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Introduction. The Stanford Biodesign process is a needs-driven approach to innovation which begins in the clinical setting and environment and is championed by practicing clinicians and surgeons. Here, our team applied the Stanford Biodesign process through clinical immersion to identify potential unmet clinical needs in the field of head and neck surgery, brainstormed and prototyped solutions to solve the top unmet need, and developed a commercialized medical device. Methods. The team underwent the 3 phases of the Biodesign process: identify, invent, and implement. The team underwent clinical immersion and followed head and neck surgeons from the Department of Head and Neck Surgery for a duration of 1 month. The needs identified were then filtered through a structured process using predefined filters, and a top need was chosen. After multiple rounds of brainstorming and prototyping, a final concept was developed. Results. The team collected 111 unmet needs and designed the in vivo surgical lighting concept that eventually led to the development of the KLARO™ in vivo surgical lighting device with a commercial partner. KLARO™ is a fully flexible 4.6-mm diameter light-emitting diode light strip that is freely bendable to be safely placed into deep cavities during open surgeries. Conclusion. The Biodesign process provides a standardized way to turn these needs into solution to advance the field of head and neck surgery and improve the outcome of patients.

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-associated mortality in the world. However, with the associated low five-year survival and high recurrence rates, alternative treatment modalities specifically immunotherapy have been researched. A correlation between CD38+tumour-infiltrating leukocyte (TIL) density and improved prognosis was found in a recent study. However, studies relating to CD38 expression in immune infiltrates within tumours are limited. In the present study, we confirmed the expression of CD38 on macrophages in HCC and determined the relationship between CD38+leukocytes and lymphocytes and patient response to immunotherapy. Using immunohistochemistry, we analysed tissue samples obtained from 20 patients from Singapore with HCC prior to immunotherapy. Tumour infiltrating leukocytes expression within tumour were correlated to the responsiveness of patients to immunotherapy.Expression of CD38 was found within the tumour cells and surrounding immune infiltrates including lymphocytes and macrophages. We then ask whether CD38 expression by the distinct cell populations may acquire theranostic relevance. Patients with higher level of CD38+immune infiltrate subsets had significantly better response to anti-PD-1 immunotherapy, and this is also true for CD38+lymphocytes within the tumour microenvironment. In particular, a cut-off of 13.0% positive out of total leukocytes and 12.4% positive out of total lymphocytes is found to be of strong predictive value of responsiveness to immunotherapy treatment, thus a strong theranostic impact is seen by using CD38 as a biomarker for anti-PD-1 therapy.The establishment of an association between CD38 expression and the response to anti-PD-1 immunotherapy in HCC, could be applied to a larger cohort outside Singapore. These may eventually change the routine testing in clinical practice to identify HCC patients suitable for immunotherapy.

IntroductionHepatocellular carcinoma (HCC) is the fourth leading cause of cancer-associated mortality globally. Immune-checkpoint blockade (ICB) is one of the systemic therapy options for HCC. However, response rates remain low, necessitating robust predictive biomarkers. In the present study, we examined the expression of CD38, a molecule involved in the immunosuppressive adenosinergic pathway, on immune cells present in the tumor microenvironment. We then investigated the association between CD38 and ICB treatment outcomes in advanced HCC.MethodsClinically annotated samples from 49 patients with advanced HCC treated with ICB were analyzed for CD38 expression using immunohistochemistry (IHC), multiplex immunohistochemistry/immunofluorescence (mIHC/IF) and multiplex cytokine analysis.ResultsIHC and mIHC/IF analyses revealed that higher intratumoral CD38+cell proportion was strongly associated with improved response to ICB. The overall response rates to ICB was significantly higher among patients with high proportion of total CD38+cells compared with patients with low proportion (43.5% vs 3.9%, p=0.019). Higher responses seen among patients with a high intratumoral CD38+cell proportion translated to a longer median progression-free survival (mPFS, 8.21 months vs 1.64 months, p=0.0065) and median overall survival (mOS, 19.06 months vs 9.59 months, p=0.0295). Patients with high CD38+CD68+macrophage density had a better mOS of 34.43 months compared with 9.66 months in patients with low CD38+CD68+macrophage density. CD38himacrophages produce more interferon γ (IFN-γ) and related cytokines, which may explain its predictive value when treated with ICB.ConclusionsA high proportion of CD38+cells, determined by IHC, predicts response to ICB and is associated with superior mPFS and OS in advanced HCC.

In the original version of this Article, the concentration of boric acid buffer for the SDS clearing solution was given incorrectly as ‘1 M sodium borate’ and should have read ‘0.2 M boric acid’. Also, the composition of PBST incorrectly read ‘1% Triton X-100 (vol/vol) and 0.1% sodium azide (wt/vol)’ and should have read ‘0.1% Triton X-100 (vol/vol) and 0.01% sodium azide (wt/vol)’. Further, the pH of the OPTIClear solution was not stated, and should have read ‘with a pH between 7 to 8 adjusted with hydrochloric acid’. These errors have been corrected in both the PDF and HTML versions of the Article.