Impact of quantitative CT texture analysis on the outcome of CT-guided bone biopsy.

Texture analysis can provide new imaging-based biomarkers. Texture analysis derived from computed tomography (CT) might be able to better characterize patients undergoing CT-guided percutaneous bone biopsy. The present study evaluated this and correlated texture features with bioptic outcome in patients undergoing CT-guided bone biopsy. Overall, 123 patients (89 female patients, 72.4 %) were included into the present study. All patients underwent CT-guided percutaneous bone biopsy with an 11 Gauge coaxial needle. Clinical parameters and quantitative imaging features were investigated. Random forest classifier was used to predict a positive biopsy result. Overall, 69 patients had osteolytic metastasis (56.1 %) and 54 had osteoblastic metastasis (43.9 %). The overall positive biopsy rate was 72 %. The developed radiomics model demonstrated a prediction accuracy of a positive biopsy result with an AUC of 0.75 [95 %CI 0.65 - 0.85]. In a subgroup of breast cancer patients, the model achieved an AUC of 0.85 [95 %CI 0.73 - 0.96]. In the subgroup of non-breast cancer patients, the signature achieved an AUC of 0.80 [95 %CI 0.60 - 0.99]. Quantitative CT imaging findings comprised of conventional and texture features can aid to predict the bioptic result of CT-guided bone biopsies. The developed radiomics signature aids in clinical decision-making, and could identify patients at risk for a negative biopsy.

Exploring the relationship between metabolism and immune microenvironment in osteosarcoma based on metabolic pathways.

BACKGROUND: Metabolic remodeling and changes in tumor immune microenvironment (TIME) in osteosarcoma are important factors affecting prognosis and treatment. However, the relationship between metabolism and TIME needs to be further explored. METHODS: RNA-Seq data and clinical information of 84 patients with osteosarcoma from the TARGET database and an independent cohort from the GEO database were included in this study. The activity of seven metabolic super-pathways and immune infiltration levels were inferred in osteosarcoma patients. Metabolism-related genes (MRGs) were identified and different metabolic clusters and MRG-related gene clusters were identified using unsupervised clustering. Then the TIME differences between the different clusters were compared. In addition, an MRGs-based risk model was constructed and the role of a key risk gene, ST3GAL4, in osteosarcoma cells was explored using molecular biological experiments. RESULTS: This study revealed four key metabolic pathways in osteosarcoma, with vitamin and cofactor metabolism being the most relevant to prognosis and to TIME. Two metabolic pathway-related clusters (C1 and C2) were identified, with some differences in immune activating cell infiltration between the two clusters, and C2 was more likely to respond to two chemotherapeutic agents than C1. Three MRG-related gene clusters (GC1-3) were also identified, with significant differences in prognosis among the three clusters. GC2 and GC3 had higher immune cell infiltration than GC1. GC3 is most likely to respond to immune checkpoint blockade and to three commonly used clinical drugs. A metabolism-related risk model was developed and validated. The risk model has strong prognostic predictive power and the low-risk group has a higher level of immune infiltration than the high-risk group. Knockdown of ST3GAL4 significantly inhibited proliferation, migration, invasion and glycolysis of osteosarcoma cells and inhibited the M2 polarization of macrophages. CONCLUSION: The metabolism of vitamins and cofactors is an important prognostic regulator of TIME in osteosarcoma, MRG-related gene clusters can well reflect changes in osteosarcoma TIME and predict chemotherapy and immunotherapy response. The metabolism-related risk model may serve as a useful prognostic predictor. ST3GAL4 plays a critical role in the progression, glycolysis, and TIME of osteosarcoma cells.

The validity of the distress thermometer in patients with musculoskeletal tumors.

Background: Visits to an outpatient cancer clinic represent a challenging situation for patients, which can trigger anxiety and helplessness in those affected. It is important to identify patients with high psychological distress as early as possible in order to provide them with supportive psychological interventions. The aim of this study was to validate the Distress Thermometer (DT), a widely used screening for distress, in a cohort of patients with musculoskeletal tumors and to explore associations between distress, treatment satisfaction and health literacy. Methods: All patients presenting to a University outpatient clinic for musculoskeletal cancers were asked to complete a set of questionnaires including the DT), the Hospital Anxiety and Depression Scale (HADS) as a comparison scale, the Patient Satisfaction with Comprehensive Cancer Care (SCCC) and European Health Literacy Survey Questionnaire (HLS-EU-Q16).To assess the sensitivity and specificity of the DT in a cohort of patients with musculoskeletal tumors, we compare the performance of the DT in relation to an established screener for anxiety and depression using receiver operating characteristics (ROC) analyses. Results: A total of 120 patients (age 58 ± 18, 51% female) were analyzed. Patients reported a mean DT of 5.0 (SD 2.3, range, 0 to 10). Eighty-six patients (71.7 %) had a DT score ≥ 5 indicating moderate or severe psychological distress.The mean total HADS score (scale 0 to42 points) was 11.7 (SD 7.6, range, 0 to 32) with a HADS score of ≥ 15 in 29.2% of patients. The DT correlated moderately with anxiety and depression (HADS total r = 0.48, p < 0.001), while the correlation with depression (HADS-D, r = 0.47, p < 0.001) was stronger than with anxiety (HADS-A, r = 0.38, p < 0.001).For a DT score ≥ 5, ROC analysis yielded a sensitivity of 71.4% and a specificity of 75.3% for detecting moderate or severe psychological distress (HADS ≥ 15, AUC 0.782).The REPERES-G, collected from a subgroup (n = 49), showed high treatment satisfaction with a median score of 132 (min 90, max 163). Especially the "satisfaction with medical aspects of treatment" (REPERES-G medical aspects) showed a moderate correlation with the DT (r = 0.51, p < 0.001) a strong correlation with anxiety and depression (HADS total, r = 0.69, p < 0.001). Conclusion: About three in four patients with musculoskeletal tumors have relevant psychological distress. A visual analogue scale can only be a rough guide for identifying patients in need of psychological support, with a sensitivity of 71.4 % and a specificity of 75.3 %. A strong relationship between patient and care team was associated with lower patient psychological distress.Consequently, screening tools cannot replace detailed discussion and personal contact, especially in the treatment of malignant diseases.

Virtual versus in-person multidisciplinary musculoskeletal tumor conferences in times of COVID-19.

Introduction: Multidisciplinary tumor conferences are a fundamental component in the treatment of oncological patients. The COVID-19 pandemic and its resulting social distancing restrictions offered the opportunity to compare in-person to virtual multidisciplinary tumor conferences. Methods: Retrospective analysis of first-time presentations in tumor conferences at a university musculoskeletal tumor center in the time periods from September 2019 to February 2020 (in-person) and May 2020 to October 2020 (virtual). Results: A total of 209 patients were first-time discussed in one of 52 analyzed musculoskeletal multidisciplinary tumor conferences (105 patients in 25 in-person, and 104 patients 27 virtual meetings). The total number of participants was slightly lower with virtual meetings (p < .001) and more disciplines were represented in virtual tumor conferences (p < .001). With median six consultants present in either, the level of available expertise did not differ between the conference formats (p = .606). Compared to in-person tumor meetings, the patients were discussed earlier in the virtual conferences (p = .028). The interval between first presentation to biopsy was significantly shorter after virtual tumor conferences (median 4 vs. 7 days, p < .001). There was no significant difference in the interval between initial presentation and resection (p = .544) among the two conference formats. Conclusions: The implementation of virtual tumor conferences appears to have had a positive effect on timely diagnosis and multidisciplinarity during tumor conferences. This may result in better decision-making and treatment of patients with musculoskeletal tumors and could be routinely implemented into cancer care.

A tumor microenvironment-based prognostic index for osteosarcoma.

BACKGROUND: The tumor microenvironment (TME) has a central role in the oncogenesis of osteosarcomas. The composition of the TME is essential for the interaction between tumor and immune cells. The aim of this study was to establish a prognostic index (TMEindex) for osteosarcoma based on the TME, from which estimates about patient survival and individual response to immune checkpoint inhibitor (ICI) therapy can be deduced. METHODS: Based on osteosarcoma samples from the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) database, the ESTIMATE algorithm was used to estimate ImmuneScore and StromalScore. Combined differentially expressed gene analysis, weighted gene co-expression network analyses, the Least Absolute Shrinkage and Selection Operator regression and stepwise regression to construct the TMEindex. The prognostic role of TMEindex was validated in three independent datasets. The molecular and immune characteristics of TMEindex and the impact on immunotherapy were then comprehensively investigated. The expression of TMEindex genes in different cell types and its effects on osteosarcoma cells were explored by scRNA-Seq analysis and molecular biology experiments. RESULTS: Fundamental is the expression of MYC, P4HA1, RAMP1 and TAC4. Patients with high TMEindex had worse overall survival, recurrence-free survival, and metastasis-free survival. TMEindex is an independent prognostic factor in osteosarcoma. TMEindex genes were mainly expressed in malignant cells. The knockdown of MYC and P4HA1 significantly inhibited the proliferation, invasion and migration of osteosarcoma cells. A high TME index is related to the MYC, mTOR, and DNA replication-related pathways. In contrast, a low TME index is related to immune-related signaling pathways such as the inflammatory response. The TMEindex was negatively correlated with ImmuneScore, StromalScore, immune cell infiltration, and various immune-related signature scores. Patients with a higher TMEindex had an immune-cold TME and higher invasiveness. Patients with a low TME index were more likely to respond to ICI therapy and achieve clinical benefit. In addition, the TME index correlated with response to 29 oncologic drugs. CONCLUSIONS: The TMEindex is a promising biomarker to predict the prognosis of patients with osteosarcoma and their response to ICI therapy, and to distinguish the molecular and immune characteristics.

[Multimodal treatment of localized high-grade soft tissue sarcomas of the extremities : Summary and discussion of the current S3 guidelines on adult soft tissue sarcomas and the ESMO guidelines on soft tissue and visceral sarcomas]. / Multimodale Therapie der lokalisierten High-grade-Weichgewebesarkome der Extremitäten : Zusammenfassung und Diskussion der aktuellen S3-Leitlinie "Adulte Weichgewebesarkome" und der ESMO-Guideline "Soft tissue and visceral sarcomas".

Soft tissue sarcomas are rare, heterogeneous tumors that are frequently in the extremities. Treatment includes surgical resection, combination chemotherapy and/or radiotherapy, as well as supplementary procedures such as isolated limb perfusion and regional deep hyperthermia. The prognosis depends on the tumor stage and the approximately 70 histological subtypes, with specific treatment approaches existing only for some subtypes. This review summarizes the recommendations of the German S3 guideline "Adult Soft Tissue Sarcomas" and the European Society for Medical Oncology (ESMO) guideline "Soft tissue and visceral sarcomas" regarding the diagnostic workup and therapy of soft tissue sarcomas of the extremities.

PLOD Family: A Novel Biomarker for Prognosis and Personalized Treatment in Soft Tissue Sarcoma.

Despite various treatment attempts, the heterogenous group of soft tissue sarcomata (STS) with more than 100 subtypes still shows poor outcomes. Therefore, effective biomarkers for prognosis prediction and personalized treatment are of high importance. The Procollagen-Lysine, 2-Oxoglutarate 5-Dioxygenase (PLOD) gene family, which is related to multiple cancer entities, consists of three members which encode important enzymes for the formation of connective tissue. The relation to STS, however, has not yet been explored. In this study, data from The Cancer Genome Atlas (TCGA) and Genotype-Tissue Expression (GTEx) databases were used to analyze the role of PLOD1-3 in STS. It was found that an overexpression of PLOD family members correlates with poor prognosis, which might be due to an increased infiltration of immune-related cells in the tumor microenvironment. In STS, the expression of PLOD genes could be a novel biomarker for prognosis and a personalized, more aggressive treatment in these patients.

Procollagen-Lysine, 2-Oxoglutarate 5-Dioxygenase Family: Novel Prognostic Biomarkers and Tumor Microenvironment Regulators for Lower-Grade Glioma.

Lower-grade glioma (LGG) is a group of tumors arising from the cells of the central nervous system. Although various therapy interventions are used, the prognosis remains different. Novel biomarkers are needed for the prognosis of disease and novel therapeutic strategies in LGG. The procollagen-lysine, 2-oxoglutarate 5-dioxygenase (PLOD) family contains three members and is related to multiple cancers, yet it was not investigated in LGG. Data from the Chinese Glioma Genome Atlas (CGGA) and The Cancer Genome Atlas (TCGA) cohorts were used to analyze the role of PLOD in LGG. As the PLOD family is involved in processes, such as tumor formation and cancer metastasis, we focused on its relationship to the tumor microenvironment (TME) in LGG. A high expression of the PLOD family relates to poor prognosis and high infiltration of immune cells within the TME. The expression level of the PLOD family might become a novel biomarker for prognosis and is a potential target for individual treatment decisions in LGG.

Identification of Tumor Antigens and Immune Subtypes for the Development of mRNA Vaccines and Individualized Immunotherapy in Soft Tissue Sarcoma.

Soft tissue sarcomas (STS) are a rare disease with high recurrence rates and poor prognosis. Missing therapy options together with the high heterogeneity of this tumor type gives impetus to the development of individualized treatment approaches. This study identifies potential tumor antigens for the development of mRNA tumor vaccines for STS and explores potential immune subtypes, stratifying patients for immunotherapy. RNA-sequencing data and clinical information were extracted from 189 STS samples from The Cancer Genome Atlas (TCGA) and microarray data were extracted from 103 STS samples from the Gene Expression Omnibus (GEO). Potential tumor antigens were identified using cBioportal, the Oncomine database, and prognostic analyses. Consensus clustering was used to define immune subtypes and immune gene modules, and graph learning-based dimensionality reduction analysis was used to depict the immune landscape. Finally, four potential tumor antigens were identified, each related to prognosis and antigen-presenting cell infiltration in STS: HLTF, ITGA10, PLCG1, and TTC3. Six immune subtypes and six gene modules were defined and validated in an independent cohort. The different immune subtypes have different molecular, cellular, and clinical characteristics. The immune landscape of STS reveals the immunity-related distribution of patients and intra-cluster heterogeneity of immune subtypes. This study provides a theoretical framework for STS mRNA vaccine development and the selection of patients for vaccination, and provides a reference for promoting individualized immunotherapy.

A Novel Four-Gene Prognostic Signature for Prediction of Survival in Patients with Soft Tissue Sarcoma.

Soft tissue sarcomas (STS), a group of rare malignant tumours with high tissue heterogeneity, still lack effective clinical stratification and prognostic models. Therefore, we conducted this study to establish a reliable prognostic gene signature. Using 189 STS patients' data from The Cancer Genome Atlas database, a four-gene signature including DHRS3, JRK, TARDBP and TTC3 was established. A risk score based on this gene signature was able to divide STS patients into a low-risk and a high-risk group. The latter had significantly worse overall survival (OS) and relapse free survival (RFS), and Cox regression analyses showed that the risk score is an independent prognostic factor. Nomograms containing the four-gene signature have also been established and have been verified through calibration curves. In addition, the predictive ability of this four-gene signature for STS metastasis free survival was verified in an independent cohort (309 STS patients from the Gene Expression Omnibus database). Finally, Gene Set Enrichment Analysis indicated that the four-gene signature may be related to some pathways associated with tumorigenesis, growth, and metastasis. In conclusion, our study establishes a novel four-gene signature and clinically feasible nomograms to predict the OS and RFS. This can help personalized treatment decisions, long-term patient management, and possible future development of targeted therapy.

A Human Pan-Cancer System Analysis of Procollagen-Lysine, 2-Oxoglutarate 5-Dioxygenase 3 (PLOD3).

The overexpression of the enzymes involved in the degradation of procollagen lysine is correlated with various tumor entities. Procollagen-lysine, 2-oxoglutarate 5-dioxygenase 3 (PLOD3) expression was found to be correlated to the progression and migration of cancer cells in gastric, lung and prostate cancer. Here, we analyzed the gene expression, protein expression, and the clinical parameters of survival across 33 cancers based on the Clinical Proteomic Tumor Analysis Consortium (CPTAC), function annotation of the mammalian genome 5 (FANTOM5), Gene Expression Omnibus (GEO), Genotype-Tissue Expression (GTEx), Human Protein Atlas (HPA) and The Cancer Genome Atlas (TCGA) databases. Genetic alteration, immune infiltration and relevant cellular pathways were analyzed in detail. PLOD3 expression negatively correlated with survival periods and the infiltration level of CD8+ T cells, but positively correlated to the infiltration of cancer associated fibroblasts in diverse cancers. Immunohistochemistry in colon carcinomas, glioblastomas, and soft tissue sarcomas further confirm PLOD 3 expression in human cancer tissue. Moreover, amplification and mutation accounted for the largest proportion in esophageal adenocarcinoma and uterine corpus endometrial carcinoma, respectively; the copy number alteration of PLOD3 appeared in all cancers from TCGA; and molecular mechanisms further proved the effect of PLOD3 on tumorigenesis. In particular, PLOD3 expression appears to have a tumor immunological effect, and is related to multiple immune cells. Furthermore, it is also associated with tumor mutation burden and microsatellite instability in various tumors. PLOD3 acts as an inducer of various cancers, and it could be a potential biomarker for prognosis and targeted treatment.

Integrative and Comprehensive Pancancer Analysis of Regulator of Chromatin Condensation 1 (RCC1).

Regulator of Chromatin Condensation 1 (RCC1) is the only known guanine nucleotide exchange factor that acts on the Ras-like G protein Ran and plays a key role in cell cycle regulation. Although there is growing evidence to support the relationship between RCC1 and cancer, detailed pancancer analyses have not yet been performed. In this genome database study, based on The Cancer Genome Atlas, Genotype-Tissue Expression and Gene Expression Omnibus databases, the potential role of RCC1 in 33 tumors' entities was explored. The results show that RCC1 is highly expressed in most human malignant neoplasms in contrast to healthy tissues. RCC1 expression is closely related to the prognosis of a broad variety of tumor patients. Enrichment analysis showed that some tumor-related pathways such as "cell cycle" and "RNA transport" were involved in the functional mechanism of RCC1. In particular, the conducted analysis reveals the relation of RCC1 to multiple immune checkpoint genes and suggests that the regulation of RCC1 is closely related to tumor infiltration of cancer-associated fibroblasts and CD8+ T cells. Coherent data demonstrate the association of RCC1 with the tumor mutation burden and microsatellite instability in various tumors. These findings provide new insights into the role of RCC1 in oncogenesis and tumor immunology in various tumors and indicate its potential as marker for therapy prognosis and targeted treatment strategies.

Examination of ex-vivo viability of human adipose tissue slice culture.

Obesity is associated with significantly higher mortality rates, and excess adipose tissue is involved in respective pathologies. Here we established a human adipose tissue slice cultures (HATSC) model ex vivo. HATSC match the in vivo cell composition of human adipose tissue with, among others, mature adipocytes, mesenchymal stem cells as well as stroma tissue and immune cells. This is a new method, optimized for live imaging, to study adipose tissue and cell-based mechanisms of obesity in particular. HATSC survival was tested by means of conventional and immunofluorescence histological techniques, functional analyses and live imaging. Surgery-derived tissue was cut with a tissue chopper in 500 µm sections and transferred onto membranes building an air-liquid interface. HATSC were cultured in six-well plates filled with Dulbecco's Modified Eagle's Medium (DMEM), insulin, transferrin, and selenium, both with and without serum. After 0, 1, 7 and 14 days in vitro, slices were fixated and analyzed by morphology and Perilipin A for tissue viability. Immunofluorescent staining against IBA1, CD68 and Ki67 was performed to determine macrophage survival and proliferation. These experiments showed preservation of adipose tissue as well as survival and proliferation of monocytes and stroma tissue for at least 14 days in vitro even in the absence of serum. The physiological capabilities of adipocytes were functionally tested by insulin stimulation and measurement of Phospho-Akt on day 7 and 14 in vitro. Viability was further confirmed by live imaging using Calcein-AM (viable cells) and propidium iodide (apoptosis/necrosis). In conclusion, HATSC have been successfully established by preserving the monovacuolar form of adipocytes and surrounding macrophages and connective tissue. This model allows further analysis of mature human adipose tissue biology ex vivo.

[Generation Y in surgery-the competition battle for talent in times of talent shortage]. / Generation Y in der Chirurgie ­ der Konkurrenzkampf um Talente in Zeiten des Nachwuchsmangels.

BACKGROUND: Surgical disciplines are fighting with a critical and escalating shortage of recruits. Potential young professionals belong to the Generation Y, a generation that is constantly challenging senior consultants and human resources departments. The aim of this study was the analysis of various measures of personnel acquisition with respect to motivating factors of young medical students. MATERIAL AND METHODS: A survey was carried out among students of the first and ninth semesters of a medical faculty on individual motivating factors, aspiration for medical specialist training and professional experience gained in surgery. RESULTS: Results from 179 out of 269 medical students were available for analysis (66.5% response rate). The interest in a specialist training in surgery was high in the first semester of medical school (21%) but dropped noticeably up to the ninth semester (13%, p = 0.23). Medical students in the ninth semester, who favored professional advancement and appreciation over flexible working hours showed a significantly higher interest in a specialist training in surgery (p = 0.022). Surgical experience gained was valued with an average grade of 2+ (1 = best, 6 = worst). CONCLUSION: The high fundamental interest in a surgical residency during the beginning of medical studies is a competitive advantage of surgical disciplines; however, the diverse recruiting efforts are mainly aimed at later stages of studies. Timely hands-on courses in the core working area of surgery, the operating theatre, have proven to be particularly successful for the long-term acquisition and retention of junior doctors.

Texture analysis parameters derived from T1-and T2-weighted magnetic resonance images can reflect Ki67 index in soft tissue sarcoma.

BACKGROUND AND OBJECTIVES: Texture analysis derived from morphological magnetic resonance (MR) images might be associated with histopathology in tumors. The present study sought to elucidate possible associations between texture features derived from T1-and T2-weighted images with proliferation index Ki67 in soft tissue sarcomas. METHODS: Overall, 29 patients (n = 13, 44.8% female) with a median age of 52 years were included into this retrospective study. Several soft tissue sarcomas were investigated. Texture analysis was performed on pre-contrast T1-weighted and T2-weighted images using the free available Mazda software. RESULTS: The best correlation coefficients with Ki67 index were identified for the following parameters: T1-weighted images "45dgr_RLNonUni (p = 0.50, P = 0.006), T2-weighted images "S (4,0)SumAverg" (p = -0.45, P = 0.02). A ROC analysis was performed for Ki67-index with a threshold of 10%. The highest area under the curve (AUC) was found for the parameter "T1_WavEnHL_s-7" with an AUC of 0.90. For the threshold of Ki67 = 20% the highest AUC was identified for the parameter "T2_S (1,1)Entropy" with an AUC of 0.77. CONCLUSION: Several texture features derived from T1-and T2-weighted images correlated with proliferation index Ki67 and might be used as valuable novel biomarkers in soft tissue sarcomas.

Adeno-Associated Viral Vectors Transduce Mature Human Adipocytes in Three-Dimensional Slice Cultures.

Adipose tissue plays a pivotal role, both in the regulation of energy homeostasis and as an endocrine organ. Consequently, adipose tissue dysfunction is closely related to insulin resistance, morbid obesity, and metabolic syndrome. To study molecular mechanisms and to develop novel therapeutic strategies, techniques are required to genetically modify mature adipocytes. Here, we report on adeno-associated viral (AAV) vectors as a versatile tool to transduce human mature adipocytes in organotypic three-dimensional tissue cultures.

Organotypic slice cultures of human gastric and esophagogastric junction cancer.

Gastric and esophagogastric junction cancers are heterogeneous and aggressive tumors with an unpredictable response to cytotoxic treatment. New methods allowing for the analysis of drug resistance are needed. Here, we describe a novel technique by which human tumor specimens can be cultured ex vivo, preserving parts of the natural cancer microenvironment. Using a tissue chopper, fresh surgical tissue samples were cut in 400 µm slices and cultivated in 6-well plates for up to 6 days. The slices were processed for routine histopathology and immunohistochemistry. Cytokeratin stains (CK8, AE1/3) were applied for determining tumor cellularity, Ki-67 for proliferation, and cleaved caspase-3 staining for apoptosis. The slices were analyzed under naive conditions and following 2-4 days in vitro exposure to 5-FU and cisplatin. The slice culture technology allowed for a good preservation of tissue morphology and tumor cell integrity during the culture period. After chemotherapy exposure, a loss of tumor cellularity and an increase in apoptosis were observed. Drug sensitivity of the tumors could be assessed. Organotypic slice cultures of gastric and esophagogastric junction cancers were successfully established. Cytotoxic drug effects could be monitored. They may be used to examine mechanisms of drug resistance in human tissue and may provide a unique and powerful ex vivo platform for the prediction of treatment response.