Citations

Abstract Background: Tumor endothelial cells (ECs) are a population of stromal cells required for tumor growth that cooperate with tumors to form angiogenic structures. In blood, circulating ECs (CECs) are normal constituents of healthy individuals, although a Cancer Associated Vascular Endothelial cell (CAVE) subtype has been observed in cancer patients. The CAVE population has been isolated and identified using their large size or multicellular clustering and a pooled mixture of classical EC markers (i.e. CD31 and CD146). However, there has been no attempt to differentiate CAVEs from the many EC subtypes. This is not surprising as in-depth phenotyping of ECs requires an array of biomarkers that until recently has not been feasible. A multi-phenotypic screening of EC markers was tested on CAVEs from 116 blood samples in 3 types of solid tumors. This data suggests that CAVEs exist as a common and diverse subtype of tumor derived CECs that may express cytokeratin (CK) and various EC biomarkers, correlating to disease stage. Methods: Peripheral blood samples from 116 cancer patients (stage I-IV) were drawn from 2012-2014 including breast (n=42), lung (n=39) and prostate (n=35), as well as blood from 34 healthy controls. Blood was processed by an established filtration approach, i.e. the CellSieveTM microfiltration technique (Creatv MicroTech), filtering blood by size exclusion and staining cells for CK 8, 18 & 19, EpCAM and CD45. After identification and imaging, the QUAS-R (Quench, Underivatize, Amine-Strip and Restain) technique was used to remove fluorescence signal and restain all cells with CD31, CD146, CD144, & DAPI. After reimaging, QUAS-R was again used to remove fluorescence and restain the cells for CD14, CD105, CD34, & DAPI. Results: Out of 116 patient samples, we identified CAVEs in 63 patients (54%) based on positivity of CD31, CD144 or CD146, but none were found in healthy controls. CAVEs per 7.5mL sample in patients averaged 5.1 (breast), 5.6 (prostate) and 7.9 (lung). Presence of CAVEs appeared related to stage with 26% in stage 1, 61% in stage 2, 68% in stage 3, and 74% in stage 4 patients. No CAVEs were positive for CD14 or CD45. CD31 was the most present marker, found on 93% of CAVEs, followed by CD144 (85%), CD34 (64%), CD146 (45%), & CD105 (4%). In contrast with the previous study on this topic, CK was found in 67% of CAVEs, but was not a universal marker. Conclusions: It has been reported that CK+ and CD45- CECs are isolated from the blood of cancer patients in colon and lung cancers, prompting some to classify them as circulating tumor cells. However, subtyping these CECs is incomplete when characterized with only 3-4 biomarkers. A multi-phenotypic subtyping technique was used to properly identify and subtype these CECs in cancer patients. This data suggest that a subset of CECs, e.g. CAVEs, are found in circulation as CK+/CD45-, but exist as a heterogeneous population of cancer specific circulating cells that require further study. Citation Format: Daniel L. Adams, R. Katherine Alpaugh, Steven H. Lin, Jeffrey R. Marks, Raymond Bergan, Stuart S. Martin, Sarany Chumsri, Massimo Cristofanilli, Cha-Mei Tang, Steingrimur Stefansson. Identifying, subtyping and classifying tumor associated circulating endothelial cells in patients with solid tumors [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 778. doi:10.1158/1538-7445.AM2017-778

Abstract Background: Circulating cancer associated macrophage-like cells (CAMLs) are cancer specific giant cells circulating in the blood of patients with solid tumors. Since their discovery, few studies have been done to elucidate their lineage or phenotypic identity. The difficulty in classifying CAMLs is exemplified by their expression of multiple heterogeneous markers that defy conventional identification. Recently, we described a restaining method (QUAS-R) to screen individual cells using an array of up to 15 biomarkers. We used this method to screen CAMLs isolated from 152 cancer patient samples in 4 types of solid tumors to classify CAMLs by phenotypic immunostaining. These data suggest that CAMLs are a morphologically diverse and phenotypically heterogeneous population of cancer specific giant cells with overlapping myeloid, epithelial, and endothelial phenotypes. Methods: This multi-institutional study used peripheral blood samples from 152 cancer patients (stage I-IV) from breast (n=42), lung (n=39), renal cell carcinoma (36) and prostate (n=35). Blood was processed by the CellSieve™ microfiltration technique at 5 institutions and stained for cytokeratin 8, 18 & 19, EpCAM, and CD45. After identification/imaging, the QUAS-R (Quench, Underivatize, Amine-Strip and Restain) technique was used to quench fluorescence signal of cells and then restain with vimentin/CD146/CD144, CD14/CD11b/CD41, CD11c/CD68/TIE2, or CD34/CD41/CD61. After staining, QUAS-R was again used to remove the fluorescence and samples restained with a third panel. Each patient sample was stained, quenched and restained with the above mentioned panels. Results: In agreement with a number of studies, CAMLs were found in 86% of cancer patients (n=131/152), with increased detection from stage 1 (71%), followed by stage 2 (94%), stage 3 (88%) to stage 4 (88%). Breast cancer had the most CAMLs per sample (14.1 cells/7.5mL), followed by prostate (6.8), renal cell carcinoma (4.9) and lung (3.2). CD34 was most prevalent, found on 88% of CAMLs, followed by cytokeratin (81%), CD41 (79%), CD61 (78%), CD45 (75%), CD14 (72%), vimentin (63%), EpCAM (56%), CD146 (53%), CD68 (44%), CD11c (38%), TIE-2 (25%) and CD11b (0%). Based on our results, CAMLs seem to express overlapping phenotypes from a variety of lineages i.e. macrophage (CD14/CD68/CD11c), epithelial (cytokeratin/EpCAM), endothelial (CD146/TIE-2) and megakaryocyte (CD41/CD61). Conclusions: Although identification of CAMLs is straightforward by morphological criteria (size and nuclear profile), their identification and lineage remains undetermined. We report the first mass screening of CAMLs to determine phenotypic expression. These data suggest that CAMLs cannot be grouped into any known cell subtype based on their expression profiles and represent a heterogeneous and variably differentiated population whose biological consequences in cancer remain under investigation. Citation Format: Daniel L. Adams, R Katherine Alpaugh, Thai H. Ho, Steven H. Lin, Jeffrey R. Marks, Raymond Bergan, Stuart S. Martin, Saranya Chumsri, Cha-Mei Tang, Massimo Cristofanilli. Multiplex phenotyping of circulating cancer associated macrophage-like cells in patients with solid tumors [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 3798. doi:10.1158/1538-7445.AM2017-3798

Objectives: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that commonly affects the knee.The purpose of this study is to (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated non-operatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Methods: 86 patients (mean age 21.4 years) with OCD lesions treated nonoperatively were identified between 1976 and 2014. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Factors predictive of arthritis and arthroplasty (age, gender, body mass index, and lesion location) were examined. Results: At a mean follow-up of 12.6 (±9.8) years from diagnosis, 13 patients (15%) were diagnosed with arthritis corresponding to a cumulative incidence of 5.0% at 5 years, 10.0% at 10 years, 20.0% at 25 years, and 30.0% at 35 years. The cumulative incidence of arthroplasty was 1.0% at 5 years, 3.0% at 10 years, 8.0% at 25 years, and 8.0% at 35 years. BMI greater than 25 kg/m 2 (HR 15.4, 95% CI: 1.9, 124.5) and patellar OCD lesions (HR 15.0, 95% CI: 1.3, 345.3) were associated with arthritis. Conclusion: Arthritis following nonoperative treatment of OCD lesions is a challenging problem with an estimated 30% cumulative incidence at 35 years after diagnosis. In contrast, the long-term rate of arthroplasty is low. BMI greater than 25 kg/m 2 and patellar OCD lesions are predisposing factors for arthritis. Older age at diagnosis was associated with a greater risk of arthritis and knee arthroplasty.

Objectives: Medial meniscus posterior root tears (MMPRTs) are recognized as a source of pain and dysfunction, but treatment options remain a clinical challenge. Currently, outcomes are unknown following partial meniscectomy for these lesions. To determine (1) the efficacy of partial meniscectomy to treat MMPRTs compared to a matched group of non-operatively treated MMPRTs, and (2) risk factors for worse clinical and radiographic outcome. Methods: This retrospective comparative study was performed to include 27 patients with MMPRTs that were treated with arthroscopic partial meniscectomy (PMM) and a minimum 2-year follow-up. These patients were then matched by age, gender, and BMI to a group of 27 patients with MMPRTs treated non-operatively (control group). Demographic data, radiographic findings, final Tegner and IKDC scores were obtained and compared between the two groups. Risk factors for worse clinical and radiographic outcome in the PMM group alone, including age, sex, BMI, initial K-L grade, subchondral edema, and insufficiency fracture on MRI were determined. Results: Overall, 54 patients were included in the study. 27 patients (10M: 17F) with a mean age of 55±9 and a mean BMI of 32.8±5.3 were treated with PMM and followed for a mean of 5.5±2 years (range 2.3-9.3 years). In the PMM group, final median Tegner score was 3, mean IKDC scores were 67.8±20, median KL grades on weight-bearing AP films demonstrated progressive arthritis (median grade 1 to 2, p=0.001) and more patients had grade II or higher arthritis at final follow-up than baseline (91.3% vs. 36% p<0.01. Overall, 14 of the 27 patients (52%) treated operatively progressed to total knee arthroplasty at a mean of 54.3 months. When comparing the PMM and control groups, there was no significant difference in final median Tegner scores, mean IKDC, median K-L grades, progression to arthroplasty, or overall failure rate. Following PMM, female patients had lower final IKDC scores (74.6±16.7 vs. 44.00±2.8, p=0.02) compared to males, as well as a higher rate of arthroplasty (70.6% vs, 20.0%, p=0.009). Higher BMI correlated with lower IKDC scores (r=-0.91, p=0.01) and meniscal extrusion was associated with higher rate of arthritis at final follow-up (100% vs. 57%, p=0.02). Conclusion: Partial meniscectomy for a MMRT provides no benefit in halting arthritic progression. Patients who undergo arthroscopic debridement for MMPRTs still progress to significant arthritis, poor clinical outcomes and a high arthroplasty rate (52%) at over 5-year follow-up. Compared to a non-operative control group, there was no benefit in any subjective or objective outcome measures from the arthroscopic partial meniscectomy. Female patients, higher BMI, and presence of meniscus extrusion were associated with worse outcomes and a higher rate of subsequent knee arthroplasty.

Objectives: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that causes adverse effects on the overlying cartilage and commonly affects the knee. The purpose of this study is to (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated operatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Methods: 221 patients (mean age 26.1 ± 13.6 years) with OCD lesions treated operatively were identified between 1976 and 2014 and followed for a mean of 16.3 (±11.4) years from diagnosis. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Surgical treatment was classified as palliative (fragment excision) or restorative (lesion drilling, fragment fixation, osteochondral allograft or autograft). Factors predictive of arthritis and arthroplasty were examined. Results: In the palliative group, the cumulative incidence of arthritis was 12.0% at 5 years, 17.0% at 10 years, 26.0% at 15 years, 39.0% at 20 years, and 70% at 30 years. The cumulative incidence of arthroplasty was 2.0% at 5 years, 4.0% at 10 years, 4.0% at 15 years, 10.0% at 20 years, and 32.0% at 30 years. In the restorative group, the cumulative incidence of arthritis was 3.0% at 5 years, 7.0% at 10 years, 16.0% at 15 years, 25.0% at 20 years, and 51% at 30 years. The cumulative incidence of arthroplasty was 0.0% at 5 years, 0.0% at 10 years, 3.0% at 15 years, 6.0% at 20 years, and 11.0% at 30 years. BMI greater than 25 kg/m 2 (HR 3.3, 95% CI: 1.6, 7.0), older age at diagnosis (HR 4.9, 95% CI: 1.8, 17.3) and fragment excision (HR 2.3, 95% CI: 1.2, 4.6) were predictive of arthritis. Conclusion: OCD patients treated with fragment excision have a high rate of arthritis and knee arthroplasty at long-term follow-up. In contrast, patients treated with fragment repair or osteochondral restoration have lower rates of arthritis and arthroplasty. BMI greater than 25 kg/m 2 , older age at diagnosis, and fragment excision were predictive of arthritis.

Objectives: Patellar dislocation can occur in isolation or be associated with chronicinstability. The goals of this study are to describe the rate and factors associated with additional patellar instability events (ipsilateral recurrence and contralateral dislocation), as well as the incidence of patellofemoral arthritis among skeletally immature patients following patellar dislocation. Methods: The study included a population-based cohort of 232 skeletally immature patients who experienced a first-time lateral patellar dislocation between 1990 and 2010. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were followed for a mean of 12.1 years to determine the rate of subsequent patellar dislocation (ipsilateral recurrence or contralateral dislocation) as well as clinically significant patellofemoral arthritis. Results: 104 patients had ipsilateral recurrent patellar dislocation. The cumulative incidence of recurrent dislocation was 11% at 1 year, 21.1% at 2 years, 37.0% at 5 years, 45.1% at 10 years, 54.0 % at 15 years, and 54.0% at 20 years. Patella alta (HR: 10.6, 95% CI: 3.6, 36.1), increased TT-TG distance (HR 18.7, 95% CI: 1.7, 228.2), and trochlear dysplasia (HR 23.7, 95% CI: 1.0, 105.2) were associated with recurrence. Similarly, 18 patients (7.8%) had contralateral patellar dislocation. The cumulative incidence of patellofemoral arthritis was 0% at 2 years, 1.0% at 5 years,2.0% at 10 years, 10.1% at 15 years, 17%% at 20 years, and 39.0% at 25 years. Osteochondral injury was associated with arthritis (HR 25.7, 95% CI: 6.2, 143.8). Conclusion: Skeletally immature patients have a high rate of recurrent patellarinstability that is associated with structural abnormalities such as patella alta and trochlear dysplasia. In contrast, the rate of subsequent contralateral dislocation is low. Osteochondral injury is associated with arthritis after patellar dislocation, but the overall incidence of symptomatic arthritis with advanced radiographic changes in pediatric patients is low at 12-year follow-up.

Background: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that commonly affects the knee. Purpose: To (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated nonoperatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Study Design: Case series; Level of evidence, 4. Methods: Eighty-six patients (mean age, 21.4 years) with OCD lesions treated nonoperatively were identified between 1976 and 2014. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Factors predictive of arthritis and arthroplasty (age, sex, body mass index [BMI], and lesion location) were examined. Results: At a mean ± SD follow-up of 12.6 ± 9.8 years from diagnosis, 13 patients (15%) were diagnosed with arthritis, corresponding to a cumulative incidence of 5.0% at 5 years, 10.0% at 10 years, 20.0% at 25 years, and 30.0% at 35 years. The cumulative incidence of arthroplasty was 1.0% at 5 years, 3.0% at 10 years, 8.0% at 25 years, and 8.0% at 35 years. BMI at diagnosis greater than 25 kg/m 2 (hazard ratio [HR], 15.4; 95% CI, 1.9-124.5), patellar OCD lesions (HR, 15.0; 95% CI, 1.3-345.3), and diagnosis as an adult (HR, 21.7; 95% CI, 2.7-176.3) were factors associated with an increased risk of arthritis. Conclusion: Arthritis after nonoperative treatment of OCD lesions is a challenging problem, with an estimated 30% cumulative incidence at 35 years after diagnosis. In contrast, the long-term rate of arthroplasty is low. BMI at diagnosis greater than 25 kg/m 2 and patellar OCD lesions are predisposing factors for arthritis. Diagnosis of OCD as an adult was associated with a greater risk of arthritis.

A cohort of 282 elite amateur ice hockey players were analyzed to 1) record the number, type, location, and severity of head, neck, and facial injuries sustained during games; 2) examine the relationship between injuries and the type of facial protection (none, partial, or full) according to individual playing time; and 3) determine whether full or partial facial protection is associated with an increased incidence of concussions, eye injuries, and neck injuries. Fifty-two injuries (158.9 per 1000 player-game hours) occurred in players wearing no facial protection, 45 (73.5 per 1000 player-game hours) in players wearing partial facial protection (half shield), and 16 (23.2 per 1000 player-game hours) in players wearing full facial protection (full cage or shield). Players wearing no protection were injured at a rate more than twice that of players wearing partial protection and almost seven times higher than those wearing full protection. Concussions occurred in four players wearing no protection, five players wearing partial protection, and two players wearing full protection; these differences were not significant. The risk of eye injury was 4.7 times greater for players wearing no protection compared with those wearing partial protection. No eye or neck injuries occurred in players wearing full protection. This study demonstrates that both full and partial facial protection significantly reduce injuries to the eye and face without increasing neck injuries and concussions.

Primary sclerosing cholangitis (PSC) is strongly associated with several human leukocyte antigen (HLA) haplotypes. Due to extensive linkage disequilibrium and multiple polymorphic candidate genes in the HLA complex, identifying the alleles responsible for these associations has proven difficult. We aimed to evaluate whether studying populations of admixed or non‐European descent could help in defining the causative HLA alleles. When assessing haplotypes carrying HLA‐DRB1*13:01 (hypothesized to specifically increase the susceptibility to chronic cholangitis), we observed that every haplotype in the Scandinavian PSC population carried HLA‐DQB1*06:03. In contrast, only 65% of HLA‐DRB1*13:01 haplotypes in an admixed/non‐European PSC population carried this allele, suggesting that further assessments of the PSC‐associated haplotype HLA‐DRB1*13:01‐DQA1*01:03‐DQB1*06:03 in admixed or multi‐ethnic populations could aid in identifying the causative allele.