Prospective Randomized Controlled Trial Comparing Absorbable and Nonabsorbable Sutures in A1 Pulley Release

BACKGROUND

Both absorbable and nonabsorbable sutures are used to correct palmar incisions or lacerations. Nonabsorbable sutures have been used without complications but require removal at a follow-up appointment. Alternatively, the use of absorbable sutures has increased in popularity as postoperative suture removal is not required but is associated with local immunological and inflammatory responses. In this study, we compared the scar quality and outcomes of nonabsorbable and absorbable sutures in A1 pulley release.

METHODS

Patients who underwent A1 pulley release were randomized to 1 of 2 suture materials. The Patient Scar Assessment Scale, Observer Scar Assessment Scale, Visual Analogue Scale, and Disabilities of the Arm, Shoulder, and Hand scores were collected at 2, 6, and 12 weeks postoperatively. Among the 41 patients included in the study, 23 were randomized to the nonabsorbable suture group, and 18 to the absorbable suture group.

RESULTS

There were no significant differences between the two suture groups in the aforementioned assessments. Complication rates were higher in the nonabsorbable suture group, but the difference was not statistically significant. Notably, 1 case in the absorbable suture group had uncontrolled postoperative bleeding and required reoperation.

CONCLUSION

We found no significant difference between the two materials in terms of the Patient or Observer Scar Assessment Scales, overall complication rates, symptom scores, or pain scores. Therefore, the choice using absorbable or nonabsorbable can be guided by other factors such as physician or patient preference, availability, and cost.

Comparison of Early Outcomes of Stereotactic Accelerated Partial Breast Irradiation vs. Volumetric Modulated Arc Therapy-Based FAST-FORWARD Whole Breast Irradiation for Breast Cancer

PURPOSE/OBJECTIVE(S)

Despite evidence supporting APBI from 8 published prospective randomized trials enrolling over 10,000 women, the uptake of APBI in clinical practice is surprisingly low. This is being exacerbated by a new, convenient, and safe shortened WBI schedule. Here, we report the dosimetric and early outcome analyses of the first >1000 patients treated at our institution since the first adoption of stereotactic APBI and the ultra-hypofractionated WBI regimen.

MATERIALS/METHODS

From 2016 to 2022, 801 women with breast cancers in the suitable or cautionary categories according to the ASTRO APBI consensus panel guidelines, received 30 Gy in 5 fractions (92%) either using a robotic stereotactic radiation system (83%) or stereotactic volumetric-based arc therapy (VMAT, 17%). Between 2020 and 2022, 468 women, who were not candidates for APBI and not undergoing any regional irradiation received 26 Gy in 5 fractions using VMAT to the whole breast with the addition of cardiac sparing technique in left-sided breast cancer patients. Tumor bed boosts were delivered in 99% of FF-WBI patients. We evaluated dose-volume histogram parameters for target volumes and organs-at-risk and radiation-related toxicities during RT or within 6 months after the end of RT.

RESULTS

Target volume coverage was acceptable in both groups, with mean 96% of the target volumes receiving 95% of the prescribed doses and 0 cm3 within target volumes exceeding 105% of the prescribed doses. S-APBI resulted in small, but statistically significant, reductions in the radiation dose delivered to the ipsilateral breast, contralateral breast, lungs, heart, and coronary artery compared with FF-WBI. Comparing WBI to APBI, the mean contralateral breast dose, ipsilateral lung V20 Gy, mean contralateral lung dose, and mean heart dose, were reduced by 89%, 78%, 73%, and 29%, respectively. With median follow-up periods of 32 months for s-APBI and 19 months for FF-WBI, acute toxicity was assessable in all patients. The risks of any grade acute toxicity were 21% for s-APBI and 25% for FF-WBI (p = .117). Among them, grade 2 rates were 1.3% in both groups and no severe toxicity has been reported.

CONCLUSION

We found s-APBI and VMAT-based FF WBI were associated with favorable dosimetric and acute toxicity profiles. However, considering significantly less irradiated volume in the breast, lungs, and heart, APBI with advanced available technique options should be considered over any WBI-based approach for patients at low risk for local recurrence.

Patterns and Longitudinal Changes in The Practice of Breast Cancer Radiotherapy in Korea: Korean Radiation Oncology Group 22-01

PURPOSE/OBJECTIVE(S)

To analyze contemporary practice patterns in breast cancer radiotherapy (RT) and to assess longitudinal changes therein over 5 years in Korea.

MATERIALS/METHODS

A nationwide survey was conducted among board-certified radiation oncologists in Korea by the Division for Breast Cancer of the Korean Radiation Oncology Group in March 2022. The survey consisted of 44 questions related to six domains: hypofractionated (HypoFx) whole breast RT, accelerated partial breast RT (APBI), regional nodal irradiation (RNI), RT for ductal carcinoma in situ (DCIS), postmastectomy RT (PMRT), and tumor bed boost.

RESULTS

In total, 70 radiation oncologists from 61 of 101 (60%) institutions participated in the survey. HypoFx RT was used by 62 respondents (89%), which has significantly increased from 36% in 2017. The HypoFx RT was commonly administered at 40-42.5 Gy in 15-16 fractions. APBI was used by 12 respondents (17%), which has increased from 5% in 2017. The use of RNI did not change significantly: ≥ pN2 (6%), ≥ pN1 (33%), and ≥ pN1 with pathological risk factors (61%). However, the indications for use of internal mammary lymph node (IMN) irradiation have expanded. In particular, the rates of routine treatment of IMN (11% from 6% in 2017) and treatment in cases of ≥ pN2 (27% from 14% in 2017) have doubled; however, the rate of treatment for only IMN involvement, identified on imaging, has decreased to 31% from 47% in 2017. With regard to DCIS, the use of hypoFx RT increased to 75% from 25%, and the rate of omission on of RT after breast-conserving surgery decreased to 38% from 48% in 2017. The use of hypoFx RT for PMRT also increased to 36% from 8% in 2017.

CONCLUSION

The adoption of HypoFx RT after breast-conserving surgery in invasive breast cancer and DCIS has increased significantly, whereas that for PMRT has increased moderately, compared to 2017. Further studies are required to determine the optimal use of RNI.

Cancer-associated fibroblast-derived secreted phosphoprotein 1 contributes to resistance of hepatocellular carcinoma to sorafenib and lenvatinib

BACKGROUND

Cancer-associated fibroblasts (CAFs) play an important role in the induction of chemo-resistance. This study aimed to clarify the mechanism underlying CAF-mediated resistance to two tyrosine kinase inhibitors (TKIs), sorafenib and lenvatinib, and to identify a novel therapeutic target for overcoming TKI resistance in hepatocellular carcinoma (HCC).

METHODS

We performed a systematic integrative analysis of publicly available gene expression datasets and whole-transcriptome sequencing data from 9 pairs of CAFs and para-cancer fibroblasts isolated from human HCC and para-tumor tissues, respectively, to identify key molecules that might induce resistance to TKIs. We then performed in vitro and in vivo experiments to validate selected targets and related mechanisms. The associations of plasma secreted phosphoprotein 1 (SPP1) expression levels before sorafenib/lenvatinib treatment with progression-free survival (PFS) and overall survival (OS) of 54 patients with advanced HCC were evaluated using Kaplan-Meier and Cox regression analysis.

RESULTS

Bioinformatic analysis identified CAF-derived SPP1 as a candidate molecule driving TKI resistance. SPP1 inhibitors reversed CAF-induced TKI resistance in vitro and in vivo. CAF-derived SPP1 activated rapidly accelerated fibrosarcoma (RAF)/mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) through the integrin-protein kinase C-alpha (PKCα) signaling pathway and promoted epithelial-to-mesenchymal transition (EMT). A high plasma SPP1 level before TKI treatment was identified as an independent predictor of poor PFS (P = 0.026) and OS (P = 0.047) in patients with advanced HCC after TKI treatment.

CONCLUSIONS

CAF-derived SPP1 enhances TKI resistance in HCC via bypass activation of oncogenic signals and EMT promotion. Its inhibition represents a promising therapeutic strategy against TKI resistance in HCC. Moreover, plasma SPP1 level before TKI treatment represents a potential biomarker for treatment response prediction.

Does spinopelvic motion change after total hip arthroplasty?

PURPOSE

Spinopelvic motion plays an important role in functional acetabular cup position after total hip arthroplasty (THA). Sacral slope (SS) has been a useful surrogate for spinopelvic motion. The present study aimed to investigate statistical characteristics of spinopelvic motion before and after THA using changes in SS in supine, standing, and sitting positions.

METHODS

A total of 76 patients (88 hips) were assessed. To classify spinopelvic mobility, defined as a change in SS from standing to sitting position (ΔSS_stand/sit), 10° ≤ ΔSS_stand/sit ≤ 30°, ΔSS_stand/sit < 10°, and ΔSS_stand/sit > 30° were considered normal, stiff, and hypermobile, respectively.

RESULTS

Over ± 7° changes in SS between before and one year after THA were observed in 39 (44.3%) hips in the sitting position, 19 (21.6%) hips in the supine position, seven (7.9%) in the standing position. Percentages of hips with stiff spinopelvic mobility (11.4% vs. 22.7%) and hypermobile spinopelvic mobility (23.9% vs. 12.5%) between before THA and one year after THA were significantly different (p = 0.034 and p = 0.016, McNemar's test). At one year after THA, 40.0% (4/10) of hips with stiff spinopelvic mobility and 57.1% (12/21) of hips with hypermobile spinopelvic mobility shifted to normal spinopelvic mobility.

CONCLUSIONS

Change in SS between before THA and one year after THA had a high inter-subject variability especially in the sitting position. In addition, there was a distinct shift to normal spinopelvic mobility postoperatively in hips with stiff and hypermobile spinopelvic mobility pre-operatively.

Objective Assessment of Countries' National Action Plans on Antimicrobial Resistance

The Article Abstract is not available.  

Safety and Efficacy of Stent-Assisted Coiling of Unruptured Intracranial Aneurysms Using Low-Profile Stents in Small Parent Arteries

BACKGROUND AND PURPOSE

Stent-assisted coiling of intracranial aneurysms arising from small vessels (≤ 2.0 mm) is a common procedure. However, data regarding its treatment outcomes are scarce. This study evaluated the clinical and radiologic outcomes of stent-assisted coiling using low-profile stents for aneurysms of small parent arteries.

MATERIALS AND METHODS

From November 2015 to October 2020, sixty-four patients with 66 aneurysms arising from parent arteries of ≤2.0 mm were treated with stent-assisted coiling using a Low-Profile Visualized Intraluminal Support Junior (LVIS Jr) or the Neuroform Atlas stent in a single institution. The clinical and radiologic data were retrospectively reviewed, and the risk factors for procedure-related complications were evaluated.

RESULTS

The LVIS Jr and Neuroform Atlas stents were used in 22 (33.3%) and 44 (66.7%) cases, respectively. Technical success was achieved in 66 cases (100%). Immediate postprocedural aneurysm occlusion grades assessed by the Raymond-Roy occlusion classification were I (57.6%), II (19.7%), and III (22.7%), respectively. Procedure-related complications occurred in 10 cases (15.2%), with 8 thromboembolic complications (12.1%) and 2 hemorrhagic complications (3.0%). Procedure-related morbidity was 4.5% without mortality. On multivariate analysis, current smoking (odds ratio = 7.1, P = .021) had a statistically significant effect on procedure-related complications.

CONCLUSIONS

Stent-assisted coiling of intracranial aneurysms with low-profile stents in small vessels (≤ 2.0 mm) had a 100% success rate and a 15.2% overall complication rate with 4.5% morbidity. Current smoking was a significant risk factor associated with procedure-related complications.

Urgent Action on Tackling Antibiotic Resistance

The article's abstract is not available.  

A Diagnostic Method for Gastric Cancer Using Two-Photon Microscopy With Enzyme-Selective Fluorescent Probes: A Pilot Study

BACKGROUND

Endoscopy is the most important tool for gastric cancer diagnosis. However, it relies on naked-eye evaluation by endoscopists, and the histopathologic confirmation is time-consuming. We aimed to visualize and measure the activity of various enzymes through two-photon microscopy (TPM) using fluorescent probes and assess its diagnostic potential in gastric cancer.

METHODS

β-Galactosidase (β-gal), carboxylesterase (CES), and human NAD(P)H: quinone oxidoreductase (hNQO1) enzyme activities in the normal mucosa, ulcer, adenoma, and gastric cancer biopsy samples were measured using two-photon enzyme probes. The fluorescence emission ratio at long and short wavelengths (Ch2/Ch1) for each probe was comparatively analyzed. Approximately 8,000 - 9,000 sectional images in each group were obtained by measuring the Ch2/Ch1 ratio according to the tissue depth. Each probe was cross-validated by measuring enzymatic activity from a solution containing lysed tissue.

RESULTS

Total of 76 subjects were enrolled in this pilot study (normal 21, ulcer 18, adenoma 17, and cancer 20 patients, respectively). There were significant differences in the mean ratio values of β-gal (0.656 ± 0.142 vs. 1.127 ± 0.109, P < 0.001) and CES (0.876 ± 0.049 vs. 0.579 ± 0.089, P < 0.001) between the normal and cancer, respectively. The mean ratio value of cancer tissues was different compared to ulcer and adenoma (P < 0.001). The hNQO1 activity showed no significant difference between cancer and other conditions. Normal mucosa and cancer were visually and quantitatively distinguished through β-gal and CES analyses using TPM images, and enzymatic activity according to depth, was determined using sectional TPM ratiometric images. The results obtained from lysis buffer-treated tissue were consistent with TPM results.

CONCLUSIONS

TPM imaging using ratiometric fluorescent probes enabled the discrimination of gastric cancer from normal, ulcer, and adenoma. This novel method can help in a visual differentiation and provide quantitative depth profiling in gastric cancer diagnosis.

Factors affecting the diagnostic yield of endoscopic transpapillary forceps biopsy in patients with malignant biliary strictures

BACKGROUND AND AIM

Transpapillary biliary forceps biopsy (TBFB) is a common method to obtain histological evidence for the differential diagnosis of biliary stricture. This study aimed to evaluate the factors associated with a positive cancer diagnosis from TBFB and the number of tissue samples required to increase the diagnostic yield in patients with malignant biliary strictures.

METHODS

A total of 376 patients who underwent TBFB for investigation of biliary stricture were included. Factors affecting the diagnostic yield of TBFB were determined using univariate analysis and multivariate logistic regression analyses.

RESULTS

Bile duct cancer (odds ratio [OR] = 3.50, P = 0.002), intraductal growing type (OR = 9.01, P = 0.001), and number of tissue samples (n < 5 vs 5 ≤ n < 10, OR = 4.13, P = 0.01; n < 5 vs n ≥ 10, OR = 12.25, P < 0.001; 5 ≤ n < 10 vs n ≥ 10, OR = 2.97, P = 0.046) were significant factors associated with positive results for malignancy. In patients with periductal infiltrating-type bile duct cancer, the number of tissue samples was a significant factor for diagnostic sensitivity (54.3% in the n < 5 group, 83.3% in the 5 ≤ n < 10 group and 98.2% in the n ≥ 10 group) (P < 0.001).

CONCLUSIONS

Bile duct cancer, intraductal growing type, and five or more tissue samples were significant predictors of positive TBFB results in patients with malignant biliary stricture. Increasing the number of tissue samples by five or more led to higher sensitivity in bile duct cancer patients with the periductal infiltrating type.

The effects of a single-dose subacromial injection of a nonsteroidal anti-inflammatory drug in geriatric patients with subacromial impingement syndrome: a randomized double-blind study

Background

As nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids have similar effects, steroids can be avoided to reduce adverse effects. This study aimed to compare the differences in symptom improvement after subacromial injection of steroids or NSAIDs.

Methods

Sixty patients with rotator cuff syndrome for at least 3 months were enrolled and divided into steroid and NSAID groups. The steroid group received a mixture of 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of lidocaine hydrochloride 2%, while the NSAID group received a mixture of 1 mL of Ketorolac Tromethamine (30 mg/mL) and 1 mL of lidocaine hydrochloride 2%. The patients were assessed before and at 3, 6, and 12 weeks after the procedure. Shoulder scores from visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) were used for evaluation.

Results

Both groups showed improvements in the clinical outcomes. Overall VAS, ASES, and UCLA scores improved from 6.9, 32.7, and 16.0 before the procedure to 2.0, 1.2, and 1.1; 81.5, 87.6, and 88.5; and 29.7, 31.8, and 32.0 at weeks 3, 6, and 12 weeks after the procedure, respectively. Twenty-six patients (86.7%) in the steroid group and 28 (93.3%) in the NSAID group reported satisfactory treatment outcomes. There were no significant differences in the outcomes between the two groups (p=0.671).

Conclusions

Subacromial injection of NSAIDs for rotator cuff tendinitis with shoulder pain had equivalent outcomes with those of steroid injection at the 12-week follow-up.

Cytomegalovirus-Associated Hemophagocytic Syndrome Diagnosed by Liver Biopsy in a Kidney Transplant Recipient

Hemophagocytic syndrome (HPS) is a rare but potentially life-threatening disease in kidney transplant recipients, and is caused by systemic proliferation of macrophages actively phagocytizing other blood cells in the bone marrow, lymph nodes, and the spleen. Here, we report a 40-year-old male kidney transplant recipient who presented with fever, bicytopenia, and elevated liver enzymes 2 months after transplantation. Given that cytomegalovirus antigenemia and real-time polymerase chain reaction tests were positive, liver biopsy was performed under an assumption of cytomegalovirus-induced hepatitis. Hepatic histology revealed multifocal microabscess with cytomegalovirus inclusion bodies, marked Kupffer cell hyperplasia, and erythrophagocytosis by activated macrophages. As laboratory findings such as hyperferritinemia, elevated serum lactate dehydrogenase, low natural killer cell activity, and high soluble interleukin-2 receptor were also compatible with HPS, the recipient was diagnosed as having cytomegalovirus-induced hepatitis combined with reactive HPS. Following intravenous ganciclovir therapy with continuous administration of tacrolimus and corticosteroid, the symptoms resolved and laboratory findings were normalized. As far as we know, this is the first report of cytomegalovirus-induced hepatitis combined with reactive HPS in a kidney transplant recipient that is diagnosed by liver biopsy.

Comparison of the Effectiveness of Three Lumbosacral Orthoses on Early Spine Surgery Patients: A Prospective Cohort Study

Objective

To compare the convenience and effectiveness of the existing lumbosacral orthoses (LSO) (classic LSO and Cybertech) and a newly developed LSO (V-LSO) by analyzing postoperative data.

Methods

This prospective cohort study was performed from May 2019 to November 2019 and enrolled and analyzed 88 patients with degenerative lumbar spine disease scheduled for elective lumbar surgery. Three types of LSO that were provided according to the time of patient registration were applied for 6 weeks. Patients were randomized into the classic LSO group (n=31), Cybertech group (n=26), and V-LSO group (n=31). All patients were assessed using the Oswestry Disability Index (ODI) preoperatively and underwent plain lumbar radiography (anteroposterior and lateral views) 10 days postoperatively. Lumbar lordosis (LS angle) and frontal imbalance were measured with and without LSO. At the sixth postoperative week, a follow-up assessment with the ODI and orthosis questionnaire was conducted.

Results

No significant differences were found among the three groups in terms of the LS angle, frontal imbalance, ODI, and orthosis questionnaire results. When the change in the LS angle and frontal imbalance toward the reference value was defined as a positive change with and without LSO, the rate of positive change was significantly different in the V-LSO group (LS angle: 41.94% vs. 61.54% vs. 83.87%; p=0.003).

Conclusion

The newly developed LSO showed no difference regarding its effectiveness and compliance when compared with the existing LSO, but it was more effective in correcting lumbar lordosis.

Association Between Waiting Time from Diagnosis to Endoscopic Submucosal Dissection and Non-curative Resection in Gastric Neoplasm

BACKGROUND/AIM

Currently, there are no standard guidelines for the waiting time from the diagnosis of gastric neoplasms to endoscopic submucosal dissection (ESD).

PATIENTS AND METHODS

A total of 1,605 patients who had undergone ESD for early gastric cancer (EGC) or high-grade dysplasia (HGD) were enrolled. Waiting time for ESD was defined as the time from the first diagnosis to ESD. Multivariable logistic regression analysis was conducted.

RESULTS

The curative resection rate was 86.8% and the mean waiting time was 36.8 days. In the multivariable model, longer waiting time did not significantly affect non-curative resection, whereas age >70 years, submucosal fibrosis, and initial cancer diagnosis were significantly associated with non-curative resection. Waiting time was still not identified as a risk factor for non-curative resection in EGC and HGD groups.

CONCLUSION

A longer waiting time from diagnosis to ESD was not associated with non-curative resection.

Potential Benefits of Allogeneic Haploidentical Adipose Tissue-Derived Stromal Vascular Fraction in a Hutchinson-Gilford Progeria Syndrome Patient

Hutchinson-Gilford progeria syndrome (HGPS) is a rare, fatal, and genetic disorder in the LMNA gene encoding for prelamin A. Normally, prelamin A is processed to become lamin A protein. In HGPS patients, there is a heterozygous mutation in LMNA gene, in which there is a deletion of genetic codes responsible for 50 amino acids at the C-terminus of prelamin A. The processing of the abnormal prelamin A results in abnormal lamin A protein, called progerin, causing symptoms of accelerated early aging, probably due to the inflammaging process. It is well known that adipose tissue-derived mesenchymal stem cells (MSCs) have anti-inflammatory effects by modulating inflammatory cytokines and by extracellular vesicles. Here, we present a case of an HGPS patient who responded positively to injections of allogeneic haploidentical adipose tissue-derived stromal vascular fractions containing MSCs by showing rapid height and weight growth along with increased blood level of insulin-like growth factor 1.

Controlled decompression of large ovarian cystic tumors via mini-laparotomy using Dermabond Advanced™

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Using surgical glue and a glove, we decompress and remove a large ovarian tumor.

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The seal created by the Dermabond Advanced^TM prevents spillage of tumor contents.

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The technique uses low cost materials that are found in most operating rooms.

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The method has been successfully used on masses as large as 29 cm.

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This method can be used when a large cyst needs to be drained without spillage.

Large cystic ovarian tumors usually require surgical removal because of symptoms and the possibility of malignancy. The ideal surgical approach would minimize the risk of spillage of tumor contents while minimizing surgical morbidity. The present study aims to demonstrate a novel technique to drain large cystic ovarian tumors without spillage. A mini-laparotomy is performed and the tumor surface is exposed. Dermabond Advanced™ (USA Medical and Surgical Supplies 2019a) is applied to the tumor and a surgical glove (USA Medical and Surgical Supplies 2019b) is applied to the glue area. A small incision is made in the center of the portion of the glove that is adherent to the tumor. The cyst fluid is allowed to drain into the glove where it is suctioned away, collapsing the tumor. Once the tumor is sufficiently decompressed, it is exteriorized and resected with the glove still attached. The technique was initially developed in a pig model and subsequently successfully performed by mini-laparotomy on two patients with >20 cm ovarian masses. This novel technique uses inexpensive and readily available materials for draining large cystic ovarian tumors without spillage so that they can be removed via mini-laparotomy.

Efficacy and Safety of Flow-Diverter Therapy for Recurrent Aneurysms after Stent-Assisted Coiling

BACKGROUND AND PURPOSE

Flow-diverter treatment for previously stented aneurysms has been reported to be less effective and prone to complications. In this study, we evaluated the effectiveness and safety of flow diverters for recurrent aneurysms after stent-assisted coiling.

MATERIALS AND METHODS

Patients who underwent flow-diverter placement for recurrent aneurysms after stent-assisted coiling between March 2015 and March 2019 were recruited. Clinical and radiographic characteristics and clinical and angiographic outcomes were retrospectively evaluated.

RESULTS

Among 133 patients who underwent flow-diverter insertion, 17 (male/female ratio = 5:12; mean age, 53.8 years) were treated for recurrent aneurysms after stent placement with (n = 16) or without (n = 1) coiling. Eight patients initially presented with subarachnoid hemorrhage; 7, with headache; and 2, with visual field defects. Angiographic morphology included large/giant saccular in 12 patients, dissecting in 2, fusiform in 1, traumatic pseudoaneurysm in 1, and ruptured blood blister-like aneurysm in 1. The duration between the first treatment and flow-diverter placement ranged from 2 weeks to 15 months (median, 6 months). Flow-diverter placement was successful in all cases without any complications. All patients had favorable outcomes (mRS, 0-2), without any newly appearing symptoms. Aneurysms were followed up with conventional angiography at least once in 6-18 months. Sixteen aneurysms showed complete occlusion, and 1 aneurysm was enlarged.

CONCLUSIONS

Results from this case series investigating flow-diverter placement for recurrent aneurysms after stent-assisted coiling suggested that the procedure is safe and effective. Further study in a larger population may be warranted.

Single-Arm Phases 1 and 2 Trial of Niraparib in Combination With Pembrolizumab in Patients With Recurrent Platinum-Resistant Ovarian Carcinoma

IMPORTANCE

Patients with recurrent ovarian carcinoma frequently develop resistance to platinum-based chemotherapy, at which time treatment options become limited.

OBJECTIVE

To evaluate the poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitor niraparib combined with pembrolizumab in patients with recurrent ovarian carcinoma.

DESIGN, SETTING, AND PARTICIPANTS

The TOPACIO/KEYNOTE-162 (Niraparib in Combination With Pembrolizumab in Patients With Triple-Negative Breast Cancer or Ovarian Cancer) trial, an open-label, single-arm phases 1 and 2 study enrolled women with advanced or metastatic triple-negative breast cancer (TNBC) or recurrent ovarian carcinoma, irrespective of BRCA mutation status. Median follow-up was 12.4 months (range, 1.2 to ≥23.0 months). Data were collected from April 15, 2016, through September 4, 2018, with September 4, 2018, as a data cutoff, and analyzed from September 4, 2018, through January 30, 2019.

INTERVENTIONS

The recommended phase 2 dose (RP2D) was 200 mg of oral niraparib once daily and 200 mg of intravenous pembrolizumab on day 1 of each 21-day cycle.

MAIN OUTCOMES AND MEASURES

The primary objectives of phase 1 were to evaluate dose-limiting toxic effects and establish the RP2D and dosing schedule. The primary objective of phase 2 was to assess objective response rate (ORR; complete plus partial responses). Results from the phase 1 ovarian carcinoma and TNBC cohorts and phase 2 ovarian carcinoma cohort are reported. Because of the similarity in the phase 1 and 2 ovarian carcinoma populations, the data were pooled to perform an integrated efficacy analysis.

RESULTS

Fourteen patients (9 with ovarian carcinoma and 5 with TNBC) in phase 1 and 53 patients with ovarian carcinoma in phase 2 were enrolled, for a pooled ovarian carcinoma cohort of 62 patients (median age, 60 years [range, 46-83 years]). In the integrated efficacy phases 1 and 2 ovarian carcinoma population (60 of 62 evaluable patients), ORR was 18% (90% CI, 11%-29%), with a disease control rate of 65% (90% CI, 54%-75%), including 3 (5%) with confirmed complete responses, 8 (13%) with confirmed partial responses, 28 (47%) with stable disease, and 20 (33%) with progressive disease. The ORRs were consistent across subgroups based on platinum-based chemotherapy sensitivity, previous bevacizumab treatment, or tumor BRCA or homologous recombination deficiency (HRD) biomarker status. Median duration of response was not reached (range, 4.2 to ≥14.5 months). At data cutoff, 2 patients with a response and 1 patient with stable disease continued to receive treatment.

CONCLUSIONS AND RELEVANCE

Niraparib in combination with pembrolizumab is tolerable, with promising antitumor activity for patients with ovarian carcinoma who have limited treatment options regardless of platinum status, biomarker status, or prior treatment with bevacizumab. Responses in patients without tumor BRCA mutations or non-HRD cancers were higher than expected with either agent as monotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02657889.

Abstract P3-12-12: Impact of regional nodal irradiation for breast cancer patients with supraclavicular and/or internal mammary lymph node involvement: A multicenter, retrospective study (KROG 16-14)

Purpose: To evaluate the treatment outcomes of radiotherapy (RT) for breast cancer with ipsilateral supraclavicular (SCL) and/or internal mammary (IMN) lymph node involvement.

Methods: A total of 353 patients from 11 institutions were included. One hundred and thirty-six patients had SCL involvement, 148 had IMN involvement, and 69 had both. All patients received neoadjvant systemic therapy followed by breast conserving surgery or mastectomy, and postoperative RT to whole breast/chest wall. As for regional lymph node irradiation, SCL RT was given to 344 patients, and IMN RT to 236 patients. The median RT dose was 50.4 Gy.

Results: The median follow-up duration was 61 months (range, 7-173). In-field progression was present in SCL (n=20) and/or IMN (n=7). The 5-year disease-free survival (DFS) and overall survival rates were 57.8% and 75.1%, respectively. On multivariate analysis, both SCL/IMN involvement, number of axillary lymph node ≥4, triple negative subtype, and mastectomy were significant adverse prognosticators for DFS (p = 0.022, 0.001, 0.001, and 0.004, respectively). Regarding the impact of regional nodal irradiation, SCL RT dose ≥54 Gy was not associated with DFS (5-yr rate, 52.9% vs. 50.9%, p = 0.696) in SCL-involved patients, and the receipt of IMN RT was not associated with DFS (5-yr rate, 56.1% vs. 78.1%, p = 0.099) in IMN-involved patients.

Conclusion: Neoadjuvant chemotherapy followed by surgery and postoperative RT achieved an acceptable in-field regional control rate in patients with SCL and/or IMN involvement. However, a higher RT dose to SCL or IMN RT was not associated with the improved DFS in these patients.

Citation Format: Kim K, Jeong Y, Shin KH, Kim JH, Ahn SD, Kim SS, Suh C-O, Kim YB, Choi DH, Park W, Cha J, Chun M, Lee DS, Lee SY, Kim JH, Park HJ. Impact of regional nodal irradiation for breast cancer patients with supraclavicular and/or internal mammary lymph node involvement: A multicenter, retrospective study (KROG 16-14) [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 P3-12-12.

Reuse of Living-Donor Liver Graft in Second Recipient with Long-Term Survival

Brain death is a rare situation after living-donor liver transplantation. However, the recipient who suffers from brain death and has functional liver graft is a potential liver donor. We report the 1st case of successful reuse of extended right living-donor liver graft after brain death of the first recipient. The first recipient, who had acute liver failure caused by hepatitis A virus, experienced brain death on the 2nd day after the transplantation. The allograft had a favorable regeneration and functional recovery. On the 7th day, the allograft was procured with a patent hepatic artery, bile duct, portal vein, and reconstructed outflow (right hepatic vein and middle hepatic vein) and successfully implanted into the second recipient. The second recipient has experienced a long-term survival without any complications.

Analysis of endoscopic features for histologic discrepancies between biopsy and endoscopic submucosal dissection in gastric neoplasms: 10-year results

BACKGROUND AND AIM

The histologic discrepancies between preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) specimens sometimes confuse the endoscope operator. This study aimed to analyze the limitation of the biopsy-based diagnosis before ESD and to evaluate which factors affect the discordant pathologic results between EFB and ESD.

METHODS

A total of 1427 patients, who were diagnosed with gastric adenoma by EFB, were enrolled. Cancer confirmed on EFB was excluded (n = 513). We retrospectively reviewed cases and compared histologic diagnoses in the biopsy sample with the final diagnosis in the endoscopically resected specimen.

RESULTS

The diagnosis was upgraded (from low-grade dysplasia to high-grade dysplasia or adenocarcinoma, or from high-grade dysplasia to adenocarcinoma) in 328 cases (23.0%), concordant in 944 (66.1%), and downgraded (from high-grade dysplasia to low-grade dysplasia or non-neoplasia, or from low-grade dysplasia to non-neoplasia) in 155 (10.9%). Multivariate logistic regression analysis showed that surface ulceration and depressed lesions were associated with significant risk factors for upgrading. Age younger than 60 years and size <1 cm were associated with significant factors for downgrading.

CONCLUSIONS

Careful endoscopic observation should consider size, ulceration, and depression to ensure accurate diagnosis when a gastric neoplasm is suspected.

The capsule appearance of hepatocellular carcinoma in gadoxetic acid-enhanced MR imaging: Correlation with pathology and dynamic CT

This study aimed to evaluate the capability of gadoxetic acid-enhanced MR (GAeMR) to detect presence of capsule appearance in hepatocellular carcinoma (HCC), and to correlate it with dynamic computed tomography (CT) and pathological features.Sixty-three patients (54: 9 = M: F, mean age 55.8) surgically confirmed HCCs with preoperative CT and GAeMR were included in this retrospective study. Two readers evaluated presence of capsule appearances on CT and GAeMR images in each phase including precontrast (Pre), portal phase (PP), delayed phase (DP), transitional phase (TP), and hepatobiliary phase (HBP). Histologic capsule was compared with CT and GAeMR. Diagnostic performance of CT and GAeMR of each phase for histologic capsule was evaluated and compared by receiver operating characteristic curve. Interobserver agreement was assessed with kappa statistics.Histologically the capsule was complete in 12.7% (8/63) and incomplete in 60.3% (38/63). Four cases (6.3%) were pseudocapsule. Interobserver agreement for capsule appearance on GAeMR was good in Pre (κ = 0.684), moderate in PP (κ = 0.434), poor in TP (κ = 0.187), fair in HBP (κ = 0.395), and moderate on CT in PP (κ = 0.476) and DP (κ = 0.485). Diagnostic performance and sensitivity for the histologic capsule in DP on CT was highest among PP on CT and other phases on GAeMR. DP on CT images showed a higher Az value than PP on CT images with statistical significance (P < .001). PP on MR images revealed higher Az value than PP on CT images.The capsule appearance was most frequently observed in the DP on CT with highest diagnostic performance, and so DP images should be obtained on CT study for liver mass categorization. GAeMR yielded comparable capsule appearance to CT with moderate interobserver agreement. Considering hypointense rim on the HBP as fibrous capsule on pathology should be refrained, and so further study is warranted to correlate HBP hypointense rim with pathologic findings.

Prognostic Significance of Lymphocyte Counts in Colon Cancer Patients Treated with FOLFOX Chemotherapy

PURPOSE

There is increasing interest in immune function in combination with chemotherapy for cancer treatment. However, the effects of chemotherapy on the human immune system remain to be determined. The aim of this study was to investigate the prognostic impact of lymphocyte and neutrophil counts in colon cancer patients who were treated with curative surgery and adjuvant chemotherapy.

METHODS

Two hundred thirty-one patients with colon cancers who underwent curative surgery and FOLFOX adjuvant chemotherapy between November 2005 and December 2011 were included. Oncologic outcomes were analyzed with neutrophil count, lymphocyte count, and neutrophil-to-lymphocyte ratio (NLR) before and after chemotherapy.

RESULTS

The 5-year DFS rate was lower in colon cancer patients with low lymphocyte count during chemotherapy (61.9 vs. 76.7%, P = 0.026). Cox multivariate analysis demonstrated that low lymphocyte count during chemotherapy was independently associated with poor disease-free survival (HR 1.829; 95% CI 1.096-3.050; P = 0.021) in colon cancer patients who underwent FOLFOX adjuvant chemotherapy.

CONCLUSION

Lymphocyte count during chemotherapy is a strong predictor of worse disease-free survival in colon cancer patients who have undergone FOLFOX adjuvant chemotherapy.

Clinical Implication of Tests for Prostate-specific Antigen in Brain-dead Organ Donors

BACKGROUND

Although cancer screening tests are not mentioned under brain-dead organ donor care guidelines in Korea, we assessed the level of prostate-specific antigen (PSA), an important prostate cancer marker, and performed prostate biopsies when needed in brain-dead organ donors. We believe that insisting on a screening test for cancer diagnosis in donors' organs is important.

MATERIALS AND METHODS

Data were collected between January 2010 and July 2015 from Ajou University Hospital. We retrospectively analyzed the PSA levels and prostate biopsy results in 111 male brain-dead organ donors (mean age, 48.4 years).

RESULTS

The mean PSA level was 7.395 ng/mL (range, 0.062 to 61.780; reference, 0 to 4 ng/mL). Ultrasonography or computed tomographic examination did not reveal prostate cancer, and a rectal examination was not performed. After checking the PSA levels, prostate biopsies were performed in 16 patients based on the recommendations of a urologist, and 4 patients (3.6% of 111) were diagnosed with prostate cancer. All cancers involved adenocarcinomas (acinar type) histopathologically. In 2 patients, the Gleason score was 6 (3 + 3), whereas the other 2 showed a score of 7 (3 + 4). Among the patients diagnosed with prostate cancer, 1 donated his liver and corneas, and the remaining 3 could not donate.

CONCLUSION

Well-defined cancer screening tests are needed in Korea. Additionally, when the probability of organ transplantation-induced cancer metastasis is low or a recipient is at a high risk owing to not receiving organs, the law should allow organ donation even if prostate cancer is diagnosed in the donor.

Antimicrobial Resistance of Hypervirulent Klebsiella pneumoniae: Epidemiology, Hypervirulence-Associated Determinants, and Resistance Mechanisms

Klebsiella pneumoniae is one of the most clinically relevant species in immunocompromised individuals responsible for community-acquired and nosocomial infections, including pneumonias, urinary tract infections, bacteremias, and liver abscesses. Since the mid-1980s, hypervirulent K. pneumoniae, generally associated with the hypermucoviscosity phenotype, has emerged as a clinically significant pathogen responsible for serious disseminated infections, such as pyogenic liver abscesses, osteomyelitis, and endophthalmitis, in a generally younger and healthier population. Hypervirulent K. pneumoniae infections were primarily found in East Asia and now are increasingly being reported worldwide. Although most hypervirulent K. pneumoniae isolates are antibiotic-susceptible, some isolates with combined virulence and resistance, such as the carbapenem-resistant hypervirulent K. pneumoniae isolates, are increasingly being detected. The combination of multidrug resistance and enhanced virulence has the potential to cause the next clinical crisis. To better understand the basic biology of hypervirulent K. pneumoniae, this review will provide a summarization and discussion focused on epidemiology, hypervirulence-associated factors, and antibiotic resistance mechanisms of such hypervirulent strains. Epidemiological analysis of recent clinical isolates in China warns the global dissemination of hypervirulent K. pneumoniae strains with extensive antibiotic resistance in the near future. Therefore, an immediate response to recognize the global dissemination of this hypervirulent strain with resistance determinants is an urgent priority.

Interregional correlations of glucose metabolism between the basal ganglia and different cortical areas: an ultra-high resolution PET/MRI fusion study using 18F-FDG

Basal ganglia have complex functional connections with the cerebral cortex and are involved in motor control, executive functions of the forebrain, such as the planning of movement, and cognitive behaviors based on their connections. The aim of this study was to provide detailed functional correlation patterns between the basal ganglia and cerebral cortex by conducting an interregional correlation analysis of the ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) data based on precise structural information. Fifteen participants were scanned with 7-Tesla magnetic resonance imaging (MRI) and high resolution research tomography (HRRT)-PET fusion system using ¹⁸F-FDG. For detailed interregional correlation analysis, 24 subregions of the basal ganglia including pre-commissural dorsal caudate, post-commissural caudate, pre-commissural dorsal putamen, post-commissural putamen, internal globus pallidus, and external globus pallidus and 80 cerebral regions were selected as regions of interest on the MRI image and their glucose metabolism were calculated from the PET images. Pearson's product-moment correlation analysis was conducted for the interregional correlation analysis of the basal ganglia. Functional correlation patterns between the basal ganglia and cerebral cortex were not only consistent with the findings of previous studies, but also showed new functional correlation between the dorsal striatum (i.e., caudate nucleus and putamen) and insula. In this study, we established the detailed basal ganglia subregional functional correlation patterns using ¹⁸F-FDG PET/MRI fusion imaging. Our methods and results could potentially be an important resource for investigating basal ganglia dysfunction as well as for conducting functional studies in the context of movement and psychiatric disorders.

Clinical Significance of the Endoscopic Finding in Predicting Complete Tumor Response to Preoperative Chemoradiation Therapy in Rectal Cancer

BACKGROUND

There are reports that suggest conservative treatment when a tumor shows clinically complete response (CR) after preoperative chemoradiotherapy in rectal cancer. The aim of this study is to investigate the association between endoscopic complete response (E-CR) and pathologic CR (pCR) and to determine the sensitivity and specificity of E-CR and its clinical utility after preoperative chemoradiotherapy in rectal cancer.

METHODS

We analyzed prospectively collected data of patients with middle and lower rectal cancers who underwent preoperative chemoradiotherapy, between January 2010 and January 2015.

RESULTS

Nineteen patients (17.9 %) showed E-CR, and 87 patients showed E-non CR. Twenty-three patients (21.7 %) were confirmed to have pCR. E-CR was closely associated with pCR (p < 0.001). E-CR reflected pCR with an accuracy of 88.7 %, sensitivity of 65.2 %, specificity of 95.2 %, PPV of 78.9 %, NPV of 90.8 %, and a p value of <0.001.

CONCLUSIONS

E-CR after preoperative chemoradiotherapy in rectal cancer is significantly associated with pCR. However, a wait and see policy should be performed carefully with current endoscopic prediction for pCR to avoid inadequate treatment in patients who show E-CR after preoperative chemoradiotherapy.

Accuracy of Preoperative Local Staging of Primary Colorectal Cancer by Using Computed Tomography: Reappraisal Based on Data Collected at a Highly Organized Cancer Center

Purpose

In patients with colorectal cancer, preoperative staging using various imaging technologies is important for establishing the treatment plan and predicting the prognosis. Although computed tomography (CT) has been used most widely, the versatility of CT accuracy was primarily because of the lack of specialization. In this study, we aimed to identify whether any advancement in abdominal CT accuracy in the prediction of local staging has occurred.

Methods

Between December 2014 and November 2015, patients with colorectal cancer were retrospectively enrolled. All CT findings were retrospectively reported. A total of 285 patients were included, and their retrospectively collected data were retrospectively reviewed, focusing on a comparison between preoperative and postoperative staging.

Results

The overall prediction accuracy of the T stage was 55.1%, with overstaging occurring in 63 (22.1%) and understaging in 65 patients (22.8%). The sensitivity and specificity were 90.0% and 68.4%, respectively. The overall prediction accuracy of the N stage was 54.7%, with overstaging occurring in 89 (31.2%) and understaging in 40 patients (14.1%). The sensitivity and specificity were 71.9% and 63.2%, respectively. The CT accuracies by pathologic stage were 0%, 62.2%, 25.3%, and 81.2% for stages 0 (Tis N0), I, II, and III, respectively.

Conclusion

CT has good sensitivity for detecting colon cancers with tumor invasion beyond the bowel wall. However, detection of nodal involvement using CT is unreliable. In our opinion, abdominal CT alone has limitations in predicting the local staging of colorectal cancer, and additional technologies, such as CT plus positron emission tomography and/or colonography, will improve its accuracy.

A Novel Roux-en-Y Reconstruction Involving the Use of Two Circular Staplers after Distal Subtotal Gastrectomy for Gastric Cancer

Purpose

Although Roux-en-Y (R-Y) reconstruction after distal gastrectomy has several advantages, such as prevention of bile reflux into the remnant stomach, it is rarely used because of the technical difficulty. This prospective randomized clinical trial aimed to show the efficacy of a novel method of R-Y reconstruction involving the use of 2 circular staplers by comparing this novel method to Billroth-I (B-I) reconstruction.

Materials and Methods

A total of 118 patients were randomly allocated into the R-Y (59 patients) and B-I reconstruction (59 patients) groups. R-Y anastomosis was performed using two circular staplers and no hand sewing. The primary end-point of this clinical trial was the reflux of bile into the remnant stomach evaluated using endoscopic and histological findings at 6 months after surgery.

Results

No significant differences in clinicopathological findings were observed between the 2 groups. Although anastomosis time was significantly longer for the patients of the R-Y group (P<0.001), no difference was detected between the 2 groups in terms of the total surgery duration (P=0.112). Endoscopic findings showed a significant reduction of bile reflux in the remnant stomach in the R-Y group (P<0.001), and the histological findings showed that reflux gastritis was more significant in the B-I group than in the R-Y group (P=0.026).

Conclusions

The results of this randomized controlled clinical trial showed that compared with B-I reconstruction, R-Y reconstruction using circular staplers is a safe and feasible procedure. This clinical trial study was registered at www.ClinicalTrials.gov (registration No. NCT01142271).

Immune-camouflaged graphene oxide nanosheets for negative regulation of phagocytosis by macrophages

Signal regulatory protein alpha (SIRPα) is highly expressed in macrophages of the reticuloendothelial system and in tumor-associated macrophages, whereas tumor cells express the surface membrane protein, CD47, which interacts with SIRPα to negatively regulate phagocytosis. In this study, we modified the surfaces of graphene oxide (GO) nanosheets with a CD47-like SIRPα-binding peptide (SP). The presence of SP on GO nanosheets reduced the macrophage uptake to a greater extent than the PEGylation of such nanosheets. This reduced uptake was found to be mediated by the activation of Src homology region 2 domain-containing phosphatase 1 (SHP-1) and the downstream inhibition of myosin assembly, which is necessary for phagosome formation. Unlike SP-coated GO nanosheets, PEGylated GO nanosheets did not affect myosin assembly or phagocytosis. After in vivo systemic administration, the clearance of SP-coated GO nanosheets was slower than that of PEGylated GO nanosheets, and this difference increased with repeated administration. Finally, SP-coated GO nanosheets showed a higher distribution to tumor tissues than PEGylated GO nanosheets or a physical mixture of SP and GO nanosheets. Our findings indicate that immune-camouflaged GO nanosheets with natural CD47-like SIRPα-binding molecules can reduce the nonspecific loss of such nanosheets through macrophage uptake, thereby enhancing their blood circulation and tumor delivery after multiple injections.

Plugged percutaneous biopsy of the liver in living-donor liver transplantation recipients suspected to have graft rejection

Background Percutaneous biopsy is a widely-accepted technique for acquiring histologic samples of the liver. When there is concern for bleeding, plugged percutaneous biopsy (PPB) may be performed, which involves embolization of the biopsy tract. Purpose To evaluate the efficacy and safety of PPB of the liver in patients suspected to have graft rejection after living-donor liver transplantation (LDLT). Material and Methods During January 2007 and December 2013, 51 patients who underwent PPB of the liver under the suspicion of post-LDLT graft rejection were retrospectively analyzed. A total of 73 biopsies were performed. Biopsy was performed with a 17-gauge core needle and 18-gauge cutting needle. The needle tract was embolized using gelatin sponge (n = 44) or N-butyl cyanoacrylate (NBCA) (n = 29). The specimens were reviewed to determine their adequacy for histologic diagnosis. We reviewed all medical records after PPB. Results Specimens were successfully acquired in all procedures (100%). They were adequate for diagnosis in 70 cases (95.9%) and inadequate in three (1.3%). Average of 9.8 complete portal tracts was counted per specimen. One minor complication (1.4%) occurred where the patient had transient fever after the procedure. Conclusion PPB is easy and safe to perform in LDLT recipients and provides high diagnostic yield.

Imaging of regional air distributions in porcine lungs using high-performance electrical impedance tomography system

Electrical impedance tomography (EIT) allows functional imaging of regional lung ventilation for real-time bedside monitoring of mechanically ventilated patients. Images showing time-changes of regional air distributions in the lungs can provide valuable diagnostic information for lung protective mechanical ventilation. This paper reports in vivo porcine imaging experiments of regional lung ventilation using a 16-channel parallel EIT system. Real-time time-difference chest images of 10 animals were reconstructed during mechanical ventilations with a temporal resolution of 50 frame/s. Analyzing the images together with the airway volume-pressure information from the mechanical ventilator, we could successfully produce regional compliance images at PEEP (positive end expiratory pressure) titration. From in vivo animal experiments, we propose the method as a continuous monitoring means for LPV (lung protective ventilation).

The influence of gonadotropin releasing hormone agonist treatment on the body weight and body mass index in girls with idiopathic precocious puberty and early puberty

PURPOSE

This study aimed to investigate the influence of gonadotropin releasing hormone agonist (GnRHa) treatment on the weight and body mass index (BMI) of girls who were diagnosed with idiopathic central precocious puberty (CPP) or early puberty (EP).

METHODS

Patients who were younger than 8 years of age at diagnosis were classified as CPP and patients aged between 8 and 9 years at diagnosis were classified as EP. Of 129 patients, 34 were diagnosed with CPP and 95 were diagnosed with EP. The patients were divided according to pretreatment weight status into normal weight group, an overweight group, or an obese group.

RESULTS

No significant changes were observed with respect to the weight standard deviation score (SDS) before and after 1 year, 2 years of treatment, respectively (P>0.05, P>0.05) in all patient groups. No significant changes were observed in relation to the BMI SDS before and after 1 year, 2 years of treatment, respectively (P>0.05, P>0.05) in all patient group. Depending on the degree of obesity, differences with respect to the weight SDS and BMI SDS were observed.

CONCLUSION

BMI SDS increased in the GnRHa-treated patients as a whole group, but was not statistically significant. But BMI SDS increased significantly in the normal weight group after 2 years of GnRHa treatment. So, GnRHa treatment may affect the change of BMI SDS depending on degree of obesity.

Biology of Acinetobacter baumannii: Pathogenesis, Antibiotic Resistance Mechanisms, and Prospective Treatment Options

Acinetobacter baumannii is undoubtedly one of the most successful pathogens responsible for hospital-acquired nosocomial infections in the modern healthcare system. Due to the prevalence of infections and outbreaks caused by multi-drug resistant A. baumannii, few antibiotics are effective for treating infections caused by this pathogen. To overcome this problem, knowledge of the pathogenesis and antibiotic resistance mechanisms of A. baumannii is important. In this review, we summarize current studies on the virulence factors that contribute to A. baumannii pathogenesis, including porins, capsular polysaccharides, lipopolysaccharides, phospholipases, outer membrane vesicles, metal acquisition systems, and protein secretion systems. Mechanisms of antibiotic resistance of this organism, including acquirement of β-lactamases, up-regulation of multidrug efflux pumps, modification of aminoglycosides, permeability defects, and alteration of target sites, are also discussed. Lastly, novel prospective treatment options for infections caused by multi-drug resistant A. baumannii are summarized.

Risk factor for ischemic-type biliary lesion after ABO-incompatible living donor liver transplantation

AIM: To evaluate the risk factors for ischemic-type biliary lesion (ITBL) after ABO-incompatible (ABO-I) adult living donor liver transplantation (ALDLT).

METHODS: Among 141 ALDLTs performed in our hospital between 2008 and 2014, 27 (19%) were ABO-I ALDLT and 114 were ABO-identical/compatible ALDLT. In this study, we extensively analyzed the clinico-pathological data of the 27 ABO-I recipients to determine the risk factors for ITBL after ABO-I ALDLT. All ABO-I ALDLT recipients underwent an identical B-cell depletion protocol with preoperative rituximab, plasma exchange (PE), and operative splenectomy. The median follow-up period after transplantation was 26 mo. The clinical outcomes of the 27 ABO-I ALDLT recipients were compared with those of 114 ABO-identical/compatible ALDLT recipients.

RESULTS: ITBL occurred in four recipients (14.8%) between 45 and 112 d after ABO-I ALDLT. The overall survival rates were not different between ABO-I ALDLT and ABO-identical/compatible ALDLT (P = 0.303). Among the ABO-I ALDLT recipients, there was no difference between patients with ITBL and those without ITBL in terms of B-cell and T-cell count, serum isoagglutinin titers, number of PEs, operative time and transfusion, use of graft infusion therapy, or number of remnant B-cell follicles and plasma cells in the spleen. However, the perioperative NK cell counts in the blood of patients with ITBL were significantly higher than those in the patients without ITBL (P < 0.05). Preoperative NK cell count > 150/μL and postoperative NK cell count > 120/μL were associated with greater relative risks (RR) for development of ITBL (RR = 20 and 14.3, respectively, P < 0.05).

CONCLUSION: High NK cell counts in a transplant recipient’s blood are associated with ITBL after ABO-I ALDLT. Further research is needed to elucidate the molecular mechanism of NK cell involvement in the development of ITBL.

Tumor-related leukocytosis is associated with poor radiation response and clinical outcome in uterine cervical cancer patients

BACKGROUND

To evaluate response to radiation and clinical outcome of uterine cervical cancer patients with tumor-related leukocytosis (TRL) at initial diagnosis and during definitive radiotherapy.

PATIENTS AND METHODS

We retrospectively analyzed 2456 patients with stage IA-IVA uterine cervical cancer who received definitive radiotherapy with (37.4%) or without (62.6%) platinum-based chemotherapy between 1986 and 2012. TRL was defined as two or more occurrences of leukocytosis over 9000/μl at the time of diagnosis and during the course of treatment. Locoregional failure-free survival (LFFS) and overall survival (OS) were compared between patients with or without TRL.

RESULTS

The median age of all patients was 55 years, and the median follow-up time was 65.1 months. TRL was observed in 398 patients (16%) at initial diagnosis; TRL (+) patients were younger and had larger tumors, advanced stage, and more frequent lymph node metastases (all P < 0.05). TRL (+) patients showed a significantly lower rate of complete remission than TRL (-) patients (89.9% versus 96.3%, respectively, P = 0.042). Ten-year LFFS and OS for all patients were 84% and 78%, respectively. LFFS and OS were significantly lower in TRL (+) patients than TRL (-) patients (10-year LFFS: 69% versus 87% respectively, P < 0.001; 10-year OS: 63% versus 81% respectively P < 0.001). After propensity score matching, LFFS and OS rates in TRL (+) patients remained significantly lower than for TRL (-) patients; this significant difference was also observed on multivariate analysis. Twenty-six percent of patients with locoregional failure (n = 345) were TRL (+) and had significantly poorer median OS (6 versus 12 months, P = 0.001).

CONCLUSION

This study reveals the aggressive nature of cervical cancer with TRL and its poor response to radiation therapy. Given the unfavorable prognosis and higher probability of treatment failure, optimal diagnostic and therapeutic approaches and careful monitoring for early detection of recurrence should be considered for these patients.

Vaccinia-related kinase 1 promotes hepatocellular carcinoma by controlling the levels of cell cycle regulators associated with G1/S transition

We identified the specific role of vaccinia-related kinase 1 (VRK1) in the progression of hepatocellular carcinoma (HCC) and evaluated its therapeutic and prognostic potential. VRK1 levels were significantly higher in HCC cell lines than a normal hepatic cell line, and were higher in HCC than non-tumor tissue. VRK1 knockdown inhibited the proliferation of SK-Hep1, SH-J1 and Hep3B cells; moreover, depletion of VRK1 suppressed HCC tumor growth in vivo. We also showed that VRK1 knockdown increased the number of G1 arrested cells by decreasing cyclin D1 and p-Rb while upregulating p21 and p27, and that VRK1 depletion downregulated phosphorylation of CREB, a transcription factor regulating CCND1. Additionally, we found that luteolin, a VRK1 inhibitor, suppressed HCC growth in vitro and in vivo, and that the aberrant VRK1 expression correlated with poor prognostic features of HCC. High levels of VRK1 were associated with shorter overall and disease-free survival and higher recurrence rates. Taken together, our findings suggest VRK1 may act as a tumor promoter by controlling the level of cell cycle regulators associated with G1/S transition and could potentially serve as a therapeutic target and/or prognostic biomarker for HCC.

Abstract B14: Discoidin domain receptor 1 activity drives an aggressive phenotype in gastric adenocarcinoma

Purpose: Stromal content in gastric cancer patients inversely correlates with outcome. However, underlying molecular mechanisms for these clinical observations have not been determined. Here, we investigated the contribution of the collagen receptor, discoidin domain receptor-1 (DDR1), in the aggressive phenotype of gastric cancer induced by tumor stroma.

Experimental Design: We conducted immunohistochemical analyses with a tissue microarray of 217 gastric cancer specimens. We examined the effect of collagen-induced activation of DDR1 on cell signaling, tumorigenesis and cell migration in gastric cancer, and evaluated the effects of DDR1 inhibition in organotypic culture and xenograft animal models of gastric cancer.

Results: High DDR1 expression in gastric cancer tissue significantly correlated with poor prognosis. Gastric cancer patients were classified into two groups based on the stromal collagen and the expression of DDR1 was significantly associated with cancer invasion and lymph node metastasis in the collagen-positive group. Decreased expression of E-cadherin was associated with cancer progression in the collagen and DDR1 positive groups. We also demonstrated that collagen activated DDR1 and increased clonogenicity and cell migration. Importantly, we demonstrated that a DDR1 inhibitor, 7rh benzamide, reduced the invasiveness of gastric cancer in organotypic culture system and suppressed tumor growth in gastric cancer xenografts.

Conclusions: Taken together, these findings suggest that collagen enhances the aggressive phenotype of gastric cancer through the DDR1 signaling pathway and that inhibition of DDR1 is an attractive candidate for the therapy of aggressive gastric cancer.

Citation Format: Hoon Hur, In-hye Ham, Da Keun Lee, Hye-Jin Jin, Aguilera Kristina Y., Hae Jeong Oh, Sang-Uk Han, Ji-Eun Kwon, Young Bae Kim, Ke Ding, Rolf Brekken. Discoidin domain receptor 1 activity drives an aggressive phenotype in gastric adenocarcinoma. [abstract]. In: Proceedings of the AACR Special Conference: Function of Tumor Microenvironment in Cancer Progression; 2016 Jan 7–10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2016;76(15 Suppl):Abstract nr B14.

Numerical Simulation of PU Foaming Flow in a Refrigerator Cabinet

We have developed a numerical method for unsteady three-dimensional (3D) simulation of rigid polyurethane (PU) foaming flow in a refrigerator cabinet in this study. The governing equation for the compressible foaming flow is approximated with the Navier-Stokes equation, which means the foaming flow is assumed to be Newtonian. Numerical methods of simulation for unsteady compressible PU foaming flow with a free surface have been designed using a finite volume method (FVM) and the semi-implicit method for pressure-linked equations (SIMPLE) scheme as a pressure correction method. The formulation of numerical methods is developed on the basis of hexahedral meshes. Air in a refrigerator cabinet is neglected in the numerical method, and the free surface is traced with the volume of fluid (VOF) method. Viscosity and density of foam are assumed to be uniform in space and time-dependent, which are obtained with experimental methods. Results of numerical simulation for filling pattern and a finally filled position have been compared with the experimental results in a plate mold and a simple refrigerator cabinet. Simulation results of foaming fronts and finally filled position show good agreement with the experimental results. Numerical simulation of PU foaming flow is a useful tool to design a new refrigerator model and predict foam quality related to distance of foaming flow, air trapping, and location of finally filled position.

Global Dissemination of Carbapenemase-Producing Klebsiella pneumoniae: Epidemiology, Genetic Context, Treatment Options, and Detection Methods

The emergence of carbapenem-resistant Gram-negative pathogens poses a serious threat to public health worldwide. In particular, the increasing prevalence of carbapenem-resistant Klebsiella pneumoniae is a major source of concern. K. pneumoniae carbapenemases (KPCs) and carbapenemases of the oxacillinase-48 (OXA-48) type have been reported worldwide. New Delhi metallo-β-lactamase (NDM) carbapenemases were originally identified in Sweden in 2008 and have spread worldwide rapidly. In this review, we summarize the epidemiology of K. pneumoniae producing three carbapenemases (KPCs, NDMs, and OXA-48-like). Although the prevalence of each resistant strain varies geographically, K. pneumoniae producing KPCs, NDMs, and OXA-48-like carbapenemases have become rapidly disseminated. In addition, we used recently published molecular and genetic studies to analyze the mechanisms by which these three carbapenemases, and major K. pneumoniae clones, such as ST258 and ST11, have become globally prevalent. Because carbapenemase-producing K. pneumoniae are often resistant to most β-lactam antibiotics and many other non-β-lactam molecules, the therapeutic options available to treat infection with these strains are limited to colistin, polymyxin B, fosfomycin, tigecycline, and selected aminoglycosides. Although, combination therapy has been recommended for the treatment of severe carbapenemase-producing K. pneumoniae infections, the clinical evidence for this strategy is currently limited, and more accurate randomized controlled trials will be required to establish the most effective treatment regimen. Moreover, because rapid and accurate identification of the carbapenemase type found in K. pneumoniae may be difficult to achieve through phenotypic antibiotic susceptibility tests, novel molecular detection techniques are currently being developed.

Comparison of Surrogate Markers as Measures of Uncomplicated Insulin Resistance in Korean Adults

Background

Metabolic syndrome (MS) is known to increase the risk of various cardiometabolic diseases and in-sulin resistance (IR) has known to have central role in the development of MS. Many surrogate indices of IR have been proposed and the detection of MS might be a suitable model for assessing the accuracy of surrogate indices. The aims of our study are to invest the most appropriate index by assessment of the diagnostic capacity of IR among each surrogate index and identifying cut-off values for discriminating uncomplicated MS in Korean adults.

Methods

A cross-sectional study was performed, assessing 294 Korean adults, 85 of whom were diagnosed with uncomplicated MS. The sensitivities and specificities of five surrogate IR indices were compared to discriminate MS from healthy subjects; these included fasting serum insulin, homeostasis model assessment–insulin resistance index, quantitative insulin sensitivity check index, McAuley index, and Disse index. Correlations between each index value were assessed using Pearson's and Spearman's correlation methods.

Results

The McAuley index showed the highest area under the curve (0.85), specificity (86.12%), accuracy (82.31%), positive predictive value (68.13%), and negative predictive value (88.67%) to distinguish MS, with a cut-off point of 5.3 defined. Correlation coefficients of the five indices showed that the McAuley index had the strongest correlation with IR.

Conclusion

The McAuley index showed the best accuracy in the detection of MS as a surrogate marker of IR. To establish more effective and accurate standards of measuring IR, comprehensive and multi-scaled studies are required.