Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer (GC), published in late 2022 and the updated ESMO Gastric Cancer Living Guideline published in July 2023, were adapted in August 2023, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with GC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with GC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), coordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with GC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Exploration of electrocardiographic and echocardiographic findings to screen transthyretin amyloid cardiomyopathy in patients with mild left ventricular hypertrophy

Background

The transthyretin amyloid cardiomyopathy (ATTR-CM), a common condition in the elderly, is a life-threatening disease; however, it is treatable. The early accurate diagnosis is, therefore, an important key to improve the patient's outcomes. Electrocardiography and echocardiography are instant diagnostic tools with red flags for the screening of the ATTR-CM. In fact, ATTR-CM often mimics left ventricular hypertrophy (LVH), and the differential diagnosis is difficult to establish. Thus, the characteristics of cardiac amyloidosis may be obscured in ATTR-CM patients with mild LVH, possibly making the disease difficult to diagnose. Therefore, in this study, the effect of LVH on the occurrence of electrocardiographic and echocardiographic parameters for ATTR-CM was investigated, and their incremental value over the age for the screening of ATTR-CM in the patients with mild LVH was recorded.

Methods

This study retrospectively studied 319 consecutive nonischemic LVH patients with a sinus rhythm who underwent detailed diagnostic tests. The light chain-associated amyloidosis was an exclusion criterion. The mean left ventricular wall thickness (MWT) <12 mm was defined as mild LVH, while MWT ≥12 mm was defined as moderate to severe LVH. The ATTR-CM was diagnosed with biopsy or 99 mTc-PYP scintigraphy. The elderly were defined as people aged ≥65 years in males and ≥70 years in females, according to the literature. Each electrocardiographic and echocardiographic parameter was binarized with an external cut-off point to increase the external validity, being the incremental benefit of each parameter over age for identifying ATTR-CM assessed using a receiver operating characteristic curve analysis and comparisons of the area under the curve (AUC).

Results

Fourteen patients (8%) among the 170 patients with mild LVH had ATTR-CM, while 27 patients (18%) among the 149 patients with moderate to severe LVH had ATTR-CM. The patients with mild LVH had fewer electrocardiographic and echocardiographic parameters, showing a significant difference between ATTR-CM and non-ATTR-CM patients than those with moderate to severe LVH (Table 1). Among several binarized parameters, the voltage-to-mass ratio, E/A ratio, the global longitudinal strain, and also the relative apical sparing pattern demonstrated additive value for identifying the ATTR-CM over aging (Table 2). In addition, the discriminative ability of the propensity score calculated from these four variables and age was considered excellent for the screening of ATTR-CM (AUC = 0.98).

Conclusion

The patients with mild LVH appear to have fewer electrocardiographic and echocardiographic specific findings of the ATTR-CM compared to patients with moderate to severe LVH. However, several red flags may be useful for screening ATTR-CM even in patients with a mild LVH.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Left atrial dysfunction still exists in patients who obtain normal left atrial volume after successful ablation of atrial fibrillation

Introduction

Atrial fibrillation (AF) promotes left atrial (LA) remodeling and vice versa. LA volume index (LAVI) ≥34 mL/m2 is an established cut-off value for identifying an enlarged left atrium. Catheter ablation has become an established therapy for AF and provides a reduction of LA volume by maintaining sinus rhythm (reverse remodeling). However, the definition of LA reverse remodeling after AF ablation is undetermined.

Purpose

We hypothesized that patients with LA dilatation who obtain normal LA volume (LAVI <34 mL/m2) after AF ablation would have better long-term outcomes than those who do not. Furthermore, we investigated whether patients with a normal LA volume could also obtain normal LA function with AF ablation.

Methods

We enrolled 140 AF patients with baseline LAVI ≥34 mL/m2, without AF recurrence for 1 year after the initial AF ablation. We acquired conventional and speckle-tracking echocardiographic parameters within 24 h and at 1 year after the procedure. Late recurrence was defined as AF recurrence >1 year after the initial ablation. To define the normal range of LA function, age-and sex-matched 140 controls without a history of AF were also enrolled.

Results

After restoration of sinus rhythm, overall LA structural and functional parameters were significantly improved, and 75 patients (54%) had normal LA volume at the time of follow-up (Table). During a median follow-up of 44 (31–61) months, 32 patients (23%) experienced a late recurrence of AF. Patients who obtained normal LA volume after AF ablation had fewer late recurrences than those who did not (P<0.01) (Figure). However, LA functional abnormalities still existed in AF patients, even if LA volume was normalized as in controls (Table).

Conclusion

Patients who obtain normal LA volume have better long-term outcomes of AF ablation than those who do not. Although AF ablation promotes beneficial effects on LA structure and function, LA function cannot be normalized even in patients who obtain normal LA volume after successful ablation. Thus, physicians should carefully consider long-term follow-up and residual AF risks, regardless of sinus rhythm restoration by catheter ablation.

Funding Acknowledgement

Type of funding sources: None.

Clinical significance of the relative apical sparing pattern of longitudinal strain in patients with cardiac amyloidosis

Background

The relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis (CA). However, some patients with CA do not show the RASP, and their clinical characteristics have not been fully clarified. We sought to investigate the clinical significance of RASP in patients with CA.

Methods

One hundred consecutive CA patients who were diagnosed by biopsy or myocardial pyrophosphate scintigraphy and evaluated for RASP (mean age: 76 years, male: 77%, LV mean wall thickness: 13.5 mm, light-chain [AL] type: 33 cases, transthyretin [TTR] type: 67 cases) were retrospectively enrolled. The RASP was semi-quantitatively and quantitatively assessed. Semi-quantitative RASP was defined as reduction of LS (≥−10%) in ≥5 (of 6) basal segments relative to preserved LS (<−15%) in ≥1 apical segment. Quantitative RASP was calculated according to the following formula: Quantitative RASP = [Average apical LS] / [Average basal LS + Average mid LS]. We adapted three validated thresholds (>1.00, >0.90, and >0.87) according to the literature.

Results

Semi-quantitative and binalized quantitative RASP (>1.00, >0.90, and >0.87) were observed in 55, 55, 63, and 65 patients, respectively. RASP in each definition was more prevalent in the TTR group than in the AL group. Additionally, RASP was significantly associated with higher LV wall thickness even after adjustment for the CA subtypes (all, p<0.05, Figure). After the RASP assessment, 35 all-cause deaths and 26 cardiac deaths were observed during the follow-up period (median, 1.1 years). Although these events were significantly associated with poor nutrition, lower blood pressure, higher New York Heart Association class, and the AL group, no association was found with RASP and LV wall thickness.

Conclusions

The incidence of RASP is low in the case of thin LV wall thickness in CA patients, which may indicate the difficulty of early diagnosis of CA using RASP in patients with mild LV hypertrophy. The prognostic prediction using RASP may be challenging in this cohort.

Figure 1

Funding Acknowledgement

Type of funding source: None

Utility of scoring system including relative apical sparing pattern for screening cardiac amyloidosis in patients with left ventricular hypertrophy

Background

Cardiac amyloidosis (CA) is an infiltrative disease mimicking left ventricular hypertrophy (LVH), although its prognosis is poorer than other diseases with LVH. Moreover, because CA is treatable, appropriate screening for CA is an important area of study for clinicians to prevent and treat the disease. Several imaging predictors of CA have been reported so far;. in particular, deformation parameters such as relative apical sparing patterns of longitudinal strain (RASP) may diagnose CA with better precision than conventional parameters. Accordingly, we hypothesized that the inclusion of deformation parameters into the established diagnostic parameters would permit derivation of a risk score for CA screening in patients with LVH. Thus, we aimed to 1) investigate the incremental benefits of deformation parameters over established diagnostic parameters for CA screening in patients with LVH; 2) determine the risk score to screen CA patients with LVH using all of these variables; and 3) externally validate the score.

Methods

We retrospectively studied 295 consecutive non-ischemic patients with LVH who underwent echocardiography as well as the detailed work-up for LVH (biopsy, technetium pyrophosphate scintigraphy (99mTc-PYP) or cardiac magnetic resonance imaging) (median age, 67 years; MWT, 12 mm). CA was diagnosed by biopsy or 99mTc-PYP. The base model consisted of age (≥65 [male], ≥70 [female]), low voltage in electrocardiography, and posterior wall thickness ≥14 mm in reference to previous studies. Continuous echocardiographic variables were binarized by the use of generally accepted external cutoff points to avoid best clinical scenario. Incremental benefits were assessed using receiver operating characteristic curve analysis and area under the curve (AUC) comparison. Multiple logistic regression analysis was performed to determine the risk score. The score was then validated in the external validation sample (N=178, median age, 70 years; MWT, 12 mm).

Results

CA was observed in 54 patients (18%) and of the several echocardiographic parameters studied, only RASP demonstrated a significant incremental benefit for the screening of CA over the base model (Figure A). After multiple logistic regression analysis in the prediction of CA with 4 variables (RASP and basal model components), each was assigned a numeric value based on its relative effect (Figure B). The incidence rate of CA clearly increased as the sum of the risk score increased (Figure C). The score had good discrimination ability, with an AUC of 0.87, a total score of ≥2 with 70% sensitivity and 90% specificity. Similarly, the discrimination ability of the score in the validation cohort was sufficient (AUC = 0.87).

Conclusion

Overall, we determined a simple risk score including RASP to screen CA. This score takes into account 4 common parameters used in daily practice, and therefore, has potential utility in risk stratification and management of patients with LVH.

Figure 1

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Kitaishikai

Feasibility, reproducibility, and clinical implications of the fully automated assessment for global longitudinal strain

Background

Despite of evidence on its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine because it requires proficiency and is time-consuming. Automated assessment of GLS may be a solution to these barriers. This study sought to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semi-automated and manual assessment for global longitudinal strain.

Methods

In this validation study, different methods for the assessment of GLS were applied to echocardiograms of 561 asymptomatic people (age 71±5 years) with heart failure (HF) risk factors, recruited from the community. All patients were followed up for new-onset of HF and cardiovascular death. Measurement of GLS was repeated using the same apical images on three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semi-automated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator). We defined abnormal GLS for discrimination of LV systolic dysfunction using the cut-off of GLS =18% (absolute value).

Results

AutoStrain measurements were feasible in 99.5% of patients. Calculation time for automated (0.5±0.1 min/patient) and semi-automated assessment (2.7±0.6 min/patient) were significantly shorter than that for manual assessment (4.5±1.6 min/patient) (both p<0.001), and the automated assessment showed excellent reproducibility. There was considerable discordance between automated and semi-automated/manual GLS (Figure 1), but normal systolic function was reliable identified. The prediction of cardiovascular events was reliable with automated, semi-automated and manual GLS (Figure 2).

Conclusion

A novel fully automated assessment for GLS is a feasible, rapid, reproducible and clinically applicable means of assessing LV function, and measurements in the normal range predict a favorable outcome.

Figure 1

Funding Acknowledgement

Type of funding source: None

Incremental benefits of echocardiographic indices over clinical parameters for screening cardiac amyloidosis in patients with left ventricular hypertrophy

Background

Cardiac amyloidosis (CA), characterized by amyloid protein deposition in the heart, is a treatable disease. Although left ventricular (LV) wall thickness is the most established imaging predictor for CA, several echocardiographic indices including deformation parameters also contribute to the screening of CA. However, it is unclear whether additive values of echocardiographic indices have greater benefit over the conventional clinical predictors for the screening of CA. Therefore, we sought to compare the incremental benefits of echocardiographic indices over the clinical parameters for the screening of CA and externally validate their incremental benefits.

Methods

We retrospectively studied 295 consecutive patients (median age, 67 years; male, 65%; mean LV wall thickness (MWT), 12 mm) with LV hypertrophy who underwent echocardiography as well as the detailed work-up for myocardium (Biopsy, technetium pyrophosphate scintigraphy (99mTc-PYP) or cardiac magnetic resonance imaging). CA was diagnosed through biopsy or 99mTc-PYP. The clinical model considers patients' age and the low-voltage in electrocardiography in reference to previous studies. Continuous echocardiographic variables were represented in binary through generally accepted external cutoff points. The incremental benefits of the echocardiography findings over the clinical model were assessed using with the help of both receiver-operated characteristic curve analysis and comparison of area under the curves. Furthermore, these incremental benefits were validated in the external validation sample (median age, 70 years; male, 69%; MWT, 12 mm).

Results

Among the enrolled patients, CA was observed in 18% of cases. Table presents the results of this study. Of the echocardiographic parameters, relative apical sparing pattern (RASP) was the greatest contributor for improvement of diagnostic accuracy of the clinical model. The next greatest contributor was LV wall thickness, followed by left atrial reservoir strain (LAS), E/e', left atrial volume index, ejection fraction strain ratio, and pericardial effusion, respectively. Similarly, RASP, LV wall thickness, global longitudinal strain, ejection fraction, LAS, and granular sparkling showed significant incremental benefit in the validation cohort. Only mean wall thickness, LV wall thickness, LAS, E/e' and RASP consistently improved the diagnostic accuracy of the clinical model.

Conclusion

During the screening process, adding LV wall thickness, LAS, and RASP to the clinical parameters may be useful for the accurate diagnosis of CA in patients with LV hypertrophy.

Figure 1

Funding Acknowledgement

Type of funding source: None

The risk of interstitial lung disease during biological treatment in Japanese patients with psoriasis

BACKGROUND

With the increasing use of biological agents for the treatment of psoriasis, the numbers of patients with interstitial lung disease (ILD) associated with biologics have also increased. Many of these cases were associated with tumour necrosis factor (TNF)-α inhibitors, but cases associated with other families of biologics have also been reported in Japan.

AIM

To analyse the background factors of patients who developed ILD, and to discuss better management of biological treatment.

METHOD

We reviewed 246 patients with psoriasis who were treated with biological agents in our department to identify any pulmonary adverse events (AEs). Data on patients who developed ILD were extracted to analyse background factors, clinical type of psoriasis, time to onset of ILD, pre-existing ILD, smoking habit and prescribed drugs.

RESULTS

Pulmonary AEs were seen in 22 cases, of which 11 were diagnosed as drug-induced ILD. The causative drugs were mainly TNF-α inhibitors, accounting for eight cases (six treated with infliximab, two with adalimumab). The remaining three cases were associated with secukinumab, ustekinumab and ixekizumab (n = 1 each). Notably, these three cases also had a history of drug-induced ILD.

CONCLUSION

Patients with a history of drug-induced ILD seem to be more susceptible to developing another ILD induced by biologics, even if treated with interleukin-17 inhibitors. Thorough screening of risk factors and evaluation for eligibility, and careful monitoring during treatment are the best solutions to avoid serious pulmonary AE. Early detection and precise diagnosis of pulmonary AEs, especially differentiation from infectious diseases, is essential for managing biological treatment.

P1482Preclinical diastolic dysfunction assessed by left atrial strain and association with incident heart failure

Background

Left atrial strain in the reservoir phase (LASr) measures passive LA stretch and is a sensitive marker of left ventricular diastolic dysfunction (DD). However, reduced LASr has not been prospectively validated against clinical heart failure (HF) endpoints and its place in diastology evaluation is unclear.

Aim

We sought whether DD grades defined by previously validated ranges of LASr predicted incident HF and whether reclassifying indeterminate diastolic function based on reduced LASr could facilitate assessment of HF risk.

Methods

Community dwelling elderly subjects were recruited and underwent baseline clinical and echocardiographic assessment. Where imaging was suitable, speckle-tracking echocardiography assessed LASr and subjects were assigned DD grades based on published ranges: normal >35%, grade 1 24–35%, grade 2 19–24%, grade 3 <19%. Current ASE/EACVI recommendations were used to identify those with indeterminate function; LASr-defined DD (LASr-DD) was defined as LASr ≤23%. Follow-up was ≤2 years and incident HF adjudicated by Framingham criteria.

Results

Of 610 subjects (age 71±5 yrs., 46% male) LASr analysis was feasible in 590 (97%); average LASr was 39% (IQR 34–43%). Incident HF was associated with LASr-DD grade, occurring in 8 (36%) with grade ≥2, 14 (10%) with grade 1 and 39 (9%) with normal function (p<0.001). Adjusted odds ratio for incident HF for LASr-DD grade ≥2 was 3.12 (95% CI 1.06–9.1, p=0.038) Diastolic function was indeterminate in 147 (24%) subjects; of 144 (98%) with LAS analysis, 6 (75%) of those with LASr-DD vs. 15 (11%) with normal LASr experienced incident HF (p<0.001).

Univariable Multivariable* OR (95% CI) p-value OR (95% CI) p-value LASr-DD grade:   1 1.13 (0.59–2.15) 0.7 0.84 (0.42–1.69) 0.63   ≥2 5.7 (2.26–14.5) <0.001 3.12 (1.06–9.1) 0.038 *Adjusted for age, hypertension, diabetes, BMI, global longitudinal strain, E/e', LA volume index, LV mass index (all p<0.1 on univariable analysis).

Incorporating LA strain in practice

Conclusion

DD defined by LASr is predictive of HF for grades ≥2 independent of other diastolic measures. Indeterminate diastolic function with LASr ≤23% is associated with incident HF. LASr may complement current diastolic function assessment recommendations.

Acknowledgement/Funding

Baker Heart and Diabetes Institute

P5976Prediction of ventricular arrhythmias with mechanical dispersion assessed by strain echocardiography: a systematic review and meta-analysis

Background

Recent studies have demonstrated that left ventricular mechanical dispersion (LVMD) assessed by speckle tracking might be a powerful marker in risk stratification for ventricular arrhythmias (VA). We sought to perform a systematic review and meta-analysis to i) assess the prognostic value of this parameter (previous studies were predominantly single-center), ii) define the value relative to other parameters, iii) identify the most appropriate cutoff for designating risk.

Purpose

To assess the association between LVMD and the incidence of VA.

Methods

A systemic review of studies reporting the predictive value of LVMD for VA was undertaken from a search of Medline and Embase. LVMD was defined as the standard deviation of time from Q/R on ECG to peak negative strain from each LV segment. VA events were defined as sudden cardiac death, cardiac arrest, documented ventricular tachyarrhythmia, and appropriate implantable cardioverter defibrillator therapy. Hazard ratios (HRs) were extracted from univariable and multivariable models reporting on the association of LVMD and VA and described as pooled estimates with 95% confidence intervals (CIs). In a meta-analysis, the predictive value of LVMD was compared to that of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS).

Results

Among 3198 patients (weighted mean, 63 years, 30% female; 82% ischemic heart disease) in 12 published articles, 387 (12%) had VA events over a follow-up (17–70 months). Patients with VA events had a significantly greater mechanical dispersion compared with those without VA events (weighted mean difference, −20.3 ms; 95% CI, −27.3 to −13.2; p<0.01); 60 ms was found to be the optimal cutoff LVMD value for predicting VA events. Each 10 ms increment of LVMD was significantly and independently associated with VA events (HR, 1.19; 95% CI, 1.09 to 1.29; p<0.01). The predictive value of LVMD was superior to that of LVEF or GLS (Figure).

Figure 1

Conclusion

LVMD assessed by speckle tracking provides important predictive value for VA in patients with a number of cardiac diseases and appears to have superior predictive value to LVEF and GLS for risk stratification.

3224Incremental benefit of left ventricular global longitudinal strain over clinical and left atrial parameters for predicting new-onset atrial fibrillation

Background

Although LV hypertrophy and dysfunction are associated with atrial fibrillation (AF), AF often occurs in the absence of LV hypertrophy or reduced ejection fraction. The effect of subclinical LV dysfunction on AF has not been fully studied.

Purpose

We sought the association between subclinical LV dysfunction (measured with global longitudinal strain, GLS) and new-onset AF.

Methods

This observational study evaluated 531 consecutive patients (median age, 67 years [interquartile range, 56 to 78]; 56% male), without a history of AF who underwent strain echocardiography after cryptogenic stroke. The CHARGE-AF score was used to calculate the 5-year risk of developing AF. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir strain, pump strain, and conduit strain) and LV strain (GLS). A strain analysis was conducted using a dedicated software package, using R-R gating. The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared.

Results

Over 2.5 years of follow-up, 61 patients (11%) had new-onset AF. Patients who developed AF were older, had a higher CHARGE-AF score, larger LA volume, worse LA strain, and worse GLS than those who did not. Areas under the receiver-operating curve for GLS (0.84) was comparable to CHARGE-AF (0.79), LA pump strain (0.83), and LA reservoir strain (0.85). In the nested Cox models, GLS demonstrated an independent and incremental predictive value over the clinical and LA parameters (Figure). Moreover, adding GLS to the combined clinical and LA parameters model resulted in a significantly improved reclassification (net reclassification improvement, 0.32; p=0.016). Importantly, the predictive value of GLS was confirmed in patients with abnormal LA volumes (LA volume index≥34ml/m2) but not in patients with normal LA volumes.

Figure 1

Conclusion

GLS is associated with new-onset AF, especially in patients with abnormal LA volumes. This effect is independent of and incremental to the clinical and LA parameters.

P5979Impact of disease stage on performance of strain markers for prediction of atrial fibrillation

Background

Efforts to predict incident atrial fibrillation (AF) may be associated with complications, and there is interest in AF prediction in primary prevention (PP; pts with risk factors) and secondary prevention (SP; pts with possible AF complications). These pts have different risk levels, we sought whether that influenced the predictive value of LV dysfunction (measured as global longitudinal strain, GLS) or LA dysfunction (LA reservoir strain).

Methods

The PP cohort comprised 351 community-based pts ≥65 years with ≥1 risk factor for AF (age 70±4y,43% male, median follow-up 22 months) and the SP cohort comprised 532 pts after transient ischaemic attack or stroke (age 68±12y, 51% male, median follow-up 36 months). GLS and LA strain were measured offline (Image Arena-Tomtec, Germany). AF was diagnosed by 12 lead ECG, Holter or by single lead monitor. The clinical and echocardiographic characteristics of those with AF were compared to those in sinus rhythm. Nested Cox-regression models were used to assess for independent and incremental predictive value of LA strain/GLS in both cohorts.

Results

Compared to SP, PP had higher clinical AF risk (CHARGE-AF 5.6±5.5% vs 4.7±12.1%, p=0.02) but a lower thromboembolic risk (CHA2DS2-VASC 3±2 vs. 4±2, p<0.001). AF developed in 42 PP pts (12%) and 61 SP (12%). AF patients were older, with higher CHARGE-AF score, LA volume and LV mass. Pts developing AF had reduced GLS (17±4% vs. 20±3%, p<0.001), reservoir (28±11% vs. 35±8%, p<0.001) and pump strain (13±7% vs. 17±5%, p<0.001). GLS and LA strain had greater AUC in SP (0.84 vs 0.58 for GLS and 0.85 vs 0.57 for reservoir strain, both p<0.001). Nested cox-regression models showed that LA reservoir strain was independently associated with AF in both cohorts (p<0.05). GLS was only independently associated with incident AF in SP (Figure).

Conclusion

LA reservoir strain is independently associated with AF in different risk cohorts and its effect is incremental to clinical parameters and LA volume. GLS may be more useful in AF risk assessment in those in SP.

Acknowledgement/Funding

This study was partially supported by the Tasmanian Community Fund and Siemens Healthcare Australia.

P1831Prediction of cardiovascular events by atheromatous plaques detected by non-obstructive general angioscopy: two-year results of EAST-NOGA Registry

Background

Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on.

Purpose

EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events.

Methods

Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study.

Results

The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p<0.001, 12 [4–20] vs. 6 [3–12], p=0.014, respectively). In a univariate analysis, the number of aortic atheromatous plaques and ruptured plaque were significant predictors of MACE (HR: 1.09 95% confidence interval 1.05–1.14, p<0.001) and (HR: 1.12, 95% confidence interval 1.02–1.23, p=0.02). In a multivariate logistic analysis, the number of aortic atheromatous plaques is one of the independent predictors of MACE (HR 1.05, 95% confidence interval 1.00–1.10, p=0.032).

Conclusion

The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events.

Acknowledgement/Funding

None

Histopathological Features of Mycobacterium chelonae Infection in Two Farmed Japanese Pufferfish (Takifugu rubripes)

Granulomatous lesions were observed in the swim bladder, kidney, spleen and gills of two farmed Japanese pufferfish (Takifugu rubripes) infected with Mycobacterium chelonae. Three types of lesions were noted: unencapsulated clusters of epithelioid cells without central necrosis (type 1), encapsulated granulomas without central necrosis (type 2) and encapsulated granulomas with central necrosis (type 3). Type 3 lesions occurred most frequently in the swim bladder, while type 1 and type 2 lesions occurred frequently in the kidney and spleen, and the gills exhibited mostly type 1 lesions. This suggests that the lesions in the swim bladder were more fully developed than those occurring elsewhere and that the swim bladder may be more susceptible to infection with M. chelonae. This is the first report describing the histopathological features of M. chelonae infection in Tetraodontidae.

Complete nucleotide sequence of a new potexvirus, 'Cnidium virus X', isolated from Cnidium officinale in Japan

A flexuous virus was detected in a Cnidium officinale plant in Japan showing mosaic symptoms. The virus was assigned to the genus Potexvirus based on analysis of its complete nucleotide sequence. The genomic RNA of the virus was 5,964 nucleotides in length, excluding the 3'-terminal poly(A) tail. It contained five open reading frames (ORFs), consistent with other members of Potexvirus. The ORF sequences differ from those of previously reported potexviruses. Phylogenetic analysis indicated that the polymerase of the virus is closely related to that of strawberry mild yellow edge virus; and the CP, to those of both yam virus X and vanilla virus X. We propose that this virus be designated as "cnidium virus X" (CnVX).

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with metastatic oesophageal cancer: a JSMO-ESMO initiative endorsed by CSCO, KSMO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of oesophageal cancer was published in 2016, and covered the management and treatment of local/locoregional disease, limited disease, locally advanced disease and the management of advanced/metastatic disease. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and the Japanese Society of Medical Oncology (JSMO) to convene a special guidelines meeting immediately after the JSMO Annual Meeting in 2018. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic oesophageal cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic oesophageal cancer representing the oncological societies of Japan (JSMO), China (CSCO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices and the drug availability and reimbursement situations in the individual participating Asian countries.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with metastatic gastric cancer: a JSMO-ESMO initiative endorsed by CSCO, KSMO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of gastric cancer (GC) was published in 2016, and covered the management and treatment of local, locoregional, locally advanced and metastatic disease. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and The Japanese Society of Medical Oncology (JSMO) to convene a special guidelines meeting immediately after the JSMO Annual Meeting in 2018. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic GC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic GC representing the oncological societies of Japan (JSMO), China (CSCO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of both the current treatment practices and the drug availability and reimbursement situations in the individual participating Asian countries.

Mitochondrial DNA haplogroups and age at onset of Machado-Joseph disease/spinocerebellar ataxia type 3: a study in patients from multiple populations

BACKGROUND AND PURPOSE

Mitochondrial dysfunction has been implicated in the pathogenesis of several neurodegenerative disorders, including Machado-Joseph disease (MJD), an autosomal dominant late-onset polyglutamine ataxia that results from an unstable expansion of a CAG tract in the ATXN3 gene. The size of the CAG tract only partially explains age at onset (AO), highlighting the existence of disease modifiers. Mitochondrial DNA (mtDNA) haplogroups have been associated with clinical presentation in other polyglutamine disorders, constituting potential modifiers of MJD phenotype.

METHODS

A cross-sectional study, using 235 unrelated patients from Portugal, Brazil, India and Japan, was performed to investigate if mtDNA haplogroups contribute to AO of MJD. mtDNA haplogroups were obtained after sequencing the mtDNA hypervariable region I. Patients were classified in 15 phylogenetically related haplogroup clusters.

RESULTS

The AO was significantly different among populations, implying the existence of other non-CAG factors, which seem to be population specific. In the Portuguese population, patients classified as belonging to haplogroup JT presented the earliest onset (estimated onset 34.6 years of age). Haplogroups W and X seem to have a protective effect, causing a delay in onset (estimated onset 47 years of age). No significant association between haplogroup clusters and AO was detected in the other populations or when all patients were pooled. Although haplogroup JT has already been implicated in other neurodegenerative disorders, no previous reports of an association between haplogroups W and X and disease were found.

CONCLUSIONS

These findings suggest that haplogroups JT, W and X modify AO in MJD. Replication studies should be performed in European populations, where the frequency of the candidate modifiers is similar.

Hepatotoxicity, nephrotoxicity, and drug/chemical interaction toxicity of platinum nanoparticles in mice

Nanomaterials are frequently used in microelectronics, cosmetics, and sunscreens. Platinum reagents are commonly used in disease diagnosis, cosmetics, and the food industry. Although research into the development of nanomaterialbased drug delivery systems has yielded promising results, the toxicity of these materials is not fully understood. We investigated the toxicity and drug interactions of 1- and 8-nm diameter platinum nanoparticles (nPt1 and nPt8, respectively) in mice. Acute hepato-renal toxicity of intravenously administered platinum nanoparticles was evaluated biochemically and histologically. Dose-dependent increases in serum markers of hepato-renal function (serum aminotransferases and blood urea nitrogen) were observed following administration of nPt1, whereas nPt8 had no effect, even at 20 mg/kg. Moreover, nPt1 induced interleukin (IL)-6 and IL-1β production 3 and 6 hours after administration. The effect of nPts on drug-induced toxicity was evaluated in mice injected intraperitoneally with carbon tetrachloride or cisplatin, with or without intravenous administration of platinum nanoparticles. All treatments in the absence of nanoparticles were non-lethal and resulted in moderate toxicity. However, exacerbated toxicity was observed in mice injected with carbon tetrachloride or cisplatin together with nPt1, but not in mice co-injected with nPt8. We found that nPt1 cause hepato-renal damage, and the effect is enhanced by chemical inducers of hepatotoxicity and nephrotoxicity. This is the first report demonstrating that nPt1 not only are hepatotoxic and nephrotoxic but also exacerbate drug toxicity. These findings will be useful for future nanotechnology and nanoscience research.

Accelerated anaerobic release of K, Mg and P from surplus activated sludge for element recovery and struvite formation inhibition

Accelerated release of potassium (K), magnesium (Mg) and phosphorus (P) from surplus activated sludge (SAS) was investigated to develop a new system for the recovery of the elements. Anaerobic cultivation of SAS during 24 h released 78% of K and about 50% of Mg and P from SAS more effectively compared to aerobic cultivation (K: 40%, Mg: 15%, P: 15%). Furthermore, the addition of sodium acetate as an organic carbon source remarkably accelerated the release of K, Mg and P from SAS under anaerobic condition. However, no increase in the maximum release efficiencies was observed. The elements released from SAS could be transferred to separate liquid with the existing mechanical thickener and be recovered as MgKPO₄ by some additional process. Furthermore, the removal of the elements from SAS would inhibit the formation of struvite causing the blockage of sludge transport pipe after anaerobic digestion process of thickened sludge.

Gold Nanoparticles Inhibit Matrix Metalloproteases without Cytotoxicity

Nanoparticles (NPs) are currently the focus of considerable attention for dental applications; however, their biological effects have not been fully elucidated. The long-term, slow release of matrix metalloproteases (MMPs) digests collagen fibrils within resin-dentin bonds. Therefore, MMP inhibitors can prolong the durability of resin-dentin bonds. However, there have been few reports evaluating the combined effect of MMP inhibition and the cytotoxic effects of NPs for dentin bonding. The aim of this study was to evaluate MMP inhibition and cytotoxic responses to gold (AuNPs) and platinum nanoparticles (PtNPs) stabilized by polyvinylpyrrolidone (PVP) in cultured murine macrophages (RAW264) by using MMP inhibition assays, measuring cell viability and inflammatory responses (quantitative reverse transcription polymerase chain reaction [RT-qPCR]), and conducting a micromorphological analysis by fluorescence and transmission electron microscopy. Cultured RAW264 cells were exposed to metal NPs at various concentrations (1, 10, 100, and 400 µg/mL). AuNPs and PtNPs markedly inhibited MMP-8 and MMP-9 activity. Although PtNPs were cytotoxic at high concentrations (100 and 400 µg/mL), no cytotoxic effects were observed for AuNPs at any concentration. Transmission electron microscopy images showed a significant nonrandom intercellular distribution for AuNPs and PtNPs, which were mostly observed to be localized in lysosomes but not in the nucleus. RT-qPCR analysis demonstrated inflammatory responses were not induced in RAW264 cells by AuNPs or PtNPs. The cytotoxicity of nanoparticles might depend on the core metal composition and arise from a “Trojan horse” effect; thus, MMP inhibition could be attributed to the surface charge of PVP, which forms the outer coating of NPs. The negative charge of the surface coating of PVP binds to Zn2+ from the active center of MMPs by chelate binding and results in MMP inhibition. In summary, AuNPs are attractive NPs that effectively inhibit MMP activity without cytotoxicity or inflammatory responses.

Anti-HER3 monoclonal antibody patritumab sensitizes refractory non-small cell lung cancer to the epidermal growth factor receptor inhibitor erlotinib

Human epidermal growth factor receptor (HER) 3 is aberrantly overexpressed and correlates with poor prognosis in non-small cell lung cancer (NSCLC). Patritumab is a monoclonal antibody against HER3 that has shown promising results in early-phase clinical trials, but an optimal target population for the drug has yet to be identified. In the present study, we examined whether heregulin, a HER3 ligand that is also overexpressed in a subset of NSCLC, can be used as a biomarker to predict the antitumorigenic efficacy of patritumab and whether the drug can overcome the epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) resistance induced by heregulin. Patritumab sensitivity was associated with heregulin expression, which, when abolished, resulted in the loss of HER3 and AKT activation and growth arrest. Furthermore, heregulin overexpression induced EGFR TKI resistance in NSCLC cells harbouring an activating EGFR mutation, while HER3 and AKT activation was maintained in the presence of erlotinib in heregulin-overexpressing, EGFR-mutant NSCLC cells. Sustained HER3-AKT activation was blocked by combining erlotinib with either anti-HER2 or anti-HER3 antibody. Notably, heregulin was upregulated in tissue samples from an NSCLC patient who had an activating EGFR mutation but was resistant to the TKI gefitinib. These results indicate that patritumab can overcome heregulin-dependent EGFR inhibitor resistance in NSCLC in vitro and in vivo and suggest that it can be used in combination with EGFR TKIs to treat a subset of heregulin-overexpressing NSCLC patients.