Remaining Issues Related to Serum Cytokines in Patients with Unresectable Hepatocellular Carcinoma Treated by Atezolizumab plus Bevacizumab Combination Treatment

INTRODUCTION

Atezolizumab plus bevacizumab (AteBev) combination treatment is widely used as first-line systemic therapy for unresectable hepatocellular carcinoma (uHCC). We aimed to clarify therapeutic issues regarding serum cytokines and the immune reaction in patients with uHCC treated with AteBev.

METHODS

We analyzed preserved serum from a previous prospective study on adult Japanese patients with chronic liver disease and uHCC who received AteBev treatment at our hospital. In that study, AteBev were administered intravenously every 3 weeks, and blood samples were collected before and after 3 weeks' treatment. Dynamic computed tomography was performed after 6 weeks of treatment to assess response.

RESULTS

In the prospective study, 21 of the 59 patients showed partial response (PR) and 19 patients showed stable disease (SD), but 19 patients showed progressive disease (PD). We found that serum levels of tumor necrosis factor-alpha, interleukin (IL)-6, and soluble IL-2 receptor (IL-2R) increased significantly in the PR group, but only soluble IL-2R increased significantly in the PD group. Regulatory T cells decreased significantly in the PD group, but there was no significant change in Th1 or Th2 cells from before to after treatment in any group. As regards soluble MHC-class I, pre-treatment levels were significantly lower in the PD group than in the PR group, and serum levels increased significantly with treatment in the PD group.

CONCLUSION

These findings reveal a need to further improve T-cell priming and to further make T-cells recognize tumor antigens in uHCC.

Hepatitis B Virus-related Membranous Nephropathy with Crescentic Formation in an Inactive Carrier of Positive Hepatitis B Surface Antigen with Undetectable DNA under Anti-viral Treatment

A man who was an inactive hepatitis B virus (HBV) carrier with positive hepatitis B surface antigen (HBs antigen) and undetectable HBV-DNA under anti-viral treatment developed nephrotic syndrome at 52 years old, and a renal biopsy revealed advanced membranous nephropathy (MN) with focal cellular crescents, interstitial hemorrhaging, and peritubular capillaritis. Immunofluorescence studies demonstrated granular IgG deposition and HBs antigen-positivity along the capillaries. Glomeruli were negative for phospholipase A2 receptor 1. There were no clinical findings of systemic vasculitis. We considered MN combined with small-vessel vasculitis due to HBV infection. These results suggest that HBV-related kidney disease should be considered even in patients with an inactive HBV carrier status under treatment.

Fibroblast growth factor 18 stimulates the proliferation of hepatic stellate cells, thereby inducing liver fibrosis

Liver fibrosis results from chronic liver injury triggered by factors such as viral infection, excess alcohol intake, and lipid accumulation. However, the mechanisms underlying liver fibrosis are not fully understood. Here, we demonstrate that the expression of fibroblast growth factor 18 (Fgf18) is elevated in mouse livers following the induction of chronic liver fibrosis models. Deletion of Fgf18 in hepatocytes attenuates liver fibrosis; conversely, overexpression of Fgf18 promotes liver fibrosis. Single-cell RNA sequencing reveals that overexpression of Fgf18 in hepatocytes results in an increase in the number of Lrat+ hepatic stellate cells (HSCs), thereby inducing fibrosis. Mechanistically, FGF18 stimulates the proliferation of HSCs by inducing the expression of Ccnd1. Moreover, the expression of FGF18 is correlated with the expression of profibrotic genes, such as COL1A1 and ACTA2, in human liver biopsy samples. Thus, FGF18 promotes liver fibrosis and could serve as a therapeutic target to treat liver fibrosis.

Importance of Atezolizumab Plus Bevacizumab Combination Treatment as First-line Therapy for Immunological Changes in Patients With Unresectable Hepatocellular Carcinoma

BACKGROUND/AIM

The atezolizumab plus bevacizumab (AteBev) therapy is recommended as first-line treatment for unresectable hepatocellular carcinoma (uHCC). However, there remains a need to examine its efficacy with and without previous chemotherapy. Therefore, in patients with uHCC who underwent AteBev therapy, we aimed to clarify the effects of previous chemotherapy by examining serum immunological changes.

PATIENTS AND METHODS

We retrospectively analyzed data of 29 patients with uHCC treated by AteBev therapy as part of a prospective study and divided participants into two groups depending on whether they had received prior chemotherapy. Dynamic computed tomography was performed after 6 weeks of treatment. Blood samples were collected at baseline and after 3 weeks of treatment.

RESULTS

The group with prior treatment included 15 patients and the group without prior treatment included 14 patients. Objective response rates after six weeks of treatment were 13.3% and 28.6% in the groups with and without prior treatment, respectively. Serum levels of interleukin (IL)-6 and tumor necrosis factor-alpha showed no significant change in the group with prior treatment but increased significantly in the group without prior treatment. The percentage of regulatory T cells decreased significantly after treatment only in the group without prior treatment.

CONCLUSION

In patients with uHCC, AteBev therapy can be expected to elicit an effective immune response in patients without prior treatment, but it may not do so in patients with prior treatment. Thus, AteBev appears to be more effective when used as first-line chemotherapy.

Risk Factors for Lenvatinib-Induced High-Grade Hypothyroidism in Patients with Hepatocellular Carcinoma: A Retrospective Study

INTRODUCTION

Lenvatinib mesylate (LEN) is an orally administered tyrosine kinase inhibitor used for the treatment of various cancers, including hepatocellular carcinoma (HCC). HCC treatment with LEN is associated with a very high incidence of adverse events, especially hypothyroidism. This study investigated the incidence of hypothyroidism due to LEN and the relationships between hypothyroidism incidence and patient demographics by analyzing clinical laboratory data from HCC patients treated with LEN.

METHODS

This was a single-center, retrospective study of HCC patients who received LEN between April 19, 2018, and September 30, 2020. The observation period was from 1 week before the start of LEN administration to 1 month after the end of administration.

RESULTS

In total, 61 patients with HCC were enrolled. High-grade hypothyroidism (CTCAE Grade 2-3) was found in 36.1% (22/61 patients). In high-grade hypothyroidism, eosinophil (EOSINO) count was significantly low (p = 0.029). The cutoff value of EOSINO count was estimated to be approximately 150/µL. The adjusted odds ratios of high-grade hypothyroidism for current smoking and EOSINO count <150/µL were 0.237 (95% confidence interval: 0.063-0.893) and 4.219 (95% confidence interval: 1.119-15.92), respectively.

CONCLUSION

The results showed that noncurrent smoking and EOSINO count <150/µL are risk factors for LEN-induced high-grade hypothyroidism.

Effects of Lenvatinib on Skeletal Muscle Volume and Cardiac Function in Patients with Hepatocellular Carcinoma

INTRODUCTION

Previously, we reported that the tyrosine kinase inhibitor (TKI) sorafenib decreases serum levels of carnitine and reduces skeletal muscle volume. Moreover, others reported that TKIs might lead to cardiomyopathy or heart failure. Therefore, this study aimed to evaluate the effects of lenvatinib (LEN) on skeletal muscle volume and cardiac function in patients with hepatocellular carcinoma (HCC).

METHODS

This retrospective study included 58 adult Japanese patients with chronic liver diseases and HCC treated with LEN. Blood samples were collected before and after 4 weeks of treatment, and serum carnitine fraction and myostatin levels were measured. Before and after 4-6 weeks of treatment, the skeletal muscle index (SMI) was evaluated from computed tomography images and cardiac function was assessed by ultrasound cardiography.

RESULTS

After treatment, SMI, serum levels of total carnitine, and global longitudinal strain were significantly lower, but serum levels of myostatin were significantly higher. Left ventricular ejection fraction showed no significant change.

CONCLUSION

In patients with HCC, LEN decreases serum levels of carnitine, skeletal muscle volume, and worsens cardiac function.

Comparison of strain elastography and shear wave elastography in diagnosis of fibrosis in nonalcoholic fatty liver disease

PURPOSE

To reveal the ability of S-Map strain elastography to diagnose fibrosis in nonalcoholic fatty liver disease (NAFLD) and to compare its diagnostic ability with that of shear wave elastography (SWE).

METHODS

Participants were patients with NAFLD who were scheduled to undergo liver biopsy at our institution between 2015 and 2019. A GE Healthcare LOGIQ E9 ultrasound system was used. For S-Map, the right lobe of the liver was visualized in the section where the heartbeat was detected by right intercostal scanning, a 4 × 2-cm region of interest (ROI) was defined at 5 cm from the liver surface, and ROI strain images were acquired. Measurements were repeated six times, with the average taken as the S-Map value. Correlations of S-Map and SWE values with fibrosis stage determined by liver biopsy were analyzed using multiple comparisons. The diagnostic performance of S-Map for fibrosis staging was assessed using receiver operating characteristic curves.

RESULTS

In total, 107 patients (65 men, 42 women; mean age 51 ± 14 years) were analyzed. The S-Map value by fibrosis stage was 34.4 ± 10.9 for F0, 32.9 ± 9.1 for F1, 29.5 ± 5.6 for F2, 26.7 ± 6.0 for F3, and 22.8 ± 4.19 for F4. By fibrosis stage, the SWE value was 1.27 ± 0.25 for F0, 1.39 ± 0.20 for F1, 1.59 ± 0.20 for F2, 1.64 ± 0.17 for F3, and 1.88 ± 0.19 for F4. The diagnostic performance of S-Map (measured by area under the curve) was 0.75 for F2, 0.80 for F3, and 0.85 for F4. The diagnostic performance of SWE (measured by area under the curve) was 0.88 for F2, 0.87 for F3, and 0.92 for F4.

CONCLUSION

S-Map strain elastography was inferior to SWE in terms of ability to diagnose fibrosis in NAFLD.

A case of multiple hepatocellular carcinoma experiencing complete responses to sorafenib and atezolizumab-bevacizumab and developing severe, refractory venous congestive cutaneous ulcers on either regimen

A man in his eighties presented with a history of bilateral leg congestive phlebitis, and multiple hepatocellular carcinoma (HCC) treated with sorafenib. When the dose was increased to 400 mg, ulcers appeared under both knees, which worsened, and the drug was discontinued 2 months after administration. However, the ulcers to 30 mm in diameter, requiring debridement and antibiotics. The HCC showed a complete response (CR) based on modified-RECIST criteria; however, after several rounds of locoregional therapy for recurrence, multiple HCCs and metastatic lesions in the Morrison's fossa were detected. Therefore, atezolizumab 1200 mg-bevacizumab 900 mg was started. After the first course, the patient complained of pain below both knees, and when the second course was administered, leg ulcers re-appeared and rapidly worsened. The ulcers were circular and multiple and progressed to deep digging, leading to tendon exposure. Bevacizumab-induced congestive venous ulcer was diagnosed, requiring skin grafts to heal. HCC then showed a CR based on m-RECIST criteria. Initially, the cause of the ulcer was thought to be immune-related adverse effects due to atezolizumab, but experience with sorafenib led us to conclude that the cause was stagnant venous ulcers due to vascular endothelial growth factor receptor inhibitor, which inhibited angiogenesis.

Lenvatinib Might Induce Activation of Host Immunity in Patients with Hepatocellular Carcinoma

INTRODUCTION

Atezolizumab, an immune checkpoint inhibitor, plus bevacizumab, a monoclonal antibody that binds to vascular endothelial growth factor (VEGF), is an approved first-line systemic treatment for unresectable hepatocellular carcinoma (HCC). Immune checkpoint inhibitors are more effective in patients with HCC when administered with anti-VEGF drugs; however, these drugs affect host immunity. Lenvatinib is an anti-VEGF agent used to treat HCC; therefore, this study evaluated the effect of treatment of HCC with lenvatinib on host immunity in patients with chronic liver disease (CLD).

METHODS

We studied adult Japanese patients with CLD and unresectable HCC treated with lenvatinib at our hospital. Lenvatinib was administered for 4 weeks (8 mg/day for bodyweight <60 kg; 12 mg/day for bodyweight >60 kg). Blood samples were collected at baseline and at 4 weeks of treatment and examined for immune-related changes.

RESULTS

Forty-three patients were enrolled in this study. We found a significant increase in T helper (Th) 1 cells following 4 weeks of lenvatinib treatment, although there was no significant difference in Th2 cells and regulatory T cells. We also found a significant increase in serum levels of TNF-alpha, soluble TNF-alpha receptor I, and endothelial growth factor following 4 weeks of lenvatinib treatment. Furthermore, an increase in Th1 cells and serum levels of TNF-alpha was found in patients with partial response.

CONCLUSION

Lenvatinib might induce Th1-dominant host immunity in patients with CLD and unresectable HCC treatment in patients who showed a partial response. These changes in host immunity may be a biomarker in HCC patients treated with lenvatinib.

Arrival-Time Parametric Imaging in Contrast-Enhanced Ultrasound for Diagnosing Fibrosis in Primary Biliary Cholangitis

Liver biopsy is usually required for diagnosing fibrosis in primary biliary cholangitis (PBC), but contrast-enhanced ultrasonography (CEUS) is a possible alternative. The aim of this study was to investigate arrival-time parametric imaging (At-PI) in for diagnosing fibrosis in PBC. Forty-eight patients (male/female, 8/40; mean age, 60 ± 13 years) with PBC diagnosed by liver biopsy underwent CEUS during 2009-2019. Of these, 27 who also underwent shear wave elastography (SWE) were further analyzed. Perflubutane was intravenously injected and CEUS performed. Contrast dynamics of hepatic segment V and the right kidney were recorded and At-PI generated. The ratio of red indicating contrast arrival time <5 seconds to the entire liver contrast-enhanced area was calculated and compared with shear wave velocity (Vs) measured by SWE by fibrosis stage (F0-F3), bile duct loss score, cholangitis activity, hepatitis activity (HA0-HA3), and disease stage, as determined by liver biopsy. Ratio of red significantly differed between F0 and F2-F3 and between F1 and F2-F3. Using ratio of red to diagnose ≥F1 (≥F2), area under the receiver operating characteristic curve was 0.77 (0.92) (cutoff, 36.7% [47.1%]; sensitivity, 0.75 [0.92]; specificity, 0.82 [0.81]). At-PI was useful for diagnosing fibrosis, especially F2 or worse, in PBC, suggesting that At-PI can correctly diagnose fibrosis regardless of hepatic inflammation.

The ultrasound-guided attenuation parameter is useful in quantification of hepatic steatosis in non-alcoholic fatty liver disease

Aim

To determine the utility of the ultrasound‐guided attenuation parameter (UGAP) for quantifying hepatic steatosis in non‐alcoholic fatty liver disease (NAFLD).

Methods

Subjects were 84 patients with NAFLD (53 men, 31 women; mean age 54 [20–81] years) who underwent liver biopsy and ultrasonography using a GE LOGIQ E9 system and C1‐6 probe at our hospital between 2017 and 2020. B‐Mode imaging of segment V in the liver was acquired and echo attenuation was assessed using UGAP. Steatosis score (S0: <5%; S1: 5%–33%; S2: 34%–66%; S3: ≥67%) from liver specimens was compared with the attenuation coefficient (AC; dB/cm/MHz) using UGAP.

Results

Steatosis score was S0 for 9 patients, S1 for 40, S2 for 21, and S3 for 14. AC by steatosis score was 0.52 ± 0.07, 0.63 ± 0.07, 0.74 ± 0.06, and 0.78 ± 0.06 dB/cm/MHz for S0, S1, S2, and S3, respectively. AC by UGAP differed significantly between S0 and S1, S0 and S2, S0 and S3, S1 and S2, and S1 and S3 (all P < 0.01), demonstrating a significant increase with steatosis score. Receiver operating characteristic analysis showed good diagnostic performance of UGAP for patients with steatosis score ≥1, ≥2, and ≥3 (AUROC = 0.94, 0.95, and 0.88, respectively). Liver fat content (%) from liver specimens and AC (r = 0.81, P < 0.01) showed a significant positive correlation.

Conclusion

UGAP is useful for quantifying hepatic steatosis in patients with NAFLD.

Tivantinib Decreases Hepatocyte Growth Factor-Induced BCRP Expression in Hepatocellular Carcinoma HepG2 Cells

Tivantinib, a mesenchymal-epithelial transition factor (cMET) inhibitor, is a molecular targeting drug that kills hepatocellular carcinoma (HCC) cells. Tivantinib alone does not affect the overall survival of patients with HCC, and combination treatment with tivantinib and other therapies has not been evaluated. This study was conducted to clarify the effect of the tivantinib in regulating breast cancer therapy-resistant protein (BCRP), a key transporter of 5-fluorouracil (5-FU), and dihydropyridine dehydrogenase (DPYD), a major metabolic enzyme of 5-FU. To this end, cMET gene expression was determined by RT-PCR in HepG2 (human hepatoma) cells. The transcriptional start sites of BCRP were determined by 5'-rapid amplification of cDNA ends (5'-RACE). BCRP and DPYD mRNA levels were determined by real-time RT-PCR, and promoter activities were measured by dual-luciferase assays. Results show that hepatocyte growth factor (HGF) upregulated the mRNA level of BCRP, but not DPYD, in HepG2 cells. The upregulation of BCRP expression by HGF was down-regulated by tivantinib. We also identified two transcriptional start sites (E1α, E1β) in BCRP by 5'-RACE. The transcriptional activity of the region -287 to E1α of BCRP was upregulated by HGF, which was decreased by tivantinib, whereas activity of the region -297 to E1βo f BCRP was not affected by tivantinib. Therefore, tivantinib regulates BCRP expression upstream of exon 1α. Combination treatment of tivantinib and 5-FU should be further evaluated for HCC therapy.

Usefulness of virtual touch tissue quantification for predicting the presence of esophageal varices in patients with liver cirrhosis

BACKGROUND AND AIM

Measuring the hepatic venous pressure gradient (HVPG) is an established technique to detect increased portal pressure and predict the presence of esophageal varices (EVs); however, the risk of the test is greater than the information it provides. This study aimed to clarify the usefulness of virtual touch tissue quantification (VTQ), which assesses liver stiffness, in predicting the presence of EVs in patients with liver cirrhosis by comparing it with HVPG.

METHODS

Two hundred seventeen patients with liver cirrhosis underwent VTQ, HVPG measurement, and upper endoscopy. Patients were divided into three groups: group V, hepatitis C virus liver cirrhosis (n = 40); group A, alcoholic liver cirrhosis (n = 116); and group N, other liver cirrhosis (n = 61). In each group, we performed linear regression analysis of VTQ and HVPG data. The accuracy of VTQ and HVPG measurement in predicting the presence of EVs and high-risk EVs (EV category F2 and F3) was assessed by area under the receiver operating characteristic curve (AUROC).

RESULTS

VTQ was significantly correlated with the HVPG in the whole patients and in each group, and both VTQ and HVPG values were significantly higher in patients with EVs and high-risk EVs than in those without. The AUROC for the presence of EVs for VTQ was 0.76 in the whole sample, 0.76 in group V, 0.79 in group A, and 0.67 in group N; and for HVPG, 0.92, 0.94, 0.93, and 0.88, respectively. For VTQ, the AUROC for the presence of high-risk EVs was 0.78 in the whole sample, 0.78 in group V, 0.73 in group A, and 0.73 in group N; and for HVPG, it was 0.85, 0.82, 0.85, and 0.82, respectively.

CONCLUSION

VTQ was reliable at predicting the presence of EVs and high-risk EVs. Therefore, we propose that VTQ is a useful, noninvasive tool for predicting the presence of EVs in daily medical care.

The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (&lt;120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (&gt;150 ms): 14 ± 7% (p &lt;0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p &lt;0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.

Quantitative analysis of dyssynchrony assessed by multidetector computed tomography can predict clinical outcome after cardiac resynchronization therapy

Background

The degree of mechanical dyssynchrony has been suggested as a predictor for long-term survival after cardiac resynchronization therapy (CRT). There have been little reports of dyssynchrony assessment with the use of cardiac computed tomography (CCT).

Methods

We studied 35 heart failure (HF) patients (average age 67±10 years) referred for CRT with NYHA III-IV heart failure, left ventricular (LV) ejection fraction (EF) 20±10% (all ≤35%), and QRS duration 156±22 ms (all ≥120ms). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT was performed before CRT. Based on CCT, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and the time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software “Myocardial Contraction Map”. The standard deviation modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. The predefined primary end-point was the first HF hospitalization or death over 2 years.

Results

%SD was feasible in all patients, respectably. There were 16 events over 2 years; 11 HF hospitalizations and 5 deaths. Patients with %SD ≥22% (optimal cutoff for outcome by ROC curve analysis) had a better clinical outcome than patients with %SD &lt;22% (p=0.01, Figure).

Conclusion

Patients who had %SD ≥22% assessed by MDCT had a particularly favorable event-free survival following CRT, and this appears to be an important prognostic marker.

Funding Acknowledgement

Type of funding source: None

Catheter ablation of atrial fibrillation benefits the patients with heart failure and preserved ejection fraction as well as those with heart failure and reduced ejection fraction

Background

Although catheter ablation of atrial fibrillation (AF) has recently been shown to improve the cardiac function and even mortality in patients with heart failure (HF) and reduced ejection fraction (HFrEF), few studies have examined the outcomes of AF catheter ablation in patients with HF with preserved ejection fraction (HFpEF).

Purpose

To verify the impact of AF catheter ablation on the cardiac function and HF status in patients with HFpEF.

Methods

We studied 306 patients with HF who had a history of an HF hospitalization and/or preprocedural serum BNP levels &gt;100pg/ml (age, 68.9±8.2 years old; male, 66.3%; non-paroxysmal AF, 63.1%, left atrial diameter [LAD], 42.5±6.3 mm; left ventricular ejection fraction [LVEF], 60.6±12.0%) out of 596 consecutive patients who underwent pulmonary vein isolation-based catheter ablation of AF. The patients with an LVEF ≥50% were defined as having HFpEF (n=262; age, 69.0±8.2 years old; male, 64.5%; non-paroxysmal AF, 61.8%, LAD, 42.1±5.9 mm; left LVEF, 64.0±8.2%) and the remaining patients with an LVEF &lt;50% were defined as having HFrEF (n=44, age, 67.9±8.7 years old; male, 77.0%; non-paroxysmal AF, 70.5%, LAD, 44.9±8.2 mm; LVEF, 40.1±10.2%). The patients received periodic follow-ups for 12 months after the catheter ablation. The cardiac function parameters including the echocardiographic findings and HF functional status of the patients were compared between baseline and 12 months, stratified by the HF subgroup.

Results

AF recurred in 60 patients with HFpEF (22.9%) and in 14 with HFrEF (31.8%) during the 12 month follow-up (p=0.27), however, sinus rhythm was maintained at 12 months in most of the patients (253 patients with HFpEF [96.6%] and 42 patients with HFrEF [95.5%]) (p=0.71). Figure 1 compares the changes in the cardiac function parameters and NYHA functional class from baseline to the 12-month follow-up stratified by the HF subgroup. Both the patients with HFpEF and HFrEF had significant improvements in the serum BNP levels, chest thorax ratio, and LVEF determined by echocardiography. LA reverse remodeling as shown by a significant reduction in the LAD was observed in both HF subgroups, however, the E/E', an index of the LV diastolic function, did not significantly change in either of the subgroups. Similar to the patients with HFrEF, an improvement in the NYHA functional class was seen in those with HFpEF.

Conclusions

Catheter ablation of AF may benefit patients with HFpEF as well as those with HFrEF. Sinus rhythm maintenance achieved by AF catheter ablation in patients with HFpEF may lead to LA reverse remodeling and a better LV systolic function, thereby improving the NYHA functional class. It is unclear whether changes in the LV diastolic function may contribute to this favorable process.

Funding Acknowledgement

Type of funding source: None

Rechallenge of voriconazole successfully tolerated after hepatic toxicity

Infections caused by Aspergillus species are often life-threatening. Drugs effective for Aspergillus infection are limited. Voriconazole is one of the most important drugs, however, considerable portion of patients experience liver toxicity and have to stop the drug administration. We frequently experience liver toxicity even though the serum concentration of voriconazole is within the target range. Historically, in some life-threatening situations like tuberculosis, where a suitable alternative is unavailable, rechallenge has been attempted. However, there have been no report on the rechallenge of voriconazole. We report cases of successful re-administration of voriconazole after liver toxicity.

Sorafenib Might Induce Sarcopenia in Patients With Hepatocellular Carcinoma by Inhibiting Carnitine Absorption

BACKGROUND/AIM

Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of cancers. Sorafenib, an oral multi-target TKI, improves the median overall survival time in patients with hepatocellular carcinoma (HCC). It also inhibits the absorption of carnitine by down-regulating the human organic cationic transporter OCTN2 located largely in the small intestinal mucosa and skeletal muscle. The aim of the study was to determine, by assessing carnitine metabolism, whether sarcopenia is induced in patients with HCC who are receiving sorafenib.

PATIENTS AND METHODS

This retrospective study included 110 adult Japanese patients with liver cirrhosis and HCC who received sorafenib. Sorafenib was administered at a dose of 200-800 mg/day for 4 weeks. Blood samples were collected before and after treatment, and serum carnitine fraction and myostatin levels were measured. Cross-sectional areas (cm²) of the skeletal muscles at the third lumbar vertebra level were determined by manually outlining computed tomography images before and after treatment. The cross-sectional areas were normalized for height [skeletal muscle index (SMI), cm²/m²].

RESULTS

Patients were allocated to two groups according to Child-Pugh (CP) class; 81 had CP-A liver function, and 29 had CP-B. SMI after treatment was significantly lower than that before treatment in both groups. Serum levels of total carnitine and free carnitine after treatment were significantly lower than those before treatment in both groups. There were no differences in serum levels of myostatin before and after treatment in either group.

CONCLUSION

Sorafenib might decrease serum levels of carnitine by inhibiting carnitine absorption. Decreasing of serum levels of carnitine might lead to presarcopenia.

The Prognosis of Hepatocellular Carcinoma Treated with Sorafenib in Combination with TACE

OBJECTIVE

Sorafenib have been shown to be effective in the treatment of advanced HCC and has been standard therapy since its release in Japan in 2009 (Llovet et al., 2008; Cheng et al., 2009). However, due to a low response rate, more aggressive combination treatment has been utilized as a multimodal strategy. The present study aimed to determine the efficacy of sorafenib alone and in combination with transarterial chemoembolization (TACE) for the treatment of advanced HCC.

METHODS

All patients with unresectable advanced HCC who were prescribed sorafenib at Kanto Rosai Hospital were included in the study. Five-year overall survival (OS) rates were estimated for patients treated with sorafenib alone or in combination with TACE. Multivariate and univariate regression analyses were performed to identify factors affecting OS. Analysis using propensity score matching and inverse-probability weights were also performed.

RESULTS

A total of 46 patients were treated with sorafenib up to June 2018. The total sorafenib dose administered was higher in the TACE combination group (70900 mg vs. 24000 mg vs. with sorafenib alone), although the relative dose intensity was lower (11.7% vs. 17.6%, respectively). The 5-year survival prognosis estimated using the Kaplan-Meier method was longer in patients treated with sorafenib in combination with TACE versus sorafenib alone (36.3% vs. 7.7%). Combination with TACE was the only factor associated with improved OS in both univariate and multivariate analysis. Among cases matched by propensity scores the hazard rate for combination with TACE was 0.067 (95% CI 0.091-1.128).

CONCLUSION

With an array of therapeutic options currently available, it is important to determine the efficacy of different multimodal strategies, such as sorafenib combined TACE, for patients with unresectable HCC.

1677 Global longitudinal strain during dobutamine stress echocardiography can predict left ventricular remodeling after anterior wall acute myocardial infarction

Background

Although dobutamine stress echocardiography (DSE) at the early stage of acute myocardial infarction (AMI) is useful for the prediction of functional and clinical prognosis, the interpretation requires expertise. In this study, we sought to investigate if global longitudinal strain (GLS) during DSE after AMI can predict left ventricular remodeling (LVR).

Methods

Consecutive 30 patients with anterior wall AMI (18 male, age = 58 ± 13 years) were performed DSE 3 days after AMI. GLS was calculated as an averaged value of peak longitudinal strain in the apical 4- and 2-chamber views at baseline echocardiography, low-dose DSE (10 μg/kg/min) using available software (QLAB, Philips Medical Systems). Left ventricular remodeling (LVR) was defined as an echocardiographically determined increase in both EDVI and ESVI of 20% or more from baseline to the 6 month follow-up echocardiography.

Results

12 patients (40%) evolved with LVR. The change in GLS during low-dose DSE was significantly different between the remodeling and non-remodeling group (8 ± 5% v.s. 27 ± 20%, p &lt; 0.05). Interestingly, it predicted LVR with sensitivity of 88%, specificity of 92% at the cut-off value of 12% (Area under the curve = 0.94, p &lt; 0.0001).

Conclusion

The change in GLS during low-dose DSE can be used as a predictor for the LVR after AMI. This observation has promise for clinical applications.

Abstract 1677 Figure.

Whole hepatic lipid volume quantification and color mapping by multi-slice and multi-point magnetic resonance imaging

AIM

Current approaches for hepatic steatosis assess only a small point within the liver and might cause inaccuracy for longitudinal observation. We aimed to establish a reliable non-invasive method for whole hepatic lipid content evaluation.

METHODS

A total of 52 patients with hepatic steatosis underwent liver biopsy. Hepatic lipid content was assessed by Dixon in-phase/out-of-phase magnetic resonance imaging and proton magnetic resonance spectroscopy. Using multi-slice and multi-point magnetic resonance imaging, we calculated the lipid intensity of every voxel throughout the liver and showed the color-mapped lipid distributions. This new analysis could also quantify the whole hepatic lipid and whole liver volumes absolutely. The diagnostic performance of hepatic lipid content between the new analysis and proton magnetic resonance spectroscopy methods was compared by receiver operating characteristic curve analysis referring to the steatosis scores of the liver biopsy.

RESULTS

Areas under the receiver operating characteristic for the diagnosis of steatosis scores ≥1, ≥2, and ≥3 using magnetic resonance imaging and proton magnetic resonance spectroscopy were 0.86 (95% confidence interval [CI] 0.70-1.00) and 0.98 (95% CI 0.93-1.00), 0.94 (95% CI 0.87-1.00) and 0.93 (95% CI 0.86-1.00), and 0.95 (95% CI 0.89-1.00) and 0.97 (95% CI 0.93-1.00), respectively, showing comparable diagnostic accuracies. However, color mapping showed some inconsistencies between the methods.

CONCLUSIONS

We described a non-invasive and repeatable evaluation method of whole hepatic lipid accumulation with absolute quantification and color mapping. Hepatic steatosis was accurately evaluated regardless of heterogeneous lipid accumulation. The whole hepatic lean volume, reflecting the hepatic parenchymal condition, can also be determined by this method.

Secretory IgA accumulated in the airspaces of idiopathic pulmonary fibrosis and promoted VEGF, TGF-β and IL-8 production by A549 cells

Secretory IgA (SIgA) is a well-known mucosal-surface molecule in first-line defense against extrinsic pathogens and antigens. Its immunomodulatory and pathological roles have also been emphasized, but it is unclear whether it plays a pathological role in lung diseases. In the present study, we aimed to determine the distribution of IgA in idiopathic pulmonary fibrosis (IPF) lungs and whether IgA affects the functions of airway epithelial cells. We performed immunohistochemical analysis of lung sections from patients with IPF and found that mucus accumulated in the airspaces adjacent to the hyperplastic epithelia contained abundant SIgA. This was not true in the lungs of non-IPF subjects. An in-vitro assay revealed that SIgA bound to the surface of A549 cells and significantly promoted production of vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β and interleukin (IL)-8, important cytokines in the pathogenesis of IPF. Among the known receptors for IgA, A549 cells expressed high levels of transferrin receptor (TfR)/CD71. Transfection experiments with siRNA targeted against TfR/CD71 followed by stimulation with SIgA suggested that TfR/CD71 may be at least partially involved in the SIgA-induced cytokine production by A549 cells. These phenomena were specific for SIgA, distinct from IgG. SIgA may modulate the progression of IPF by enhancing synthesis of VEGF, TGF-β and IL-8.

P3587Tip detection method using the new short-tip IVUS with pull-back system which facilitates the 3D wiring technique in percutaneous coronary intervention for chronic total occlusion

Background

The strategy of intravascular ultrasound (IVUS)-guided wiring for CTO PCI, that is, leading the second guidewire into the true lumen under observing by IVUS from subintimal space, is the last resort. We developed the angiography-based 3D wiring method. During establishment of the angiography-based 3D wiring method, we deduced that observation of the guidewire tip as well as the shaft named “The tip detection method” simplifies and facilitates 3D wiring under IVUS-guided wiring. Therefore, we produced New CTO IVUS which is the upgraded version of Navifocus WR IVUS by adding the pull-back transducer system. This pull-back system enables us to detect the tip as well as the shaft of the second guidewire in real time (tip detection method), which facilitates the 3D wiring technique under IVUS-guided wiring.

Objective

We evaluated the efficacy of the tip detection method during 3D wiring for CTO PCI with New CTO IVUS.

Method

We created a target pinpoint penetration model and performed the procedures using an experimental heartbeat model. The target (a tube with a lumen 0.6 mm in diameter) was placed in the distal part of a CTO 20 mm in length made of 2.5% agar. After the second guidewire (Conquest-12g) was advanced into the CTO lesion to within 5mm of the target using the angiography-based wiring, IVUS-guided wiring was performed by using Navifocus WR or New CTO IVUS each five times.

Result

The frequency of the puncture time was reduced using the new CTO IVUS compared to the Navifocus WR (1.7±0.8 vs. 28.8±23.2, p=0.17). The procedure time was significantly shorter using the new CTO IVUS compared to the Navifocus WR (103±61 vs. 459±373 seconds, p=0.04).

Conclusion

The tip detection method during 3D wiring with the new short tip IVUS with the pull-back system enables us to easily perform 3D wiring and will change the CTO PCI strategy.

P1038Device implantation after catheter ablation of paroxysmal atrial fibrillation with coexisting sick sinus syndrome: Insights from the Kansai Plus Atrial Fibrillation (KPAF) study

Background

Sick sinus syndrome (SSS) and atrial fibrillation (AF) frequently coexist and interact to initiate and perpetuate each other. Several retrospective or small cohort studies have suggested that successful catheter ablation of AF may help to waive device implantations in patients with paroxysmal AF plus SSS, however, no prospective large studies are so far available on this scenario.

Purpose

We aimed to elucidate the device implantation-free survival after catheter ablation of paroxysmal AF with coexisting SSS in a prospective large-scale registry. We also determined the risk factors for device implantations after catheter ablation of paroxysmal AF.

Methods

The Kansai Plus Atrial Fibrillation (KPAF) study is a multi-center prospective registry that enrolled 5,019 consecutive patients that underwent an initial pulmonary vein isolation-based radiofrequency catheter ablation of AF. This study was comprised of 3,226 patients with paroxysmal AF registered in the KPAF study (age, 64.8±10.5 years old; female, n=999 [31.0%]; left atrial diameter [LAD], 37.5±8.0 mm; left ventricular ejection fraction [LVEF], 65.3±8.4%, CHADS2 score, 1.09±1.05). The atrial tachyarrhythmia-free and device-free survivals after catheter ablation were compared between patients with SSS (n=368; tachy-brady syndrome, 88%) and without SSS (control; n=2,858).

Results

The atrial tachyarrhythmia-free survival was almost identical between the two groups both after the first ablation session (Fig.1A) and after the last procedure with an average of 1.3±0.5 sessions. At baseline, the devices had already been implanted in 53 (14.4%) SSS and 36 (1.3%) control patients. In the remaining patients, devices were newly implanted in 54 (17.1%) SSS and 62 (2.2%) control patients during the follow-up of 3 years after the catheter ablation (Figure 1B). In the SSS group, devices were implanted predominantly within 6 months after the catheter ablation, and atrial tachyarrhythmia recurrence preceded the device implantation in 48 (89%) patients. Multivariate predictors of device implantations after the paroxysmal AF ablation included: SSS (hazard ratio [HR] 6.85, 95% confidence interval [CI] 4.61–10.19, p<0.001), an age>75 years old (HR 1.69, 95% CI 1.08–2.64, p=0.019), a female gender (HR 2.16, 95% CI 1.44–3.24, p<0.001), the LAD (mm) (HR 1.05, 95% CI 1.02–1.08, p=0.006), and the LVEF (%) (95% CI 0.96, 95% CI 0.94–0.98, p<0.001).

Figure 1

Conclusions

Device implantations could be waived in >80% of patients with SSS at 3 years of follow-up after the catheter ablation of paroxysmal AF in this real world all comer prospective registry. In addition to coexisting SSS, predictors of device implantations after paroxysmal AF ablation included: the elderly, a female gender, a large LA, and a reduced LVEF.

Acknowledgement/Funding

None

Adverse reactions associated with long-term drug administration in Mycobacterium avium complex lung disease

SETTING

The number of patients with non-tuberculous mycobacterial lung disease (NTM-LD) worldwide has been increasing. Mycobacterium avium complex lung disease (MAC-LD) accounts for 90% of NTM-LD. MAC-LD necessitates long-term treatment, but adverse reactions with long-term administration of drugs are poorly understood.

OBJECTIVE

To evaluate adverse reactions with long-term administration of drugs for MAC-LD.

DESIGN

We conducted a retrospective single-centre medical chart review of 364 patients administered two or more drugs between July 2010 and June 2015.

RESULTS

The prevalence and median time to onset of adverse reactions were as follows: hepatotoxicity 19.5%, 55 days; leucocytopaenia 20.0%, 41 days; thrombocytopaenia 28.6%, 61.5 days; cutaneous reactions 9.3%, 30 days; ocular toxicity 7.7%, 278 days; and increase in serum creatinine 12.4%, 430.5 days. Multivariate analysis showed that rifampicin use was independently associated with thrombocytopaenia, and ethambutol use was independently associated with increases in serum creatinine.

CONCLUSION

The main adverse reactions appeared within 3 months after start of treatment. Most patients were able to continue treatment with liver-supporting therapy, antihistamine agents or desensitisation therapy; however, ocular toxicity must be monitored for up to 1 year after start of treatment.

A New Method to Quantify Concentration of Microbubbles in Attenuating Media Using Bubble Destruction Curve Analysis of the Contrast-Enhanced Ultrasound

It is known that the microbubbles of Sonazoid are accumulated in the liver parenchyma due to the phagocytosis of Kupffer cells in the sinusoid. Because this phagocytic function decreases due to the progression of fibrosis in chronic liver disease, the deterioration of the liver function may be quantified by measuring the concentration of the accumulated Sonazoid microbubbles. In this article, a new method to quantify the concentration of microbubbles accumulated in attenuating media is proposed. This method utilizes the contrast-enhanced imaging with high mechanical index, measures the depth of the bubble destruction for each frame and analyze the shape of the destruction curve to estimate the concentration of the bubbles. A phantom experiment was performed with various concentrations of the contrast agent Sonazoid solution as well as various attenuation coefficients of the viscous media. Because of the theoretical model proposed, the estimated attenuation indexes, related to the concentration of Sonazoid microbubbles, were independent of the background attenuation of the propagating medium. The result suggest it has a potential to quantify Sonazoid concentration in the liver parenchyma more precisely against different liver attenuation conditions.

Flash Imaging Used in the Post-vascular Phase of Contrast-Enhanced Ultrasonography is Useful for Assessing the Progression in Patients with Hepatitis C Virus-Related Liver Disease

Sonazoid is a commonly used contrast agent for characterizing liver tumors in ultrasonography (US). We performed flash imaging in the post-vascular phase of contrast-enhanced US (CEUS) to investigate associations between collapse of Sonazoid microbubbles (MB) and progression of liver disease. This study enrolled 409 patients (205 men, 204 women) with hepatitis C virus-related liver disease (CLD) between 2007 and 2017 (mean age 60 ± 14 y; range 20-90 y). In the post-vascular phase, 10 min after administering Sonazoid, flash imaging was performed to burst MB in the liver parenchyma; the range of bubble destruction was measured from the surface of the liver. The range of bubble destruction, stage of fibrosis, shear wave velocity (Vs), serologic markers and fibrosis-4 (FIB4) index were analyzed in 259 patients who underwent liver biopsy. Fibrosis stage was F0-1 in 108 patients, F2 in 73, F3 in 38 and F4 in 40. In 150 patients with cirrhosis, diagnosis was made based on imaging findings. The range of bubble destruction was 42.0 ± 10.4 mm in F0-1 patients, 42.9 ± 13.2 mm in F2, 51.5 ± 15.9 mm in F3 and 55.4 ± 17.3 mm in F4 and was significantly increased according to progression of fibrosis staging. The range of bubble destruction was positively correlated with Vs (r = 0.34; p < 0.01), total bilirubin (r = 0.25; p < 0.01) and FIB4 index (r = 0.38; p < 0.01). In contrast, the range of bubble destruction was negatively correlated with serum levels of albumin (r = -0.34; p < 0.01), platelet count (r = -0.35; p < 0.01) and prothrombin time (r = -0.36; p < 0.01). The results indicated that flash imaging in the post-vascular phase of CEUS was a non-invasive assessment and could predict disease progression in patients with CLD.

Influence of Sorafenib on Host Immunity in Patients with Liver Cirrhosis With Advanced Hepatocellular Carcinoma Stratified by Etiology

AIM

We previously reported that sorafenib induces Th1 [interferon-γ (IFNγ)-positive interleukin 4 (IL4)-negative] dominance which prevents tumor cells from escaping the host immune system in patients with liver cirrhosis (LC) and advanced hepatocellular carcinoma (aHCC). However, in that study we did not assess the influence of sorafenib on host immunity according to the etiology of LC. Therefore, this study was retrospectively performed to evaluate the impact of sorafenib therapy for aHCC on host immunity in patients stratified according to the etiology of LC: Patients and Methods: A total of 116 adult Japanese patients with LC and aHCC received sorafenib therapy at our hospital. Blood samples were collected before and after treatment for 4 weeks.

RESULTS

Twenty-two patients had hepatitis B virus (HBV)-related LC, 62 patients had hepatitis C virus (HCV)-related LC, 22 patients had alcoholic LC, and 10 patients had LC without these causative factors. In patients receiving sorafenib at a dose of 400 mg/day, patients in Child-Pugh class A, and patients with stage IVA aHCC, Th2 (IFNγ-negative/IL4-positive) cells decreased significantly after treatment, although there was no significant impact on the tumor response. In addition, Th2 cells decreased significantly in patients with HCV-related LC after treatment, while there were no significant changes in the other groups.

CONCLUSION

Sorafenib might prevent tumor cells from escaping the host immune system in patients with aHCC and HCV-related LC, although it does not seem to do so in those with LC of other etiologies.

Secretory immunoglobulin A induces human lung fibroblasts to produce inflammatory cytokines and undergo activation

Immunoglobulin (Ig)A is the most abundant immunoglobulin in humans, and in the airway mucosa secretory IgA (sIgA) plays a pivotal role in first-line defense against invading pathogens and antigens. IgA has been reported to also have pathogenic effects, including possible worsening of the prognosis of idiopathic pulmonary fibrosis (IPF). However, the precise effects of IgA on lung fibroblasts remain unclear, and we aimed to elucidate how IgA activates human lung fibroblasts. We found that sIgA, but not monomeric IgA (mIgA), induced interleukin (IL)-6, IL-8, monocyte chemoattractant protein (MCP)-1 and granulocyte-macrophage colony-stimulating factor (GM-CSF) production by normal human lung fibroblasts (NHLFs) at both the protein and mRNA levels. sIgA also promoted proliferation of NHLFs and collagen gel contraction comparable to with transforming growth factor (TGF)-β, which is involved in fibrogenesis in IPF. Also, Western blot analysis and real-time quantitative polymerase chain reaction (PCR) revealed that sIgA enhanced production of α-smooth muscle actin (α-SMA) and collagen type I (Col I) by NHLFs. Flow cytometry showed that NHLFs bound sIgA, and among the known IgA receptors, NHLFs significantly expressed CD71 (transferrin receptor). Transfection of siRNA targeting CD71 partially but significantly suppressed cytokine production by NHLFs co-cultured with sIgA. Our findings suggest that sIgA may promote human lung inflammation and fibrosis by enhancing production of inflammatory or fibrogenic cytokines as well as extracellular matrix, inducing fibroblast differentiation into myofibroblasts and promoting human lung fibroblast proliferation. sIgA's enhancement of cytokine production may be due partially to its binding to CD71 or the secretory component.

Talbot interferometry for imaging two-dimensional electron density distribution over discharge plasma with higher sensitivity

The basic properties of a Talbot interferometer implementing pinhole arrays were experimentally and numerically investigated for the improvement of measurement sensitivity of laser wavefront sensors utilized for electron density imaging over discharge plasmas. A numerical simulation using a plane wave decomposition method indicated that the pinhole arrays with a pitch of 300 μm and a pinhole diameter of 150 μm were most suitable for the measurement of the millimetre-scale discharge plasmas, in consideration of the spatial resolution and measurement accuracy. The plane wave decomposition simulation expected that the measurement sensitivity of the 8th-Talbot-length interferometer could be improved by a factor of 4 compared with the previously developed Shack-Hartmann type laser wavefront sensors, which was experimentally verified by the self-image behavior of the pinhole arrays. The Talbot interferometric system was successfully used for electron density imaging over the vacuum arcs generated between a 3-mm gap. The electron density image observed by the Talbot interferometers was in excellent agreement with that visualized by the previously developed Shack-Hartmann sensors. The practical notification for the pinhole array fabrication was also presented.

Estimate of Fukushima-derived radiocaesium in the North Pacific Ocean in summer 2012

Distributions of radiocaesium (134Cs and 137Cs) derived from the Tokyo Electric Power Company (TEPCO) Fukushima Dai-ichi Nuclear Power Plant (FNPP1) accident in the North Pacific Ocean in the summer of 2012 were investigated. We have estimated the radiocaesium inventory in the surface layer using the optimal interpolation analysis and the subducted amount into the central mode water (CMW) by using vertical profiles of FNPP1-134Cs and mass balance analysis as the first approach. The inventory of the 134Cs in the surface layer in the North Pacific Ocean in August-December 2012 was estimated at 5.1 ± 0.9 PBq on 1 October 2012, which corresponds to 8.6 ± 1.5 PBq when it was decay corrected to the date of the FNPP1 accident, 11 March 2011. It was revealed that 56 ± 10% of the released 134Cs into the North Pacific Ocean, which was estimated at 15.3 ± 2.6 PBq, transported eastward in the surface layer in 2012. The amount of 134Cs subducted in the CMW was estimated to be 2.5 ± 0.9 PBq based on the mass balance among the three domains of the surface layer, subtropical mode water, and CMW.

Hepatic arterialization can predict the development of collateral veins in patients with HCV-related liver disease

Purpose

Arrival time parametric imaging (At-PI) using contrast-enhanced ultrasonography (CEUS) is a procedure for evaluating liver disease progression in chronic hepatitis C infection (CHC). We investigated At-PI diagnostic efficacy in predicting development of collateral veins.

Methods

In total, 171 CHC patients underwent CEUS and upper gastrointestinal (UGI) endoscopy before liver biopsy. Conventional US was performed before CEUS to identify paraumbilical veins (PV) or splenorenal shunts (SRS). After intravenous perflubutane, contrast dynamics of liver segments 5–6 and the right kidney were saved as raw data. At-PI image ratio of red (ROR) pixels to the entire liver was analyzed. Receiver operating characteristic (ROC) curves were generated to investigate the utility of At-PI for collateral vein identification.

Results

Conventional US revealed PV in two patients and SRS in five patients; UGI endoscopy detected esophageal varices (EV) in eight patients. Diagnostic capability of At-PI for detecting PV, SRS, and EV was satisfactory, and high for PV and SRS [PV; area under the ROC curve (AUROC) 0.929, cutoff value 77.9%, SRS; AUROC 0.970, cutoff value 82.0%, EV; AUROC 0.883, cutoff value 66.9%].

Conclusions

Evaluation of hepatic arterialization by At-PI was useful for predicting collateral vein development in CHC patients.

MIB-1 index is unlikely to predict relapse-free survival in patients who underwent R0-esophagectomy for esophageal squamous cell carcinoma

MIB-1 is a cell proliferation marker and has previously been investigated as a diagnostic or prognostic indicator of malignancy. Previous studies have investigated MIB-1 index and clinicopathological factors in relation to prognosis of patients with esophageal cancer, with conflicting results. The aim of this study is to assess the prognostic significance of MIB-1 index in patients with thoracic esophageal squamous cell carcinoma. A total of 78 patients who underwent R0-esophagectomy for thoracic esophageal squamous cell carcinoma were enrolled in this study. Preoperatively, 29 patients underwent chemotherapy, six underwent chemoradiotherapy, and the remaining did not undergo any preoperative therapy. The MIB-1 labeling index was reported by counting 500 tumor cells in the hot spots of nuclear labeling. Correlations between MIB-1 index, clinicopathological factors, and relapse-free survival (RFS) were investigated. The mean MIB-1 index was 39.3 ± 21.0 (range: 0-91.3). There was no significant correlation between clinicopathological factors and MIB-1 index in the study patients, irrespective of whether they underwent preoperative therapy. Univariate analysis revealed no significant association between MIB-1 index and RFS. However, depth of tumor invasion, lymph node metastasis and stage, all showed a significant correlation to RFS. Multivariate analysis of RFS revealed that stage was the only significant factor. Conversely, MIB-1 index was not significantly related to RFS (p = 0.41). In conclusion, MIB-1 index is unlikely to be a significant prognostic indicator for esophageal cancer.

In Vitro and in Vivo Antigen-Induced Release of High-Molecular Weight Neutrophil Chemotactic Activity from Human Nasal Tissue

High molecular weight neutrophil chemotactic activity has been identified in resected human nasal polyps, inferior turbinates, and nasal secretions following antigen challenge. The estimated molecular weight, by gel filtration chromatography, was approximately 600,000. However, a heterogeneity of molecular weight in some patients was recognized. Our results suggest a possible role for high molecular weight-neutrophil chemotactic activity in the pathogenesis of hypersensitivity in the human nasal cavity.