Genomic Profiling of Bronchoalveolar Lavage Fluid in Lung Cancer.

Genomic profiling of bronchoalveolar lavage (BAL) samples may be useful for tumor profiling and diagnosis in the clinic. Here, we compared tumor-derived mutations detected in BAL samples from subjects with non-small cell lung cancer (NSCLC) to those detected in matched plasma samples. Cancer Personalized Profiling by Deep Sequencing (CAPP-Seq) was used to genotype DNA purified from BAL, plasma, and tumor samples from patients with NSCLC. The characteristics of cell-free DNA (cfDNA) isolated from BAL fluid were first characterized to optimize the technical approach. Somatic mutations identified in tumor were then compared with those identified in BAL and plasma, and the potential of BAL cfDNA analysis to distinguish lung cancer patients from risk-matched controls was explored. In total, 200 biofluid and tumor samples from 38 cases and 21 controls undergoing BAL for lung cancer evaluation were profiled. More tumor variants were identified in BAL cfDNA than plasma cfDNA in all stages (P < 0.001) and in stage I to II disease only. Four of 21 controls harbored low levels of cancer-associated driver mutations in BAL cfDNA [mean variant allele frequency (VAF) = 0.5%], suggesting the presence of somatic mutations in nonmalignant airway cells. Finally, using a Random Forest model with leave-one-out cross-validation, an exploratory BAL genomic classifier identified lung cancer with 69% sensitivity and 100% specificity in this cohort and detected more cancers than BAL cytology. Detecting tumor-derived mutations by targeted sequencing of BAL cfDNA is technically feasible and appears to be more sensitive than plasma profiling. Further studies are required to define optimal diagnostic applications and clinical utility. SIGNIFICANCE: Hybrid-capture, targeted deep sequencing of lung cancer mutational burden in cell-free BAL fluid identifies more tumor-derived mutations with increased allele frequencies compared with plasma cell-free DNA. See related commentary by Rolfo et al., p. 2826.

Turning Practicing Surgeons Into Health Technology Innovators: Outcomes From the Stanford Biodesign Faculty Fellowship.

Background. The Stanford Biodesign Faculty Fellows program was established in 2014 to train Stanford Medical and Engineering faculty in a repeatable innovation process for health technology translation while also being compatible with the busy clinical schedules of surgical faculty members. Methods. Since 2014, 62 faculty members have completed the fellowship with 42% (n = 26) coming from 14 surgical subspecialties. This eight-month, needs-based innovation program covers topics from identifying unmet health-related needs, to inventing new technology, developing plans for intellectual property (IP), regulatory, reimbursement, and business models to advance the technologies toward patient care. Results/Conclusion. Intake and exit survey results from three years of program participants (n = 36) indicate that the fellowship is a valuable hands-on educational program capable of improving awareness and experience with skill sets required for health technology innovation and entrepreneurship.

Impact of a bronchial genomic classifier on clinical decision making in patients undergoing diagnostic evaluation for lung cancer.

BACKGROUND: Bronchoscopy is frequently used for the evaluation of suspicious pulmonary lesions found on computed tomography, but its sensitivity for detecting lung cancer is limited. Recently, a bronchial genomic classifier was validated to improve the sensitivity of bronchoscopy for lung cancer detection, demonstrating a high sensitivity and negative predictive value among patients at intermediate risk (10-60 %) for lung cancer with an inconclusive bronchoscopy. Our objective for this study was to determine if a negative genomic classifier result that down-classifies a patient from intermediate risk to low risk (<10 %) for lung cancer would reduce the rate that physicians recommend more invasive testing among patients with an inconclusive bronchoscopy. METHODS: We conducted a randomized, prospective, decision impact survey study assessing pulmonologist recommendations in patients undergoing workup for lung cancer who had an inconclusive bronchoscopy. Cases with an intermediate pretest risk for lung cancer were selected from the AEGIS trials and presented in a randomized fashion to pulmonologists either with or without the patient's bronchial genomic classifier result to determine how the classifier results impacted physician decisions. RESULTS: Two hundred two physicians provided 1523 case evaluations on 36 patients. Invasive procedure recommendations were reduced from 57 % without the classifier result to 18 % with a negative (low risk) classifier result (p < 0.001). Invasive procedure recommendations increased from 50 to 65 % with a positive (intermediate risk) classifier result (p < 0.001). When stratifying by ultimate disease diagnosis, there was an overall reduction in invasive procedure recommendations in patients with benign disease when classifier results were reported (54 to 41 %, p < 0.001). For patients ultimately diagnosed with malignant disease, there was an overall increase in invasive procedure recommendations when the classifier results were reported (50 to 64 %, p = 0.003). CONCLUSIONS: Our findings suggest that a negative (low risk) bronchial genomic classifier result reduces invasive procedure recommendations following an inconclusive bronchoscopy and that the classifier overall reduces invasive procedure recommendations among patients ultimately diagnosed with benign disease. These results support the potential clinical utility of the classifier to improve management of patients undergoing bronchoscopy for suspect lung cancer by reducing additional invasive procedures in the setting of benign disease.

High-dose renal replacement therapy for acute kidney injury: Systematic review and meta-analysis.

OBJECTIVE: To determine the effect of renal replacement therapy dose on mortality and dialysis dependence in patients with acute kidney injury. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to October 2009; PubMed "Related Articles;" bibliographies of included trials; and additional information from trial authors. STUDY SELECTION: Randomized and quasi-randomized, controlled trials in adults with acute kidney injury prescribed highvs. standard-dose continuous renal replacement therapy (> or =30 mL/kg/hr vs. <30 mL/kg/hr), intermittent hemodialysis, or sustained low-efficiency dialysis (daily vs. alternate day, or by target biochemistry). DATA EXTRACTION: Three authors independently selected studies and extracted data on outcomes and study quality. Meta-analyses used random-effects models. DATA SYNTHESIS: Of 5416 citations, 12 trials (n = 3999) met inclusion criteria. Modalities included continuous renal replacement therapy (7 trials), intermittent hemodialysis (3 trials), sustained low-efficiency dialysis (1 trial), and all three (1 trial). Study quality was moderate-high. Meta-analyses found no effect of high-dose renal replacement therapy on mortality (risk ratio, 0.89; 95% confidence interval, 0.77-1.03; 12 trials; n = 3954) or dialysis dependence among survivors (risk ratio, 1.15; 95% confidence interval, 0.92-1.44; 8 trials with events; n = 1743). The effect on mortality was similar (all interaction p values were nonsignificant) in patients with sepsis (risk ratio, 1.02; 95% confidence interval, 0.85-1.23; 9 trials; n = 1786) vs. without sepsis (risk ratio, 0.89; 95% confidence interval, 0.75-1.05; 8 trials; n = 1955), treated exclusively with continuous renal replacement therapy (risk ratio, 0.87; 95% confidence interval, 0.71-1.06; 7 trials; n = 2462) vs. other modalities alone or in combination (risk ratio, 0.92; 95% confidence interval, 0.70 -1.21; 5 trials; n = 1492), and in trials with low (risk ratio, 0.96; 95% confidence interval, 0.85-1.09; 6 trials; n = 3475) vs. higher (risk ratio, 0.76; 95% confidence interval, 0.53-1.09; 6 trials; n = 479) risk of bias. CONCLUSIONS: High-dose renal replacement therapy in acute kidney injury does not improve patient survival or recovery of renal function overall or in important patient subgroups, including those with sepsis.

Plasma membrane calcium ATPase overexpression in arterial smooth muscle increases vasomotor responsiveness and blood pressure.

In vascular smooth muscle cells (SMCs), several mechanisms act in concert to regulate the intracellular calcium concentration [Ca2+]i, which may in turn affect vascular tone. One such mechanism is the extrusion of Ca2+ by the plasma membrane calcium ATPase (PMCA). To address, in particular, the role of the neuronal nitric oxide synthase (nNOS)-associating isoform PMCA4b in regulating vascular tone, a doxycycline-responsive transgene for human PMCA4b was overexpressed in arterial SMCs of mice. Overexpression of hPMCA4b resulted in a 2-fold increase in total aortic PMCA4 protein expression and significant real-time RT-PCR-documented differences in the levels of endogenous mouse PMCA1, PMCA4, SERCA2, and IP3R1 gene expression in arterial SMCs. Whereas no significant difference in basal [Ca2+]i or Ca2+ sensitivity was observed in vascular SMCs or mesenteric arteries, respectively, from hPMCA4b-overexpressing versus control mice, hPMCA4b-overexpressing mice revealed a reduced set-point and increased extent of myogenic response and heightened sensitivity to vasoconstrictors. Treatment of arteries with an nNOS inhibitor resulted in a reduced set-point and increased extent of the myogenic response in control but not hPMCA4b-overexpressing mice. Moreover, aortic SMCs from hPMCA4b-overexpressing mice exhibited reduced levels of cGMP under both basal and phenylephrine-stimulated conditions. These changes were associated with significant doxycycline-reversible elevations in blood pressure. Taken together, these data show that overexpression of hPMCA4b in arterial SMCs increases vascular reactivity and blood pressure, an effect that may be mediated in part by negative regulation of nNOS.

Effects of age, gender, and blood pressure on myogenic responses of mesenteric arteries from C57BL/6 mice.

The myogenic response (MR) may represent an important physiological parameter underlying arterial blood pressure (BP). We studied the effects of age, gender, and BP on the MR of mesenteric arteries from 8- to 52-wk-old mice. Increasing age and BP are associated with an increase in the perfusion pressure at which tone develops (myogenic set point). An inverse correlation exists between age and extent (magnitude) of the MR in male (r(2) = 0.93, P = 0.0087) and female mice (r(2) = 0.90, P = 0.013) as well as between BP and extent of the MR in male (r(2) = 0.96, P = 0.0036) and female (r(2) = 0.90, P = 0.014) mice. In contrast, the strength of the MR (slope of active diameter-pressure relationship) and phenylephrine-mediated constriction did not differ among these groups. Although gender had no effect on MR at any perfusion pressure or age, only male mice showed significant salt-induced hypertension and an associated increase in the set point and reduction in the extent of the MR. The set point and extent of the MR is linked to the in vivo pressure during development and experimental hypertension.