Bhaskar Kallakury

Hepatic Explant Pathology of Pediatric Intestinal Transplant Recipients Previously Treated with Omega-3 Fatty Acid Lipid Emulsion

OBJECTIVEnTo evaluate and compare the biochemical and histologic effect of parenteral fish oil lipid emulsion that is rich in omega-3 polyunsaturated fatty acids (O3FAs), Omegaven (Fresenius Kabi AG, Bad Homburg, Germany) with standard omega-6 polyunsaturated fatty acid (O6FA) parenteral nutrition.nnnSTUDY DESIGNnComparison of hepatic explant pathology and biochemical outcome on pediatric patients with intestinal failure treated with either parental O3FA or O6FA who had received a liver-inclusive intestine transplant.nnnRESULTSnSeven liver-inclusive intestinal transplants were performed in 7 patients who received O3FA for a mean of 62% ± 13% of total patient life-span (16.1 ± 7.0 months) before transplant. Median total bilirubin fell from 6.9 mg/dL at the start of treatment to 0.7 mg/dL at the time transplant (P < .02), which was a significant decrease compared with the similarly matched O6FA cohort (P = .012). All 7 of the 03FA-treated patients received a liver-inclusive intestinal transplant had advanced fibrosis (stage 3 or 4) noted on explant pathologic examination, despite a resolution of cholestasis at the time of transplant. Histologic inflammatory scores were lower (P = .056) in the 03FA group with similar degrees of advanced fibrosis as in the O6FA group.nnnCONCLUSIONSnIn a matched comparison of patients undergoing intestinal transplantation with a history of extended O3FA lipid emulsion therapy that successfully reversed hyperbilirubinemia, significant hepatic fibrosis was present in the explanted livers despite a reduction in inflammation. This result confirms concern that the use of O3FA may have a limited role in altering the development of hepatic fibrosis from parenteral nutrition.

Clinicopathologic features of post-transplant lymphoproliferative disorders arising after pediatric small bowel transplant

Few studies examined the clinicopathologic features of PTLD arising in pediatric SBT patients. Particularly, the association between ATG and PTLD in this population has not been described. Retrospective review of 81 pediatric patient charts with SBT – isolated or in combination with other organs – showed a PTLD incidence of 11%, occurring more frequently in females (median age of four yr) and with clinically advanced disease. Monomorphic PTLD was the most common histological subtype. There was a significant difference in the use of ATG between patients who developed PTLD and those who did not (p < 0.01); a similar difference was seen with the use of sirolimus (p < 0.001). These results suggested a link between the combination of ATG and sirolimus and development of more clinically and histologically advanced PTLD; however, the risk of ATG by itself was not clear. EBV viral loads were higher in patients with PTLD, and median time between detection of EBV to PTLD diagnosis was three months. However, viral loads at the time of PTLD diagnosis were most often lower than at EBV detection, thereby raising questions on the correlation between decreasing viral genomes and risk of PTLD.

Chronic Leg Ulceration Associated with Polycythemia Vera Responding to Ruxolitinib (Jakafi)

We present the case of a 63-year-old white male with bilateral chronic leg ulcers due to polycythemia vera and hydroxyurea therapy who demonstrated dramatic healing of his wounds in response to ruxolitinib (Jakafi(®), Novartis), a novel Janus kinase-1 and -2 inhibitor. This patients wound had previously been refractory to multiple surgical interventions and immunosuppression. After the initiation of ruxolitinib, the patient underwent successful split-thickness skin grafting, with resultant healing of his wounds. He was stable without prednisone and other immunosuppressant therapy and had healed at 6 months. Ruxolitinib therapy could represent a novel option for patients who develop persistent inflammatory wounds in the setting of polycythemia vera and hydroxyurea therapy.

Plasma IGF-1 and IGFBP-3 may be imprecise surrogates for breast concentrations: an analysis of healthy women

We investigated insulin-like growth factor (IGF)-1 and IGF binding protein (IGFBP)-3 concentrations in histologically normal breast tissues and assessed their association with plasma concentrations, and breast cancer risk factors. IGF-1 and IGFBP-3 were assessed in plasma and breast tissues of 90 women with no history of any cancer and undergoing reduction mammoplasty. Pearson correlations and ANOVAs were used to describe plasma-breast associations and biomarker differences by breast cancer risk factors, respectively. Multivariable regression models were used to determine associations between risk factors, and breast IGF-1 and IGFBP-3. The mean age of the study sample was 37.3xa0years, 58xa0% were white, and generally these women were obese (mean BMIxa0=xa030.8xa0kg/m2). We observed no plasma-breast correlation for IGF-1, IGFBP-3, or IGF-1/IGFBP-3 (rxa0=xa0−0.08, rxa0=xa00.14, and rxa0=xa00.03, respectively; p-values >0.05). Through age- and BMI-adjusted analysis, BMI and years of oral contraceptive (OC) use were inversely associated with breast IGF-1 (p-valuesxa0=xa00.02 and 0.003, respectively) and age was associated with breast IGFBP-3 (pxa0=xa00.01), while breast IGF-1/IGFBP-3 was higher in blacks than whites (1.08 vs. 0.68, pxa0=xa00.04) and associated with age and BMI (p-valuesxa0=xa00.03 and 0.002, respectively). In multivariable-adjusted models, some breast cancer risk factors studied herein explained 24, 10, and 15xa0% of the variation in breast IGF-1, IGFBP-3, and IGF-1/IGFBP-3, respectively. While reasons for the lack of plasma-breast hormone correlations in these cancer-free women are unknown, several factors were shown to be associated with breast concentrations. The lack of correlation between blood and tissue IGF-1 and IGFBP-3 suggests that studies of breast cancer risk assessing blood IGF-1 and IGFBP-3 may have important limitations in understanding their role in breast carcinogenesis.

Donor Factors Including Donor Risk Index Predict Fibrosis Progression, Allograft Loss, and Patient Survival following Liver Transplantation for Hepatitis C Virus

BACKGROUNDnThe utilization of liver transplantation (LT) is limited by the availability of suitable organs. This study aimed to assess the impact of the donor risk index (DRI) and other donor characteristics on fibrosis progression, graft, and patient survival in hepatitis C virus (HCV)-infected LT recipients.nnnMETHODSnHCV-infected LT recipients who had at least 2 post-LT protocol liver biopsy specimens available were included. Hazard ratio for bivariate analysis was computed using Cox proportional hazard regression analysis.nnnRESULTSnOf 312 recipients, 26.6% died over a median follow-up of 58.5 months (95% CI: 46.5-67.3). Fourteen patients underwent re-transplantation. Mean time to graft failure was 84.3 months, median follow-up: 59 months, 95% CI (48.2, 68.3). DRI >1.5 was significantly associated with patient and graft survival (Pxa0=xa00.04). Of the subset of 104 individuals who underwent histological analysis, 67.3% progressed to ≥F2. On multivariate analysis, significant donor-specific predictors of fibrosis progression were: donor age >50 years and DRI >1.7.nnnCONCLUSIONSn(1) Fibrosis progression in HCV-infected LT recipients is strongly associated with donor characteristics, specifically donor age and DRI. (2) DRI, an objective measure of donor quality, appears to correlate both with rate of histological progression and overall patient/graft survival.

Late failure of a split-thickness skin graft in the setting of homozygous factor V Leiden mutation: a case report and correlative animal model from the Wound Etiology and Healing (WE-HEAL) study.

We present the case of a 53‐year‐old Caucasian male smoker with remote history of left lower extremity deep venous thrombosis (DVT) and a strong family history of thrombosis, who presented to the Center for Wound Healing at MedStar Georgetown University Hospital with spontaneous left leg ulceration. Prothrombotic evaluation showed homozygosity for the factor V Leiden (FVL) mutation. Therapeutic anticoagulation was commenced with warfarin (Coumadin®) and the patient underwent successful debridement and Apligraf® followed by split‐thickness skin graft (STSG) of two wounds. He had an uneventful postoperative course and on the 27th postoperative day the grafts were 95% intact. However, by postoperative day 41 there was 10% graft loss, and over the subsequent 2u2009weeks both grafts necrosed. On further questioning, it transpired that the patient had discontinued his warfarin on postoperative day 37 because he thought that it was no longer necessary. The patient is enrolled in the Wound Etiology and Healing (WE‐HEAL) study, and at the time of the original graft, residual skin fragments from the STSG were transplanted onto a nude mouse for development of an animal model of wound healing. The mouse graft was successful and was harvested at postoperative day 87 for pathological examination. We review the mechanisms by which prothrombotic states, particularly FVL mutation, can contribute to skin graft failure and delayed wound healing. This case highlights the importance of considering prothrombotic conditions in patients with spontaneous leg ulcerations and the impact of therapeutic anticoagulation on healing. It further allows us to demonstrate the efficacy of the animal model in which residual fragments of STSG tissue are utilised for transplant onto nude mice for manipulation in the laboratory.

Harmonization of PD-L1 Immunohistochemistry Assays for Lung Cancer: A Working Progress

Note: Low indicates 1% to 49% of tumor cells showed membranous staining and High indicates at least 50% of tumor cells showed membranous staining. PD-LI, programmed death ligand 1; IHC, immunohistochemistry. To the Editor: We read with great interest the abstract of the programmed death ligand 1 (PD-L1) assay comparison study by Hirsch et al., which examined 39 NSCLC cases and concluded that three of the four PD-L1 immunohistochemistry (IHC) assays (22C3 [Dako, Carpenteria, CA], 28-8 [Dako, Carpenteria, CA], SP142 [Spring Bioscience, Pleasanton, CA], and SP263 [Ventana Medical Systems, Tucson, AZ]) showed similar staining whereas the fourth (SP142) showed consistently less staining in tumor cells (TCs). Harmonization of the available assays is necessary to provide patients with greater access to the anti–PD-L1 agents available in the market. This project is a great first step in that direction, as it attempts to delineate the comparability of assay results. However, additional independent studies of larger numbers of case are needed to validate the results and demonstrate reproducibility. Here, we report the comparability of three PD-L1 IHC assays (22C3, 28-8, and SP142) in 29 NSCLC cases that we have tested at our facility. The samples included lung adenocarcinoma without oncogene mutations (n 1⁄4 13), with mutated KRAS (n 1⁄4 8), or with mutated EGFR (n 1⁄4 8). Cases with positive PD-L1 expression in TCs (>1%) were further categorized into cases with lowor high-level expression on the basis of 1% to 49% or at least 50% of TCs showing

Exploring the interchangeability of PD-L1 Immunohistochemistry Assays in Melanoma.

nomenon acts by direct cytolysis, anticipated apoptosis and a subsequent activation of fibrocytes, as demonstrated by the presence of scattered fibrotic bands (Figure 1A). We observed the same phenomenon in gastrointestinal and pancreatic carcinoids; thus, the lung parenchyma is not alone in favouring this immunological reaction. The small sample size of our study invites a larger clinical series; however, we should like to suggest including this feature of carcinoid behaviour among immunoscoring parameters (as has already been suggested for other neoplasms), in order to increase the predictive value of diagnostic protocols.

Abstract 3724: PDL1 protein expression and tumor mutation burden in hematologic malignancies: correlation with Hodgkin and high grade lymphoma

Background: The success of anti PD–1 therapy in Hodgkin lymphoma has led to clinical trials in other types of lymphomas. However, there is limited data on PD–L1 expression in acute leukemias. In this study, we analyzed PD–L1 protein expression and tumor mutational burden in various hematologic malignancies including leukemias, lymphomas and myelomas. Methods: In the IHC cohort, formalin fixed paraffin embedded sections from 92 hematologic malignancies including acute myeloid and lymphoblastic leukemia (AML, ALL), Hodgkin lymphoma (HL), diffuse large B-cell lymphoma (DLBCL), low-grade non-Hodgkin lymphoma (LGNHL) and myeloma were immunostained using the FDA approved PD-L1 IHC 22C3 pharmDx assay [monoclonal mouse anti-PD–L1 antibody (DAKO clone 22C3)]. Any perceptible partial or complete membrane staining in all viable tumor cells was scored as follows: 50%-high level PD-L1 expression. In the second cohort of 2064 cases, comprehensive genomic profiling (CGP) was performed using a hybrid–capture, adaptor ligation assay to a mean depth of >672X. Tumor mutation burden (TMB) was calculated from a minimum of 1.11MB of sequenced DNA as previously described and reported as mutations/MB. High PD–L1 expression was noted in 100% of HL. DLBCL showed significantly higher PD–L1 positivity compared to LGNHL (p=0.01). No correlation for PD–L1 expression was noted between AML and ALL (p = 0.2). On CGP analysis of the second cohort, TMB was significantly higher in DLBCL as compared to LGNHL (p Conclusion: The high PD-L1 expression in both HL and DLBCL and high TMB in DLBCL may be linked to enhanced responsiveness to check point inhibitor therapy in these cancers. PD-L1 expression and TMB are relatively infrequent and at low levels in acute leukemias. Additionally, novel anti PD–1/PD–L1 therapeutic strategies are worthy of consideration for both advanced stage refractory/relapsed acute myeloid and lymphoblastic leukemias. Citation Format: Lina Abdul Karim, Peng Wang, Jose de Guzman, Brandi Higgins, Joeffrey Chahine, Christine Sheehan, Bhaskar Kallakury, Jeffrey S. Ross. PDL1 protein expression and tumor mutation burden in hematologic malignancies: correlation with Hodgkin and high grade lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3724. doi:10.1158/1538-7445.AM2017-3724

Programmed Death Ligand 1: A Step Toward Immunoscore for Esophageal Cancer

BACKGROUNDnThis study sought to evaluate the effect of tumor-infiltrating lymphocyte (TIL) density and programmed death ligand 1 (PD-L1) expression on the prognosis of esophageal cancer.nnnMETHODSnBanked tissue specimens from 53 patients who underwent esophagectomies for malignancy at a single institution over a 6-year period were stained for cluster of differentiation 3 (CD3), CD8, and PD-L1. Tumors were characterized as staining high or low density for CD3 and CD8, as well as positive or negative for PD-L1. TIL density and PD-L1 expression were analyzed in the context of survival, recurrence, and perioperative characteristics.nnnRESULTSnMedian follow-up was 823 days, with 92.5% survival and 26.8% recurrence rates. All tumors were adenocarcinomas. Neoadjuvant chemotherapy was given in 56.6% of cases, and neoadjuvant radiotherapy was given in 37.7%. High CD3 density was found in 83%, whereas high CD8 density was found in 56.6%. A total of 18.9% of the tumors stained positive for PD-L1. Survival was significantly shorter in Kaplan-Meier analysis for patients with primary tumors staining positive for PD-L1 (log rank: pxa0= 0.05). Multivariable analysis controlling for neoadjuvant therapy, TIL markers, PD-L1, age, and sex found no significant difference in recurrence or survival.nnnCONCLUSIONSnPositive staining for PD-L1 may be a prognostic marker for decreased survival in esophageal adenocarcinoma. Additional TIL cell types should be investigated for creation of an esophageal cancer Immunoscore. PD-L1 has potential as a therapeutic target.