Anai Kothari

Osteopontin Mediates an MZF1-TGF-β1-Dependent Transformation of Mesenchymal Stem Cells into Cancer Associated Fibroblasts in Breast Cancer

Interactions between tumor cells and cancer-associated fibroblasts (CAFs) in the tumor microenvironment significantly influence cancer growth and metastasis. Transforming growth factor-β (TGF-β) is known to be a critical mediator of the CAF phenotype, and osteopontin (OPN) expression in tumors is associated with more aggressive phenotypes and poor patient outcomes. The potential link between these two pathways has not been previously addressed. Utilizing in vitro studies using human mesenchymal stem cells (MSCs) and MDA-MB231 (OPN+) and MCF7 (OPN−) human breast cancer cell lines, we demonstrate that OPN induces integrin-dependent MSC expression of TGF-β1 to mediate adoption of the CAF phenotype. This OPN–TGF-β1 pathway requires the transcription factor, myeloid zinc finger 1 (MZF1). In vivo studies with xenotransplant models in NOD-scid mice showed that OPN expression increases cancer growth and metastasis by mediating MSC-to-CAF transformation in a process that is MZF1 and TGF-β1 dependent. We conclude that tumor-derived OPN engenders MSC-to-CAF transformation in the microenvironment to promote tumor growth and metastasis via the OPN–MZF1–TGF-β1 pathway.

Implementation of an Acuity Adaptable Patient Care Unit is associated with improved outcomes after major pulmonary resections.

BACKGROUND Many centers have adapted an Acuity Adaptable Cardiothoracic Unit (AACU) to fast track cardiac surgery patients, yet few data exist on the impact of such a unit on general thoracic surgery outcomes. We examined the effects of implementing an Acuity Adaptable Cardiothoracic Unit on patients undergoing major pulmonary resections. METHODS We reviewed data from an IRB-approved, prospective thoracic surgery database for patients during the 3-y periods pre- and post-adoption of an Acuity Adaptable Cardiothoracic Unit. As surrogate endpoints to quality and cost, we examined length of stay, place of discharge, readmission rate, and 30-d mortality during these two time periods. RESULTS A total of 488 patients underwent major pulmonary resections (416 lobectomies, 72 pneumonectomies) in this 6-y time period. Patients cared for in the AACU model had a shorter length of stay (LOS) compared with patients in a traditional ICU/general care model. The mean and median LOS for patients in the AACU model was 4.2 ± 0.3 d and 3 d, and for the traditional ICU/general care model these were 7.8 ± 1.2 d and 5 d, respectively (P < 0.001). Relative risk of readmission was 0.86 (95% CI = 0.45, 1.66, P = 0.392) and 30-d mortality was 0.49 (95% CI = 0.14, 1.68, P = 0.205) for patients in the AACU model compared with patients in the traditional ICU/general care unit. CONCLUSIONS Implementation of an Acuity Adaptable Cardiothoracic Unit is associated with reduced length of hospital stay in patients undergoing major lung resections, without increased risk of readmission or 30-d mortality. Future studies will evaluate post-operative events unique to an AACU model.

Acute Kidney Injury in Burn Patients: Clinically Significant Over the Initial Hospitalization and 1 Year After Injury: An Original Retrospective Cohort Study.

Objective: To examine the development of acute kidney injury (AKI) after burn injury as an independent risk factor for increased morbidity and mortality over initial hospitalization and 1-year follow-up. Background: Variability in fluid resuscitation and difficulty recognizing early sepsis are major barriers to preventing AKI after burn injury. Expanding our understanding of the burden AKI has on the clinical course of burn patients would highlight the need for standardized protocols. Methods: We queried the Healthcare Cost and Utilization Project State Inpatient Databases in the states of Florida and New York during the years 2009 to 2013 for patients over age 18 hospitalized with a primary diagnosis of burn injury using ICD-9 codes. We identified and grouped 18,155 patients, including 1476 with burns >20% total body surface area, by presence of AKI. Outcomes were compared in these cohorts via univariate analysis and multivariate logistic regression models. Results: During initial hospitalization, AKI was associated with increased pulmonary failure, mechanical ventilation, pneumonia, myocardial infarction, length of stay, cost, and mortality, and also a lower likelihood of being discharged home. One year after injury, AKI was associated with development of chronic kidney disease, conversion to chronic dialysis, hospital readmission, and long-term mortality. Conclusions: AKI is associated with a profound and severe increase in morbidity and mortality in burn patients during initial hospitalization and up to 1 year after injury. Consensus protocols for initial burn resuscitation and early sepsis recognition and treatment are crucial to avoid the consequences of AKI after burn injury.

The LACE Score as a Tool to Identify Radical Cystectomy Patients at Increased Risk of 90-Day Readmission and Mortality

Introduction: Radical cystectomy for bladder cancer is associated with high rates of readmission. We investigated the LACE score, a validated prediction tool for readmission and mortality, in the radical cystectomy population. Materials & Methods: Patients who underwent radical cystectomy for bladder cancer were identified by ICD-9 codes from the Healthcare Cost and Utilization Project State Inpatient Database for California years 2007-2010. The LACE score was calculated as previously described, with components of L: length of stay, A: acuity of admission, C: comorbidity, and E: number of emergency department visits within 6 months preceding surgery. Results: Of 3,470 radical cystectomy patients, 638 (18.4%) experienced 90-day readmission, and 160 (4.6%) 90-day mortality. At a previously validated “high-risk” LACE score ≥ 10, patients experienced an increased risk of 90-day readmission (22.8 vs. 17.7%, p = 0.002) and mortality (9.1 vs. 3.5%, p < 0.001). On adjusted multivariable analysis, “high risk” patients by LACE score had increased 90-day odds of readmission (adjusted OR = 1.24, 95% CI: 0.99-1.54, p = 0.050) and mortality (adjusted OR = 2.09, 95% CI: 1.47-2.99, p < 0.001). Conclusion: The LACE score reasonably identifies patients at risk for 90-day mortality following radical cystectomy, but only poorly predicts readmission. Providers may use the LACE score to target high-risk patients for closer follow-up or intervention.

Osteopontin-myeloid zinc finger 1 signaling regulates transforming growth factor-ß expression in cancer

Transforming growth factor-β (TGF-β) is known to be a critical mediator of the cancer associated fibroblast (CAF) phenotype, and osteopontin (OPN) expression in tumors is associated with more aggressive phenotypes and poor patient outcomes. The potential link between these two pathways has not been well characterized. In human breast cancer and hepatocellular cancer models (HCC), OPN induces mesenchymal stem cell (MSC)-to-CAF transformation. OPN binds to cell-surface integrin receptors to activate the transcription factor, myeloid zinc finger 1 (MZF1) to induce MSC production of TGF-β1. OPN induces MZF1 protein to positively feedback regulate its own transcription via binding to the MZF1 promoter and further enhance TGF-β1 expression. The adoption of the CAF phenotype is associated with increased local tumor growth and metastases. Blockade of OPN abolishes this MZF1-TGF-β1 mediated MSC-to-CAF transformation. This suggests interrupting the MZF1-dependent elaboration of TGF-β by blockade of OPN may be an effective clinical strategy for tumor growth inhibition. This review will describe the regulatory pathways by which OPN and MZF1 mediated TGF-β expression induces the CAF phenotype to potentiate cancer growth and metastasis. *Correspondence to: Paul C Kuo, MD, USF Department of Surgery, 2 Tampa General Circle, Rm 7015, Tampa, FL 33606, USA, Tel: 813-250-2572; E-mail: paulkuo@health.usf.edu Received: April 20, 2018; Accepted: May 02, 2018; Published: May 07, 2018 Introduction Interactions between tumor cells and cancer-associated fibroblasts (CAFs) in the tumor microenvironment (TMEN) significantly influence cancer growth and metastasis. Tumor growth and metastasis is highly dependent on complex dynamic interactions between cancer cells and tumor stroma, mediated by direct cell-cell contact and secreted growth factors and cytokines. CAFs, a tumor stromal element, are involved in tumor growth potentiation, extracellular matrix degradation, tumor cell motility, inhibition of host anti-tumor response, promotion of angiogenesis and metastasis. CAF origin is likely multifactorial, derived from local fibroblasts, bone marrow-mesenchymal stem cells (MSCs), pericytes and tumor cells. Specific molecular markers and signaling pathways that mediate CAF activation are poorly understood. Nevertheless, it is generally accepted that α-smooth muscle actin (SMA), tenascin-C, vimentin and fibroblast specific protein-1 (FSP-1), among others, describe the CAF phenotype [1,2]. Transforming growth factor-β (TGF-β) is known to be a critical mediator of the CAF phenotype. TGF-β is critical for CAF activation and elaboration of a protumorigenic microenvironment [3-6]. Signaling by TGF-β regulates tumor initiation, progression and metastasis through tumor cellautonomous and host–tumor interactions. TGF-β mediates fibroblast differentiation, tumor stroma formation and regulates all stages of tumor development via tumor cell-autonomous and host-tumor interactions [3-6]. Resident fibroblasts and bone marrow-derived MSCs convert into CAFs during tumor progression. A TGF-β autocrine/ paracrine signaling loop acts to initiate/maintain this CAF phenotype and CAFs increase tumor invasion [7-10]. The loss of TGF-β1 reverses this growth advantage imparted by CAFs [11]. The process wherein epithelial cells differentiate back into ECMsecreting mesenchymal stem cells is termed epithelial mesenchymal transition (EMT). Epithelial cells lose their cell-cell adhesions, polarity, and epithelial cell markers and gain mobility and mesenchymal cell markers. As such, EMT is vital to the physiologic process of wound healing and the pathologic process of metastasis. Various transcription factors and signaling pathways act to induce EMT and promote either the epithelial or mesenchymal phenotype, including TGF-β, an important suppressor of epithelial cell proliferation and inducer of tumor progression and metastasis. TGF-β is secreted from the tumor stroma in many malignancies, largely sourced from CAFs [7]. CAFderived TGF-β can induce EMT in several tumors via a multitude of mechanisms. Breast cancer cell lines undergo EMT in response to treatment with conditioned medium from CAFs isolated from invasive breast specimens. In this model, neutralizing antibody and smallmolecule inhibition of TGF-β signaling prevents EMT in these cell lines [12]. TGF-β secreted by CAFs can also lead to EMT in bladder cancer cells, a process regulated by the long-coding RNA ZEB2NAT. Following the depletion of lncRNA-ZEB2NAT, conditioned media from CAFs fail to induce EMT in human bladder cancer cell lines (5637, T24, and J82) [13]. TGF-β can also result in the formation of cancer stem cell populations within tumors—a process attributable to EMT. For example, TGF-β treatment of patient-derived colorectal tumor specimens results Kuo MC (2018) Osteopontin-myeloid zinc finger 1 signaling regulates transforming growth factor-β expression in cancer Volume 2(3): 2-16 Cancer Rep Rev, 2018 doi: 10.15761/CRR.1000152 in upregulation of CD44+ stem cell populations and expression of N-cadherin. This suggests that TGF-β induces the formation of cancer stem cells through EMT [14]. In non-small cell lung cancer, TGF-β has a similar effect on cancer stemness [15]. Another intermediate for TGF-β-related acquisition of cancer stemness is miR-155 which, when overexpressed, results in EMT in liver cancer [16]. These studies demonstrated the role of TGF-β signaling in CAF initiation and maintenance, leading to EMT. However, the initiating steps for TGF-β synthesis in this context have never been addressed. Osteopontin (OPN), a phosphoprotein secreted by malignant cells and tumor stromal cells, is a key mediator of tumor cell migration and metastasis and a marker of breast cancer progression and metastasis [17-23]. Recent findings suggest that tumor-derived OPN instigates bone marrow-derived MSC trafficking to the TMEN [24-26], which is characterized by the outgrowth of a desmoplastic stroma rich in CAFs that promotes cancer growth and metastasis [24,25,27]. Serendipitously, OPN induces TGF-β expression and fibroblast activation in models of inflammation and fibrosis [28,35]. In our previous work with in vitro and in vivo human cancer models, we found that OPN induces MSC-to-CAF transformation. OPN binds to cell-surface integrin receptors to activate the transcription factor, myeloid zinc finger 1 (MZF1), and induce MSC production of TGF-β1 with increased CAF phenotype markers. The adoption of the CAF phenotype is associated with increased local tumor growth and metastases. Extracellular blockade of OPN abolishes this MZF1-TGF-β1 mediated MSC-to-CAF transformation. However, the relationship between OPN, TGF-β and the CAF phenotype remains poorly understood. This review will describe the regulatory pathways by which OPN and MZF1 mediated TGF-β expression induces the CAF phenotype to potentiate cancer growth and metastasis.

PD36-01 THE VALIDATED LACE SCORE IDENTIFIES PATIENTS AT INCREASED RISK OF 90-DAY READMISSION AND MORTALITY FOLLOWING RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Radical cystectomy for bladder cancer is performed in an aged, highly comorbid population, and associated with high rates of readmission. We investigated the LACE score, a validated prediction tool for readmission and mortality, in the radical cystectomy population. METHODS: Patients who underwent radical cystectomy for bladder cancer were identified by ICD-9 codes from the Healthcare Cost and Utilization Project State Inpatient Database for California between years 2007-2010. The LACE score was calculated as previously described, with components of L: length of stay, A: acuity of admission, C: comorbidity, and E: number of emergency department visits within 6 months preceding surgery (Figure). Descriptive statistics were performed, and multivariable logistic regression models were fit in a nonparsimonious fashion, including all patient demographic and clinical variables, in order to isolate the effect of the LACE score on outcomes (90-day readmission and mortality). RESULTS: Of 3,470 radical cystectomy patients, 638 (18.4%) experienced 90-day readmission, and 160 (4.6%) 90-day mortality. At a previously validated ’high-risk’ LACE score 10, patients experienced an increased risk of 90-day readmission (22.8% vs 17.7%, p1⁄40.002) and mortality (9.1% vs 3.5%, p<0.001). On adjusted multivariable analysis, 0high risk0 patients by LACE score had increased 90-day odds of readmission (aOR1⁄41.24, 95% CI: 0.99-1.54, p1⁄40.050) and mortality (aOR1⁄42.09, 95% CI: 1.47-2.99, p<0.001). Separate multivariate models demonstrated a one point increase in LACE score had a 7.3% increased adjusted odds of readmission, and a 33.2% increased odds of mortality. CONCLUSIONS: The LACE score reasonably predicts patients at risk for 90-day readmission and mortality following radical cystectomy. Providers may use the LACE score to target high-risk patients for closer follow-up or intervention. Source of Funding: None

Adhesive Bowel Obstruction Following Urologic Surgery: Improved Outcomes with Early Intervention

Objective: To describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (2006-2011) were used to identify major urologic oncologic surgery patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis was performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, urinary tract infection, deep vein thrombosis, and pneumonia), major complications (myocardial infarction, pulmonary embolism, and sepsis), death, and postoperative length-of-stay were assessed. Results: Major urologic surgery was performed on 104,400 patients, with subsequent 5-year cumulative incidence of adhesive bowel obstruction admission of 12.4% following radical cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. During adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18 vs. 30%, p = 0.001), major complications (10 vs. 19%, p = 0.002), and median postoperative length of stay (8 vs. 11 days, p < 0.001) compared with delayed surgery. On multivariate analysis early surgery decreased the odds of minor/ moderate complications by 43% (p = 0.01), major complications by 45% (p = 0.03), and postoperative length of stay by 3.1 days (p = 0.01). Conclusion: Adhesive bowel obstruction is a significant long-term sequela of urologic surgery, for which early surgical management may be associated with improved perioperative outcomes.

Preoperative Evaluation and Preparation in the Elderly Thoracic Surgery Patient

The United States population is aging and median life expectancy is increasing as well. Older age is one of the strongest predictors for heart disease and cancer that require cardiothoracic surgery. The traditional preoperative evaluation has been unsuccessful in risk stratifying the older patient fit for elective surgery. This chapter is innovative, focusing on the preoperative assessment of the geriatric patient prior to cardiothoracic surgery, with a particular emphasis on novel assessment methods, incorporating elements of the comprehensive geriatric assessment, meant to identify geriatric syndromes and ways to potentially modulate the higher risks of surgery present for some patients.