Serial changes in serum phosphorylated neurofilament and value for prediction of clinical outcome after traumatic brain injury

Background:

Phosphorylated neurofilament heavy subunit (pNF-H) is a constituent protein of the nerve axon, which leaks into the peripheral blood in various central nervous disorders. This study examined the time course of pNF-H value up to 1 month after injury and investigated the correlation with clinical outcome.

Methods:

Serum pNF-H concentration was measured on admission, and at 24 h, 72 h, 1 week, 2 weeks, and 1 month after injury in 20 patients, 15 males and 5 females aged 35–68 years (mean 52 years), with traumatic brain injury (TBI) transported to our hospital between April 2016 and March 2017. The clinical outcome at discharge was evaluated by Glasgow Outcome Scale.

Results:

The pNF-H value showed no increase in patients without brain parenchymal injury, but pNF-H value increased depending on the severity of brain damage. pNF-H value peaked at 2 weeks after injury. Two patients with peak value exceeding 10,000 unit had very severe injury and died during hospitalization. Peak pNF-H value was 3210 ± 1073 unit in 12 patients with good outcome and 9884 ± 2353 unit in 8 patients with poor outcome (P = 0.0119).

Conclusion:

Serum pNF-H level tended to increase and peak at 2 weeks after injury, and the peak pNF-H value was correlated with clinical outcome after TBI. The temporal profile of blood pNF-H seems to be useful to predict the clinical outcome after TBI.

Investigation of the impact of preconditioning with lipopolysaccharide on inflammation-induced gene expression in the brain and depression-like behavior in male mice

Although several recent studies have suggested that neuroinflammation plays a role in depression, both medication and neuroinflammatory preventive strategies have been poorly investigated. Recent studies have indicated that preconditioning with lipopolysaccharide (LPS) reduces the damage that occurs following ischemic stroke and brain trauma. However, to date, the effects of LPS preconditioning on psychiatric symptoms have not been reported. Thus, we assessed gene expression and behavioral changes affected by preconditioning with low-dose (LD) LPS in male mice with systemic inflammation induced by administration of high-dose (HD) LPS. mRNA expression analyses of cytokine-, glial-, and oxidative stress-associated genes revealed that majority of these genes responded to HD LPS. Differential gene expression in the presence and absence of LD LPS preconditioning, identified a subset of genes that may contribute to the mechanism of LPS preconditioning in the brain. Notably, LPS preconditioning attenuated an increase in expression of the astrocyte marker Gfap caused by systemic inflammation, suggesting that astrocytes have a key role in endotoxin tolerance in the brain induced by LPS preconditioning. As increased astrocyte in the brain of patients with depression is suggested to contribute to the pathophysiology of major depression, LPS preconditioning might be applicable to the prevention and treatment of depression. Unfortunately, in this study, LPS preconditioning did not show a reversal effect on behavior decline due to high-dose LPS-induced systemic inflammation. Alternative aspects of behavioral changes should be assessed to identify behavioral components that are affected by LPS preconditioning. Nonetheless, the findings in the present study indicate the possibility of the mechanism of endotoxin tolerance induction in the brain via astrocyte regulation by LPS preconditioning. Since there has been reported pharmacological significance of astrocytes in psychiatric disorders, regulation of endotoxin tolerance might be a key method to control psychiatric symptoms.

GCT-69. VOLUMETRIC CHANGE BEFORE CHEMORADIOTHERAPY AND INFLUENCE OF DIAGNOSTIC RADIATION EXPOSURE IN INTRACRANIAL GERMINOMAS

BACKGROUND

Spontaneous regression in intracranial germ cell tumors has been reported in some literatures, but the mechanism has not been well known. We retrospectively measured the tumor volume before chemoradiotherapy and analyzed factors that influence reduction of tumor volume.

PATIENTS AND METHODS

Plural MRI scans were done before the first course of chemotherapy regimen in 27 patients with primary intracranial germinomas. Their age ranged from 8 to 31 years. 35 lesions from them were enrolled and included 13 pineal, 4 neurohypophyseal, 4 basal ganglia, 4 bifocal type, and 2 multiple lesions. All regions were verified as pure germinoma or HCG-producing germinoma by histopathological examination. Tumor volume of 35 lesions was analyzed by volumetric assessment based on MRI. Ratio of volumetric change between the first MRI and the scan immediately before chemotherapy was defined as shrinking rate (%). Period between disease onset and the first chemotherapy was 20 to 47 days. Diagnostic radiation dose was calculated in each case.

RESULTS

Initial tumor volume ranged from 0.962 to 72.356 cubic centimeters (mean: 8.27). Diagnostic radiation dose: 40.5 to 910.1 mGy. Shrinking rate ranged from -57.8 to 85.4% (mean: 30.8). In 10 regions, shrinking rate was within 30%. Shrinking rate was significant positively influenced by diagnostic radiation dose (p<0.05) and negatively influenced by initial volume (p<0.05). But, other factors such as age, sex, histopathological parameters did not influence tumor shrinkage.

CONCLUSION

This study shows that the volume of intracranial germ cell tumors is changing dynamically before chemoradiotherapy in many cases. Diagnostic exposure to low-dose radiation influences tumor shrinkage of intracranial germinomas.

QOL-44. ASSESSMENT OF NEUROCOGNITIVE FUNCTION AND MRI PARAMETERS IN LONG-TERM SURVIVORS WITH POSTERIOR FOSSA TUMORS: A COMPARISON BETWEEN MEDULLOBLASTOMAS TREATED BY REDUCED-DOSE CRANIOSPINAL IRRADIATION AND OTHER TUMORS

BACKGROUND

Children with medulloblastoma cannot avoid chemoradiotherapy including craniospinal radiation, although prognosis of medulloblastoma has improved and previous studies have reported a significant risk of intellectual disturbance by these treatments. We retrospectively analysed neurocognitive functions, clinical MRI parameters of patients with posterior fossa tumors, especially medulloblastomas.

MATERIALS AND METHODS

Twenty-two patients (12 medulloblastomas, 5 ependymomas, 5 astrocytomas) treated in our institution were enrolled in this study. Mean age was 7.8 years and 6.5 years, percentage of hydrocephalus at onset was 66.7% and 60%, respectively in medulloblastoma group and in other tumor group (ependymoma and astrocytoma). Postoperative chemoradiotherapy including reduced-dose craniospinal irradiation (18Gy) was done for medulloblastoma group and local radiation or operation only was done for other group. Version 3 or 4 of Wechsler Intelligent Scale for Children (WISC) was used by neurocognitive function analysis. Ventricular size, white matter volume and other parameters were also was estimated based on MRI. Follow-up duration was 6–17 years (mean: 10.5 years).

RESULTS

Evaluations of neurocognitive functions based on WISC pointed out lower performance IQ than verbal IQ in long term survivor of both group, especially working memory (P=0.05). Both hydrocephalus and cranial nerve complications was influenced lower scores of WISC, but age at onset did not influence WISC scores. Comparison between both group showed there was no significant difference about cognitive function and white matter volume.

MPC-02 Prognostic effects of molecular factors in elderly patients with IDH-wildtype Glioblastomas

BACKGROUND: Geriatric neuro-oncology is an important research field, because the elderly patients is growing at a very rapid rate. This study investigates molecular features and their prognostic effects in the elderly glioblastomas (GBM). METHODS: We collected adult cases diagnosed with IDH-wildtype GBM and enrolled in Kansai Molecular Diagnosis Network for CNS Tumors (212 cases). Clinical and molecular features were analyzed retrospectively and independent prognostic factors were identified statistically. Focusing on the elderly (&gt;=70 years) cases, the association between molecular factors and overall survivals (OS) was examined. RESULTS: Included in the study were 92 elderly cases (43.4%) and median OS was 12.8 months. MGMT promoter was methylated in 50 (54.3%). Triple CNA (EGFR amplification/gain & PTEN deletion & CDKN2A deletion) was detected in 23 (25.0%). NFKBIA was deleted in 23 (25.0%). In the elderly cases, adjuvant radiation and temozolomide (RT+TMZ) was performed in 39 (42.4%) (mOS = 17.1 months). Statistical analyses of the elderly plus non-elderly cases treated with RT+TMZ (148 cases), MGMT promoter, triple CNA and NFKBIA were identified as independent molecular prognostic factors. In the elderly group, however, there was no significant difference in OS according to MGMT status (methylated = 18.7 vs. unmethylated = 17.1, p = 0.3885) or triple CNA status (triple = 13.6 vs. non-triple = 19.6, p = 0.1734). On the other hand, statistical difference was observed according to NFKBIA status (del = 12.1 vs. non-del = 18.7, p = 0.0157*) even in the elderly cases. CONCLUSION: Prognostic effects of molecular factors might be attenuated in the elderly patients. Further investigation in a larger population is necessary.

STMO-03 Surgical resection for precentral gyrus glioma

Primary motor cortex glioma is usually considered unresectable because of its high risk for motor deficit. However, recent reports suggest that surgical resection for primary motor cortex brain tumor is feasible for selected patients. In this study, we analyzed the neurological outcomes for 27 patients who underwent surgical resections for precentral gyrus glioma. Glioma grades for 27 patients were Grade II in 6 cases, Grade III in 7 cases, and Grade IV in 13 cases. 11 patients were recurrent glioma cases and glioma grade for those patients were Grade II in 4 cases, Grade III in 3 cases, and Grade IV in 4 cases. Extent of resection for 27 patients was biopsy in 2 cases, partial resection in 16 cases, and more than 90% of resections in 9 cases. 6 patients underwent awake surgery and glioma grade for those patients were Grade II in 3 cases, Grade III in 2 cases, and Grade IV in 1 case. Median extent of resection for patients who underwent awake surgery was 90%. Transient neurological worsening was observed in 5 patients, however, no patient exhibited permanent neurological deficit. Surgical resections for primary motor cortex glioma were feasible in selected patients without severe neurological complication. Careful intraoperative awake mapping is desirable to achieve maximum resections.

ANGI-03 Functional roles of CD166/activated leukocyte cell adhesion molecule (CD166/ALCAM) for glioblastoma invasion

CD166/activated leukocyte cell adhesion molecule (CD166/ALCAM) is a transmembrane receptor, widely expressed in various tissues, and is involved in several functions such as cell adhesion, neurogenesis and angiogenesis. We have previously reported that CD166/ALCAM is expressed on glioblastoma progenitor cells and is involved in glioblastoma invasion. However, we only have analyzed the functional roles of ALCAM using glioblastoma cell lines, not using patient derived xenografts. In this study, we investigated the functional roles of CD166/ALCAM using patient derived xenografts. We established CD166/ALCAM knocked-down glioblastoma patient derived cell lines by shRNA. For in vitro analysis, we seeded control and CD166/ALCAM knocked-down glioblastoma cells on culture dishes and performed time lapse analysis to investigate cell motility. For in vivo analysis, we orthotopically injected control and CD166/ALCAM knocked-down glioblastoma cells into the immunodeficient mice. When the mice got sick due to the tumor, we dissected the mice and analyzed the difference in invasion by immunohistochemical analysis. We found that CD166/ALCAM knocked-down glioblastoma cells significantly decreased cell motility by time lapse analysis. In addition, CD166/ALCAM knocked-down glioblastoma cells suppressed cell invasion and leptomeningeal metastasis by immunohistochemical analysis from patient derived xenografts. Our results suggest that CD166/ALCAM is involved in glioblastoma invasion, thus future studies are necessary to investigate whether CD166/ALCAM could be a therapeutic target for glioblastoma.

NI-13 The effectiveness and limitation of survival prediction in primary glioblastoma using machine learning-based texture analysis

Introduction: Clinical application of survival prediction of primary glioblastoma (pGBM) using preoperative images remains challenging due to a lack of robustness and standardization of the method. This research focused on validating a machine learning-based texture analysis model for this purpose using internal and external cohorts. Method: We included all cases of IDH wild-type pGBM available of preoperative MRI (T1WI, T2WI, and Gd-T1WI) from the databases of Kansai Molecular Diagnosis Network for CNS tumors (KN) and The Cancer Genome Atlas (TCGA). Of 242 cases from KN, we assigned 137 cases as a training dataset (D1), and the remaining 105 cases as an internal validation dataset (D2). Furthermore, we extracted 96 cases from TCGA as an external validation dataset (D3). Preoperative MRI scans were semi-quantitatively analyzed, leading to the acquisition of 489 texture features as explanatory variables. Dichotomous overall survival (OS) with a 16.6 months cutoff was regarded as the response variable (short/long OS). We employed Lasso regression for feature selection, and a survival prediction model constructed for D1 via cross-validation (M1) was applied to D2 and D3 to ensure the model robustness. Results: The population of predicted short OS by M1 significantly showed poorer prognosis in D2 (median OS 11.1 vs. 19.4 months; log-rank test, p=0.03), while there was no significant difference in D3 (median OS 14.2 vs. 11.9 months; p=0.61). In the comparative analysis using t-SNE, there was little variation in the feature distribution among three datasets. Conclusion: We were able to validate the prediction model in the internal but not in the external cohort. The presented result supports the use of machine learning-based texture analysis for survival prediction of pGBM in a localized population or country. However, further consideration is required to achieve a universal prediction model for pGBM, irrespective of regional difference.

ACT-07 Clinical Trials of 11C-Methionine PET for brain tumors

Background: Although 11C-Methionine (MET) PET has widely used, 11C-MET tracer has not been approved in Japan. We conducted multi-center prospective clinical trials using MET for drug approval in diagnosis of brain tumors[Methods] Two trials using 11C-MET PET were performed in Hokkaido University, Osaka University and Fukushima Medical University; 1) Diagnostic accuracy in differentiating tumor recurrence from radiation injury after radiotherapy in brain tumors, 2) The diagnostic efficacy in newly-diagnosed gliomas. 1) The patients with suspected brain tumor recurrence underwent MET and 18F-Fluorodeoxyglucose (FDG) PET. When the target lesion showed MET and/or FDG uptake, the patients underwent target resection for pathological confirmation. Positive prediction values of each tracer uptake were assessed as primary outcome measure, and the sensitivities and specificities of each PET exams were also assessed. 2) The patients with suspected gliomas underwent MET PET. Tissue samplings were performed from MET uptake lesions without contrast-enhancement on MRI in each patient, and evaluated the existence of tumor cells. Diagnostic additional values of MET PET on contrast-enhanced MRI was also investigated. Safety of MET PET was also assessed in each trial.[Result] 1) 57 cases were investigated. 38 cases underwent surgery and 32 cases (84%) were confirmed tumor recurrence histopathologically. MET and FDG uptake in 32 recurrence cases were 100% and 50%, respectively. Sensitivities and specificities of tumor recurrence were 84% and 89% in MET, and 100% and 56% in FDG. 2) 53 glioma cases were enrolled. Viable tumor cells were proven in 98% in MET uptake lesion without contrast-enhancement. In 42 out of 53 cases (78%), MET PET depicted tumor area beyond the contrast-enhancement area on MRI. No severe adverse events were observed in both trials. [Conclusions] MET PET were effective in diagnosis of brain tumors, and safety of MET was demonstrated.

SS-2 Current status and future perspective of radiomics in glioma imaging

Qualitative imaging, primarily focusing on brain tumors’ genetic alterations, has gained traction since the introduction of molecular-based diagnosis of gliomas. This trend started with fine-tuning MRS for detecting intracellular 2HG in IDH-mutant astrocytomas and further expanded into a novel research field named “radiomics”. Along with the explosive development of machine learning algorithms, radiomics became one of the most competitive research fields in neuro-oncology. However, one should be cautious in interpreting research achievements produced by radiomics as there is no “standard” set in this novel research field. For example, the method used for image feature extraction is different from research to research, and some utilize machine learning for image feature extraction while others do not. Furthermore, the types of images used for input vary among various research. Some restrict data input only for conventional anatomical MRI, while others could include diffusion-weighted or even perfusion-weighted images. Taken together, however, previous reports seem to support the conclusion that IDH mutation status can be predicted with 80 to 90% accuracy for lower-grade gliomas. In contrast, the prediction of MGMT promoter methylation status for glioblastoma is exceptionally challenging. Although we can see sound improvements in radiomics, there is still no clue when the daily clinical practice can incorporate this novel technology. Difficulty in generalizing the acquired prediction model to the external cohort is the major challenge in radiomics. This problem may derive from the fact that radiomics requires normalization of qualitative MR images to semi-quantitative images. Introducing “true” quantitative MR images to radiomics may be a key solution to this inherent problem.

COT-18 Prognosis and problems about secondary intracranial neoplasm in childhood cancer survivors: a single-institution retrospective cohort study

Objective: As childhood cancer survivors gradually increased, late complications of treatment have been at issue and risk of secondary neoplasm is increasing cumulatively. We retrospectively analyzed clinical outcome and problems of treatment for secondary intracranial neoplasm. Patients and Methods: 497 patients (children, adolescents and young adults) with malignant central nervous system neoplasm were treated in our institution from 1971 to 2015. 188 cases (37.8%) were enrolled in this follow-up study. Diagnosis of primary neoplasm included low grade glioma (29%), embryonal tumor (23.5%), germ cell tumor (24.5%), ependymoma (8%), other (15%). Results: Fourteen cases of them were diagnosed as secondary intracranial neoplasm. Twelve cases were operated and histopathological diagnosis included 6 glioblastomas, 1 anaplastic astrocytoma, 1 anaplastic ependymoma, 4 meningiomas. In all cases, histopathological finding and molecular profile of secondary intracranial neoplasm differed from that of primary malignant brain tumors. Duration from the first operation of primary tumors to diagnosis of secondary intracranial neoplasm ranged from 5 to 36 years (average: 29.3). In malignant glioma cases except meningioma cases, origin of them was contained in high irradiation field (&gt;40Gy). In malignant glioma cases, Chemotherapies using temozolomide and bevacizumab were selected after tumor removal. In 3 cases of them, reirradiation was performed. Response for treatment was poor or transient in most cases, median survival time was 12 months. Of late complications, such as endocrinological problem needed replacement (55%), cerebrovascular event (15.9%), secondary neoplasm (7.4%), secondary neoplasm was importantly related with prognosis. Conclusion: It is difficult to plan therapeutic strategies against second malignant neoplasm because of lack of information in case of long-term survivors and restriction for first radiation. Clinical outcome of them is poor and new treatment targets should be developed. It is important to plan clinical trials to reduce treatment intensity and usable long-term follow-up system.

CBIO-02. COMPREHENSIVE ANALYSIS OF MECHANISMS AND MOLECULAR TARGETS FOR BREAST CANCER LEPTOMENINGEAL METASTASIS

Leptomeningeal metastasis from solid cancer is a devastating state for cancer patients. Leptomeningeal metastasis is diagnosed either by cerebrospinal fluid cytology and/or magnetic resonance imaging (MRI). However, it remains unclear as to whether tumor cells attached to leptomeninges are the same from floating tumor cells in cerebrospinal fluid (CSF). In this study, we aim to analyze the differences between tumor cells attached to leptomeninges and floating cells in CSF by xenograft models. We used breast cancer cell line, MDA-MB-231, labelled with green fluorescent protein (GFP) and luciferase. We injected those cells into right lateral ventricle of NOD/Shi-scid IL2Rγ KO mice. When the mice got any signs of tumor, we dissected spinal cord and got CSF from mice. We sorted tumor cells by flow cytometry and extracted RNA from the sorted tumor cells from spinal cord and CSF, respectively. We analyzed transcriptome differences between tumor cells from spinal cord and CSF by RNA sequencing. We found that extracellular matrix related proteins were highly upregulated while cell growth related proteins were downregulated in tumor cells from spinal cord compared with those from CSF. These results suggest that tumor cells attached to leptomeninges have different transcriptome profiles from floating tumor cells in CSF and extracellular matrix related proteins could be therapeutic targets for breast cancer leptomeningeal metastasis.

NIMG-29. DEVELOPING AUTOMATIC SEGMENTATION METHOD FOR BRAIN TUMOR MR IMAGES THAT CAN BE USED AT MULTIPLE FACILITIES

BACKGROUND

Manual segmentation of brain tumor images from a large volume of MR images generated in clinical routines is difficult and time-consuming. Hence, it is imperative to develop a machine learning model for automated segmentation of brain tumor images.

PURPOSE

Machine learning models for automated MR image segmentation of gliomas may be useful. However, the image differences among facilities cause performance degradation and impede successful automatic segmentation. In this study, we proposed a method to solve this issue.

METHODS

We used the data from the Multimodal Brain Tumor Image Segmentation Benchmark (BraTS) and the Japanese cohort (JC) datasets collected from 10 facilities. Three models for tumor segmentation were developed. The BraTS model was trained on the BraTS dataset, and the JC model was trained on the JC dataset; whereas, the Fine-tuning model was a fine-tuned BraTS model using the JC dataset.

RESULTS

MR images of 544 patients were obtained for the JC dataset. Half of the JC dataset was used for independent testing. The Dice coefficient score of the JC model for the JC dataset was 0.779± 0.137, whereas that of the BraTS model was remarkably lower (0.717 ± 0.207). The mean of the Fine-tuning models for the JC dataset was 0.769 ± 0.138. There was a significant difference between the BraTS and JC models (P &lt; 0.0001) and the BraTS and Fine-tuning models (P = 0.002); however, no significant difference was observed between the JC and Fine-tuning models (P = 0.673).

CONCLUSIONS

Application of the BraTS model to heterogeneous datasets can significantly reduce its performance; however, fine-tuning can solve this issue. Since our fine-tuning method only requires less than 20 cases, this methodology is particularly useful for a facility where there are a few glioma cases.

NIMG-11. IMPACT OF INVERSION TIME FOR FLAIR ACQUISITION ON THE T2-FLAIR MISMATCH DETECTABILITY FOR IDH-MUTANT, NON-CODEL ASTROCYTOMAS

PURPOSE

The current research tested the hypothesis that TI shorter than 2400 ms under 3T for FLAIR can improve the diagnostic accuracy of the T2-FLAIR mismatch sign for identifying IDHmt, non-CODEL astrocytomas.

EXPERIMENTAL DESIGN

We prepared three different cohorts; 94 MRI from 76 IDHmt, non-CODEL LrGGs, 33 MRI from 31 LrGG under the restriction of FLAIR being acquired with TI &lt; 2400 ms for 3T or 2016 ms for 1.5T, and 103 MRI from 103 patients from the TCIA/TCGA dataset for LrGG. The presence or absence of the “T2-FLAIR mismatch sign” was evaluated, and we compared diagnostic accuracies according to TI used for FLAIR acquisition.

RESULTS

The T2-FLAIR mismatch sign was more frequently positive when TI was shorter than 2400 ms under 3T for FLAIR acquisition (p = 0.0009, Fisher’s exact test). The T2-FLAIR mismatch sign was positive only for IDHmt, non-CODEL astrocytomas even if we confined the cohort with FLAIR acquired with shorter TI (p = 0.0001, Fisher’s exact test). TCIA/TCGA dataset validated that the sensitivity, specificity, PPV, and NPV of the T2-FLAIR mismatch sign to identify IDHmt, non-CODEL astrocytomas improved from 31%, 90%, 79%, and 51% to 67%, 94%, 92%, and 74%, respectively if we acquired FLAIR with TI shorter than 2400 ms.

CONCLUSIONS

We revealed that TI for FLAIR impacts diagnostic accuracy of the T2-FLAIR mismatch sign and that FLAIR scanned with TI &lt; 2400 ms in 3T is necessary for LrGG imaging.

Impact of right ventricular contractile reserve on exercise capacity in patients with heart failure: clinical application of low-load exercise stress echocardiography

Background

The peak oxygen uptake (VO2) evaluated by the cardiopulmonary exercise test (CPX) is an established marker of exercise capacity in patients with heart failure (HF). In particular, peak VO2 &lt;14 ml/kg/min is used to be one of the criteria for heart transplantation. However, given exercise intolerance in patients with HF, it is difficult for refractory HF patients to reach sufficient exercise load. A recent report has highlighted significant impact of right ventricular (RV) function on mortality and urgent heart transplantation. Taken together, we hypothesized that the assessment of RV function was helpful to predict exercise capacity by using low-load exercise stress echocardiography (low-load ESE) in patients with HF.

Purpose

We evaluated whether RV dysfunction assessed by the low-load ESE determined a low peak VO2 &lt;14 ml/kg/min in patients with HF.

Methods

We studied 67 consecutive hospitalized patients with HF (mean age, 65 years; 75% male; mean LV ejection fraction, 36%) who underwent ESE and CPX after stabilized HF condition, and the time interval of CPX and ESE tests was within 48 hours. CPX was performed using an upright cycle ergometer by a ramp protocol, while ESE was performed using ergometer in semi-supine position and the workload was generally increased by 25 watts every 3 minutes. The low-load ESE was defined as the 25 watts exercise. The increments of RV s' velocity at tricuspid annulus and RV strain in the free wall were considered as a preservation of RV contractile reserve. Among the study population, 26 patients were performed right heart catheterization and RV dP/dt/Pmax was estimated as an invasive marker of RV contractility.

Results

The achieved intensity of exercise was 50.4±21.0 watts, and all patients completed the low-load ESE. The invasive study showed that the change of RV s' velocity during the low-load ESE significantly correlated with RV dP/dt/Pmax (r=0.706, p&lt;0.001). As shown in Figure, the non-invasive parameters of RV contractile reserve during the low-load ESE were significantly correlated with peak VO2 (RV s' velocity: r=0.787, p&lt;0.001; RV strain: r=0.244, p=0.047). ROC analysis showed that the change of RV s' velocity during the low-load ESE correctly identified patients with peak VO2 &lt;14 ml/kg/min (AUC=0.95, sensitivity 92.3%, specificity 85.2%). In terms of inter- and intra-observer variabilities, ICCs of the change of RV s' velocity were 0.86 and 0.96, and ICCs of the changes of RV strain were 0.63 and 0.70, respectively.

Conclusion

The change of RV s' velocity during the low-load ESE could determine exercise tolerance in patients with HF. The assessment of RV contractile reserve might be clinically useful to discriminate high risk HF patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Biodegradable-polymer versus durable-polymer drug eluting stents for coronary artery disease: systematic review and a meta-analysis

Background

Biodegradable polymer drug-eluting stents (BP-DES) has been developed to overcome the potential drawbacks of the first-generation durable polymer drug-eluting stents (DP-DES). However, it is still under debate whether BP-DES is associated with superior efficacy and safety over DP-DES.

Purpose

We sought to compare the effects of BP-DES and DP-DES in patients with coronary artery disease.

Methods

We performed systematic review and a meta-analysis of randomized controlled trials comparing BP-DES and DP-DES on clinical outcomes in patients with coronary artery disease using CE-mark approved drug-eluting stents (DES) with at least 1-year follow-up. We included 32 studies involving 39,686 patients (BP-DES: 21,439 patients, and DP-DES: 18,247 patients). Primary outcome measure was target vessel failure (TVF; equivalent to the composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target vessel revascularization). We performed subgroup analysis according to the DP-DES generations (newer-generation DP-DES: 15,179patients, and first-generation DP-DES: 3,068 patients), and the effects of newer-generation DP-DES was compared with the BP-DES according to the BP-DES strut thickness (Ultra-thin strut [&lt;80μm]: 7,572 patients, Thin-strut [80–100μm]: 5,465 patients, and Thick-strut [≥80μm]: 5,876 patients).

Results

The odds for TVF was not significantly different between the BP-DES group and the DP-DES group in the entire study population (odds ratio [OR] 0.96, 95% confidence interval [CI] [0.90–1.02], P=0.20). The odds for TVF was significantly low in the BP-DES group relative to the first-generation DP-DES group, however the odds were comparable between the BP-DES group and the newer-generation DP-DES group (BP-DES versus first-generation DP-DES: OR 0.82, 95% CI [0.73–0.92], P&lt;0.001, and BP-DES versus newer-generation DP-DES: OR 1.00, 95% CI [0.93–1.08], P=0.99). We also found no significant differences between the BP-DES and newer-generation DP-DES, in all subgroups stratified by the BP-DES strut thickness (Ultra-thin strut BP-DES versus newer-generation DP-DES: OR 0.88, 95% CI [0.76–1.02], P=0.10, Thin-strut BP-DES versus newer-generation DP-DES: OR 1.01, 95% CI [0.90–1.13], P=0.89, and Thick strut BP-DES versus newer-generation DP-DES: OR 1.11, 95% CI [0.99–1.25], P=0.08).

Conclusions

In this meta-analysis of randomized controlled trials evaluating clinical outcomes, there was no significant differences between BP-DES and DP-DES. We found beneficial effects of BP-DES relative to the first-generation DP-DES, however, there was no statistical differences between BP-DES and newer-generation DP-DES, irrespective of the BP-DES strut thickness.

Pooled odds ratios for clinical outcomes

Funding Acknowledgement

Type of funding source: None

A comparison of thyroidal protection by stable iodine or perchlorate in the case of acute or prolonged radioiodine exposure

In the case of a nuclear power plant accident, repetitive/prolonged radioiodine release may occur. Radioiodine accumulates in the thyroid and by irradiation enhances the risk of cancer. Large doses of non-radioactive iodine may protect the thyroid by inhibiting radioiodine uptake into the gland (iodine blockade). Protection is based on a competition at the active carrier site in the cellular membrane and the Wolff-Chaikoff effect, the latter being, however, only transient (24-48 h). Perchlorate may alternatively provide protection by a carrier competition mechanism only. Perchlorate has, however, a stronger affinity to the carrier than iodide. Based on an established biokinetic-dosimetric model developed to study iodine blockade, and after its extension to describe perchlorate pharmacokinetics and the inhibition of iodine transport through the carrier, we computed the protective efficacies that can be achieved by stable iodine or perchlorate in the case of an acute or prolonged radioiodine exposure. In the case of acute radioiodine exposure, perchlorate is less potent than stable iodine considering its ED50. A dose of 100 mg stable iodine has roughly the same protective efficacy as 1000 mg perchlorate. For prolonged exposures, single doses of protective agents, whether stable iodine or perchlorate, offer substantially lower protection than after acute radioiodine exposure, and thus repetitive administrations seem necessary. In case of prolonged exposure, the higher affinity of perchlorate for the carrier in combination with the fading Wolff-Chaikoff effect of iodine confers perchlorate a higher protective efficacy compared to stable iodine. Taking into account the frequency and seriousness of adverse effects, iodine and perchlorate at equieffective dosages seem to be alternatives in case of short-term acute radioiodine exposure, whereas preference should be given to perchlorate in view of its higher protective efficacy in the case of longer lasting radioiodine exposures.

Radiation-induced gastrointestinal syndrome is exacerbated in vitamin C-insufficient SMP30/GNL knockout mice

OBJECTIVES

Accidental exposure to high-dose radiation causes life-threatening acute radiation syndrome, features that include gastrointestinal syndrome (GIS) and hematopoietic syndrome (HS). Administration of vitamin C (VC), a free radical scavenger, has been reported to increase survival of mice in GIS and HS models. The effect of nutritional VC status on radiation injury remains unknown because, unlike humans, mice can synthesize VC. The aim of this study was to investigate the effect of VC insufficiency on acute radiation syndrome using senescence marker protein 30 (SMP30)/gluconolactonase knockout (SMP30-KO) mice.

METHODS

SMP30-KO mice, which cannot synthesize VC, were given water with or without sufficient VC supplementation, and were analyzed in GIS and HS models.

RESULTS

In the GIS model, in which bone marrow failure is rescued by bone marrow transplantation, VC-insufficient mice had a lower survival rate than VC-sufficient mice. The intestine of VC-insufficient GIS mice showed epithelial cell atrophy, inflammatory cell infiltration, and decreased crypt cell proliferation. We observed rapid VC oxidation after total body irradiation in the intestine of mice supplemented with VC-sufficient water. In the HS model, which was not combined with bone marrow transplantation, there was no difference in survival between VC-insufficient and -sufficient mice.

CONCLUSION

The results of this study demonstrated that nutritionally sufficient VC exerts a radioprotective effect against radiation-induced GIS.

Efficacy of the Endoscopic Triportal Transmaxillary Approach for Treating Lateral Middle Skull Base Tumors: A Technical Note and Retrospective Case Series

BACKGROUND

The endoscopic approach, chiefly via the maxillary sinus, has growing applications for the lateral skull base, and can be classified into the use of "endonasal" or "sublabial" entry. Although the endonasal transmaxillary approach has been well accepted, it has a limitation with respect to the lateral exposure. A possible solution is the use of the sublabial transmaxillary approach via the canine fossa, which assures lateral accessibility. In clinical practice, we have taken advantage of the concomitant use of the endonasal and sublabial transmaxillary approach for selected patients harboring lateral skull base lesions. In addition to binostril pathways, canine fossa trephination was constructed to facilitate this combined approach, termed the endoscopic triportal transmaxillary approach (ETTA).

METHODS

The efficacy of the ETTA was evaluated within a case series. A single-institution retrospective analysis was performed in patients with lateral middle skull base tumors treated via ETTA.

RESULTS

In clinical practice, 4 patients were eligible for the study, including 1 receiving a combined endoscopic and transcranial approach. No major complications occurred in patients included in this series. The ETTA facilitated the dynamic manipulation of instruments, which led to rapid hemostasis and the satisfactory surgical resection of tumors. Furthermore, it reduced intraoperative postural stress experienced by the surgeons who performed the procedures.

CONCLUSIONS

The concomitant use of the trans-canine fossa approach effectively ameliorated significant technical challenges that tend to occur when using a purely endonasal approach. The ETTA can be an attractive option for treating lateral and middle skull base lesions.

Intraosseous transfusion of hemoglobin vesicles in the treatment of hemorrhagic shock with collapsed vessels in a rabbit model

BACKGROUNDS

Intravenous transfusion sometimes encounters difficulty under prehospital conditions when peripheral vessels are collapsed and inaccessible. We investigated whether the cellular type hemoglobin-based oxygen carriers (Hemoglobin Vesicles: HbVs) allow intraosseous administration into blood circulation for the resuscitation of rabbits with severe hemorrhagic shock.

STUDY DESIGN AND METHODS

New Zealand white rabbits (2.5 kg average) were set in severe hemorrhagic shock [mean arterial pressure (MAP): 21 ± 2 mm Hg, Hb 5.1 ± 0.8 g/dL]. Immediately thereafter, 12 mL/kg of HbVs, 5% human serum albumin (HSA), autologous whole blood (WB), stored red blood cells (RBCs) or 36 mL/kg of Lactated Ringer's (LR) were intraosseously transfused, followed by an additional intraosseous transfusion with 8 mL/kg of HSA (following HbV, HSA or stored RBC transfusion), or WB or 24 mL/kg of LR (following LR transfusion), respectively.

RESULTS

Intraosseous transfusion of HbVs increased MAP (48 ± 9 mm Hg) and improved hypohemoglobinemia (7.1 ± 0.6 g/dL) as well as WB or RBC transfusion. In contrast, neither HSA nor LR improved hemodynamics or Hb levels. Seven out of 10 rabbits receiving HbVs survived for 24 hours, while only one out of 10 rabbits receiving LR survived (WB and RBC; 100% survivals, HSA; 30% survival).

CONCLUSIONS

Intraosseous infusion of HbVs might be an effective initial treatment to maintain hemodynamics during acute hemorrhagic shock. This approach could be used in emergency situations in which access to peripheral vessels is difficult.

OP0306 CD11C-SPECIFIC ABLATION OF SHP1 INDUCES AUTOIMMUNE SIALADENITIS SIMILAR TO SJÖGREN’S SYNDROME

Background:

Dendritic cells (DCs) play important roles in inducing immune response as well as maintaining immune tolerance. Src homology 2 domain-containing protein tyrosine phosphatase-1 (Shp1) is a negative regulator of signaling in hematopoietic cells and is expressed in a variety of immune cells including DCs. Shp1 homozygous mutant mice (motheaten mice) develop multiple immunological abnormalities and they die around four weeks after birth because of severe pneumonitis. Motheaten mice produce large amounts of autoantibodies, and besides, B-1a cells, a distinct B cell subset, which are an important source of autoantibodies increase in these mice. The functional abnormality of DCs in motheaten mice has not been characterized, but DCs and macrophages increase in various organs of motheaten mice.

To analyze the function of Shp1 in DCs, we generated Shp1 conditional knockout mice (Shp1 CKO) in whichShp1gene is specifically depleted in CD11c+cells. We found that aged shp1 CKO developed autoimmune glomerulonephritis. We also found that they developed severe tubulointerstitial nephritis (TIN) at the age of 40 weeks, which is characterized by the infiltration of CD11c+and F4/80+cells. CD4+T cells from Shp1 CKO produce much more amount of IFNγ. Collectively, Shp1 in DCs acts as a key regulatory molecule to protect against autoimmunity.

Objectives:

We analyzed salivary glands of CKO to confirm whether they have autoimmune sialadenitis because TIN is known to be the most common renal manifestations of Sjögren’s syndrome in human.

Methods:

Shp1 CKO are generated by crossing a mouse line carrying floxedShp1allele to mice expressing Cre recombinase under the control of the CD11c promoter. Sex- and age-matchedPtpn6fl/fllittermates withoutCregene were studied as controls. We analyzed secretory function of the salivary glands in response to pilocarpine stimulation in Shp1 CKO at the age of 40 weeks or older. We then performed histological examination of salivary glands (submandibular glands and sublingual glands) with light-microscopy and immunohistochemical staining. The mononuclear cells prepared from the salivary glands were analyzed by flow cytometry (FCM). We also quantified anti-SSA/Ro60 antibodies and anti-SSB/LA antibodies by ELISA.

Results:

Shp1 CKO secreted less saliva flow compared to control mice by pilocarpine stimulation. Histological study showed Shp1 CKO exhibited massive infiltration of inflammatory cells in salivary glands associated with periductal foci and periductal fibrosis. Most of infiltrated cells were stained by anti- CD4 or B220 mAbs. FCM revealed that B cells increased in the salivary glands of Shp1 CKO. In addition, B-1a cells also increased in the salivary glands of the mice. The levels of anti-SSA/Ro60 antibodies and anti-SSB/LA antibodies were increased in Shp1 CKO.

Conclusion:

CD11c-specific ablation of Shp1 induces the ectopic generation of lymphoid structure in salivary glands and impairment of salivary secretion. Autoantibody profile in Shp1 CKO resembled that in human Sjögren’s syndrome. Our findings suggest that aged Shp1 CKO have the potential to become a new mouse model for the analysis of Sjögren’s syndrome.

References:

[1]Green C. M. et al. J Heredity. 1975; 250-258.

[2]Kaneko T. et al. J Immunology. 2012; 5397-540.

[3]Watanabe M. et al. Biochem Biophys Rep. in press.

Disclosure of Interests:

Masato Kinoshita: None declared, Yoriaki Kaneko Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc.b, Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Mitsuharu Watanabe: None declared, Yoichi Imai: None declared, Shreya Shrestha: None declared, Junya Suwa: None declared, Yuko Ohishi: None declared, Hiroko Hamatani: None declared, Masao Nakasatomi: None declared, Toru Sakairi: None declared, Hidekazu Ikeuchi Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Yoshihisa Nojima: None declared, Keiju Hiromura Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc.

Randomized phase III study of high-dose methotrexate and whole brain radiotherapy with or without concomitant and adjuvant temozolomide in patients with newly diagnosed primary central nervous system lymphoma: JCOG1114C

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Background: Temozolomide (TMZ) is an oral alkylating agent that penetrates the blood-brain barrier with moderate toxicity, and has shown anti-tumor activity in primary central nervous system lymphoma (PCNSL) in single arm studies. Our goal was to determine whether the addition of concomitant and adjuvant TMZ chemotherapy to standard treatment of high-dose methotrexate (HD-MTX) and whole brain radiotherapy (WBRT) for PCNSL improves survival in a randomized controlled trial. Methods: We did an open-label, randomized phase III trial at 30 hospitals in Japan enrolling immunocompetent patients (pts) aged 20-70 years with histologically confirmed newly diagnosed PCNSL. Pts enrolled at step 1 registration received HD-MTX (MTX; 3.5 g/m2 at day 1, 15, 29). Pts who received at least 1 cycle of HD-MTX were randomly assigned (1:1) at step 2 registration to receive WBRT (30 Gy) ± 10 Gy boost (control arm: A) or WBRT ± boost with concomitant TMZ (75 mg/m2 daily) and adjuvant TMZ (150-200 mg/m2 daily for 5 days every 28 days) for two years after initiation of HD-MTX or until tumor progression (experimental arm: B). Randomization was adjusted by institution, PS (0-1 / 2-3), age (≤60/≥61 years), presence or absence of intraparenchymal tumor after HD-MTX. The primary endpoint was overall survival (OS). The planned sample size was 130 pts in total, to provide an 80% power to detect a 0.52 hazard ratio (65% vs 80% in 2y-OS) for arm B to A and a one-sided alpha of 5%. Results: Between September 29, 2014 and October 15, 2018, 134 pts were enrolled, of whom 122 were randomly assigned and analyzed; 62 to arm A and 60 to arm B. At the planned interim analysis, the 2-y OS was 86.8% (95% CI: 72.5-94.0) in arm A and 71.4% (56.0-82.2) in arm B. The hazard ratio was 2.18 (95% CI: 0.95 to 4.98) with predictive probability for showing the superiority of arm B at the final analysis was calculated to be 1.3%. The study was terminated due to futility. The 2-y progression-free survival was 60.6% (43.6-73.8) in arm A and 49.9% (34.4-63.5) in arm B with a hazard ratio of 1.54 (0.88 to 2.70). The most common grade 3 and 4 toxicities were lymphopenia, observed in 7 (11.5%) pts during WBRT in arm A, 18 (30%) pts during WBRT + concomitant TMZ and 18 (37.5%) pts during adjuvant TMZ in arm B. Conclusions: This study failed to demonstrate the benefit of the addition of TMZ to WBRT and adjuvant TMZ in newly diagnosed PCNSL. Possible biomarkers including methylation status of the MGMT promoter in the tumors will be analyzed. Clinical trial information: jRCTs031180207 .

Molecular characteristics and clinical outcomes of elderly patients with IDH-wildtype glioblastomas: comparative study of older and younger cases in Kansai Network cohort

Aging is a known negative prognostic factor in glioblastomas (GBM). Whether particular genetic backgrounds are a factor in poor outcomes of elderly patients with GBM warrants investigation. We aim to elucidate any differences between older and younger adult patients with IDH-wildtype GBM regarding both molecular characteristics and clinical outcomes. We collected adult cases diagnosed with IDH-wildtype GBM from the Kansai Network. Clinical and pathological characteristics were analyzed retrospectively and compared between older (≥ 70 years) and younger (≤ 50 years) cases. Included were 92 older vs. 33 younger cases. The older group included more patients with preoperative Karnofsky performance status score < 70 and had a shorter survival time than the younger group. MGMT promoter was methylated more frequently in the older group. TERT promoter mutation was more common in the older group. There were significant differences in DNA copy-number alteration profiles between age groups in PTEN deletion and CDK4 amplification/gain. In the older group, no molecular markers were identified, but surgical resection was an independent prognostic factor. Age-specific survival difference was significant in the MGMT methylated and TERT wildtype subgroup. Elderly patients have several potential factors in poor prognosis of glioblastomas. Varying molecular profiles may explain differing rates of survival between generations.