Clinical implication of the geometric location (fundal end versus cystic ductal end) of gallbladder cancer

BACKGROUND

Management of early-stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder.

METHODS

The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery.

RESULTS

A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence-free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology.

CONCLUSIONS

Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.

Risk of Ischemic Heart Disease in Patients With Postpancreatectomy Diabetes and Pancreatic Cancer: A Population-Based Study

BACKGROUND

Postpancreatectomy diabetes can be caused by resection of functioning pancreatic tissue and is associated with postoperative pancreatic islet cell mass loss and subsequent endocrine dysfunction. Diabetes is a well-known risk factor for ischemic heart disease. However, no previous studies have investigated ischemic heart disease in patients with postpancreatectomy diabetes and pancreatic cancer.

METHODS AND RESULTS

Rates of patients with diabetes diagnosed with pancreatic cancer who underwent pancreatectomy between 2002 and 2019 in South Korea were obtained from the Korean National Health Insurance Service database. Patient-level propensity score matching was conducted to reduce the possibility of selection bias, and multivariate Cox proportional hazards models were used to determine the association between postpancreatectomy diabetes and ischemic heart disease. In total, 30 242 patients were initially enrolled in the study. After applying exclusion criteria and propensity score matching, 2952 patients were included in the comparative analysis between the postpancreatectomy group with diabetes and the group without diabetes. Patients in the postpancreatectomy group with diabetes had significantly higher rates of ischemic heart disease than those in the group without diabetes. In total, 3432 patients were included in the comparison between the postpancreatectomy and prepancreatectomy groups with diabetes. There was no significant difference in the risk of ischemic heart disease between the postpancreatectomy and prepancreatectomy groups with diabetes.

CONCLUSIONS

Patients who developed diabetes after pancreatectomy had a higher risk of ischemic heart disease than patients who did not develop diabetes after pancreatectomy, and the rate of ischemic heart disease in these patients was similar to that in patients preoperatively diagnosed with diabetes.

Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report

BACKGROUND

Laparoscopic choledocholithotomy for a large impacted common bile duct (CBD) stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications, even in this era of minimally invasive surgery. Herein, we present a case of large impacted CBD stones.

CASE SUMMARY

A 71-year-old man showed a distal CBD stone (45 mm × 20 mm) and a middle CBD stone (20 mm × 15 mm) on computed tomography. Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum. Laparoscopic choledocholithotomy was decided, and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately. Then, the location, size, and shape of the stones were detected using a laparoscopic intraoperative ultrasound. The CBD was opened with a 2-cm-sized vertical incision. After irrigating several times, two CBD stones were removed with the Endo BabcockTM. T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge. The patient had no postoperative complications.

CONCLUSION

Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Comparison between radiofrequency ablation and CHIVA procedure in patients with varicose veins

OBJECTIVE

Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire, the French acronym for CHIVA, is a strategy aimed to convert a venous reflux into a physiological drainage. We compared CHIVA with radiofrequency ablation and determined its possible advantages.

METHODS

We retrospectively analyzed the clinical recurrence, ultrasound recurrence, quality of life scores, and complications. They were compared after propensity score matching.

RESULTS

212 limbs of 166 patients were included: 42 limbs underwent radiofrequency ablation and 170 limbs underwent CHIVA. The hospital stay was shorter in the CHIVA group. There was no difference in clinical, ultrasound recurrence, quality of life scores and complications between the two groups. The preoperative saphenous vein diameter was larger in the recurrence cases.

CONCLUSIONS

CHIVA showed comparable results to radiofrequency ablation. There was more ultrasound recurrence with larger vein diameters. The CHIVA appears to be a simple and more efficient treatment method when performed on select patients.

AB0344 EFFICACY OF SUBCUTANEOUS INFLIXIMAB (CT-P13 SC) COMPARED WITH INTRAVENOUS INFLIXIMAB IN RHEUMATOID ARTHRITIS: A POST-HOC ANALYSIS OF A PHASE 3 RANDOMIZED CONTROLLED TRIAL

Background

Subcutaneous (SC) CT-P13 is the first and only subcutaneous formulation of infliximab (IFX) approved by the EMA.1 In the pivotal study (NCT03147248), non-inferiority of SC IFX to intravenous (IV) was demonstrated in rheumatoid arthritis (RA) patients using 28-joint Disease Activity Score (DAS28) C-reactive protein (CRP) improvement at Week 22, with a statistically significant treatment difference of 0.27 (95% CI 0.02, 0.52) favoring the SC versus the IV arm.2,3 At Week 30, numerical differences in efficacy outcomes were shown between SC and IV IFX favoring SC IFX. IV group patients switched to SC IFX by Week 30, and the difference between the groups was reduced at Week 54.2

Objectives

To investigate whether there was a statistically significant difference between SC and IV IFX at Weeks 30 and 54 in the phase 3 pivotal study of CT-P13 SC using conservative missing imputation methods.

Methods

Patients with active RA who had an inadequate response to MTX received IV IFX 3mg/kg at Weeks 0 and 2 for induction and were randomized at a 1:1 ratio to receive SC IFX 120mg every 2 weeks or IV 3mg/kg every 8 weeks thereafter for maintenance. Patients who were randomized to receive IV IFX switched to SC at Week 30. In this post-hoc analysis, non-responder imputation (NRI) and last observation carried forward (LOCF) methods were used to investigate whether the difference in efficacy outcomes between SC and IV IFX at Weeks 30 and 54 was statistically significant. Assessments included EULAR (CRP/ESR)/ACR response; remission rate and low disease activity (LDA) rate based on DAS28 (CRP/ESR), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI); Boolean remission rate; and the proportion of patients achieving a minimal clinically important difference (MCID) in Health Assessment Questionnaire (HAQ).

Results

Of the 343 randomized patients, 165 patients who received SC IFX and 174 patients who received IV IFX from the efficacy population were included in the analysis. There was a statistically significant difference in SC IFX compared to IV treated patients at Week 30 using both NRI and LOCF methods in almost all the clinical variables. However, the difference in efficacy outcomes between SC IFX and IV was reduced at Week 54 after the IV group switched to SC. This supports the improved efficacy of SC IFX at Week 30. Some of the key results (EULAR [CRP] responses, LDA rates based on DAS28 [CRP], CDAI, and SDAI) were presented in Figure 1. Analysis using LOCF and NRI methods yielded consistent results across most of the efficacy outcomes.

Figure 1.

Comparison of clinical outcomes between SC IFX and IV IFX in patients with active rheumatoid arthritis.

*P<0.05.

P-value for difference in proportion between SC and IV treatment group was obtained by asymptotic Wald test.

Low disease activity based on DAS28 (CRP) (< 3.2), CDAI (eatment group AI (≤ 11.0).

Conclusion

Statistical analyses using conservative missing imputation methods showed significantly greater improvements in clinical outcomes with SC IFX compared to IV at Week 30 in patients with RA. Between-group differences was reduced at Week 54, suggesting improved responses after switching from IV to SC.

References

[1]Remsima summary of product characteristics. https://www.ema.europa.eu/en/documents/product-information/remsima-epar-product-information_en.pdf. Published 2021. Accessed 10 January 2022.

[2]Westhovens R, Wiland P, Zawadzki M, et al. Efficacy, pharmacokinetics and safety of subcutaneous versus intravenous CT-P13 in rheumatoid arthritis: a randomized phase I/III trial. Rheumatology (Oxford). 2021;60(5):2277-2287.

[3]Combe B, Allanore Y, Alten R, et al. Comparative efficacy of subcutaneous (CT-P13) and intravenous infliximab in adult patients with rheumatoid arthritis: a network meta-regression of individual patient data from two randomised trials. Arthritis Res Ther. 2021;23(1):119.

Disclosure of Interests

Arnaud Constantin Speakers bureau: Abbvie, Amgen, Boehringer, Celltrion, Galapagos, Janssen, Lilly, Novartis, Sanofi, UCB, Consultant of: Abbvie, Amgen, Boehringer, Celltrion, Galapagos, Janssen, Lilly, Novartis, Sanofi, UCB, Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Lilly, Pfizer, Fresenius-Kabi, MSD, UCB, Roche,Janssen, Novartis, Sandoz, Consultant of: Abbvie, Amgen, BMS, Celltrion, Galapagos, Lilly, Pfizer, MSD, UCB, Janssen, Novartis, Sandoz, Christopher John Edwards Speakers bureau: Abbvie, Astra Zeneca, Celltrion, Chugai, Fresenius, Galapagos, Gilead, GSK, Lilly, Janssen, Pfizer, Roche, Consultant of: Abbvie, Astra Zeneca, Chugai, Galapagos, Gilead, GSK, Lilly, Janssen, Pfizer, Roche, Grant/research support from: Celltrion, Pfizer, Abbvie, Joao Eurico Fonseca Speakers bureau: Abbvie, Ache, Janssen, Lilly, Medac, Novartis, Pfizer, Consultant of: Abbvie, Celltrion, Janssen, Lilly, Pfizer, Grant/research support from: Abbvie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Florenzo Iannone Speakers bureau: Abbvie, BMS, Celltrion, Galapagos, MSD, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, BMS, Celltrion, Galapagos, MSD, Eli-Lilly, Janssen, Pfizer, Grant/research support from: BMS, MSD, Edward Keystone Speakers bureau: Amgen, AbbVie, Celltrion, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi Genzyme, Consultant of: AbbVie, Amgen, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Grant/research support from: Amgen, Merck, Pfizer Pharmaceuticals, Hendrik Schulze-Koops Consultant of: Celltrion, Taeksang Kwon Employee of: Celltrion Healthcare, Seungmin Kim Employee of: Celltrion Healthcare, Sangwook Yoon Employee of: Celltrion Healthcare, Dong-Hyeon Kim Employee of: Celltrion Healthcare, Gahee Park Employee of: Celltrion Inc., DaeHyun Yoo Speakers bureau: Celltrion, Celltrion Healthcare

POS0911 SIMILAR CLINICAL RESPONSES ACHIEVED WITH LOWER VERSUS STANDARD DOSES OF INFLIXIMAB BIOSIMILAR CT-P13 IN PATIENTS WITH ANKYLOSING SPONDYLITIS: REAL-WORLD RESULTS FROM THE RAAS STUDY

Background:

CT-P13, an infliximab biosimilar, is effective for treating ankylosing spondylitis (AS) at a dose of 5 mg/kg infused once every 6–8 weeks. Evidence suggests that patients with AS may benefit from a lower dose, and individualised dose/interval adjustments should be based on treatment response.

Objectives:

To analyse real-world treatment patterns (doses and infusion intervals) and outcomes for CT-P13-treated patients with AS over 5 years.

Methods:

The RAAS study collected medical record data for adults with AS treated with CT-P13 at five referral hospitals in the Republic of Korea (2012–2017). Patients were infliximab naïve at CT-P13 initiation (‘naïve’) or had switched to CT-P13 from reference infliximab (‘switched’). Patients were analysed by baseline dose (BD) (<4 mg/kg; ≥4–<5 mg/kg; ≥5 mg/kg), defined as the third (naïve) or first (switched) infusion dose. Baseline infusion intervals were the average of the three infusion intervals after BD. Over time, patients with both constant dose and infusion interval were compared with those with changes in dose and/or infusion interval. Data were analysed by Kruskal–Wallis test, chi-squared test and one-way analysis of variance, and drug survival by log-rank test.

Results:

Overall, 337 patients (219 naïve; 118 switched) were identified. Of those with BD data, 71, 117 and 82 patients had BDs of <4 mg/kg, ≥4–<5 mg/kg and ≥5 mg/kg, respectively. Most patients were male (74.8%). Patients with higher BDs tended to have higher Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores; switched patients had lower scores than naïve patients. Of 186 evaluable patients (118 naïve; 68 switched), 85 (46 naïve; 39 switched) did not have dose and/or interval changes (‘combined constant’ group). More naïve (n=72; 61.0%) versus switched (n=29; 42.6%) patients had dose and/or interval changes (‘combined changed’ group). Considering dose and interval separately, 18/235 evaluable patients (152 naïve; 83 switched) had dose changes (12 increased; 6 decreased) and 110/224 evaluable patients (140 naïve; 84 switched) had interval changes (79 increased; 31 decreased). Cumulative annual doses were similar between naïve and switched patients; switched patients had longer infusion intervals than naïve patients (Figure 1). There were no significant differences in drug survival between BD groups overall or for naïve and switched patients. BASDAI scores over time showed that disease activity was well controlled (Table 1). Patients in the combined changed versus combined constant group had greater improvements in BASDAI score.

Table 1.

BASDAI scores

GroupStatisticW0W54W102W156W210Combined constantTotal (N=85)n7273574231Mean (SD)5.50 (3.12)2.50 (1.71)2.35 (1.66)2.42 (1.66)2.36 (1.68)Median6.322.602.402.552.60Naïve (n=46)n3939261812Mean (SD)7.86 (1.45)2.49 (1.82)2.41 (1.75)2.34 (1.70)1.94 (1.58)Median7.802.201.751.901.44Switched (n=39)n3334312419Mean (SD)2.71 (2.07)2.50 (1.60)2.31 (1.60)2.48 (1.67)2.63 (1.73)Median2.582.752.502.802.70Combined changedTotal (N=101)n8785765335Mean (SD)5.68 (2.89)1.81 (1.45)1.58 (1.27)1.49 (1.34)1.40 (1.24)Median6.701.321.191.201.00Naïve (n=72)n6360543418Mean (SD)7.18 (1.37)2.01 (1.44)1.65 (1.22)1.54 (1.26)1.52 (0.97)Median7.301.831.351.311.35Switched (n=29)n2425221917Mean (SD)1.74 (1.94)1.33 (1.36)1.42 (1.41)1.39 (1.50)1.28 (1.50)Median0.920.800.850.700.58

SD, standard deviation; W, Week

Conclusion:

These real-world data demonstrate that adjusting dose and infusion interval can improve clinical outcomes for CT-P13-treated patients with AS. Drug survival and BASDAI results show that patients with lower baseline BASDAI receiving low CT-P13 doses can achieve the same outcomes as those dosed with ≥5 mg/kg. Findings support the lack of impact of switching from reference infliximab to CT-P13 on efficacy, underlining conclusions previously drawn for efficacy and safety.1

References:

[1]Kim T-H, et al. Clin Drug Investig 2020;40:541–53.

Acknowledgements:

Funding: This study was supported by Celltrion Healthcare Co., Ltd. (Incheon, Republic of Korea). Medical writing support was provided by Beatrice Tyrrell, DPhil (Aspire Scientific, Bollington, UK), and funded by Celltrion Healthcare Co., Ltd. (Incheon, Republic of Korea).

Disclosure of Interests:

Shin-Seok Lee: None declared, Tae-Hwan Kim: None declared, Won Park Consultant of: Celltrion, Inc., Yeong Wook Song: None declared, Chang-Hee Suh Speakers bureau: AbbVie Inc., Astellas Pharma Inc., Samsung Bioepis Co., Ltd, Consultant of: Celltrion Healthcare Co., Ltd., Eli Lilly and Company, GlaxoSmithKline plc, Janssen Pharmaceuticals, Yungjin Pharmaceutical, Co., Ltd, SooKyoung Kim Shareholder of: Celltrion Healthcare Co., Ltd., Employee of: Celltrion Healthcare Co., Ltd., DaeHyun Yoo Speakers bureau: Celltrion, Consultant of: Celltrion, Grant/research support from: Celltrion

Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion: A single-center experience with 109 patients

Pancreatectomy for pancreatic cancer with arterial invasion is controversial and performed infrequently. As its indication evolves and neoadjuvant chemotherapy also evolves, it is meaningful to identify short- and long-term outcomes of pancreatectomy with arterial resection (AR). This study aimed to retrospectively analyze the clinical outcomes of pancreatectomy with AR for pancreatic ductal adenocarcinoma.Patients with pancreatic ductal adenocarcinoma treated with pancreatectomy with AR at our institute between January 2000 and April 2017 were retrospectively reviewed. Operative outcome and survival were compared according to the presence of neoadjuvant chemotherapy.This study included 109 patients (38 underwent surgery after neoadjuvant chemotherapy, 71 underwent upfront surgery). The median hospital stay was 17 (interquartile range, 12-26.5) days. Clinically relevant postoperative pancreatic fistula (grade B or C) occurred in 14 patients (12.8%). The major morbidity (≥grade III) and mortality rates were 26.6% and 0.9%, respectively. R0 resection was achieved in 80 patients (73.4%). Microscopic actual tumor invasion into the arterial wall was identified in 25 patients (22.9%). The median overall survival (OS) of all patients was 18.4 months. The neoadjuvant chemotherapy group showed better OS than the upfront surgery group, without statistical significance (25.3 vs 16.2 months, P = .06). Progression-free survival was better in patients with neoadjuvant chemotherapy (13.2 vs 7.1 months, P = .01). Patients with partial response to neoadjuvant chemotherapy showed better OS than those with stable disease (33.7 vs 17.5 months, P = .04).Pancreatectomy with AR for advanced pancreatic cancer showed acceptable procedure-related morbidity and mortality. A survival benefit of neoadjuvant chemotherapy was identified, compared to upfront surgery.

A Comparative Study of Laparoscopic versus Open Pancreaticoduodenectomy for Ampulla of Vater Carcinoma

Several studies have compared laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with periampullary carcinoma; however, only a few studies have made such a comparison on patients with ampulla of Vater cancer (AVC). We compared the perioperative and oncologic outcomes between LPD and OPD in patients with AVC using propensity-score-matched analysis. A total of 359 patients underwent PD due to AVC during the study period (76 LPD, 283 OPD). After propensity score matching, the LPD group showed significantly longer operation time than did the OPD group (400.2 vs. 344.6 min, p < 0.001). Nevertheless, the LPD group had fewer painkiller administrations (8.3 vs. 11.1, p < 0.049), fewer Grade II or more severe postoperative complications (15.9% vs. 34.8%, p = 0.012), and shorter postoperative hospital stays (13.7 vs. 17.3 days, p = 0.048), compared with the OPD group. There was no significant difference in recurrence-free outcomes and overall survival between the two groups (p = 0.754 and 0.768, respectively). Compared with OPD, LPD for AVC had comparative oncologic outcomes with less pain, less postoperative morbidity, and shorter hospital stays. LPD may serve as a promising alternative to OPD in patients with AVC.

Association between Metformin Use and Clinical Outcomes Following Pancreaticoduodenectomy in Patients with Type 2 Diabetes and Pancreatic Ductal Adenocarcinoma

Retrospective studies on the association between metformin and clinical outcomes have mainly been performed on patients with non-resectable pancreatic ductal adenocarcinoma and may have been affected by time-related bias. To avoid this bias, recent studies have used time-varying analysis; however, they have only considered the start date of metformin use and not the stop date. We studied 283 patients with type 2 diabetes and pancreatic ductal adenocarcinoma following pancreaticoduodenectomy, and performed analysis using a Cox model with time-varying covariates, while considering both start and stop dates of metformin use. When start and stop dates were not considered, the metformin group showed significantly better survival. Compared with previous studies, adjusted analysis based on Cox models with time-varying covariates only considering the start date of postoperative metformin use showed no significant differences in survival. However, although adjusted analysis considering both start and stop dates showed no significant difference in recurrence-free survival, the overall survival was significantly better in the metformin group (Hazard ratio (HR), 0.747; 95% confidence interval (CI), 0.562–0.993; p = 0.045). Time-varying analysis incorporating both start and stop dates thus revealed that metformin use is associated with a higher overall survival following pancreaticoduodenectomy in patients with type 2 diabetes and pancreatic ductal adenocarcinoma.

THU0186 CLINICAL EVALUATION OF THE IMMUNOGENICITY TO CT-P13 FOR SUBCUTANEOUS USE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS: 1-YEAR CLINICAL RESULTS FROM A MULTICENTER, RANDOMIZED CONTROLLED PIVOTAL TRIAL

Background:

Novel subcutaneous infliximab (CT-P13 SC) was developed to augment the flexibility in therapeutic use of infliximab and noninferiority (NI) of CT-P13 SC versus CT-P13 intravenous (IV) was demonstrated for efficacy in patients with rheumatoid arthritis (RA) [1]. CT-P13 SC 120mg biweekly showed consistent higher therapeutic trough levels during the treatment period, which helps in maintaining efficacy over time. Since immunogenicity has clinical importance in patients using anti-TNF alpha agents and there is a general presumption that SC route is more immunogenic than IV route, this needs careful assessment.

Objectives:

Immunogenicity assessment of CT-P13 SC with further impact analysis has been performed on the pivotal data set [1] to determine whether there was any correlation between the magnitude of anti-drug antibody (ADA) positivity and clinical outcomes in RA patients.

Methods:

The immune response against CT-P13 in human serum was detected using an electrochemiluminescence (ECL) platform with an Affinity Capture Elution (ACE) step. An ADA ECL ACE assay showed ability to detect ADA at low levels in all samples regardless of residual drug in serum (25 ng/mL ADA in the presence of 80 μg/mL of CT-P13 in RA serum). To investigate the impact of ADA titer on PK, efficacy and safety, key clinical parameters were assessed by visit based ADA titer quartile. All patients who had ‘Positive’ ADA status result at each visit were included in the analysis and categorized into 4 groups using the 25th, 50th, 75th percentiles of ADA titer result, respectively.

Results:

The four subgroups categorized by quartiles at each visit from week 22 to week 54 were: 1st (ADA titer ≤ 3), 2nd (3 < ADA titer ≤ 9), 3rd (9 < ADA titer ≤ 27) and 4th (27 < ADA titer). There was a trend for pre-dose concentration to decrease as ADA titer increases for both CT-P13 SC and CT-P13 IV arms as expected (Figure 1). Patients in the 1st and 2nd subgroup maintained the sufficient therapeutic drug concentration level. Figure 2 shows the correlation between ADA titer and efficacy outcomes where the change from baseline of DAS28 (CRP) and the proportion of patients achieving ACR20 were lower in the 3rd and 4th subgroups. The ADA impact was especially apparent in the 4th subgroup where the mean pre-dose concentration of the patients was below the therapeutic drug concentration level (1 μg/mL), which led to worse efficacy outcomes in both arms, IV as well as SC. Nevertheless, no impact of ADA on safety profile in both arms was observed. A neutralizing antibody (NAb) method with enhanced drug tolerance but limited performance was also developed and clinical consequences of NAb titer in terms of PK, efficacy and safety were not different from the results with ADA.

Conclusion:

The analysis of both ADA positivity and titer is clinically meaningful in the prediction of PK profile and clinical response. CT-P13 SC administration did not result in a greater incidence of ADA compared to the CT-P13 IV and there were no clinical differences depending on the formulation.

References:

[1]Westhovens R, et al. Annals of the Rheumatic Diseases 2019;78:1158-1159.

Disclosure of Interests:

Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, DaeHyun Yoo Grant/research support from: Celltrion, Inc, Consultant of: Celltrion, Inc, Speakers bureau: Celltrion Healthcare, Inc, Piotr Wiland Grant/research support from: Celltrion, Inc, Speakers bureau: Novartis, Pfizer, Abbvie, Gedeon-Richter, Lilly, Roche, Sandoz, Marek Zawadzki Grant/research support from: Celltrion, Inc, Delina Ivanova Grant/research support from: Celltrion, Inc, Alfredo Berrocal Grant/research support from: Celltrion, Inc, Speakers bureau: Pfizer, Elias Chalouhi Grant/research support from: Celltrion, Inc, Éva Balázs Grant/research support from: Celltrion, Inc, Consultant of: Amgen, Sergii Shevchuk Grant/research support from: Celltrion, Inc, Sang Joon Lee Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc, Sung Hyun Kim Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc, JeeHye Suh Employee of: Celltrion, Inc, Chankyoung Hwang Employee of: Celltrion, Inc, Dae Seok Choi Shareholder of: Celltrion, Inc, Employee of: Celltrion, Inc

Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a single surgeon's experience of 228 consecutive cases

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities.

METHODS

A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017.

RESULTS

The analysis included 228 consecutive patients (LDP, n = 182; Robotic-assisted laparoscopic distal pancreatectomy [R-LDP], n = 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7 min; p = 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%; p = 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups.

CONCLUSIONS

R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.

Comparative analysis of afferent loop obstruction between laparoscopic and open approach in pancreaticoduodenectomy

BACKGROUND

Afferent loop obstruction (ALO) is a rare mechanical complication of pancreaticoduodenectomy (PD) and is associated with a high rate of morbidity and mortality.

METHODS

Data from patients who underwent PD between May 2007 and July 2017 at a single large-volume center were retrospectively reviewed.

RESULTS

Of the 3,223 patients who underwent PD, 67 developed ALO. More patients in the laparoscopic PD (LPD) group had developed ALO due to internal herniation than did those in the open PD (OPD) group (46.2 vs. 4.7%, P < 0.001). Patients in the LPD group also showed earlier occurrence of ALO (ALO occurrence within 60 days: 76.9 vs. 22.2%, P < 0.001) and more frequent requirement for surgical treatment (76.9 vs. 18.9%, P < 0.001) than did those in the OPD group.

CONCLUSIONS

The characteristics of ALO were significantly different between patients who had received LPD and OPD. The most common cause of ALO in the LPD group was internal herniation occurring in the early postoperative period. Internal herniation following LPD may be prevented by routine closure of mesocolic window and should be treated by emergency surgery if it occurs.

Prognostic value of adjacent organ resection in patients with left-sided pancreatic ductal adenocarcinoma following distal pancreatectomy

BACKGROUND

We evaluated whether distal pancreatectomy (DP) with adjacent organ resection (AOR) affected perioperative outcomes and survival in patients with left-sided pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective cohort study was conducted at single large volume academic medical center from January 2000 to December 2016.

RESULTS

Five hundred and twenty-three patients had undergone standard DP (without additional vessel/organ resection) and 40 had undergone DP with AOR due to adjacent organ infiltration. There were no differences of postoperative morbidity and hospital stay between the two groups. In the patients with AJCC 8th stage I and II PDAC, there were significant differences of median disease-specific and progression-free survivals between the standard and AOR groups (37.9 vs. 20.2 months; P = 0.05, 20 vs. 10 months; P = 0.028, respectively). DP with AOR was identified as independent prognostic factor of stage I and II PDAC by multivariate Cox regression analysis.

CONCLUSIONS

Distal pancreatectomy with AOR could be an acceptable surgical treatment for left-sided PDAC. However, AOR group shows poor prognosis than that of the standard group in patients with AJCC 8th stage I and II PDAC. AOR should be considered indicative of a more aggressive tumor in AJCC 8th stage I and II PDAC.

Neutropenia following Perioperative Intraperitoneal Chemotherapy

Introduction

The purpose of this retrospective report was to evaluate clinical features associated with profound neutropenia in patients with peritoneal carcinomatosis who were treated with heated intraoperative intraperitoneal chemotherapy (HIIC) followed by early postoperative intraperitoneal chemotherapy (EPIC). Common clinical denominators for significant neutropenia were analyzed.

Materials and Methods

A retrospective study of all available clinical data of six patients with postoperative neutropenia out of a total of 242 was undertaken. All patients underwent cytoreductive surgery, HIIC with mitomycin C (n = 4) or cisplatin (n = 1) and EPIC with 5-fluorouracil (5-FU) for 4 (n = 1) or 5 (n = 5) days.

Results

All six patients presented with hematologic toxicity of WHO criteria grade 4; four of them died postoperatively. Two of the patients who died, and one who did not die, developed bowel perforations. Five patients had prior chemotherapy with 5-FU; three of them had toxic side effects. All patients were overweight, and three patients were anemic preoperatively. The neutropenia presented with fever, leukopenia and thrombocytopenia on postoperative days 10–15. The leukocyte count courses showed a pattern suggesting the 5-FU as the cause of leukopenia. There was no consistent warning signal for predicting severe neutropenia.

Discussion

Neutropenia following cytoreductive surgery combined with HIIC and EPIC has a high mortality (66%). Patients who are at special risk and should have a dose reduction include patients who had toxicities from prior chemotherapy, who present with obesity and anemia. The groups have an increased risk of developing postoperative profound neutropenia. This condition can result in a prohibitively high mortality and morbidity rate. Therefore, reduced doses of chemotherapy in selected patients are necessary to prevent this condition from developing.

Effect of low speed drilling on osseointegration using simplified drilling procedures

Our aim was to find out whether simplified drilling protocols would provide biological responses comparable to those of conventional drilling protocols at the low rotational speed of 400rpm. Seventy-eight root form endosseous implants with diameters of 3.75, 4.2, and 5mm were placed into canine tibias and allowed to heal for 3 and 5 weeks. After the dogs had been killed, the samples of implanted bone were retrieved and processed for non-decalcified histological sectioning. Bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO) analyses were made on the histological sections. Implants treated by the simplified protocol resulted in BIC and BAFO values comparable to those obtained with the conventional drilling protocol, and there were no significant differences in the technique or diameter of the drilling. The results suggest that the simplified procedure gives biological outcomes comparable to those of the conventional procedure.

Pancreatic atrophy relative to external versus internal drainage of the pancreatic duct after pylorus-preserving pancreaticoduodenectomy

BACKGROUND

Atrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD.

METHODS

Fifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7.

RESULTS

Univariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year.

CONCLUSIONS

Both external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.

Evaluation of bone response to various anorganic bovine bone xenografts: an experimental calvaria defect study

This in vivo study investigated the in vivo performance of two newly developed synthetic bone substitutes and compared them to commercially available xenografts (Bio-Oss, Geistlich Pharma AG, Switzerland; OsteoGraf, Dentsply, USA). The materials were tested in a rabbit calvaria model, and the bone forming properties were observed at 4 and 8 weeks after implantation by means of histomorphometry and micro computed tomography (micro-CT). Defects without any graft material were used as negative controls. Micro-CT showed that all materials tested presented new bone formation that filled the defects at both time points, whereas the negative control presented less bone formation, with soft tissue infiltration into the defects. Comparable bone fill percentages were observed for histomorphometric and micro-CT results. Even though no statistically significant difference was found quantitatively between all of the bone graft substitute groups, a higher mean decrease in graft material filling the defects, along with higher remodelling activity, was evident for the experimental materials compared to the commercially available xenografts at 8 weeks. The results indicate that the experimental materials possess high degradability, along with osteoconduction comparable to commercially available xenografts.

[Development of a nested polymerase chain reaction test for the diagnosis of transmissible gastroenteritis of pigs]

The aim of this study was to develop a nested polymerase chain reaction (nested PCR) for the rapid detection of transmissible gastroenteritis virus (TGEV) of pigs. The primers were designed on the basis of highly conserved regions of several TGEV sequences included in the analysis. External primers were used to amplify a fragment of the expected size (441 bp) in all the samples evaluated using reverse transcriptase polymerase chain reaction (RT-PCR), but with very low intensity. In the second amplification (nested PCR), internal primers were used to amplify a fragment of the expected size (168 bp), with good concentration. The performance of the test based on virus isolates in tissue culture and in clinical samples was judged good for the virological diagnosis of transmissible gastroenteritis of pigs.

Vibration response imaging in prediction of pulmonary function after pulmonary resection

BACKGROUND

Vibration response imaging (VRI) is a new technique that captures lung sounds generated by the flow of air through the lungs. It predicts postoperative values for an intended lung resection. In this study, we measured the predicted postoperative pulmonary function as determined by a perfusion lung scan and the VRI, and compared with results from the postoperative pulmonary function.

METHODS

This study was performed prospectively in patients who were candidates for major pulmonary resection. Each patient underwent a pulmonary function test, perfusion scintigraphy, and VRI within 1 week before operation. Postoperative lung function was measured at 4 to 6 weeks.

RESULTS

The study enrolled 44 patients. There were no significant differences for predicted postoperative forced expiratory volume in 1 second (ppoFEV(1)) and predicted postoperative diffusion capacity of the lung for carbon monoxide (ppoDlco) between scan and VRI. Both ppoFEV(1) and ppoDlco using a scan and VRI predicted the postoperative results well, respectively. The postoperative FEV(1) was correlated with ppoFEV(1) using a scan (r = 0.83, p < 0.001), and the ppoFEV(1) using a VRI (r = 0.83, p < 0.001). The postoperative Dlco was correlated with the ppoDlco using a scan (r = 0.85, p < 0.001), and the ppoDlco using a VRI (r = 0.80, p < 0.001).

CONCLUSIONS

The VRI was highly predictive of postoperative FEV(1) and Dlco for lung resection.

SU-E-J-23: Prostate Bed Motion Study Using Surgical Clips Based on Daily CBCT

PURPOSE

To study prostate-bed motion after prostatectomy using the surgical clips as a surrogate.

METHODS

On the treatment planning CT, surgical clips within the PTV are identified and contoured. They are also identified and contoured in each daily CBCT. The center of mass (COM) coordinates for each clip within the native reference frame of each image set of CT and CBCT are recorded. Each CBCT (for daily image guidance) is registered to the planning CT based on the pelvic bony structure. The resulted 3D transformation matrix is used to convert the clip coordinates in the CBCT to the planning CT reference frame. Difference between the converted COM coordinates and the one in planning CT is taken as the rigid motion of the prostate bed relative to the pelvic bony structure during the course of radiation therapy. The motion data are then analyzed using statistical error analysis and quantified by the commonly defined M (average over all fractions and all patients), S (stdev of averages per patient, the systematic motion), and s (root mean square of stdev per patient, the random motion). Among a large pool of patients, seven patients were selected for this retrospective study, each with 3 to 11 identifiable clips and 17 to 26 CBCT sets. The total number of clips is 44 and total daily CBCT sets 160.

RESULTS

In the (right-left, anterio-posterior, foot-head) directions, the M values are (0.2 mm, 0.4 mm, -0.6 mm), S (0.2, 2.5, 3.2), and s (1.7, 2.6, 2.1).

CONCLUSIONS

Relative to the bony pelvic structure, the prostate bed motion characteristics are similar to that of intact prostate, as summarized in Table 2 of Rasch et al 2005 ('Target Definition in Prostate, Head, and Neck.' Semin Radiat Oncol 15:136-145).