Abstract 5984: CDK9 inhibition as a potential therapeutic strategy in Ewing sarcoma

Ewing sarcoma (EWS) is the second most common bone and soft tissue sarcoma in children and adolescents and accounts for approximately 2% of all childhood cancer diagnoses. EWS is a highly aggressive cancer: the overall 5-year survival rate for localized and metastatic EWS are 67 and 38%, respectively. Each year, approximately 200 children and adolescents in the United States are diagnosed with EWS. Genetically, nearly all EWS have chromosomal translocations in which a member of the FET gene family is fused with an ETS transcription factor, with 85% of cases being EWSR1-FLI1. Cyclin-dependent kinase 9 (CDK9) is a serine/threonine protein kinase involved in transcription elongation through phosphorylation and activation of RNA polymerase II (RPB1) and increases the levels of key oncogenic genes like myeloid cell leukemia-1 (MCL-1) and c-Myc, which are reported to be involved in chemoresistance. CDK9 may be a viable target in transcriptionally addicted cancers including EWS driven by oncogenic fusion genes like EWSR1-FLI1. TP-1287 is an investigational orally delivered phosphate pro-drug of alvocidib, a potent CDK9 inhibitor. We hypothesized that alvocidib, the pharmaceutically active form of TP-1287, may show activity in EWS cells as a single agent and in combination with standard of care agents. Alvocidib demonstrated the suppression of downstream targets of CDK9 including c-Myc in EWS cell lines after 6-hr treatment. In cell viability assays using CellTiter-Glo, alvocidib resulted in IC50 values of 68 - 125 nM in EWS cell lines after 3-day treatment and 27 - 160 nM in EWS cells from patient derived xenograft (PDX) models, after 6-day treatment. MCL-1 amplified EWS cells were observed significantly more sensitive to alvocidib than MCL-1 diploid EWS cells in the EWS cells from PDX models (p=0.004). Further bioinformatic analysis to predict alvocidib sensitivity is currently underway. Alvocidib demonstrated an additive inhibitory response in combination with topotecan, phosphoramide mustard, a biologically active metabolite of cyclophosphamide, and palifosfamide, a biologically active metabolite of ifosfamide, in EWS cell lines after 3-day treatment. Alvocidib treatment showed reduction of RAD51 which is involved in DNA damage response (DDR), suggesting the activity of alvocidib on DDR may contribute to this additive response. In an in vivo preclinical study using the A-673 model, TP-1287 (2.5 mg/kg, QD) showed tumor growth inhibition (TGI). In vivo combination studies with standard of care agents using EWS xenograft models are currently ongoing. In summary, alvocidib has shown activity inhibiting the growth of EWS cells as a single agent and an additive response in combination with EWS standard of care agents in EWS cell lines. TP-1287 may be a potential therapeutic option for the current regimen in EWS. TP-1287 is being investigated for solid tumors including EWS (clinicaltrials.gov, NCT03604783).

Citation Format: Yuta Matsumura, Richard E. Heinz, Curtis A. Allred, Adam Siddiqui, Jason M. Foulks, Steven L. Warner. CDK9 inhibition as a potential therapeutic strategy in Ewing sarcoma. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5984.

Abstract 2853: TP-6379, an investigational TGFBR1 inhibitor, shows improvement in survival and enhances activity of standard of care in preclinical ovarian cancer models

Ovarian cancer is still associated with poor prognosis and remains amongst the leading causes of cancer related deaths in females. High recurrence rates, resistance to chemotherapy, and meager outcome highlight the need for improved therapies that stem from understanding the complex and multifactorial etiology of ovarian malignancies. Transforming growth factor-β (TGF-β) signaling can regulate both oncogenesis and metastasis in ovarian cancer (Kumri et al. 2021). This, in part, is done by affecting apoptosis and survival mechanisms, epithelial to mesenchymal transition, immune cell recruitment and response. Inhibition of the TGF-β signaling pathway is a potential pharmaceutical approach for treating ovarian malignancies.TP-6379 is a potent and orally available investigational TGF-β receptor 1 (TGFBR1) inhibitor and is currently in preclinical development at Sumitomo Pharma Oncology, Inc. (SMP Oncology). We hypothesized that TP-6379 may inhibit the TGF-β signaling pathway and show activity in preclinical ovarian cancer models. TP-6379 was observed to inhibit TGFBR1 potently in a biochemical kinase assay. Dose dependent increase in compound concentration was observed in ES-2 tumor burdened animals treated with TP-6379. Preclinical data showed TP-6379 (150 mg/kg, BID) treatment significantly improved overall survival compared to vehicle treatment in an ES-2 mouse xenograft model of clear cell carcinoma. We hypothesize this result was, in part, due to alleviation of ovarian cancer induced cachexia, as animals treated with TP-6379 showed retention of muscle mass in their hind limbs compared to the vehicle treated animals. To investigate a combination effect with the standard of care in ovarian cancer, a SK-OV-3 ovarian cancer adenocarcinoma cell line was treated in vitro with TP-6379 and paclitaxel. Class III β-tubulin (TUBB3), a potential resistance mechanism to paclitaxel, showed induced expression in response to TGF-β, paclitaxel or both, after 24 hr treatment, and this effect was observed to be inhibited by TP-6379 treatment. In a SK-OV-3 xenograft model, TP-6379 (150 mg/kg, BID) treatment showed the trend of tumor growth inhibition (TGI) as a monotherapy and showed enhanced TGI in combination with paclitaxel (7.5 mg/kg, QW) when compared to vehicle treatment. Combination treatment in this xenograft model showed significant reduction of TUBB3 mRNA compared to paclitaxel treatment alone. In conclusion, our preliminary preclinical studies have shown promising activity for TP-6379 in ovarian malignancies as monotherapy and/or in combination with standard of care. TP-6379 may be a viable therapeutic option by targeting the TGF-β pathway in ovarian cancer.

Citation Format: Tetyana V. Forostyan, David A. Kircher, Richard E. Heinz, Curtis Allred, Sal Sommakia, Yuta Matsumura, Adam Siddiqui, Jason M. Foulks, Steven L. Warner. TP-6379, an investigational TGFBR1 inhibitor, shows improvement in survival and enhances activity of standard of care in preclinical ovarian cancer models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2853.

Abstract 1617: TGFBR1 as a novel therapeutic target in adult granulosa cell tumors

Adult granulosa cell tumor (AGCT) is a subtype of sex-cord stromal tumors and accounts for ~5% of all ovarian neoplasms. Nearly 100% of AGCT cases are caused by an oncogenic point mutation in the Forkhead Box L2 (FOXL2) transcription factor. Weis-Banke et al. found this gain-of-function mutation (FOXL2C134W) allows FOXL2 to hijack the nuclear SMAD2/3/4 complex, the downstream effector of transforming growth factor- ß (TGF-ß), and redirect to novel transcription sites, inducing transcription of epithelial to mesenchymal transition (EMT) and other oncogenes. We hypothesized that FOXL2 mutant AGCT would be sensitive to TGF-ß inhibition. To test this hypothesis, we treated two GCT cell lines with TP-6379, an orally available, investigational small molecule kinase inhibitor of TGFBR1 that has been shown to block the phosphorylation and nuclear translocation of SMAD2 and SMAD3 in cells. TP-6379 was tested in the KGN cell line, derived from an AGCT patient and heterozygous for the FOXL2C134W mutation, and the COV434 cell line, derived from a juvenile GCT patient, which is FOXL2 wild type (WT). KGN cells (IC50 = 135 nM) were observed to be more than 70-fold more sensitive to TP-6379 treatment than COV434 (IC50 = >10,000 nM), after a 6- and 7- day treatment, respectively. KGN cells that were edited to remove the WT FOXL2 or both the WT and FOXL2C134W alleles were observed to be 1.6-fold more sensitive to TP-6379 and 22-fold less sensitive than the parental KGN cells. In vivo testing using KGN cells is ongoing. Viably cryopreserved dissociated tumor cells (DTCs) from two AGCT patients and one JGCT patient, which contain a mixture of tumor, immune, endothelial, and other stromal cells, were also tested in proliferation assays with TP-6379. All three ex vivo samples were positive for the FOXL2C134W mutation as detected by a qPCR genotyping assay and were sensitive to TP-6379 (IC50 = 555-1600 nM) after 6-day treatment. Xenograft models using these patient samples are currently under development. TGF-ß signaling is also a master regulator of the tumor microenvironment (TME) and immune evasion by modulating deposition of extracellular matrix and suppression of immune cells. We performed an immunophenotyping assay in tissue microarrays of thin-needle biopsy cores of multiple cancer types by looking at the distribution of CD8 T cells within tumor and stroma. AGCT showed the strongest excluded and desert phenotype among the tested cancer types, where CD8 T cells were confined to the stroma or absent entirely. TP-6379 treatment was observed to increase expression and reverse TGF-ß induced suppression of HLA class I in KGN cells. These data suggest that TGF-ß may play a significant role in the TME of AGCT. In conclusion, preclinical data shows inhibition of TGFß signaling with TP-6379 in FOXL2C134W mutant AGCT is active at blocking cell growth and may prove to be a potential therapy in this rare disease.

Citation Format: Curtis A. Allred, Richard E. Heinz, Yuta Matsumura, Tetyana V. Forostyan, David Kircher, Salah Sommakia, Thomas Welte, Veena Vuttaradhi, Jason M. Foulks, Steven L. Warner, R Tyler Hillman. TGFBR1 as a novel therapeutic target in adult granulosa cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1617.

Abstract 2309: CDK9 as a potential therapeutic target in sarcomas

Sarcomas are a heterogeneous group of over 80 different tumors which arise from mesenchymal or connective tissue, accounting for 1% of adult malignancies. The annual incidence of soft tissue sarcoma (STS) is approximately 11,000 cases in the United States and STS is among the top five causes of cancer deaths for those under 20 years old. Cyclin-dependent kinase 9 (CDK9) is a serine/threonine protein kinase involved in transcription elongation through phosphorylation and activation of RNA polymerase II (RPB1), which increases the levels of key oncogenic genes like myeloid cell leukemia-1 (MCL-1) and c-Myc. CDK9 inhibition reduces their expression, leading to cell cycle arrest and apoptosis. TP-1287 is an orally delivered phosphate pro-drug of alvocidib, a potent CDK9 inhibitor. We hypothesized that alvocidib, the pharmaceutically active form of TP-1287, can inhibit the CDK9 signaling pathway and suppress tumor growth of sarcoma cells. Alvocidib demonstrated the suppression of the phosphorylation of RPB1 (p-RPB1) and MCL-1 expression in an A-673 Ewing sarcoma cell line and U-2 OS and MG-63 osteosarcoma cell lines after 6-hr treatment. In U-2 OS cells, 24-hr treatment with alvocidib induced the cleavage of PARP-1, an indicator of apoptosis, whereas less than 6-hr treatment with alvocidib failed to induce PARP-1 cleavage, suggesting that long-term CDK9 suppression would be necessary for the apoptosis induction in sarcoma cells. In cell viability assays using CellTiter-Glo, alvocidib demonstrated an IC50 of around 100 nM: 32 - 90 nM in sarcoma cell lines after 4-day treatment and 24 - 174 nM in sarcoma cells, which were obtained from patient derived xenograft (PDX) models, after 6-day treatment. In the sarcoma cells from PDX models, MCL-1 mRNA expression was moderately correlated with alvocidib sensitivity. Further bioinformatic analysis to predict alvocidib sensitivity is currently underway. In immunofluorescence analysis, alvocidib induced the activation of caspase-3/7, another indicator of apoptosis, after 2-day treatment in the sarcoma cells from PDX models. In an in vivo pharmacodynamic (PD) study using BALB/c mice, p-RPB1 and MCL-1 suppression in peripheral blood mononuclear cells (PBMCs) was observed after single administration of TP-1287. In an in vivo efficacy study using the A-673 model, TP-1287 showed a trend of tumor growth inhibition (TGI) at 2.5 mg/kg (QD), but not at 7.5 mg/kg (Q3D). These in vivo studies suggest that CDK9 signaling pathway was inhibited after TP-1287 administration in vivo and that continuous CDK9 inhibition would be needed for TGI in sarcoma models. In vivo efficacy and PD studies using sarcoma PDX models are currently ongoing. Taken together, alvocidib has shown activity in inhibiting the growth of sarcoma cells and TP-1287 could be a viable therapeutic option targeting the CDK9 pathway in sarcomas. TP-1287 is being investigated for solid tumors including sarcomas (clinicaltrials.gov, NCT03604783).

Citation Format: Yuta Matsumura, Hiroki Umehara, Jun Oishi, Adam Siddiqui, Jason M. Foulks, Setsuko Yamamoto, Steven L. Warner. CDK9 as a potential therapeutic target in sarcomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2309.

A highly photostable and bright green fluorescent protein

The low photostability of fluorescent proteins is a limiting factor in many applications of fluorescence microscopy. Here we present StayGold, a green fluorescent protein (GFP) derived from the jellyfish Cytaeis uchidae. StayGold is over one order of magnitude more photostable than any currently available fluorescent protein and has a cellular brightness similar to mNeonGreen. We used StayGold to image the dynamics of the endoplasmic reticulum (ER) with high spatiotemporal resolution over several minutes using structured illumination microscopy (SIM) and observed substantially less photobleaching than with a GFP variant optimized for stability in the ER. Using StayGold fusions and SIM, we also imaged the dynamics of mitochondrial fusion and fission and mapped the viral spike proteins in fixed cells infected with severe acute respiratory syndrome coronavirus 2. As StayGold is a dimer, we created a tandem dimer version that allowed us to observe the dynamics of microtubules and the excitatory post-synaptic density in neurons. StayGold will substantially reduce the limitations imposed by photobleaching, especially in live cell or volumetric imaging.

StayGold is over one order of magnitude more photostable than current fluorescent proteins

Prevalence of and risk factors for depressive symptoms in non-tuberculous mycobacterial pulmonary disease

BACKGROUND: The presence of depressive symptoms in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD) is an important research topic; however, the prevalence of depressive symptoms and the factors that influence their development are unclear.OBJECTIVE: To analyse the association between CES-D (Center for Epidemiological Studies Depression Scale) scores and clinical parameters such as age, disease duration, pulmonary function, imaging findings, blood data, physical functions, sleep disturbances, respiratory symptoms and health-related quality of life (HRQOL).METHODS: We conducted a cross-sectional retrospective study of 114 patients with NTM-PD at a single centre from March 2016 to January 2021 to evaluate the relationship between CES-D scores and clinical parameters.RESULTS: Participants had a median age of 64 years; 32.5% of them had depressive symptoms. Disease duration, albumin, C-reactive protein, pulmonary function, dyspnoea, exercise capacity, respiratory symptoms, cough-related HRQOL and sleep disturbances were associated with depressive symptoms. Binomial logistic regression analyses indicated that the CES-D score was significantly associated with cough-related HRQOL and sleep disturbances.CONCLUSION: A high percentage of NTM-PD patients in this study experienced depressive symptoms, and these patients had abnormalities of various clinical parameters. Cough-related HRQOL and sleep disturbance had a strong influence on the development of depressive symptoms.

Abstract P255: Alvocidib synergizes with BRD4 inhibitors to improve cytotoxity in an AML cell line

The super enhancer complex (SEC) is a group of transcription regulatory proteins that coordinate the expression of genetic programs which determine cell identity and drive diseases such as cancer. In acute myeloid leukemia (AML), SECs have been shown to turn on transcriptional programs that drive tumorigenesis and progression. SEC-regulated transcription begins as Cyclin-Dependent Kinase 9 (CDK9) and Cyclin T1 are recruited from an inhibitory complex by bromodomain 4 (BRD4) and brought to the transcriptional start site of genes. CDK9 phosphorylates RNA polymerase II, releasing it from the SEC and leading to transcriptional elongation and gene expression. Alvocidib is a potent CDK9 inhibitor with clinical activity in AML from multiple Phase II studies. Additionally, BRD4 inhibitors have shown early promise in clinical studies with a focus on AML. Starting with the observation of close association of CDK9 and BRD4 and the central role of the SEC in AML, we previously showed that CDK9 inhibitors combined with bromodomain inhibitors inhibited the SEC more effectively than either of these compounds alone. In this study, we sought to quantify the synergy between alvocidib and each of the BRD4 inhibitors, OTX015, IBET762, and CPI-0610, in the MV-4-11 AML cell line. After determining the single agent IC50 value of each agent, 6x6 matrix combination assays were used to determine synergy between alvocidib and OTX015, IBET762, or CPI-0610. The matrix combination assays consisted of concentrations of each : 4x IC50, 2x IC50, 1x IC50, 0.5x IC50, 0.25x IC50, and 0.125x IC50 value. In the combination assays, the cells were incubated with alvocidib for 48 h, then a BRD4 inhibitor was added, and the cells were incubated with alvocidib and the BRD4 inhibitor for a further 48 h. Combination index (CI) values were calculated using the Chou-Talalay method, where CI values less than 1 indicate synergism and lower CI values indicating stronger synergism. Synergistic interactions were observed in MV-4-11 cells for all three combinations of alvocidib plus a BRD4 inhibitor. For the combination of alvocidib and OTX015, synergy was observed for 81% (29/36) of the tested combinations, with the strongest synergy (CI = 0.155) observed at 20 nM alvocidib and 1.472 µM OTX015. For the combination of alvocidib and IBET762, synergy was observed for 75% (27/36) of the tested combinations, with the strongest synergy (CI = 0.144) observed at 10 nM alvocidib and 6.288 µM IBET762. For the combination of alvocidib and CPI-0610, synergy was observed for 72% (26/36) of the tested combinations, with the strongest synergy (CI = 0.101) observed at 10 nM alvocidib and 5.312 µM CPI-0610. These results suggest that combination strategies might be rationally designed to improve tumor targeting effects while reducing adverse side effects. Clinical studies utilizing these combination strategies are the next steps to further explore this approach.

Citation Format: Sal Sommakia, Ethika Tyagi, Yuta Matsumura, Jason M. Foulks, Steven L. Warner. Alvocidib synergizes with BRD4 inhibitors to improve cytotoxity in an AML cell line [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P255.

Nasal delivery of single-domain antibody improves symptoms of SARS-CoV-2 infection in an animal model

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes the disease COVID-19 can lead to serious symptoms, such as severe pneumonia, in the elderly and those with underlying medical conditions. While vaccines are now available, they do not work for everyone and therapeutic drugs are still needed, particularly for treating life-threatening conditions. Here, we showed nasal delivery of a new, unmodified camelid single-domain antibody (VHH), termed K-874A, effectively inhibited SARS-CoV-2 titers in infected lungs of Syrian hamsters without causing weight loss and cytokine induction. In vitro studies demonstrated that K-874A neutralized SARS-CoV-2 in both VeroE6/TMPRSS2 and human lung-derived alveolar organoid cells. Unlike other drug candidates, K-874A blocks viral membrane fusion rather than viral attachment. Cryo-electron microscopy revealed K-874A bound between the receptor binding domain and N-terminal domain of the virus S protein. Further, infected cells treated with K-874A produced fewer virus progeny that were less infective. We propose that direct administration of K-874A to the lung could be a new treatment for preventing the reinfection of amplified virus in COVID-19 patients.

Long-term prognostic factors of coronary artery disease patients after out-of-hospital cardiac arrest

Background

The long-term prognosis of survival in patients with out-of-hospital cardiac arrest (OHCA) with coronary artery disease (CAD) remains poor.

Methods

There were 2391 out-of-hospital cardiac arrest (OHCA) patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among them, 204 patients had CAD that caused OHCA (39%: multi-vessel disease, 19%: chronic total occlusion (CTO), 13%: vasospastic angina (VSA)). To predict mortality, we investigated patients' characteristics, pre-hospital information and findings of CAG.

Results

At 1-year later, 104 patients (51%) survived. Younger age (P<0.001), VF survivor (P<0.001), pre-hospital ROSC (P<0.001), bystander CPR (P=0.013), without ECMO (P<0.001), lower lactate level on admission (P<0.001), and higher geriatric nutritional risk index score (P<0.001) were associated with low 1-year mortality, while with ST-segment elevation (P=0.778), BMI level (P=0.344), and sex (0.401) were not. And in the findings of CAG, the past history of CAD (P=0.049), the higher number of coronary vessel disease (P=0.003) such as multi-vessel disease (P=0.022), higher SYNAX score (P=0.016), and larger infarct size (max CK level; P=0.013, max CK-MB level; P<0.001) were associated with high 1-year mortality. On the other hand, acute coronary syndrome (P=0.300), any coronary lesion (RCA (P=0.447), LAD (P=0.089), LCX (P=0.096), or LMT (P=0.842)), and with CTO lesion (P=0.140) were not associated. Zero-vessel disease (VSA, P=0.001) had lower mortality among the CAD patients. In the multivariate Cox proportional hazards model, age (hazards ratio; HR: 1.03, 95%confidence interval (CI) 1.00–1.06, P<0.001) and bystander CPR (HR: 0.36, 95% CI 0.20–0.65, P<0.001) were the independent predictors of mortality.

Conclusions

Younger age and pre-hospital support after OHCA with CAD were the predictors of low mortality. Pre-hospital information, systemic condition on arrival, or anatomical coronary complexity were important to predict low mortality.

Funding Acknowledgement

Type of funding sources: None.

Neurological outcome at 30-day as an estimator of 1-year functional status after out-of-hospital cardiac arrest with post-encephalopathy

Background

Implantation of implantable cardioverter-defibrillators (ICD) for secondary prevention is fully recommended for those with an estimated survival over 1-year with a good functional status. However, we often face the difficulty to estimate the functional status and hesitate to implant ICD for patients with post-resuscitation encephalopathy.

Methods

There were 2391 out-of-hospital cardiac arrest (OHCA) patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among the patients, 343 patients could be considered to be implanted ICD for secondary prevention according to the initial waveform or the causes of OHCA. At 1-month later, 184 patients (54%) survived. To assess the association of functional status at 30-day and 1-year, we investigated patients' characteristics, pre-hospital information and clinical findings, and evaluated the neurological outcome according to the cerebral performance category (CPC) scale.

Results

At 1-month later, 145 patients (79%) survived with CPC≤2, and 39 patients (21%) survived with CPC>2. Bystander CPR (P=0.009), pre-hospital ROSC (P<0.001), low lactate level on admission (P=0.001), high geriatric nutritional risk index score (P<0.001) and without ECMO (P=0.002) were significantly associated with good neurological outcome at 30-day. The 1-year Kaplan-Meier event rate revealed significantly different survival rate (CPC>2 at 30-day:38.5%, vs CPC≤2 at 30-day:97.2%; P<0.001). In multivariate analysis, CPC scale at 30-day (OR 0.022; 95% CI 0.003–0.140; p<0.001) was the independent predictor of favorable neurological outcome at 1-year. Among the patients with CPC>2 at 30-day, only 3 patients (7.7%) of CPC=3 achieved the improvement of neurological outcome at 1-year (CPC≤2), while no patient of CPC=4 did. And one patient (2.5%) with CPC=3 was implanted ICD during the follow-up period. Twenty-five patients (64%) died of non-cardiovascular death with frailty of post-resuscitation encephalopathy after they were transferred to other hospital with the acceptation and intention of the do-not-attempt-resuscitation.

Conclusions

Neurological prognosis at 30-day after OHCA might be an estimator of 1-year functional status to guide us to implant ICD for secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

Abstract 606: Pkm2 activation modulates the tumor-immune microenvironment and enhances response to checkpoint inhibitors in preclinical solid tumor models

Pyruvate kinase is a crucial enzyme responsible for the last step of glycolysis. Cancer cells can use the M2 isoform of pyruvate kinase (PKM2), to better balance respiration and biosynthesis due to allosteric switching between the less active dimeric and fully active tetrameric forms. Additionally, the dimeric form of PKM2 can translocate to the nucleus, altering transcription to enhance cancer cells' ability to grow and evade immune detection. Inducing tetramerization presents an opportunity to target PKM2 resulting in the metabolic reprogramming of tumor-immune microenvironment (TME). TP-1454 is a potent PKM2 activator with low nanomolar PKM2 activation in biochemical assays (AC50 = 10 nM) and multiple cell types (AC < 50 nM), tolerated in mice, rats and dogs after repeat doses as high as 1000 mg/kg/day and has recently entered a Phase I clinical trial (NCT04328740).

We hypothesize that PKM2 activation may reverse the immune-suppressive TME. To test this hypothesis, we examined the activity of TP-1454 combination with immunotherapy (I/O) in multiple mouse syngeneic tumor models. TP-1454 and anti-PD-1 combination therapy in colorectal cancer models resulted in tumor growth inhibition versus vehicle (53% in CT26; 99% in MC38, P < 0.001). We observed decreases in multiple glycolytic intermediates in TP-1454-treated tumors versus vehicle. We conducted immunophenotyping of the TME in multiple models to identify targets of PKM2 activation. TP-1454 treatment reduced the CD4+ Foxp3+ T-regulatory (Treg) population in MC38, 4T1, RENCA models. Further, we assayed TP-1454 induced PKM2 activation in different immune cell types. To confirm the effect of PKM2 activation on Treg cells we conducted an in vitro assay to explore TP-1454 treatment response on polarization of Tregs and/or toxicity and proliferation. We further utilized LCMS to explore metabolic intermediates that play a critical role in Treg regulation, including regulation of the O-linked β-N-acetylglucosamine (O-GlcNac) post-translational modification, which is reported to stabilize Foxp3 in CD4+ cells. We are currently exploring the effect of TP-1454 treatment on O-GlcNac of Foxp3 and its stability in HEK293 cells, to support the link between PKM2 activation and stabilization of Foxp3.

TP-1454 effects on tumor-specific immunity were validated using tumor rechallenge studies. The results of a tumor rechallenge study will be presented using murine MC38 or RENCA xenograft models that are treated with TP-1454 and I/O combination therapies that exhibited a complete response (CR) and were re-implanted.

These preclinical studies indicate a unique mechanism modulating tumor metabolism and the TME to improve the response of cancer patients to immunotherapy.

Citation Format: Salah Sommakia, Satya Pathi, Yuta Matsumura, Curtis Allred, Ethika Tyagi, Matthew Lalonde, Jason Foulks, Adam Siddiqui, Clifford Whatcott, David Bearss, Steven Warner. Pkm2 activation modulates the tumor-immune microenvironment and enhances response to checkpoint inhibitors in preclinical solid tumor models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 606.

Abstract 1345: Pharmacodynamic biomarkers for Pim inhibition with TP-3654 in patients with solid tumors

Proviral integration site for Moloney murine leukemia virus-1 (Pim-1) is a serine/threonine kinase downstream of Jak/Stat signaling which promotes cell growth, survival, and drug resistance. Pim-1 kinase is an important driver of tumorigenesis and tumor survival through its role in a number of downstream pathways, including inhibition of apoptosis through phosphorylation of the BH3-only protein BAD. Pim-1 is expressed at very low levels in most normal tissues, but is overexpressed in many cancers, such as prostate, colorectal, and many hematologic malignancies. Pim-1 kinase activity is constitutive and therefore directly proportional to protein expression. As such, Pim-1 is an attractive therapeutic target. TP-3654 is a second-generation, oral Pim inhibitor currently in Phase I clinical trials in solid tumors and myelofibrosis (NCT03715504 and NCT04176198). TP-3654 inhibits all three Pim kinases, with Ki values for Pim-1 (5nM), and Pim-2 and Pim-3 &lt250 nM in a biochemical assay. Treatment with TP-3654 in Jurkat and HEL cell lines showed dose-dependent modulation of the downstream targets of PIM, such as pS6K and pBad. A dose-dependent increase of TP-3654 Cmax was observed in plasma and subcutaneous PC-3 xenograft tumors in animals dosed orally at 50, 100 and 200 mg/kg with Tmax at 1 hour. Animals bearing HEL tumors were dosed similarly and Cmax values increased in a dose-dependent manner with Tmax at 2 hours. Plasma and tumor TP-3654 concentrations were above the measurement threshold out to 24 hours post dose. We further explored pharmacodynamic biomarkers of Pim inhibition (pBad, pS6K, and pS6RP) in flash frozen (FF) tumor tissue at various time points in both models by western blot and saw a maximum of 40% decrease in phosphorylated S6K at 2 hours, and an 80% decrease in pBad at 8 hrs in PC3 xenograft tumors in mice treated with 100 mg/kg of TP-3654. We hypothesized that treatment with TP-3654 would modulate Pim signaling in both cancer cells and peripheral blood mononuclear cells (PBMCs). This allows for detection of pharmacodynamic markers using repeated peripheral blood draws instead of invasive biopsies. We treated PBMCs from multiple healthy human donors with TP-3654 ex vivo at 0.3 and 3 µM to assess the movement of Pim biomarkers. Two phosphorylation markers, pS6K and pS6RP consistently exhibited dose-dependent decreases (30-70%) as measured by western blot. Inhibition of pBad was dependent on pretreatment phosphorylation state. These results were confirmed in an automated western blot system.

Citation Format: Curtis A. Allred, Yuta Matsumura, Ethika Tyagi, Mark Wade, Clifford Whatcott, Jason Foulks, Adam Siddiqui, David J. Bearss, Steven L. Warner. Pharmacodynamic biomarkers for Pim inhibition with TP-3654 in patients with solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1345.

Abstract 1959: CDK9 inhibition combined with hypomethylating agents target MCL-1 dependency in MDS and AML

Myelodysplastic syndrome (MDS) is a heterogeneous group of hematopoietic stem cell disorders. Approximately 70% of patients diagnosed with higher-risk (HR) MDS progress to acute myeloid leukemia (AML). Cyclin-dependent kinase 9 (CDK9) influences transcription through phosphorylation and activation of RNA polymerase II (RPB1), which increases the levels of key oncogenic survival genes like myeloid cell leukemia-1 (MCL-1). MCL-1 dependent malignancies can be identified through a functional assay by adding a NOXA mimetic MCL-1 antagonist peptide to patient samples and measuring the subsequent induction of apoptosis. The assay has been tested in bone marrow mononuclear cells (BMMCs) from AML and MDS patients to examine MCL-1 dependency prior to therapy with alvocidib. Approximately 25% of AML patient BMMCs and 60% of MDS patient BMMCs are MCL-1 dependent (data not shown). We hypothesized that the hypomethylating agents (HMAs) azacitidine and decitabine, which are currently approved for treatment of MDS, can increase MCL-1 dependency through re-expression of pro-apoptotic proteins like NOXA, normally repressed through DNA methylation in malignancies. In the MV-4-11 AML cell line and primary CD34+ MDS BMMCs, alvocidib treatment resulted in a dose dependent reduction in p-RPB1 and MCL-1. In cell viability assays using CellTiter-Glo, treatment with alvocidib and azacitidine resulted in IC50 values of ~100 nM and ~3000 nM, respectively in both cell types. Treatment with HMAs increased NOXA expression and alvocidib suppressed MCL-1 expression, whereas sequential treatment of azacitidine and alvocidib showed both NOXA induction and MCL-1 suppression. Sequential treatment of azacitidine and alvocidib showed synergistic apoptosis induction compared with either treatment alone. Azacitidine treatment sensitized MV-4-11 and MDS BMMCs to MCL-1 inhibition in an MCL-1 dependency assay. In an in vivo efficacy study using the MOLM13 AML xenograft model, the combination of alvocidib and azacitidine or decitabine inhibited tumor growth 71% and 84%, respectively. Alvocidib, azacitidine and decitabine alone showed 51%, 5.7% and 19% tumor growth inhibition (TGI), respectively. Pharmacodynamic analysis in a Phase 1 trial with alvocidib (clinicaltrials.gov, NCT03593915) showed DNA methylation of NOXA gene locus was reduced and NOXA gene expression was upregulated, while MCL-1 gene expression was suppressed in peripheral blood mononuclear cells (PBMCs) after azacitidine and alvocidib treatment. These pre-clinical and clinical data suggest that an alvocidib/HMA combination may constitute a viable therapeutic regimen whose rationale focuses on hypertargeting of NOXA/MCL-1. Taken together, these studies indicate that the combination of alvocidib and HMAs drives AML/MDS cells toward MCL-1 dependent apoptosis.

Citation Format: Yuta Matsumura, Ethika Tyagi, Satya Pathi, Dan D. Vo, Tianxiang Zhu, Suman Verma, Clifford J. Whatcott, Stephen P. Anthony, Adam Siddiqui, Jason M. Foulks, David J. Bearss, Steven L. Warner. CDK9 inhibition combined with hypomethylating agents target MCL-1 dependency in MDS and AML [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1959.

Health-related quality of life associates with clinical parameters in patients with NTM pulmonary disease

BACKGROUND: Previous studies have shown a reduction in health-related quality of life (HRQoL) in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD). However, the causes of this decline and the factors that contribute to it are unknown. This study was conducted to analyse the association between the St George´s Respiratory Questionnaire (SGRQ) and clinical parameters, including age, disease duration, body composition, pulmonary function, chest X-ray findings, blood data and physical function.METHODS: We performed a single-centre, cross-sectional, retrospective study of 101 patients with NTM-PD from December 2016 to October 2019. The relationship between the SGRQ scores and clinical parameters was evaluated.RESULTS: The median patient age was 67.0 years. Pulmonary function, radiological score, albumin levels, C-reactive protein levels and incremental shuttle walk test distance (ISWD) were significantly correlated with the total and component scores on the SGRQ. Multiple regression analysis showed that the SGRQ score was significantly associated with radiological score, pulmonary function and ISWD.CONCLUSION: This study was the first to assess the effect of clinical parameters on the SGRQ in patients with NTM-PD. HRQoL as determined using the SGRQ was associated with the radiological score, pulmonary function and ISWD in patients with NTM-PD.

Abstract 5813: Pharmacodynamic biomarker strategies for CDK9 inhibition

Cyclin-dependent kinase 9 (CDK9) is a promising target for cancer therapy due to its regulation of RNA polymerase II (RPB1) and key downstream anti-apoptosis proteins such as myeloid cell leukemia-1 (MCL-1). TP-1287 is a novel oral prodrug of alvocidib, a potent CDK9 inhibitor, and is currently under clinical investigation in patients with advanced solid tumors (clinicaltrials.gov, NCT03604783). TP-1287 is converted to alvocidib by alkaline phosphatases. CDK9 mediates phosphorylation of RPB1 at Ser2 and subsequently drives transcription of key oncogenic signaling genes, such as MCL-1. MCL-1 is a critical factor for survival of tumor types including acute myeloid leukemia (AML), multiple myeloma (MM) and myelodysplastic syndromes (MDS). MCL-1 is also expressed in normal peripheral blood mononuclear cells (PBMCs), thus it was hypothesized that CDK9 inhibition can be assessed clinically using PBMCs as a surrogate biomarker at multiple time points. We hypothesized that alvocidib, the pharmaceutically active form of TP-1287, would modulate CDK9 signaling pathways in cancer cells, resulting in tumor growth inhibition. In cell viability assays using CellTiter-Glo to evaluate the in vitro anti-tumor activity of alvocidib, we observed an IC50 of around 100 nM in AML and MM cell lines: 53-78 nM in MOLM-13, MV-4-11, and HL-60 AML cell lines and 31-223 nM in NCI-H929 and RPMI-8226 MM cell lines. In flow cytometry analysis, alvocidib reduced phosphorylation of RPB1 (p-RPB1) and MCL-1 protein expression in RPMI-8226 and MV-4-11 cells in a dose and time-dependent manner. In a pharmacodynamic study using the RPMI-8226 xenograft model after a single oral administration of TP-1287, we observed a substantial decrease of p-RPB1 and MCL-1 in tumor tissues followed by induction of cleaved caspase-3, an indicator of apoptosis. Furthermore, in an in vivo efficacy study using the RPMI-8226 model, TP-1287 achieved tumor growth inhibition (%TGI), ranging from 17.3% at 0.5 mg/kg (QD) to 86.6% at 15 mg/kg (Q7D) at day 22 after treatment. We hypothesized that PBMCs could serve as a surrogate tissue to measure CDK9 inhibition. To assess this approach in PBMCs, we performed ex vivo assays using human PBMCs from multiple healthy donors. Alvocidib demonstrated dose-dependent p-RPB1 and MCL-1 inhibition after 24 hr treatment. Preliminary data from the Phase 1 trial with TP-1287 showed p-RPB1 suppression in PBMCs from multiple patients, suggesting the successful execution of this assay and evidence of target engagement in the clinical setting. Taken together, TP-1287 demonstrated potent cell and tumor growth inhibition in multiple hematological cell lines, including AML and MM. Furthermore, a newly established flow cytometry system for p-RPB1 and MCL-1 to evaluate CDK9 inhibition in human PBMCs was developed, which could be useful as a surrogate biomarker for TP-1287 in clinical trials and warrants further investigation.

Citation Format: Yuta Matsumura, Ethika Tyagi, Clifford J. Whatcott, Jason M. Foulks, Adam Siddiqui-Jain, David J. Bearss, Steven L. Warner. Pharmacodynamic biomarker strategies for CDK9 inhibition [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5813.

Material stiffness variation in mosquito antennae

The antennae of mosquitoes are model systems for acoustic sensation, in that they obey general principles for sound detection, using both active feedback mechanisms and passive structural adaptations. However, the biomechanical aspect of the antennal structure is much less understood than the mechano-electrical transduction. Using confocal laser scanning microscopy, we measured the fluorescent properties of the antennae of two species of mosquito—Toxorhynchites brevipalpis and Anopheles arabiensis—and, noting that fluorescence is correlated with material stiffness, we found that the structure of the antenna is not a simple beam of homogeneous material, but is in fact a rather more complex structure with spatially distributed discrete changes in material properties. These present as bands or rings of different material in each subunit of the antenna, which repeat along its length. While these structures may simply be required for structural robustness of the antennae, we found that in FEM simulation, these banded structures can strongly affect the resonant frequencies of cantilever-beam systems, and therefore taken together our results suggest that modulating the material properties along the length of the antenna could constitute an additional mechanism for resonant tuning in these species.

Search for η^{'} Bound Nuclei in the ^{12}C(γ,p) Reaction with Simultaneous Detection of Decay Products

We measured missing mass spectrum of the ^{12}C(γ,p) reaction for the first time in coincidence with potential decay products from η^{'} bound nuclei. We tagged an (η+p) pair associated with the η^{'}N→ηN process in a nucleus. After applying kinematical selections to reduce backgrounds, no signal events were observed in the bound-state region. An upper limit of the signal cross section in the opening angle cosθ_{lab}^{ηp}<-0.9 was obtained to be 2.2  nb/sr at the 90% confidence level. It is compared with theoretical cross sections, whose normalization ambiguity is suppressed by measuring a quasifree η^{'} production rate. Our results indicate a small branching fraction of the η^{'}N→ηN process and/or a shallow η^{'}-nucleus potential.

Attenuated relationship between salivary oxytocin levels and attention to social information in adolescents and adults with autism spectrum disorder: a comparative study

BACKGROUND

Previous research studies have assessed the relationship between attention to social information and peripheral (e.g., plasma and salivary) oxytocin (OT) levels in typically developing (TD) children and children with autism spectrum disorder (ASD). A relationship between them was observed in TD children, but not in children with ASD. However, this relationship remains unexamined in other age groups. To clarify whether this lack of association is maintained throughout development in individuals with ASD, we aimed to assess the relationship between salivary OT levels and attention to social information in adolescents and adults with and without ASD.

METHODS

We recruited male adolescents and adults with ASD (n = 17) and TD participants (n = 24). Using the all-in-one eye-tracking system Gazefinder, we measured the percentage fixation time allocated to social information. We also measured the salivary OT levels and Autism Spectrum Quotient (AQ) of participants. Subsequently, we confirmed group differences and conducted a correlation analysis to investigate the relationships between these three measures.

RESULTS

Salivary OT levels did not show any significant difference between the ASD and TD groups and were negatively correlated with the AQ in the whole-group analysis, but not in within-group analysis. Individuals with ASD had significantly lower percentage fixation times than did TD individuals for eye regions in human faces with/without mouth motion, for upright biological motion, and for people regions in the people and geometry movies. The percentage of fixation for geometric shapes in the people and geometry movies was significantly higher in the ASD than in the TD group. In the TD group, salivary OT levels were positively correlated with percentage fixation times for upright biological motion and people and negatively correlated with inverted biological motion and geometry. However, no significant correlations were found in the ASD group.

CONCLUSIONS

Our exploratory results suggest that salivary OT levels in adolescents and adults with ASD are less indicative of attention to social stimuli than they are in TD adolescents and adults. It is suggested that their association is slightly weaker in adolescents and adults with ASD and that this attenuated relationship appears to be maintained throughout development.

Abstract C081: Targeting CDK9 and MCL1 in castration-sensitive and resistant prostate cancer models

Prostate cancer is the most prevalent cancer in men, comprising 20% of all new cancer cases in United States, as per the Cancer Statistics, 2019. Many therapies for prostate cancer function by lowering androgen levels and include androgen deprivation therapy alone or in combination with surgical or chemical castration. Hormone therapy has been a mainstay treatment for prostate cancer, ultimately leading to progression free disease in over 80% of patients over short time periods. Unfortunately, these effects are not durable, and the majority of patients experience progressive disease. Ultimately, the disease progresses and becomes invasive and lethal in the form of castration-resistant prostate cancer (CRPC). Understanding the mechanism by which prostate cancer cells lose their inherent dependence on the canonical androgen signaling pathway for survival has been critical in developing new therapeutic options for patients with CRPC. CDK9 may constitute one such mechanism. CDK9 phosphorylates RNA polymerase II (RNA Pol II), resulting in gene transcription of anti-apoptotic proteins such as MCL1, that can influence prostate cancer cell survival. Additionally, CDK9 is known to phosphorylate the androgen receptor (AR) and both AR and RNA Pol II cooperate for transcription of key prostate cancer genes, including PSA. Therefore, inhibition of CDK9 has great potential to halt constitutive activity of both AR and the RNA Pol II -driven transcriptional program that drives CRPC. Here, we describe tumor growth inhibition in CRPC models using the CDK9 inhibitor TP-1287, an oral alvocidib prodrug, alone and in combination with docetaxel or venetoclax, a BCL-2 inhibitor that is currently being evaluated in a Phase II clinical trial for metastatic CRPC. The CDK9 inhibitor alvocidib demonstrates low nanomolar IC50 values in CRPC cell lines PC3, 22Rv1 and castration dependent PCa cell lines VCAP and LnCAP ranging from 25-175 nM. Alvocidib treatment inhibits RNA Pol II in 22Rv1 cells (~50%) at 80 and 160 nM, 3 and 24 hrs post treatment and regulates MCL-1 protein expression in PC3 cells (300 nM, 24 hrs). Alvocidib treatment also inhibited AR phosphorylation at Ser 81, reducing PSA gene expression (~50%) and inducing caspase activation in 22Rv1 cells (80-160 nM for 24 hrs). We explored the tumor growth inhibition of TP-1287, in several PCa xenograft models namely PC3, 22Rv1, LnCAP and C4-2 models. In androgen sensitive models, 1.25 mpk BID TP-1287 combined well with 10 mpk docetaxel, demonstrating 90% and 81% TGI in C4-2 and LnCAP models respectively. TP-1287 treatment (1.25 mpk BID) in combination with 100 mpk venetoclax demonstrated 64% tumor growth inhibition in the 22Rv1 CRPC model that was resistant to docetaxel, enzalutamide and venetoclax alone. These data support the potential of TP-1287 to be used in combination with currently available or novel therapies to achieve better efficacy for androgen sensitive and CRPC patients.

Citation Format: Tetyana V Forostyan, Evita Weagel, Yuta Matsumura, Ethika Tyagi, Jason M Foulks, Clifford J Whatcott, Adam Siddiqui-Jain, David J Bearss, Steven L Warner. Targeting CDK9 and MCL1 in castration-sensitive and resistant prostate cancer models [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr C081. doi:10.1158/1535-7163.TARG-19-C081

P1918Comparison of the clinical outcome of pulmonary vein isolation with cryoballoon and radiofrequency ablation for atrial fibrillation with pulmonary vein triggers

Background

Pulmonary vein isolation (PVI) using radiofrequency (RF) or cryoballoon (CB) has been an established treatment for atrial fibrillation. PVI using RF is the most common method with a rather complex technique of a point-by-point tissue heating and navigation of electro-anatomical-guided mapping system, and PVI with CB is also the common method with a relatively simple technique of freezing balloon occlusion. These 2 types of ablation are comparable in terms of the efficacy of the PVI procedure.

Purpose

The data on the clinical outcome of each AF type with PV triggers has been limited. We compared the outcome of success rate between RF and CB group with respect to each AF type, and further assessed the efficacy of pulmonary vein isolation for AF patients with the origin of only PV.

Methods

A total of 3402 AF patients (age 64±11; 2463 males) underwent initial PVI from May 2009 to July 2018 (PAF: 67%, non-PAF: 37%). Radiofrequency using irrigation-tip catheter was employed to 1796 patients since May 2009 (RF-PAF: 55%, RF-non-PAF: 45%). Second-generation cryoballoon was employed to other 1606 patients since September 2014 (CB-PAF: 81%, CB-non-PAF: 19%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using isoproterenol infusion and rapid atrial pacing (RF-AF: 34%, CB-AF: 32%; p=0.107).

Results

In all PAF patients, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 83.2%, RF 75.2%; log-rank p<0.001). The percentage of patients with non-PV foci was almost equivalent in both group (CB 30%, RF 31%, p=0.644). And in PAF patients with only PV-foci, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 85.0%, RF 78.8%; log-rank p<0.001). On the other hand, in all non-PAF patients, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 65.5%, RF-non-PAF 70.0%; log-rank p=0.9). The percentage of patients with non-PV foci was almost equivalent in both group (CB 40%, RF 39%, p=0.731), And in non-PAF patients with only PV-foci, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 69.7%, RF 73.0%; log-rank p=0.376).

Conclusions

Our study showed better outcome of PVI with CB for PAF patients with PV triggers, and indicated the non-inferiority of PVI with CB for non-PAF patients with PV triggers to PVI with RF.

P6380The impact of coronary artery disease to predict mortality and neurological outcome in post-cardiac arrest patients

Background

Some studies reported that performing coronary angiography (CAG) for patients with out-of-hospital cardiac arrest (OHCA) is effective for the prognosis and neurological outcome. However, the impact of complexity of coronary artery disease (CAD) on CAG findings has not been evaluated sufficiently.

Purpose

We sought to investigate the complexity of CAD to predict the prognosis and neurological outcome in patients with OHCA.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, we performed CAG for 160 patients. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, coronary anatomical angiographical findings.

Results

Ventricular fibrillation (VF) (P=0.001), younger age (P=0.007), pre-hospital ROSC (P<0.001) and normal coronary artery on CAG findings (P=0.014) were associated with low 30-days mortality in hospital. VF (P=0.003), younger age (P=0.004), pre-hospital ROSC (P<0.001), bystander cardiopulmonary resuscitation (CPR) (P=0.043) and normal coronary artery (P=0.001) were associated with good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. We further investigated 100 patients who had any coronary artery stenosis on CAG findings. Among these patients, 55 patients (55.0%) had multi-vessel coronary artery disease and 29 patients (29.0%) had at least a chronic total occlusion lesion. VF survivor (P=0.035), without previous history of CAD (P=0.008), pre-hospital ROSC (P=0.013), and Syntax score (P=0.002) were associated with low 30-days mortality. In multivariate analysis, Syntax score (OR 0.94; 95% confidence interval (CI) 0.88–0.99; P=0.042) was independent predictor of mortality. Bystander CPR (P=0.001), pre-hospital ROSC (P<0.001) were associated with good neurological outcome at 30 days. Bystander CPR (OR 5.92; 95% CI 2.01–17.5; P<0.001) and pre-hospital ROSC (OR 9.22; 95% CI 3.34–25.5; P<0.001) were predictive for good neurological outcome.

Conclusions

OHCA patients with any coronary stenosis had high mortality and bad neurological outcome in comparison with those who had normal coronary arteries. OHCA patients with CAD had complex lesions such as multi-vessel disease or chronic total occlusion lesions. The coronary complexity in patients with OHCA was a predictor of in-hospital 30-days mortality. However, pre-hospital care such as bystander CPR and pre-hospital ROSC were the most important to achieve good neurological outcome at 30 days in the present study.

P2266The predictor of mortality and neurological outcome in out-of-hospital cardiac arrest patients with non-ST-segment elevation

Background

The prognosis of patients with out-of-hospital cardiac arrest (OHCA) remains poor. Coronary artery disease (CAD) is the most frequent cause of OHCA. The prompt evaluation and revascularization for coronary artery in OHCA patients with ST-segment elevation are recommended because they often have CAD. However, OHCA patients without ST-segment elevation also have any coronary stenosis in the non-negligible proportion. The predictor of mortality and neurological outcome in OHCA patients with no ST-segment elevation has not been sufficiently elucidated.

Purpose

We sought to investigate the predictor of mortality and neurological outcome at 30 days in OHCA patients without ST-segment elevation.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, 183 patients' electrocardiogram after ROSC were without ST-segment elevation. We performed coronary angiography (CAG) for 103 patients, who were eligible for final analysis. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, post-hospital care.

Results

Any coronary stenosis was founded in 50 patients (48.5%). Male (P=0.007), older age (P<0.001), past history of coronary artery disease (CAD) (P=0.037) and diabetes mellitus (P=0.087) were associated with coronary artery stenosis on CAG findings. Age (OR 1.05; 95% confidence interval (CI) 1.02–1.08; P<0.001), male (OR 5.33; 95% CI 1.37–20.7; P<0.001) were independent predictors of coronary artery stenosis. Among those who had stenosis, 34 patients (68.0%) survived and 27 patients (54.0%) achieved good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. Successful revascularization by percutaneous coronary intervention (PCI) was not associated with low mortality (P=0.77). Past history of CAD (P=0.014) and high Syntax score (P=0.030) were associated with mortality. Bystander cardiopulmonary resuscitation (CPR) (P-0.021), pre-hospital ROSC (P<0.001) was more frequent in patients with good neurological outcome. Pre-hospital ROSC (OR 14.7; 95% CI 3.1–69.3; P<0.001) was independently predictive for good neurological outcome.

Conclusions

Successful PCI for OHCA patients with no ST-segment elevation was not a predictor of mortality. CAD past history and complex CAD was associated with mortality. Pre-hospital information such as pre-hospital ROSC was important to achieve good neurological outcome.

P1919The assessment of the application and the efficacy of pulmonary vein isolation with cryoballoon for non-paroxysmal atrial fibrillation

Background

Pulmonary vein isolation (PVI) using second generation cryoballoon (CB) ablation has become an established treatment for paroxysmal atrial fibrillation (PAF) patients. On the other hand, PVI with radiofrequency (RF) has been an established treatment for non-PAF patients, in addition to PAF patients.

Purpose

The data on second generation CB ablation for non-PAF patients is limited. We assessed the application of PVI with CB for non-PAF patients and compared the outcomes of success rate, radiational time, and procedural time.

Methods

A total of 2632 AF patients (age 64±10; 1873 males) underwent initial PVI from September 2014 to June 2018. Second-generation CB was employed to 1587 patients (CB-PAF: 80%, CB-non-PAF: 20%) and RF using irrigation-tip catheter was employed to other 1045 patients (RF-PAF: 40%, RF-non-PAF: 60%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using ISP infusion and rapid atrial pacing.

Results

AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB-non-PAF 66.3%, RF-non-PAF 69.8%; log-rank p=0.297). There was significantly difference in procedural time (CB-non-PAF 132±56min, RF-non-PAF: 189±52min, p<0.001), and radiation time (CB-non-PAF: 47±40min, RF-non-PAF: 75±31min, p<0.001). The percentage of patients with non-PV foci was significantly higher in CB group (CB-non-PAF 41%, RF-non-PAF 54%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was almost equivalent in both group (2-years Kaplan-Meier event rate, CB-non-PAF 75.4%, RF-non-PAF 78.8%; log-rank p=0.577). On the other hand, in patients in CB, AF free survival rate was significantly superior in PAF group (2-years Kaplan-Meir event rate, CB-PAF 83.3%, CB-non-PAF 65.2%; log-rank p<0.001). There was significantly difference in procedural time (CB-PAF: 117±47min, CB-non-PAF: 132±56min, p<0.001), and radiation time (CB-PAF: 38±22min, CB-non-PAF: 46±27min, p<0.001). The percentage of patients with non-PV foci was significantly higher in non-PAF group (CB-PAF 30%, CB-non-PAF 41%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was also significantly superior in PAF group (2-years Kaplan-Meier event rate, CB-PAF 85.1%, CB-non-PAF 69.8%; log-rank p<0.001).

Conclusions

For non-PAF patients with PV triggers, PVI with CB might be non-inferior to PVI with RF. Our study showed the efficacy of CB in terms of the shortening of procedural time, and the reduction of radiational exposure. PVI with CB for non-PAF patients was inferior to that for PAF patients.

Abstract 2197: The AXL kinase inhibitor, TP-0903, demonstrates efficacy in preclinical models of colorectal cancer independent of KRAS mutation status

Colorectal cancer (CRC) is the third leading cause of cancer-related mortality in the US (2017). Most patients present with stage II or III disease at diagnosis, with the 5-year survival rate between 53-89%. Survival in patients with stage IV CRC, however, is a discouraging 11%. Metastasis in CRC is linked to a mesenchymal phenotype, which is associated with chemoresistance. AXL, a receptor tyrosine kinase, promotes the mesenchymal phenotype in cancer cells and its expression is associated with drug resistance and poor outcomes. TP-0903, a clinical-stage, investigational small molecule inhibitor of AXL has been shown to reverse the mesenchymal phenotype and restore drug sensitivity in cells that no longer respond to standard agents in preclinical models. TP-0903 is hypothesized to be an active agent in CRC through reversal of the mesenchymal phenotype. In cell viability assays of CRC lines, TP-0903 treatment resulted in IC50 values ranging from 4.5 – 123 nM. Notably, cell growth inhibition by TP-0903 was independent of KRAS mutation status; the KRAS mutant HCT-116 line was the most sensitive CRC cell line tested. Mesenchymal markers, including Snail, were suppressed by 7.6-fold (mRNA) and 4.9-fold (protein) in the HCT-116 line at 500 nM. TP-0903 activity was also assessed in vivo using two KRAS mutant CRC models: HCT-116 and a patient-derived xenograft (PDX) model. In the HCT-116 xenograft model, single agent TP-0903 treatment achieved 69% tumor growth inhibition (%TGI) with an oral dosing schedule at 40 mg/kg. In a KRAS-mutant PDX model, TP-0903 achieved 44% TGI when mice were dosed at 40 mg/kg. Pharmacodynamic analyses were performed on tissues from the HCT-116 and PDX models. The ligand for AXL, GAS6, was significantly upregulated in tissues after TP-0903 treatment in both CRC in vivo models while soluble AXL and GAS6 were significantly downregulated in plasma in the PDX model. Furthermore, Axin2, a Wnt/β-catenin regulated gene, was downregulated by TP-0903 in tumor tissue from the PDX model, suggesting inhibition of the Wnt/βcatenin pathway. These data support a potential role for AXL in the promotion of the mesenchymal phenotype in CRC, and showed that AXL inhibition by TP-0903 suppressed the mesenchymal phenotype and was effective against CRC cells regardless of KRAS mutation status. These observations support further clinical investigation of TP-0903 as a potential therapeutic agent in metastatic CRC. A Phase I trial with this investigational agent is ongoing, including patients with KRAS mutant CRC (clincaltrials.gov, NCT02729298).

Citation Format: Ryan Mangelson, Peter Peterson, Jason M. Foulks, Yuta Matsumura, Lars Mouritsen, Clifford J. Whatcott, David J. Bearss, Steven L. Warner. The AXL kinase inhibitor, TP-0903, demonstrates efficacy in preclinical models of colorectal cancer independent of KRAS mutation status [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2197.

Abstract 3166: Evaluation of genetic modulation of ACVR1 (aka ALK2) kinase gene as a clinical biomarker of the ACVR1 inhibitor TP-0184

The receptor kinase ALK2, the product of the ACVR1 gene, is a member of the bone morphogenic protein (BMP) receptor family and a type I receptor of the greater TGFβ family. Germline mutations in ACVR1, and specifically the R206H manifestation, are a driving factor in the development of fibrodysplasia ossificans progressiva (FOP). Additionally, the childhood brain tumor, diffuse intrinsic pontine glioma (DIPG), is also associated with mutations in the ACVR1 gene including R206H, but accounts for approximately only 25% of DIPG. In adult cancers, mutations in the ACVR1 gene are observed, yet their role is less established. TP-0184 is a small molecule inhibitor of ACVR1 which inhibits the kinase activity of wild-type and mutant forms of ALK2. We examined the genetic make-up of ACVR1 mutations across large data sets to evaluate which mutations may portend benefit with TP-0184 treatment. Using publicly available sequence databases (e.g. cBioPortal, Cosmic, TCGA) we searched for ACVR1 mutations in tissues of cancer patients. Results were compared to the known mutations of ACVR1 in the literature associated with various cancers or demonstrate gain-of-function activity. Multiple mutations were found within ACVR1. The FOP community has done extensive work to identify and understand mutations that can drive aberrant activation of ACVR1. These mutations include L196P, R206H, Q207E, R258S, G328E/R, and G356D to name a few. ACVR1 mutations identified in adult cancers include many of these FOP mutations, but also demonstrate more diversity in their ACVR1 mutational profile with fewer “hotspots” and many mutations of unknown significance. For example, 8.49% (45/530) of endometrial cancer patients in the TCGA database have ACVR1 mutations, yet these are represented by 52 different mutations. The most common ACVR1 mutation in endometrial cancer is the bona fide R206H mutation, but it only makes up 0.9% of the 8.49% of ACVR1 mutations in endometrial cancer. If all ACVR1 mutations of known significance are considered, 2.45% of endometrial cancers have validated gain-of-function mutations in ACVR1. The remaining ACVR1 mutations in endometrial cancer are of unknown significance. Similar results were observed in other types of cancer such as melanoma, prostate and breast cancer and in other publicly available databases. The results from surveying these rare mutations in multiple cancer types will be presented. Since the BMP and TGFβ pathways are frequently dysregulated in cancers, the importance of any mutation that regulates ACVR1 activity in cancer may be an important regulator of tumorigenesis and a target of ACVR1 inhibitors. A Phase I trial with TP-0184 is in progress and will assess the correlation of ACVR1 mutations and compound clinical activity (Clinical trial information: NCT03429218). Further studies are in progress to assess the consequences and causal impact of ACVR1 mutations in cancer.

Citation Format: Mark L. Wade, C Lars Mouritsen, Yuta Matsumura, Breeann V. Bryan, David J. Bearss, Steven L. Warner. Evaluation of genetic modulation of ACVR1 (aka ALK2) kinase gene as a clinical biomarker of the ACVR1 inhibitor TP-0184 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3166.

Understanding the NaCl-dependent behavior of hydrogen production of a marine bacterium, Vibrio tritonius

Biohydrogen is one of the most suitable clean energy sources for sustaining a fossil fuel independent society. The use of both land and ocean bioresources as feedstocks show great potential in maximizing biohydrogen production, but sodium ion is one of the main obstacles in efficient bacterial biohydrogen production. Vibrio tritonius strain AM2 can perform efficient hydrogen production with a molar yield of 1.7 mol H₂/mol mannitol, which corresponds to 85% theoretical molar yield of H₂ production, under saline conditions. With a view to maximizing the hydrogen production using marine biomass, it is important to accumulate knowledge on the effects of salts on the hydrogen production kinetics. Here, we show the kinetics in batch hydrogen production of V. tritonius strain AM2 to investigate the response to various NaCl concentrations. The modified Han-Levenspiel model reveals that salt inhibition in hydrogen production using V. tritonius starts precisely at the point where 10.2 g/L of NaCl is added, and is critically inhibited at 46 g/L. NaCl concentration greatly affects the substrate consumption which in turn affects both growth and hydrogen production. The NaCl-dependent behavior of fermentative hydrogen production of V. tritonius compared to that of Escherichia coli JCM 1649 reveals the marine-adapted fermentative hydrogen production system in V. tritonius. V. tritonius AM2 is capable of producing hydrogen from seaweed carbohydrate under a wide range of NaCl concentrations (5 to 46 g/L). The optimal salt concentration producing the highest levels of hydrogen, optimal substrate consumption and highest molar hydrogen yield is at 10 g/L NaCl (1.0% (w/v)).

Stiffness gradients facilitate ovipositor bending and spatial probing control in a parasitic wasp

Many parasitic wasps use slender and steerable ovipositors to lay eggs in hosts hidden in substrates, but it is currently unknown how steering is achieved. The ovipositors generally consist of three longitudinally connected elements, one dorsal and two ventral valves that can slide along each other. For the parasitic wasp Diachasmimorpha longicaudata, it has been shown that protraction of the ventral valves causes incurving of the ventral valves towards the dorsal one, which results in a change in probing direction. We hypothesise that this shape change is due to differences in bending stiffness along the ovipositor. Alignment of the stiff tip of the dorsal valve with a more flexible ventral S-shaped region situated just behind the tip straightens this S-bend and results in upwards rotation of the ventral tip. We show that the S-shaped region of the ventral valves has a low bending stiffness because it contains soft materials such as resilin. In contrast, the large cross-sectional area of the dorsal valve tip area probably results in a high bending stiffness. Elsewhere, the dorsal valve is less stiff than the ventral valves. Our results support the hypothesis that the interaction between the stiff dorsal valve portion and the more flexible S-shaped region co-determine the configurational tip changes required for steering the ovipositor in any desired direction along curved paths in the substrate. This provides novel insights in the understanding of steering mechanisms of the hymenopteran ovipositor, and for the application in man-made probes.

Fluoroquinolones versus trimethoprim-sulfamethoxazole for the treatment of Stenotrophomonas maltophilia infections: a systematic review and meta-analysis

BACKGROUND

Fluoroquinolones are a popular alternative to trimethoprim-sulfamethoxazole for Stenotrophomonas maltophilia infections.

OBJECTIVES

To compare the effects of fluoroquinolones and trimethoprim-sulfamethoxazole on mortality of S. maltophilia infections.

DATA SOURCES

PubMed and EMBASE.

STUDY ELIGIBILITY CRITERIA

Clinical studies reporting mortality outcomes of S. maltophilia infections.

PARTICIPANTS

Patients with clinical infections caused by S. maltophilia.

INTERVENTIONS

Fluoroquinolone monotherapy in comparison with trimethoprim-sulfamethoxazole monotherapy.

METHODS

Systematic review with meta-analysis technique.

RESULTS

Seven retrospective cohort and seven case-control studies were included. Three cohort studies were designed to compare the two drugs, whereas others had other purposes. A total of 663 patients were identified, 332 of which were treated with trimethoprim-sulfamethoxazole (50.1%) and 331 with fluoroquinolones (49.9%). Three cohort studies were designed to compare the effect of the two drugs, whereas the others had other purposes. Levofloxacin was most frequently used among fluoroquinolones (187/331, 56.5%), followed by ciprofloxacin (114/331, 34.4%). The overall mortality rate was 29.6%. Using pooled ORs for the mortality of each study, fluoroquinolone treatment (OR 0.62, 95% CI 0.39-0.99) was associated with survival benefit over trimethoprim-sulfamethoxazole treatment, with low heterogeneity (I² = 18%). Specific fluoroquinolones such as ciprofloxacin (OR 0.44, 95% CI 0.17-1.12) and levofloxacin (OR 0.78, 95% CI 0.48-1.26) did not show a significant difference in comparison with trimethoprim-sulfamethoxazole. In the sub-group analyses of adult and bacteraemic patients, significant differences in mortality were not observed between fluoroquinolones and trimethoprim-sulfamethoxazole.

CONCLUSIONS

Based on a meta-analysis of non-randomized studies, fluoroquinolones demonstrated comparable effects on mortality of S. maltophilia infection to trimethoprim-sulfamethoxazole, supporting the use of fluoroquinolones in clinical S. maltophilia infections. Although the pooled analysis of overall studies favoured fluoroquinolones over trimethoprim-sulfamethoxazole, the studies included were observational, and sub-group analyses of certain fluoroquinolone agents did not show statistical differences with trimethoprim-sulfamethoxazole. Randomized clinical studies are needed to address these issues.

The Application of an Institutional Clinical Data Warehouse to the Assessment of Adverse Drug Reactions (ADRs)

Objectives: To apply an institutional clinical data warehouse (CDW) to the assessment of adverse drug reactions (ADRs) and demonstrate its utility through a specific example.

Methods: We modeled the process for assessing ADRs through retrospective cohort design by using CDW at the Osaka University Hospital as follows: 1) We defined a drug X, an adverse drug reaction (ADR) Y, and a laboratory measurement Z to assess Y during a given study period; 2) we excluded those whose Z value exceeded the defined criteria or were not available at the inception of the cohort; 3) we divided the patients into two groups based on exposure or non-exposure to X; 4) we matched the patient characteristics between the two groups through stratification and randomization; and 5) we compared the frequency of patients who presented Y during the study period between the two groups. Aminoglycoside and Cephalosporin associated nephrotoxicity in pediatric inpatients was used as an example to demonstrate the usefulness of this approach.

Results: Our evaluation indicates that there is an increased risk of nephrotoxicity for pediatric inpatients who were prescribed cephalosporin either alone or in combination with aminoglycoside; further, aminoglycoside tends to increase the cephalosporin-associated nephrotoxicity.

Conclusions: Our findings are consistent with those drawn from other studies, indicating thatthe method of a pplying an institutional CDW is useful for assessing ADRs.

Development of a System that Generates Structured Reports for Chest X-ray Radiography

Objectives: Radiology reports are typically made in narrative form; this is a barrier to the implementation of advanced applications for data analysis or a decision support. We developed a system that generates structured reports for chest x-ray radiography.

Methods: Based on analyzing existing reports, we determined the fundamental sentence structure of findings as compositions of procedure, region, finding, and diagnosis. We categorized the observation objects into lung, mediastinum, bone, soft tissue, and pleura and chest wall. The terms of region, finding, and diagnosis were associated with each other. We expressed the terms and the relations between the terms using a resource description framework (RDF) and developed a reporting system based on it. The system shows a list of terms in each category, and modifiers can be entered using templates that are linked to each term. This system guides users to select terms by highlighting associated terms. Fifty chest x-rays with abnormal findings were interpreted by five radiologists and reports were made either by the system or by the free-text method.

Results: The system decreased the time needed to make a report by 12.5% compared with the free-text method, and the sentences generated by the system were well concordant with those made by free-text method (F-measure = 90%). The results of the questionnaire showed that our system is applicable to radiology reports of chest x-rays in daily clinical practice.

Conclusions: The method of generating structured reports for chest x-rays was feasible, because it generated almost concordant reports in shorter time compared with the free-text method.

Alert System for Inappropriate Prescriptions Relating to Patients’ Clinical Condition

Objectives: Because information of contraindication and careful indication of medication is vast, there have been numerous cases of prescribing medication inappropriately. Our goal is to have a clinical decision support system (CDSS) combined with a computerized physician order entry (CPOE) to aid physicians in prescribing medication appropriately. In this study we developed an alert system for evaluating renal function and checking doses of medication according to the patient’s renal function. In addition, we developed functions of extracting target problems from the raw data and verifying if contraindicated medication has being prescribed.

Methods: This system scrutinizes data handled in the CPOE system. It picks up the data needed to ascertain problems and the data of medication entered from the order entry system. First we made an alert system for renal dysfunction. Creatinine clearance (Ccr) of a patient was calculated by the estimate equation of Cockcroft and Gault. If a patient data fulfills the condition of impaired renal function, the alert message is sent to the database. The alert system also checks the dosage of each medication according to a patient’s renal function. When the dosage is over-prescribed, an alert is sent. Next, we made an alert system targeting contraindication for liver diseases, renal diseases and diabetes mellitus. The criteria of these problems were set in the knowledge base. If a patient’s data meets the criteria, that fact is stored in the problem database. The system also keeps a prescription check master and checks whether the patient has a problem which is a contraindication of the prescribed medication. If a problem exists, an alert is sent to the alert message database. The alert-presenting module is a web system. After accepting patients’ ID indicated by a user, the system searches the alerts concerning the patients from the database and constructs pages presenting the alert message.

Results: We compared the period during which the contraindicated medication was prescribed before and after the alert system was put into operation. Of the patients with renal dysfunction who were prescribed the contraindicated medication, 24% had their medication discontinued before the alert system was put into operation. In contrast, the rate significantly increased to 54% after the alert system began to function.

Conclusion: We developed an alert system for inappropriate prescriptions for each patient’s clinical condition. The alerts generated by this system were effective for discontinuing contraindicated medication.

Chiral effects on the final step of an octahedron-shaped coordination capsule self-assembly

The final step of the self-assembly of an octahedron-shaped coordination capsule was investigated by a novel theoretical method.

Intravenous immunoglobulin contributes to the control of antimelanoma differentiation-associated protein 5 antibody-associated dermatomyositis with palmar violaceous macules/papules

Autoantibodies to melanoma differentiation-associated protein 5 (MDA5) are associated with a subset of patients with dermatomyositis (DM) who have rapidly progressive interstitial lung disease (RP-ILD) with poor prognosis. Intensive immunosuppressive therapy is initiated before irreversible lung damage can occur; however, there are few lines of evidence for the treatment of RP-ILD. Here, we report three cases of anti-MDA5 antibody-associated DM with RP-ILD in which the patients were treated with combined-modality therapy, including high-dose prednisolone, tacrolimus, intravenous cyclophosphamide and intravenous immunoglobulin (IVIG). In all three cases, serum ferritin levels, which are known to represent the disease activity of RP-ILD, were decreased after IVIG administration. IVIG might contribute to the control of the disease activity of anti-MDA5 antibody-positive DM. Moreover, palmar violaceous macules/papules around the interphalangeal joints, which was observed in all three cases in the incipient stage, might be a useful sign in suggesting a diagnosis of anti-MDA5 antibody-associated DM.