Citations

Background: The use of artificial intelligence (AI) in health care has grown exponentially with the promise of facilitating biomedical research and enhancing diagnosis, treatment, monitoring, disease prevention, and health care delivery. We aim to examine the current state, limitations, and future directions of AI in thyroidology. Summary: AI has been explored in thyroidology since the 1990s, and currently, there is an increasing interest in applying AI to improve the care of patients with thyroid nodules (TNODs), thyroid cancer, and functional or autoimmune thyroid disease. These applications aim to automate processes, improve the accuracy and consistency of diagnosis, personalize treatment, decrease the burden for health care professionals, improve access to specialized care in areas lacking expertise, deepen the understanding of subtle pathophysiologic patterns, and accelerate the learning curve of less experienced clinicians. There are promising results for many of these applications. Yet, most are in the validation or early clinical evaluation stages. Only a few are currently adopted for risk stratification of TNODs by ultrasound and determination of the malignant nature of indeterminate TNODs by molecular testing. Challenges of the currently available AI applications include the lack of prospective and multicenter validations and utility studies, small and low diversity of training data sets, differences in data sources, lack of explainability, unclear clinical impact, inadequate stakeholder engagement, and inability to use outside of the research setting, which might limit the value of their future adoption. Conclusions: AI has the potential to improve many aspects of thyroidology; however, addressing the limitations affecting the suitability of AI interventions in thyroidology is a prerequisite to ensure that AI provides added value for patients with thyroid disease.

e18807 Background: CUP represents both a diagnostic and a management challenge. Despite improvements through sophisticated imaging modalities, specific and sensitive testing using immunohistochemistry, a concrete determination of the site of origin of the primary tumor can still be a diagnostic challenge Hereby, we described the genomic landscape of patients with CUP treated at our institution. Methods: Retrospective study of patients with CUP treated at Mayo Clinic Rochester MN from 2010 to 2021. Next generation sequencing (NGS) information was abstracted, and alterations were ranked into different levels of actionability following the Onco KB framework. All data were analyzed by the SPSS version 22.0 software (SPSS, Chicago, IL, United States). Results: From a total of 214 patients, we identified 67 (32%) patients in whom NGS was performed. Among patients with available NGS the median age was 64 years (range: 35-86) and 51% were female. the most prevalent histology included adenocarcinoma (39%), carcinoma NOS (31%), and neuroendocrine tumors (12%). NGS on tumor (t-NGS) was available in 56 (84 %) patients, circulating tumor NGS (b-NGS) was available in 12 (18%) patients, and only 1 patient had both testing available. Among the 56 patients with available t-NGS, MSI-high was detected in 9 patients, whereas among the 12 patients with available b-NGS, MSI-high was detected in 8 patients; yielding an MSI-high detection rate of 16% and 67% for t-NGS and b-NGS. In this cohort, there were a total of 474 genomic alterations detected from which 103 (22 %) were able to be ranked into one therapeutic level following the OncoKB framework. Genomic alterations were most observed among patients with carcinoma (n = 50, 48.53%) adenocarcinoma (n = 33, 32.03 %), squamous cell carcinoma (n = 3, 2.91 %) and neuroendocrine tumor (n = 2, 1.94%). Following the OncoKB framework, 39-level 1 genomic alterations were detected in a total of 14 genes. The most common level 1 genomic alterations comprised the BRCA2 (20.51%), NF1 ATM (17.95%) and HER2/NEU (ERBB2) (15.38%) genes. Therapeutic level 2 included 51 genomic alterations in 13 genes of which KRAS (17.65%), BRAF (15.69%), and BRCA2 (15.69%) were the most prevalent mutated genes. Additionally, level R comprised 13 genomic alterations in the following genes: KRAS (69.23) NRAS (23.08%) and PDGFRA (7.69%). Conclusions: CUP are malignancies rich in potentially actionable alterations, and NGS of tissue and blood samples can inform systemic therapy decisions. Alteration-specific targeted therapy may be an option for a substantial proportion of patients. NGS of tumor tissue or blood should be considered for all patients with CUP.

e18803 Background: CUPs are a heterogeneous group of metastatic cancers for which a standardized diagnostic work-up fails to identify the site of origin at the time of diagnosis. CUP accounts for 3%-5% of all cancer diagnoses worldwide, and the natural history of patient with CUP differs from that of patients (pts) with cancer with known primary tumor. Here we report and summarize the clinical features of patients with CUP treated at Mayo Clinic. Methods: Retrospective study of patients treated at Mayo Clinic Rochester MN from 2010 to 2021. Patient demographics, tumor-related variables, treatment-related variables, and clinical data were extracted. Descriptive statistics were used, and all data were analyzed by the SPSS version 22.0 software (SPSS, Chicago, IL, United States). Results: From a total of 214 pts, 207 pts were included, as primary tumor site was identified in 7 patients after initial evaluation. The pts in this study were predominantly white (87%) of female (50.2%) gender with a mean age of 63 (SD: 13) without history of smoking (51%) and either private or public insurance (82.6%). The predominant histology was adenocarcinoma (30%), followed by neuroendocrine neoplasms (27%), and carcinoma NOS (not otherwise specified) (25%). The most prevalent grade in this cohort was grade III with poorly differentiated tumor cells. All pts had diagnostic imaging and the most used imaging modalities included CT (81.2%), and PET-CT (43.5%). In our cohort, the 3 most common sites of metastases included lymph nodes (57.5%), liver (37.8%), lung (34.3%), and bone (23.7%); and in 64% of pts, there was a specific presentation pattern including liver-predominant (24.6%), lymph node-predominant (24.6%), bone-predominant (7.7%), and peritoneal carcinomatosis (7.7%). The majority of pts received systemic therapy (69%) as first line of therapy and the most frequent first line regimens included platinum-doublet (26.5%), gemcitabine-based regimen (20.7%), 5FU-based regimens (18%) and somatostatin analogs (16.7%); whereas salvage radiation and ablation were offered to 11% of pts and surgery to 17%. The median follow-up time was 22 months (IQR: 45) with a median survival time of 23 months and the 3-year cumulative survival rate was 30%. Conclusions: The heterogenous nature of CUPs and lack of specific immunohistochemical signature prevents primary tissue of origin diagnoses in CUP pts. Without the identification of a primary origin site, treatment is restricted to generic chemotherapy with limited benefit as demonstrated in this cohort.

e18802 Background: CUP is a rare cancer with an incidence of 7–12 cases per 100,000/year. CUP is defined as metastatic cancer with no identifiable primary tumor despite comprehensive evaluation. Despite its heterogeneous clinicopathological presentation, the treatment of CUP has primarily been with platinum-based combination chemotherapies but results are poor and survival is short. Here, we describe survival outcomes in real-world dataset of patients with CUP seen at a tertiary referral center. Methods: Retrospective study of patients treated at Mayo Clinic, Rochester MN, from 2010 to 2021. Survival probabilities were estimated with the Kaplan-Meier method. We used Cox proportional hazard regression with forward modeling to explore the association between each variable and death. Overall survival (OS) analysis was conducted in the entire cohort, and it was stratified by histological subtype. For the hypothesis test, we considered p < 0.05 to be statistically significant; all tests were two-sided. All data were analyzed by the SPSS version 22.0 software (SPSS, Chicago, IL, United States). Results: From a total of 214 patients, 198 patients were included in the survival analysis. The patients were predominantly white (87%), female (50.2%), with a mean age of 63 (SD: 13) without history of smoking (51%). The predominant histology was adenocarcinoma (30%), followed by neuroendocrine neoplasms (NEN) (27%), carcinoma NOS (25%), squamous cell carcinoma (SCC) (10%) and non-classifiable tumors (7%). The median follow-up time was 23 months, and medial OS was 23 months in the entire cohort. OS by histology was as follows: 51 months for NEN, 34 months for SCC, 18 months for carcinomas NOS and 11 months for adenocarcinomas (p < 0.001) (fig.1). Similar OS trends were observed when we restricted the analysis to poorly differentiated tumors. The 3- and 5-year cumulative survival by histology were as follows: 7% and 0% for adenocarcinoma, 25% and 8% for carcinoma NOS, 39% and 17% for SCC, and 56% and 22% for NEN. In Cox regression models we did not identify any prognostic factors among patients with adenocarcinoma. Conclusions: Patients with adenocarcinoma of unknown primary possess a considerable challenge and the OS is short. CUP of other histologies have higher OS. This study highlights the need of accurate tumor identification and better treatment, perhaps as a multiomics therapeutic approach.

Gender inequality across the world has been associated with a higher risk to mental health problems and lower academic achievement in women compared to men. We also know that the brain is shaped by nurturing and adverse socio-environmental experiences. Therefore, unequal exposure to harsher conditions for women compared to men in gender-unequal countries might be reflected in differences in their brain structure, and this could be the neural mechanism partly explaining women’s worse outcomes in gender-unequal countries. We examined this through a random-effects meta-analysis on cortical thickness and surface area differences between adult healthy men and women, including a meta-regression in which country-level gender inequality acted as an explanatory variable for the observed differences. A total of 139 samples from 29 different countries, totaling 7,876 MRI scans, were included. Thickness of the right hemisphere, and particularly the right caudal anterior cingulate, right medial orbitofrontal, and left lateral occipital cortex, presented no differences or even thicker regional cortices in women compared to men in gender-equal countries, reversing to thinner cortices in countries with greater gender inequality. These results point to the potentially hazardous effect of gender inequality on women’s brains and provide initial evidence for neuroscience-informed policies for gender equality.

Abstract The class I genes in the murine MHC are genetically divided into the K, D, Qa, and T1a region subfamilies. These genes presumably arose by duplication from a common class I ancestor. Oligonucleotide probes specific for sequences associated with a moderately repetitive B2 SINE element, which is inserted into the 3' untranslated region of the H-2D and H-2L genes, were used to examine the evolutionary relationship between these classically defined D region genes (H-2D and H-2L) and the other members of the class I gene family. Hybridization analyses of recombinant cosmid and genomic DNA indicated that the D region genes separated genetically from the other members of the class I gene family 12 to 14 million years ago. The evidence suggests that during this time frame the chromosomal segment harboring the characteristic insertion became fixed in the ancestral population which gave rise to Mus domesticus. Previous studies have shown that the number of genes present in the Qa and T1a regions varies among inbred strains and among laboratory stocks of wild mice derived from more distant species on the genus Mus. No evidence was found in this study to support the hypothesis that variation in class I gene number is the result of recent duplications of the functionally defined class I genes of the D region, H-2D and H-2L.

Abstract By using microscopic, fluorometric, and immunologic methods, we have assessed the effects of eosinophil granule proteins on the microcirculation of the hamster cheek pouch. The plasma clearance of FITC-dextran 150 (FITC-dx 150) was used to quantify macromolecular transport. Topical application of major basic protein (MaBP) at 0.1 and 0.5 nM increased the clearance of FITC-dx 150 from a base line of 591 to 1283 and 1966 nl/60 min/g, respectively. Numerous muscle fasciculations were also observed with the 0.5 nM dose of MaBP. Eosinophil cationic protein (ECP) was as potent as MaBP and caused an increase in the clearance of FITC-dx 150, 0.5 nM eliciting 2156 nl/60 min/g. In contrast, topical application of 0.5 nM eosinophil peroxidase (EPO) increased clearance of FITC-dx 150 to a significantly lower level, 1113 nl/60 min/g. Supplementing 0.5 nM EPO with 1 nM H2O2 enhanced the clearance of FITC-dx 150 to 2404 nl/60 min/g, suggesting separate cationic charge and enzymatic activity-related effects. Compared with these eosinophil granule proteins, eosinophil-derived neurotoxin (EDN) required a 2000-fold higher concentration (1 microM) to elicit a significant increase in the clearance of FITC-dx 150 (1505 nl/60 min/g). Neither EPO, EPO+H2O2, ECP, nor EDN at 1 mM caused muscle fasciculations. Quantitative analysis of the suffusates from the preparations exposed to these eosinophil proteins did not contain histamine. Our results demonstrate that MaBP, ECP, EPO, and EDN increase microvascular transport in the hamster cheek pouch and that this increase is independent of endogenous histamine release. The concentrations of eosinophil granule proteins causing increased vascular permeability are achieved in many pathologic conditions suggesting that the granule proteins play an important role in disease.

Abstract The number of genes encoding functional Ag-presenting molecules in the D region of the murine MHC differs among haplotypes. For example, the H-2b D region contains a single "D/L" gene, H-2Db, whereas the d-haplotype encodes two, H-2Db and Ld. Using D/L specific oligonucleotide probes, we have found that, as with H-2d, the q- and v-haplotypes contain two D/L genes, whereas the other haplotype examined have one. Hybridization analysis using cloned probes that map between H-2Dd and Ld revealed similar structures in each of the three haplotypes (d, q, and v) which have "duplicated" D regions. Two approaches were used to examine allelic relationships among the D/L genes. First, the 5' region of the H-2Db gene was sequenced, and found to be more similar to H-2Ld than to H-2Dd. Second, oligonucleotide probes that distinguish H-2Ld from H-2Dd revealed H-2Ld-related genes in several haplotypes, including the duplicated haplotypes H-2q and H-2v. Analogous probes specific for H-2Dd, however, did not detect similar sequences in the other haplotypes. We interpret these results to mean that the three duplicated D regions arose from a common duplication event, and share the five gene structure of the D region cluster defined in H-2d. However, subsequent events have generated sequence divergence at the D-locus.

Abstract A rare D-region recombination event which gave rise to the B10.RQDB major histocompatibility complex haplotype has been examined to ascertain the nature of the crossover and to determine which class I genes are present in the new alignment of D-region genes. Serologic analysis have shown that the B10 . RQDB major histocompatibility complex recombinant mouse inherited the H-2Dd gene from the B10.T(6R) parental line and the H-2Dd gene from the B10.A(2R) parental line, representing the first example of an intra-D-region crossover resulting from an intercross. Previous molecular genetic analyses of the d and b haplotypes revealed structural diversity in the organization of their D-region gene clusters. Hence, the D region is comprised of five class I genes in the d haplotype and only one in the b haplotype. Because allelic relationships among the various D-region genes are not defined, either a homologous or nonhomologous alignment of genes has generated the RQDB crossover. Therefore, the possibility that all three D-region antigen-presenting molecules (Dd, Ld, and Db) might be encoded by the RQDB haplotype was examined. Fluorescence-activated cell sorter and cytotoxic T lymphocyte analyses revealed no detectable levels of H-2Ld cell-surface expression, confirming earlier studies with antibody-mediated cytotoxicity and immunoprecipitation. Southern blot analysis localized the recombination point to within a 1-kb region at the centromeric end of the H-2Ld gene on the B10 . T(6R) chromosome in a region of high homology to the H-2Db gene on the B10 . A(2R) chromosome. Together, these studies define the D region of the RQDB haplotype as containing the five class I genes: Dd, D2d, D3d, D4d, and Db. In addition to providing insight into rare recombination events in the D region, the B10.RQDB mouse should be a useful tool for exploring the function of D-region genes.