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Understanding the evolutionary pathways to metastasis and resistance to immune-checkpoint inhibitors (ICI) in melanoma is critical for improving outcomes. Here, we present the most comprehensive intrapatient metastatic melanoma dataset assembled to date as part of the Posthumous Evaluation of Advanced Cancer Environment (PEACE) research autopsy program, including 222 exome sequencing, 493 panel-sequenced, 161 RNA sequencing, and 22 single-cell whole-genome sequencing samples from 14 ICI-treated patients. We observed frequent whole-genome doubling and widespread loss of heterozygosity, often involving antigen-presentation machinery. We found KIT extrachromosomal DNA may have contributed to the lack of response to KIT inhibitors of a KIT-driven melanoma. At the lesion-level, MYC amplifications were enriched in ICI nonresponders. Single-cell sequencing revealed polyclonal seeding of metastases originating from clones with different ploidy in one patient. Finally, we observed that brain metastases that diverged early in molecular evolution emerge late in disease. Overall, our study illustrates the diverse evolutionary landscape of advanced melanoma.Significance:Despite treatment advances, melanoma remains a deadly disease at stage IV. Through research autopsy and dense sampling of metastases combined with extensive multiomic profiling, our study elucidates the many mechanisms that melanomas use to evade treatment and the immune system, whether through mutations, widespread copy-number alterations, or extrachromosomal DNA.

Supplementary figure 1: Cohort overview. Number of samples sequenced with whole exome, panel or whole RNA sequencing. Supplementary figure 2: Phylogeny and WGD events in CRUKP1047. Supplementary figure 3: Ploidy and SCNA burden. Supplementary figure 4: Overview of each case. Supplementary figure 5: MEDICC2 copy number sample trees. Supplementary figure 6: MEDICC tree of all exome samples demonstrating that samples cluster together by patient, and not by melanoma subtype. Supplementary figure 7: SCNA frequency of cutaneous (a), acral (b) and melanoma of unknown primary (MUP, c). Supplementary figure 8: Correlation between liver copy number distance to other sites and time of emergence after stage IV diagnosis. Supplementary figure 9: Examination of tumour heterogeneity of alterations to antigen-presentation machinery genes, with site and patient annotation. Supplementary figure 10: Boxplots indicating the proportion of losses in the cohort for each segment. Supplementary figure 11: Balance of expression between nonsynonymous mutations that were not predicted to be neoantigens and clonal predicted neoantigens. Supplementary figure 12: Barplot of TIL infiltration score frequencies, determined by pathologist assessment of histology, across all samples. Supplementary figure 13: Number of samples per patient that are classified as either none-low in terms of TILs or moderate-heavy. Supplementary figure 14: Histogram of purity for samples with RNA-seq data. Supplementary figure 15: TME deconvolution. Supplementary figure 16: The effect of metastatic site on transcriptional profiles. Supplementary figure 17: Association of PHF3 copy number with expression. Supplementary figure 18: Overview of gene fusions identified in RNA-seq data. Supplementary figure 19: Comparison of ploidy estimates from panel sequencing data, exome data and FISH. Supplementary figure 20: Comparison of ploidy estimates in panel, exome, FISH and single cell data. Supplementary figure 21: FACs sort plot for CRUKP2567 diaphragmatic metastasis. Supplementary figure 22: Ploidy and wGII values from single cell sequencing of FACS-sorted tumour cells. Supplementary figure 23: Copy number profiles on chromosome 5 for bulk samples from primary and DI_2_R2, a diaphragmatic metastasis. Supplementary figure 24: Histogram of purity of samples for which RNA-seq was performed faceted by patient. Supplementary figure 25: Histogram of purity of samples for which RNA-seq was performed faceted by tissue site.

S. Table 1: List of PEACE Consortium members. S. Table 2: Sample database used for the study for Panel, Exome and RNASeq samples. S. Table 3: Overview of lines of treatment given to each patient. S. Table 4: Lesions and patients included in the lesion-level response to ICI analysis. S. Table 5: Hallmark genesets significantly upregulated in normal tissue vs tumor tissue. Table shows p-values for tissue type, purity; T value for tissue type, purity; q-value for tissue type, purity (FDR corrected). S. Table 6: Hallmark genesets significantly upregulated in tumor tissue vs normal tissue. Table shows p-values for tissue type, purity; T value for tissue type, purity; q-value for tissue type, purity (FDR corrected). S. Table 7: Genes included in the target panel. S. Table 8: Tree topology comparisons between manually constructed trees and pairtree-constructed trees.

Background Medullary thyroid carcinoma (MTC) in the context of multiple endocrine neoplasia type 2 (MEN2) is caused by mutations in the RET proto-oncogene. Therefore, in children with MEN2 and advanced MTC, the RET tyrosine kinase (TK) pathway is a target for treatment with selpercatinib, a selective RET TK inhibitor. Patients and methods A retrospective review of the clinical, genetic, biochemical (calcitonin and carcinoembryonic antigen [CEA]) and imaging data of six medically untreated children with MEN2 and recurrent and or progressive MTC. The main parameters were safety and objective treatment response to selpercatinib. Results Six children (three males and three females, aged 3–12 years), four with MEN2B and two MEN2A, are reported. All had initial total thyroidectomy and extensive neck dissections but subsequently developed recurrent and progressive disease. All experienced an improvement in clinical symptoms with a concomitant biochemical response evidenced by significant fall in serum calcitonin and CEA concentrations. The fall in serum calcitonin was evident within 2 weeks of the start of selpercatinib, and responses were ongoing at a median follow-up of 13 months (range, 11–22 months). Four children with measurable radiological disease had good volume reduction. The most common adverse effects were transient but reversible grade 1 or 2 increase in alanine aminotransferase, serum bilirubin and constipation. No child required a dose modification or had to discontinue selpercatinib because of a drug-related adverse event. Conclusion Selpercatinib has shown excellent therapeutic efficacy with minimal toxicity in children with MEN2 and progressive metastatic RET-mutated MTC.

AIM Differentiated thyroid cancer (DTC) in children and adolescents is rare and data about its presentation and management are not well known. The aim of this study was to provide evidence of the current practice in the United Kingdom before the launch of the Rare National Paediatric Endocrine Tumours Guidelines (to be published in 2020). METHODS Seventy-two children and adolescents with DTC (

INTRODUCTION Whilst excision biopsy is traditionally preferred, advances in radiological and histological techniques warrant a re-look at core biopsy as a viable primary diagnostic method. METHOD Over a 3-year period, all patients who underwent core biopsy to investigate lymphoma at our centre were included. RESULTS 554 consecutive patients were included (40.1% prior lymphoma and 59.4% new presentations). Three or more cores were taken in 420 (75.8%) cases. Median time from request to biopsy and biopsy to histology report was 2 (0-40) days and 7 (1-24) days, respectively. 510/544 (93.8%) biopsies were diagnostic. There was no difference in whether the biopsy was diagnostic based on indication (new vs. relapsed lymphoma) (P = .445), whether biopsy was PET-directed (P = .507), for T-cell lymphoma (P = .468) or nodal vs. extra-nodal (P = .693). Thirty-eight patients (6.9%) required a second biopsy due to inadequate tissue. In a patient experience survey, only 13.9% reported any complications (1 self-limiting minor bleeding, 4 bruising) whilst 16.7% reported any discomfort beyond 12 hours. CONCLUSION Core biopsy performed by experienced radiologists and analysed by expert haemato-pathologists is a reliable, well-tolerated method for diagnosing lymphoma and confirming relapse. Multiple cores can be obtained under local anaesthetic yielding sufficient material in the majority of cases.

Patient: Female, 67-year-old Final Diagnosis: Thyroid cancer Symptoms: Weaknes of lower limbs Medication:— Clinical Procedure: — Specialty: Oncology Objective: Unusual clinical course Background: Papillary thyroid carcinoma is usually an indolent disease, with an almost 80% 5-year survival rate for meta-static disease. Conversely, anaplastic thyroid cancer is much more aggressive, with median overall survival rates of 4 months. Case Report: A 67-year-old woman presented with metastatic papillary thyroid cancer with bone metastasis, including an unstable L4 pathological fracture. Initially, she underwent lumbar stabilization surgery, followed by high-dose palliative radiotherapy to the lumbar spine. Subsequently, a total thyroidectomy was performed, followed by an ablative dose of radioiodine and supraphysiological doses of levothyroxine to achieve TSH suppression to less than 0.1 mU/L. The treatment dose of radioiodine was administered 4 times at 6-month intervals. The treatment was well tolerated, with a dramatic thyroglobulin response, and the disease remained radioiodine-sensitive. Prior to a fifth planned dose of radioiodine, our patient presented with cauda equina syndrome and underwent urgent decompressive surgery. Further oncological treatment was planned; however, she deteriorated rapidly following surgery, and repeat imaging showed progressive disease at the surgical site. Histopathology from the lumbar decompression revealed anaplastic thyroid cancer. Our patient died 5 weeks after surgery. Conclusions: This is the first published case of transformation from papillary to anaplastic thyroid cancer presenting as cauda equina compression. Transformation from papillary to anaplastic thyroid cancer has been previously described in the literature; however, it is rarely present distant from the neck, and has an aggressive course. Malignant transformation should be considered in cases of differentiated thyroid cancer that do not fit the previous disease trajectory.

A 7-year-old girl presented with a painless neck swelling localised near the left lobe of the thyroid gland, which was initially investigated by fine needle aspiration cytology. This raised a differential diagnosis of medullary thyroid carcinoma and small round blue cell tumour. Only after several additional clinical investigations and a total thyroidectomy was a definitive diagnosis of spindle cell tumour with thymus-like differentiation (SETTLE) reached. This case report highlights how contemporaneous clinical and investigation findings made arriving at a definitive diagnosis challenging, contributed to diagnostic delay, and ultimately influenced choice of treatment.

SummaryAntigen recognition and T-cell mediated cytotoxicity in clear-cell renal cell carcinoma (ccRCC) remains incompletely understood. To address this knowledge gap, we analysed 115 multiregion tumour samples collected from 15 treatment-naïve patients pre- and post-nivolumab therapy, and at autopsy in three patients. We performed whole-exome sequencing, RNAseq, TCRseq, multiplex immunofluorescence and flow cytometry analyses and correlated with clinical response. We observed pre-treatment intratumoural TCR clonal expansions suggesting pre-existing immunity. Nivolumab maintained pre-treatment expanded, clustered TCR clones in responders, suggesting ongoing antigen-driven stimulation of T-cells. T-cells in responders were enriched for expanded TCF7+CD8+T-cells and upregulated GZMK/B upon nivolumab-binding. By contrast, nivolumab promoted accumulation of new TCR clones in non-responders, replacing pre-treatment expanded clonotypes. In this dataset, mutational features did not correlate with response to nivolumab and human endogenous retrovirus expression correlated indirectly. Our data suggests that nivolumab potentiates clinical responses in ccRCC by binding pre-existing expanded CD8+T-cells to enhance cytotoxicity.

Antigen recognition and T-cell mediated cytotoxicity in clear-cell renal cell carcinoma (ccRCC) remains incompletely understood. To address this knowledge gap, we analysed 115 multiregion tumour samples collected from 15 treatment-naive patients pre- and post-nivolumab therapy, and at autopsy in three patients. We performed whole-exome sequencing, RNAseq, TCRseq, multiplex immunofluorescence and flow cytometry analyses and correlated with clinical response. We observed pre-treatment intratumoural TCR clonal expansions suggesting pre-existing immunity. Nivolumab maintained pre-treatment expanded, clustered TCR clones in responders, suggesting ongoing antigen-driven stimulation of T-cells. T-cells in responders were enriched for expanded TCF7+CD8+ T-cells and upregulated GZMK/B upon nivolumab-binding. By contrast, nivolumab promoted accumulation of new TCR clones in non-responders, replacing pre-treatment expanded clonotypes. In this dataset, mutational features did not correlate with response to nivolumab and human endogenous retrovirus expression correlated indirectly. Our data suggests that nivolumab potentiates clinical responses in ccRCC by binding pre-existing expanded CD8+ T-cells to enhance cytotoxicity.

ADAPTeR is a prospective, phase II study of nivolumab (anti-PD-1) in 15 treatment-naive patients (115 multiregion tumor samples) with metastatic clear cell renal cell carcinoma (ccRCC) aiming to understand the mechanism underpinning therapeutic response. Genomic analyses show no correlation between tumor molecular features and response, whereas ccRCC-specific human endogenous retrovirus expression indirectly correlates with clinical response. T cell receptor (TCR) analysis reveals a significantly higher number of expanded TCR clones pre-treatment in responders suggesting pre-existing immunity. Maintenance of highly similar clusters of TCRs post-treatment predict response, suggesting ongoing antigen engagement and survival of families of T cells likely recognizing the same antigens. In responders, nivolumab-bound CD8+ T cells are expanded and express GZMK/B. Our data suggest nivolumab drives both maintenance and replacement of previously expanded T cell clones, but only maintenance correlates with response. We hypothesize that maintenance and boosting of a pre-existing response is a key element of anti-PD-1 mode of action.

This abstract is being presented as a short talk in the scientific program. A full abstract is available in the Proffered Abstracts section (PR002) of the Conference Proceedings. Citation Format: Alexander Coulton, Irene Lobon, Lavinia Spain, Andrew Rowan, Desiree Shnidrig, Scott Shepherd, Ben Shum, Fiona Byrne, Lewis Au, Kim Edmonds, Ellie Carlyle, Alexandra Renn, Christina Messiou, Charlotte Spencer, Andreas M. Schmidt, Zayd Tippu, Aljosja Rogiers, Max Emmerich, Camille Gerard, Husayn Pallikonda, Cristina Naceur-Lombardelli, Floris Foijer, Hilda van den Bos, René Wardenaar, Diana Spierings, Kate Young, Lisa Pickering, Andrew Furness, Elaine Borg, Miriam Mitchison, David Moore, Mary Falzon, Ian Proctor, Ruby Stewart, Ula Mahadeva, Anna Green, James Larkin, Charles Swanton, Mariam Jamal-Hanjani, Kevin Litchfield, Samra Turajlic. Advanced melanoma exhibits a diversity of evolutionary routes to lethality [abstract]. In: Proceedings of the AACR Special Conference on the Evolutionary Dynamics in Carcinogenesis and Response to Therapy; 2022 Mar 14-17. Philadelphia (PA): AACR; Cancer Res 2022;82(10 Suppl):Abstract nr A012.

International audience; Although thousands of solid tumors have been sequenced to date, a fundamental under-sampling bias isinherent in current methodologies. This is caused by a tissue sample input of fixed dimensions (e.g., 6 mmbiopsy), which becomes grossly under-powered as tumor volume scales. Here, we demonstrate representative sequencing (Rep-Seq) as a new method to achieve unbiased tumor tissue sampling. Rep-Seq uses fixed residual tumor material, which is homogenized and subjected to next-generation sequencing. Analysis of intratumor tumor mutation burden (TMB) variability shows a high level of misclassification using current single-biopsy methods, with 20% of lung and 52% of bladder tumors having at least one biopsy with high TMB butlow clonal TMB overall. Misclassification rates by contrast are reduced to 2% (lung) and 4% (bladder) when a more representative sampling methodology is used. Rep-Seq offers an improved sampling protocol for tumor profiling, with significant potential for improved clinical utility and more accurate deconvolution of clonal structure.

The brain is a particularly rare site of metastasis from papillary microcarcinoma, with only few cases described in the literature. We present a case of 59-year-old man who presented with seizures and dysphasia due to left frontal lobe cystic mass, which was excised and turned out on histopathology to be of thyroid origin. Total thyroidectomy was performed and histology showed multifocal papillary microcarcinoma with the largest focus of 3mm with no other adverse features. The patient had ablative radioactive iodine postoperatively, with subsequent exit scan showing no uptake in the brain. Follow-up brain magnetic resonance imaging showed continuous regression of the surgical cavity. Although rare, such cases should be aggressively treated and followed up over the long term, because of reported associated high mortality.

The aim of this study was to review the histopathological, phenotypic, and molecular characteristics of pediatric-type follicular lymphoma (PTFL) and to assess the diagnostic value of novel immunohistochemical markers in distinguishing PTFL from follicular hyperplasia (FH). A total of 13 nodal PTFLs were investigated using immunohistochemistry, fluorescence in situ hybridization (FISH), and PCR and were compared with a further 20 reactive lymph nodes showing FH. Morphologically, PTFL cases exhibited a follicular growth pattern with irregular lymphoid follicles in which the germinal centers were composed of numerous blastoid cells showing a starry-sky appearance. Immunohistochemistry highlighted preserved CD10 (13/13) and BCL6 (13/13) staining, CD20 (13/13) positivity, a K light chain predominance (7/13), and partial BCL2 expression in 6/13 cases (using antibodies 124, E17, and SP66). The germinal center (GC)–associated markers stathmin and LLT-1 were positive in most of the cases (12/13 and 12/13, respectively). Interestingly, FOXP-1 was uniformly positive in PTFL (12/13 cases) in contrast to reactive GCs in FH, where only a few isolated positive cells were observed. FISH revealed no evidence ofBCL2,BCL6, orMYCrearrangements in the examined cases. By PCR, clonal immunoglobulin gene rearrangements were detected in 100% of the tested PTFL cases. Our study confirmed the unique morphological and immunophenotypic features of PTFL and suggests that FOXP-1 can represent a novel useful diagnostic marker in the differential diagnosis between PTFL and FH.

// Matthew T. Huggett 1, 2 , Slavica Tudzarova 2 , Ian Proctor 2 , Marco Loddo 2, 3 , Margaret G. Keane 1 , Kai Stoeber 2 , Gareth H. Williams 2, 3 , Stephen P. Pereira 1 1 UCL Institute for Liver and Digestive Health and UCL Cancer Institute, University College London, London, UK 2 The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK 3 Oncologica Ltd, The Science Village, Chesterford Research Park, Cambridge, UK Correspondence to: Gareth Williams, e-mail: gareth.williams@oncologica.com Keywords: pancreatic cancer, cell cycle, DNA replication, Cdc7 Received: July 22, 2015 Accepted: January 23, 2016 Published: February 23, 2016 ABSTRACT Purpose: Cdc7 is a serine/threonine kinase which is responsible for the ‘firing’ of replication origins leading to initiation of DNA replication. Inhibition or depletion of Cdc7 in normal cells triggers a DNA origin activation checkpoint causing a reversible G1 arrest. Here we investigate Cdc7 as a novel therapeutic target in pancreatic cancer. Experimental design: Cdc7 target validation was performed by immunoexpression profiling in a cohort of 73 patients with pancreatic adenocarcinoma including 24 controls. Secondly Cdc7 kinase was targeted in Capan-1 and PANC-1 pancreatic cancer cell line models using either an siRNA against Cdc7 or alternatively a small molecule inhibitor (SMI) of Cdc7 (PHA-767491). Results: Cdc7 was significantly overexpressed in pancreatic adenocarcinoma compared to benign pancreatic tissue (median LI 34.3% vs. 1.3%; P

Introduction Lymph node excision has historically been preferred to core biopsy in diagnosing lymphoma given reported higher diagnostic yield and concerns that core biopsies yielded insufficient material. However, core biopsy is associated with lower morbidity and has been reported to be more cost effective. Consequently, advances in radiological and histological techniques in extracting and processing material warrants a re-look at the efficacy of core biopsy as a viable primary diagnostic method. Method Over a three year period (January 2016 - December 2018), all patients who underwent core biopsy at our centre for investigation of possible lymphoma or relapse, were identified from a local database. Argon medical BioPinceTM needles were used for the majority of procedures. Data collected included: indication and final diagnosis, number of cores taken, waiting times from referral to histological diagnosis, diagnostic rates and any histological request for extra tissue due to sample inadequacy. A patient telephone survey was undertaken to document patient experience and record complications. Results 554 consecutive patients were included. 225 (40.1%) patients had a prior lymphoma diagnosis whilst 329 (59.4%) were new presentations. 78 (14.1%) biopsies were guided by prior PET imaging of which 69/78 (88.5%) were to assess relapsed disease. Biopsies sites were: 326 (58.8%) cervical, 71 (12.8%) axilla, 96 (17.3%) inguinal and 61 (11.0%) extra nodal. Three or more cores were taken in 420 (75.8%) cases. The median time from request to biopsy was 2 days (range 0-40 days) whilst median time from biopsy to histology report was 7 days (range 1-24 days). Final diagnoses were: 195 (35.2%) reactive/non-malignant, 346 (62.5%) lymphoma [88 (15.9%) Diffuse large B cell lymphoma, 76 (13.7%) Follicular lymphoma, 56 (10.1%) Hodgkin lymphoma, 37 (6.7%) T-cell lymphoma, 28 (5.1%) Chronic lymphocytic leukaemia, 61 (11.0%) other B cell lymphoma], 12 (2.2%) other malignancy and 1 (0.18%) inadequate for interpretation. 510/544 (93.8%) biopsies were diagnostic inclusive of 74/78 (94.9%) PET-directed biopsies. 35/37 (94.6%) biopsies confirming T-cell lymphoma were diagnostic whilst in 2 cases repeat biopsy was required. There was no significant difference in whether the biopsy was diagnostic based on whether it was indicated for new or relapsed lymphoma (p=0.445), PET-directed (p=0.507), for a diagnosis of T-cell lymphoma (p=0.468) or nodal vs. extra nodal (p=0.693). The histologist requested additional tissue in 64 (11.6%) cases. Of these, 38/64 (59.4%) patients were adjudged by the clinician to require a second biopsy. 3/195 (1.5%) reactive cases went on to be diagnosed with lymphoma within 6 months. 2/3 had inadequate biopsies and the histology report advised repeat. A third patient was diagnosed with DLBCL based on a repeat biopsy done for clinical suspicion. Of 35 consecutive patients, 31 agreed to participate in the patient experience survey. Only 5/31 (16.1%) reported any complications (1 self-limiting minor bleeding, 4 minor bruising). 6/31 (19.4%) reported any discomfort beyond 12 hours. Median waiting time in department pre-biopsy was 10 minutes (range 5-60 minutes) and all patients left the department within 20 minutes of the procedure. Conclusion Core biopsy performed by experienced interventional radiologists and analysed by expert haemato-pathologists is a reliable and convenient method for diagnosing lymphoma and confirming relapse inclusive of T-cell lymphoma (which is typically harder to diagnose). Multiple cores can be obtained under local anaesthetic and this yields sufficient material without need for further biopsy in the majority of cases (88.4%) including where samples are also required for trials purposes. Using PET to direct biopsy is highly effective in confirming relapse. Core biopsy is well tolerated and can be performed safely and effectively in the outpatient setting with a median time from referral to biopsy of only 2 days in our centre. Disclosures Ardeshna: Celgene: Consultancy, Honoraria; Gilead: Consultancy, Honoraria.

Objectives To develop and validate a qualitative scoring system for enteric Crohn's disease activity using MR enterography (MRE). Methods MRE was performed in 16 patients (mean age 33, 8 male) undergoing small bowel resection. Mural thickness, T2 signal, contrast enhancement, and perimural oedema were scored qualitatively (0–3) at 44 locations. Transmural histopathological scoring of acute inflammation (AIS) was performed at all locations (score 0–13). MRI parameters best predicting AIS were derived using multivariate analysis. The MRI activity index was applied to 26 Crohn's patients (mean age 32, range 13–69 years, 15 male) and correlated to terminal ileal biopsy scores of acute inflammation (“eAIS” score 1–6). Receiver operator characteristic curves were calculated. Results Mural thickness (coefficient 1.34 (95% CI 0.36, 2.32)], p = 0.007) and T2 signal (coefficient 0.90 (95% CI −0.24, 2.04) p = 0.06) best predicted AIS (AIS = 1.79 + 1.34*mural thickness + 0.94*mural T2 score [R-squared 0.52]). There was a significant correlation between the MRI index and eAIS (Kendall's tau = 0.40, 95% CI 0.11–0.64, p = 0.02). The model achieved a sensitivity of 0.81 (95% CI 0.54–0.96), specificity of 0.70 (0.35–0.93) and AUC 0.77 for predicting acute inflammation (eAIS ≥2). Conclusions A simple qualitative MRI Crohn's disease activity score appears predictive against a histopathological standard of reference.

To compare quantified terminal ileal (TI) motility during MR enterography (MRE) with histopathological severity of acute inflammation in Crohn's disease.A total of 28 Crohn's patients underwent MRE and endoscopic TI biopsy. Axial and coronal TrueFISP, HASTE and post-gadolinium VIBE images were supplemented by multiple coronal TrueFISP cine motility sequences through the small bowel volume. TI motility index (MI) was quantified using validated software; an acute inflammation score (eAIS; 0-6) was assigned to the biopsy. Two observers qualitatively scored mural thickness, T2 signal, contrast enhancement and perimural oedema (0-3) to produce an activity score (aMRIs) based on anatomical MRI. The association among the MI, eAIS and aMRIs was tested using Spearman's rank correlation. Wilcoxon rank sum test compared motility in subjects with and without histopathological inflammation.Mean MI and mean eAIS were 0.27 (range 0.06-0.55) and 1.5 (range 0-5), respectively. There was a significant difference in MI between non-inflamed (mean 0.37, range 0.13-0.55) and inflamed (mean 0.19, range 0.06-0.44) TI, P = 0.002, and a significant negative correlation between MI and both eAIS (Rho = -0.52, P = 0.005) and aMRIs (R = -0.7, P 0.001).Quantified TI motility negatively correlates with histopathological measures of disease activity and existing anatomical MRI activity biomarkers.• Magnetic resonance imaging is increasingly used to assess Crohn's disease. • MRI measurements can provide a quantitative assessment of small bowel motility. • MR enterography can grade Crohn's disease. • Small bowel motility can be used as a marker of inflammatory activity.

Purpose The accurate diagnosis of hematologic malignancies remains a challenging area for histopathologists. In 2003, the North Central London Lymphoma network was established to provide a centralized expert review service for general histopathologists based in peripheral nonspecialist hospitals. By studying samples sent for review, we sought to assess the diagnostic and clinical impact of centralized expert review in lymphoma diagnosis. Methods A total of 1,949 patient samples were subject to expert review between 2003 and 2008. Diagnostic discordance rates were identified after expert review, and the impact on patient management was assessed by a hematologic oncology specialist. Results An overall discordance rate of 27.3% was identified. Among the 10 most commonly referred lymphoid malignancies, the discordance rate varied between 3.6% and 34.1%. A small but significant number of reactive (n = 17) and malignant (n = 5) discordant diagnoses were also identified. Expert central review resulted in a major change to patient management in 2.1% of patients and prevented delays in treatment in 9.3% of patients. During the 6-year study, the discordance rate improved significantly, decreasing from 32% to 13%. Although centralized review incurred additional costs, these were relatively small compared with the costs associated with treatment. Conclusion This retrospective study demonstrates the importance of expert central review in the accurate diagnosis and timely management of lymphoid malignancies. Furthermore, it shows that where full centralization of services is not viable, a network comprising nonspecialist hospitals linked to a center providing expert review is a practical alternative to full unification of services at a single location and can help prevent local deskilling.

Treatment options for triple-receptor negative (ER-/PR-/Her2-) and Her2-overexpressing (ER-/PR-/Her2+) breast cancers with acquired or de novo resistance are limited, and metastatic disease remains incurable. Targeting of growth signaling networks is often constrained by pathway redundancy or growth-independent cancer cell cycles. The cell-cycle protein Cdc7 regulates S phase by promoting DNA replication. This essential kinase acts as a convergence point for upstream growth signaling pathways and is therefore an attractive therapeutic target. We show that increased Cdc7 expression during mammary tumorigenesis is linked to Her2-overexpressing and triple-negative subtypes, accelerated cell cycle progression (P < 0.001), arrested tumor differentiation (P < 0.001), genomic instability (P = 0.019), increasing NPI score (P < 0.001), and reduced disease-free survival (HR = 1.98 [95% CI: 1.27-3.10]; P = 0.003), thus implicating its deregulation in the development of aggressive disease. Targeting Cdc7 with RNAi, we demonstrate that p53-mutant Her2-overexpressing and triple-negative breast cancer cell lines undergo an abortive S phase and apoptotic cell death due to loss of a p53-dependent Cdc7-inhibition checkpoint. In contrast, untransformed breast epithelial cells arrest in G1, remain viable, and are able to resume cell proliferation on recovery of Cdc7 kinase activity. Thus, Cdc7 appears to represent a potent and highly specific anticancer target in Her2-overexpressing and triple-negative breast cancers. Emerging Cdc7 kinase inhibitors may therefore significantly broaden the therapeutic armamentarium for treatment of the aggressive p53-mutant breast cancer subtypes identified in this study.

Cancer biomarkers provide an opportunity to diagnose tumours earlier and with greater accuracy. They can also identify those patients most at risk of disease recurrence and predict which tumours will respond to different therapeutic approaches. Such biomarkers will be especially useful in the diagnosis and management of bladder cancer. At present, bladder tumours are diagnosed and followed-up using a combination of cystoscopic examination, cytology and histology. These are not only expensive, but also highly subjective investigations and reveal little about the underlying molecular characteristics of the tumour. In recent years numerous diagnostic and prognostic biomarkers of bladder cancer have been identified. Two separate approaches to biomarker discovery have been employed. The first is hypothesis-driven and focuses upon proteins involved in molecular pathways known to be implicated in tumorigenesis. An alternative approach has been to study the global expression of genes (so-called 'genomics') looking for characteristic signatures associated with disease outcomes. In this review we summarize the current state of biomarker development in this field, and examine why so few have made the successful transition into the clinic. Finally, we introduce a novel approach to biomarker development utilizing components of the DNA replication licensing machinery.

Clear-cell renal cell carcinoma (ccRCC) exhibits a broad range of metastatic phenotypes that have not been systematically studied to date. Here, we analyzed 575 primary and 335 metastatic biopsies across 100 patients with metastatic ccRCC, including two cases sampledat post-mortem. Metastatic competence was afforded by chromosome complexity, and we identify 9p loss as a highly selected event driving metastasis and ccRCC-related mortality (p = 0.0014). Distinct patterns of metastatic dissemination were observed, including rapid progression to multiple tissue sites seeded by primary tumors of monoclonal structure. By contrast, we observed attenuated progression in cases characterized by high primary tumor heterogeneity, with metastatic competence acquired gradually and initial progression to solitary metastasis. Finally, we observed early divergence of primitive ancestral clones and protracted latency of up to two decades as a feature of pancreatic metastases. S.T. and H.X. are funded by Cancer Research UK (CRUK) (C50947/A18176). S.T., T.C., J.L., and M.G. are funded by the NIH Research (NIHR) Biomedical Research Centre (BRC) at the Royal Marsden Hospital and Institute of Cancer Research (A109). J.I.L. is funded by the Ministerio de Economia y Competitividad (MINECO, SAF2016-79847-R). M.S., A.S., J.L., R.F., L.A., and L.S. are funded by the Royal Marsden Cancer Charity. K.L. is funded by UK Medical Research Council (MR/P014712/1). N.M. receives funding from CRUK, Rosetrees, and the NIHR BRC at University College London Hospitals. C.S is Royal Society Napier Research Professor. C.S. is funded by Cancer Research UK (TRACERx and CRUK Cancer Immunotherapy Catalyst Network), the CRUK Lung Cancer Centre of Excellence, Stand Up 2 Cancer (SU2C), the Rosetrees and Stoneygate Trusts, NovoNordisk Foundation (ID 16584), the Breast Cancer Research Foundation (BCRF), the European Research Council (THESEUS), Marie Curie Network PloidyNet, the NIHR BRC at University College London Hospitals, and the CRUK University College London Experimental Cancer Medicine Centre. The work presented in this manuscript was funded by Cancer Research UK (grant reference number C50947/A18176), Ventana Medical Systems (grant reference numbers 10467 and 10530), the Kidney Cancer Fund of The Royal Marsden Cancer Charity, NIHR BRC at the Royal Marsden Hospital and Institute of Cancer Research (grant reference number A109), and the Francis Crick Institute, which receives its core funding from Cancer Research UK (FC001202), the UK Medical Research Council (FC001202), and the Wellcome Trust (FC001202). In particular, we acknowledge the support of the Advanced Sequencing Facility and the High-Performance Computing at the Francis Crick Institute. This project was enabled through access to the MRC eMedLab Medical Bioinformatics infrastructure, supported by the Medical Research Council (grant number MR/L016311/1).

Concerns about whether the junior doctor changeover in the UK is associated with an increased risk of death have been reawakened by a retrospective study ( Jen et al, 2009 ). Examination of overall mortality data has consistently failed to demonstrate any increase in mortality during the changeover. However, regional and national trends may mask this increase, so a study was undertaken to compare mortality in a busy London teaching hospital with regional and national trends. No evidence of an increase in mortality in August was found for any of the time periods examined, even after comparison with regional and national trends. The authors conclude that examination of overall mortality data is a blunt and impractical instrument for settling the question of whether an increase in morbidity and mortality occurs. Preventable morbidity and mortality should be audited.

Before a body can be cremated doctors must complete a series of lengthy forms better known as 'crem forms'. One doctor first completes a medical certificate (Cremation Form 4, previously known as 'Part B') while a second must complete a confirmatory medical certificate (Cremation Form 5, previously 'Part C').

Aim To assess how frequently smoking is cited as a cause of death (COD) on death certificates. Methods A retrospective study of 2128 death certificates and 236 postmortem reports issued at a large teaching hospital between 2003 and 2009. Results Smoking was identified as the underlying COD on only 2 (0.1%) death certificates and included in part II of the death certificate on 10 (0.5%). The two death certificates citing smoking as the underlying COD were in cases of lung cancer and chronic obstructive pulmonary disease. The study included 279 deaths in which these diagnoses were cited on the death certificate and in the majority of these cases the deceased was a smoker or ex-smoker. A review of postmortem reports from the same period failed to identify a single case in which the pathologist cited smoking as causing or contributing to death. In marked contrast to smoking, 57.4% (vs 0.5%) of death certificates, which included diagnoses linked to alcohol use, cited alcohol in part I of the death certificate. Conclusion This study demonstrates that smoking is rarely cited on death certificates, even in cases where the causal link with smoking is very strong. There are many reasons why smoking is not cited on death certificates. One frequently cited reason is the reluctance of doctors to stigmatise the deceased. Interestingly, such reluctance did not extend to citing alcohol as a COD. By not recording smoking on death certificates doctors are failing to gather important epidemiological and pathological data.

Fluidised beds are widely used in the pharmaceutical industry for granulation, drying and coating. The product quality strongly depends on the operation parameters and process conditions, e.g. inlet airflow rate, temperature and spraying flow rate. For granulation and drying processes, the flow conditions can change dramatically due to different moisture level, because of the change in physical characteristics of particles, including viscosity, density and diameter. Also, the flow regime of a fluidised bed would change with the diameter and density of particles. Due to high moisture content, particles could agglomerate and stick up to the wall and distributor plate, resulting in a fault process. Therefore, it is necessary to monitor a drying or granulation process, identify their flow regime and control the processes according to the particle properties. This paper describes an application of electrical capacitance tomography (ECT) to monitor the process conditions and for diagnosis of fault with a semi-industrial scale pharmaceutical fluidised bed. Preliminary test results with granulation and drying processes are given. Future work on fluidised bed control based on the information provided by ECT will be discussed.

Multiparameter analysis of core regulatory proteins involved in G1–S and G2–M cell-cycle transitions provides a powerful biomarker readout for assessment of the cell-cycle state. We have applied this algorithm to breast cancer to investigate how the cell cycle impacts on disease progression. Protein expression profiles of key constituents of the DNA replication licensing pathway (Mcm2, geminin) and mitotic machinery (Plk1, Aurora A and the Aurora substrate histone H3S10ph) were generated for a cohort of 182 patients and linked to clinicopathological parameters. Arrested differentiation and genomic instability were associated with an increased engagement of cells into the cell division cycle (P

Based on protein expression profiles of core regulatory proteins involved in the G1-S and G2-M phase transitions, we have identified three distinct cell cycle phenotypes in a series of 200 breast cancers: a G0 out-of-cycle state (18% of cases); a G1 arrested/delayed state (24% cases); and accelerated S-G2-M phase progression (58% of cases). The accelerated cell cycle progression phenotype had a higher risk of relapse when compared with G0 and G1-delayed/arrested phenotypes (HR = 3.90 (95% CI = 1.81 to 8.4), P < 0.001) and was associated with Her2 and triple negative subtypes (P < 0.001). High-grade tumours with the G1-delayed/arrested phenotype showed an identical low risk of relapse compared with well-differentiated G0 tumours. In addition to its prognostic significance, the cell cycle phenotype also impacts on individualised therapeutic decisions. Only patients showing the actively cycling, aggressive cell cycle phenotype are likely to benefit from conventional chemotherapeutic S-phase-directed or M-phase-directed agents or from the new generation of targeted cell cycle inhibitors that are now entering clinical trials. The DNA replication initiation factor Cdc7 is an emerging anticancer target. Cdc7 inhibition results in an abortive S phase and potent cancer cell killing. Specificity is based on normal cells undergoing a reversible G1 arrest following Cdc7 inhibition due to activation of a novel cell cycle checkpoint that is lost or impaired in cancer cells. Our analysis of the molecular circuitry underlying this replication origin activation checkpoint reveals that G1 arrest is dependent on three nonredundant checkpoint axes coordinated through the Forkhead transcription factor FoxO3a and p53. We show that only breast cancers displaying the accelerated cell cycle phenotype express elevated Cdc7 levels and are therefore highly represented in p53 mutant Her2-subtype and triple negative tumours. Breast cancers of the luminal subtype expressing low levels of Cdc7 undergo a cytostatic G1 arrest after Cdc7 inhibition due to their p53 wild-type status, a checkpoint response mimicking untransformed cells. In contrast, Her2 and triple negative tumours show a marked response to Cdc7 inhibitors with potent cancer-cell-specific killing as a result of overexpression of the target protein and a result of impairment of the origin activation checkpoint due to p53 lesions. We have thus defined a new therapy and a means of assessing response.

Based on protein expression profiles of core regulatory proteins involved in the G1–S and G2–M phase transitions, we have identified three distinct cell cycle phenotypes in a series of 200 breast cancers: (I) a G0 “out-of-cycle” state (18% of cases); (II) a G1 arrested/delayed state (24% cases); and (III) accelerated S-G2-M phase progression (58% of cases). The accelerated cell cycle progression phenotype had a higher risk of relapse when compared with G0 and G1-delayed/arrested phenotypes (HR=3.90 (1.81-8.4, p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2148.

Abstract #5066 BACKGROUND: The cell cycle machinery acts as an integration point for information transduced through complex and redundant upstream oncogenic signalling pathways. Multiparameter analysis of core regulatory proteins involved in G1-S and G2-M cell cycle phase transitions provides a powerful biomarker readout for assessment of the cell cycle state. We have applied this novel algorithm to breast cancer, investigating its cell cycle kinetics, and determining how this impacts on pathobiology and disease progression in-vivo. METHODS AND FINDINGS: Protein expression profiles of key constituents of the DNA replication licensing pathway (Mcm2, geminin) and mitotic machinery (Plk1, Aurora A, Aurora substrate Histone H3S10ph), mediators of G1-S and G2-M transition respectively, were generated for a cohort of 182 patients. Arrested differentiation and development of genomic instability was associated with increased engagement of cells into the cell division cycle (p Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5066.