The state of the art for artificial intelligence in lung digital pathology.

Lung diseases carry a significant burden of morbidity and mortality worldwide. The advent of digital pathology (DP) and an increase in computational power have led to the development of artificial intelligence (AI)-based tools that can assist pathologists and pulmonologists in improving clinical workflow and patient management. While previous works have explored the advances in computational approaches for breast, prostate, and head and neck cancers, there has been a growing interest in applying these technologies to lung diseases as well. The application of AI tools on radiology images for better characterization of indeterminate lung nodules, fibrotic lung disease, and lung cancer risk stratification has been well documented. In this article, we discuss methodologies used to build AI tools in lung DP, describing the various hand-crafted and deep learning-based unsupervised feature approaches. Next, we review AI tools across a wide spectrum of lung diseases including cancer, tuberculosis, idiopathic pulmonary fibrosis, and COVID-19. We discuss the utility of novel imaging biomarkers for different types of clinical problems including quantification of biomarkers like PD-L1, lung disease diagnosis, risk stratification, and prediction of response to treatments such as immune checkpoint inhibitors. We also look briefly at some emerging applications of AI tools in lung DP such as multimodal data analysis, 3D pathology, and transplant rejection. Lastly, we discuss the future of DP-based AI tools, describing the challenges with regulatory approval, developing reimbursement models, planning clinical deployment, and addressing AI biases. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Development and evaluation of deep learning-based segmentation of histologic structures in the kidney cortex with multiple histologic stains.

The application of deep learning for automated segmentation (delineation of boundaries) of histologic primitives (structures) from whole slide images can facilitate the establishment of novel protocols for kidney biopsy assessment. Here, we developed and validated deep learning networks for the segmentation of histologic structures on kidney biopsies and nephrectomies. For development, we examined 125 biopsies for Minimal Change Disease collected across 29 NEPTUNE enrolling centers along with 459 whole slide images stained with Hematoxylin & Eosin (125), Periodic Acid Schiff (125), Silver (102), and Trichrome (107) divided into training, validation and testing sets (ratio 6:1:3). Histologic structures were manually segmented (30048 total annotations) by five nephropathologists. Twenty deep learning models were trained with optimal digital magnification across the structures and stains. Periodic Acid Schiff-stained whole slide images yielded the best concordance between pathologists and deep learning segmentation across all structures (F-scores: 0.93 for glomerular tufts, 0.94 for glomerular tuft plus Bowman's capsule, 0.91 for proximal tubules, 0.93 for distal tubular segments, 0.81 for peritubular capillaries, and 0.85 for arteries and afferent arterioles). Optimal digital magnifications were 5X for glomerular tuft/tuft plus Bowman's capsule, 10X for proximal/distal tubule, arteries and afferent arterioles, and 40X for peritubular capillaries. Silver stained whole slide images yielded the worst deep learning performance. Thus, this largest study to date adapted deep learning for the segmentation of kidney histologic structures across multiple stains and pathology laboratories. All data used for training and testing and a detailed online tutorial will be publicly available.

Middle ear promontory osteoma.

Osteomas are benign lesions of the lamellar bone that within the temporal region are common in the external ear canal. Osteomas of the middle ear are extremely rare and until now there are only 14 reported cases. They usually present with conductive hearing loss while others are asymptomatic and diagnosed incidentally.

A Review of AI-Based Radiomics and Computational Pathology Approaches in Triple-Negative Breast Cancer: Current Applications and Perspectives.

Breast cancer is one of the most common and deadly cancers worldwide. Approximately, 20% of all breast cancers are characterized as triple negative (TNBC). TNBC typically is associated with a poorer prognosis relative to other breast cancer subtypes. Due to its aggressiveness and lack of response to hormonal therapy, conventional cytotoxic chemotherapy is the usual treatment; however, this treatment is not always effective, and an important percentage of patients develop recurrence. More recently, immunotherapy has started to be used on some populations with TNBC showing promising results. Unfortunately, immunotherapy is only applicable to a minority of patients and responses in metastatic TNBC have overall been modest in comparison to other cancer types. This situation evidences the need for developing effective biomarkers that help to stratify and personalize patient management. Thanks to recent advances in artificial intelligence (AI), there has been an increasing interest in its use for medical applications aiming at supporting clinical decision making. Several works have used AI in combination with diagnostic medical imaging, more specifically radiology and digitized histopathological tissue samples, aiming to extract disease-specific information that is difficult to quantify by the human eye. These works have demonstrated that analysis of such images in the context of TNBC has great potential for (1) risk-stratifying patients to identify those patients who are more likely to experience disease recurrence or die from the disease and (2) predicting pathologic complete response. In this manuscript, we present an overview on AI and its integration with radiology and histopathological images for developing prognostic and predictive approaches for TNBC. We present state of the art approaches in the literature and discuss the opportunities and challenges with developing AI algorithms regarding further development and clinical deployment, including identifying those patients who may benefit from certain treatments (e.g., adjuvant chemotherapy) from those who may not and thereby should be directed toward other therapies, discovering potential differences between populations, and identifying disease subtypes.

Computational pathology improves risk stratification of a multi-gene assay for early stage ER+ breast cancer.

Prognostic markers currently utilized in clinical practice for estrogen receptor-positive (ER+) and lymph node-negative (LN-) invasive breast cancer (IBC) patients include the Nottingham grading system and Oncotype Dx (ODx). However, these biomarkers are not always optimal and remain subject to inter-/intra-observer variability and high cost. In this study, we evaluated the association between computationally derived image features from H&E images and disease-free survival (DFS) in ER+ and LN- IBC. H&E images from a total of n = 321 patients with ER+ and LN- IBC from three cohorts were employed for this study (Training set: D1 (n = 116), Validation sets: D2 (n = 121) and D3 (n = 84)). A total of 343 features relating to nuclear morphology, mitotic activity, and tubule formation were computationally extracted from each slide image. A Cox regression model (IbRiS) was trained to identify significant predictors of DFS and predict a high/low-risk category using D1 and was validated on independent testing sets D2 and D3 as well as within each ODx risk category. IbRiS was significantly prognostic of DFS with a hazard ratio (HR) of 2.33 (95% confidence interval (95% CI) = 1.02-5.32, p = 0.045) on D2 and a HR of 2.94 (95% CI = 1.18-7.35, p = 0.0208) on D3. In addition, IbRiS yielded significant risk stratification within high ODx risk categories (D1 + D2: HR = 10.35, 95% CI = 1.20-89.18, p = 0.0106; D1: p = 0.0238; D2: p = 0.0389), potentially providing more granular risk stratification than offered by ODx alone.

Deep computational image analysis of immune cell niches reveals treatment-specific outcome associations in lung cancer.

The tumor immune composition influences prognosis and treatment sensitivity in lung cancer. The presence of effective adaptive immune responses is associated with increased clinical benefit after immune checkpoint blockers. Conversely, immunotherapy resistance can occur as a consequence of local T-cell exhaustion/dysfunction and upregulation of immunosuppressive signals and regulatory cells. Consequently, merely measuring the amount of tumor-infiltrating lymphocytes (TILs) may not accurately reflect the complexity of tumor-immune interactions and T-cell functional states and may not be valuable as a treatment-specific biomarker. In this work, we investigate an immune-related biomarker (PhenoTIL) and its value in associating with treatment-specific outcomes in non-small cell lung cancer (NSCLC). PhenoTIL is a novel computational pathology approach that uses machine learning to capture spatial interplay and infer functional features of immune cell niches associated with tumor rejection and patient outcomes. PhenoTIL's advantage is the computational characterization of the tumor immune microenvironment extracted from H&E-stained preparations. Association with clinical outcome and major non-small cell lung cancer (NSCLC) histology variants was studied in baseline tumor specimens from 1,774 lung cancer patients treated with immunotherapy and/or chemotherapy, including the clinical trial Checkmate 057 (NCT01673867).

Computational image features of immune architecture is associated with clinical benefit and survival in gynecological cancers across treatment modalities.

BACKGROUND: We present a computational approach (ArcTIL) for quantitative characterization of the architecture of tumor-infiltrating lymphocytes (TILs) and their interplay with cancer cells from digitized H&E-stained histology whole slide images and evaluate its prognostic role in three different gynecological cancer (GC) types and across three different treatment types (platinum, radiation and immunotherapy). METHODS: In this retrospective study, we included 926 patients with GC diagnosed with ovarian cancer (OC), cervical cancer, and endometrial cancer with available digitized diagnostic histology slides and survival outcome information. ArcTIL features quantifying architecture and spatial interplay between immune cells and the rest of nucleated cells (mostly comprised cancer cells) were extracted from the cell cluster graphs of nuclei within the tumor epithelial nests, surrounding stroma and invasive tumor front compartments on H&E-stained slides. A Cox proportional hazards model, incorporating ArcTIL features was fit on the OC training cohort (N=51), yielding an ArcTIL signature. A unique threshold learned from the training set stratified the patients into a low and high-risk group. RESULTS: The seven feature ArcTIL classifier was found to significantly correlate with overall survival in chemotherapy and radiotherapy-treated validation cohorts and progression-free survival in an immunotherapy-treated validation cohort. ArcTIL features relating to increased density of TILs in the epithelium and invasive tumor front were found to be associated with better survival outcomes when compared with those patients with an increased TIL density in the stroma. A statistically significant association was found between the ArcTIL signature and signaling pathways for blood vessel morphogenesis, vasculature development, regulation of cell differentiation, cell-substrate adhesion, biological adhesion, regulation of vasculature development, and angiogenesis. CONCLUSIONS: This study reveals that computationally-derived features from the spatial architecture of TILs and tumor cells are prognostic in GCs treated with chemotherapy, radiotherapy, and checkpoint blockade and are closely associated with central biological processes that impact tumor progression. These findings could aid in identifying therapy-refractory patients and further enable personalized treatment decision-making.

A machine learning model for separating epithelial and stromal regions in oral cavity squamous cell carcinomas using H&E-stained histology images: A multi-center, retrospective study.

OBJECTIVE: Tissue slides from Oral cavity squamous cell carcinoma (OC-SCC), particularly the epithelial regions, hold morphologic features that are both diagnostic and prognostic. Yet, previously developed approaches for automated epithelium segmentation in OC-SCC have not been independently tested in a multi-center setting. In this study, we aimed to investigate the effectiveness and applicability of a convolutional neural network (CNN) model to perform epithelial segmentation using digitized H&E-stained diagnostic slides from OC-SCC patients in a multi-center setting. METHODS: A CNN model was developed to segment the epithelial regions of digitized slides (n = 810), retrospectively collected from five different centers. Deep learning models were trained and validated using well-annotated tissue microarray (TMA) images (n = 212) at various magnifications. The best performing model was locked down and used for independent testing with a total of 478 whole-slide images (WSIs). Manually annotated epithelial regions were used as the reference standard for evaluation. We also compared the model generated results with IHC-stained epithelium (n = 120) as the reference. RESULTS: The locked-down CNN model trained on the TMA image training cohorts with 10x magnification achieved the best segmentation performance. The locked-down model performed consistently and yielded Pixel Accuracy, Recall Rate, Precision Rate, and Dice Coefficient that ranged from 95.8% to 96.6%, 79.1% to 93.8%, 85.7% to 89.3%, and 82.3% to 89.0%, respectively for the three independent testing WSI cohorts. CONCLUSION: The automated model achieved a consistently accurate performance for automated epithelial region segmentation compared to manual annotations. This model could be integrated into a computer-aided diagnosis or prognosis system.

Tissue Selection for PD-L1 Testing in Triple Negative Breast Cancer (TNBC).

Atezolizumab in combination with nab-paclitaxel has been introduced for the treatment of locally advanced or recurrent triple negative breast cancer (TNBC). Patient selection relies on the use of immunohistochemistry using a specific monoclonal PD-L1 antibody (clone SP142) in a tightly controlled companion diagnostic test (CDx) with a defined interpretative algorithm. Currently there are no standardized recommendations for selecting the optimal tissue to be tested and there is limited data to support decision making, raising the possibility that tissue selection may bias test results. We compared PD-L1 SP142 assessment in a collection of 73 TNBC cases with matched core biopsies and excision samples. There was good correlation between PD-L1-positive core biopsy and subsequent excision, but we found considerable discrepancy between PD-L1 negative core biopsy and matched excision, with a third of cases found negative on core biopsies converting to positive upon examination of the excision tissue. In view of these findings, we developed a workflow for the clinical testing of TNBC for PD-L1 and implemented it in a central referral laboratory. We present audit data from the clinical PD-L1 testing relating to 2 years of activities, indicating that implementation of this workflow results in positivity rates in our population of TNBC similar to those of IMpassion130 clinical trial. We also developed an online atlas with a precise numerical annotation to aid pathologists in the interpretation of PD-L1 scoring in TNBC.

Image analysis reveals molecularly distinct patterns of TILs in NSCLC associated with treatment outcome.

Despite known histological, biological, and clinical differences between lung adenocarcinoma (LUAD) and squamous cell carcinoma (LUSC), relatively little is known about the spatial differences in their corresponding immune contextures. Our study of over 1000 LUAD and LUSC tumors revealed that computationally derived patterns of tumor-infiltrating lymphocytes (TILs) on H&E images were different between LUAD (N = 421) and LUSC (N = 438), with TIL density being prognostic of overall survival in LUAD and spatial arrangement being more prognostically relevant in LUSC. In addition, the LUAD-specific TIL signature was associated with OS in an external validation set of 100 NSCLC treated with more than six different neoadjuvant chemotherapy regimens, and predictive of response to therapy in the clinical trial CA209-057 (n = 303). In LUAD, the prognostic TIL signature was primarily comprised of CD4+ T and CD8+ T cells, whereas in LUSC, the immune patterns were comprised of CD4+ T, CD8+ T, and CD20+ B cells. In both subtypes, prognostic TIL features were associated with transcriptomics-derived immune scores and biological pathways implicated in immune recognition, response, and evasion. Our results suggest the need for histologic subtype-specific TIL-based models for stratifying survival risk and predicting response to therapy. Our findings suggest that predictive models for response to therapy will need to account for the unique morphologic and molecular immune patterns as a function of histologic subtype of NSCLC.

An Imaging Biomarker of Tumor-Infiltrating Lymphocytes to Risk-Stratify Patients With HPV-Associated Oropharyngeal Cancer.

BACKGROUND: Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has excellent control rates compared to nonvirally associated OPSCC. Multiple trials are actively testing whether de-escalation of treatment intensity for these patients can maintain oncologic equipoise while reducing treatment-related toxicity. We have developed OP-TIL, a biomarker that characterizes the spatial interplay between tumor-infiltrating lymphocytes (TILs) and surrounding cells in histology images. Herein, we sought to test whether OP-TIL can segregate stage I HPV-associated OPSCC patients into low-risk and high-risk groups and aid in patient selection for de-escalation clinical trials. METHODS: Association between OP-TIL and patient outcome was explored on whole slide hematoxylin and eosin images from 439 stage I HPV-associated OPSCC patients across 6 institutional cohorts. One institutional cohort (n = 94) was used to identify the most prognostic features and train a Cox regression model to predict risk of recurrence and death. Survival analysis was used to validate the algorithm as a biomarker of recurrence or death in the remaining 5 cohorts (n = 345). All statistical tests were 2-sided. RESULTS: OP-TIL separated stage I HPV-associated OPSCC patients with 30 or less pack-year smoking history into low-risk (2-year disease-free survival [DFS] = 94.2%; 5-year DFS = 88.4%) and high-risk (2-year DFS = 82.5%; 5-year DFS = 74.2%) groups (hazard ratio = 2.56, 95% confidence interval = 1.52 to 4.32; P < .001), even after adjusting for age, smoking status, T and N classification, and treatment modality on multivariate analysis for DFS (hazard ratio = 2.27, 95% confidence interval = 1.32 to 3.94; P = .003). CONCLUSIONS: OP-TIL can identify stage I HPV-associated OPSCC patients likely to be poor candidates for treatment de-escalation. Following validation on previously completed multi-institutional clinical trials, OP-TIL has the potential to be a biomarker, beyond clinical stage and HPV status, that can be used clinically to optimize patient selection for de-escalation.

Artificial Intelligence in Surveillance of Barrett's Esophagus.

A study by Waterhouse and colleagues in a previous issue of Cancer Research describes the development and prospective validation of an artificial intelligence approach in conjunction with spectral imaging to enhance endoscopic detection of Barrett's esophagus-related neoplasia. The authors developed a novel spectral endoscope with external optics suitable for routine Barrett's esophagus surveillance with diffuse tissue reflectance to define multispectral data correlated with histopathology. A convolutional neural network was trained on the absis of the spectral signatures acquired as part of a small, prospective clinical trial to distinguish Barrett's esophagus from Barrett's esophagus neoplasia. The results from the study suggest the utility of artificial intelligence for diagnosis of Barrett's esophagus.See related article by Waterhouse et al., Cancer Res 2021;81:3415-25.

Computational pathology reveals unique spatial patterns of immune response in H&E images from COVID-19 autopsies: preliminary findings.

Purpose: We used computerized image analysis and machine learning approaches to characterize spatial arrangement features of the immune response from digitized autopsied H&E tissue images of the lung in coronavirus disease 2019 (COVID-19) patients. Additionally, we applied our approach to tease out potential morphometric differences from autopsies of patients who succumbed to COVID-19 versus H1N1. Approach: H&E lung whole slide images from autopsy specimens of nine COVID-19 and two H1N1 patients were computationally interrogated. 606 image patches ( ∼ 55 per patient) of 1024 × 882 pixels were extracted from the 11 autopsied patient studies. A watershed-based segmentation approach in conjunction with a machine learning classifier was employed to identify two types of nuclei families: lymphocytes and non-lymphocytes (i.e., other nucleated cells such as pneumocytes, macrophages, and neutrophils). Based off the proximity of the individual nuclei, clusters for each nuclei family were constructed. For each of the resulting clusters, a series of quantitative measurements relating to architecture and density of nuclei clusters were calculated. A receiver operating characteristics-based feature selection method, violin plots, and the t-distributed stochastic neighbor embedding algorithm were employed to study differences in immune patterns. Results: In COVID-19, the immune response consistently showed multiple small-size lymphocyte clusters, suggesting that lymphocyte response is rather modest, possibly due to lymphocytopenia. In H1N1, we found larger lymphocyte clusters that were proximal to large clusters of non-lymphocytes, a possible reflection of increased prevalence of macrophages and other immune cells. Conclusion: Our study shows the potential of computational pathology to uncover immune response features that may not be obvious by routine histopathology visual inspection.

Radiomic Features Associated With HPV Status on Pretreatment Computed Tomography in Oropharyngeal Squamous Cell Carcinoma Inform Clinical Prognosis.

PURPOSE: There is a lack of biomarkers for accurately prognosticating outcome in both human papillomavirus-related (HPV+) and tobacco- and alcohol-related (HPV-) oropharyngeal squamous cell carcinoma (OPSCC). The aims of this study were to i) develop and evaluate radiomic features within (intratumoral) and around tumor (peritumoral) on CT scans to predict HPV status; ii) investigate the prognostic value of the radiomic features for both HPV- and HPV+ patients, including within individual AJCC eighth edition-defined stage groups; and iii) develop and evaluate a clinicopathologic imaging nomogram involving radiomic, clinical, and pathologic factors for disease-free survival (DFS) prediction for HPV+ patients. EXPERIMENTAL DESIGN: This retrospective study included 582 OPSCC patients, of which 462 were obtained from The Cancer Imaging Archive (TCIA) with available tumor segmentation and 120 were from Cleveland Clinic Foundation (CCF, denoted as SCCF) with HPV+ OPSCC. We subdivided the TCIA cohort into training (ST, 180 patients) and validation (SV, 282 patients) based on an approximately 3:5 ratio for HPV status prediction. The top 15 radiomic features that were associated with HPV status were selected by the minimum redundancy-maximum relevance (MRMR) using ST and evaluated on SV. Using 3 of these 15 top HPV status-associated features, we created radiomic risk scores for both HPV+ (RRSHPV+) and HPV- patients (RRSHPV-) through a Cox regression model to predict DFS. RRSHPV+ was further externally validated on SCCF. Nomograms for the HPV+ population (Mp+RRS) were constructed. Both RRSHPV+ and Mp+RRS were used to prognosticate DFS for the AJCC eighth edition-defined stage I, stage II, and stage III patients separately. RESULTS: RRSHPV+ was prognostic for DFS for i) the whole HPV+ population [hazard ratio (HR) = 1.97, 95% confidence interval (CI): 1.35-2.88, p < 0.001], ii) the AJCC eighth stage I population (HR = 1.99, 95% CI: 1.04-3.83, p = 0.039), and iii) the AJCC eighth stage II population (HR = 3.61, 95% CI: 1.71-7.62, p < 0.001). HPV+ nomogram Mp+RRS (C-index, 0.59; 95% CI: 0.54-0.65) was also prognostic of DFS (HR = 1.86, 95% CI: 1.27-2.71, p = 0.001). CONCLUSION: CT-based radiomic signatures are associated with both HPV status and DFS in OPSCC patients. With additional validation, the radiomic signature and its corresponding nomogram could potentially be used for identifying HPV+ OPSCC patients who might be candidates for therapy deintensification.

Collagen fiber orientation disorder from H&E images is prognostic for early stage breast cancer: clinical trial validation.

Collagen fiber organization has been found to be implicated in breast cancer prognosis. In this study, we evaluated whether computerized features of Collagen Fiber Orientation Disorder in Tumor-associated Stroma (CFOD-TS) on Hematoxylin & Eosin (H&E) slide images were prognostic of Disease Free Survival (DFS) in early stage Estrogen Receptor Positive (ER+) Invasive Breast Cancers (IBC). A Cox regression model named MCFOD-TS, was constructed using cohort St (N = 78) to predict DFS based on CFOD-TS features. The prognostic performance of MCFOD-TS was validated on cohort Sv (N = 219), a prospective clinical trial dataset (ECOG 2197). MCFOD-TS was prognostic of DFS in both St and Sv, independent of clinicopathological variables. Additionally, the molecular pathways regarding cell cycle regulation were identified as being significantly associated with MCFOD-TS derived risk scores. Our results also found that collagen fiber organization was more ordered in patients with short DFS. Our study provided a H&E image-based pipeline to derive a potential prognostic biomarker for early stage ER+ IBC without the need of special collagen staining or advanced microscopy techniques.

Rhinotillexomania: A Manifestation of Psychiatric Illness.

OBJECTIVE: To increase the knowledge of rhinotillexomania, or compulsive nose picking, as a manifestation of psychiatric disease through the presentation of a case series and a review of the literature. MATERIAL: We present three clinical cases with self-destructive nasal injuries as a symptom of different psychiatric diseases. RESULTS: One patient presented amputation of the middle turbinate as a manifestation of an obsessive-compulsive disorder of bipolar disease. Two patients had a septal perforation. In the first patient it was the first symptom of factitious dermatitis and in the second it was during the course of schizophrenia. Only control with psychological treatment and psychotropic drugs stabilised the nasal injury. CONCLUSION: Self-induced injuries are a diagnostic and treatment challenge for the ENT specialist. A knowledge of psychiatric diseases related to destructive injuries to the nose will improve the approach to patients and prevent the progression of local damage and its complications.

Computerized tumor multinucleation index (MuNI) is prognostic in p16+ oropharyngeal carcinoma.

BACKGROUNDPatients with p16+ oropharyngeal squamous cell carcinoma (OPSCC) are potentially cured with definitive treatment. However, there are currently no reliable biomarkers of treatment failure for p16+ OPSCC. Pathologist-based visual assessment of tumor cell multinucleation (MN) has been shown to be independently prognostic of disease-free survival (DFS) in p16+ OPSCC. However, its quantification is time intensive, subjective, and at risk of interobserver variability.METHODSWe present a deep-learning-based metric, the multinucleation index (MuNI), for prognostication in p16+ OPSCC. This approach quantifies tumor MN from digitally scanned H&E-stained slides. Representative H&E-stained whole-slide images from 1094 patients with previously untreated p16+ OPSCC were acquired from 6 institutions for optimization and validation of the MuNI.RESULTSThe MuNI was prognostic for DFS, overall survival (OS), or distant metastasis-free survival (DMFS) in p16+ OPSCC, with HRs of 1.78 (95% CI: 1.37-2.30), 1.94 (1.44-2.60), and 1.88 (1.43-2.47), respectively, independent of age, smoking status, treatment type, or tumor and lymph node (T/N) categories in multivariable analyses. The MuNI was also prognostic for DFS, OS, and DMFS in patients with stage I and stage III OPSCC, separately.CONCLUSIONMuNI holds promise as a low-cost, tissue-nondestructive, H&E stain-based digital biomarker test for counseling, treatment, and surveillance of patients with p16+ OPSCC. These data support further confirmation of the MuNI in prospective trials.FUNDINGNational Cancer Institute (NCI), NIH; National Institute for Biomedical Imaging and Bioengineering, NIH; National Center for Research Resources, NIH; VA Merit Review Award from the US Department of VA Biomedical Laboratory Research and Development Service; US Department of Defense (DOD) Breast Cancer Research Program Breakthrough Level 1 Award; DOD Prostate Cancer Idea Development Award; DOD Lung Cancer Investigator-Initiated Translational Research Award; DOD Peer-Reviewed Cancer Research Program; Ohio Third Frontier Technology Validation Fund; Wallace H. Coulter Foundation Program in the Department of Biomedical Engineering; Clinical and Translational Science Award (CTSA) program, Case Western Reserve University; NCI Cancer Center Support Grant, NIH; Career Development Award from the US Department of VA Clinical Sciences Research and Development Program; Dan L. Duncan Comprehensive Cancer Center Support Grant, NIH; and Computational Genomic Epidemiology of Cancer Program, Case Comprehensive Cancer Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, the US Department of VA, the DOD, or the US Government.

Rhinotillexomania: a manifestation of psychiatric illness. / Rinotilexomanía: manifestación de enfermedades psiquiátricas.

OBJECTIVE: To increase the knowledge of rhinotillexomania, or compulsive nose picking, as a manifestation of psychiatric disease through the presentation of a case series and a review of the literature. MATERIAL: We present three clinical cases with self-destructive nasal injuries as a symptom of different psychiatric diseases. RESULTS: One patient presented amputation of the middle turbinate as a manifestation of an obsessive-compulsive disorder of bipolar disease. Two patients had a septal perforation. In the first patient it was the first symptom of factitious dermatitis and in the second it was during the course of schizophrenia. Only control with psychological treatment and psychotropic drugs stabilised the nasal injury. CONCLUSION: Self-induced injuries are a diagnostic and treatment challenge for the ENT specialist. A knowledge of psychiatric diseases related to destructive injuries to the nose will improve the approach to patients and prevent the progression of local damage and its complications.

Apkinson: the smartphone application for telemonitoring Parkinson's patients through speech, gait and hands movement.

Aim: This paper introduces Apkinson, a mobile application for motor evaluation and monitoring of Parkinson's disease patients. Materials & methods: The App is based on previously reported methods, for instance, the evaluation of articulation and pronunciation in speech, regularity and freezing of gait in walking, and tapping accuracy in hand movement. Results: Preliminary experiments indicate that most of the measurements are suitable to discriminate patients and controls. Significance is evaluated through statistical tests. Conclusion: Although the reported results correspond to preliminary experiments, we think that Apkinson is a very useful App that can help patients, caregivers and clinicians, in performing a more accurate monitoring of the disease progression. Additionally, the mobile App can be a personal health assistant.

Inlay butterfly miringoplasty. Our experience. / Miringoplastia con cartílago en alas de mariposa. Nuestra experiencia.

INTRODUCTION: Multiple surgical techniques have been proposed to close tympanic perforations. Eavey, two decades ago, described a technique aimed at closing central perforations in children. For this, he designed a butterfly-shaped cartilage graft that was placed between the tympanic membrane in an inlay manner. This technique showed great effectiveness for the closure of perforations as well as low morbidity, rapidity and great economic difference. METHODS: We performed a descriptive study of a series of cases analysing 32 interventions in children and adults with the modified Eavey technique, during the period from January 2012 to November 2016. We evaluated the surgical and audiometric functional results. RESULTS: Surgical success was achieved in 93% of cases, including complete closures in 27 patients (84%) and 3 cases in which minimal asymptomatic dehiscences occurred. There was rejection of the graft and persistence of the perforation in only one case. No major surgical or postoperative complications associated with the procedure were described. The mean improvement in the audiometric gap was from 17dB preoperatively to 7dB after the intervention. CONCLUSIONS: The modified Eavey technique is a low morbidity, cost-effective procedure with a technical facility that proves effective for the closure of tympanic perforations in adults and children.