Catalytic thiolation-depolymerization-like decomposition of oxyphenylene-type super engineering plastics via selective carbon-oxygen main chain cleavages

As the effective use of carbon resources has become a pressing societal issue, the importance of chemical recycling of plastics has increased. The catalytic chemical decomposition for plastics is a promising approach for creating valuable products under efficient and mild conditions. Although several commodity and engineering plastics have been applied, the decompositions of stable resins composed of strong main chains such as polyamides, thermoset resins, and super engineering plastics are underdeveloped. Especially, super engineering plastics that have high heat resistance, chemical resistance, and low solubility are nearly unexplored. In addition, many super engineering plastics are composed of robust aromatic ethers, which are difficult to cleave. Herein, we report the catalytic depolymerization-like chemical decomposition of oxyphenylene-based super engineering plastics such as polyetheretherketone and polysulfone using thiols via selective carbon-oxygen main chain cleavage to form electron-deficient arenes with sulfur functional groups and bisphenols. The catalyst combination of a bulky phosphazene base P4-tBu with inorganic bases such as tripotassium phosphate enabled smooth decomposition. This method could be utilized with carbon- or glass fiber-enforced polyetheretherketone materials and a consumer resin. The sulfur functional groups in one product could be transformed to amino and sulfonium groups and fluorine by using suitable catalysts.

Tips for Preparing and Practicing Thermal Ablation Therapy of Hepatocellular Carcinoma

Thermal ablation therapy, including radiofrequency ablation (RFA) and microwave ablation (MWA), is considered the optimal locoregional treatment for unresectable early-stage hepatocellular carcinomas (HCCs). Percutaneous image-guided ablation is a minimally invasive treatment that is being increasingly performed because it achieves good clinical outcomes with a lower risk of complications. However, the physics and principles of RFA and MWA markedly differ. Although percutaneous thermal ablation under image guidance may be challenging in HCC cases with limited access or a risk of thermal injury, a number of ablative techniques, each of which may be advantageous and disadvantageous for individual cases, are available. Furthermore, even when a HCC is eligible for ablation based on tumor selection and technical factors, additional patient factors may have an impact on whether it is the appropriate treatment choice. Therefore, a basic understanding of the advantages and limitations of each ablation device and imaging guidance technique, respectively, is important. We herein provide an overview of the basic principles of tissue heating in thermal ablation, clinical and laboratory parameters for ablation therapy, preprocedural management, imaging assessments of responses, and early adverse events. We also discuss associated challenges and how they may be overcome using optimized imaging techniques.

Achievement of Complete Response and Drug-Free Status by Atezolizumab plus Bevacizumab Combined with or without Curative Conversion in Patients with Transarterial Chemoembolization-Unsuitable, Intermediate-Stage Hepatocellular Carcinoma: A Multicenter Proof-Of-Concept Study

Introduction

Atezolizumab plus bevacizumab therapy is extremely effective in the treatment of intermediate-stage hepatocellular carcinoma (HCC), with a response rate of 44%, as reported in the IMbrave150 trial. When tumor shrinkage is obtained, achieving complete response (CR) is possible in many cases using curative conversion with resection, ablation, or superselective transarterial chemoembolization (TACE) with curative intent. This concept, i.e., curative conversion by combining systemic therapy and locoregional therapy, has not been reported before. This multicenter proof-of-concept study was conducted to show the value of curative conversion in immunotherapy-treated intermediate-stage HCC meeting TACE-unsuitable criteria.

Methods

This study included 110 consecutive Child-Pugh A patients who received atezolizumab plus bevacizumab as first-line treatment for unresectable and TACE-unsuitable intermediate-stage HCC at seven centers in Japan. CR rate, drug-free rate, time to CR, change in liver function, efficacy in positron emission tomography (PET)-positive HCC, progression-free survival (PFS), and overall survival (OS) were assessed in patients who achieved CR using resection, ablation, superselective TACE with curative intent following atezolizumab plus bevacizumab or atezolizumab plus bevacizumab alone.

Results

Clinical or pathological CR was achieved in 38 patients (35%) (median observation period: 21.2 months). The modalities of curative conversion in 35 patients were as follows: resection, 7; ablation, 13; and superselective TACE, 15. Three patients achieved clinical CR with atezolizumab plus bevacizumab therapy alone. Among the 38 CR patients, 25 achieved drug-free status. PFS was not reached, and 3 patients experienced recurrence after reaching CR. Regarding OS, there were no deaths in any of the CR patients. The albumin-bilirubin score did not deteriorate after locoregional therapy or resection. Of seven PET-positive patients who achieved CR with atezolizumab plus bevacizumab followed by curative conversion, five achieved drug-free status.

Conclusion

The achievement of CR rate by curative conversion in patients treated with atezolizumab plus bevacizumab as the preceding therapy for unresectable and TACE-unsuitable intermediate-stage HCC was 35%. Overall, 23% of patients achieved drug-free status and no recurrence was observed from this patient subgroup with CR and drug-free status. Thus, achieving CR and/or drug-free status should be a therapeutic goal for patients with intermediate-stage HCC without vascular invasion or extrahepatic spread.

Hydroxylation-Depolymerization of Oxyphenylene-Based Super Engineering Plastics To Regenerate Arenols

Super engineering plastics, high-performance thermoplastic resins, show high thermal stability and mechanical strength as well as chemical resistance. On the other hand, chemical recycling for these plastics has not been developed due to their stability. This study describes depolymerization of oxyphenylene super engineering plastics via carbon-oxygen main chain cleaving hydroxylation reaction with an alkali hydroxide nucleophile. This method is conducted with cesium hydroxide as a hydroxy source and calcium hydride as a dehydration agent in 1,3-dimethyl-2-imidazolidinone, which provides hydroxylated monomers effectively. In the case of polysulfone, both 4,4'-sulfonyldiphenol (bisphenol S) and 4,4'-(propane-2,2-diyl)diphenol (bisphenol A) were obtained in high yields. Other super engineering plastics such as polyethersulfone, polyphenylsulfone, and polyetheretherketone were also applicable to this depolymerization.

Characterization of a half-wave plate for cosmic microwave background circular polarization measurement with POLARBEAR

A half-wave plate (HWP) is often used as a modulator to suppress systematic error in the measurements of cosmic microwave background (CMB) polarization. A HWP can also be used to measure circular polarization (CP) through its optical leakage from CP to linear polarization. The CP of the CMB is predicted from various sources, such as interactions in the Universe and extension of the standard model. Interaction with supernova remnants of population III stars is one of the brightest CP sources. Thus, the observation of the CP of CMB is a new tool for searching for population III stars. In this paper, we demonstrate the improved measurement of the leakage coefficient using the transmission measurement of an actual HWP in the laboratory. We measured the transmittance of linearly polarized light through the HWP used in Polarbear in the frequency range of 120-160 GHz. We evaluate the properties of the HWP by fitting the data with a physical model using the Markov Chain Monte Carlo method. We then estimate the band-averaged CP leakage coefficient using the physical model. We find that the leakage coefficient strongly depends on the spectra of CP sources. We thus calculate the maximum fractional leakage coefficient from CP to linear polarization as 0.133 ± 0.009 in the Rayleigh-Jeans spectrum. The nonzero value shows that Polarbear has a sensitivity to CP. Additionally, because we use the bandpass of detectors installed in the telescope to calculate the band-averaged values, we also consider systematic effects in the experiment.

Non-Inflamed Tumor Microenvironment and Methylation/Downregulation of Antigen-Presenting Machineries in Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a refractory cancer; a majority of CCAs represents a non-inflamed tumor phenotype that should be resistant to treatment, including immune checkpoint inhibitors (ICIs). In this study, we aimed to understand the molecular characteristics associated with non-inflamed CCAs. The genetic/epigenetic status of 36 CCAs was obtained from the Cancer Genome Atlas (PanCancerAtlas). CCAs were classified based on immune class using hierarchical clustering analysis of gene expressions related to tumor-infiltrating lymphocytes. The associations between immune class and genetic/epigenetic events were analyzed. We found that the tumors with alterations in FGFR2 and IDH1/2 had a "non-inflamed" tumor phenotype. A significant association was observed between the non-inflamed group and the downregulation of genes involved in antigen presentation (p = 0.0015). The expression of antigen-presenting machineries was inversely correlated with their DNA methylation levels, where 33.3% of tumors had an upregulation/low-methylation pattern, and 66.7% of tumors had a downregulation/high-methylation pattern. All tumors in the "inflamed" group exhibited an upregulation/low-methylation pattern. In contrast, 24 of 30 tumors in the non-inflamed group represent the downregulation/high-methylation pattern (p = 0.0005). Methylation with downregulation of antigen-presenting machineries is associated with the "non-inflamed" tumor phenotype of CCAs. This evidence provides important insights for developing new strategies for treating CCA.

Role of β-Catenin Activation in the Tumor Immune Microenvironment and Immunotherapy of Hepatocellular Carcinoma

Recently, the therapeutic combination of atezolizumab and bevacizumab was widely used to treat advanced hepatocellular carcinoma (HCC). According to recent clinical trials, immune checkpoint inhibitors (ICIs) and molecular target agents are expected to be key therapeutic strategies in the future. Nonetheless, the mechanisms underlying molecular immune responses and immune evasion remain unclear. The tumor immune microenvironment plays a vital role in HCC progression. The infiltration of CD8-positive cells into tumors and the expression of immune checkpoint molecules are key factors in this immune microenvironment. Specifically, Wnt/β catenin pathway activation causes "immune exclusion", associated with poor infiltration of CD8-positive cells. Some clinical studies suggested an association between ICI resistance and β-catenin activation in HCC. Additionally, several subclassifications of the tumor immune microenvironment were proposed. The HCC immune microenvironment can be broadly divided into inflamed class and non-inflamed class, with several subclasses. β-catenin mutations are important factors in immune subclasses; this may be useful when considering therapeutic strategies as β-catenin activation may serve as a biomarker for ICI. Various types of β-catenin modulators were developed. Several kinases may also be involved in the β-catenin pathway. Therefore, combinations of β-catenin modulators, kinase inhibitors, and ICIs may exert synergistic effects.

Achievement of cancer- and treatment-free status by atezolizumab plus bevacizumab combined with or without curative conversion in patients with transarterial chemoembolization-unsuitable, intermediate-stage hepatocellular carcinoma: A multicenter cohort study

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Background: Atezolizumab plus bevacizumab therapy is extremely effective in the treatment of intermediate-stage hepatocellular carcinoma (HCC), with a response rate of 44%, as reported in the IMbrave150 trial. Tumor shrinkage is achieved, and cancer- and treatment-free status is possible in many cases using curative conversion with resection, ablation, or selective transarterial chemoembolization (TACE). This concept, i.e., curative conversion by combining systemic therapy and locoregional therapy, has not been reported before. This multicenter study was conducted to clarify the value of curative conversion in intermediate-stage HCC meeting TACE-unsuitable criteria. Methods: This study included 110 consecutive Child-Pugh A patients who received atezolizumab plus bevacizumab as first-line treatment for unresectable and TACE-unsuitable intermediate-stage HCC at seven centers in Japan. Cancer-free rate, treatment-free rate, time to cancer-free status, change in liver function, efficacy in positron emission tomography (PET)-positive HCC, recurrence-free survival (RFS), and overall survival (OS) were assessed in patients who achieved cancer-free status using resection, ablation, selective TACE, or atezolizumab plus bevacizumab alone. Results: Cancer-free status was achieved in 38 patients (35%) (median observation period: 17. 7 months). The modalities of curative conversion were as follows: resection, 7; ablation (including patients who underwent ablation after TACE), 13; and selective TACE (including lenvatinib-TACE sequential therapy), 15. Three patients achieved cancer-free status with only atezolizumab plus bevacizumab therapy. Among the 38 cancer-free patients, 24 achieved treatment-free status. RF5 was 31.8 months (95% confidence interval, 30.5-33.0), and two patients experienced recurrence after reaching cancer-free status. Regarding OS, there were no deaths in any of the groups, and excellent outcomes were obtained. The albumin-bilirubin score did not deteriorate after locoregional therapy or resection. Of seven PET-positive patients who achieved cancer-free status, five achieved treatment-free status. Conclusions: The curative conversion rate (cancer-free rate) in patients treated with atezolizumab plus bevacizumab as the preceding therapy for unresectable and TACE-unsuitable intermediate-stage HCC was 35%. Overall, 22% of patients achieved treatment-free status. Thus, achieving cancer-free and/or treatment-free status should be a therapeutic goal for patients with intermediate-stage HCC without vascular invasion or extrahepatic spread. Clinical trial information: NCT03434379 .

High thrombotic risk is associated with higher prevalence of suboptimal stent results in patients with high bleeding risk

Funding Acknowledgements

Type of funding sources: None.

Background

Shorter duration of dual antiplatelet therapy after drug-eluting stent implantation is required in patients with high bleeding risk (HBR) irrespective of the presence of concomitant high thrombotic risk (HTR). The prevalence of post-stent suboptimal findings in patients with HBR remains unclear.

Purpose

To clarify the prevalence of post-stent suboptimal findings assessed by optical coherence tomography (OCT) in patients with HBR according to the presence of HTR.

Methods

A total of 607 consecutive patients with stable coronary disease, who underwent OCT imaging of the culprit lesion were included. HBR was defined based on the Academic Research Consortium for High Bleeding Risk (ARC-HBR). HTR was defined as lesions with diffuse long (≧60 mm), treated with more than three stents, chronic total occlusion or diffuse long lesion (≧32 mm) in patients with diabetes mellitus. Post-stent suboptimal OCT criteria was defined as minimum stent area (MSA) <4.5 mm2, edge dissection and stent malapposition.

Results

The prevalence of HBR was 55.8%. The prevalence of HTR was significantly higher in patients with HBR than in those without HBR (35.0 vs. 26.6%, p=0.028) (Figure A). Among patients with HBR, the prevalence of post-stent suboptimal OCT criteria was significantly higher in patients with HTR than in those without HTR (86.2 vs. 64.7%, p<0.001), mainly due to the higher prevalence of MSA <4.5 mm2 (Figure B) in patients with HTR.

Conclusions

HTR was associated with a higher prevalence of post-stent suboptimal findings among patients with HBR. The present results may suggest the importance of optimal stenting in patients with HBR, particularly in those with concomitant HTR.

Depolymerization of robust polyetheretherketone to regenerate monomer units using sulfur reagents

Super engineering plastics, high-performance thermoplastic resins such as polyetheretherketone, and polyphenylene sulfide have been utilized in industries, owing to their high thermal stability and mechanical strength. However, their robustness hinders their depolymerization to produce monomers and low-weight molecules. Presently, chemical recycling for most super engineering plastics remains relatively unexplored. Herein, we report the depolymerization of insoluble polyetheretherketone using sulfur nucleophiles via carbon-oxygen bond cleavages to form benzophenone dithiolate and hydroquinone. Treatment with organic halides converted only the former products to afford various dithiofunctionalized benzophenones. The depolymerization proceeded as a solid-liquid reaction in the initial phase. Therefore, this method was not affected by the shape of polyetheretherketone, e.g., pellets or films. Moreover, this depolymerization method was applicable to carbon- or glass fiber-enforced polyetheretherketone material. The depolymerized product, dithiofunctionalized benzophenones, could be converted into diiodobenzophenone, which was applicable to the polymerization.

Prognostic Factors for Overall Survival in Patients with HCV-Related HCC Undergoing Molecular Targeted Therapies: Beyond a Sustained Virological Response

Background: The treatment of the hepatitis C virus (HCV) has reduced the risk of hepatocellular carcinoma (HCC)-related mortality. Many patients with advanced HCC have achieved longer survival through systemic chemotherapy. However, survivors of HCC may develop liver cancer during and after treatment. Therefore, the present study investigated prognostic factors for survival in patients with HCV-related HCC in the new era of molecular targeted therapy. Methods: A total of 359 patients with HCV-related HCC treated with first-line chemotherapy were reviewed. A Cox proportional hazards model and Kaplan−Meier curve were used to identify prognostic factors associated with survival outcomes. Results: The median follow-up duration was 16.0 months (range, 1.0−115.7) and the median duration of first-line systemic therapy was 3.73 months (range, 0.7−86.9). The achievement of a sustained virological response (SVR) (p  <  0.001), albumin−bilirubin (ALBI) grade II/III (p  <  0.001), Barcelona Clinic Liver Cancer (BCLC) stage C (p  =  0.005), extrahepatic spread (p < 0.001), baseline AFP (alpha-fetoprotein) level ≥ 90 (p = 0.038), baseline DCP (des-γ-carboxy prothrombin) level ≥ 500 (p < 0.001), and a fibrosis-4 (FIB-4) index ≥ 4 (p  =  0.003) were identified as prognostic factors for overall survival. Conclusions: The achievement of SVR was most strongly associated with overall survival. Other factors, such as the BCLC stage, extrahepatic spread, baseline tumor marker (AFP/DCP) levels, ALBI grade, and FIB-4 index need to be considered in the management of patients with HCV-related HCC.

Cardiovascular risk factors and underlying pathology and prevalence of lipid plaques in women with acute coronary syndromes in different age groups

Background

An incidence of cardiovascular events increases with age in women. The relationship between cardiovascular risk factors, and the underlying pathology and the prevalence of lipid plaques has not been systematically studied in different age groups in women presented with acute coronary syndromes (ACS).

Purpose

We investigated the underlying pathology and the prevalence of lipid plaques in culprit lesions by optical coherence tomography (OCT) in women with different risk factors.

Methods

A total of 382 women who underwent pre-intervention OCT imaging were included. The underlying pathology and the prevalence of lipid plaques in the culprit lesion was compared between women with and without cardiovascular risk factors (i.e. hypertension, smoking, hyperlipidemia, diabetes mellitus, family history and chronic kidney disease) in three different age groups (&lt;60 yr, 60–70 yr, &gt;70 yr).

Results

The relative prevalence of plaque erosion was higher in younger women (&lt;60 yr) and decreased with age (from 51% to 28%, p&lt;0.001). There was no significant difference in the prevalence of lipid plaques between women with and without risk factors, except a higher prevalence of lipid plaques in current smokers compared to non-smokers (79% vs. 63%, p=0.003). In women with hyperlipidemia, the prevalence of lipid plaques was modest in young ages (&lt;60 yr), but increased steeply with age (p&lt;0.001). The increasing age trend for lipid plaque was also observed in women with hypertension (p=0.03) and current smokers (p=0.01). In women with diabetes mellitus and family history, the prevalence of lipid plaques was high even in young ages (&lt;60 yr) and did not increase with age.

Conclusion

The prevalence of plaque erosion was higher in younger women (&lt;60 yr) and decreased with age. Current smokers had significantly higher prevalence of lipid plaque. Patients with diabetes and positive family history had a higher prevalence of lipid plaque at young age. The prevalence of lipid plaques increased with age particularly in women with hyperlipidemia and hypertension.

Funding Acknowledgement

Type of funding sources: Foundation.

Higher triglyceride level is associated with the higher prevalence of layered plaque in nonculprit coronary plaques

Background

The impact of the high triglyceride (TG) level on the characteristics of coronary plaque in nonculprit lesion remains to be elucidated.

Purpose

To clarify the association between the TG level and the characteristics of nonculprit coronary plaque in patients with stable coronary disease using optical coherence tomography (OCT).

Methods

A total of 531 consecutive patients who underwent OCT imaging of the nonculprit lesion were included. Patients were classified into either the higher TG group (non-fasting TG ≥150 mg/dL, n=197) or the lower TG group (non-fasting TG &lt;150 mg/dL, n=334). The morphologies of nonculprit plaque assessed by OCT were compared between the two groups.

Results

The median (interquartile range) of TG in the two groups was 193.0 (168.0–244.0) mg/dL and 95.0 (75.0–120.0) mg/dL, respectively. The prevalence of layered plaque was significantly higher in the higher TG group than the lower TG group (40.1 vs. 27.5%, p=0.004), whereas the prevalence of other plaque components was comparable between the two groups (Figure 1). The prevalence of layered plaque was significantly higher in the higher TG group than in the lower TG group among patients with diabetes mellitus (DM) (44.2 vs. 28.7%, p=0.037) although it was comparable between the two groups among patients without DM (Figure 2).

Conclusion

A higher TG level was associated with a higher prevalence of layered plaque in nonculprit plaques in patients with stable coronary disease, particularly in patients with DM. The present results may partly explain the impact of TG on the progression of coronary plaque and the increased incidence of recurrent events in patients with coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Progression from early to advanced stage of immune-related cholangitis

AIM

We report a rare case of immune-related cholangitis in which the natural course could be demonstrated.

CASE PRESENTATION

Eight courses of pembrolizumab maintenance therapy were given as first-line treatment for squamous cell lung cancer; however, the patient was subsequently hospitalized due to a rapid increase in hepatobiliary enzymes. On endoscopic ultrasound, the common bile duct was dilated to 11 mm, and the wall, throughout its length from the papilla, was thickened. Endoscopic retrograde cholangiopancreatography showed no obvious stenosis in the lower bile duct; however, a parapapillary diverticulum was found, and papillary incision and bile duct plastic stent insertion were carried out. However, the liver disorder did not improve and overt jaundice appeared subsequently; therefore, an immune-related cholangitis was suspected, and prednisolone (PSL) 35 mg/day was introduced from day 59 of admission. Following PSL initiation, a decrease in serum bilirubin level was observed; however, significant decrease was not observed in alkaline phosphatase. Given the history of recurrent infectious cholangitis, magnetic resonance cholangiopancreatography was carried out on day 70 of admission. The intrahepatic bile duct showed stenosis and dilated findings, which was considered to be a factor for repeated infectious cholangitis.

CONCLUSION

No previous case reports have described the changes and progression in bile duct images in immune-related adverse events. Therefore, this case is noteworthy for considering the progression of immune-related cholangitis.

Clinical implication of immune checkpoint inhibitor on the chronic hepatitis B virus infection

AIM

The risk of hepatitis B virus (HBV) reactivation with immune checkpoint inhibitors (ICIs) is an important issue that has not yet been fully investigated. ICI is also expected to have an antiviral effect on HBV due to its immune tolerance inhibitory effect. We herein investigated the risk of HBV reactivation and the antiviral effect of ICI administration.

METHODS

This study included 892 patients on ICIs between September 2014 and May 2021 at our hospital. The frequency of HBV reactivation and antiviral effects were investigated.

RESULTS

Among the 892 patients who underwent ICI, 27 were hepatitis B surface antigen (HBsAg) positive. HBV reactivation was evaluated in 24 cases, among which 4.1% (1/24) had HBV reactivation. Nucleic acid analog prophylaxis was not administered to patients with reactivation. In a study of 15 cases, the amount of HBsAg decreased from baseline; 2.18 ± 0.77 log to 48 weeks later; 1.61 ± 1.38 log (p = 0.17). Forty-eight weeks after the start of ICI, disappearance of HBsAg was observed in two out of 15 cases (13.3%), and one case each with and without nucleic acid analog.

CONCLUSION

In rare cases, HBsAg-positive patients may be reactivated by ICI administration. On the other hand, when ICI is administered, it is expected to have an antiviral effect on HBV due to its immune tolerance inhibitory effect, and future drug development is expected.

Synthesis of Multisubstituted Benzenes from Phenols via Multisubstituted Benzynes

A new method to synthesize multifunctionalized arenes from simple phenols through aryne intermediates is described. Multisubstituted aryne precursors were prepared from phenols by Ir-catalyzed C–H borylation, deborylthiolation, O-triflylation, S-oxidation, and further modification through ortho-deprotonation directed by the sulfoxide moiety. Various multisubstituted arenes were synthesized by transformations of highly functionalized aryne intermediates generated from the o-sulfinylaryl triflates.

How Compatible Are Immune Checkpoint Inhibitors and Thermal Ablation for Liver Metastases?

Simple Summary

Although immune checkpoint inhibitors (ICIs) have achieved great progression in cancer treatment, the efficacy of ICI monotherapy is still limited. Meanwhile, the negative efficacy of thermal ablation for liver metastases is the high rate of local tumor progression. Since thermal ablation-induced inflammation and increases in tumor antigens have been suggested to promote the cancer-immunity cycle, thermal ablation and ICI can boost the immune response against cancer cells as one of the positive synergy effects. The findings of preclinical and clinical research have provided supportive evidence for the combination of ICIs with thermal ablation reversing T-cell exhaustion and demonstrating synergy. However, the clinical feasibility of immune response activation by combination therapy with ICI monotherapy and thermal ablation appears to be limited, it may be not very common phenomena.

Abstract

Cancer immunotherapy, which reactivates the weakened immune cells of cancer patients, has achieved great success, and several immune checkpoint inhibitors (ICIs) are now available in clinical practice. Despite promising clinical outcomes, favorable responses are only observed in a fraction of patients, and resistance mechanisms, including the absence of tumor antigens, have been reported. Thermal ablation involves the induction of irreversible damage to cancer cells by localized heat and may result in the release of tumor antigens. The combination of immunotherapy and thermal ablation is an emerging therapeutic option with enhanced efficacy. Since thermal ablation-induced inflammation and increases in tumor antigens have been suggested to promote the cancer-immunity cycle, the combination of immuno-oncology (IO) therapy and thermal ablation may be mutually beneficial. In preclinical and clinical studies, the combination of ICI and thermal ablation significantly inhibited tumor growth, and synergistic antitumor effects appeared to prolong the survival of patients with secondary liver cancer. However, evidence for the efficacy of ICI monotherapy combined with thermal ablation is currently insufficient. Therefore, the clinical feasibility of immune response activation by ICI monotherapy combined with thermal ablation may be limited, and thermal ablation may be more compatible with dual ICIs (the IO–IO combination) to induce strong immune responses.

Cosmic Birefringence from the Planck Data Release 4

We search for the signature of parity-violating physics in the cosmic microwave background, called cosmic birefringence, using the Planck data release 4. We initially find a birefringence angle of β=0.30°±0.11° (68% C.L.) for nearly full-sky data. The values of β decrease as we enlarge the Galactic mask, which can be interpreted as the effect of polarized foreground emission. Two independent ways to model this effect are used to mitigate the systematic impact on β for different sky fractions. We choose not to assign cosmological significance to the measured value of β until we improve our knowledge of the foreground polarization.

High sensitivity C-reactive protein is associated with vulnerable characteristics in non-culprit plaques in patients with ST-segment elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Higher level of high sensitivity C-reactive protein (hsCRP) is associated with an increased risk of recurrent cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). However, the association between hsCRP and the characteristics of non-culprit plaques in patients with STEMI remains to be elucidated.

Purpose

To clarify the morphological characteristics of non-culprit plaque in patients with STEMI according to the hsCRP levels using optical coherence tomography (OCT).

Methods

A total of 79 non-culprit plaques in 76 consecutive patients with STEMI, who underwent OCT imaging of the non-culprit plaques in a culprit vessel were included. The characteristics of non-culprit plaques assessed by OCT were compared between the higher hsCRP group (hsCRP ≥ 0.16 mg/dL, 38 plaques in 38 patients) and the lower hsCRP group (hsCRP &lt; 0.16 mg/dL, 41 plaques in 38 patients).

Results

The prevalence of plaque with macrophage (63.2 vs. 31.7%, p = 0.006), plaque with large lipid (maximal lipid arc &gt; 180 °) (57.9 vs. 31.7%, p = 0.018), healed plaque (50.0 vs. 26.8%, p = 0.045) and cholesterol crystal (18.4 vs. 2.4%, p = 0.045) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Figure). In a multivariate analysis, the higher hsCRP was independently associated with the presence of plaque with macrophage (Odds ratio [OR], 3.031; 95% confidence interval [CI]: 1.112-8.264, p = 0.030), plaque with large lipid (OR, 2.897; 95% CI: 1.122-7.478, p = 0.026) and healed plaque (OR, 2.666; 95% CI: 1.030-6.896, p = 0.040).

Conclusions

Higher level of hsCRP is associated with a higher prevalence of vulnerable characteristics in non-culprit plaques in patients with STEMI. The present results may partly explain the pathogenesis of an increased incidence of recurrent cardiovascular events in patients with STEMI. Abstract Figure.

Final results of adjuvant nivolumab for hepatocellular carcinoma (HCC) after surgical resection (SR) or radiofrequency ablation (RFA) (NIVOLVE): A phase 2 prospective multicenter single-arm trial and exploratory biomarker analysis

416

Background: The NIVOLVE trial was designed to assess the efficacy and safety of nivolumab as an adjuvant therapy for HCC, and to identify biomarkers predictive of recurrence in patients after SR or RFA (Registration # UMIN 000026648). Methods: The trial involved 11 sites and was conducted in patients with HCC who showed a complete response after SR (n = 33) or RFA (n = 22) (ITT). Overall, 53 of 55 patients with Child-Pugh A received nivolumab (240 mg/body every 2 weeks (8 cycles)), followed by nivolumab (480 mg/body every 4 weeks [8 cycles]) within 6 weeks after SR or RFA. The primary endpoint was the 1-year recurrence-free survival rate (RFSR). The key secondary endpoint was RFS. Exploratory biomarker analysis included mutations, copy number alterations, and positivity of immune cells. Techniques included next generation sequencing, immunohistochemical staining (IHC) of formalin-fixed paraffin-embedded tissues (n = 31 [13 with recurrence and 18 without]) for CD8, PD-1, PD-L1, Foxp3, and β-catenin, and ctDNA analysis using pre-nivolumab whole blood by deep sequencing (CAPP-seq; Avenio). Results: The 1-year RFSR and median RFS were 78.6% and 26.3 months (95% confidence interval (CI), 16.8-NR), respectively, with no difference between SR and RFA. Copy number gains (CNGs) in WNT/β-catenin related genes ( APC, CTNNB1, TCF7L1, TCF7L2) (n = 30) correlated with shorter RFS (positive: 10.6 months vs. negative: not reached [NR]; p < 0.0001). IHC revealed that negative staining for PD-1 (p < 0.0001), a low combined positive score for PD-L1 (p = 0.005), a low number of CD8+ tumor infiltrating lymphocytes (TILs) (p < 0.001), and positivity for Foxp3+ cells (p = 0.015) correlated with recurrence. HCC cases with low numbers of CD8+ TILs or cases positive for Foxp3+ cells (n = 16) showed a significantly shorter RFS (16.8 months [95% CI, 8.7-25.2]) than those with high numbers of CD8+ TILs and those positive for PD-1/PD-L1 expression (n = 15) (NR [95% CI,26.2months–NR]) (p < 0.0001). HCC cases with activation of the WNT/β-catenin pathway assessed by IHC (n = 9) showed shorter RFS (17.0 months [95% CI,1.1–26.2]) than those without activation (n = 22) (NR [95% CI,23.0 months–NR]) (p = 0.014). Patients positive for ctDNA (n = 15) before nivolumab tended to have shorter RFS than those without ctDNA (n = 9) (26.3 vs. NR). There was no correlation between TMB and RFS. Treatment-emergent adverse events (AEs) (n = 53) were as follows: all grades, 93%; grades 3–4 (18.9%); and immune related AEs, 25%. Conclusions: The 1-year RFSR and RFS in the NIVOLVE trial were 78.6% and 26.3 months, respectively. No new safety signal was observed. CNG in WNT/β-catenin-related genes, activation of the WNT/β-catenin pathway, the presence of Foxp3+ cells, and low numbers of CD8+ TILs may predict recurrence after SR or RFA with adjuvant nivolumab. Clinical trial information: UMIN 000026648.

Higher Enhancement Intrahepatic Nodules on the Hepatobiliary Phase of Gd-EOB-DTPA-Enhanced MRI as a Poor Responsive Marker of Anti-PD-1/PD-L1 Monotherapy for Unresectable Hepatocellular Carcinoma

Introduction

Immune checkpoint inhibitors (ICIs) are promising agents for the treatment of hepatocellular carcinoma (HCC). However, the establishment of noninvasive measure that could predict the response to ICIs is challenging. This study aimed to evaluate tumor responses to ICIs using the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI), which was shown to reflect Wnt/β-catenin activating mutation.

Methods

A total of 68 intrahepatic HCC nodules from 18 patients with unresectable HCC and Child-Pugh class A liver function who received anti-programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1) monotherapy were enrolled in this study. All patients had viable intrahepatic lesions evaluable using the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI within the 6 months prior to the treatment. The relative enhancement ratio was calculated, and the time to nodular progression (TTnP) defined as 20% or more increase in each nodule was compared between higher or hypo-enhancement HCC nodules. Then, the progression-free survival (PFS) and objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) were compared between patients with and without HCC nodules with higher enhancement on hepatobiliary phase images.

Results

The median PFS was 2.7 (95% confidence interval [CI]: 1.4-4.0) months in patients with HCC nodules with higher enhancement (n = 8) and 5.8 (95% CI: 0.0-18.9) months in patients with hypointense HCC nodules (n = 10) (p = 0.007). The median TTnP of HCC nodules with higher enhancement (n = 23) was 1.97 (95% CI: 1.86-2.07) months and that of hypointense HCC nodules (n = 45) was not reached (p = 0.003). The ORR was 12.5% (1/8) versus 30.0% (3/10); the disease control rate was 37.5% (3/8) versus 70.0% (7/10), respectively, in patients with or without higher enhancement intrahepatic HCC nodules.

Conclusion

The TTnP on HCC nodules with higher enhancement and the median PFS in patients who carried higher enhancement intrahepatic HCC nodules were significantly shorter than those in hypointense HCC nodules with anti-PD-1/PD-L1 monotherapy. The intensity of the nodule on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is a promising imaging biomarker for predicting unfavorable response with anti-PD-1/PD-L1 monotherapy in patients with HCC.

Accumulation of Genetic and Epigenetic Alterations in the Background Liver and Emergence of Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease

The incidence of hepatocellular carcinoma (HCC) related to non-alcoholic fatty liver disease (NAFLD) is increasing worldwide. We analyzed 16 surgically resected HCC cases in which the background liver was pathologically diagnosed as NAFLD. Specimens with Brunt classification grade 3 or higher were assigned as the fibrotic progression group (n = 8), and those with grade 1 or lower were classified as the non-fibrosis progression group (n = 8). Comprehensive mutational and methylome analysis was performed in cancerous and noncancerous tissues. The target gene mutation analysis with deep sequencing revealed that CTNNB1 and TP53 mutation was observed in 37.5% and TERT promoter mutation was detected in 50% of cancerous samples. Furthermore, somatic mutations in non-cancerous samples were less frequent, but were observed regardless of the progression of fibrosis. Similarly, on cluster analysis of methylome data, status for methylation events involving non-cancerous liver was similar regardless of the progression of fibrosis. It was found that, even in cases of non-progressive fibrosis, accumulation of gene mutations and abnormal methylation within non-cancerous areas were observed. Patients with NAFLD require a rigorous liver cancer surveillance due to the high risk of HCC emergence based on the accumulation of genetic and epigenetic abnormalities, even when fibrosis is not advanced.

Low serum chloride level gives renin-angiotensin system inhibitor a prognostic impact in heart failure patients with preserved ejection fraction

Background

Hypochloremia is associated with a poor prognosis of heart failure (HF) patients. This phenomenon is sustained even in HF with preserved ejection fraction (HFpEF). Serum chloride level is known to be affected by serum renin secretion; however, this relationship is one of the least investigated field in HF patients. Renin-angiotensin system (RAS) inhibitor is recommended as a first-line medication for HF patients with reduced left ventricular ejection fraction, but no prior studies of RAS inhibitors have achieved to improve the prognosis of HFpEF patients.

Purpose

We investigated the relationship between baseline serum chloride level and the prognostic impact of RAS inhibitor in HFpEF patients.

Methods

This is an observational study including 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive in a single university hospital. After excluding patients who received regular hemodialysis and whose left ventricular ejection fraction were under 50%, 506 HFpEF patients were ultimately analyzed. They were categorized into tertiles by serum chloride levels at discharge (T1: −100 mEq/L, T2: 101–104 mEq/L, T3: 105- mEq/L), and patients in each category were further divided into subgroups depending on the prescription of RAS inhibitor at discharge (RAS inhibitor group and Non-RAS inhibitor group). The primary endpoint of this study was death from any cause.

Results

During the observation period with 479 days of median follow-up, 77 (15.2%) died. Patients in the RAS inhibitor group had significantly better prognosis than those in the Non-RAS inhibitor group in T1 category (Log-rank: p=0.003, Figure). In contrast, there was no statistical difference in the mortality between the RAS inhibitor group and Non-RAS inhibitor group in T2 and T3 categories (Log-rank: p=0.15, p=0.81, respectively, Figure). Multivariate Cox regression analysis in T1 category revealed that taking RAS inhibitor at discharge was independently associated with a lower mortality rate, even after the adjustment of diverse covariates (hazard ratio: 0.40, 95% confidence interval: 0.20–0.80).

Conclusion

In this observational study, the administration of RAS inhibitor was associated with an improved prognosis of HFpEF patients only in low serum chloride level at discharge. Therapeutic strategy focusing on the chloride level may be one of the promising options to find the light on a unintervenable prognosis of HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic advantage of optimal medical therapy is not cancelled in hospitalized heart failure patients receiving regular hemodialysis

Background

As the first-line medications, renin-angiotensin-aldosterone system inhibitor (RAASi) and β-blocker provide prognostic benefits in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, the negative inotropic effect of these drugs may destabilize the hemodynamics during hemodialysis (HD) and become prognostically controversial in patients receiving regular HD. Indeed, prior studies have reported the cancellation of the favorable prognostic effects of RAASi and β-blocker in patients with HD. However, it is totally unknown whether the guideline-directed medical therapy affects the prognosis in HF patients receiving regular HD.

Purpose

We aimed to evaluate the prognostic impact of RAASi and β-blocker on the cardiovascular (CV) events in HF patients on regular HD.

Methods

This observational study initially included 1,930 consecutive patients who were hospitalized due to HF and discharged alive. Of these, 151 patients who received regular HD were ultimately analyzed. They were classified into 3 groups depending on the prescribing medications at discharge; patients who received none of RAASi or β-blocker (None group: N=19), either RAASi or β-blocker (Either group: N=56), and both RAASi and β-blocker (Both group: N=76). The primary endpoint was a composite of CV death and readmission due to HF.

Results

During the observation period of median 501 (interquartile range: 197–954) days, the primary endpoint occurred in 61 patients (40%). Kaplan-Meier analysis showed the highest rate of composite endpoint in the None group (log-rank for trend: p&lt;0.001, Figure). After adjusting for covariates of age, sex, LVEF, and systolic blood pressure and heart rate at discharge, the hazard ratio (HR) for a composite endpoint was significantly lower in the Either group or Both group than that in the None group [HR: 0.19, 95% confidence interval (CI): 0.08–0.45; HR: 0.16, 95% CI: 0.06–0.42, respectively].

Conclusions

The prescription of RAASi or β-blocker at discharge was associated with lower adverse CV event rates in patients on regular HD who were hospitalized for HF. In order to improve long-term prognosis of HF patients on HD, we should consider the prescription of RAASi or β-blocker for them if hemodynamics during HD is affordable.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Can the Entire Ablative Hyperechoic Zone be Regarded as a Necrotic Lesion After Radiofrequency Ablation of the Liver?

Developments in image fusion technology made it possible to visualize the ablative margin on ultrasound (US). The purpose of the present study was to assess the ablative area of radiofrequency ablation for hepatocellular carcinoma and compare it with the ablative hyperechoic zone with a non-enhanced area on contrast-enhanced US/contrast-enhanced computed tomography (CEUS/CECT) in the same cross-section. This retrospective study included 25 patients with 27 hepatocellular carcinomas. The long and short dimensions of the ablative hyperechoic zone were measured using B-mode US, and those of the non-enhanced area were assessed with CEUS/CECT on the same cross-section measured with B-mode US, using image fusion techniques. The technical effectiveness of ablation with an adequate ablative margin in a single session was determined in all patients. The long and short dimensions of the ablative hyperechoic zone ranged between 15.0 and 40.7 mm (mean: 27.3 ± 6.9 mm) and between 14.0 and 33.0 mm (mean: 23.3 ± 5.8 mm), respectively. R values for the long and short dimensions were 0.99 and 0.98, respectively, between B-mode US and CEUS, and 0.96 and 0.92, respectively, between B-mode US and CECT. The ablative hyperechoic zone may be regarded as a necrotic lesion after radiofrequency ablation.

Higher Enhancement Intrahepatic Nodules on the Hepatobiliary Phase of Gd-EOB-DTPA-Enhanced MRI as a Poor Responsive Marker of Anti-PD-1/PD-L1 Monotherapy for Unresectable Hepatocellular Carcinoma

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are promising agents for the treatment of hepatocellular carcinoma (HCC). However, the establishment of noninvasive measure that could predict the response to ICIs is challenging. This study aimed to evaluate tumor responses to ICIs using the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI), which was shown to reflect Wnt/β-catenin activating mutation.

METHODS

A total of 68 intrahepatic HCC nodules from 18 patients with unresectable HCC and Child-Pugh class A liver function who received anti-programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1) monotherapy were enrolled in this study. All patients had viable intrahepatic lesions evaluable using the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI within the 6 months prior to the treatment. The relative enhancement ratio was calculated, and the time to nodular progression (TTnP) defined as 20% or more increase in each nodule was compared between higher or hypo-enhancement HCC nodules. Then, the progression-free survival (PFS) and objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) were compared between patients with and without HCC nodules with higher enhancement on hepatobiliary phase images.

RESULTS

The median PFS was 2.7 (95% confidence interval [CI]: 1.4-4.0) months in patients with HCC nodules with higher enhancement (n = 8) and 5.8 (95% CI: 0.0-18.9) months in patients with hypointense HCC nodules (n = 10) (p = 0.007). The median TTnP of HCC nodules with higher enhancement (n = 23) was 1.97 (95% CI: 1.86-2.07) months and that of hypointense HCC nodules (n = 45) was not reached (p = 0.003). The ORR was 12.5% (1/8) versus 30.0% (3/10); the disease control rate was 37.5% (3/8) versus 70.0% (7/10), respectively, in patients with or without higher enhancement intrahepatic HCC nodules.

CONCLUSION

The TTnP on HCC nodules with higher enhancement and the median PFS in patients who carried higher enhancement intrahepatic HCC nodules were significantly shorter than those in hypointense HCC nodules with anti-PD-1/PD-L1 monotherapy. The intensity of the nodule on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is a promising imaging biomarker for predicting unfavorable response with anti-PD-1/PD-L1 monotherapy in patients with HCC.

Comparison of efficacy and safety of entecavir and switching from entecavir to tenofovir alafenamide fumarate in chronic hepatitis B: Long-term effects from a prospective study

AIM

Both entecavir (ETV) and tenofovir alafenamide fumarate (TAF) are widely used to treat chronic hepatitis B (CHB) in Japan. However, it remains unclear whether the efficacy of TAF in decreasing the hepatitis B surface antigen (HBsAg) level, and its safety, are superior to those of ETV. This study aimed to report the long-term effects and safety of 96-week ETV and TAF treatment in patients with CHB.

METHODS

A prospective comparative observational study was undertaken on the following two groups: patients with CHB who received continuous ETV (n = 32) and patients with CHB who were switched from ETV to TAF upon request (n = 48). The HBsAg, urinary β2-microglobulin (β2MG)/creatinine (Cr), urinary N-acetyl-β-D-glucosaminidase (NAG)/Cr, and serum alanine aminotransferase (ALT) levels, estimated glomerular filtration rate (eGFR), and bone mineral density (lumbar spine and femur) at 96 weeks were compared.

RESULTS

The two groups did not significantly differ with respect to mean age, male / female patient ratio, or rate of hepatitis B e antigen-positive status. The mean changes in serum HBsAg level and eGFR at 96 weeks were not significantly different between the two groups. The β2MG/Cr and NAG/Cr levels at 96 weeks were similar between the two groups. Additionally, the bone mineral density of the lumbar spine and femur as well as the serum ALT did not significantly differ.

CONCLUSIONS

When compared with patients who received continuous ETV, those who were introduced to TAF after ETV showed similar effects in terms of the decrease in HBsAg level and safety.

Immunological Microenvironment Predicts the Survival of the Patients with Hepatocellular Carcinoma Treated with Anti-PD-1 Antibody

INTRODUCTION

Although immune checkpoint inhibitors (ICIs) have been considered as promising agents for the treatment of advanced hepatocellular carcinoma (HCC), previous clinical trials revealed that the response to anti-programmed cell death protein 1 (anti-PD-1) monotherapy was as low as 20%. Identifying subgroups that respond well to ICIs is clinically important. Here, we studied the prognostic factors for anti-PD-1 antibody treatment based on the molecular and immunological features of HCC.

METHODS

Patients who were administered anti-PD1 antibody for advanced HCC at Kindai University Hospital were included. Clinicopathological backgrounds and antitumor responses were examined in 34 cases where tumor tissues before treatment were available. Transcriptome analysis was performed using 40 HCC samples obtained from surgical resection, and immune status was compared between 20 HCCs with activating mutations in β-catenin and those without the mutations using transcriptome-based immunogram.

RESULTS

Univariate analysis showed that the disease control rate was significantly better in patients with α-fetoprotein < 400 ng/mL, negative for β-catenin/glutamate synthetase (GS) staining, high combined positive score (CPS) of programmed death-ligand 1 (PD-L1), and increased infiltration of CD8⁺ cells in tumor tissues. Among them, negative staining of β-catenin/GS, CPS of PD-L1 ≥ 1, and high degree of CD8⁺ tumor-infiltrating lymphocytes (TILs) were significantly associated with longer survival in both progression-free survival (PFS) and overall survival (OS). The combination of these factors well stratified the survival of the patients on anti-PD-1 antibody in both PFS and OS (p < 0.0001 and p = 0.0048 for PFS and OS, respectively). In addition, the immunogram revealed that tumor-carrying mutations in β-catenin showed downregulation of immune-related genes, especially in those related to priming and activation by dendritic cells, interferon-γ response, inhibitory molecules, and regulatory T cells.

DISCUSSION/CONCLUSION

The combined score including Wnt/β-catenin activation, CPS of PD-L1, and degree of CD8⁺ TILs in HCC is informative for predicting the response to ICI in HCC cases. Constitutive activation of β-catenin can induce an immune cold phenotype with downregulation of immune-related genes, and immunohistochemistry-based evaluation is beneficial for identifying the subgroup that shows a good response to ICI.

Utility of contrast-enhanced harmonic endoscopic ultrasonography for predicting the prognosis of pancreatic neuroendocrine neoplasms

BACKGROUND AND AIMS

Pancreatic neuroendocrine neoplasms (PanNENs), including Grade 1 (G1) or G2 tumors, can have a poor prognosis. This study investigated the value of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for predicting the prognosis of PanNENs.

METHODS

This single-center, retrospective study included 47 consecutive patients who underwent CH-EUS and were diagnosed with PanNEN by surgical resection or EUS-guided fine needle aspiration between December 2011 and February 2016. Patients were divided into aggressive and non-aggressive groups according to the degree of clinical malignancy. CH-EUS was assessed regarding its capacity for diagnosing aggressive PanNEN, the correspondence between contrast patterns and pathological features, and its ability to predict the prognosis of PanNEN.

RESULTS

There were 19 cases of aggressive PanNEN and 28 cases of non-aggressive PanNEN. The aggressive group included three G1, four G2, three G3 tumors, three mixed neuroendocrine non-neuroendocrine neoplasms, and six neuroendocrine carcinomas. CH-EUS was superior to contrast-enhanced computed tomography for the diagnosis of aggressive PanNEN (P < 0.001): hypo-enhancement on CH-EUS was an indicator of aggressive PanNEN, with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 94.7%, 100%, 100%, 96.6%, and 97.9%, respectively. Among G1/G2 PanNENs, cases with hypo-enhancement on CH-EUS had a poorer prognosis than those with hyper/iso-enhancement (P = 0.0009). Assessment of 36 resected specimens showed that hypo-enhancement on CH-EUS was associated with smaller and fewer vessels and greater degree of fibrosis.

CONCLUSION

Contrast-enhanced harmonic endoscopic ultrasonography may be useful for predicting the prognosis of PanNENs.

Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other's work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

Catalytic Reductive Cleavage of Poly(phenylene sulfide) Using a Hydrosilane

The solvent-insoluble poly(phenylene sulfide) main chain was reductively cleaved by using triethylsilane as a hydrogen source under palladium/IcHex catalytic conditions. After the reaction, benzene and bis(triethylsilyl) sulfide as a sulfide source were formed efficiently. This method could be operated on a gram scale.

Adjuvant nivolumab for hepatocellular carcinoma (HCC) after surgical resection (SR) or radiofrequency ablation (RFA) (NIVOLVE): A phase 2 prospective multicenter single-arm trial and exploratory biomarker analysis

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Background: The NIVOLVE trial was designed to assess the efficacy and safety of nivolumab as an adjuvant therapy for HCC, and to identify biomarkers predictive of recurrence in patients after SR or RFA (Registration # UMIN 000026648). Methods: The trial involved 11 sites and was conducted in patients with HCC who showed a complete response after SR (n = 33) or RFA (n = 22) (ITT). Overall, 53 of 55 patients with Child-Pugh A received nivolumab (240 mg/body every 2 weeks (8 cycles)), followed by nivolumab (480 mg/body every 4 weeks (8 cycles)) within 6 weeks after SR or RFA. The primary endpoint was the 1 year recurrence-free survival rate (RFSR). The key secondary endpoint was RFS. Exploratory biomarker analysis included mutations, copy number alterations, and tumor mutation burden in tumor tissues. Techniques included next generation sequencing, immunohistochemical staining (IHC) of formalin-fixed paraffin-embedded tissues (n = 31, 13 with recurrence and 18 without) for CD8, PD-1, PD-L1, Foxp3, and β-catenin, and ctDNA analysis using pre-nivolumab whole blood by deep sequencing (CAPP-seq; Avenio). Results: The 1-year RFSR and median RFS were 76.7% and 26.0 months (95% confidence interval (CI), 23.9–28.1), respectively, with no difference between SR and RFA. Copy number gains (CNGs) in WNT/β-catenin related genes ( APC, CTNNB1, TCF7L1, TCF7L2) (n = 8) correlated with shorter RFS (positive: 11.8 months vs. negative: not reached [NR]; p = 0.0003). IHC revealed that negative staining for PD-1 (p < 0.0001), a low combined positive score for PD-L1 (p = 0.0113), a low number of CD8+ tumor infiltrating lymphocytes (TILs) (p = 0.0130), and positivity for Foxp3+ cells (p = 0.0076) correlated with recurrence. Treatment-related adverse events (AEs) (n = 53) were as follows: all grades, 68%; grades 3–4 (18.9%); and immune related AEs, 25%. HCC cases with low numbers of CD8+ TILs or cases positive for Foxp3+ cells (n = 16) showed a significantly shorter RFS (16.8 months [95% CI, 8.7–25.1]) than those with high numbers of CD8+ TILs and those positive for PD-1/PD-L1 expression (n = 15) (NR [95% CI,26.2months–NR]) (p < 0.0001). HCC cases with activation of the WNT/β-catenin pathway assessed by IHC (n = 9) showed shorter RFS (17.0 months [95% CI,1.1–26.2]) than those without activation (n = 22) (NR [95% CI,24.7 months–NR]) (p = 0.0191). Patients positive for ctDNA (n = 10) before nivolumab tended to have shorter RFS than those without ctDNA (n = 30) (26.2 vs. NR). There was no correlation between TMB and RFS. Conclusions: The 1 year RFSR and RFS in the NIVOLVE trial were 76.6% and 26.0 months, respectively. No new safety signal was observed. CNG in WNT/β-catenin-related genes, activation of the WNT/β-catenin pathway, the presence of Foxp3+ cells, and low numbers of CD8+ TILs may predict recurrence after SR or RFA with adjuvant nivolumab. Clinical trial information: 000026648.

AB0583 FRAILTY IN THE PATIENTS WITH OSTEOARTHRITIS OF THE KNEE WAS NOT CAUSED BY SARCOPENIA

Background:

Osteoarthritis of the knee (knee OA) decreases mobility of the elderly, which function could be significantly improved with artificial joint replacement in many cases. Successful results of the surgery depend on several factors including preoperative muscle strength of lower limbs.

Objectives:

We assessed morbidity and skeletal muscle mass and strength in patients with knee OA immediately before undergoing arthroplasty and investigated the relationship between impairment of mobility and skeletal muscle function.

Methods:

All patients scheduled to undergo knee arthroplasty at our hospital after July 2020 were assessed for basic attributes, clinical assessment, blood tests, radiography, whole-body mode DXA, knee muscle strength by dynamometer with written consent (UMIN ID: 000040940). And Japanese Cardiovascular Health Study criteria for frailty, and sarcopenia by Asian Working Group for Sarcopenia 2019 criteria were evaluated.

Results:

Among 46 patients (40 women, mean age 75.4 years) the overall distribution in frailty is no: 15.9%, pre-frailty: 56.8%, and frailty: 27.3%. That in sarcopenia is no: 91.3%, yes: 2.2%, and severe: 4.3%. Ninety-one % of the patients with frailty did not suffer from sarcopenia. Between the patients with frailty and those without frailty there was a significant difference in walking speed (0.71±0.29m/sec, 1.12±0.29m/sec; p=0.004 adjusted by age and sex). Meanwhile, between those 2 groups of patients no significant differences were observed in skeletal muscle mass (6.40±0.87 kg/m2, 6.59±1.09 kg/m2; p=0.35) and knee extension power (120.4±37.4 N, 143.7±67.9 N; p=0.88) adjusted by age and sex. Together with these results, decrease in lower limb motor functions of the patients with knee OA was not caused by sarcopenia. In other words, improvement of mobility in the patients with knee OA could be expected by surgical intervention because of pain relief and ROM improvement.

Conclusion:

In the patients with knee OA immediately before arthroplasty, frailty was not caused by sarcopenia.

Disclosure of Interests:

None declared.

Clinicopathological analysis of hepatic immune-related adverse events in comparison with autoimmune hepatitis and graft-versus host disease

Immune checkpoint inhibitors (ICIs) targeting programmed cell death 1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) are widely used to treat advanced metastatic cancers. Neutralisation of PD-1 or CTLA-4 by ICIs results in immune-related adverse events (irAEs). The clinicopathological features of twelve patients with hepatic irAEs were evaluated and compared to those of ten patients with autoimmune hepatitis (AIH) or graft-versus-host disease (GVHD). No significant difference was seen in serum levels of transaminases, whereas serum levels of IgG and anti-nuclear antibody were higher in patients with AIH than in those with GVHD or hepatic irAEs. Inflammation was limited to the liver lobes in patients with GVHD or hepatic irAEs, whereas patients with AIH exhibited both portal and lobular inflammation. Immunohistochemical analyses revealed a predominant infiltration of CD8⁺ T cells and defective accumulation of regulatory T cells (Tregs) expressing forkhead box p3 (FOXP3) in the lobular areas of patients with hepatic irAEs and GVHD. In contrast, periportal lesions of patients with AIH were characterised by an infiltration of CD4⁺ T cells, CD8⁺ T cells, CD20⁺ B cells, and FOXP3⁺ Tregs. Overall, the activation of CD8⁺ T cells in the absence of activation of Tregs potentially underlies the immunopathogenesis of hepatic irAEs.

Three-Dimensional Radiological Assessment of Ablative Margins in Hepatocellular Carcinoma: Pilot Study of Overlay Fused CT/MRI Imaging with Automatic Registration

BACKGROUND

We investigate the feasibility of image fusion application for ablative margin assessment in radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) and possible causes for a wrong initial evaluation of technical success through a side-by-side comparison.

METHODS

A total of 467 patients with 1100 HCCs who underwent RFA were reviewed retrospectively. Seventeen patients developed local tumor progressions (LTPs) (median size, 1.0 cm) despite initial judgments of successful ablation referring to contrast-enhanced images obtained in the 24 h after ablation. The ablative margins were reevaluated radiologically by overlaying fused images pre- and post-ablation.

RESULTS

The initial categorizations of the 17 LTPs had been grade A (absolutely curative) (n = 5) and grade B (relatively curative) (n = 12); however, the reevaluation altered the response categories to eight grade C (margin-zero ablation) and nine grade D (existence of residual HCC). LTP occurred in eight patients re-graded as C within 4 to 30.3 months (median, 14.3) and in nine patients re-graded as D within 2.4 to 6.7 months (median, 4.2) (p = 0.006). Periablational hyperemia enhancements concealed all nine HCCs reevaluated as grade D.

CONCLUSION

Side-by-side comparisons carry a risk of misleading diagnoses for LTP of HCC. Overlay fused imaging technology can be used to evaluate HCC ablative margin with high accuracy.

Image Guidance in Ablation for Hepatocellular Carcinoma: Contrast-Enhanced Ultrasound and Fusion Imaging

The ultrasound (US) imaging technology, including contrast-enhanced US (CEUS) and fusion imaging, has experienced radical improvement, and advancement in technology thus overcoming the problem of poor conspicuous hepatocellular carcinoma (HCC). On CEUS, the presence or absence of enhancement distinguishes the viable portion from the ablative necrotic portion. Using volume data of computed tomography (CT) or magnetic resonance imaging (MRI), fusion imaging enhances the three-dimensional relationship between the liver vasculature and HCC. Therefore, CT/MR-US fusion imaging provides synchronous images of CT/MRI with real-time US, and US-US fusion imaging provides synchronous US images before and after ablation. Moreover, US-US overlay fusion can visualize the ablative margin because it focuses the tumor image onto the ablation zone. Consequently, CEUS and fusion imaging are helpful to identify HCC with little conspicuity, and with more confidence, we can perform ablation therapy. CEUS/fusion imaging guidance has improved the clinical effectiveness of ablation therapy in patients with poor conspicuous HCCs. Therefore; this manuscript reviews the status of CEUS/fusion imaging guidance in ablation therapy of poor conspicuous HCC.

Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR

Background

Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) is an effective tool for patients with refractory cardiac arrest (CA). Since VA-ECMO provides strong afterload, IABP is often used to increase left ventricular load. Recently, in Japan, the effectiveness of VA-ECMO in combination with IMPELLA, a forward flow mechanical circulatory support device (ECPELLA) is gaining attention.

Purpose

We investigated usefulness of ECPELLA in patients with refractory CA.

Method

We reviewed 133 patients that had E-CPR from January 2012 through January 2020 {mean age: 67±15 years, male 65%, Out of hospital Cardiac Arrest (OHCA) 35%, Acute coronary Syndrome (ACS) 54%}. We divided these patients into ECMO with IMPELLA (ECPELLA group), ECMO with IABP (IABP group) and ECMO alone (ECMO alone group). The primary endpoint is 30-day survival and good neurological prognosis defined as CPC (cerebral performance categories) 1 or 2.

Result

During the study period, of the 133 patients, there were 20 in the ECPELLA group, 78 in the IABP group, 35 in the ECMO alone group. There were no significant differences in age in all three groups. There were more males, shockable rhythm, OHCA and ACS in the ECPELLA and IABP groups compared to the ECMO alone group. But there was no significant difference between the ECPELLA and IABP groups. Compared with other groups, ECPELLA had the shortest time from cardiac arrest to ECMO placement. Regarding endpoints, the rate of 30-day survival and favorable neurological prognosis were higher in the ECPELLA group, followed by the IABP group and then the ECMO alone group. (ECPELLA: 55% vs. IABP: 23% vs. ECMO alone: 9%; P=0.0009, ECPELLA: 35% vs. IABP: 13% vs. ECMO alone: 9%; P=0.04) Next, Kaplan Meier analysis was performed to analyze 30-day all-cause mortality. The ECPELLA group had a significantly higher survival rate (P=0.01 by log-rank test). Multivariate cox proportional hazard analysis including the age, OHCA, shockable rhythm, ACS, Collapse-to-ECMO under 60 min revealed that the age (hazard ratio [HR], 1.28 (10 years increase), 95% confidence interval [CI], 1.08–1.53, P=0.004) and Collapse-to-ECMO under 60 min (HR, 0.37, 95% CI, 0.21–0.68, P=0.001) or ECPELLA (HR, 0.46, 95% CI, 0.20–0.694, P=0.03) were significantly associated with mortality.

Conclusion

ECPELLA used with E-CPR is an effective tool to improve mortality and neurologic status.

Funding Acknowledgement

Type of funding source: None

Plaque erosion is associated with less systemic atherosclerosis than other plaque types of acute coronary syndrome

Background

Previous studies have demonstrated that plaque erosion is associated with less atheromatous plaque at both culprit and non-culprit lesion than other plaque types of acute coronary syndrome (ACS). However, the status of systemic atherosclerosis in patients with plaque erosion remains to be elucidated.

Purpose

To clarify if plaque erosion is associated with less systemic atherosclerosis than other plaque types of ACS.

Methods

A total of 239 consecutive patients with ACS who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. Patients were classified into either plaque erosion (PE, n=45) or non-plaque erosion (non-PE, n=194) including plaque rupture and calcified nodule based on OCT findings of the culprit lesions. The status of systemic atherosclerosis was assessed by the findings of carotid echography, the severity of aortic arch calcification (AAC; grade 0–3) on chest X-ray, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABPI).

Results

The maximum intima media thickness (IMT) was significantly thinner in the PE group than in the non-PE group (1.9±0.8 vs. 2.3±0.9 mm, p=0.023) (Panel A). The prevalence of heterogeneous plaque and calcified plaque was significantly lower in the PE group than in the non-PE group (25.0 vs. 50.4%, p=0.010, 18.8 vs. 38.5%, p=0.037, respectively). The prevalence of AAC grade was significantly different between the two groups with a tendency toward lower AAC grade in the PE group than the non-PE group (Panel B). The mean baPWV (1588.1±420.6 vs. 1686.5±363.5 cm/sec, p=0.186) and ABPI (1.1±0.1 vs. 1.1±0.1, p=0.270) was comparable between the two groups.

Conclusion

Plaque erosion was associated with less atherosclerosis in carotid artery and aortic arch than non-plaque erosion. These findings may help further clarify the distinct pathophysiology of plaque erosion.

Funding Acknowledgement

Type of funding source: None

Lower levels of low-density lipoprotein cholesterol are associated with lower prevalence of thin-cap fibroatheroma in statin-treated patients with coronary artery disease

Background

Lowering low-density lipoprotein cholesterol (LDL-C) with statins slows progression of atherosclerotic plaques and reduces cardiovascular events. The 2019 European Society of Cardiology guideline for the management of dyslipidaemias recommends the absolute LDL-C treatment target as &lt;55mg/dL for very high-risk patients, &lt;70 mg/dL for high-risk patients and &lt;100 mg/dL for moderate-risk patients. However, the difference in plaque composition of coronary lesions according to these LDL-C levels remains to be elucidated.

Purpose

To investigate plaque morphologies according to LDL-C levels in statin-treated patients with coronary artery disease (CAD).

Methods

A total of 685 consecutive statin-treated patients with CAD, who underwent optical coherence tomography (OCT) imaging of culprit lesions were enrolled. The prevalence of vulnerable compositions in culprit plaques evaluated by OCT was compared among the groups of patients classified by LDL-C levels (&lt;55, 55–70, 70–100, ≥100 mg/dL).

Results

LDL-C levels &lt;55 mg/dL, &lt;70 mg/dL and &lt;100 mg/dL were observed in 6.3%, 21.8% and 63.9% of patients, respectively. The prevalence of thin-cap fibroatheroma was significantly different among the groups (P=0.014, Figure) with a trend toward lower prevalence in the lower two LDL-C groups than in the higher two LDL-C groups. A gradient with lower prevalence of thrombus in lower LDL-C groups was observed, although the statistical significance was not demonstrated (Figure). There was no significant difference in the prevalence of macrophage or cholesterol crystal among the groups.

Conclusions

Lower LDL-C level was associated with a trend toward lower prevalence of thin-cap fibroatheroma and thrombus in statin-treated patients with CAD.

Funding Acknowledgement

Type of funding source: None

Predictors for rapid progression of coronary calcification: an optical coherence tomography (OCT) study

Background

The natural progression of coronary calcification has not been systematically studied. In vivo coronary calcium can be evaluated by OCT.

Purpose

To identify the incidence and predictors for rapid progression of coronary calcification.

Methods

Patients with serial OCT imaging at baseline and at 6 months were selected from our database. Changes in calcium index during 6-month follow-up and predictors for progression of calcification were studied. Calcium index was defined as the product of the mean calcium arc and calcium length. Rapid progression of calcification was defined as an increase in calcium index above the median value.

Results

Among 187 patients who had serial OCT imaging, 235 calcified plaques were identified in 108 patients (57.8%) at baseline with median calcium index of 132.0 (Interquartile range 58.5–281.2). After 6 months, the calcium index increased in 95.3% of calcified plaques from 132.0 to 178.2 (p&lt;0.001). In multivariable analysis, diabetes mellitus (DM), chronic kidney disease (CKD), lipid-rich plaque, and macrophages were found to be independent predictors for rapid progression of coronary calcification (table). Interestingly, rapid progression of calcification was associated with a significant reduction of inflammatory features (thin-cap fibroatheroma [TCFA]; baseline 21.2% vs. follow-up 11.9%, p=0.003, macrophages; baseline 74.6% vs. follow-up 61.0%, p=0.001).

Conclusions

This study demonstrated that DM, CKD, lipid-rich plaque, and macrophages were independent predictors for rapid progression of coronary calcification. High level of vascular inflammation may stimulate rapid progression of calcification.

Funding Acknowledgement

Type of funding source: None

Higher level of high sensitivity C-reactive protein is associated with more fibrocalcific plaque and longer lesion in patients with acute coronary syndrome

Background

The association between the level of high sensitivity C-reactive protein (hsCRP) and coronary plaque characteristics in patients with acute coronary syndrome (ACS) remains to be elucidated.

Purpose

To clarify the morphological characteristics of culprit lesion in patients with ACS according to the hsCRP levels using optical coherence tomography (OCT).

Methods

A total of 215 consecutive patients with ACS, who underwent OCT imaging of culprit lesions were included. The patients were classified into either the higher hsCRP group (hsCRP ≥0.14 mg/dL, n=108) or the lower hsCRP group (hsCRP &lt;0.14 mg/dL, n=107) according to the median preprocedural hsCRP level. The morphological characteristics of culprit lesion assessed by OCT were compared between the two groups.

Results

The higher hsCRP group had higher prevalence of insulin therapy (14 vs. 6%, p=0.037) and current smoker than the lower hsCRP group (37 vs. 18%, p=0.002). The prevalence of long lesion (≥25 mm, 67 vs. 53%, p=0.041) and fibrocalcific plaque (53 vs. 33%, p=0.003) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Figure). On the other hand, the prevalence of plaque rupture (36 vs. 46%, p=0.174) and lipid-rich plaque (47 vs. 64%, p=0.011) was rather lower in the higher hsCRP group than in the lower hsCRP group (Figure). In a multivariate analysis, fibrocalcific plaque (odds ratio [OR]: 2.098, 95% confidence interval [CI]: 1.125–3.913, p=0.019), lesion length (mm, OR: 1.036, 95% CI: 1.010–1.061, p=0.004) and current smoker (OR: 2.757, 95% CI: 1.388–5.476, p=0.003) was independently associated with higher hsCRP level.

Conclusions

ACS patients with high hsCRP levels had more fibrocalcific plaque and longer lesion than those with low hsCRP levels. The association between high hsCRP levels and vulnerable characteristics of culprit plaque was not demonstrated.

Funding Acknowledgement

Type of funding source: None

Baseline clinical features in a large-scale registration survey of patient with hypertrophic cardiomyopathy throughout Japan: J-HCM registry study

Background

Hypertrophic cardiomyopathy (HCM) is a most prevalent primary myocardial disorder with heterogeneous clinical features. However, there have been few studies on clinical features of HCM as a prospective cohort. In 2015, we established a large-scale registration survey of patients with HCM throughout Japan, named J-HCM registry study.

Purpose

The aim of this study was to clarify the clinical features of Japanese patients with HCM.

Methods

J-HCM registry study is a prospective, multicenter investigation, consisting of 24 hospitals. This time, we present the baseline clinical characteristics in this survey.

Results

Total 1484 patients were registered. The ages at registration and at diagnosis were 65±15 and 56±17 years, respectively, and 806 patients (54%) were men. Majority of the patients (95%) was NYHA class I or II. With regard to subtypes of HCM, there were 526 patients (36%) in the HCM with left ventricular (LV) outflow tract obstruction, 126 patients (8%) in the mid-ventricular obstruction, 57 patients (4%) in the end-stage phase characterized by LV ejection fraction &lt;50%, and 197 patients (14%) in apical HCM. At registration, 80 patients (6%) had prior successful recovery from sustained ventricular tachycardia or ventricular fibrillation, 162 patients (11%) suffered from heart failure hospitalization, and 64 patients (4%) had history of embolic event. Regarding invasive treatment, 160 patients (10%) had prior septal reduction therapy and 162 patients (11%) had ICD implantation. According to the 2014 European Society of Cardiology Guidelines on sudden cardiac death (SCD) prevention, the study patients were divided into 3 categories by the HCM Risk-SCD calculator: patients distribution, 4% in the high risk group (≥6% calculated HCM Risk-SCD at 5 years), 7% in the intermediate risk group (4% to &lt;6%), 69% in the low risk group (&lt;4%), and 16% in the patients with extreme characteristics (Figure 1).

Conclusions

In this multicenter registration survey of patients with HCM, the baseline clinical characteristics were almost similar to several retrospective large-scale cohorts in Western countries except older age and less symptomatic state. This study will provide important knowledge regarding management of HCM.

Figure 1

Funding Acknowledgement

Type of funding source: None

Predictors of rapid plaque progression: an optical coherence tomography study

Background

Two patterns of plaque progression have been described: slow linear progression and rapid step-wise progression. The former will cause stable angina when the narrowing reaches a critical threshold, while the latter may lead to acute coronary syndromes or sudden cardiac death.

Purpose

The aim of the study was to identify morphologic predictors for rapid plaque progression.

Methods

Patients who had OCT imaging during the index procedure and follow-up angiography with a minimum of 6-month interval were selected. Non-culprit lesion was defined as a plaque with a diameter stenosis ≥30% on index angiogram. Lesion progression was defined as the decrease of angiographic minimum lumen diameter ≥0.4 mm at follow-up (mean, 7.1 months). Baseline morphological characteristics of the plaques with rapid progression were evaluated by OCT. In a subgroup with follow-up OCT imaging for plaques with progression, morphological changes from baseline to follow-up were assessed.

Results

Among 517 lesions, 50 lesions showed progression. These lesions had a significantly higher prevalence of lipid-rich plaque (76.0% vs. 50.5%), thin-cap fibroatheroma (TCFA) (20.0% vs. 5.8%), layered plaque (60.0% vs. 34.0%), macrophage accumulation (62.0% vs. 42.4%), microvessel (46.0% vs. 29.1%), plaque rupture (12.0% vs. 4.7%), and thrombus (6.0% vs. 1.1%), compared to those without progression. The multivariable analysis identified lipid-rich plaque [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.02–4.62, p=0.045], TCFA (OR 5.85, 95% CI 2.01–17.03, p=0.001), and layered plaque (OR 2.19, 95% CI 1.03–4.17, p=0.040) as predictors of subsequent lesion progression. In a subgroup with follow-up OCT, a new layer was detected in 14/41 (34.1%) plaques.

Conclusions

Lipid-rich plaque, TCFA, and layered plaque were predictors of subsequent rapid plaque progression. A new layer, a signature of rapid progression through plaque disruption and healing, was detected in 1/3 of the cases.

Funding Acknowledgement

Type of funding source: None