Chemotherapy after nivolumab for advanced gastric cancer (REVIVE): a prospective observational study

BACKGROUND

Nivolumab therapy is a standard-of-care treatment for heavily pretreated patients with advanced gastric cancer (AGC). Previous studies have reported improvement in the objective response rate to chemotherapy after nivolumab therapy for other types of cancer. This study evaluated the efficacy and safety of chemotherapy after nivolumab therapy in AGC.

PATIENTS AND METHODS

We conducted a prospective, multicenter, observational study in pretreated patients with nivolumab-refractory or -intolerant AGC. Patients received irinotecan, oxaliplatin-containing regimens, or trifluridine/tipiracil. The primary endpoint was overall survival.

RESULTS

A total of 199 patients were included (median age: 69 years; male: 70%; female: 30%). Median overall survival and progression-free survival were 7.5 months [95% confidence interval (CI): 6.7-9.7 months] and 2.9 months (95% CI: 2.2-3.5 months), respectively. Objective response and disease control rates were 16.8% (95% CI: 11.6% to 23.6%) and 18.9% (95% CI: 38.9% to 54.6%), respectively. A prognostic index using alkaline phosphatase and the Glasgow Prognostic Score was generated to classify patients into three risk groups (good, moderate, and poor). The hazard ratios of the moderate and poor groups to the good group were 1.88 (95% CI: 1.22-2.92) and 3.29 (95% CI: 1.92-5.63), respectively. At the initiation of chemotherapy, 42 patients had experienced immune-related adverse events due to prior nivolumab therapy. The most common grade 3-4 adverse events were neutropenia (7.5%), anemia (8.0%), and anorexia (7.5%).

CONCLUSIONS

The administration of cytotoxic chemotherapy after nivolumab therapy may give rise to a synergistic antitumor effect in AGC. Further investigation is warranted to confirm these findings.

The clinical utility of comprehensive measurement of autoimmune disease-related antibodies in patients with advanced solid tumors receiving immune checkpoint inhibitors: a retrospective study

BACKGROUND

The comprehensive measurement of autoimmune disease-related antibodies (Abs) before immune checkpoint inhibitor (ICI) treatment may be useful for predicting the development of immune-related adverse events (irAEs); however, the clinical utility is not well known.

MATERIALS AND METHODS

We retrospectively analyzed patients with advanced solid tumors treated with ICI monotherapy or doublet combination therapy between July 2014 and December 2020 at single institute. Anti-nuclear antibody (ANA), anti-thyroglobulin (Tg) Ab, anti-thyroid peroxidase (TPO) Ab, anti-glutamic acid decarboxylase (GAD) Ab, anti-acetylcholine esterase receptor (AchR) Ab, and platelet-associated immunoglobulin G (PA-IgG) Ab were comprehensively measured for the screening before ICI therapy.

RESULTS

Of 275 registered patients (median age, 70 years; male, 64.4%; Eastern Cooperative Oncology Group performance status of 0 or 1, 88.7%; and prior regimen of 0-1/≥2, 88.7%/11.3%), 128 non-small-cell lung cancer, 35 gastric cancer, 33 head and neck cancer, 24 melanoma, 19 renal cell carcinoma, 13 urothelial carcinoma, 12 esophageal cancer, 5 malignant mesothelioma of pleura, 2 endometrial cancer, and 4 other cancer were included. The number of patients with positive ANA, Tg, TPO, PA-IgG, GAD, and AchR Abs was 52 (24.9%), 38 (14.5%), 11 (10.1%), 6 (3.5%), 5 (2.0%), and 1 (0.5%), respectively. There was no association between the development of any irAEs and Abs positivity, while thyroid dysfunction developed more frequently among patients with than without Tg Ab or TPO Ab (39.5% versus 12.5%, P < 0.01; 45.5% versus 14.3%, P = 0.02).

CONCLUSIONS

The clinical utility of comprehensive measurement of autoimmune disease-related Abs before introduction of ICI therapy was limited for predicting irAE. However, Tg and TPO Abs were risk factors as regards the development of ICI-induced thyroid dysfunction.

[Distal Stentgraft-induced New Entry Developed after Surgery for Aortic Dissection]

We experienced 2 cases with distal stentgraft-induced new entry (distal SINE) after thoracic endovascular aortic repair( TEVAR) for type B aortic dissection and 1 case after total arch replacement and frozen elephant trunk method for type A dissection. We successfully performed additional TEVAR in all cases. If the stent graft is bent at deployment, distal SINE may occur on the great curvature side of the aorta by the spring back force. Therefore, we must pay attention to appropriate device selection, and even when remodeling of the aorta is good, meticulous follow-up is necessary.

Synthesis and Properties of Hyaluronic Acid Conjugated Nucleic Acid Analogs—1: Synthesis of Deacetylhyaluronan and Introduction of Nucleic Acid Bases

The conjugation of nucleic acid base with hyaluronan was achieved by using the activated ester of pentachlorophenyl trichloroacetate. The conditions of de-N-acetylation of sodium hyaluronic acid were studied. In low concentrations of NaOH, the degree of deacetylation was 26%, while in 7.4N NaOH, the degree of deacetylation was 76% and the viscosity was 1.12 dL/g. Thymine and 5-fluorouracil bases were quantitatively conjugated to deacetylhyaluronan in 65% and 51%, respectively. The interaction of thymine hyaluronan conjugate with the complementary base of polyadenylate showed a small hypochromicity.

Efficacy of nafamostat mesilate as anticoagulation during cardiopulmonary bypass for early surgery in patients with active infective endocarditis complicated by stroke

BACKGROUND AND AIM OF THE STUDY

Recent brain complications (e.g., bleeding or infarction) in patients with active infective endocarditis (AIE) are recognized as a contraindication for early surgery. Nafamostat mesilate (NM) is a synthetic protease-inhibiting agent that has not only potent inhibitory activity against coagulation factors (Xlla, Xa) but also an anti-inflammatory action. Herein is reported the authors' successful surgical experience using NM with low-dose heparinization in patients with AIE complicated by recent cerebral complications.

METHODS

Twenty-eight patients (mean age 54.9 +/- 18.7 years) who had undergone surgery for AIE of the native valve (n = 21) or prosthetic valve (n = 7) were reviewed retrospectively. AIE was present in the aortic (n = 8), mitral (n = 16), aortic/mitral (n = 4) and tricuspid (n = 1) valves. Twenty-two of 28 patients had preoperative stroke, and six had active brain bleeding. Surgery was performed at a mean of 2.4 +/- 2.1 days after the onset of stroke. NM (209 +/- 152 mg) with low-dose heparin (3796 +/- 1218 IU; 67.4 +/- 20.3 IU/kg) was used for anticoagulation during cardiopulmonary bypass (CPB). The activated clotting time (ACT) was maintained at 350-450 s by the precise administration of NM into a cardiotomy reservoir (0.5 mg/kg/h) and a venous reservoir (sliding controlled dose at 1.5 mg/kg/h).

RESULTS

The CPB time was 181.3 +/- 92.6 min. Five patients (17.8%) died during hospitalization due to persistent sepsis (n = 3), brain death caused by massive brain embolism before CPB establishment (n = 1), and pneumonia (n = 1). There was no further aggravation of intracranial bleeding, and no new hemorrhagic stroke.

CONCLUSION

Nafamostat mesilate, administered in conjunction with low-dose heparinization, served as an effective anticoagulant for early surgery in patients with AIE complicated by stroke, and caused no further deterioration of the cerebral lesions.

Strategies for the treatment of aorto-oesophageal fistula

OBJECTIVES

Presenting a surgical strategy for aorto-oesophageal fistula (AEF).

METHODS

From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed.

RESULTS

Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction.

CONCLUSIONS

Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment.

Double triangular resection for a widely prolapsed posterior mitral leaflet

A wide and redundant prolapse of the posterior mitral leaflet in active infective endocarditis cannot be easily repaired. A sliding plasty can be attempted, but the range of annular plication is often too large. Chordal replacement is another option, but is prone to long-term degeneration because the redundant leaflet still exists. Here, we describe a simple resection technique that utilizes only two small triangular resections. The resections are sutured with no need to shorten the annulus. The leaflet tissue between the two triangular resections must be preserved to make an appropriately shaped posterior leaflet.

[New concept of mitral valve repair for posterior leaflet prolapse]

BACKGROUND

Conventional repair of posterior mitral valve prolapse involves quadrangular resection and sliding plasty. However, these 2 methods require annular plication and useful leaflet tissue is sacrificed.

METHODS

Our concept is to make an ideally shaped posterior leaflet without annular plication. When the leaflet is not high, we select triangular resection( TRR). For a high leaflet, we developed hourglass resection (HGR). The hourglass shape consists of 2 triangles:the upper inverted triangle is resected and the lower triangle is resected and sutured to the annulus. From 2007 to 2012, 65 patients with mitral regurgitation (MR) with leaflet prolapse were repaired. 49 patients who had posterior leaflet prolapse were analized in this study. The mean age was 61.7±11.5 years and 67.3% were men.

RESULTS

All patients underwent successful repair. There were no hospital deaths, or no systolic anterior motion. In 1 patient, repair was repeated 1 month post-operatively. The mean follow-up period was 2.6±1.5 (0.1 ~ 4.9) years. There were no late deaths. The most recent echocardiogram revealed no MR in 36, mild MR in 12, and moderate MR in 1 cases.

CONCLUSION

The short-term results of our strategy for posterior leaflet repair are good.

Giant sinus of valsalva aneurysm with severe aortic incompetence treated with a valve-sparing operation

Typically, a sinus of Valsalva aneurysm with severe aortic incompetence is repaired with patch closure and aortic valve replacement. Here, we describe a very rare case of a giant nonruptured right Valsalva aneurysm, combined with severe aortic incompetence, treated with a valve-sparing aortic root replacement. During surgery we noted that the lengths of the free margin of the cusps and annuli were not uniform. As a result, we placed the first layer of sutures for the Valsalva graft in the same ratio as the annuli. It is difficult to preserve the geometry of the aortic annulus and position the commissures in the graft. One surgical tip for valve-sparing aortic root replacement for a sinus of Valsalva aneurysm with severe aortic incompetence is to suture the commissures inside the graft in the same ratio as the length of the cusp free margins.

A single papillary muscle with chordal rupture in an adult

A single papillary muscle (SPM) is a rare anomaly in normal adults. It is sometimes associated with a complete common atrioventricular canal. Chordal rupture combined with a single papillary muscle in an adult has not been reported. We repaired the mitral valve with chordal replacement, although this was technically difficult, because the decision to place an artificial chordal attachment on the papillary muscle plays an important role. This report presents successful chordal replacement and band annuloplasty in a case of chordal rupture with a single papillary muscle. A surgical tip for chordal replacement with a single papillary muscle is to suture artificial chords on the same side of the SPM head as the affected side of the mitral valve, considering the direction of pull of the artificial chords.

Chordal replacement for leaflet prolapse in a posterior mitral valve with a calcified mitral annulus

Mitral annular calcification (MAC) is sometimes associated with Carpentier type 2 mitral valve regurgitation and is a challenge to repair. Complete annular decalcification and mitral valve reconstruction is considered the ideal treatment. This report demonstrates the success of chordal replacement and band annuloplasty without resection of the leaflet and MAC. We have followed the patient for 7 years postoperatively, with no progression of MAC and no regurgitation by echocardiography.

[How to repair a mitral valve prolapse;an assessment of operative techniques dependent on late results]

BACKGROUND

In this study, we assessed the repair techniques employed for mitral valve prolapse.

PATIENTS AND METHODS

Between 1992 and 2011, we repaired 173 consecutive patients with mitral valve prolapse. The mean age of the patients was 60.1 years and 68.6% were male. For anterior leaflet (AL) prolapse, 27 patients with fibroelastic deficiency (FED) were treated with chordal replacement (CR). In 21 patients with Barlow type, 2 were repaired with CR and the remaining 19 were repaired with resection. In 130 patients with a prolapse of the posterior leaflet (PL), we selected quadrangular resection( QR:44), sliding plasty( SP:12), folding plasty and CR. More recently, triangular resection (TrR:22) was selected for ≤18 mm height leaflets, and an hourglass resection( HgR:21) for high leaflets.Hourglass represents the shape of the resection.

RESULTS

In 1 patient of the AL CR group, the expanded polytetrafluoroethylene (ePTFE) was broken. Other patients in this group showed no mitral regurgitation (MR) and no re-operation during 16 years. Two patients receiving CR for AL Barlow received re-repair, whilst the other 19 patients in this group displayed good results over the following 19 years. In the QR and SP groups, 1 patient was rerepaired,whilst 3 patients displayed complicated mitral stenosis. In the TrR and HgR groups, no MR,no re-operation and no late deaths occurred during the following 4.5 years.

CONCLUSIONS

CR for AL FED, resection for AL Barlow and TrR or HgR for PL were durable techniques for the treatment of mitral valve prolapse.

[The formula of the aortic valve repair for bicuspid aortic valve]

BACKGROUND

The treatment of aortic regurgitation( AR) with bicuspid aortic valve( BAV) repair is still uncommon as the reproducibility of the repair is low and the 5-year durability is poor. In this study, we examined a method of cusp suspension after triangular resection. In addition, the relationship between the length of the cusp margin and diameter of the sino-tubular( ST) junction was evaluated.

PATIENTS AND METHODS

We repaired 8 regurgitant BAVs between 1997 and 2011. The mean patient age was 35±14 years and 87.5% were male. All lesions were raphe type:7 were anterior-posterior type and 1 was left-right type. The basic technique was triangular resection of the pseudo-commissure.When the annulus or ST junction was dilated, annuloplasty or ST junction plication was added. Cusp suspension was performed in 7 patients. In 2 patients, the half-length of the cusp margin (d) was related to the diameter of the ST junction( D) as described by d=D/2+1.

RESULTS

Two cases were on a 2nd pump run because of residual AR. The valve was replaced in 1 case, while the cause of AR was found to be symmetric prolapse in the analysis. The coaptation depth was 6.2 mm. Another case was re-repaired because AR was caused by an untied suspension suture.Seven cases( 87.5%) were repaired successfully. No in-hospital deaths or complications occurred. The mean follow-up period was 5.42 years (range 1~15). No patients required re-operation and no recurrent AR greater than moderate occurred. The mean coaptation depth of the 7 successful patients was 11±3 mm.

CONCLUSION

When repairing a regurgitant BAV, triangular resection alone is sometimes ineffective due to the occurrence of symmetric prolapse. For reproducible repair, it is useful to add cusp suspension.Lastly, the rate of suspension is related to the diameter of the ST junction.

The activity ratio of the cytosolic MDH/LDH and the isoenzyme pattern of LDH in the peripheral leukocytes of dogs, cats and rabbits

The activities of malate dehydrogenase (MDH) and lactate dehydrogenase (LDH) and the pattern of the isoenzymes of LDH were determined in the peripheral blood leukocytes of dogs, rabbits and cats. Rabbits had significantly higher plasma glucose concentrations than dogs or cats. Feline leukocytes showed higher LDH and lower MDH activities than canine or rabbit leukocytes. The M/L ratio, defined as the MDH activity divided by the LDH activity in cytosolic fractions, was considered to be a good indicator with which to evaluate the metabolic state in animal tissues. The M/L ratio was highest in canine and lowest in feline leukocytes. LDH-2 and LDH-3 isoenzymes were dominant in canine leukocytes. LDH-1 and LDH-2 were dominant in rabbit leukocytes, whereas LDH-5 was dominant in feline leukocytes. It was evident that there were significant differences in energy metabolism between the leukocytes of dogs, rabbits and cats.

Comparison of the effects of nifedipine and nisoldipine on coronary vasoconstriction in the Langendorff-perfused rat heart

By using Langendorff-perfused rat hearts, we compared the relaxant effects of two dihydropyridine calcium antagonists (nifedipine and nisoldipine) on the coronary vasculature. Hearts were perfused at a constant flow rate (13 ml/min), and the coronary perfusion pressure was monitored to assess vasoconstriction and relaxation. Administration of 5 nM endothelin significantly increased the perfusion pressure within 5 min, and it did not decrease during the subsequent 10-min washout period. Washout with 1 nM nisoldipine or 10 nM nifedipine almost completely normalized the perfusion pressure. Administration of a nitric oxide synthase inhibitor, N(G)-nitro-L-arginine (100 microM), elevated the perfusion pressure at 5 min. When 1 nM nifedipine was added to the perfusate, it failed to decrease the pressure, but 10 and 100 nM nifedipine partly decreased it (96.4+/-8.2 and 87.0+/-8.8 mm Hg for 10 and 100 nM, respectively). Nisoldipine alleviated the pressure elevation almost completely at 10 nM (60.0+/-5.2 mm Hg). The vasodilatory effect of nisoldipine was also approximately 10 times more potent than that of nifedipine when coronary vasoconstriction was induced by hypoxia-reoxygenation. These results suggest that nisoldipine has a stronger effect than nifedipine at the organ level, which does not depend on the cause of coronary vasoconstriction.