Mcl-1 mediates intrinsic resistance to RAF inhibitors in mutant BRAF papillary thyroid carcinoma.

Papillary thyroid carcinoma (PTC) is the most frequent form of thyroid cancer. PTC commonly presents with mutations of the serine/threonine kinase BRAF (BRAFV600E), which drive ERK1/2 pathway activation to support growth and suppress apoptosis. PTC patients often undergo surgical resection; however, since the average age of PTC patients is under 50, adverse effects associated with prolonged maintenance therapy following total thyroidectomy are a concern. The development of mutant-selective BRAF inhibitors (BRAFi), like vemurafenib, has been efficacious in patients with metastatic melanoma, but the response rate is low for mutant BRAF PTC patients. Here, we assay the therapeutic response of BRAFi in a panel of human PTC cell lines and freshly biopsied patient samples. We observed heterogeneous responses to BRAFi, and multi-omic comparisons between susceptible and resistant mutant BRAF PTC revealed overrepresented stress response pathways and the absence of compensatory RTK activation - features that may underpin innate resistance. Importantly, resistant cell lines and patient samples had increased hallmarks of failed apoptosis; a cellular state defined by sublethal caspase activation and DNA damage. Further analysis suggests that the failed apoptotic phenotypes may have features of "minority mitochondrial outer membrane permeabilization (MOMP)" - a stress-related response characterized by fragmented and porous mitochondria known to contribute to cancer aggressiveness. We found that cells presenting with minority MOMP-like phenotypes are dependent on the apoptotic regulator, Mcl-1, as treatment with the Mcl-1 inhibitor, AZD5991, potently induced cell death in resistant cells. Furthermore, PI3K/AKT inhibitors sensitized resistant cells to BRAFi; an effect that was at least in part associated with reduced Mcl-1 levels. Together, these data implicate minority MOMP as a mechanism associated with intrinsic drug resistance and underscore the benefits of targeting Mcl-1 in mutant BRAF PTC.

Orbital resection by intranasal technique (ORBIT): A new classification system for reporting endoscopically resectable primary benign orbital tumors.

BACKGROUND: The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs. METHODS: Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class. RESULTS: Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05). CONCLUSION: Endoscopic treatment of PBOTs is an effective approach, with favorable short-term and long-term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs.

Identifying Treatments for Taste and Smell Disorders: Gaps and Opportunities.

The chemical senses of taste and smell play a vital role in conveying information about ourselves and our environment. Tastes and smells can warn against danger and also contribute to the daily enjoyment of food, friends and family, and our surroundings. Over 12% of the US population is estimated to experience taste and smell (chemosensory) dysfunction. Yet, despite this high prevalence, long-term, effective treatments for these disorders have been largely elusive. Clinical successes in other sensory systems, including hearing and vision, have led to new hope for developments in the treatment of chemosensory disorders. To accelerate cures, we convened the "Identifying Treatments for Taste and Smell Disorders" conference, bringing together basic and translational sensory scientists, health care professionals, and patients to identify gaps in our current understanding of chemosensory dysfunction and next steps in a broad-based research strategy. Their suggestions for high-yield next steps were focused in 3 areas: increasing awareness and research capacity (e.g., patient advocacy), developing and enhancing clinical measures of taste and smell, and supporting new avenues of research into cellular and therapeutic approaches (e.g., developing human chemosensory cell lines, stem cells, and gene therapy approaches). These long-term strategies led to specific suggestions for immediate research priorities that focus on expanding our understanding of specific responses of chemosensory cells and developing valuable assays to identify and document cell development, regeneration, and function. Addressing these high-priority areas should accelerate the development of novel and effective treatments for taste and smell disorders.

TERT, HRAS, and EIF1AX Mutations in a Patient with Follicular Adenoma.

BACKGROUND: Molecular markers are increasingly used as diagnostic tools in the management of thyroid nodules. There is a paucity of studies evaluating the prevalence of molecular markers in benign lesions. PATIENT FINDINGS: A 68-year-old woman with hypothyroidism presented with a right thyroid nodule, which was atypia of undetermined significance on cytology. The fine-needle aspirate of the nodule was examined with next-generation sequencing and found to harbor a C228T mutation in the TERT gene, a Q61R mutation in the HRAS gene, and an A113_splice mutation in the EIF1AX gene. Right thyroid lobectomy was performed, with final pathology showing follicular adenoma. All three mutations detected in the original fine-needle aspirate specimen were detected in the final surgical specimen as well. CONCLUSIONS: A rare case of TERT, HRAS, and EIF1AX mutations is reported in a patient with follicular adenoma. TERT promoter mutations may be an early genetic event in the molecular pathogenesis of follicular thyroid carcinoma.

Nasal Structural and Aerodynamic Features That May Benefit Normal Olfactory Sensitivity.

Nasal airflow that effectively transports ambient odors to the olfactory receptors is important for human olfaction. Yet, the impact of nasal anatomical variations on airflow pattern and olfactory function is not fully understood. In this study, 22 healthy volunteers were recruited and underwent computed tomographic scans for computational simulations of nasal airflow patterns. Unilateral odor detection thresholds (ODT) to l-carvone, phenylethyl alcohol (PEA) and d-limonene were also obtained for all participants. Significant normative variations in both nasal anatomy and aerodynamics were found. The most prominent was the formation of an anterior dorsal airflow vortex in some but not all subjects, with the vortex size being significantly correlated with ODT of l-carvone (r = 0.31, P < 0.05). The formation of the vortex is likely the result of anterior nasal morphology, with the vortex size varying significantly with the nasal index (ratio of the width and height of external nose, r = -0.59, P < 0.001) and nasal vestibule "notch" index (r = 0.76, P < 0.001). The "notch" is a narrowing of the upper nasal vestibule cartilage region. The degree of the notch also significantly correlates with ODT for PEA (r = 0.32, P < 0.05) and l-carvone (r = 0.33, P < 0.05). ODT of d-limonene, a low mucosal soluble odor, does not correlate with any of the anatomical or aerodynamic variables. The current study revealed that nasal anatomy and aerodynamics might have a significant impact on normal olfactory sensitivity, with greater airflow vortex and a narrower vestibule region likely intensifying the airflow vortex toward the olfactory region and resulting in greater olfactory sensitivity to high mucosal soluble odors.

EIF1AX Mutation in a Patient with Hürthle Cell Carcinoma.

The EIF1AX gene is a novel cancer gene that has been reported in the tumorigenesis of papillary thyroid carcinoma, follicular variant papillary thyroid carcinoma, and anaplastic thyroid carcinoma. A 71-year-old woman presented with a right thyroid mass, which was follicular neoplasm on cytology. The fine needle aspirate of the nodule was examined by next-generation sequencing and found to harbor EIF1AX and TP53 mutations. Right thyroid lobectomy was performed with final pathology showing Hürthle cell carcinoma with capsular and vascular invasion. We report an EIF1AX mutation in a patient found to have Hürthle cell carcinoma.

Investigation of the abnormal nasal aerodynamics and trigeminal functions among empty nose syndrome patients.

BACKGROUND: Abnormal nasal aerodynamics or trigeminal functions have been frequently implicated in the symptomology of empty nose syndrome (ENS), yet with limited evidence. METHODS: Individual computed tomography (CT)-based computational fluid dynamics (CFD) was applied to 27 ENS patients to simulate their nasal aerodynamics and compared with 42 healthy controls. Patients' symptoms were confirmed with Empty Nose Syndrome 6-item Questionnaire (ENS6Q), 22-item Sino-Nasal Outcome Test (SNOT-22), and Nasal Obstruction Symptom Evaluation (NOSE) scores. Nasal trigeminal sensitivity was measured with menthol lateralization detection thresholds (LDTs). RESULTS: ENS patients had significantly lower (∼25.7%) nasal resistance and higher (∼2.8 times) cross-sectional areas compared to healthy controls (both p < 0.001). Despite inferior turbinate reductions, CFD analysis demonstrated that ENS patients had increased airflow concentrated in the middle meatus region (66.5% ± 18.3%) compared to healthy controls (49.9% ± 15.1%, p < 0.0001). Significantly less airflow (25.8% ± 17.6%) and lower peak wall shear stress (WSS) (0.58 ± 0.24 Pa) were found in the inferior meatus (vs healthy: 36.5% ± 15.9%; 1.18 ± 0.81 Pa, both p < 0.05), with the latter significantly correlated with the symptom scores of ENS6Q (r = -0.398, p = 0.003). Item-wise, complaints of "suffocation" and "nose feels too open" were also found to be significantly correlated with peak WSS around the inferior turbinate (r = -0.295, p = 0.031; and r = -0.388, p = 0.004, respectively). These correlations were all negative, indicating that less air-mucosal stimulations resulted in worse symptom scores. ENS patients (n = 12) also had impaired menthol LDT when compared to healthy controls (p < 0.0001). CONCLUSION: This is the first CFD examination of nasal aerodynamics in a large cohort of ENS patients. The results indicated that a combination of loss of neural sensitivity and poorer inferior air-mucosal stimulation may potentially lead to ENS symptomology.

Biochemical Effects of Exercise on a Fasciocutaneous Flap in a Rat Model.

IMPORTANCE: An overwhelming amount of data suggest that cardiovascular exercise has a positive effect on the mind and body, although the precise mechanism is not always clear. OBJECTIVE: To assess the clinical and biochemical effects of voluntary cardiovascular exercise on pedicled flaps in a rodent model. DESIGN, SETTING, AND PARTICIPANTS: Eighteen adult Sprague-Dawley male rats were randomized into a resting animal group (RAG) (n=9) and an exercise animal group (EAG) (n=9) for 14 days (July 23, 2013, through July 30, 2013). A pedicled transposition flap was performed on the ventral surface of the rat, and biopsy specimens were taken from the proximal, middle, and distal portions on postoperative days 0, 2, 5, and 9. Flap survival was analyzed planimetrically, and biopsy specimens were analyzed by hematoxylin-eosin-stained microscopy and immunoblotting. The housing, exercise, surgery, and analysis of the rats were conducted at a single basic science research laboratory at the tertiary care center campus of Thomas Jefferson University in Philadelphia, Pennsylvania. EXPOSURES: The rats were caged for 14 days or housed in a cage connected to an exercise wheel and pedometer. MAIN OUTCOMES AND MEASURES: Study measures were gross and micrographic necrosis and expression of proteins within cell survival and apoptosis pathways. RESULTS: A total of 18 rats were studied, 9 in the RAG and 9 in the EAG. the mean (SEM) amount of necrosis in flaps was 41.3% (3%) in the RAG rats and 10.5% (3.5%) in the EAG rats (P < .001). Immunoblotting revealed increased Caspase-9 activity resulting in poly-(adenosine diphosphate-ribose) polymerase 1 cleavage in the RAG vs the EAG, as well as lower phosphorylated protein kinase B (also known as Akt), signal transducer and activator of transcription 3, and total B-cell leukemia/lymphoma 2 protein levels. Throughout the postoperative period, the cumulative vascular endothelial growth factor A levels of the EAG flaps were significantly higher than those of the RAG flaps (2.30 vs 1.25 fold induction [FI], P = .002), with differences of 2.76 vs 1.54 FI in the proximal segment, 2.40 vs 1.20 FI in the middle segment, and 1.90 vs 0.79 FI in the distal segment. A similar response was noted when comparing phosphorylated Akt, with cumulative mean (SEM) p-Akt expression levels of 0.62 (0.04) for RAG and 1.98 (0.09) for EAG (P = .002 between the 2 groups). CONCLUSIONS AND RELEVANCE: Voluntary preoperative exercise improves survival in pedicled fasciocutaneous flaps; the EAG rats had less necrosis, decreased apoptotic markers, and increased amounts of vascular endothelial growth factor A and prosurvival proteins. These results have implications to increase flap survival in other mammal populations, such as humans. LEVEL OF EVIDENCE: 3.

Multicompartment metabolism in papillary thyroid cancer.

OBJECTIVES/HYPOTHESIS: In many cancers, varying regions within the tumor are often phenotypically heterogeneous, including their metabolic phenotype. Further, tumor regions can be metabolically compartmentalized, with metabolites transferred between compartments. When present, this metabolic coupling can promote aggressive behavior. Tumor metabolism in papillary thyroid cancer (PTC) is poorly characterized. STUDY DESIGN: Immunohistochemical staining of tissue samples. METHODS: Papillary thyroid cancer specimens from 46 patients with (n = 19) and without advanced disease (n = 27) were compared to noncancerous thyroid tissue (NCT) and benign thyroid specimens (n = 6 follicular adenoma [FA] and n = 5 nodular goiter [NG]). Advanced disease was defined as the presence of lateral neck lymphadenopathy. Immunohistochemistry was performed for translocase of outer mitochondrial membrane 20 (TOMM20), a marker of oxidative phosphorylation, and monocarboxylate transporter 4 (MCT4), a marker of glycolysis. RESULTS: Papillary thyroid cancer and FA thyrocytes had high staining for TOMM20 compared to NCT and nodular goiter (NG) (P < 0.01). High MCT4 staining in fibroblasts was more common in PTC with advanced disease than in any other tissue type studied (P < 0.01). High MCT4 staining was found in all 19 cases of PTC with advanced disease, in 11 of 19 samples with low-stage disease, in one of five samples of FA, in one of 34 NCT, and in 0 of six NG samples. Low fibroblast MCT4 staining in PTC correlated with the absence of clinical adenopathy (P = 0.028); the absence of extrathyroidal extension (P = 0.004); low American Thyroid Association risk (P = 0.001); low AGES (age, grade, extent, size) score (P = 0.004); and low age, metastasis, extent of disease, size risk (P = 0.002). CONCLUSION: This study suggests that multiple metabolic compartments exist in PTC, and low fibroblast MCT4 may be a biomarker of indolent disease. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:2410-2418, 2016.

Aging effects on pedicled fasciocutaneous flap survival in rats.

BACKGROUND: Poorer surgical outcomes in older patients undergoing locoregional head and neck reconstruction have raised questions about tolerance of aging tissue to iatrogenic ischemic insults. METHODS: We examined the effects of aging on viability of pedicled composite flaps in 2-month and 6-month old Sprague-Dawley male rats and correlated flap survival with vascular endogenous growth factor (VEGF) and VEGF receptor 2-mediated signaling events. Flap segments were assessed for gross/cellular necrosis by optical microscopy and for proangiogenic, apoptotic, and proliferative protein-marker content. RESULTS: Flap necrosis significantly increased with age (4.2% in young vs 49.17% in old), correlating with reduced expression of VEGF, inhibition of signal transducer and activator of transcription 3 (STAT3), and Akt activation, impaired Akt-dependent endothelial nitric oxide synthase (eNOS) phosphorylation, elevated Bax/Bcl-2 ratio, activation of Caspase-3, upregulated nuclear poly (ADP-ribose) polymerase-1 (PARP-1) cleavage and lower proliferating cell nuclear antigen (PCNA) levels. CONCLUSION: Pedicled flap survival is higher in younger rats in part because of unhindered expression of VEGF and enhanced activity of cell survival and promigratory signaling pathways. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1152-E1162, 2016.

Mitochondrial Metabolism as a Treatment Target in Anaplastic Thyroid Cancer.

Anaplastic thyroid cancer (ATC) is one of the most aggressive human cancers. Key signal transduction pathways that regulate mitochondrial metabolism are frequently altered in ATC. Our goal was to determine the mitochondrial metabolic phenotype of ATC by studying markers of mitochondrial metabolism, specifically monocarboxylate transporter 1 (MCT1) and translocase of the outer mitochondrial membrane member 20 (TOMM20). Staining patterns of MCT1 and TOMM20 in 35 human thyroid samples (15 ATC, 12 papillary thyroid cancer [PTC], and eight non-cancerous thyroid) and nine ATC mouse orthotopic xenografts were assessed by visual and Aperio digital scoring. Staining patterns of areas involved with cancer versus areas with no evidence of cancer were evaluated independently where available. MCT1 is highly expressed in human anaplastic thyroid cancer when compared to both non-cancerous thyroid tissues and papillary thyroid cancers (P<.001 for both). TOMM20 is also highly expressed in both ATC and PTC compared to non-cancerous thyroid tissue (P<.01 for both). High MCT1 and TOMM20 expression is also found in ATC mouse xenograft tumors compared to non-cancerous thyroid tissue (P<.001). These xenograft tumors have high (13)C- pyruvate uptake. ATC has metabolic features that distinguish it from PTC and non-cancerous thyroid tissue, including high expression of MCT1 and TOMM20. PTC has low expression of MCT1 and non-cancerous thyroid tissue has low expression of both MCT1 and TOMM20. This work suggests that MCT1 blockade may specifically target ATC cells presenting an opportunity for a new drug target.

Using ultrasonic preoperative thyroid volume to determine incision length for minimally invasive thyroid surgery.

The determination of the volume of a diseased thyroid lobe or an entire gland by preoperative ultrasonography may enable surgeons to select candidates for a minimally invasive approach to thyroid lobectomy or total thyroidectomy. We retrospectively reviewed the charts of 71 adults who had undergone minimally invasive nonendoscopic thyroid surgery at our hospital from January 2007 through May 2009. We compiled data on ultrasonic preoperative thyroid volumes and operative incision lengths. Of the 71 patients, 40 had undergone lobectomy and 31 had undergone total thyroidectomy. The lobectomy group was evenly subdivided into two groups based on the median volume of the affected lobe; 20 patients had a volume of <28.32 ml and 20 had a volume of >28.32 ml. The incision length ranged from 2.0 to 3.8 cm (mean: 3.1 ± 0.53) in the smaller-volume lobectomy group and from 2.5 to 5.0 cm (mean: 3.7 cm ± 0.71) in the larger-volume lobectomy group; the difference was statistically significant (p < 0.01). The 31 patients in the total thyroidectomy group were subdivided on the basis of the median volume of the entire thyroid gland; 16 patients had a volume of <49.24 ml and 15 had a total volume of >49.24 ml. The incision length in those two groups ranged from 2.5 to 4.0 cm (mean: 3.4 ± 0.53) and 3.6 to 6.0 (mean: 5.1 ± 0.99), respectively; again, the difference was statistically significant (p < 0.001). The findings of our study suggest that preoperative ultrasonographic thyroid lobe volume or total thyroid gland volume can be used to determine the appropriate minimum length for the surgical incision.

Computational fluid dynamics as surgical planning tool: a pilot study on middle turbinate resection.

Controversies exist regarding the resection or preservation of the middle turbinate (MT) during functional endoscopic sinus surgery. Any MT resection will perturb nasal airflow and may affect the mucociliary dynamics of the osteomeatal complex. Neither rhinometry nor computed tomography (CT) can adequately quantify nasal airflow pattern changes following surgery. This study explores the feasibility of assessing changes in nasal airflow dynamics following partial MT resection using computational fluid dynamics (CFD) techniques. We retrospectively converted the pre- and postoperative CT scans of a patient who underwent isolated partial MT concha bullosa resection into anatomically accurate three-dimensional numerical nasal models. Pre- and postsurgery nasal airflow simulations showed that the partial MT resection resulted in a shift of regional airflow towards the area of MT removal with a resultant decreased airflow velocity, decreased wall shear stress and increased local air pressure. However, the resection did not strongly affect the overall nasal airflow patterns, flow distributions in other areas of the nose, nor the odorant uptake rate to the olfactory cleft mucosa. Moreover, CFD predicted the patient's failure to perceive an improvement in his unilateral nasal obstruction following surgery. Accordingly, CFD techniques can be used to predict changes in nasal airflow dynamics following partial MT resection. However, the functional implications of this analysis await further clinical studies. Nevertheless, such techniques may potentially provide a quantitative evaluation of surgical effectiveness and may prove useful in preoperatively modeling the effects of surgical interventions.

Contrast-enhanced ultrasound-guided Sentinel lymph node biopsy of the ocular conjunctiva.

OBJECTIVES/HYPOTHESIS: Sentinel lymph node biopsy (SLNB) has been utilized for cutaneous melanoma and other malignancies arising from the eye and ocular adnexa. Currently, SLNB requires blue dyes and/or radiopharmaceuticals; both of which have significant shortcomings. This study sought to evaluate the feasibility of SLNB with the use of real-time, contrast-enhanced ultrasound (CEUS) as an alternative technique for tumors arising in the conjunctiva. STUDY DESIGN: Prospective feasibility study in a porcine model. METHODS: Twelve experiments were performed on six non-tumor-bearing Yorkshire swine. An ultrasound contrast agent, Sonazoid (GE Healthcare, Oslo, Norway), (99m) technetium ((99m) Tc), and methylene blue (MB) (Covidien, Mansfield, MA) were injected in the ocular conjunctiva. Sentinel lymph nodes (SLNs) were localized with CEUS and findings were compared to that of MB and (99m) Tc. Fisher exact test was used. RESULTS: Contrast-enhanced SLNs were identified within an average of 6.2 minutes from time of injection of Sonazoid. A total of 17 SLNs were identified by at least one of the three techniques. Correlation between Sonazoid and (99m) Tc was 94.1% (16/17 SLNs). Correlation between (99m) Tc and MB was 88.2% (15/17). One SLN that was positive for (99m) Tc but negative for Sonazoid and was considered to be a false positive (1/17); findings were similar for MB (1/17). Differences between the three techniques were not significant (P = .886). CONCLUSIONS: CEUS-guided injection of conjunctiva for SLNB is technically feasible and correlates well with standard detection techniques. This technique shows promise for rapid, real-time, intraoperative imaging for SLNB, using a widely available imaging modality and avoiding the need for radiopharmaceuticals. LEVEL OF EVIDENCE: NA

Endoscopic ultrasonic dacryocystorhinostomy for recurrent dacryocystitis following rhinoplasty.

UNLABELLED: The lacrimal sac is the structure most vulnerable to injury when performing rhinoplastic osteotomies. When performed in a low lateral position or along the frontal process of the frontal-maxillary suture, osteotomies can potentially tear the medial canthal tendon and injure the underlying lacrimal sac, possibly resulting in dacryocystitis. In this case report, the authors discuss a case of dacryocystitis following primary rhinoplasty; this injury was repaired with endoscopic dacryocystorhinostomy (DCR) using a Sonopet ultrasonic bone aspirator (Stryker, Kalamazoo, Michigan) at a single institution. This method achieved nasolacrimal duct patency, and the patient continued to be symptom-free at an 18-month follow-up. This is the first reported case of recurrent dacryocystitis following rhinoplasty as treated by endoscopic DCR. LEVEL OF EVIDENCE: 5.