Microscopic Metastases Research Articles

MRI-only breast cancers are less aggressive than cancers identifiable on conventional imaging

BackgroundMagnetic resonance imaging (MRI) has a superior sensitivity for the diagnosis of breast cancer, leading to lesions primarily detected by MRI. Some of these lesions cannot be identified by targeted second-look ultrasound (SLUS) examinations and are thus referred to as MRI-only lesions. We hypothesize that biologically more aggressive cancers lead to more distinct tissue damage improving visibility on SLUS. ObjectiveTo investigate whether there are differences in cancer subtypes between MRI-only and SLUS-detected malignant lesions. MethodsThis retrospective single-center observational study evaluated 435 patients who received breast MRI examinations between January 2017 and December 2022, with at least one lesion primarily detected on MRI and histologically confirmed as malignant. Demographic characteristics, lesion type (mass or non-mass), MRI-assessed lesion size (mm), histological diagnosis, stage, immunohistochemical analysis (ER, PR, HER-2, Ki-67), and lymph node status were assessed and compared between MRI-only and SLUS-detected. ResultsAmong 435 patients (mean age of 57.4 ± 13.3), 34.02 % (n = 148) were in the MRI-only group, while the remaining 65.98 % (n = 287) were identified by SLUS. MRI-only cases were significantly smaller in size (10 mm vs 20 mm), mostly staged as T1 (66.9 %) and showed features associated with less biological aggressiveness (higher pure ductal carcinoma in situ rates: 30.4 % vs 5.2 %; lower Ki-67, median values: 10 vs 20) compared to SLUS-detected cases (P < 0.001). SLUS-detected cancers had higher ratios of microscopic (4.9 % vs 3.4 %) and macroscopic axillary metastasis (26.8 % vs 7.4 %) compared to MRI-only lesions (P < 0.001). ConclusionMRI-only lesions presented histologically and immunohistochemically with less aggressive patterns compared to those detected via SLUS.Clinic Impact: Our data provide evidence that MRI-only lesions are biologically less aggressive and of lower stage, offering the potential of earlier treatment chance since they are visible on MRI before becoming more aggressive and destructive.

SENTINEL LYMPH NODE BIOPSY IN THE MANAGEMENT OF PATIENTS WITH MALIGNANT MELANOMA

Objectives: To evaluate the efficacy of sentinel lymph node biopsy in the treatment of malignant melanoma. Materials and Methods: Thirty-two melanoma patients without distant or clinical lymph node metastasis underwent preoperative lymphoscintigraphy using Tc99m and a handheld gamma probe to identify sentinel lymph nodes for biopsy. In cases with detected sentinel lymph node metastasis, the patient may require total complete lymph node dissection, combined with optional systemic therapy. Follow-up was performed to evaluate the efficacy of this procedure. Results: In 32 melanoma patients, the most common site of primary tumors was the extremity, accounting for 90.6%, with a mean Breslow index (thickness of the primary tumor) of 1.84 mm. The incidence of microscopic lymph node metastasis was 34.4%. For cases with no detected sentinel lymph node metastasis, 100% of patients had a stable condition, and no recurrence or metastasis was detected. In 11 cases with occult nodal metastasis: 2 deaths, 4 patients were treated with chemotherapy, and 5 cases without chemotherapy. The mean duration of hospitalization for the group with sentinel lymph node metastasis was greater than that of the group without sentinel lymph node metastasis, 25.1 ± 3.1 days and 13.5 ± 1.3 days, respectively. Conclusion: Our results suggest that sentinel lymph node biopsy is a less invasive technique for melanoma patients with no clinically detectable lymph node and distant metastases. This procedure has shown initial outcomes, but it is necessary to conduct a study with a larger sample size and a longer follow-up time, as well as comparing it with a control group for accurate evaluation. Received 23 June 2023Revised 22 September 2023Accepted 27 November 2023

Apoptosis Induction by New Coumarin Derivatives in a Mice Model of Breast Cancer.

In the last decades, numerous studies have focused on the search for new agents to suppress the growth of cancer cells. In this study, we investigated the effect of two novel synthetic coumarin derivatives, namely 2-amino-4-(4-(2-hydroxyethoxy)-3-methoxyphenyl)-5-oxo-4H,5H-pyrano[3,2-c]coumarin-3-carbonitrile and 2-amino-4-(4-hydroxyphenyl)-5-oxo-4H,5H-pyrano[3,2-c]coumarin-3-carbonitrile, on the induction of apoptosis in breast cancer in a mouse model. Breast cancer was induced in BALB/c mice, which were randomly divided into six groups and then underwent the experiment. The groups and treatments included A1: coumarin A with a low dose (10 µm), A2: coumarin A with a high dose (1 mM), B1: coumarin B with a low dose (10 µm), B2: coumarin B with a high dose (1 mM), D: doxorubicin, and C: cancer control/ treatment with normal saline. The samples underwent treatments for 5 weeks. Animals were euthanized, and tissue samples, including the lung, liver, and tumor mass, were collected for histopathological examination. In addition, quantitative real-time polymerase chain reaction (qRT-PCR) was performed to determine some apoptotic markers, such as BCL-2, caspase-9, COX-2, and c-Myc. The qRT-PCR presented that both coumarin compounds could significantly alter the expression levels of BCL-2, caspase-9, COX-2, and c-Myc. Consistent with these results, histopathological observations showed a significant reduction in pathological lesions and severity of malignancy of the tumor mass, as well as a decrease in microscopic metastases in the lung and liver. This suggests that the present new coumarin compounds may induce apoptosis in breast cancer cells by altering some apoptosis-related genes that may play a chemotherapeutic role in breast cancer therapy in the future.

Impact of albumin-lymphocyte-platelet-C-reactive protein index as a prognostic indicator of hepatocellular carcinoma after resection: Associated with nuclear factor erythroid 2-related factor 2.

To investigate the prognostic value of the preoperative albumin-lymphocyte-platelet-C-reactive protein (ALPC) index in patients with hepatocellular carcinoma (HCC) undergoing curative hepatectomy. We also evaluated the relationship between the ALPC index and the phosphorylated nuclear factor erythroid 2-related factor 2 (p-Nrf2) levels. Data were analyzed retrospectively from 256 patients who underwent resection for HCC. For cross-validation, patients were divided into the training and testing cohort. We assessed eight combinations of inflammatory markers for predictive value for recurrence. We examined the associations of the ALPC index with recurrence-free survival and overall survival in univariate and multivariate analyses (Cox proportional hazards model). Immunohistochemical staining of p-Nrf2 was performed on tumor samples of 317 patients who underwent hepatic resection forHCC. A high preoperative ALPC index correlated with a high serum albumin concentration, small tumor size, low rate of poor differentiation, solitary tumor, early Barcelona Clinic Liver Cancer stage, and low rate of microscopic intrahepatic metastasis in the training dataset. A high preoperative ALPC index correlated with a high serum albumin concentration, high serum alpha-fetoprotein concentration, small tumor size, a low rate of poor differentiation and a low rate of microscopic intrahepatic metastasis in the testing dataset. A higher preoperative ALPC index was an independent predictor of longer recurrence-free survival and overall survival in the training and testing datasets. A high ALPC index was associated with negative p-Nrf2 expression in HCC tumor cells. We showed that a high ALPC index was an independent prognostic factor for patients with HCC undergoing curative hepatic resection.

Apoptosis Induction by New Coumarin Derivatives in a Mice Model of Breast Cancer

In the last decades, numerous studies have focused on the search for new agents to suppress the growth of cancer cells. In this study, we investigated the effect of two novel synthetic coumarin derivatives, namely 2-amino-4-(4-(2-hydroxyethoxy)-3-methoxyphenyl)-5-oxo-4H,5H-pyrano[3,2-c]coumarin-3-carbonitrile and 2-amino-4-(4-hydroxyphenyl)-5-oxo-4H,5H-pyrano[3,2-c]coumarin-3-carbonitrile, on the induction of apoptosis in breast cancer in a mouse model. Breast cancer was induced in BALB/c mice, which were randomly divided into six groups and then underwent the experiment. The groups and treatments included A1: coumarin A with a low dose (10 µm), A2: coumarin A with a high dose (1 mM), B1: coumarin B with a low dose (10 µm), B2: coumarin B with a high dose (1 mM), D: doxorubicin, and C: cancer control/ treatment with normal saline. The samples underwent treatments for 5 weeks. Animals were euthanized, and tissue samples, including the lung, liver, and tumor mass, were collected for histopathological examination. In addition, quantitative real-time polymerase chain reaction (qRT-PCR) was performed to determine some apoptotic markers, such as BCL-2, caspase-9, COX-2, and c-Myc. The qRT-PCR presented that both coumarin compounds could significantly alter the expression levels of BCL-2, caspase-9, COX-2, and c-Myc. Consistent with these results, histopathological observations showed a significant reduction in pathological lesions and severity of malignancy of the tumor mass, as well as a decrease in microscopic metastases in the lung and liver. This suggests that the present new coumarin compounds may induce apoptosis in breast cancer cells by altering some apoptosis-related genes that may play a chemotherapeutic role in breast cancer therapy in the future.

Transferrin Receptor is Associated with Sensitivity to Ferroptosis Inducers in Hepatocellular Carcinoma.

Transferrin receptor (TFR), a membrane protein that has a critical role in the transport of iron into cells, is known to be a ferroptosis-related marker. Although TFR is reported to be abundantly expressed in tumor cells, its relationship with ferroptosis inducers in hepatocellular carcinoma (HCC) remains unclear. The authors performed immunohistochemical staining of TFR and divided 350 HCC patients into two groups according to its expression. They analyzed the association between TFR expression and prognosis or clinicopathologic factors. In addition, the regulation of malignant activity and its effect on the efficacy of ferroptosis inducers were investigated in vitro. For this study, 350 patients were divided into TFR-positive (n =180, 51.4%) and TFR-negative (n = 170, 48.6%) groups. The TFR-positive group had more hepatitis B surface antigen (HBs-Ag) (p = 0.0230), higher α-fetoprotein (AFP) levels (p = 0.0023), higher des-gamma-carboxyprothrombin (DCP) levels (p = 0.0327), a larger tumor size (p = 0.0090), greater proportions of Barcelona Clinic Liver Cancer (BCLC) stage B or C (p = 0.0005), poor differentiation (p < 0.0001), and microscopic intrahepatic metastasis (p = 0.0066). In the multivariate analyses, TFR expression was an independent prognostic factor in disease-free survival (p = 0.0315). In vitro, TFRC knockdown decreased cell motility. In addition, TFRC knockdown abolished artesunate (AS)-, lenvatinib-, and sorafenib-induced ferroptosis in HCC cell lines. The study demonstrated that simultaneous treatment of AS with multi-kinase inhibitor augmented the ferroptosis-inducing effects of AS in HCC cell lines. TFR expression is a poor prognostic factor in HCC, but its expression increases sensitivity to ferroptosis-inducing agents.

A rare case of ocular and testicular T-cell lymphoma in a hermaphrodite koi carp (Cyprinus carpio Linnaeus 1758): clinical, histopathological, and immunohistochemical study

BackgroundLymphatic neoplasia may occur in various types, such as lymphoma, lymphosarcoma, lympholeukemia, and plasmacytoid leukemia. Lymphoma, defined as a malignant tumour of lymphoid tissue, has been found in a number of fish families including Esocidae and Salmonidae. However, the occurrence of lymphoma is rare in those belonging to the Cyprinidae. A final diagnosis of ocular and testicular T-cell lymphoma in the present study was based on the clinical signs, morphology, and texture of the tumour masses in the macroscopic and microscopic examinations. In addition, histopathological and immunohistochemical findings corresponded to T-cell lymphoma characteristics.Case presentationA 2-year-old hermaphrodite koi carp (Cyprinus carpio Linnaeus 1758) with a large ocular mass and severe exophthalmia in the right eye was referred to the Ornamental Fish Clinic in October 2020. Under anesthesia, enucleation was performed. 57 days after enucleation of the right eye, exophthalmia in the left eye was discovered. 221 days after surgery, the fish was discovered to be dead. At necropsy, a large soft tissue mass attached to the left testis was discovered. There were also small whitish nodules on the surface of the liver. Histopathology revealed a hypercellular ocular mass with scant connective tissue. The sections also revealed multifocal hemorrhages, round to ovoid neoplastic cells, mild-to-moderate anisokaryosis and anisocytosis, and mitotic figures. Basophilic neoplastic cells were found in blood vessels within the testicular mass, raising the possibility of systemic spread. The liver showed microscopic metastasis with morphologic similarities to the ocular and testicular tumors. The neoplastic cells infiltrating the left and right eyes as well as the testicular mass were immunohistochemically positive for CD3 but negative for CD20. The masses were diagnosed as T-cell lymphoma based on histopathological and immunohistochemical findings.ConclusionsThis case report provides the first evidence of clinical, histopathological, morphological, and immunohistochemical findings of an ocular and testicular T-cell lymphoma in a hermaphrodite koi carp (Cyprinus carpio) in Iran.

C-Reactive Protein and Lymphocyte-to-Monocyte Ratio Predict Recurrence in Stage III Melanoma Patients with Microscopic Sentinel Lymph Node Metastasis.

Although adjuvant therapies with immune checkpoint inhibitors (ICI) and BRAF/MEK inhibitors improve recurrence-free survival (RFS) in stage III melanoma patients significantly, prognostic factors are needed to identify patients with a high risk of disease recurrence. Therefore, the aim of our study was to investigate the prognostic potential of routinely collected blood parameters for stage III melanoma patients with microscopic sentinel lymph node (SLN) metastasis. Altogether, we retrospectively analyzed 138 stage III melanoma patients who were diagnosed with microscopic SLN metastasis at the skin cancer center of the University Hospital Cologne between 2011 and 2020 and who did not receive prior adjuvant therapy with ICI or BRAF/MEK-inhibitors. Univariate and multivariate Cox regression analyses, Kaplan-Meier survival analyses and receiver operating characteristic (ROC) curves were performed to assess the impact of preoperatively collected blood parameters and blood ratios on recurrence-free survival (RFS; primary endpoint) and overall survival (OS). A high neutrophil-to-lymphocyte ratio (NLR), low lymphocyte-to-monocyte ratio (LMR) and high C-reactive protein (CRP) value were significantly associated with shorter RFS in multivariate analysis. For LMR (cut-off 3.5) and for CRP (cut-off 3.0) this effect remained after dichotomization. CRP showed a stronger association with RFS than NLR or LMR, with the highest association being detected for the combination of low LMR and high CRP. Additionally, derived NLR ≥ 2.0 was significantly associated with shorter OS in multivariate analysis. In summary, our data suggest that CRP in combination with LMR should be considered as a marker for melanoma recurrence in stage III melanoma patients with microscopic SLN metastasis.

The localization of thyroid cancers on the thyroid gland is a new risk factor for metastases of perithyroidal, peritracheal and central lymph nodes

Lymph node metastasis is frequently detected in differentiated thyroid cancers. Central dissection is performed to the lymph nodes in patients with microscopic metastases in the intraoperative evaluation. Other indications for central dissections are tumor size and cervical lateral lymph node metastasis. We consider that the localization of thyroid cancer in the thyroid lodge may be another risk factor for central lymph node metastasis. For this reason, the purpose of the present study was to investigate the relations between thyroid cancer localization and lymph node metastasis in differentiated thyroid cancer patients who had no preoperative cervical metastases and who underwent total thyroidectomy, and peritracheal, perithyroidal, and central lymph node dissection. A total of 213 differentiated thyroid cancer cases followed in our general surgery and endocrinology clinic between September 2016 and May 2020 were evaluated retrospectively. Based on the data in the files, the patients who underwent total thyroidectomy, and central, perithyroidal, and peritracheal lymph node dissection were included in the study. The patients were divided into four Groups according to tumor localizations, those with tumors adjacent to the trachea (Group 1), upper thyroid pole (Group 2), thyroid middle part (Group 3), thyroid inferior (Group 4). The demographic characteristics, laboratory parameters, cancer types, and lymph node metastasis rates of the Groups were evaluated. A total of 84% (179) of the cases had thyroid papillary cancer, 11.73% (25) had thyroid follicular cancer, and 4.2% (9) had poorly differentiated thyroid cancer. The mean age of all patients was found to be 49 ± 8.3years, and the female/male ratio was 2.4. It was found that the differentiated thyroid cancers metastasized to the perithyroidal, peritracheal, and central lymph nodes at a rate of 57.74%. The distribution of these metastases according to the Groups was; 62.85% in Group 1, 11.53% in Group 2, 43.9% in Group 3, and 88.57% in Group 4. It was also found that 80.32% of the papillary cancer cases and 57.14% of the follicular cancer cases metastasized to central (level VI) lymph nodes in Group 4. The localization of differentiated thyroid cancers is a new risk factor for perithyroidal metastases.

Myeloid-derived suppressor cell infiltration is associated with a poor prognosis in patients with hepatocellular carcinoma.

The clinicopathological features of myeloid-derived suppressor cell (MDSC) and CD8+ T-cell infiltration in hepatocellular carcinoma (HCC) are poorly understood. The present study examined MDSC and CD8+ T-cell infiltration in surgically resected primary HCC specimens and investigated the association of MDSC and CD8+ T-cell infiltration with clinicopathological features and patient outcomes. Using a database of 466 patients who underwent hepatic resection for HCC, immunohistochemical staining of CD33 (an MDSC marker) and CD8 was performed. High infiltration of MDSCs within the tumor was observed in patients with a poorer Barcelona Clinic Liver Cancer stage, larger tumor size, more poorly differentiated HCC, and greater presence of portal venous thrombosis, microscopic vascular thrombosis and macroscopic intrahepatic metastasis. MDSC infiltration and CD8+ T-cell infiltration were independent predictors of recurrence-free survival and overall survival, respectively. Stratification based on the MDSC and CD8+ T-cell status of the tumors was also associated with recurrence-free survival (10 year-recurrence-free survival; MDSChighCD8+ T-cellLow, 3.68%; others, 25.7%) and overall survival (10 year-overall survival; MDSChighCD8+ T-cellLow, 12.0%; others, 56.7%). In conclusion, the present large cohort study revealed that high MDSC infiltration was associated with a poor clinical outcome in patients with HCC. Furthermore, the combination of the MDSC and tumor-infiltrating CD8+ T-cell status enabled further classification of patients based on their outcomes.

Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression\u2014a case report

BackgroundGallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer.Case presentationA 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later.ConclusionAxillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Significance of Lymph Node Metastasis in the Treatment of Gastric Cancer and Current Challenges in Determining the Extent of Metastasis.

The stomach exhibits abundant lymphatic flow, and metastasis to lymph nodes is common. In the case of gastric cancer, there is a regularity to the spread of lymph node metastasis, and it does not easily metastasize outside the regional nodes. Furthermore, when its extent is limited, nodal metastasis of gastric cancer can be cured by appropriate lymph node dissection. Therefore, identifying and determining the extent of lymph node metastasis is important for ensuring accurate diagnosis and appropriate surgical treatment in patients with gastric cancer. However, precise detection of lymph node metastasis remains difficult. Most nodal metastases in gastric cancer are microscopic metastases, which often occur in small-sized lymph nodes, and are thus difficult to diagnose both preoperatively and intraoperatively. Preoperative nodal diagnoses are mainly made using computed tomography, although the specificity of this method is low because it is mainly based on the size of the lymph node. Furthermore, peripheral nodal metastases cannot be palpated intraoperatively, nodal harvesting of resected specimens remains difficult, and the number of lymph nodes detected vary greatly depending on the skill of the technician. Based on these findings, gastrectomy with prophylactic lymph node dissection is considered the standard surgical procedure for gastric cancer. In contrast, several groups have examined the value of sentinel node biopsy for accurately evaluating nodal metastasis in patients with early gastric cancer, reporting high sensitivity and accuracy. Sentinel node biopsy is also important for individualizing and optimizing the extent of uniform prophylactic lymph node dissection and determining whether patients are indicated for function-preserving curative gastrectomy, which is superior in preventing post-gastrectomy symptoms and maintaining dietary habits. Notably, advancements in surgical treatment for early gastric cancer are expected to result in individualized surgical strategies with sentinel node biopsy. Chemotherapy for advanced gastric cancer has also progressed, and conversion gastrectomy can now be performed after downstaging, even in cases previously regarded as inoperable. In this review, we discuss the importance of determining lymph node metastasis in the treatment of gastric cancer, the associated difficulties, and the need to investigate strategies that can improve the diagnosis of lymph node metastasis.

Feasibility of Laparoscopic Para-Aortic Lymphadenectomy for Locally Advanced Cervical Cancer.

Background:Radiological evaluation of para-aortic lymph node metastasis in patients with locally advanced cervical cancer (LACC) possess the risk of missing microscopic metastasis. We commenced laparoscopic para-aortic lymphadenectomy (Lap-PAN) on patients with LACC for surgical staging in 2016. We assessed the feasibility of Lap-PAN in patients with LACC.Methods:We retrospectively reviewed the records of 31 patients with LACC who were staged at International Federation of Gynecology and Obstetrics (FIGO) 2009 IIB to IVA without enlargement of the para-aortic lymph nodes who underwent radiation therapy in our hospital between January 1, 2011 and December 31, 2018. The postoperative outcomes of Lap-PAN were analyzed, and distinct parameters for each patient, including sites of recurrence and disease-free survival, were compared between the Lap-PAN (n = 12) and no surgery (n = 19) groups.Results:The average operation time for Lap-PAN was 167 min, and the estimated blood loss was less than 50 ml in all patients. There were no perioperative complications. The average number of excised lymph nodes was 25, and no pathological metastases were observed. There was no difference in disease-free survival rates between the Lap-PAN and no surgery groups (p = 0.42). During the follow-up period, there were two cases of recurrence in the cervix in the Lap-PAN group, and three and four cases of lung and para-aortic lymph node recurrence, respectively in the no-surgery group.Conclusions:Lap-PAN was safely performed as a pretherapeutic staging method for LACC without worsening patient prognosis. Although Lap-PAN requires a high level of skill, it may be a method to avoid excessive radiation for LACC.

Lymph Node Dissection for Papillary Thyroid Carcinoma.

Cervical lymph node metastasis is frequent in patients with papillary thyroid carcinoma. In addition to the extent of thyroidectomy, the need as well as the extent of concomitant lymphadenectomy has been a subject of controversy and debate. The central compartment is the most frequent site of metastasis followed by the lateral compartment although skip metastasis in the lateral compartment can occur. Papillary thyroid carcinoma can also present with cervical lymph node metastasis, while the primary tumor remains clinically undetectable. Surgical removal of clinically involved nodal metastasis should be mandatory to prevent recurrence and improve disease prognosis. However, despite a low accuracy of preoperative imaging for microscopic disease and the frequent microscopic metastasis to the central compartment, routine prophylactic neck dissection has not been shown to haveany relevance to prevent recurrence or improve disease cure. Routine or prophylactic central compartment dissection is generally not recommended unless in the presence of high-risk tumors. The potential benefit of reducing central compartment recurrence or avoiding high-risk reoperation probably outweighs the risk of inducing surgical complication including hypoparathyroidism during routine central neck dissection. Therapeutic lateral neck dissection is performed for clinically involved nodes detected by preoperative imaging confirmed by needle biopsy, while prophylactic lateral neck dissection is contraindicated. The extent of neck dissection has been de-escalated, and compartmental nodal dissection aiming at preservation of function is performed to achieve a complete surgical resection. Postoperative adjuvant radioiodine is frequently administered for patients with positive nodal metastasis (intermediate-risk group) to avoid future recurrence. Routine central neck dissection may also upstage patients with microscopic nodal metastases and increase the use of postoperative adjuvant radioiodine.

Early immunohistochemical detection of pulmonary micrometastases in dogs with osteosarcoma

BackgroundDespite decades of research, the early phases of metastatic development are still not fully understood. Canine osteosarcoma (OS) is a highly aggressive cancer, with a high metastatic rate (> 90%), despite a low overt metastatic prevalence at initial diagnosis (< 15%). Canine OS is generally regarded as a good clinically relevant model for human OS. The aim of this hypothesis-generating study was to evaluate a method to detect pulmonary micrometastases and study their prevalence in dogs with OS without macroscopic metastases. We prospectively enrolled dogs with OS that received no cancer-specific treatment (n = 12) and control dogs without cancer (n = 2). Dogs were necropsied and sampled immediately after euthanasia. The OS dogs were classified as having macroscopic metastases (n = 2) or not (n = 10). We immunohistochemically stained one tissue sample from each of the seven lung lobes from each dog with a monoclonal antibody (TP-3) to identify micrometastases (defined as clusters of 5–50 tumour cells), microscopic metastases (> 50 tumour cells) and TP-3 positive single cells (< 5 tumour cells).ResultsWe showed that pulmonary micrometastases easily overseen on routine histology could be detected with TP-3. Pulmonary micrometastases and microscopic metastases were present in two dogs with OS without macroscopic metastases (20%). Micrometastases were visualised in three (43%) and four (57%) of seven samples from these two dogs, with a mean of 0.6 and 1.7 micrometastases per sample. Microscopic metastases were present in one (14%) and four (57%) of seven samples from the same two dogs, with a mean of 0.14 and 1.0 microscopic metastases per sample. There were four (57%) and two (29%) samples with neither microscopic metastases nor micrometastases for each of these two dogs. The prevalence of pulmonary micrometastases (20%) was significantly lower than expected (> 90%) based on commonly expected metastatic rates after amputation (P < 0.0001). There was no statistically significant difference in the number of TP-3 positive single cells in between groups (P = 0.85).ConclusionsPulmonary micrometastases could be detected with TP-3 immunohistochemistry in a subset of dogs with OS before macroscopic metastases had developed. We propose that dogs with spontaneous OS represent clinically relevant models to study early micrometastatic disease.

Impact of Nuclear Factor Erythroid 2-Related Factor 2 in Hepatocellular Carcinoma: Cancer Metabolism and Immune Status.

We examined phosphorylated nuclear factor erythroid 2–related factor 2 (P‐NRF2) expression in surgically resected primary hepatocellular carcinoma (HCC) and investigated the association of P‐NRF2 expression with clinicopathological features and patient outcome. We also evaluated the relationship among NRF2, cancer metabolism, and programmed death ligand 1 (PD‐L1) expression. In this retrospective study, immunohistochemical staining of P‐NRF2 was performed on the samples of 335 patients who underwent hepatic resection for HCC. Tomography/computed tomography using fluorine‐18 fluorodeoxyglucose was performed, and HCC cell lines after NRF2 knockdown were analyzed by array. We also analyzed the expression of PD‐L1 after hypoxia inducible factor 1α (HIF1A) knockdown in NRF2‐overexpressing HCC cell lines. Samples from 121 patients (36.1%) were positive for P‐NRF2. Positive P‐NRF2 expression was significantly associated with high alpha‐fetoprotein (AFP) expression, a high rate of poor differentiation, and microscopic intrahepatic metastasis. In addition, positive P‐NRF2 expression was an independent predictor for recurrence‐free survival and overall survival. NRF2 regulated glucose transporter 1, hexokinase 2, pyruvate kinase isoenzymes L/R, and phosphoglycerate kinase 1 expression and was related to the maximum standardized uptake value. PD‐L1 protein expression levels were increased through hypoxia‐inducible factor 1α after NRF2 overexpression in HCC cells. Conclusions: Our large cohort study revealed that P‐NRF2 expression in cancer cells was associated with clinical outcome in HCC. Additionally, we found that NRF2 was located upstream of cancer metabolism and tumor immunity.

Phase II Clinical Trial Evaluating Complete Metastasis Ablation After Progression on Checkpoint Inhibition

Retrospective and prospective studies in patients with oligometastatic non-small-cell lung cancer (NSCLC) suggested clinical benefit after complete metastatic ablation (CMA). So far, no studies have addressed the toxicity and efficacy of CMA to oligometastatic lesions in patients that progressed during immune checkpoint inhibitors (ICIs) therapy. Here, we report results of a single arm- radiotherapy (RT) to oligometastatic lesions from our ongoing phase II trial (NCT02710253).This study enrolled patients that progressed within 6 months of ICI therapy and developed oligo-metastases. Treatment intervention allowed for any dose and fractions of RT per the treating physician to all metastatic sites, with irradiation for up to 6 sites. Primary endpoints of this study are time to new lesion development, and disease control rate (DCR) by RECIST 1.1. Secondary endpoints are toxicity, progression-free survival (PFS), overall survival (OS) and absolute lymphocyte counts (ALC).Of the 30 patients initially enrolled in this study, 26 patients (N = 21 NSCLC; N = 5 melanoma) were included in the analysis as they had completed imaging follow-up. A total of 64 lesions were irradiated with a mean of 2.5 lesions per patient. Most frequent location of irradiated was lung (n = 45), followed by adrenal (n = 7), liver (n = 4), bone (n = 4) and others (n = 4); 50% of patients received SBRT. At a median follow-up time of 23.0 months (range, 5.0-44.7 months), 12 patients had no new lesions, while 14 patients developed new lesions in lung (50%), bone (25%), brain (21%). Median time to new lesion development was 14.6 months. DCR was 77% (complete response 19%, partial response 19%, stable disease 38%); median PFS was 10.1 months and median OS was not reached. No toxicities greater than grade 2 was observed. Pre-RT ALC is an independent risk factor for time to new lesion development (P = 0.006, HR = 0.1, 95% CI, 0.02-0.51). Patients without new lesion development had significantly higher baseline ALC (P = 0.011) and more ALC after RT at 1 month (P = 0.025), 3 months (P = 0.006), 6 months (P = 0.002) and 12 months (P = 0.045) compared to patients with new lesions. Other factors including age, gender, SBRT, baseline tumor size, performance status and tumor histology did not affect the time to new lesion development.In patients with oligometastatic lesions that progressed on ICI, CMA may be a valid treatment option that generates clinical benefits. By eradicating gross sites of disease by converting area sites into in-situ vaccines, T cells are able to access microscopic metastasis. Larger randomized trials are indicated to further define the role of CMA for ICIs resistance.

From Oncological Paradigms to Non-Communicable Disease Pandemic. The Need of Recovery Human Biology Evolution.

The paradigm of the Somatic Mutation Theory (SMT) is failing, and a new paradigm is underway but not yet established. What is being challenged is a conceptual approach that involves the entire human biology and the development of chronic diseases. The behavior of breast and other solid cancers is compatible with the concept that the primary tumor is able to control its microscopic metastases, in the same way that an organ (e.g., the liver) is able to control its physiological size. This finding suggested that cancer and its metastases may behave as an organoid. The new paradigm under construction considers the origin of tumors as a disturbance in the communication network between tissue cell populations and between cells and extracellular matrix, and supports a systemic approach to the study of both healthy and pathologic tissues. The commentary provides a rationale for the role of physical exercise in the control of tumor dormancy according to a human evolutionary perspective.

Preoperative PSMA-PET/CT as a predictor of biochemical persistence and early recurrence following radical prostatectomy with lymph node dissection.

This study aims to evaluate the predictive value of lymph nodes (LN) suspicious for metastases on preoperative prostate-specific membrane antigen (PSMA) PET/CT for biochemical persistence (BCP) and early biochemical recurrence (BCR) following robotic-assisted radical prostatectomy (RARP) with extended pelvic LN dissection (ePLND). We evaluated 213 patients with intermediate and high-risk prostate cancer (PCa) who underwent clinical staging with preoperative 68Ga- or 18F-PSMA-PET/CT scan and subsequent RARP with ePLND. Patients were grouped as PSMA- or PSMA+ depending on their LN status on PSMA-PET/CT and subdivided according to histological LN status in pN0 or pN1. Diagnostic accuracy of PSMA-PET/CT for the detection of pN1 was evaluated. BCP was defined as a first postoperative serum PSA level ≥0.1 ng/mL 6-12 weeks following RP. Early BCR was defined as detectable PSA > 0.2 ng/mL within 12 months of follow-up. Univariable logistic regression analyses were used to evaluate the effect of PSMA+ on BCP and BCR. Forty patients (19%) were PSMA+. The overall incidence of pN1 was 23%. Sensitivity, specificity, PPV and NPV on a per patient level for the detection of pN1 was 29%, 84%, 35%, and 80% respectively. BCP was observed in 26 of 211 patients (12%) and early BCR in 23 of 110 patients (21%). The presence of PSMA+ was a significant predictor for BCP (OR 7.1, 2.9-17.1 95% CI) and BCR (OR 8.1, 2.9-22.6 95% CI). Preoperative PSMA-PET/CT may be a valuable tool for patient counseling for RARP and ePLND as it is a significant predictor for the risk of postoperative BCP and early BCR. We conclude that an ePLND should not be avoided in men with intermediate or high-risk PCa and preoperative negative PSMA-PET/CT, as 20% have microscopic LN metastasis.

Lymphocyte-to-C-reactive protein ratio as a prognostic factor for hepatocellular carcinoma.

Systemic inflammation has been correlated with worse survival for some cancers. We evaluated prognostic values of various inflammatory factor combinations in patients who underwent resections for hepatocellular carcinoma (HCC). We retrospectively analysed 306 consecutive patients with HCC who underwent curative liver resections. After assessing eight combinations of inflammatory markers for predictive value for recurrence, we focused on lymphocyte-to-C-reactive protein ratio (LCR) to elucidate its associations with recurrence-free survival (RFS) and overall survival (OS) in univariate and multivariate analyses (Cox proportional hazards model). We also used immunohistochemical CD34 and CD8 staining to investigate the mechanism of LCR elevation. LCR showed the highest association with RFS in HCC patients among the compared indices. High preoperative LCR correlated with a high serum albumin concentration, small tumour size, early Barcelona Clinic Liver Cancer stage and low rates of microscopic vascular invasion and microscopic intrahepatic metastasis. Higher preoperative LCR was an independent predictor of longer RFS and OS in this cohort. High LCR patients had fewer vessels encapsulating tumour clusters, and higher intratumoural CD8+ T-cell counts than low LCR patients. Preoperative LCR is a novel and convenient prognostic marker for patients with HCC, and is associated with the tumour microenvironment immune status.