Patterns of Locoregional Pancreatic Cancer Recurrence after Total Neoadjuvant Therapy and Implications on Optimal Neoadjuvant Radiation Treatment Volumes

PURPOSE/OBJECTIVE(S)

Neoadjuvant treatment for patients with localized pancreatic adenocarcinoma (PDAC) has improved survival duration. As survival increases, local disease control becomes even more important. We sought to understand the patterns of locoregional recurrence following total neoadjuvant therapy (TNT) and determine the impact of treatment volumes on recurrence.

MATERIALS/METHODS

Patients with PDAC managed with neoadjuvant chemotherapy and chemoradiation (TNT) followed by surgery who developed an isolated locoregional or simultaneously locoregional and distant recurrence were identified. Locoregional recurrences were individually contoured utilizing commercially available software. When available, original neoadjuvant dose distributions were registered to the scans on which the locoregional recurrences were contoured. Recurrences where then classified as in-field (> 95% of prescription dose), marginal (50-95% of prescription dose), or out of field (< 50% of prescription dose). Target volumes were created using four commonly utilized PDAC contouring guidelines to characterize the relationship of the local recurrence to the RT dose distribution.

RESULTS

Of 474 patients treated with TNT and surgery, 80 (17%) patients developed a locoregional recurrence with or without distant recurrence, visible on diagnostic imaging. Of the 80 patients, 56 (70%) had tumors in the pancreatic head; 46 (57.5%) were borderline resectable, 23 (28.8%) locally advanced, and 11 (13.6%) resectable. The most common initial neoadjuvant therapies were FOLFIRINOX (57.5%) and gemcitabine/nab-paclitaxel (18.8%). Chemoradiation included concurrent gemcitabine (47.5%) or 5-fluorouracil (26.3%). RT dose distributions were available for 38 patients; 22 (57.9%) had in-field failures, 9 (23.7%) marginal failures, and 7 (18.4%) out of field failures. Each published contouring atlas covered a relatively low percentage of recurrences, which are summarized in Table 1. Regions at particularly high likelihood of recurrence that were under covered on existing atlases included: aortic-diaphragmic junction, retro-pancreatic duodenal nodal basin, and the region to the right of the superior mesenteric artery (SMA).

CONCLUSION

We present the largest series (to our knowledge) of mapped locoregional recurrences for patients being treated with TNT in PDAC. These recurrences differ substantially from established atlases and highlight anatomical regions of highest priority for RT coverage. A novel visual contouring volume highlighting these regions will be presented which will strive to advance the use of RT in the TNT setting.

Neoadjuvant Chemotherapy for Pancreatic Cancer: Quality over Quantity

BACKGROUND AND OBJECTIVES

The ideal duration of neoadjuvant chemotherapy (NACT) in patients with localized pancreatic adenocarcinoma (PDAC) treated with curative intent is unclear. We sought to determine the prognostic significance of both duration of NACT and Carbohydrate Antigen 19-9 (CA19-9) normalization to NACT.

METHODS

We examined patients with resectable and borderline resectable PDAC treated with NACT and chemoradiation. Patients were compared by NACT duration (2 vs 4 months) and by CA19-9 normalization after NACT.

RESULTS

Among 171 patients, 83 (49%) received two months of NACT and 88 (51%) received four months. After NACT completion, 115 (67%) patients had persistently elevated CA19-9 and 56 (33%) had normalized. Of the 125 patients who had successful surgery, 73 (58%) had normalized CA19-9 postoperatively. Duration of NACT was not associated with overall survival (OS) while CA19-9 normalization after NACT (regardless of duration) was associated with improved OS (HR 0.56, 95% CI 0.35-0.89, p=0.02). Adjuvant chemotherapy was associated with improved OS among patients without CA19-9 normalization after NACT (HR 0.42, CI 0.20-0.86, p=0.02) but not among those that normalized, independent of duration.

CONCLUSIONS

CA19-9 normalization after NACT is a clinically significant endpoint of treatment; patients without CA19-9 normalization may benefit from additional therapy. This article is protected by copyright. All rights reserved.

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Background

Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit.

Purpose

This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice.

Methods

This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI &gt;5% prior to ablation, mean systolic/diastolic blood pressure &gt;125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) &gt;6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed.

Results

The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI &gt;5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c &gt;6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1.

Conclusion

Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c &gt;6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

The effects of lithium and inflammation on the atherosclerosis of older bipolar patients at high risk for cardiovascular disease

Introduction

Atherosclerosis can result in serious cardiovascular disease (CVD) and is associated with inflammation and psychopharmacological treatment in bipolar disorder.

Objectives

We attempt to investigate the effects of lithium and inflammation on the atherosclerotic development in older bipolar adults at high risk for cardiovascular disease.

Methods

The euthymic out-patients with bipolar I disorder aged over 45 years and concurrent endocrine or cardiovascular disease were recruited to measure their bilateral carotid intima media thickness (CIMT) and circulating levels of lithium, valproate, sTNF-R1, sIL-6R, and lipid profile. All clinical information were obtained by directly interviewing patients and reviewing all medical records.

Results

Forty eight patients with mean 48.3 years old and mean 27.2 years of age at illness onset were recruited. After controlling for the body mass index, multivariate regression analyses showed that older age, lower lithium level, and higher plasma sTNF-R1 level were associated with higher CIMT and collectively accounting for 33.1% of the variance in CIMT. Blood level of low density lipid or valproate has none relationship with CIMT.

Conclusions

Lithium treatment may protect older bipolar patient, even those at high risk for CVD, from atherosclerotic development. Furthermore, persistent inflammatory activation, particularly macrophage activation, may be associated with the accelerating development of atherosclerosis.

Disclosure

No significant relationships.

Pre-ablation interatrial conduction delay or block predicts atrial fibrillation recurrence after ablation among obese patients

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity is associated with greater risk of atrial fibrillation (AF) recurrence post-ablation and higher incidence of conduction delay compared to non-obese patients. Pre-ablation P-wave duration (PWD) and morphology (PWM) indicating interatrial delay are easily assessed in the clinic and may predict AF recurrence post-ablation in these patients.

Purpose

Evaluate the predictive value of PWD and PWM on AF recurrence post-ablation in obese patients.

Methods

Pre-ablation PWD and PWM (negative P-wave in lead II or III) were analyzed on consecutive patients with BMI ≥30 kg/m2 who underwent initial AF ablation from 2012–19. The primary outcome was recurrent AF after a 3-month post-ablation blanking period. Multivariate analysis adjusted for baseline characteristics was performed.

Results

For 205 patients (61.0±9.5 years old, 39.0% female), mean BMI was 36.9±5.7 kg/m2 and 71.7% had persistent AF pre-ablation. Recurrent AF post-ablation occurred in 115 (56.1%) during a median follow up of 491 (270, 1001) days. PWD &gt;130 ms was significantly associated with higher AF recurrence (AHR of 1.62, 95%CI 1.04-2.57, p=0.03) after adjusting for age, persistent AF and left atrial volume index (LAVI). In a subgroup with LAVI &lt;42 mL/m2 (n=112), PWD &gt;130 ms and negative P-waves in lead II or III were independently associated with increased risk of recurrent AF (AHR 2.06, 95%CI 1.12-3.91; p=0.019 and AHR 1.94, 95% CI 1.00-3.56; p=0.05, respectively) (Figure 1).

Conclusion

AF recurred in &gt;50% of obese patients within 1.5 years of ablation. Pre-ablation PWD &gt;130 ms and negative P-waves in lead II or III independently predicted recurrent AF post-ablation in this cohort of obese patients. These easily assessed findings add predictive value to other risk factors.

Poor glycemic control in diabetic patients increases the risk of recurrent atrial arrhythmia and cardiovascular hospitalizations among morbidly obese patients undergoing atrial fibrillation ablation

Background/Introduction

Obesity and atrial fibrillation (AF) coexist and share multiple cardiovascular risk factors. Lifestyle modifications can reduce AF burden in obese patients. However, the time invested in pursing lifestyle changes may delay AF ablation, which could negate the procedural benefit.

Purpose

To examine the effects of lifestyle modifications and the timing of catheter ablation on morbidly obese patients with AF.

Methods

This retrospective study included 217 consecutive AF patients with a body mass index (BMI) ≥35 kg/m2 undergoing AF ablation at a tertiary care center from 2012 to 2019. Modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation of BMI &gt;5% or an increase in BMI &gt;3% prior to ablation, mean systolic blood pressure &gt;130 mmHg or diastolic blood pressure &gt;80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) ≥6.5%. The primary outcome was a composite of recurrent atrial arrhythmias and cardiovascular (CV) hospitalizations following AF ablation. A multivariate analysis adjusting for age, gender and modifiable risks was performed.

Results

The mean age was 61±9 years old, 58% were female and 45% had persistent AF. A substantial portion of the study patients had modifiable risk factors, ranging from 2.7% with excessive alcohol use to 67.3% experiencing delayed AF ablation, Figure 1. The median time from diagnosed AF to ablation was 1.3 years. During a mean follow-up of 2.9 years after AF ablation, 136 (62.7%) patients met the primary outcome. Only HbA1c ≥6.5% was an independent risk factor with adjusted hazard ratio of 1.57, 95% confidence interval 1.02–2.36, P=0.0412, Figure 2A. Delayed AF ablation did not alter the outcome, Figure 2B. There was no interaction between time of ablation and HbA1c ≥6.5% (P=0.67).

Conclusion

Substantial portions of morbidly obese patients undergoing AF ablation have potentially modifiable risk factors. Poor glycemic control with HbA1c ≥6.5% predicts an increased risk of recurrent atrial arrhythmias and CV hospitalizations, while delayed AF ablation does not. This finding underscores an importance of optimizing HbA1c in morbidly obese patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: None.

Enhanced homology-directed repair for highly efficient gene editing in hematopoietic stem/progenitor cells

Lentivector gene therapy for X-linked chronic granulomatous disease (X-CGD) has proven to be a viable approach, but random vector integration and subnormal protein production from exogenous promoters in transduced cells remain concerning for long-term safety and efficacy. A previous genome editing-based approach using Streptococcus pyogenes Cas9 mRNA and an oligodeoxynucleotide donor to repair genetic mutations showed the capability to restore physiological protein expression but lacked sufficient efficiency in quiescent CD34+ hematopoietic cells for clinical translation. Here, we report that transient inhibition of p53-binding protein 1 (53BP1) significantly increased (2.3-fold) long-term homology-directed repair to achieve highly efficient (80% gp91phox+ cells compared with healthy donor control subjects) long-term correction of X-CGD CD34+ cells.

In-vivo engineering of B cells elicits memory retention and allows for secretion of broadly neutralizing antibodies in mice

A potential single-shot HIV therapy may be transplanted engineered B cells allowing strong secretion of broadly neutralizing antibodies (bNAbs). However, extensive, and expensive ex-vivo manipulations performed in specialized facilities hinders clinical potential of this approach. Furthermore, allogeneic B cell therapy necessitates MHC-II compatibility to receive mandatory T-cell help.

To overcome these limitations, we engineer B cells in-vivo. In particular, we demonstrate that a single, systemic dose of dual AAV, one coding for CRISPR/Cas9 and another coding for a bNAb donor cassette, allows for site specific integration in B cells. Following immunizations, we show memory retention and bNAb secretion at high titers. Antibodies secreted by the engineered B cells were found to be of multiple isotypes and IgGs could neutralize autologous and heterologous pseudoviruses. We found engineered B cell subsets in the spleen and blood. We detected homing of in-vivo engineered cells to germinal centers and bone marrow. Biodistribution of the donor AAV over time and as compared to a CRISPR- group, indicated expansion of engineered B cells in lymphatic tissues. We determined minimal CRISPR/Cas9 off-target cleavage, using unbiased, highly sensitive, CHANGE-Seq analysis. Finally, we diminished on-target, non-productive double-strand breaks at undesired tissues by expressing Cas9 from a B cell specific promoter.

Eliciting a specific, neutralizing serological response to hypervariable viruses is a long-standing challenge in medicine. B cell engineering provides an opportunity to express therapeutic antibodies to generate an adaptive and evolving immunity.

0819 Objective Sleep Efficiency is Associated with Longitudinal Risk of High Depressive Symptoms in Pregnant Women

Introduction

Sleep disturbances are one of the most frequent complaints identified during routine prenatal care visits. Sleep and mood disturbances are often intertwined, and depression in particular is a leading cause of disability and disease burden worldwide. The purpose of this study was to examine the predictive association of objective actigraphic and subjective sleep disturbances with depressive symptoms in pregnant women.

Methods

We recruited 204 first-trimester pregnant women from a large university-affiliated hospital. They provided baseline socio-demographic and health information, wore a wrist actigraph for 7 days, and completed the Pittsburgh Sleep Quality Index and Center for Epidemiologic Studies - Depression Scale and repeated this again in the second and third trimesters. Each data collection was scheduled at least 8 weeks apart. Unadjusted and multivariable adjusted odds ratios with 95% confidence intervals were used to evaluate sleep disturbances at 1st trimester and risk of high depressive symptoms at follow-up.

Results

A total of 121 (59.3%) women had actigraphic sleep efficiency of &lt; 85% and 92 (45.1%) had Pittsburgh Sleep Quality Index global scores &gt; 5 indicative of poor sleep quality. In multivariable adjusted models, 1st trimester objectively measured sleep efficiency &lt; 85% was associated with 2.65-, 3.86-, and 5.27-fold increased odds having risk of high depressive symptoms at 2nd trimester, 3rd trimester, and both 2nd and 3rd trimesters, respectively. No subjective sleep disturbance variables were significantly associated with risk of high depressive symptoms in multivariate adjusted models.

Conclusion

Objectively assessed poor sleep efficiency in the 1st trimester plays a crucial role in the development of both elevated and persistent high depressive symptoms in pregnancy. Future studies using objective sleep measurements and clinical diagnostic interviews are warranted to examine whether early interventions to improve sleep may help reduce high depressive symptom risk and lower depression rates in women during pregnancy.

Support

This study was funded by the Ministry of Science and Technology, Taiwan (MOST-101-2314-B-002-049-MY3).

0509 Use of Blinded Hypnotic Tapering for Hypnotic Discontinuation

Introduction

Many patients have difficulties achieving hypnotic discontinuation due to anxiety that arises when they knowingly reduce their hypnotic dose or withhold it entirely. This study tested a blinded tapering approach to reduce patients’ anxiety and help them discontinue their hypnotics.

Methods

The study sample included 78 (M age = 55.2 ± 12.8 yrs.; 65.4% women) users of benzodiazepine and benzodiazepine receptor agonists. Following baseline assessments, enrollees first completed 4 sessions of cognitive behavioral insomnia therapy (CBTI). Subsequently they were randomized to one of three 20-week, double-blinded tapering protocols wherein their medication dosage either remained unchanged (CTRL) or was reduced by 25% or 10% every two weeks. At the end of the 20-week period the study blind was eliminated and those who completed one of the two blinded tapering protocols entered a 3-month follow-up period, whereas CTRL participants were offered an open label taper before completing the follow-up.

Results

Among those who completed one of the blinded tapering protocols, 92.9% totally discontinued their medication use by the end of the 20-week tapering phase, whereas 77.3% in the CTRL group discontinued hypnotic use by the end of their open label tapering. At follow-up 72.1% of those who completed blinded tapering remained medication free whereas only 52% of those who underwent open-label tapering remained medication free. Comparisons at follow-up showed those who received the open-label taper continued to use hypnotics on average 2-3 nights/week compared to about 1 time every other week for the blinded taper group (p = .05). The average weekly diazepam equivalent dose of medication used by the open label tapering group was about 5 times higher than the average weekly dose used by the blind tapering group (p = .025).

Conclusion

CBTI combined with blinded hypnotic tapering is a promising treatment approach for helping hypnotic users overcome their medication dependence.

Support

National Institute of Drug Abuse, Grant # R34 DA042329-01

1134 Light Exposure At Daytime On Sleep Quality In Stroke Patient During Rehabilitation

Introduction

Lights maintain the day and night rhythm to set patients’ “wake-up cycle” and to stabilize their physiological functions, which may be expected to improve sleep. This study was aimed to investigate the relations between sleep quality and daytime light exposure in stroke patient during rehabilitation.

Methods

A cross-sectional study design was adopted and 120 stroke patients were recruited from rehabilitation wards of two medical centers and 116 patients completed this study. Research instruments including the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Log, and Somnowatch (Germany) for actigaphy sleep and light were used to collect data and urinary melatonin concentration were measured.

Results

47.4% of the patients had poor sleep quality (PSQI&gt;5), 74.1% had actigraphic sleep efficiency less than 85%, and 90.5% waked more than 30 minutes after sleep onset. The average exposure time at lower level light (≤149 lux) were 288.8 minutes, accounting for 48% of the day (8:00-18:00). Compared to lower light exposure group (less than 319.5 min at &gt;150 lux), those who exposed to higher level light (more than 319.5 min at &gt;150 lux) had increased 52.1 minutes in actigraphic total sleep time (TST, t=-2.134, p=0.035), increased 8% in actigraphic sleep efficiency (SE, t=-2.053, p=0.042), and decreased 41.1 minutes in actigraphic wake-after-sleep-onset (WASO, t=2.209, p=0.029). Urinary melatonin concentration increased 52.7 pg/ml, but not statistically significant (t=-1.277, p=0.205). Result of multiple regression analysis showed that after controlling for age, gender, post-stroke complications, and environmental interference, time of bright light exposure significantly affected subjective sleep satisfaction (p=0.014), TST (p=0.04), SE (p=0.041), and WASO (p=0.026).

Conclusion

Increasing time of bright illumination (≥150 lux) during daytime may improve sleep quality. Results of this study provide empirical references for non-drug intervention to improve sleep quality in patients with stroke.

Support

This study was supported by the Ministry of Science and Technology, MOST 105-2628-B-040 -005 -MY2.

De novo DNA methylation programs regulate CAR T-cell exhaustion

Chimeric antigen receptor (CAR) T-cell therapy is revolutionizing cancer immunotherapy for patients with B cell malignancies. While clinical trials have demonstrated the curative potential of this approach, a significant and well-established limitation is the heightened contraction and transient persistence that CAR T-cells experience during prolonged antigen exposure. Building upon our prior observation that deleting the de novo DNA methyltransferase 3a (Dnmt3a) prevents T cell exhaustion in the prototypical model of LCMV-induced T cell exhaustion, we assessed the role of DNMT3A programming in the dysfunction of human CAR T-cells. Deletion of DNMT3A in multiple human CAR T-cell systems resulted in a striking preservation of the CAR T-cell’s ability to proliferate and mount an effector response during chronic antigen exposure. Whole genome methylation profiling of DNMT3A KO CAR T-cells established an atlas of epigenetically regulated genes targeted during CAR T-cell dysfunction. Cross-reference of our published murine exhaustion methylation profiles with our newly identified human CAR T-cell methylation atlas revealed conservation of epigenetically regulated exhaustion-associated genes. Using a novel epigenetic-based bioinformatic tool that predicts human T-cell differentiation we further documented the preserved developmental plasticity of the DNMT3A KO CAR T-cells. Lastly, analysis of publicly available RNAseq expression data from CD19-CAR T-cell products prior to infusion into CLL patients demonstrated that DNMT3A programming is significantly coupled to clinical outcome. Collectively our results demonstrate that de novo DNA methylation programming is a key factor limiting T-cell based immunotherapy.

The brief window of time comprising a wheelchair transfer confers a significant fracture risk on elderly Americans

OBJECTIVES

Wheelchairs grant increased mobility to their users but can result in injuries of varying severities, including fractures which are often associated with wheelchair transfers. However, this fracture burden remains poorly characterized in elderly Americans. The purpose of this study was to report demographic and environmental risk factors for these injuries.

STUDY DESIGN

We used data from the National Electronic Injury Surveillance System (NEISS) for the years 2007-2017 to perform a retrospective, cross-sectional analysis of wheelchair transfer fractures in patients aged 65 years and older.

METHODS

Each yearly sample in the NEISS database was queried between 2007 and 2017 for fractures associated with wheelchair transfers in patients aged 65 years or older. The narrative sections of the database were individually read and reviewed to identify cases in which a patient explicitly transferred into or out of a wheelchair while sustaining said fracture.

RESULTS

Between 2007 and 2017, the average number of patients aged 65 years and older presenting to US emergency departments was 3924 (95% confidence interval [CI] = 2792-5055). A significantly higher percentage of fractures (61.8%; 95% CI = 56.7%-66.8%) is associated with transferring out of wheelchairs. Moreover, such fractures were often associated with transferring to and from beds (29.9%; 95% CI = 25.4%-34.3%), with the hip (37.5%; 95% CI = 33.3%-41.6%) being the most commonly fractured anatomical region overall. A majority of patients required admission to the hospital (60.2%; 95%CI = 52.4%-68.0%) and most wheelchair transfer fractures occurred at home (44.1%; 95% CI = 36.7%-51.5%), with women (71.9%; 95% CI = 68.3%-75.6%) comprising the majority of these patients.

CONCLUSIONS

Our findings show that wheelchair transfers are associated with significant risk of severe fracture in elderly Americans. As such, wheelchair transfer events merit extra attention from healthcare providers because they comprise a brief window of time relative to the number of occupancy hours in full-time wheelchair users yet can result in significant morbidity and mortality. Preventative measures and patient education should be encouraged to preserve patient mobility and reduce injury.

Neuroendocrine Tumor Awareness Program in Taiwan

Background and context: Neuroendocrine tumor (NET) is difficult to detect. It's often presented with symptoms common to other diseases. To raise awareness and improve the understanding of NET, the International Neuroendocrine Cancer Alliance (INCA) announced 10th November as the World NET Cancer Day. HOPE FOUNDATION for CANCER CARE has joined the advocacy events since 2011. Aim: To raise awareness and to improve the understanding of NET. Strategy/Tactics: To raise the awareness of the 10 symptoms of NET. To provide correct information about NET. To improve the understanding of NET. Program/Policy process: We held a series of campaigns in November 2017, including: theme decorations in 11 hospitals, 3 parades and shows at public places, a new animation with online marketing and outdoor advertising. By combining online and offline events, we have reached as many people as possible to increase the awareness and improve the knowledge of NET. We built the first as well as the only NET Mandarin Web site ( www.net.org.tw ) Outcomes: We cooperated with 11 hospitals in Taiwan to display educational posters and wall stickers. The information of NET cancers not only reached the public but also oncologists. This event had 3 newspaper reports and 16 online news reports. We conducted 3 educational parades and shows with zebra theme in three main cities in Taiwan. The parade in capital city Taipei gained total 86 reports including 71 online news media, 8 television channels and 7 newspapers. We cooperated with a celebrity artist to create a zebra mascot, which represents international symbol for NET. In addition, we created awareness lightbox advertising and animated video with the mascot to attract public attention and raise awareness of NET. This animated video was published on YouTube platform, and had 504,209 impressions and 208,427 views by 31st December 2017. Moreover, it was broadcasted on taxis in Taiwan as well. It was broadcasted 1,163,248 times during the promotion period. We also implemented an online advocacy plan through Facebook. This plan was designed with 4 posts, which contained a comic strip, an online memory game, a profile picture frame and an animated video. This plan totally had 332,625 impressions and reached 154,089 people on the Internet. What was learned: According to our experience with cancer patients, we realize that utilizing mascot characters to deliver educational information is more easily perceived by the public. This year we designed a new mascot of NET which was applied to animated video and outdoor advertising. Also, we conducted 3 educational parades with zebra theme and traditional Taiwanese features, which opened up a new dimension in advocacy for cancer awareness. Overall, these events received good response from the public and oncologists. The NET Mandarin Web site also showed a significant result with an increase of 98% of monthly page views and 69.7% of new visitors views.

Human Kallikrein 3 (prostate-specific antigen) and Human Kallikrein 5 Expression in Salivary Gland Tumors

The human kallikrein 5 protein (hK5) is expressed in many normal tissues, most notably in skin, breast, salivary gland and esophagus. It has also been shown to be a potential biomarker for breast, ovarian and testicular cancer. Human kallikrein 3 (hK3; prostate-specific antigen) is the most useful marker for adenocarcinoma of the prostate gland. The aim of this study was to determine whether hK3 and hK5 are expressed in salivary gland tissues and salivary gland tumors (both benign and malignant), in order to compare normal with tumor tissues. Pleomorphic adenomas, adenoid cystic carcinomas, polymorphous low-grade adenocarcinomas, acinic cell carcinomas, mucoepidermoid carcinomas and adenocarcinomas not otherwise specified of both minor and major salivary glands were examined. The results of this study indicate that most salivary gland tumors do not show high levels of expression of hK5. Staining was most prominent in keratinizing epithelia in pleomorphic adenomas. hK3 is not expressed in salivary gland tumors.

Poor Glycemic Control Is Associated with Failure to Complete Neoadjuvant Therapy and Surgery in Patients with Localized Pancreatic Cancer

BACKGROUND

The impact of glycemic control in patients with pancreatic cancer treated with neoadjuvant therapy is unclear.

METHODS

Glycated hemoglobin (HbA1c) values were measured in patients with localized pancreatic cancer prior to any therapy (pretreatment) and after neoadjuvant therapy prior to surgery (preoperative). HbA1c levels greater than 6.5% were classified as abnormal. Patients were categorized based on the change in HbA1c levels from pretreatment to preoperative: GrpA, always normal; Gr B, worsened; GrpC, improved; and GrpD, always abnormal.

RESULTS

Pretreatment HbA1c levels were evaluable in 123 patients; there were 67 (55%) patients in GrpA, 8 (6%) in GrpB, 22 (18%) in GrpC, and 26 (21%) in GrpD. Of the 123 patients, 92 (75%) completed all intended therapy to include surgery; 57 (85%) patients in GrpA, 4 (50%) patients in GrpB, 16 (72%) patients in GrpC, and 15 (58%) patients in GrpD (p = 0.01). Elevated preoperative carbohydrate antigen 19-9 (CA19-9) (OR 0.22;[0.07-0.66]), borderline resectable (BLR) disease stage (OR 0.20;[0.01-0.45]) and abnormal preoperative HbA1c (OR 0.30;[0.11-0.90]) were negatively associated with completion of all intended therapy. Abnormal preoperative HbA1c was associated with a 2.74-fold increased odds of metastatic progression during neoadjuvant therapy (p = 0.08).

CONCLUSIONS

Elevated preoperative HbA1c is associated with failure to complete neoadjuvant therapy and surgery and a trend for increased risk of metastatic progression.

The Molecular Circuit Regulating Tooth Development in Crocodilians

Alligators have robust regenerative potential for tooth renewal. In contrast, extant mammals can either renew their teeth once (diphyodont dentition, as found in humans) or not at all (monophyodont dentition, present in mice). Previously, the authors used multiple mitotic labeling to map putative stem cells in alligator dental laminae, which contain quiescent odontogenic progenitors. The authors demonstrated that alligator tooth cycle initiation is related to β-catenin/Wnt pathway activity in the dental lamina bulge. However, the molecular circuitry underlying the developmental progression of polyphyodont teeth remains elusive. Here, the authors used transcriptomic analyses to examine the additional molecular pathways related to the process of alligator tooth development. The authors collected juvenile alligator dental laminae at different developmental stages and performed RNA-seq. This data shows that Wnt, bone morphogenetic protein (BMP), and fibroblast growth factor (FGF) pathways are activated at the transition from pre-initiation stage (bud) to initiation stage (cap). Intriguingly, the activation of Wnt ligands, receptors and co-activators accompanies the inactivation of Wnt antagonists. In addition, the authors identified the molecular circuitry at different stages of tooth development. The authors conclude that multiple pathways are associated with specific stages of tooth development in the alligator. This data shows that Wnt pathway activation may play the most important role in the initiation of tooth development. This result may offer insight into ways to modulate the genetic controls involved in mammalian tooth renewal.

Collaborative case conferences in rectal cancer: case series in a tertiary care centre

BACKGROUND

In many hospitals, resource barriers preclude the use of preoperative multidisciplinary cancer conferences (mccs) for consecutive patients with cancer. Collaborative cancer conferences (cccs) are modified mccs that might overcome such barriers.

METHODS

We established a ccc at an academic tertiary care centre to review preoperative plans for patients with rectal cancer. Attendees included only surgeons who perform colorectal cancer procedures and a radiologist with expertise in cross-sectional imaging. Individual reviews began with the primary surgeon presenting the case information and initial treatment recommendations. Cross-sectional images were then reviewed, the case was discussed, and consensus on ccc-treatment recommendations was achieved. Outcomes for the present study were changes in treatment recommendations defined as "major" (that is, redirection of patient to preoperative radiation from straight-to-surgery or uncertain plan, or redirection of the patient to straight-to-surgery from preoperative radiation or plan uncertain) or as "minor" (that is, referral to a multidisciplinary cancer clinic, request additional tests, change type of neoadjuvant therapy, change type of surgery). Chart reviews provided relevant patient, tumour, and treatment information.

RESULTS

Between September 2011 and September 2012, 101 rectal cancer patients were discussed at a ccc. Of the 35 management plans (34.7%) that were changed as a result, 8 had major changes, and 27 had minor changes. Available patient and tumour factors did not predict for a change in treatment recommendation.

CONCLUSIONS

Preoperative cccs at a tertiary-care centre changed treatment recommendations for one third of patients with rectal cancer. Given that no specific factor predicted for a treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.

p38γ MAPK is required for inflammation-associated colon tumorigenesis

Chronic inflammation has long been considered to causatively link to colon cancer development. However, signal transduction pathways involved remain largely unidentified. Here, we report that p38γ mitogen-activated protein kinase mediates inflammatory signaling to promote colon tumorigenesis. Inflammation activates p38γ in mouse colon tissues and intestinal epithelial cell-specific p38γ knockout (KO) attenuates colitis and inhibits pro-inflammatory cytokine expression. Significantly, p38γ KO inhibits tumorigenesis in a colitis-associated mouse model. The specific p38γ pharmacological inhibitor pirfenidone also suppresses pro-inflammatory cytokine expression and colon tumorigenesis. The tumor-promoting activity of epithelial p38γ was further demonstrated by xenograft studies. In addition, p38γ is required for β-catenin/Wnt activities and p38γ stimulates Wnt transcription by phosphorylating β-catenin at Ser605. These results show that p38γ activation links inflammation and colon tumorigenesis. Targeting p38γ may be a novel strategy for colon cancer prevention and treatment.

Visualization of surface topology of human lymphoid cells by scanning electron microscopy

We have studied the surface characteristics of human lymphoid cells with the scanning electron microscope (SEM). We obtained thymic cells by mincing thymus and isolating peripheral blood lymphocytes from normal donors as well as patients with acute and chronic lymphocytic leukemia (ALL and CLL). Prior to SEM, we purified the lymphocytes in isoosmotic Ficoll-Hypaque gradients. In addition, we examined several lymphoid cell lines in permanent culture derived from normal persons, patients with infectious mononucleosis, as well as from patients with ALL. The surfaces of most thymic cells appear smooth with only a few short microvilli. A small number of thymic cells, on the other hand, are found to exhibit many more microvilli of uniform shape and length. We could further identify lymphocytes from normal donors as T- and B-types according to their rosetting spontaneously with sheep red blood cells (SRBC) resemble thymic cells in their surface topology. However, B-cells rosetting with amboceptor--and complement--treated SRBC show greater number of microvilli. The surface morphology of lymphocytes from leukemic patients appears more or less characteristic of the disease type. In contrast, the surfaces of cultured lymphoid cells show a diversified surface topology, often with large smooth areas, very long and very short microcilli, which may often cluster in groups. These data bear directly upon techniques of plasma membrane fractionation and we suspect that the topology differences correlate with their differentiation patterns.

Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer

BACKGROUND

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

METHODS

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

RESULTS

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238).

CONCLUSIONS

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Profiling and targeting of cellular bioenergetics: inhibition of pancreatic cancer cell proliferation

BACKGROUND

Targeting both mitochondrial bioenergetics and glycolysis pathway is an effective way to inhibit proliferation of tumour cells, including those that are resistant to conventional chemotherapeutics.

METHODS

In this study, using the Seahorse 96-well Extracellular Flux Analyzer, we mapped the two intrinsic cellular bioenergetic parameters, oxygen consumption rate and proton production rate in six different pancreatic cancer cell lines and determined their differential sensitivity to mitochondrial and glycolytic inhibitors.

RESULTS

There exists a very close relationship among intracellular bioenergetic parameters, depletion of ATP and anti-proliferative effects (inhibition of colony-forming ability) in pancreatic cancer cells derived from different genetic backgrounds treated with the glycolytic inhibitor, 2-deoxyglucose (2-DG). The most glycolytic pancreatic cancer cell line was exquisitely sensitive to 2-DG, whereas the least glycolytic pancreatic cancer cell was resistant to 2-DG. However, when combined with metformin, inhibitor of mitochondrial respiration and activator of AMP-activated protein kinase, 2-DG synergistically enhanced ATP depletion and inhibited cell proliferation even in poorly glycolytic, 2-DG-resistant pancreatic cancer cell line. Furthermore, treatment with conventional chemotherapeutic drugs (e.g., gemcitabine and doxorubicin) or COX-2 inhibitor, celecoxib, sensitised the cells to 2-DG treatment.

CONCLUSIONS

Detailed profiling of cellular bioenergetics can provide new insight into the design of therapeutic strategies for inhibiting pancreatic cancer cell metabolism and proliferation.

Application of a functional marker for the effect of cryoprotectant agents on gorgonian coral (Junceella juncea and J. fragilis) sperm sacs

BACKGROUND

The establishment of coral sperm repositories which retain good post-rewarming viability and fertility play a vital role in species conservation.

OBJECTIVE

This study aimed at obtaining baseline information regarding the effects of cryoprotectant agents (CPAs) on gorgonian coral (Junceella juncea and J. fragilis) sperm sacs.

METHODS

The adenosine triphosphate assay was used to determine the energy level of the gorgonian sperm sacs as an indicator of sperm viability after exposure to cryoprotectants.

RESULTS

The 'no observed effect concentrations' (NOECs) of methanol, dimethyl sulfoxide (DMSO), polypropylene glycol (PG), ethylene glycol (EG) and glycerol for J. juncea sperm sacs were 3 M, 3 M, 1 M, 2 M and 1 M respectively after 20 min exposure; whilst the NOECs for J. fragilis oocytes were 2 M, 3 M, 1 M, 2 M and 2 M, respectively. Methanol and DMSO had the least impact. PG was the most toxic CPA after 10 min exposure. ATP content of J. juncea and J. fragilis sperm sacs did not differ significantly from the control with incubation times of 10-20 min with 2 M EG. However, ATP content dropped significantly after exposing sperm sacs to 2 M EG for 40 min with average values of 2.34 +/- 0.12 and 1.97 +/- 0.48 microg/ml respectively. ATP content for J. juncea and J. fragilis sperm sacs was significantly decreased to 1.79 +/- 0.31 and 2.40 +/- 0.36 microg/ml after 20 min incubation in 2 M PG when compared to the control with 2.98 +/- 0.16 and 4.14 +/- 0.42 microg/ml respectively. Normalized ATP content for sperm sacs of two different gorgonian coral after incubation in methanol, DMSO, PG, EG and glycerol showed that J. juncea sperm sacs were slightly less tolerant to CPAs compared to J. fragilis sperm sacs.

CONCLUSIONS

DMSO or methanol can be considered as efficient CPAs for gorgonian sperm sacs cryopreservation. The ATP luminescence assay provided sensitive and rapid quantification of mitochondrial activity in gorgonian coral sperm sacs. The study on the impact of CPA will contribute to the development of a cryopreservation protocol for coral sperm conservation.