Real-world evidence of Pressure-Enabled Drug Delivery for trans-arterial chemoembolization and radioembolization among patients with hepatocellular carcinoma and liver metastases

OBJECTIVES

Pressure-Enabled Drug Delivery (PEDD), a method using pressure to advance catheter-delivered drug distribution, can improve treatment for hepatocellular carcinoma (HCC) and liver metastases, but real-world evidence is limited. We compared baseline patient characteristics, clinical complexity, and post-procedure healthcare resource utilization (HRUs) and clinical complications for PEDD and non-PEDD procedures.

METHODS

This study used a retrospective, longitudinal, cohort design of claims data from Clarivate's Real World Data Repository, which includes 98% of US payers with over 300 million unique patients from all US states. We identified patients with a trans-arterial chemoembolization (TACE) or trans-arterial radioembolization (TARE) from 1 January 2019 to 31 December 2022. Subsamples grouped patients with HCC receiving a TARE procedure at their first embolization and patients with metastatic colorectal cancer (CRC) that received a TARE procedure. We reported descriptive comparisons of our full sample of patients with HCC and liver metastases receiving PEDD versus non-PEDD procedures. We then conducted a matching-adjusted comparison of HRUs and clinical complications for PEDD and non-PEDD patients among our subsamples (HCC receiving a TARE procedure at their first embolization and patients with metastatic CRC that received a TARE procedure). Matching was based on baseline demographic and clinical characteristics using coarsened exact matching and propensity-score matching. HRUs included inpatient, outpatient, and emergency department visits. Clinical complications included ascites, cholecystitis, fatigue, gastric ulcer, gastritis, jaundice, LFT increase, lymphopenia, portal hypertension, and post-embolization syndrome.

RESULTS

PEDD procedures were used on patients with worse baseline disease burdens: baseline Charlson comorbidity index (mean of 6.5 vs. 5.8), any prior clinical complication related to underlying disease (33.7 vs. 31.0%), and prior systemic therapy (22.1% vs. 16.2%). PEDD patients had a greater number of procedural codes indicative of technical complexity for TACE (PEDD mean = 226.3; non-PEDD mean = 134.5; p value <.01) and TARE (PEDD mean = 205.56; non-PEDD mean = 94.8; p value <0.01). Matching-adjusted analyses of patients with HCC and CRC demonstrated comparable HRU and clinical complications for PEDD and non-PEDD procedures post-index.

CONCLUSION

Despite higher baseline disease burden and complexity, post-procedure HRU and clinical complications for PEDD patients were similar to non-PEDD patients. The complex baseline clinical profile may reflect selection of challenging cases for PEDD use. Future studies should validate the benefits observed with PEDD embolization in larger samples with greater statistical power.

Treatment of hypoplastic left heart syndrome: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

This meta-analysis aimed to consolidate existing data from randomised controlled trials on hypoplastic left heart syndrome.

METHODS

Hypoplastic left heart syndrome specific randomised controlled trials published between January 2005 and September 2021 in MEDLINE, EMBASE, and Cochrane databases were included. Regardless of clinical outcomes, we included all randomised controlled trials about hypoplastic left heart syndrome and categorised them according to their results. Two reviewers independently assessed for eligibility, relevance, and data extraction. The primary outcome was mortality after Norwood surgery. Study quality and heterogeneity were assessed. A random-effects model was used for analysis.

RESULTS

Of the 33 included randomised controlled trials, 21 compared right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig-Thomas shunt during the Norwood procedure, and 12 regarded medication, surgical strategy, cardiopulmonary bypass tactics, and ICU management. Survival rates up to 1 year were superior in the right ventricle-to-pulmonary artery shunt group; this difference began to disappear at 3 years and remained unchanged until 6 years. The right ventricle-to-pulmonary artery shunt group had a significantly higher reintervention rate from the interstage to the 6-year follow-up period. Right ventricular function was better in the modified Blalock-Taussig-Thomas shunt group 1-3 years after the Norwood procedure, but its superiority diminished in the 6-year follow-up. Randomised controlled trials regarding medical treatment, surgical strategy during cardiopulmonary bypass, and ICU management yielded insignificant results.

CONCLUSIONS

Although right ventricle-to-pulmonary artery shunt appeared to be superior in the early period, the two shunts applied during the Norwood procedure demonstrated comparable long-term prognosis despite high reintervention rates in right ventricle-to-pulmonary artery shunt due to pulmonary artery stenosis. For medical/perioperative management of hypoplastic left heart syndrome, further randomised controlled trials are needed to deliver specific evidence-based recommendations.

Bridging and downstaging with TACE in early and intermediate stage hepatocellular carcinoma: Predictors of receiving a liver transplant

Background and Aims

In patients with surgically unresectable early and intermediate stage hepatocellular carcinoma (HCC), only liver transplant (LT) offers a cure. Locoregional therapies, such as transarterial chemoembolization (TACE), are widely used to bridge patients waiting for an LT or downstage tumors beyond Milan Criteria (MC). However, there are no formal guidelines on the number of TACE procedures patients should receive. Our study explores the extent to which repeated TACE might offer diminishing gains toward LT.

Approach

We retrospectively analyzed 324 patients with BCLC stage A and B HCC who had received TACE with the intention of disease downstaging or bridging to LT. In addition to baseline demographics, we collected data on LT status, survival, and the number of TACE procedures. Overall survival (OS) rates were estimated using the Kaplan-Meier method, and correlative studies were calculated using chi-square or Fisher's exact test.

Results

Out of 324 patients, 126 (39%) received an LT, 32 (25%) of whom had responded favorably to TACE. LT significantly improved OS: HR 0.174 (0.094-0.322, P < .001). However, the LT rate significantly decreased if patients received ≥3 vs < 3 TACE procedures (21.6% vs 48.6%, P < .001). If their cancer was beyond MC after the third TACE, the LT rate was 3.7%.

Conclusions

An increased number of TACE procedures may have diminishing returns in preparing patients for LT. Our study suggests that alternatives to LT, such as novel systemic therapies, should be considered for patients whose cancers are beyond MC after three TACE procedures.

Quality of life in Barth syndrome

Introduction

Barth syndrome (BTHS) is a rare X-linked disorder characterized by cardiomyopathy, neutropenia, growth abnormalities, and skeletal myopathy. There have been few studies investigating health-related quality of life (HRQoL) in this population. This study investigated the impact of BTHS on HRQoL and select physiologic measures in affected boys and men.

Methods

In this study, we characterize HRQoL in boys and men with BTHS through cross-sectional analysis of a variety of outcome measures including the Pediatric Quality of Life Inventory (PedsQLTM) Version 4.0 Generic Core Scales, PedsQLTM Multidimensional Fatigue Scale, Barth Syndrome Symptom Assessment, the PROMISTM Fatigue Short Form, the EuroQol Group EQ-5DTM, the Patient Global Impression of Symptoms (PGIS), and the Caregiver Global Impression of Symptoms (CaGIS). For a specific subset of participants, physiologic data were available in addition to HRQoL data.

Results

For the PedsQLTM questionnaires, 18 unique child and parent reports were analyzed for children aged 5-18 years, and nine unique parent reports were analyzed for children aged 2-4 years. For the other HRQoL outcome measures and physiologic measurements, the data from 12 subjects (age range 12-35 years) were analyzed. Based on parent and child reports, HRQoL is significantly impaired in boys and men with BTHS, especially in school functioning and physical functioning. Parent and child reports of more severe fatigue are significantly correlated with more impaired HRQoL. When exploring the potential relationship between physiology and HRQoL, the CaGIS as a whole for pediatric subjects and individual questionnaire items from the PGIS and CaGIS for pediatric subjects assessing tiredness, muscle weakness, and muscle pain showed the strongest correlations.

Conclusion

This study provides a unique characterization of the HRQoL in boys and men with BTHS using a variety of outcome measures, and it highlights the negative impact of fatigue and muscle weakness on HRQoL in BTHS.

Trial registry name

A Trial to Evaluate Safety, Tolerability and Efficacy of Elamipretide in Subjects with Barth Syndrome (TAZPOWER). https://clinicaltrials.gov/ct2/show/NCT03098797.Registration Number: NCT03098797.

Outcome of early and intermediate-stage hepatocellular carcinoma (HCC): A single institution experience at MGUH

328

Background: Liver transplant (LT) remains the best curative standard for HCC within Milan criteria (Milan). Nonsurgical locoregional treatments, including TACE and ablation, offer a bridge to surgical management and attempt to downstage or maintain patients (pts) within Milan pending liver transplant and donor organ availability. We investigated clinical factors that predict successful downstaging of HCC and liver transplant. Methods: In this single-institutional retrospective analysis, pts with early-intermediate stage HCC within Milan (control) vs beyond Milan were evaluated for clinical outcome. Clinical factors including treatment and response, demographics, TACE distribution (number of treatments, timing, and response), and status of liver transplantation (timing and if received) were correlated to overall survival (OS). OS was calculated using the Kaplan-Meier method. Results: HCC pts (n = 343) considered for LT or downstage to LT were included in the study: 75% male, 13% African American, 55% Caucasian, and 14% Asian. 12% of pts had HBV, 53% had HCV, 2% had both HBV and HCV. 221 pts were diagnosed within Milan vs 122 beyond Milan, in which 36% (n = 44) were still within UCSF criteria (UCSF). 43% of those diagnosed within Milan ultimately received LT vs 16% of those diagnosed beyond Milan. 49% of pts (n = 60) initially beyond Milan were downstaged to within Milan, via TACE, wherein 27% received LT; this group accounted for 13% all LT. However, in the subset of pts beyond Milan but within UCSF, 68% were downstaged to within Milan, wherein 40% received LT. In pts initially within Milan, 21% (n = 47) progressed beyond Milan, but 40% of this subset was downstaged back to within Milan. Pts both within and beyond Milan had a median of 2 TACE procedures. Differences in the rates of LT relative to the number of TACE were significant (p = 0.022) for pts initially within Milan; for < / = 2 TACE, 54% had LT; for > 2 TACE, 26% had LT. Similar comparison was nonsignificant for pts initially beyond Milan (p = 0.95); rates of LT for < / = 2 TACE and > 2 TACE were 17% and 16% respectively. Median OS for non-LT recipients was 5 years vs not reached for LT recipients ( > 70% alive at 8 years, p < 0.001). Pts initially beyond Milan but within UCSF criteria had similar OS vs those initially within Milan (both 75% at 4 years), but OS was worse (50% at 4 years) for those beyond UCSF (p = 0.024). Conclusions: Liver transplantation significantly increased OS in early-intermediate stage HCC. Increased number of TACE procedures was associated with decreased likelihood of ultimate LT in pts initially diagnosed within Milan, particularly when they had > 2 TACE. Pts initially beyond Milan but within UCSF criteria had similar OS vs those initially within Milan; this former subset had a good chance of being downstaged to Milan and ultimately receive LT. Additional clinical factors that predict successful downstaging of HCC and LT are being investigated.

A phase II study of atezolizumab (ATEZO) and bevacizumab (Bev) in combination with Y90 TARE in patients (Pts) with hepatocellular carcinoma (HCC)

TPS358

Background: The anti–PD-L1 antibody ATEZO prevents PD-L1 from interacting with PD-1 and B7.1, thus reinvigorating antitumor T cell activity. Anti-VEGF BEV can increase dendritic cell maturation, enhance T cell infiltration, and reduce myeloid-derived suppressor cells and regulatory T-cells in tumors. This combination has been FDA approved for first-line treatment of advanced HCC based on the IMbrave 150 study. On the other hand, locoregional radiotherapy (e.g., Y90 TARE) enhances the diversity of the intratumoral T cell receptor repertoire. It is the standard of care for pts with intermediate-stage HCC (iHCC). Based on preclinical and clinical data, we hypothesize that the combination of Y90 TARE, BEV, and ATEZO induces synergistic tumor-killing. Methods: This is an open-label, multicenter, randomized phase II study of Y90 TARE and BEV plus ATEZO compared with Y90 TARE alone in pts with unresectable IHCC. The primary study objective is to assess and compare the progression-free survival (PFS) (per mRECIST 1.1) of pts in each arm. The main secondary objective is to determine the safety and tolerability (CTCAE v5) of TARE combined with ATEZO and BEV in pts with HCC. Exploratory objectives are to assess the role of the immunoscore and PD-L1 expression levels in the prediction of improved clinical outcome in pts receiving Y-90 TARE and BEV plus ATEZO; the composition of tumor-infiltrating immune cell subtypes in predicting response to a chosen therapy; how Y90 therapy affects the proportion of antigen-presenting cells in the tumor; and symptoms experienced by pts receiving TARE and BEV plus ATEZO treatment, using patient-reported outcomes. Eligible pts have either HCC that is not amenable to surgical resection, confirmed by pathology review, or at least BCLC stage B HCC outside of downstaging criteria. Other standard eligibility criteria apply. Pts must have a pretreatment liver biopsy taken and then be randomized 1:1 to TARE (Arm A) or TARE followed by ATEZO and BEV (Arm B). Pts will have TARE mapping during week (wk) 1 and TARE treatment during wk 2. In Arm B, pts will start BEV plus ATEZO 4 wks (±1 wk) after TARE treatment. Pts will have abdominal MRI or CT scans every 12 weeks, CT scans of the chest every 24 wks, and a second tumor biopsy at 4 wks. Disease progression will be captured by both RECIST 1.1 and mRECIST. We plan to assess the safety of TARE with BEV and ATEZO in the first 10 pts randomized to Arm B for two cycles. If there are no grade ≥ 3 unexpected toxicities possibly, probably or definitely related to combined TARE plus BEV plus ATEZO, the study will continue to accrue 128 pts in total. Pts will continue study treatment (Arm B) for a total of 24 months from initiation of TARE or until intolerable toxicity or disease progression occur, whichever is earlier. Enrollment began in September 2020. Clinical trial information: NCT04541173.

Current State of Combination of Locoregional Therapies with Immune Checkpoint Inhibition

Advances in immunotherapy have changed the landscape of oncology over the past decade. Still, most patients with solid organ tumors do not derive a durable benefit from immunotherapies. How these tumors evade treatment has not been fully elucidated, but several studies are seeking ways to stimulate treatment response in these immunologically quiescent tumors. Of these, the combination of locoregional therapy with immune checkpoint inhibition is of interest to the interventional radiologist. This brief report provides an overview of current trials testing the effectiveness of locoregional therapy in combination with immune checkpoint inhibitors and identifies future research goals.

Pitfalls in the Diagnosis of Hereditary Fructose Intolerance

Establishing the diagnosis of hereditary fructose intolerance (HFI) remains difficult despite the availability of specific molecular genetic testing of the ALDOB gene. This is attributable, at least in part, to the lack of a specific and practical biomarker. We report the incidental diagnosis of HFI as a consequence of nontargeted genetic testing ordered for alternative indications in 5 patients, including 3 children and 2 adults. Two of the children were diagnosed with HFI after extensive evaluations that ultimately involved clinical or research exome sequencing. The third child was diagnosed with HFI during subsequent genetic testing of at-risk family members. Both adults learned to avoid fructose and remained asymptomatic of HFI before diagnosis. One was diagnosed with HFI during preconception, nontargeted expanded carrier screening. For the other, concern for HFI was initially raised by indeterminate direct-to-consumer genetic testing results. None of these patients presented with infantile acute liver failure or other acute decompensation. Our findings suggest that the emphasis of classic teaching on infantile liver failure after first exposure to fructose may be inadvertently increasing the likelihood of missing cases of HFI characterized by other manifestations. HFI is likely underdiagnosed and should be considered for patients with nonspecific findings as well as for individuals with significant aversion to sweets.

Suitability of the woodchuck HCC as a preclinical model for evaluation of intra-arterial therapies

The most commonly used preclinical models of hepatocellular carcinoma (HCC) are limited for use in testing of intra-arterial therapies such as transarterial chemoembolization and radioembolization. Issues encountered with the more commonly used animal models include dissimilarity in their disease development compared with humans and the size of the vasculature which can make intra-arterial therapy testing difficult or impossible. Here we describe the suitability of the woodchuck HCC model for testing of intra-arterial therapies. We describe the techniques for pre-embolization imaging assessment using CT and MRI, technical tips on performing angiography and embolization, and pathological assessment of treated liver.

High-dose hydroxocobalamin achieves biochemical correction and improvement of neuropsychiatric deficits in adults with late onset cobalamin C deficiency

Cobalamin C (cblC) deficiency is the most common inborn error of intracellular cobalamin metabolism caused by pathogenic variant(s) in MMACHC and manifests with methylmalonic acidemia, hyperhomocysteinemia, and hypomethioninemia with a variable age of presentation. Individuals with late‐onset cblC may be asymptomatic until manifesting neuropsychiatric symptoms, thromboembolic events, and renal disease. Although hydroxocobalamin provides a foundation for therapy, optimal dose regimen for adult patients has not been systematically evaluated. We report three adult siblings with late‐onset cblC disease, and their biochemical and clinical responses to high‐dose hydroxocobalamin. The 28‐year‐old proband presented with severe psychosis, progressive neurological deterioration, and deep venous thrombosis complicated by a pulmonary embolism. MRI studies identified lesions in the spinal cord, periventricular white matter, and basal ganglia. Serum homocysteine and methylmalonic acid levels were markedly elevated. Hydroxocobalamin at standard dose (1 mg/day) initially resulted in partial metabolic correction. A regimen of high‐dose hydroxocobalamin (25 mg/day) together with betaine and folic acid resulted in rapid and sustainable biochemical correction, resolution of psychosis, improvement of neurological functions, and amelioration of brain and spinal cord lesions. Two siblings who did not manifest neuropsychiatric symptoms or thromboembolism achieved a satisfactory metabolic control with the same high‐dose regimen. Hydroxocobalamin injection was then spaced out to 25 mg weekly with good and sustainable metabolic control. All three patients are compound heterozygotes for c.271dupA p.Arg91LysfsX14 and c.389A > G p.Tyr130Cys. This study highlights the importance of evaluating intracellular cobalamin metabolism in adults with neuropsychiatric manifestations and/or thromboembolic events, and demonstrates that high‐dose hydroxocobalamin achieves rapid and sustainable metabolic control and improvement in neuropsychiatric outcomes in adults with late‐onset cblC disease.

Oxytocin alleviates cellular senescence through oxytocin receptor-mediated extracellular signal-regulated kinase/Nrf2 signalling

BACKGROUND

Oxytocin (OT) is a neuropeptide hormone that has many beneficial biological effects, including protection against age-related disorders. However, less is known about its role in intrinsic skin ageing, which is accelerated by an increase in senescent cell fraction in skin tissue.

OBJECTIVES

To investigate the novel function and the underlying mechanism of OT in preventing cellular senescence in normal human dermal fibroblasts (NHDFs) isolated from the skin of female donors of different ages.

METHODS

NHDFs from young and old donors were exposed to conditioned medium from senescent or control NHDFs in the presence or absence of 10 nmol L^-1 OT for 3 days, and were continuously subcultured for 12 days. Subsequently, various age-associated signs of senescence including decreased proliferation rate, elevated p16 and p21 levels, and positivity for senescence-associated β-galactosidase expression were examined.

RESULTS

We found that OT suppressed senescence-associated secretory phenotype-induced senescence in NHDFs, and its effect depended on the age of the donor's NHDFs. The inhibitory effects of OT required signalling by OT receptor-mediated extracellular signal-regulated kinase/Nrf2 (nuclear factor erythroid 2-related factor 2). The age-dependent antisenescence effects of OT are closely related to hypermethylation of the OT receptor gene (OXTR).

CONCLUSIONS

Our findings bring to light the role of OT in the prevention of skin ageing, which might allow development of new clinical strategies. What's already known about this topic? Senescent keratinocytes and fibroblasts accumulate with age in the skin and contribute to the loss of skin function and integrity during ageing. Senescent cells secrete senescence-associated secretory phenotype (SASP), which includes the release of proinflammatory cytokines such as interleukin (IL)-6 and IL-1, chemokines, extracellular matrix-remodelling proteases and growth factors. The neuropeptide oxytocin (OT) and its receptor (OXTR) have protective effects against various age-related disorders. What does this study add? OT suppressed SASP-induced cellular senescence in normal human dermal fibroblasts (NHDFs), depending on the age of the NHDFs' donor. The inhibitory effects of OT on cellular senescence required OXTR-mediated phosphorylation of extracellular signal-regulated kinase, which enhanced nuclear localization of Nrf2, a vital factor in the antioxidant defence system. The age-specific antisenescent effects of OT were closely related to hypermethylation of OXTR. What is the translational message? Our results suggest that OT and OXTR agonists could be clinically promising agents for the improvement of age-associated skin ageing, especially in women.

Bridging Hepatocellular Carcinoma to Transplant: Transarterial Chemoembolization Response, Tumor Biology, and Recurrence after Transplantation in a 12-Year Transplant Cohort

PURPOSE

To evaluate tumor response to transarterial chemoembolization as well as biologic characteristics of the tumor as predictors of recurrence after transplantation in patients with hepatocellular carcinoma (HCC) who were bridged or down-staged to liver transplantation.

MATERIALS AND METHODS

An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, single-institution retrospective analysis was performed on all patients with HCC who were treated with the use of conventional transarterial chemoembolization or transarterial chemoembolization with drug-eluting embolics (DEE) over a 12-year period and who subsequently underwent liver transplantation (n = 142). Treatment response was based on modified Response Evaluation Criteria in Solid Tumors (mRECIST) imaging criteria and then correlated with tumor characteristics and recurrence. Of the 142 patients followed after transplantation, 127 had imaging after transarterial chemoembolization but before transplantation. Imaging response and post-transplantation recurrence were correlated with patient demographics, liver function, and tumor morphology. HCC recurred in 9 patients (mean time from transplantation, 526 days). Recurrence was analyzed with the use of univariate and multivariate statistics. Kaplan-Meier recurrence-free survival curves were calculated based on immediate imaging response before transplantation with the use of the log-rank test.

RESULTS

Before transplantation, 57% of patients (72/127) demonstrated complete response (CR) and 24% (31/127) showed partial response (PR). Complete pathologic necrosis occurred in 54% (39/72) of CR patients and 20% (6/31) of PR patients. Poor treatment response, defined as stable disease (SD) or progressive disease (PD), occurred in 18% of patients (24/127) before transplantation and was present in 67% of cases of recurrence (6/9; P < .001). Post-transplantation recurrence was present in 1.4% of patients (1/71) with CR and in 6.5% of patients (2/31) with PR. In patients with SD after transarterial chemoembolization, HCC recurred in 18.8% of transplant patients (3/16) and in 43% of patients (3/7) with PD. Larger pretreatment tumor size (P = .05), higher Child-Pugh score (P = .002), higher tumor grade at explantation (P = .04), and lymphovascular invasion at explantation (P = .008) also were associated with increased incidence of post-transplantation recurrence.

CONCLUSIONS

Poor tumor response to transarterial chemoembolization before transplantation identifies patients at increased risk for post-transplantation recurrence.

Growth hormone deficiency, aortic dilation, and neurocognitive issues in Feingold syndrome 2

We report three patients with Feingold 2 syndrome with the novel features of growth hormone deficiency associated with adenohypophyseal compression, aortic dilation, phalangeal joint contractures, memory, and sleep problems in addition to the typical features of microcephaly, brachymesophalangy, toe syndactyly, short stature, and cardiac anomalies. Microdeletions of chromosome 13q that include the MIR17HG gene were found in all three. One of the patients was treated successfully with growth hormone. In addition to expanding the phenotype of Feingold 2 syndrome, we suggest management of patients with Feingold 2 syndrome include echocardiography at the time of diagnosis in all patients and consideration of evaluation for growth hormone deficiency in patients with short stature.

Trans-Radial Embolization of Bleeding Renal Angiomyolipoma in Pregnant 30-Year-Old Female - A Case Report

Trans-radial access offers several unique advantages and is being used more frequently for interventional radiology procedures. We report the use of trans-radial arterial access to embolize a large bleeding angiomyolipoma in a 30-year-old pregnant patient presenting in the first trimester. Trans-radial approach was chosen to minimize the effects of radiation on the fetus. Subsequent postprocedural pregnancy course was uneventful with stability of the angiomyolipoma and no further hemorrhage. This case highlights the benefits of trans-radial embolotherapy in gravid patients to reduce the risk of radiation exposure to the fetus.

Utility of MR Angiography in the Identification of Prostatic Artery Origin Prior to Prostatic Artery Embolization

In 17 patients who underwent prostate artery embolization for treatment of lower urinary tract symptoms, the accuracy of preprocedural magnetic resonance (MR) angiography was retrospectively compared with intraprocedural digital subtraction angiography (DSA) in the identification of prostatic artery origin. Of 34 vessels, 26 MR angiography identified origins (76.5%) were confirmed by DSA at the time of embolization. Although image postprocessing is required, the ability of MR angiography to accurately identify prostatic artery origins prior to embolization is useful in treatment planning and can obviate the need for separate computed tomographic angiography, thus reducing both radiation dose and time demand on patients.

IFN-free therapy is associated with restoration of type I IFN response in HIV-1 patients with acute HCV infection who achieve SVR

Interferon (IFN)-free direct-acting antiviral agents (DAAs) have revolutionized chronic hepatitis C virus (HCV) treatment; early studies suggest excellent efficacy in acute HCV. However, changes in innate immune responses during DAA therapy for acute HCV are unknown. We studied interferon-stimulated gene (ISG) expression and related cytokines/chemokines in HIV-infected patients with acute HCV receiving sofosbuvir plus ribavirin (SOF+RBV) as part of the A5327 clinical trial. ISG expression was determined from PBMCs, and circulating cytokines/chemokines were quantified from serum from study participants. The overall sustained virologic response (SVR) was 57%; all treatment failures were due to virologic relapse. Apart from NOS2a, baseline ISG/chemokine/cytokine levels were similar irrespective of treatment outcome. Downregulation of ISGs was observed at treatment week four and end of treatment (EOT), implicating HCV in establishing elevated ISGs early during HCV infection. Levels of many of these ISGs increased at post-treatment week 12 (PTW12) in relapsers only, coinciding with recurrent HCV RNA. Eleven ISGs were differentially expressed in responders vs relapsers. On-treatment viral suppression was also associated with a reduction in IP-10, CXCL11 and MIP-1β levels. In contrast, circulating IFN-α levels were significantly higher at EOT and PTW12 in responders vs relapsers. Upregulation of peripheral ISG expression is established early in the course of HCV infection during acute HCV infection, but did not predict subsequent treatment outcome with SOF+RBV. ISGs were downregulated during therapy and increased post-therapy in relapsers. IFN-α levels were higher in responders at EOT/PTW12, suggesting that impaired type I IFN production/secretion may contribute to relapse.

Trans-intra-arterial gemcitabine versus continuation of IV gemcitabine and nab-paclitaxel following radiotherapy for locally advanced pancreatic cancer (TIGeR-PaC)

TPS529

Background: Treatment of locally advanced pancreatic cancer (LAPC) remains a challenge, and novel therapy options for local treatment of disease beyond systemic therapy are needed. Recently published data of intra-arterial delivery of gemcitabine (IAG) for local disease control has shown this approach to be safe (J. Pancreatic Cancer 3(1) 58:65). Furthermore, in patients who have received prior radiation for LAPC, there seems to be an effect on the local microvasculature that enhances the clinical efficacy of IAG. TIGeR-PaC is a randomized Phase 3 trial designed to test if the combination of induction systemic chemotherapy plus radiation followed by IAG is superior to systemic chemotherapy plus radiation alone (NCT03257033). Methods: All subjects with biopsy proven, and imaging-confirmed LAPC (by the NCCN guidelines) will receive induction therapy with IV gemcitabine plus nab-paclitaxel, for approximately four months, during which time a course of radiation therapy will also be incorporated. Subjects without evidence of disease progression will then be randomized to receive either IAG (test group); or continue only IV gemcitabine plus nab-paclitaxel (control group). Subjects will receive the randomized treatments for up to 16 weeks or until progression. Non-progressing patients from both groups will then receive, at the discretion of the investigator, either a continuation of IV gemcitabine and nab-paclitaxel, or oral capecitabine until disease progression. The primary endpoint is progression free survival; secondary endpoints will include overall survival, neutropenia, quality of life, and neuropathy assessed over 2 years. Based on an assumed superiority of IAG therapy, which will lead to an increased PFS from 6 months (control group) up to 12 months (IAG group), with an alpha-error of 0.05 and a 90% power, 132 patients will be randomized; assuming a 30% dropout during the induction phase prior to randomization, 200 patients will be recruited. TIGeR-PaC will test the hypothesis that IAG local therapy, after induction systemic chemotherapy plus radiation in patients with LAPC is superior to systemic therapy plus radiation alone. Clinical trial information: NCT03257033.

Molecular profiling to predict outcomes following Y90 radioembolization for metastatic colorectal cancer

686

Background: Radioembolizaton with yttrium-90 (Y90) has been shown to decrease progression within the liver in patients with unresectable metastatic colorectal cancer (CRC). Molecular profiling (MP) plays an important role in providing precision based therapy for our patients. The purpose of this study was to evaluate predictive associations between genetic mutations in Y90 treated CRC pts and treatment outcomes. Methods: A retrospective chart review of patients at GUMH was conducted for patients who underwent Y90 radioembolization for metastatic CRC between 2010 and 2017. Inclusion criteria were: Liver metastasis, Y90 treatment and MP. Y90 response of the treated liver lesions was evaluated according to RECIST criteria within 4 months of treatment; non-responders were classified as those with progressive disease (PD) and all others were considered responders. Statistical analysis was performed to reveal any significant associations. Results: Out of 285 CRC records with MP screened, 32 pts adhered to our inclusion criteria. Of these 47% were male and 53% female. The average age at diagnosis was 50.4 yrs. For22 pts (69%) Y90 treatment was combined with chemotherapy. Y90 response data showed response in 50% (n = 16) and PD in 31% (n = 10) of the pts. Six pts did not have Y90 response data. Median OS between groups was not significant but longer for those responders (33 vs 26 m). Next Generation Sequencing revealed pathogenic mutations for APC in 20 pts (63%), KRAS in 12 (38%) and TP53 in 13 pts (41%) none of them showing any significant association with Y90 response data (p > 0.05). OS from date of Y90 was significantly improved in patients with TP53 mutations and KRAS WT. There was no association between differences in MP and OS from date of diagnosis. Conclusions: TP53 and KRAS mutations were predictive of survival but not response following Y90 for metastatic colorectal cancer patients. This hypothesis generating study demonstrates the MP may be helpful in stratifying CRC patients who benefit from radiation therapy. Further study is necessary.

Technology of irreversible electroporation and review of its clinical data on liver cancers

INTRODUCTION

Irreversible electroporation (IRE) has developed as a novel percutaneous ablative technique over the past decade and its utility in the treatment of primary and metastatic liver disease has progressed rapidly.

AREAS COVERED

After discussing the principles behind the technology and the practical steps in its use, this article offers a detailed analysis of the recent published work that evaluates its safety and efficacy. The strengths and weaknesses of other ablative techniques, including radiofrequency ablation, microwave ablation and cryoablation, are discussed in detail. Other aspects of IRE, including post-treatment clinical follow-up, expected imaging findings, and the most frequently encountered complications, are covered. Finally, the future of IRE is examined as it pertains to advancements in the treatment of hepatic malignancy.

EXPERT COMMENTARY

The characteristics of IRE that make this technology uniquely suited for the treatment of liver tumors have allowed it to gain a significant foothold in interventional oncology. Continued development of IRE will lead to further advances in the management of previously untreatable liver cancers.

Short-term imaging response after drug-eluting embolic trans-arterial chemoembolization delivered with the Surefire Infusion System® for the treatment of hepatocellular carcinoma

Purpose

To review the initial imaging responses after drug-eluting embolic trans-arterial chemoembolization (DEE-TACE) delivered with the Surefire Infusion System ^® for the treatment of hepatocellular carcinoma (HCC).

Methods

Single center retrospective evaluation of patients who underwent DEE-TACE for HCC, delivered with SIS. Information was gathered from available medical records. Treatment response rates were assessed using the modified Response Evaluation Criteria in Solid Tumors criteria. Assessment of adverse events was categorized per Common Terminology Criteria for Adverse Events version 4.03.

Results

Twenty-two patients with 39 hepatocellular carcinoma lesions were treated with the surefire infusion system. Complete response was demonstrated in 32% of patients and 54% of lesions after a single treatment session. Overall disease response was demonstrated in 91% of patients and 85% of lesions after a single treatment. No grade 3 or higher elevations in liver function tests were demonstrated in the short-term.

Conclusion

SIS delivered DEE-TACE leads to a higher than expected initial response in patients with HCC.

Selective Release System for Antioxidative and Anti-Inflammatory Activities Using H2O2-Responsive Therapeutic Nanoparticles

We developed nanoparticles that were degraded by H₂O₂, a reactive oxygen species (ROS), to study a drug delivery system that targets damaged skin cells with oxidative stress and inflammation. In this study, tyrosol-incorporated copolyoxalate (TPOX) was synthesized by using 1,4-cyclohexanedimethanol, 4-(2-hydroxyethyl)phenol (tyrosol), and oxalyl chloride (M_w ∼ 8835 Da). In vitro drug release behavior was assessed by loading nile red, a lipophilic fluorescent material such as quercetin, into the TPOX nanoparticles. The results indicated that the release of TPOX nanopaticles depended on the H₂O₂ concentration, but was pH-independent. We confirmed that TPOX nanoparticles under oxidative conditions in oxidative- or inflammatory-damaged cells selectively released entrapped nile red through the degradation by H₂O₂ for contributing to antioxidant and anti-inflammatory effects. For application, we prepared and evaluated the cytoprotective effect of quercetin-loaded TPOX (QTPOX) nanoparticles against oxidative and inflammatory stress. They showed a strong cytoprotective effect against H₂O₂-induced cell damage in HaCaT and RAW 264.7 cells. Also, QTPOX nanoparticles inhibited the main factors of LPS-induced inflammation, including iNOS, COX-2, IL-1, TNF-α, and NO production. These results suggest that QTPOX as H₂O₂-responsive therapeutic nanoparticles is highly potent and versatile as drug delivery system through selective and intensive drug release mechanism for the treatment of abnormal and inflammatory skin diseases.

Radioembolization with yttrium-90 resin microspheres for liver metastases of pancreatic adenocarcinoma: A retrospective multicenter analysis

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Background: Patients with chemotherapy-treated metastatic pancreatic cancer typically survive for 7 to 11 months. Liver metastases from the pancreas are common and can reduce survival. Radioembolization of these metastases with Y-90 resin microspheres (Y-90 resin) may reduce tumor burden and improve prognosis, but data are limited. We report early data from a multicenter database of patients with pancreatic adenocarcinoma treated with Y-90 resin. Methods: Retrospective patient, treatment, and outcome data were entered by each site (Georgetown, U Maryland). Outcomes included overall survival (OS, determined with Kaplan-Meier analyses), response rate (RECIST), and adverse events (AEs; CTCAE v4.0). Results: Data from the first 24 patients (79% male, mean age 63 y [range 51-77 y]) were analyzed. ECOG status was 0 (n = 10), 1 (n = 13), and 2 (n = 1). Median (IQR) time from diagnosis to Y-90 resin was 10.2 (6.1) mo. Nine patients had extrahepatic disease. Median (IQR) dose delivered to the right (n = 14), left (n = 2), or whole (n = 8) liver was 1.36 (0.42) GBq. Y-90 resin was given concurrently with first-line chemotherapy in 12/21 patients (57%), with a minimum of 4 mo between the onset of chemotherapy and Y-90 resin treatment. Median OS was 6.0 mo (95% CI: 3.9, 12.5) from Y-90 resin and 16.7 mo (95% CI: 13.3, 26.1) from diagnosis. Five patients experienced a partial response. Most AEs were grade 1 or 2. Three patients had grade 3 AEs (abdominal distension or pain, fatigue, ascites, odynophagia, oral sores, biliary duct dilation), and 4 had grade 3 laboratory values (white blood cells, bilirubin, alkaline phosphatase, albumin). Two patients experienced grade 4 AEs, 1 with peripheral neuropathy and 1 with elevated ALT & AST suggesting post-radioembolization hepatitis. Conclusions: Overall, Y-90 resin was safe, with few serious AEs. Survival in this retrospective study was promising, given the generally poor prognosis for pancreatic adenocarcinoma; however, further investigation is needed.

Genetic basis for variation in plasma IL-18 levels in persons with chronic hepatitis C virus and human immunodeficiency virus-1 infections

Inflammasomes are multi-protein complexes integrating pathogen-triggered signaling leading to the generation of pro-inflammatory cytokines, including interleukin-18 (IL-18). Hepatitis C virus (HCV) and human immunodeficiency virus-1 (HIV) infections are associated with elevated IL-18, suggesting inflammasome activation. However, there is marked person-to-person variation in the inflammasome response to HCV and HIV. We hypothesized that host genetics may explain this variation. To test this, we analyzed the associations of plasma IL-18 levels and polymorphisms in 10 genes in the inflammasome cascade. 1538 participants with active HIV and/or HCV infection in 3 ancestry groups are included. Samples were genotyped using the Illumina Omni 1-quad and Omni 2.5 arrays. Linear regression analyses were performed to test the association of variants with logIL-18 including HCV and HIV infection status and HIV-RNA, in each ancestry group and then meta-analyzed. Eleven highly correlated SNPs (r2=0.98-1) in the IL18-BCO2 region were significantly associated with logIL-18; Each T allele of rs80011693 confers a decrease of 0.06 log pg/mL of IL-18 after adjusting for covariates (rs80011693; rs111311302 β=-0.06, P-value=2.7×10^-4). In conclusion, genetic variation in IL18 is associated with IL-18 production in response to HIV and HCV infection and may explain variability in the inflammatory outcomes of chronic viral infections.

Ledipasvir-sofosbuvir and sofosbuvir plus ribavirin in patients with chronic hepatitis C and bleeding disorders

INTRODUCTION

Chronic hepatitis C virus (HCV) infection is prevalent among patients with inherited bleeding disorders and is a leading cause of mortality in those with haemophilia.

AIM

We evaluated the efficacy and safety of ledipasvir-sofosbuvir and sofosbuvir plus ribavirin in patients with chronic HCV genotype 1-4 infection and an inherited bleeding disorder.

METHODS

Ledipasvir-sofosbuvir was administered for 12 weeks to patients with genotype 1 or 4 infection and for 12 or 24 weeks to treatment-experienced cirrhotic patients with genotype 1 infection. Patients with genotype 2 and 3 infection received sofosbuvir plus ribavirin for 12 and 24 weeks respectively.

RESULTS

The majority of the 120 treated patients had a severe bleeding disorder (55%); overall, 65% of patients had haemophilia A and 26% of patients had haemophilia B; 22% were HIV coinfected. Sustained virologic response at 12 weeks posttreatment was 99% (98/99) in patients with genotype 1 or 4 infection; 100% (5/5) in treatment-experienced cirrhotic patients with genotype 1 infection; 100% (10/10) in patients with genotype 2 infection; and 83% (5/6) in patients with genotype 3 infection. There were no treatment discontinuations due to adverse events (AEs). The most frequent non-bleeding AEs were fatigue, headache, diarrhoea, nausea and insomnia. Bleeding AEs occurred in 22 patients, of which all but one were considered unrelated to treatment.

CONCLUSION

Treatment with ledipasvir-sofosbuvir for patients with HCV genotype 1 or 4 infection or sofosbuvir plus ribavirin for patients with genotype 2 or 3 infection was highly effective and well tolerated among those with inherited bleeding disorders.

Incorporating Yttrium-90 trans-arterial radioembolization (TARE) in the treatment of metastatic pancreatic adenocarcioma: a single center experience

BACKGROUND

The purpose of this retrospective study was to evaluate the efficacy of incorporating trans-arterial radioembolization (TARE) with systemic chemotherapy in the treatment of liver-dominant metastatic pancreatic ductal adenocarcinoma, with the aim of destroying liver metastases and improving patient outcomes.

METHODS

We retrospectively evaluated 16 patients with liver-dominant metastatic pancreatic ductal adenocarcinoma who underwent TARE between February 2012 and August 2015; 15 of these patients also underwent concurrent systemic chemotherapy. Patient outcomes were assessed using Response Evaluation Criteria In Solid Tumors (RECIST), Version 1.1 and included disease response, median overall survival from the time of diagnosis of metastatic disease, and median overall survival following receipt of TARE. Treatment-related adverse events were assessed using Common Terminology Criteria for Adverse Events (CTCAE), Version 4.03.

RESULTS

The median overall survival from the time of diagnosis of metastatic disease and following receipt of TARE was 22.0 and 12.5 months, respectively. Overall and liver specific disease response were assessed for 13 patients with follow-up imaging available at the time of study (range 2-13 weeks post TARE). Four patients (31 %) demonstrated partial response and five patients (38 %) had stable disease in the liver at follow-up. One patient developed grade 3 elevation of total bilirubin three months post-treatment and another patient developed radiation cholecystitis directly following TARE. No treatment-related grade 4 or 5 toxicities were seen.

CONCLUSION

TARE can be safely combined with systemic chemotherapy for the treatment of liver-dominant metastatic pancreatic cancer. Patient outcomes following this treatment strategy are promising but prospective evaluations are needed to validate these preliminary findings.

Diverse clinical outcome and predictors for clinical outcome in patients with HCC treated with TACE

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Background: Hepatocellular carcinoma (HCC) is the sixth most common cancer, and the second leading cause of cancer-related death, worldwide. This reflects the challenges facing HCC treatment. Methods: Patients (pts) with HCC receiving TACE treatment (n = 96) were examined retrospectively for clinical outcome and its possible predictors. The number of TACE treatments and the time elapsed between each treatment were assessed and correlated with overall survival (OS) using the log rank test of Kaplan Meier curves. T-stage, level of differentiation, vascular invasion, and Child Pugh score at the time of HCC diagnosis were compared among pts who received different numbers of TACE treatments (Kaplan-Meier survival analysis, ANOVA and student T test). Results: TACE treated pts had a median OS of 46 month (mo) and progression free survival of 12 mo (difference in time between the date of first progression and the date of diagnosis). Pts received 1-2 (n = 52), 3-4 (n = 28), or 5-6 (n = 16) TACE treatments. We found that pts who had only 1-2 TACE treatments had significantly shorter median OS (38 mo) than those who received 3-4 or 5-6 treatments (48 and 83 mo; p < 0.05). Of the 96 pts studied 22, 33, 37, and 3 pts had T1, T2- T3 and T4-stage HCC, respectively. Only 39 pt tumors underwent pathological analysis, and 13 were well-differentiated (WD), while 24 were moderately- or poorly- differentiated (MPD) (p > 0.05). Tumor T-stage and differentiation were correlated with the number of TACE treatments received. Thus, 30% of pts (n = 10) with T2-stage disease compared with 10% (n = 4) with T3-stage disease received 5-6 TACE treatments (p < 0.001). Similarly, 30% of WD cases (n = 4) compared with only 8% of MPD cases (n = 2) received 5-6 TACE treatments (p < 0.001). The duration between the second and third TACE treatments ( < 4 mo, 5-8 mo or > 8 mo) seemed to correlate with outcome (p < 0.05). Conclusions: Pt survival time following TACE treatment is diverse and correlates with the number of TACE treatments. Pts with T3-stage, or MPD HCC tended to receive fewer TACE treatments than those with T2-stage or WD HCC, and have worse outcomes. Other therapies should certainly be considered for pts with T3-stage and/or MPD tumors.

Regorafenib in metastatic colorectal cancer: An exploratory biomarker trial

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Background: Treatment with Regorafenib (REGO) has shown significant clinical benefits in metastatic colorectal cancer (mCRC) patients (pts) as demonstrated in the CORRECT and CONCUR trials. Results from both studies suggest that subgroups have differential responses. Further research to identify these subgroups through the identification of molecular biomarkers is needed. Methods: Forty pts with refractory mCRC are being enrolled in this study. The primary objective is to prospectively identify tissue and serum-based biomarkers that can predict response to REGO. Secondary objectives are to determine molecular mechanisms by which REGO controls refractory mCRC, as well as molecular pathways involved in the acquisition of resistance. Tumor and blood samples are obtained prior to and 2 weeks after starting REGO. Blood samples are collected on day 1 of each cycle thereafter. Pts will receive 160 mg REGO daily for 3 weeks of each 4-week cycle until disease progression or unacceptable toxicity. Multi-omic based biomarker discovery approaches will be used to uncover predictive marker candidates with special attention to the tumor microenvironment. Laser capture microdissection will be used on tumor tissue to procure highly enriched populations of pt-matched epithelial and stromal/immune cell infiltrates. Each of these entities will be analyzed for RNA expression changes and protein signaling/drug target activation mapping. Protein signaling analysis will be performed by reverse phase protein array of key REGO-related proteins and phosphoproteins (e.g. phosphoVEGFR, Tie2, phosphoRET), as well as broad-scale mapping of mitogenic, survival, autophagy, inflammatory, motility, and signaling networks. Tumor profiling will include next-generation sequencing for 592 genes with 53 selected gene fusions, and IHC and FISH/CISH for selected biomarkers, including PDL1, HER2, MSI, TS, ERCC1, and TOPO1. Blood samples will undergo protein, miRNA, and mutated DNA analysis, as well as exosomal signature study via a proprietary synthetic polyligand multiplexed aptamer-based assay. Exploratory analysis of biomarkers will be used to determine correlations between the presence of, or change in, biomarker levels and clinical response. Clinical trial information: NCT01949194.

The impact of the multiple types of treatments on OS and the decline of liver function in patients with advanced stage of HCC

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Background: Hepatocellular carcinoma (HCC) is the sixth most common cancer and the second leading cause of cancer-related death worldwide. Most HCCs develop in severely damaged liver. Methods: The effect of multiple treatment options on liver function (LF) and disease outcome of patients (pts) with HCC (n = 185) were examined retrospectively. Pt tumor burden (using Barcelona clinic liver cancer [BCLC] classification) and LF (Child Pugh [CP]) were assessed at time of diagnosis and then after treatment. Using Kaplan Meier with log rank and T tests, BCLC and CP scores were correlated with overall survival (OS) following individual treatment regimens. Results: We show that better BCLC and LF scores at time of diagnosis predict a better outcome (median OS; p < 0.05). Pts received one or more of the following: no treatment, experimental treatment, TACE, Y90 radioembolization, radiofrequency ablation, resection, radiation, and sorafenib (SFB). Considering all treatment scenarios, LF improved in 9.5%, did not change in 33%, and worsened in 57% of pts. Sixty percent of untreated pts experienced LF decline, compared with 33, 54, 48 and 50% of pts receiving TACE, SFB, TACE/SFB, and Y90/SFB, respectively (no significant differences [NS]); 72% of pts receiving TACE/Y90/SFB (NS); and 85% of pts receiving other Y90/SFB combinations (p = 0.006). In general, pts who saw no change or an improvement in LF from baseline had longer median OS versus pts who had declining LF (p < 0.002). However, pts receiving TACE/Y90/SFB (n = 29) had similar OS to those receiving TACE/SFB (n = 35), despite the toxicity difference (72% [TACE/Y90/SFB] vs. 48% [TACE/SFB] of pts had declining LF). TACE/SFB or TACE/Y90/SFB led to longer median OS than any other treatment group (p = 0.017). Conclusions: The outcome of pts with HCC depends on disease stage and LF. Most pts experience LF decline during treatment. Despite LF decline in 48% of pts receiving a SFB/TACE, these pts experienced longer median OS than pts on any other treatment. Balancing survival benefit with liver toxicities is critical to the successful treatment of pts with advanced HCC. Agents with good antitumor activity and minimal liver toxicity are desperately needed for these pts.

Incorporating trans-arterial radioembolization (TARE) in the treatment of metastatic pancreatic adenocarcioma: A single center experience

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Background: There is a lack of data on the potential efficacy of the incorporation of trans-arterial radioembolization (TARE) for metastatic pancreatic adenocarcinoma. We retrospectively evaluated the efficacy of TARE in the management of patients with liver dominant metastatic pancreatic adenocarcinoma Methods: Sixteen patients were treated with concurrent systemic therapy and TARE for liver-dominant pancreatic adenocarcinoma from February, 2014 to August, 2015. Electronic chart review was performed for this group of patients to assess response Results: Eleven male and 5 female patients were treated for liver dominant metastatic pancreatic adenocarcinoma with Yttrium-90 resin microspheres. The average age was 64 (50 - 77). All patients were treated with at least one line of systemic therapy. Five had prior or concurrent SBRT treatment for the primary lesion. Eleven patients had extra-hepatic disease with evidence of nodal, pulmonary and/or omental disease on pretreatment imaging. All patients had adequate hepatic reserve and functional status at treatment. Eight of the 16 patients were alive at the time of analysis. The median overall survival from diagnosis of liver metastases to time of analysis is 22 months (11 – 50, 95% CI). The median time of survival from TARE is 12.5 months (4 – not reached, 95% CI). The estimated survival rate at 6 months, 1 year, 2 year and 3 years from diagnosis is 100%, 84%, 39% and 26%. Follow up imaging was available on 13 patients. Local PR, SD and PD based on RECIST criteria were seen in 4 (31%), 7 (54%) and 2 (15%) patients. The average local and systemic PFS was 4.9 and 3.4 months, respectively Conclusions: We found promising results for the incorporation of TARE in the treatment of patients with metastatic pancreatic adenocarcinoma. In our cohort, the median overall survival from the time of metastatic diagnosis was 22 months, a significant improvement from the expected median survival. Although our data is promising, there are inherent weaknesses of our study due to the small number of patients and its retrospective nature. Further studies are needed to validate our findings. For this purpose, a prospective trial is currently being in development.

Metabolic Syndrome Is not an Independent Risk Factor for Hearing Impairment

OBJECTIVE

We aimed to investigate the association between metabolic syndrome (MS) and hearing impairment (HI) using nationally representative data from Korean adults.

DESIGN, SETTING AND PARTICIPANTS

A total of 16,799 subjects (≥19 years old; 7,170 men and 9,629 women) who underwent pure tone audiometry testing were included in the analysis. Data were obtained from the fifth Korea National Health and Nutrition Examination Survey (2010-2012). Subjects were divided into two groups according to the presence of MS.

RESULTS

Among the subjects with MS, 47% had HI. Logistic regression analysis revealed that MS was not an independent risk factor for HI, although increased fasting plasma glucose (OR 1·4, 95% CI: 1·1-1·8) was independently associated with HI. In addition, older age, male sex, very low body mass index (≤17·5 kg/m2), lower education level, smoking history, and occupational noise exposure were independently associated with HI. For low-frequency HI, independent risk factors included older age, lower educational level, lower economic status, and very low BMI (≤17·5 kg/m2). For high-frequency HI, independent risk factors included older age, male sex, lower educational level, lower economic status, increased blood pressure, lower high-density lipoprotein cholesterol, and smoking history.

CONCLUSIONS

MS itself was not an independent risk factor for HI, and, among the individual metabolic components, only increased fasting plasma glucose was independently associated with HI.

A longitudinal study of hepatitis C virus testing and infection status notification on behaviour change in people who inject drugs

BACKGROUND

Hepatitis C virus (HCV) testing and counselling have the potential to impact individual behaviour and transmission dynamics at the population level. Evidence of the impact of an HCV-positive status notification on injection risk reduction is limited. The objective of our study was to (1) assess drug and alcohol use and injection risk behaviours following notification; (2) to compare behaviour change in people who inject drugs (PWID) who received a positive test result and those who remained negative; and (3) to assess the effect of age on risk behaviour.

METHODS

Data from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study) were analysed. Participants who were initially HCV seronegative were followed prospectively with periodic HCV blood testing and post-test disclosure and interview-administered questionnaires assessing drug use and injection behaviours. Multivariable generalised estimating equations were used to assess behavioural changes over time.

RESULTS

Notification of an HCV-positive test was independently associated with a small increase in alcohol use relative to notification of a negative test. No significant differences in postnotification injection drug use, receptive sharing of ancillary injecting equipment and syringe borrowing postnotification were observed between diagnosis groups. Younger PWID receiving a positive HCV test notification demonstrated a significant increase in subsequent alcohol use compared with younger HCV negative.

CONCLUSIONS

The proportion of PWID reporting alcohol use increased among those receiving an HCV-positive notification, increased the frequency of alcohol use postnotification, while no reduction in injection drug use behaviours was observed between notification groups. These findings underscore the need to develop novel communication strategies during post-test notification to improve their impact on subsequent alcohol use and risk behaviours.

Clinical impact of treatment timing for chronic hepatitis C infection: a decision model

Recent advances in the treatment of hepatitis C virus (HCV) infection have led to the availability of both highly efficacious interferon-containing and interferon-sparing regimens. However, the use of such therapies faces restrictions due to high costs. For patients who are medically eligible to receive interferon, the choice between the two will likely be impacted by preferences surrounding interferon, severity of disease, coverage policies and out-of-pocket costs. We developed a decision model to quantify the trade-offs between immediate, interferon-containing therapy and delayed, interferon-free therapy for patients with chronic, genotype 1 HCV infection. We projected the quality-adjusted life expectancy stratified by the presence or absence of cirrhosis for four strategies: (i) no treatment; (ii) immediate, one-time treatment with an interferon-containing regimen; (iii) immediate treatment as above with the opportunity for retreatment in patients who fail to achieve sustained virologic response with interferon-free therapy in 1 year; and (iv) delayed therapy with interferon-free therapy in 1 year. When compared to one-time immediate treatment with the interferon-containing regimen, delayed treatment with the interferon-free regimen in 1 year resulted in longer life expectancy, with a 0.2 quality-adjusted life year (QALY) increase in noncirrhotic patients, and a 1.1 QALY increase in patients with cirrhosis. This superiority in health benefits was lost when wait time for interferon-free therapy was greater than 3-3.2 years. In this modelling analysis, interferon-free therapy resulted in superior health benefits compared to immediate therapy with interferon until wait time exceeded 3-3.2 years. Such data can inform decision-making regarding treatment initiation for HCV as healthcare financing evolves.

Effect of nanogroove geometry on adipogenic differentiation

We present the effect of nanotopographically defined surfaces on adipocyte differentiation using various nanogroove patterns. Parallel nanogroove arrays with equal inter-groove distance (400, 550, 800 nm width) and varying distances (550 nm width with three different spacings of 550, 1100, and 2750 nm) were fabricated by UV-assisted capillary force lithography (CFL) on 18 mm diameter glass coverslips using biocompatible polyurethane (PU)-based material. After coating with fibronectin and subsequent culture of 3T3-L1 preadipocytes, the degree of adipocyte differentiation was determined by Oil Red O staining and adipogenic gene expression. We observed that adipocyte differentiation was slightly but substantially affected by culture on various nanogrooved surfaces. In particular, the cell crawling into nanogrooves contributed substantially to an enhanced level of differentiation with higher contact guidance, suggesting that cell-to-surface interactions would play a role for the adipocyte differentiation.

SCCRO (DCUN1D1) is an essential component of the E3 complex for neddylation

Covalent modification of cullins by the ubiquitin-like protein NEDD8 (neddylation) regulates protein ubiquitination by promoting the assembly of cullin-RING ligase E3 complexes. Like ubiquitination, neddylation results from an enzymatic cascade involving the sequential activity of a dedicated E1 (APPBP1/Uba3), E2 (Ubc12), and an ill-defined E3. We show that SCCRO (also known as DCUN1D1) binds to the components of the neddylation pathway (Cullin-ROC1, Ubc12, and CAND1) and augments but is not required for cullin neddylation in reactions using purified recombinant proteins. We also show that SCCRO recruits Ubc12 approximately NEDD8 to the CAND1-Cul1-ROC1 complex but that this is not sufficient to dissociate or overcome the inhibitory effects of CAND1 on cullin neddylation in purified protein assays. In contrast to findings in cellular systems where no binding is seen, we show that SCCRO and CAND1 can bind to the neddylated Cul1-ROC1 complex in assays using purified recombinant proteins. Although neddylated (not unneddylated) Cul1-ROC1 is released from CAND1 upon incubation with testis lysate from SCCRO+/+ mice, the addition of recombinant SCCRO is required to achieve the same results in lysate from SCCRO(-/-) mice. Combined, these results suggest that SCCRO is an important component of the neddylation E3 complex that functions to recruit charged E2 and is involved in the release of inhibitory effects of CAND1 on cullin-RING ligase E3 complex assembly and activity.

Gastric schwannomas: radiological features with endoscopic and pathological correlation

AIM

To describe the radiological, endoscopic, and pathological findings of gastric schwannomas in 16 patients.

MATERIALS AND METHODS

The radiological, endoscopic, and pathological findings of 16 surgically proven cases of gastric schwannoma were retrospectively reviewed. All patients underwent computed tomography (CT) and four patients were evaluated with upper gastrointestinal series. Two radiologists reviewed the CT and upper gastrointestinal series images by consensus with regard to tumour size, contour, margin, and growth pattern, the presence or absence of ulcer, cystic change, and the CT enhancement pattern. Endoscopy was performed in eight of these 16 patients. Six patients underwent endoscopic ultrasonography. Pathological specimens were obtained from and reviewed in all 16 patients. Immunohistochemistry was performed for c-kit, CD34, smooth muscle actin, and S-100 protein.

RESULTS

On radiographic examination, gastric schwannomas appeared as submucosal tumours with the CT features of well-demarcated, homogeneous, and uncommonly ulcerated masses. Endoscopy with endoscopic ultrasonography demonstrated homogeneous, submucosal masses contiguous with the muscularis propria in all six examined cases. On pathological examination, gastric schwannomas appeared as well-circumscribed and homogeneous tumours in the muscularis propria and consisted microscopically of interlacing bundles of spindle cells. Strong positivity for S-100 protein was demonstrated in all 16 cases on immunohistochemistry.

CONCLUSION

Gastric schwannomas appear as submucosal tumours of the stomach and have well-demarcated and homogeneous features on CT, endoscopic ultrasonography, and gross pathology. Immunohistochemistry consistently reveals positivity for S-100 protein in the tumours.

Secretin-stimulated MRCP

Secretin-stimulated magnetic resonance cholangiopancreatography not only facilitate the depiction of anatomic variations or morphologic changes of the pancreatic duct in the normal and diseased pancreas but also help assessing functional abnormalities of the exocrine pancreas. In this article, we illustrate findings of normal pancreas and various pancreatic diseases on magnetic resonance cholangiopancreatography after secretin stimulation.

Characterization of full-length hepatitis C virus genotype 4 sequences

Over 85% of the world's nearly 170 million hepatitis C virus (HCV)-infected subjects exist in regions of Africa, Southeast Asia and Middle Eastern countries where genotypes 4-6 are very common. In particular, HCV genotype 4 is highly prevalent in Egypt with more than 19% of the population infected and chronic HCV representing one of the top five leading causes of death, due in part to ineffective interferon alpha treatment against this genotype. Despite this, very little work has been carried out to characterize the sequence diversity of genotype 4, which will be critical to the development of effective vaccines and antiviral therapies against this genotype. As a result of the paucity of sequence data available for HCV genotype 4, for which only one full genome sequence is currently available, we were interested in characterizing additional genotype 4 sequences and to provide reagents for amplification of this genotype. Here we describe seven unique HCV genotype 4a full genomes, in addition to a single genotype 4d genome, and characterize their sequence diversity in relation to other more closely characterized HCV genotypes.

Primary sclerosing lipogranuloma of the rectum: CT findings

Sclerosing lipogranuloma is a rare, benign disease which is a peculiar granulomatous reaction of fatty tissue. This disease affects multiple organs and the majority of cases are secondary to exogenous foreign bodies. The authors report a case of primary sclerosing lipogranuloma of the rectum mimicking a submucosal rectal tumour.

Autoimmune pancreatitis: radiologic findings in 20 patients

BACKGROUND

Autoimmune pancreatitis is a new clinical entity that is characterized by peculiar histopathologic and laboratory findings and by a dramatic clinical response to corticosteroid therapy. We evaluated the radiologic findings of autoimmune pancreatitis.

METHODS

Computed tomographic, magnetic resonance imaging, endoscopic retrograde cholangiopancreatographic, and ultrasonographic findings of 20 patients with autoimmune pancreatitis in our hospital between November 2000 and December 2003 were retrospectively reviewed regarding changes and ancillary findings in the pancreatic parenchyma, the main pancreatic duct, peripancreatic vessels, and distal common bile duct. In addition, follow-up images were reviewed for changes in any abnormality seen on the initial examinations.

RESULTS

Pancreatic parenchymal enlargement was invariably seen that was diffuse (n = 19) or focal (n = 1), with homogeneous contrast enhancement on computed tomography (n = 20) and magnetic resonance imaging (n = 15). Capsule-like rim enhancement was seen in six patients. There was focal (n = 18) or diffuse (n = 2) narrowing of the main pancreatic duct and it was usually multifocal (n = 17) in the former. Narrowing of the peripancreatic veins was seen in 14 patients. There was tapered (n = 15) or abrupt (n = 3) narrowing of the distal common bile duct in 18 patients, with contrast enhancement of the narrowed segment in eight. Invariably, changes in the pancreatic parenchyma, main pancreatic duct, peripancreatic vessels, and common bile duct were normalized on follow-up studies after steroid therapy.

CONCLUSION

In this series, common radiologic findings of autoimmune pancreatitis were (a) diffuse pancreas enlargement, (b) multifocal narrowing of the main pancreatic duct, (c) narrowing of peripancreatic veins, and (d) tapered narrowing of the distal common bile duct with frequent contrast enhancement. These findings were usually reversible with steroid therapy.

Gastric cancer by multidetector row CT: preoperative staging

The role of computed tomography (CT) in the preoperative staging of gastric cancer, even if controversial, may be fundamental for evaluating the local extent and nodal involvement of the disease, especially in locally advanced cases. However, previous results of CT staging have not been satisfactory for predicting the invasive depth of the tumor or possible nodal metastases. Recently introduced multidetector row CT (MDCT) and three-dimensional (3D) imaging are expected to overcome the limitations in cancer staging by offering rapid and accurate information for space perception, detailed hemodynamics, and real-time 3D processing of volumetric data sets. In particular, virtual endoscopic imaging may be helpful for detecting early gastric cancer. In our experience, T and N stagings of gastric cancer were improved with 3D MDCT when using volume rendering and virtual endoscopic imaging compared with conventional axial two-dimensional (2D) CT (accuracy of T staging with 3D vs. 2D CT images, 84% vs. 77%; accuracy of N staging, 63% vs. 61% with 3D vs. 2D images, respectively). In particular, the detection rate of early gastric cancer was markedly increased up to 96% when using 3D MDCT. Therefore, we believe that 3D MDCT of the stomach may enhance the performance of CT in the preoperative evaluation of patients who have gastric cancer by offering easy early detection of lesions and accurate tumor staging through the 3D imaging process.

Abdominal cavernous Iymphangiomas: CT findings

Two adult patients with histopathologically proved cavernous lymphangiomas and one adult patient with lymphangiomas of strongly presumed cavernous type by cytologic and computed tomographic findings are reported. On computed tomograms, multiple, aggregated, small, and tiny cysts without a solid portion, along the lymphatic channels are characteristic computed tomographic findings for cavernous lymphangiomas.

Accuracy of magnetic resonance cholangiopancreatography for locating hepatolithiasis and detecting accompanying biliary strictures

BACKGROUND AND STUDY AIMS

Magnetic resonance cholangiopancreatography (MRCP) is rapidly replacing diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in various pancreaticobiliary diseases. This study was designed to evaluate the accuracy of MRCP in detection of hepatolithiasis and accompanying biliary strictures.

PATIENTS AND METHODS

A prospective study over 2 years was conducted in 66 patients with primary intrahepatic stones. All patients with hepatolithiasis underwent percutaneous transhepatic cholangioscopy (PTC) within 2 weeks of the MRCP examination. The MRCP findings were compared with those of PTC as the reference standard for assessing the location of intrahepatic stones and the presence or absence of accompanying biliary strictures.

RESULTS

The sensitivity, specificity, and accuracy of MRCP for detecting and locating intrahepatic stones were 97 %, 99 %, and 98 %, respectively. The sensitivity, specificity, and accuracy of MRCP for detecting and locating intrahepatic bile duct strictures were 93 %, 97 %, and 97 %, respectively. During PTC, six of the 66 patients (9 %) were found on histology to have intraductal cholangiocarcinoma in stone-bearing ducts, which had not been suspected on MRCP.

CONCLUSIONS

In this study, MRCP allowed intrahepatic stones and accompanying biliary strictures to be located accurately. MRCP may therefore be able to replace diagnostic ERCP in patients with primary intrahepatic stones. However, MRCP had a limited ability to reveal concurrent intraductal cholangiocarcinoma associated with hepatolithiasis.