Comparative Efficacy of Subcutaneous and Intravenous Infliximab and Vedolizumab for Maintenance Treatment of TNF-naive Adult Patients with Inflammatory Bowel Disease: A Systematic Literature Review and Network Meta-analysis

BACKGROUND

Infliximab and vedolizumab are widely used to treat Crohn's disease (CD) and ulcerative colitis (UC).

AIMS

This systematic review and network meta-analysis evaluated comparative efficacy of various regimens for intravenous or subcutaneous infliximab and vedolizumab during maintenance treatment in CD and UC.

METHODS

Parallel-group randomized controlled trials (RCTs) were identified by a systematic literature review (CRD42022383401) and included if they evaluated therapeutics of interest for maintenance treatment of adults with moderate-to-severe luminal CD or UC and assessed clinical remission between Weeks 30 and 60. Clinical remission rates in CD or UC and mucosal healing rates in UC were analyzed in a Bayesian network meta-analysis model. Endoscopic outcomes in CD were synthesized by proportional meta-analysis.

RESULTS

Overall, 13 RCTs were included in the analyses. All vedolizumab studies randomized induction responders to maintenance treatment; infliximab studies used a treat-through design. Subcutaneous infliximab 120 mg every 2 weeks had the highest odds ratio (OR) [95% credible interval] versus placebo for clinical remission during the maintenance phase (CD: 5.90 [1.90-18.2]; UC: 5.45 [1.94-15.3]), with surface under the cumulative ranking curve (SUCRA) values of 0.91 and 0.82, respectively. For mucosal healing in UC, subcutaneous infliximab 120 mg every 2 weeks showed the highest OR (4.90 [1.63-14.1]), with SUCRA value of 0.73, followed by intravenous vedolizumab 300 mg every 4 weeks (SUCRA value, 0.70). Endoscopic outcomes in CD were better with subcutaneous infliximab 120 mg every 2 weeks than intravenous infliximab 5 mg/kg every 8 weeks.

CONCLUSIONS

Subcutaneous infliximab showed a favorable efficacy profile for achieving clinical remission and endoscopic outcomes during maintenance treatment in CD or UC.

CT findings of inferior vena cava trauma according to the level of injury: a retrospective analysis of 19 cases in a single trauma centre

AIM

To analyse the clinicoradiological characteristics of traumatic inferior vena cava (IVC) injury level on preoperative computed tomography (CT).

MATERIALS AND METHODS

This retrospective study evaluated patients from a single trauma centre treated for traumatic IVC injury between January 2014 and January 2021. Data on demographics, mechanism of injury, Injury Severity Score, radiological findings on CT and angiography, IVC injury level in surgical findings, complications, and clinical outcomes were collected.

RESULTS

During the 8-year study period, 36 patients presented with traumatic IVC injury: 19 underwent preoperative CT with 17 (89%) blunt and two (11%) penetrating injuries. The most common primary CT sign was contour abnormality (53%, n=10), followed by intraluminal flap and active extravasation (21%, n=4). Among the secondary signs, hepatic laceration (53%, n=10) and retroperitoneal haemorrhage (53%, n=10) were the most common. Frequencies of primary and secondary signs were higher in the infrarenal and suprarenal than in the retrohepatic vena cava injuries. Diagnostic capability of preoperative CT for IVC injury differed according to the IVC level. The detection rate was the highest for an infrarenal vena cava injury at 100% (n=4), followed by that for a suprarenal, suprahepatic, and retrohepatic vena cava injuries at 75% (n=3), 43% (n=3), and 25% (n=1), respectively.

CONCLUSION

CT findings of traumatic IVC injuries may vary depending on the mechanism and anatomical site of injury. Familiarity with IVC injury imaging features may help in diagnosis and surgical treatment planning.

Overexpression of Dock180 and Elmo1 in Melanoma is Associated with Cell Survival and Migration

BACKGROUND

Melanoma is one of the most aggressive and metastatic skin cancers. Although overexpression of Dock180 and Elmo1 has been identified in various cancers, including glioma, ovarian cancer, and breast cancer, their expression and functions in melanoma remain unknown.

OBJECTIVE

This study aims to confirm the expression of Dock180 and Elmo1, their underlying mechanisms, and roles in melanoma.

METHODS

Both immunohistochemical staining and Western blotting were used to confirm expression of Dock180 and Elmo1 in human melanoma. To identify roles of Dock180 and Elmo1 in cell survival, apoptosis and migration, downregulation of Dock180 or Elmo1 in melanoma cells with small interfering RNA (siRNA) was performed.

RESULTS

We identified overexpression of Dock180 and Elmo1 in human melanoma compared to normal skin ex vivo. Inhibition of Dock180 or Elmo1 following siRNA in melanoma cells reduced cell viability and increased apoptosis as supported by increased proportion of cells with Annexin V-PE (+) staining and sub-G0/G1 peak in cell cycle analysis. Moreover, inhibition of Dock180 or Elmo1 regulated apoptosis-related proteins, showing downregulation of Bcl-2, caspase-3, and PARP and upregulation of Bax, PUMA, cleaved caspase-3, and cleaved PARP. Furthermore, knockdown of Dock180 and Elmo1 in melanoma cells reduced cell migration and changed cellular signaling pathways including ERK and AKT. Vemurafenib decreased cell viability in concentration-dependent manner, while transfection with Dock180- or Elmo1-specific siRNA in melanoma cells significantly reduced cell viability.

CONCLUSION

Our results suggest that both Dock180 and Elmo1 may be associated with cancer progression, and can be potential targets for treatment of melanoma.

Monitoring of single extracellular vesicle heterogeneity in cancer progression and therapy

Cancer cells actively release lipid bilayer extracellular vesicles (EVs) that affect their microenvironment, favoring their progression and response to extracellular stress. These EVs contain dynamically regulating molecular cargos (proteins and nucleic acids) selected from their parental cells, representing the active biological functionality for cancer progression. These EVs are heterogeneous according to their size and molecular composition and are usually defined based on their biogenetic mechanisms, such as exosomes and ectosomes. Recent single EV detection technologies, such as nano-flow cytometry, have revealed the dynamically regulated molecular diversity within bulk EVs, indicating complex EV heterogeneity beyond classical biogenetic-based EV subtypes. EVs can be changed by internal oncogenic transformation or external stress such as chemotherapy. Among the altered combinations of EV subtypes, only a specific set of EVs represents functional molecular cargo, enabling cancer progression and immune modulation in the tumor microenvironment through their altered targeting efficiency and specificity. This review covers the heterogeneity of EVs discovered by emerging single EV analysis technologies, which reveal the complex distribution of EVs affected by oncogenic transformation and chemotherapy. Encouragingly, these unique molecular signatures in individual EVs indicate the status of their parental cancer cells. Thus, precise molecular profiling of circulating single EVs would open new areas for in-depth monitoring of the cancer microenvironment and shed new light on non-invasive diagnostic approaches using liquid biopsy.

Mass-produced gram-negative bacterial outer membrane vesicles activate cancer antigen-specific stem-like CD8+ T cells which enables an effective combination immunotherapy with anti-PD-1

Despite the capability of extracellular vesicles (EVs) derived from Gram-negative and Gram-positive bacteria to induce potent anti-tumour responses, large-scale production of bacterial EVs remains as a hurdle for their development as novel cancer immunotherapeutic agents. Here, we developed manufacturing processes for mass production of Escherichia coli EVs, namely, outer membrane vesicles (OMVs). By combining metal precipitation and size-exclusion chromatography, we isolated 357 mg in total protein amount of E. coli OMVs, which was equivalent to 3.93 × 1015 particles (1.10 × 1010 particles/μg in total protein amounts of OMVs) from 160 L of the conditioned medium. We show that these mass-produced E. coli OMVs led to complete remission of two mouse syngeneic tumour models. Further analysis of tumour microenvironment in neoantigen-expressing tumour models revealed that E. coli OMV treatment causes increased infiltration and activation of CD8+ T cells, especially those of cancer antigen-specific CD8+ T cells with high expression of TCF-1 and PD-1. Furthermore, E. coli OMVs showed synergistic anti-tumour activity with anti-PD-1 antibody immunotherapy, inducing substantial tumour growth inhibition and infiltration of activated cancer antigen-specific stem-like CD8+ T cells into the tumour microenvironment. These data highlight the potent anti-tumour activities of mass-produced E. coli OMVs as a novel candidate for developing next-generation cancer immunotherapeutic agents.

Quantitative proteomics and biological activity of extracellular vesicles engineered to express SARS-CoV-2 spike protein

SARS-CoV-2 viral infection led to the devastating COVID-19 pandemic, where illness stemmed from interactions between virions and recipient host cells resulting in multi-layered pathological consequences. The role of the infection portal is now understood to be the cellular angiotensin converting enzyme-2 (ACE2) receptor, which binds to viral spike (S) protein initiating virion internalisation process. Since SARS-CoV-2 virions bear some resemblance to endogenously produced small extracellular vesicles (sEVs) we reasoned that EVs engineered to express S protein (viral mimics) may interfere with viral infection. Here, we report generation of HEK293T cells producing sEVs enriched for transmembrane S-protein tagged with green fluorescent protein (S/GFP). Strikingly, S protein drove the GFP tag to the membrane of sEVs, while GFP alone was not efficiently included in the sEV cargo. High-throughput quantitative proteomics revealed that S/GFP sEVs contained over 1000 proteins including canonical components of the exosomal pathway such as ALIX, syntenin-1, and tetraspanins (CD81, CD9), but depleted for calnexin and cytochrome c. We found that 84 sEV proteins were significantly altered by the presence of S/GFP. S protein expressing EVs efficiently adhered to target cells in an ACE2-dependent manner, but they were poorly internalised. Importantly, prolonged administration of S/GFP EV to K18-hACE2 mice provided a significant protection against SARS-CoV-2 infection. Thus, the generation of sEV containing S protein can be considered as a novel therapeutic approach in reducing the transmission of SARS-CoV-2.

Proteomic Assessment of Extracellular Vesicles from Canine Tissue Explants as a Pipeline to Identify Molecular Targets in Osteosarcoma: PSMD14/Rpn11 as a Proof of Principle

Osteosarcoma (OS) is a highly malignant bone tumour that has seen little improvement in treatment modalities in the past 30 years. Understanding what molecules contribute to OS biology could aid in the discovery of novel therapies. Extracellular vesicles (EVs) serve as a mode of cell-to-cell communication and have the potential to uncover novel protein signatures. In our research, we developed a novel pipeline to isolate, characterize, and profile EVs from normal bone and osteosarcoma tissue explants from canine OS patients. Proteomic analysis of vesicle preparations revealed a protein signature related to protein metabolism. One molecule of interest, PSMD14/Rpn11, was explored further given its prognostic potential in human and canine OS, and its targetability with the drug capzimin. In vitro experiments demonstrated that capzimin induces apoptosis and reduces clonogenic survival, proliferation, and migration in two metastatic canine OS cell lines. Capzimin also reduces the viability of metastatic human OS cells cultured under 3D conditions that mimic the growth of OS cells at secondary sites. This unique pipeline can improve our understanding of OS biology and identify new prognostic markers and molecular targets for both canine and human OS patients.

Suspected human intravenous immunoglobulin-induced acute haemolytic anaemia in a dog

A 2-year-old mixed breed dog presented with a 1-year history of crust and erosion on the nasal planum. Because histopathological examination revealed ruptured intraepidermal pustules and superficial dermal inflammation, the dog was diagnosed with pemphigus foliaceus. Human intravenous immunoglobulin was administered in two consecutive doses of 0.5 g/kg/day due to poor therapeutic response to previous immunosuppressive therapy. From Day 3 after the first dose of human intravenous immunoglobulin, tachypnoea, pale mucous membrane, haemoglobinuria and haemoglobinemia were observed, thus confirming haemolytic anaemia. Other drug-induced haemolytic anaemias were excluded because no additional drugs had been administered before the haemolysis occurred. Immune-mediated haemolytic anaemia was also excluded because the direct antiglobulin test was negative. Two transfusions were performed, and haemolysis was not observed from Day 4 of haemolytic anaemia onset. In conclusion, human intravenous immunoglobulin-induced haemolytic anaemia should be considered in dogs that develop haemolysis following the administration of human intravenous immunoglobulin.

TAMI-73. GLIOBLASTOMA CELL POPULATIONS WITH DISTINCT ONCOGENIC PROGRAMS RELEASE PODOPLANIN AS PROCOAGULANT EXTRACELLULAR VESICLES

BACKGROUND

Vascular anomalies, including thrombosis, are a hallmark of glioblastoma (GBM) and an aftermath of dysregulated cancer cell genome and epigenome. Up-regulation of podoplanin (PDPN) by cancer cells has recently been linked to an increased risk of venous thromboembolism in glioblastoma patients. Thus, regulation of this platelet activating protein by transforming events and release from cancer cells is of considerable interest.

AIMS

I. Investigate the pattern of PDPN expression and characterize PDPN-expressing cellular populations in GBM. II. Evaluate the contribution of oncogenic drivers to PDPN expression in GBM models. III. Investigate the potential involvement of extracellular vesicles (EVs) as a mechanism for systemic dissemination of PDPN and tissue factor (TF). IV. Examine the role of PDPN in intratumoral and systemic thrombosis.

METHODS

Bioinformatics (single-cell and bulk transcriptome data mining), GBM cell lines and stem cell lines, xenograft models in mice, ELISA assays for PDPN and TF, platelet (PF4) and clotting activation markers (D-dimer), EV electron microscopy, density gradient fractionation, and nano-flow cytometry.

RESULTS

PDPN is expressed by distinct glioblastoma cell subpopulations (mesenchymal) and downregulated by oncogenic mutations of EGFR and IDH1 genes, via changes in chromatin modifications (EZH2) and DNA methylation, respectively. GBM cells exteriorize PDPN and/or TF as cargo of exosome-like EVs shed both in vitro and in vivo. Injection of glioma PDPN-EVs activates platelets. Increase of platelet activation (PF4) or coagulation markers (D-dimer) occurs in mice harboring the corresponding glioma xenografts expressing PDPN or TF, respectively. Co-expression of PDPN and TF by GBM cells cooperatively increases tumor microthrombosis.

CONCLUSION

Distinct cellular subsets drive multiple facets of GBM-associated thrombosis and may represent targets for diagnosis and intervention. We suggest that the preponderance of PDPN expression as a risk factor in glioblastoma and the involvement of platelets may merit investigating anti-platelets for potential inclusion in thrombosis management in GBM.

OPTC-5. Molecular signatures of podoplanin expressing glioblastoma cell subsets with putative role in cancer associated thrombosis and microthrombosis

Vascular anomalies, including thrombosis, are a hallmark of glioblastoma (GBM) and an aftermath of dysregulated cancer cell genome and epigenome. Upregulation of podoplanin (PDPN) by cancer cells has recently been linked to an increased risk of venous thromboembolism in glioblastoma patients. Thus, regulation of this platelet activating transmembrane protein by transforming events and release from cancer cells into the circulation are of considerable interest. We took advantage of single-cell and bulk GBM transcriptome dataset mining and investigated the pattern of PDPN expression across several databases. Our analysis indicated that PDPN is expressed by distinct (mesenchymal) glioblastoma cell subpopulations and is downregulated by oncogenic mutations of EGFR and IDH1 genes, via changes in chromatin modifications (EZH2) and DNA methylation, respectively. Additionally, we utilized isogenic and stem GBM cell lines, xenograft models in mice, ELISA assays for PDPN, tissue factor (TF), platelet factor 4 (PF4) and clotting activation markers (D-dimer), and multicolor nano-flow cytometry to show that GBM cells exteriorize PDPN and/or TF as cargo of exosome-like coagulant extracellular vesicles EVs. We also documented an increase of platelet activation (PF4) or coagulation markers (D-dimer) in mice harboring the corresponding PDPN- or TF-expressing glioma xenografts, respectively. While PDPN was a dominant regulator of systemic platelet activation, co-expression of PDPN and TF impacted local microthrombosis. Our work suggests that distinct cellular subsets drive multiple facets of GBM-associated thrombosis and may represent targets for diagnosis and intervention.

Oncogenic RAS drives the CRAF-dependent extracellular vesicle uptake mechanism coupled with metastasis

Oncogenic RAS impacts communication between cancer cells and their microenvironment, but it is unclear how this process influences cellular interactions with extracellular vesicles (EVs). This is important as intercellular EV trafficking plays a key role in cancer invasion and metastasis. Here we report that overexpression of mutant RAS drives the EV internalization switch from endocytosis (in non-transformed cells) to macropinocytosis (in cancer cells) resulting in enhanced EV uptake. This process depends on the surface proteoglycan, fibronectin and EV engulfment mechanism regulated by CRAF. Both mutant RAS and activated CRAF expression is associated with formation of membrane ruffles to which they colocalize along with actin, sodium-hydrogen exchangers (NHEs) and phosphorylated myosin phosphatase (pMYPT). RAS-transformed cells internalize EVs in the vicinity of ruffled structures followed by apparent trafficking to lysosome and degradation. NHE inhibitor (EIPA) suppresses RAS-driven EV uptake, along with adhesion-independent clonal growth and experimental metastasis in mice. Thus, EV uptake may represent a targetable step in progression of RAS-driven cancers.

Onyiuke Grading Scale: A clinical classification system for the diagnosis and management of Bertolotti syndrome

BACKGROUND

Lumbosacral transitional vertebrae (LSTV) is a common anatomic variant of the spine, characterized by the formation of a pseudoarticulation between the transverse process of the lumbar vertebrae and sacrum or ilium. LSTVs have been implicated as a potential source of low back pain - dubbed Bertolotti syndrome. Traditionally, LSTVs have only been subdivided into types I-IV based on the Castellvi radiographic classification system.

OBJECTIVE

Solely identifying the type of LSTV radiographically provides no clinical relevance to the treatment of Bertolotti syndrome. Here, we seek to analyze such patients and identify a clinical grading scale and diagnostic-therapeutic algorithm to optimize care for patients with this congenital anomaly.

METHODS

Patients presenting with back pain between 2011 and 2018 attributable to a lumbosacral transitional vertebra were identified retrospectively. Data was collected from these patients' charts regarding demographic information, clinical presentation, diagnostic imaging, treatment and outcomes. Based on evaluation of these cases and review of the literature, a diagnostic-therapeutic algorithm is proposed.

RESULTS

Based on our experiences evaluating and treating these patients and review of the existing literature, we propose a clinical classification system for Bertolotti syndrome: we proposed a 4-grade scale for patients with Bertolotti syndrome based upon location, severity, and characteristics of pain experienced due to LSTVs.

CONCLUSION

Based on our experience with the cases illustrated here, we recommend managing patients with LSTV based on our diagnostic-therapeutic algorithm. Moving forward, a larger prospective study with a larger patient cohort is needed to further validate the treatment paradigm.

Extracellular Vesicle Mediated Vascular Pathology in Glioblastoma

Glioblastoma (GBM) is an incurable, infiltrative high-grade brain tumour associated with dramatic vascular responses observed both locally (angiogenesis, vascular cooption, angiocrine effects, microthrombosis) and systemically (venous thromboembolism). GBM-associated vascular pathology is diagnostically relevant and constitutes a source of morbidity, mortality and progressive changes in tumour biology. Extracellular vesicles (EVs) have emerged as unique mediators of vascular effects in brain tumours acting as vehicles for intercellular transfer of oncoproteins (e.g. EGFRvIII), RNA, DNA and molecular effectors of angiogenesis and thrombosis. Vascular effects of GBM EVs are regulated by cancer cell genome, epigenome and microenvironment and differ between subtypes of cancer cells and stem cells. Understanding and targeting EV-driven vascular processes in GBM may offer new approaches to diagnose and treat these intractable tumours.

Root Coverage Predictability in the Treatment of Gingival Recessions on Mandibular Anterior Teeth

INTRODUCTION

Mandibular anterior teeth are most frequently affected by gingival recession. However, data regarding mucogingival treatment aimed at root coverage in this specific location are limited.

OBJECTIVE

The purpose of this study was to systematically review the scientific literature and to use the meta-analytic approach to address the following focused question: "What is the effectiveness of different surgical approaches on clinical and patient-related outcomes in the treatment of buccal gingival recessions on mandibular anterior teeth?"

METHODS

Studies were located by searching 3 electronic databases (Medline, Scopus, and Cochrane databases) and cross-referencing. Randomized and nonrandomized studies including at least 1 arm involving the use of pedicle flaps and/or free soft tissue grafts in the treatment of gingival recessions (recession type [RT] 1 and RT2) located on the buccal aspects of mandibular centrals, laterals and canines, were included in the analysis. Primary outcome was mean root coverage (mRC), expressed in percentage, based on a 3- to 12-mo follow-up observation. A Bayesian single-arm network meta-analysis was performed to identify a treatment hierarchy of the different surgical techniques.

RESULTS

Sixteen studies, with a total of 23 arms, were included in the quantitative analysis. The greatest mRC is associated with laterally positioned flap (LPF) + connective tissue graft (CTG) (91.2%) and tunnel (TUN) + CTG (89.4%), whereas LPF alone, coronally advanced flap (CAF) + CTG, and free gingival graft (FGG) showed lower mRC (79.1%, 78.9%, and 68.5% respectively). TUN + CTG provides significantly greater mRC compared to CAF+CTG. No difference among the procedures could be observed in terms of keratinized tissue width gain.

CONCLUSIONS

Treatment hierarchy generated by an arm-based network meta-analysis model suggested that tunnel and laterally positioned flap, both in combination with connective tissue graft, may provide the greatest mean root coverage in the treatment of mandibular anterior recessions.

KNOWLEDGE TRANSFER STATEMENT

The results of the present systematic review can be used by clinicians when deciding which approach to adopt when treating buccal gingival recessions on mandibular anterior teeth. In particular, procedures based on a laterally positioned flap or a tunneling technique, both in combination with connective tissue graft, seem to be the most predictable therapeutic decision.

Risk factors and outcomes of immune and non-immune causes of diffuse alveolar hemorrhage: a tertiary-care academic single-center experience

Diffuse alveolar hemorrhage (DAH) is a rare but potentially life-threatening emergency that has both immune and non-immune etiologies. The objective of this investigation was to compare the risk factors and outcomes of immune and non-immune causes of DAH at a tertiary-care academic center. This was a retrospective observational study conducted at a University center. We reviewed all chest radiographs spanning 12 years (2007-2019) at our institute with the words "diffuse alveolar hemorrhage" in the body of their report, and ascertained cases of DAH through a detailed chart review. We used Chi-squared test to determine the differences in risk factors and outcomes between immune versus non-immune causes of DAH. We performed logistic regressions to assess whether baseline demographics and clinical features influence four critical outcomes: death, shock, renal failure, and severe anemia requiring transfusions. Over the 12-year period, there were 88 patients with DAH, 55 with non-immune and 33 with immune etiologies. Among immune causes of DAH, granulomatosis with polyangiitis (GPA) (10.2%), microscopic polyangiitis (MPA) (9%) and systemic lupus erythematosus (SLE) (9%) were most common. Among non-immune causes of DAH, coagulopathy (6.8%), decompensated heart failure (4.5%) and infection (3.4%) were most common. Patients with non-immune causes of DAH were 45.8% more likely to die and 20.7% less likely to experience sustained remission (p = 0.001). Patient with immune causes of DAH were 21% more likely to have extra-pulmonary findings and 23.7% more likely to have received hemodialysis (HD). The presence of extra-pulmonary findings was statistically significantly correlated with the number of blood products received, the need for HD and non-statistically significantly correlated with likelihood of death. Patients with immune causes of DAH were 71.5% more likely to receive multimodal therapy including corticosteroids. Immune-mediated DAH is associated with a better prognosis than non-immune DAH, despite its greater association with extra-pulmonary findings and requirement for hemodialysis.

Retroductal Delivery of Epidermal Growth Factor Protects Salivary Progenitors after Irradiation

Salivary gland hypofunction after irradiation is associated with a deficit of epithelial stem/progenitors in salivary glands. Although epidermal growth factor (EGF) is known to stimulate the proliferation of epithelial cells, the therapeutic effect of EGF on salivary epithelial stem/progenitors remains undetermined. In this study, we administered EGF to submandibular glands (SMGs) via a retrograde route through the SMG excretory duct before fractionated irradiation and examined whether EGF could protect salivary epithelial progenitor cells from radiation and alleviate radiation-induced salivary hypofunction. EGF-treated mice exhibited greater body and gland weights at 12 wk after irradiation than untreated mice. The retroductal delivery of EGF improved salivary secretory function and increased salivary amylase activity in a dose-dependent manner. Histological examinations highlighted the amelioration of the loss of keratine-14⁺ (KRT14⁺) basal ductal and/or MIST1⁺ acinar cells, as well as induction of fibrosis, following irradiation in EGF-treated mice. An additional in vitro experiment using a salivary gland organoid irradiation model indicated that the radioprotective effects of EGF promoted the growth and inhibited the apoptotic cell death of salivary epithelial cells. Our results suggest that retroductal delivery of EGF may be a promising therapeutic option for preventing radiation-induced salivary gland hypofunction.

MRI Features May Predict Molecular Features of Glioblastoma in Isocitrate Dehydrogenase Wild-Type Lower-Grade Gliomas

BACKGROUND AND PURPOSE

Isocitrate dehydrogenase (IDH) wild-type lower-grade gliomas (histologic grades II and III) with epidermal growth factor receptor (EGFR) amplification or telomerase reverse transcriptase (TERT) promoter mutation are reported to behave similar to glioblastoma. We aimed to evaluate whether MR imaging features could identify a subset of IDH wild-type lower-grade gliomas that carry molecular features of glioblastoma.

MATERIALS AND METHODS

In this multi-institutional retrospective study, pathologically confirmed IDH wild-type lower-grade gliomas from 2 tertiary institutions and The Cancer Genome Atlas constituted the training set (institution 1 and The Cancer Genome Atlas, 64 patients) and the independent test set (institution 2, 57 patients). Preoperative MRIs were analyzed using the Visually AcceSAble Rembrandt Images and radiomics. The molecular glioblastoma status was determined on the basis of the presence of EGFR amplification and TERT promoter mutation. Molecular glioblastoma was present in 73.4% and 56.1% in the training and test sets, respectively. Models using clinical, Visually AcceSAble Rembrandt Images, and radiomic features were built to predict the molecular glioblastoma status in the training set; then they were validated in the test set.

RESULTS

In the test set, a model using both Visually AcceSAble Rembrandt Images and radiomic features showed superior predictive performance (area under the curve = 0.854) than that with only clinical features or Visually AcceSAble Rembrandt Images (areas under the curve = 0.514 and 0.648, respectively; P < . 001, both). When both Visually AcceSAble Rembrandt Images and radiomics were added to clinical features, the predictive performance significantly increased (areas under the curve = 0.514 versus 0.863, P < .001).

CONCLUSIONS

MR imaging features integrated with machine learning classifiers may predict a subset of IDH wild-type lower-grade gliomas that carry molecular features of glioblastoma.

Human multipotent mesenchymal stromal cells cytokine priming promotes RAB27B-regulated secretion of small extracellular vesicles with immunomodulatory cargo

Background

The paracrine effects of multipotent mesenchymal stromal cells (MSCs) are mediated by their secretome composed by soluble factors (i.e., cytokines, growth factors, hormones) and extracellular vesicles (EVs). EVs promote intercellular communication, and the EV cargoes [e.g., proteins, soluble factors, microRNAs (miRNAs), messenger RNA (mRNA), DNA] reflect the molecular and functional characteristics of their parental cells. MSC-derived EVs (MSC-EVs) are currently evaluated as subcellular therapeutics. A key function of the MSC secretome is its ability to promote immune tolerance (i.e., immunopotency), a property that is enhanced by priming approaches (e.g., cytokines, hypoxia, chemicals) and inversely correlates with the age of the MSC donors. We evaluated mechanisms underlying MSC vesiculation and the effects of inflammation and aging on this process.

Methods

We evaluated the effects of interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α) on human adipose-derived MSC: (a) vesiculation (custom RT² Profiler PCR Array), (b) EV profiles (Nanoparticle Tracking Analysis and Nanoparticle Flow Cytometry), (c) EV cargo (proteomic analysis and Western blot analysis), and (d) immunopotency (standard MSC:CD4 T cell proliferation inhibition assay). We confirmed the role of RAB27B on MSC vesiculation (RAB27B siRNA) and assessed its differential contribution to vesiculation in adult and pediatric MSCs (qPCR).

Results

Cytokine priming upregulated RAB27B in adipose-derived MSCs increasing their secretion of exosome-like small EVs (sEVs; < 200 nm) containing two key mediators of immunopotency: A20 and TSG-6. These EVs inhibited T cell proliferation in a dose-dependent manner. RAB27B siRNA inhibited MSC vesiculation. Adipose-derived MSCs isolated from pediatric donors exhibited higher RAB27B expression and secreted more sEVs than adult MSCs.

Conclusions

Cytokine priming is a useful strategy to harvest anti-inflammatory MSC-sEVs for clinical applications. Of relevance, donor age should be considered in the selection of MSC-sEVs for clinical applications.

Coronary angiographic manifestations of fibromuscular dysplasia and clinical outcomes in patients with spontaneous coronary artery dissection

Background

Fibromuscular dysplasia (FMD) is a common predisposing condition for spontaneous coronary artery dissection (SCAD), which is an important cause of myocardial infarction (MI) in young to middle-aged women. However, its impact on clinical presentation, coronary anatomies, and outcomes have not been reported.

Purpose

To evaluate coronary angiographic characteristics and clinical outcomes in SCAD patients with or without underlying extracoronary FMD.

Methods

We retrospectively analyzed patients enrolled in our Vancouver SCAD registries who were screened for extracoronary FMD. Extracoronary FMD was defined as the presence of multifocal FMD on catheter or noninvasive angiography (computed tomographic or magnetic resonance imaging) in ≥1 extracoronary vascular beds. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (i.e. irregular stenosis, smooth stenosis, dilatation/ectasia, and tortuosity). Severe tortuosity was defined as ≥2 consecutive bends ≥180° at any cardiac cycle or 360° loop in ≥1 epicardial artery that was ≥2 mm in diameter. Clinical outcomes of major adverse cardiovascular event (MACE), a composite of all-cause death, MI, and stroke, were evaluated.

Results

We included 346 SCAD patients, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6±9.5 vs. 51.7±9.8 years) and more likely to have prior history of MI (7.2% vs. 1.0%, p=0.047) and stroke (4.4% vs. 0%, p=0.081) compared with non-FMD patients. The proportion of multivessel SCAD and TIMI flow was not different between groups, but type 3 SCAD was more commonly observed in FMD group (11.6% vs. 3.1%, p=0.026). On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs. 36.5%, p&lt;0.001), whereas rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were not significantly different (Figure). Percutaneous coronary intervention was performed in 13.2% of FMD and 15.6% of non-FMD group, with similar success rates (75.8% vs. 69.2%, p=0.65). In-hospital and long-term MACE rate at median follow-up of 1032 (IQR 453–1096) days were not different between FMD and non-FMD groups (in-hospital: 5.6% vs. 8.3%, p=0.492; long-term: 19.6% vs. 15.6%, p=0.185).

Conclusion

In SCAD patients, severe coronary tortuosity was more prevalent in patients with FMD than those without. Despite the complex coronary anatomy, FMD was not associated with worse outcomes.

Differences in coronary manifestations

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research

Machine learning for predicting fractional flow reserve based on optical coherence tomography in intermediate coronary stenosis

Background

Machine learning approaches using intravascular optical coherence tomography (OCT) to predict fractional flow reserve (FFR) have not been previously investigated. The objective of the study was to evaluate a machine learning method to estimate FFR based on intravascular OCT images in intermediate coronary lesions.

Methods

Data from both OCT- and wire-based FFR methods were obtained for lesions of the left anterior descending artery in 125 patients. Based on the total number of lesions, training and testing groups were partitioned at a ratio of 5:1. For the training group, 36 features, including 16 clinical and lesion characteristics, and 21 OCT features, were used to model machine learning-FFR. machine learning-FFR values were then derived for the testing group and compared with wire-based FFR values in terms of a diagnosis of ischemia (FFR &lt;0.8).

Results

Clinical and lesion characteristics and OCT features between the training and testing groups were similar. During the machine learning modeling of the training group, six important features of machine learning-FFR were identified: minimal luminal area, percentage of the stenotic area, lesion length, proximal luminal area, pre-procedural platelet count, and hypertension. machine learning-FFR values showed a good correlation (r=0.853, P&lt;0.001) with wire-based FFR values (Figure 1A). The diagnostic power of an FFR value less than 0.8, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of machine learning-FFR values for the testing group were 85.7%, 100%, 100%, 77.8%, and 90.5%, respectively (Figure 1B). Additionally, OCT-based machine learning-FFR values showed a good diagnostic accuracy compared with other image-based FFR values.

Conclusions

The OCT-based machine learning-FFR method can be used to simultaneously acquire information on both image and functional modalities using one invasive procedure, suggesting that it may be used to optimize treatments for intermediate coronary artery stenosis, as well as save time and cost.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Funded by the Korean government (MSIT) (no. 2017R1A2B2003191)

Trastuzumab-induced upregulation of a protein set in extracellular vesicles emitted by ErbB2-positive breast cancer cells correlates with their trastuzumab sensitivity

Background

ErbB2/HER2 oncoprotein often drives breast cancers (BCs) which are treated with the anti-ErbB2 antibody trastuzumab. The efficacy of trastuzumab-based metastatic BC therapies is routinely assessed by imaging studies. Trastuzumab typically becomes ineffective in the case of this disease and is then replaced by other drugs. Biomarkers of BC trastuzumab response could allow imaging studies and the switch to other drugs to occur earlier than is now possible. Moreover, bone-only BC metastases can be hard to measure, and biomarkers of their trastuzumab response could facilitate further treatment decisions. Such biomarkers are presently unavailable. In this study, we searched for proteins whose levels in BC cell-emitted extracellular vesicles (EVs) potentially correlate with BC trastuzumab sensitivity.

Methods

We isolated EVs from cultured trastuzumab-sensitive and trastuzumab-resistant human BC cells before and after trastuzumab treatment and characterized these EVs by nanoparticle tracking analysis and electron microscopy. We found previously that ErbB2 drives BC by downregulating a pro-apoptotic protein PERP. We now tested whether trastuzumab-induced PERP upregulation in EVs emitted by cultured human BC cells correlates with their trastuzumab sensitivity. We also used mass spectrometry to search for additional proteins whose levels in such EVs reflect BC cell trastuzumab sensitivity. Once we identified proteins whose EV levels correlate with this sensitivity in culture, we explored the feasibility of testing whether their levels in the blood EVs of trastuzumab-treated metastatic BC patients correlate with patients’ response to trastuzumab-based treatments.

Results

We found that neither trastuzumab nor acquisition of trastuzumab resistance by BC cells affects the size or morphology of EVs emitted by cultured BC cells. We established that EV levels of proteins PERP, GNAS2, GNA13, ITB1, and RAB10 correlate with BC cell trastuzumab response. Moreover, these proteins were upregulated during trastuzumab-based therapies in the blood EVs of a pilot cohort of metastatic BC patients that benefited from these therapies but not in those derived from patients that failed such treatments.

Conclusions

Upregulation of a protein set in EVs derived from cultured breast tumor cells correlates with tumor cell trastuzumab sensitivity. It is feasible to further evaluate these proteins as biomarkers of metastatic BC trastuzumab response.

TEK is a novel prognostic marker for clear cell renal cell carcinoma

OBJECTIVE

Clear cell renal cell carcinoma (ccRCC) is the most common type of kidney cancer. However, effective therapeutics for ccRCC are lacking. Novel biomarkers could provide critical information when determining prognoses for patients with ccRCC. In this study, we sought to determine if the expression of receptor tyrosine kinase (TEK) could be a potential novel prognostic biomarker for ccRCC. TEK, originally identified as an endothelial cell-specific receptor, plays an important role in the modulation of vasculogenesis and remodeling. Altered TEK expression has been observed in tumor tissues (e.g., oral squamous cell carcinomas, leukemia) and breast, gastric and thyroid cancers. However, the role of TEK in ccRCC remains unknown.

PATIENTS AND METHODS

Differential TEK expression between non-metastatic (stage M0) and metastatic (stage M1) ccRCC patient cohorts was determined from The Cancer Genome Atlas (TCGA) and the International Cancer Genome Consortium (ICGC). Furthermore, TEK expression was assessed as a prognostic factor using the time-dependent area under the curve (AUC) of Uno's C-index, the AUC value of the receiver operating characteristics (ROC) at 5 years, Kaplan-Meier survival curves and multivariate analyses.

RESULTS

A Kaplan-Meier curve analysis revealed that the downregulation of TEK expression was associated with a poor prognosis for patients with ccRCC with good discrimination (p<0.0001 and p=0.0044 for the TGCA and ICGC cohorts, respectively). Analyses of C-indices and receiver operating characteristic AUC values further support this discriminative ability. Moreover, multivariate analyses showed the prognostic significance of TEK expression levels (p<0.001).

CONCLUSIONS

Although additional clinical investigations will be needed, our results suggest that TEK is a potential biomarker for ccRCC.

Magnesium-Dependent Promotion of H2O2 Production Increases Ecological Competitiveness of Oral Commensal Streptococci

The pyruvate oxidase (SpxB)-dependent production of H₂O₂ is widely distributed among oral commensal streptococci. Several studies confirmed the ability of H₂O₂ to antagonize susceptible oral bacterial species, including caries-associated Streptococcus mutans as well as several periodontal pathobionts. Here we report a potential mechanism to bolster oral commensal streptococcal H₂O₂ production by magnesium (Mg²⁺) supplementation. Magnesium is a cofactor for SpxB catalytic activity, and supplementation increases the production of H₂O₂ in vitro. We demonstrate that Mg²⁺ affects spxB transcription and SpxB abundance in Streptococcus sanguinis and Streptococcus gordonii. The competitiveness of low-passage commensal streptococcal clinical isolates is positively influenced in antagonism assays against S. mutans. In growth conditions normally selective for S. mutans, Mg²⁺ supplementation is able to increase the abundance of S. sanguinis in dual-species biofilms. Using an in vivo biophotonic imaging platform, we further demonstrate that dietary Mg²⁺ supplementation significantly improves S. gordonii oral colonization in mice. In summary, our results support a role for Mg²⁺ supplementation as a potential prebiotic to promote establishment of oral health-associated commensal streptococci.

SAT0247 PREDICTORS OF ADVERSE OUTCOMES IN DIFFUSE ALVEOLAR HEMORRHAGE OF IMMUNE AND NON-IMMUNE CAUSES: 12-YEAR EXPERIENCE FROM A UNIVERSITY HOSPITAL

Background:

Diffuse alveolar hemorrhage (DAH) is a rare, life-threatening condition that has either immune or non-immune etiologies1. DAH caused by capillaritis can be immune-mediated (IM-DAH), e.g. anti-neutrophil cytoplasmic antibody (ANCA) vasculitis and systemic lupus erythematosus, but DAH may also result from anticoagulation, heart failure, drugs or inhaled toxins. Since IM-DAH has specific therapies available, we hypothesized that patients with IM-DAH would have a better prognosis.

Objectives:

We did a retrospective analysis of all DAH cases seen at our university hospital in the last 12 years to investigate the predictors of adverse outcomes.

Methods:

Using Epic radiant and Agfa Radiology Information System databases, we queried electronic medical records of all patients admitted to our university between Jan 2007 to Jan 2019 who had the words “diffuse alveolar hemorrhage” in their chest x-ray report. We manually reviewed charts of all these patients to confirm true DAH. True DAH was defined as suspicion of DAH on chest x-ray plus inclusion of DAH on the discharge problem list. We did a detailed chart review of true DAH cases to extract information regarding demographics, baseline disease characteristics, physical/serology/imaging findings, treatment received, and outcomes. The outcomes of interest were death, intubation, shock, need for hemodialysis (HD), and red blood cell transfusions. We compared IM-DAH with non IM-DAH cases using descriptive statistics, t-test, and chi-squared tests. We used logistic regression models to assess the influence of baseline characteristics on outcomes. A p-value < 0.05 was considered statistically significant.

Results:

There were 88 cases of DAH (M:F 54:34, median age 57) fulfilling inclusion criteria (Table 1). The non-immune etiology was diagnosed in 63%, while 36% were IM-DAH (18% ANCA associated, 9% SLE, 2% decompensated heart failure, the rest were others). No clear etiology for DAH was found in 37.5% cases. Death within 90 days of onset of DAH occurred in 37.5%, 5.6% had recurrent DAH, and 56.8% had sustained remission. Non-IM DAH cases had worse outcomes such as death and were less likely to experience sustained remission (Chi-squared = 19.1, p < 0.001), though IM-DAH were more likely to receive HD (Chi-squared = 7.5, p-value 0.01). Presence of extrapulmonary findings (e.g. nephritis) was a risk factor for adverse outcome, and was statistically significantly correlated with the amount of blood products received, need for HD and likelihood of death, which did not reach statistical significance. Shock and intubation were associated with a higher likelihood of death (p = 0.02 and p = 0.001, respectively).

Table 1.

Comparison of Clinical Characteristics of Immune versus Non-Immune Cases of Diffuse Alveolar Hemorrhage

VariableImmune cases(N = 32)Non-immune cases(N = 56)Statistical comparisonAge (years)51.0955.91P = 0.196%Female43.835.7P = 0.510%presenting with hemoptysis8 (25%)14 (25%)P = 0.101%extrapulmonary findings20 (62.5%)1 (1.7%)P = 6.9*e-10pANCA positive16 (50%)2 (3.6%)P = 0.0004% on anticoagulation9.42.5P = 0.090Mean Creatinine2.381.89P = 0.507Mean hospital length of stay (days)16.6923.27P = 0.139Drop in Hemoglobin prior to DAH and day of DAH0.241.17P = 0.070%Bronchoscopy-confirmed DAH62.575.0P = 0694Mean units of blood transfused1.912.66P = 0.448%Need for hemodialysis37.512.5P = 0.010%Shock (any kind)21.932.1P = 0.338%Need for intubation43.862.5P = 0.122%Death within 90 days12.552.7P = 0.0009

Conclusion:

DAH, a life-threatening condition, has both immune and non-immune etiologies. Our 12-years, single-center, university hospital experience showed that IM-DAH has a better prognosis than non IM-DAH. Presence of extrapulmonary manifestations was associated with worse outcomes.

References:

[1]Moo Suk Park. Diffuse Alveolar Hemorrhage. Tuberc Respir Dis (Seoul). 2013 Apr; 74(4): 151–162.

[2]Nasser M, Cottin V. Alveolar Hemorrhage in Vasculitis (Primary and Secondary). Semin Respir Crit Care Med. 2018 Aug;39(4):482-493.

Disclosure of Interests:

Ambika Bhushan: None declared, Dongseok Choi: None declared, Guy Maresh: None declared, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB

Extracellular vesicles from genetically unstable, oncogene-driven cancer cells trigger micronuclei formation in endothelial cells

Oncogenic transformation impacts cancer cell interactions with their stroma, including through formation of abnormal blood vessels. This influence is often attributed to angiogenic growth factors, either soluble, or associated with tumor cell-derived extracellular vesicles (EVs). Here we examine some of the cancer-specific components of EV-mediated tumor-vascular interactions, including the impact of genetic driver mutations and genetic instability. Cancer cells expressing mutant HRAS oncogene exhibit aberrations of chromatin architecture, aneuploidy, cytoplasmic chromatin deposition and formation of micronuclei with a non-random chromosome content. EVs released from such HRAS-driven cells carry genomic DNA, including oncogenic sequences, and transfer this material to endothelial cells while inducing abnormal formation of micronuclei, along with cell migration and proliferation. Micronuclei were also triggered following treatment with EVs derived from glioma cells (and stem cells) expressing EGFRvIII oncogene, and in both endothelial cells and astrocytes. EVs from HRAS and EGFRvIII-driven cancer cells carry 19 common proteins while EVs from indolent control cells exhibit more divergent proteomes. Immortalized endothelial cell lines with disrupted TP53 pathway were refractory to EV-mediated micronuclei induction. We suggest that oncogenic transformation and intercellular trafficking of cancer-derived EVs may contribute to pathological vascular responses in cancer due to intercellular transmission of genomic instability.

Quantitative proteomic analysis of trypsin-treated extracellular vesicles to identify the real-vesicular proteins

Extracellular vesicles (EVs) are nano-sized vesicles surrounded by a lipid bilayer and released into the extracellular milieu by most of cells. Although various EV isolation methods have been established, most of the current methods isolate EVs with contaminated non-vesicular proteins. By applying the label-free quantitative proteomic analyses of human colon cancer cell SW480-derived EVs, we identified trypsin-sensitive and trypsin-resistant vesicular proteins. Further systems biology and protein-protein interaction network analyses based on their cellular localization, we classified the trypsin-sensitive and trypsin-resistant vesicular proteins into two subgroups: 363 candidate real-vesicular proteins and 151 contaminated non-vesicular proteins. Moreover, the protein interaction network analyses showed that candidate real-vesicular proteins are mainly derived from plasma membrane (46.8%), cytosol (36.6%), cytoskeleton (8.0%) and extracellular region (2.5%). On the other hand, most of the contaminated non-vesicular proteins derived from nucleus, Golgi apparatus, endoplasmic reticulum and mitochondria. In addition, ribosomal protein complexes and T-complex proteins were classified as the contaminated non-vesicular proteins. Taken together, our trypsin-digested proteomic approach on EVs is an important advance to identify the real-vesicular proteins that could help to understand EV biogenesis and protein cargo-sorting mechanism during EV release, to identify more reliable EV diagnostic marker proteins, and to decode pathophysiological roles of EVs.

A reference map of the human binary protein interactome

Global insights into cellular organization and genome function require comprehensive understanding of the interactome networks that mediate genotype-phenotype relationships^1,2. Here, we present a human “all-by-all” reference interactome map of human binary protein interactions, or “HuRI”. With ~53,000 high-quality protein-protein interactions (PPIs), HuRI has approximately four times more such interactions than high-quality curated interactions from small-scale studies. Integrating HuRI with genome³, transcriptome⁴, and proteome⁵ data enables the study of cellular function within most physiological or pathological cellular contexts. We demonstrate the utility of HuRI in identifying specific subcellular roles of PPIs. Inferred tissue-specific networks reveal general principles for the formation of cellular context-specific functions and elucidate potential molecular mechanisms underlying tissue-specific phenotypes of Mendelian diseases. HuRI represents a systematic proteome-wide reference linking genomic variation to phenotypic outcomes.

Exposure to oral bisphosphonates and risk of gastrointestinal cancer

Few studies have explored the association of oral bisphosphonate exposure and gastrointestinal cancer within Asian populations. In this study, we investigated 45,397 Korean women from the nationwide population-based cohort from 2002 to 2013. Oral bisphosphonate exposure did not appear to be associated with elevated or reduced risk for gastrointestinal cancer.

INTRODUCTION

While several studies suggested increased risk in upper gastrointestinal (GI) cancer or reduced risk in colorectal cancer upon bisphosphonate exposure, the association is less explored within Asian populations. We investigated the effect of oral bisphosphonate exposure on the risk of GI cancers within a nationwide population-based cohort.

METHODS

This study used two separate cohorts. The first cohort included 45,397 women aged 60 years or older from the National Health Insurance Service-Health Screening Cohort during 2002-2013. Participants were classified into bisphosphonate users and non-users based on drug exposure during 2002-2007, and followed-up from the index date of January 1, 2008. The second cohort included 25,665 newly diagnosed osteoporosis patients who started taking oral bisphosphonate during 2003-2008. After 4 years of drug exposure period, patients were separated into quartiles based on cumulative oral bisphosphonate exposure. Participants were followed-up until December 31, 2013 for GI cancer, stomach cancer, and colorectal cancer. Cox proportional hazard regression models were used to assess the hazard ratios (HRs) and 95% confidence intervals (CIs) for the cancer risks.

RESULTS

Compared to bisphosphonate non-users, no significant risk difference was observed among bisphosphonate users on GI (HR 1.06; 95% CI 0.87-1.28), stomach (HR 1.11; 95% CI 0.85-1.47) and colorectal cancers (HR 1.04; 95% CI 0.79-1.37). Among bisphosphonate users, increasing doses of bisphosphonate exposure was not associated with elevated or reduced risk for GI cancer (p for trend 0.573).

CONCLUSION

Oral bisphosphonate use did not appear to be associated with elevated or reduced risk for GI cancers.

Spinal Stenosis in Familial Transthyretin Amyloidosis

Here we describe a patient with genetically confirmed ATTR, a family history of the disease and histological confirmation following carpal tunnel release surgery but no other manifestations. The first major neurological or systemic manifestation was cauda equina syndrome with ATTR deposits contributing to lumbar spinal stenosis. Recent gene therapy trials showed improvement in the neuropathy in TTR amyloidosis. This case highlights the need for awareness of the heterogeneous neurological phenotype seen in ATTR to aid earlier diagnosis especially now that disease modifying therapies are available.

P4393Current smoking and gender difference in South Korean AMI patients who underwent PCI with DES

Background

There is some debate on whether or not there is a gender difference is present between current smoking and cardiovascular disease.

Purpose

We decide to evaluate the impact of sex difference on the 2-year clinical outcomes in Korean acute myocardial infarction (AMI) patients who currently smoke and who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Methods

The data of this study was obtained from the Korea Acute Myocardial Infarction (KAMIR) registry. More than fifty high-volume universites or community hospitals with facilities for primary PCI and onsite cardiac surgery participated in this KAMIR registry. A total of 12565 current smoker AMI patients were enrolled and divided into the male (n=11767, 93.6%) or female (n=798, 6.4%) group. The clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), and total repeat revascularization.

Results

Before risk adjustment, the cumulative incidences of MACE (7.2% vs. 10.0%, hazard ratio [HR], 1.419; 95% confidence interval [CI], 1.125–1.790; P=0.003), all-cause death (HR, 1.988; 95% CI, 1.417–2.789; P<0.001), and re-MI (HR, 1.885; 95% CI, 1.154–3.078; P=0.011) were significantly higher in the female group compared with the male group. However, after adjustment the cumulative incidences of MACE (adjusted HR, 1.047; 95% CI, 0.756–1.450; P=0.782), all-cause death, re-MI, total repeat revascularization, TLR, TVR, and non-TVR were similar between the two groups.

Clinical outcomes at 2-year Outcomes Cumulative Events at 2-year (%) Unadjusted Adjusted* Propensity-score adjusted Male Female Log-rank Hazard Ratio (95% CI) p value Hazard Ratio (95% CI) p value Hazard Ratio (95% CI) p value MACE 819 (7.2) 78 (10.0) 0.003 1.419 (1.125–1.790) 0.003 1.047 (0.756–1.450) 0.782 1.133 (0.871–1.473) 0.352 All-cause death 283 (2.5) 38 (4.8) <0.001 1.988 (1.417–2.789) <0.001 0.764 (0.457–1.279) 0.306 1.105 (0.744–1.641) 0.620 Cardiac death 224 (1.9) 25 (3.2) 0.016 1.654 (1.094–2.500) 0.017 0.512 (0.261–1.005) 0.052 0.822 (0.511–1.322) 0.419 Re-MI 142 (1.3) 18 (2.4) 0.010 1.885 (1.154–3.078) 0.011 1.741 (0.887–3.419) 0.107 1.835 (1.109–3.375) 0.062 Total revascularization 444 (4.0) 27 (3.6) 0.594 0.900 (0.610–1.327) 0.594 1.069 (0.654–1.748) 0.789 0.956 (0.627–1.458) 0.835 TLR 121 (1.1) 8 (1.1) 0.956 0.980 (0.479–2.004) 0.956 0.955 (0.366–2.497) 0.926 0.868 (0.395–1.910) 0.726 TVR 228 (2.1) 14 (1.9) 0.726 0.908 (0.529–1.558) 0.726 1.051 (0.518–2.135) 0.890 0.935 (0.519–1.684) 0.823 Non-TVR 223 (2.0) 13 (1.7) 0.602 0.862 (0.493–1.508) 0.602 1.060 (0.536–2.097) 0.867 0.942 (0.514–1.726) 0.847

Conclusion

Before risk adjustment, a gender difference was suggested in the female group compared with the male in these current smoker South Korean AMI patients during a 2-year follow-up period. However, after adjustment, gender difference was not observed in these AMI patients with a history of current smoking.

P833Two-year clinical outcomes between statin with ACE inhibitor or ARB in patients with ST-segment elevation myocardial infarction after successful PCI with DES

Background

Limited comparative data are available.

Purpose

We decided to compare 2-year major clinical outcomes between statin with ACEI and statin ARB therapy in patients with STEMI after PCI with drug-eluting stents (DES).

Methods

A total 11706 STEMI patients who underwent PCI with DES and who prescribed statin were enrolled and they were divided into two groups, the statin with ACEI group (n=8705) and the statin with ARB group (n=3001). The primary endpoint was the major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-TVR. The secondary endpoints were the cumulative incidences of individual components of MACE and target vessel failure (TVF), a composite of death related to the target vessel, re-MI, or clinically driven TVR.

Results

Two PSM groups (2835 pairs, n=5670, C-statistic = 0.680) were generated. The relative risk of MACE was higher in the statin with ARB group compared to statin with ACEI groups after propensity score-matched (PSM) analysis (hazard ratio [HR]: 1.323, 95% confidence interval [CI]: 1.085–1.613, p=0.006). The relative risks of cardiac death (HR: 1.831, 95% CI: 1.199–2.740, p=0.005), total repeat revascularization (HR: 1.487, 95% CI: 1.133–1.950, p=0.004), and non-TVR (HR: 1.696, 95% CI: 1.122–2.564, p=0.012) were also higher in the statin with ARB group after PSM.

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value Statin + ACEI Statin + ARB Log-rank Propensity score matched Patients MACE 173 (6.5) 225 (8.5) 0.006 1.323 (1.085–1.613) 0.006 All-cause death 58 (2.2) 80 (3.0) 0.054 1.391 (0.992–1.950) 0.056 Cardiac death 35 (1.3) 63 (2.3) 0.004 1.831 (1.199–2.740) 0.005 Re-MI 39 (1.5) 44 (1.7) 0.548 1.141 (0.742–1.756) 0.548 Total repeat revascularization 88 (3.4) 128 (4.9) 0.004 1.487 (1.133–1.950) 0.004 TLR 26 (1.0) 40 (1.5) 0.075 1.561 (0.953–2.558) 0.077 TVR 53 (2.0) 71 (2.8) 0.086 1.364 (0.955–1.946) 0.088 Non-TVR 36 (1.4) 60 (2.3) 0.011 1.696 (1.122–2.564) 0.012 TVF 140 (5.3) 173 (6.6) 0.050 1.249 (1.000–1.561) 0.050

Conclusions

In this study, we suggest that the combination of statin with ACEI may be beneficial for reducing the cumulative incidences of MACE, total repeat revascularization rate, and non-TVR rather than the statin with ARB after PCI with DES in STEMI patients.

P5362Impact of statin therapy on long-term clinical outcomes between STEMI and NSTEMI after stent implantation

Background

Although European guideline recommends that statin should be given to all patients with acute myocardial infarction (AMI), irrespective of cholesterol concentration, limited studies were focused on the long-term effects of statin therapy between ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI).

Purpose

The authors conducted the study to compare the relative beneficial role of statin on 2-year major clinical outcomes between STEMI and NSTEMI in patients who underwent successful PCI with DES.

Methods

Finally, a total of 26317 AMI patients who underwent stent implantation and who were prescribed the statin were enrolled and they were separated into two groups; the STEMI group (n=15002) and the NSTEMI group (n=11315). The clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), total coronary revascularization (target lesion revascularization [TLR], target vessel revascularization [TVR], non-TVR) during 2-year follow-up period.

Results

After propensity score-matched (PSM) analysis, two PSM groups (7746 pairs, n=15492, C-statistic = 0.766) were generated. In the total study population, the cumulative incidences of MACE, all-cause death, and cardiac death were significantly higher in the NSTEMI group. However, after PSM, the cumulative incidence of all-cause death (Hazard ratio, 1.386; 95% CI, 1.133–1.696; p=0.002) was significantly higher in the NSTEMI group. The cumulative incidences of MACE, cardiac death, re-MI, total revascularization, TLR, TVR, and non-TVR were similar between the two groups (Table 1).

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value STEMI NSTEMI Log-rank Propensity score matched patients MACE 532 (7.2) 584 (8.1) 0.092 1.106 (0.984–1.244) 0.092 All-cause death 163 (2.2) 224 (3.1) 0.001 1.386 (1.133–1.696) 0.002 Cardiac death 121 (1.5) 148 (2.0) 0.088 1.232 (0.969–1.566) 0.089 Re-MI 117 (1.6) 107 (1.5) 0.545 0.922 (0.710–1.199) 0.545 Total revascularization 291 (4.1) 307 (4.4) 0.422 1.068 (0.910–1.254) 0.423 TLR 92 (1.3) 89 (1.2) 0.880 0.978 (0.731–1.309) 0.880 TVR 173 (2.4) 184 (2.6) 0.478 1.078 (0.876–1.327) 0.478 Non-TVR 123 (1.7) 130 (1.9) 0.593 1.070 (0.836–1.369) 0.539

Conclusion

The mortality reduction capability of statin was more prominent in the STEMI group compared with the NSTEMI group.

P5494Impact of the gender difference on long-term clinical outcomes in dyslipidemic South Korean AMI patients who underwent PCI with new-generation DES

Background

There are limited comparative data concerning long-term major clinical outcomes between male and female in dyslipidemic AMI patients after PCI with new-generation DES.

Purpose

We thought to investigate the impact of gender difference on the 2-year clinical outcomes.

Methods

Finally, a total of 2403 eligible dyslipidemic AMI patients who underwent PCI with new-generation DES were enrolled and they were separated into two groups; the male group (n=1800) and the female group (n=603). The primary endpoint was major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), target lesion revascularization (TLR), and target vessel revascularization (TVR). The secondary endpoints were the incidence of the individual components of MACE and target vessel failure (TVF), a composite of death related to the target vessel, re-MI, or clinically driven TVR

Results

Two propensity score-matched (PSM) groups (422 pairs, n=844, C-statistic = 0.850) were generated. In the total study population, the cumulative incidences of MACE, all-cause death, re-MI, and TVF were significantly higher in the female group compared with the male group. However, after propensity score-matched (PSM) analysis, the cumulative incidences of MACE (HR, 0.971; 95% CI, 0.628–1.501; p=0.895), all-cause death (HR, 1.061; 95% CI, 0.536–2.100; p=0.865), re-MI (HR, 1.212; 95% CI, 0.433–2.907; p=0.813), and TVF (HR, 0.764; 95% CI, 0.474–1.229; p=0.267) were similar between the two groups. In addition, the cumulative incidences of cardiac death, TLR, TVR were not significantly different between the two groups (Table 1).

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value Male Female Log-rank Propensity score matched patients MACE 41 (10.4) 40 (10.3) 0.895 0.971 (0.628–1.501) 0.895 All-cause death 16 (4.0) 17 (4.2) 0.865 1.061 (0.536–2.100) 0.865 Cardiac death 13 (3.3) 9 (2.2) 0.391 0.691 (0.295–1.616) 0.393 Re-MI 8 (2.0) 9 (2.4) 0.813 1.212 (0.433–2.907) 0.813 TLR 7 (1.8) 6 (1.6) 0.781 0.857 (0.298–2.550) 0.781 TVR 16 (4.3) 10 (2.7) 0.236 0.623 (0.283–1.373) 0.241 TVF 39 (10.2) 30 (7.8) 0.265 0.764 (0.474–1.229) 0.267

Conclusion

The gender difference was not apparent in these dyslipidemic South Korean AMI patients who underwent PCI with new-generation DES during 2-year follow-up period.

Mapping Subpopulations of Cancer Cell-Derived Extracellular Vesicles and Particles by Nano-Flow Cytometry

The elusive complexity of membranous extracellular vesicle (EV) and membrane-less extracellular particle (EP) populations released from various cellular sources contains clues as to their biological functions and diagnostic utility. In this study, we employed optimized multicolor nano-flow cytometry, structured illumination (SIM), and atomic force microscopy (AFM) to bridge sensitive detection at the single EV/EP level and high-throughput analysis of cancer cell secretomes. We applied these approaches to particles released from intact cells driven by several different transforming mechanisms or to cells under therapeutic stress imposed by pharmacological inhibition of their oncogenic drivers, such as epidermal growth factor receptor (EGFR). We demonstrate a highly heterogeneous distribution of biologically relevant elements of the EV/EP cargo, including oncoproteins (EGFR), clotting factors (tissue factor), pro-metastatic integrins (ITGA6, ITGA4), tetraspanins (CD63), and genomic DNA across the entire particulate secretome of cancer cells. We observed that targeting EGFR activity with irreversible kinase inhibitors (dacomitinib) triggers emission of DNA containing EP/EV subpopulations, including particles (chromatimeres) harboring both EGFR and DNase-resistant chromatin. While nano-flow cytometry enables quantification of these changes across the entire particular secretome, SIM reveals individual molecular topography of EV/EP subsets and AFM exposes some of their physical properties, including the presence of nanofilaments and other substructures. We describe differential uptake rates of distinct EV subsets, resulting in preferential internalization of exosome-like small EVs by cancer cells to the exclusion of larger EVs. Thus, our study illustrates the potential of nano-flow cytometry coupled with high-resolution microscopy to explore the cancer-related EV/EP landscape.

P02.01 Analysis of Multimodal Intraoperative Monitoring During Intramedullary Spinal Ependymoma Surgery

BACKGROUND

To evaluate the validity of intraoperative somatosensory-evoked potential (SSEP) and motor-evoked potential (MEP) monitoring according to two different warning criteria for 6 months after intramedullary spinal ependymoma (IMSE) surgery.

MATERIAL AND METHODS

To evaluate the validity of intraoperative somatosensory-evoked potential (SSEP) and motor-evoked potential (MEP) monitoring according to two different warning criteria for 6 months after intramedullary spinal ependymoma (IMSE) surgery.

RESULTS

The success rates of SSEP and MEP monitoring were 84.9% and 83.7%, respectively. There was one indeterminate case in SSEP and six in MEP. All-or-none criterion in SSEP and MEP monitoring showed higher specificity, PPV, and DOR than 50% decline criterion during 6 months. During the follow up, 37 of 38 extremities (97.4%) and 21 of 29 extremities (72.4%) were observed the improvement of sensory and motor deficit, respectively. Seven indeterminate cases also showed good clinical outcomes. However, most patients remained some degree of neurologic deficit.

CONCLUSION

Many false positive and false negative results of SSEP and MEP monitoring occurred immediately postoperative period. All-or-none criterion was more beneficial for IMSE surgery than 50% decline criterion. This trend was maintained until 6 months after surgery.

P92 What is a benign notochordal cell tumour?

Objectives

Characteristics from a large systematic review.

Design

The first systematic review of benign notochordal cell tumours.

Subjects

All studies, in any language, published at any time, identified using specified search terms.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Results

So-called benign notochordal cell tumours exhibited the following features: pain was the sole presenting symptom in 37/81 (45.7%) and neurological deficit in 36/81 (44.4%). Incidental discovery upon imaging was reported in 8/81 (9.9%). Radiologically, lesions were small, (≤30 millimetres at their maximum diameter) in 57/65 (87.7%), hypointense on T1 sequences and hyperintense on T2 sequences on magnetic resonance imaging (106/130; 81.5%), did not enhance following contrast administration (62/74; 83.8%) and were non-lytic (80/160; 50.0%). Histologically, these tumours lacked myxoid matrix (66/84; 78.6%) and nuclear atypia (100/112; 89.3%). In those managed conservatively, follow up was between 8.5 and 120 months. Most were stable at follow up (22/25; 88.0%), one lesion grew (4.0%), one patient died of an unrelated cause (4.0%) and outcome was not stated in one case (4.0%).

Conclusions

BNCTs exhibit a spectrum of features, none of which are pathognomonic and diagnosis is subjective. The majority of reports describe small, non-progressive, non-lytic lesions that lack contrast enhancement, intercellular myxoid matrix and nuclear atypia. They are nevertheless difficult to distinguish from small chordomas.

P25 Hydrogel systems to enhance the delivery of cell therapy for traumatic spinal cord injury

Objectives

Cell therapies are an emerging therapeutic approach for spinal cord injury. We assessed the survival and phenotype of olfactory ensheathing cells (OECs) in hydrogel delivery systems suitable for clinical use.

Design

Laboratory study.

Methods

Cell survival in different formulations of collagen and fibrin hydrogels was assessed using Syto 9 and propidium iodide. The proportion of cells staining positive for a key repair marker (p75NTR) was also quantified using immunocytochemistry and fluorescence microscopy.

Results

There were significant differences in OEC survival between the various collagen and fibrin hydrogel formulations tested (p<0.001 one-way ANOVA, n=17). 10% v/v fibrin conferred the best cell survival with 85% of OECs remaining alive. Incorporating OECs into collagen hydrogels promoted the highest proportion of p75NTR immunopositive cells (78%) and this was significantly higher than both fibrin hydrogels and traditional monolayer culture (53% and 20%, respectively, p<0.0001 one-way ANOVA, n=24).

Conclusions

Collagen and fibrin hydrogels both have the potential to enhance the delivery, survival and retention of transplanted OECs for spinal cord repair. Both materials are clinically scalable, promote favourable OEC survival and have the potential to increase the proportion of cells expressing a key repair marker (p75NTR). Optimised hydrogel delivery systems may provide a valuable approach to improve the delivery of OECs for spinal cord repair in the future.

Oncogenic Regulation of Extracellular Vesicle Proteome and Heterogeneity

Mutational and epigenetic driver events profoundly alter intercellular communication pathways in cancer. This effect includes deregulated release, molecular composition, and biological activity of extracellular vesicles (EVs), membranous cellular fragments ranging from a few microns to less than 100 nm in diameter and filled with bioactive molecular cargo (proteins, lipids, and nucleic acids). While EVs are usually classified on the basis of their physical properties and biogenetic mechanisms, recent analyses of their proteome suggest a larger than expected molecular diversity, a notion that is also supported by multicolour nano-flow cytometry and other emerging technology platforms designed to analyze single EVs. Both protein composition and EV diversity are markedly altered by oncogenic transformation, epithelial to mesenchymal transition, and differentiation of cancer stem cells. Interestingly, only a subset of EVs released from mutant cells may carry oncogenic proteins (e.g., EGFRvIII), hence, these EVs are often referred to as "oncosomes". Indeed, oncogenic transformation alters the repertoire of EV-associated proteins, increases the presence of pro-invasive cargo, and alters the composition of distinct EV populations. Molecular profiling of single EVs may reveal a more intricate effect of transforming events on the architecture of EV populations in cancer and shed new light on their biological role and diagnostic utility.

Extracellular Vesicles as Conduits of Non-Coding RNA Emission and Intercellular Transfer in Brain Tumors

Non-coding RNA (ncRNA) species have emerged in as molecular fingerprints and regulators of brain tumor pathogenesis and progression. While changes in ncRNA levels have been traditionally regarded as cell intrinsic there is mounting evidence for their extracellular and paracrine function. One of the key mechanisms that enables ncRNA to exit from cells is their selective packaging into extracellular vesicles (EVs), and trafficking in the extracellular space and biofluids. Vesicular export processes reduce intracellular levels of specific ncRNA in EV donor cells while creating a pool of EV-associated ncRNA in the extracellular space and biofluids that enables their uptake by other recipient cells; both aspects have functional consequences. Cancer cells produce several EV subtypes (exosomes, ectosomes), which differ in their ncRNA composition, properties and function. Several RNA biotypes have been identified in the cargo of brain tumor EVs, of which microRNAs are the most studied, but other species (snRNA, YRNA, tRNA, and lncRNA) are often more abundant. Of particular interest is the link between transforming oncogenes and the biogenesis, cargo, uptake and function of tumor-derived EV, including EV content of oncogenic RNA. The ncRNA repertoire of EVs isolated from cerebrospinal fluid and serum is being developed as a liquid biopsy platform in brain tumors.