Madeleine P. Strohl

Prevalence of atopic disease in patients with eosinophilic esophagitis

The objective of this work was to evaluate prevalence of eosinophilic esophagitis (EoE) in the United States, and analyze prevalence of atopic disease in patients with EoE. The study design was a retrospective administrative database analysis in U.S.‐based outpatient settings.

Surgery for Localized Pancreatic Cancer: The Trend Is Not Improving

ObjectivesThe aim of this study was to examine the trend in the use of surgery for localized pancreatic adenocarcinoma for the past 2 decades using the Surveillance, Epidemiology, and End Results database. MethodsWe identified a cohort of patients who received a diagnosis of localized pancreatic adenocarcinoma between 1988 and 2010 in the United States. Univariate and multivariate methods were used to determine factors associated with not receiving surgery. Cox proportional hazards regression modeling was used to determine factors associated with survival. ResultsOf 6742 patients with a diagnosis of localized pancreatic adenocarcinoma, 1715 patients (25.4%) underwent surgery. There was no significant change in use of surgery over time. Patients were less likely to undergo surgery if they were older than 50 years, black, unmarried, and located outside the East and had pancreatic head or body lesions, higher tumor grades, or tumor size greater than 2 cm (P < 0.0001). Receiving surgery had the most significant impact on the hazard of disease-specific death (hazards ratio, 1.41; 95% confidence interval, 1.29–1.53; P < 0.0001). ConclusionsIn contrast to recent studies that suggest an increasing use of surgery, the present study demonstrates that there has been no change in the rate of use of surgery in patients with localized pancreatic disease.

Hypoglossal nerve stimulation rescue surgery after multiple multilevel procedures for obstructive sleep apnea.

Hypoglossal nerve stimulation (HNS) is a new procedure offered for the treatment of moderate-to-severe obstructive sleep apnea (OSA) that has been shown to decrease the severity and symptoms of OSA in select patients. We report on a case of a patient with persistent symptoms and findings of OSA despite a history of multiple multilevel procedures, including an uvulopalatopharyngoplasty (UPPP) with revision, a genioglossus advancement, and a maxillomandibular advancement. The patient then underwent HNS with significant improvement of his symptoms and severity. The success of this patients HNS surgery demonstrates that we need to examine where HNS fits into the approach to surgery for OSA. There could be benefit to considering cranial nerve stimulation earlier than conventional approaches for select patients.

T cells derived from human melanoma draining lymph nodes mediate melanoma-specific antitumor responses in vitro and in vivo in human melanoma xenograft model

It has been established in murine models that lymph nodes draining a progressively growing tumor contain antigen-specific T cells capable of mediating protective immune responses upon adoptive transfer. However, naturally occurring human tumor-draining lymph nodes (TDLNs) have yet to be fully investigated. In this study, we analyzed TDLNs from patients with stage III melanoma who were undergoing routine lymph node dissection. Following short-term (14 d) culture activation with anti-CD3/anti-CD28 microbeads and expansion in low concentrations of IL-2, the melanoma-draining lymph node (MDLN) cells were ∼60% CD4-activated and ∼40% CD8-activated T cells. The activated MDLN cells demonstrated reactivity in response to overlapping peptides spanning the sequence of 4 different known melanoma antigens MAGEA1, Melan-A/MART-1, NY-ESO-1, and Prame/OIP4, suggesting the presence of melanoma-specific T cells. Coculture of activated MDLN T cells with cancer cells in vitro resulted in preferential apoptosis of human cancer cell lines that were cocultured with T cells with high degree of MHC matching. Adoptive transfer of MDLN T cells with high degree of MHC matching to A375 to mice-bearing human A375 melanoma xenografts resulted in dose-dependent improvement in survival. Although prior human studies have demonstrated the immune responses within melanoma vaccine-draining lymph nodes, this study presents evidence for the first time that naturally occurring human MDLN samples contain melanoma-experienced CD4 and CD8 T cells that can be readily cultured and expanded to mediate protective immune responses both in vitro and in vivo in a human melanoma xenograft model.

Human Papillomavirus–Associated Oropharyngeal Cancer: Patterns of Nodal Disease:

Objective To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed. Results Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment. Conclusions For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.

A Novel Approach to Oropharyngeal Foreign Body Removal

Grill wire brush bristle foreign bodies most commonly embed in the oropharynx. Often these bristles can be removed in the clinic; however, on occasion, the patient requires general anesthesia for retrieval because of the gag reflex and difficulty with access and visualization. We report here on 2 cases of patients who underwent successful transoral robotic surgical retrieval of wire bristles from the base of tongue after unsuccessful direct laryngoscopy. Otolaryngologists should be aware of the use of robotic assistance for oropharyngeal foreign body retrieval.

Surgeon-performed ultrasound for the assessment of parotid masses

BACKGROUND Studies on parotid gland ultrasound assessments performed specifically by surgeons are seldom reported. METHODS Retrospective series of a single academic surgeon experience, analyzing 70 new parotid masses with evaluable preoperative SP-US characteristics, location measurements, and perioperative events. RESULTS 31/70 masses were malignant. SP-US characteristics significantly associated with both malignancy and positive margins included extraparenchymal extension, irregular borders, hypervascularity, infiltration, and the lack of deep enhancement. The larger the skin-to-deep-aspect-of-tumor distance, the more likely the tumor was deep to FN. For the 39 cytologically benign tumors, neither CT nor MRI provided additional information to change management except for full delineation of parapharyngeal space extension in 2 cases. CONCLUSION SP-US can help predict parotid mass benignity/malignancy, positive margin risk, and tumor relation to FN. SP-US may be used as the sole imaging in cytologically benign tumors unless the deep tumor extent cannot be identified.

Abstract 17: Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection

Background: The aim of this study is to address the paucity of data on the potentially unique patterns of neck nodal metastases in HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPSCC). Methods: The neck dissection (ND) specimens of varying levels of HPV+OPSCC patients at University of California-San Francisco from 2010-2016 were reviewed for the numbers and frequencies of clinically evident and occult nodes by neck level, and for those with extra-capsular spread (ECS). Smoking history (>10 pack-years), T status, and local, regional and distal recurrences were also assessed for possible associations with nodal metastatic behavior. Results: Sixty HPV+OPSCC patients underwent primary site trans-oral robotic surgery and 65 NDs, of which 21 (32%) were elective. Forty-three (65%) NDs were in non-smokers. Overall, the mean number of positive nodes per ND was 2.5 (range 1-9). The frequencies of at least one pathologically positive node for neck levels 1b, 2, 2a, 2b, 3, 4, and 5 were 0% (0/41), 67.7% (44/65), 43% (23/53), 13% (7/53), 27.7% (18/65), 7% (4/54), and 8% (2/23), respectively. All positive level 5 positive nodes were clinically evident preoperatively. Five of 21 (24%) elective NDs had occult disease only in levels 2A, 2B, and 3, with a mean number of positive nodes of 1.8 (range 1-3). Three of 21 (14%) elective NDs had nodes with ECS. Six of 44 (13%) therapeutic NDs had occult nodes outside the known preoperative distribution in levels 2b, 3 and 4. There were no occult 2a nodes. Smoking history, primary site, and T status were not statistically significantly associated with a differing metastatic nodal behavior. Twenty-three of 60 and 18 of 60 patients underwent adjuvant radiation and adjuvant chemoradiation, respectively. Thirteen of the 19 patients who only underwent surgery had positive lymph nodes, of which five had N1 disease and four had N2b disease. All four of N2b disease patients refused adjuvant therapy and none have had a recurrence as of follow-up (mean 28 months, range 3-51). The overall mean follow-up was 29.1 months (range 2-76 months), with 72% of patients having at least 12 months. One of 65 (1.5%) NDs developed a neck recurrence in the skin overlying level 2 in a patient in the therapeutic ND cohort who had undergone chemoradiation for ECS. No undissected neck levels developed metastatic nodal disease. Two of 60 (3%) patients developed local recurrence. No patients developed distant metastases. One patient in the cohort died of an unrelated cause. There have been no cancer-related deaths. Conclusions: For HPV+OPSCC, therapeutic NDs should encompass any levels bearing suspicious nodes and levels 2a, 2b, 3, and 4, while elective NDs should be performed and encompass at least levels 2a, 2b, and 3. ECS may be present in occult nodes. For HPV+OPSCC, these selective ND plans, followed by the indicated adjuvant treatment, is associated with a low neck recurrence rate. Citation Format: Madeleine P. Strohl, Steven J. Wang, Patrick K. Ha, Jonathan R. George, Chase M. Heaton, Ivan H. El-Sayed, Jon Mallen St Clair, William R. Ryan. Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 17.

Use of high throughput T cell receptor (TCR) DNA sequencing to characterize T cell infusion products and track clonal expansion in vivo

Background During the process of T cell priming to peptide antigens, the T cell receptor (TCR) undergoes gene rearrangements that result in a peptide-binding region (complementarity determining region, CDR) which can act as a unique molecular fingerprint for similar T cell clonotypes. The purpose of this study was to assess high-throughput TCR DNA sequencing to analyze qualitative and quantitative measures of human T cell clonotype expansions both in vitro and in vivo. Methods Human lymph nodes derived from patients with melanoma (melanoma-draining lymph node cells, MDLN) were culture-activated using either anti-CD3/CD28 beads and IL-2 100 IU/ml alone or in combination with antiVEGF neutralizing antibody, for 14 days. The two resultant MDLN cultures were compared for overall T cell expansion, cell surface phenotype, intracellular cytokine staining and high-throughput TCR DNA sequencing (ImmunoSEQ, Adaptive Biotechnologies). In addition, both TDLN cell cultures were injected intravenously into SCID mice bearing A375 melanoma xenografts and bone marrow was harvested to assess for persistence of transferred human melanoma MDLN cells. Results Overall T cell expansion and cell surface phenotype of MDLN cell cultures was similar. MDLN cells cultured in the presence of anti-VEGF neutralizing antibody demonstrated higher baseline levels of intracellular interferon-g. TCR sequencing analysis comparing day 0 versus day 14 cultured MDLN cells demonstrated approximately 10% shared T cell clonotypes following culture activation with anti-CD3/CD28 beads and IL-2. As a point of reference, the proportion of shared T cell clonotypes between two different patient MDLN cells was approximately 0.6%. Addition of anti-VEGF antibody during culture of MDLN cells resulted in common T cell clonotypes of approximately 1% (day 0 versus day 14), confirming the expansion of molecularly distinct T cell clonotypes. Human MDLN cells infused into SCID mice bearing A375 melanoma xenografts demonstrated persistence of T cell clonotypes in the bone marrow several weeks after infusion. It is notable that none of the low frequency T cell clonotype expansion differences between samples could be readily identified using VDJ gene usage or CDR3 length analysis. Conclusions

Abstract 16: Immunomodulatory effects of VEGF on human lymph node antigen-presenting and lymphoid cells

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CA Background: Vascular endothelial growth factor (VEGF) is a potent pro-angiogenic signal associated with the growth and metastasis of tumors. In addition, VEGF has also been implicated in the suppression of immune cell function. The purpose of this study was to characterize VEGF secretion, receptor expression and effect of soluble VEGF neutralization in human lymph node cells both at rest and during activation. Methods: Human lymph nodes derived from patients with melanoma (IRB CASE 3610) containing T cells, B cells, monocyte/macrophages and dendritic cells were cultured with anti-CD3/CD28 beads and IL-2 in order to induce an inflammatory response in vitro. Culture supernatant was assayed for the presence of soluble VEGF on days 4, 7, 11 and 14 of culture. Multiparameter FACS analysis was performed to assess the cell surface expression of VEGF receptor subtypes 1 and 2 over the 14-day culture period. In addition, intracellular expression of cytokines within effector T cells was assessed at the end of the culture. Finally, a parallel culture containing a VEGF neutralizing antibody was performed to assess the effect of VEGF neutralization on effector T cell phenotype. High-throughput T cell receptor CDR3 sequencing was used to determine the molecular sequence of the variable region of the T cell receptors (ImmunoSEQ, Seattle, WA). Results: VEGF was measureable in the culture supernatant on days 4 and beyond. The proportion of cells expressing intracellular VEGF peaked at day 4 and subsequently decreased. CD11b+(monocyte/macrophage), CD11c+ (dendritic cells) and CD19+ (B) cells had the highest proportion of cells which expressed intracellular VEGF. VEGF R1 and R2 were not constitutively expressed on resting immune cells, but receptor expression was upregulated upon activation of the T cells in vitro. Day 14 T cells demonstrated intracellular IFN-γ, IL-2 and TNF-α. The addition of VEGF-blocking antibody in the culture of MDLN cells effectively neutralized the amount of soluble VEGF detected in the culture supernatant at all days. The addition of the VEGF-blocking antibody also increased the proportion of T cells expressing intracellular IFN-γ as compared T cells in the non-VEGF blocked culture and resulted in distinct molecularly defined T cell clones. Conclusion: These results confirm that soluble VEGF is produced by immune cells during activation, even in the absence of tumor. VEGF receptor expression on lymph node immune cell subsets is constitutive, but low, and then upregulated during in vitro activation of T cells, presumably due to secondary cytokine production. Neutralization of soluble VEGF resulted in qualitative differences in effector cytokine expression and T cell receptor sequences. Whether the effect on these T cells is direct via VEGF interaction with the cognate receptor or from an indirect effect on antigen-presenting cells is currently under investigation. Citation Format: Madeleine P. Strohl, Hallie Graor, Mei Zhang, Anthony Visioni, John Ammori, Isabelle Rivers-McCue, Julian Kim. Immunomodulatory effects of VEGF on human lymph node antigen-presenting and lymphoid cells. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 16. doi:10.1158/1538-7445.AM2014-16