Early on-treatment tumor growth rate (EOT-TGR) determines treatment outcomes of advanced non-small-cell lung cancer patients treated with programmed cell death protein 1 axis inhibitor

BACKGROUND

Tumor growth rate (TGR), denoted as percentage change in tumor size per month, is a well-established indicator of tumor growth kinetics. The predictive value of early on-treatment TGR (EOT-TGR) for immunotherapy remains unclear. We sought to establish and validate the association of EOT-TGR with treatment outcomes in patients with advanced non-small-cell lung cancer (aNSCLC) undergoing anti-PD-1/PD-L1 (programmed cell death protein 1/programmed death-ligand 1) therapy.

PATIENTS AND METHODS

This bicenter retrospective cohort study included a training cohort, a contemporaneously treated internal validation cohort, and an external validation cohort. Computed tomography images were retrieved to calculate EOT-TGR, denoted as tumor burden change per month during a period between baseline and the first imaging evaluation after immunotherapy. Kaplan-Meier methodology and Cox regression analysis were conducted for survival analyses.

RESULTS

In the pooled cohort (n = 172), 125 patients (72.7%) were males; median age at diagnosis was 58 (range 28-79) years. Based on the training cohort, we determined the optimal cut-off value for EOT-TGR as 10.4%/month. Higher EOT-TGR was significantly associated with inferior overall survival [OS; hazard ratio (HR) 2.93, 95% confidence interval (CI) 1.47-5.83; P = 0.002], worse progression-free survival (PFS; HR 2.44, 95% CI 1.46-4.08; P = 0.001), and lower objective response rate (3.3% versus 20.9%; P = 0.040) and durable clinical benefit rate (6.7% versus 41.9%; P = 0.001). Results were reproducible in the two validation cohorts for OS and PFS. Among 43 patients who had a best response of progressive disease in the training cohort, those with high EOT-TGR had worse OS (HR 2.64; P = 0.041) and were more likely to progress due to target lesions at the first tumor evaluation (85.2% versus 0.0%; P <0.001).

CONCLUSIONS

Higher EOT-TGR was associated with inferior OS and immunotherapeutic response in patients with aNSCLC undergoing anti-PD-1/PD-L1 therapy. This easy-to-calculate radiologic biomarker may help evaluate the abilities of immunotherapy to prolong survival and assist in tailoring patients' management.

TRIAL REGISTRATION

ClinicalTrials.govNCT04722406; https://clinicaltrials.gov/ct2/show/NCT04722406.

Noise-resilient edge modes on a chain of superconducting qubits

Inherent symmetry of a quantum system may protect its otherwise fragile states. Leveraging such protection requires testing its robustness against uncontrolled environmental interactions. Using 47 superconducting qubits, we implement the one-dimensional kicked Ising model, which exhibits nonlocal Majorana edge modes (MEMs) with ℤ 2 parity symmetry. We find that any multiqubit Pauli operator overlapping with the MEMs exhibits a uniform late-time decay rate comparable to single-qubit relaxation rates, irrespective of its size or composition. This characteristic allows us to accurately reconstruct the exponentially localized spatial profiles of the MEMs. Furthermore, the MEMs are found to be resilient against certain symmetry-breaking noise owing to a prethermalization mechanism. Our work elucidates the complex interplay between noise and symmetry-protected edge modes in a solid-state environment.

POS1247 THE EFFECT OF IMMUNOSUPPRESSIVE AGENTS ON ANTIBODY FORMATION AFTER COVID-19 VACCINATION IN RHEUMATOID ARTHRITIS PATIENTS

Background

There is still controversy about the efficacy of COVID-19 vaccination and its extent in lowering immunogenicity of Rheumatoid Arthritis (RA) patients. The guideline in whether immunosuppressive agents need to be discontinued before the vaccination is continuously updated because it is considered to lower immunogenicity. Furthermore, there is great discussion on the effectiveness of the COVID-19 booster vaccine and interest in antibody generation in different types of vaccine, as in South Korea there are many patients who were prescribed the mRNA booster vaccine after two doses of ChAdOx1-S nCoV-19 vaccine.

Objectives

Thus, we investigated the differences of antibody production between patients who received only two doses of ChAdOx1-S nCoV-19 and those who received the mRNA booster vaccine. Also, antibody production under different types of immunosuppressive agents was analyzed.

Methods

From October 14, 2021 to January 21, 2022 at a tertiary referral center, two patient groups diagnosed with RA were studied prospectively; one group that completed 1st and 2nd doses of ChAdOx1-S nCoV-19 vaccine, second group that completed mRNA booster vaccine as well as two doses of ChAdOx1-S nCoV-19 vaccine. SARS-CoV-2 antibody testing on the semiquantitative anti-SARS-CoV-2 S enzyme immunoassay was done, and differences in antibody titers were analyzed in patients who received different immunosuppressive agents such as csDMARD, TNF inhibitor, JAK inhibitor, Tocilizumab, Abatacept and Corticosteroid. Statistical analysis with a multivariate logistic regression model was performed.

Results

In a total of 261 patients, 153 patients had completed two doses of ChAdOx1-S nCoV-19, 108 patients had completed third mRNA booster vaccine. Anti-SARS-CoV-2 RBD antibody positive rate (titer>0.8U/mL) was 97%(149/153) and 99%(107/108) respectively, and only 5 patients showed negative result. In the aspect of high antibody titer(>250U/mL), which is the upper limit of the RBD antibody immunoassay, the result showed rate of 31% (47/153) in the non-booster group and 94%(102/108) in the booster group respectively.

Among the different immunosuppressive agents and other clinical aspects, multivariate analysis revealed that corticosteroid use (OR 0.91; 95% CI: 0.86-0.98), older age(OR 4.33; 95% CI: 1.34-13.91), and male gender(OR 0.35; 95% CI 0.16-0.75) were significantly associated with low rate of high antibody titer.

Furthermore, out of 14 patients who underwent antibody test twice before and after the mRNA booster vaccine, other than four patients who already showed high titer of >250U/mL before the mRNA booster vaccine, 10 patients showed an increase in titer after the booster vaccine and 7 patients were acquired high titer of >250U/mL.

Figure 1.

Anti-SARS-CoV RBD antibody titer of two groups

Table 1.

Analysis of immunosuppressive agents and other clinical aspects for high antibody titer(>250U/mL) after two doses of ChAdOx1-S nCoV-19

Univariate analysisMultivariate analysisParameterOR95% CIp valueOR95% CIp valueClinical features Age0.9170.860-0.9780.0080.9170.857-0.9810.012 Sex3.6741.206-11.1910.0224.3301.348-13.9120.014 DAS 281.1440.670-1.9500.622 Duration0.9300.830-1.0430.214Medications csDMARD1.2730.639-2.5331.273 TNF inhibitor2.2110.795-6.1450.128 JAK inhibitor0.6650.275-1.6070.365 Abatacept0.3680.038-3.6020.391 Tocilizumab1.2640.438-3.6480.665 Corticosteroid0.4720.235-0.9490.0350.3490.163-0.7480.007Medication dose Methotrexate0.9930.919-1.0720.855 Corticosteroid0.8490.719-1.0030.054

Conclusion

Anti-SARS-CoV-2 RBD antibody positive rate was 97% or more regardless of the mRNA booster vaccination. However, patients who received the mRNA booster vaccine after two doses of ChAdOx1-S nCoV-19 vaccine showed high antibody titer (>250U/mL) three times more than those who did not receive the booster shot.

Our findings also showed that corticosteroid use, old age, and male gender is significantly associated with low rate of acquiring high antibody titer.

Disclosure of Interests

None declared

AB0476 PREDICTIVE FACTORS FOR THE DEVELOPMENT OF SYSTEMIC LUPUS ERYTHEMATOSUS IN PATIENTS WITH IMMUNE THROMBOCYTOPENIA

Background

Patients with immune thrombocytopenia (ITP) have a risk of developing systemic lupus erythematosus (SLE). We sought to examine the clinical characteristics of patients with primary ITP who later developed SLE, and identified the risk factors for the development of SLE.

Objectives

We retrospectively examined patients who were diagnosed with primary ITP at a tertiary hospital between August 2001 and November 2019. We compared the clinical characteristics according to the development of SLE. Logistic regression analysis was performed to identify the factors associated with the development of SLE.

Methods

Of 130 patients with primary ITP, 10 (7.7%) were later diagnosed with SLE during follow-up (median, 30 months [IQR, 15.5–105]). The presence of skin bleeding, organ bleeding, lymphopenia, anemia, and positive antinuclear antibody (ANA) titer (> 1:160) were more common among patients who later developed SLE than did those who did not develop SLE. Multivariate analysis showed that young age (< 40 years; odds ratio [OR], 8.359 [95% confidence interval (CI), 1.230–56.793]; p = 0.033), organ bleeding (OR, 18.349 [95% CI, 2.771–121.517]; p = 0.003), and ANA positivity (>1:160; OR, 7.692 [95% CI, 1.482–39.910]; p = 0.015) were significantly associated with the development of SLE.

Results

Young age (< 40 years), organ bleeding, and ANA positivity (> 1:160) were risk factors for the development of SLE in patients with primary ITP.

Conclusion

These results suggest that continued follow-up for the detection of SLE development is needed for patients with ITP, particularly those with young age, ANA positivity, or organ bleeding.

References

[1]Zhu, Fang-Xiao, et al. “Risk of systemic lupus erythematosus in patients with idiopathic thrombocytopenic purpura: a population-based cohort study.” Annals of the rheumatic diseases 79.6 (2020): 793-799.

Table 1.

Factors associated with the development of SLE in patients with primary ITP

UnivariateMultivariateOR95% CIP valueOR95% CIP valueYoung agea5.4441.332–22.2500.0188.3591.230–56.7930.033Female4.3330.530–35.4220.17BMI0.8730.717–1.0700.20Skin bleeding8.4191.034–68.5330.046Mucosa bleeding1.2500.247–6.3300.79Organ bleeding14.8643.633–60.815< 0.00118.3492.771–121.5170.003Platelet counts0.9110.828–1.0020.06ANA positivityb16.5003.984–68.341< 0.0017.6921.482–39.9100.015Neutropeniac2.1110.229–19.4990.51Lymphopeniad4.8461.189–19.7590.028Anemiae10.1182.044–50.0910.005

SLE: systemic lupus erythematosus, ITP: immune thrombocytopenia, BMI: body mass index, ANA: antinuclear antibody, OR: odds ratio, CI: confidence interval.

aYoung age = age < 40 years

bANA positivity ≥ 1:160

cNeutropenia = Absolute neutrophil count < 1500 μL

dLymphopenia = Absolute lymphocyte count < 1500 μL

eAnemia = Hemoglobin < 12 g/dL

Disclosure of Interests

None declared

AB0456 DISEASE FLARE OF SYSTEMIC LUPUS ERYTHEMATOSUS IN PATIENTS WITH END-STAGE RENAL DISEASE ON DIALYSIS

Background

The systemic lupus erythematosus (SLE) disease activity in patients with lupus nephritis (LN) generally declines after the initiation of renal replacement therapy (RRT); this is known as the “burn out” phenomenon that possibly occurs due to the suppression of cellular and humoral immunity in the end-stage renal disease (ESRD) state and elimination of disease pathogenic factor by dialysis [1-4]. However, several studies showed that SLE flares could occur even during RRT [5-8]. Nevertheless, the details of disease flares of SLE in patients under dialysis have not been studied yet.

Objectives

This study aimed to investigate the clinical features, risk factors, and treatment details of SLE patients experiencing disease flare under RRT.

Methods

The medical records of SLE patients who received dialysis at two tertiary referral hospitals in Seoul and Ulsan, South Korea were reviewed. All patients in this study were either clinically or histologically diagnosed with LN

Results

Of a total of 121 patients with SLE on dialysis, 96 (79.3%) were on hemodialysis (HD) and 25 (20.6%) were on peritoneal dialysis (PD). During a median follow-up of 45 months (IQR, 23–120) after the initiation of dialysis, 32 (26.4%) patients experienced SLE flare (HD, n = 25; PD, n = 7). The most common features of SLE flare were hematologic (40.6%) and constitutional manifestations (40.6%). Treatments for disease flares were based on corticosteroids, and 11 (34.3%) patients required additional immunosuppressants including cyclophosphamide and mycophenolate mofetil. There was no case of severe adverse events related to medication. non-renal SLE Disease Activity Index (SLEDAI) score before dialysis initiation (HR 1.235; 95% CI, 1.122–1.359; P = 0.001) was a significant risk factor for disease flare during dialysis.

Table 1.

Multivariable analysis of factors associated with SLE flare under dialysis

Hazard ratio95% CIP-valueNon-renal SLEDAI at the initiation of dialysis1.2351.122–1.3590.001Hematologic manifestation prior to dialysis1.2560.690–2.8260.150Cumulative amount of steroid during 1 year prior to the initiation of dialysis1.0400.995–1.0870.086Dialysis modality: hemodialysis0.7660.262–2.2430.630

Conclusion

More than one-quarter of SLE patients experienced disease flare during dialysis, which most commonly had hematologic manifestations. Continued follow-up and appropriate treatments including immunosuppressants should be considered for patients with SLE under dialysis.

References

[1]Coplon NS, Diskin CJ, Petersen J, Swenson RS. The Long-Term Clinical Course of Systemic Lupus Erythematosus in End-Stage Renal Disease. New England Journal of Medicine 1983;308:186-90.

[2]Lee P-T, Fang H-C, Chen C-L, Chiou Y-H, Chou K-J, Chung H-M. Poor prognosis of end-stage renal disease in systemic lupus erythematosus: a cohort of Chinese patients. Lupus 2003;12:827-32.

[3]Pahl MV, Gollapudi S, Sepassi L, Gollapudi P, Elahimehr R, Vaziri ND. Effect of end-stage renal disease on B-lymphocyte subpopulations, IL-7, BAFF and BAFF receptor expression. Nephrology Dialysis Transplantation 2010;25:205-12.

[4]Ribeiro FM, Fabris CL, Bendet I, Lugon JR. Survival of lupus patients on dialysis: a Brazilian cohort. Rheumatology 2013;52:494-500.

[5]Okano K, Yumura W, Nitta K et al. Analysis of Lupus Activity in End-Stage Renal Disease Treated by Hemodialysis. Internal Medicine 2001;40:598-602.

[6]Barrera-Vargas A, Quintanar-Martínez M, Merayo-Chalico J, Alcocer-Varela J, Gómez-Martín D. Risk factors for systemic lupus erythematosus flares in patients with end-stage renal disease: a case–control study. Rheumatology 2015:kev349.

[7]Cucchiari D, Graziani G, Ponticelli C. The dialysis scenario in patients with systemic lupus erythematosus. Nephrology Dialysis Transplantation 2014;29:1507-13.

[8]Kang S-H, Chung B-H, Choi S-R et al. Comparison of Clinical Outcomes by Different Renal Replacement Therapy in Patients with End-Stage Renal Disease Secondary to Lupus Nephritis. The Korean Journal of Internal Medicine 2011;26:60.

Disclosure of Interests

None declared

AB1273 MACROPHAGE ACTIVATION SYNDROME IN RHEUMATIC DISEASE: CLINICAL CHARACTERISTICS AND PROGNOSIS OF 20 PATIENTS

Background

Macrophage activation syndrome (MAS) is a hyperinflammatory condition that is known to be secondary hemophagocytic lymphohistiocytosis (HLH) in patients with rheumatic disease.

Objectives

The aim of study was to evaluate the clinical manifestations and outcomes in patients with MAS with rheumatic disease.

Methods

We performed a retrospective study of 20 adult patients who were diagnosed with MAS from 2012 to 2020. MAS was classified according to the HLH-2004 criteria. Patients’ information, including clinical features, laboratory findings, and treatment regimens, was collected, and the overall survival rate was estimated by the Kaplan–Meier method.

Results

Twenty patients (18 women, 35.6 ± 18.3 years) who met the HLH-2004 criteria also fulfilled the 2016 EULAR/ACR/PRINTO classification criteria for MAS, and HScore was higher than 169 (median, 238.5). Fourteen patients with systemic lupus erythematosus and 6 patients with adult-onset Still’s disease were included. All patients were treated initially with corticosteroids, and 16 patients required additional immunosuppressants. The overall survival at 3 and 6 months was 75.2% and 64.3%. In survivors, renal impairment was less common (23.1% versus 42.9%, p = 0.007), the levels of AST (202.0 versus 72.0 IU/L, p = 0.006) and LDH (1144.0 versus 343.0IU/L, p = 0.001), and platelet count (90.0 versus 46.0 × 109/L, p = 0.016) were higher in compared to non-survivors. Nine patients had opportunistic infections, five of whom died during admission.

Conclusion

The mortality of patients with MAS remains high. Renal impairment, levels of AST and LDH, and platelet count might be associated with prognosis.

Table 1.

Treatments and management characteristics of patients with MAS

No.Age/sexDiseaseDisease duration (months)1st Treatment (corticosteroids)2nd Treatment3rd TreatmentCombined infectionAlive/dead119/FSLE11 mg/kgIVIG + PPTCZ, RTXBacteremiaDead220/MSLE01 mg/kg---Alive320/FAOSD11 mg/kgVP16--Alive422/FSLE1100 mgIVIG + PP-PneumoniaDead522/FAOSD0500 mgIVIG--Alive623/FSLE1821 mg/kg---Alive723/FSLE411 mg/kg---Alive830/FSLE1461 mg/kgIVIGCsA-Alive932/FSLE1271 mg/kgIVIG + PPCsA, TCZPneumoniaAlive1035/FAOSD01 mg/kgCsA-Viral infectionAlive1137/FSLE651 mg/kgCsA, VP16-BacteremiaAlive1238/FSLE01 mg/kgIVIG + PPRTX-Dead1340/FAOSD00.5 mg/kgCsA--Alive1443/FSLE601 mg/kgIVIG + PPTCZ, RTX, CsA,PCP,DeadVP16, IFXViral infection1549/FSLE01 mg/kgCYC-BacteremiaAlive1651/FAOSD01 mg/kg---Alive1757/FSLE01 mg/kgIVIG + PPCsA, VP16Fungal infectionDead1861/FSLE21 mg/kgIVIG + PPTCZ-Dead1968/FSLE21 mg/kgIVIG + PPCsAFungal infectionAlive2070/MAOSD01 mg/kgIVIG + PPCsA, VP16Fungal infectionDead

SLE: Systemic lupus erythematosus, IVIG: Intravenous immunoglobulin, PP: Plasmapheresis, TCZ: Tocilizumab, RTX: Rituximab, AOSD: Adult-onset still’s disease, VP16: Etoposide, PCP: Pneumocystis pneumonia, CsA: Cyclosporin, IFX: Infliximab, MCTD: Mixed connective tissue disease.

Disclosure of Interests

None declared

POS0762 LONG-TERM RENAL OUTCOMES OF PATIENTS WITH NON-PROLIFERATIVE LUPUS NEPHRITIS

Background

Although proliferative (class III or IV) lupus nephritis (LN) is the most common finding in the classification of LN, pure membranous (class V) or mesangial (class I or II) LN can occur as a form of LN. Even though non-proliferative LN (class I, II, or V) is a less severe form with good outcomes, data on long-term renal prognosis are limited.

Objectives

This study investigated the long-term outcomes and prognostic factors in non-proliferative LN.

Methods

We retrospectively reviewed the medical records of patients with systemic lupus erythematosus who were diagnosed with LN class I, II, V or II+IV by kidney biopsy between 1997 and 2021 at a tertiary referral center. Clinical and laboratory data were compared between patients with and without poor renal outcomes. Poor renal outcome was defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m2 or death due to renal cause. Univariate and multivariate analyses were performed with the Cox proportional hazard model to identify the factors associated with poor renal outcomes.

Results

We included 71 patients with non-proliferative LN (4: class I; 17: class II; 48: class V, 17; 2: class II+V). Median follow-up duration was 103 months (interquartile range 27–185) and the overall rate of poor renal outcomes at last follow-up was 29% (21/71), including end-stage renal disease (n=2) and renal death (n=1).

Univariate analysis indicated that older age (HR 1.05; 95% CI: 1.00–1.09), low eGFR (HR 0.97; 95% CI: 0.95–0.99) and failure to reach complete remission at 6 months (HR 0.332; 95% CI: 0.12–0.92) were significantly associated with poor renal outcomes. Multivariate analysis revealed that low eGFR at 6 months (HR 0.97; 95% CI: 0.95–0.99) was significantly associated with poor renal outcomes.

Figure 1.

Renal outcomes at last follow up

eGFR, estimated glomerular filtration rate (ml/min/1.73m2)

Table 1.

Univariate and multivariate Cox proportional hazard regression analyses of the factor associated with poor renal outcomes

ParameterUnivariate analysisMultivariate analysisHR95% CIp valueHR95% CIp valueClinical features Age1.0461.003-1.0910.0361.0020.960-1.0470.921 Sex1.6540.375-7.2980.506 SLEDAI1.0360.965-1.1120.327 Extra renal SLEDAI1.0380.971-1.110.272Renal profiles eGFR at LN diagnosis0.9930.976-1.0110.456 Proteinuria at LN diagnosis1.0001.000-1.0000.444 > 1g/24 hours0.6690.243-1.8410.437  > 3g/24 hours0.6240.229-1.6990.356 eGFR at 6M0.9670.948-0.9860.0010.9680.948-0.9880.002 eGFR at 12M0.9640.947-0.9810.000 Complete remission at 6M0.3320.119-0.9240.0350.5530.179-1.7070.303 Complete remission at 12M0.6670.232-1.9140.451 Transformation1.2460.423-0.7010.692Laboratory data Anti-dsDNA1.0010.999-1.0030.196 C31.0201.000-1.0410.051 C41.0270.969-1.0890.367 Albumin1.1800.661-2.1090.576ClassificationaClass I0.8020.102-6.3030.834Class II1.2980.412-4.0880.656Class V0.8870.308-2.5570.824Class II+V0.0480.000-16850.837Medicationsb ACEi/ARB1.6520.603-4.5280.329 Hydroxychloroquine1.3260.414-4.2420.635 Corticosteroid1.1860.154-9.1080.870 CNI2.4390.464-12.8240.292 MMF3.7880.959-14.9650.057  　 AZA0.5890.133-2.6110.486

a LN classifications were based on the International Society of Pathology/Renal Pathology Society (ISN/RPS) classification.

b Medications maintained at least one year since Lupus Nephritis diagnosis.

HR, hazard ratio; 95% CI, 95% confidence interval; SLEDAI, systemic lupus erythematosus disease activity index; eGFR, estimated glomerular filtration rate; LN, lupus nephritis; anti-dsDNA, anti-double strand DNA; C3/C4; complement 3/4; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CNI, carcineurin inhibitor; MMF, mycophenolate mofetil; AZA, azathioprine.

Conclusion

Poor renal outcomes occurred in approximately 30% of patients with non-proliferative LN (class I, II or V) after long-term follow-up.

Our findings suggest that more active management may be needed for non-proliferative LN, particularly in patients with low eGFR at 6 months.

Disclosure of Interests

None declared

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Association of Total Thyroidectomy or Thyroid Lobectomy With the Quality of Life in Patients With Differentiated Thyroid Cancer With Low to Intermediate Risk of Recurrence

IMPORTANCE

Owing to the good prognosis of differentiated thyroid cancer (DTC), guidelines recommend total thyroidectomy (TT) or thyroid lobectomy (TL) as surgical treatment for DTC with low to intermediate risk of recurrence. However, the association of these surgeries with the health-related quality of life (HRQOL) of patients with DTC with low to intermediate risk of recurrence is unclear.

OBJECTIVE

To longitudinally compare the HRQOL of patients with DTC undergoing different surgeries.

DESIGN, SETTING, AND PARTICIPANTS

This prospective observational longitudinal cohort study enrolled patients diagnosed with DTC with low to intermediate risk of recurrence at the First Affiliated Hospital, Sun Yat-sen University, China, from October 1, 2018, to September 31, 2019. Eligible patients were categorized into TL and TT groups according to the surgery they underwent. They were evaluated preoperatively and followed up at 1, 3, 6, and 12 months postoperatively using 3 HRQOL-related questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, version 3.0; Hospital Anxiety and Depression Scale; and Thyroid Cancer-Specific Quality of Life Questionnaire); serum thyrotropin levels, complications, and patient satisfaction were also monitored. Data were analyzed to compare the HRQOL of patients undergoing different surgeries at different time points.

EXPOSURES

Total thyroidectomy or TL.

MAIN OUTCOMES AND MEASURES

The primary end point was HRQOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, version 3.0; Hospital Anxiety and Depression Scale; and Thyroid Cancer-Specific Quality of Life Questionnaire) at different time points, and the secondary end points were postoperative complications, thyrotropin level, and patient satisfaction.

RESULTS

Of the 1060 eligible patients, 563 underwent TL (438 women [77.8%]; median [IQR] age, 38 [31-45] years), and 497 underwent TT (390 women [78.5%]; median [IQR] age, 38 [32-48] years). Compared with the TL group, including the 1- to 4-cm tumor subgroup, the TT group experienced more postoperative HRQOL problems at 1 and 3 months postoperatively. However, nearly all the differences disappeared at 6 and 12 months postoperatively.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that HRQOL of patients with DTC with low to intermediate risk of recurrence is not associated with the extent of surgery, and HRQOL may not be an important consideration when making surgical decisions. If better HRQOL is requested in the short term, TL may be preferred.

Distinct molecular subtypes of papillary thyroid carcinoma and gene signature with diagnostic capability

Papillary thyroid carcinoma (PTC) is heterogeneous and its molecular characteristics remain elusive. We integrated transcriptomic sequencing, genomic analysis and clinicopathologic information from 582 tissue samples of 216 PTC and 75 benign thyroid nodule (BTN) patients. We discovered four subtypes of PTC including Immune-enriched Subtype, BRAF-enriched Subtype, Stromal Subtype and CNV-enriched Subtype. Molecular subtypes were validated in an external cohort of 497 PTC cases from the TCGA. Tumors in the Immune-enriched Subtype showed higher immune infiltration and overexpression of immune checkpoints, whilst BRAF-enriched Subtype showed a higher tendency for extrathyroidal extension and more advanced TNM stage. Key oncogenes including LRRK2, SLC34A2, MUC1, FOXQ1 and KRT19 were overexpressed and enriched in oncogenic MAPK and PI3K/AKT signaling pathways in BRAF-enriched subtype. Further analysis of BRAF-enriched Subtype identified three subclasses with different degrees of malignancies. We also uncovered the molecular link of the initiation and progression from BTN to subtypes of PTC using trajectory analysis. Moreover, a 20-gene expression signature was generated for differential diagnosis of PTC from BTN patients. Together, our work identified previously unreported molecular subtypes of PTC, offering opportunities to stratify patients into optimal treatment plans based on molecular subtyping.

The role of obesity, type 2 diabetes, and metabolic factors in gout: A Mendelian randomization study

BACKGROUND

Several epidemiological studies have reported a possible correlation between risk of gout and metabolic disorders including type 2 diabetes, insulin resistance, obesity, dyslipidemia, and hypertension. However, it is unclear if this association is causal.

METHODS

We used Mendelian randomization (MR) to evaluate the causal relation between metabolic conditions and gout or serum urate concentration by inverse-variance-weighted (conventional) and weighted median methods. Furthermore, MR-Egger regression and MR-pleiotropy residual sum and outlier (PRESSO) method were used to explore pleiotropy. Genetic instruments for metabolic disorders and outcome (gout and serum urate) were obtained from several genome-wide association studies on individuals of mainly European ancestry.

RESULTS

Conventional MR analysis showed a robust causal association of increasing obesity measured by body mass index (BMI), high-density lipoprotein cholesterol (HDL), and systolic blood pressure (SBP) with risk of gout. A causal relationship between fasting insulin, BMI, HDL, triglycerides (TG), SBP, alanine aminotransferase (ALT), and serum urate was also observed. These results were consistent in weighted median method and MR-PRESSO after removing outliers identified. Our analysis also indicated that HDL and serum urate as well as gout have a bidirectional causal effect on each other.

CONCLUSIONS

Our study suggested causal effects between glycemic traits, obesity, dyslipidemia, blood pressure, liver function, and serum urate as well as gout, which implies that metabolic factors contribute to the development of gout via serum urate, as well as potential benefit of sound management of increased serum urate in patients with obesity, dyslipidemia, hypertension, and liver dysfunction.

Realizing topologically ordered states on a quantum processor

[Figure: see text].

Multiparametric quantitative MRI for the evaluation of dysthyroid optic neuropathy

OBJECTIVE

To evaluate the ability of quantitative MRI parameters for predicting dysthyroid optic neuropathy (DON).

METHODS

We retrospectively collected and analyzed the clinical features and 3.0 T MRI data of 59 patients with Graves orbitopathy (GO), with (n = 26) and without DON (n = 33). We compared MRI quantitative parameters, including the modified muscle index (mMI), proptosis, volume of intra-orbital fat, mean apparent diffusion coefficient value, and T2 value of the optic nerve among patients with and without DON. A logistic regression analysis was performed to identify the risk factors associated with DON. Moreover, we performed a receiver operating characteristic curve analysis and decision curve analysis to evaluate the diagnostic performance of the identified parameters for DON.

RESULTS

We studied 118 orbits (43 and 75 with and without DON, respectively). The mMI and mean T2 value of the optic nerve were significantly greater in orbits with DON (p < 0.001). A greater mMI at 21 mm (odds ratio (OR), 1.039; 95% confidence interval (CI): 1.019, 1.058) and higher mean T2 value of the optic nerve (OR, 1.035; 95% CI: 1.017, 1.054) were associated with a higher risk of DON. A model combining the mMI at 21 mm and mean T2 values for the optic nerve effectively predicted DON in patients with GO, with a sensitivity and specificity of 95.3% and 76%, respectively.

CONCLUSION

A quantitative MRI parameter combining the mMI at 21 mm and mean T2 value of the optic nerve can be an effective imaging marker for identifying DON.

KEY POINTS

• Patients with GO and DON had greater mMI than those without DON. • Optic nerves in patients with DON demonstrated an increased T2 value. • The quantitative MRI parameter combining the mMI at 21 mm and mean T2 value of the optic nerve is the most effective method for diagnosing DON.

Corneal Endothelium: A Promising Quantitative Index for Graves Ophthalmopathy Activity Evaluation

PURPOSE

To investigate the corneal endothelium damage in Graves ophthalmopathy (GO) and its role as a promising quantitative index to evaluate GO activity.

DESIGN

Cross-sectional study.

METHODS

This study included 128 eyes of 64 patients with GO. All subjects underwent ophthalmologic examinations, including proptosis, tear break-up time (BUT), corneal fluorescein staining, and Schirmer test. Corneal endothelium was measured by noncontact specular microscope and ocular biometric parameters were measured by IOLMaster 700. Each eye was assigned a specific clinical activity score (CAS), then grouped as active (CAS ≥3 points) or inactive (CAS <3 points). Ocular parameters between the 2 groups were compared using generalized estimating equations accounting for inter-eye correlation, and receiver operating characteristic (ROC) curves were also obtained. Main outcome measures were parameters of corneal endothelium.

RESULTS

Among the included eyes, 81 eyes had inactive GO and 47 eyes had active GO. Corneal endothelial cell morphology was altered in active GO compared with inactive GO. The coefficient variation of cell area (CV) was significantly higher in active GO compared with inactive GO (37.0 [34.4-41.2]% vs 33.9 [30.9-36.8]%, P = .001), and positively correlated with CAS (r = 0.322, P < .001). Moreover, CV showed a diagnostic capacity to differentiate the active eyes from inactive eyes. The area under the ROC curve was 0.705.

CONCLUSIONS

Active GO had morphologic changes in corneal endothelium compared with inactive GO. CV is a sensitive indicator to reflect corneal endothelial function, and has the potential to be adopted as a noninvasive, objective, and quantitative index for evaluating the activity status of GO patients.

The ETS Inhibitor YK-4-279 Suppresses Thyroid Cancer Progression Independent of TERT Promoter Mutations

Hotspot mutations in the core promoter region of the telomerase reverse transcriptase (TERT) gene have been well established to associate with aggressive clinical characteristics, radioiodine refractory, tumor recurrence, and mortality in thyroid cancer. Several E-twenty-six (ETS) transcription factors were reported to selectively bound to the mutant TERT promoter and activated TERT expression. In this study we aimed to investigate whether TERT promoter mutations confer sensitivity to ETS inhibitor YK-4-279 in thyroid cancer cells and whether this inhibitor could be served as a potential therapeutic agent for thyroid cancer. In vitro assays showed that YK-4-279 treatment sharply suppressed cell viability, colony formation, migration, and invasion, as well as induced cell cycle arrest and apoptosis in a panel of thyroid cancer cells. The cell viability after YK-4-279 treatment was similar between cell lines harboring mutant and wild-type TERT promoters. Furthermore, YK-4-279 treatment reduced both luciferase activity and mRNA expression of TERT independent of TERT promoter mutation status. Data from RNA-seq further revealed that YK-4-279 significantly affected biological processes including DNA replication and cell cycle. Reduced DNA helicase activity and decreased expression of several helicase genes were observed after YK-4-279 treatment. Moreover, YK-4-279 significantly inhibited tumor growth and induced apoptosis in a xenograft mice model. Thus, ETS inhibitor YK-4-279 suppressed TERT expression and conferred anti-tumor activity in a TERT promoter mutation-independent manner, and it could be a potential agent for the treatment of advanced thyroid cancers.