CT imaging patterns of paraduodenal pancreatitis: a unique clinicoradiological entity

AIM

To analyse the computed tomography (CT) findings of paraduodenal pancreatitis (PP) in patients treated at Amrita Institute of Medical Sciences.

MATERIALS AND METHODS

Clinical, laboratory, and CT findings of 30 patients with PP treated from July 2007 to December 2020 were reviewed retrospectively.

RESULTS

The average age of the patients was 45.9 years (19-60 years), which included 29 (96.7%) men, and 90% had a history of alcohol abuse. The majority [22 (73.3%)] presented with recurrent abdominal pain. Serum amylase was elevated in 21 (70%) patients and serum lipase was elevated in 25 (83.3%) patients. Carbohydrate antigen (CA 19-9) was elevated in three (10%) patients. The cystic pattern was seen in three (10%), solid pattern in 13 (43.3%), and solid-cystic pattern in 14 (46.7%) patients. The pure form of the disease was seen in seven (23.3%) patients, whereas the segmental form was seen in 23 (76.7%) patients. Descending duodenal wall thickening and enhancement was seen in 25 (83.3%) and 18 (60%) patients, respectively. The gastroduodenal artery was displaced medially in 12 (40%) patients and encased in five (16.7%) patients; however, it was not occluded in any of the patients. Calcifications were seen in the groove lesion in nine (30%) patients. The pancreas showed atrophic changes in 14 (46.6%) patients and calcifications in 12 (40%) patients. Distal common bile duct strictures were seen in three (10%) patients.

CONCLUSIONS

The presence of sheet-like soft-tissue thickening in the groove with diffuse duodenal thickening and intramural/paraduodenal cysts are highly suggestive of PP. Identifying characteristic imaging findings of PP may help in prospective diagnosis and lead to conservative management of most of these patients avoiding unnecessary invasive procedures.

Tumor Genotype Is Shaping Immunophenotype and Responses to Immune Checkpoint Inhibitors in Solid Tumors

A major breakthrough in cancer treatment was ushered in by the development of immune checkpoint blockade therapy such as anti-CTLA4 antibody and anti-PD-1 and anti-programmed cell death-ligand 1 antibodies that are now approved for use in an increasing number of malignancies. Despite the relative success of immune checkpoint inhibitors with certain tumor types, many patients still fail to respond to such therapies, and the field is actively trying to understand the mechanisms of resistance, intrinsic or acquired, to immune checkpoint blockade. Herein, we discuss the roles that somatic genomic mutations in oncogenic pathways play in immune editing, as well as some of the current approaches toward improving response to immunotherapy.

Evolving trends in strabismus following retinal surgery: is there still a role for botulinum toxin?

Purpose Ocular motility disturbances following retinal detachment surgery are well documented, resulting in ocular misalignment and disabling diplopia. Interestingly, there has been a downward trend over the last decade across the United Kingdom with the evolution of refined vitrectomy techniques and instrumentation. We aim to report our updated experience on factors influencing botulinum toxin outcomes in view of the trend toward vitrectomy. Methods The Moorfields strabismus service carried out a follow-up retrospective study of all subjects that received botulinum toxin for retinal surgery-related strabismus at our center over an eleven-year period. All new onset constant or intermittent strabismus following retinal detachment surgery were included. Botulinum toxin response was stratified to good and poor. Results 32 patients fulfilled our criteria, with a mean follow-up of 20 months. The majority were vitrectomised eyes (62%), presented with diplopia (60%) and exotropia (66%). All isolated and combined vertical deviations (18%) were noted among cryobuckled eyes only. Baseline largest mean horizontal deviation was 49 and 51 prism diopters (PD) among the good and poor responders, respectively. A statistically and clinically significant reduction in the horizontal angle of deviation was noted among the good (p < .0001) responders, requiring a mean of six injections, in comparison to the poor responders (p = .03). Of the good responders, five patients (16%) with decompensated phorias regained fusion control. A small number of complications (15%) were noted, the most marked being intractable diplopia in a good responder (3%) with failure to fuse. Conclusions Botulinum toxin is a useful treatment modality, particularly when surgical options are limited. It can restore binocularity in patients with preexisting fusion potential. Ocular cosmesis can be achieved but requires ongoing injections. Barriers to fusion restoration include multiple retinal surgeries, persistent macula pathology and central-peripheral retinal rivalry. This highlights the need for rigorous baseline macula assessment to allow a tailored approach when considering botulinum toxin therapy for strabismus.

Operationalization of Next-Generation Sequencing and Decision Support for Precision Oncology

Genomic testing has become a part of routine oncology care and plays critical roles in diagnosis, prognostic assessment, and treatment selection. Thus, in parallel, the variety of genomic testing providers and sequencing platforms has grown exponentially. Selection of the best-fit panel for each case can be daunting, with many factors to consider. Among them is whether alteration interpretation and therapy/clinical trial matching are included and/or sufficient. In this article, we review some common commercially available sequencing platforms for the genes and types of alterations tested, samples needed, and reporting content provided. We review publicly available resources for a do-it-yourself approach to alteration interpretation when it is not provided or when supplemental research is needed, along with resources to identify genomically matched treatment options that are approved and/or investigational. However, with both commercially provided interpretation and publicly available resources, there are still caveats and limitations that can stem from insufficient or ambiguous nomenclature as well as from the presentation of information. Use cases in which clinical decision making was affected are discussed. After treatment options are identified, it is important to assess the level of evidence for use within the patient's tumor type and molecular profile. However, numerous level-of-evidence scales have been published in recent years, so we provide a publicly available tool to facilitate interoperability. The level of evidence, along with other factors, such as allelic frequency and copy number, can be used to prioritize treatment options when multiple are identified.

Abstract 5506: NOTCH1 activation in head and neck squamous cell carcinoma leads to growth inhibition, changes in gene expression associated with early differentiation, and acquisition of stem cell-like properties

Background: The NOTCH1 gene functions as either an oncogene or tumor suppressor in cancer depending upon the tumor type. Our group previously characterized the genomic alterations in head and neck squamous cell carcinoma (HNSCC), discovering that NOTCH1 is frequently altered with a pattern of inactivating mutations suggesting it is a tumor suppressor in this cancer type. However, recent work by others suggests NOTCH1 signaling plays a more complex role, possibly promoting a more aggressive phenotype or cancer stem cell-like properties in HNSCCs with wild type NOTCH1. Our present study aimed to systematically compare the phenotypic consequences of NOTCH1 signaling in HNSCC to better understand its function in cancer, and identify targets downstream of NOTCH1 signaling. Methods: Established HNSCC cell lines wild type for NOTCH1 (PJ34, FADU) or harboring an inactivating mutation (UMSCC22A) were engineered to express activated cleaved NOTCH1 (cl-NOTCH1) from a doxycycline-inducible promoter. In vitro cell growth was measured with clonogenic assays. Stem cell-like properties were measured by orosphere formation and anoikis resistance. Stem cell markers for HNSCC including Aldehyde dehydrogenase activity (ALDH), CD133, and CD44 expression were measured by flow cytometry. NOTCH1-regulated downstream gene expression changes were examined by RNA-seq and qRT-PCR. Results: Activation of NOTCH1 inhibited clonogenic growth of all three cell lines, regardless of original NOTCH1 gene status. Growth inhibition was frequently accompanied by spontaneous formation of spheroid-like structures, characteristic of stem cells. NOTCH1 activation in UMSCC22A and FADU cells promoted orosphere formation and anoikis resistance, conveying some stem cell-like properties. However, classical stem cell markers including ALDH activity, CD133, and CD44 expression were not affected by NOTCH1 activation. Furthermore, RNA-seq demonstrated that critical cancer-associated pathways, including proliferation, differentiation, and migration, were regulated by NOTCH1. NOTCH1 activation downregulated gene expression of ITGA3, ITGA4, ITGB1, ITGB6, and LAMC2, which are key adhesion molecules that human basal keratinocytes use for attachment to the basement membrane and maintenance of the stem cell compartment. Concomitantly, NOTCH1 activation increased the basal/superbasal marker SOX2, but also the early differentiation markers KRT4 and KRT13. SiRNA-mediated SOX2 silencing blocked NOTCH1-promoted anoikis resistance. Conclusion: NOTCH1 activation inhibits in vitro growth regardless of mutational status. We hypothesize that stem cell-like properties associated with NOTCH1 activation in HNSCC may be a consequence of pathways that recapitulate early differentiation, rather than true stem cell maintenance.

Citation Format: Chenfei Huang, Shhyam Moorthy, Qiuli Li, Rami Saade, Jiping Wang, Xiayu Rao, Noriaki Tanaka, Jiexin Zhang, Lin Tang, Curtis R. Pickering, Patrick A. Zweidler-McKay, Abdullah A. Osman, Tong-Xin Xie, Eve Shinbrot, Liu Xi, David Wheeler, Adel K. El-Naggar, Jing Wang, Jeffrey N. Myers, Mitchell J. Frederick. NOTCH1 activation in head and neck squamous cell carcinoma leads to growth inhibition, changes in gene expression associated with early differentiation, and acquisition of stem cell-like properties [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 5506.

Paralingual and sublingual space invasion in magnetic resonance imaging of squamous cell carcinoma of anterior two-thirds of tongue: Is there a prognostic significance? A prospective evaluation

BACKGROUND

Magnetic resonance imaging (MRI) in tumors of anterior two-thirds of tongue has a significant role in assessing different tumor parameters, and in prognosticating.

AIM

This prospective study conducted in a tertiary cancer care center, focused on patients with squamous cell carcinoma of anterior two-thirds of tongue. The significance of invasion of paralingual and sublingual spaces in relation to the pathological grade of these tumors, and its predictive value in pathological nodal involvement were analyzed.

MATERIALS AND METHODS

All consecutive patients with the required inclusion criteria were accrued. Imaging was done with 3 Tesla MRI and invasion of sublingual and paralingual spaces were accurately assessed. Data elucidated were tabulated and analysed using IBM SPSS version 20.0. Chi-square test, nonparametric correlation using Spearman's Rho correlation, and two-independent sample test using Mann-Whitney's U-test were used to arrive at correlations between the imaging and histopathological parameters.

RESULTS

Sixty-three patients were analyzed. Mean age was 52.3 ± 11.45 years. 74.6% were males. MRI showed sublingual space invasion in 47.6%. 18/28 with and 11/33 without invasion had node positivity. Paralingual space involvement was observed in 31.7% of patients. Thirteen of these and 16/43 with no involvement had positive cervical nodes. No statistically significant correlation was observed.

CONCLUSION

This prospective study did not establish any statistically sound correlation, and robust data are lacking to support newer parameters such as sublingual space and paralingual space as probable predictors of cervical nodal involvement, and for prognostication.

Development of a prognostic scoring system for patients with advanced cancer enrolled in immune checkpoint inhibitor phase 1 clinical trials

Background:

We sought to develop a prognostic scoring system to aid in patient selection for immune checkpoint inhibitor (ICI) phase 1 clinical trials.

Methods:

Clinical data from patients treated in phase 1 ICI clinical trials at MD Anderson (MDA) Center were analysed. Seventeen clinical factors were studied. Recursive partitioning analysis, a tree-based model, was used to develop a regression tree and identify optimal cut-points based on differences in survival for each clinical factor. A Cox proportional hazards regression model was then used to identify factors independently affecting overall survival. A prognostic scoring system was subsequently developed.

Results:

A total of 172 patients (105 CTLA4- and 67 PD1-based) were analysed. Seven factors were independently associated with worse overall survival (OS): age>52 years (hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.1–2.4), Eastern Cooperative Oncology Group performance status>1 (HR 2.81, 95%CI 1.3–6.3), lactate dehydrogenase >466 (which is 0.75 × the upper limit of normal at our institution) (HR 2.1, 95% CI 1.4–3.2), platelet count >300 × 10³μL⁻¹ (HR 1.8, 95% CI 1.2–2.8), absolute neutrophil count >4.9 × 10³μL⁻¹ (HR 2.3, 95% CI 1.5–3.5), absolute lymphocyte count <1.8 × 10³μL⁻¹ (HR 3.3, 95% CI 1.9–5.7), and liver metastases (HR 1.8, 95% CI 1.2–2.6). An index was created by dividing the cohort into risk groups based on the number of factors present: 0–2, 3, 4, or 5–6. Median OS was 24.2 months, 11.6 months, 8.0 months, and 3.8 months for patients with 0–2, 3, 4, or 5–6 risk factors, respectively; log-rank test, P<0.0001. The Harrell c-index of this scoring system was 0.72, indicating better predictability than the Royal Marsden Hospital score (c-index 0.67) and MDA score (c-index 0.61).

Conclusions:

We have developed a novel ‘MDA-ICI’ prognostic scoring system for patients treated in phase 1 ICI clinical trials. Prospective evaluation and external validation is warranted and may help aid patient selection for future clinical trials.

Dosimetric comparison of three dimensional conformal radiation therapy versus intensity modulated radiation therapy in accelerated partial breast irradiation

AIM OF STUDY

Breast conserving surgery (BCS) is the standard treatment for stage I and II breast cancer. Multiple studies have shown that recurrences after lumpectomy occur mainly in or near the tumor bed. Use of accelerated partial breast irradiation (APBI) allows for significant reduction in the overall treatment time that results in increasing patient compliance and decreasing healthcare costs. We conducted a treatment planning study to evaluate the role of intensity modulated radiation therapy (IMRT) with regards to three-dimensional conformal radiation therapy (3DCRT) in APBI.

MATERIALS AND METHODS

Computed tomography planning data sets of 33 patients (20 right sided and 13 left sided) with tumor size less than 3 cm and negative axillary lymph nodes were used for our study. Tumor location was upper outer, upper inner, central, lower inner, and lower outer quadrants in 10, 10, 5, 4 and 4 patients, respectively. Multiple 3DCRT and IMRT plans were created for each patient. Total dose of 38.5 Gy in 10 fractions were planned. Dosimetric analysis was done for the best 3DCRT and IMRT plans.

RESULTS

The target coverage has been achieved by both the methods but IMRT provided better coverage (P = 0.04) with improved conformity index (P = 0.01). Maximum doses were well controlled in IMRT to below 108% (P < 0.01). Heart V2 Gy (P < 0.01), lung V5 Gy (P = 0.01), lung V10 Gy (P = 0.02), contralateral breast V1 Gy (P < 0.01), contralateral lung V2 Gy (P < 0.01), and ipsilateral uninvolved breast (P < 0.01) doses were higher with 3DCRT compared to IMRT.

CONCLUSION

Dosimetrically, IMRT-APBI provided best target coverage with less dose to normal tissues compared with 3DCRT-APBI.

Integrative genomic characterization of oral squamous cell carcinoma identifies frequent somatic drivers

The survival of patients with oral squamous cell carcinoma (OSCC) has not changed significantly in several decades, leading clinicians and investigators to search for promising molecular targets. To this end, we conducted comprehensive genomic analysis of gene expression, copy number, methylation, and point mutations in OSCC. Integrated analysis revealed more somatic events than previously reported, identifying four major driver pathways (mitogenic signaling, Notch, cell cycle, and TP53) and two additional key genes (FAT1, CASP8). The Notch pathway was defective in 66% of patients, and in follow-up studies of mechanism, functional NOTCH1 signaling inhibited proliferation of OSCC cell lines. Frequent mutation of caspase-8 (CASP8) defines a new molecular subtype of OSCC with few copy number changes. Although genomic alterations are dominated by loss of tumor suppressor genes, 80% of patients harbored at least one genomic alteration in a targetable gene, suggesting that novel approaches to treatment may be possible for this debilitating subset of head and neck cancers.

Ruptured idiopathic pulmonary artery aneurysm: unusual case of hemothorax treated by selective embolization

Aneurysm of the peripheral pulmonary arteries is rare. Rupture of pulmonary artery aneurysms manifesting as recurrent hemoptysis with exsanguination is well recognized. We report the case of a young woman who presented with massive hemothorax and shock at the sixth month of pregnancy due to a ruptured lingular artery aneurysm. She was treated with selective coil embolization of the lingular artery to achieve hemostasis. Subsequently, clot evacuation from the pleural space was done. This case is reported for its unsuspected presentation, rarity and to highlight the use of catheter coil embolization to achieve control of bleeding and exclusion of the aneurysm from the pulmonary circulation.

Expression of functional domains of beta G-spectrin disrupts epithelial morphology in cultured cells

Spectrin is a major structural protein associated with the cytoplasmic surface of plasma membranes of many types of cells. To study the functions of spectrin, we transfected Caco-2 intestinal epithelial cells with a plasmid conferring neomycin resistance and encoding either actin-binding or ankyrin-binding domains of beta G-spectrin fused with beta-galactosidase. These polypeptides, in principle, could interfere with the interaction of spectrin with actin or ankyrin, as well as block normal assembly of alpha- and beta-spectrin subunits. Cells expressing the fusion proteins represented only a small fraction of neomycin-resistant cells, but they could be detected based on expression of beta-galactosidase. Cells expressing spectrin domains exhibited a progressive decrease in amounts of endogenous beta G-spectrin, although alpha-spectrin was still present. Beta G-spectrin-deficient cells lost epithelial cell morphology, became multinucleated, and eventually disappeared after 10-14 d in culture. Spectrin-associated membrane proteins, ankyrin and adducin, as well as the Na+,K(+)-ATPase, which binds to ankyrin, exhibited altered distributions in cells transfected with beta G-spectrin domains. E-cadherin and F-actin, in contrast to ankyrin, adducin, and the Na+,K(+)-ATPase, were expressed, and they exhibited unaltered distribution in beta G-spectrin-deficient cells. Cells transfected with the same plasmid encoding beta-galactosidase alone survived in culture as the major population of neomycin-resistant cells, and they exhibited no change in morphology or in the distribution of spectrin-associated membrane proteins. These results establish that beta G-spectrin is essential for the normal morphology of epithelial cells, as well as for their maintenance in monolayer culture.

Whipple's disease with minimal intestinal involvement

An uncharacteristic case of Whipple's disease is reported, in which, although overt intestinal involvement was absent, and there was only a patchy histological lesion, the diagnosis was confirmed by electron-microscopic examination of peroral intestinal biopsies.