Combinatorial Hypofractionated Radiotherapy and Pembrolizumab in Anaplastic Thyroid Cancer.

Objectives Anaplastic thyroid cancer (ATC) is an aggressive disease associated with poor outcomes and resistance to therapies. Our study aim was to evaluate the activity of a combinatorial regimen of sandwich sequencing of pembrolizumab immunotherapy and hypofractionated radiotherapy (RT). Methods In this case series, patients with ATC received hypofractionated RT (QUAD-shot) and intravenous pembrolizumab 200mg every 3-4 weeks. Pembrolizumab was continued until disease progression or up till 24 months. Concurrent Lenvatinib treatment was allowed. Primary endpoint was best overall response (BOR) and progression-free survival (PFS). Additionally, we performed immune profiling of circulating T cells in a responder to investigate the immune response to our combinatorial treatment. Results At median follow-up of 32.6 months (IQR: 26.4-38.8), of a cohort of 5 patients, BOR was 80%; with 2 complete responses (CR) and 2 partial responses (PR). Patients who achieved CR remained disease-free at last follow-up. Median PFS was 7.6 months (IQR: 6.2-NR), and 1-year PFS and overall survival rate was 40% (95% CI: 13.7-100) for both. Treatment was well-tolerated, with mostly grade 1-2 adverse events. Immune profiling of one partial responder revealed an increase in activated CD4 and CD8 T cells post-QUAD-shot RT, which was further enhanced during the maintenance phase of pembrolizumab. Conclusions Herein, we reported a case series of 5 patients with ATC, with 2 long-term survivors who were treated with surgical debulking followed by QUAD-shot RT and pembrolizumab, possibly due to synergy of local and systemic treatments in activating anti-tumour immunogenic cytotoxicity. This regimen warrants further investigation in a larger cohort of patients.

Time trend and Age-Period-Cohort analysis of potentially HPV-related oral and pharyngeal cancer incidence in Singapore between 1968 and 2017.

OBJECTIVES: To examine trends and age-period-cohort effects (APC) on oral and pharyngeal cancers incidence in Singapore between 1968 and 2017 by human papillomavirus (HPV) status. METHODS: All diagnosed oral and pharyngeal cancers and population size were extracted from the Singapore Cancer Registry and the Department of Statistics Singapore, respectively. Anatomical subsites were used as a proxy for HPV infection. Prais-Winsten regression assessed trends of age-standardised incidence rate (ASIR) (per 100,000 person-years); Poisson regression assessed APC effects on HPV-related and HPV-unrelated cancers. RESULTS: Over 50 years, 1,618 HPV-related and 2,977 HPV-unrelated oral and pharyngeal cancers were diagnosed, with the highest ASIR in Indians (6.93), followed by Chinese (2.81), and Malays (1.81). Overall, ASIR HPV-related cancers were stable while HPV-unrelated cancers decreased. The male-female ASIR ratio reduced from 5.82 (1968-1977) to 4.0 (2008-2017) for HPV-related cancers, and from 2.58 (1968-1977) to 1.52 (2008-2017) for HPV-unrelated cancers. HPV-unrelated ASIR in males decreased, but in females only among Indians. HPV-related ASIR decreased only among Indian females. The cohort born between 1983 and 1992 had the lowest incidence of HPV-related cancers in males but the highest in HPV-unrelated cancers. Period effect mainly contributed to HPV-related cancer among males with increased incidence after 1997. Overall, the age effect was more pronounced in males. CONCLUSIONS: HPV-related cancers accounted for 1/3 of oral and pharyngeal cancers. A significant decline was observed only for HPV-unrelated cancers. The cohort effect was mainly attributed to HPV-unrelated cancer incidence, while the period effect largely contributed to HPV-related cancer incidence, but only among males.

Stratification of follicular thyroid tumours using data-independent acquisition proteomics and a comprehensive thyroid tissue spectral library.

Thyroid nodules occur in about 60% of the population. A major challenge in thyroid nodule diagnosis is to distinguish between follicular adenoma (FA) and carcinoma (FTC). Here, we present a comprehensive thyroid spectral library covering five types of thyroid tissues. This library includes 121 960 peptides and 9941 protein groups. This spectral library can be used to quantify up to 7863 proteins from thyroid tissues, and can also be used to develop parallel reaction monitoring (PRM) assays for targeted protein quantification. Next, to stratify follicular thyroid tumours, we compared the proteomes of 24 FA and 22 FTC samples, and identified 204 differentially expressed proteins (DEPs). Our data suggest altered ferroptosis pathways in malignant follicular carcinoma. In all, 31 selected proteins effectively distinguished follicular tumours. Of those DEPs, nine proteins were further verified by PRM in an independent cohort of 18 FA and 19 FTC. Together, we present a comprehensive spectral library for DIA and targeted proteomics analysis of thyroid tissue specimens, and identified nine proteins that could potentially distinguish FA and FTC.

Incorporation of adverse features in advanced oral cancer improves precision in staging and patient prognostication.

BACKGROUND: Despite revised staging criteria, stratification of patients with advanced oral squamous cell carcinoma (OSCC) remains difficult. Well-established features like perineural invasion (PNI), differentiation, and lymphovascular-invasion (LVI) are controversial, and hence omitted from staging. We endeavor to better stratify this cohort by identifying predictors of survival in advanced OSCC (T3-4). METHODS: Seven hundred and forty-two patients with T3-4 OSCC underwent surgery from 2006 to 2013. Cox regression was performed to determine predictors of overall survival (OS). RESULTS: OS was adversely impacted by PNI (p = 0.046), LVI (p = 0.038), moderate/poor differentiation (p = 0.001), close/involved surgical margins (p = 0.002), pT (p = 0.034), and pN (p < 0.001). The cumulative number of adverse histopathological features predicted poorer OS; HR 2.64 (CI 1.42-4.90) for one adverse feature and HR 4.23 (CI 2.34-7.67) for ≥2. CONCLUSION: In advanced OSCC, stratification with histopathologic risk factors can predict survival even in maximally treated patients; adjuvant therapies are unable to entirely mitigate this risk. Incorporation of adverse features into future editions of TNM can improve precision in staging and identify candidates for treatment escalation.

Prognostic Matrisomal Gene Panel and Its Association with Immune Cell Infiltration in Head and Neck Carcinomas.

Squamous cell carcinoma of the head and neck (SCCHN) is common worldwide and related to several risk factors including smoking, alcohol consumption, poor dentition and human papillomavirus (HPV) infection. Different etiological factors may influence the tumor microenvironment and play a role in dictating response to therapeutics. Here, we sought to investigate whether an early-stage SCCHN-specific prognostic matrisome-derived gene signature could be identified for HPV-negative SCCHN patients (n = 168), by applying a bioinformatics pipeline to the publicly available SCCHN-TCGA dataset. We identified six matrisome-derived genes with high association with prognostic outcomes in SCCHN. A six-gene risk score, the SCCHN TMI (SCCHN-tumor matrisome index: composed of MASP1, EGFL6, SFRP5, SPP1, MMP8 and P4HA1) was constructed and used to stratify patients into risk groups. Using machine learning-based deconvolution methods, we found that the risk groups were characterized by a differing abundance of infiltrating immune cells. This work highlights the key role of immune infiltration cells in the overall survival of patients affected by HPV-negative SCCHN. The identified SCCHN TMI represents a genomic tool that could potentially aid patient stratification and selection for therapy in these patients.

Comprehensive Mutational and Phenotypic Characterization of New Metastatic Cutaneous Squamous Cell Carcinoma Cell Lines Reveal Novel Drug Susceptibilities.

Cutaneous squamous cell carcinoma (cSCC) is a common skin cancer. Most patients who develop metastases (2-5%) present with advanced disease that requires a combination of radical surgery and adjuvant radiation therapy. There are few effective therapies for refractory disease. In this study, we describe novel patient-derived cell lines from cSCC metastases of the head and neck (designated UW-CSCC1 and UW-CSCC2). The cell lines genotypically and phenotypically resembled the original patient tumor and were tumorogenic in mice. Differences in cancer-related gene expression between the tumor and cell lines after various culturing conditions could be largely reversed by xenografting and reculturing. The novel drug susceptibilities of UW-CSCC1 and an irradiated subclone UW-CSCC1-R to drugs targeting cell cycle, PI3K/AKT/mTOR, and DNA damage pathways were observed using high-throughput anti-cancer and kinase-inhibitor compound libraries, which correlate with either copy number variations, targetable mutations and/or the upregulation of gene expression. A secondary screen of top hits in all three cell lines including PIK3CA-targeting drugs supports the utility of targeting the PI3K/AKT/mTOR pathway in this disease. UW-CSCC cell lines are thus useful preclinical models for determining targetable pathways and candidate therapeutics.

Implementing the Biodesign Process for Medical Device Innovation in Head and Neck Surgery.

Introduction. The Stanford Biodesign process is a needs-driven approach to innovation which begins in the clinical setting and environment and is championed by practicing clinicians and surgeons. Here, our team applied the Stanford Biodesign process through clinical immersion to identify potential unmet clinical needs in the field of head and neck surgery, brainstormed and prototyped solutions to solve the top unmet need, and developed a commercialized medical device. Methods. The team underwent the 3 phases of the Biodesign process: identify, invent, and implement. The team underwent clinical immersion and followed head and neck surgeons from the Department of Head and Neck Surgery for a duration of 1 month. The needs identified were then filtered through a structured process using predefined filters, and a top need was chosen. After multiple rounds of brainstorming and prototyping, a final concept was developed. Results. The team collected 111 unmet needs and designed the in vivo surgical lighting concept that eventually led to the development of the KLARO™ in vivo surgical lighting device with a commercial partner. KLARO™ is a fully flexible 4.6-mm diameter light-emitting diode light strip that is freely bendable to be safely placed into deep cavities during open surgeries. Conclusion. The Biodesign process provides a standardized way to turn these needs into solution to advance the field of head and neck surgery and improve the outcome of patients.

Establishment and Characterization of Humanized Mouse NPC-PDX Model for Testing Immunotherapy.

Immune checkpoint blockade (ICB) monotherapy shows early promise for the treatment of nasopharyngeal carcinoma (NPC) in patients. Nevertheless, limited representative NPC models hamper preclinical studies to evaluate the efficacy of novel ICB and combination regimens. In the present study, we engrafted NPC biopsies in non-obese diabetic-severe combined immunodeficiency interleukin-2 receptor gamma chain-null (NSG) mice and established humanized mouse NPC-patient-derived xenograft (NPC-PDX) model successfully. Epstein-Barr virus was detected in the NPC in both NSG and humanized mice as revealed by Epstein-Barr virus-encoded small RNA (EBER) in situ hybridization (ISH) and immunohistochemical (IHC) staining. In the NPC-bearing humanized mice, the percentage of tumor-infiltrating CD8+ cytotoxic T cells was lowered, and the T cells expressed higher levels of various inhibitory receptors, such as programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) than those in blood. The mice were then treated with nivolumab and ipilimumab, and the anti-tumor efficacy of combination immunotherapy was examined. In line with paired clinical data, the NPC-PDX did not respond to the treatment in terms of tumor burden, whilst an immunomodulatory response was elicited in the humanized mice. From our results, human proinflammatory cytokines, such as interferon-gamma (IFN-γ) and interleukin-6 (IL-6) were significantly upregulated in plasma. After treatment, there was a decrease in CD4/CD8 ratio in the NPC-PDX, which also simulated the modulation of intratumoral CD4/CD8 profile from the corresponding donor. In addition, tumor-infiltrating T cells were re-activated and secreted more IFN-γ towards ex vivo stimulation, suggesting that other factors, including soluble mediators and metabolic milieu in tumor microenvironment may counteract the effect of ICB treatment and contribute to the tumor progression in the mice. Taken together, we have established and characterized a novel humanized mouse NPC-PDX model, which plausibly serves as a robust platform to test for the efficacy of immunotherapy and may predict clinical outcomes in NPC patients.

Factors driving frequent attendance at emergency departments for patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer have a higher risk of emergency department (ED) frequent attender (FA). We hypothesized that FAs present with issues different from non-FAs. METHODS: A retrospective cohort study was conducted on Singapore residents with head and neck cancers using de-identified registry merged with electronic medical record data. A competing risk regression analysis was performed to identify factors associated with FA. Aggregated primary diagnoses were compared for patients with and without FA risk factors. RESULTS: Thirteen percent of patients with head and neck cancer were FAs. FA risk factors were Charlson comorbidity index (3+), and socioeconomic status (SES). FAs had a higher proportion of respiratory infections. The spectrum of diagnosis was similar for patients with low and high SES. Current smokers had a greater proportion of respiratory complaints, relative to never smokers. CONCLUSION: Patients with greater comorbidity scores or higher SES were more likely to be FA. FAs were more likely to present with respiratory complaints, likely related to cancer treatment, or smoking status.

Concurrent Single-Cell RNA and Targeted DNA Sequencing on an Automated Platform for Comeasurement of Genomic and Transcriptomic Signatures.

BACKGROUND: The comeasurement of both genomic and transcriptomic signatures in single cells is of fundamental importance to accurately assess how the genetic information correlates with the transcriptomic phenotype. However, existing technologies have low throughput and laborious work flows. METHODS: We developed a new method for concurrent sequencing of the transcriptome and targeted genomic regions (CORTAD-seq) within the same single cell on an automated microfluidic platform. The method was compatible with the downstream library preparation, allowing easy integration into existing next-generation sequencing work flows. We incorporated a single-cell bioinformatics pipeline for transcriptome and mutation analysis. RESULTS: As proof of principle, we applied CORTAD-seq to lung cancer cell lines to dissect the cellular consequences of mutations that result in resistance to targeted therapy. We obtained a mean detection of 6000 expressed genes and an exonic rate of 50%. The targeted DNA-sequencing data achieved a 97.8% detection rate for mutations and allowed for the identification of copy number variations and haplotype construction. We detected expression signatures of tyrosine kinase inhibitor (TKI) resistance, epidermal growth factor receptor (EGFR) amplification, and expansion of the T790M mutation among resistant cells. We also identified characteristics for TKI resistance that were independent of EGFR T790M, indicating that other alterations are required for resistance in this context. CONCLUSIONS: CORTAD-seq allows assessment of the interconnection between genetic and transcriptomic changes in single cells. It is operated on an automated, commercially available single-cell isolation platform, making its implementation straightforward.

Diagnostic pitfall: Adenoid cystic carcinoma of the tongue presenting as an isolated hypoglossal nerve palsy, case report and literature review.

INTRODUCTION: We describe a patient with an unusual presentation of an isolated hypoglossal nerve palsy as a result of perineural invasion (PI) from adenoid cystic carcinoma (ACC). We will also discuss the diagnostic pitfalls as well as present a short literature review of adenoid cystic carcinomas and suggest improvement to the current diagnostic algorithm for isolated hypoglossal nerve palsies. PRESENTATION OF CASE: A 63year old Malay female presented with progressive dysphagia and slurred speech for one year. Physical examination showed unilateral right tongue wasting, fasciculation and deviation to the right. An MRI showed atrophy of the tongue due to denervation and subsequently she was treated in a neurology clinic for 8 months. Due to lack of improvement, she was referred to our surgical unit and underwent examination under anaesthesia (EUA) and biopsy. Histology showed adenoid cystic carcinoma with perineural involvement, resulting in lower motor neuron signs. She underwent radiotherapy to the base of her tongue (70Gy/35#). A PET-CT one month post treatment showed complete response. DISCUSSION: Adenoid cystic carcinoma (ACC) is a salivary gland neoplasm. It is characterized by local invasiveness with frequent recurrence and indolent growth. It affects major salivary glands more than minor salivary glands. In malignancies that have a propensity for PI such as ACC, patients may present atypically with nerve palsies. In infiltrative lesions, the primary tumour may not be evident on magnetic resonance imaging. Therefore, to achieve a diagnosis, a high index of suspicion is required. When the diagnosis is in question, deep biopsy and positron emission tomography may be useful.

Metastasectomy for metachronous pulmonary and hepatic metastases from nasopharyngeal carcinoma: Report of 6 cases and review of the literature.

BACKGROUND: Metastatic nasopharyngeal carcinoma (NPC) is commonly treated with palliative chemotherapy. The purpose of this study was to review the feasibility of metastasectomy for metachronous pulmonary and hepatic metastases from NPC. METHODS: We present 6 patients who developed metachronous metastases from NPC (4 patients with pulmonary metastases and 2 patients with hepatic metastases) and underwent curative resection. RESULTS: Four patients are still alive with no recurrence of NPC after metastasectomy. Two patients died with postoperative survival periods of 57 and 70 months and recurrence-free intervals of 14 and 39 months, respectively. CONCLUSION: Metastasectomy is a feasible option for the treatment of metachronous and resectable oligometastatic NPC to the lung and liver. Application of appropriate selection criteria would be required.

Paracrine factors of human fetal MSCs inhibit liver cancer growth through reduced activation of IGF-1R/PI3K/Akt signaling.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death in the world. The multikinase inhibitor sorafenib only demonstrated marginal improvement in overall survival for advanced disease prompted the search for alternative treatment options. Human mesenchymal stem cells (MSCs) have the ability to home to tumor cells. However, its functional roles on the tumor microenvironment remain controversial. Herein, we showed that conditioned media derived from human fetal MSC (CM-hfMSCs) expressed high level of the insulin growth factor binding proteins IGFBPs and can sequester free insulin-like growth factors (IGFs) to inhibit HCC cell proliferation. The inhibitory effect of IGFBPs on IGF signaling was further evident from the reduction of activated IGF-1R and PI3K/Akt, leading eventually to the induction of cell cycle arrest. We also demonstrated that CM-hfMSCs could enhance the therapeutic efficacy of sorafenib and sunitinib. To the best of our knowledge, this is the first report to show that CM-hfMSCs has a tumor-specific, antiproliferative effect that is not observed with normal human hepatocyte cells and patient-derived matched normal tissues. Our results thus suggest that CM-hfMSCs can provide a useful tool to design alternative/adjuvant treatment strategies for HCC, especially in related function to potentiate the effects of chemotherapeutic drugs.

p300/CBP and cancer.

p300 and cyclic AMP response element-binding protein (CBP) are adenoviral E1A-binding proteins involved in multiple cellular processes, and function as transcriptional co-factors and histone acetyltransferases. Germline mutation of CBP results in Rubinstein-Taybi syndrome, which is characterized by an increased predisposition to childhood malignancies. Furthermore, somatic mutations of p300 and CBP occur in a number of malignancies. Chromosome translocations target CBP and, less commonly, p300 in acute myeloid leukemia and treatment-related hematological disorders. p300 mutations in solid tumors result in truncated p300 protein products or amino-acid substitutions in critical protein domains, and these are often associated with inactivation of the second allele. A mouse model confirms that p300 and CBP function as suppressors of hematological tumor formation. The involvement of these proteins in critical tumorigenic pathways (including TGF-beta, p53 and Rb) provides a mechanistic route as to how their inactivation could result in cancer.