Anti-PD-1 antibody monotherapy versus anti-PD-1 plus anti-CTLA-4 combination therapy as first-line immunotherapy in unresectable or metastatic mucosal melanoma: a retrospective, multicenter study of 329 Japanese cases (JMAC study)

Background

Anti-programmed cell death protein 1 (PD-1) antibody monotherapy (PD1) has led to favorable responses in advanced non-acral cutaneous melanoma among Caucasian populations; however, recent studies suggest that this therapy has limited efficacy in mucosal melanoma (MCM). Thus, advanced MCM patients are candidates for PD1 plus anti-cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) combination therapy (PD1 + CTLA4). Data on the efficacy of immunotherapy in MCM, however, are limited. We aimed to compare the efficacies of PD1 and PD1 + CTLA4 in Japanese advanced MCM patients.

Patients and methods

We retrospectively assessed advanced MCM patients treated with PD1 or PD1 + CTLA4 at 24 Japanese institutions. Patient baseline characteristics, clinical responses (RECIST), progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier analysis, and toxicity was assessed to estimate the efficacy and safety of PD1 and PD1 + CTLA4.

Results

Altogether, 329 patients with advanced MCM were included in this study. PD1 and PD1 + CTLA4 were used in 263 and 66 patients, respectively. Baseline characteristics were similar between both treatment groups, except for age (median age 71 versus 65 years; P < 0.001). No significant differences were observed between the PD1 and PD1 + CTLA4 groups with respect to objective response rate (26% versus 29%; P = 0.26) or PFS and OS (median PFS 5.9 months versus 6.8 months; P = 0.55, median OS 20.4 months versus 20.1 months; P = 0.55). Cox multivariate survival analysis revealed that PD1 + CTLA4 did not prolong PFS and OS (PFS: hazard ratio 0.83, 95% confidence interval 0.58-1.19, P = 0.30; OS: HR 0.89, 95% confidence interval 0.57-1.38, P = 0.59). The rate of ≥grade 3 immune-related adverse events was higher in the PD1 + CTLA4 group than in the PD1 group (53% versus 17%; P < 0.001).

Conclusions

First-line PD1 + CTLA4 demonstrated comparable clinical efficacy to PD1 in Japanese MCM patients, but with a higher rate of immune-related adverse events.

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Anti-PD-1 plus anti-CTLA-4 antibody therapy (PD1 + CTLA4) is an option for patients with advanced mucosal melanoma (MCM).

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Data on the efficacy of PD1 + CTLA4 compared with PD-1 monotherapy (PD1) for MCM, however, are limited.

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We retrospectively analyzed data from 329 Japanese patients with advanced MCM treated with PD1 or PD1 + CTLA4.

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No significant differences in objective response rate, progression-free survival, or overall survival were observed.

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Immune-related adverse events resulting in treatment cessation were higher in the PD1 + CTLA4 group.

Influence of lingual plate fracture pattern on remodelling site during the healing process of sagittal split ramus osteotomy

The purpose of this study was to investigate whether differences in the pattern of the lingual plate split in sagittal split ramus osteotomy (SSRO) affect the remodelling of the split site. Sixty-one patients with mandibular prognathism (122 sides) underwent SSRO. Computed tomography (CT) was performed at 1 week and 1 year after SSRO. Bone splits were classified according to the lingual split scale (LSS) and the lateral bone cut end (LBCE) by evaluating CT images at 1 week. The remodelling at the split sites was evaluated by superimposing the CT images obtained at 1 week and 1 year. Regarding the LSS pattern, significant differences were observed in the distance between anteroposterior ramus points (P = 0.033) and the ramus area in the axial image (P = 0.011). The LBCE pattern also showed a significant difference in the distance between anteroposterior ramus points (P = 0.043). In conclusion, the differences in the lingual plate split and ramus cut end of the SSRO influence the postoperative remodelling in the anteroposterior region of the split site.

Shift-and-add image processing incorporated with the unsharp masking method

Shift-and-add (SAA) is a simple image processing procedure. SAA was devised to reconstruct a diffraction-limited image from atmospherically degraded stellar images. Recently SAA has been applied to biological imaging. There are several variants of SAA. Here proposed is an SAA procedure incorporated with unsharp masking (USM). The SAA procedure proposed here encompasses an extended version of USM. The proposed SAA method retains the simplicity and easiness, and the basic features of SAA. The effectiveness of the proposed method is examined by restoring atmospherically degraded solar images. It is shown that the USM SAA reconstructed image exhibits high contrast and reveals fine structures blurred by atmospheric turbulence. It is also shown that the USM SAA performs better with a data frame selection scheme.

Difamilast ointment, a selective phosphodiesterase 4 inhibitor, in paediatric patients with atopic dermatitis: A phase 3 randomised double-blind, vehicle-controlled trial

Background

In atopic dermatitis (AD), phosphodiesterase 4 (PDE4) inhibition reduces proinflammatory mediators and cytokines. Difamilast is a new selective PDE4 inhibitor.

Objectives

To demonstrate the superiority of topical difamilast to vehicle in Japanese paediatric patients with AD.

Methods

This was a phase III randomized, double‐blind, vehicle‐controlled trial. Patients aged 2–14 years with an Investigator Global Assessment (IGA) score of 2 or 3 received difamilast 0·3% (n = 83), difamilast 1% (n = 85) or vehicle (n = 83) ointment twice daily for 4 weeks.

Results

The primary endpoint was the percentage of patients with an IGA score of 0 or 1 with improvement by at least two grades at week 4. The success rates in IGA score at week 4 were 44·6%, 47·1% and 18·1% in the difamilast 0·3%, difamilast 1% and vehicle groups, respectively. Both difamilast groups demonstrated significantly higher success rates in IGA score compared with vehicle at week 4 [difamilast 0·3% (P < 0·001); difamilast 1% (P < 0·001)]. Regarding secondary endpoints, improvements in Eczema Area and Severity Index (EASI; improvement of ≥ 50%, ≥ 75% and ≥ 90% in overall score) at week 4 were significantly higher in patients in the difamilast 0·3% and 1% groups than those in the vehicle group. EASI score in the difamilast 0·3% and 1% groups was significantly reduced compared with that of patients in the vehicle group at week 1. The significant difference between both the difamilast groups and the vehicle groups was maintained from week 1 through to week 4. Most treatment‐emergent adverse events were mild or moderate, and no serious events or deaths were reported.

Conclusions

Difamilast 0·3% and 1% ointments are superior to vehicle and well tolerated in Japanese paediatric patients with AD.

Basophils are recruited to inflamed lungs and exacerbate memory Th2 responses in mice and humans

BACKGROUND

Although the contribution of basophils as inducers or amplifiers of Th2 responses is still debated, prolonged basophil/CD4 T cell interactions were observed in lungs but not lymph nodes (LNs) of parasite-infected mice. However, the impact of basophils on the function of tissue CD4 effector T cells remains unknown.

METHODS

Basophils were purified from the lungs of ovalbumin (OVA)-sensitized and OVA-challenged (OVA-immunized) mice or human peripheral blood for in vivo and in vitro functional studies. Pulmonary basophils were adoptively transferred to OVA-sensitized hosts to assess airway inflammation in bronchoalveolar lavage fluid (BALF) and Th2 responses in lung explants and draining LNs. Basophils were co-cultured with effector T cells or Ag-specific naïve T cells alone or in combination with dendritic cells (DCs); IL-4 production was determined by flow cytometry and ELISA.

RESULTS

Basophils accumulated in lungs of OVA-immunized mice. Adoptive transfer of basophils to OVA-sensitized hosts enhanced lung IL-4 and IL-13 release while co-administration of OVA further aggravated airway inflammation and Th2 responses in LNs. Mechanistic in vitro studies revealed that pulmonary basophils interacted with lung CD4 effectors, in the absence of DCs, to increase T cell survival and Th2 cytokine expression at the single cell level but amplified OVA-loaded DC-driven Th2 differentiation. Finally, human basophils augmented in vitro IL-4 expression in effector memory CD4 T cells that include CRTH2(+) cells through IL-4 and TCR-independent pathways.

CONCLUSIONS

Basophils may worsen Th2 inflammatory disorders through direct interactions with pathogenic CD4 T cells as well as by enhancing DC-induced Th2 cell development.

Structure-activity relationship of antioxidants for inhibitors of linoleic acid hydroperoxide-induced toxicity in cultured human umbilical vein endothelial cells

Structure-activity relationship of antioxidants for the protective effects on linoleic acid hydroperoxide (LOOH)-induced toxicity were examined in cultured human umbilical vein endothelial cells. alpha-Tocopherol, 2,2,5,7,8-pentamethylchroman-6-ol, butylated hydroxytoluene, probucol, and fatty acid esters of ascorbic acid provided efficient protection against the cytotoxicity of LOOH in pretreatment, but phenols without alkyl groups at the ortho positions and hydrophilic antioxidants such as Trolox and ascorbic acid provided no protection. Probably, the effectiveness of the protection against cytotoxicity by these antioxidants dependsprimarily on their rate of incorporation into cells due to their lipophilicity, secondly on their antioxidant activity, and thirdly on their orientation in biomembranes. On the other hand, flavones, such as baicalein and luteolin bearing 3 to 5 hydroxyl groups, and flavonols showed a protective effect against LOOH cytotoxicity when added together with LOOH,but not by pretreatment. Among catechins, (+)-catechin and (-)-epigallocatechin gallate monoglucoside and diglucoside were effective in suppressing LOOH-induced cytotoxicity, but their effects were not so strong. The structure-activity relationship of flavonoids revealed the presence of either theortho-dihydroxy structure in the B ring of flavonoids or the 3-hydroxyl and 4-oxo groups in the C ring to be important forthe protective activities. Furthermore, coumarins such as esculetin containing the ortho catechol structure had protective effects in both pretreatment and concurrent treatment. These results suggest that ortho catechol moiety of flavonoids, catechins, and coumarins is an important structure in the protection against LOOH-induced cytotoxicity,and that the alkyl groups of monophenols are critical for protection.

Study of Pd-Ag dental alloys: examination of effect of casting porosity on fatigue behavior and microstructural analysis

The goals of this study were to investigate the fatigue limits of two Pd-Ag alloys (Ivoclar Vivadent) with differing mechanical properties and varying proportions of secondary alloying elements, examine the effect of casting porosity on fatigue behavior, and determine the effect of casting size on microstructures and Vickers hardness. The alloys selected were: IPS d.SIGN 59 (59.2Pd-27.9Ag-8.2Sn-2.7In-1.3Zn); and IS 64 (59.9Pd-26.0Ag-7.0Sn-2.8Au-1.8 Ga-1.5In-1.0Pt). Tension test bars, heat-treated to simulate dental porcelain application, were subjected to cyclic loading at 10 Hz, with R-ratio of -1 for amplitudes of compressive and tensile stress. Two replicate specimens were tested at each stress amplitude. Fracture surfaces were examined with a scanning electron microscope (SEM). Sectioned fatigue specimens and additional cast specimens simulating copings for a maxillary central incisor restoration were also examined with the SEM, and Vickers hardness was measured using 1 kg load. Casting porosity was evaluated in sectioned fatigue fracture specimens, using an image analysis program. The fatigue limit (2 × 10(6) loading cycles) of IS 64 was approximately 0.20 of its 0.2% yield strength, while the fatigue limit of d.SIGN 59 was approximately 0.25 of its 0.2% yield strength. These relatively low ratios of fatigue limit to 0.2% yield strength are similar to those found previously for high-palladium dental alloys, and are attributed to their complex microstructures and casting porosity. Complex fatigue fracture surfaces with striations were observed for both alloys. Substantial further decrease in the number of cycles for fatigue failure only occurred when the pore size and volume percentage became excessive. While the heat-treated alloys had equiaxed grains with precipitates, the microstructural homogenization resulting from simulated porcelain firing differed considerably for the coping and fatigue test specimens; the latter specimens had significantly higher values of Vickers hardness.

Furuncular myiasis: unusual case of African Dermatobia hominis

Human cutaneous myiasis is a common disease in endemic tropical zones. Increased international travel has produced increases in imported cases. We present an unusual patient with myiasis infestation of the leg caused by Dermatobia hominis, which manifested after returning from the Democratic Republic of Congo. This particular infestation has not been reported in Morocco prior to this case. Furuncular cutaneous miyasis must be considered when travellers exhibit draining nodules. Medical treatment consists of occlusion of the furuncular punctum with vaseline to stimulate extrusion of the larva or surgical debridement under local anesthesia.

Immature platelet fraction measurement in patients with chronic liver disease: a convenient marker for evaluating cirrhotic change

Platelet number is often used as an indicator of the severity of liver disease. Although inadequate thrombopoietin production and decreased platelet production have been proposed as major causes of cirrhotic thrombocytopenia, the underlying mechanism has not yet been fully clarified. We examined whether the measurement of the immature platelet fraction (IPF) in thrombocytopenic patients with liver dysfunction is useful as a rapid and noninvasive method for the differential diagnosis of chronic liver diseases. We examined 20 liver cirrhosis patients, 56 patients with chronic hepatitis, 9 patients with fatty liver, and 86 patients without liver disease. The percentage value of IPF (IPF%) was measured using an XE-2100 multiparameter automatic hematology analyzer. Using a receiver operating characteristic curve, we found diagnostic significance of the absolute platelet count and the absolute number of the IPF between cirrhotic patients and noncirrhotic patients, and developed a powerful multivariate discriminant analysis (MDA) function based on the platelet count and the IPF%. The diagnostic accuracy obtained by the MDA function was superior to that obtained by the absolute number of platelets and the IPF. We therefore propose our IPF% measurement for the diagnosis of liver cirrhosis.

Method to reconstruct exoplanetary spectrum

We present a method for spectroscopic observations of exoplanets. Coronagraphic image of a star-planet system and its objective spectra are observed simultaneously. Stellar image and objective spectrum without coronagraphic suppression are also obtained as reference. By convolution of the coronagraphic image with the reference stellar spectrum, pseudo-objective spectra are synthesized. The difference between the observed and the synthesized pseudospectra reveals the distinctive features of planetary spectrum. We carry out laboratory demonstration of the proposed technique and show that the planetary spectrum is reconstructed.

A case of Evans syndrome combined with systemic lupus erythematosus successfully treated with rituximab

Evans syndrome is a rare autoimmune disorder with unknown aetiology. Although corticosteroids and/or intravenous immunoglobulin (IVIG) are commonly used in its treatment, no standard strategy has been established. We report here a 44-year-old male with refractory Evans syndrome combined with systemic lupus erythematosus (SLE) who responded well to rituximab. He was admitted to our hospital with severe bleeding caused by worsening of Evans syndrome. Despite treatment with a high-dose corticosteroid and IVIG, his thrombocytopaenia and haemolytic anaemia did not improve. We started rituximab at a dose of 375 mg/m(2) once a week for a total of two doses. There was significant improvement in his thrombocytopaenia and anaemia 1 month after administration of rituximab. Although the total immunoglobulin G (IgG) level did not change, the titres of platelet-associated IgG (PA-IgG) and of an indirect antiglobulin test (IAT) decreased under the treatment with rituximab. It is suggested that rituximab would be a powerful candidate in the treatment of refractory Evans syndrome by depleting abnormal clone-producing autoantibody.

A new learning algorithm for the hierarchical structure learning automata operating in the nonstationary S-model random environment

An extended algorithm of the relative reward strength algorithm is proposed. It is shown that the proposed algorithm ensures the convergence with probability I to the optimal path under the certain type of nonstationary environment. Several computer simulation results confirm the effectiveness of the proposed algorithm.

Polarization degree analysis of objective spectrum in polarization differential stellar coronagraph

It is shown that the degree of polarization analysis is useful to find objective spectra of exoplanets immersed in noisy stellar spectra. We report the laboratory experiment of polarization differential objective spectroscopy with a four-quadrant polarization mask coronagraph, where partially polarized planetary signal is expected to be discerned from unpolarized stellar noise. The detection of the planet signal is impeded by the stellar noise remained after subtracting mutually orthogonally polarized components of light. We distinguish clearly the planetary spectrum by use of the degree of polarization. We also show the refinement of the spectrum of the planet model.

[Cutaneous blastomycosis revealing intravascular B-cell lymphoma: a case in Morocco]

Blastomycosis is a systemic fungal infection caused by a thermally dimorphic fungus, Blastomyces dermatitidis. The incidence in immunocompromised patients has increased in the last two decades. A 55-year-old man consulted for inflammatory nodules on the forearm. Biopsy of one nodules showed a pseudoepitheliomatous hyperplastic epidermis overlaying a dense agranulomatous inflammatory infiltrate containing free-formed ovoid bodies enclosing giant macrophageous cells. These findings were consistent with blastomycosis. After a month of treatment cutaneous lesions regressed partially but the patient's general status continued to deteriorate with the appearance of an edematous-ascitic syndrome and icterus. Laboratory blood testing demonstrated cholestasia and abdominal ultrasound showed hepatosplenomegaly. Needle liver biopsy revealed giant B-cell lymphomatous infiltration of the hepatic ducts. The patient's condition worsened rapidly and he died five months after diagnosis despite four rounds of chemotherapy. Blastomycosis is rare in Morocco. Primary infection is usually a pneumonic process. Isolated cutaneous infection is possible but uncommon. To our knowledge the association of blastomycosis and intravascular lymphoma has not been previously reported. In immunocompromised patients, clinical findings can be alarming and the outcome can be rapidly fatal.