Development and validation of a machine learning model to predict time to renal replacement therapy in patients with chronic kidney disease

BACKGROUND

Predicting time to renal replacement therapy (RRT) is important in patients at high risk for end-stage kidney disease. We developed and validated machine learning models for predicting the time to RRT and compared its accuracy with conventional prediction methods that uses the rate of estimated glomerular filtration rate (eGFR) decline.

METHODS

Data of adult chronic kidney disease (CKD) patients who underwent hemodialysis at Oita University Hospital from April 2016 to March 2021 were extracted from electronic medical records (N = 135). A new machine learning predictor was compared with the established prediction method that uses the eGFR decline rate and the accuracy of the prediction models was determined using the coefficient of determination (R2). The data were preprocessed and split into training and validation datasets. We created multiple machine learning models using the training data and evaluated their accuracy using validation data. Furthermore, we predicted the time to RRT using a conventional prediction method that uses the eGFR decline rate for patients who had measured eGFR three or more times in two years and evaluated its accuracy.

RESULTS

The least absolute shrinkage and selection operator regression model exhibited moderate accuracy with an R2 of 0.60. By contrast, the conventional prediction method was found to be extremely low with an R2 of -17.1.

CONCLUSIONS

The significance of this study is that it shows that machine learning can predict time to RRT moderately well with continuous values from data at a single time point. This approach outperforms the conventional prediction method that uses eGFR time series data and presents new avenues for CKD treatment.

Effects of an elemental diet to reduce adverse events in patients with esophageal cancer receiving docetaxel/cisplatin/5-fluorouracil: a phase III randomized controlled trial-EPOC 2 (JFMC49-1601-C5)

Background

Oral mucositis (OM) is an unpleasant adverse event in patients receiving chemotherapy. A prospective feasibility study showed that elemental diet (ED), an oral supplement that does not require digestion, may prevent OM. Based on this, we established a central review system for oral cavity assessment by dental oncology specialists blinded to background data. We used this system to elucidate the preventive effect of an ED against OM in patients with esophageal cancer receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy.

Patients and methods

In this phase III, multicenter, parallel-group, controlled trial, patients consuming a normal diet orally were randomly assigned (1 : 1) to receive two cycles of DCF with (group A) or without (group B) an ED (Elental® 160 g/day). We assessed the incidence of grade ≥2 OM evaluated by two reviewers, changes in body weight, prealbumin, C-reactive protein, and DCF completion rate based on ED compliance.

Results

Of the 117 patients randomly assigned to treatment, four failed to start treatment and were excluded from the primary analysis; thus, groups A and B comprised 55 and 58 patients, respectively. There were no significant differences in background characteristics. Grade ≥2 OM was observed in eight (15%) and 20 (34%) patients in groups A and B, respectively (P = 0.0141). Changes in body weight and prealbumin during the two DCF cycles were significantly higher in group A than B (P = 0.0022 and 0.0203, respectively). During the first cycle, changes in C-reactive protein were significantly lower in group A than B (P = 0.0338). In group A (receiving ED), the DCF completion rate was 100% in patients with 100% ED compliance and 70% in patients failing ED completion (P = 0.0046).

Conclusions

The study findings demonstrate that an ED can prevent OM in patients with esophageal cancer receiving chemotherapy.

•

Patients receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy commonly develop oral mucositis (OM).

•

An elemental diet (ED) was able to prevent OM in patients with esophageal cancer receiving DCF.

•

Grade ≥2 OM was observed in 15% of patients receiving the ED versus 34% of those not receiving the ED (P = 0.0141).

•

Body weight was maintained in the ED group, and hematologic toxicities were lower, compared with the non-ED group.

•

The DCF completion rate significantly correlated with ED compliance (P = 0.0046).

Radiation doses of workers engaged in decontamination of the environment

After the accident at Fukushima Daiichi nuclear power plant on 11 March 2011, radioactive materials were released into the atmosphere resulting in environmental contamination. Following the implementation of environmental decontamination efforts, the Radiation Dose Registration Centre of the Radiation Effects Association established the radiation dose registration system for decontamination and related workers to consolidate and prevent the loss of radiation records. This article presents statistics on the radiation doses of decontamination and related workers using official records. Since approximately 10 years have passed since the accident in Fukushima, the types of work conducted in the affected restricted areas have changed over time. Therefore, changes in radiation dose for each type of work and comparisons with nuclear workers are presented.

[Construction of System to Making Antibiograms Based was used by Japan Nosocomial Infections Surveillance (JANIS) Data]

Making the antibiogram necessary for infectious disease treatment is an important operation of the microbiology laboratory. Antibiogram is required to be up-to-date and to keep up with the annual updates of the Clinical & Laboratory Standards Institute (CLSI). However, these operation and managements require a lot of effort. In addition, even in the surveillance and analysis comparison of multiple facilities, the difference in CLSI base year becomes a barrier, making unified analysis difficult. On the other hand the antibiogram by Japan Nosocomial Infections Surveillance (JANIS) has restrictions on the bacterial species, antibacterial agents, and date range. Accordingly we focused on the fact that the data transmitted to JANIS is in a common format, and attempt construction a system to making the antibiogram based on this. This system uses data transmitted to JANIS, is convenient, can use not only the latest but also past base year CLSI category, has no restrictions on bacterial species, antibacterial agents, date range, works on Microsoft Windows environment, pursuit of compliance with the guidelines, and automatically making the antibiogram.

Magnetic Friedel Oscillation at the Fe(001) Surface: Direct Observation by Atomic-Layer-Resolved Synchrotron Radiation ^{57}Fe Mössbauer Spectroscopy

The surface magnetism of Fe(001) was studied in an atomic layer-by-layer fashion by using the in situ iron-57 probe layer method with a synchrotron Mössbauer source. The observed internal hyperfine field H_{int} exhibits a marked decrease at the surface and an oscillatory behavior with increasing depth in the individual upper four layers below the surface. The calculated layer-depth dependencies of the effective hyperfine field |H_{eff}|, isomer shift δ, and quadrupole shift 2ϵ agree well with the observed experimental parameters. These results provide the first experimental evidence for the magnetic Friedel oscillations, which penetrate several layers from the Fe(001) surface.

Autologous skeletal myoblast sheet prevents cardiomyocyte ischemia and right heart dysfunction in pressure-overloaded right heart porcine model

Introduction

Severe heart failure (HF) with congenital heart disease (CHD) have demonstrated life threatening disorder despite of remarkable progress in medical therapies. Autologous skeletal myoblast sheet transplantation therapy showed clinical efficacy for left ventricular dysfunction by cytokine paracrine effects, which are expected to be sufficiently effective against right ventricular (RV) dysfunction which is often seen in end-stage of CHD patients with severe HF.

Hypothesis

An autologous skeletal myoblast sheet transplantation alleviates RV dysfunction in a pressure-overloaded right heart in a porcine model.

Methods

Five-to-six-month-old Göttingen mini-pigs underwent pulmonary artery banding with vascular occluding system. To create the porcine model of chronic pressure-overloaded right heart, vascular occluding system was gradually inflated, over a month, to make pulmonary stenosis to banding velocity >3.0 m/s measured by echocardiography (UCG), and then fixed for another month. Two months after banding, autologous skeletal myoblast sheet was placed on the epicardium of the RV free wall and followed for 2 months. Groups were as follows: control (C, n=5), sheet implantation (S, n=5). Cardiac function was measured using UCG, cardiac computed tomography (CT), and cardiac catheterization (Cath). Two months after sheet implantation, hearts were dissected for histologic analysis.

Results

Before sheet implantation, RV dysfunction was equal in groups; however, 2 months after sheet implantation, RV dysfunction and myocardial ischemia was significantly ameliorated in group S than group C. On CT, RV ejection fraction exacerbation were well controlled in Group S compared to Group C (S 44.9±2.2 vs C 31.9±2.1% [p=0.0042]). UCG and Cath revealed well maintained systolic and diastolic function in Group S compared to Group C (Tei index: S 0.42±0.06 vs C 0.70±0.07 [p=0.0240], Fraction Area Change: S 45.8±7.8 vs C 19.5±1.3% [p=0.0240], Isovolumic Relaxation Time; S 44.3±9.2 vs C 97.3±9.5 ms [p=0.0304]). On C11-Acetate Positron Emission Tomography, myocardial ischemia was more prominent in Group C compared to Group S (K mono-Rest/Stress: S 3.17±0.69 vs C 2.03±0.65 min-1 [p=0.0421], Myocardial Blood Flow-Rest/Stress: S 3.22±0.39 vs C 2.13±0.92 min-1 [p=0.0421]). In histologic analysis, Group S presented less progressed hypertrophic change in periodic acid-Schiff stain (S 13.5±0.9 vs C 18.0±3.0 μg [p=0.0240]), anti-fibrotic changes in picrosirius red stain (S 3.0±0.3 vs C 4.2±0.2% [p=0.0421]), more angiogenesis in CD31 expression (S 18.3±1.5 vs C 10.7±2.8 / 104 μm2 [p=0.0240]), and less production of reactive oxygen species in fluorescent immunostaining (S 5.9±1.7 vs C 18.4±1.7% [p=0.0304]).

Conclusion

Autologous skeletal myoblast sheet transplantation alleviates cardiomyocyte Ischemia and RV dysfunction in a porcine model of pressure-overloaded right heart.

Funding Acknowledgement

Type of funding source: None

P315In-vivo and vitro mitochondrial transfer from adipose-derived mesenchymal stem cell to ischemic cardiomyocyte

Background

Although transplantation of human Adipose-derived Mesenchymal stem cell (hADSC) shows efficacy in the treatment of ischemic cardiomyopathy, its therapeutic mechanisms have not been fully elucidated. It has been already reported that mitochondria transfer to recipient cells have impact on resistance to injury and tissue regeneration, however this phenomenon has not been elucidated in the damaged heart. Therefore, we hypothesized that ADSC transfer own mitochondria to cardiomyocytes in-vivo and in-vitro under ischemic condition, resulting in the functional recovery of cardiomyocyte.

Method and result

Transplantation of hADSC (group A) to the heart surface or sham operation (group C) was performed in rats that were subjected to LAD ligation 2 weeks prior to the treatment (n=10 each). The number of transplant cell was 1x106/body. Three days after transplantation, transferred hADSCs' mitochondria were observed in recipient cardiomyocytes histologically (Figure). Quantitative PCR analysis revealed that mitochondrial genome of recipient myocytes increased over time. The cardiac function assessed with echocardiography was significantly better in group A. Furthermore, live-imaging of hADSC transplantation revealed the suspected transfer of mitochondria to beating heart.

In-vitro, the co-culture of rat cardiomyocytes (rCM) and hADSC was observed with time-lapse photography and demonstrated mitochondrial transfer under the hypoxic condition. The measuring the oxygen consumption rate (OCR) of these cells showed that OCR of rCM was reinforced by co-culture with hADSC conspicuously.

Figure 1

Conclusion

Mitochondrial transfer from hADSC to rCM was suggested in-vivo and in-vitro ischemic condition and suspected to be related to functional recovery of ischemic cardiomyocyte.

P5391Systemic administration of high-mobility group box 1 can suppress adverse post-infarction ventricular remodeling in a rat infarction model by enhancing self-regeneration

Background

High-mobility group box 1 protein (HMGB1) reportedly enhances CXCR4-positive bone marrow-derived mesenchymal stem cell (BM-MSC) recruitment to damaged tissue to promote tissue regeneration.

Purpose

Our aim of this study is to evaluate whether systemic administration of HMGB1 might promote tissue repair in a rat myocardial infarction (MI) model.

Methods

We prepared 26 MI model rats with high ligation of the left coronary artery. Two weeks later, HMGB1 (3 mg/kg/day) or phosphate-buffered saline (control: 3 mL/kg/day) was administered for 4 days via femoral vein. Cardiac performance was evaluated by ultrasonography, left ventricular (LV) remodeling via immunostaining. We then used immunostaining to examine MSC recruitment to damaged tissue in green fluorescent protein bone marrow transplantation (GFP-BMT) model rats, and also performed intravital imaging using two-photon microscopy to visualize BM-cells recruitment in real time.

Results

Compared with control rats, there was a significant improvement in the left ventricular ejection fraction of the HMGB1 group (HMGB1 vs. control: 48.6% ± 5.5% vs. 33.6% ± 5.4%; p<0.01) at 4 weeks after each administration. LV remodeling, characterized by interstitial fibrosis, cardiomyocyte hypertrophy, and a decrease of capillary density, was significantly attenuated in the HMGB1 group compared with control rats. On QT-PCR analysis, VEGF mRNA expression was significantly higher in the HMGB1 group than in the control (border zone; 1.6±0.6 vs. 1.1±0.2; p=0.02, septal zone; 1.1±0.1 vs. 0.9±0.1; p<0.01). In GFP-BMT rats, GFP+/PDGFR+ cells were significantly mobilized to the border zone in the HMGB1 group compared with the control (1331±197 vs. 615±45 /mm2; p<0.01), leading to formation of newly developed vasculature (Figure 1). In intravital imaging, more GFP+ cells were mobilized to the infarction area in the HMGB1 group than in the control, which was further enhanced at 12h later. Additionally, SDF-1 expression in the peri-infarction area increased significantly in MI rats compared with normal rats (MI vs. normal; 2.1±0.4 vs. 0.9±0.1; p<0.01), in where some cell-adhesions of vascular endothelial cells were destroyed.

Conclusions

Systemic administration of HMGB1 mobilized BM-MSCs to the damaged myocardium via the SDF-1/CXCR4 signaling complex. Those BM-MSCs might migrate to extracellular matrix in the border zone via the gap of each endothelial cell, leading to induction of angiogenesis and reduced fibrosis.

Acknowledgement/Funding

None

Two Cases of Equine Multinodular Pulmonary Fibrosis in Japan

Equine multinodular pulmonary fibrosis (EMPF) is a recently described form of interstitial pneumonia associated with equine herpesvirus type 5 (EHV-5). This disease has been reported in North and South America, Europe and Oceania but not, to our knowledge, in horses in Japan. We diagnosed EMPF in two Thoroughbred horses in Japan on the basis of gross and histopathological findings. In both cases, significant gross lesions, restricted to the lungs, consisted of numerous firm and coalescing nodules widely distributed throughout the lung. The nodules were <3 cm in diameter and pale white to tan in colour. Microscopically, they showed severe interstitial fibrosis and infiltration of macrophages, neutrophils, lymphocytes and a few eosinophils. The residual alveoli were lined by cuboidal epithelial cells (type II pneumocytes) and filled with many macrophages, which rarely displayed oval eosinophilic to amphophilic intranuclear inclusion bodies. Polymerase chain reaction and sequence analyses identified the glycoprotein H gene of EHV-5, and in-situ hybridization detected EHV-5 in the alveolar macrophages in the lesions. In one case, electron microscopy revealed herpesvirus-like particles and EHV-5 was isolated from pulmonary lesions.

Abstract OT2-05-02: International retrospective cohort study of locoregional and systemic therapy in oligometastatic breast cancer (OLIGO-BC1)

Breast cancer (BC) is so-called “systemic disease”, because disseminated cancer cells in bone marrow and blood are detected even in early BC patients. Despite adjuvant therapy and postoperative radiation therapy, patients with triple negative BC and Luminal B-like BC often relapse early and systemic therapy is the only way to control disease progression. On the other hand, some BC patients relapse several years later. In such patients, oligometastases are occasionally diagnosed, because metastatic cancer cells are slowly growing and indolent. Oligometastatic BC is defined as low volume metastatic disease with limited number and size of metastatic lesions (up to five and not necessarily in the same organ). This definition is proposed in the Advanced Breast Cancer guidelines that are developed as a joint effort from European School of Oncology and European Society of Medical Oncology. Several retrospective studies demonstrated survival benefit of locoregional therapy in addition to systemic therapy. Locoregional therapy consisted of surgical resection, radiation therapy, ablation therapy, etc. However, it remains unclear about survival benefit of combined therapy in oligometastatic BC. To improve the standard of cancer treatment through the cooperate studies on more effective therapeutic strategies based on drugs, surgery and/or radiotherapy, Federation of Asian Clinical Oncology (FACO) was established in 2012 by Chinese Society of Clinical Oncology (CSCO), Korean Society of Medical Oncology (KSMO) and Japan Society of Clinical Oncology (JSCO). Thus, FACO conducted a retrospective cohort study on oligometastatic BC. The primary endpoint is to compare the estimated 5-year overall survival (OS) of oligometastatic BC patients treated with combined therapy and systemic therapy alone. To hypothesize that combined therapy has more advantage of OS in oligometastatic BC, the 5-year OS rates are expected to be 50% and 40%, respectively. The estimated sample size is calculated to be the number of 698 cases (349 cases in each group) needed to prove the superiority of survival with a two-sided type I error rate of 5% and a statistical power of 80%. Case registry opened in February 2018 and will close in January 2019. We planned to register 700 cases, i.e., 234 cases each from investigators of CSCO, KSMO and JSCO. Update information will be discussed.

Citation Format: Imoto S, Futamura M, Toi M, Fujiwara Y, Ueno T, Im Y-H, Im S-A, Ahn SG, Lee JE, Park YH, Wang K, Kitagawa Y, Nishiyama M. International retrospective cohort study of locoregional and systemic therapy in oligometastatic breast cancer (OLIGO-BC1) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-05-02.

Abstract P4-08-29: Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer

[Background]

In patients with node-negative (N0), hormone receptor-positive, human epidermal growth factor receptor (HER2) -negative (luminal) breast cancer, the impact of lymphatic invasion (ly) on the prognosis remains to be clarified.

[Methods]

Among 3,158 patients with primary breast cancers who underwent surgery in our institute from January 2007 to December 2009, we analyzed 1027 N0 luminal invasive breast cancers without preoperative systemic therapy. The luminal breast cancer was defined as hormone receptor-positive (ER of ≥ 10% or PgR of ≥ 10%) and HER2-negative (immunohistochemistry: 0, 1+ or FISH: ratio &lt; 2.0) cancer in the postoperative pathological specimen. ly was defined as positive when cancer cell nests were detected within the lymph duct in the whole specimen. N0 was confirmed pathologically by the sentinel lymph node biopsy in all the patients. The Fisher's exact test was used for comparison between different categories. The distant recurrence rate (DRR) was analyzed using the Kaplan-Meier method and the log-rank test. For multivariate analysis, Cox's regression analysis was performed.

[Results]

The median follow-up period was 103.8 months (range: 5.6-128.8). Recurrence with distant metastasis occurred in 26 patients (2.5%). There were 5 (0.7%) deaths related to breast cancer. ly was detected in 240 patients (23.4%). In the ly-positive group, the tumor size was larger (p = 0.007), and the nuclear grade (NG) was higher (p &lt; 0.001) than in the ly-negative group. Postoperative endocrine therapy (p &lt; 0.001) and postoperative chemotherapy (p &lt; 0.001) were more frequently employed for patients with ly-positive tumor. The univariate analysis showed that ly positivity (p &lt; 0.001), large tumor size (p &lt; 0.001), high NG (p &lt; 0.001), PgR negativity (p = 0.002) and the history of adjuvant chemotherapy (p &lt; 0.001) were associated with high DRR. In the multivariate analysis, large tumor size (p = 0.007) and PgR negativity (p = 0.015) remained significant. Although positive ly had a risk ratio of 2.2, it was not an independent risk factor.When restricted to T1 tumor (n = 899), the aforementioned factors still showed prognostic value in the univariate analysis, among which ly positivity (p = 0.004)remained significant together with PgR negativity (p = 0.047)in themultivariate analysis.The 8-year DRR was very favorable (0.8%) in patients with ly-negative T1N0 tumor while it was modest (6.6%) in patients with ly-positive T1N0 tumor (p &lt; 0.001). Only 1.3% of the patients had received adjuvant chemotherapy in the ly-negative group while 27% of the patients had in the ly-positive group.

[Conclusion]

Lymphatic invasion was associated with higher DRR although it was not independent in the multivariate analysis among patients with N0 luminal breast cancer. When restricted to patients with T1N0 luminal breast cancer, the presence of ly was independently associated with higher risk of distant recurrence. It suggests that the assessment of ly is clinically more relevant when considering treatment options for small luminal breast cancer.

Citation Format: Abe T, Ito Y, Fukada I, Shibayama T, Ono M, Kobayashi T, Kobayashi K, Takahashi S, Horii R, Akiyama F, Iwase T, Ueno T, Ohno S. Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-29.

Abstract P5-18-11: Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situof the breast

Background: By definition, ductal carcinoma in situ (DCIS) does not metastasize to the lymph nodes. However, since the introduction of molecular whole-node analysis using the one-step nucleic acid amplification (OSNA) assay for sentinel node (SN) biopsies, the number of DCIS patients with SN metastasis has increased. The clinical management of node-positive DCIS remains controversial because these patients can be treated as different stages based on the pathogenesis: e.g. occult invasive cancer with true nodal metastasis (T1N1) or true DCIS with iatrogenic dissemination of benign or tumor cells into lymph node (TisN0). In this retrospective cohort study, we aimed to elucidate the pathogenesis of nodal metastasis in DCIS and the clinical management of node-positive DCIS.

Patients and Methods: Subjects comprised of 427 patients with a routine postoperative diagnosis of DCIS who underwent SN biopsy using the OSNA assay between 2009 and 2012. The cut-off values of the OSNA assay for negative/positive results and micro/macrometastasis were defined at 250 and 5,000 copies/μL of cytokeratin 19 mRNA, respectively. In the SN-positive patients, all paraffin blocks containing the primary tumor were step-sectioned with 0.5-mm intervals until the tissue was exhausted, and all microscopic slides were examined for detecting occult invasions. Afterwards, the patients were classified into three cohorts based on the SN status and occult invasion: (1) no SN metastasis (TisN0), (2) SN metastasis without occult invasion (TisN1), and (3) SN metastasis with occult invasion (T1N1). Tumor characteristics including risk factors of occult invasions (e.g. large size, comedo-type), prognosis, and SN and non-SN status were compared among the three cohorts. The median follow-up time was 73.6 months.

Results: Of the 427 patients, 408 (95.6%) were SN-negative and 19 (4.4%) were SN-positive. By examining a total of 1,421 step-sectioned slides, 9 of the 19 SN-positive patients had occult invasions in the primary tumors. Overall, 408 (95.6%), 10 (2.3%), and 9 (2.1%) were classified into the TisN0, TisN1, and T1N1 cohorts, respectively. Either of adjuvant endocrine therapy or chemotherapy was given much more in the TisN1 and T1N1 cohorts than in the TisN0 cohort (80.0% and 88.9% vs. 5.4%).Other tumor characteristics were similar among the three cohorts. Although one patients had distant recurrence in the TisN0 cohort, none had locoregional or distant recurrences in the TisN1 and T1N1 cohorts. Regarding the lymph node status in the TisN1 and T1N1 cohorts, median tumor burdens in the SN are 590 and 310 copies/μL, and 2 (20.0%) and 2 (22.2%) patients had additional non-SN metastasis in the axillary dissection materials, respectively.

Conclusions: Tumor characteristics and prognosis were similar among the three cohorts albeit the TisN1 and T1N1 cohorts tended to received adjuvant systemic therapy. Moreover, the SN and non-SN status were similar between the TisN1 and T1N1 cohorts. Therefore, pathogenesis of nodal metastasis in DCIS cannot uniformly be explained, and tumors with different stages may be mixed in the node-positive DCIS. Thus, considering the favorable prognosis of node-positive DCIS, the clinical management should be determined on a case-by-case basis.

Citation Format: Yonekura R, Osako T, Iwase T, Ogiya A, Ueno T, Ohno S, Akiyama F. Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situof the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-11.

Abstract P3-03-23: Which factor of metastatic lymph nodes–The number, tumor volume or anatomical location–Is independently prognostic in breast cancer? - A prospective cohort study using molecular whole-node analysis of all removed axillary nodes

Background: Axillary lymph node status is one of the most powerful prognostic factors in breast cancer. However, it remains unknown which factor of metastatic lymph nodes–the number, tumor volume or anatomical location–is independently prognostic. Conventional pathological examinations of lymph nodes have limited ability to accurately measure metastatic tumor volume due to the partial evaluation of nodes. On the other hand, the one-step nucleic acid amplification (OSNA) assay, a novel molecular method, can quantify the tumor volume in a whole node based on cytokeratin 19 (CK19) mRNA copy number. In this prospective cohort studyusing the OSNA whole-node analysis, we aimed to elucidate the independent prognostic factor of lymph node metastasis in breast cancer.

Patients and Methods: The subjects consisted of 307 cN0 patients with invasive breast cancer, who underwent axillary dissection after a metastatic sentinel node (SN) biopsy and whose SNs and non-SNs were all examined using the OSNA whole-node assaybetween 2009 and 2012.The cut-off values of the OSNA assay for negative/positive results and micro/macrometastasis were defined at 250 and 5,000 copies/μL of CK19 mRNA, respectively. The total tumor volume in the SN or non-SN was defined as the sum of CK19 mRNA copy numbers from all samples in the SN or non-SN. The cut-off value for the total tumor volume in the SN was set at 2,810 copies/μL according to our previous study (Osako et al. Br J Cancer 2017). The anatomical location of metastasis was classified into Level I (confined to SN), Level I (spread to non-SN), or Level II/III. Predictive factors for distant disease-free survival (DDFS) were investigated using the univariate log-rank tests and multivariate Cox proportional hazards models.The median follow-up time was 6.1 years (range, 0.2–8.6).

Results: Of the 307 patients, 130 (42.3%) and 177 (57.7%) had the total tumor volume &lt;2,810 and ≥2,810 copies/μL in the SN, respectively. Five-year DDFS was 96.0% in the entire cohort. In the univariate analysis, DDFS was significantly related to the pT classification, grade, hormone receptor status, triple-negative subtype, total tumor volume in the SN and cytotoxic chemotherapy. However, DDFS was not significantly related to the number of metastatic or macrometastatic nodes in the SN, non-SN, or all nodes (i.e. SN + non-SN); the total tumor volume in the non-SN or all nodes; the AJCC pN classification; or the anatomical location of metastasis. In the multivariate analysis, the total tumor volume in the SN (&lt;2810 vs. ≥2810 copies/μL, hazard ratio 5.2, 95% confidence interval 1.2–23.2, P=0.03) and cytotoxic chemotherapy (- vs. +, hazard ratio 0.05, 95% confidence interval 0.02–0.17, P&lt;0.001) remained significant.

Conclusions: The total tumor volume in the SN was the independent prognostic factor of lymph node metastasis in SN-positive invasive breast cancer. Accurate evaluation of metastatic tumor burden in the SN can be important for predicting prognosis and may help to guide the precise therapeutic decision making for breast cancer patients.

Citation Format: Osako T, Iwase T, Ushijima M, Ogiya A, Ueno T, Ohno S, Akiyama F. Which factor of metastatic lymph nodes–The number, tumor volume or anatomical location–Is independently prognostic in breast cancer? - A prospective cohort study using molecular whole-node analysis of all removed axillary nodes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-23.

Morphometric geometrical analysis to determine the centre of the acetabular component placement in Crowe type IV hips undergoing total hip arthroplasty

AIMS

We analyzed the acetabular morphology of Crowe type IV hips using CT data to identify a landmark for the ideal placement of the centre of the acetabular component, as assessed by morphometric geometrical analysis, and its reliability.

PATIENTS AND METHODS

A total of 52 Crowe IV hips (42 patients; seven male, 35 female; mean age 68.5 years (32 to 82)) and 50 normal hips (50 patients; eight male, 42 female; mean age 60.7 years (34 to 86)) undergoing total hip arthroplasty were retrospectively identified. In this CT-based simulation study, the acetabular component was positioned at the true acetabulum with a radiological inclination of 40° and anteversion of 20°. Acetabular shape and the position of the centre of the acetabular component were analyzed by morphometric geometrical analysis using the generalized Procrustes analysis.

RESULTS

The acetabular shapes of Crowe IV hips were distinctively triangular; the ideal position of the centre of the acetabular component was superior on the posterior bony wall. The first and second relative warps explained 34.2% and 18.4% of the variance, respectively, compared with that of 28.6% and 18.0% in normal hips. We defined the landmark as one-third the distance from top on the posterior bony wall in Crowe IV hips. The average distance from the centre of the acetabular component was 5.6 mm.

CONCLUSION

Crowe IV hips are distinctively triangular; the point one-third from the top on the posterior bony wall was a useful landmark for placing the acetabular component.

Exposure-Response Analysis for Efficacy of Daclatasvir, Asunaprevir, and Beclabuvir Combinations in HCV-Infected Patients

The combination regimen of daclatasvir, asunaprevir, and beclabuvir (3DAA regimen) was developed as a fixed-dose combination for the treatment of hepatitis C virus (HCV) infection in Japan. The objectives of this analysis were to characterize the relationship between drug exposure and sustained virologic response at posttreatment week 12 (SVR12) in HCV-infected subjects and to evaluate the impact of demographic covariates and clinical factors on the exposure-response (E-R) relationship. The E-R efficacy analysis was performed with data from phase 2 and phase 3 studies in HCV-infected subjects treated with the 3DAA regimen. The relationship between the probability of achieving SVR12 and exposure to daclatasvir, asunaprevir, and beclabuvir was described using a logistic regression model and included assessments of the potential covariate effects. The impacts of the covariates on the rate of SVR12 and interactions of covariates with the individual drug effects were tested. The final model for SVR12 included effects of non-genotype-1a status, resistance-associated NS5A-Q30 substitution in genotype-1a subjects, and baseline RNA level on the intercept, and effect of prior peg-interferon failure on the beclabuvir slope. Sex, race, age, weight, fibrosis score, alanine transaminase, and cirrhosis status had no statistically significant impact on the rate of SVR12. The individual E-R relationships with each drug, were relatively flat, and the effects of exposure were not significant. With the exception of the NS5A-Q30 substitution in genotype-1a subjects, statistically significant covariate effects had little impact on SVR12 rates. Overall, the E-R model was developed that captured the high SVR12 rates and the effect of covariates for the 3DAA regimen in HCV-infected patients.

Impact of Donor Age on Outcome of Intestinal Transplantation in Japan

BACKGROUND

Donor age for intestinal transplantation (ITx) is somewhat younger than that for other solid organs. Clear criteria for adequate donors have not been established. There is a donor scarcity for ITx in Japan due to the shortage of young donors.

METHODS

We reviewed outcomes associated with ITx in Japan based on donor age for cadaveric and living donation.

RESULTS

Standardized report forms were sent to all known ITx programs, asking for information on ITxs performed between 1996 and 2016. All programs responded. Patient and graft survival estimates were obtained using the Kaplan-Meier method. Five institutions provided data on 27 grafts in 24 patients. There were 14 cadaveric and 13 living donor transplants. Median donor age for ITxs was 40 (range, 17-60) years. Graft survival at 5 years was 66% for patients >40 years old (n = 18) and 47% for those <40 years old (n = 9), not a statistically significant difference (P = .49). Graft survival at 5 years was 60% in those >50 years old (n = 5) and 57% for those <50 years old (n = 22), again not a significant difference (P = .27).

CONCLUSION

There is no difference in survival between for those with donor age <40 vs >40 years. Donor age for ITx can be extended from >40 to up to 50 years, which may help to mitigate the donor shortage. It will be necessary to clarify the donor criteria for ITx through accumulation of further data on ITx.

Pulmonary Arterial Pressure Management Based on Oral Medicine for Pediatric Living Donor Liver Transplant With Portopulmonary Hypertension

Pediatric living donor liver transplantation (LDLT) in patients with advanced portopulmonary hypertension (PoPH) is associated with poor prognoses. Recently, novel oral medications, including endothelin receptor antagonists (ERAs), phosphodiesterase 5 (PDE5) inhibitors, and oral prostacyclin (PGI2) have been used to treat PoPH. Pediatric patients with PoPH who underwent LDLT from 2006 to 2016 were enrolled. Oral pulmonary hypertension (PH) medication was administered to control pulmonary arterial pressure (PAP). Four patients had PoPH. Their ages ranged from 6 to 16 years, and their original diseases were biliary atresia (n = 2), portal vein obstruction (n = 1), and intrahepatic portal systemic shunt (n = 1). For preoperative management, 2 patients received continuous intravenous PGI2 and 2 oral medications (an ERA alone or an ERA and a PDE5 inhibitor), and 2 received only oral drugs (an ERA and a PDE5 inhibitor). One patient managed only with intravenous PGI2 died. In the remaining 3 cases, intravenous PGI2 or NO was discontinued before the end of the first postoperative week. Postoperative medications were oral PGI2 alone (n = 1), an ERA alone (n = 1), or the combination of an ERA and a PDE5 inhibitor (n = 1). An ERA was the first-line therapy, and a PDE5 inhibitor was added if there was no effect. New oral PH medications were effective and safe for use in pediatric patients following LDLT. In particular, these new oral drugs prevent the need for central catheter access to infuse PGI2.

Early Outcomes of Living-Donor Kidney Transplantation With Immunosuppression Therapy Induction With Tacrolimus Extended-Release: A Comparison With Cyclosporine

BACKGROUND

Extended-release tacrolimus (TacER), administered once daily, offers improved adherence with reduced side effects while still maintaining an immunosuppressive potency equivalent to that of conventional tacrolimus preparations.

METHODS

The study included 83 patients who received consecutive living-donor kidney transplants at our facility from June 2013 to December 2016. Comparisons were made between 48 cases of induction with TacER and 35 cases of induction with cyclosporine (CyA). The observation period was 3 months after transplantation. Transplanted kidney function, rejection, infectious disease, lipid abnormalities, and glucose tolerance were compared.

RESULTS

The 2 groups showed no significant difference in donor background or transplanted kidney function. Within the 3-month observation period, an acute rejection response was observed in 2 cases in the TacER group and in 8 cases in the CyA group. After transplantation, hyperlipidemia requiring medication was observed more frequently in the CyA group. The 2 groups did not show a marked difference in systemic infection or renal calcineurin inhibitor toxicity in histopathologic examination of the transplanted kidneys 3 months after surgery.

DISCUSSION

Proactive use of TacER leads to improved adherence while yielding immunosuppressive potency equivalent to that of conventional tacrolimus preparations; however, tacrolimus has a potent blood sugar-elevating effect; thus, direct comparison with the CyA group is important for assessing the side effects.

CONCLUSION

TacER has the potential to also reduce side effects in the early stages after surgery, suggesting its potential as a drug of first choice.

Pharmacokinetic/Pharmacodynamic Analysis for Doripenem Regimens in Intensive Care Unit Patient

Doripenem (DRPM) is a broad-spectrum antibacterial agent often used as empirical therapy for critically ill patients, although there is a lack of studies validating the recommended dosage regimen for patients admitted to intensive care unit (ICU), based on pharmacokinetic (PK)/pharmacodynamic (PD) index. In this study, we estimated the free time above minimum inhibitory concentration (fT>MIC (%)) of DRPM using population PK analysis of 12 patients in ICU, and evaluated the validity of the dosage regimen stratified by creatinine clearance. Using a 2-compartment population PK model reported previously, the mean total clearance or distribution volume of DRPM estimated by Bayesian estimation was significantly lower or higher than that of based on population PK model. The estimated fT>MIC (%) of the recommended standard (normal renal function: 0.5 g every 8 h, moderate: 0.25 g every 8 h, severe renal impairment: 0.25 g every 12 h) and higher doses (normal: 1.0 g every 8 h, moderate: 0.5 g every 8 h, severe: 0.25 g every 8 h) against MICs of 0.5, 1 and 2 µg/mL exceeded 40% in all patients. When stratified by creatinine clearance, the PK/PD breakpoints estimated by Monte Carlo simulation in three grades of renal function tended to be higher than the previously reported PK/PD breakpoints for patients with urinary tract infection, an infection of lesser severity than ICU patients. These results suggest that the dosage regimen stratified by renal function derived from Japanese package insert may be sufficient to achieve effective treatment in ICU patients.

Pathway level alterations rather than mutations in single genes predict response to HER2-targeted therapies in the neo-ALTTO trial

Background

We performed whole-exome sequencing of pretreatment biopsies and examined whether genome-wide metrics of overall mutational load, clonal heterogeneity or alterations at variant, gene, and pathway levels are associated with treatment response and survival.

Patients and Methods

Two hundred and three biopsies from the NeoALTTO trial were analyzed. Mutations were called with MuTect, and Strelka, using pooled normal DNA. Associations between DNA alterations and outcome were evaluated by logistic and Cox-proportional hazards regression.

Results

There were no recurrent single gene mutations significantly associated with pathologic complete response (pCR), except PIK3CA [odds ratio (OR) = 0.42, P = 0.0185]. Mutations in 33 of 714 pathways were significantly associated with response, but different genes were affected in different individuals. PIK3CA was present in 23 of these pathways defining a ‘trastuzumab resistance-network’ of 459 genes. Cases with mutations in this network had low pCR rates to trastuzumab (2/50, 4%) compared with cases with no mutations (9/16, 56%), OR = 0.035; P < 0.001. Mutations in the ‘Regulation of RhoA activity’ pathway were associated with higher pCR rate to lapatinib (OR = 14.8, adjusted P = 0.001), lapatinib + trastuzumab (OR = 3.0, adjusted P = 0.09), and all arms combined (OR = 3.77, adjusted P = 0.02). Patients (n = 124) with mutations in the trastuzumab resistance network but intact RhoA pathway had 2% (1/41) pCR rate with trastuzumab alone (OR = 0.026, P = 0.001) but adding lapatinib increased pCR rate to 45% (17/38, OR = 1.68, P = 0.3). Patients (n = 46) who had no mutations in either gene set had 6% pCR rate (1/15) with lapatinib, but had the highest pCR rate, 52% (8/15) with trastuzumab alone.

Conclusions

Mutations in the RhoA pathway are associated with pCR to lapatinib and mutations in a PIK3CA-related network are associated with resistance to trastuzumab. The combined mutation status of these two pathways could define patients with very low response rate to trastuzumab alone that can be augmented by adding lapatinib or substituting trastuzumab with lapatinib.