P827EXPLORE-J: Lipid management and 2-year long-term clinical outcome in Japanese patients with acute coronary syndrome

Background

The cardiovascular event rate in Japan is much lower than that in Western countries. However, the incidence of atherosclerotic CV disease and its burden are expected to increase in the Japanese society with rapid aging, westernization of lifestyles and metabolic derangement. An increase in patients with CAD has been remarkable in spite of various preventive measures. The positive linear correlation of LDL-C level with CAD incidence along with LDL-C lowering and CAD event reduction is established by large-scale studies in Western countries, but data in Japan are limited. EXPLORE-J, observational study, was conducted to gain insights into the relationship between LDL-C management and CV events in the Japanese ACS patients.

Purpose

The primary objective was to evaluate the status of post-ACS lipid management and CV events in Japan.

Method

ACS patients aged ≥20 years were enrolled and followed up for 2 years. The primary endpoint was the incidence proportion of major adverse cardiovascular events (MACE), including CV death (death associated with MI/stroke and other CV deaths), non-fatal ACS/stroke requiring hospitalization during the observation period. Other endpoints were medications and metabolic parameters. Additional stratified analyses of MACE incidence proportions by median LDL-C reduction category (above/below absolute or % reduction) from the first measurement after ACS to V1 (Day 1 + 14 days) was also conducted.

Result

Of the 2016 registered patients, 1944 were analyzed. The mean age and BMI were 66.0 years and 24.2 kg/m2, respectively. At 2-year follow up, the cumulative incidence proportion of MACE was 6.8%. The cumulative incidence proportions of CV death, non-fatal ACS and stroke were 0.7%, 4.5% and 1.7%, respectively. Statin, intensive statin, and ezetimibe were prescribed, respectively, to 93.6%, 8.2%, and 3.9% at V1, and 92.3%, 10.5%, and 11.6% at V5 (Day 730±30 days).

The mean LDL-C levels were 121.2, 99.4, 80.9, and 79.8 mg/dL at the first measurement after ACS, V1, V2 (Day 30±7 days) and V5, respectively. The proportions of patients who achieved LDL-C <70 and <100 mg/dL at V1 and V5 were 14.4% to 34.6% and 56.5% to 82.8%, respectively. The incidence rate of MACE was lower among patients with larger than median absolute reduction in LDL-C level than among those with smaller reduction (median −17.0 mg/dL; 5.5% vs 8.3%, p=0.0435). The same trend was observed in patients with higher LDL-C reduction rate (median −15.36%; 6.3% vs 7.6%, p=0.4302).

Kaplan-Meier estimates of MACE incidence

Conclusion

The results show the status of medical management and CV event rates in post-ACS Japanese patients. It also shows that half of the ACS patients did not achieve the recommended LDL-C levels of <70 mg/dL per guidelines, indicating the need to intensify lipid lowering therapy. To further characterize and quantify the patient population and the benefit of lipid management, we plan to conduct additional analyses with risk stratification of the population.

Acknowledgement/Funding

This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.

Treatment of twin-reversed arterial perfusion sequence using high-intensity focused ultrasound

We describe our experience of high-intensity focused ultrasound (HIFU) for fetal therapy in twin-reversed arterial perfusion (TRAP) sequence. Six pregnant women underwent HIFU therapy, five before 16 weeks and one at 26 weeks. Two types of HIFU system were used: the first-generation system, which comprised a biaxial transducer and continuous exposure pattern, and the second-generation system, which comprised a coaxial transducer and sequential exposure pattern. The first-generation apparatus was used in four cases and the second-generation apparatus was used in two. In three cases, occlusion of the blood vessels mediating flow to the acardiac twin was achieved by HIFU. Two cases experienced intrauterine fetal death despite vessel occlusion. The total survival rate of pump fetuses 2 years after HIFU was 67% and the efficiency rate (the proportion of cases with occlusion or reduced blood flow on ultrasound after HIFU) was 83%. After more than 2 years of follow-up, the surviving infants had no severe clinical complications and no postnatal developmental problems. There was no significant difference in survival rate compared with TRAP cases managed expectantly. Given that complete occlusion of the blood vessels was not achieved in half of the cases, we could not show that HIFU therapy is superior to other treatments. However, HIFU can reduce the cardiac load of the pump fetus and, as it does not require uterine puncture for fetal therapy, there were no fatal complications, such as bleeding, rupture of membranes or infection. Thus, HIFU therapy may represent a less-invasive treatment for TRAP sequence in early pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Influence of the trapeziometacarpal joint fusion on thumb muscles and thumb-tip movement: A cadaveric study

BACKGROUND

Trapeziometacarpal (TMC) arthrodesis provides stability and strength of the thumb, whereas fixation of the TMC joint restricts motion of the thumb, which may consequently impair the activity of daily living. The objective of our study was to investigate how length and area of the thumb-tip trajectory were reduced after the TMC joint fusion.

METHODS

Six fresh, frozen cadavers were used for this study. Tension was applied to the distal tendons of 4 extrinsic thumb muscles (extensor pollicis longus, flexor pollicis longus, abductor pollicis longus, and extensor pollicis brevis) by servomotor, whereas tension was applied to 4 intrinsic muscles (abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis) using static weights. The thumb-tip trajectory was examined using a motion capture system without tension and with 5 different weights to induce intrinsic muscle tension before and after the TMC joint fusion.

FINDINGS

When tension was applied to the intrinsic muscles, the length of the thumb-tip trajectory decreased in all conditions compared with that before the TMC joint fusion, whereas the trajectory decreased only when the abductor pollicis longus was pulled. The overall thumb-tip trajectory area was reduced to approximately 30% compared with that before the TMC joint fusion.

INTERPRETATION

Thumb-tip trajectory was restricted by the TMC joint fusion to approximately 30%. However, the reduced area was found tolerable for performing daily activities. Thus, arthrodesis can be the first-line treatment in patients who wish to engage in activities of daily living without difficulties.

Modelling approach to obtain regional respiratory mechanics using electrical impedance tomography and volume-dependent elastance model

OBJECTIVE

This paper presents a method for breath-by-breath estimation of regional respiratory mechanics without the need for special manoeuvres (such as inspiratory pause or low-flow inflation) using electrical impedance tomography (EIT) associated with pressure/airflow waveforms.

APPROACH

We developed a method to estimate regional parameters using the regional impedance fraction, by multiplying it by global flow and volume waveforms. A volume-dependent elastance model was used to obtain compliance, resistance, volume-independent (E ₁), and volume-dependent (E ₂) components. Three swine under invasive mechanical ventilation were used to assess internal consistency and illustrate potential applications of our method. One animal (case 1) was ventilated with a broad range of tidal volumes to compare the consistency between regional and global resistances and compliances. Two other animals (cases 2 and 3) had respiratory compliance decreased, respectively, by overdistension and collapse as quantified by x-ray computed tomography.

MAIN RESULTS

In case 1, derived global estimates obtained from the independent regional estimates were strongly associated with direct measurements of global mechanics (correlation coefficients of 0.9976 and 0.9981 for compliances and resistances, respectively), suggesting consistency of our modelling. In cases 2 and 3, the development of lung overdistension and collapse over time was captured by regional estimates.

CONCLUSIONS

Using EIT and pressure/airflow waveforms, regional respiratory parameters can be obtained cycle-by-cycle, refining lung function monitoring.

SIGNIFICANCE

The method allows real-time monitoring of regional parameters and their trends over time, which might be helpful to differentiate deterioration in lung compliance due to overdistension or collapse.

Reproductive interference by alien hornet Vespa velutina threatens the native populations of Vespa simillima in Japan

The yellow-legged hornet Vespa velutina has become one of the major alien species in European and East Asian countries. As in its homeland, the invading V. velutina is reported as the major predator of honeybees and is becoming a threat to beekeeping in Europe. However, it remains unknown how V. velutina might affect native hornets when it invades Asia, where a large number of Vespa species are distributed. Thus, by analyzing the mitochondrial cytochrome c oxidase subunit I gene, we investigated whether interspecific mating occurs between V. velutina and Japanese native Vespa spp. Our results showed that the alien V. velutina causes reproductive interference in Japanese native hornet Vespa simillima. Forty-three percent of native V. simillima queens had the sperm of V. velutina males, and among the all V. simillima queens analyzed, 28% only had V. velutina sperm. We did not find evidence of V. velutina queens having the sperm of V. simillima males. These findings suggest that reproductive interference by V. velutina males poses a threat to the native V. simillima populations. A decline of V. simillima may also negatively affect other insects that interact with V. simillima.

S-1 and irinotecan plus bevacizumab versus mFOLFOX6 or CapeOX plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer (TRICOLORE): a randomized, open-label, phase III, noninferiority trial

Background

Combination therapy with oral fluoropyrimidine and irinotecan has not yet been established as first-line treatment of metastatic colorectal cancer (mCRC). We carried out a randomized, open-label, phase III trial to determine whether S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab in terms of progression-free survival (PFS).

Patients and methods

Patients from 53 institutions who had previously untreated mCRC were randomly assigned (1 : 1) to receive either mFOLFOX6 or CapeOX plus bevacizumab (control group) or S-1 and irinotecan plus bevacizumab (experimental group; a 3-week regimen: intravenous infusions of irinotecan 150 mg/m2 and bevacizumab 7.5 mg/kg on day 1, oral S-1 80 mg/m2 twice daily for 2 weeks, followed by a 1-week rest; or a 4-week regimen: irinotecan 100 mg/m2 and bevacizumab 5 mg/kg on days 1 and 15, S-1 80 mg/m2 twice daily for 2 weeks, followed by a 2-week rest). The primary end point was PFS. The noninferiority margin was 1.25; noninferiority would be established if the upper limit of the 95% confidence interval (CI) for the hazard ratio (HR) of the control group versus the experimental group was less than this margin.

Result

Between June 2012 and September 2014, 487 patients underwent randomization. Two hundred and forty-three patients assigned to the control group and 241 assigned to the experimental group were included in the primary analysis. Median PFS was 10.8 months (95% CI 9.6-11.6) in the control group and 14.0 months (95% CI 12.4-15.5) in the experimental group (HR 0.84, 95% CI 0.70-1.02; P < 0.0001 for noninferiority, P = 0.0815 for superiority). One hundred and fifty-seven patients (64.9%) in the control group and 140 (58.6%) in the experimental group had adverse events of grade 3 or higher.

Conclusion

S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab with respect to PFS as first-line treatment of mCRC and could be a new standard treatment.

Clinical trials number

UMIN000007834.

Abstract P1-06-11: Microsatellite instability in triple negative breast cancers

Background:Microsatellite instability (MSI) is a phenotype resulting from defect in mismatch repair genes. The Food and Drug Administration approved anti-programmed death 1 (PD-1) immune checkpoint inhibitor for any solid tumor with MSI-high (MSI-H). Some tumors had good response to PD-1 blockade and it is a promising treatment for a part of refractory breast cancers. Our goal was to determine the frequency of MSI in triple negative breast cancer (TNBC), one of the most clinically aggressive subtypes.

Patients and Methods:This study included 228 patients with primary TNBC underwent resection without neoadjuvant chemotherapy between January 2004 and December 2014. Genomic DNA was extracted from formalin-fixed and paraffin-embedded tissue. Tumor and control DNA were amplified by polymerase chain reaction at the following 5 microsatellite markers: NR-21, BAT-26, BAT-25, NR-24, MONO-27. We classified the tumors as microsatellite stable(MSS), MSI-low or MSI-H.

Results: The mean age of patients was 59 years (range: 30-89) and all were women. T1 tumors were 57.9% and N0 were 67.5%. Meanwhile, the tumors with nuclear grade 3 were 66.2% and high Ki-67 (&gt; 30%) were 66.7%. Among the 228 tumors, 222 tumors (97.4%) revealed MSS, of which 6 (2.6%) revealed MSI and 2 (0.9%) were MSI-H. Among the MSI tumors, T and N factor were showed as follows: T1: 2 tumors, T2: 3 tumors, T3: 1 tumor, N0: 5 tumors and N1: 1 tumor. Of two MSI-H tumors, one showed T1N0 and another showed T2N0. The both of them showed nuclear grade 3, high Ki-67 (&gt; 30%) and had common following instable markers: NR-21, BAT-26 and BAT-25.

Conclusions: Our results demonstrated that the frequency of MSI-H was 0.9% (2/228). MSI might not be useful as a biomarker for immune check point inhibitors. MSI should be combined with another biomarker such as tumor mutational burden in TNBC.

Citation Format: Kurata K, Kubo M, Mori H, Kawaji H, Motoyama Y, Kuroki L, Yamada M, Kaneshiro K, Kai M, Nakamura M. Microsatellite instability in triple negative breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-06-11.

Abstract P2-08-59: Different predictive and prognostic impact of intra-tumor heterogeneity, tumor biology, and microenvironment in triple negative breast cancer

Background

Intra-tumor heterogeneity, tumor biology, and microenvironment in triple negative breast cancer (TNBC) has been reported to be predictive and prognostic factors. However, it is not well known how these factors are correlated each other according to response to chemotherapy and their prognosis. The aim of this study was to assess the predictive and prognostic impact of these factors in TNBC.

Method

Biopsy samples before neoadjuvant chemotherapy (NAC) from 59 TNBC patients who underwent surgery after NAC from 2001 to 2007 were retrospectively assessed. For tumor biology, tumors were classified as Hormonal related luminal androgen receptor (LAR) if &gt;10% staining of AR, Basal-like if positive for cytokeratin 5/6 and EGFR, and Others. Claudin 1 and p16 expression levels were assessed for intra-tumor heterogeneity. and stromal tumor-infiltrating lymphocytes (Str-Tils) levels for tumor-microenvironment were also assessed as low for ≤10%, Intermediate for 10-49%, and high for &gt;50%.The predictive and prognostic impact of clinicopathological factors including age, nuclear grade (NG), lymph node status, were also assessed. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and were compared between groups using the log-rank test.

Results

A median overall survival period of the 59 patients was 98 month(6 -172 month).Eighteen (30.5%) were classified in LAR, 16 (27.1%) in Basal-like, and 25 (42.4%) in Others. According to response to NAC, 10 patients (16.9%) achieved pathologic complete response (pCR). These biological classifications were not associated with pCR rate (p=0.135). high-p16 had significantly high pCR rate (p=0.046).However, Str-Tils level was not associated with pCR rate. Patients with lymph node metastasis had significantly low pCR rate (p=0.017).In terms of their prognosis, age&lt;50 had significantly shorter OS and DFS than that of age&gt;50 (OS: p=0.023, DFS: p=0.027). NG3 had a trend of short OS compared to NG 1 or 2 (NG 1 vs 3, OS: p=0.053, and NG 2 vs 3, OS: p=0.073). There were no difference of their prognosis among three tumor biology classifications except Basal-like had significantly shorter OS than that of LAR (LAR vs Basal OS:p=0.041, DFS:p=0.574, LAR vs Others OS:p=0.407, DFS:p=0.866, Basal vs Others OS:p=0.162, DFS:p=0.713).Claudin 1 and p16 expression levels were not associated with OS and DFS. Low-Str-Tils had a trend of shorter OS and DFS than that of intermediate- or high-Str-Tils (low vs int; OS:p=0.085, DFS:p=0.026, low vs high; OS:p=0.062, DFS:p=0.055).In multivariate analysis, age&lt;50 was only independent prognostic factor (p&lt;0.05).

Conclusion

We showed that intra-tumor heterogeneity, tumor biology, and microenvironment had different predictive and prognostic impact in TNBC. These results might suggest the strategy of additional targeting treatment to non-pCR patients.

Citation Format: Hayashi N, Nakamura M, Kobayashi D, Suzuki K, Yamauchi H. Different predictive and prognostic impact of intra-tumor heterogeneity, tumor biology, and microenvironment in triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-59.

Abstract P4-06-22: Transcription factor T-bet and PD-L1 expression in tumor microenvironment of triple-negative breast cancer

Background: Many analyzes regarding immunotherapies using checkpoint blockade has made it clear that tumor infiltrating lymphocytes (TILs) plays an important role in treating cancers with high levels of somatic mutations such as triple-negative breast cancer (TNBC). We reported the relationship between TILs and PD-L1 expression, and revealed that high-TILs/positive-PD-L1 expression population in TNBC was associated with better prognosis (Oncotarget 2017). However, its molecular mechanism is still unclear. Meanwhile, T-box transcription factor 21 (T-bet) which regulates effecter T-cells activation is derived by stimulation of T-cell receptor and IL-12. Activated T-cells work as antitumor lymphocytes by enhancing the production of cytokines such as INFγ. We focused on T-bet and examined the function of activated T-cells.

Patients and Methods: This study included 242 patients with primary TNBC who underwent resection without neoadjuvant chemotherapy at our three hospitals between January 2004 and December 2014. The immunohistochemistry scoring for CD8 and T-bet expression on TILs was defined as ≥30 per 0.00625mm2. PD-L1 positivity was defined as ≥1% of tumor cells staining positive for PD-L1.

Results: Of the 242 TNBC, CD8 on TILs was expressed as positive in 127 (52.5%) tumors, T-bet on TILs was expressed as positive in 67 (27.7%) tumors, and PD-L1 expression on tumor cells was expressed as positive in 99 (40.9%) tumors. T-bet expression was significantly correlated with CD8 expression (P&lt;0.0001) and PD-L1 expression (P=0.0004). There was no significant difference in recurrence free survival (RFS) and overall survival (OS) regardless of CD8 or PD-L1expression level. Meanwhile, the patients with T-bet-positive tumors had a longer OS, compared to those with T-bet-negative tumors (P = 0.13 in RFS and P = 0.047 in OS). The multivariate analysis revealed that T-bet expression on TILswas an independent and positive prognostic factor for OS(HR = 0.5, 95%CI 0.1-0.9, P = 0.035).

Conclusion: OS was significantly longer among patients with high T-bet expressing TNBC. These results may validate the significance of T-bet as a biomarker for various immunotherapies in TNBC.

Citation Format: Mori H, Kubo M, Kai M, Kurata K, Kawaji H, Kaneshiro K, Motoyama Y, Kuroki R, Yamada M, Nishimura R, Okido M, Oda Y, Nakamura M. Transcription factor T-bet and PD-L1 expression in tumor microenvironment of triple-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-22.

Spectral dynamics of shift current in ferroelectric semiconductor SbSI

Photoexcitation in solids brings about transitions of electrons/holes between different electronic bands. If the solid lacks an inversion symmetry, these electronic transitions support spontaneous photocurrent due to the geometric phase of the constituting electronic bands: the Berry connection. This photocurrent, termed shift current, is expected to emerge on the timescale of primary photoexcitation process. We observe ultrafast evolution of the shift current in a prototypical ferroelectric semiconductor antimony sulfur iodide (SbSI) by detecting emitted terahertz electromagnetic waves. By sweeping the excitation photon energy across the bandgap, ultrafast electron dynamics as a source of terahertz emission abruptly changes its nature, reflecting a contribution of Berry connection on interband optical transition. The shift excitation carries a net charge flow and is followed by a swing over of the electron cloud on a subpicosecond timescale. Understanding these substantive characters of the shift current with the help of first-principles calculation will pave the way for its application to ultrafast sensors and solar cells.

Current-Voltage Characteristic and Shot Noise of Shift Current Photovoltaics

We theoretically study the current-voltage relation, the I-V characteristic, of the photovoltaics due to the shift current, i.e., the photocurrent generated without the external dc electric field in noncentrosymmetric crystals through the Berry connection of the Bloch wave functions. We find that the I-V characteristic and shot noise are controlled by the difference of group velocities between conduction and valence bands, i.e., v_{11}-v_{22}, and the relaxation time τ. Since the shift current itself is independent of these quantities, there are a wide variety of possibilities to design it to maximize the energy conversion rate and also to suppress the noise. We propose that the Landau levels in noncentrosymmetric two-dimensional systems are a promising candidate for energy conversion.

An immunologically relevant rodent model demonstrates safety of therapy using a tumour-specific IgE

BACKGROUND

Designing biologically informative models for assessing the safety of novel agents, especially for cancer immunotherapy, carries substantial challenges. The choice of an in vivo system for studies on IgE antibodies represents a major impediment to their clinical translation, especially with respect to class-specific immunological functions and safety. Fcε receptor expression and structure are different in humans and mice, so that the murine system is not informative when studying human IgE biology. By contrast, FcεRI expression and cellular distribution in rats mirror that of humans.

METHODS

We are developing MOv18 IgE, a human chimeric antibody recognizing the tumour-associated antigen folate receptor alpha. We created an immunologically congruent surrogate rat model likely to recapitulate human IgE-FcεR interactions and engineered a surrogate rat IgE equivalent to MOv18. Employing this model, we examined in vivo safety and efficacy of antitumour IgE antibodies.

RESULTS

In immunocompetent rats, rodent IgE restricted growth of syngeneic tumours in the absence of clinical, histopathological or metabolic signs associated with obvious toxicity. No physiological or immunological evidence of a "cytokine storm" or allergic response was seen, even at 50 mg/kg weekly doses. IgE treatment was associated with elevated serum concentrations of TNFα, a mediator previously linked with IgE-mediated antitumour and antiparasitic functions, alongside evidence of substantially elevated tumoural immune cell infiltration and immunological pathway activation in tumour-bearing lungs.

CONCLUSION

Our findings indicate safety of MOv18 IgE, in conjunction with efficacy and immune activation, supporting the translation of this therapeutic approach to the clinical arena.

Prognostic nutritional index and early mortality with percutaneous endoscopic gastrostomy

BACKGROUND

Although percutaneous endoscopic gastrostomy (PEG) is a well-accepted and less invasive method of feeding tube placement in patients with swallowing difficulties, complications and early death after PEG have been reported.

AIM

This study aimed to evaluate predictive factors associated with 30-day mortality after PEG, and to assess the utility of nutritional supporting period before PEG in reducing early mortality following PEG.

DESIGN

An observational study.

METHODS

We retrospectively analyzed 268 patients who underwent PEG at Sapporo Shirakaba-dai Hospital from 2006 to 2010, using clinical and laboratory data to analyze predictive factors associated with early death after PEG. Then, we prospectively assessed 152 consecutive patients assessed for eligibility for PEG from 2011 to 2014. We assessed the patients' nutritional condition using Onodera's prognostic nutritional index (PNI), and supported nutrition for more than 10 days before PEG in patients with a poor nutritional index (PNI < 37).

RESULTS

In both univariate and multivariate analyses in the retrospective study, Onodera's PNI of less than 37 was the only predictive factor for early mortality. In the second study, among the 115 patients who finally underwent PEG, early mortality rates improved to 1.7% from 5.2% in the first study. Conversely, 32% of patients with malnutrition who did not undergo PEG died within 30 days.

CONCLUSION

Nutritional status might be a predictive factor for early mortality after PEG. In patients with poor nutritional status, nutritional supporting period before PEG might improve the outcomes and reduce unnecessary PEG.