Small cell transformation of non-small cell lung cancer under immunotherapy: Case series and literature review

In advanced lung cancer treatment, immunotherapy provides durable responses in some patients. However, other patients experience progressive disease and the resistance mechanisms to immunotherapy have yet been fully elucidated. Small cell transformation of non‐small cell lung cancer (NSCLC) is commonly recognized as one of the resistance mechanisms to epidermal growth factor receptor (EGFR)‐tyrosine kinase inhibitors in EGFR‐mutant NSCLC treatment. As a resistant mechanism for immunotherapy, we report the first case of small cell transformation in 2017. Since then, eight similar cases have been reported and the concept of small cell transformation is now becoming more prevalent as a mechanism of immunotherapy resistance. In our facility, we have experienced four cases of small cell transformation after immunotherapy (including the reported case in 2017). The histology of each primary tumor was squamous cell carcinoma, large cell type neuroendocrine carcinoma, or poorly differentiated NSCLC. None had driver gene mutations. Nivolumab was administered in all four cases and atezolizumab was administered as a next line to nivolumab treatment in one case. The best response to immunotherapy was partial response or stable disease. There was a wide range of periods from the start of immunotherapy to confirmation of small cell transformation (from 2 weeks to almost 3 years). In conclusion, small cell transformation is an important resistance mechanism in cancer immunotherapy. When NSCLC progresses after immunotherapy, the possibility of small cell transformation and rebiopsy should always be encouraged, as it leads to clarification of the resistance mechanisms and frequency.

Favorable clinical response and drug retention of anti-IL-6 receptor inhibitor in rheumatoid arthritis with high CRP levels: the ANSWER cohort study

OBJECTIVE

Currently, biological disease-modifying anti-rheumatic drugs (bDMARDs) with different modes of action [tumour necrosis factor inhibitor (TNFi), interleukin-6 receptor inhibitor (IL-6Ri), or cytotoxic T-lymphocyte antigen 4-immunoglobulin (CTLA4-Ig)] are used in clinical practice to treat rheumatoid arthritis (RA). However, it is unclear which type of bDMARD is the most efficacious for a specific clinical situation. C-reactive protein (CRP) is an acute-phase reactant driven by IL-6 signalling. Here, we aimed to establish whether therapeutic efficacy differs between IL-6Ri and other bDMARDs with alternative modes of action in RA patients according to their CRP level.

METHOD

RA patients treated with bDMARDs were enrolled from an observational multicentre registry in Japan. Patients were classified into three groups according to baseline CRP tertiles. The overall 3 year retention rates of each bDMARD category were assessed. The Clinical Disease Activity Index (CDAI) was also assessed before and 3, 6, and 12 months after bDMARD initiation.

RESULTS

A total of 1438 RA patients were included and classified into three groups according to tertiles of baseline CRP levels (CRP¹, 0-0.3; CRP², 0.3-1.8; CRP³, 1.8-18.4 mg/dL). In CRP³, the overall 3 year drug retention rates were significantly higher for IL-6Ri than for TNFi and CTLA4-Ig (77.5 vs 48.2 vs 67.3, respectively). No significant difference was evident in terms of CDAI 12 months after bDMARD initiation in CRP¹-CRP³.

CONCLUSION

IL-6Ri may be a favourable therapeutic option over TNFi and CTLA4-Ig in RA patients with high CRP levels.

Sigma 1 receptor agonist cutamesine promotes plasticity of serotonergic boutons in lumbar enlargement in spinal cord injured rats

Cutamesine, a sigma-1 receptor agonist, functions in both neuroprotection and neurite outgrowth. We assessed the therapeutic effects of cutamesine in a rodent spinal cord injury (SCI) model to demonstrate pre-clinical proof-of-concept. First of all, in order to determine optimal cutamesine dose, cutamesine was administered to normal rats and BDNF protein levels in the lumbar spinal cord were assessed by Western blot. Next, for the SCI model, spinal cords of adult female Sprague-Dawley rats were contused using an Infinite Horizon Impactor. Two weeks post-injury, rats were randomly assigned to receive daily subcutaneous injections of either cutamesine (3.0 mg/kg/day) or saline (as a control) for another two weeks. Immunohistochemistry for BDNF and 5-HT was assessed at four and twelve weeks post-injury in the lumbar spinal cord. Locomotor function was assessed weekly using the BBB locomotor scale until twelve weeks after SCI and CatWalk XT 10.5 gait analysis was conducted at twelve weeks after SCI. In normal rats, cutamesine treatment (3.0 mg/kg/day) significantly up-regulated BDNF expression in the lumbar spinal cord. In SCI rats, cutamesine treatment (3.0 mg/kg/day) significantly increased the fluorescence intensity of neuronal BDNF and serotonin boutons in the injured spinal cord compared to saline. However, cutamesine treatment did not promote significant locomotor recovery. Recent work indicates that cutamesine treatment alone did not promote locomotor recovery in spite of immunohistological changes. Future work will explore the influence of combining cutamesine with other treatment promoting plasticity (e.g. rehabilitative training) in SCI rats.

Radiomics analysis of myocardial perfusion SPECT images in patients with cardiomyopathy and heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI Grants

Background

Although myocardial perfusion heterogeneity due to focally damaged cardiomyocytes is observed in single−photon emission computed tomography (SPECT) imaging, a current perfusion defect scoring system does not allow us to provide sufficient diagnostic information for heterogeneity.

Purpose

The aim of this study was to perform radiomics analysis of myocardial perfusion SPECT (MPS) images to investigate the potential to detect myocardial perfusion heterogeneity.

Methods

Patients with hypertrophic cardiomyopathy (n = 3), heart failure (n = 9), and with a low likelihood of coronary artery disease (n =15) (Figure 1), who underwent a rest 99mTc-MIBI myocardial perfusion SPECT, were assessed using a LIFEx software. Four shape−based features, 6 histogram−based features, and 32 textural features were computed. The relevant features for the classification of the patients were selected using the Boruta algorithm, and hierarchical clustering of the selected features using the Spearman correlation coefficient was also performed for the feature reduction. The receiver operating characteristics (ROC) analysis was performed by the support vector machine to calculate the area under the ROC curve (AUC) for the selected features.

Results

Of 40 features, 17 were selected by the classification analysis, and these features were classified into 7 classes by the correlation analysis (Figure 2). The ROC AUCs for 7 features extracted from each class were 0.99, 0.97, 0.96, 0.92, 0.90, 0.86, and 0.83 for the contrast of NDGLDM, the entropy of histogram, ZLNU of GLZLM, the energy of GLCM, the energy of histogram, SZLGE of GLZLM, and the correlation of GLCM, respectively, as compared to 0.39 for a summed rest score.

Conclusions

Radiomics analysis successfully determined the myocardial perfusion heterogeneity in patients with cardiomyopathy and heart failure. It might be promising for the evaluation of myocardial damages that cannot be analyzed by the conventional scoring method.

POS0345 CLINICOGENETIC STUDY OF FIVE NOVEL SUSCEPTIBILITY LOCI FOR TAKAYASU ARTERITIS: SUSCEPTIBILITY LOCI IN THE IL12B AND PTK2B REGION, BUT NOT THE LILRA3, DUSP22, KLHL33 REGIONS, ARE ASSOCIATED WITH VASCULAR DAMAGE IN TAKAYASU ARTERITIS

Background:

We have previously identified single nucleotide polymorphism (SNP) rs6871626 in IL12B, rs103294 in LILRA3, rs17133698 in DUSP22, rs2322599 in PTK2B, and rs1713450 in KLHL33 as non-HLA susceptibility loci in Takayasu arteritis (TAK) [1, 2]. However, the association of these SNPs with clinical features has scarcely investigated.

Objectives:

In this study, we aimed to examine how these SNPs contribute to clinical features and vascular damage in TAK.

Methods:

We enrolled 99 TAK patients who were enrolled in our previous genome-wide association study (GWAS) [2]. To assess vascular damage, Takayasu Arteritis Damage Score (TADS) and Vasculitis Damage Index (VDI) were measured at the last visit before November 2020. As for organ damages, the presence or absence of aortic regurgitation (AR), hypertension, ischemic heart disease, cerebrovascular event, visual loss, end-stage renal failure, and inflammatory bowel disease were evaluated. Treatment profiles including immunosuppressive drugs and vascular interventions were also reviewed.

Results:

The incidence of AR was positively associated with the risk allele of IL12B rs6871626 (p=0.0052; odds ratio (OR) 2.45, 95% confidence interval (CI) 1.27-4.73), and so was the proportion of patients who underwent aortic valve replacement (p=0.023; OR 3.64, 95% CI 1.08-12.24) (table 1). The incidence of hypertension was associated with the risk allele of IL12B rs6871626 (p=0.049; OR 1.82, 95% CI 0.99-3.36) and PTK2B rs2322599 (p=0.044; OR 2.52, 95% CI 0.97-6.54) (table 1). The proportion of biologic users tended to be higher in the risk genotypes of IL12B rs6871626 (p=0.15; OR1.80, 95% CI 0.79-3.99). Regarding vascular damage, there was positive correlation between TADS and the risk allele of IL12B rs6871626 (p=0.0035; β= 1.35) (Figure 1). Moreover, VDI was also positively correlated with the allele (p=0.0054; β= 0.96) (Figure 1). No other clinicogenetic associations were observed between five SNPs and vasculitis-associated damages.

Table 1.

The association of the five SNPs with aortic regurgitation and hypertension

Aortic regurgitationHypertensionOR (95% CI)p valueOR (95% CI)p valueIL12B rs68716262.45 (1.27-4.73)0.0052*1.82 (0.99-3.36)0.049*PTK2B rs23225991.21 (0.51-2.86)0.672.51 (0.97-6.54)0.044*LILRA3 rs1032941.16 (0.52-2.61)0.711.20 (0.55-1.64)0.64DUSP22 rs171336980.56 (0.28-1.13)0.0900.87 (0.46-1.63)0.66KLHL33 rs17134500.89 (0.42-1.91)0.771.48 (0.68-3.22)0.31

SNP, single nucleotide polymorphism; OR, odds ratio; CI, confidence interval

Conclusion:

In the present study, IL12B rs6871626 was closely correlated with vascular damage. We also found association between PTK2B rs2322599 and hypertension. There was no significant relevance between vascular damage and LILRA3 rs103294, DUSP22 rs17133698, or KLHL33 rs1713450.

References:

[1]Terao C et al. Am J Hum Genet. 2013;93(2):289-97.

[2]Terao C et al. Proc Natl Acad Sci U S A. 2018;115(51):13045-50.

Disclosure of Interests:

Keiichiro Kadoba: None declared, Ryu Watanabe Speakers bureau: I have received speaker’s fee from Mitsubishi Tanabe Pharma, Pfizer, Sanofi, AbbVie, Asahi Kasei, Eisai, Eli Lilly, Bristol-Myers Squibb, and Janssen., Takeshi Iwasaki: None declared, Koji Kitagori Grant/research support from: KK has received research grants from GlaxoSmithKline., Syuji Akizuki: None declared, Kosaku Murakami Speakers bureau: I have received speaking fees from Eisai Co. Ltd, Chugai Pharmaceutical Co. Ltd., Pfizer Inc., Bristol-Myers Squibb, Mitsubishi Tanabe Pharma Corporation, UCB Japan Co. Ltd, Daiichi Sankyo Co. Ltd. and Astellas Pharma Inc., Ran Nakashima: None declared, Motomu Hashimoto Speakers bureau: I have received a research grant and/or speaker fee from Bristol-Myers, Eisai, Ely Lilly, Mitsubishi Tanabe Pharma., Grant/research support from: I have received a research grant and/or speaker fee from Bristol-Myers, Eisai, Ely Lilly, Mitsubishi Tanabe Pharma., Masao Tanaka Speakers bureau: I have received research grants and/or speaker fees from AbbVie GK, Asahi Kasei Pharma Corporation, Astellas Pharma Inc., Bristol-Myers Squibb, Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly and Company, Pfizer Inc., UCB Japan Co., Ltd., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Corporation, Novartis Pharma K.K., Taisho Pharma Co., Ltd, and Takeda Pharmaceutical Company Limited., Koichiro Ohmura Speakers bureau: I have received speaker’s fee from Abbvie, Actelion, Asahikasei Pharma, Astellas, AYUMI, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, GSK, Janssen, JB, Mitsubishi Tanabe, Nippon Kayaku, Nippon Shinyaku, Novartis, Sanofi and Takeda., Grant/research support from: I have received research grants from GlaxoSmithKline., Akio Morinobu Speakers bureau: I have received speaking fees from Chugai Pharmaceutical Co. Ltd., Grant/research support from: I have received research grants from Chugai Pharmaceutical Co. Ltd., Chikashi Terao: None declared, Hajime Yoshifuji Speakers bureau: I have received lecture fees from Chugai., Consultant of: I have been an advisory board for a clinical trial conducted by Janssen.

POS1482-HPR PAIN CATASTROPHIZING IS ASSOCIATED WITH RESIDUAL PAIN AFTER REACHING IMPROVED CONDITIONS OF SWOLLEN/TENDER JOINTS AND SERUM C-REACTIVE PROTEIN LEVEL

Background:

It has long been recognized that immune-mediated inflammatory diseases, such as rheumatoid arthritis (RA), are prone to coexist with depression due to the effects of cytokines, and that these two illnesses lead to an elevation in patients’ pain. However, we often encounter patients with RA who suffer from residual pain despite an improvement in disease activity and inflammation. The specific psychological factors associated with residual pain have not yet been clarified. In addition to the traditional psychological factors, such as depression and anxiety, we focused on pain catastrophizing due to the distortion of pain perception and explored its association with residual pain.

Objectives:

To examine whether psychological factors, such as pain catastrophizing, depression, and anxiety, are associated with self-reported pain visual analogue scale (pain-VAS) scores in RA patients with 1 or less on 28joints- swollen/tender counts (SJC/TJC) and CRP.

Methods:

This was a cross-sectional study of 290 RA outpatients (85% of whom were women) with scores of less than 1 on SJC, TJC, and CRP, with a median (IQR) age of 66 (57–73) years. The participants completed questionnaires, including pain VAS (0–100 mm), Pain Catastrophizing Scale (PCS, 0–52 scale), and Hospital Depression and Anxiety Scale (HADS, 0–42 scale). Using linear regression analyses, we analysed whether PC (PCS ≥30), depression (HADS-D ≥11), and anxiety (HADS-A ≥11) (independent variables) were associated with pain VAS scores (dependent variable). After univariate regression analysis, multivariate analysis adjusted for confounding factors was performed.

Results:

Patients reported a wide range of pain severity with a median (range) pain VAS score of 9 (0–96mm). The prevalence of anxiety and depression were 5.5% and 5.9%, respectively. Meanwhile, 24.1% of the patients experienced pain catastrophizing. Pain catastrophizing was associated with pain VAS scores in univariate and multivariate analyses (Table 1). The presence of anxiety and depression was not associated with pain VAS scores in any model. Multivariate analysis of other covariates showed that age, disease duration, and presence of SJC/TJC of joints other than the 28 joints were positively correlated with pain VAS scores.

Table 1.

Univariate and multivariate regression analysis for independent variables associated with pain-VAS scores

UnivariateMultivariate independent variablesModel 1*Model 2**Pain catastrophizingEstimate3.74.13.695%CI 0.7 to 6.61.1 to 7.00.5 to 6.6p-value0.0150.0060.021AnxietyEstimate3.74.40.595%CI -1.9 to 9.2 -1.0 to 9.9 -3.5 to 7.9p value0.1980.1080.453DepressionEstimate3.54.23.995%CI -1.9 to 8.9 -1.1 to 9.5 -1.9 to 8.7p-value0.2040.1190.210

The covariates in multivariate analysis are as follows: age, sex, body mass index, disease duration, Steinbrocker’s Stage, prednisolone dosage, biologic agents use, and presence of swollen joint counts/tender joint counts of joints other than the 28 joints.

*Model 1: each psychological independent variable and the above covariates.

**Model 2: all psychological independent variables and the above covariates.

Conclusion:

Pain catastrophizing was associated with pain VAS scores in RA patients with 1 or less on 28joints-SJC/TJC and CRP, emphasising that residual pain in the patients should be treated in a biopsychosocial framework focussing on pain catastrophizing.

Disclosure of Interests:

Tamami Yoshida: None declared, Motomu Hashimoto Speakers bureau: Mitsubishi Tanabe Pharma Corporation; Bristol-Myers Squibb; Eisai Co., Ltd.; and Eli Lilly and Company., Grant/research support from: Mitsubishi Tanabe Pharma Corporation; Bristol-Myers Squibb; Eisai Co., Ltd.; and Eli Lilly and Company., Kosaku Murakami Speakers bureau: Eisai Co., Ltd.; Chugai Pharmaceutical Co., Ltd.; Pfizer Inc.; Bristol-Myers Squibb; Mitsubishi Tanabe Pharma Co; UCB Japan Co., Ltd.; Daiichi Sankyo Co., Ltd.; and Astellas Pharma Inc., Consultant of: Eisai Co., Ltd.; Chugai Pharmaceutical Co., Ltd.; Pfizer Inc.; Bristol-Myers Squibb; Mitsubishi Tanabe Pharma Co; UCB Japan Co., Ltd.; Daiichi Sankyo Co., Ltd.; and Astellas Pharma Inc., Koichi Murata Speakers bureau: Eisai Co., Ltd. and Astellas Pharma Inc., Consultant of: Eisai Co., Ltd. and Astellas Pharma Inc., Kohei Nishitani Grant/research support from: Asahi-Kasei Pharma., Ryu Watanabe Speakers bureau: Mitsubishi Tanabe Pharma Co; Pfizer Inc.; Sanofi S.A.; AbbVie GK; Asahi Kasei Pharma; Eisai Co., Ltd.; Eli Lilly and Company; Bristol-Myers Squibb; and Janssen Pharmaceutical K.K., Teruhide Koyama: None declared, Ritei Uehara: None declared, Masao Tanaka Speakers bureau: AbbVie GK, Asahi Kasei Pharma., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Novartis Pharma K.K., Pfizer Inc., Taisyo Pharma., Ltd., UCB Japan Co., Ltd., Grant/research support from: AbbVie GK, Asahi Kasei Pharma., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Novartis Pharma K.K., Pfizer Inc., Taisyo Pharma., Ltd., UCB Japan Co., Ltd., Hiromu Ito Grant/research support from: Bristol-Myers Squibb, Eisai Co, Taisyo Pharma., and Mochida., Shuichi Matsuda: None declared

POS0544 INFLUENCE OF EATING HABITS ON FRAILTY AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: KURAMA COHORT

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that contributes to accelerating frailty, a clinical state of increased vulnerability due to declined physiological function. Although accumulating evidence suggests the importance of nutritional therapy for frailty in the general population, there is little evidence on dietary recommendations for preventing frailty in patients with RA.

Objectives:

The present study aimed to reveal clinical associations between frailty status, eating habits and RA disease activity.

Methods:

We conducted a cross-sectional study of 306 female outpatients enrolled from the KURAMA (Kyoto University Rheumatoid Arthritis Management Alliance) cohort database. The participants were classified into three groups (robust, prefrail and frail) according to simplified frailty scale (SOF index), and dietary data were collected using a self-reported food frequency questionnaire as previously reported. We performed multivariate logistic analyses for the presence of frailty/prefrailty with or without eating habits.

Results:

Frail group showed physical decline such as decreased skeletal muscle index, hand grip strength and walking speed, and DAS28-ESR in the frail group was significantly higher compared to that in the others. In multivariate logistic analysis, the presence of frailty/prefrailty was correlated with DAS28-ESR (OR 1.71, p=0.00004) and methotrexate use (OR 0.47, p=0.0097). Cochran-Armitage trend test also showed that the intake frequency of five ingredients (meat, fish, milk, fruits and vegetables) was inversely associated with the prevalence of frailty/prefrailty. In additional multivariate logistic analyses with dietary habits, habitual intake of fish (at least three times per week), rather than meat or other foods, was independently correlated with the presence of frailty/prefrailty (OR 0.33, p=0.00027).

Conclusion:

Our results suggest that habitual intake of fish, rather than meat or other foods, may be beneficial in preventing frailty among RA patients.

References:

[1]Ferrucci, L. & Fabbri, E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol 15, 505-522, doi:10.1038/s41569-018-0064-2 (2018).

[2]Hernandez Morante, J. J., Gomez Martinez, C. & Morillas-Ruiz, J. M. Dietary factors associated with frailty in old adults: a review of nutritional interventions to prevent frailty development. Nutrients 11, doi:10.3390/nu11010102 (2019).

Table 1.

Multivariate logistic analysis for RA patients with prefrailty or frailty

variables including eating habitsFish + MeatAllOR (95% CI)P valueOR (95% CI)P valueDAS28-ESR1.78 (1.34 - 2.37)0.000031.73 (1.30 - 2.30)0.00009MTX use0.43 (0.23 - 0.79)0.00550.42 (0.23 - 0.78)0.0050Age (1 year)1.02 (1.00 - 1.05)0.0371.03 (1.01 - 1.06)0.0015PSL use1.23 (0.69 - 2.21)0.491.22 (0.67 - 2.20)0.51Duration of RA (1 year)1.00 (0.98 - 1.02)0.721.00 (0.98 - 1.02)0.84Body mass index1.00 (0.93 - 1.07)0.980.99 (0.92 - 1.07)0.85Biological agents use1.02 (0.60 - 1.72)0.941.04 (0.62 - 1.77)0.87Fish dish0.31 (0.17 - 0.55)0.000040.33 (0.18 - 0.61)0.00027Meat dish0.86 (0.49 - 1.50)0.600.89 (0.51 - 1.57)0.69Milk0.71 (0.41 - 1.24)0.23Vegetable0.95 (0.47 - 1.93)0.89Fruits0.77 (0.41 - 1.42)0.40Figure 1.

The prevalence of prefrailty or frailty for subjects by intake frequency

Acknowledgements:

We thank S. Nakagawa and M. Iida for technical assistance.

Disclosure of Interests:

Masao Katsushima: None declared, Hiroto Minamino: None declared, Mie Torii: None declared, Motomu Hashimoto Speakers bureau: M.H. receives grants and/or speaker fees from Bristol-Meyers, Eisai, Eli Lilly, and Tanabe Mitsubishi., Grant/research support from: M.H. belongs to the department financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Wataru Yamamoto: None declared, Ryu Watanabe Grant/research support from: R.W. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei). KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Kosaku Murakami: None declared, Koichi Murata Grant/research support from: K.M. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Masao Tanaka Grant/research support from: M.T. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei).

KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Hiromu Ito Speakers bureau: H.I. receives a research grant and/or speaker fee from Bristol-Myers, Eisai, Mochida, Taisho, and Asahi-Kasei., Grant/research support from: H.I. belongs to the department that is financially supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Tanabe-Mitsubishi, Chugai, UCB Japan, Ayumi and Asahi-Kasei). KURAMA cohort study is supported by a grant from Daiichi Sankyo Co. Ltd., Akio Morinobu Speakers bureau: A.M. has received speaking fees and/or research grants from Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma and Chugai Pharmaceutical Co. Ltd., Grant/research support from: A.M. has received speaking fees and/or research grants from Eli Lilly Japan K.K., Ono Pharmaceutical Co., Pfizer Inc., UCB Japan, AbbVie G.K., Asahi Kasei Pharma and Chugai Pharmaceutical Co. Ltd.

The Ferric Citrate Uptake System Encoded in a Novel bla CTX-M-3- and bla TEM-1-Harboring Conjugative Plasmid Contributes to the Virulence of Escherichia coli

Escherichia coli is one major cause of bacterial infections and can horizontally acquire antimicrobial resistance and virulence genes through conjugation. Because conjugative plasmids can rapidly spread among bacteria of different species, the plasmids carrying both antimicrobial resistance and virulence genes may pose a significant threat to public health. Therefore, the identification and characterization of these plasmids may facilitate a better understanding of E. coli pathogenesis and the development of new strategies against E. coli infections. Because iron uptake ability is a potential virulence trait of bacteria, we screened for E. coli conjugative plasmids able to confer both iron uptake ability and ampicillin resistance. The plasmid pEC41, which was derived from the bacteremia clinical isolate EC41, was identified. EC41, which carried the fimH27 allele, belonged to sequence type (ST) 405 and phylogroup D. According to the sequencing analyses, pEC41 was 86 kb in size, and its backbone structure was almost identical to that of another highly conjugative plasmid, pCTX-M3, in which the extended-spectrum β-lactamase gene bla_CTX–M–3 was originally identified. pEC41 carried bla_CTX–M–3 and bla_TEM–1. The ferric citrate uptake (fec) system was identified in pEC41 and was responsible for conferring iron uptake ability. The fec system contributes to the pathogenesis of EC41 in systemic infections but not in urinary tract infections (UTIs). However, this system promoted competitive fitness of a cystitis-associated clinical isolate to colonize urinary tracts. Additionally, the distribution of the fec system was related to E. coli isolates associated with human bacteremia and UTIs. In summary, the present study identified a novel conjugative plasmid, pEC41, which conferred both antimicrobial resistance and an extra iron uptake ability to E. coli. The iron uptake ability was encoded in the fec system and contributed to E. coli pathogenesis. This study is the first to show that the fec system is a virulence factor in E. coli.

Observation of topological superconductivity in a stoichiometric transition metal dichalcogenide 2M-WS2

Topological superconductors (TSCs) are unconventional superconductors with bulk superconducting gap and in-gap Majorana states on the boundary that may be used as topological qubits for quantum computation. Despite their importance in both fundamental research and applications, natural TSCs are very rare. Here, combining state of the art synchrotron and laser-based angle-resolved photoemission spectroscopy, we investigated a stoichiometric transition metal dichalcogenide (TMD), 2M-WS₂ with a superconducting transition temperature of 8.8 K (the highest among all TMDs in the natural form up to date) and observed distinctive topological surface states (TSSs). Furthermore, in the superconducting state, we found that the TSSs acquired a nodeless superconducting gap with similar magnitude as that of the bulk states. These discoveries not only evidence 2M-WS₂ as an intrinsic TSC without the need of sensitive composition tuning or sophisticated heterostructures fabrication, but also provide an ideal platform for device applications thanks to its van der Waals layered structure.

Efficacy and safety of immune checkpoint inhibitors in patients with non-small cell lung cancer aged 80 years or older

BACKGROUND

In Japan, over 25% of the population is elderly. As the risk of lung cancer increases with age, the number of elderly patients with lung cancer also increases. Given the challenges of an aging society, it is critical that elderly patients receive safe therapies.

AIM

We assessed the safety and efficacy of immune checkpoint inhibitors (ICIs) in patients with non-small cell lung cancer (NSCLC) aged ≥80 years.

METHODS

We retrospectively reviewed NSCLC patients aged ≥80 years old who received ICIs in the National Hospital Organization Kyoto Medical Center. We collected data on patient characteristics, prior treatments, number of cycles, response, and immune-related adverse events (irAEs) during ICI monotherapy.

RESULTS

A total of 45 patients were reviewed. The patients' median age was 85 years. Twenty-one, 17, and 7 patients received nivolumab, pembrolizumab, and atezolizumab, respectively. The disease control rate (partial response [PR] + stable disease [SD]) was 60.0%, and the progression-free survival was 3.4 months. In patients with nivolumab, seven patients (33.3%) achieved SD, and three patients (14.2%) achieved PR. In patients treated with pembrolizumab, seven patients (41.2%) achieved SD, and six patients (35.3%) achieved PR. In patients with atezolizumab, three patients (42.9%) achieved SD, and one patient (14.2%) achieved PR. Sixteen (36%) patients presented with a poor performance status. Three patients treated with pembrolizumab experienced grade 3 pneumonia, while one patient treated with nivolumab experienced grade 5 pneumonia.

CONCLUSION

This study suggested that ICIs are an acceptable treatment option for NSCLC patients aged ≥80 years. Oncologists should pay attention to severe irAEs.

Usability of the lateral decubitus position on four-dimensional ultra-low-dose computed tomography for the detection of localized pleural adhesion in the pulmonary apical region

BACKGROUND

Localized pleural adhesion (LPA) evaluation in the apical region is difficult even with four-dimensional ultra-low-dose computed tomography (4D-ULDCT) in the supine position due to smaller pleural movements.

PURPOSE

To assess usability of 4D-ULDCT in the lateral decubitus (LD) position for LPA detection in the apical region.

MATERIAL AND METHODS

Forty-seven patients underwent 4D-ULDCT of a single respiration cycle with 16-cm coverage of body axis in supine and LD positions with the affected lung uppermost. Intraoperative thoracoscopic findings confirmed LPA presence. A pleural point and a corresponding point on costal outer edge were placed in identical axial planes at end-inspiration. Pleuro-chest wall distance between two points (PCD) was calculated at each respiratory phase. In the affected lung, average change in amount of PCD (PCD_ACA) was compared between patients with and without LPA in total and two sub-groups (non-COPD and COPD, non-emphysematous and emphysematous patients) in supine and non-dependent (ND) LD positions. Receiver operating characteristic (ROC) curve analysis was performed to determine optimal thresholds in PCD_ACA for differentiating patients with LPA from those without.

RESULTS

In COPD/emphysematous patients and total population, PCD_ACA with LPA was smaller than in those without in the supine and NDLD positions for overall, lateral, and dorsal regions. For the lateral region in COPD patients, area under ROC curve (AUC) increased from supine (0.64) to NDLD position (0.81). For the dorsal region in emphysematous patients, AUC increased from supine (0.76) to NDLD position (0.96).

CONCLUSION

4D-ULDCT in LD position may be useful for LPA detection in apical regions for COPD and/or emphysematous patients.

Effect of cyclooxygenase inhibitor use on immunotherapy efficacy in non-small cell lung cancer

BACKGROUND

A synergistic effect of cyclooxygenase inhibitors (COX-I) and immune checkpoint inhibitors (ICIs) has been suggested. However, the impact of COX-I on the efficacy of ICIs is unclear. Here, we aimed to evaluate the relationship between COX-I use and the efficacy of ICI in patients with non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed NSCLC patients who received ICI monotherapy. We defined COX-I use as regular use of COX-I other than low-dose aspirin during the initiation of ICIs to the first evaluation of efficacy. The efficacy of ICIs was evaluated with response rate (RR), disease control rate (DCR), progression free survival (PFS), and overall survival (OS). Differences in baseline characteristics by COX-I use were controlled by using an inverse probability of treatment weighting (IPW) adjusted analysis.

RESULTS

A total of 198 patients with NSCLC received ICIs; 128, 50, and 20 patients received nivolumab, pembrolizumab, and atezolizumab, respectively; there were 65 (32.8%) COX-I users. While there was no significant difference in RR (15.4% vs. 13.5%; p = 0.828), DCR (41.5% vs. 49.6%; p = 0.294), PFS (median, 2.69 vs. 3.68 months; 95% confidence intervals [CI], 1.77-5.19 vs. 2.20-4.60 months; p = 0.630), COX-I users had significantly shorter OS than non-COX-I users (median, 6.08 vs. 16.10 months; 95% CI: 3.78-11.66 vs. 9.49-19.68 months; p = 0.003). On IPW adjusted analysis, there was no significant difference in OS (median, 7.85 vs. 15.11 months; 95% CI: 5.03-14.92 vs. 9.49-19.32 months; p = 0.081).

CONCLUSIONS

There was no additional or negative impact of COX-I use on the efficacy of ICIs in NSCLC.

Iron Acquisition of Urinary Tract Infection Escherichia coli Involves Pathogenicity in Caenorhabditis elegans

Uropathogenic Escherichia coli (UPEC) is a major bacterial pathogen that causes urinary tract infections (UTIs). The mouse is an available UTI model for studying the pathogenicity; however, Caenorhabditis elegans represents as an alternative surrogate host with the capacity for high-throughput analysis. Then, we established a simple assay for a UPEC infection model with C. elegans for large-scale screening. A total of 133 clinically isolated E. coli strains, which included UTI-associated and fecal isolates, were applied to demonstrate the simple pathogenicity assay. From the screening, several virulence factors (VFs) involved with iron acquisition (chuA, fyuA, and irp2) were significantly associated with high pathogenicity. We then evaluated whether the VFs in UPEC were involved in the pathogenicity. Mutants of E. coli UTI89 with defective iron acquisition systems were applied to a solid killing assay with C. elegans. As a result, the survival rate of C. elegans fed with the mutants significantly increased compared to when fed with the parent strain. The results demonstrated, the simple assay with C. elegans was useful as a UPEC infectious model. To our knowledge, this is the first report of the involvement of iron acquisition in the pathogenicity of UPEC in a C. elegans model.

Peptidoglycan Endopeptidase Spr of Uropathogenic Escherichia coli Contributes to Kidney Infections and Competitive Fitness During Bladder Colonization

Uropathogenic Escherichia coli (UPEC) is the most common pathogen of urinary tract infections (UTIs). Antibiotic therapy is the conventional measure to manage such infections. However, the rapid emergence of antibiotic resistance has reduced the efficacy of antibiotic treatment. Given that the bacterial factors required for the full virulence of the pathogens are potential therapeutic targets, identifying such factors may facilitate the development of novel therapeutic strategies against UPEC UTIs. The peptidoglycan (PG) endopeptidase Spr (also named MepS) is required for PG biogenesis in E. coli. In the present study, we found that Spr deficiency attenuated the ability of UPEC to infect kidneys and induced a fitness defect during bladder colonization in a mouse model of UTI. Based on the liquid chromatography (LC)/mass spectrometry (MS)/MS analysis of the bacterial envelope, spr deletion changed the levels of some envelope-associated proteins, suggesting that Spr deficiency interfere with the components of the bacterial structure. Among the proteins, FliC was significantly downregulated in the spr mutant, which is resulted in reduced motility. Lack of Spr might hinder the function of the flagellar transcriptional factor FlhDC to decrease FliC expression. The motility downregulation contributed to the reduced fitness in urinary tract colonization. Additionally, spr deletion compromised the ability of UPEC to evade complement-mediated attack and to resist intracellular killing of phagocytes, consequently decreasing UPEC bloodstream survival. Spr deficiency also interfered with the UPEC morphological switch from bacillary to filamentous shapes during UTI. It is known that bacterial filamentation protects UPEC from phagocytosis by phagocytes. In conclusion, Spr deficiency was shown to compromise multiple virulence properties of UPEC, leading to attenuation of the pathogen in urinary tract colonization and bloodstream survival. These findings indicate that Spr is a potential antimicrobial target for further studies attempting to develop novel strategies in managing UPEC UTIs.

[The Early Removal of the Implant after Nuss Procedure Due to the Infection in Case of Pectus Excavatum with Atopic Dermatitis]

Nuss procedure for pediatric patients with pectus excavatum has been practiced worldwide, including in Japan, due to the simple procedure and has a high therapeutic effect. Because it is usually performed under thoracoscopy to secure the safety, it is performed not only by pediatric or plastic surgeons but also by general thoracic surgeons. On the other hand, a risk of infection must always be considered in this method in which a foreign metal bar is used. In particular, when the skin barrier mechanism is declining due to skin diseases such as atopic dermatitis, the risk of infection of the implant may increase. The present case was an 8-year-old male with a history of atopic dermatitis. He underwent thoracoscopic Nuss procedure. Although there was no problem during his hospitalization, the bar was exposed from the skin on the 58th postoperative day with the infection triggered, and the unexpected early bar removal was performed on the 66th postoperative day. We report this case with some literature review.

Preoperative assessment of localized pleural adhesion: Utility of software-assisted analysis on dynamic-ventilation computed tomography

PURPOSE

To assess the usefulness of software analysis using dynamic-ventilation CT for localized pleural adhesion (LPA).

MATERIALS AND METHODS

Fifty-one patients scheduled to undergo surgery underwent both dynamic-ventilation CT and static chest CT as preoperative assessments. Five observers independently evaluated the presence and severity of LPA on a three-point scale (non, mild, and severe LPA) for 9 pleural regions (upper, middle, and lower pleural aspects on ventral, lateral, and dorsal areas) on the chest CT by three different methods by observing images from: static high-resolution CT (static image); dynamic-ventilation CT (movie image), and dynamic-ventilation CT while referring to the adhesion map (movie image with color map), which was created using research software to visualize movement differences between the lung surface and chest wall. The presence and severity of LPA was confirmed by intraoperative thoracoscopic findings. Parameters of diagnostic accuracy for LPA presence and severity were assessed among the three methods using Wilcoxon signed rank test in total and for each of the three pleural aspects.

RESULTS

Mild and severe LPA were confirmed in 14 and 8 patients. Movie image with color map had higher sensitivity (56.9 ± 10.7 %) and negative predictive value (NPV) (91.4 ± 1.7 %) in LPA detection than both movie image and static image. Additionally, for severe LPA, detection sensitivity was the highest with movie image with color map (82.5 ± 6.1 %), followed by movie image (58.8 ± 17.0 %) and static image (38.8 ± 13.9 %). For LPA severity, movie image with color map was similar to movie image and superior to static image in accuracy as well as underestimation and overestimation, with a mean value of 80.2 %.

CONCLUSION

Software-assisted dynamic-ventilation CT may be a useful novel imaging approach to improve the detection performance of LPA.

Single-center analysis of antiresorptive agent-related osteonecrosis of the jaw in lung cancer patients

BACKGROUND

Over the past two decades, antiresorptive agent-related osteonecrosis of the jaw (ARONJ) has become a growing concern. We examined the incidence of ARONJ and identified its risk factors in lung cancer patients in the real-world clinical setting. To our knowledge, we are the first to do so.

PATIENTS AND METHODS

We retrospectively analyzed lung cancer patients with bone metastases who had received anti-resorptive agents (zoledronate or denosumab) at the National Hospital Organization Kyoto Medical Center from October 2012 to September 2018. All ARONJ cases were diagnosed by the dentists according to the established diagnostic criteria.

RESULTS

A total of 171 patients were reviewed, 13 (7.6%) of whom experienced ARONJ. Among the 13 patients, six (46.2%), four (30.8%) and three (23.1%) had adenocarcinoma, squamous carcinoma and not otherwise specified, respectively. ARONJ was stage 2 in three (23.1%) patients and stage 3 in 10 (76.9%). More cycles of antiresorptive agents (odds ratio [OR] = 11.54; 95% confidence interval [CI], 2.47-53.99; P < 0.01), use of immune checkpoint inhibitors (ICIs; OR = 5.05; 95% CI, 1.56-16.37; P < 0.01) and longer survival duration (≥2 years; OR = 12.16; 95% CI, 3.17-46.65; P < 0.01) were independently associated with ARONJ in a multivariate analysis.

CONCLUSIONS

The incidence of ARONJ was relatively high in lung cancer patients with bone metastases. When using antiresorptive agents, oncologists should closely monitor patients for ARONJ during the course of treatment and regularly consult with dentists, especially in patients receiving ICIs.

Identification of MltG as a Prc Protease Substrate Whose Dysregulation Contributes to the Conditional Growth Defect of Prc-Deficient Escherichia coli

Microbial proteases play pivotal roles in many aspects of bacterial physiological processes. Because a protease exerts its biological function by proteolytically regulating its substrates, the identification and characterization of the physiological substrates of a protease advance our understanding of the biological roles of the protease. Prc (also named Tsp) is an Escherichia coli periplasmic protease thought to be indispensable for E. coli to survive under low osmolality at 42°C. The accumulation of the Prc substrate MepS due to Prc deficiency contributes to the conditional growth defect. Because preventing MepS accumulation only partially restored the growth of Prc-deficient E. coli, we hypothesized that other unidentified Prc substrates intracellularly accumulate due to Prc deficiency and contribute to the conditional growth defect. To identify previously undiscovered substrates, 85 E. coli proteins able to physically interact with Prc were identified using E. coli proteome arrays. Ten proteins were shown to be cleavable by Prc in vitro. Among these candidates, MltG was able to interact with Prc in E. coli. Prc regulated the intracellular level of MltG, indicating that MltG is a physiological substrate of Prc. Prc deficiency induced the accumulation of MltG in the bacteria. Blocking MltG accumulation by deleting mltG partially restored the growth of Prc-deficient E. coli. In addition, Prc-deficient E. coli with blocked MltG and MepS expression exhibited higher growth levels than those with only the MltG or MepS expression blocked under low osmolality at 42°C, suggesting that these accumulated substrates additively contributed to the conditional growth defect. MltG is a lytic transglycosylase involved in the biogenesis of peptidoglycan (PG). In addition to MltG, the previously identified physiological Prc substrates MepS and PBP3 are involved in PG biogenesis, suggesting a potential role of Prc in regulating PG biogenesis.

cjrABC-senB hinders survival of extraintestinal pathogenic E. coli in the bloodstream through triggering complement-mediated killing

BACKGROUND

Extraintestinal pathogenic E. coli (ExPEC) is a common gram-negative organism causing various infections, including urinary tract infections (UTIs), bacteremia, and neonatal meningitis. The cjrABC-senB gene cluster of E. coli contributes to ExPEC virulence in the mouse model of UTIs. Consistently, the distribution of cjrABC-senB is epidemiologically associated with human UTIs caused by E. coli. cjrABC-senB, which has previously been proposed to encode an iron uptake system, may facilitate ExPEC survival in the iron availability-restricted urinary tract. Given that the bloodstream is also an iron limited environment to invading bacteria, the pathogenic role of cjrABC-senB in ExPEC bacteremia, however, remains to be investigated.

METHODS

The ability of ExPEC RS218 strains with and without cjrABC-senB to survive in the mouse bloodstream and human serum was evaluated. Subsequently, the role of this gene cluster in the ExPEC interaction with the complement system was evaluated. Finally, the distribution of cjrABC-senB in human clinical E. coli isolates was determined by PCR. The frequency of cjrABC-senB in bacteremia isolates that were not associated with UTIs (non-UTI bacteremia isolates) was compared with that in UTI-associated isolates and fecal isolates.

RESULTS

Expression of cjrABC-senB attenuated the survival of RS218 in the mouse bloodstream and human serum. The cjrABC-senB-harboring strains triggered enhanced classical- and alternative-complement pathway activation and became more vulnerable to complement-mediated killing in serum. cjrA was identified as the major gene responsible for the attenuated serum survival. Expressing cjrABC-senB and cjrA increased bacterial susceptibility to detergent and induced periplasmic protein leakage, suggesting that the expression of these genes compromises the integrity of the outer membrane of ExPEC. In addition, the frequency of cjrABC-senB in non-UTI bacteremia isolates was significantly lower than that in UTI-associated isolates, while the frequencies in non-UTI bacteremia isolates and fecal isolates showed no significant difference. Consistently, this epidemiological investigation suggests that cjrABC-senB does not contribute to E. coli bacteremia in humans.

CONCLUSION

The contribution of cjrABC-senB to the pathogenesis of ExPEC is niche dependent and contradictory because the genes facilitate ExPEC UTIs but hinder bacteremia. The contradictory niche-dependent characteristic may benefit the development of novel strategies against E. coli-caused infections.

Enhanced and Prolonged Activity of Enzymes Adsorbed on TEMPO-Oxidized Cellulose Nanofibers

2,2,6,6-Tetramethylpiperidine-1-oxyl (TEMPO)-oxidized cellulose nanofibers (TOCNs) have a width of about 4 nm and a very large specific surface area. TOCN is a negatively charged bionanomaterial having carboxy groups on the surface and promising physical properties. In particular, TOCN can be used as an adsorbent for biomolecules for biotechnological applications, but the adsorption behavior of biomolecules on the TOCN surface requires investigation. Thus, in this study, we investigated the adsorption behavior of pyrroloquinoline quinone-dependent glucose dehydrogenase (PQQ-GDH) on TOCN and evaluated the activity, structure, and long-term stability of the adsorbed enzyme. Transmission electron microscopy observation revealed that the enzyme was aligned and adsorbed on the TOCNs, and circular dichroism measurements were used to determine the structure of the enzyme adsorbed on TOCN. Interestingly, the adsorbed enzyme showed higher activity after adsorption, resulting in long-term retention of enzyme activity, probably because the stability of PQQ-GDH was improved by adsorption. These results suggest that TOCN is an excellent biomolecule immobilization material. Our results can be used for the development of biomaterials using TOCN as a scaffold for the adsorption of enzymes with increased stability and activity.