Idiopathic thoracic spinal cord herniation into the vertebra progressing for 3 years

A 43-year-old, previously healthy man experienced a decreased sensation in the left lower extremity without preceding spinal trauma. At presentation, the patient exhibited slight motor weakness in the left lower extremity, in addition to decreased pain sensation below the ipsilateral T7. Spinal magnetic resonance imaging (MRI) revealed abnormal findings consistent with idiopathic thoracic spinal cord herniation (ITSCH) at the T5/6 level. Computed tomography (CT) revealed a small vertebral erosion at the lower T5. The patient's symptoms gradually progressed over the next 3 years. MRI revealed marked lateral elongation of the cord at the T5/6 and apparent intravertebral cord herniation. The patient underwent ITSCH reduction through T5-6 laminectomies. The herniated cord was vertically long with a bulbous rostral part. Successful ITSCH reduction was achieved and the patient's postoperative course was uneventful. ITSCH is a progressive pathology that requires prompt surgical reduction. Certain ITSCHs may be complicated by intravertebral cord herniation.

Dural-based large B-cell lymphoma masquerading as a tentorial meningioma

A 53-year-old woman presented with a 2-week history of headache and vertigo. Computed tomography revealed a hyperdense tumor, measuring 30 × 31 × 36 mm in diameter, in the anteromedial parts of the cerebellar hemispheres. Cerebral magnetic resonance imaging 10 days later revealed an apparent extra-axial tumor with broad attachment to the medial tentorium cerebelli and rapid growth to a diameter of 40 × 41 × 46 mm. Cerebral angiography revealed no obvious feeding vessels or tumor stains. The patient underwent biopsy through the left occipital transtentorial route. The histological appearance was consistent with diffuse large B-cell lymphoma. Intracranial lymphoma may present as a dural tumor that mimics a meningioma. Rapid tumor growth incongruous with benign meningiomas should be assumed to be possible lymphoma, and prompt biopsy should be performed.

Unusually elongated superior thyroid cornu associated with recurrent cerebral embolisms

The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.

Are there characteristic indicators for increased pressure in chronic subdural hematoma?

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical disorders. However, no study has yet documented biomarkers indicating increased CSDH pressure. This study aimed to explore such indicators. A total of 50 patients underwent measurement for CSDH pressure during burr-hole irrigation. The mean hematoma pressure was 16.8 ± 7.6 cmH2O with no significant difference between new-onset and recurrent CSDHs. In 12 patients with a CSDH pressure ≥25 cmH2O, further analyses were carried out. Eight of them had bilateral CSDHs. All six patients with a CSDH pressure ≥28 cmH2O suffered headaches before surgery. Two out of three patients with a CSDH pressure ≥29 cmH2O felt nauseous. In statistical analyses, headache was positively correlated with a high CSDH pressure, whereas age and hematoma thickness were negatively correlated with it. Patients' sex, initial Glasgow coma scale score, motor weakness, midline shift on computed tomography scans, and administration of anticoagulants/antiplatelet agents, showed no significant correlation. When patients with bilateral CSDHs are not older adults and suffering headaches, an increased CSDH pressure should be assumed. For such patients, a prompt hematoma evacuation is indicated.

Diameters of the optic sheath and superior ophthalmic vein can expand and contract at positional changes: a magnetic resonance imaging study

PURPOSE

This study aimed to explore the diameters of the optic sheath (OSD) and superior ophthalmic vein (SOVD) in response to positional changes using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Fifty adult outpatients who presented to the hospital underwent thin-slice coronal T2-weighted MRI in the supine position followed by the prone position.

RESULTS

The OS and SOV were well delineated in all the patients. The OSD in the anterior orbit was measured in the supine and prone positions on both sides. In addition, the SOVD in the anterior and posterior orbits was measured in the supine and prone positions on both sides. The OSD demonstrated an increase on both sides in 100% of the cases. The SOVD demonstrated an increase on both sides in 94% of the cases, whereas the remaining 6% demonstrated a decrease. The OSD measured at the anterior orbit and the SOVD at the anterior and posterior orbits significantly increased on both sides with positional changes from the supine to the prone position.

CONCLUSION

OSD and SOVD may expand and contract in response to alterations in the intracranial pressure and venous flow patterns. MRI examination in the supine position combined with positional changes can help to better understand the OS and SOV as dynamic structures.

De novo meningiomas and cavernous malformations developing after coil embolization for dural arteriovenous fistula

A 25-year-old woman presented with exophthalmos. With the diagnosis of dural arteriovenous fistula of the transverse sinus, the patient underwent coil embolization. Fifteen years later, she sustained visual disturbance due to de novo tuberculum sellae meningioma that was resected. Surveillance magnetic resonance imaging (MRI) performed at the age of 42 years detected tumor recurrence and small, apparent meningioma in the cerebral convexity. The patient underwent the second tumor resection at the age of 46 years. The histological appearance was consistent with meningothelial meningioma. In addition, surveillance MRI at the age of 43 years detected de novo cerebral and cerebellar cavernous malformations (CMs). These CMs showed repeat hemorrhages on MRI but remained asymptomatic during the next 38 months. De novo meningiomas and CMs may develop in association with radiation exposure during endovascular therapy. Sufficiently long-term follow-up is recommended after endovascular therapy for monitoring secondary pathologies.

Delineation of the central retinal artery using computed tomography: a pilot study

PURPOSE

The prospective study aimed to examine the central retinal artery (CRA) using computed tomography (CT).

MATERIALS AND METHODS

Seventy adult outpatients comprising 32 men and 38 women, at a mean age of 60.6 ± 13.3 years, were enrolled in the study. The patients underwent contrast-enhanced CT. The scan timing was set to start 5.0 s after the circle of Willis began to be delineated.

RESULTS

The ophthalmic arteries (OphAs) were comfortably delineated in all. In 97% of the patients, the CRA was delineated from the original site on the OphA to a more distal segment coursing on the optic sheath. Unilateral and bilateral CRA delineations were observed in 44% and 53% of cases, respectively. The delineated CRAs demonstrated highly variable morphologies in terms of the course and length on the optic sheath. In addition, the distance between the original site of the CRA and the posterior limit of the bulb was measured. The mean distance was 18.6 ± 5.0 mm on the right and 17.8 ± 4.3 mm on the left, respectively. No significant right-to-left differences in the measurements (p > 0.05) were observed.

CONCLUSIONS

If optimal scan timing is adopted, the CRA segments coursing on the optic sheath can be delineated using contrast-enhanced CT. CT may be a useful diagnostic modality for the CRAs and associated pathological conditions.

Do the mammillary bodies atrophy with aging? A magnetic resonance imaging study

PURPOSE

This retrospective study aimed to explore age-related atrophy of the mammillary bodies (MBs) based on their temporal change using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

The study included 30 adult outpatients who presented to the hospital and were followed for more than 100 months with annual MRIs. The bi-ventricular width (BVW), third ventricle width (TVW), and bi-mammillary dimension (BMD) were measured on axial T2-weighted imaging and analyzed.

RESULTS

The 30 patients comprised 1 in their 40s, 5 in their 50s, 6 in their 60s, 11 in their 70s, 5 in their 80s, and 2 in their 90s. The MBs were consistently detected with left-to-right symmetry. The mean BVW was 32 ± 2.2 mm on the initial (BVW1) and 32 ± 2.4 mm on the last (BVW2) MRI. The mean TVW was 7.0 ± 2.3 mm on the initial (TVW1) and 7.6 ± 2.7 mm on the last (TVW2) MRI. Furthermore, the mean BMD was 9.9 ± 1.3 mm on the initial (BMD1) and 10 ± 1.3 mm on the last (BMD2) MRI. Statistically, no age ranges had a large dimension for BVW1, BVW2, TVW1, TVW2, BMD1, or BMD2. Changes between TVW1 and TVW2 were significantly different in the patients in their 80s; changes between BMD1 and BMD2 were not different for any age range or between sexes.

CONCLUSIONS

Aging alone does not seem to promote MB atrophy. In healthy brains, the MBs may be stationary structures throughout life.

Large arachnoid granulation protruding into the transverse sinus: A probable cause of intermittent otologic symptoms

A 69-year-old woman suffered attacks of hearing disturbance and vertigo for seven years. Her otologic and ophthalmological examinations did not show any significant findings. Cerebral magnetic resonance imaging revealed a cystic mass in the left cerebellar convexity. Computed tomography demonstrated a contrast defect of the distal left transverse sinus. Magnetic resonance imaging revealed a cyst protruding into the transverse sinus, and enlarging in the supine. Cerebral angiography demonstrated a congestive venous flow in the left transverse sinus, at the upstream of the cyst. At rest, the venous sinus pressure was 13 cm H2O at the upstream of the cyst and 8 cm H2O at the downstream. When the patient held a breath, the upstream pressure increased to 37 cm H2O, while the maximal downstream pressure was 22 cm H2O. A large AG protruding into the cranial dural sinus may cause intermittent venous congestion and associated otologic symptoms. Movements accompanied by a transient decrease in cardiac venous return and changes in head position can attribute to an enlargement of such AG.

Large rhabdoid meningioma presenting prominent hyperintensity in the optic nerve: An indicator of visual disturbance on constructive interference steady-state sequence?

BACKGROUND

Rhabdoid meningiomas (RMs) are a rare type of malignant meningioma. Here, we report a case of intracranial RM presenting with visual disturbance and prominent hyperintensity in the optic nerve (ON).

CASE DESCRIPTION

A 20-year-old female presented with a 1-year history of headache. At presentation, her visual acuity (VA) was 20/50 on the right side and 20/40 on the left, with an intraocular pressure of 17 mmHg on both sides. Cerebral magnetic resonance imaging revealed a broad-based tumor in the right frontal convexity. It measured 82 mm × 65 mm × 70 mm in diameter, accompanied by cystic components, and was inhomogeneously enhanced. The intraorbital ONs demonstrated prominent intramedullary hyperintensity on the constructive interference steady-state sequence. Gross total tumor resection was performed and the pathology was consistent with RM. Immediately after surgery, her VA and IOP were 20/17 and 10 mmHg, respectively, with a remarkable resolution of the intramedullary hyperintensity.

CONCLUSION

Prominent hyperintensity in the ON identified in patients with chronic intracranial hypertension may be an indicator of visual disturbance. It can rapidly resolve after resolution of intracranial hypertension with functional recovery.

Does the superior ophthalmic vein dilate in acute intracranial hypertension due to hemorrhagic stroke?

A 65-year-old man presented with coma. The cranial computed tomography (CT) revealed a massive hematoma in the left cerebral hemisphere, accompanied by intraventricular hemorrhage (IVH) and ventriculomegaly. Contrast examination revealed ectatic superior ophthalmic veins (SOVs). The patient underwent emergent hematoma evacuation. Contrast CT performed on postoperative day (POD) 2 showed a remarkable reduction in the diameters of both SOVs. A second patient, a 53-year-old man, presented with consciousness disturbance and right hemiparesis. CT revealed a large hematoma in the left thalamus, accompanied by massive IVH. Contrast CT demonstrated the bold delineation of the SOVs. The patient underwent endoscopic IVH removal. Contrast CT performed on POD 7 showed a remarkable reduction in the diameters of both SOVs. A third patient, a 72-year-old woman, presented with severe headache. CT revealed diffuse subarachnoid hemorrhage and ventriculomegaly. Contrast CT demonstrated a saccular aneurysm on the internal carotid artery-anterior choroidal artery branching site with the bold delineation of the SOVs. The patient underwent microsurgical clipping. Contrast CT performed on POD 68 showed a remarkable reduction in the diameters of both SOVs. The SOVs may function as an alternative venous drainage pathway in the setting of acute intracranial hypertension due to hemorrhagic stroke.

Delineation of the lacrimal vein: a magnetic resonance imaging study

PURPOSE

To our knowledge, anatomical knowledge about the lacrimal vein (LV) is missed. Therefore, this retrospective study aimed to explore them using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Eighty-one patients who underwent contrast-enhanced MRI and three donated bodies to science were enrolled.

RESULTS

On the sagittal images, the measured mean right long (LD) and short diameters (SD) of the lacrimal gland (LG) were 17.3 ± 2.4 mm and 13.7 ± 2.1 mm, while the left LD and SD were 17.0 ± 2.6 mm and 13.6 ± 2.6 mm, respectively. Laterality or sex differences were not found in the LD and SD groups. In addition, no specific age range was associated with a significantly longer LD or SD. LVs were identified in 94% of axial images. Their course was classified into as follows: three types: connecting to the superolateral cavernous sinus (CS), to the superior ophthalmic vein (SOV), and the diploic channels of the greater wing of the sphenoid bone (DCGW). The CS type was the most frequently identified, followed by the SOV and DCGW types. In dissected specimens, the LVs consistently coursed between the posterior margin of the LG and the superolateral part of the CS, above the upper margin of the lateral rectus muscle.

CONCLUSIONS

The LV may consistently emerge from the upper posterior margin of the LG. It commonly pours into the SOV or superolateral part of the CS.

Possible association between minor head injury and intratumoral hemorrhage: A metastatic brain tumor from thyroid carcinoma

A 78-year-old woman presented after a fall and injury in the left forehead. She had undergone surgery for papillary thyroid carcinoma 14 years prior and breast carcinoma 7 years prior. The patient had exhibited uneventful postoperative courses without relapse or metastasis. Anticoagulants or antiplatelet agents were not prescribed her. At presentation, the patient exhibited no focal neurological deficits. Computed tomography revealed a 19 × 20 mm hemorrhagic lesion in the right temporal lobe. On cerebral magnetic resonance imaging, the center of the lesion exhibited inhomogeneous intensity on both T1- and T2-weighted sequences with heterogeneous enhancement. In contrast, the perilesional hemorrhagic regions, appearing hyperintense on both T1- and T2-weighted sequences, showed temporary regression followed by marked enlargement over the subsequent 123 days. The patient underwent total tumor resection. The microscopic findings of the resected specimens were consistent with papillary thyroid carcinoma. Minor head injuries may trigger intratumoral hemorrhage in metastatic brain tumors. Metastasis should be assumed when patients with a history of thyroid carcinoma present with a solitary parenchymal lesion with the appearance of cerebral cavernous malformation, even if they have been disease free for a long period.

Delineation of intermammillary relationships using magnetic resonance imaging

PURPOSE

No study has investigated intermammillary relationships using neuroimaging modalities. This study aimed to explore them using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We enrolled 72 patients who underwent conventional MRI examinations, followed by constructive interference steady-state sequence in the coronal plane. The intermammillary distances (IMDs) were measured at the uppermost level of the intermammillary gap (IMD_upp) and the lowest level (IMD_low) of the mammillary bodies (MBs).

RESULTS

MBs with varying morphologies were consistently delineated. The appearance of both MBs could be classified into four patterns based on the size and relative levels, with the symmetrical type being the most common. Intermammillary relationships exhibited five patterns. In 69%, the IMD_upp was discernible and measured 0.7 ± 0.4 mm, while it was not discernible in 31% due to the presence of intermammillary connection and adhesion. The age distribution did not differ between populations with and without discernible IMD_upp. The IMD_low was measured 4.4 ± 0.9 mm. Although the IMD_low was not significantly different between both sexes; it was longer in subjects in their 70s.

CONCLUSIONS

Intermammillary relationships show variable morphologies with gaps formed between both MBs. The IMD_low may become more evident in association with age-related increase in the width of the third ventricle and atrophy of the MBs.

Penetrating orbitocranial injury by shoji frame: A rare indoor accident in a Japanese style house

Background

To the best of our knowledge, there are no reports of penetrating orbitocranial injury (POCI) caused by a shoji frame.

Case Description

A 68-year-old man fell in his living room and was stuck headfirst by a shoji frame. At presentation, marked swelling was noted in the right upper eyelid, with the edge of the broken shoji frame exposed superficially. Computed tomography (CT) revealed a hypodense linear structure located in the upper lateral sector of the orbit, partially protruding into the middle cranial fossa. Contrast-enhanced CT revealed intact ophthalmic artery and superior ophthalmic vein. The patient was managed with frontotemporal craniotomy. The shoji frame was extracted by pushing out the extradurally located proximal edge from the cranial cavity and simultaneously pulling the distal edge from the stab wound in the upper eyelid. Postoperatively, the patient received intravenous antibiotic therapy for 18 days.

Conclusion

POCI can be caused by shoji frames as a result of an indoor accident. The broken shoji frame is evidently delineated on CT, which can result in prompt extraction.

Atypical meningioma originating from the spinal accessory nerve

Background

Atypical meningiomas rarely originate from the spinal accessory nerve at the C1-C2 level.

Case Description

A 57-year-old female presented with a 1-month history of headache. The cervical MR revealed a well-demarcated intradural/extramedullary tumor compressing the spinal cord at the C1-C2 level that measured 12 mm × 10 mm × 25 mm. She underwent microsurgical tumor resection. Intraoperatively, the tumor was adherent to the spinal accessory nerve, rather than the dura mater. Gross total tumor resection was performed, and the pathology was consistent with an atypical meningioma.

Conclusion

Atypical meningiomas rarely originate from the spinal accessory nerve. Gross total resection is the procedures of choice to mitigate the risk of tumor recurrence.

Oculomotor nerve segment between proximal posterior and superior cerebellar arteries: an MRI study

PURPOSE

No study has documented the oculomotor nerve (OMN) segment lying between the posterior cerebral (PCA) and superior cerebellar (SCA) arteries adjacent to the brainstem. The present study aimed to characterize it.

METHODS

A total of 71 patients underwent thin-sliced, sagittal T2-weighted magnetic resonance imaging for analysis.

RESULTS

The OMN segments lying between the PCA and SCA were identified in all patients. The OMN segment in relation to the PCA and SCA was classified into five types. Of them, the PCA-OMN contact type was the most frequent and found in 35.2% of 71 sides on the right and 39.4% on the left. Also, the PCA-OMN compression type was identified in 12.7% on the right and 15.5% on the left. In these types, the mean distance between the brainstem and contact/compression sites were measured 4.4 ± 2.3 mm on the right and 4.4 ± 1.6 mm on the left. In more than forty percent, the sites were located at the level of the pontomesencephalic junction.

CONCLUSIONS

The OMN may be frequently in contact with the PCA near the brainstem. The site located more distal than the central-peripheral myelin junction of the OMN can attribute to a low frequency of neurovascular compression syndrome of the nerve.

Does diploic venous flow drain extracranially in the pterional area? A magnetic resonance imaging study

Background:

To the best of our knowledge, no study using neuroimaging modalities has documented calvarial diploic veins (DVs) connected to the extracranial sites. This study aimed to characterize them using magnetic resonance imaging (MRI).

Methods:

A total of 88 patients underwent thin-sliced contrast MRI. In addition, the DVs coursing through the pterional area were observed on three injected cadaver heads.

Results:

On postcontrast MRI, the DVs of the pterional area directly drained into the temporalis muscle or supplied branches coursing into the muscle in 43% on the right side and 40% on the left. The DVs and their branches were highly variable in diameter and number. In 9% of cases, the DV of the pterional area was found to drain into an extracranial site and connected to large venous channels distributed in the temporalis muscle. Furthermore, in 17% of cases, the DVs drained into the extracranial sites in the frontal skull region, followed by 9% in the parietal, 2% in the occipital, and 1% in the temporal regions. The DVs coursed superficially in the pterional area on both sides of all three cadaver heads. On one side, the DV in the area was open to an extracranial site.

Conclusion:

Part of the diploic venous flow drains extracranially in the pterional area. This area may provide an important interface between the calvarial DVs and the extracranial venous system.

Subsequent bilateral intracerebral hemorrhages in the putamen and thalamus: A report of four cases

Background:

Subsequent bilateral intracerebral hemorrhage (SBICH) in the putamen and thalamus is a rare condition. Herein, we report four such cases.

Case Description:

Case 1: A 47-year-old woman presented with the left hemiparesis and elevated blood pressure. Neuroimaging revealed a right thalamic hemorrhage and a small left thalamic hemorrhage accompanying the hyperdense rim on computed tomography (CT) and the hypointense rim on gradient-echo T2*-weighted imaging (T2*WI). Case 2: A 53-year-old man presented with a disturbance of consciousness and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage that appeared hyperdense on CT and hypointense on T2*WI. Case 3: A 65-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left putaminal hemorrhage and a small right thalamic hemorrhage accompanied by a hyperdense rim on CT and a hypointense rim on T2*WI. Case 4: A 75-year-old woman presented with the right hemiparesis and elevated blood pressure. Neuroimaging revealed a left thalamic hemorrhage and small hemorrhages in the right thalamus and cerebellar hemisphere. These hemorrhages appeared hyperdense on CT and hypointense on T2*WI.

Conclusion:

SBICHs are rare bilateral hemorrhages that may present with asymptomatic microbleeds in the putamen or thalamus coupled with symptomatic, subsequent hemorrhages in the contralateral counterparts. The latter hemorrhage may develop during the subacute phase of microbleeds in the putamen or thalamus.

Calvarial Langerhans cell histiocytosis in an adult presenting rapid growth

Background

Langerhans cell histiocytosis (LCH) arising in the skull is rare in adulthood.

Case Description

A 58-year-old woman experienced a durable headache. Cerebral magnetic resonance imaging (MRI) at presentation showed no abnormalities; however, MRI and computed tomography (CT) performed 6 weeks later revealed the emergence of a well-demarcated, heterogeneously enhancing calvarial tumor accompanied by irregular-shaped bone erosion. On MRI, the temporalis muscle and subcutaneous tissue adjacent to the tumor were extensively swollen and enhanced. The patient underwent en bloc resection. The microscopic appearance of the tumor was consistent with that of LCH. Postoperative systemic 18F-fluorodeoxyglucose positron emission tomography/CT did not detect any abnormal accumulation.

Conclusion

LCH may develop within a short period. It should be considered as a differential diagnosis when a rapidly growing calvarial tumor is encountered, even when the patient is an adult. Prompt histological verification is recommended in such cases.

Calvarial angiomatous meningioma developed in the diploe

Background:

Angiomatous meningioma is a rare subtype of meningiomas. To the best of our knowledge, there have been no reports of intradiploic angiomatous meningioma.

Case Description:

A 53-year-old previously healthy woman was diagnosed with a calvarial lesion during a brain checkup. Cerebral magnetic resonance imaging showed an intradiploic tumor, 11 × 14 × 12 mm, in the right parietal bone. It was an enhancing, lobular tumor presenting as isointensity on T1- and hyperintensity on T2-weighted sequences, with an intense enhancement of the adjacent dura mater. Computed tomography revealed bone erosion at the tumor site, extending predominantly into the inner side, and sclerotic changes in the surrounding bone. Total resection was performed. Microscopically, the tumor tissue comprised cells with low-grade meningioma and intervening prominent vasculatures, consistent with angiomatous meningioma.

Conclusion:

Angiomatous meningioma should be considered as a differential diagnosis when an intradiploic tumor shows a lobular structure, intense enhancement of the adjacent dura mater, and sclerotic changes in the surrounding skull. These findings can support prompt tumor resection.

POS0651 CLINICAL AND FUNCTIONAL RESPONSE TO TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: PROBABILITY PLOT ANALYSIS OF RESULTS FROM A 48-WEEK PHASE 3b/4 METHOTREXATE WITHDRAWAL STUDY

Background:

The Phase 3b/4 study ORAL Shift (NCT02831855) demonstrated sustained efficacy/safety of tofacitinib modified-release 11 mg QD following MTX withdrawal, that was non-inferior to continued tofacitinib + MTX use, in patients (pts) with moderate to severe RA who achieved LDA with tofacitinib + MTX at Week (W)24.1

Objectives:

To assess differences and similarities in clinical/functional responses in pts receiving tofacitinib ± MTX in ORAL Shift.

Methods:

In ORAL Shift, pts received open-label tofacitinib + MTX to W24; at W24, pts who achieved CDAI LDA were randomised to receive tofacitinib + MTX or tofacitinib + placebo (PBO) from W24–48. In this post hoc analysis, clinical efficacy endpoints were ACR-N (minimum % change from baseline [BL; Δ] at W48 achieved by each pt in 3 efficacy measures), ΔDAS28-4(ESR), and DAS28-4(ESR) remission/LDA (scores ≤3.2) and moderate/high disease activity (scores >3.2). Functional efficacy endpoints were ΔHAQ-DI and HAQ-DI clinically relevant functional progression (CRFP) status at W48, defined as failure to achieve improvement in HAQ-DI ≥ minimum clinically important difference (MCID; ≥0.22 decrease from BL in HAQ-DI). Thus, CRFP was defined as <0.22 decrease, no change or increase from BL in HAQ-DI at W48. All efficacy endpoints were summarised descriptively. Cumulative probability plots of ACR-N and ΔHAQ-DI were produced. Median of mean CRP values from BL–W24 and >W24–48 were assessed by response subgroups.

Results:

266 pts receiving tofacitinib + MTX and 264 pts receiving tofacitinib + PBO in W24–48 were included. At W48: mean ACR-N was numerically greater with tofacitinib + MTX vs tofacitinib + PBO (60.8 vs 53.1); mean decrease in HAQ-DI was generally similar between groups (-0.71 vs -0.67); mean decrease in DAS28-4(ESR) was numerically greater with tofacitinib + MTX vs tofacitinib + PBO (-2.95 vs -2.68). The differences/similarities between groups in ACR-N and ΔHAQ-DI were also seen in cumulative probability plots (Figure 1). CRFP rates were numerically lower with tofacitinib + MTX (18.7%) vs tofacitinib + PBO (23.5%), and in pts with remission/LDA (tofacitinib + MTX, 12.1%; tofacitinib + PBO, 16.8%) vs moderate/high disease activity (tofacitinib + MTX, 26.2%; tofacitinib + PBO, 30.8%). Median of mean CRP over time was generally numerically lower in pts with CRFP vs non-CRFP and DAS28-4(ESR)-defined remission/LDA vs moderate/high disease activity; and in those receiving tofacitinib + PBO vs tofacitinib + MTX, irrespective of CRFP or DAS28-4(ESR) disease status (Table 1).

Table 1.

Median of mean CRPa up to W48 by response subgroups

Tofacitinib 11 mg QD + MTXTofacitinib 11 mg QD + PBOMean CRP,amedian (IQR) [n]>BL–W24>W24–48>BL–W24>W24–48HAQ-DI CRFP2.84 (1.15–7.30)2.30 (0.82–4.75)1.45 (0.77–4.42)2.28 (0.53–7.28)[45][46][56][56]HAQ-DI non-CRFP2.81 (1.09–6.19)2.91 (1.19–5.84)2.26 (0.98–4.63)2.47 (1.13–5.53)[195][195][176][178]DAS28-4(ESR) remission/LDA2.48 (1.05–4.95)2.46 (1.07–4.76)1.70 (0.89–4.14)1.95 (0.81–3.82)[126][127][115][117]DAS28-4(ESR) moderate/high disease activity3.56 (1.17–7.13)3.58 (1.36–8.33)2.60 (0.87–5.16)2.68 (1.34–8.23)[107][107][115][115]

aMean CRP was calculated as the average CRP value during each time period (>BL–W24 or >W24–48)

CRP, C-reactive protein; DAS28-4(ESR), Disease Activity Score in 28 joints, erythrocyte sedimentation rate; HAQ-DI, Health Assessment Questionnaire-Disability Index; IQR, interquartile range; LDA, low disease activity; MTX, methotrexate; n, number of pts meeting assessment criteria; QD, once daily

Conclusion:

Although clinical/functional responses were generally similar between treatment groups, numerical improvements were seen for some efficacy endpoints with tofacitinib + MTX vs tofacitinib + PBO. A numerically higher CRFP rate may be associated with higher DAS28-4(ESR) disease activity. CRP changes up to W48 may not trend with CRFP status.

References:

[1]Cohen et al. Lancet Rheumatol 2019; 1: E23-34.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Anthony G McCluskey, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Stanley B. Cohen Consultant of: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Yi-Hsing Chen Grant/research support from: Bristol-Myers Squibb, GlaxoSmithKline, Pfizer Inc, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Tatjana Lukic Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jerome Paulissen Consultant of: Pfizer Inc, Haiyun Fan Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Tomohiro Hirose Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Edward Keystone Speakers bureau: AbbVie, Amgen, F. Hoffman-La Roche, Janssen, Merck, Novartis, Pfizer Inc, Sanofi Genzyme, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celltrion, Eli Lilly, F. Hoffman-La Roche, Gilead Sciences, Janssen, Merck, Myriad Autoimmune, Pfizer Inc, Sandoz, Sanofi Genzyme, Samsung Bioepsis, Grant/research support from: Amgen, Merck, Pfizer Inc, PuraPharm

POS0650 PREDICTORS OF DURABLE CLINICAL RESPONSE TO TOFACITINIB 11 MG ONCE DAILY WITH OR WITHOUT METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS: POST HOC ANALYSIS OF DATA FROM A PHASE 3b/4 METHOTREXATE WITHDRAWAL STUDY

Background:

ORAL Shift, a global Phase 3b/4 non-inferiority study, demonstrated sustained efficacy and safety of tofacitinib modified-release (MR) 11 mg once daily (QD) following methotrexate (MTX) withdrawal in patients with rheumatoid arthritis (RA) who achieved Clinical Disease Activity Index (CDAI) low disease activity (LDA) after treatment with tofacitinib + MTX.1

Objectives:

To assess predictors of durable clinical response in patients receiving tofacitinib MR 11 mg QD in ORAL Shift.

Methods:

ORAL Shift (NCT02831855) enrolled patients aged ≥18 years with moderate to severe RA and an inadequate response to MTX. Patients received open-label tofacitinib MR 11 mg QD + MTX for 24 weeks. Patients achieving LDA (CDAI score ≤10) at Week (W)24 entered the 24-week double-blind MTX withdrawal phase and were randomised 1:1 to receive tofacitinib MR 11 mg QD + placebo (tofacitinib monotherapy; ie blinded MTX withdrawal) or continue tofacitinib + MTX. In this post hoc analysis of randomised patients, we assessed predictors of durable response (maintenance of response from W24–48) per CDAI LDA and remission (CDAI score ≤2.8) criteria. All covariates were initially assessed for significance in a univariate logistic regression. Highly correlated covariates were reviewed to assess which would be removed prior to modelling in a multivariable logistic regression. Remaining significant (p≤0.10) covariates in the univariate regression were selected in the model using a stepwise selection process with p≤0.15 entry and p≤0.05 stay criteria. From the final model, estimated odds ratios (ORs) with 95% confidence intervals (CIs) are presented.

Results:

In the double-blind phase of ORAL Shift, durable CDAI LDA and remission rates were: 66.2% and 14.7%, respectively, with tofacitinib + MTX (N=266); and 55.3% and 11.0%, respectively, with tofacitinib + placebo (N=264) (Table 1). In the multivariable analysis, five patient covariates significantly predicted durable CDAI LDA (Figure 1; discussed hereafter). Each unit increase in CDAI score at W24 reduced the likelihood of maintaining CDAI LDA by 22.0%. Each unit increase in C-reactive protein (CRP) at W24 increased the likelihood of maintaining CDAI LDA by 4.0%; this may have been due to imbalanced CRP levels at W24 (randomisation) between treatment groups (Figure 1, footnote c). The odds of durable CDAI LDA were 53.0% lower in the US vs Europe and 61.0% lower in the US vs ‘other’ regions. Each unit increase in baseline Health Assessment Questionnaire-Disability Index (HAQ-DI) score reduced the odds of durable CDAI LDA by 34.0%. Patients receiving tofacitinib + MTX had 66.0% greater odds of durable CDAI LDA vs patients receiving tofacitinib + placebo. CDAI at W24 was the only significant predictor of durable CDAI remission in the multivariable analysis: OR (95% CI) 0.32 (0.24, 0.43); p<0.0001. Each unit increase in CDAI score at W24 reduced the odds of durable CDAI remission by 68.0%.

Table 1.

Durable CDAI LDA and remissiona in patients receiving tofacitinib MR 11 mg QD with MTX or placebo in the double-blind phase of ORAL Shift

Tofacitinib + MTX(N=266)Tofacitinib + placebo(N=264)Durable CDAI LDA, n (%)176 (66.2)146 (55.3)Durable CDAI remission, n (%)39 (14.7)29 (11.0)

aDurable CDAI LDA or remission was defined as achievement of LDA (CDAI score ≤10) or remission (CDAI score ≤2.8), respectively, at W24–48

N, number of patients in each group; n, number of patients achieving outcome

Conclusion:

This post hoc analysis of data from ORAL Shift found that CDAI and CRP at W24, geographic region, baseline HAQ-DI and treatment could be predictors for durable CDAI LDA. As these findings were limited to patients who achieved CDAI LDA at W24 with tofacitinib MR 11 mg QD + MTX, additional data in the general patient population need to be investigated.

References:

[1]Cohen et al. Lancet Rheumatol 2019; 1: E23-34.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Sarah Piggott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Kunihiro Yamaoka Speakers bureau: Actelion, Astellas, Chugai, Eisai, Eli Lilly, GlaxoSmithKline, Janssen, Mitsubishi Tanabe, Nippon Shinyaku, Pfizer Inc, Takeda, Consultant of: Actelion, Astellas, Chugai, Eisai, Eli Lilly, GlaxoSmithKline, Janssen, Mitsubishi Tanabe, Nippon Shinyaku, Pfizer Inc, Takeda, Stanley B. Cohen Consultant of: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Harry Shi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Josef S. Smolen Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead Sciences, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Roche, Samsung, Sanofi, Grant/research support from: AbbVie and AstraZeneca

OP0187 INCIDENCE OF MALIGNANCY IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE JAPANESE IORRA PATIENT REGISTRY

Background:

The risk of some types of malignancy is increased in patients (pts) with rheumatoid arthritis (RA), compared with the general population. We have previously reported the incidence of malignancy in Japanese pts with RA.1-4

Objectives:

This analysis further evaluated the incidence of malignancy in Japanese pts with RA using recent data from the large prospective observational study, IORRA.

Methods:

This analysis included all pts with RA aged ≥18 years who were enrolled in IORRA from April 2013 to October 2018, with follow-up through October 2019, and participated in ≥2 surveys. Index was defined as the date of the first entry in the IORRA database, with baseline defined as the 6-month period prior to the index date. Malignancies were identified in pt reports of biannual IORRA surveys and confirmed using medical records. Age- and sex-standardised incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated.

Results:

In total, 8020 pts were included. At baseline, the majority (85.0%) of pts were female; mean disease duration was 12.8 years, 5.8% and 4.8% of pts had a past history of malignancy or comorbid malignancy at baseline, respectively, and the majority (75.9%) of pts were receiving methotrexate (Table). The SIR (95% CI) was 0.90 (0.80, 1.01). SIRs (95% CI) of site-specific malignancies were: breast cancer, 0.91 (0.69, 1.18); lung cancer, 0.67 (0.44, 0.97); colon cancer, 0.93 (0.62, 1.32); stomach cancer, 0.82 (0.56, 1.14); and lymphoma, 3.74 (2.73, 4.96).

Table 1.

Patient demographics and baseline disease characteristics

Patients with RA (N=8020)Age (years), mean (SD)59.3 (13.8)Female, n (%)6816 (85.0)Duration of RA (years), mean (SD)12.8 (10.3)Never smoked, n (%)5086 (66.2)DAS28, mean (SD)2.8 (1.1)J-HAQ, mean (SD)0.60 (0.72)Malignancy status, n (%)Past history of malignancy467 (5.8)Comorbid malignancy at baseline386 (4.8)Medication use, n (%)MTX6088 (75.9)Tacrolimus787 (9.8)Corticosteroids2641 (32.9)bDMARD use1508 (18.8)TNFi1163 (14.5)Tocilizumab311 (3.9)Abatacept106 (1.3)JAK inhibitors4 (0.05)

bDMARD, biological disease-modifying antirheumatic drug; DAS28, Disease Activity Score in 28 joints; JAK, Janus kinase; J-HAQ, Japanese Health Assessment Questionnaire; MTX, methotrexate; N, the number of patients included in the analysis, the number of patients assessed for each characteristic may be fewer than N; n, the number of patients with each characteristic; SD, standard deviation; TNFi, tumour necrosis factor inhibitor

Conclusion:

Overall risk of malignancy was similar to that in the general Japanese population, although a significantly higher risk of lymphoma was identified.

References:

[1]Sugimoto et al. Rheumatol Int 2017; 37: 1871-1878.

[2]Shimizu et al. Clin Rheumatol 2017; 36: 1237-1245.

[3]Askling et al. Ann Rheum Dis 2016; 75: 1789-1796.

[4]Yamada et al. Rheumatol Int 2011; 31: 1487-1492.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Anthony G McCluskey, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

masayoshi harigai Speakers bureau: AbbVie Japan, Ayumi, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kissei, Pfizer Japan Inc, Takeda, Teijin, Consultant of: AbbVie Japan, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Kissei, Teijin, Grant/research support from: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Kissei, Mitsubishi Tanabe, Nippon Kayaku, Sekiui Medical, Shionogi, Taisho, Takeda, Teijin, Naohiro Sugitani: None declared, Ryoko Sakai Speakers bureau: Bristol-Myers Squibb, Eisuke Inoue Speakers bureau: Pfizer Japan Inc, Bristol-Myers Squibb, Michika MOCHIZUKI Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Shigeyuki Toyoizumi Employee of: Pfizer R&D Japan, Noritoshi Yoshii Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Eiichi Tanaka Speakers bureau: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kyowa, Janssen, Mochida, Pfizer Japan Inc, Takeda, Teijin, Hisashi Yamanaka Speakers bureau: Astellas, Bristol-Myers-Squibb, Pfizer Inc, Mitsubishi Tanabe, Teijin, YLBio, Consultant of: Corrona, LLC

POS0286 INCIDENCE OF MALIGNANCIES IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM A LARGE JAPANESE NATIONAL REGISTRY

Background:

Patients (pts) with rheumatoid arthritis (RA) have an increased risk of some malignancies vs the general population, and this can vary by region/race.1,2 Data on the epidemiology and impact of biological (b)DMARDs and targeted synthetic (ts)DMARDs, such as Janus kinase (JAK) inhibitors, on the incidence of malignancies in Japanese pts with RA are limited. The National Database of Rheumatic Diseases in Japan (NinJa) is one of the largest RA registries in Japan.

Objectives:

To evaluate the incidence of malignancies in Japanese pts with RA using NinJa registry data.

Methods:

This retrospective observational study analysed NinJa registry data for Japanese pts with RA aged ≥18 years with ≥1 data entry between 2013 (first JAK inhibitor approval for RA in Japan) and 2018. The overall cohort included all pts with RA, and two sub-cohorts were analysed: pts exposed and unexposed to bDMARDs (exposure defined as ≥1 bDMARD reported in database). Crude incidence rates (IRs) for malignancies (including non-melanoma skin cancer) were calculated as the number of events per 100 pt-years of follow-up (time between start of follow-up or the date of first bDMARD exposure [for bDMARD-exposed pts] and end of observation period, or withdrawal from database). The most recent data for incidence of malignancy in the Japanese general population (2013–2017 data from the National Cancer Center, Japan) were used to calculate standardised incidence ratios (SIRs) and age- and sex-adjusted standardised rates (ASRs) for malignancies. Cross-sectional (per calendar year) and cumulative analyses were performed for the overall cohort. Cumulative rates were calculated for sub-cohorts, and all cumulative analyses were repeated excluding pts exposed to JAK inhibitors (ie ≥1 JAK inhibitor reported in database).

Results:

Data were collected for 26 607 Japanese pts with RA from 2013–2018. In the cross-sectional analysis (Table 1), the SIR and ASR for malignancies in all pts with RA were generally consistent from 2013–2018. In the cumulative analysis, the SIR (95% CI) for malignancies from 2013–2018 was 0.97 (0.91, 1.03) in all pts with RA, and 0.93 (0.82, 1.04) and 0.99 (0.92, 1.07) in pts exposed and unexposed to bDMARDs, respectively (Figure 1). Adjusting for age/sex, the cumulative ASR (95% CI) for malignancies from 2013–2018 was 0.83 (0.76, 0.90) in all pts with RA, and 0.82 (0.69, 0.95) and 0.86 (0.77, 0.96) in pts exposed and unexposed to bDMARDs, respectively (Figure 1). In all cohorts, the cumulative SIR and ASR were similar when pts exposed to JAK inhibitors were excluded (Figure 1).

Table 1.

Cross-sectional analysis of the incidence of malignancies in Japanese pts with RA from 2013–2018

All RA2013 (N=13 423)2014 (N=15 584)2015 (N=15 751)2016 (N=16 107)2017 (N=15 994)2018(N=15 003)Total follow-up, PY13 35314 86614 82914 97014 74814 898Pts with events, n140164174168161211Crude IRa(95% CI)1.05(0.89, 1.24)1.10(0.95, 1.29)1.17(1.01, 1.36)1.12(0.97, 1.31)1.09(0.94, 1.27)1.42(1.24, 1.62)ASRa,b(95% CI)0.76(0.60, 0.93)0.76(0.62, 0.90)0.90(0.68, 1.11)0.88(0.68, 1.07)0.80(0.62, 0.98)0.88(0.74, 1.01)SIRb(95% CI)0.97(0.82, 1.14)1.01(0.86, 1.17)1.02(0.87, 1.18)0.88(0.75, 1.02)0.86(0.73, 1.00)1.10(0.95, 1.25)

aIR/ASR were calculated as number of events per 100 PY of follow-up

bData from a Japanese general population database of malignancy incidence from 2013–2017, provided by the Center for Cancer Control and Information Services, National Cancer Center, Japan

PY, pt-years

Conclusion:

The incidence of malignancies in Japanese pts with RA, registered in the NinJa database from 2013–2018, was similar to that in the Japanese general population. The SIR and ASR for malignancies were comparable in pts exposed and unexposed to bDMARDs. In all cohorts, rates did not increase when pts exposed to JAK inhibitors were included.

References:

[1] Dougados et al. Ann Rheum Dis 2014; 73: 62-68.

[2] Parikh-Patel et al. Cancer Causes Control 2009; 20: 1001-1010.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Christina Viegelmann, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Toshihiro Matsui Speakers bureau: Astellas, Ayumi, Chugai, Daiichi-Sankyo, Eli Lilly, Ono, Pfizer Inc, Takeda, Tanabe-Mitsubishi, Consultant of: Pfizer Inc, Grant/research support from: Chugai, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Shigeyuki Toyoizumi Employee of: Pfizer R&D Japan, Fujio Matsuyama Consultant of: Pfizer Inc, Employee of: CRECON Medical Assessment Inc, Tatsunori Murata Consultant of: Pfizer Inc, Employee of: CRECON Medical Assessment Inc, Yukitomo Urata Speakers bureau: Asahi Kasei, Chugai, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Asahi Kasei, Chugai, Pfizer Inc, Kimito Kawahata Speakers bureau: Pfizer Inc, Consultant of: Pfizer Inc, Grant/research support from: Pfizer Inc, Shigeto Tohma Speakers bureau: Astellas, Ayumi, Chugai, Ono, Pfizer Inc, Takeda, Consultant of: Pfizer Inc

Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle

Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.

A novel human in vitro papillomavirus type 16 positive tonsil cancer cell line with high sensitivity to radiation and cisplatin

Background

Human papillomavirus (HPV) is an established risk factor for oropharyngeal squamous cell carcinoma (OSCC). The aim was to establish cell lines from HPV-positive tonsil carcinomas to be used for treatment development.

Methods

Fresh samples from 23 HPV-positive tonsil carcinomas were cultivated in vitro. The established cell line was analyzed for viral characteristics, cell karyotype, TP53 status, and growth capabilities in nude mice. In vitro studies of sensitivities to radiation, cisplatin and cetuximab were performed.

Results

After 19 months (eight passages), one cell line, LU-HNSCC-26, was established in vitro and also grew as xenografts. The tumor was from a 48 year old non-smoking man with non-keratinizing, p16 positive tonsil OSCC, stage T2N0M0 with HPV16. It contained 19.5 (CV% 3.7) HPV16 copies/cell (passage 8). The complete HPV16 genome sequence was obtained. Episomal HPV16 was present with an E2/E7 ratio of 1.1 (CV% 2.6). In addition, HPV16 mRNA specific for the intact E2 gene was detected. The viral expression manifested 1.0 (CV% 0.1) E7 mRNA copies per HPV16 genome. The karyotype was determined and the cell line demonstrated wild type TP53. The ID50 for radiation was 0.90 Gy and the IC50 for cisplatin was 0.99 μmol/L. The cell line was inhibited to a maximum of 18% by cetuximab.

Conclusions

We established an in vitro tonsil carcinoma cell line containing episomal HPV16. This is an important step towards efficient treatment development.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5469-8) contains supplementary material, which is available to authorized users.

Short half-life of HPV16 E6 and E7 mRNAs sensitizes HPV16-positive tonsillar cancer cell line HN26 to DNA-damaging drugs

Here we show that treatment of the HPV16-positive tonsillar cancer cell line HN26 with DNA alkylating cancer drug melphalan-induced p53 and activated apoptosis. Melphalan reduced the levels of RNA polymerase II and cellular transcription factor Sp1 that were associated with HPV16 DNA. The resulting inhibition of transcription caused a rapid loss of the HPV16 early mRNAs encoding E6 and E7 as a result of their inherent instability. As a consequence of HPV16 E6 and E7 down-regulation, the DNA damage inflicted on the cells by melphalan caused induction of p53 and activation of apoptosis in the HN26 cells. The BARD1-negative phenotype of the HN26 cells may have contributed to the failure to repair DNA damage caused by melphalan, as well as to the efficient apoptosis induction. Finally, nude mice carrying the HPV16 positive tonsillar cancer cells responded better to melphalan than to cisplatin, the chemotherapeutic drug of choice for tonsillar cancer. We concluded that the short half-life of the HPV16 E6 and E7 mRNAs renders HPV16-driven tonsillar cancer cells particularly sensitive to DNA damaging agents such as melphalan since melphalan both inhibits transcription and causes DNA damage.

Malignant Subdural Hematoma Associated with High-Grade Meningioma

A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with recurrence of the tumor. We performed removal of the tumor combined with SSS resection as Simpson grade II. After tumor removal, since a left dominant bilateral chronic subdural hematoma (CSDH) appeared, it was treated by burr hole surgery. However, because the CSDH rapidly and repeatedly recurred and eventually changed to acute subdural hematoma, elimination of the hematoma with craniotomy was accomplished. The patient unfortunately died of worsening of general condition despite aggressive treatment. Histopathology of brain autopsy showed invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma. Subdural hematoma is less commonly associated with meningioma. Our case indicates the possibility that subdural hematoma associated with meningioma is formed by a different mechanism from those reported previously.

Abstract PD5-03: TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients

Background: Neoadjuvant therapy for locally advanced breast cancer has the potential to improve surgical therapeutic outcomes without sacrificing the survival advantages of adjuvant therapy. However, determining whether ER+ patients (pts) will respond to neoadjuvant (NA) chemotherapy (CT) or hormone therapy (HT) can be difficult. Not all ER+ pts respond to NACT, while response to NAHT can vary across ER+ pts. Thus, the ability to select pts more likely to benefit from NAHT would represent progress in clinical management of breast cancer. NEOS is a randomized phase III study assessinglong-term prognosis of ER+ primary breast cancer with/without adjuvant CT following NAHT (UMIN 000001090, http://www.umin.ac.jp/). We used archived core biopsy tumor samples from the NEOS study to validate the RS result as a predictor of clinical response and its association with successful breast conserving surgery (BCS) in pts treated with 6 months of NAHT.

Methods: NEOS enrolled 904 postmenopausal pts with ER+, HER2-, clinically node negative (cN0) breast cancer to evaluate whether adjuvant CT was necessary for pts who responded to NAHT. In this current study, we enrolled pts with tumors ≥2cm from the NEOS study. Biopsy samples of 333 pts were assessed for the Oncotype DX assay. Response to NAHT was recorded as complete/partial response (CR/PR), or stable/progressive disease (SD/PD).

Primary endpoint of this study was to evaluate clinical response (CR/PR) to NA letrozole between pts with low (&lt;18) and high (≥31) RS result. Secondary endpoints include evaluating the relationships between clinical response and continuous RS results, and other covariates including age, tumor size, grade, Ki67 by IHC, ER and PR single gene scores, and ER and proliferation gene group scores by RT-PCR.

Results: The analysis included 294 pts with median age of 63 yrs, median tumor size of 25mm, and 66% were nuclear grade 1. 156 (53.0%), 83 (28.6%) and 54(18.4%) cases were low, intermediate, and high RS groups by Oncotype DX, respectively. Six (2%), 126 (42.8%), 149 (50.3%), 13 (4.4%) cases experienced CR, PR, SD, PD as clinical response, respectively, similar to that of all NEOS pts. Clinical response rate was 54%, 42% and 22% in low, intermediate, and high RS groups, respectively. The proportion of pts with clinical response was significantly higher in the low RS group vs the high RS group (p&lt;0.001). In univariate analyses, continuous RS was significantly associated with clinical response (p&lt;0.001), along with ER (p=.02), PR (p&lt;0.001), and ER gene group score (p&lt;0.001). Other covariates were not associated with clinical response.

Conclusion: The Oncotype DX RS test in core biopsy samples is validated as a predictive assay for clinical response of NAHT in postmenopausal, ER+/HER2-, cN0, primary early breast cancer pts. Further results on the association of RS results with BCS outcomes following NAHT will be presented. These results when combined with previously published data on RS in NACT studies help guide pts with ER+, HER2- breast cancer with NAHT vs NACT treatment options to maximize clinical response.

Citation Format: Yamamoto Y, Iwata H, Masuda N, Fujisawa T, Toyama T, Kashiwaba M, Ohtani S, Taira N, Sakai T, Hasegawa Y, Nakamura R, Akabane H, Shibahara Y, Sasano H, Yamaguchi T, Sakamaki K, Chao C, McCullough D, Sugiyama N, Ohashi Y. TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD5-03.

Obstetrical correlates and perinatal consequences of neonatal hypoglycemia in term infants

OBJECTIVE

To determine independent perinatal and intrapartum factors associated with neonatal hypoglycemia.

METHOD

Of singleton pregnancies delivered at term in 2013; 318 (3.8%) neonates diagnosed with hypoglycemia were compared to 7955 (96.2%) neonate controls with regression analysis.

RESULTS

Regression analysis showed that independent prenatal factors were multiparity (odds-ratio [OR] = 1.61), gestational age (OR = 0.68), gestational diabetes (OR = 0.22), macrosomia (OR = 4.87), small for gestational age neonate [SGA] (OR = 6.83) and admission cervical dilation (OR = 0.79). For intrapartum factors, only cesarean section (OR = 1.57) and last cervical dilation (OR = 0.92) were independently significantly associated with neonatal hypoglycemia. For biologically plausible risk factors, independent factors were cesarean section (OR = 4.18), gentamycin/clindamycin in labor (OR = 5.35), gestational age (OR = 0.59) and macrosomia (OR = 5.62). Mothers of babies with neonatal hypoglycemia had more blood loss and longer hospital stays, while neonates with hypoglycemia had worse umbilical cord gases, more neonatal hypoxic conditions, neonatal morbidities and NICU admissions.

CONCLUSION

Diabetes was protective of neonatal hypoglycemia, which may be explained by optimum maternal glucose management; nevertheless macrosomia was independently predictive of neonatal hypoglycemia. Cesarean section and decreasing gestational age were the most consistent independent risk factors followed by treatment for chorioamnionitis and SGA. Further studies to evaluate these observations and develop preventive strategies are warranted.

Novel classification of the posterior auricular artery based on angiographical appearance

Purpose

To investigate the length variation of the posterior auricular artery and propose a novel classification of the posterior auricular artery based on angiographical appearance.

Patients and Methods

A series of 234 consecutive patients who had undergone conventional cerebral angiography was analyzed. The posterior auricular artery was examined on the lateral projection of the external carotid or common carotid arteriography. The posterior auricular artery was classified into four groups by length, using the external auditory canal and the top of the helix as radiographical landmarks. Our proposed classification is as follows: Type A, posterior auricular artery terminates between its origin and the center of the external auditory canal; Type B, posterior auricular artery terminates between the center of the external auditory canal and the top of the helix; Type C, posterior auricular artery terminates between the top of the helix and the vertex; and Type D, posterior auricular artery reaches up to the vertex.

Results

A total of 424 (right, 214; left, 210) posterior auricular arteries were analyzed in 111 men and 123 women aged 11 to 91 years (mean, 61.0 years) examined for aneurysms in 78 cases, occlusive vascular diseases in 56, intracranial hemorrhages in 41, tumors in 35, and others in 24. Types A, B, C, and D were found in 15.1%, 34.9%, 48.8%, and 1.2% of the patients, respectively.

Conclusion

A novel classification of the posterior auricular artery identifies four types based on its length on cerebral angiography.

Outcome comparison of ABO-incompatible kidney transplantation with low-dose rituximab and ABO-compatible kidney transplantation: a single-center experience

BACKGROUND

The development of immunosuppressive techniques has helped overcome the ABO incompatibility barrier. However, the outcomes of ABO-incompatible (ABOi) kidney transplantation remain a controversial issue with the advent of the anti-CD20 chimeric antibody rituximab. Herein, we report the outcomes of ABOi kidney transplantation with low-dose rituximab.

PATIENTS AND METHODS

Between June 2006 and April 2013, 42 patients underwent living-related kidney transplantation at our hospital. The patients were divided into 2 groups: ABO-compatible (ABOc; n = 29) and ABOi kidney transplants using low-dose rituximab (100 mg/m(2)) without splenectomy (n = 13). The basic immunosuppression regimen (calcineurin inhibitor [CNI], mycophenolate mofetil [MMF], and steroids) was the same for both groups, except for the use of rituximab and therapeutic apheresis in the ABOi group. We compared post-transplantation renal function, incidents of virus infection, episodes of rejection, and graft survival between the 2 groups.

RESULTS

In our hospital, 30% of recipients received ABOi kidney transplants. The estimated glomerular filtration rate (eGFR) did not differ between the groups. Rejection episodes confirmed by biopsy in the ABOc and ABOi groups were 8 (28%) and 4 (31%) patients (P = .833), acute antibody-mediated rejection was observed in 1 (3.5%) and 2 (15%) patients (P = .165), and virus infection was observed in 14 (48%) and 3 (23%) patients (P = .252), respectively. The 5-year patient survival rate was 100% in both groups, and the 5-year graft survival rates were 95% for ABOc and 100% for ABOi transplants (P = .527).

CONCLUSIONS

These results suggest that the outcomes of ABOi kidney transplantation with low-dose rituximab are similar to those of ABOc kidney transplantation. Further study is necessary to address the efficacy and safety of ABOi kidney transplantation.

Solitary epicranial neurofibroma with NF1-related germline mutation: case report

A 33-year-old male became aware of a painless soft mass in the left occipital region. His medical and family history were unremarkable for neurofibromatosis type 1 (NF1) or other genetic disorders. Physical examination showed no signs of NF1. Neurological and ophthalmological examinations found no abnormality. Cranial computed tomography showed an isodense mass located subcutaneously with irregular deformities in the adjacent occipital bone. Magnetic resonance (MR) imaging demonstrated that the lesion, 7.5 × 5.5 cm in diameter, was hypointense both on T1- and T2-weighted images and intensely enhanced after gadolinium infusion. The patient requested to remove the large mass. The subcutaneous tumor was well circumscribed, encapsulated, and less vascular, and resected en bloc. The histological diagnosis was neurofibroma without findings of cell atypia, whereas genomic exploration identified abnormal gains in NF1 gene, and resultant absence of neurofibromin, a protein coded on NF1 gene. Solitary neurofibromas in "clinically" non-NF1 patients may originate from the genomic changes in NF1 gene.

Involvement of estrogen receptor β in maintenance of serotonergic neurons of the dorsal raphe

The serotonergic neurons of the dorsal raphe (DR) nucleus in the CNS are involved in fear, anxiety and depression. Depression and anxiety occur quite frequently in postmenopausal women, but estrogen replacement to correct these CNS disorders is at present not favored because estrogen carries with it an increased risk for breast cancer. Serotonin synthesis, release and reuptake in the DR are targets of pharmaceuticals in the treatment of depression. In the present study we have examined by immunohistochemistry, the expression of two nuclear receptors, that is, the estrogen receptors ERα and ERβ. We found that ERβ but not ERα is strongly expressed in the DR and there is no sex difference and no change with ageing in the number of tryptophan hydroxylase (TPH)-positive neurons in the DR of wild-type (WT) mice. However, in ovariectomized (OVX) WT and in ERβ(-/-) mice, there was a marked reduction in the number of TPH-positive normal-looking neurons and a marked increase in TPH-positive spindle-shaped cells. These neuronal changes were prevented in mice 1-3 weeks (but not 10 weeks) after OVX by the selective ERβ agonist, LY3201, given as continuous release pellets for 3 days. The ERβ agonist had no effects on glucose homeostasis. Thus, the onset of action of the ERβ agonist is rapid but there is a limited window in time after estrogen loss when the drug is useful. We conclude that, rather than estradiol, ERβ agonists could be useful pharmaceuticals in maintaining functional DR neurons to treat postmenopausal depression.

Factors affecting assessment of severity of aggressive incidents: using the Staff Observation Aggression Scale - Revised (SOAS-R) in Japan

The aim of this study is to investigate factors associated with overall judgements of aggression severity as provided by ward nurses, using the Japanese-language version of the Staff Observation Aggression Scale - Revised (SOAS-R). Nurses who observed 326 aggressive incidents involving psychiatric inpatients at five mental health facilities in Japan provided their assessments of the incident severity both on the established rating scale, the SOAS-R, and on a visual analogue scale (VAS), a one-item scale to indicate overall aggression severity. To evaluate the factors influencing the VAS severity scores, a multiple regression analysis was performed, in which consumer, nurse and ward characteristics were added consecutively, along with SOAS-R severity scores as independent variables. SOAS-R scores explained 17.6% of the VAS severity scores. Independently from the SOAS-R scores, the gender and age of the aggressive consumers (adjusted R(2) = 10.0%), as well as the gender of the nurses who reported the aggression (adjusted R(2) = 4.1%), each explained VAS severity score to a significant degree. Apart from the SOAS-R scores, consumer and nurse characteristics appeared to influence the overall judgements of severity of aggressive incidents, which may be connected to decisions about the use of coercive measures, such as seclusion/restraint or forced medication.

T cell-specific overexpression of interleukin-27 receptor α subunit (WSX-1) prevents spontaneous skin inflammation in MRL/lpr mice

BACKGROUND

Interleukin (IL)-27 and WSX-1, the receptor α-specific subunit, have been shown to play important roles in initiating Th1 responses and in inducing immune modulation, and the immunosuppressive effect of IL-27 appears to be exerted via suppression of IL-10 and IL-17, which may participate in the pathogenesis of human systemic lupus erythematosus (SLE).

OBJECTIVES

To examine the significance of IL-27/WSX-1 signalling in spontaneous skin inflammation of MRL/lpr mice, a model for SLE.

METHODS

The severity and development of skin lesions, dermal inflammatory cells and epidermal-dermal depositions in the skin lesions of MRL/lpr mice with CD2-promoted WSX-1 overexpression (WSX-1 Tg mice) and those with globally disrupted WSX-1 (WSX-1 KO mice) were examined and compared with those of MRL/lpr mice.

RESULTS

By 4 months of age, both WSX-1 KO mice and control MRL/lpr mice developed predominantly similar skin inflammation, while WSX-1 Tg mice hardly did so, demonstrating that intensifying IL-27/WSX-1 signalling on T cells prevents the spontaneous skin inflammation. WSX-1 KO mice showed Th2-type skin inflammation as evidenced by the Th2-prone dermal infiltrating cells and an absence of cutaneous Th1-type IgG deposition. Interestingly, there were significant IL-17+ dermal infiltrating cells in both WSX-1 KO and control MRL/lpr mice, which might potentially contribute to the formation of skin inflammation in these mice.

CONCLUSIONS

These data indicate that IL-27/WSX-1 signalling may play a protective role in the development of SLE-like skin inflammation, and modulating IL-27/WSX-1 signalling might be an interesting therapeutic strategy in the treatment of SLE.

Spatiotemporal dynamics of the expression of estrogen receptors in the postnatal mouse brain

This study reports on the spatiotemporal dynamics of the expression of estrogen receptors (ERs) in the mouse central nervous system (CNS) during the early postnatal and the peripubertal period. At postnatal day 7 (P7), neurons with strong nuclear immunostaining for both ERalpha and ERbeta1 were widely distributed throughout the brain. Sucrose density gradient sedimentation followed by western blotting supported the histochemical evidence for high levels of both ERs at P7. Over the following 2 days, there was a rapid downregulation of ERs. At P9, ERalpha expression was visible only in the hypothalamic area. Decline in ERbeta1 expression was slower than that of ERalpha, and ERalpha-negative, ERbeta1-positive cells were observed in the dentate gyrus and walls of third ventricle. Between P14 and P35, ERs were undetectable except for the hypothalamic area. As before P7, the ovary does not produce estrogen but does produce 5alpha-androstane-3beta, 17beta-diol (3betaAdiol), an estrogenic metabolite of dihydrotestosterone, we examined the effects of high levels of 3betaAdiol in the postnatal period. We used CYP7B1 knockout mice which cannot hydroxylate and inactivate 3betaAdiol. The brains of these mice are abnormally large with reduced apoptosis. In the early postnatal period, there was 1-week delay in the timing of the reduction in ER expression in the brain. These data reveal that the time when ERs might be activated in the brain is limited to the first 8 postnatal days. In addition, the importance of aromatase has to be reconsidered as the alternative estrogen, 3betaAdiol, is important in neuronal function in the postnatal brain.