Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Pre-transplant phase angle as a potential marker for predicting the development of infection after allogeneic hematopoietic stem cell transplantation

BACKGROUND & AIMS

Nutritional assessment in allogeneic hematopoietic stem cell transplantation (allo-HSCT) is important and decreased skeletal muscle mass is a risk factor for the development of infection. Recently, it has become clear that qualitative rather than skeletal muscle mass loss is a marker that reflects post-transplant outcome, but its association with the development of infection remains unclear. Therefore, we assessed skeletal muscle status by body composition using bioelectrical impedance analysis (BIA) and investigated its association with the development of infection.

METHODS

A retrospective cohort study was conducted to assess the quantity as well as quality of skeletal muscle using the body composition of BIA assessment. The quantitative (appendicular skeletal muscle mass index; ASM) and qualitative (phase angle; PhA) indicators of skeletal muscle calculated from body composition analysis were used to determine factors influencing the development of infection after allo-HSCT.

RESULTS

In total, 80 adult patients, aged 20-70 years (median, 52) were included in this study. The ASM was mildly decreased after allo-HSCT and PhA was significantly decreased. Furthermore, low pre-transplant PhA was identified as an independent risk factor for the development of infection early after transplantation, with a cutoff value of 4.9°.

CONCLUSION

In particular, pre-transplant PhA may predict the development of infection early after allo-HSCT, and muscle indices that can be assessed with pre-transplant body composition are a useful evaluation method that can discriminate post-transplant outcomes.

Minimal important difference of the 6-minute walk test after allogenic hematopoietic stem cell transplantation

PURPOSE

The 6-min walk test (6MWT) of allogenic hematopoietic stem cell transplantation (allo-HSCT) recipients has been gaining attention; however, minimal differences have not been reported. This study aimed to determine the minimal important difference (MID) in the 6MWT among hospitalized patients with allo-HSCT.

MATERIALS AND METHODS

The MID of the 6MWT was calculated using three different methodologies based on an anchor-based method; basic anchor-based methods, linear regression analysis, and receiver operating characteristic (ROC) curve analysis. The decrease in the score of Question 2 of the European Organization for Research and Treatment of Cancer Quality of life questionnaire core-30 was included as an anchor question for calculating the MID. Both actual and percentage changes in 6MWT values from baseline and at discharge were used in the MID calculations. In the actual and percentage change of the 6MWT, the one with the larger the area under the curve in the ROC curve was recommended as the MID.

RESULTS

Among the three methods using actual values, the largest MID of the 6MWT was -37.5 m (sensitivity: 54%, specificity: 88%).

CONCLUSION

More careful follow-up after discharge is necessary for allo-HSCT patients who show a reduction of 37.5 m or more in the acute illness phase.

Clinical significance of the expression of FOXP3 and TIGIT in Merkel cell carcinoma

The pathogenesis of 80% of Merkel cell carcinoma (MCC) cases is associated with Merkel cell polyomavirus (MCPyV). Forkhead helix transcription factor P3 (FOXP3) and the T cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibition motif domains (TIGIT)-CD155 pathway, which are targets for immunotherapy, were assessed as prognostic factors of MCC. We analyzed mRNA expression data of 111 patients with MCC and performed immunohistochemical analysis to detect the expression of programmed death ligand 1 (PD-L1), CD8, FOXP3, TIGIT, and CD155 in 65 cases of MCC. In CD8 and FOXP3 immunostaining, the number of expressing-infiltrating cells was determined by dividing the region into tumor center and invasive front areas. FOXP3 expression was evaluated separately in cells with high and low intensities. Aberrant TIGIT expression and weak CD155 staining were observed in MCC cells. CD8- and FOXP3-positive cell infiltrations were higher in the invasive front than in the tumor center. Multivariate Cox hazard analysis revealed that high infiltration of cells with low-intensity FOXP3 expression in the invasive front is a favorable prognostic factor (p = 0.025). Thus, targeting TIGIT-CD155 signaling and FOXP3 as well as PD-L1 may be a therapeutic strategy for MCC.

Imaging of Liver Tissues Using a Combination of Silver Impregnation and Low-Vacuum Scanning Electron Microscopy; A Simple Method for the High-Resolution Visualization of Reticulin Structures with Applicability to a Quantitative Analysis

Background

Low-vacuum scanning electron microscopy (LVSEM) enables the detailed three-dimensional imaging of archival tissues without special pretreatments. The clinical utility of LVSEM in the assessment of liver diseases has not yet been defined. So, we investigated the utility of LVSEM imaging in morphological assessments of normal and diseased liver tissues, with a focus on reticulin structures.

Methods

Formalin-fixed tissue samples of two normal livers and two hepatocellular carcinomas with background regenerative nodules/areas were stained with platinum blue stain or silver-impregnated using Watanabe's method and then comparatively observed under LVSEM. We also evaluated the applicability of LVSEM imaging of liver tissues to a quantitative analysis using a digital image analysis technique.

Results

Optimal high-resolution images of reticulin structures were obtained using 10-μm-thick silver-impregnated sections. Reticulin fibers were clearly observed to run dendritically around sinusoids in normal livers, and markedly increased in regenerative nodules/areas. Normal reticulin frameworks were lost in hepatocellular carcinoma, leaving a few fragments of reticulin fibers within tumors. Moreover, when a quantitative analysis was applied to these images, we successfully demonstrated a significantly higher reticulin fiber density in regenerative nodules/areas than in the normal liver (P < 0.05).

Conclusion

We not only obtained detailed three-dimensional images of reticulin structures in various liver tissues by LVSEM combined with silver impregnation but also showed their applicability to a quantitative analysis. The method presented herein may be applied to future studies for the more accurate diagnosis and better classification/risk stratification of various liver diseases.

Development of a Prognostic Scoring System using MYC Expression and Soluble Interleukin Receptor -2 level for Diffuse Large B-cell Lymphoma

Background

Diffuse large B-cell lymphoma, not otherwise specified (DLBCL-NOS), is the most frequent type of lymphoid neoplasm.

Methods

We investigated the relationships between clinical factors of DLBCL-NOS and MYC immunohistochemistry (IHC) staining.

Results

A total of 110 patients diagnosed with DLBCL-NOS from 2012 to 2020 at Tottori University Hospital and treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) chemotherapy were included. IHC staining of MYC in formalin-fixed, paraffin-embedded tumor specimens was performed, and ROC-curve analysis revealed the cut-off value of the MYC positive rate as 55%. The 2-year overall survival (OS) rates of the MYC-negative and -positive groups were 84.7% vs 57.7% (P = 0.0091), and the progression-free survival rates were 77.8% vs 54.7% (P = 0.016), respectively. Multivariate analysis for OS showed prognostic significance of MYC positivity [hazards ratio (HR): 2.496; P = 0.032], and serum levels of soluble interleukin-2 receptor (sIL-2R) > 2000 U/mL (HR: 3.950; P = 0.0019), as well as age > 75 (HR: 2.356; P = 0.068). The original scoring system was developed based on these findings. By assigning one point to each item, age (> 75), MYC positivity, and sIL-2R level (> 2000), all patients were classified into three risk categories: group 1 (0 points), group 2 (1 point), and group 3 (2-3 points). The 2-year survival rates were 100%, 83.0%, and 47.1% for the groups 1, 2, and 3, respectively (P < 0.0001).

Conclusion

We suggest that a prognostic scoring system using MYC expression and soluble interleukin receptor -2 level is useful for the prediction of prognosis, contributing to further stratification in DLBCL-NOS.

Belt Electrode-Skeletal Muscle Electrical Stimulation During Early Hematopoietic Post-Transplantation To Prevent Skeletal Muscle Atrophy and Weakness

A decline in physical functions at the early stage of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a serious issue. Belt electrode-skeletal muscle electrical stimulation (B-SES) can induce significant muscle contractions with electrical stimulation and reduce muscle weakness. However, this approach has not been used in allo-HSCT patients. This study aimed to examine the effect of B-SES on physical function, and safety in patients during the early post-transplantation period. Forty-three adult patients who underwent B-SES after allo-HSCT were stratified into 2 groups based on the intensity of electrical stimulation (high versus low). B-SES was performed in combination with exercise therapy for 4 post-transplantation weeks. Knee extensor strength (KES) in the low B-SES group decreased significantly, whereas no change was observed in the high-intervention group. A significant positive correlation was observed between total intensity and ΔKES. A reduction in the 6-minute walking distance in the high B-SES group patients was lower than that of historical data. Two patients had B-SES-related complications including muscle pain. This study is the first to propose a new rehabilitation intervention strategy for allo-HSCT. Combined use of B-SES may be a new approach to reducing the decline of physical function in the early post-transplantation period.

Evaluation of plasma nucleosome concentrations in dogs with a variety of common cancers and in healthy dogs

Background

Cell free DNA, in the form of nucleosomes, is released into circulation during apoptosis and necrosis in a variety of diseases. They are small fragments of chromosomes that are composed of DNA wrapped around a histone core made of four duplicate histone proteins forming an octamer. The nucleosome compartment is a relatively uninvestigated area of circulating tumor biomarkers in dogs. The objectives of this study were to quantify and better characterize nucleosome concentrations in 528 dogs with various common malignancies and compare them to 134 healthy dogs.

Results

The sensitivity of increased circulating nucleosome concentrations for the detection of cancer in all dogs was 49.8% with a specificity of 97% with an area under the curve of 68.74%. The top 4 malignancies detected by the test included lymphoma, hemangiosarcoma, histiocytic sarcoma and malignant melanoma. The malignancies least likely to be detected were soft tissue sarcomas, osteosarcoma and mast cell tumors.

Conclusions

A variety of tumor types may cause increased nucleosome concentrations in dogs. Tumors of hematopoietic origin are most likely to cause elevations and local tumors such as soft tissue sarcomas are least likely to cause elevations in plasma nucleosome concentrations.

POS0734 THE CLINICAL JUDGMENT FOR THE ACCEPTABILITY OF PREGNANCY IN PATIENTS WITH SEROLOGICALLY ACTIVE SLE IN JAPAN: A NATIONWIDE ONLINE SURVEY FROM THE VIGNETTE STUDY

Background

The risk of pregnancy complications, such as gestational hypertension is high in pregnancies with SLE. In addition, the risk of flare is elevated if pregnancy occurs during the high disease activity. The EULAR recommendation provides a checklist for preconception counseling, in which patients with SLE desiring pregnancy were required the condition that the disease activity prior to pregnancy should be stable for 6-12 months in terms of serological activity (1). However, it does not provide specific criteria for serological activity so that physicians should evaluate the risk of pregnancy in each case by their clinical intuitions.

Objectives

In order to uncover the present clinical situation for the acceptability of pregnancy in patients with SLE, we performed questionnaire survey to physicians regarding to the degree of serological activity.

Methods

This cross-sectional study was performed to physicians registered with the Japanese College of Rheumatology from December 2020 to January 2021 using the online survey. The questionnaire asked about the characteristics of physicians, facilities and the permission of pregnancies with SLE using vignette scenarios. In this study, data from vignettes of women visiting a regular outpatient clinic were used. The vignettes varied in age (28 or 35 years), duration of stable disease and serological activity. Analysis methods were descriptive statistics, chi-square test. generalized estimating equations (GEE) was performed to investigate the relationship between the determining permission for pregnancy and the scenario patient’s characteristics (age, period of stable disease, titer of anti ds-DNA antibody)

Results

The questionnaire was distributed to 4946 physicians, and 463 responded. Completion rate (ratio agreed to participate/finished survey) of survey was 91.1%. The median age of physicians was 46 (interquartile range (IQR) 2-10). The specialty was rheumatology (84.9%), other internal medicine (8%), and pediatrics (5.6%). There were no significant differences in patient’s age about the acceptability of pregnancy (coeffficianet -0.02, 95% CI -0.17 -0.01, p=0.42). Case who had been stable for 6 months were more tolerant of pregnancy than case who had been stable for 3 months (coeffficianet 0.12, 95% CI 0.09-0.15, P<0.001) Pregnancy was not allowed in case with mild or high serological activity (mild: coefficient -0.49, 95% CI -0.29- -0.22, p <0.001, high: -0.64, 95% CI -0.65 - -0.61, p <0.001). In contrast, as many as 92 (19.2%) physicians tolerated pregnancy even in the presence of residual high anti ds-DNA antibody titers. Female physicians are significantly more cautious about pregnancy than male when patients have a serologically high activity (12% vs 37.5%, p<0.001). There were no significant differences in specialty status or clinical experience.

Conclusion

We found that even mild serological activity alone had a significant negative effect on the physician’s decision to allow pregnancy. We conclude that current physicians make cautious decisions about pregnancies of patients with SLE following the recommendation. On the other hand, an additional investigation should be performed about the results of pregnancies in patients with serological abnormalities, since there are some physicians who thought that pregnancy may be acceptable for patients with only serological abnormalities if the clinical symptoms are stable.

References

[1]Ann Rheum Dis．2017 Mar;76(3):476-485

Acknowledgements

I would like to express my gratitude to the members of Japan College of Rheumatology who cooperated in filling out the questionnaire.

Disclosure of Interests

Sakiko Isojima: None declared, Nobuyuki Yajima: None declared, Ryo Yanai: None declared, Yoko Miura: None declared, Shingo Fukuma: None declared, Kayoko Kaneko: None declared, Keishi Fujio: None declared, Kenji Oku: None declared, Masakazu Matsushita: None declared, Takako Miyamae: None declared, Takashi Wada: None declared, Yuko Kaneko: None declared, Yoshiya Tanaka Speakers bureau: Y. Tanaka has received speaking fees and/or honoraria from Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Grant/research support from: Y. Tanaka has received research grants from Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, and consultant fee from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie., Ayako Nakajima: None declared, ATSUKO MURASHIMA: None declared

OP0238 CLINICAL ANALYSIS OF 34 CASES OF CARDIAC COMPLICATIONS REQUIRING SURGICAL INTERVENTION IN SYSTEMIC LUPUS ERYTHEMATOSUS AND ASSESSMENT ABOUT MECHANISM OF DEVELOPMENT WITH IMMUNOLOGICAL ANALYSIS

Background

In cases of systematic lupus erythematosus (SLE) that lead to surgery due to the development of heart diseases such as valvular disease, ischemic heart disease and aortic aneurysm, early detection and careful monitoring are important. An absence of background diseases or immunopathological examination of the myocardial tissue in SLE cases with cardiovascular lesions demonstrates the lack of knowledge in this area. In recent years, however, there have been reports of neutrophil extracellular traps being involved in the fulminant onset of SLE.

Objectives

This study aimed to analyze clinically and immunohistopathologically the pathophysiology of heart diseases associated with SLE.

Methods

We performed left atrial appendage resection in 34 patients, including patients with cardiovascular lesions, who underwent heart surgery for SLE complications from 2012 to 2021. Tissue analysis was conducted in 9 cases. The left atrial appendage, in cases of non-collagen valvular disease, was used as the control. Tissue staining of cardiomyocytes was carried out by adding anti-neutrophil extracellular(NE) antibodies(Abs) to anti-human IgG antibody (Ab), anti-IgM Ab and anti-C3 Ab.

Results

Of the 34 SLE patients 14 had valvular disease, 8 had ischemic heart disease and 12 had aneurysms. Preoperative SLE activity was relatively stable with only 1 patient below the CH50 standard and 6 patients above the anti-DNA Ab standard. The Ab positivity rate for the patients in this study was higher than that of the 687 SLE patients who were previously tested in 2019. The presence of anti-CL Abs was 55.6%, which was higher than the 25.5% observed in previous SLE patients. In this study, anti-SS-A and anti-RNP Abs tended to be relatively numerous. An example of immunohistochemical staining of IgG in the left atrial appendage is presented (Figure 1a). IgG deposits were not observed on the left side of the myocardial fibers in the control group, whereas IgG deposits were observed on the right side in the SLE group. Deposits were also observed in tissues that were not located in the affected areas. The presence or absence of tissue deposition in the myocardial fibers and clinical findings in 2 cases of the control group and 9 cases of the SLE complication group are reported in Table 1. IgG deposits were found in the myocardial fibers of 6 of the 9 patients in the SLE complication group, and deposits were found in the left atrial appendage tissue regardless of the type of heart disease, suggesting a potential change in the heart tissue. In the SLE group, 5 cases were positive for antiphospholipid (APS) Abs, while 7 cases were positive for either anti-SS-A or anti-RNP Abs. Only 2 cases had elevated preoperative anti-DNA Ab and complement reduction. Of the SLE complication group, 2 of the 9 cases were negative for all Abs but IgG deposits were observed in a case. Of these 4 cases were selected and stained with anti-IgM, anti-C3 and anti-NE Abs. However IgM and C3 deposits were only observed in one patient who developed myocardial infarction at the age of 39 and was triple positive for APS, anti-SS-A and anti-RNP Abs (Figure 1b). There were also no NE deposits in any of the cases. Even if complement and anti-DNA Ab levels in the serum are normal, attention should be paid to heart disease complications during the long-term observation of SLE patients. In particular, attention should be paid to various autoantibody-positive cases such as APS, anti-SS-A Ab and anti-RNP Ab. The anti-NE Ab was not stained in this study because the tissue was different from the lesion site and because it occurred during the chronic course.

Conclusion

In SLE patients who developed cardiovascular lesions and required surgery, immunological abnormalities may occur in the myocardial tissue even if serum complement and anti-DNA Ab levels are stable.

References

[1]Stephane Zuily et al. Valvular Curr Rheumatol Rep (2013) 15:320.

[2]Zawadowski GM et al. Lupus. 2012;21(13):1378-84.

[3]Daniel Appelgren et al. Autoimmunity 2018,vol51,No.6,310-318.

Disclosure of Interests

None declared

Merkel cell polyomavirus-negative Merkel cell carcinoma is associated with JAK-STAT and MEK-ERK pathway activation

Merkel cell polyomavirus (MCPyV) is monoclonally integrated into the genomes of approximately 80% of Merkel cell carcinomas (MCCs). While the presence of MCPyV affects the clinicopathological features of MCC, the molecular mechanisms of MCC pathogenesis after MCPyV infection are unclear. This study investigates the association between MCPyV infection and activation of the MEK-ERK and JAK-STAT signaling pathways in MCC to identify new molecular targets for MCC treatment. The clinicopathological characteristics of 30 MCPyV-positive and 20 MCPyV-negative MCC cases were analyzed. The phosphorylation status of MEK, ERK, JAK, and STAT was determined by immunohistochemical analysis. The activation status of the MEK-ERK and JAK-STAT pathways and the effects of a JAK inhibitor (ruxolitinib) was analyzed in MCC cell lines. Immunohistochemically, the expression of pJAK2 (P = .038) and pERK1/2 (P = .019) was significantly higher in MCPyV-negative than in MCPyV-positive MCCs. Male gender (hazard ratio [HR] 2.882, P = .039), older age (HR 1.137, P < .001), negative MCPyV status (HR 0.324, P = .013), and advanced cancer stage (HR 2.672, P = .041) were identified as unfavorable prognostic factors; however, the phosphorylation states of JAK2, STAT3, MEK1/2, and ERK1/2 were unrelated to the prognosis. The inhibition of cell proliferation by ruxolitinib was greater in MCPyV-negative MCC cell lines than in an MCPyV-positive MCC cell line. The expression of pERK1/2 and pMEK was higher in MCPyV-negative than in MCPyV-positive cell lines. These results suggest that activation of the JAK2 and MEK-ERK pathways was more prevalent in MCPyV-negative than in MCPyV-positive MCC and the JAK inhibitor ruxolitinib inhibited MEK-ERK pathway activation. Consequently, the JAK-STAT and MEK-ERK signaling pathways may be potential targets for MCPyV-negative MCC treatment.

Seed production and storage for endangered Morus boninensis using an ex-situ living collection

Meaningful conservation techniques for the endangered Morus boninensis require seed production and storage, since in situ purebred seed production is infrequent in Ogasawara Islands (World Natural Heritage Site) in Japan. Ex situ living M. boninensis specimens produced seeds by open- and artificial-pollination in a greenhouse. Seed desiccation tolerance and storage characteristics were examined. Open-pollinated seeds were dried at 75, 33 and 8% relative humidity (RH) for 5 days then cryopreserved at -170 °C. Artificially pollinated seeds were dried at 8% RH then stored cryogenically at -170 °C and in freezers at -80 or -20 °C for 6 months. Germination rates were compared among seeds before and after drying and storage. Germination rates of undried seeds were 83% for open-pollinated seeds and 65% for artificially pollinated seeds. M. boninensis seeds exhibited the characteristic high desiccation tolerance of orthodox seeds and maintained a high germination rate after drying to a moisture content of approximately 4%. Cryopreservation of open-pollinated dry seeds with moisture contents of ca. 12, 7 and 4% maintained germination rates, while cryopreservation of undried seeds (moisture content ca. 44%) resulted in no germinability. Cryogenic and freezer storage of artificially pollinated dry seeds for 6 months resulted in maintenance of germination rates comparable to undried seeds before storage. Seed production was enabled by ex situ M. boninensis collection. The present study also developed a method for low temperature seed storage. Ex situ living tree collection represents a feasible seed resource for reintroduction and restoration programmes for M. boninensis.

Human Papilloma Virus 18-Positive Submucosal Small Cell Neuroendocrine Carcinoma of the Vagina: An Immunohistochemical and Genomic Study

Primary vaginal neuroendocrine carcinoma (NEC) is extremely rare among female genital tract tumors. Here, we report 2 cases of vaginal small cell NEC (SCNEC) using immunohistochemistry and next-generation sequencing (NGS) analysis. The 2 patients were in their mid-to-late 70s, presented with abnormal vaginal bleeding and had a vaginal submucosal mass. The biopsied or resected tumors showed a typical neuroendocrine morphology consisting of solid nests of atypical tumor cells, with no specific organoid patterns, and proliferating in the vaginal submucosa. Immunohistochemical analysis showed strong and diffuse expression of chromogranin A, synaptophysin, and p16, but no thyroid transcription factor 1 expression. Additionally, both cases were positive for human papillomavirus (HPV) 18. An NGS-based cancer panel analysis revealed that the tumors carried NF1 and AR mutations, but no major driver mutations were detected. The results of this study suggested that HPV18 infection is linked to vaginal SCNEC.

Impact of hinge motion on stent edge restenosis after new generation drug-eluting-stent implantation in RCA

Background

Edge restenosis still occurs after stent implantation, even by using new generation drug-eluting stents (DES) considered to have favorable biomechanical properties. Mechanical stress imposed on the stent edge are thought to be aggravated by hinge motion at a point between the stented and unstented segments, inducing chronic local inflammation and neointimal overgrowth.

Purpose

The aim of this study was to investigate the association between the development of edge restenosis and hinge motion in right coronary artery (RCA) where the excessive vessel movement is commonly observed.

Methods

Among consecutive 650 lesions in RCA where new generation DESs were implanted between 2009 and 2019, 427 serial lesions with sets of angiographies at baseline and follow-up (6–18 month) were included. In addition to conventional quantitative angiography analysis, hinge angle at stent edges was measured (Fig. 1). All the appropriate data for intravascular imaging were analyzed for both stent edges and reference segments.

Results

Binary restenosis occurred in 43 lesions, and 39 of them were referred to re-intervention. Fifty five percent of them were related to stent edges (15 at proximal and 9 at distal edges). Classical risk factors including diabetes and hemodialysis were more prevalent in the restenosis group (p&lt;0.05). Hinge angle was statistically larger in edge restenosis group than body restenosis or no restenosis group (17.3° vs 11.6° vs 10.6°, p&lt;0.001, Fig. 2). In per-edge analysis, hinge angle, dissection and residual plaque ratio were the independent predictors for binary restenosis (Table 1) with the optimal cut-off value of hinge angle 11.5°. The coexistence of excessive hinge angle and residual plaque burden had an amplified effect on the angiographic stenotic progression at stent edge (p for interaction &lt;0.001) and the incidents of binary restenosis (16.7% vs 1.7% p&lt;0.01, Figs. 3,4).

Conclusion

Substantial stress determined by angulation at the stent edge and its interaction with residual plaque can be considered as one of the plausible mechanisms for edge restenosis. For tortuous RCA lesions, it would be important to decide the stent-landing zone for minimizing hinge motion and optimize the future stent design.

Funding Acknowledgement

Type of funding source: None

Mapping of a New Deformation Region around ^{62}Ti

We performed the first direct mass measurements of neutron-rich scandium, titanium, and vanadium isotopes around the neutron number 40 at the RIKEN RI Beam Factory using the time-of-flight magnetic-rigidity technique. The atomic mass excesses of ^{58-60}Sc, ^{60-62}Ti, and ^{62-64}V were measured for the first time. The experimental results show that the two-neutron separation energies in the vicinity of ^{62}Ti increase compared to neighboring nuclei. This shows that the masses of Ti isotopes near N=40 are affected by the Jahn-Teller effect. Therefore, a development of Jahn-Teller stabilization appears below the Cr isotopes, and the systematics in Sc, Ti, and V isotopes suggest that ^{62}Ti is located close to the peak of the Jahn-Teller effect.

Sequential Nature of (p,3p) Two-Proton Knockout from Neutron-Rich Nuclei

Twenty-one two-proton knockout (p,3p) cross sections were measured from neutron-rich nuclei at ∼250  MeV/nucleon in inverse kinematics. The angular distribution of the three emitted protons was determined for the first time, demonstrating that the (p,3p) kinematics are consistent with two sequential proton-proton collisions within the projectile nucleus. Ratios of (p,3p) over (p,2p) inclusive cross sections follow the trend of other many-nucleon removal reactions, further reinforcing the sequential nature of (p,3p) in neutron-rich nuclei.

SAT0262 PROPOSAL FOR OPTIMIZATION OF DIAGNOSTIC IMAGING FOR GIANT CELL ARTERITIS USING THREE-DIMENSIONAL COMPUTED TOMOGRAPHY ANGIOGRAPHY IMAGE AND CONSTRUCTING VASCULAR MAPPING FROM VASCULAR ULTRASONOGRAPHY AS REFERENCES

Background:

The development of rapid and accurate methods of diagnosing giant cell arteritis (GCA) is critical to prevent blindness and stroke, which may develop rapidly in patients with GCA. In 2018, EULAR published recommendations that the first imaging modality for GCA should be vascular ultrasonography without biopsy. However, many institutions still consider biopsy to make an important contribution to the diagnosis of GCA.

Objectives:

Our purpose is to eliminate blindness and stroke among GCA patients by optimizing diagnostic imaging and method to diagnose GCA employed by vascular ultrasonography (V-US), CT Angiography (CTA), MRI/A, and PET/CT without biopsy.

Methods:

We evaluated the clinical and serological characteristics of 20 patients who were diagnosed with GCA at our hospital from 2012 to 2018, and compared the image and biopsy findings of these patients. We then evaluated the effect of optimizing diagnostic imaging and methods for patients with suspected GCA who visited our hospital during 2019. Vascular mapping was carried out using V-US for 3DCTA and other imaging methods as references.

Results:

Table 1 shows the clinical characteristics of the study population. The sensitivity of CTA for GCA was 85.7% (12 of 14 patients), which was the highest of the studied imaging methods. All biopsy-positive cases were diagnosed as GCA, and we compared these cases with cases with positive imaging findings. This revealed that CTA findings were correct (i.e., positive) in 66.7% (four of six patients), MRI/A findings were correct in in 33.3% (three of nine), V-US findings were correct in 50.0% (three of six). Therefore, CTA exhibited the highest sensitivity for positive findings. Comparison of biopsy-positive cases with cases in which imaging findings were negative revealed that CTA findings were correct (negative) in 33.3% (two of six patients), MRI/A findings were correct in 55.6% (five of nine), V-US was correct in 50.0% (three of six). Thus, CTA had the lowest sensitivity for negative findings. Comparison of CTA findings of positive cases with other imaging modalities which reported positive findings revealed MRI/A findings to be correct in 44.4% (four of nine patients), PET/CT findings to be correct in 50.0% (one of two), V-US to be correct in 63.3% (five of eight). Thus, V-US had the highest agreement with CTA. We carried out vascular mapping by V-US using 3DCTA and other imaging methods and produced references to improve the accuracy of diagnosis. Using these references, we diagnosed five cases of GCA among the 20 patients; the positive predictive value of V-US was 80% (four of five patients) and negative predictive value was 86.7% (13 of 15 patients).

Table 1.

Baseline characteristics of the study sample

    

The number of biopsies performed decreased from 50% (10 of 20 patients) from 2012 to 2018 to 15% (3 of 20 patients) in 2019. Two cases in the present study had positive findings in both biopsy and V-US; in one case, biopsy, CTA, and MRI/A were negative while V-US revealed positive findings. No patients with GCA developed blindness or stroke during 2019.

Conclusion:

We propose that V-US should be performed as the first examination for the diagnosis of GCA by the creation of vascular mappings when GCA is suspected in order to prevent blindness and stroke.

References:

[1]Christian Dejaco et al.EULAR recommendations for the use of imaging in large vasculitis in clinical practice.Annals of the Rheumatic Diseases,2018 May;77(5):636-643

[2]Kawamoto T et al.Diagnosis of giant cell arthritis by head-contrast three-dimensional computed tomography angiography.Journal of Medical Case Reports2019 Sep 11;13(1):285.

Figure 1.

Left side is before, right side is after thrapy. (A) 3DCTA finding, (B) determination of V-US arrangement with vascular location to evaluate wall thickening of V-US, compression sign, stenosis and stoppage of vessels.

Disclosure of Interests:

None declared

AB0422 LEFT VENTRICULAR ABNORMALITIES IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS FOLLOWED BY SEQUENTIAL ECHOCARDIOGRAPHY

Background:

Cardiovascular disease (CVD) is detected in up to 50% of systemic lupus erythematosus (SLE) patients1and major cause of death2. Even clinically silent SLE patients can develop left ventricular (LV) diastolic dysfunction3. Proper echocardiographic follow up of SLE patients is required.

Objectives:

To clarify how the prevalence of LV abnormalities changes over follow-up period and identify the associated clinical factors, useful in suspecting LV abnormalities.

Methods:

29 SLE patients (24 females and 5 men, mean age 52.8±16.3 years, mean disease duration 17.6±14.5 years) were enrolled. All of them underwent echocardiography as the baseline examination and reexamined over more than a year of follow-up period(mean 1075±480 days) from Jan 2014 to Sep 2019. Patients complicated with pulmonary artery hypertension, deep venous thrombosis or pulmonary embolism and underwent cardiac surgery during the follow-up period were excluded. Left ventricular(LV) systolic dysfunction was defined as ejection fraction (EF) < 50%. LV diastolic dysfunction was defined according to ASE/EACVI guideline4. LV dysfunction (LVD) includes one or both of LV systolic dysfunction and LV diastolic function. Monocyte to HDL ratio (MHR) was calculated by dividing monocyte count with HDL-C level.

Prevalence of left ventricular abnormalities was analysed at baseline and follow-up examination. Clinical characteristics and laboratory data were compared among patient groups as follows; patients with LV dysfunction (Group A) and without LV dysfunction (Group B) at the follow-up echocardiography, patients with LV asynergy at any point of examination (Group C) and patients free of LV abnormalities during the follow-up period (Group D).

Results:

At the baseline examination, LV dysfunction (5/29 cases, 13.8%), LV asynergy (6/29 cases, 21.7%) were detected. Pericarditis was detected in 7 patients (24.1%, LVD in 3 patients, LV asynergy in 2 patients) and 2 of them with subacute onset had progressive LV dysfunction, while 5 patients were normal in echocardiography after remission induction therapy for SLE. At the follow-up examination, LV dysfunction (9/29 cases, 31.0%, 5 new-onset and 1 improved case), LV asynergy (6/29 cases, 21.7%, 2 new-onset and 2 improved cases) were detected. Though any significant differences were observed between Group A and Group B at the baseline, platelet count (156.0 vs 207.0, p=0.049) were significantly lower in LV dysfunction group (Group A) at the follow-up examination. Group C patients had significantly higher uric acid (p=0.004), monocyte count (p=0.009), and MHR (p=0.003) than Group D(results in table).

Conclusion:

LV dysfunction is progressive in most of patients and requires regular follow-up once they developed. Uric acid, monocyte count and MHR are elevated in SLE patients with LV asynergy. Since MHR elevation was reported as useful marker of endothelial dysfunction5, our future goal is to analyse involvement of monocyte activation and endothelial dysfunction in LV asynergy of SLE patients.

References:

[1]Doria A et al. Lupus. 2005;14(9):683-6.

[2]Manger K et al. Ann Rheum Dis. 2002 Dec;61(12):1065-70.

[3]Leone P et al. Clin Exp Med. 2019 Dec 17.

[4]Nagueh SF et al. J Am Soc Echocardiogr. 2016 Apr;29(4):277-314.

[5]Acikgoz N et al. Angiology. 2018 Jan;69(1):65-70.

Numbers are median (interquartile range), Mann-Whitney u test were performed, p value less than 0.05 was considered statistically significant.

Disclosure of Interests: :

None declared

FRI0179 A STUDY ON THE ACHIEVEMENT OF LUPUS LOW DISEASE ACTIVITY STATE AND QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: FROM THE JUNTENDO UNIVERSITY SLE PROSPECTIVE REGISTRY STUDY

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown etiology that affects mostly young women. Multiorgan complications and prolonged treatment significantly cause physical and mental stress in patients. Improving patients’ quality of life (QOL) in SLE treatment is essential. We examined the treatment effects on disease activity and QOL of SLE patients.

Objectives:

In recent years, lupus low disease activity state (LLDAS) has been proposed as a treatment target for SLE. Patients who achieve LLDAS have a low recurrence rate for lupus and a low risk of serious complications (1). The aim of this study is to investigate whether achieving LLDAS reduces not only recurrence rate and complications of SLE but also improves patients’ QOL.

Methods:

A total of 104 SLE patients were enrolled in our prospective SLE registry study (Juntendo, Multi-center, Prospective cohort for investigation of clinical course and outcome in SLE: JUMP) conducted at our institution. SLE was diagnosed using the American College of Rheumatology (ACR) 1982 criteria (revised in 1997). QOL was evaluated using the standard version of the 36-item short form health survey version 2 (SF36v2). Participants were divided into the LLDAS achievement and non-achievement groups, and the characteristics of each group including results of SF36v2 were examined.

Results:

This study included 104 SLE patients, 94 female and 10 male, and the average age and disease duration were 46.4±13.8 and 14.5±11.3 years, respectively. The average corticosteroid dose was 8.0±17.4 mg/day in terms of prednisolone, and anti-dsDNA antibody titer was 16.8±38.5 IU/ml. Of the 104 patients, 57 achieved LLDAS. The subscale’s standard scoring using SF36v2 for role physical (RP) was 78.9±24.0 and 64.6±27.6 (P<0.01), general health (GH) was 50.0±17.0 and 42.0±19.3 (P<0.05), vitality (VT) was 55.8±15.8 and 38.0±24.1 (P<0.01), social functioning (SF) was 82.0±20.7 and 66.5±26.3 (P<0.01), role emotional (RE) was 89.0±16.1 and 73.4±28.1 (P<0.01), and mental health (MH) was 72.4±15.9 and 58.3±21.8 (P<0.01) in the LLDAS achievement and non-achievement groups, respectively. Furthermore, scoring based on the national standard value in the LLDAS achievement group showed that two categories were >50. However, in the LLDAS non-achievement group, all categories were <50. In particular, RP, GH, VT, SF, RE, and MH of the LLDAS achievement group had significantly higher scores than the LLDAS non-achievement group (RP and GH: p<0.05 and VT, SF, RE and MH: p<0.01).

Conclusion:

Results of examining the association between LLDAS and QOL using SF36v2 in SLE patients showed that patients who achieved LLDAS had significantly better standard statistical scores in many subscale categories. Thus, LLDAS achievement as a treatment target for SLE patients greatly contributes to improving patients’ QOL.

References:

[1]Franklyn K, et al. Definition and initial validation of a Lupus Low Disease Activity State (LLDAS).Ann Rheum Dis. 2016 Sep;75(9):1615-21.

Disclosure of Interests:

None declared

Deficiency of sphingomyelin synthase 2 prolongs survival by the inhibition of lymphoma infiltration through ICAM-1 reduction

The tumor microenvironment (TME) formation involving host cells and cancer cells through cell adhesion molecules (CAMs) is essential for the multiple steps of cancer metastasis and growth. Sphingomyelin synthase 2 (SMS2) is involved in inflammatory diseases such as obesity and diabetes mellitus by regulation of the SM/ceramide balance. However, the involvement of SMS2 in TME formation and metastasis is largely unknown. Here, we report that SMS2-deficient (SMS2-KO) mice show suppressed the EL4 cell infiltration to liver and prolonged survival time. ICAM-1 was identified as a candidate for the inhibition of TME formation in immortalized mouse embryonic fibroblasts (tMEFs) from mRNA array analysis for CAMs. Reduced SM/ceramide balance in SMS2-KO tMEFs suppressed the attachment of EL4 cells through transcriptional reduction of ICAM-1 by the inhibition of NF-κB activation. TNF-α-induced NF-κB activation and subsequent induction of ICAM-1 were suppressed in SMS2-KO tMEFs but restored by SMS2 re-introduction. In the EL4 cell infiltration mouse model, EL4 injection increased ICAM-1 expression in WT liver but not in SMS2-KO mouse liver. Therefore, inhibition of SMS2 may be a therapeutic target to suppress the infiltration of malignant lymphoma.

Fragmentation of Single-Particle Strength around the Doubly Magic Nucleus ^{132}Sn and the Position of the 0f_{5/2} Proton-Hole State in ^{131}In

Spectroscopic factors of neutron-hole and proton-hole states in ^{131}Sn and ^{131}In, respectively, were measured using one-nucleon removal reactions from doubly magic ^{132}Sn at relativistic energies. For ^{131}In, a 2910(50)-keV γ ray was observed for the first time and tentatively assigned to a decay from a 5/2^{-} state at 3275(50) keV to the known 1/2^{-} level at 365 keV. The spectroscopic factors determined for this new excited state and three other single-hole states provide first evidence for a strong fragmentation of single-hole strength in ^{131}Sn and ^{131}In. The experimental results are compared to theoretical calculations based on the relativistic particle-vibration coupling model and to experimental information for single-hole states in the stable doubly magic nucleus ^{208}Pb.

Decreased H3K27me3 Expression Is Associated With Merkel Cell Polyomavirus-negative Merkel Cell Carcinoma, Especially Combined With Cutaneous Squamous Cell Carcinoma

BACKGROUND/AIM

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin cancer, frequently infected with Merkel cell polyomavirus (MCPyV). H3K27me3 acts as a repressive histone modification that epigenetically controls gene transcription. The aim of this study was to examine H3K27me3 expression in MCC.

MATERIALS AND METHODS

H3K27me3 expression levels were immunohistochemically analyzed in 20 MCPyV-positive MCCs, 15 MCPyV-negative MCCs with squamous cell carcinoma (SCC) (combined MCCs), and six MCPyV-negative pure MCCs.

RESULTS

Reduced H3K27me3 expression was variously observed in MCCs. H3K27me3 H-score was significantly lower in MCPyV-negative MCCs than in MCPyV-positive MCCs (p=0.002). H3K27me3 expression was significantly lower in MCPyV-negative combined MCC component than in MCPyV-positive MCCs (p<0.001), MCPyV-negative pure MCCs (p=0.036), or pure MCC histology (p<0.001). Kaplan-Meier analysis showed no association of H3K27me3 with outcome.

CONCLUSION

Differential reduction in H3K27me3 expression was observed based on MCPyV status and morphological type. These results implicate H3K27me3-mediated epigenetic changes in tumorigenesis of MCC, especially in MCPyV-negative MCC combined with SCC.

Subclinical Epstein-Barr Virus Primary Infection and Lytic Reactivation Induce Thyrotropin Receptor Autoantibodies

Epstein-Barr virus (EBV) is a herpes virus that mainly infects in B lymphocytes and occasionally reactivates lytically. Most individuals have been infected with EBV primarily in their childhood with no symptoms, and the virus persists latently for life. We have previously reported that EBV-infected B cells with thyrotropin receptor autoantibodies (TRAbs) on their surface [TRAb(+) EBV(+) cells] were present in the peripheral blood mononuclear cells (PBMCs) of healthy adult controls and patients with Graves' disease, and that TRAbs released in the culture medium of PBMCs containing TRAb(+) EBV(+) cells by EBV reactivation. EBV lytic reactivation induced the differentiation of host B cells into plasma cells and antibody production. Various autoantibodies have been detected during the acute phase of infectious mononucleosis (IM) that is the symptomatic primary infection of EBV. Therefore, the autoantibody production may be induced by the asymptomatic primary infection. In this study, we examined the presence of TRAb(+) cells, EBV(+) cells, and TRAb(+) EBV(+) cells in PBMCs from 29 healthy or subclinical children without Graves' disease and one cord blood that were divided into six age groups, and also measured plasma TRAb levels. The results obtained demonstrated that low levels of TRAb production occurred with EBV primary infection and lytic reactivation in children without symptoms of IM. Furthermore, the populations of TRAb(+) cells, EBV(+) cells, and TRAb(+) EBV(+) cells were small in the period of primary infection, but they potentially expand with repeated EBV lytic reactivation. This may partly explain why the onset of Graves' disease often occurs in young adults, but rarely in infancy.

Juvenile Granulosa Cell Tumor with Elevated Peripheral Interleukin-6 Level Shows Prolonged Fever and Delayed Puberty

Juvenile granulosa cell tumor (JGCT), classified as a sex cord-stromal tumor, is a rare neoplasm. This is an instructive case report of JGCT accompanied by augmented interleukin (IL)-6 secretion. A 13-year-old girl with prolonged fever and delayed puberty was diagnosed with JGCT of the left ovary based on an imaging study and pathological investigation. Although it was not clear whether IL-6 was secreted from the tumor cells, her serum level of IL-6 was very high. After tumorectomy, the patient's symptoms immediately disappeared, her IL-6 level decreased, and she entered puberty. Therefore, augmented IL-6 secretion production induced by tumors should be considered a potential cause of prolonged fever and/or delayed puberty.

High Level Estradiol Induces EBV Reactivation and EBV gp350/220(+)CD138(+) Double-positive B Cell Population in Graves' Disease Patients and Healthy Controls

Graves' disease occurs predominantly in women. Epstein-Barr virus (EBV) mainly persists in human B lymphocytes, and its reactivation stimulates antibody production. We previously suggested that the EBV reactivation-induced production of TRAb and IgM at 100 nM estradiol (pregnant level) was lower than that at 0 nM estradiol and that class switch recombination may be increased by estradiol. In this study, we examined the effect of estradiol on EBV reactivation. We identified the expression of EBV-glycoprotein 350/220 (gp350/220) in the late phase of reactivation and plasma cell differentiation of EBV-infected cells using 72A1 antibody and CD138 antibody, respectively. We found the mean ratio of gp 350/220(+) CD138(+) cells at 100 nM estradiol was higher than that at 0 nM estradiol. These results suggested that EBV-infected cells could survive with keeping the ability of antibody production in 100 nM estradiol, which is consistent with the improvement of Graves' disease during maternity and exacerbation postpartum.

Prominence of Pairing in Inclusive (p,2p) and (p,pn) Cross Sections from Neutron-Rich Nuclei

Fifty-five inclusive single nucleon-removal cross sections from medium mass neutron-rich nuclei impinging on a hydrogen target at ∼250  MeV/nucleon are measured at the RIKEN Radioactive Isotope Beam Factory. Systematically higher cross sections are found for proton removal from nuclei with an even number of protons as compared to odd-proton number projectiles for a given neutron separation energy. Neutron removal cross sections display no even-odd splitting, contrary to nuclear cascade model predictions. Both effects are understood through simple considerations of neutron separation energies and bound state level densities originating in pairing correlations in the daughter nuclei. These conclusions are supported by comparison with semimicroscopic model predictions, highlighting the enhanced role of low-lying level densities in nucleon-removal cross sections from loosely bound nuclei.

SAT-555 Cytotoxicity of Epstein-Barr Virus Reactivation-Induced TRAb-IgM to Thyrocytes

Epstein-Barr virus (EBV) is a human herpes virus persisting in B lymphocytes, and is occasionally reactivated. Healthy controls as well as Graves’ disease patients have EBV-infected B cells that have TSH receptor antibodies (TRAbs) as their surface globulin (TRAb(+)EBV(+) cells) (1), and peripheral blood mononuclear cells (PBMCs) containing TRAb(+)EBV(+) cells produce TRAbs in reaction to EBV-reactivation induction (2). We proposed the EBV reactivation-induced immunoglobulin (Ig) production which is distinct pathway from the antibody production through germinal center and bone marrow (3). Since this pathway does not contain a germinal center, the majority of produced antibodies are IgM, but not affinity-maturated IgG. However, an EBV reactivation-induced Ig production system can rescue the autoreactive B cells that could not encounter their specific autoantigens and thus never enter lymphoid tissue, and drive autoreactive B cells to differentiate and produce autoantibodies. We observed that patient serum contains considerable amounts of TRAb-IgM (4) One of the characteristic histologies of Graves’ disease is lymphoid cell infiltration often associated with regenerated colloid follicles, suggesting the destructive event of follicular epithelia. We hypothesized that TRAbs, especially induced by EBV reactivation, have the capacity to injure follicular epithelial cells resulting in spreading of autoantigens. We observed that porcine thyroid follicular cells cultured with serum from Graves’ disease patients were often damaged and dying. The levels of cAMP in the lysate of these damaged cells increased. In order to study whether this cell death process is an poptosis or not, we stained these cells by Hoechst 33258, and then performed DNA fragmentation analyses of extracted DNA. However, we could not detect any chromatin condensation or apoptotic DNA ladders. Follicular cell injury was blocked by inactivated serum and anti-human TSH receptor monoclonal antibody instead of patient’s serum. Therefore, we considered that follicular cell injury could be necrosis through TRAbs and the classical pathway of complement activation. We would like to demonstrate these data with further experiments with TRAb-IgM and purified complement. References: (1) Nagata et al., Autoimmunity 2014; 47: 193-200. (2) Nagata et al., Autoimmunity 2015; 48: 328-335. (3) Nagata et al. Viral Immunology 2017; 30: 240-249. (4) Kumata et al., Viral Immunology 2016; 29: 459-463.

Detection of Disease-specific Fusion Genes of Soft Tissue Tumors Using Formalin-fixed Paraffin-embedded Tissues; Its Diagnostic Usefulness and Factors Affecting the Detection Rates

BACKGROUND

Recent rapid advances in molecular biology have led the discovery of disease-specific novel fusion genes in a variety of soft tissue tumors. In this study, we attempted to detect these fusion genes using formalin-fixed paraffin-embedded (FFPE) tumor tissues and investigated their clinical utility and factors that affect the results of examination.

METHODS

Reverse transcription polymerase chain reaction for the detection of tumor-specific fusion genes was performed using 41 FFPE tumor samples obtained from 37 patients representing nine histological types of soft tissue tumors that were diagnosed from 2006 to 2017 in our laboratory.

RESULTS

Fusion genes in 19 (51.3%) out of 37 cases were detected successfully. Relatively high detection rates were observed in synovial sarcomas (100%, 4/4) and alveolar rhabdomyosarcomas (75%, 3/4). The detection rates of fusion genes were inversely correlated with the storage period of FFPE blocks. Decalcification by Plank-Rychlo solution significantly affected detection rates of the internal control gene (P = 0.0038). In contrast, there was no significant difference in detection rates between primary and metastatic lesion, or biopsy and resection material, or presence and absence of treatment history.

CONCLUSION

In certain histological types, detection of disease-specific fusion genes of soft tissue tumors using FFPE tissues showed high sensitivity and thus had diagnostic utility. However, due to the diversity of fusion patterns and the low-quality of nucleic acid, the detection rate as a whole was sluggish and required further improvement. For factors affecting the detection results, our results suggested that it was impossible to detect fusion genes by decalcified FFPE tissues, but it may be not necessary to consider factors such as the type of specimen (biopsy or resection) and treatment history of the patients when selecting the FFPE tissues.

Expression of Notch 3 and Jagged 1 Is Associated With Merkel Cell Polyomavirus Status and Prognosis in Merkel Cell Carcinoma

BACKGROUND/AIM

Merkel cell carcinoma (MCC) is a rare, aggressive, neuroendocrine skin cancer and most MCCs are related to infection with Merkel cell polyomavirus (MCPyV). Notch signaling modulates cell fate in various tissues including the skin during development and homeostasis, and its aberrant activity relates to onset and progression of various malignancies. Therefore, association of NOTCH1/ NOTCH2/NOTCH3/jagged 1 (JAG1) expression with MCPyV status and prognosis in MCC was investigated.

MATERIALS AND METHODS

A total of 19 MCPyV-positive and 19 MCPyV-negative MCC samples from patients were stained immunohistochemically with antibodies against NOTCH1, NOTCH2, NOTCH3, and JAG1 and analyzed.

RESULTS

Expression of NOTCH1 and NOTCH2 was not associated with MCPyV status or prognosis. However, higher JAG1 expression was found in MCPyV-negative than in MCPyV-positive MCC (p<0.001), and NOTCH3 expression was higher in MCPyV-positive MCC (p=0.062). Kaplan-Meier and multivariate analyses showed that patients with MCC with higher NOTCH3 expression had better overall survival than otherwise (p=0.001 and p=0.033, respectively).

CONCLUSION

Expression of NOTCH3, as a tumor suppressor, is an independent predictor of MCC outcome.

Cytologic Features of SMARCA4-Deficient Thoracic Sarcoma: A Case Report and Comparison with Other SWI/SNF Complex-Deficient Tumors

BACKGROUND

SMARCA4-deficient thoracic sarcoma is a recently proposed entity of soft tissue tumors associated with an extremely poor prognosis. Its cytologic features have not been well described in the literature yet.

CASE

A woman in her early 30s who presented with chest pain was found to have a tumor in the right chest wall. Cytologic smears revealed numerous atypical round-to-polygonal cells appearing singly or in loosely cohesive clusters. These cells had a well-defined cell border, scant-to-moderate cytoplasm, and enlarged vesicular nuclei with prominent nucleoli. In addition, some cells with eosinophilic globular intracytoplasmic inclusions and eccentrically located nuclei, consistent with rhabdoid cells, were observed. Immunocytochemically, the cells were at least focally positive for cytokeratin CAM5.2 and CD34 and showed a significantly reduced BRG1/SMARCA4 expression. The diagnosis was confirmed by histological, immunohistochemical, and genetic analysis of a metastatic lesion to the left axillary lymph node.

CONCLUSION

Although the cytologic features of SMARCA4-deficient thoracic sarcoma are not fully unique, they are sufficiently characteristic to suspect this tumor in cases of supporting clinical and radiological features, which may promote additional immunological or molecular testing to establish a definitive diagnosis.

Expression of the IDO1/TDO2-AhR pathway in tumor cells or the tumor microenvironment is associated with Merkel cell polyomavirus status and prognosis in Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin cancer, with approximately 80% of cases related to Merkel cell polyomavirus (MCPyV). Indoleamine 2,3-dioxygenase 1 (IDO1) and tryptophan 2,3-dioxygenase 2 (TDO2) are the key rate-limiting enzymes of the tryptophan-to-kynurenine metabolic pathway. With aryl hydrocarbon receptor (AhR), an intracellular transcription factor, they play a role in escaping the immunosurveillance process in several cancers. IDO1/TDO2/AhR expression associated with the MCPyV status and prognosis in MCC was investigated. Samples included 24 MCPyV-positive MCCs, 12 MCPyV-negative MCCs with squamous cell carcinoma, and 7 MCPyV-negative pure MCCs. They were stained immunohistochemically with IDO1, TDO2, and AhR antibodies and analyzed. Higher IDO1 expression in MCC tumor cells was found in MCPyV-negative than in MCPyV-positive MCC (P < .001). The tumor microenvironment (TME) in MCPyV-negative MCC expressed higher TDO2 than in MCPyV-positive MCC (P < .001). Kaplan-Meier and log-rank tests showed that MCC with lower IDO1 expression in tumor cells and with lower TDO2 and AhR expressions in TME had better overall survival than otherwise (P = .043, .008, and .035, respectively); lower TDO2 expression in TME was also associated with longer disease-specific survival (P = .016). This suggests that IDO1, TDO2, and AhR express differentially in tumor cells or TME and play different roles in tumorigenesis between MCPyV-positive and MCPyV-negative MCC that may affect the MCC biology. Evaluating IDO1/TDO2/AhR expression is important for selecting the most likely patients with MCC for immunotherapies targeting the IDO1/TDO2-AhR pathway.

Epstein-Barr Virus Lytic Reactivation Induces IgG4 Production by Host B Lymphocytes in Graves' Disease Patients and Controls: A Subset of Graves' Disease Is an IgG4-Related Disease-Like Condition

Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a newly recognized systemic fibroinflammatory disease with characteristic histological findings and high serum IgG4 levels. Epstein–Barr virus (EBV) is a persistent herpesvirus in B lymphocytes, and we previously reported EBV reactivation-induced Ig production. We showed that EBV reactivation induced the production of thyrotropin receptor antibodies, the causative antibodies of Graves' disease. In the present study, we investigated whether EBV reactivation induced IgG4 production and if EBV-positive B cells or IgG4-positive plasma cells are present in the thyroid tissues of Graves' disease patients with lymphoplasmacytic infiltration. EBV-encoded small RNA1 (EBER1) in situ hybridization and immunohistochemistry for IgG and IgG4 were performed on seven resected thyroid tissues with lymphoplasmacytic infiltration collected from the thyroids of 11 Graves' disease patients. We then cultured the lymphocytes of 13 Graves' disease patients and 14 controls and induced EBV reactivation to measure IgG4 levels in culture fluids. We detected EBER1-positive cells and IgG4-positive plasma cells in the same area of thyroid tissues. EBV-reactivated cells with IgG4 on their surface were observed in culture cells, and IgG4 production was detected in culture fluids. The IgG4/IgG percentage was higher than that in normal serum level. A subset of Graves' disease is an IgG4-RD-like condition, not an IgG4-RD. EBV reactivation stimulates IgG4 production, which may result in high serum IgG4 levels and promote IgG4-positive plasma cell infiltration. EBER1 needs to be examined when an increase in IgG4-positive plasma cell numbers is noted.

Erratum: Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu [Phys. Rev. Lett. 119, 192501 (2017)]

This corrects the article DOI: 10.1103/PhysRevLett.119.192501.

Merkel cell polyomavirus and Langerhans cell neoplasm

BACKGROUND

The relationship between various external agents such as pollen, food, and infectious agents and human sensitivity exists and is variable depending upon individual's health conditions. For example, we believe that the pathogenetic potential of the Merkel cell polyomavirus (MCPyV), the resident virus in skin, is variable and depends from the degree of individual's reactivity. MCPyV as well as Epstein-Barr virus, which are normally connected with humans under the form of subclinical infection, are thought to be involved at various degrees in several neoplastic and inflammatory diseases. In this review, we cover two types of Langerhans cell neoplasms, the Langerhans cell sarcoma (LCS) and Langerhans cell histiocytosis (LCH), represented as either neoplastic or inflammatory diseases caused by MCPyV.

METHODS

We meta-analyzed both our previous analyses, composed of quantitative PCR for MCPyV-DNA, proteomics, immunohistochemistry which construct IL-17 endocrine model and interleukin-1 (IL-1) activation loop model, and other groups' data.

RESULTS

We have shown that there were subgroups associated with the MCPyV as a causal agent in these two different neoplasms. Comparatively, LCS, distinct from the LCH, is a neoplastic lesion (or sarcoma) without presence of inflammatory granuloma frequently observed in the elderly. LCH is a proliferative disease of Langerhans-like abnormal cells which carry mutations of genes involved in the RAS/MAPK signaling pathway. We found that MCPyV may be involved in the development of LCH.

CONCLUSION

We hypothesized that a subgroup of LCS developed according the same mechanism involved in Merkel cell carcinoma pathogenesis. We proposed LCH developed from an inflammatory process that was sustained due to gene mutations. We hypothesized that MCPyV infection triggered an IL-1 activation loop that lies beneath the pathogenesis of LCH and propose a new triple-factor model.

Estradiol Affects Epstein-Barr Virus Reactivation-Induced Thyrotropin Receptor Antibody and Immunoglobulin Production in Graves' Disease Patients and Healthy Controls

Epstein-Barr virus (EBV) is a gamma-herpesvirus persisting mainly in human B lymphocytes. EBV reactivation induces host cells to differentiate into plasma cells and is related to autoimmune diseases. Graves' disease, an autoimmune hyperthyroidism, is caused by the thyrotropin receptor antibody (TRAb), which overstimulates thyroid stimulating hormone receptor. The disease occurs predominantly in women, which suggests involvement with estrogen. Graves' disease patients and healthy controls have EBV-infected lymphocytes with TRAb on the surface (TRAb(+)EBV(+) cells) in peripheral blood mononuclear cells (PBMCs). TRAb can be produced by reactivation of EBV in vitro, which is an alternative system of antibody production. In this study, we cultured PBMCs from Graves' disease patients and healthy controls with 0, 1, and 100 nM estradiol, corresponding to control, midluteal, and pregnancy levels, respectively, and analyzed the levels of TRAb, total-IgG, and total-IgM during EBV reactivation. We found that 1 nM estradiol increased TRAb levels and 100 nM estradiol slightly lowered them in both patients and controls. In patients, IgM production at 100 nM estradiol was significantly lower than that at 0 nM estradiol (p = 0.028). Estradiol increased the ratio of IgG production to immunoglobulin G (IgG) and immunoglobulin M (IgM) production (IgG/IgG + IgM), which suggested an increase in class switch recombination in the process of EBV reactivation-induced Ig production. Moreover, TRAb production was stimulated by a midluteal level of estradiol and was suppressed by a pregnancy level of estradiol in controls and patients. These results were consistent with premenstrual worsening and maternity improving of autoimmune diseases, including Graves' disease.

Magic Nature of Neutrons in ^{54}Ca: First Mass Measurements of ^{55-57}Ca

We perform the first direct mass measurements of neutron-rich calcium isotopes beyond neutron number 34 at the RIKEN Radioactive Isotope Beam Factory by using the time-of-flight magnetic-rigidity technique. The atomic mass excesses of ^{55-57}Ca are determined for the first time to be -18650(160), -13510(250), and -7370(990)  keV, respectively. We examine the emergence of neutron magicity at N=34 based on the new atomic masses. The new masses provide experimental evidence for the appearance of a sizable energy gap between the neutron 2p_{1/2} and 1f_{5/2} orbitals in ^{54}Ca, comparable to the gap between the neutron 2p_{3/2} and 2p_{1/2} orbitals in ^{52}Ca. For the ^{56}Ca nucleus, an open-shell property in neutrons is suggested.

Temperature Effect on Bilirubin Adsorption with the Anion Exchange Resin BR-601

Plasma perfusion with the anion exchange resin BR-601 is an effective method to treat patients with hepatic failure and hyperbilirubinemia. To assess the temperature dependency of bilirubin sorption in vitro, isotherm studies with human pathologic plasmas and an albumin-bilirubin solution were carried out. Results showed that BR-601 was more effective at 37°C and 42°C than at 4°C and 25°C for sorbing bilirubin. Therefore, plasma sorption at near physiologic temperature would be expected to be more efficient for plasma treatment than sorption at ambient temperature.

Factor XII Osaka: Abnormal factor XII with partially defective prekallikrein cleavage activity

A healthy Japanese male had reduced factor XII (FXII) activity (35%) in contrast to normal antigen levels (81%). The F12 of this proband had a 9775G to C mutation in exon 10 and an 11276G to A mutation in exon 13 that resulted in two amino acid substitutions of Ala324Pro (GCG→CCG) in the proline-rich connecting region and Gly531Glu (GGG→GAG) near the active Ser544 in the catalytic domain. His father had the nucleotide 46T/T and a heterozygous 9775G/C mutation. The FXII activity (32%) and antigen level (38%) of the father were about half that of normal individuals with 46T/T, suggesting a heterozygous cross reacting material (CRM)-negative deficiency. His mother had a 46C/T and heterozygous 11276G/A mutation, and 80% FXII activity was incompatible with the corresponding antigen level (125%), suggesting a heterozygous CRM-positive deficiency. The substitution of Ala324Pro probably caused the CRM-negative mutation and the Gly531Glu caused the CRM-positive mutation. We developed three methods based on chromogenic substrates to assay the distinct functions of FXII, namely its autoactivation on a negatively charged surface, activation by kallikrein cleavage and the prekallikrein cleavage activity of FXIIa. The ratios of autoactivated FXIIa/FXII antigen (0.80–1.10) and of kallikrein-induced FXIIa/FXII antigen (0.86–1.00) in plasma from the proband were within normal ranges, whereas those of FXIIa-induced kallikrein/FXII antigen were reduced to 0.41–0.45. In conclusion, the 9775G to C and 11276G to A mutations of F12 led to a CRM-negative and -positive FXII deficiency, and the F12 with 11276A produced a dys-functional type of FXII with a partial defect (0.41–0.45) in prekallikrein cleavage activity.

Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu

In-beam γ-ray spectroscopy of ^{79}Cu is performed at the Radioactive Isotope Beam Factory of RIKEN. The nucleus of interest is produced through proton knockout from a ^{80}Zn beam at 270  MeV/nucleon. The level scheme up to 4.6 MeV is established for the first time and the results are compared to Monte Carlo shell-model calculations. We do not observe significant knockout feeding to the excited states below 2.2 MeV, which indicates that the Z=28 gap at N=50 remains large. The results show that the ^{79}Cu nucleus can be described in terms of a valence proton outside a ^{78}Ni core, implying the magic character of the latter.

CXorf48 is a potential therapeutic target for achieving treatment-free remission in CML patients

Although the introduction of tyrosine kinase inhibitors (TKIs) has improved overall survival of patients with chronic myeloid leukemia (CML), about half of the patients eventually relapse after cessation of TKIs. In contrast, the remainder of the patients maintain molecular remission without TKIs, indicating that the patients' immune system could control proliferation of TKI-resistant leukemic stem cells (LSCs). However, the precise mechanism of immunity against CML-LSCs is not fully understood. We have identified a novel immune target, CXorf48, expressed in LSCs of CML patients. Cytotoxic T cells (CTLs) induced by the epitope peptide derived from CXorf48 recognized CD34⁺CD38^- cells obtained from the bone marrow of CML patients. We detected CXorf48-specific CTLs in the peripheral blood mononuclear cells from CML patients who have discontinued imatinib after maintaining complete molecular remission for more than 2 years. Significantly, the relapse rate of CXorf48-specific CTL-negative patients was 63.6%, compared to 0% in CXorf48-specific CTL-positive patients. These results indicate that CXorf48 could be a promising therapeutic target of LSCs for immunotherapy to obtain durable treatment-free remission in CML patients.

Higher Expression of Activation-induced Cytidine Deaminase Is Significantly Associated with Merkel Cell Polyomavirus-negative Merkel Cell Carcinomas

BACKGROUND

Merkel cell carcinomas (MCCs), clinically aggressive neuroendocrine skin cancers, are divided into Merkel cell polyomavirus (MCPyV)-positive and -negative tumors, which show different clinicopathological features and may develop through different mechanisms of carcinogenesis. Aberrant expression of activation-induced cytidine deaminase (AID) as a genomic modulator was demonstrated through pathogen-related NF-κB signal in Helicobacter pylori-associated gastric cancer, adult T cell leukemia/lymphoma (HTLV-1), hepatoma (HCV), and Burkitt lymphoma (EBV).

METHODS

To elucidate the relation of aberrant AID expression in MCPyV-positive and -negative MCCs, we evaluated immunohistochemical expressions of AID and AID-regulating factors between 24 MCPyV-positive and 17 MCPyV-negative MCCs.

RESULTS

AID expression was significantly higher in MCPyV-negative MCCs than MCPyV-positive ones (P = 0.026), although expression of NF-κB p65 (phospho S536) (AID-enhancer) was significantly higher in MCPyV-positive MCCs than MCPyV-negative ones (P = 0.034). Expressions of PAX5 and c-Myb were not significantly different between these subgroups. Expressions of AID and AID-regulating factors were not correlated to prognosis of MCC patients.

CONCLUSION

Our findings suggest that although pathogen-induced AID expression through upregulation of NF-κB may be relevant to carcinogenesis of MCPyV-positive MCCs, the significantly higher aberrant AID expression in MCPyV-negative MCCs is consistent with the fact that MCPyV-negative MCCs have an extremely higher mutation burden than MCPyV-positive ones.

Aberrant expression of AID and AID activators of NF-κB and PAX5 is irrelevant to EBV-associated gastric cancers, but is associated with carcinogenesis in certain EBV-non-associated gastric cancers

Epstein-Barr virus-associated gastric carcinoma (EBVaGC) is a distinct subtype of gastric cancer characterized by clinicopathological features including lymphoepithelioma-like histology. Aberrant expression of activation-induced cytidine deaminase (AID) as a genomic modulator was demonstrated through pathogen-related nuclear factor κB (NF-κB) signaling in Helicobacter pylori-associated gastric cancer. To elucidate whether or not AID expression is relevant to carcinogenesis in EBVaGC, immunohistochemical expression of AID and AID-regulatory factors between EBVaGC and EBV-non-associated gastric carcinoma (GC) were evaluated, each using 15 cases of GC with lymphoid stroma (GCLS) and other types of GC. Aberrant expression of AID, NF-κB and paired box 5 (PAX5) were significantly decreased in EBVaGC (0/11, 1/11 and 1/11) compared with in EBV-non-associated GC (7/19, 12/19 and 11/19) (P=0.025, 0.005 and 0.01, respectively); however, no significant difference in c-Myb proto-oncogene expression was identified. AID expression was also decreased in EBV-associated GCLS (0/10) compared with in EBV-non-associated GCLS (3/5). Unexpectedly, decreased expression of NF-κB and PAX5 was observed in GCLS (1/15 and 2/15) compared with in GC without LS (12/15 and 10/15) (P<0.001 and P=0.003, respectively). Decreased AID expression observed in EBVaGC is consistent with the reported molecular characterization of hypermethylation and rare somatic gene mutation in EBVaGC. Only PAX5 was identified to be significantly associated with venous invasion (P=0.022). The results of the present study suggest that pathogen-induced AID expression may be irrelevant to carcinogenesis of EBVaGC, whereas it contributes to carcinogenesis in certain types of EBV-non-associated GC.