Serum sodium improvement: change in Comprehensive Geriatric Assessment parameters in geriatric patients with hyponatremia

BACKGROUND

Hyponatremia presents with symptoms considered age-associated in the elderly. We assess the change in Comprehensive Geriatric Assessment (CGA) parameters after hyponatremia improvement in hospitalized geriatric patients.

METHODS

We took 100 hyponatremic and same number of eunatremic geriatric patients (> 60 years) who were comorbidity, presenting-complaints, and age-matched. Four CGA parameters were utilized, the new Hindi Mental State Examination (HMSE), Barthel's index of activities of daily living (ADL), Timed up and go Test (TUG), and handgrip strength by hand dynamometer (HG). We analyzed these at admission and discharge, and their relationship with change in sodium levels.

RESULTS

Average age was 68.1 ± 5.8 years, with males constituting 75%. The CGA parameters demonstrated worse values amongst the hyponatremia than the normonatremia group. Severe hyponatremia group showed worse CGA scores in comparison with moderate and mild. With improvement in sodium level, the improvements in ADL, TUG, and HMSE scores were greater in the hyponatremia group (8.8 ± 10.1, 2.2 ± 2.5, and 1.7 ± 2.3 respectively) in comparison to the normonatremia reference group (4.7 ± 9.0, 1 ± 2.0, and 0.7 ± 1.3 respectively, P < 0.05).

CONCLUSION

Our study is the first utilizing HMSE to assess change in cognitive ability with improvement in serum sodium levels in the Indian elderly. Hyponatremic patients show worse baseline CGA parameters, and hyponatremia severity correlates with worse motor and cognitive function. Improvement in the serum sodium level improves the CGA parameters. Correction of hyponatremia in the geriatric age group significantly impacts life quality.

Comparing the performance of full-field digital mammography and digital breast tomosynthesis in the post-treatment surveillance of patients with a history of breast cancer: A retrospective study

INTRODUCTION

The purpose of our study was to compare the performance of 2D (FFDM) against 3D (FFDM plus DBT) examinations in the post-treatment surveillance of asymptomatic breast cancer survivors.

METHODS

A list of women with a history of breast cancer who underwent screening mammography (2D or 3D) from 5/2017 to 5/2020 was retrieved. A total of 20,210 examinations were identified and performance metrics were compared.

RESULTS

There were no statistically significant difference in cancer detection rate (CDR) (p = 0.38), recall rate (RR) (p = 0.087), or positive predictive value (PPV) (p = 0.74) between 2D vs. 3D examinations. Stratification by breast tissue identified no statistically significant difference in CDR (p = 0.581 and p = 0.428), RR (p = 0.230 and p = 0.205), or PPV (p = 0.908 and p = 0.721) between fatty/scattered and heterogeneous/extremely dense breast tissue when comparing 2D vs 3D examinations. Stratification by age did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 2D vs. 3D examinations in the 60-69 years group (p = 0.021). Stratification by race did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 3D vs. 2D examinations in white women (p = 0.036). Stratification by laterality (bilateral vs. unilateral post mastectomy) did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased in 2D vs. 3D examinations in unilateral studies (p = 0.009).

CONCLUSION

For asymptomatic women with a history of breast cancer, there is no evidence that the addition of DBT to FFDM improves CDR, RR, or PPV.

IMPLICATIONS FOR PRACTICE

More studies are needed concerning screening methodologies supplementing FFDM in the screening regimens of breast cancer survivors.

Added value of the measles-rubella supplementary immunization activity in reaching unvaccinated and under-vaccinated children, a cross-sectional study in five Indian districts, 2018-20

INTRODUCTION

Supplementary immunization activities (SIAs) aim to interrupt measles transmission by reaching susceptible children, including children who have not received the recommended two routine doses of MCV before the SIA. However, both strategies may miss the same children if vaccine doses are highly correlated. How well SIAs reach children missed by routine immunization is a key metric in assessing the added value of SIAs.

METHODS

Children aged 9 months to younger than 5 years were enrolled in cross-sectional household serosurveys conducted in five districts in India following the 2017-2019 measles-rubella (MR) SIA. History of measles containing vaccine (MCV) through routine services or SIA was obtained from documents and verbal recall. Receipt of a first or second MCV dose during the SIA was categorized as "added value" of the SIA in reaching un- and under-vaccinated children.

RESULTS

A total of 1,675 children were enrolled in these post-SIA surveys. The percentage of children receiving a 1st or 2nd dose through the SIA ranged from 12.8% in Thiruvananthapuram District to 48.6% in Dibrugarh District. Although the number of zero-dose children prior to the SIA was small in most sites, the proportion reached by the SIA ranged from 45.8% in Thiruvananthapuram District to 94.9% in Dibrugarh District. Fewer than 7% of children remained measles zero-dose after the MR SIA (range: 1.1-6.4%) compared to up to 28% before the SIA (range: 7.3-28.1%).

DISCUSSION

We demonstrated the MR SIA provided considerable added value in terms of measles vaccination coverage, although there was variability across districts due to differences in routine and SIA coverage, and which children were reached by the SIA. Metrics evaluating the added value of an SIA can help to inform the design of vaccination strategies to better reach zero-dose or undervaccinated children.

POS0230 THE miR-320 FAMILY IS UPREGULATED IN FAST-PROGRESSING RADIOGRAPHIC KNEE OSTEOARTHRITIS: DATA FROM THE OSTEOARTHRITIS INITIATIVE

Background

There is an outstanding need for prognostic biomarkers to reliably detect fast-progressing knee osteoarthritis (OA) such that preventative interventions can be targeted to this patient population. MicroRNA-sequencing is an unbiased approach for comprehensive profiling of circulating microRNAs in liquid biopsies to discover novel biomarkers of disease. As negative regulators of gene expression, microRNAs hold potential not only as biomarkers, but also as mechanistic drivers of knee OA.

Objectives

To apply microRNA-sequencing to identify unique circulating microRNAs as potential biomarkers that distinguish fast-progressing radiographic knee OA from both slow- and non-progressing radiographic knee OA.

Methods

Leveraging the Osteoarthritis Initiative (OAI) longitudinal cohort, we applied our customized microRNA-sequencing pipeline [1] to blood plasma samples collected at both baseline and 4-year follow-up from 106 participants. The disease trajectory for each participant was constructed by plotting their Kellgren-Lawrence (KL) grades over an 8-year follow-up period. Based on these trajectories, we defined fast-progression as an increase from KL 0/1 at baseline to KL 3/4 by 4-year follow-up, slow-progression as an increase from KL 0/1 at baseline to KL 2/3/4 by 8-year follow-up, and non-progression as no increase from KL0/1 at baseline throughout the 8-year follow-up. Following differential expression analysis, we assessed predictive performance and identified putative gene targets for prioritized microRNAs.

Results

Comparing fast-progressors to both slow-progressors and non-progressors, we identified differentially expressed microRNAs within timepoints (i.e., 48 microRNAs at baseline and 2 microRNAs at 4-year follow-up) and across timepoints. Among these microRNAs were four members of the miR-320 family, with miR-320d showing an increase in fast-progressors at both timepoints, compared to both slow- and non-progressors. The predictive models we constructed included miR-320 members and had good accuracy (area under the receiver operating characteristic curves ranging from 82.6 to 91.9) in distinguishing fast-progressors. Putative gene targets of the miR-320 family included members of the 14-3-3 gene family (Table 1), including YWHAE, whose downregulation in OA cartilage was reported to promote deterioration [2].

Table 1.

Predicted gene targets of the miR-320 family include members of the 14-3-3 gene family.

14-3-3 gene family memberhsa-miR-320bhsa-miR-320chsa-miR-320dhsa-miR-320eSFNMMMLYWHABMMMMYWHAEVVVHYWHAGVVVMYWHAHVVVMYWHAQVVVMYWHAZVVVM

All mirDIP results with bold text indicating the prediction was among the top 1% for that microRNA/gene target pair. Letters denote the mirDIP score class with V=very high, H=high, M=medium, and L=low.

Conclusion

This microRNA-sequencing study is the first of its kind, profiling circulating microRNAs at two timepoints in 106 participants with data-driven construction of knee OA trajectories. We identify the miR-320 family of microRNAs to be associated with fast-progressing radiographic knee OA over time. While our data suggest this microRNA family could have applications as prognostic biomarkers for knee OA, and could be regulating gene targets to impact OA severity, validation of these findings in independent longitudinal cohorts is required.

References

[1]Potla P, Ali SA, Kapoor M. A bioinformatics approach to microRNA-sequencing analysis. Osteoarthritis and Cartilage Open. 2021;3(1):100131. doi: https://doi.org/10.1016/j.ocarto.2020.100131.

[2]Fu W, Hettinghouse A, Chen Y, Hu W, Ding X, Chen M, Ding Y, Mundra J, Song W, Liu R, Yi YS, Attur M, Samuels J, Strauss E, Leucht P, Schwarzkopf R, Liu CJ. 14-3-3 epsilon is an intracellular component of TNFR2 receptor complex and its activation protects against osteoarthritis. Ann Rheum Dis. 2021 Dec;80(12):1615-1627. doi: 10.1136/annrheumdis-2021-220000.

Disclosure of Interests

None declared

India's Second COVID Wave: How is it different from the First Wave?

Purpose

India is witnessing the resurgence of the COVID-19 pandemic in the form of a hard-hitting second wave. We wanted to compare the clinical profile of the first wave (April-June 2020) with the second wave (March-May 2021) of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), to help prioritize the target population group and management strategies. This will further help in the management of any upcoming third COVID wave.

Methods & Materials

We conducted a retrospective observational study and examined the demographic profile, symptoms, illness severity, baseline investigations, treatment given, comorbidities, and outcomes of the COVID-19 patients belonging to the first (W1) and the second (W2) waves of the Indian COVID pandemic.

Results

W2 had most people affected in the age group 50.5 (17.7) years compared with 37•1 (16•9) for W1. Baseline oxygen saturation was lower for W2 [84•0 (13•4) % versus(v/s) 91•9 (7•4) %] than W1. 70.2 % of the cases belonged to the severe category in W2 compared to 37.5% in W1. The level of hepatic transaminases was higher for W2 [AST, 108.3 (99.3) v/s 54.6 (69.3); ALT, 97.6 (82.3) v/s 58.7 (69.7) IU/L] than W1. CT severity score in W2 [29.5 (6.7)] was greater than W1 [23•2 (11•5)] [All P<0.05]. The standardized mortality ratio for W2 was 3.5 times that of W1. Higher proportion of patients require oxygen (81.8% v/s 11.2%), high flow nasal cannula (11.4% v/s 5.6%), non-invasive ventilation (41.2% v/s 1.5%), invasive ventilation (24.5% v/s 0.9%), and ICU admissions (56.4% v/s 12.0%) in W2 as compared with W1. We found the second wave to be stronger in terms of oxygen requirement, organ dysfunction, and mortality

Conclusion

Higher age, oxygen and ventilator requirement, ICU admissions, and organ failure are more prevalent in the second COVID wave that has hit India compared to the first wave and is associated with more deaths. India swiftly needs to scale up the prevalent ICU set up and oxygen production capacity to help accommodate the higher load.

Direct Observation of PFIB-Induced Clustering in Precipitation-Strengthened Al Alloys by Atom Probe Tomography

The effect of sample preparation on a pre-aged Al–Mg–Si–Cu alloy has been evaluated using atom probe tomography. Three methods of preparation were investigated: electropolishing (control), Ga+ focused ion beam (FIB) milling, and Xe+ plasma FIB (PFIB) milling. Ga+-based FIB preparation was shown to introduce significant amount of Ga contamination throughout the reconstructed sample (≈1.3 at%), while no Xe contamination was detected in the PFIB-prepared sample. Nevertheless, a significantly higher cluster density was observed in the Xe+ PFIB-prepared sample (≈25.0 × 1023 m−3) as compared to the traditionally produced electropolished sample (≈3.2 × 1023 m−3) and the Ga+ FIB sample (≈5.6 × 1023 m−3). Hence, the absence of the ion milling species does not necessarily mean an absence of specimen preparation defects. Specifically, the FIB and PFIB-prepared samples had more Si-rich clusters as compared to electropolished samples, which is indicative of vacancy stabilization via solute clustering.

Zinc finger protein-440 promotes cartilage degenerative mechanisms in human facet and knee osteoarthritis chondrocytes

OBJECTIVES

To investigate the role of zinc finger protein 440 (ZNF440) in the pathophysiology of cartilage degeneration during facet joint (FJ) and knee osteoarthritis (OA).

METHODS

Expression of ZNF440 in FJ and knee cartilage was determined by immunohistochemistry, quantitative (q)PCR, and Western blotting (WB). Human chondrocytes isolated from FJ and knee OA cartilage were cultured and transduced with ZNF440 or control plasmid, or transfected with ZNF440 or control small interfering RNA (siRNA), with/without interleukin (IL)-1β. Gene and protein levels of catabolic, anabolic and apoptosis markers were determined by qPCR or WB, respectively. In silico analyses were performed to determine compounds with potential to inhibit expression of ZNF440.

RESULTS

ZNF440 expression was increased in both FJ and knee OA cartilage compared to control cartilage. In vitro, overexpression of ZNF440 significantly increased expression of MMP13 and PARP p85, and decreased expression of COL2A1. Knockdown of ZNF440 with siRNA partially reversed the catabolic and cell death phenotype of human knee and FJ OA chondrocytes stimulated with IL-1β. In silico analysis followed by validation assays identified scriptaid as a compound with potential to downregulate the expression of ZNF440. Validation experiments showed that scriptaid reduced the expression of ZNF440 in OA chondrocytes and concomitantly reduced the expression of MMP13 and PARP p85 in human knee OA chondrocytes overexpressing ZNF440.

CONCLUSIONS

The expression of ZNF440 is significantly increased in human FJ and knee OA cartilage and may regulate cartilage degenerative mechanisms. Furthermore, scriptaid reduces the expression of ZNF440 and inhibits its destructive effects in OA chondrocytes.

Osteoarthritis year in review: genetics, genomics, epigenetics

OBJECTIVE

In this review, we have highlighted advances in genetics, genomics and epigenetics in the field of osteoarthritis (OA) over the past year.

METHODS

A literature search was performed using PubMed and the criteria: "osteoarthritis" and one of the following terms "genetic(s), genomic(s), epigenetic(s), epigenomic(s), noncoding RNA, microRNA, long noncoding RNA, lncRNA, circular RNA, RNA sequencing, single cell sequencing, or DNA methylation between April 1, 2019 and April 30, 2020.

RESULTS

We identified 653 unique publications, many studies spanned multiple search terms. We summarized advances relating to evolutionary genetics, pain, ethnicity specific risk factors, functional studies of gene variants, and interactions between coding and non-coding RNAs in OA pathogenesis.

CONCLUSIONS

Studies have identified variants contributing to OA susceptibility, candidate biomarkers for diagnosis and prognosis, as well as promising therapeutic candidates. Validation in multiple cohorts, multi-omics strategies, and machine learning aided computational analyses have all contributed to the strength of published literature. Open access data-sets, greater sample sizes to capture broader populations and understanding disease mechanisms by investigating the interactions between multiple tissue types will further aid in progress towards understanding and curing OA.

1614. Gwt1 Inhibitor, APX2104, Protects Against Invasive Aspergillosis in Neutropenic Mouse Model

Background

Aspergillus fumigatus is the leading cause of invasive aspergillosis (IA), a lethal infection among immunocompromised patients. Guideline-recommended antifungal therapy against IA is a triazole antifungal, with other secondary options including an echinocandin and amphotericin B. Concerns about drug-host toxicity and antifungal resistance have been globally reported, so new, safe, and effective therapeutics are imperative.

Methods

In vitro, CLSI standards were upheld as we tested APX2041, voriconazole, caspofungin, and amphotericin B against various A. fumigatus strains. In vivo we assessed toxicity and efficacy of APX2104 in immunocompromised mice respectively. Neutropenia was induced with 150 mg/kg of cyclophosphamide on days -2/+3 and 250 mg/kg of cortisone acetate on days -1/+6. Immunocompromised mice were infected in an inhalation chamber via 12 mL of aerosolized spores of A. fumigatus CEA10 at a concentration of 1x10⁹ spores/mL (Day 0). Treatment started day +1 and ended day +7.

Results

In vitro, APX2041, the active-form of APX2104, has over a 16-fold lower minimum effective concentration (MEC) when compared to voriconazole, caspofungin, and amphotericin B against various A. fumigatus strains, including echinocandin- and azole-resistant strains.

In vivo, given preliminary pharmacokinetic data, APX2104 was tested in non-infected immunocompromised mice at 60 mg/kg and 78 mg/kg once per day (QD). Deaths due to toxicity were seen only at a dose of 78 mg/kg, so 60 mg/kg was set as a safe dose for our in vivo efficacy studies. In IA-challenged neutropenic mice, treatment with either posaconazole (20 mg/kg BID) or APX2104 (60 mg/kg QD) equally prolonged survival in 14 of 15 (93%) mice 14 days post-infection (p= 0.985). Untreatment control yielded a survival of 3 of 15 (20%) 14 days post-infection (p= < 0.001). Consistent with our survival studies, H&E and GMS histological samples also demonstrated that APX2104 treatment decreased fungal burden within the lungs of neutropenic mice when compared to the untreated group.

Conclusion

Future studies will test the efficacy of APX2104 and posaconazole against azole antifungal resistant strains in vivo, as our preliminary findings suggest that APX2104 is a plausible solution to cure IA disease and combat antifungal resistance.

Disclosures

All Authors: No reported disclosures

1275. Evaluation of in vitro activity of manogepix against multidrug-resistant and pan-resistant Candida auris from the New York Outbreak

Background

An ongoing Candida auris outbreak in the New York metropolitan area is the largest recorded to date in North America. NY C. auris isolates demonstrate resistance to fluconazole and variable resistance to other antifungals. Thus, there is an urgent need for new drugs with a novel mechanism of action to combat the resistance challenge. Manogepix (MGX) is a first-in-class agent that targets the fungal Gwt1 enzyme. The prodrug, fosmanogepix, is in clinical development for the treatment of invasive fungal infections.

Methods

We evaluated the susceptibility of 200 NY C. auris isolates (2017-2020) to MGX and 10 comparators. Testing was performed using TREK frozen broth microdilution panels for FLC, VRC, ITC, ISA, POS, AFG, CAS, and MFG. MGX MICs were evaluated (CLSI M27-A3 guidelines) using a 50% reduction in fungal growth endpoint at 24 h. MICs were determined by ETEST® at 24 h for AMB and FLC. We defined pan-resistant C. auris as isolates with in vitro resistance to two or more azoles, all echinocandins, and AMB. The epidemiological cutoff values (ECVs, ECOFFs) for MGX were estimated using the Microsoft Excel spreadsheet calculator ECOFFinder.

Results

MGX demonstrated lower MICs than comparators (MIC50 and MIC90 0.03 mg/L; range 0.004-0.06 mg/L). MGX was 8-32-fold more active that the echinocandins, 16-64-fold more active than the azoles, and 64-fold more active than AMB. No differences were found in the MGX or comparators’ MIC50, MIC90, or GEOMEAN values when subsets of clinical, surveillance, and environmental isolates were evaluated. The range of MGX MIC values for six C. auris pan-resistant isolates was 0.008-0.015 mg/L, and the median and mode MIC values were 0.015 mg/L, demonstrating that MGX retains activity against these isolates. The MGX epidemiological cutoff value (ECV, 99% cutoff) was 0.06 mg/L.

Conclusion

MGX MICs were low against C. auris isolates including those with variable patterns of resistance to AMB, azoles, and echinocandins. In addition, MGX retained potent activity against six pan-resistant isolates. These data support the continued clinical evaluation of fosmanogepix for the treatment of C. auris infections, including highly resistant isolates.

Disclosures

Karen J. Shaw, PhD, Amplyx (Consultant)Forge Therapeutics (Consultant) Vishnu Chaturvedi, PhD, Amplyx (Grant/Research Support)

Fibroblasts and their responses to chronic injury in pulmonary fibrosis

The field of pulmonary fibrosis is rapidly expanding as new insights highlight novel mechanisms that influence fibroblast biology and likely promote aberrant and chronic activation of the tissue repair response. Current paradigms suggest repeated epithelial microinjury as a driver for pathology; however, the rapid expansion of pulmonary fibrosis research calls for an overview on how fibroblasts respond to both neighbouring cells and the injury microenvironment. This review seeks to highlight recent discoveries and identify areas that require further research regarding fibroblasts, and their role in pulmonary fibrosis.

Sequencing identifies a distinct signature of circulating microRNAs in early radiographic knee osteoarthritis

OBJECTIVE

MicroRNAs act locally and systemically to impact osteoarthritis (OA) pathophysiology, but comprehensive profiling of the circulating miRNome in early vs late stages of OA has yet to be conducted. Sequencing has emerged as the preferred method for microRNA profiling since it offers high sensitivity and specificity. Our objective was to sequence the miRNome in plasma from 91 patients with early [Kellgren-Lawrence (KL) grade 0 or 1 (n = 41)] or late [KL grade 3 or 4 (n = 50)] symptomatic radiographic knee OA to identify unique microRNA signatures in each disease state.

DESIGN

MicroRNA libraries were prepared using the QIAseq miRNA Library Kit and sequenced on the Illumina NextSeq 550. Counts were produced for microRNAs captured in miRBase and for novel microRNAs. Statistical, bioinformatics, and computational biology approaches were used to refine and interpret the final list of microRNAs.

RESULTS

From 215 differentially expressed microRNAs (FDR < 0.01), 97 microRNAs showed an increase or decrease in expression in ≥85% of samples in the early OA group as compared to the median expression in the late OA group. Increasing this threshold to ≥95%, seven microRNAs were identified: hsa-miR-335-3p, hsa-miR-199a-5p, hsa-miR-671-3p, hsa-miR-1260b, hsa-miR-191-3p, hsa-miR-335-5p, and hsa-miR-543. Four novel microRNAs were present in ≥50% of early OA samples and had 27 predicted gene targets in common with the prioritized set of predicted gene targets from the 97 microRNAs, suggesting common underlying mechanisms.

CONCLUSION

Sequencing of well-characterized patient cohorts produced unbiased profiling of the circulating miRNome and identified a unique panel of 11 microRNAs in early radiographic knee OA.

TAT-Beclin-1 induces severe synovial hyperplasia and does not protect from injury-induced osteoarthritis in mice

OBJECT

Autophagy maintains cartilage homeostasis and is compromised during osteoarthritis (OA), contributing to cartilage degeneration. We sought to determine if D-isomer TAT-Beclin-1, a potent inducer of autophagy, could attenuate post-traumatic OA in mice.

METHODS

10-week-old mice underwent destabilization of the medial meniscus (DMM) surgery to induce post-traumatic OA, or sham surgery (control), and injected intra-articularly with D-isomer TAT-Beclin-1 (0.5-2 mg/kg) or PBS 1 week post-surgery for up to 9 weeks. Mice were sacrificed at 2 or 10 weeks post-surgery. Knee joint sections were evaluated by histopathology for cartilage degeneration and synovitis, and immunostaining for key markers of autophagy (LC3B), cell proliferation (nuclear Ki67), activated fibroblasts (αSMA), and cells of hematopoietic origin (CD45).

RESULTS

All D-isomer TAT-Beclin-1-treated DMM mice had no difference in the degree of cartilage degeneration compared to PBS-injected DMM mice. Surprisingly, all D-isomer TAT-Beclin-1-treated mice exhibited substantial synovial hyperplasia, with increased cellularity and ECM deposition (fibrosis-like phenotype), as compared to PBS-injected mice. Synovial effects of D-isomer TAT-Beclin-1 were dose- and injection frequency-dependent. An increased percentage of cells positive for LC3B and nuclear Ki67 were found in the synovial intima early after injection, which persisted after frequent injections.

CONCLUSIONS

D-isomer TAT-Beclin-1 did not attenuate cartilage degeneration, but rather induced synovial hyperplasia associated with increased expression of key markers of autophagy and cell proliferation and a fibrosis-like phenotype, independent of markers of fibroblast activation or persistent hematopoietic-origin cell infiltration. These data suggest that, if not tissue-targeted, caution should be taken using autophagy activators due to diverse cellular responses in the joint.

OP0050 ADALIMUMAB INTRODUCTION VERSUS METHOTREXATE DOSE ESCALATION IN PATIENTS WITH INADEQUATELY CONTROLLED PSORIATIC ARTHRITIS: RESULTS FROM RANDOMIZED PHASE 4 CONTROL STUDY

Background:

Methotrexate (MTX) is often used as first-line therapy for patients (pts) with psoriatic arthritis (PsA) despite limited efficacy and data on appropriate dosage. Minimal Disease Activity (MDA) is suggested as an optimal treat-to-target outcome. Biologic disease-modifying antirheumatic drugs (bDMARDs) have demonstrated improved outcomes (including MDA rates) over MTX. However, more data are needed to define the optimal timing of bDMARD initiation and characterize efficacy of MTX dose escalation, to achieve optimal outcomes.

Objectives:

To compare achievement of MDA between adding adalimumab (ADA) vs escalating MTX dose in PsA pts with inadequate disease control after initial MTX therapy.

Methods:

The open-label, 2-part CONTROL study enrolled bDMARD-naive adult pts with active PsA (not in MDA at screening and ≥3 tender and ≥3 swollen joints) despite MTX 15 mg every wk (ew) for ≥4 wks. Pts were randomized to ADA 40 mg every other wk + MTX 15 mg (ADA+MTX) or escalated MTX to 20–25 mg ew or highest tolerable dose during 16-wk part 1 (Fig 1). The primary endpoint was achievement of MDA, defined as fulfilling ≥5 of the 7 criteria: tender joint count 68 (TJC68) ≤1, swollen joint count 66 (SJC66) ≤1, Psoriasis Area Severity Index (PASI) ≤1 or body surface area (BSA) ≤3%, pt’s pain (visual analogue scale [VAS] 0–100) ≤15, Pt’s Global Assessment of disease activity (PtGA) VAS ≤20, Health Assessment Questionnaire Disability Index (HAQ-DI) ≤0.5 and tender entheseal points (0–8) ≤1. Key secondary efficacy endpoints were achievement of ACR20 and PASI75 and change from baseline in HAQ-DI and Leeds Enthesitis Index (LEI) at wk 16.

Results:

Overall, 246 pts were randomized; 245 received treatment (ADA+MTX, n=123; escalated MTX, n=122); 117 (95%) pts and 110 (90%) pts, respectively, completed part 1. Baseline characteristics were similar between groups (Table). During part 1, the average dose of MTX was 21.8 mg/wk (55% on oral MTX) in the escalated MTX group. Significantly higher proportion of pts in ADA+MTX (42%) vs escalated MTX (13%) group achieved MDA at wk 16 (non-responder imputation [NRI]; difference [95% CI] 28% [18%–39%];P<0.001;Fig 2). Observed case analysis confirmed the NRI analysis. Lower MDA rates at wk 16 were observed in the escalated MTX arm regardless of prior MTX duration (Fig 2). Significant improvements in key secondary endpoints were also observed with ADA+MTX vs escalated MTX (allP<0.05;Fig 2). In part 1, the proportion of patients with adverse events was similar between groups (ADA+MTX, 62% vs escalated MTX, 57%); no opportunistic infections, tuberculosis, malignancies, or deaths were reported during part 1.

Conclusion:

A significantly higher proportion of pts achieved MDA at wk 16 after introducing ADA compared with escalating MTX dose; higher rates were observed regardless of prior MTX duration. Significantly higher responses in musculoskeletal, skin, and quality of life measures were observed with ADA+MTX vs escalated MTX. No new safety signals with ADA were identified in this pt population.

Table 1.

Baseline Demographics

Characteristics, mean (SD)ADA+MTXn=123Escalated MTXn=122Female, n (%)64 (52.0)59 (48.4)Age, y51.4 (12.2)48.8 (12.7)BSA >3%, n (%)74 (60.2)78 (63.9)Pt pain63.7 (19.5)62.3 (20.9)PtGA65.0 (19.9)62.9 (20.9)HAQ-DI1.2 (0.6)1.2 (0.7)LEI + plantar count3.5 (2.1)3.5 (2.1)

Disclosure of Interests:

Laura C Coates: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Maria Antonietta D’Agostino Consultant of: AbbVie, BMS, Novartis, and Roche, Speakers bureau: AbbVie, BMS, Novartis, and Roche, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Erin McDearmon-Blondell Shareholder of: AbbVie, Employee of: AbbVie, Xianwei Bu Shareholder of: AbbVie, Employee of: AbbVie, Liang Chen Shareholder of: AbbVie, Employee of: AbbVie, Mudra Kapoor Shareholder of: AbbVie, Employee of: AbbVie, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

Evaluation of Resistance Development to the Gwt1 Inhibitor Manogepix (APX001A) in Candida Species

Manogepix (MGX) targets the conserved fungal Gwt1 enzyme required for acylation of inositol early in the glycosylphosphatidylinositol biosynthesis pathway. The prodrug fosmanogepix is currently in clinical development for the treatment of invasive fungal infections. We determined that the median frequencies of spontaneous mutations conferring reduced susceptibility to MGX in Candida albicans, C. glabrata, and C. parapsilosis ranged from 3 × 10-8 to <1.85 × 10-8 Serial passage on agar identified mutants of C. albicans and C. parapsilosis with reduced susceptibility to MGX; however, this methodology did not result in C. glabrata mutants with reduced susceptibility. Similarly, serial passage in broth resulted in ≤2-fold changes in population MIC values for C. tropicalis, C. auris, and C. glabrata A spontaneous V163A mutation in the Gwt1 protein of C. glabrata and a corresponding C. albicans heterozygous V162A mutant were obtained. A C. glabrata V163A Gwt1 mutant generated using CRISPR, along with V162A and V168A mutants expressed in C. albicans and Saccharomyces cerevisiae Gwt1, respectively, all demonstrated reduced susceptibility to MGX versus control strains, suggesting the importance of this valine residue to MGX binding across different species. Cross-resistance to the three major classes of antifungals was evaluated, but no changes in susceptibility to amphotericin B or caspofungin were observed in any mutant. No change was observed in fluconazole susceptibility, with the exception of a single non-Gwt1 mutant, where a 4-fold increase in the fluconazole MIC was observed. MGX demonstrated a relatively low potential for resistance development, consistent with other approved antifungal agents and those in clinical development.

Synthesis of analogs of the Gwt1 inhibitor manogepix (APX001A) and in vitro evaluation against Cryptococcus spp

Fosmanogepix (APX001) is a first-in-class prodrug molecule that is currently in Phase 2 clinical trials for invasive fungal infections. The active moiety manogepix (APX001A) inhibits the novel fungal protein Gwt1. Gwt1 catalyzes an early step in the GPI anchor biosynthesis pathway. Here we describe the synthesis and evaluation of 292 new and 24 previously described analogs that were synthesized using a series of advanced intermediates to allow for rapid analoging. Several compounds demonstrated significantly (8- to 32-fold) improved antifungal activity against both Cryptococcus neoformans and C. gattii as compared to manogepix. Further in vitro characterization identified three analogs with a similar preliminary safety and in vitro profile to manogepix and superior activity against Cryptococcus spp.

P71 Neurosurgical presentation of hereditary transthyretin (ATTR) amyloidosis: early recognition for earlier genetic therapies

Objectives

Hereditary Transthyretin (ATTR) amyloidosis is a genetic disorder where insoluble amyloid fibrils deposit in heart, nerves and various musculoskeletal tissues. Early recognition of TTR-FAP is important as new genetic therapies become available.

Design

We present one confirmed and one clinical case of ATTR deposition in ligamentum flavum causing lumbar canal stenosis.

Subjects

The first case is a 44-year-old female with TTR 184S heterozygous mutation who developed urinary urgency and bilateral leg pain exacerbated by walking. Neurological examination was normal. MRI lumbar spine showed a disc bulge in combination with ligamentum flavum thickening at L2/3 causing stenosis of the vertebral canal. She had a laminectomy of the L2/3 level. Histopathological analysis of the surgical tissue was positive on Congo red staining for amyloid and immunohistochemically identified as TTR type. The second case is a 68-year-old man with TTR V122I heterozygous mutation. He presented with paraesthesia from the knees to dorsum of the feet. On examination, power was normal and he had a length dependent neuropathy. A CT myelogram demonstrated spondylosis at L4/5 and L3/4 from disc bulge and marked flaval hypertrophy causing canal stenosis. He was placed on the waitlist for L4-5 decompression but unfortunately died prior to surgery.

Conclusions

Identifying ATTR in surgical specimens may diagnose hereditary amyloidosis in otherwise asymptomatic patients and in the future, provide early access to effective therapies.

APX001 and Other Gwt1 Inhibitor Prodrugs Are Effective in Experimental Coccidioides immitis Pneumonia

Coccidioidomycosis is a systemic fungal infection caused by the inhalation of the arthroconidia of either of two closely related dimorphic fungi, Coccidioides immitis and C. posadasii, that are endemic in the southwestern United States and other areas in the Western Hemisphere. Chronic cavitary pulmonary infections and extrapulmonary sites of infection are very difficult to treat and often require lifelong azole therapy. APX001A is the first in a new class of broad-spectrum antifungal agents that inhibit Gwt1, an enzyme which is required for cell wall localization of glycosylphosphatidylinositol (GPI)-anchored mannoproteins in fungi. APX001A and several analogs were highly active against clinical isolates of Coccidioides, inhibiting hyphal growth at low nanogram/ml concentrations. APX001 is the N-phosphonooxymethyl prodrug of APX001A, currently in clinical trials for the treatment of invasive fungal infections. Mice were treated orally once daily with 26 mg/kg/day of APX001 and the prodrug analog APX2097, 2 h after administration of the pan-cytochrome P450 inhibitor 1-aminobenzotriazole, which was used to enhance drug half-life and exposures to more closely mimic human pharmacokinetics of APX001A. Five days of treatment reduced lung colony counts by nearly 3 logs and prevented dissemination, similar to the efficacy of fluconazole dosed orally at 25 mg/kg twice daily. In a survival experiment, both APX001- and APX2097-treated mice survived significantly longer than control and fluconazole-treated mice. APX001 and other members of this new class of antifungal agents may offer great promise as effective therapies for coccidioidomycosis.

CCL22 is a biomarker of cartilage injury and plays a functional role in chondrocyte apoptosis

BACKGROUND

Osteoarthritis (OA) is one of the leading causes of disability worldwide. Previous history of knee injury is a significant risk factor for OA. It has been established that low-level chronic inflammation plays a pivotal role in the onset and pathogenesis of OA. The primary aim of this research was to determine if a history of knee joint injury is associated with systemic inflammation. A secondary aim was to determine if systemic inflammation is related to knee pain and joint structure.

METHODS

Differences in serum cytokine association networks, knee joint structural changes (MRI), and self-reported pain (i.e., Knee Injury and Osteoarthritis Outcome Score Pain subscale, KOOS_PAIN and Intermittent and Constant Osteoarthritis Pain score, ICOAP) between individuals who had sustained a youth (aged 15-26 years) sport-related knee injury 3-10 years previously and age- and sex-matched controls were examined. Proteins of interest were also examined in an OA rat model.

RESULTS

Cytokine association networks were found to differ significantly between study groups, yet no significant associations were found between networks and KOOS_PAIN or MRI-defined OA. A group of cytokines (MCP1/CCL2, CCL22 and TNFα) were differentially associated with other cytokines between study groups. In a pre-clinical rat OA model, serum CCL22 levels were associated with pain (r = 0.255, p = 0.045) and structural changes to the cartilage. CCL22 expression was also observed in human OA cartilage and furthermore, CCL22 induced apoptosis of isolated human chondrocytes.

DISCUSSION

These results suggest that CCL22 may be an early factor in the onset/pathogenic process of cartilage degeneration and/or related to pain OA.

WED 241 Clinical relevance of regular blood monitoring in IG treatment

Background

ABN immunoglobulin (Ig) guidelines advise routine FBC and U and E monitoring with every treatment episode and screening for IgA deficiency.

Aims

We audited compliance in inflammatory neuropathy patients on longterm treatment in two UK Neurology departments. We looked for evidence of clinically relevant haematological or AKI Ig-related events.

Methods

Data was collected from Nov 2015 to Nov 2017. Accepted definitions for clinically and/or biochemically significant haemolysis, neutropenia, thrombocytopenia and AKI were used.

Results

1919 treatment episodes in 90 patients were analysed. Mean age (SD)=57.6 (14.4)years, 69.1% male, 74% CIDP (26% MMN), 94% IVIg (6% SCIg). Mean dose=1.57 (0.74) g/kg/month or 97.1 (37.3) g/infusion. No clinically significant episodes of haemolysis, neutropenia, thrombocytopenia or AKI occurred in relation to Ig treatment. An asymptomatic drop of >10 g/L Hb occurred in 68/1919 episodes in 38 individuals (3.5%); mean reduction 17.7 g/L, lowest Hb 99 g/L. Two patients with CRF (stage 3) received 28 (IV) and 104 (SC) infusions respectively without impact on eGFR. Two individuals with relative IgA deficiency (0.38 g/L, 0.4 g/L) received 16 infusions over 1.5 years without complications.

Conclusions

No clinically significant Ig-related events were identified in this representative cohort. We suggest annual screening or clinically indicated testing as safe and more appropriate in longterm IVIg use.

An endophenotype approach to the genetics of alcohol dependence: a genome wide association study of fast beta EEG in families of African ancestry

Fast beta (20-28 Hz) electroencephalogram (EEG) oscillatory activity may be a useful endophenotype for studying the genetics of disorders characterized by neural hyperexcitability, including substance use disorders (SUDs). However, the genetic underpinnings of fast beta EEG have not previously been studied in a population of African-American ancestry (AA). In a sample of 2382 AA individuals from 482 families drawn from the Collaborative Study on the Genetics of Alcoholism (COGA), we performed a genome-wide association study (GWAS) on resting-state fast beta EEG power. To further characterize our genetic findings, we examined the functional and clinical/behavioral significance of GWAS variants. Ten correlated single-nucleotide polymorphisms (SNPs) (r²>0.9) located in an intergenic region on chromosome 3q26 were associated with fast beta EEG power at P<5 × 10^-8. The most significantly associated SNP, rs11720469 (β: -0.124; P<4.5 × 10^-9), is also an expression quantitative trait locus for BCHE (butyrylcholinesterase), expressed in thalamus tissue. Four of the genome-wide SNPs were also associated with Diagnostic and Statistical Manual of Mental Disorders Alcohol Dependence in COGA AA families, and two (rs13093097, rs7428372) were replicated in an independent AA sample (Gelernter et al.). Analyses in the AA adolescent/young adult (offspring from COGA families) subsample indicated association of rs11720469 with heavy episodic drinking (frequency of consuming 5+ drinks within 24 h). Converging findings presented in this study provide support for the role of genetic variants within 3q26 in neural and behavioral disinhibition. These novel genetic findings highlight the importance of including AA populations in genetics research on SUDs and the utility of the endophenotype approach in enhancing our understanding of mechanisms underlying addiction susceptibility.

Stage-specific differences in secretory profile of mesenchymal stromal cells (MSCs) subjected to early- vs late-stage OA synovial fluid

OBJECTIVE

Although, mesenchymal stromal cells (MSCs) are being clinically investigated for their use in osteoarthritis (OA), it is unclear whether their postulated therapeutic properties are equally effective in the early- and late-stages of OA. In this study we investigated MSC cytokine secretion post-exposure to synovial fluid (SF), obtained from early- vs late-stage knee OA patients to justify a potential patient stratification strategy to maximize MSC-mediated treatment effects.

METHOD

Subjects were recruited and categorized into early- [Kellgren-Lawrence (KL) grade I/II, n = 12] and late-stage (KL-III/IV, n = 12) knee OA groups. SF samples were obtained, and their proteome was tested using multiplex assays, after 3-days culture, with and without MSCs. SFs cultured without MSCs were used as a baseline to identify MSC-secreted factors into SFs cultured with MSCs. Linear mixed-effect models and non-parametric tests were used to identify alterations in the MSC secretome during exposure to OA SF (3-days). MSCs cultured for 3-days in 0.5% fetal bovine serum (FBS)-supplemented medium were used to compare SF results with culture medium.

RESULTS

Following exposure to OA SF, the MSC secretome contained proteins that are involved in tissue repair, angiogenesis, chemotaxis, matrix remodeling and the clotting process. However, chemokine (C-X-C motif) ligand-8 (CXCL8; chemoattractant), interleukin-6 (IL6) and chemokine (C-C motif) ligand 2 (CCL2) were elevated in the MSC-secretome in response to early- vs late-stage OA SF.

CONCLUSION

Early- vs late-stage OA SF samples elicit a differential MSC secretome response, arguing for stratification of OA patients to maximize MSC-mediated therapeutic effects.

A calcineurin antifungal strategy with analogs of FK506

A novel antifungal strategy targeting the inhibition of calcineurin is described. To develop a calcineurin based inhibitor of pathogenic fungi, analogs of FK506 were synthesized that were able to permeate mammalian but not fungal cells. Antagonists in combination with FK506 were not immunosuppressive and retained antifungal activity in A. fumigatus. To reduce the dosage burden of the antagonist, murine oral PK was improved an order of magnitude relative to previous FK506 antagonists.

Abstract P3-02-04: Is breast magnetic resonance imaging (MRI) useful for diagnosis of additional sites of disease in patients recently diagnosed with ductal carcinoma in situ (DCIS)?

Purpose: To determine if breast MRI is useful for detecting additional sites of disease in patients initially diagnosed with pure DCIS.

Materials and Methods: A retrospective review of women diagnosed with pure DCIS who underwent a breast MRI for evaluation of extent of disease was performed at a single institution from January 2013 to April 2015. Data analysis included imaging (mammography, ultrasound and MRI) and pathology characteristics (histology and biomarker status) of the primary DCIS as well as descriptors for the additional sites of disease incidentally found by breast MRI.

Results: A total of 94 patients were diagnosed with pure DCIS during this time period, ages ranging from 38 to 79 years old (median, 58.5 years); sizes ranging from 0.6 to 16 cm (mean, 4.5 cm). A total of 28 patients (30%) had other MRI findings suspicious for additional sites of disease in either breast. From this group of patients, 23 (82%) patients underwent MRI-guided biopsy. The 5 patients who did not have the MRI guided-biopsy either underwent total mastectomies or declined biopsy. Five out of the twenty-three patients (22%) were diagnosed with an additional site of cancer. Three of these patients were Hispanic, one was Asian/Pacific and one was Caucasian. Of the five patients, five had contralateral disease (100%) and none had a second site of disease in the ipsilateral breast. The size of the additional sites of disease ranged from 0.4 to 7.2 cm (mean, 2.1 cm) and the size of the primary lesion in this selected group ranged from 0.4 to 9 cm (mean, 3.4 cm). Ages ranged from 47 to 63 years old (median, 55 years). Four out of five patients (80%) presented with the first site of disease as pure DCIS with estrogen (ER) and progesterone (PR) receptors positive and one case (20%) was pure DCIS ER/PR- negative. The second incidental lesion found on MRI demonstrated 3 cases of contralateral pure DCIS. From this group, all the biomarkers status for the first and second site were concordant. From the 5 cases of second disease, 2 (40%) presented with invasive component in the contralateral side of the initially biopsy-proven pure DCIS and, one of these cases had discordant biomarkers compared with the first site of disease, the first site of pure DCIS was ER/PR-negative and the second site of invasive ductal carcinoma (IDC) presented with ER/PR-positive status.

Conclusion: From a total of 94 patients with recent diagnosis of pure DCIS who underwent breast MRI examination for diagnosis of additional sites of disease, approximately 5% were diagnosed with an additional site of cancer and 2% of the total cases had invasive disease in the additional sites with different biomarker status; changing their management and prognosis. Breast MRI plays a role in the setting of staging patients initially diagnosed with pure DCIS.

Citation Format: Ortiz-Perez T, Benveniste AP, Ebuoma LO, Sepulveda KA, Severs FJ, Kapoor M, Sedgwick EL. Is breast magnetic resonance imaging (MRI) useful for diagnosis of additional sites of disease in patients recently diagnosed with ductal carcinoma in situ (DCIS)? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-04.

A procedure to create isoconcentration surfaces in low-chemical-partitioning, high-solute alloys

A proximity histogram or proxigram is the prevailing technique of calculating 3D composition profiles of a second phase in atom probe tomography. The second phase in the reconstruction is delineated by creating an isoconcentration surface, i.e. the precipitate-matrix interface. The 3D composition profile is then calculated with respect to this user-defined isoconcentration surface. Hence, the selection of the correct isoconcentration surface is critical. In general, the preliminary selection of an isoconcentration value is guided by the visual observation of a chemically partitioned second phase. However, in low-chemical -partitioning systems, such a visual guide is absent. The lack of a priori composition information of the precipitate phase may further confound the issue. This paper presents a methodology of selecting an appropriate elemental species and subsequently obtaining an isoconcentration value to create an accurate isoconcentration surface that will act as the precipitate-matrix interface. We use the H-phase precipitate in the Ni-Ti-Hf shape memory alloy as our case study to illustrate the procedure.

Genetic deletion of mPGES-1 abolishes PGE2 production in murine dendritic cells and alters the cytokine profile, but does not affect maturation or migration

We undertook this study to determine the role of Microsomal PGE Synthase-1 (mPGES-1), and mPGES-1-generated Prostaglandin (PG) E2 on Dendritic Cell (DC) phenotype and function. Using mPGES-1 KnockOut (KO) mice, we generated bone marrow derived DCs and determined their eicosanoid production profile, cell surface marker expression, and cytokine production. We also assessed DC migratory and functional capacity in vivo. Compared to wild-type, mPGES-1 deficient DCs exhibited a markedly attenuated increase in PGE2 production upon LPS stimulation, and displayed preferential shunting towards PGD2 production. mPGES-1 KO DCs did not display deficiencies in maturation, migration or ability to sensitize T cells. However, mPGES-1 deficient DCs generated reduced amounts of the Th1 cytokine IL-12, which may in part be due to increased PGD2 rather than decreased PGE2. These findings provide useful information on the effects of inducible PGE2 on the innate immune system, and have important implications regarding potential consequences of pharmacologic mPGES-1 inhibition.

Use of gene expression analysis of periampullary carcinomas to identify biliary-like and intestinal-like subgroups of ampullary and duodenal carcinomas

161

Background: Though adenocarcinomas of the ampulla of Vater are classified as biliary cancers, the epithelium of origin and treatment approach for these rare tumors remains controversial. We compared the gene expression profiles of ampullary carcinomas with that of known periampullary carcinomas.

Methods: We analyzed 32 fresh-frozen resected untreated periampullary carcinomas (8 pancreatic, 2 extrahepatic biliary, 8 non-ampullary duodenal, and 14 ampullary) with verified histology and >70% tumor tissue using the Affymetrix U133 Plus 2.0 genome array. Hierarchical clustering of all samples based upon pancreatic and duodenal differentially expressed genes and unsupervised hierarchical clustering was done. Ampullary and duodenal samples were analyzed for histologic subtype (pancreaticobiliary, intestinal, mixed), MSI by PCR, CDX-2 by IHC and KRAS and PI3K mutations by mass spectroscopy-based sequencing (Sequenom).

Results: We identified 3 subgroups: pancreatic (8 pancreatic, 1 duodenal), biliary-like (4 duodenal, 7 ampullary, 2 biliary) and intestinal-like (3 duodenal, 7 ampullary). The intestinal-like subgroup had a significantly improved RFS (p=0.03) and OS (p =0.04) compared to the biliary-like subgroup, after stratification by grade and stage. Unsupervised clustering of only ampullary and duodenal samples identified very similar good prognostic (4 duodenal, 5 ampullary) and bad prognostic groups (3 duodenal, 9 ampullary) with 3-year RFS 75% vs. 31%, p =0.05 and 3-year OS 100% vs. 27%, p =0.01. These 2 groups showed no statistically significant differences in adenoma (56% vs 25%), poor differentiation (11% vs 42%), T4 (33% vs 25%), N1 (67% vs 100%), MSI-high (22% vs 0%), KRAS mutations (33% vs 17%), or PI3K mutations (0% vs 17%). CDX-2 expression (100% vs 50%, p=.04) and intestinal histologic subtype (100% vs 0%, p <0.01) were more common in the good prognostic group.

Conclusions: Gene expression analysis classifies ampullary carcinomas with duodenal carcinomas and identifies a good prognosis intestinal-like group and a poor prognosis biliary-like group. These findings have therapeutic implications.

[Table: see text]