Tumor histoculture captures the dynamic interactions between tumor and immune components in response to anti-PD1 in head and neck cancer

Dynamic interactions within the tumor micro-environment drive patient response to immune checkpoint inhibitors. Existing preclinical models lack true representation of this complexity. Using a Head and Neck cancer patient derived TruTumor histoculture platform, the response spectrum of 70 patients to anti-PD1 treatment is investigated in this study. With a subset of 55 patient samples, multiple assays to characterize T-cell reinvigoration and tumor cytotoxicity are performed. Based on levels of these two response parameters, patients are stratified into five sub-cohorts, with the best responder and non-responder sub-cohorts falling at extreme ends of the spectrum. The responder sub-cohort exhibits high T-cell reinvigoration, high tumor cytotoxicity with T-cells homing into the tumor upon treatment whereas immune suppression and tumor progression pathways are pre-dominant in the non-responders. Some moderate responders benefit from combination of anti-CTLA4 with anti-PD1, which is evident from better cytotoxic T-cell: T-regulatory cell ratio and enhancement of tumor cytotoxicity. Baseline and on-treatment gene expression signatures from this study stratify responders and non-responders in unrelated clinical datasets.

Contrasting clinical outcomes and socio-economic impact of young versus elderly-onset oral squamous cell carcinoma, a novel health economic analysis

OBJECTIVES

The incidence of young-onset oral squamous cell carcinoma (OSCC) is growing, even among non-smokers/drinkers. The effects of adverse histopathological features on long-term oncologic outcomes between the young and old are controversial and confounded by significant heterogeneity. Few studies have evaluated the socio-economic impact of premature mortality from OSCC. Our study seeks to quantify these differences and their economic impact on society.

MATERIALS AND METHODS

Four hundred and seventy-eight young (<45 years) and 1660 old patients (≥45 years) with OSCC were studied. Logistic regression determined predictors of recurrence and death. Survival analysis was calculated via the Kaplan-Meier method. A separate health economic analysis was conducted for India and Singapore. Years of Potential Productive Life Lost (YPPLL) were estimated with the Human Capital Approach, and premature mortality cost was derived using population-level data.

RESULTS

Adverse histopathological features were seen more frequently in young OSCC: PNI (42.9% vs. 35%, p = 0.002), LVI (22.4% vs. 17.3%, p = 0.013) and ENE (36% vs. 24.5%, p < 0.001). Although 5-year OS/DSS were similar, the young cohort had received more intensive adjuvant therapy (CCRT 26.9% vs. 16.6%, p < 0.001). Among Singaporean males, the premature mortality cost per death was US $396,528, and per YPPLL was US $45,486. This was US $397,402 and US $38,458 for females. Among Indian males, the premature mortality cost per death was US $30,641, and per YPPLL was US $595. This was US $ 21,038 and US $305 for females.

CONCLUSION

Young-onset OSCC is an aggressive disease, mitigated by the ability to receive intensive adjuvant treatment. From our loss of productivity analysis, the socio-economic costs from premature mortality are substantial. Early cancer screening and educational outreach campaigns should be tailored to this cohort. Alongside, more funding should be diverted to genetic research, developing novel biomarkers and improving the efficacy of adjuvant treatment in OSCC.

Improving accuracy in nodal staging of oral cancer: Proposal of a new system

BACKGROUND

Despite introduction of extranodal extension (ENE) into the AJCC 8th edition of oral cancer staging, previous criticisms persist, such as limited discrimination between sub-stages and doubtful prognostic value of contralateral nodal disease. The purpose of this study was to compare our novel nodal staging system, based on the number of positive nodes and ENE, to the AJCC staging system in surgically treated patients.

METHODS

Retrospective analysis of 4710 patients with oral squamous cell carcinoma (OSCC) treated with surgery±adjuvant therapy in 8 institutions in Australia, North America and Asia. With overall survival (OS) and disease specific survival (DSS) as endpoint, the prognostic performance of AJCC 8th and 7th editions were compared using hazard consistency, hazard discrimination, likelihood difference and balance.

RESULTS

Our new nodal staging system (PN) a progressive and linear increase in hazard ratio (HR) from pN0 to pN3, with good separation of Kaplan Meier curves. Using the predetermined criteria for evaluation of a staging system, our proposed staging model outperformed AJCC 8th and 7th editions in prediction of OS and DSS.

CONCLUSION

PN was the lymph node staging system that provided the most accurate prediction of OS and DSS for patients in our cohort of OSCC. Additionally, it can be easily adopted, addresses the shortcomings of the existing systems and should be considered for future editions of the TNM staging system.

Inter-observer agreement among specialists in the diagnosis of oral potentially malignant disorders and oral cancer using store-and-forward technology

OBJECTIVES

Oral cancer is a leading cause of morbidity and mortality. Screening and mobile Health (mHealth)-based approach facilitates early detection remotely in a resource-limited settings. Recent advances in eHealth technology have enabled remote monitoring and triage to detect oral cancer in its early stages. Although studies have been conducted to evaluate the diagnostic efficacy of remote specialists, to our knowledge, no studies have been conducted to evaluate the consistency of remote specialists. The aim of this study was to evaluate interobserver agreement between specialists through telemedicine systems in real-world settings using store-and-forward technology.

MATERIALS AND METHODS

The two remote specialists independently diagnosed clinical images (n=822) from image archives. The onsite specialist diagnosed the same participants using conventional visual examination, which was tabulated. The diagnostic accuracy of two remote specialists was compared with that of the onsite specialist. Images that were confirmed histopathologically were compared with the onsite diagnoses and the two remote specialists.

RESULTS

There was moderate agreement (k= 0.682) between two remote specialists and (k= 0.629) between the onsite specialist and two remote specialists in the diagnosis of oral lesions. The sensitivity and specificity of remote specialist 1 were 92.7% and 83.3%, respectively, and those of remote specialist 2 were 95.8% and 60%, respectively, each compared with histopathology.

CONCLUSION

The diagnostic accuracy of the two remote specialists was optimal, suggesting that "store and forward" technology and telehealth can be an effective tool for triage and monitoring of patients.

CLINICAL RELEVANCE

Telemedicine is a good tool for triage and enables faster patient care in real-world settings.

CD44-SNA1 integrated cytopathology for delineation of high grade dysplastic and neoplastic oral lesions

The high prevalence of oral potentially-malignant disorders exhibits diverse severity and risk of malignant transformation, which mandates a Point-of-Care diagnostic tool. Low patient compliance for biopsies underscores the need for minimally-invasive diagnosis. Oral cytology, an apt method, is not clinically applicable due to a lack of definitive diagnostic criteria and subjective interpretation. The primary objective of this study was to identify and evaluate the efficacy of biomarkers for cytology-based delineation of high-risk oral lesions. A comprehensive systematic review and meta-analysis of biomarkers recognized a panel of markers (n: 10) delineating dysplastic oral lesions. In this observational cross sectional study, immunohistochemical validation (n: 131) identified a four-marker panel, CD44, Cyclin D1, SNA-1, and MAA, with the best sensitivity (>75%; AUC>0.75) in delineating benign, hyperplasia, and mild-dysplasia (Low Risk Lesions; LRL) from moderate-severe dysplasia (High Grade Dysplasia: HGD) along with cancer. Independent validation by cytology (n: 133) showed that expression of SNA-1 and CD44 significantly delineate HGD and cancer with high sensitivity (>83%). Multiplex validation in another cohort (n: 138), integrated with a machine learning model incorporating clinical parameters, further improved the sensitivity and specificity (>88%). Additionally, image automation with SNA-1 profiled data set also provided a high sensitivity (sensitivity: 86%). In the present study, cytology with a two-marker panel, detecting aberrant glycosylation and a glycoprotein, provided efficient risk stratification of oral lesions. Our study indicated that use of a two-biomarker panel (CD44/SNA-1) integrated with clinical parameters or SNA-1 with automated image analysis (Sensitivity >85%) or multiplexed two-marker panel analysis (Sensitivity: >90%) provided efficient risk stratification of oral lesions, indicating the significance of biomarker-integrated cytopathology in the development of a Point-of-care assay.

Inter-observer agreement among specialists in the diagnosis of Oral Potentially Malignant Disorders and Oral Cancer using Store-and-Forward technology

Oral Cancer is one of the most common causes of morbidity and mortality. Screening and mobile Health (mHealth) based approach facilitates remote early detection of Oral cancer in a resource-constrained settings. The emerging eHealth technology has aided specialist reach to rural areas enabling remote monitoring and triaging to downstage Oral cancer. Though the diagnostic accuracy of the remote specialist has been evaluated, there are no studies evaluating the consistency among the remote specialists, to the best of our knowledge. The purpose of the study was to evaluate the interobserver agreement between the specialists through telemedicine systems in real-world settings using store and forward technology. Two remote specialists independently diagnosed the clinical images from image repositories, and the diagnostic accuracy was compared with onsite specialist and histopathological diagnosis when available. Moderate agreement (k = 0.682) between two remote specialists and (k = 0.629) between the onsite specialist and two remote specialists in diagnosing oral lesions. The sensitivity and specificity of remote specialist 1 were 92.7% and 83.3%, whereas remote specialist 2 was 95.8% and 60%, respectively, compared to histopathology. The store and forward technology and telecare can be effective tools in triaging and surveillance of patients.

Pharmacokinetics and Pharmacodynamics of a Novel U500 Insulin Aspart Formulation: A Randomized, Double-Blind, Crossover Study in People With Type 1 Diabetes

OBJECTIVE

To evaluate the pharmacokinetics, pharmacodynamics, and safety of a novel U500 insulin aspart formulation (AT278 U500) compared with insulin aspart (IAsp U100).

RESEARCH DESIGN AND METHODS

This single-center, randomized, double-blind study was conducted in 38 men with type 1 diabetes (body weight ≤100 kg and total insulin dose <1.2 units/kg/day). Participants received a single dose of either AT278 U500 or IAsp U100 (0.3 units/kg s.c.) in a crossover design, followed by an 8-h euglycemic clamp in the absence of basal insulin.

RESULTS

With AT278 U500, onset of appearance in serum was 6 min earlier (P < 0.0001) and reached 50% of maximum concentration 23 min faster (P < 0.0001). Insulin exposure with AT278 U500 was 4.0-fold higher within the first 30 min (95% CI 3.29, 4.90), 1.5-fold higher within the first 60 min (95% CI 1.35, 1.76), and statistically superior up to 90 min postdose (P < 0.05). With AT278 U500, onset of action was 10 min earlier (P < 0.0001) and reached 50% of maximum glucose infusion rate 20 min faster (P < 0.0001). The glucose-lowering effect with AT278 U500 was 8.9-fold higher within the first 30 min (95% CI 5.96, 17.46), 2.4-fold higher within the first 60 min (95% CI 1.92, 3.22), and statistically superior up to 2 h postdose (P < 0.0001). Overall insulin exposure and glucose-lowering effect were comparable. No significant safety findings were observed.

CONCLUSIONS

AT278 U500 offers rapid-acting characteristics in a reduced dose volume, with accelerated absorption and onset of action compared with IAsp U100 in the studied population.

Exploring uncertainty measures in convolutional neural network for semantic segmentation of oral cancer images

SIGNIFICANCE

Oral cancer is one of the most prevalent cancers, especially in middle- and low-income countries such as India. Automatic segmentation of oral cancer images can improve the diagnostic workflow, which is a significant task in oral cancer image analysis. Despite the remarkable success of deep-learning networks in medical segmentation, they rarely provide uncertainty quantification for their output.

AIM

We aim to estimate uncertainty in a deep-learning approach to semantic segmentation of oral cancer images and to improve the accuracy and reliability of predictions.

APPROACH

This work introduced a UNet-based Bayesian deep-learning (BDL) model to segment potentially malignant and malignant lesion areas in the oral cavity. The model can quantify uncertainty in predictions. We also developed an efficient model that increased the inference speed, which is almost six times smaller and two times faster (inference speed) than the original UNet. The dataset in this study was collected using our customized screening platform and was annotated by oral oncology specialists.

RESULTS

The proposed approach achieved good segmentation performance as well as good uncertainty estimation performance. In the experiments, we observed an improvement in pixel accuracy and mean intersection over union by removing uncertain pixels. This result reflects that the model provided less accurate predictions in uncertain areas that may need more attention and further inspection. The experiments also showed that with some performance compromises, the efficient model reduced computation time and model size, which expands the potential for implementation on portable devices used in resource-limited settings.

CONCLUSIONS

Our study demonstrates the UNet-based BDL model not only can perform potentially malignant and malignant oral lesion segmentation, but also can provide informative pixel-level uncertainty estimation. With this extra uncertainty information, the accuracy and reliability of the model’s prediction can be improved.

Isolated Infratemporal Fossa Desmoid Fibromatosis: A Rare Case Report and Review of Literature

Desmoid fibromatosis (DF) arising from musculoaponeurotic structures rarely affects the head and neck region with the abdomen being the most common site of origin. These are benign tumors with locally infiltrative nature usually presenting as painless swellings that are rapidly growing. The infratemporal fossa DF is an extremely rare location with few clinical reports. This article discusses the management of a 2-year-old child with DF of the infratemporal fossa (ITF) along with literature review.

Risk Stratification in Oral Cancer: A Novel Approach

Background

Oral squamous cell carcinoma (OSCC) is a common head and neck cancer with high morbidity and mortality. Currently, treatment decisions are guided by TNM staging, which omits important negative prognosticators such as lymphovascular invasion, perineural invasion (PNI), and histologic differentiation. We proposed nomogram models based on adverse pathological features to identify candidates suitable for treatment escalation within each risk group according to the National Comprehensive Cancer Network (NCCN) guidelines.

Methods

Anonymized clinicopathologic data of OSCC patients from 5 tertiary healthcare institutions in Asia were divided into 3 risk groups according to the NCCN guidelines. Within each risk group, nomograms were built to predict overall survival based on histologic differentiation, histologic margin involvement, depth of invasion (DOI), extranodal extension, PNI, lymphovascular, and bone invasion. Nomograms were internally validated with precision–recall analysis and the Kaplan–Meier survival analysis.

Results

Low-risk patients with positive pathological nodal involvement and/or positive PNI should be considered for adjuvant radiotherapy. Intermediate-risk patients with gross bone invasion may benefit from concurrent chemotherapy. High-risk patients with positive margins, high DOI, and a high composite score of histologic differentiation, PNI, and the American Joint Committee on Cancer (AJCC) 8th edition T staging should be considered for treatment escalation to experimental therapies in clinical trials.

Conclusion

Nomograms built based on prognostic adverse pathological features can be used within each NCCN risk group to fine-tune treatment decisions for OSCC patients.

Interpretable deep learning approach for oral cancer classification using guided attention inference network

SIGNIFICANCE

Convolutional neural networks (CNNs) show the potential for automated classification of different cancer lesions. However, their lack of interpretability and explainability makes CNNs less than understandable. Furthermore, CNNs may incorrectly concentrate on other areas surrounding the salient object, rather than the network's attention focusing directly on the object to be recognized, as the network has no incentive to focus solely on the correct subjects to be detected. This inhibits the reliability of CNNs, especially for biomedical applications.

AIM

Develop a deep learning training approach that could provide understandability to its predictions and directly guide the network to concentrate its attention and accurately delineate cancerous regions of the image.

APPROACH

We utilized Selvaraju et al.'s gradient-weighted class activation mapping to inject interpretability and explainability into CNNs. We adopted a two-stage training process with data augmentation techniques and Li et al.'s guided attention inference network (GAIN) to train images captured using our customized mobile oral screening devices. The GAIN architecture consists of three streams of network training: classification stream, attention mining stream, and bounding box stream. By adopting the GAIN training architecture, we jointly optimized the classification and segmentation accuracy of our CNN by treating these attention maps as reliable priors to develop attention maps with more complete and accurate segmentation.

RESULTS

The network's attention map will help us to actively understand what the network is focusing on and looking at during its decision-making process. The results also show that the proposed method could guide the trained neural network to highlight and focus its attention on the correct lesion areas in the images when making a decision, rather than focusing its attention on relevant yet incorrect regions.

CONCLUSIONS

We demonstrate the effectiveness of our approach for more interpretable and reliable oral potentially malignant lesion and malignant lesion classification.

Bayesian deep learning for reliable oral cancer image classification

In medical imaging, deep learning-based solutions have achieved state-of-the-art performance. However, reliability restricts the integration of deep learning into practical medical workflows since conventional deep learning frameworks cannot quantitatively assess model uncertainty. In this work, we propose to address this shortcoming by utilizing a Bayesian deep network capable of estimating uncertainty to assess oral cancer image classification reliability. We evaluate the model using a large intraoral cheek mucosa image dataset captured using our customized device from high-risk population to show that meaningful uncertainty information can be produced. In addition, our experiments show improved accuracy by uncertainty-informed referral. The accuracy of retained data reaches roughly 90% when referring either 10% of all cases or referring cases whose uncertainty value is greater than 0.3. The performance can be further improved by referring more patients. The experiments show the model is capable of identifying difficult cases needing further inspection.

Classification of imbalanced oral cancer image data from high-risk population

SIGNIFICANCE

Early detection of oral cancer is vital for high-risk patients, and machine learning-based automatic classification is ideal for disease screening. However, current datasets collected from high-risk populations are unbalanced and often have detrimental effects on the performance of classification.

AIM

To reduce the class bias caused by data imbalance.

APPROACH

We collected 3851 polarized white light cheek mucosa images using our customized oral cancer screening device. We use weight balancing, data augmentation, undersampling, focal loss, and ensemble methods to improve the neural network performance of oral cancer image classification with the imbalanced multi-class datasets captured from high-risk populations during oral cancer screening in low-resource settings.

RESULTS

By applying both data-level and algorithm-level approaches to the deep learning training process, the performance of the minority classes, which were difficult to distinguish at the beginning, has been improved. The accuracy of "premalignancy" class is also increased, which is ideal for screening applications.

CONCLUSIONS

Experimental results show that the class bias induced by imbalanced oral cancer image datasets could be reduced using both data- and algorithm-level methods. Our study may provide an important basis for helping understand the influence of unbalanced datasets on oral cancer deep learning classifiers and how to mitigate.

Validation of a Point-of-Care Optical Coherence Tomography Device with Machine Learning Algorithm for Detection of Oral Potentially Malignant and Malignant Lesions

Non-invasive strategies that can identify oral malignant and dysplastic oral potentially-malignant lesions (OPML) are necessary in cancer screening and long-term surveillance. Optical coherence tomography (OCT) can be a rapid, real time and non-invasive imaging method for frequent patient surveillance. Here, we report the validation of a portable, robust OCT device in 232 patients (lesions: 347) in different clinical settings. The device deployed with algorithm-based automated diagnosis, showed efficacy in delineation of oral benign and normal (n = 151), OPML (n = 121), and malignant lesions (n = 75) in community and tertiary care settings. This study showed that OCT images analyzed by automated image processing algorithm could distinguish the dysplastic-OPML and malignant lesions with a sensitivity of 95% and 93%, respectively. Furthermore, we explored the ability of multiple (n = 14) artificial neural network (ANN) based feature extraction techniques for delineation high grade-OPML (moderate/severe dysplasia). The support vector machine (SVM) model built over ANN, delineated high-grade dysplasia with sensitivity of 83%, which in turn, can be employed to triage patients for tertiary care. The study provides evidence towards the utility of the robust and low-cost OCT instrument as a point-of-care device in resource-constrained settings and the potential clinical application of device in screening and surveillance of oral cancer.

Mobile-based oral cancer classification for point-of-care screening

SIGNIFICANCE

Oral cancer is among the most common cancers globally, especially in low- and middle-income countries. Early detection is the most effective way to reduce the mortality rate. Deep learning-based cancer image classification models usually need to be hosted on a computing server. However, internet connection is unreliable for screening in low-resource settings.

AIM

To develop a mobile-based dual-mode image classification method and customized Android application for point-of-care oral cancer detection.

APPROACH

The dataset used in our study was captured among 5025 patients with our customized dual-modality mobile oral screening devices. We trained an efficient network MobileNet with focal loss and converted the model into TensorFlow Lite format. The finalized lite format model is ∼16.3  MB and ideal for smartphone platform operation. We have developed an Android smartphone application in an easy-to-use format that implements the mobile-based dual-modality image classification approach to distinguish oral potentially malignant and malignant images from normal/benign images.

RESULTS

We investigated the accuracy and running speed on a cost-effective smartphone computing platform. It takes ∼300  ms to process one image pair with the Moto G5 Android smartphone. We tested the proposed method on a standalone dataset and achieved 81% accuracy for distinguishing normal/benign lesions from clinically suspicious lesions, using a gold standard of clinical impression based on the review of images by oral specialists.

CONCLUSIONS

Our study demonstrates the effectiveness of a mobile-based approach for oral cancer screening in low-resource settings.

Geographical heterogeneity in the American Joint committee on Cancer oral cancer staging and prognostic implications

OBJECTIVES

The AJCC 8th edition (AJCC 8) has introduced depth of invasion (DOI) and extranodal extension (ENE) into staging for oral squamous cell carcinoma (OSCC). Although validations have been performed on institutional datasets have shown a good performance, particularly in early OSCC, there have been no studies on diverse patient populations that determine the impact on prognostic heterogeneity.

MATERIALS AND METHODS

Retrospective analysis of 4710 patients with oral squamous cell carcinoma (OSCC) treated with surgery +/- adjuvant therapy in 8 institutions in Australia, North America and Asia. With overall survival (OS) as endpoint, the prognostic performance of AJCC 7th and 8th editions were compared using Akaike Information Criterion (AIC), Bayesian Information Criteria (BIC), Harrell's concordance index (C-index).

RESULTS

When comparing AJCC 8 to AJCC 7, the heterogeneity in prediction of OS increased for T-category and N-category while remaining unchanged for TNM staging, suggesting AJCC 8 increased complexity with no improvement in predictive value. There were significant differences in median DOI and incidence of ENE between geographical regions, resulting in dissimilar rates of stage-migration when adopting AJCC 8.

CONCLUSION

In an attempt to improve prognostic performance, AJCC 8 introduced more variables; however heterogeneity in these results in significant geographical differences in model discrimination and performance. Caution should be applied as this may result in inaccurate and unreliable prognostic predictions that may impact treatment recommendations.

Intra-operative point-of-procedure delineation of oral cancer margins using optical coherence tomography

OBJECTIVES

Surgical margin status is a significant determinant of treatment outcome in oral cancer. Negative surgical margins can decrease the loco-regional recurrence by five-fold. The current standard of care of intraoperative clinical examination supplemented by histological frozen section, can result in a risk of positive margins from 5 to 17 percent. In this study, we attempted to assess the utility of intraoperative optical coherence tomography (OCT) imaging with automated diagnostic algorithm to improve on the current method of clinical evaluation of surgical margin in oral cancer.

MATERIALS AND METHODS

We have used a modified handheld OCT device with automated algorithm based diagnostic platform for imaging. Intraoperatively, images of 125 sites were captured from multiple zones around the tumor of oral cancer patients (n = 14) and compared with the clinical and pathologic diagnosis.

RESULTS

OCT showed sensitivity and specificity of 100%, equivalent to histological diagnosis (kappa, ĸ = 0.922), in detection of malignancy within tumor and tumor margin areas. In comparison, for dysplastic lesions, OCT-based detection showed a sensitivity of 92.5% and specificity of 68.8% and a moderate concordance with histopathology diagnosis (ĸ = 0.59). Additionally, the OCT scores could significantly differentiate squamous cell carcinoma (SCC) from dysplastic lesions (mild/moderate/severe; p ≤ 0.005) as well as the latter from the non-dysplastic lesions (p ≤ 0.05).

CONCLUSION

The current challenges associated with clinical examination-based margin assessment could be improved with intra-operative OCT imaging. OCT is capable of identifying microscopic tumor at the surgical margins and demonstrated the feasibility of mapping of field cancerization around the tumor.

Abstract 3070: Cancer stem cells in field cancerization of oral squamous cell carcinoma

Introduction: Field cancerization, the occurrence of transformed cells in the area adjacent to the tumor, has been attributed to the probable reasons of local recurrence of oral squamous cell carcinoma. Cancer stem cells (CSCs) have properties of tumor initiation, migration, and metastasis. The objective of the study was to evaluate their role in field cancerization.

Experimental Procedure: A panel of CSCs and its related markers was established from literature and validated in i) samples from surgical margins, ii) samples from 1 cm and 2 cm distance from margin around the tumor and in additional sides. First-phase validation was done in retrospective surgical margins of tumor (N=23) by qPCR and immunohistochemistry. The best marker subset from qPCR to predict recurrence was identified by ROC curve and logistic regression analysis and validated by immunohistochemistry. The final validation is being carried out in prospective samples from tumor-adjacent normal area as mentioned above. The marker profiles were correlated with the histology of the samples and the clinical outcome of the patients on follow-up.

Summary of Data: Out of 18 markers selected from literature CD44, CD147, SOX2, Snail, ATR, CyclinD1, MMP9 were selected from gene expression of first-phase validation. Among these SOX2, ATR, Cyclin D1, CD44 and CD147 were selected from IHC of first phase for second-phase validation in prospective samples (n=10) collected from 27 patients, which were clinically normal with varied grades of dysplasia; these samples were evaluated by the selected markers from the first set of validation. The correlation of markers expression with disease outcome of patients and with other clinical parameters is currently ongoing.

Conclusion: Our results suggest that CSCs have role in field cancerization and might be predictive of tumor recurrence/reinitiation and/or development of second primary tumor.

Citation Format: Simple Mohanta, Ravindra DR, Vikram Kekatpure, Naveen Hedne, Vijay Pillai, Shubhra Chauhan, Naveen BS, Athira Ramakrishnan, Bichu Jacob, Vishak Surendra, Leeky Mohanty, Anjana Muralidharan, Amritha Suresh, Moni Abraham Kuriakose. Cancer stem cells in field cancerization of oral squamous cell carcinoma [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 3070.

Role of Preablative Stimulated Thyroglobulin in Prediction of Nodal and Distant Metastasis on Iodine Whole-Body Scan

Background:

Preablative stimulated thyroglobulin (ps-Tg) is an important investigation in the follow-up of patients with Differentiated thyroid cancer(DTC) after surgery. Levels of ps-Tg >2–10 ng/ml have been suggested to predict metastasis to cervical and extracervical sites. There is still debate on the need for routine iodine whole-body scan (¹³¹I WBS) in the management of low-to-intermediate-risk DTC patients.

Objective:

We analyzed our data of patients with DTC who underwent total thyroidectomy to discuss the predictability of ps-Tg on metastatic disease on the ¹³¹I WBS.

Materials and Methods:

Retrospective analysis of patient records.

Results:

One hundred and seventeen patients with DTC (95 papillary thyroid cancer [71 had classic histology, 8 had tall cell variant, 16 had follicular variant] and 22 follicular thyroid cancer [18 minimally invasive, 2 hurtle cell, and 2 widely invasive cancers]) had undergone total thyroidectomy. All these patients underwent ps-Tg assessment and an ¹³¹I WBS. About 65% of them went on to have radioiodine ablation along with a posttherapy ¹³¹I WBS. We divided the cohort into four groups based on their ps-Tg levels: Group 1 (ps-Tg <1), Group 2 (ps-Tg 1–1.9), Group 3 (ps-Tg 2–5), and Group 4 (ps-Tg >5). None of the patients in Group 1, 7% of those combined in Groups 2 and 3 (2 out of 28 patients), and 26% (12 out of 47) of those in Group 4 had either cervical or extracervical metastasis. Those with extracervical metastatic disease to lungs and bones had a mean (standard deviation) ps-Tg value of 436 (130) and median of 500 ng/ml and those with cervical metastatic disease had a mean Tg value of 31 (64) and median 6.6 ng/ml.

Conclusions:

A ps-Tg value in the absence of anti-Tg antibodies <1 ng/ml reliably excludes metastatic disease in DTC, while a value >5 ng/ml has a 26% risk of having either cervical or extracervical metastasis.

Radio-guided Minimally Invasive Parathyroidectomy: A Descriptive Report of the Experience from Tertiary Center in Bangalore

OVERVIEW

Minimally invasive parathyroidectomy (MIP) is an accepted surgical procedure for parathyroid adenomas. In the patients with parathyroid adenoma localized by dual phase ^99mTc-Sestamibi scan, a focused approach utilizing the gamma probe intra-operatively helps in ensuring complete resection and avoiding exploration of the other parathyroid glands.

OBJECTIVE

The aim of the study was to evaluate the performance of radio-guided MIP for parathyroid adenomas detected by dual phase ^99mTc-MIBI preoperatively, without intra-operative parathyroid hormone (ioPTH) monitoring for patients who had evidence of single-gland disease.

PATIENTS AND METHODS

A retrospective dataset of 30 patients diagnosed with solitary parathyroid adenoma operated between 2009 and 2014 were reviewed. All of the patients underwent radio-guided MIP and were followed up for at least 6 months post-operatively. The biochemical parameters (serum calcium and serum parathyroid hormone levels), imaging parameters (ultrasonography and ^99mTc-MIBI), and operative times were analyzed.

RESULTS

Our study consisted of 30 patients with 50% females, with a mean age of 42.5 + 12 years. The mean surgical duration was 20 + 12 min. All of the patients achieved biochemical cure (normalization of serum calcium) and remained eucalcemic at follow-up. No major surgical complications were noted.

CONCLUSIONS

Focused parathyroidectomy using the gamma probe localization could be a potential alternative for ioPTH assay in ensuring the completeness of surgical resection of parathyroid adenoma. It is also likely to shorten operative time.

Improving Bethesda Reporting in Thyroid Cytology: A Team Effort Goes a Long Way and Still Miles to Go…

CONTEXT

Fine-needle aspiration cytology is the first step in evaluation of thyroid nodules. Although the Bethesda classification for reporting thyroid cytology has been purported that this uniformity in reporting cytology thereby facilitating clinical decision-making, there are also studies indicating that the reporting percentage and the rates of malignancy in each category vary considerably from center to center making the clinical decision more difficult.

AIM AND MATERIALS AND METHODS

We looked at our retrospective cytology and histopathology data of thyroid nodules operated between 2012 and 2014 and then prospectively collected data during 2015-2016. In the prospective arm, for every thyroid nodule that was sampled, there was a discussion between the endocrinologist and the cytopathologist on the risk of thyroid cancer (based on the patient's history, examination findings, sonographic pattern, and the cytological appearance).

RESULTS

We noted that there was considerable improvement in reporting standards with the rates of nondiagnostic cytology dropping from 11% to 5%, an increased reporting of Bethesda Category 2 and 6 which are the definitive strata of benign and malignant nodules (38% to 41% in Category 2 and 7% to 11% in Category 6) with a high specificity (100%). There was a decline in numbers of Category 4 and 5 (13% to 9% in Category 4 and 12% to 3% in Category 5). The reporting prevalence of Category 3 increased from 19% to 27%.

CONCLUSIONS

We conclude that a team approach between the clinician who performs the ultrasound and the reporting cytopathologist improves Bethesda reporting, its predictive value, and thus potentially avoiding unnecessary thyroidectomies in benign thyroid nodules and hemithyroidectomies in thyroid cancers.

Versatility of adipofascial anterolateral thigh flap for reconstruction of maxillary defects with infratemporal fossa extension

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm(2) (range, 120-180 cm(2)). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.

Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage

Introduction:

Facial contour deformities presents with varied aetiology and degrees severity. Accurate assessment, selecting a suitable tissue and sculpturing it to fill the defect is challenging and largely subjective. Objective assessment with imaging and software is not always feasible and preparing a template is complicated. A three-dimensional (3D) wax template pre-fabricated over the facial moulage aids surgeons to fulfil these tasks. Severe deformities demand a stable vascular tissue for an acceptable outcome.

Materials and Methods:

We present review of eight consecutive patients who underwent augmentation of facial contour defects with free flaps between June 2005 and January 2011. De-epithelialised free anterolateral thigh (ALT) flap in three, radial artery forearm flap and fibula osteocutaneous flap in two each and groin flap was used in one patient. A 3D wax template was fabricated by augmenting the deformity on facial moulage. It was utilised to select the flap, to determine the exact dimensions and to sculpture intraoperatively. Ancillary procedures such as genioplasty, rhinoplasty and coloboma correction were performed.

Results:

The average age at the presentation was 25 years and average disease free interval was 5.5 years and all flaps survived. Mean follow-up period was 21.75 months. The correction was aesthetically acceptable and was maintained without any recurrence or atrophy.

Conclusion:

The 3D wax template on facial moulage is simple, inexpensive and precise objective tool. It provides accurate guide for the planning and execution of the flap reconstruction. The selection of the flap is based on the type and extent of the defect. Superiority of vascularised free tissue is well-known and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.

[Severe airway distress following cervical spine operation: retrospective breakdown of the chain of errors]

A 71-year-old female patient received a prothesis due to a cervical disc prolapsed and bleeding into the collar soft tissues occurred postoperatively. Following a computed tomography examination severe peracute respiratory decompensation occurred while administering topical anesthesia to the pharynx in order to perform fiber optic intubation. Endotracheal intubation using conventional laryngoscopy was unsuccessful and the patient required immediate cricothyroidotomy. As an on-site cricothyrotomy set to establish a secure airway was not available the decision was taken to perform surgical cricothyroidotomy. As a conclusion to this life-threatening event in the case of symptoms, such as dyspnea, dysphonia and dysphagia after operations of the cervical spine the airway has to be secured early and according to the local algorithm.

Persistent left fifth aortic arch with pentalogy of Fallot

Congenital double-lumen aortic arch resulting from persistence of the fifth aortic arterial arch (PFAA) is a rare congenital anomaly. It appears as a vascular structure running inferior and parallel to the "real" aortic arch from the innominate artery to the left subclavian artery. We report a case of persistent fifth aortic arch (systemic-to-systemic arterial connection) with pentalogy of Fallot in a patient who underwent successful intracardiac repair with a transannular patch with very proximal aortic cannulation for cardiopulmonary bypass (CPB).

Production of type II collagen specific monoclonal antibodies

Immunoassays are used for the specific measurement of type II collagen, a major cartilage protein, which is lost in osteoarthritic joints. Poor immunogenicity and species dependent immune response to type II collagen make it difficult to obtain specific antibodies required for immunoassay development. In addition, type II collagen antibodies exhibit reactivity to structurally dissimilar antigens such as actin, myoglobin, thyroglobulin and ssDNA, complicating the isolation of specific antibodies. It is therefore necessary to characterize the antibody reactivity against both noncollagenous antigens and different collagen types. In this study, immune response to type II collagen was improved by conjugation to carrier proteins, KLH and BSA. Hybridomas were generated by fusions of lymphocytes derived from lymph nodes or spleens with X63-653-Ag8 myeloma cells. Compared to spleens, the utilization of lymph nodes as a source of lymphocytes resulted in a 23% higher number of hybridomas secreting type II collagen antibodies. Hybridomas secreting polyreactive antibodies were identified based on their reactivity to thyroglobulin and eliminated. Extensive testing of the remaining monoclonal antibodies with other structurally dissimilar antigens and various types of collagen for reactivity, allowed us to isolate specific monoclonal antibodies to type II collagen. We emphasize the importance of characterization of the reactivity of type II collagen monoclonal antibodies before employing them for immunoassays.

Plant regeneration from mesophyll protoplasts of Centaurea cyanus, Senecio x hybridus and Callistephus chinensis

Protoplasts were isolated from leaves of glasshouse-grown plants of Centaurea cyanus and axenic shoot cultures of Senecio x hybridus. Upon culture, using modified MS-based media, protoplasts of both systems entered division to produce callus, followed by plant regeneration. Leaf protoplasts of Callistephus chinensis entered sustained division only following the preconditioning for 24h of peeled leaf tissues on agar-solidified MS-based medium. Protoplasts were also isolated from cell suspensions of C. chinensis and divided in MS-based or KM media. However, only leaf mesophyll protoplasts of Callistephus produced callus, which developed shoots.The establishment of protoplast-to-plant protocols for these ornamental species has provided a basis for broadening their gene pools through somatic hybridisation.