Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Development of Rat Caries-Induced Pulpitis Model for Vital Pulp Therapy

Rodent animal models for vital pulp therapy are commonly used in dental research because their tooth anatomy and cellular processes are similar to the anatomy and processes in humans. However, most studies have been conducted using uninfected sound teeth, which makes it difficult to adequately assess the inflammatory shift after vital pulp therapy. In the present study, we aimed to establish a caries-induced pulpitis model based on the conventional rat caries model and then evaluate inflammatory changes during the wound-healing process after pulp capping in a model of reversible pulpitis induced by carious infection. To establish the caries-induced pulpitis model, the pulpal inflammatory status was investigated at different stages of caries progression by immunostaining targeted to specific inflammatory biomarkers. Immunohistochemical staining revealed that both Toll-like receptor 2 and proliferating cell nuclear antigen were expressed in moderate and severe caries-stimulated pulp, indicating that an immune reaction occurred at both stages of caries progression. M2 macrophages were predominant in moderate caries-stimulated pulp, whereas M1 macrophages were predominant in the severe caries-stimulated pulp. Pulp capping in teeth with moderate caries (i.e., teeth with reversible pulpitis) led to complete tertiary dentin formation within 28 d after treatment. Impaired wound healing was observed in teeth with severe caries (i.e., teeth with irreversible pulpitis). During the wound-healing process in reversible pulpitis after pulp capping, M2 macrophages were predominant at all time points; their proliferative capacity was upregulated in the early stage of wound healing compared with healthy pulp. In conclusion, we successfully established a caries-induced pulpitis model for studies of vital pulp therapy. M2 macrophages have an important role in the early stages of the wound-healing process in reversible pulpitis.

Novel Functional Peptide for Next-Generation Vital Pulp Therapy

Although vital pulp therapy should be performed by promoting the wound-healing capacity of dental pulp, existing pulp-capping materials were not developed with a focus on the pulpal repair process. In previous investigations of wound healing in dental pulp, we found that organic dentin matrix components (DMCs) were degraded by matrix metalloproteinase-20, and DMC degradation products containing protein S100A7 (S100A7) and protein S100A8 (S100A8) promoted the pulpal wound-healing process. However, the direct use of recombinant proteins as pulp-capping materials may cause clinical problems or lead to high medical costs. Thus, we hypothesized that functional peptides derived from recombinant proteins could solve the problems associated with direct use of such proteins. In this study, we identified functional peptides derived from the protein S100 family and investigated their effects on dental pulp tissue. We first performed amino acid sequence alignments of protein S100 family members from several mammalian sources, then identified candidate peptides. Next, we used a peptide array method that involved human dental pulp stem cells (hDPSCs) to evaluate the mineralization-inducing ability of each peptide. Our results supported the selection of 4 candidate functional peptides derived from proteins S100A8 and S100A9. Direct pulp-capping experiments in a rat model demonstrated that 1 S100A8-derived peptide induced greater tertiary dentin formation compared with the other peptides. To investigate the mechanism underlying this induction effect, we performed liquid chromatography-tandem mass spectrometry analysis using hDPSCs and the S100A8-derived peptide; the results suggested that this peptide promotes tertiary dentin formation by inhibiting inflammatory responses. In addition, this peptide was located in a hairpin region on the surface of S100A8 and could function by direct interaction with other molecules. In summary, this study demonstrated that a S100A8-derived functional peptide promoted wound healing in dental pulp; our findings provide insights for the development of next-generation biological vital pulp therapies.

Carbon-ion beam irradiation in combination with cisplatin effectively suppresses xenografted malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare aggressive cancer. This study investigated the growth-inhibitory effects of the combination of carbon ion beam irradiation (IR) and cisplatin (CDDP) on MPM xenografts. Carbon-ion beam IR at 15 Gy effectively inhibited tumor growth and decreased the tumor volume more than 90% after 9 weeks. However, tumor regrowth was observed after 17 weeks. The combination of carbon-ion beam IR (15 Gy) and CDDP significantly suppressed tumor growth after 9 weeks, with tumor regression being observed for more than 18 weeks. In contrast, X-ray IR (30 Gy) alone or in combination with CDDP effectively suppressed tumor growth and decreased the tumor volume after 11 weeks, but tumor growth was observed after 15 weeks. Carbon-ion beam IR at 25 Gy resulted in complete tumor regression without tumor regrowth in the 20-week follow-up period. Histopathological analysis revealed that combination of carbon-ion beam IR and CDDP exerted effective cytotoxic effects on MPM xenograft tumor cells and significantly promoted tumor cell necrosis, cavitation, and fibrosis when compared with individual treatment with carbon-ion beam, X-ray IR, or CDDP. Immunohistochemical analysis revealed that the expression levels of tumor cell migration and invasion-related proteins such as CXCL12, MMP2 and MMP9 were not significantly affected upon low dose (15 Gy) carbon-ion beam IR alone or in combination with CDDP but were markedly upregulated upon treatment with CDDP alone relative to control. However, IR with a high dose (25 Gy) carbon-ion beam inhibited tumor growth without upregulating these proteins. In conclusion, the combination of IR with a low dose (15 Gy) carbon ion beam and CDDP effectively suppressed MPM tumor in vivo without significantly upregulating CXCL12, MMP2 and MMP9, suggesting that combination therapy of carbon ion beam IR and chemotherapy is a promising therapeutic strategy for MPM.

A Randomized Controlled Phase 2 Study of Neoadjuvant Eribulin Versus Paclitaxel in Women with Operable Breast Cancer: The JONIE-3 Study

OBJECTIVE

Neoadjuvant chemotherapy (NAC) is essential for surgical downstaging of early-stage breast cancer, but taxane administration is associated with neuropathy. We investigated whether eribulin induces less neuropathy than paclitaxel.

METHODS

In this multicentre, randomised study (UMIN000012817), patients diagnosed with invasive breast cancer between December 2013 and April 2016 were randomly assigned to group E (eribulin followed by fluorouracil, epirubicin, and cyclophosphamide; FEC) or group P (paclitaxel followed by FEC). The primary endpoint was incidence of grade 1 or higher peripheral neuropathy according to the Common Terminology Criteria for Adverse Events (CTCAE). Secondary endpoints were pathological complete response (pCR), clinical response, breast-conserving surgery, adverse events, disease-free survival (DFS), and patient neurotoxicity questionnaire (PNQ) analysis.

RESULTS

One hundred and eighteen cases were analyzed for safety and 115 were evaluated for efficacy. Peripheral sensory neuropathy was significantly lower in group E after week 6, while peripheral motor neuropathy in group E was significantly lower at weeks 9, 12, and 15. pCR in groups E and P was 20.7% and 29.8% (P = .289), respectively, and clinical response was 55.2% and 77.2% (P = .017), respectively. Three-year DFS was 89.7% in group E and 86.0% in group P (P = .561). Neutropenia was more frequent and more severe in group E. PNQ was evaluated for 4 years, and item 1 (sensory) was consistently lower in group E.

CONCLUSION

Neuropathy was significantly less frequent and less severe in patients who received eribulin compared with paclitaxel. Thus, eribulin could be a good alternative to paclitaxel in patients suffering severe neuropathy.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no predictor of AD onset is available nor therapeutic intervention to specifically prevent the progressive destruction in AD, because the molecular pathogenesis is largely unknown. Clinical and experimental studies highlighted the importance of inflammation in AD, although the regulatory mechanism of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation causes cellular senescence that can induce inflammatory response, we hypothesized that cellular senescence participates in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in mouse AD model.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the induction of senescence markers Ink4a from day 3 before AD onset and persisted for the 14 days of the observational period.

Cellular senescence, as demonstrated by the expression of senescence-associated beta-galactosidase, was evident in intimal endothelial cells, medial smooth muscle cells, adventitial macrophages and fibroblasts. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence marker, prevented the death by AD rupture, and ameliorated the severity of AD lesion compared to the vehicle treatment. Transcriptome analysis revealed that ABT treatment suppressed the immune and inflammatory response in AD. Quantitative RT-PCR confirmed that ABT treatment prevented the induction of p21Cip1, interleukin-6, several chemokines and their receptors by 3-day infusion of BAPN+AngII.

Conclusions

These findings demonstrated that senescence of multiple cell types precedes AD development, which is likely to induce the inflammatory response. Elimination of senescent cells effectively prevented AD progression and death. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

M. avium complex pulmonary disease: does the diagnostic method affect severity and progression?

SETTING: Diagnosis of Mycobacterium avium complex pulmonary disease (MAC-PD) requires positive culture of expectorated sputum or specimens acquired by bronchoscopy. Whether patients diagnosed using bronchoscopy have milder disease and milder progression than those diagnosed using sputum remains uncertain.OBJECTIVE: To clarify whether disease severity and progression differ according to the diagnostic method.METHODS: We retrospectively analysed 92 patients with MAC-PD. We compared characteristics of patients and disease progression according to the diagnostic methods used: sputum or bronchoscopy. Additionally, we investigated the impact of these methods on disease progression using multivariate analysis.RESULTS: Patients diagnosed using sputum were younger than those diagnosed using bronchoscopy; however, there were small differences from the viewpoint of clinical practice in disease severity, and estimated progression-free survival rate did not differ significantly. The predictors of disease progression were disease forms other than non-cavitary nodular/bronchiectatic disease, hypoalbuminemia and severe radiographic scores.CONCLUSION: The diagnostic methods had no significant impact on disease severity and disease progression of MAC-PD. If the diagnosis cannot be established by sputum culture or if sputum cannot be obtained in the patients with risk factors for disease progression, bronchoscopy would be useful to provide opportunity of treatment for MAC-PD.

Tissue 2-Hydroxyglutarate and Preoperative Seizures in Patients With Diffuse Gliomas

BACKGROUND AND OBJECTIVES

Mutant isocitrate dehydrogenase (IDH) 1/2 gene products gain a new ability to produce D-2-hydroxyglutarate (D2HG). IDH1/2 mutations are thought to be associated with seizures owing to the structural similarity between D2HG and glutamate. However, the effects of D2HG on seizures in clinical settings are not fully understood. We sought to investigate the relationship between tissue 2-hydroxyglutarate (2HG) concentration and preoperative seizures using clinical samples.

METHODS

We included 104 consecutive patients with diffuse glioma who underwent surgery from August 2008 to May 2016 and whose clinical presentation and IDH1/2 status were identified. The presence of preoperative seizures, tumor location, histopathologic diagnosis, IDH1/2 status, and 1p/19q codeletion were assessed from the patient charts. Tissue 2HG concentration was measured using liquid chromatography-tandem mass spectrometry. To evaluate 2HG distribution without artefactual tissue disruption, we applied matrix-assisted laser desorption/ionization high-resolution mass spectrometry imaging (MALDI-MSI) in 12 patients' surgically resected samples. We assessed the correlation of preoperative seizures with tissue 2HG concentration, IDH1/2 status, WHO grade, and 1p/19q codeletion.

RESULTS

Tissue 2HG concentration was higher in IDH1/2 mutant tumors (IDH-Mut, n = 42) than in IDH1/2 wild-type tumors (IDH-WT, n = 62) (median 4,860 ng/mg vs 75 ng/mg) (p < 0.0001). MALDI-MSI could detect 2HG signals in IDH-Mut, but not in IDH-WT. Preoperative seizures were observed in 64.3% of patients with IDH-Mut and 21.0% patients with IDH-WT (p < 0.0001). The optimal cutoff value of tissue 2HG concentration for predicting preoperative seizures was 1,190 ng/mg, as calculated by the receiver operating characteristic curve. Increased preoperative seizure risk was only observed in tumors with 2HG concentration above the cutoff value among IDH-Mut (IDH-Mut with above the cutoff value: 71.4% vs IDH-Mut with below the cutoff value: 28.6%; p = 0.031). Multivariate analysis, including IDH1/2 mutation status, tissue 2HG concentration, WHO grade, and 1p/19q codeletion, revealed that only increased tissue 2HG concentration was associated with preoperative seizures (odds ratio 5.86, 95% confidence interval 1.02-48.5; p = 0.048).

DISCUSSION

We showed that high tissue 2HG concentration was associated with preoperative seizures, suggesting that excess 2HG increases risk of preoperative seizures in IDH1/2 mutant tumors.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no reliable predictor is available for AD development and surgical intervention is the only therapeutic option to prevent the fatal events after AD development, because the pathogenesis of AD is largely unknown.

Clinical and experimental studies highlighted the importance of inflammation in AD pathogenesis, although the trigger of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation triggers cellular senescence and senescent cells secrete of proinflammatory cytokines and matrix metalloproteinases, we hypothesized that cellular senescence may participate in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in a mouse model of AD.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the appearance of senescent cells that are positive for senescence-associated beta-galactosidase, and expression of senescence markers Arf and Ink4a in the aortic walls. Appearance of cellular senescence occurred in one day of BAPN+AngII infusion and continued throughout the observational period of 14 days. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence markers. In the vehicle-treated group, the mortality was 66.7% (12/18), whereas that of ABT263-treated group was 35% (14/20, P&lt;0.05 by log-rank test). The severity of AD, as assessed by the lesion length in vehicle group was33.2±3.1 mm, whereas that in ABT263 group was 24.6±1.8 mm (P&lt;0.05).

Conclusions

These findings demonstrated that cellular senescence precedes AD development, and ABT263 effectively prevented AD progression and death, indicating the involvement of cellular senescence in AD pathogenesis. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

Involvement of FAK in aortic dissection: potential role in aortic interstitial cells

Background

Aortic dissection (AD) is a fatal disease where the intimomedial layer of the aorta suddenly fail. Although it is widely accepted that hemodynamic stress on the aortic wall triggers its destruction that is further promoted by inflammatory response as exemplified by the infiltration of neutrophils and macrophages, molecular mechanism is unknown for the link of aortic wall stress, inflammation and tissue destruction. In general, mechanical stress to the tissue is converted to the cellular response through the cell adhesion molecules and the activation of focal adhesion kinase (Fak). Although it has been reported that Fak is involved in pathogenesis of aortic aneurysm by promoting migration and activation of macrophages, its role in AD is unknown. We hypothesized that Fak may be involved in AD pathogenesis.

Purpose

We investigated the involvement of Fak in AD pathogenesis, focusing on its role in inflammatory cells.

Methods and results

We created a mouse model of AD by continuous infusion of beta-aminopropionitrile, a collagen crosslink inhibitor, and angiotensin II (BAPN + Ang II). Immunostaining for activated Fak revealed that Fak was not activated in normal aorta, but was activated in the infiltrating inflammatory cells and in interstitial cells of the aortic wall after AD development. We examined the role of Fak by oral administration of PND-1186, a specific Fak inhibitor, in mouse AD model. Vehicle-treated group showed 63.6% mortality, whereas PND-1186-treated group showed 20% mortality (P&lt;0.01, n=20 for each group) in 14 days of the observational period. The aortic arch lesion, the most critical part in AD, was improved from 1.96±0.41 mm in vehicle group to 0.66±0.29 mm in PND group (P&lt;0.05). We next examined the cell type-specific role of Fak in AD by creating macrophage and granulocyte-specific deletion of Fak driven by LysM-Cre and floxed Fak system. Unexpectedly, the genetic deletion of Fak in macrophages and granulocytes had no impact on the mortality nor the severity of AD.

Conclusions

These findings proved that Fak plays a critical role in AD progression and death. Because Fak is dispensable for macrophages and granulocytes, other cell types, possibly aortic wall interstitial cells, may be regulated by Fak in AD pathogenesis. Deciphering the role of Fak would provide the fundamental understanding of AD pathogenesis.

Funding Acknowledgement

Type of funding sources: None.

Carbon-Ion Beam Irradiation and the miR-200c Mimic Effectively Eradicate Pancreatic Cancer Stem Cells Under in vitro and in vivo Conditions

Purpose

The study investigated the molecular mechanisms that killed pancreatic cancer cells, including cancer stem cells (CSCs), by carbon ion beam irradiation alone or in combination with miRNA-200c under in vitro and in vivo conditions.

Methods

Human pancreatic cancer (PC) cells, PANC1 and PK45, were treated with carbon-ion beam irradiation alone or in combination with microRNA-200c (miR-200c) mimic. Cell viability assay, colony and spheroid formation assay, quantitative real-time PCR analysis of apoptosis-, autophagy-, and angiogenesis-related gene expression, xenograft tumor control and histopathological analyses were performed.

Results

The cell viability assay showed that transfection of the miRNA-200c (10 nM) mimic into pancreatic CSC (CD44+/ESA+) and non-CSC (CD44-/ESA-) significantly suppressed proliferation of both types of cell populations described above. Combining carbon-ion beam irradiation with the miRNA-200c mimic significantly reduced the colony as well as spheroid formation abilities compared to that observed with the treatment of carbon-ion beam alone or X-ray irradiation combined with the miRNA-200c mimic. Moreover, the combination of carbon ion beam irradiation and miRNA-200c mimic increased the expression of apoptosis-related gene BAX, autophagy-related genes Beclin-1 and p62, addition of gemcitabine (GEM) further enhanced the expression of these genes. In vivo data showed that carbon-ion beam irradiation in combination with the miRNA-200c mimic effectively suppressed xenograft tumor growth and significantly induced tumor necrosis and cavitation.

Conclusion

The combination of miRNA-200c mimic and carbon ion beam irradiation may be powerful radiotherapy that significantly kills pancreatic cancer cells containing CSCs and enhances the effect of carbon-ion beam irradiation compared to carbon-ion beam irradiation alone.

Fabrication of Vascularized DPSC Constructs for Efficient Pulp Regeneration

Dental pulp regeneration is a promising approach to restore the vitality of necrotic teeth. We have previously reported the fabrication of scaffold-free cell constructs containing only dental pulp stem cells (DPSCs) and their ability to form pulp-like tissue in the pulpless tooth. However, the DPSC construct could not build pulp-like tissue with a full root length because it is difficult to induce blood vessels from a small root canal foramen. Therefore, we hypothesized that vascular structure could be preformed in the DPSC construct by employing endothelial differentiation capability of DPSCs, and vascularized constructs might facilitate dental pulp regeneration in the pulpless tooth. In this study, vascularized DPSC constructs were fabricated by inducing endothelial differentiation, and then we investigated the behavior of differentiated DPSCs, the internal structure of cell constructs, and their pulp regenerative ability in vivo. We observed that DPSCs positive for CD31 and von Willebrand factor were localized at the outer layer of constructs and formed a reticulated lumen structure. The cells constituting the outer layer of the construct expressed endothelial differentiation markers at higher levels than cells in the inner part. These results indicated that DPSCs in the outer layer differentiated into endothelial cells and formed vascular-like structures in the cell construct. Next, a vascularized DPSC construct was transplanted into the human pulpless tooth that was implanted into immunodeficient mice in the subcutaneous space. After 6 wk of implantation, the vascularized construct formed pulp-like tissues with higher density of human CD31-positive blood vessels when compared with specimens implanted with a DPSC construct without prevascularization. These results suggest that the vascular structure formed in the DPSC construct facilitated the blood supply and enhanced pulp regeneration. This study demonstrates that a vascularized DPSC construct is a prospective biomaterial as an implant for novel dental pulp regeneration.

Clinical imaging for the prediction of neoadjuvant chemotherapy response in breast cancer

Increased use of cancer screening, improved imaging, and diagnostic intervention techniques has led to the diagnosis of smaller cancers, including breast cancer. Most breast cancer patients receive systemic therapy, and some treatments are given before surgery, such as neoadjuvant therapy, even in an operable setting. Improved neoadjuvant chemotherapy has increased rates of pathological complete response; however, surgery is still required to determine complete tumor remission. Inadequate preoperative evaluations after neoadjuvant therapy can result in excessive surgical stress. Clinical imaging tests such as ultrasound and magnetic resonance imaging of the breast are often performed with neoadjuvant therapy. These clinical imaging techniques, in addition to measuring tumor size, have made it possible to evaluate certain functional aspects of the tumors. Herein, we review the current state of clinical imaging research focused on predicting neoadjuvant chemotherapy response in breast cancer. We also discuss the upfront prediction of treatment response before and during neoadjuvant therapy and the later prediction of pathological residual tumors, including pathological complete response, using ultrasound and magnetic resonance imaging. Upfront prediction can help decision-making and develop new treatment strategies. Predicting the localization of microscopic residual tumors may contribute to disease management without surgery, using radiation or other local treatments. Further larger studies on the prediction of neoadjuvant therapy response using clinical imaging could improve clinical practice and patient benefits.

Impact of tapered-shaped left ventricular outflow tract on permanent pacemaker implantation after the third-generation balloon-expandable valve implantation

Background

In the era of transcatheter aortic valve implantation (TAVI) for patients with lower surgical risk, conduction disturbances requiring permanent pacemaker implantation (PPI) after TAVI remain a serious concern. The association between tapered-shaped left ventricular outflow tract (LVOT) and PPI after TAVI has not been elucidated.

Purposes

This study sought to identify predictors for PPI after TAVI with the third-generation balloon-expandable valve, with focus on LVOT morphology.

Methods

Of 272 consecutive patients treated with the third-generation balloon-expandable valve, 256 patients without previous PPI or bicuspid valve were retrospectively analyzed.

Results

PPI was implanted after TAVI in 20 (7.8%) patients. Patients requiring PPI had smaller LVOT area (356.3 mm2 vs. 399.4 mm2, p=0.011). Moreover, receiver-operating characteristic (ROC) statistics showed that LVOT area /annulus area possessed significantly higher predictive ability than LVOT area (area under the curve: 0.91 [95% confidence interval [CI]: 0.84 to 0.95] vs. 0.67 [95% CI: 0.57 to 0.77], p&lt;0.001). Multivariable analysis revealed LVOT area /annulus area (odds ratio [OR]: 1.93 [95% CI: 1.38–2.71]; p&lt;0.001 per % of decreasing), the difference between membranous septum length and implantation depth (ΔMSID) (OR: 6.82 [95% CI 2.39–19.48]; p&lt;0.001 per mm of decreasing) and pre-existing complete right bundle branch block (CRBBB) (OR: 32.38 [95% CI 2.30–455.63]; p=0.002) as independent predictors of PPI. Further analysis using ROC statistics revealed LVOT area / annulus area of 88.5% and ΔMSID of 1.8 mm as the optimal cutoff points for prediction of PPI after the third-generation balloon-expandable valve implantation, with high negative predictive values of 98.1% and 99.0%, respectively. Figure shows the PPI rates stratified by the number of following predictors: LVOT area /annulus area &lt;88.5%, ΔMSID &lt;1.8 mm and pre-existing CRBBB. Patients with 2 or more predictors had significantly higher PPI rates than those with 1 or less predictor (67% [18 of 27 patients] vs. 1% [2 of 229 patients], p&lt;0.001).

Conclusions

LVOT area /annulus area, ΔMSID and pre-existing CRBBB were identified as powerful independent predictors for PPI after TAVI. Higher valve implantation is important to prevent excessive PPI especially for patients with pre-procedural tapered-shaped LVOT, short membranous septum or pre-existing CRBBB.

PPI rates stratified by predictors

Funding Acknowledgement

Type of funding source: None

A novel therapeutic approach for coronary inflammation and lymphatic vessels using non-invasive low-intensity pulsed ultrasound in a porcine model with DES-induced coronary hyperconstricting responses

Background

The coronary adventitia harbors lymphatic vessels (LVs). We previously demonstrated that coronary adventitial inflammation and LV dysfunction play important roles in the pathogenesis of coronary artery spasm, including drug-eluting stent (DES)-induced coronary hyperconstricting responses, in pigs and humans. However, a direct therapeutic approach to the coronary adventitia remains to be developed.

Purpose

In this study, we aimed to examine whether our novel and non-invasive therapy with low-intensity pulsed ultrasound (LIPUS) ameliorates DES-induced coronary hyperconstricting responses, and if so, what mechanisms are involved.

Methods

An everolimus-eluting stent (EES) was implanted into the left anterior descending (LAD) coronary artery in normal male pigs. They were randomly assigned to the LIPUS or the sham therapy groups. After EES implantation, in the LIPUS group, LIPUS (32 cycles, 193 mW/cm2) was applied to the heart at 3 different levels (proximal and distal stent edges and middle portion of the stent) through X-ray fluoroscopy for 20 min at each level for every other day for 2 weeks (6 days in total) (Fig. 1A, B). The sham therapy group was treated in the same manner but without LIPUS. At 4 weeks after the procedure, we performed coronary angiography to examine coronary vasoconstricting responses to intracoronary serotonin in vivo. Finally, stented coronary vessels were harvested for immunohistochemistry of vasa vasorum (vWF), LVs (LYVE-1), vascular inflammation (CD68-positive macrophages and IL-1β expression), vascular endothelial growth factor A (VEGF-A, angiogenesis marker), VEGF-C and VEGF receptor 3 (VEGFR3, lymphangiogenesis markers).

Results

Coronary vasoconstricting responses to intracoronary serotonin at the DES edges in the LAD were significantly enhanced in the sham group but were significantly suppressed in the LIPUS group, while those responses were comparable at the non-DES implanted left circumflex (LCx) coronary artery between the 2 groups (Fig. 1C, D). In addition, in vivo lymph transport speed was significantly faster in the LIPUS group than in the sham group (Fig. 1E–G). In histological analysis, the number of LVs was significantly increased in the LIPUS group compared with the sham group, whereas those of CD68 and IL-1β expressions were significantly reduced in the LIPUS group compared with the sham group. In contrast, the density of vasa vasorum was comparable between the 2 groups. Mechanistically, the extents of VEGF-C and VEGFR3 expressions were increased in the LIPUS group, whereas that of VEGF-A was comparable between the 2 groups (Fig. 1G–K). Importantly, there were significant correlations among the LV-related changes and enhanced coronary vasoconstricting responses.

Conclusion

These results provide the first evidence that the LIPUS therapy ameliorates DES-induced coronary hyperconstricting responses in pigs in vivo through structural and functional alterations of LVs (Fig. 1L).

Figure 1

Funding Acknowledgement

Type of funding source: None

The role of B cells and IgG in aortic dissection

Background

Aortic dissection (AD) is one of the destructive and fatal aortic diseases, for which molecular pathogenesis is largely unknown. Recent studies have highlighted the importance of inflammatory response in AD. We and others reported that B cells and immunoglobulins participate in pathogenesis of abdominal aortic aneurysm, another form of aortic destructive disease, by promoting inflammatory response. It is not known whether and how B cells participate in AD pathogenesis.

Methods and results

Immunohistochemical staining of human AD tissue revealed that B cells were clustered together with T cells, macrophages and neutrophils at the entry site of AD with medial disruption. B cell cluster was also observed at the site of medial disruption in mouse model of AD that was induced by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII). In muMT mouse, which is deficient for B cells and immunoglobulins due to genetic deletion of immunoglobulin heavy chain, BAPN+AngII induced significantly less severe AD compared to that in wild type. Depositions of IgG and fibrinogen, one of the endogenous antigen for natural IgG, were observed after BAPN+AngII infusion before and after AD development in wild type mice. Deposition of fibrinogen was also observed in mMT mice after BAPN+AngII infusion. The rate of aortic rupture and sudden death was approximately 42% in wild type mice, while that in muMT mouse was 12% (P&lt;0.05). Administration of mouse normal polyclonal IgG to muMT mice resulted in dramatic increase in aortic rupture and sudden death, starting at day 7 of BAPN+AngII infusion, and reaching 69% of rupture rate, indicating the critical role of IgG in AD.

Conclusion

These findings demonstrated B cells and IgG are critically involved in the destructive inflammation of AD pathogenesis. Further, the deposition of fibrinogen, one of the targets of natural IgG, precedes the development of AD. Our findings may provide the conceptual foundation of the diagnostic strategy for on-going tissue destruction and for the therapeutic opportunities to intervene the progressive tissue destruction in AD.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Japan Society for the Promotion of Science

Phosphoethanolamine Accumulation Protects Cancer Cells under Glutamine Starvation through Downregulation of PCYT2

Tolerance to severe tumor microenvironments, including hypoxia and nutrient starvation, is a common feature of aggressive cancer cells and can be targeted. However, metabolic alterations that support cancer cells upon nutrient starvation are not well understood. Here, by comprehensive metabolome analyses, we show that glutamine deprivation leads to phosphoethanolamine (PEtn) accumulation in cancer cells via the downregulation of PEtn cytidylyltransferase (PCYT2), a rate-limiting enzyme of phosphatidylethanolamine biosynthesis. PEtn accumulation correlated with tumor growth under nutrient starvation. PCYT2 suppression was partially mediated by downregulation of the transcription factor ELF3. Furthermore, PCYT2 overexpression reduced PEtn levels and tumor growth. In addition, PEtn accumulation and PCYT2 downregulation in human breast tumors correlated with poor prognosis. Thus, we show that glutamine deprivation leads to tumor progression by regulating PE biosynthesis via the ELF3-PCYT2 axis. Furthermore, manipulating glutamine-responsive genes could be a therapeutic approach to limit cancer progression.

Combination of carbon-ion beam and dual tyrosine kinase inhibitor, lapatinib, effectively destroys HER2 positive breast cancer stem-like cells

To investigate whether carbon-ion beam alone, or in combination with lapatinib, has a beneficial effect in targeting HER2-positive breast cancer stem-like cells (CSCs) compared to that of X-rays, human breast CSCs derived from BT474 and SKBR3 cell lines were treated with a carbon-ion beam or X-rays irradiation alone or in combination with lapatinib, and then cell viability, spheroid formation assays, apoptotic analyses, gene expression analysis of related genes, and immunofluorescent γ-H2AX foci assays were performed. Spheroid formation assays confirmed that ESA+/CD24- cells have CSC properties compared to ESA-/CD24+ cells. CSCs were more highly enriched after X-ray irradiation combined with lapatinib, whereas carbon-ion beam combined with lapatinib significantly decreased the proportion of CSCs. Carbon-ion beam combined with lapatinib significantly suppressed spheroid formation compared to X-rays combined with lapatinib or carbon ion beam alone. Cell cycle analysis showed that carbon ion beam combined with lapatinib predominantly enhanced sub-G1 and G2/M arrested population compared to that of carbon-ion beam, X-ray treatments alone. Carbon-ion beam combined with lapatinib significantly enhanced apoptosis and carbon-ion beam alone dose-dependently increased autophagy-related expression of Beclin1 and in combination with lapatinib greatly enhanced ATG7 expression at protein levels. In addition, a large-sized γH2AX foci in CSCs were induced by carbon ion beam combined with lapatinib treatment in CSCs compared to cells receiving X-rays or carbon-ion beam alone. Altogether, combination of carbon-ion beam irradiation and lapatinib has a high potential to kill HER2-positive breast CSCs, causing severe irreparable DNA damage, enhanced autophagy, and apoptosis.

Phase I/II study of adding intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis

BACKGROUND

Intraperitoneal chemotherapy using paclitaxel is considered an experimental approach for treating peritoneal carcinomatosis. This study aimed to determine the recommended dose, and to evaluate the clinical efficacy and safety, of the combination of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis.

METHODS

The frequencies of dose-limiting toxicities were evaluated, and the recommended dose was determined in phase I. The primary endpoint of the phase II analysis was overall survival rate at 1 year. Secondary endpoints were antitumour effects, symptom-relieving effects, safety and overall survival.

RESULTS

The recommended doses of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel were 800, 75 and 20 mg/m² respectively. Among 46 patients enrolled in phase II, the median time to treatment failure was 6·0 (range 0-22·6) months. The response and disease control rates were 21 of 43 and 41 of 43 respectively. Ascites disappeared in 12 of 30 patients, and cytology became negative in 18 of 46. The median survival time was 14·5 months, and the 1-year overall survival rate was 61 per cent. Conversion surgery was performed in eight of 46 patients, and those who underwent resection survived significantly longer than those who were not treated surgically (median survival not reached versus 12·4 months). Grade 3-4 haematological toxicities developed in 35 of 46 patients, whereas non-haematological adverse events occurred in seven patients.

CONCLUSION

Adding intraperitoneal paclitaxel had clinical efficacy with acceptable tolerability.

Histone deacetylase inhibition enhances the therapeutic effects of methotrexate on primary central nervous system lymphoma

Background

Polyglutamylation is a reversible protein modification that commonly occurs in tumor cells. Methotrexate (MTX) in tumor cells is polyglutamylated and strongly binds to dihydrofolate reductase (DHFR) without competitive inhibition by leucovorin. Therefore, tumor cells with high polyglutamylation levels are supposed to be selectively killed, whereas normal cells with lower polyglutamylation are rescued by leucovorin. This study investigated the combined effects of MTX plus histone deacetylase inhibitors (HDACIs), which upregulate MTX polyglutamylation, in primary central nervous system lymphoma (PCNSL).

Methods

We evaluated cell viability after MTX treatment and leucovorin rescue and compared the expression of folylpolyglutamate synthetase (FPGS), γ-glutamyl hydrolase (GGH), and DHFR in 2 human PCNSL-derived cell lines (HKBML and TK) and a human Burkitt lymphoma cell line (TL-1). Combination treatments were created using 4 HDACIs: panobinostat, vorinostat, sodium butyrate, and valproic acid. The expression of DHFR was examined as well as ratios of FPGS/GGH expression. The combined effects of MTX plus HDACIs were evaluated using a cell viability assay, mass spectroscopy imaging, and subcutaneous and intracranial xenograft models.

Results

HDACIs upregulated the ratio of FPGS/GGH expression resulting in increased polyglutamylation of MTX, but also downregulated expression of the target molecule of MTX: DHFR. The combination of MTX and vorinostat decreased cell viability in vitro (P < .05) and tumor volumes in a subcutaneous model (P < .0001), and prolonged survival in an intracranial model (P < .01), relative to controls.

Conclusion

HDACIs enhanced the therapeutic effect of MTX through increased polyglutamylation of MTX and concomitant downregulation of DHFR expression.

CD68- and CD163-positive tumor-associated macrophages in triple negative cancer of the breast

Tumor-associated macrophages (TAMs) have recently been reported as an important factor in tumor growth and the progression of cancer. The prognostic significance of localizations and densities of TAMs in triple negative cancer (TNC) of the breast is not well understood. The aim of this study was to assess the localizations and densities of the TAMs subtype in TNC and examine their clinicopathological features. The study was based on 107 TNC cases operated on at Dokkyo Medical University Hospital using the pan-macrophage marker CD68 and the M2 macrophage marker CD163 in the tumor stroma (TS) and tumor nest (TN), respectively, and examined the clinicopathological significance. Multivariate Cox regression analyses revealed that age and CD163+ TAMs in both the TS and TN were independent prognostic factors for relapse-free survival and overall survival. No correlation was found between the number of CD68+ cells or the CD163/CD68 ratio either in TS or TN, or clinicopathological features. Our study found that infiltration of CD163+ TAMs, rather than CD68+, in both TS and TN was associated with poor prognosis in TNC patients by multivariate analysis. This suggests that CD163+ TAMs may affect the prognosis of TNC by not only regulating the immune reaction by TAMs in TS, but also because of their direct influence on TN.

The effect of two composite placement techniques on fracture resistance of MOD restorations with various resin composites

OBJECTIVE

The aim of this in vitro study was to compare the effect of two restorative placement techniques, centripetal incremental technique (CIT) and bulk-fill technique (BT) on the fracture resistance of Class II MOD restorations with various resin composites in molar teeth.

MATERIALS AND METHODS

Fifty-six extracted, caries free third molars were prepared with MOD preparations and restored with resin composites. The specimens were divided into two groups by placement technique, centripetal incremental technique (CIT) and bulk-fill technique (BT). Each group was subdivided into four groups according to resin composite: hybrid (Aelite LS), nano-hybrid (Virtuoso Universal), bulk fill (Filtek One Bulk Fill) and the micro-hybrid (Herculite XRV) as the control.

RESULTS

Two-way analysis of variance test (ANOVA) followed by the multiple comparison procedure, Student-Newman-Keuls Method showed no a statistically significant difference between placement techniques and fracture resistance of Class II resin composite restorations (P > 0.05). Herculite XRV resisted a significantly higher load before fracture than the other three materials at a 0.05 level of significance, while Virtuoso Universal scored the lowest load.

CONCLUSIONS

There was no significant effect of the two placement techniques on the fracture resistance of Class II resin composite restorations CLINICAL SIGNIFICANCE: Resin composite restorations in Class II MODs using a simplified bulk fill placement technique showed no significant difference in fracture resistance with the centripetal technique in molar teeth.

Association between dexamethasone treatment and alterations in serum concentrations of trace metals

Previously, a significant elevation in the serum levels of iron (Fe) was observed within a few days after the initiation of cisplatin (CDDP)-based chemotherapy. To clarify the underlying mechanisms, the serum concentration of hepcidin, a negative regulator of Fe release, was determined in the clinical samples obtained from six patients with cancer. The result showed that the serum concentration of hepcidin in patients receiving CDDP-based chemotherapy was significantly increased after 4-6 days of treatment, in comparison to the baseline level, suggesting that aforementioned excessive systemic Fe was not explained by the change of serum hepcidin level. All these patients received antiemetic premedication. We next evaluated of the effects of Pt-containing drugs and prophylactic antiemetic dexamethasone medication on the serum concentration of trace metals in mice, and on the hepatic and renal concentration of trace metals. The serum concentrations of Fe, Cu, and Zn in the CDDP-treated and oxaliplatin-treated mice were not significantly altered in comparison to those of the vehicle-treated control group. The serum concentrations of Fe, Cu, and Zn were increased after 24 h of dexamethasone treatment, compared to those of the control group (P < 0.05). The hepatic concentration of Mn was significantly reduced, whereas those of Fe and Cu inclined to diminish. The present findings suggest that dexamethasone can partly contribute to the changes in the serum concentrations of trace metals during anticancer chemotherapy.

In silico experiments of bone remodeling explore metabolic diseases and their drug treatment

Bone structure and function are maintained by well-regulated bone metabolism and remodeling. Although the underlying molecular and cellular mechanisms are now being understood, physiological and pathological states of bone are still difficult to predict due to the complexity of intercellular signaling. We have now developed a novel in silico experimental platform, V-Bone, to integratively explore bone remodeling by linking complex microscopic molecular/cellular interactions to macroscopic tissue/organ adaptations. Mechano-biochemical couplings modeled in V-Bone relate bone adaptation to mechanical loading and reproduce metabolic bone diseases such as osteoporosis and osteopetrosis. V-Bone also enables in silico perturbation on a specific signaling molecule to observe bone metabolic dynamics over time. We also demonstrate that this platform provides a powerful way to predict in silico therapeutic effects of drugs against metabolic bone diseases. We anticipate that these in silico experiments will substantially accelerate research into bone metabolism and remodeling.

Minimally invasive oesophagectomy with extended lymph node dissection and thoracic duct resection for early-stage oesophageal squamous cell carcinoma

BACKGROUND

Oesophageal squamous cell carcinoma is an aggressive disease owing to early and widespread lymph node metastases. Multimodal therapy and radical surgery may improve prognosis. Few studies have investigated the efficacy of radical lymph node and thoracic duct resection.

METHODS

Patients with oesophageal squamous cell carcinoma who underwent transthoracic minimally invasive oesophagectomy (TMIE) for cancer at Keio University Hospital between January 2004 and December 2016 were selected. Between 2004 and 2008, TMIE was performed in the lateral decubitus position without thoracic duct resection (standard TMIE). From 2009 onwards, TMIE with extended lymph node and thoracic duct resection was introduced (extended TMIE). Demographics, co-morbidity, number of retrieved lymph nodes, pathology, postoperative complications and recurrence-free survival (RFS) were compared between groups.

RESULTS

Forty-four patients underwent standard TMIE and 191 extended TMIE. There were no significant differences in clinical and pathological tumour stage or postoperative complications. The extended-TMIE group had more lymph nodes removed at nodal stations 106recL and 112. Among patients with cT1 N0 disease, RFS was better in the extended-TMIE group (P < 0·001), whereas there was no difference in RFS between groups in patients with advanced disease.

CONCLUSION

Extended TMIE including thoracic duct resection increased the number of lymph nodes retrieved and was associated with improved survival in patients with cT1 N0 oesophageal squamous cell carcinoma.

Abstract P2-16-07: Randomized controlled trial of neoadjuvant eribulin mesylate versus paclitaxel in women with operable breast cancer (JONIE-3 study)

Background: Eribulin mesylate (ERI) improved the overall survival in metastatic breast cancer (BC) patients. However, the efficacy has not been reported in early breast cancer. We performed the neoadjuvant chemotherapy (NAC) study based on hypothesis that ERI is less toxic, particularly in peripheral neuropathy, and has similar efficacy to paclitaxel (PTX) in patients with operable BC. Methods: This is a multicenter open label randomized phase 2 study (UMIN000012817). Patients were randomly assigned to either ERI (1.4mg/m2, d1 and d8, q21 days, 4 cycles) followed by FEC (fluorouracil 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2) (ERI-FEC) or PTX (80mg/m2, weekly, 12 cycles) followed by FEC (PTX-FEC) with stratified by ER, HER2, and menopausal status. Trastuzumab was added in patients with HER2 positive disease. Primary endpoint was the incidence of peripheral sensory and motor neuropathy (PSN and PMN) with Grade 1 or higher according to CTCAE ver.4.0. Secondary endpoints were pathological complete response (pCR) rates (ypT0/is/ypN0), clinical response rates (CR+PR), adverse events, disease-free survival (DFS) and patient neurotoxicity questionnaire (PNQ) analysis. Here, we report 3 year’s DFS and PNQ analysis in this study Results: Between December 2013 to March 2016, 121 cases were enrolled and 5 cases were excluded from the primary assessment. One hundred sixteen cases were finally randomized and treated by ERI-FEC in 58 cases and PTX-FEC in 57 cases. A median follow-up time of ERI-FEC and PTX-FEC was 54.2 and 51.4 months, respectively. Three year-DFS rate were 89.7% in the ERI-FEC group (95% CI 51.1 - 57.3) and 86.0% in the PTX-FEC group. (p=0.561). The incidences of PSN and PMN were significantly lower in the ERI-FEC group than the PAX-FEC group at the end of treatments (previously reported). PNQ analysis after treatments is now undergone. Conclusion: DFS was not different between them. Although the pCR rate was lower in ERI-FEC than PAC-FEC as reported at the previous meeting. ERI was more favorable on adverse events than PTX during NAC treatments. Long-term results on neurotoxicity of these two drugs will be presented at the meeting.

Citation Format: Takahiko Kawate, Takashi Ishikawa, Daishu Miura, Yoshie Hasegawa, Akihiko Tachibana, Jun Horiguchi, Mitsuhiro Hayashi, Masaru Miyashita, Tomoyuki Kubota, Kazutaka Narui, Masato Suzuki, Kouhei Akazawa, Norio Kohno. Randomized controlled trial of neoadjuvant eribulin mesylate versus paclitaxel in women with operable breast cancer (JONIE-3 study) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-16-07.

MPC-11 IDH1/2 MUTATIONS ARE ASSOCIATED WITH SEIZURE ONSET AND VETRY IMAGING IN PATIENTS WITH DIFFUSE GLIOMA VISUALIZING 2-HYDROXYGLUTARATE BY MASS SPECTRUM

BACKGROUND

Mutations in isocitrate dehydrogenase 1 or 2 genes (IDH1/2) frequently occur in lower-grade gliomas. Mutant IDH1/2 proteins gain a new ability to produce 2-hydroxyglutarate (2HG). IDH1/2 mutations have shown to be related with seizure through the structural similarity of 2HG to glutamate. We, therefore, sought to investigate the relationship between seizure and IDH1/2 mutations and to visualize tissue 2HG distribution in patients with diffuse gliomas.

METHODS

We assessed 149 patients with diffuse glioma, and measured tissue 2HG concentrations in 104 patients by using liquid chromatography-tandem mass spectrometry. The matrix-assisted laser desorption/ionization high resolution mass spectrometry imaging (MALDI-HR-MSI) was used to visualize tissue 2HG distribution for 12 tissue samples.

RESULTS

Seizure onset was observed in 34 among 56 (60.7%) patients with IDH1/2 mutant tumor, whereas in 18 among 93 (19.4%) patients with IDH1/2 wild-type tumor (p<0.0001). The tissue 2HG concentration was significantly higher in IDH1/2 mutant tumor than in IDH1/2 wild-type tumor (median: 4862 ng/mg vs 75 ng/mg) (p<0.0001). Multivariate analysis, including tissue 2HG concentration, IDH1/2 status, histology, grade, and location, showed that IDH1/2 mutations was significantly correlated with seizure onset. The MALDI-HR-MSI showed that 2HG spread in various concentration independent of cellularity and also in extracellular space in IDH1/2 mutant tumor tissue.

CONCLUSIONS

We demonstrated the association between IDH1/2 mutations and seizure, and the heterogeneous 2HG distribution not only in cellular area but also in extracellular space. These findings suggest the potential role of 2HG as an intercellular mediator to tumor environment, resulting in epileptogenesis formation.

P6494Activation of focal adhesion kinase is involved in pathogenesis of aortic dissection in mice

Background

Aortic dissection (AD) is a fatal disease where the media of the aorta suddenly fail. Currently, Molecular pathogenesis of AD is unknown. Recently, we discovered that the activity of MRTF-A, a mechanosensitive transcriptional regulator, promotes AD development. The activity of MRTF-A is regulated by mechanical stress to cells, which is transduced through focal adhesion and actin dynamics. However, it is currently unknown whether the mechanotransduction mechanism is involved in AD pathogenesis.

Purpose

We investigated the role of focal adhesion kinase (FAK), a signaling molecule that transduces mechanostress from focal adhesion to actin dynamics, in AD pathogenesis.

Methods

We created a mouse model of AD with a continuous infusion of beta-aminopropionitrile (150 mg/kg/day), a collagen crosslink inhibitor, and angiotensin II (1,000 ng/kg/min) (BAPN + AngII) by an osmotic pump. This model caused about 60% death in all mice due to AD rupture within 2 weeks. In this model, we examined the severity and mortality rate of aortic dissection after 2 weeks in mice administered with PND-1186, an orally available FAK inhibitor, and in those treated with vehicle (n=20 for each group). We performed immunochemical staining, immunofluorescence staining and Western blot for activated (phosphorylated) FAK (pFAK) to evaluate the activation status of FAK in the aortic tissue. We also performed transcriptome analysis of the aortic tissue in with and without PND-1186 with BAPN + AngII stimulation before AD development.

Results

Immunochemical staining revealed that FAK was inactive in normal mouse aorta, but was strongly activated in the aortic walls after AD development. Immunofluorescence staining showed that FAK was activated mainly in smooth muscle cells after AD development. Western blot analysis also revealed that FAK was activated in 3 days after BAPN + AngII infusion before AD development, followed by transient reduction at day 7, and re-activation after AD at day 14. Significantly, administration of PND-1186 resulted in a significant reduction in the severity of AD in the aortic arch (1.96±0.41 mm in vehicle group, 0.66±0.29 mm in PND group, P<0.05). In addition, survival rate improved from 36.4% to 80.0% by administration of PND-1186 (P<0.01). In immunofluorescence staining, the PND-1186 treated group showed weaker staining of pFAK. Transcriptome analysis showed that genes for hematopoiesis and immune system were suppressed in PND-1186 treated group.

Conclusions

These findings proved that FAK plays a central role in the pathogenesis of AD probably by transmitting pathological stress to the aortic wall to cause tissue destruction. We propose that FAK is a potential therapeutic target for limiting the fatal destruction of the aortic wall of AD.

P1032Efficacy and safety of radiofrequency catheter ablation for atrial fibrillation in patients undergoing hemodaialysis

Introduction

Although radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) has become a standard therapy, the ablation outcomes in patients undergoing hemodialysis (HD) has not been fully elucidated. The present study aimed to evaluate the clinical outcomes of RFCA for AF in patients undergoing HD.

Methods

Twenty-three patients undergoing HD (17 men, age 65±8 years, 19 paroxysmal AF) who underwent RFCA for drug-refractory AF in two institutes were enrolled in the study and defined as HD group. The clinical parameters, recurrence free rate and frequency of periprocedural complications were compared to 46 randomly selected age, gender and left atrial diameter matched controls not requiring HD defined as non-HD group (34men, age 67±7 years, 38 paroxysmal AF).

Results

The patients in HD group had a significantly lower body mass index (21±3 vs. 25±3 P<0.01), higher prevalence of coronary artery disease (30% vs. 10% P=0.04), and higher prevalence of congestive heart failure (52% vs. 10% P<0.01) compared to patients in non-HD group. Echocardiography indicated lower left ventricular ejection fraction (57±17% vs. 65±9% P=0.02), higher E/e' (20±8 vs. 12±4 P<0.01), higher tricuspid regurgitation pressure gradient (30mmHg vs. 24mmHg P<0.01) and more impaired left ventricular diastolic function in HD group. All the subjects underwent bilateral pulmonary vein isolation plus additional linear lesion. The number of ablation procedure was similar between the two groups (1.43±0.5 vs. 1.46±0.6 P=0.88). During the follow-up period of 37±25 months after the last procedure, the arrhythmia free rate was similar between the two groups (86% vs. 84% log-rank P=0.82). Vascular access complication occurred in two patients in HD group, and pericardial effusion occurred in one patient in non-HD group, while no life-threatening complications were observed in either group. Cardiogenic cerebral infarction occurred in one patient in non-HD group. Discontinuation of oral anticoagulation after the ablation was more often seen in the HD group compared to non-HD group (91% vs. 60% P<0.01).

Conclusions

Although patients undergoing HD had more impaired left ventricular systolic and diastolic function, RFCA for AF in patients with HD was shown to be as effective and safe as in non-HD patients. RFCA may be an efficient approach to manage AF in patients undergoing HD.

P4601Reduced exercise capacity and clinical outcomes following acute myocardial infarction

Background

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. The purpose of this study is to assess the associated factors and clinical influence of exercise capacity measured by CPX in AMI patients.

Methods

Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9±11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed five days after the onset of AMI. Reduced exercise capacity was defined as peak oxygen consumption (peak VO2) ≤12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed.

Results

Among 136 patients, reduced exercise capacity (peak VO2 ≤12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atria. Median follow-up term was 12 months (interquartile range: 9–22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2≤12 than those with peak VO2>12 (p<0.001). Multivariate logistic analysis showed that E/e' (Odds ratio, 1.19, 95%, confidence interval 1.09 to 1.31, p<0.001) was an independent predictor of reduced exercise capacity (peak VO2≤12).

Cumulative incidence of clinical events

Conclusion

Diastolic dysfunction is associated with reduced exercise capacity following successful primary PCI in AMI patients and may lead to poorer clinical outcomes.

P6493Syk activation is a defense mechanism in murine model of aortic dissection

Background

Aortic dissection (AD) is a serious clinical condition with unknown etiology that frequently results in fatal outcome. Recent studies showed essential role of inflammatory response both in promoting AD and aortic aneurysm (AA). However, the difference of the molecular pathogenesis between AD and AA is unclear. Previously, we reported that Syk, a tyrosine kinase that regulates differentiation and activation of inflammatory cells, promotes AA formation in a mouse model.

Objective

In the current study, we investigated the role of Syk in AD.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile (125 mg/kg/day) and angiotensin II (1,000 ng/min/kg) (BAPN+AngII), which caused AD in approximately 80% of mice within 14 days. Immunohistochemical staining for activated (phosphorylated) Syk (pSyk) revealed that Syk was inactive in normal mouse aorta, but was activated in the aortic walls after AD development. Double immunofluorescence staining for pSyk and smooth muscle alpha actin showed that Syk was active not only in the infiltrating inflammatory cells, but also in smooth muscle cells in AD tissue. Western blot analysis revealed that BAPN+AngII treatment caused Syk activation at 3 days before AD development, followed by transient suppression, and reactivation at 14 days after AD development. We examined the significance of Syk activation in AD by treating mice with fostamatinib, a specific Syk inhibitor, before and during BAPN+AngII infusion. Notably, fostamatinib-treated group developed more severe AD compared to the vehicle-treated group. The AD lesion length was 3.80±0.86 mm for vehicle group and 8.87±1.69 mm for fostamatinib group (P<0.05, n=12 for each group). In addition, fostamatinib significantly worsened the mortality of mice due to the rupture of the aorta from 0% to 42% (P<0.05, n=12 for each group). Transcriptome analysis revealed that fostamatinib suppressed both positive and negative regulators of immune response, defense response and inflammatory response.

Conclusions

These findings uncovered the previously unrecognized role of Syk for protecting the aortic tissue in AD pathogenesis, and suggested fundamentally different disease mechanisms of AD and AA.

P4620Circulating concentration of presepsin improves early prediction of short-term mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocytic activation. Presepsin appears to be an accurate diagnostic marker of sepsis, but its clinical significance remains unclear in cardiovascular disease.

Purpose

This prospective study aimed to investigate the predictive value of plasma presepsin levels on admission to medical (non-surgical) cardiac intensive care units (MCICUs) for short-term mortality.

Methods

We examined 1560 patients hospitalized in MCICUs and measured the baseline plasma presepsin levels at admission.

Results

Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Before MCICUs admission, emergent coronary angiography or percutaneous coronary intervention was performed in 36%, mechanical ventilation was required for respiratory insufficiency in 2.1%, and intraaortic balloon pumps were needed for hemodynamic instability in 8.9%. During 6 months after admission, there were 113 (7.2%) deaths. Patients who died were older (median: 77 vs. 71 years, P<0.0001); had higher levels of presepsin (263 vs. 119 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 696 vs. 186 pg/mL, P<0.0001), high-sensitivity troponin T (hsTnT: 81 vs. 47 pg/mL, P=0.004), and high-sensitivity C-reactive protein (13.8 vs. 2.2 mg/L, P<0.0001); and had lower levels of estimated glomerular filtration rate (50 vs. 65 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (43% vs. 51%, P<0.0001) than those of the survivors. In the multivariate Cox regression analysis, higher levels of presepsin (P=0.0002), BNP (P=0.04), and hsTnT (P=0.009) were all independent predictors of 6-month deaths. Quartiles of presepsin levels were associated with higher mortality rates within 6 months after admission (Table). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsTnT further enhanced reclassification (P=0.004) and discrimination (P=0.003) beyond that of the baseline model.

Mortality rates according to presepsin Presepsin quartile 1st 2nd 3rd 4th P value ≤80 pg/mL 81–124 pg/mL 125–232 pg/mL >232 pg/mL 1-month mortality 0.8% 2.0% 3.3% 8.0% <0.0001 6-month mortality 0.8% 3.8% 8.2% 16.3% <0.0001

Conclusions

Presepsin levels at admission could improve the prediction of short-term mortality in patients hospitalized at MCICUs.

Risk Analysis for Chemotherapy-induced Nausea and Vomiting (CINV) in Patients Receiving FEC100 Treatment

BACKGROUND/AIM

Risk factors for chemotherapy-induced nausea and vomiting (CINV) with anthracycline-containing regimen for breast cancer patients remain unknown. The risk factors for CINV with FEC100 were investigated.

PATIENTS AND METHODS

Data on CINV events and patient backgrounds of 180 patients were collected from the first cycle of FEC100 treatment. In this regimen, patients were administered various antiemetics (ADs). The combinations of ADs were classified into four categories, while body mass index (BMI) was stratified into three categories. Risk factors were selected based on patient characteristics and combination of ADs. Risks for CINV were analyzed by univariate and multivariate analyses.

RESULTS

In the univariate analysis of nausea, BMI was a significant factor, while BMI and combination of ADs were significant in vomiting. In the multivariate analysis concerning nausea, BMI was a significant factor. In the analysis concerning vomiting, the combination of ADs and BMI were significant.

CONCLUSION

BMI was the most important risk factor for nausea and vomiting, while the combination of ADs was for vomiting.

Eribulin penetrates brain tumor tissue and prolongs survival of mice harboring intracerebral glioblastoma xenografts

Glioblastoma is one of the most devastating human malignancies for which a novel efficient treatment is urgently required. This pre-clinical study shows that eribulin, a specific inhibitor of telomerase reverse transcriptase (TERT)-RNA-dependent RNA polymerase, is an effective anticancer agent against glioblastoma. Eribulin inhibited the growth of 4 TERT promoter mutation-harboring glioblastoma cell lines in vitro at subnanomolar concentrations. In addition, it suppressed the growth of glioblastoma cells transplanted subcutaneously or intracerebrally into mice, and significantly prolonged the survival of mice harboring brain tumors at a clinically equivalent dose. A pharmacokinetics study showed that eribulin quickly penetrated brain tumors and remained at a high concentration even when it was washed away from plasma, kidney or liver 24 hours after intravenous injection. Moreover, a matrix-assisted laser desorption/ionization mass spectrometry imaging analysis revealed that intraperitoneally injected eribulin penetrated the brain tumor and was distributed evenly within the tumor mass at 1 hour after the injection whereas only very low levels of eribulin were detected in surrounding normal brain. Eribulin is an FDA-approved drug for refractory breast cancer and can be safely repositioned for treatment of glioblastoma patients. Thus, our results suggest that eribulin may serve as a novel therapeutic option for glioblastoma. Based on these data, an investigator-initiated registration-directed clinical trial to evaluate the safety and efficacy of eribulin in patients with recurrent GBM (UMIN000030359) has been initiated.

Effect of tissue inhibitor of metalloprotease 1 on human pulp cells in vitro and rat pulp tissue in vivo

AIM

To evaluate the dentinogenetic effects of tissue inhibitor of metalloprotease (TIMP1) on human pulp cells in vitro and rat pulp tissue in vivo.

METHODOLOGY

The effect of TIMP1 on pulp cell functions related to hard tissue formation as part of the wound healing process (i.e. biocompatibility, proliferation, differentiation and mineralized nodule formation) was evaluated in vitro and using a direct pulp capping experimental animal model in vivo. The effects of different-sized cavity preparations on hard tissue formation induced by ProRoot MTA at 2 weeks were evaluated using micro-computed tomography (micro-CT). Tertiary dentine formation quality and quantity after pulp capping using TIMP1, ProRoot MTA and phosphate-buffered saline (PBS) was also evaluated after 4 weeks using micro-CT in term of dentine volume (DV), dentine mineral density (DVD) and histological analysis. The data were evaluated by Student's t-test, one-way ANOVA with Tukey's post hoc test, the Kruskal-Wallis test or the Steel-Dwass test. P values < 0.05 were considered statistically significant.

RESULTS

TIMP1 significantly stimulated dental pulp stem cell proliferation, differentiation, and mineralization and was more biocompatible compared with the PBS control (P < 0.05). In the pulp capping model, the amount of tertiary dentine that formed was directly proportional to the size of the pulp exposure; greater amounts of tertiary dentine were observed in pulps with larger exposures after 2 weeks. 4-week samples of TIMP1 and ProRoot MTA had similar characteristics, but both sample significantly induced tertiary dentine formation beneath the cavity compared with PBS (P <  0.05) under standardized cavity preparations.

CONCLUSIONS

TIMP1 has an important role in pulpal wound healing, which makes it a potential biological pulp capping material and candidate molecule for regenerative endodontic therapy.

Abstract P1-11-07: Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment

BACKGROUND:

Anthracycline-containing regimens are standard treatment options in adjuvant and neoadjuvant chemotherapy in breast cancer. Chemotherapy-induced nausea and vomiting (CINV) is experienced frequently in patients receiving these regimens, but the risk factors for CINV are unknown.

OBJECTIVE:

The aim of this study was to investigate risk factors for CINV in anthracycline-containing regimens retrospectively.

METHODS:

Data were collected from the JONIE study, which was conducted in order to estimate the efficacy of zoledronic acid in a neoadjuvant setting from March 2010 to June 2012 (UMIN000003261). A total of 180 patients were recruited, and we used CINV data from the first cycle of FEC100 treatment and patient backgrounds. As the protocol regulation allowed the use of antiemetic drugs,in the first cycle of the FEC100 regimen, patients received various types of antiemetic agents, which we classified into four groups: Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1) (DEX+5-HT3+NK1) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3) (DEX+5HT3) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+dopamine receptor antagonist (DRA) (DEX+5HT3+DRA) group; and Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1)+ dopamine receptor antagonist (DRA) (DEX+5-HT3+NK1+DRA) group. Risk factors were selected from patient backgrounds and the combinations of antiemetic drugs. In patient backgrounds, the body mass index (BMI) was stratified into 3 categories: Less than 18.5 (underweight group); equal to or more than 18.5 but less than 25 (standard BMI group); and equal to or more than 25 (overweight group). The risks for CINV were analyzed by univariate and multivariate analyses. P values of less than 0.05 were defined as significant.

RESULTS:

In a univariate analysis of nausea, the body mass index (BMI) was the only significant factor (P&lt;0.05). On the other hand, BMI and the combination of antiemetic drugs were significant factors in vomiting. (P&lt;0.05 and 0.005, respectively). In a multivariate analysis of nausea, the P value for BMI was 0.02. The odds ratio for the underweight group was 7.745 (confidence interval: 2.171 to 27.634) compared with the standard BMI group. In a multivariate analysis of vomiting, BMI and the combination of antiemetic drugs were significant risk factors (P=0.025 and 0.023, respectively). The odds ratio for the underweight group was 3.481 (confidence interval: 1.183 to 10.241)compared with the standard BMI group. Furthermore, the odds ratios in the DEX+5-HT3+DRA and DEX+5HT3 groups were 5.005 (confidence interval: 1.543 to 16.239) and 4.178 (confidence interval: 1.428 to 12.222), respectively, compared with the DEX+5-HT3+NK1 group, which was consistent with the CINV guidelines in 2011.

CONCLUSIONS:

This study revealed that BMI was the most important risk factor for nausea, and that BMI and the combination of antiemetic drugs were risk factors for vomiting. Underweight-patients tend to have CINV in anthracycline-containing regimen. The DEX+5-HT3+NK1 group was the best antiemetic drug combination. These result show that following the CINV guideline treatment is mandatory in order to prevent CINV.

Citation Format: Hayashi M, Nakazawa K, Hasegawa Y, Horiguchi J, Miura D, Ishikawa T, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Tanino Y, Yamada K, Kimura K, Akazawa K, Kohno N. Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment [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 P1-11-07.

Abstract OT3-02-02: PATHWAY: Asian, multicenter, phase 3 trial of tamoxifen with or without palbociclib ± goserelin in women with hormone receptor-positive, HER2-negative advanced or metastatic breast cancer

BACKGROUND:

The incidence rates of breast cancer (BC) in Asian counties have been rising rapidly. The age-specific female BC incidence rates peak before menopause (around 40-50 years of age) in Asia, however treatment options for pre/perimenopausal patients are limited. Palbociclib (P) is an oral novel cyclin-dependent kinase 4/6 (CDK4/6) inhibitor. The addition of P to endocrine therapy (ET) such as aromatase inhibitor or fulvestrant has been demonstrated improved progression-free survival (PFS) in phase 3 studies PALOMA-2 and PALOMA-3. This study is designed to evaluate efficacy and safety of P plus tamoxifen (TAM) in patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic BC regardless of menopausal status. This study is conducted as a Clinical Research Collaboration by National Cancer Center Hospital with research funding from Pfizer.

TRIAL DESIGN:

PATHWAY/NCCH1607 is a double-blind, placebo-controlled, randomized, phase 3 study. Patients will be randomized 1:1 to receive either P (125 mg once daily, days1-21 of a 28-day cycle) or placebo in combination with TAM (20 mg once daily, continuously). Pre/perimenopausal women should receive concurrent ovarian function suppression with goserelin. Randomization will be stratified by prior ET for advanced/metastatic BC (1st line ET vs. 2nd line ET) and menopausal status (pre/perimenopausal vs. postmenopausal).

KEY ELIGIBILITY CRITERIA:

Eligible patients include women of any menopausal status with HR-positive, HER2-negative advanced or metastatic BC; candidates to receive TAM as 1st line or 2nd line ET for advanced/metastatic disease; ≥18 years of age; measurable or non-measurable disease (RECIST v.1.1); ECOG performance status 0-1; adequate organ function; have not received treatment with TAM (except for patients who have had more than 12 months from completion of adjuvant therapy with TAM); and have not received any CDK4/6 or phosphoinositide 3-kinase (PI3K) - mammalian target of rapamycin (mTOR) inhibitors.

SPECIFIC AIMS:

The primary endpoint is PFS as assessed by the investigator. Secondary endpoints include overall survival (OS), 1, 2, and 3-year survival probabilities, objective response (OR), duration of response, clinical benefit rate (CBR), pharmacokinetics, safety, and patient-reported outcomes.

STATISTICAL METHODS:

The sample size was determined to detect a 38% reduction in the hazard of disease progression or death in P plus TAM arm with a 1-sided significance level of 2.5% and power of 80%. A stratified log rank test will be used to compare PFS between the 2 treatment arms.

PRESENT ACCRUAL AND TARGET ACCRUAL:

Target accrual of 180 patients will be enrolled within 23 sites among Japan, Korea, Taiwan, and Singapore. As of June 2018, 46 patients have been enrolled.

CONTACT INFORMATION:

This trial is registered at ClinicalTrials.gov NCT03423199 and UMIN000030816. For more information, email NCCH1607_office@ml.res.ncc.go.jp

Citation Format: Noguchi E, Hata T, Nakamura K, Kuchiba A, Hayashi M, Hamada A, Yonemori K, Sohn J, Lu Y-S, Yap Y-S, Fujiwara Y, Tamura K. PATHWAY: Asian, multicenter, phase 3 trial of tamoxifen with or without palbociclib ± goserelin in women with hormone receptor-positive, HER2-negative advanced or metastatic 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 OT3-02-02.

Abstract OT1-05-04: Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial)

Background: It is well known that the prognosis of non pCR TNBC patients was poor after anthracycline and taxan treatment. For such patients, capecitabine seems to be effective to reduce recurrence based on the HR 0.58 of the CREATE X trial (Masuda, N. et al. Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy. N Engl J Med. 376, 2147. 2017) . However, the target of capecitabine is still unclear for TNBC. We classified non pCR tumors as BRCAness and Sporadic using BRCAness test(MRC-Holland, Amsterdam, the Netherlands). The recurrence rate of the BRCAness group was about 70%. Carboplatine is expected to be effective against BRCAness tumors, as it is a DNA damaging agent. In this study BRCAness can be checked just before carboplatin treatment using surgical specimens. Then the efficacy of carboplatin will be directly known to make comparison between DFS in the carboplatin group and that of the observation group.

Trial design: This is anopen label, randomized phase III study that will enroll TNBC with residual invasive cancer after surgery with preoperative chemotherapy including both anthracycrine and taxan. Patients are randomly assigned to either the carboplatin group or observation group. The patients in the carboplatin group are treated with carboplatin at AUC 6 and those in the observation group are observed at only 3 years.

Eligibility criteria:

1) ER and PgR&lt;1%, HER2 0, 1+ or 2+ with FISH negative on core needle biopsy before the chemotherapy and surgical specimens.

2) Preoperative chemotherapy including both anthracycrine and taxan.

3) Residual invasive cancer on breast tumors or lymph node metastasis in surgical specimens.

4) 20-79 year old women.

5) No chemotherapy within 5 years.

6) Not bilateral breast cancer, without metastasis, no prior breast cancer.

7) No severe bone marrow suppression.

Specific aims:Primary objective is DFS (Disease Free Survival). Secondary objectives are overall survival and safety.

STATISTICAL METHODS:

The 3 years recurrence rate of the observation group was estimated as 40% and hazard ratio at 0.58 based on the CREATE X trial. For both groups, 135 patients are necessary. This study is powered to approximately 80% to test the superiority of carboplatin group at a 2-sided α=0.05 using a stratified log-rank test.

Activation Date:22ndMarch 2018. No patients had been enrolled till 3rd July.

Citation Format: Tanino H, Suzuki M, Kaise H, Miyashita M, Chishima T, Hayashi M, Miyoshi Y, Futamura M, Ohtani S, Nagahashi M, Ohta T, Kosaka Y, Ishikawa T, Hasegawa Y, Kubota T, Sangai T, Iwatani T, Yamada A, Akazawa K, Kohno N. Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial) [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 OT1-05-04.

Population Pharmacokinetics and Adverse Events of Erlotinib in Japanese Patients with Non-small-cell Lung Cancer: Impact of Genetic Polymorphisms in Metabolizing Enzymes and Transporters

Determinants of interindividual variability in erlotinib pharmacokinetics (PK) and adverse events remain to be elucidated. This study with 50 Japanese non-small-cell lung cancer patients treated with oral erlotinib at a standard dose of 150 mg aimed to investigate whether genetic polymorphisms affect erlotinib PK and adverse events. Single nucleotide polymorphisms (SNPs) in genes encoding metabolizing enzymes (CYP1A1, CYP1A2, CYP2D6, CYP3A4, CYP3A5, UGT1A1, UGT2B7, GSTM1, and GSTT1) or efflux transporters (ABCB1, and ABCG2) were analyzed as covariates in a population PK model. The ABCB1 1236C>T (rs1128503) polymorphism, not ABCB1*2 haplotype (1236TT-2677TT-3455TT, rs1128503 TT-rs2032582 TT-rs1045642 TT), was a significant covariate for the apparent clearance (CL/F), with the TT genotype showing a 29.4% decrease in CL/F as compared with the CC and the CT genotypes. A marginally higher incidence of adverse events (mainly skin rash) was observed in the TT genotype group; however, patients with high plasma erlotinib exposure did not always experience skin rash. None of the other SNPs affected PK or adverse events. The ABCB1 genotype is a potential predictor for erlotinib adverse events. Erlotinib might be used with careful monitoring of adverse events in patients with ABCB1 polymorphic variants.