. Evaluation of LTB, via a unique signature may complement objective response classification and characterize the logistics of sustained antitumor immune responses.
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Affiliation(s)
- Ioannis A Vathiotis
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA.
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA.
| | - Leonidas Salichos
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, CT, USA
- Department of Biological and Chemical Sciences, New York Institute of Technology, New York, USA
| | - Sandra Martinez-Morilla
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Niki Gavrielatou
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Thazin Nwe Aung
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Saba Shafi
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Shlomit Jessel
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Harriet M Kluger
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Konstantinos N Syrigos
- Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Mark Gerstein
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, CT, USA
- Department of Computer Science, Yale University, New Haven, CT, USA
- Department of Statistics and Data Science, Yale University, New Haven, CT, USA
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
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4
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Hon NWL, Wu MZ, Yu SY, Wong PF, Tse YK, Li HL, Tsui LH, Yu SY, Yiu KH. Role of prenatal cardiovascular magnetic resonance imaging in determining pregnancy risk in repaired Tetralogy of Fallot patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Addressing pregnancy risks poses as a new challenge among women with repaired tetralogy of Fallot (TOF). The high-output state of pregnancy may predispose women to late complications of repaired TOF. However, guidelines regarding antenatal and or perinatal cardiovascular assessment has not been outlined. Noninvasive modalities such as cardiac magnetic resonance imaging (CMR) that do not require the utilization of ionizing radiation are feasible methods of assessment. Risk stratification of baseline CMR parameters has been sparsely investigated among repaired TOF cohorts. This study aims to identify baseline CMR parameters that may predict adverse outcomes of pregnancy among women with repaired TOF.
Sixty-five successful pregnancies were recorded from a cohort of 105 pregnant episodes. Patients with CMR studies performed within 5 years prior to delivery events were included. Adverse clinical outcomes of interest included arrhythmia, heart failure admissions, gestational hypertension, pre-eclampsia toxemia and all-cause mortality. Baseline CMR parameters regarding ventricular mechanics such as left and right ventricular end-diastolic and end-systolic volumes, left and right ventricular ejection fractions and pulmonary regurgitant fraction were measured, and their association with adverse clinical outcomes were evaluated using an independent-samples t-test.
Within all 65 successful pregnancies, 26 baseline CMR images were obtained and included in this study. The mean maternal age was 29.7 ± 6.7 years old with a mean birth weight of 2.91 ± 0.49 kg at a mean gestational age of 38.4 ± 2.0 weeks. There was a total of 12 patients with adverse clinical outcome: 5 patients with heart failure hospitalizations, 4 patients with gestational hypertension, 4 patients with arrhythmia and 2 patients with pre-eclampsia toxemia.
Assessment of baseline CMR parameters of ventricular mechanics revealed that increased left ventricular end-diastolic volumes (LVEDV) (144.7mL/m2 ± 4.9; P = 0.011), left ventricular end-systolic volumes (LVESV) (65.1mL/m2 ± 9.4; P = 0.004), right ventricular end-diastolic volumes (RVEDV) (235.2 ± 29.0; P = 0.021) and right ventricular end-systolic volumes (RVESV) (122.2mL/m2 ± 38.1; P = 0.033) were associated with an increased incidence of arrhythmia during pregnancy. Nonetheless, there was no significant association between baseline ventricular mechanics with heart failure, gestational hypertension, and pre-eclampsia toxemia.
Baseline assessment of cardiac magnetic resonance imaging among pregnant TOF women revealed that larger left and right ventricular volumes were associated with arrythmia development during pregnancy. Further studies with larger cohort sizes evaluating the role of antenatal and perinatal cardiovascular imaging assessment using CMR in predicting the risks of cardiovascular complications during pregnancy are warranted.
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Affiliation(s)
- N W L Hon
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - P F Wong
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - Y K Tse
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - H L Li
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - L H Tsui
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - K H Yiu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
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5
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Ren QW, Teng THK, Wang T, Tse YK, Wong PF, Li HL, Yu SY, Wu MZ, Li XL, Tse HF, Lam CSP, Yiu KH. Incidence, clinical correlates and associated outcomes of dementia in heart failure: a population-based cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Dementia, in the setting of heart failure (HF), portends poorer outcomes and poses great challenges in its clinical management.
Purpose
We investigated the incidence, types, clinical correlates, and the prognostic impact of dementia in a population-based cohort of patients with HF. Further, we examined the interactions of age and sex, and education status with dementia incidence.
Methods
The previously validated Hong Kong Clinical Data Analysis Reporting System (CDARS), a territory-wide database was interrogated to identify patients with HF (N= 202,121) from 1995 to 2018. Associations of clinical correlates with incident dementia and its risk with all-cause mortality were assessed using competing risk/multivariable Cox regression models where appropriate.
Results
Among a total cohort aged ≥18 years with HF (mean age: 75.3 ± 13.0 years, 51.3% women), new-onset dementia occurred in 22,145 (11.0%) over a median follow-up of 5.5 years. Alzheimer’s disease occurred in 27.0%; vascular dementia (18.1%) and unspecified dementia (in 55.1%). Age-standardized rate of dementia incidence in women was 1297 (95%CI, 1276-1318) (vs. 744, 95%CI, 723-765) per 10000 population in men. Other independent predictors of dementia include: Increasing age (HR 1.08), Female sex (HR 1.19), Nil/< primary (vs tertiary) education (HR 1.29), Parkinson’s disease (HR 1.73), head injury (HR 1.37), peripheral vascular disease (HR 1.31), stroke (HR 1.29), depression (HR 1.18), alcohol intake (HR1.17), anaemia (HR 1.14), hypertension (HR 1.08), among other common comorbidities in HF (Figure 1A).
Notably, a significant interaction (p < 0.001) between age and sex on dementia incidence was observed, such that women in all age groups were observed to have higher sHR compared to men (Figure 1B). After accounting for competing risk, dementia was not associated with adjusted hazard of all-cause mortality.
Conclusions
Female sex, lower socioeconomic status, increasing age and common comorbidities were associated with higher hazards of incident dementia. Abstract Figure 1A and Figure 1B
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Affiliation(s)
- Q W Ren
- The University of Hong Kong, Hong Kong, China
| | - T H K Teng
- National Heart Centre Singapore, Singapore, Singapore
| | - T Wang
- National Heart Centre Singapore, Singapore, Singapore
| | - Y K Tse
- The University of Hong Kong, Hong Kong, China
| | - P F Wong
- The University of Hong Kong, Hong Kong, China
| | - H L Li
- The University of Hong Kong, Hong Kong, China
| | - S Y Yu
- The University of Hong Kong, Hong Kong, China
| | - M Z Wu
- The University of Hong Kong, Hong Kong, China
| | - X L Li
- Nanjing Medical University, Nanjing, China
| | - H F Tse
- The University of Hong Kong, Hong Kong, China
| | - C S P Lam
- National Heart Centre Singapore, Singapore, Singapore
| | - K H Yiu
- The University of Hong Kong, Hong Kong, China
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Tsui L, Yiu KH, Tse HF, Lam LY, Leung CKL, Yu ASY, Wu MZ, Ren QW, Wong PF, Tse YK, Yu SSY, Li HL, Hon WL. Prognostic value of pre-operative left atrial strain on composite endpoint in patients received aortic valve replacement for severe aortic stenosis: a retrospective cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Objective
Severe aortic stenosis (AS) is the most common primary valvular heart disease, treatable only by aortic valve replacement (AVR). Current literatures have shown that severe AS may precede atrial dysfunction which predicts adverse outcomes. However, predictive value of pre-operative left atrial (LA) function on post-AVR clinical outcomes is uncertain. The study aims to evaluate the prognostic value of pre-operative LA strain on post AVR all-cause mortality and heart failure.
Methods
Patients aged 18 years old or above with severe AS were recruited and assessed using speckle-tracking echocardiography pre-operatively. Severe AS was defined according to 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Peak Atrial Longitudinal Strain (PALS) was measured as a surrogate of LA function. Patients with underlying pre-operative atrial fibrillation and other severe valvular heart diseases were excluded. High PALS was defined as PALS higher than 15.94%. Patients were followed up until death or end of the study. The primary endpoint is a composite endpoint of all-cause mortality and heart failure during hospitalisation. The association of LA function with composite endpoint of all-cause mortality and heart failure was evaluated by Cox Proportional Hazards analysis.
Results
A total of 128 patients (mean age 65.3.9 ± 9.4 years, 56.3% male) were analysed. Patients were followed up for a mean period of 3.9 ± 2.4years. A total of 65 of 128 patients (50.8%) belonged to low PALS group. During the study period, 23 patients developed events on the composite endpoint. Among those with composite endpoint, low PALS group accounted for 18 (78.3%) patients and high PALS group accounted for 5 (21.7%) patients. Higher PALS was independently associated with lower risk of composite endpoint of all-cause mortality and heart failure (HR, 0.33; 95% CI 0.117-0.916, p = 0.03) after adjustment for EuroSCORE II.
Conclusion
Higher PALS, a surrogate of LA function, is associated with a lower risk of composite endpoints of mortality and heart failure in patients with severe AS undergoing AVR, independent of EuroSCORE II. Evaluation of LA function by assessing speckle tracking derived PALS may aid in prognostication for patients undergoing AVR.
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Affiliation(s)
- L Tsui
- The University of Hong Kong, Hong Kong, Hong Kong
| | - K H Yiu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - H F Tse
- The University of Hong Kong, Hong Kong, Hong Kong
| | - L Y Lam
- The University of Hong Kong, Hong Kong, Hong Kong
| | - C K L Leung
- The University of Hong Kong, Hong Kong, Hong Kong
| | - A S Y Yu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - Q W Ren
- The University of Hong Kong, Hong Kong, Hong Kong
| | - P F Wong
- The University of Hong Kong, Hong Kong, Hong Kong
| | - Y K Tse
- The University of Hong Kong, Hong Kong, Hong Kong
| | - S S Y Yu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - H L Li
- The University of Hong Kong, Hong Kong, Hong Kong
| | - W L Hon
- The University of Hong Kong, Hong Kong, Hong Kong
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Wu MZ, Teng TH, Tay WT, Ren QW, Wong PF, Tse HF, Lam SP, Yiu KH. Chronic kidney disease begets heart failure and vice versa; temporal associations between heart failure events in relation to incident chronic kidney disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Diabetes, chronic kidney disease (CKD) and heart failure (HF) are fast-growing causes of morbidity and mortality worldwide. Diabetes is an optimal model to study the inter-play of cardiovascular disease and renal disease.
Purpose
To investigate the association of CKD with HF and its prognosis in a large, population-based cohort of diabetes, in which incident CKD and HF events were ascertained longitudinally.
Methods
A population-based cohort of patients aged ≥18 years with diabetes, but without CKD, HF or acute kidney injury at baseline was identified from the previously validated territory-wide Clinical Data Analysis Reporting System between 2000 and 2015. Patients were followed up through December 31,2020 for incident CKD and/or HF or all-cause mortality. Multi-state modelling was used to examine the association of the subgroups (with/without CKD or HF).
Results
Among 294,413 patients (mean age: 65 ± 14 years; 49.5% women), new-onset CKD occurred in 51,583, in whom one-fifth (21.3%) had HF. In contrast, among 28,335 patients with new-onset HF, nearly two-fifth (38.7%) had CKD (Figure 1A). Median duration from baseline to incident CKD was shorter than incident HF [8.27 (4.69-11.97) years vs. 8.76 (5.28-12.37) years, p <0.001]. However, median duration for incident event of HF after CKD diagnosis was 2.15 (0.83-4.50) years and 1.73 (0.62-3.87) years for incident CKD after HF diagnosis. The incidence rate of CKD and HF was 20.39 per 1000 person-years and 10.61 per 1000 person-years, respectively.
Presence of CKD was associated with incident HF (odds ratios [OR] 1.27 [95%CI 1.21-1.33]), and HF with incident CKD (OR 1.26 [95%CI 1.18-1.33]). The presence of both CKD and HF (regardless of which comes first) portends higher risk (6 to 8-fold hazards) of all-cause mortality than neither condition (Figure 1B).
Conclusions
Incident HF occurs in one-fifth of patients with new-onset CKD, and CKD occurs in about 40% with new-onset HF. CKD seems to precede HF. More research on the inter-play of these dual conditions is warranted in view of the high mortality risk. Abstract Figure.
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Affiliation(s)
- M Z Wu
- Hongkong University of Shenzhen Hospital, Division of Cardiology, Department of Medicine, Shenzhen, China
| | - T H Teng
- National Heart Centre Singapore, Singapore, Singapore
| | - W T Tay
- National Heart Centre Singapore, Singapore, Singapore
| | - Q W Ren
- the University of Hong Kong, Hong Kong, China
| | - P F Wong
- the University of Hong Kong, Hong Kong, China
| | - H F Tse
- the University of Hong Kong, Hong Kong, China
| | - S P Lam
- National Heart Centre Singapore, Singapore, Singapore
| | - K H Yiu
- Hongkong University of Shenzhen Hospital, Division of Cardiology, Department of Medicine, Shenzhen, China
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Hon NWL, Wu MZ, Yu SY, Wong PF, Tse YK, Li HL, Tsui LH, Yu SY, Yiu KH. Serial echocardiography assessment and clinical outcomes among pregnant women with Tetralogy of Fallot. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Following advancements in intracardiac repair of Tetralogy of Fallot (TOF), a greater proportion of patients survive well beyond child-bearing age. Pulmonary regurgitation (PR) and subsequent progressive right ventricular dilatation occur frequently as an intrinsic complication of surgical repair of TOF. High-output states such as pregnancy may exacerbate these late complications. The advocation of pre-pregnancy pulmonary valve replacement to mitigate pregnancy-related cardiac burden has remained controversial. This study aims to delineate the outcomes of pregnancy among women with repaired TOF.
105 pregnant episodes among were identified from a cohort of 240 adult female patients with TOF between 1990 to 2021. Patients with echocardiographic studies performed within 1 year prior to and following delivery were included for cardiac functional analysis. A paired sample t-test was performed to compare echocardiographic parameters between pre-delivery and post-delivery periods. Linear regression was used to identify changes to identify significant changes in echocardiographic parameters among patients with a baseline of severe PR.
Within all pregnant episodes (n = 105), 65 successful pregnancies, 16 spontaneous miscarriages, 21 termination of pregnancies and 3 ectopic pregnancies were recorded. The mean maternal age was 28.9 (±6.7) years with deliveries at 37.86 (30-41) gestational weeks. Cardiovascular events occurred in 19 pregnancies with 4 patients having gestational hypertension, 4 patients with pre-eclampsia toxemia, 7 patients with heart failure symptoms and 4 patients with arrhythmias. Other complications included 4 patients with gestational diabetes mellitus, 3 patients with impaired glucose tolerance, 2 patients with anemia, 3 patients with maternal thyroid disease and 1 patients with proteinuria.
Echocardiographic studies demonstrated significant changes in left ventricular ejection fraction (LVEF) (Pre-delivery = 60.69 ±8.73; post-delivery = 59.39 ±9.36) (P = 0.007), left ventricular end diastolic volume (LVEDV) (Pre-delivery: 89.71mL ±18.22mL; Post-delivery: 80.96mL ±12.32mL; P = 0.007), left end systolic volume (LVESV) (Pre-delivery: 35.43 ±12.36; Post-delivery: 32.70 ± 8.83; P = 3.7x10-5) and right ventricular index of myocardial performance score (Pre-delivery: 0.34 ±0.12; Post-delivery: 0.33 ±0.12; P = 0.007). Patients with severe PR was found to have significantly worse right ventricular global longitudinal strain (RV GLS) (P = 0.029). 2 patients progressed to severe PR following delivery.
Adult female patients with TOF can have viable pregnancies with acceptable mortality and morbidity. Deterioration in echocardiographic parameters were identified when comparing between pre-delivery and post-delivery studies. TOF patients should be closely monitored throughout and post-delivery for detection of deterioration of cardiac function and clinical symptoms.
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Affiliation(s)
- N W L Hon
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - P F Wong
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - Y K Tse
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - H L Li
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - L H Tsui
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
| | - K H Yiu
- The University of Hong Kong Shenzhen Hospital, Shenzhen, China, Hong Kong, Hong Kong
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9
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Li HL, Tse YK, Ren QW, Wu MZ, Yu SY, Yu SY, Wong PF, Tse HF, Yiu KH. The evolving characteristics and outcomes of acute myocardial infarction in Hong Kong, 1999–2018. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The burden of myocardial infarction (MI) with its assorted comorbid complications is increasing parallel to rising life expectancy. Careful characterisation of patient characteristics and identification of short- and long-term complications is critical to their management. Nonetheless, data on the evolving profiles of patient features and outcomes, particularly in an Asian population, remain sparse.
Purpose
We aim to describe the evolving characteristics and outcomes of MI patients in Hong Kong in the past 2 decades.
Methods
From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. The primary outcome was 30-day all-cause death, while secondary outcomes include haemorrhagic stroke, and pneumonia, at both 30 days and 5 years. Temporal trends in baseline characteristics were evaluated using Poisson regression, while trends in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications.
Results
A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Over time, while there was no change in the proportion of females (P=0.196), the increase in mean age (APC 0.23% [0.21 to 0.24], P<0.001) was concordant with the increase in mean CCI (APC 5.1%, [4.8 to 5.3], P<0.001), with more patients suffering from baseline comorbidities (Figure 1; range of APC 1.7% to 4.3%; all P<0.001). The proportion of ST elevation increased significantly (APC 2.5% [2.4 to 2.5], P<0.001).
The adjusted all-cause 30-day mortality rate decreased increased significantly (APC 0.3% [0.1 to 0.5], P=0.005). The increasing trend was significant in older patients (≥70 years), non-ST elevation, and female, while there was a decreasing trend mortality rate in ST elevation and young patients; no significant trend was observed in male. Strikingly, there is an alarming increase in the rate of haemorrhagic stroke (APC 3.4% [2.3 to 4.4], P<0.001) and pneumonia (APC 1.5% [1.3 to 1.7], P<0.001) at 30 days (Figure 2). Although the rate of 5-year all-cause death declined slightly (APC −0.8% [−0.9 to −0.6], P<0.001), there were increasing rates of haemorrhagic stroke (APC 1.0% [0.3 to 1.7], P=0.004) and pneumonia (APC 3.8% [3.6 to 4.1], P<0.001). Patients who were older, had ST elevation, and more comorbid were more likely to develop pneumonia.
Conclusions
Patients with MI have evolved to be older and more comorbid. Alarmingly, despite reduction in long-term all-cause death over time, the reduction was small; risk of death in short-term significantly increased and patients suffer from more complications including haemorrhagic stroke and pneumonia. These results highlight the emergence of extra-cardiac outcomes that drive poor prognosis and accentuate the need to develop tailored strategies to tackle these potentially lethal complications.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical Discipline; The Sanming Project of HKU-SZH Cardiology
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Affiliation(s)
- H L Li
- The University of Hong Kong, Hong Kong, China
| | - Y K Tse
- The University of Hong Kong, Hong Kong, China
| | - Q W Ren
- The University of Hong Kong, Hong Kong, China
| | - M Z Wu
- The University of Hong Kong, Hong Kong, China
| | - S Y Yu
- The University of Hong Kong, Hong Kong, China
| | - S Y Yu
- The University of Hong Kong, Hong Kong, China
| | - P F Wong
- The University of Hong Kong, Hong Kong, China
| | - H F Tse
- The University of Hong Kong, Hong Kong, China
| | - K H Yiu
- The University of Hong Kong, Hong Kong, China
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10
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Li KY, Lam LY, Leung CKL, Yu ASY, Wu MZ, Ren QW, Wong PF, Tse YK, Yu SSY, Li HL, Feng Y, Huo Y, Yiu KH. Prognostic value of a novel index: computational pressure-flow dynamics derived fractional flow reserve in patients with stable coronary artery disease treated with optimal medical therapy alone. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The use of fractional flow reserve (FFR) is limited due to the need of invasive pressure wire and hyperaemic stimulus. Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel non-invasive index to determine the FFR in patients with stable coronary artery disease (CAD).
Purpose
The clinical value of caFFR remains uncertain. The aim of the study is to evaluate the prognostic role of caFFR in patients with stable CAD who were treated by optimal medical therapy alone.
Methods
A total of 558 stable CAD patients (mean age=64.5±11.2, 59.0% male) with ≥1 coronary lesion detected during conventional coronary angiogram were included. All of them did not undergo percutaneous coronary intervention and were treated with optimal medical therapy alone. Patients were then classified into 4 groups according to their caFFR value; caFFR ≤0.70 (n=40), caFFR = 0.71–0.80 (n=28), caFFR = 0.81–0.90 (n=292), caFFR = 0.91–1.00 (n=198), with a lower caFFR indicating a greater magnitude of myocardial ischemia. The primary endpoint was 3-year major adverse cardiac events (MACE), defined as a composite of all-cause mortality, myocardial infarction or any unplanned revascularization.
Results
During a median follow-up of 36 months, a total of 49 composite events occurred, including 27 all-cause mortality, 4 myocardial infarction and 18 unplanned revascularization.
After multivariate adjustment, caFFR was an independent predictor of MACE (adjusted hazard ratio [HR] = 0.97 per 0.01 increase in caFFR; 95% confidence interval [Cl], 0.95–0.99; P<0.01), all-cause mortality (adjusted HR = 0.96 per 0.01 increase in caFFR; 95% Cl, 0.94–0.99; P<0.01), and stroke (adjusted HR = 0.95 per 0.01 increase in caFFR; 95% Cl, 0.90–0.99; P=0.03).
The area under the curve (AUC) by receiver-operating characteristic curve analysis (ROC) is 0.70 (95% Cl, 0.62–0.78; P<0.01). The optimal cut-off of caFFR defined by ROC analysis for predicting MACE is 0.80, concluding that patients with caFFR ≤0.80 have significantly higher adverse event rate, which is consistent with the cut-off from wire-based FFR.
Using caFFR = 0.91–1.00 as reference, the risk of MACE was highest in patients with caFFR ≤0.70 (adjusted HR = 4.65; 95% Cl, 1.81–11.94; P<0.01), followed by caFFR = 0.71–0.80 (adjusted HR = 3.67; 95% Cl, 1.12–11.33; P=0.02). The risk of MACE was nonetheless similar among patients with caFFR >0.8 (adjusted HR = 1.39; 95% Cl, 0.61–3.19, P=0.44).
Conclusion
In patients with stable CAD who were treated with optimal medical therapy alone, those with more significant myocardial ischemia, indicated by lower caFFR, had higher risks of adverse outcomes. The finding thus supports the use of this non invasive index to quantify the severity of myocardial ischemia, improve risk-stratification, and predict adverse outcomes in patients with stable CAD.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): The University of Hong Kong, Queen Mary Hospital
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Affiliation(s)
- K Y Li
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - L Y Lam
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - C K L Leung
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - A S Y Yu
- Queen Mary Hospital, The University of Hong Kong, Department of Medicine, Hong Kong, Hong Kong
| | - M Z Wu
- Queen Mary Hospital, The University of Hong Kong, Department of Medicine, Hong Kong, Hong Kong
| | - Q W Ren
- Queen Mary Hospital, The University of Hong Kong, Department of Medicine, Hong Kong, Hong Kong
| | - P F Wong
- Queen Mary Hospital, The University of Hong Kong, Department of Medicine, Hong Kong, Hong Kong
| | - Y K Tse
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - S S Y Yu
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - H L Li
- The University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - Y Feng
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Y Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - K H Yiu
- Queen Mary Hospital, The University of Hong Kong, Department of Medicine, Hong Kong, Hong Kong
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11
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Tse YK, Li HL, Yu SY, Wu MZ, Ren QW, Chen Y, Yu SY, Wong PF, Lam LY, Li KY, Leung KL, Tse HF, Yiu KH. Prognostic value of longitudinal assessment of hepatorenal function and nutritional status in patients undergoing valvular heart surgery. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Hepatorenal dysfunction and malnutrition are frequent extracardiac consequences of valvular heart disease (VHD) and have emerged as prominent drivers of adverse prognosis in selected valvular interventions. Nonetheless, data in a general VHD population is sparse, and their interaction and changes following valvular surgery remain unexplored.
Purpose
We aim to characterise the temporal changes, interaction, and prognostic implications of hepatorenal dysfunction and malnutrition before and after valvular surgery.
Methods
Baseline and temporal changes in hepatorenal dysfunction (assessed by the modified model for end-stage liver disease [MELD-XI] score) and nutritional status (assessed by Controlling Nutritional Status [CONUT] score) were correlated with adverse events (composite of all-cause mortality and hospitalisation for heart failure) using Cox proportional hazards model, adjusted with clinical and echocardiographic covariates, medications, type of valvular procedure, and cardiac surgery risk-stratification models (EuroSCORE II and STS score).
Results
Our study included 909 patients who underwent valvular surgery. At baseline, 216 (24%) and 554 (61%) had hepatorenal dysfunction (MELD-XI >12.43) and malnutrition (CONUT ≥2), respectively. MELD-XI scores were modestly correlated with CONUT scores (R=0.36, p<0.001), with concomitant hepatorenal dysfunction and malnutrition present in 177 (19%) patients.
Over a median follow-up of 4.1 years, 101 (11%) patients died and 119 (13%) were hospitalised for heart failure. There was a stepwise increase in mortality (χ2 89.1, p<0.001) and adverse events (χ2 92.9, p<0.001) from patients with normal hepatorenal function and nutrition to concomitant hepatorenal dysfunction and malnutrition (Figure 1). This association remained consistent in fully adjusted models. MELD-XI and CONUT scores significantly improved the discriminatory accuracy of EuroSCORE II (area under the curve [AUC]: 0.80 vs 0.73, p<0.001) and STS score (AUC: 0.79 vs 0.72, p=0.004) for all-cause mortality.
In patients with MELD-XI and CONUT scores 1 year after surgery (n=707), ΔMELD-XI (follow-up MELD-XI minus baseline MELD-XI score) and ΔCONUT scores were significantly associated with adverse events (HR 1.08, 95% CI 1.03–1.14, p=0.001 for ΔMELD-XI; HR 1.18, 95% CI 1.02–1.35, p=0.02 for ΔCONUT). Patients remaining with hepatorenal dysfunction and malnutrition experienced worse survival (log-rank χ2 65.2, p<0.001) and adverse events (log-rank χ2 90.4, p<0.001) (Figure 2).
Conclusions
In patients undergoing valvular surgery, hepatorenal function and nutritional status at baseline, and their temporal changes, are strongly linked to clinical outcomes. These results highlight the role of hepatorenal and nutritional assessment for risk-stratification in valvular surgery.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- Y K Tse
- The University of Hong Kong, Hong Kong, Hong Kong
| | - H L Li
- The University of Hong Kong, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - Q W Ren
- The University of Hong Kong, Hong Kong, Hong Kong
| | - Y Chen
- The University of Hong Kong, Hong Kong, Hong Kong
| | - S Y Yu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - P F Wong
- The University of Hong Kong, Hong Kong, Hong Kong
| | - L Y Lam
- The University of Hong Kong, Hong Kong, Hong Kong
| | - K Y Li
- The University of Hong Kong, Hong Kong, Hong Kong
| | - K L Leung
- The University of Hong Kong, Hong Kong, Hong Kong
| | - H F Tse
- The University of Hong Kong, Hong Kong, Hong Kong
| | - K H Yiu
- The University of Hong Kong, Hong Kong, Hong Kong
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12
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Lam LY, Leung CKL, Li KY, Wu MZ, Ren QW, Li HL, Yu SSY, Tse YK, Yu ASY, Wong PF, Tse HF, Feng Y, Huo Y, Yiu KH. Association between non-wire based computational angiography fractional flow reserve treatment threshold and major adverse cardiac events in patients with stable coronary artery disease. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Despite class IA guideline recommendations, the use of fractional flow reserve (FFR) in guiding percutaneous coronary intervention (PCI) in stable coronary artery disease (CAD) patients remains low due to limitations including the need of guidewire placement and hyperaemic stimulus. A novel non-invasive index, computational pressure-flow dynamics derived FFR (caFFR), was developed for measuring functional myocardial ischemia and overcoming the limitations of FFR. However, the clinical relevance of caFFR remains to be investigated. In the present study, we aim at evaluating the prognostic value of caFFR among stable CAD patients.
Methods
We retrospectively included patients with stable CAD who underwent coronary angiography during 2014–2016 at our center. Based on the caFFR value, patients were considered to be ischemic (caFFR ≤0.8) and non-ischemic (caFFR >0.8). Further, we recombined the patients to form the adherence cohort, where patients were defined as adherent-to-caFFR if they were ischemic with PCI or non-ischemic without PCI, and nonadherent-to-caFFR if they were ischemic without PCI or non-ischemic with PCI. The primary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause mortality, non-fatal myocardial infarction, and any revascularization. Inverse probability of treatment weighting was used to account for treatment selection bias (PCI vs without PCI, or adherent vs non-adherent), and Cox proportional hazard model was used to evaluate the association with MACE.
Results
A total of 1322 patients, 782 patients in the ischemic cohort and 540 patients in the non-ischemic cohort respectively, were included in our analysis. PCI was associated with a lower risk of MACE in the ischemic cohort (hazard ratio [HR] 0.52; 95% confidence interval [CI], 0.34–0.80; P=0.002), but was not associated with MACE in the non-ischemic cohort. In the adherence cohort, adherent-to-caFFR group (n=803) had a lower risk of MACE compared with nonadherent-to-caFFR group (n=566) (HR, 0.61; 95% CI, 0.44–0.85; P=0.003).
Conclusion
Our study is the first to demonstrate the prognostic value of caFFR, a non-wire based assessment of myocardial ischemia, in patients with stable CAD undergoing PCI. These findings support the use of caFFR that bears the potential of a wider adoption compared with wire-based FFR through a reduction in procedure time, risk and costs.
Funding Acknowledgement
Type of funding sources: None. Weighted Kaplan-Meier curvesWeighted Cox proportional hazards model
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Affiliation(s)
- L Y Lam
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - C K L Leung
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - K Y Li
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong Shenzhen Hospital, Department of Medicine, Shenzhen, China
| | - Q W Ren
- The University of Hong Kong Shenzhen Hospital, Department of Medicine, Shenzhen, China
| | - H L Li
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - S S Y Yu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Y K Tse
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - A S Y Yu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - P F Wong
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - H F Tse
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Y Feng
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Y Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - K H Yiu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
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13
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Li H, Tse YK, Ren QW, Wu MZ, Yu SY, Yu SY, Wong PF, Tse HF, Yiu KH. Trends and sex differences in characteristics and outcomes in myocardial infarction: a 20-year analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
There are considerable sex differences in patients with myocardial infarction (MI). However, the recent temporal trends in characteristics and outcomes in women vs. men, particularly in an Asian population, remain poorly understood.
Purpose
We aim to evaluate the sex differences in characteristics and outcomes, and how have these differences evolved over the past 2 decades in patients with MI.
Methods
From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. Outcomes of interest include, at 30 days, all-cause death, new-onset heart failure (HF), and ischaemic stroke. Trends in sex differences in baseline characteristics were evaluated using linear and Poisson regression, while differences in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications. A Fine-Gray model was used to evaluate HF and ischaemic stroke to account for competing risk, with all-cause death defined as competing event.
Results
A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Women were older (79.5±11.7 vs. 69.6±13.8 years, P<0.001) and had a more pronounced increasing trend in age over time (interaction P<0.001). Women were also more comorbid overall (Charlson Comorbidity Index [CCI] 1.25 vs 0.85, age-adjusted P<0.001), but the rising trend in CCI over time was less pronounced than in men (interaction P<0.001) (Figure 1). Women had more baseline hypertension, diabetes, and severe renal disease than men (age-adjusted P<0.001), while the increasing trends in these comorbidities were all more pronounced in men than in women (all interaction P<0.001). Women were more likely to have ST-elevation overall (P<0.001).
Although the crude 30-day mortality rate was higher in women (32.6% vs 23.9%), after adjustment for confounders, they had a lower risk of death (hazard ratio [HR] 0.97, 95% CI [0.96 to 0.99], P=0.003). There was no significant difference in the decreasing trend in 30-day mortality between both sexes (interaction P=0.787) (Figure 1). Women had a higher risk of developing HF (HR 1.04 [1.01 to 1.08], P=0.012) and ischemic stroke (HR 1.36 [1.24 to 1.48], P<0.001) in 30 days.
Among patients aged ≤55 (N=15,324), women (N=2,161, 14.1%) had higher risks of all-cause death (HR 1.61 [1.40 to 1.85], P<0.001), HF (HR 1.64 [1.17 to 2.32], P=0.004), and ischemic stroke (HR 1.69 [1.14 to 2.51], P=0.010) in 30 days, even after adjustment for covariates. The excess mortality in women declined over time (interaction P=0.002).
Conclusions
Women MI patients were older and more comorbid compared to men, which contributed to the higher risk of death, HF, and ischemic stroke among women. Among young MI patients, the increased risk for adverse outcomes among women was particularly pronounced, though the sex differences in mortality reduced over time.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology
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Affiliation(s)
- H Li
- The University of Hong Kong, Hong Kong, China
| | - Y K Tse
- The University of Hong Kong, Hong Kong, China
| | - Q W Ren
- The University of Hong Kong, Hong Kong, China
| | - M Z Wu
- The University of Hong Kong, Hong Kong, China
| | - S Y Yu
- The University of Hong Kong, Hong Kong, China
| | - S Y Yu
- The University of Hong Kong, Hong Kong, China
| | - P F Wong
- The University of Hong Kong, Hong Kong, China
| | - H F Tse
- The University of Hong Kong, Hong Kong, China
| | - K H Yiu
- The University of Hong Kong, Hong Kong, China
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14
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Leung CKL, Lam LY, Li KY, Yu ASY, Wu MZ, Ren QW, Wong PF, Tse YK, Yu SSY, Li HL, Feng Y, Huo Y, Tse HF, Yiu KH. Prognostic value of per-vessel treatment adherence in stable coronary artery disease based on novel computational pressure-flow dynamics derived fractional flow reserve. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel index developed to evaluate the extent of myocardial ischemia in patients with coronary artery disease (CAD), which eliminates the need of invasive pressure guidewire and hyperaemic stimulus in conventional fractional flow reserve (FFR) measurement. Studies have shown improved clinical outcomes associated with adherence to functional myocardial ischemia assessment when deciding to perform percutaneous coronary intervention (PCI) at a per-patient level. However, the clinical significance of such treatment adherence at a per-vessel level remains uncertain.
Methods
A total of 928 patients (mean age 66.2±10.5, male 72.7%) with stable CAD were included in this study. The caFFR of all three major coronary vessels were obtained for every patient, and the FFR threshold of 0.8 was adopted as the threshold for caFFR to indicate functionally significant artery stenosis which warrants PCI, and vice versa. Based on the caFFR of each major coronary vessel and whether PCI was performed to the respective vessel, patients were stratified into 0–1 vessel with treatment adherence group (group 1) (n=105), 2 vessels with treatment adherence group (group 2) (n=338), and 3 vessels with treatment adherence group (group 3) (n=485). The primary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause mortality, non-fatal myocardial infarction and any subsequent revascularization.
Results
The severity of CAD based on SYNTAX score assessment was 18.6±10.2 in group 1, 14.6±8.9 in group 2, and 11.5±9.9 in group 3 (P<0.001). The rates of MACE at 3 years were significantly different across groups 1, 2 and 3 (17.1% vs. 12.1% vs. 7.4%; P=0.004). With reference to group 3, the risk of MACE at 3 years was increased in group 2 (adjusted hazard ratio [HR]=1.597; 95% confidence interval [CI]=1.020–2.501; P=0.041), and further increased in group 1 (adjusted HR=1.933; 95% CI=1.081–3.457; P=0.026).
Conclusion
In stable CAD patients, the risk of MACE is incremental when fewer major coronary vessels are treated with adherence to caFFR threshold of 0.8. Per-vessel treatment adherence significantly affects clinical outcomes in terms of MACE.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C K L Leung
- The University of Hong Kong, Hong Kong, Hong Kong
| | - L Y Lam
- The University of Hong Kong, Hong Kong, Hong Kong
| | - K Y Li
- The University of Hong Kong, Hong Kong, Hong Kong
| | - A S Y Yu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - M Z Wu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Q W Ren
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - P F Wong
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Y K Tse
- The University of Hong Kong, Hong Kong, Hong Kong
| | - S S Y Yu
- The University of Hong Kong, Hong Kong, Hong Kong
| | - H L Li
- The University of Hong Kong, Hong Kong, Hong Kong
| | - Y Feng
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Y Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - H F Tse
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - K H Yiu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
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15
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Lam LY, Leung CKL, Li KY, Li HL, Wu MZ, Ren QW, Yu ASY, Wong PF, Tse YK, Yu SSY, Feng Y, Huo Y, Tse HF, Yiu KH. Long-term prognostic implications of PCI in ACS patients without ischemia on the basis of computational pressure-flow dynamics derived fractional flow reserve. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A substantial proportion of patients with acute coronary syndrome (ACS) may have intermediate lesion that are non-ischemic during emergency coronary angiography. The prognosis of such patients, compared to those with stable ischemic heart disease (SIHD) without ischemic lesion is however uncertain. Recently, a novel index, computational pressure-flow dynamics derived fractional flow reserve (caFFR), has been developed to assess myocardial ischemia, without the need of invasive pressure wire and hyperaemic stimulus as required in conventional fractional flow reserve (FFR). By utilizing caFFR to assess for ischaemic status during coronary angiography, the aim of our study is first to assess the prognostic difference between ACS and SIHD with non-ischaemia intermediate lesions. Second, we ascertain whether PCI in patients with ACS with non-ischaemia intermediate lesions provides survival benefit in addition to medical therapy.
Methods
We retrospectively recruited 551 patients (mean age 64.4 years; male 59.9%) with absence of myocardial ischaemia, defined as caFFR ≥0.80 in all vessels, from our Hospital. Patients were stratified into those with index presentation of ACS (n=132) and those with SIHD (n=491). Among the ACS cohort, patients were further divided into those with PCI (n=83) and with medical therapy alone (n=49). The SIHD cohort (n=491), all of whom were treated with medical therapy alone, was considered as referent group. The primary end point was major adverse cardiovascular events (MACE) at 3 years, which was defined as a composite of all-cause mortality, non-fatal myocardial infarction (MI), and any unplanned revascularization.
Results
During a median follow-up of 36 months, 54 composite events occurred, including 38 all-cause mortality, 5 MI, and 14 unplanned revascularization. Compared to those with SIHD, patients with ACS was independently associated with MACE even in the absence of myocardial ischaemia (adjusted Hazard Ratios=2.531; 95% confidence interval=1.397–4.586; P=0.002). The 3-year incidence rate of MACE was the highest in ACS patients with medical therapy alone, followed by ACS patients with immediate PCI; the SIHD cohort had the lowest incidence rates (30.6% vs 12.0% vs 5.9%, P<0.001). This was mainly driven by the rate of all-cause death (26.5% vs 12.0% vs 3.1%; P<0.001). Similar findings were observed for hospitalisation due to heart failure (14.3% vs 6.0% vs 3.1%, P=0.031) and cardiac death (8.2% vs 4.8% vs 0.4%, P<0.001) at 3 years.
Conclusion
In patients with intermediate lesion without myocardial ischaemia (defined as caFFR ≥0.8), those presented with ACS had a higher risk of MACE at 3 years compared to SIHD. Among ACS patients with intermediate lesion without myocardial ischaemia, PCI significantly reduces the rate of MACE. In patients with ACS, our finding suggests that PCI should be advocated to intermediate lesion even without myocardial ischaemia.
Funding Acknowledgement
Type of funding sources: None. Kaplan-Meier curve for MACECumulative Events at 3 Years
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Affiliation(s)
- L Y Lam
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - C K L Leung
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - K Y Li
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - H L Li
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - M Z Wu
- The University of Hong Kong Shenzhen Hospital, Department of Medicine, Shenzhen, China
| | - Q W Ren
- The University of Hong Kong Shenzhen Hospital, Department of Medicine, Shenzhen, China
| | - A S Y Yu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - P F Wong
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Y K Tse
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - S S Y Yu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - Y Feng
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - Y Huo
- PKU-HKUST Shenzhen-Hongkong Institution, Shenzhen, China
| | - H F Tse
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
| | - K H Yiu
- Queen Mary Hospital, Department of Medicine, Hong Kong, Hong Kong
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16
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Ding CH, Wahab AA, Marina Z, Leong CL, Umur N, Wong PF. Adult-onset nasopharyngeal diphtheria: an uncommon but rapidly progressive and potentially fatal infection. Trop Biomed 2021; 38:119-121. [PMID: 34172699 DOI: 10.47665/tb.38.2.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Nasopharyngeal diphtheria is an acute infectious upper respiratory tract disease caused by toxigenic strains of Corynebacterium diphtheriae. We report a case of a young adult who presented to us with a short history of fever, sore throat, hoarseness of voice and neck swelling. He claimed to have received all his childhood vaccinations and had no known medical illnesses. During laryngoscopy, a white slough (or membrane) was seen at the base of his tongue. The epiglottis was also bulky and the arytenoids were swollen bilaterally. The membrane was sent to the microbiology laboratory for culture. A diagnosis of nasopharyngeal diphtheria was made clinically and the patient was treated with an antitoxin together with erythromycin, while awaiting the culture result. Nevertheless, the patient's condition deteriorated swiftly and although the laboratory eventually confirmed an infection by toxin-producing C. diphtheriae, the patient had already succumbed to the infection.
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Affiliation(s)
- C H Ding
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - A A Wahab
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysi
| | - Z Marina
- Department of Pathology, Hospital Kuala Lumpur, Ministry of Health of Malaysia, 50586 Kuala Lumpur, Malaysia
| | - C L Leong
- Department of Medicine, Hospital Kuala Lumpur, Ministry of Health of Malaysia, 50586 Kuala Lumpur, Malaysia
| | - N Umur
- Department of Pathology, Hospital Shah Alam, Ministry of Health of Malaysia, 40000 Shah Alam, Selangor, Malaysia
| | - P F Wong
- Cheras Baru Health Clinic, Health Department of Federal Territory of Kuala Lumpur and Putrajaya, Ministry of Health of Malaysia, Kampung Cheras Baru, 56100 Kuala Lumpur, Malaysia
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17
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Berry S, Giraldo NA, Green BF, Cottrell TR, Stein JE, Engle EL, Xu H, Ogurtsova A, Roberts C, Wang D, Nguyen P, Zhu Q, Soto-Diaz S, Loyola J, Sander IB, Wong PF, Jessel S, Doyle J, Signer D, Wilton R, Roskes JS, Eminizer M, Park S, Sunshine JC, Jaffee EM, Baras A, De Marzo AM, Topalian SL, Kluger H, Cope L, Lipson EJ, Danilova L, Anders RA, Rimm DL, Pardoll DM, Szalay AS, Taube JM. Analysis of multispectral imaging with the AstroPath platform informs efficacy of PD-1 blockade. Science 2021; 372:372/6547/eaba2609. [PMID: 34112666 DOI: 10.1126/science.aba2609] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/08/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
Next-generation tissue-based biomarkers for immunotherapy will likely include the simultaneous analysis of multiple cell types and their spatial interactions, as well as distinct expression patterns of immunoregulatory molecules. Here, we introduce a comprehensive platform for multispectral imaging and mapping of multiple parameters in tumor tissue sections with high-fidelity single-cell resolution. Image analysis and data handling components were drawn from the field of astronomy. Using this "AstroPath" whole-slide platform and only six markers, we identified key features in pretreatment melanoma specimens that predicted response to anti-programmed cell death-1 (PD-1)-based therapy, including CD163+PD-L1- myeloid cells and CD8+FoxP3+PD-1low/mid T cells. These features were combined to stratify long-term survival after anti-PD-1 blockade. This signature was validated in an independent cohort of patients with melanoma from a different institution.
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Affiliation(s)
- Sneha Berry
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nicolas A Giraldo
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Benjamin F Green
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tricia R Cottrell
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Julie E Stein
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth L Engle
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Haiying Xu
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Aleksandra Ogurtsova
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Charles Roberts
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daphne Wang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Peter Nguyen
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Qingfeng Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sigfredo Soto-Diaz
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jose Loyola
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Inbal B Sander
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Pok Fai Wong
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Shlomit Jessel
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Joshua Doyle
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Danielle Signer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Richard Wilton
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jeffrey S Roskes
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Margaret Eminizer
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Seyoun Park
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joel C Sunshine
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth M Jaffee
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alexander Baras
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Angelo M De Marzo
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Suzanne L Topalian
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Harriet Kluger
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Leslie Cope
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Evan J Lipson
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Ludmila Danilova
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert A Anders
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - David L Rimm
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Drew M Pardoll
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alexander S Szalay
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Janis M Taube
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA. .,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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18
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Berry S, Giraldo NA, Green BF, Cottrell TR, Stein JE, Engle EL, Xu H, Ogurtsova A, Roberts C, Wang D, Nguyen P, Zhu Q, Soto-Diaz S, Loyola J, Sander IB, Wong PF, Jessel S, Doyle J, Signer D, Wilton R, Roskes JS, Eminizer M, Park S, Sunshine JC, Jaffee EM, Baras A, De Marzo AM, Topalian SL, Kluger H, Cope L, Lipson EJ, Danilova L, Anders RA, Rimm DL, Pardoll DM, Szalay AS, Taube JM. Analysis of multispectral imaging with the AstroPath platform informs efficacy of PD-1 blockade. Science 2021. [PMID: 34112666 DOI: 10.1126/science.aba2609.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Next-generation tissue-based biomarkers for immunotherapy will likely include the simultaneous analysis of multiple cell types and their spatial interactions, as well as distinct expression patterns of immunoregulatory molecules. Here, we introduce a comprehensive platform for multispectral imaging and mapping of multiple parameters in tumor tissue sections with high-fidelity single-cell resolution. Image analysis and data handling components were drawn from the field of astronomy. Using this "AstroPath" whole-slide platform and only six markers, we identified key features in pretreatment melanoma specimens that predicted response to anti-programmed cell death-1 (PD-1)-based therapy, including CD163+PD-L1- myeloid cells and CD8+FoxP3+PD-1low/mid T cells. These features were combined to stratify long-term survival after anti-PD-1 blockade. This signature was validated in an independent cohort of patients with melanoma from a different institution.
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Affiliation(s)
- Sneha Berry
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nicolas A Giraldo
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Benjamin F Green
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tricia R Cottrell
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Julie E Stein
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth L Engle
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Haiying Xu
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Aleksandra Ogurtsova
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Charles Roberts
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daphne Wang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Peter Nguyen
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Qingfeng Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sigfredo Soto-Diaz
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jose Loyola
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Inbal B Sander
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Pok Fai Wong
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Shlomit Jessel
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Joshua Doyle
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Danielle Signer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Richard Wilton
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jeffrey S Roskes
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Margaret Eminizer
- Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Seyoun Park
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joel C Sunshine
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth M Jaffee
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alexander Baras
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Angelo M De Marzo
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Suzanne L Topalian
- Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Harriet Kluger
- Division of Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Leslie Cope
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Evan J Lipson
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Ludmila Danilova
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert A Anders
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - David L Rimm
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Drew M Pardoll
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alexander S Szalay
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Astronomy and Physics, Johns Hopkins University, Baltimore, MD 21218, USA.,Institute for Data Intensive Engineering and Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Janis M Taube
- The Mark Foundation Center for Advanced Genomics and Imaging, Johns Hopkins University, Baltimore, MD 21287, USA. .,Bloomberg~Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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19
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Martinez-Morilla S, Villarroel-Espindola F, Wong PF, Toki MI, Aung TN, Pelekanou V, Bourke-Martin B, Schalper KA, Kluger HM, Rimm DL. Biomarker Discovery in Patients with Immunotherapy-Treated Melanoma with Imaging Mass Cytometry. Clin Cancer Res 2021; 27:1987-1996. [PMID: 33504554 DOI: 10.1158/1078-0432.ccr-20-3340] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/22/2020] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Imaging mass cytometry (IMC) is among the first tools with the capacity for multiplex analysis of more than 40 targets, which provides a novel approach to biomarker discovery. Here, we used IMC to characterize the tumor microenvironment of patients with metastatic melanoma who received immunotherapy in efforts to find indicative factors of treatment response. In spite of the new power of IMC, the image analysis aspects are still limited by the challenges of cell segmentation. EXPERIMENTAL DESIGN Here, rather than segment, we performed image analysis using a newly designed version of the AQUA software to measure marker intensity in molecularly defined compartments: tumor cells, stroma, T cells, B cells, and macrophages. IMC data were compared with quantitative immunofluorescence (QIF) and digital spatial profiling. RESULTS Validation of IMC results for immune markers was confirmed by regression with additional multiplexing methods and outcome assessment. Multivariable analyses by each compartment revealed significant associations of 12 markers for progression-free survival and seven markers for overall survival (OS). The most compelling indicative biomarker, beta2-microglobulin (B2M), was confirmed by correlation with OS by QIF in the discovery cohort and validated in an independent published cohort profiled by mRNA expression. CONCLUSIONS Using digital image analysis based on pixel colocalization to assess IMC data allowed us to quantitively measure 25 markers simultaneously on formalin-fixed, paraffin-embedded tissue microarray samples. In addition to showing high concordance with other multiplexing technologies, we identified a series of potentially indicative biomarkers for immunotherapy in metastatic melanoma, including B2M.
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Affiliation(s)
| | | | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Maria I Toki
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Thazin Nwe Aung
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Vasiliki Pelekanou
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | | | - Kurt A Schalper
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Harriet M Kluger
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut.
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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20
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Martinez-Morilla S, Zugazagoitia J, Wong PF, Kluger HM, Rimm DL. Quantitative analysis of CMTM6 expression in tumor microenvironment in metastatic melanoma and association with outcome on immunotherapy. Oncoimmunology 2020; 10:1864909. [PMID: 33457084 PMCID: PMC7781756 DOI: 10.1080/2162402x.2020.1864909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/12/2020] [Indexed: 12/31/2022] Open
Abstract
Chemokine-like factor (CKLF)-like MARVEL transmembrane domain containing 6 (CMTM6) modulates degradation of a number of proteins, including programmed death ligand-1 (PD-L1) by protecting it from ubiquitin-mediated degradation. In this role, it could modulate the effectiveness of immunotherapy. Here, for the first time, we characterize CMTM6 expression in melanoma and evaluate its association with response to immune checkpoint inhibitors (ICI). We evaluated the expression of CMTM6, PD-L1 and other immune-related proteins in 60 pretreatment biopsies from metastatic melanoma patients who received immunotherapy, in a tissue microarray (TMA) using quantitative immunofluorescence (QIF). Expression of mRNA from control patients obtained from The Cancer Genome Atlas (TCGA) database was also compared. CMTM6 expression was positively correlated with PD-L1, CD3, CD20, and CD68 markers, at protein (Pearson's r = 0.53-0.81, all P < .0001) and mRNA (Spearman's r = 0.15-0.44, all P < .002, except for CD68 where P = .26) levels. CMTM6 protein was associated with longer survival after immunotherapy when measured in the stromal (P = .007) and all the immune compartments tested (T cells, B cells, and macrophages). Multivariable analyses also revealed significant CMTM6 survival associations when measured in stromal (Hazard Ratio (HR) = 0.12, P = .001) and CD68-positive (HR = 0.30, P = .043) compartments. Additionally, PD-L1 but not CMTM6 showed prognostic value in control patients. Finally, high CMTM6 and PD-L1 co-expression in the stromal compartment was significantly associated with longer survival in treated patients (P = .028). Consequently, CMTM6 expression shows potential as a predictive factor for ICI treatments.
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Affiliation(s)
| | - Jon Zugazagoitia
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pok Fai Wong
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harriet M. Kluger
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David L. Rimm
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Vathiotis IA, Reeves J, Toki M, Wong PF, Kluger H, Aung TN, Syrigos KN, Warren S, Rimm DL. Abstract 3095: Combination of spatial protein data with bulk transcriptional profiling of the same cohort shows relationships between RNA and protein and facilitates combined predictive signatures. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-3095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Although there are several mRNA signatures with some ability to predict outcomes in melanoma patients treated with immunotherapy, more robust predictive models are needed to optimize therapeutic selection. Here, we integrated spatially-resolved protein information acquired by the NanoString® GeoMx® Digital Spatial Profiler (DSP) with information from bulk mRNA gene expression acquired using NanoString® nCounter® PanCancer IO 360™ panel on the same cohort of immunotherapy treated melanoma patients to create predictive models associated with clinical outcomes.
Methods: We assessed pretreatment tumor samples from 59 immunotherapy treated melanoma patients. RNA for gene expression was extracted from formalin-fixed paraffin-embedded whole tissue sections, then hybridized to the 770-plex PanCancer IO 360™ panel and measured on the nCounter platform. The same cases were represented in a tissue microarray, where 32 protein targets were quantified in three different compartments (tumor [s100+], leukocyte [CD45+] and macrophage [CD68+]) using NanoString's GeoMx DSP platform (Toki et al, CCR 2018). The combined dataset of IO 360 gene expression and GeoMx DSP protein data was compared to patient overall survival (OS), objective response (OR), or clinical benefit (CB) using univariate cox or logistic regression models, as well as receiver operator characteristic (ROC) analysis. For each outcome, we used either Lasso (L1 Regularization) or Elastic Net (L0.5 Regularization) approaches to select analytes that were initially identified as nominally significant univariate analysis (P<0.05). Internal leave one out cross-validation was used to ensure model robustness.
Results: Hierarchical clustering of both data sets showed that the DSP data generally clustered away from bulk RNA profiling data. PD-L1 mRNA showed weak correlation with spatially-derived protein (R2=0.04 in the s100+, 0.11 in the CD68+ and 0.12 in the CD45+ compartment). IDO1 mRNA was moderately correlated with protein (R2=0.39 in the s100+, 0.21 in the CD68+ and 0.23 in the CD45+ compartment). A total of 228 variables (including 191 mRNA and 37 protein) that were statistically significant in univariate analysis were identified. Models were constructed to predict OR, OS and CB with individual and mixed modality markers with AUCs above 0.7.
Conclusions: This work supports the integration of spatially-derived protein data with bulk mRNA gene expression data for the construction of predictive models for melanoma patients receiving immune checkpoint inhibition and lays the groundwork for validation in an independent dataset.
Citation Format: Ioannis A. Vathiotis, Jason Reeves, Maria Toki, Pok Fai Wong, Harriet Kluger, Thazin Nwe Aung, Konstantinos N. Syrigos, Sarah Warren, David L. Rimm. Combination of spatial protein data with bulk transcriptional profiling of the same cohort shows relationships between RNA and protein and facilitates combined predictive signatures [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3095.
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Martinez-Morilla S, Villarroel-Espindola F, Wong PF, Kluger H, Toki M, Aung TN, Pelekanou V, Bourke-Martin B, Rimm DL. Abstract 2001: Biomarker discovery in immunotherapy-treated melanoma patients with imaging mass cytometry. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-2001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Understanding the complexity of the tumor microenvironment could allow identification of new biomarkers that predict response to immunotherapy in cancer patients and anticipate the toxicity associated with the treatment. Since the number of targets measurable by quantitative immunofluorescence (QIF) is limited, we applied Imaging Mass Cytometry (IMC), a metal-conjugated antibody-based high-plex technology, to generate a multidimensional analysis of the microenvironment. We interrogated a 25-antibody panel, including tumor and immune cell markers, in a cohort of melanoma patients treated with immune checkpoint blockers.
Methods: We used a validated, optimized panel of 25 antibodies conjugated to unique metals, including a DNA intercalator conjugated with 191/193Ir, for detection using HyperionTM (Fluidigm). Digital image analysis was performed using a newly designed version of the AQUA software (Navigate BP) to measure marker intensity in molecularly defined masks or compartments as follows: all cells (DNA intercalator Ir191/193), tumor cells (HMB45/S100), stroma (tumor cells subtracted from all cells), T cells (CD3), B cells (CD20) and macrophages (CD68). Results were compared to QIF and Digital Spatial Profiling (DSP), a NanoString technology based on primary antibodies conjugated to indexing DNA oligos. We examined archived formalin-fixed paraffin-embedded (FFPE) samples from a metastatic melanoma cohort treated with immunotherapy (n=60) in tissue microarray format.
Results: Immune markers such as CD3, CD4 and CD8 showed a high correlation between the three multiplexing methods: IMC, DSP and QIF (r=0.48-0.89, p<0.0001). Moreover, high CD3 and CD8 levels assessed by IMC were statistically significantly associated with favorable outcome, confirming results previously published on the same cohort (Toki et al, CCR, 2018). Multivariable analyses revealed significant associations of MHC-I, CSF1R, IRF1, LAG3, PD1, MHC-II and beta2-microglobulin (B2M) in tumor with progression-free survival (PFS) independent of age, sex, mutation, stage, treatment, and prior immune checkpoint blockade treatment. In stroma, high TIM3 and high PD-L2 also predicted response to immunotherapy. Furthermore, we tested for validation by QIF B2M, MHC-I and CSF1R, predictive markers identified by IMC. However, only B2M showed a statistically significant correlation with overall survival.
Conclusion: Using IMC technology and digital image analysis based on pixel colocalization, we were able to evaluate simultaneously 25 markers on FFPE tissue microarray samples. There was a high concordance with QIF and DSP for immune markers such as CD3, CD4 and CD8. A series of potentially predictive biomarkers for immunotherapy in metastatic melanoma were identified.
Citation Format: Sandra Martinez-Morilla, Franz Villarroel-Espindola, Pok Fai Wong, Harriet Kluger, Maria Toki, Thazin New Aung, Vasiliki Pelekanou, Brian Bourke-Martin, David L. Rimm. Biomarker discovery in immunotherapy-treated melanoma patients with imaging mass cytometry [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2001.
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Wong LP, Wong PF, AbuBakar S. Vaccine hesitancy and the resurgence of vaccine preventable diseases: the way forward for Malaysia, a Southeast Asian country. Hum Vaccin Immunother 2020; 16:1511-1520. [PMID: 31977285 DOI: 10.1080/21645515.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
This study engaged health professionals in in-depth, semi-structured interviews to explore their opinions concerning the issues surrounding vaccine hesitancy in Malaysia and strategies to improve vaccination to stamp the rise of vaccine preventable diseases (VPDs). Opinions on how to address the resurgence of VPDs in the era of increasing vaccine hesitancy were obtained. Eight health professionals, including geriatricians, pediatricians, microbiologists, public health specialists, and family medicine specialists were interviewed. The influence of anti-vaccination propaganda, past-experience of adverse event following immunization (AEFI), perceived religious prohibition, a belief that traditional complementary and alternative medicine (TCAM) use is safer, pseudoscience beliefs, and anti-vaccine conspiracy theories were identified as reasons for refusing to vaccinate. The interplay of social, cultural and religious perspectives in influencing perceived religious prohibition, pseudoscience beliefs, and the use of TCAM contributing to vaccine refusal was found. Five broad themes emerged from the health professionals regarding strategies to address vaccine hesitancy, including establishing an electronic vaccination registry, increasing public awareness initiatives, providing feedback to the public on the findings of AEFI, training of front-line healthcare providers, and banning the dissemination of anti-vaccine information via social media. With regards to identifying strategies to address the resurgence of VPDs, mandatory vaccination received mixed opinions; many viewed supplementary immunization activity and the prevention of travel and migration of unvaccinated individuals as being necessary. In conclusion, the present study identified unique local cultural, traditional and religious beliefs that could contribute to vaccine hesitancy in addition to issues surrounding vaccination refusal similarly faced by other countries around the world. This information are important for the formulation of targeted intervention strategies to stamp vaccine hesitancy in Malaysia which are also a useful guide for other countries especially in the Southeast Asia region facing similar vaccine hesitancy issues.
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Affiliation(s)
- L P Wong
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - P F Wong
- Department of Pharmacology, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - S AbuBakar
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
- Tropical Infectious Diseases Research and Educational Centre (TIDREC), University of Malaya , Kuala Lumpur, Malaysia
- WHO Collaborating Centre for Arbovirus Reference and Research (Dengue and Severe Dengue) MAA-12, University of Malaya , Kuala Lumpur, Malaysia
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Krutikova EV, Stepanova EA, Wong PF, Kiseleva IV, Grigor'eva EP, Rudenko LG. Genetic Basis of Attenuation of Cold-Adapted Influenza Strain B/Leningrad/14/17/55 - Backup Master Donor Virus for Influenza Type B Live Attenuated Vaccines. Bull Exp Biol Med 2020; 168:669-672. [PMID: 32248454 DOI: 10.1007/s10517-020-04777-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Indexed: 10/24/2022]
Abstract
The reassortant vaccine strain of live attenuated influenza vaccine inherits temperature sensitivity and areactogenicity from cold-adapted attenuated master donor virus. In Russia, B/ USSR/60/69 master donor virus (B60) is currently in use for the preparation of live attenuated type B influenza vaccine candidates. Trivalent live attenuated influenza vaccine based on A/ Leningrad/134/17/57 and B60 are licensed for the use in Russia for single dose vaccination of adults and children over 3 years. B/Leningrad/14/17/55 (B14) cold-adapted virus is a backup master donor virus for live attenuated type B influenza vaccine. According to our preliminary estimates, it is more attenuated than B60, which can allow expanding applicability of this vaccine for children under 3 years of age. In this paper, the role of B14 genes in its attenuation was assessed. Representative collection of reassortants of B14 with epidemic influenza B viruses was obtained, a phenotypic analysis of reassortants was performed, and their pathogenicity for animals was assessed. The leading role of PB2 and PA genes in attenuation of B14 master donor virus was proven.
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Affiliation(s)
- E V Krutikova
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia.
| | - E A Stepanova
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - P F Wong
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - I V Kiseleva
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - E P Grigor'eva
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - L G Rudenko
- A. A. Smorodintsev Department of Virology, Institute of Experimental Medicine, St. Petersburg, Russia
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Ng CJ, Teo CH, Ang KM, Kok YL, Ashraf K, Leong HL, Taher SW, Mohd SZ, Zakaria ZF, Wong PF, Hor CP, Ong TA, Hussain H, V P, Ng CW, Agamutu K, Abd Razak MA. Barriers to implementing a national health screening program for men in Malaysia: An online survey of healthcare providers. Malays Fam Physician 2020; 15:6-14. [PMID: 32284799 PMCID: PMC7136681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION This study aimed to determine the views and practices of healthcare providers and barriers they encountered when implementing the national health screening program for men in a public primary care setting in Malaysia. METHODS An online survey was conducted among healthcare providers across public health clinics in Malaysia. All family medicine specialists, medical officers, nurses and assistant medical officers involved in the screening program for adult men were invited to answer a 51-item questionnaire via email or WhatsApp. The questionnaire comprised five sections: participants' socio-demographic information, current screening practices, barriers and facilitators to using the screening tool, and views on the content and format of the screening tool. RESULTS A total of 231 healthcare providers from 129 health clinics participated in this survey. Among them, 37.44% perceived the implementation of the screening program as a "top-down decision." Although 37.44% found the screening tool for adult men "useful," some felt that it was "time consuming" to fill out (38.2%) and "lengthy" (28.3%). In addition, 'adult men refuse to answer' (24.1%) was cited as the most common patient-related barrier. CONCLUSIONS This study provided useful insights into the challenges encountered by the public healthcare providers when implementing a national screening program for men. The screening tool for adult men should be revised to make it more user-friendly. Further studies should explore the reasons why men were reluctant to participate in health screenings, thus enhancing the implementation of screening programs in primary care.
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Affiliation(s)
- C J Ng
- MBBS, MMed (Fam Med), PhD Professor Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
| | - C H Teo
- BMedImag, PhD Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
| | - K M Ang
- Medical student Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
- School of Medicine, Queen's University Belfast, Belfast United Kingdom, UK
| | - Y L Kok
- MBBS Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
| | - K Ashraf
- BSc, MAppStat Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
| | - H L Leong
- MBBS Department of Primary Care Medicine Faculty of Medicine, University of Malaya, Malaysia
| | - S W Taher
- MBBS, MMed Klinik Kesihatan Simpang Kuala Alor Setar, Kedah, Malaysia
| | - Said Z Mohd
- MBBS, MMed Family Health Development Division Ministry of Health, Putrajaya Malaysia
| | - Z F Zakaria
- MBBS, MMed Klinik Kesihatan Setapak Kuala Lumpur, Malaysia
| | - P F Wong
- MBBS, Dr Fam Med, FRACGP, MAFP Klinik Kesihatan Cheras Baru Kuala Lumpur, Malaysia
| | - C P Hor
- MB BCh BAO, MSc Department of Medicine, Kepala Batas Hospital
- Institute for Clinical Research, National Institutes of Health, Malaysia
| | - T A Ong
- MBBS, MMed Department of Surgery, Faculty of Medicine, University of Malaya Kuala Lumpur, Malaysia
| | - H Hussain
- MBBS, MMed Klinik Kesihatan Salak, Sepang Selangor, Malaysia
| | - Paranthaman V
- MBBS, MMed Jelapang Health Clinic, Klinik Kesihatan Jelapang, 30020 Ipoh Perak, Malaysia
| | - C W Ng
- MBBS, MPH, MPH (Health Services Management), PhD Professor Department of Social and Preventive Medicine, Faculty of Medicine University of Malaya, Kuala Lumpur Malaysia
- Centre for Epidemiology and Evidence-based Practice, University of Malaya, Kuala Lumpur, Malaysia
| | - K Agamutu
- MBBS, MPH Family Health Development Division Ministry of Health, Putrajaya Malaysia
| | - M A Abd Razak
- BSc Institute for Public Health, National Institute of Health, Setia Alam 40170 Selangor, Malaysia
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26
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Wong LP, Wong PF, AbuBakar S. Vaccine hesitancy and the resurgence of vaccine preventable diseases: the way forward for Malaysia, a Southeast Asian country. Hum Vaccin Immunother 2020; 16:1511-1520. [PMID: 31977285 DOI: 10.1080/21645515.2019.1706935] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
This study engaged health professionals in in-depth, semi-structured interviews to explore their opinions concerning the issues surrounding vaccine hesitancy in Malaysia and strategies to improve vaccination to stamp the rise of vaccine preventable diseases (VPDs). Opinions on how to address the resurgence of VPDs in the era of increasing vaccine hesitancy were obtained. Eight health professionals, including geriatricians, pediatricians, microbiologists, public health specialists, and family medicine specialists were interviewed. The influence of anti-vaccination propaganda, past-experience of adverse event following immunization (AEFI), perceived religious prohibition, a belief that traditional complementary and alternative medicine (TCAM) use is safer, pseudoscience beliefs, and anti-vaccine conspiracy theories were identified as reasons for refusing to vaccinate. The interplay of social, cultural and religious perspectives in influencing perceived religious prohibition, pseudoscience beliefs, and the use of TCAM contributing to vaccine refusal was found. Five broad themes emerged from the health professionals regarding strategies to address vaccine hesitancy, including establishing an electronic vaccination registry, increasing public awareness initiatives, providing feedback to the public on the findings of AEFI, training of front-line healthcare providers, and banning the dissemination of anti-vaccine information via social media. With regards to identifying strategies to address the resurgence of VPDs, mandatory vaccination received mixed opinions; many viewed supplementary immunization activity and the prevention of travel and migration of unvaccinated individuals as being necessary. In conclusion, the present study identified unique local cultural, traditional and religious beliefs that could contribute to vaccine hesitancy in addition to issues surrounding vaccination refusal similarly faced by other countries around the world. This information are important for the formulation of targeted intervention strategies to stamp vaccine hesitancy in Malaysia which are also a useful guide for other countries especially in the Southeast Asia region facing similar vaccine hesitancy issues.
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Affiliation(s)
- L P Wong
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - P F Wong
- Department of Pharmacology, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - S AbuBakar
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia.,Tropical Infectious Diseases Research and Educational Centre (TIDREC), University of Malaya , Kuala Lumpur, Malaysia.,WHO Collaborating Centre for Arbovirus Reference and Research (Dengue and Severe Dengue) MAA-12, University of Malaya , Kuala Lumpur, Malaysia
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Acs B, Ahmed FS, Gupta S, Wong PF, Gartrell RD, Sarin Pradhan J, Rizk EM, Gould Rothberg B, Saenger YM, Rimm DL. An open source automated tumor infiltrating lymphocyte algorithm for prognosis in melanoma. Nat Commun 2019; 10:5440. [PMID: 31784511 PMCID: PMC6884485 DOI: 10.1038/s41467-019-13043-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/15/2019] [Indexed: 12/15/2022] Open
Abstract
Assessment of tumor infiltrating lymphocytes (TILs) as a prognostic variable in melanoma has not seen broad adoption due to lack of standardization. Automation could represent a solution. Here, using open source software, we build an algorithm for image-based automated assessment of TILs on hematoxylin-eosin stained sections in melanoma. Using a retrospective collection of 641 melanoma patients comprising four independent cohorts; one training set (N = 227) and three validation cohorts (N = 137, N = 201, N = 76) from 2 institutions, we show that the automated TIL scoring algorithm separates patients into favorable and poor prognosis cohorts, where higher TILs scores were associated with favorable prognosis. In multivariable analyses, automated TIL scores show an independent association with disease-specific overall survival. Therefore, the open source, automated TIL scoring is an independent prognostic marker in melanoma. With further study, we believe that this algorithm could be useful to define a subset of patients that could potentially be spared immunotherapy.
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Affiliation(s)
- Balazs Acs
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA.,Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Swati Gupta
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Robyn D Gartrell
- Department of Medicine, Division of Hematology/Oncology, Columbia University Medical Center/New York Presbyterian, New York, NY, USA
| | - Jaya Sarin Pradhan
- Department of Pathology and Cell Biology, Division of Oral and Maxillofacial Pathology, Columbia University Irving Medical Center/New York Presbyterian, New York, NY, USA
| | - Emanuelle M Rizk
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center/New York Presbyterian, New York, NY, USA
| | | | - Yvonne M Saenger
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center/New York Presbyterian, New York, NY, USA
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA. .,Department of Medicine, Yale School of Medicine, New Haven, CT, 06510, USA.
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Kulkarni PM, Robinson EJ, Sarin Pradhan J, Gartrell-Corrado RD, Rohr BR, Trager MH, Geskin LJ, Kluger HM, Wong PF, Acs B, Rizk EM, Yang C, Mondal M, Moore MR, Osman I, Phelps R, Horst BA, Chen ZS, Ferringer T, Rimm DL, Wang J, Saenger YM. Deep Learning Based on Standard H&E Images of Primary Melanoma Tumors Identifies Patients at Risk for Visceral Recurrence and Death. Clin Cancer Res 2019; 26:1126-1134. [PMID: 31636101 PMCID: PMC8142811 DOI: 10.1158/1078-0432.ccr-19-1495] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/09/2019] [Accepted: 10/16/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Biomarkers for disease-specific survival (DSS) in early-stage melanoma are needed to select patients for adjuvant immunotherapy and accelerate clinical trial design. We present a pathology-based computational method using a deep neural network architecture for DSS prediction. EXPERIMENTAL DESIGN The model was trained on 108 patients from four institutions and tested on 104 patients from Yale School of Medicine (YSM, New Haven, CT). A receiver operating characteristic (ROC) curve was generated on the basis of vote aggregation of individual image sequences, an optimized cutoff was selected, and the computational model was tested on a third independent population of 51 patients from Geisinger Health Systems (GHS). RESULTS Area under the curve (AUC) in the YSM patients was 0.905 (P < 0.0001). AUC in the GHS patients was 0.880 (P < 0.0001). Using the cutoff selected in the YSM cohort, the computational model predicted DSS in the GHS cohort based on Kaplan-Meier (KM) analysis (P < 0.0001). CONCLUSIONS The novel method presented is applicable to digital images, obviating the need for sample shipment and manipulation and representing a practical advance over current genetic and IHC-based methods.
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Affiliation(s)
- Prathamesh M Kulkarni
- Department of Psychiatry, School of Medicine, NYU School of Medicine, New York, New York
| | - Eric J Robinson
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, New York, New York
| | - Jaya Sarin Pradhan
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | | | - Bethany R Rohr
- Department of Pathology, Geisinger Health System, Danville, Pennsylvania
| | - Megan H Trager
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Larisa J Geskin
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
| | - Harriet M Kluger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Balazs Acs
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Emanuelle M Rizk
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chen Yang
- Department of Medicine, Jiaotong University School of Medicine, Shanghai, China
| | - Manas Mondal
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Michael R Moore
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Iman Osman
- Departments of Dermatology, Medicine, and Urology, NYU School of Medicine, New York, New York
| | - Robert Phelps
- Departments of Pathology and Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Basil A Horst
- Department of Pathology, University of British Columbia, Vancouver, Canada
| | - Zhe S Chen
- Department of Psychiatry, School of Medicine, NYU School of Medicine, New York, New York
- Department of Neuroscience and Physiology, NYU School of Medicine, New York, New York
| | - Tammie Ferringer
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - David L Rimm
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, New York, New York.
- Department of Neuroscience and Physiology, NYU School of Medicine, New York, New York
| | - Yvonne M Saenger
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.
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Gupta S, McCann L, Chan YGY, Lai EW, Wei W, Wong PF, Smithy JW, Weidler J, Rhees B, Bates M, Kluger HM, Rimm DL. Closed system RT-qPCR as a potential companion diagnostic test for immunotherapy outcome in metastatic melanoma. J Immunother Cancer 2019; 7:254. [PMID: 31533832 PMCID: PMC6751819 DOI: 10.1186/s40425-019-0731-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background In melanoma, there is no companion diagnostic test to predict response to programmed cell death 1 (PD-1) axis immune checkpoint inhibitor (ICI) therapy. In the adjuvant setting, only one in five patients may benefit from ICI, so a biomarker is needed to select those that may or may not benefit. Here, we test a new 4-gene multiplex immunotherapy panel with research use only (RUO) prototype mRNA expression profile on the GeneXpert closed system using real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) for association with clinical benefit after treatment with ICI therapy in metastatic melanoma patients. Methods Pretreatment formalin-fixed paraffin-embedded (FFPE) tissue sections from melanoma patients treated with anti-PD-1 therapy (pembrolizumab, nivolumab, or ipilimumab plus nivolumab) between 2011 and 17 were selected from the Yale Pathology archives. FFPE sections were macrodissected to enrich for tumor for quantitative assessment of CD274 (PD-L1), PDCD1LG2 (PD-L2), CD8A, and IRF1 by RT-qPCR multiplex mRNA panel. Multiplex panel transcript levels were correlated with clinical benefit (complete response [CR], partial response [PR], stable disease [SD]); disease outcomes (progression-free survival [PFS] and overall survival [OS]); and protein levels assessed by quantitative immunofluorescence (QIF). Results Transcript levels were significantly higher in responders (CR/PR/SD) than in nonresponders (PD) for CD8A (p = 0.0001) and IRF1 (p = 0.0019). PFS was strongly associated with high CD274 (p = 0.0046), PDCD1LG2 (p = 0.0039), CD8A (p = 0.0002), and IRF1 (p = 0.0030) mRNA expression. Similar associations were observed for OS with high CD274 (p = 0.0004), CD8A (p = 0.0030), and IRF1 (p = 0.0096) mRNA expression. Multivariate analyses revealed significant PFS and OS associations with immunotherapy panel markers independent of baseline variables. Exploratory analyses revealed a novel significant association of high combined CD274 & PDCD1LG2 (L1/L2) transcript expression with PFS (p < 0.0001) and OS (p = 0.0011), which remained significant at a multivariate level for both PFS (HR = 0.31) and OS (HR = 0.39). Conclusions Individual immunotherapy panel markers CD274, PDCD1LG2, CD8A, IRF1 and a combined L1/L2 mRNA levels show promising associations with melanoma immunotherapy outcome. The turnaround time of the test (2 h) and easy standardization of the platform makes this an attractive approach for further study in the search for predictive biomarkers for ICI.
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Affiliation(s)
- Swati Gupta
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT, 06510, USA
| | - Leena McCann
- Oncology Research and Development, Cepheid, Sunnyvale, CA, USA
| | - Yvonne G Y Chan
- Oncology Research and Development, Cepheid, Sunnyvale, CA, USA
| | - Edwin W Lai
- Oncology Research and Development, Cepheid, Sunnyvale, CA, USA
| | - Wei Wei
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Pok Fai Wong
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT, 06510, USA
| | - James W Smithy
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jodi Weidler
- Medical and Scientific Affairs and Strategy, Oncology, Cepheid, Sunnyvale, CA, USA
| | - Brian Rhees
- Oncology Research and Development, Cepheid, Sunnyvale, CA, USA
| | - Michael Bates
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Harriet M Kluger
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - David L Rimm
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT, 06510, USA. .,Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA.
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Wong PF, Wei W, Gupta S, Smithy JW, Zelterman D, Kluger HM, Rimm DL. Multiplex quantitative analysis of cancer-associated fibroblasts and immunotherapy outcome in metastatic melanoma. J Immunother Cancer 2019; 7:194. [PMID: 31337426 PMCID: PMC6651990 DOI: 10.1186/s40425-019-0675-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background The cancer-associated fibroblast (CAF) population is implicated in immune dysregulation. Here, we test the hypothesis that CAF profiles in pretreatment tumor specimens are associated with response to immune checkpoint blockade of programmed cell death 1 (PD-1). Methods Pretreatment whole tissue sections from 117 melanoma patients treated with anti-PD-1 therapy were assessed by multiplex immunofluorescence to detect CAFs defined by Thy1, smooth muscle actin (SMA), and fibroblast activation protein (FAP). Two independent image analysis technologies were used: inForm software (PerkinElmer) to quantify cell counts, and AQUA™ to measure protein by quantitative immunofluorescence (QIF). CAF parameters by both methodologies were assessed for association with previously measured immune markers (CD3, CD4, CD8, CD20, CD68, PD-L1), best overall response, progression-free survival (PFS), and overall survival (OS). Results CAF parameters, by cell counts or QIF, did not correlate with immune markers nor with best overall response. However, both Thy1 and FAP cell counts had significant positive associations with PFS (all P < 0.05) and OS (all P < 0.003). SMA cell counts showed negative associations with outcome in anti-PD-1 treated patients. Similar associations were not observed in a control cohort of historical melanoma patients predating immunotherapy. Instead, FAP was a negative prognostic biomarker (P = 0.01) in the absence of immunotherapy. Multivariable analyses revealed significant PFS and OS associations with the CAF parameters were independent of baseline variables. Conclusions Pretreatment CAF profiles are associated with melanoma immunotherapy outcome. Multiplex CAF analysis has potential as an objective companion diagnostic in immuno-oncology. Electronic supplementary material The online version of this article (10.1186/s40425-019-0675-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA.,Yale Cancer Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Wei Wei
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Swati Gupta
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA.,Yale Cancer Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - James W Smithy
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA.,Yale Cancer Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Daniel Zelterman
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Harriet M Kluger
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, 06510, USA.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06510, USA. .,Yale Cancer Center, Yale School of Medicine, New Haven, CT, 06510, USA. .,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA. .,Department of Pathology, Yale School of Medicine, 310 Cedar St, BML 116, PO Box 208023, New Haven, CT, 06520, USA.
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Gupta S, McCann L, Chan YG, Lai EW, Wong PF, Smithy JW, Weidler J, Rhees B, Bates M, Kluger HM, Rimm DL. Abstract 3142: A CD274, PDCD1LG2, CD8A, and IRF1 multiplex in a closed system RT-qPCR panel and immunotherapy outcome in metastatic melanoma. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-3142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In melanoma, there is no companion diagnostic test to predict response to programmed cell death 1 (PD-1) axis immune checkpoint inhibitor therapy (ICI). In the adjuvant setting, only 1 in 5 patients may benefit from ICI, so biomarker is needed to select those that may or may not benefit. Candidate techniques for the assessment of predictive markers include immunohistochemistry (IHC), multiplex fluorescence, genome sequencing, and RNA expression profiles. Here we test a new 4-gene research use only (RUO)* prototype mRNA expression profile on the GeneXpert closed system using real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) for association with clinical benefit after treatment with ICI in metastatic melanoma patients.
Methods: Pretreatment formalin-fixed paraffin-embedded (FFPE) tissue sections from melanoma patients treated with anti-PD-1 therapy (pembrolizumab, nivolumab, or ipilimumab plus nivolumab) between 2011-17 were selected from the Yale Pathology archives. FFPE sections were macrodissected to enrich for tumor for quantitative assessment of CD274 (PD-L1), PDCD1LG2 (PD-L2), CD8A, and IRF1 by RT-qPCR multiplex mRNA panel. Multiplex panel transcript levels were correlated with clinical benefit (CR/PR/SD); disease outcomes (progression-free survival, PFS and overall survival, OS); and protein levels assessed by quantitative immunofluorescence (QIF). Median values for each marker were used to define high versus low mRNA or protein expression groups. This study was approved by Yale Human Investigation IRB protocol ID 9505008219.
Results: Inter-transcript regression was observed among all four markers with R2 ranging from 0.20 to 0.51. Transcript levels were significantly higher in CR/PR/SD than in PD for CD8A (p = 0.0001) and IRF1 (p = 0.0019). PFS was strongly associated with high CD274 (p = 0.0046), PDCD1LG2 (p = 0.0039), CD8A (p = 0.0002), and IRF1 (p = 0.0030) mRNA expression. Similar associations were observed for OS with high CD274 (p = 0.0004), CD8A (p = 0.0030), and IRF1 (p = 0.0096) mRNA expression. Multivariate analyses revealed significant associations with OS independent of age, sex, stage, mutation, treatment, and prior ICI for CD274 (HR = 0.30), CD8A (HR = 0.40) and IRF1 mRNA (HR = 0.36). Similar PFS association with CD8A (HR = 0.39) and IRF1 (HR = 0.48) parameters were observed by multivariate analyses. Nonlinear exponential relationship was observed between transcript and protein levels for CD8A (R2 = 0.66) and IRF1 (R2 = 0.40).
Conclusions: Although tested in only a single melanoma cohort, CD274, CD8A and IRF1 mRNA levels show promising associations with outcome. The turnaround time of the test (2h) and easy standardization of the platform makes this an attractive approach for further study in the search for predictive biomarkers for ICI. *for Research Use Only - not approved or reviewed by any regulatory body
Citation Format: Swati Gupta, Leena McCann, Yvonne G.Y. Chan, Edwin W. Lai, Pok Fai Wong, James W. Smithy, Jodi Weidler, Brian Rhees, Michael Bates, Harriet M. Kluger, David L. Rimm. A CD274, PDCD1LG2, CD8A, and IRF1 multiplex in a closed system RT-qPCR panel and immunotherapy outcome in metastatic melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3142.
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Affiliation(s)
- Swati Gupta
- 1Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Leena McCann
- 2Oncology Research and Development, Sunnyvale, CA
| | | | - Edwin W. Lai
- 2Oncology Research and Development, Sunnyvale, CA
| | - Pok Fai Wong
- 1Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - James W. Smithy
- 3Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jodi Weidler
- 4Medical and Scientific Affairs and Strategy, Oncology, Sunnyvale, CA
| | - Brian Rhees
- 2Oncology Research and Development, Sunnyvale, CA
| | - Michael Bates
- 4Medical and Scientific Affairs and Strategy, Oncology, Sunnyvale, CA
| | - Harriet M. Kluger
- 5Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT
| | - David L. Rimm
- 1Department of Pathology, Yale University School of Medicine, New Haven, CT
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Toki MI, Merritt CR, Wong PF, Smithy JW, Kluger HM, Syrigos KN, Ong GT, Warren SE, Beechem JM, Rimm DL. High-Plex Predictive Marker Discovery for Melanoma Immunotherapy-Treated Patients Using Digital Spatial Profiling. Clin Cancer Res 2019; 25:5503-5512. [PMID: 31189645 DOI: 10.1158/1078-0432.ccr-19-0104] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/14/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Protein expression in formalin-fixed, paraffin-embedded tissue is routinely measured by IHC or quantitative fluorescence (QIF) on a handful of markers on a single section. Digital spatial profiling (DSP) allows spatially informed simultaneous assessment of multiple biomarkers. Here we demonstrate the DSP technology using a 44-plex antibody cocktail to find protein expression that could potentially be used to predict response to immune therapy in melanoma.Experimental Design: The NanoString GeoMx DSP technology is compared with automated QIF (AQUA) for immune marker compartment-specific measurement and prognostic value in non-small cell lung cancer (NSCLC). Then we use this tool to search for novel predictive markers in a cohort of 60 patients with immunotherapy-treated melanoma on a tissue microarray using a 44-plex immune marker panel measured in three compartments (macrophage, leukocyte, and melanocyte) generating 132 quantitative variables. RESULTS The spatially informed variable assessment by DSP validates by both regression and variable prognostication compared with QIF for stromal CD3, CD4, CD8, CD20, and PD-L1 in NSCLC. From the 132 variables, 11 and 15 immune markers were associated with prolonged progression-free survival (PFS) and overall survival (OS). Notably, we find PD-L1 expression in CD68-positive cells (macrophages) and not in tumor cells was a predictive marker for PFS, OS, and response. CONCLUSIONS DSP technology shows high concordance with QIF and validates based on both regression and outcome assessment. Using the high-plex capacity, we found a series of expression patterns associated with outcome, including that the expression of PD-L1 in macrophages is associated with response.
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Affiliation(s)
- Maria I Toki
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | | | - Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - James W Smithy
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts
| | - Harriet M Kluger
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Konstantinos N Syrigos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,3rd Department of Medicine, University of Athens, School of Medicine, Sotiria General Hospital, Athens, Greece
| | - Giang T Ong
- NanoString Technologies, Seattle, Washington
| | | | | | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut. .,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Wong PF, Wei W, Smithy JW, Acs B, Toki MI, Blenman KRM, Zelterman D, Kluger HM, Rimm DL. Multiplex Quantitative Analysis of Tumor-Infiltrating Lymphocytes and Immunotherapy Outcome in Metastatic Melanoma. Clin Cancer Res 2019; 25:2442-2449. [PMID: 30617133 PMCID: PMC6467753 DOI: 10.1158/1078-0432.ccr-18-2652] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/19/2018] [Accepted: 01/03/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Because durable response to programmed cell death 1 (PD-1) inhibition is limited to a subset of melanoma patients, new predictive biomarkers could have clinical utility. We hypothesize that pretreatment tumor-infiltrating lymphocyte (TIL) profiles could be associated with response. EXPERIMENTAL DESIGN Pretreatment whole tissue sections from 94 melanoma patients treated with anti-PD-1 therapy were profiled by multiplex immunofluorescence to perform TIL quantification (CD4, CD8, CD20) and assess TIL activation (CD3, GZMB, Ki67). Two independent image analysis technologies were used: inForm (PerkinElmer) to determine cell counts, and AQUA to measure protein by quantitative immunofluorescence (QIF). TIL parameters by both methodologies were correlated with objective response or disease control rate (ORR/DCR) by RECIST 1.1 and survival outcome. RESULTS Pretreatment lymphocytic infiltration, by cell counts or QIF, was significantly higher in complete or partial response than in stable or progressive disease, particularly for CD8 (P < 0.0001). Neither TIL activation nor dormancy was associated with outcome. CD8 associations with progression-free survival (HR > 3) were independently significant in multivariable analyses and accounted for similar CD3 associations in anti-PD-1-treated patients. CD8 was not associated with melanoma prognosis in the absence of immunotherapy. Predictive performance of CD8 cell count (and QIF) had an area under the ROC curve above 0.75 (ORR/DCR), which reached 0.83 for ipilimumab plus nivolumab. CONCLUSIONS Pretreatment lymphocytic infiltration is associated with anti-PD-1 response in metastatic melanoma. Quantitative TIL analysis has potential for application in digital precision immuno-oncology as an "indicative" companion diagnostic.
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Affiliation(s)
- Pok Fai Wong
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Wei Wei
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - James W Smithy
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Balazs Acs
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Maria I Toki
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Kim R M Blenman
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Zelterman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Harriet M Kluger
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David L Rimm
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut.
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Wong PF, Smithy JW, Blenman KR, Kluger HM, Rimm DL. Abstract 3638: Quantitative assessment of tumor-infiltrating lymphocytes and immunotherapy outcome in metastatic melanoma. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-3638] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Durable responses to immune checkpoint blockade against programmed cell death 1 (PD-1) are limited to a subset of metastatic melanoma patients, so there is a need for predictive biomarkers. Tumor-infiltrating lymphocytes (TILs) are the major cellular target of anti-PD-1 therapy, so we hypothesized that pretreatment TIL profiles would be associated with response.
Methods: Pretreatment whole-tissue sections from 94 melanoma patients treated with anti-PD-1 therapy (pembrolizumab, nivolumab, or ipilimumab plus nivolumab) from 2011-17 were collected from Yale Pathology archives, and stained to visualize nuclei (DAPI) and melanoma cells (S100 & HMB45) in combination with two multiplex immunofluorescence panels to: (1) perform TIL quantitation of helper T cells by CD4 (SP35, Spring), cytotoxic T cells by CD8 (C8/144B, Dako), and B cells by CD20 (L26, Dako); and (2) assess TIL activation by identifying T cells by CD3 (SP7, Novus), cytolytic activity by GZMB (4E6, Abcam), and proliferation by Ki67 (MIB-1, Dako). Cell phenotyping and counting were performed using inForm software (PerkinElmer) and protein expression was measured by the AQUA method of quantitative immunofluorescence (QIF). Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 were used to classify best overall response as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD). Objective response rate (ORR; CR/PR), disease control rate (DCR; CR/PR/SD), and progression-free survival (PFS) were correlated with TIL parameters measured by both methodologies.
Results: Pretreatment lymphocytic infiltration, by cell counts or QIF, was significantly higher in CR/PR than in SD/PD, particularly for CD3 and CD8 (P < 0.0001). Neither TIL activation (CD3 high, Ki67 and/or GZMB high) nor TIL dormancy (CD3 high, Ki67 and GZMB low) was significantly associated with outcome. Multivariable analyses revealed significant CD8 associations (HR > 3) with PFS independent of age, sex, mutation, stage, treatment, and prior immune checkpoint blockade, which accounted for similar CD3 PFS associations as expected. The favorable predictive performance of CD8 cell count (and QIF) had an area under the receiver operating characteristic (ROC) curve of 0.75 for ORR and 0.78 for DCR, which reached 0.83 (ORR or DCR) for dual therapy (ipilimumab plus nivolumab). Interestingly, in contrast to previous hypothetical classifications, there were a number of responders (CR/PR) in the CD3 or CD8 low (immune desert) category.
Conclusions: Pretreatment lymphocytic infiltration, by cell counts or QIF, is associated with anti-PD-1 response in metastatic melanoma. Multiplex analysis of the tumor microenvironment has the potential to be used as a companion diagnostic test for precision immunotherapy.
Citation Format: Pok Fai Wong, James W. Smithy, Kim R. Blenman, Harriet M. Kluger, David L. Rimm. Quantitative assessment of tumor-infiltrating lymphocytes and immunotherapy outcome in metastatic melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3638.
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Toki MI, Wong PF, Kluger H, Liu Y, Merritt C, Ong G, Warren S, Beechem JM, Rimm DL. Abstract 3621: High-plex immune marker spatial profiling quantitation by NanoString Digital Spatial Profiling technology and quantitative immunofluorescence. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-3621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Quantitative immunofluorescence (QIF) offers the advantage of multiple target measurement on a single slide, but is limited by the number of fluorescence channels. NanoString's Digital Spatial Profiling (DSP)* can detect and quantify immune markers at higher multiplex with spatial resolution within specific regions of interest on FFPE tissue. Here, we compare NanoString DSP to automated QIF (AQUA), for immune marker compartment specific measurement. Additionally, we assess their agreement on the prognostic value of commonly used biomarkers in Non-Small Cell Lung Cancer (NSCLC). Finally, we explore the predictive value of a 30-plex panel of immune markers on two cohorts of treated patients.
Methods: NanoString DSP technology uses a cocktail of primary antibodies conjugated to indexing DNA oligos. Regions of interest (ROI) on the tissue are selected with fluorescently labeled antibodies, and oligos from that region are UV cleaved and quantified on the nCounter platform. The comparator for this technology was the AQUA method of QIF. We retrospectively examined a NSCLC cohort of over 100 patients for prognostic markers and two treated patient cohorts for associations between immune markers expression and response to treatment, all in tissue microarray format. The treated cohorts included an Epidermal Growth Factor Receptor Tyrosine kinase inhibitor (EGFR TKI) treated NSCLC cohort and a melanoma immunotherapy (ITx) treated cohort.
Results: Multiple immune markers (CD3, CD4, CD8, CD20, PD-L1) were assessed and a high correlation was found between NanoString DSP counts and QIF scores, when the measurements were performed in the same ROIs (tumor or stroma). The prognostic value of the immune markers tested was concordant between the two assays with high expression of CD3 assessed by either assay showing a statistically significantly better overall survival (OS). For the EGFR TKI treated NSCLC cohort none of the immune markers was correlated with response to treatment or favorable outcome. However, in the ITx treated melanoma patients, PD-L1, PD-1, CD68, CD3, CD8A and b2-microglobulin tumor expression predicted response to treatment. Each marker also predicted better outcome, but only CD8A was an independent predictive marker of prolonged survival.
Conclusion: NanoString DSP offers the capacity of highly multiplexed immune marker measurements on selected compartments. It shows high concordance with AQUA, which was further validated by comparing prognostic significance. The pilot study of the Melanoma ITx cohort also illustrates the potential to simultaneously evaluate a range of markers and possibly construct new predictive signatures based on a cohort represented by very small tissue samples. *FOR RESEARCH USE ONLY. Not for use in diagnostic procedures.
Citation Format: Maria I. Toki, Pok Fai Wong, Harriet Kluger, Yuting Liu, Chris Merritt, Giang Ong, Sarah Warren, Joseph M. Beechem, David L. Rimm. High-plex immune marker spatial profiling quantitation by NanoString Digital Spatial Profiling technology and quantitative immunofluorescence [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3621.
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Affiliation(s)
| | | | | | - Yuting Liu
- 1Yale Univ. School of Medicine, New Haven, CT
| | | | - Giang Ong
- 2NanoString Technologies, Seattle, WA
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Smithy JW, Moore LM, Pelekanou V, Rehman J, Gaule P, Wong PF, Neumeister VM, Sznol M, Kluger HM, Rimm DL. Nuclear IRF-1 expression as a mechanism to assess "Capability" to express PD-L1 and response to PD-1 therapy in metastatic melanoma. J Immunother Cancer 2017; 5:25. [PMID: 28331615 PMCID: PMC5359951 DOI: 10.1186/s40425-017-0229-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/17/2017] [Indexed: 12/12/2022] Open
Abstract
Background Predictive biomarkers for antibodies against programmed death 1 (PD-1) remain a major unmet need in metastatic melanoma. Specifically, response is seen in tumors that do not express programmed death ligand 1 (PD-L1), highlighting the need for a more sensitive biomarker. We hypothesize that capacity to express PD-L1, as assessed by an assay for a PD-L1 transcription factor, interferon regulatory factor 1 (IRF-1), may better distinguish patients likely to benefit from anti-PD-1 immunotherapy. Methods Samples from 47 melanoma patients that received nivolumab, pembrolizumab, or combination ipilimumab/nivolumab at Yale New Haven Hospital from May 2013 to March 2016 were collected. Expression of IRF-1 and PD-L1 in archival pre-treatment formalin-fixed, paraffin-embedded tumor samples were assessed by the AQUA method of quantitative immunofluorescence. Objective radiographic response (ORR) and progression-free survival (PFS) were assessed using modified RECIST v1.1 criteria. Results Nuclear IRF-1 expression was higher in patients with partial or complete response (PR/CR) than in patients with stable or progressive disease (SD/PD) (p = 0.044). There was an insignificant trend toward higher PD-L1 expression in patients with PR/CR (p = 0.085). PFS was higher in the IRF-1-high group than the IRF-1-low group (p = 0.017), while PD-L1 expression had no effect on PFS (p = 0.83). In a subset analysis, a strong association with PFS is seen in patients treated with combination ipilimumab and nivolumab (p = 0.0051). Conclusions As a measure of PD-L1 expression capability, IRF-1 expression may be a more valuable predictive biomarker for anti-PD-1 therapy than PD-L1 itself. Electronic supplementary material The online version of this article (doi:10.1186/s40425-017-0229-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James W Smithy
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Lauren M Moore
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Vasiliki Pelekanou
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Jamaal Rehman
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Patricia Gaule
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Pok Fai Wong
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Veronique M Neumeister
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA
| | - Mario Sznol
- Section of Medical Oncology, Yale School of Medicine, New Haven, CT USA
| | - Harriet M Kluger
- Section of Medical Oncology, Yale School of Medicine, New Haven, CT USA
| | - David L Rimm
- Department of Pathology, BML116 Yale School of Medicine, 310 Cedar Street, PO Box 208023, 06520 New Haven, CT USA.,Section of Medical Oncology, Yale School of Medicine, New Haven, CT USA
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Wong PF, Gall MG, Bachovchin WW, McCaughan GW, Keane FM, Gorrell MD. Neuropeptide Y is a physiological substrate of fibroblast activation protein: Enzyme kinetics in blood plasma and expression of Y2R and Y5R in human liver cirrhosis and hepatocellular carcinoma. Peptides 2016; 75:80-95. [PMID: 26621486 DOI: 10.1016/j.peptides.2015.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 10/17/2015] [Accepted: 11/20/2015] [Indexed: 12/27/2022]
Abstract
Fibroblast activation protein (FAP) is a dipeptidyl peptidase (DPP) and endopeptidase that is weakly expressed in normal adult human tissues but is greatly up-regulated in activated mesenchymal cells of tumors and chronically injured tissue. The identities and locations of target substrates of FAP are poorly defined, in contrast to the related protease DPP4. This study is the first to characterize the physiological substrate repertoire of the DPP activity of endogenous FAP present in plasma. Four substrates, neuropeptide Y (NPY), peptide YY, B-type natriuretic peptide and substance P, were analyzed by mass spectrometry following proteolysis in human or mouse plasma, and by in vivo localization in human liver tissues with cirrhosis and hepatocellular carcinoma (HCC). NPY was the most efficiently cleaved substrate of both human and mouse FAP, whereas all four peptides were efficiently cleaved by endogenous DPP4, indicating that the in vivo degradomes of FAP and DPP4 differ. All detectable DPP-specific proteolysis and C-terminal processing of these neuropeptides was attributable to FAP and DPP4, and plasma kallikrein, respectively, highlighting their combined physiological significance in the regulation of these neuropeptides. In cirrhotic liver and HCC, NPY and its receptor Y2R, but not Y5R, were increased in hepatocytes near the parenchymal-stromal interface where there is an opportunity to interact with FAP expressed on nearby activated mesenchymal cells in the stroma. These novel findings provide insights into the substrate specificity of FAP, which differs greatly from DPP4, and reveal a potential function for FAP in neuropeptide regulation within liver and cancer biology.
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Affiliation(s)
- Pok Fai Wong
- Centenary Institute of Cancer Medicine and Cell Biology, Sydney Medical School, The University of Sydney, NSW 2006, Australia
| | - Margaret G Gall
- Centenary Institute of Cancer Medicine and Cell Biology, Sydney Medical School, The University of Sydney, NSW 2006, Australia
| | - William W Bachovchin
- Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Geoffrey W McCaughan
- Centenary Institute of Cancer Medicine and Cell Biology, Sydney Medical School, The University of Sydney, NSW 2006, Australia
| | - Fiona M Keane
- Centenary Institute of Cancer Medicine and Cell Biology, Sydney Medical School, The University of Sydney, NSW 2006, Australia
| | - Mark D Gorrell
- Centenary Institute of Cancer Medicine and Cell Biology, Sydney Medical School, The University of Sydney, NSW 2006, Australia.
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Liao SB, Cheung KH, Cheung MPL, Wong PF, O WS, Tang F. Adrenomedullin increases the short-circuit current in the rat prostate: Receptors, chloride channels, the effects of cAMP and calcium ions and implications on fluid secretion. Andrology 2014; 2:474-80. [PMID: 24711244 DOI: 10.1111/j.2047-2927.2014.00189.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 12/22/2013] [Accepted: 01/12/2014] [Indexed: 12/01/2022]
Abstract
In this study, we have investigated the effects of adrenomedullin on chloride and fluid secretion in the rat prostate. The presence of adrenomedullin (ADM) in rat prostate was confirmed using immunostaining, and the molecular species was determined using gel filtration chromatography coupled with an enzyme-linked assay for ADM. The effects of ADM on fluid secretion were studied by short-circuit current technique in a whole mount preparation of the prostate in an Ussing chamber. The results indicated that the ADM level was higher in the ventral than the dorso-lateral prostate and the major molecular species was the active peptide. ADM increased the short-circuit current through both the cAMP- and calcium-activated chloride channels in the ventral lobe, but only through the calcium-activated channels in the dorso-lateral lobe. These stimulatory effects were blocked by the calcitonin gene-related peptide (CGRP) receptor antagonist, hCGRP8-37. We conclude that ADM may regulate prostatic fluid secretion through the chloride channels, which may affect the composition of the seminal plasma bathing the spermatozoa and hence fertility.
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Affiliation(s)
- S B Liao
- Department of Anatomy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Physiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Obstetrics and Gynecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Wu J, Zuo F, Du J, Wong PF, Qin H, Xu J. Icariside II induces apoptosis via inhibition of the EGFR pathways in A431 human epidermoid carcinoma cells. Mol Med Rep 2013; 8:597-602. [PMID: 23807305 DOI: 10.3892/mmr.2013.1557] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 06/18/2013] [Indexed: 11/05/2022] Open
Abstract
Improvements in skin cancer treatment are likely to derive from novel agents targeting the molecular pathways that promote tumor cell growth and survival. Icariside II (IS) is a metabolite of icariin, which is derived from Herba Epimedii. The aim of the present study was to evaluate the antitumor effects of IS and to determine the mechanism of apoptosis in A431 human epidermoid carcinoma cells. A431 cells were treated with IS (0‑100 µM) for 24 or 48 h and cell viability was detected using the WST‑8 assay. Apoptosis was measured by the Annexin‑V/propidium iodide (PI) flow cytometric assay. Western blot analysis was used to measure the expression of cleaved caspase‑9, cleaved poly ADP ribose polymerase (PARP), phosphorylated signal transducer and activator of transcription 3 (P‑STAT3), phosphorylated extracellular signal-regulated kinase (P‑ERK), and P‑AKT. A431 cells were also pretreated with IS (0‑100 µM) 2 h prior to treatment with epidermal growth factor (EGF; 100 ng/ml) for 10 min. Phosphorylated EGF receptor (P‑EGFR), P‑STAT3, P‑ERK and P‑AKT were detected by western blot analysis. The results demonstrated that IS inhibited the cell viability of the A431 cells in a dose‑dependent manner. Pretreatment with LY294002 [a phosphatidylinositol 3-kinase (PI3K) inhibitor], EGF (an EGFR agonist) and AG1478 (an EGFR inhibitor) partially reversed IS‑induced decreases in cell viability. Treatment with 50 µm IS resulted in an increased number of apoptotic cells mirrored by increases in cleaved caspase‑9 and cleaved PARP. In addition, treatment with 50 µM IS significantly inhibited the activation of the Janus kinase (JAK)‑STAT3 and mitogen‑activated protein kinase (MAPK)‑ERK pathways, but promoted the activation of the PI3K‑AKT pathway. Furthermore, IS effectively inhibited the EGF-induced activation of the EGFR pathways. In conclusion, IS inhibited the cell viability of the A431 cells through the regulation of apoptosis. These effects were mediated, at least in part, by inhibiting the activation of the EGFR pathways.
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Affiliation(s)
- Jinfeng Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China
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Levina A, Aitken JB, Gwee YY, Lim ZJ, Liu M, Singharay AM, Wong PF, Lay PA. Biotransformations of anticancer ruthenium(III) complexes: an X-ray absorption spectroscopic study. Chemistry 2013; 19:3609-19. [PMID: 23361836 DOI: 10.1002/chem.201203127] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Indexed: 11/06/2022]
Abstract
An anti-metastatic drug, NAMI-A ((ImH)[Ru(III) Cl4 (Im)(dmso)]; Im=imidazole, dmso=S-bound dimethylsulfoxide), and a cytotoxic drug, KP1019 ((IndH)[Ru(III) Cl4 (Ind)2 ]; Ind=indazole), are two Ru-based anticancer drugs in human clinical trials. Their reactivities under biologically relevant conditions, including aqueous buffers, protein solutions or gels (e.g, albumin, transferrin and collagen), undiluted blood serum, cell-culture medium and human liver (HepG2) cancer cells, were studied by Ru K-edge X-ray absorption spectroscopy (XAS). These XAS data were fitted from linear combinations of spectra of well-characterised Ru compounds. The absence of XAS data from the parent drugs in these fits points to profound changes in the coordination environments of Ru(III) . The fits point to the presence of Ru(IV/III) clusters and binding of Ru(III) to S-donor groups, amine/imine and carboxylato groups of proteins. Cellular uptake of KP1019 is approximately 20-fold higher than that of NAMI-A under the same conditions, but it diminishes drastically after the decomposition of KP1019 in cell-culture media, which indicate that the parent complex is taken in by cells through passive diffusion.
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Affiliation(s)
- Aviva Levina
- School of Chemistry, The University of Sydney, Sydney, NSW 2006, Australia
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Liao SB, Wong PF, Cheung BMY, Tang F. Effects of adrenomedullin on tumour necrosis factor alpha, interleukins, endothelin-1, leptin, and adiponectin in the epididymal fat and soleus muscle of the rat. Horm Metab Res 2013; 45:31-7. [PMID: 22956308 DOI: 10.1055/s-0032-1321879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adrenomedullin (ADM) is a peptide hormone, which participates in the development of metabolic syndrome. In this study, we have investigated the interaction of ADM and cytokines, endothelin-1 (EDN-1) and adipokines in the epididymal fat and the soleus muscle. Epididymal fat and soleus muscles from adult male Sprague-Dawley rat were incubated with ADM at concentration of 100 nM for the study of the gene expression and secretion of tumour necrosis factor (TNF-α), EDN-1, leptin, adiponectin, interleukin 1β (IL-1β), and IL-6. The effects of TNF-α and EDN-1 on ADM gene expression and secretion were also investigated. The results showed that ADM decreased the gene expression and protein secretion of TNF-α in both the epididymal fat and the soleus muscle and decreased IL-1β gene expression and secretion in the soleus muscle. It also decreased endothelin gene expression and adiponectin gene expression and release and increased IL-6 and leptin gene expression and secretion in the epididymal fat. These effects were effectively blocked by the calcitonin gene-related peptide (CGRP) receptor antagonist, hCGRP8-37, but not by the ADM receptor antagonist, hADM22-52. The reduction of inflammatory cytokines and EDN-1 may help to decrease insulin resistance and increase glucose uptake. As TNF-α also increases ADM levels in the epididymal fat and the soleus muscle and EDN-1 also increases ADM levels in the epididymal fat, they may form a feedback loop with ADM in these tissues. The increase in leptin and the decrease in adiponectin by ADM in the epididymal fat may have opposite effects on metabolism.
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Affiliation(s)
- S B Liao
- Department of Anatomy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Wu J, Guan M, Wong PF, Yu H, Dong J, Xu J. Icariside II potentiates paclitaxel-induced apoptosis in human melanoma A375 cells by inhibiting TLR4 signaling pathway. Food Chem Toxicol 2012; 50:3019-24. [PMID: 22743248 DOI: 10.1016/j.fct.2012.06.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 11/24/2022]
Abstract
Combination therapy of paclitaxel (taxol) with natural anti-tumor agents that are capable of inhibiting survival signals may provide a rational molecular basis for novel chemotherapeutic strategies. Our previous study showed that icariside II (IS), derived from Herba Epimedii, inhibited the proliferation of melanoma cells in vivo and in vitro through the regulation of apoptosis. In this report, the combination effects of paclitaxel and IS were investigated in human melanoma A375 cells. As compared to the treatment with paclitaxel alone, the co-administration of IS and paclitaxel resulted in an enhancement of apoptosis as revealed by WST-8 and PI assays. Meanwhile, Western blot analysis showed that the co-administration of IS and paclitaxel resulted in increases of cleaved caspase-3, one of the terminal pro-apoptotic proteins. In melanoma, IL-8 and VEGF are positively correlated with disease stage and a high probability of progression. We demonstrated that treatment of A375 cells with IS in combination with paclitaxel resulted in a significant decrease in the production of IL-8 and VEGF, compared with paclitaxel alone. Recent studies suggest that TLR4-MyD88-ERK signaling may be a novel target for reversing chemoresistance to paclitaxel. Our flow cytometry and Western blot data showed that paclitaxel activated TLR4-MyD88-ERK signaling and that IS treatment could effectively inhibit this paclitaxel-induced activation of TLR4-MyD88-ERK signaling. In conclusion, this study demonstrated for the first time that IS could potentiate paclitaxel-induced apoptosis in melanoma cells. These effects were mediated, at least in part, by inhibiting the activation of the TLR4 signal transduction pathways. These findings support further preclinical evaluation of IS as a new potential anti-tumor agent.
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Affiliation(s)
- Jinfeng Wu
- Department of Dermatology, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai 200040, China
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Abstract
In this study, the gene expression of adrenomedullin (Adm) in the peripheral tissues which include lung, adrenal, kidney, and heart during development was investigated in the rat. The preproadrenomedullin (preproAdm) mRNA and mRNAs of its related receptor components, calcitonin receptor-like receptor (Crlr), and receptor activity-modifying proteins (Ramp1, 2 and 3) of the lung, adrenal, kidney, and heart were measured by real-time RT-PCR and the ADM peptide measured by radioimmunoassay in 1-, 7-, 21-day-old rats and the adult rats. From day 1 to 21, preproAdm mRNA levels increased with age in the lung, the kidney, and the heart but decreased with age in the adrenal. ADM levels, however, increased with age in the lung but decreased with age in the kidney, the adrenal, and the heart. The preproAdm levels in the lung, in the kidney, and in the adrenal all increased in the adult rat. ADM peptide levels, however, decreased in the adult rat. Crlr and Ramp2 gene expression increased with age in the lung, in the kidney, and in the heart but decreased with age in the adrenal in the prepubertal rats. The results indicate that the levels of preproAdm mRNA, ADM peptide and its receptor component mRNAs in different tissues followed different patterns of changes during development.
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Affiliation(s)
- P F Wong
- Department of Physiology, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
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Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007; 94:421-6. [PMID: 17380549 DOI: 10.1002/bjs.5631] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypothermia is common in the operating theatre and may increase susceptibility to postoperative complications. Intraoperative systemic warming has been shown to improve outcomes of surgery. This study aimed to examine the effects of additional perioperative systemic warming on postoperative morbidity. METHODS All patients admitted for elective major abdominal surgery and fulfilling the inclusion criteria were randomized into control or warming groups. Both groups were warmed during surgery, but patients in the warming group were additionally warmed 2 h before and after surgery using a conductive carbon polymer mattress. RESULTS The trial recruited 103 patients (56 in the control group, 47 in the warming group). Both groups were well matched for age, sex and clinical state. Patients in the warming group had lower blood loss (median 200 (range 5-1000) ml versus median 400 (range 50-2300) ml in the control group; P = 0.011) and complication rates (15 (32 per cent) of 47 versus 30 (54 per cent) of 56 in the control group; P = 0.027). There were three deaths; two in the control group (P = 0.566). CONCLUSION Extending systemic warming to the perioperative period had additional beneficial effects, with minimal additional cost and patient discomfort.
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Affiliation(s)
- P F Wong
- Professorial Unit of Surgery, University Hospital of North Tees, Stockton-on-Tees TS19 8PE, UK.
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Abstract
BACKGROUND Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity. OBJECTIVES To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA. Bibliographies of identified studies were screened for further relevant trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team. DATA COLLECTION AND ANALYSIS Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals. MAIN RESULTS Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels. AUTHORS' CONCLUSIONS No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.
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Affiliation(s)
- P F Wong
- Professorial Unit of Surgery, University Hospital of North Tees, Hardwick, Stockton on Tees, UK, TS19 8PE.
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Abstract
Conventional methods of treating superficial head and neck tumors, such as the wedge pair technique or the use of multiple electron fields of varying energies, can result in excellent tumor control. However, in some cases, these techniques irradiate healthy tissue unnecessarily and/or create hot and cold spots in junction regions, particularly in patients with complex surface contour modification or varying planning target volume (PTV) thickness. The objective of this work is to demonstrate how bolus electron conformal therapy can be used for these patients. Two patients treated using this technique are presented. The first patient was diagnosed with malignant fibrous histiocytoma involving the right ear concha and was treated with 12-MeV electrons. The second patient was diagnosed with acinic cell carcinoma of the left parotid gland and was treated with 20-MeV electrons after having undergone a complete parotidectomy. Each patient's bolus was designed using bolus design tools implemented in an in-house treatment-planning system (TPS). The bolus was fabricated using a computer-controlled milling machine. As part of the quality assurance process to ensure proper fabrication and placement of the bolus, the patients underwent a second computed tomography (CT) scan with the bolus in place. Using that data, the final dose distribution was computed using the Philips Pinnacle(3) TPS (Philips Medical Systems, Andover, MA). Results showed that the 90% isodose surface conformed well to the PTV and that the dose to critical structures such as cord, brain, and lung was well below tolerance limits. Both patients showed no evidence of disease six months post-radiotherapy. In conclusion, electron bolus conformal therapy is a viable option for treating head and neck tumors, particularly patients having a variable thickness PTV or surface anatomy with surgical defects.
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Affiliation(s)
- R J Kudchadker
- Department of Radiation Physics, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA.
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Gole LA, Wong PF, Ng PL, Wang XQ, Ng SC, Bongso A. Does sperm morphology play a significant role in increased sex chromosomal disomy? A comparison between patients with teratozoospermia and OAT by FISH. J Androl 2001; 22:759-63. [PMID: 11545287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Eight semen samples from men with teratozoospermia (T), along with samples from 3 men with normal fertility and 5 samples from men with oligoasthenoteratozoospermia (OAT) were analyzed for X and Y chromosomal anomalies with the use of fluorescently labeled centromeric probes. This study was undertaken to determine whether patients with abnormal sperm morphology (teratozoospermia) have increased or decreased incidence of a sex chromosomal anomaly. The sex chromosome disomy for the T samples was 0.36% and for the OAT group it was 0.61%, compared with baseline value for the normozoospermia group (0.09%).
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Affiliation(s)
- L A Gole
- Department of Obstetrics and Gynecology, National University Hospital, Singapore
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Abstract
PURPOSE To determine whether radiation therapy delivered to the paranasal sinuses causes any long-term impairment in neurocognitive function as a result of incidental brain irradiation. METHODS AND MATERIALS Nineteen patients who received paranasal sinus irradiation at least 20 months and up to 20 years before assessment were given a battery of neuropsychologic tests of cognitive function. Radiation was delivered by a three-field (one anteroposterior and two lateral) technique. The median radiation dose was 60 Gy (range 50-68 Gy) in fractions of 1.8 to 2 Gy. The volume of irradiated brain was calculated from planning computed tomography slices or simulation films. The results of the neuropsychologic tests were compared to normative control values. RESULTS Memory impairment was found in 80% of the patients, and one-third manifested difficulty with visual-motor speed, frontal lobe executive functions, and fine motor coordination. Two of the patients had frank brain necrosis with resultant dementia and blindness, and three had evidence of brain atrophy. Three of the fourteen patients without documented cerebral atrophy or necrosis were disabled from their normal activities. Three patients also developed pituitary dysfunction. Neurocognitive symptoms were related to the total dose of radiation delivered but not to the volume of brain irradiated, side of radiation boost, or chemotherapy treatment. The pattern of test findings was consistent with radiation injury to subcortical white matter. CONCLUSIONS Radiation therapy for paranasal sinus cancer may cause delayed neurocognitive side effects. Currently, however, the development of severe adverse effects appears to be decreasing because of improvements in the techniques used to deliver radiation. Lowering the total dose and improving dose distributions should further decrease the incidence of delayed brain injury due to radiation.
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Affiliation(s)
- C A Meyers
- Department of Neuro-Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, USA.
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Yiu AK, Wong PF, Yeung SY, Lam SM, Luk SK, Cheung WT. Immunohistochemical localization of type-II (AT2) angiotensin receptors with a polyclonal antibody against a peptide from the C-terminal tail. Regul Pept 1997; 70:15-21. [PMID: 9250577 DOI: 10.1016/s0167-0115(97)00010-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A polyclonal antibody has been prepared against a synthetic peptide derived from the C-terminal tail of the cloned rat AT2 angiotensin receptor, corresponding to amino acid residue 341-351. The antibody was of high titer and displayed monospecific activity toward the synthetic peptide in the ELISA assay. Western blot analysis indicated that the antiserum recognised only a single protein band with a mean apparent molecular mass of 75.4 kDa in the rat adrenals. Immunohistochemical studies with affinity purified antibody localised immunoreactive AT2 angiotensin receptor in medulla cells of the adrenals. Immunoreactivity was also observed in pyramidal tract, but no specific immunoreactivity can be detected in regions of rat brain that are known to express AT2 angiotensin receptors, including inferior olive, locus coeruleus and cerebellum.
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Affiliation(s)
- A K Yiu
- Department of Biochemistry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T
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Affiliation(s)
- E Barasch
- Department of Internal Medicine, University of Texas Health Science Center at Houston 77030, USA
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