Hyperthermic pressurized intraperitoneal aerosol drug delivery system in a large animal model: a feasibility and safety study

BACKGROUND

We developed a novel drug delivery system called hyperthermic pressurized intraperitoneal aerosol chemotherapy (HPIPAC) that hybridized Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). The present study aims to assess the feasibility and safety of HPIPAC system in a large animal survival model.

METHODS

Eleven pigs (eight non-survival models and three survival models) were used in the experiment. The heat module in the HPIPAC controller circulates hyperthermic CO2 in a closed-loop circuit and creates gas-based dry intraperitoneal hyperthermia. Three 12 mm trocars were placed on the abdomen. The afferent CO2 tube wound with heat generating coil was inserted into a trocar, and the efferent tube was inserted into another trocar. Heated CO2 was insufflated and circulated in a closed circuit until the intra-abdominal and peritoneal surface temperature reached 42 °C. 100 ml of 5% dextrose in water was nebulized for 5 min and the closed-loop circulation was resumed for 60 min at 42 °C. Tissue biopsies were taken from several sites from the pigs in the survival model.

RESULTS

The average change in core temperature of the pigs was 2.5 ± 0.08 °C. All three pigs displayed no signs of distress, and their vital signs remained stable, with no changes in their diet. In autopsy, inflammatory and fibrotic responses at the biopsy sites were observed without serious pathologic findings.

CONCLUSIONS

We successfully proved the feasibility and safety of our novel HPIPAC system in an in-vivo swine survival model.

Single-port intragastric wedge resection using the tunnel method: a novel surgical approach for treating endophytic gastric subepithelial tumors

BACKGROUND

Intragastric wedge resection is an effective method for treating endophytic gastric subepithelial tumors (SETs). However, retracting the stomach wall to the umbilicus is difficult in certain patients. In response, we developed a novel surgical technique for single-port intragastric wedge resection, which we termed the "tunnel method."

METHODS

A transumbilical incision is made, and a wound retractor is applied. After diagnostic laparoscopy, a gastrostomy is made on the greater curvature, lower body. Another small wound retractor is inserted into the gastrostomy, and extracted through the transumbilical incision, creating a tunnel from the gastrostomy site to the umbilicus. Articulating laparoscopic instruments are inserted via the tunnel, and intragastric wedge resection is performed. We collected and analyzed the clinicopathologic and operative data of patients who underwent intragastric wedge resection via the tunnel method.

RESULTS

Twenty-seven patients who underwent single-port intragastric wedge resection via the tunnel method in a single tertiary referral hospital were included in this study. The mean age of the patients was 54.6 ± 11.4 years, body mass index was 26.5 ± 3.4 kg/m2. Twenty-four (88.9%) patients had tumors located in the upper third of the stomach. The average operative time was 65.0 ± 24.2 min. None of the patients experienced Clavien-Dindo grade IIIa or higher postoperative complications. The average postoperative hospital stay length was 2.5 ± 0.8 days. Thirteen gastrointestinal stromal tumors, nine leiomyomas, and one neuroendocrine carcinoma, schwannoma, lipoma, spindle cell proliferative lesion, and fibrotic lesion were pathologically diagnosed. The average tumor size was 2.6 ± 1.3 cm. All cases had negative resection margins.

CONCLUSIONS

Single-port intragastric wedge resection by the tunnel method is a feasible and safe approach for treating endophytic gastric SETs.

Feasibility of articulating laparoscopic instruments in laparoscopic gastrectomy using propensity score matching

Advancements in minimally invasive surgery has led to the development of several surgical instruments, including the ArtiSential®. This new instrument provides a greater range of motion and improved dexterity to laparoscopic procedures, making it an alternative option to traditional straight instruments, and the Da Vinci robot system. The purpose of this study is to compare the postoperative outcomes of a prospective cohort of patients who underwent laparoscopic gastrectomy using articulating instruments with those of a historical cohort of patients who underwent the same procedure using straight instruments. The study was designed as a prospective observational cohort study matched to a retrospective historical cohort using propensity score matching. The primary outcome was the rate of early complications within 90 days of surgery. Other outcomes included the operation time, estimated blood loss, time to first flatus, time to first soft fluid diet, hospital stay, and mortality. After propensity score matching, 41 patients were enrolled in both groups. The mean age was 62.4 ± 12.3 years in the conventional group and 63.5 ± 9.6 years in the artisential group (p = 0.647). Mean operative time was significantly shorter in the artisential group compared to the conventional group (136.1 min vs. 163.9 min, p = 0.032). The time to first soft fluid diet was also significantly shorter in the artisential group (2.2 days vs. 2.8 days, p = 0.030), but there was no significant difference in the time to first flatus and overall hospital stay. The incidence of early complications was lower in the artisential group, but the difference was not significant (24.4% vs 7.3%, p = 0.070). There was no mortality in either group. The use of articulating instruments for laparoscopic gastrectomy did not increase postoperative morbidity compared to straight laparoscopic instruments. The use of articulating instruments may be associated with faster bowel recovery and less early complications.

Proteogenomic Analysis of Human Uterine Cervical Cancer (UCC) Reveals Treatment-Resistant Subtypes of UCC

PURPOSE/OBJECTIVE(S)

Locally advanced uterine cervical cancer (UCC) is treated by radiotherapy with concurrent chemotherapy, but heterogenous treatment responses are frequently observed. To better optimize therapeutic options based on molecular signatures, we performed proteogenomic analysis of UCC.

MATERIALS/METHODS

UCC tissue and blood samples were collected from patients who underwent primary radiotherapy ± chemotherapy at the National Cancer Center (NCC) in Korea from July 2004 to March 2020. Most samples were obtained via biopsy. Genomic DNA for WES was isolated from frozen biopsy tumor tissues and peripheral blood buffy-coat of patients. Both global proteome and phosphoproteome were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Whole exome sequencing, RNA sequencing, global proteomics and phosphoproteomics were performed using 253, 337, and 147 cervical cancer samples, respectively. Patient-derived xenograft were established using intratongue implantation using 2 primary cell lines from sub3 and sub5, and flow cytometric analysis was performed.

RESULTS

Fourteen significantly mutated genes (SMG) were found in our study cohort which include 5 newly identified SMGs. Mutation-phosphorylation analysis revealed association with apoptosis and actin cytoskeleton pathway. Proteogenomic analysis defined 6 molecular subtypes of UCC. Of those, 3 subtypes (i.e., Sub3, Sub5 and Sub6) were associated with treatment-resistant phenotypes. The cell-type deconvolution analysis suggested activated stroma with activation of cancer-associated fibroblast in Sub 3, while Sub5 showed low levels of activated stroma and high levels of myeloid immune cells. FACS analysis of UCC mouse models established from these 2 radio-resistant primary cell lines showed high component of PDGFRA+CAF infiltration in Sub 3, and high level of PVR+CD45+ immune cells mainly composed of polymorphonuclear myeloid-derived suppressor cells (PMN-MDSC) in Sub5. For Sub6, genes and/or protein signatures represented mucin-related processes (e.g., mucin glycosylation/sugar metabolism), which are linked to metastasis-associated Tn antigen production.

CONCLUSION

The proteogenomic analysis thus suggests potential targets for radiotherapy-resistant subtypes of UCC; secretory factors from activated stroma and cancer-associated fibroblast (Sub3); RHOA signaling, PVR, and PMN-MDSCs (Sub5), and keratin/chondroitin sulfate proteoglycan and Tn antigen production (Sub6). Our study shows the importance of proteogenomic analysis in unveiling the subtype specific molecular pathways of UCC that are beyond reach by genomic data alone. The validity of our molecular pathway and cellular signatures linking these pathways should be further validated through detailed functional experiments and in larger UCC cohorts.

The Shorr Versus Modified Ultrafast Papanicolaou Method for Intraoperative Diagnosis of Peritoneal Washing Cytology in Advanced Gastric Cancer: A Phase II Study

PURPOSE

According to the American Joint Committee on Cancer cancer staging system, positive peritoneal washing cytology (PWC) indicates stage IV gastric cancer. However, rapid intraoperative diagnosis of PWC has no established reliable method. This study evaluated and compared the diagnostic accuracy of the Shorr and the modified ultrafast Papanicolaou (MUFP) methods for intraoperative PWC.

MATERIALS AND METHODS

This study included patients with gastric cancer who were clinically diagnosed with stage cT3 or higher. The Shorr and MUFP methods were performed on all PWC specimens, and the results were compared with those of conventional Papanicolaou (PAP) staining with carcinoembryonic antigen immunohistochemistry. Sensitivity, specificity, and partial likelihood tests were used to compare the 2 methods.

RESULTS

Forty patients underwent intraoperative PWC between November 2019 and August 2021. The average time between specimen reception and slide preparation using Shorr and MUFP methods was 44.4±4.5 minutes, and the average time between specimen reception and pathologic diagnosis was 53.9±8.9 minutes. Eight patients (20.0%) had positive cytology in PAP staining. The Shorr method had a sensitivity of 75.0% and specificity of 93.8%; the MUFP method had 62.5% sensitivity and 100.0% specificity. The area under the curve was 0.844 for Shorr and 0.813 for MUFP. In comparing the C-indices of each method with overall survival, no difference was found among the Shorr, MUFP, and conventional PAP methods.

CONCLUSIONS

The Shorr and MUFP methods are acceptable for the intraoperative diagnosis of PWC in advanced gastric cancer.

Postoperative pain and quality of life after single-incision distal gastrectomy versus multiport laparoscopic distal gastrectomy for early gastric cancer - a randomized controlled trial

BACKGROUND

Although it has been more than ten years since its first introduction, single-incision distal gastrectomy (SIDG) still lacks solid evidence and there are also no reports on patient quality of life (QOL). This study evaluates the postoperative outcomes and patient QOL of SIDG compared to multiport laparoscopic distal gastrectomy (MLDG).

METHODS

This study was designed as a prospective phase II randomized controlled study. Patients diagnosed with early gastric cancer in the distal 2/3rd of the stomach were randomized to either multiport or single-port group. Primary endpoint was pain using the visual analogue scale on postoperative day (POD) 1. Other outcomes include operative data, complications, and patient QOL using the EORTC C30 and STO22 modules.

RESULTS

A total of 43 patients in the SIDG group and 40 patients in the MLDG group were enrolled from September 2017 to February 2020. Mean operation time was 154.3 ± 53.3 min in the MLDG group and 148.9 ± 50.1 min in the SIDG group (p = 0.631). There was no difference in POD1 pain scores between the two groups (MLDG = 4.0 ± 1.3, SIDG = 4.3 ± 1.3, p = 0.372). Mean hospital stay was 5.5 (range 4-12) days in the MLDG group and 5 (range 4-17) days in the SIDG group (p = 0.993). There was no statistical significance in postoperative QOL scores.

CONCLUSION

Unlike previous reports, there was no difference in POD1 pain scores between SIDG and MLDG. Nevertheless, SIDG did not increase short-term morbidity compared to MLDG and had similar outcomes in QOL.

Postoperative major bleeding risk in patients using oral antiplatelets and/or anticoagulants after laparoscopic gastric cancer surgery

Purpose

The use of antiplatelet and/or anticoagulant therapies has become common. In rare cases, these therapies may increase the risk of dangerous postoperative bleeding. We investigated the association of antiplatelets and/or anticoagulants with postoperative major bleeding risk in laparoscopic gastric cancer surgery.

Methods

We retrospectively enrolled 3,663 gastric cancer patients (antiplatelet/anticoagulant group, 518; control group, 3,145) who had undergone laparoscopic surgery between January 2012 and December 2017. To minimize selection bias, 508 patients in each group were matched using propensity score matching (PSM) method. The primary outcome was postoperative major bleeding. Secondary outcomes were intraoperative, postoperative transfusion and early complications.

Results

After PSM, postoperative major bleeding occurred in 10 (2.0%) and 3 cases (0.6%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.090). Intraoperative and postoperative transfusions were not significantly different between 2 groups (2.4% vs. 1.4%, P = 0.355 and 5.5% vs. 4.3%, P = 0.469). Early complications developed in 58 (11.4%) and 43 patients (8.5%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.142). The mean amounts of intraoperative and postoperative transfusions were not significantly different between the groups (366.67 ± 238.68 mL vs. 371.43 ± 138.01 mL, P = 0.962; 728.57 ± 642.25 mL vs. 508.09 ± 468.95 mL, P = 0.185). In multivariable analysis, male (P = 0.008) and advanced stage (III, IV) (P = 0.024) were independent significant risk factors for postoperative major bleeding.

Conclusion

Preoperative antiplatelets and/or anticoagulants administration did not significantly increase the risk of postoperative major bleeding after laparoscopic gastric cancer surgery.

Prasugrel-based de-escalation vs. conventional therapy after percutaneous coronary intervention in ACS patients according to the renal function

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): A consortium of six companies in Korea (Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio).

Background

Patients with coronary artery disease and impaired renal function are at higher risk for both bleeding and ischemic adverse events after percutaneous coronary intervention (PCI).

Purpose

We assessed the efficacy and safety of a prasugrel based de-escalation strategy in patients with impaired renal function.

Methods

We conducted a post-hoc analysis of the HOST-REDUCE-POLYTECH-ACS study. Patients with available estimated glomerular filtration rate (eGFR) (n=2,311) were categorized into three groups. (high eGFR: ≥90 mL/min; intermediate eGFR: ≥60 and <90 mL/min; low eGFR: <60 mL/min). The endpoints were bleeding outcomes (Bleeding Academic Research Consortium type 2, or higher), ischemic outcomes (cardiovascular death, myocardial infarction, stent thrombosis, repeat revascularization, and ischemic stroke), and net adverse clinical events (all cause death, BARC 2 or greater bleeding, MI, stent thrombosis, repeat revascularization, and ischemic stroke) at 1 year follow-up. The hazard ratio (HR) and 95% Confidence interval (CI) were calculated from the multivariate Cox proportional hazard regression analysis. Covariates that were considered clinically meaningful were included. The probability risk ratio was obtained by dividing ischemic hazard function from the bleeding hazard function.

Results

With respect to net adverse clinical events, prasugrel de-escalation was beneficial regardless of baseline renal function (p for interaction = 0.508). The relative reduction in bleeding risk from prasugrel de-escalation was higher in the low eGFR group compared with that from both the intermediate and high eGFR groups (relative reduction: 64% [HR 0.36, 95% CI 0.15–0.83] vs. 50% [HR 0.50, 95% CI 0.28-0.90] and 52% [HR 0.48, 95% CI 0.21-1.13] for low, intermediate, and high eGFR groups, p for interaction=0.646). Ischemic risk from prasgurel de-escalation was not significant in all eGFR groups ([HR 1.18, 95% CI 0.47-2.98], [HR 0.95, 95% CI 0.53-1.69], and [HR 0.61, 95% CI 0.26-1.39)], respectively, p for interaction=0.119). The probability risk ratio was highest in low eGFR group (1.06 vs. 1.26 vs. 1.36, for high, intermediate, and low eGFR groups, respectively, p for trend<0.001), suggesting higher relative bleeding risk above ischemic risk. Within those randomized to the de-escalation strategy, the mean probability risk ratio was not significantly different according to renal function (0.89, vs. 0.84 vs. 0.80 respectively, p for trend = 0.053), which was in contrast to those randomized to the conventional strategy where the mean probability risk ratio increased significantly as renal function decreased (1.24 vs. 1.67 vs. 1.94 respectively, p for trend<0.001).

Conclusion

The beneficial effect of prasugrel-based de-escalation strategy was consistent regardless of the baseline renal function, which was mostly driven by a reduction in bleeding risk which was greatest in those with low eGFR.

A novel index reflecting both anatomical and physiologic parameters in coronary artery disease, the FFR adjusted SYNTAX score (FaSs)

Background

Various physiology-based indices have been proposed to predict adverse clinical events in patients with coronary artery disease (CAD), such as the sum of three vessel-fractional flow reserve (3v-FFR), and the functional SYNTAX score (fSS). However, these values could not fully reflect the anatomical factors, which remains as a barrier for clinical application of these indices.

Purpose

To propose a novel index which can reflect both anatomical and physiologic features in CAD patients, and evaluate the additional predictive value for cardiovascular adverse events compared to previous indices.

Methods

For an index which can reflect both anatomical and physiologic features, we proposed the FFR adjusted SYNTAX score (FaSs). The FaSs is calculated by adding the product of the SYNTAX score and `1-FFR', for all three major coronary arteries. Among the 1136 patients who enrolled at 3V FFR-FRIENDS study, we investigated 866 patients, after excluding those who had missing variables. The 3v-FFR, fSS and FaSs were calculated, derived from the baseline FFR and SYNTAX score. Patients were divided into two groups according to the median value of each index. The primary endpoint was major adverse cardiac events (MACE, a composite of cardiac death, myocardial infarction and ischemia-driven revascularization) at 2 years follow-up.

Results

Among the total population, MACE occurred in 35 (4.04%) patients. Using the median value in a multivariable COX regression model, only FaSs was associated with an increased risk of MACE, (Hazard Ratio [HR] 5.256, 95% confidence interval [CI] 2.014–13.720), while 3v-FFR (HR 1.383, 95% CI 0.685–2.790) and fSS (HR 1.640, 95% CI 0.830–3.243) were not significantly associated with a higher risk of MACE. This was also observed in the Kaplan Meier survival curve analysis (log-rank p value: p<0.001 for FaSs, 0.153 for 3v-FFR, and 0.061 for fSS; Figure 1) The sensitivity and specificity of the FaSs was 85.7% and 51.6%, which was higher compared to the 3v-FFR (62.9% and 49.3%, respectively) and fSS (57.1% and 58.5%, respectively). When these indices were combined with clinical risk factors (age, sex, hypertension, diabetes, hyperlipidemia, chronic renal failure, LVEF<40%), FaSs was superior compared with 3v-FFR and fSS assessed in regards of the predictive accuracy for MACE (Figure 2).

Conclusion

The FaSs, which is a novel index calculated by a formula using the SYNTAX score and FFR, showed a superior predictive value for MACE compared to previous indices. Our results confirm the importance of considering both anatomical and physiologic parameters in evaluating the patient's risk for cardiovascular adverse outcomes.

Funding Acknowledgement

Type of funding sources: None.

Clinical effectiveness of house dust mite immunotherapy in mono- versus poly-sensitised patients with allergic rhinitis: a systematic review and meta-analysis

Selecting an appropriate allergen-specific immunotherapy (AIT) regimen for polysensitised allergic rhinitis (AR) patients is challenging for clinicians. Although previous studies showed comparable effectiveness of single-allergen AIT with house dust mite (HDM) extract between monosensitised and polysensitised AR patients, there is no systematic review and meta-analysis demonstrating the comparable effectiveness of HDM AIT. In this meta-analysis, we analysed nine studies to compare the clinical effectiveness of HDM AIT. The primary outcome was nasal symptom score and secondary outcomes were medication and quality of life scores. The changes in nasal symptom score after HDM AIT did not significantly differ between monosensitised and polysensitised patients. The clinical effectiveness of HDM AIT regarding medication and quality of life score was not significantly different between monosensitised and polysensitised patients). In conclusion, single-allergen AIT with HDM extract showed comparable clinical effectiveness between polysensitised and monosensitised patients with AR.

Improved Glioma Grading Using Deep Convolutional Neural Networks

BACKGROUND AND PURPOSE

Accurate determination of glioma grade leads to improved treatment planning. The criterion standard for glioma grading is invasive tissue sampling. Recently, radiomic features have shown excellent potential in glioma-grade prediction. These features may not fully exploit the underlying information in MR images. The objective of this study was to investigate the performance of features learned by a convolutional neural network compared with standard radiomic features for grade prediction.

MATERIALS AND METHODS

A total of 237 patients with gliomas were included in this study. All images were resampled, registered, skull-stripped, and segmented to extract the tumors. The learned features from the trained convolutional neural network were used for grade prediction. The performance of the proposed method was compared with standard machine learning approaches, support vector machine, random forests, and gradient boosting trained with radiomic features.

RESULTS

The experimental results demonstrate that using learned features extracted from the convolutional neural network achieves an average accuracy of 87%, outperforming the methods considering radiomic features alone. The top-performing machine learning model is gradient boosting with an average accuracy of 64%. Thus, there is a 23% improvement in accuracy, and it is an efficient technique for grade prediction.

CONCLUSIONS

Convolutional neural networks are able to learn discriminating features automatically, and these features provide added value for grading gliomas. The proposed framework may provide substantial improvement in glioma-grade prediction; however, further validation is needed.

Prognostic value of pre-revascularization fractional flow reserve mediated by the post-revascularization level: a causal mediation analysis

Background

The prognostic value of pre-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) can depend on that of the post-PCI FFR and their interaction. To correctly interpret the prognostic value of pre-PCI FFR, it is essential to understand to what extent the relationship between pre-PCI FFR and clinical outcome is explained by pre-PCI FFR-related post-PCI FFR.

Purpose

The aim of this study is to investigate the extent to which post-PCI FFR mediates the relationship between pre-PCI FFR and vessel-related outcomes using a global, multicenter collaboration registry.

Methods

Patient data from 4 global FFR registries were pooled and 1488 patients with pre-PCI FFR ≤0.80 were analyzed. The primary outcome was target vessel failure (TVF) during 2-years of follow-up. We evaluated the extent to which post-PCI FFR <0.90 mediated the association between pre-PCI FFR <0.75 and TVF employing a causal mediation analysis in a counterfactual framework.

Results

Among 1488 patients, the mean (standard deviation) age was 63.5 (9.9) years and 78% (1161 patients) were male. The median (IQR) pre-PCI and post-PCI FFR were 0.71 (0.62–0.76) and 0.88 (0.83–0.92), respectively. The direct effect of low pre-PCI FFR (<0.75) on TVF was significantly elevated (OR: 1.81, 95% CI: 1.03–3.18, p=0.038), and was not mediated by post-PCI FFR<0.90 (indirect effect, OR: 1.01, 95% CI: 0.98–1.05, p=0.39). In the model, post-PCI FFR explained only 2.2% of the association between pre-PCI FFR and TVF. The subgroup analysis implicated that the prognostic information of pre-PCI FFR was mainly for diffuse lesions.

Conclusions

The prognostic information of pre-PCI FFR did not greatly depend on the results of PCI assessed by post-PCI FFR. Pre-PCI FFR, as a prognostic marker, may mainly reflect the global atherosclerotic burden of the artery, not the extent of the modifiable epicardial stenosis, thus providing independent information from post-PCI FFR.

Interpretation

Funding Acknowledgement

Type of funding source: None