Multi-slice computed tomography coronary angiography for the detection of coronary artery disease in a district hospital setting

Coronary artery disease (CAD) is the leading cause of mortality in Scotland (population 5.2 million), accounting for around 9000 deaths each year. Accurate diagnosis of the presence and extent of CAD is essential to guide management. Invasive coronary angiography (I-CA) is the gold standard diagnostic investigation but is associated with a small risk of significant vascular complications. Over the last decade multi-slice computed tomography coronary angiography (MSCT-CA) has emerged as a non-invasive imaging modality capable of visualising the coronary arteries. Incremental advances in scanner technology have greatly improved the accuracy of MSCT-CA in comparison to I-CA. Implementation of MSCT-CA in routine clinical practice in Scotland is desirable in terms of patient safety and convenience in addition to reducing pressure on cardiac catheterisation laboratory time. The latter is particularly relevant considering the recent introduction of primary percutaneous intervention for myocardial infarction. However, at the time of conducting this study the evidence for MSCT-CA accuracy was limited and only minimal guidance on appropriate use of MSCT-CA was available. Furthermore, the majority of existing evidence for MSCT-CA accuracy was derived from specialist academic centres with substantial experience in the technique and the accuracy of MSCT-CA in smaller centres with variable expertise and a more heterogeneous population was unknown. The aim of this prospective, comparative study was to determine the accuracy of MSCT-CA in comparison to I-CA for the detection of significant CAD in patients presenting to a district general hospital in Scotland and to consider the health economic implications of introducing MSCT-CA into routine clinical practice. One hundred patients with suspected CAD on the basis of symptoms and non-invasive stress testing underwent both 40-Slice MSCT-CA and I-CA. Studies were reported by independent, blinded radiologists and cardiologists and compared using the 15-Segment model of the American Heart Association. A stenosis of ≥ 50% was considered significant. The accuracy of MSCT-CA was determined in patient-based, artery-based and segment-based analyses and the impact of various patient characteristics on image quality and diagnostic accuracy was evaluated. Inter-observer agreement was determined for both MSCT-CA and I-CA and the possibility of a “learning curve effect” investigated. The cost-effectiveness of an “MSCT-CA first” strategy was considered in a health economic analysis. The primary analysis considered MSCT-CA accuracy on a per patient basis. Patient prevalence of significant CAD was 38%. Patients with MSCT-CAs deemed not fully evaluable were included and considered to have significant underlying CAD. This strategy was considered clinically relevant as in practice a patient with an unevaluable MSCT-CA would proceed to I-CA for definitive diagnosis. This work demonstrated that 40-Slice MSCT-CA has a high sensitivity (92%) and a high negative predictive value (NPV) (91%) for the detection of significant CAD on a per patient basis. Specificity and positive predictive value (PPV) were less impressive and significantly compromised by the inclusion of patients with scans considered not fully evaluable by MSCT-CA. On segment-based and artery-based analyses respectively, distal segments were more often unevaluable than proximal segments owing to their smaller size, and the right coronary and circumflex arteries were the arteries most often unevaluable, likely due to their higher mobilities. Heart rate during MSCT-CA was not optimally controlled with oral beta blockers and rate limiting calcium channel blockers. The mean number of MSCT-CA evaluable segments per patient was significantly higher in the lower heart rate group. More than half the study population had coronary artery calcification and there was a non-significant trend towards more unevaluable segments in this patient group. Coronary artery calcification had the effect of reducing NPV while increasing PPV. One third of the study patients were obese and a non-significant trend towards an increasing number of unevaluable segments with increasing body mass index was observed. Pre-test probability of significant underlying CAD was determined by the Duke Clinical Score. Fifty-nine per cent of patients had a low-intermediate pre-test probability and 41% a high pre-test probability of CAD. The prevalence of significant CAD in the high pre-test probability group and the low-intermediate pre-test probability group was 73% and 14% respectively. Correspondingly, the sensitivity and PPV of MSCT-CA were higher in the high pre-test probability group while specificity and NPV were lower. Inter-observer agreement of the MSCT-CA reporters was substantial and comparable to that of the I-CA reporters in the patient-based analysis. A small observed improvement in MSCT-CA reporter diagnostic specificity during the study was not statistically significant. This study demonstrated MSCT-CA to be cost effective in the detection of significant CAD in a patient population with low-intermediate pre-test probability and hence fairly low prevalence of disease. Savings would be increased with improved MSCT-CA specificity. A strategy of screening patients being considered for I-CA on the basis of their risk level and referring ‘low-intermediate risk’ cases for MSCT-CA could affect around 60% of patients currently referred for diagnostic I-CA in North Glasgow and subsequently avoid I-CA in at least half of these patients. To permit the development of an effective MSCT-CA service future work must focus on ensuring appropriate training for those performing and reporting MSCT-CA and on the development of local guidelines to govern patient selection for MSCT-CA. Audit of MSCT-CA referrals could determine the extent of adherence to guidelines. Further research could be observational in nature with follow-up of patients who have MSCT-CA and are then referred for I-CA and also follow-up of patients with “negative” MSCT-CA who do not have subsequent I-CA in terms of subsequent cardiac events

The human squamous oesophagus has widespread capacity for clonal expansion from cells at diverse stages of differentiation.

OBJECTIVE: Knowledge of the cellular mechanisms involved in homeostasis of human squamous oesophagus in the steady state and following chronic injury is limited. We aimed to better understand these mechanisms by using a functional 3D approach. DESIGN: Proliferation, mitosis and the expression of progenitor lineage markers were assessed in normal squamous oesophagus from 10 patients by immunofluorescence on 3D epithelial whole mounts. Cells expressing differential levels of epithelial and progenitor markers were isolated using flow cytometry sorting and characterised by qPCR and IF. Their self-renewing potential was investigated by colony forming cells assays and in vitro organotypic culture models. RESULTS: Proliferation and mitotic activity was highest in the interpapillary basal layer and decreased linearly towards the tip of the papilla (p<0.0001). The orientation of mitosis was random throughout the basal layer, and asymmetric divisions were not restricted to specific cell compartments. Cells sorted into distinct populations based on the expression of epithelial and progenitor cell markers (CD34 and EpCAM) showed no difference in self-renewal in 2D culture, either as whole populations or as single cells. In 3D organotypic cultures, all cell subtypes were able to recapitulate the architecture of the tissue of origin and the main factor determining the success of the 3D culture was the number of cells plated, rather than the cell type. CONCLUSIONS: Oesophageal epithelial cells demonstrate remarkable plasticity for self-renewal. This situation could be viewed as an ex vivo wounding response and is compatible with recent findings in murine models

The genetics of virus particle shape in equine influenza A virus

Background Many human strains of influenza A virus produce highly pleomorphic virus particles that at the extremes can be approximated as either spheres of around 100 nm diameter or filaments of similar cross-section but elongated to lengths of many microns. The role filamentous virions play in the virus life cycle remains enigmatic. Objectives/Methods Here, we set out to define the morphology and genetics of virus particle shape in equine influenza A virus, using reverse genetics and microscopy of infected cells. Results and Conclusions The majority of H3N8 strains tested were found to produce filamentous virions, as did the prototype H7N7 A/eq/Prague/56 strain. The exception was the prototype H3N8 isolate, A/eq/Miami/63. Reassortment of equine influenza virus M genes from filamentous and non-filamentous strains into the non-filamentous human virus A/PR/8/34 confirmed that segment 7 is a major determinant of particle shape. Sequence analysis identified three M1 amino acid polymorphisms plausibly associated with determining virion morphology, and the introduction of these changes into viruses confirmed the importance of two: S85N and N231D. However, while either change alone affected filament production, the greatest effect was seen when the polymorphisms were introduced in conjunction. Thus, influenza A viruses from equine hosts also produce filamentous virions, and the major genetic determinants are set by the M1 protein. However, the precise sequence determinants are different to those previously identified in human or porcine viruses

Transmission of Equine Influenza Virus to English Foxhounds

We retrospectively demonstrated that an outbreak of severe respiratory disease in a pack of English foxhounds in the United Kingdom in September 2002 was caused by an equine influenza A virus (H3N8). We also demonstrated that canine respiratory tissue possesses the relevant receptors for infection with equine influenza virus

Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma.

The poor outcomes in esophageal adenocarcinoma (EAC) prompted us to interrogate the pattern and timing of metastatic spread. Whole-genome sequencing and phylogenetic analysis of 388 samples across 18 individuals with EAC showed, in 90% of patients, that multiple subclones from the primary tumor spread very rapidly from the primary site to form multiple metastases, including lymph nodes and distant tissues-a mode of dissemination that we term 'clonal diaspora'. Metastatic subclones at autopsy were present in tissue and blood samples from earlier time points. These findings have implications for our understanding and clinical evaluation of EAC.MRC core grant (RG84369), an NIHR Research Professorship (RG67258) and Cancer Research UK (RG66287)

Risk stratification of Barrett's oesophagus using a non-endoscopic sampling method coupled with a biomarker panel: a cohort study.

BACKGROUND: Barrett's oesophagus predisposes to adenocarcinoma. However, most patients with Barrett's oesophagus will not progress and endoscopic surveillance is invasive, expensive, and fraught by issues of sampling bias and the subjective assessment of dysplasia. We investigated whether a non-endoscopic device, the Cytosponge, could be coupled with clinical and molecular biomarkers to identify a group of patients with low risk of progression suitable for non-endoscopic follow-up. METHODS: In this multicentre cohort study (BEST2), patients with Barrett's oesophagus underwent the Cytosponge test before their surveillance endoscopy. We collected clinical and demographic data and tested Cytosponge samples for a molecular biomarker panel including three protein biomarkers (P53, c-Myc, and Aurora kinase A), two methylation markers (MYOD1 and RUNX3), glandular atypia, and TP53 mutation status. We used a multivariable logistic regression model to compute the conditional probability of dysplasia status. We selected a simple model with high classification accuracy and applied it to an independent validation cohort. The BEST2 study is registered with ISRCTN, number 12730505. FINDINGS: The discovery cohort consisted of 468 patients with Barrett's oesophagus and intestinal metaplasia. Of these, 376 had no dysplasia and 22 had high-grade dysplasia or intramucosal adenocarcinoma. In the discovery cohort, a model with high classification accuracy consisted of glandular atypia, P53 abnormality, and Aurora kinase A positivity, and the interaction of age, waist-to-hip ratio, and length of the Barrett's oesophagus segment. 162 (35%) of 468 of patients fell into the low-risk category and the probability of being a true non-dysplastic patient was 100% (99% CI 96-100) and the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 0% (0-4). 238 (51%) of participants were classified as of moderate risk; the probability of having high-grade dysplasia was 14% (9-21). 58 (12%) of participants were classified as high-risk; the probability of having non-dysplastic endoscopic biopsies was 13% (5-27), whereas the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 87% (73-95). In the validation cohort (65 patients), 51 were non-dysplastic and 14 had high-grade dysplasia. In this cohort, 25 (38%) of 65 patients were classified as being low-risk, and the probability of being non-dysplastic was 96·0% (99% CI 73·80-99·99). The moderate-risk group comprised 27 non-dysplastic and eight high-grade dysplasia cases, whereas the high-risk group (8% of the cohort) had no non-dysplastic cases and five patients with high-grade dysplasia. INTERPRETATION: A combination of biomarker assays from a single Cytosponge sample can be used to determine a group of patients at low risk of progression, for whom endoscopy could be avoided. This strategy could help to avoid overdiagnosis and overtreatment in patients with Barrett's oesophagus. FUNDING: Cancer Research UK.The BEST2 study was funded by Cancer Research UKThis is the author accepted manuscript. The final version is available from Elsevier via https://doi.org/10.1016/S2468-1253(16)30118-

Transcriptomic profiling reveals three molecular phenotypes of adenocarcinoma at the gastroesophageal junction.

Cancers occurring at the gastroesophageal junction (GEJ) are classified as predominantly esophageal or gastric, which is often difficult to decipher. We hypothesized that the transcriptomic profile might reveal molecular subgroups which could help to define the tumor origin and behavior beyond anatomical location. The gene expression profiles of 107 treatment-naïve, intestinal type, gastroesophageal adenocarcinomas were assessed by the Illumina-HTv4.0 beadchip. Differential gene expression (limma), unsupervised subgroup assignment (mclust) and pathway analysis (gage) were undertaken in R statistical computing and results were related to demographic and clinical parameters. Unsupervised assignment of the gene expression profiles revealed three distinct molecular subgroups, which were not associated with anatomical location, tumor stage or grade (p > 0.05). Group 1 was enriched for pathways involved in cell turnover, Group 2 was enriched for metabolic processes and Group 3 for immune-response pathways. Patients in group 1 showed the worst overall survival (p = 0.019). Key genes for the three subtypes were confirmed by immunohistochemistry. The newly defined intrinsic subtypes were analyzed in four independent datasets of gastric and esophageal adenocarcinomas with transcriptomic data available (RNAseq data: OCCAMS cohort, n = 158; gene expression arrays: Belfast, n = 63; Singapore, n = 191; Asian Cancer Research Group, n = 300). The subgroups were represented in the independent cohorts and pooled analysis confirmed the prognostic effect of the new subtypes. In conclusion, adenocarcinomas at the GEJ comprise three distinct molecular phenotypes which do not reflect anatomical location but rather inform our understanding of the key pathways expressed.We would like to acknowledge The Human Research Tissue Bank which is supported by the NIHR Cambridge Biomedical Research Centre ... This work has been supported by the research scholarship BO4097/1‐1 from the Deutsche Forschungsgemeinschaft (DFG) for JB, grant RG67258 of the National Institute for Health and Research (NIHR) and grant RG66287 of Cancer Research UK (CRUK) have been awarded to RCF

Organoid cultures recapitulate esophageal adenocarcinoma heterogeneity providing a model for clonality studies and precision therapeutics

Esophageal adenocarcinoma (EAC) incidence is increasing while 5-year survival rates remain less than 15%. A lack of experimental models has hampered progress. We have generated clinically annotated EAC organoid cultures that recapitulate the morphology, genomic and transcriptomic landscape of the primary tumor including point mutations, copy number alterations and mutational signatures. Karyotyping has confirmed polyclonality reflecting the clonal architecture of the primary and subclones underwent clonal selection associated with driver gene status. Medium throughput drug sensitivity testing demonstrates the potential of targeting receptor tyrosine kinases and downstream mediators. EAC organoid cultures provide a pre-clinical tool for studies of clonal evolution and precision therapeutics

Mutational signatures in esophageal adenocarcinoma define etiologically distinct subgroups with therapeutic relevance.

Esophageal adenocarcinoma (EAC) has a poor outcome, and targeted therapy trials have thus far been disappointing owing to a lack of robust stratification methods. Whole-genome sequencing (WGS) analysis of 129 cases demonstrated that this is a heterogeneous cancer dominated by copy number alterations with frequent large-scale rearrangements. Co-amplification of receptor tyrosine kinases (RTKs) and/or downstream mitogenic activation is almost ubiquitous; thus tailored combination RTK inhibitor (RTKi) therapy might be required, as we demonstrate in vitro. However, mutational signatures showed three distinct molecular subtypes with potential therapeutic relevance, which we verified in an independent cohort (n = 87): (i) enrichment for BRCA signature with prevalent defects in the homologous recombination pathway; (ii) dominant T>G mutational pattern associated with a high mutational load and neoantigen burden; and (iii) C>A/T mutational pattern with evidence of an aging imprint. These subtypes could be ascertained using a clinically applicable sequencing strategy (low coverage) as a basis for therapy selection.Whole-genome sequencing of esophageal adenocarcinoma samples was performed as part of the International Cancer Genome Consortium (ICGC) through the oEsophageal Cancer Clinical and Molecular Stratification (OCCAMS) Consortium and was funded by Cancer Research UK. We thank the ICGC members for their input on verification standards as part of the benchmarking exercise. We thank the Human Research Tissue Bank, which is supported by the National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre, from Addenbrooke’s Hospital and UCL. Also the University Hospital of Southampton Trust and the Southampton, Birmingham, Edinburgh and UCL Experimental Cancer Medicine Centres and the QEHB charities. This study was partly funded by a project grant from Cancer Research UK. R.C.F. is funded by an NIHR Professorship and receives core funding from the Medical Research Council and infrastructure support from the Biomedical Research Centre and the Experimental Cancer Medicine Centre. We acknowledge the support of The University of Cambridge, Cancer Research UK (C14303/A17197) and Hutchison Whampoa Limited. We would like to thank Dr. Peter Van Loo for providing the NGS version of ASCAT for copy number calling. We are grateful to all the patients who provided written consent for participation in this study and the staff at all participating centres. Some of the work was undertaken at UCLH/UCL who received a proportion of funding from the Department of Health’s NIHR Biomedical Research Centres funding scheme. The work at UCLH/UCL was also supported by the CRUK UCL Early Cancer Medicine Centre.This is the author accepted manuscript. The final version is available from Nature Publishing Group via http://dx.doi.org/10.1038/ng.365

Patient-specific cancer genes contribute to recurrently perturbed pathways and establish therapeutic vulnerabilities in esophageal adenocarcinoma

Abstract: The identification of cancer-promoting genetic alterations is challenging particularly in highly unstable and heterogeneous cancers, such as esophageal adenocarcinoma (EAC). Here we describe a machine learning algorithm to identify cancer genes in individual patients considering all types of damaging alterations simultaneously. Analysing 261 EACs from the OCCAMS Consortium, we discover helper genes that, alongside well-known drivers, promote cancer. We confirm the robustness of our approach in 107 additional EACs. Unlike recurrent alterations of known drivers, these cancer helper genes are rare or patient-specific. However, they converge towards perturbations of well-known cancer processes. Recurrence of the same process perturbations, rather than individual genes, divides EACs into six clusters differing in their molecular and clinical features. Experimentally mimicking the alterations of predicted helper genes in cancer and pre-cancer cells validates their contribution to disease progression, while reverting their alterations reveals EAC acquired dependencies that can be exploited in therapy