Search

The primary objective of this study is to evaluate the clinical significance of RANK/L expression, in both a retrospective cohort of surgically resected stage I-III NSCLC (Lungscape) and a randomized clinical trial-cohort (SPLENDOUR) of advanced NSCLC treated with chemotherapy alone or in combination with denosumab.RANK-L expression was assessed on tissue microarrays (TMAs) in Lungscape and whole sections in SPLENDOUR, using immunohistochemistry, with H-scores values 0 indicating positivity. Prevalence of RANK positivity and its association with clinicopathological characteristics, and patient outcome was explored in a subset of the ETOP Lungscape cohort and in SPLENDOUR. Also investigated were the prevalence of RANK overexpression (proportion of positive cancer cells ≥ 50%) in the Lungscape cohort, and RANK-L in the SPLENDOUR trial.In the Lungscape cohort, RANK expression was assessed at a median follow-up of 46 months (N = 488 patients; 4 centers); 35% were female, 44/49/6% adenocarcinomas (AC)/squamous cell carcinomas (SCC)/other, 48/27/25% with stage I/II/III. Median RFS/TTR/OS were 58/Not reached/74 months. Prevalence of RANK expression was 31% (95%CI:27%-35%); significantly higher in AC: 50% (95%CI:43%-57%) vs SCC: 12% (95%CI:8%-16%) (p 0.001); more frequent in females (42% vs 25%, p 0.001) and tumors ≤ 4 cm (35.3% vs 23.3%, p = 0.0065). No association with outcome was found. In the SPLENDOUR trial (463 patients), the prevalence of membranous and cytoplasmic RANK positivity was 34% (95%CI:30%-38%) and 9% (95%CI:7%-12%), respectively, while prevalence for RANK-L was 5% (95%CI:3%-7%) and 36% (95%CI:31%-40%), respectively. Cytoplasmic RANK-L positivity was more common among females (47% vs 31%, p = 0.001) and in non-SCC histology (45% vs 10%, p 0.0001). At the pre-specified 1% significance level, no prognostic or predictive effect was found.Both cohorts indicate that RANK expression is more common in adenocarcinoma/non-squamous NSCLC and in female patients. No prognostic effect is found, and in the clinical trial involving addition of denosumab to chemotherapy no predictive effect is detected.

The consequence of cardiac substructure irradiation in patients receiving stereotactic body radiation therapy (SBRT) is not well characterized. We reviewed the charts of patients with central lung tumors managed by definitive SBRT from June 2010–April 2019. All patients were treated with five fractions, typically either 5000 cGy (44.6%) or 5500 cGy (42.2%). Via a multi-patient atlas, fourteen cardiac substructures were autosegmented, manually reviewed and analyzed using dosimetric parameters. A total of 83 patients were included with a median follow up of 33.4 months. Univariate Cox regression analysis identified a D45% dose to the right atria and ventricle for further study. Sequential log-rank testing evaluating an association between non-cancer associated survival and D45% dose to the right atria or ventricle and association was employed, identifying candidate cutoff values of 890.3 cGy and 564.4 cGy, respectively. Kaplan–Meier analysis using the reported cutoff values found the D45% right atria constraint to be significantly associated with non-cancer associated (p ≤ 0.001) and overall survival (p ≤ 0.001) but not the right ventricle constraint. Within a multivariate model, the proposed right atria D45% cutoff remained significantly correlated with non-cancer associated survival (Hazard’s Ratio (HR) ≤ 8.5, 95% confidence interval (CI) 1.1–64.5, p ≤ 0.04) and OS (HR ≤ 6.1, 95% CI 1.0–36.8, p ≤ 0.04). In conclusion, a dose to D45% of the right atria significantly correlated with outcome and the candidate constraint of 890 cGy stratified non-cancer associated and OS. The inclusion of these findings with previously characterized relationships between proximal airway constraints and survival enhances our understanding of why centrally located tumors are high risk and potentially identifies key constraints in organ at risk prioritization.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Small Cell Lung Cancer (SCLC) provide recommended management for patients with SCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. This selection for the journal focuses on metastatic (known as extensive-stage) SCLC, which is more common than limited-stage SCLC. Systemic therapy alone can palliate symptoms and prolong survival in most patients with extensive-stage disease. Smoking cessation counseling and intervention should be strongly promoted in patients with SCLC and other high-grade neuroendocrine carcinomas. The “Summary of the Guidelines Updates” section in the SCLC algorithm outlines the most recent revisions for the 2022 update, which are described in greater detail in this revised Discussion text.

Introduction: Sudden cardiac death (SCD) is responsible for approximately 380,000 deaths per year. One third of the patients dying of heart disease present with SCD as the first manifestation. There are limited data on the clinico-pathological determinants of SCD. Hypothesis: We hypothesized that, compared to overall deaths, silent coronary atherosclerosis and myocardial fibrosis could be associated with increased frequency of SCDs. Methods: We reviewed the post-mortem data registry from two tertiary care hospitals located at the Buffalo-Niagara Region. Of the 1,314 subjects that underwent comprehensive post-mortem analysis, we identified 187 subjects that died suddenly. For this initial pilot data analysis protocol, we compared the demographic, clinical, electrocardiographic and coronary vascular and myocardial histopathological characteristics of 109 subjects with sudden death vs. 34 age-matched controls with non-sudden death. Results: We found that, of the total 1,314 subjects screened, 14% had SCD. Comparison of age-matched SCD with non-SCD subjects (age in years, SCD: 60±14; non-SCD: 61±20) showed that SCD groups had larger cardiac size (heart weight in grams, SCD: 550±150; non-SCD: 480±117, P=0.03), increased wall thickness (posterior wall thickness in cm, SCD: 1.7±0.4; non-SCD: 1.5±0.2, P=0.01), but reduced LV function reported before the event (LV ejection fraction in %, SCD: 41±17; non-SCD: 58±9, P=0.007). In addition, SCD groups had higher frequency of coronary atherosclerosis (SCD, 76% vs., non-SCD, 52%, P=0.007), and myocardial fibrosis involving both left ventricular free wall (SCD, 47% vs., non-SCD, 26%, P=0.03), and interventricular septum (SCD, 29% vs., non-SCD, 3%, P=0.02). There were no differences on serum electrolytes, circulating biomarkers and the extent of right ventricular fibrosis. Conclusions: The subjects that died suddenly had larger cardiac size, reduced contractile function with myocardial interstitial fibrosis, and silent coronary atherosclerosis. Further studies are in progress to fully examine the clinico-pathological correlates of SCD in our longitudinal study cohorts.

Introduction: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of many incurable cancers. However, serious cardiotoxic side effects, such as fatal myocarditis, have been reported. Autoimmunity against cardiac proteins has been suspected but the underlying mechanism is not known. Hypothesis: Combination ICIs are more cardiotoxic than monotherapy alone and can induce both T- and B-cell mediated responses against cardiac proteins. Methods: We intraperitoneally administered either 200μg of programmed cell death-1 (PD-1) antibody (Ab), 100μg of cytotoxic T-lymphocyte associated protein-4 (CTLA-4) Ab, both treatment Abs, or IgG control every 3 days for a total of 17 doses in mice. Cardiac function was monitored by MRI and myocardial inflammatory cells were characterized by immunohistochemistry. After identifying specific cardiac troponin I (cTnI) antigenic sequences by bioinformatic analyses, biotinylated peptides were synthesized and immobilized to streptavidin-coated plates for enzyme-linked immunosorbent assays (ELISA) to detect self-reactive anti-troponin Abs. Results: PD-1 Ab, CTLA-4 Ab, and the combination significantly decreased cardiac contractile velocities compared to IgG (peak systolic velocity cm/s: IgG -1.27 ± 0.131, PD-1 Ab -1.14 ± 0.0531, p=0.02 vs. IgG, CTLA-4 Ab -1.07 ± 0.0359, p+ cells with combination treatment (cells/mm 2 : IgG 3.03 ± 1.34, PD-1+CTLA-4 Ab 7.93 ± 2.41, p=0.004). Serum ELISA showed cross-reactivity against cTnI, suggesting the formation of auto-antibodies and significantly high titers were detected with combination treatment (450 nm absorbance: IgG 0.162 ± 0.0859, PD-1+CTLA-4 Ab 0.397 ± 0.121, p=0.002). Conclusions: Our study showed that ICI-therapy induced myocardial inflammation (including CD8 + T-cell infiltration), contractile dysfunction, and immune-reactive antibodies directed against immunogenic targets of cTnI. These data suggest a novel mechanism of ICI-induced cardiotoxicity, which warrants further investigation.

Introduction: In cancer survivors exposed to ionizing radiation (IR) exposure to the chest and heart, coronary endothelial injury and disruption of vascular barrier integrity is noted. The mechanisms driving the IR-induced leakiness of the coronary microvasculature are not known. There is no therapy to prevent such injury. Hypothesis: IR exposure downregulates a tight junction protein claudin-1 (cldn1), which can lead to altered endothelial barrier integrity. Ac-SDKP, an endogenous peptide, prevents cldn1 loss and preserves coronary vascular barrier function. Methods: We tested the constitutive and physiological effects of cldn1 both in vitro and in vivo . Human coronary vascular endothelial cells (HMVECs) lacking cldn1 by siRNA silencing were used for loss-of-function studies. Newly developed vascular-specific (VE-cadherin promotor-linked) cldn1 overexpressing transgenic (TG) mice were used for cldn1 gain-of-function studies. Mice were exposed to 45Gy chest radiation in fractionated doses (3Gy/day). A subgroup of irradiated mice was treated with Ac-SDKP (3.2mg/kg/day) for 3-weeks. Evans blue dye was injected via tail-vein 30 mins before euthanasia and dye extravasation through coronary microvasculature was quantified. Cldn1 expression was examined by Western blot and in vitro cell permeability was examined by FITC-dextran permeability assays. Results: Cldn1 silencing with siRNA showed increased permeability in HMVECs (control, 1.0±0.01, siRNA, 1.3±0.01; p=0.0002). Cardiac irradiation significantly decreased myocardial cldn1 (control 1.0±0.27, IR 0.45±0.31; p=0.001). Consequently, there was a significant increase in myocardial Evans blue dye extravasation compared to controls (control 1.0±0.22, IR 1.3±0.23, p=0.039). Cldn1 overexpression mice had decreased dye extravasation compared to WT controls (WT 1.0±0.23, TG 0.38±0.27 p=0.002). Ac-SDKP restored cldn1 protein expression, and inhibited dye leakage in the myocardium after IR exposure (0.57±0.21, p=0.048 vs IR). Conclusions: Our study shows that IR exposure induces endothelial barrier disruption through a reduced expression of endothelial tight-junction protein, cldn1. Ac-SDKP prevents these effects, at least in part, by preventing loss of claudin-1.

Introduction: Immune checkpoint inhibitors (ICIs), and adoptive cell transfer (ACT) - which involves collecting and using patient’s own immune cells to treat their cancer, are two rapidly emerging therapeutic modalities for various advanced stage cancers. Emerging cardiovascular side effects of ICIs and ACTs are currently being recognized. Objective: We analyzed the newly reported side-effect profiles of FDA-approved ICIs (anti-CTLA-4, anti-PD-1 and anti-PD-L1) and ACTs (also known as CAR-T therapy). Methods: We utilized the global data available in VigiBase®, World Health Organization’s global database for adverse drug reactions (ADRs), maintained by the Uppsala Monitoring Centre. We extracted information on reports of suspected ADRs, also called Individual Case Safety Reports (ICSRs). ICSRs of ICI and ACT therapy on cardiovascular system were extracted, and the side effect profile of the two groups of immunotherapies were systematically analyzed. Results: Based on the records obtained to-date, a total of 6,000 cardiovascular ADRs caused by ICIs (Ipilimumab, Nivolumab, Pembrolizumab, Cemiplimab, Atezolizumab, Avelumab and Durvalumab), and 500 ADRs by ACTs (Kymriah, Yescarta, Tecartus, Brevanzi and Abecma) have been reported. ICI therapies were predominantly associated with myocarditis (1098), cardiac failure (614), acute coronary syndrome (548) and pericarditis/pericardial effusion (516). ACT therapies were associated with tachyarrhythmia (263), cardiac arrest (44) and cardiorenal events (25). A propensity analysis demonstrated ICIs to be associated with autoimmunity-related ADRs, whereas ACTs were associated with acute cytokine release-related ADRs. Conclusions: Using a large-scale global WHO data platform, we have identified unique tendencies for cardiovascular ADRs resulting from non-selective (ICIs) and highly-selective (ACTs) immunotherapies for cancer: the former is associated with serious autoimmune effects, and the latter is associated with acute cytokine-release-related ADRs.

Background: Myocardial Gal3 (galectin-3) expression is associated with cardiac inflammation and fibrosis. Increased Gal3 portends susceptibility to heart failure and death. There are no data reporting the causative role of Gal3 to mediate cardiac fibro-inflammatory response and heart failure. Methods: We developed a cardioselective Gal3 gain-of-function mouse ( Gal3+/+ ) using α-myosin heavy chain promotor. We confirmed Gal3-transgene expression with real-time polymerase chain reaction and quantified cardiac/circulating Gal3 with Western blot and immunoassays. We used echocardiogram and cardiac magnetic resonance imaging to measure cardiac volumes, function, and myocardial velocities. Ex vivo, we studied myocardial inflammation/fibrosis and downstream TGF (transforming growth factor) β1-mRNA expression. We examined the effects of acute myocardial ischemia in presence of excess Gal3 by inducing acute myocardial infarction in mice. Two subsets of mice including mice treated with N-acetyl-seryl-aspartyl-lysyl-proline (a Gal3-inhibitor) and mice with genetic Gal3 loss-of-function ( Gal3 −/−) were studied for comparative analysis of Gal3 function. Results: Gal3+/+ mice had increased cardiac/circulating Gal3. Gal3+/+ mice showed excess pericardial fat pad, dilated ventricles and cardiac dysfunction, which was partly normalized by N-acetyl-seryl-aspartyl-lysyl-proline. Cardiac magnetic resonance imaging showed reduced myocardial contractile velocities in Gal3+/+ . The majority of Gal3+/+ mice did not survive acute myocardial infarction, and the survivors had profound cardiac dysfunction. Myocardial histology of Gal3+/+ mice showed macrophage/mast-cell infiltration, fibrosis and higher TGFβ1-mRNA expression, which were mitigated by both Gal3 gene deletion and N-acetyl-seryl-aspartyl-lysyl-proline administration. Conclusions: Our study shows that cardioselective Gal3 overexpression leads to multiple cardiac phenotypic defects including ventricular dilation and cardiac dysfunction. Pharmacological Gal3 inhibition conferred protective effects with reduction of inflammation and fibrosis. Our study highlights the importance of translational studies to counteract Gal3 function and prevent cardiac dysfunction.

Background: Immune checkpoint inhibitor (ICI)-induced cardiac side effects in cancer patients are increasingly being recognized and can be fatal. There is no standardized cardiac imaging test to examine the effects of ICIs in myocardial morphology and function. Objective: To study the utility of echocardiography and cardiac MRI in examining regional and global changes arising from ICI-induced myocarditis and cardiomyopathy in high-risk subjects suspected to have developed ICI cardiomyopathy. Methods: We studied eight consecutive patients referred for cardiac MRI (CMR) from a comprehensive cancer center for suspected ICI-induced myocarditis and compared the data with sixteen age-matched controls. Using newly developed strain analysis algorithms, we measured myocardial strain and strain rates using echocardiography and CMR. Then, we compared the mean longitudinal strain and strain rates derived from echocardiography and CMR in the same ICI-treated cohort of patients (n = 8). They underwent both of these imaging studies with images taken 24–48 h apart and followed up prospectively within the same hospital course. Results: All our cases had preserved ejection fraction (EF) > 50%. Echocardiogram showed reduced mean systolic longitudinal strain (LS, %) (ICI: −12.381 ± 4.161; control: −19.761 ± 1.925; p < 0.001), peak systolic strain rate (SRS, s−1) (ICI: −0.597 ± 0.218; control: −0.947 ± 0.135; p = 0.002) and early diastolic strain rate (SRE, s−1) (ICI: 0.562 ± 0.295; control: 1.073 ± 0.228; p = 0.002) in ICI-treated cases. Direct comparison between the echocardiogram vs. CMR obtained within the same hospital course demonstrated strong a correlation of LS scores (r = 0.83, p = 0.012) and SRS scores (r = 0.71, p = 0.048). The Bland–Altman plots showed that 95% of the data points fitted within the ±1.96 SD of the mean difference, suggesting an agreement among these two imaging modalities. Conclusion: In this feasibility cohort study, both echocardiography- and CMR-based strain indices illustrate changes in myocardial contractility and relaxation suggestive of ICI-induced cardiomyopathy. Our data, after validation in a larger cohort, can form the basis of myocardial imaging in cancer patients treated with ICIs.

Since the approval of the first immune checkpoint inhibitor (ICI) 9 years ago, ICI-therapy have revolutionized cancer treatment. Lately, antibodies blocking the interaction of programmed cell death protein (PD-1) and ligand (PD-L1) are gaining momentum as a cancer treatment, with multiple agents and cancer types being recently approved for treatment by the US Food and Drug Administration (FDA). Unfortunately, immunotherapy often leads to a wide range of immune related adverse events (IRAEs), including several severe cardiac effects and most notably myocarditis. While increased attention has been drawn to these side effects, including publication of multiple clinical observational data, the underlying mechanisms are unknown. In the event of IRAEs, the most widely utilized clinical solution is administration of high dose corticosteroids and in severe cases, discontinuation of these ICIs. This is detrimental as these therapies are often the last line of treatment options for many types of advanced cancer. In this review, we have systematically described the pathophysiology of the PD-1/PD-L1 axis (including a historical perspective) and cardiac effects in pre-clinical models, clinical trials, autoimmune mechanisms, and immunotherapy in combination with other cancer treatments. We have also reviewed the current challenges in the diagnosis of cardiac events and future directions in the field. In conclusion, this review will delve into this expanding field of cancer immunotherapy and the emerging adverse effects that should be quickly detected and prevented.

Background: Radiation emergencies are rare but can have minor confined effects to catastrophic consequences across the large geographical territories. Geographical disparities in the preparedness for radiation emergencies can negatively impact public-safety and delay protective actions. We examined such disparities using the global and regional radiation preparedness data from the revised annual International Health Regulations (IHR) datasets. Methods: We used IHR State Party Annual Reporting (SPAR) tool and its associated health indicators developed to mitigate public health-risk from radiation emergencies. Using the most recent (2019) SPAR database developed for radiation emergencies, along with 12 other cross-sector indicators, we examined the disparities among World Health Organization (WHO) state and region-wide capacity scores for operational preparedness. Findings: Based on the analysis of the 2019 annual reporting datasets from 171 countries, radiation emergency was one of the top 3 global challenges with an average global preparedness capacity of 55%. Radiation emergency preparedness capacity scores showed highest dispersion score amongst all 13 capacities suggesting higher disparities for preparedness across the globe. Only 38% of the countries had advanced functional capacity with ≥80% operational readiness, with 28% countries having low to very-low operational readiness. No geographical regions had ≥80% operational readiness for radiation emergencies, with 4/6 geographical regions showing limited capacity or effectiveness. Interpretation: We found major global disparities for the operational preparedness against radiation emergencies. Collaborative approaches involving the public health officials and policymakers at the regional and state levels are needed to develop additional guidance to adapt emergency preparedness plans for radiation incidents. Funding Information: This research was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR001412 to the University at Buffalo and Roswell Park Comprehensive Cancer Center, and by Roswell Park and National Cancer Institute under award number P30CA016056. UCS is supported by KO8HL131987 and RO1HL152090 Award from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI). SP received support from NIH/NHLBI (Award Numbers R21HL154028 and RO1HL150266). Declaration of Interests: None.

Background Biomarkers involved in inflammation and stress response were implicated in patients who were successfully resuscitated from out of hospital cardiac arrest (sR-OHCA). Here we report that macrophage-expressed gene, perforin-2, an evolutionarily conserved protein with membrane attack domain, is associated with poor neurological outcomes and mortality after sR-OHCA. Objectives To examine the association between circulating perforin-2 protein measured within 6-h of sR-OHCA, mortality and neurological outcomes. Methods We prospectively enrolled 144 sR-OHCA patients from 4 different tertiary care centers. We measured perforin-2 and other conventional clinical biomarkers and compared between survivors vs. non-survivors. The neurological outcomes were dichotomized as poor or good according to the cereberal performance score. Results At the end of the hospital stay, 45% of the patients had died and 46% had poor neurological outcomes. Serum perforin-2 levels were significantly higher in patients with poor neurological recovery, compared to the ones with good neurological recovery (ng/mL, 13.7 ± 45.9 vs. 1.2 ± 7.0, p = 0.01). There were no differences in other routinely measured biomarkers and left ventricular ejection fraction. On multivariate logistic regression, elevated perforin-2 (OR: 12.78, 95% CI: 1.0–17.8, p = 0.02), comatose on presentation (OR: 27.82, 95% CI: 0.2–19.5, p = 0.02) and non-shockable rhythm (OR: 17.04, 95% CI: 0.7–15.7, p = 0.01) were the significant predictors of poor neurological outcome. Conclusions This study reports a novel macrophage-expressed circulating biomarker perforin-2 to be strongly associated with reduced survival and poor neurological outcomes in sR-OHCA. These data can guide clinicians to prognosticate survival and neurological outcomes in sR-OHCA, and also form the basis for future therapeutic approaches.

Introduction: Immunotherapy has revolutionized the treatment of advanced stage lung cancers and melanoma. However, serious cardiotoxic side effects such as acute myocarditis, heart block, and sudden cardiac arrest have been reported. There is an urgent need to develop accurate diagnostic modalities for the early detection of this condition, such that toxic therapies can be adjudicated based on the anticipated risks vs. benefits. Hypothesis: Programmed cell death-1 (PD-1) blockade-induced cardiotoxicity, presenting as myocarditis or contractile dysfunction, can be detected at an early stage by cardiac magnetic resonance imaging (MRI). Methods: To develop a murine model of PD-1 blockade-induced cardiotoxicity, we intraperitoneally administered 200 μg (10 mg/kg) of PD-1 antibody (Ab) or IgG isotype control every 3 days for a total of 14 doses. Cardiac function was monitored by MRI with gadolinium infusion. Serum was collected at 27 days and at the time of sacrifice. Immunohistochemical stains were performed on formalin-fixed paraffin embedded tissues. Results: Blockade in mice trended towards reduced myocardial signal intensity (SI) after the gadolinium injection, one month after the last dose of PD-1 antibody (myocardial SI: control 2.55 ± 0.168, PD-1 Ab 2.02 ± 0.164, p=0.063, n=4-7). Three months after the last injection, late gadolinium myocardial SI was significantly reduced in treated mice (myocardial SI: control 2.84 ± 0.352, PD-1 Ab 1.50 ± 0.308, p=0.024, n=4-5). There were also significant decreases in stroke volume (mL: control 10.4 ± 0.355, PD-1 Ab 8.36 ± 0.599, p=0.030, n=4-5), radial strain (%: control 49.9 ± 3.91, PD-1 Ab 33.5 ± 3.00, p=0.012, n=4-5), peak acceleration (cm/s 2 : control 7.24 ± 1.03, PD-1 Ab 3.51 ± 1.08, p=0.044, n=4-5), and peak deceleration (cm/s 2 : control -8.03 ± 0.78, PD-1 Ab -4.64 ± 1.04, p=0.042, n=4-5) times. Interestingly, a subset of animals also had serum antibodies directed against cardiac troponin I peptide sequence. Conclusions: Our study showed that cardiac MRI with gadolinium can identify abnormal myocardial perfusion and reduced contractile function in mice treated with a PD-1 blocker. The presence of serum antibodies against cardiac troponin I may have a mechanistic value, which warrants further investigation.

PD-L1, as assessed by immunohistochemistry, is a predictive biomarker for immuno-oncology treatment in lung cancer. Different scoring methods have been used to assess its status, resulting in a wide range of positivity rates. We use the European Thoracic Oncology Platform Lungscape non-small cell lung carcinoma cohort to explore this issue. PD-L1 expression was assessed via immunohistochemistry on tissue microarrays (up to four cores per case), using the DAKO 28-8 immunohistochemistry assay, following a two-round external quality assessment procedure. All samples were analyzed under the same protocol. Cross-validation of scoring between tissue microarray and whole sections was performed in 10% randomly selected samples. Cutoff points considered: ≥1, 50 (primarily), and 25%. At the two external quality assessment rounds, tissue microarray scoring agreement rates between pathologists were: 73% and 81%. There were 2008 cases with valid immunohistochemistry tissue microarray results (50% all cores evaluable). Concordant cases at 1, 25, and 50% were: 85, 91, and 93%. Tissue microarray core results were identical for 70% of cases. Sensitivity of the tissue microarray method for 1, 25, and 50% was: 80, 78, and 79% (specificity: 90, 95, 98%). Complete agreement between tissue microarrays and whole sections was achieved for 60% of the cases. Highest sensitivity rates for 1% and 50% cutoffs were detected for higher number of cores. Underestimation of PD-L1 expression on small samples is more common than overestimation. We demonstrated that classification of PD-L1 on small biopsy samples does not represent the overall expression of PD-L1 in all non-small cell cancer carcinoma cases, although the majority of cases are ‘correctly’ classified. In future studies, sampling more and larger biopsies, recording the biopsy size and tumor load may permit further refinement, increasing predictive accuracy.

Over the past few decades, the diagnosis and management of children with various malignancies have improved tremendously. As a result, there are an increasing number of children who are long-term cancer survivors. With improved survival, however, has come an increased risk of treatment-related cardiovascular complications that can appear decades after treatment. These problems are serious enough that all caregivers of childhood cancer survivors, including oncologists, cardiologists, and other health care personnel, must pay close attention to the short- and long-term effects of chemotherapy and radiotherapy on these children. This review discusses the effects of treatment-related cardiovascular complications from anthracyclines and radiotherapy and the methods for preventing, screening, and treating these complications.

The NCCN Guidelines for Small Cell Lung Cancer (SCLC) address all aspects of disease management. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for SCLC regarding immunotherapy, systemic therapy, and radiation therapy. For the 2018 update, new sections were added on "Signs and Symptoms of SCLC" and "Principles of Pathologic Review."

Background: For decades, bio-markers involved in inflammation and stress response were implicated in patients who were successfully resuscitated from out of hospital cardiac arrest (sR-OHCA). Here we report that increased serum levels of Macrophage-expressed gene 1 (MPEG1), an evolutionary conserved protein with membrane attack complex domain, is associated with increased mortality and poor neurological outcomes after sR-OHCA. Objectives: To examine the association between circulating MPEG-1 protein measured within the first 6-hours of sR-OHCA, and inpatient survival and neurological outcomes. Methods: We prospectively enrolled 144 sR-OHCA patients from 4 different tertiary care centers. We measured MPEG-1 protein, and other conventional clinical bio-markers including troponin-I and CK-MB in the sera obtained within the first 6-hours of resuscitation. The clinical covariates during hospitalization (till the time death or discharge) were obtained via medical record review. We compared MPEG-1 protein, troponin-I, and CK-MB between survivors vs . non-survivors, and neurological outcomes dichotomized as poor or good according to cerebral performance score (CPS). Results: At the end of the hospital stay, 47% of the patients had poor neurological status based on the CPS score of ≥ 4. Within these patients, 95% had inhospital mortality. The mean serum MPEG-1 levels were significantly higher in patients with poor neurological status, compared to the ones with good neurological recovery (ng/ml, 15.17 ± 48.04 vs 1.15 ± 6.73, p=0.017). There were no differences in other conventionally measured bio-markers, such as peak troponin , CK-MB or left ventricular ejection fraction. Elevated MPEG-1 of more than 8.8 ng/ml had significantly higher odds of predicting poor neurological outcome (OR: 8.37, 95% CI: 1.79-39.14, p=0.006). Conclusions: This study reports a novel macrophage-expressed circulating bio-marker strongly associated with reduced survival and poor neurological outcomes in sR-OHCA. These data can guide clinicians to prognosticate survival and neurological outcomes in sR-OHCA, and also form the basis for future therapeutic approaches.

Background Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. Methods This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. Results Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin’s lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p

Primary tracheobronchial neoplasms represent approximately 0.1% of all pulmonary tumors (1). They have been a topic of interest for many decades due to the challenge in their diagnosis and management. Many of tracheobronchial tumors are found incidentally. They are sometimes misdiagnosed as asthma or chronic obstructive pulmonary disease.

Inflammation and its precursors have long been implicated to have effect on the neurological recovery of the patients after out of hospital cardiac arrest. We examined the role of macrophage expressed inflammatory marker involved in cell apoptosis on the long-term neurological recovery in patients

Background: Advances in radiotherapy for thoracic cancers have resulted in improvement of survival. However, radiation exposure to the heart can induce cardiotoxicity. No therapy is currently available to inhibit these untoward effects. We examined whether a small tetrapeptide, N-acetyl-Ser-Asp-Lys-Pro (Ac-SDKP), can counteract radiation-induced cardiotoxicity by inhibiting macrophage-dependent inflammatory and fibrotic pathways. Methods and Results: After characterizing a rat model of cardiac irradiation with magnetic resonance imaging protocols, we examined the effects of Ac-SDKP in radiation-induced cardiomyopathy. We treated rats with Ac-SDKP for 18 weeks. We then compared myocardial contractile function and extracellular matrix by cardiac magnetic resonance imaging and the extent of inflammation, fibrosis, and Mac-2 (galectin-3) release by tissue analyses. Because Mac-2 is a crucial macrophage-derived mediator of fibrosis, we performed studies to determine Mac-2 synthesis by macrophages in response to radiation, and change in profibrotic responses by Mac-2 gene depleted cardiac fibroblasts after radiation. Cardiac irradiation diminished myocardial contractile velocities and enhanced extracellular matrix deposition. This was accompanied by macrophage infiltration, fibrosis, cardiomyocyte apoptosis, and cardiac Mac-2 expression. Ac-SDKP strongly inhibited these detrimental effects. Ac-SDKP migrated into the perinuclear cytoplasm of the macrophages and inhibited radiation-induced Mac-2 release. Cardiac fibroblasts lacking the Mac-2 gene showed reduced transforming growth factor β1, collagen I, and collagen III expression after radiation exposure. Conclusions: Our study identifies novel cardioprotective effects of Ac-SDKP in a model of cardiac irradiation. These protective effects are exerted by inhibiting inflammation, fibrosis, and reducing macrophage activation. This study shows a therapeutic potential of this endogenously released peptide to counteract radiation-induced cardiomyopathy.

A 33-year-old woman with a family history of multiple cancers had been undergoing surveillance scans. Magnetic resonance imaging revealed cysts in the kidney and pancreas, multiple hemangiomas in the liver, and a lesion in the left lower lobe (LLL) of the lung. Repeat positron emission tomogram/computed tomography demonstrated a 1.8 1.6-cm nodule (Fig. 1) within the LLL. The patient underwent endobronchial ultrasound– guided fine needle aspiration biopsy of the LLL nodule, which showed hypercellular smears containing uniform, cuboidal, round, and oval medium-sized cells. They were diffusely positive for thyroid transcription factor-1, and negative for neuroendocrine cell markers. The diagnosis was well-differentiated lung adenocarcinoma. The patient underwent video-assisted thoracoscopic LLL lobectomy, which showed a well-circumscribed 2.5-cm yellow-tan nodule composed of mostly monomorphic, cuboidal surface cells and round cells with pink to clear cytoplasm and well-defined cell borders in papillary, solid, and sclerotic growth patterns. Occasional hemorrhagic foci were also present. A focal area of mild cytologic atypia was noted. A focus of metastatic tumor deposit containing solid sheets of cells was identified in one of the peribronchial lymph nodes. The results of staining for thyroid transcription factor-1 and epithelial membrane antigen were positive in both surface and round cells, but cytokeratin 7 and cytokeratin AE1/AE3 stained only surface cells (Fig. 2). The cytomorphologic examination findings and immunoprofile were consistent with sclerosing pneumocytoma (SP) with a lymph node metastasis. SP (previously called sclerosing hemangioma) is a rare tumor of the lung that is thought to arise from primitive respiratory epithelium. This tumor usually occurs in middle-aged adults with a male-to-female ratio of 1:5. 1 Surgical resection is curative without a need for additional treatment. Although SP is considered a benign tumor, we found a lymph node (LN)

Myocardial matrix turnover involves a dynamic balance between collagen synthesis and degradation, which is regulated by matrix metalloproteinases (MMPs). N-acetyl-Ser-Asp-Lys-Pro (Ac-SDKP) is a small peptide that inhibits cardiac inflammation and fibrosis. However, its role in MMP regulation is not known. Thus, we hypothesized that Ac-SDKP promotes MMP activation in cardiac fibroblasts and decreases collagen deposition via this mechanism. To that end, we tested the effects of Ac-SDKP on interleukin-1β (IL-1β; 5 ng/ml)-stimulated adult rat cardiac fibroblasts. We measured total collagenase activity, MMP-2, MMP-9, and MMP-13 expressions, and activity along with their inhibitors, tissue inhibitor of metalloproteinase (TIMP)-1 and TIMP-2. In order to examine the effects of Ac-SDKP on the signaling pathway that controls MMP transcription, we also measured nuclear factor-κB (NFκB) and p42/44 mitogen-activated protein kinase (MAPK) activation. Ac-SDKP did not alter collagenase or gelatinase activity in cardiac fibroblasts under basal conditions, but blunted the IL-1β-induced increase in total collagenase activity. Similarly, Ac-SDKP normalized the IL-1β-mediated increase in MMP-2 and MMP-9 activities and MMP-13 expression. Inhibition of MMPs by Ac-SDKP was associated with increased TIMP-1 and TIMP-2 expressions. Collagen production was not affected by Ac-SDKP, IL-1β, or a combination of both agents. Ac-SDKP blocked IL-1β-induced p42/44 phosphorylation and NFκB activation in cardiac fibroblasts. We concluded that the Ac-SDKP-inhibited collagenase expression and activation was associated with increased expression of TIMP-1 and TIMP-2. These pharmacological effects of Ac-SDKP may be linked to the inhibition of MAPK and NFκB pathway.

Background Acute myocardial infarction (MI) causes significant changes in cardiac morphology and function. Galectin-3 is a novel and potentially therapeutically important mediator of cardiac remodelling. Myocardial and serum galectin-3 expression dynamics in response to the early cardiovascular outcomes after acute MI are not fully elucidated.Methods We first performed a comprehensive longitudinal microarray analyses in mice after acute MI. We then measured the serum levels of galectin-3 in a translational porcine model of coronary microembolism-induced post-ischaemic cardiac remodelling. We validated our pre-clinical studies in humans by measuring serum galectin-3 levels of 52 patients with acute ST-elevation MI (STEMI) and 11 healthy controls. We analysed galectin-3 data in relation to the development of major adverse cardiovascular outcomes (MACO).Results Of the 9,753 genes profiled at infarcted and remote myocardium at eight different time points, dynamic myocardial overexpression of galectin-3 mRNA was detected. In a pig model of diffuse myocardial damage and cardiac remodelling, galectin-3 localised to the areas of tissue damage and myocardial fibrosis, with proportionate increase of their serum galectin-3 expression levels. In humans, increased serum galectin-3 level was associated with in-hospital MACO.Conclusions In this translational study, we demonstrated that galectin-3 is dynamically overexpressed in response to acute MI-induced cardiac remodelling. Elevated galectin-3 levels are associated with the development of in-hospital MACO.

Introduction: Increased galectin-3 is associated with ischemic cardiomyopathy, although its role in early remodeling post-myocardial infarction (MI) has not been fully elucidated. There are no data demonstrating that blocking galectin-3 expression would have an impact on the heart and that its relationship to remodeling is not simply an epiphenomenon. The direct association between galectin-3 and myocardial inflammation, dysfunction, and adverse cardiovascular outcomes post-MI was examined using clinical and translational studies. Methods: We performed expression analysis of 9753 genes in murine model of acute MI. For galectin-3 loss of function studies, homozygous galectin-3 knock-out (KO) mice were subjected to coronary artery ligation procedure to induce acute MI (MI, N = 6; Sham, N = 6). For clinical validation, serum galectin-3 levels were measured in 96 patients with ST-elevation MI. Echocardiographic and angiographic parameters of myocardial dysfunction and 3-month composite outcome including mortality, recurrent MI, stroke, and heart failure hospitalization were measured. Results: In the infarct regions of murine models, galectin-3 was a robustly expressed gene. Elevated galectin-3 expression strongly correlated with macrophage-mediated genes. Galectin-3 KO mice showed reduced myocardial macrophage infiltration after acute MI. Galectin-3 levels were higher in patients with early systolic dysfunction, and predicted 3-month major adverse cardiovascular events (area under the curve [AUC]: 0.917 ± 0.063; P = .001). Conclusions: Galectin-3 is directly associated with early myocardial inflammation post-MI and may represent a potential target for therapeutic inhibition.

Inflammation contributes to the process of ventricular remodeling after acute myocardial injury. To investigate the role of macrophages in the chronic process of cardiac remodeling, they were selectively depleted by intravenous administration of liposomal clodronate in heart failure-prone hypertensive Ren-2 rats from the age of 7 until 13 weeks. Plain liposomes were used for comparison. Liposomal clodronate treatment reduced the number of blood monocytes and decreased the number of macrophages in the myocardium. Compared to plain liposomes, liposomal clodronate treatment rapidly worsened left ventricular ejection function in hypertensive rats. Liposomal clodronate- treated Ren-2 rat hearts showed areas of myocyte loss with abundant inflammatory cell infiltration, predominantly comprising CD4 positive T lymphocytes. The current study showed that lack of macrophages was associated with earlier development of myocardial dysfunction in hypertensive rats. Modulation of macrophage function may be of value in the evolution of cardiomyopathy. © 2009 Sage Publications.

Sharma U, Rhaleb NE, Pokharel S, Harding P, Rasoul S, Peng H, Carretero OA. Novel anti-inflammatory mechanisms of N-Acetyl-Ser-Asp-Lys-Pro in hypertension-induced target organ damage. Am J Physiol Heart Circ Physiol 294: H1226–H1232, 2008. First published January 4, 2008; doi:10.1152/ajpheart.00305.2007.— High blood pressure (HBP) is an important risk factor for cardiac, renal, and vascular dysfunction. Excess inflammation is the major pathogenic mechanism for HBP-induced target organ damage (TOD). N-acetyl-Ser-Asp-Lys-Pro (Ac-SDKP), a tetrapeptide specifically degraded by angiotensin converting enzyme (ACE), reduces inflammation, fibrosis, and TOD induced by HBP. Our hypothesis is that Ac-SDKP exerts its anti-inflammatory effects by inhibiting: 1) differentiation of bone marrow stem cells (BMSC) to macrophages, 2) activation and migration of macrophages, and 3) release of the proinflammatory cytokine TNF-α by activated macrophages. BMSC were freshly isolated and cultured in macrophage growth medium. Differentiation of murine BMSC to macrophages was analyzed by flow cytometry using F4/80 as a marker of macrophage maturation. Macrophage migration was measured in a modified Boyden chamber. TNF-α release by activated macrophages in culture was measured by ELISA. Myocardial macrophage activation in mice with ANG II-induced hypertension was studied by Western blotting of Mac-2 (galectin-3) protein. Interstitial collagen deposition was measured by picrosirius red staining. We found that Ac-SDKP (10 nM) reduced differentiation of cultured BMSC to mature macrophages by 24.5% [F4/80 positivity: 14.09 ± 1.06 mean fluorescent intensity for vehicle and 10.63 ± 0.35 for Ac-SDKP; P ˂ 0.05]. Ac-SDKP also decreased galectin-3 and macrophage colony-stimulating factor-dependent macrophage migration. In addition, Ac-SDKP decreased secretion of TNF-α by macrophages stimulated with bacterial LPS. In mice with ANG II-induced hypertension, Ac-SDKP reduced expression of galectin-3, a protein produced by infiltrating macrophages in the myocardium, and interstitial collagen deposition. In conclusion, this study demonstrates that part of the anti-inflammatory effect of Ac-SDKP is due to its direct effect on BMSC and macrophage, inhibiting their differentiation, activation, and cytokine release. These effects explain some of the anti-inflammatory and antifibrotic properties of Ac-SDKP in hypertension.

NUT midline carcinoma (NMC) is a poorly differentiated tumor typically driven by a t(15;19) rearrangement leading to a NUT fusion event. This rare and uniformly fatal tumor arises in multiple organ sites; however the clinical, radiographic, and pathologic characteristics of primary pulmonary NMC are poorly defined. We identified eight cases of primary pulmonary NMC in our consult practice over 4 years and, using a NUT immunohistochemistry screen, retrospectively identified one additional case from 166 (0.6%) consecutive in-house biopsies of lung carcinomas lacking glandular differentiation. Eight cases had available clinical and radiographic data and shared a remarkable degree of similarity. The median age at presentation was 30 (range 21–68). Six patients had little or no smoking history. All complained of 1 to 3 months of cough at presentation. Computed tomography scans showed a large, centrally located primary mass with confluent involvement of mediastinal lymph nodes, pleural disease, and sparing of the contralateral lung. Lytic bone metastases were common but brain metastases were absent in all cases. Pathologically, all cases showed primitive-appearing round to epitheloid cells growing in nests and sheets. All tumors expressed keratin, p63 or p40, and NUT protein. Eight cases had a fluorescence in situ hybridization-proven BRD4-NUT or BRD3-NUT rearrangement; one case was presumed to have a NUT-variant fusion event. Median overall survival was 2.2 months. Despite the rarity of primary pulmonary NMC, it is important to recognize this entity to counsel patients regarding outcome and to identify candidates for targeted BRD inhibitors currently in clinical trials.

Microarray analysis has become a widely available tool for the generation of gene expression data on a genomic scale. Since the studies with similar protocols are growing, it has become necessary to systematically revise the large body of literature to decipher the gene expression data. In this review, we analyzed and critically discussed the database presented from 14 published studies that showed the gene expression profile in heart failure (HF) using microarray as a primary tool. After comparing the diverse database from these studies, we explain the protein translational, matri-cellular, immunological and fibrosis-related mechanisms in HF. In addition to previously annotated genes, we analyzed two differentially expressed expressed sequence tags (ESTs) (KIAA0152 and Suppressor of G(Two) allele of the suppressor of kinetochore protein-1, SGT1) in HF and showed how bio-informatic analysis of ESTs can lead to the identification of novel pathways active in HF. We have also discussed the new publicly accessible tools that link the gene expression data to gene ontogeny (GO) and functionality. Finally, we have systematically revised the chromosomal localization of the genes that are specifically up-regulated in HF. We have thus spotted chromosome 1, 2, 11 and 12 as the chromosomal hotspots of HF. This methodical approach will simplify the existing concepts on the evolution and progression of HF and lead us toward the development of newer diagnostic and therapeutic tools. Although modeled to HF, this approach should be of broader scientific interest to elaborate multiple genes and complex pathways.