Enhanced Apoptosis in a Hepatic Ischaemia-Reperfusion Injury Model.

Background:Prior to reperfusion, a variable period of ischaemia occurs in transplanted donor organs There is growing evidence that apoptosis contributes to the ischaemia-reperfusion injury conundrum that follows, but its extent has not been precisely quantified. Understanding its extent and effects can help find ways to mitigate or counteract such an injury in the liver. We therefore evaluated the extent of apoptosis semi-quantitatively from the expression of Caspase-3 and M30 in a porcine ex-vivo hepatic ischaemia-reperfusion injury model and correlated the timing of expression of M30 antibody with that of Caspase-3. Method:Livers were harvested from three healthy white Landrace Cross pigs and perfused for six hours using oxygenated extracorporeal circuits with heparinized autologous blood at 380C as described in our previous work [1]. A 2-hour delay prior to perfusion represented the period of ischaemia. All the livers were uniformly perfused. Three biopsies were taken for each of 7 time points (total 21); before dissection of the liver (BD) of the livers, after dissection (AD), after connection (AC) to the circuit, at one hour perfused (1hrP) & non-perfused (1hrNP), at 4 hours perfused (4hrP) and non-perfused (4hrNP). Samples were stained with standard Haematoxylin–Eosin (HE) and immunohistochemically with Caspase-3 and M30 monoclonal antibodies. Positive cells were quantified using an ocular grid and expressed as number per square area. Cells positive for Caspase-3 & M30 antibodies were counted on the whole section. Data were expressed as median number per square millimetre. Statistical analysis was done using AVOVA and t-test. Results: After four hours of perfusion, multiple areas of perfusion defects appeared macroscopically in all 3 livers. HE staining confirmed that these non-perfused areas were ischaemic. There was a gradual increase in Caspase-3 expression over time in all samples. There was no statistically significant difference in the Capase-3 and M30 between the 9 specimens at 1hrP (P=0.06) but there was a highly significant difference between Caspase-3 and M30 at 1hrNP (0.001). Caspase-3 expression peaked at 4hrP (P=0.001) and 4hrNP (P=0.03). A similar pattern was noted with M30 which peaked at 1hrP (P=0.001) and maintained a non-significant expression at 4hrP (P=0.07) and 4hNP (P=0.1). Conclusion: The significant expression of Caspase-3 and M30 confirms that apoptosis plays an important part in tissue loss in this model of liver ischemia-reperfusion injury. Inhibiting both Caspase-3 and M30 might be useful in alleviating hepatic reperfusion injury.

Apoptosis Post Microwave Ablation of the Liver: Does it Change with Power?

Summary: Apoptosis is a type of the delayed or indirect cellular responses that happen after microwave ablation. It helps eradicate the few cancer cells that might survive the applied heat during cancer ablation. The extent of its expression is yet to be defined. Aims: We investigated whether the ablation power made any difference to the expression of apoptosis in the ablated and normal areas. Methods: Ablations with 50W, 70W, and 90W powers were created in three ex vivo perfused porcine livers. Biopsies were collected from the lesions and were assessed with Hematoxylin-Eosin and immunohistochemistry (Caspase 3 and M30) looking for apoptosis in each zone (central necrotic zone [CNZ], transitional zone [TZ], and normal surrounding zone [NZ]). Statistical analysis was performed using ANOVA and t-test. Results: None of the CNZ showed expression of Caspase-3. In the TZ, there was significant difference between 50W and 90W (P = 0.009), but not between 50W and 70W (P = 0.8), or between 70W and 90W (P = 0.4). In the NZ, a highly significant difference was noted between 50W and 90W (P = 0.003), a significant difference between 50W and 70W (P = 0.01), but not between 70W and 90W (P = 0.06). For M30, no expression of M30 was noted in all necrotic zones. A significant difference was noted between 50W and 90W (P = 0.02). There were no significant differences between 50W and 70W (P = 0.4) or between 70W and 90W (P = 0.07). Conclusion: Increasing power enhances apoptosis in the ablated areas. This response can be an adjunct for eradicating cancer cells that might escape the heat in the ablated zones

Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an “unascertained” outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.</p

Impact of changing from autopsy to post-mortem CT in an entire HM Coroner region due to a shortage of available pathologists

A significant problem facing routine medicolegal coroner-referred autopsies is a shortfall of pathologists prepared to perform them. This was particularly acute in Lancashire, where the coroner decided to initiate a service that relied on post-mortem computed tomography (PMCT). This involved training anatomical pathology technologists (APTs) to perform external examinations, radiographers to perform scans, and radiologists to interpret them. The service started in 2018 and now examines over 1,500 cases per year. This study outlines the PMCT process using NHS staff, with CT equipment and logistics managed by the commercial sector. It compares the demographics and outcomes of PM investigations for two 6-month periods: the autopsy service prior to 2018, and then the PMCT service. These data were then compared with previous UK PMCT data. Referrals for adult non-suspicious deaths were made in 913 cases of which 793 (87%) had PMCT between 01/10/2018 and 31/03/2019. Fifty-six cases had autopsy after PMCT, so 81% of cases potentially avoided autopsy. The PMCT service did not delay release of bodies to the next-of-kin. Comparing the cause of death given shows no difference in the proportions of natural and unnatural deaths. There was an increase in diagnosis of coronary artery disease for PMCT, with less respiratory diagnoses, a feature not previously demonstrated. These data suggest PMCT is a practical solution for potentially failing autopsy services. By necessity, this involves changes in diagnoses, as PMCT and autopsy have different strengths and weakness, but the ability to pick up unnatural death appears unaffected.</p

NICE 2022 guidelines on the management of melanoma: Update and implications

Aims: In July 2022, NICE updated the guidelines on the management of melanoma by lowering the number of follow-up appointments and sentinel lymph node biopsy (SLNB) but increasing the number of scans. This study aims to evaluate the implications of executing the new guidelines in terms of cost-effectiveness and personnel. Methods: All patients newly diagnosed with melanoma in 2019 at a regional skin cancer specialist center were reviewed. Data were analyzed for their journey on an idealized pathway modeled over a 5-year follow-up period when adhering to both the previous and new guidelines. Differences in the management of melanoma were elucidated by comparing these changes. The cost was quantified on a perpatient basis and the financial implication on each department was considered. Results: One hundred and ten patients were diagnosed with melanoma in 2019, stages I-III. The changes ease the burden on plastic surgery and dermatology; however, increased pressure is faced by radiologists and histopathologists. An overall cost benefit of £141.85 perpatient was calculated, resulting in a decrease of 1.22 hospital visits on average and an increase in the time spent there (19.55 min). The additional expenses of implementing the new guidelines due to the added BRAF tests, CT, and ultrasound scans are outweighed by savings from the reduction in follow-up appointments and SLNB. Conclusion: The focus has shifted to less invasive procedures for lower melanoma stages and fewer follow-up appointments, at the expense of more genetic testing and imaging. This paper serves as a useful baseline for other centers to plan their service provision and resource allocation to adhere to the updated guidelines

Curcumin combined with FOLFOX chemotherapy is safe and tolerable in patients with metastatic colorectal cancer in a randomized phase IIa trial.

Background: Curcumin is the main active ingredient of the spice turmeric, investigated extensively for putative anti-cancer properties. Objective: This phase IIa open-labelled randomized controlled trial aimed to assess safety, efficacy, quality of life, neurotoxicity, curcuminoids, and C-X-C-motif chemokine ligand 1 (CXCL1) in patients receiving folinic acid/5-fluorouracil/oxaliplatin chemotherapy (FOLFOX) compared to FOLFOX + 2 g daily oral curcumin (CUFOX). Methods: Twenty eight patients aged >18 with a histological diagnosis of metastatic colorectal cancer were randomized (1:2) to receive either FOLFOX or CUFOX. Safety was assessed by Common Toxicity Criteria-Adverse Event (CTC-AE) reporting, and efficacy via progression free survival (PFS) and overall survival (OS). Quality of life and neurotoxicity were assessed using questionnaires (European Organization for Research and Treatment Quality of life (EORTC QLQ-C30) and Functional Assessment of Cancer Treatment-Gynecologic Oncology Group-Neurotoxicity (FACT-GOG-NTX)). Plasma curcuminoids were determined with liquid chromatography electrospray ionization mass spectrometry (LC-ESI-MS/MS) and CXCL1 by enzyme-linked immunosorbent assay (ELISA). Results: Addition of daily oral curcumin to FOLFOX chemotherapy was safe and tolerable (primary outcome). Similar adverse event profiles were observed for both arms. In the intention to treat population, the hazard ratio for PFS was 0.57 (0.24, 1.36) (P = 0.2) (median of 171 vs 291 days for FOLFOX and CUFOX respectively), and for OS was 0.34 (0.14, 0.82) (P = 0.02) (median of 200 vs 502 days for FOLFOX and CUFOX respectively). There was no significant difference between arms for quality of life (P = 0.248) or neurotoxicity (P = 0.223). Curcumin glucuronide was detectable at levels >1.00 pmol/mL in 15 of 18 patients receiving CUFOX. Curcumin did not significantly alter CXCL1 over time (P = 0.712). Conclusions: Curcumin is a safe and tolerable adjunct to FOLFOX chemotherapy in patients with metastatic colorectal cancer. Trial registration was with ClinicalTrials.gov (NCT01490996) and the European Drug Regulating Authorities (EudraCT 2011-002289-19)

Abemaciclib in patients with p16ink4A-deficient mesothelioma (MiST2): a single-arm, open-label, phase 2 trial

Background: Genetically stratified therapy for malignant mesothelioma is unavailable. Mesotheliomas frequently harbour loss of the chromosome 9p21.3 locus (CDKN2A–MTAP), which is associated with shorter overall survival due to loss of the tumour suppressor p16ink4A, an endogenous suppressor of cyclin-dependent kinase (CDK)4 and CDK6. Genetic restoration of p16ink4A suppresses mesothelioma in preclinical models, underpinning the rationale for targeting CDK4 and CDK6 in p16ink4A-negative mesothelioma. We developed a multicentre, stratified, phase 2 trial to test this hypothesis. Methods: The MiST2 study was a single-arm, open-label, phase 2 clinical trial done two UK centres. Patients older than 18 years with any histologically confirmed subtype of mesothelioma (pleural or peritoneal) with radiological progression after at least one course of platinum-based chemotherapy were molecularly screened by immunohistochemistry for p16ink4A. Patients with p16ink4A-negative mesothelioma were eligible for inclusion in the study. Patients were required to have measurable disease by modified Response Evaluation Criteria in Solid Tumours version 1.1 for malignant mesothelioma, a predicted life expectancy of at least 12 weeks, and an Eastern Cooperative Oncology Group performance status score of 0–1. Patients received oral abemaciclib 200 mg twice daily, administered in 28-day cycles for 24 weeks. The primary endpoint was the disease control rate (patients with complete responses, partial responses, or stable disease) at 12 weeks. The null hypothesis could be rejected if at least 11 patients had disease control. The efficacy and safety populations were defined as all patients who received at least one dose of the study drug. The study is registered with ClinicalTrials.gov, NCT03654833, and is ongoing (but MiST2 is now closed). Findings: Between Sept 31, 2019, and March 2, 2020, 27 eligible patients consented to molecular screening. The median follow-up was 18·4 weeks (IQR 6·7–23·9). One patient was excluded before treatment because of a serious adverse event before study drug allocation. 26 (100%) of 26 treated patients were p16ink4A deficient and received at least one dose of abemaciclib. Disease control at 12 weeks was reported in 14 (54%) of 26 patients (95% CI 36–71). Grade 3 or worse treatment-related adverse events (of any cause) occurred in eight (27%) of 26 patients (diarrhoea, dyspnoea, thrombocytopenia, vomiting, urinary tract infection, increased alanine aminotransferase, ascites, chest infection or suspected chest infection, neutropenic sepsis, alopecia, blood clot left calf, fall [broken neck and collar bone], haemoptysis, lower respiratory tract infection, and pulmonary embolism). Grade 3 or worse treatment-related adverse events occurred in three (12%) of 26 patients (diarrhoea, thrombocytopenia, vomiting, increased alanine aminotransferase, and pulmonary embolism). Serious adverse events occurred in six (23%) of 26 patients, leading to treatment discontinuation in one (4%) patient (diarrhoea, urinary tract infection, chest infection, neutropenic sepsis, fall [broken neck and collar bone], haemoptysis, lower respiratory tract infection, and pulmonary embolism). One patient had a serious adverse event related to abemaciclib (diarrhoea). One (4%) of 26 patients died from an adverse event (neutropenic sepsis). Interpretation: This study met its primary endpoint, showing promising clinical activity of abemaciclib in patients with p16ink4A-negative mesothelioma who were previously treated with chemotherapy, and warrants its further investigation in a randomised study as a targeted stratified therapy. Funding: University of Leicester, Asthma UK and British Lung Foundation Partnership, and the Victor Dahdaleh Foundation