Open-label phase II study of the efficacy of nivolumab for cancer of unknown primary

BACKGROUND

Cancer of unknown primary (CUP) has a poor prognosis. Given the recent approval of immune checkpoint inhibitors for several cancer types, we carried out a multicenter phase II study to assess the efficacy of nivolumab for patients with CUP.

PATIENTS AND METHODS

Patients with CUP who were previously treated with at least one line of systemic chemotherapy constituted the principal study population. Previously untreated patients with CUP were also enrolled for exploratory analysis. Nivolumab (240 mg/body) was administered every 2 weeks for up to 52 cycles. The primary endpoint was objective response rate in previously treated patients as determined by blinded independent central review according to RECIST version 1.1.

RESULTS

Fifty-six patients with CUP were enrolled in the trial. For the 45 previously treated patients, objective response rate was 22.2% [95% confidence interval (CI), 11.2% to 37.1%], with a median progression-free survival and overall survival of 4.0 months (95% CI, 1.9-5.8 months) and 15.9 months (95% CI, 8.4-21.5 months), respectively. Similar clinical benefits were also observed in the 11 previously untreated patients. Better clinical efficacy of nivolumab was apparent for tumors with a higher programmed death-ligand 1 expression level, for those with a higher tumor mutation burden, and for microsatellite instability-high tumors. In contrast, no differences in efficacy were apparent between tumor subgroups based on estimated tissue of origin. Adverse events were consistent with the known safety profile of nivolumab. No treatment-related death was observed.

CONCLUSIONS

Our results demonstrate a clinical benefit of nivolumab for patients with CUP, suggesting that nivolumab is a potential additional therapeutic option for CUP.

Multimodal imaging of indapamide-induced bilateral choroidal effusion: a case report

Background

Indapamide, a sulfonamide diuretic used to treat hypertension, has been reported to have ocular side effects of acute angle-closure glaucoma, transient myopia and choroidal effusion whose immediate etiology is uncertain. This report aims to clarify the nature of indapamide-induced edema of the entire eyeball using multimodal imaging.

Case presentation

A 60-year-old woman who was following a long-term carbohydrate-restricted diet and receiving oral treatment for hypertension was referred to our department for eye pain. Indapamide (1 mg daily) was prescribed for uncontrolled hypertension 5 days before her visit; she took the medication for only 3 days and then stopped due to dry eye. However, she began to feel eye pain the day after her last dose, and the pain gradually intensified. She experienced no decrease in visual acuity at the initial visit; however, an extremely shallow anterior chamber was observed in both eyes, along with a slight increase in intraocular pressure. For differential diagnosis, ocular manifestations were evaluated with wide-field fundus photography, optical coherence tomography (OCT) of both anterior and posterior segments, fluorescein / indocyanine green angiography, ultrasound biomicroscopy and head magnetic resonance, showing edema of the entire eyeball. Treatment with tropicamide and phenylephrine hydrochloride drops resulted in rapid recovery of the anterior chamber depth and disappearance of the choroidal effusion within 3 days.

Conclusions

Multimodal imaging is useful for diagnosing drug-induced choroidal effusion by evaluating ocular conditions before and after treatment.

A Case of Idiopathic Dense Vitreous Hemorrhage: Suspected Rupture of a Large Retinal Arterial Macroaneurysm on the Optic Disc

We report a novel case of vitreous hemorrhage associated with suspected rupture of 2-disc-diameter retinal arterial macroaneurysm on the optic disc. A 90-year-old woman presented with blurred vision (sudden onset) in her left eye. Examination of the fundus revealed acute onset vitreous hemorrhage of unknown origin without retinal detachment. She underwent vitrectomy, but after excision of the dense vitreous hemorrhage, a 2-disc-diameter hematoma appeared on the optic disc and was removed promptly. Because the bleeding at the base of the hematoma was of arterial origin and pulsating, the first vitrectomy could not achieve hemostasis. Five days after the first surgery, we performed a second vitrectomy. This revealed a subretinal hemorrhage along the superior and inferior arcade vessels and a macular hole, which was almost completely closed with an inverted internal limiting membrane flap. Unfortunately, the macular hole reopened 41 days after the second surgery. In patients presenting with only a large hematoma on the optic disc, it might be prudent to leave the hematoma. However, this large retinal arterial macroaneurysm was on a rare location on the optic disc, making it doubly difficult for the surgeons to diagnose and choose the best option intraoperatively. The differential diagnosis for dense vitreous hemorrhage of unknown origin should include a large retinal arterial macroaneurysm on the optic disc.

OPERA tau neutrino charged current interactions

The OPERA experiment was designed to discover the vτ appearance in a vμ beam, due to neutrino oscillations. The detector, located in the underground Gran Sasso Laboratory, consisted of a nuclear photographic emulsion/lead target with a mass of about 1.25 kt, complemented by electronic detectors. It was exposed from 2008 to 2012 to the CNGS beam: an almost pure vμ beam with a baseline of 730 km, collecting a total of 1.8·1020 protons on target. The OPERA Collaboration eventually assessed the discovery of vμ→vτ oscillations with a statistical significance of 6.1 σ by observing ten vτ CC interaction candidates. These events have been published on the Open Data Portal at CERN. This paper provides a detailed description of the vτ data sample to make it usable by the whole community.

AB0136 ASSESSING THE RELATIONSHIP AMONG OBESITY, GENETIC POLYMORPHISM, AND CLINICAL PARAMETERS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Several study suggested body mass index(BMI) may influence development of rheumatoid arthritis(RA). There are conflicting reports concerning the impact of high BMI on development of RA, but several reports of obese on drug resistance and functional impairment. The relationship of genetic polymorphism on obesity is unclear in RA.

Objectives:

To examine the relationship among BMI, genetic polymorphism of obesity, disease activity of RA, laboratory parameters, and therapeutic agent of RA.

Methods:

We have carried out a retrospective observational study by systematically analyzing medical records of total 289 patients diagnosed with RA in Shinko Hospital between March 2016 and December 2019. We also conducted genotyping single nucleotide polymorphisms (SNPs) including FTO (rs1558902 and rs9939609), UCP1 (rs1800592), ADR2(rs1042713) and ADR3(rs4994) after informed consent. Obesity was defined as BMI over than 25 and patients were divided between obese (“Ob”) and non-obese (“non-Ob”). These SNPs, DAS28CRP, laboratory parameters, methotrexate dose, use of biological DMARDs were compared between Ob and non-Ob patients.

Results:

Of these 289 patients, 82.7% was female, mean age was 61.9 years and BMI was 22.4. Univariate logistic regression showed differences (p<0.1) between Ob and non Ob groups in UCP1 gene mutation(63.6% vs 78%, P=0.018), DAS(2.24 vs 1.99, P=0.033),triglyceride abnormality(23.8% vs 9.3%, P=0.021), HDL(56 vs 71, P=0.00009), HbA1c abnormality(26.5% vs 12.1%, P=0.019),γGTP(32 vs 21, P=0.00037), ALP (253 vs 230, P=0.0058), ALT (26.5 vs 20, P=0.029),and MTX dose(6 vs 8, P=0.066). Multivariate logistic regression showed that Ob group was significantly associated with HDL(OR=0.976, 95%CI 0.958 to 0.995), UCP1 gene mutation(OR=0.446, 95%CI 0.202 to 0.984), γGTP(OR=2.321, 95%CI 1.269 to 4.245), and MTX dose(OR=0.866, 0.784 to 0.957).

Conclusion:

Obesity in patients with RA had significant positive correlation with γGTP, and negative correlation with HDL, UCP gene mutation and MTX dose.

Disclosure of Interests:

None declared

POS0868 THE FORMULA TO PREDICT TACROLIMUS CONCENTRATION ACCORDING TO GENOTYPING OF CYP3A5 IS USEFUL FOR EFFECTIVE TREATMENT IN INTERSTITIAL LUNG DISEASE WITH DERMATOMYOSITIS

Background:

Tacrolimus (TAC), an immunosuppressant, can be used in second-line maintenance therapy for interstitial lung disease (ILD) in patients with dermatomyositis (DM) [1]. Although some studies reported the clinical efficacy of initial high-trough levels of TAC in combination with GC and IVCY in induction therapy for severe DM-ILD [2], there have been no useful clinical tools for deciding suitable initial dose of TAC. Genotype of polymorphisms in cytochrome P450 (CYP) 3A5 enzyme was reported to play an important role in pharmacokinetics of TAC [3], and we made a formula for deciding initial dose of TAC according to CYP3A5 genotypes in our previous study.

Objectives:

In our previous study (retrospective study), we set the target trough according to the severity for nine DM-ILD patients, six of whom were CYP3A5 *3/*3 and investigated the dose of TAC that could attain the trough using their CYP3A5 genootyping. Using these results, we developed a formula for deciding initial daily dose of TAC (target trough*weight / [(151.1, if CYP3A5 *3/*3) or (86.5, if CYP3A5 *1 allele)]). In this study, we prospectively examined the usefulness and accuracy of this formula.

Methods:

We introduced TAC for new six DM-ILD patients who visited our hospital between November 2019 and May 2020 (prospective study). The starting dose of TAC was decided by using the formula. We assessed the association between predicted and observed trough concentration of TAC at first measurement date (from day 2 to day4), using linear regression analysis. We also assessed the days for attaining the target trough concentration between the patients using the formula (prospective group) and six patients with CYP3A5 *3/*3 (retrospective group).

Results:

CYP3A5 genotype of all six DM-ILD patients were *3/*3 and underwent the TAC treatment by using the formula. The predicted and observed trough concentration of first measurement date were significantly correlated in the patients (r 2= 0.897, p=0.0041) (Fig.1). Compared with our retrospective study, target trough was more quickly attained in patients of the prospective study (Fig.2).

Conclusion:

The formula which we made for attainment target trough concentration based on CYP3A5 genotype was useful for deciding the starting dose of TAC. We also showed that we could attain the target trough concentration at early stage of initial treatment by using the formula.

References:

[1]Oddis CV and Aggarwal R. Nat Rev Rheumatol 2018;14(5):279-89.

[2]Suzuka T et al. Int J Rheum dis 2019;22: 303-13.

[3]Y. Muraki et al. Exp Ther Med 2018;15:532-38.

Figure 1.

Correlation of predicted and observed tacrolimus trough concentration at first measurement in the prospective study

Figure 2.

Days to attain the target trough concentration of tacrolimus in the prospective group and the retrospective group

Disclosure of Interests:

None declared

Impact of photoreceptor density in a 3D simulation of panretinal laser photocoagulation

Background

During panretinal photocoagulation (PRP), the outer retina, especially the photoreceptors, are destroyed. During such procedures, the impact of the retinal photocoagulation, which is performed in the same photocoagulated area, may change if it is applied to different locations with different photoreceptor densities. Thus, we aimed to evaluate the influence of photoreceptor density on PRP.

Methods

We constructed a three-dimensional (3D) average distribution of photoreceptors with 3D computer-aided design (CAD) software using previously derived photoreceptor density data and calculated the number of photoreceptors destroyed by scatter PRP and full-scatter PRP (size 400-μm on the retina, spacing 1.0 spot) using a geometry-based simulation. To investigate the impact of photoreceptor density on PRP, we calculated the ratio of the number of photoreceptors destroyed to the total number of photoreceptors, termed the photoreceptor destruction index.

Results

In this 3D simulation, the total number of photoreceptors was 96,571,900. The total number of photoreceptors destroyed by scatter PRP and full-scatter PRP were 15,608,200 and 19,120,600, respectively, and the respective photoreceptor destruction indexes were 16.2 and 19.8%, respectively.

Conclusions

Scatter PRP is expected to have 4/5 of the number of photoreceptors destroyed by full-scatter PRP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01945-z.

N-acetylcysteine attenuates PGE2 and ROS production stimulated by 4-META/MMA-based resin in murine osteoblastic cells

This study examined the effects of N-acetylcysteine (NAC) on the inflammatory reactions of murine osteoblastic cells cultured on the 4-methacryloxyethyl trimellitate anhydride/methyl methacrylate (4-META/MMA)-based resin. Superbond C&B (SB) was used as the 4-META/MMA-based resin and placed in a 48-well cell culture plate. The cells were cultured in αMEM (control) as well as on SB and SB in αMEM with NAC (SB+NAC). They were examined using the WST-1 proliferation assay, real-time PCR, enzyme-linked immunosorbent assay (ELISA), intracellular reactive oxygen species (ROS) measurements, and cellular glutathione (GSH) detection. COX-2 and IL-6 gene expressions were upregulated in SB; however, they were suppressed by NAC. Furthermore, PGE₂ production in the culture medium was increased in SB, whereas NAC decreased the PGE₂ production. NAC lowered the ROS level in the culture medium and significantly increased the intracellular GSH level. The present in vitro study demonstrated that NAC might be effective for dental material detoxification.

Conduction gaps after pulmonary vein isolation due to high contact force ablation in patients with atrial fibrillation

Background

Catheter ablation for atrial fibrillation (AF) with high contact force (CF) has been reported to lead to the gaps after pulmonary vein isolation (PVI), and the appearance of the gaps depends on the site in the left atrium (LA).

Purpose

The aim of this study is to clarify the relationship between the gaps appearance and high CF.

Methods

In the clinical study, 74 consecutive patients (39 males, age 71±9, 46 with paroxysmal AF) underwent conventional PVI with a point-by-point radiofrequency (RF) ablation using a CF sensing catheter (TactiCath SETM). RF energy (J), number of RF point, Lesion index (LSI), force-time integral (FTI), average CF (g), and the degree of LA depression with high CF were evaluated. In the experimental study (figure), the relationship between the ablation area and the degree of depression with high CF using bovine left ventricular wall.

Results

In the clinical study, the gaps were found in 175 of 1182 sites after first path PVI ablation. The CF in the gap sites was higher than without the gap sites in RPV roof, anterior RSPV and anterior RPV carina (18.9±6.8 vs 15.0±5.7g p=0.0262, 26.4±11.6 vs 19.5±6.0g p=0.0029, 22.7±6.4 vs 19.1±5.5g, p=0.0161). Meanwhile, there were no differences in RF energy, number of RF point, LSI, FTI. High CF (≥30g) showed a depression of 3 mm or more in only RPV roof and anterior RPV (figure). In the experimental study, the ablation range narrowed as the indentation deepened with more than 30g CF (r=0.6417, p=0.0625).

Conclusion

Catheter ablation for AF with high contact force might lead to the gaps in RPV roof and anterior RPV site by the reduction of the ablation area due to depression caused by the pressure.

Extension of each contact force

Funding Acknowledgement

Type of funding source: None

Sex-related differences in geometry, plaques and shear stress related plaque-progression in human coronary arteries

Background

Atherosclerosis manifests itself differently in women compared to men. Since the pathophysiology of atherosclerotic plaques is known to be related to endothelial shear stress (ESS), it was hypothesized that female compared to male coronary arteries demonstrate a different i) ESS and ii) ESS related plaque progression.

Methods

1183 coronary arteries (male/female:944/239) from the PREDICTION trial were studied for differences in vessel geometry (plaque area (PA) and lumen area (LA)), hemodynamic parameters (flow, minimal ESS over 90 degree arc (minESS) and maximal ESS over 90 degree arc (maxESS)) and ESS related plaque progression (1 year follow up) measured as change in maximal plaque thickness and plaque burden comparing female to male arteries. Arterial geometry and ESS measures were derived from IVUS-based vascular profiling and reported per 3 mm segments. For plaque progression studies minESS was subdivided into low, mid and high (&lt;1,1–1.7,&gt;1.7 Pa). To test statistical differences univariate anova or linear mixed models were used.

Results

13030 3mm-segments (m/f: 10.465/2565) were analyzed. Female compared to male coronary arteries were smaller and presented with less plaque area (Table I). No differences in average ESS, minESS and maxESS were found for male versus female coronary arteries, partly explained by the lower flows in female arteries (Table I). The ESS-related plaque growth showed for both sexes an significant inverse relationship between maximal wall thickness (Figure, left) and plaque burden (Figure, right) and the three minESS categories. However, ESS-related plaque growth was not different for male vs females.

Conclusion

Our data demonstrated that vessel and plaque size are smaller in female compared to male coronary arteries. However, ESS and ESS related plaque progression were not different.

Shear stress related plaque progression

Funding Acknowledgement

Type of funding source: None

Coronary plaque natural history displays significant longitudinal heterogeneity along the length of individual coronary plaques

Background

The natural history of plaque growth is, among other systemic risk factors, related to the blood flow induced local shear stress. Especially at regions of low shear stress plaques are initiated. Upon plaque encroachment into the lumen, plaques will be exposed to high shear stress. Interestingly, it has been observed that individual plaques are very heterogeneous regarding the local shear stress exposure and remodeling patterns along the plaque length. However no information is available on the spatial heterogeneity of temporal changes in plaques burden. We studied the longitudinal spatial heterogeneity of plaque burden progression, regression, quiescence in human coronary plaques.

Methods

591 coronary arteries from 302 patients with coronary artery disease who presented with an acute coronary syndrome from the PREDICTION study were investigated for local plaque progression, regression, quiescence patterns after 6–10 months follow up. Arterial geometry was derived from angiography/IVUS-based vascular profiling and reported in 3 mm segments. Plaques were defined as &gt;3 consecutive segments with maximal wall thickness&gt;0.5 mm. Plaque progression was defined as &gt;5% increase, regression as &lt;−5% decrease, and quiescence as no change in plaque burden (plaque area/ total vessel area * 100%). Logistic mixed model regression analysis was performed with plaque progression features as outcome and plaque length as independent variable with vessel as random factor to account for clustering of the data.

Results

5658 3mm-segments of 661 plaques were analyzed. Plaque burden changes over time ranged from −22% to +20%, with an average of −0.4%±4% which was not significant different from 0. Among all plaques, 56% showed segments with plaque progression of more than 5%, 60% with plaque regression (&lt;−5%) and 96% of the plaques had segments that did not change over time (quiescence). On average, 17% of the plaque length displayed plaque progression, 20% regression and 63% was quiescent. The presence and number of features (progression, regression, quiescence) within the plaque were significantly related to the plaque length (figure).

Conclusion

Plaques are very heterogeneous in plaque progression patterns. Most of the plaques show within the plaque length simultaneously more than one plaque progression feature (segments that do not change in plaque burden, segments that regress or progress). The number of observed plaque progression features was related to the plaque length.

Funding Acknowledgement

Type of funding source: None

Chronotropic incompetence and exercise capacity after mitral valve surgery: the importance of blood hemoglobin level

Background

Chronotropic incompetence (CI) is sometimes observed during exercise training of cardiac rehabilitation in patients with cardiac surgery, however, little is known concerning the differences between patients with mitral valve (MV) and aortic valve (AV) surgery.

Purpose

Because the possibility exists that cardiac sympathetic nerves might be impaired by left atrium incision, we hypothesized that the incidence of CI was higher in patients with MV surgery (Mitral Valve Replacement and Mitral Valvuloplasty) as compared with patients with AV surgery (Aortic Valve Replacement). And if so, which factor determines the exercise capacity of patients after MV surgery. We thus aimed this study to elucidate the hypothesis with cardiopulmonary exercise testing (CPX).

Methods

We performed CPX by ramp loading with ergometer exercise in total 61 patients who had undergone elective cardiac valve operation (25 patients with MV surgery, age 59.2±9.9 years; 36 patients with AV surgery, age 64.6±12.3 years). We analyzed chronotropic response index (CRI), peak oxygen uptake (peak VO2/W), anaerobic threshold (AT), and peak oxygen pulse (peak VO2/HR) with CPX, and blood hemoglobin concentration (Hb).

Results

The value of CRI was significantly decreased in the patients with MV surgery compared with those with AV surgery (MV; 0.19±0.10 vs. AV; 0.41±0.17, p&lt;0.001). Peak VO2, peak VO2/HR and Hb were not significantly different between patients with MV and those with AV surgery. Patients with MV surgery showed correlations between peak VO2 and Hb (r=0.45, p&lt;0.05), AT and Hb (r=0.52, p&lt;0.01), and a strong correlation between peak VO2 and peak VO2/HR (r=0.63, p&lt;0.001), but not in those with AV surgery.

Conclusions

The present study demonstrated that higher incidence of CI was shown in patients with MV surgery as compared with those with AV surgery. The exercise capacity of patients with MV surgery was determined by peak VO2/HR and Hb. These results suggest that 1) left atrium incision impairs cardiac sympathetic nerves and causes CI, 2) peak VO2/HR which is consisted of arterio-venous oxygen difference and Hb is critical indicator for exercise capacity in patients with MV surgery with CI.

Main results

Funding Acknowledgement

Type of funding source: None