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We report a case of progressive, severe mpox virus (MPXV) infection in a patient with AIDS despite a standard course of tecovirimat. He significantly improved after administration of vaccinia immune globulin intravenous (VIGIV) highlighting its use as an adjunct for severe disease in immunocompromised hosts.

We report a case of progressive, severe mpox virus (MPXV) infection in a patient with acquired immune deficiency syndrome (AIDS) despite a standard course of tecovirimat. He significantly improved after administration of intravenous vaccinia immune globulin (VIGIV) highlighting its use as an adjunct for severe disease in immunocompromised hosts.

The role played by interfaces in metallic multilayers is not only to change the momenta of incident electrons; their symmetry lowering also results in an enhancement of the effects of spin-orbit coupling, in particular the flipping of the spins of conduction electrons. This leads to a significant reduction of a spin current through a metallic interface that is quantitatively characterized by a dimensionless parameter $\delta$ called the spin memory loss (SML) parameter, the interface counterpart of the spin-flip diffusion length for bulk metals. In this paper we use first-principles scattering calculations that include temperature-induced lattice and spin disorder to systematically study three parameters that govern spin transport through metallic interfaces of Cu with Pt, Pd, Py (permalloy) and Co: the interface resistance, spin polarization and the SML. The value of $\delta$ for a Cu$|$Pt interface is found to be comparable to what we recently reported for a Au$|$Pt interface [Gupta {\it et al.}, Phys. Rev. Lett. 124, 087702 (2020)]. For Cu$|$Py and Cu$|$Co interfaces, $\delta$ decreases monotonically with increasing temperature to become negligibly small at room temperature. The calculated results are in good agreement with currently available experimental values in the literature. Inserting a Cu layer between Pt and the Py or Co layers slightly increases the total spin current dissipation at these "compound" interfaces.

Immune cell infiltration has been identified as a prognostic biomarker in several cancers. However, no immune based biomarker has yet been validated for use in pancreatic ductal adenocarcinoma (PDAC). We undertook a systematic review and meta‐analysis of immune cell infiltration, measured by immunohistochemistry (IHC), as a prognostic biomarker in PDAC. All other IHC prognostic biomarkers in PDAC were also summarised. MEDLINE, EMBASE and Web of Science were searched between 1998 and 2018. Studies investigating IHC biomarkers and prognosis in PDAC were included. REMARK score and Newcastle–Ottawa scale were used for qualitative analysis. Random‐effects meta‐analyses were used to pool results, where possible. Twenty‐six articles studied immune cell infiltration IHC biomarkers and PDAC prognosis. Meta‐analysis found high infiltration with CD4 (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.51–0.83.) and CD8 (HR = 0.68, 95% CI = 0.55–0.84.) T‐lymphocytes associated with better disease‐free survival. Reduced overall survival was associated with high CD163 (HR = 1.62, 95% CI = 1.03–2.56). Infiltration of CD3, CD20, FoxP3 and CD68 cells, and PD‐L1 expression was not prognostic. In total, 708 prognostic biomarkers were identified in 1101 studies. In summary, high CD4 and CD8 infiltration are associated with better disease‐free survival in PDAC. Increased CD163 is adversely prognostic. Despite the publication of 708 IHC prognostic biomarkers in PDAC, none has been validated for clinical use. Further research should focus on reproducibility of prognostic biomarkers in PDAC in order to achieve this.

AIMS The introduction of TNM 8 into UK pathology practice in January 2018 considers tumour deposits in colorectal cancer staging for the first time. The impact of this new classification on pathology reporting practices has yet to be evaluated. METHODS AND RESULTS A clinical audit was conducted, comparing consecutive colorectal cancer resection specimens reported under TNM 5 classification guidelines in 2017 (n = 177) and TNM 8 guidelines in 2018 (n = 234). Tumour features (venous invasion, perineural invasion, lymph node metastatic disease, tumour deposits) and changes in reporting practices were evaluated among four specialist gastrointestinal pathologists working within a large pathology department. Adoption of TNM 8 practice led to an approximate doubling in the use of ancillary stains (41.0% of TNM 8 versus 22.0% of TNM 5 cases, P

Symmetry lowering at an interface leads to an enhancement of the effect of spin-orbit coupling and to a discontinuity of spin currents passing through the interface. This discontinuity is characterized by a "spin-memory loss" (SML) parameter $\delta$ that has only been determined directly at low temperatures. Although $\delta$ is believed to be significant in experiments involving interfaces between ferromagnetic and nonmagnetic metals, especially heavy metals like Pt, it is more often than not neglected to avoid introducing too many unknown interface parameters in addition to often poorly known bulk parameters like the spin-flip diffusion length $l_{\rm sf}$. In this work, we calculate $\delta$ along with the interface resistance $AR_{\rm I}$ and the spin-asymmetry parameter $\gamma$ as a function of temperature for Co$|$Pt and Py$|$Pt interfaces where Py is the ferromagnetic Ni$_{80}$Fe$_{20}$ alloy, permalloy. We use first-principles scattering theory to calculate the conductance as well as local charge and spin currents, modeling temperature-induced disorder with frozen thermal lattice and, for ferromagnetic materials, spin disorder within the adiabatic approximation. The bulk and interface parameters are extracted from the spin currents using a Valet-Fert model generalized to include SML., Comment: 18 pages, 13 figures

Background: Radium-223 and enzalutamide are approved agents for patients with metastatic castration-resistant prostate cancer (mCRPC). Combining radium-223 and enzalutamide to improve outcomes is of clinical interest due to their differing modes of action and non-overlapping toxicity profiles. Methods: This phase II study enrolled patients with mCRPC and bone metastases. Patients received six cycles of radium-223 in combination with enzalutamide, followed by enzalutamide alone. The primary endpoint was safety for the combination; secondary endpoints included radiographic/clinical progression-free survival (PFS), PSA PFS, overall survival (OS), change in alkaline phosphatase, patient-reported pain outcomes and skeletal related events. Results: Forty-five patients received the combination treatment: 42 patients (93.3%) received all six cycles. Fourteen patients (31.1%) developed grade 3 or 4 toxicities, most commonly fatigue and neutropaenia. Fractures during the combination period occurred in four patients (8.9%). A further 13 patients (28.9%) developed fractures after completing combination treatment, giving a total of 17 patients (37.8%) who developed a fracture at any time on study. The median time to fracture was greater than 17.2 months [95% confidence interval (CI), 17.2–not estimable]. The median time to PSA progression was 18.1 months (95% CI, 12.68–22.60) and the median time to radiological/clinical progression was 28.0 months (95% CI, 22.54–not reached). At the primary analysis, 19 (42.2%) out of 45 patients had died with a median OS not reached (mean 34.8 months, standard error 1.4). Conclusion: In men with progressive mCRPC and bone metastases, the combination of radium-223 and enzalutamide was tolerable with the majority of patients completing the combination treatment. Bone fractures during the combination period were uncommon; however, we did identify a higher incidence of fractures occurring in patients after completing combination treatment. Bone health agents should be administered and bone health should be closely monitored following treatment with radium-223 and enzalutamide.

Ovarian high-grade neuroendocrine carcinomas (NECs) (small cell and large cell NEC) are rare neoplasms. They may arise in association with other ovarian tumors, most commonly epithelial neoplasms and rarely teratomas. We report a case of an 19-yr-old female with bilateral ovarian teratomas with a high-grade NEC (immunohistochemically positive with chromogranin, synaptophysin, and CD56 and MIB1 proliferation index in excess of 90%) arising within one of these. Although CK20 was negative, the NEC exhibited an immunophenotype suggestive of a Merkel cell carcinoma with diffuse positive staining with FLI-1, SATB2 and neurofilament, markers which are preferentially expressed in Merkel cell carcinoma compared with other NECs. There was also diffuse staining for SALL4. Immunohistochemistry and molecular studies for Merkel cell polyomavirus were negative. Immunohistochemical staining for CK20, FLI-1, SATB2, neurofilament, and SALL4 was performed in 6 additional primary ovarian high-grade NECs; One, 5, 5, 1, and 0 cases were positive for CK20, FLI-1, SATB2, neurofilament, and SALL4, respectively, usually with very focal immunoreactivity. Pathologists should be aware of these potential unexpected staining patterns in ovarian NECs as positivity may result in consideration of other neoplasms.

Little is known about the spin-flip diffusion length $l_{\rm sf}$, one of the most important material parameters in the field of spintronics. We use a density-functional-theory based scattering approach to determine values of $l_{\rm sf}$ that result from electron-phonon scattering as a function of temperature for all 5d transition metal elements. $l_{\rm sf}$ does not decrease monotonically with the atomic number Z but is found to be inversely proportional to the density of states at the Fermi level. By using the same local current methodology to calculate the spin Hall angle $\Theta_{\rm sH}$ that characterizes the efficiency of the spin Hall effect, we show that the products $\rho(T)l_{\rm sf}(T)$ and $\Theta_{\rm sH}(T)l_{\rm sf}(T)$ are constant., Comment: Accepted for publication in Physical Review Letters

Introduction Physiological deterioration often precedes clinical deterioration as patients develop critical illness. Use of a specific Paediatric Early Warning Score (PEWS), based on physiological measurements, may help identify children prior to their clinical deterioration and have been used for paediatric inpatients for many years. NHS Scotland has adopted a single national PEWS – PEWS (Scotland) with the intention the score is used throughout the whole patient journey. We aimed to assess whether a single set of observations recorded as a PEWS (Scotland) in an unselected group of paediatric ambulance patients could be a predictor of adverse outcome. Methods We performed a retrospective cohort of all ambulance patients aged under 16 years conveyed to hospital in Scotland between 2011 and 2015. Patients were matched to their 30 day mortality and ICU admission using data linkage. Results Full results were available for 21,202 children and young people. On multivariate logistic regression, PEWS (Scotland) was an independent predictor of the primary outcome (ICU admission within 48 h or death within 30 days) with an odds ratio of 1.403 (95%CI 1.349–1.460, p Discussion These data show PEWS (Scotland) to be a useful tool in a pre-hospital setting. A single set of physiological observations undertaken prior to arrival at hospital can identify a group of children at higher risk of an adverse in-hospital outcome. With the changing structure of receiving arrangements for paediatric patients, PEWS (Scotland) could allow for re-routing patients to appropriate receiving centres, when it is recognised that there is an increased risk of requiring active intervention including admission to intensive care, or the skills of a trauma team.

Aims Ki67 proliferative index (PI) is essential for grading gastroenteric and pancreatic neuroendocrine tumours (GEP NETs). Analytical and preanalytical variables can affect Ki67 PI. In contrast to counting methodology, until now little attention has focused on the question of clone equivalence and the effect of hot-spot size on Ki67 PI in GEP NETs. Using manual counting and image analysis, this study compared the Ki67 PI achieved using MM1, K2 and 30-9 to MIB1, a clone which has been validated for, and is referenced in, guidelines relating to assessment of Ki67 PI in GEP NETs. Methods and results Forty-two pancreatic NETs were each immunohistochemically stained for the anti-Ki67 clones MIB1, MM1, K2 and 30-9. Ki67 PI was calculated manually and by image analysis, the latter using three different hot-spot sizes. In manual comparisons using single hot-spot high-power fields, non-MIB1 clones overestimated Ki67 PI compared to MIB1, resulting in grading discordances. Image analysis shows good agreement with manual Ki67 PI but a tendency to overestimate absolute Ki67 PI. Increasing the size of tumour hot-spot from 500 to 2000 cells resulted in a decrease in Ki67 PI. Conclusion Different anti-Ki67 clones do not produce equivalent PIs in GEP NETs, and clone selection may therefore affect patient care. Increasing the hot-spot size decreases the Ki67 PI. Greater standardisation in terms of antibody clone selection and hot-spot size is required for grading GEP NETs. Image analysis is an effective tool for assisting Ki67 assessment and allows easier standardisation of the size of the tumour hot-spot.

We use density functional theory to explore the possibility of making the semiconducting transition-metal dichalcogenide ${\mathrm{MoS}}_{2}$ ferromagnetic by introducing holes into the narrow Mo $d$ band that forms the top of the valence band. In the single impurity limit, the repulsive Coulomb potential of an acceptor atom and intervalley scattering lead to a twofold orbitally degenerate effective-mass-like ${e}^{\ensuremath{'}}$ state being formed from Mo ${d}_{{x}^{2}\ensuremath{-}{y}^{2}}$ and ${d}_{xy}$ states, bound to the $K$ and ${K}^{\ensuremath{'}}$ valence band maxima. It also leads to a singly degenerate ${a}_{1}^{\ensuremath{'}}$ state with Mo ${d}_{3{z}^{2}\ensuremath{-}{r}^{2}}$ character bound to the slightly lower lying valence band maximum at $\mathrm{\ensuremath{\Gamma}}$. Within the accuracy of our calculations, these ${e}^{\ensuremath{'}}$ and ${a}_{1}^{\ensuremath{'}}$ states are degenerate for ${\mathrm{MoS}}_{2}$ and accommodate the hole that polarizes fully in the local spin density approximation in the impurity limit. With spin-orbit coupling included, we find a single ion magnetic anisotropy of $\ensuremath{\sim}5$ meV favoring out-of-plane orientation of the magnetic moment. Pairs of such hole states introduced by V, Nb, or Ta doping are found to couple ferromagnetically unless the dopant atoms are too close in which case the magnetic moments are quenched by the formation of spin singlets. Combining these exchange interactions with Monte Carlo calculations allows us to estimate ordering temperatures as a function of the dopant concentration $x$. For $x\ensuremath{\sim}9%$, Curie temperatures as high as 100 K for Nb and Ta and in excess of 160 K for V doping are predicted. Factors limiting the ordering temperature are identified and suggestions made to circumvent these limitations.

Density functional theory is used to explore the possibility of inducing impurity band ferromagnetism in monolayers of semiconducting MoS2 by introducing holes into the narrow Mo 4d band that forms the top of the valence band. A large out of plane anisotropy is found for unpaired spins bound to the substitutional acceptor impurities V, Nb and Ta that couple ferromagnetically for all but the shortest separations. Using the separation dependent exchange interactions as input to Monte Carlo calculations, we estimate ordering temperatures as a function of the impurity concentration. For about 9% of V impurities, Curie temperatures in excess of 160 K are predicted. The singlet formation at short separations that limits the ordering temperature is explained and we suggest how it can be circumvented., 6 pages, 4 figures

Adult granulosa cell tumor (AGCT) is a low-grade malignant neoplasm with a significant propensity for late recurrence and metastasis. Almost all AGCTs are composed of cells with bland nuclear features and even when these tumors recur or metastasize, the nuclear features are almost always low-grade. We report 5 cases of AGCT in patients aged 37 to 88 years composed of areas of typical AGCT with low-grade morphology admixed with areas of high-grade morphology, with marked nuclear atypia, often with bizarre multinucleate cells and high mitotic activity; this is the first reported series of high-grade transformation in AGCTs. The high-grade areas often morphologically closely resembled juvenile granulosa cell tumor with abundant eosinophilic cytoplasm, significant mitotic activity, and intermediate sized follicles. Four cases were FIGO stage IA at diagnosis and 1 was stage IIIC with omental involvement. FOXL2 mutation analysis of both the morphologically low-grade and high-grade areas in 4 of 5 cases confirmed the presence of missense point mutation, c.402C>G, p.(Cys134Trp), providing conclusive evidence that the high-grade component represents transformation of typical AGCT rather than the coexistence of another sex cord-stromal tumor, such as juvenile granulosa cell tumor, which has been suggested for such neoplasms. In 3 of 4 cases where immunohistochemistry was undertaken, there was a striking difference between the p53 staining in the low-grade and high-grade components with wild-type staining in the former and diffuse mutation-type immunoreactivity in the latter, suggesting that TP53 mutation is likely to play a role in high-grade transformation. TP53 mutation analysis covering exons 4 to 10 was undertaken in 4 cases and TP53 mutations were identified in the high-grade component of 2 of the cases. In 1 case, there was diffuse block-type p16 staining in the high-grade component. Follow-up in the 4 stage IA neoplasms revealed no evidence of tumor recurrence in 3 (6 to 9 mo follow-up) while the other patient developed mediastinal, peritoneal, and pulmonary metastasis 17 months after diagnosis. High-grade transformation is uncommon in AGCTs and given that one of our cases was advanced stage at diagnosis, another exhibited widespread metastasis within a short period and there have been occasional case reports of aggressive behavior in AGCTs with high-grade transformation, this event may herald an aggressive clinical course.

Background The optimal EBRT schedule for MSCC is undetermined. Our aim was to determine whether a single fraction (SF) was non-inferior to five daily fractions (5Fx), for functional motor outcome. Methods Patients not proceeding with surgical decompression in this multicentre non-inferiority, Phase 3 trial were randomised to 10 Gy/SF or 20 Gy/5Fx. A change in mobility from baseline to 5 weeks for each patient, was evaluated by a Modified Tomita score: 1 = ‘Walk unaided’, 2 = ‘With walking aid’ and 3 = ‘Bed-bound’. The margin used to establish non-inferiority was a detrimental change of −0.4 in the mean difference between arms. Results One-hundred and twelve eligible patients were enrolled. Seventy-three patients aged 30–87 were evaluated for the primary analysis. The 95% CI for the difference in the mean change in mobility scores between arms was −0.12 to 0.6. Since −0.4 is not included in the interval, there is evidence that 10 Gy/SF is non-inferior to 20 Gy/5Fx. One grade 3 AE was reported in the 5Fx arm. Twelve (26%) patients in the 5Fx arm had a Grade 2–3 AE compared with six (11%) patients in the SF arm (p = 0.093). Conclusion For mobility preservation, one 10-Gy fraction is non-inferior to 20 Gy in five fractions, in patients with MSCC not proceeding with surgical decompression. Clinical Trial Registration Cancer Trials Ireland ICORG 05-03; NCT00968643; EU-20952.

Local charge and spin currents are evaluated from the solutions of fully relativistic quantum mechanical scattering calculations for systems that include temperature-induced lattice and spin disorder as well as intrinsic alloy disorder. This makes it possible to determine material-specific spin transport parameters at finite temperatures. Illustrations are given for a number of important materials and parameters at 300 K. The spin-flip diffusion length $l_{\rm sf}$ of Pt is determined from the exponential decay of a spin current injected into a long length of thermally disordered Pt; we find $l_{\rm sf}^{\rm Pt}= 5.3\pm0.4 \,$nm. For the ferromagnetic substitutional disordered alloy Permalloy (Py), we inject currents that are fully polarized parallel and antiparallel to the magnetization and calculate $l_{\rm sf}$ from the exponential decay of their difference; we find $l_{\rm sf}^{\rm Py}= 2.8 \pm 0.1 \,$nm. The transport polarization $\beta$ is found from the asymptotic polarization of a charge current in a long length of Py to be $\beta = 0.75 \pm 0.01$. The spin Hall angle $\Theta_{\rm sH}$ is determined from the transverse spin current induced by the passage of a longitudinal charge current in thermally disordered Pt; our best estimate is $\Theta_{\rm sH}^{\rm Pt}=4.5 \pm 1 \%$ corresponding to the experimental room temperature bulk resistivity $\rho =10.8 \mu \Omega \,$cm., Comment: 21 pages, 14 figures

TPS266 Background: Radiation therapy (RT), plus androgen deprivation therapy (ADT) with a luteinizing hormone releasing hormone analogue (LHRHA), is standard of care for men with very high-risk localized prostate cancer (PC), or with very high- risk features and persistent PSA after radical prostatectomy (RP). Despite this, incurable distant metastases develop within 5 years in 15% of men with very high-risk features. Darolutamide is a structurally distinct oral androgen receptor antagonist with low blood-brain-barrier penetration, a demonstrated favorable safety profile and low potential for drug-drug interactions. Our aim is to determine the efficacy of adding darolutamide to ADT and RT in the setting of either primary definitive therapy, or adjuvant therapy for very high-risk PC. Methods: This study is a randomized (1:1) phase III placebo-controlled, double-blind trial for men planned for RT who have very high-risk localized PC; or very high-risk features with PSA persistence or rise within one year following RP. The trial will be stratified by: RP; use of adjuvant docetaxel; pelvic nodal involvement. 1100 participants will be randomized to darolutamide 600 mg or placebo twice daily for 96 weeks. Participants will receive LHRHA for 96 weeks, plus RT starting week 8-24 from randomisation. Participants are allowed nonsteroidal antiandrogen (up to 90 days) in addition to LHRHA up until randomisation. Early treatment with up to 6 cycles of docetaxel completed at least 4 weeks prior to RT is permitted. The primary endpoint is metastasis-free survival (ICECaP-validated), with secondary endpoints overall survival, PC-specific survival, PSA-progression free survival, time to subsequent hormonal therapy, time to castration-resistance, frequency and severity of adverse events, health related quality of life, fear of recurrence. Tertiary endpoints include incremental cost-effectiveness, and identification of prognostic and/or predictive biomarkers of treatment response, safety and resistance to study treatment. Clinical trial information: NCT04136353.

Background and AimsTo compare endoscopy and pathology sizing in a large population-based series of colorectal adenomas and to evaluate the implications for patient stratification into surveillance colonoscopy.MethodsEndoscopy and pathology sizes available from intact adenomas removed at colonoscopies performed as part of the Northern Ireland Bowel Cancer Screening Programme, from 2010 to 2015, were included in this study. Chi-squared tests were applied to compare size categories in relation to clinicopathological parameters and colonoscopy surveillance strata according to current American Gastroenterology Association and British Society of Gastroenterology guidelines.ResultsA total of 2521 adenomas from 1467 individuals were included. There was a trend toward larger endoscopy than pathology sizing in 4 of the 5 study centers, but overall sizing concordance was good. Significantly greater clustering with sizing to the nearest 5 mm was evident in endoscopy versus pathology sizing (30% vs 19%, p

Pancreatic cancer remains one of the most lethal forms of cancer with a 10-year survival of 60% (p 80%, p

A density functional theory based two-terminal scattering formalism that includes spin-orbit coupling and spin non-collinearity is described. An implementation using tight-binding muffin-tin orbitals combined with extensive use of sparse matrix techniques allows a wide variety of inhomogeneous structures to be flexibly modelled with various types of disorder including temperature induced lattice and spin disorder. The methodology is illustrated with calculations of the temperature dependent resistivity and magnetization damping for the important substitutional disordered magnetic alloy Permalloy (Py), Ni$_{80}$Fe$_{20}$. Comparison of calculated results with recent experimental measurements of the damping (including its temperature dependence) indicates that the scattering approach captures the most important contributions to this important property., 26 pages, 24 figures

Background We studied the effects of pre-hospital heparin in primary PCI patients, on infarct artery patency and long-term mortality. Methods Consecutive patients (n=1000) admitted to Ninewells Hospital, Dundee, from 2010–2014 for PPCI were allocated to two groups: 437 (44%) pre-hospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin (IHH). A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and 5 years. Cox proportional hazards regression models were generated. Results The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 min vs 251 min, p 30 day mortality in PHH was 2.5% vs 8.3%, p 5 year mortality in PHH was 13.0% vs 21.6%, p Conclusion Pre-hospital heparin was associated with reduced short and long-term mortality after adjusting for important potential confounders.

This chapter discusses the interaction between currents and magnetization, which can cause undesirable effects such as enhanced magnetic noise in read heads made from magnetic multilayers. While most research has been carried out on metallic structures, current-induced magnetization dynamics in semiconductors or even insulators has been pursued as well. These issues have attracted many physicists because, on top of the practical aspects, the underlying phenomena are fascinating. Berger and Slonczewski are acknowledged to have started the field in general through their introduction of the concept of current-induced magnetization dynamics by the transfer of spin. The reciprocal effect, i.e., spin pumping, was expected long ago, but it took some time before Tserkovnyak et al. developed a rigorous theory of spin pumping for magnetic multilayers, including the associated increased magnetization damping.

Lymphoepithelioma-like carcinoma (LELC) is an uncommon variant of squamous cell carcinoma, which is histologically identical to lymphoepithelial carcinoma of the nasopharynx. LELCs have been reported at a variety of sites, including the stomach, salivary gland, thymus, cervix, endometrium, breast, skin, bladder, and lung. We report 2 LELCs of the vagina and 1 of the anal canal, the first report of LELC at the latter site. All 3 neoplasms were diffusely positive with p16 (block-type immunoreactivity) and the anal canal lesion contained high-risk human papillomavirus type 16; the 2 vaginal neoplasms underwent human papillomavirus testing but were unsuitable for analysis. All cases were Epstein-Barr virus negative. In reporting these cases, we highlight the potential for misdiagnosis and suggest an association with human papillomavirus infection similar to LELCs in the uterine cervix.

Small bowel accounts for only 0.5% of cancer cases in the US but incidence rates have been rising at 2.4% per year over the past decade. One-third of these are adenocarcinomas but little is known about their molecular pathology and no molecular markers are available for clinical use. Using a retrospective 28 patient matched normal-tumor cohort, next-generation sequencing, gene expression arrays and CpG methylation arrays were used for molecular profiling. Next-generation sequencing identified novel mutations in IDH1, CDH1, KIT, FGFR2, FLT3, NPM1, PTEN, MET, AKT1, RET, NOTCH1 and ERBB4. Array data revealed 17% of CpGs and 5% of RNA transcripts assayed to be differentially methylated and expressed respectively (p < 0.01). Merging gene expression and DNA methylation data revealed CHN2 as consistently hypermethylated and downregulated in this disease (Spearman -0.71, p < 0.001). Mutations in TP53 which were found in more than half of the cohort (15/28) and Kazald1 hypomethylation were both were indicative of poor survival (p = 0.03, HR = 3.2 and p = 0.01, HR = 4.9 respectively). By integrating high-throughput mutational, gene expression and DNA methylation data, this study reveals for the first time the distinct molecular profile of small bowel adenocarcinoma and highlights potential clinically exploitable markers.

Neuroendocrine tumours are uncommon or rare at all sites in the female genital tract. The 2014 World Health Organisation (WHO) Classification of neuroendocrine tumours of the endometrium, cervix, vagina and vulva has been updated with adoption of the terms low-grade neuroendocrine tumour and high-grade neuroendocrine carcinoma. In the endometrium and cervix, high-grade neoplasms are much more prevalent than low-grade and are more common in the cervix than the corpus. In the ovary, low-grade tumours are more common than high-grade carcinomas and the term carcinoid tumour is still used in WHO 2014. The term ovarian small-cell carcinoma of pulmonary type is included in WHO 2014 for a tumour which in other organs is termed high small-cell neuroendocrine carcinoma. Neuroendocrine tumours at various sites within the female genital tract often occur in association with other neoplasms and more uncommonly in pure form.

AimsThis multi-institutional study and a re-evaluation of the TCGA cohort explores the morphological spectrum, genetics and outcome of GI (gastrointestinal) hepatoid tumours, tumours expressing alpha-fetoprotein (AFP) and fetal-type (FT) GI adenocarcinomas.Methods44 tumours with evidence of hepatocellular differentiation were evaluated for morphology as well as by immunohistochemistry for AFP, HepPar1, glypican-3 and arginase-1 and by in situ hybridisation for albumin. Three categories were defined: type I (hepatoid: morphological evidence of hepatocellular differentiation), type II (FT GI adenocarcinoma: tubular profiles and subnuclear vacuolisation, resembling fetal intestine) and type III: positive for at least two hepatocyte-specific markers but lacking morphological evidence of hepatocellular differentiation. GI adenocarcinomas in the TCGA cohort were also evaluated (n=829).Results18 cases were classified as type I, 19 as FT GI adenocarcinomas and 7 as type III (resembling conventional gastrointestinal carcinomas). Serum AFP was elevated in 92% of cases. 93% of tumours were positive for glypican-3, 90% for albumin and 89% for AFP. Arginase-1 was restricted to 35% of type 1 tumours. TCGA gastric tumours with elevated AFP expression showed morphological features of FT GI adenocarcinoma (70%) and were exclusively MSI stable. TCGA gastric adenocarcinomas with high AFP expression showed inferior survival on univariate and multivariate analysis.ConclusionsFT GI adenocarcinomas show a distinctive morphological and immunohistochemical profile. Gastric adenocarcinomas with elevated expression of AFP morphologically resemble FT GI adenocarcinomas, demonstrate aggressive behaviour, independent of grade and stage, and a distinct genetic profile.

We thank Park et al for their interest in our work and for bringing to our attention their alternative microenvironmental score for assessing colorectal cancer prognosis. 1-3 We are largely in agreement with many of the points raised. The scoring systems proposed by these two studies share many similarities, highlighting the importance of the non-epithelial tumour components and combining assessments of peritumoral inflammatory response and tumour stromal percentage to derive a prognostically valuable fibroinflammatory or microenvironmental score. Despite the overall similarity, a number of small, albeit clinically important, differences lie in the methodologies chosen for assessment of each individual parameter, and in the statistical approaches used. This article is protected by copyright. All rights reserved.

215 Background: This phase II single arm study, previously reported on the safety and tolerability of the combination of R223 and ENZA in pts with mCRPC. R223 in combination with ENZA was well tolerated with acceptable safety and toxicity profiles. Methods: This study enrolled pts with mCRPC to bone with or without visceral/lymph node involvement progressing on ADT. Pts received 6 cycles of R223 (55 kBq/kg IV Q4W) in combination with ENZA (160mg/day), followed by ENZA alone. Bone health agents were initiated as per treating clinician choice. SREs were defined as: a pathologic fracture, spinal cord compression (SCC), necessity for external beam radiation (EBRT) or surgery to bone. SREs during the combination period and after completion of R223 are reported here. An unplanned retrospective analysis of all scans performed on each patient for any fracture was performed and is included. Results: From July 2015 to July 2017, 45 pts were enrolled. 42 pts (93.3%) received all 6 cycles of combination therapy. 16 pts (35.5%) remain on ENZA alone. In total, 6 pts (13.3%) had SREs. 4 developed pathological fractures (femur = 1, vertebrae = 3) while 3 had EBRT for pain. Of these 6 pts, 2 developed SCC requiring EBRT. The average time from starting R223 to SRE was 615 days. 2/6 pts were not receiving bone protection. One pt who developed a pathological fracture has subsequently died related to progressive disease (time to death = 292 days). In the retrospective analysis, 4 pts (8.8%) developed fractures which were associated with a history of trauma (radius = 1, tibia = 1 ribs = 2). 11 pts (24.4%) developed asymptomatic insufficiency fractures (ankle = 1, femur = 1, sacrum = 2, vertebrae = 4, ribs = 4). The average time to insufficiency fracture was 354 days. No interventions were required. The majority of pts (75.5%) on the study were receiving bone health agents. Conclusions: SREs were in keeping with previously published data. In an unplanned retrospective analysis, there was a higher incidence of asymptomatic insufficiency fractures in this cohort of patients, however no interventions were required. Clinical trial information: NCT02225704.

Structurally ordered interfaces between ferromagnetic electrodes and graphene or graphite are of great interest for carbon spintronics, since they allow spin-filtering due to k-vector conservation. By solid phase epitaxy of amorphous/nanocrystalline CoFeB at elevated temperatures, the feasibility of fabricating crystalline interfaces between a 3d ferromagnetic alloy and graphite is demonstrated, without suffering from the unwetting problem that was commonly seen in many previous studies with 3d transition metals. The films fabricated on graphite in this way are found to have a strong body-centered-cubic (110) texture, albeit without a unique, well-defined in-plane epitaxial relationship with the substrate lattice. Using various X-ray spectroscopic techniques, it is shown that boron suppresses the formation of CoFe-O during CoFeB deposition, and then diffuses out of the CoFe lattice. Segregation of B occurred exclusively to the film surface upon in situ annealing, and not to the interface between CoFeB and graphite. This is favorable for obtaining a high spin polarization at the hybrid CoFe/graphite crystalline interface. The Co and Fe spin moments in the crystalline film, determined by X-ray magnetic circular dichroism, are found to be bulk-like, while their orbital moments show an unusual giant enhancement which has yet to be understood.

AimsBoth morphological and molecular approaches have highlighted the biological and prognostic importance of the tumour microenvironment in colorectal cancer (CRC). Despite this, microscopic assessment of tumour microenvironment has not been adopted into routine practice.Methods and ResultsBased on existing evidence, we selected specific morphological features relating to peritumoral inflammatory and stromal responses, agreed criteria for scoring, and assessed these in representative H&E-stained whole tumour sections, from a population-based cohort of 445 stage II/III colon cancer cases. Moderate/severe peritumoral diffuse lymphoid inflammation and Crohn's disease-like reaction were associated with significantly reduced risks of CRC-specific death (adjusted HR 0.48, 95% CI 0.31-0.76, and HR 0.60, 95% CI 0.42-0.84, respectively). The presence of >50% tumour stromal percentage, assessed by global evaluation of tumour area, was associated with a significantly increased risk of CRC-specific death (HR 1.60 95% CI 1.06-2.41). A composite, “fibroinflammatory score” (0-3), combining dichotomised scores of these three features, showed a highly significant association in relation to survival outcomes. Those with a score ≥2 had an almost 2.5 fold increased risk of CRC-specific death (HR 2.44, 95% CI: 1.56-3.81), compared with those scoring zero. These associations were stronger in MSI-high tumours, potentially identifying a subset of MSI-high colon cancers which lack characteristic morphological features and have an associated worse prognosis.ConclusionsIn summary, reporting on H&E staining of selected microscopic features of the tumour microenvironment, independently or in combination, offers valuable prognostic information in stage II/III colon cancer and may allow morphological correlation with developing molecular classifications of prognostic and predictive relevance.

We report a case of thyrotoxicosis associated with chorea and detectable anti-phospholipid antibodies in which a structural abnormality could not be detected on routine imaging but cerebral perfusion single photon emission computed tomography scans suggested a reversible alteration of basal ganglia perfusion. The pathophysiological mechanisms of phospholipid antibody causing chorea in thyrotoxicosis are discussed.

A 59-year-old man was admitted to the hospital because of 9 months of abdominal pain, vomiting, and weight loss. He was born in a Caribbean country and had been treated for intestinal strongyloidiasis years earlier. A diagnosis of celiac disease had recently been made elsewhere.

The prototypic pancreatic ductal adenocarcinoma shows small-caliber glands that are placed within an exuberant desmoplastic stromal reaction. A number of histologic patterns have been described, and the majority of these patterns are genetically and biologically related to conventional ductal adenocarcinomas. In this report we describe our experience with a heretofore undescribed histologic pattern of pancreatic adenocarcinoma that mimics intraductal papillary mucinous carcinoma, both morphologically and radiologically.We identified 10 cases of pancreatic adenocarcinoma with large-caliber malignant glands and an intraluminal papillary pattern. The demographic, clinical, radiologic, and outcome data were recorded. In addition to a review of the histologic features we also performed elastin stains, immunohistochemistry for selected oncogenes and tumor suppressor genes including SMAD4. Immunohistochemical staining for MUC proteins was also performed.The median age of the patients was 67 years, and there were 6 women and 4 men. Grossly, the cut surface in 6 of these cases showed an admixture of solid and cystic areas. The papillary cystic architecture was intimately mixed with areas of conventional adenocarcinoma, the latter characterized by invasive small-caliber tubular structures. None of the tumors showed a pure papillary cystic pattern; however, in 8 cases, this was the predominant pattern (50% of the tumor). The cysts and papillae were lined predominantly by tall columnar hypermucinous epithelium. Elastin fibers were not identified around these dilated malignant cysts and glands. The intratumoral stroma was paucicellular and hyalinized. Seven of the 10 tumors were negative for SMAD4. The lack of pericystic elastin fibers and loss of SMAD4 in the majority of cases argue against these lesions representing an intraductal papillary mucinous neoplasm. All 10 tumors stained for MUC1; focal MUC2 reactivity was noted in 1 case. The majority of cases were positive for MUC5AC (9/10) and MUC6 (8/10). Seven patients died of their disease, whereas 1 patient is alive with widely metastatic disease. Two patients were lost to follow up.The adenocarcinoma described herein is a unique morphologic pattern of pancreatic ductal adenocarcinoma. The biology and genetics (as estimated by immunohistochemistry) are no different from that of conventional ductal adenocarcinoma but are distinctly different from that of an intraductal papillary mucinous carcinoma, its closest morphologic mimic.

Paul J Kelly, Robert Spence, Bobby V Dasari, Alastair D Burt, Mark Taylor, Maurice B Loughrey

Purpose Whole-brain radiation therapy (WBRT) is the standard of care after resection of a brain metastasis. However, concern regarding possible neurocognitive effects and the lack of survival benefit with this approach has led to the use of stereotactic radiosurgery (SRS) to the resection cavity in place of WBRT. We report our initial experience using an image-guided linear accelerator-based frameless stereotactic system and review the technical issues in applying this technique. Methods and Materials We retrospectively reviewed the setup accuracy, treatment outcome, and patterns of failure of the first 18 consecutive cases treated at Brigham and Women’s Hospital. The target volume was the resection cavity without a margin excluding the surgical track. Results The median number of brain metastases per patient was 1 (range, 1–3). The median planning target volume was 3.49 mL. The median prescribed dose was 18 Gy (range, 15–18 Gy) with normalization ranging from 68% to 85%. In all cases, 99% of the planning target volume was covered by the prescribed dose. The median conformity index was 1.6 (range, 1.41–1.92). The SRS was delivered with submillimeter accuracy. At a median follow-up of 12.7 months, local control was achieved in 16/18 cavities treated. True local recurrence occurred in 2 patients. No marginal failures occurred. Distant recurrence occurred in 6/17 patients. Median time to any failure was 7.4 months. No Grade 3 or higher toxicity was recorded. A long interval between initial cancer diagnosis and the development of brain metastasis was the only factor that trended toward a significant association with the absence of recurrence (local or distant) (log-rank p = 0.097). Conclusions Frameless stereotactic irradiation of the resection cavity after surgery for a brain metastasis is a safe and accurate technique that offers durable local control and defers the use of WBRT in select patients. This technique should be tested in larger prospective studies.

The spin Hall angle (SHA) is a measure of the efficiency with which a transverse spin current is generated from a charge current by the spin-orbit coupling and disorder in the spin Hall effect (SHE). In a study of the SHE for a Pt$|$Py (Py=Ni$_{80}$Fe$_{20}$) bilayer using a first-principles scattering approach, we find a SHA that increases monotonically with temperature and is proportional to the resistivity for bulk Pt. By decomposing the room temperature SHE and inverse SHE currents into bulk and interface terms, we discover a giant interface SHA that dominates the total inverse SHE current with potentially major consequences for applications.