Regulation of vascular endothelial growth factor production and angiogenesis by the cytoplasmic tail of tissue factor

Tissue factor (TF), a transmembrane receptor for coagulation factor VII/VIIa, is aberrantly expressed in human cancers. We demonstrated a significant correlation between TF and vascular endothelial growth factor (VEGF) production in 13 human malignant melanoma cell lines (r(2) = 0.869, P < 0.0001). Two of these cell lines, RPMI-7951, a high TF and VEGF producer, and WM-115, a low TF and VEGF producer, were grown s.c. in severe combined immunodeficient mice. The high-producer cell line generated solid tumors characterized by intense vascularity, whereas the low producer generated relatively avascular tumors, as determined by immunohistologic staining of tumor vascular endothelial cells with anti-von Willebrand factor antibody. To investigate the structure-function relationship of TF and VEGF, a low-producer melanoma cell line (HT144) was transfected with a TF cDNA containing the full-length sequence, a cytoplasmic deletion mutant lacking the coding sequence for the distal three serine residues (potential substrates for protein kinase C), or an extracellular domain mutant, which has markedly diminished function for activation of factor X. Cells transfected with the full-length sequence produced increased levels of both TF and VEGF. Transfectants with the full-length sequence and the extracellular domain mutant produced approximately equal levels of VEGF mRNA. However, cells transfected with the cytoplasmic deletion mutant construct produced increased levels of TF, but little or no VEGF. Thus, the cytoplasmic tail of TF plays a role in the regulation of VEGF expression in some tumor cells.

Fluvastatin inhibits up-regulation of tissue factor expression by antiphospholipid antibodies on endothelial cells

BACKGROUND

Mechanisms of thrombosis induced by antiphospholipid (aPL) antibodies include up-regulation of tissue factor (TF) expression on endothelial cells (ECs). Statins have been shown to reduce levels of TF induced by tumor necrosis factor (TNF-alpha) and lipopolysaccharide (LPS) on ECs. In a recent study, fluvastatin inhibited thrombogenic and proinflammatory properties of aPL antibodies in in vivo models. The aim of this study was to determine whether fluvastatin has an effect on aPL-induced expression of TF on ECs.

METHODS

IgGs were purified from four patients with APS (IgG-APS) and from control sera (IgG-NHS). Cultured human umbilical vein endothelial cells (HUVEC) were treated with IgG-APS or IgG-NHS or with medium alone or with phorbol myristate acetate (PMA), as a positive control. In some experiments, cells were pretreated with fluvastatin (2.5, 5 or 10 micro m) with and without mevalonate (100 micro m). TF expression on HUVECs was measured by ELISA.

RESULTS

PMA and the four IgG-APS preparations increased the expression of TF on EC significantly (4.9-, 2.4-, 4.2-, 3.5- and 3.1-fold, respectively), in a dose-dependent fashion. Fluvastatin (10 micro m) inhibited the effects of PMA and the four IgG-APS on TF expression by 70, 47, 65, 22 and 68%, respectively, and this effect was dose-dependent. Mevalonate (100 micro m) completely abrogated the inhibitory effects of fluvastatin on TF expression induced by aPL.

CONCLUSION

Because of the suggested pathogenic role of aPL on induction of TF on ECs, our data provide a rationale for using statins as a therapeutic tool in treatment of thrombosis in APS.

Comprehensive microRNA-sequencing of exosomes derived from head and neck carcinoma cells in vitro reveals common secretion profiles and potential utility as salivary biomarkers

Exosomes are nano-scale, membrane encapsulated vesicles that are released by cells into the extracellular space and function as intercellular signaling vectors through horizontal transfer of biologic molecules, including microRNA (miRNA). There is evidence that cancer-derived exosomes enable the tumor to manipulate its microenvironment, thus contributing to the capacity of the tumor for immune evasion, growth, invasion, and metastatic spread. The objective of this study was to characterize differential secretion of exosomal miRNA by head and neck squamous cell carcinoma (HNSCC) and identify a set of candidate biomarkers that could be detected in non-invasive saliva samples. We isolated exosomes from conditioned media from 4 HNSCC cell lines and oral epithelial control cells and applied miRNA-sequencing to comprehensively characterize their miRNA cargo and compare transcript levels of each HNSCC cell line to that of oral epithelial control cells. A candidate set of miRNA differentially secreted by all 4 HNSCC cell lines was further evaluated in saliva collected from HNSCC patients and healthy controls. We observed extensive differences in exosomal miRNA content between HNSCC cells when compared to normal oral epithelial control cells, with a high degree of overlap in exosomal miRNA profiles between the 4 distinct HNSCC cell lines. Importantly, several of the exosomal miRNA secreted solely by cancer cells in culture were detected at substantially elevated levels in saliva from HNSCC patients relative to saliva from healthy controls. These findings provide important insight into tumor biology and yields a promising set of candidate HNSCC biomarkers for use with non-invasive saliva samples.

Phase II Clinical Trial of Neoadjuvant and Adjuvant Pembrolizumab in Resectable Local-Regionally Advanced Head and Neck Squamous Cell Carcinoma

PURPOSE

Patients with resected, local-regionally advanced, head and neck squamous cell carcinoma (HNSCC) have a one-year disease-free survival (DFS) rate of 65%-69% despite adjuvant (chemo)radiotherapy. Neoadjuvant PD-1 immune-checkpoint blockade (ICB) has demonstrated clinical activity, but biomarkers of response and effect on survival remain unclear.

PATIENTS AND METHODS

Eligible patients had resectable squamous cell carcinoma of the oral cavity, larynx, hypopharynx, or oropharynx (p16-negative) and clinical stage T3-T4 and/or two or more nodal metastases or clinical extracapsular nodal extension (ENE). Patients received neoadjuvant pembrolizumab 200 mg 1-3 weeks prior to surgery, were stratified by absence (intermediate-risk) or presence (high-risk) of positive margins and/or ENE, and received adjuvant radiotherapy (60-66 Gy) and concurrent pembrolizumab (every 3 weeks × 6 doses). Patients with high-risk HNSCC also received weekly, concurrent cisplatin (40 mg/m2). Primary outcome was one-year DFS. Secondary endpoints were one-year overall survival (OS) and pathologic response (PR). Safety was evaluated with CTCAE v5.0.

RESULTS

From February 2016 to October 2020, 92 patients enrolled. The median age was 59 years (range, 27-80), 30% were female, 86% had stage T3-T4, and 69% had ≥N2. At a median follow-up of 28 months, one-year DFS was 97% (95% CI, 71%-90%) in the intermediate-risk group and 66% (95% CI, 55%-84%) in the high-risk group. Patients with a PR had significantly improved one-year DFS relative to patients without response (93% vs. 72%, hazard ratio 0.29; 95% CI, 11%-77%). No new safety signals were identified.

CONCLUSIONS

Neoadjuvant and adjuvant pembrolizumab increased one-year DFS rate in intermediate-risk, but not high-risk, HNSCC relative to historical control. PR to neoadjuvant ICB is a promising surrogate for DFS.

Early HPV ctDNA Kinetics and Imaging Biomarkers Predict Therapeutic Response in p16+ Oropharyngeal Squamous Cell Carcinoma

PURPOSE

In locally advanced p16+ oropharyngeal squamous cell carcinoma (OPSCC), (i) to investigate kinetics of human papillomavirus (HPV) circulating tumor DNA (ctDNA) and association with tumor progression after chemoradiation, and (ii) to compare the predictive value of ctDNA to imaging biomarkers of MRI and FDG-PET.

EXPERIMENTAL DESIGN

Serial blood samples were collected from patients with AJCC8 stage III OPSCC (n = 34) enrolled on a randomized trial: pretreatment; during chemoradiation at weeks 2, 4, and 7; and posttreatment. All patients also had dynamic-contrast-enhanced and diffusion-weighted MRI, as well as FDG-PET scans pre-chemoradiation and week 2 during chemoradiation. ctDNA values were analyzed for prediction of freedom from progression (FFP), and correlations with aggressive tumor subvolumes with low blood volume (TVLBV) and low apparent diffusion coefficient (TVLADC), and metabolic tumor volume (MTV) using Cox proportional hazards model and Spearman rank correlation.

RESULTS

Low pretreatment ctDNA and an early increase in ctDNA at week 2 compared with baseline were significantly associated with superior FFP (P < 0.02 and P < 0.05, respectively). At week 4 or 7, neither ctDNA counts nor clearance were significantly predictive of progression (P = 0.8). Pretreatment ctDNA values were significantly correlated with nodal TVLBV, TVLADC, and MTV pre-chemoradiation (P < 0.03), while the ctDNA values at week 2 were correlated with these imaging metrics in primary tumor. Multivariate analysis showed that ctDNA and the imaging metrics performed comparably to predict FFP.

CONCLUSIONS

Early ctDNA kinetics during definitive chemoradiation may predict therapy response in stage III OPSCC.

Congestive heart failure: clinical management by use of continuous nasoenteric feeding

Congestive heart failure (CHF) is often associated with undernutrition. Although loss of lean tissue may be detrimental to the host, a protective effect is conveyed as cardiac demands are reduced by lower whole-body oxygen consumption (VO2) and circulating fluid volume. The aim of this study was to determine if continuous nasoenteric feeding could promote an anabolic state with increments in lean tissue in moderate-severe CHF patients without adversely effecting cardiac performance. Undernourished CHF patients on a metabolic ward were fed a formula diet infused intragastrically for 2 wk. The energy infusion rate was maintained at 1.4-1.8 X measured resting metabolic rate. During the infusion period, body weight, elemental balances, VO2, and cardiac function (echocardiography) were monitored. Results showed a loss in weight and extracellular fluid, gain in lean body mass (eg, + delta N and delta K), unaltered VO2, and unchanged cardiac function. Cardiac cachexia is therefore safely and effectively manageable by maintenance or repletional levels of nasoenteric feeding.

Ethanol: relative fuel value and metabolic effects in vivo

A nasogastric formula infusion method was used to evaluate the steady-state fuel value of ethanol relative to that of glucose in eight chronically alcoholic men undergoing a 4- or 5-week balance experiment. Each subject received a maintenance infusion of the formula diet throughout the study. When control formula glucose (week 1) was isocalorically replaced with ethanol [week 2, 30% of kcal; week 3 or 4 (5-week experiment) 40% to 60% of kcal], the following was observed: weight loss; zero energy balance and reduced or negative balances of N, K, P, Mg, and Na; increased urinary urea N and 3-methylhistidine; lowered urinary C-peptide; no change in indirectly or directly measured thermal energy losses; and a blood level related rise in breath and urinary ethanol losses. All of these changes promptly reversed during the middle (week 3 in 5-week experiment) and final control weeks. Accounting for all diet-related energy losses (urine, breath, thermal), the fuel value of the ethanol-containing diet relative to the glucose control formula varied between 0.95 and 0.99, depending upon the blood alcohol level. Hence weight loss during short-term (seven-day) ethanol infusion is unrelated to overall negative energy balance, stems primarily from decrements in protein, minerals, and fluid, and may in part be mediated by the reduction in insulin secretion that accompanies switching from dietary glucose to ethanol.

Energy expenditure during continuous intragastric infusion of fuel

Influence of intragastric formula infusion rate on resting thermogenesis was evaluated in 24 healthy subjects. Metabolic rate (M) was measured by indirect calorimetry following an overnight fast. Subgroups then received a continuous intragastric infusion of a formula diet at three levels: submaintenance (mean +/- SEM, 1.02 +/- 0.04 times fasting M, n = 6), maintenance (1.39 +/- 0.01 times fasting M, n = 20), or supramaintenance (2.77 +/- 0.2 times fasting M, n = 14). Formula inflow was started in the evening, and intraprandial M was measured throughout the following day. Relative to fasting, submaintenance and maintenance infusions produced no detectable change in M. With supramaintenance infusion, M increased significantly (10.1%, p less than 0.05) above fasting level. Hence during continuous formula infusion a rise in M above fasting occurs only when rate of energy infusion exceeds rate of thermal energy losses. These results have implications in regard to energetic efficiency of continuous fuel infusion relative to intermittent food or formula ingestion.

Resting energy expenditure in lung and colon cancer

Elevated resting energy expenditure (REE) is a possible mechanism of cancer cachexia. We measured REE by whole-body direct calorimetry in patients with colon and non-small cell lung cancer and compared the results with REE in groups of healthy subjects and in patients with anorexia nervosa, with nonmalignant gastrointestinal (GI) disease, with miscellaneous reasons for weight loss, and with chronic lung disease. The mean REE of the cancer patients was not different from healthy subjects, those with GI disease, miscellaneous causes of cachexia, and chronic lung disease, and there was no significant difference in REE between those cancer patients with weight loss and controls with weight loss, except for the anorexia nervosa patients. The REE of the anorexia nervosa patients (female) was significantly lower than the REE of females with lung cancer. Weight loss correlated with REE in female lung cancer patients. Serial comparison of REE of ten cancer patients who lost 5% to 18% of their body weight during study showed no consistent change in REE. We conclude that patients with colon and non-small cell lung cancer, including those with weight loss, have REE similar to normal controls. Relative hypermetabolism may contribute to cancer cachexia, as may absolute hypermetabolism in some subsets of cancer patients.

Anthropometric assessment of the adult hospitalized patient

Anthropometry is a technique in which simple measuring instruments are used to describe human form. By applying the measurement directly or through use of additional calculations, the practitioner can partition the body into fat and fat-free components. Quantifying these two body spaces provides information on the amount and rate of change over time in whole body energy supply and protein mass. These data can then be used in association with other indices of energy and protein metabolism. Whereas anthropometry is simple, practical, and inexpensive, the technique is limited to a qualitative tool by several sources of error. A thorough understanding of the strengths, limitations, and appropriate applications of anthropometry is essential when applying the method in clinical practice.

Fiber supplementation of enteral formulas: effects on the bioavailability of major nutrients and gastrointestinal tolerance

Two fiber-supplemented enteral formulas were recently introduced for patient application, Susta II and Enrich (12.4-g and 38.5-g soy polysaccharide/2000 kcal, respectively). This investigation had a 3-fold purpose: to determine if and to what extent fiber-supplementation changes the chemical composition of stool relative to a fiber-free formula (Ensure); to establish the clinical tolerance of the two new formulas; and to quantify the effects of soy polysaccharide on nutrient bioavailability. The study was conducted in two consecutive phases: A (n = 6 subjects; random assignment to either Ensure or Susta II for 1-2 weeks followed by isocaloric cross-over to the alternate formula for an equal period of time) and B (n = 8 subjects evaluated as in phase A except Enrich replaced Ensure). Each balance week consisted of clinical/subjective monitoring, evaluation of stool composition (H2O and dry weight), apparent nutrient absorption (energy, fat, N, P, K, Ca, Mg, Zn, Na, and Cl), and metabolic balance (N, P, K, Ca, Mg, Na, and Cl). Relative to the fiber-free formula the two fiber-supplemented solutions produced increases in fecal N, fat, H2O, and minerals of variable magnitude; there were corresponding reductions in net absorption of organic compounds and minerals. The additional minerals added to the fiber-supplemented formulas and the minimal effects on N absorption preserved balance; the retention of N, P, K, Ca, Mg, Na, and Cl were similar for all three formulas. No adverse clinical effects of the fiber-supplemented formulas were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Spatial and Transcriptomic Analysis of Perineural Invasion in Oral Cancer

PURPOSE

Perineural invasion (PNI), a common occurrence in oral squamous cell carcinomas, is associated with poor survival. Consequently, these tumors are treated aggressively. However, diagnostic criteria of PNI vary and its role as an independent predictor of prognosis has not been established. To address these knowledge gaps, we investigated spatial and transcriptomic profiles of PNI-positive and PNI-negative nerves.

EXPERIMENTAL DESIGN

Tissue sections from 142 patients were stained with S100 and cytokeratin antibodies. Nerves were identified in two distinct areas: tumor bulk and margin. Nerve diameter and nerve-to-tumor distance were assessed; survival analyses were performed. Spatial transcriptomic analysis of nerves at varying distances from tumor was performed with NanoString GeoMx Digital Spatial Profiler Transcriptomic Atlas.

RESULTS

PNI is an independent predictor of poor prognosis among patients with metastasis-free lymph nodes. Patients with close nerve-tumor distance have poor outcomes even if diagnosed as PNI negative using current criteria. Patients with large nerve(s) in the tumor bulk survive poorly, suggesting that even PNI-negative nerves facilitate tumor progression. Diagnostic criteria were supported by spatial transcriptomic analyses of >18,000 genes; nerves in proximity to cancer exhibit stress and growth response changes that diminish with increasing nerve-tumor distance. These findings were validated in vitro and in human tissue.

CONCLUSIONS

This is the first study in human cancer with high-throughput gene expression analysis in nerves with striking correlations between transcriptomic profile and clinical outcomes. Our work illuminates nerve-cancer interactions suggesting that cancer-induced injury modulates neuritogenesis, and supports reclassification of PNI based on nerve-tumor distance rather than current subjective criteria.

Rate of weight loss during underfeeding: relation to level of physical activity

The kinetics and bioenergetic-metabolic determinants of weight loss were examined in obese women ingesting 900 kcal/d for 5 weeks. The patients were assigned either to a sedentary group (n = 5) or to an exercise group (n = 6) in which the participants expended an additional (X +/- SD) 346 +/- 61 kcal/d in aerobic physical activity. The percentage weight loss and the fractional rates (K1 = fast component; K2 = slow component) of weight loss were almost identical between the two groups. The failure of added exercise to increase the velocity of weight loss could not be explained by differences between the groups in any of the following: gastrointestinal energy and nitrogen (N) absorption; fractional rates of urinary urea N and total N loss; or the thermic effect of the formula diet. The cumulative and fractional rates of protein (ie N) loss were also similar between the groups. The exercise group lost more fat (5.3 +/- 1.0 kg) than the non-exercise group (4.4 +/- 1.6 kg, P less than .001) as measured by underwater weighing. The maximum between-group difference in the rate of fat loss, as determined by energy-N balance, occurred during early underfeeding. With continuation of the 900 kcal/d diet, the between-group differences in the rate of fat loss diminished. The exercise subjects significantly lowered their resting heat losses relative to the non-exercise subjects (P less than .025). This in turn reduced the degree of negative energy balance in the more energy-deficient exercise group.(ABSTRACT TRUNCATED AT 250 WORDS)

Flow Fields and Acoustics in a Unilateral Scarred Vocal Fold Model

Objectives:

From prior work in an excised canine larynx model, it has been shown that intraglottal vortices form between the vocal folds during the latter part of closing. It has also been shown that the vortices generate a negative pressure between the folds, producing a suction force that causes sudden, rapid closing of the folds. This rapid closing will produce increased loudness and increased higher harmonics. We used a unilateral scarred excised canine larynx model to determine whether the intraglottal vortices and resulting acoustics were changed, compared to those of normal larynges.

Methods:

Acoustic, flow field, and high-speed imaging measurements from 5 normal and 5 unilaterally scarred canine larynges are presented in this report. Scarring was produced by complete resection of the vocal fold mucosa and superficial layer of the lamina propria on the right vocal fold only. Two months later, these dogs were painlessly sacrificed, and testing was done on the excised larynges during phonation. High-speed video imaging was then used to measure vocal fold displacement during different phases. Particle image velocimetry and acoustic measurements were used to describe possible acoustic effects of the vortices.

Results:

A higher phonation threshold was required to excite the motion of the vocal fold in scarred larynges. As the subglottal pressure increased, the strength of the vortices and the higher harmonics both consistently increased. However, it was seen that increasing the maximum displacement of the scarred fold did not consistently increase the higher harmonics. The improvements that result from increasing subglottal pressure may be due to a combination of increasing the strength of the intraglottal vortices and increasing the maximum displacement of the vocal fold; however, the data in this study suggest that the vortices play a much more important role.

Conclusions:

The current study indicates that higher subglottal pressures may excite higher harmonics and improve loudness for patients with unilateral vocal fold scarring. This finding implies that therapies that raise the subglottal pressure may be helpful in improving voice quality.

Bioenergetic and metabolic response to continuous v intermittent nasoenteric feeding

Resting thermal energy losses and metabolic balances of N, K, P, Ca, Na, and Mg were compared during continuous and intermittent nasoenteric formula infusion in four healthy men. Each feeding protocol lasted 1 week in a 4-week double crossover experiment. The initial feeding schedule was established randomly. Continuous nasoenteric formula infusion produced no increase in thermal energy losses above the fasting level; energy expenditure fell with sleep to the same extent as with intermittent feeding. Thermal losses were similar during intermittent feeding with the exception of the thermic effect of food that produced an additional average energy loss of 115.7 kcal/d. The total resting and sleeping 24-hour energy expenditure was significantly lower (P less than .01) during continuous formula infusion (means +/- SD for n = 8 balance periods, 1344 +/- 119 kcal) compared to intermittent feeding (1457 +/- 179 kcal). No significant differences in nutrient absorption or balances of N, Na, Ca, and Mg were detected between the two feeding protocols. In contrast, continuous infusion of formula was accompanied by negative balances of K and the cytosolic portion of P; weight balance was slightly negative. Weight, K, and cytosolic P balances were all positive during intermittent feeding (P = NS, less than 0.01, and P less than .05 compared to respective continuous infusion periods). Hence, 1 week of continuous nasogastric formula infusion is associated with similar nutrient absorption, a significant reduction in thermal energy losses, and equivalent protein (N) balance relative to intermittent feeding. Differences in weight balance between the two feeding protocols can be ascribed largely to fluid and mineral shifts. These results suggest that energy requirements are lower during continuous formula infusion by about 100 kcal/d compared to regular meal ingestion.

Predictors of severe long-term toxicity after re-irradiation for head and neck cancer

OBJECTIVE

To identify predictive factors of severe long-term toxicity after re-irradiation of recurrent/persistent or second-primary head and neck cancer.

METHODS

Outcomes and treatment plans of patients who underwent modern IMRT based re-irradiation to the head and neck from 2008-2015 were reviewed. Co-variables including demographic, clinical and oncologic factors, as well as interval to re-irradiation and re-irradiated planning tumor volume (PTV) were analyzed as predictors of developing severe (CTCAE grade⩾3) long-term toxicity with death as a competing risk.

RESULTS

A total of 66 patients who met inclusion criteria were eligible for analysis. A median re-irradiation dose of 70Gy was delivered at a median of 37.5months after initial radiotherapy. Re-irradiation followed surgical resection in 25 (38%) patients, and concurrent chemotherapy was delivered to 41 (62%) patients. Median follow-up after re-irradiation was 23months and median overall survival was 22months (predicted 2year overall survival 49%). Of the 60 patients who survived longer than 3months after re-irradiation, 16 (25%) patients experienced severe long-term toxicity, with the majority (12 of 16) being feeding tube -dependent dysphagia. In multivariable analysis, shorter intervals to re-irradiation (<20months) and larger re-irradiated PTVs (>100cm(3)) were independent predictors of developing severe long-term toxicity. Patients with longer disease-free intervals and smaller PTVs had a 94% probability of being free of severe toxicity at two years.

CONCLUSION

Selection of patients with longer re-irradiation intervals and requiring smaller re-irradiated PTVs can independently predict avoidance of severe long-term toxicity.

Characterization of very late dysphagia after chemoradiation for oropharyngeal squamous cell carcinoma

OBJECTIVES

Improved prognosis for p16+ oropharyngeal squamous cell carcinoma (OPSCC) has led to efforts to mitigate long-term complications of treatment, which remains poorly defined in late survivors. Here we characterize very late dysphagia in OPSCC.

MATERIALS AND METHODS

Long-term review of 93 p16+ OPSCC patients treated with chemoradiation was performed. We scored videofluoroscopic swallow studies (VFSS) according to the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Very late dysphagia was defined >2.5 years from end of treatment. Fine-Gray regression models were used to assess dysphagia with competing risk of death.

RESULTS

Median follow up was 10.5 years. 402 total VFSS were assessed (median 4 per patient, range 0-8). 15.1% of patients had a DIGEST score ≥2 very late after treatment. Very late DIGEST score ≥2 correlated with T-stage (HR 1.7, p = 0.049), second cancer (HR 6.5, p = 0.004), superior pharyngeal constrictor dose (HR 1.11, p = 0.050), total tongue dose (HR 1.07, p = 0.045), but not hypoglossal nerve dose (p > 0.2). Seven patients (7.5%) had late progressive dysphagia, defined as DIGEST score that increased by ≥2 beyond one year after treatment, and this correlated with higher ipsilateral hypoglossal nerve D1cc dose (75 vs 72 Gy, p = 0.037).

CONCLUSION

In p16+ OPSCC patients treated with definitive chemoradiation, at least 7.5% developed late progressive dysphagia, and 15.1% experienced moderate dysphagia >2.5 years from treatment. Our study suggests that dose to tongue musculature may be associated with very late dysphagia, and hypoglossal nerve dose may be associated with late progressive dysphagia. More intensive long-term dysphagia survivorship monitoring is suggested.

Association of pathological response to neoadjuvant pembrolizumab with tumor PD-L1 expression and high disease-free survival (DFS) in patients with resectable, local-regionally advanced, head and neck squamous cell carcinoma (HNSCC)

6006

Background: Patients with resected HNSCC, with high-risk (positive margins, extracapsular spread [ECE]) or intermediate-risk pathological features have an estimated 1-year DFS of 65% and 69%, respectively. Immune checkpoint blockade improved survival of patients with recurrent/metastatic HNSCC, and preclinical models indicate radiotherapy (RT) synergizes with anti-PD-1. Therefore, we administered the PD-1 inhibitor pembrolizumab (pembro) pre- and post-surgery with adjuvant RT +/- cisplatin in patients with resectable, locoregionally advanced (clinical T3/4 and/or ≥2 nodal metastases) HNSCC (NCT02641093). Methods: Eligible patients received pembro (200 mg I.V. x 1) 1-3 weeks before resection. Adjuvant pembro (q3 wks x 6 doses) was administered with RT (60-66Gy) with or without weekly cisplatin (40mg/m2 X 6) for patients with high-risk and intermediate-risk features, respectively. The primary endpoint was 1-year DFS estimated by Kaplan Meier curves. Safety was evaluated by CTCAE v5.0. Pathological response (PR) to neoadjuvant pembro was evaluated by comparing pre- and post-surgical tumor specimens for treatment effect (TE), defined as tumor necrosis and/or histiocytic inflammation and giant cell reaction to keratinaceous debris. PR was classified as no (NPR, < 20%), partial (PPR, ≥20% and < 90%) and major (MPR, ≥90%). Tumor PD-L1 immunohistochemistry was performed with 22c3 antibody and reported as combined positive score (CPS). Results: Ninety-two patients were enrolled. Seventy-six patients received adjuvant pembro and were evaluable for DFS. Patient characteristics included: median age 58 (range 27 – 80) years; 32% female; 88% oral cavity, 8% larynx, and 3% human papillomavirus negative oropharynx; 86% clinical T3/4 and 65% ≥2N; 49 (53%) high-risk (positive margins, 45%; ECE, 78%); 64% (44/69 available) had PD-L1 CPS ≥1. At a median follow-up of 20 months, 1-year DFS was 67% (95%CI 0.52-0.85) in the high-risk group and 93% (95%CI 0.84-1) in the intermediate-risk group. Among 80 patients evaluable for PR, TE scoring resulted in 48 NPR, 26 PPR and 6 MPR. Patients with PPR/MPR had significantly improved 1-year DFS when compared with those with NPR (100% versus 68%, p = 0.01; HR = 0.23). PD-L1 CPS ≥ 1 was not independently associated with 1-year DFS, but was highly associated with MPR/PPR (p = 0.0007). PPR/MPR in PD-L1 CPS < 1, ≥1 and ≥20, were estimated as 20, 55 and 90%, respectively. Grade ≥ 3 adverse events occurred in 62% patients with most common including dysphagia (15%), neutropenia (15%), skin/wound infections (10%), and mucositis (9%). Conclusions: PR to neoadjuvant pembro is associated with PD-L1 CPS≥1 and high DFS in patients with resectable, local-regionally advanced, HNSCC. Clinical trial information: NCT02641093.

Predictive Values of MRI and PET Derived Quantitative Parameters for Patterns of Failure in Both p16+ and p16- High Risk Head and Neck Cancer

Purpose: FDG-PET adds to clinical factors, such tumor stage and p16 status, in predicting local (LF), regional (RF), and distant failure (DF) in poor prognosis locally advanced head and neck cancer (HNC) treated with chemoradiation. We hypothesized that MRI-based quantitative imaging (QI) metrics could add to clinical predictors of treatment failure more significantly than FDG-PET metrics. Materials and methods: Fifty four patients with poor prognosis HNCs who were enrolled in an IRB approved prospective adaptive chemoradiotherapy trial were analyzed. MRI-derived gross tumor volume (GTV), blood volume (BV), and apparent diffusion coefficient (ADC) pre-treatment and mid-treatment (fraction 10), as well as pre-treatment FDG PET metrics, were analyzed in primary and individual nodal tumors. Cox proportional hazards models for prediction of LRF and DF free survival were used to test the additional value of QI metrics over dominant clinical predictors. Results: The mean ADC pre-RT and its change rate mid-treatment were significantly higher and lower in p16- than p16+ primary tumors, respectively. A Cox model identified that high mean ADC pre-RT had a high hazard for LF and RF in p16- but not p16+ tumors (p = 0.015). Most interesting, persisting subvolumes of low BV (TV_bv) in primary and nodal tumors mid-treatment had high-risk for DF (p < 0.05). Also, total nodal GTV mid-treatment, mean/max SUV of FDG in all nodal tumors, and total nodal TLG were predictive for DF (p < 0.05). When including clinical stage (T4/N3) and total nodal GTV in the model, all nodal PET parameters had a p-value of >0.3, and only TV_bv of primary tumors had a p-value of 0.06. Conclusion: MRI-defined biomarkers, especially persisting subvolumes of low BV, add predictive value to clinical variables and compare favorably with FDG-PET imaging markers. MRI could be well-integrated into the radiation therapy workflow for treatment planning, response assessment, and adaptive therapy.

Overfeeding: cardiovascular and metabolic response during continuous formula infusion in adult humans

The cardiovascular and metabolic response to continuous nasoenteric formula infusion was monitored in eight healthy men during three consecutive 1-wk balance periods: maintenance-stabilization, overfeeding at twice the maintenance infusion rate, and postoverfeeding return to maintenance infusion. Elemental balance, thermogenic, and stable-isotope studies carried out throughout protocol identified 1) two distinct phases during overfeeding (early, days 1-4, and late, days 4-7); 2) changes in extracellular fluid (sodium balance) as the major determinant of overfeeding weight gain; 3) individual differences in percentage of excess fuels retained during overfeeding (76-87%), derived from variation in both digestive and thermogenic processes; and 4) a sustained physiologic response during the postoverfeeding period. These initial findings suggest that individuals differ in response to overfeeding and that specific aspects of this variation are amenable to future study. In addition, the timing of observed fluid, metabolic, and cardiovascular changes during overfeeding suggests specific strategies aimed at preventing refeeding circulatory complications.

Increased Nerve Density Adversely Affects Outcome in Oral Cancer

PURPOSE

Perineural invasion (PNI) in oral cavity squamous cell carcinoma (OSCC) is associated with poor survival. Because of the risk of recurrence, patients with PNI receive additional therapies after surgical resection. Mechanistic studies have shown that nerves in the tumor microenvironment promote aggressive tumor growth. Therefore, in this study, we evaluated whether nerve density (ND) influences tumor growth and patient survival. Moreover, we assessed the reliability of artificial intelligence (AI) in evaluating ND.

EXPERIMENTAL DESIGN

To investigate whether increased ND in OSCC influences patient outcome, we performed survival analyses. Tissue sections of OSCC from 142 patients were stained with hematoxylin and eosin and IHC stains to detect nerves and tumor. ND within the tumor bulk and in the adjacent 2 mm was quantified; normalized ND (NND; bulk ND/adjacent ND) was calculated. The impact of ND on tumor growth was evaluated in chick chorioallantoic-dorsal root ganglia (CAM-DRG) and murine surgical denervation models. Cancer cells were grafted and tumor size quantified. Automated nerve detection, applying the Halo AI platform, was compared with manual assessment.

RESULTS

Disease-specific survival decreased with higher intratumoral ND and NND in tongue SCC. Moreover, NND was associated with worst pattern-of-invasion and PNI. Increasing the number of DRG, in the CAM-DRG model, increased tumor size. Reduction of ND by denervation in a murine model decreased tumor growth. Automated and manual detection of nerves showed high concordance, with an F1 score of 0.977.

CONCLUSIONS

High ND enhances tumor growth, and NND is an important prognostic factor that could influence treatment selection for aggressive OSCC. See related commentary by Hondermarck and Jiang, p. 2342.