Gut microbiome predicts gastrointestinal toxicity outcomes from chemoradiation therapy in patients with head and neck squamous cell carcinoma.

OBJECTIVES: Chemoradiation (CRT) in patients with locally advanced head and neck squamous cell cancer (HNSCC) is associated with significant toxicities, including mucositis. The gut microbiome represents an emerging hallmark of cancer and a potentially important biomarker for CRT-related adverse events. This prospective study investigated the association between the gut microbiome composition and CRT-related toxicities in patients with HNSCC, including mucositis. MATERIALS AND METHODS: Stool samples from patients diagnosed with locally advanced HNSCC were prospectively collected prior to CRT initiation and analyzed using shotgun metagenomic sequencing to evaluate gut microbiome composition at baseline. Concurrently, clinicopathologic data, survival outcomes and the incidence and grading of CRT-emergent adverse events were documented in all patients. RESULTS: A total of 52 patients were included, of whom 47 had baseline stool samples available for metagenomic analysis. Median age was 62, 83 % patients were men and 54 % had stage III-IV disease. All patients developed CRT-induced mucositis, including 42 % with severe events (i.e. CTCAE v5.0 grade ≥ 3) and 25 % who required enteral feeding. With a median follow-up of 26.5 months, patients with severe mucositis had shorter overall survival (HR = 3.3, 95 %CI 1.0-10.6; p = 0.02) and numerically shorter progression-free survival (HR = 2.8, 95 %CI, 0.8-9.6; p = 0.09). The gut microbiome beta-diversity of patients with severe mucositis differed from patients with grades 1-2 mucositis (p = 0.04), with enrichment in Mediterraneibacter (Ruminococcus gnavus) and Clostridiaceae family members, including Hungatella hathewayi. Grade 1-2 mucositis was associated with enrichment in Eubacterium rectale, Alistipes putredinis and Ruminococcaceae family members. Similar bacterial profiles were observed in patients who required enteral feeding. CONCLUSION: Patients who developed severe mucositis had decreased survival and enrichment in specific bacteria associated with mucosal inflammation. Interestingly, these same bacteria have been linked to immune checkpoint inhibitor resistance.

Helicobacter pylori serology is associated with worse overall survival in patients with melanoma treated with immune checkpoint inhibitors.

The microbiome is now regarded as one of the hallmarks of cancer and several strategies to modify the gut microbiota to improve immune checkpoint inhibitor (ICI) activity are being evaluated in clinical trials. Preliminary data regarding the upper gastro-intestinal microbiota indicated that Helicobacter pylori seropositivity was associated with a negative prognosis in patients amenable to ICI. In 97 patients with advanced melanoma treated with ICI, we assessed the impact of H. pylori on outcomes and microbiome composition. We performed H. pylori serology and profiled the fecal microbiome with metagenomics sequencing. Among the 97 patients, 22% were H. pylori positive (Pos). H. pylori Pos patients had a significantly shorter overall survival (p = .02) compared to H. pylori negative (Neg) patients. In addition, objective response rate and progression-free survival were decreased in H. pylori Pos patients. Metagenomics sequencing did not reveal any difference in diversity indexes between the H. pylori groups. At the taxa level, Eubacterium ventriosum, Mediterraneibacter (Ruminococcus) torques, and Dorea formicigenerans were increased in the H. pylori Pos group, while Alistipes finegoldii, Hungatella hathewayi and Blautia producta were over-represented in the H. pylori Neg group. In a second independent cohort of patients with NSCLC, diversity indexes were similar in both groups and Bacteroides xylanisolvens was increased in H. pylori Neg patients. Our results demonstrated that the negative impact of H. pylori on outcomes seem to be independent from the fecal microbiome composition. These findings warrant further validation and development of therapeutic strategies to eradicate H. pylori in immuno-oncology arena.

A Natural Polyphenol Exerts Antitumor Activity and Circumvents Anti-PD-1 Resistance through Effects on the Gut Microbiota.

Several approaches to manipulate the gut microbiome for improving the activity of cancer immune-checkpoint inhibitors (ICI) are currently under evaluation. Here, we show that oral supplementation with the polyphenol-rich berry camu-camu (CC; Myrciaria dubia) in mice shifted gut microbial composition, which translated into antitumor activity and a stronger anti-PD-1 response. We identified castalagin, an ellagitannin, as the active compound in CC. Oral administration of castalagin enriched for bacteria associated with efficient immunotherapeutic responses (Ruminococcaceae and Alistipes) and improved the CD8+/FOXP3+CD4+ ratio within the tumor microenvironment. Moreover, castalagin induced metabolic changes, resulting in an increase in taurine-conjugated bile acids. Oral supplementation of castalagin following fecal microbiota transplantation from ICI-refractory patients into mice supported anti-PD-1 activity. Finally, we found that castalagin binds to Ruminococcus bromii and promoted an anticancer response. Altogether, our results identify castalagin as a polyphenol that acts as a prebiotic to circumvent anti-PD-1 resistance. SIGNIFICANCE: The polyphenol castalagin isolated from a berry has an antitumor effect through direct interactions with commensal bacteria, thus reprogramming the tumor microenvironment. In addition, in preclinical ICI-resistant models, castalagin reestablishes the efficacy of anti-PD-1. Together, these results provide a strong biological rationale to test castalagin as part of a clinical trial. This article is highlighted in the In This Issue feature, p. 873.

Histopatología, inmunohistoquímica y metástasis en pacientes con carcinoma basocelular: Revisión Narrativa / Histopathology, immunohistochemistry, and metas-tasis in patients with basal cell carcinoma: A bibliographic review / Histopatologia, imunohistoquímica e metástases em pacientes com carcinoma basocelular: revisão narrativa

Introducción: El carcinoma basocelular (CBC)es una de las neoplasias más comunes de la piel. En nuestro país, por su localización, representa una entidad patológica de gran importancia, por la radiación ultravioleta elevada, que es inversamente proporcional a la latitud geográfica en la que nos encontramos en Ecuador. El objetivo del presente trabajo es revisar las características claves que distinguen al Carcinoma basocelular, y actualizar los conocimientos, incluyendo la evidencia disponible en hallazgos histopatológicos, marcadores de inmunohistoquímica y metástasis en esta patología

Introduction: Basal cell carcinoma BCC is one of the most common skin neoplasms. In our country, because of its location, it represents a pathological entity of great importance, due to the high ultraviolet radiation, that is inversely proportional to the geographical latitude we are in Ecuador. This paper objective is to review the key features that distinguish basal cellcarcinoma, and update knowledge, including the available evidence on histopathological findings, immunohistochemical markers and metastasis in this pathology.

Introdução: Carcinoma basocelular O CBC é uma das neoplasias cutâneas mais comuns. Em nosso país, por sua localização, representa uma entidade patológica de grande importância, devido à alta radiação ultravioleta, que é inversamente proporcional à latitude geográfica em que nos encontramos no Equador. O objetivo deste artigo é revisar as principais características que distinguem o carcinoma basocelular e atualizar o conhecimento, incluindo as evidências disponíveis sobre achados histopatológicos, marcadores imunohistoquímicos e metástases nessa patologia.

Transient monoclonal gammopathy and hypercalcemia in a male patient with Systemic Lupus Erythematosus / Gammapatía monoclonal transitoria e hipercalcemia en un paciente masculino con lupus eritematoso sistémico

Systemic Lupus Erythematosus (SLE) as an autoimmune disorder, is characterized by a profound B cell activation, however, the association of this disease with a monoclonal gammopathy has been infrequently reported, while hypercalcemia is associated with Hypercalcemia-Lymphadenopathy Syndrome (HL-SLE). We report the case of a 45-year-old man, with anemia, hypoalbuminemia, hypergammaglobulinemia, hypercalcemia, and bone marrow infiltrated with plasma cells. He was diagnosed as Monoclonal Gammopathy of Undetermined Significance (MGUS), one year later he attended with erythematous macules on both arms, at this time the electrophoresis reported a polyclonal hypergammaglobulinemia. Immunologic panel reported ANA 1:2560, mitochondrial ANA 1:80, anti-double-stranded DNA IgG 15.3 and hipocomplementemia. We confirmed SLE and treatment was initiated. In our patient we ruled out MGUS, γHCD (γ-heavy-chain disease) and hypercalcemia related to HL-SLE. To our knowledge, the findings of monoclonal gammopathy and hypercalcemia as the onset of SLE have never been reported and the role of clinical laboratory was very important in the approach to establish a definitive diagnosis

El lupus eritematoso sistémico (LES) es un padecimiento autoinmune, caracterizado por la activación de las células B. Se ha reportado ocasionalmente su asociación con la gammapatía monoclonal. Reportamos el caso de un varón de 45 años con anemia, hipoalbuminemia, hipergammaglobulinemia, hipercalcemia e infiltración de médula ósea con células plasmáticas. Se diagnosticó de gammapatía monoclonal de significado incierto. Posteriormente presentó máculas en brazos, con hipergammaglobulinemia policlonal y serología con ANA 1:2.560, ANA mitocondriales 1:80, IgG 15,3 e hipocomplementemia que establecieron el diagnóstico de LES. La presencia de hipercalcemia y gammapatía monoclonal en asociación con LES no se había reportado con anterioridad

Glucocorticoid receptor modulation decreases ER-positive breast cancer cell proliferation and suppresses wild-type and mutant ER chromatin association.

BACKGROUND: Non-ER nuclear receptor activity can alter estrogen receptor (ER) chromatin association and resultant ER-mediated transcription. Consistent with GR modulation of ER activity, high tumor glucocorticoid receptor (GR) expression correlates with improved relapse-free survival in ER+ breast cancer (BC) patients. METHODS: In vitro cell proliferation assays were used to assess ER-mediated BC cell proliferation following GR modulation. ER chromatin association following ER/GR co-liganding was measured using global ChIP sequencing and directed ChIP analysis of proliferative gene enhancers. RESULTS: We found that GR liganding with either a pure agonist or a selective GR modulator (SGRM) slowed estradiol (E2)-mediated proliferation in ER+ BC models. SGRMs that antagonized transcription of GR-unique genes both promoted GR chromatin association and inhibited ER chromatin localization at common DNA enhancer sites. Gene expression analysis revealed that ER and GR co-activation decreased proliferative gene activation (compared to ER activation alone), specifically reducing CCND1, CDK2, and CDK6 gene expression. We also found that ligand-dependent GR occupancy of common ER-bound enhancer regions suppressed both wild-type and mutant ER chromatin association and decreased corresponding gene expression. In vivo, treatment with structurally diverse SGRMs also reduced MCF-7 Y537S ER-expressing BC xenograft growth. CONCLUSION: These studies demonstrate that liganded GR can suppress ER chromatin occupancy at shared ER-regulated enhancers, including CCND1 (Cyclin D1), regardless of whether the ligand is a classic GR agonist or antagonist. Resulting GR-mediated suppression of ER+ BC proliferative gene expression and cell division suggests that SGRMs could decrease ER-driven gene expression.

Metabolic tumor volume changes assessed by interval 18fluorodeoxyglucose positron emission tomography-computed tomography for the prediction of complete response and survival in patients with diffuse large B-cell lymphoma.

An early discrimination of survival probability is required for patients with diffuse large B cell lymphoma (DLBCL), which may identify patients that require other treatment options, for example clinical trials. To the best of our knowledge, the impact of interim evaluation with 18fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) has not yet been determined in this type of neoplasia. The aim of the present study was to determine the role of changes in metabolic tumor volume (MTV) between baseline and interim 18F-FDG PET/CT scans, following three courses of chemotherapy in order to predict complete response (CR) and overall survival (OS) in patients with DLBCL. Patients with previously untreated DLBCL who had received the standard 6-8 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone were included in the present study. A predictive model was constructed using changes in MTV and other clinical factors including age, gender, East Cooperative Oncology Group (ECOG) status, clinical stage, B symptoms, the presence of bulky disease and elevated lactate dehydrogenase levels, and data were analyzed using logistic regression analysis. In total, 50 patients with DLBCL were included in the present study. The majority of patients presented with stage III/IV disease (64%), B symptoms (72%) and bulky disease (58%). According to the International Prognostic Index score, 44% of patients were in the intermediate-high or high-risk categories for risk of relapse, and therefore considered to have poor prognosis. In total, ≥94% of patients achieving a decrease in total MTV had a 2-year OS rate of 95%, compared with the 58% OS rate of those with a suboptimal response. A multivariate model, including a change in MTV (a decrease of ≥94%), the ECOG performance status ≥2, a change in leukocyte counts and age, was used to predict CR. This model was used to define two groups according to the predicted probability of recurrence (cutoff, 0.69). The 2-year survival rates of the two groups were 95 and 59%, respectively. Analysis of changes in MTV in the interim 18F-FDG PET/CT revealed significant prognostic value for the prediction of CR and OS in patients with DLBCL.

A prognostic score for survival in patients older than 65 years with Diffuse Large B-Cell Lymphoma.

BACKGROUND: Available prognosis scores for patients with diffuse large B-cell lymphoma (DLBCL) included a limited number of patients ≥ 65 years of age, and most of them did not include comorbidities. Here, we propose a prognostic score for overall survival (OS) for this group of patients. MATERIALS AND METHODS: Patients ≥ 65 years with DLBCL treated at a single national reference center were included. Clinical features including comorbidities and biochemical parameters were analyzed. RESULTS: We included 141 patients. Response rate in the whole group was 77%. Based on multivariate analysis, the presence of the European Cooperative Oncology Group (ECOG) > 2, elevated levels of beta-2 microglobulin, bulky disease, and anemia (hemoglobin < 10 g/dL) had a significant effect on OS. These parameters were considered when computing the prognostic score, which identified three groups with differential survival: Low, intermediate, and high risk of death, with a probability of survival at 60 months of 80.05%, 55.5%, and 29.84%, respectively. DISCUSSION: This score may select patients to optimize treatment. The presence of high levels of beta-2 microglobulin, bulky disease, and hemoglobin < 10 g/dL, and ECOG > 2 was associated with poor OS in elderly patients with DLBCL.

Neoplasia blástica de células dendríticas plasmocitoides: casos clínicos / Blastic plasmacytoid dendritic cell neoplasm: report of three cases

Blastic plasmacytoid dendritic cell neoplasm is a rare hematological malignancy derived from immature plasmacytoid dendritic cells. The tumor cells have an immature blastic appearance, and diagnosis is based on the expression of CD4, CD56 y CD123 in the absence of other lymphoid, natural killer, or myeloid antigens. The majority of affected individuals are older people with a mean age of 66 years. Male to female ratio is approximately 3:1. Common presentation includes cutaneous lesions followed by tumor dissemination. Treatment with conventional chemotherapy is ineffective and allogeneic hematopoietic stem cell transplantation is required to achieve remission. We report three male patients, aged 23, 27 and 51 years with the disease. All had multiple, infiltrated pink plaques and nodules on the skin of their face, neck and thorax, measuring 1 to 12 cm in diameter. All tumors were histologically characterized by a monotonous proliferation of medium size cells with blastic features. Tumor cells were positive for CD123, CD56, CD4 and CD7 in all cases. After a mean of follow-up of 14.6 months, one patient died of the disease, one patient is alive and the disease relapsed after 17 months of remission and one patient is alive with no evidence of the disease.

Encouraging results with the compassionate use of hydralazine/valproate (TRANSKRIP™) as epigenetic treatment for myelodysplastic syndrome (MDS).

The hypomethylating agents azacytidine and decitabine are unaffordable for many patients with MDS. The combination of the DNA methyltransferase inhibitor hydralazine and the histone deacetylase inhibitor valproate has shown preliminary efficacy in MDS. The aim of this study is to evaluate the clinical efficacy and safety of hydralazine/valproate in a case series of MDS patients treated in a compassionate manner. Hydralazine was dosed according to the acetylation genotype of patients (slow acetylators 83 mg daily; fast acetylators 182 mg daily), and valproate was dosed at 30 mg/kg/day. Both drugs were given daily until disease progression. Response and toxicity were evaluated with the International Working Group criteria and CTCAE, version 4, respectively. Survival parameters were estimated with the Kaplan-Meier method. From 2009 to 2012, 14 patients were treated. The median age ± SD was 55.2 ± 19.52 (range 23-87) years. According to the IPSS, cases were graded as intermediate-1 (n = 8/14; 57.2%) or intermediate-2 (n = 6/14; 42.8%). Responses were as follows: five (35.7%) complete response, one (7.1%) partial response, and two (14.28%) became transfusion independent. The mean duration of response ± SD was 60 ± 35.28 months (range 5-94). Three patients progressed to AML. At a median follow-up of 57 months (range 1-106), the median OS was 27 months. At that point, five patients remained on the treatment, one with partial response and four with complete response. The median OS was not reached in the eight patients who saw a clinical benefit from the treatment, in comparison to an OS of 7 months in the six patients who had no treatment. The combination of hydralazine and valproate is safe and effective in MDS, and its further testing is highly desirable.

[Blastic plasmacytoid dendritic cell neoplasm. Report of three cases]. / Neoplasia blástica de células dendríticas plasmocitoides. Casos clínicos.

Blastic plasmacytoid dendritic cell neoplasm is a rare hematological malignancy derived from immature plasmacytoid dendritic cells. The tumor cells have an immature blastic appearance, and diagnosis is based on the expression of CD4, CD56 y CD123 in the absence of other lymphoid, natural killer, or myeloid antigens. The majority of affected individuals are older people with a mean age of 66 years. Male to female ratio is approximately 3:1. Common presentation includes cutaneous lesions followed by tumor dissemination. Treatment with conventional chemotherapy is ineffective and allogeneic hematopoietic stem cell transplantation is required to achieve remission. We report three male patients, aged 23, 27 and 51 years with the disease. All had multiple, infiltrated pink plaques and nodules on the skin of their face, neck and thorax, measuring 1 to 12 cm in diameter. All tumors were histologically characterized by a monotonous proliferation of medium size cells with blastic features. Tumor cells were positive for CD123, CD56, CD4 and CD7 in all cases. After a mean of follow-up of 14.6 months, one patient died of the disease, one patient is alive and the disease relapsed after 17 months of remission and one patient is alive with no evidence of the disease.

Enfermedad de Hailey-Hailey: reporte de un caso / Hailey-Hailey disease: case report

La enfermedad de Hailey-Hailey o pénfigo familiar benigno es una enfermedad ampollar rara, con herencia autosómica dominante. Usualmente se inicia en la adolescencia o inicios de la segunda década. Presentamos el caso de una mujer de 40 años que fue referida a nuestro servicio con una historia de cuatro años de erupciones continuas en región axilar y ocasionalmente en zona inguinal, que dejan úlceras dolorosas, y se presentan en forma periódica exacerbándose en épocas de calor. No tuvo fiebre ni malestar previo a la erupción en la piel. Presentaba pápulas vesiculares con base eritematosa y algunas lesiones costrosas en ambas axilas. Respondió adecuadamente a la corticoterapia.

The Hailey-Hailey disease or familial benign chronic pemphigus, is a rare blistering disorder. The onset is usually in the late teens or early twenties. It is inherited in an autosomal dominant manner. A 40 year-old woman with familial benign chronic pemphigus (Hailey-Hailey disease) was referred to our department with a 4 years history of these continuous eruptions occasionally axillary, groin, leaving painful wounds are periodically exacerbated in hot weather. She had no fever and malaise prior to rash. There were based vesicular erythematous papules and somecrusted lesions on both arms. She responded to corticosteroids.

Liquen plano hipertrófico generalizado / Generalized hypertrophic lichen planus

El liquen plano hipertrófico generalizado es una dermatosis subaguda o crónica e inflamatoria, autolimitada de etiología desconocida, que afecta a la piel, mucosas y anexos cutáneos (uñas y pelo). Es una enfermedad relativamente frecuente en adultos, pero extremadamente rara en niños y se presenta en la población general con una prevalencia menor al 1%. La forma infantil es clínicamente similar a la del adulto, aunque la afectación mucosa es excepcional. Se comunica el caso de un niño de 8 años de edad, con lesiones cutáneas generalizadas de liquen plano, con buena evolución y respuesta a tratamiento con corticoides tópicos.

Generalized hypertrophic lichen planus is asubacute or chronic dermatoses, self-limited, inflammatory of unknown etiology that affects the skin, mucous membranes and skin appendages (nails and hair). It is a relatively common disease in adults, but extremely rare in children and occurs in the general population with a prevalence below 1%. The infantile form is clinically similar to adult, although the mucosal involvement is exceptional. We report the case of a child of 08 years of age, with generalized skin lesions of lichen planus, with good outcome and response to treatment with topical corticosteroids.

Epidermolisis bulosa distrófica pruriginosa dominante / Dominant dystrophic epidermolysis bullosa pruriginosa

La epidermólisis bulosa distrófica es un trastorno hereditario poco frecuente y clínicamente heterogéneo. Una variante clínica inusual es la epidermolisis bulosa pruriginosa (EBP), que se caracteriza por prurito intenso y lesiones similares a prurigo nodular o liquen simple crónico; y también por la fragilidad de la piel puede conducir a hipertrofia, liquenificación, nódulos y placas. Como en las otras formas de epidermólisis bulosa distrófica, las lesiones se localizan principalmente en extremidades; la patología molecular implica mutaciones en el gen que codifica la proteína fibrilar de anclaje, el colágeno tipo VII (COL7A1). Reportamos el caso de un paciente adulto sin antecedentes patológicos con compromiso cutáneo cuyo tratamiento resultó insatisfactorio, siendo pocos los aportes de la literatura en el manejo exitoso de esta patología.

Dystrophic epidermolysis bullosa is a rare, hereditary, clinically heterogeneous skin disorder. Epidermolysis bullosa pruriginosa is an unusual clinical variant characterized by severe pruritus and simplex lichenoid or nodular prurigo-like lesions; and also by the skin fragility that may lead to hypertrophic, lichenified nodules and plaques. Like other forms of dystrophic epidermolysis bullosa, lesions are located primarily in extremities; molecular pathology involves mutations in the gene encoding the anchoring fibril protein, type VII collagen (COL7A1). We report a case of a previously healthy male adult patient with skin lesions, whose treatment was unsatisfactory, with few contributions from the literature in the successful management of this disease.

Melanoma acral amelanótico desmoplásico / Acral amelanotic desmoplastic melanoma

Se reporta el caso de un paciente varón de 68 años de edad que presentó tumoración exofítica en planta de pie derecho que al estudio histopatológico fue compatible con melanoma acral amelanótico desmoplásico. El melanoma desmoplásico es una variante histológica de presentación poco frecuente, más aún el tipo amelanótico, y de localización acral, por lo que requiere de un diagnóstico precoz para el tratamiento oportuno, mejorando así el pronóstico del paciente.

We report the case of a male patient aged 68, who presented an exophytic tumor in his right foot plant that, by histopathological study, was compatible with acral amelatonic desmoplastic melanoma. Desmoplastic melanoma is a subtype of rare representation, and even more the amelatonic type of acral location, therefore it requires early diagnosis for prompt treatment and thereby improving patient prognosis.