Research Items (54)
Colorectal liver metastasis is one of most aggressive liver ma-lignancies. While the definition of lesion type based on CT images determines the diagnosis and therapeutic strategy, the discrimination between cancerous and non-cancerous lesions are critical and requires highly skilled expertise, experience and time. In the present work we introduce an end-to-end deep learning approach to assist in the discrimination between liver metastases from colorectal cancer and benign cysts in abdominal CT images of the liver. Our approach incorporates the efficient feature extraction of InceptionV3 combined with residual connections and pre-trained weights from ImageNet. The architecture also includes fully connected classification layers to generate a probabilistic output of lesion type. We use an in-house clinical biobank with 230 liver lesions originating from 63 patients. With an accuracy of 0.96 and a F1-score of 0.92, the results obtained with the proposed approach surpasses state of the art methods. Our work provides the basis for incorporating machine learning tools in specialized radiology software to assist physicians in the early detection and treatment of liver lesions.
- Dec 2018
Background: Previous studies comparing the survival outcomes of liver resections with and without preoperative portal vein embolization (PVE) for colorectal liver metastases (CLM) have linked PVE to higher rate of tumor progression, lower overall survival (OS) and lower disease-free survival (DFS). The lack of adjusted models to compare these outcomes is a limitation of these studies since patients requiring PVE may differ significantly from the ones receiving upfront surgery. Materials and methods: Prospective cohort study of 128 patients undergoing CLM resection. The OS analysis followed an intent-to-treat (ITT) approach. The adjusted impact of PVE on OS and DFS was evaluated using multivariate Cox regression models. Results: Seventy-one patients underwent PVE before attempting a liver resection while 57 received upfront surgery (NoPVE). All NoPVE patients were resected while 14 PVE participants (19.7%) were not operated (tumor progression = 9/14). PVE patients had a significantly higher preoperative lesions count (3 [1.75–4] vs 1 [1–2.5]; p < 0.001), a higher prevalence of bilateral metastases (23.5% vs 8.8, p = 0.028) and a higher count of neo-adjuvant chemotherapy cycles compared to NoPVE patients. The OS of PVE patients was similar to NoPVE participants (44.7 months [26.9–69.5] vs 49.0 [24.9–64.8], p = 0.761). The DFS of resected PVE patients was higher than NoPVE patients (33.2 months [10.7–54.6] vs 23.4 months [14.1–58.1], p = 0.991). In the adjusted models, preoperative lesions count was the only significant predictor of overall mortality (HR+IC95 = 1.06 (1.02–1.11) p = 0.005) and cancer recurrence (HR+IC95 = 1.14 (1.03–1.27) p = 0.012). Conclusion: In the context of CLM, patients requiring PVE differ significantly from patients receiving upfront surgery. This confirms the need for adjusted models when comparing the clinical outcomes of both groups. Our adjusted analysis suggests that PVE is not a significant predictor of a lower OS or DFS. PVE allowed the resection of 80% of participants with initially unresectable CLM. Institutional protocol number: 12.106 Study registration number: NCT03168230.
- Aug 2018
Purpose To evaluate the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS) v2017 major features, the impact of ancillary features, and categories on contrast-enhanced computed tomography (CECT) for the diagnosis of hepatocellular carcinoma (HCC). Materials and methods This retrospective study included 59 patients (104 observations including 72 HCCs) with clinical suspicion of HCC undergoing CECT between 2013 and 2016. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category based on major features only and in combination with ancillary features. The composite reference standard included pathology or imaging. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by generalized estimating equation models. Results Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) respectively had a sensitivity of 86.1%, 81.6%, 20.7%, and 26.1% and specificity of 39.3%, 67.9%, 89.9%, and 85.0% for HCC. Ancillary features (ultrasound visibility as discrete nodule, subthreshold growth, and fat in mass more than adjacent liver) respectively had a sensitivity of 42.6%, 50.8%, and 15.1% and a specificity of 79.2%, 66.9%, and 96.4% for HCC. Ancillary features modified the final category in 4 of 104 observations. For HCC diagnosis, categories LR-3, LR-4, LR-5, and LR-TIV (tumor in vein) had a sensitivity of 5.3%, 29.0%, 53.7%, and 10.7%; and a specificity of 49.1%, 84.4%, 97.3%, and 96.4%, respectively. Conclusion On CT, LR-5 category has near-perfect specificity for the diagnosis of HCC and ancillary features modifies the final category in few observations.
Purpose To evaluate the performance of major features, ancillary features, and categories of Liver Imaging Reporting and Data System (LI-RADS) version 2014 at magnetic resonance (MR) imaging for the diagnosis of hepatocellular carcinoma (HCC). Materials and Methods This retrospective institutional review board-approved study included patients with liver MR imaging and at least one pathologically proved lesion. Between 2004 and 2016, 102 patients (275 observations including 113 HCCs) met inclusion criteria. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by using generalized estimating equation models. Results Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) had a sensitivity of 88.5%, 60.6%, 32.9%, and 41.6%, and a specificity of 18.6%, 84.8%, 98.8%, and 83.2% for HCC, respectively. Ancillary features (mild-moderate T2 hyperintensity, restricted diffusion, mosaic architecture, intralesional fat, lesional fat sparing, blood products, and subthreshold growth) had a sensitivity of 62.2%, 54.8%, 9.9%, 30.9%, 23.1%, 2.8%, and 48.3%, and a specificity of 79.4%, 90.6%, 99.4%, 94.2%, 83.1%, 99.3%, and 91.4% for HCC, respectively. The LR-5 or LR-5 V categories had a per-lesion sensitivity of 50.8% and a specificity of 95.8% for HCC, respectively. The LR-4, LR-5, or LR-5 V categories (determined by using major features only vs combination of major and ancillary features) had a per-lesion sensitivity of 75.9% and 87.9% and a per-lesion specificity of 87.5% and 86.2%, respectively. Conclusion The use of ancillary features in combination with major features increases the sensitivity while preserving a high specificity for the diagnosis of HCC.
Background: Within the tumor microenvironment, the cell surface enzyme CD73 can mediate tumor immune escape by degrading extra-cellular adenosine triphosphate into immune suppressive adenosine. Although CD73 is emerging as a promising target for cancer immunotherapy, its relevance in pancreatic ductal adenocarcinoma (PDAC) has not been determined. Our goal was to investigate CD73 expression in resected PDAC and its prognostic value. Methods: Using tissue microarrays, automated quantifi- cation (Visiomorph) of CD73 (Abcam), cytokeratins (CK8/ 18, Dako) and DAPI expression was measured by multiplex immunofluorescence on 108 tumors and paired peritumoral pancreatic tissue resected between 2000 and 2008. We tested associations between immune and clinicopathological features. Results: CD73 expression (mean fluorescence intensity) was 1.8 fold higher on cancer cells compared to peritumoral pancreatic cells (P < 0.001). The mean CD73 expression on cancer cells was higher in stage IIb vs. I-IIa tumors (P=0.049), moderate/poor vs. well differentiated tumors (P = 0.008), T3 vs. T1-T2 tumors (P = 0.043) and N+ vs. N0 tumors (P = 0.049). The median time to recurrence and overall survival in patients with CD73high tumors (11.1 and 11.5 months, respectively) was significantly shorter than those with CD73low tumors (23.4 and 26.5 months, respectiverly, see Fig. 1). By multivariate analysis, high CD73 expression by pancreatic cancer cells was associated with poor patient prognosis independently of clinicopathological factors. Conclusion: Our results suggest that CD73 may be a relevant immunotherapeutic target in PDAC and a promising immune prognostic biomarker. Further validation on independent cohorts and in metastases appears warranted.
Background: Patients with lesions in the posterosuperior (PS) segments of the liver have been considered poor candidates for laparoscopic liver resection (LLR). This study aims to compare short-term outcomes of LLR and open liver resections (OLR) in the PS segments. Methods: This multicenter study consisted of all patients who underwent LLR in the PS segments and all patients who underwent OLR in the PS segments between October 2011 and July 2016. Laparoscopic cases were case-matched with those who had an identical open procedure during the same period based on tumor location (same segment) and the Brisbane classification of the resection. Demographics, comorbid factors, perioperative outcomes, short-term outcomes, necessity of adjuvant chemotherapy, and the interval between surgery and initiation of adjuvant chemotherapy were compared between the two groups. Data were retrieved from a prospectively maintained electronic database. Results: Both groups were comparable for age, sex, ASA score, maximum tumor diameter, and number of patients with additional liver resections outside the posterior segments. Operative time was similar in both groups (median 140 min; p = 0.92). Blood loss was less in the LLR-group (median: 150 vs. 300 ml in OLR-group). Median hospital stay was 6 days in both groups. There was no significant difference in postoperative complications (OLR-group: 31.4% vs. LLR-group: 25.7%; p = 0.60). There was no significant difference in R0 resections (LLR: 97.2 vs. 100% in OLR; p = 1.00). Tumor-free margins were less in the LLR group (LLR: 5 vs. 9.5 mm in OLR; p = 0.012). Patients undergoing LLR were treated with chemotherapy sooner compared to those undergoing OLR (41 vs. 56 days, p = 0.02). Conclusion: This study suggests that laparoscopic parenchymal preserving liver resections in the PS segments can be performed with comparable short-term outcomes as similar OLR. The shorter interval to chemotherapy might provide long-term oncologic benefits in patients who underwent LLR.
- Jul 2017
Objective: This study aims to validate a previously reported recurrence clinical risk score (CRS). Summary of background data: Salvage transplantation after hepatocellular carcinoma (HCC) resection is limited to patients who recur within Milan criteria (MC). Predicting recurrence patterns may guide treatment recommendations. Methods: An international, multicenter cohort of R0 resected HCC patients were categorized by MC status at presentation. CRS was calculated by assigning 1 point each for initial disease beyond MC, multinodularity, and microvascular invasion. Recurrence incidences were estimated using competing risks methodology, and conditional recurrence probabilities were estimated using the Bayes theorem. Results: From 1992 to 2015, 1023 patients were identified, of whom 613 (60%) recurred at a median follow-up of 50 months. CRS was well validated in that all 3 factors remained independent predictors of recurrence beyond MC (hazard ratio 1.5-2.1, all P < 0.001) and accurately stratified recurrence risk beyond MC, ranging from 19% (CRS 0) to 67% (CRS 3) at 5 years. Among patients with CRS 0, no other factors were significantly associated with recurrence beyond MC. The majority recurred within 2 years. After 2 years of recurrence-free survival, the cumulative risk of recurrence beyond MC within the next 5 years for all patients was 14%. This risk was 12% for patients with initial disease within MC and 17% for patients with initial disease beyond MC. Conclusions: CRS accurately predicted HCC recurrence beyond MC in this international validation. Although the risk of recurrence beyond MC decreased over time, it never reached zero.
- Mar 2017
- 70th Society of Surgical Oncology Annual Meeting
Introduction: Approximately 25% of patients with a new diagnosis of colorectal cancer present with synchronous liver metastases. Surgery combined with chemotherapy is the standard of care, yet uncertainty remains regarding the optimal treatment sequence and patient selection for best outcomes. Our institutional policy has been a “Liver First” approach, whereby liver metastases are resected prior to the asymptomatic primary tumor in chemo-responsive/stable patients. This study evaluates the clinical and pathological factors asso-ciated with overall (OS) and disease-free (DFS) survival in these patients. Methods: Retrospective analysis of prospectively collected data in patients with resectable synchronous colorectal cancer liver metastases (CRLMs), who underwent liver prior to primary tumor resection and peri-operative chemother-apy in one institution (2011-2015). Association between clinico-pathological factors and OS and DFS were evaluated by the Kaplan-Meier method and log-rank test. Results: Fifty-one patients were followed for a median time of 20 months. Thirty-six (70.6%) were male, mean age 62 years, 24 (47.1%) rectal cancer, 34 (66.7%) bilobar CRLMs, median number of 2 CRLMs, of 2.5cm median size, and median pre-op CEA 7.9 ng/mL. Pre-hepatectomy chemotherapy was given for 5 cycles on average (82% Folfox). The median OS and DFS were 41.3 months (death rate 25.5%) and 11.4 months (recur-rence rate 54.9%), respectively. All recurrences were found in the liver and/or lungs, except for carcinomatosis in 3 patients. The factors significantly associated with shorter DFS and OS were unfavorable pathologic response to chemotherapy (Blazer score) and positive liver resection margins. The Fong clinical risk score had no significant impact on OS or DFS. Conclusion: Patients with synchronous CRLMs undergoing a “Liver first” approach are at high risk of systemic recurrence, especially those with suboptimal control of their metastases. Biomarkers of resistance to first line chemotherapy and of early systemic recurrence are needed to identify patients in whom surgery is unlikely to confer survival benefit.
- Aug 2016
- Canadian Surgery Forum 2016
One in 4 patients with a new diagnosis of colorectal cancer present with synchronous liver metastases (CRLMs). Uncertainty remains regarding the best surgical sequence and the “Liver First” approach may be beneﬁcial for patients with an important meta-static burden. The goal of this study was to evaluate survival and prognostic factors of patients with CRLMs undergoing this sur-gical treatment. A prospective cohort study was conducted on patients with incidental metastatic colorectal cancer and syn chron-ous CRLMs to the liver only, treated by hepatic surgery ﬁrst and colorectal surgery second (2011–2015). Overall and disease-free survival and potential predictive factors were calculated with Kaplan–Meier, chi-square and ANOVA tests. Of the 35 patients included in this study, 29 (82.9%) completed the treatment sequence. The cohort consisted of 22 (62.9%) men, mean age 60 years, and 16 (45.7%) had a rectal cancer. Major hepatic resections (≥3segments) were performed for 21 (60%) patients and 10 (29%) had >3 CRLMs. Mortality after hepatic surgery was 2.9% and mor-bidity 31%. Four (11.4%) patients died after a median of 17 (1–47) months and 19 (54.3%) recurred after a median of 8 (4–20) months. The main sites of recurrence were liver only (47.4%), lungs only (10.5%) or both liver and lungs (26.3%). Patients with >3 CRLMs (p = 0.05) and with positive hepatic resection margins (p = 0.03) were more likely to recur. Patients with good patho-logical response to chemotherapy (low Blazer or Rubbia-Brandt score) had a trend toward lower recurrence rates (p = 0.06 and p = 0.12, respectively). The “Liver First” approach is a safe surgical option with a low mortality and morbidity rate. Patients with few CRLMs, negative margins and good response to neoadjuvant chemo therapy appear to beneﬁt most from this surgical strategy. A longer follow-up period is required to draw conclusions on the overall survival of this population.
- Jan 2016
Purpose: Risk stratification after surgery for colorectal cancer liver metastases (CRLM) is achieved using clinicopathologic variables, however, is of limited accuracy. We sought to derive and externally validate a multigene expression assay prognostic of overall survival (OS) that is superior to clinicopathologic variables in patients with surgically resected CRLM. Experimental design: We measured mRNA expression in prospectively collected frozen tumor from 96 patients with surgically resected CRLM at Memorial Sloan Kettering Cancer Center (MSKCC, New York, NY). We retrospectively generated a 20-gene molecular risk score (MRS) and compared its prognostic utility for OS and recurrence-free survival (RFS) with three common clinical risk scores (CRS). We then tested the prognostic ability of the MRS in an external validation cohort (European) of 119 patients with surgically resected CRLM at the University Medical Center Utrecht (Utrecht, the Netherlands) and Paul Brousse Hospital (Villejuif, France). Results: For OS in the MSKCC cohort, MRS was the strongest independent prognosticator (HR, 3.7-4.9; P < 0.001) followed by adjuvant chemotherapy (HR, 0.3; P ≤ 0.001). For OS in the European cohort, MRS was the only independent prognosticator (HR, 3.5; P = 0.007). For RFS, MRS was also independently prognostic in the MSKCC cohort (HR, 2.4-2.6; P ≤ 0.001) and the European cohort (HR, 1.6-2.5; P ≤ 0.05). Conclusions: Compared with CRSs, the MRS is more accurate, broadly applicable, and an independent prognostic biomarker of OS in resected CRLM. This MRS is the first externally validated prognostic multigene expression assay after metastasectomy for CRLM and warrants prospective validation. Clin Cancer Res; 1-8. ©2015 AACR.
- Oct 2015
It is unknown whether the human immune system frequently mounts a T-cell response against mutations expressed by common epithelial cancers. Using a next-generation sequencing approach combined with high-throughput immunologic screening, we demonstrated that tumor-infiltrating lymphocytes (TIL) from 9/10 patients with metastatic gastrointestinal cancers contained CD4+ and/or CD8+ T cells that recognized one to three neo-epitopes derived from somatic mutations expressed by the patient's own tumor. There were no immunogenic epitopes shared between these patients. However, in one patient we identified a human leukocyte antigen (HLA)-C*08:02-restricted T-cell receptor from CD8+ TIL that targeted the KRAS(G12D) hotspot driver mutation found in many human cancers. Thus, a high frequency of patients with common gastrointestinal cancers harbor immunogenic mutations which could potentially be exploited for the development of highly personalized immunotherapies.
- Jan 2015
Though immune responses correlate with prognosis in primary colorectal cancer, the role of tumor immunity in metastatic disease is less clear. We hypothesized that patient survival and tumor recurrence correlate with transcriptional evidence of lymphocyte proliferation/activation in resected colorectal cancer liver metastases (CRLM). Microarray gene analysis was performed on liver tumor specimens from 96 patients who underwent resection for CRLM. A Cox proportional hazards model identified genes associated with overall (OS) and recurrence-free survival (RFS). Conventional gene ontology (GO) enrichment analysis ranked biologically relevant processes. Survival probabilities of prioritized processes were assessed. Protein expression was validated with immunohistochemistry in an independent set of patients. GO analysis identified and ranked unique biologic processes that correlated with survival. Genes that specifically functioned in the biologic process of "T-cell proliferation" were significant predictors of OS (p = 0.01) and both "T-cell proliferation" and "activation" were highly associated with RFS (p≤0.01). Analysis of genes in these GO categories identified increased TNFSF14/LIGHT expression to be most associated with improved OS and RFS (p≤0.0006). Immunohistochemistry of an independent validation set of CRLM confirmed that both increased tumor infiltrating lymphocytes (TIL) and higher LIGHT expression on TIL were associated with improved OS and RFS. Differential expression of genes involved in T-cell proliferation/activation were associated with survival outcomes in a large number of surgical patients who underwent resection of CRLM. These biologic functions determined by GO analysis of the tumor microenvironment have identified specific immune-related genes that may be involved in an anti-tumor immune response. Copyright © 2015, American Association for Cancer Research.
Accumulating evidence suggests that the efficacy of ACT in melanoma is mediated by T cells that target somatic mutations expressed by the patients' tumors. Moreover, in one patient with metastatic epithelial (bile duct) cancer, we recently identified tumor-infiltrating Th1 cells that specifically recognized a mutation in ERBB2IP expressed by the patient's tumors and observed tumor regression after adoptive transfer of a highly enriched population of ERBB2IP mutation-specific Th1 cells. Thus, we hypothesize that mutation-specific T cells may be frequently elicited in patients with metastatic gastrointestinal (GI) cancers and may be harnessed for ACT. To test this, we first performed whole-exome sequencing on metastatic lesions from GI cancer patients to identify the mutations. Next, we generated mingene constructs that encoded each mutation and transfected these minigenes into autologous antigen presenting cells (APCs) to allow for the processing and presentation of all the mutations expressed by the tumor. These APCs were then co-cultured with tumor infiltrating lymphocytes (TIL) and T cell reactivity against the mutations was determined by IFN-γ ELISPOT and 4-1BB and OX40 upregulation by flow cytometry. In one patient with colon cancer, 119 mutations were evaluated for mutation reactivity. Several, but not all, TIL cultures were found to contain highly variable proportions of CD8+ T cells that specifically recognized a mutation in CASP8 (67 F→V). Intriguingly, upon further expansion in vitro, these mutation-reactive CD8+ T cells were markedly outgrown by other cells in culture. In another patient with rectal cancer, 155 mutations were evaluated for mutation reactivity. We found at least 3 different mutation reactivities, two comprising CD8+ T cell responses and one CD4+ T cell response. In a third patient (cholangiocarcinoma), we did not detect T cells reactive against 38 mutations tested. For this patient, the "mutation call" threshold has been lowered and an additional 125 putative mutations will be evaluated. Thus, our preliminary data suggests that the ability of the human immune system to mount a T cell response against somatic mutations in metastatic GI cancers may not be a rare event. Current efforts are focused on evaluating more patients for mutation-specific T cell responses and on developing methods to enrich mutation-specific T cells or T cell receptors for therapy, which may provide a path to extend cell transfer immunotherapy to almost all common solid cancers.
- Aug 2014
Rationale and Objectives To assess the optimal pancreatic phase delay in terms of parenchymal enhancement and tumor-to-pancreas contrast with a bolus-tracking method. Materials and Methods Patients referred for suspicion of pancreatic tumor and undergoing 64-detector computed tomography scanner were randomized to an individualized scan delay of 10, 20, or 30 seconds of nonionic contrast material (370 mg I/mL) after aortic enhancement above 150 Hounsfield units. The volume of contrast was adjusted to patient weight. Pancreatic and tumor enhancements were measured. Statistical analysis included analysis of variance and post hoc Tukey tests. Results One hundred and fifty patients were randomized to individualized scan delays of 10, 20, or 30 seconds. Pancreatic parenchymal enhancement in all patients (n = 150) was significantly higher with a delay of 20 or 30 seconds than that with 10 seconds (P < .001 for both). Tumor-to-pancreas contrast for solid tumors (n = 59) was significantly higher with a delay of 30 seconds than that with 10 seconds (P = .015). Adenocarcinoma-to-pancreas contrast during pancreatic phase was significantly higher for a 20- or 30-second delay than for a 10-second delay (P = .027 and .011, respectively) for one reader. Conclusions With a flow rate of 4 mL/s and weight-adjusted contrast volume, an individualized scan delay of 30 seconds after aortic transit time revealed higher pancreatic enhancement and tumor-to-pancreas contrast than that with a delay of 10 seconds.
Tumor-infiltrating lymphocytes (TIL) in colorectal cancer liver metastases (CLM) have been associated with more favorable patient outcomes, but whether MHC class I (MHC-I) expression on cancer cells affects prognosis is uncertain. Immunohistochemistry was performed on a tissue microarray of 158 patients with CLM, who underwent partial hepatectomy with curative intent. Using the antibody HC-10, which detects HLA-B and HLA-C antigens and a minority of HLA-A antigens, MHC-I expression was correlated with β-2 microglobulin (β2m; r = 0.7; P < 0.001), but not with T-cell density (r < 0.32). The median follow-up for survivors was 9.7 years. High levels of MHC-I expression in tumors concomitant with high T-cell infiltration (CD3, CD4, or CD8) best identified patients with favorable outcomes, compared with patients with one or none of these immune features. The median overall survival (OS) of patients with MHC-I(hi)CD3(hi) tumors (n = 31) was 116 months compared with 40 months for the others (P = 0.001), and the median time to recurrence (TTR) was not reached compared with 17 months (P = 0.008). By multivariate analysis, MHC(hi)CD3(hi) was associated with OS and TTR independent of the standard clinicopathologic variables. An immune score that combines MHC-I expression and TIL density may be a valuable prognostic tool in the treatment of patients with CLM. Cancer Immunol Res; 2(6); 530-7. ©2014 AACR.
- May 2014
Limited evidence exists that humans mount a mutation-specific T cell response to epithelial cancers. We used a whole-exomic-sequencing-based approach to demonstrate that tumor-infiltrating lymphocytes (TIL) from a patient with metastatic cholangiocarcinoma contained CD4+ T helper 1 (TH1) cells recognizing a mutation in erbb2 interacting protein (ERBB2IP) expressed by the cancer. After adoptive transfer of TIL containing about 25% mutation-specific polyfunctional TH1 cells, the patient achieved a decrease in target lesions with prolonged stabilization of disease. Upon disease progression, the patient was retreated with a >95% pure population of mutation-reactive TH1 cells and again experienced tumor regression. These results provide evidence that a CD4+ T cell response against a mutated antigen can be harnessed to mediate regression of a metastatic epithelial cancer.
Adoptive transfer of tumor-infiltrating lymphocytes (TILs) can mediate regression of metastatic melanoma; however, TILs are a heterogeneous population, and there are no effective markers to specifically identify and select the repertoire of tumor-reactive and mutation-specific CD8+ lymphocytes. The lack of biomarkers limits the ability to study these cells and develop strategies to enhance clinical efficacy and extend this therapy to other malignancies. Here, we evaluated unique phenotypic traits of CD8+ TILs and TCR β chain (TCRβ) clonotypic frequency in melanoma tumors to identify patient-specific repertoires of tumor-reactive CD8+ lymphocytes. In all 6 tumors studied, expression of the inhibitory receptors programmed cell death 1 (PD-1; also known as CD279), lymphocyte-activation gene 3 (LAG-3; also known as CD223), and T cell immunoglobulin and mucin domain 3 (TIM-3) on CD8+ TILs identified the autologous tumor-reactive repertoire, including mutated neoantigen-specific CD8+ lymphocytes, whereas only a fraction of the tumor-reactive population expressed the costimulatory receptor 4-1BB (also known as CD137). TCRβ deep sequencing revealed oligoclonal expansion of specific TCRβ clonotypes in CD8+PD-1+ compared with CD8+PD-1- TIL populations. Furthermore, the most highly expanded TCRβ clonotypes in the CD8+ and the CD8+PD-1+ populations recognized the autologous tumor and included clonotypes targeting mutated antigens. Thus, in addition to the well-documented negative regulatory role of PD-1 in T cells, our findings demonstrate that PD-1 expression on CD8+ TILs also accurately identifies the repertoire of clonally expanded tumor-reactive cells and reveal a dual importance of PD-1 expression in the tumor microenvironment.
To evaluate whether patients with metastatic gastrointestinal (GI) adenocarcinomas refractory to chemotherapy harbor tumor-reactive cytotoxic T cells. Expansion of CD8+ tumor-infiltrating lymphocytes (TIL) and cancer cell lines was attempted from GI cancer metastases in 16 consecutive patients for the study of anti-tumor immune recognition. Retroviral transduction of genes encoding T-cell receptors (TCR) was used to define HLA-restriction elements and specific reactivity. TIL were expanded from metastases in all patients, and new tumor cell lines generated in five patients. Autologous tumor-recognition without cross-reactivity against allogeneic HLA-matched GI tumors was found in CD8+ TIL from three of these five patients. In a patient with gastric cancer liver metastases, the repertoire of CD8+ TIL was dominated by cytolytic sister clones reactive to 2 out of 4 autologous cancer cell lines restricted by HLA-C*0701. From the same patient, a rare CD8+ TIL clone with a distinct TCR recognized all four cancer cell lines restricted by HLA-B*4901. In a patient with bile duct cancer, two distinct anti-tumor cytolytic clones were isolated from a highly polyclonal CD8+ TIL repertoire. TCRs isolated from these clones recognized epitopes restricted by HLA-A*0201. In a third patient, CD8+ TIL reactivity was progressively lost against an autologous colon cancer cell line that displayed loss of HLA haplotype. This study provides a basis for the development of immunotherapy for patients with advanced GI malignancies by first establishing the presence of naturally occurring tumor-reactive CD8+ TIL at the molecular level.
Adoptive cell transfer of tumor-infiltrating lymphocytes (TILs) can mediate cancer regression in patients with metastatic melanoma, but whether this approach can be applied to common epithelial malignancies remains unclear. In this study, we compared the phenotype and function of TILs derived from liver and lung metastases from patients with gastrointestinal (GI) cancers (n = 14) or melanoma (n = 42). Fewer CD3(+) T cells were found to infiltrate GI compared with melanoma metastases, but the proportions of CD8(+) cells, T cell differentiation stage, and expression of costimulatory molecules were similar for both tumor types. Clinical-scale expansion up to ∼50 × 10(9) T cells on average was obtained for all patients with GI cancer and melanoma. From GI tumors, however, TIL outgrowth in high-dose IL-2 yielded 22 ± 1.4% CD3(+)CD8(+) cells compared with 63 ± 2.4% from melanoma (p < 0.001). IFN-γ ELISA demonstrated MHC class I-mediated reactivity of TIL against autologous tumor in 5 of 7 GI cancer patients tested (9% of 188 distinct TIL cultures) and in 9 of 10 melanoma patients (43% of 246 distinct TIL cultures). In these assays, MHC class I-mediated up-regulation of CD137 (4-1BB) expression on CD8(+) cells suggested that 0-3% of TILs expanded from GI cancer metastases were tumor-reactive. This study implies that the main challenge to the development of TIL adoptive cell transfer for metastatic GI cancers may not be the in vitro expansion of bulk TILs, but the ability to select and enrich for tumor-reactive T cells.
Background: Patients with von Hippel-Lindau disease (VHL) commonly develop pancreatic cysts and neuroendocrine neoplasms (PNENs or PNETs). Solid microcystic serous adenoma (SMSA), a rare neoplasm described in VHL patients, can be mistaken for PNEN on imaging. Methods: Clinical, pathologic, and radiologic data were reviewed on VHL patients who underwent surgery for a preoperative diagnosis of PNEN since 1994 at 1 institution. Blinded to the pathologic diagnoses, radiologists reassessed available imaging. Results: For 55 patients, 79 pancreatectomies were performed for presumed PNENs. Ten (18%) patients underwent 12 (15%) resections for neoplasms diagnosed as SMSA on final pathology. The average size of a SMSA leading to operation was 3.6 ± 0.4 cm. Four out of 11 SMSAs were still mistaken for PNENs when imaging was reassessed. The mean FDG-positron emission tomography (PET) standardized uptake value was greater for 17 PNENs (12.1 ± 1.2) compared with 6 SMSAs (4.2 ± 0.5; P = .002). The mean doubling time of SMSAs and PNENs was similar. Seven (15%) patients with pathologically proven PNENs had malignant disease. Conclusion: SMSAs can mimic PNENs on nonfunctional imaging; FDG-PET may help to differentiate them. A high index of suspicion is needed to minimize operations performed for SMSA and to counsel VHL patients of their risks of undergoing operation for a lesion with no known malignant potential.
- Jul 2012
Myeloid-derived suppressor cells (MDSC) have emerged as an immune-regulatory cell type that is expanded in tumor-bearing mice, but less is known about their immune-suppressive role in patients with cancer. To study the importance of MDSC in patients with melanoma, we characterized the frequency, phenotype, and suppressive function of blood myeloid-derived cells and tumor-infiltrating myeloid cells in 26 freshly resected melanomas. Blood and tumor-infiltrating myeloid cells (Lin(-) CD11b(+)) could be phenotypically and morphologically classified into monocytes/macrophages, neutrophils, eosinophils, and immature myeloid cells according to marker expression (CD14(+), CD14(-) CD15(hi), CD14(-) CD15(int), and CD14(-) CD15(-), respectively). In contrast to the expansion of MDSC reported in tumor-bearing mice, we found no differences in the frequency and phenotype of myeloid subsets in the blood of patients with melanoma compared with healthy donors. Myeloid cells represented 12% of the live cells in the melanoma cell suspensions, and were phenotypically diverse with high tumor-to-tumor variability. Interestingly, a positive association was found between the percentage of Tregs and granulocytic cells (Lin(-) CD11b(+) CD14(-)CD15(+)) infiltrating melanoma tumors. However, melanoma-infiltrating myeloid cells displayed impaired suppression of nonspecific T-cell proliferation compared with peripheral blood myeloid cells, in which monocytes and eosinophils were suppressive. Our findings provide a first characterization of the nature and suppressive function of the melanoma myeloid infiltrate and indicate that the suppressive function of MDSC in patients with melanoma seems far less than that based on murine tumor models. Clin Cancer Res; 18(19); 5212-23. ©2012 AACR.
The current role of intra-operative ultrasound (IOUS) is questioned because of recent progress in medical imaging. The aim of the present study was to determine the accuracy of IOUS in the detection of a hepatic tumour (HT) compared with a pre-operative multi-detector computed tomography (MDCT) scan and magnetic resonance imaging (MRI). This retrospective study included 418 patients evaluated using an 8-slice MDCT scan (SCAN8), 64-slice MDCT scan (SCAN64) and MRI alone or combined with a computed tomography (CT) scan. The pathological result was used as a gold standard. Correlation rates for the number of detected lesions compared with pathology results were 0.627 for SCAN8, 0.785 for SCAN64, 0.657 for MRI and 0.913 for IOUS. Compared with pathology, the rate of concordance was significantly higher with IOUS (0.871) than with SCAN8 (0.736; P=0.011), SCAN64 (0.792; P<0.001) and MRI (0.742; P<0.001). IOUS was responsible for a change in operative strategy in 16.5% of patients. Surgery was extended in 12.4%, limited in 1.7% and abandoned in 2.4%. Compared with cross-sectional pre-operative imaging, IOUS is still superior for the detection of HT and the planning of surgery. IOUS remains recommended as a routine procedure in patients having a hepatic resection in the era of modern pre-operative imaging.
After decades of research on solid tumor immunology, immunotherapy has shown effectiveness in patients with metastatic solid cancers. Immune modulators such as IL-2 and anti-CTLA-4 can mediate tumor regression in patients with metastatic melanoma and renal cancer, two tumor types that appear exceptional in their ability to spontaneously harbor endogenous antitumor immune cells. The responses can be long lasting, but the number of patients who benefit from these molecules remains limited. Combinations of these agents with cytotoxic and biologic agents are being investigated as a means to increase response rates and in an attempt to broaden application to other cancer types. Rare responses to cancer vaccines suggest that a better understanding of the underlying biology and mechanism of actions may lead to wider application in the future. The most effective form of immunotherapy thus far, capable of eradicating large tumor burdens in melanoma patients, is the ACT of TIL given to patients after lymphodepletion. As an alternative, lymphocytes engineered to recognize tumor-associated antigens can be safely infused to patients. With this approach, tumor regression is now being reported for cancers other than melanoma, but success remains constrained by the identification of antigens expressed with high specificity by cancer cells and not by normal tissues.
Polyfunctionality is the capacity of a T-cell to execute a variety of effector functions mainly mediated by production of cytokines, chemokines, and cytolytic enzymes. Studies in anti-viral immunity have acknowledged the importance of polyfunctionality in the clearance of infections and maintenance of protection. Although accepted in the field, this concept has not been as well characterized in cancer immunology. Here, we report the polyfunctionality profile analysis of a CD8(+) T-cell clone isolated from a lung cancer patient and directed against Dickkopf-1, a potentially new tumor-associated antigen (TAA). The clone showed Tc1/Th1 effector tendencies confirmed by secretion of cytokines such as IFN-γ, IP-10, MIP-1β, MIP-1α, IL-2, GM-CSF, and expression of cytolytic enzyme granzyme B. This secretion profile is of particular interest in the context of an anti-tumor response. Although secretion of IL-5 and IL-13 was also detected, absence of IL-4 and IL-10 opposes the idea of cytokine-dependent Th1 inhibition. Establishing a comprehensive cytokine secretion profile may help predict T cells' specific response against a novel TAA in a peptide vaccination context. It may further help in selecting clones with an optimal functional profile from the peripheral blood of cancer patients for expansion and adoptive cell transfer therapy.
- Sep 2010
This report presents a phenotypical characterization of the immune cell infiltrate in a rare case of endobronchial carcinoma. A patient initially treated for an adenocarcinoma of the esophagus developed an endobronchial carcinoma surrounded by gastric metaplasia distal to a suspected gastrobronchial fistula, 11 years after esophagectomy. Our hypothesis is that the sustained exposure of the bronchial mucosa to a mixed acid and pancreatobiliary refluxate led to chronic inflammation and promoted malignant transformation. We performed an immunohistochemical study of the tumor microenvironment evaluating the density of CD3(+), CD8(+) T lymphocytes, CD20(+) B lymphocytes, CD68(+) macrophages and FoxP3(+) regulatory T cells. Quantification of immune cell density was completed using a novel software-based analysis method. Our results suggest that, within all the tissues analyzed, FoxP3(+) regulatory T cells were present at their highest density in the malignant and metaplastic tissues. The endobronchial metaplasia biopsied several years prior to the detection of the endobronchial adenocarcinoma was already densely infiltrated by B cells and macrophages, when compared to the immune cell infiltrate of the endobronchial carcinoma. Altogether, these observations support the current understanding of carcinogenesis promoted by chronic inflammation.
- Jun 2010
Complete surgical cytoreduction of peritoneal implants and immediate intraperitoneal (lP) chemotherapy offers the greatest survival in selected patients with peritoneal carcinomatosis. This study was undertaken to describe the metabolism and pharmacokinetics of normothermic intraperitoneal CPT-11, free and glucuronized SN-38, in a pig model. Thirteen pigs were used for experimentation. Animals were grouped for IV and IP CPT-1 1 administration. Eleven pigs underwent laparotomy through a midline incision and instillation of 100, 200, and 400mg IP CPT-11. Systemic venous blood, portal blood and peritoneal fluid samples were taken at 5, 10, 20, 30, and 45 min, then every hour up to 8 hr for the 100 mg. For the three groups, peritoneal CPT-11 exposition was on average 4.9 times greater in the peritoneum than in the systemic venous or portal circulations and the systemic CPT-11 fraction absorbed from the peritoneum linearly increased with time. Free SN-38 was measurable in the earliest peritoneal samples taken. The initial instillation dose of CPT-11 did not impact on the SN-38 converted fraction, which remained stable at approximately 0.04% during the first 4 hour. Mean peritoneal SN-38: CPT-11 AUC ratio was 0.043. OPT-11 peritoneal conversion into SN-38 appeared slightly Inferior to the systemic conversion ratio. This norrnothermic IP OPT-11 pharmacokinetic study performed in a pig model confirms the possibility to achieve at least a 30 times higher peritoneal than systemic exposure. Peritoneal exposure to active SN-38 begins at the moment of CPT-11 peritoneal instillation. A fixed and small traction of less than 0.1% of CPT-11 is converted into SN-38, underlying the importance of a sufficient initial IP dose of CPT-11. J. Surg. Oncol. 2010; 101:637–642. © 2010 Wiley-Liss, Inc.
- Mar 2009
Fistulization of the gastric conduit into the tracheobronchial tree is a potential complication after esophageal reconstruction. In this situation, the effects of the refluxate on the mucosa of the tracheobronchial tree is unknown. This article presents the 11-year evolution of a patient who tolerated a fistulous communication between the gastric interposition and the right mainstem bronchus, resulting in an adenocarcinoma of the bronchus.
Prostate-derived Ets transcription factor (PDEF) has recently been associated with invasive breast cancer, but no expression profile has been defined in clinical specimens. We undertook a comprehensive PDEF transcriptional expression study of 86 breast cancer clinical specimens, several cell lines, and normal tissues. PDEF expression profile was analyzed according to standard clinicopathologic parameters and compared with hormonal receptor and HER-2/neu status and to the expression of the new tumor biomarker Dikkopf-1 (DKK1). Wide ranging PDEF overexpression was observed in 74% of tested tumors, at higher levels than the average expression found in normal breasts. High PDEF expression was associated with hormone receptor positivity (P < .001), moderate to good differentiation (less than grade III, P = .01), and dissemination to axillary lymph nodes (P = .002). PDEF was an independent risk factor for nodal involvement (multivariate analysis, odds ratio 1.250, P = .002). It was expressed in a different subgroup compared to DKK1-expressing tumors (P < .001). Our data imply that PDEF mRNA expression could be useful in breast cancer molecular staging. Further insights into PDEF functions at the protein level, and possible links with hormone receptors biology, bear great potential for new therapeutic avenues.
BACKGROUND: Despite the beneficial effects of epidurals in intra-abdominal surgery, the incidence of anastomotic leak remains controversial when used. Moreover, studies have also shown that fluid overload may be deleterious to anastomoses. The purpose of this paper is to evaluate the effects of varying intraoperative fluid protocols, in the presence of an epidural, on the burst pressure strength of colonic anastomoses. METHODS: An epidural was installed in 18 rabbits, divided into three groups. Group 1 received 30 mL/kg/h Ringer’s lactate, Group 2 received 100 mL/kg/h Ringer’s lactate, and Group 3 received 30 mL/kg/h Pentaspan. Two colo-colonic anastomoses were performed per rabbit. On postoperative day 7 the anastomoses were resected and their burst pressures measured as a surrogate for anastomotic leak. RESULTS: When comparing the average burst pressures of all three groups, there was a significant difference (P ¼ 0.04). The anastomoses in the 100 mL/kg/h Ringer’s lactate group were shown to be the weakest, with 64% of the anastomoses having burst under 120 mm Hg. The rabbits hydrated with Pentaspan had the highest strength, with no anastomoses bursting under 120 mm Hg. This translated into significant burst pressure differences (P ¼ 0.02) between Group 2 and Group 3. CONCLUSION: These results suggest that fluid overload with a crystalloid, in the presence of an epidural, may be deleterious to the healing of colonic anastomoses, creating a higher risk of anastomotic leak. Intraoperative resuscitation should thus focus on goal-directed euvolemia with appropriate amounts of colloids and/or crystalloids to prevent the risk of weakening anastomoses, especially in patients with epidurals.
In addition to new tumour antigens, new prognostic and diagnostic markers are needed for common cancers. In this study, we report the expression of Dickkopf-1 (DKK1) in multiple common cancers. This constitutes a comprehensive analysis of the DKK1 expression profile. Dickkopf-1 expression was evaluated by classical and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbant assay for protein determination, in cancer lines and clinical specimens of several cancer origins. For breast cancer, expression was correlated with clinicopathological parameters. Dickkopf-1 expression was confirmed in several cancer cell lines derived from breast and other common cancers. Dickkopf-1 protein secretion was documented in breast, prostate and lung cancer lines, but was negligible in melanoma. Analysis of DKK1 expression in human cancer specimens revealed DKK1 expression in breast (21 out of 73), lung (11 out of 23) and kidney cancers (six out of 20). Interestingly, DKK1 was preferentially expressed in oestrogen and progesterone receptor-negative tumours (ER(-)/PR(-); P=0.005) and in tumours from women with a family history of breast cancer (P=0.024). Importantly, DKK1 protein production was confirmed in multiple breast cancer specimens that were positive by RT-PCR. This work establishes DKK1 as a potential prognostic and diagnostic marker for cohorts of breast cancer patients with poor prognosis. Dickkopf-1 may also become a relevant candidate target for immunotherapy of different cancers.
- Sep 2006
Peripherally inserted central venous catheters (PICC) have supplanted central venous catheters (CVC) for the administration of intravenous antibiotics and total parenteral nutrition to patients in our hospital. From the literature, it appears that this change has occurred in a number of other surgical units. Accounting for the change are the expected advantages of low complication rates at insertion, prolonged use without complications and interruption, and cost- and time-savings. We have proceeded with a review of the literature to understand and justify this change in practice. Our hypothesis was that the routine adoption of PICC instead of CVC for the acute care of surgical patients has occurred in the absence of strong scientific evidence. Our aim was to compare the associated infectious, thrombotic, phlebitic, and other common complications, as well as PICC and CVC durability. Articles concerning various aspects of PICC- and CVC-related complications in the acute care of adult patients were selected from the literature. Studies were excluded when they primarily addressed the use of long-term catheters, outpatient care, and pediatric patients. Data were extracted from 48 papers published between 1979 and 2004. Our results show that infectious complications do not significantly differ between PICC and CVC. Thrombotic complications appear to be more significant with PICC and to occur early after catheterization. Phlebitic complications accounted for premature catheter removal in approximately 6% of PICC. Finally, prospective data suggest that approximately 40% of PICC will have to be removed before completion of therapy, possibly more often and earlier than CVC. We believe that there is no clear evidence that PICC is superior to CVC in acute care settings. Each approach offers its own advantages and a different profile of complications. Therefore, the choice of central venous access should be individualized for surgical patients on the ward. More comparative prospective studies are needed to document the advantages of PICC over CVC.
- Sep 2005
The causal relationship between GERD and esophageal adenocarcinoma, although unclear just a few decades ago, now is established fairly well. The physiologic changes and the biocellular alterations of the damaged esophageal mucosa are documented better. Despite this knowledge, the dramatic increase in the incidence of esophageal cancer cannot be explained. The absolute risk of esophageal adenocarcinoma arising from GERD is low, and, at present, does not justify population-screening programs. Still, with the notion that adenocarcinoma of the esophagus is an aggressive cancer once documented, important questions still are in need of answers for patients suffering from reflux symptoms. Patients who have reflux disease are not necessarily symptomatic. It remains unclear if patients experiencing reflux symptoms should undergo mandatory endoscopy with biopsies at the esophagogastric junction. Furthermore, metaplasia of the lower esophagus often is not readily recognizable at endoscopy, and only biopsies can document abnormal histology. A severe and prolonged history of reflux always should orient to the possibility of a reflux-related columnar-lined esophagus. Once documented, Barrett's esophagus needs to be seen as a premalignant condition not necessarily leading to adenocarcinoma formation; despite their increased risk of tumor formation, most patients who have Barrett's esophagus die of other causes. During regular endoscopic follow-up, multilevel circumferential biopsies should document the evolution of the histologic changes in the lower esophagus and at the gastroesophageal junction of these patients. It is the only method available to document the appearance of dysplasia. It still is unclear if medicine or surgery provides the best quality of life and the best protection against the development of dysplasia and the possible progression toward adenocarcinoma formation when intestinal metaplasia is present in the esophagus.
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