Mortality risk factors and fulminant sub-phenotype in anaerobic bacteremia: a 10-year retrospective, multicenter, observational cohort study

PURPOSE

During the last decade, the incidence of anaerobic bacteremia (AB) has been increasing. Patients with AB may develop complex underlying diseases, which can occasionally be accompanied by fatal or fulminant outcomes. However, the risk factors for AB-related mortality remain unclear. Herein, we sought to elucidate the risk factors for AB-related mortality.

METHODS

In this multicenter, retrospective, observational study, we enrolled patients with culture-proven AB from six tertiary hospitals in Japan, between January 2012 and December 2021. Data on patient and infection characteristics, laboratory findings, treatment, and outcome were collected, and their associations with mortality were analyzed.

RESULTS

A total of 520 participants were included. The 30-day mortality in the study cohort was 14.0% (73 patients), and malignant tumors were frequently observed comorbidities in 48% of the entire cohort. Multivariable logistic regression analysis showed a Charlson comorbidity score of > 6, serum creatinine level of > 1.17 mg/dL, and hypotension to be independent risk factors for 30-day mortality in AB (odds ratios [ORs] 2.12, 2.25, and 5.12, respectively; p < 0.05), whereas drainage significantly reduced this risk (OR, 0.28; p < 0.0001). Twelve patients (2.3% of the whole cohort and 16.4% of the deceased patients) presented with extremely rapid progression leading to fatal outcome, consistent with "fulminant AB."

CONCLUSIONS

This study identified acute circulatory dysfunction and performance of drainage as independent predictive factors for 30-day AB-related mortality and revealed the existence of a fulminant AB sub-phenotype. Our findings could serve as a practical guide to predict the clinical outcomes of AB.

Newborn screening for spinal muscular atrophy in Osaka -challenges in a Japanese pilot study

OBJECTIVE

This study aimed to establish an optional newborn screening program for spinal muscular atrophy (SMA-NBS) in Osaka.

METHODS

A multiplex TaqMan real-time quantitative polymerase chain reaction assay was used to screen for SMA. Dried blood spot samples obtained for the optional NBS program for severe combined immunodeficiency, which covers about 50% of the newborns in Osaka, were used. To obtain informed consent, participating obstetricians provided information about the optional NBS program to all parents by giving leaflets to prospective parents and uploading the information onto the internet. We prepared a workflow so that babies that were diagnosed with SMA through the NBS could be treated immediately.

RESULTS

From 1 February 2021 to 30 September 2021, 22,951 newborns were screened for SMA. All of them tested negative for survival motor neuron (SMN)1 deletion, and there were no false-positives. Based on these results, an SMA-NBS program was established in Osaka and included in the optional NBS programs run in Osaka from 1 October 2021. A positive baby was found by screening, diagnosed with SMA (the baby possessed 3 copies of the SMN2 gene and was pre-symptomatic), and treated immediately.

CONCLUSION

The workflow of the Osaka SMA-NBS program was confirmed to be useful for babies with SMA.

Association between cerebrospinal fluid parameters and developmental and neurological status in glucose transporter 1 deficiency syndrome

OBJECTIVE

In glucose transporter 1 deficiency syndrome (Glut1DS), cerebrospinal fluid glucose (CSFG) and CSFG to blood glucose ratio (CBGR) show significant differences among groups classified by phenotype or genotype. The purpose of this study was to investigate the association between these biochemical parameters and Glut1DS severity.

METHODS

The medical records of 45 patients who visited Osaka University Hospital between March 2004 and December 2021 were retrospectively examined. Neurological status was determined using the developmental quotient (DQ), assessed using the Kyoto Scale of Psychological Development 2001, and the Scale for the Assessment and Rating of Ataxia (SARA). CSF parameters included CSFG, CBGR, and CSF lactate (CSFL).

RESULTS

CSF was collected from 41 patients, and DQ and SARA were assessed in 24 and 27 patients, respectively. Simple regression analysis showed moderate associations between neurological status and biochemical parameters. CSFG resulted in a higher R² than CBGR in these analyses. CSF parameters acquired during the first year of life were not comparable to those acquired later. CSFL was measured in 16 patients (DQ and SARA in 11 and 14 patients, respectively). Although simple regression analysis also showed moderate associations between neurological status and CSFG and CSFL, the multiple regression analysis for DQ and SARA resulted in strong associations through the use of a combination of CSFG and CSFL as explanatory variables.

CONCLUSION

The severity of Glut1DS can be predicted from CSF parameters. Glucose and lactate are independent contributors to the developmental and neurological status in Glut1DS.

A Case of Paraneoplastic Neurological Syndrome Associated with Breast Cancer Detected while Searching for the Cause of Involuntary Movement

Our case involved a 66-year-old woman who noticed progressive asymmetric involuntary movement, difficulty speaking, and difficulty swallowing. The patient fractured her femur due to a lower extremity involuntary movement while walking. During the course of her treatment for the fracture, her neurological symptoms worsened. Approximately 2 months after becoming aware of her symptoms, she visited our clinic for evaluation of difficulty with unassisted walking and weight loss due to dysphagia. To identify the cause of her neurological symptoms, hematological examination, brain magnetic resonance imaging, single-photon emission computed tomography for cerebral blood flow, electroencephalography, and a somatosensory evoked potential test were conducted. Although the cause of her neurological symptoms could not be determined, computed tomography revealed the presence of breast cancer, which led us to suspect paraneoplastic neurological syndrome (PNS). After breast cancer treatment, her neurological symptoms improved simultaneously. Therefore, the patient was retrospectively diagnosed with PNS. We report a case of PNS whose neurological symptoms followed a subacute course and were relieved after breast cancer treatment.

POS1429 ORAL DYSBIOSIS REFLECTS THE IMMUNOLOGICAL ALTERATION OF RA REGARDING TO HLA DRB1*SE, ACPA AND CIGARETTE SMOKING: NAGASAKI ISLAND STUDY

Background:

Anti-citrullinated protein antibody (ACPA) production is observed in several organs even prior to the onset of rheumatoid arthritis (RA), and oral mucosa is considered to be one of the important tissues. Saliva is considered to reflect the oral microbiota(oralMB) including periodontal disease. A gene-environment interaction between cigarette smoking and shared epitope genes in HLA-DRB1*shared epitope (SE) provides a high risk of ACPA-positive RA. However, the interaction of HLA-DRB1*SE, ACPA, cigarette smoking and oralMB of RA patients remains to be elucidated.

Objectives:

We investigated that the difference of oralMB among RA patients and healthy subjects(HS) regarding to ACPA, HLA-DRB1*SE and cigarette smoking.

Methods:

The Nagasaki Island Study, which had started in 2014 collaborating with Goto City, Nagasaki Prefecture, Japan, is intended for research of the preclinical stage of RA, including ACPA, HLA genotype screening, oralMB and lifestyle habit. Both of blood and salivary samples were obtained from 1422 subjects out of 4276 participants in this study from 2016 to 2018. ACPA positivity was 1.7 % in total 4276 subjects. At this point, we selected 291 subjects, who were ACPA positive non-RA HS(n=22) and patients with RA (n=33, 11 subjects were ACPA positive and 22 ACPA negative, respectively) as the case, age and gender matched ACPA negative non-RA HS (n=236) as the control. In RA subjects, current smoker was n=1(3.0%) and ever smoker was n=8(24.2%). In HS, current smoker was n=29(11.2%) and ever smoker was n=55(21.3%). ACPA was measured by ELISA, and HLA genotyping was quantified by next-generation sequencing (Ref.1). The operational taxonomic unit (OTU) analysis using 16S rRNA gene sequencing were performed. The richness of microbial diversity within subject (α-diversity) was scaled via Shannon entropy. The dissimilarity between microbial community composition was calculated using Bray-Curtis distance as a scale, and differences between groups (β-diversity) were tested by permutational multivariate analysis of variance (PERMANOVA). In addition, UniFrac distance calculated in consideration of the distance on the phylogenetic tree were performed.

Results:

Median age 71 y.o., % Female 58.4 %. Among RA and non-RA subjects, not α-diversity but β-diversity was statistically smaller significantly in RA (p=0.022). In the HS, there was no decrease in α-diversity between the ACPA-positive and HLA-DRB1*SE-positive groups, but in the ACPA-positive group, there was a decrease in α-diversity in the HLA-DRB1*SE-positive group. When we compared α-diversity stratified by the presence or absence of three factors (RA, ACPA, and HLA-DRB1*SE), the RA group with ACPA and HLA-DRB1*SE positive tended to have the lowest diversity (Figure 1 lower right). RA subjects, presence of HLA-DRB1*SE did not show the difference but the tendency of lower α-diversity (p=0.29).

Conclusion:

HS with ACPA-positive HLA-DRB1*SE tended to show lower α-diversity than ACPA-positive HS and HLA-DRB1*SE positive HS. Furthermore, RA subjects with ACPA-positive HLA-DRB1*SE showed lower α-diversity than HS with ACPA-positive HLA-DRB1*SE.

Our study suggested that the oral dysbiosis may reflect the immunological status of patients with RA. Because of the small number of ACPA-positive patients, stratification by smoking history was difficult. Further examination is needed to clarify the gene-environment interaction and microbiome.

References:

[1]Kawaguchi S, et al. Methods Mol Biol 2018;1802: 22.

Disclosure of Interests:

None declared

PIK3CA mutation detected by liquid biopsy in patients with metastatic breast cancer

BACKGROUND

PIK3CA is associated with tumor progression, and the prevalence of its mutation is high in breast cancer. Liquid biopsy offers convenient, non-invasive, and real-time insight into genetic alternation. In this study, we attempted to detect PIK3CA mutations in breast cancer patients through liquid biopsy.

METHODS

We recruited patients with histologically confirmed breast cancer with distant metastases between April 2020 and September 2020. Circulating DNA was extracted from plasma (ctDNA) and exosomes (exoDNA). PIK3CA mutations (exons 9 and 20) were analyzed by droplet digital PCR.

RESULTS

Of a total of 52 patients recruited, 16 had PIK3CA mutations in their tumor tissue or blood, which comprised 9 with exon 9 mutations (E542K and E545K) and 8 with exon 20 mutations (H1047L and H1047R). In 8 (15%) of the 52 patients, PIK3CA mutations were detected by liquid biopsies using ctDNA in 5 (9%), exoDNA in 6 (11%), and both ctDNA and exoDNA in 3 (6%). Of the 8 patients with PIK3CA mutations detected by liquid biopsies, 3 had no PIK3CA mutations in the primary tumors.

CONCLUSIONS

PIK3CA mutations can be detected using liquid biopsy even in patients with no PIK3CA mutations in their primary tumors; thus, combination analysis using tissue and liquid biopsies can provide clinically useful information for patients with breast cancer.

Neoadjuvant endocrine therapy in women with operable breast cancer: A retrospective analysis of real-world use

BACKGROUND

A retrospective study of the real-world use of neoadjuvant endocrine therapy (NET) is important for standardizing its role in breast cancer care.

MATERIALS AND METHODS

In a consecutive series of women with operable breast cancer who received NET for ≥28 days, NET objectives, NET outcomes, adjuvant chemotherapy use after NET, and survivals, were examined for the correlation with clinicopathological factors.

RESULTS

NET objectives were for surgery extent reduction in 49 patients, surgery avoidance in 31, and treatment until scheduled surgery in 8. The mean duration of NET was 349.5 (range, 34-1923), 869.8 (range, 36-4859), and 55.8 (range, 39-113) days in the above cohorts (success: 79.6%, 64.5%, and 100%), respectively, with significant difference. In patients of the former two cohorts, better progression-free survival was significantly correlated with stage 0 or I, ductal carcinoma in situ or invasive ductal carcinoma, ≥71% estrogen receptor (ER) positivity, and the surgery extent reduction cohort than the other counterparts. Postoperative chemotherapy use was significantly correlated with lymph node metastasis, a high Ki67 labeling index, lymphovascular invasion, and a high Preoperative Endocrine Prognostic Index, at surgery after NET. Better recurrence-free survival after surgery was significantly correlated with high ER expression after NET and high PgR expression before and after NET.

CONCLUSIONS

NET can help to reduce the surgery extent or to avoid surgery in women with breast cancer of early-stage, ductal carcinoma, or high ER expression. NET may also contribute to appropriate decision of postoperative systemic therapy to improve survivals.

Epilepsy in patients with advanced Fukuyama congenital muscular dystrophy

BACKGROUND

Recent advances in respiratory management have improved survival for patients with Fukuyama congenital muscular dystrophy (FCMD), characterized by congenital muscular dystrophy and brain malformation. Previous studies reported that more than half of patients exhibit seizures in childhood. However, little is known about epilepsy after childhood.

METHODS

To elucidate the long-term clinical course of epilepsy, we retrospectively reviewed all medical records in nine patients (6 males, mean age 20.7 years) with FCMD diagnosed between 1981 and 2019.

RESULTS

The follow-up periods ranged from 6 to 30 years (mean 18.4 years). A total of 75 EEG recordings were available from nine patients. In some patients, EEGs were normal during early childhood but tended to show paroxysmal discharges with age. Overall, epileptic seizures were observed in six patients. Except for one presenting with afebrile seizure at one year of age, the remaining five patients developed epilepsy between 13 and 22 years of age. The most common seizure type was focal impaired awareness seizure. After adolescence, four patients exhibited status epilepticus. Their convulsive movements of the seizures became less prominent with progression of the disease. At the last evaluation, most patients (5/6) had uncontrolled seizures.

CONCLUSIONS

Despite presence of distinct brain malformation, epileptic seizures may develop after childhood in FCMD patients. Our experience suggests that clinicians should be careful not to overlook epileptic seizures, especially in advanced-stage patients who had profound muscle weakness.

AB1232 ORAL DYSBIOSIS REFLECTS THE IMMUNOLOGICAL ALTERATION OF RA REGARDING TO ACPA AND HLA DRB1*SE: NAGASAKI ISLAND STUDY

Background:

Anti-citrullinated protein antibody (ACPA) production is observed in several organs even prior to the onset of rheumatoid arthritis (RA), and oral mucosa is considered to be one of the important tissues. The presence of HLA-DRB1*SE closely associates with ACPA production. Saliva is considered to reflect the oral microbiota including periodontal disease. Alteration of oral microbiota of RA becomes to be normalized by DMARDs treatment, however, the interaction of HLA-DRB1*SE, ACPA and oral microbiota of RA patients remains to be elucidated.

Objectives:

The Nagasaki Island Study, which had started in 2014 collaborating with Goto City, is intended for research of the preclinical stage of RA, including ACPA/HLA genotype screening and ultrasound and magnetic resonance imaging examinations in high-risk subjects. Using the samples accumulated in this cohort, we have tried to investigate the difference of oral microbiota among RA patients and healthy subjects regarding to ACPA and HLA-DRB1*SE.

Methods:

Blood and salivary samples were obtained from 1422 subjects out of 4276 who have participated in the Nagasaki Island Study from 2016 to 2018. ACPA positivity was 1.7 % in total. Some of RA patients resided in Goto City participated in the Nagasaki Island Study. At this point, we selected 291 subjects, who were ACPA positive non-RA healthy subjects (n=22) and patients with RA (n=33, 11 subjects were ACPA positive and 22 ACPA negative respectively) as the case, age and gender matched ACPA negative non-RA healthy subjects (n=236) as the control. ACPA was measured by an enzyme-linked immunosorbent assay, and HLA genotyping was quantified by next-generation sequencing (Ref.1). The operational taxonomic unit (OUT) analysis using 16S rRNA gene sequencing were performed. The richness of microbial diversity within-subject (alpha diversity) was scaled via Shannon entropy. The dissimilarity between microbial community composition was calculated using Bray-Curtis distance as a scale, and differences between groups (beta diversity) were tested by permutational multivariate analysis of variance (PERMANOVA). In addition, UniFrac distance calculated in consideration of the distance on the phylogenetic tree were performed.

Results:

Median age 70 y.o., % Female 58.8 %. Among RA and non-RA subjects, not alpha diversity but beta diversity was statistically significance (p=0.022, small in RA). In RA subjects, both alpha and beta diversity is small (p<0.0001), especially significant in ACPA positive RA (Figure 1). Amongt RA subjects, presence of HLA-DRB1*SE did not show the difference but the tendency of being small of alpha diversity (p=0.29).

Conclusion:

Our study has suggested for the first time the association of oral microbiota alteration with the presence of ACPA and HLA-DRB1*SE. Oral dysbiosis may reflect the immunological status of patients with RA.

References:

[1]Kawaguchi S, et al. Methods Mol Biol 2018;1802: 22

Disclosure of Interests:

None declared

Abstract P2-15-08: Efficacy and possible predictive factors of eribulin in a real-world population of HER-2 negative metastatic breast cancer patients in Japan

Background Eribulin mesylate, a non-taxane microtubule inhibitor, has unique characteristics that modify the tumor microenvironment by reversing epithelial-mesenchymal transition (EMT) to mesenchymal-epithelial transition (MET). These effects might benefit the efficacy of chemotherapies, particularly those administered after eribulin. In fact, the EMBRACE study demonstrated that eribulin did not prolong progression-free survival (PFS) but rather overall survival (OS) when compared to the treatment of physician’s choice (TPC). However, the effects of eribulin on post-eribulin chemotherapy regimens remain unclear. Thus, this retrospective study aimed to assess PFS, OS, and post progression survival (PPS) of women with HER-2 negative metastatic breast cancer (MBC) as real-world data. In addition, clinical and pathological factors were analyzed as predictive factors for the survival measurements. Furthermore, the effect of eribulin on post-eribulin chemotherapies was also evaluated by assessing PFS of post-eribulin chemotherapy compared with PFS of eribulin and PFS of pre-eribulin chemotherapy.

Methods A total of 75 women with HER-2 negative MBC who were treated with eribulin between January 2011 and June 2019 were included in this study. PFS, OS, and PPS were calculated according to the Kaplan-Meier method for each patient. The clinical and pathological factors analyzed in this study were hormone receptors, age, number of prior regimens, metastatic site, number of metastatic sites, and hematologic parameters such as neutrophil (NEU) counts, lymphocyte (LYM) counts, and neutrophil to lymphocyte ratio (NLR). A cox model was used to correlate these factors with survivals. In this study, PFS of the post-eribulin chemotherapy cohort divided by PFS of the eribulin-receiving cohort or PFS of the pre-eribulin chemotherapy cohort was analyzed as a unique parameter of the PFS ratio (PFSr, the former was PFSr A and the latter was PFSr B). A PFS ratio of 1.0 or higher may be the significantly favorable effect of eribulin on post-eribulin chemotherapy. Of a total of 75 patients, 46 and 36 were analyzed for assessing PFSr A and B, respectively, since patients who were not eligible for the calculation of PFSr were excluded. Single and multiple regression analyses were used to evaluate the associated factors with PFSr B.

Results The median PFS, OS, and PPS were 3.5 months (95%CI 2.5-4.4), 13.1 (95% CI 9.4-16.7), and 13.1(95%CI 9.4-22.9), respectively. In univariate analysis, an age of 65 or older (p=0.001) and lower NLR (p=0.003) were associated with longer PFS. In multivariate analyses, an age of 65 or older (p=0.041) and lower NLR (p=0.008) were associated with superior PFS. NEU counts lower than 4500 (p=0.0028) and lower NLR (p=0.003) were correlated with longer OS in both univariate and multivariable analyses. There were no correlating factors with PPS. The median PFSr A and B were 0.86 and 0.65, respectively, and the percentages of PFSr A and B were 43% and 33%, respectively. Single and multiple regression analysis each showed that none of the factors are correlated with PFSr B.

Conclusion The median PFS and OS in our study were comparable to those reported in the EMBRACE study which were 3.7 and 13.1 months, respectively. Age and NLR were associated with PFS and NEU count and NLR was associated with OS. The correlation of NEU count and NLR with PFS and OS suggests that the effects of eribulin might be diminished by a high inflammatory state but enhanced by higher oncologic immune status. In terms of eribulin’s effect on post-eribulin chemotherapy, no conclusive data were obtained in this study, and a larger number of patients should be analyzed.

Citation Format: Sera Satoi, Hiroyuki Takei, Keiko Yanagihara, Tomoko Kurita, Maki Nakai, Meishi Hankyo, Rina Kanamaru, Ai Sato. Efficacy and possible predictive factors of eribulin in a real-world population of HER-2 negative metastatic breast cancer patients in Japan [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-15-08.

Abstract P1-20-17: Magnetic guided localization for non-palpable breast lesion: A multi-center open-label trial in Japan

Background: Non-palpable breast lesions represent about 25-35% of all breast cancers diagnosed in developed countries, according to findings based on the evolution of imaging modalities such as MRI, and the uses reliable biopsy techniques such as ultrasound-guided or stereo-guided vacuum assisted biopsy. Wire -guided localization (WGL), radio-guided localization (RGL), and SAVI SCOUT localization (SSL) have been presented as a surgical procedure for non-palpable breast lesion. The reported disadvantages of WGL are related to mechanical stimulation of wire plucking, kinking, and patient discomfort. RGL has issues regarding radioactive licensing, handling, and waste management, and the SSL system requires high start-up costs. To eliminate these problems, we verified the magnetically guided localization (MGL) method for breast lesion localization by means of the combinations of the magnetic probe TAKUMI (ISO13485, Matrix cell Research Institute Inc., Tokyo, Japan) and the guiding-marker system® (Hakko, Tokyo, JAPAN). The TAKUMI is a novel handheld magnetic probe with a permanent magnet and a Hall magnetic sensor for detecting magnetic substances. It was newly developed at the University of Tokyo under a grant from the Japan Agency for Medical Research and Development (AMED). The aim of this study was to evaluate the feasibility and safety of our MGL system. Method: Patients were enrolled in this multi-center, open-label trial from January 2019 to March 2019 at two University Hospitals. The inclusion criteria were age 20 or older female patients who had non-palpable breast lesions, for which breast-conserving surgery or tumor resection was performed. Patients who had a metal allergy, pregnancy, or inflammatory breast cancer were excluded. The guiding-marker system® consists of a stainless-steel hook (φ 0.28 × 10 mm) connected with a nylon thread and an a 21-gauge 10 cm long steel needle.The marker was inserted into the center of the target lesions using ultrasound guidance or stereo guidance within 4 days before surgery. The TAKUMI was used to determine whether the guiding marker was detectable or not before, during, and after the surgical resection of the specimen. The resection rate of the guiding marker, surgical margin status, and re-operation rates were evaluated as the primary outcomes, and the volume and weight of the excised specimen were evaluated as secondary outcomes. The study protocol of the evaluation of magnetic probe system for detecting of non-palpable lesions of the breast was approved by the Institutional Review Board of Nippon Medical School Foundation (CRB3180001) and was registered at https://jrct.niph.go.jp/re (protocol record jRCTs032180422). Written informed consent was obtained from all participants. Results: Forty-one patients were recruited into this study. Thirty-eight patients (92.6%) underwent breast-conserving surgery for breast cancer treatment, and 3 (7.3%) underwent tumor resection for biopsy purposes. All guiding markers were resected during the initial surgical operation. Three out of 38 breast cancer patients (7.9%) were diagnosed as margin positive in frozen section analysis; 2 (5.2%) underwent additional resection during the initial surgery due to the positive margin, and 1 (2.6%) underwent subsequent surgery due to the positive margin on final pathology. Eight patients (21%) underwent boost radiation therapy due to the close margin (&lt;5mm). The median excised specimen weight was 28 g. The range was wide (2-131 g) and depended on the expanse of the lesion. No complications or adverse events were recorded in relation to either the marker placement or the surgery. Conclusion: These data clearly show that MGL is a reliable, accurate, and convenient localization system for non-palpable breast lesions. It is able to eliminate the disadvantages of WGL, RGL, and SSL.

Citation Format: Tomoko Kurita, Kanae Taruno, Seigo Nakamura, Hiroyuki Takei, Katsutoshi Enokido, Takashi Kuwayama, Yoko Kanada, Sadako Akashi, Maki Nakai, Meishi Hankyo, Keiko Yanagihara, Takashi Sakatani, Kentaro Sakamaki, Akihiko Kuwahata, Masaki Sekino, Moriaki Kusakabe. Magnetic guided localization for non-palpable breast lesion: A multi-center open-label trial in Japan [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-17.

De novo mutations of the ATP6V1A gene cause developmental encephalopathy with epilepsy

V-type proton (H⁺) ATPase (v-ATPase) is a multi-subunit proton pump that regulates pH homeostasis in all eukaryotic cells; in neurons, v-ATPase plays additional and unique roles in synapse function. Through whole exome sequencing, we identified de novo heterozygous mutations (p.Pro27Arg, p.Asp100Tyr, p.Asp349Asn, p.Asp371Gly) in ATP6V1A, encoding the A subunit of v-ATPase, in four patients with developmental encephalopathy with epilepsy. Early manifestations, observed in all patients, were developmental delay and febrile seizures, evolving to encephalopathy with profound delay, hypotonic/dyskinetic quadriparesis and intractable multiple seizure types in two patients (p.Pro27Arg, p.Asp100Tyr), and to moderate delay with milder epilepsy in the other two (p.Asp349Asn, p.Asp371Gly). Modelling performed on the available prokaryotic and eukaryotic structures of v-ATPase predicted p.Pro27Arg to perturb subunit interaction, p.Asp100Tyr to cause steric hindrance and destabilize protein folding, p.Asp349Asn to affect the catalytic function and p.Asp371Gly to impair the rotation process, necessary for proton transport. We addressed the impact of p.Asp349Asn and p.Asp100Tyr mutations on ATP6V1A expression and function by analysing ATP6V1A-overexpressing HEK293T cells and patients’ lymphoblasts. The p.Asp100Tyr mutant was characterized by reduced expression due to increased degradation. Conversely, no decrease in expression and clearance was observed for p.Asp349Asn. In HEK293T cells overexpressing either pathogenic or control variants, p.Asp349Asn significantly increased LysoTracker® fluorescence with no effects on EEA1 and LAMP1 expression. Conversely, p.Asp100Tyr decreased both LysoTracker® fluorescence and LAMP1 levels, leaving EEA1 expression unaffected. Both mutations decreased v-ATPase recruitment to autophagosomes, with no major impact on autophagy. Experiments performed on patients’ lymphoblasts using the LysoSensor™ probe revealed lower pH of endocytic organelles for p.Asp349Asn and a reduced expression of LAMP1 with no effect on the pH for p.Asp100Tyr. These data demonstrate gain of function for p.Asp349Asn characterized by an increased proton pumping in intracellular organelles, and loss of function for p.Asp100Tyr with decreased expression of ATP6V1A and reduced levels of lysosomal markers. We expressed p.Asp349Asn and p.Asp100Tyr in rat hippocampal neurons and confirmed significant and opposite effects in lysosomal labelling. However, both mutations caused a similar defect in neurite elongation accompanied by loss of excitatory inputs, revealing that altered lysosomal homeostasis markedly affects neurite development and synaptic connectivity. This study provides evidence that de novo heterozygous ATP6V1A mutations cause a developmental encephalopathy with a pathomechanism that involves perturbations of lysosomal homeostasis and neuronal connectivity, uncovering a novel role for v-ATPase in neuronal development.

Abstract P5-21-07: Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer

Background: Pertuzumab provided overall and progression-free survival (PFS) benefits in HER2-positive metastatic breast cancer patients (pts) in the CLEOPATRA (Clinical evaluation of docetaxel, pertuzumab and trastuzumab) study. However, few studies have described the efficacy of other drugs in combination with pertuzumab plus trastuzumab. Here, we present a pre-specified analysis of eribulin in combination with pertuzumab plus trastuzumab as first- and second-line therapy for advanced or metastatic breast cancer (AMBC) in a multicenter, open-label phase II study (UMIN000012232, JBCRG-M03).

Methods: HER2-positive AMBC with no or single prior chemotherapy for AMBC were enrolled. All pts were administered trastuzumab and taxane as adjuvant or first-line chemotherapy. Treatment consisted of eribulin 1.4 mg/m2 on days 1 and 8 of a 21-day cycle and trastuzumab (8 mg/kg loading dose, then 6 mg/kg) plus pertuzumab (840 mg/body loading dose, then 420 mg/ body) once every 3 weeks, all administered intravenously. The primary endpoint was PFS, and secondary endpoints included overall response rate (ORR) and safety. PFS was determined using Kaplan–Meier analysis. Tumor response was assessed according to RECIST ver. 1.1.

Results: Fifty pts were enrolled from November 2013 to April 2016. Forty-nine pts were eligible for safety analysis and the full analysis set (FAS) included 46 pts. The median age was 56 years (23–70), and 8 (16%) and 41 (84%) pts were treated in first- and second-line settings, respectively. Eleven pts (23.9%) were de-novo Stage 4, and 35 pts (76.1%) had progressed in metastatic disease after completion of local therapy. Median PFS was 9.3 months (M) (95% confidence interval [CI]: 6.4–12.3). Table 1 shows the efficacy data for each treatment line and includes ORR, complete response rate (CR), partial response rate (PR), stable disease rate (SD), progressive disease rate (PD), not evaluable rate (NE) and PFS in the FAS. The median relative dose intensities of eribulin, trastuzumab, and pertuzumab were 93.3% (77.0%–100%), 100% (96.0%–100%), and 100% (89.7%–100%), respectively, in the FAS. The grade 3/4 adverse events (AE) were neutropenia in 5 pts (10.2%), including 2 pts (4.1%) with febrile neutropenia; hypertension in 3 pts (6.1%), and other AEs in only one patient. The average of the ejection fraction did not decrease significantly. Symptomatic left ventricular systolic dysfunction was not observed.

Conclusion: In pts with HER2-positive AMBC, first- and second-line therapy of eribulin in combination with pertuzumab plus trastuzumab demonstrated substantial antitumor activity with an acceptable safety profile. We are planning a phase III study comparing eribulin with taxanes in combination with pertuzumab plus trastuzumab for the treatment of HER2-positive AMBC.

Efficacy data for each treatment lineTreatment LineTotal (n=46)First line (n=8)Second line (n=38)PFS (95% CI), months9.3 (6.4-12.3)20.8 (2.8-38.7)8.7 (7.2-10.2)ORR (%)28 (60.9)7 (87.5)21 (55.3)CR (%)8 (17.4)3 (37.5)5 (13.2)PR (%)20 (43.5)4 (50.0)16 (42.1)SD (%)11 (23.9)1 (12.5)10 (26.3)PD (%)5 (10.9)05 (13.2)NE (%)2 (4.3)02 (5.3)

Citation Format: Kawaguchi H, Yamashita T, Masuda N, Kitada M, Narui K, Hattori M, Yoshinami T, Matsunami N, Yanagihara K, Kawasoe T, Nagashima T, Bando H, Yano H, Hasegawa Y, Nakamura R, Kashiwaba M, Morita S, Ohno S, Toi M. Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-07.

Prognostic significance of mucin expression profiles in breast carcinoma with signet ring cells: a clinicopathological study

Background

Signet ring cells (SRCs) often accompany gastrointestinal carcinoma, referred to as SRC carcinoma; however, breast cancers containing SRCs have not been well characterized, leaving the prognostic significance of SRCs undetermined. We have described clinicopathological characteristics of patients with breast cancer containing SRCs in relation to the expression levels of MUC1, MUC2, MUC4, MUC5AC, and MUC6.

Methods

Twenty-two breast cancer cases with variable degrees of SRC population were retrospectively studied. Each case was categorized as high (>31 %) or low (<30 %) SRC tumor. The SRCs were morphologically classified into the intra-cytoplasmic lumen (ICL) type, or the non-ICL type. The expression levels of MUC1, MUC2, MUC4, MUC5AC and MUC6 were determined immunohistochemically. Depending on its subcellular localization, MUC1 was categorized as the luminal and cytoplasmic (LC) type, or the cytoplasmic with circumferential membranous accentuation (CM) type. These histological findings were compared with other clinicopathological parameters.

Results

The series consisted of invasive ductal carcinoma (n = 9), invasive lobular carcinoma (n = 9), and mucinous carcinoma (n = 4) cases. The SRC population accounted for 8–81 % of the tumor cells. Eight cases had ICL type SRCs, and the remaining 14 had non-ICL type SRCs. Neither the high (n = 12) and low (n = 10) percentage of SRCs, nor the SRC types affected the clinicopathological parameters. In the low MUC1 group (n = 11), larger tumors, higher nuclear grade, lymph node metastasis, and negativity for estrogen receptor was more frequently identified compared to the high MUC1 group (n = 11; p = 0.01, p = 0.002, p = 0.008, and p = 0.02, respectively). The CM group (n = 7) had more patients with large-sized tumors, lymph node metastasis, lymphovascular invasion, and higher Ki67 indices than the LC group (n = 15; p = 0.04, p = 0.001, p = 0.006, and p = 0.03, respectively). The expression levels of MUC2, MUC4, MUC5AC, and MUC6 showed no clinicopathological significance. Two patients with low MUC1 expression and CM patterns had tumor recurrence, resulting in death, while all the other patients survived without recurrence.

Conclusion

Our results demonstrate that in breast cancers containing SRCs, low MUC1 expression and/or its CM subcellular localization patterns are associated with unfavorable clinicopathological factors. The utility of MUC1 expression as a prognostic marker remains to be verified in future studies.

Pleomorphic lobular carcinoma of the breast: a comparison of cytopathological features with other lobular carcinoma variants

OBJECTIVE

Pleomorphic lobular carcinoma (PLC) is a subtype of breast cancer with unique morphological features, but it remains controversial whether PLC should be considered an independent disease entity. The aim of this study was to illustrate cytopathological characteristics of PLC in comparison with other lobular carcinoma variants.

METHODS

We investigated clinicopathological features of PLC (n = 11) compared with those of other variants of invasive lobular carcinoma (ILC, non-PLC) (n = 32). Histological variants of the non-PLC group consisted of classic (n = 25), solid (n = 2), alveolar (n = 1) and a tubulolobular type (n = 4). A review of cytological reports and fine needle aspiration (FNA) smear samples was performed for the PLC (n = 9) and non-PLC (n = 27) groups.

RESULTS

Patients with PLC were older, and had a higher nuclear grade and a higher incidence of axillary lymph node metastasis and triple negative phenotype than non-PLC patients (P = 0.007, P < 0.001, P = 0.02 and P < 0.001, respectively). Cytological findings in PLC included medium- to large-sized nuclei, prominent nucleoli, a moderate-to-severe degree of pleomorphism, apocrine change and background necrosis, none of which were evident in the smears of the non-PLC group (P < 0.001, P = 0.002, P < 0.001, P < 0.001, and P = 0.03, respectively). Despite these differences, patients with PLC and non-PLC showed similar clinical outcomes in our follow-up period.

CONCLUSIONS

Based on our results, a cytological diagnosis of PLC should be proposed if there are moderate- to large-sized nuclei, prominent nucleoli, a moderate-to severe degree of nuclear pleomorphism, apocrine change and necrosis in the background in FNA biopsy samples.

Outcome of ketogenic diets in GLUT1 deficiency syndrome in Japan: A nationwide survey

OBJECTIVES

To evaluate the outcome of ketogenic diets (KDs) in patients with glucose transport type 1 deficiency syndrome (GLUT1DS) in Japan.

METHODS

A nationwide survey for GLUT1DS was conducted by sending questionnaires to board-certified pediatric neurologists nationwide to obtain clinical and laboratory data.

RESULTS

Among 39 patients whose diagnosis was confirmed molecularly or by the 3-O-methylglucose uptake assay, 31 were treated with KDs for longer than 1month. Seventeen patients (55%) were on the modified Atkins diet, 11 (35%) were on the classic KD, and 3 were on the medium-chain triglyceride (MCT) diet. The median values and ranges of serum β-hydroxybutyrate levels in patients on the modified Atkins diet, classic KD and MCT diet were 2.5mM (0.75-4.1), 1.7mM (0.23-3.5) and 2.6mM (1.5-3.0), respectively. The KDs were effective on seizures (80%), aggravation after fasting (80%) and ataxia (79%). Thus, ataxia was as responsive as seizures. Two patients on the classic KD with a ketogenic ratio as low as 1:1 showed improvement in neurological symptoms. The development or intelligence quotient measured using the same psychological scales before and after the KDs in 9 patients did not show a significant improvement; the median quotients before and after the diets were 40 (12-91) and 46 (12-67).

CONCLUSION

The KDs were most effective on seizures, transient aggravation after fasting and ataxia. The efficacy on intellectual development was equivocal. The modified Atkins diet was more commonly used for GLUT1DS in this study, and its ketogenicity was equivalent to the classic KD.

Combining Fulvestrant with Low-Dose Capecitabine is Effective and Tolerable in Woman with Metastatic Breast Cancer

Although the use of endocrine therapy in combination with intravenous chemotherapy has not been standardized, the combination of fulvestrant and chemotherapy may be promising. A 62-year-old woman came to our hospital's outpatient clinic with extensive ascites. Approximately 10 years earlier, she had undergone mastectomy and sentinel lymph node biopsy. Pathologically invasive lobular carcinoma, with a maximum diameter of 28 mm, had been diagnosed in the left breast. The cancer had a histological grade of 2, was positive for estrogen receptor (95% or more positive cells), and was negative for both progesterone receptor (less than 1% positive cells) and human epidermal growth factor receptor 2. For 5 years the patient underwent adjuvant endocrine therapy with tamoxifen and then with anastrozole. Four years 2 months after adjuvant endocrine therapy had been completed, she felt abdominal distention, and her symptoms gradually worsened. A series of intensive examinations indicated that the invasive lobular carcinoma had metastasized to the peritoneum, pleura, uterus, and bone. Aromatase inhibitor was administered as a first-line therapy for the metastatic disease and was accompanied by denosumab injected every 28 days. For 2 months after the start of treatment with anastrozole, the ascites did not decrease and tumor markers increased. Because anastrozole had not been effective, fulvestrant (500 mg) and low-dose capecitabine (500 mg) were administered for the first 21 days of a 28-day cycle; this regimen had been shown by a phase 2 trial to be effective and tolerable in patients with metastatic breast cancer. The patient felt an improvement in abdominal distention, and the tumor markers decreased 2 weeks after the start of this combination therapy. By 10 months after the start of the combined therapy the ascites had decreased and pleural effusion had completely disappeared. The uterine wall became thinner, and the endometrial cavity became smaller. Tumor markers continued decreasing. No adverse events were observed. The combination of fulvestrant and low-dose capecitabine is promising because of its efficacy and tolerability for the treatment of patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer.

Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis and Guillain-Barre Syndrome in a 16-Month-Old Child

A 16-month-old girl was diagnosed with Epstein-Barr virus hemophagocytic lymphohistiocytosis and transferred to our hospital on the 58th day of the hemophagocytic lymphohistiocytosis after treatment failure according to the Hemophagocytic Lymphohistiocytosis-2004 protocol. On admission to our hospital, she had a flaccid paralysis of her lower limbs. Nerve conduction studies showed a acute motor axonal neuropathy, and a diagnosis of Guillain-Barre syndrome was established. Intravenous immunoglobulin G was started on the 57th day of the Guillain-Barre syndrome. To date, her neurological recovery is incomplete. For hemophagocytic lymphohistiocytosis, after treatment failure of THP-COP regimen (pirarubicin, cyclophosphamide, vincristine, and prednisone) and 2 courses of ESCAP regimen (etoposide, prednisone, cytarabine, L-asparaginase), we are now in the process of coordinating unrelated umbilical cord blood transplantation. To the best of our knowledge, we report the youngest case of Guillain-Barre syndrome accompanied by Epstein-Barr virus hemophagocytic lymphohistiocytosis. Rapid progression of Guillain-Barre syndrome, the electrophysiological subtype of Guillain-Barre syndrome, and treatment delay possibly led to poor neurological outcome.

Mucinous carcinoma of the breast: a comparative study on cytohistological findings associated with neuroendocrine differentiation

OBJECTIVE

Mucinous carcinoma (MCA) may show neuroendocrine differentiation (ND), but the cytological features characteristic of ND remains elusive. We compared fine needle aspiration (FNA) findings of MCA between cases with high and low degrees of ND.

METHODS

Histological sections of 37 MCA cases were immunohistochemically evaluated for expression of chromogranin A and synaptophysin, and were graded as 0 to 3+ degrees of ND. They were divided into low ND (grade 0 and 1+) and high ND (grade 2+ and 3+) groups. Pre-operative FNA samples of each group were assessed for cytological features.

RESULTS

The mean age of the high ND group (n = 18) was higher than the low ND group (n = 19, P = 0.01). In FNA samples of the high ND group, 17 cases showed moderate to severe degrees of discohesiveness, but low ND cases mainly showed no or only mild discohesiveness (P < 0.001). Nine of the low ND cases displayed overlapped, cohesive cell clusters, whereas, in the high ND cases, the cells were arranged in a loose, flat and monolayered pattern (P = 0.045). Fourteen of the high ND cases had round nuclei, but oval nuclei were predominant in the low ND cases (P = 0.027). The nuclei were eccentrically located in 12 of the high ND cases but were centrally located in 14 of the low ND cases (P = 0.01).

CONCLUSIONS

Mucinous carcinoma with high ND may be diagnosed by the presence of discohesiveness, a flat, monolayered pattern, and round or eccentrically located nuclei. Features of ND in carcinomas in other organs, such as intracytoplasmic granules and coarse chromatin, may not be reliable cytological features of ND in MCA.

Grade 4 epistaxis in a woman with metastatic breast cancer treated with bevacizumab: a case report

We describe a 39-year-old woman with metastatic breast cancer who had grade 4 epistaxis induced by bevacizumab. The patient visited our outpatient clinic with complaints of a lump in her right breast, fatigue, dyspnea, abdominal distention, appetite loss, and weight loss of 10 kg over 1 year. Liver dysfunction was detected, with elevated levels of aspartate aminotransferase (271 IU/L), alanine aminotransferase (100 IU/L), alkaline phosphatase (4,205 IU/L), total bilirubin (2.7 mg/dL), and direct bilirubin (2.1 mg/dL). A secondary liver tumor that occupied most of the liver volume was found, and bone metastasis, ascites, and pleural effusion were also discovered. The Eastern Cooperative Oncology Group performance status was 2. A core needle biopsy of the right breast tumor revealed invasive ductal carcinoma of the breast (nuclear grade 1) that was positive for estrogen receptor and progesterone receptor and negative for human epidermal growth factor receptor 2 overexpression and had a high Ki-67 score. We chose combination chemotherapy with paclitaxel (80 mg/m(2) on days 1, 8, and 15) and bevacizumab (10 mg/kg on days 1 and 15) for 28 days (1 cycle). After completion of the first cycle of chemotherapy, the ascites and pleural effusion decreased, and the metastatic liver tumor shrank. The performance status improved from 2 to 1. On day 3 of the third cycle of chemotherapy, however, she began having persistent epistaxis. On day 6, she lost consciousness and was transported to the emergency room of our hospital. The hemoglobin level was 5.6 g/dL. Blood transfusion and endoscopic hemostasis were immediately started. Bevacizumab was discontinued, and paclitaxel alone was continued; after this change, epistaxis did not recur.

Cytological features of complex type fibroadenoma in comparison with non-complex type fibroadenoma

BACKGROUND

To determine the cytomorphological features of complex type fibroadenoma (CFA), we reviewed fine needle aspiration (FNA) cytology with correlation to its histopathology findings, and compared them with non-complex type fibroadenoma (NCFA).

METHODS

From excisional biopsy or resected specimens of fibroadenoma (FA) cases treated at our institution from 2004 to 2013, we chose 46 patients who underwent FNA before a diagnosis of FA was established. We histologically re-classified them into two groups: CFA and NCFA. FNA diagnosis was retrospectively re-evaluated from FNA reports. We further re-assessed detailed characteristics of each FNA smears to identify cytomorphological features of CFA.

RESULTS

We found that 15 cases fulfilled the diagnostic criteria of CFA, in which 7 (46.7 %) had an FNA diagnosis of "suspicious for malignancy" or "indeterminate" while only 2 NCFA cases had that of "indeterminate" (p = 0.004). FNA smears from CFA cases showed discohesiveness, enlarged nuclei, prominent nucleoli, and fewer myoepithelial cells more often than NCFA. Although no significant difference was noted in patients' age and tumor size between CFA and NCFA, 5 CFA cases (33.3 %) were accompanied by the presence of carcinoma in the same breast or the contralateral breast while no NCFA cases had carcinoma in the breast.

CONCLUSIONS

FNA of CFA can lead to erroneous or indeterminate interpretation, due to proliferative and/or hyperplastic changes of ductal epithelium with or without atypia. It is important to recognize the disease entity and characteristic cytomorphological findings of CFA to reach accurate FNA diagnosis of breast lesions.

Ictal 99mTc-Ethyl Cysteinate Dimer SPECT Findings of a Girl With Refractory Localization-Related Epilepsy Who Developed Transient Ictal Bradycardia

Ictal bradycardia, which is considered to be one of the causes of sudden unexplained death in epilepsy, is rare. A 10-year-old girl with focal cortical dysplasia in her right centroparietal region developed transient ictal bradycardia during cluster seizures. Brain magnetic resonance imaging demonstrated a high signal intensity lesion adjacent to the focal cortical dysplasia lesion. Ictal ^99mTc-ethyl cysteinate dimer single-photon emission computed tomography (SPECT) detected hyperperfusion in an area containing the high signal intensity lesion, which was located close to the insular cortex. Since the hyperperfusion zone observed on SPECT was considered to reflect seizure propagation, it is possible that the ictal bradycardia experienced in the present case was caused by the following mechanism: The repetitive seizure activity caused the high-intensity lesion seen on MRI to expand into the right insular cortex, which controls cardiac rhythm, resulting in ictal bradycardia.

Benign neonatal sleep myoclonus: our experience of 15 Japanese cases

PURPOSE

Benign neonatal sleep myoclonus is a non-epileptic movement disorder that may mimic neonatal seizures. The aim of this study was to clarify the clinical manifestations and outcomes in Japanese infants with benign neonatal sleep myoclonus.

METHODS

We reviewed the clinical manifestations and outcomes in 15 consecutive patients with benign neonatal sleep myoclonus (males: 10), including three paired familial cases, referred to our center between 1996 and 2011. The diagnosis of benign neonatal sleep myoclonus was based on a neonatal onset, characteristic myoclonic jerks that occurred during sleep, and normal electroencephalogram findings.

RESULTS

All were healthy full-term neonates at birth. The age at onset ranged from 1 to 18 days (median: 7 days). Prior to referral to our center (3-8 weeks), two infants had been placed on antiepileptic drugs, without effects. During the clinical course, the myoclonic jerks resolved by 6 months in 14 of the 15 patients. On follow-up (final evaluation, mean: 38 months), all but one patient (speech delay) showed normal development. None developed epilepsy. Of note, migraine occurred after 5 years of age in three children, including one who developed cyclic vomiting syndrome, evolving to migraine. Another boy developed cyclic vomiting syndrome, a precursor of migraine, before 1 year, and was being followed. A high incidence of migraine was observed in five (42%) of 12 parents whose detailed family history was available.

CONCLUSION

Our study suggests that benign neonatal sleep myoclonus is related to migraine. With the high rate of familial cases, further genetic study, including migraine-related gene analysis, is necessary to determine the underlying mechanism responsible for benign neonatal sleep myoclonus.

[Evaluation of six cases with hypothalamic hamartoma: the relationship between MRI findings and clinical features]

OBJECTIVE

We evaluated the relationship between MRI findings and clinical features in patients with hypothalamic hamartoma (HH).

METHODS

We retrospectively reviewed MRI and clinical data (mental retardation, precocious puberty, behavioral problems, and epilepsy) in six patients (3 males and 3 females, ages 12 to 26) with HH. Based on the MRI classification by Arita, HH was classified into two types: parahypothalamic (P) and intrahypothalamic (I).

RESULTS

Only one patient was classified as having P-type HH and five were classified as having I-type HH. The patient with P-type HH (diameter 21 mm) showed precocious puberty and mild behavioral problems, but did not developed epilepsy. On the other hand, all patients with I-type HH (diameter 10-32 mm, median 17 mm) developed epilepsy and behavioral problems. Except for one patient, who had the smallest sized HH, I-type four patients developed mental retardation and precocious puberty. Among patients with I-type HH, the size of the tumor was inversely correlated with the age at epilepsy onset and with the degree of mental retardation (DQ/IQ).

CONCLUSION

Our data suggested that the MRI classification by Arita, when combined with tumor size, might be helpful in predicting the clinical manifestations in patients with HH.

Tks5 activation in mesothelial cells creates invasion front of peritoneal carcinomatosis

Scirrhous gastric cancer is frequently associated with peritoneal dissemination, and the interaction of cancer cells with peritoneal mesothelial cells (PMCs) is crucial for the establishment of the metastasis in the peritoneum. Although cells derived from PMCs are detected within tumors of peritoneal carcinomatosis, how PMCs are incorporated into tumor architecture is not understood. The present study shows that PMCs create the invasion front of peritoneal carcinomatosis, which depends on activation of Tks5 in PMCs. In peritoneal tumor implants, PMCs represent majority of cells located at the invasive edge of the cancer tissue. Exogenously implanted PMCs and host PMCs aggressively invade into abdominal wall upon the peritoneal inoculation of cancer cells, and PMCs locate ahead of cancer cells in the direction of invasion. Tks5, a substrate of Src kinase, is predominantly expressed in the PMCs of cancer tissue, and promotes the invasion of PMCs and cancer cells. Expression and activation of Tks5 was induced in PMCs following their exposure to gastric cancer cells, and increased Tks5 expression was detected in PMCs located at the invasion front. Reduced Tks5 expression in PMCs blocked PMC invasion, which in turn prevents cancer cell invasion both in vitro and in vivo. The peritoneal dissemination of gastric cancer was significantly increased by mixing cancer cells and PMCs, and was suppressed by knockdown of Tks5 in PMCs. These results suggest that cancer-activated PMCs create invasion front by guiding cancer cells. Signaling leading to Tks5 activation in PMCs may be a suitable therapeutic target for prevention of peritoneal carcinomatosis.

Contralateral breast cancer adjacent to a fibroadenoma: report of a case

A 64-year-old woman noticed a lump of the right breast and consulted our outpatient clinic. She had undergone multiple excisional biopsies of fibroadenomas in both breasts and mastectomy for invasive ductal carcinoma (IDC) of the left breast. After completing 5 years of treatment with adjuvant tamoxifen, she had undergone screening with annual physical examinations and occasional computed tomography. She was declared recurrence-free 13 years after breast cancer surgery, although lumps were detected in the right breast, probably due to fibroadenomas. Mammography, ultrasonography, and magnetic resonance imaging revealed that the lump was irregularly shaped, 2 cm in diameter, and adjacent to a fibroadenoma with macrocalcification. Two axillary lymph nodes were enlarged and suggestive of metastasis. A core needle biopsy revealed IDC of the right breast. She underwent a right partial mastectomy with axillary lymph node dissection. The IDC was 2 cm in diameter, of nuclear grade 2, and adjacent to a 0.7-cm fibroadenoma with a macrocalcification. The margins of the IDC close to the fibroadenoma were clearly demarcated by the fibrous capsule of the fibroadenoma. Four axillary lymph nodes were positive for metastasis. In the present case the presence of fibroadenoma might have interfered with the early detection of the contralateral IDC. The history of multiple excisions of fibroadenomas and mastectomy for breast cancer suggests an increased risk of contralateral breast cancer for the patient's entire life; therefore, regular annual follow-up, such as physical examinations and mammography, is recommended.

[Successful treatment with intravenous steroid pulse therapy of a boy with recurrent idiopathic sixth nerve palsy]

A 3-year-old boy developed left-sided convergent strabismus one week after upper respiratory infection. All examinations, including analysis of cerebrospinal fluid, a tensilon test, and brain MRI, were negative. He was diagnosed with idiopathic sixth nerve palsy. His symptom resolved gradually with vitamin B12, and remitted completely three months after onset. At the age of 6 years, he experienced recurrence of left-sided sixth nerve palsy. After vitamin B12 failed, his symptom responded markedly to intravenous steroid pulse therapy starting on day 26 after relapse. He has been symptom-free for three years since the second remission. Steroid therapy might be effective, and should be considered in children with idiopathic sixth nerve palsy who do not show spontaneous remission.

Expression of myeloperoxidase in acute myeloid leukemia blasts mirrors the distinct DNA methylation pattern involving the downregulation of DNA methyltransferase DNMT3B

Myeloperoxidase (MPO) has been associated with both a myeloid lineage commitment and favorable prognosis in patients with acute myeloid leukemia (AML). DNA methyltransferase inhibitors (decitabine and zeburaline) induced MPO gene promoter demethylation and MPO gene transcription in AML cells with low MPO activity. Therefore, MPO gene transcription was directly and indirectly regulated by DNA methylation. A DNA methylation microarray subsequently revealed a distinct methylation pattern in 33 genes, including DNA methyltransferase 3 beta (DNMT3B), in CD34-positive cells obtained from AML patients with a high percentage of MPO-positive blasts. Based on the inverse relationship between the methylation status of DNMT3B and MPO, we found an inverse relationship between DNMT3B and MPO transcription levels in CD34-positive AML cells (P=0.0283). In addition, a distinct methylation pattern was observed in five genes related to myeloid differentiation or therapeutic sensitivity in CD34-positive cells from AML patients with a high percentage of MPO-positive blasts. Taken together, the results of the present study indicate that MPO may serve as an informative marker for identifying a distinct and crucial DNA methylation profile in CD34-positive AML cells.

In vitro and in vivo activities of piperacillin-tazobactam and meropenem at different inoculum sizes of ESBL-producing Klebsiella pneumoniae

The inoculum effect is a laboratory phenomenon in which the minimal inhibitory concentration (MIC) of an antibiotic is increased when a large number of organisms are exposed. Due to the emergence of extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-Kpn) infections, the inoculum effect of ESBL-Kpn on β-lactams was studied in vitro and in vivo using an experimental model of pneumonia. The in vitro inoculum effect of 45 clinical ESBL-Kpn isolates on β-lactams was evaluated at standard (10(5) CFU/mL) and high (10(7) CFU/mL) organism concentrations. The MIC50 of piperacillin-tazobactam, cefotaxime and cefepime was increased eight-fold or more and that of meropenem was increased two-fold. The in vivo inoculum effect was evaluated in an ESBL-Kpn pneumonia mouse model treated with bacteriostatic effect-adjusted doses of piperacillin-tazobactam (1000 mg/kg four times daily, %T>MIC; 32.60%) or meropenem (100 mg/kg twice daily, %T>MIC; 28.65%) at low/standard (10(4) CFU/mouse) and high (10(6) CFU/mouse) inocula. In mice administered a low inoculum, no mice died after treatment with piperacillin-tazobactam or meropenem, whereas all the control mice died. In contrast, in the high inoculum model, all mice in the piperacillin-tazobactam-treated group died, whereas all meropenem-treated mice survived and had a decreased bacterial load in the lungs and no invasion into the blood. In conclusion, meropenem was more resistant to the inoculum effect of ESBL-Kpn than piperacillin-tazobactam both in vitro and in vivo. In the management of severe pneumonia caused by ESBL-Kpn, carbapenems may be the drugs of choice to achieve a successful outcome.

Integrated genomic and functional analyses reveal glyoxalase I as a novel metabolic oncogene in human gastric cancer

Chromosomal abnormalities are good guideposts when hunting for cancer-related genes. We analyzed copy number alterations of 163 primary gastric cancers using array-based comparative genomic hybridization and simultaneously performed a genome-wide integrated analysis of copy number and gene expression using microarray data for 58 tumors. We showed that chromosome 6p21 amplification frequently occurred secondary to ERBB2 amplification, was associated with poorer prognosis and caused overexpression of half of the genes mapped. A comprehensive small interfering RNA knockdown of 58 genes overexpressed in tumors identified 32 genes that reduced gastric cancer cell growth. Enforced expression of 16 of these genes promoted cell growth in vitro, and six genes showing more than two-fold activity conferred tumor-forming ability in vivo. Among these six candidates, GLO1, encoding a detoxifying enzyme glyoxalase I (GLO1), exhibited the strongest tumor-forming activity. Coexpression of other genes with GLO1 enhanced growth-stimulating activity. A GLO1 inhibitor, S-p-bromobenzyl glutathione cyclopentyl diester, inhibited the growth of two-thirds of 24 gastric cancer cell lines examined. The efficacy was found to be associated with the mRNA expression ratio of GLO1 to GLO2, encoding glyoxalase II (GLO2), another constituent of the glyoxalase system. GLO1 downregulation affected cell growth through inactivating central carbon metabolism and reduced the transcriptional activities of nuclear factor kappa B and activator protein-1. Our study demonstrates that GLO1 is a novel metabolic oncogene of the 6p21 amplicon, which promotes tumor growth and aberrant transcriptional signals via regulating cellular metabolic activities for energy production and could be a potential therapeutic target in gastric cancer.

Detection of breast cancer with a computer-aided detection applied to full-field digital mammography

A study was conducted to evaluate the sensitivity of computer-aided detection (CAD) with full-field digital mammography in detection of breast cancer, based on mammographic appearance and histopathology. Retrospectively, CAD sensitivity was assessed in total group of 152 cases for subgroups based on breast density, mammographic presentation, lesion size, and results of histopathological examination. The overall sensitivity of CAD was 91 % (139 of 152 cases). CAD detected 100 % (47/47) of cancers manifested as microcalcifications; 98 % (62/63) of those manifested as non-calcified masses; 100 % (15/15) of those manifested as mixed masses and microcalcifications; 75 % (12/16) of those manifested as architectural distortions, and 69 % (18/26) of those manifested as focal asymmetry. CAD sensitivity was 83 % (10/12) for cancers measuring 1-10 mm, 92 % (37/40) for those measuring 11-20 mm, and 92 % (92/100) for those measuring >20 mm. There was no significant difference in CAD detection efficiency between cancers in dense breasts (88 %; 69/78) and those in non-dense breasts (95 %; 70/74). CAD showed a high sensitivity of 91 % (139/152) for the mammographic appearance of cancer and 100 % sensitivity for identifying cancers manifested as microcalcifications. Sensitivity was not influenced by breast density or lesion size. CAD should be effective for helping radiologists detect breast cancer at an earlier stage.

The babkin reflex in infants: clinical significance and neural mechanism

BACKGROUND

There have been very few studies concerning the Babkin reflex-opening of the mouth and flexion of the arms in response to stimulation of the palms. We attempted to clarify the clinical significance and neural mechanism of the reflex through systematic review.

METHODS

Searches were conducted on Medline, Embase, and Google Scholar from their inception through August 2012.

RESULTS

In normal term infants, the Babkin reflex can be elicited from the time of birth, becomes increasingly suppressed with age, and disappears in the great majority by the end of the fifth month of age. A marked response in the fourth or fifth month of age and persistence of the reflex beyond the fifth month of age are generally regarded as abnormal. On the other hand, because there are some normal infants showing no response during the neonatal period or early infancy, the absence of the response during these periods is not necessarily an abnormal finding.

CONCLUSIONS

Infants with these abnormal findings should be carefully observed for the appearance of neurological abnormalities including cerebral palsy and mental retardation. It is most likely that the Babkin reflex is mediated by the reticular formation of the brainstem, which receives inputs from the nonprimary motor cortices. On the basis of the hand-mouth reflex, more adaptive movement develops as control of the nonprimary motor cortices over the reflex mechanism in the reticular formation increases. Soon it evolves into the voluntary eye-hand-mouth coordination necessary for food intake as the control of the prefrontal cortex over the nonprimary motor cortices becomes predominant.

Genetic status of p53 and induction of apoptosis by radiation or isoflavones in human gastric carcinoma cell lines

We have shown previously that various human cancer cell lines undergo morphological changes and internucleosomal DNA fragmentation characteristic of apoptosis after exposure to ionizing radiation or isoflavones. Here, we assessed the role of p53 gene in cell cycle and apoptosis following treatment of 11 gastric carcinoma cell lines with gamma-rays, genistein, biochanin A, or daidzein. Cell survival was measured by trypan blue staining, and apoptosis was assessed by fluorochrome staining. The rate of cell survival and apoptosis of the cells by gamma-irradiation or isoflavones did not correlate with p53 gene abnormalities. Flow cytometric measurement of DNA content demonstrated that while gamma-irradiation and genistein induced G(2) arrest, biochanin A and daidzein blocked the cell cycle of all carcinoma cells at G(1) phase. At multiple time points following irradiation, G(2) arrest was observed at 12-16 h in the wild-type and mutant p53 cell lines. Induction of p53 and p21 proteins was not observed in wild-type p53 lines after exposure to gamma-irradiation or isoflavones by Western blotting. Moreover, transfection of the wild-type p53 gene into MKN-1 cells failed to induce G(1) arrest by gamma-irradiation and genistein. Based on these results, we hypothesize that gastric cancer cells may possess a signal pathway which is different from the usual mechanisms of the p53-mediated DNA damage response in normal or hematopoietic tumor cells.