Light-Activated Assembly of Connexon Nanopores in Synthetic Cells.

During developmental processes and wound healing, activation of living cells occurs with spatiotemporal precision and leads to rapid release of soluble molecular signals, allowing communication and coordination between neighbors. Nonliving systems capable of similar responsive release hold great promise for information transfer in materials and site-specific drug delivery. One nonliving system that offers a tunable platform for programming release is synthetic cells. Encased in a lipid bilayer structure, synthetic cells can be outfitted with molecular conduits that span the bilayer and lead to material exchange. While previous work expressing membrane pore proteins in synthetic cells demonstrated content exchange, user-defined control over release has remained elusive. In mammalian cells, connexon nanopore structures drive content release and have garnered significant interest since they can direct material exchange through intercellular contacts. Here, we focus on connexon nanopores and present activated release of material from synthetic cells in a light-sensitive fashion. To do this, we re-engineer connexon nanopores to assemble after post-translational processing by a protease. By encapsulating proteases in light-sensitive liposomes, we show that assembly of nanopores can be triggered by illumination, resulting in rapid release of molecules encapsulated within synthetic cells. Controlling connexon nanopore activity provides an opportunity for initiating communication with extracellular signals and for transferring molecular agents to the cytoplasm of living cells in a rapid, light-guided manner.

The impact of tumor size and histology on local control when utilizing high-dose-rate interstitial brachytherapy for gynecologic malignancies.

OBJECTIVE: To report long-term results of an outpatient template-based high-dose-rate interstitial brachytherapy (HDR ISBT) program for the treatment of gynecologic malignancies. METHODS: Patients treated between 2006 and 2020 at an academic hospital with outpatient template based HDR ISBT without spinal or general anesthesia were reviewed. Patients who had previously received HDR ISBT were excluded. Baseline patient, tumor, and treatment characteristics, such as tumor size, histology, and/or total EQD2 including prior external beam radiation therapy (EBRT) were recorded. Local control and overall survival were estimated using the Kaplan-Meier method, and factors associated with local control and overall survival were evaluated using Cox regression analyses. RESULTS: 150 patients received HDR ISBT for a gynecologic tumor and the median follow-up time was 2.98 years (0.89-4.82). Of those, 74/150 (49%) were treated definitively, 69/150 (46%) were treated for tumor recurrence/persistence, and 7/150 (5%) were treated for durable palliation. Median tumor size was 3.00 cm (1.50-4.00). 124/150 (83%) patients received EBRT prior to HDR ISBT. Median HDR ISBT dose was 18 Gy delivered in eight fractions. Local control was 71% (64%-79%), 58% (50%-68%), and 57% (48%-67%) at one, three, and five years, respectively. On multivariate analysis, non-endometrial adenocarcinoma histology (HR = 2.423, 95% CI = 1.011-5.808, p = 0.047) and tumor size ≥ 3 cm (HR = 2.903, 95% CI 1.053-3.441, p = 0.033) were associated with lower local control. CONCLUSIONS: The majority of patients who received outpatient-based twice daily HDR ISBT had long-term local control. Larger tumor size and non-endometrial adenocarcinoma histology were detrimental to local control.

Expression of Potential Biomarker Targets by Immunohistochemistry in Cervical Carcinomas.

There have been few clinically useful targetable biomarkers in uterine cervical carcinomas. Estrogen receptor (ER), HER2, and fibroblast activation protein (FAP) are potential therapeutic or theranostic targets in other gynecologic and genitourinary carcinoma types. We determined the immunohistochemical expression patterns of these markers in treatment-naive cervical carcinoma, and whether expression correlated with clinical outcomes after definitive chemoradiation therapy. Tissue microarrays were created from 71 patient samples taken before therapy (57 squamous cell carcinomas and 14 nonsquamous cell carcinomas) and stained for ER, HER2, and FAP. ER was positive in 25/70 cases (36%). Of 66 tumors with evaluable HER2 staining, only 1 had positive (3+) staining (3%, positive for HER2 amplification by fluorescence in situ hybridization), and 1 had equivocal (2+) staining (negative for amplification by fluorescence in situ hybridization). The remainder were negative for HER2 overexpression. FAP expression was widely variably in the tumor stroma. ER positivity and FAP expression did not correlate with cervical recurrence, pelvic recurrence, distant recurrence, or cancer death. In conclusion, HER2 amplification is very rare in nonmetastatic treatment-naive cervical carcinomas, but if present, could represent a target for antibody therapy. ER and FAP were expressed in a subset of tumors, but expression did not correlate with clinical outcomes. These immunohistochemical markers do not demonstrate prognostic significance in treatment-naive cervical cancer, but they may have utility in targeted therapy or imaging.

Neutrophils promote tumor resistance to radiation therapy.

Nearly two-thirds of cancer patients are treated with radiation therapy (RT), often with the intent to achieve complete and permanent tumor regression (local control). RT is the primary treatment modality used to achieve local control for many malignancies, including locally advanced cervical cancer, head and neck cancer, and lung cancer. The addition of concurrent platinum-based radiosensitizing chemotherapy improves local control and patient survival. Enhanced outcomes with concurrent chemoradiotherapy may result from increased direct killing of tumor cells and effects on nontumor cell populations. Many patients treated with concurrent chemoradiotherapy exhibit a decline in neutrophil count, but the effects of neutrophils on radiation therapy are controversial. To investigate the clinical significance of neutrophils in the response to RT, we examined patient outcomes and circulating neutrophil counts in cervical cancer patients treated with definitive chemoradiation. Although pretreatment neutrophil count did not correlate with outcome, lower absolute neutrophil count after starting concurrent chemoradiotherapy was associated with higher rates of local control, metastasis-free survival, and overall survival. To define the role of neutrophils in tumor response to RT, we used genetic and pharmacological approaches to deplete neutrophils in an autochthonous mouse model of soft tissue sarcoma. Neutrophil depletion prior to image-guided focal irradiation improved tumor response to RT. Our results indicate that neutrophils promote resistance to radiation therapy. The efficacy of chemoradiotherapy may depend on the impact of treatment on peripheral neutrophil count, which has the potential to serve as an inexpensive and widely available biomarker.

FIGO 2018 staging criteria for cervical cancer: Impact on stage migration and survival.

OBJECTIVE: To compare FIGO 2009 and FIGO 2018 cervical cancer staging criteria with a focus on stage migration and treatment outcomes. METHODS: This study is based on a database cohort of 1282 patients newly diagnosed with cervical cancer from 1997 to 2019. All underwent standard clinical examination and whole-body FDG-PET. Tumor stage was recorded using the FIGO 2009 system, which excluded surgical pathologic, FDG-PET and other advanced imaging findings, and then re-classified to the FIGO 2018 system, including surgical pathologic and imaging findings. Patient management was based on clinical, surgical, and imaging findings. Stage migration and prognosis were evaluated. RESULTS: The distribution per the 2009 staging system was stage I in 593 (46%), stage II in 342 (27%), stage III in 263 (21%), and stage IV in 84 (7%) and the 2018 staging system was stage I in 354 (28%), stage II in 156 (12%), stage III in 601 (47%), and stage IV in 171 (13%). No patients were down-staged. Stage migration occurred in 53% (676/1282) and was attributable to detection of occult lymph node metastasis in 520 (41%), occult distant metastasis in 90 (7%), and tumor size and extent in 66 (5%). The 5-year progression-free survivals (PFS) by FIGO 2009 versus FIGO 2018 were as follows: stage I, 80% vs. 87% (p = 0.02); stage II, 59% vs. 71% (p = 0.002); stage III, 35% vs. 55% (p < 0.001), and stage IV, 20% vs. 16% (p = 0.41). CONCLUSION: Inclusion of surgical pathologic and imaging findings resulted in upward stage migration in the majority, mostly related to nodal and distant metastasis. While FIGO 2018 improves survival discriminatory ability for stages I and IV patients, survival remains heterogeneous among stage III substages.

A multi-institutional analysis of clinical outcomes and patterns of care of 1p/19q codeleted oligodendrogliomas treated with adjuvant or salvage radiation therapy.

PURPOSE: Practice patterns vary for adjuvant treatment of 1p/19q-codeleted oligodendroglioma patients. This study evaluates the outcomes of adjuvant (aRT) versus salvage radiation therapy (sRT) in a multi-institutional cohort. METHODS: Oligodendroglioma patients with confirmed 1p/19q codeletion who were treated with RT with or without chemotherapy from 2000 to 2017 at four tertiary centers were retrospectively reviewed. Overall survival (OS), post-RT progression-free survival (PFS), freedom-from-RT (FFRT), and radiation necrosis (RN) rates were determined using Kaplan-Meier analyses. OS1/PFS1 were defined from the initial surgery. OS2/PFS2 were defined from the RT start-date. Multivariable analyses (MVAs) of prognostic factors for OS and PFS were performed with Cox regression. RESULTS: One hundred eighty-six patients were identified: 124(67%) received aRT and 62(33%) received sRT; of sRT patients, 58% were observed after surgery while 42% received chemotherapy without aRT. The median time from initial diagnosis to sRT was 61 months, and 74% had reoperations before sRT. sRT had longer OS1 than aRT (94% vs. 69% at 10 years, p = 0.03) and PFS1 (10-year PFS of 80% vs. 68%, p = 0.03), though sRT was not associated with significantly different OS1/PFS1 on MVAs. Chemotherapy did not delay sRT compared to observation and had worse PFS2 (42% vs. 79% at 5 years, p = 0.08). Higher RT dose was not associated with improved clinical outcomes but was associated with higher symptomatic RN rate (15% vs. 0% at 2 years, p = 0.003). CONCLUSIONS: Delaying RT for selected oligodendroglioma patients appears safe. Adjuvant chemotherapy does not delay sRT longer than observation and may be associated with worse PFS after RT.

Long-term outcomes of intensity-modulated radiation therapy (IMRT) and high dose rate brachytherapy as adjuvant therapy after radical hysterectomy for cervical cancer.

OBJECTIVE: Compared with 3D-planned pelvic radiation, intensity-modulated radiation therapy (IMRT) has been shown to reduce acute toxicity in cervical cancer patients after radical hysterectomy. This study evaluated late toxicity and patterns of failure after post-operative pelvic IMRT interdigitated weekly with high dose rate brachytherapy. METHODS: This retrospective study included 53 cervical cancer patients treated between January 2006 and August 2019 with radical hysterectomy, lymphadenectomy, and post-operative IMRT and high dose rate brachytherapy. The decision to include chemotherapy was made by the treating gynecologic oncologist based on patient-specific criteria including positive pelvic lymph nodes, positive surgical margins, or positive parametrial invasion. The actuarial rates of genitourinary and gastrointestinal toxicity, vaginal cuff/regional nodal/distant failure, and overall survival were calculated using the Kaplan-Meier method. RESULTS: Median follow-up was 70 months (range 5.4-148) months and age at diagnosis was 47 (range 24-73) years. The 2018 International Federation of Gynecology and Obstetrics (FIGO) clinical stages were IB1 (n=19), IB2 (n=7), IIB (n=7), IIIC1 (n=19), and IIIC2 (n=1). Median radiation dose delivered in 160 cGy daily fractions was 5120 (range 4640-5120) cGy. Median brachytherapy dose prescribed to the vaginal surface delivered in six weekly fractions was 2400 (range 1200-4800) cGy. Concurrent chemotherapy was delivered in 35 (66%) patients. There were no acute grade >3 genitourinary or gastrointestinal toxicities. Late grade >3 occurred in two (3.8%) patients, including a small bowel obstruction and a ureteral stricture. The 5-year actuarial rate for gastrointestinal or genitourinary toxicity was 1.9%. There were no vaginal cuff recurrences. The 5-year actuarial rates for regional nodal failure, distant failure outside the radiation field, any failure, and overall survival were 11%, 11%, 14%, and 85%, respectively. CONCLUSIONS: Post-operative IMRT with high dose rate brachytherapy for patients with cervical cancer is associated with excellent outcomes and limited rates of radiation-related non-hematologic toxicity.

Clinical outcomes after isolated pelvic failure in cervical cancer patients treated with definitive radiation.

PURPOSE: To describe clinical outcomes in patients with isolated pelvic failures after definitive radiation treatment for cervical cancer. METHODS AND MATERIALS: Cervical cancer patients with isolated pelvic failure after definitive radiation with brachytherapy boost were identified in a tertiary academic center database from 1997 to 2016. All patients received an FDG-PET scan prior to their initial treatment and at the time of their first recurrence. Isolated failures in the cervix or pelvic nodes were biopsy-proven. Distant failure and overall survival (OS) were censored outcomes. RESULTS: Isolated pelvic failure was detected in 67(11%) out of 607 consecutive patients treated with external beam pelvic radiation and brachytherapy boost. The median time to isolated pelvic recurrence was 9 months (range 3-198). Median follow-up time for patients alive after isolated pelvic recurrence was 40 months (range 0.6-183). Of these 67 patients, 28(42%) received salvage surgery, 17(25%) received chemotherapy alone, and 22(33%) received neither surgery nor chemotherapy. The median time to distant failure after isolated pelvic failure was 20 months (95% CI 3-37), with no significant difference between patients treated surgically vs. non-surgically. FDG-avid pelvic and para-aortic nodes at initial presentation were associated with worse distant control after isolated pelvic failure (HR = 3.4, 95% CI 1.0-12). Median OS for patients treated with surgery, chemotherapy alone, and neither surgery nor chemotherapy was 29 months (95% CI 16-41), 12 months (95% CI 3-21), and 3 months (95% CI 1-5), respectively. CONCLUSIONS: Patients who have pelvic and para-aortic nodal disease at initial presentation are at higher risk of failing distantly after isolated pelvic failure, which should be considered when counseling patients on aggressive surgical salvage. Surgical salvage was associated with prolonged survival after isolated pelvic failure.

Impact of tumor histology on detection of pelvic and para-aortic nodal metastasis with 18F-fluorodeoxyglucose-positron emission tomography in stage IB cervical cancer.

OBJECTIVE: 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) detection of metastatic nodal disease is useful for guiding cervical cancer treatment but the impact of tumor histology is unknown. This study reports the detection of FDG avid pelvic and para-aortic lymph nodes in patients with early stage cervical cancer with squamous carcinoma and adenocarcinoma tumor histology. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-2 cervical cancer who underwent pre-surgical FDG-PET between March 1999 and February 2018 were identified in a tertiary academic center database. All patients had radical hysterectomy with pelvic and para-aortic lymph node dissection. Detection of pelvic and para-aortic lymph nodes by FDG-PET versus surgical dissection was compared. FDG-PET sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined and stratified by tumor histology. RESULTS: We identified 212 patients with early stage cervical cancer (84% FIGO IB1, 16% IB2) who underwent pre-surgical FDG-PET; 137 (65%) patients had squamous carcinoma and 75 (35%) patients had adenocarcinoma. PET/computed tomography was performed in 189 (89%) patients and 23 (11%) had PET only. Surgical dissection revealed positive pelvic and para-aortic lymph nodes in 25% and 3.3% of patients, respectively. For squamous carcinoma, sensitivity, specificity, PPV, and NPV of FDG-PET for pelvic nodal metastasis were 44%, 99%, 95%, and 78%, respectively. For adenocarcinoma, the corresponding results for pelvic nodal metastasis were 25%, 99%, 67%, and 92%, respectively. The overall values for sensitivity, specificity, PPV, and NPV of FDG-PET for para-aortic nodal metastasis were 29%, 99%, 67%, and 98%, respectively. DISCUSSION: Pelvic nodal metastasis was less likely to be detected by FDG-PET in patients with early stage adenocarcinoma than with squamous carcinoma.

Impact of concurrent versus adjuvant chemotherapy on the severity and duration of lymphopenia in glioma patients treated with radiation therapy.

Prolonged severe lymphopenia has been shown to persist beyond a year in glioma patients after radiation therapy (RT) with concurrent and adjuvant chemotherapy. This study examines the differential impact of concurrent versus adjuvant chemotherapy on lymphopenia after RT. WHO grade II-III glioma patients who received RT with concurrent and/or adjuvant chemotherapy from 2007 to 2016 were retrospectively analyzed. Concurrent chemotherapy was temozolomide (TMZ), and adjuvant chemotherapy was either TMZ or procarbazine/lomustine/vincristine (PCV). Absolute lymphocyte count (ALC) was analyzed at baseline, 1.5, 3, 6, and 12 months after the start of RT. Univariable and multivariable logistic regression were used to identify the clinical variables in predicting acute or late lymphopenia. There were 151 patients with evaluable ALC: 91 received concurrent and adjuvant TMZ (CRT + ADJ), 32 received only concurrent TMZ (CRT), and 28 received only adjuvant TMZ or PCV (ADJ). There were 9 (10%) versus 6 (19%) versus 0 (0%) cases of grade 3 lymphopenia (ALC < 500/mm3) at 6 weeks and 4 (6%) versus 0 (0%) versus 3 (17%) cases at 12 months in CRT + ADJ, CRT and ADJ groups, respectively. On multivariable analyses, concurrent chemotherapy (odds ratio [OR] 72.3, p < 0.001), female sex (OR 10.8, p < 0.001), and older age (OR 1.06, p = 0.002) were the most significant predictors for any grade ≥ 1 lymphopenia (ALC < 1000/mm3) at 1.5 months. Older age (OR 1.08, p = 0.02) and duration of adjuvant chemotherapy (OR 1.19, p = 0.003) were significantly associated with grade ≥ 1 lymphopenia at 12 months. Thus, concurrent chemotherapy appears as the dominant contributor to the severity of acute lymphopenia after RT in WHO grade II-III glioma patients, and duration of adjuvant chemotherapy appears as the key factor to prolonged lymphopenia.

In vivo optical signatures of neuronal death in a mouse model of Alzheimer's disease.

BACKGROUND: There currently is a need for cost-effective, quantitative techniques to evaluate the gradual progression of Alzheimer's disease (AD). Measurement techniques based on diffuse optical spectroscopy can detect blood perfusion and brain cellular composition changes, through measuring the absorption (µa ) and reduced scattering (µs ') coefficients, respectively, using non-ionizing near-infrared light. Previous work has shown that brain perfusion deficits in an AD mouse model can be detected. The objective of this study was to determine if µs ' is sensitive to the inflammation and neuron death found in AD. METHODS: We used spatial frequency domain imaging (SFDI) to form quantitative maps of µa and µs ' in 3-month old male CaM/Tet-DTA mice harboring transgenes for the doxycyline-regulated neuronal expression of diphtheria toxin. When doxycycline is removed from the diet, CaM/Tet-DTA mice develop progressive neuronal loss in forebrain neurons. Mice (n = 5) were imaged longitudinally immediately prior to and after 23 days of lesion induction, and µa and µs ' (30 wavelengths, 650-970 nm) were compared to properties obtained from Tet-DTA controls (n = 5). Neuron death and infiltration of inflammatory cells in brain cortical slices was confirmed with immunohistochemistry. RESULTS: No significant difference in baseline scattering and absorption were measured between CaM/Tet-DTA mice and controls. After 23 days of lesion induction, brain cortical µs ' was 11-16% higher in the CaM/Tet-DTA mice than in controls (P < 0.03). Longitudinal imaging showed no significant difference in µs ' between the first and 23rd day of imaging in controls. Removing doxycycline from the diet was associated with a significant decrease in total hemoglobin concentrations (119 ± 9 µM vs. 91 ± 8 µM) (P < 0.05) in controls, but not in CaM/Tet-DTA mice. CONCLUSIONS: Neuronal death and brain inflammation are associated with increased tissue scattering (µs ') and this optical biomarker may be useful in pre-clinical AD therapy evaluation or monitoring of disease progression in AD patients.

Engineering Tissue-Scale Properties with Synthetic Cells: Forging One from Many.

In metazoans, living cells achieve capabilities beyond individual cell functionality by assembling into multicellular tissue structures. These higher-order structures represent dynamic, heterogeneous, and responsive systems that have evolved to regenerate and coordinate their actions over large distances. Recent advances in constructing micrometer-sized vesicles, or synthetic cells, now point to a future where construction of synthetic tissue can be pursued, a boon to pressing material needs in biomedical implants, drug delivery systems, adhesives, filters, and storage devices, among others. To fully realize the potential of synthetic tissue, inspiration has been and will continue to be drawn from new molecular findings on its natural counterpart. In this review, we describe advances in introducing tissue-scale features into synthetic cell assemblies. Beyond mere complexation, synthetic cells have been fashioned with a variety of natural and engineered molecular components that serve as initial steps toward morphological control and patterning, intercellular communication, replication, and responsiveness in synthetic tissue. Particular attention has been paid to the dynamics, spatial constraints, and mechanical strengths of interactions that drive the synthesis of this next-generation material, describing how multiple synthetic cells can act as one.

A Rational Approach to Unilateral Neck RT for Head and Neck Cancers in the Era of Immunotherapy.

Radiotherapy plays an important role in the definitive and adjuvant treatment of head and neck squamous cell carcinoma (HNSCC). However, standard courses of radiation therapy may contribute to the depletion of circulating lymphocytes and potentially attenuate optimal tumor antigen presentation that may be detrimental to the efficacy of novel immunotherapeutic agents. This review explores the advantages of restricting radiation to the primary tumor/tumor bed and ipsilateral elective neck as it pertains to the evolving field of immunotherapy.

Standardized Uptake Value for 18F-Fluorodeoxyglucose Is a Marker of Inflammatory State and Immune Infiltrate in Cervical Cancer.

PURPOSE: Chemoradiotherapy for locally advanced cervical cancer fails in over a third of patients. Biomarkers with therapeutic implications are therefore needed. We investigated the relationship between an established prognostic marker, maximum standardized uptake value (SUVmax) on 18F-fluorodeoxyglucose positron emission tomography, and the inflammatory and immune state of cervical cancers. EXPERIMENTAL DESIGN: An SUVmax most prognostic for freedom from progression (FFP) was identified and compared with known prognostic clinical variables in a cohort of 318 patients treated with definitive radiation with prospectively collected clinical data. Gene set enrichment analysis (GSEA) and CIBERSORT of whole-transcriptome data from 68 patients were used to identify biological pathways and immune cell subpopulations associated with high SUVmax. IHC using a tissue microarray (TMA, N = 82) was used to validate the CIBERSORT findings. The impact of macrophages on cervical cancer glucose metabolism was investigated in coculture experiments. RESULTS: SUVmax <11.4 was most prognostic for FFP (P = 0.001). The GSEA showed that high SUVmax is associated with increased gene expression of inflammatory pathways, including JAK/STAT3 signaling. CIBERSORT and CD68 staining of the TMA showed high SUVmax tumors are characterized by a monocyte-predominant immune infiltrate. Coculture of cervical cancer cells with macrophages or macrophage-conditioned media altered glucose uptake, and IL6 and JAK/STAT3 signaling contribute to this effect. CONCLUSIONS: SUVmax is a prognostic marker in cervical cancer that is associated with activation of inflammatory pathways and tumor infiltration of myeloid-derived immune cells, particularly macrophages. Macrophages contribute to changes in cervical cancer glucose metabolism.See related commentary by Williamson et al., p. 4136.

Molecular Imaging for Radiotherapy Planning and Response Assessment for Cervical Cancer.

Positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) leverages imaging contrast from accelerated and aberrant glucose metabolism, which is a hallmark of cancer. FDG-PET is essential for assessing involved lymph nodes and distant metastases for cervical cancer. It is also utilized for target delineation in radiation treatment planning, with investigations into functional bone marrow sparing intensity modulated radiation therapy. Tumor heterogeneity in FDG-uptake is part of a radiomics approach to potentially escalate treatment to radiation-resistant tumors. Standardizing posttreatment PET surveillance could also allow early surgical salvage of recurrent tumors. The future of molecular imaging in cervical cancer will require development of novel PET tracers to personalize treatments based on tumor biology.

Combining stereotactic body radiation therapy with immunotherapy: current data and future directions.

Stereotactic body radiation therapy (SBRT) offers excellent local control of early-stage non-small cell lung cancer (NSCLC), but there currently is a need for tolerable systemic therapy to address regional and distant disease progression. One potential option is immunotherapy, which in metastatic NSCLC has shown promise for sustained disease control in a subset of patients. There is also growing evidence for a clinical synergy between radiation and immunotherapy, with several ongoing trials studying the abscopal effect. This review summarizes the current data in the fast-changing field of immuno-radiation therapy, highlighting updates from recent clinical trials.

Postradiation hypothyroidism in head and neck cancers: A Department of Veterans Affairs single-institution case-control dosimetry study.

We performed a case-control study to characterize the dose-volume relationship and other variables leading to hypothyroidism after head and neck (H&N) cancer radiation therapy (RT) in a homogenous Veterans Affairs (VA) population. All records of patients receiving RT for various H&N cancers at a single VA medical center between 2007 and 2013 (n = 143) were screened for post-RT thyroid stimulating hormone (TSH) levels (n = 77). The thyroid gland was contoured on each slice of the planning computed tomography scan when available (hypothyroid: n = 18; euthyroid > 2 years: n = 16), and dose-volume histograms based on physical dose and biologically equivalent dose (BED) were compared systematically to find the significant dose-volume thresholds that distinguish the patients who developed clinical hypothyroidism. Dosimetric and clinical variables were considered in univariate and multivariate analysis. Preirradiation prevalence of hypothyroidism was 8 of 143 (5.6%). After RT, 36 of 77 (47%) screened patients had abnormally high TSH, of which 22 of 36 (61%) had clinical hypothyroidism after 1.29 ± 0.99 years. The median follow-up durations were 3.3 years and 4.7 years for euthyroid and hypothyroid patients, respectively. Compared with the euthyroid cohort (n = 41), these hypothyroid patients displayed no significant difference in age, gender, primary tumor site, thyroid volume, hypertension, diabetes, or use of chemotherapy, surgery, or intensity-modulated radiation therapy (IMRT). They were more likely to have had stage 3 or 4 cancer than euthyroid patients (86.5% vs 73.2%, p = 0.01). The odds ratios of hypothyroidism for stage 3 + 4 cancers and V50Gy < 75% were 5.0 and 0.2, respectively (p < 0.05). Equivalent BED threshold of V75Gy3 < 75% gave an odds ratio of 0.156 for developing hypothyroidism (p = 0.02). The prevalence of post-RT clinical hypothyroidism was relatively high for patients with H&N cancers and warrants routine surveillance, especially in those with higher stage malignancy. V50Gy < 75% may be a useful guideline to avoid hypothyroidism. We also show BED data which could be used for unconventionally fractionated schemes, and V75Gy3 < 75% may be a useful guideline.

Brachytherapy and survival in small cell cancer of the cervix and uterus.

PURPOSE: Small cell cancer involving the cervix and uterus is considered the same rare disease, but management is controversial and disparate. Patterns of care and outcomes in the United States are unclear. METHODS AND MATERIALS: Clinical data from patients with small cell cancer of the cervix and uterus were abstracted from the National Cancer Database from 2004 to 2014. Patients with missing clinical stage, incomplete followup, or receiving treatment >90 days from diagnosis were excluded. RESULTS: There were 621 cervical and 95 uterine patients with cancer treated from 2004 to 2014. Compared to patients with a cervix primary site, patients with a uterine primary site were older (median age 64 years vs. 47 years), more likely to present with distant metastatic disease (47% vs. 33%), less likely to receive any pelvic radiation (31% vs. 64%), less likely to receive brachytherapy (3% vs. 27%), more likely to have at least a total hysterectomy (58% vs. 28%), and less likely to receive chemotherapy (74% vs. 88%), all p < 0.05. Brachytherapy was associated with improved overall survival (OS) for patients with locally advanced cervical small cell carcinoma (II-IVA, p = 0.03), but only 38% of patients with Stage II-IVA disease received brachytherapy. For the uterine site, hysterectomy (p = 0.001) and external irradiation (p = 0.03) were associated with improved OS in unadjusted Kaplan-Meier analysis, but only chemotherapy and stage were significantly associated with higher OS in multivariable analysis. CONCLUSIONS: Brachytherapy may improve OS for Stage II-IVA small cell cancer of the cervix but appears underutilized. Brachytherapy was not commonly delivered for uterine primaries.

Concurrent chemoradiation for cervical cancer: Comparison of LDR and HDR brachytherapy.

PURPOSE: To compare clinical outcomes between low-dose-rate (LDR) brachytherapy and high-dose-rate (HDR) brachytherapy for cervical cancer patients. METHODS AND MATERIALS: All consecutive newly diagnosed cervical cancer patients undergoing pretreatment 18-fluorodeoxyglucose positron emission tomography imaging and treated with curative-intent definitive chemoradiation from 1997 to 2016 at a U.S. academic center were included. Brachytherapy boost was LDR or HDR 2D treatment planning from 1997 to 2005 and HDR with MR-based 3D planning from 2005 to 2016. Local control (LC), cancer-specific survival (CSS), and late bowel/bladder complications were evaluated. RESULTS: Tumor stages were International Federation of Gynecology and Obstetrics IB1-IIB (n = 457; 75%) and III-IVA (n = 152; 25%). Brachytherapy was LDR for 104 patients and HDR for 505 patients. Concurrent weekly cisplatin was administered to 536 patients (88%). With median followup of 9.4 years, there was no difference in LC (p = 0.24) or CSS (p = 0.50) between LDR and HDR brachytherapy. Cox multivariable regression showed that only International Federation of Gynecology and Obstetrics stage III-IVA (HR=2.4, p = 0.004) was associated with worse LC. A propensity-matched cohort (90 LDR vs. 90 HDR) was created, and the 5-year LC rates were 88% LDR and 82% HDR, p = 0.26; 5-year CSS rates were 66% LDR and 58% HDR, p = 0.19; 5-year grade ≥3 bowel/bladder toxicities were 23% LDR and 16% HDR, p = 0.44. For all patients, the 5-year late toxicity in stage III-IVA patients was higher with LDR 47% vs. HDR 15%, p = 0.03, with no difference in LC, 86% and 75%, respectively (p = 0.09). CONCLUSIONS: There was no difference in LC with either LDR or HDR brachytherapy. The late complication rate was reduced with HDR and 3D-planned brachytherapy compared to LDR and 2D-planned brachytherapy.

A molecular approach combined with American Thyroid Association classification better stratifies recurrence risk of classic histology papillary thyroid cancer.

BACKGROUND: Prognosis among patients with differentiated thyroid cancer is widely variable. Better understanding of biologic subtypes is necessary to stratify patients and improve outcomes. METHODS: In patients diagnosed with classic histology papillary thyroid cancer treated from 1973 to 2009, BRAF V600E mutation status was determined on surgical tumor specimens by restriction fragment length polymorphism analysis. A tissue microarray (TMA) was constructed from tumor specimens in triplicate and stained by immunohistochemistry for RET, phospho-MEK, MAPK(dpERK), PPARγ, and phospho-AKT(pAKT). Stained slides were scored independently and blindly by two investigators and compared to tumor and patient characteristics and outcomes. RESULTS: A total of 231 patients had archived formalin-fixed, paraffin-embedded tumor tissue available and were included on the TMA. Mean age at diagnosis was 44 years (range 6-82 years); proportion of patients with female sex was (72%); 2015 American Thyroid Association (ATA) risk stratification was low (26%), intermediate (32%), and high (42%). BRAF V600E mutation was found in 74% of specimens, and IHC was scored as positive for RET (61%), MAPK (dpERK) (14%), PPARγ (27%), and pAKT (39%). Positive RET staining was associated with a lower risk of recurrence (HR = 0.46, 95% CI 0.22-0.96). No other molecular biomarkers were independent predictors of recurrence on univariable analysis. On RPA, patients with RET-negative and either MAPK(dpERK)-positive or pAKT-positive tumors were identified to have a high risk of recurrence (HR = 5.4, 95%CI 2.5-11.7). This profile remained associated with recurrence in a multivariable model including ATA risk stratification (HR = 2.8, 95% CI 1.3-6.0). CONCLUSION: Characterization of molecular pathways involved in cPTC tumorigenesis may add further risk stratification for recurrence beyond the 2015 ATA risk categories alone.