Development of statistical auto-segmentation method for diffusion restriction gray matter lesions in patients with newly diagnosed sporadic Creutzfeldt-Jakob disease

Quantification of diffusion restriction lesions in sporadic Creutzfeldt-Jakob disease (sCJD) may provide information of the disease burden. We aim to develop an automatic segmentation model for sCJD and to evaluate the volume of disease extent as a prognostic marker for overall survival. Fifty-six patients (mean age ± SD, 61.2 ± 9.9 years) were included from February 2000 to July 2020. A threshold-based segmentation was used to obtain abnormal signal intensity masks. Segmented volumes were compared with the visual grade. The Dice similarity coefficient was calculated to measure the similarity between the automatic vs. manual segmentation. Cox proportional hazards regression analysis was performed to evaluate the volume of disease extent as a prognostic marker. The automatic segmentation showed good correlation with the visual grading. The cortical lesion volumes significantly increased as the visual grade aggravated (extensive: 112.9 ± 73.2; moderate: 45.4 ± 30.4; minimal involvement: 29.6 ± 18.1 mm3) (P < 0.001). The deep gray matter lesion volumes were significantly higher for positive than for negative involvement of the deep gray matter (5.6 ± 4.6 mm3 vs. 1.0 ± 1.3 mm3, P < 0.001). The mean Dice similarity coefficients were 0.90 and 0.94 for cortical and deep gray matter lesions, respectively. However, the volume of disease extent was not associated with worse overall survival (cortical extent: P = 0.07; deep gray matter extent: P = 0.12).

Enhancing local recurrence detection in patients with high-grade soft tissue sarcoma: value of short-term Ultrasonography added to post-operative MRI surveillance

BACKGROUND

Limited data exist on the optimal postoperative surveillance protocol for high-grade soft tissue sarcoma, particularly regarding the optimal imaging modality and imaging interval for detecting local recurrence. This study aimed to assess the benefit of short-term postoperative ultrasonography (USG) for detecting local recurrence in patients with high-grade soft tissue sarcoma.

METHODS

Patients with newly diagnosed high-grade soft tissue sarcoma who underwent surgical resection between January 2010 and June 2020 were included. Short-term USG was added to the follow-up protocol as a surveillance tool alongside routine magnetic resonance imaging (MRI). The primary outcome was the additional detection rate of short-term USG compared with routine MRI surveillance for early local recurrence detection. Subgroup analysis was performed to evaluate factors influencing USG detection rate. The additional detection rate of short-term USG for detection of metastatic lymph nodes was also evaluated. The secondary outcome was the false referral rate of short-term USG.

RESULTS

In total, 198 patients (mean age ± standard deviation: 52.1 ± 15.8 years; 94 women) were included. Local recurrence occurred in 20 patients (10.1%; 20/198). Short-term USG detected local recurrence in advance of routine MRI visits in 7 out of 198 patients, resulting in an additional detection rate of 3.5% (95% CI: 1.7-7.1%). Subgroup analysis showed no significant difference in the short-term USG detection rate based on initial tumor characteristics, and receipt of radiotherapy or chemotherapy. Short-term USG additionally detected five of seven patients with metastatic lymph nodes [2.5% (95% CI, 1.1-5.8%, 5/198)]. The false referral rate of short-term USG was 3.5% (95% CI: 1.7-7.1%; 7/198).

CONCLUSIONS

Short-term USG as part of postoperative surveillance for high-grade soft tissue sarcoma can enhance early detection of local tumor recurrence and metastatic lymphadenopathy. Early detection of local tumor recurrence could lead to a prompt surgical resection and aid in local disease control.

Development and validation of an automatic classification algorithm for the diagnosis of Alzheimer's disease using a high-performance interpretable deep learning network

OBJECTIVES

To develop and validate an automatic classification algorithm for diagnosing Alzheimer's disease (AD) or mild cognitive impairment (MCI).

METHODS AND MATERIALS

This study evaluated a high-performance interpretable network algorithm (TabNet) and compared its performance with that of XGBoost, a widely used classifier. Brain segmentation was performed using a commercially approved software. TabNet and XGBoost were trained on the volumes or radiomics features of 102 segmented regions for classifying subjects into AD, MCI, or cognitively normal (CN) groups. The diagnostic performances of the two algorithms were compared using areas under the curves (AUCs). Additionally, 20 deep learning-based AD signature areas were investigated.

RESULTS

Between December 2014 and March 2017, 161 AD, 153 MCI, and 306 CN cases were enrolled. Another 120 AD, 90 MCI, and 141 CN cases were included for the internal validation. Public datasets were used for external validation. TabNet with volume features had an AUC of 0.951 (95% confidence interval [CI], 0.947-0.955) for AD vs CN, which was similar to that of XGBoost (0.953 [95% CI, 0.951-0.955], p = 0.41). External validation revealed the similar performances of two classifiers using volume features (0.871 vs. 0.871, p = 0.86). Likewise, two algorithms showed similar performances with one another in classifying MCI. The addition of radiomics data did not improve the performance of TabNet. TabNet and XGBoost focused on the same 13/20 regions of interest, including the hippocampus, inferior lateral ventricle, and entorhinal cortex.

CONCLUSIONS

TabNet shows high performance in AD classification and detailed interpretation of the selected regions.

CLINICAL RELEVANCE STATEMENT

Using a high-performance interpretable deep learning network, the automatic classification algorithm assisted in accurate Alzheimer's disease detection using 3D T1-weighted brain MRI and detailed interpretation of the selected regions.

KEY POINTS

• MR volumetry data revealed that TabNet had a high diagnostic performance in differentiating Alzheimer's disease (AD) from cognitive normal cases, which was comparable with that of XGBoost. • The addition of radiomics data to the volume data did not improve the diagnostic performance of TabNet. • Both TabNet and XGBoost selected the clinically meaningful regions of interest in AD, including the hippocampus, inferior lateral ventricle, and entorhinal cortex.

Use of "Diagnostic Yield" in Imaging Research Reports: Results from Articles Published in Two General Radiology Journals

OBJECTIVE

"Diagnostic yield," also referred to as the detection rate, is a parameter positioned between diagnostic accuracy and diagnosis-related patient outcomes in research studies that assess diagnostic tests. Unfamiliarity with the term may lead to incorrect usage and delivery of information. Herein, we evaluate the level of proper use of the term "diagnostic yield" and its related parameters in articles published in Radiology and Korean Journal of Radiology (KJR).

MATERIALS AND METHODS

Potentially relevant articles published since 2012 in these journals were identified using MEDLINE and PubMed Central databases. The initial search yielded 239 articles. We evaluated whether the correct definition and study setting of "diagnostic yield" or "detection rate" were used and whether the articles also reported companion parameters for false-positive results. We calculated the proportion of articles that correctly used these parameters and evaluated whether the proportion increased with time (2012-2016 vs. 2017-2022).

RESULTS

Among 39 eligible articles (19 from Radiology and 20 from KJR), 17 (43.6%; 11 from Radiology and 6 from KJR) correctly defined "diagnostic yield" or "detection rate." The remaining 22 articles used "diagnostic yield" or "detection rate" with incorrect meanings such as "diagnostic performance" or "sensitivity." The proportion of correctly used diagnostic terms was higher in the studies published in Radiology than in those published in KJR (57.9% vs. 30.0%). The proportion improved with time in Radiology (33.3% vs. 80.0%), whereas no improvement was observed in KJR over time (33.3% vs. 27.3%). The proportion of studies reporting companion parameters was similar between journals (72.7% vs. 66.7%), and no considerable improvement was observed over time.

CONCLUSION

Overall, a minority of articles accurately used "diagnostic yield" or "detection rate." Incorrect usage of the terms was more frequent without improvement over time in KJR than in Radiology. Therefore, improvements are required in the use and reporting of these parameters.

Diagnostic yield of TOF-MRA for detecting incidental vascular lesions in patients with cognitive impairment: An observational cohort study

Objectives

The role of three-dimensional (3D) TOF-MRA in patients with cognitive impairment is not well established. We evaluated the diagnostic yield of 3D TOF-MRA for detecting incidental extra- or intracranial artery stenosis and intracranial aneurysm in this patient group.

Methods

This retrospective study included patients with cognitive impairment undergoing our brain MRI protocol from January 2013 to February 2020. The diagnostic yield of TOF-MRA for detecting incidental vascular lesions was calculated. Patients with positive TOF-MRA results were reviewed to find whether additional treatment was performed. Logistic regression analysis was conducted to identify the clinical risk factors for positive TOF-MRA findings.

Results

In total, 1,753 patients (mean age, 70.2 ± 10.6 years; 1,044 women) were included; 199 intracranial aneurysms were detected among 162 patients (9.2%, 162/1,753). A 3D TOF-MRA revealed significant artery stenoses (>50% stenosis) in 162 patients (9.2%, 162/1,753). The overall diagnostic yield of TOF-MRA was 16.8% (294/1,753). Among them, 92 patients (31.3%, 92/294) underwent either medical therapy, endovascular intervention, or surgery. In total, eighty-one patients with stenosis were prescribed with either antiplatelet medications or lipid-lowering agent. In total, fifteen patients (aneurysm: 11 patients, stenosis: 4 patients) were further treated with endovascular intervention or surgery. Thus, the “number needed to scan” was 19 for identifying one patient requiring treatment. Multivariate logistic regression analysis showed that being female (odds ratio [OR] 2.05) and old age (OR 1.04) were the independent risk factors for intracranial aneurysm; being male (OR 1.52), old age (OR 1.06), hypertension (OR 1.78), and ischemic heart disease history (OR 2.65) were the independent risk factors for significant artery stenosis.

Conclusions

Our study demonstrated the potential benefit of 3D TOF-MRA, given that it showed high diagnostic yield for detecting vascular lesions in patients with cognitive impairment and the considerable number of these lesions required further treatment. A 3D TOF-MRA may be included in the routine MR protocol for the work-up of this patient population, especially in older patients and patients with vascular risk factors.

Diagnostic performance of hippocampal volumetry in Alzheimer's disease or mild cognitive impairment: a meta-analysis

OBJECTIVE

To evaluate the diagnostic performance of hippocampal volumetry for Alzheimer's disease (AD) or mild cognitive impairment (MCI).

METHODS

The MEDLINE and Embase databases were searched for articles that evaluated the diagnostic performance of hippocampal volumetry in differentiating AD or MCI from normal controls, published up to March 6, 2022. The quality of the articles was evaluated by the QUADAS-2 tool. A bivariate random-effects model was used to pool sensitivity, specificity, and area under the curve. Sensitivity analysis and meta-regression were conducted to explain study heterogeneity. The diagnostic performance of entorhinal cortex volumetry was also pooled.

RESULTS

Thirty-three articles (5157 patients) were included. The pooled sensitivity and specificity for AD were 82% (95% confidence interval [CI], 77-86%) and 87% (95% CI, 82-91%), whereas those for MCI were 60% (95% CI, 51-69%) and 75% (95% CI, 67-81%), respectively. No difference in the diagnostic performance was observed between automatic and manual segmentation (p = 0.11). MMSE scores, study design, and the reference standard being used were associated with study heterogeneity (p < 0.01). Subgroup analysis demonstrated a higher diagnostic performance of entorhinal cortex volumetry for both AD (pooled sensitivity: 88% vs. 79%, specificity: 92% vs. 89%, p = 0.07) and MCI (pooled sensitivity: 71% vs. 55%, specificity: 83% vs. 68%, p = 0.06).

CONCLUSIONS

Our meta-analysis demonstrated good diagnostic performance of hippocampal volumetry for AD or MCI. Entorhinal cortex volumetry might have superior diagnostic performance to hippocampal volumetry. However, due to a small number of studies, the diagnostic performance of entorhinal cortex volumetry is yet to be determined.

KEY POINTS

• The pooled sensitivity and specificity of hippocampal volumetry for Alzheimer's disease were 82% and 87%, whereas those for mild cognitive impairment were 60% and 75%, respectively. • No significant difference in the diagnostic performance was observed between automatic and manual segmentation. • Subgroup analysis demonstrated superior diagnostic performance of entorhinal cortex volumetry for AD (pooled sensitivity: 88%, specificity: 92%) and MCI (pooled sensitivity: 71%, specificity: 83%).

[Brain MRI-Based Artificial Intelligence Software in Patients with Neurodegenerative Diseases: Current Status]

The incidence of neurodegenerative diseases in the older population has increased in recent years. A considerable number of studies have been performed to characterize these diseases. Imaging analysis is an important biomarker for the diagnosis of neurodegenerative disease. Objective and reliable assessment and precise detection are important for the early diagnosis of neurodegenerative diseases. Artificial intelligence (AI) using brain MRI applied to the study of neurodegenerative diseases could promote early diagnosis and optimal decisions for treatment plans. MRI-based AI software have been developed and studied worldwide. Representatively, there are MRI-based volumetry and segmentation software. In this review, we present the development process of brain volumetry analysis software in neurodegenerative diseases, currently used and developed AI software for neurodegenerative disease in the Republic of Korea, probable uses of AI in the future, and AI software limitations.

Quality Reporting of Systematic Review and Meta-Analysis According to PRISMA 2020 Guidelines: Results from Recently Published Papers in the Korean Journal of Radiology

OBJECTIVE

To evaluate the completeness of the reporting of systematic reviews and meta-analyses published in a general radiology journal using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

MATERIALS AND METHODS

Twenty-four articles (systematic review and meta-analysis, n = 18; systematic review only, n = 6) published between August 2009 and September 2021 in the Korean Journal of Radiology were analyzed. Completeness of the reporting of main texts and abstracts were evaluated using the PRISMA 2020 statement. For each item in the statement, the proportion of studies that met the guidelines' recommendation was calculated and items that were satisfied by fewer than 80% of the studies were identified. The review process was conducted by two independent reviewers.

RESULTS

Of the 42 items (including sub-items) in the PRISMA 2020 statement for main text, 24 were satisfied by fewer than 80% of the included articles. The 24 items were grouped into eight domains: 1) assessment of the eligibility of potential articles, 2) assessment of the risk of bias, 3) synthesis of results, 4) additional analysis of study heterogeneity, 5) assessment of non-reporting bias, 6) assessment of the certainty of evidence, 7) provision of limitations of the study, and 8) additional information, such as protocol registration. Of the 12 items in the abstract checklists, eight were incorporated in fewer than 80% of the included publications.

CONCLUSION

Several items included in the PRISMA 2020 checklist were overlooked in systematic review and meta-analysis articles published in the Korean Journal of Radiology. Based on these results, we suggest a double-check list for improving the quality of systematic reviews and meta-analyses. Authors and reviewers should familiarize themselves with the PRISMA 2020 statement and check whether the recommended items are fully satisfied prior to publication.

Prognostic value of diffusion-weighted imaging in patients with newly diagnosed sporadic Creutzfeldt-Jakob disease

OBJECTIVES

To evaluate clinico-radiologic markers that predict poor overall survival (OS) in sporadic Creutzfeldt-Jakob disease (sCJD) and to develop a prognostic model.

MATERIALS AND METHODS

Patients with newly diagnosed sCJD were included who underwent diffusion-weighted imaging (DWI) from February 2000 to July 2020. The impact of 9 clinico-radiologic features on OS was analyzed using univariable and multivariable Cox proportional hazards regression model. The DWI prognostic score model was generated. The weighted kappa was calculated for interobserver agreement.

RESULTS

Sixty patients (mean age ± SD, 61.0 ± 9.7 years, 32 women) were included. Univariable analysis showed positive associations between poor OS and patient age (p = 0.003), extent of involved cortical lobes (p = 0.11), involvement of caudate nucleus (p = 0.07), and putamen (p = 0.04). Multivariable analysis demonstrated two independent prognostic factors: age ≥ 60 (HR 2.65, 95% CI, 1.41-4.98), and diffusion restriction in caudate nucleus and putamen (HR 2.24, 95% CI, 1.15-4.37). Based on these features, the DWI prognostic score model was generated: low-risk (0-1 point), intermediate-risk (2-3 points), and high-risk (4-5 points) groups. Median OS in high-risk group was 1.7 months, which was significantly shorter than those in the intermediate-risk (14.2 months) and low-risk (26.5 months) groups (p < 0.001). Interobserver agreements were excellent (κ = 0.91-0.92).

CONCLUSIONS

Our study demonstrated that age and diffusion restriction in caudate nucleus and putamen were the independent prognostic factors of poor overall survival in sporadic Creutzfeldt-Jakob disease. Our DWI prognostic score model may be useful in clinical settings for disease stratification.

KEY POINTS

• Age ≥ 60, and diffusion restriction in caudate nucleus and putamen were the independent prognostic factors of poor overall survival in sCJD. • Based on our DWI prognostic score model, median overall survival in high-risk group was 1.7 months, which was significantly shorter than those in the intermediate-risk group (14.2 months) and low-risk group (26.5 months) (p < 0.001). • The proposed DWI prognostic score model may be useful in clinical settings for disease stratification.

Diagnostic performance of the medial temporal lobe atrophy scale in patients with Alzheimer's disease: a systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic performance and reliability of the medial temporal lobe atrophy (MTA) scale in patients with Alzheimer's disease.

METHODS

A systematic literature search of MEDLINE and EMBASE databases was performed to select studies that evaluated the diagnostic performance or reliability of MTA scale, published up to January 21, 2021. Pooled estimates of sensitivity and specificity were calculated using a bivariate random-effects model. Pooled correlation coefficients for intra- and interobserver agreements were calculated using the random-effects model based on Fisher's Z transformation of correlations. Meta-regression was performed to explain the study heterogeneity. Subgroup analysis was performed to compare the diagnostic performance of the MTA scale and hippocampal volumetry.

RESULTS

Twenty-one original articles were included. The pooled sensitivity and specificity of the MTA scale in differentiating Alzheimer's disease from healthy control were 74% (95% CI, 68-79%) and 88% (95% CI, 83-91%), respectively. The area under the curve of the MTA scale was 0.88 (95% CI, 0.84-0.90). Meta-regression demonstrated that the difference in the method of rating the MTA scale was significantly associated with study heterogeneity (p = 0.04). No significant difference was observed in five studies regarding the diagnostic performance between MTA scale and hippocampal volumetry (p = 0.40). The pooled correlation coefficients for intra- and interobserver agreements were 0.85 (95% CI, 0.69-0.93) and 0.83 (95% CI, 0.66-0.92), respectively.

CONCLUSIONS

Our meta-analysis demonstrated a good diagnostic performance and reliability of the MTA scale in Alzheimer's disease.

KEY POINTS

• The pooled sensitivity and specificity of the MTA scale in differentiating Alzheimer's disease from healthy control were 74% and 88%, respectively. • There was no significant difference in the diagnostic performance between MTA scale and hippocampal volumetry. • The reliability of MTA scale was excellent based on the pooled correlation coefficient for intra- and interobserver agreements.

Comprehensive Updates in the Role of Imaging for Multiple Myeloma Management Based on Recent International Guidelines

The diagnostic and treatment methods of multiple myeloma (MM) have been rapidly evolving owing to advances in imaging techniques and new therapeutic agents. Imaging has begun to play an important role in the management of MM, and international guidelines are frequently updated. Since the publication of 2015 International Myeloma Working Group (IMWG) criteria for the diagnosis of MM, whole-body magnetic resonance imaging (MRI) or low-dose whole-body computed tomography (CT) and ¹⁸F-fluorodeoxyglucose positron emission tomography/CT have entered the mainstream as diagnostic and treatment response assessment tools. The 2019 IMWG guidelines also provide imaging recommendations for various clinical settings. Accordingly, radiologists have become a key component of MM management. In this review, we provide an overview of updates in the MM field with an emphasis on imaging modalities.

A therapeutic intervention for Alzheimer's disease using ginsenoside Rg3: its role in M2 microglial activation and non-amyloidogenesis

Previously, we have reported that ginsenoside Rg3 has typical activities for neuroprotection and Aβ42 clearance by modulating microglia. In this study, we determined the pivotal role of ginsenoside Rg3 in microglia and neuronal cells. In human microglia, Rg3 and its stereoisomers significantly restored inflammatory M1 to normal M0 state and promoted M2 activation by up-regulating acute cytokines such as interleukin-10 and Arginase 1. Moreover, scavenger receptor type A (SRA) was significantly elevated in the presence of ginsenoside Rg3 and 20(S)-Rg3. This indicated that ginsenoside Rg3 could play a crucial role in Aβ uptake and clearance under activated M2 state. We also observed that soluble amyloid precursor protein-alpha (sAPPα) and ADAM10 levels were increased in APP swe-transfected Nuro-2a neuronal cells, whereas sAPPβ was not processed, suggesting that ginsenoside Rg3 was involved in non-amyloidogenic processing. In immunocytochemistry, SRA and a disintegrin and metalloproteinase 10 (desintegrin and metalloproteinase-containing protein 10, ADAM10) were coincidently upregulated in the presence of ginsenoside Rg3 and its stereoisomers compared to those in normal control. Taken together, these results suggested that ginsenoside Rg3 could boost acute activation of microglia, promote Aβ uptake, and elevate the sAPPα processing under activated M2 state. Although in vivo studies need to be performed, it is certain that ginsenoside Rg3 is highly involved in ameliorating the pathogenesis of neurodegeneration and can be a promising candidate for treating Alzheimer's disease as a new therapeutic intervention.

P–370 RPL-protease A as a potential biomarker for predicting recurrent pregnancy loss

Study question

Could the reduction of RPL-protease A be involved in the dysfunctional trophoblast for resulting in recurrent pregnancy loss (RPL).

Summary answer

Low expression of RPL-protease A may result in RPL and low serum RPL-protease A level may be a potential biomarker for predicting RPL.

What is known already

The RPL-protease A is expressed and secreted by placenta. The RPL-protease A is involved in the pathogenesis of pre-eclampsia, and the serum RPL-protease A level is higher in the patients with pre-eclampsia than that of normal groups. In our previous study, we identified that the RPL-protease A mRNA level was lower in the villi of patients with RPL than that of normal groups.

Study design, size, duration

Using the CRISPR/Cas9 system, the RPL-protease A gene knockout BeWo cell (BeWo KO) line was established, and the wild type (BeWo WT) and BeWo KO cells were applied to investigate the roles of RPL-protease A in trophoblasts. The human serum RPL-protease A levels were investigated by Western blot analysis and ELISA kit.

Participants/materials, setting, methods

The cell-cell fusion, cell counting analysis, invasion and scratch wound assays, cell cycle analysis, and immunocytochemical analysis were used to investigate cellular functions of RPL-protease A in trophoblast. The sera were obtained from 32 normal pregnant women and 60 women with RPL. The Western blot analysis and ELISA were used for detection of serum RPL-protease A levels.

Main results and the role of chance

The β-hCG was detected in fused BeWo WT cells, while the BeWo KO cells cannot fuse and did not express the β-hCG. The ability of invasion was decreased, but the capacity of migration and proliferation was higher in BeWo KO cells than BeWo WT cells. Cell fusion related factor (β-hCG), and cell invasion related factors (MMP–2 and MMP–9) were highly expressed in BeWo WT cells, and cell related factor (FAK), and cell proliferation related factors (ERK, p38, JNK, MKK3, MKK6, Raf, and Ras) were highly expressed in BeWo KO cells. The Western blot analysis and ELISA indicate that the serum RPL-protease A level was decreased in patients with RPL compared to that of normal groups.

Limitations, reasons for caution

The results of this study have the limitation of RPL-protease A functions in vitro.

Wider implications of the findings: The cellular functions of RPL-protease A in trophoblasts were investigated to explain the pathogenesis of RPL, and low serum RPL-protease A level can be used for a potential biomarker predicting RPL.

Trial registration number

Not applicable

Prognostic Utility of Disproportionately Enlarged Subarachnoid Space Hydrocephalus in Idiopathic Normal Pressure Hydrocephalus Treated with Ventriculoperitoneal Shunt Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Disproportionately enlarged subarachnoid space hydrocephalus is a specific radiologic marker for idiopathic normal pressure hydrocephalus. However, controversy exists regarding the prognostic utility of disproportionately enlarged subarachnoid space hydrocephalus.

PURPOSE

Our aim was to evaluate the prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and its predictive utility regarding prognosis in patients treated with ventriculoperitoneal shunt surgery.

DATA SOURCES

We used MEDLINE and EMBASE databases.

STUDY SELECTION

We searched for studies that reported the prevalence or the diagnostic performance of disproportionately enlarged subarachnoid space hydrocephalus in predicting treatment response.

DATA ANALYSIS

The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was obtained. Pooled sensitivity, specificity, and area under the curve of disproportionately enlarged subarachnoid space hydrocephalus to predict treatment response were obtained. Subgroup and sensitivity analyses were performed to explain heterogeneity among the studies.

DATA SYNTHESIS

Ten articles with 812 patients were included. The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus was 44% (95% CI, 34%-54%). The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was higher in the studies using the second edition of the Japanese Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus compared with the studies using the international guidelines without statistical significance (52% versus 43%, P = .38). The pooled sensitivity and specificity of disproportionately enlarged subarachnoid space hydrocephalus for prediction of treatment response were 59% (95% CI, 38%-77%) and 66% (95% CI, 57%-74%), respectively, with an area under the curve of 0.67 (95% CI, 0.63-0.71).

LIMITATIONS

The lack of an established method for assessing disproportionately enlarged subarachnoid space hydrocephalus using brain MR imaging served as an important cause of the heterogeneity.

CONCLUSIONS

Our meta-analysis demonstrated a relatively low prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and a poor diagnostic performance for treatment response.

Realistic High-Resolution Body Computed Tomography Image Synthesis by Using Progressive Growing Generative Adversarial Network: Visual Turing Test

BACKGROUND

Generative adversarial network (GAN)-based synthetic images can be viable solutions to current supervised deep learning challenges. However, generating highly realistic images is a prerequisite for these approaches.

OBJECTIVE

The aim of this study was to investigate and validate the unsupervised synthesis of highly realistic body computed tomography (CT) images by using a progressive growing GAN (PGGAN) trained to learn the probability distribution of normal data.

METHODS

We trained the PGGAN by using 11,755 body CT scans. Ten radiologists (4 radiologists with <5 years of experience [Group I], 4 radiologists with 5-10 years of experience [Group II], and 2 radiologists with >10 years of experience [Group III]) evaluated the results in a binary approach by using an independent validation set of 300 images (150 real and 150 synthetic) to judge the authenticity of each image.

RESULTS

The mean accuracy of the 10 readers in the entire image set was higher than random guessing (1781/3000, 59.4% vs 1500/3000, 50.0%, respectively; P<.001). However, in terms of identifying synthetic images as fake, there was no significant difference in the specificity between the visual Turing test and random guessing (779/1500, 51.9% vs 750/1500, 50.0%, respectively; P=.29). The accuracy between the 3 reader groups with different experience levels was not significantly different (Group I, 696/1200, 58.0%; Group II, 726/1200, 60.5%; and Group III, 359/600, 59.8%; P=.36). Interreader agreements were poor (κ=0.11) for the entire image set. In subgroup analysis, the discrepancies between real and synthetic CT images occurred mainly in the thoracoabdominal junction and in the anatomical details.

CONCLUSIONS

The GAN can synthesize highly realistic high-resolution body CT images that are indistinguishable from real images; however, it has limitations in generating body images of the thoracoabdominal junction and lacks accuracy in the anatomical details.

Diagnostic performance and interobserver agreement of the callosal angle and Evans' index in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic performance and interobserver agreement of the callosal angle and Evans' index in idiopathic normal pressure hydrocephalus (iNPH).

METHODS

A systematic search of MEDLINE and EMBASE was performed to find studies assessing the diagnostic performance or interobserver agreement of the callosal angle and Evans' index in iNPH. Pooled sensitivity and specificity of the two radiologic indices were calculated. The area under the curve (AUC) was obtained based on a hierarchical summary receiver operating characteristic curve. The diagnostic performances of both radiologic indices were compared in subgroup analysis. To evaluate interobserver agreement, the pooled correlation coefficient was calculated.

RESULTS

Ten original articles (874 patients) were included. The pooled sensitivity and specificity of the callosal angle in the diagnosis of iNPH were 91% (95% CI, 86-94%) and 93% (95% CI, 89-96%), respectively. The pooled sensitivity and specificity of Evans' index were 96% (95% CI, 47-100%) and 83% (95% CI, 77-88%), respectively. Subgroup analysis demonstrated a significant higher specificity of the callosal angle than that of Evans' index (p < 0.01). The AUC of the callosal angle and Evans' index were 0.97 (95% CI, 0.95-0.98) and 0.87 (95% CI, 0.84-0.90), respectively. The pooled correlation coefficients for the callosal angle and Evans' index were 0.92 (95% CI, 0.82-0.96) and 0.92 (95% CI, 0.83-0.97), respectively.

CONCLUSIONS

Our meta-analysis demonstrated a high performance of the callosal angle in the diagnosis of iNPH. Evans' index showed reasonable diagnostic performance with high sensitivity but low specificity. Interobserver agreements were excellent in both radiologic indices.

KEY POINTS

• Callosal angle showed high diagnostic performance in idiopathic normal pressure hydrocephalus. • Evans' index showed reasonable diagnostic performance with high sensitivity but low specificity. • Interobserver agreements were excellent in both callosal angle and Evans' index.

Role of whole-body MRI for treatment response assessment in multiple myeloma: comparison between clinical response and imaging response

BACKGROUND

Whole-body MRI (WB-MRI) including diffusion-weighted image (DWI) have been widely used in patients with multiple myeloma. However, evidence for the value of WB-MRI in the evaluation of treatment response remains sparse. Therefore, we evaluated the role of WB-MRI in the response assessment.

METHODS

In our WB-MRI registry, we searched multiple myeloma patients treated with chemotherapy who underwent both baseline and follow-up WB-MRI scans. Clinical responses were categorized as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD), using IMWG criteria. Using RECIST 1.1, MD Anderson (MDA) criteria, and MDA-DWI criteria, imaging responses on WB-MRI were rated as CR, PR, SD, or PD by two radiologists independently. Then, discrepancy cases were resolved by consensus. Weighted Kappa analysis was performed to evaluate agreement between the imaging and clinical responses. The diagnostic accuracy of image responses in the evaluation of clinical CR, objective response (CR and PR), and PD was calculated.

RESULTS

Forty-two eligible patients were included. There was moderate agreement between imaging and clinical responses (κ = 0.54 for RECIST 1.1, κ = 0.58 for MDA criteria, κ = 0.69 for MDA-DWI criteria). WB-MRI showed excellent diagnostic accuracy in assessment of clinical PD (sensitivity 88.9%, specificity 94.7%, positive predictive value [PPV] 84.2%, negative predictive value [NPV] 96.4% in all three imaging criteria). By contrast, WB-MRI showed low accuracy in assessment of clinical CR (sensitivity 4.5%, specificity 98.1%, PPV 50.0%, NPV 71.2% in all three imaging criteria). As to the clinical objective response, the diagnostic accuracy was higher in MDA-DWI criteria than RECIST 1.1 and MDA criteria (sensitivity/specificity/PPV/NPV, 84.2%/94.4%/98.0%/65.4, 54.4%/100%/100%/40.9, and 61.4%/94.4%/97.2%/43.6%, respectively).

CONCLUSIONS

In the imaging response assessment of multiple myeloma, WB-MRI showed excellent performance in the evaluation of PD, but not in the assessment of CR or objective response. When adding DWI to imaging response criteria, diagnostic accuracy for objective response was improved and agreement between imaging and clinical responses was increased.

P1416 Clinical importance of consecutive transthoracic echocardiography in the patients with hypertrophic cardiomyopathy

Funding Acknowledgements

nothing

OnBehalf

nothing

Background

prediction of outcomes Hypertrophic cardiomyopathy (HCM) have been robustly analyzed with echocardiography. However, there is limited data of serial follow-up (FU) transthoracic echocardiography (TTE) to predict outcomes in patients with HCM.

Objectives

This study aim is to discover clinical predictors associated with consecutive TTE follow-up in patients with HCM.

Methods

From 2010 to 2016, 162 patients with HCM were enrolled retrospectively. Concentric LVH and others systolic disease related to wall thickness were excluded. Index TTE (baseline) was measured when firstly admitted in our hospital. FU TTE was analyzed at the end of follow-up, defined as the last recorded value in patients who did not develop events or the last recorded value before events developed.

Results

The average of FU TTE and clinical FU period was 3.7 ± 2.0 years. Clinical outcomes were defined as stroke, syncope, heart failure, arrhythmia and death. Interestingly, only baseline TR V max was a predictor for clinical outcome whereas the others echo parameters were not associated with events (Table 1). KM curve showed the TR Vmax ≥2.5m/s was also significant (log rank = 0.008, Fig 1.)

Conclusions Our study showed short-term FU TTE did not bring clinician with clinical benefits in the aspect of prediction for events. Only baseline TR V max was good correlation with cardiovascular outcomes and even in the survival analysis.

Serial TTE and changed values Total N = 162 index TTE (baseline) FU TTE Change of FU per year event no event p-value event no event p-value event no event p-value IVDd, mm 14 ± 4 15 ± 5 0.500 15 ± 5 14 ± 5 0.758 0.23 ± 0.51 -0.07 ± 1.27 0.200 LVIDd, mm 47 ± 5 48 ± 6 0.256 47 ± 7 48 ± 6 0.560 -0.22 ± 2.79 0.10 ± 2.27 0.444 LVEF, % 62 ± 5 61 ± 7 0.379 61 ± 6 61 ± 10 0.927 -0.43 ± 3.10 -0.04 ± 4.94 0.620 LAVI 43 ± 9 43 ± 8 0.879 57 ± 27 58 ± 23 0.849 0.53 ± 14.5 3.11 ± 7.2 0.134 EA ratio 0.9 ± 0.6 0.9 ± 0.6 0.782 1.0 ± 0.8 0.9 ± 0.6 0.595 -0.02 ± 0.76 0.003 ± 0.027 0.594 DT,ms 196 ± 58 201 ± 62 0.603 203 ± 91 217 ± 89 0.370 17 ± 57 5 ± 40 0.154 septal e` 4.4 ± 2.1 4.2 ± 1.6 0.585 4.4 ± 1.6 4.6 ± 1.7 0.438 0.24 ± 0.91 0.05 ± 0.65 0.190 E of e` 17 ± 11 17 ± 23 0.993 15 ± 9 15 ± 6 0.726 -0.48 ± 4.42 -1.66 ± 22.78 0.728 TR velocity 2.6 ± 0.5 2.4 ± 0.4 0.012 2.7 ± 0.6 2.6 ± 0.4 0.604 0.05 ± 0.30 0.04 ± 0.18 0.905 Max wall thickness 17 ± 3 18 ± 3 0.137 17 ± 4 17 ± 3 0.888 -0.01 ± 2.19 -0.18 ± 1.14 0.522

Abstract P1416 Figure. TR Vmax and CV outcomes in the KM curve

Advances in whole body MRI for musculoskeletal imaging: Diffusion-weighted imaging

Recent advances in imaging technology have enabled the acquisition of anatomical and functional imaging from head to toe in a reasonably short scan time. Accordingly, whole body magnetic resonance imaging (WB-MRI) and diffusion-weighted imaging (WB-DWI) have gained recent attention for the management of musculoskeletal problems such as bone tumors and rheumatologic diseases. WB-MRI is especially useful in diagnosing systemic or widespread disease requiring whole body evaluation, such as bone metastases, multiple myeloma, lymphoma, neurofibromatosis, and spondyloarthropathies. Among WB-MRI sequences, the WB-DWI technique greatly increases the value of WB-MRI in the evaluation of disease extent and characterization as well as treatment monitoring. In support of the utilization of WB-MRI and WB-DWI in orthopedic clinics for various musculoskeletal diseases, we provide an overview of the technical aspects of WB-MRI and WB-DWI and their clinical applications in musculoskeletal tumors and rheumatic diseases.

Once-daily dosing of amikacin for treatment of Mycobacterium abscessus lung disease

SETTING

Tertiary referral centre, Samsung Medical Center, South Korea.

OBJECTIVE

To evaluate the pharmacokinetic parameters and toxicities of once-daily amikacin (AMK) dosing for lung disease due to Mycobacterium abscessus.

DESIGN

A retrospective review of 48 patients with M. abscessus lung disease who received once-daily AMK for 4 weeks between January 2012 and June 2015.

RESULTS

With a starting dose of 15 mg/kg/day and adjustment of AMK dose according to the peak serum level (Cmax), the Cmax target of 55-65 μg/ml was achieved in 31.3% (15/48) of patients in the first week, 68.8% (33/48) in week 2, 91.7% (44/48) in week 3 and 95.8% (46/48) in week 4. Transient nephrotoxicity developed in 6.3% (3/48) of patients and ototoxicity in 25.0% (6/24), which was determined by audiogram as hearing loss, asymptomatic in five patients and tinnitus in one. Multivariate analysis revealed that the highest drug concentration 12 h after administration was significantly associated with the development of toxicities (adjusted odds ratio 1.862, P = 0.047).

CONCLUSION

Our results suggest that once-daily AMK for 4 weeks with a target Cmax of 55-65 μg/ml can be used in patients with M. abscessus lung disease, with careful monitoring of toxicity.

The 100 most-cited articles on non-tuberculous mycobacterial infection from 1995 to 2015

SETTING

Citation analyses aid in assessing quality, trends and future directions of research fields.

OBJECTIVE

To identify the most influential articles on infections caused by non-tuberculous mycobacteria (NTM) in the last 20 years.

DESIGN

We performed a cited reference search of the Web of Science database from 1995 to 2015. The 100 most cited articles on NTM infections were analysed.

RESULTS

The top 100 articles were cited 114-1471 times, and were published from 1995 to 2013. Sixty-five were laboratory-based, basic science articles, with the major topics being pathophysiology (n = 20) and molecular methods for NTM identification (n = 15). Among the 35 non-laboratory studies, major topics were clinical management (n = 15) and epidemiology (n = 14). The top article was a clinical treatise on the management of NTM disease, published in 2007. Although there was a correlation between article rank and journal impact factor (P = 0.043, ρ = -0.202), the five articles from the journals with highest impact factors did not rank among the top 10 articles.

CONCLUSION

A large proportion of influential articles on NTM infection are basic scientific studies, and the most influential articles are not always published in high-impact journals.

Liquid culture enhances diagnosis of patients with milder forms of non-tuberculous mycobacterial lung disease

OBJECTIVE

To evaluate the proportion and clinical characteristics of patients with non-tuberculous mycobacteria (NTM) lung disease diagnosed based on positive culture results in liquid medium only.

METHODS

We reviewed the medical records of 978 patients diagnosed with NTM lung disease. All clinical samples were cultured in both solid and liquid media.

RESULTS

Of the 978 patients, 111 (11.3%) were culture-positive in liquid medium only (liquid culture group), and 867 (88.7%) (solid culture group) on solid medium, regardless of the culture results in liquid medium. At the time of diagnosis, the liquid culture group was less likely than the solid culture group to have haemoptysis (11.7% vs. 20.0%, P = 0.04), positive sputum smear for acid-fast bacilli (14.4% vs. 50.2%, P < 0.001) or the fibrocavitary form of NTM lung disease (3.6% vs. 14.6%, P = 0.001). During the median follow-up period of 28.9 months (interquartile range 19.1-41.6), the proportion of patients requiring antibiotic treatment was lower in the liquid culture group than in the solid culture group (44.1% vs. 61.6%, P < 0.001).

CONCLUSIONS

Liquid media culture is helpful in the diagnosis of patients with less severe forms of NTM lung disease.

Implication of vitamin D-associated factors in patients with non-tuberculous mycobacterial lung disease

BACKGROUND

Little information is available regarding vitamin D-associated factors in patients with non-tuberculous mycobacteria (NTM) lung disease.

OBJECTIVE

To determine the association between vitamin D-related factors and susceptibility to NTM lung disease.

DESIGN

The relative gene expression levels of cathelicidin (CAMP), defensin (DEFB4), vitamin D receptor (VDR) and 1-hydroxylase (CYP27B1), as well as the serum levels of 25-hydroxyvitamin D (25[OH]D), cathelicidin (LL-37), defensin (hBD-2) and vitamin D-binding protein (DBP) from 82 patients with NTM lung disease and 28 control subjects were analysed.

RESULTS

Gene expression of CAMP and DEFB4 was significantly higher, and gene expression of VDR and CYP27B1 was significantly lower, in NTM patients than controls. Serum LL-37 and hBD-2 levels were not significantly different between NTM patients and controls; however, the serum DBP level was higher in NTM patients than controls. The serum vitamin D status of patients did not correlate with serum LL-37, hBD-2, or DBP concentration or gene expression of CAMP, DEFB4, VDR or CYP27B1.

CONCLUSION

A higher level of gene expression for antimicrobial peptide is more likely to be associated with NTM lung disease than serum vitamin D status.

Novel device-based acne treatments: comparison of a 1450-nm diode laser and microneedling radiofrequency on mild-to-moderate acne vulgaris and seborrhoea in Korean patients through a 20-week prospective, randomized, split-face study

BACKGROUND

While device-based acne treatments are widely applied for patients not tolerating conventional medications, related controlled studies have been still limited. Recently, non-ablative 1450-nm diode laser (DL) and fractional microneedling radiofrequency (FMR) have been effectively used for acne, in addition to well-recognized dermal remodelling effects.

OBJECTIVE

To compare the clinical course of acne treatment between DL and FMR.

METHODS

Twenty-five Korean patients with mild-to-moderate facial acne completed treatments with DL and FMR through a 20-week, randomized split-face study. One randomly assigned half side of each patient's face received DL and the other side by FMR. Treatments were scheduled to receive three consecutive sessions at 4-week intervals. Objective assessments including revised Leeds grades, lesion counts, sebum output measurements, and patients' subjective satisfaction were investigated.

RESULTS

Both DL and FMR demonstrated steady improvement of acne and seborrhoea during treatment sessions. While results between two devices were similar during treatment sessions, FMR was superior to DL in the 12-week follow-up. Patients' subjective assessments for seborrhoea improvement were similar between two devices, while those for acne, skin texture, and acne scars were more satisfactory for FMR. For safety profile, no significant difference was observed between two regimens, while mild postinflammatory hyperpigmentation was observed only in DL side.

CONCLUSION

Both DL and FMR demonstrated efficacies for acne and seborrhoea, with reasonable safety profile. FMR was more effective than DL for the long-term maintenance, and subjective assessments for texture and scar improvements. Therefore, a few sessions of these devices would be a viable option for acne treatments.

Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department

Introduction

Our purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.

Methods

This retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.

Results

Sensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.

Conclusions

PAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.

Percutaneous Transparaumbilical Embolization of Spontaneous Portosystemic Shunts for the Treatment of Hepatic Encephalopathy

The medical records of 7 patients who underwent percutaneous transparaumbilical embolization of spontaneous portosystemic shunts for treatment of hepatic encephalopathy (HE) were retrospectively reviewed. Technical success was achieved in 100% (7/7) of patients. Four patients had complete resolution and 3 had improvement of signs and symptoms of HE within 3 days after the procedure for a clinical success rate of 100% (7/7). New-onset esophageal varices, a major complication, occurred in 1 patient. No other major complications were encountered. HE recurred in 71.4% (5/7) of patients during a median follow-up period of 43 months (range, 4-111 months).

Mucosal production of uric acid by airway epithelial cells contributes to particulate matter-induced allergic sensitization

Exposure to particulate matter (PM), a major component of air pollution, contributes to increased morbidity and mortality worldwide. PM induces innate immune responses and contributes to allergic sensitization, although the mechanisms governing this process remain unclear. Lung mucosal uric acid has also been linked to allergic sensitization. The links among PM exposure, uric acid, and allergic sensitization remain unexplored. We therefore investigated the mechanisms behind PM-induced allergic sensitization in the context of lung mucosal uric acid. PM10 and house dust mite exposure selectively induced lung mucosal uric acid production and secretion in vivo, which did not occur with other challenges (lipopolysaccharide, virus, bacteria, or inflammatory/fibrotic stimuli). PM10-induced uric acid mediates allergic sensitization and augments antigen-specific T-cell proliferation, which is inhibited by uricase. We then demonstrate that human airway epithelial cells secrete uric acid basally and after stimulation through a previously unidentified mucosal secretion system. Our work discovers a previously unknown mechanism of air pollution-induced, uric acid-mediated, allergic sensitization that may be important in the pathogenesis of asthma.

Imaging Single mRNA Dynamics in Live Neurons and Brains

RNA is a key player in the process of gene expression. Whereas fluorescence in situ hybridization allows single mRNA imaging in fixed cells, the MS2-GFP labeling technique enables the observation of mRNA dynamics in living cells. Recently, two genetically engineered mouse models have been developed for the application of the MS2-GFP system in live animals. First, the Actb-MBS mouse was generated by knocking in 24 repeats of the MS2 stem-loop sequence in the 3' untranslated region of the β-actin gene. Second, the MCP mouse was made to express the NLS-HA-MCP-GFP transgene in all cell types. By crossing Actb-MBS and MCP mice, a double homozygous mouse line, MCP×MBS, was established to visualize endogenous β-actin mRNA labeled with multiple green fluorescent proteins. By imaging hippocampal neurons or brain slices from MCP×MBS mice, the dynamics of mRNA, such as transcription, transport, and localization, can be studied at single mRNA resolution. In this chapter, we explain the basics of MCP×MBS mice and describe methods for utilizing these animals.

Abstract P4-09-21: Dual expression of aquaporin 3 and 5 in patients with early breast cancer

Background: We reported separately that AQP5 or AQP3 expression in tumor tissue may predict survival after surgery for the specific types of early breast cancer (EBC). However, there is no definitive evidence for the role of dual expression of the two AQPs. Therefore, the current study focused the association and its prognostic impact of their tumoral expressions in the same patients.

Patients and Methods: AQP3 and AQP5 expressions were investigated on the basis of the immunohistochemistry of tissue microarray specimens from 447 EBC patients who underwent surgery between 2003 and 2008 as described in previous studies. Patients were divided into 4 subgroups based on AQP3 and AQP5 expressions: group1 for (-/-), group2 for (-/+), group 3 for (+/-), and group 4 for (+/+), respectively.

Results: Among 477 patients, the number of patients for each group was as follows: group 1 (n=193, 43.2%), group 2 (n=74, 16.6%), group3 (n=110, 24.6%) and group 4 (n=70, 15.7%), respectively. In the current study a positive correlation was identified between AQP3 and 5 expressions (P=0.017 by a χ2- test) in particular for HER2- overexpressing and ER-positive tumors (P=0.009 and 0.044, respectively). Multivariate survival analysis showed that dual expression of AQP3 and AQP5 was a negative prognostic factor for relapse-free or distant disease-free survival for patients with HER2-overexpressing EBC (HR=3.107 and 3.683; P=0.043 and 0.027, respectively), statistically more prominent compared in case with AQP3 expression alone (HR=3.137 and 2.784; P=0.036 and 0.070, respectively).

Conclusion: Dual expression of AQP3 and AQP5 in tumor tissue may be considered as a potential prognostic marker in patients with HER2-overexpressing EBC after curative surgery.

Citation Format: Lee SJ, Chae YS, Kwon TJ, Chung JH, Lee J, Jung JH, Kim WW, Park HY, Jeong JY, Park S-H, Park S. Dual expression of aquaporin 3 and 5 in patients with early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-21.

Abstract P4-13-09: Clinical effectiveness of everolimus and exemestane in advanced breast cancer patients from Asia and Africa: First efficacy and updated safety results from the phase IIIb EVEREXES study

Background

BOLERO-2 phase III trial established the efficacy of everolimus (EVE) plus exemestane (EXE) for the treatment of postmenopausal patients with hormone receptor (HR)-positive, HER2-negative, advanced breast cancer (aBC). However, in this study only a minority (&lt;10%) of patients were recruited from African and Asia Pacific countries. Considering the potential effects of ethnic and cultural differences on treatment effectiveness, it remains compelling to confirm the safety and efficacy profile of EVE+EXE in these populations.

Methods

EVEREXES is an open-label phase IIIb, single arm, multi-center trial, which from March 2013 to October 2014 enrolled 232 post-menopausal, HR-positive and HER2-negative, aBC patients previously treated with aromatase inhibitors, across 13 countries in Asia Pacific, Middle East, North and South Africa, with a significant majority of patients being of Asian ethnicity (196, 84.5%). Its primary objective was to investigate the safety and tolerability profile of EVE+EXE. Secondary objectives were the evaluation of efficacy (assessed by PFS, ORR, and CBR based on RECIST 1.1 criteria) and change in ECOG performance status.

Results

At data cut off of 31st of January 2015, at a median follow up of 11.7 months, median PFS for the ITT population was 9.5 months [9.2-11.6 months], based on local assessment, with the observation of 1 (0.4%) CR and 35 (15.4%) PR. Regarding safety and tolerability, a majority (81.1%) of grade (G) 1/2 adverse events (AEs) was reported. In particular, the following pattern was observed in terms of % of patients who developed G1/G2/G3 mTOR-inhibition induced AEs: stomatitis (36.1, 13.7, 10.6), rash (21.6/6.2/0), fatigue (10.6, 4.4, 2.2), hyperglycemia (6.2, 11.5, 7.0), weight decrease (7.5, 7, 0.9), pneumonitis (5.7, 7, 0.9). No Grade 4 AEs related to EVE+EXE treatment were observed, with exception of one case of non infectious pneumonitis (0.4%). Median dose intensity of everolimus was 9.2 mg/day.

Conclusions

Efficacy and safety results from EVEREXES trial further confirm the role of EVE+EXE for the treatment of HR+/Her2- advanced BC patients in Eastern countries. Results were consistent with data previously reported in BOLERO-2 trial.

Citation Format: Im Y-H, Uslu R, Lee KS, Nagarkar R, Sohn J, Sevinc A, Altundag K, Chang Y-C, Abdel-Razeq H, Im S-A, Jeong J, Park HY, Arpornwirat W, Bastick P, Le TH, Ocak Arikan O, Xue HL, Canatar A, Valenti R, Kim S-B. Clinical effectiveness of everolimus and exemestane in advanced breast cancer patients from Asia and Africa: First efficacy and updated safety results from the phase IIIb EVEREXES study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-09.

Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015

In this report, we describe 37 MERS-CoV infection cases (1 primary, 25 secondary, 11 tertiary cases) in a single hospital in South Korea. The median incubation period was six days (95% CI: 4–7 days) and the duration between suspected symptom onset and laboratory confirmation was 6.5 days (95% CI: 4–9). While incubation period was two days longer, the duration from suspected symptom onset to confirmation was shorter in tertiary compared with secondary infections.

Psychological effects of a cosmetic education programme in patients with breast cancer

Treatments for breast cancer often include interventions related to psychosocial issues such as negative body image, loss of femininity, and low self-esteem. We identified the psychological effects of a cosmetics education programme in patients with breast cancer. Cosmetic programme is a specific care designed to help patients handle appearance-related side effects. Thirty-one women with breast cancer at a university hospital in South Korea who received a cosmetics education programme were compared with 29 subjects in a control group who received the treatment as usual. Psychological factors including distress, self-esteem, and sexual functioning were assessed three times (before and after the programme, and at the 1-month follow-up). After the programme, patients in the treatment group were significantly less likely than those in the control group to rely on distress (P = 0.038) and avoidance coping (P < 0.001) but not on self-esteem. The mean scores in the treatment group for sexual functioning were higher than those in the control group after the treatment. Our results suggest the potential usefulness of a brief cosmetics education programme for reducing distress and reliance on negative coping strategies. Implementing a cosmetics programme for patients with breast cancer may encourage patients to control negative psychological factors.

Changes in serum immunomolecules during antibiotic therapy for Mycobacterium avium complex lung disease

Little information is available regarding changes in immune status for patients with Mycobacterium avium complex (MAC) lung disease during antibiotic therapy. Serum immunomolecules from 42 patients with MAC lung disease were assayed comparatively using an array-based system according to (i) patients with MAC lung disease at the time of diagnosis versus healthy controls and (ii) alterations after 12 months of antibiotic therapy in the MAC lung disease group. In addition, cytokine analyses were performed to determine whether cytokine responses were associated specifically with the disease phenotype, treatment outcome and aetiological agent. Notably, the serum concentrations of type 1 cytokine-associated molecules, such as CD40L, interferon (IFN)-γ, interleukin (IL)-8 and IL-23, were decreased significantly in patients at the time of diagnosis, suggesting that these molecules may serve as indicators of host susceptibility to MAC disease. Although the overall serum level of T helper type 1 (Th1)-related molecules, such as CD40L and IFN-γ, was restored after treatment, Th17-related cytokines, such as IL-17 and IL-23, were down-regulated significantly at 12 months post-treatment compared to pretreatment. Furthermore, these cytokine patterns differed among patient subgroups. Decreased serum concentrations of IL-17 and/or IL-23 were associated with failure of sputum conversion, the fibrocavitary disease phenotype and M. intracellulare lung disease. Thus, the reciprocal balance between Th1 and Th17 immunity during antibiotic therapy for MAC lung disease is critical for dictating the treatment response. In conclusion, a low level of Th1-related immunomolecules may perpetuate MAC lung disease, and the serum concentrations of Th17-related cytokines can reflect the treatment outcome, disease phenotype and aetiological agent.

Abstract P2-19-05: Oncoplastic breast conserving surgery with perforator flap in breast cancer patients

Purpose : Oncoplastic breast surgery has been used widely as a treatment protocol for breast cancer. Thoracodorsal artery perforator (TDAP) flap and intercostal artery perforator (ICAP) flap can provide adequate cover without sacrificing any muscle and allow closing of the donor sites in inconspicuous sites. Therefore, among the oncoplastic volume replacement techniques indicated using local flap that can adequately cover the volume of breast, TDAP and ICAP are especially suggested. This study describes the use of TDAP and ICAP flap techniques after breast conserving surgery. Methods : From March 2010 to August 2012, 38 patients with breast cancer received breast reconstruction. All patients who were selected had small- to moderate-sized defects on breasts, middle aged, and were not sensitive to scars. The TDAP flap is the first choice for performing the surgery, but if the perforator of the TDAP flap is not found, a dissection toward the anterior area to find an adequate perforator is made and the serratus anterior artery perforator is normally used. Otherwise after the dissection is performed more anterior, ICAP can be used. If the perforator penetrates the LD muscle, the TDAP flap can be used. The perforator that penetrates from the serratus anterior muscle is also used in the anterior area. Otherwise, ICAP can be used in partial breast reconstruction. The TDAP flap can be applied to any defect site regardless of the size of the defect area. Results : The mean age was 44.9 years and the average follow-up interval was 6 months. The average specimen weight was 98g. Complications developed in 4 cases including 3 cases of venous congestion, though self-limited, and 1 case of wound disruption on the inframammary fold suture area. Majority of the patients were satisfied with the cosmetic result.

Conclusion : Thoracodorsal artery perforator flap (TDAP) and intercostal artery perforator flap (ICAP) techniques can be reliable and useful in correcting breast deformity after breast conservation surgery, especially in patients with small- to moderate-sized defects on breasts.

Key Words : intercostal artery perforator flap, thoracodorsal artery perforator flap Oncoplastic surgery, ICAP, TDAP.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-19-05.

Abstract P6-05-24: Expression of aquaporin 5 and its polymorphisms predict survival in patients with early breast cancer

Background. Our previous study showed the association of AQP5 up-regulation with cancer proliferation and migration in hormone-responsive breast cancer cell lines (MCF-7) and with unfavorable prognosis in a small number of patients with breast cancer. Accordingly, we analyzed the prognostic impact of AQP5 expression and polymorphisms in a large number of patients with early breast cancer (EBC).

Methods. AQP5 expression was investigated based on the immunohistochemistry of tissue microarray specimens from 609 EBC patients who underwent surgery between 2003 and 2008. We scored the staining intensity (IS) and percentage of positive tumor cells (PC). The genomic DNA was extracted from paraffin-embedded tumor-free tissue and then genotyped for 3 polymorphisms (rs3736309, rs1964676, and rs74091167) using the Sequenom Mass array system.

Results. Among the 3 polymorphisms, AQP5 overexpression (IS + PC ≥6) was correlated with AQP5 rs74091167 GG genotype. AQP5 overexpression and AQP5 rs74091167 was significantly associated with disease-free survival (DFS; P &lt; 0.001 and P = 0.021, respectively). Moreover, a multivariate survival analysis revealed that AQP5 overexpression and the GG genotype of AQP5 rs74091167 were significantly associated with DFS (HR = 2.026, 95% CI 1.058-3.881, P = 0.030; HR = 0.377, 95% CI 0.179-0.793, P = 0.010, respectively) adjusted to clinicopathological variables, which was prominent in patients with an ER/PgR-positive tumor.

Conclusions. Consistent with our previous study of breast cancer cell lines, AQP5 expression and AQP5 rs74091167 variant can be considered as a prognostic marker in patients with EBC after curative surgery. In the future, functional relevance of this variant needs to be clarified.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-24.

Genotyping of Mycobacterium intracellulare isolates and clinical characteristics of lung disease

BACKGROUND

Variable number of tandem repeats (VNTR) loci were recently identified in Japanese isolates of Mycobacterium intracellulare. We hypothesised that some mycobacterial genotypes are more virulent than others, resulting in particular genotypes being associated with disease phenotype and progression.

OBJECTIVE

To evaluate the VNTR loci of M. intracellulare in clinical isolates from Korean patients, and investigate the association between mycobacterial genotype and disease phenotype and progression.

DESIGN

In total, 70 M. intracellulare clinical isolates were genotyped using 16 M. intracellulare VNTR loci.

RESULTS

VNTR typing showed strong discriminatory power and genetic diversity for molecular epidemiological studies of M. intracellulare. In a phylogenetic tree, the M. intracellulare clinical isolates were divided into two clusters (A and B). Cluster A was observed more frequently (77%) than Cluster B; however, there was no association between the clinical characteristics, disease progression, drug susceptibility and clusters based on VNTR genotyping.

CONCLUSIONS

VNTR typing could be used for epidemiological studies of M. intracellulare lung disease; however, no association was found between the specific VNTR genotypes of M. intracellulare and the clinical characteristics of Korean patients.

Clinical characteristics of patients with tuberculosis-destroyed lung

SETTING

Multicentre study.

OBJECTIVE

To define the clinical characteristics of patients with tuberculosis (TB) destroyed lung due to past TB.

DESIGN

We reviewed patients with TB-destroyed lung between May 2005 and June 2011.

RESULTS

A total of 595 patients from 21 hospitals were enrolled. The mean age was 65.63 ± 0.47 (mean ± standard error); 60.5% were male. The mean number of lobes involved was 2.59 ± 0.05. Pleural thickening was observed in 54.1% of the patients. Mean forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC, bronchodilator response and number of exacerbations per year were respectively 2.06 ± 0.03 l (61.26% ± 0.79), 1.16 ± 0.02 l (49.05% ± 0.84), 58.03% ± 0.70, 5.70% ± 0.34, and 0.40 ± 0.04. The number of lobes involved was significantly correlated with FVC and FEV(1), and with the number of exacerbations per year. Use of long-acting muscarinic antagonists or long-acting beta-2 agonists plus inhaled corticosteroids resulted in bronchodilatory effects. Multivariable regression analysis showed that age, initial FEV(1) (%) and number of exacerbations during follow-up were independent factors affecting change in FEV(1).

CONCLUSION

Decreased lung function with exacerbation, and progressive decline of FEV(1) were observed in patients with TB-destroyed lung.

Correction of Wassel type IV thumb duplication with zigzag deformity: results of a new method of flexor pollicis longus tendon relocation

The purpose of this study is to present a treatment algorithm and a method of flexor pollicis longus tendon relocation for Wassel type IV thumb duplication with zigzag deformity. Forty-two thumbs in 42 patients were included in this study and the mean follow-up was 4 years. In addition to excision of the extra digit, tendon relocation and metacarpal and/or proximal phalangeal osteotomy were carried out, based on the degree of angulation at the metacarpophalangeal and interphalangeal joints. Tendon relocation was achieved using our pull-out suture technique. The results were assessed using an evaluation form for thumb polydactyly provided by the Japanese Society for Surgery of the Hand. At the time of latest clinical contact, eight cases were rated good, 31 cases fair, and three cases poor. It is useful to decide surgical procedures according to the degree of angulation of the metacarpophalangeal and interphalangeal joints and flexor pollicis longus tendon relocation is important to prevent malalignment at the interphalangeal joint.

Abstract TP406: Impact Of Warfarin Pharmacogenomics In The Time In Therapeutic Range In Korean Patients With Atrial Fibrillation

Background: Warfain is highly effective for stroke prevention in patients with atrial fibrillation (AF), but also has narrow therapeutic window (usually INR 2-3). Even in clinical trials with selected, closely monitored patients, the times in therapeutic range (TTR) of those taking warfarin is less than two thirds. Single nucleotide polymorphisms in genes affecting warfarin metabolism (cytochrome-P450 2C9, CYP2C9) and response (vitamin-K epoxide reductase complex 1, VKORC1) have an important influence on warfarin therapy. Initial INR response to warfain was reportedly associated with genetic variability in VKORC1 than with CYP2C9. However, warfarin pharmacogenics associated with long-term intraindividual variation (TTR during the warfarin maintenance) is unsettled.

Methods: Clinical and genetic data form 330 Korean patients with AF (200 had AF-related stroke) were collected and followed for average 36 months. Patients were included who had AF, who were eligible to take warfarin , in whom genetic testing was available, and who were followed for more than 6 months. Thromboembolism and hemorrhagic complication was monitored with clinical and laboratory findings, including thromboemoblic [CHADS2 and CHA2DS2-Vasc] and hemorrhagic [ATRIA] risk schemes, as confounders.

Results: Genotypic frequencies of CYP2C9 *1/*1, *1/*3, and *3/*3 were 90%, 6.7%, 0.3%, respectively, whereas VKORC1 +1173 TT, CT, and CC were 84%, 15.2%, 0.6%, respectively. TTR varies greatly depending on the CYP2C9 polymorphism: TTR of INR 2-3 was 65±20% in *1/*1 carriers, 42±22% in *1/*3 carriers, and 1.4±2.2% in *3/*3 carriers. TTR of INR was not different depending on the VKORC1 polymorphism.

Conclusions: Novel oral anticoagulants have recently been introduced. However, there is a lack of consensus regarding the indication of these novel agents in patients with AF. Our results indicated that TTR during warfarin maintenance was associated with genetic variability in CYP2C9 than with VKORC1. Warfarin alternatives could be particularly helpful in patients who have specific CYP2C9 polymorphism other than *1/*1. Further studies are needed testing the impact of warfarin genetic polymorphism in other ethnic group (i.e. white) where these CYP2C9 polymorphisms were prevalent.

Abstract P1-01-24: Which combinations are helpful to predict axillary lymph node metastasis in T1 breast cancer with ultrasonography and contrast-enhanced MRI and contrast-enhanced 18F-FDG PET-CT?

Backgrounds: Axillary lymph node(ALN) status has been important factor of treatment and prognosis for patients with breast cancer. Even though the better ultrasonographic instruments have been developed, it is still difficult to predict axillary lymh node metastasis (ALNM) with only ultrasonography(US) in T1 breast cancers which most of newly diagnosed breast cancers are recently since T1 breast cancers have low rate and less tumor burden of ALNM. This study evaluated the accuracy of prediction of ALNM in T1 breast cancer with US, contrast-enhanced MRI (cMRI) and contrast-enhanced 18F-FDG PET/CT (cPET/CT) and found out adequate combinations of these modalities.

Method: Retrospectively, we reviewed 351 breast cancer patients with tumors(T1) ≤2cm in size between January 2008 and December 2011 who were preoperatively examined with US, cMRI, and cPET/CT and underwent pathologic evaluation of axillary lymph nodes acquired by sentinel lymph node biopsy or axillary dissection.

Clinicopathological correlation of cutaneous metastatic breast carcinoma using lymphatic and vascular markers: lymphatics are mainly involved in cutaneous metastasis

Precise clinicopathological correlations of the clinical features of metastatic breast carcinoma with lymphatic-specific markers are rare. We classified 28 patients with metastatic breast carcinoma according to their clinical features. Immunohistochemical staining was performed using D2-40, CD31 and CD34. Of the 28 patients, 8 (28.6%) had inflammatory metastatic carcinoma, 6 (21.4%) had the telangiectatic type, 5 had the nodular type, 3 had the en cuirasse type, 3 had alopecia neoplastica, and 3 had a combination of features. D2-40 staining revealed dilated lymphatic channels (lymphangiectasia) in the upper dermis of all patients; in addition, 13 patients (46.4%) had intralymphatic tumour-cell emboli, which were common in those with the inflammatory and telangiectatic types. Intratumoral lymphatic invasion in the main tumour nodule was seen in 12 patients (42.9%). Our results suggest that cutaneous metastatic breast carcinomas have various clinical presentations, and that lymphatic vessels play an important role in all types of cutaneous metastasis.

P2-16-15: Oncological Safety and Survival Rate According to Reconstructive Surgery in Advanced Breast Cancer after Neoadjuvant Chemotherapy

Purpose: Oncoplastic surgery has received attention according as the incidence of breast cancer is rising and quality of life including cosmetic result after surgery is regarded as important. The aim of this study is to compare combined reconstructive surgery with standard surgery regarding to oncological safety and survival rate in advanced breast cancer after neoadjuvant chemotherapy (CTx).

Method: Thirty-seven patients underwent neoadjuvant CTx and surgery with advanced breast cancer were analyzed from September 2007 to March 2010. Group A (n=12) received combined reconstructive surgery, group B (n=25) had standard surgery.

Results: There were no differences in age, size, metastatic LN, stage, ER/PR/Her-2 status, recurrence, metastasis and death between group A and B. Patients with good response in neoadjuvant chemotherapy (26 cases (72.9%)) had CTx-operation-radiation therapy (RTx), cases with poor response (10 cases (27.1%)) underwent CTx-RTx-operation. There was significant difference in order of treatment, eight patients among group A(66.6%) had CTx-RTx-operation, 22 cases in group B(88.0%) received CTx-operation-RTx (p=0.006). Mean follow up period was 22 months, 2 patients (5.2%) experienced local recurrences, 11 cases (34.3%) diagnosed with distant metastasis, and 4 patients (10.5%) expired with breast cancer.

Expression of amnionless in mouse testes and Leydig cells

Vitamin B(12) (cobalamin) deficiency results in atrophy of seminiferous tubules and aplasia of spermatozoa and spermatid. The transmembrane protein amnionless (AMN) directs endocytosis of cubilin with its ligand, contributing to intrinsic factor-vitamin B(12) absorption. To understand vitamin B(12) transport in testis, we analysed AMN expression in developing mouse testes and in Leydig cells and speculated the possible role of AMN in testis. In testes, Amn mRNA levels were low until 14 days post partum (pp) and markedly increased from puberty onwards. In the interstitium, Amn mRNA levels were low at 14 days pp and increased at puberty (28 days pp) together with 3-beta-hydroxysteroid dehydrogenase type 6 mRNA. Strong AMN immunoreactivity was observed in early spermatocytes from 7 days pp, suggesting that AMN participates in meiosis. In Leydig cells, AMN was not observed until 14 days pp but was strongly expressed after 28 days pp, suggesting a positive relationship between AMN expression and functional differentiation of adult Leydig cells. Together, AMN may participate in meiosis in early spermatocytes and in functional differentiation of adult Leydig cells through the mediation of vitamin B(12) transport in the mouse testes. This is the first report on AMN expression in the germ cells and soma of mammalian testes.